Ro Kulkarni

 Over booked clinics – little time with patients  Inappropriate referrals – A & E – one visit - discharge / or not  Inappropriate speciality – one visit - referral to appropriate speciality  No teaching time  Increasing complaints – junior decision making – never seen a consultant  Poor patient experience – parking, waiting, and time with doctor

 Scottish new design Lech Rymaszewski GRI  Leicester format  Exeter ideas – Nigel Giles  Swedish model  My DH outpatient tariff work  My ideas

 Better patient experience – appropriate visits, less visits, quicker decisions and appropriate Rx  The right patient seen in the right clinic at the right time  Better trainee experience, teaching and support  Better staff experience  More time with patients  Financial saving

 Focus on quality and patient experience  Not to decrease number of fracture clinics  Not to replace fracture clinic time with elective patients  Not to increase numbers  To protect teaching and patient contact times

 A & E referrals to # clinic March - Sept 2012 = 3281 ( 5624)  7% reattenders, rest new  A & E referrals to # clinic – per day – 18 (6-30)  Speciality break down  Hand and wrist – 31%  Feet/ankle – 17%  Shoulder & Elbows – 12%  Knees – 6%  Unknown Dx – 8%  The rest – Mixed bag

Three Point Plan

Decrease Inappropriate A & E Referrals

 Torus #s, Radial head(Mason 1), Mallet finger, Neck of 5 th metacarpal, 5 th metatarsal #s & paediatric clavicle #s  Perhaps others  NO need for # clinic follow up  Exclusions - A & E education  Appropriate advice given  Appropriate method of access for problems

 Seen in A & E  Treated with support that can be discarded by patient -Disposable splints for 5 th MT #s and torus fractures  Appropriate advice given  Protocol leaflets given  No follow up

RK 04/13

Torus #s = 2 Radial head(undisplaced) = 2 Mallet fingers= 3 Neck of 5 th metacarpal= 2 5 th metatarsal #s= 3.5 Paediatric clavicle #s= 2.5

Virtual Clinic

 No routine appointments to # clinic  All A & E referred patients screened in a virtual clinic  All referrals except discharges form ortho  Out of area attenders  Only attend – for something to be done Assessment POP off Investigation etc

 Consultant review  A & E notes and images pre loaded  App 2 mins per patient  Diagnosis and plan recorded  Average 18 patients per day - app 40 mins  10pm to 10 pm  Dictated by 12 next day for action by 3 pm  On call consultant  Job plan

 Options  # clinic – speciality(shoulder/knee/hand/team etc)  # clinic - generic ( any team)  Wound/dressing clinic  Time of review – next clinic/ one week etc  Discharged (no need for follow up)with advice  Nurse prac  Discharged and same week patients phoned same day  Letter to GP  OP appointment booked through booking centre

RK 04/13

 Consultant led  Team approach( Medical, nursing, plaster, x-ray etc)  All new patients notes and x-rays reviewed  Information recorded  Diagnosis  Plan – pre being seen – ROP, x-ray, wound check  Plan after being seen – will need FU next week, scan, rule out cuff injury etc  To be seen by – SHO, Reg, Consultant etc  To be discussed with consultant after review

 All new patients ‘reviewed’ by Consultant  Teaching  Robust treatment plans  Decrease in follow up ( to see how they are doing!)  Time saving  Team approach

 Appropriate patients seen  In the right Clinic  At the right time  Better patient experience  Money saved

 Yes - Multiple senior review  A&E review  Virtual Clinic Consultant review  Fracture clinic Consultant Review  Actual clinic review

 Consultant buy in  Management support  A & E support  No need for extra finance or infrastructure

 New slots – 3270  New filled – 2452  25% decrease  F/U slots – 6960  F/U filled – 4550  35% decrease  Total DNA – 967 – 14%  New DNA – 5%  NO complaints or adverse incidents