The Dedicated Orthopaedic Trauma Room Model: Adopting a New Standard of Care

Identifying Reasons for Nonmedical Delays in Fixation of Femur, Pelvis, and Acetabular Fractures at a Level 1 Trauma Center

OBJECTIVE

To identify reasons for nonmedical delays in femur, pelvis, and acetabular fracture fixation at an institution with a dedicated orthopaedic trauma room (DOTR) and an early appropriate care practice model.

DESIGN

Retrospective review of a prospective registry.

SETTING

Urban Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundred ninety-four patients undergoing 313 procedures for 226 femur, 63 pelvis, and 42 acetabular fractures.

INTERVENTION

Definitive fixation.

MAIN OUTCOME MEASUREMENTS

Reasons for delays in fixation after hospital day 2.

RESULTS

Delays occurred in 12.5% of procedures (39/313), with 7.7% (24/313) having medical delays and 4.8% (15/313) having nonmedical delays. Nonmedical delays were most commonly due to the operating room being at-capacity (n = 6) and nonpelvic trauma specialists taking weekend call (n = 5). Procedures with nonmedical delays were associated with younger age (median difference -16.0 years, 95% confidence interval [CI], -28 to -5.0; P = 0.006), high-energy mechanisms (proportional difference [PD] 58.5%, 95% CI, 37.0-69.7; P < 0.0001), Thursday through Saturday hospital admission (PD 30.3%, 95% CI, 5.0-50.0; P < 0.0001), pelvis/acetabular fractures (PD 51.8%, 95% CI, 26.7-71.0%; P < 0.0001), and external fixation (PD 33.0%, 95% CI, 11.8-57.3; P < 0.0001).

CONCLUSION

Only 4.8% of procedures experienced nonmedical delays using an early appropriate care model and a DOTR. Nonmedical delays were most commonly due to 2 modifiable factors-the DOTR being at-capacity and nonpelvis trauma specialists taking weekend call. Patients with nonmedical delays were more likely to be younger, with pelvis/acetabular fractures, high-energy mechanisms, external fixation, and to be admitted between Thursday and Saturday.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of a Dedicated Orthopaedic Trauma Room on Elective Arthroplasty Case Volume

OBJECTIVE

To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on elective arthroplasty volume.

DESIGN

Retrospective cohort study.

SETTING

Level I academic trauma center.

INTERVENTION

A retrospective analysis was performed for two 3-year intervals before and after DOTR introduction on January 20, 2013, at a Level I trauma center. Surgeons were included if they performed elective primary total hip arthroplasty (THA), total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), or reverse total shoulder arthroplasty (RTSA) regularly from 2010 to 2015.

MAIN OUTCOME MEASURES

Change in elective arthroplasty volume after the implementation of a DOTR.

RESULTS

A total of 2339 cases were performed by surgeons A-E, with an average of 303.3 cases per year pre-DOTR and an average of 476.3 cases per year post-DOTR. On average, within our institution, there were 75.79 per 10,000 cases/year in Michigan pre-DOTR and 104.2 per 10,000 cases/year in Michigan post-DOTR. Surgeons A-E averaged 173.0 more cases per year and increased their average proportion of elective arthroplasty case volume in Michigan. There was a statistically significant market share increase of 9.8 per 10,000 cases/year in Michigan, at our hospital in the post-DOTR periods ( P = 0.039) (CI [0.5442, 19.21], SE = 4.523). This market share increase of 9.8 cases/10,000 cases was the yearly increase in market share that our average surgeons saw after the DOTR implementation, this took into account the observed annual increase in arthroplasty volume statewide during those years.

CONCLUSION

Implementation of a DOTR was associated with increases in the total number, annual mean, and annual proportion of elective arthroplasty cases performed in Michigan for both elective surgeons and the institution as a whole. These findings reveal a benefit of DOTR implementation to elective arthroplasty surgeons and health systems on a larger scale, in the form of increased arthroplasty case volume.

Are Canadian orthopaedic surgeons and American orthopaedic surgeons on par? A Canadian practice survey of orthopaedic traumatologists

Objectives:

The purpose of this study was to obtain information on Canadian orthopaedic trauma surgeon practices and salary demographics. It was hypothesized that most of the practicing surgeons recognize specific practice aspects (compensation, call schedule, operating room availability, and provided support staff) as key factors in employment opportunity evaluation.

Design:

Cross-sectional survey study.

