Abstract

• Objective: To describe the highlights of our medical center’s implementation of the Society of Critical Care Medicine’s ABCDEF bundle in 3 medical intensive care units (ICUs).
• Methods: After a review of our current clinical practices and written clinical guidelines, we evaluated deficiencies in clinical care and employed a variety of educational and clinical change interventions for each element of the bundle. We utilized an interdisciplinary team approach to facilitate the change process.
• Results: As a result of our efforts, improvement in the accuracy of assessments of pain, agitation, and delir-ium across all clinical disciplines and improved adherence to clinical practice guidelines, protocols, and instruments for all bundle elements was seen. These changes have been sustained following completion of the data collection phase of the project.
• Conclusion: ICU care is a team effort. As a result of participation in this initiative, there has been an increased awareness of the bundle elements, improved collaboration among team members, and increased patient and family communication.

Key words: intensive care; delirium; sedation; mobility.

Admission to the intensive care unit (ICU) is a stressful and challenging time for patients and their families. In addition, significant negative sequelae following an ICU stay have been reported in the literature, including such post-ICU complications as post-traumatic stress disorder [1–9], depression [10,11], ICU-acquired weakness [12–19], and post-intensive care syndrome [20–23]. Pain, anxiety, and delirium all contribute to patient distress and agitation, and the prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. The Society of Critical Care Medicine (SCCM) developed the ABCDEF bundle (Table) to facilitate implementation of their 2013 clinical practice guidelines for the management of pain, agitation, and delirium (PAD) [24]. The bundle emphasizes an integrated approach to assessing, treating and preventing significant pain, over or undersedation, and delirium in critically ill patients.

In 2015, SCCM began the ICU Liberation Collaborative, a clinical care collaborative designed to implement the ABCDEF bundle through team-based care at hospitals and health systems across the country. The Liberation Collaborative’s intent was to “liberate” patients from iatrogenic aspects of care [25]. Our medical center participated in the collaborative. In this article, we describe the highlights of our medical center’s implementation of the ABCDEF bundle in 3 medical ICUs.

Settings

The Ohio State University Wexner Medical Center is a 1000+–bed academic medical center located in Columbus, Ohio, containing more than 180 ICU beds. These ICU beds provide care to patients with medical, surgical, burn, trauma, oncology, and transplantation needs. The care of the critically ill patient is central to the organization’s mission “to improve people’s lives through innovation in research, education and patient care.”

At the start of our colloborative participation, all of the ABCDEF bundle elements were protocolized in these ICUs. However, there was a lack of knowledge of the content of the bundle elements and corresponding guidelines among all members of our interdisciplinary teams, and our written protocols and guidelines supporting many of the bundle elements had inconsistent application across the 3 clinical settings.

We convened an ABCDEF bundle/ICU liberation team consisting of an interdisciplinary group of clinicians. The team leader was a critical care clinical nurse specialist. The project required outcome and demographic data collection for all patients in the collaborative as well as concurrent (daily) data collection on each bundle element. The clinical pharmacists who work in the MICUs and are part of daily interdisciplinary rounds collected the daily bundle element data while the patient demographic and outcome data were collected by the clinical nurse specialist, nurse practitioner, and clinical quality manager. Oversight and accountability for the ABCDEF bundle/ICU liberation project was provided by an interdisciplinary critical care quality committee. Our ABCDEF bundle/ICU liberation team met weekly to discuss progress of the initiative and provided monthly updates to the larger quality committee.

Impacting the Bundle—Nursing Assessments

The PAD guidelines recommend the routine assessment of pain, agitation, and delirium in ICU patients. For pain, they recommend the use of patient self-report or the use of a behavioral pain scale as the most valid and reliable method for completing this assessment [24]. Our medical center had chosen to use the Critical Care Pain Observation Tool (CPOT), a valid and reliable pain scale, for assessment of pain in patients who are unable to communicate [26], which had been in use in the clinical setting for over a year when this project began. For agitation, the PAD guidelines recommended assessment of the adequacy and depth of sedation using the Richmond Agitation Sedation Scale (RASS) or Sedation Agitation Scale (SAS) [24] for all ICU patients. Our medical center has chosen to use the RASS as our delirium assessment. The RASS had been in use in the clinical setting for approximately 10 years when this project started. For delirium assessment, the Confusion Assessment Method for ICU (CAM-ICU) [27] or the Intensive Care Delirium Screening Checklist (ICDSC) [28] is recommended. Our medical center used the CAM-ICU, which had been in place for approximately 10 years prior to the start of this project. Even though the assessment tools were in place in our MICU unit and hospital-based policies and guidelines, the accuracy of the assessments for PAD was questioned by many clinicians.

To improve the accuracy of our nursing assessments for PAD, a group of clinical nurse specialists and nursing educators developed an education and competency program for all critical care nursing staff. This education program focused on the PAD guidelines and our medical center’s chosen assessment tools. Education included in-person continuing education lectures, online modules, demonstrations, and practice in the clinical setting. After several months of education and practice, all staff registered nurses (RNs) had to demonstrate PAD assessment competency on a live person. We used standardized patients who followed written scenarios for all of the testing. The RN was given 1 of 8 scenarios and was charged with completing a PAD assessment on the standardized patient. RNs who did not pass had to review the education materials and re-test at a later date. More than 600 RNs completed the PAD competency. After completion of the PAD competency, the clinical nurse specialists observed clinical practice and audited nursing documentation. The accuracy of assessments for PAD had increased. Anecdotally, many our critical care clinicians acknowledged that they had increased confidence in the accuracy of the PAD assessments. There was increased agreement between the results of the assessments performed by all members of the interdisciplinary team.

Impacting the Bundle—Standardized Nurse Early Report Facilitation

Communication among the members of the interdisciplinary team is essential in caring for critically ill patients. One of the ways that the members of the interdisciplinary team communicate is through daily patient rounds. Our ABCDEF bundle/ICU liberation team members attend and participate in daily patient rounds in our 3 MICUs on a regular basis. The ABCDEF bundle/ICU liberation team members wanted to improve communication during patient rounds for all elements of the bundle.

Nurse Early Report Facilitation was a standard that was implemented approximately 5 years prior to the start of the ICU Liberation Collaborative. Nurse early report facilitation requires that the bedside staff RN starts the daily patient rounds discussion on each of his/her patients. The report given by the bedside RN was designed to last 60 to 90 seconds and provide dynamic information on the patient’s condition. Requiring the bedside RN to start the patient rounding provides the following benefits: requires bedside RN presence, provides up-to-the-minute information, increases bedside RN engagement in the patient’s plan of care, and allows for questions and answers. Compliance from the bedside RNs with this process of beginning patient rounds was very high; however, the information that was shared when the bedside RN began rounds was variable. Some bedside RNs provided a lengthy report on the patient while others provided 1 or 2 words.

The ABCDEF bundle/ICU liberation team members thought that a way to hardwire the ABCDEF bundle elements would be to add structure to the nurse early report. By using the ABCDEF elements as a guide, the ABCDEF bundle/ICU liberation team members developed the Structured Nurse Early Report Facilitation in which the bedside RN provides the following information at the beginning of each patient discussion during rounds: name of patient, overnight events (travels, clinical changes, etc.), pain (pain score and PRN use), agitation (RASS and PRN use), delirium (results of CAM-ICU). When the bedside RN performs the nurse early report using the structured format, the team is primed to discuss the A, B, C, and D elements of the bundle.

To implement the Structured Nurse Early Report Facilitation in the MICUs, the critical care clinical nurse specialists provided in-person education at the monthly staff meetings. They also sent emails, developed education bulletin boards, made reminder cards that were placed on the in-room computers, and distributed “badge buddy” reminder cards that fit on the RNs’ hospital ID badges. We provided emails and in-person education to our physician and nurse practitioner teams so they were aware of the changes. Our physician and nurse practitioners were encouraged to ask for information about any elements missing from the Structured Nurse Early Report in the early days of the process change.

After a few months, the critical care clinical nurse specialists reported that the Structured Nurse Early Report Facilitation was occurring for more than 80% of MICU patients. Besides the increase in information related to pain, agitation, and delirium, the Structured Nurse Early Report Facilitation increased the interdisciplinary team’s use of the term “delirium.” Prior to the structured nurse early report, most of the interdisciplinary team members were not naming delirium as a diagnosis for our MICU patients and used terms such as ICU psychosis, confused, and disoriented to describe the mental status of patients with delirium. As a result of this lack of naming, there may have been a lack of recognition of delirium. Using the word “delirium” has increased our interdisciplinary team’s awareness of this diagnosis and has increased the treatment of delirium in patients who have the diagnosis.

In addition to improved assessment and diagnosis, the clinical pharmacist began leading the discussions around choice of sedation during daily rounds. Team members began to discuss the patient’s sedation level, sedation goals, and develop a plan for each patient. This discussion included input from all members of the interdisciplinary team and allowed for a comprehensive patient-specific plan to be formed during the daily patient rounds episode.

Impacting the Bundle—Focus on Mobility

There have been many articles published in the critical care literature on the topic of mobility in the ICU. The evidence shows that early mobilization and rehabilitation of patients in ICUs is safe and may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay [29–31]. Our institution had developed a critical care mobility guideline in 2008 for staff RNs to follow in determining the level of mobility that the patient required during the shift. Over the years, the mobility guideline was used less and less. As other tasks and interventions became a priority, mobility became an intervention that was completed for very few patients.

Our ABCDEF bundle/ICU liberation team determined that increasing mobility of our MICU patients needed to be a plan of care priority. We organized an interdisciplinary team to discuss the issues and barriers to mobility for our MICU patients. The interdisciplinary mobility team had representatives from medicine, nursing, respiratory therapy, physical therapy, occupational therapy, and speech therapy. Initially, this team sent a survey to all disciplines who provided care for the patients in the MICU. Data from this survey was analyzed by the team to determine next steps.

Despite the fact that there were responses from 6 unique disciplines, several common barriers emerged. The largest barrier to overcome was staffing/time for mobility. It was clear from the survey respondents that all health care team members were busy providing patient care. Any change in the mobility guideline or practice needed to make efficient use of the practitioner’s time. Other barriers included space/equipment, communication, patient schedules, knowledge, patient and staff safety, and unit culture. The interdisciplinary mobility team divided into smaller workgroups to tackle the issues and barriers.

Mobility Rounds

Mobility rounds were implemented to attempt to decrease the barriers of time, communication, and know-ledge. Mobility rounds were designed as a start to the shift discussion on the topic of mobility. Mobility rounds included a clinical nurse specialist, a physical therapist (PT), an occupational therapist (OT), and a pulmonary physician/ nurse practitioner. This team met at 7:30 each weekday morning and walked room-to-room through our MICUs. The mobility rounds team laid eyes on each patient, developed a mobility plan for the day, and communicated this plan with the staff RN assigned to the patient. Mobility rounds were completed on all 48 MICU patients in 30 minutes.

Having the mobility rounds team at each patient’s bedside was important in several ways. First, it allowed the team members to see each patient, which gave the patient an opportunity to be part of his/her mobility plan. Also, the staff RNs and respiratory therapists (RTs) were often in the patient’s room. This improved communication as the staff RNs and RTs discussed the mobility plan with the PT and OT. For patients who required many resources for a mobility session, the morning bedside meeting allowed RNs, RTs, PTs, OTs, and physicians to set a schedule for the day’s mobility session. Having a scheduled time for mobility increased staff and patient communication. Also, it allowed all of the team members to adjust their workloads to be present for a complex mobility session.

Another benefit of mobility rounds was the opportunity for the PT and OT team members to provide education to their nursing and physician colleagues. Many nursing and physician providers do not understand the intricacies of physical and occupational therapy practice. This daily dialogue provided the PT/OT a forum to explain which patients would benefit from PT/OT services and which would not. It allowed the RNs and physicians to hear the type of therapy provided on past sessions. It allowed the PT/OT to discuss and evaluate the appropriateness of each patient consult. It allowed the RN and physician to communicate which patients they felt were highest priority for therapy for that day. Mobility rounds are ongoing. Data are being collected to determine the impact of mobility rounds on the intensity of mobility for our MICU patients.

Nurse-Driven Mobility Guideline

Another subgroup revised the outdated critical care mobility guideline and developed the new “Nurse-Driven Critical Care Mobility Guideline.” The guideline has been approved through all of the medical center quality committees and is in the final copyright and publication stages, with implementation training to begin in the fall. The updated guideline is in an easy-to-read flowchart format and provides the staff RN with a pathway to follow to determine if mobility is safe for the patient. After determining safety, the staff RN uses the guideline to determine and perform the patient’s correct mobility interventions for his/her shift. The guideline has built in consultation points with the provider team and the therapy experts.

Other Mobility Issues

A third subgroup from the interdisciplinary mobility team has been working on the equipment and space barriers. This subgroup is evaluating equipment such as bedside chairs, specialty beds, and assistive devices. Many of our MICU patient rooms have overhead lifts built into the ceilings. This equipment is available to all staff at all times. The equipment/space subgroup made sure that there were slings for use with the overhead lifts in all of the MICU equipment rooms. They provided staff education on proper use of the overhead lifts. They worked with the financial department and MICU nurse managers to purchase 2 bariatric chairs for patient use in the MICU.

