Barbed sutures versus staples for closure in total hip arthroplasty using wound ooze as a primary outcome measure: A prospective study.

BACKGROUND: Prosthetic joint infection is a rare, but devastating complication of primary total hip arthroplasty (THA). Postoperative wound discharge and deep infection are related. We examined whether barbed sutures were associated with a decrease in the incidence of postoperative wound discharge when compared with skin closure using metal staples. METHODS: Prospective nonrandomized comparison between two groups (35 barbed suture closures vs. 49 staple closures). Wounds were assessed daily for postoperative wound discharge until dry. Hemoglobin and hematocrit were recorded at the preoperative assessment and on day 3 postoperative. RESULTS: There were no significant differences between the groups with regard to age, body mass index, gender, preoperative hemoglobin, preoperative hematocrit, or estimated blood volume. The number of days elapsed until the wound was dry was significantly lower in the barbed suture group than the staples group (p < 0.0001). In the staples cohort, ongoing wound ooze resulted in delayed hospital discharge in three (6%) patients, six bed days total. CONCLUSION: Barbed sutures reliably reduce the period of postoperative wound ooze following primary THA compared to staple closure. The use of barbed sutures may prevent delayed patient discharge from hospital, decreasing the bed burden.

Improving analgesia prescription for trauma inpatients.

Patients value effective pain relief. Complications of inadequate pain control include increased risk of infection, decreased patient comfort and progression to chronic pain, all of which have significant socioeconomic consequence. Accessibility to analgesia is vital to effective administration. This improvement project aimed to improve the consistency and adequacy of analgesia prescribing for trauma inpatients over a 12-month period. Four PDSA ('plan, do, study, act') cycles resulted in sustained and significant improvements in analgesia prescription. The interventions included senior encouragement, teaching sessions, targeted inductions and implementation of a novel e-prescribing protocol. Prospective data and real-time discussion from stakeholder medical and management teams enabled iterative change to practice. Drug charts were reviewed for all trauma inpatients (n=276) over a 10-month period, recording all analgesia prescribed within 24 hours of admission. Each prescription was scored (maximum of 10 points) according to parameters agreed by the acute pain specialty leaders. An improving trend was observed in the analgesia score over the study period. Each intervention was associated with improved practice. Based on observed improvements, a novel electronic prescribing protocol was developed in conjunction with the information technology department, resulting in maximum scores for prescribing which were sustained over the final 3 months of the study. This was subsequently adopted as standard practice within the department. One year following completion of the project, a further 3 weeks of data were collected to assess long-term sustainability-scores remained 10 out of 10. Addressing the prescribing habits of junior doctors improved accessibility to analgesia for trauma patients. The electronic prescribing tool made prescribing straightforward and faster, and was the most successful intervention. Doctor satisfaction using this time-saving tool was high. Identifying a stakeholder within the information technology department proved pivotal to transferring the project aims into clinical practice.

Reducing returns to theatre for neck of femur fracture patients.

The Royal United Hospital, Bath, admits approximately 550 patients with neck of femur fractures per year. The risks from returning to theatre for this patient group are often life-threatening. Post-operative wound ooze was noted to cause a significant rate of return to theatre, with increased lengths of stay and patient morbidity. A wound closure protocol was agreed by the consultant body. This information was disseminated by email and teaching sessions to all members of the multidisciplinary team, including surgeons, theatre staff and ortho-geriatricians. The plan-do-study-act model for improvement was used to reduce rates of returns to theatre for wound ooze. Interventions included cyclical teaching during each trainee rotation, updated inductions, posters, email reminders and scrub team involvement to open the protocol sutures unprompted. The primary outcome measure was returns to theatre for wound complications. Baseline data showed 4 returns to theatre over a two month period (4.40% of patients). Length of stay for each patient affected by wound ooze was also compared to the departmental mean. In the 6 month intervention period there was one return to theatre (0.36% of patients). The observed reduction saved the department an estimated £13,831 in length of stay alone. The standardisation of wound closure protocol, with continued reinforcement to all members of the multidisciplinary team, improves patient outcome in this group. Mobilising a group of clinicians across a variety of specialities, with one common goal, is highly effective for patients, improves multidisciplinary working and reduces cost.

