Pediatric Fracture Care: Mending the Break through a Systems Approach

Purpose: Interdepartmental collaboration in a pediatric healthcare system has been limited between the pediatric emergency departments (EDs), urgent care centers (UCs) that provide immediate fracture care, and outpatient clinics that manage patient follow-up care. A review of internally reported adverse events showed an upward trend of incidences related to preventable casting and splinting-related injuries. A literature review was performed for evidence-based recommendations on safe cast removal and a series of interventions were implemented. An evidence-based practice (EBP) project was initiated July 2020 to improve staff education and collaboration between departments and reduce fracture care related complications while improving transparency of event reporting.

Description: Data was collected via an internal occurrence notification system (ONS) on incidences of pressure injuries related to splint application, and cast saw burns secondary to cast removal or bivalving/univalving of casts. An initial incidence rate per year was established. Interventions that were implemented included creation of a best practice instruction for safe cast removal, and creation of an orthopedic clinic shadowing program for ED orthopedic technicians. Evidence-based practice found during the literature review suggested proper saw technique, adequate cast padding, use of protective barriers, safe patient positioning, and attention to blade temperature were all contributing factors for safe cast removal and reduction in injuries. These EBP guidelines were included in the best practice instruction. Quarterly instruction and new hire skill validation sessions were developed for ED and UC nurses, techs, and medics. Regular communication of departmental policies and education with leaders in the EDs, UCs, and orthopedic practice was encouraged.

Evaluation/outcomes: ONS data showed a total of 17 reported incidents of fracture care-related injuries from October 2019 to September 2020. Rates after full implementation of improvement efforts decreased to 7 total incidents the following 12-month period from October 2020 to September 2021. Ongoing education for new hires will be continued as well as trending of incident reporting. Additionally, anonymous staff survey data demonstrated a reported increase in both knowledge and confidence with skills for performing ordered splinting secondary to education and skills validation sessions. The above described collaboration and educational efforts contributed to a 59% decrease in fracture care related injuries, as well as a reported increase of 16% in staff knowledge and 23% in staff confidence.