Standardized Protocol for Chest Tube Management for Trauma Patients Significantly Decreases Complications.

Background: As health care shifts to a value-based model with a focus on patient outcomes per dollar spent, it is important to develop and evaluate standardized protocols that ultimately lead to improved patient outcomes and decreased hospital complications. Prior to our chest tube protocol, chest tube management at our Trauma Center was nonuniform and surgeon-specific. The aim of this study was to (1) develop an institutional standardized protocol for chest tube management at our Level II Trauma Center and (2) compare patient outcomes before and after the implementation of our protocol. Methods: An institutional, standardized protocol was initiated at our Level II-Certified Trauma Center teaching hospital in 2014. An IRB-approved, single-institution retrospective chart review was performed between January 2011 and May 2017, in order to capture the 3 years prior and 3 years after protocol implementation. All patients with a diagnosis of hemothorax or pneumothorax (H/PTX) from blunt or penetrating trauma that resulted in a >24 French chest tube placement were included in the study. Patients were excluded if interventional radiology (IR) placed the chest tube, the mechanism was nontraumatic, or the patient expired at index hospitalization. Univariate analyses were performed to evaluate significant differences in patient outcomes before and after the implementation of the protocol. Results: A total of 143 patients were analyzed for this study, with 43 preprotocol patients and 100 postprotocol patients. Hospital length of stay (LOS), persistent H/PTX, and the need for further surgical intervention all improved after the implementation of the standardized protocol (p < 0.04). Conclusions: Our standardized protocol for chest tube management at our Level II Trauma Center significantly improved patient outcomes and can serve as a model for similar institutions.

Acute Proximal Hamstring Tears Can be Defined Using an Imaged-Based Classification.

Purpose: To develop a clinically meaningful proximal hamstring tear classification system and to present outcome data for defined subtypes. Methods: Retrospective review was undertaken of patients diagnosed with proximal hamstring tears at a single institution from 2012 to 2019. Images were reviewed by an orthopedic surgeon and musculoskeletal radiologist. Tears were classified as Type 1: partial with subtypes (1A, 1 cm or mild complete tear; 1B, 1-2 cm or full tear with <2 cm retraction), Type 2: complete single-tendon tears with subtypes (2c conjoint tendon only; 2s semimembranosus tendon only); or Type 3: complete tears with >2 cm retraction. Demographics, patient-reported outcome measures including Hip Outcome Score, Activities of Daily Living Subscore (HOS-ADL) and patient satisfaction were evaluated. A poor outcome was defined as HOS-ADL < 80%, and the patient acceptable symptom state (PASS) was defined as HOS-ADL 89.7%. Results: At a mean follow-up of 38.6 (range: 12-94) months for 114 patients, distributions were as follows: 18.4% Type 1A, 19.2% Type 1B, 7.8% Type 2c, 3.5% Type 2s, and 50.9% Type 3. Intra-observer and inter-observer reliability had a mean Kappa of 0.985 (95% CI: .956, 1.01) and .905 (95% CI: .895 .915). 66 patients underwent surgery, with 68.97% of them being Type 3. The mean HOS-ADL and PASS rate were higher for operatively treated patients (95%, 93.4%) than for nonoperatively treated patients (81.86%, 44.7%). There were significantly more patients satisfied in the surgery group in both Type 1 and Type 3 tears (P = .046 and P = .049). Body mass index was a significant predictor of a poor outcome in Type 3 tears (P = .039). History of corticosteroid or PRP injection, smoking, and diabetes were not significant predictors of a poor outcome. Conclusion: We present an MRI-based classification system for proximal hamstring injuries with both excellent intra-observer and inter-observer reliability. Outcome measures were improved in patients who underwent surgery. Level of Evidence: IV, cohort study: diagnostic case series.

The Geriatric Nutritional Risk Index Is an Independent Predictor of Adverse Outcomes for Total Joint Arthroplasty Patients.

