TraumaLink: A Community-Based First-Responder System for Traffic Injury Victims in Bangladesh.

INTRODUCTION: Road traffic injuries are a rapidly growing epidemic in low- and middle-income countries (LMICs). However, many countries lack formal prehospital emergency medical services, often leaving victims without access to first aid when it can be most effective in preventing death or disability. METHODS: To address the lack of a dedicated prehospital emergency medical system in Bangladesh, we developed TraumaLink, a community-based network of volunteer first responders for traffic injury victims. The service uses an emergency hotline number and 24-hour call center with local first responders who are trained in basic trauma first aid, given essential medical supplies, and dispatched to crash scenes through mobile phone text message notifications. We designed the training curriculum to teach simple lifesaving skills that people with any level of education and no prior medical background could learn and perform. We retrospectively analyzed data originally collected for quality monitoring and evaluation to provide a descriptive analysis of the program's impact. RESULTS: During the first 6 years, operations were expanded from a 14-km section of 1 highway to 135 km on 3 national highways, and free care was provided to 3,119 patients involved in 1,544 crashes. All calls to the service received a response, and in 88% of cases, first responders were at the scene in 5 minutes or less. Most patients were young adult men, and 76% of victims transported to the hospital arrived there within 30 minutes of the crash. Assessments of injury severity at the accident scene aligned closely with patient dispositions, reflecting the accuracy of these triage decisions. CONCLUSION: The strong community support and rapid, reliable volunteer responses suggest that this flexible and scalable model could be expanded throughout Bangladesh and adapted for other LMICs that face similar challenges with traffic injury victims.

Post-COVID-19 syndrome risk factors and further use of health services in East England.

Post-COVID syndrome, defined as symptoms persisting for more than twelve weeks after the diagnosis of COVID-19, has been recognised as a new clinical entity in the context of SARS-CoV-2 infection. This study was conducted to characterise the burden and predictors for post-COVID-19 syndrome in the local population. It was a community-based web-survey study conducted in Norfolk, East England, UK. We sent the survey to patients with confirmed COVID-19 infection by real-time polymerase chain reaction by December 6th, 2020. Questions related to the pre-COVID and post-COVID level of symptoms and further healthcare use. Baseline characteristics were collected from the primary care records. Logistic regression analysis was conducted to establish predictors for post-COVID-19 syndrome and further healthcare utilisation. Of 6,318 patients, survey responses were obtained from 1,487 participants (23.5%). Post-COVID-19 syndrome symptoms were experienced by 774 (52.1%) respondents. Male sex compared to female sex was a factor protective of post-COVID symptoms; relative risk (RR) 0.748, 95% confidence interval (CI), 0.605-0.924. Body mass index was associated with a greater risk of developing post-COVID-19 symptoms (RR 1.031, 95% CI, 1.016-1.047, for 1 kg/m2). A total of 378 (25.4%) people used further health services after their index COVID-19 infection, of whom 277 (73.2%) had post-COVID symptoms. Male sex was negatively associated with the use of further health services (RR 0.618, 95% CI, 0.464-0.818) whereas BMI was positively associated (RR 1.027, 95% CI, 1.009-1.046). Overall, post-COVID-19 symptoms increased the probability of using health services with RR 3.280, 95% CI, 2.540-4.262. This survey of a large number of people previously diagnosed with COVID-19 across East England shows a high prevalence of self-reported post-COVID-19 syndrome. Female sex and BMI were associated with an increased risk of post-COVID-19 syndrome and further utilisation of healthcare.

Implementation of the Canadian Cardiovascular Society guidelines for perioperative risk assessment and management: an interrupted time series study.