Introducing a post-operative proforma for elective lower limb arthroplasty patients - improving patient care and junior doctor confidence.

The assessment of post-operative patients is vital to identify early complications and ensure patient safety. Good clinical record keeping is essential for effective continuity of care and patient safety in the post-operative period. A group of foundation year 2 (FY2) doctors noted a disparity in levels of confidence and ability in performing this assessment. The aim of the project was to improve documentation and understanding of day one lower limb arthroplasty reviews by FY2 doctors. The Plan-Do-Study-Act model for continuous improvement was adopted from September 2015 to July 2016. A composite score comprising the twelve most important review parameters for documentation was used to score the quality of documentation on an ongoing basis. An electronic survey was completed by every FY2 rotating through the department. Interventions included registrar-led teaching sessions and an integrated review form placed in the medical notes. Further iterations of the proforma and further interventions were coordinated with the ward clerks, sisters, physiotherapists and senior clinicians. The baseline mean composite score was 6.3/12. Following implementation of a standardised proforma this score improved to 10.5 in those who had used the proforma, but 5.7 in those who hadn't. Electronic survey responses showed the proforma and teaching were effective in improving knowledge and understanding of post-operative reviews. The use of an integrated proforma in the medical notes and teaching it's use at induction, improves the documentation and understanding of day one post-operative reviews. Coordinating ward-based change across a cohort of FY2s, with involvement from the multidisciplinary team and management, affects sustained improvements in patient reviews.

Bring on the weekend - Improving the quality of junior doctor weekend handover.

While it is widely recognised that communication and handover are a fundamental component in providing safe clinical care for hospital patients (1,2.3). The Royal College of Physicians found that the majority of hospital doctors are dissatisfied with the standard of their handovers (4). These findings were mirrored by the junior staff at the Royal United Hospital, who felt that the weekend handover was inadequate, and detrimental to patient safety. A group of eight junior doctors at the Royal United Hospital, Bath utilised The Model For Improvement to systematically analyse and improve various aspects of the weekend handover system. Handover sheets from a subset of wards were assessed to observe direct effects of staged interventions over a nine month period, allowing small-scale testing prior to widespread implementation of a standardised intranet-based weekend handover. The effects of interventions were evaluated using a predesigned scoring system and data was collected continuously throughout the project. Over a nine month period the quality of handovers improved significantly from 76% to 93% (p <0.01): a success which was supported by a 100% improvement in formal feedback collected from hospital doctors and highlighted by the desire of senior staff and directors to implement the system throughout the trust. Using The Model For Improvement a group of junior doctors were able to introduce and develop a standardised weekend handover system that met their requirements. A structured, efficient and auditable system has been successfully produced which improves the quality and safety of patient care.

Improving documentation of treatment escalation decisions in acute care.

The aim of this project was to improve the documentation of treatment escalation decisions at a district general hospital in southwest England. A pilot "Ceiling of Treatment" proforma was trialled on the care of the elderly wards at the Royal United Hospital (RUH), Bath. Successive PDSA cycles enabled revision of the proforma for use across the Trust. Data were collected on the proportion of patients with a documented treatment escalation decision. Formative feedback was collected via questionnaire from trainees and discussion with special interest groups of consultants within the hospital. This approach involved collaboration between acute medicine, intensive care, elderly care, the resuscitation department, palliative care and the legal department. Documentation of ceiling of treatment decisions rose from 30% to 90% during the study. A survey of medical trainees showed 67% (n=36) had seen the ceiling of treatment form, of which, 100% found it useful on on-call shifts. Initiating a proforma to record treatment escalation decisions and combining this with the existing 'Do not attempt cardiopulmonary resuscitation' (DNAR) paperwork, increased decision making and documentation. This intervention ensures patients receive the appropriate level of care, as indicated by their consultant, and reduces anxiety for junior doctors during on-call shifts.