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Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre
YBJOM-5158;
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ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre J. Haq ∗ , J. Olding, S. Chegini, C. Huppa, R. Bentley, K. Fan Dept. of Oral & Maxillofacial Surgery, King’s College Hospital, Denmark Hill, London. SE5 9RS Accepted 11 April 2017
Abstract There is a subgroup of patients with mandibular fractures who could safely and effectively be managed in an outpatient day-care unit. Suitability depends on medical, social, and operative factors, and identification of the correct criteria will govern management after that in the emergency department. Reduced use of beds would lead to less money being spent on emergency treatment, and increased capacity for elective surgery. The aims of this study were to identify a group of patients with mandibular fractures whose duration of operation and period of recovery would be suitable for treatment in the day-care unit, and to evaluate the potential financial benefits. Inpatients were assessed for day surgery using medical, social, and surgical criteria. Each patient’s suitability for discharge was assessed two, three, and five hours postoperatively. A financial feasibility study was made retrospectively on a larger sample of patients with mandibular fractures. The discharge criteria from the day-care unit were fully met by 26/40 patients at five hours postoperatively, mean (range) duration of operation was 145 (40–285) minutes, and mean (SD) Mandibular Injury Severity Score was 13 (3), range 7–20. When all the criteria were combined (n = 100), 12 of the patients were suitable for day care. With 24 bed-day savings/100 patients, potential earnings would increase to around £80 000/year at this hospital. In conclusion, we have identified a group of patients who were suitable for management of mandibular fractures in the day-care unit. Considerable cost savings are anticipated. © 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Mandible; Day surgery; Ambulatory care; Maxillofacial trauma
Introduction Inpatient beds are the most valuable resource in the NHS,1 and admissions for the management of mandibular fractures account for a considerable number of inpatient bed-days.2 A proportion of these are patients who are waiting on a clinically-prioritised emergency operating list and then ∗
Corresponding author. E-mail addresses: [email protected] (J. Haq), [email protected] (J. Olding), [email protected] (S. Chegini), [email protected] (C. Huppa), [email protected] (R. Bentley), [email protected] (K. Fan).
recovering as inpatients. The complexity and duration of these operations varies depending on factors such as the severity of the fracture, the presence of infection, and coexisting conditions. There is already a system for rapid access to the daycare unit operating theatres, which relies on assessment of the patient followed by booking from the emergency department. This has been adopted for other surgical specialties (general surgery and gynaecology) for management of minor acute conditions when we anticipate a short operation, and discharge the same day. In this paper we present evidence in favour of the adoption of a rapid-access, day-care service for outpatient management
http://dx.doi.org/10.1016/j.bjoms.2017.04.006 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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of an identified group of patients with mandibular fractures. Such patients must be medically and socially suitable for day care, with the duration of operation being less than one session, and the postoperative recovery period short enough to permit discharge the same day before 8 pm. We hope that, through the adoption of primary scoring of the severity of the injury and medical and social screening, a group of patients can be identified who can safely be sent home from the emergency department with an appointment booked for operation in the day-care unit. This will reduce our use of inpatient beds while maintaining good clinical practice. We know of no reports that have suggested that patients with mandibular fractures are being managed as outpatients elsewhere in the UK, or that it results in poorer clinical outcome.
Patients and methods Aims We first wanted to identify a group of patients whose duration of operation and recovery period were suitable for the management of mandibular fractures by outpatient day surgery. We also wanted to evaluate the potential financial benefits of outpatient management of mandibular fractures that resulted from the reduced use of both inpatient beds and the main operating theatre.
Table 1 Day surgery unit guidelines for patients suitable for discharge. Blood pressure and pulse within preoperative range Has minimal or no pain Is able to tolerate fluids and food Has minimal nausea Can breath comfortably Is fully conscious and orientated Has passed urine Operation site is satisfactory Does patient feel ready to go home?
Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
Results Forty complete proformas were returned and these comprised the study group. There were 32 men and eight women, mean (range) age 30 (17-46) years. Thirty-one of them would have been suitable for admission to the day-care unit based on their ASA grade and domestic arrangements. Of the nine who would not have been suitable, six had nobody to take them home or stay with them overnight, and three were ASA grade II or more. The mean (range) delay from injury to treatment was 3 (014) days and each of them would have taken up an inpatient bed for one day. The mean (SD) MISS was 13 (3), range 7-20, and details of the fractures are shown in Table 2. Thirty-three of the 40 operations started during working hours (8am–5pm), the latest at 10 pm, and the mean (range) Table 2 Details of the fractures by their Mandible Injury Severity Scores.
Methods Non-consecutive adults who were admitted with isolated mandibular fractures over a 12-month period were included in the study. These patients followed the traditional path of assessment and admission from the emergency department to an inpatient ward, fasting until an emergency (NCEPOD classification) theatre slot became available, being operated on, and recovering postoperatively on the ward. These patients were then assessed for their theoretical suitability for parallel management as outpatients in the daycare unit. Data for each patient were collected prospectively using a proforma that assessed their suitability for daycare management by established general medical, anaesthetic (American Society of Anesthesiologists’ grade), and social criteria. The injury was scored using the mandibular injury severity score (MISS).3 Duration of operation from induction to extubation, and method of fixation, were also recorded. Each patient was then assessed at two, three, and five hours postoperatively to see if they were suitable for discharge according to the established criteria (Table 1). There was no further difference from current accepted practice. After we had identified a clinically suitable group of patients, we made a retrospective financial feasibility study on a larger group of patients with mandibular fractures.
Fracture
No.
Fracture: Simple Comminuted Bony defect
34 5 1
Site: Parasymphysis Body Angle Condyle Ramus Canine
18 10 26 9 5 2
Occlusion: Malocclusion Normal
38 2
Involvement of soft tissue: Closed Open intraorally Open extraorally Soft tissue defect
4 34 1 1
Infected: Yes No
2 38
Displacement: Mild Moderate Severe
8 19 13
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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3
300
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240
Duration of operation (mins)
210
180
150
120
90
60
30
0
0
2
4
6
8
10
12
14
16
18
20
22
Score
Fig. 1. Mandibular injury severity score and duration of operation (y = 11.483x − 6.585. R2 = 0.2245).
duration of anaesthesia was 145 (40-285) minutes. Thirty-six patients had intermaxillary fixation (IMF; archbars, Leonard buttons, or IMF screws) and 36/40 had one or more fractures that required open reduction and internal fixation. One patient needed an extra-oral approach with a reconstruction plate for an infected fracture. The duration of operation of 285 minutes was that of a patient who was treated by the restorative trauma dentist during the same anaesthetic. Fig. 1 shows the MISS correlated with duration of operation. The current discharge criteria used in the day-care unit for time from operation to recovery were fully met by three of
the 40 patients at two hours, nine at three hours, and 26 at five hours, postoperatively. These figures relate to physiological recovery only, and not overall suitability for discharge. Table 3 shows the number of patients who achieved the criteria. The overall inpatient duration of stay for the group included was two days, which was divided roughly equally into one day before, and just over one day after, operation. Most of the delay between injury and operation was before the patient presented, so cannot be modified. In switching to a day-care service, we hope that the overall delay to treatment is
Table 3 Number of patients who met the discharge criteria at the three postoperative time points. Discharge criteria
At two hours
At three hours
At five hours
Not recovered
Blood pressure/pulse within normal limits Minimal pain Fluids/food Minimal nausea Breathing OK Fully conscious Passed urine Operation site OK
35 21 21 26 37 35 14 36
5 9 11 6 2 4 7 3
0 4 5 5 1 1 14 1
0 6 3 3 0 0 5 0
