The correct prescription of antibiotics for in-patients is paramount to patient safety. Trust policy states that all in-patients on antibiotics must have a start date, duration, and indication for antibiotics documented on the drug-card. On a single day all drug-cards were reviewed assessing whether documentation was in line with policy. In the initial audit, 28 antibiotic courses were prescribed; of these courses only 15 (53.5%) had an indication documented and 15 (53.5%) had a review/stop date documented. A monthly league table, coined ‘The Champions League’, was created. This named individuals who had correctly or incorrectly prescribed antibiotics, following identification in the monthly audit. It was published monthly and displayed in the doctors' office, on wards and circulated to all Consultants. After two published league tables, 19 antibiotic courses were prescribed. Indication was documented in 18 (94.7%) and 16 (84.2%) had the review date documented. This improvement has continued to the present day. Prescribing standards appear to have improved with the use of this novel motivational tool. The competitive nature of surgical trainees has led to the Champions League becoming a talking point. Top placed doctors are rewarded with Premiership rugby tickets and those who consistently underperform are sensitively offered remedial instruction.
The mechanical stresses and strains surrounding orthopaedic implants can influence bone resorption and formation, micro-fracture, and consequently implant fixation or loosening. Experimental measurement of these internal parameters is generally not feasible. Computational predictions by finite element modeling are promising, but until recently have been limited to assuming the surrounding cancellous bone as a continuous volume, without modeling individual trabeculae. A recent study demonstrated errors in bone-implant stiffness exceeding 100% when using this continuum assumption [1]. Conversely, recently micro-finite element computer models have been built from high resolution imaging of trabecular bone. In the present study we developed such models of central pegs cemented into cadaveric glenoids. We hypothesized that additional applied cement would lead to stronger implant fixation, but less physiologic strains in the trabeculae. Two cadaveric specimens were implanted, with the applied cement volume in the Specimen 2 approximately double that of Specimen 1. The specimens were imaged by micro-computed tomography (vivaCT 40, Scanco, Switzerland) with a resolution of 12 microns. Images were filtered and resampled, then imported in Mimics (Materialise, Belgium) for semi-automated segmentation and 3D reconstruction based on our laboratory's published methods. Finite element models containing 1.7 to 1.8 million elements having sides of 0.1 mm were generated by a direct image voxel-to-element approach [2] (Fig. 1). The material properties of cement and bone were assumed linear elastic (bone: E = 3.5 GPa, cement: E = 3.0 GPa, and implant (UHMWPE): E = 1.3 GPa), and interfaces were assumed fully bonded. All outer walls of the bone were fixed, and a downward force of 250 N was applied to the implant peg. Simulations were run using Abaqus (Simulia, Pawtucket RI) on a 32-core, 1 TB-memory server at PSU's High Performance Computing Systems.Introduction:
Methods:
The management of patients with displaced intra-capsular hip fractures is usually a hip hemiarthoplasty procedure. NICE guideline 124 published in 2011 suggested that Total Hip Replacement (THR) surgery should be considered in a sub group of patients with no cognitive impairment, who walk independently and are medically fit for a major surgical procedure. The Royal Devon and Exeter Hospital manages approximately 600 patients every year who have sustained a fracture of neck of femur, of which approximately 90 patients fit the above criteria. Prior to the guideline less than 20% of this sub-group were treated with a THR whereas after the guideline over 50% of patients were treated with THR, performed by sub-specialist Hip surgeons. This change was achieved by active leadership, incorporation of ‘Firebreak’ lists, looking for cases, flexible use of theatre time and operating lists and the nomination of an individual senior doctor who was tasked with a mission to improve practice. This practice is financially viable; the Trust makes over £1000 per THR for fracture. Complete outcome data at 120 days show significantly fewer patients stepping down a rung in terms of both independent living and independent walking.
