Do Transferred Patients Increase the Risk of Venous Thromboembolism in Trauma Centers?

Trauma patients often require initial stabilization followed by transfer for ongoing trauma care. Thus, the administration of VTE prophylaxis is often delayed until admission to the receiving hospital. It is unclear if transfer status is a risk factor for VTE. The National Trauma Database v6.2 was used to identify patients admitted to Level I and II trauma centers. Exclusions included patients on anticoagulation, <18 years, known VTE before trauma, or pregnant. Patients transferred were compared with nontransferred patients. Analysis included 736,374 patients with 189,166 (25.69%) transferred patients within 24 hours of injury. Using weighted measures, VTE was identified in 11,619 (1.50%) patients. The VTE rate was significantly higher in the transferred group compared with the nontransferred group (1.73% vs 1.42%, P = 0.002) including deep venous thrombosis (1.39% vs 1.14%, P = 0.004) and pulmonary embolism (0.45% vs 0.39%, P = 0.003). Multivariable analyses adjusting for patient-level risk factors demonstrated that transfer was associated with a higher likelihood of VTE (aOR 1.18; 95% CI: 1.09-1.28, P ≤ 0.001), pulmonary embolism (aOR 1.21; 95% CI: 1.11-1.33, P ≤ 0.001), and deep venous thrombosis (aOR 1.17; 95% CI: 1.07-1.28, P = 0.0004). Transfer status of trauma patients is a risk factor for VTE. Accepting a transferred patient results in an increased VTE risk and may not be reflective of the quality of care at the receiving facility.

Do Transferred Patients Increase the Risk of Venous Thromboembolism in Trauma Centers?

Trauma patients often require initial stabilization followed by transfer for ongoing trauma care. Thus, the administration of VTE prophylaxis is often delayed until admission to the receiving hospital. It is unclear if transfer status is a risk factor for VTE. The National Trauma Database v6.2 was used to identify patients admitted to Level I and II trauma centers. Exclusions included patients on anticoagulation, <18 years, known VTE before trauma, or pregnant. Patients transferred were compared with nontransferred patients. Analysis included 736,374 patients with 189,166 (25.69%) transferred patients within 24 hours of injury. Using weighted measures, VTE was identified in 11,619 (1.50%) patients. The VTE rate was significantly higher in the transferred group compared with the nontransferred group (1.73% vs 1.42%, P = 0.002) including deep venous thrombosis (1.39% vs 1.14%, P = 0.004) and pulmonary embolism (0.45% vs 0.39%, P = 0.003). Multivariable analyses adjusting for patient-level risk factors demonstrated that transfer was associated with a higher likelihood of VTE (aOR 1.18; 95% CI: 1.09–1.28, P ≤ 0.001), pulmonary embolism (aOR 1.21; 95% CI: 1.11–1.33, P ≤ 0.001), and deep venous thrombosis (aOR 1.17; 95% CI: 1.07–1.28, P = 0.0004). Transfer status of trauma patients is a risk factor for VTE. Accepting a transferred patient results in an increased VTE risk and may not be reflective of the quality of care at the receiving facility.

Hospital characteristics associated with increased conversion rates among organ donors in New England

BACKGROUND

It is unknown whether hospital characteristics affect institutional performance with regard to organ donation. We sought to determine which hospital- and patient-level characteristics are associated with high organ donor conversion rates after brain death (DBD).

METHODS

Data were extracted from the regional Organ Procurement Organization (2011-2014) and other sources. Hospitals were stratified into high-conversion hospitals (HCH; upper-tertile) and low-conversion hospitals (LCH; lower-tertile) according to conversion rates. Hospital- and patient-characteristics were compared between groups.

RESULTS

There were 564 potential DBD donors in 27 hospitals. Conversion rates differed between hospitals in different states (p < 0.001). HCH were more likely to be small (median bed size 194 vs. 337; p = 0.024), non-teaching hospitals (40% vs. 88%; p = 0.025), non-trauma center (30% vs. 77%; p = 0.040). Potential donors differed between HCH and LCH in race (p < 0.01) and mechanism of injury/disease process (p < 0.01).

