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Baxter S, Johnson AH, Brennan JC, Rana P, Friedmann E, Spirt A, Turcotte JJ, Keblish D. Inpatient or Outpatient: Does Initial Disposition Affect Outcomes in Trimalleolar Ankle Fractures? Cureus 2024; 16:e59586. [PMID: 38826959 PMCID: PMC11144383 DOI: 10.7759/cureus.59586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 06/04/2024] Open
Abstract
Background The repair of trimalleolar fractures can be challenging for surgeons and may be managed as an inpatient or an outpatient. However, it is often unclear whether these patients should be admitted immediately or sent home from the emergency department (ED). This study aims to evaluate trimalleolar fractures treated surgically in the inpatient or outpatient settings to evaluate differences in outcomes for these patients. Methods A retrospective chart review of 223 patients undergoing open reduction internal fixation of a trimalleolar ankle fracture was performed from January 2015 to August 2022. Patients were classified by whether the fixation was performed as an inpatient or outpatient. Outcomes of interest included time from injury to surgery, complications, ED returns, and readmissions within 90 days. Results Inpatients had significantly higher ASA scores, BMI, and rates of comorbidities. Inpatient treatment was associated with faster time to surgery (median 2.0 vs. 9.0 days) and fewer delayed surgeries more than seven days from injury (18.4 vs. 67.9%). There were no differences in complications, 90-day ED returns, readmissions, or reoperation between groups. Conclusions Inpatient admission of patients presenting with trimalleolar ankle fractures resulted in faster time to surgery and fewer surgical delays than outpatient surgery. Despite having more preoperative risk factors, inpatients experienced similar postoperative outcomes as patients discharged home to return for outpatient surgery. Less restrictive admission criteria may improve the patient experience by providing more patients with support and pain control in the hospital setting while decreasing the time to surgery.
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Affiliation(s)
- Samantha Baxter
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
| | | | - Jane C Brennan
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
| | - Parimal Rana
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
| | | | - Adrienne Spirt
- Orthopedic Surgery, Anne Arundel Medical Center, Annapolis, USA
| | - Justin J Turcotte
- Orthopedic and Surgical Research, Anne Arundel Medical Center, Annapolis, USA
| | - David Keblish
- Orthopedic Surgery, Anne Arundel Medical Center, Annapolis, USA
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2
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Yongqiang D, Lin W. Application of multidisciplinary collaboration in the operating room for orthopedic surgery. Asian J Surg 2023; 46:5698-5699. [PMID: 37640642 DOI: 10.1016/j.asjsur.2023.08.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Affiliation(s)
- Dai Yongqiang
- Department of Nursing, Cangzhou Clinical College of Integrated Traditional Chinese and Western Medicine of Hebei Medical University, Cangzhou, 061000, China.
| | - Wu Lin
- Department of Nursing, Cangzhou Clinical College of Integrated Traditional Chinese and Western Medicine of Hebei Medical University, Cangzhou, 061000, China
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Zhou H, Ngune I, Roberts PA, Della PR. Integrated clinical pathways for lower limb orthopaedic surgeries: An updated systematic review. J Clin Nurs 2023; 32:2433-2454. [PMID: 35703679 DOI: 10.1111/jocn.16344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/20/2022] [Accepted: 04/25/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of the study was to comprehensively synthesise the components of integrated clinical pathways (ICPs) and post-operative outcomes of patients undergone total hip and knee arthroplasty (THA & TKA) and hip fracture surgeries. BACKGROUND Previous systematic reviews examined components and effectiveness of ICPs for lower limb joint replacement and hip fracture surgeries. DESIGN AND METHODS An updated systematic review guided by the Whittemore and Knafl (2005) framework. Electronic databases, Ovid MEDLINE, EBSCOhost-CINAHL, the Cochrane Reviews and Trails, EMBASE and PubMed, were searched from 2007 to 31 January 2021. Due to the heterogeneity of the methods and data collection tools of included studies, pooling of the quantitative data was not possible. Therefore, the included studies were synthesised and presented narratively under subthemes of arthroplasty and hip fracture surgeries. The PRISMA checklist for systematic reviews was used. RESULTS Twenty-four studies met selection criteria with 11 examined ICPs for hip fracture and 13 for the THA and TKA. Twenty-one ICPs were reviewed, and 33 components were extracted. The most frequently included components for hip fracture subgroup were 'discharge disposition arrangement' and 'dedicated personnel and resources'. 'Exercise plan' and 'pain management' were for the arthroplasty subgroup. A significant reduction in the length of stay and post-operative complications were associated with the ICPs. Results were mixed for the effectiveness of ICPs in reducing unplanned hospital admissions, mortality rates, post-operative complications and hospital costs. CONCLUSION The number of ICP components varied across studies. This review could not recommend a one size-fits-all ICP that could be adapted for use for patients undergoing hip fracture and joint replacement surgeries. RELEVANCE FOR CLINICAL PRACTICE This review identified research evidence-based components considered as essential for the inclusion in ICP's for hip fracture and arthroplasty surgeries. Further research is suggested to determine the patient experience and healthcare providers' acceptance of ICPs.
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Affiliation(s)
- Huaqiong Zhou
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Irene Ngune
- School of Nursing, Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - Pam A Roberts
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Phillip R Della
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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Tewari P, Sweeney BF, Lemos JL, Shapiro L, Gardner MJ, Morris AM, Baker LC, Harris AS, Kamal RN. Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review. JAMA Netw Open 2022; 5:e2231911. [PMID: 36112373 PMCID: PMC9482052 DOI: 10.1001/jamanetworkopen.2022.31911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors. OBJECTIVE To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS. EVIDENCE REVIEW A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components. FINDINGS Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements. CONCLUSIONS AND RELEVANCE In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.
