Bricolage IS WRITTEN by Jeff Cable and is based in the United Kingdom.

This blog aspires to provide COHERENT and relevant Material for all cast TECHNICIANS. 

Patient Workflow

The patient workflow which is used in any cast-room ought to ensure that every patient is treated appropriately and in a timely manner. Cast-room personnel do not have to think too hard about how to improve the patient workflow through their own cast-room environment.

Sadly, the methods which many clinics use to see and treat their patients (who will need to make use of the casting services) tends towards being based around a local administrative imperative.

This frequently means that a staff member without a clinical background makes the decisions as to how the clinics will run. The usual result is that patients who need a cast removal on arrival and an X-ray examination are left waiting until the end of the clinic time before they are sent to the plaster room and subsequently to the diagnostic imaging suite.

Stress in the workplace is detectable where the employees cannot carry out their assigned tasks and duties in the manner in which they were detailed. Employees may be expected to work to a certain standard which often includes timings for work completed and other work quality related initiatives.

Dissatisfaction ensues and staff may be found working under a permanent state of duress. This usually results in frequent and extended absences for bouts of sickness which are often trivial.

What can cast technicians do about workplace workflows? Initially, staff must document clear cases where the cast room personnel are involved with patients. The audit need only occupy one or two months but it will confirm suspicions about clinical activity which militates against the work of the cast-room.

Any clinical audit should be designed to detect instances of the conduct or treatment that requires illumination for making the case for a change in clinical practice. 

One commonly seen example of how a workflow may be frustrating the work of cast-room staff is where a request to remove a cast is followed by the instruction to request the treating clinician to review the patient out of cast. This can require a person with a leg injury to remain in the cast-room occupying a couch until they are seen by the clinician.

Frequently, this may occupy a further 45 minutes before the patient is seen and the work of the cast-room personnel is slowed by them blocking their own working space.

Reviewing patients in a cast-room environment is usually requested where the patient has a surgically created wound. The environment is often not even socially clean and the air will be laden with dust from cast removal and the associated particles of skin from other patients.

This is a poor clinical practice and patients should be transferred to a clean room to await assessment by the clinician. This would also assist the redressing of a surgically created wound because the environment would be socially clean.

Requesting that all patients who will require a cast removal on arrival and/or an X-ray examination must mandate that these patients are seen at the beginning of any clinic. This would ensure that the patients are sent to the X-ray department early.

They will not overload the X-ray department when the working day is under way after numerous demands have been placed upon the time of the available radiographers. 

Patients who require a check X-ray after cast removal should be identified at their previous clinic attendance. Ideally, the radiographic examination may be requested electronically or a written request completed and appended to the clinical care record.

It should be made clear to the patient that they must attend in the early morning for a cast removal and an X-ray examination at their next clinical appointment. The clinical case record can carry an identifying mark on the outside such as a red sticker for cast off and say... a green sticker for X-ray examination. 

This method includes the benefit of making it obvious how many patients are to be dealt with in this manner. After all of these patients are dealt with by cast room staff, the normal clinic work can take place and the clinicians will be seeing patients who are still in the middle of treatment.

It only requires that the first hour of clinic time be set aside for all review cases who will be seen in the cast-room to have a cast removed and possibly a check X-ray examination.

Seeing patients in the plaster room who are wearing a 'backslab' indicates that they have not undergone a clinical examination by the treating/prescribing clinician. It is strongly suggested that the cast-room patient workflow should not include patients who are still wearing their 'backslab' after they have seen the clinician. The clinician will not have examined the injury and will be guilty of treating just the radiograph. 

This is unacceptable treatment and it places an additional burden upon the shoulders of the cast technician. The cast technician must be alert to the possibility of missed injuries and clinical problems which were unappreciated by the treating clinician who did not examine the patient. Cast technicians are not trained for such a role and it creates a stressful working environment, where the cast technician has to supervise the work of the treating clinician.

Cast techniques can play a significant part in determining the frequency of review for patients during the course of their treatment. Carefully applied casts can ensure that a patient is only seen once at the start of their treatment cycle and once at the end of it.

It is costly in terms of cash and resources to see a simple fracture twice during the treatment cycle of a fracture as well as at the beginning and the end of the treatment cycle duration. This applies to all injuries which may be expected to run a normal course and become functionally stable after six weeks have elapsed.

Frequent changes to a cast which was well-constructed serve no clinical purpose. Injuries which require regular X-ray examination should not have plaster of Paris (POP) layers under them. It scatters X radiation and obscures fine detail. If position is important and regular X-ray checks will be required through the course of treatment, then POP cast layers should be avoided where possible.

Regular observation of a wound requires a cast to be removed rather than a small window cutting in the cast. Windows are cut when the soft tissues are at their most vulnerable and the practice of cutting a window in a cast should be deprecated.

This is because the soft tissues will protrude through the window when they are at their most vulnerable stage. Additionally, a good general rule is to assume that the window will not be large enough to create an adequate sterile field for dressings, unless it is large enough to impair the structural integrity of the cast.

There are few sights and sounds worse than having a terrified child screaming inconsolably while having their cast removed with a very noisy cast saw. I would consider it to be negligent not to use a product such as 3M Softcast for the very young child who must wear a cast. Additionally Softcast is a helpful treatment adjunct when following the tenets of the Virtual Fracture Clinic.

It can reduce the need for at least one clinic appointment (that which is used to remove the cast) and thereby ease the workload burden on the cast-room and the clinic. With its now wide acceptance, it can also remove the need to apply a cast in the first instance for torus and buckle wrist fractures as per NICE guideline NG38; from February 2016.  

It is easy to feel irritated when we have applied a cast to a patient's injured limb during the previous week, only to find that we have to remove it in the fracture clinic and then reapply it. Identifying this type of clinic element is essential if we are to order clinics in the way that is most sensible in terms of patient care. We should not be needlessly (or mindlessly) carrying out the orders of unthinking clinicians.

Our patient care should place the patient at the very top of our rationale for undertaking the work which we do. We should take care not to let administrative expediency obstruct the care we deliver to our patients. Second best is not good enough for our patients and we should accept the mantle of responsibility for the way that our patients progress through the outpatient clinic environment and our cast-rooms.  

Dismal Standards

Full Cast Application