Case series of acute appendicitis association with SARS-CoV-2 infection.

BACKGROUND: Describe the indications for surgical interventions in asymptomatic patients with SARS-CoV-2. We are unaware of previous reports of an association between SARS-CoV-2 and acute appendicitis. METHODS: We performed a single institution retrospective review of SARS-CoV-2 pre-procedure testing and indications for surgical intervention. Statistical comparisons were performed using Chi Square analysis or two-tailed Student T test. RESULTS: We report a high prevalence of SARS-CoV-2 in both all testing and pre-procedure testing during the enrollment period. We observe a high prevalence of acute appendicitis among patients identified to be SARS-CoV-2 positive during pre-procedure testing and without recognized symptoms of COVID19. CONCLUSION: We report a previously unrecognized association between SARS-CoV-2 and acute appendicitis.

Changing Osteoporosis Knowledge and Behaviors Through Structured Education.

Osteoporosis is a silent disease that is associated with enormous cost and can lead to disability and death. We identified that individuals who have sustained a fracture from a fall are often unaware of osteoporosis risk factors and have a knowledge deficit regarding osteoporosis. Therefore, they do not receive the proper treatment. An evidence-based practice project was completed using "pre-post" intervention tools with an educational intervention to measure osteoporosis knowledge and self-efficacy in individuals hospitalized with a fragility fracture. A convenience sample of 25 participants 50 years and older, who were admitted with a fragility fracture, received targeted education. Descriptive and comparative statistics were used for comparison of pre- and postintervention data. Hospitalized osteoporotic individuals have a gap in knowledge regarding the existence of osteoporosis. Healthcare workers can improve knowledge and self-efficacy by offering osteoporosis education for these individuals.

Longer Length of Stay Increases 1-year Readmission Rate in Patients Undergoing Hip Fracture Surgery.

BACKGROUND: Proximal femur fractures are prevalent among the elderly and associated with substantial morbidity, mortality, and early readmission. Early readmission is gaining popularity as a measure of quality of hospital care and can lower reimbursement. A better understanding of the patient and treatment characteristics associated with readmission may help inform program improvement initiatives. This study tested the primary null hypothesis that length of stay is not associated with higher rates of readmission within 30 days and 1 year in patients having operative treatment of a proximal femur fracture, accounting for discharge destination and other factors. METHODS: We performed a secondary analysis on a database of 1,061 adult patients, age 55 years or older, admitted for treatment of a proximal femoral fracture in an urban level 2 trauma center. Multivariable logistic and linear regression models were created to account for the influence of age, sex, race, BMI, American Society of Anesthesiologists score (ASA), fracture type (AO/OTA), fixation type, operating surgeon, operative duration, and discharge destination. RESULTS: In multivariable logistic regression analysis, treatment by surgeon 4 was independently associated with a lower 30-day readmission rate. Higher one-year readmission rate was associated with a longer length of stay, ASA class 3, 4 and 5. CONCLUSION: The observation that patients cared for by specific surgeons are more likely to experience readmission within one year of surgery for a fracture of the proximal femur, suggests that program improvements to identify and disseminate best practices might reduce readmission rates. LEVEL OF EVIDENCE: III.

Lower Bone Mineral Density is Associated with Intertrochanteric Hip Fracture.

BACKGROUND: A better understanding of how bone mineral density and vitamin D levels are associated with femoral neck and intertrochanteric hip fractures may help inform healthcare providers. We asked: 1) In patients age ≥ 55 years, is there a difference in quantitative ultrasound of the heel (QUS) t-score between patients with fractures of the femoral neck and those with fractures of the intertrochanteric region, accounting for other factors 2) In patients age ≥ 55 years, is there a difference in vitamin D level between those with fractures of the femoral neck and those with fractures of the intertrochanteric region, accounting for other factors? 3) Is there an association between vitamin D level and QUS t-score? METHODS: In this retrospective cohort study, 1,030 patients were identified using CPT codes for fixation of hip fractures between December 2010 and September 2013. Patients ≥ 55 years of age who underwent operative management for a hip fracture following a fall from standing height were included. Three orthopaedic surgeons categorized fracture type using patient radiographs. Upon hospital admission, QUS t-scores and vitamin D levels were determined. Descriptive statistics, bivariate analyses and multivariable regression were performed. RESULTS: Accounting for potential confounders, patients with lower QUS t-scores were more likely to have intertrochanteric femur fractures than femoral neck fractures. In a bivariate analysis, there was no association between vitamin D level and either fracture type. There was no association between vitamin D level and bone mineral density. CONCLUSION: Patients with lower bone density that fracture their hips are more likely to fracture in the intertrochanteric region than the femoral neck, but vitamin D levels are unrelated. Awareness of this association emphasizes the importance of bone mineral density screening to assist with intertrochanteric hip fracture prevention. LEVEL OF EVIDENCE: III.

Substantial improvement in prophylactic antibiotic administration for open fracture patients: results of a performance improvement program.

