Injury, Int. J. Care Injured (2005) 36, 771—774
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Orthopaedic trauma care: a two-tier system? Amol Tambe *, Juan C. Rodriguez, John Monk, Chih-Mei Chen, Denis Calthorpe Derbyshire Royal Infirmary, Orthopaedics, London Road, Derby DE1 2QY, UK Accepted 21 December 2004
KEYWORDS Trauma; Surgery; Delay; Weekend; Weekday; Trauma lists
Summary Orthopaedic trauma requiring surgical admission presents to our hospitals right throughout the week. However, the level of service provided to trauma patients appears to fluctuate with more surgery facilities available during weekday ‘‘office-hours’’ with reduced facilities at the weekend. The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) in 1999 laid down guidelines for orthopaedic trauma surgery in elderly patients clearly stating that no elderly patient requiring an urgent operation should have to wait for more than 24 h once fit for surgery. We see no reason to exclude the younger population from such a directive and have hence applied the same standard of ‘‘surgery within 24 h of admission’’ as our index of appropriate practice. Audit of our consultant delivered performance confirmed that while an average 88% of ‘‘weekday service’’ patients admitted Sunday through Thursday achieved this standard, only an average of 64% of weekend service patients admitted on Friday or Saturday achieved the same standard. The purpose of this report is to increase awareness of what we believe to be a widespread dilemma. The day of the week should not dictate the treatment of the patient. # 2004 Elsevier Ltd. All rights reserved.
Introduction A previous internal audit at our hospital has shown that 14.7% of trauma cases including hip fractures are cancelled on a daily basis due to lack of time facilities, despite two designated trauma lists daily, with this figure rising to 21.3% over the weekend when orthopaedic trauma competes with the other * Corresponding author. Tel.: +44 1332 347141. E-mail address:
[email protected] (A. Tambe).
major specialities for theatre time. Apart from the humanitarian implications, delay in surgery in trauma patients results in increased mortality, morbidity, and longer in-patient stay and thus carries financial implications as well. A study published by a maxillo-facial unit in the UK has concluded that dedicated trauma lists allow the unit to comply with the recommendations of both NCEPOD and the Calman report, in that they maximise training opportunities for all staff and facilitate both audit and research.2
0020–1383/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.12.035
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The National Confidential Enquiry into Perioperative Deaths (NCEPOD)5 in 1999 clearly set out the bench mark to this effect, stating: ‘‘There should be sufficient, fully staffed, daytime theatre and recovery facilities to ensure that no elderly patient requiring an operation waits for more than 24 h once fit for surgery. This includes weekends.’’ We believe that there is no reason why the younger population should be disadvantaged by their exclusion from such a directive. We have thus investigated the trauma practice in our large district general hospital, comparing it to the index of surgery within 24 h of admission in the context of weekday versus weekend. We feel obliged to report results which indicate the existence of a two-tier trauma care system in the NHS, possibly not unique to our hospital, where the weekend ‘‘emergency’’ orthopaedic patient is significantly disadvantaged by the day of his/her admission.
Standard for study Given the variability in case mix, there are no established definitive guidelines on what constitutes an acceptable waiting period before surgery, once a trauma admission has been made. However, over a period of time, the mean interval between trauma admission and necessary surgery can be used as a measure in assessing the functional efficiency of a trauma service. In order to either confirm or refute the anecdotal impression of a prevailing two-tier weekday and weekend orthopaedic trauma service at our hospital, we seek to address the index question–—What proportion of orthopaedic trauma admissions (requiring surgery) for each day of the week underwent surgery within 24 h of admission once deemed fit?
