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1.  Orthopaedic surgical treatment delays at a tertiary hospital in sub Saharan Africa: Communication gaps and implications for clinical outcomes 
Background:
Delay in surgical treatment is a source of distress to patients and an important reason for poor outcome. We studied the delay before carrying out scheduled operative orthopaedic procedures and the factors responsible for it.
Materials and Methods:
This prospective study was carried out between March 2011 and December 2012. Temporal details of the surgical procedures at our hospital were recorded in a proforma including the patients’ perception of the causes of the delay to surgery. Based on the urgency of the need for surgery, patients were classified into three groups using a modification of the method employed by Lankester et al. Data was analyzed using the Statistical Package for the Social Sciences, version 17.0. Predictors of surgical delay beyond 3 days were identified by logistic regression analysis.
Results:
Two hundred and forty-nine patients with a mean age 36.2 ± 19.2 years and M:F ratio 1.3 were recruited. 34.1% were modified Lankester group A, 45.4% group B and 20.5% group C. 47 patients (18.9%) had comorbidities, hypertension being the commonest (22 patients; 8.8%). Median delay to surgery was 4 days (mean = 17.6 days). Fifty percent of emergency room admissions were operated on within 3 days, the figure was 13% for other admissions. Lack of theatre slot was the commonest cause of delay. There was full concordance between doctors and patients in only 70.7% regarding the causes of the delay. In 15.7%, there was complete discordance. Logistic regression analysis confirmed modified Lankester groups B and C (P = 0.003) and weekend admission (P = 0.016) as significant predictors of delay to surgery of >3 days.
Conclusion:
Promptness to operative surgical care falls short of the ideal. Theatre inefficiency is a major cause of delay in treating surgical patients in our environment. Theatre facilities should be expanded and made more efficient. There is a need for better communication between surgeons and patients about delays in surgical treatment.
doi:10.4103/0300-1652.126301
PMCID: PMC3948967  PMID: 24665159
Africa; communication; orthopaedic surgery; trauma; treatment delays
2.  Does the Number of Trauma Lists Provided Affect Care and Outcome of Patients with Fractured Neck of Femur? 
INTRODUCTION
Delay in surgery for fractured neck of femur is associated with increased mortality; it is recommended that patients with fractured neck of femur are operated within 48 h. North West hospitals provide dedicated trauma lists, as recommended by the British Orthopaedic Association, to allow rapid access to surgery. We investigated trauma list provision by each trust and its effects on the time taken to get neck of femur patients to surgery and patient survival.
PATIENTS AND METHODS
The number of trauma lists provided by 13 acute trusts was determined by telephone interview with the theatre manager. Data on operating delays, reasons for delay and 30-day mortality were obtained from the Greater Manchester and Wirral fractured neck of femur audit.
RESULTS
A total of 883 patients were included in the audit (35–126 per hospital). Overall, 5–15 trauma lists were provided each week, and 80% of lists were consultant-led. Of patients, 31.8% were operated on within 24 h and 36.9% were delayed more than 48 h; 37.7% of delays were for non-medical reasons. The 30-day mortality rates varied between 5–19% (mean, 11.8%). There were no significant relationships between the number of trauma lists and these variables. When divided into hospitals with > 10 lists per week (n = 6) and those with < 10 lists per week (n = 7) there were no significant differences in 48-h delay, non-medical delay or mortality. However, 24-h delay showed a trend to be lower in those with > 10 lists (34.6% of patients versus 28.9%; P = 0.09).
CONCLUSIONS
Most trusts provided at least one dedicated daily list. This study shows that extra lists may enable trusts to cope better with fractured neck of femur but do not change mortality.
doi:10.1308/003588409X391839
PMCID: PMC2749390  PMID: 19220949
Fracture; Neck of femur; Hip surgery; Trauma
3.  Management of open fractures of the tibial shaft in multiple trauma 
Indian Journal of Orthopaedics  2008;42(4):395-400.
Background:
The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients.
Materials and Methods:
The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8–10 days after the trauma.
Results:
The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation.
Conclusion:
Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8–10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture.
doi:10.4103/0019-5413.43378
PMCID: PMC2740337  PMID: 19753226
Intramedullary nailing; multiple trauma; open tibial shaft fracture
4.  First aid and treatment for cervical spinal cord injury with fracture and dislocation 
Indian Journal of Orthopaedics  2007;41(4):300-304.
Background:
Traumatic cervical spinal cord injury with subaxial fracture and dislocation not only indicates a highly unstable spine but can also induce life-threatening complications. This makes first aid critically important before any definitive operative procedure is undertaken. The present study analyzes the various first aid measures and operative procedures for such injury.
Materials and Methods:
Two hundred and ninety-five patients suffered from cervical spinal cord injury with fracture and dislocation. The average period between injury and admission was 4.5 days (range 5 h-12 weeks). The injury includes burst fractures (n = 90), compression fractures with herniated discs (n = 50), fractures and dislocation (n = 88) and pure dislocation (n = 36). Other injuries including developmental spinal canal stenosis and/or multi-segment spinal cord compression associated with trauma (n = 12), lamina fractures compressing the spinal cord (n = 6), ligament injuries (n = 7) and hematoma (n = 6) were observed in the present study. The injury level was C4 (n = 17), C5 (n = 29), C6 (n = 39), C7 (n = 35), C4-5 (n = 38), C5-6 (n = 58), C6-7 (n = 49), C4-6 (n = 16) and C5-7 (n = 14). According to the Frankel grading system, grade A was observed in 20 cases, grade B in 91, grade C in 124 and grade D in 60. One hundred and eighteen (40%) patients had a high fever and difficulty in breathing on presentation. First aid measures included early reduction and immobilization of the injured cervical spine, controlling the temperature, breathing support, and administration of high-dose methylprednisolone within eight hours of the injury (n = 12) and administration of dehydration and neurotrophy medicine. Oxygen support was given and tracheotomy was performed for patients with serious difficulty in breathing. Measures were taken to prevent bedsores and infections of the respiratory and urological systems. Two hundred and thirty six patients were treated with anterior decompression, 31 patients were treated by posterior approach surgery and combined anterior and posterior approach surgery was performed in a single sitting on 28 patients.
