An observational mixed methods study was conducted among health care professionals from August 2021 to June 2022, parallel to the implementation of DD in 3 hospitals. Both quantitative and qualitative data were collected and analyzed separately by a quantitative team (GW and JS) and a qualitative team (WDL and Elke Mathijssen). The Bowen feasibility framework was used to organize both data sources with the following parameters: implementation, acceptability, preliminary efficacy, demand, and applicability [22]. After separate analyses, quantitative and qualitative data were triangulated with the Pillar Integration Process [23]. This study was reported according to the Good Reporting on a Mixed Methods Study (GRAMMS) criteria (Multimedia Appendix 1) [24].

The 3 participating centers were urban, level-2 trauma centers with up to 3 locations per hospital, treating between 1200 and 1800 patients with low-complex traumatic musculoskeletal injuries annually. Each center had a similar size and structure. All centers consisted of 3 locations, with 1 large location focusing on low-to-high complex traumatic injuries and having an ED with more rooms compared with the other locations. The 2 other locations were smaller and had no particular focus on patients with trauma, but they treated low-complex patients with trauma if they sought care at these locations. Per center, all 3 locations have 1 team taking care of all patients. These teams consisted of (orthopedic) trauma surgeons, residents, plaster technicians, ED physicians, and ED nurses. In total, 217 eligible health care professionals were exposed to DD based on data provided by participating hospitals. Changes in tasks per health care professional are described in Figure 1. These changes apply per center, including all 3 hospitals per center. The variance in the number of employees was correlated with the size of the hospital. The 2 centers implemented DD in September 2021 and 1 in March 2022.

Before DD was implemented, patients were treated according to the local trauma protocols. These protocols consisted of immobilization or support with either a cast, sling, bandage, or splint and brief information about the injury at the ED. At least 1 outpatient follow-up appointment was scheduled at the plaster room or in the outpatient clinic within 2 weeks after the injury for review, extensive information, and definitive management planning.

This protocol was derived from the British model of a Virtual Fracture Clinic (VFC) and adapted to the Dutch health care setting in 2019 [25]. In its Dutch adaptation, DD includes 11 treatment protocols for low-complex, stable traumatic orthopedic injuries with additional injury-related criteria (Multimedia Appendix 2) [25]. If patients met the injury-related inclusion criteria in Multimedia Appendix 2 and spoke Dutch or English fluently, they were included; no further predefined restrictions (eg, age or comorbidity) were used. Patients were excluded from the protocol at the ED if they had initial treatment in another hospital; follow-up in another hospital (eg, closer to home); multiple injuries; a reason for follow-up other than the injury (eg, social-care reasons); an eye-, motor-, or verbal-score <15 at presentation; or intoxication. With DD, patients were discharged directly from the ED without routine outpatient follow-up. They received a removable orthosis or a sling (eg, brace instead of a cast) and extensive information at the ED, summarized in a mobile self-care app (the VFC app). Patient eligibility for the protocol was re-evaluated on the next workday (within 24 hours) by a team consisting of an (orthopedic) trauma surgeon and a radiologist. If patients were incorrectly discharged directly based on the injury-related or social inclusion criteria during the second review the next day, then they were contacted by phone and scheduled for a face-to-face appointment. This re-evaluation was a standard procedure in both protocols and was used to check previous decisions of young doctors by a senior group of medical professionals based on the radiographs and electronic patient record.

The VFC app provides self-care assistance through information, videos, and a helpline and can be downloaded for free at the Google Play Store and iOS App Store (Figure 2). Injury-specific leaflets with recovery information, treatment rules, and red flags were included. Furthermore, frequently asked questions, audiovisual exercise, immobilization, and analgesic instructions were included to assist patients. If patients required human contact in addition to the information, a helpline by phone operated by a health care professional was available during working hours. The VFC app aimed to increase self-management and self-care during recovery and to substitute face-to-face follow-up.

