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C OPYRIGHT ! 2019 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

The Development of a Standardized Pathway for

Outpatient Ambulatory Fracture Surgery
To Admit or Not to Admit
Jesse I. Wolfstadt, MD, MSc, FRCSC, Lisa Wayment, BN, MN, Martin A. Koyle, MD, MSc, FAAP, FACS, FRCSC,
David J. Backstein, MD, MEd, FRCSC, and Sarah E. Ward, MD, MSc, FRCSC

Investigation performed at Mount Sinai Hospital, Toronto, Ontario, Canada

Background: Increased scrutiny of health-care costs and inpatient length of stay has resulted in many orthopaedic
procedures transitioning to outpatient settings. Recent studies have supported the safety and efficiency of outpatient
fracture procedures. The aim of the present study was to reduce unnecessary inpatient hospitalizations for healthy
patients awaiting surgical treatment of a fracture by 80% by June 30, 2017, with a focus on timely, efficient, and patient-
centered care.
Methods: The study design was a time series using statistical process control methodology. Baseline data from October
2014 to June 2016 were compared with the intervention period from July 2016 to December 2018. The Model for
Improvement was used as the framework for developing and implementing interventions. The main interventions were a
policy change to allow booking of outpatient urgent-room cases, education for patients and nurses, and the development
of a standardized outpatient pathway.
Results: One hundred and eighty-seven patients during the pre-intervention period and 308 patients during the intervention
period were eligible for the ambulatory pathway. The percentage of patients managed as outpatients increased from 1.6% pre-
intervention to 89.1% post-intervention. The length of stay was reduced from 2.8 to 0.2 days, a decrease of 94.0%. Patient
satisfaction remained high, and there were no safety concerns while patients waited at home for the surgical procedure.
Conclusions: The outpatient fracture pathway vastly improved the efficiency and timeliness of care and reduced health-
care costs. A patient-centered culture and support from hospital administration were integral in producing sustainable
improvement.
Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

O
rthopaedic surgeons are constantly challenged to
deliver higher-value care by improving quality and
outcomes while reducing health-care costs1,2. The
introduction of bundled payments and rising scrutiny of
health-care costs has led to an increased focus on minimizing
unnecessary hospital admissions3. Critical to this paradigm
shift is a transition of care from the sick-patient model to the
well-patient model4. Several orthopaedic procedures have
safely transitioned to outpatient settings, including hip and
knee arthroplasty, shoulder procedures, and pediatric trauma
procedures5-10. Several recent studies have confirmed the safety
and efficiency of outpatient surgical procedures for healthy
patients with ambulatory fractures, colloquially referred to as
the “walking wounded.”10-13 However, outpatient fracture pro-
cedures require a coordinated effort from the health-care team,
thorough preoperative assessment, patient education, strong
communication, and strict patient selection to minimize the
risk of unplanned admission and/or readmission10.
Our hospital is a large, academic hospital in a major
metropolitan city with several high-volume tertiary-refer-
ral surgical programs. All urgent cases are completed in a
limited number of shared “urgent” operating rooms (<5 per
week), leading to extended wait-times for less urgent cases.
Ambulatory fractures are typically booked as C cases, which
have a target of completion within 48 hours and a lower
priority than most urgent cases. Historically, patients
required a hospital admission to facilitate a surgical pro-
cedure, with >25% of patients waiting >48 hours in-

Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest
forms are provided with the online version of the article (http://links.lww.com/JBJS/F569).

J Bone Joint Surg Am. 2020;102:110-8 d http://dx.doi.org/10.2106/JBJS.19.00634

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Fig. 1
Ishikawa diagram.

hospital for a surgical procedure. Between October 2014
and October 2016, 251 healthy patients with a fracture were
admitted for a surgical procedure, accounting for 521
conservable bed days. This practice carried a huge financial
burden on the hospital.
The aim of this quality-improvement project was to
reduce unnecessary inpatient hospitalizations for patients
awaiting semi-urgent fracture care by 80% by June 30, 2017, as
measured by the percentage of patients undergoing outpatient
procedures within 7 days of diagnosis. We hoped to improve