Results:
All patients were followed for 0.5-18 years (mean 11.8 years). At least one Frankel grade improvement was observed in 178 (60.3%) patients. In the anterior surgery group, the best results were observed in the cases with slight compressive fracture with disc herniation (44/50 patients, 88.0%). In the posterior surgery group, one Frankel grade improvement was observed in the cases with developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries and hematoma (27/31, 87.1%). Most of the patients in the Frankel D group recovered normal neurological function after surgery. The majority of the patients with Frankel C neurological deficit (102/124) had the ability to walk postoperatively, while most of the seriously injured patients (Frankel A and B) had no improvement in their neurological function. Radiolographic fusion of the operated segments occurred in most patients within three months. Loss of intervertebral height and cervical physiological curvature was observed to varying degrees in 30.1% (71/236) of the cases in the anterior surgery group.
Conclusion:
First aid measures of early closed reduction or realignment and immobilization of the cervical spine, breathing support and high-dose methylprednisolone were most important in the treatment for traumatic spinal cord injury. Surgery should be performed as soon as the indications of spinal injury appear. The choice of the approach—anterior, posterior or both, should be based on the type of the injury and the surgeon's experience. Any complications should be actively prevented and treated.
doi:10.4103/0019-5413.36991
PMCID: PMC2989519  PMID: 21139782
Cervical spine; first aid; spinal cord injury; surgical treatment
5.  Fractured neck of femur patient care improved by simulated fast-track system 
Background
Fractured neck of femur patients represent a large demand on trauma services, and timely management results in improvements in morbidity and mortality. NICE guidance, advocating surgery on the day of admission or the following day, emphasises this. We set out to investigate whether a simulated fast-track management system could improve neck of femur fracture patient care.
Materials and methods
This prospective study was performed in a district general hospital in South West England, following a change in practise. We studied 429 patients over a 1-year period. Patients were phoned through, by the ambulance crew, to a trauma coordinator who arranged prompt radiological assessment and review. Patients with confirmed fractures were transferred to an optimisation area for orthopaedic and anaesthetic assessment prior to surgery the same day or early the following day. Our primary outcome measures were time to theatre (h) and length of hospital stay (days/h).
Results
Time to theatre reduced from 44.95 (±27.42) to 29.28 (±21.23) h. Length of stay reduced from 10 days (245.92 (±131.02) h) to 9 days (225.30 (±128.75) h). Both of these improvements were statistically significant (P < 0.05). Despite operating on virtually all patients, no increase in adverse events was seen, there was no increase in 30-day mortality and there were no perioperative deaths.
Conclusions
This coordinated management pathway improves the efficiency of the service and reduces inpatient length of stay. Increased productivity may lead to financial savings and improve our ability to meet guidelines.
doi:10.1007/s10195-013-0240-4
PMCID: PMC3751275  PMID: 23558794
Fractured neck of femur; Pathway; Optimisation
6.  The incidence of compartment syndrome after flexible nailing of pediatric tibial shaft fractures 
Purpose
Pediatric tibial shaft fractures are common injuries encountered by the orthopaedic surgeon. Flexible intramedullary nailing has become popular for pediatric patients with tibial shaft fractures that require operative fixation. The purpose of our study was to evaluate the incidence of, and the risk factors for, compartment syndrome (CS) after flexible intramedullary nailing of these injuries.
Methods
A retrospective review of tibial shaft fractures treated consecutively with flexible intramedullary nailing at our institution from 2003 to 2010 was performed. The incidence of CS after flexible nailing was recorded. In addition, age, weight, mechanism of injury, polytrauma, presence of an open fracture, presenting neurovascular exam, fracture pattern, delay in treatment (>24 h from injury), prior closed reduction attempts, method of reduction (open vs. closed) in the operating room, total fluoroscopy time, and operative time were recorded. Comparisons were made between children who developed CS and those who did not.
Results
Thirty-one children met inclusion criteria with a mean age of 11.2 years (range, 6.3–15.3 years); all were boys. Nearly, 20% of children developed CS after flexible nailing of their fractures. Those who developed CS after flexible nailing were heavier than the unaffected group (52.6 ± 14.5 kg vs. 39.4 ± 15.2 kg, P = 0.05); with a greater percentage of children 50 kg or greater (83.3% vs. 26.1%, P = 0.02) within the CS group. Children who developed CS were also more likely to present with neurologic deficits in the absence of compartmental swelling prior to surgery (66.7% vs. 9.1%, P = 0.009), and more likely to have comminuted/complex fracture patterns (83.3% vs. 29.1%, P = 0.02). There was no difference between patients who did and did not develop CS in regards to age (P = 0.42), high-energy injury mechanism (P = 0.30), polytrauma (P = 1.0), delay in treatment (P = 0.28), prior closed reduction attempts (P = 1.0), method of reduction (open vs. closed; P = 1.0) in the operating room, total fluoroscopy time (P = 0.96), and total operative time (P = 0.45). In addition, there was no difference (P = 0.65) in the rates of CS between children with open and closed fractures.
Conclusions
There is a high risk of CS after flexible intramedullary nailing of pediatric tibial shaft fractures regardless of whether an injury is open or closed. Variables that would seemingly be associated with the development of CS (high-energy injury mechanisms, polytrauma, treatment delay, prior closed reduction attempts, and closed reduction in the operating room) were not statistically associated with CS in our study. Clinicians should be wary for the development of CS whenever utilizing flexible nails for tibial shaft fractures, especially when the following co-morbidities are present: the child weighs greater than 50 kg, has complex/comminuted fracture patterns, or has a neurologic deficit in the absence of compartmental swelling prior to operative intervention.
doi:10.1007/s11832-011-0374-y
PMCID: PMC3221761  PMID: 23205145
Compartment syndrome; Tibia fracture; Flexible nailing; Pediatric
7.  Neck of femur fractures in the over 90s: a select group of patients who require prompt surgical intervention for optimal results 
Background
Patients in the extremes of old age with a femoral neck fracture represent a challenging subgroup, and are thought to be associated with poorer outcomes due to increased numbers of comorbidities. Whilst many studies are aimed at determining the optimum time for surgical fixation, there is no agreed consensus for those over 90. The aim of this study is to report the surgical outcome of this population, to understand the role surgical timing may have on operative outcomes using the orthopaedic POSSUM scoring system and to identify whether medical optimization occurs during the period of admission before surgery.
