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Specialist Orthopaedic Nurses: Frontline for Fracture Clinic Referrals
Abstract
Emergency department (ED) and general practitioner (GP) referrals to orthopaedic fracture clinics are increasing. As a consequence, these clinics regularly operate at or beyond full capacity. In many institutions, all ED referrals are booked into and seen in the fracture clinic within 24 hours of presentation to the ED. A proportion of these appointments will prove unnecessary and, in other cases, review within several days of the injury will prove unnecessarily early. This precipitates lengthy delays, leading to inefficiency and patient dissatisfaction.
Background
Musculoskeletal conditions are the world’s fourth largest burden of disease, accounting for more than 50% of chronic health conditions in the population aged >50 years (Briggs et al., 2016). This increasing burden is due to a progressively overweight, sedentary and ageing population and is often poorly recognised as a priority globally in an under-resourced health care system. This article reviews the current literature to identify where Orthopaedic Nurse Practitioners (ONPs) currently fill gaps in care delivery through varied scopes of practice in musculoskeletal trauma, degenerative disease, tumour and bone health. The varied scopes of practice include, fracture management, surgical assisting, performing surgical and/or advanced clinical procedures, prescribing treatment for bone health, conducting home visits and managing ONP led outpatient clinics. The article will outline current ONP roles in orthopaedic trauma, pain management, surgical assisting, fragility fractures and osteoporosis, bone and soft tissue sarcoma and orthopaedic outpatient clinics which effectively address long waiting lists, gaps in care delivery and reduce costs currently being managed by the health care system.
Method
A brief search of the literature published from January 2008 – January 2020 on CINAHL, Cochrane Library, MEDLINE, Joanna Briggs Institute, Ovid, PubMed, Embase and Pro Quest databases was undertaken using key words Orthopaedic Nurse Practitioner, Advanced Practice Nurse (APN), musculoskeletal health, bone health, nurse-led and nurse specialist.
Conclusion
ONPs offer an innovative, viable and cost-effective solution to providing comparable, effective and efficient care with varied scopes of practice and valuable experience in both the inpatient and outpatient settings.
After special training a nurse practitioner ran an independent clinic for follow-up patients with breast disease. All patients referred to a single surgical firm with breast cancer and most patients with benign disease who required follow-up were included.
In the first 2 years of the service 382 clinic visits were recorded (median 5/clinic, range 1–12). The nurse practitioner reviewed 236 (62%) patients alone but involved the consultant surgeon in the remainder. No significant lesion was missed in these patients.
The nurse-led clinic is popular with patients and, subject to careful supervision, offers an attractive option for follow-up of patients with breast disease.
Our hospital operates a consultant-led, rapid review process of X-rays and case notes of all musculoskeletal injury patients on a daily basis. This compares with other centres where patients are reviewed in out-patient fracture clinics soon after injury. The aim of this study was to evaluate the effectiveness of this consultant-led, rapid review process compared to standard consultant fracture clinics.
A prospective study of the rapid review process over 4 weeks of all musculoskeletal injury patients was conducted. The total number of patients referred per day, time taken to review these patients X-rays and case notes, number of recalls and reason for recall were documented. This was compared to consultant-led fracture clinics, which included time taken to review patients.
A total of 797 patients were processed through the rapid review over 4 weeks: 53 (6%) patients were recalled, 32 (4%) for a change of management and 21 (2.6%) because of lack of information. The mean number of patients referred per day was 28 taking a mean of 28 min; thus the mean time to review one patient was 1.0 min. The mean number of patients recalled per day was two. The mean time taken to review a patient in a standard fracture clinic was 11 min. Therefore, the total time that would have taken to review 28 patients in a standard fracture clinic would be 308 min.
A consultant-led, rapid review process of all patients with musculoskeletal injury is a very efficient process. The rapid review process saves clinic time and resources, minimises delays in clinical decision-making and saves the patient an unnecessary visit to the outpatient department.
We aimed to assess the care and outcome of patients with minor injuries who were managed by a nurse practitioner or a junior doctor in our accident and emergency department.
1453 eligible patients, over age 16 years, who presented at our department with minor injuries were randomly assigned care by a nurse practitioner (n=704) or by a junior doctor (n=749). Each patient was first assessed by the nurse practitioner or junior doctor who did a clinical assessment; the assessments were transcribed afterwards to maintain masked conditions. Patients were then assessed by an experienced accident and emergency physician (research registrar) who completed a research assessment, but took no part in the clinical management of the patient. A standard form was used to compare the clinical assessment of the nurse practitioner or junior doctor with the assessment of the research registrar. The primary outcome measure was the adequacy of care (history taking, examination of patient, interpretation of radiographs, treatment decision, advice, and follow-up).
Compared with the rigorous standard of the experienced accident and emergency research registrar, nurse practitioners and junior doctors made clinically important errors in 65 (9.2%) of 704 patients and in 80 (10.7%) of 749 patients, respectively. This difference was not significant. The nurse practitioners were better than junior doctors at recording medical history and fewer patients seen by a nurse practitioner had to seek unplanned follow-up advice about their injury. There were no significant differences between nurse practitioners and junior doctors in the accuracy of examination, adequacy of treatment, planned follow-up, or requests for radiography. Interpretation of radiographs was similar in the two groups.
Properly trained accident and emergency nurse practitioners, who work within agreed guidelines can provide care for patients with minor injuries that is equal or in some ways better than that provided by junior doctors.
A solution to safeguard high quality diabetes care may be to allocate care to the nurse specialist. By using a one group pretest-posttest design with additional comparisons, this study evaluated effects on patient outcomes of a shared care model with the diabetes nurse as main care-provider for patients with type 2 diabetes in a primary care setting. The shared care model resulted in an improved glycaemic control, additional consultations and other outcomes being equivalent to diabetes care before introduction, with the general practitioner as main care-provider. Assignment of care for patients with type 2 diabetes to nurse specialists seems to be justified.
A prospective study was conducted to assess nurse-led follow-up of patients with fracture.