A fourth subgroup has been working on the electronic documentation system. They are partnering with members of the information technology department to update the nursing and provider documentation regarding mobility. They have also worked on updating and elaborating on the electronic activity orders for our MICU patients. There have been many changes to various patient order sets to clarify mobility and activity restrictions. The admission order set for our MICU patients has an activity order that allows our staff RNs to fully utilize the new nurse-driven critical care mobility guideline.

Impacting the Bundle—Family Engagement and Empowerment

Family support is important for all hospitalized patients but is crucial for ICU patients. The medical center implemented an open visitation policy for all ICUs in 2015. Despite open visitation, the communication between patients, families, and interdisciplinary ICU teams was deficient. Families spoke to many different team members and had difficulty remembering all of the information that they received.

To increase family participation in the care of the MICU patient, we invited family members to participate in daily rounds. The families were invited to listen and encouraged to ask questions. During daily rounds, there is a time when all care providers stop talking and allow family members to inquire about the proposed plan of care for their family member. For family members who cannot attend daily rounds, our ICU teams arrange daily in-person or telephone meetings to discuss the patient’s plan of care. RNs provide a daily telefamily call to update the designated family member on the patient’s status, answer questions, and provide support.

In addition to the medical support for families, there is an art therapy program integrated into the ICU to assist families while they are in the medical center. This program is run by a certified art therapist who holds art therapy classes 2 afternoons a week. This provides family members with respite time during long hospital days. There are also nondenominational services offered multiple times during the week and a respite area is located in the lobby of the medical center.

In addition to these programs, the medical center added full-time social workers to be available 24 hours a day/ 7 days a week. The social worker can provide social support for our patients and families as well as help facilitate accommodations for those who travel a far distance. The social worker plays in integral part on the ICU team, often bridging the gap for families that can be overlooked by the medical team.

Conclusion

Care of the ICU patient is complex. Too often we work in our silos of responsibility with our list of tasks for the day. Participating in the ABCDEF bundle/ICU Liberation Collaborative required us to work together as a team. We were able to have candid conversations that improved our understanding of other team members’ perspectives, helping us to reflect on our behaviors and overcome barriers to improving patient care.

Even though the ICU Liberation Collaborative has ended, our work at the medical center continues. We are in the process of evaluating all of the interventions, processes, and guideline updates that our ABCEDF bundle/ICU liberation team worked on during our 18-month program. There have been many improvements such as increased accuracy of pain and delirium assessments, along with improved treatment of pain in the MICU patient. We have noticed increased communication with the patient and family and among all of the members of the interdisciplinary team. We have changed our language to accurately reflect the patient’s sedation level by using the correct RASS score and delirium status by using the term “delirium” when this condition exists. There is increased collaboration among team members in the area of mobility. More patients are out of bed on bedside chairs and more patients are walking in the halls. Over the next several months our ABCEDF bundle/ICU liberation team will continue to review and analyze the data that we collected in the collaborative. We will use that data and the clinical changes we see on a daily basis to continue to improve the care for our MICU patients.

Corresponding author:  Michele L. Weber, DNP, RN, CCRN, CCNS, AOCNS, OCN, ANP-BC, The Ohio State University Wexner Medical Center, 410 West 10th Ave., Columbus, OH 43210, [email protected].

Abstract

• Objective: To describe the highlights of our medical center’s implementation of the Society of Critical Care Medicine’s ABCDEF bundle in 3 medical intensive care units (ICUs).
• Methods: After a review of our current clinical practices and written clinical guidelines, we evaluated deficiencies in clinical care and employed a variety of educational and clinical change interventions for each element of the bundle. We utilized an interdisciplinary team approach to facilitate the change process.
• Results: As a result of our efforts, improvement in the accuracy of assessments of pain, agitation, and delir-ium across all clinical disciplines and improved adherence to clinical practice guidelines, protocols, and instruments for all bundle elements was seen. These changes have been sustained following completion of the data collection phase of the project.
• Conclusion: ICU care is a team effort. As a result of participation in this initiative, there has been an increased awareness of the bundle elements, improved collaboration among team members, and increased patient and family communication.

Key words: intensive care; delirium; sedation; mobility.

Admission to the intensive care unit (ICU) is a stressful and challenging time for patients and their families. In addition, significant negative sequelae following an ICU stay have been reported in the literature, including such post-ICU complications as post-traumatic stress disorder [1–9], depression [10,11], ICU-acquired weakness [12–19], and post-intensive care syndrome [20–23]. Pain, anxiety, and delirium all contribute to patient distress and agitation, and the prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. The Society of Critical Care Medicine (SCCM) developed the ABCDEF bundle (Table) to facilitate implementation of their 2013 clinical practice guidelines for the management of pain, agitation, and delirium (PAD) [24]. The bundle emphasizes an integrated approach to assessing, treating and preventing significant pain, over or undersedation, and delirium in critically ill patients.

In 2015, SCCM began the ICU Liberation Collaborative, a clinical care collaborative designed to implement the ABCDEF bundle through team-based care at hospitals and health systems across the country. The Liberation Collaborative’s intent was to “liberate” patients from iatrogenic aspects of care [25]. Our medical center participated in the collaborative. In this article, we describe the highlights of our medical center’s implementation of the ABCDEF bundle in 3 medical ICUs.

Settings

The Ohio State University Wexner Medical Center is a 1000+–bed academic medical center located in Columbus, Ohio, containing more than 180 ICU beds. These ICU beds provide care to patients with medical, surgical, burn, trauma, oncology, and transplantation needs. The care of the critically ill patient is central to the organization’s mission “to improve people’s lives through innovation in research, education and patient care.”

At the start of our colloborative participation, all of the ABCDEF bundle elements were protocolized in these ICUs. However, there was a lack of knowledge of the content of the bundle elements and corresponding guidelines among all members of our interdisciplinary teams, and our written protocols and guidelines supporting many of the bundle elements had inconsistent application across the 3 clinical settings.

We convened an ABCDEF bundle/ICU liberation team consisting of an interdisciplinary group of clinicians. The team leader was a critical care clinical nurse specialist. The project required outcome and demographic data collection for all patients in the collaborative as well as concurrent (daily) data collection on each bundle element. The clinical pharmacists who work in the MICUs and are part of daily interdisciplinary rounds collected the daily bundle element data while the patient demographic and outcome data were collected by the clinical nurse specialist, nurse practitioner, and clinical quality manager. Oversight and accountability for the ABCDEF bundle/ICU liberation project was provided by an interdisciplinary critical care quality committee. Our ABCDEF bundle/ICU liberation team met weekly to discuss progress of the initiative and provided monthly updates to the larger quality committee.

Impacting the Bundle—Nursing Assessments

The PAD guidelines recommend the routine assessment of pain, agitation, and delirium in ICU patients. For pain, they recommend the use of patient self-report or the use of a behavioral pain scale as the most valid and reliable method for completing this assessment [24]. Our medical center had chosen to use the Critical Care Pain Observation Tool (CPOT), a valid and reliable pain scale, for assessment of pain in patients who are unable to communicate [26], which had been in use in the clinical setting for over a year when this project began. For agitation, the PAD guidelines recommended assessment of the adequacy and depth of sedation using the Richmond Agitation Sedation Scale (RASS) or Sedation Agitation Scale (SAS) [24] for all ICU patients. Our medical center has chosen to use the RASS as our delirium assessment. The RASS had been in use in the clinical setting for approximately 10 years when this project started. For delirium assessment, the Confusion Assessment Method for ICU (CAM-ICU) [27] or the Intensive Care Delirium Screening Checklist (ICDSC) [28] is recommended. Our medical center used the CAM-ICU, which had been in place for approximately 10 years prior to the start of this project. Even though the assessment tools were in place in our MICU unit and hospital-based policies and guidelines, the accuracy of the assessments for PAD was questioned by many clinicians.

To improve the accuracy of our nursing assessments for PAD, a group of clinical nurse specialists and nursing educators developed an education and competency program for all critical care nursing staff. This education program focused on the PAD guidelines and our medical center’s chosen assessment tools. Education included in-person continuing education lectures, online modules, demonstrations, and practice in the clinical setting. After several months of education and practice, all staff registered nurses (RNs) had to demonstrate PAD assessment competency on a live person. We used standardized patients who followed written scenarios for all of the testing. The RN was given 1 of 8 scenarios and was charged with completing a PAD assessment on the standardized patient. RNs who did not pass had to review the education materials and re-test at a later date. More than 600 RNs completed the PAD competency. After completion of the PAD competency, the clinical nurse specialists observed clinical practice and audited nursing documentation. The accuracy of assessments for PAD had increased. Anecdotally, many our critical care clinicians acknowledged that they had increased confidence in the accuracy of the PAD assessments. There was increased agreement between the results of the assessments performed by all members of the interdisciplinary team.

Impacting the Bundle—Standardized Nurse Early Report Facilitation

Communication among the members of the interdisciplinary team is essential in caring for critically ill patients. One of the ways that the members of the interdisciplinary team communicate is through daily patient rounds. Our ABCDEF bundle/ICU liberation team members attend and participate in daily patient rounds in our 3 MICUs on a regular basis. The ABCDEF bundle/ICU liberation team members wanted to improve communication during patient rounds for all elements of the bundle.

Nurse Early Report Facilitation was a standard that was implemented approximately 5 years prior to the start of the ICU Liberation Collaborative. Nurse early report facilitation requires that the bedside staff RN starts the daily patient rounds discussion on each of his/her patients. The report given by the bedside RN was designed to last 60 to 90 seconds and provide dynamic information on the patient’s condition. Requiring the bedside RN to start the patient rounding provides the following benefits: requires bedside RN presence, provides up-to-the-minute information, increases bedside RN engagement in the patient’s plan of care, and allows for questions and answers. Compliance from the bedside RNs with this process of beginning patient rounds was very high; however, the information that was shared when the bedside RN began rounds was variable. Some bedside RNs provided a lengthy report on the patient while others provided 1 or 2 words.

The ABCDEF bundle/ICU liberation team members thought that a way to hardwire the ABCDEF bundle elements would be to add structure to the nurse early report. By using the ABCDEF elements as a guide, the ABCDEF bundle/ICU liberation team members developed the Structured Nurse Early Report Facilitation in which the bedside RN provides the following information at the beginning of each patient discussion during rounds: name of patient, overnight events (travels, clinical changes, etc.), pain (pain score and PRN use), agitation (RASS and PRN use), delirium (results of CAM-ICU). When the bedside RN performs the nurse early report using the structured format, the team is primed to discuss the A, B, C, and D elements of the bundle.

To implement the Structured Nurse Early Report Facilitation in the MICUs, the critical care clinical nurse specialists provided in-person education at the monthly staff meetings. They also sent emails, developed education bulletin boards, made reminder cards that were placed on the in-room computers, and distributed “badge buddy” reminder cards that fit on the RNs’ hospital ID badges. We provided emails and in-person education to our physician and nurse practitioner teams so they were aware of the changes. Our physician and nurse practitioners were encouraged to ask for information about any elements missing from the Structured Nurse Early Report in the early days of the process change.

After a few months, the critical care clinical nurse specialists reported that the Structured Nurse Early Report Facilitation was occurring for more than 80% of MICU patients. Besides the increase in information related to pain, agitation, and delirium, the Structured Nurse Early Report Facilitation increased the interdisciplinary team’s use of the term “delirium.” Prior to the structured nurse early report, most of the interdisciplinary team members were not naming delirium as a diagnosis for our MICU patients and used terms such as ICU psychosis, confused, and disoriented to describe the mental status of patients with delirium. As a result of this lack of naming, there may have been a lack of recognition of delirium. Using the word “delirium” has increased our interdisciplinary team’s awareness of this diagnosis and has increased the treatment of delirium in patients who have the diagnosis.

In addition to improved assessment and diagnosis, the clinical pharmacist began leading the discussions around choice of sedation during daily rounds. Team members began to discuss the patient’s sedation level, sedation goals, and develop a plan for each patient. This discussion included input from all members of the interdisciplinary team and allowed for a comprehensive patient-specific plan to be formed during the daily patient rounds episode.

Impacting the Bundle—Focus on Mobility

There have been many articles published in the critical care literature on the topic of mobility in the ICU. The evidence shows that early mobilization and rehabilitation of patients in ICUs is safe and may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay [29–31]. Our institution had developed a critical care mobility guideline in 2008 for staff RNs to follow in determining the level of mobility that the patient required during the shift. Over the years, the mobility guideline was used less and less. As other tasks and interventions became a priority, mobility became an intervention that was completed for very few patients.

Our ABCDEF bundle/ICU liberation team determined that increasing mobility of our MICU patients needed to be a plan of care priority. We organized an interdisciplinary team to discuss the issues and barriers to mobility for our MICU patients. The interdisciplinary mobility team had representatives from medicine, nursing, respiratory therapy, physical therapy, occupational therapy, and speech therapy. Initially, this team sent a survey to all disciplines who provided care for the patients in the MICU. Data from this survey was analyzed by the team to determine next steps.