TABLE I Timeline of Quality-Improvement Project and Key Interventions*

Timeline Intervention Details

July 2016 Start of quality-improvement • Identification of problem through de-identified administrative data, including time from
project admission to booking, time from booking to the surgical procedure, and length of stay
August 2016 Change idea #1: outpatient • Director of Patient Flow changed the policy to allow outpatient cases to be booked on
booking of ambulatory fracture urgent list
patients
September to October Stakeholder engagement/ • Met with key stakeholders
2016 diagnostics • Completed Ishikawa diagram, multi-voting, and Pareto chart to identify change ideas
October 7-9, 2016 Outpatient trial procedure #1 • Team lead was on call and worked with OR nurse team lead, admitting department,
and PACU staff to facilitate a test of the outpatient program
October 19, 2016 Meeting with perioperative • Presented key findings from stakeholder engagement and identified 3 change ideas (1
business unit (quality had already been implemented in August 2016)
improvement team)
December 23-25, Outpatient trial procedure #2 • Team lead was on call and worked with OR nurse team lead, admitting department,
2016 and PACU staff to facilitate a test of the outpatient program
March 20, 2017 Process mapping • Frontline workers, key stakeholders, and patient representatives met to complete
current state and future state process mapping
• Informed the development of the streamlined outpatient pathway and standard work
April 2017 Change idea #2: training of PACU • PACU staff received mobility training from the physiotherapy department and training
nurses from the inpatient nurses regarding safety and discharge instructions for patients
May 2017 Change idea #2: training of ED • ED nurses received an in-service regarding the outpatient pathway and mobility
nurses training from the physiotherapy department
May 2017 Change idea #3: streamlined • Launched outpatient pathway with standard work
outpatient pathway • Clerical staff took over communication with patients, including pull system
June 14, 2017 Meeting with perioperative • Report on quality-improvement project
business unit and division chiefs • Spread to other services with similar patient populations

*OR = operating room.

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Fig. 2
Current state for all operative fracture patients (pre-intervention).

the timeliness, efficiency, and patient-centeredness of care for admitted and awaited the surgical procedure in the same queue
ambulatory patients with a fracture. as outpatients. Baseline data from October 2014 to June 2016
(pre-intervention group) were gathered retrospectively with use
Materials and Methods of the surgical scheduling database. The parameters collected
Study Design included age, sex, diagnosis, procedure, time from booking to

T he study design was a time series using statistical process

control methodology14,15. All ambulatory patients with a
fracture were included. Patients were ineligible for the outpa-
tient pathway if they had poorly controlled medical comor-
bidities (based on the clinical judgment of the on-call
orthopaedic surgeon and anesthesiologist), were unable to
safely mobilize with crutches, lacked social support to ensure
safe discharge, or required urgent surgical intervention (e.g.,
open fractures). Patients who did not meet the criteria were
the surgical procedure, and length of stay. Ongoing data col-
lection from July 2016 onward (intervention group) was per-
formed prospectively with support from the Department of
Quality and Performance at our institution.
Quality-Improvement Framework
The Model for Improvement was used as the framework for
our quality-improvement project16. The first step involved the
creation of a project charter and the assemblage of a quality-

Fig. 3
Future state for outpatient ambulatory fracture care (as of May 2017). OR = operating room, NPO = nil per os (nothing by mouth).
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(1) an unwritten historical policy dictated that emergency cases

TABLE II Patient Demographics
could only be booked after the patient was admitted; (2) ED
Pre-Intervention Post-Intervention P Value nurses lacked training to safely discharge patients with a
fracture to await the surgical procedure at home and PACU
No. of patients 187 308
nurses lacked training to discharge patients directly from the
Mean age (yr) 46.8 46.6 0.821 recovery room after the surgical procedure (they lacked
Sex* 0.452 training in cast-care instructions, arranging fracture clinic
Female 101 (54%) 177 (57%) follow-up, and mobility training); and (3) the hospital lacked
Male 86 (46%) 131 (43%) a streamlined, standardized outpatient fracture treatment
Fracture type* 0.872 pathway. The project was introduced in an iterative fashion
Lower extremity 104 (56%) 169 (53%) over a full year, beginning in July 2016 (Table I). Change ideas
Upper extremity 83 (44%) 139 (47%) were linked to the root causes and tested with use of the plan-
do-study-act model on a small scale when the Project Lead
*Values are given as the number of patients, with the percentage in
parentheses.
was on call over 2 weekends in October and December 2016.
Firstly, the director of admitting changed the booking policy,
allowing outpatient cases to be booked on the shared urgent
improvement team. The team comprised the Surgeon-In-Chief, list. A half-day process mapping session was held in March 2017
the operating room senior director, an orthopaedic surgeon with with patients and frontline staff to map out the current state (Fig.
training in quality improvement (Project Lead), and stake- 2) and develop the streamlined future-state pathway (Fig. 3),
holders from the admitting department, inpatient wards, Divi- standard work (Appendix A), and patient handbook (Appendix
sion of Emergency Medicine (ED), and post-anesthesia care unit B). PACU and ED nurses received instructions on discharge
(PACU). The subsequent task involved meeting with frontline preparedness and were given mobility training and access to
workers and patients to better understand the existing practice of mobility aids (crutches and slings) in April 2017. The stream-
inpatient-only fracture procedures and identify factors that lined pathway launched in June 2017. The team met weekly to
impeded the development of an outpatient pathway. review our progress and address issues that arose.

