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Orthopedic fast track: An efficient patient-care service
RESEARCH FORUM ABSTRACTS
demonstrates that emergency physicians and nurses are unable to judge a patient’s language ability, and it suggests that a more liberal use of interpreters may be indicated.
135
An Academic Emergency Department Experience With Prosthetic Hip Dislocation: A Five-Year Retrospective Study
door-to-surgery time was reduced by 63.0%, whereas door-to-discharge time was cut down by 77.1%. In addition, the average patient bill size was halved. Conclusion: Close cooperation between the ED and inpatient disciplines can improve services and increase efficiency dramatically, which will benefit patients and the institution. Such fast tracking may be extended to other minor surgical conditions. It challenges traditional, often inefficient, ED processes.
Germann CA, Perron AD/Maine Medical Center, Portland, ME Study objectives: Dislocation is a common complication after total hip arthroplasty (THA) that occurs in 2% to 5% of primary THA patients and up to 27% of patients after revision THA. Few medical publications have addressed the proper management and potential complications of prosthetic hip dislocation. No large emergency department (ED) series on this entity has been reported to date. The purpose of this study is to determine the rate of successful reduction in the ED and the incidence and type of acute complications seen with prosthetic hip dislocation patients. Methods: This was a retrospective explicit medical record review approved by the institutional review board and conducted in an academic ED with an annual census of 52,000 visits. Study dates were February 1, 1999, to February 22, 2004. Patients were identified using ED admission and discharge diagnosis. All patients recognized as having prosthetic hip dislocation were included in the study, with exclusion of nonprosthetic injuries. Two trained abstractors used a standardized sequential medical record review to extract predefined variables including age, location of reduction, physician(s) performing the reduction, and the presence of any orthopedic complication. An orthopedic complication was defined as any reported osseous, hardware, neurologic, or vascular injury. Results: The cohort was composed of 116 patient encounters during a 5-year period made up of 66 individuals with prosthetic hip(s). The mean age was 65 years. Four of the 116 patients were taken directly to the operating room for closed reduction without any attempts in the ED. Of the remaining 112 patients, 102 (91%) had successful reductions performed in the ED. Eighty-one patients had hip reduction attempted by an emergency physician, with a 91% success rate. Twentyeight (90%) of the remaining 31 patients had successful reduction performed by either an orthopedic surgeon or an emergency physician and an orthopedic surgeon while in the ED. No pre- or postreduction complications were recorded. Conclusion: Previous published series of hip dislocation have come from orthopedic literature and have largely focused on demographics and operative theory. We sought to determine the incidence of successful relocation by emergency physicians in a general ED population while accounting for any associated orthopedic complications. The finding that ED staff was successful in reducing prosthetic hip dislocations in a large majority of the patients is significant, as is the fact that it can be done without evident complication.
136
Orthopedic Fast Track: An Efficient Patient-Care Service
137
Cardiac Arrest and Bedside Ultrasonography: A Survey of Practicing Emergency Physicians
Shoenberger JM, Sartor KM, Henderson SO/Keck School of Medicine, University of Southern California, Los Angeles, CA Study objectives: Physicians make decisions to terminate resuscitative measures during cardiac arrest according to several criteria. If ultrasonography is available in the emergency department, this modality is used frequently in the setting of cardiac arrest. When the physician visualizes absent cardiac motion through echocardiography, it may prompt him or her to terminate resuscitative efforts. Our hypothesis is that emergency physicians terminate resuscitative efforts sooner with visualization of cardiac standstill and feel more comfortable in doing so. Methods: We surveyed graduates of our residency program who received training in ultrasonography during their term of residency. Surveys were mailed to 172 practicing emergency physicians who had graduated after 1993. Results: One hundred twenty-seven (73%) surveys were returned. Fourteen physicians responded that they had not been trained in ultrasonography. The remaining 113 surveys (89%) made up the study cohort. During training, the majority of individuals reported that they had used ultrasonography during more than 10 cardiac arrests. It was used for documentation of cardiac activity and pericardial effusions. Ninety percent of individuals used the ultrasonography as an aid in deciding to terminate resuscitative efforts during cardiac arrest, and 60% believed it shortened their resuscitation time. Since graduation, almost 48% of individuals in this study have ultrasonography available in their clinical practice. These individuals stated that they were comfortable in terminating resuscitations without ultrasonography (8.7 on a 10point visual scale: range 3 to 10). There remains a belief among these individuals that the use of ultrasonography would shorten their ‘‘code time’’ (62%) but that without it they can operate at a comparable standard of care (73%). For those with access to ultrasonography, the majority (44%) use it in more than 76% of their cardiac arrest situations. Ultrasonography is used in these scenarios to shorten the code time (63%), to reassure and confirm the presence of cardiac standstill for the physician (87%), and for the resuscitation team (59%). Conclusion: Bedside ultrasonography is a useful modality in the setting of cardiac arrest. The majority of physicians who use it believe that it shortens code times through visualization of cardiac standstill. However, fewer than 50% of the physicians who were trained in ultrasonography during residency at our institution have access to ultrasonography in their daily practice.