Interested centers contacted 1 of the trauma surgeons or the main email address of the initiating Onze Lieve Vrouwe Gasthuis (OLVG) Hospital, Amsterdam, the Netherlands. The OLVG Hospital created several tools to assist the implementation in other hospitals. The tools were created to streamline the implementation process as hospitals had similar questions during implementation and medical doctors struggled with the implementation of eHealth in their daily practice, partly due to inexperience with implementation and accompanying barriers and facilitators. These tools consisted of an email address that health care professionals could contact, an implementation guide, a digital PowerPoint presentation with an overview of the concept, and an information set with standardized information. This information set included posters, pocket cards, training guides, smart phrases for electronic patient records, standardized discharge letters, and a tool to personalize the layout of the VFC app. Participating centers started implementation preparations 3 months before the actual start of DD as the standard of care. Based on the experiences of the implementation in previous centers, 3 months was considered a sufficient amount of time to implement DD. There were minor differences between hospitals to optimize local fit (eg, the available hours of the staffed helpline).

Health care professionals involved in the in-hospital treatment of patients with eligible low-complex, stable traumatic orthopedic injuries on a daily basis were included in this study (Figure 1). Health care professionals were excluded from the final analysis if they did not provide the correct contact details or did not complete both surveys.

A total of 4 weeks before the implementation of DD, the 217 potentially eligible health care professionals were asked to participate in the study through education moments, e-learnings, and by email. The health care professionals were given a survey distribution link by email to a preimplementation survey in Research Electronic Data Capture (REDCap; Vanderbilt University), a digital survey system [26]. Potentially eligible participants were remembered twice, 1 week after the initial email. Participants were excluded if they did not complete both surveys or if they did not provide any contact details to send the second survey to. Within the survey, consent for an additional semistructured interview was asked. Age, sex, occupation, medical specialty, and hospital were used to select a purposive sample among health care professionals who consented. During sample selection for the interviews, ED nurses and plaster technicians were underrepresented. Through an open call, nonresponders were recruited through email, after which the definitive sample was selected. Eligible health care professionals were contacted to schedule a web-based, semistructured interview. Health care professionals were reminded through email to complete the survey. The second survey was sent 3 months after the implementation of the DD protocol (Figure 3). We aimed to collect completed quantitative data from 100 health care professionals and qualitative data from 15 health care professionals.

Data were collected from surveys and semistructured interviews.

Patients or health care professionals were not involved in the design, intervention, research question, or outcome measures of this study.

This study, including the process analysis, was reviewed and approved by the Medical Ethical Committee of Utrecht, Netherlands (W21.261).

Patients provided consent for participation in the research, and could opt out at any time after request by e-mail. The original consent or IRB approval covers secondary analysis without additional consent. Data is de-identified. A data key is stored at the local hospitals in a secured map and coded file. This is only accessible to JS and GW. The accessible data has been de-identified as far as possible (e.g., age in years instead of date of birth). Patients received no compensation to participate in this research.

Of the 217 estimated eligible health care professionals, 128 started the primary survey, 42 did not complete the primary survey, and 49 did not complete both surveys (Figure 4). Of the 37 included health care professionals (response rate of 17%), 23 (62%) were female, and the median age was 38 (IQR 32-45) years. Current occupations were medical specialists (14/37, 38%), residents (14/37, 38%), plaster technicians (7/37, 19%), and ED nurses (2/37, 5%; Table 1). The baseline characteristics of health care professionals who solely filled out the primary surveys did not vary statistically significantly in age (P=.98) or sex (P=.28) as compared to those who filled out both surveys. A total of 15 health care professionals, 5 per hospital, participated in the web-based, semistructured interviews, of which 60% (9/15) were female.

Qualitative data showed that the implementation strategy varied between hospitals and was adjusted to improve the local fit (eg, available hours of the helpline or brace brands). Changes in tasks, immobilization material, and the number of follow-up appointments influenced the implementation experience the most. Some nurses reported that coworkers had difficulties applying the braces, sometimes because their schooling during implementation was suboptimal or delayed, for example, because someone was ill (quote 1 in Table 2). Health care professionals reported that adequate schooling and involvement of the previous responsible health care professional in the implementation process were essential to executing the DD protocol adequately. Mainly because the ED nurse, now responsible for applying the braces, had less experience immobilizing fractures than the plaster technician.

