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Setting Up an Effective Orthoplastic Service 

Setting Up an Effective Orthoplastic Service
Chapter:
Setting Up an Effective Orthoplastic Service
DOI:
10.1093/med/9780198849360.003.0020
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date: 29 November 2020

Summary

  1. 1. The National Institute for Health and Care Excellence (NICE) defined an orthoplastic centre as: ‘A hospital with a dedicated, combined service for orthopaedic and plastic surgery in which consultants from both specialties work simultaneously to treat open fractures as part of regular, scheduled, combined orthopaedic and plastic surgery operating lists. Consultants are supported by combined review clinics and specialist nursing teams.’

    The BAPRAS/BOA group recommend that for clarity this narrative description of an orthoplastic service by NICE is broken into its component parts as follows:

    • A combined service of orthopaedic and plastic surgery consultants.

    • Sufficient combined operating lists with consultants from both specialties to meet the standards for timely management of open fractures.

    • Scheduled, combined review clinics for severe open fractures.

    • Specialist nursing teams able to care for both fractures and flaps.

    In addition, an effective orthoplastic service will also:

    • Submit data on each patient to the Trauma Audit Research Network (TARN).

    • Hold regular clinical audit meetings with both orthopaedic and plastic surgeons present.

  2. 2. The most cost-effective treatment strategy, if it can be achieved, is wound excision, definitive fixation, and definitive soft tissue reconstruction as a combined surgical procedure within 24 hours of injury.

  3. 3. There are several models in evolution throughout the UK, but the development of the orthoplastic unit is least challenging in hospitals with co-location of trauma orthopaedic surgery and plastic surgery departments.

  4. 4. It is vital to establish an adequately resourced service by engaging with specialised (NHS England or equivalent) and non-specialised commissioners (clinical commissioning groups) to support the service and ensure that the treating centres are appropriately reimbursed for delivering optimal care.

Introduction

Open fractures can be both limb-threatening injuries and devastating. The true incidence is difficult to ascertain, although it is estimated that open fractures comprise 3.2% of all fractures (1), with up to 21% of tibial fractures being open. Open fractures are more common in older people, with 296.6/106/year in those aged under 65 years compared with 323.3/106/year in those aged over 65 years, and 446.7/106/year in over 80-year-olds (2, 3). Fracture distribution curves demonstrate a bimodal form with similar incidence in the young male population, 15–19 years of age, and females >90 years of age. Only 22.3% of all open fractures are a result of high-energy injuries (3) and most often affect young adults at their most productive time of life. Although the total number of patients with open fractures is relatively small compared with the total number of fractures treated each year, open fractures cause significant morbidity and represent an enormous burden on healthcare resources. Healthcare providers, managers, and clinicians have a duty to improve outcomes and use resources efficiently.

In 2016, the National Institute for Health and Care Excellence (NICE) published guidance for trauma (4, 5). The Quality Standard from NICE includes a statement on the management of complex open limb trauma, recommending an ‘orthoplastic approach’ to treatment (6).

NICE defined an orthoplastic centre as:

A hospital with a dedicated, combined service for orthopaedic and plastic surgery in which consultants from both specialties work simultaneously to treat open fractures as part of regular, scheduled, combined orthopaedic and plastic surgery operating lists. Consultants are supported by combined review clinics and specialist nursing teams (4).

The British Association of Plastic, Reconstructive and Aesthetic Surgeons/British Orthopaedic Association (BAPRAS/BOA) group recommend that for clarity this narrative description of an orthoplastic service by NICE is defined in its component parts as follows:

  • A combined service of orthopaedic and plastic surgery consultants.

  • Sufficient combined operating lists with consultants from both specialties to meet the standards for timely management of open fractures.

  • Scheduled, combined review clinics for severe open fractures.

  • Specialist nursing teams able to care for both fractures and flaps.

In addition, an effective orthoplastic service will also:

  • Submit data on each patient to TARN.

  • Hold regular clinical audit meetings with both orthopaedic and plastic surgeons present.

For some hospitals managing patients with open fractures, such a strict definition of an orthoplastic service would signal a major change from their current infrastructure. This may cause concern as wholesale service changes would need to be implemented to achieve this new standard, at a cost that few hospitals could afford. Furthermore, there is no prescriptive template for such a service due to variations across the NHS in the UK, as well as a differing approach to trauma delivery between the home nations. However, the coordinated treatment plan defined by the combined approach results in expeditious care of the patient. Hospitals that have established orthoplastic services have demonstrated reductions in deep infection rates that offer cost savings that would be attractive to underfunded healthcare systems (7).