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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not prolonged beyond the current three days. However, given that the day-care unit slots are available only three times a week, this may not be possible depending on availability and day of presentation. A paper by Lucca et al4 described no increase in complications in patients whose treatment was delayed compared with those who were treated early, and this is further supported by Moulton-Barrett et al,5 who looked at a group treated up to 10 days after injury. The proposed criteria of a MISS of <11, and social/medical fitness for admission to the day-care unit, were applied retrospectively. One hundred patients who were operated on for a fractured mandible were included in the retrospective analysis. One patient was excluded because of associated panfacial fractures that resulted in a longer operation and inpatient stay. Eighty-seven of the patients were male, with a mean (range) age of 30 (12-53) years, and the mean (range) MISS was 16 (7–33). The mean (range) duration of anaesthesia was 153 (40-293) minutes, and 82 operations began during working hours. Sixteen patients had MISS of less than 11, and all 16 had operations that lasted less than 165 minutes (mean (range) 101 (60-157) minutes). Two patients were excluded from the day-care unit on social grounds as they had nobody to take them home. Two further patients were excluded as they were under 18 years old, and therefore too young for the rapid access lists. All 16 patients were medically fit for day surgery. Once all the criteria had been applied, 12 of the 16 patients would have been suitable for admission to the daycare unit, surgical treatment, and discharge five hours later. When extrapolated to a mean inpatient duration of stay of two days/patient, a saving of 24 bed days would have been made for every 100 patients treated. Comparison of costs and financial savings Costs of the inpatient and day surgery theatres are comparable at £213.64 and £211.69/15 minutes, respectively. Potential inpatient bed-day earnings are £1831. There is a premium Healthcare Resource Group tariff of £102.80 for intermediate oral and maxillofacial procedures done in the day-surgery theatre compared with inpatient treatment. If the savings were 24 bed days for every 100 patients, potential earnings would increase by at least £44 310, which equates to around £80 000 a year at this hospital. Discussion The patterns of mandibular fracture and demographics are broadly in line with what has been published elsewhere.6,7 Most of the identified group would fit the medical/social criteria for management in the day-care unit, which probably reflects the fact that patients were relatively young with minimal coexisting conditions. Most exclusions were for domestic reasons, with lack of a carer or difficulties with transport being the most common. Such social issues could be
addressed given notice as would be the case if the day-surgery theatre was booked, which would increase the number of suitable patients. The mean duration of operation of 145 minutes is in accordance with reports from elsewhere.8 This time period describes the total duration of anaesthesia from intubation to the patient leaving the theatre, so the actual operating time may be around 30 minutes shorter. It should be noted that 36/40 patients were treated with some form of intermaxillary fixation, and Dimitroulis reported an increased duration of 58.5 minutes when this was done.9 Although not recorded, the NCEPOD operations are often done by trainee surgeons, and if a day-case service was to be led and done by a consultant, the operating times would probably be shorter. The rapid access operating lists are threehour sessions, so 31/40 of the operations would have been suitable. The MISS is slighter higher in this cohort than in the paper by Shetty et al in which the mean (SD) was 12 (4).3 There was a relation between severity of the fracture and the duration of anaesthesia (Fig. 1), although this was not significant. Fractures with a MISS <17 were associated with an operating time of 180 minutes, although on all six occasions when they were longer, the mean MISS was only 14 (range 12–16). On no occasion did an operation take longer than three hours with a MISS of less than 12. All patients were assessed postoperatively at strict time points, although there is a degree of interobserver variability because of the logistics of data collection, and the objectivity of the analysis must be maintained. Most patients took longer than three hours to recover fully. The slowest discharge criteria to recover are pain control, passing urine, relief of nausea, and tolerance of eating and drinking. All patients with MISS <11 had recovered within five hours. Such a recovery period would be appropriate for a morning operating session, but might cause issues if the operation started after midday. This is an important factor when booking a list. Most patients (36/40) were actually discharged the next day after being reviewed on the ward round, so would be classified as ambulatory care (23 hours admission to discharge). We have identified 19/40 patients who are medically and socially fit for treatment in the day-care unit, had an operation that lasted less than three hours, and recovered within five hours of operation. As far as the relations between MISS, duration of operation, and recovery time are concerned, we can use a cut-off point of 10 for assessment of suitability for day-case management and discharge the same day. For example, such a patient would have a unilateral, minimally-displaced, parasymphyseal fracture. This threshold includes only about 10% of patients, but it is safer to initiate a new service such as this in a conservative manner. The system can develop beyond this through reaudit and evaluation, with the potential for increasing the threshold for suitability. There are limitations to the MISS score, and there are other severity scores. However, there needs to be some form
