An observational study of timing versus appropriateness of acute plastic surgery referrals in the UK.

AIM: A commitment made by the UK government that all patients presenting to Accident and Emergency (A&E) should be treated within 4h of arrival has challenged both A&E departments and those to whom they refer. It has been suggested on one hand that referrals from A&E are not always seen promptly enough to meet waiting time targets, and on the other hand that referrals are sometimes made to help busy A&Es clear their waiting rooms rather than through clinical need. METHODS: To investigate these claims 'Referral Time' (the time between a patient arriving at A&E and being referred to Plastic Surgery), 'Review Time' (the time taken from referral to review by the Plastic Surgery Senior House Officer) and their relationship with referral appropriateness were prospectively examined in a UK teaching hospital. RESULTS: The mean Referral Time was 84 min (SD=57.3) and Review Time was 33 min (SD=27.4). Review Time did not vary significantly between 'appropriate' and 'inappropriate' referrals (31.3 vs 36.1 min, p=0.357) but Referral Time was significantly quicker for 'inappropriate' than 'appropriate' referrals (92.8 vs 62.7 min, p=0.028). CONCLUSION: This data suggests that Review Time did not significantly contribute to the risk of patients breaching the A&E waiting time target in this study, but a correlation between reduced Referral Time and decreased referral appropriateness is consistent with referrals sometimes being made for non-clinical reasons. It is felt that such tactics are an inevitable consequence of an unachievable target placed on A&E departments and that this target should be reconsidered.

A comparison of one- versus two-stage surgery in an experimental model of functional muscle transfer with interposed nerve grafting.

Functional muscle transfer (FMT) combined with cross-facial nerve grafting (CFNG) is the gold standard treatment of chronic unilateral facial palsy, performed by most surgeons over two operative stages to minimise FMT denervation atrophy. Proponents of one-stage surgery cite shorter total recovery time, fewer operative procedures and a possible beneficial neurotrophic effect of muscle attachment. This study aimed to compare one- and two-stage surgery in terms of neural and muscle reinnervation and FMT force production. Forty New Zealand white rabbits underwent one- or two-stage rectus femoris FMT and interposed nerve grafting under different reinnervation conditions. For two-stage surgery, nerve grafting was followed by FMT after three months and by final experiments after a further six months, whereas one-stage groups experienced nerve grafting and FMT together and final experiments after nine months. Outcomes compared were nerve graft and rectus nerve morphometry, FMT reinnervation measured using PGP 9.5, and FMT force production. Statistical analysis was performed by means of the independent samples t-test or the Mann-Whitney Rank Sum test using Statistics Package for the Social Sciences version 11.0.4 for Mac OS X. Nerve graft reinnervation was similar for respective one- and two-stage surgery groups or favoured one-stage surgery. There was no significant difference between respective groups in terms of rectus nerve morphometry, muscle reinnervation, or absolute, weight-adjusted or weight- and control-adjusted tetanic force production. One-stage surgery offers potential advantages including a reduction in the number of surgical procedures, a shorter total recovery time and beneficial economic and healthcare delivery implications. This data supports previous clinical and experimental studies and questions the basis for performing facial reanimation by FMT combined with CFNG over two separate operative stages.

A prospective evaluation of the Modified Hand Injury Severity Score in predicting return to work.

Hand injuries are the main cause of work-related disability in young adults. We have devised the Modified Hand Injury Scoring System to quantify hand, wrist and forearm injuries. This study aims to determine its value in predicting ability and time taken to return to work after such injury. Prospectively-assigned MHISS at presentation was compared with demographic, injury, employment and quality of life information 40-52months after acute hand or forearm injury. MHISS score was the only variable investigated found to predict ability to return to work. Factors not associated included age at injury, occupation, hand injury side or dominance, main earner status and compensation-seeking. Median time to return to work increased from 30 to 760days for Mild and Major MHISS categories respectively. Injury severity quantified using MHISS is an important determinant of return to work after hand or forearm injury. Only 60% of patients return to work following a Major injury and may take over a year to do so. Such information may allow the patient to make early informed personal financial and retraining decisions after their injury.