Improving the weekend spinal ward round at a major trauma centre.

BACKGROUND/AIMS: Documentation is key for communicating between members of the multidisciplinary team, allowing for better care, but documentation for spinal patients in the authors' centre was poor. METHODS: Every ward round encounter was analysed for six weekends. Data were analysed and presented to the department. A weekend ward round proforma was designed to help improve ward-round documentation. Ward round entries were then re-audited over four weekends to assess the usefulness of the new proforma. RESULTS: A total of 69 patient encounters were analysed in cycle 1, 58 in cycle 2 and 92 in cycle 3. In cycle 1, 80% of encounters had inadequate documentation. Following introduction of the ward round proforma there was a significant improvement in documentation in six out of fields, which was maintained in four out of seven fields 2 years later. CONCLUSIONS: The authors believe that this improvement may avoid adverse effects on patient care, streamline doctors' time and reduce medicolegal consequences.

Implementing the "Getting It Right First Time" (GIRFT) Report Recommendations: The Results of Introducing a Shoulder and Elbow Multidisciplinary Team.

Objective In this study, we aimed to analyse the impact of implementing the "Getting It Right First Time" (GIRFT) recommendations in our shoulder and elbow unit, which included the introduction of a shoulder and elbow multidisciplinary team (MDT) meeting for all patients being considered for surgery. Methods A retrospective patient case-note review was undertaken to assess the impact of replacing the pre-admission clinic with an MDT meeting. We analysed how many of the proposed management plans were changed as a result of this new MDT, as well as the associated cost savings. Results Of note, 118/148 patients who attended the MDT had a provisional operative plan; 24/118 (20%) had their plan changed to non-operative management, 13/118 (11%) had a change of operation, and 6/118 (5%) were recommended further investigations or tertiary referral. This reduced theatre time required by 47 hours, an estimated saving of over £51,000. Significantly, 20/24 patients who had their plan changed from operative to non-operative still had not had an operation after a median follow-up of 39 months. Conclusion The introduction of a shoulder and elbow MDT for all patients being considered for an operation has improved decision-making, allowed optimisation of non-operative management, and helped prevent patients from having unnecessary operations. This has led to a better patient experience and a more efficient service delivery, which is associated with cost savings.

Dual Surgeon Operating in Reverse Geometry Total Shoulder Replacement: The Learning Curve and Its Effects on Complication Rates.

Aims We analyse the impact of implementing dual surgeon operating for reverse geometry total shoulder replacement (RGTSR) as part of the "Getting It Right First Time" (GIRFT) recommendations in our shoulder and elbow unit, and the learning curve associated with it. Methods We performed a retrospective cohort study comparing operative time and complication rates in patients who underwent RGTSR performed by a single consultant surgeon versus two consultant surgeons over a six-year period in a single centre, in addition to an analysing the learning curve over the same period. Results A total of 74 RGTSRs were performed over a six-year period: 35 patients had a single surgeon perform their procedure and 39 had dual surgeon operating. Observed complication rates for RGTSR nearly halved following the introduction of dual surgeon operating (22.9% vs 12.8%, p=0.36). The complication rate for the first 37 cases was 9/37 (24.4%) versus 4/37 (10.8%, p=0.22) for the next 37 cases. Conclusion The implementation of dual surgeon operating may lead to reduced operative complications, provide cost savings to the hospital and produced several other non-tangible benefits to the surgeons and the department. An observed reduction in complication rates demonstrates the learning curve associated with this procedure.

Rationalization of Orthopaedic Surgical Instrument Trays: Three Years' Experience of a Practical Approach to Cut Down Unnecessary Costs.

Background This study aimed to rationalize the surgical instrument trays (SITs) used in some trauma and orthopedic (T&O) procedures to reduce unnecessary costs. Methods SITs for several T&O procedures at our trust were assessed to judge the utility of each instrument. SITs for hip, knee, and shoulder arthroscopy, dynamic hip screw (DHS), rotator cuff repair, shoulder stabilization, total shoulder arthroplasty (TSR), and proximal humerus fracture fixation were reviewed. Infrequently used and irrelevant instruments were removed to minimize the number of used trays for each procedure. A qualitative survey was conducted following SIT rationalization to assess the practicality and suitability of these changes. Results The number of SITs was rationalized from four to two for DHS, three to one for hip, knee, and shoulder arthroscopy, five to two for rotator cuff repair and shoulder stabilization, three to one for TSR, and proximal humerus fracture fixation. Based on the local database figures for these procedures, the estimated number of used trays reduced from 2,785 to 1.015 (36.4%) trays per year. Based on the sterilization cost of £35 per tray, annual savings amounted to about £61,950. Qualitative analysis of theatre staff feedback showed increased time efficiency and a positive feeling of practicality. Conclusion The critical appraisal of the departmental operating practice is an effective tool to achieve cost-efficient practice. The rationalization of SITs for orthopedic procedures can result in significant savings by reducing sterilization costs alone.

The use of low-intensity pulsed ultrasound in treating delayed union of fifth metatarsal fractures.

BACKGROUND: There are no studies looking at the success rate of low-intensity pulsed ultrasound (LIPUS) in fifth metatarsal fracture delayed unions to our knowledge. The aim of this study is to investigate the use of LIPUS treatment for delayed union of fifth metatarsal fractures. METHODS: A retrospective review of patients who were treated with LIPUS following a delayed union of fifth metatarsal fracture was conducted over a three-year period. RESULTS: There were thirty patients (9 males, 21 females) in this cohort. The average age was 39.3 years. Type 2 fractures made up 43% of our cohort. Twenty-seven (90%) patients went on to progress to union clinically and radiologically following LIPUS treatment. Smoking (p=0.014) was predictive of non-union. Assuming that there were 10 delayed unions a year and 6 went on to non-union as previously suggested by a systematic review, the cost savings of using LIPUS (90% success rate; 10 LIPUS machine and surgery for 1 non-union) vs operative intervention (surgery for 6 non-union) equates to a cost saving of £7765 a year. CONCLUSION: There is a role for the use of LIPUS in delayed union of fifth metatarsal fractures and can serve as an adjunct prior to consideration of surgery. The findings of this study also suggest the use of LIPUS to be a cost effective treatment modality compared to surgical management. LEVEL OF EVIDENCE: Level 4.

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.

R3 Cup Does Not Have a High Failure Rate in Conventional Bearings: A Minimum of 5-Year Follow-Up.

BACKGROUND: The R3 cementless acetabular system was first marketed in Australia and Europe in 2007. Previous papers have shown high failure rates of the R3 cup with up to 24% with metal-on-metal bearing. There are currently no medium term clinical results on this cup. The aim of the study is to review our results of the R3 acetabular cup with conventional bearings with a minimum of 5-year follow-up. METHODS: Patients who were implanted with the R3 acetabular cup were identified from our center's arthroplasty database. A total of 293 consecutive total hip arthroplasties were performed in 286 patients. The primary outcome was revision. The secondary outcomes were the Oxford Hip Scores (OHS) and radiographic evaluation. RESULTS: The mean age of the patients was 69.4 years. The mean preoperative OHS was 23 (range 10-34) and the mean OHS was 40 (range 33-48) at the final follow-up. Radiological evaluation showed an excellent ARA score in all patients at 5 years. None of the R3 cups showed osteolysis at the final follow-up. There were 3 revisions in our series, of which 2 R3 cups were revised. The risk of revision was 1.11% at 5 years. CONCLUSION: Our experience of using the R3 acetabular system with conventional bearings showed high survivorship and is consistent with the allocated Orthopaedic Data Evaluation Panel rating of 5A* as rated in 2015 in the United Kingdom.