There is evidence that outcomes of these patients are greatly improved with combined orthoplastic management at a designated centre, within defined time frames (5) compared with sequential treatment by separate specialties often within different hospitals. As well as reduced infection rates, improved outcomes include lower rates for non-union and amputation (7, 8), fewer unnecessary trips to theatre both for planning definitive treatment and revision surgery (9, 10, 11), reduction in time to soft tissue coverage (8, 10, 12, 13), shorter hospital stays and cost (10, 12, 13), and earlier recovery of function (14).

The case for setting up an effective orthoplastic service for the effective management of open long bone fractures is, therefore, compelling. The aim of this chapter is to describe how this can be achieved, the minimum required infrastructure for an operational orthoplastic unit, and to illustrate some of the systems and processes required in setting it up.

Requirements for the service

Initiating the model for change

There is no single model for effective implementation of a new service. Established practices are deep-rooted and may appear ‘too difficult to’ or ‘not requiring’ change. Every organisation will have its own approach to the delivery of patient care. The model for change is not an easy assignment. The ideal unit has to be aspired to, adequately resourced in terms of both clinical and managerial time, and the steps both owned and understood to enable service goals and outcomes to be achieved. The process should begin with engagement of senior management and consultants within the hospital trust or trusts. Clear leadership enables top-down commitment to delivering evidence-based practice. Having broken down the task into manageable stages, the approach to change can then be managed by ‘incremental gains’.

Hospital set-up

There are three basic organisational structures that exist for the potential establishment of an orthoplastic unit within a major trauma network in England. First, there may be co-location of orthopaedic and plastic surgery (acute services) within the same hospital. The second scenario is that of cross-site working within the same trust. Finally, the two specialties may reside in different trusts. It goes without saying that the first situation is by far the most convenient for delivery of seamless care.

In a hospital with co-located services, the need for a new sub-specialty, driven clinically, is most likely to be supported at executive level if little infrastructural change is required. There is a potential for conflict between the specialties when funds are designated to a service not recognised as an income generator. However, the costs associated with the service can be recouped when the significant financial consequences of suboptimal management of open fractures are taken into consideration (15). The costs and income can then be shared equitably between specialties.

Cross-site working within the same trust is more challenging. Although trust objectives will be standardised across the hospitals, the move for part of the department to form the orthoplastic service at the site of the major trauma centre poses logistical challenges and additional investment will be required. Where plastic surgery services are not on site at the major trauma centre, this must be prioritised and capacity established for provision of a service that can provide free tissue transfer. This must be delivered by a group of consultants dedicated to ensure service provision every day of the week.

The most difficult circumstances for establishment of a new unit arise where services are in separate trusts. This is by far the most challenging set-up, as trusts face unique pressures and will have differing strategies to address these. There will be an even more significant burden for both cost and set-up. Even when executive-level support is achieved, the operational requirements, in terms of coordinating the services and the resources, management, administration, and information technology, will need financial and personal investment. A phased implementation plan may be required with a clear route to achieving key milestones and reviewed at regular intervals.

Whatever the structural organisation, it is imperative that there are dedicated leaders in both specialties for the orthoplastic unit to work. Furthermore, alongside the clinical expertise, there must be the infrastructure support for operational delivery of the service. Without this, there is an unsustainable scenario that will fail to deliver excellence in patient care. Irrespective of the precise model of the orthoplastic service, all institutions must share the same goal of providing combined care to the highest standards, as defined by national guidance (4, 5, 16, 17).

National support

Whilst Scotland, Wales, and Northern Ireland continue to develop their trauma provision, the most mature system in the UK is the major trauma network in England, with 26 major trauma centres. These provide an overall structure for trauma delivery, with support from surrounding trauma units and local emergency departments. These networks are supported by data collected via national reporting to the Trauma Audit Research Network (TARN). This allows each trauma network to assess and compare their delivery of major trauma care and continue to develop improvements towards the standards.

Local support

Each hospital trust must support the creation of the orthoplastic unit for provision of care for complex limb trauma. Executive- and board-level agreement is key. Local negotiations may take time and on occasion may appear fruitless, but the overriding agenda remains the provision of excellence in care for trauma as illustrated by the published standards (4, 16, 17). Alongside support within the hospital system, support from the local commissioning groups is also important. The major trauma and burns clinical reference group within NHS England produces the service specification. Centralised funding by way of specialist commissioning enables delivery of trauma care to be supported nationally. However, much complex orthoplastic limb reconstruction falls outside the national tariffs and support from local commissioners for a special local tariff can considerably enhance management support for service delivery.

