Background: The Health Service Executive (HSE) National Model of Care for Trauma and Orthopaedics... more Background: The Health Service Executive (HSE) National Model of Care for Trauma and Orthopaedics and the British Orthopaedic Association both recommend the use of an ambulatory care model for the management of distal radius fractures. The ambulatory care model recommends suitable patients should be discharged home following diagnosis and return as a planned day case admission for their definitive treatment to avoid unnecessary inpatient stays and bed blocking. We identified an issue in 2018 as there was no pathway to facilitate the ambulatory care model in University Hospital Limerick (UHL) and as such we conducted this audit to identify the impact of this service deficit on patients and the health system. Since then Croom Orthopaedic Hospital now has capacity for ambulatory trauma care Monday to Friday and as such we reaudited to assess the effect of this new pathway on service provision in UHL. Methods: A retrospective audit of how many distal radius fractures were treated in UHL over a 1-year period from 2018 to 2019 as compared to the same period from 2020-2021 as per the ambulatory care model. Data was collected from theatre meridian logbook, the theatre imaging system and HIPE database. Time of diagnosis, time of operation, inpatient duration and inpatient location were measured. Results: There were 176 patients with distal radius fracture treated in the period spanning 2018-2019. For the same period in 2020-2021, 141 patients were treated. Although there was a very small subset of patients that required admission to UHL for the surgical management of their distal radius fracture due to medical comorbidities/other confounding injuries, the vast majority were suitable for the ambulatory care pathway. Of those patients managed via the ambulatory pathway 100% were managed on an orthopaedic ward compared to 61% in 2018 and none had an inpatient stay >12 hours prior to their surgery compared to an average of 52.8 hours as inpatient preoperatively in 2018. Conclusions: The ambulatory care pathway is a safe, convenient and cost-effective method of managing these types of injuries.
A study in 2011 by (Doody et al. Ir Med J 106(10):300-302, 2013) looked at comparing inpatient ad... more A study in 2011 by (Doody et al. Ir Med J 106(10):300-302, 2013) looked at comparing inpatient adverse events recorded prospectively at the point of care, with adverse events recorded by the national Hospital In-Patient Enquiry (HIPE) System. In the study, a single-centre University Hospital in Ireland treating acute hip fractures in an orthopaedic unit recorded 39 patients over a 2-month (August-September 2011) period, with 55 adverse events recorded prospectively in contrast to the HIPE record of 13 (23.6%) adverse events. With the recent change in the Irish hospital funding model from block grant to an 'activity-based funding' on the basis of case load and case complexity, the hospital financial allocation is dependent on accurate case complexity coding. A retrospective assessment of the financial implications of the two methods of adverse incident recording was carried out. A total of €39,899 in 'missed funding' for 2 months was calculated when the ward-based, pr...
Background Hip fracture is a common serious injury afflicting the geriatric population and is ass... more Background Hip fracture is a common serious injury afflicting the geriatric population and is associated with poor clinical outcomes, functional and walking disabilities and high 1-year mortality rates. A multidisciplinary approach has been shown to improve outcomes of geriatric patients with fragility fracture. Aims We piloted a dedicated orthogeriatric service for hip fracture patients to determine if the service facilitated a change in major patient outcomes, such as mortality, length of stay and dependency. Methods A dedicated orthogeriatrics service for hip fracture was established as a collaborative project between the Department of Geriatric Medicine and Department of Orthopaedic Surgery at a university teaching hospital. Orthogeriatrics service data were collected prospectively on an orthogeriatric filemaker database from July 2011 to July 2012 (N = 206). Data were compared to previously recorded data (Irish Hip Fracture Database) on a cohort of hip fracture patients admitted to the same orthopaedic trauma unit from July 2009 to July 2010 (N = 248). Results Patients in the orthogeriatric service group experienced significant reductions in 1-year mortality (v 2 = 13.34, P \ 0.001), length of acute hospital stay (U =-3.77, P \ 0.001) and requirements for further rehabilitation (v 2 = 26.59, P \ 0.001). Patients in the preservice establishment group were significantly more dependent following their fracture than the patients in the orthogeriatric service group (v 2 = 5.34, P = 0.021). Conclusions A multidisciplinary management approach to fragility fracture of the femoral neck that involves comprehensive geriatric assessment, daily medical involvement of a geriatric team and specialised follow-up assessment leads to a significant reduction in mortality and improved outcomes. Keywords Orthogeriatric Á Fragility fracture Á Neck of femur Á Hip fracture Á Comprehensive geriatric assessment
We describe the implementation of a care pathway for patients with fractured neck of femur (NOF) ... more We describe the implementation of a care pathway for patients with fractured neck of femur (NOF) using Lean and Six Sigma principles. After introduction of the Lean pathway, 32 patients out a total of 86 (37%) with fractured NOF were admitted to the Trauma Ward within 4 hours of presentation to the hospital; prior to implementation this was 16 patients out of a total of 59 (27%). Post-Lean an earlier mean theatre start time of 8.40am was achieved, resulting in a 38 minute increase in daily theatre time. An additional 52 patients (12%) received surgery within 24 hours of admission, resulting in 1 night length of stay reduction. Lean methodology proved an effective method to guide change resulting in an improved journey for the patient and significant workflow gains.
