Incidence and root causes of delays in emergency orthopaedic procedures: a single-centre experience of 36,017 consecutive cases over seven years

Reducing trauma theatre list delays through improved communication between orthopaedic teams and radiographers: A quality improvement project

AIMS

This quality improvement project was performed to improve delays in starting our trauma theatre lists by implementing measures to improve effective communication between the surgical team and the theatre radiographers.

MATERIALS AND METHODS

This was a quality improvement project performed prospectively for 30 orthopaedic trauma lists over two cycles. Only lists requiring fluoroscopy guidance (image intensifier) for the first case were included. Interventions included improvements in use of theatre booking forms with fluoroscopy request checkboxes, dedication of an allocated radiographer for the trauma lists, timely communication of the finalised theatre list order and radiographers participating in the team briefing.

RESULTS

Improvements in the timing of fluoroscopy requests and prompt arrival of the radiographer to the theatre were achieved. Furthermore, there was elimination of radiographer-related surgical start time delays following implementation of the interventions. Nevertheless, only minimal improvements were achieved in the participation of the radiographers for the trauma theatre team briefings.

CONCLUSION

Although reasons for trauma theatre delays are multifactorial, this quality improvement project has demonstrated that these delays can be reduced through improved communication between radiographers and the orthopaedic team. This is especially important for theatre cases requiring the use of an image intensifier.

Ambulation Distance Within 72 Hours after Surgical Management Is a Predictor of 90-Day Ambulatory Capacity in Elderly Patients with Hip Fracture

INTRODUCTION

The inability to mobilize after surgical intervention for hip fractures in the elderly is established as a risk factor for greater morbidity and mortality. Previous studies have evaluated the association between the timing and distance of ambulation in the postoperative acute care phase with postoperative complications. The purpose of this study was to evaluate the association between ambulatory distance in the acute postoperative setting and ambulatory capacity at 3 months.

METHODS

Patients aged 65 and older who were ambulatory at baseline and underwent surgical intervention for hip fractures from 2014 to 2019 were retrospectively reviewed. Consistent with previous literature, patients were divided into two groups: those who were able to ambulate 5 feet within 72 hours after surgical fixation (early ambulatory) and those who were not (minimally ambulatory).

RESULTS

One hundred seventy patients (84 early ambulatory and 86 minimally ambulatory) were available for analysis. Using a multivariable ordinal logistic regression model, variables found to be statistically significant predictors of ambulatory status at 3 months were the ability to ambulate five feet in 72 hours (P < 0.0001), ambulatory distance at discharge (P = 0.012), and time from presentation to surgery (P = 0.039). Patients who were able to ambulate 5 feet within 72 hours had 9 times the odds of being independent ambulators rather than a lower ambulatory class (cane, walker, and nonambulatory). Pertrochanteric fractures were less likely than femoral neck fractures to independently ambulate at 3 months (17.2% vs. 42.3%; P = 0.0006).

DISCUSSION

Ambulating 5 feet within 72 hours after hip fracture surgery is associated with an increased likelihood of independent ambulation at 3 months postoperatively. This simple and clear goal may be used to help enhance postoperative mobility and independence while providing a metric to guide therapy and help counsel patients and families.

Hospital Diabetes Meeting 2022

The annual Virtual Hospital Diabetes Meeting was hosted by Diabetes Technology Society on April 1 and April 2, 2022. This meeting brought together experts in diabetes technology to discuss various new developments in the field of managing diabetes in hospitalized patients. Meeting topics included (1) digital health and the hospital, (2) blood glucose targets, (3) software for inpatient diabetes, (4) surgery, (5) transitions, (6) coronavirus disease and diabetes in the hospital, (7) drugs for diabetes, (8) continuous glucose monitoring, (9) quality improvement, (10) diabetes care and educatinon, and (11) uniting people, process, and technology to achieve optimal glycemic management. This meeting covered new technology that will enable better care of people with diabetes if they are hospitalized.

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

Introduction

Operation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines.

Methods

This was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes.

Results

Our documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05).

Conclusion

The use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.

Developing a conceptual model for studying various points of delays and underlying factors in the emergency healthcare system

To review various literature related to emergency healthcarerelated delays and synthesize a conceptual framework for future research. Critical Interpretative Synthesis is employed to analyze and develop themes from selected articles. A total of 25 articles were selected for analysis after the careful selection process. Diseases including acute heart disease, stroke, pneumonia, infections, and gastrointestinal disorders were included. During analysis, three major phases of delays emerged: pre-hospital delay, inhospital delay, and ambulance off-load delay. Various factors, including socioeconomic factors, health system factors, organizational level factors, etc., are related to delays in emergency care settings. The model evolved from this literature analysis is similar to the 3 delays model. This review identified three significant delay segments related to emergency health care management.

