2021: BGS Autumn meeting platform presentation abstract
805 Clinical quality – clinical effectiveness
L Shaw; T Maggs; P Braude; D Shipway; S Srivastava; M Kelly
Introduction
Upper limb fractures are the second most common fracture requiring admission to hospital after hip fracture [Jennison, 2019]. At 1-year 20.5% have died, compared to 29.5% in hip fracture [Wiedl, 2021]. Local Problems: At North Bristol Trust most patients with upper limb fractures and a Clinical Frailty Score ≥ 5 are managed non-operatively on medical wards. Local service evaluation identified a long length of stay of 23 days. Case note review revealed: ∙ Delayed transfers of care (DTOCs) had been managed non-weight bearing in slings for 4-6 weeks. ∙ Non-weight bearing status resulted in DTOC due to declined access to social care and rehabilitation due to perceived health needs. ∙ A high rate of hospital-acquired complications and failure to rehabilitate. ∙ Breakdown in interdisciplinary communication and ownership across the pathway.
Methods
A multidisciplinary QI project was commenced. Using local data through business analytics, clinician and patient feedback, a new Trust guideline was developed for older people with frailty and upper limb fractures. Data collected determined average length of stay before and after implementation of the service change. A standard process control chart was created monitoring the effect of the changes in the pathway. The multidisciplinary team met regularly to make alterations during implementation. The resulting intervention included: ∙ Removal of functional restrictions; allow free use of limb as comfort permits. ∙ Simplified slings and minimised light weight casts. ∙ Proactive integration of orthopaedic plan into CGA documentation. ∙ Proactive interdisciplinary communication across pathways. ∙ Patient information leaflets.
Results
Pre-intervention average length of stay was 23 days. Post-intervention was 14 days.
Conclusion
Proactive, structured management of upper limb fractures in people with frailty is associated with significant reduction in acute hospital length of stay. Next steps include a business case for a frailty trauma specialist therapist embedded into medicine.
Addendum 2023
Additional thanks for ongoing support from Tahid Alam, Alasdair Bott, Andrew Riddick, Frances Verey, Lynn Hutchings, Nathanael Ahearn