Managing Craniomaxillofacial Injury Without Inpatient Consult: Outcomes and Patient Cost Savings.

BACKGROUND: We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients. METHODS: A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded. RESULTS: 303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS (P < .001) and needed surgery on admission (P < .001), while no-CMF consults had shorter length of stay (P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96. DISCUSSION: Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

Development of an Operative Trauma Course in Uganda-A Report of a Three-Year Experience.

BACKGROUND: Trauma is a leading cause of morbidity and mortality in low-income countries. Improved health care systems and training are potential avenues to combat this burden. We detail a collaborative and context-specific operative trauma course taught to postgraduate surgical trainees practicing in a low-resource setting and examine its effect on resident practice. METHOD: Three classes of second year surgical residents participated in trainings from 2017 to 2019. The course was developed and taught in conjunction with local faculty. The most recent cohort logged cases before and after the course to assess resources used during initial patient evaluation and operative techniques used if the patient was taken to theater. RESULTS: Over the study period, 52 residents participated in the course. Eighteen participated in the case log study and logged 117 cases. There was no statistically significant difference in patient demographics or injury severity precourse and postcourse. Postcourse, penetrating injuries were reported less frequently (40 to 21% P < 0.05) and road traffic crashes were reported more frequently (39 to 60%, P < 0.05). There was no change in the use of bedside interventions or diagnostic imaging, besides head CT. Of patients taken for a laparotomy, there was a nonstatistically significant increase in the use of four-quadrant packing 3.4 to 21.7%) and a decrease in liver repair (20.7 to 4.3%). CONCLUSIONS: The course did not change resource utilization; however, it did influence clinical decision-making and operative techniques used during laparotomy. Additional research is indicated to evaluate sustained changes in practice patterns and clinical outcomes after operative skills training.

[Prioritization or unlimited resources in orthopedics and trauma surgery?] / Priorisierung oder unbegrenzte Ressourcen in Orthopädie und Unfallchirurgie?

The development of the healthcare system in Germany is increasingly approaching human and economic limits. A social consensus and a political concept at which point priorities are promoted and for which services the money should be primarily spent, do not exist on the whole. As soon as it becomes clear that resources are limited and that is now, prioritization has to be introduced to avoid the alternative threat of rationing of treatment benefits. The goal of prioritization is to rationally and optimally use the existing but limited resources. Medical progress and the relationship to the demographic development are the variables in the future. The individual care of the patient, patients' needs and dependence on access to treatment are the foundations of ethical actions. They must be at the center of attention for doctors and nurses because, after all they are the patient's advocates in the complex healthcare system. At the same time, unjustified claims for entitlement must be rejected just as a preservation of vested rights. Efficiency and economic considerations in diagnostics and treatment are not mutually exclusive. The physician acts as a mediator between the claims of the patient to be treated, the individual realization and the existing resources in the healthcare system.

An Opinion Survey of Orthopaedic and Traumatology Surgeons Working in Outpatient Care (Society, Laws and Patients). / Eine Meinungsumfrage bei niedergelassenen Fachärzten für Orthopädie und Unfallchirurgie (Gesellschaft, Gesetz und Patienten).

BACKGROUND: The German health care system is well accepted, but efficiency, costs and patient satisfaction are sometimes criticised. Opinions and models prevail, and empirical data are rarely presented, although quantitative data are a precondition to assess the acceptance of the health care system. METHOD: To determine the appraisal of the patient-doctor relationship, economic situation and cooperation with clinical institutions, a 37 item was developed where participants indicated their agreement with a statement on a four point Likert scale. This questionnaire was answered by 525 German orthopaedic and/or traumatology surgeons, representing 7.7% of all German specialists working in outpatient care. RESULTS: 75% of all respondents felt challenged by demanding patients and a need for justification; what was less pronounced was the feeling of being exploited as physicians. Restrictions in medical treatment from budgeting expenses were seen by 74%. More than 90% considered that it was impossible to finance their medical practice expenses by conservative medical treatment only. The respondents felt similarly critical about the current cooperation with hospitals - only 19% were not interested in closer cooperation and 96% advocated higher fees for this cooperation. 74% confirmed that hospitals are taking over outpatient tasks, whereas only 35% agreed that more clinical patient care can be provided by outpatient providers, especially due to legal restrictions. DISCUSSION: Practitioning orthopaedic and traumatology surgeons feel exploited by uninformed patients, misallocation of reimbursement funds and legal restrictions, as well as unilateral substitution of outpatient care by hospitals. They do not consider that the current structures are sustainable for long term patient care.

