Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 142 No. 2930 (2012)

Fracture clinic redesign: improving standards in patient care and interprofessional education

  • Odhrán Murray
  • Kate Christen
  • Andrew Marsh
  • Jens Bayer
Cite this as:
Swiss Med Wkly. 2012;142:w13630


INTRODUCTION: Current fracture clinic models, especially with the advent of reductions in junior doctors’ hours, may limit outpatient trainee education and patient care. We have designed a new fracture clinic model, involving an initial consultant-led case review focused on patient management and trainee education.

METHODS: Prospective outcomes for all new patients attending the redesigned fracture clinic over a 3-week period in 2010 (n = 240) were compared with a historical cohort from the same period in 2009 (n = 296). The primary outcome measure was the proportion of patients with direct consultant input. Secondary outcome measures included patient discharge rates, return rates, use of the nurse-led fracture clinic and the incidence of adverse event reporting. Trainees attending each clinic completed a five-point Likert questionnaire assessing the adequacy of education, support, staff morale and standards of patient care, before and after introduction of the clinic redesign. Using a separate Likert questionnaire, emergency room (ER) staff were evaluated to determine the impact of the new style clinic on their education, daily practice and interprofessional relations. Adverse events were gathered from the ‘incident record 1’ (IR1) reporting system.

RESULTS: The percentage of cases given consultant input increased significantly from 33% in 2009 to 84% in 2010 (p <0.0001), while the proportion of patients requiring physical review by a consultant fell by 21% (p <0.0001). Return rates were reduced by 14% (p = 0.013) and use of the nurse-led fracture clinic improved by 10% (p = 0.0028). There was a median improvement in trainee perception of education from 2 (interquartile range 1.25–2.75) to 5 (4.25–5, p = 0.011), senior support from 2 (2–3) to 5 (4–5, p = 0.017) and patient care from 3 (3-4) to 5 (4–5, p = 0.015). ER staff found the new style clinic was educational, practice changing and improved interprofessional relations, but that it did not interfere with ER duties. The incidence of adverse incidents reported fell from 8 per year to 0 per year after the introduction of the new style clinic.

CONCLUSIONS: Our model of fracture-clinic redesign has significantly enhanced consultant input into patient care without additional funding. In addition, we have demonstrated increased service efficiency and significant improvements in staff support, morale and education. In the face of current economic and training challenges, we recommend this new model as a tool that will enhance patient and trainee experience.


