“All referrals should be made through the ED Consultant/Senior” – What does this mean in practical terms? Does this mean that SHOs are not allowed to refer on to Ortho and this is done thru the cons/middle grade only? Does that then mean that the availability of the cons or middle grade (who might be dealing with an emergency), will slow the referral process? In short how does the referral process work, so that it is maximally efficient?
We don’t want our SHOs making poor referrals i.e. those that we can deal with / advise on management ourselves. We therefore vet the referrals. Nevertheless there is not always a consultant or middle grade in minors so some do inevitably slip through. There is a cons in ED til midnight M-F and weekends 8-6 and a cons specifically in minors each afternoon. The rest of the time middle grades are available. In practice, it doesn’t take long to make most decisions after a glance at the images. The SHO or nurse practitioner would then make the referral if appropriate.
How does the Cauda Equina pathway work?
This is a local add on to the redesign and not a core feature. We were seeing significant numbers of patients with GP queries of cauda equina syndrome spending a significant period of time waiting to see a junior orthopod who then didn’t know what to do. When senior advice was eventually sought it was too late to organise an MRI as the service at the local MRI service is only available 9-5 M-F. Therefore between those hours our consultants stepped in and made a decision based on their own clinical assessment about whether an MRI was required and organised it (we can do this much more easily than an FY2 in orthopaedics. As you would expect most patients ended up having an MRI (because someone has raised a concern even if history is a bit soft) and most scans ended up revealing an alternative diagnosis – so we send most of the patients home. If we can’t get the scan in time (and it’s not a barn door compression syndrome) we admit to ortho overnight for a morning scan; similarly out of hours the ortho SHO will do the same. If it is barn door we transfer them to neurosurgery at the near-by regional unit.
What were the problems with ‘Ward Work-Up’?
There is a tension between us clerking in patients for ortho juniors and us getting patients moved efficiently to the ward. At present we ensure bloods, ECGs and relevant x-rays are done and complete a ward drug kardex for interim analgesia. The ward staff would like us to do more, we would like to do less, so that’s where we have settled for the time being. This requires local negotiation based on the local availability of appropriate resources.
What was the implication of Boots vs slabs cost? Do you use Boots for stable Weber B ankle fractures?
Boots are used for stable Weber B fractures. Overall the cost is equivalent when basic materials and time factors are taken into consideration. The boot is more rapidly applied does not need subsequent conversion.
Has the “Virtual Trauma Clinic Fracture Clinic Redesign” model been beneficial for its local ED and if so in what way? Specifically has it helped you meet time targets or has it taken up too much of your time?
Virtual fracture clinic is excellent for ED:
- Slightly less time spent by patients in ED – especially if splinted rather than slabbed – even though there is more time explaining process.
- Decision making is much easier.
- No increase in unplanned A&E re-attendance
- Quicker admissions – and less of them (more brought back to VFC for semi-urgent planned admission)