Evaluating the success of an inpatient PA and NP program through trends in ED consults.

OBJECTIVE: We investigated the effect of an inpatient physician associate/assistant (PA) and NP program on consult volume, length of stay (LOS), and ED returns. METHODS: A retrospective observational study of 4,118 orthopedic ED consults was conducted from January 2017 to March 2022. Univariate statistics were used to evaluate outcomes between cohorts and multivariate regression to evaluate the odds of an LOS of less than 24 hours. RESULTS: After implementation of the PA and NP program, surgeon consults steadily declined and orthopedic consults increased markedly. Statistically significant differences were found in LOS of less than 24 hours and ED arrival-to-discharge time. Adjusting for case mix, patients were 47% more likely to be discharged within 24 hours. Survey results noted that more than 80% of surgeons felt on-call workload, disruptions to clinic and surgical schedules decreased, and quality of care increased. CONCLUSIONS: Implementation of an inpatient PA and NP program reduced orthopedic surgeon consults and hospital LOS while improving surgeon satisfaction with on-call workload, schedule disruptions, and quality of care.

Effect of Weight Change on Patient-Reported Outcomes Following Total Joint Arthroplasty.

BACKGROUND: Increased body mass index (BMI) has been previously described as a risk factor for complications after total joint arthroplasty (TJA); however, its effect on patient-reported outcomes has not been thoroughly investigated. This study examines the effect of postoperative weight change on the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scores for total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients. METHODS: A retrospective review of 988 patients undergoing THA or TKA was performed. PROMIS-PF scores and BMI were recorded throughout the study duration. Patients were classified by a 5% change in BMI. A univariate analysis evaluated differences across groups. Mixed-effect models evaluated predictors of change in functional score over the postoperative follow-up time. RESULTS: 43.1% patients had a THA and 56.9% patients had a TKA. At 0 to 3 months, 92% of patients had no change in BMI, 3 to 6 months 82% had no change, and 6 to 12 months 80% had no change. There were no significant demographic or comorbidity differences across groups for both THA and TKA. Similar improvements in PROMIS-PF scores were observed across weight change groups. In the mixed-effect models, postoperative time was found to be a significant predictor of postoperative PF score. Both THA and TKA patients saw greater improvements in PROMIS-PF scores in patients with lower preoperative BMIs. CONCLUSION: These results demonstrate most patients do not experience substantial changes in weight following TJA. However, lower BMIs at the time of surgery were associated with an increased functional improvement. Therefore, efforts to optimize BMI should be focused preoperatively to improve surgical outcomes.

Labor unions: a public health institution.

Using a social-ecological framework, we drew on a targeted literature review and historical and contemporary cases from the US labor movement to illustrate how unions address physical and psychosocial conditions of work and the underlying inequalities and social determinants of health. We reviewed labor involvement in tobacco cessation, hypertension control, and asthma, limiting articles to those in English published in peer-reviewed public health or medical journals from 1970 to 2013. More rigorous research is needed on potential pathways from union membership to health outcomes and the facilitators of and barriers to union-public health collaboration. Despite occasional challenges, public health professionals should increase their efforts to engage with unions as critical partners.

Factors associated with wound complications in women with obstetric anal sphincter injuries (OASIS).

OBJECTIVE: We sought to determine factors associated with perineal wound complications in women with obstetric anal sphincter injuries (OASIS). STUDY DESIGN: A retrospective chart review of women who sustained an OASIS from Nov. 2, 2005, through March 1, 2010, was performed. RESULTS: In all, 1629 women sustained an OASIS; 909 had follow-up data. Wound complications (infection, breakdown, packing, operative intervention, secondary repair) occurred in 7.3% (n = 66) of patients. Smoking (odds ratio [OR], 4.04; 95% confidence interval [CI], 1.4-12.2; P = .01), increasing body mass index (OR, 1.06; 95% CI, 1.01-1.12; P = .04), fourth-degree laceration (OR, 1.89; 95% CI, 0.99-3.61; P = .05), operative vaginal delivery (OR, 1.76; 95% CI, 1.15-2.68; P = .009), and use of postpartum antibiotics (OR, 2.46; 95% CI, 1.11-5.63; P = .03) were associated with complications; intrapartum antibiotics were protective (OR, 0.29; 95% CI, 0.14-0.59; P = .001). In all, 44% of patients with a complication (n = 29) required hospital readmission; most (72%) were in the first 2 postpartum weeks. CONCLUSION: Wound complications after OASIS are associated with modifiable factors and often require hospital readmission.