CONCLUSION

There is significant variation between hospitals in terms of organ donor conversion rates. This suggests that there is a pool of potential donors in large specialized hospitals that are not successfully converted to DBD.

Regionalisation of trauma care in England

AIMS

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

PATIENTS AND METHODS

An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital.

RESULTS AND CONCLUSION

A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.

Geographic Distribution of Trauma Burden, Mortality, and Services in the United States: Does Availability Correspond to Patient Need?

BACKGROUND

The association between the need for trauma care and trauma services has not been characterized previously. We compared the distribution of trauma admissions with state-level availability of trauma centers (TCs), surgical critical care (SCC) providers, and SCC fellowships, and assessed the association between trauma care provision and state-level trauma mortality.

STUDY DESIGN

We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality rates. Normalized densities (per million population [PMP]) were calculated and generalized linear models were used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per-capita income, and age-adjusted mortality rates.

RESULTS

There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP), and 1,987 TCs across the country, of which 521 were Level I or II (1.65 PMP). There was considerable variation between the top 5 and bottom 5 states in terms of Level I/Level II TCs and SCC surgeon availability (approximately 8.0/1.0), despite showing less variation in trauma admission density (1.5/1.0). Distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p ≤ 0.001), and inversely associated with per-capita income (p < 0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC provider PMP, there was a decrease of 618 deaths per year.

CONCLUSIONS

There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and location of Level I/Level II TCs. In the wake of efforts to regionalize TCs, additional efforts are needed to address disparities in the provision of quality care to trauma patients.

World Hip Trauma Evaluation (WHiTE): framework for embedded comprehensive cohort studies

INTRODUCTION

Osteoporotic hip fractures present a significant global challenge to patients, clinicians and healthcare systems. It is estimated that hip fracture accounts for 1.4% of total social and healthcare costs in the established market economies.

METHODS AND ANALYSIS

The World Hip Trauma Evaluation (WHiTE) was set up to measure outcome in a comprehensive cohort of UK patients with hip fracture. All patients in the cohort are treated under a single comprehensive treatment pathway. A core outcome set, including health-related quality of life, is collected on all the patients. This protocol describes the current multicentre project that will be used as a vehicle to deliver a series of embedded observational studies.

ETHICS AND DISSEMINATION

Research Ethics Committee approval was granted (Rec reference 11/LO/0927, approved 18/8/2011) and each hospital trust provided National Health Service (NHS) approvals.

TRIAL REGISTRATION NUMBER

The study is registered with National Institute of Health Research Portfolio (UKCRN ID 12351) and the ISRCTN registry (ISRCTN63982700).

Unplanned 30-day readmissions in orthopaedic trauma

INTRODUCTION

30-day readmission is increasingly used as a hospital quality metric. The objective of this study was to describe the patient factors associated with unplanned 30-day hospital readmission of orthopaedic trauma patients.

METHODS

A statewide observational study was undertaken using data from all acute hospitals in California. All hospital inpatients with a primary diagnosis of fracture or dislocation (ICD-9-CM codes 800-829) were included, except for those with isolated injuries to the skull, face, or ribs. The primary outcome measure was unplanned 30-day readmission to any hospital in California.

RESULTS

416,568 trauma admissions were available for analysis. The overall readmission rate was 6.5%, and 27.3% of readmitted patients presented to a different hospital. Factors significantly associated with readmission were male sex (OR 1.23, 95% CI 1.19-1.27), age 46-65 (2.61 [2.27-2.99]), black race (1.19 [1.11-1.27]), entitlement to publicly funded healthcare (1.38 [1.25-1.52]), Charlson Comorbidity Index ≥2 (1.84 [1.79-1.90]), discharge against medical advice (3.13 [2.67-3.68]), and spinal fracture (1.42 [1.34-1.49]). Major reasons for readmission included: cardiopulmonary disease (25.6%), infections (20.1%), musculoskeletal problems (18.1%), and procedural complications (12.0%).