Chik Loon F, Seow E/Ten Tock Seng Hospital, Singapore, Singapore Study objectives: Previously, patients who presented to our emergency department (ED) with minor hand injuries requiring specialist operative care were all admitted to the wards. They waited an average of 10 hours 14 minutes before surgery. Postoperatively, they returned to the wards and waited for the next morning’s ward round, after which most of them were discharged. They spent an average of 26 hours 22 minutes in hospital. We analyzed our traditional ED workflow, streamlined our processes, and aimed to provide a more efficient service to our patients. We attempt to get patients with minor hand injuries requiring specialist intervention to surgery and eventually discharged in the shortest possible time. Methods: We collaborated with the orthopedic and anesthesiology departments and identified a group of patients who could be ‘‘fast-tracked’’ directly to the operating room instead of being admitted to the wards. Criteria for fast track were fingertip injuries, cut flexor tendons, cut digital nerves, single-digit fractures, and cut extensor tendon of the hands. Postoperatively, most of these patients were discharged directly from the recovery room. Results: Thirty-three patients were fast tracked. The average time taken to reach the operating room was 3 hours 47 minutes. Of the 21 patients who were discharged on the same postoperative day, the average length of hospital stay was 6 hours 3 minutes. The
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
138
Management of Epistaxis and Complications Associated With Anterior Nasal Packing
Germann CA, Southall JC/Maine Medical Center, Portland, ME Study objectives: Epistaxis is a common illness, with 6% of the US population requiring medical attention at least once in their lifetime. Divergence exists in the clinical management of epistaxis patients with regard to prophylactic antibiotic use after nasal packing placement. However, there is no clear evidence in the literature to support this practice. The purpose of this study is to review the clinical practice of anterior epistaxis in an academic emergency department (ED) and describe the complications attributed to placement of packing in the anterior nare(s). Methods: This is a retrospective explicit chart review approved by the institutional review board and conducted in an ED with an annual census of 52,000 visits. Study dates were November 1, 2000, to October 31, 2001. Patients were identified using ED admission chief complaint. All patients recognized as having anterior epistaxis were included in the study. Posterior or postoperative epistaxis patients were excluded. A trained abstractor used a standardized sequential medicalrecord review to extract predefined variables including age, use of packing or
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demonstrates that emergency physicians and nurses are unable to judge a patient’s language ability, and it suggests that a more liberal use of interpreters may be indicated.
135
An Academic Emergency Department Experience With Prosthetic Hip Dislocation: A Five-Year Retrospective Study
door-to-surgery time was reduced by 63.0%, whereas door-to-discharge time was cut down by 77.1%. In addition, the average patient bill size was halved. Conclusion: Close cooperation between the ED and inpatient disciplines can improve services and increase efficiency dramatically, which will benefit patients and the institution. Such fast tracking may be extended to other minor surgical conditions. It challenges traditional, often inefficient, ED processes.
Germann CA, Perron AD/Maine Medical Center, Portland, ME Study objectives: Dislocation is a common complication after total hip arthroplasty (THA) that occurs in 2% to 5% of primary THA patients and up to 27% of patients after revision THA. Few medical publications have addressed the proper management and potential complications of prosthetic hip dislocation. No large emergency department (ED) series on this entity has been reported to date. The purpose of this study is to determine the rate of successful reduction in the ED and the incidence and type of acute complications seen with prosthetic hip dislocation patients. Methods: This was a retrospective explicit medical record review approved by the institutional review board and conducted in an academic ED with an annual census of 52,000 visits. Study dates were February 1, 1999, to February 22, 2004. Patients were identified using ED admission and discharge diagnosis. All patients recognized as having prosthetic hip dislocation were included in the study, with exclusion of nonprosthetic injuries. Two trained abstractors used a standardized sequential medical record review to extract predefined variables including age, location of reduction, physician(s) performing the reduction, and the presence of any orthopedic complication. An orthopedic complication was defined as any reported osseous, hardware, neurologic, or vascular injury. Results: The cohort was composed of 116 patient encounters during a 5-year period made up of 66 individuals with prosthetic hip(s). The mean age was 65 years. Four of the 116 patients were taken directly to the operating room for closed reduction without any attempts in the ED. Of the remaining 112 patients, 102 (91%) had successful reductions performed in the ED. Eighty-one patients had hip reduction attempted by an emergency physician, with a 91% success rate. Twentyeight (90%) of the remaining 31 patients had successful reduction performed by either an orthopedic surgeon or an emergency physician and an orthopedic surgeon while in the ED. No pre- or postreduction complications were recorded. Conclusion: Previous published series of hip dislocation have come from orthopedic literature and have largely focused on demographics and operative theory. We sought to determine the incidence of successful relocation by emergency physicians in a general ED population while accounting for any associated orthopedic complications. The finding that ED staff was successful in reducing prosthetic hip dislocations in a large majority of the patients is significant, as is the fact that it can be done without evident complication.
