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Witkowski C, Kimmel L, Edwards E, Cosic F. Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients. AUST HEALTH REV 2021; 46:204-209. [PMID: 34749881 DOI: 10.1071/ah21112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/15/2021] [Indexed: 11/23/2022]
Abstract
ObjectiveThe medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR).MethodsA review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery.ResultsIn all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P = 0.032).ConclusionThe EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record.What is known about the topic?Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record.What does this paper add?Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement.What are the implications for practitioners?The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.
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Affiliation(s)
- Chris Witkowski
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Vic., Australia
| | - Lara Kimmel
- Department of Physiotherapy, Alfred Hospital, Melbourne, Vic., Australia
| | - Elton Edwards
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Vic., Australia
| | - Filip Cosic
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Vic., Australia
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Zibis A, Varitimidis S, Fyllos A, Raoulis V, Karachalios T, Malizos K. An observational study of complications in patients with established multiple compartments syndrome of the leg. Arch Orthop Trauma Surg 2021; 141:253-259. [PMID: 32474698 DOI: 10.1007/s00402-020-03488-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Established multiple compartments syndrome of the leg (EMCSL) is defined as permanent ischemic lesions of muscles and nerves of the compartment, leading to multiple muscle contractions, muscle weakness and wasting and reduced limb sensation. The leg is seriously affected and the patient is unable to return to prior activities. The objective of this research is to quantify long-term consequences, morbidity and socioeconomic impact of established multiple compartments syndrome of the leg MATERIALS AND METHODS: 28 patients suffering from complications from EMCSL were referred to our clinic for secondary management between January 2012 and April 2016 and were followed for mean 41.4 months. Reconstructive procedures to address multiple conditions following established tibia compartment syndrome were performed. The number of reconstructive procedures, days of hospitalization, relationship, educational and employment status per patient were recorded. Preop and postop SF-12 score at final follow-up was documented for the 21 patients who were operated on. RESULTS A median of three reconstructive procedures was performed per patient for 21 patients. The hospitalization period ranged from 6 to 365 days, with a mean period of 47.5 days (SD 71.4). At the final follow-up, 19 patients had lost their occupation, 3 patients had returned to lighter manual labor, 5 patients had lost two school years, and 1 patient had abandoned school. At the time of injury, 24 patients were single. At final follow-up, 19 of these patients, with a mean age of 38.5 years, were still single. Preoperative and postoperative (at final follow-up) physical and mental components of the SF-12 score had a statistically significant difference (p < 0.001), but final values were not normal. CONCLUSIONS Despite advancements in surgical reconstructive intervention, patients with established compartment tibia syndrome experience permanent grave residual disability with personal and social implications.
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Affiliation(s)
- Aristeidis Zibis
- Department of Anatomy, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Sokratis Varitimidis
- Department of Orthopaedics and Musculoskeletal Trauma, Faculty of Medicine, University of Thessaly, Larisa, Greece. .,Department of Orthopaedic Surgery, Faculty of Medicine, University of Thessaly, 3 Panepistimiou St, Biopolis, 41110, Larissa, Greece.