Dutch health care professionals considered the DD protocol a safe and satisfactory alternative to traditional treatment, leading to a perceived decrease in SHU. Although providing information with DD required more (explanation) time for residents and physicians at the ED, the logistical benefits (ie, reduced number of follow-up appointments) outweighed the slight increase in time. Before and after implementation, no statistically significant differences were found regarding workload or job satisfaction. However, qualitative data reported benefits in workload and job satisfaction for trauma surgeons and residents, and disadvantages for some plaster technicians in terms of job satisfaction and workload. Furthermore, health care professionals reported increased quality of information and comparable quality of care. Almost all health care professionals would like to continue using DD after implementation. To improve DD, several new app functionalities were suggested, and the earlier involvement of stakeholders who performed new tasks was suggested.

The study results show that DD is an acceptable alternative to traditional follow-up for health care professionals. Health care professionals reported similar, high satisfaction scores with treatment as previously reported patient satisfaction scores for similar protocols [18,33]. To further improve health care professionals’ satisfaction scores, health care professionals in this study suggested a short numerical feedback system to monitor injury recovery remotely (eg, recovery questions after 3 months). In the literature, health care professionals have also mentioned this as an important feature of eHealth developed for patients with musculoskeletal injuries [34,35]. A challenge to incorporating this is that these functions would require a more enhanced app that complies with current laws and regulations for data storage and requires substantial financial investment. In addition, this request might also be a sign of early-stage adoption, where health care professionals feel a bit uncertain about the patients they would normally see for follow-up but who are now out of sight. As time progresses, it seems likely they will feel more comfortable not seeing these patients anymore, as this is then considered standard of care.

Preliminary efficacy was partly in line with the literature [18,20,33]. Most health care professionals considered DD a safe alternative to face-to-face follow-up, leading to a perceived reduction of SHU. This finding is consistent with previous articles, which concluded that DD is safe based on low, comparable complication numbers, with significantly reduced SHU compared to traditional treatment [9,18,33]. The perceived reduction in SHU varied among stakeholders. The reduction was perceived as most beneficial in qualitative data regarding workload for (orthopedic) trauma surgeons and least beneficial for plaster technicians, as they enjoyed this particular part of their workload. This study has been unable to demonstrate statistically significant differences regarding workload and job satisfaction before and after implementation. Even though the introduction of DD at the ED increased valuable treatment time for some stakeholders, which decreased but remained longer after implementation, almost all reported that the benefits of less SHU outweighed this downside. These findings are interesting, as the increase in time has been reported as one of the most important personal barriers to implementing and adopting eHealth but was not reported as an important disadvantage in this study [14,35].

Similar quality of care and increased quality of information after the introduction of DD are in accordance with earlier findings [11,20,36]. Particular advantages of DD were uniform, injury-specific, and on-demand information, consistent with a study pointing out the current heterogeneity in treatments for these injuries and the demand for uniform treatment [37]. The disadvantages of DD were the care being less personal, the loss of care activities for several stakeholders, and the inability to monitor recovery. A previous study described that VFCs might influence learning curves as residents become less experienced with the follow-up and full recovery of these injuries [38]. This was not supported by our results. However, a lack of follow-up has led to a tendency for some (often inexperienced) residents to be more explanatory at the ED to ensure the patient had received all information during the only contact moment. To reassure themselves and identify the small group of patients with persistent complaints, some health care professionals suggested a feedback system to ensure they had recovered adequately. Such a system should not increase workload but only filter patients with remaining questions, pain, or complications. This should be developed with patients and health care professionals and could contain anchor-based questions or patient-reported outcome measures with predefined cut-off values.