Local commissioning

In order to recognise the ‘front end’ costs of the orthoplastic service for acute open fractures a meeting with local commissioners is essential. This will require detailed costing for the treatment of these patients in their current setting (18) to address the fiscal imbalance. These economic data can be presented together with audit data of patient numbers, demographics, and outcomes at the commissioners’ meeting. This will enable the commissioners to evaluate the data and appreciate the cost-saving benefit of appropriately funding an effective orthoplastic service via agreed local tariffs.

Workforce planning

How many surgeons are required for an effective orthoplastic service? Is it feasible for every hospital in the UK treating open fractures to recruit several trauma-trained plastic surgeons to provide a microvascular service throughout the week and would the volume of work be sufficient to justify this? With crossover into other areas of plastic surgery sub-specialisation such as hand surgery, head and neck, or sarcoma, a plastic surgery department would likely have sufficient other complex cases to sustain a full orthoplastic service. The increasing numbers of open fragility fractures must also be factored in to service development.

If each of the 26 major trauma centres in England require six plastic surgeons for this service, then around 150 surgeons will be required nationally. Whilst this number may not sound daunting, there is no accurate information on plastic surgeons in practice or training with a special interest in trauma. Orthopaedic surgery has already seen a surge in interest in trauma as a career path and there are unlikely to be problems finding sufficient numbers of appropriately skilled surgeons in the future. Formal assessment of workforce and training needs would greatly assist workforce planning.

Working patterns in orthopaedics and plastic surgery need to provide consultant flexibility to perform open fracture wound excision with less than 12 hours’ notice. The majority of these procedures would occur in daytime hours, so continuous daytime availability 7 days per week would be required, with an out-of-hours on-call facility. Whilst smaller units might struggle to achieve this, some larger departments have already moved to a consultant of the week or some other form of on-call arrangement where a consultant is available at all times to manage the unscheduled part of the service. Most NHS orthopaedic departments looking after major trauma have already developed this type of model.

The complexity of surgery for open fractures requires a dedicated all-day theatre list, with two or three such lists per week avoiding clashes with other plastic or orthopaedic surgery lists and the possibility of cancellation of elective cases. This would imply that two or three plastic and two or three orthopaedic surgeons are job-planned for those lists. Whilst this appears a significant commitment, it enables the strict timelines to be adhered to for the treatment of all open fractures.

No two hospitals in the NHS have the same working arrangements or on-call commitments for their orthopaedic or plastic surgeons. This suggests that there is no single ideal formula and local solutions need to be identified. However, those who are planning to provide a safe and effective orthoplastic service must have a degree of flexibility written and agreed in their job plans and dedicated sessions allocated for service provision.

Clinical involvement is not only restricted to dedicated consultant orthopaedic and plastic surgeons, available on call 24 hours a day, 7 days a week, but must also include other specialists such as infectious diseases/microbiology consultants, radiologists with specialist interest in musculoskeletal disorders, and rehabilitation consultants, together with allied healthcare professionals and specialist nurses. This multidisciplinary team must be supported by administrative assistance and fully coordinated so that continuous quality improvement is demonstrated.

Operational requirements

  1. 1) Facilities:

    • Access to trauma operating lists 24/7 for those fractures requiring immediate surgical intervention, such as the devascularised limb or the highly contaminated wound, or for return to theatre for a complication such as a compromised free flap.

    • Availability of combined operating lists for provision of definitive fixation and potential free flap coverage of open fractures during the week.

    • Weekly clinic for review.

    • Regular multidisciplinary team clinic with orthopaedic and plastic surgeons, physiotherapists, rehabilitation specialist, radiologist, microbiologist/infectious disease consultant.

    • Information technology support.

  2. 2) Personnel:

    • Plastic and orthopaedic consultant surgeons with a major commitment to trauma in their job plans and who can provide a full on-call service 24 hours a day, 7 days a week.

    • Specialist nursing teams on the ward who have the skills to care for the complex trauma patient from both an orthopaedic and plastic surgery perspective, in particular with reference to managing the postoperative course for both plastic surgery free tissue transfer and orthopaedic circular frames, external fixators, and pin sites.

    • Consultant microbiologist.

    • Specialist theatre staff for orthopaedic fixation and free flap surgery.

    • Outpatient nursing for dressings.

    • Plaster technicians and orthotic expertise.

    • Physiotherapists for mobilisation and care of the polytrauma patient.

    • Rehabilitation expertise with reference to amputation and prosthetic requirements.

    • Consultant rehabilitation specialists.

    • Dedicated administrative support.

