628 COVID is not all bad. Service improvement to fracture manipulation in the children’s emergency department

Background As part of a QI project looking at forearm fractures, a retrospective audit was performed looking at a 1-year period of wrist and forearm fractures up to March 2018. Over this period 98 patients had fractures that required intervention and 34% of these had a manipulation in CED. Reasons for not having a manipulation were cited a possibility child would not tolerate procedure under entonox and intranasal diamorphine and not having a sedation trained practitioner free to administer intravenous sedation instead. This resulted in the remainder requiring admission for manipulation under anaesthetic. Given the concerns re noscomial COVID 19 transmission as well as lack of theatre capacity in the first wave of the pandemic, a change was made to our forearm fracture guideline in partnership with the Orthopaedic team with emphasis on attempt at manipulation in the emergency department with entonox and intranasal diamorphine prior to admission to actively avoid as many admissions as possible. Given this change is practice we wanted to ascertain parent/patient satisfaction with this and see if this reduced hospital admission. Objectives . Ascertain if promoting manipulation of forearm fracture as first line treatment is effective at avoiding hospital admission and subsequent further manipulation in theatre and reduces admission rates compared to previous audit data . Ascertain if using entonox and intranasal diamorphine for the manipulation of forearm fractures was perceived by parents to be satisfactory pain relief for the procedure . Ascertain if using entonox and intranasal diamorphine for the manipulation of forearm fractures provides a satisfactory patient experience Methods A specially designed parental/patient experience survey was developed and given out to patients requiring a forearm manipulation in CED between June - October 2020. Retrospective case notes review of all patients <16 years attending CED with a forearm fracture during the same period to identify management and outcome. Results During the survey period 47 children attended CED with a forearm fracture requiring manipulation. Of these 21 parents completed the survey. Overall 85% of all patients attending CED with a forearm fracture requiring manipulation had it done in CED compared to 34% in 2018. 100% of survey respondents felt their child's pain was well managed during the procedure. Only 14% of patients with forearm fracture attending CED were admitted for manipulation in theatre during this period compared to 66% found in audit data previously. Conclusions Use of Entonox and IN diamorphine is provides effective pain relief for manipulation of forearm fractures that is acceptable to parents. A change in practice to using this first line can reduce admission rates and subsequent theatre time for this common fracture significantly.