Despite the fact that there were responses from 6 unique disciplines, several common barriers emerged. The largest barrier to overcome was staffing/time for mobility. It was clear from the survey respondents that all health care team members were busy providing patient care. Any change in the mobility guideline or practice needed to make efficient use of the practitioner’s time. Other barriers included space/equipment, communication, patient schedules, knowledge, patient and staff safety, and unit culture. The interdisciplinary mobility team divided into smaller workgroups to tackle the issues and barriers.

Mobility Rounds

Mobility rounds were implemented to attempt to decrease the barriers of time, communication, and know-ledge. Mobility rounds were designed as a start to the shift discussion on the topic of mobility. Mobility rounds included a clinical nurse specialist, a physical therapist (PT), an occupational therapist (OT), and a pulmonary physician/ nurse practitioner. This team met at 7:30 each weekday morning and walked room-to-room through our MICUs. The mobility rounds team laid eyes on each patient, developed a mobility plan for the day, and communicated this plan with the staff RN assigned to the patient. Mobility rounds were completed on all 48 MICU patients in 30 minutes.

Having the mobility rounds team at each patient’s bedside was important in several ways. First, it allowed the team members to see each patient, which gave the patient an opportunity to be part of his/her mobility plan. Also, the staff RNs and respiratory therapists (RTs) were often in the patient’s room. This improved communication as the staff RNs and RTs discussed the mobility plan with the PT and OT. For patients who required many resources for a mobility session, the morning bedside meeting allowed RNs, RTs, PTs, OTs, and physicians to set a schedule for the day’s mobility session. Having a scheduled time for mobility increased staff and patient communication. Also, it allowed all of the team members to adjust their workloads to be present for a complex mobility session.

Another benefit of mobility rounds was the opportunity for the PT and OT team members to provide education to their nursing and physician colleagues. Many nursing and physician providers do not understand the intricacies of physical and occupational therapy practice. This daily dialogue provided the PT/OT a forum to explain which patients would benefit from PT/OT services and which would not. It allowed the RNs and physicians to hear the type of therapy provided on past sessions. It allowed the PT/OT to discuss and evaluate the appropriateness of each patient consult. It allowed the RN and physician to communicate which patients they felt were highest priority for therapy for that day. Mobility rounds are ongoing. Data are being collected to determine the impact of mobility rounds on the intensity of mobility for our MICU patients.

Nurse-Driven Mobility Guideline

Another subgroup revised the outdated critical care mobility guideline and developed the new “Nurse-Driven Critical Care Mobility Guideline.” The guideline has been approved through all of the medical center quality committees and is in the final copyright and publication stages, with implementation training to begin in the fall. The updated guideline is in an easy-to-read flowchart format and provides the staff RN with a pathway to follow to determine if mobility is safe for the patient. After determining safety, the staff RN uses the guideline to determine and perform the patient’s correct mobility interventions for his/her shift. The guideline has built in consultation points with the provider team and the therapy experts.

Other Mobility Issues

A third subgroup from the interdisciplinary mobility team has been working on the equipment and space barriers. This subgroup is evaluating equipment such as bedside chairs, specialty beds, and assistive devices. Many of our MICU patient rooms have overhead lifts built into the ceilings. This equipment is available to all staff at all times. The equipment/space subgroup made sure that there were slings for use with the overhead lifts in all of the MICU equipment rooms. They provided staff education on proper use of the overhead lifts. They worked with the financial department and MICU nurse managers to purchase 2 bariatric chairs for patient use in the MICU.

A fourth subgroup has been working on the electronic documentation system. They are partnering with members of the information technology department to update the nursing and provider documentation regarding mobility. They have also worked on updating and elaborating on the electronic activity orders for our MICU patients. There have been many changes to various patient order sets to clarify mobility and activity restrictions. The admission order set for our MICU patients has an activity order that allows our staff RNs to fully utilize the new nurse-driven critical care mobility guideline.

Impacting the Bundle—Family Engagement and Empowerment

Family support is important for all hospitalized patients but is crucial for ICU patients. The medical center implemented an open visitation policy for all ICUs in 2015. Despite open visitation, the communication between patients, families, and interdisciplinary ICU teams was deficient. Families spoke to many different team members and had difficulty remembering all of the information that they received.

To increase family participation in the care of the MICU patient, we invited family members to participate in daily rounds. The families were invited to listen and encouraged to ask questions. During daily rounds, there is a time when all care providers stop talking and allow family members to inquire about the proposed plan of care for their family member. For family members who cannot attend daily rounds, our ICU teams arrange daily in-person or telephone meetings to discuss the patient’s plan of care. RNs provide a daily telefamily call to update the designated family member on the patient’s status, answer questions, and provide support.

In addition to the medical support for families, there is an art therapy program integrated into the ICU to assist families while they are in the medical center. This program is run by a certified art therapist who holds art therapy classes 2 afternoons a week. This provides family members with respite time during long hospital days. There are also nondenominational services offered multiple times during the week and a respite area is located in the lobby of the medical center.

In addition to these programs, the medical center added full-time social workers to be available 24 hours a day/ 7 days a week. The social worker can provide social support for our patients and families as well as help facilitate accommodations for those who travel a far distance. The social worker plays in integral part on the ICU team, often bridging the gap for families that can be overlooked by the medical team.

Conclusion

Care of the ICU patient is complex. Too often we work in our silos of responsibility with our list of tasks for the day. Participating in the ABCDEF bundle/ICU Liberation Collaborative required us to work together as a team. We were able to have candid conversations that improved our understanding of other team members’ perspectives, helping us to reflect on our behaviors and overcome barriers to improving patient care.

Even though the ICU Liberation Collaborative has ended, our work at the medical center continues. We are in the process of evaluating all of the interventions, processes, and guideline updates that our ABCEDF bundle/ICU liberation team worked on during our 18-month program. There have been many improvements such as increased accuracy of pain and delirium assessments, along with improved treatment of pain in the MICU patient. We have noticed increased communication with the patient and family and among all of the members of the interdisciplinary team. We have changed our language to accurately reflect the patient’s sedation level by using the correct RASS score and delirium status by using the term “delirium” when this condition exists. There is increased collaboration among team members in the area of mobility. More patients are out of bed on bedside chairs and more patients are walking in the halls. Over the next several months our ABCEDF bundle/ICU liberation team will continue to review and analyze the data that we collected in the collaborative. We will use that data and the clinical changes we see on a daily basis to continue to improve the care for our MICU patients.

Corresponding author:  Michele L. Weber, DNP, RN, CCRN, CCNS, AOCNS, OCN, ANP-BC, The Ohio State University Wexner Medical Center, 410 West 10th Ave., Columbus, OH 43210, [email protected].

Abstract

• Objective: To describe the highlights of our medical center’s implementation of the Society of Critical Care Medicine’s ABCDEF bundle in 3 medical intensive care units (ICUs).
• Methods: After a review of our current clinical practices and written clinical guidelines, we evaluated deficiencies in clinical care and employed a variety of educational and clinical change interventions for each element of the bundle. We utilized an interdisciplinary team approach to facilitate the change process.
• Results: As a result of our efforts, improvement in the accuracy of assessments of pain, agitation, and delir-ium across all clinical disciplines and improved adherence to clinical practice guidelines, protocols, and instruments for all bundle elements was seen. These changes have been sustained following completion of the data collection phase of the project.
• Conclusion: ICU care is a team effort. As a result of participation in this initiative, there has been an increased awareness of the bundle elements, improved collaboration among team members, and increased patient and family communication.

Key words: intensive care; delirium; sedation; mobility.

Admission to the intensive care unit (ICU) is a stressful and challenging time for patients and their families. In addition, significant negative sequelae following an ICU stay have been reported in the literature, including such post-ICU complications as post-traumatic stress disorder [1–9], depression [10,11], ICU-acquired weakness [12–19], and post-intensive care syndrome [20–23]. Pain, anxiety, and delirium all contribute to patient distress and agitation, and the prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. The Society of Critical Care Medicine (SCCM) developed the ABCDEF bundle (Table) to facilitate implementation of their 2013 clinical practice guidelines for the management of pain, agitation, and delirium (PAD) [24]. The bundle emphasizes an integrated approach to assessing, treating and preventing significant pain, over or undersedation, and delirium in critically ill patients.

In 2015, SCCM began the ICU Liberation Collaborative, a clinical care collaborative designed to implement the ABCDEF bundle through team-based care at hospitals and health systems across the country. The Liberation Collaborative’s intent was to “liberate” patients from iatrogenic aspects of care [25]. Our medical center participated in the collaborative. In this article, we describe the highlights of our medical center’s implementation of the ABCDEF bundle in 3 medical ICUs.

Settings

The Ohio State University Wexner Medical Center is a 1000+–bed academic medical center located in Columbus, Ohio, containing more than 180 ICU beds. These ICU beds provide care to patients with medical, surgical, burn, trauma, oncology, and transplantation needs. The care of the critically ill patient is central to the organization’s mission “to improve people’s lives through innovation in research, education and patient care.”

At the start of our colloborative participation, all of the ABCDEF bundle elements were protocolized in these ICUs. However, there was a lack of knowledge of the content of the bundle elements and corresponding guidelines among all members of our interdisciplinary teams, and our written protocols and guidelines supporting many of the bundle elements had inconsistent application across the 3 clinical settings.

We convened an ABCDEF bundle/ICU liberation team consisting of an interdisciplinary group of clinicians. The team leader was a critical care clinical nurse specialist. The project required outcome and demographic data collection for all patients in the collaborative as well as concurrent (daily) data collection on each bundle element. The clinical pharmacists who work in the MICUs and are part of daily interdisciplinary rounds collected the daily bundle element data while the patient demographic and outcome data were collected by the clinical nurse specialist, nurse practitioner, and clinical quality manager. Oversight and accountability for the ABCDEF bundle/ICU liberation project was provided by an interdisciplinary critical care quality committee. Our ABCDEF bundle/ICU liberation team met weekly to discuss progress of the initiative and provided monthly updates to the larger quality committee.

Impacting the Bundle—Nursing Assessments

The PAD guidelines recommend the routine assessment of pain, agitation, and delirium in ICU patients. For pain, they recommend the use of patient self-report or the use of a behavioral pain scale as the most valid and reliable method for completing this assessment [24]. Our medical center had chosen to use the Critical Care Pain Observation Tool (CPOT), a valid and reliable pain scale, for assessment of pain in patients who are unable to communicate [26], which had been in use in the clinical setting for over a year when this project began. For agitation, the PAD guidelines recommended assessment of the adequacy and depth of sedation using the Richmond Agitation Sedation Scale (RASS) or Sedation Agitation Scale (SAS) [24] for all ICU patients. Our medical center has chosen to use the RASS as our delirium assessment. The RASS had been in use in the clinical setting for approximately 10 years when this project started. For delirium assessment, the Confusion Assessment Method for ICU (CAM-ICU) [27] or the Intensive Care Delirium Screening Checklist (ICDSC) [28] is recommended. Our medical center used the CAM-ICU, which had been in place for approximately 10 years prior to the start of this project. Even though the assessment tools were in place in our MICU unit and hospital-based policies and guidelines, the accuracy of the assessments for PAD was questioned by many clinicians.

To improve the accuracy of our nursing assessments for PAD, a group of clinical nurse specialists and nursing educators developed an education and competency program for all critical care nursing staff. This education program focused on the PAD guidelines and our medical center’s chosen assessment tools. Education included in-person continuing education lectures, online modules, demonstrations, and practice in the clinical setting. After several months of education and practice, all staff registered nurses (RNs) had to demonstrate PAD assessment competency on a live person. We used standardized patients who followed written scenarios for all of the testing. The RN was given 1 of 8 scenarios and was charged with completing a PAD assessment on the standardized patient. RNs who did not pass had to review the education materials and re-test at a later date. More than 600 RNs completed the PAD competency. After completion of the PAD competency, the clinical nurse specialists observed clinical practice and audited nursing documentation. The accuracy of assessments for PAD had increased. Anecdotally, many our critical care clinicians acknowledged that they had increased confidence in the accuracy of the PAD assessments. There was increased agreement between the results of the assessments performed by all members of the interdisciplinary team.

Impacting the Bundle—Standardized Nurse Early Report Facilitation

Communication among the members of the interdisciplinary team is essential in caring for critically ill patients. One of the ways that the members of the interdisciplinary team communicate is through daily patient rounds. Our ABCDEF bundle/ICU liberation team members attend and participate in daily patient rounds in our 3 MICUs on a regular basis. The ABCDEF bundle/ICU liberation team members wanted to improve communication during patient rounds for all elements of the bundle.

Nurse Early Report Facilitation was a standard that was implemented approximately 5 years prior to the start of the ICU Liberation Collaborative. Nurse early report facilitation requires that the bedside staff RN starts the daily patient rounds discussion on each of his/her patients. The report given by the bedside RN was designed to last 60 to 90 seconds and provide dynamic information on the patient’s condition. Requiring the bedside RN to start the patient rounding provides the following benefits: requires bedside RN presence, provides up-to-the-minute information, increases bedside RN engagement in the patient’s plan of care, and allows for questions and answers. Compliance from the bedside RNs with this process of beginning patient rounds was very high; however, the information that was shared when the bedside RN began rounds was variable. Some bedside RNs provided a lengthy report on the patient while others provided 1 or 2 words.