    • Dedicated service management support.

    • A dedicated coordinator to support the case management of patients.

Cost effectiveness

The true cost of trauma is unknown. The financial costs of immediate trauma care have been estimated at between £0.3 and £0.4 billion a year (19). Costs for subsequent hospital treatments, rehabilitation, social care home support, and individual personal care are difficult to calculate, and the cost to an individual in terms of function and loss of earnings are undetermined. Figures from the National Audit Office estimate a lost annual economic output of up to £3.7 billion.

A robust systems approach was adopted by the NICE Guidance Development Groups regarding clinical evidence and cost effectiveness. Cost effectiveness denotes the expected costs of different options in relation to their expected health benefit, rather than total implementation cost (20). The available data were reviewed and modelled by health economists at NICE.

The cost efficacy for the combined orthoplastic approach for the treatment of open fractures for patients managed at specialist centres was elegantly demonstrated (4). Sequential care by plastic surgeons following initial orthopaedic management was associated with higher infection rates, increased numbers of surgical procedures and inter-hospital transfers for non-co-located specialties, and prolonged hospital stay dramatically increased the cost per patient.

NICE considered the evidence relating to the presence of the plastic surgeon with the orthopaedic surgeon at the initial surgical wound excision and stabilisation. This was split into three areas: the initial wound excision, the timing of soft tissue cover, and potential multiple theatre sessions. Various outcome measures were considered, including unplanned complexity of the soft tissue reconstruction (impacting on surgical time, equipment, and staffing), free flap failure, as well as hospital stay and further unplanned surgery. The results demonstrated a reduction in the costs associated with wound excision at all time points if a plastic surgeon was present. This is because, even with the additional staff and theatre time, the combined orthoplastic approach resulted in fewer complications and hence was cost effective.

Other clinical studies have investigated comparisons between treatment between the two specialties and that combined in one unit. Specifically considering healthcare utilisation, Page et al. demonstrated that when patients with open tibial fractures were admitted directly to an orthoplastic centre, they had significantly fewer operations and GP attendances thereafter, compared with patients undergoing initial management elsewhere, with subsequent transfer (21).

Whilst the cost and clinical benefits are compelling, the initial investment required to set up the service can be extremely challenging.

So how do you do it?

The NICE guidance and quality standards can be used as levers to implement change and introduce best working practices to achieve optimal patient outcomes. The optimum route to growing a service will depend on the environment. Successful orthoplastic units in England have grown their service progressively (7, 18). This perspective from cross-trust working in the UK has led us to consider the stepwise approach when clinical priorities must be balanced alongside financial and care quality pressures.

  • Short, medium, and long-term goals must be established and the availability of limited resources recognised.

  • Executive support is key to sponsoring and ensuring the release of management and clinical time and other resources.

  • Board member appreciation of the goal to provide excellent patient care in line with national guidance.

  • With any collaborative board set-up, central representation from NHS England or equivalent is also required and important so all commissioners are represented.

  • If financial pressures or trust directives become more of a priority, the negotiations for orthoplastic capacity should centre on NICE quality standards and guidance.

  • This requires alignment of the trust(s) strategic objectives with provision of excellent patient care, and the potential for changes within departments, such as addition of staff members, separate business cases that will support not only the case for trauma but more generic need on wards, clinics, and in theatres.

  • Utilise the major trauma peer review process and GIRFT (get it right first time) reviews for plastics and orthopaedic trauma to benchmark progress and facilitate change.

  • Engage those other departments and directorates that have both a key interest and dependency on the service and where an essential partnership and joint working is needed.

  • Raise the risk of the service to the trust for risk register reporting if the service is not appropriately resourced or where patient care may be compromised.

  • Represent the unit nationally at association trauma interest groups and national trauma meetings.

  • Major trauma networks and clinical governance reporting will continue to raise the agenda nationally to the major trauma clinical directorate and TARN.

  • Outcomes and audit must continue to be presented departmentally, hospital-wide, regionally, and nationally, together with publications.

Conclusion

This chapter aims to give insight into the most important prerequisite for the delivery of the Standards: that of the orthoplastic unit. The merits of this set-up have been recognised worldwide, and yet, in the cost-pressured NHS we are yet to achieve this gold standard in all of our major trauma centres throughout England and the rest of the UK.

We have defined what is required, and highlighted the evidence for the need for this combined management. We have highlighted the difficulties encountered. It can take 5 years or more to achieve this standard of care. Delivering optimal outcomes in terms of a functional limb and a rehabilitated patient in a cost-efficient manner remains at the heart of service development and delivery.

References

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