136
Orthopedic Fast Track: An Efficient Patient-Care Service
137
Cardiac Arrest and Bedside Ultrasonography: A Survey of Practicing Emergency Physicians
Shoenberger JM, Sartor KM, Henderson SO/Keck School of Medicine, University of Southern California, Los Angeles, CA Study objectives: Physicians make decisions to terminate resuscitative measures during cardiac arrest according to several criteria. If ultrasonography is available in the emergency department, this modality is used frequently in the setting of cardiac arrest. When the physician visualizes absent cardiac motion through echocardiography, it may prompt him or her to terminate resuscitative efforts. Our hypothesis is that emergency physicians terminate resuscitative efforts sooner with visualization of cardiac standstill and feel more comfortable in doing so. Methods: We surveyed graduates of our residency program who received training in ultrasonography during their term of residency. Surveys were mailed to 172 practicing emergency physicians who had graduated after 1993. Results: One hundred twenty-seven (73%) surveys were returned. Fourteen physicians responded that they had not been trained in ultrasonography. The remaining 113 surveys (89%) made up the study cohort. During training, the majority of individuals reported that they had used ultrasonography during more than 10 cardiac arrests. It was used for documentation of cardiac activity and pericardial effusions. Ninety percent of individuals used the ultrasonography as an aid in deciding to terminate resuscitative efforts during cardiac arrest, and 60% believed it shortened their resuscitation time. Since graduation, almost 48% of individuals in this study have ultrasonography available in their clinical practice. These individuals stated that they were comfortable in terminating resuscitations without ultrasonography (8.7 on a 10point visual scale: range 3 to 10). There remains a belief among these individuals that the use of ultrasonography would shorten their ‘‘code time’’ (62%) but that without it they can operate at a comparable standard of care (73%). For those with access to ultrasonography, the majority (44%) use it in more than 76% of their cardiac arrest situations. Ultrasonography is used in these scenarios to shorten the code time (63%), to reassure and confirm the presence of cardiac standstill for the physician (87%), and for the resuscitation team (59%). Conclusion: Bedside ultrasonography is a useful modality in the setting of cardiac arrest. The majority of physicians who use it believe that it shortens code times through visualization of cardiac standstill. However, fewer than 50% of the physicians who were trained in ultrasonography during residency at our institution have access to ultrasonography in their daily practice.
Chik Loon F, Seow E/Ten Tock Seng Hospital, Singapore, Singapore Study objectives: Previously, patients who presented to our emergency department (ED) with minor hand injuries requiring specialist operative care were all admitted to the wards. They waited an average of 10 hours 14 minutes before surgery. Postoperatively, they returned to the wards and waited for the next morning’s ward round, after which most of them were discharged. They spent an average of 26 hours 22 minutes in hospital. We analyzed our traditional ED workflow, streamlined our processes, and aimed to provide a more efficient service to our patients. We attempt to get patients with minor hand injuries requiring specialist intervention to surgery and eventually discharged in the shortest possible time. Methods: We collaborated with the orthopedic and anesthesiology departments and identified a group of patients who could be ‘‘fast-tracked’’ directly to the operating room instead of being admitted to the wards. Criteria for fast track were fingertip injuries, cut flexor tendons, cut digital nerves, single-digit fractures, and cut extensor tendon of the hands. Postoperatively, most of these patients were discharged directly from the recovery room. Results: Thirty-three patients were fast tracked. The average time taken to reach the operating room was 3 hours 47 minutes. Of the 21 patients who were discharged on the same postoperative day, the average length of hospital stay was 6 hours 3 minutes. The
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
138
Management of Epistaxis and Complications Associated With Anterior Nasal Packing
Germann CA, Southall JC/Maine Medical Center, Portland, ME Study objectives: Epistaxis is a common illness, with 6% of the US population requiring medical attention at least once in their lifetime. Divergence exists in the clinical management of epistaxis patients with regard to prophylactic antibiotic use after nasal packing placement. However, there is no clear evidence in the literature to support this practice. The purpose of this study is to review the clinical practice of anterior epistaxis in an academic emergency department (ED) and describe the complications attributed to placement of packing in the anterior nare(s). Methods: This is a retrospective explicit chart review approved by the institutional review board and conducted in an ED with an annual census of 52,000 visits. Study dates were November 1, 2000, to October 31, 2001. Patients were identified using ED admission chief complaint. All patients recognized as having anterior epistaxis were included in the study. Posterior or postoperative epistaxis patients were excluded. A trained abstractor used a standardized sequential medicalrecord review to extract predefined variables including age, use of packing or
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