Root-Cause Analysis Interventions

The 3 key root causes of poor timeliness and efficiency with Interventions included (1) a policy change to permit the
ambulatory fractures were identified with use of Ishikawa booking of outpatient cases on the urgent list; (2) education
diagrams (Fig. 1), voting in which multiple answers were al- sessions with key stakeholders in the ED, inpatient ward, and
lowed, and Pareto charts. Three major factors were identified: PACU to ensure safe mobilization and discharge of patients;

Fig. 4
Statistical process control chart (P chart) showing the percentage of patients managed as outpatients. QI = quality improvement.
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Fig. 5
Statistical process control chart (X chart) showing the average length of stay for ambulatory fracture patients.

and (3) a streamlined perioperative outpatient pathway and
development of a pull system to bring patients into the hospital
when they are next in the queue. Strict rules were established to
ensure outpatients were not bumped by inpatient cases unless
they had a higher priority.
Family of Measures
The primary outcome measure was the percentage of patients
managed as outpatients. The process measure for changing the
historical culture of admitting patients for a surgical procedure
was the average hospital length of stay. The balancing measures,
used to capture unintended consequences, included the time
from consent to the surgical procedure (to ensure that outpa-
tients did not wait longer at home than they would as an
inpatient) and patient satisfaction (measured with use of the 3-
item Care Transitions Measure [CTM-3]17).
Statistical Analysis
Demographic data were analyzed with use of an independent t
test for age and a chi-square test for sex and fracture type.

