O0486 Oct.4: 4:15pm - A Quality Improvement Project to Reduce Unnecessary Orthopedic Follow-up for Patients with Distal Forearm Buckle Fractures

Background

Distal forearm buckle fractures (DFBF) are one of the most common pediatric fractures. Studies have shown that prefabricated splints (PS) are as effective as casting. Follow up visits and re-imaging are not useful and create undue cost and burden. In order to improve value, the primary aim was to decrease orthopedic clinic follow-up visits after initial Emergency Department (ED) diagnosis by 50% from 87% to 45% over a 9 month period.

Methodology

A multidisciplinary team devised a standardized approach for the management of DFBFs and created a clinical pathway. Patients were included if they presented to the ED with an isolated DFBF(s). Exclusion criteria consisted of presence of bone or joint disease, fractures requiring reduction, unclear diagnosis, or neurovascular compromise. PS stocked in the ED were changed to match the ones utilized in the orthopedic clinic. Patients meeting inclusion criteria were placed into a PS and were instructed to remove the splint after 3 weeks. They were educated to follow-up in the orthopedic clinic only if they had symptoms at the end of the 3 week period or if they developed new symptoms while immobilized. A corresponding handout was attached to the patient’s discharge instructions. ED and orthopedic staff were asked for feedback prior to implementation and were educated utilizing a multi-tiered approach including emails, staff meetings, and one-on-one training. Plan-do-check-act cycles were performed regularly. Post intervention medical records were reviewed monthly and individual feedback was provided to improve adherence. The primary outcome measure was the percentage of patients that followed up in the orthopedic clinic, ED or primary care office within one month after diagnosis. The process measure was the percentage of patients placed in a PS. Balancing measures included complications and ED length of stay. Outcomes were measured using statistical process control charts. Hospital costs were calculated using time driven activity based cost analysis.

Results

130 pre implementation and 73 post implementation encounters were reviewed from October 2018-February 2020. ED PS utilization rate increased from 14% to 90%. The follow up rate decreased from 87% to 26%, surpassing the goals of this project. Median ED length of stay decreased from 134 (interquartile range 102 to 174) minutes pre implementation to 119 minutes (interquartile range 871 to 155; p=0.04) post implementation. This initiative equated to a hospital cost savings of $130 per patient and total savings of $20,800 per year. No adverse events or complications occurred.

Conclusion

Implementation of a clinical pathway that utilized PS for children with distal forearm buckle fractures effectively improved value by decreasing unnecessary resource utilization. This project will be scaled to partner hospitals and urgent care centers within the organization. A similar clinical pathway will be created for distal fibular injuries.