Improving Wrist Injury Pathways (I-WIP): a Qualitative Study

Around 70,000 patients per year in the UK attend hospitals with serious wrist pain after an injury, which although painful on examination, look 'normal' on x-ray. The National Institute of Care and Health Excellence (NICE) advises that this large group of patients who have pain, but normal x-rays, should be given MRI (magnetic resonance imaging) scans early on. Early MRI gives patients the best care, by picking up the serious injuries requiring early treatment and by enabling those without serious injuries to get back to activities quickly after being reassured and potentially saves NHS resource by reducing unnecessary clinic attendances(1). Although these benefits from early use of MRI scans, and the NICE guidance, are clear, it is known from our recent national (UK) survey that MRI scans are underused around the country. Only 13% (11 of 87) of centres currently use MRI directly for patients(2).

There are multiple, often complicated reasons, for centres not being able to follow the NICE guidance, however when they do use MRI scans early on, it makes patients better faster, and saves the NHS money(3). This implementation gap between what best evidence recommends and what happens in clinical practice is a complex issue that requires further investigation. To develop an effective complex intervention to address this problem, a far better understanding of the reasons underlying this failure to implement NICE guidance is needed. In 2000, the UK Medical Research Council (MRC) established guidance for developing and evaluating complex interventions to improve the delivery of health care services(4).This guidance advises that six core elements are considered when developing a complex intervention:

1. How does the intervention interact with its context?
2. What is the underpinning programme theory?
3. How can diverse stakeholder perspectives be included in the research?
4. What are the key uncertainties?
5. How can the intervention be refined?
6. Do the effects of the intervention justify its cost?

A vital early task in ensuring evidence-based treatment of wrist injuries is to develop a theoretical understanding of the drivers (or root causes) of the problem. To do this, we need to draw on existing evidence and theory from similar contexts, and verify our initial assumptions through primary research, for example interviews with stakeholders and the detailed mapping of care pathways. In this case, the relevant stakeholders are a highly diverse group including commissioners, managers, ED staff (including doctors, paramedics, nurses and other allied health professionals), administrative staff, radiologists, radiographers and surgical staff (including surgeons, nurses, physiotherapists and other allied health professionals).

It will be important to consider the potential barriers and facilitators to complex interventions in orthopaedic surgery. The Donabedian model of quality assessment is useful here(5). This model proposes that any given outcome (in this case early MRI of the wrist) is the product of (a) process factors (the way care is organised or delivered) and (b) structural factors (the physical capacity of the service to deliver the target outcome). Our exploratory work has demonstrated deeply entrenched negative views regarding the value of early MRI which are likely to be a barrier to change in some centres. MRI capacity may be a significant barrier to implementation. Process barriers might include inefficient use of existing MRI capacity, which would be amenable to pathway implementation to streamline and improve efficiency. Conversely structural problems, such as insufficient capacity despite optimising MRI efficiency may require the purchase of more scanners and recruitment of more staff. Structural problems are harder to influence with behaviour change interventions and generally need a different approach e.g., business case or funding (6).