Background Trauma places a burden on healthcare services accounting for a large proportion of Eme... more Background Trauma places a burden on healthcare services accounting for a large proportion of Emergency Department presentations. COVID-19 spread rapidly affecting over 30 million worldwide. To manage trauma presentations the Department of Trauma & Orthopaedic Surgery reorganised service delivery. Aim To assess the impact of service reorganisation and Virtual Clinics on patients in a Regional Unit in Ireland. Methods A retrospective review of trauma activity following introduction of Virtual Fracture Clinics and Theatre COVID Pathways for a 10 week period in comparison with the same 2019 period. All patients underwent both nasopharyngeal and oropharyngeal swabs PCR testing prior to operations. Theatre and outpatient activity were evaluated. Clinic data were accumulated using the Integrated Patient Management System. Results Theatre Activity. 242 patients underwent surgery in our trauma unit (mean 2.98 per list) during the COVID- 19 period. 29 cases were performed in repurposed elective hospital giving a total of 271 during the 2020 study period. 371 cases were performed in the same 2019 period (mean 4.58 per list). Outpatient Activity. We noted a 25.86% fracture clinic referral reduction during the COVID 19 period compared to 2019. There was a 150.77% increase in patients managed through Trauma Assessment Clinic. 639 patients were managed through the Virtual Fracture Clinic Pathway during COVID 19 period. Conclusions Over one in four fracture clinic patients can be managed virtually. A new dedicated Acute Fracture Unit within our institution permitted streamlining of care and social distancing. The “Non-COVID” pathway for ambulatory trauma was essential in managing the growing presentations of these injuries.
Lenehan B. Validating the role of orthopaedic advanced nurse practioners in the management of fra... more Lenehan B. Validating the role of orthopaedic advanced nurse practioners in the management of fracture clinic patients.
International Journal of Orthopaedic and Trauma Nursing, 2017
Patients with a hip fracture may be appropriately delayed for surgery as they require optimisatio... more Patients with a hip fracture may be appropriately delayed for surgery as they require optimisation or clinical interventions to treat acute medical illnesses (Moja et al., 2012) Other patients are inappropriately delayed due to hospital factors (Brener, 2013; Lee & Elfar, 2014). Timely efficient admission and surgery is well documented as the best course of management for these patients. The aim of this prospective cohort longitudinal follow-up study was to establish if a relationship existed between duration of time spent in the Emergency Department (ED), time to surgery and functional ability in patients with hip fractures and examine the effect prolonged waits may have had on the ability to return home. Functional ability for fifty one patients with a hip fracture was evaluated using the Barthel Index Score (BIS) on admission and at six weeks post-surgery. Data were analysed by using SPSS version 20. The study findings reveal a change in BIS at 6 weeks for patients who are delayed to surgery. Patients who experienced long delays (>12hrs) in the ED awaiting admission functioned less well (Kruskal-Wallis test p =.033). Correlation existed between time to surgery and returning to pre-fracture place of residence, (p= .000 Pearson chi-square), which also remained significant while controlling for age. Results indicate that prolonged waits had an overall negative impact on patients' post-fracture functional ability. This study highlights the deleterious effects on functional ability when surgery is delayed.
