Recording adverse events following orthopaedic trauma: Financial implications and validation of an adverse event assessment form in an Irish regional trauma unit.

BACKGROUND: In Ireland, funding of orthopaedic trauma is based on an activity-based funding (ABF) model. Clinically similar cases are split into diagnostic-related groups (DRG), with base funding per DRG provided. Increased complexity of cases (length of stay; complications incurred; occurrence of adverse events) attracts additional remuneration to the base funding. In our institution these adverse events are recorded via retrospective chart-abstraction methods by administrative staff. Incidences which are not included from this review affect both follow up with family physicians and patient care; as well as skewing budgetary decisions that impact fiscal viability of the service. The aim of this study was to compare a prospectively implemented adverse events form with the current national retrospective chart abstraction method. Our outcomes in terms of pay-by-results financial implications. METHODS: An adverse events database adapted from a similar validated model was used to prospectively record complications in 216 patients admitted via the orthopaedic trauma service. Data was contemporaneously collected via a GDPR compliant secure medical messaging platform. Results were compared with the same cohort using an existing data abstraction method. Both data sets were coded in accordance with current standards for case funding. RESULTS: Overall, 49 adverse events were recorded during the study through prospective charting of adverse events, compared with 26 events documented by customary method (p<0.01).Anaemia requiring blood transfusion n = 11 22.4%) was the most common complication, followed by delirium n = 6 (12%), acute kidney injury n = 6 (12%), and pneumonia n = 5 (10.2%). Missed appropriate funding through conventional methods totalled €40,293 . CONCLUSION: This pilot study demonstrates the ability to improve capture of adverse events through use of a well-designed assessment form. Proper perioperative data handling is a critical aspect of financial subsidies, enabling optimal allocation of funds.

Student Acceptance of Virtual Bedside Surgical Tutorials During COVID-19: A Randomized Controlled Trial.

BACKGROUND: The social distancing recommendations from the WHO during the pandemic has resulted in a pivot point in the delivery of medical education. With the medical student clinical experience constantly under threat; novel methods to maintain adequate surgical patient exposure and student interaction on a platform amenable to the interactive format required were devised using a virtual platform to compliment current pedagogical approaches. METHODS: A parallel randomized controlled trial evaluated the perceived use of remote learning in place of bedside teaching. Participants were randomized to undergo surgical bedside teaching in person or virtually. Feedback questionnaires and exit interviews carried out following each session. Content analysis of transcripts was performed to evaluate the presence and quality of perceived learning, benefits and limitations to each modality. RESULTS: Feedback demonstrated greater engagement, satisfaction, involvement and learning (P < 0.001) in the bedside teaching group. Content analysis yielded three main themes; Technological, Interpersonal Component, Provision of Content. Participants in the virtual group reported a limited ability to elicit clinically relevant findings in surgical patients. Students however reported the virtual teaching was an acceptable method of learning with 90% satisfaction reported for learning via the virtual platform. DISCUSSION: The pandemic posed challenges to adequate student-patient exposure. Delivering surgical bedside teaching remotely is a method amenable to learning for students, with advantages including convenience, fewer reports of information fatigue, and decreased perceived pressure identified with this learning modality.

Acquisition of Surgical Skills in Medical Students via Telementoring: A Randomized Controlled Trial.

BACKGROUND: Pandemic related changes have radically altered the delivery of medical teaching. The practical skills of medicine which students should be proficient in at time of graduation have tended to require in-person tutelage, with reduced access resulting in the risk of skill deficits in newly qualified doctors. Small group teaching sessions are amenable to a virtual mode of delivery, with the ability of the virtual platform to confer practical skills unproven. The objective of the study was to evaluate the use of teleproctoring in acquisition of suturing skills in medical students. METHODS: This was a single blinded two- armed randomized control trial. Medical students undergoing clinical rotations in their penultimate and final years who were able to complete the suturing tutorial were invited to participate in this study. Control groups underwent conventional suturing training under direct supervision, with the interventional group undergoing the tutorial in a remote learning setting via live streaming. Pre- and post-test assessment was carried out using validated suturing Global Rating Scale tool. RESULTS: A total of 24 participants were recruited, with 23 participants completing the task. Adequacy of sampling was demonstrated in both groups using Box's M test (P = 0.9). Participants' individual and composite scores were comparable at baseline (P = 0.28) and following the tutorial (P = 0.52). Participants improved to a statistically significant degree regardless of method of teaching delivery, in all skill parameters (P < 0.001). CONCLUSIONS: Teleproctoring is an effective tool in the provision of teaching basic suturing skills in medical students. Research on its use in more complex practical skills is warranted.

Upscaling Virtual Fracture Clinic Use Is a Safe, Effective Measure in the Delivery of Trauma Care.

The Virtual Fracture Clinic (VFC) has proved beneficial in reducing footfall within the hospital setting, improving the cost of running a trauma service, while satisfying the majority of referred patients. The mandatory upscaling of telemedicine use, specifically the enhancement of the VFC, amidst the COVID-19 pandemic, was analyzed. The remit of the VFC within our hospital was expanded so as to include all referred ambulatory trauma. Outcomes of our VFC review over the 6-week period following the introduction of the national Irish COVID-19-related restrictions were gathered. These outcomes were analyzed and compared with the corresponding 6-week period from 2019. A 77.2% increase in the VFC referral volume was observed throughout the COVID-19-related period. Patients were directly discharged in 55.2% of cases in 2020, as opposed to 47.8% in 2019 (P = 0.044); referred directly for physiotherapy in 32.9% of cases in 2020, as opposed to 28.9% in 2019 (P = 0.173); and referred to a fracture clinic in 11.9% of cases in 2020, as opposed to 23.7% in 2019 (P < 0.001). Also, 3.0% of patients returned to the clinic after discharge in 2020, compared with 4.4% in 2019 (P = 0.237); 4.5% of patients were referred for surgery in 2020, as opposed to 2.2% in 2019 (P = 0.105). The VFC proved to be an efficient tool in managing ambulatory trauma throughout the pandemic. Upscaling the VFC to include all ambulatory trauma is a safe, effective method in reducing clinic attendances and hospital footfall, whilst ensuring that high care standards are maintained. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Challenges faced by orthopaedic trainees during the Covid-19 pandemic - An Irish perspective.

BACKGROUND: The recent SARS-CoV2/COVID-19 pandemic has caused a change in most aspects of our daily lives. Our health systems have had to adjust at an unprecedented rate to accommodate care for patients affected by the virus. As a result there has been widespread disruption to trauma and elective services throughout the Orthopaedic community Worldwide. We discuss the changes facing orthopaedic residents in training and the adaptations that have been made. METHODS: We discuss the challenges posed from a reduction in caseload to surgeons in training, teaching activities, patient interaction, workforce reinforcement and support networks in Ireland. RESULTS: A structured deployment of residents has taken place ensuring maximum exposure to operative cases to maintain competency. Teaching activities have been virtualised into a new curriculum that provides trainees with convenient access to a wide range of specialists at defined time periods during the week. Strategies have been employed to reinforce the workforce in anticipation of an acute reduction in staff due to the Covid-19 virus. CONCLUSIONS: The changes have been rapid and despite many of these adjustments being borne out of necessity, the innovation displayed will almost certainly alter how training is ultimately delivered long after the crisis has ceased.