Setting:

Orthopaedic Trauma Association (OTA) practice surveys.

Participants:

All active Canadian members of the OTA were eligible to participate.

Main Outcome Measurement:

A 50-question survey was sent through email to OTA members assessing physician, practice, and compensation metrics of Canadian orthopaedic traumatologists.

Results:

Fifty-two of 113 Canadian OTA members participated giving a response rate of 46%. All surgeons worked in an academic practice, either for a university (83%) or community hospital (17%). Only 2% of surgeons have changed jobs in the last 5 years, and over 73% of surgeons maintain the same place of employment during their careers. Most had an available dedicated orthopaedic trauma operating room (73%). The majority indicated having residents (71%) and fellows (63%) as support staff. Many reported completing 300–500 cases per year (42%), which decreased during COVID-19 for 50% of surgeons. The most common reported compensation was between $400,000 and $600,000 US dollars (25%) with many working 4–6 call shifts a month (48%) and 51–70 hours a week (48%).

Conclusion:

This study demonstrated the varying practice and physician economic variables currently in Canada. The identification and continued surveillance of these employment variables will allow for transparency in job market evaluation by applicants.

Level of Evidence:

Level V.

A Dedicated Orthopaedic Trauma Room Improves Efficiency While Remaining Financially Net Positive

OBJECTIVES

To determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency and finances.

DESIGN

Retrospective cost-analysis.

SETTING

Single midsized academic-affiliated community hospital in Toronto, Canada.

PARTICIPANTS

All patients that underwent the most frequently performed orthopaedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a 4-year period from 2016 to 2019 were included.

INTERVENTION

Patient data acquired for 2 years before the implementation of a DOTR was compared with data acquired for a 2-year period after its implementation, adjusting for the number of cases performed.

MAIN OUTCOME MEASUREMENTS

The primary outcome was surgical duration. The secondary outcome was financial impact, including after-hours costs incurred and opportunity cost of displaced elective surgeries.

RESULTS

One thousand nine hundred sixty orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR (mean improvement of 33.4%). The number of daytime operating hours increased 21%, whereas after-hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2476.

CONCLUSIONS

Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Widespread implementation can improve patient care while still remaining financially favorable.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Implementation of a Dedicated Orthopaedic Trauma Room in Hip and Femur Fracture Care: A 17-Year Analysis

OBJECTIVE

To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on hip and femur fracture care.

DESIGN

A retrospective cohort study. Setting: Level 1 trauma center. Patients: 2928 patients with femoral neck, pertrochanteric, and femoral shaft and distal femur (FSDF) fractures.

INTERVENTION

Implementation of a DOTR.

MAIN OUTCOME MEASURES

Hospital length of stay (LOS), emergency department (ED) LOS, intensive care unit (ICU) LOS, and time to operating room (TTOR).

RESULTS

Implementation of a DOTR resulted in significant improvement in TTOR for all patient groups ( P < 0.05). We found shorter TTOR for pertrochanteric ( P < 0.001), femoral neck ( P = 0.039), and FSDF groups ( P = 0.046). Total hospital LOS was shorter for patients with pertrochanteric ( P < 0.001) and femoral neck fractures ( P = 0.044). Patients with pertrochanteric hip fractures demonstrated shorter ICU LOS ( P < 0.001). No LOS improvements were observed among patients in the FSDF group. ED LOS was significantly longer in all patient groups ( P < 0.001).

CONCLUSIONS

Implementation of a DOTR was associated with shorter TTOR, shorter hospital and ICU LOS, and longer ED LOS. There was a greater number of patients transferred into the investigating institution and fewer patients transferred out. These data support the utility of a DOTR as it relates to an improvement in hospital stay-related outcomes in patients with fractures of the hip and femur. Our results suggest that a DOTR in a Level I trauma hospital is associated with improvement in patient care.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Results of a Nationwide Practice Survey of Orthopaedic Traumatologists

OBJECTIVE

To describe the current practice setting, clinical metrics, and reimbursements for orthopaedic traumatologists in the United States.

DESIGN AND SETTING

Nationwide survey of orthopaedic traumatologists.

PARTICIPANTS

Orthopaedic traumatologists with an active clinical practice.