| | - Apostolos Fyllos
- Department of Orthopaedics and Musculoskeletal Trauma, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Vasilios Raoulis
- Department of Orthopaedics and Musculoskeletal Trauma, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Theophilos Karachalios
- Department of Orthopaedics and Musculoskeletal Trauma, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Konstantinos Malizos
- Department of Orthopaedics and Musculoskeletal Trauma, Faculty of Medicine, University of Thessaly, Larisa, Greece
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A systematic review of the effect of regional anesthesia on diagnosis and management of acute compartment syndrome in long bone fractures. Eur J Trauma Emerg Surg 2020; 46:1281-1290. [DOI: 10.1007/s00068-020-01320-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/04/2020] [Indexed: 01/09/2023]
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Lutter C, Schöffl V, Hotfiel T, Simon M, Maffulli N. Compartment Syndrome of the Foot: An Evidence-Based Review. J Foot Ankle Surg 2019; 58:632-640. [PMID: 31256897 DOI: 10.1053/j.jfas.2018.12.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Indexed: 02/03/2023]
Abstract
Compartment syndrome of the foot (CSF) is a surgical emergency, with high risk of morbidity and poor outcome, including persistent neurologic deficits or amputation. Uncertainty remains regarding surgical approaches, pressure monitoring values, and the extent of surgical treatment. This review provides a summary of the current knowledge and reports evidence-based diagnostic and therapeutic management options for CSF. Articles describing CSF were identified from MEDLINE, PubMed, and Cochrane databases up until February 2018. Experimental and original articles, systematic and nonsystematic reviews, case reports, and book chapters, independent of their level of evidence, were included. Crush injuries are the leading cause of CSF, but CSF can present after fractures of the tarsal or metatarsal bones and dislocations of the Lisfranc or Chopart joints. CSF is often associated with persistent neurologic deficits, claw toes, amputations, and skin healing problems. Diagnosis is made after accurate clinical evaluation combined with intracompartmental pressure monitoring. A threshold value of <20 mmHg difference between the diastolic blood pressure and the intracompartmental pressure is considered diagnostic. Management consists of surgery, whereby 2 dorsal incisions are combined with a medioplantar incision to the calcaneal compartment. The calcaneal compartment can serve as an "indicator compartment," as the highest-pressure values can regularly be measured within this compartment. Appropriately powered studies of CSF are necessary to further evaluate and compare diagnostic and therapeutic options.
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Affiliation(s)
- Christoph Lutter
- Orthopedic Surgeon, Department of Orthopedics, University Medical Center, Rostock, Germany; Orthopedic Surgeon, Department of Sports Orthopedics, Sports Medicine, Sports Traumatology, Klinikum Bamberg, Germany
| | - Volker Schöffl
- Professor of Trauma and Orthopaedic Surgery, Department of Sports Orthopedics, Sports Medicine, Sports Traumatology, Klinikum Bamberg, Germany; Professor of Trauma and Orthopaedic Surgery, Department of Trauma and Orthopedic Surgery, Friedrich Alexander University Erlangen-Nuremberg, Germany
| | - Thilo Hotfiel
- Orthopedic Surgeon, Department of Orthopedic Surgery, Friedrich Alexander University Erlangen-Nuremberg, Germany; Orthopedic Surgeon, Department of Orthopedic, Trauma and Hand Surgery, Klinikum Osnabrück, Germany
| | - Michael Simon
- Orthopedic Surgeon, Department of Sports Orthopedics, Sports Medicine, Sports Traumatology, Klinikum Bamberg, Germany
| | - Nicola Maffulli
- Professor of Trauma and Orthopaedic Surgery and Consultant Trauma and Orthopaedic Surgeon, Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Italy; Professor of Trauma and Orthopaedic Surgery and Consultant Trauma and Orthopaedic Surgeon, Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, London, UK; Professor of Trauma and Orthopaedic Surgery and Consultant Trauma and Orthopaedic Surgeon, Institute of Science and Technology in Medicine, Keele University School of Medicine, UK.
