Robert J. Derksen

Cost-effectiveness of the SEN-concept: Specialized Emergency Nurses (SEN) treating ankle/foot injuries

BackgroundEmergency Departments (EDs) are confronted with progressive overcrowding. As a consequence, the workload for ED physicians increases and waiting times go up with the risk of unnecessary complications and patient dissatisfaction. To cope with these problems, Specialized Emergency Nurses (SENs), regular ED-nurses receiving a short, injury-specific course, were trained to assess and treat minor injuries according to a specific protocol.MethodsAn economic evaluation was conducted alongside a randomized controlled trial comparing House Officers (HOs) and SENs in their assessment of ankle and foot injuries. Cost prices were established for all parts of healthcare utilization involved. Total costs of health care utilization were computed per patient in both groups. Cost-effectiveness was investigated by comparing the difference in total cost between groups with the difference in sensitivity and specificity between groups in diagnosing fractures and severe sprains. Finally, cost-effectiveness ratios were calculated and presented on a cost-effectiveness plane.ResultsNo significant differences were seen between treatment groups for any of the health care resources assessed. However, the waiting times for both first assessment by a treatment officer and time spent waiting between hearing the diagnosis and final treatment were significantly longer in the HO group. There was no statistically significant difference in costs between groups. The total costs were € 186 (SD € 623) for patients in the SEN group and € 153 (SD € 529) for patients in the HO group. The difference in total costs was € 33 (95% CI: – € 84 to € 155). The incremental cost-effectiveness ratio was € 27 for a reduction of one missed diagnosis and € 18 for a reduction of one false negative.ConclusionConsidering the benefits of the SEN-concept in terms of decreased workload for the ED physicians, increased patient satisfaction and decreased waiting times, SENs appear to be a useful solution to the problem of ED crowding.

Nadroparin or fondaparinux versus no thromboprophylaxis in patients immobilised in a below-knee plaster cast (PROTECT): A randomised controlled trial

BACKGROUND The immobilisation of the lower leg is associated with deep vein thrombosis (DVT). However, thromboprophylaxis in patients with a below-knee plaster cast remains controversial. We examined the efficacy and safety of nadroparin and fondaparinux to ascertain the need for thromboprophylaxis in these patients. METHODS PROTECT was a randomised, controlled, single-blind, multicentre study that enrolled adults with an ankle or foot fracture who required immobilisation for a minimum of four weeks. The patients were randomly assigned (1:1:1) to a control group (no thromboprophylaxis) or to one of the intervention groups: daily subcutaneous self-injection of either nadroparin (2850 IE anti-Xa=0.3ml) or fondaparinux (2.5mg=0.5ml). A venous duplex sonography was performed after the removal of the cast or earlier if thrombosis was suspected. The primary outcome was the relative risk of developing DVT in the control group compared with that in both intervention groups. This trial is registered at ClinicalTrials.gov, number NCT00881088. RESULTS Between April 2009 and December 2015, 467 patients were enrolled and assigned to either the nadroparin group (n=154), the fondaparinux group (n=157), or the control group (n=156). A total of 273 patients (92, 92, and 94 patients, respectively) were analysed. The incidence of DVT in the nadroparin group was 2/92 (2.2%) compared with 11/94 (11.7%) in the control group, with a relative risk of 5.4 (95% CI 1.2-23.6; p=0.011). The incidence of DVT in the fondaparinux group was 1/92 (1.1%), yielding a relative risk of 10.8 (95% CI 1.4-80.7; p=0.003) compared with that in the control group. No major complications occurred in any group. CONCLUSION Thromboprophylaxis with nadroparin or fondaparinux significantly reduces the risk of DVT in patients with an ankle or foot fracture who were treated in a below-knee cast without any major adverse events.

Diagnostic accuracy of lower extremity X-ray interpretation by 'specialized' emergency nurses.

