A representative assessment of the management of open fractures of the lower limb within UK orthoplastic centres: A two-centre audit of compliance with national standards

• Published in: Injury 2017-10, Vol.48 (10), p.2266-2269
• Main Authors: Rymer, B., Dimovska, E.O.F., Chou, D.T.S., Choa, R., Davis, B., Huq, S.
• Format: Article
• Language: English
• Subjects: After-Hours Care - economics; After-Hours Care - statistics & numerical data; After-Hours Care - utilization; Boast 4; Debridement; Female; Fracture Fixation, Internal - economics; Fracture Fixation, Internal - statistics & numerical data; Fractures, Open - economics; Fractures, Open - epidemiology; Fractures, Open - surgery; Guideline Adherence; Humans; Injury Severity Score; Lower Extremity; Lower limb; Male; Medical Audit; Middle Aged; Open fracture; Orthoplastic; Practice Guidelines as Topic; Reconstructive Surgical Procedures - economics; Reconstructive Surgical Procedures - statistics & numerical data; Soft Tissue Injuries - economics; Soft Tissue Injuries - epidemiology; Soft Tissue Injuries - surgery; Surgical Wound Infection - economics; Surgical Wound Infection - epidemiology; Surgical Wound Infection - surgery; Trauma Centers - economics; Trauma Centers - standards; United Kingdom
• ISSN: 0020-1383; 1879-0267; 1879-0267
• DOI: 10.1016/j.injury.2017.07.012

Open fractures of the lower limb represent a complex and varied array of injuries. The BOAST 4 document produced by BAPRAS and the BOA provides standards on how to manage these patients, and NICE have recently produced additional guidance. We aimed to assess concordance with these standards in a large cohort representative of UK orthoplastic centres. Patients admitted to the orthoplastic units at Norfolk and Norwich University Hospital and Royal Stoke University Hospital with open lower limb fractures between 2009 and 2014 were included. Data was gathered from notes and endpoints based on the BOAST 4 document. In total, 84 patients were included across the two sites, with 83 having their initial debridement within 24h (98.8%). Forty-two patients had a documented out-of-hours initial surgery. Of these, 10 (23.8%) had an indication for urgent surgery. This pattern was consistent across both hospitals. A plastic surgeon was present at 33.3% of initial operations. Of 78 patients receiving definitive soft tissue cover, 56.4% had cover within 72h and 78.2% within 7days. Main reasons for missing these targets were transfer from other hospitals, plastic surgeons not present at initial operation and intervening critical illness. This study has identified key areas for improving compliance with the national BOAST 4 and NICE standards. Out-of-hours operating is occurring unnecessarily and time targets are being missed. The development of dedicated referral pathways and a true orthoplastic approach are required to improve the management of this complex set of injuries.