A graphical assessment of emergency surgical list efficiency to determine operating theatre capacity needs

BACKGROUND

Unlike elective lists, full utilisation of an emergency list is undesirable, as it could prevent patient access. Conversely, a perpetually empty emergency theatre is resource wasteful. Separately, measuring delayed access to emergency surgery from time of booking the urgent case is relevant, and could reflect either deficiencies in patient preparation or be because of an occupied (over-utilised) emergency theatre.

METHODS

We developed a graphical method recognising these two separate but linked elements of performance: (i) delayed access to surgery and (ii) operating theatre utilisation. In a plot of one against the other, data fell into one of four quadrants, with delays associated with high utilisation signifying the need for more emergency capacity. However, delays associated with low utilisation reflect process deficiencies in the emergency patient pathway. We applied this analysis to 73 consecutive lists (>300 cases) from two UK hospitals.

RESULTS

Although both hospitals experienced similar rates of delayed surgery (21.8% vs 21.0%; P=0.872), in one hospital 83% of these were associated with low emergency theatre utilisation (suggesting predominant process deficiencies), whereas in the other 73% were associated with high utilisation (suggesting capacity deficiency; P<0.0001). Increasing emergency capacity in the latter resulted in shorter delays (just 6.7% cases excessively delayed; P<0.0001 for effect of intervention).

CONCLUSIONS

This simple graphical analysis indicates whether more emergency capacity is necessary. We discuss potential applications in managing emergency surgery theatres.

Delayed and cancelled orthopaedic surgery; are there solutions to reduce the complex set of problems? A systematic literature review

BACKGROUND

Unexpected cancellations of, and delays to, orthopaedic surgery have adverse effects, with a negative impact on hospital performance and undesirable patient outcomes. As cancellations and delays are common, finding measures to prevent them is a matter of urgency.

METHODS

The present systematic review conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and the Cochrane Handbook. Peer-reviewed studies reporting on cancellations or delays in patients requiring emergency orthopaedic or planned orthopaedic surgery that compared care action/intervention with no action or traditional care were included. The Grading of Recommendations Assessment, Development and Evaluation used to assess the quality of evidence of the results from the included studies. The objective of the present study was systematically to search and review the literature for qualitative evidence of factors that might reduce cancellations of and delays to orthopaedic surgical procedures.

RESULTS

The electronic search yielded 1209 studies and eight articles were included in the performed quality assessment. The heterogeneity of the studies and the lack of calculations and statistics in the studies resulted in no meta-analysis. The result of the quality assessment indicated that the evidence ranked from low to very low across the different outcomes. The main limiting factor, which was the reason for a decrease in quality in some outcomes, was the study designs, which were non-randomised control or retrospective approach. The interventions in the included studies could help to support a reduction in the risk of cancelled and delayed orthopaedic procedures.

CONCLUSION

This systematic literature review has revealed important evidence to help reduce the risk of cancelled and delayed orthopaedic procedures associated with a variety of care action exposures. They include a fast-track pathway, pre-operative guidelines and telephone contact with patients prior to surgery, as well as careful consideration of additional pre-operative tests.

A sense of being rejected: Patients' lived experiences of cancelled knee or hip replacement surgery

BACKGROUND

Growing care queues, reduced access to care and cancelled surgery are realities for some patients being treated with total hip or knee replacement surgery in Sweden. Most of the patients on the waiting lists have experienced pain and limited motion for a varying period of time, with a negative effect on their everyday lives. Overbooked surgical schedules are already contributing to the lengthy waiting times, but, with the addition of cancellations, longer waiting times will increase still further and may affect patients' well-being.

METHODS

In the present study, we aimed to illuminate the experience of having planned surgery cancelled, based on narratives from 10 participants. The interview transcriptions were analysed using a phenomenological hermeneutic approach.

RESULTS

The comprehensive analyses revealed that the participants described the agony of being deselected and the additional impression of being excluded. Metaphors of being damaged and feeling physical pain were used and the interpretations referred to the cancellations as unpleasant. Additionally, the important relationship and the trust between the health workers and the patient were negatively affected by the cancellation.

CONCLUSION

After the cancellation, the participants expressed being vulnerable and from their perspective the cancelled surgery affected them deeply; in fact, much more than the healthcare workers appeared to understand. Therefore, information around the cancellation must be given respectfully and with dignity, in a dialogue between the patient and the healthcare workers. Taken together, to enable an opportunity to be involved in the continued care. The cancellations should be seen as an interruption, in which the patients' chance of living a pain-free, active life is postponed.

Canceled Total Joint Arthroplasty: Who, What, When, and Why?

BACKGROUND

Unexpected cancelation of scheduled total joint arthroplasty (TJA) procedures creates patient distress and disruption for the clinical team. The purpose of this study is to identify the etiology and fate of cancelations for scheduled TJAs.