Health care professionals report that DD fits the public demand to develop more efficient (outpatient) care, and digital assistance could help deal with constrained resources. This partly aligns with the literature, as attitudes toward the usefulness of eHealth vary [39-41]. Almost all health care professionals would like to continue using DD after its implementation. This finding complements current literature showing the widespread implementation of DD protocols and VFCs in the United Kingdom, Australia, New Zealand, and India [8,33,42,43]. This further strengthens the idea of at least adequate acceptance and the general applicability of this concept in different countries. The applicability of DD varied among stakeholders and was influenced by the increase or loss of tasks after implementation of the protocol and their experience with that particular increase or loss of tasks. Even though evaluation of applicability for health care professionals and health care professional satisfaction with the protocol seems vital to determining feasibility, it has not been reported previously for DD protocols, despite the many centers that have implemented similar protocols. Health care professionals reported that early stakeholder involvement during implementation could be beneficial to cope with the changes in tasks and transfer of knowledge, which aligned with the results of Logishetty [21] reporting the importance of early stakeholder involvement during VFC implementation in a quality improvement approach. The lack of early involvement of stakeholders and limited feasibility among health care professionals are known risks for nonadoption or abandonment [3,44,45].

This study has several strengths. To date, this is the first study to explore the in-depth views of several stakeholders involved in DD protocols and VFCs. The COVID-19 pandemic has accelerated the implementation of DD in the Netherlands, emphasizing the demand for a shift in patient care, where eHealth alternatives have become the new standard [46]. The views and perceptions of health care professionals about different eHealth services are valuable to further tailor these services to their needs and preferences. A second strength of this study is the multidisciplinary involvement of the research team during evaluation and analysis. This approach ensured that the data were analyzed from all possible angles. A third strength is a mixed methods approach to evaluating DD because the separate collection of both data sources combined with the triangulation increased the likelihood of our results being a realistic representation of the daily clinical activities of the involved health care professionals. The fourth strength is the use of a validated framework to evaluate DD, which allowed for a structured insight into each feasibility parameter. The fifth strength was the heterogeneity in the sizes and locations of the three study sites. This allowed us to investigate the applicability within different types of hospitals.

This study also has limitations that need to be addressed. The first limitation is the small quantitative sample size and low response rate. Even though the response rate among health care professionals is 10% to 15% lower compared to patient studies, the quantitative sample size remains limited [47]. Nevertheless, for almost all parameters, quantitative and qualitative data were similar, indicating a realistic response from most health care professionals. A third limitation is that ED nurses were not involved in the initial design of this study and did not provide quantitative data. Nevertheless, they have been included in the qualitative data to strengthen the study results.

DD protocols reduce SHU without negatively influencing PHU, satisfaction, complications, or functional outcomes [17]. By assisting patients through the VFC app, they can receive care at home, potentially reducing health care costs [9]. Health care costs in the Netherlands have increased drastically, particularly due to specialized in-hospital care. In addition, there is a growing shortage of personnel. Digitally assisted solutions are suggested to cope with the rise of these costs and limited personnel, but implementation remains difficult [14]. The technical (eg, compliance and complication numbers) and logistic outcomes of this concept are well explored, but the social and cultural elements of DDs have not been explored. These findings help optimize future implementation strategies for eHealth in orthopedic and trauma surgery by providing preconditions and learning lessons such as early stakeholder involvement. These findings might be generalizable for other short treatment processes in other (surgical) departments with high volumes of relatively low-complex surgical patients (eg, low-complex dermatology or otorhinolaryngology).

As DD is introduced rapidly to cope with constrained financial and human resources and health care professionals expect DD to stay, a thorough evaluation of caregivers and patients is essential to ensuring sustainable adoption. Results of this study have improved our DD protocol and have led to 2 corresponding major points of improvement among all stakeholders and many points of improvement, such as ideas for illustrations, adjusted language (levels), and adjustable font size from 1 or more health care professionals. Future studies should focus on co-designing numerical feedback with patients and health care professionals. Furthermore, a thorough evaluation of patient perspectives should be performed to gain insight into the end users’ perspective on this innovation. Particularly to investigate the potential link between different levels of literacy (health literacy, digital literacy, and literacy) and health equity, as suggested in previous studies [48,49].

Health care professionals perceive DD as an acceptable, applicable, safe, and efficacious alternative to traditional treatment. A short numerical feedback system could alleviate concerns about a full recovery and further improve DD protocols. DD can reduce SHU, which is important in times of constrained resources. Nonetheless, both advantages and disadvantages should be considered while evaluating this type of protocol. In the future, clinicians and policy makers can use these insights to further optimize and implement DD and VFC in clinical practice and guidelines.