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BackgroundScaphoid fractures comprise approximately 50–70% of carpal bone fractures but can be difficult to detect on initial plain film radiographs. A delayed diagnosis can lead to a high rate of non-union, avascular necrosis and Complex Regional Pain Syndrome. Current literature supports cone beam CT (CBCT) (within 10–14 days) as an effective method for diagnosing scaphoid fractures. We implemented an early outpatient CBCT pathway, prior to specialist review, with the aim to increase the proportion of patients with suspected scaphoid fracture undergoing CBCT within 7 days.MethodsWe designed an ambulatory pathway for suspected scaphoid fractures in the Emergency Department (ED) in which outpatient CBCT was requested by emergency medicine clinicians. A retrospective audit of current management of these patients was performed between 1 August 2022 and 31 October 2022 (prepathway period). A list of patients who underwent CBCT performed for the indication ‘suspected scaphoid or carpal bone fracture’ in the hospital was obtained and screened. Implementation of the pathway took place in February 2023 and was reviewed by continuous audit monitoring from 1 March 2023 to 31 May 2023 (postpathway period).ResultsPrepathway implementation, 54 patients underwent CBCT. Following implementation of our pathway, the number of CBCTs performed in the hospital for this clinical indication increased to 111 (postpathway). The proportion of patients undergoing CBCT within 7 days increased from 11.1% (6/54) to 91.8% (102/111) (p<0.000). There was a 71.9% reduction in fracture clinic attendances (50/54 (92.6%) prepathway and 23/111 (22.5%) post pathway (p<0.000).ConclusionWe successfully implemented an ambulatory pathway for suspected scaphoid fractures in the ED that significantly increased the proportion of patients with suspected scaphoid fractures undergoing early (<7 days) CBCT and definitive care.

Background and AimsRib fractures represent a substantial health burden. Chest injuries contribute to 25% of deaths after trauma and survivors can experience long standing consequences, such as reduced functional capabilities and loss of work. Over recent years there has been an increase in awareness of the importance of early identification, aggressive pain management and adequate safety-netting for these patients. Poor management leads to increase rates of morbidity and mortality. Aim: Development of an evidence based, multidisciplinary chest injury pathway for the management of patients presenting with rib injuries in the Emergency DepartmentMethodsWe used Plan Do study Act cycles as a framework for our quality improvement project. Patients‘ note presenting with torso trauma were reviewed from march to June 2021. Our five Specific, Measurable Actionable Realistic and Timely (SMART) measures were: analgesia on arrival, time to analgesia, fascial block performed, discharge leaflet given and compliance with the pathway.ResultsImplementation of the pathway increased rates of documented analgesia received from 39% to 70%. The number of regional blocks performed went from 0% to 60% and the number of patients receiving discharge advice went from 7% to 70%. The use of the pathway by doctor and nurses was 63%.ConclusionsThis quality improvement project involved the development of a multidisciplinary pathway for patients presenting to the Emergency Department with rib fractures in order to drive a change from previous practice. The quality of care provided to patients attending with rib fractures showed improvement with increases in analgesia received, blocks performed, and discharge advice given.

Rib fractures represent a substantial health burden. Chest injuries contribute to 25% of deaths after trauma and survivors can experience long-standing consequences, such as reduced functional capabilities and loss of employment. Over recent years, there has been an increase in the awareness of the importance of early identification, aggressive pain management and adequate safety netting for patients with chest injuries. Substandard management leads to increased rates of morbidity and mortality. The development of protocols in the emergency department (ED) for management of patients with chest wall injuries has demonstrated reduction of complication rates.Our aim was to develop an evidence-based, multidisciplinary chest injury pathway for the management of patients presenting with rib injury to our ED.Prior to implementation of the pathway in our department, only 39% of patients were documented as having received analgesia and only 7% of discharged patients had documented written verbal advice. There was no standardised method to perform regional anaesthetic blocks. Using quality improvement methods, we standardised imaging modality, risk stratification with a scoring system, analgesia with emphasis on regional anaesthesia blocks and disposition with information leaflets for those discharged.Implementation of the pathway increased rates of documented analgesia received from 39% to 70%. The number of regional anaesthetic blocks performed went from 0% to 60% and the number of patients receiving discharge advice went from 7% to 70%. Compliance of doctors and nurses with the pathway was 63%.Our previous audits showed substandard management of patients with chest injuries in our department. Through this quality improvement project, we were able to improve the quality of care provided to patients attending with rib fractures by increasing rate of analgesia received, regional blocks performed and discharge advice given.

[...]if thrombosis is present within the non-compressible region of the clavicle, ultrasound may be falsely negative. 2 MR or CT venogram is recommended if index of suspicion is high after a negative Doppler ultrasound scan. 2 Learning points Paget Schroetter syndrome is rare but should be ruled out in young patients presenting with signs and symptoms of upper limb deep venous thrombosis. 1 Repetitive strain and subsequent subclavian vein impingement is thought to be the underlying aetiology.