CONCLUSIONS

Many orthopaedic trauma readmissions are potentially unrelated to the initial hospitalization. Penalties for unplanned readmissions risk penalizing hospitals that serve disadvantaged communities and treat a high proportion of trauma patients.

The obesity paradox in patients with severe soft tissue infections

BACKGROUND

The "obesity paradox" has been demonstrated in chronic diseases but not in acute surgery. We sought to determine whether obesity is associated with improved outcomes in patients with severe soft tissue infections (SSTIs).

METHODS

The 2006 to 2010 Nationwide Inpatient Sample was used to identify adult patients with SSTIs. Patients were categorized into nonobese and obese (nonmorbid [body mass index 30 to 39.9] and morbid [body mass index ≥ 40]). Logistic regression provided risk-adjusted association between obesity categories and inhospital mortality.

RESULTS

There were 2,868 records with SSTI weighted to represent 14,080 patients. Obese patients were less likely to die in hospital than nonobese patients (odds ratio [OR] = .42; 95% confidence interval [CI], .25 to .70; P = .001). Subanalysis revealed a similar trend, with lower odds of mortality in nonmorbid obesity (OR = .46; 95% CI, .23 to .91; P = .025) and morbid obesity (OR = .39; 95% CI, .19 to .80; P = .011) groups.

CONCLUSIONS

Obesity is independently associated with reduced inhospital mortality in patients with SSTI regardless of the obesity classification. This suggests that the obesity paradox exists in this acute surgical population.

A negative association between condom availability and incidence of urethral discharge in a closed Malawian community

Condom promotion in sub-Saharan Africa has been accused by some conservative groups of encouraging promiscuity. This study explored the relationship between condom availability and sexually transmitted infection (STI) incidence in a closed Malawian community. An audit of clinic records charted the changing availability of condoms and the concurrent incidence of patients presenting with STI-associated urethral discharge (UD). When condoms first became available, their distribution steadily increased and the UD incidence declined. During a three-month period of unavailability, this previously uninterrupted decline was reversed and UD incidence increased. Once condoms again became available, UD incidence resumed its decline. This association was found to be statistically significant (Spearman's correlation coefficient, −0.499; P = 0.035). In a small community largely isolated from neighbouring towns, condom distribution appeared to negatively correlate with the number of patients presenting with UD. This may challenge the local belief that condoms have a damaging effect on sexual health in Malawi.

Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis

A systematic review was conducted on 30 December 2014 to determine whether prophylactic antibiotics reduce the risk of superficial infection and osteomyelitis following open distal phalanx fractures. Four randomized controlled trials (353 fractures) were suitable for meta-analysis. There was no statistically significant difference between rates of superficial infection in the two groups. This finding persisted when only the two most recent and highest quality trials were included. There were no reported cases of osteomyelitis in the pooled dataset, despite patients with 164 fractures not receiving antibiotics. These results fail to show any effect of prophylactic antibiotics on the rate of superficial infections following open distal phalanx fractures. The focus of treatment should be on prompt irrigation and debridement rather than administration of prophylactic antibiotics.

Inequalities in use of total hip arthroplasty for hip fracture: population based study

OBJECTIVES

To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there are systematic inequalities.

DESIGN

Observational cohort study using the National Hip Fracture Database (NHFD).

SETTING

All hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland.

PARTICIPANTS

Patients within the national database (all aged ≥60) who received operative treatment for a non-pathological displaced intracapsular hip fracture from 1 July 2011 to 31 April 2015.

MAIN OUTCOME MEASURES

Provision of THA to patients considered eligible under criteria published by the National Institute for Health and Care Excellence (NICE).

