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. 

Reasonable Workloads

Background
What is a reasonable workload for a cast technician? Reasonable workloads are difficult to pin down in an anecdotal manner. The use of time and motion studies is unhelpful because every patient interaction and prescribed treatment is different from all other interactions. Each case brings its own clinical imperatives to the mix.

The baseline treatment for every case is identical even though the specifics may vary widely. Every patient must have their broken limbs placed into the ideal position to promote healing. Casting and splinting techniques are used to support bone alignment and fracture apposition after limb trauma and surgery. Pain and damage to soft tissues is reduced by excellence in casting and a return to full functionality is the aim of applying casts which fit well. 

The projected outcome of any patient’s treatment is our objective. It is the notion of an ideal projected outcome which guides every clinical interaction and intervention between the cast technician and our patients. Cast technician staff are the orthopaedic clinician’s proxy pair of hands for delivering prescribed treatments and we must understand the fundamentals of any prescribed course of action.

Certainty concerning the underpinnings of our technical knowledge will assist cast technicians to deliver best clinical practice while following accepted science in a manner which is quantifiable and reproducible. Before establishing any methods with which to determine when the workload of cast technicians is reasonable, it is helpful to look at the situations which cast technicians find to be unreasonable. An appraisal of the situations which constitute unreasonable working conditions should form the basis of a blueprint for establishing reasonable workloads for cast technicians.

One clearly unreasonable working practice is where cast technicians do not stop working to take a lunch break. They continue to work through their own lunch period because the morning clinic work has not ended within the allocated clinic time slot. The afternoon work usually begins before the morning clinic work is complete.

This type of abusive workload allocation may prompt cast technicians to feel as if they are being undervalued. They frequently do not have sufficient available free time to stop for a drink. All other support staff to the clinics usually take meal breaks and do not appear to be under a similar pressure to work until every clinic patient has been seen and treated.

Clinic profiles are often partially responsible for unevenly spread cast room workloads. I have worked in places where there was no limit placed upon clinic attendance patient numbers. This workload strategy produces patient throughput bottlenecks which are entirely predictable. Giving patients choice (i.e. you can have any appointment time you want) is frequently responsible for this misguided method of clinic management by a local NHS Trust.

It is probably used to appear liberal and facilitative of personal choice. Clinical services should be be supplied only when the hospital has sufficient resources to complete the work efficiently. Patients should attend the clinic once the resources are made available to deal with them effectively. Patient choice frequently affects the provision of clinical services in a negative manner. 

Glaring differences between the available clinic time and the concomitant lack of resources management, would suggest that much plaster service provision requires a complete overhaul. My current cast room location accepts patients primarily from fracture and orthopaedic clinics, an urgent care treatment centre, the accident & emergency department and podiatry/diabetes services.

Work is also accepted from orthopaedic theatre, surgical, medical, care of the elderly, paediatric and assessment unit wards. At the end of this long list are other local hospital clinics (including private institutions) and patients who contact the cast room directly on a daily basis.

The demands placed upon cast room staff frequently feel excessive. There is a general lack of policy and strategy for dealing with unplanned demand from the various service users. Some days feel as if multiple separate unplanned clinics are being run within planned clinics. The competing demands for cast technician attention appear impossible to manage after the various clinical needs have been subsumed into the general work of the cast room.

Cast room work is primarily and properly concerned with trauma management. A legitimate secondary usage is that of supporting elective orthopaedic cases. Supporting elective surgery cases includes applying casts within a routine orthopaedic theatre list. In the case of children, cast technicians can expect to be asked to manage developmental conditions like congenital talipes equino-varus, developmental dysplasia of the hip, idiopathic toe walking and idiopathic scoliosis.

It is implicit in the paragraph immediately before this one that any essential equipment, tools and protocols are provided to enable the cast technician to complete the work. e.g. It is unhelpful for an orthopaedic theatre to request a cast technician’s expert services, where there are insufficient personnel to complete the normal day-to-day work expected of the cast room.

I have been asked to apply a hip spica to a paediatric case under anaesthetic, without a hip spica table. Any cast technician, who has had a similar experience, will be able to explain why applying a hip spica to an anaesthetised child (which is being held in the arms of two surgeons) is a wrongheaded undertaking.

In a wider consideration of the work undertaken by cast technicians, the constant failure to provide essential tools, staff and equipment conspires to make the work more difficult. This increases the time spent on completing any particular aspect of the work. Less obvious, but equally effective, in extending the working time is the availability of cast technician time to complete the work required in any given shift period.

