Buckle Fracture Treatment with Removable Wrist Orthosis Achieves Clinical Excellence (BRACE): A Quality Improvement Study
Buckle Fracture Treatment with Removable Wrist Orthosis Achieves Clinical Excellence (BRACE): A Quality Improvement Study
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Caroline Wang v2.pdfCaroline Wang, MD, MBA; Donald T. Kephart, MD; Holly B. Leshikar, MD, MPH; Julia N. Magana, MD
Caroline Wang, MD, MBA; Donald T. Kephart, MD; Holly B. Leshikar, MD, MPH; Julia N. Magana, MD
Oral Presentation
Oral Presentation
Caroline Wang.mp3Background: Distal radius and ulna buckle fractures are a frequent reason for pediatric ED visits and were historically managed by immobilization in a cast, requiring orthopedic surgery consultation. Studies have shown equivalent outcomes in using a removable splint rather than a cast, with reduced costs, increased efficiency, and improved patient/family satisfaction.
Background: Distal radius and ulna buckle fractures are a frequent reason for pediatric ED visits and were historically managed by immobilization in a cast, requiring orthopedic surgery consultation. Studies have shown equivalent outcomes in using a removable splint rather than a cast, with reduced costs, increased efficiency, and improved patient/family satisfaction.
Aim: To increase the use of removable splints in our pediatric ED from 17% to 90% within 18 months. A secondary outcome was to reduce orthopedic consultations in the ED for these injuries from 88% to <10%.
Aim: To increase the use of removable splints in our pediatric ED from 17% to 90% within 18 months. A secondary outcome was to reduce orthopedic consultations in the ED for these injuries from 88% to <10%.
Methods: Inclusion criteria were children 2-18 years old with distal forearm buckle fractures on x-ray in the ED. A key driver diagram was developed. Key interventions included a standardized protocol, provider education, and standardized discharge instructions. The protocol involved placing splints without consultation or follow-up with orthopedics. The primary outcome was proportion of patients with splint placement. The secondary outcomes were proportion of patients with orthopedic consults, orthopedic follow-up, x-ray number, and length of stay. The balance measure was proportion of patients with a 30-day return ED visit. Monthly data was reviewed on a run chart to inform PDSA cycles. Two-sample t-tests assuming unequal variances was used to compare pre- versus post-improvement project outcomes.
Methods: Inclusion criteria were children 2-18 years old with distal forearm buckle fractures on x-ray in the ED. A key driver diagram was developed. Key interventions included a standardized protocol, provider education, and standardized discharge instructions. The protocol involved placing splints without consultation or follow-up with orthopedics. The primary outcome was proportion of patients with splint placement. The secondary outcomes were proportion of patients with orthopedic consults, orthopedic follow-up, x-ray number, and length of stay. The balance measure was proportion of patients with a 30-day return ED visit. Monthly data was reviewed on a run chart to inform PDSA cycles. Two-sample t-tests assuming unequal variances was used to compare pre- versus post-improvement project outcomes.
Results: In the first 13 months of our improvement project, the proportion of eligible patients with removable splints increased from 17% (n=9) to 87% (n=27) (p<0.001). Orthopedic consults decreased from 88% (n=46) to 17% (n=5) (p<0.001), and surgical clinic follow up decreased from 86% (n=45) to 20% (n=6) (p<0.001). Average x-rays decreased from 1.3 to 1.0 (p<0.001). There was no statistically significant difference of the decreased length of stay from 203 to 171 minutes (p=0.06, CI -6.4-70.3). The balance measure was unchanged.
Results: In the first 13 months of our improvement project, the proportion of eligible patients with removable splints increased from 17% (n=9) to 87% (n=27) (p<0.001). Orthopedic consults decreased from 88% (n=46) to 17% (n=5) (p<0.001), and surgical clinic follow up decreased from 86% (n=45) to 20% (n=6) (p<0.001). Average x-rays decreased from 1.3 to 1.0 (p<0.001). There was no statistically significant difference of the decreased length of stay from 203 to 171 minutes (p=0.06, CI -6.4-70.3). The balance measure was unchanged.
Conclusions: Initiation of our improvement interventions has increased the use of removal splints and reduced orthopedic consults, clinic follow up, and x-ray number. Limitations include only having access to our hospital records and a lower sample size. We are unable to directly reach all providers in the community, and resident turnover can be a challenge. Next steps include continuing education for all treatment teams, and to further partner with caregivers to ensure discharge instructions are brought to their PCP follow-ups to prevent unnecessary referrals.
Conclusions: Initiation of our improvement interventions has increased the use of removal splints and reduced orthopedic consults, clinic follow up, and x-ray number. Limitations include only having access to our hospital records and a lower sample size. We are unable to directly reach all providers in the community, and resident turnover can be a challenge. Next steps include continuing education for all treatment teams, and to further partner with caregivers to ensure discharge instructions are brought to their PCP follow-ups to prevent unnecessary referrals.
Resident Statement of Involvement: In collaboration with Dr.’s Magana, Leshikar, and Kephart, we conceived the project idea. Together we created and implemented the protocol. I received and analyzed monthly data. I presented our QI project as an oral presentation at WSPR and was accepted for a poster presentation at PAS.
Resident Statement of Involvement: In collaboration with Dr.’s Magana, Leshikar, and Kephart, we conceived the project idea. Together we created and implemented the protocol. I received and analyzed monthly data. I presented our QI project as an oral presentation at WSPR and was accepted for a poster presentation at PAS.
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