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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of screening that can identify the suitable patients in the emergency department in a reliable and reproducible way. If such a model were to be adopted, the standard practice of giving antibiotics intravenously before, and for a prolonged period after, operation is not possible. In place of this, the patient would be given a course of antibiotics in the emergency department to take orally at home to cover this period. Other publications support the use of prophylactic antibiotics for open mandibular surgery to reduce infection.10 However, one systematic review did state that there is no evidence that route or length of course is important.11 It is possible to give antibiotics intravenously in outpatients, and a number of acute departments provide the service already for conditions such as cellulitis. Such an addition to the model may or may not be necessary. Another alteration to the accepted hospital protocol is delay of postoperative radiographs. These are currently taken while the patient is in hospital, usually on the first postoperative day, and checked before discharge. With the adoption of a day-care service, it is likely that the radiographs would be taken at the first clinic appointment for review, which may be 1-2 weeks later. The evidence, however, suggests that postoperative plain films are of little clinical benefit.12 The rate of retreatment based on radiographic assessment alone has been shown to be low (0.2%),13 with only 1.2% of patients being returned to theatre during the same episode, all of which were based on clinical findings.14 Conclusions We plan to implement this model in our hospital and to audit its effectiveness. We think that savings will be made in cost/bed-day, and the opportunity for potential earnings is predicted to increase by the adoption of a day/ambulatory care model for management of mandibular fractures. No clinically deleterious consequences have been identified as a result of this proposed change of practice, and we hope that this paper will provide some guidance and ideas for the design of similar outpatient models in other hospitals and surgical specialties. Conflict of interest
5
Ethics statement/Confirmation of patients’ permission Ethics statement not required. There is no identifying information about patients given. References 1. Emmi Poteliakhoff JT. DATABriefing 2011; Dec 22:1–6. Available https://www/kingsfund.org.uk/sites/files/kf/DATAfrom URL: briefing-Emergency-bed-useWhat-the-numbers-tell-us-EmmiPoteliakhoff-James-Thompson-Kings-Fund-December-2011.pdf Last accessed 6 2017. 2. Boffano P, Roccia F, Zavattero E, et al. European Maxillofacial Trauma (EURMAT) project: a multicentre and prospective study. J Craniomaxillofac Surg 2015;43:62–70. 3. Shetty V, Atchison K, Der-Matirosian C, et al. The mandible injury severity score: development and validity. J Oral Maxillofac Surg 2007;65:663–70. 4. Lucca M, Shastri K, McKenzie W, et al. Comparison of treatment outcomes associated with early versus late treatment of mandible fractures: a retrospective chart review and analysis. J Oral Maxillofac Surg 2010;68:2484–8. 5. Moulton-Barrett R, Rubinstein AJ, Salzhauer MA, et al. Complications of mandibular fractures. Ann Plast Surg 1998;41:258–63. 6. Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg 2003;61:713–8. 7. Dongas P, Hall GM. Mandibular fracture patterns in Tasmania, Australia. Aust Dent J 2002;47:131–7. 8. Schmidt BL, Kearns G, Gordon N, et al. A financial analysis of maxillomandibular fixation versus rigid internal fixation for treatment of mandibular fractures. J Oral Maxillofac Surg 2000;58:1206–11. 9. Dimitroulis G. Management of fractured mandibles without the use of intermaxillary wire fixation. J Oral Maxillofac Surg 2002;60:1435–9. 10. Chole RA, Yee J. Antibiotic prophylaxis for facial fractures: a prospective, randomized clinical trial. Arch Otolaryngol Head Neck Surg 1987;113:1055–7. 11. Andreasen JO, Jensen SS, Schwartz O, et al. A systematic review of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J Oral Maxillofac Surg 2006;64:1664–8. 12. Childress CS, Newlands SD. Utilization of panoramic radiographs to evaluate short-term complications of mandibular fracture repair. Laryngoscope 1999;109:1269–72. 13. van den Bergh B, Goey Y, Forouzanfar T. Postoperative radiographs after maxillofacial trauma: Sense or nonsense? Int J Oral Maxillofac Surg 2011;40:1373–6. 14. Bali N, Lopes V. An audit of the effectiveness of postoperative radiographs—do they make a difference? Br J Oral Maxillofac Surg 2004;42:331–4.
