ABSTRACT
BACKGROUND: In 1991 the orthopedics department at St Paul's Hospital, Vancouver, British Columbia, Canada, identified the clinical path as a way to shorten length of stay, improve efficiency of resource use, and minimize variation in care processes without compromising clinical outcomes for patients admitted for elective knee or hip arthroplasty. METHODS: A team of direct care providers collected baseline data for 77 patients to identify variables influencing length of stay (LOS) and variability in care processes. The team proposed an improved sequence of coordinated clinical decisions and treatments on a daily basis. The clinical path was disseminated by educating nursing and medical staff and by developing pre-printed orders and modifying the nursing care plan. RESULTS: Nine months after implementation of the clinical path, there was a statistically significant reduction in median LOS (12 to 9 days; p < 0.001), which was sustained for at least 18 additional months. Decreased use of inappropriate perioperative antibiotics and laboratory tests and no change in postoperative complications or readmission rate were also found. DISCUSSION: A new team is now developing a clinical path for hip fracture patients. In addition, other programs are using the template employed by the arthroplasty team to develop clinical paths for acute myocardial infarction, coronary artery bypass grafting, stroke, and drug overdose in the intensive care unit. SUMMARY: The team is now working toward a seven-day LOS for these patients. This experience has served as a model for development and implementation of other clinical paths for other groups of patients at the hospital.
Subject(s)
Critical Pathways , Hip Prosthesis/standards , Knee Prosthesis/standards , Program Development/methods , Total Quality Management/methods , British Columbia , Data Collection/methods , Forms and Records Control , Hospital Departments/standards , Humans , Institutional Management Teams , Length of Stay , Orthopedics/standards , Outcome and Process Assessment, Health CareABSTRACT
We present a case of Clostridial gas gangrene following closed reduction of a Colles' fracture. A review of the laboratory and clinical literature on treatment of gas gangrene revealed wide differences of opinion regarding the effectiveness of surgery, antibiotics, antitoxin and especially hyperbaric oxygen. We found no previous report of clostridial gas gangrene in closed reduction of a Colles' fracture. The survival rates for 28 cases of Clostridial myonecrosis treated at Vancouver General Hospital with surgery, antibiotics and hyperbaric oxygen were 100% for extremity gangrene and 65% for trunk gangrene. We conclude: Gas gangrene is rare, but can complicate even minor trauma or procedures performed in hospital. Prevention depends on proper debridement of wounds and open fractures. Compartment syndromes may be important as etiologic and complicating factors. Hyperbaric oxygen may have therapeutic value but its use has not improved on survival rates achieved during World War II with surgery and antibiotics alone.
