The virtual hand clinic: its use in optimizing trauma footfall in a hand trauma unit

Fenelon

et al. 2020

Clin Orthop Relat Res

Background Virtual fracture clinics are an alternative to the traditional model of fracture care. Since their introduction in 2011, they have become increasingly used in the United Kingdom and Ireland. The coronavirus disease 2019 (COVID-19) health crisis has driven institutions to examine such innovative solutions to manage patient care. The current controversies include quantifying safety outcomes, such as potential delayed or missed injuries, inadequate treatment, and medicolegal claims. Questions also exist regarding the potential for cost reductions and efficiencies that may be achieved. Physical distancing has limited the number of face-to-face consultations, so this review was conducted to determine if virtual fracture clinics can provide an acceptable alternative in these challenging times. Questions/purposes The aim of this systematic review was to describe (1) adverse outcomes, (2) cost reductions, and (3) efficiencies associated with the virtual fracture clinic model. Methods A systematic review of the PubMed, MEDLINE, and Embase databases was conducted from database inception to March 2020. The keywords “virtual” or “telemedicine” or “telehealth” or “remote” or “electronic” AND “fracture” or “trauma” or “triage” AND “clinic” or “consultation” were entered, using the preferred reporting items for systematic reviews and meta-analyses. Inclusion criteria included adults and children treated for injuries by a virtual clinic model at the initial review. Eligible injuries included injuries deemed to not need surgical intervention, and those able to be treated remotely using defined protocols. Exclusion criteria consisted of patients reviewed by telemedicine using video links or in person at the initial review. Initially, 1065 articles were identified, with 665 excluded as they did not relate to virtual fracture clinics. In all, 400 articles were screened for eligibility, and 27 full-text reviews were conducted on 18 studies (30,512 virtual fracture clinic encounters). Three subdomains focusing on adverse outcomes, cost reductions, and efficiencies were recorded. The term adverse outcomes was used to describe any complications, further surgeries, re-referrals back to the clinic, or deviations from the protocols. Efficiency described the number of patients reviewed and discharged using the model, savings in clinic slots, reduced waiting times, or a reduction in consumption of resources such as radiographs. All studies were observational and the quality was assessed using Newcastle-Ottawa tool, which demonstrated a median score of 6 ± 1.8, indicating moderate quality. Results Six studies reported adverse outcomes in detail, with events ranging from inappropriate splinting, deviations from protocols, and one patient underwent an osteotomy for a malunion. Efficiency varied from direct discharge proportions of 18% in early studies to 100% once the virtual fracture clinic model was more established. Cost reductions compared with estimates derived from conventional fracture clinics varied from USD 53 to USD 297 and USD 39,125 to USD 305876 compared with traditional fracture clinic visits. Conclusions Virtual fracture clinics may provide a means to treat patients remotely, using agreed-upon protocols. They have an important role in the current COVID-19 pandemic, due to the possibility to provide ongoing care in an otherwise challenging setting. More robust studies looking at this model of care will be needed to assess its long-term effects on patients, institutions, and health care systems. Level of Evidence Level IV, therapeutic study.

Section: Assessment Of Study Qualitymentioning

confidence: 99%

Are Virtual Fracture Clinics During the COVID-19 Pandemic a Potential Alternative for Delivering Fracture Care? A Systematic Review

Fenelon

et al. 2020

Clin Orthop Relat Res

Eur J Trauma Emerg Surg

“…Ten studies (38%) compared DD to routine care [8][9][10][11][12][13][14][15][16][17], whereas 16 (62%) studies did not have a control cohort [1,2,[18][19][20][21][22][23][24][25][26][27][28][29][30][31]. Twenty-four studies (92%) were conducted in the UK and two in New Zealand (8%) [25,26].…”

Section: Study Characteristicsmentioning

confidence: 99%

“…Secondary surgery rates were reported in two comparative studies and three non-comparative studies, ranging from 0.0 to 1.1% in the control cohort [9,12], [9,12,18,20,28] vs. 0.0-2.3% in the DD cohort [9,12,18,20,28]. Four non-comparative studies reported that 'no adverse outcomes' occurred [22,23,27,31].…”