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elapsed from admission etc. Out of hours and on weekends, emergency orthopaedic cases have to compete with the other specialities for access to operating theatres. Data of non-elective admissions over the period of 1 year was obtained (April 2002 to April 2003) from the hospital records office. These data were then broken down to give the number of admissions according to each day of the week from Monday to Sunday. The proportion of patients who had surgery within 24 h of their admission was then analysed. The following exclusion criteria were applied: 1. Elective admissions 2. Social admissions–—for example, elderly patient assessed unfit for home discharge or failure to mobilise, etc. 3. Non-operative treatment 4. Patients who remained medically unfit more than 24 h after admission On final analyses a set of underlying assumptions have been made, but which are considered to be reasonable given the number of patients in the study and the period of 1 year over which they were collected: That the proportion of patients who are fit for surgery is the same on each day of admission over a period of 1 year. That the proportion of patients who require an operation on the day they are admitted is similar regardless of the day of the week of their admission. Over the period of 1 year, the case mix of admissions is similar by day of the week Statistical advice was taken during the stage of data analyses. Logistic regression was applied to obtain odds ratios with 95% confidence intervals on each weekday admission against the index weekend day, Saturday.
Methodology
Results
This study was carried out in a large teaching district general hospital (DGH) where currently 2300 orthopaedic trauma operations are carried out per annum. This reflects a 32% increase in trauma surgery over the last 10 years. All patients waiting for emergency orthopaedic surgery are formally discussed at the multi-disciplinary meeting each morning (365) when the trauma list is formulated as the trauma cases are democratically ranked according to the nature and severity of injury, age, time
The total number of non-elective admissions after application of exclusion criteria for the period of 12 months amounted to 2491. Table 1 shows the breakdown of cases admitted on each day of the week over a year. Examination of Table 1 shows that the proportion of patients operated on within 24 h of admission varies significantly according to the day of the week. A much lower proportion of patients admitted on Friday and Saturday were operated on within 24 h of
Orthopaedic in trauma care
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Table 1 (X2 = 178.05, d.f. = 6, p < 0.001) Admission day
Non-elective admissions
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total
Operations within 24 h
406 350 411 375 383 284 282
331 329 317 330 251 178 252
2491
1988
Table 3 Percent within 24 h
Speciality
Percent of total weekend activity
82 94 77 88 66 63 89
Orthopaedics HANDS (separate hand unit) General surgery Maxillo-facial Ophthalmology ENT
52 20 16 10 1 1
admission (66 and 63%, respectively) compared to those admitted during the rest of the week (77— 94%). This data was further subjected to a logistic regression model. We calculated the expected odds ratios for admissions of each weekday and Sunday against the index weekend day, Saturday. 95% CI limits were then calculated. Using the regression model the overall percent prediction of patients having operation within 24 h of admission was 80%. The results obtained from fitting a logistic regression model to the data are shown in Table 2. The odds of people who had surgery within 24 h when admitted on Sunday is five times higher, on Monday three times higher, on Tuesday nine times higher, on Wednesday two times higher and on Thursday four times higher when compared to people admitted on Saturday. For admissions on Friday the odds ratio is approximately equal to one (95% CI of 0.88—1.56), hence, no real difference is observed for admissions made on Friday when compared to that of Saturday. This demonstrates that a significantly higher proportion of trauma admissions on Friday and Saturday (‘‘weekend trauma practice’’) have admissionoperation interval more than 24 h when compared to ‘‘weekday trauma practice’’ trauma admissions from Sunday to Thursday.
The data in Table 2 also show a wide variation of odds ratios within the week itself. We feel that for admissions made on Sunday, the higher odds ratio (5.002) could be attributed to the fact that on many occasions trauma cases were accommodated within elective lists on the Monday to clear the back log of pending trauma cases. It has been difficult, from theatre records to ascertain the actual number of trauma cases that were accommodated with in such elective lists. Similarly, for Thursday admissions, the odds ratio of 4 could indicate a trend in the department towards clearing up any pending trauma cases by Friday to avoid the inevitable delay these cases might face should they be left for the weekend. A further analysis of the weekend emergency lists has revealed that trauma and orthopaedics are the single biggest users of emergency theatre facilities in the hospital (Table 3). Furthermore, it was noted that on 311 occasions during the specified period patient’s surgery was cancelled or postponed at a weekend. This does not relate to 311 individual patients, but it does reflect 311 occasions when the capacity of the service was not sufficient to meet the needs of the patient. There was a disproportionate amount of cancellation involving orthopaedic patients. Whilst 52% of weekend emergency operating activity involved orthopaedic patients, 70% of all cancellations, due mainly to ‘‘lack of time’’, involved orthopaedic patients.
