Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties

Purpose We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward. Methods 200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period. Results 166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%. Conclusion Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

254 An Audit to Assess the Completion of Consent Forms in the Department of Trauma and Orthopaedics

Aim The objective was to audit how well the consent forms were being completed by junior doctors and registrars in the orthopaedic ward. This helped to assess whether the consent forms before orthopaedic procedures were being filled out according to the standards stated in the RCS and NICE guidelines. Method The initial audit was carried out in January 2020 in the three orthopaedic surgery wards at the Queen’s Medical Centre in Nottingham. Cross sectional data was collected by checking the consent forms to assess whether the important headings and sub-headings were filled out legibly with adequate information. Results All consent forms filled up in the study sample had the patient details and the name of the surgery written completely and accurately. 75.6% of the forms had the name of the Responsible Health Professional written, while the remaining had left the space blank or wrote an incorrect name. More than 90% of the forms had the intended benefit, and the possible risks of the orthopaedic operation written in the most suitable format. The likelihood of a blood transfusion being required was filled out in 78.6% of the forms. All consent forms were signed by a doctor, however, only 53% of the doctors provided both their name in print and contact number in the consent form. Conclusions Consent is an essential prerequisite for any operative procedure. By detecting the parts of the consent form that were frequently filled out inadequately, awareness was raised about the possible legal consequences of it.

Introduction of Day Case Hip and Knee Replacement Programme at an Inpatient Ward is Safe and May Expedite Shortening of Hospital Stays of Traditional Arthroplasties

Purpose: We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward.Methods: 200 patients underwent elective, unilateral primary day case total hip (THA, n=94), total knee (TKA, n=60) and unicondylar knee replacements (UKA, n=46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n=6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period.Results: 166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5 %), urine retention (3 %) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%. Conclusion: Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

Analysis of factors predisposing to degenerative hip joint lesions based on orthopaedic ward patients

WstępChorobę zwyrodnieniową stawu biodrowego (ChZSB), zwaną koksartrozą, uznawano za występującą głównie u ludzi w podeszłym wieku, niemniej jednak coraz częściej dotyka osób młodszych, przyczyniając się do ich inwalidztwa i absencji w pracy.Materiał i metodyBadania przeprowadzono u 100 pacjentów z ChZSB, przyjmowanych kolejno na oddziały ortopedyczne szpitali rejonowych. Analizy dokonano dla dwóch grup, uwzględniających dwa przedziały wiekowe: osoby młodsze (n = 30) – poniżej 60 roku życia (r.ż.), i osoby starsze (n = 70) – w wieku ≥ 60 lat.WynikiW młodszej grupie chorych najczęstszymi czynnikami predysponującymi do rozwoju koksartrozy były: otyłość brzuszna – 27 (90%), wady postawy – 20 (67%), praca na siedząco ≥ 8 h/dobę przy braku regularnej aktywności fizycznej po pracy – 19 (63%), nadwaga – 15 (50%), ciężka praca fizyczna – 14 (47%), praca na stojąco ≥ 8 h/dobę – 14 (47%); w starszej grupie chorych były to: otyłość brzuszna – 67 (96%), praca na siedząco ≥ 8h/dobę przy braku regularnej aktywności fizycznej po pracy – 43 (61%), wady postawy – 38 (54%), ciężka praca fizyczna – 37 (53%), nadwaga – 36 (51%), zespół metaboliczny – 33 (47%).WnioskiU chorych z badanej grupy występowały liczne czynniki predysponujące do rozwoju ChZSB, najczęstsze zaś były otyłość brzuszna i praca na siedząco; obciążenie rodzinne w kierunku zmian zwyrodnieniowych występowało rzadziej.

Haemoglobin and transfusions in elderly patients with hip fractures: the effect of a dedicated orthogeriatrician

Background Hip fractures are common in elderly patients, in whom it is important to monitor blood loss; however, unnecessary transfusions should be avoided. The primary objective of this study was to assess whether the employment of a dedicated orthogeriatrician in an Orthopaedic Department allows to optimise the clinical conditions of patients, influencing blood loss and consequently the number of transfusions. The secondary objective was to determine whether the influence of the orthogeriatrician differs according to the type of surgical treatment. Methods A total of 620 elderly patients treated for hip fracture were included in the study. These patients were divided into two groups according to the presence or not of the orthogeriatrician. For each patient, age, sex, comorbidities, type of fracture, surgical treatment, length of hospital stay, time from hospitalisation and surgery, time from surgery to discharge, haemoglobin (Hb) values (admission, 24h post-surgery, lowest Hb reached, discharge) and the number of transfusions were recorded. Results Regardless of the surgical procedure performed, in patients managed by the orthogeriatrician, the Hb at discharge was significantly higher (p = 0.003). In addition to the highest Hb at discharge, in patients who underwent hemiarthroplasty, the number of transfusions per patient is significantly reduced (p = 0.03). Conclusion The introduction of the orthogeriatrician in an orthopaedic ward for the management of elderly patients treated for hip fracture allows to discharge the patients with higher Hb values, reducing the risk of anemisation and the costs related to possible re-admission.

