Orthopedic Surgery Draws up SCAMP to Answer Questions
Distal radius fracture (a fracture of the radius in the forearm)
is the most common fracture in the upper extremity in the U.S., accounting for
one-sixth of all fractures treated in the nation's emergency departments. Yet,
there is great variation in practice for treating these patients, many of whom
"These fractures are only increasing with the aging population in
the U.S.," said Philip Blazar, MD, of Orthopedic Surgery. "We want to address
the practice variations and understand which patients should have surgery,
which patients need to be screened for osteoporosis, and of those, which
patients would benefit from an osteoporosis intervention."
To answer those questions, the Department of Orthopedic Surgery
became one of the first departments across BW/F to create and implement a
SCAMP, or standardized clinical assessment and management plan. Developed by
Children's Hospital Boston, SCAMPs collect and analyze clinical decisions data
to standardize care in a fast-evolving clinical environment. SCAMPs are one of
the strategies being implemented in care redesign efforts throughout BWF.
The goals of a SCAMP are three-fold: to standardize care through
pathways and ultimately improve quality and reduce unnecessary resource utilization;
to continually adapt and improve pathways; and to use pathways to create new
knowledge about how to manage a certain condition.
"SCAMPs shed light on areas where we have uncertainty," said
Jeffrey Greenberg, MD, who is leading the SCAMP team at BWH. "SCAMPs focus on
areas where there is variability in practice and where we don't have
Blazar and colleague Brandon Earp, MD, chief of Orthopedic Surgery
at Faulkner Hospital, had already been conducting research on distal radius
fractures and looking at ways to reduce practice variation and ensure cost-effectiveness
of care. When they heard that BWH was beginning to use SCAMPs, they agreed it
was a natural next step and worked with Greenberg's team to put the idea into
Their SCAMP involves the entire course of care for both
non-operative and operative fractures: surgical versus non-operative
decision-making; therapy protocols; radiographic follow-up; evaluation of
osteoporosis; and pain management pathways. It aims to find answers about how
to limit unnecessary tests, radiation and surgery, ensuring that all patients
receive the right care for them.
"The whole team was on board right from the start, and there is
incredible enthusiasm to do this," said Earp.
"The other important thing that is making this run smoothly is that it's
not a major time investment that changes people's workflow. We've been able to
streamline it, using forms with check boxes, so that it fits right into our current
The forms ask questions and allow providers to check the answer,
and then follow a particular pathway. But it's not set in stone - SCAMPs
encourage deviation from the pathway when appropriate, as clinical practice is
more fluid than any one standard algorithm.
"Deviations are welcome, but you have to explain why you are
deviating," said Earp. "The whole process challenges you to be thoughtful about
what you're doing at every step along the way. It's a perpetual learning
process for all of us."
Deviations are important, said Greenberg. "The answer to why you
are deviating can help in determining if the pathway should be modified."
Since the work began in April, more than 60 patients are already
in the SCAMP, a number that will continue to grow. In December, six-month data will be collected
and analyzed. The SCAMP may be modified depending on what the data shows.
The process continues to be a positive experience, said Blazar.
"To work with a group of people who are willing to put personal and
professional agendas aside to do the right thing for our patients is really
inspiring," he said. "We all share the belief that we need to try to make
things better for our patients."
A good SCAMP focuses on a condition in which uncertainty in
management exists or an area in which guidelines do not exist or are not well
followed, and practice variation exists. A condition with room to improve
outcomes, or one with multiple decision points involving diagnostic test,
treatments and other management conditions, also make for good SCAMPs.
At BWH, SCAMPs are underway or in development in the
Plastic Surgery - Breast reconstruction
Cardiology - Low risk chest-pain admissions
Orthopedic Surgery - Distal radius fracture
Neurosurgery - Lumbar spinal fusion
EM - Renal colic (or may collaborate with chest
Renal - Use of CVVH in the MICU
To learn more, contact Jeffrey Greenberg, MD, Roya
Ghazinouri, PT, DPT, MS, or Lara