Adrian,
 
I seem to remember this started as an issue of bed-sores. Theory being that immobile NOF patients could develop sores within as little as an hour on an A&E trolley, but that a hospital bed would miraculously prevent these (I have my doubts - sore prevention has more to do with good nursing care than the exact type of hard surface !). Perhaps Ian Hepworth or one of the other nurses on the list can help us tell if this idea was evidence based or just guesswork.
 
The early MTOS work threw up a lot of "unexpected" trauma deaths with ISS 9 and perfect RTS (ie good physiology) - fractured neck of femur being one of the main culprits. Early treatment in A&E might well have a direct influence on whether the patient's final triage card is green or black. This needs more research though.
 
Cheers           Rob Cocks      HK
-----Original Message-----
From: Adrian Fogarty [mailto:[log in to unmask]]
Sent: Thursday, November 09, 2000 8:22 AM
To: A&E List
Subject: Re: Seniority of doctors

----- Original Message -----
From: <[log in to unmask]>
>
> I think this is one of the problems with a system of direct admission to
the
> wards especially when it is performed by junior A&E doctors. Sometimes
patients
> won't have had the appropriate tests or treatment in A&E and thay may not
be
> seen for hours on the ward to have this rectified. A recent study in the
region
> has suggested that patients with #NOFs who are fasttracked do worse than
patients
> with #NOFs who spend longer in A&E.

You know, this doesn't surprise me. I've always wondered why many people
consider fast-tracking of #NOFs to be such an important quality issue or
performance indicator. Of all the patients we see, surely these patients are
among the least acute...yes they need sorting out for humanitarian reasons,
and early management will marginally influence morbidity and mortality, but
they do not have an immediately life-threatening illness and they are not in
the same league as acute MI patients, for example, or any patient with
physiological derangement in the resus room. For #NOF patients analgesia and
a comfortable bed are important, fluids are more debatable as most of these
patients are euvolaemic, but rapid admission to an orthopaedic ward seems a
perverse measure of quality - orthopaedic wards are decidedly dangerous
places to be if you have a chance of having a serious medical condition. Who
dreamt up this performance indicator? If an indicator were needed, surely it
should be time to surgery, especially where ORIF is carried out on
intracapsular fractures where delay equals avascular necrosis. But hey - I
don't want to step on the orthopods toes again!

Adrian Fogarty