Validation of the Primary Care Pathway Model for Management of Orthopedic Injuries: Results of a Prospective, Queensland Study

Abstract

Objective: A “virtual fracture clinic” (VFC) is viewed as a safe, cost effective method of managing suitable low risk orthopedic injuries without direct orthopedic review. This method is used throughout the Glasgow Royal Infirmary (GRI) and National Health System (NHS) as a cornerstone for efficient patient care. This study assessed the outcomes of a newly implemented Queensland based Primary Care Pathway (PCP) for management of simple orthopedic injuries. Methods: A prospective cohort was formed of patients presenting over a 4-week period with an acute orthopedic injury to either the Emergency Department (ED) or Primary Care Providers within the Logan Hospital catchment in Queensland, Australia. Patients were triaged to either a PCP management protocol with General Practitioners (GP), Allied-Health Professionals (AHP) or to a traditional in-person Fracture Clinic (FC) orthopedic review. Patients were followed for 6-months. Data were collected about epidemiology, complications, appropriate allocation, and injury type. Results: A total of 1283 patients were referred over the study period, of which 267 were triaged to PCP management. ED referrals accounted for 62.5% of appropriate referrals to either clinic. Upper limb injuries were the most common conditions managed through the PCP. Patients managed by the PCP model of care experienced a 4.29% complication rate over the 6-month follow-up period. Conclusion: The PCP model of care is effective in managing criteria specific, low risk orthopedic injuries with a low rate of complications (4.29%) without direct orthopedic FC review. Use of a PCP reduces demand on hospital resources, and provides a safe, cost-effective alternative to a resource-restricted outpatient service.

CORR Synthesis: What Triage Recommendations Are Available for Emergent or Urgent Musculoskeletal Conditions?

“…We found a variety of studies describing triage practices in the outpatient primary care or orthopaedic setting [9, 16], ED setting [1, 2, 8, 10, 12, 19, 25, 32, 34], and in the trauma center setting [5, 7]. Although we did not find any studies related specifically to triage practices in the UCC or MUCC setting, some of the triage guidelines intended for use in the ED may be adapted for use in urgent care facilities.…”

“…Published triage protocols designed for use in the primary care setting were more targeted toward identifying low-acuity conditions that can be safely treated outside the ED [9,16]. One study conducted in the primary care setting included a table listing the upper and lower limb musculoskeletal conditions that can be safely managed by a primary care provider to reduce the demand on hospital resources; however, this study focused more on specific injuries rather than symptoms that could be used to direct patients to the most appropriate care setting [9]. Another study done in the outpatient setting included a table with referral protocols for specific musculoskeletal symptoms and diagnoses separated by part of the body [16].…”

“…Triage guidelines that can be used before arrival at a care facility are necessary to ensure patients are receiving orthopaedic care in the correct setting. Additionally, the two studies that were intended for use in the primary care setting mostly listed injuries that are appropriate for this setting instead of including questions that would help a provider distinguish between nonurgent and urgent orthopaedic conditions [9,16].…”

“…We found two articles that detailed triage guidelines for use in the primary care setting that described triage for low-risk orthopaedic injuries [9] and general orthopaedic injuries [16]. Two articles described triage guidelines for use in the ED focusing on upper extremity trauma and infections [10] and general orthopaedic injuries [34].…”

“…Additionally, many of the studies we found in our review were published in the early 2000s. Of the 13 studies included in our final review, only four were published after 2010 [5,9,10,25]. Of the seven studies specific to imaging in the ED, only one was published after 2010 [25].…”