Materials and methods
We conducted a prospective observational study; data was collected from two district general hospitals over 32 consecutive months. All patients aged 90 and above who were deemed suitable for surgical fixation were included. Each one had their orthopaedic POSSUM score calculated at admission and at surgery, using their computerised and paper medical records. Assessment of outcome was based on morbidity and mortality at 30 days.
Results
A total of 146 consecutive patients above the age of 90 underwent surgery and were followed. The average age of the patients was 93 years, 123 (84 %) were female and 23 (16 %) male. Sixty-one patients were operated on within 24 h from admission, 52 patients within 24 and 48 h and 33 had surgery after 48 h from admission. In total, 21 deaths (14.4 %) were recorded and 81 patients (55.5 %) had a post-operative complication within 30 days. The orthopaedic POSSUM scoring system predicted 30-day mortality in 23 patients and morbidity in 83 patients. This gave observed to predicted ratios of 0.91 and 0.98 respectively. Overall, there was a small improvement in physiological scores taken just prior to surgery compared to those at admission. Mortality and morbidity rates were higher for those operated on or after 24 and 48-h cutoffs compared to those proceeding to surgery within 24 h (P = 0.071 and P = 0.021 respectively and P = 0.048 and P = 0.00011 respectively). When stratified according to their POSSUM scores, patients with scores of 41+ and surgery after 48 h had a significantly higher mortality rate than if they had surgery earlier (P = 0.038). Morbidity rates rose after 24 h of surgical delay (P = 0.026). Patients with a total POSSUM score between 33 and 40 exhibited a higher morbidity after a 24-h delay to surgery (P = 0.0064).
Conclusion
As life expectancy increases, older patients are becoming commoner in our hospital systems. We believe the orthopaedic POSSUM scoring system can be used as an adjuvant tool in prioritising surgical need, and allow for a more impartial evaluation when changes to practice are made. Our findings show that timing of surgery has an important bearing on mortality and morbidity after hip surgery, and older patients with higher orthopaedic POSSUM scores are sensitive to delays in surgery.
doi:10.1007/s10195-013-0248-9
PMCID: PMC3948521  PMID: 23860690
Fracture neck of femur; Nonagenarians; Timing of surgery
8.  Abdominal injuries in a low trauma volume hospital - a descriptive study from northern Sweden 
Background
Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and radiologic findings, and delay definite treatment. Here, we determined the incidence, diagnosis, and treatment of traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative management of patients with these injuries in a low trauma volume hospital.
Methods
This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147 abdominal injuries from an isolated abdominal trauma (n = 70 patients) or during multiple trauma (n = 40 patients). Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009.
Results
The median New Injury Severity Score was 9 (range: 1–57) for 147 abdominal injuries. Most patients (94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with CT < 60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was performed for 28 patients, either immediately (n = 17) as result of operative management or later (n = 11), due to non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days.
Conclusions
Non-operative management of patients with abdominal injuries, except for hollow viscus injuries, was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of trauma care at low trauma volume hospitals.
doi:10.1186/s13049-014-0048-0
PMCID: PMC4237946  PMID: 25124882
Abdominal injuries; Low trauma volume hospital; Non-operative management
9.  Acute compartment syndrome in children: a case series in 24 patients and review of the literature 
International Orthopaedics  2010;35(4):569-575.
Trauma-associated acute compartment syndrome (ACS) of the extremities is a well-known complication in adults. There are only a handful of articles that describe the symptoms, the diagnostic procedure and treatment of ACS in children. The aim of this study was to analyse the diagnostic procedures in children compared to adolescents with ACS to obtain evidence for the diagnosis, treatment and outcome of children with ACS. Twenty-four children and adolescents with ACS have been treated at the Department of Trauma Surgery of the Medical University of Vienna, Austria. Two age-related groups were investigated to compare the diagnostic and therapeutic algorithm: group A comprising children aged 2–14 years (n = 12) and group B comprising adolescents aged 15–18 years (n = 12). Patient characteristics, diagnosis and therapy-associated data, complications and clinical outcome were analysed. In both groups we found fractures in most of our patients (n = 19) followed by contusion of the soft tissues (n = 3). In group A most of our patients were injured as pedestrians in car accidents (n = 5) followed by low-energy blunt trauma (n = 3). The most common region of injury and traumatic ACS was the lower leg (n = 7) followed by the feet (n = 3). For fracture stabilisation most of the patients (n = 6) received an external fixator. The mean time from admission to the fasciotomy was 27.9 hours. In four patients a compartment pressure measurement was performed with pressure levels from 30 to 75 mmHg. A histological examination of soft tissue was performed in five patients. From fasciotomy to definitive wound closure 2.4 operations were necessary. The mean hospital stay was 18.9 days. In group B most of our patients had a motorcycle accident (n = 5). The most common region for traumatic ACS in this group was also the lower leg (n = 9). In most of the patients (n = 6) intramedullary nails could be implanted. The mean time from admission to the fasciotomy was 27.1 hours. In six patients a compartment pressure measurement was performed with pressures from 25 to 90 mmHg. In five patients a histological examination was performed. From fasciotomy to definitive wound closure 2.3 operations were necessary. The mean hospital stay was 18.4 days. Secondary fasciotomy closure was performed in all cases. A split-skin graft was only necessary in three patients (13%). We avoided primary closure in the same setting when the fasciotomy was performed. Thus, we found no difference between the two groups in the diagnostic procedures, the indication for fasciotomy, the number of operations needed from fasciotomy to definitive wound closure, time of hospitalisation and clinical outcome. The rate of permanent complications was 4.2% (one patient from group A), which means that nearly all patients experienced full recovery after fasciotomy. ACS represents a surgical emergency and the indication should be determined early even in doubtful cases to avoid complications.
doi:10.1007/s00264-010-1016-6
PMCID: PMC3066331  PMID: 20401657
10.  Emergency surgical revascularisation for coronary angioplasty complications. 
British Heart Journal  1994;72(5):428-435.