Table 2 Admission day
Number operated within 24 h
Number operated after 24 h
Odds ratio (95% CI)
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
252 331 329 317 330 251 178
30 75 21 94 45 132 106
5.002 (3.09, 7.52) 2.628 (1.85, 3.72) 9.325 (5.54, 15.41) 2.008 (1.44, 2.80) 4.367 (2.94, 6.47) 1.13 (0.88, 1.56) 1
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Discussion During the past 10 years, elective orthopaedic patients have benefited from the energised political approach to waiting lists with a 141% increase in elective orthopaedic surgery facilities at our hospital. During the same period, the surgical facilities for emergency orthopaedic patients, which includes the emergency complications from elective surgery, has effectively remained static. The 32% increased demand for emergency orthopaedic surgery facilities was being met with a 33% increase in surgery facilities. This study has revealed that, despite the increase in orthopaedic trauma surgery ‘‘Trauma list’’ facilities, the still inadequate level of weekday orthopaedic trauma surgery facilities is further compounded during the weekends leading to a two-tier weekday/weekend emergency orthopaedic trauma practice. Clinicians are ultimately held responsible for maintaining high standards of practice and providing adequate and balanced treatment with extant resources.4 In the current climate of clinical governance, the fact that a proportion of patients admitted over the weekend are disadvantaged solely by their day of admission, cannot constitute ‘‘best practice’’. The NCEPOD 1999 report discussed similar problems in the elderly.5 They reported that trauma admissions appeared to be skewed towards the weekdays especially beginning of the week. The report has questioned whether there is a problem in the provision of health care to the elderly, as this group appeared to avoid weekends to seek medical advice. With regard to operative delays, the report indicated that 19% of the delays were for non-medical reasons and this figure includes 8% in which the delay was caused by lack of operating theatre time. In another study, authors who conducted an audit to examine the structure and process of trauma operating reported that lack of theatre time resulted in a delay in trauma surgery in a significant proportion of their trauma admissions.3 Longer pre-operative waiting time increases the post-operative morbidity and mortality. Increased pre-operative wait for emergency hip surgery in elderly patients significantly increases post-operative stay. Roughly doubling pre-operative wait increases postoperative stay by 19%.1 Improvement in access to operating theatres should reduce the
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pre-operative stay, and thus reduce the overall length of hospital stay for the patient, and should contribute to increasing overall capacity and efficiency. Our study has attempted to underline the deficiencies in the trauma service in a busy DGH using the admission to surgery interval as an index of measurement. We believe our experience is not unique. Traumatised patients, by being more unstable by definition than their ‘‘elective’’ counterparts, democratically deserve prioritisation. Too often they experience the opposite. This study shows that their experience can be even further confounded by the day of their admission to the hospital, a situation which would not be tolerated in any of the other emergency services.
Conclusions Increased focus on elective orthopaedic surgery targets has a negative impact on the surgical treatment of orthopaedic trauma patients. 87% of weekday orthopaedic trauma service patients achieve their necessary surgery within 24 h of admission. Only 64% of those exposed to the weekend orthopaedic trauma service achieve equal treatment resulting in a two-tier service. A rational approach recognising and prioritising clinical need with a real increase in orthopaedic trauma operating time is essential to redress the present imbalance.
References 1. Charalambous CP, Yarwood S, Paschalides C, et al. Factors delaying surgical treatment of hip fractures in elderly patients. Ann R Coll Surg Engl 2003;85(2):117—9. 2. Edmondson MJ, Cousin GCS, Lowry JC, et al. Impact of dedicated trauma lists on a maxillo-facial surgical service. Br J Oral Maxillofacial Surg 2000;38(5):492—5. 3. Lankester BJA, Paterson MP, Capon G, Belcher J. Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation. Ann R Coll Surg Engl 2000;82:322—6. 4. Royal College of Physicians, London. Physicians maintaining good medical practice: clinical governance and self-regulation. RCP, London, 1999. 5. The 1999 Report of the National Confidential Enquiry into Perioperative Deaths-Extremes of Age, London (published 17 November 1999), p. 59—62.
