Using collaborative leadership and interdisciplinary pathways towards achieving national recommendations. Excellent results from 1884 rapid MRI scans for ‘suspected scaphoid fracture’

INTRODUCTION: National Institute of Clinical Effectiveness (NICE) guidance mandated early MRI scans for suspected scaphoid fractures in 2016. In national surveys, only 15% of NHS Emergency Departments achieve this. Missed fractures may require bone grafting surgery for non-union. NHS litigation costs are high. Conversely, over-treatment harms patients' lifestyle and income. METHODS: With leadership across Orthopaedics, Radiology and the Emergency Department, we co-created a rapid MRI pathway for suspected scaphoid fractures at site A. We defined the technical specification for a 5 min MRI scan.100 patients from site A were compared with 100 from site B (traditional pathway).Features driving successful implementation are highlighted.Medical students helped analyse scan results, requests and demographics. RESULTS: Statistically significantly fewer clinic appointments and fewer late diagnoses occurred at the rapid MRI site compared with the traditional site.Key features included:Working across staff groups (radiology/orthopaedics/emergency departments/receptionists/radiographers/clinic-booking/casting).Co-creating a pathway and clear proforma for Emergency staff to request MRI scans, including prompts for smoking cessation, splinting and patient information with QR codes.Using educational videos for induction.Pathway including a 2-week Orthopaedic fracture clinic appointment to review scan results and individualise treatment.Over 8 years, 1884 rapid MRI scans were performed on 1871 patients aged 9 to 102. This is the largest global series of suspected scaphoid fractures. There were no missed fractures. Diagnoses were: 13.2% scaphoid fracture positive, 21.6% other injury, 27.3% other condition, 22.6% minor injury with pre-existing condition and 15.2% normal scan. 74.0% were requested by Emergency department nurses or doctors. 47% of patients were over age 50, with 8.4% positive (17.4% positive in patients aged up to 50). 57% were female, with 8.9% positive (18.9% positive in men). CONCLUSION: Guidance mandating NHS standards may not achieve change. Co-creating a successful pathway needs gentle clinical leadership, local organic solutions, patient-centredness and responsive cross-professional team-working.