The ABCDEF bundle/ICU liberation team members thought that a way to hardwire the ABCDEF bundle elements would be to add structure to the nurse early report. By using the ABCDEF elements as a guide, the ABCDEF bundle/ICU liberation team members developed the Structured Nurse Early Report Facilitation in which the bedside RN provides the following information at the beginning of each patient discussion during rounds: name of patient, overnight events (travels, clinical changes, etc.), pain (pain score and PRN use), agitation (RASS and PRN use), delirium (results of CAM-ICU). When the bedside RN performs the nurse early report using the structured format, the team is primed to discuss the A, B, C, and D elements of the bundle.

To implement the Structured Nurse Early Report Facilitation in the MICUs, the critical care clinical nurse specialists provided in-person education at the monthly staff meetings. They also sent emails, developed education bulletin boards, made reminder cards that were placed on the in-room computers, and distributed “badge buddy” reminder cards that fit on the RNs’ hospital ID badges. We provided emails and in-person education to our physician and nurse practitioner teams so they were aware of the changes. Our physician and nurse practitioners were encouraged to ask for information about any elements missing from the Structured Nurse Early Report in the early days of the process change.

After a few months, the critical care clinical nurse specialists reported that the Structured Nurse Early Report Facilitation was occurring for more than 80% of MICU patients. Besides the increase in information related to pain, agitation, and delirium, the Structured Nurse Early Report Facilitation increased the interdisciplinary team’s use of the term “delirium.” Prior to the structured nurse early report, most of the interdisciplinary team members were not naming delirium as a diagnosis for our MICU patients and used terms such as ICU psychosis, confused, and disoriented to describe the mental status of patients with delirium. As a result of this lack of naming, there may have been a lack of recognition of delirium. Using the word “delirium” has increased our interdisciplinary team’s awareness of this diagnosis and has increased the treatment of delirium in patients who have the diagnosis.

In addition to improved assessment and diagnosis, the clinical pharmacist began leading the discussions around choice of sedation during daily rounds. Team members began to discuss the patient’s sedation level, sedation goals, and develop a plan for each patient. This discussion included input from all members of the interdisciplinary team and allowed for a comprehensive patient-specific plan to be formed during the daily patient rounds episode.

Impacting the Bundle—Focus on Mobility

There have been many articles published in the critical care literature on the topic of mobility in the ICU. The evidence shows that early mobilization and rehabilitation of patients in ICUs is safe and may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay [29–31]. Our institution had developed a critical care mobility guideline in 2008 for staff RNs to follow in determining the level of mobility that the patient required during the shift. Over the years, the mobility guideline was used less and less. As other tasks and interventions became a priority, mobility became an intervention that was completed for very few patients.

Our ABCDEF bundle/ICU liberation team determined that increasing mobility of our MICU patients needed to be a plan of care priority. We organized an interdisciplinary team to discuss the issues and barriers to mobility for our MICU patients. The interdisciplinary mobility team had representatives from medicine, nursing, respiratory therapy, physical therapy, occupational therapy, and speech therapy. Initially, this team sent a survey to all disciplines who provided care for the patients in the MICU. Data from this survey was analyzed by the team to determine next steps.

Despite the fact that there were responses from 6 unique disciplines, several common barriers emerged. The largest barrier to overcome was staffing/time for mobility. It was clear from the survey respondents that all health care team members were busy providing patient care. Any change in the mobility guideline or practice needed to make efficient use of the practitioner’s time. Other barriers included space/equipment, communication, patient schedules, knowledge, patient and staff safety, and unit culture. The interdisciplinary mobility team divided into smaller workgroups to tackle the issues and barriers.

Mobility Rounds

Mobility rounds were implemented to attempt to decrease the barriers of time, communication, and know-ledge. Mobility rounds were designed as a start to the shift discussion on the topic of mobility. Mobility rounds included a clinical nurse specialist, a physical therapist (PT), an occupational therapist (OT), and a pulmonary physician/ nurse practitioner. This team met at 7:30 each weekday morning and walked room-to-room through our MICUs. The mobility rounds team laid eyes on each patient, developed a mobility plan for the day, and communicated this plan with the staff RN assigned to the patient. Mobility rounds were completed on all 48 MICU patients in 30 minutes.

Having the mobility rounds team at each patient’s bedside was important in several ways. First, it allowed the team members to see each patient, which gave the patient an opportunity to be part of his/her mobility plan. Also, the staff RNs and respiratory therapists (RTs) were often in the patient’s room. This improved communication as the staff RNs and RTs discussed the mobility plan with the PT and OT. For patients who required many resources for a mobility session, the morning bedside meeting allowed RNs, RTs, PTs, OTs, and physicians to set a schedule for the day’s mobility session. Having a scheduled time for mobility increased staff and patient communication. Also, it allowed all of the team members to adjust their workloads to be present for a complex mobility session.

Another benefit of mobility rounds was the opportunity for the PT and OT team members to provide education to their nursing and physician colleagues. Many nursing and physician providers do not understand the intricacies of physical and occupational therapy practice. This daily dialogue provided the PT/OT a forum to explain which patients would benefit from PT/OT services and which would not. It allowed the RNs and physicians to hear the type of therapy provided on past sessions. It allowed the PT/OT to discuss and evaluate the appropriateness of each patient consult. It allowed the RN and physician to communicate which patients they felt were highest priority for therapy for that day. Mobility rounds are ongoing. Data are being collected to determine the impact of mobility rounds on the intensity of mobility for our MICU patients.

Nurse-Driven Mobility Guideline

Another subgroup revised the outdated critical care mobility guideline and developed the new “Nurse-Driven Critical Care Mobility Guideline.” The guideline has been approved through all of the medical center quality committees and is in the final copyright and publication stages, with implementation training to begin in the fall. The updated guideline is in an easy-to-read flowchart format and provides the staff RN with a pathway to follow to determine if mobility is safe for the patient. After determining safety, the staff RN uses the guideline to determine and perform the patient’s correct mobility interventions for his/her shift. The guideline has built in consultation points with the provider team and the therapy experts.

Other Mobility Issues

A third subgroup from the interdisciplinary mobility team has been working on the equipment and space barriers. This subgroup is evaluating equipment such as bedside chairs, specialty beds, and assistive devices. Many of our MICU patient rooms have overhead lifts built into the ceilings. This equipment is available to all staff at all times. The equipment/space subgroup made sure that there were slings for use with the overhead lifts in all of the MICU equipment rooms. They provided staff education on proper use of the overhead lifts. They worked with the financial department and MICU nurse managers to purchase 2 bariatric chairs for patient use in the MICU.

A fourth subgroup has been working on the electronic documentation system. They are partnering with members of the information technology department to update the nursing and provider documentation regarding mobility. They have also worked on updating and elaborating on the electronic activity orders for our MICU patients. There have been many changes to various patient order sets to clarify mobility and activity restrictions. The admission order set for our MICU patients has an activity order that allows our staff RNs to fully utilize the new nurse-driven critical care mobility guideline.

Impacting the Bundle—Family Engagement and Empowerment

Family support is important for all hospitalized patients but is crucial for ICU patients. The medical center implemented an open visitation policy for all ICUs in 2015. Despite open visitation, the communication between patients, families, and interdisciplinary ICU teams was deficient. Families spoke to many different team members and had difficulty remembering all of the information that they received.

To increase family participation in the care of the MICU patient, we invited family members to participate in daily rounds. The families were invited to listen and encouraged to ask questions. During daily rounds, there is a time when all care providers stop talking and allow family members to inquire about the proposed plan of care for their family member. For family members who cannot attend daily rounds, our ICU teams arrange daily in-person or telephone meetings to discuss the patient’s plan of care. RNs provide a daily telefamily call to update the designated family member on the patient’s status, answer questions, and provide support.

In addition to the medical support for families, there is an art therapy program integrated into the ICU to assist families while they are in the medical center. This program is run by a certified art therapist who holds art therapy classes 2 afternoons a week. This provides family members with respite time during long hospital days. There are also nondenominational services offered multiple times during the week and a respite area is located in the lobby of the medical center.

In addition to these programs, the medical center added full-time social workers to be available 24 hours a day/ 7 days a week. The social worker can provide social support for our patients and families as well as help facilitate accommodations for those who travel a far distance. The social worker plays in integral part on the ICU team, often bridging the gap for families that can be overlooked by the medical team.

Conclusion

Care of the ICU patient is complex. Too often we work in our silos of responsibility with our list of tasks for the day. Participating in the ABCDEF bundle/ICU Liberation Collaborative required us to work together as a team. We were able to have candid conversations that improved our understanding of other team members’ perspectives, helping us to reflect on our behaviors and overcome barriers to improving patient care.

Even though the ICU Liberation Collaborative has ended, our work at the medical center continues. We are in the process of evaluating all of the interventions, processes, and guideline updates that our ABCEDF bundle/ICU liberation team worked on during our 18-month program. There have been many improvements such as increased accuracy of pain and delirium assessments, along with improved treatment of pain in the MICU patient. We have noticed increased communication with the patient and family and among all of the members of the interdisciplinary team. We have changed our language to accurately reflect the patient’s sedation level by using the correct RASS score and delirium status by using the term “delirium” when this condition exists. There is increased collaboration among team members in the area of mobility. More patients are out of bed on bedside chairs and more patients are walking in the halls. Over the next several months our ABCEDF bundle/ICU liberation team will continue to review and analyze the data that we collected in the collaborative. We will use that data and the clinical changes we see on a daily basis to continue to improve the care for our MICU patients.

Corresponding author:  Michele L. Weber, DNP, RN, CCRN, CCNS, AOCNS, OCN, ANP-BC, The Ohio State University Wexner Medical Center, 410 West 10th Ave., Columbus, OH 43210, [email protected].

From the Early Psychosis Intervention Program, Institute of Mental Health, Singapore.

Abstract

• Objective: To develop and apply interventions to reduce lost-to-follow-up rates in patients discharged from an early psychosis intervention program.
• Methods: A team comprising clinical staff, case managers, and patients was formed to carry out a clinical practice improvement project. Tools such as brainstorming and root cause analysis were used to derive causes of patient loss to follow-up and interventions to address them were implemented. Plan, Do, Study, and Act cycles were used to evaluate the effectiveness of identified interventions.
• Results: After the 3 interventions were implemented, there was a decrease in the default rate, and the target default rate of 0% was achieved in less than 6 months.
• Conclusion: Easily implemented program changes led to rapid and sustained improvement in reducing lost-to-follow-up rates in patients discharged from an early psychosis intervention program.

Key words: Transfusion; red blood cells; plasma; platelets; veterans.

Psychosis is a mental illness in which affected individuals lose contact with reality. The lifetime prevalence of all psychotic disorders is 3.06% [1]. The typical symptoms consist of hallucinations, delusions, disorganized speech and thinking and negative symptoms (apathy, avolition, alogia, affective flattening, and anhedonia). Treatment is primarily with antipsychotics and psychological and social therapies.

The key to better prognosis is shortening the duration of untreated psychoses (DUP), defined as the period of time between the onset of psychosis and initiation of adequate treatment [2]. Longer DUP is one of the poorer prognostic factors in the outcome of first episode psychosis patients [3]. Over the past 2 decades, there has been considerable interest in developing and implementing specialized treatment programs for first episode psychosis [4], and early intervention is now a well-established therapeutic approach [5]. Early intervention has 2 elements that are distinct from standard care: early detection and phase-specific treatment (phase-specific treatment is a psychological, social, or physical treatment developed, or modified, specifically for use with people at an early stage of the illness). It is not only the initial care that is important, but regular follow up in the stable phase is necessary to reduce chances of relapse.

The Early Psychosis Intervention Programme (EPIP) in Singapore is a national program whose mission is early detection of young people with early psychosis or at risk of developing a psychotic illness and engagement with these individuals and families with the aim of providing accessible, empowering, individualized, evidence-based care in a least restrictive environment. The program was initiated in April 2001 under the auspices of the Ministry of Health, Singapore. EPIP has a multidisciplinary team of doctors, case managers, occupational therapists, psychologists, family therapists, social workers, and nurses to provide a comprehensive and personalized client-centered service across inpatient, outpatient, and community settings. The program spans 3 years and has 3 phases, beginning with acute intervention, followed by the stabilization phase, and then the stable phase, which focuses on relapse prevention, healthy lifestyle, stress management and plan for transition to downstream care. The frequency of visits and interaction with the team is tailored to suit individual patient needs and phase of care and can range from every day to once every 3 months. Following the 3-year program, clients are discharged from EPIP to continuity care (community psychiatry teams).

The relapse signature card was used every 2 months in the last 6 months during the period that the improvement project was ongoing. As it was found effective, now we use it every 6 months until 30 months and then every 2 months until conclusion of the 3-year program.

In addition, an appreciation card (Figure 2) was designed that is given to patients who keep their first downstream appointment. The card highlights independence and responsibility for one’s own care.

