# Optimising Hand Trauma Management in a Tertiary National Health Service (NHS) Plastic Surgery Department: A Quality Improvement Initiative Aligned With the United Kingdom’s Prevalence Data and British Society for Surgery of the Hand (BSSH) Guidelines

## TL;DR

This study evaluates how well a UK NHS hospital follows guidelines for hand trauma surgery, aiming to improve patient outcomes and reduce healthcare costs.

## Contribution

The study provides a quality improvement analysis of hand trauma management aligned with UK prevalence data and BSSH guidelines.

## Key findings

- Overall compliance with BSSH surgical timing guidelines reached 83%, exceeding the 80% target.
- Persistent challenges remain in managing open and closed fractures, with compliance rates of 64% and 67%, respectively.
- Median time from decision to surgery was 42.7 hours, indicating delays in complex cases.

## Abstract

Background: Hand trauma constitutes a significant proportion of emergency department presentations in the United Kingdom, leading to considerable functional impairment and imposing substantial healthcare burdens. The British Society for Surgery of the Hand (BSSH) provides critical guidelines for the timing of surgical intervention, aiming to optimise patient outcomes. This paper evaluates compliance with BSSH guidelines within a tertiary National Health Service (NHS) Plastic Surgery Department, correlating local findings with UK-wide prevalence data to identify systemic challenges and propose solutions to reduce the clinical and economic burden.

Methods: A retrospective observational audit, representing the second cycle of a quality improvement initiative, was conducted at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust. Data from 148 hand trauma cases managed between January 1st and March 31st, 2025, were analysed. The primary objective was to assess the adherence of surgical interventions to established BSSH timeframes: within 24 hours for open fractures and open joints, bites within 24 hours, within four days for other open hand injuries, and within seven days for closed hand fractures. The first cycle audit (August 2022-May 2023) formed part of the national BSSH-RSTN collaborative audit.

Results: The audit revealed an encouraging overall compliance rate of 83% (82 of 99 eligible cases) for surgical intervention, successfully exceeding the project's 80% target and demonstrating an improvement from the 73% observed in the first cycle. While open soft tissue injuries showed high compliance (average 89-97%), persistent challenges were noted for open fractures (64% (9 of 14 cases) compliance) and particularly for closed hand fractures (67% (16 of 24 cases) overall compliance, with surgical fixation at 50% (7 of 14 cases). The median time from the decision to treat to surgical intervention was 42.7 hours.

Conclusion: Despite notable progress in overall compliance, persistent delays in the management of complex injuries such as open and closed fractures highlight ongoing systemic bottlenecks within the hand trauma pathway. Strategic interventions, derived from departmental Quality Improvement and Patient Safety (QIPS) discussions, are essential to further enhance patient outcomes and mitigate the substantial functional and economic burden of hand trauma in the UK, estimated at approximately £287 million annually. Key recommendations include increasing dedicated trauma list capacity, enhancing Minor Injuries Unit (MIU) and 52 Pre-Op (daily plastics trauma clinic) capabilities, implementing targeted education for referring units, and establishing regular rolling audits with comprehensive documentation.