Aims

To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC).

Introduction

The aim of this study was to compare the results and length of stay of patients of early (within 12 hours) versus conventional (after 48 hours) ankle fixation our hospital.

Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centres for their management are initially admitted to DGHs. The referral is made by mailing radiographs with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, financial and medico-legal implications. We discuss these issues between index DGH (Poole General Hospital) and its tertiary referral centres.

To review the existing management of spinal injury admissions at our hospital, analyse critical/adverse incidents and to identify areas for improving patient care.

A comprehensive retrospective review of all spinal admissions/referrals made to tertiary centres over 6 months was undertaken. Twenty eight of the 64 admissions warranted referrals. A structured proforma was used to document the time of admission, time of booking and performing scans, time of referral & response from tertiary centre and time of transfer from hospital notes and delays at each level were critically analysed.

Seven of the 28 referrals had either neurodeficit or spinal instability. Common issues were delay in obtaining CT/MRI scans (av 2.5 days), delay due to reporting/failing to act on results (av 1.8 days), delays due to missing/lost in transit’ scans (av 1.5 day), delay in obtaining opinion (av 4 days) and non-availability of bed for transfer (av 5.5 days). There was 1 mortality and 5 other complications while awaiting transfer. The financial costs incurred were approximately £73,000 & loss of 246 patient-days.

Training on induction day, implementation of spinal care pathway and diligent documentation/communication coupled with succinct referral were strictly enforced following this study. The website www.neurorefer.co.uk was set up by Wessex neurological centre to streamline referrals and enhance efficiency. This website has now grown into a national secure referral portal incorporating other referral centres.

Goals: In this study we analysed the patients admitted with orthopaedic problems who had coffee ground vomitus for incidence, risk factors, investigations and the management. This project was to highlight this significant but rather neglected problem and to draw up local guidelines in the prevention.

Methods: This is a prospective study conducted for a period of six months from 1st of July 2005 to 31st of Dec 2005. All patients admitted with Orthopaedic problems who had coffee ground vomitus were included in the study after confirmation with haemoccult test. Their case notes were studied to identify the risk factors, preventive measures that could have been taken and their management.

Results: There were 34 (2.3%) patients who had coffee ground vomitus, out of 1427 orthopaedic admissions during the study period. There were 14 (41%) men and 20 (59%) women. The mean age was 73.7 yrs in men and 82.2 yrs in women. This problem was more common in 8th decade with 15 patients (45.5%). There were 6 patients each in 7th and 9th decade, 5 patients in 6th decade and only 2 patients in 5th decade.

There were 19 (55.5%) trauma admissions with fractures and 15 (45.5%) elective admissions. There were 12 (35.2%) patients with previous gastric problems. There were 20 (59%) patients who were on gastric irritant medications, out of which only 5 (25%) were on gastro protective medications. All 34(100%) patients were on low molecular weight heparin for thromboprophylaxis. There were 2 patients on steroids and 2 patients on warfarin.

Coffee ground vomitus occurred preoperatively in 4 (13.4%) and postoperatively in 26 (86.6%). It happened with in the first six hours after surgery in 25 (96.5%) patients. Only in one patient it happened after 3 weeks.

All patients were kept nil by mouth, started on fluid resuscitation and intravenous ranitidine followed by oral omeprazole. Patients who were haemodynamically unstable were investigated by endoscopy. 17 (50%) patients had oral gastroduodenoscopy. 2 patients had blood transfusion because of significant drop in haemoglobin and one died before the transfusion was started.

There were 5 (14.7%) deaths in our study group. The cause of 2 deaths was directly related to gastrointestinal bleeding and the other three were confirmed to have had concurrent chest infection.

Conclusions: Gastro intestinal bleeding is a neglected but not an uncommon problem in orthopaedic patients. Identification of high-risk patients and implementation of preventive measures could avoid this potential life threatening complication. We recommend withdrawal of gastric irritants and co-prescription of gastro protective medications for high-risk orthopaedic patients.

Introduction: Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centers for their management are initially admitted to DGHs. The referral is usually done by mailing patient’s x-rays/scans with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, mortality & morbidity, financial and medicolegal implications. We discuss these issues between index DGH (Poole Gen Hosp, Dorset) and its tertiary referral centers (Southampton/Reading/Bristol/Oxford/Stanmore).

Objectives: To review the existing management of spinal injury admissions at Poole DGH, analyse critical/ adverse incidents and efforts aimed at minimising them, to identify areas for improving patient care & safety and to draft a regional management protocol/care pathway for spinal admissions.

Methods: A comprehensive retrospective review of all spinal admissions/referrals made to tertiary centers over 6 months (Jan–June 05) was undertaken. 28 of the 64 admissions warranted referrals. A structured proforma was used to document the time of admission, time of formulating clinical diagnosis, time of booking scans, time of performing scans, time of referral to tertiary centre, time of response from tertiary centre and time of transfer were retrieved from case notes and reasons for delay (if any) at each level were critically analysed.

Results: 7 of the 28 referrals had either neurodeficit or spinal instability. Common reasons for delay were delay in obtaining CT/MRI scans (av 2.5 days), delay due to reporting/failing to act on scan results (av 1 day), delays due to missing/‘lost in transit’ scans (av 1.5 day), delay in obtaining opinion from tertiary centre (av 4 days) and non-availability of bed for transfer (av 5.5 days). There was 1 mortality and 5 other complications while awaiting transfer. The financial costs incurred were appx £73,000 & loss of 246 patient-days.

Discussion: Training of junior doctors at induction, implementation of spinal care pathway and diligent documentation/communication coupled with succinct referral to the tertiary centre were strictly enforced following this study. The website www.neurorefer.co.uk was set up by Wessex neurological centre, Southampton to streamline referrals, circumvent lost in transit scans and enhance efficiency which has now grown into a national secure referral portal incorporating other referral centers.