Fig. 6
Kaplan-Meier analysis of time from booking to the surgical procedure.
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Fig. 7
Patient satisfaction measured using the CTM-3.
Shewhart charts were used to assess the impact of the inter-
ventions18, which consisted of a series of data points plotted in
time order, with horizontal lines indicating the mean and
upper and lower control limits. These charts are interpreted
with use of validated rules for special-cause variation (i.e.,
unnatural variation as a result of unique events or changes to a
stable process) and common-cause variation (i.e., natural
variation that inherently occurs within a stable process)18. The
percentage of eligible patients managed as outpatients was
analyzed with use of a P chart (for classification data), and the
average conservable bed days utilized per patient were analyzed
with use of an X chart (for continuous data). The time from
booking to the surgical procedure was analyzed with use of a
Kaplan-Meier curve and an independent t test. Patient satis-
faction was reported on a bar chart indicating patient responses
on the CTM-3.
This study was reviewed by our institutional research ethics
board and exempted from a formal review process. The manu-
script was prepared with use of the SQUIRE 2.0 guidelines19.
Results
D uring the pre-intervention period (October 2014 to June
2016), 187 patients were eligible for the outpatient
pathway, compared with 308 during the intervention period
(July 2016 onwards). There were no differences in age, sex, or
fracture type between the 2 cohorts (Table II). Prior to the
intervention, 1.6% of eligible patients underwent outpatient
procedures (Fig. 4), compared with 89.1% post-intervention.
Common-cause variation occurred throughout the entire
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post-intervention period (starting in June 2017), suggesting
a steady state with almost 90% of patients managed as
outpatients.
Pre-intervention, the average length of stay for ambula-
tory patients with a fracture was 2.8 days (Fig. 5). During the
implementation of the change ideas, length of stay decreased to
1.8 days. The Shewhart chart demonstrated special-cause var-
iation from December 2016 to May 2017, coinciding with our
early trials (October and December 2016) and the im-
plementation of the second and third interventions (April and
June 2017). In the post-intervention period (July 2017 to
December 2018), the average length of stay was 0.2 day, a
decrease of 94.0% compared with the pre-intervention period.
After the start of the quality-improvement project, no patient
waited longer than 7 days for a surgical procedure (Fig. 6).
Patients waited an average of 30 hours prior to June 2016
compared with an average of 32 hours during the intervention
period (July 2016 to May 2017) and 48 hours in the post-
intervention period (p < 0.001), demonstrating a significant
change in the time from booking to the surgical procedure for
individuals waiting at home as an outpatient. From July 2016
onward, only 10 (3.3%) of 307 patients were called in for a
surgical procedure and subsequently delayed by an unexpected
urgent booking. Patients were overwhelmingly satisfied with
their care and with the preparedness for the outpatient surgical
procedure (Fig. 7). No patient had an unplanned ED visit or
readmission during the study period, and there were no
complications while patients were waiting at home for the
surgical procedure.
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Discussion
T he aim of this quality-improvement project was to reduce
unnecessary inpatient hospitalizations for patients await-
ing semi-urgent fracture care by 80% by June 30, 2017.
Based on the available literature and experiences at other
academic and community hospitals in our city, we focused
on the development of a standardized perioperative path-
way, booking of outpatient emergency cases, enhancing
patient education, and careful selection of patients with few
or no medical comorbidities to develop a successful and
sustainable outpatient ambulatory fracture pathway. We
successfully implemented an outpatient ambulatory frac-
ture care program that increased the percentage of patients
undergoing outpatient surgical procedures and reduced the
average length of stay to almost zero.
Increases in the percentage of patients managed as
outpatients and decreases in the conservable bed days
occurred following each of the interventions. Special-cause
variation during the intervention period (July 2016 to June
2017) suggests that these improvements were not the result
of chance; rather, they occurred because of the interventions.
These results are consistent with several recent studies that
have illustrated the safety and cost savings associated with
transferring operative fracture care from inpatient to out-
patient settings10,20,21. Qin et al. showed a significant decrease
in length of stay for outpatient surgical procedures compared
with inpatient surgical procedures (0.48 ± 0.88 compared
with 3.96 ± 4.93 days, respectively; p < 0.001)11. Weckbach
et al. had similar results investigating the safety and feasi-
bility of outpatient ankle fracture procedures12. They showed
that outpatient procedures had a decreased rate of compli-
cations (3.1% compared with 9.1% for inpatient) and
unplanned surgical revisions (1.2% compared with 3.6% for
inpatient; p < 0.05 for both comparisons). Kakarlapudi et al.
found that inpatient service costs accounted for the bulk of
expenditures for the care of distal radial fractures20. Murray
et al. found significant financial savings with newer strategies
that safely transitioned patients to waiting at home prior to
surgical procedures22.
This project had a wide-ranging impact on the care of
our patients, addressing the 4 tenets of the Institute for
Healtcare Improvement quadruple aim23. We lowered per-
capita health-care costs by reducing conservable bed days;
improved the patient experience by decreasing length of stay,
improving communication, and educating patients; opti-
mized health outcomes by minimizing the risk of nosocomial
infections, more efficiently utilizing the urgent operating
room time, and increasing capacity for inpatient programs;
and improved the provider experience by standardizing
workflow. The 1 unexpected negative outcome was the sig-
nificant increase in time to the surgical procedure for patients
waiting at home (30 hours prior to June 2016 compared with
an average of 48 hours after July 2017; p < 0.001). The cause
of this increase is likely multifactorial. First, patients waiting
at home may have had the procedure delayed to the following
morning if the procedure could not be performed the prior
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evening with enough time allowed for safe discharge directly
