Is clinician reported practice in Western Australian emergency departments aligned with direct discharge pathway protocols for minor self-limiting fractures? A multi-centre professional survey

Objective: To determine ED clinician's current management for five common minor self-limiting fractures (MSLF) and evaluate practice against evidence-informed direct discharge pathway (DD) protocols.

Methods: A survey was provided to doctors, nurse practitioners and advanced scope physiotherapists working in seven metropolitan, public health EDs in Perth, Australia. The relative odds of ED location (e.g. which facility) and clinician level factors (e.g. country of initial training, years of ED experience, profession) on recommending care completely consistent with evidence informed direct discharge pathway protocols were estimated.

Results: Two hundred sixty-two clinicians completed the survey. There was variability in practice across all sites, with most reported care assessed at 60%-76% consistency with individual elements of DD care provision. Highest consistency was seen in lower limb immobilisation and DVT prophylaxis. Lowest consistency was seen in weight bearing advice, pain management and (boxer's) fracture reduction and immobilisation. There were very low levels of complete consistency, ranging from 9% (boxer's fracture) to 25% (radial head fracture). Two factors were associated with increased odds of completely consistent care: (i) clinician experience working in ED, with greater duration of practice associated with increased odds ratios (OR range, 1.6-3.3); and (ii) profession, where advanced scope physiotherapy was associated with increased odds ratios (OR range, 3.2-25.0).

Conclusions: Survey results suggested system wide variation in ED fracture management practice and target areas for service improvement. Avenues for service improvement could include hospital wide agreed management plans for specific fractures and support for less experienced clinicians.