Background Upper limb fractures are common to the Paediatric Emergency Department (PED). Most angulated and/or displaced fractures are traditionally referred to the orthopaedic team to admit for manipulation under anaesthesia (MUA). The Emergency Department (ED) believes that their manipulations and associated analgaesia are sub-optimal to those performed/given in theatre. This means a higher number of avoidable overnight paediatric admissions, long waiting times while fasting, and the theoretical risks of general anaesthesia and surgery.

Aims Reduce the number of hospital admissions for MUA from the PED by managing suitable upper limb fractures safely and appropriately. Encourage long-term changes in clinician readiness to manipulate suitable paediatric injuries.

Objectives

• Increase number of patients identified with upper limb fractures suitable for manipulation in PED

• Reduce number of patients in this cohort requiring admission to hospital for MUA

Method and Design A Plan-Do-Study-Act methodology was implemented. Adherence to our local policy was measured, specifically: inclusion/exclusion criteria, modes of analgesia and presence of a senior Orthopaedic doctor.

From October 2020 -June 2021, interventions were undertaken: a teaching package for Emergency Nurse Practitioners and doctors, posters placed in the PED, meetings with key stakeholders including the orthopaedic team and the introduction of a new departmental guideline. Data was collected between June 2021–September 2021 to see if results were maintained.

Results and Conclusion Results Rate of manipulations in PED increased from 41% to 78% in the 3rd cycle; improving to 86.36% after interventions stopped. Of those manipulated in PED, 73.68% were discharged from the department. Admissions for MUA decreased from 85% to 70% in the 3rd cycle; decreasing to 36.36% after interventions stopped.

The project showed success in improving management of paediatric angulated upper limb fractures. By identifying appropriate fractures, involving the senior orthopaedic team and providing adequate analgesia, admission for general anaesthesia can be avoided.