Virtual Fracture Clinic: A pandemic-ready tool for improving the efficiency of fracture clinic

Background: The traditional model of care of the Orthopaedic Fracture Clinic (OFC) is labour intensive, expensive, has poor satisfaction rates, and often has minimal impact on management and outcomes of patients with minor injuries. Our aim was to implement a Virtual Fracture Clinic (VFC) for the management of minor injuries that is safe, reduces OFC clinic workload and reduces the OFC failure to attend (FTA) rate. Methods: This study was a retrospective longitudinal audit of OFC workload before (January 2012 -February 2017) and after (March 2017 – December 2019) implementation of the VFC. It was performed in an urban district general hospital in South East Queensland, Australia. The primary outcome measures included attendances per timepoint (month). Results: Overall, we observed a significant reduction in total number of patients from 1,055 (IQR 104.5) to 831 (IQR: 103) per month) coming through the OFC following the introduction of the VFC (F = 21.9; df=1; p <0.0001). The failure to attend rate was reduced by 44% from 271 (IQR: 127.3) to 151 (IQR: 72.8) (F=4.0; df=1; p = 0.047). Conclusion: The VFC implementation was successful in improving efficiency and reducing the current OFC workload, as well as reducing FTA rate. Reduction in clinic workload allows more time to be spent with complex patients, prevents clinic backlogs and overbooking, and crowding of waiting rooms. In the midst of a global pandemic that is spread by close contact, virtual clinics seem the way of the future to treat patients whilst minimising risk of COVID-19 spread.

Virtual fracture clinic reduces patient X-ray volume for common wrist and ankle fractures

Background Virtual fracture clinics (VFC) have been widely adopted worldwide as part of the changes in healthcare delivery during the COVID-19 pandemic. They have been shown to be a safe and effective method of delivering trauma care for injuries which do not require immediate intervention or specialist management, whilst maintaining high levels of patient satisfaction. Aims Our aim was to evaluate whether VFCs reduce the volume of X-rays performed for common fractures of the wrist and ankle. Methods A retrospective cohort review was performed. The pre-VFC group consisted of 168 wrist and 108 ankle referrals from March to September 2019. The VFC group included 75 wrist and 68 ankle referrals, during the period March to September 2020. The total number of X-ray images, carried out within a 3-month period for each fracture was summated, with statistical analysis performed following fracture pattern classification. Findings A statistically significant decrease in mean X-rays was observed for isolated stable fracture patterns, such as non-displaced distal radius, − 0.976 (p = 0.00025), and Weber A ankle fractures, − 0.907 (p = 0.000013). A reduction was also observed for more complex fracture patterns such as dorsally displaced distal radius, − 0.701 (p = 0.129) and Weber B ankle fractures, − 0.786 (p = 0.235), though not achieving statistical significance. Conclusions Virtual fracture clinics can reduce X-ray frequency for common stable wrist and ankle fractures, with resultant benefits for both patients and healthcare systems. These benefits may be sustained in patient care beyond the current COVID-19 pandemic.

Optimizing orthopedic trauma care delivery during the COVID-19 pandemic. A closed-loop audit of implementing a virtual fracture clinic and fast-track pathway in a Dutch level 2 trauma center

BackgroundGuidelines concerning outpatient management of patients during the coronavirus pandemic required minimized face-to-face follow-up and increased remote care. In response, we established a virtual fracture clinic (VFC) review for emergency department (ED) patients with musculoskeletal injuries, meaning patients are reviewed ‘virtually’ the next workday by a multidisciplinary team, instead of routine referral for face-to-face fracture clinic review. Patients wait at home and are contacted afterwards to discuss treatment. Based on VFC review, patients with minor injuries are discharged, while for other patients an extensive treatment plan is documented using injury-specific care pathways. Additionally, we established an ED orthopedic trauma fast-track to reduce waiting time. This study aimed to evaluate the extent to which our workflow supported adherence to national coronavirus-related guidelines and effects on ED waiting time.MethodsA closed-loop audit was performed during two 4-week periods using predefined standards: (1) all eligible ED orthopedic trauma patients are referred for VFC review; (2) reached afterwards; and follow-up is (3) patient initiated, or (4) performed remotely, whenever possible. Total ED waiting time, time to review, time for review, and time after review were assessed during both audit periods and compared with previous measurements.ResultsDuring both audits, the majority of eligible ED patients were referred for VFC review (1st: n=162 (88.0%); 2nd: n=302 (98.4%)), and reached afterwards (1st: 98.1%; 2nd: 99.0%). Of all referred patients, 17.9% and 13.6% were discharged ‘virtually’ during first and second audits, respectively, while 45.0% and 41.1% of scheduled follow-up appointments were remote. Median total ED waiting time was reduced (1st: −36 minutes (p<0.001); 2nd: −33 minutes (p<0.001)). During the second audit, median ED time to review was reduced by −13 minutes (p<0.001), as well as time for review: −10 minutes (p=0.019).DiscussionIn line with national guidelines, our VFC review allowed time-effective review and triage of the majority of ED orthopedic trauma patients, supporting patient-initiated and remote follow-up, whenever possible. ED waiting time was reduced after implementing the VFC review and orthopedic trauma fast-track.Level of evidenceIV.

