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Improving adherence to appropriate use criteria for paediatric supracondylar humerus fractures: a three-cycle quality
Osama Embaby1,2, Mahmoud Mersal3, Mohamed Elalfy2,4
1Orthopaedic Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK osama.embaby@nhs.net.
Background:
The appropriate use criteria (AUC) developed by the American Academy of Orthopaedic Surgeons (AAOS) provide evidence-based guidance for managing paediatric supracondylar humerus fractures (SCHFs), yet adherence varies widely in clinical practice. This quality improvement project aimed to improve the rate of 'appropriate' management for paediatric SCHF at a tertiary referral centre in Egypt by systematically implementing the AAOS AUC through a structured, multicycle intervention.
Methods:
We conducted a three-cycle plan-do-study-act quality improvement project at Mansoura University Emergency Hospital between January 2021 and May 2023, including all children under 18 years with acute SCHFs. Cycle 1 (n=58) established baseline adherence. Cycle 2 (n=62) implemented educational workshops and a departmental protocol. Cycle 3 (n=58) introduced reinforcement training, regular case discussions, visual reminders and individualised audit feedback. The primary outcome was the proportion of cases managed 'appropriately' according to the AUC.
Results:
Among 178 patients, appropriate management increased from 62.1% at baseline to 75.8% after initial education and 87.9% after reinforcement interventions, representing a 25.8% absolute improvement. Rarely appropriate management decreased from 19.0% to 3.4%. The greatest improvements occurred in Gartland type II fractures. Key baseline barriers included the lack of AUC awareness (78% of surgeons unfamiliar), absence of standardised protocols and variable surgeon preferences. Following sustained educational interventions and audit feedback, AUC tool utilisation increased from 45% to 95%.
Conclusions:
A phased quality improvement initiative combining education, protocolisation, reinforcement training and audit feedback significantly improved adherence to evidence-based guidelines for paediatric SCHFs. Sustained educational interventions with regular case-based discussions and individualised feedback are essential for long-term practice change. Organisational factors, particularly lack of awareness and inconsistent application of guidelines, represent the primary modifiable barriers to adherence.