[Cost and Revenue Relationship in Orthopaedic and Trauma Surgery Patients in Relation to Body Mass Index]. / Kosten-Erlös-Verhältnis orthopädisch-unfallchirurgischer Patienten in Abhängigkeit vom Body-Mass-Index.

BACKGROUND: Growing numbers of patients in orthopaedic and trauma surgery are obese. The risks involved are e.g. surgical complications, higher costs for longer hospital stays or special operating tables. It is a moot point whether revenues in the German DRG system cover the individual costs in relation to patients' body mass index (BMI) and in which area of hospital care potentially higher costs occur. MATERIAL AND METHODS: Data related to BMI, individual costs and revenues were extracted from the hospital information system for 13,833 patients of a large hospital who were operated in 2007 to 2010 on their upper or lower extremities. We analysed differences in cost revenue relations dependent on patients' BMI and surgical site, and differences in the distribution of hospital cost areas in relation to patients' BMI by t and U tests. RESULTS: Individual costs of morbidly obese (BMI ≥ 40) and underweight patients (BMI < 18.5) significantly (p < 0.05) exceeded individual DRG revenues. Significantly higher cost revenue relations were detected for all operations on the lower and upper extremities except for ankle joint surgeries in which arthroscopical procedures predominate. Most of the incremental costs resulted from higher spending for nursing care, medication and special appliances. Costs for doctors and medical ancillary staff did not increase in relation to patients' BMI. CONCLUSION: To avoid BMI related patient discrimination, supplementary fees to cover extra costs for morbidly obese or underweight patients with upper or lower extremities operations should raise DRG revenues. Moreover, hospitals should be organisationally prepared for these patients.

The role of computed tomography scans in diaphyseal femur fractures following gunshot injuries: A survey of orthopaedic traumatologists.

The objective of this study was to analyze if the addition of CT changed the management of femoral shaft fractures caused by gunshot wounds when compared to those managed with plain radiography alone. METHODS: A multiple-choice, single-answer electronic survey was created to compare utility of advanced imaging when treating femur fractures resulting from gunshot injury. A total of ten femoral shaft fracture cause by gunshot injuries were selected for an online survey to be administered to orthopeaedic traumatologists. The survey compared the use the of fixation device and surgical planning before and after the CT scan. RESULTS: A total of 99 surveys were initiated, of which 82 were completed. For proximal shaft fractures, 37% of experts reported that a CT scan should be ordered based on the radiograph alone, prior to reviewing the CT. After reviewing the CT, 5% of experts reported that they would have performed a "major" change, and 10% reported that they would have performed a "minor" change. 4% of surveyors would have changed their decision regarding ordering a CT. For distal femoral shaft fractures, 42% of experts selected that a CT scan would have been ordered prior to reviewing the CT. After reviewing the CT, 2% would have performed a "major" change, and 8% would have performed a "minor" change in management. 5% of surveyors would have changed their decision regarding ordering a CT. CONCLUSION: Our study demonstrated that CT scans are relatively unlikely to cause major changes in fracture management of gunshot-induced fractures of femoral shaft.

[Endoprostheses in the elderly : Biomaterials, implant selection and fixation technique]. / Endoprothetik des älteren Menschen : Biomaterialien, Implantatwahl, Verankerungstechnik.

The replacement of hip and knee joints is one of the greatest success stories in orthopedics. Due to continuous improvement of biomaterials and implant design, patient-associated problems are now mostly multifactorial and only rarely caused by the implant. Abrasion was significantly reduced by the introduction of highly cross-linked polyethylene (PE), antioxidant stabilized PE, new ceramics and the development of ceramic and protective surfaces. It is assumed that further reduction of frictional resistance will not lead to a significantly better clinical result: however, the problem of periprosthetic infections and implant-related incompatibility is still unsolved and remains challenging for biomaterial research. For the knee joint PE will be irreplaceable for joint articulation even in the future due to the contact situation. Mobile bearings and fixed bearings are two established successful philosophies, which have shown comparably good clinical results. For the hip joint, it is forecasted that ceramic-on-ceramic will be the system of the future if the correct positioning and mounting of the components can be solved so that the problems, such as development of noise and breakage can be reduced to a minimum. An in-depth understanding and detailed knowledge of the biomaterials by the surgeon can prevent implant-related problems. For elderly patients it is assumed that the economic burden on the public healthcare system will have the strongest impact on implant selection.

Operating Room Efficiency: Benefits of an Orthopaedic Traumatologist at a Level II Trauma Center.

