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Improving Diagnostic Safety in Orthopaedics

Improving Diagnostic Safety in Orthopaedics

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4 September 2024

RCSEd Communications Team

General

The Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (RCSEd) are delighted to lend our enthusiastic support to the sixth World Patient Safety Day (WPSD). This event, established by the World Health Organisation (WHO) in 2019, takes place on 17 September every year. It helps to raise global awareness amongst all stakeholders about key Patient Safety issues and foster collaboration between patients, health care workers, health care leaders and policy makers to improve patient safety. Each year a new theme is selected to highlight a priority patient safety area for action.

The theme set by the WHO for this year’s WPSD is “Improving diagnosis for patient safety”, recognising the vital importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.

Safety Orthopaedic surgery is a high-volume speciality where the execution of an effective safe operation relies on extremely varied skills depending on the nature of treatments (casting, splinting immobilisation, open and closed surgery, arthroscopy, etc.), at varying anatomical sites (hand surgery, shoulder surgery, spine surgery, etc.) with patients of all ages age including paediatric and geriatric populations. This means orthopaedic clinicians must develop a wide-ranging set of surgical and diagnostic skills through a long period of training. Evolution of surgical techniques offers tantalising alternatives that allow a faster recovery, but involve greater risk related to surgery that are often highly technical (e.g., intraoperative computerised navigation). Where the complexity is high, there is a greater risk of making mistakes so appreciating the extent of disease or injury from the outset is paramount.

There are two distinct areas orthopaedics and traumatology, where the latter is characterised by a clinical path that begins suddenly, requiring time-sensitive diagnostic and therapeutic choices often offering no opportunity for proper planning. The acceleration of any diagnostic-therapeutic procedure generates a greater risk of error, adverse events, or harm. Any damage so caused produces unavoidable functional repercussions to the patient and impacts on their support network for years to come and so getting it right from the beginning is important.

In the UK an estimated 20.3 million people are affected by MSK conditions, accounting for 21% of years of life lived with disability with referrals increasing at a rate of 7-8% a year. Early access to appropriate specialist review improves diagnostic accuracy by bringing in senior decision makers. In the trauma setting virtual fracture clinics have ensured effective triage identifying those in need of early intervention, enhanced diagnostics and sub specialist review with good satisfaction rates in line with Get it Right First-Time principles (GiRFT).

Improved access to investigations such as Magnetic Resonance Imaging (MRI) improves diagnostic security by finding hip fractures in the non-weight bearing when radiographs are negative and earlier diagnosis of scaphoid fractures from the emergency department after an initial negative radiograph. This has been underpinned by pathways that facilitate decision making. Logistical tools also improve the 'sampling process' where the necessary surgical implements, transport vials, and labels necessary are organised in a kit to standardise sampling processes helping diagnose infections and malignancy.

Technology enhancements have improved safety such as the incorporation of Artificial Intelligence (AI) and deep learning into practice in interpreting imaging 'tells' that the human eye misses and with mathematical modelling determining that obtaining five to six surgical specimens for culture was necessary to obtain acceptable sensitivity and specificity. Sonification, spectrometry and molecular techniques have helped identify the organisms involved in infections.

A pivotal part in the diagnostic pathway is the development of a treatment plan based on the patient's history and diagnostic tests with appropriate Multi-Disciplinary Team (MDT) meetings helping facilitate planning in trauma, arthroplasty, infection and tumour cases that then improves outcomes. However shared decision making with patients remains key to ensuring those outcomes are achieved.

Predictive modelling for personalised treatment plans, the integration of telemedicine for remote patient monitoring, and the prospects of 3D printing for customised implants herald a future where patient care is increasingly precise, accessible, and tailored to individual needs.

Written by Professor Neil Ashwood, Consultant Trauma and Orthopaedic Surgeon, University Hospitals of Derby and Burton

References

Barneschi G, Raspanti F, Capanna R. Patient Safety in Orthopedics and Traumatology. 2020 Dec 15. In: Donaldson L, Ricciardi W, Sheridan S, et al., editors. Textbook of Patient Safety and Clinical Risk Management [Internet]. Cham (CH): Springer; 2021. Chapter 19. Available from: https://www.ncbi.nlm.nih.gov/books/NBK585599/ doi: 10.1007/978-3-030-59403-9_19.

Higgins E, Suh GA, Tande AJ. Enhancing Diagnostics in Orthopedic Infections. J Clin Microbiol. 2022 Jun 15;60(6):e0219621. doi: 10.1128/jcm.02196-21. Epub 2022 Mar 10. PMID: 35264020; PMCID: PMC9199406.

https://www.england.nhs.uk/long-read/msk-orthopaedic-approach-to-referral-optimisation/

Shen D., Wu G., Suk H. I. (2017). Deep learning in medical image analysis. Annu. Rev. Biomed. Eng. 19, 221–248. 10.1146/annurev-bioeng-071516-044442

Griffiths, A., Dixon, J., Egglestone, A., Edwards, A., Handley, R., Trompeter, A. and Eardley, W.G., 2021. Evidence-based orthopaedic trauma care in the United Kingdom: guidelines, registries, carrots and sticks. European Journal of Orthopaedic Surgery & Traumatology, 31, pp.937-945.

Dean, B.J., Little, C., Riley, N.D., Sellon, E., Sheehan, W., Burford, J., Hormbrey, P. and Costa, M.L., 2021. Suspected scaphoid injuries managed by MRI direct from the emergency department: a single-centre prospective cohort study. Bone & Joint Open, 2(6), pp.447-453.

Gil, H., Tuttle, A.A., Dean, L.A., Johnson, D.A., Portelli, D., Baird, J. and Raukar, N.P., 2020. Dedicated MRI in the emergency department to expedite diagnostic management of hip fracture. Emergency Radiology, 27, pp.41-44.

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