Impact of Weight-Band Dosing of Tinzaparin for Venous Thromboembolism Prophylaxis on Persistent Wound Drainage in Adult Patients Undergoing Hip and Knee Arthroplasty.

BACKGROUND: Persistent wound drainage and venous thromboembolism (VTE) are potential complications of total joint arthroplasty, and these risks can be challenging to balance in clinical practice. Anecdotal observation has suggested that following joint arthroplasty, persistent wound drainage occurs more frequently with higher body weight and higher doses of tinzaparin when compared with lower body weight and lower doses of tinzaparin. OBJECTIVE: The overall purpose of this study was to describe the impact of a tinzaparin weight-band dosing table for VTE prophylaxis on wound healing, thrombosis, and bleeding outcomes in patients undergoing total joint arthroplasty. METHODS: This retrospective chart review included patients who underwent total hip or knee arthroplasty and received tinzaparin for thromboprophylaxis per their weight-banding category. The primary outcome was the incidence of persistent wound drainage. Secondary outcomes include the occurrence of VTE and clinically important bleeding during hospital admission. RESULTS: A total of 231 patients were included in the analysis. There was no significant difference in persistent wound drainage between the 3 weight categories, and there were no differences in rates of VTE or clinically important bleeding. Concurrent use of low-dose acetylsalicylic acid was associated with a 3-fold increased risk of persistent wound drainage (risk ratio = 3.35; 95% CI = 2.14-5.24; P = 0.00003). CONCLUSION AND RELEVANCE: In joint arthroplasty patients, we observed no significant difference in rates of persistent wound drainage between various weight categories receiving different weight-banded doses of tinzaparin. Our results do not suggest that the current weight-band dosing table for tinzaparin needs to be adjusted to optimize patient outcomes.

Rapid conversion of an in-patient hospital unit to accommodate COVID-19: An interdisciplinary human factors, ethnography, and infection prevention and control approach.

BACKGROUND: In response to the Coronavirus disease-19 (COVID-19) pandemic, in-patient units in hospitals around the world have altered their patient care routines and Infection Prevention and Control (IPC) practices. Our interdisciplinary team of applied Human Factors (HF), ethnography, and IPC experts assisted one Unit, normally serving general surgical and orthopedic patients, as it rapidly converted to deliver COVID-19-specific care. This paper describes the conversion experience of the Unit, and outlines broader lessons for other acute care teams faced with similar issues. METHODS: We deployed walkthroughs, simulations, and ethnography to identify important safety gaps in care delivery processes on the Unit. These interventions were undertaken using interdisciplinary theories of implementation that combined systems-level HF perspectives, ethnographic approaches, and individual-level IPC perspectives. Timely recommendations were developed and delivered to Unit staff for feedback and implementation. RESULTS: We describe three interventions on the Unit: 1) the de-cluttering and re-organization of personal protective equipment (PPE); 2) the reconfiguring of designated 'dirty' tray tables and supplies; and 3) the redesign of handling pathways for 'dirty' linens and laundry. Each of these interventions was implemented to varying degrees, but all contributed to discussions of safety and IPC implementation that extended beyond the Unit and into the operations of the broader hospital. CONCLUSIONS: Leveraging our team's interdisciplinary expertise and blended approaches to implementation, the interventions assisted in the Unit's rapid conversion towards providing COVID-19-specific care. The deployment and implementation of the interventions highlight the potential of collaboration between HF, ethnography, and IPC experts to support frontline healthcare delivery under pandemic conditions in an effort to minimize nosocomial transmission potential in the acute healthcare setting.

Antiemetics for Postoperative Nausea and Vomiting in Patients Undergoing Elective Arthroplasty: Scheduled or As Needed?

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most commonly reported adverse experiences after surgery. PONV is a major risk factor for delayed patient mobilization and consequently increased length of hospital stay. OBJECTIVES: The primary objective was to compare the effectiveness of scheduled versus as-needed administration of antiemetic for the prevention and treatment of PONV in the first 48 h after elective hip or knee arthroplasty. The secondary objective was to determine whether PONV affected mobilization on either postoperative day 0 or postoperative day 1 in each study group. METHODS: This retrospective cohort study used chart reviews for collection of patient data. PONV and mobilization were compared for patients who received antiemetics on a scheduled or as-needed basis following elective hip or knee arthroplasty performed between January and September 2016. RESULTS: Of the 132 patients included in the study, 65 received antiemetics on an as-needed basis and 67 had scheduled antiemetic therapy. Thirty-one (46%) of the patients in the "scheduled" group received antiemetics as intended; the others missed one or more of the scheduled doses. There was no statistical difference in PONV between treatment groups with either intention-to-treat or as-treated analysis. Furthermore, there was no statistically significant difference in mobilization, on either POD 0 or POD 1, between patients who received scheduled antiemetic and those who received antiemetic on an as-needed basis. CONCLUSIONS: Scheduled use of antiemetics did not significantly affect PONV, nor did it positively influence mobilization in the postoperative period for patients undergoing elective arthroplasty. Further high-quality prospective studies are needed to confirm these results.

CONTEXTE: Les nausées et vomissements postopératoires sont parmi les réactions indésirables les plus fréquentes après une intervention chirurgicale. Elles représentent un facteur de risque important de retard de mobilisation et par conséquent de prolongation du séjour à l'hôpital. OBJECTIFS: L'objectif principal visait la comparaison de l'efficacité d'une administration régulière d'antiémétiques à une administration au besoin pour la prévention et le traitement des nausées et vomissements postopératoires au cours des 48 heures suivant une arthroplastie nonurgente de la hanche ou du genou. L'objectif secondaire était de déterminer si les nausées et vomissements postopératoires avaient des répercussions sur la mobilisation des patients durant la journée postopératoire 0 ou 1 dans chaque groupe à l'étude. MÉTHODES: Les données de la présente étude de cohorte rétrospective proviennent des analyses de dossiers des patients. La comparaison portait sur les nausées et vomissements postopératoires et la mobilisation de patients ayant reçu des antiémétiques prescrits régulièrement ou au besoin après avoir subi une arthroplastie non-urgente de la hanche ou du genou, réalisée entre janvier et septembre 2016. RÉSULTATS: Parmi les 132 patients admis à l'étude, 65 ont reçu des antiémétiques au besoin et 67 en ont pris régulièrement. Trente et un (46 %) patients du groupe auquel on avait prescrit une prise régulière ont reçu des antiémétiques comme prévu, les autres ont sauté une ou plusieurs doses prévues. Aucune différence statistique n'a été relevée quant aux nausées et vomissements postopératoires entre les groupes, que ce soit à l'aide d'une analyse selon l'intention de traiter ou selon le traitement reçu. De plus, il n'y avait aucune différence statistiquement significative du point de vue de la mobilisation, pour les jours postopératoires 0 et 1 entre les patients ayant pris régulièrement des antiémétiques et ceux en ayant pris au besoin. CONCLUSIONS: L'administration régulière d'antiémétiques n'a pas eu d'effet significatif sur les nausées et vomissements postopératoires tout comme elle n'a pas influencé positivement la mobilisation au cours de la période postopératoire des patients ayant subi une arthroplastie non-urgente. De plus amples études prospectives de grande qualité sont nécessaires pour confirmer ces résultats.