Disparities in Hand Surgery Exist in Unexpected Populations.

Background The purpose of our study is to investigate disparities in the patient populations and outcomes of carpal tunnel release (CTR) and trigger finger release (TFR).  Methods A retrospective review of 777 CTR and 395 TFR patients from May 2021 to August 2022 was completed. The shortened form of the Disabilities of the Arm, Shoulder, and Hand (DASH) scores (QuickDASH) was recorded to evaluate physical function preoperatively and at one and three months postoperatively. This study was deemed institutional review board-exempt by the institutional clinical research committee. Results Compared to CTR, TFR patients resided in zip codes with higher levels of social vulnerability across dimensions of 'household composition and disability' (p=0.018) and 'minority status and language' (p=0.043). When analyzing QuickDASH scores by demographics and procedure, preoperative scores were statistically significantly higher for non-married (p=0.002), White (p=0.003), and female sex (p=0.001) CTR patients. Further, one-month postoperative scores were statistically higher for White and non-married CTR patients (0.016 and 0.015, respectively). At three months postoperatively, female and non-married patients had statistically significant higher scores (0.010 and 0.037, respectively). In TFR patients, one-month postoperative QuickDASH scores for White and female patients were statistically significantly higher (0.018 and 0.007, respectively). There were no significant differences in QuickDASH scores between rural and non-rural patients, household income (HHI) above or below the median, or the Social Vulnerability Index (SVI) dimensions.  Conclusion Our study found marital status, sex, and race were associated with disparities in pre-and postoperative physical function in patients undergoing carpal tunnel or trigger finger release. However, future studies are warranted to confirm and develop solutions to disparities within this population.

The Impact of Total Hip Arthroplasty Surgical Approach on Short-Term Postoperative and Patient-Reported Outcomes.

Background While multiple studies have compared outcomes between the direct anterior approach (DAA) and posterolateral (PL) total hip arthroplasty (THA), the debate over the optimal approach remains. Proponents of the DAA suggest that its muscle-sparing properties and unrestricted rehabilitation facilitate a more rapid return to function. The majority of studies demonstrate that patient-reported outcomes (PROs) are similar between approaches beyond the one-year timeframe, but results are mixed when evaluating earlier time points. The purpose of this study was to compare clinical outcomes and PROs between DAA and PL THAs at six weeks postoperatively. Methods A retrospective review of 749 primary THAs (151 PL, 598 DAA) from March 2020 to November 2022 was performed. All surgeries were performed by one of the five board-certified and fellowship-trained orthopedic surgeons. All patients completed Patient Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) questionnaires preoperatively and at six weeks postoperatively. A univariate comparison of clinical outcomes (length of stay (LOS), home discharge rate, 90-day ED returns, and readmissions) and six-week PROMIS-PF scores between approaches was performed. Multivariate analysis was performed to evaluate the effect of the approach on outcomes after adjusting for baseline differences between groups. Results Patients undergoing DAA THA experienced significantly shorter average LOS (0.71 vs. 1.36 days, p<0.001), higher rates of home discharge (99.0 vs. 92.1%, p<0.001), and lower rates of 90-day readmissions (0.7 vs. 6.0%, p<0.001) than those undergoing the PL approach. At six weeks postoperatively, DAA patients achieved higher average PROMIS-PF scores (42.2 vs. 39.9, p=0.001). After adjusting for the Charlson Comorbidity Index and baseline physical function, the DAA was significantly associated with shorter LOS (ß=-0.52, p<0.001), increased odds of home discharge (OR=5.70, p=0.001), reduced risk of 90-day readmission (OR=0.14, p=0.001), and higher PROMIS-PF scores at six weeks postoperatively (ß=1.37, p=0.045). Conclusion In comparison to patients undergoing PL THA, those treated using the DAA experienced improved clinical and PROs over the six-week postoperative period. While both approaches resulted in satisfactory outcomes, these results support the assertion that DAA THA may result in more rapid recovery and return to function.