3. Provide a designated contact person

To ensure a smooth transition to the new service, we provided a designated person to contact for continuity care. Arrangement was made to transfer care to a specific community team of specific doctors and case managers, and their hospital contact details were provided on a card that was given to patients. Of the 8 patients who were transferred, 1 defaulted, 1 went overseas, 1 followed up with a private psychiatrist and the remaining 5 came for their first visit appointments.

Results

shown).

Figure 3. Run chart showing percentage of patients who failed to attend their first appointment with continuity care following transfer out of the program. Pre-intervention, default rates ranged from 9% to 75%. In the first 2 months after all the interventions were instituted (Dec 1 2012–March 1 2013), 2 patients defaulted, after which the default rate decreased to 0%.

Discussion

Making 3 small changes in our early psychosis intervention program led to rewarding gains in improving our patients’ follow-up with continuity care and the changes have become part of our standard operating procedure. In reviewing our processes to identify the root causes for loss of patients to follow-up, we found that obtaining the patient’s perspective was invaluable. It was interesting to learn that the word “discharge” might be impacting the way patients thought about follow-up after completion of  the early intervention program. The interventions  have become part of our standard operating procedure and we continue to audit the results every month to ensure that 0% default is being maintained. We are also looking into improving out psychoeducational materials for patients and caregivers and using more visual and interactive materials.

Corresponding author: Basu Sutapa, MD, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore, S539747, [email protected].

Financial disclosures: None.

From the Early Psychosis Intervention Program, Institute of Mental Health, Singapore.

Abstract

• Objective: To develop and apply interventions to reduce lost-to-follow-up rates in patients discharged from an early psychosis intervention program.
• Methods: A team comprising clinical staff, case managers, and patients was formed to carry out a clinical practice improvement project. Tools such as brainstorming and root cause analysis were used to derive causes of patient loss to follow-up and interventions to address them were implemented. Plan, Do, Study, and Act cycles were used to evaluate the effectiveness of identified interventions.
• Results: After the 3 interventions were implemented, there was a decrease in the default rate, and the target default rate of 0% was achieved in less than 6 months.
• Conclusion: Easily implemented program changes led to rapid and sustained improvement in reducing lost-to-follow-up rates in patients discharged from an early psychosis intervention program.

Key words: Transfusion; red blood cells; plasma; platelets; veterans.

Psychosis is a mental illness in which affected individuals lose contact with reality. The lifetime prevalence of all psychotic disorders is 3.06% [1]. The typical symptoms consist of hallucinations, delusions, disorganized speech and thinking and negative symptoms (apathy, avolition, alogia, affective flattening, and anhedonia). Treatment is primarily with antipsychotics and psychological and social therapies.

The key to better prognosis is shortening the duration of untreated psychoses (DUP), defined as the period of time between the onset of psychosis and initiation of adequate treatment [2]. Longer DUP is one of the poorer prognostic factors in the outcome of first episode psychosis patients [3]. Over the past 2 decades, there has been considerable interest in developing and implementing specialized treatment programs for first episode psychosis [4], and early intervention is now a well-established therapeutic approach [5]. Early intervention has 2 elements that are distinct from standard care: early detection and phase-specific treatment (phase-specific treatment is a psychological, social, or physical treatment developed, or modified, specifically for use with people at an early stage of the illness). It is not only the initial care that is important, but regular follow up in the stable phase is necessary to reduce chances of relapse.

The Early Psychosis Intervention Programme (EPIP) in Singapore is a national program whose mission is early detection of young people with early psychosis or at risk of developing a psychotic illness and engagement with these individuals and families with the aim of providing accessible, empowering, individualized, evidence-based care in a least restrictive environment. The program was initiated in April 2001 under the auspices of the Ministry of Health, Singapore. EPIP has a multidisciplinary team of doctors, case managers, occupational therapists, psychologists, family therapists, social workers, and nurses to provide a comprehensive and personalized client-centered service across inpatient, outpatient, and community settings. The program spans 3 years and has 3 phases, beginning with acute intervention, followed by the stabilization phase, and then the stable phase, which focuses on relapse prevention, healthy lifestyle, stress management and plan for transition to downstream care. The frequency of visits and interaction with the team is tailored to suit individual patient needs and phase of care and can range from every day to once every 3 months. Following the 3-year program, clients are discharged from EPIP to continuity care (community psychiatry teams).

The relapse signature card was used every 2 months in the last 6 months during the period that the improvement project was ongoing. As it was found effective, now we use it every 6 months until 30 months and then every 2 months until conclusion of the 3-year program.

In addition, an appreciation card (Figure 2) was designed that is given to patients who keep their first downstream appointment. The card highlights independence and responsibility for one’s own care.

3. Provide a designated contact person

To ensure a smooth transition to the new service, we provided a designated person to contact for continuity care. Arrangement was made to transfer care to a specific community team of specific doctors and case managers, and their hospital contact details were provided on a card that was given to patients. Of the 8 patients who were transferred, 1 defaulted, 1 went overseas, 1 followed up with a private psychiatrist and the remaining 5 came for their first visit appointments.

Results

shown).

Figure 3. Run chart showing percentage of patients who failed to attend their first appointment with continuity care following transfer out of the program. Pre-intervention, default rates ranged from 9% to 75%. In the first 2 months after all the interventions were instituted (Dec 1 2012–March 1 2013), 2 patients defaulted, after which the default rate decreased to 0%.

Discussion

Making 3 small changes in our early psychosis intervention program led to rewarding gains in improving our patients’ follow-up with continuity care and the changes have become part of our standard operating procedure. In reviewing our processes to identify the root causes for loss of patients to follow-up, we found that obtaining the patient’s perspective was invaluable. It was interesting to learn that the word “discharge” might be impacting the way patients thought about follow-up after completion of  the early intervention program. The interventions  have become part of our standard operating procedure and we continue to audit the results every month to ensure that 0% default is being maintained. We are also looking into improving out psychoeducational materials for patients and caregivers and using more visual and interactive materials.

Corresponding author: Basu Sutapa, MD, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore, S539747, [email protected].

Financial disclosures: None.

From the Early Psychosis Intervention Program, Institute of Mental Health, Singapore.

Abstract

• Objective: To develop and apply interventions to reduce lost-to-follow-up rates in patients discharged from an early psychosis intervention program.
• Methods: A team comprising clinical staff, case managers, and patients was formed to carry out a clinical practice improvement project. Tools such as brainstorming and root cause analysis were used to derive causes of patient loss to follow-up and interventions to address them were implemented. Plan, Do, Study, and Act cycles were used to evaluate the effectiveness of identified interventions.
• Results: After the 3 interventions were implemented, there was a decrease in the default rate, and the target default rate of 0% was achieved in less than 6 months.
• Conclusion: Easily implemented program changes led to rapid and sustained improvement in reducing lost-to-follow-up rates in patients discharged from an early psychosis intervention program.

Key words: Transfusion; red blood cells; plasma; platelets; veterans.

Psychosis is a mental illness in which affected individuals lose contact with reality. The lifetime prevalence of all psychotic disorders is 3.06% [1]. The typical symptoms consist of hallucinations, delusions, disorganized speech and thinking and negative symptoms (apathy, avolition, alogia, affective flattening, and anhedonia). Treatment is primarily with antipsychotics and psychological and social therapies.

The key to better prognosis is shortening the duration of untreated psychoses (DUP), defined as the period of time between the onset of psychosis and initiation of adequate treatment [2]. Longer DUP is one of the poorer prognostic factors in the outcome of first episode psychosis patients [3]. Over the past 2 decades, there has been considerable interest in developing and implementing specialized treatment programs for first episode psychosis [4], and early intervention is now a well-established therapeutic approach [5]. Early intervention has 2 elements that are distinct from standard care: early detection and phase-specific treatment (phase-specific treatment is a psychological, social, or physical treatment developed, or modified, specifically for use with people at an early stage of the illness). It is not only the initial care that is important, but regular follow up in the stable phase is necessary to reduce chances of relapse.

The Early Psychosis Intervention Programme (EPIP) in Singapore is a national program whose mission is early detection of young people with early psychosis or at risk of developing a psychotic illness and engagement with these individuals and families with the aim of providing accessible, empowering, individualized, evidence-based care in a least restrictive environment. The program was initiated in April 2001 under the auspices of the Ministry of Health, Singapore. EPIP has a multidisciplinary team of doctors, case managers, occupational therapists, psychologists, family therapists, social workers, and nurses to provide a comprehensive and personalized client-centered service across inpatient, outpatient, and community settings. The program spans 3 years and has 3 phases, beginning with acute intervention, followed by the stabilization phase, and then the stable phase, which focuses on relapse prevention, healthy lifestyle, stress management and plan for transition to downstream care. The frequency of visits and interaction with the team is tailored to suit individual patient needs and phase of care and can range from every day to once every 3 months. Following the 3-year program, clients are discharged from EPIP to continuity care (community psychiatry teams).

The relapse signature card was used every 2 months in the last 6 months during the period that the improvement project was ongoing. As it was found effective, now we use it every 6 months until 30 months and then every 2 months until conclusion of the 3-year program.

In addition, an appreciation card (Figure 2) was designed that is given to patients who keep their first downstream appointment. The card highlights independence and responsibility for one’s own care.

3. Provide a designated contact person

To ensure a smooth transition to the new service, we provided a designated person to contact for continuity care. Arrangement was made to transfer care to a specific community team of specific doctors and case managers, and their hospital contact details were provided on a card that was given to patients. Of the 8 patients who were transferred, 1 defaulted, 1 went overseas, 1 followed up with a private psychiatrist and the remaining 5 came for their first visit appointments.

Results

shown).

Figure 3. Run chart showing percentage of patients who failed to attend their first appointment with continuity care following transfer out of the program. Pre-intervention, default rates ranged from 9% to 75%. In the first 2 months after all the interventions were instituted (Dec 1 2012–March 1 2013), 2 patients defaulted, after which the default rate decreased to 0%.

Discussion

Making 3 small changes in our early psychosis intervention program led to rewarding gains in improving our patients’ follow-up with continuity care and the changes have become part of our standard operating procedure. In reviewing our processes to identify the root causes for loss of patients to follow-up, we found that obtaining the patient’s perspective was invaluable. It was interesting to learn that the word “discharge” might be impacting the way patients thought about follow-up after completion of  the early intervention program. The interventions  have become part of our standard operating procedure and we continue to audit the results every month to ensure that 0% default is being maintained. We are also looking into improving out psychoeducational materials for patients and caregivers and using more visual and interactive materials.

Corresponding author: Basu Sutapa, MD, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore, S539747, [email protected].

Financial disclosures: None.

Study Overview

Objective. To develop and test a photoaging app designed for melanoma prevention through enhancing sun protective behaviors.

Design. Cross-sectional pilot study.

Setting and participants. 25 students (56% male) with a median age of 22 years (range 19–25) attending the University of Essen in Germany.

Intervention. The researchers tested a free mobile app called Sunface. The app has the user take a self-portrait (selfie) and then photoages the image based on self-reported Fitzpatrick skin type and individual UV protection behavior. The 6 categories of skin on the Fitzpatrick Scale are Type I – always burns, never tans; Type II – usually burns, tans minimally; Type III – sometimes mild burn, gradually tans; Type IV – rarely burns, tans with ease; Type V – very rarely burns, tans very easily; Type VI – never burns, tans very easily. Afterward, the app explains the results and provides recommendations on sun protection as well as the ABCDE rule for skin cancer detection (asymmetrical shape, border, color, diameter, evolution). An interviewer walked up to each student, asked for oral consent, handed them an iPod Touch with the app pre-installed, and let them use the app.

Main outcome measures. Student attitudes about the app as collected on an anonymous paper and pencil questionnaire. Items were statements (see Results below), and responses were on a Likert scale ranging from fully agree to fully disagree.

Results. The majority of students (82%) stated that they would download the app, that the intervention had the potential to motivate them to use sun protection (92%) and that they thought such an app could change their perceptions that tanning makes you attractive (76%). Only a minority of students disagreed or fully disagreed that they would download such an app (2/25, 8%) or that such an app could change their perceptions on tanning and attractiveness (4/25, 16%).

Conclusion. Based on previous studies and the initial study results presented here, it is reasonable to speculate that the app may induce behavioral change in the target population. Further work is required to implement and examine the effectiveness of app-based photoaging interventions within risk groups from various cultural backgrounds.

Commentary

The relationship between skin cancer and ultraviolet radiation is well established [1]. Despite the known risks, tanning behavior, including use of tanning beds, is common. Indoor tanning is prevalent, particularly among female adolescents, and aligns with other risk behaviors, appearance-related factors, and intentional sunbathing [2]. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection against ultraviolet radiation [1].Significantly lower frequencies of almost all recommended sun-protective measures are found in younger patient subgroups (age 14 to 25 years) [3]. Thus, it makes sense to target interventions at the adolescent age-group.

Counseling adolescents regarding the dangers of tanning can be difficult due to the pressure the media places on young women and men to enhance their appearance. As a result, appeals to the negative cosmetic impact of sun and indoor tanning may be more effective than health-based appeals [4].