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Cosic F, Kimmel L, Edwards E. Medical record keeping and system performance in orthopaedic trauma patients. AUST HEALTH REV 2018; 40:619-624. [PMID: 26885685 DOI: 10.1071/ah15160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/15/2015] [Indexed: 11/23/2022]
Abstract
Objective The medical record is critical for documentation and communication between healthcare professionals. The aim of the present study was to evaluate important aspects of the orthopaedic medical record and system performance to determine whether any deficiencies exist in these areas. Methods Review of 200 medical records of surgically treated traumatic lower limb injury patients was undertaken. The operative report, discharge summary and first and second outpatient reviews were evaluated. Results In all cases, an operative report was completed by a senior surgeon. Weight-bearing status was adequately documented in 91% of reports. Discharge summaries were completed for 82.5% of admissions, with 87.3% of these having instructions reflective of those in the operative report. Of first and second outpatient reviews, 69% and 73%, respectively, occurred within 1 week of the requested time. Previously documented management plans were changed in 30% of reviews. At 6-months post-operatively, 42% of patients had been reviewed by a member of their operating team. Discussion Orthopaedic medical record documentation remains an area for improvement. In addition, hospital out-patient systems perform suboptimally and may affect patient outcomes. What is known about the topic? Medical records are an essential tool in modern medical practice. Despite the importance of comprehensive documentation in the medical record, numerous examples of poor documentation have been demonstrated, including substandard documentation during consultant ward rounds by junior doctors leading to a breakdown in healthcare professional communication and potential patient mismanagement. Further inadequacies of medical record documentation have been demonstrated in surgical discharge notes, with complete and correct documentation reported to be as low as 65%. What does this paper add? Standards of patient care should be constantly monitored and deficiencies identified in order to implement a remedy and close the quality loop. The present study has highlighted that the standard of orthopaedic trauma medical record keeping at an Australian Level 1 trauma centre is below what is expected and several key areas of documentation require improvement. This paper further evaluates the system performance of the out-patient system, an area where, to the authors knowledge, there is no previous work published. The findings show that the performance was below what is expected for surgical review, with many patients failing to be reviewed by their operating surgeon. What are the implications for practitioners? The present study shows that there is a poor level of documentation and a standard of out-patient review below what is expected. The implications of these findings will be to highlight current deficiencies to practitioners and promote change in current practice to improve the quality of medical record documentation among medical staff. Further, the findings of poor system performance will promote change in the current system of delivering out-patient care to patients.
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Affiliation(s)
- Filip Cosic
- Department of Orthopaedic Surgery, The Alfred, P.O. Box 315, Prahran, Vic. 3181, Australia. Email
| | - Lara Kimmel
- Department of Physiotherapy, The Alfred, P.O. Box 315, Prahran, Vic. 3181, Australia. Email
| | - Elton Edwards
- Department of Orthopaedic Surgery, The Alfred, P.O. Box 315, Prahran, Vic. 3181, Australia. Email
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Sellei RM, Andruszkow H, Weber C, Damen TO, Pape HC, Hildebrand F. [Diagnostics and treatment decisions in acute compartment syndrome. Results of a survey in German hospitals]. Unfallchirurg 2017; 119:125-32. [PMID: 25015736 DOI: 10.1007/s00113-014-2609-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The presented survey was intended to evaluate whether a standardization of diagnostics and therapy for acute compartment syndrome has been achieved. MATERIALS AND METHODS University hospitals, academic teaching hospitals, and county hospitals in Germany were included. RESULTS A total of 38% (n=120) of all contacted hospitals participated in this study with questions mainly answered by consulting physicians (68%). In general the importance of the clinical examination was considered as being more important than other diagnostic measures. In cases where further diagnostics were necessary, the intramuscular pressure measurement was used most frequently. Of the participants 50% performed surgical fasciotomy based on the clinical examination in combination with the intramuscular pressure measurement; however, there were considerable differences between the participating hospitals with respect to the anatomical position of intramuscular measurements, the limiting value of the intramuscular pressure and the surgical technique for performing fasciotomy. CONCLUSION According to the presented analysis the diagnosis and indications for surgical treatment in patients developing an acute compartment syndrome do not seem to be sufficiently clarified. The establishment of unified treatment guidelines could help to reduce the number of delayed diagnoses of compartment syndrome.