We have no conflicts of interest
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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ARTICLE IN PRESS Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre J. Haq ∗ , J. Olding, S. Chegini, C. Huppa, R. Bentley, K. Fan Dept. of Oral & Maxillofacial Surgery, King’s College Hospital, Denmark Hill, London. SE5 9RS Accepted 11 April 2017
Abstract There is a subgroup of patients with mandibular fractures who could safely and effectively be managed in an outpatient day-care unit. Suitability depends on medical, social, and operative factors, and identification of the correct criteria will govern management after that in the emergency department. Reduced use of beds would lead to less money being spent on emergency treatment, and increased capacity for elective surgery. The aims of this study were to identify a group of patients with mandibular fractures whose duration of operation and period of recovery would be suitable for treatment in the day-care unit, and to evaluate the potential financial benefits. Inpatients were assessed for day surgery using medical, social, and surgical criteria. Each patient’s suitability for discharge was assessed two, three, and five hours postoperatively. A financial feasibility study was made retrospectively on a larger sample of patients with mandibular fractures. The discharge criteria from the day-care unit were fully met by 26/40 patients at five hours postoperatively, mean (range) duration of operation was 145 (40–285) minutes, and mean (SD) Mandibular Injury Severity Score was 13 (3), range 7–20. When all the criteria were combined (n = 100), 12 of the patients were suitable for day care. With 24 bed-day savings/100 patients, potential earnings would increase to around £80 000/year at this hospital. In conclusion, we have identified a group of patients who were suitable for management of mandibular fractures in the day-care unit. Considerable cost savings are anticipated. © 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Mandible; Day surgery; Ambulatory care; Maxillofacial trauma
Introduction Inpatient beds are the most valuable resource in the NHS,1 and admissions for the management of mandibular fractures account for a considerable number of inpatient bed-days.2 A proportion of these are patients who are waiting on a clinically-prioritised emergency operating list and then ∗
Corresponding author. E-mail addresses: [email protected] (J. Haq), [email protected] (J. Olding), [email protected] (S. Chegini), [email protected] (C. Huppa), [email protected] (R. Bentley), [email protected] (K. Fan).
recovering as inpatients. The complexity and duration of these operations varies depending on factors such as the severity of the fracture, the presence of infection, and coexisting conditions. There is already a system for rapid access to the daycare unit operating theatres, which relies on assessment of the patient followed by booking from the emergency department. This has been adopted for other surgical specialties (general surgery and gynaecology) for management of minor acute conditions when we anticipate a short operation, and discharge the same day. In this paper we present evidence in favour of the adoption of a rapid-access, day-care service for outpatient management
http://dx.doi.org/10.1016/j.bjoms.2017.04.006 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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of an identified group of patients with mandibular fractures. Such patients must be medically and socially suitable for day care, with the duration of operation being less than one session, and the postoperative recovery period short enough to permit discharge the same day before 8 pm. We hope that, through the adoption of primary scoring of the severity of the injury and medical and social screening, a group of patients can be identified who can safely be sent home from the emergency department with an appointment booked for operation in the day-care unit. This will reduce our use of inpatient beds while maintaining good clinical practice. We know of no reports that have suggested that patients with mandibular fractures are being managed as outpatients elsewhere in the UK, or that it results in poorer clinical outcome.
Patients and methods Aims We first wanted to identify a group of patients whose duration of operation and recovery period were suitable for the management of mandibular fractures by outpatient day surgery. We also wanted to evaluate the potential financial benefits of outpatient management of mandibular fractures that resulted from the reduced use of both inpatient beds and the main operating theatre.
Table 1 Day surgery unit guidelines for patients suitable for discharge. Blood pressure and pulse within preoperative range Has minimal or no pain Is able to tolerate fluids and food Has minimal nausea Can breath comfortably Is fully conscious and orientated Has passed urine Operation site is satisfactory Does patient feel ready to go home?
Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
Results Forty complete proformas were returned and these comprised the study group. There were 32 men and eight women, mean (range) age 30 (17-46) years. Thirty-one of them would have been suitable for admission to the day-care unit based on their ASA grade and domestic arrangements. Of the nine who would not have been suitable, six had nobody to take them home or stay with them overnight, and three were ASA grade II or more. The mean (range) delay from injury to treatment was 3 (014) days and each of them would have taken up an inpatient bed for one day. The mean (SD) MISS was 13 (3), range 7-20, and details of the fractures are shown in Table 2. Thirty-three of the 40 operations started during working hours (8am–5pm), the latest at 10 pm, and the mean (range) Table 2 Details of the fractures by their Mandible Injury Severity Scores.
Methods Non-consecutive adults who were admitted with isolated mandibular fractures over a 12-month period were included in the study. These patients followed the traditional path of assessment and admission from the emergency department to an inpatient ward, fasting until an emergency (NCEPOD classification) theatre slot became available, being operated on, and recovering postoperatively on the ward. These patients were then assessed for their theoretical suitability for parallel management as outpatients in the daycare unit. Data for each patient were collected prospectively using a proforma that assessed their suitability for daycare management by established general medical, anaesthetic (American Society of Anesthesiologists’ grade), and social criteria. The injury was scored using the mandibular injury severity score (MISS).3 Duration of operation from induction to extubation, and method of fixation, were also recorded. Each patient was then assessed at two, three, and five hours postoperatively to see if they were suitable for discharge according to the established criteria (Table 1). There was no further difference from current accepted practice. After we had identified a clinically suitable group of patients, we made a retrospective financial feasibility study on a larger group of patients with mandibular fractures.
Fracture
No.
Fracture: Simple Comminuted Bony defect
34 5 1
Site: Parasymphysis Body Angle Condyle Ramus Canine
18 10 26 9 5 2
Occlusion: Malocclusion Normal
38 2
Involvement of soft tissue: Closed Open intraorally Open extraorally Soft tissue defect
4 34 1 1
Infected: Yes No
2 38
Displacement: Mild Moderate Severe
8 19 13
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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3
300
270
240
Duration of operation (mins)
210
180
150
120
90
60
30
0
0
2
4
6
8
10
12
14
16
18
20
22
Score
Fig. 1. Mandibular injury severity score and duration of operation (y = 11.483x − 6.585. R2 = 0.2245).
duration of anaesthesia was 145 (40-285) minutes. Thirty-six patients had intermaxillary fixation (IMF; archbars, Leonard buttons, or IMF screws) and 36/40 had one or more fractures that required open reduction and internal fixation. One patient needed an extra-oral approach with a reconstruction plate for an infected fracture. The duration of operation of 285 minutes was that of a patient who was treated by the restorative trauma dentist during the same anaesthetic. Fig. 1 shows the MISS correlated with duration of operation. The current discharge criteria used in the day-care unit for time from operation to recovery were fully met by three of
the 40 patients at two hours, nine at three hours, and 26 at five hours, postoperatively. These figures relate to physiological recovery only, and not overall suitability for discharge. Table 3 shows the number of patients who achieved the criteria. The overall inpatient duration of stay for the group included was two days, which was divided roughly equally into one day before, and just over one day after, operation. Most of the delay between injury and operation was before the patient presented, so cannot be modified. In switching to a day-care service, we hope that the overall delay to treatment is
Table 3 Number of patients who met the discharge criteria at the three postoperative time points. Discharge criteria
At two hours
At three hours
At five hours
Not recovered
Blood pressure/pulse within normal limits Minimal pain Fluids/food Minimal nausea Breathing OK Fully conscious Passed urine Operation site OK
35 21 21 26 37 35 14 36
5 9 11 6 2 4 7 3
0 4 5 5 1 1 14 1
0 6 3 3 0 0 5 0
