November 30, 2007
Ontario Orthopaedic Association (OOA) and
OMA Section on Orthopaedic Surgery,
124 - 1333 Sheppard Avenue East
Toronto, ON M2J 1V1
OOA Submission to HPRAC re: CNO Proposals:
HPRAC Committee Members,
The Ontario Orthopaedic Association (OOA) and OMA Section on Orthopaedic Surgery would like to thank HPRAC for the opportunity to comment on the expanded Scope of Practice proposals from the College of Nurses of Ontario (CNO). We will comment on the proposed amendments to the Regulated Health Professions Act, 1991 and the Nursing Act, 1991 which pertains to the delivery of Orthopaedic / musculoskeletal fracture care in the Province of Ontario.
The CNO proposal to HPRAC:
The expanded Scope of Practice proposals from the College of Nurses of Ontario (CNO) for RN(EC)s include permitting access to three new controlled acts, one of which pertains directly to the practice of Orthopaedic surgery in the province of Ontario. This new controlled act is described as follows:
Ø “Setting or casting a fracture of a bone or a dislocation of a joint.”
In addition, draft changes were made to the RN(EC) Practice Standard (Appendix C) to support the proposed changes in legislation. The revised Practice Standard outlines restrictions to controlled acts that are thought necessary to protect the public. They are outlined below.
Ø Limits and conditions: A Nurse Practitioner shall not:
o Set or cast a fracture that is open, displaces a growth plate/epiphysis, extends into a joint, is a pathologic fracture, or is a fracture of the elbow, hip, pelvis or femur.
o Set or cast a fracture or dislocation where there is reason to believe that blood vessels, ligaments, nerves or muscles are damaged or;
o Reduce a displaced fracture without physician consultation.
Ø Before setting or casting a fracture of a bone or a dislocation of a joint, a Nurse Practitioner shall;
o Perform and document the findings of an advanced focused health assessment and physical examination and;
o Order and document the findings of diagnostic tests.
The proposal and its appendices further indicate that the proposed changes were to have been made through an ‘extensive consultation process’ involving input from expert focus groups, teleconferences, legal council, and broad stakeholder involvement from multiple practice settings and geographical locations.
According to the proposal the proposed changes are intended to:
Ø Reflect current practice, education and competencies of RN(EC)s;
Ø Increase client access to timely health care services;
Ø Enable RN(EC)s to provide health services to hospitalized in-patients;
Ø Increase efficiencies within the system and enhance cost effectiveness by decreasing duplication; and
Ø Clarify and enhance RN(EC) accountability.
According to the Nurse Practitioners’ Association of Ontario the proposed changes are:
Ø An important step forward in strengthening the safety of Ontario’s health care system.
Ø Enabling nurses in the Extended Class to function autonomously without medical directives or delegation, which will strengthen professional accountability and ensure that patients have access to comprehensive, safe, quality care.
Ø Going to provide more timely access to care for patients, facilitate earlier discharge for patients and reduce waiting times, improve continuity of care, support best evidence in prescribing and remove unnecessary burdens and promote more effective utilization of physician resources.
What is the Current Standard of Care for the “Setting or Casting of a Fracture of a Bone or a Dislocation of a Joint” in the Province of Ontario?
In Orthopaedic surgery there is a well know pearl of wisdom which states, “If it is not broken, don’t attempt to fix it”. The CNO proposal described above, as it pertains to the management of displaced fractures and dislocations (including fracture dislocations) for Ontarians, represents a marked changed in care from the current ‘gold standard’. Before such a recommendation is made, one would have expected for there to be a significant and measurable deficiency in the current model of fracture care. In addition, such a proposal should have included an environmental scan including a detailed description of how the current model works and where such marked gaps in care exist.
Environmental Scan:
How does the current fracture care system work?
