Outcomes after implementation of an open fracture clinical pathway
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TRAUMA SURGERY
Outcomes after implementation of an open fracture clinical pathway Wei Jie Tan1 · Ernest Beng Kee Kwek2 Received: 21 August 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Introduction Open fractures are associated with high rates of complication, morbidity and high economic costs. To improve outcomes, an open extremity fracture clinical pathway that protocolized surgical management and encouraged multidisciplinary collaboration was implemented in our institution. This study evaluates the clinical outcomes before and after the implementation of the pathway. Methodology Retrospective review of open tibial and femur fractures covering the 2 year periods before and after pathway implementation was conducted. Patient demographics, fracture location, fixation methods and Gustilo–Anderson classification type were recorded. Primary outcomes include complications of wound infection, implant infection, delayed/ non-union and flap failure occurring in a 1 year follow-up period. Secondary outcomes include length of hospital stay, time from emergency department (ED) entrance to first wound debridement, time from ED to flap coverage and total number of operations required. Results A total of 43 pre-pathway and 46 post-pathway patients were included in this study. There was a significant reduction in length of hospital stay, a 37.5% decrease from a median of 11.2 to 7 days after pathway implementation. There was also a significant decrease in the number of fractures fixed with external fixators from 47 to 26%. No significant differences were found for the other secondary variables. In a subgroup analysis of type III fractures, there was a significant decrease in length of hospital stay as well as the number of operations required. Median length of hospital stay decreased by 46.7% from 15 to 8 days and total number of operations decreased by 50% from a median of four operations to two operations. Conclusion This study demonstrates that the implementation of an open extremity fracture clinical pathway significantly reduces the proportion of external fixation surgeries, length of hospital stay, and number of operations in patients with open tibial and femur fractures, without compromising complication rates. Keywords Open fractures · Tibial fractures · Femoral fractures · Critical pathways · Outcome assessment (health care) · Wound infection · Length of stay · Debridement · Surgical flaps
Introduction Open fractures are usually sustained from high-energy trauma causing significant soft tissue damage, thus increasing the risk of associated complications such as deep infection and non-union. Despite the adoption of classification systems such as the Gustilo–Anderson classification and the continued development of management principles for open * Wei Jie Tan [email protected] 1
MOH Holdings Pte Ltd, 1 Maritime Square, Singapore 099253, Singapore
Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore, Singapore
2
fractures of varying severity, complication
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