Introducing a post-operative proforma for elective lower limb arthroplasty patients - improving patient care and junior doctor confidence.
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ABSTRACT:
SUBMITTER: Olivier J
PROVIDER: S-EPMC5492475 | biostudies-other | 2017
REPOSITORIES: biostudies-other
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Project description:Patient safety is one of the most important issues in healthcare. In recent years there has been much focus on "Black Wednesday"; the day that Foundation doctors start their first jobs. Great efforts have been made to ensure that patient safety on this day has improved, with the main example being that newly qualified doctors now use some of their free time between medical school and starting their first job to shadow their outgoing counterparts. However, because Foundation doctors start a brand new job approximately every four months for two years, subsequent job changeovers were identified as a time of potential problems and increased patient risk. It is not practical to shadow prior to every job because junior doctors are needed in their current post right up until changeover day, so a simple way to smooth this transition was needed. A handover lunch seemed to be a feasible solution. The day before Foundation doctors change jobs, an hour is dedicated for Foundation Year 1 doctors (F1's) to sit down together over lunch (provided by the mess) and take a formal handover of all relevant information about their forthcoming job and discuss current inpatients. Results showed that 100% of those surveyed mentioned face to face handover as essential, 93.75% said it was either helpful or extremely helpful to have a dedicated time for F1's to handover, and 12.5% said they would not have sought a face to face handover otherwise. Apart from being extremely simple and cheap, it was very popular with the F1's in the trust. It enables effective working from day one and is a great team building activity.
| S-EPMC4949623 | biostudies-literature
Project description:Doctors commencing Foundation Year (FY) training face many stresses and challenges. FY doctors are often the first point of contact for acutely unwell and deteriorating patients. Trust guidelines are used to aid acute medical management. Accessing guidelines is often fraught with barriers. Evidence suggests aide-memoire cards can provide easier access to guidelines and management pathways. We aimed to improve prescribing accuracy and efficiency of FY doctors for acute medical conditions within Gloucestershire trust by improving access to and usability of trust guidelines. Questionnaires were distributed to FY doctors to identify acute medical conditions to include on the emergency prescription cards (EPCs). Two small double-sided cards were created containing bullet pointed trust guidelines for: hyper/hypokalaemia, status epilepticus, diabetic emergencies, arrhythmias, myocardial infarction, acute asthma, pulmonary oedema, anaphylaxis and a ward-round checklist. Feedback was used to improve EPCs prior to distribution. Pre (N=53) and post-intervention (N=46) written questionnaires were completed by FY doctors. These assessed acute clinical management including use of guidance, confidence in management, speed of prescribing and EPC "usability". To assess prescribing accuracy, prescriptions for acute medical conditions were reviewed pre (N=8) and post-intervention (N=12). The EPCs were well received (80% quite/very useful) and found "easy to use" (83%). The introduction of EPCs increased guidance use (pre-intervention 58.8%, post-intervention 71.7%), increased confidence (pre-intervention 79%, post-intervention 89%) and significantly improved prescribing speed (p=0.05). There was a significant correlation with confidence and prescribing speed (p = 0.023). The accuracy of prescribed doses improved (pre-intervention 62.5%, post-intervention 87.5% accurate) as did details regarding route / additional required information (pre-intervention 75%, post-intervention 97.7%). The EPCs support the management of unwell patients, are relevant to the workload of modern doctors practice and may improve patient care. This improvement measure could be applied to other NHS trusts and medical specialties.
| S-EPMC4822022 | biostudies-other
Project description:Junior doctors frequently rely on electronic access to clinical guidelines to inform assessment and management, particularly whilst on-call and occasionally during emergencies. Difficulties in locating and accessing up to date guidance from different hospital intranet sites can lead to delays or errors in patient management. We used a focus group and email feedback to redesign an intranet site for junior doctors which logically organised the documents which doctors said they needed access to in one readily accessible location. A quality improvement project was carried out over six months, testing two iterations of the new junior doctors' intranet site before a third version was launched and evaluated. Their performance was measured by the number of mouse clicks and the time required for doctors to find a representative subset of five guidelines, and revisions were made at each cycle based on feedback from doctors and stakeholders. Cumulatively, we demonstrated a decrease in the total number of clicks required to access the sample of guidelines from 18 to 12 clicks, a corresponding decrease in the time required to access the sample of guidelines from 130 seconds to 22 seconds, and an increase in user satisfaction. We maintained one-click access to emergency guidance. In conclusion, we have developed and implemented an electronic resource for junior doctors which provides more immediate access to both emergency and non-emergency clinical guidance. To ensure the resource remains up to date, it will be maintained by Foundation Programme representatives at our hospital on a rolling basis.
