Using collaborative leadership and interdisciplinary pathways towards achieving national recommendations. Excellent results from 1884 rapid MRI scans for ‘suspected scaphoid fracture’

Introduction National Institute of Clinical Effectiveness (NICE) guidance mandated early MRI scans for suspected scaphoid fractures in 2016. In national surveys, only 15% of NHS Emergency Departments achieve this. Missed fractures may require bone grafting surgery for non-union. NHS litigation costs are high. Conversely, over-treatment harms patients’ lifestyle and income. Methods With leadership across Orthopaedics, Radiology and the Emergency Department, we co-created a rapid MRI pathway for suspected scaphoid fractures at site A. We defined the technical specification for a 5 min MRI scan. 100 patients from site A were compared with 100 from site B (traditional pathway). Features driving successful implementation are highlighted. Medical students helped analyse scan results, requests and demographics. Results Statistically significantly fewer clinic appointments and fewer late diagnoses occurred at the rapid MRI site compared with the traditional site. Key features included: Working across staff groups (radiology/orthopaedics/emergency departments/receptionists/radiographers/clinic-booking/casting). Co-creating a pathway and clear proforma for Emergency staff to request MRI scans, including prompts for smoking cessation, splinting and patient information with QR codes. Using educational videos for induction. Pathway including a 2-week Orthopaedic fracture clinic appointment to review scan results and individualise treatment. Over 8 years, 1884 rapid MRI scans were performed on 1871 patients aged 9 to 102. This is the largest global series of suspected scaphoid fractures. There were no missed fractures. Diagnoses were: 13.2% scaphoid fracture positive, 21.6% other injury, 27.3% other condition, 22.6% minor injury with pre-existing condition and 15.2% normal scan. 74.0% were requested by Emergency department nurses or doctors. 47% of patients were over age 50, with 8.4% positive (17.4% positive in patients aged up to 50). 57% were female, with 8.9% positive (18.9% positive in men). Conclusion Guidance mandating NHS standards may not achieve change. Co-creating a successful pathway needs gentle clinical leadership, local organic solutions, patient-centredness and responsive cross-professional team-working.