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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not prolonged beyond the current three days. However, given that the day-care unit slots are available only three times a week, this may not be possible depending on availability and day of presentation. A paper by Lucca et al4 described no increase in complications in patients whose treatment was delayed compared with those who were treated early, and this is further supported by Moulton-Barrett et al,5 who looked at a group treated up to 10 days after injury. The proposed criteria of a MISS of <11, and social/medical fitness for admission to the day-care unit, were applied retrospectively. One hundred patients who were operated on for a fractured mandible were included in the retrospective analysis. One patient was excluded because of associated panfacial fractures that resulted in a longer operation and inpatient stay. Eighty-seven of the patients were male, with a mean (range) age of 30 (12-53) years, and the mean (range) MISS was 16 (7–33). The mean (range) duration of anaesthesia was 153 (40-293) minutes, and 82 operations began during working hours. Sixteen patients had MISS of less than 11, and all 16 had operations that lasted less than 165 minutes (mean (range) 101 (60-157) minutes). Two patients were excluded from the day-care unit on social grounds as they had nobody to take them home. Two further patients were excluded as they were under 18 years old, and therefore too young for the rapid access lists. All 16 patients were medically fit for day surgery. Once all the criteria had been applied, 12 of the 16 patients would have been suitable for admission to the daycare unit, surgical treatment, and discharge five hours later. When extrapolated to a mean inpatient duration of stay of two days/patient, a saving of 24 bed days would have been made for every 100 patients treated. Comparison of costs and financial savings Costs of the inpatient and day surgery theatres are comparable at £213.64 and £211.69/15 minutes, respectively. Potential inpatient bed-day earnings are £1831. There is a premium Healthcare Resource Group tariff of £102.80 for intermediate oral and maxillofacial procedures done in the day-surgery theatre compared with inpatient treatment. If the savings were 24 bed days for every 100 patients, potential earnings would increase by at least £44 310, which equates to around £80 000 a year at this hospital. Discussion The patterns of mandibular fracture and demographics are broadly in line with what has been published elsewhere.6,7 Most of the identified group would fit the medical/social criteria for management in the day-care unit, which probably reflects the fact that patients were relatively young with minimal coexisting conditions. Most exclusions were for domestic reasons, with lack of a carer or difficulties with transport being the most common. Such social issues could be
addressed given notice as would be the case if the day-surgery theatre was booked, which would increase the number of suitable patients. The mean duration of operation of 145 minutes is in accordance with reports from elsewhere.8 This time period describes the total duration of anaesthesia from intubation to the patient leaving the theatre, so the actual operating time may be around 30 minutes shorter. It should be noted that 36/40 patients were treated with some form of intermaxillary fixation, and Dimitroulis reported an increased duration of 58.5 minutes when this was done.9 Although not recorded, the NCEPOD operations are often done by trainee surgeons, and if a day-case service was to be led and done by a consultant, the operating times would probably be shorter. The rapid access operating lists are threehour sessions, so 31/40 of the operations would have been suitable. The MISS is slighter higher in this cohort than in the paper by Shetty et al in which the mean (SD) was 12 (4).3 There was a relation between severity of the fracture and the duration of anaesthesia (Fig. 1), although this was not significant. Fractures with a MISS <17 were associated with an operating time of 180 minutes, although on all six occasions when they were longer, the mean MISS was only 14 (range 12–16). On no occasion did an operation take longer than three hours with a MISS of less than 12. All patients were assessed postoperatively at strict time points, although there is a degree of interobserver variability because of the logistics of data collection, and the objectivity of the analysis must be maintained. Most patients took longer than three hours to recover fully. The slowest discharge criteria to recover are pain control, passing urine, relief of nausea, and tolerance of eating and drinking. All patients with MISS <11 had recovered within five hours. Such a recovery period would be appropriate for a morning operating session, but might cause issues if the operation started after midday. This is an important factor when booking a list. Most patients (36/40) were actually discharged the next day after being reviewed on the ward round, so would be classified as ambulatory care (23 hours admission to discharge). We have identified 19/40 patients who are medically and socially fit for treatment in the day-care unit, had an operation that lasted less than three hours, and recovered within five hours of operation. As far as the relations between MISS, duration of operation, and recovery time are concerned, we can use a cut-off point of 10 for assessment of suitability for day-case management and discharge the same day. For example, such a patient would have a unilateral, minimally-displaced, parasymphyseal fracture. This threshold includes only about 10% of patients, but it is safer to initiate a new service such as this in a conservative manner. The system can develop beyond this through reaudit and evaluation, with the potential for increasing the threshold for suitability. There are limitations to the MISS score, and there are other severity scores. However, there needs to be some form
