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How we cut A&E to fracture clinic waiting times by more than 30%


By Andrew Tunnicliffe
23 May 2019

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A few years ago, Stepping Hill Hospital, part of Stockport NHS Foundation Trust, decided to investigate solutions to improving the care offered to fracture patients.

Many of these patients were attending a face-to-face appointment with a consultant when it was not needed, resulting in time wasted both for clinicians and patients.

To address this, the hospital introduced a virtual fracture clinic in November 2017 – using the latest scanning and communication technology to allow orthopaedic consultants to examine fractures on screen.

The initiative helped them save one and a half hour of clinician time per day and cut waiting times from A&E to fracture clinics by more than 30%.

Stockport Foundation Trust business manager Andrew Tunnicliffe tells Healthcare Leader how they achieved this.

The problem

Many patients would come to our fracture clinic to see a doctor when they didn’t need to.

Patients would sometimes have to take a morning or an afternoon off work to come in for their appointment and be seen for five minutes when they could actually have been dealt with in a more effective way [for instance, through telephone advice].

That would have been better for them in terms of not having to pay for parking or not take time off work to attend their appointment.

We want more to be done in the community or intuitively via different means – such as virtual or telephone review clinics. In our area, we want to reduce consultant-lead hospital care and the number of outpatients we see in hospital.

The solution

We were aware that the virtual fracture clinic model had been implemented successfully in other organisations.

It had spread to quite a few of the health providers in Scotland and it was gradually starting to filter its way to England, through trials. There was quite a good evidence base for it, which grabbed our attention.

Before, our way of working consisted of offering access to our orthopaedic consultant-led fracture clinic every day. The consultants would see patients who had previously attended the emergency department with an orthopaedic injury but were later discharged from A&E with a fracture clinic appointment.

This meant that those patients would return to the fracture clinic a few days later to see an orthopaedic specialist, and have another x-ray. The next course of action would then be determined, in terms of whether any surgery was appropriate or if it was conservative management that was required.

What we do with the virtual fracture clinic now is that, rather than having all patients leave the emergency department with a face-to-face appointment, we add them to our virtual fracture clinic.

[This is how it works]: a consultant orthopaedic surgeon triages the previous day’s fracture clinic referrals, looking at the emergency department notes and records relevant to those patients. They can get all the x-rays up on the computer screen and decide on the next steps to take for that patient.

Some of those patients need a face-to-face follow-up appointment and will be invited to attend one.

However, other patients don’t necessarily need to come in. They can be safely discharged with some advice, which we provide in the form of leaflets and a letter that goes directly to the patient.

Other patients are instead sent straight to physio, instead of having to come and see an orthopaedic doctor at our fracture clinic first.

[The virtual fracture clinic also allows us to make] sure that patients end up in the right place with the right specialist. For example, if you have a particularly nasty wrist fracture, the orthopaedic doctor might decide to send you directly to a specialist hand surgeon, rather than to a general trauma surgeon.

Our clinicians can now make clinical judgements based on the data and images received through the virtual fracture clinic.

The evidence comes directly from our A&E department. The information that feeds into the virtual fracture clinic has been collated during the emergency department episode – including admission notes and any x-rays that the patient may have had.

The challenges

The main change was for our consultants – the virtual fracture clinic is different from their previous way of working. However, I think the consultants all very much bought into the idea because of the evidence behind it and because of their own experience of fracture clinics.

The fracture clinics were generally busy and crowded and clinicians were sometimes frustrated that patients would attend a face-to-face appointment when they didn’t need to.

[I think the greatest challenge was] around how would we fit those virtual fracture clinics into the consultant’s schedule every day: they were busy doctors already.

We’ve addressed this in two different ways. Initially, the daily responsibility of undertaking the virtual fracture clinic every day was left to our on-call consultant.

We’ve changed this in December last year. After manging to reduce the volume of activity at our face-to-face fracture clinic we decided that, rather than having an on-call consultant providing the virtual fracture clinic each day, we needed to build it into our existing fracture clinics.

We estimate that the virtual fracture clinic allows us to save, on average, about an hour and a half of consultant time a day.

The benefits

Since we introduced the virtual fracture clinic in November 2017, we have reviewed over 2,300 patients.

We’ve seen a 16% reduction in the number of patients attending physical fracture clinic appointments and fewer than 7% of those discharged from the virtual clinic needed to return for another appointment.

The virtual fracture clinic has also allowed us to cut waiting time from A&E to fracture clinic by over 30%. This means that patients who do need to come in now have quicker access to face-to-face appointments; waiting on average two-to-four days instead of four-to-seven before being seen by a consultant.

We estimate that about 25% of the virtual fracture clinic patients are discharged without needing a face-to-face appointment.

Additional reporting by Valeria Fiore 

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