VIRTUAL CLINICS
DEVELOPING CONSENSUS
- protocols, guidelines, competence
Lech Rymaszewski
Consultant Orthopaedic Surgeon
Glasgow Royal Infirmary
PRINCIPLES
• customizing care literally to the level of the individual
- asking, “How would you like this done?”
•
equipping every pt for self-care as much as each wants
- “Nothing about me without me.”
DON BERWICK
TRADITIONAL
FRACTURE (#) CLINIC
All # patients are routinely seen
- within a few days after E/D visit
WHY ?
Many discharged at first visit with no change Rx
GRI – 2011/12
ED
7,056
> 1,500
TRAUMA
OPERATIONS
NEW # CLINIC PTS
THE PROBLEM ?
Traditional fracture clinics
- not fit for purpose (for the patient)
V busy
ie No time
- Unwarranted variation
- Junior - poor supervision / training
- Unnecessary review / overtreatment of simple injuries
- Attendance often - wrong time / wrong clinic
- Poor treatment for the rarer, more complex pts
The Problem…
GRI ED
referrals
- fracture
clinic
2011/12
The Solution…
ED referrals to Orthopaedics
and Fracture Clininc Appointments
Number of ED referrals per week
or Fracture Clininc Appointments
250
250
200
200
150
150
100
100
50
50
00
Oct
Oct Nov
Nov Dec
Dec Jan
Jan Feb
Feb Mar Apr May Jun Jul Aug Sep Oct
GRI ED referrals
- Fracture clinic
2011/12
GRI ED referrals
- Virtual clinic
2012/13
GRI Fracture Clinic
Face-to-face Appts
2012/13
GRI FRACTURE CLINIC
CLINICIAN-LED MODERNISATION
Patients Attending Fracture Clinic Appointments
Traditional Fracture
Clinic
Re-designed Fracture
Clinic System
80
7,098
60
40
2086
C
o
Su ns
Fr b ul
ac -s ta
tu pe nt
re ci Le
C alt d
lin y
ic
ic
545
0
N
Fr urs
ac e
tu Le
re d
C
lin
20
C
Fr on
ac su
tu lta
re nt
C Le
lin d
ic
Percentage of Patients
100
Mid-Oct 2011 – Mid-Oct 2012
http://www.fractureclinicredesign.org
GENERIC PROBLEMS OF MEDICINE
? BEST PRACTICE
• Everyone wants to do what is best for patients
• Medical culture of divergence in opinion
• BUT - not everyone can be right
• Unwarranted variation impacts negatively on
overall clinical care (potential overtreatment)
• Costs of poor clinical decisions, both diagnostic and
treatment, borne by the patient and society
“ If maths was taught like medicine”
REQUIREMENTS
- MODERNISATION
INVESTMENT
PERMISSION
PROTOCOLS = CONSENSUS
– all local ED and Ortho Consultants
A/E – ORTHOPAEDIC INTERFACE
HOW did we get consensus?
– Discussions with ED - what did they need ?
– NO money on the table
Protocols
- barn door admissions = direct admit
- definitive specialist opinion
> avoid 4h target breaches
Sustained reduction of ED 4 hour breach rate
- fall
from an av of 26 per month to 10 per month
30
25
20
15
10
5
3
-S
Ap
r1
3
-M
12
O
ct
ep
t1
ar
13
2
ep
t1
-S
Ap
r1
2
-M
11
O
ct
Ap
r1
1
-S
ep
t1
ar
12
1
0
CONSENSUS
– all local ED and Ortho Consultants
PATIENT INFORMATION LEAFLETS
•
•
•
•
•
•
Torus #’s
Radial head/neck #’s (fat pad signs)
Neck of 5th metacarpal #’s
Mallet fingers
5th metatarsal #’s
Child’s clavicle #
Seen ED / MIU - standardised info provided
- no routine ortho follow-up
Glasgow Royal Infirmary
Emergency Department
Torus “Buckle” Fractures
Discharge Advice
Your child has suffered a ‘Torus’ or ‘Buckle’ fracture
(Break) of their wrist.
