Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion Rates-A Multicenter Study Using the MARCQI Total Joint Registry Database.

BACKGROUND: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending transfusion guidelines. There was a later recommendation to consider intraoperative use of tranexamic acid. METHODS: All MARCQI-registered unilateral TKA and THA cases from the 28 member hospitals (pre-November 2013) were included. For 3 time periods (before November 13, 2013; November 13, 2013, to November 12, 2014; and after November 12, 2014), we calculated average risk and range of transfusion, transfusion with nadir hemoglobin >8 g/dL, mean length of stay, and 90-day risk of discharge to nursing home, readmission, deep infection, and emergency department visits. RESULTS: For THA, risk and range of transfusion decreased over the 3 time periods: 12.6% (2.5%-36.2%), 7.6% (2.2%-23.8%), and 4.5% (0.7%-14.4%); for TKA, 6.3% (1.3%-15.6%), 3.1% (0%-12.5%), and 1.3% (0%-7.4%). Decreases were also noted for transfusion with a nadir hemoglobin >8 g/dL with a near elimination of "unnecessary" transfusions. There was no evidence of increase in length of stay, discharge to nursing home, readmission, deep infection, or emergency department visits. CONCLUSION: A simple intervention can decrease unnecessary blood transfusions during and after elective primary unilateral THA or TKA. A collaborative registry can be used effectively to improve the quality of patient care and set a new benchmark for transfusion.

Normothermia in Arthroplasty.

BACKGROUND: Since the initial design of surgical theatres, the thermal environment of the operating suite itself has been an area of concern and robust discussion. In the 1950s, correspondence in the British Medical Journal discussed the most suitable design for a surgeon's cap to prevent sweat from dripping onto the surgical field. These deliberations stimulated questions about the effects of sweat-provoking environments on the efficiency of the surgical team, not to mention the effects on the patient. Although these benefits translate to implant-based orthopedic surgery, they remain poorly understood and, at times, ignored. METHODS: A review and synthesis of the body of literature on the topic of maintenance of normothermia was performed. RESULTS: Maintenance of normothermia in orthopedic surgery has been proven to have broad implications from bench top to bedside. Normothermia has been shown to impact everything from nitrogen loss and catabolism after hip fracture surgery to infection rates after elective arthroplasty. CONCLUSION: Given both the physiologic impact this has on patients, as well as a change in the medicolegal environment around this topic, a general understanding of these concepts should be invaluable to all surgeons.

Resource scarcity drives lethal aggression among prehistoric hunter-gatherers in central California.

The origin of human violence and warfare is controversial, and some scholars contend that intergroup conflict was rare until the emergence of sedentary foraging and complex sociopolitical organization, whereas others assert that violence was common and of considerable antiquity among small-scale societies. Here we consider two alternative explanations for the evolution of human violence: (i) individuals resort to violence when benefits outweigh potential costs, which is likely in resource poor environments, or (ii) participation in violence increases when there is coercion from leaders in complex societies leading to group level benefits. To test these hypotheses, we evaluate the relative importance of resource scarcity vs. sociopolitical complexity by evaluating spatial variation in three macro datasets from central California: (i) an extensive bioarchaeological record dating from 1,530 to 230 cal BP recording rates of blunt and sharp force skeletal trauma on thousands of burials, (ii) quantitative scores of sociopolitical complexity recorded ethnographically, and (iii) mean net primary productivity (NPP) from a remotely sensed global dataset. Results reveal that sharp force trauma, the most common form of violence in the record, is better predicted by resource scarcity than relative sociopolitical complexity. Blunt force cranial trauma shows no correlation with NPP or political complexity and may reflect a different form of close contact violence. This study provides no support for the position that violence originated with the development of more complex hunter-gatherer adaptations in the fairly recent past. Instead, findings show that individuals are prone to violence in times and places of resource scarcity.

Can an Arthroplasty Registry Help Decrease Transfusions in Primary Total Joint Replacement? A Quality Initiative.

BACKGROUND: Standardized care plans are effective at controlling cost and quality. Registries provide insights into quality and outcomes for use of implants, but most registries do not combine implant and care quality data. In 2012, several Michigan area hospitals and a major insurance provider formed a voluntary statewide total joint database/registry, the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), to collect procedural, hospital, discharge, and readmission data. Noting substantial variation in transfusion practices after total joint arthroplasty (TJA) in our institutions, we used these prospectively collected data to examine whether awareness and education of the American Association of Blood Banks' (AABB) transfusion guidelines would result in decreased transfusions. QUESTIONS/PURPOSES: (1) Can an established arthroplasty registry help implement a quality initiative (QI) designed to decrease the proportion of transfused postoperative patients undergoing TJA? (2) Do data-driven transfusion protocols decrease length of stay without increasing ischemic complications (myocardial infarctions and cerebrovascular accidents)? (3) Are decreased transfusion proportions associated with decreased readmissions, nonischemic morbidity (including deep vein thrombosis and deep prosthetic infection), and mortality in postoperative patients who had undergone TJA? METHODS: After reviewing data from the recently established MARCQI registry, the orthopaedic department noticed many discrepancies and practice variances regarding blood transfusions among their providers. In October 2013, a QI was implemented to raise awareness of the discrepancies and education about the AABB guidelines was presented at the monthly orthopaedic service line meeting. A total of 1872 TJA cases were reviewed; 50 were excluded for incomplete data and two for intraoperative transfusions for the period before education (May 2012 to June 2013, n = 1240) and after education (November 2013 to April 2014, n = 580). Data collected included gender, age, length of stay, body mass index, preoperative hemoglobin level, lowest postoperative hemoglobin level during admission, transfusion status, number of units transfused, ischemic and nonischemic morbidity, hospital readmissions within 90 days, and mortality. Pre- and post-QI transfusion proportions were calculated. Chi-square test, Student's t-test, and a multivariate analysis were performed to compare differences in transfusion proportions for patients with a postoperative hemoglobin ≥ 8 g/dL. RESULTS: Overall, the percentage of patients transfused with a postoperative hemoglobin ≥ 8 g/dL decreased 80% (6.5% [71 of 1092] versus 1.3% [seven of 538]; odds ratio, 5.3; 95% confidence interval, 2.4-11.6; p < 0.001) after the educational intervention. Before education, 16% (195 of 1240) of all patients undergoing TJA were transfused, whereas 6.5% (71 of 1092) were outside recommended AABB guidelines (hemoglobin ≥ 8 g/dL). In the 6 months after QI initiation, overall transfusions decreased to 6% (35 of 580) with 1.3% (seven of 538) having a hemoglobin ≥ 8 g/dL. The mean length of stay for nontransfused patients was shorter (2.4 days ± 0.9 versus 3.3 days ± 1.1, p < 0.001) and ischemic complications did not differ between groups (0.32% [four of 1240] versus 0.34% [two of 580], p = 0.61). Before and after education, neither the number of readmissions (5.4% [67 of 1240] versus 4.7% [27 of 580], p = 0.50) nor morbidity (3.6% [45 of 1240] versus 2.4% [14 of 580], p = 0.17) differed between time periods. There were no deaths. CONCLUSIONS: Simple education and awareness of quality practices drive safety and compliance. The impact can be immediate and lasting. Arthroplasty registries that combine procedural and care quality data are vital and may be used for important data-driven QIs. LEVEL OF EVIDENCE: Level III, therapeutic study.