OBJECTIVES--To evaluate trends in referrals for emergency operations after percutaneous transluminal coronary angioplasty (PTCA) complications; to analyse morbidity and mortality and assess the influence of PTCA backup on elective surgery. DESIGN--A retrospective analysis of patients requiring emergency surgical revascularisation within 24 hours of percutaneous transluminal coronary angioplasty. PATIENTS--Between January 1980 and December 1990, 75 patients requiring emergency surgery within 24 hours of percutaneous transluminal coronary angioplasty. SETTING--A tertiary referral centre and postgraduate teaching hospital. RESULTS--57 patients (76%) were men, the mean age was 55 (range 29-73) years, and 30 (40%) had had a previous myocardial infarction. Before PTCA, 68 (91%) had severe angina, 59 (79%) had multivessel disease, and six (8%) had a left ventricular ejection fraction of less than 40%. A mean of 2.1 grafts (range one to five) were performed; the internal mammary artery was used in only one patient. The operative mortality was 9% and inhospital mortality was 17%. There was a need for cardiac massage until bypass was established in 19 patients (25%): this was the most important outcome determinant (P = 0.0051) and was more common in those patients with multivessel disease (P = 0.0449) and in women (P = 0.0388). In 10 of the 19 cases a vacant operating theatre was unavailable, the operation being performed in the catheter laboratory or anaesthetic room. These 19 patients had an operative mortality of 32% and inhospital mortality of 47%, compared with 2% and 7% respectively for the 56 patients who awaited the next available operating theatre. Complications included myocardial infarction, 19 patients (25%); arrhythmias, 10 patients (3%); and gross neurological event, two patients (3%). The mean intensive care unit stay was 2.6 days (range 1 to 33 days) and the mean duration of hospital admission was 13 days (range 5-40 days). CONCLUSIONS--Patients undergoing emergency surgery after PTCA complications have a substantially increased inhospital mortality and morbidity. PTCA in this unit continues to require surgical cover. Delays in operating on stable patients in centres which operate a "next available theatre" backup policy may not differ from some units performing PTCA with offsite cover for PTCA complications. Particularly in the presence of multivessel disease, however, PTCA complications may be associated with the need for "crash" bypass and such patients are unlikely to survive hospital transfer. The proportion of patients requiring "crash" bypass has increased during the period reviewed because of the extent of disease in the emergency surgical group increased. These results indicate that surgery should not be denied to these patients.
Images
PMCID: PMC1025609  PMID: 7818959
11.  Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study 
PLoS Medicine  2014;11(6):e1001664.
Using a large multicentre cohort, Pablo Perel and colleagues evaluate the association of red blood cell transfusion with mortality according to the predicted risk of death for trauma patients.
Please see later in the article for the Editors' Summary
Background
Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.
Methods and Findings
A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%–20%, 21%–50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, p<0.0001, and OR 2.31, 95% CI 1.96–2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.
Conclusions
The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.
Trial registration
www.ClinicalTrials.gov NCT01746953
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Trauma—a serious injury to the body caused by violence or an accident—is a major global health problem. Every year, injuries caused by traffic collisions, falls, blows, and other traumatic events kill more than 5 million people (9% of annual global deaths). Indeed, for people between the ages of 5 and 44 years, injuries are among the top three causes of death in many countries. Trauma sometimes kills people through physical damage to the brain and other internal organs, but hemorrhage (serious uncontrolled bleeding) is responsible for 30%–40% of trauma-related deaths. Consequently, early trauma care focuses on minimizing hemorrhage (for example, by using compression to stop bleeding) and on restoring blood circulation after blood loss (health-care professionals refer to this as resuscitation). Red blood cell (RBC) transfusion is often used for the management of patients with trauma who are bleeding; other resuscitation products include isotonic saline and solutions of human blood proteins.
Why Was This Study Done?
Although RBC transfusion can save the lives of patients with trauma who are bleeding, there is considerable uncertainty regarding the balance of risks and benefits associated with this procedure. RBC transfusion, which is an expensive intervention, is associated with several potential adverse effects, including allergic reactions and infections. Moreover, blood supplies are limited, and the risks from transfusion are high in low- and middle-income countries, where most trauma-related deaths occur. In this study, which is a secondary analysis of data from a trial (CRASH-2) that evaluated the effect of tranexamic acid (which stops excessive bleeding) in patients with trauma, the researchers test the hypothesis that RBC transfusion may have a beneficial effect among patients at high risk of death following trauma but a harmful effect among those at low risk of death.
What Did the Researchers Do and Find?
The CRASH-2 trail included 20,127 patients with trauma and major bleeding treated in 274 hospitals in 40 countries. In their risk-stratified analysis, the researchers investigated the effect of RBC transfusion on CRASH-2 participants with a predicted risk of death (estimated using a validated model that included clinical variables such as heart rate and blood pressure) on admission to hospital of less than 6%, 6%–20%, 21%–50%, or more than 50%. That is, the researchers compared death rates among patients in each stratum of predicted risk of death who received a RBC transfusion with death rates among patients who did not receive a transfusion. Half the patients received at least one transfusion. Transfusion was associated with an increase in all-cause mortality at 28 days after trauma among patients with a predicted risk of death of less than 6% or of 6%–20%, but with a decrease in all-cause mortality among patients with a predicted risk of death of more than 50%. In absolute figures, compared to no transfusion, RBC transfusion was associated with 5.1 more deaths per 100 patients in the patient group with the lowest predicted risk of death but with 11.9 fewer deaths per 100 patients in the group with the highest predicted risk of death.
What Do These Findings Mean?
These findings show that RBC transfusion is associated with an increase in all-cause deaths among patients with trauma and major bleeding with a low predicted risk of death, but with a reduction in all-cause deaths among patients with a high predicted risk of death. In other words, these findings suggest that the effect of RBC transfusion on all-cause mortality may vary according to whether a patient with trauma has a high or low predicted risk of death. However, because the participants in the CRASH-2 trial were not randomly assigned to receive a RBC transfusion, it is not possible to conclude that receiving a RBC transfusion actually increased the death rate among patients with a low predicted risk of death. It might be that the patients with this level of predicted risk of death who received a transfusion shared other unknown characteristics (confounders) that were actually responsible for their increased death rate. Thus, to provide better guidance for clinicians caring for patients with trauma and hemorrhage, the hypothesis that RBC transfusion could be harmful among patients with trauma with a low predicted risk of death should be prospectively evaluated in a randomised controlled trial.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001664.
