Pulmonary embolism following ankle fractures treated without an operation - an analysis using National Health Service data.

The majority of ankle fractures are stable and can be treated without an operation, most commonly with cast immobilisation. Based on concerns regarding the risk of a venous thromboembolic event (VTE) while immobilised, there is currently debate as to whether these patients should receive VTE prophylaxis for the duration of treatment. Rates of pulmonary embolism (PE) in this patient group are unknown. This retrospective cohort study was designed to identify patients treated without an operation for ankle fracture and determine the occurrence of PE and inpatient mortality within 90 days of injury using the English National Health Service administrative databases. Logistic regression models were used to assess the influence of age, gender and Charlson co-morbidity score on these outcomes. We identified 14777 adult patients over a 54-month period (April 2007-September 2011) that met our linkage and inclusion criteria (isolated, unilateral closed ankle fracture that did not require hospitalisation). Mean age was 46.4 years (range 18-99) and the majority had a Charlson 0 score (97.7%). There were 32 (0.22%) PEs within 90 days of the fracture (including in one patient who subsequently died). After adjustment, Charlson score of ≥1 was associated with a greater risk of PE (Odds ratio = 11.97, p < 0.001) compared to Charlson 0. Risk for these patients was 2.08%. In total, fifteen patients (0.11%) died in hospital within 90 days. Pulmonary embolism is rare following ankle fractures treated without an operation. Patients with multiple co-morbidities are at a higher risk. Based on this evidence, an ankle fracture treated without an operation does not appear to be an indication for routine VTE prophylaxis.

Does the introduction of a COPD pro-forma improve the standards of care delivered by junior doctors in the emergency department.

AIM: To determine if pro-forma based management improves standards of care delivered by junior doctors in chronic obstructive pulmonary disease (COPD) patients in the Emergency Department (ED). INTRODUCTION: National COPD audits have found large variations in ED standards of care compared to guidelines. They concluded that the publication of guidelines itself does not translate to an improvement in care. METHOD: A pro-forma based on the British Thoracic Society Guidelines on COPD, 1997, NICE Guidelines CG12, 2004 and Non Invasive Ventilation (NIV), 2002 was devised and implemented following targeted education. Data were collected pre and post pro-forma implementation and analysed. The primary end point was categorisation of respiratory failure as it was felt that this concept was fundamental in COPD management. Secondary endpoints included the administration of controlled oxygen, repeat blood gases and appropriate referral for NIV. RESULTS: There were a total of 55 patients in each group. The correct categorisation of respiratory failure improved significantly from 4% in the pre- compared to 89% (p < 0.0001) in the post-intervention group. Similarly the administration of controlled oxygen (47% compared to 92%, p < 0.0001), repeat arterial blood gases (50% compared to 83%, p = 0.0098), and appropriate referral for NIV (33% compared to 100%, p = 0.0023) showed significant improvement after the pro-forma was introduced. CONCLUSION: Pro-forma aided management significantly improves the standards of care in COPD patients in the ED.