RESULTS

114 119 patients with hip fracture were included, 11 683 (10.2%) of whom underwent THA. Of those who satisfied the NICE criteria, 32% (6780) : received a THA. Of patients who underwent THA, 42% (4903) did not satisfy the NICE criteria. A recursive partitioning algorithm found that the NICE eligibility criteria did not optimally explain which patients underwent THA. A model with superior explanatory power drew distinctions that are not supported by NICE, which were an age cut off at 76 and a different ambulation cut off. Among patients who satisfied the NICE eligibility, the use of THA was less likely with higher age (odds ratio 0.88, 95% confidence interval 0.87 to 0.88), worsening abbreviated mental test scores (0.49 (0.41 to 0.58) for normal cognition v borderline cognitive impairment)), worsening American Society of Anesthesiologists score (0.74, 0.66 to 0.84), male sex (0.85, 0.77 to 0.93), worsening ambulatory status (0.32, 0.28 to 0.35 for walking with a stick v independent ambulation), and fifths of worsening socioeconomic area deprivation (0.76 (0.66 to 0.88) for least v most deprived fifth). Patients receiving treatment during the working week were more likely to receive THA than at the weekend (0.90, 0.83 to 0.98).

CONCLUSIONS

There are wide disparities in the use of THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those who require surgery at the weekend were less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimal treatment for older adults with hip fractures can depend on where and when they present to hospital.

Hospital case volume and outcomes for proximal femoral fractures in the USA: an observational study

OBJECTIVE

To explore whether older adults with isolated hip fractures benefit from treatment in high-volume hospitals.

DESIGN

Population-based observational study.

SETTING

All acute hospitals in California, USA.

PARTICIPANTS

All individuals aged ≥65 that underwent an operation for an isolated hip fracture in California between 2007 and 2011. Patients transferred between hospitals were excluded.

PRIMARY AND SECONDARY OUTCOMES

Quality indicators (time to surgery) and patient outcomes (length of stay, in-hospital mortality, unplanned 30-day readmission, and selected complications).

RESULTS

91,401 individuals satisfied the inclusion criteria. Time to operation and length of stay were significantly prolonged in low-volume hospitals, by 1.96 (95% CI 1.20 to 2.73) and 0.70 (0.38 to 1.03) days, respectively. However, there were no differences in clinical outcomes, including in-hospital mortality, 30-day re-admission, and rates of pneumonia, pressure ulcers, and venous thromboembolism.

CONCLUSIONS

These data suggest that there is no patient safety imperative to limit hip fracture care to high-volume hospitals.

A Twin Study of Perthes Disease

BACKGROUND

Legg-Calvé-Perthes disease (LCPD) is an idiopathic avascular necrosis of the femoral head. Its etiology is poorly understood, although previous studies have implicated low birth weight and possible genetic determinants. The aim of this study was to identify potential birth weight and genetic associations with LCPD.

METHODS

We extracted all twin pairs from the Danish Twin Registry (DTR) in which at least 1 individual had LCPD. The DTR captures every twin pair born alive in Denmark, and those with LCPD were identified by using health record linkage. Probanwise concordance was calculated to describe the likelihood that any given individual had LCPD if their co-twin was also diagnosed.

RESULTS

There were 81 twin pairs: 10 monozygotic, 51 dizygotic, and 20 unclassified (unknown zygosity [UZ]). There was no association between birth weight and being the affected co-twin. Four pairs (2 dizygotic and 2 UZ) were concordant for LCPD, which is greater than would be expected assuming no familial aggregation. There were no concordant monozygotic twin pairs. The overall probandwise concordance was 0.09 (95% confidence interval [CI]: 0.01-0.18): 0.00 for the monozygotic, 0.08 (95% CI: 0.00-0.18) for the dizygotic, and 0.18 (95% CI: 0.00-0.40) for the UZ twin pairs.

CONCLUSIONS

This study found evidence of familial clustering in LCPD but did not show a genetic component. The absolute risk that a co-twin of an affected individual will develop LCPD is low, even in the case of monozygotic twin pairs.

Quality of care for patients with a fracture of the hip in major trauma centres

Aims

In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip.

