Orthopaedic Trauma

The Trust quality committee should have mechanisms ensuring that BPT criteria, and NICE, GIRFT, and BOAST recommendations and similar clinical guidance are applied to all the clinically relevant orthopaedic trauma patient cohort, and not just the patient cohort referred to in the guidance. For example, this would mean that Fragility Hip and Femur Fracture BPT criteria are applied to all non-ambulatory fragility fractures.

Trusts should ensure that patients, over the age of 50, who sustain a fracture either from a low-energy mechanism (such as a fall from a standing height or less) or with no clear history of trauma are identified. This can be done by using radiology reports. Following identification there should be an active, robust mechanism for assessing the patient for increased bone fragility and associated high risk of further fractures and ensuring the patient is initiated on bone sparing treatment where appropriate. Appropriately resourced secondary fracture prevention services (often referred to as Fracture Liaison Services) should be in place to ensure this happens in a reliable and consistent manner. This is in accordance with recommendations in the Best Collaborative Pathway Improvement Programme's High Impact Restoration Strategy. It is also in line with recommendations in: The NHS Long Term Plan (2019); NICE Quality Standard 149 (2017); Public Health England's falls and fractures consensus statement (2017); The Department of Health's 'Falls and Fractures – Effective Interventions in Health and Social Care' (2009); The British Orthopaedic Associations' Blue Book (2008).

The Trust Quality Committees should ensure that all clinicians delivering the pathway of care for orthopaedic trauma patients contribute to its quality improvement. This requires proportionate involvement in governance, audit and mortality and morbidity (M&M) meetings from staff groups commonly including, but not restricted to: Trauma and orthopaedics; Emergency medicine; Radiology/radiography; Orthogeriatrics; Anaesthetics and peri-operative medicine; Junior doctors; Nursing and allied health profession (AHP) staff.

Trusts should have written policies identifying the clinical staff involved in the treatment of 'orphan conditions', for which there is no one specialty that considers themselves to be trained to manage patient care. We will also co-develop guidance on collaborative management of orphan conditions with specialty associations and colleagues in national bodies, such as the GMC and elsewhere in NHSE, as needed. These conditions include: chest injuries; nonsurgical head injuries; pubic rami fractures. As it is unlikely that any individual specialty is going to accept full responsibility for some conditions it is important that each specialty should play its part to prepare itself for collaborative management of its patients in its curriculum and training.

Trust should ensure that in line with NICE guidance orthopaedic trauma patients are admitted to an orthopaedic ward. Where this is not possible, outlying patients (other than those who are medically fit for discharge) should be seen daily by senior medical and nursing staff appropriate to their clinical needs.

Trusts should manage their trauma service using an automated theatre workload dashboard including prioritisation categories reflecting the nationally recommended time to surgery within NICE, BOAST, and BPT tariff guidance. This will enable trusts, systems and national leaders to: monitor and respond to real-time fluctuations in the orthopaedic surgical trauma workload and theatre utilisation (locally and nationally); anticipate potential delays to orthopaedic trauma patient care; decide what actions are required to bring treatment times in line with national guidelines, referring to the decision tree provided in figure 13.

Using a multidisciplinary governance approach, trusts should run a quarterly baseline audit of recommendations relevant to orthopaedic trauma patients. Relevant NICE, GIRFT and BOAST recommendations should be reviewed and either implemented in collaboration across ICSs, where necessary, or non-implementation justified – see below for existing guidance and GIRFT advice.

Trusts should ensure that the pathway of care for the older or frail orthopaedic trauma patient is monitored and modified with respect to the 25 organisational factors highlighted in the REDUCE study as important to improving patient outcomes and reducing length of stay.

Trusts should ensure that when a surgical procedure is required and it is clinically appropriate for the patient to be carried out as a day case*, it should be done as a day case.

Trusts should reduce litigation costs using the GIRFT programme's five-point plan and by addressing common causes of litigation in orthopaedic trauma with respect to limb injuries, common interventions, such as plastering and splint application, and use of intraoperative tourniquets. GIRFT five-point Plan: a. Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT 'Litigation data pack.' b. Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c. Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d. Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI)/serious incidents (SI)/ patient safety incidents (PSI) and where a claim has not already been reviewed as SUI/SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including Multidisciplinary Team meetings, Morbidity and Mortality meetings where appropriate). The staff groups involved in these meeting will need to grow beyond trauma and orthopaedics to include: orthogeriatrics, anaesthetics and peri-operative medicine, nursing and allied health profession (AHP) staff, emergency medicine and radiology. e. Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT will be asking national clinical leads and regional improvement teams to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit. Common causes of litigation in orthopaedic trauma: a. Trusts should ensure that clinical staff use standard neurovascular observation record charts for limb injuries whether in patients notes or part of the electronic patient record. These should include a clear description of the examination performed to ensure consistency in approach through the patient pathway. b. Trusts should ensure that they avoid incidents from common interventions, such as plaster or splint application, by implementing shared learning of those performing these interventions across different departments to ensure a consistently high performance of intervention regardless of point in care pathway. c. Trusts should ensure that BOAST guidance on 'the safe use of intraoperative torniquets' is followed.