Background: In our institution patients with fifth metacarpal neck fractures used to be referred to fracture clinic. The first audit aimed to assess if the referral changes management. This resulted in implementation of new practice, followed by the re-audit and follow up. Methods: We looked at 6 months data retrospectively, followed by prospective data collection for 6 months after initiation of new practice and electronic monitoring of re-referrals. Local systems were used for data extraction. Fracture assessment included angulation, rotational deformity and whether it was an open injury. The financial department assessed the cost of each fracture clinic. Results: Thirty-six patients included in the first audit compared to 27 in the re-audit, referral rate is 97% and 78%, respectively. All injuries were closed and there was no rotational deformity. Two patients had volar angulation more than 50 in the second sample but none in the first one. All patients were treated with neighbour strapping for one to two weeks and subsequent mobilisation. There were no instances of change of management with attendance at fracture clinic. Sixty percent got discharged in first appointment, compared to 50% after re-auditing. Re-referral rate is 0%. Each fracture clinic costs just over £700. Conclusions: Patients with fifth metacarpal neck fractures should be managed in the ED through an agreed pathway, unless they have rotational deformity, are open or angled beyond 50 in which case they should be referred to the fracture clinic or on call orthopaedic team as appropriate. This will not only avoid an unnecessary attendance at fracture clinic, but also provide cost saving.
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system for which there is no known cure. There are licensed treatments available to influence the disease course, but for a small group of patients, progression of the disease may continue at an alarming rate. Mitoxantrone, a cytotoxic agent normally used in the treatment of cancer, has been shown to reduce disease activity in patients who have this more aggressive form of MS. However, the immunosuppressive action and side-effect profile of mitoxantrone mean that this drug should be used with caution. This article describes a MS nurse-led initiative where an evidence-based, integrated care pathway was designed to ensure a safe, high-quality service provision for this select patient group.
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