The effect of a multidisciplinary care bundle on the incidence of delirium after hip fracture surgery: a quality improvement study.

Delirium is a common complication following hip fracture surgery. We introduced a peri-operative care bundle that standardised management in the emergency department, operating theatre and ward. This incorporated: use of fascia iliaca blocks; rationalisation of analgesia; avoidance of drugs known to trigger delirium; a regular education program for staff; and continuous auditing of compliance. The study was conducted between June 2017 and December 2018. We recruited 150 patients before (control group) and 150 patients after (care bundle group) the introduction of the care bundle. In patients having surgery for a hip fracture, there was a lower incidence of delirium on the third postoperative day in the care bundle group compared with the control group (33 patients (22%) vs. 49 patients (33%)), respectively; p = 0.04). Patients in the care bundle group had an adjusted OR of 2.2 (95%CI 1.1-4.4) (p = 0.03) for the avoidance of delirium on the third postoperative day. There was no difference between groups for the secondary outcome measures (measured at 30 days postoperatively) including: all-cause mortality; composite morbidity; institutionalisation; and walking status. During the study period, compliance with elements of the care bundle improved in the emergency department (49 patients (33%) compared with 85 patients (59%); p < 0.001) and anaesthetic department (40 patients (27%) compared with 104 patients (69%); p < 0.001), while orthogeriatrics maintained a high level of compliance (140 patients (93%) compared with 143 patients (95%); p = 0.45). There was a clinically and statistically significant reduction in the incidence of delirium following hip fracture surgery in patients treated with a multidisciplinary care bundle.

The pre-hospital epidemiology and management of spinal cord injuries in New South Wales: 2004-2008.

CONTEXT: Patients who have sustained a traumatic spinal cord injury require appropriate management in the immediate post-injury period for both survival and to reduce the chances of costly and disabling permanent neurological deficits. Emerging time-critical neuroprotective therapies require the prompt recognition and transfer of patients to a specialised centre for early intervention. METHODS: The Ambulance Research Institute, with the New South Wales State Spinal Cord Injury Service retrospectively linked prehospital data to spinal cord injury unit (SCIU) outcome data for all 324 patients transported by ambulance and subsequently admitted to a SCIU with a persisting traumatic spinal cord injury (SCI) between January 2004 and June 2008, with the aim of identifying factors that impact on the provision of timely and appropriate care. RESULTS: Paramedics appropriately managed 88% of SCI patients. Only 4.9% of patients had initial vital signs potentially indicative of neurological injury. The median time to a SCIU was 12h, with 60% of patients undergoing multiple transfers. The odds of reaching a SCIU in over 24h were 1.71 times greater for patients injured in a major city (95% CI 1.00-2.90) in comparison to other areas of NSW. More SCI patients with multiple trauma experienced delays in reaching a SCIU (59%), compared to patients with isolated SCI (40%; p=0.039). Patients initially transported to a designated major trauma centre were more likely to be delayed in reaching a SCIU, regardless of whether their injury was an isolated SCI or associated with multiple trauma, compared with other patients. Patients who took greater than 24h to reach a SCIU were 2.5 times more likely to develop a secondary complication (95% CI 1.51-4.17, p=0.0004). Patients who sustained their SCI as a result of a low fall were older and less likely to have their SCI identified and treated early, with less than half of this group reaching a SCIU within 24h compared with other SCI patients (OR 0.42, 95% CI 0.19-0.93, p=0.004). CONCLUSION: Early recognition, appropriate prehospital management, triage, timely and appropriate interfacility transfers of all SCI patients are critical for access to specialised care and reducing preventable complications. Elderly fallers present particular challenges to early identification.

Noninvasive hemodynamic monitoring in the emergency department.

PURPOSE OF REVIEW: Emergency department patients are frequently undifferentiated, need accurate risk assessment and stratification, and are time-critical in their need for diagnosis and resuscitation. Valid, noninvasive hemodynamic monitoring modalities are essential to differentiate high from low risk patients, and to perform goal-directed management. This review analyses recent literature, which describes innovation in the range of noninvasive monitoring tools and places them in the emergency medicine context. RELEVANT FINDINGS: A range of noninvasive measures of hemodynamic status are both commonly used, or are in the research and development phase. Pulse oximetry waveforms, electrocardiogram-based heart rate variability, Doppler and B-mode ultrasound, echocardiography, transthoracic bioimpedance, pressure pulse waveform analysis and near-infrared spectroscopy all have potential value in diagnosis and monitoring of hemodynamics, particularly used to explore autonomic nervous system control of cardiovascular function and by extension the early phases of compensation for illness and injury. Noninvasive techniques coupled with advances in data visualization and pattern recognition bring the potential for revolution to emergency department hemodynamic monitoring. SUMMARY: Noninvasive measures of hemodynamic status and function are increasingly being used, although much still remains in the research domain. Noninvasive measures may not only offer similar variables to traditional vital signs, but add a new dimension of hemodynamic descriptors.

Digital photography.

OBJECTIVE: The emergence of a new generation of "point-and-shoot" digital cameras offers doctors a compact, portable and user-friendly solution to the recording of highly detailed digital photographs and video images. This work highlights the use of such technology, and provides information for those who wish to record, store and display their own medical images. METHODS: Over a 3-month period, a digital camera was carried by a doctor in a busy, adult emergency department and used to record a range of clinical images that were subsequently transferred to a computer database. RESULTS: In total, 493 digital images were recorded, of which 428 were photographs and 65 were video clips. These were successfully used for teaching purposes, publications and patient records. CONCLUSIONS: This study highlights the importance of informed consent, the selection of a suitable package of digital technology and the role of basic photographic technique in developing a successful digital database in a busy clinical environment.

Pulse oximetry: evolution and directions.

Pulse oximetry monitoring is a relatively recent technique that has been embraced enthusiastically by medical, nursing and paramedical personnel in many clinical situations. Few people, however, have any idea of how it provides the reading of arterial blood saturation. This review performs several functions: it discusses the haemoglobin molecular structure and explains its relation to spectrophotometry, describes the history and principles of pulse oximetry and the nature of the equipment used, and reviews its common uses. It also explores the principles and proposed uses of its lesser known corollary, photoplethysmography.