Fractures and dislocations are managed outside of the hospital setting by both physicians and allied health professionals. The non-physician group includes Paramedics, St. Johns Ambulance providers, Ski Patrol and Athletic Trainers. The initial phase of management includes taking a history of the injury, reviewing relevant past medical history, and completing a physical examination of the injured areas. These providers then administer provisional treatment including improving the alignment (modified reduction) and splinting of all types of fractures (including fracture dislocations) and the splinting of suspected dislocations. This pre-hospital fracture/dislocation management is performed on an emergency basis in the field. The patients with suspected fractures/dislocations are then taken to a hospital Emergency Room (ER) where they are seen by an emergency room physician. At that moment the ER physician becomes the most responsible person (MRP) caring for the patient. The physician’s education, skills and experience allows them to determine the magnitude of the injury, likely secondary areas of injury, whether the injury is open/closed, the presence of subtle or significant neurological or vascular injury and concomitant ligament and/or other important soft tissue injury. The physician then orders the radiological tests which they deem necessary. This includes plain radiographs (including special views), CT scan and MRI. The physician will then either perform the definitive management themselves, ask for help from the nursing staff/Cast Technician, or delegate various components of the care to the nursing staff and/or Cast Technologists. The management of non-displaced fractures requires plaster or non-plaster splinting. This technical task is frequently delegated to the nursing/Cast Technician staff. The management of all displaced fractures, fracture dislocations and dislocations are assessed by the ER physician as indicated above and a decision is made by the ER physician as to whether or not they can provide the next level of care, i.e. a reduction of the fracture, fracture dislocation, or dislocation. The physician will typically do so using regional anesthesia, intravenous narcotic analgesics and/or conscious sedation. They will often perform the reduction procedure using fluoroscopic radiography. They will also typically engage the assistance of the nursing staff and/or a Cast Technologist. For those cases which they are not skilled to manage or believe that they will require surgical management they will make an urgent referral to an Orthopaedic surgeon on call in their hospital, to an Orthopaedic surgeon on call in another hospital or they will have to refer the patient to Criticall. Most patients managed by the ER physician require follow-up with an Orthopaedic surgeon in their Fracture Clinic, and are typically seen within forty-eight hours of the initial ER visit. The patient is subsequently assessed/managed in the fracture clinic by an Orthopaedic surgeon. The surgeon then assumes the role of MRP for the patients’ musculoskeletal injuries until such a time when the patient no longer requires medical care or at which point the Orthopaedic surgeon must refer the patient to a more specialized Orthopaedic surgeon. Those patients which do not require referral to an Orthopaedic surgeon are followed-up with their family doctor, a walk-in clinic if necessary, or on occasion are brought back to the emergency for a re-check if necessary. Finally, there are some patients who do not need any follow-up and are discharged after seeing the ER physician.
What are the elements, judgment and integrated care inherent in the current model of fracture/dislocation care?
The above description of Orthopaedic/musculoskeletal care like almost any aspect of medicine or nursing, can be broken down into multiple constituent elements (e.g. “Setting a fracture of a bone”). Although we believe that there are very few individual elements of nursing or medical practice that cannot be taught to, learned by, and practiced by virtually any member of the health care team (physician, physician assistant, nurse, physiotherapist etc.) we also strongly believe that the best practice involves the application of judgment and experience to successfully integrate many of these individual procedures. This is inherently different to demonstrating proficiency with any one element.
Although catastrophic outcomes after fracture management are rare, patient perceived negative outcomes after fracture management are not uncommon (e.g. malunion). It is with judgment and experience that the treating physician (most often Orthopaedic surgeon) guides the patient through the process of fracture care to reduce the overall exposure to such adverse events and the potentially negative perception of the patient that their fracture treatment has failed. The relative infrequency of such adverse outcomes may however lull some individuals into a false sense of security that managing fractures and dislocations is straightforward. It stands to reason that when the patient depends on the clinician’s judgment, insight, and experience, that the more training the provider has the better.
What are the current educational requirements which support the physician’s role of MRP for the “Setting or casting a fracture of a bone or a dislocation of a joint.”?
All physicians must first complete a medical school degree which includes clinical decision making (patient assessment, use of investigations, and formulation of a musculoskeletal-based diagnosis) and hands on training in the field of Orthopaedic surgery, in the setting of the emergency department, surgical wards, and physician offices. Next, Family physicians must complete an additional two years of Family Practice Fellowship Training which once again will include a substantial amount of time assessing and treating musculoskeletal injuries. Emergency Physician specialists will go on to complete additional years of training focusing on the management of the injured and acutely sick patients. The additional training will also serve to further their musculoskeletal-based diagnostic and technical skills beyond that of the Family Physician. Finally, the Orthopaedic surgery residency is a five year clinical/technical training program which is dedicated to the management of musculoskeletal injury and disease.