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006
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of screening that can identify the suitable patients in the emergency department in a reliable and reproducible way. If such a model were to be adopted, the standard practice of giving antibiotics intravenously before, and for a prolonged period after, operation is not possible. In place of this, the patient would be given a course of antibiotics in the emergency department to take orally at home to cover this period. Other publications support the use of prophylactic antibiotics for open mandibular surgery to reduce infection.10 However, one systematic review did state that there is no evidence that route or length of course is important.11 It is possible to give antibiotics intravenously in outpatients, and a number of acute departments provide the service already for conditions such as cellulitis. Such an addition to the model may or may not be necessary. Another alteration to the accepted hospital protocol is delay of postoperative radiographs. These are currently taken while the patient is in hospital, usually on the first postoperative day, and checked before discharge. With the adoption of a day-care service, it is likely that the radiographs would be taken at the first clinic appointment for review, which may be 1-2 weeks later. The evidence, however, suggests that postoperative plain films are of little clinical benefit.12 The rate of retreatment based on radiographic assessment alone has been shown to be low (0.2%),13 with only 1.2% of patients being returned to theatre during the same episode, all of which were based on clinical findings.14 Conclusions We plan to implement this model in our hospital and to audit its effectiveness. We think that savings will be made in cost/bed-day, and the opportunity for potential earnings is predicted to increase by the adoption of a day/ambulatory care model for management of mandibular fractures. No clinically deleterious consequences have been identified as a result of this proposed change of practice, and we hope that this paper will provide some guidance and ideas for the design of similar outpatient models in other hospitals and surgical specialties. Conflict of interest
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Ethics statement/Confirmation of patients’ permission Ethics statement not required. There is no identifying information about patients given. References 1. Emmi Poteliakhoff JT. DATABriefing 2011; Dec 22:1–6. Available https://www/kingsfund.org.uk/sites/files/kf/DATAfrom URL: briefing-Emergency-bed-useWhat-the-numbers-tell-us-EmmiPoteliakhoff-James-Thompson-Kings-Fund-December-2011.pdf Last accessed 6 2017. 2. Boffano P, Roccia F, Zavattero E, et al. European Maxillofacial Trauma (EURMAT) project: a multicentre and prospective study. J Craniomaxillofac Surg 2015;43:62–70. 3. Shetty V, Atchison K, Der-Matirosian C, et al. The mandible injury severity score: development and validity. J Oral Maxillofac Surg 2007;65:663–70. 4. Lucca M, Shastri K, McKenzie W, et al. Comparison of treatment outcomes associated with early versus late treatment of mandible fractures: a retrospective chart review and analysis. J Oral Maxillofac Surg 2010;68:2484–8. 5. Moulton-Barrett R, Rubinstein AJ, Salzhauer MA, et al. Complications of mandibular fractures. Ann Plast Surg 1998;41:258–63. 6. Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg 2003;61:713–8. 7. Dongas P, Hall GM. Mandibular fracture patterns in Tasmania, Australia. Aust Dent J 2002;47:131–7. 8. Schmidt BL, Kearns G, Gordon N, et al. A financial analysis of maxillomandibular fixation versus rigid internal fixation for treatment of mandibular fractures. J Oral Maxillofac Surg 2000;58:1206–11. 9. Dimitroulis G. Management of fractured mandibles without the use of intermaxillary wire fixation. J Oral Maxillofac Surg 2002;60:1435–9. 10. Chole RA, Yee J. Antibiotic prophylaxis for facial fractures: a prospective, randomized clinical trial. Arch Otolaryngol Head Neck Surg 1987;113:1055–7. 11. Andreasen JO, Jensen SS, Schwartz O, et al. A systematic review of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J Oral Maxillofac Surg 2006;64:1664–8. 12. Childress CS, Newlands SD. Utilization of panoramic radiographs to evaluate short-term complications of mandibular fracture repair. Laryngoscope 1999;109:1269–72. 13. van den Bergh B, Goey Y, Forouzanfar T. Postoperative radiographs after maxillofacial trauma: Sense or nonsense? Int J Oral Maxillofac Surg 2011;40:1373–6. 14. Bali N, Lopes V. An audit of the effectiveness of postoperative radiographs—do they make a difference? Br J Oral Maxillofac Surg 2004;42:331–4.
We have no conflicts of interest
Please cite this article in press as: Haq J, et al. Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.04.006