Patients and Methods

All patients in the United Kingdom National Hip Fracture Database, between April 2010 and December 2013, were included. The indicators of quality that were recorded included the time to arrival on an orthopaedic ward, to review by a geriatrician, and to operation. The clinical outcomes were the development of a pressure sore, discharge home, length of stay, in-hospital mortality, and re-operation within 30 days.

Results

There were 289 466 patients, 49 350 (17%) of whom were treated in hospitals that are now MTCs. Using multivariable logistic and generalised linear regression models, there were no significant differences in any of the indicators of the quality of care or clinical outcomes between MTCs, hospitals awaiting MTC designation and non-MTC hospitals.

Conclusion

These findings suggest that the regionalisation of major trauma in England did not improve or compromise the overall care of elderly patients with a fracture of the hip. Take home message: There is no evidence that reconfiguring major trauma services in England disrupted the treatment of older adults with a fracture of the hip. Cite this article: Bone Joint J 2016;98-B:414–19.

Does Hospital Experience Rather than Volume Improve Outcomes in Geriatric Trauma Patients?

BACKGROUND

Although high absolute hospital geriatric trauma volume (GTV) is associated with improved outcomes among geriatric trauma patients, the actual geriatric trauma proportion (GTP) might be a better predictor of outcomes.

STUDY DESIGN

Adult trauma admissions were identified in the California State Inpatient Database, 2007 to 2011. Hospital characteristics were extracted from the American Hospital Association database. The annual trauma volume of patients 65 years and older was calculated for each hospital. The GTP was derived by dividing the GTV by the overall adult trauma volume and hospitals were categorized into tertiles of GTP. Outcomes were hospital mortality, failure to rescue (FTR), and 30-day readmission in geriatric trauma patients. Independent risk factors were assessed with clustered multivariate logistic regression models adjusted for patient and hospital characteristics.

RESULTS

There were 61,915 geriatric trauma patients included from 63 trauma centers. Hospital mortality, FTR, and 30-day readmission rates were 4.99%, 16.07%, and 12.03%, respectively. The adjusted odds ratios and 95% CIs for in-hospital mortality and FTR per 100 patient increase in GTV were 0.91 (95% CI, 0.83-1.00) and 1.01 (95% CI, 0.90-1.14), respectively. As compared with hospitals in the lowest tertile, adjusted odds of mortality and FTR in the highest tertile were 0.71 (95% CI, 0.54-0.94) and 0.67 (95% CI, 0.48-0.92), respectively. None of the hospital factors measured was significantly associated with readmission. The Wald test revealed that GTP played a larger role than GTV in predicting hospital mortality (p = 0.018 vs p = 0.048) and FTR (p = 0.015 vs p = 0.985).

CONCLUSIONS

Treatment at hospitals with higher GTP is associated with lower hospital mortality and FTR among geriatric patients. These findings suggest that creation of specialized services for geriatric trauma care can improve outcomes among geriatric trauma patients.

Are appendectomy outcomes in level I trauma centers as good as we think?

BACKGROUND

Designated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy.

METHODS

An observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007-2011). All patients with an ICD-90-CM diagnosis of "acute appendicitis" (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors.

RESULTS

There were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14-0.36]), stayed in hospital longer (0.83 d [0.36-1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13-2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes.

CONCLUSIONS

Odds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings.

The truth about trauma readmissions

BACKGROUND

There is a paucity of data on the causes and associated patient factors for unplanned readmissions among trauma patients.

METHODS

We examined patients admitted for traumatic injuries between 2007 and 2011 in the California State Inpatient Database. Using chi-square tests and multivariate logistic regression models, we determined rates, reasons, locations, and patient factors associated with 30-day readmissions.

RESULTS

Among 252,752 trauma discharges, the overall readmission rate was 7.56%, with 36% of readmissions occurring at a hospital different from the hospital of initial admission. Predictors of readmissions included being discharged against medical advice (odds ratio [OR]: 2.56 [2.35 to 2.76]); Charlson scores ≥2 (OR: 2.00 [1.91 to 2.10]); and age ≥45 years (OR: 1.29 [1.25 to 1.33]). Major reasons for readmissions were musculoskeletal complaints (22.29%), psychiatric conditions (9.40%), and surgical infections (6.69%).

