Paediatric Trauma and Orthopaedic Surgery

Paediatric orthopaedic surgery should realign its networks with the operational delivery networks (ODNs) in surgery in children (SIC) to produce a robust system that results in trusts being supported by high volume providers. a Engage with paediatric orthopaedic surgeons to determine and action best network design b Review procedures so that no trauma units experience obstructions to MT transfer of children c Identify gaps in provision/retirements and actively succession plan.

Networks, working with member trusts, to review caseloads and activity, particularly for complex and low volume activity, and agree appropriate networked models of care. a Issue guidance about what levels represent low surgical volumes in different conditions. b Ensure adequate paediatric orthopaedic input into ODNs. c Adopt a regional ODN approach to managing paediatric T&O volumes appropriately across networks. d Maximise quality by considering how trusts can manage volumes through hub and spoke models and dual-surgeon operating.

Networks to determine approach to rare bone diseases. a Review networking and pathways for care in osteogenesis imperfecta. b Review composition of skeletal dysplasia clinics. c Ensure multidisciplinary and multi-professional clinics for spina bifida and associated conditions are standard.

Implement pathways in trusts that support the treatment of simple fractures in ways that avoid children requiring admission and unnecessary hospital attendance. Common injuries to be treated in ED according to protocol with no or minimal follow-up. a Enact recommendations from the BOA's Standards for Treatment. b Standardise protocols for the treatment and discharge of straightforward injuries.

Implement virtual fracture and orthopaedic clinics to minimise unnecessary patient journeys. a Provide adequate staffing and support to allow virtual clinics to function.

Ensure that surgeons treating children's fractures are experienced in appropriate methods. a Implement audit and training in elastic nailing of forearm and femur. b Provide supracondylar fracture refresher training as standard.

Trusts to ensure facilities are available for appropriate procedures in clinic. a Facilitate and audit wire removal, which should be performed in clinic.

Networks to develop policies/guidelines for complex fractures. a Review and agree transfer criteria for rare/complex fractures. b Agree transfer timescales.

Ensure that trusts audit lower limb fractures with a view to reduction in length of stay and to support early mobilisation and discharge. a Audit length of stay in femur fractures. b Instigate hip spica pathway for appropriate cases. c Audit numbers of tibial fractures undergoing no procedure.

All trusts to review local arrangements to ensure appropriate theatre access for paediatric trauma teams. This should include reviewing day case unit usage. The aim should be to minimise the chances that children become unnecessary inpatient admissions. a Develop pathways to allow patients to wait at home for day case fracture treatment. b Increase numbers of specific trauma lists for children. c Increase attendance in theatre by plaster staff for spica application.

Deliver early developmental dysplasia of hip (DDH) care in an efficient family friendly multidisciplinary format. a Organise secondary DDH screening clinics as one-stop clinics with ultrasound, physical examination by appropriate professional and fitting of splint as required. National standards and timescales should be achieved. b Make accurate and complete returns to NIPE on the national system (SMaRT4NIPE), allowing allow national data analysis of the adequacy of the current screening schedule. c Ensure local electronic patient record systems and NIPE returns can be completed without requiring duplicate data entry. d Ensure that primary hip screening diagnoses clinical instability with average frequency (1%). e Review local processes to ensure that all secondary screening clinics have formal links to a paediatric orthopaedic surgeon who should supervise and be available to advise.

Review the national system of DDH screening. a Complete further trials and pilots of universal ultrasound screening. b Investigate the practicalities and economics of universal ultrasound screening should be undertaken.

Optimise operative interventions for late DDH. a Institute same day cross-sectional imaging following closed or open reduction of the hip in infants. Progress should be made towards substituting MRI for CT scans in this circumstance to reduce radiation exposure.

Standardise club foot care and audit on a regional and national basis. a Undertake regional peer-reviewed audit of all units doing Ponseti. This should include numbers of casts, tenotomy rate, relapse rate, tendon transfer rate and frequency of major release. b Consider the case for a national registry for club foot care. c Perform Achilles tenotomy in primary club feet in infants under six months in the clinic under local anaesthetic. d Seek second opinion before significant club foot release surgery.

Standardise orthopaedic care in cerebral palsy to allow equality of care across England. a Ensure that CPIP is used universally, and the examinations and database funded. b Make formal instrumented gait analysis available and ensure it is used before all major interventions in walking children. c Commission and complete a trial to investigate the role of botulinum toxin. d Reduce variability in botulinum toxin use via audits and strict goal setting. e Perform major interventions in CP through suitable network-determined settings, with access to PICU/HDU as required.