BACKGROUND: Malnutrition affects patient outcomes after total joint arthroplasty (TJA). Although hypoalbuminemia has been used as a surrogate, there is no unanimous method for screening and assessing malnutrition. This study aimed to determine if malnutrition, as defined by the Geriatric Nutritional Risk Index (GNRI), is independently correlated with short-term (<30 days) postoperative complications and prognosis in patients undergoing TJA. METHODS: The 2016-2019 American College of Surgeons National Surgical Quality Improvement Program was queried for all patients aged >65 years who underwent TJA. Based on GNRI value, patients were divided into 3 groups: normal nutrition (GNRI >98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI <92). After adjusting for potential confounders, multivariable regression models were used to analyze the association between GNRI and patient outcomes. RESULTS: A total of 191,087 patients were included in the study. Prevalence of malnutrition based on body mass index (<18.5 kg/m2), albumin (<3.5 mg/dL), and GNRI (≤98) was 0.41% (784), 4.17% (7975), and 15.83% (30,258). Adjusted analysis showed that compared with normal nutrition, moderate and severe malnutrition status were associated with a higher rate of transfusion, readmission, and postoperative length of stay over 8 days (P < .05). Severe malnutrition was also associated with pneumonia, surgical site infection, urinary tract infection, sepsis, and revision surgery (P < .05). CONCLUSION: Malnutrition, as defined by GNRI, is an independent predictor of adverse outcomes after TJA, including 30-day readmission, revision surgery, and increased length of stay. GNRI can be used to routinely screen and assess patient nutritional status before TJA and counsel patients and families appropriately. LEVEL OF EVIDENCE: Level 3: Retrospective Cohort Study.

Variation in the Profit Margin for Different Types of Total Joint Arthroplasty.

BACKGROUND: As health care shifts to a value-based model with bundled-payment methods, it is important to understand the costs and reimbursements of arthroplasty procedures that represent the largest expenditure of Medicare. The aim of the present study was to characterize the variation in (1) total hospital costs, (2) reimbursement, and (3) profit margin for different arthroplasty procedures. METHODS: The total hospital costs of total knee arthroplasty (TKA), total hip arthroplasty (THA), anatomic total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and total ankle arthroplasty (TAA) were calculated with use of time-driven activity-based costing at an orthopaedic institution from 2018 to 2020. The average reimbursement for each type of procedure was determined. Profit margin, defined as the reimbursement profit after direct costs, was calculated by deducting the average time-drive activity-based total hospital costs from the reimbursement value. Multivariate analyses were performed to evaluate the associations between costs, reimbursement, and profit margins. RESULTS: There were 13,545 arthroplasty procedures analyzed for this study, including 6,636 TKAs, 5,902 THAs, 346 TSAs, 577 RSAs, and 84 TAAs. Costs and reimbursement were highest for TAA. THA and TKA resulted in the highest profit margins, whereas RSA resulted in the lowest. The strongest associations with profit margin were private insurance (0.46547), age (-0.22732), and implant cost (-0.19240). CONCLUSIONS: THA and TKA had greater profit margins overall than TAA and upper-extremity arthroplasty in general. Profit margins for RSA, TSA, and TAA were all at least 28% lower than those for TKA or THA. Lower-volume arthroplasty procedures were associated with decreased profit margins. Study findings suggest that optimizing implant costs and length of stay are important for sustaining institutional fiscal health when performing shoulder and ankle arthroplasty surgery.

Elimination of Routine Urinalysis before Elective Orthopaedic Surgery Reduces Antibiotic Utilization without Impacting Catheter-associated Urinary Tract Infection or Surgical Site Infection Rates.

PURPOSE: Routine preoperative urinalysis has been the standard of care for the orthopedic population for decades, regardless of symptoms. Studies have demonstrated antibiotic overuse and low concordance between bacteria cultured from the surgical wound and the urine. Testing and treatment of asymptomatic urinary tract colonization before total joint arthroplasty (TJA) is unnecessary and increases patient risk. We investigated reducing antibiotic use by (1) modifying testing algorithms to target patients at risk, (2) modifying reflex to culture criteria, and (3) providing treatment guidelines. MATERIALS AND METHODS: A pre-post study was conducted to determine identify the impact of eliminating universal urinalysis prior to TJA on surgical site infection (SSI) and catheter-associated urinary tract infection (CAUTI) rates and number of antibiotic prescriptions. Patients who underwent primary hip or knee TJA or spinal fusions from February 2016 to March 2018 were included. Patient data was collected for pre- and post-practice change period (February 2016-October 2016 and August 2017-March 2018). Patient demographics, urinalysis results, cultures, and prescriptions were analyzed retrospectively from every tenth chart in the pre-period and prospectively on all patients in the post-period. RESULTS: A total of 4,663 patients were studied. There was a 96% decrease in urinalyses performed (P<0.0001), and a 93% reduction rate in antibiotic utilization (P<0.001). No significant difference in SSI and CAUTI rates was observed (P>0.05). CONCLUSION: The elimination of routine urinalysis before orthopedic surgery resulted in a reduction in antibiotic utilization with no significant change in the SSI or CAUTI rates. Cost savings resulted from reduced antibiotic usage.