Table 1

Changes to existing workflow

NamePrevious situationChange
(1) Treatment protocolsLocal protocols based on national guidelines.Local protocols were changed based on expert opinion in consensus meetings using the following principles: face-to-face appointments are minimized; remote consultations are increasingly used; and follow-up imaging is performed only in case of a possible significant change in management.
(2) Decision-making in the EDIn case of any uncertainty or concern, the ED staff contacts the orthopedic consultant. Patients possibly requiring surgical treatment are always discussed with an orthopedic consultant. All non-operative patients in the ED are immobilized and an appointment is scheduled for face-to-face review in the fracture clinic after approximately 1 week.In case of uncertainty about the need for acute admission, or in case of any concern or questions that cannot wait until the next workday, the ED staff contacts the orthopedic consultant. Patients who require acute admission for surgical treatment are always discussed with an orthopedic consultant. Patients who require surgical treatment, but not acute admission, are referred for VFC review on the next workday to be scheduled. All trauma patients are immobilized in the ED and referred for VFC review on the next workday.
(3) Virtual fracture clinic treatment planDuring the first fracture clinic appointment, the patient is assessed by a physician. Based on the assessment and the local protocols the physician decides if imaging is performed, if and when the next appointment will take place, and if further immobilization or change in management is necessary. This is repeated until discharge from follow-up.A multidisciplinary specialist-led team documents an extensive treatment plan for each patient referred to the virtual fracture clinic using the protocols mentioned under (1) Treatment protocols. This includes all appointments, duration of immobilization, instructions on imaging and specific examination per appointment, if applicable.
(4) Fast-track pathway in the EDPatients are triaged by the ED triaging nurse and then take place in the ED waiting room. There is one ED team that reviews patients according to urgency priority order.Four ED rooms are used as dedicated fast-track rooms, adjacent to the ED. Patients take place in a separate fast-track waiting room. The dedicated fast-track team continuously screens the waiting room for patients eligible for fast-track treatment.
  • ED, emergency department; VFC, virtual fracture clinic.