Mary Bridge Children’s orthopedic surgeons and ED doctors partner for improved results

By Walter Neary

Forearm fractures — broken arms — are among the most frequently encountered orthopedic injuries in children. In fact, more than 200 children are treated each year for these injuries at the Mary Bridge Children’s Hospital Emergency Department (ED). When you think of the experts who fix broken bones, many people might think of orthopedic surgeons. But at Mary Bridge Children’s, when a child comes in with a forearm fracture, it’s the ED doctors that reduce and cast almost all of the forearm factures.

Having an orthopedic surgeon available right away to treat an urgent injury like a broken arm can be challenging for many reasons. Having ED doctors who can expertly treat pediatric forearm fractures reduces delays in patient care and pain management.

Around 25 years ago, two pediatric orthopedic surgeons on the Mary Bridge hospital staff at that time offered voluntary mentoring in fracture reduction and casting to all members of the ED doctors to help meet the orthopedic needs of the Emergency Departments and decrease the call burden on the orthopedists. Since then, the ED doctors have maintained an ongoing internal mentoring program with experienced ED doctors teaching each new ED member techniques of fracture reduction and casting.

They’ve been doing a very good job — but has it been good enough? To answer that question, Dr. Tom Hurt, MD, former Medical Director of the Mary Bridge Emergency Department; and Rebecca Whitesell, MD, pediatric orthopedic surgeon at Mary Bridge; decided to work together to determine just how well the ED doctors were doing, and if they could be doing better.

The science and art of casting

Being able to cast properly is a skill that not every emergency doctor has. Training programs across the country are inconsistent in teaching this skill. Casting is both a science and an art. There are subtleties to casting — sometimes a cast needs to lean in slightly over the point of injury, so the bone does not slip back to a bad alignment. Though occasionally unavoidable, redoing a cast may mean having to redo the whole process — a trip to the operating room, anesthesia and rebreaking the bone. Not something any health care professional wants to subject a child and family to unnecessarily. So, it’s important to try to get a cast right the first time.

The pediatric ED doctors wanted to do all that they could to decrease the need for re-casting a broken arm.

“We could align the fractures well — get the broken bones nicely lined up. And when we put the cast on, we did it in a way that we felt was correct,” says Dr. Hurt. “But some of the time we recognized that the quality of our casting, the technique of our casting, was not as good as it should be. What we discovered was that after leaving the ED, even though the cast may have looked really good, a week or two after the injury, there were some cases where the alignment had slipped or angled. And that meant the setting and casting possibly had to be redone.”

“It takes practice to make a cast that not only looks good, but also feels good and maintains the alignment of the bone,” says Dr. Whitesell.

Using data to improve care

The ED doctors’ path to improvement began in 2015 and involved research, dedication and partnership.
That year, Dr. Hurt, decided he wanted to look at the outcomes of fracture reduction and casting by the ED physicians at Mary Bridge to see if there was room for improvement. He started by doing a chart review of a year’s worth of patients with broken forearms —over 200 patients — in order to quantify the results.

In collaboration with Dr. Whitesell, the data was presented to MultiCare’s Institute for Research and Innovation. Bethann Pflugeisen, Research Scientist; and Jin Mou, MD, Senior Research Epidemiologist; carried out a complex statistical analysis of the results.

“This project was a big win for all of us,” Pflugeisen said. “This was a successful partnership between the Research Institute and people who are on the ground with patients. Through that partnership, we all learn from each other.”

After analyzing the data, the research team knew exactly how many times a bone had slipped in a cast and a fracture had to be reset. It was determined, as anticipated, that there was room for improvement. The doctors concluded that they needed to make their casts snugger – but not too snug. The question was, “How could this be accomplished?”

“We had to find a sweet spot: it’s a skill you learn with experience,” Dr. Hurt says.

A process improvement plan was developed. Over the following year, Drs. Hurt and Whitesell coached the ED doctors extensively, using x-rays of past treated fractures and hands-on practice with simulated bone models. Dr. Whitesell built the models herself and stole time from her one ‘non-clinic day’ each week to provide one-on-one coaching with the ED doctors.

“The ED physicians did a great job at lining up the bone, but they weren’t always aware of the pressure points to build into a cast. So, we talked about those,” Dr. Whitesell says. “I was so impressed that everyone wanted to learn. They seemed truly excited about learning from a subspecialist. It was so awesome to see this collaboration come together.”

At the end of the year-long coaching process, the research team collected data for another year. Results showed that forearm fracture outcomes had improved significantly, with the percentage of casts that held the bone in the right position for healing the first time increased from 81 to 91 percent, translating to roughly 20 children each year who would not have to come back to have a cast re-done or bones re-set. This is an exceptional accomplishment.

Accolades and awards

In 2016, the team won the Best Ongoing Research award at the Research Institute’s yearly competition and the following year won the Best Completed Research award.

Then in 2019, the team’s work was published in the June 19 issue of the Journal of Emergency Medicine as the article: “Does Mentoring by Orthopedic Surgeons Improve Forearm Fracture Reduction Outcomes by Pediatric Emergency Physicians? Evaluation of a Process Improvement Intervention Program.”

Later that same year, the project was awarded MultiCare’s President’s Award for Excellence in Clinical Patient Outcomes & Quality.

“The work Drs. Whitesell and Hurt did is both inspiring and valuable, says Dr. Mou. “This study benefits patients and is a good example for other hospitals.”