Documentation in orthopaedic surgery - do integrated care pathways work?
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Integrated care pathways (ICPs) are being widely adopted in orthopaedic surgery. This study compares the quality of medical notation in an ICP with traditional record keeping. During a 3-month period, 53 total hip replacements (ICP notation) and 30 total knee replacements (traditional notation) were performed. The records of each patient were scrutinised using a standardised scoring system, based on The Royal College of Surgeons of England guidelines on medical record keeping. Each set of records (83) was scored for: admission clerking, subsequent entries, consent form, operation note, and discharge letters. The time taken to retrieve this information was recorded. The overall score for traditional records (mean, 70%) was significantly higher (P = 0.001 ) than for the ICP records (mean, 62%). The mean scores for initial clerking, subsequent entries and consent form were higher in the traditional record group. It took 35% longer to retrieve information from the ICP group (P < 0.001). In this study, the quality of record keeping was higher when using the traditional notation than an established ICP. In both groups, the frequency of omissions was high. (+info)
Doctor-patient communication in a musculoskeletal unit: relationship between an observer-rated structured scoring system and patient opinion.
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OBJECTIVES: To investigate the ability of consultant rheumatologists and orthopaedic surgeons to communicate well with patients and to determine the validity of a structured proforma used to assess medical students' communication skills. METHODS: Seventy new patient appointments with consultant rheumatologists and orthopaedic surgeons were assessed for communication skills exhibited by the consultants and patient satisfaction. Communication skills were assessed using a proforma previously used to examine medical students, and patient ratings were obtained using visual analogue scales. RESULTS: Median scores attained using the structured proforma for rheumatology, elective orthopaedic and fracture clinic consultations were 17, 15 and 14 out of 20 (P < 0.05). Patient satisfaction scores were high in all three domains measured. Scores were statistically significantly higher for rheumatology appointments than in fracture clinic (median scores 29.5, 29.5 and 28 out of 30). Consultation durations varied, with a median of 23 min for rheumatology and 10.5 and 4 min for orthopaedic surgeons in clinic and fracture clinic, respectively. CONCLUSIONS: Consultant rheumatologists and orthopaedic surgeons demonstrate good communication skills, according to a tool used to assess medical students. These scores correlate with patient views, suggesting that teaching and assessment of communication skills at medical schools may address concerns of patients. Scores and satisfaction correlate with the duration of the consultation. (+info)
Orthopaedic GP Fellowship: does it work?
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BACKGROUND: General practitioners (GPs) see a significant number of musculoskeletal problems in their daily caseload. However, orthopaedic training often forms a relatively small part of their undergraduate and postgraduate training. METHODS: A training fellowship for GPs was set up in Warrington to improve management of patients with common orthopaedic complaints in the primary care setting, and to facilitate more appropriate referrals to orthopaedic surgeons. Following the fellowship, GP referral patterns were examined. RESULTS: It was found that the GP fellows were managing many conditions more appropriately, either conservatively, or with skills learnt during the fellowship. There was an increase in the number of referred cases being listed for surgery indicating a more appropriate referral pattern to hospital. CONCLUSIONS: The Orthopaedic GP Fellowship has improved patient management in primary care and helped GPS better identify those patients who need to be referred for a specialist orthopaedic opinion. (+info)
A randomized trial of opinion leader endorsement in a survey of orthopaedic surgeons: effect on primary response rates.
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BACKGROUND: Opinion leaders have been shown to have significant influence on the practice of health professionals and patient outcomes. METHODS: Using focus groups, key informants, and sampling to redundancy techniques, we developed a questionnaire of surgeons' preferences in the treatment of tibial shaft fractures. Twenty-two well-respected and widely known orthopaedic traumatologists endorsed the questionnaire. We randomized 395 surgeon members of the Orthopaedic Trauma Association to receive either a questionnaire that included a letter informing them of the opinion leaders' endorsement, or a questionnaire without the endorsement. RESULTS: Surgeons who received the letter of endorsement had a significantly lower response rate at 2, 4, and 8 weeks. The absolute difference in response rates was 7.8% (4.6% versus 12.4%, P < 0.05) at 2 weeks, 13.1% at 4 weeks (28.6% versus 41.7% P < 0.02), and 12.3% at 8 weeks (47.5% versus 59.8% P = 0.02). CONCLUSIONS: The addition of a letter listing expert surgeons who endorse the survey lead to significantly lower primary response rates. Those interested in influencing physician responses cannot always assume a positive effect from endorsement by opinion leaders (+info)
An audit of medicolegal conferencing.