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Affiliation(s)
- Pariswi Tewari
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Brian F. Sweeney
- Stanford University School of Medicine, Mountain View, California
| | - Jacie L. Lemos
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lauren Shapiro
- Department of Orthopaedic Surgery, University of California, San Francisco
| | - Michael J. Gardner
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Arden M. Morris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Laurence C. Baker
- Department of Health Research and Policy, Stanford University, Stanford, California
| | - Alex S. Harris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Robin N. Kamal
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- VOICES Health Policy Research Center, Stanford University, Stanford, California
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Roberts HJ, Rogers SE, Ward DT, Kandemir U. Protocol-based interdisciplinary co-management for hip fracture care: 3 years of experience at an academic medical center. Arch Orthop Trauma Surg 2022; 142:1491-1497. [PMID: 33651146 DOI: 10.1007/s00402-020-03699-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Interdisciplinary standardized protocols for the care of patients with hip fractures have been shown to improve outcomes. A hip fracture protocol was implemented at our institution to standardize care, focusing on emergency care, pre-operative medical management, operative timing, and geriatrics co-management. The aim of this study was to evaluate the efficacy of this protocol. METHODS We conducted a retrospective review of adult patients admitted to a single tertiary care institution who underwent operative management of a hip fracture between July 2012 and March 2020. Comparison of patient characteristics, hospitalization characteristics, and outcomes were performed between patients admitted before and after protocol implementation in 2017. RESULTS A total of 517 patients treated for hip fracture were identified: 313 before and 204 after protocol implementation. Average age, average Charlson Comorbidity Index, percent female gender, and distribution of hip fracture diagnosis did not vary significantly between groups. There was a significant reduction in time from admission to surgical management, from 37.0 ± 47.7 to 28.5 ± 27.1 h (p = 0.0016), and in the length of hospital stay, from 6.3 ± 6.5 to 5.4 ± 4.0 days (p = 0.0013). The percentage of patients whose surgeries were performed under spinal anesthesia increased from 12.5 to 26.5% (p = 0.016). There was no difference in 90-day readmission rate or mortality at 30 days, 90 days, or 1 year between groups. CONCLUSION With the implementation of an interdisciplinary hip fracture protocol, we observed significant and sustained reductions in time to surgery and hospital length of stay, important metrics in hip fracture management, without increased readmission or mortality. This has implications to minimize health care costs and improve outcomes for our aging population. LEVEL OF EVIDENCE III, therapeutic.
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Affiliation(s)
- Heather J Roberts
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave MU 320-W, San Francisco, CA, 94143, USA
| | - Stephanie E Rogers
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Derek T Ward
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave MU 320-W, San Francisco, CA, 94143, USA
| | - Utku Kandemir
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave MU 320-W, San Francisco, CA, 94143, USA.
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Roberts HJ, Barry J, Nguyen K, Vail T, Kandemir U, Rogers S, Ward D. 2021 John Charnley Award: A protocol-based strategy when using hemiarthroplasty or total hip arthroplasty for femoral neck fractures decreases mortality, length of stay, and complications. Bone Joint J 2021; 103-B:3-8. [PMID: 34192920 DOI: 10.1302/0301-620x.103b7.bjj-2020-2414.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. METHODS In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol. RESULTS A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024). CONCLUSION The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3-8.
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Affiliation(s)
- Heather J Roberts
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey Barry
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kevin Nguyen
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Thomas Vail
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Utku Kandemir
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Stephanie Rogers
- Department of Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
| | - Derek Ward
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
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Murphy RP, Reddin C, Murphy EP, Waters R, Murphy CG, Canavan M. Key Service Improvements After the Introduction of an Integrated Orthogeriatric Service. Geriatr Orthop Surg Rehabil 2019; 10:2151459319893898. [PMID: 31853381 PMCID: PMC6906332 DOI: 10.1177/2151459319893898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/11/2019] [Indexed: 11/20/2022] Open
Abstract
Introduction: Models of orthogeriatric care have been shown to improve functional outcomes for
patients after hip fractures and can improve compliance with best practice guidelines
for hip fracture care. Methods: We evaluated improvements to key performance indicators in hip fracture care after
implementation of a formal orthogeriatric service. Compliance with Irish Hip Fracture
standards of care was reviewed, and additional outcomes such as length of stay, access
to rehabilitation, and discharge destination were evaluated. Results: Improvements were observed in all of the hip fracture standards of care. Mean length of
stay decreased from 19 to 15.5 days (mean difference 3.5 days; P <
.05). A higher proportion of patients were admitted to rehabilitation (16.7% vs 7.9%,
P < .05), and this happened in a timelier fashion (17.8 vs 24.8
days, P < .05). We found that less patients required convalescence
post-hip fracture. Discussion: A standardized approach to integrated post-hip fracture care with orthogeriatrics has
improved standards of care for patients. Conclusion: Introduction of orthogeriatric services has resulted in meaningful improvements in
clinical outcomes for older people with hip fractures.
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Affiliation(s)
- R P Murphy
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Galway, Ireland
| | - C Reddin
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Galway, Ireland
| | - E P Murphy
- Department of Orthopedics and Trauma, University Hospital Galway, Galway, Ireland
| | - R Waters
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Galway, Ireland
| | - C G Murphy
- Department of Orthopedics and Trauma, University Hospital Galway, Galway, Ireland
| | - M Canavan
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Galway, Ireland
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