This is the most common type of fracture in young
children.
Young bone is still soft and very flexible. For this
reason, instead of breaking all the way through, the
bone has a small crack or kink on one side only.
This type of injury heals very well in a simple and
easy to apply splint rather than a cumbersome
plaster.
Most of these injuries heal perfectly well if the splint is
worn for 3 weeks.
min 2 more visits
after A/E
It is important to give your child appropriate doses of
paracetamol or ibuprofen to help with the pain as it
will still be sore for a short period even after the
application of the splint.
The splint can be removed for bathing/showering
without risk to the fracture.
If after 3 weeks the wrist is a little sore and stiff after
being used, the splint can be reapplied for comfort.
Do this for short periods only as it is best to try to
start gently using the arm as normally as possible
from now on. Use a simple painkiller such as
paracetamol or ibuprofen if required.
However - if after 3 weeks the wrist still seems very
sore, swollen, or the child is not willing to use it
contact the Fracture clinic to arrange follow-up.
If the child removes the splint before the 3 weeks
and appears to be comfortable and can use the arm
freely then there is no reason to force them to wear
the splint for the full 3 weeks.
It is best to avoid sports and rough and tumble play
when wearing the splint and for the week or two after
its removal.
Should you have any worries or concerns
following discharge from hospital, please
contact either the
1) Fracture Clinic: 0141 211 5034
(8.30am until 4.30pm, Monday to Friday)
or
2) Emergency Department: 0141 211 4344
(outwith these times)
£10.62p
… best wishes to all the
“experts”
NATURAL HISTORY
- INJURIES IN MAMMALS
GRI - FRACTURE CLINIC
Oct 2011 – Oct 2012
E/D
c 150 #’s
/week
Fracture
Virtual Clinic
(Nurse-led)
Clinic
Consultant review
(100%)
PROTOCOLS
LEAFLETS
62%
38%
no follow-up
c50-60
pts/week
POTENTIAL SOLUTIONS
- VIRTUAL CLINICS
Face-to-face Ortho consultation only if required
but “open-door” policy crucial
VIRTUAL CLINIC
• Consultant review daily
- ED electronic record + PACS
< 2 mins / pt
• Diagnosis / plan recorded
•
Snr Nurse - Every pt phoned same day
- Virtual discharge or OP appt
- Letter / copy to GP
- Agreed plan > database
GRI - FRACTURE CLINIC
Oct 2011 – Sept 2012
E/D
62%
c 150 #’s
/week
Virtual Clinic
Consultant review
(100%)
PROTOCOLS
LEAFLETS
Fracture
Sub-specialty
(Nurse-led)
# (30%)
Clinic
& nurse-led
c50-60
clinics
(10.5%)
38%
no follow-up
PHONE
LETTER
pts/week
21.5%
no follow-up
OP CLINICS
Complex
clinical
problems
Teaching
Training
TIME
Audit
research
Management
Admin
“The key to freeing time is to
challenge / change clinical practice”
Des Spence BMJ
PRINCIPLES
- a bottom-up process
•
Start with patient - clinically-driven vision
– clear, patient-focused aims
•
Grass-root consensus
– all clinical staff agree to support the pilot project
•
Real-time database > accountability
allows trouble shooting + audit cycles > credibility and trust
•
Informal communication crucial
Have we made things better?
AUDIT OF PATIENT SATISFACTION
AND OUTCOME
Clinical Audit
Have we
made things
better?
How much are
we doing?
Are we doing
things
correctly?
Clinical
Audit
Data
(Good Quality)
Are we
achieving
appropriate
standards?
Are we safe?
Real-time Database
• Instant clinical record
– Electronic tracking of every patient
– Easy access to clinical details if patient calls help line
• Facilitates clinical audit
• Provides credibility and confidence
ou
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lde
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% of all Dischaged Fracutres
•
Cl
AIM - To audit management/outcome
All non-operative limb # patients GRI E/D /Stobhill MIU
Mid-Oct 2011 to mid-October 2012 - c 7,000 pts
Comparing each injury type before and after redesign
EDIS October '11 - October '12: Discharged Fracture
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Glasgow Royal Infirmary
Emergency Department
Discharge advice following attendance
with a Radial Head/Neck Fracture
-You have a very small break in the radial head or
neck - one of the bones in your elbow.