PURPOSE: The Canadian Cardiovascular Society (CCS) guidelines for patients undergoing non-cardiac surgery address the lack of standardized management for patients at risk of perioperative cardiovascular complications. Our interdisciplinary group evaluated the implementation of these guidelines. METHODS: We used an interrupted time series design to evaluate the effect of implementation of the CCS guidelines, using routinely collected hospital data. The study population consisted of elective, non-cardiac surgery patients who were: i) inpatients following surgery and ii) age ≥ 65 or age 45-64 yr with a Revised Cardiac Risk Index ≥ 1. Outcomes included adherence to troponin I (TnI) monitoring (primary) and adherence to appropriate consultant care for patients with elevated TnI (secondary). Exploratory outcomes included cost measures and clinical outcomes such as length of stay. RESULTS: We included 1,421 patients (706 pre- and 715 post-implementation). We observed a 67% absolute increase (95% confidence interval, 55 to 80; P < 0.001) in adherence to TnI testing following the implementation of the guidelines. In patients who had elevated TnI following guideline implementation (n = 64), the majority (85%) received appropriate follow-up care in the form of a general medicine or cardiology consult, all received at least one electrocardiogram, and half received at least one advanced cardiac test (e.g., cardiac perfusion scan, or percutaneous intervention). CONCLUSIONS: Our study showed the ability to implement and adhere to the CCS guidelines. Large-scale multicentre evaluations of CCS guideline implementation are needed to gain a better understanding of potential effects on clinically relevant outcomes.

RéSUMé: OBJECTIF: Les lignes directrices de la Société canadienne de cardiologie (SCC) concernant les patients subissant une chirurgie non cardiaque ont été conçues pour pallier l'absence de standardisation dans la prise en charge des patients à risque de complications cardiovasculaires périopératoires. Notre groupe interdisciplinaire a évalué la mise en œuvre de ces lignes directrices. MéTHODE: Nous avons utilisé une méthodologie de série chronologique interrompue pour évaluer l'effet de la mise en œuvre des lignes directrices de la SCC, à l'aide des données hospitalières habituellement recueillies. La population à l'étude se composait de patients de chirurgies non cardiaques non urgentes qui étaient : i) hospitalisés après leur chirurgie et ii) âgés de ≥ 65 ans ou de 45 à 64 ans avec un Indice de risque cardiaque révisé ≥ 1. Les critères d'évaluation comprenaient l'observance du monitorage de la troponine I (TnI) (critère d'évaluation primaire) et l'observance des soins spécialisés appropriés aux patients présentant un taux élevé de TnI (critère secondaire). Les critères exploratoires comprenaient des mesures de coûts et des résultats cliniques tels que la durée de séjour. RéSULTATS: Nous avons inclus 1421 patients (706 avant et 715 après la mise en œuvre). Nous avons observé une augmentation absolue de 67 % (intervalle de confiance de 95 %, 55 à 80; P < 0,001) de l'observance des tests de la TnI suite à la mise en œuvre des lignes directrices. Parmi les patients présentant un taux élevé de TnI suite à la mise en œuvre des lignes directrices (n = 64), la majorité (85%) a reçu des soins de suivi appropriés sous la forme d'une consultation en médecine générale ou en cardiologie; tous ont subi au moins un électrocardiogramme, et la moitié ont passé au moins un examen cardiaque subséquent (p. ex., évaluation de la perfusion myocardique par scintigraphie ou cathétérisme percutané). CONCLUSION: Notre étude a montré qu'il est possible de mettre en œuvre et d'adhérer aux nouvelles lignes directrices de la SCC. Des évaluations multicentriques à grande échelle portant sur la mise en œuvre des lignes directrices de la SCC sont nécessaires pour mieux comprendre ses effets potentiels sur les devenirs cliniquement pertinents.

Postoperative Home Monitoring After Joint Replacement: Feasibility Study.

BACKGROUND: We conducted a prospective observational study of patients undergoing elective primary hip or knee replacements to examine the feasibility of a postoperative home monitoring system as transitional care to support patients following their surgery in real time. OBJECTIVE: The primary outcome was the mean percentage of successful wireless transmissions from home of blood pressure levels, heart rate, oxygen saturation levels, and pain scores until postoperative day 4 with a feasibility target of ≥90%. METHODS: Patients with an expected length of stay ≤1 day, age 18-80 years, Revised Cardiac Risk Index ≤ class 2, and caretakers willing to assist at home were eligible. Patient satisfaction, as a secondary outcome, was also evaluated. Wireless monitoring equipment (remote patient monitoring, Telus Canada) was obtained and a multidisciplinary care team was formed. RESULTS: We conducted the study after obtaining Research Ethics Board approval; 54 patients completed the study: 21 males, 33 females. In total, we evaluated 9 hips, 4 hip resurfacing, 26 total knees, and 15 hemi-knees. The mean transmission rate was 96.4% (SD 5.9%; 95% CI 94.8-98.0). The median response to "I would recommend the Remote Monitoring System program to future patients" was 4.5 (interquartile range 4-5), with 1 being "strongly disagree" and 5 "strongly agree." At 30 days postop, there was no mortality or readmission. CONCLUSIONS: This is an evolving new paradigm for postoperative care and the first feasibility study on monitoring biometrics after primary hip or knee replacement. Postoperative home monitoring combines current technology with real-time support by a multidisciplinary transitional care team after discharge, facilitating postsurgical care with successful wireless transmission of vitals. The postoperative home monitoring implementation is, therefore, generalizable to other surgical discharges from hospitals. TRIAL REGISTRATION: ClinicalTrials.gov NCT02143232; https://clinicaltrials.gov/ct2/show/NCT02143232 (Archived by WebCite at http://www.webcitation.org/71ugAhhIk).

