Necrotizing Fasciitis (NF) is a life-threatening infectious condition which requires expedient diagnosis to proceed with urgent surgical debridement. However, it can be difficult to establish an early diagnosis and expedite operative management as signs and symptoms are often non-specific and may mimic other pathology. Scoring systems such as The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) have been proposed to incorporate laboratory findings to predict whether a soft tissue infection is likely to be NF. Recent studies have found the sensitivity and specificity of the LRINEC tool to be lower than originally cited by the LRINEC authors in a validation cohort. Furthermore, there seems to be a predilection for certain geographic locations of patients with NF transferred to our tertiary care center for management, however, to our knowledge, geographic risk factors for NF have not been reported. This study also aims to determine the morbidity and mortality rate of NF at our Canadian tertiary hospital in recent years.

Comorbidities such as smoking, diabetes, and steroid use will be analyzed for any correlation with developing NF. Identification of patient factors in correlation with laboratory values may help identify patients at higher risk for having NF upon their presentation to the emergency department. A resultant earlier diagnosis of necrotizing soft tissue infections would allow for earlier surgical debridement and positively influence patient outcomes.

A retrospective chart review of 125 cases of NF at Kingston Health Sciences Centre from 2005 to 2017 was carried out to assess the validity of the LRINEC in our population and to examine the effect of comorbid factors such as smoking, diabetes, and corticosteroid use on the development of NF. The study cohort included patients treated by all surgical disciplines at our institution over twelve years. A separate cohort of 125 cellulitis or abscess cases was analyzed to assess the validity of the LRINEC tool in differentiating necrotizing fasciitis from non-necrotizing infections such as cellulitis and soft tissue abscess.

The 30-day mortality rate of NF treated at our institution during the study period was 21%. Advanced age was found to be a significant risk factor for death within 30 days of diagnosis (p=0.001). Smoking and steroid use were both found to increase risk for developing NF (p=0.01 and p=0.03, respectively). Diabetes did not appear to increase risk NF. There was no statistical difference in mortality rates between males and females with NF. The sensitivity of LRINEC in detecting NF was only 47% with a specificity of 74%.

The mortality rate of NF at our center is similar to that of other countries in recent years. Males and females have nearly equal mortality rates from NF. Smoking and steroid use appear to increase risk for developing NF, while diabetes may not. The LRINEC assessment tool alone may underestimate risk for developing NF, however, use of other clinical factors such as comorbidity analysis will further aide in the diagnosis of NF allowing for earlier surgical debridement.

Objectives

to evaluate effect of a dedicated ward for patients with fractured neck of femur on length of acute bed stay and 30 days mortality rate.

Current fracture-clinic models, especially in the advent of reductions in junior doctors hours, may limit outpatient trainee education and patient care. We designed a new model of fracture-clinic, involving an initial consultant led case review focused on patient management and trainee education.

Prospective outcomes for all new patients attending the redesigned fracture-clinic over a 3-week period in 2010 (n=240) were compared with the traditional clinic in the same period in 2009(n=296). Trainees attending the fracture clinic completed a Likert questionnaire (1 [strongly dissagree] − 5 [strongly agree]) assessing the adequacy of education, support, staff morale & standards of patient care.

The percentage of cases given consultant input increased significantly from 33% in 2009 to 84% in 2010 (p< 0.0001), while the proportion of patients requiring physical review by a consultant fell by 21% (p< 0.0001). Return rates were reduced by 14.3% (p< 0.013) & utilization of the nurse lead fracture clinic improved by 10.1% (p< 0.0028). These improvements were most marked in the target group ?StR2 (24.2% & 22.3% respectively). There were significant improvements in staff perception of their education from 2 to 4.75 (p< 0.0001), provision of senior support from 2.38 to 4.5 (p=0.019), morale from 3.68 to 4.13 (p=0.0331) & their overall perception of patient care from 3.25 to 4.5 (p=0.0016). A&E staff found the new style clinic educational, practice changing & that it improved interdisciplinary relations, but did not interfere with their A&E duties.

Our model of fracture-clinic redesign has significantly enhanced consultant input into patient care without additional funding. In addition, we have demonstrated increased service efficiency and significant improvements in staff support, morale and education. In the face of current economic and training challenges, we recommend this new model as a tool for enhancing patient and trainee experiences.

The National Institute of Clinical Excellence (NICE) published guidance for reducing the risk of venous thromboembolism (VTE) in January 2010. This guidance has had a significant impact on the management of all inpatients. It is now mandatory to risk assess every inpatient and commence appropriate treatment if indicated. The guidelines specifically exclude outpatients although NICE recognises' that lower limb cast immobilisation is a risk factor for VTE. The purpose of our study was to establish the current practice for the management of outpatients treated with lower limb casts in England.

The NHS Choices website lists 166 acute hospitals in England. A telephone audit was conducted in February 2011. A member of the on call orthopaedic team was asked: 1. Are you aware of the NICE guidelines for VTE prophylaxis? 2. In your department, outpatients treated with a lower limb cast, are they risk assessed for VTE? 3. If a patient undergoes Open Reduction Internal Fixation (ORIF) for an ankle fracture and is discharged wearing a cast, are they given VTE prophylaxis? 4. If yes - for how long are they treated?

Responses were obtained from 150 eligible hospitals (1 FY1, 28 FY2, 44 ST1-ST2, 76 ST3+, 1 Consultant). 62% of responders stated that they were aware of the NICE guidance. 40% of responders stated that outpatients were routinely risk assessed for VTE. 32% of responders stated that ankle fractures treated with an ORIF and discharged wearing a cast would receive VTE prophylaxis. The duration of treatment varied from 5 days, to 6 weeks, to removal of cast.

The management of patients treated with a lower limb cast is variable and inconsistent throughout England. Although there are no national guidelines for this patient group, the routine risk assessment of outpatients was higher than anticipated by the authors. We recommend that if VTE prophylaxis is commenced as an inpatient, then it should be continued until the cast is removed.