ED Reference Guideline for Common Adult Orthopaedic Limb Injuries

Several challenges presented during development and implementation that taught lessons for future approaches:

• Stakeholder feedback takes time and relies upon common goals and directives. Identifying and emphasising reciprocal benefits for work unit management and patient care in ED and in flow up care is important for stakeholder input and buy in
• Access to guidelines and procedures for clinical care is of utmost importance. If a guideline is not readily accessible for clinical staff with minimal effort, it is unlikely to be utilised. Similarly, resources across multiple platforms are unlikely to be effectively used due to inconsistent access in clinical care by clinicians
• Centralising resources to a single document made our guideline centralised, and by placing upon the two most commonly access platforms in our setting (QHEPS and DEM tools) coupled to regular staff education and circulation in comms, ensured staff were aware of and using this resource. The nature of constantly rotating junior staff in ED is challenging to ensure all aware of guideline, how and when to access. Our strategy was to include our guideline within routine education and training programs, and once embedded senior medical staff would direct staff to its use. 
• Guidelines are useful but need not be rigid due to variation in patient presentation and concurrent or comorbid factors. Hence our guideline served as a decision-making tool rather than a rigid procedural document 
• Guidelines need constant monitoring and updating as clinical care evolves or unique situations are identified that reveal limitations. Therefore, a centralised document that can be easily updates in lien with clinical needs is important. Many platforms for guideline publications can make this difficult or cumbersome, with delays to re-publication that may impact immediate change in care/practice. 
• Unfortunately, we could not record how often our guideline was accessed in its electronic locations. Moving forward we will plan to have this recorded as part of future data collection. 
• Future plans will include QR code-based resources for patient specifics to different presentations, and additional clinician resources for assessment procedures.