Isolated Orthopedic Injury Admission Guidelines

Purpose

·         To identify which isolated traumatically injured patients can appropriately be admitted to the Orthopedic Service

Background/Definitions 

Quality of care and length of stay continue to be areas for improvement at Nebraska Medicine.  Given Orthopedic Surgery’s expertise and current workflow/resources, certain trauma patients with isolated Orthopedic issues, may be better served on the Orthopedic Service to improve quality of care and expedite disposition.

Guideline Inclusion Criteria

• Isolated traumatic fracture patients.
• Minimal medical problems or past medical issues which are currently stable and not exacerbated by the injury
• Deemed appropriate for admission to the Orthopedic Service by both the Trauma and Orthopedic Service. 
• “Full” or “Limited” activations with isolated injuries.

Guideline Exclusion Criteria 

• Poly-trauma patients with fractures.
• Deemed inappropriate for admission to the Orthopedic Service based on medical complexity.  If the patient has minimal medical problems or past medical issues which are currently stable and not exacerbated by the injury, then the patient should be admitted to the Orthopedic service.  It is highly encouraged for a Trauma/Orthopedic staff conversation in these situations

Diagnostic Evaluation

• Standard trauma work-up per ATLS standards.
• Routine trauma lab work.
• Body region  X-ray and/or CT scan
• Pan scan CT as indicated by mechanism or provider discretion
• Trauma Team consultation to make sure trauma work up is complete and no other injuries are present.  Also to evaluate appropriateness of Orthopedic Surgery admission.
• Orthopedic Surgery consultation to evaluate patient’s isolated traumatic injury and determine disposition (admission to hospital versus outpatient follow-up) as well as to evaluate appropriateness of Orthopedic Surgery admission.   

Practice Recommendations for Management

Patient Entrance into Nebraska Medical Center

• Patients transferred in from an outside institution will be directed to Nebraska Medicine ED (ER→ER).  Trauma Team will do the initial trauma evaluation and work-up in the emergency department.
• Patient primarily presents to NMC and meets criteria for an activation (Full or Limited), both the Emergency Medicine and Trauma Team will respond appropriately and the trauma work-up will be conducted as per usual.
  
• If the patient does not meet activation criteria, Emergency Medicine will perform the initial evaluation.

**If a fracture is identified, Trauma Surgery should be consulted for additional trauma evaluation to make sure the trauma work-up is complete.  In all instances, they will be responsible for completion of the tertiary exam.**

Admitting Service and Consultant Involvement

• If a fracture is identified along with other injuries, Orthopedic Surgery will be consulted as well as other consulting services as needed
  • • • Patient will be admitted to Nebraska Medical Center (NMC) by the Trauma Service for further trauma management as deemed appropriate.  
• If an isolated fracture is identified, Orthopedic Surgery will be consulted for their recommendations.
  • • • If the decision to admit the patient is made in order to repair the isolated fracture, Orthopedic Surgery will admit the patient to their service based on ACS requirements that trauma patients need to be admitted by a surgeon.
        • • • If there is concern from the Trauma Service or Orthopedic Service that Orthopedics should not admit the patient, a staff-to-staff conversation should be held between the two services to decide which service the patient should be admitted to.
            • Whether the patient needs surgery or not, the standard Nebraska Medicine Enhanced Recovery after Surgery (NERAS) pathway that has been established for isolated fracture patients will be followed.

• • • If the decision to discharge the patient is made, the discharge paperwork should be completed by the accepting/managing team with outpatient follow-up orders to be placed by the Orthopedic Surgery service.

** Regardless of the admitting service, the Surgical Co-Management Service should be consulted for all fragility fractures (e.g. resulting from ground level fall) and in any other cases for which preoperative risk stratification is desired.  **

Follow-up Care

• If the patient is a poly-trauma patient and admitted to NMC per the Trauma Service, discharge and follow-up recommendations will be provided by all consulting services as needed and PT/OT.
  • • All attempts will be made to discharge patient to appropriate location based on patient/family preferences, PT/OT recommendations, and discretion of the Trauma Service
• If the patient is an isolated fracture patient admitted to NMC per the Orthopedic Service, discharge and follow-up recommendations will be provided by Orthopedic Surgery and PT/OT.
  • • All attempts will be made to discharge patient to appropriate location based on patient/family preferences, PT/OT recommendations, and discretion of the Orthopedic Service.

Outcome Measures and Guideline Adherence

• All traumatically injured patients, whether poly-trauma or isolated Orthopedic injured patients, will be tracked and entered into the NMC and National Trauma Database.
•  Performance improvement opportunities will be review by the appropriate service when needed based on the ACS pre-defined hospital complications (see ACS 2022 Trauma Standards Grey Category).
• Non-surgeon admissions of trauma patients will be tracked and updated monthly to the individual services as well as at the monthly PIPS meeting.  Each non-surgeon admission will be reviewed per the PI process based on ACS Trauma Standards to determine appropriateness.    

Key Contributors

• Zachary Bauman, DO, MHA
• Justin Siebler, MD
• Sara Putnam, MD
• Jason Schiffermiller, MD

Last Updated

February, 2024

References

1.   American College of Surgeons 2022 Trauma Standards