Improving Sustainable Value of Paediatric Buckle Fracture Care and improving awareness of Wessex Healthier Together

Project completed as part of the 2024 Hampshire Hospitals NHS Foundation Trust Green Team Competition.

Team members:

• Dr Daniel Lopez Baez, Emergency Medicine Trainee ST1
• Dr Rachel Harrison, Paediatric Emergency Department (ED) Consultant
• Dr Nitya Mandeda, Clinical Fellow in Emergency Medicine

Setting / patent group:  

• Paediatric Emergency Department

Issue:

Children are disproportionately highly represented amongst an overall increase in Emergency Department (ED) attendances. The most common cause of these attendances are injuries, among which the most common are buckle fractures. The Forearm Fracture Recovery in Children Evaluation (FORCE) suggests that less is more, and that there is no significant difference between managing such injuries with a bandage and a splint and cast. The ‘FORCE’ protocol, though, has low uptake, with a local audit finding 0% of buckle fractures were managed with a bandage.

The same investigation also found that many other upper limb injuries did not require interventions and so could have been managed from home. A survey of caregivers found that most believe an online resource could have removed the need for an ED attendance, but there was low awareness of such resources, even where they already existed.

Intervention:

An initial survey of doctors, emergency medicine nurses, and physician associates showed awareness of the FORCE protocol was only 20%, and in no cases were bandages used ahead of splints or casts and reattendance. The team decided to intervene through a campaign to increase awareness of the force protocol through infographics, reminder communications, and education for clinicians. The initial survey itself also served as a mechanism for raising awareness, as did engagement with senior leadership.

To increase awareness of a local online information resource for managing injuries at home (Wessex Healthier Together), the team engaged with patients and caregivers through infographics in paediatric ED waiting areas and encouraging clinical staff to explain the resource to their patients.

In a first month of measurement there were 120 buckle fractures and 57% were treated with a bandage, up from a 0% prior to the intervention. This led to savings through using a lower carbon footprint alternative (bandages produce 0.1852kg CO2e compared to 0.3535kg CO2e for a splint), and a reduction in ED attendances (13.8kg CO2e)

Outcomes:

• Environmental
  • 11.5kgCO2e per month; projected to 138kgCO2e a year
  • Projected reduction of 125 unnecessary reattendances, equivalent to 20,700kg CO2e across a year
• Social
  • Improved confidence for staff managing fractures more sustainably
  • Increased confidence for caregivers managing injuries at home
• Clinical
  • Faster return to normality and reduced muscle atrophy when FORCE protocol applied
  • Increased standardisation of care
• Financial
  • Monthly saving of £857.17, projected to £10,286 over a year
  • Increasing at home management of injuries could reduce unnecessary attendances worth £141,000 a year

Key learning point:

Increasing awareness of the FORCE protocol has increased the standardisation of care for paediatric buckle fractures and reduced the carbon and financial cost of that care. In bringing about the change in practice, it was particularly valuable to ensure that key decision makers were onboard, and foster word of mouth and ‘shopfloor conversations’ through ongoing education and awareness raising.

The work to increase at home management of injuries revealed that caregivers believe an online resource could reduce the need for reattendance at ED. This highlights the need to focus on patient education to reduce attendances. Further work should be done to promote such resources not only to patients who have presented to ED, but also the wider population.