341 Alder Hey Experience of Paediatric Virtual Fracture Clinic During The COVID-19 Pandemic

Introduction The SARS-CoV2/COVID-19 pandemic represented an unprecedented emergency prompting a drive to minimise non-essential patient contact and the need for a virtual fracture clinic (VFC); an uncommon practice in paediatric units. Management of paediatric fractures requires a greater degree of vigilance to safeguard children. The current climate has created social challenges that theoretically increase the risk of harm and exploitation to children. This study investigates VFC in the management of paediatric fractures to determine the efficiency of such a process and the risk of safeguarding. Method A protocol was devised in affiliation with BSCOS for the immediate management and streamlining of paediatric fractures into VFC. We retrospectively audited 235 VFC consults over a 1-month period. Patient sex was roughly evenly distributed, and age ranged from 9 months to 16 years (mean 8.4 years). Results 42% of patients were recalled for a face-to-face (F2F) review (26% expedited), primarily for clinical assessment, plaster complaints and imaging requirements. 33% were discharged and 15% continued follow-up in VFC. All clavicle fractures were discharged. Forearm, hand, foot and elbow injuries were more likely to be discharged. Lower leg, upper arm and knee presentations more frequently required a F2F review. 2.3% of cases required safeguarding reviews. Conclusions Given the rapid transition to VFC without the use of triage we have determined a number of non-complex fractures safely managed and discharged via VFC. The low percentage of recall due to safeguarding concern highlights this may not be a barrier to the continuation of virtual care outside of the context of a pandemic.

42 An Analysis of Virtual Fracture Clinics in Orthopaedic Trauma in the UK During the Coronavirus Crisis

Aim Virtual Fracture Clinics (VFC) are advocated by new Orthopaedic (British Orthopaedic Association) and National Health Service (NHS) guidelines in the United Kingdom. We discuss benefits and limitations, reviewing the literature. As well as recommendations on introducing a VFC service during the Coronavirus pandemic and into the future. Method A narrative review identifying current literature on virtual fracture clinic outcomes when compared to traditional model fracture clinics in the UK. We identify 9 relevant publications related to VFC. Results The Glasgow Model initiated in 2011 has become the benchmark. Clinical efficiency can be improved, reducing the number of ED referrals seen in VFC by 15%-28% and face to face consultations by 65%. 33-60% of patients may be discharged after review in the VFC. Some studies have shown no negative impact on the Emergency Department (ED), the time to discharge was not increased. Patients satisfaction ranges from 91%-97% using a VFC service, and there may be cost saving benefits annually from £67,385-£212,705. Non-attendance may be reduced by 75% and there are educational opportunities for trainees. However, evidence is limited, 28% of patients prefer face-to-face consultations and not all have access to internet or email (72%). Conclusions We propose a pathway integrating the VFC model, whilst having Senior Orthopaedic decision makers available in ED, during normal working hours, to cope with the pandemic. Beyond the pandemic, evidence suggests the Glasgow model is viable for day-to-day practice.

194 Referral of Paediatric Fractures from The Emergency Department to Virtual Fracture Clinic

Introduction Virtual Fracture clinics (VFCs) are an alternative to the traditional fracture clinic. Recent evidence reports them to be safe, cost-effective, and efficient model without significant compromise to patient care. Aim This audit aims to assess VFC referrals from the paediatric emergency department (ED) and ensure the appropriateness of these referrals. Method This was a retrospective audit done at a large district general hospital in the United Kingdom (UK). We included patients under 18 years old presented to the emergency department with suspected or confirmed fractures and referred to virtual fracture clinics within a period of one month. The performance was measured against both local and national guidance (NICE & BOAST 7). Results Thirty patients were eligible. Thirty-three per cent of patients were appropriately referred to the VFC and ’seen’ within 72 hours. Comparing those referred 63.3% were appropriate, with inappropriate referrals mainly due to false-positive fracture diagnosis or fractures safe to be discharged home. Only 67.8% per cent of patients were managed correctly as per suspected or confirmed diagnosis with regards to fixation (i.e., splint). Conclusions The target of 100% compliance has failed. Fractures deemed safe to be discharged home from the ED are being repeated referred, radiographic interpretations often over-diagnose, and management within the department in sub-optimal. Recommendations include improving junior radiographic interpretation skills and awareness of the local and national guidelines, with another audit cycle to assess for improvement.