CONCLUSIONS

Health and social vulnerabilities influence readmission among trauma patients, with many readmitted at other hospitals. Targeted interventions among high-risk patients may reduce readmissions after traumatic injuries.

Whatever happens to trauma patients who leave against medical advice?

BACKGROUND

Although trauma patients are frequently discharged against medical advice (AMA), the fate of these patients remains mostly unknown.

METHODS

Patients with traumatic injuries were identified in the California State Inpatient Database, 2007 to 2011. Readmission characteristics of patients discharged AMA were compared with patients discharged home.

RESULTS

There were 203,756 (75.65%) patients discharged home and 4,480 (1.66%) discharged AMA. Compared with those discharged home, patients discharged AMA had significantly higher 30-day readmission rates (17.12% vs 6.75%), rates of multiple readmissions (3.83% vs 1.12%), and likelihood of being readmitted at different hospitals (44.83% vs 33.82%) (all P < .001). The commonest reasons for readmission in patients discharged AMA were psychiatric conditions [adjusted odds ratio: 1.67 (1.21 to 2.27)].

CONCLUSIONS

Discharge AMA is associated with multiple readmissions and higher rates of readmissions at different hospitals. Early identification of vulnerable patients and improved modalities to prevent discharge AMA among these patients may reduce the negative outcomes associated with discharge AMA among trauma patients.

Removal of disinfection by-product precursors by coagulation and an innovative suspended ion exchange process

This investigation aimed to compare the disinfection by-product formation potentials (DBPFPs) of three UK surface waters (1 upland reservoir and 2 lowland rivers) with differing characteristics treated by (a) a full scale conventional process and (b) pilot scale processes using a novel suspended ion exchange (SIX) process and inline coagulation (ILCA) followed by ceramic membrane filtration (CMF). Liquid chromatography-organic carbon detection analysis highlighted clear differences between the organic fractions removed by coagulation and suspended ion exchange. Pretreatments which combined SIX and coagulation resulted in significant reductions in dissolved organic carbon (DOC), UV absorbance (UVA), trihalomethane and haloacetic acid formation potential (THMFP, HAAFP), in comparison with the SIX or coagulation process alone. Further experiments showed that in addition to greater overall DOC removal, the processes also reduced the concentration of brominated DBPs and selectively removed organic compounds with high DBPFP. The SIX/ILCA/CMF process resulted in additional removals of DOC, UVA, THMFP, HAAFP and brominated DBPs of 50, 62, 62, 62% and 47% respectively compared with conventional treatment.

Prophylactic antibiotics in elective hip and knee arthroplasty: an analysis of organisms reported to cause infections and National survey of clinical practice

Objectives

We wanted to investigate regional variations in the organisms reported to be causing peri-prosthetic infections and to report on prophylaxis regimens currently in use across England.

Methods

Analysis of data routinely collected by Public Health England’s (PHE) national surgical site infection database on elective primary hip and knee arthroplasty procedures between April 2010 and March 2013 to investigate regional variations in causative organisms. A separate national survey of 145 hospital Trusts (groups of hospitals under local management) in England routinely performing primary hip and/or knee arthroplasty was carried out by standard email questionnaire.

Results

Analysis of 189 858 elective primary hip and knee arthroplasty procedures and 1116 surgical site infections found statistically significant variations for some causative organism between regions. There was a 100% response rate to the prophylaxis questionnaire that showed substantial variation between individual trust guidelines. A number of regimens currently in use are inconsistent with the best available evidence.

Conclusions

The approach towards antibiotic prophylaxis in elective arthroplasty nationwide reveals substantial variation without clear justification. Only seven causative organisms are responsible for 89% of infections affecting primary hip and knee arthroplasty, which cannot justify such widespread variation between prophylactic antibiotic policies.

Cite this article: Bone Joint Res 2015;4:181–189.