Before questioning the working methods of the cast room and the cast technicians, it is helpful to look at practices which are imposed upon the cast room work by dint of clinic profiles, staff allocation, clinician practices and the clinical strategies and local policies of service providers. These factors can have a profound effect on the way in which cast technicians provide the required services.

Insufficient numbers of staff trained to work in the cast room will create an atmosphere where the cast technicians will feel under pressure to work faster than is compatible with a high standard of patient care. The unremitting nature of dealing with far too many patients requiring cast room treatment adds to the pressure of working too quickly to get through the work required.

Local policies may have determined that the number of trained cast room personnel be established at x and that annual leave and sickness will be dealt with by using the formula x-1. The local NHS, in many institutions, does not currently permit casual expenditure on locum staff which may previously have been used to keep cast room staff numbers constant. 

In a cast room with a permanent establishment of three experienced full time equivalent staff, the total annual leave entitlement equates to 24 weeks. Whenever annual leave is taken, the cast room is understaffed by 33.3%. For almost half a year (24 weeks) the cast room in the given example case will be knowingly understaffed.

Once a staff member falls ill, the same staff numbers have to fill the gap and still try to take their own annual leave. The gap to plug is impossible and the workload is not reduced to reflect the reduced capability. In my current location there are three people absent from the WTE establishment. One staff member has retired and has not been replaced and one is on maternity leave and one is taking extended sick leave. 

The workload is precisely as it was before the staff absence and has not been reduced. Additionally; the establishment of clinic staff is reduced. Up to eight staff members are simultaneously taking annual leave in the coming week! There is no indication that existing workloads will be reduced. Local policies and clinical practices notwithstanding this ad hoc annual leave system can have a significant effect on cast room throughput.

Example case one: the patient was receiving a posterior POP slab for a distal radius fracture yesterday. The cast room staff are expected to apply a complete cast one or two days post injury. The cast will not fit the patient within 48 hours because the oedema will have increased and made the cast uncomfortably tight.

The patient will require it to be changed within a short time of application. We fail to permit soft tissue oedema to take its natural course and subsequently fail to fit a definitive cast at around 14 days post injury. The delayed cast be a much better fit and is likely to last the patient for the duration of treatment.

Fitting a complete cast too early in the treatment cycle, will cause the patient to make further unnecessary clinic/plaster room attendances. This usually involves additional visits (in excess of the planned treatment visits) to have the ill-fitting cast removed and reapplied.

Occasionally, we know that the working diagnosis requires more radiographic evidence and a scan using Magnetic Resonance Imaging (MRI) or Computerised Tomography (CT) techniques is also required. These scans may also necessitate cast removal and a further cast application.

The constant application and removal of casts may have a deleterious effect on the healing fracture site. The increased plaster room workload derives from applying full casts too early. e.g. One day post operative restorative surgery or one or two days post injury/manipulation and temporary plaster splinting. 

Applying a full cast before sutures or clips are removed mandates that the cast must be removed so that skin wound closures can be removed at the appropriate time point. Post operative wound checks are another reason that casts are removed and reapplied. It has to be asked as to why a wound check is considered necessary one or two days post operative intervention.

What has happened in theatre work which makes it an essential part of post operative care? When I trained as a nurse during the 70s, no surgically made wound was touched for 14 days after surgery. The wound was compressed for twenty minutes after skin closure and the the surgeon applied the dressing to the wound. This dressing was not touched without express permission from the surgeon before 14 days had elapsed.

Today, it appears to be a commonplace that surgical site infections are an expected norm. The continuous fiddling with sterile dressings (which were placed under aseptic conditions) appears to militate against excellence in wound care. Many theatre placed surgical dressings are heavily bloodstained when seen in the plaster room and this demonstrates that bleeding post skin closure is common.

Warm, moist blood is an ideal medium for bacterial growth and it cannot be surprising when wounds are infected under such conditions. Applying a complete cast to a surgically fixed limb just one or two days after surgery is of limited value. Where the surgical fixation is competently performed, then a simple POP splint should suffice until after the wound has had the closure devices removed.

Lightweight casting tapes are completely impervious to liquids. Bleeding or any infected exudates will not be seen when under a polyester or fibreglass cast; which are effectively plastic. If the cast was constructed from plaster of Paris, any bleeding/wound exudate would soak through the plaster and be visible. Posterior slabs supporting surgical wounds may be all that is required until the oedema from both the injury and the insult of surgery has resolved. 

