Primary care pathway- a novel way to reduce the burden on orthopaedic fracture clinics within the pediatric subgroup: A Queensland multi-centered review.

ABSTRACT: Emergency departments receive an increasing amount of musculoskeletal injuries, with the majority referred to a fracture clinic (FCs). A literature review revealed certain orthopaedic injuries can be safely managed away from the FC pathway by general practitioners (GPs) or allied health professionals (AHPs). The present study aims to review all paediatric presentations to FCs at 2 Queensland hospitals, identifying low risk injuries that could potentially be managed by GPs or AHPs. This study is a continuation from Cleary et al in which a primary care pathway (PCP) was proposed for the management of low risk adult orthopaedic injuries. A PCP has the potential to have significant savings to the health system.A retrospective study was conducted looking at paediatric patients (<16 years) referrals to 2 FCs over 8 weeks. Injuries were categorised into those requiring FC care supervised by an orthopaedic surgeon, and those that can be safely managed by GPs or AHPs via a PCP.Four hundred ninety (57.7%) of the 849 patients referred to FC were assessed as suitable for PCP care. The most common upper limb injury deemed suitable was radius and ulna buckle fractures (18.4%), while the most common lower limb injury is ankle sprains (8%). Total failure to attend rate in the PCP group was 6.7%.Adopting the PCP has the potential to significantly reduce FC referrals. With proven success of similar pathways abroad, the PCP may generate significant time and financial savings for both the health care system and patient.

Validation of the Primary Care Pathway Model for Management of Orthopedic Injuries: Results of a Prospective, Queensland Study.

OBJECTIVE: A "virtual fracture clinic" (VFC) is viewed as a safe, cost effective method of managing suitable low risk orthopedic injuries without direct orthopedic review. This method is used throughout the Glasgow Royal Infirmary (GRI) and National Health System (NHS) as a cornerstone for efficient patient care. This study assessed the outcomes of a newly implemented Queensland based Primary Care Pathway (PCP) for management of simple orthopedic injuries. METHODS: A prospective cohort was formed of patients presenting over a 4-week period with an acute orthopedic injury to either the Emergency Department (ED) or Primary Care Providers within the Logan Hospital catchment in Queensland, Australia. Patients were triaged to either a PCP management protocol with General Practitioners (GP), Allied-Health Professionals (AHP) or to a traditional in-person Fracture Clinic (FC) orthopedic review. Patients were followed for 6-months. Data were collected about epidemiology, complications, appropriate allocation, and injury type. RESULTS: A total of 1283 patients were referred over the study period, of which 267 were triaged to PCP management. ED referrals accounted for 62.5% of appropriate referrals to either clinic. Upper limb injuries were the most common conditions managed through the PCP. Patients managed by the PCP model of care experienced a 4.29% complication rate over the 6-month follow-up period. CONCLUSION: The PCP model of care is effective in managing criteria specific, low risk orthopedic injuries with a low rate of complications (4.29%) without direct orthopedic FC review. Use of a PCP reduces demand on hospital resources, and provides a safe, cost-effective alternative to a resource-restricted outpatient service.

Are Unnecessary Serial Radiographs Being Ordered in Children with Distal Radius Buckle Fractures?

Background. Torus or buckle distal radius fractures are common injuries in the pediatric population. By definition, they are stable and can be treated conservatively with a wrist splint or soft crepe bandage. Objective. The objective of this study was to evaluate the utility of serial radiographs in the clinical outcome of children with stable distal radius buckle fractures. Materials and Methods. A one-month retrospective analysis was undertaken at two major hospitals in Queensland-Logan and Redlands Hospital. Statistical analysis was performed to identify any relationships between serial radiographs and certain demographic parameters including fracture characteristics, age, sex, and limb side. Results. Of the 136 patients, 50% had more than one radiograph series taken. A total of 576 single radiographs and 251 radiograph series were taken. All fractures healed without complications and did not require active intervention. There was a statistically significant relationship (p = 0.0015) between fracture angulation and multiple radiographs series. A cost analysis revealed $55,890 per year could be saved by not performing serial radiographs. Conclusion. Serial radiographs did not appear to change the excellent clinical outcome for children with distal radius buckle fractures. There is a potential to reduce costs and prevent unnecessary ionizing radiation exposure to children.

Do all adult orthopaedic injuries seen in emergency departments need to attend fracture clinic? A Queensland multicentred review.

OBJECTIVE: Musculoskeletal injuries account for a significant proportion of ED presentations annually, with a large percentage being referred to the fracture clinic (FC). A literature review found that many referrals could be safely managed outside the traditional model of care. The present study aims to review all adult presentations to FCs at two Queensland metropolitan hospitals, finding low-risk injuries that can safely and appropriately be managed by their general practitioner (GP) or allied health professionals (AHPs), potentially affording significant savings to the health system. METHODS: A retrospective study at Logan and Redland Hospitals was undertaken, reviewing all adult patients (≥16 years) referred to FCs over an eight week period. Injuries were categorised into those requiring FC care supervised by an orthopaedic surgeon (fracture clinic pathway) and those that could be safely managed by GPs or AHPs, with the aid of evidence-based, protocol-driven guidelines known as the primary care pathway (PCP). RESULTS: A total of 1367 patients were referred to FC over the study period, of whom 546 (40%) were assessed as suitable candidates for PCP. Redland Hospital accounted for 65% of all PCP-suitable patients, whereas Logan Hospital accounted for 35%. Failure-to-attend rates were significantly higher (P < 0.001) in the PCP patients compared to other patients attending FCs. CONCLUSION: Adopting the PCP could potentially reduce fracture clinic referrals by 40%. Having a structured pathway has the potential to empower primary health professionals, which could result in a more streamlined process that aids in significant time and financial savings and maintains good patient satisfaction and outcomes.