| S-EPMC4693045 | biostudies-literature
Project description:While it is widely recognised that communication and handover are a fundamental component in providing safe clinical care for hospital patients (1,2.3). The Royal College of Physicians found that the majority of hospital doctors are dissatisfied with the standard of their handovers (4). These findings were mirrored by the junior staff at the Royal United Hospital, who felt that the weekend handover was inadequate, and detrimental to patient safety. A group of eight junior doctors at the Royal United Hospital, Bath utilised The Model For Improvement to systematically analyse and improve various aspects of the weekend handover system. Handover sheets from a subset of wards were assessed to observe direct effects of staged interventions over a nine month period, allowing small-scale testing prior to widespread implementation of a standardised intranet-based weekend handover. The effects of interventions were evaluated using a predesigned scoring system and data was collected continuously throughout the project. Over a nine month period the quality of handovers improved significantly from 76% to 93% (p <0.01): a success which was supported by a 100% improvement in formal feedback collected from hospital doctors and highlighted by the desire of senior staff and directors to implement the system throughout the trust. Using The Model For Improvement a group of junior doctors were able to introduce and develop a standardised weekend handover system that met their requirements. A structured, efficient and auditable system has been successfully produced which improves the quality and safety of patient care.
| S-EPMC4663818 | biostudies-literature
Project description:BackgroundRequirements for allogeneic red cell transfusion after total lower limb arthroplasty are still high (20-50%), and post-operative intravenous iron has been shown to reduce transfusion requirements for this surgery. We performed a cost analysis to ascertain whether this alternative is also likely to be cost-effective.Materials and methodsData from 182 matched-pairs of total lower limb arthroplasty patients, managed with a restrictive transfusion protocol and without (control group) or with post-operative intravenous iron (iron group), were retrospectively reviewed. Acquisition and administration costs of iron (iron sucrose or ferric carboxymaltose) and allogeneic red cell concentrates, haemoglobin measurements, and prolonged stay in hospital were used for blood management cost analysis.ResultsPatients in the iron group received 600 mg intravenous iron, without clinically relevant incidents, and had a lower allogeneic transfusion rate (11.5% vs 26.4% for the iron and control groups, respectively; p=0.001). The reduction in transfusion rate was more pronounced in anaemic patients (17% vs 40%; p=0.015) than in non-anaemic ones (9.6% vs 21.2%; p=0.011). There were no differences with respect to post-operative infection rate. Patients receiving allogeneic transfusion stayed in hospital longer (+1.9 days [95% CI: 1.2-2.6]). As intravenous iron reduces the allogeneic transfusion rate, both iron formulations were cost-neutral in the different cost scenarios (-25.5 to 62.1 €/patient for iron sucrose, and -51.1 to 64.4 €/patient for ferric carboxymaltose).DiscussionIn patients presenting with or without pre-operative anaemia, post-operative intravenous iron after total lower limb arthroplasty seems to be safe and is associated with reduced transfusion rates, without incremental costs. For anaemic patients, its efficacy could be increased by associating some other blood-saving method.