Objectives In the quest for a cost-effective and quality-preserving solution to manage crowding in the emergency department, the possibility of deploying regular emergency nurses for the treatment of acute ankle injuries was investigated. The aim of this study is to compare the diagnostic accuracy of emergency nurses with that of senior house officers in interpreting ankle and foot radiographs. Methods A prospective study comparing the assessment of 60 radiographs (30 feet and 30 ankles) by 16 emergency nurses before and after an educational session was performed. Each subset of 30 radiographs contained 12 fractures, hand-picked by a radiologist to represent everyday traumatology in the emergency department. The control group consisted of eight senior house officers representing everyday expertise. The outcome of the diagnostic assessment, represented as the pooled sensitivity and specificity for both groups, was compared using Z-statistics. Results Before the training session, the specialized emergency nurse group showed a sensitivity of 0.87 (confidence interval 0.83–0.91) compared with 0.93 (confidence interval 0.88–0.96) for the control group (P=0.05). The specificity of specialized emergency nurses was 0.87 (confidence interval 0.81–0.92) compared with 0.93 (confidence interval 0.89–0.95) for the senior house officers (P<0.05). After the training session, specialized emergency nurse diagnostic parameters did not differ significantly from the control group, displaying a sensitivity of 0.89 (confidence interval 0.86–0.92) and specificity of 0.92 (confidence interval 0.87–0.95). Conclusion Before the training session, the specialized emergency nurse group showed a significantly lower accuracy than the SHO group. After training, however, the diagnostic accuracy did not differ significantly between groups. Therefore, we conclude that emergency nurses are able to accurately interpret foot and ankle radiographs after a short educational session.

Identical fracture patterns in combat vehicle blast injuries due to improvised explosive devices; a case series

BackgroundIn November 2008, a surgical team from the Red Cross Hospital Beverwijk, the Netherlands, was deployed in Afghanistan for three months to attend in the army hospital of Kandahar.During their stay, four incidents of armored personnel carriers encountering an improvised explosive device were assessed. In each incident, two soldiers were involved, whose injuries were strikingly similar.Case presentationThe described cases comprise paired thoracic vertebral fractures, radial neck fractures, calcaneal fractures and talar fractures. Moreover, the different types of blast injury are mentioned and related to the injuries described in our series. Acknowledging the different blast mechanisms is important for understanding possible injury patterns.ConclusionFrom this case series, as well as the existing literature on injury patterns caused by blast injuries, it seems appropriate to pay extra attention to bodily areas that were injured in other occupants of the same vehicle. Obviously, the additional surveillance for specific injuries should be complementary to the regular trauma work-up (e.g., ATLS).

Swim cast versus traditional cast in pediatric distal radius fractures: a prospective randomized controlled trial

PurposeNon-displaced distal radius fractures in children are traditionally treated in a forearm cast. However, a traditional cast does not tolerate getting wet, with skin lesions and bad smell as result. A Swim cast, which has the ability to dry quickly, is an airy cast that is applied using the MOKcast technique. We hypothesize that Swim casts contribute to higher patient satisfaction scores than traditional casts, without any adverse effects on fracture healing or skin condition.MethodsA prospective, randomized, single-center, blinded study was conducted to compare traditional and Swim cast treatment in children aged 5–15 years with greenstick or torus fractures of the distal radius. Primary endpoint was the patient and parent satisfaction, as determined by a questionnaire. Secondary endpoints were radiographic and clinical bone healing and cast-related skin conditions.ResultsA total of 68 patients, divided into two treatment groups (traditional case and Swim cast;n = 34 per group). Baseline characteristics were similar between the groups. The overall satisfaction score (0–10) reported by the patients was 8.6 in the Swim cast group versus 7.5 in the traditional cast group (p < 0.002); the overall satisfaction score reported by the parents was 8.3 and 7.7, respectively (p < 0.02). There was no difference in radiographic or clinical healing between groups, and skin conditions also did not differ significantly between groups.ConclusionIn our patient group, treatment of non-displaced, pediatric, distal radius fractures by Swim cast yielded better patient satisfaction results compared to treatment with the traditional, cotton-lined cast, without adverse effects on fracture healing or skin condition.

A54 Functional outcome after orif versus external fixation in type-C distal radius fractures

and populations. No HIT was reported in 826 patients with lower extremity injuries requiring immobilisation. Conclusions: Only a few studies have reported on the incidence of HIT in trauma patients who receive prophylactic LMWH. In the heterogenous populations of the available studies, the incidence of HIT appears to be very low (0.36%) and comparable to other patient populations. There is hardly any literature on the incidence of HIT in patients with isolated lower leg injuries receiving LMWH, but incidence appears very low. Monitoring of platelet count could be considered in hospitalised patients with a high risk for development of HIT. A pre-test scoring system may identify these patients.