As clinicians we have an obligation to review our practice and strive to provide high quality care for all.

We should also endeavour to be responsible stewards of the finite resources available to the NHS. This is even more relevant in the current financial climate. 

Occasionally it is possible to combine these two ideals without compromising care. This was the idea behind setting up and running a home therapy treatment program for adult, unstable, ankle fractures. 

Ankle fractures are common injuries which tend to affect an active and independent adult population. Hospitalisation for a number of days is poorly tolerated by this group of patients.  This was borne out by an audit undertaken at Poole General Hospital between February and April 2008. The audit findings led to the conception and implementation of a HTP.

The aim of the HTP was to reduce the overall length of hospital stay in a safe and effective manner in keeping with Poole Hospital Foundation Trust’s philosophy, “to provide friendly, professional patient centred care with dignity and respect for all.”

Poole General Hospital is an acute district general hospital containing 789 beds. It is the major trauma centre for East Dorset as well as providing other specialist services.

This study assesses the safety, efficacy and patient opinion of the home therapy program.

 

Over a three month period between February and April 2008, 46 adult patients underwent surgery for unstable acute ankle fractures. The average length of hospital stay on an acute trauma ward was eight days. The initial four and a half days were spent waiting for the ankle swelling to resolve to a sufficiently safe level in order to allow surgery. The post operative three and a half days were spent recovering and learning safe mobilisation on crutches or zimmer frame.

Patients expressed their dissatisfaction and frustration with their whole hospital pathway in a survey.

A home therapy treatment program was initiated on 1 November 2008. Data was collected prospectively over a continuous four month period. All patients with isolated ankle fractures requiring surgery were included in the study. Patients were excluded if they had: an open or particularly unstable ankle fracture pattern, were medically unstable or social circumstances precluded a safe home discharge.

After confirmation of an ankle fracture, the patients were referred to the on-call orthopaedic team via the emergency department as per the care pathway. A post manipulation radiograph of the ankle in a plaster of Paris backslab was reviewed by the middle grade surgeon. If the ankle was in a satisfactory position and there were no contravening factors then the patient was enrolled into the program. A senior physiotherapist discussed the study with the patient, gained consent and taught and assessed safe mobilisation with crutches. The patient was instructed on elevation technique and exercises prior to discharge home with a provisional operation date four to six days later. Both verbal and written instructions were provided.

Every day the senior physiotherapist would contact each HTP patient by telephone and run through a short series of questions to screen for complications. If there was any concern from the physiotherapist or patient, arrangements were made for a prompt hospital review. If no complications arose then patients were assessed in the physiotherapy department the morning of surgery to ensure that the post traumatic oedema had resolved to a sufficient level in order to allow surgery to proceed. An ankle was deemed to be suitable for surgery when the skin creases had reappeared. 

 

Twenty three out of 76 patients were suitable for home therapy. The pie chart shows the reasons for exclusion from the home therapy program. The average length of time on home therapy was six days (0-11).  The mean pre-operative hospital length of stay was 1.6 days (0-4) and the mean post-operative hospital stay was 1.3 days (0-4). When compared with the original audit this resulted in a saving of 136 bed days which equated to £30,975 over the four month period.  This was based on the cost of a trauma bed being £231 per day.  This extrapolates to a predicted saving of about £93,000 per year.

The trial period involved 64 hours of physiotherapy time.

Patients were satisfied with their management whilst on the HTP. Table 1 shows the survey results. This compares to general patient dissatisfaction and frustration noted in the original audit.

Complications

The physiotherapy telephone questions highlighted concerns which were followed up with appropriate clinical and radiological assessments. Only three patients complained that they had felt their ankles move in plaster. Clinical and radiographic examination did confirm displacement of the ankle mortise. Two patients were admitted and underwent re-manipulation of the ankle and application of a new cast under X-ray control. Their scheduled operation dates were postponed by three days but the other patient went ahead with surgery as planned.

There were no adverse outcomes from the complications.

 

Breach in operation date

Eleven out of 23 patients did not receive their operation on the original scheduled date.  Two patients with slipped ankle fractures were rescheduled three days later following re-manipulation in order to allow sufficient time for the soft tissues to settle. Five patients were still too swollen the morning of surgery and rescheduled for uneventful surgery two to three days later. Unfortunately, four patients were admitted to a ward on the day of surgery but their operations were postponed by 24 hours because of more urgent trauma cases.

 

The optimal management of acute ankle fractures remains surgical stabilisation within eight hours of injury. This results in the lowest rate of complications and allows early patient discharge1-3.  However, a reduction in working hours combined with an ever increasing trauma work load and a drive towards reducing “out of hours” operating means that the eight hours goal is rarely achievable. If the eight hour window is missed then the AO group recommend delaying surgery until at least day four post injury4. This reduces the chance of wound complications from the post traumatic swelling. It was this majority group of patients to whom this study was targeted.

