A physiotherapy led service improvement project for people attending the emergency department with traumatic anterior shoulder dislocations [conference abstract]

Purpose: Traumatic anterior shoulder dislocations are the
most common joint dislocation. Soft tissue, bony and neurological injuries are relatively common with a high incidence of re-dislocation. The treatment goal in the acute setting is to successfully identify the dislocation, any associated injuries and to reduce the dislocation.

The aim of this project was to improve the care given
to people with traumatic anterior shoulder dislocations. The
objectives were to evaluate whether teaching and introduction
of a traumatic shoulder dislocation pathway could improve
patient care and adherence to the British Elbow and Shoulder Society (BESS)/British Orthopaedic Association (BOA)
standards.

Methods: Retrospective analysis of electronic notes and
radiographs was undertaken on people attending an acute hospital trust with traumatic anterior shoulder dislocations from June 2018 to June 2019. 472 records were identified. 273 people (54 females; 219 males) with an age range of 16–100 years (M = 37.2) met the inclusion criteria of a traumatic anterior shoulder dislocation with radiographic evidence or assessment findings consistent with anterior dislocation.

Exclusion criteria included; under 16 years, three/four-part fracture dislocations and other shoulder injuries.
The BESS/BOA Patient Care Pathways for Traumatic
Anterior Shoulder Instability were used to audit adherence
to the standards before and after teaching and the introduction of a new pathway. The standards included; neurovascular (NV) assessment pre-reduction, radiographs in two planes pre-reduction, NV assessment post-reduction, radiographs in two planes post-reduction and appropriate follow-up.

Results: Before the introduction of the pathway, people
attending with traumatic anterior shoulder dislocation had
their NV status documented 65.4% of the time pre-reduction.
Radiographs in two planes were completed in 87.4% of people pre-reduction. NV status was documented post-reduction
in 21.7% of cases. Radiographs post-reduction, in two planes,
were taken in 86.7% of people. 70% were discharged with
appropriate follow-up. 11.1% of cases met all the standards.
Results of the audit were fed back to relevant staff and
feedback was received. Key stakeholders were identified, culminating in a working group, led by the author, to improve managing traumatic anterior shoulder dislocations in the emergency department (ED). The training was delivered to
front line staff by the physiotherapist and the pathway was
introduced. Re-audit has shown a much-improved performance; 85.7% of patients correctly meeting all standards.

Conclusion(s): Introduction of teaching and a new pathway in the ED has led to significant improvements in care in accordance with the BESS/BOA standards from 11.1% to 85.7%. Feedback regarding the training provided and the new pathway has resulted in an updated version of the pathway that will hopefully improve compliance further. This will be enhanced further when integrated into the electronic notes system. This project’s results may lack generalizability as reduced NV testing, inadequate radiographs and inappropriate follow up might only be relevant to our trust.

Impact: Physiotherapists are a key workforce in the NHS
long-term plan. An advanced practice physiotherapist was
able to lead a change of service delivery in a large, multidisciplinary team in the ED for people with traumatic anterior shoulder dislocations. Other trusts may consider evaluating their performance in managing people with traumatic anterior dislocations using this project as a benchmark.