1787 ‘Skills and drills’: staff training sessions in the paediatric emergency department of a major trauma centre

Introduction Pelvic fractures are indicative of high-energy injuries and carry a significant morbidity and mortality and pelvic binders are used to stabilise them in both the pre-hospital and emergency department setting. Our unit gained major trauma centre status in April 2012 as part of a national programme to centralise trauma care and improve outcomes. This study investigated whether major trauma centre status led to a change in workload and clinical practice at our centre. Methods A retrospective analysis of all patients admitted with a pelvic fracture for the six-month periods before, after and at one-year following major trauma centre status designation. Data were retrospectively collected from electronic patient records and binder placement assessed using an accepted method. Patients with isolated pubic rami fractures were excluded. Results Overall, 6/16 (37.5%) pelvic fracture admissions had a binder placed pre-major trauma centre status, rising to 14/34 (41.2%) immediately post-major trauma centre status and 22/32 (68.8%) ( p = 0.025) one year later. Binders were positioned accurately in 4 patients (80%, one exclusion) pre-major trauma centre status, 12 (92.4%) post-major trauma centre status and 22 (100%) at one year. CT imaging was the initial imaging used in 9 (56.3%) patients pre-major trauma centre status, 29 (85.3%) ( p = 0.04) post-major trauma centre status and 27 (84.4%) at one year. Discussion Pelvic fracture admissions doubled following major trauma centre status. Computed tomography, as the initial imaging modality, increased significantly with major trauma centre status, likely a reflection of the increased resources made available with this change. Although binder application rates did not change immediately, a significant improvement was seen after one year, with binder accuracy increasing to 100%. This suggests that although changes in clinical practice often do not occur immediately, with the increased infrastructure and clinical exposure afforded through centralisation of trauma services, they will occur, ultimately leading to improvements in trauma patient care.

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Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre

BMJ Open Quality ◽

10.1136/bmjoq-2018-000550 ◽

2020 ◽

Vol 9 (1) ◽

pp. e000550

Author(s):

Alex Peter Magnussen ◽

Christopher Watura ◽

Nicola Torr ◽

Miny Walker ◽

Dimitri Amiras ◽

...

Keyword(s):

Emergency Department ◽

Major Trauma ◽

Delayed Diagnosis ◽

Trauma Centre ◽

Current Evidence ◽

Shoulder Injury ◽

Posterior Shoulder ◽

Major Trauma Centre ◽

Fracture Dislocations ◽

Axial View

BackgroundA high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that these missed injuries were causing serious consequences due to the need for surgical intervention and poor functional outcome.ObjectiveTo identify factors contributing to missed diagnosis and propose solutions.MethodsA local quality improvement report was performed investigating time from admission to diagnosis of simple posterior dislocations and fracture dislocations over a 5-year period. Factors contributing to a delayed diagnosis were analysed.ResultsThe findings supported current evidence: a posterior shoulder dislocation was more often missed if there was concurrent fracture of the proximal humerus. Anteroposterior and scapular Y view radiographs were not always diagnostic for dislocation. Axial views were more reliable in assessment of the congruency of the joint and were associated with early diagnosis and appropriate treatment of the injury.DiscussionAs a result of these findings a new protocol was produced by the orthopaedic and radiology departments and distributed to our emergency department practitioners and radiography team. The protocol included routine axial or modified trauma axial view radiographs for all patients attending the emergency department with a shoulder injury, low clinical suspicion for dislocation and a low threshold for CT scan. Reaudit and ongoing data collection have shown significant increase in axial view radiographs and improved diagnosis.

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