Background: The Health Service Executive (HSE) National Model of Care for Trauma and Orthopaedics... more Background: The Health Service Executive (HSE) National Model of Care for Trauma and Orthopaedics and the British Orthopaedic Association both recommend the use of an ambulatory care model for the management of distal radius fractures. The ambulatory care model recommends suitable patients should be discharged home following diagnosis and return as a planned day case admission for their definitive treatment to avoid unnecessary inpatient stays and bed blocking. We identified an issue in 2018 as there was no pathway to facilitate the ambulatory care model in University Hospital Limerick (UHL) and as such we conducted this audit to identify the impact of this service deficit on patients and the health system. Since then Croom Orthopaedic Hospital now has capacity for ambulatory trauma care Monday to Friday and as such we reaudited to assess the effect of this new pathway on service provision in UHL. Methods: A retrospective audit of how many distal radius fractures were treated in UHL over a 1-year period from 2018 to 2019 as compared to the same period from 2020-2021 as per the ambulatory care model. Data was collected from theatre meridian logbook, the theatre imaging system and HIPE database. Time of diagnosis, time of operation, inpatient duration and inpatient location were measured. Results: There were 176 patients with distal radius fracture treated in the period spanning 2018-2019. For the same period in 2020-2021, 141 patients were treated. Although there was a very small subset of patients that required admission to UHL for the surgical management of their distal radius fracture due to medical comorbidities/other confounding injuries, the vast majority were suitable for the ambulatory care pathway. Of those patients managed via the ambulatory pathway 100% were managed on an orthopaedic ward compared to 61% in 2018 and none had an inpatient stay >12 hours prior to their surgery compared to an average of 52.8 hours as inpatient preoperatively in 2018. Conclusions: The ambulatory care pathway is a safe, convenient and cost-effective method of managing these types of injuries.
A study in 2011 by (Doody et al. Ir Med J 106(10):300-302, 2013) looked at comparing inpatient ad... more A study in 2011 by (Doody et al. Ir Med J 106(10):300-302, 2013) looked at comparing inpatient adverse events recorded prospectively at the point of care, with adverse events recorded by the national Hospital In-Patient Enquiry (HIPE) System. In the study, a single-centre University Hospital in Ireland treating acute hip fractures in an orthopaedic unit recorded 39 patients over a 2-month (August-September 2011) period, with 55 adverse events recorded prospectively in contrast to the HIPE record of 13 (23.6%) adverse events. With the recent change in the Irish hospital funding model from block grant to an 'activity-based funding' on the basis of case load and case complexity, the hospital financial allocation is dependent on accurate case complexity coding. A retrospective assessment of the financial implications of the two methods of adverse incident recording was carried out. A total of €39,899 in 'missed funding' for 2 months was calculated when the ward-based, pr...
Background Hip fracture is a common serious injury afflicting the geriatric population and is ass... more Background Hip fracture is a common serious injury afflicting the geriatric population and is associated with poor clinical outcomes, functional and walking disabilities and high 1-year mortality rates. A multidisciplinary approach has been shown to improve outcomes of geriatric patients with fragility fracture. Aims We piloted a dedicated orthogeriatric service for hip fracture patients to determine if the service facilitated a change in major patient outcomes, such as mortality, length of stay and dependency. Methods A dedicated orthogeriatrics service for hip fracture was established as a collaborative project between the Department of Geriatric Medicine and Department of Orthopaedic Surgery at a university teaching hospital. Orthogeriatrics service data were collected prospectively on an orthogeriatric filemaker database from July 2011 to July 2012 (N = 206). Data were compared to previously recorded data (Irish Hip Fracture Database) on a cohort of hip fracture patients admitted to the same orthopaedic trauma unit from July 2009 to July 2010 (N = 248). Results Patients in the orthogeriatric service group experienced significant reductions in 1-year mortality (v 2 = 13.34, P \ 0.001), length of acute hospital stay (U =-3.77, P \ 0.001) and requirements for further rehabilitation (v 2 = 26.59, P \ 0.001). Patients in the preservice establishment group were significantly more dependent following their fracture than the patients in the orthogeriatric service group (v 2 = 5.34, P = 0.021). Conclusions A multidisciplinary management approach to fragility fracture of the femoral neck that involves comprehensive geriatric assessment, daily medical involvement of a geriatric team and specialised follow-up assessment leads to a significant reduction in mortality and improved outcomes. Keywords Orthogeriatric Á Fragility fracture Á Neck of femur Á Hip fracture Á Comprehensive geriatric assessment
We describe the implementation of a care pathway for patients with fractured neck of femur (NOF) ... more We describe the implementation of a care pathway for patients with fractured neck of femur (NOF) using Lean and Six Sigma principles. After introduction of the Lean pathway, 32 patients out a total of 86 (37%) with fractured NOF were admitted to the Trauma Ward within 4 hours of presentation to the hospital; prior to implementation this was 16 patients out of a total of 59 (27%). Post-Lean an earlier mean theatre start time of 8.40am was achieved, resulting in a 38 minute increase in daily theatre time. An additional 52 patients (12%) received surgery within 24 hours of admission, resulting in 1 night length of stay reduction. Lean methodology proved an effective method to guide change resulting in an improved journey for the patient and significant workflow gains.
