Approximately 9000 patients present to Western Sydney Local Health District (WSLHD) emergency departments (EDs) each year following a hand trauma, with 13% of those patients re-presenting to Auburn Hospital ED within 48 hours for surgical review.
A lack of clarity around referral pathways has increased the number of unplanned presentations to ED for patients requiring surgical intervention, leading to an increase in surgical cancellation rates and use of overtime to ensure operating theatres are staffed appropriately. The majority of hand trauma patients requiring surgical review are filtered through to half-day outpatient plastics clinics at Auburn Hospital, staffed with medical, nursing, administrative and allied health staff. From 2021-2023, the Auburn Hospital Outpatient Plastics Clinic saw an increase from 5200 Occasions of Service (OOS) to 6500. Although already trending upwards, this sudden increase in OOS has led to increased waiting times of up to three hours, increased “Did Not Attend” (DNA) rates and increased walk-in rates. The lack of predictability in clinic attendance numbers has impacted the workflow through the clinic and has also led to difficulties in allocating appropriate staffing and poor patient experience.
Hand Therapy teams located at Auburn, Westmead, Blacktown & Mount Druitt Hospitals are well equipped to take on a primary contact role for patients with stable closed fractures and dislocations, as well as closed soft tissue injuries of the hand and wrist. While pathways to direct appropriate patients to local hand therapy services directly from ED presentation have been established, awareness and utilisation remains poor.
A helping hand to patient access
The Hand in Hand project aims to improve patient access to appropriate and timely care within WSLHD by December 2024. Key outcomes include:
- decrease the number of hand trauma-related emergency department re-presentations to WSLHD EDs from 16% (~1300 patients/year) to 8% by December 2024
- reduce the number of walk-in patients attending Auburn Hospital Outpatient Plastics Clinic from 26% (~1700 patients/year) to 10% by December 2024
- decrease the number of emergency theatre list cancellations from ~25% (~50 cases/month) to 5% by December 2024
- decrease the number of procedures that only require local anaesthetic being performed in operating theatres from 40% (~600 cases/year) to 10% by December 2024
- reduce the number of patients reporting excessive waiting times in the Auburn Hospital Outpatient Plastics Clinic as a concern from 37% to 10% by December 2024.
Facilitating rapid patient assessment
Three solutions were identified and developed in consultation with key stakeholders from across WSLHD. Additional one-hour “mini clinics” have been implemented on weekdays, allowing rapid assessment of patients requiring emergency surgery as an ED avoidance strategy. Previously, patients requiring urgent surgical review were directed to Auburn Hospital ED, leading to high numbers of planned ED re-presentations. Inclusion and exclusion criteria were developed by the stakeholder group and the ‘mini clinics’ underwent a trial phase three days per week for a 10-week period. Data was gathered and presented to the project executive steering committee before being endorsed in February 2024.
It was noted during project diagnostics, that a key issue was the lack of clearly documented processes for staff to refer to when managing patients presenting with hand injuries. This included no documented Model of Care (MoC) and numerous site-specific operational guidelines and business rules that were often difficult to locate. The project team and working group developed the WSLHD Integrated Hand Service Model of Care to document current practice as well as desired “future state” with a focus on improvements to the patient journey.
Finally, an opportunity was identified to reallocate procedures suitable for local anaesthetic only to a Minor Procedure Room (MPR). This will reduce pressure on operating theatre resources as well as allowing more timely access to procedures for patients, improving patient experience. Both the future state MoC and the MPR will be implemented in a staged approach pending the successful endorsement of a business case to be completed in the coming months. Quick wins include an updated clinic patient information handout, updated e-Referrals and the development of clinic specific Did Not Attend (DNA) policy.
Unnecessary use of ED resources avoided
During the testing phase, 106 patients were seen within the mini clinics, avoiding secondary ED presentations and unnecessary use of ED resources. Patients were seen, and departed from the clinic in an average of 49 minutes, and 90% of patients were admitted directly from clinic for surgery. A full project evaluation will be undertaken in December 2024 to review if the project outcomes are on track or have been achieved, including patient surveys, staff surveys, outpatient data reports, theatre data reports and ED presentation reports.
View this project's poster from the Centre for Healthcare Redesign graduation May 2024.