This study is further discussed in a PLOS Medicine Perspective by Druin Burch
The World Health Organization provides information on injuries and on violence and injury prevention (in several languages)
The US Centers for Disease Control and Prevention has information on injury and violence prevention and control
The National Trauma Institute, a US-based non-profit organization, provides information about hemorrhage after trauma and personal stories about surviving trauma
The UK National Health Service Choices website provides information about blood transfusion, including a personal story about transfusion after a serious road accident
The US National Heart, Lung, and Blood Institute also provides detailed information about blood transfusions
MedlinePlus provides links to further resources on injuries, bleeding, and blood transfusion (in English and Spanish)
More information in available about CRASH-2 (in several languages)
doi:10.1371/journal.pmed.1001664
PMCID: PMC4060995  PMID: 24937305
12.  The impact of trauma centre designation on open tibial fracture management 
Introduction
The British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons guidelines for the management of open tibial fractures recommend early senior combined orthopaedic and plastic surgical input with appropriate facilities to manage a high caseload. The aim of this study was to assess whether becoming a major trauma centre has affected the management of patients with open tibial fractures.
Methods
Data were obtained prospectively on consecutive open tibial fractures during two eight-month periods: before and after becoming a trauma centre.
Results
Overall, 29 open tibial fractures were admitted after designation as a major trauma centre compared with 15 previously. Of the 29 patients, 21 came directly or as transfers from another accident and emergency deparment (previously 8 of 15). The time to transfer patients admitted initially to local orthopaedic departments has fallen from 205.7 hours to 37.4 hours (p=0.084). Tertiary transferred patients had a longer hospital stay (16.3 vs 14.9 days) and had more operations (3.7 vs 2.6, p=0.08) than direct admissions. As a trauma centre, there were improvements in time to definitive skeletal stabilisation (4.7 vs 2.2 days, p=0.06), skin coverage (8.3 vs 3.7 days, p=0.06), average number of operations (4.2 vs 2.3, p=0.002) and average length of hospital admission (26.6 vs 15.3 days, p=0.05).
Conclusions
The volume and management of open tibial fractures, independent of fracture grade, has been directly affected by the introduction of a trauma centre enabling early combined senior orthopaedic and plastic surgical input. Our data strongly support the benefits of trauma centres and the continuing development of trauma networks in the management of open tibial fractures.
doi:10.1308/003588413X13511609957416
PMCID: PMC4165241  PMID: 23827288
Open fracture; Trauma network; Major trauma centre; Gustilo; Tibial fracture
13.  Vascular trauma in civilian practice. 
Vascular trauma is associated with major morbidity and mortality, but little is known about its incidence or nature in Britain. A retrospective study of 36 patients requiring operative intervention for vascular trauma under one vascular surgeon over a 6-year period was undertaken. Twenty-four patients suffered iatrogenic trauma (median age 61 years); including cardiological intervention (19), radiological intervention (2), varicose vein surgery (1), umbilical vein catherisation (1) and isolated hyperthermic limb perfusion (1). There were 23 arterial and three venous injuries. Twelve patients had accidental trauma (median age 23 years). Three of the ten patients with blunt trauma were referred for vascular assessment before orthopaedic intervention, two after an on-table angiogram and five only after an initial orthopaedic procedure (range of delay 6 h to 10 days). Injuries were arterial in nine, venous in two and combined in one. Angiography was obtained in six patients, and in two patients with multiple upper limb fractures identified the site of injury when clinical localisation was difficult. A variety of vascular techniques were used to treat the injuries. Two patients died postoperatively and one underwent major limb amputation. Thirty-two (89%) remain free of vascular sequelae after a median follow-up of 48 months (range 3-72 months). Vascular trauma is uncommon in the United Kingdom. To repair the injuries a limited repertoire of vascular surgery techniques is needed. Therefore, vascular surgical assessment should be sought at an early stage to prevent major limb loss.
PMCID: PMC2502474  PMID: 8540659
14.  Incidence and causes of mortality following acute orthopaedic and trauma admissions. 
PURPOSE: To analyse the incidence and causes of mortality of orthopaedic and trauma patients. METHODS: Between March 1995 and October 2000, there were 594 (404 females) in-patient deaths (2.8%) with a mean age of 82.14 years (range, 21-102 years) out of 21,122 acute admissions. The cause of death and details of the acute episode were collected from the hospital records, death certificates and postmortem examinations. Data collected were computerised and analysed using the Astute statistical package, University of Leeds. RESULTS: The most common primary diagnosis on admission was fracture neck of femur 392 (69.1%; P = 0.001). In total, 443 (78.1%) patients underwent surgical intervention of their injuries prior to mortality with 21 patients (4.7%) dying on the same day of the operation. The mean number of days between the initial surgical intervention and death was 22.3 days (range, 0-154 days). Of the patients who were treated non-operatively, 124 died due to poor medical condition (4 [3.2%] died within 24 h, 66 [51.6%] died within the first week and the rest died thereafter). In the death certificate, the most common primary cause of death recorded in the group of patients of 64 years of age and below was cancer followed by multi-organ failure. In the age group of 65 years and above, the most common primary cause of mortality was pneumonia followed by heart failure and myocardial infarction. CONCLUSIONS: In orthopaedic and trauma patients below the age of 65 years, the most common cause of death appears to be cancer followed by multiple system organ failure; in the elderly, pneumonia predominates followed by heart failure and myocardial infarction. Proximal femoral fractures accounted for 70% of the deaths.
doi:10.1308/003588404323043256
PMCID: PMC1964185  PMID: 15140297
15.  Development of an orthopedic surgery trauma patient handover checklist 
Canadian Journal of Surgery  2014;57(1):8-14.
Background
In surgery, preoperative handover of surgical trauma patients is a process that must be made as safe as possible. We sought to determine vital clinical information to be transferred between patient care teams and to develop a standardized handover checklist.
