Clinical Audit of Manipulation of Paediatric Forearm Fractures in the Emergency Department at a District General Hospital: A Quality Improvement Project.

Background Early reduction of paediatric forearm fractures under procedural analgesia has the benefit of avoiding admission and general anaesthesia. In addition to lowering the risks of treatment and reducing the number of treatment episodes, this approach also reduces the psychological stresses on the child and the parents. British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) and Getting It Right First Time (GIRFT) guidelines recommend that all units managing paediatric fractures should have protocols to facilitate procedural analgesia for manipulation of forearm fractures. A recent standard operating procedure has been created for this purpose and has outlined local standards to adhere to. Regular audits of paediatric manipulations in the emergency department must be undertaken in line with GIRFT recommendations. The aim is to identify potential barriers to implementation, which can be improved, and to ensure that a high standard of care is delivered.  Aim The aim of this study was to assess the effects of the introduction of local guidelines on the manipulation of paediatric fractures in the emergency department, to assess the adherence of the emergency/orthopaedic departments with these guidelines, and to assess the outcome of all childhood forearm manipulations at University Hospitals Dorset (UHD), to help guide further practice. Material and methods This was a retrospective and prospective study in which the patients admitted to Poole Hospital, Poole, United Kingdom were identified according to the criteria and were analyzed in three separate groups in terms of pre-implementation and post-implementation. Patients were gathered from the orthopaedic on-call trauma lists. All paediatric patients who had a forearm fracture were included (including those who were not manipulated). The first group was the surveillance group in which a clinical audit was completed to review if any of the paediatric patients with forearm fractures were being manipulated in accident and emergency (A&E). The second group included the patients for whom the first standard operating procedure documentation was initiated with the intention of improving the service provided and reduce the number of paediatric forearm fractures going to theatre for simple manipulation and prevent a general anaesthetic. The third group was to review the established pathway and to see which areas of the pathway needed focus to make it better and more in line with the flow of patients through the emergency department. These plan, do, study, act (PDSA) cycles took place from March 2022 to March 2023. Paediatric patients with open or neurovascular damage were excluded from the cohort. The findings and the data were analysed in Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States) and presented through regional meetings to discuss the progress and potential changes in making the pathway by involving all the stakeholders, i.e., the emergency department, orthopaedic department, and theatre managers. Results  An overall reduction was seen in paediatric forearm fractures going to theatre. Almost 30% of the forearm fractures were attended to in the emergency department, identification of factors that affect the numbers was quantified, and improvement in documentation throughout the PDSA cycles was observed.