1700 Using Intra-Operative Imaging as A Tool to Provide Peer Review, Scoring, Feedback and Education for Hand and Wrist Trauma Cases - A Quality Improvement Project

Aim

To improve the efficiency of intraoperative hand trauma x-ray review, introduce a scoring system for quality of fixation achieved and use this as an education and feedback tool for trainees.

Method

A large QI project in 2019 demonstrated that intra-operative images taken using the mini C-arm were not being reviewed. In March 2020 the first QI cycle introduced an Access database to ensure that as cases were removed from the trauma board, they were added to a review list. Each x-ray was also scored in the trauma meeting (good, acceptable, poor) to assess the radiographic quality of fixation. The second QI cycle identified the named surgeon for each case, allowing surgeon specific feedback. Finally, we trained all qualified users of the mini C-arm to upload their own images after each case, reducing the mean time to upload.

Results

This QI project has improved the review rate of mini C-arm images from 30% to 100% and every x-ray is scored. The mean time to review images has reduced from 4 days to less than 24 hours. All trainees can access their scores for imaged hand and wrist trauma and receive written constructive feedback.

Conclusions

This project ensures appropriate and prompt review of all hand and wrist trauma cases allowing early identification of any concerns. All x-rays are scored, and this process acts as an educational prompt in the trauma meeting. A final report can be printed for each trainee which can be uploaded to their portfolio to document their surgical progress.

828 STITCH And B**** - A Novel Programme Combining Pastoral Support and Surgical Skills

Aim

Foundation training can be a challenging time for Junior doctors; though help and support is offered, it is not always taken up. This programme aims to create a safe environment to facilitate discussion and provide pastoral support alongside teaching them new surgical skills.

Method

Four different sessions were organised over the period of four months (August 2020 – November 2020) and FY1/FY2 doctors working in the Orthopaedic department at the GWH, Swindon were invited to attend. Each session focussed on assorted suturing techniques and knot tying. In addition, the facilitator directed conversation towards opportunities to discuss frustrations, challenges, queries as well as positive occurrences. A questionnaire was distributed at the final session to evaluate participant experience.

Results

100% of attendees agreed or strongly agreed that they found their FY1 rotation challenging so far. 100% also scored 9/10 when asked how comfortable they were talking about concerns, worries or issues at these sessions. All the participants recorded ‘yes’ when asked if the session provided them with a listening ear, helpful advice, feeling supported, understanding/empathy and reassurance. 100% of the attendees scored that their confidence at suturing had improved (average: 4 points on a scale of 1-10).

Conclusions

Through these sessions, practical changes and improvements were achieved in the running of the Trauma and Orthopaedic department. Placement feedback was obtained, suggestions on things to improve or change and key issues were escalated to supervisors. There do not appear to be any similar programmes run that combine directed pastoral support and surgical skills teaching.

Acute postoperative pain at rest after hip and knee arthroplasty: severity, sensory qualities and impact on sleep

INTRODUCTION

The management of acute postoperative pain poses a significant challenge in surgical specialities. Despite the prevalence and impact of acute postoperative pain, there is a paucity of published data regarding its occurrence and sensory qualities after joint replacement.

HYPOTHESIS

That a proportion of patients would experience severe acute postoperative pain at rest after total hip replacement (THR) and total knee replacement (TKR).

MATERIALS AND METHODS

Pain was assessed preoperatively, and then five times daily for the first three postoperative days in 105 THR and TKR patients. Pain severity was assessed using a pain Visual Analogue Scale and the sensory qualities of pain were assessed using the pain descriptors from the Short-Form McGill Pain Questionnaire.

RESULTS

Median acute pain scores peaked on the first postoperative day, with 58% of TKR patients and 47% of THR patients reporting moderate-severe pain. Preoperative pain was most frequently described as aching, stabbing and sharp, whereas acute postoperative pain was described as aching, heavy and tender. Night pain disturbed between 44-57% of TKR patients and 21-52% of THR patients on postoperative nights 1-3.

DISCUSSION

These findings demonstrate that acute postoperative pain at rest after joint replacement, particularly TKR, is poorly managed, although it does not reach the severity of preoperative pain.

LEVEL OF EVIDENCE

Level IV (observational cohort study).

Whiplash injury

We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.