Trauma Assessment Clinic: A virtual fracture clinic model that delivers on its PROMise!

BACKGROUND: The use of virtual fracture clinics across the United Kingdom and Ireland is growing and have been shown in an increasing number of studies to be safe, cost-effective and associated with good functional outcomes and patient satisfaction rates for certain fracture types. Initially pioneered at Glasgow Royal Infirmary, many centres have adopted similar templates, or variations of, and the overall aim of this study was to assess functional outcomes and injury recovery satisfaction rates of patients discharged directly following review in a specific virtual fracture clinic model known as the Trauma Assessment Clinic (TAC). METHODS: A prospective observational study was carried out of paediatric (aged <17 years) and adult (aged >17 years) patients, with the five most commonly observed fracture types, who were discharged directly following review at the TAC in a single hospital centre over a 12 month period from January to December 2018. Primary and secondary outcomes were assessed via telephone administered questionnaires and patient reported outcome measures (PROMs). RESULTS: A total of 198 patients were included in the study (n = 98 paediatric and n = 100 adult). Overall, 192 (97%) patients or parents/guardians of patients stated that they either strongly agreed (n = 148, 74.9%) or agreed (n = 44, 22.1%) that they were satisfied with their own or their child's recovery from their injury at a median follow-up of 9 months post direct discharge from the TAC. Adult patients had an EQ-5D-5L index median value of 1 (range 0-1), an EQ-VAS median of 87 (range 0-100), a QuickDASH median score of 0 (range 0-100) and a median LEFS of 80 (range 0-80). CONCLUSION: The virtual management of trauma patients via the TAC model is a safe and patient-centred approach to treating certain injuries and fracture patterns. This study reports excellent patient reported outcome measures and patient injury recovery satisfaction rates. The use of current available technology in tandem with up-to-date best clinical practice and guidelines play a central role in this novel care pathway.

Hip fracture care during Covid-19: a regional trauma centre's experience.

INTRODUCTION: The Covid-19 pandemic has caused worldwide upheaval from early 2020. Trauma and orthopaedic services are no different. A fundamentally important and significant portion of trauma services is the treatment of fragility fractures of the proximal femur, otherwise known as hip fractures. The hip fracture "Blue book Standards", the key performance indicators (KPIs) associated with appropriate hip fracture care are challenging during non-crisis times. We aim to review Blue Book compliance during the Covid-19 crisis and review outcomes of hip fractures, including Covid-19 infection rates. METHODS: We retrospectively reviewed IHFD data to collection demographic data, IHFD standards of care, 30-day mortality rates and complications between 23rd March and 20th May 2020 and 2019. Covid-19 rates in 2020 were also recorded. RESULTS: A total of 36 hip fractures were recorded in 2020, compared with 45 in 2019, resulting in a 20% reduction in presentations. Thirty-day mortality in hip fractures during the Covid-19 crisis was 8.3% compared with 2.2% in 2020. Covid-19 infection was statistically associated with 30-day mortality in the 2020 cohort. Statistically significant improvements in time-dependent KPIs (time to ward and time to surgery) were noted in the 2020 cohort. CONCLUSIONS: Despite improvements in hip fracture care KPIs, the Covid-19 crisis was associated with increased 30-day mortality in hip fracture patients. A positive Covid-19 swab was associated with higher mortality. These observations are of paramount importance to ensure adequate service planning and provision in the face of a potential "second wave" of Covid-19 infections leading into the winter months of 2020.

Remote Delivery of the Satellite Virtual Fracture Clinic - a Pilot Report of the First 500 Cases.

