Evaluating the potential for cone beam CT to improve the suspected scaphoid fracture pathway: InSPECTED: A single-centre feasibility study.

BACKGROUND: The suspected scaphoid fracture remains a diagnostic conundrum with over-treatment a common risk-averse strategy. Cross-sectional imaging remains the gold standard with MRI recommended but CT used by some because of easier access or limited MRI availability. The aim of this feasibility study was to evaluate whether cone beam computed tomography (CBCT) could support early diagnosis, or exclusion, of scaphoid fractures. METHODS: Patients with a suspected scaphoid were recruited fracture between March and July 2020. All underwent a 4-view X-ray. If this examination was normal, they were immediately referred for a CBCT scan of the wrist. Those with a normal scan were discharged to research follow-up at 2 and 6-weeks. RESULTS: 68 participants were recruited, 55 had a normal or equivocal X-ray and underwent CBCT. Nine additional radiocarpal fractures (16.2%) were demonstrated on CBCT, the remainder were discharged to research follow-up. Based on the 2-week and 6-week follow up three patients (4.4%) were referred for MRI to investigate persistent symptoms with no bony injuries identified. CONCLUSIONS: CBCT scans enabled a rapid pathway for the diagnosis or exclusion of scaphoid fractures, identifying other fractures and facilitating early treatment. The rapid pathway also enabled those with no bony injury to start rehabilitation, suggesting that patients can be safely discharged with safety-net advice following a CBCT scan.

Improving accessibility to outpatient clinics for adults with suspected seizures from the emergency department: A quality improvement project.

INTRODUCTION: Seizure-related presentations or suspected seizures, (i.e. epileptic seizures, PNES, cardiogenic and acute symptomatic seizures) comprise 1.9% of the entire caseload for the Mid Yorkshire Hospitals NHS Trust,United Kingdom in 2020. Patients with suspected seizures who are diagnosed in the emergency department (ED) require appropriate immediate management and a robust follow-up pathway. National audits conducted in the United Kingdom (UK) (NASH 1, 2 and 3) have highlighted the wide intersite variability in care provided towards patients with suspected seizures and the need for better organised and accessible care. This quality improvement (QI) project aimed to improve patient safety by ensuring a streamlined referral process from the ED and subsequently reducing the risk of loss to follow-up. METHODS: This QI project used the Institute of Healthcare Improvement (IHI) model for improvement to drive change and Lewin's change management model to guide stakeholder interaction. The project started in 2018 and employed three distinct Plan-Do-Study-Act (PDSA) cycles to drive improvement. The outcome measure was waiting time to be seen at the first seizure clinic from ED discharge. RESULTS: The median waiting time pre-QI was 65.0 days (range 37 days to 163 days), and the median waiting time post-intervention was 31.0 days (range 8 days to 175 days). Using log-transformed data, the reduction in mean daily waiting time following the introduction of the intervention was statistically significant at the 5% significance level (t30.9 = 9.42; p<0.001). Process measures were met with 100% compliance. Post-intervention period, there was a 4.1% (10/243) rejection rate of referrals from the ED by the neurology services. However, the project failed to meet NICE's recommendation of a waiting time of 14 days to be seen in the first seizure clinic. DISCUSSION AND CONCLUSION: This QI project has made significant improvements in the management of patients presenting with suspected seizures to the ED's at MYHT. Additionally, the project has provided opportunities for development of new protocols, cost savings and patient advice leaflets. Teamwork and organisational skills played a crucial part in the outcome of this QI project. The use of a theory-driven change management strategy was key to managing a large organisation with multiple stakeholders.