OBJECTIVES: Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center. DESIGN: Retrospective review. SETTING: Level II community-based trauma hospital. PATIENTS/PARTICIPANTS: Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011. INTERVENTION: Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons. MAIN OUTCOME MEASUREMENTS: Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods. RESULTS: A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P , 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001). CONCLUSIONS: This study demonstrates that in our communitybased trauma system, fracture care provided by traumatologists results in improved utilization of hospital-based resources when compared with equivalent services provided by GOSs. Significantly decreased operative times, surgical labor expenses, and supply and implant costs by the fellowship-trained group represent enhanced control of the design, plan, execution, and monitoring of orthopaedic trauma care. Traumatologists can provide leadership recommendations for operating room efficiency in community-based orthopaedic trauma care models. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of Hospital-Employed Physician Assistants on a Level II Community-Based Orthopaedic Trauma System.

OBJECTIVES: The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital. DESIGN: Retrospective case series. SETTING: Level II trauma center. PATIENTS/PARTICIPANTS: One thousand one hundred four trauma patients with orthopaedic injuries. INTERVENTION: PA involvement. MAIN OUTCOME MEASUREMENTS: Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients. RESULTS: At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27). CONCLUSIONS: Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Value of a Dedicated Saturday Orthopaedic Trauma Operating Room.

OBJECTIVES: To determine the effect of an additional scheduled operative day on length of stay, distribution of caseload, waiting time to surgery, and direct variable hospital costs. DESIGN: Retrospective chart review. SETTING: Urban level 1 trauma center. PATIENTS: Consecutive operative tibia and femur fractures admitted from November 1, 2009, to October 31, 2011. INTERVENTION: Addition of a dedicated Saturday orthopaedic trauma operating room. MAIN OUTCOME MEASUREMENTS: Length of stay, distribution of caseload, and waiting time to surgery. RESULTS: The overall length of stay for all trauma patients admitted with femur or tibia fractures was significantly reduced by 2.7 days from a mean of 14.0-11.3 days (P value 0.018). Additionally, there was a trend toward shorter waiting time to surgery (average reduction of 25.1 hours) for patients admitted on a Friday (48.6 vs. 23.5 hours, P value 0.06). Furthermore, there was an increase in the number of cases performed on Saturdays by 59% (6.2% of the total caseload), whereas the originally disproportionally high number of cases on Mondays was appropriately reduced by 33% (6.7% of the total caseload). The estimated direct variable cost savings per year for the hospital was $1.13 million. CONCLUSIONS: Overall, these findings support the continuation of a dedicated Saturday orthopaedic trauma operating room and can provide the foundation for other departments with similar circumstances to negotiate for more dedicated operative time on weekends to improve efficiency. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

What is the effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients? Study protocol for a randomised controlled trial.

BACKGROUND: Missed injury is commonly used as a quality indicator in trauma care. The trauma tertiary survey (TTS) has been proposed to reduce missed injuries. However a systematic review assessing the effect of the TTS on missed injury rates in trauma patients found only observational studies, only suggesting a possible increase in early detection and reduction in missed injuries, with significant potential biases. Therefore, more robust methods are necessary to test whether implementation of a formal TTS will increase early in-hospital injury detection, decrease delayed diagnosis and decrease missed injuries after hospital discharge. METHODS/DESIGN: We propose a cluster-randomised, controlled trial to evaluate trauma care enhanced with a formalised TTS procedure. Currently, 20 to 25% of trauma patients routinely have a TTS performed. We expect this to increase to at least 75%. The design is for 6,380 multi-trauma patients in approximately 16 hospitals recruited over 24 months. In the first 12 months, patients will be randomised (by hospital) and allocated 1:1 to receive either the intervention (Group 1) or usual care (Group 2). The recruitment for the second 12 months will entail Group 1 hospitals continuing the TTS, and the Group 2 hospitals beginning it to enable estimates of the persistence of the intervention. The intervention is complex: implementation of formal TTS form, small group education, and executive directive to mandate both. Outcome data will be prospectively collected from (electronic) medical records and patient (telephone follow-up) questionnaires. Missed injuries will be adjudicated by a blinded expert panel. The primary outcome is missed injuries after hospital discharge; secondary outcomes are maintenance of the intervention effect, in-hospital missed injuries, tertiary survey performance rate, hospital and ICU bed days, interventions required for missed injuries, advanced diagnostic imaging requirements, readmissions to hospital, days of work and quality of life (EQ-5D-5 L) and mortality. DISCUSSION: The findings of this study may alter the delivery of international trauma care. If formal TTS is (cost-) effective this intervention should be implemented widely. If not, where already partly implemented, it should be abandoned. Study findings will be disseminated widely to relevant clinicians and health funders. TRIAL REGISTRATION: ANZCTR: ACTRN12613001218785, prospectively registered, 5 November 2013.