In this pilot study, the authors tested a creative sun protection app that photoages the user’s image based on skin type and aging algorithms. The underlying aging algorithms are based on publications showing UV-induced skin damage by outdoor as well as indoor tanning. Afterward, the app explains the visual results and aims at increasing self-competence on skin cancer prevention by providing guideline recommendations on sun protection and the ABCDE rule for melanoma self-detection. The app was very well received by the partipating college students, and the researchers concluded that the app may aid in the prevention of melanoma by enhancing the adoption of sun protective behaviors. However, this study was very small.

Mobile phone apps are proliferating and they are recognized as a potential low cost way to deliver health interventions [5]. A previous trial by Buller [6] used a randomized controlled design to evaluate a smartphone app that delivered real-time advice about sun protection, such as alerts to apply or reapply sunscreen or wear a hat. Only 1 out of 7 sun-safety practices was used more frequently by intervention versus control participants. The authors of an evidence review of the effectiveness of mobile phone apps in achieving health-related behavior change note that adequately powered and relatively longer RCTs are needed to better determine the effectiveness of app-based interventions [5].

Applications for Clinical Practice

Warnings on the dangers of sunburn and indoor tanning at any age should be emphasized, and there is an important role for primary care physician and other clinician counseling as well as public health outreach. Phone apps have the benefit of being able to reach large numbers at low cost and can offer an interactive and personalized health education experience. Such nontraditional strategies offer promise. Further studies should shed light on what app features are most important to users and whether their deployment can have a measurable impact on cancer prevention.

Study Overview

Objective. To develop and test a photoaging app designed for melanoma prevention through enhancing sun protective behaviors.

Design. Cross-sectional pilot study.

Setting and participants. 25 students (56% male) with a median age of 22 years (range 19–25) attending the University of Essen in Germany.

Intervention. The researchers tested a free mobile app called Sunface. The app has the user take a self-portrait (selfie) and then photoages the image based on self-reported Fitzpatrick skin type and individual UV protection behavior. The 6 categories of skin on the Fitzpatrick Scale are Type I – always burns, never tans; Type II – usually burns, tans minimally; Type III – sometimes mild burn, gradually tans; Type IV – rarely burns, tans with ease; Type V – very rarely burns, tans very easily; Type VI – never burns, tans very easily. Afterward, the app explains the results and provides recommendations on sun protection as well as the ABCDE rule for skin cancer detection (asymmetrical shape, border, color, diameter, evolution). An interviewer walked up to each student, asked for oral consent, handed them an iPod Touch with the app pre-installed, and let them use the app.

Main outcome measures. Student attitudes about the app as collected on an anonymous paper and pencil questionnaire. Items were statements (see Results below), and responses were on a Likert scale ranging from fully agree to fully disagree.

Results. The majority of students (82%) stated that they would download the app, that the intervention had the potential to motivate them to use sun protection (92%) and that they thought such an app could change their perceptions that tanning makes you attractive (76%). Only a minority of students disagreed or fully disagreed that they would download such an app (2/25, 8%) or that such an app could change their perceptions on tanning and attractiveness (4/25, 16%).

Conclusion. Based on previous studies and the initial study results presented here, it is reasonable to speculate that the app may induce behavioral change in the target population. Further work is required to implement and examine the effectiveness of app-based photoaging interventions within risk groups from various cultural backgrounds.

Commentary

The relationship between skin cancer and ultraviolet radiation is well established [1]. Despite the known risks, tanning behavior, including use of tanning beds, is common. Indoor tanning is prevalent, particularly among female adolescents, and aligns with other risk behaviors, appearance-related factors, and intentional sunbathing [2]. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection against ultraviolet radiation [1].Significantly lower frequencies of almost all recommended sun-protective measures are found in younger patient subgroups (age 14 to 25 years) [3]. Thus, it makes sense to target interventions at the adolescent age-group.

Counseling adolescents regarding the dangers of tanning can be difficult due to the pressure the media places on young women and men to enhance their appearance. As a result, appeals to the negative cosmetic impact of sun and indoor tanning may be more effective than health-based appeals [4].

In this pilot study, the authors tested a creative sun protection app that photoages the user’s image based on skin type and aging algorithms. The underlying aging algorithms are based on publications showing UV-induced skin damage by outdoor as well as indoor tanning. Afterward, the app explains the visual results and aims at increasing self-competence on skin cancer prevention by providing guideline recommendations on sun protection and the ABCDE rule for melanoma self-detection. The app was very well received by the partipating college students, and the researchers concluded that the app may aid in the prevention of melanoma by enhancing the adoption of sun protective behaviors. However, this study was very small.

Mobile phone apps are proliferating and they are recognized as a potential low cost way to deliver health interventions [5]. A previous trial by Buller [6] used a randomized controlled design to evaluate a smartphone app that delivered real-time advice about sun protection, such as alerts to apply or reapply sunscreen or wear a hat. Only 1 out of 7 sun-safety practices was used more frequently by intervention versus control participants. The authors of an evidence review of the effectiveness of mobile phone apps in achieving health-related behavior change note that adequately powered and relatively longer RCTs are needed to better determine the effectiveness of app-based interventions [5].

Applications for Clinical Practice

Warnings on the dangers of sunburn and indoor tanning at any age should be emphasized, and there is an important role for primary care physician and other clinician counseling as well as public health outreach. Phone apps have the benefit of being able to reach large numbers at low cost and can offer an interactive and personalized health education experience. Such nontraditional strategies offer promise. Further studies should shed light on what app features are most important to users and whether their deployment can have a measurable impact on cancer prevention.

Study Overview

Objective. To develop and test a photoaging app designed for melanoma prevention through enhancing sun protective behaviors.

Design. Cross-sectional pilot study.

Setting and participants. 25 students (56% male) with a median age of 22 years (range 19–25) attending the University of Essen in Germany.

Intervention. The researchers tested a free mobile app called Sunface. The app has the user take a self-portrait (selfie) and then photoages the image based on self-reported Fitzpatrick skin type and individual UV protection behavior. The 6 categories of skin on the Fitzpatrick Scale are Type I – always burns, never tans; Type II – usually burns, tans minimally; Type III – sometimes mild burn, gradually tans; Type IV – rarely burns, tans with ease; Type V – very rarely burns, tans very easily; Type VI – never burns, tans very easily. Afterward, the app explains the results and provides recommendations on sun protection as well as the ABCDE rule for skin cancer detection (asymmetrical shape, border, color, diameter, evolution). An interviewer walked up to each student, asked for oral consent, handed them an iPod Touch with the app pre-installed, and let them use the app.

Main outcome measures. Student attitudes about the app as collected on an anonymous paper and pencil questionnaire. Items were statements (see Results below), and responses were on a Likert scale ranging from fully agree to fully disagree.

Results. The majority of students (82%) stated that they would download the app, that the intervention had the potential to motivate them to use sun protection (92%) and that they thought such an app could change their perceptions that tanning makes you attractive (76%). Only a minority of students disagreed or fully disagreed that they would download such an app (2/25, 8%) or that such an app could change their perceptions on tanning and attractiveness (4/25, 16%).

Conclusion. Based on previous studies and the initial study results presented here, it is reasonable to speculate that the app may induce behavioral change in the target population. Further work is required to implement and examine the effectiveness of app-based photoaging interventions within risk groups from various cultural backgrounds.

Commentary

The relationship between skin cancer and ultraviolet radiation is well established [1]. Despite the known risks, tanning behavior, including use of tanning beds, is common. Indoor tanning is prevalent, particularly among female adolescents, and aligns with other risk behaviors, appearance-related factors, and intentional sunbathing [2]. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection against ultraviolet radiation [1].Significantly lower frequencies of almost all recommended sun-protective measures are found in younger patient subgroups (age 14 to 25 years) [3]. Thus, it makes sense to target interventions at the adolescent age-group.

Counseling adolescents regarding the dangers of tanning can be difficult due to the pressure the media places on young women and men to enhance their appearance. As a result, appeals to the negative cosmetic impact of sun and indoor tanning may be more effective than health-based appeals [4].

In this pilot study, the authors tested a creative sun protection app that photoages the user’s image based on skin type and aging algorithms. The underlying aging algorithms are based on publications showing UV-induced skin damage by outdoor as well as indoor tanning. Afterward, the app explains the visual results and aims at increasing self-competence on skin cancer prevention by providing guideline recommendations on sun protection and the ABCDE rule for melanoma self-detection. The app was very well received by the partipating college students, and the researchers concluded that the app may aid in the prevention of melanoma by enhancing the adoption of sun protective behaviors. However, this study was very small.

Mobile phone apps are proliferating and they are recognized as a potential low cost way to deliver health interventions [5]. A previous trial by Buller [6] used a randomized controlled design to evaluate a smartphone app that delivered real-time advice about sun protection, such as alerts to apply or reapply sunscreen or wear a hat. Only 1 out of 7 sun-safety practices was used more frequently by intervention versus control participants. The authors of an evidence review of the effectiveness of mobile phone apps in achieving health-related behavior change note that adequately powered and relatively longer RCTs are needed to better determine the effectiveness of app-based interventions [5].

Applications for Clinical Practice

Warnings on the dangers of sunburn and indoor tanning at any age should be emphasized, and there is an important role for primary care physician and other clinician counseling as well as public health outreach. Phone apps have the benefit of being able to reach large numbers at low cost and can offer an interactive and personalized health education experience. Such nontraditional strategies offer promise. Further studies should shed light on what app features are most important to users and whether their deployment can have a measurable impact on cancer prevention.

Study Overview

Objective. To compare the effectiveness of a group exercise program focusing on the timing and coordination of movement (ie, On the Move [OTM]) with a seated strength, endurance, and flexibility program (usual care) at improving function, disability, and walking ability in older adults.

Design. Cross-sectional pilot study.

Setting and participants. Participants were community-dwelling older adults who were residents or members of 32 independent living facilities, senior apartment buildings, and community centers in the greater Pittsburgh, Pennsylvania, area. Participants were recruted between April 2012 and January 2014. Inclusion criteria included age 65 years or older, ability to walk independently with a gait speed of at least 0.60 m/s, and ability to follow 2-step commands. Individuals were excluded if they were non-English speaking, medically unstable, planning to leave the area for an extended time period, or had abnormal blood pressure or heart rate following a 6-minute walk test. The 32 participating facilities were randomly assigned to the OTM intervention (16 sites, 152 participants) or usual care (16 sites, 146 participants). The OTM and usual care exercise programs had the same frequency and duration (50 minutes per session, twice weekly for 12 weeks), and all exercise sessions were held on site at the facilities. The usual care program was a strength, flexibility, and endurance program based on programs that were being conducted in the participating facilities. It included a warm-up (range-of-motion exercises and stretching), upper and lower extremity strength exercises, aerobic activities, and a cool-down and was conducted with the participants sitting.

Intervention. The OTM program consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and cool down exercises, with most of the exercises conducted in a standing position (40 minutes) and the remainder (10 minutes) sitting. The stepping and walking patterns were designed to promote the timing and coordination of stepping, integrated with the phases of the gait pattern.

Main Results. The average participant age was 80.0 (SD, 8.1) years, most participants were female (84.2%) and white (83.65%), and the average number of chronic conditions was 2.8 (SD, 1.4). The 2 groups were similar except for small differences in facility type. 142 (93.4%) OTM participants and 139 (95.2%) usual care participants completed post-intervention testing. The OTM group had significantly greater mean (SD) improvements than the usual care group in gait speed (0.05 [0.13] m/s versus −0.01 [0.11] m/s; adjusted difference 0.05 [0.02] m/s; P = 0.002) and 6MWD (20.6 [57.1] m versus 4.1 [55.6] m; adjusted difference = 16.7 [7.4] m; P = 0.03). Class attendance was lower in the OTM group than in the usual care group (76 [50.0%] OTM participants versus 95 [65.1%] usual care participants attended at least 20 classes; P = 0.03). There were no other significant differences between the groups in primary or secondary outcomes.

Conclusion. The OTM intervention was more effective at improving mobility than a usual care exercise program.

Commentary

The ability to walk is fundamental to maintaining a high quality of life and living independently in the community. Walking difficulty is a common problem among older persons and is linked to higher rates of loss of independence, morbidity, disability, and mortality in this population [1,2]. Walking difficulty associated with aging is often reflected in reduced gait speed and walking distance. A decline in gait speed of as little as 1 m/s is associated with a 10% decrease in ability to perform activities of daily living [3,4].

According to the authors, previous studies that explored the impact of structured exercise programs on walking ability in older individuals have had mixed results. These studies typically used exercise interventions focused on improving lower extremity muscle strength, flexibility, and general conditioning. In this study, the authors examined a community-based group exercise program (OTM) that incorporated exercises targeting the timing and coordination of movement important for walking in addition to flexibility and strengthening exercises. The results showed that the OTM program was more effective at improving walking ability than usual care. This intervention produced changes in gait speed (0.5 m/s) and 6MWD (16.7 m) that met or nearly met the clinically meaningful change criteria established for research use (0.5 m/s and 20 m, respectively) [5].