Postoperative Home Monitoring After Joint Replacement: Retrospective Outcome Study Comparing Cases With Matched Historical Controls.

BACKGROUND: A retrospective cohort study was conducted in patients undergoing postoperative home monitoring (POHM) following elective primary hip or knee replacements. OBJECTIVE: The objectives of our study were to compare the cost per patient, readmissions rate, emergency room visits, and mortality within 30 days to the historical standard of care using descriptive analysis. METHODS: After Research Ethics Board approval, patients who were enrolled and had completed a POHM study were individually matched to historical controls by age, American Society of Anesthesiology class, and procedure at a ratio 1:2. RESULTS: A total of 54 patients in the study group and 107 in the control group were eligible for the analysis. Compared with the historical standard of care, the average cost per case was Can $5826.32 (SD 1418.89) in the POHM group and Can $9198.58 (SD 1513.59) for controls. After 30 days, there were 2 emergency room visits (3.7%) and 0 readmissions in the POHM group, whereas there were 8 emergency room visits (7.5%) and 2 readmissions (1.9%) in the control group. No mortalities occurred in either group. CONCLUSIONS: The POHM study offers an early hospital discharge pathway for elective hip and knee procedures at a 38% reduction of the standard of care cost. The multidisciplinary transitional POHM team may provide a reliable forum to minimize readmissions, and emergency room visits within 30 days postoperatively. TRIAL REGISTRATION: ClinicalTrials.gov NCT02143232; https://clinicaltrials.gov/ct2/show/NCT02143232 (Archived by WebCite at http://www.webcitation.org/73WQ9QR6P).

Outpatient unicompartment knee arthroplasty with indwelling femoral nerve catheter.

Contemporary multimodal anesthesia regimens allow the performance of unicompartment knee arthroplasty (UKA) on an outpatient basis. Our initial pilot experience is presented using a continuous femoral nerve block as an adjunct for 24 patients classified as American Society of Anesthesiology class 1 (14 men, 10 women; median age, 56 years; range, 46-72 years). After minimally invasive UKA, patients documented their pain and oral medication use while at home for the first 5 days. Adverse events, medication adverse effects, and the amount of infused ropivacaine were recorded. Median pain scores for the first 3 days were 1, 2, and 2 (at rest) and 4, 5, and 3 (during physical therapy). Eighteen patients (75%) required less than 4 mg oral hydromorphone/d. Of the 18, 10 (42%) did not require supplemental oral opioids. The median catheter use was 3 days. Our results suggest that with careful patient selection and adequate teaching, continuous femoral nerve blocks may be used as part of a multimodal pain regimen to assist the delivery of outpatient UKA with high patient satisfaction.

From skepticism to engagement.

WellStar Kennestone Hospital's patient flow improvement initiative is a case study in engaging physicians in a collaborative effort that benefits both the physicians and the hospital. Kennestone's success was in large part due to the active participation of physician leaders on the committee charged with leading the project. The initiative provides a lesson for hospitals looking to collaborate with physicians in meeting reform's mandate for the highest-quality care delivered with the highest level of efficiency at the lowest possible cost.

Improving patient flow in the cath lab.

Key steps that led to Kennestone Hospital's success in improving patient flow in the cath lab included: Developing an urgency classification system for patients. Creating a more accurate scheduling system to increase throughput and efficiency. Establishing a project team. Developing a time line. Recognizing ongoing challenges