Existing literature has demonstrated the efficacy of a virtual fracture assessment clinic pathway, however there is limited research exploring patients' experiences of a complete pathway, from initial presentation at the Emergency Department or Injury Unit to discharge. The aim of this study was to explore the experiences of patients who have recently sustained a stable peripheral limb fracture, having received care across a complete virtual fracture assessment clinic pathway, in order to improve patient care. One-to-one semi-structured interviews were completed via recorded phone and video calls, with a purposive sample of 12 participants. Interviews were completed until data saturation was achieved. Interviews were transcribed verbatim and data was analysed using thematic analysis. Six overarching themes were identified; 'trust' (in the pathway and management plan), 'conflicting advice' (on diagnosis and management plan), 'information' (need for more basic information), 'severity of injury' (participants' perceptions of the severity of their injuries), 'reassurance' (through follow-up x-rays and physiotherapy consultations) and 'efficiency'. This is the first qualitative study exploring patients' experiences of a complete virtual fracture assessment clinic pathway. Patients' experiences may be improved through patient education on the pathway process and providing standardised injury-specific patient information documentation. Regular communication between different healthcare professionals involved in the pathway may reduce conflicting advice. Developing an opt-in physiotherapy service and providing patients with a standardised text message informing patients when their virtual consultation will occur may also improve patients' experience of the pathway. Establishing a referral pathway with a fracture liaison service is also recommended to further enhance a virtual fracture assessment clinic pathway. Future research is needed to investigate how therapeutic relationships can be developed when care is delivered virtually and to explore the experiences of patient cohorts who were not included in this study.

Increasing numbers of older patients are presenting to the ED following trauma. These patients require multidisciplinary care that the traditional trauma model fails to provide. A Silver Trauma Review Clinic (STRC) was developed in conjunction with the geriatric ED and multidisciplinary services to improve the post-discharge care of patients with non-operative traumatic injuries.We aimed to assess the STRC by reviewing the journey and outcomes of patients who attended the clinic. A retrospective review of electronic chart data was performed on all patients who attended the clinic over the initial 1-year period. Data were collected on patient demographics, medical history, medications, timelines, trauma assessments and further investigations, fracture types, occult injuries, geriatric assessments (Comprehensive Geriatric Assessment, Clinical Frailty Scale, bone health, falls, Orthostatic Hypotension (OH), cognitive screening, mobility), number of reviews and discharge destination. 137 patients were reviewed with a median age of 80 years (IQR 74-86) and 69% were female. The median Clinical Frailty Scale was 3 with a median time from the patient's initial ED presentation to clinic of 15 days (IQR 9.75-21) and median time from initial review to discharge 20 days (IQR 1-35). 71% of presentations were as a result of falls under 2 m. Tertiary survey in the STRC identified previously unrecognised injuries in 24 patients (18%). In total, 56 patients were reviewed with vertebral fractures. 87% of these patients (n=49) were further investigated with a CT or MRI and 95% of patients (n=53) were referred for physiotherapy. Patients attending the STRC had a comprehensive geriatric assessment with abnormal Mini-Cog assessments found in 29%, a new diagnosis of osteoporosis in 43% and orthostatic hypotension diagnosed in 13% of patients. 61% were discharged to primary care and 19% linked into a specialist geriatric clinic. The STRC is a novel approach allowing timely, patient-focused, comprehensive and collaborative trauma care of older patients following non-operative injuries.

Key summary points Aim To determine the prevalence of frailty among older people attending emergency care. Findings Across 14 European countries, 40% of older people using emergency care were living with at least mild frailty. 14% of all adult users were older people with frailty. Message The high prevalence of frailty in emergency care indicates the need to accordingly configure healthcare systems and plan workforces. Introduction Current emergency care systems are not optimized to respond to multiple and complex problems associated with frailty. Services may require reconfiguration to effectively deliver comprehensive frailty care, yet its prevalence and variation are poorly understood. This study primarily determined the prevalence of frailty among older people attending emergency care. Methods This cross-sectional study used a flash mob approach to collect observational European emergency care data over a 24-h period (04 July 2023). Sites were identified through the European Task Force for Geriatric Emergency Medicine collaboration and social media. Data were collected for all individuals aged 65 + who attended emergency care, and for all adults aged 18 + at a subset of sites. Variables included demographics, Clinical Frailty Scale (CFS), vital signs, and disposition. European and national frailty prevalence was determined with proportions with each CFS level and with dichotomized CFS 5 + (mild or more severe frailty). Results Sixty-two sites in fourteen European countries recruited five thousand seven hundred eighty-five individuals. 40% of 3479 older people had at least mild frailty, with countries ranging from 26 to 51%. They had median age 77 (IQR, 13) years and 53% were female. Across 22 sites observing all adult attenders, older people living with frailty comprised 14%. Conclusion 40% of older people using European emergency care had CFS 5 + . Frailty prevalence varied widely among European care systems. These differences likely reflected entrance selection and provide windows of opportunity for system configuration and workforce planning.

Acknowledgement: I would like to acknowledge the Mater Foundation Charity without whom purchase and acquisition of a dedicated ultrasound machine for the Mater Misericordiae University University Hospital Emergency Department would not have been possible.