The authors pointed out several strengths of this study. First, the OTM program was compared to a usual care exercise program taught by trained exercise professionals, making it more difficult to demonstrate a difference between the 2 interventions. Similar prior studies have used nonexercise controls as the comparator. In addition, the effectiveness of the OTM program was demonstrated in 3 different community settings, suggesting that it can be implemented in various settings. Finally, the study participants were frail, older-old adults, who typically are not included in exercise studies. An important limitation of this study is that because outcomes were measured only at the conclusion of the intervention, it is not known whether the walking improvements persist over time or what effects the intervention has on mobility, function, and disability over the long term.

Applications for Clinical Practice

This study adds to the current literature on group exercise programs for improving mobility among community-dwelling older adults and supports incorporation of timing and coordination exercises into such programs. As the authors note, however, follow-up studies exploring the impact of the OTM intervention on long-term disability outcomes are needed before routine implementation in clinical practice can be recommended.

—Ajay Dharod, MD, Wake Forest School of Medicine, Winston-Salem, NC

Study Overview

Objective. To compare the effectiveness of a group exercise program focusing on the timing and coordination of movement (ie, On the Move [OTM]) with a seated strength, endurance, and flexibility program (usual care) at improving function, disability, and walking ability in older adults.

Design. Cross-sectional pilot study.

Setting and participants. Participants were community-dwelling older adults who were residents or members of 32 independent living facilities, senior apartment buildings, and community centers in the greater Pittsburgh, Pennsylvania, area. Participants were recruted between April 2012 and January 2014. Inclusion criteria included age 65 years or older, ability to walk independently with a gait speed of at least 0.60 m/s, and ability to follow 2-step commands. Individuals were excluded if they were non-English speaking, medically unstable, planning to leave the area for an extended time period, or had abnormal blood pressure or heart rate following a 6-minute walk test. The 32 participating facilities were randomly assigned to the OTM intervention (16 sites, 152 participants) or usual care (16 sites, 146 participants). The OTM and usual care exercise programs had the same frequency and duration (50 minutes per session, twice weekly for 12 weeks), and all exercise sessions were held on site at the facilities. The usual care program was a strength, flexibility, and endurance program based on programs that were being conducted in the participating facilities. It included a warm-up (range-of-motion exercises and stretching), upper and lower extremity strength exercises, aerobic activities, and a cool-down and was conducted with the participants sitting.

Intervention. The OTM program consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and cool down exercises, with most of the exercises conducted in a standing position (40 minutes) and the remainder (10 minutes) sitting. The stepping and walking patterns were designed to promote the timing and coordination of stepping, integrated with the phases of the gait pattern.

Main Results. The average participant age was 80.0 (SD, 8.1) years, most participants were female (84.2%) and white (83.65%), and the average number of chronic conditions was 2.8 (SD, 1.4). The 2 groups were similar except for small differences in facility type. 142 (93.4%) OTM participants and 139 (95.2%) usual care participants completed post-intervention testing. The OTM group had significantly greater mean (SD) improvements than the usual care group in gait speed (0.05 [0.13] m/s versus −0.01 [0.11] m/s; adjusted difference 0.05 [0.02] m/s; P = 0.002) and 6MWD (20.6 [57.1] m versus 4.1 [55.6] m; adjusted difference = 16.7 [7.4] m; P = 0.03). Class attendance was lower in the OTM group than in the usual care group (76 [50.0%] OTM participants versus 95 [65.1%] usual care participants attended at least 20 classes; P = 0.03). There were no other significant differences between the groups in primary or secondary outcomes.

Conclusion. The OTM intervention was more effective at improving mobility than a usual care exercise program.

Commentary

The ability to walk is fundamental to maintaining a high quality of life and living independently in the community. Walking difficulty is a common problem among older persons and is linked to higher rates of loss of independence, morbidity, disability, and mortality in this population [1,2]. Walking difficulty associated with aging is often reflected in reduced gait speed and walking distance. A decline in gait speed of as little as 1 m/s is associated with a 10% decrease in ability to perform activities of daily living [3,4].

According to the authors, previous studies that explored the impact of structured exercise programs on walking ability in older individuals have had mixed results. These studies typically used exercise interventions focused on improving lower extremity muscle strength, flexibility, and general conditioning. In this study, the authors examined a community-based group exercise program (OTM) that incorporated exercises targeting the timing and coordination of movement important for walking in addition to flexibility and strengthening exercises. The results showed that the OTM program was more effective at improving walking ability than usual care. This intervention produced changes in gait speed (0.5 m/s) and 6MWD (16.7 m) that met or nearly met the clinically meaningful change criteria established for research use (0.5 m/s and 20 m, respectively) [5].

The authors pointed out several strengths of this study. First, the OTM program was compared to a usual care exercise program taught by trained exercise professionals, making it more difficult to demonstrate a difference between the 2 interventions. Similar prior studies have used nonexercise controls as the comparator. In addition, the effectiveness of the OTM program was demonstrated in 3 different community settings, suggesting that it can be implemented in various settings. Finally, the study participants were frail, older-old adults, who typically are not included in exercise studies. An important limitation of this study is that because outcomes were measured only at the conclusion of the intervention, it is not known whether the walking improvements persist over time or what effects the intervention has on mobility, function, and disability over the long term.

Applications for Clinical Practice

This study adds to the current literature on group exercise programs for improving mobility among community-dwelling older adults and supports incorporation of timing and coordination exercises into such programs. As the authors note, however, follow-up studies exploring the impact of the OTM intervention on long-term disability outcomes are needed before routine implementation in clinical practice can be recommended.

—Ajay Dharod, MD, Wake Forest School of Medicine, Winston-Salem, NC

Study Overview

Objective. To compare the effectiveness of a group exercise program focusing on the timing and coordination of movement (ie, On the Move [OTM]) with a seated strength, endurance, and flexibility program (usual care) at improving function, disability, and walking ability in older adults.

Design. Cross-sectional pilot study.

Setting and participants. Participants were community-dwelling older adults who were residents or members of 32 independent living facilities, senior apartment buildings, and community centers in the greater Pittsburgh, Pennsylvania, area. Participants were recruted between April 2012 and January 2014. Inclusion criteria included age 65 years or older, ability to walk independently with a gait speed of at least 0.60 m/s, and ability to follow 2-step commands. Individuals were excluded if they were non-English speaking, medically unstable, planning to leave the area for an extended time period, or had abnormal blood pressure or heart rate following a 6-minute walk test. The 32 participating facilities were randomly assigned to the OTM intervention (16 sites, 152 participants) or usual care (16 sites, 146 participants). The OTM and usual care exercise programs had the same frequency and duration (50 minutes per session, twice weekly for 12 weeks), and all exercise sessions were held on site at the facilities. The usual care program was a strength, flexibility, and endurance program based on programs that were being conducted in the participating facilities. It included a warm-up (range-of-motion exercises and stretching), upper and lower extremity strength exercises, aerobic activities, and a cool-down and was conducted with the participants sitting.

Intervention. The OTM program consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and cool down exercises, with most of the exercises conducted in a standing position (40 minutes) and the remainder (10 minutes) sitting. The stepping and walking patterns were designed to promote the timing and coordination of stepping, integrated with the phases of the gait pattern.

Main Results. The average participant age was 80.0 (SD, 8.1) years, most participants were female (84.2%) and white (83.65%), and the average number of chronic conditions was 2.8 (SD, 1.4). The 2 groups were similar except for small differences in facility type. 142 (93.4%) OTM participants and 139 (95.2%) usual care participants completed post-intervention testing. The OTM group had significantly greater mean (SD) improvements than the usual care group in gait speed (0.05 [0.13] m/s versus −0.01 [0.11] m/s; adjusted difference 0.05 [0.02] m/s; P = 0.002) and 6MWD (20.6 [57.1] m versus 4.1 [55.6] m; adjusted difference = 16.7 [7.4] m; P = 0.03). Class attendance was lower in the OTM group than in the usual care group (76 [50.0%] OTM participants versus 95 [65.1%] usual care participants attended at least 20 classes; P = 0.03). There were no other significant differences between the groups in primary or secondary outcomes.

Conclusion. The OTM intervention was more effective at improving mobility than a usual care exercise program.

Commentary

The ability to walk is fundamental to maintaining a high quality of life and living independently in the community. Walking difficulty is a common problem among older persons and is linked to higher rates of loss of independence, morbidity, disability, and mortality in this population [1,2]. Walking difficulty associated with aging is often reflected in reduced gait speed and walking distance. A decline in gait speed of as little as 1 m/s is associated with a 10% decrease in ability to perform activities of daily living [3,4].

According to the authors, previous studies that explored the impact of structured exercise programs on walking ability in older individuals have had mixed results. These studies typically used exercise interventions focused on improving lower extremity muscle strength, flexibility, and general conditioning. In this study, the authors examined a community-based group exercise program (OTM) that incorporated exercises targeting the timing and coordination of movement important for walking in addition to flexibility and strengthening exercises. The results showed that the OTM program was more effective at improving walking ability than usual care. This intervention produced changes in gait speed (0.5 m/s) and 6MWD (16.7 m) that met or nearly met the clinically meaningful change criteria established for research use (0.5 m/s and 20 m, respectively) [5].

The authors pointed out several strengths of this study. First, the OTM program was compared to a usual care exercise program taught by trained exercise professionals, making it more difficult to demonstrate a difference between the 2 interventions. Similar prior studies have used nonexercise controls as the comparator. In addition, the effectiveness of the OTM program was demonstrated in 3 different community settings, suggesting that it can be implemented in various settings. Finally, the study participants were frail, older-old adults, who typically are not included in exercise studies. An important limitation of this study is that because outcomes were measured only at the conclusion of the intervention, it is not known whether the walking improvements persist over time or what effects the intervention has on mobility, function, and disability over the long term.

Applications for Clinical Practice

This study adds to the current literature on group exercise programs for improving mobility among community-dwelling older adults and supports incorporation of timing and coordination exercises into such programs. As the authors note, however, follow-up studies exploring the impact of the OTM intervention on long-term disability outcomes are needed before routine implementation in clinical practice can be recommended.

—Ajay Dharod, MD, Wake Forest School of Medicine, Winston-Salem, NC

Study Overview

Objective. To evaluate the impact of addiction consultation during hospitalization on addiction severity and self-reported abstinence at 30 days post discharge.

Design. Prospective quasi-experimental study.

Setting and participants. 399 adults admitted to an urban academic medical center between 1 April 2015 and 1 April 2016 who screened as high risk for having an alcohol or drug use disorder (using the Alcohol Use Disorders Identification Test–Consumption and the National Institute on Drug Abuse single-question screen for drug use) or who were clinically identified by the primary nurse as having a substance use disorder. Pregnant patients, those who were unable to be interviewed due to medical reasons, and those who screened solely for marijuana use were excluded.

Intervention. The intervention was a multidisciplinary addiction consult team (ACT) comprising a psychiatrist, an internist with addiction expertise, advanced practice nurses, 3 social workers, a clinical pharmacist, a recovery coach, and a resource specialist. The ACT provided patients with a diagnosis and longitudinal management plan begun in the hospital including pharmacotherapy initiation when appropriate, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment upon discharge. The ACT was available to patients on 12 of the hospital’s 14 floors. Patients on the 2 floors where ACT was not implemented and patients who were eligible for inpatient addiction consults but did nor receive them served as controls. Control patients received access to a general psychiatry consult liaison team and floor social work, and management of control patients included withdrawal treatment and referral to outpatient addiction care.

Main outcome measures. The primary outcomes were change in Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post discharge compared to baseline. The ASI is a standardized instrument for assessing the severity of problems for patients with substance use disorder. Participants were assessed at enrollment (baseline) and at 30 and 90 days post discharge.

Main results. 256 patients received the intervention and 143 did not (control). Of the 399 participants, 265 completed the 30-day assessment, which showed that patients in the intervention group (n = 165) had a greater reduction in the ASI composite score for alcohol and drug use than patients in the control group (n = 100), with mean ASI-alcohol and ASI-drug decreases of 0.24 (vs 0.08, P < 0.001) and 0.05 (vs 0.02, P = 0.003), respectively. The intervention group also had a greater increase in number of days of abstinence than the control group (12.7 days vs 5.6 days, P < 0.001). These differences all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity. The increase in abstinence days and reduction in alcohol use severity remained significantly greater in the intervention group 90 days after discharge.

Conclusion. Inpatient addiction consultation reduced alcohol and drug addiction severity and increased the number of days of abstinence in the 30 days following discharge.

Commentary

In the United States, national mortality rates due to unintentional overdose, driven largely by opioid misuse and abuse, have surpassed mortality due to HIV and motor vehicle accidents [1]. Individuals with substance use disorder frequently use hospital services for management of acute problems, and up to 1 in 7 hospitalized patients has an active substance use disorder [2]. Hospitalization thus provides an opportunity to engage these patients in addiction treatment. Evidence supports the use of several interventions for patients with substance use disorders in the general medical setting [2–5], but implementation of these interventions in clinical practice remains limited.