METHODS

A consecutive series of 11,670 patients at a single institution from 2013 to 2017 was reviewed in March 2020. All patients who were scheduled for a primary total hip arthroplasty or total knee arthroplasty and subsequently canceled were identified. The etiology of cancelation and time to rescheduling were recorded.

RESULTS

Of the 505 (4.3%) canceled patients, 209 (42%) were due to medical reasons. Three hundred ninety-one patients (77%) eventually underwent their procedure at a mean delay of 165 days (19-1908). Only 53 (25%) patients canceled for a medical reason underwent further diagnostic or therapeutic intervention for their medical condition. When compared to patient-driven cancelations, those canceled for medical reasons had a higher mean Charlson Comorbidity Index (0.82 vs 0.39, P < .001), were canceled closer to the scheduled surgery date (8.55 vs 18.1 days, P < .001), and were more likely to eventually undergo surgery (86% vs 73%, P = .004).

CONCLUSION

Canceled elective TJA surgeries are most often due to a medical concern, however only a minority of these patients undergo intervention for that medical condition. To minimize the risk of cancelation, healthcare providers may consider early referral of medically complex patients to the patient's primary care physician. After cancelation, patients should have a clearly defined path to return to the operative schedule to prevent further delays.

Surgery cancellation: A scoping review of patients' experiences

AIMS AND OBJECTIVES

To review the literature on patients' experiences of surgery cancellation to gain knowledge of nursing care needs and identify gaps in evidence.

BACKGROUND

Surgery cancellations are an ongoing challenge in healthcare systems with negative impacts on healthcare costs, hospital staff and patients. Most research addresses the reasons for cancellation and implementation of preventive interventions, but limited knowledge exists about patients' experiences of cancellation.

DESIGN

The scoping review was undertaken using the methodology recommended by the Joanna Briggs Institute for Scoping Reviews and the Reporting Cheklist for Scoping Reviews (PRISMA-ScR).

METHODS

A systematic search was conducted by two independent researchers in Cochrane Library, CINAHL, PubMed and PsycINFO. A forward and backward citation search was performed in Scopus, and references in relevant studies were explored. The tool Covidence was applied to select, compare and discuss relevant articles. The Mixed Methods Appraisal Tool was used for critical appraisal.

RESULTS

Surgery cancellation is emotionally harmful with negative effects on patients. Four themes were identified: 'Initial reactions to cancellation', 'Reactions during a new waiting period at home and during readmission to hospital', 'Information about cancellation' and 'The experience of new practical arrangements'. Patients whose surgery was cancelled experienced initial feelings such as anger, rejection and anxiety and physical/psychosomatic symptoms in the extended waiting period. Patients prefered early sufficient information about cancellation from the surgeon. The practical arrangements were stressfull for the patients.

CONCLUSION

Nursing care and identification of vulnerable patients are essential to prevent negative effects in the extended waiting period. Provision of timely, sufficient and professional information about cancellation from the surgeon is important. Further research assessing consequences of cancellation is needed.

RELEVANCE TO CLINICAL PRACTICE

Patients would benefit if hospitals find systems to minimise cancellation, and healthcare professionals could systematically develop professional supportive interventions tailored to patients' individual needs.

Global prevalence and reasons for case cancellation on the intended day of surgery: A systematic review and meta-analysis

BACKGROUND

Cancellation of operation on the intended day of surgery affects the efficiency of Operation Room which incurs a significant financial loss for the patient, hospital, and health care cost of a country at large. This systematic and Meta-Analysis was intended to provide evidence on the global prevalence and determinants of case cancellation on the intended day of surgery.

METHODS

A comprehensive search was conducted in PubMed/Medline; Science direct and LILACS from January 2010 to May 2020 without language restriction. The Heterogeneity among the included studies was checked with forest plot, χ2 test, I2 test, and the p-values. All observational studies reporting prevalence and determinants were included.

RESULTS

A total of 1207 articles were identified from different databases with an initial search. Fort-eight articles were selected for evaluation after the successive screening. Thirty-three Articles with 306,635 participants were included. The Meta-Analysis revealed that the global prevalence of case cancellation on the intended day of surgery was 18% (95% CI: 16 to 20). The Meta-Analysis also showed that lack of operation theatre facility accounted for the major reason for cancellation followed by no attendant and change in medical condition.

CONCLUSION

The meta-analysis revealed that the prevalence of case cancellation was very high in low and middle-income countries and the majorities were avoidable which entails rigorous activities on operation theatre facilities, preoperative evaluation and preparation, patient and health care provider communications.

REGISTRATION

This Systematic Review and Meta-Analysis was registered in a research registry (researchregistry5746) available at https://www.researchregistry.com/browse-the-registry#home/.