Prospective Validation of the Calgary Kids' Hand Rule: A Clinical Prediction Rule for Pediatric Hand Fracture Triage.

Introduction: Pediatric hand fractures are common and routinely referred to surgeons, yet most heal well without surgical intervention. This trend inspired the development of the Calgary Kids' Hand Rule (CKHR), a clinical prediction rule designed to predict "complex" fractures that require surgical referral. The CKHR was adapted into a checklist whereby the presence of any 1 of 6 clinically or radiologically identifiable fracture characteristics predicts a complex fracture. The aim of this study was to assess the accuracy of the CKHR in a prospective sample of children with hand fractures. Methods: Physicians were asked to complete the CKHR checklist when referring pediatric patients (< 18 years) to hand surgeons at a Canadian pediatric hospital (April 2019-September 2020). Completed checklists represented predicted outcomes and were compared to observed outcomes (determined via chart review). Predictive accuracy (primary outcome) was evaluated based on sensitivity and specificity. Secondary outcomes were interrater reliability between referring physicians and surgeons, and survey assessment of CKHR user satisfaction. Results: In total 365 fractures were included, with only 16 requiring surgical intervention. Overall performance of the CKHR was good with 84% sensitivity and 71% specificity. Percent agreement between referring physicians and surgeons ranged from 84.1% to 96.3% on individual predictors, with 78.1% agreement on the presence of any predictors. Survey results showed general user satisfaction but also identified areas for improvement. Conclusion: This study posits the CKHR as an accurate and clinically useful prediction rule and highlights the importance of education for its effective use and eventual scale and spread.

Introduction : Les fractures pédiatriques de la main sont fréquentes et régulièrement orientées vers les chirurgiens. Néanmoins, la plupart guérissent bien sans intervention chirurgicale. Cette tendance a inspiré l'élaboration de la Calgary Kids' Hand Rule (CKHR), un outil de prédiction clinique conçu pour prédire quelles fractures « complexes ¼ doivent être orientées vers un chirurgien. La CKHR a été adaptée sous forme de liste de contrôle où la présence de l'une quelconque de six caractéristiques cliniques ou radiologiques identifiables de fracture permet de conclure à une fracture complexe. Le but de cette étude était d'évaluer l'exactitude de la CKHR dans un échantillon prospectif d'enfants ayant une fracture de la main. Methodes : Les médecins ont été invités à remplir la liste de contrôle CKHR quand ils orientaient des patients pédiatriques (< 18 ans) à des chirurgiens de la main dans un hôpital pédiatrique canadien (avril 2019 à septembre 2020). Les listes de contrôle remplies représentaient les aboutissements prédits et elles ont été comparées aux aboutissements observés (établis par une revue des dossiers). La précision de la prédiction (critère d'évaluation principal) a été évaluée en termes de sensibilité et de spécificité. Les critères d'évaluation secondaires étaient la fiabilité inter-évaluateurs entre médecins référents et chirurgiens et l'évaluation de la satisfaction de l'utilisateur de la CKHR dans le cadre d'une enquête. Résultats : Au total, 365 fractures ont été incluses; seulement 16 d'entre elles ont nécessité une intervention chirurgicale. La performance globale de la CKHR a été bonne avec une sensibilité de 84% et une spécificité de 71%. Le pourcentage de concordance entre médecins référents et chirurgiens était compris entre 84,1% et 96,3% selon les éléments prédictifs individuels, avec une concordance de 78,1% sur la présence de l'un quelconque des éléments prédictifs. Les résultats de l'enquête ont montré une satisfaction globale des utilisateurs, mais ont aussi mis en évidence des domaines à améliorer. Conclusion : Cette étude assoit la CKHR comme règle de prédiction exacte et cliniquement utile; elle souligne aussi l'importance de l'éducation pour son utilisation efficace et une éventuelle plus grande diffusion.

Strategies Addressing Barriers to the Implementation of a Pediatric Hand Fracture Care Pathway.

We recently highlighted shortcomings in the care of pediatric hand fractures in our local context. The Calgary Kids' Hand Rule (CKHR) was developed to predict hand fractures that require referral to a hand surgeon. The aims of this study were to identify barriers to a new care pathway for pediatric hand fractures, based on the CKHR and to generate tailored strategies to support its implementation. Methods: We performed a conventional content analysis of transcripts from four focus groups (parents, emergency/urgent care physicians, plastic surgeons, and hand therapists) to identify relevant concepts (facilitators and barriers). These concepts were mapped to two frameworks. Generic strategies to address the barriers were identified, and further discussions with key stakeholders resulted in tailored strategies for implementation. Results: Five facilitators to implementation of a CKHR-based hand fracture care pathway included established rapport between hand therapists and surgeons, potential for more streamlined care, agreement on identifying another care provider, positive perceptions of hand therapist expertise, and opportunity for patient education. Two individual barriers were concern for poor outcomes and trust. Three systemic barriers were awareness and usability, referral process, and cost and resources. Strategies to address these barriers include pilot-testing of the new care pathway, ensuring closed loop communication, multiple knowledge translation activities, integration of CKHR into the clinical information system, coordinating care and development of parent handouts. Conclusion: Mapping barriers to established implementation frameworks has informed tailored implementation strategies, bringing us one step closer to successfully implementing a new pediatric hand fracture pathway.

Healthcare Providers and Parents Highlight Challenges of Pediatric Hand Fracture Care.

Pediatric hand fractures are common, and many are referred to hand surgeons despite less than 10% of referrals requiring surgical intervention. We explored healthcare provider and parent perspectives to inform a new care pathway. Methods: We conducted a qualitative descriptive study using virtual focus groups. Emergency physicians, hand therapists, plastic surgeons, and parents of children treated for hand fractures were asked to discuss their experiences with existing care for pediatric hand fractures, and perceptions surrounding the implementation of a new care pathway. Data were analyzed using directed content analysis with an inductive approach. Results: Four focus groups included 24 participants: 18 healthcare providers and six parents. Four themes were identified: educating parents throughout the hand fracture journey, streamlining the referral process for simple hand fractures, identifying the most appropriate care provider for simple hand fractures, and maintaining strong multidisciplinary connections to facilitate care. Participants described gaps in the current care, including a need to better inform parents, and elucidated the motivations behind emergency medicine physicians' existing referral practices. Participants also generally agreed on the need for more efficient management of simple hand fractures that do not require surgical care. Healthcare providers believed the strong preexisting relationship between surgeons and hand therapists would facilitate the changes brought forward by the new care pathway. Conclusion: These findings highlighted shortcomings of existing care for pediatric hand fractures and will inform the co-development and implementation of a new care pathway to enable more efficient management while preserving good patient outcomes.