1. Audit of fracture clinic services N. Picardo-Green, S. Jaufuraully, U. Ashraf, A. Carlos February 2015

2. BOAST guidelines BOAST 1 -Patients sustaining a fragility hip fracture BOAST 2 - Spinal clearance in the trauma patient BOAST 3 - Pelvic and acetabular fracture management BOAST 4 - The management of severe open lower limb fractures BOAST 5 - Peripheral nerve injury BOAST 6 - Management of arterial injuries BOAST 7 - Fracture clinic services BOAST 8 - The management of traumatic spinal cord injury BOAST 9 - Fracture liaison services BOAST 10 - Diagnosis and management of compartment syndrome of the limbs BOAST 11 - Supracondylar fractures in the humerus in children

3. Aim To evaluate the quality of our fracture clinic service compared to the BOAST guidelines If required, to make recommendations for improvements to the service

4. Prospective review of patients from 30 fracture clinic sessions over 4 months- 1.10.14 -6.2.15. Patients were under care of 5 different consultants; AC, MP, SDB, SM, RG Method

5. 1. Following acute traumatic orthopaedic injury, patients should be seen in new fracture clinic within 72 hours of presentation with the injury. 63 new referrals to fracture clinic. Mean time to first appointment 4.81 days (1 – 17) 27 patients were seen in clinic within 72 hours from A+E presentation (43.5%)

6. All clinics had both a consultant and registrar present. No junior doctors or extended scope practitioners were seeing patients 2. Fracture clinics must be consultant-led clinics. All new patients must be seen by senior orthopaedic staff or by supervised juniors.

7. Examined casenotes of 23 Patients returning to clinic after a first initial appointment to look at previous letter to GP 2 letters did not state the management plan Therefore 21/23 patients (91.3%) had comprehensive letters sent to the GP after first appointment. None of the patients received copies of their GP letters. 3. All new fracture clinic appointments must lead to a management plan, including any clinical interventions; which is communicated to GP and patient in writing

8. All clinics had plaster room and radiographer facilities. 4. Plaster room facilities and the ability to perform plain radiographs must be available during all fracture clinics

9. 5. Should patients require further imaging- eg.US, CT or MRI, this should be performed and reviewed within appropriate time scale. Local referral and reporting protocols should be in place to avoid delays. 22 patients required further imaging; 10 MRI scans, 9 CT scans, 3 US scans MRI scan Mean time from request to scan: 20.1 days (1-35 days) Mean time from scan to report: 7.73 days ( 0-23) Mean time from request to review with imaging: 46.5 days ( 6-85)

10. CT scans Mean time from request to scan – 4.93 days 4 out of 9 scans done on same day Mean time from scan to report – 2.92 days Mean time from request to review in clinic = 17.2 days US scans Mean time from request to scan – 6.3 days Mean time from request to review in clinic = 21.7 days

11. All patients can be referred to physiotherapy and occupational therapy via a referral form which the patient takes to the therapies department 6. In fracture clinics, there should be the ability to make direct referrals to physiotherapy and occupational therapy departments

12. All 73 patients were under a named consultant 29 out of 32 patients (90.6%) had up to date medical records available for the follow-up appt All patients had imaging available on the system 7. Patients seen in follow-up fracture clinics should be under care of named consultant with all images and medical records available.

13. Patients are not being routinely referred to falls prevention clinic A falls prevention clinic exists at East ham day centre which patients can be referred to Currently no fragility fracture service 8. Fragility fracture and falls prevention ( Fracture Liaison services) should be fully integrated into fracture clinics allowing screening of all patients and onward referral where appropriate

14. Currently this does not exist. Once discharged, patients must re-present back to A+E or be referred back via the GP. 9. There must be a system in place that allows patients rapid access back to the fracture clinic if they have problems related to their initial presenting injury

15. We currently do not give out any patient information booklets in clinic. Physiotherapy department do give out exercise sheets 10. For common injuries, patient information booklets and exercise sheets should be provided.

16. All patients in our study who had casts, received cast instructions from the plaster technicians 10 cont.. When the treatment involves cast splintage, written care instructions should be provided

17. No patients in our study were identified as having a regional pain syndrome. Patients can be referred to the pain team via a dictated letter. 11. Complex regional pain syndrome should be identified early and there should be an agreed protocol for analgesia and therapy within the local pain clinic.

18. 10 patients in our study needed operative intervention. All seen by SHO in clinic, clerked and preassessed All were discussed in trauma meeting and operated on within sensible timescale (<2 weeks) 12. Patients seen in fracture clinic who require operative intervention should have a planned admission for their treatment within a maximum time period set by the surgeon that will not compromise patient safety or outcome

19. Recommendations Inform A+E that all new patients need to be seen within 72 hours All clinic doctors to handwrite and dictate a management plan in the notes Patient to receive a copy of their clinic letter Patients to inform POD when they have had their investigation so they can be seen in next available clinic At start of clinic, staff to check through notes to make sure scan results are available

20. Recommendations Distribute falls clinic referral forms to fracture clinic and inform nursing staff

21. Set up a fragility fracture service Then audit it according to the new BOAST 9 guidelines! Recommendations

22. Allow patients to call POD after discharge to get rapid access back to fracture clinic if any problems ( phone number on clinic letter) Develop patient information booklets for clinic Re-audit in 4 months time to see if these recommendations have improved the service. Recommendations

23. Discussion

24. Thank you