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Affiliation(s)
- R M Sellei
- Klinik für Unfallchirurgie und Orthopädische Chirurgie, Sana Klinikum Offenbach, Starkenburgring 66, 63069, Offenbach, Deutschland. .,Klinik für Unfall- und Wiederherstellungschirurgie , Universitätsklinikum Aachen, Aachen, Deutschland.
| | - H Andruszkow
- Klinik für Unfall- und Wiederherstellungschirurgie , Universitätsklinikum Aachen, Aachen, Deutschland
| | - C Weber
- Klinik für Unfall- und Wiederherstellungschirurgie , Universitätsklinikum Aachen, Aachen, Deutschland
| | - T O Damen
- Klinik für Unfall- und Wiederherstellungschirurgie , Universitätsklinikum Aachen, Aachen, Deutschland
| | - H-C Pape
- Klinik für Unfall- und Wiederherstellungschirurgie , Universitätsklinikum Aachen, Aachen, Deutschland
| | - F Hildebrand
- Klinik für Unfall- und Wiederherstellungschirurgie , Universitätsklinikum Aachen, Aachen, Deutschland
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Driscoll EBS, Maleki AH, Jahromi L, Hermecz BN, Nelson LE, Vetter IL, Evenhuis S, Riesenberg LA. Regional anesthesia or patient-controlled analgesia and compartment syndrome in orthopedic surgical procedures: a systematic review. Local Reg Anesth 2016; 9:65-81. [PMID: 27785097 PMCID: PMC5063486 DOI: 10.2147/lra.s109659] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A systematic review of the literature on the use of regional anesthesia (RA) and patient-controlled analgesia (PCA) was conducted in patients who require orthopedic extremity procedures to determine whether either analgesic technique contributes to a delayed diagnosis of compartment syndrome (CS). A total of 34 relevant articles (28 case reports and six research articles) were identified. Of all case report articles published after 2009, the majority (75%) concluded that RA does not put the patient at an increased risk of a delayed diagnosis of CS. Of these, only two relevant prospective research studies focusing on RA or PCA and their relationship to CS were identified. Neither study resulted in any cases of CS. However, both had relatively small sample sizes. Given the lack of evidence identified in this systematic review, prospective studies or large-scale retrospective data reviews are needed to more strongly advocate the use of one modality of analgesia over the other in this patient population.
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Affiliation(s)
| | - Ana Hosseinzadeh Maleki
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Leila Jahromi
- Department of Biology, Georgia State University, Atlanta, GA
| | - Brittany Nelson Hermecz
- Department of Diagnostic Radiology, University of Alabama at Birmingham School of Medicine, Birmingham
| | | | - Imelda L Vetter
- School of Health Professions, Lister Hill Library, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Spencer Evenhuis
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Lee Ann Riesenberg
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
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Thomas A, Kimber C, Bramwell D, Jaarsma R. Improving clinical examination in acute tibial fractures by enhancing visual cues: the case for always 'cutting back' a tibial back-slab and marking the dorsalis pedis pulse. Int J Orthop Trauma Nurs 2016; 22:36-43. [PMID: 27236718 DOI: 10.1016/j.ijotn.2015.11.002] [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: 11/14/2014] [Revised: 11/25/2015] [Accepted: 11/29/2015] [Indexed: 11/19/2022]
Abstract
Look, feel, move is a simple and widely taught sequence to be followed when undertaking a clinical examination in orthopaedics (Maher et al., 1994; McRae, 1999; Solomon et al., 2010). The splinting of an acute tibial fracture with a posterior back-slab is also common practice; with the most commonly taught design involving covering the dorsum of the foot with bandaging (Charnley, 1950; Maher et al., 1994; McRae, 1989). We investigated the effect of the visual cues provided by exposing the dorsum of the foot and marking the dorsalis pedis pulse. We used a clinical simulation in which we compared the quality of the recorded clinical examination undertaken by 30 nurses. The nurses were randomly assigned to assess a patient with either a traditional back-slab or one in which the dorsal bandaging had been cut back and the dorsalis pedis pulse marked. We found that the quality of the recorded clinical examination was significantly better in the cut-back group. Previous studies have shown that the cut-back would not alter the effectiveness of the back-slab as a splint (Zagorski et al., 1993). We conclude that all tibial back-slabs should have the bandaging on the dorsum of the foot cut back and the location of the dorsalis pedis pulse marked. This simple adaptation will improve the subsequent clinical examinations undertaken and recorded without reducing the back-slab's effectiveness as a splint.
