Fewer delays in starting a trauma list can reduce cancellations. A novel system has been previously described where a patient is identified the day before and optimised for theatre. The patient is listed first and designated “Golden Patient”. This project aimed to assess the impact of introducing a “Golden Patient” system on trauma list start times in a district general hospital. Two months of first case sending and anaesthetic start times were recorded retrospectively (43 cases). The “Golden Patient” system was introduced with a multi-disciplinary implementation group. Target send time of 0830 hours (hrs) and anaesthetic start time of 0900hrs was agreed. First patients on trauma lists were noted in two cycles, two months apart (Cycle 1: 46, Cycle 2: 38). Prior to implementation: Mean Send Time (MST) of 0855hrs, Mean Anaesthetic Start Time (AST) of 0921hrs.
Implementation of the “Golden Patient” produced a significant improvement in trauma list starts overall. Specifically, “Golden Patients” help to improve efficiency in sending and anaesthetic start times, by up to 19 minutes on average.
An enhanced recovery programme for knee arthroplasty was introduced two years ago to our orthopaedic department. It involved the setting up of an educational programme for patients along with an extensive rehabilitation programme. The main aim of the programme is to provide an efficient and personalised service that results in an improved patient experience and fewer bed days following surgery. We carried out a retrospective study, randomly selecting 100 patients over a period of a year who were enrolled in the enhanced recovery programme. We analysed three main areas involving the pre-, peri- and post-operative period. We looked for any key factors that led to an increase or decrease in bed days. The re-admissions were analysed and the cost benefit was calculated. 99 patients were randomly selected and satisfied the inclusion criteria. We found that with the enhanced recovery programme the average length of stay for a knee arthroplasty was four days. There were no re-admissions within the population. We would like to share our enhanced recovery programme model as we feel it is a robust and effective way of providing a high level of care and decreasing the length of stay post-operatively.
Fascia iliaca compartment block (FIB), performed in the Emergency Department (A&E) in patients presenting with femoral neck fracture, has gained increasing recognition as an adjunctive analgesic. The purpose of this study was to investigate whether FIB significantly reduced the requirement for systemic opiates in the pre-operative setting. Analgesia requirements for all patients admitted with fractured neck of femur to one unit over a four month period were gathered prospectively. 33% patients had received FIB at diagnosis in ED, dependant on the expertise of the attending physician. Morphine requirements on arrival on the ward between groups were analysed. Over a four month period 144 patients were admitted with fractured neck of femur. Over this time period, introduction of an informal educational programme in A&E increased the incidence of FIB provision at diagnosis and reduced the average amount of morphine administered. Administration of FIB reduced the average morphine requirement in A&E by 56%, when compared with those who received systemic analgesia alone (CI 0.4–3.5, p=0.014). No adverse effects were reported with FIB. Fascia Iliaca Compartment Block is a safe and effective method of providing analgesia to patients with fractured neck of femur and reduces morphine requirement.
Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery. Prospective analysis of 150 patients who had operative fixation of neck of femur fractures in a district general hospital. Patients were asked on the third post-operative day to select which procedure they had undergone from a diagram of four different neck of femur surgeries (cannulated screws, cephalomedullary nail, dynamic hip screw and hemiarthroplasty). Exclusion criteria for patient selection - mini mental score of < 20 and confusion secondary to delirium.Background
Method
Independent sector treatment centres (ISTCs) were introduced in October 2003 in the United Kingdom in order to reduce waiting times for elective operations and to improve patient choice and experience. Many concerns have been voiced from several authorities over a number of issues related to these centres. One of these concerns was regarding the practice of ‘cherry-picking’. Trusts are paid according to ‘payment by results’ at national tariffs. The national tariff is an average of costs occurring in an average mix of patients. The assumption is that the higher the co-morbidities of the patients the more likely they are to consume a higher amount of resource and to require a longer length of stay. Cherry-picking may also affect the quality of training available to trainees. This audit was aimed at identifying if, and how much this practice occurs. It also identifies what affect this has on the case-load of patients left for the NHS hospitals. We looked at the number of co-morbidities amongst 198 consecutive patients undergoing hip and knee primary total arthroplasty at an ISTC, a district general hospital whose PCTs provide patient to the ISTC (Doncaster Royal Infirmary - DRI), and a district general hospital in the same area whose PCT did not provide choice at that time and who therefore did not send patients to the ISTC (Bassetlaw District General Hospital - BDGH). We found a statistically significant difference in the number of co-morbidities per patient at the ISTC compared with the DRI (1.23 vs. 2.05) and the ISTC compared with the BDGH (1.23 vs. 1.76). We were unable to show a statistically significant difference between the DRI and the BDGH. We conclude that cherry-picking does take place, and further work should be done to assess the impact on training and finance.