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In the English civil justice system, experts involved in a case are now commonly required to confer before the hearing and identify the areas of agreement and disagreement. A prospective study of 50 consecutive medicolegal conferences of experts was undertaken, with a view to defining their benefits, weaknesses and the optimum conference format. A record was kept of the dates of first instruction, court deadlines, and date, time and duration of conferences, together with related calls and correspondence. The manner of preparation of the statement was noted, the level of agreement/disagreement, any compromise, any later modifications of the draft, and the author's fees. Subsequently the instructing solicitors were asked to comment on the suitability of the joint statement and its contribution to settlement. Medicolegal conferencing is time-consuming and expensive. It may be of limited value where there is little or no difference of opinion, either between experts in a single field or between experts in different fields. The instructing solicitors must ensure that the participants receive, in advance of the conference, copies of all relevant documents including medical reports and medical records. An agenda is helpful in ensuring that matters of importance are not overlooked. Conferences are more effective when held in person than when conducted by telephone. The joint statement is best dictated in the presence of all participants during or after the conference. To ensure the most efficient and economical use of consultant time a formal combined audit of conferencing should be undertaken by the medical and legal professions. (+info)
Lymphocyte DNA damage precedes DNA repair or cell death after orthopaedic surgery under general anaesthesia.
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Anaesthetics have gained a lot of attention for their potential mutagenic/carcinogenic effects. In the present study we have investigated the genotoxicity of the inhalation anaesthetic sevoflurane on DNA of lymphocytes isolated from 20 patients undergoing orthopaedic surgery. The genotoxicity of the anaesthetic was studied by assaying DNA damage, apoptosis, DNA repair enzyme activity and GSH content in peripheral lymphocytes before, 15 min after anaesthesia and 24 h after surgery. Lymphocytes isolated 15 min after anaesthesia showed an increase in oxidized purine and pyrimidine bases without DNA strand break formation. DNA strand breaks occurred on the first post-operative day, associated with an enhancement of DNA repair activity and a decrease in GSH. Formation of strand breaks could be the consequence of DNA repair activity. In fact, at 24 h after surgery most of the oxidized DNA bases were repaired. When DNA damage was not repaired, activation of the cell cycle checkpoint protein p53 could lead to apoptosis. An altered redox status may contribute to lymphocytopenia due to an apoptotic event as a consequence of surgical trauma. The presence of apoptotic cells at 1 day after surgery could support the hypothesis that highly damaged peripheral lymphocytes are committed to undergo programmed cell death if the damage is not repaired. In conclusion, the actual risk from anaesthesia is presumably extremely small. However, these findings contribute to our understanding of the regulation of DNA damage/repair and cell death. (+info)
Natural history of the aging spine.
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The unrelenting changes associated with aging progressively affects all structures of the spinal units. The degenerative process starts early during the first decade of life at the disc level. Discal degeneration is associated with biochemical changes followed by macroscopic alterations including tears and fissures, which may lead to discal herniation, the main cause of radiculopathy in the young adult. Moreover, nociceptive nerve fibers have been demonstrated in degenerated discs. They may be a source of nociception and of pure low-back pain. Facet joint changes are usually secondary to discal degeneration. They include subluxation, cartilage alteration and osteophytosis. Facet hypertrophy and laxity, associated with discal degeneration, and enlargement of the ligamentum flavum progressively create narrowing of the spinal canal as well as degenerative instabilities such as spondylolisthesis and scoliosis, which are the main causes of neurogenic claudication and radiculopathy in old persons. Vertebral bodies are the static elements of the spinal unit. With advancing age, osteoporosis weakens the bony structures and facilitates bone remodeling and rotatory deformities. Finally, aging of bone, discs, facets, ligaments, and muscles may ultimately lead to rotatory scoliosis, destabilization, and rupture of equilibrium. (+info)
Hardware in orthopedic surgery.
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Insertion of foreign material into the human body has been performed with increasing frequency during the past 50 years and has received added encouragement in the antimicrobial era. Nevertheless, no matter how rational the utilization of these inflexible foreign bodies may seem, their introduction into the human framework is accompanied by evidence of nature's intolerance to hardware when substituted for living tissue. Numerous surgical complications occur following the use of internal fixation and prosthetic devices in orthopedic surgery. (+info)