-These fractures almost always heal well with time
and use - no specific treatment is required and
therefore routine follow-up is unnecessary.
-A sling will hold your elbow in a comfortable
position for a few days.
-You should wean yourself off this as your pain
settles and aim to remove the sling completely as
soon as you feel able.
-You may initially require regular pain killers as it is
important to keep gently moving the elbow and
gradually resume daily activities within the limits of
discomfort. This will prevent stiffness and ensure the
quickest return to normal function
-Forcible stretching is unnecessary, and is likely to
cause pain and delay your recovery.
- Symptoms are usually minor, but may take up to 36 weeks to settle.
- There may be slightly reduced movement at the elbow,
especially on straightening it, but this is unlikely to affect
your function.
Should you have any worries or concerns
following discharge from hospital, please
contact either the
1) Fracture Clinic: 0141 211 5034
(8.30am until 4.30pm, Monday to Friday)
or
2) Emergency Department: 0141 211 4344
(outwith these times)
Radial Head Fractures (n=202)
QUESTIONNAIRE OUTCOMES
• 156 patients (157 injuries) out of the 202 (76.4%)
responded to questionnaires by mail or phone
• Satisfaction with the services provided:
Satisfaction
Number of patients (Percentage)
Injury outcome
92%
A&E leaflets
95%
Telephone helpline
93% (n=15)
5TH METATARSAL FRACTURES
5th Metatarsal Fractures (n=340 / year)
100
90
Percentage of patients
80
70
Emergency
Department
Virtual Clinic
Fracture
Clinic
60
50
40
30
20
10
0
Total Number of
Cases (n=145)
Discharged by ED Reviewed in Virtual
Clinic
Discharged from
Virtual Clinic
Reviewed in
Fracture Clinic
Change in Fracture Clinic Utilisation for 5th
Metatarsal Fractures
100
Percentage of patients
Attending Appointment
90
80
70
60
50
Pre-change
40
Post-change
30
20
10
0
1st
2nd
3rd
Fracture Clinic Appointments Attended
4+
Change in treatment modality for
5th Metatarsal Fractures
P = <0.0001
70
% Patients
60
Pre-change
50
Post-change
40
30
20
10
0
Plaster
Velcro Boot
Elastic/Crepe
Bandage
Buddy Strapping
Nil Required
Operative
Intervention
5th Metatarsal Fracture - Patient
Satisfaction Audit
• n=179
Factor
% Very Satisfied
or Satisfied
% Neither
% Dissatisfied or
very dissatisfied
Injury outcome
82%
4%
14%
Service /
Information
provided
79%
6%
15%
Satisfaction with Injury Outcome
Overall Satisfaction with Injury Outcome
– All Injuries n=1022
100
90
80
% of patients
70
60
50
40
30
20
10
0
Very Satisfied /satisfied
Neither
Disatisfied / very
disatisfied
Satisfaction with Service / Information
Overall Satisfaction with Service - All Injuries
n=1022
100
90
% of patients
80
70
60
50
40
30
20
10
0
Very Satisfied /satisfied
Neither
Disatisfied / very
disatisfied
FRACTURE CLINIC REDESIGN
- ACHIEVEMENTS
• Better patient care
- Empowered to self-care / shared decision making / “open-door”
- Much better for “hard to reach groups” eg pts with dementia
• Better value
- Reduction in unnecessary patient attendances
• Consultant time freed up
– Allowing focus on complex patients / training junior doctors
MEDICS
SAFETY ?
MANAGERS
DEPT of
HEALTH
£?
INCOMPATIBLE
DATASETS ?
Here is Edward Bear, coming
downstairs now, bump, bump,
bump on the back of his head,
behind Christopher Robin.
It is, as far as he knows, the only
way of coming downstairs,
but sometimes he feels that there
really is another way, if only he
could stop that bumping for a
moment and think of it.