Are Process Changes Measurable? An Analysis of 4136 Proximal Femur Fractures over 16 Year. / Sind Prozessänderungen messbar? Eine Analyse über 16 Jahre mit 4163 proximalen Femurfrakturen.

Prozessänderungen im perioperativen Setting werden selten analysiert, weil ihre Ergebnisse nicht unmittelbar fassbar sind und es einer hohen Fallzahl bedarf. Primäres Ziel war es, Prozessänderungen retrospektiv anhand proximaler Femurfrakturen (PF) zu evaluieren und deren Effekt mit verschiedenen Zielkriterien zu überprüfen. Sekundäres Ziel war die Definition möglicher Qualitätskriterien für die Versorgung von PF.Retrospektive Analyse der Datenbank eines Level-1-Traumazentrums zu PF. Eingeschlossen wurden alle osteosynthetisch und endoprothetisch versorgten PF im Behandlungszeitraum vom 01.01.2006 bis 31.12.2021. Der Zeitraum von 16 Jahren wurde für die Statistik trichotom aufgeteilt und die ersten 6 Jahre als Ausgangsbasis verwendet. Insgesamt 10 Prozessänderungen wurden in den folgenden 10 Jahren vorgenommen. Die Auswirkungen dieser Änderungen wurden anhand 1. der operativen Revisionsrate, 2. der Infektionsrate, 3. der perioperativen Transfusionsrate sowie 4. der 1-Jahres-Letalität überprüft.Insgesamt 4163 PF wurden analysiert. Hinsichtlich der Zielkriterien zeigten die Änderungen der ersten 5 Jahre (2012-2016; intramedulläres Verfahren für Osteosynthesen sowie Einwegabdeckung und Einwegkittel) den stärksten Effekt mit einer erstmaligen Senkung der operativen Revisionsrate unter 10% auf Dauer. Weitere Prozessoptimierungen der letzten 5 Jahre (2017-2021) erbrachten ebenfalls messbare Verbesserungen (Senkung der Infektions- und Transfusionsrate). Die 1-Jahres-Letalität blieb unverändert, auch während der COVID-19-Pandemie.Prozessänderungen bei PF führen nicht unmittelbar zu objektiv messbaren Verbesserungen. Rückblickend erscheint der Paradigmenwechsel von extra- auf intramedulläre Osteosynthese den höchsten Effekt erzielt zu haben, wenngleich über die letzten 10 Jahre eine schrittweise Besserung aller Zielkriterien eintrat - mit Ausnahme der Letalität. Als objektive Qualitätskontrolle sollte eine 1-Jahres-Revisionsrate unter 10% angestrebt sein.

Two-thousand hip fractures treated within 12 h and > 12-24 h after admission: Are survival and adverse events affected?

BACKGROUND: The effects of immediate operation on hip fracture (HF) are unclear. Therefore, we investigated the influence of time to operation within 12 h vs. > 12-24 h on survival and adverse events. METHODS: This retrospective study was based on our database from 2006 to 2019. Patients ≥ 20 years of age with operations for HF were included. A total of 40 characteristics were analyzed for operations within 12 h (group 1) and > 12-24 h (group 2) after admission. The primary endpoint was survival at 1 year after operation. Secondary endpoints were revision surgery for any reason, infection, and serious adverse events. RESULTS: A total of 1015 patients received operations within 12 h (group 1), and 985 patients received operations > 12-24 h (group 2) after admission. The mean age of the patients was 78.8 ± 12.3 years. Patients in group 1 were younger and had better health status and shorter hospitalizations than those in group 2. However, no differences were found for revision surgery, infection or adverse events. The mortality rates at 30 days, 90 days, 6 months, and 1 year were 6.2, 11.8, 15.9, and 21.0%, respectively. The mortality rate at day 30 was significantly better (p = 0.04) in group 1, but no further differences in survival were observed (hazard ratio 1.071; 95% confidence interval 0.864-1.328; log rank 0.179). A subgroup analysis of geriatric patients ≥ 65 years assessed no differences according the primary and secondary endpoints. CONCLUSIONS: Within the limits of single-center analysis, the patients receiving treatment for HF within 12 h were younger and healthier and had the benefits of shorter hospitalizations and a higher 30-day survival rate than patients treated > 12-24 h after admission. At the endpoint 1 year after operation, no differences were observed in adverse events or survival rates.

[Residency program under scrutiny (part 2)-How do residents prepare for emergency operations?] / Weiterbildung unter der Lupe (Teil 2) ­ Wie bereiten sich Weiterbildungsassistenten auf Notfalloperationen vor?

BACKGROUND: Postgraduate medical education in trauma and orthopedic surgery residents largely relates to learning and teaching surgery. During this crucial stage of surgical development some of the didactic challenges are caused by heterogeneous and contradictory expectations of trainees and trainers alike. So how do residents prepare for emergency surgery? To date there is neither an expert consensus nor scientific investigations in the clinical context on this topic. METHODS: Between February and April 2015 questionnaires were issued to all physicians active in the field of trauma and orthopedic surgery within the Trauma Network East Bavaria (27 clinics, 255 physicians). The participants were asked to rate the importance of certain elements functioning in the preparation of two emergency operations using a Likert scale. The intensity with which residents generally realize these elements of preparation was also documented. The aim was to objectify if and to what extent the presumed normal practices diverge from clinical reality. RESULTS: A total of 150 questionnaires were analyzed (return rate 59%). Discussion with the consultant (85.3%, n = 128), examination of the patient (80.0%, n = 120), surgical approach (76.0%, n = 114) and study of patient files (68.0%, n = 102) were considered to be the most important elements; however, many of the participants admitted that these elements of preparation are not sufficiently performed. CONCLUSION: The personal preparation of residents for an emergency operation should be classified as extremely important; however, the requirements and reality do not seem to hold true in the clinical environment. This seems to be most likely due to structural and organizational issues.

[Residency program under scrutiny-how do residents prepare for elective operations?] / Weiterbildung unter der Lupe ­ Wie bereiten sich Weiterbildungsassistenten auf elektive Operationen vor?

BACKGROUND: A wide variety of technical, emotional and organizational aspects of the residency program are aligned with "learning and teaching operations". When a resident is assigned as an operator to the operation program, many chances are provided for teaching and learning with preparation, intraoperative and postoperative care. But the moment when a resident starts preparing for an operation, heterogeneous and partly old-fashioned attitudes as well as contradictory practices must be faced in the clinical context. In the daily practice there is no consensus about a structured preparation for an operation. There have been no scientific investigations on this topic so far. METHODS: From February to April 2015 questionnaires were sent to all trauma and orthopedic surgeons in the trauma network of East Bavaria (27 clinics, 255 physicians). Using Likert scales, the participants could rate the importance of certain elements of preparation for two elective operations and the intensity of how the residents succeeded in these. The aim was to objectify if and to what extent the aspirations diverge from clinical reality. RESULTS: A total of 150 forms could be analyzed (response rate 59%). The surgical approach, patient examinations, study of patient files, discussion with the consultant and the operation technique were considered to be the most important elements; however, approximately half of the participants stated that they did not sufficiently accomplish these elements. Gender-specific differences or differences between the age groups could only be sporadically detected. CONCLUSION: A mismatch could be recognized between aspiration and reality concerning the personal preparations of residents for operations. Hospital-specific concepts and a standardized, preoperative dialogue between residents and consultants could be an important element in a successful preparation for interventions.