| S-EPMC3926727 | biostudies-literature
Project description:BACKGROUND:Postoperative stroke is a rare but potentially devastating complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of the current study was to determine the incidence, independent risk factors, and timing of stroke following THA and TKA utilizing the National Surgical Quality Improvement (NSQIP) database. METHODS:Patients who underwent elective primary THA and TKA were identified in the 2005-2016 NSQIP database. Thirty-day postoperative strokes were identified, timing was characterized, and an incidence curve was created. Multivariate analyses determined the independent predictors of these strokes. RESULTS:Of 333,117 patients identified, 286 (0.09%) experienced a stroke. Given that THA vs TKA was not a univariate predictor of stroke, the two procedures were considered together. The majority (65%) of strokes occurred before discharge. Of the strokes observed, 25% occurred by postoperative day one, 50% by postoperative day two, and 75% by postoperative day nine. Independent risk factors for postoperative stroke were: age (60-69 years old odds ratio [OR] = 4.2; 70-79 years old OR = 8.1; ?80 years old OR = 16.1), higher American Society of Anesthesiologists (ASA) score (ASA?3 OR = 1.7), and smoking [OR = 1.6). CONCLUSION:The incidence of stroke after THA/TKA was low at 0.09%, with the majority occurring prior to discharge and half occurring by postoperative day two. Patients who were older, sicker, or who were smokers were at greater risk of postoperative stroke. These findings can be used to council patients and to optimize patient care. LEVEL OF EVIDENCE:Level III, Retrospective comparative study.
| S-EPMC7498016 | biostudies-literature
Project description:BackgroundAs part of an ongoing service improvement project, a digital 'joint school' (DJS) was developed to provide education and support to patients undergoing total hip (THR) and total knee (TKR) replacement surgery. The DJS allowed patients to access personalised care plans and educational resources using web-enabled devices, from being listed for surgery until 12 months post-operation. The aim of this study was to compare a cohort of patients enrolled into the DJS with a cohort of patients from the same NHS trust who received a standard 'non-digital' package of education and support in terms of Health-Related Quality of Life (HRQoL), functional outcomes and hospital length of stay (LoS).MethodsA retrospective comparative cohort study of all patients undergoing primary TKR/THR at a single NHS trust between 1st Jan 2018 and 31st Dec 2019 (n = 2406) was undertaken. The DJS was offered to all patients attending the clinics of early adopting surgeons and the remaining surgeons offered their patient's standard written and verbal information. This allowed comparison between patients that received the DJS (n = 595) and those that received standard care (n = 1811). For each patient, demographic data, LoS and patient reported outcome measures (EQ-5D-3L, Oxford hip/knee scores (OKS/OHS)) were obtained. Polynomial regressions, adjusting for age, sex, Charlson Comorbidity Index (CCI) and pre-operative OKS/OHS or EQ-5D, were used to compare the outcomes for patients receiving DJS and those receiving standard care.FindingsPatients that used the DJS had greater improvements in their EQ-5D, and OKS/OHS compared to patients receiving standard care for both TKR and THR (EQ-5D difference: TKR coefficient estimate (est) = 0.070 (95%CI 0.004 to 0.135); THR est = 0.114 (95%CI 0.061 to 0.166)) and OKS/OHS difference: TKR est = 5.016 (95%CI 2.211 to 7.820); THR est = 4.106 (95%CI 2.257 to 5.955)). The DJS had a statistically significant reduction on LoS for patients who underwent THR but not TKR.ConclusionThe use of a DJS was associated with improved functional outcomes when compared to a standard 'non-digital' method. The improvements between pre-operative and post-operative outcomes in EQ-5D and OKS/OHS were higher for patients using the DJS. Furthermore, THR patients also had a shorter LoS.
| S-EPMC9053557 | biostudies-literature
Project description:Background:The use of tranexamic acid (TXA) in total hip replacement (THR) typically reduces blood loss by approximately 400 mL, and typical total blood loss is still approximately 1 L. A barrier to harnessing the full potential of TXA is disagreement on the optimum timing of administration. To address this, we aimed to identify the period of greatest blood loss. Methods:We analyzed the perioperative data of 870 patients who had undergone THR, total knee replacement, or unicompartmental knee replacement just before the introduction of TXA to our unit. Total blood loss was calculated on postoperative day (POD) 1 and POD2 using an equation based on change in hematocrit. Results:Average total blood loss at POD2 was 1505, 1322, and 611 mL for THR, total knee replacement, and unicompartmental knee replacement, respectively. Between 86% and 96% of this blood loss occurred in the period between skin closure and POD1. Intraoperative loss did not correlate with total loss at POD2. Blood transfusion was more likely if the patient was female (odds ratio [OR], 6.8) or if they had preoperative anemia (OR, 8.3) than if there was a high-volume blood loss (OR, 1.6). Conclusions:Approximately 90% of blood loss occurs between skin closure and the first postoperative 24 hours. "Intraoperative blood loss" and "transfusion rate" are not reliable markers of total blood loss. The full potential of TXA could be harnessed by using it during the period of greatest blood loss, that is, during the first postoperative 24 hours.
