Penthrox enables quicker management of fractures, dislocations and more: learning lessons from expedited care of trauma patients during the COVID-19 pandemic.

INTRODUCTION: Methoxyflurane is an historical anaesthetic agent that has undergone a renaissance with the introduction of a smaller dose in a handheld 'Penthrox' device. The benefits of Penthrox include its ease of use, with disposable individual packets, and the need for less monitoring and staff, when compared with deeper sedation. The literature acknowledges its use for analgesia and in the management of anterior shoulder dislocation but in no other procedural orthopaedic circumstance. METHODS: Following institutional approval, we undertook a retrospective review of all incidences of Penthrox use to facilitate minor procedures within a 2-month period starting 24 March 2020. Time to procedure and success were recorded using the surrogate markers of patient attendance and x-Ray occurrence times. RESULTS: Some 101 Penthrox doses were given to 89 patients over 97 unique episodes between 24 March and 26 May 2020. No complications were recorded following the use of Penthrox during this period. Patient demographics were explored. Fracture manipulations and casting (n=54) had a 100% success rate in achieving adequate and safe reduction. Joint dislocations (n=34) were treated with varying success. Native elbow dislocations were reduced most successfully (4/4, 100%). Native shoulder dislocations were seen in 17 patients and successful relocation was seen in 11 cases, giving a success rate of 65%. CONCLUSIONS: This is the first study, outside anterior shoulder dislocations, to report on the efficacy of Penthrox within emergent orthopaedic scenarios. We have demonstrated Penthrox to be a safe tool for helping to manage trauma procedures in the emergency department.

Learning from excellence: Sharing success, a quality improvement project

Background A Learning From Excellence (LFE) scheme was initiated in the Paediatric Department of a District General Hospital (DGH) to highlight and celebrate good practice. This scheme was implemented at a time when stress levels were particularly high at the start of the Covid-19 pandemic. Due to the popularity of the scheme, it was later expanded to include the maternity department. Nominations were received via email to a centralised address. On a monthly basis, certificates were sent out to nominees and themes of excellence were shared with the wider team. Objectives To evaluate staff opinions of the LFE scheme, in particular the impact on morale, working relationships, teamworking and patient safety. To also explore staff opinions on the functionality of the scheme and their experience of submitting and receiving nominations. Methods A survey was distributed to all participants in the scheme 4 months after the project was initiated. An additional poll was performed at 10 months, and all members of the paediatric and maternity teams were invited to participate. Data was also collected on the number and theme of nominations, as well as staff members nominated/nominating. Results 44 nominations were submitted within the first 4 months. There was a 73.0% response rate to the survey following this period (n=36), of which 72.0% fully completed the survey (n=26). The majority of nominations (57%) were from Paediatric Registrars in the first four months, but there was a spread across the wider MDT. All respondents reported that the LFE initiative had some impact on improving morale in the workplace, improved their motivation in the workplace and had been effective in improving teamwork. 96.2% felt LFE was effective in breaking down boundaries between staff and 88.5% felt it had an impact on improving patient safety. The qualitative responses received highlight the positive feelings experienced by participants and the impact on individual wellbeing - not only experienced by those who were nominated, but also the nominators. Momentum built in the 10 months since the scheme was introduced, with the numbers of nominations growing from a mean of 6 per month initially to a peak of 25 per month (overall total of 146 nominations.) The spread of nominees over time was more inclusive of the wider MDT. A follow up survey was performed at 10 months and 40 responses were received. 100% of respondents felt that LFE was a beneficial initiative, and 100% felt that LFE had a positive impact on their work environment. Conclusions The LFE scheme implemented during the Covid- 19 pandemic in our paediatric department has contributed to improvement in staff morale, motivation and teamworking. The increase in nominations is evidence of development of a positive culture in which recognition of colleagues' contribution to the team is becoming part of the ethos of the department. Encouragement has never been more crucial than during the current global pandemic. We aim to expand this initiative by using digital innovation to make the process more efficient, and across different sites, so that learning points can be shared amongst the wider Trust.