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Affiliation(s)
- Alasdair Thomas
- Orthopaedic Department, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia.
| | - Cheryl Kimber
- Orthopaedic Department, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia
| | - Donald Bramwell
- International Musculoskeletal Research Institute, Department of Orthopaedic Surgery, Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Ruurd Jaarsma
- Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia
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Do one-time intracompartmental pressure measurements have a high false-positive rate in diagnosing compartment syndrome? J Trauma Acute Care Surg 2014; 76:479-83. [DOI: 10.1097/ta.0b013e3182aaa63e] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bauer EC, Koch N, Janni W, Bender HG, Fleisch MC. Compartment syndrome after gynecologic operations: evidence from case reports and reviews. Eur J Obstet Gynecol Reprod Biol 2014; 173:7-12. [DOI: 10.1016/j.ejogrb.2013.10.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 10/10/2013] [Accepted: 10/31/2013] [Indexed: 11/26/2022]
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Disaster nephrology: crush injury and beyond. Kidney Int 2013; 85:1049-57. [PMID: 24107850 DOI: 10.1038/ki.2013.392] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 07/20/2013] [Accepted: 07/25/2013] [Indexed: 01/09/2023]
Abstract
Disasters result in a substantial number of renal challenges, either by the creation of crush injury in victims trapped in collapsed buildings or by the destruction of existing dialysis facilities, leaving chronic dialysis patients without access to their dialysis units, medications, or medical care. Over the past two decades, lessons have been learned from the response to a number of major natural disasters that have impacted significantly on crush-related acute kidney injury and chronic dialysis patients. In this paper we review the pathophysiology and treatment of the crush syndrome, as summarized in recent clinical recommendations for the management of crush syndrome. The importance of early fluid resuscitation in preventing acute kidney injury is stressed, logistic difficulties in disaster conditions are described, and the need for an implementation of a renal disaster relief preparedness program is underlined. The role of the Renal Disaster Relief Task Force in providing emergency disaster relief and the logistical support required is outlined. In addition, the importance of detailed education of chronic dialysis patients and renal unit staff in the advance planning for such disasters and the impact of displacement by disasters of chronic dialysis patients are discussed.
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Improving physician clinical documentation quality: evaluating two self-efficacy-based training programs. Health Care Manage Rev 2013; 38:29-39. [PMID: 22472728 DOI: 10.1097/hmr.0b013e31824c4c61] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical documentation is critical to health care quality and cost. The generally poor quality of such documentation has been well recognized, yet medical students, residents, and physicians receive little or no training in it. When clinical documentation quality (CDQ) training for residents and/or physicians is provided, it excludes key constructs of self-efficacy: vicarious learning (e.g., peer demonstration) and mastery (i.e., practice). CDQ training that incorporates these key self-efficacy constructs is more resource intensive. If such training could be shown to be more effective at enhancing clinician performance, it would support the investment of the additional resources required by health care systems and residency training programs. PURPOSES The aim of this study was to test the impact of CDQ training on clinician self-efficacy and performance and the relative efficacy of intervention designs employing two versus all four self-efficacy constructs. METHODOLOGY/APPROACH Ninety-one internal medicine residents at a major academic medical center in the northeastern United States were assigned to one of two self-efficacy-based training groups or a control group, with CDQ and clinical documentation self-efficacy measured before and after the interventions. A structural equation model (AMOS) allowed for testing the six hypotheses in the context of the whole study, and findings were cross-validated using traditional regression. FINDINGS Although both interventions increased CDQ, the training designed to include all four self-efficacy constructs had a significantly greater impact on improving CDQ. It also increased self-efficacy. PRACTICE IMPLICATIONS CDQ may be significantly improved and sustained by (a) training physicians in clinical documentation and (b) employing all four self-efficacy constructs in such training designs.