| S-EPMC6288045 | biostudies-literature
Project description:AimsThis research investigated the effectiveness of an intervention for improving the prescribing and patient safety behaviour among Foundation Year doctors. The intervention consisted of simulated clinical encounters with subsequent personalised, structured, video-enhanced feedback and deliberate practice, undertaken at the start of four-month sub-specialty rotations.MethodsThree prospective, non-randomised control intervention studies were conducted, within two secondary care NHS Trusts in England. The primary outcome measure, error rate per prescriber, was calculated using daily prescribing data. Prescribers were grouped to enable a comparison between experimental and control conditions using regression analysis. A break-even analysis evaluated cost-effectiveness.ResultsThere was no significant difference in error rates of novice prescribers who received the intervention when compared with those of experienced prescribers. Novice prescribers not participating in the intervention had significantly higher error rates (P = .026, 95% confidence interval [CI] Wald 0.093 to 1.436; P = .026, 95% CI 0.031 to 0.397) and patients seen by them experienced significantly higher prescribing error rates (P = .007, 95% CI 0.025 to 0.157). Conversely, patients seen by the novice prescribers who received the intervention experienced a significantly lower rate of significant errors compared to patients seen by the experienced prescribers (P = .04, 95% CI -0.068 to -0.001). The break-even analysis demonstrates cost-effectiveness for the intervention.ConclusionSimulated clinical encounters using personalised, structured, video-enhanced feedback and deliberate practice improves the prescribing and patient safety behaviour of Foundation Year doctors. The intervention is cost-effective with potential to reduce avoidable harm.
| S-EPMC7576627 | biostudies-literature
Project description:ObjectiveWe sought to correlate various spinopelvic and lower limb alignments, and to examine the current spinopelvic theories on a Chinese cohort.MethodsWe retrospectively reviewed 166 patients undergoing THA. Among them, 138 patients with unilateral THA met the inclusion criteria. Sagittal alignments and cup orientations were measured on standing and sitting lateral EOS images. Patients were categorized into two groups with a scoring system for lumbar spine degeneration. Patients' demographics including age, sex, lumbar spine degeneration and radiographic measurements were studied.ResultsPT, SS, LL and TK differed significantly between standing and sitting within each group except for TK in degenerative group (32.8 ± 13.9 vs. 32.9 ± 14.2, p = 0.905). Compared with degenerative spine group, non-degenerative spine patients have great pelvic mobility (ΔPT, -24.4 ± 12.5° vs. -17.6 ± 10.7, p = 0.0008), greater lumbar mobility (ΔLL, -34.8 ± 15.2 vs. -21.7 ± 12.2, p = < 0.0001) and compensatory cup orientation changes (ΔRA, -15.5 ± 11.1 vs. -12.0 ± 8.4, p = 0.00920; ΔRI, -10.8 ± 11.5 vs. -5.6 ± 7.5, p = 0.0055). Standing PT and ankle dorsiflexion angle correlated positively (R2 = 0.236, p = 0.005).ConclusionTHA patients in this cohort showed a spinopelvic motion paradigm similar to that from previous studies on Caucasians. Ankle dorsiflexion indicate greater posterior pelvic tilt on standing. Surgeons should beware of risks of instability in patients with lower limb compensations.Advances in knowledgeThis study provides new insights into the clinical relevance of lower limb alignments to spinopelvic motion after THA in a relatively young Chinese population.
| S-EPMC9773480 | biostudies-literature