Section: Patient Outcomesmentioning

confidence: 99%

Direct discharge of patients with simple stable musculoskeletal injuries as an alternative to routine follow-up: a systematic review of the current literature

Geerdink

Verbist

Dongen

et al. 2021

Purpose There is growing evidence that patients with certain simple stable musculoskeletal injuries can be discharged directly from the Emergency Department (ED), without compromising patient outcome and experience. This study aims to review the literature on the effects of direct discharge (DD) of simple stable musculoskeletal injuries, regarding healthcare utilization, costs, patient outcome and experience. Methods A systematic review was performed in Medline, Embase, CINAHL, Cochrane Library and Web of Science using PRISMA guidelines. Comparative and non-comparative studies on DD of simple stable musculoskeletal injuries from the ED in an adult/paediatric/mixed population were included if reporting ≥ 1 of: (1) logistic outcomes: DD rate (proportion of patients discharged directly); number of follow-up appointments; DD return rate; (2) costs; (3) patient outcomes/experiences: functional outcome; treatment satisfaction; adverse outcomes; other. Results Twenty-six studies were included (92% conducted in the UK). Seven studies (27%) assessed functional outcome, nine (35%) treatment satisfaction, and ten (38%) adverse outcomes. A large proportion of studies defined DD eligibility criteria as injuries being minor/simple/stable, without further detail. ED DD rate was 26.7–59.5%. Mean number of follow-up appointments was 1.00–2.08 pre-DD, vs. 0.00–0.33 post-DD. Return rate was 0.0–19.4%. Costs per patient were reduced by €69–€210 (ranging from − 38.0 to − 96.6%) post-DD. Functional outcome and treatment satisfaction levels were ‘equal’ or ‘better’ (comparative studies), and ‘high’ (non-comparative studies), post-DD. Adverse outcomes were low and comparable. Conclusions This systematic review supports the idea that DD of simple stable musculoskeletal injuries from the ED provides an opportunity to reduce healthcare utilization and costs without compromising patient outcomes/experiences. To improve comparability and facilitate implementation/external validation of DD, future studies should provide detailed DD eligibility criteria, and use a standard set of outcomes. Systematic review registration number: 120779, date of first registration: 12/02/2019.

“…Literature shows a number of examples of VCs being used within surgical specialties in recent years, including in hand trauma for the purpose of reviewing nonemergency referrals. [17][18][19][20][21][22][23] A randomized controlled trial (RCT) has demonstrated the safety of video-assisted consultations for the purpose of follow-up in patients having undergone ortho pedic surgery; however, it is important to note the presence of a trained nurse at the remote location. 21 Within this department, soft tissue injuries are reviewed 6 weeks postoperatively by the surgical team, after a period of hand therapy starting from 3 to 5 days following surgical repair.…”

Section: Discussionmentioning

confidence: 99%

Hand Trauma Virtual Clinics Prove Effective During the COVID-19 Pandemic

Popova

Young

Hobday

et al. 2021

Hand (New York, N,Y.)

Background Due to the devastating and far-reaching impact of the novel COVID-19 pandemic, hospital resources have been redirected to protect patients and health care staff, thereby vastly reducing the capacity for outpatient follow-up within a busy Plastic Surgery and Hand Trauma center. Through the use of telephone and video technology, virtual clinics were rapidly introduced to reduce hospital footfall. Methods This retrospective cohort study analyzed patient experiences in virtual and traditional face-to-face clinics through the month of April 2020, from the second week of the government-imposed lockdown. A 5-point Visit-Specific Satisfaction Questionnaire was used to subsequently collect patients’ feedback regarding their appointments. Results A total of 107 hand injury–related follow-up appointments were recorded during the 4-week period. Sixty (56.0%) appointments were performed as a virtual consultation, and 47 (43.9%) face-to-face consultations were carried out on site. It was possible to discharge 43.3% from the virtual clinic group and 57.4% from the face-to-face group. We identified no significant difference in patient satisfaction ( P = .368, Mann-Whitney U test) between the 2 cohorts. Conclusion Virtual clinics appear to be safe and effective for the follow-up of patients with traumatic hand injuries during the COVID-19 pandemic. This approach may prove beneficial in terms of workforce organization, reducing waiting times, and providing an alternative for patients unable to attend physical appointments.