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Large Joints Feature

Source: Wikimedia Commons and U.S. Navy

Race and Outcome Data. Back Surgery’s Effect on THA. Contamination in the OR!

Elizabeth Hofheinz, M.P.H., M.Ed. • Mon, July 17th, 2017

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New Study Tackles Race and Outcome Data

Researchers from Stanford University School of Medicine and the Veterans Administration Palo Alto Health Care System have attempted to tease out the details of pain-related readmissions after total hip and knee replacement surgery.

The study, “Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care,” was published in the Journal of Bone & Joint Surgery on June 21, 2017.

Tina Hernandez-Boussard, Ph.D., M.P.H., M.S. associate professor of Medicine, Biomedical Data Science, and Surgery at Stanford School of Medicine and co-author on the study, told OTW, “I have been studying post-operative pain for several years now, and we are interested in pain-related outcomes. Under a changing healthcare system, with focused attention on the quality and value of care, readmissions have become a target for quality improvement efforts.”

“Federal agencies focus on inpatient hospital readmissions, however our work suggests that emergency department readmissions are also an important part of the quality and continue of care, particular after elected total hip and knee replacements.”

The authors wrote, “Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED.”

“There was a significantly increased risk of isolated ED visits including pain-related visits, with regard to type of insurance. Patients with both Medicaid and Medicare payers were at higher risk for ED readmissions compared with patients with private insurance.”

Dr. Hernandez-Boussard commented to OTW, “Our work leverages administrative data to understand the extent of pain-related readmissions. These types of data provide an overview of events at a population-level. These data suggest that pain-related readmissions are common and an important piece of the quality of healthcare delivered. Patients with public insurance might lack adequate and/or appropriate pain management therapies following these major surgeries and their close monitoring could improve rates of pain-related readmissions.”

“We found that among patients with Medicaid insurance, blacks were more than twice as likely to have a subsequent emergency department visit or a pain-related emergency department visit following total hip or knee replacement. These results support other literature that suggests blacks are less likely to receive appropriate pain management regimes compared to whites. Further research is needed to understand these results and the drivers behind these differences.”

“As there are a growing number of patients on Medicaid insurance and therefore a growing number of patients with access to these elective surgeries, it is important to consider their risks of these adverse pain-related outcomes and likely their need for additional discharge resources, such as follow-up pain management resources.”

New Study: High Rates of Contamination in OR

There is “clean” and then there’s the kind of clean you want in your OR. A new study shows that we may be a long way from the latter.

The surprising study, “What Orthopaedic Operating Room Surfaces Are Contaminated With Bioburden? A Study Using the ATP Bioluminescence Assay,” was published in the July 2017 edition of Clinical Orthopaedics and Related Research.

Thomas R. Bowen, M.D. is an associate in the Department of Orthopaedics at Geisinger Health in Danville, Pennsylvania, and a co-author on the study. He commented to OTW, “This work came from an informal discussion I had with Dr. Christopher P. Beauchamp of the Mayo Clinic in Phoenix, Arizona. We were attending a meeting of the Musculoskeletal Tumor Society (MSTS) discussing the problems of prosthetic joint infection in musculoskeletal reconstruction. We were specifically discussing our personal efforts in improving operating room cleanliness when the idea arose. Chris’ inspiration to this research is acknowledged in our article.”

The authors wrote, “When energy is required for cellular work, ATP [adenosine] breaks down into adenosine bisphosphate (ADP) and phosphate (P) and in that process releases energy. This process is inherent to all living things and can be detected as light emission with the use of bioluminescence assays.”

“On a given day, six different orthopedic surgery operating rooms (two adult reconstruction, two trauma, two spine) were tested before surgery with an ATP bioluminescence assay kit. All of the cases were considered clean surgery without infection, and this included the previously performed cases in each sampled room. These rooms had been cleaned and prepped for surgery but the patients had not been physically brought into the room.”

“A total of 13 different surfaces were sampled once in each room: the operating room (OR) preparation table (both pre- and post-draping), OR light handles, Bovie machine buttons, supply closet countertops, the inside of the Bair Hugger hose, Bair Hugger buttons, right side of the OR table headboard, tourniquet machine buttons, the Clark-socket attachment, and patient positioners used for total hip and spine positioning.”

“The relative light units (RLUs) obtained from each sample were recorded and data were compiled and averaged for analysis. These values were compared with previously published ATP benchmark values of 250 to 500 RLUs to define cleanliness in both the hospital and restaurant industries.”

“We were most alarmed by the very high levels of contamination under the headboard of the OR table. This means that the areas of contamination in the OR may not be entirely predictable or in areas routinely cleaned. The high levels of contamination on the areas of common hand contact by OR staff, like the buttons of the tourniquet, were expected but are important reminders of how OR rooms should be cleaned.”

“It’s not just where the patient touches that matters. Where the OR staff touches is also important. The low levels of contamination in the patient warming device, the ‘Bair Hugger,’ were encouraging as these patient warming devices have been under investigation as a possible contributing factor in surgical site infection.”

“I think the beauty in this study is its simplicity—it is just a pilot study. This kind of investigation can be performed at almost any hospital with the appropriate equipment. The equipment is readily available for purchase with a reasonable cost. Even more importantly, the results are available ‘in real time.’ So, this technique is well-suited for daily quality management in the operating room (OR).”

“At a more philosophical level, I hope this research helps orthopedic surgeons to become champions for cleanliness in their OR. The surgeon must be a continuous agent of quality improvement. A driver is only as good as his pit crew; a surgeon is only as good as his OR staff.”

Previous Low Back Surgery=Worse THA Outcomes?

Brace yourself, say researchers. If you’ve had lumbar surgery and now need total hip arthroplasty (THA), your outcomes may not be so great. Scientists from Sweden have paired two large registries and published their work in the May 31, 2017 in The Bone & Joint Journal. The study is entitled, “Lumbar surgery prior to total hip arthroplasty is associated with worse patient-reported outcomes.”

Ola Rolfson, M.D., Ph.D. is associate professor and consultant orthopaedic surgeon at the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and a co-author on the study, Dr. Rolfson told OTW, “This work was done because the combination of degenerative diseases of the hip and spine, known as the ‘hip-spine syndrome’ are common encounters in patients eligible for total hip replacement and low back surgery. As these disorders cause similar symptoms it is often problematic in clinical practice to determine the origin of pain. Orthopedic surgeons have for long discussed whether to start of surgical interventions to the hip or the spine in this group of patients with ‘hip-spine syndrome.’”

“By linking two high quality registers, the Swedish Hip Arthroplasty Register and the Swedish Spine Register, we investigated patient-reported outcomes following total hip replacement in patients with a previous low back surgery. We also compared these results to a matched group of patients on both demographical, surgical and PROMs [patient-reported outcomes data] data with no history of a previous total hip replacement.”

“We found that patients with previous low back surgery had worse outcomes following total hip replacement measured by the health related quality of life instrument EQ-5D [EuroQal five dimensions questionnaire], a hip pain visual analogue scale and a satisfaction scale compared to patients without a previous low back surgery.”

“We believe this knowledge is important to consider in the assessment of risk and expected benefits. The information is useful in the communication and shared decision making process prior to surgery in patients eligible for total hip replacement with previous low back surgery.”

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