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Perry MD, Manoli A. Reconstruction of the foot after leg or foot compartment syndrome. Crit Care Nurs Clin North Am 2012; 24:311-22. [PMID: 22548865 DOI: 10.1016/j.ccell.2012.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Mark D Perry
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390-8883, USA.
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Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res 2010; 468:940-50. [PMID: 19472025 PMCID: PMC2835588 DOI: 10.1007/s11999-009-0891-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Accepted: 04/30/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Compartment syndrome of the lower leg or foot, a severe complication with a low incidence, is mostly caused by high-energy deceleration trauma. The diagnosis is based on clinical examination and intracompartmental pressure measurement. The most sensitive clinical symptom of compartment syndrome is severe pain. Clinical findings must be documented carefully. A fasciotomy should be performed when the difference between compartment pressure and diastolic blood pressure is less than 30 mm Hg or when clinical symptoms are obvious. Once the diagnosis is made, immediate fasciotomy of all compartments is required. Fasciotomy of the lower leg can be performed either by one lateral incision or by medial and lateral incisions. The compartment syndrome of the foot requires thorough examination of all compartments with special focus on the calcaneal compartment. Depending on the injury, clinical examination, and compartment pressure, fasciotomy is recommended via a dorsal and/or medial plantar approach. Surgical management does not eliminate the risk of developing nerve and muscle dysfunction. When left untreated, poor outcomes with contractures, toe deformities, paralysis, and sensory neuropathy can be expected. In severe cases, amputation may be necessary. LEVEL OF EVIDENCE Level III. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael Frink
- Department of Traumatology, Hannover Medical School, Hannover, Germany
| | - Frank Hildebrand
- Department of Traumatology, Hannover Medical School, Hannover, Germany
| | - Christian Krettek
- Department of Traumatology, Hannover Medical School, Hannover, Germany
| | - Jurgen Brand
- Praxisklinik Uelzen, Celler Str. 26A, 29525 Uelzen, Germany
| | - Stefan Hankemeier
- Department of Traumatology, Hannover Medical School, Hannover, Germany
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Variation in Diagnosis of Compartment Syndrome by Surgeons Treating Tibial Shaft Fractures. ACTA ACUST UNITED AC 2009; 67:735-41. [DOI: 10.1097/ta.0b013e3181a74613] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kashuk JL, Moore EE, Pinski S, Johnson JL, Moore JB, Morgan S, Cothren CC, Smith W. Lower extremity compartment syndrome in the acute care surgery paradigm: safety lessons learned. Patient Saf Surg 2009; 3:11. [PMID: 19527510 PMCID: PMC2704180 DOI: 10.1186/1754-9493-3-11] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 06/15/2009] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Prompt diagnosis and decompression of acute lower extremity compartment syndrome (LECS) in the multisystem injured patient is essential to avoid the devastating complications of progressive tissue necrosis and amputation. Despite collaborative trauma and orthopedic management of these difficult cases, significant delays in diagnosis and treatment occur. Periodic system review of our trauma and orthopedic data for complications of LECS led us to hypothesize that delayed diagnosis and limb loss were potentially preventable events in our trauma center. SETTING Academic level 1 trauma center. METHODS We performed a prospective review of our trauma registry for all cases of LECS over a 7 year period (2/98-10/2005). Variables reviewed included demographics, injury patterns, tissue necrosis, amputation and mortality. RESULTS Eighty-three (10 female, 73 male) cases were reviewed. Mean age = 33.3 years (range 1-78). Mean ISS = 19.4, GCS = 12.5. Five (6.0%) had amputations; 7 (8.4%) died. Fractures occurred in 68.7% (n = 57), and vascular injuries were present in 38.6% (n = 32). In 7 patients (8.4%), a delayed compartment release resulted in muscle necrosis requiring multiple debridements, subsequent wound closure problems, and long term disability. Of note, none of these patients had prior compartment pressure measurements. Furthermore, 6 patients (7%) had superficial peroneal nerve transections as complications of their fasciotomy. CONCLUSION In the multisystem injured patient, LECS remains a major diagnostic and treatment challenge with significant risks of limb loss as well as complications from decompressive fasciotomy. These data underscore the importance of routine surveillance for LECS. In addition, a thorough knowledge of regional anatomy is essential to avoid technical morbidity.