Effect of Lower Extremity Osteoarthritis on Outcomes of Lumbar Decompression.

BACKGROUND: The purpose of this study is to evaluate how hip or knee osteoarthritis (OA) and total joint arthroplasty impact the outcomes of patients undergoing lumbar decompression. METHODS: A retrospective review of 342 patients undergoing lumbar decompression without fusion from January 2019 and June 2021 at a single institution was performed. Univariate and multivariate analyses were used to compare outcomes between patients with and without concomitant hip or knee OA. RESULTS: Forty-six percent of patients had a hip or knee OA diagnosis and were higher risk as they were older, had higher BMIs, were more likely to be former smokers, had higher ASA scores, and were more likely to undergo 3+ level surgery. Postoperatively, after adjusting for differences between groups, hip or knee OA patients were more likely to be readmitted (OR=12.45, p=0.026) or have a complication (OR=13.77, p=0.031). However, patient reported outcomes as measured by Patient Reported Outcomes Measurement Information System-physical function. were similar at 1-3 months and 3-6 months. Higher levels of physical function were observed at 3-6 months postoperatively in hip OA patients with a history of THA. CONCLUSION: Patients with concomitant hip or knee OA are at higher risk for readmission and postoperative complications but may achieve similar levels of physical function as those without OA.

Change in Postoperative Weightbearing Protocol Does Not Increase Postoperative Complications Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Background Postoperative rehabilitation protocols, including weightbearing restrictions following hip arthroscopy (HA) for femoracetabular impingement syndrome (FAIS), vary widely among surgeons, from complete non-weightbearing to immediate weightbearing as tolerated; it is unclear if weightbearing restrictions affect short-term outcomes in patients undergoing HA. The purpose of this study is to evaluate patients undergoing hip arthroscopy for FAIS before and after a change in weightbearing protocol, from partial weightbearing with crutches for three weeks to weightbearing and weaning from crutches as tolerated, by examining postoperative outcomes. We hypothesize that the change in weightbearing protocol will have no significant effect on patient outcomes. Methods A retrospective review was conducted of 211 patients undergoing hip arthroscopy by a single high-volume surgeon. The change in weightbearing was implemented in February 2022; previously, all patients were toe-touch weightbearing with crutches for the first three weeks postoperatively. Following this change, patients were allowed to weightbear as tolerated with crutches immediately and wean from crutches as tolerated. The patients were divided into two groups: 119 patients pre-implementation (January 2021 to January 2022) and 92 patients post-implementation (February 2022 to December 2022). The primary endpoint was any complication in the first six weeks postoperatively, divided into complications at two and six weeks, emergency department returns in the first 90 days, reoperations in the first 30 days, and pain at six weeks. We also compared patient-reported outcomes at six weeks. Results There were no significant differences in demographics between groups. There were no significant differences in postoperative outcomes between patients that had weightbearing restrictions and those that did not when looking at 30 day return to operating room (0 vs 0%, p=1.000), 90-day return to emergency department (8.4 vs. 13.0%, p=0.386), two-week complications (2.5 vs. 6.5%, p=0.279), six-week complications (1.7 vs. 1.1%, p=1.000), pain score at six weeks postoperatively (0.34 vs. 0.33, p=0.971), any pain at six weeks postoperatively 37.8 vs. 32.6%, p=0.523), and six-week Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) score (36.0 vs. 34.5, p=0.330). Conclusion Patients undergoing HA after the discontinuation of a mandatory period of protected weightbearing did not experience any significant increase in complications or continued pain, and patient-reported outcomes were similar. Routine postoperative weightbearing restrictions may not be necessary for patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. Further study is required to validate these findings and determine the optimal postoperative protocol for this patient population.

