Pia Søe Jensen

The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery

BACKGROUND: Perioperative anemia leads to increased morbidity and mortality and potentially inhibits rehabilitation after hip fracture surgery. As such, the optimum transfusion threshold after hip fracture surgery is unknown.

Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial.

Background:Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery. Methods:Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 &mgr;g/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy. Results:Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups. Conclusion:Postoperative epidural analgesia after hip fracture surgery provides superior analgesia attenuating pain as a restricting factor during rehabilitation without motor dysfunction. However, superior analgesia did not translate into enhanced rehabilitation. Future studies with multimodal rehabilitation are required to establish whether superior analgesia can be translated into enhanced rehabilitation and reduced morbidity in hip fracture patients.

An enhanced treatment program with markedly reduced mortality after a transtibial or higher non-traumatic lower extremity amputation.

Background and purpose — Historically, high 30-day and 1-year mortality post-amputation rates (> 30% and 50%, respectively) have been reported in patients with a transtibial or higher non-traumatic lower extremity amputation (LEA). We evaluated whether allocating experienced staff and implementing an enhanced, multidisciplinary recovery program would reduce the mortality rates. We also determined factors that influenced mortality rates. Patients and methods — 129 patients with a LEA were consecutively included over a 2-year period, and followed after admission to an acute orthopedic ward. Mortality was compared with historical and concurrent national controls in Denmark. Results — The 30-day and 1-year mortality rates were 16% and 37%, respectively, in the intervention group, as compared to 35% and 59% in the historical control group treated in the same orthopedic ward. Cox proportional harzards models adjusted for age, sex, residential and health status, the disease that caused the amputation, and the index amputation level showed that 30-day and 1-year mortality risk was reduced by 52% (HR =0.48, 95% CI: 0.25–0.91) and by 46% (HR =0.54, 95% CI: 0.35–0.86), respectively, in the intervention group. The risk of death was increased for patients living in a nursing home, for patients with a bilateral LEA, and for patients with low health status. Interpretation — With similarly frail patient groups and instituting an enhanced program for patients after LEA, the risks of death by 30 days and by 1 year after LEA were markedly reduced after allocating staff with expertise.

Stuck in tradition-A qualitative study on barriers for implementation of evidence-based nutritional care perceived by nursing staff

AIMS AND OBJECTIVES To explore the barriers for nutritional care as perceived by nursing staff at an acute orthopaedic ward, aiming to implement evidence-based nutritional care. BACKGROUND Previous studies indicate that nurses recognise nutritional care as important, but interventions are often lacking. These studies show that a range of barriers influence the attempt to optimise nutritional care. Before the implementation of evidence-based nutritional care, we examined barriers for nutritional care among the nursing staff. DESIGN Qualitative study. METHODS Four focus groups with thirteen members of the nursing staff were interviewed between October 2013-June 2014. The interview guide was designed according to the Theoretical Domains Framework. The interviews were analysed using qualitative content analysis. RESULTS Three main categories emerged: lacking common practice, failing to initiate treatment and struggling with existing resources. The nursing staff was lacking both knowledge and common practice regarding nutritional care. They felt they protected patient autonomy by accepting patients reluctance to eat or getting a feeding tube. The lack of nutritional focus from doctors decreased the nursing staffs focus leading to nonoptimal nutritional treatment. Competing priorities, physical setting and limited nutritional supplements were believed to hinder nutritional care. CONCLUSION The results suggest that nutritional care is in a transitional state from experience- to evidence-based practice. Barriers for nutritional care are grounded in lack of knowledge among nursing staff and insufficient collaboration between nursing staff and the doctors. There is a need for nutritional education for the nursing staff and better support from the organisation to help nursing staff provide evidence-based nutritional care. RELEVANCE TO CLINICAL PRACTICE This study contributes with valuable knowledge before the implementation of evidence-based nutritional care. The study provides an understanding of barriers for nutritional care and presents explanations to why nutritional care has failed to become an integrated part of the daily treatment and care.

Progression of disease preceding lower extremity amputation in Denmark: a longitudinal registry study of diagnoses, use of medication and healthcare services 14 years prior to amputation

Objectives Patients with non-traumatic lower extremity amputation are characterised by high age, multi-morbidity and polypharmacy and long-term complications of atherosclerosis and diabetes. To ensure early identification of patients at risk of amputation, we need to gain knowledge about the progression of diseases related to lower extremity amputations during the years preceding the amputation. Design A retrospective population-based national registry study. Setting The study includes data on demographics, diagnoses, surgery, medications and healthcare services from five national registries. Data were retrieved from 14 years before until 1 year after the amputation. Descriptive statistics were used to describe the progression of diseases and use of medication and healthcare services. Participants An unselected cohort of patients (≥50 years; n=2883) subjected to a primary non-traumatic lower extremity amputation in 2010 or 2011 in Denmark. Results The prevalence of atherosclerosis, hypertension and diabetes was 70%, 53% and 49%, respectively. Among patients with atherosclerosis, 42% had not received cholesterol-lowering treatment even though 87% had visited their general practitioner within the last year prior to amputation. Further, 16% were diagnosed with diabetes at the time of the amputation. The prevalence of cardiovascular diseases increased from 22% to 70%, atherosclerosis from 5% to 53% and diabetes from 17% to 35% over the 14 years preceding major amputation. Of all patients, 64% had been in contact with the hospital or outpatient clinics within the last 3 years, and 29% received a prescription of opioids 3 years prior to the amputation. Conclusion Among patients with non-traumatic lower extremity amputation, one-third live with undiagnosed and untreated atherosclerosis and one-sixth suffer from undiagnosed diabetes despite continuous contacts to general practitioner and the hospital. This study emphasises a need for enhanced focus, among both hospital clinicians and general practitioners, on the early identification of atherosclerosis and diabetes.