[Implementation of a department of plastic surgery in a university clinic for trauma surgery]. / Implementierung einer universitären Abteilung für Plastische Chirurgie in eine Klinik für Unfallchirurgie.

BACKGROUND: Since May 2012 plastic surgery for trauma patients at the University Hospital Leipzig is provided by an autonomous department. OBJECTIVES: This study analyzed the effect of plastic surgery on the changes in diagnosis-related groups (DRG) at a clinic for trauma surgery. MATERIALS AND METHODS: Within the first 2 years 37 patients (29 male and 8 female of which 38 were inpatient cases) were admitted to the clinic for trauma surgery and additionally received plastic surgery treatment. The appropriate DRG assignment as well as associated codes and revenues were recorded and compared with and without plastic surgery. RESULTS: A total of 261 operations were performed on these patients of which 71 were performed by the department of plastic surgery. The mean revenue was 22,156.44 EUR±20,578.22 EUR with a mean cost weighting of 7.2±6.7. Excluding plastic surgery treatment the mean revenue was 19,378.44 EUR±20,688.40 EUR and the mean cost weighting was 6.3±6.7. Thus, additional proceeds by the plastic surgery treatment were 2778.00 EUR±3857.01 EUR per case. The mean increase of the cost weighting was 0.9±1.3. A change of the DRG grouping occurred in 20 out of 38 cases treated. The mean length of stay (LoS) was 40.2±26.6 days. In the first year this was 17.9±22.4 days more than the mean national LoS of the appropriate DRG and 10.9±19.3 days in the second year. This means an average cost reduction of 4774.59 EUR per case. CONCLUSION: The implementation of a department for plastic surgery increased the revenues. Additional profits should be achieved by process enhancement and not by prolonged LoS.

The military health care system: providing quality care at a low per capita cost.

Orthopaedic trauma constitutes a significant portion of injuries in the military. By focusing on the "Quadruple Aim" of readiness, population health, experience of care, and per capita costs, the Military Health System delivers high-quality care with low costs. We examine the components of military health policy to find avenues of improvement for civilian orthopaedics. Greater emphasis on preventive medicine, alternative clinic structures, and interchangeability will help civilian orthopaedists lower costs and deliver quality patient-centered care similar to current military structure.

Medical liability and orthopaedic trauma: history and current state of affairs.

Orthopaedic trauma has been associated with the history of medical liability all the way back to the dark ages and the bubonic plague. Caps on noneconomic damages and other reforms have been challenged in many states, and an innovative approach to medical liability reform must be developed within the medical profession and the various legislatures. Orthopaedic trauma surgeons have a unique perspective in that they perform a critical service to the community, however they are often deprived of the benefit of preoperative risk reduction best practices because of the critical needs of the patients. Orthopaedic trauma surgeons must advocate for effective medical liability reforms.

Orthopaedic trauma education: how many to train and how to pay for it?

SUMMARY: Fellowship training has become an expected extension of residency. The OTA has led the way in orthopaedics with a carefully orchestrated process, which has evolved to meet the needs of the growing interest in postgraduate orthopaedic trauma fellowships. The OTA developed the Center for Orthopaedic Trauma Advancement in a time when industry support of fellowships was declining. With the growth in fellowship programs to meet the growth of fellowship applicants, quality control has become an issue. Given that every fellowship experience is unique and the lack of regulatory control for non-Accreditation Council for Graduate Medical Education programs, the OTA has initiated its own accreditation process. The purpose of this article is to discuss current trends in orthopaedic trauma fellowship education regarding how many fellows should be trained, how to adequately pay for this training, and how the current dilemmas in fellowship training could be avoided. These issues are vital to understand in the context of health policy issues surrounding orthopaedic trauma.

Global systems of health care and trauma.

Health care policy continues to occupy the center of national debate in the United States. Exploration of international health care and trauma systems allows for better comprehension of our own policies. Four basic models of health care exist across the globe: Bismarck, Beveridge, National Health Insurance, and Out-of-Pocket. Expectantly, disparities in trauma care necessarily follow inequities in overall health care and infrastructure. In this article, we aim to review several countries' health care models and their respective trauma systems. Critical analysis of international solutions to deficiencies in overall health and trauma care may serve as a guide for issues in the United States.