Is clinician reported practice in Western Australian emergency departments aligned with direct discharge pathway protocols for minor self-limiting fractures? A multi-centre professional survey.

OBJECTIVE: To determine ED clinician's current management for five common minor self-limiting fractures (MSLF) and evaluate practice against evidence-informed direct discharge pathway (DD) protocols. METHODS: A survey was provided to doctors, nurse practitioners and advanced scope physiotherapists working in seven metropolitan, public health EDs in Perth, Australia. The relative odds of ED location (e.g. which facility) and clinician level factors (e.g. country of initial training, years of ED experience, profession) on recommending care completely consistent with evidence informed direct discharge pathway protocols were estimated. RESULTS: Two hundred sixty-two clinicians completed the survey. There was variability in practice across all sites, with most reported care assessed at 60%-76% consistency with individual elements of DD care provision. Highest consistency was seen in lower limb immobilisation and DVT prophylaxis. Lowest consistency was seen in weight bearing advice, pain management and (boxer's) fracture reduction and immobilisation. There were very low levels of complete consistency, ranging from 9% (boxer's fracture) to 25% (radial head fracture). Two factors were associated with increased odds of completely consistent care: (i) clinician experience working in ED, with greater duration of practice associated with increased odds ratios (OR range, 1.6-3.3); and (ii) profession, where advanced scope physiotherapy was associated with increased odds ratios (OR range, 3.2-25.0). CONCLUSIONS: Survey results suggested system wide variation in ED fracture management practice and target areas for service improvement. Avenues for service improvement could include hospital wide agreed management plans for specific fractures and support for less experienced clinicians.

Prevalence of frailty and pain in hospitalised cancer patients: implications for older adult care.

A hospital-wide point prevalence study investigated frailty and pain in patients with a cancer-related admission. Modifiable factors associated with frailty in people with cancer were determined through logistic regression. Forty-eight patients (19%) with cancer-related admissions were 2.65 times more likely to be frail and 2.12 more likely to have moderate pain. Frailty and pain were highly prevalent among cancer-related admissions, reinforcing the need for frailty screening and importance of pain assessment for patients with cancer.

'I just need to find out if I had broken something or not.' A qualitative descriptive study into patient decisions to present to an Emergency Department with a simple fracture.

Background To investigate what factors contribute to a working age adult with a simple fracture seeking care in an Australian metropolitan Emergency Department (ED) Methods In this Qualitative Descriptive study, we interviewed ED patients with simple fractures including 5th metacarpal, 5th metatarsal, toe, radial head and clavicle fractures. Results We interviewed 30 patients aged 18-65. Two thirds of participants were aware they might have a minor injury. Many were well informed health consumers and convenience was the most important decision-making factor. Participants focussed on organising imaging, diagnosis and immobilisation. This sequence of care was often perceived as more complex and inefficient in primary care. ED was trusted and preferred to urgent primary care with an unknown doctor. Some patients defaulted to attending ED without considering alternatives due to poor health system knowledge or from escalating anxiety. Conclusions ED is safe, free and equipped to manage simple and complex injuries. Patients would attend primary care if comprehensive fracture management was easily accessible from a trusted clinician. To effectively divert simple fracture presentations from ED, primary care requires collocated imaging, imaging interpretation, orthopaedic expertise, and fracture management resources. Services need to operate 7 days a week and must have accessible 'urgent' appointments.