When HPRAC asked the CNO the following question regarding education: What educational bridging programs will be necessary for current members to practice with the proposed scope? The CNO responded: Life-long learning is a professional obligation of all nurses and is embedded in CNO’s QA program for all nurses. CNO expects that all NPs will engage in continuing education that is appropriate to their individual practice and employment settings, including continuing education that may be a direct result of scope of practice changes. CNO also posed HPRAC’s question to representatives in the education sector. McMaster University does not anticipate the need for bridging programs for its graduates. The Ontario Primary Health Care Nurse Practitioner Program indicated that continuing education (combination didactic and clinical) would be helpful to NPs, pending funding availability. This program often holds continuing education clinical workshops (i.e., suturing) for existing NPs at professional conferences; similar workshops could be produced for setting / casting fractures.
The latter paragraph indicates that the CNO believes that a Nurse with additional workshop-based training, similar in time and intensity to a workshop required to learn how to suture (usually several hours), can assess, investigate, correctly identify, reduce, cast and maintain/manage non-displaced fractures, displaced fractures, dislocations and fracture dislocations, independent of Family Physicians, Emergency Physicians and Orthopaedic surgeons is of great concern to the OOA. This decision appears to have been made without sound knowledge of the principles of fracture/dislocation management. When asked, most Orthopaedic surgeons would concur that the most difficult aspect of fracture management is the assessment, diagnosis and ongoing follow-up after the fracture has been casted and/or reduced and casted. Furthermore, the OOA is unaware of any consultation made on behalf of the CNO with any of the Orthopaedic surgeon educational experts in the province who lead their respective University’s Orthopaedic training programs.
What are the current areas of risk inherent in the current model of fracture/dislocation care?
In order to best understand the inherent risks in the management of fractures (undisplaced and displaced) and dislocations (including fracture dislocations) we communicated with Dr. John Gray, the Executive Director and CEO of the Canadian Medical Protective Association (CMPA) (personal communication November 28, 2007). Dr. Gray stated that the perception at CMPA is that many office-based GPs manage only simple fractures if they manage any at all, and even emergency physicians view fracture management as an area of risk and referrals from them to Orthopaedic surgeons are common.
Dr. Gray reviewed the CMPA database to identify cases where casting of fractures was the identified clinical issue. For the five year time period from 2002 to 2006 cases involving all types of work (not just GPs) were analyzed to determine areas of clinical risk. The CMPA identified 106 cases of which 72 were closed cases and 34 open cases.
Performance issues were the most frequently documented critical incidents and included failure to perform a procedure, and procedural issues for the named member due to the action or inaction of another individual. Clinical issues on these files were primarily related to fracture diagnosis and management as opposed to cast application or management. Diagnostic critical incidents recorded with the highest frequency included case with deficient histories or general evaluation and cases involving misinterpretation or misreading of the X-rays.
There were 6 instances where application of cast or management of cast was the documented intervention not performed. Laceration, perforation, ligation or other injury sustained during a procedure was documented on 4 cases and related to injuries sustained during the application of cast/splint, application of traction or removal of cast.
A subset of 30 (open and closed) cases only involving GPs was also identified. The most frequent diagnostic critical incidents documented on cases involving family practitioners involved deficient histories or general evaluation, failure or delay to refer a patient or consult another physician, and failure to perform a specific diagnostic test or procedure (usually an X-ray).
In summary, their analysis showed care involving diagnosis or management of fractures is more significant than cast application/removal and that fracture care does contain an inherent element of risk, and this will be needed to be taken into consideration as one considers issues such as defining appropriate liability protection for any health professionals involved in fracture care. This opinion indicates that the areas of highest risk when caring for fractures (and dislocations) lies with the diagnosis and management aspect of care. Therefore, the Orthopaedic surgeons of Ontario are of the opinion that, in order to continue to reduce the overall risk inherent in the current fracture care model in the province of Ontario, those aspects of fracture care which are dependent upon the diagnosis and management i.e. “setting or casting a fracture of a bone or a dislocation of a joint” must remain with the physician as MRP. This opinion also supports the current model of care, whereby the cast application/removal often performed by Cast Technologists / nurses is conducted as a delegated act under medical directive.