Reduce variation in the treatment and management of osteoarticular infection. a Provide an MDT for the treatment of osteoarticular infection. b Make outpatient antibiotic therapy services for children available in all trusts and systems. c Commission further research into the optimum length of intravenous and total antibiotic therapy. d Update BSCOS guideline for the management of osteoarticular infection. e Review use of CRP to guide switching to oral antibiotics (trusts with long periods of intravenous antibiotic therapy should review this.

Optimise processes for managing variants of normal. a Develop written and web-based advice for GPs and families. b Use advice and guidance to answer referrals of normal variants. c Facilitate first attendance with specialist physiotherapists or nurses for any cases that require review.

Trusts to enhance facilities for day case knee, foot and ankle surgery in the under 16s. a Establish day case facilities for children's surgery. b Ensure that day case units stay open into the evening. c Ensure availability of physiotherapy for mobilisation of patients operated in the afternoon.

Ensure satisfactory acute knee pathway for the under 16s to allow prompt and appropriate treatment. a Ensure meniscal repair is the standard procedure for meniscal injuries. b Implement recommendations of BASK/BSCOS steering committee, including imaging recommendations. c Develop MDT approach to knee problems in under 16s. d Develop the facility to record data on patients under 16 in the National Ligament Registry. Recording of data on under 16s should then be mandatory.

Trusts to review numbers of common foot and ankle interventions. a Audit hallux valgus and lesser toe straightening procedures and refine their indications, especially if in highest quartile for numbers performed. b Audit timing of toe straightening procedures to ensure children benefit from the simplest intervention.

Develop pathways for less common major interventions. a Centralise surgery for severe SUFE and adolescent dysplasia.

Adequate numbers of paediatric orthopaedic surgeons to be resourced at major centres, allowing outreach work. a Achieve overall paediatric orthopaedic surgeon numbers of at least 0.5-1 per 1,000 attendances. b Ensure resourcing of multi-professional staff, including imaging, to adequately support the service. c Increase numbers at network hubs to allow for numbers seen at peripheral hospitals. d Achieve numbers that allow adequate trauma access and dual surgeon operating.

Activity at all trusts to be maintained to prevent flow of simple cases to specialist hospitals. a Provide paediatric orthopaedic outpatients and day case surgery at most trusts treating children.

Paediatric orthopaedic surgeons to be supported by multidisciplinary team with sufficient specialist physios/nurses/plaster staff to permit local club foot and early DDH treatment and reduce waits, including management of variants of normal. a Achieve a balanced multi-professional team addressing any deficiencies identified in numbers and seniority of practitioners. b Train plaster staff in paediatric orthopaedic skills.

Training in paediatric T&O to be maintained for all orthopaedic registrars. a Maintain significant place in curriculum and exam. b Provide adequate training in paediatric trauma.

Paediatric orthopaedic trauma services to be enhanced at MTCs for children, possibly by combining staff with local children's hospitals. a Review orthopaedic staffing at paediatric MTCs.

Improve coding of inpatient procedures to give trusts and NHS England and Improvement sight of their activity. a Review codes for paediatric orthopaedics and make recommendations. b Standardise coding of procedures. Specific coding conventions to be used according to the list above. Clinicians to work with local coding teams to ensure accuracy.

Outpatient procedures should be appropriately coded, recorded and remunerated. a Upload outpatient procedures to HES. b Identify and use appropriate codes (working with clinicians) for standard outpatient procedures.

Ask NIHR to commission research on outcome measures and their suitability for use in paediatric T&O, with recommendations for routine collection of PROMs data. a Fund and support development of core outcome sets and measures b Support research and implementation of outcome measures.

Implement specific recommendations to reduce litigation costs for paediatric T&O. a Institute consent/pre-operative clinics to ensure maximum understanding of risks and benefits of proposed procedures b Use standard neurovascular observation record charts for limb injuries, particularly supracondylar fractures c Ensure that the pathway for DDH screening and surveillance is robust to avoid late diagnoses. d Avoid incidents from common interventions such as plaster application and removal or tourniquet application.

Reduce litigation costs by application of the GIRFT Programme's 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 to 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, norbidity and mortality meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional hubs 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.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a Use sources of procurement data, such as SCS and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c Use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.