British Orthopaedic Association Standards for Trauma

Severe trauma with associated pelvic fractures: The impact of regional trauma networks on clinical outcome

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32  (95% CI 1.21 - 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care.

What is the impact of a fast-track pathway on length of stay for adult patients with a hip fracture? A systematic review

INTRODUCTION

In orthopaedic surgery, hip fracture patients represent one of the largest cohorts. Hip fracture is a serious injury commonly occurring in frail and elderly patients. Fast-track admission pathways aim to streamline patients through accident and emergency departments, resulting in shorter wait times and less negative patient outcomes.

AIM

To examine the impact of a fast-track pathway on length of stay for adults admitted to an acute hospital with a hip fracture.

METHODS

CINAHL Plus with Full text (via EBSCO host), MEDLINE, Cochrane Library, and Embase database searches were carried out in January 2021, to find all relevant literature for this review, as well as through searching additional sources. Eligible studies were quantitative primary research, focusing on the use of fast-track admission pathway care versus usual care, for adults with a hip fracture. The assessment of study suitability, data extraction, and critical appraisal was carried out by two independent authors. A narrative analysis of the data was conducted, and data were meta-analysed using RevMan where possible. Quality appraisal of the included studies was undertaken using the EBL checklist.

RESULTS

Seven studies reporting data on 5723 patients were included. Length of stay, time to surgery, and mortality did not differ significantly between the fast-track care, and usual care. One study reported on delirium and found statistically significantly fewer encounters of delirium in fast-track care versus usual care. Four of the seven studies satisfied rigorous quality appraisal (> 75%) using the EBL.

CONCLUSION

The fast-track pathway avoided unnecessary delays in emergency departments due to faster X-rays, direct admission to orthopaedic wards, and reduced delirium rates. However, results were unable to show the impact of fast-track on length of stay, time to surgery, and mortality.

Open lower limb fractures in Major Trauma Centers - A loss leader?

PURPOSE

Open lower limb fractures are resource intensive injuries. Regardless of the financing model, the cost of treatment is an important consideration for any healthcare provider.

METHODS

Open lower limb fractures treated at our centre were identified over a six-month period. Isolated open femur or tibia fractures were included as well as cases with multiple fractures. Direct inpatient care costs were calculated and income was reviewed for each case according to 'Healthcare Resource Group' (HRG) cost codes.

RESULTS

A total of 41 open lower limb fractures (32 patients) were identified. There were isolated open fractures in twenty-five and multiple lower limb open fractures in seven patients. Twenty-three patients (72%) were male and nine were female (28%) with an average age of 40 years (range 10-89 years). The fractures were classified according to Gustilo and Anderson (GA) and divided into two main groups; there were 13 mild and 28 severe open fractures. The median direct cost of inpatient treatment for open lower limb fractures was £19,189 per patient. There was a net gain of £6,288 per fracture in the mild group and a loss of £7,582 in the severe group. The total deficit was £149,545 over the six-month period for this cohort of 41 fractures.

CONCLUSION

Open lower limb fractures are expensive to treat at a cost of approximately £19,200 per patient and associated with a significant loss of income in our MTC. Cost codes should reflect the complex and more expensive treatment of these patients to avoid the inadvertent financial 'penalties' of treating such patients. This study is the first to calculate the direct inpatient treatment costs of open lower limb fractures in a major trauma centre. It highlights the need for cost saving strategies and for appropriate remuneration in MTCs.

Excessive venous bleeding in a patient with acetabular pelvic fracture secondary to inferior vena cava filter occlusion

Inferior vena cava (IVC) filters can be used to prevent pulmonary embolism in cases where anticoagulation is contraindicated. Filter obstruction remains one of the major complications after its insertion. This is the rare case demonstrating excessive venous bleeding during attempted open reduction internal fixation of an acetabular fracture secondary to subcomplete IVC filter thrombosis day 1 postinsertion of the device.

Trauma networks: present and future challenges

In England, trauma is the leading cause of death across all age groups, with over 16,000 deaths per year. Major trauma implies the presence of multiple, serious injuries that could result in death or serious disability. Successive reports have documented the fact that the current ad hoc unstructured management of this patient group is associated with considerable avoidable death and disability. The reform of trauma care in England, especially of the severely injured patient, has already begun. Strong clinical leadership is embraced as the way forward. The present article summarises the steps that have been made over the last decade that led to the recent decision to move towards a long anticipated restructure of the National Health Service (NHS) trauma services with the introduction of Regional Trauma Networks (RTNs). While, for the first time, a genuine political will and support exists, the changes required to maintain the momentum for the implementation of the RTNs needs to be marshalled against arguments, myths and perceptions from the past. Such an approach may reverse the disinterest attitude of many, and will gradually evolve into a cultural shift of the public, clinicians and policymakers in the fullness of time.

Anaesthesia for proximal femoral fracture in the UK: first report from the NHS Hip Fracture Anaesthesia Network

The aim of this audit was to investigate process, personnel and anaesthetic factors in relation to mortality among patients with proximal femoral fractures. A questionnaire was used to record standardised data about 1195 patients with proximal femoral fracture admitted to 22 hospitals contributing to the Hip Fracture Anaesthesia Network over a 2-month winter period. Patients were demographically similar between hospitals (mean age 81 years, 73% female, median ASA grade 3). However, there was wide variation in time from admission to operation (24-108 h) and 30-day postoperative mortality (2-25%). Fifty percent of hospitals had a mean admission to operation time < 48 h. Forty-two percent of operations were delayed: 51% for organisational; 44% for medical; and 4% for 'anaesthetic' reasons. Regional anaesthesia was administered to 49% of patients (by hospital, range = 0-82%), 51% received general anaesthesia and 19% of patients received peripheral nerve blockade. Consultants administered 61% of anaesthetics (17-100%). Wide national variations in current management of patients sustaining proximal femoral fracture reflect a lack of research evidence on which to base best practice guidance. Collaborative audits such as this provide a robust method of collecting such evidence.