Outpatient physical therapy bundled payment models are feasible for total hip arthroplasty patients: an evaluation of utilization, cost and outcomes.

BACKGROUND: Various episode-of-care bundled payment models for patients undergoing total joint arthroplasty have been implemented. However, participation in bundled payment programs has dropped given the challenges of meeting continually lower target prices. The purpose of our study is to investigate the cost of outpatient physical therapy (PT) and the potential for stand-alone outpatient PT bundled payments for patients undergoing total hip arthroplasty (THA). METHODS: A retrospective review of 501 patients who underwent primary unilateral THA from November 2017 to February 2020 was performed. All patients included in this study received postoperative PT care at a single hospital-affiliated PT practice. Patients above the 75th percentile of therapy visits were then classified as high-PT utilizers and compared with the rest of the population using univariate statistics. Stepwise multivariate logistic regression was used to assess the predictors of high therapy utilization. RESULTS: Patients averaged 65 ± 10 years of age and a BMI of 29 ± 5 kg/m2. Overall, 80% of patients were white and 53% were female. The average patient had 11 ± 8 total therapy sessions in 42 days: one initial evaluation, one re-evaluation and 9 standard sessions. High-PT utilizers incurred estimated average costs of $1934 ± 431 per patient, compared to $783 ± 432 (P < 0.001) in the rest of the population. Further, no significant differences in 90-day outcomes including lower extremity functional scale scores, emergency department returns, readmissions, or returns to the operating room were observed between high utilizers and the rest of the population (all P > 0.08). In the multivariate analysis, women (OR = 1.68, P = 0.017) and those with sleep apnea (OR = 2.02, P = 0.012) were nearly twice as likely to be high utilizers, while white patients were 42% less likely to be high utilizers than patients of other races (OR = 0.58, P = 0.028). CONCLUSIONS: Outpatient PT utilization is highly variable in patients undergoing THA. However, despite using more services and incurring increased cost, patients in the top quartile of utilization experienced similar outcomes to the rest of the population. If outpatient therapy bundles are to be developed, 16 visits appear to be a reasonable target for pricing, given this provides adequate coverage for 75% of THA patients.

The Effect of Preoperative, Low-Dose Intrathecal Morphine on Patient Outcomes Following Lumbar Fusion Surgery: Can We Teach an Old Dog New Tricks?

BACKGROUND: Early pain control after lumbar fusion presents a challenge to patients and providers. Intrathecal morphine (ITM) has been used at the end of these procedures with limited benefit, but recent data suggest low-dose ITM at case initiation may be effective. This study aims to evaluate the use of preoperative ITM during lumbar fusion to determine whether there is a benefit for these patients. METHODS: One hundred and eighty lumbar fusion patients between 1 January 2018 and 31 May 2022 were evaluated. Patients were grouped by whether they received preoperative, low-dose ITM or not. Outcomes of interest included hospital narcotic consumption, pain scores, opioid-related complications, and complications within the first 90 days. RESULTS: Sixty-five study patients received 200 µg ITM at case initiation and 115 did not. No differences in length of stay, discharge disposition, or complications in the first 90 days were noted. ITM patients received fewer milligram morphine equivalents in the postanesthesia care unit (9.7 ± 31.23 vs 21.83 ± 21.07; P = 0.006) and on postoperative day 0 (18.60 ± 35.47 vs 35.47 ± 28.51; P = 0.001). Pain scores were lower in the ITM group both in the postanesthesia care unit and on postoperative day 0, with a decrease in extreme pain scores (>7; 35.4% vs 53.0%; P = 0.034). CONCLUSIONS: ITM appears to be safe and effective for reducing early pain and narcotic consumption on the day of surgery for lumbar fusion patients and may hold value for incorporation into rapid recovery protocols and for improving pain-related patient satisfaction. CLINICAL RELEVANCE: ITM appears to be safe and effective for reducing early pain and narcotic consumption on the day of surgery for lumbar fusion patients and may hold value for incorporation into rapid recovery protocols and for improving pain-related patient satisfaction.

