Fracture clinic redesign: improving standards in patient care and interprofessional education.

INTRODUCTION: Current fracture clinic models, especially with the advent of reductions in junior doctors' hours, may limit outpatient trainee education and patient care. We have designed a new fracture clinic model, involving an initial consultant-led case review focused on patient management and trainee education. METHODS: Prospective outcomes for all new patients attending the redesigned fracture clinic over a 3-week period in 2010 (n = 240) were compared with a historical cohort from the same period in 2009 (n = 296). The primary outcome measure was the proportion of patients with direct consultant input. Secondary outcome measures included patient discharge rates, return rates, use of the nurse-led fracture clinic and the incidence of adverse event reporting. Trainees attending each clinic completed a five-point Likert questionnaire assessing the adequacy of education, support, staff morale and standards of patient care, before and after introduction of the clinic redesign. Using a separate Likert questionnaire, emergency room (ER) staff were evaluated to determine the impact of the new style clinic on their education, daily practice and interprofessional relations. Adverse events were gathered from the 'incident record 1' (IR1) reporting system. RESULTS: The percentage of cases given consultant input increased significantly from 33% in 2009 to 84% in 2010 (p <0.0001), while the proportion of patients requiring physical review by a consultant fell by 21% (p <0.0001). Return rates were reduced by 14% (p = 0.013) and use of the nurse-led fracture clinic improved by 10% (p = 0.0028). There was a median improvement in trainee perception of education from 2 (interquartile range 1.25-2.75) to 5 (4.25-5, p = 0.011), senior support from 2 (2-3) to 5 (4-5, p = 0.017) and patient care from 3 (3-4) to 5 (4-5, p = 0.015). ER staff found the new style clinic was educational, practice changing and improved interprofessional relations, but that it did not interfere with ER duties. The incidence of adverse incidents reported fell from 8 per year to 0 per year after the introduction of the new style clinic. CONCLUSIONS: Our model of fracture-clinic redesign has significantly enhanced consultant input into patient care without additional funding. In addition, we have demonstrated increased service efficiency and significant improvements in staff support, morale and education. In the face of current economic and training challenges, we recommend this new model as a tool that will enhance patient and trainee experience.

Improving patient flow: the impact of consultant work pattern on trauma ward efficiency.

OBJECTIVE: To determine the effect on trauma ward efficiency of altering consultant shift patterns. DESIGN: Outcome measures were compared for neck of femur fracture patients before and after the consultant rota changed (Feb 2007) from a single day on-call to a full week on-call. SETTING: Patients admitted to Stirling Royal Infirmary with neck of femur fractures. PARTICIPANTS: 359 patients were identified from the Scottish Hip Fracture Audit database for the year preceding the rota change and 379 after. MAIN OUTCOME MEASURES: Time to surgery for medically fit patients and overall length of stay on the acute trauma ward. RESULTS: Patients were operated on quicker after the rota change (Mann-Whitney U-test, before v after: z=2.67, p=0.008), with a greater percentage being operated within the first 24h (60% before v 78% after; Chi-square test, before v after: χ(1)(2)=19.9, p<0.001). Overall, the length of stay on the acute trauma ward was reduced (Chi-square test, before v after by intervals: χ(3)(2)=21.1, p<0.001). The proportion of patients discharged from the ward within one week increased from 47% before the rota change to 63% after. CONCLUSION: By applying the industry-based methods of 'process management', we have shown that a simple intervention (alteration of consultant shift patterns) has had a significant impact in reducing time to theatre for neck of femur trauma patients and reducing the length of stay on the acute trauma ward. Thus, the 'patient flow' has been made more efficient making more acute trauma beds available for new admissions.

Modic vertebral body changes: the natural history as assessed by consecutive magnetic resonance imaging.

STUDY DESIGN: Changes in the vertebral body adjacent to the end plate may be associated with degenerative disc disease. These changes can be separated on magnetic resonance imaging (MRI) and have been described by Modic. It is assumed that these end plate changes represent a process that is progressive. OBJECTIVE: We have retrospectively reviewed patients who had sequential MRI of the lumbar spine to investigate the natural history of Modic vertebral body MRI changes. SUMMARY OF BACKGROUND DATA: Of 36 end plates with Modic type 1 changes in a first MRI, 18 remained the same, 13 progressed to Modic type 2 change, 3 progressed to Modic type 3 changes, and 2 end plates were found to be normal (type 0) on a subsequent MRI. Of the 22 end plates initially reported as Modic type 2 in a first MRI, 18 remained unchanged, none converted to Modic type 3, and 4 converted from Modic type 2 to Modic type 1 on a subsequent MRI. METHODS: Magnetic resonance (MR) images of the lumbar spine of 49 subjects were assessed by a senior spinal surgeon. The lumbar vertebral body adjacent to the end plate was classified by using the Modic system from L1 to S1 inclusive. RESULTS: Of the 36 end plates with Modic 1 changes in the first data set, 18 remained the same; 13 progressed to Modic 2; 3 progressed to Modic 3 changes, and, interestingly, 2 end plates were found to be normal on the repeat scan. Of the 22 end plates initially reported as Modic 2, 18 remained unchanged; none converted to Modic 3 and 4 converted back from Modic 2 to Modic 1. CONCLUSION: Our findings reflect the dynamic nature of pathological changes in the spine and have demonstrated that Modic changes are reversible. They also raise further doubt that these MRI changes should be used as an indicator of clinical symptoms or of surgical outcome.