Multidisciplinary approach to improve the quality of below-knee plaster casting

PROBLEM: In our trauma unit, we noted a high rate of incorrectly applied below-knee casts for ankle fractures, in some cases requiring reapplication. This caused significant discomfort and inconvenience for patients and additional burden on plaster-room services. Our aim was to improve the quality of plaster casts and reduce the proportion that needed to be reapplied. METHODS: Our criteria for plaster cast quality were based on the British Orthopaedic Association Casting Standards (2015) and included neutral (plantargrade) ankle position, adequacy of fracture reduction and rate of cast reapplication. Baseline data collection was performed over a 2-month period by two independent reviewers. INTERVENTIONS: After distributing findings and presenting to relevant departments, practical casting sessions with orthopaedic technicians were arranged for the multidisciplinary team responsible for casting. This was later supplemented by new casting guidelines in clinical areas and available online. Postintervention data collection was performed over two separate cycles to assess the effect and permanence of intervention. RESULTS: Data from the preintervention period (n=29) showed median ankle position was 32° plantarflexion (PF), with nine (31%) inadequate reductions and six (20%) backslabs reapplied. Following Plan-Do-Study-Act (PDSA) 1, ankle position was significantly improved (median 25° PF), there were fewer inadequate reductions (12%; 2/17) and a lower rate of reapplication (0%; 0/17). After PDSA 2 (n=16), median ankle position was 21° PF, there was one (6%) inadequate reduction and two (12%) reapplications of casts. CONCLUSIONS: Following implementation of plaster training sessions for accident and emergency and junior orthopaedic staff, in addition to publishing guidance and new protocol, there has been a sustained improvement in the quality of below-knee backslabs and fewer cast reapplications. These findings justify continuation and expansion of the current programme to include other commonly applied plaster casts.