Postoperative Outcomes in Patients Undergoing Orthopaedic Surgery Within 90 Days of Coronavirus Disease 2019.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic with several hundred million infections worldwide. COVID-19 causes systemic complications that last beyond the initial infection. It is not known whether patients who undergo elective orthopaedic surgeries after COVID-19 are at increased risk of complications. The purpose of this study was to evaluate whether patients who undergo orthopaedic procedures after recent COVID-19 diagnosis are at increased risk of complications compared with those who have not had a recent COVID-19 diagnosis. METHODS: The TriNetX Research Network database was queried for patients undergoing elective orthopaedic surgeries from April 2020 to January 2022 in the following subspecialties: arthroscopic surgery, total joint arthroplasty, lumbar fusion, upper extremity surgery, foot and ankle (FA) surgery. Cohorts were defined by patients undergoing surgery with a diagnosis of COVID-19 from 7 to 90 days before surgery and those with no COVID-19 diagnosis 0 to 90 days before surgery. These cohorts were propensity-score matched based on differences in demographics and comorbidities. The matched cohorts were evaluated using measures of association analysis for complications, emergency department (ER) visits, and readmissions occurring 90 days postoperatively. RESULTS: Patients undergoing arthroscopic surgery were more likely to experience venous thromboembolism (VTE) ( P = 0.006), myocardial infarction ( P = 0.001), and ER visits ( P = 0.001). Patients undergoing total joint arthroplasty were more likely to experience VTE ( P < 0.001), myocardial infarction ( P < 0.001), pneumonia ( P < 0.001), and ER visits ( P = 0.037). Patients undergoing lumbar fusion were more likely to experience VTE ( P = 0.016), infection ( P < 0.001), pneumonia ( P < 0.001), and readmission ( P = 0.006). Patients undergoing upper extremity surgery were more likely to experience VTE ( P = 0.001) and pneumonia ( P = 0.015). Patients undergoing foot and ankle surgery were more likely to experience VTE ( P < 0.001) and pneumonia ( P < 0.001). CONCLUSION: There is an increased risk of complications in patients undergoing orthopaedic surgery after COVID-19 infection; all cohorts were at increased risk of VTE and most at increased risk of pneumonia. Additional investigation is needed to stratify the risk for individual patients.

Surgical management of ectopic pregnancy.

Surgery remains an acceptable, and sometimes necessary, modality for the treatment of ectopic pregnancy. Laparoscopy is the preferred method of access, yet controversy remains regarding the optimal procedure and postoperative management. Generally, salpingostomy is employed with the goal of maintaining fertility, although data to support this tenet are lacking. In most cases, the decision to perform conservative versus radical surgery is on the basis of the patient's history, her desire for future fertility, and surgical findings. The procedures of salpingostomy and salpingectomy, techniques to prevent and control blood loss at the time of surgery, and surgical options for nontubal ectopic pregnancies are reviewed.

Using the associative imagery technique in qualitative health research: the experiences of homecare workers and consumers.

The associative imagery technique is a qualitative tool with which researchers use carefully selected photographs or images to trigger participants' responses to explain difficult behavioral and social concepts. In this article, we describe the development and implementation of the associative imagery method in focus groups to understand the complex relationships between homecare workers and their clients as part of a larger health and safety intervention project conducted by the National Institute for Occupational Safety and Health. A total of 116 homecare workers and clients were recruited for the study. We found that participants used images mainly in two ways. First, the images served to remind participants of specific persons, events, and/or objects. Second, the images facilitated recollections and reflections that allowed participants to metaphorically describe their experiences, feelings, and emotions. Both usages of imagery generated comments that answered the research question in a more relevant, descriptive, and vivid way.

Analysis of Risk Factors for High-Risk Patients Undergoing Total Joint Arthroplasty.