from the PACU. Historically, when these procedures were
performed as inpatients, there were no restrictions on
bringing the patient to the operating room in the late evening
or overnight. Second, the increased time to the surgical
procedure may reflect an overall increase in volume of cases
booked on the shared urgent room list. Our complex gyne-
cology case volumes tripled during the study period, forcing
the Department of Surgery to utilize the shared urgent room
time for these cases. In addition, nursing and anesthesia
shortages have led to regular cancellations of the shared
urgent room (around 1 to 2 occurrences per week over the
past year). Within the Canadian health-care system, non-
urgent orthopaedic trauma is considered a low priority
compared with other life-and-limb-threatening trauma ca-
ses. As many publicly funded Canadian hospitals do not have
access to daily trauma operating room time, it has become
common for ambulatory patients with relatively minor
fractures to be discharged to home while awaiting definitive
surgical care. The standard of care for the management of
non-urgent fracture care within this system is 7 to 10 days,
with some patients waiting up to 2 weeks for a surgical
procedure. Fortunately, the increased time to the surgical
procedure did not seem to negatively impact patient satis-
faction. Furthermore, the slight increase in time waiting for
the procedure was more than balanced by the significant
reduction in length of stay, meaning that the total time from
surgical booking to discharge was reduced.
The pathway had very few startup or maintenance costs
and can reasonably be expected to avoid around 200 con-
servable bed days annually. In a 2001 study, James et al.24
estimated that the cost per patient per day of an acute trauma
bed was £225. Converted to Canadian dollars (CAD) and
accounting for inflation, this equals approximately $550
CAD in 2017 (approximately $415 USD). Based on an 80%
reduction in admissions for ambulatory fracture patients,
approximately $110,000 CAD in cost savings can be expected
annually at our institution. Currently, these cases are funded
in part through the Health Based Allocation Model as part
of the Ministry of Health funding reform, which has been in
place since 2012. Funding of the Health Based Allocation
Model of the hospital is based on actual and expected
volumes and hospital efficiencies, relative to the rest of
the province. Using a direct acute care unit cost of $4,525
CAD per weighted case, we projected an annual reduction
in operating costs of approximately $239,825 CAD by
converting to an outpatient model. Despite saving approximately
$110,000 CAD annually in inpatient hospital costs, outpatient
care of these patients would result in a net loss of $130,000
CAD; however, we have used the bed capacity generated by
the outpatient fracture pathway to increase the volume of
elective total hip and knee replacements and improve ED and
PACU bed flow.
The problem of timely access to care is multifactorial.
Lankester et al. found that only 58% of “B” cases (which
included simple ankle fractures) occurred within the targeted
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time from admission to a surgical procedure (48 hours)25.
The authors suggested that delays to a surgical procedure
result in substantial pain and frustration for patients, longer
length of stay, and higher costs. The authors cite the delicate
balance between elective and trauma cases, noting that
improved trauma care requires careful planning and buy-in
from hospital administration. To ensure the success of our
quality-improvement project, it was important to align the
goals with the quality aims at all 3 levels of health care (i.e.,
macro, meso, and micro). Our local health integrated network
challenged hospitals to develop quality initiatives regarding
timeliness of care for ambulatory procedures. At a meso level,
1 of the quality aims of our hospital is achieving top 10% quality-
based performace benchmarked against peers for access to care
and length of stay in orthopaedics. The project received
endorsement at a micro level from the Surgeon-In-Chief and the
Clinical Operational Performance Committee. Aligning our
project goals with multiple levels of health care allowed us to
leverage support from influential key stakeholders.
Limitations
This is a single-hospital, nonrandomized study that may not be
generalizable to all institutions. Our hospital has a limited
number of shared urgent rooms and no protected time avail-
able for individual surgical services. Potential root causes may
differ at other hospitals with greater resources for managing
urgent orthopaedic cases. However, the themes of our inter-
ventions (standardized pathways, patient education and acti-
vation, improving communication and transparency, and staff
training) are generalizable.
We did not have a baseline measure of patient satisfac-
tion. Therefore, the high patient satisfaction measured with use
of the CTM-3 may have limited internal validity. The CTM-3 is
helpful in identifying major safety and satisfaction issues with
discharge preparedness, but it is not sensitive enough to tease
out minor inconveniences such as dissatisfaction with pro-
longed waits for a surgical procedure.
Conclusions
The development of our outpatient ambulatory fracture path-
way vastly improved the efficiency and timeliness of care for
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Appendix
Supporting material provided by the authors is posted
with the online version of this article as a data supplement
at jbjs.org (http://links.lww.com/JBJS/F570). n
NOTE: The authors thank Drs. Michael Zywiel and Simon Garceau with their assistance in statistical
analysis. The authors also thank Dr. Jay Wunder for his support of the quality-improvement project
and the frontline workers and patients who contributed immensely to the development of the
standardized pathway.
Jesse I. Wolfstadt, MD, MSc, FRCSC1
Lisa Wayment, BN, MN1
Martin A. Koyle, MD, MSc, FAAP, FACS, FRCSC2
David J. Backstein, MD, MEd, FRCSC1
Sarah E. Ward, MD, MSc, FRCSC3
1Granovsky Gluskin Division of Orthopaedics, Sinai Health System,
University of Toronto, Toronto, Ontario, Canada
2Division of Urology, The Hospital for Sick Children, University of
Toronto, Toronto, Ontario, Canada
3Divisionof Orthopaedics, St. Michael’s Hospital, University of Toronto,
Toronto, Ontario, Canada
Email address for J.I. Wolfstadt: jesse.wolfstadt@sinaihealthsystem.ca
ORCID iD for J.I. Wolfstadt: 0000-0003-3013-2437
ORCID iD for L. Wayment: 0000-0002-4418-9568
ORCID iD for M.A. Koyle: 0000-0002-4108-447X
ORCID iD for D.J. Backstein: 0000-0003-3339-7334
ORCID iD for S.E. Ward: 0000-0001-8229-6287
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