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Affiliation(s)
- Jeffry L Kashuk
- Department of Surgery, Denver Health Medical Center and University of Colorado, Denver Health Sciences Center 777 Bannock St MC0206 Denver, Colorado 80204, USA
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center and University of Colorado, Denver Health Sciences Center 777 Bannock St MC0206 Denver, Colorado 80204, USA
| | - Sarah Pinski
- Department of Orthopedic Surgery, Denver Health Medical Center and University of Colorado, Denver Health Sciences Center 777 Bannock St MC 0206 Denver, Colorado 80204, USA
| | - Jeffrey L Johnson
- Department of Surgery, Denver Health Medical Center and University of Colorado, Denver Health Sciences Center 777 Bannock St MC0206 Denver, Colorado 80204, USA
| | - John B Moore
- Department of Surgery, Denver Health Medical Center and University of Colorado, Denver Health Sciences Center 777 Bannock St MC0206 Denver, Colorado 80204, USA
| | - Steven Morgan
- Department of Orthopedic Surgery, Denver Health Medical Center and University of Colorado, Denver Health Sciences Center 777 Bannock St MC 0206 Denver, Colorado 80204, USA
| | - Clay C Cothren
- Department of Surgery, Denver Health Medical Center and University of Colorado, Denver Health Sciences Center 777 Bannock St MC0206 Denver, Colorado 80204, USA
| | - Wade Smith
- Department of Orthopedic Surgery, Denver Health Medical Center and University of Colorado, Denver Health Sciences Center 777 Bannock St MC 0206 Denver, Colorado 80204, USA
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Mar G, Barrington M, McGuirk B. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis † †Presented as a poster at the European Society of Regional Anaesthesia and Pain Therapy, XXVII Annual Congress, Genoa, Italy, in September 2008 and published in part as an abstract in Reg Anesth Pain Med 2008; 33: e185. Br J Anaesth 2009; 102:3-11. [DOI: 10.1093/bja/aen330] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Thati S, Carlson C, Maskill JD, Anderson JG, Bohay DR. Tibial compartment syndrome and the cavovarus foot. Foot Ankle Clin 2008; 13:275-305, vii. [PMID: 18457774 DOI: 10.1016/j.fcl.2008.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.
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Affiliation(s)
- Srinivas Thati
- Orthopaedic Associates of Grand Rapids, P.C., Foot and Ankle Division, Grand Rapids, MI 49525, USA
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Cascio BM, Pateder DB, Farber AJ, Kramer DE, Ain MC, Frassica FJ. Improvement in documentation of compartment syndrome with a chart insert. Orthopedics 2008; 31:364. [PMID: 19292285 DOI: 10.3928/01477447-20080401-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To improve documentation of compartment syndrome, an educational program was instituted and a chart insert consisting of a preprinted checklist of history and physical examination parameters for at-risk patients was created. From October 2004 to May 2005, a total of 45 consecutive at-risk patients were identified. Progress notes were divided into group 1 (educational program alone) and group 2 (educational program and checklist). Group 2 showed more complete documentation than group 1. The combination of a chart insert and an educational program proved to be more effective than an educational program alone for improving the documentation of compartment syndrome.