Background: The purpose of this study is to evaluate and redefine patients at high risk for increased resource utilization and complications after total joint arthroplasty (TJA), so interventions may focus on patients standing to receive the most benefit. Material and methods: This is a retrospective study of 787 patients undergoing primary unilateral TJA from September 1, 2020, to September 31, 2021. Patients were deemed to be at "high risk" based on criteria derived from published literature and triaged to an enhanced preoperative education program. Patients that were discharged to a skilled nursing facility, had a length of stay ≥ 2 days, returned to the emergency department, or readmitted within 30 days were classified as having a composite outcome. A univariate analysis compared patients who did and did not experience the composite outcome, and multivariate regression was performed to evaluate predictors of this endpoint. Results: Differences in rates of 5 of the 28 risk factors were present between patients who did and did not experience composite outcomes. After controlling for other factors, African American race, planned discharge to skilled nursing facility, mental health conditions or drug use, cardiac, and neurologic conditions were predictive of the composite outcome. Patients who were reclassified as "high risk" with 1 or more of these characteristics, experienced longer length of stay and lower rates of home discharge than the rest of the population. Conclusion: This study presents a profile of high-risk TJA patients that can be incorporated into clinical practice for risk stratification and targeted intervention.

Worker Perspectives on COVID-19 Risks: A Qualitative Study of Latino Construction Workers in Oakland, California.

Latino construction workers in the U.S. have faced a disproportionate risk for COVID-19 infection in the workplace. Prior studies have focused on quantifying workplace risk for COVID-19 infection; few have captured workers' experiences and perspectives. This study describes COVID-19-related workplace risks from the perspectives of Latino construction workers. We conducted a qualitative study using semi-structured phone interviews with Latino construction workers from the Fruitvale District of Oakland, California. Twenty individuals were interviewed from December 2020 to March 2021. Nearly all participants (19/20) were Spanish-speaking men; mean age 42.6 years. The majority were low-income and over one-third did not have health insurance. Participants worked in varied construction-related jobs ranging from demolition to office work; additionally, four were day laborers, and three belonged to a labor union. We identified four major themes with public health policy and workplace safety implications: (1) Major concern about the risk of SARS-CoV-2 infection for family health and economic wellbeing; (2) Clarity about mask use and social distancing but not disclosure; (3) Variability in access to additional resources provided by employers; and (4) Uncertainty around structural support for SARS-CoV-2 quarantine/isolation. Our findings provide further evidence from workers' own perspectives of the major gaps experienced during the pandemic in workplace protections and resources.

Postoperative outcomes of mepivacaine vs. bupivacaine in patients undergoing total joint arthroplasty with spinal anesthesia.

BACKGROUND: Spinal anesthesia (SA) has been previously associated with improved outcomes after total joint arthroplasty (TJA). The purpose of this study was to compare outcomes between various local anesthetics. METHODS: This was a retrospective study of 1,328 patients undergoing primary TJA with SA from September 2020-2021 at a single institution. Patients were grouped based on TKA or THA and further separated and analyzed in terms of anesthetic agents-mepivacaine (M), hyperbaric bupivacaine (HB), or isobaric bupivacaine (IB). Subgroup analysis of same-day-discharge (SDD) patients and low- (<11 mg) and high-dose bupivacaine was performed. Statistical significance was assessed at P<0.05. RESULTS: Mepivacaine use was associated with younger age, lower ASAs, and lower Charlson Comorbidity Index (CCI) scores in both THAs and TKAs. Postoperatively, significant differences were found between HB, IB, and M in LOS, the first PT ambulation distance and rates of SDD, and home discharge in both THAs and TKAs. No significant differences in outcomes were observed between high- and low-dose bupivacaine in THAs or TKAs. In SDD patients, a significant difference was found only in the first 6-clicks mobility scores. After controlling for age, BMI, sex, ASA, and procedure type, mepivacaine was found to be associated with shorter LOS, increased likelihood of SDD, home discharge, POD-0 ambulation, and, further, the first ambulation distance. No significant differences were observed in 6-clicks mobility scores, urinary retention, 30-day ED returns or 30-day readmissions. CONCLUSIONS: Both bupivacaine and mepivacaine are safe and effective local anesthetics for patients undergoing TJA as evidenced by low, similar rates of urinary retention and 30-day ED returns and readmissions. Mepivacaine does appeared to facilitate early ambulation, shorter LOS and home discharge and should be considered as the local anesthetic of choice for patients undergoing rapid recovery TJA.

