Optimising fast track care for proximal femoral fracture patients using modified early warning score

• Published in: Annals of the Royal College of Surgeons of England 2012-05, Vol.94 (4), p.267-271
• Main Authors: Ollivere, B, Rollins, K, Brankin, R, Wood, M, Brammar, T J, Wimhurst, J
• Format: Article
• Language: English
• Subjects: Aged; Clinical Protocols - standards; Critical Pathways - standards; Diagnostic Errors - statistics & numerical data; Early Diagnosis; Emergency Service, Hospital - organization & administration; Emergency Service, Hospital - standards; Femoral Neck Fractures - complications; Femoral Neck Fractures - therapy; Fluids; Fractures; Hospitals; Humans; Medical referrals; Middle Aged; Mortality; Orthopaedic Surgery; Pathology; Patients; Physiology; Prospective Studies; Referral and Consultation - standards; Trauma; Treatment Outcome
• ISSN: 0035-8843; 1478-7083
• DOI: 10.1308/003588412X13171221501744

The care for patients with a proximal femoral fracture has been dramatically overhauled with the introduction of 'fast track' protocols and the British Orthopaedic Association guidance in 2007. Fast track pathways focus on streamlining patient flow through the emergency department where the guidance addresses standards of care. We prospectively examined the impact these protocols have on patient care and propose an alternative 'streamed care' pathway to provide improved medical care within existing resource constraints. Data surrounding the treatment of 156 consecutive patients managed at 4 centres were collated prospectively. Management of patients with a traditional fast track protocol allowed 17% of patients to leave the emergency department with undiagnosed serious medical pathology and 32% with suboptimal fluid resuscitation. A streamed care pathway based on the modified early warning score was developed and employed for 48 further patients as an alternative to the traditional fast track system. The streamed care pathway improved initial care significantly by treating patients according to their physiological parameters on admission. Targeted medical reviews on admission instead of the following day reduced the rates of undiagnosed medical pathology to 2% (p = 0.0068) and inadequate fluid resuscitation to 11% (p < 0.0001). Implementation of a streamed care pathway can allow protocol driven improvement to initial care for patients with a proximal femoral fracture and results in improved access to initial specialist medical care.