3.11 Treatment of Joint Dislocation

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Description of Indicator

Relationship to Quality Medical care should be timely
Type of Indicator Hospital process, Hospital level
Proposed Data Source ED Medical Record
Definition Time from onset of injury to attempted reduction* for a joint dislocation
Numerator Time of attempted reduction for patients age 18 years and older diagnosed with a joint dislocation* - time of injury‡†
Denominator Not applicable
Risk Adjustment Not specified at present

* Time of attempted reduction = Time of first attempt to reduce a dislocated joint (non-surgical reduction or surgical reduction).
‡ Time of injury may not be precisely known, but can likely to be accurately estimated. We believe that using time of injury as a starting point for a time based measure of treatment of joint dislocation is conceptually attractive from both physiological and quality improvement perspectives as it represents the onset of tissue injury. It is analogous to using time of symptom onset in patients with stroke or myocardial infarction.
† Treatment of joint dislocation will be reported as an interval measure (mean or median) with a measure of variation (standard deviation or interquartile range).

This indicator is intended to monitor timeliness of attempted joint reduction in patients diagnosed with a dislocated joint admitted to the ED.

Panel Review
Panelists extensively discussed the most appropriate reference time point for this indicator (e.g. from time of injury, first medical contact or arrival in ED) and whether a time threshold should be proposed (it was not proposed in the end). Panelists agreed that all joints should be included. Additional questions regarding the need for radiographic documentation and management of dislocations requiring surgery were brought forward. In the end the panel suggested that the indicator focus on “attempted reduction” leaving the decision of mechanism of reduction to the treating clinicians. Panelists noted the difficulties of including patients transported from one facility to another without attempted joint reduction.

Trauma Center Review
Comments from the trauma centers largely reflected the panelists’ discussion and emphasized the need to include all joints in the indicator. It was noted that current documentation practices would make it difficult to evaluate isolated joint dislocations in patients that do not meet criteria for inclusion in a trauma registry. In addition, centers outlined that times of procedures are not consistently documented.
Similar to several other indicators, trauma centers expressed concerns about using time of injury as a reference point due to difficulties with time ascertainment and potential factors confounding prehospital care. Finally, some trauma centers suggested that evaluation of a functional outcome could be used to determine whether early reduction improved patient outcomes.

Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study demonstrated that implementation of a trauma quality improvement program that included the quality indicator was associated with reduced hospital mortality44.
Reliability: No studies identified.
Risk Adjustment: No studies identified.
Utilization: Treatment of Joint Dislocation is used as an indicator by a small number of trauma centers: USA 1% (2/200), Canada 9% (3/35), Australasia 25% (3/12).
There is some evidence for the use of an algorithm to guide treatment decisions regarding joint dislocation to decrease radiological load in the ED and the time that the patient spends in the ED66.

The indicator was initially proposed by Chadbunchachai et al.44.


44. Chadbunchachai W, Saranrittichai S, Sriwiwat S, Chumsri J, Kulleab S, Jaikwang P. Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai. 2003;86(1):1-7.
66. Hendey GW, Chally MK, Stewart VB. Selective radiography in 100 patients with suspected shoulder dislocation. J Emerg Med. 2006;31(1):23-28.