Presenting to the fracture clinic carries economic, social and societal consequences. The virtual fracture clinic (VFC) has proven to be a safe, patient-focused, cost-effective means of delivering trauma care, whilst reducing unnecessary clinic attendances. Within our institution, a Satellite VFC was established, so as to accommodate an offsite referring emergency department. The VFC database was accessed to identify the first 500 patients who were referred to the Satellite VFC. The decision made for each patient, the rate of returns to the clinic, and the rate of referrals requiring surgical intervention, following discussion at the VFC, ,were identified. A cost analysis and cost comparison was carried out between the Satellite VFC and the traditional "face to face" fracture clinic. There were 500 patients referred to the Satellite VFC within the study period. Of such patients, 288 (58%) were discharged directly following review at the Satellite VFC, 141 patients (28%) were referred to physiotherapy, 50 (10%) were redirected to the trauma clinic, 11 (2%) were sent directly to hand therapy, and 10 (2%) were sent to the ED review clinic. Patients who returned to the fracture clinic accounted for 3.8% of all referrals, and 0.2% of all referrals necessitated surgical intervention. This pilot initiative saved the Dublin Midlands Hospital Group over €50,000. The Satellite VFC is the first of its kind in the literature. Rural communities worldwide would benefit from remote orthopaedic management of suitable fracture patterns. The true value of the Satellite VFC process comes from its use of robust patient care pathways, rationalising resource use and minimising patient travel, whilst demonstrating reliable outcomes and promoting safety.

Upscaling Virtual Fracture Clinic Use Is a Safe, Effective Measure in the Delivery of Trauma Care.

The Virtual Fracture Clinic (VFC) has proved beneficial in reducing footfall within the hospital setting, improving the cost of running a trauma service, while satisfying the majority of referred patients. The mandatory upscaling of telemedicine use, specifically the enhancement of the VFC, amidst the COVID-19 pandemic, was analyzed. The remit of the VFC within our hospital was expanded so as to include all referred ambulatory trauma. Outcomes of our VFC review over the 6-week period following the introduction of the national Irish COVID-19-related restrictions were gathered. These outcomes were analyzed and compared with the corresponding 6-week period from 2019. A 77.2% increase in the VFC referral volume was observed throughout the COVID-19-related period. Patients were directly discharged in 55.2% of cases in 2020, as opposed to 47.8% in 2019 (P = 0.044); referred directly for physiotherapy in 32.9% of cases in 2020, as opposed to 28.9% in 2019 (P = 0.173); and referred to a fracture clinic in 11.9% of cases in 2020, as opposed to 23.7% in 2019 (P < 0.001). Also, 3.0% of patients returned to the clinic after discharge in 2020, compared with 4.4% in 2019 (P = 0.237); 4.5% of patients were referred for surgery in 2020, as opposed to 2.2% in 2019 (P = 0.105). The VFC proved to be an efficient tool in managing ambulatory trauma throughout the pandemic. Upscaling the VFC to include all ambulatory trauma is a safe, effective method in reducing clinic attendances and hospital footfall, whilst ensuring that high care standards are maintained. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Electronic referrals for virtual fracture clinic service using the National Integrated Medical Imaging System (NIMIS).

INTRODUCTION: Virtual fracture clinics (VFC) are now prevalent across many orthopaedic services in the UK and Ireland. The management of a variety of musculoskeletal injuries using the VFC model has been demonstrated to be safe, cost-effective and associated with high levels of patient satisfaction. Referrals were made available through the National Integrated Medical Imaging System (NIMIS). NIMIS allows for electronic movement of patient images throughout the Irish health service. METHODS: A retrospective review of 157 orthopaedic fracture referrals from a regional hospital was performed. The referrals were received during a 6-week period between May 2016 and June 2016. Each of these referrals was sent electronically. These referrals were reviewed each day by a consultant-led multi-disciplinary team. RESULTS: Thirty (93%) patients agreed or strongly agreed that they received adequate information in relation to the VFC when they attended the emergency department (ED). All patients except for one either agreed or strongly agreed that they were satisfied with their recovery (97%). Fifteen parents advised us that they would have had to take time off to attend fracture clinic with their child. Two patients attended their general practitioner (GP) or ED to seek further pain relief following their injuries. Only one patient reported a poor clinical outcome. Nine (28%) patients reported that they would have preferred a face-to-face appointment rather than being treated by the VFC. CONCLUSION: Virtual review of orthopaedic trauma patients results in satisfactory patient outcomes. Clinical outcomes were acceptable with minimal additional medical attention required following injury. Electronic transfer of information allows for the virtual service to operate from sites long distances from the primary orthopaedic centre. The NIMIS is a safe and confidential means of collaborating with other institutions and has huge potential in the areas of trauma care delivery, clinical conferencing and other image-based disciplines.