184 30% Reduction in Time to Admission for Trauma Cases; An Integrated Multidisciplinary Model of Care Pathway in a Major Tertiary Hospital

Introduction Blue Book Guidelines recommend admitting hip fracture patients to an orthopaedic ward within 4 hours of presentation. BOAST guidelines advise early multidisciplinary team management. Since 2018, our Institution has utilised an integrated, multidisciplinary model for referrals of trauma patients in the Emergency Department. We hypothesised that this significantly reduces time to admission. Method We retrospectively reviewed data on all trauma cases admitted over a two-month period in 2017 and 2019 (before and after development of our Integrated Pathway). Our Integrated Pathway is facilitated by a mobile application which is accessed by all ED and Orthopaedic medical staff, including Consultants, allowing instantaneous communication. Results Sixty-six trauma patients were admitted to our Institution between December 2017 and January 2018. Average time taken from triage in ED to admission by the Orthopaedic team was 7hrs 10mins. Sixty-three patients were admitted over the same period in December 2019 and January 2020. Average time taken from triage in ED to admission by the Orthopaedic team was 4hrs 59mins. Conclusions Our Integrated Multidisciplinary mobile application system resulted in a 30.5% decrease in time to admission, which is a significant improvement. We would recommend the introduction of similar systems in other hospitals as part of their Model of Care Pathway.

512 Trauma Meetings in the Time of COVID

Trauma & Orthopaedics (T&O) has taken a backseat during COVID-19. As the focus has shifted to care of COVID patients, other specialties have adjusted their daily working. At our local hospital, the dedicated Orthopaedic ward was absorbed into the Intensive Care department, necessitating migration to a smaller, shared working space. This project looked at ways of increasing clinical efficiency, patient safety and education within the T&O department. Members of the T&O department at The Princess Alexandra Hospital were invited to attend daily trauma meetings virtually via Microsoft Teams. In addition, the impact of moving to a larger, dedicated meeting space was assessed. Pre- and post-intervention questionnaires were delivered to assess response. Post-intervention questionnaires revealed a significant improvement in the perception of ability to see XRs (p < 0.001), quality of handover (p = 0.018), ability to discuss and formulate management plans (p = 0.002), social distancing (p < 0.001), location (p = 0.002) and trauma meetings overall (p < 0.000). The educational value of trauma meetings did not improve as anticipated, however. Virtual Trauma Meetings are a useful adjunct, allowing clinicians safely contribute to clinical care. In addition, the location of daily trauma meetings is an important factor to consider, both for the safety of patients and for the safety of clinicians.

The Burden of Orthopaedic Disease in Sub-Saharan Africa: A Focus on Tanzania

Background As road traffic crashes (RTCs) continue to rise in the developing world, the current growth rate and true burden of orthopaedic injuries are unknown. In 2015, we characterized the orthopaedic burden at Kilimanjaro Christian Medical Center (KCMC) in Tanzania. In this study, we re-evaluated the burden and growth-rate over three years in the absence of any system level changes. Additionally, we calculated the percentage of orthopaedic patients that received definitive fixation for their orthopaedic injury when surgery was indicated.Methods We prospectively collected data for 190 patients admitted to the orthopaedic ward at KCMC during June/July 2018. We also retrospectively reviewed available records for patients presenting to the KCMC emergency department, orthopaedic outpatient clinic and orthopaedic ward.Results Prospective data: RTC (48.6%) was the most common etiology and femur fractures (31.0%) the most common type of injury. Almost 96% of admitted patients were indicated for surgical fixation, but only 44.5% received definitive fracture treatment. Retrospective data: KCMC treated an average of 15,117 orthopaedic patients per year, representing a 35.3% growth in the orthopaedic burden compared to 2015.Conclusion The burden of orthopaedic surgical disease at KCMC continues to grow. Throughout the developing world, multiple system level constraints preclude delivery of definitive treatment for most patients. Without innovative strategies to address this situation, the discrepancy between the need for orthopaedic care and surgical care capacity in the developing world will continue to grow.

When fever is more than infection: two cases of vancomycin-induced drug reaction with eosinophilia and systemic symptoms (DRESS)

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, but serious systemic hypersensitivity reaction associated with a range of medications. We present two cases of vancomycin-induced DRESS, which occurred simultaneously in the orthopaedic ward in an outer metropolitan hospital. These cases demonstrate the complexity in the diagnosis and management of this inflammatory syndrome on the background of known infection as well as evidence for linezolid as an alternative to vancomycin. The first case was managed conservatively, but developed progressive renal and liver injury along with demonstrated cytomegalovirus reactivation and recurrent colitis, and was eventually palliated. The second was commenced on intravenous glucocorticoids and achieved remission, although had ongoing renal dysfunction at the time of discharge from outpatient follow-up.