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Affiliation(s)
- Brett M Cascio
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD 21224-2780, USA
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Abstract
PURPOSE OF REVIEW Controversial topics in paediatric regional anaesthesia are discussed. RECENT FINDINGS The performance of blocks under general anaesthesia, new local anaesthetics, adjuvants, location techniques, and risks of masking compartment syndromes are contemplated. SUMMARY The performance of regional blocks in anaesthetized patients is generally contra-indicated in adults but accepted in children. Levobupivacaine displays the same pharmacokinetic profile as racemic bupivacaine with possibly less cardiac toxicity. Ropivacaine undergoes slower absorption and, in some studies, concomitant increase in peak plasma concentration in infants. Conversely, continuous infusion of ropivacaine offers the safest therapeutic index. Many adjuvants have been used but only epinephrine, clonidine, and preservative-free ketamine offer clear advantages. Midazolam and neostigmine are effective but have potential drawbacks and raise safety questions. Needle and catheter positioning is critical. Electrocardiogram guidance and electrical stimulation occasionally help identify the migration of epidural catheters. Stimulating catheters might be useful for continuous peripheral blockade. Ultrasonography will probably become the reference technique for peripheral catheter placement. Patients at risk of compartment syndrome must be monitored (measurement of compartmental pressures); adequate pain management does not 'hide' this complication but, on the contrary, can facilitate early diagnosis since the increase in requirement for pain medication precedes other clinical symptoms by an average of 7.3 h.
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Affiliation(s)
- Bernard Dalens
- Department of Anaesthesiology, Quebec Central University Hospital Sainte-Foy, Quebec, Canada.
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Prayson MJ, Chen JL, Hampers D, Vogt M, Fenwick J, Meredick R. Baseline Compartment Pressure Measurements in Isolated Lower Extremity Fractures without Clinical Compartment Syndrome. ACTA ACUST UNITED AC 2006; 60:1037-40. [PMID: 16688067 DOI: 10.1097/01.ta.0000215444.05928.2f] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The diagnosis of compartment syndrome is most commonly made by clinical examination. Direct compartmental measurements generally serve an adjunctive role in establishing the diagnosis, except when patients have an alteration in mental status. There is little known on what are the expected baseline elevations in compartments after the simple occurrence of a fracture when clinical compartment syndrome does not exist. Knowledge of such measurements might influence the utility of pressure measurements in diagnosing compartment syndrome. METHODS A prospective analysis of compartment measurements was performed in 19 isolated lower extremity fractures with the opposite leg as the control. The patients had no clinical evidence of compartment syndrome, had no alteration in mental status, and underwent planned surgical treatment within 48 hours of injury. RESULTS Average compartment measurements were 35.5 +/- 13.6 mm Hg (range 10 to 62 mm Hg) in the injured leg versus 16.6 +/- 7.5 mm Hg (range 3 to 40 mm Hg) in the control leg (p = 0.0001). Eighteen patients (95%) had at least one compartment measurement that exceeded a single threshold of 30 mm Hg and 12 patients (63%) exceeded a threshold of 45 mm Hg. Eleven patients (58%) had at least one compartment reading within 20 mm Hg of their diastolic pressure and 16 patients (84%) had one within 30 mm Hg of their diastolic pressure. Ten patients (53%) had a reading within 40 mm Hg of their mean arterial pressure (delta P) and eight patients (42%) had a reading within 30 mm Hg of the mean arterial pressure. No patient developed sequelae or required surgery related to an unrecognized compartment syndrome during a minimum 1-year follow-up. CONCLUSIONS Based on our data, use of direct compartment measurements with existing thresholds and formulations to determine the diagnosis of compartment syndrome may not accurately reflect a true existence of the syndrome. A search for other quantitative measures to more accurately reflect the presence of compartment syndrome is warranted.
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Affiliation(s)
- Michael J Prayson
- Department of Orthopaedic Surgery, Miami Valley Hospital, Wright State University, Dayton, Ohio 45409, USA.
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Abstract
Compartment syndrome should be treated early and aggressively to prevent late complications. Patients may have late deformity because of a failure of diagnosis, inadequate decompression, or a delay in fasciotomies. Late reconstruction will allow a plantigrade and relatively functional foot. Complete excision of scarred muscle will prevent recurrence in established deformities. Early treatment may prevent significant functional impairment by well-placed tenotomies. In patients with severe long-term deformities with extensive soft tissue contraction, incremental correction may be an appropriate intermediate intervention.
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Affiliation(s)
- Mark D Perry
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8883, USA.
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