Implementation of an Orthopedic Trauma Program to Safely Promote Resident Autonomy

Abstract

Background There is ongoing tension in graduate medical education between progressive resident autonomy with entrustable professional activities and the need for supervision to ensure patient safety. Objective We implemented a pediatric orthopedic surgical trauma safety program that utilized a postcall review conference to provide residents graduated responsibility learning opportunities during overnight trauma call without compromising patient safety. Methods In the program, all orthopedic trauma cases seen in our main tertiary hospital emergency department by the overnight orthopedic resident were reviewed in a case conference. For 1 year, we performed an analysis of all fracture patients who were treated in the emergency department by our orthopedic surgery residents. From June 1, 2016, through June 30, 2017, all care delivery encounters were reviewed for decision-making errors, technical errors, and complication rates. Two resident groups rotated through our institution over the course of the study. Results During the year of analysis, all 1298 fracture patients seen overnight in the main tertiary hospital emergency department were reviewed. From the first to the second halves of their rotations, the rate of resident decision-making errors (3.1% [12 of 385] to 2.3% [9 of 399]) and technical errors (9.1% [35 of 395] to 7.3% [29 of 399]) decreased. Excluding decision-making and technical errors, the complication rate for patients discharged home was 3.4% (27 of 784). Conclusions Residents demonstrated decreased decision-making and technical error rates on overnight call while maintaining low complication rates.

Conscious sedation and reduction of fractures in the paediatric population: An orthopaedic perspective

“…Residents are supervised remotely by an attending board-certified paediatric orthopaedic surgeon. 15 Based off of internally-developed guidelines, residents triage patients into three groups: 1) patients who received definitive treatment (usually conscious sedation fracture reduction and casting) and are discharged home; 2) patients admitted directly to the hospital for infection, complex multi-trauma care, orthopaedic surgery or other clinical issue requiring immediate hospitalization; and 3) discharged patients who meet criteria for a satellite orthopaedic trauma OR, in which less-acute, stable, operative fracture cases receive surgical intervention at a dedicated satellite location trauma OR that week. 14 These internally-developed criteria include orthopaedic fracture type, medical and anaesthesia guidelines for cases that are appropriate for general anaesthetic in the OR opposed to conscious sedation and reduction.…”

“…Following this trauma case review, care coordinators contact patients to verify the plan of care with their families, notify them of any changes and confirm that there have been no new issues. 14,15…”

“…Following this trauma case review, care coordinators contact patients to verify the plan of care with their families, notify them of any changes and confirm that there have been no new issues. 14,15 Patient medical records were reviewed to determine diagnoses, treatment received, rates of changes in management and treatment outcomes of those patients that were deemed suitable for and received conscious sedation and reduction. We assessed for two major outcomes: 1) repeat intervention involving either cast wedging or surgical intervention for fractures that lost alignment after conscious sedation and reduction; and 2) changes in management, in which the orthopaedic resident's overnight management plan to provide procedural sedation and reduction was altered to surgical intervention after case review during morning rounds.…”