Methods
We conducted standardized small-group interviews about trauma patient handover. Based on this information, we created a questionnaire to gather perspectives from all Canadian Orthopaedic Association (COA) members about which topics they felt would be most important on a handover checklist. We analyzed the responses to develop a standardized handover checklist.
Results
Of the 1106 COA members, 247 responded to the questionnaire. The top 7 topics felt to be most important for achieving patient safety in the handover were comorbidities, diagnosis, readiness for the operating room, stability, associated injuries, history/mechanism of injury and outstanding issues. The expert recommendations were to have handover completed the same way every day, all appropriate radiographs available, adequate time, all appropriate laboratory work and more time to spend with patients with more severe illness.
Conclusion
Our main recommendations for safe handover are to use standardized checklists specific to the patient and site needs. We provide an example of a standardized checklist that should be used for preoperative handovers. To our knowledge, this is the first checklist for handover developed by a group of experts in orthopedic surgery, which is both manageable in length and simple to use.
doi:10.1503/cjs.025912
PMCID: PMC3908989  PMID: 24461220
16.  Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study. 
BMJ : British Medical Journal  1992;305(6856):737-740.
OBJECTIVE--To measure the effectiveness of management of major trauma in the United Kingdom. DESIGN--Review of the care of all seriously injured patients seen over two years. SETTING--33 hospitals which receive patients who have sustained major trauma. SUBJECTS--14,648 injured patients admitted for more than three days, transferred or admitted into an intensive care bed, or dying from their injuries. MAIN OUTCOME MEASURE--Death or survival in hospital within three months of the injury. RESULTS--21% of seriously injured patients (1299) took longer than one hour to reach hospital. Time before arrival at hospital was not related to severity of injury. A senior house officer was in charge of initial hospital resuscitation in 57% (826/1445) of patients with an injury severity score > or = 16. More senior staff were commonly responsible for definitive operations, but only 46% (165/355) of patients judged to require early operation arrived in theatre within two hours. Mortality for 6111 patients sustaining blunt trauma and treated in the 14 busiest hospitals was significantly higher (actual 408, predicted 295.6, p < 0.001) than in a comparable North American dataset. Large differences in the 14 hospitals assessed could not be explained by variations in case load or facilities. In contrast, the outcome of the 4.1% (597) of patients with penetrating injuries was better than that of a comparable group in the United States. Analysis of the 415 penetrating injuries with complete data showed that 15 patients died (19.3 predicted; p = 0.04). CONCLUSIONS--The initial management of major trauma in the United Kingdom remains unsatisfactory. There are delays in providing experienced staff and timely operations. Mortality varies inexplicably between hospitals and, for blunt trauma, is generally higher than in the United States.
PMCID: PMC1883432  PMID: 1422327
17.  Alteration in emergency theatre prioritisation does not alter outcome for acute appendicitis: comparative cohort study 
Background
Despite dedicated emergency theatre, emergency surgery can be often delayed due to competing urgencies, suggesting a need for innovative theatre time management.
Aim
To investigate if a change in the emergency theatre prioritisation affects outcomes for a common urgent operation such as appendicectomy.
Methods
We prospectively recorded data from 67 patients undergoing appendicectomy, for two cohorts of patients: before and after change in theatre prioritisation: Group 1 (Jan-Mar) and 2 (Aug-Oct) respectively. Demographic and peri-operative data, time from admission to surgery, postoperative length of stay and total length of stay and complications were compared.
Results
The two groups were comparable with regards to gender, age, time of admission and histological confirmation of appendicitis. No differences between the two groups were found regarding time from admission to surgery (24.4 (95% CI 11.2;27.6) hours versus 16.1 (95% CI 10.4;21.7) hours, Mann-Whitney U test, p = 0.35), postoperative length of stay (90.8 (95% CI 61.4;120.1) hours versus 70 (95% CI 48.3;91.6) hours, Mann-Whitney U test, p = 0.25) and total length of stay (115.2 (95% CI 84.6;145.7) hours versus 86 (95% CI 61.6;110.4) hours, Mann-Whitney U test, p = 0.07) as well as complication or re-admission rates.
Conclusion
A change in the emergency theatre prioritisation does not affect outcome for appendicectomy. Provision of a second emergency theatre could be a solution to reduce the delays in acute surgical operations.
doi:10.1186/1749-7922-4-22
PMCID: PMC2700793  PMID: 19505298
18.  Clopidogrel in Orthopaedic patients: a review of current practice in Scotland 
Thrombosis Journal  2007;5:6.
Background
Clopidogrel bisulfate is an antiplatelet agent used to prevent ischaemic events in patients with vascular disease. Current guidelines recommend withholding clopidogrel for 7 days pre-operatively. However these are not based on orthopaedic patients. We therefore decided to survey current orthopaedic practice to see whether this complied with available clinical data.
Method
A questionnaire was sent to all orthopaedic consultants in Scotland.
Four haematology departments, and the manufacturers, were contacted to ask for their recommendations, and a database search was performed.
Results
140 questionnaires were sent with a 60.7% response. 84.7% of respondents have encountered patients on clopidogrel. Of those, 13.9% did not routinely stop it, and 86.1% stopped it 5–21 days pre-operatively (47.2% at 7 days).
45.9% had a unit policy on stopping clopidogrel, and the majority (69.4%) did not consult their haematology department prior to instituting their policy.
Increased peri-operative bleeding was the most reported complication (22.6%). However this was only noted in those who stopped clopidogrel greater-than 7 days pre-operatively.
Haematology advice ranged from continuing clopidogrel peri-operatively to stopping it 7 days pre-operatively and starting low-molecular-weight-heparin for thrombo-prophylaxis. The manufacturers suggested stopping clopidogrel 7 days pre-operatively. An internet search did not reveal any data on the effect of clopidogrel peri-operatively in orthopaedic patients.
Discussion
Recommendations on stopping clopidogrel have evolved from studies conducted on patients undergoing cardio-thoracic surgery. There is no data available on the effect of clopidogrel in orthopaedic practice. Our survey indicates that increased bleeding has not been found in patients who continue clopidogrel peri-operatively.
Almost half of respondents complied with current recommendations, stopping clopidogrel 7 days pre-operatively. However there remains a lack of consensus amongst orthopaedic surgeons.
