Yuen’s Yap 5/7/17 – VFRAC update, clinical risk, paediatric forensic medicine, metaanalyses

For DEMT Terence Yuen – Teaching 5/7/17


VFRAC – virtual fracture clinic

Update from Becky Pile ED physiotherapist

3 months running now

VFRAC reviews all referrals next day and then funnels cases:

  • Direct to OT
  • To ‘traditional’ fracture clinic + organizes repeat imaging
  • conservative VFRAC management – simple fractures for phone management and LMO follow-up

Can manage other acute injuries eg. Achilles rupture

VFRAC needs to be booked for next day – please tell your clerk

No limit on booking numbers

Already a reduction of about 26% diverted from fracture clinic

Patient satisfaction information survey pending – being collected now


Adults only so far – no paeds


Clinical risk management and clinical governance

Dr Lucia Le Kim – deputy director with Dr Terence Yuen


Governance includes:

  • policy
  • Education
  • Clinical guidelines / protocol
  • Systems: escalation pathways / codes / mandatory competencies / credentialing
  • Audit / review / quality / outcomes / KPIs / M+M / satisfaction / Riskman / in-depth case reviews / adverse events

All clinicians as they progress through their careers should develop an awareness of wider process of healthcare delivery in the hospital context, over and above individual patient cases



  • Seen risk – eg. the patient you have seen who is unwell
  • Assumed risk –
  • Unseen risk – ie unseen waiting room patients and any patient who you have not personally reviewed



  • Assumptions: interpretation of case / interpretation of investigations
  • Interpretation of clinical stability
  • Diagnosis momentum
  • Geographical blindspots – eg. EOU / EDIS filters (clerical risk)



Eg. Chest pain: ECG to be seen by senior / EOU consultant review /


Mitigate risk by good communication

Avoid premature labelling / diagnosis


Take actions to re-stratify risk

  • Re-utilize resources
  • Reallocate resources
  • Retrieve additional resources


Victorian forensic paediatric medical service (VFPMS)

Dr Bindu Bali

See presentation here


Paediatric arm of adult forensic service

Mandatory reporting – suspicion of physical or sexual abuse; not mandated to tell the family per se

Social work / IRS support to support clinician or family / access to phone

Issues regarding confidentiality if contacted by DHHS

Safety concerns can trump privacy legislation however it is a grey area

Admission often necessary to facilitate further survey but if no further medical needs exist then DHHS is responsible for safe accommodation

RED FLAGS: household violence / heavy use of drugs + alcohol / serious mental illness / child’s vulnerability (eg premobile / preverbal)



  • Do not try to interpret
  • Describe only
  • Consider red flags : away from bony prominences / TEN – torso / ears / neck / if not fitting developmental stage


Journal club: EGDT and meta-analyses

Dr Ashley Loughman – see presentation here


Early goal directed therapy

How to assess meta-analyses


PRISM metaanalysis

  • Prospective collection to ensure uniformity



  • Theoretically pool information to get closer to the “common truth”
  • Increases external validity
  • Cons: inclusion biases / lack of negative studies / agenda driven bias / poor quality of original papers

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