Jon H. Lemke

Topical Administration of Tranexamic Acid in Primary Total Hip and Total Knee Arthroplasty

Major blood loss is a known potential complication in total hip and total knee arthroplasty. We conducted a prospective, stratified, randomized, double-blind, placebo-controlled trial that evaluated 100 patients undergoing total knee or total hip arthroplasty to evaluate the effect on blood loss using the topical application of tranexamic acid. Participants received either 2 g of topical tranexamic acid or the equivalent volume of placebo into the joint prior to surgical closure. Tranexamic acid resulted in a lower mean maximum decline in postoperative hemoglobin levels when compared to placebo (P = 0.013). Patients in the tranexamic acid group demonstrated an improved but non-significant reduction in the units of blood transfused compared to placebo (P = 0.423). There was no clinically significant increase in complications in the tranexamic acid group, including no incidence of venous thromboembolism.

Arthroscopic Resection Arthroplasty for Treatment of Combined Carpometacarpal and Scaphotrapeziotrapezoid (Pantrapezial) Arthritis

PURPOSE Arthroscopy of the carpometacarpal (CMC) and scaphotrapeziotrapezoid (STT) joints has been described for the purpose of diagnosing, staging, and treating CMC and STT pathology. This study evaluates the short-term outcome of arthroscopic resection arthroplasty (ARA) for pantrapezial arthritis. METHODS Thirty-five cases of ARA of the CMC and STT joints were performed in 34 patients with one year minimum follow-up. There were 27 women and 7 men. Average age was 63 (range, 46 to 79). All patients had simultaneous ARA of both the CMC and STT joints. A 2- to 3-mm section of bone was resected from the proximal and distal aspect of both the CMC and STT joints. Preoperative data collected included 10-point self-reported pain scale, Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure, range of motion, grip strength, key and chuck pinch, length of symptoms, and treatment. Postoperative data included the same data plus patient satisfaction, graded on a 0 to 5 scale. Data were collected at postoperative months 1, 3, 6, and 12. RESULTS Average time of postoperative immobilization was less than 3 weeks (range, 2-6). The DASH scores averaged 46 before surgery, and 51, 30, 20, and 19 respectively, for the aforementioned postoperative intervals. The mean improvement in key pinch was 1.3 kg. The mean improvement in grip was 4.3 kg. Pain improved from 7 before surgery to 1 at one-year follow-up. CONCLUSIONS Short-term analysis suggests that ARA for pantrapezial arthritis provides satisfactory pain relief and return of strength and function.

Implementation of a patient safety program at a tertiary health system: A longitudinal analysis of interventions and serious safety events

BACKGROUND We hypothesize that implementation of a safety program based on high reliability organization principles will reduce serious safety events (SSE). METHODS The safety program focused on 7 essential elements: (a) safety rounding, (b) safety oversight teams, (c) safety huddles, (d) safety coaches, (e) good catches/safety heroes, (f) safety education, and (g) red rule. An educational curriculum was implemented focusing on changing high-risk behaviors and implementing critical safety policies. All unusual occurrences were captured in the Midas system and investigated by risk specialists, the safety officer, and the chief medical officer. A multidepartmental committee evaluated these events, and a root cause analysis (RCA) was performed. Events were tabulated and serious safety event (SSE) recorded and plotted over time. Safety success stories (SSSs) were also evaluated over time. RESULTS A steady drop in SSEs was seen over 9 years. Also a rise in SSSs was evident, reflecting on staff engagement in the program. The parallel change in SSEs, SSSs, and the implementation of various safety interventions highly suggest that the program was successful in achieving its goals. CONCLUSION A safety program based on high-reliability organization principles and made a core value of the institution can have a significant positive impact on reducing SSEs.

Assessment of Time to Hospital Encounter after an Initial Hospitalization for Heart Failure: Results from a Tertiary Medical Center

Background Hospital inpatient readmissions for patients admitted initially with the primary diagnosis of heart failure (HF) can be as high as 20–25% within 30 days of discharge. This, however, does not include admissions for observations or emergency department (ED) visits within the same time frame and does not show a time-dependent hospital encounter following discharge after an index admission. We present data on time-dependent hospital encounter of HF patients discharged after an index admission for a primary diagnosis of HF. Methods The study recruited patients from 2 hospitals within the same health system. 500 consecutive admissions with the ICD diagnosis of HF were reviewed by inclusion and exclusion screening criteria. The 166 eligible remaining patients were tracked for post hospital discharge encounters consisting of hospital admissions, observation stays, and ED visits. Only those with a primary diagnosis of heart failure were included. Demographics were recorded on all patients. Days until hospital inpatient readmissions or hospital encounters were displayed in Kaplan–Meier plots. Results A total of 166 patients met inclusion criteria (mean age 79.3 years, males 54%). For the first 90 days following the index admission, there were a total of 287 follow-up visits (1.7 per patient), 1158 total hospitalization days (2.6 per visit, 7.0 per patient, and 8.6 per 100 days at risk), and 21 deaths (12.7%). At 30 days, 25% and 52% of patients had an inpatient readmission or a hospital encounter, respectively. The median time to inpatient readmission was 117 days and to hospital encounter was 27 days. Conclusion Time-dependent excess days in acute care (unplanned inpatient admission, outpatient observation, and ED visit) rather than 30-day hospital inpatient readmission rate is a more realistic measure of the intensity of care required for HF patients after index admission.