HandsFirst Learning report update

Read our HandsFirst Learning report here.

HandsFirst

HandsFirst2

This quality improvement (QI) project will focus on improving the quality of care for hand trauma patients. The project aims to improve outcomes for these patients by reducing variation and reducing time to surgery for this patient group.

Project goal

That 80% of hand injuries that present to any service on the day of injury and require surgical intervention should have their first operation within the timeframe given in the BSSH hand trauma standards.

 These are specifically:

• Category 1: Within 24 hours for open joints and open fractures;
• Category 2: Within four days for all other open hand injuries (96 hours);
• Category 3: Within seven days for closed hand fractures (168 hours).
  
  

Limb-threatening injuries requiring more urgent intervention are excluded. For example:

• Where revascularisation is required;
• Compartment syndrome;
• Where there is an infection or risk of infection from e.g. bite wounds.

The timeframes for children up to 10 years of age that present to any service on the day of the injury and require surgical intervention should have their first operation in the following timeframes:
• Open joints and open fractures within 24 hours
• Other open hand injuries within three days (72 hours)
• Closed fracture of the hand within four days (96 hours)

Project approach

The project will use a healthcare collaborative approach, defined as a short-term learning approach that brings together a number of teams from hospitals to seek improvement in a focused topic area.¹

Combined with QI methodology, the use of a QI collaborative aims to close the gap between potential and actual performance by testing and implementing changes quickly across many groups.² Project teams from each hospital will look at the best examples of care. Sharing of learnings within the collaborative allows each group to benefit from the successes and failures of others, addressing similar issues, reducing duplication of effort and allowing solutions to be reached more rapidly.

QI involves implementing multiple, rapid cycles of change in response to a specific, predetermined problem and adapting the approach based on the results seen from each change. This is known as a PDSA (Plan, Do, Study, Act) cycle and has the benefit of allowing solutions to be tailored to the local environment, taking into account the context of the hospital they are being implemented in.

Support from clinical and QI experts was provided by RCS England through coaching sessions, online meetings, webinars, email support, and the facilitation of group collaborative meetings.

Project team

Clinical lead:                  Mrs Sarah Tucker
RCS Council Lead:        Professor Vivien Lees
QI Consultant:                Maureen McGeorge 
QI Consultant:                Ruth Colville
QI Consultant:                Mark Fuller 
Senior Project Manager: Sheena MacSween

Timeline

Participating sites

1 Ashford and St Peters NHS Foundation 
2 Betsi Cadwaladr University Health Board
3 Birmingham Women's and Children's NHS Foundation Trust 
4 Cambridge University Hospitals NHS Foundation Trust
5 Chelsea and Westminster Foundation NHS Trust
6 East Lancashire Hospitals NHS Trust
7 Gloucestershire Hospitals NHS Foundation Trust
8 Guys and St Thomas’ NHS Foundation Trust
9 Hull University Teaching Hospitals NHS Trust
10 Lancashire Teaching Hospitals NHS Foundation Trust 
11 Manchester University Hospitals Foundation Trusts
12 Newcastle upon Tyne Hospitals NHS Trust
13 Norfolk and Norwich University Hospital NHS Foundation Trust
14 North Tees and Hartlepool Hospitals NHS Foundation Trust
15 Northumbria Healthcare NHST Trust
16 Oxford University Hospitals NHS Trust
17 Portsmouth Hospitals University NHS Trust
18 Sheffield Teaching Hospitals Trust
19 South Tees Hospitals NHS Foundation Trust
20 University Hospitals of Derby and Burton NHS Foundation Trust
21 University Hospital Coventry and Warwickshire
22 University Hospital Southampton NHS Foundation Trust
23 University Hospitals Birmingham NHS Foundation Trust
24 University Hospitals Dorset NHS Foundation Trust
25 University Hospitals North Midlands

HandsFirst2

HandsFirst2 is now live and will run until December 2024. The project focuses on improving participating sites' pathways for hand trauma patients, this will not only improve patient care but also relieve pressure on their system.

The project uses proven Quality Improvement methods and offers ongoing support to clinicians and managers to drive improvements in their hospitals. Each site will be given tailored support to make improvements depending on their local context and unique set of challenges.

HandsFirst2 proposed goals 

That 80% of hand injuries that present to any service on the day of the injury and require surgical intervention should have their first operation within the timeframe given in the BSSH hand trauma standards. 

These are specifically:
• Category 1: Within 24 hours for open joints and open fractures;
• Category 2: Within four days for all other open hand injuries (96 hours);
• Category 3: Within seven days for closed hand fractures (168 hours).

Limb-threatening injuries requiring more urgent intervention are excluded. For example:
• Where revascularisation is required;
• Compartment syndrome;
• Where there is an infection or risk of infection from e.g. bite wounds.