1254 Virtual Fracture Clinic Management of Little (5th) Metacarpal Neck Fractures; a Safe and Feasible Option?

Aim To determine the safety and efficacy of a Virtual Fracture Clinic (VFC) in managing little metacarpal neck fractures. Method Retrospective review of consecutive little MC neck fractures presenting to the ED June-December 2020 and subsequently referred on to VFC. Patient demographics and clinic outcomes were reviewed using electronic patient records and radiographs. Results Fifty patients were identified (Male:Female 37:13; mean age 26 years, range 3-89 years). Of these, 41/50 were discharged directly following VFC advice, with no adverse event. The remaining 9/50 had a face-to-face Fracture Clinic review due to safeguarding concerns (2), concurrent neck of fourth MC fracture (2), concerns regarding fracture pattern (4), and an unclear indication (1). These 9/50 were discharged after single review, with no adverse events to date. Conclusions Our data suggest that VFC review of patients with little MC neck fractures is a safe and feasible means of patient care which has the potential to reduce the requirement of face-to-face patient contact during the Covid-19 pandemic and reduce fracture clinic attendance. We suggest the routine incorporation of a Virtual Fracture Clinic for these hand injuries. Further work is needed to formally investigate associated patient satisfaction and the application of this approach to other trauma presentations.

1295 Virtual Fracture Clinic: An Audit of Referral Quality and Service Effectiveness

Aim Assessment of referral quality to the virtual fracture clinic (VFC) at the Liverpool University Hospital foundation trust compared to the standards set out by the Glasgow virtual fracture clinic pathway. As a secondary aim the effectiveness of the VFC in diverting patients not requiring further clinical management away from face-to-face specialist physical fracture clinics (PFC) was assessed. Method Outcomes of 1st attendances were collected for standard PFC's before the implementation of the VFC at our centre. This data was comparatively analysed to the outcomes of 1st ‘attendances' of VFCs post-service implementation. To assess VFC referral quality fracture type was recorded and compared to the standard set out by the Glasgow virtual fracture pathway which states that a selection of simple stable fractures should be discharged from ED directly with patient advice and telephone support. Results We analysed 529 PFC first attendances and 402 VFC first attendances. We saw a variety of simples stable fractures (21%) in the VCF including: Distal radial, Fifth metatarsal, Minor radial head, Fifth metacarpal, Mallet finger, which could have been managed with direct ED discharge and telephone support. 19.4% of PFC attendance resulted in discharge without a change in management as compared to 22.1% of 1st attendances for the VFC. Conclusions The VFC clinic has shown itself as an effective service in re-directing patients from face-to-face appointments, evidenced by the comparative rates of patient discharge on first attendance. This study has laid the foundation for improving referral quality to the VFC. Collaborative efforts between Orthopaedics and ED could improve VFC clinic efficiency further.

1571 Lower Limb Immobilisation And VTE Prophylaxis Risk Assessment: A Quality Improvement Project

Introduction Temporary cast immobilisation of the lower limb following injury is associated with a 2-3% risk of DVT. NICE guidelines recommend considering pharmacological thromboprophylaxis for those with lower limb immobilisation where VTE risk outweighs bleeding risk. The aim of this quality improvement project was to improve compliance with VTE risk assessment in patients discharged from the Emergency Department (ED) with lower limb immobilisation. Method Baseline data on completion of VTE risk assessment forms was collected retrospectively on all patients discharged from ED in lower limb boots and casts over a 3-week period. Cycle 1 included the introduction of a VTE section on the virtual fracture clinic booking form. Cycle 2 included displaying posters around the ED and placing forms inside walker boots. Data was collected following a 3-week period for each cycle. Results The baseline audit showed 45% compliance with completion of VTE risk assessment forms. Cycle 1 showed a significant increase in compliance, to 72%. A further modest increase in compliance was seen in Cycle 2, with 78% of VTE risk assessment forms completed. Conclusions Baseline compliance with VTE risk assessment for lower limb immobilisation was suboptimal. Integration of risk assessment into the virtual fracture booking form significantly improved compliance. This intervention is to be continued long-term at Harrogate District Hospital.