HTPs are a relatively common occurrence in the USA where private insurance and cost are a major driving force in patient management. It is exceptionally rare to find centres in the UK that manage their ankle fractures via home therapy. It should only be considered an acceptable alternative practice if it meets with patient approval and has an acceptable complication rate. The patient survey shows that all who participated in the trial were satisfied with the overall experience of home therapy.

Less time in hospital both pre-operatively and post operatively meant that patients were more empowered in managing their injury from the comfort of their own home. They were more involved in the decision making process and scheduling of their operation date. This flexibility enabled one patient to delay his operation by eleven days so as not to interfere with exams.

There was less chance of disappointment often experienced by hospitalised patients who are sometimes starved on a ‘just in case’ daily basis whilst awaiting surgery. This can lead to false expectations about the timing of surgery. Patients particularly appreciated the continuity of care ensured by the daily physiotherapist telephone call. They were also comforted in the knowledge that there was always a direct point of contact should it be necessary.

The hospital trust experienced some direct and indirect advantages from the HTP. Patients were happier with their overall hospital experience and care. Allocating provisional operation dates to patients ensured a stream lining of trauma theatre services. This in turn led to a more efficient and realistic booking of the operating lists resulting in fewer cancellations and over runs.

With in-hospital management, patients are reviewed on a daily basis by various members of the healthcare team. A nurse is allocated to each patient and the previously healthy individual is encouraged to become reliant on hospital staff.  The HTP allowed patients to maintain their own independence at home whilst freeing up staff who were able to direct their time and attention more appropriately.

Fewer hospitalised patients, relieves pressure off the finite resources.  It not only frees up healthcare professionals but also beds. This in turn means that patients are more likely to be admitted to trauma wards with all of the added benefits5.  Less ‘outlying’ of patients means that there is less of a negative impact on the other specialist services within the hospital.  Outlying patients are the patients admitted under a specialty service but placed on the ward of a different specialty because of a lack of bed resources.

The financial savings equate to almost £93,000 per year.

There were few disadvantages with the program. A smooth and efficient pathway was ensured only after all of the services involved had been appropriately educated. The trial period required sixty four hours of physiotherapy time. Fortunately, this was absorbed within the redundant capacity of the physiotherapy department at no extra financial cost. However, man power was redistributed within the department which will have some inevitable collateral consequence. If there is no spare capacity within the physiotherapy department or the number of patients going through the HTP increases significantly then a business proposal may have to be considered to employ an additional physiotherapist.

There were no adverse outcomes for any of the patients. They all received their surgery in a timely and efficient manner. None of the complications discussed earlier were directly attributable to home therapy. It is feasible that the daily physio screening telephone call may have increased the sensitivity of detecting a potential complication.

The breach date data was useful in showing that almost half of the patients were allocated a provisional operation date too early. In fact, it may be more appropriate to offer a date six to nine days following their injury rather than four to six days. There were four patients who were postponed due to more urgent cases. It is inevitable when dealing with an acute surgical intake that occasionally exceptional circumstances will occur.

This paper shows that home therapy is a safe and cost effective alternative to the traditional hospital management of certain patients with acute, unstable, isolated ankle fractures.  It is also the preferred option of the patients.

We still advocate that acute ankle fractures should ideally be operated on within eight hours of injury. However, for the majority of patients this is rarely achievable and home therapy offers the ideal combination of cost effectiveness and high quality care.

As a result of this study our hospital continues to offer home therapy for acute ankle fractures and we would encourage other trusts to consider the virtues.

References

 Hoiness P, Stomsoe K.  The influence of the timing of surgery on soft tissue complications and hospital stay.  Annal Chir Gynae 89: 6-9, 2000.

Carrage E, Csongradi J, Bleck E.  Early complications in the operative treatment of ankle fractures.  JBJS 73-B: 1; 79-82, 1991.

Konrath G, Karges D et al.  Early versus delayed treatment of severe ankle fractures: a comparison of results.  J Orthop Trauma 9 (5):377-380, 1995. Muller M, Allgover M, Schneider R, Willengger H.  Manual of Internal Fixation.  Berlin Heidelberg New York: Springer-verlag, 600, 1992.

Muller M, Allgover M, Schneider R, Willengger H.  Manual of Internal Fixation.  Berlin Heidelberg New York: Springer-verlag, 600, 1992.

JM Lloyd, S Elsayed et al.  Out-lying Patients Is Dangerous: A Multicentre Comparison Study of Nursing Care Provided For Trauma Patients. Injury 36: 710-713, 2005.

Rachel Martin, senior physiotherapist, Senthil Rajagopolan, staff grade trauma & orthopaedics, Nedal Zieneh, Associate specialist trauma & orthopaedics, Richard Hartley, consultant orthopaedic surgeon and John Lloyd, specialist registrar trauma & orthopaedics, are all based at Poole General Hospital.