Clinician choice plays a part in the patient timeline from trauma to discharge. Some clinicians require regular contact with the patient and each clinic visit sees the cast room staff removing and reapplying casts on these occasions. Many patients arrive in the plaster room following an initial fracture clinic appointment. The patient arrives and is still wearing a posterior slab which must have been applied in the A&E department. It is clear that the injured limb could not have been clinically examined by the fracture clinic treating orthopaedic clinician under such a circumstance.

At this point in the patient’s treatment; the cast room staff have to be alive to many possibilities and report any concerns to the treating clinician. Radiographs are valuable in confirming the treatment request. In an ideal situation, the clinician would not be treating the radiographs instead of the patient. The time spent on cast room patients can be increased considerably where the patient has not undergone an initial clinical examination before being sent to the cast room.

Limited space for patients in the cast room can create blockages to the throughput. This is often seen where a patient needs a clinical examination after the cast removal. The delay in getting a clinician to see the patient can be extensive. Post operative wound examinations, wire removal, external fixation adjustments and removal… all contribute to the waiting time of patients on a cast room chair or couch.

Specialist services such as the examination and wound care by a podiatrist also keep the patient occupying a cast room treatment position until they have been seen. Less frequently, the patient may have to wait for a physiotherapist assessment for a walking aid. 

Another source of delay to the patient occurs when healthcare assistants prepare the patient's clinical care record ahead of a scheduled clinic. The notes are written to reflect the clinic type and x-ray request forms are also completed. Additionally, the treatment prescription is written on a plaster request form before the clinic takes place. The treatment is guessed at from the previous clinic letter which was dictated by the orthopaedic clinician.

Several near disasters have been averted because the suggested treatment was not congruent with the radiographic evidence or the clinical picture. Radiographic requests are not appropriate to the clinical picture and this causes untold delays when the clinicians would rather not be disturbed while consulting with patients.

Examples or poor radiograph requests I have had to deal with include a fracture classified as a Danis-Weber B fracture of the lateral malleolus. The request is made for an AP and lateral radiograph of the ankle joint without a specific mortice view being requested. I have seen an isolated ulna fracture where the request was for a wrist AP and lateral. A Monteggia type fracture may disrupt the radial head and the rule of imaging a joint above and a joint below the injury site would prevent clinical mismanagement.

Treatment prescriptions are written by healthcare assistants and they must be invalid. They are neither dated or timed nor are they signed by the treating clinician. This is a disaster waiting to happen. Even an experienced healthcare assistant will not having sufficient knowledge or experience to prescribe the treatment required for any patient's condition. Much of my work time is spent trying to find the responsible clinician with whom I can clarify the treatment request.

It is a dangerously bad policy (and completely irresponsible) for clinicians not to write their own treatment and x-ray examination requests, after examining each patient at their initial fracture clinic presentation. Being unable to have instant access to the clinical during the clinic means that a number of patient delays can extend to 30 minutes.

I am working in an area where the Emergency Nurse Practitioners (ENP)and Advanced Nursing Practitioners (ANP) can refer patients to the orthopaedic service. Sadly, the referral does not extend to them applying their own casts and splints. This means frequent interruptions from a service that is paying high for the expertise of practitioners who then pass the work onto band 3 healthcare assistants who cover the plaster room work.

Occasionally, I get requests from an ENP/ANP which make no clinical sense. I was recently asked by an ANP to apply a below knee non weight-bearing cast to a young teenage patient whose leg appeared to be uninjured. I was told that all of the ED staff who had viewed the radiograph thought that the injury was significant and in need of treatment. I suggested that the hot reporting radiologist would have a different view and in the event pointed out the obviously closing epiphysis.

Wards sending patients without the courtesy of finding out if the work completion was possible for reasons of time or personnel is common. A patient sent on a bed to the plaster room without notice just three minutes before the shift ended and the patient had required a one hour process. All of this randomly produced work requirement is likely to make a cast technician feel that they have no part in managing their own workload.

Possible Solutions
Unplanned attendances must be managed exclusively within the gift of the cast room technicians. It is a common courtesy to ask the cast room staff when would be a convenient time to get a particular piece of work done. It would be helpful if the wards then arranged their own portering staff movement of the patient.

It is normal nursing practice to expect each patient to arrive in the plaster room with their clinical care record, a valid treatment prescription and sufficient analgesic cover. It is surprising to me that many patients are not offered the use of the toilet before they are transported to the plaster room. 

Finally, the patients should also be prepared psychologically for their cast room experience. Many patients arrive without knowing why they are coming to the plaster room. A patient escort is always necessary for patients who are assigned a dementia label or who may be disruptive.  

 

 

 

Plaster Room Noise