Background Trauma places a burden on healthcare services accounting for a large proportion of Eme... more Background Trauma places a burden on healthcare services accounting for a large proportion of Emergency Department presentations. COVID-19 spread rapidly affecting over 30 million worldwide. To manage trauma presentations the Department of Trauma & Orthopaedic Surgery reorganised service delivery. Aim To assess the impact of service reorganisation and Virtual Clinics on patients in a Regional Unit in Ireland. Methods A retrospective review of trauma activity following introduction of Virtual Fracture Clinics and Theatre COVID Pathways for a 10 week period in comparison with the same 2019 period. All patients underwent both nasopharyngeal and oropharyngeal swabs PCR testing prior to operations. Theatre and outpatient activity were evaluated. Clinic data were accumulated using the Integrated Patient Management System. Results Theatre Activity. 242 patients underwent surgery in our trauma unit (mean 2.98 per list) during the COVID- 19 period. 29 cases were performed in repurposed elective hospital giving a total of 271 during the 2020 study period. 371 cases were performed in the same 2019 period (mean 4.58 per list). Outpatient Activity. We noted a 25.86% fracture clinic referral reduction during the COVID 19 period compared to 2019. There was a 150.77% increase in patients managed through Trauma Assessment Clinic. 639 patients were managed through the Virtual Fracture Clinic Pathway during COVID 19 period. Conclusions Over one in four fracture clinic patients can be managed virtually. A new dedicated Acute Fracture Unit within our institution permitted streamlining of care and social distancing. The “Non-COVID” pathway for ambulatory trauma was essential in managing the growing presentations of these injuries.
Lenehan B. Validating the role of orthopaedic advanced nurse practioners in the management of fra... more Lenehan B. Validating the role of orthopaedic advanced nurse practioners in the management of fracture clinic patients.
International Journal of Orthopaedic and Trauma Nursing, 2017
Patients with a hip fracture may be appropriately delayed for surgery as they require optimisatio... more Patients with a hip fracture may be appropriately delayed for surgery as they require optimisation or clinical interventions to treat acute medical illnesses (Moja et al., 2012) Other patients are inappropriately delayed due to hospital factors (Brener, 2013; Lee & Elfar, 2014). Timely efficient admission and surgery is well documented as the best course of management for these patients. The aim of this prospective cohort longitudinal follow-up study was to establish if a relationship existed between duration of time spent in the Emergency Department (ED), time to surgery and functional ability in patients with hip fractures and examine the effect prolonged waits may have had on the ability to return home. Functional ability for fifty one patients with a hip fracture was evaluated using the Barthel Index Score (BIS) on admission and at six weeks post-surgery. Data were analysed by using SPSS version 20. The study findings reveal a change in BIS at 6 weeks for patients who are delayed to surgery. Patients who experienced long delays (>12hrs) in the ED awaiting admission functioned less well (Kruskal-Wallis test p =.033). Correlation existed between time to surgery and returning to pre-fracture place of residence, (p= .000 Pearson chi-square), which also remained significant while controlling for age. Results indicate that prolonged waits had an overall negative impact on patients' post-fracture functional ability. This study highlights the deleterious effects on functional ability when surgery is delayed.
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