Impact of California Safe Patient Handling Legislation: Health Care Workers' Perspectives.

BACKGROUND: Musculoskeletal injuries from patient handling are significant problems among health care workers. In California, legislation requiring hospitals to implement safe patient handling (SPH) programs was enacted in 2011. This qualitative study explored workers' experiences and perceptions about the law, their hospital's SPH policies and programs, patient handling practices, and work environment. METHODS: Three focus groups were conducted with 21 participants (19 nurses and 2 patient handling specialists) recruited from 12 hospitals located in the San Francisco Bay Area and San Joaquin Valley. Qualitative content analysis was used for data analysis. RESULTS: Multiple themes emerged from diverse experiences and perceptions. Positive perceptions included empowerment to advocate for safety, increased awareness of SPH policies and programs, increased provision of patient handling equipment and training, increased lift use, and improvement in safety culture. Perceived concerns included continuing barriers to safe practices and lift use such as difficulty securing assistance, limited availability of lift teams, understaffing, limited nursing employee input in the safety committee, blaming of individuals for injury, increased workload, and continuing injury concerns. Participants indicated the need for effective training, sufficient staffing, and management support for injured workers. CONCLUSIONS/APPLICATION TO PRACTICE: This study identified improvements in hospitals' SPH programs and practices since the passage of California's SPH law, as well as continuing challenges and barriers to safe practices and injury prevention. The findings provide useful information to understanding the positive impacts of the SPH law but also notes the potential limitations of this legislation in the view of health care workers.

The role for community-based participatory research in formulating policy initiatives: promoting safety and health for in-home care workers and their consumers.

Although community-based participatory research (CBPR) can be effective in influencing policy, the process of formulating policy initiatives through CBPR is understudied. We describe a case study to illustrate how alliances among various community partners could be united to formulate policy directions. In collaboration with partners, the National Institute for Occupational Safety and Health initiated a project aimed at improving health and safety for low-income elderly and disabled persons and their in-home care workers. Community partners and stakeholders participated in focus groups, stakeholder interviews, and meetings; they played multiple roles including identifying organizational policy changes the partners could initiate immediately, as well as broader public policy goals. Results indicated that a strong community partnership, participation, and shared values contributed to successful formulation of policy initiatives.

Subsequent pregnancy outcomes after obstetric anal sphincter injuries (OASIS).

OBJECTIVES: To describe obstetric outcomes in women with a prior obstetric anal sphincter injury (OASIS) and to identify risk factors for recurrence. METHODS: A retrospective chart review of women who sustained an OASIS between November 2005 and March 2010 at a tertiary care hospital was performed to identify risk factors for recurrence. RESULTS: One thousand six hundred twenty-nine patients had an OASIS. Of these, 758 patients (90%) subsequently delivered during the aforementioned timeframe; 685 patients had a subsequent vaginal delivery. Of the women, 3.2% had a recurrent OASIS. Recurrence was associated with larger birth weight (27% ≥4000 g vs 11.6% <4000 g; P = 0.04) and delivery mode (25.0%, 12.5%, and 2.7% for forceps-assisted, vacuum-assisted, and spontaneous deliveries, respectively (P = 0.0001)), whereas a history of fourth-degree laceration, prior wound complication, or episiotomy at subsequent delivery were not (P = 0.5, P = 0.5, and P = 0.4, respectively). CONCLUSIONS: Recurrent OASIS occurred in a small percentage of women (3.2%) who subsequently delivered vaginally. Recurrent OASIS was associated with operative vaginal delivery and birth weight 4000 g or greater. Neither episiotomy at first delivery nor at subsequent delivery conferred an increased recurrence risk.