OBJECTIVES: Administration of early and appropriate antibiotic in treating patients with open fractures is an important early factor in preventing infection and optimizing outcomes. The purpose of this study is to evaluate the effects of an orthopaedic trauma performance improvement program directed at early antibiotic administration for open fracture patients at our trauma center. DESIGN: Retrospective comparative cohort study of patients treated for an open fracture by before and after implementation of our performance improvement program specifically designed to address early open fracture care. SETTING: Single metropolitan level 2 regional trauma center. PATIENTS: Patients with open fractures treated by orthopaedic surgery (hand and spine excluded) at our institution between January 2012 and December 2013 were included. Patients transferred from another facility were excluded. INTERVENTION: Patients were divided into one of the following 2 groups. Group 1 included patients treated before our open fracture performance improvement program (January 2012-December 2012) and group 2 comprised those treated after the program was instituted (January 2013-December 2013). MAIN OUTCOME MEASUREMENTS: Patient demographics, injury factors, and performance measures relating to early open fracture care [eg, the characteristics of early antibiotic administration in their treatment course, including timeliness of prophylactic intravenous (IV) antibiotic therapy and reasons for delay or omission of these treatments] were evaluated. RESULTS: Group 1 was comprised of 127 patients with a total of 142 open fractures, whereas group 2 included 132 patients with a total of 156 open fractures. Patient and injury factors were not significantly different between the 2 groups. Group 1 received IV antibiotics at an average of 70.5 minutes after arrival at our institution compared with group 2 who received antibiotics at an average of 32.4 minutes (P < 0.001). The average times from emergency department arrival to physician evaluation improved from 6.5 to 4.5 minutes (P = 0.02) and antibiotic order to antibiotic delivery improved from 37 to 13 minutes (P < 0.001) for group 1 compared with group 2, respectively. The average time between physician evaluation and antibiotic showed a trend toward improvement (12.7-8.0 minutes, P = 0.57). Fifty percent of patients in group 1 (63/127) had antibiotics initiated within 1 hour of hospital arrival, whereas 78% (100/132) in group 2 had antibiotics initiated within 1 hour (P < 0.001). Eighty-five percent (112/127) of patients in group 1 had antibiotics initiated within 3 hours of hospital arrival, whereas 95% (125/132) in group 2 had antibiotics initiated within 3 hours (P = 0.03). Of those patients receiving standard antibiotics (cephalosporin), 79% (85/107) in group 1 and 91% (104/114) in group 2 received the recommended dose of IV antibiotic for their body weight (e.g., 2 g cefazolin for patients of >80 kg) (P < 0.006). CONCLUSIONS: Optimal treatment of open fracture patients with early and appropriate antibiotic prophylaxis was lacking for many patients at our trauma center. A multifaceted performance improvement program specifically concentrating on education, accountability, and antibiotic availability aimed at this aspect of orthopaedic trauma care was very effective in improving our early treatment of these patients. LEVEL OF EVIDENCE: Therapeutic level III. See instructions for authors for a complete description of levels of evidence.

Measures of clinical outcome before, during, and after implementation of a comprehensive geriatric hip fracture program: is there a learning curve?

OBJECTIVES: To evaluate the effects of implementing a multidisciplinary geriatric hip fracture program on clinical outcome measures at our institution. DESIGN: Retrospective comparative cohort study of consecutive patients treated before, during, and after implementation of this program, including patient data from electronic medical records and state death records. SETTING: Single metropolitan level 2 regional trauma center and community hospital. PATIENTS/PARTICIPANTS: Patients aged 60 years and older with operatively treated low-energy hip fractures were included. Patients with active cancer or a high-energy mechanism (motor vehicle crash or fall >3 ft) were excluded. INTERVENTION: Patients were divided into 1 of 3 groups: (1) those treated before our hip fracture program (July 2008-April 2009), (2) during implementation of the hip fracture program (May 2009-Feb 2010), and (3) after the hip fracture program was instituted and participation was well established (March 2010-Dec 2010). MAIN OUTCOME MEASURES: Patient demographics, injury factors, and clinical outcomes, including performance measures (eg, time to medical clearance and surgery and length of stay) and patient deaths (in-hospital, 30 days, and 1 year), were compared. RESULTS: There was significant improvement in clinical performance measures, including time to surgery and length of stay during and after implementation of our geriatric hip fracture program. The in-hospital mortality rate increased during the implementation phase of this program (P = 0.04). Once established, however, the in-hospital mortality decreased to a more typical level. Thirty-day and 1-year mortality rates were not significantly different among the 3 groups. CONCLUSIONS: Most clinical outcome measures improved significantly with implementation of our geriatric hip fracture program. Increased in-hospital mortality, however, was an unintended consequence seen while establishing this program and may represent a learning curve by health care providers. Patient demise in the longer term seemed to be unaffected by implementation of the program. LEVEL OF EVIDENCE: Therapeutic level III.

A clinical nurse specialist led journey to the Joint Commission disease-specific certification in hip fractures.

The Joint Commission's Disease-Specific Care Certification Program, launched in 2002, is designed to evaluate clinical programs across the continuum of care. Organizations may seek certification for virtually any chronic disease or condition. Successful accomplishment of certification means you have demonstrated a commitment to providing quality care and you seek to continuously improve that care. As a Level II trauma center, we know that hip fractures occurring in older adults are a common and serious condition, frequently leading to functional decline, morbidity, and mortality. As one consequence of the aging of America, the incidence of hip fractures is steadily increasing. The process of applying for this certification has provided us with a solid structure on which to continue to build and maintain our disease management programs. This has resulted in a multidisciplinary approach to standardization of care, greater efficiency, and ultimately better outcomes for the hip fracture population that we serve.