Currently elective patients should stop clopidogrel 7 days pre-operatively, and emergency patients should stop clopidogrel on admission, however their operation should not be delayed due to clopidogrel usage.
doi:10.1186/1477-9560-5-6
PMCID: PMC1894781  PMID: 17531090
19.  Distribution of emergency operations and trauma in a Swedish hospital: need for reorganisation of acute surgical care? 
Background
Subspecialisation within general surgery has today reached further than ever. However, on-call time, an unchanged need for broad surgical skills are required to meet the demands of acute surgical disease and trauma. The introduction of a new subspecialty in North America that deals solely with acute care surgery and trauma is an attempt to offer properly trained surgeons also during on-call time. To find out whether such a subspecialty could be helpful in Sweden we analyzed our workload for emergency surgery and trauma.
Methods
Linköping University Hospital serves a population of 257 000. Data from 2010 for all patients, diagnoses, times and types of operations, surgeons involved, duration of stay, types of injury and deaths regarding emergency procedures were extracted from a prospectively-collected database and analyzed.
Results
There were 2362 admissions, 1559 emergency interventions; 835 were mainly abdominal operations, and 724 diagnostic or therapeutic endoscopies. Of the 1559 emergency interventions, 641 (41.1%) were made outside office hours, and of 453 minor or intermediate procedures (including appendicectomy, cholecystectomy, or proctological procedures) 276 (60.9%) were done during the evenings or at night. Two hundred and fifty-four patients were admitted with trauma and 29 (11.4%) required operation, of whom general surgeons operated on eight (3.1%). Thirteen consultants and 11 senior registrars were involved in 138 bowel resections and 164 cholecystectomies chosen as index operations for standard emergency surgery. The median (range) number of such operations done by each consultant was 6 (3–17) and 6 (1–22). Corresponding figures for senior registrars were 7 (0–11) and 8 (1–39).
Conclusion
There was an uneven distribution of exposure to acute surgical problems and trauma among general surgeons. Some were exposed to only a few standard emergency interventions and most surgeons did not operate on a single patient with trauma. Further centralization of trauma care, long-term positions at units for emergency surgery and trauma, and subspecialisation in the fields of emergency surgery and trauma, might be options to solve problems of low volumes.
doi:10.1186/1757-7241-20-66
PMCID: PMC3568729  PMID: 22985447
Acute care surgery; Trauma; Centralization; Subspecialisation
20.  Cost analysis of a system of ad hoc theatre sessions for the management of delayed trauma cases 
Background
Reducing hospital stay optimizes bed capacity. Shortage of operating time can cause some patients to have their treatment and discharge home delayed. Extra operating sessions could help in reducing such a delay. We performed a feasibility study for a simulated model of trauma lists, implemented ad- hoc to reduce time to surgery.
Materials and methods
Two hundred thirty-five consecutive trauma admissions were audited. The time required to deliver surgical treatment was recorded. Patients waiting for their operation more than 48 h from admission were allocated into a simulated system of ad hoc trauma lists, using a realistic decision-making process. The potential to reduce time-to-operation was assessed and the number of saved bed occupancy days was calculated. A cost analysis was also performed.
Results
Surgical treatment was delivered within 48 h in 193 (85%) patients, while 32 (15%) patients waited a mean of 3.8 days (3–7), because of insufficient time. To operate on these patients earlier, additional lists would have cost £38, 703, reducing the time to surgery to 1 day (0–2). This would have saved 86 days of bed occupancy, representing a savings of £17,200. Restricting the use of extra lists to the elderly patients in the cohort would have required only 11 extra lists and reduced waiting from 3 (3–4) to 1 days (0–2), for a cost of £22,407. Elderly patients’ lists would have had space left to treat additional seven younger patients, with a total saving of 51 bed occupancy days, corresponding to £10,200.
Conclusions
The system of ad hoc trauma lists is easy to organize and it appears to impact significantly on patients’ discharge and bed capacity. Direct costs to the health service are contained, as they are partially compensated by the improvement in beds availability.
doi:10.1007/s10195-008-0042-2
PMCID: PMC2688589  PMID: 19484360
Cost analysis; Audit; Trauma; Fracture neck of femur; Bed management
21.  Management of open tibial fractures – a regional experience 
INTRODUCTION
The treatment of soft-tissue injuries associated with tibial diaphyseal fractures presents a clinical challenge that is best managed by a combined plastic and orthopaedic surgery approach. The current study was undertaken to assess early treatment outcomes and burden of service provision across five regional plastic surgery units in the South-West of England.
SUBJECTS AND METHODS
We conducted a prospective 6-month audit of open tibial diaphyseal fracture management in five plastic surgery units (Bristol, Exeter, Plymouth, Salisbury, Swansea) with a collective catchment of 9.2 million people. Detailed data were collected on patient demographics, injury pattern, surgical management and outcome followed to discharge.
RESULTS
The study group consisted of 55 patients (40 male, 15 female). Twenty-two patients presented directly to the emergency department at the specialist hospital (primary group), 33 patients were initially managed at a local hospital (tertiary group). The mean time from injury to soft tissue cover was significantly less (P < 0.001) in the primary group (3.6 ± 0.8 days) than the tertiary group (10.8 ± 2.2 days), principally due to a delay in referral in the latter group (5.4 ±1.7 days). Cover was achieved with 39 flaps (19 free, 20 local), eight split skin grafts. Nine wounds closed directly or by secondary intention. There were 11 early complications (20%) including one flap failure and four infections. The overall mean length of stay was 17.5 ± 2.8 days.
CONCLUSIONS
Multidisciplinary management of severe open tibial diaphyseal may not be feasible at presentation of injury depending on local hospital specialist services available. Our results highlight the need for robust assessment, triage and senior orthopaedic review in the early post-injury phase. However, broader improvements in the management of lower limb trauma will additionally require further development of combined specialist trauma centres.
doi:10.1308/003588410X12699663904592
PMCID: PMC3229382  PMID: 21047449
Open fracture; Soft tissue; Reconstruction; Tibia
22.  Changing the Consultant On Calls From a Daily to Weekly Rotation System Reduces Time to Theater for Patients With Hip Fracture to Improve Quality of Care 
Objective:
To determine whether changing the consultant on-call schedule resulted in a reduction in time to theater for patients presenting with a hip fracture.