  1. IDWL: Working Hours – the basics Available at: Accessed 11/28/2011, 2011.
  2. guichett – 32000L0034 – Available at:!celexapi!prod!CELEXnumdoc&lg=en&numdoc=32000L0034&model=guichett. Accessed 11/28/2011, 2011.
  3. EUR-Lex – 61998CJ0303 – EN Available at: Accessed 11/28/2011, 2011.
  4. Maxwell AJ, Crocker M, Jones TL, Bhagawati D, Papadopoulos MC, Bell BA. Implementation of the European Working Time Directive in neurosurgery reduces continuity of care and training opportunities. Acta Neurochir. 2010;152(7):1207–10.
  5. Fernandez E, Williams DG. Training and the European Working Time Directive: a 7 year review of paediatric anaesthetic trainee caseload data. Br J Anaesth. 2009;103(4):566–9.
  6. McIntyre HF, Winfield S, Te HS, Crook D. Implementation of the European Working Time Directive in an NHS trust: impact on patient care and junior doctor welfare. Clinical Medicine. 2010;10(2):134–7.
  7. Giles JA. Surgical training and the European Working Time Directive: The role of informal workplace learning. Int J Surg. 2010;8(3):179–80.
  8. Skipworth RJ, Terrace JD, Fulton LA, Anderson DN. Basic surgical training in the era of the European Working Time Directive: what are the problems and solutions? Scott Med J. 2008;53(4):18–21.
  9. Garvin JT, McLaughlin R, Kerin MJ. A pilot project of European Working Time Directive compliant rosters in a university teaching hospital. Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland. 2008;6(2):88–93.
  10. Tait MJ, Fellows GA, Pushpananthan S, Sergides Y, Papadopoulos MC, Bell BA. Current neurosurgical trainees’ perception of the European Working Time Directive and shift work. Br J Neurosurg. 2008 discussion 32-3;22(1):28–31.
  11. West D, Codispoti M, Graham T, Specialty Advisory Board in Cardiothoracic Surgery of The Royal Colleges of Surgeons of Edinburgh & Ireland. The European Working Time Directive and training in cardiothoracic surgery in the United Kingdom. Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland 2007 quiz 85, 121;5(2):81–5.
  12. Sim DJ, Wrigley SR, Harris S. Effects of the European Working Time Directive on anaesthetic training in the United Kingdom. Anaesthesia 2004;59(8):781–4.
  13. Lim E, Tsui S. Impact of the European Working Time Directive on exposure to operative cardiac surgical training. Eur J Cardiothorac Surg. 2006;30(4):574–7.
  14. Jameson S, Lamb A, Gupta S, Sher L, Wallace A, Reed M. The effect of the 48hr working week restrictions on trauma and orthopaedic operative experience: Analysis using the Elogbook. Journal of Bone & Joint Surgery, British Volume 2012;94-B(SUPP XXI):175-175.
  15. Al-Rawi S, Spargo P. A retrospective study of anaesthetic caseload of specialist registrars following the introduction of new working patterns in the Wessex region*. Anaesthesia 2009;64(3):297–300.
  16. Medical Education England Available at: Accessed 11/28/2011, 2011.
  17. Reid W. Developing and implementing organisational practice that delivers better, safer care. Quality and Safety in Health Care. 2004;13(4):247–8.
  18. WHO | Framework for action on interprofessional education and collaborative practice Available at: Accessed 11/28/2011, 2011.
  19. Melgar T, Schubiner H, Burack R, Aranha A, Musial J. A time-motion study of the activities of attending physicians in an internal medicine and internal medicine-pediatrics resident continuity clinic Acad Med 2000;75(11):1138–43.
  20. Green ML, Ciampi MA, Ellis PJ. Residents’ medical information needs in clinic: are they being met? Am J Med. 2000;109(3):218–23.
  21. Buddeberg-Fischer B, Stamm M. The medical profession and young physicians’ lifestyles in flux: challenges for specialty training and health care delivery systems. Swiss Med Wkly. 2010;140:w13134.
  22. Beiri A, Alani A, Ibrahim T, Taylor GJ. Trauma rapid review process: efficient out-patient fracture management. Ann R Coll Surg Engl. 2006;88(4):408–11.
  23. Stott I. Teaching specialist trainees in the out-patient clinic. The Clinical Teacher. 2007;4(1):21–4.
  24. Lo S, Eze N, Jonathan DA. The effect of consultant-led interactive pre-clinic case note review on follow-up rates of an otology outpatient clinic. Int J Clin Pract. 2005;59(2):256–8.
  25. Clinical Governance – Patient Safety – How do I report an incident? Available at: Accessed 11/28/2011, 2011.
  26. Freedom of Information (Scotland) Act 2002 Available at: Accessed 6/7/2012, 2012.
  27. Likert R. A technique for the measurement of attitudes. Archives of Psychology. 2008;22(140):1–55.
  28. Maurer TJ, Pierce HR. A comparison of Likert scale and traditional measures of self-efficacy. J Appl Psychol. 1998;83(2):324–9.
  29. Martin JS, Ummenhofer W, Manser T, Spirig R. Interprofessional collaboration among nurses and physicians: making a difference in patient outcome. Swiss Med Wkly. 2010;140:w13062.
  30. Schwarz D, Schwarz R, Gauchan B, Andrews J, Sharma R, Karelas G, et al. Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Quality & Safety. 2011;20(12):1082–8.
  31. Cosker TD, Ghandour A, Naresh T, Visvakumar K, Johnson SR. Does it matter whom you see? – a fracture clinic audit. Ann R Coll Surg Engl. 2006;88(6):540–2.