RESULTS

Five-hundred three orthopaedic traumatologists responded to the survey request. A plurality of respondents practiced in an academic setting (48%), with a majority in practice 10 years or less (54%), and having achieved the untenured (89%) rank of assistant professor (37%). For those within private groups, 62% had achieved "partner" status, generally within 1-3 years (53%) of employment. Most surgeons (85%) reported access to a dedicated orthopaedic trauma room, providing nearly all surgeons (97%) with a first start case on weekdays, but only 55% with a first start on weekends. The greatest degree of ancillary support came from physician assistants (80%). Orthopaedic traumatologists most often reported working between 51 and 70 hours per week (66%), with 4-6 nights of call/month (43%), 1 clinic day/week (42%), and with the majority of clinical volume (>75%) related to managing traumatic injury. More than half (53%) of respondents received compensation for call. Annual case volumes and wRVU varied widely. Commonly, respondents had 100% of their salary guaranteed (48%), and most reported eligibility for additional revenue through production bonuses (70%). Three subgroup analyses by years in practice, practice setting, and physician sex provider further insight into clinical characteristics.

CONCLUSIONS

The results of this nationwide survey provide insight into the current clinical status of orthopaedic traumatology. Providers may find this information useful in job searches and contract negotiations.

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

Introduction

Operation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines.

Methods

This was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes.

Results

Our documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05).

Conclusion

The use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.

Orthopaedic trauma on the weekend: Longer surgical wait times, and increased after-hours surgery

INTRODUCTION

Orthopaedic trauma does not present in a linear fashion. Fluctuations in trauma volumes, after-hours surgery and surgical wait times impact orthopaedic surgeons and patients. There is little research focussing on how surgical trauma volumes change throughout the week. This study investigated the relationship between day of the week and surgical orthopaedic trauma volumes, after-hours surgery, and wait times for orthopaedic trauma patients.

METHODS

All unscheduled surgical orthopaedic trauma cases presenting to one level I and three level IV urban adult trauma centers between 2008 and 2018 were retrospectively reviewed. Fluctuations in orthopaedic trauma volumes and amount of after-hours surgeries completed were investigated using Multivariable Poisson regression. Fluctuations in patient wait times were investigated using linear regression.

RESULTS

Weekends were associated with increased surgical wait times (8.9%, p<0.001) despite decreased surgical trauma volumes (9.1%, p<0.001). Surgical orthopaedic trauma volumes were elevated on weekdays and decreased on weekends. More after-hours surgeries were performed from Thursday to Saturday with most performed on Friday night (26.6%, p<0.001). Surgical wait times increased midweek and remained high until Saturday.

CONCLUSION

With a lack of dedicated trauma resources on the weekend, a significant increase in after-hours surgery and surgical wait times was identified following surgical volumes peaking on Thursday and Friday. We suggest adapting resource allocation to reflect surgical volumes. Dedicated weekend orthopaedic trauma resources or an adaptable schedule during increased orthopaedic trauma have the potential to ease this bottleneck, improve patient care, and decrease hospital costs.

Effect of a 6 am-9 am Dedicated Orthopaedic Trauma Room on Hip Fracture Outcomes in a Community Level II Trauma Center

OBJECTIVE

To assess the outcomes of elderly hip fracture surgeries performed 12 months before and 12 months after the implementation of a daily 6 am-9 am dedicated orthopaedic trauma room (DOTR) at a Level II community trauma center.

DESIGN

Retrospective cohort study.

SETTING

Level II academic trauma center.

PATIENTS

A total of 431 consecutive trauma patients undergoing surgical management of isolated low-energy hip fractures from January 1, 2018, to December 31, 2019.

INTERVENTION

Implementation of a 6 am-9 am DOTR Monday through Friday.

MAIN OUTCOME MEASURES

Time to surgery, number of cases performed after hours, surgical time, 90-day morbidity and mortality, and time to therapy.

RESULTS

Retrospective analysis showed that despite a 24% increase in surgical hip fracture volume, implementation of a part-time DOTR led to a decrease in after-hours surgery (32.4% vs. 19.6%; P = 0.008) and patients requiring the intensive care unit postoperatively (7% vs. 3.8%; P = 0.036). Surgeries performed after hours were longer than that of surgeries performed during the daytime (82.0 vs. 68 minutes; P = 0.003) and had more complications (pneumonia, pulmonary embolism, and surgical site infection; P = 0.002, 0.047, 0.024, respectively).

CONCLUSIONS

Our results show that a part-time DOTR in a community Level II hospital is associated with improvement in patient care.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.