Summary Background Data:
Guidelines in the United Kingdom state that patients presenting with a neck of femur fracture should ideally be operated on the day of or the day after admission. However, there is a best practice tariff in the United Kingdom persuading trusts to operate on elderly patients with hip fracture within 36 hours of admission. Differing formats of daily trauma operating lists and varying consultant on-call schedules have the potential to affect a trusts ability to successfully meet such demands.
Methods:
This study retrospectively analyzed whether changing the on-call schedule from a system where the on-call consultant is changed on a daily basis to one which changes weekly resulted in a reduction in time to theater for such patients and an increase in best practice tariffs paid.
Results:
With the initial rotation system, the average time to theater for a fractured neck of femur was 44 hours 46 minutes, with 44.7% of patients having a time to surgery of less than 36 hours. Patients in the modified system underwent surgery with an average time to theater of 32 hours 19 minutes. In 71.7% of these patients, time to surgery was less than 36 hours.
Conclusion:
This study demonstrates that changing the schedule to permit a consultant to have a 7-day period of trauma on call at a time instead of only 1 day dramatically reduced the time to theater for patients with hip fracture. This significantly reduced the number of these cases done outside 36 hours and increased trust financial reward.
doi:10.1177/2151458514527762
PMCID: PMC4212368  PMID: 25360334
basic research; fragility fractures; geriatric trauma; systems of care; trauma surgery
23.  Total joint replacement: implication of cancelled operations for hospital costs and waiting list management. 
Quality in Health Care  1992;1(1):34-37.
OBJECTIVE--To identify aspects of provision of total joint replacements which could be improved. DESIGN--10 month prospective study of hospital admissions and hospital costs for patients whose total joint replacement was cancelled. SETTING--Information and Waiting List Unit, Musgrave Park Regional Orthopaedic Service, Belfast. PATIENTS--284 consecutive patients called for admission for total joint replacement. MAIN MEASURES--Costs of cancellation of operation after admission in terms of hotel and opportunity costs. RESULTS--28(10%) planned operations were cancelled, 27 of which were avoidable cancellations. Five replacement patients were substituted on the theatre list, leaving 22(8%) of 232 operating theatre opportunities unused. Patients seen at assessment clinics within two months before admission had a significantly higher operation rate than those admitted from a routine waiting list (224/232(97%) v 32/52(62%), x2 = 58.6, df = 1; p < 0.005). Mean duration of hospital stay in 28 patients with cancelled operations was 1.92 days. Operating theatre opportunity costs were 73% of the total costs of cancelled total joint replacements. CONCLUSION--Patients on long waiting lists for surgery should be reassessed before admission to avoid wasting theatre opportunities, whose cost is the largest component of the total costs of cancelled operations.
PMCID: PMC1056804  PMID: 10136828
24.  A comparison of surgical delays in directly admitted versus transferred patients with hip fractures: Opportunities for improvement? 
Canadian Journal of Surgery  2014;57(1):40-43.
Background
The increasing incidence of hip fractures in our aging population challenges orthopedic surgeons and hospital administrators to effectively care for these patients. Many patients present to regional hospitals and are transferred to tertiary care centres for surgical management, resulting in long delays to surgery. Providing timely care may improve outcomes, as delay carries an increased risk of morbidity and mortality.
Methods
We retrospectively reviewed the cases of all patients with hip fractures treated in a single Level 1 trauma centre in Canada between 2005 and 2012. We compared quality indicators and outcomes between patients transferred from a peripheral hospital and those directly admitted to the trauma centre.
Results
Of the 1191 patients retrospectively reviewed, 890 met our inclusion criteria: 175 who were transferred and 715 admitted directly to the trauma centre. Transfer patients’ median delay from admission to operation was 93 hours, whereas nontransfer patients waited 44 hours (p < 0.001). The delay predominantly occurred before transfer, as the patients had to wait for a bed to become available at the trauma centre. The median length of stay in hospital was 20 days for transfer patients compared with 13 days for nontransfer patients (p < 0.001). Regional policy changes enacted in 2011 decreased the median transfer delay from regional hospital to tertiary care centre from 47 to 27 hours (p = 0.005).
Conclusion
Policy changes can have a significant impact on patient care. Prioritizing patients and expediting transfer will decrease overall mortality, reduce hospital stay and reduce the cost of hip fracture care.
doi:10.1503/cjs.002613
PMCID: PMC3908994  PMID: 24461225
25.  Reasons for Cancellation of Cases on the Day of Surgery–A Prospective Study 
Indian Journal of Anaesthesia  2009;53(1):35-39.
Summary
Late cancellation of scheduled operations is a major cause of inefficient use of operating-room time and a waste of resources. We studied elective operating theatre bookings in general surgical discipline. On the day of surgery the intended list was noted and a list of cancellations with the reason was noted by the attending anaesthesiologist.
1590 patients were scheduled for elective surgical procedures in 458 operation rooms. 30.3 % patients were cancelled on the day of surgery. Of these, 59.7% were cancelled due to lack of availability of theatre time, 10.8% were cancelled because of medical reasons and 16.2% did not turned up on the day of surgery. In 5.4% patients, surgery was cancelled by surgeons due to a change in the surgical plan, 3.7% were cancelled because of administrative reasons, and 4.2% patients were postponed because of miscellaneous reasons.
We believe that many of the on-the-day surgery cancellations of elective surgery were potentially avoidable. We observed that cancellations due to lack of theatre time were not only a scheduling problem but were mainly caused by surgeons underestimating the timeneeded for the operation. The requirement of the instruments necessary for scheduled surgical list should be discussed a day prior to planned OR list and arranged. The non-availability of the surgeon should be informed in time so that another case is substituted in that slot. All patients who have met PACU discharge criteria must be discharged promptly to prevent delay in shifting out of the operated patient. Day care patients should be counseled adequately to report on time. Computerized scheduling should be utilized to create a realistic elective schedule. Audit should be carried out at regular intervals to find out the effective functioning of the operation theatre.
PMCID: PMC2900031  PMID: 20640075
Cancellation; Operation room; Postponement cases

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