If It’s Broke, Fix It

The time for repairing a wide variety of fractures on an outpatient basis is now. With patients reluctant to be admitted to hospitals due to the pandemic, and health systems desperate to reserve resources, only the most traumatic and complex fractures need to be treated in an inpatient setting.

Patients with simple wrist and ankle fractures can have their injuries stabilized with splints as they await outpatient surgery to repair the breaks, according to Boris A. Zelle, MD, FAAOS, FAOA, professor, vice chair of research and program director of orthopedic trauma fellowship at UT Health San Antonio (Texas). He says other outpatient-friendly repairs include fractures of the collarbones, hands, fingers, kneecaps, heels and feet.

Dr. Zelle believes orthopedic surgeons must provide the best possible care to fracture patients, but they also have a duty to minimize hospital admissions and utilization of healthcare resources. He teamed with other researchers to publish a study in the journal International Orthopaedics about the feasibility of outpatient fracture repair. The team focused on what they describe as “blanket” inpatient admissions for traumatic closed ankle fractures, and found that outpatient repair of fractures is associated with low rates of readmission and postoperative complications.

Hundreds of patients involved in the study were evaluated and diagnosed in the ER, with appropriate management initiated, including closed fracture manipulation if necessary, splinting and pharmacological pain control. They were then assessed for feasibility of outpatient surgery based on patient and surgeon preference, OR availability, medical comorbidities and social circumstances. Labs, electrocardiograms and chest radiographs were obtained as necessary. Prior to being discharged, patients were provided education on at-home injury care as they awaited their same-day surgeries. On the day before surgery, patients were called to confirm the time of surgery and counselled on preoperative instructions.

On the day of surgery, most patients received peripheral nerve blocks, preoperative IV antibiotics and additional postoperative doses of IV antibiotics, along with serial neurovascular checks and appropriate pain management. They were discharged after being deemed medically stable and fulfilling discharge criteria, taking standard discharge instructions home after being scheduled for a follow-up appointment two weeks later.

The researchers analyzed 30-day rates of postoperative admission to the ER and unplanned hospital readmissions, as well as incidences of surgical site infection (SSI) within 12 weeks of surgery. They found 16.3% of the patients had an unplanned ER visit, and 1% required hospital readmission. Of the return ER visits, the most commonly recorded complaint was pain. Around 8% of the patients developed SSIs, with very few deep infections among them. Dr. Zelle says the differences in these rates when compared with inpatient recoveries are negligible.

The study shows outpatient fracture repair is feasible and pain management is a huge aspect of making it work, according to Dr. Zelle, who says ultrasound-guided nerve blocks can be used to numb the major nerves to extremities. “Patients can get 16 to 24 hours of pain control from these blocks,” he says. Upon returning home, patients begin taking pain medication before the nerve block wears off. A regimen like this prevents many patients from heading to the OR for follow-up care, says Dr. Zelle.

Given consumers’ embrace of urgent care facilities as an alternative to ER visits, orthopedic urgent care facilities that treat only fracture patients can further streamline the outpatient dynamic. “To have a place where patients are charged for a clinic appointment instead of an ER visit, and can be seen by an orthopedic surgeon right away, is a very progressive model,” he says. “Orthopedic practices need to have the resources in place to make it work. A smaller group of five surgeons would have trouble pulling it off, but a practice of 30 partners could certainly offer those services.”

An investigation performed at Mount Sinai Hospital in Toronto and published in The Journal of Bone & Joint Surgery resulted in a standardized pathway for outpatient fracture surgeries. Aiming to reduce unnecessary inpatient hospitalizations for healthy fracture patients, the study resulted in policy changes to facilitate outpatient urgent-room cases and education for patients and nurses.

“I’d grown very frustrated with seeing patients spend multiple days in a hospital bed waiting for surgery to repair their fractures,” says Jesse Wolfstadt, MD, MSc, FRCSC, an orthopedic surgeon at Sinai Health and an assistant professor at the University of Toronto. “We’re talking about wrist and ankle fractures. Patients could go home with a cast on and a set of crutches if they needed to.”

Adds Lisa Wayment, RN, MN, senior clinical program director for surgical services, “We received plenty of patient complaints and concerns related to frustration about being NPO multiple times and never getting to the OR, reflecting on the fact that they could have been at home the entire time.”

At the start, Dr. Wolfstadt consulted everyone he could at the facility, right down to patient intake personnel — even including a patient for feedback on at-home needs — to determine how to make the pathway flow efficiently while maintaining excellent outcomes. Before the study, 1.6% of fracture repair surgeries were performed on an outpatient basis at the hospital. That number is now pushing 90%. Length of stay was reduced from 2.8 days to 0.2 days, while patient satisfaction remained high, and safety concerns while patients waited at home for procedures were not a factor.

With major forces pushing fracture repair in the outpatient direction, ASCs and HOPDs are positioned for success — as long as they exercise heightened sensitivity to appropriate patient selection, employ multimodal pain management techniques, and educate providers and patients to produce positive outcomes. OSM