• The timeframes for children up to 10 years of age from an injury to the first surgical intervention for patients presenting within 24 hours are:
• Open joints and open fractures within 24 hours
• Other open hand injuries within three days (72 hours)
• Closed fracture of the hand within four days (96 hours)

That 80% of hand injuries that present to any service on the day of the injury and require surgical intervention should have their first operation within the timeframe given in the BOA Standards for Trauma and Orthopaedics (BOASTs). These are specifically:

• within 72 hours for intra-articular distal radial fractures
• within seven days for extra-articular distal radial fractures

That 80% of hand injuries that present to any service on the day of the injury and require Hand Therapy should have their first appointment within the following timeframes

• Category 1 Open fractures and joints
  o In three to five days of surgery;
  
  
• Category 2 Open hand injuries
  o In three to five days of surgery for all tendon repairs;
  o Within seven days of surgery for peripheral nerve repair excluding digital nerves;
  o Within three weeks for soft tissue loss (including amputation) 
  o Within three weeks for no structural damage
  
• Category 3 Closed hand fractures
  o Within five to seven days for surgically managed closed hand fractures. 
  o Within seven days for non-surgically managed closed hand fractures (including bony mallet injuries). 
  
• Category 4 Closed soft tissue injuries
  o Within seven days for mallet injuries 
  o Within seven days for extensor tendon central slip injuries 
  
  
  
   

What are the benefits?

Sites that join HandsFirst2 QI collaborative will receive:

• Support from clinical and QI experts through coaching sessions, email support and teleconferences.
• Access to a local data platform.
• Peer collaboration with colleagues at participating sites.
• Attendance at webinars and collaborative events.
• Specially designed programme to meet each trust or health board’s specific needs.
• Participation in leading change masterclasses for site leads

The project team will work with participating sites to: 

• Improve theatre utilisation by identifying which cases can be managed in alternative facilities.
• Improve patient flow by utilising more efficient and agreed pathways, which will relieve pressure on emergency departments and assessment clinics.

If trusts/health boards implement these service changes, they will likely save money as there will be a reduction in the use of main theatre facilities (with more cases being managed in procedures rooms). There will also be fewer complications from delayed surgery. As a result of offering patients more timely surgery, we expect trusts/health boards will see a reduction in complaints received and reduce the risk of litigation.

Timeline

Recruitment, payment and set-up 
Nov 22 - May 23

Set up and launch
Jun 23  -  Oct 23

Testing ideas in practice
Nov 23  -  June 24

Demonstrating sustained improvement 
Jul 24  -   Nov 24

Collaborative close
Dec 24

Evaluation and reporting
Jan 25 - Mar 25

Future HandsFirst projects

If you are interested in joining future rounds of the collaborative please register your interest by emailing handsfirst@rcseng.ac.uk    

Contact details

For more information, email handsfirst@rcseng.ac.uk.

Privacy statement

What is the aim of the HandsFirst QI Collaborative?

This quality improvement (QI) project will focus on improving the quality of care for hand trauma patients. The project aims to improve outcomes for these patients by reducing variation and reducing time to surgery for this patient group.

Where is patient data collected from?

The data on patients undergoing surgical interventions for open joints and open fractures, open hand injuries and closed hand fractures. Data is collected by local clinical teams at the 25 trusts/ health boards that are participating in the project. 

Data controllers

The data controllers refer jointly to The Royal College of Surgeons of England and NHS trusts and health boards. Data will be shared between the HandsFirst delivery team and the NHS trust / health board on the basis of controller to controller data transfer.

Legal basis for collecting and processing personal patient data

The data will be collected and analysed under articles 6,1(a) and 9,1(a) of the GDPR:
1. Article 6,1(a) The data subject has given consent to the processing of his or her personal data for one or more specific purposes.
2. Article 9,1(a) The data subject has given explicit consent to the processing of personal data

How do we protect your patient data?

Local clinical teams enter patient data into a secure web-based tool REDCap. Security and confidentiality are maintained through the use of passwords and a person specific registration process. Only HandsFirst QI Collaborative project team can access the data collection tool.

Patient confidentiality

The patient information received and managed by the HandsFirst QI Collaborative is treated as confidential. We analyse the data to produce information on patient care and outcomes, the HandsFirst QI Collaborative team use de-identified data and so individual patients are not identifiable. The QI project is also careful when publishing information to include graphs or tables that do not allow individuals to be identified. 

Management of patient data by the HandsFirst QI Collaborative team

The HandsFirst QI Collaborative team are based at the Royal College of Surgeons of England (RCS England). The RCS England conforms to the General Data Protection Regulation (GDPR) and other legislation that relates to the collection and use of patient data. The RCS England has strict security measures in place to safeguard patient information held in the Data Collection system and when analysing the de-identified dataset. The Data Collection IT system has various levels of security built into it, such as ID password security, which prevents unauthorised users gaining access and data encryption.

These de-identified datasets will be held by the HandsFirst QI Collaborative team for 18 months following the end of the project (the project is due to close on 30 November 2022). This is to allow evaluation for any report writing or outputs for academic journals to be completed. 

What if I do not want my information used by the HandsFirst QI Project?

We need your permission to hold information that can identify you, and you will be given a consent form to show whether or not you want the hospital to submit your personal details. Your care will not be affected by whether or not you consent.

If you give consent and then change your mind, please send an email to handtrauma@rcseng.ac.uk and put "Request to opt-out" in the subject line. Upon receipt of your email, we will remove your personal details from the database.

Alternatively, you can notify a member of your local care team that you wish to opt-out. They will then ensure that your personal details are removed from the database.

For more information on RCS England's QI collaboratives, visit the following pages:

• Chole-QuIC