November 15, 2021

By Mayo Clinic College of Medicine and Science staff

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Working with colleagues in Practice Optimization and Acceleration and the Quality Academy, the Hand Surgery Quality Improvement Team used quality tools to standardize care for patients with distal radius fractures.

Management of patients with distal radius fractures was highly variable across Mayo Clinic in Rochester.

Among hand surgeons, there were discrepancies in patient education, patient admissions, readmissions, pain management, opioid prescribing behaviors, and patient outcomes. And processes that weren't standardized created confusion about patient management for residents, allied staff, anesthesiologists, hand therapists, endocrinologists, primary care, and nursing staff.

Add to that, nearly 80% of patients who had distal radius fracture surgery were being admitted unnecessarily for overnight hospital stays. This appeared to differ from non-Mayo hospitals, where distal radius fractures patients were treated without admission and without adverse effect.

The bottom line: There was ample room for improvement.

Fractures of the distal radius are among the most common injuries seen in an adult orthopedic practice, and they account for about one-sixth of fractures treated in emergency departments. 

With this in mind, the Hand Surgery Education Optimization Project, also called the HERO Project, aimed to standardize the care of patients with distal radius fractures.

Taking on the challenge

Working with colleagues in Practice Optimization and Acceleration and the Quality Academy, the Hand Surgery Quality Improvement Team used a DMAIC framework (Define, Measure, Analyze, Improve, and Control) to standardize care for patients with distal radius fractures.

The goal was to decrease unnecessary hospital admissions and reduce the length of stay, which would open up hospital beds. Secondary goals were to improve the patient experience, decrease the use of opioids, improve staff satisfaction, improve fragility fracture care screening, and decrease the cost of care.

The team began by getting feedback from staff in the divisions of Hand Surgery and Endocrinology; from the departments of Anesthesiology, Emergency Medicine, Primary Care, and Nursing; from residents and fellows in orthopedic surgery and plastic surgery; from hand therapists; and from social workers.

The team also used the information they gathered during "waste walks" — a lean process where staff use planned visits to observe variation in processes and note gaps in the quality of care. They noted variations in physician practice among 12 hand surgeons with different backgrounds. They also saw a lack of patient education and multiple locations of care delivery.

Forming a plan of action

Using data from multiple sources, the team implemented several practice changes, including standardized patient education across Mayo Clinic, standardized order sets, smart sets, and after-visit summaries. Following surgery, the team called patients to address their concerns and improve communication. They also collected standardized patient-reported outcomes and created a fragility fracture pathway.

Using the Plan, Do, Study, Act methodology, the project team conducted a pilot over a four-week period to assess whether newly implemented education and postoperative pain management measures were functioning as planned and were sustainable.

They surveyed patients after surgery to ask them about their experiences before, during, and after surgery. They also solicited feedback on the new processes from hand surgery staff. Findings were monitored and discussed at weekly team meetings, and lessons learned from the pilot were implemented into the main Hand Surgery Education Optimization protocols.

Noteworthy results

The changes the team put in place resulted in a decreased hospital admission rate — from 80% to 30% — and a decreased length of stay — from one day to a half-day. There was no increase in readmissions. Patient satisfaction also improved, and pain control was reduced, with half of the patients not using prescribed opioids.

Three main takeaways from the Hand Surgery Education Optimization Project are:

• Patient and staff education can significantly affect the practice.
• Standardized tools and pathways are needed to implement and sustain change.
• It's critical to include all stakeholders in the decision-making process.

The changes implemented during the project resulted in a decrease in the cost of care by $120,000. Additional cost savings were realized by freeing up inpatient beds for other services and improved osteoporosis screening processes.

The physicians on the team received maintenance of certification credit, and the entire team received Silver Quality Fellow credit for their commitment to excellence in patient care.