This study adds to the literature demonstrating the efficacy of hospital-based interventions for substance abuse disorders. The authors note that the ACT intervention combined pharmacotherapy and behavioral interventions that were shown in prior studies to improve treatment retention, decrease substance use, and reduce hospital readmission. In addition to reducing alcohol/drug addiction severity and increasing days of abstinence at 1 month follow-up, the ACT intervention also reduced the number of self-reported hospital and emergency department visits by treated patients for substance use issues. The effects of the intervention on abstinence days and alcohol use severity were still evident after 3 months, suggesting that similar interventions can have benefits over the long term.

The authors highlighted several limitations of this study, including lack of randomization, which led to differences between the 2 groups on several variables. They controlled for these differences in their analysis, but there is still the potential for confounding. Also, the outcomes data was gathered through patient self-reporting without biological confirmation; however, as the authors note, this approach is widely used and self-report of substance use has shown good agreement with biological measures.

Applications for Clinical Practice

Hospitalization represents an opportunity to engage persons with substance abuse disorders in addiction treatment. This study demonstrates the effectiveness of a comprehensive inpatient substance use disorder intervention in improving substance-use–related outcomes in the first month after discharge. Further study of similar interventions in other care settings and for a longer duration is warranted.

—Ajay Dharod, MD, Wake Forest School of Medicine
Winston-Salem, NC

Study Overview

Objective. To evaluate the impact of addiction consultation during hospitalization on addiction severity and self-reported abstinence at 30 days post discharge.

Design. Prospective quasi-experimental study.

Setting and participants. 399 adults admitted to an urban academic medical center between 1 April 2015 and 1 April 2016 who screened as high risk for having an alcohol or drug use disorder (using the Alcohol Use Disorders Identification Test–Consumption and the National Institute on Drug Abuse single-question screen for drug use) or who were clinically identified by the primary nurse as having a substance use disorder. Pregnant patients, those who were unable to be interviewed due to medical reasons, and those who screened solely for marijuana use were excluded.

Intervention. The intervention was a multidisciplinary addiction consult team (ACT) comprising a psychiatrist, an internist with addiction expertise, advanced practice nurses, 3 social workers, a clinical pharmacist, a recovery coach, and a resource specialist. The ACT provided patients with a diagnosis and longitudinal management plan begun in the hospital including pharmacotherapy initiation when appropriate, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment upon discharge. The ACT was available to patients on 12 of the hospital’s 14 floors. Patients on the 2 floors where ACT was not implemented and patients who were eligible for inpatient addiction consults but did nor receive them served as controls. Control patients received access to a general psychiatry consult liaison team and floor social work, and management of control patients included withdrawal treatment and referral to outpatient addiction care.

Main outcome measures. The primary outcomes were change in Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post discharge compared to baseline. The ASI is a standardized instrument for assessing the severity of problems for patients with substance use disorder. Participants were assessed at enrollment (baseline) and at 30 and 90 days post discharge.

Main results. 256 patients received the intervention and 143 did not (control). Of the 399 participants, 265 completed the 30-day assessment, which showed that patients in the intervention group (n = 165) had a greater reduction in the ASI composite score for alcohol and drug use than patients in the control group (n = 100), with mean ASI-alcohol and ASI-drug decreases of 0.24 (vs 0.08, P < 0.001) and 0.05 (vs 0.02, P = 0.003), respectively. The intervention group also had a greater increase in number of days of abstinence than the control group (12.7 days vs 5.6 days, P < 0.001). These differences all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity. The increase in abstinence days and reduction in alcohol use severity remained significantly greater in the intervention group 90 days after discharge.

Conclusion. Inpatient addiction consultation reduced alcohol and drug addiction severity and increased the number of days of abstinence in the 30 days following discharge.

Commentary

In the United States, national mortality rates due to unintentional overdose, driven largely by opioid misuse and abuse, have surpassed mortality due to HIV and motor vehicle accidents [1]. Individuals with substance use disorder frequently use hospital services for management of acute problems, and up to 1 in 7 hospitalized patients has an active substance use disorder [2]. Hospitalization thus provides an opportunity to engage these patients in addiction treatment. Evidence supports the use of several interventions for patients with substance use disorders in the general medical setting [2–5], but implementation of these interventions in clinical practice remains limited.

This study adds to the literature demonstrating the efficacy of hospital-based interventions for substance abuse disorders. The authors note that the ACT intervention combined pharmacotherapy and behavioral interventions that were shown in prior studies to improve treatment retention, decrease substance use, and reduce hospital readmission. In addition to reducing alcohol/drug addiction severity and increasing days of abstinence at 1 month follow-up, the ACT intervention also reduced the number of self-reported hospital and emergency department visits by treated patients for substance use issues. The effects of the intervention on abstinence days and alcohol use severity were still evident after 3 months, suggesting that similar interventions can have benefits over the long term.

The authors highlighted several limitations of this study, including lack of randomization, which led to differences between the 2 groups on several variables. They controlled for these differences in their analysis, but there is still the potential for confounding. Also, the outcomes data was gathered through patient self-reporting without biological confirmation; however, as the authors note, this approach is widely used and self-report of substance use has shown good agreement with biological measures.

Applications for Clinical Practice

Hospitalization represents an opportunity to engage persons with substance abuse disorders in addiction treatment. This study demonstrates the effectiveness of a comprehensive inpatient substance use disorder intervention in improving substance-use–related outcomes in the first month after discharge. Further study of similar interventions in other care settings and for a longer duration is warranted.

—Ajay Dharod, MD, Wake Forest School of Medicine
Winston-Salem, NC

Study Overview

Objective. To evaluate the impact of addiction consultation during hospitalization on addiction severity and self-reported abstinence at 30 days post discharge.

Design. Prospective quasi-experimental study.

Setting and participants. 399 adults admitted to an urban academic medical center between 1 April 2015 and 1 April 2016 who screened as high risk for having an alcohol or drug use disorder (using the Alcohol Use Disorders Identification Test–Consumption and the National Institute on Drug Abuse single-question screen for drug use) or who were clinically identified by the primary nurse as having a substance use disorder. Pregnant patients, those who were unable to be interviewed due to medical reasons, and those who screened solely for marijuana use were excluded.

Intervention. The intervention was a multidisciplinary addiction consult team (ACT) comprising a psychiatrist, an internist with addiction expertise, advanced practice nurses, 3 social workers, a clinical pharmacist, a recovery coach, and a resource specialist. The ACT provided patients with a diagnosis and longitudinal management plan begun in the hospital including pharmacotherapy initiation when appropriate, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment upon discharge. The ACT was available to patients on 12 of the hospital’s 14 floors. Patients on the 2 floors where ACT was not implemented and patients who were eligible for inpatient addiction consults but did nor receive them served as controls. Control patients received access to a general psychiatry consult liaison team and floor social work, and management of control patients included withdrawal treatment and referral to outpatient addiction care.

Main outcome measures. The primary outcomes were change in Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post discharge compared to baseline. The ASI is a standardized instrument for assessing the severity of problems for patients with substance use disorder. Participants were assessed at enrollment (baseline) and at 30 and 90 days post discharge.

Main results. 256 patients received the intervention and 143 did not (control). Of the 399 participants, 265 completed the 30-day assessment, which showed that patients in the intervention group (n = 165) had a greater reduction in the ASI composite score for alcohol and drug use than patients in the control group (n = 100), with mean ASI-alcohol and ASI-drug decreases of 0.24 (vs 0.08, P < 0.001) and 0.05 (vs 0.02, P = 0.003), respectively. The intervention group also had a greater increase in number of days of abstinence than the control group (12.7 days vs 5.6 days, P < 0.001). These differences all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity. The increase in abstinence days and reduction in alcohol use severity remained significantly greater in the intervention group 90 days after discharge.

Conclusion. Inpatient addiction consultation reduced alcohol and drug addiction severity and increased the number of days of abstinence in the 30 days following discharge.

Commentary

In the United States, national mortality rates due to unintentional overdose, driven largely by opioid misuse and abuse, have surpassed mortality due to HIV and motor vehicle accidents [1]. Individuals with substance use disorder frequently use hospital services for management of acute problems, and up to 1 in 7 hospitalized patients has an active substance use disorder [2]. Hospitalization thus provides an opportunity to engage these patients in addiction treatment. Evidence supports the use of several interventions for patients with substance use disorders in the general medical setting [2–5], but implementation of these interventions in clinical practice remains limited.

This study adds to the literature demonstrating the efficacy of hospital-based interventions for substance abuse disorders. The authors note that the ACT intervention combined pharmacotherapy and behavioral interventions that were shown in prior studies to improve treatment retention, decrease substance use, and reduce hospital readmission. In addition to reducing alcohol/drug addiction severity and increasing days of abstinence at 1 month follow-up, the ACT intervention also reduced the number of self-reported hospital and emergency department visits by treated patients for substance use issues. The effects of the intervention on abstinence days and alcohol use severity were still evident after 3 months, suggesting that similar interventions can have benefits over the long term.

The authors highlighted several limitations of this study, including lack of randomization, which led to differences between the 2 groups on several variables. They controlled for these differences in their analysis, but there is still the potential for confounding. Also, the outcomes data was gathered through patient self-reporting without biological confirmation; however, as the authors note, this approach is widely used and self-report of substance use has shown good agreement with biological measures.

Applications for Clinical Practice

Hospitalization represents an opportunity to engage persons with substance abuse disorders in addiction treatment. This study demonstrates the effectiveness of a comprehensive inpatient substance use disorder intervention in improving substance-use–related outcomes in the first month after discharge. Further study of similar interventions in other care settings and for a longer duration is warranted.

—Ajay Dharod, MD, Wake Forest School of Medicine
Winston-Salem, NC

Abstract

• Background: Although transfusion guidelines have changed considerably over the past 2 decades, the adoption of patient blood management programs has not been fully realized across hospitals in the United States.
• Objective: To evaluate trends in red blood cell (RBC), platelet, and plasma transfusion at 3 Veterans Health Administration (VHA) hospitals from 2000 through 2010.
• Methods: Data from all hospitalizations were collected from January 2000 through December 2010. Blood bank data (including the type and volume of products administered) were available electronically from each hospital. These files were linked to inpatient data, which included ICD-9-CM diagnoses (principal and secondary) and procedures during hospitalization. Statistical analyses were conducted using generalized linear models to evaluate trends over time. The unit of observation was hospitalization, with categorization by type.
• Results: There were 176,521 hospitalizations in 69,621 patients; of these, 13.6% of hospitalizations involved transfusion of blood products (12.7% RBCs, 1.4% platelets, 3.0% plasma). Transfusion occurred in 25.2% of surgical and 5.3% of medical hospitalizations. Transfusion use peaked in 2002 for surgical hospitalizations and declined afterwards (P < 0.001). There was no significant change in transfusion use over time (P = 0.126) for medical hospitalizations. In hospitalizations that involved transfusions, there was a 20.3% reduction in the proportion of hospitalizations in which ≥ 3 units of RBCs were given (from 51.7% to 41.1%; P < 0.001) and a 73.6% increase when 1 RBC unit was given (from 8.0% to 13.8%; P < 0.001) from 2000-2010. Of the hospitalizations with RBC transfusion, 9.6% involved the use of 1 unit over the entire study period. The most common principal diagnoses for medical patients receiving transfusion were anemia, malignancy, heart failure, pneumonia and renal failure. Over time, transfusion utilization increased in patients who were admitted for infection (P = 0.009).
• Conclusion: Blood transfusions in 3 VHA hospitals have decreased over time for surgical patients but remained the same for medical patients. Further study examining appropriateness of blood products in medical patients appears necessary.

Key words: Transfusion; red blood cells; plasma; platelets; veterans.

Transfusion practices during hospitalization have changed considerably over the past 2 decades. Guided by evidence from randomized controlled trials, patient blood management programs have been expanded [1]. Such programs include recommendations regarding minimization of blood loss during surgery, prevention and treatment of anemia, strategies for reducing transfusions in both medical and surgical patients, improved blood utilization, education of health professionals, and standardization of blood management-related metrics [2]. Some of the guidelines have been incorporated into the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, including: (a) don’t transfuse more units of blood than absolutely necessary, (b) don’t transfuse red blood cells for iron deficiency without hemodynamic instability, (c) don’t routinely use blood products to reverse warfarin, and (d) don’t perform serial blood counts on clinically stable patients [3]. Although there has been growing interest in blood management, only 37.8% of the 607 AABB (formerly, American Association of Blood Banks) facilities in the United States reported having a patient blood management program in 2013 [2].

While the importance of blood safety is recognized, data regarding the overall trends in practices are conflicting. A study using the Nationwide Inpatient Sample indicated that there was a 5.6% annual mean increase in the transfusion of blood products from 2002 to 2011 in the United States [4]. This contrasts with the experience of Kaiser Permanente in Northern California, in which the incidence of RBC transfusion decreased by 3.2% from 2009 to 2013 [5]. A decline in rates of intraoperative transfusion was also reported among elderly veterans in the United States from 1997 to 2009 [6].

We conducted a study in hospitalized veterans with 2 main objectives: (a) to evaluate trends in utilization of red blood cells (RBCs), platelets, and plasma over time, and (b) to identify those groups of veterans who received specific blood products. We were particularly interested in transfusion use in medical patients.

Methods

Participants were hospitalized veterans at 3 Department of Veterans Affairs (VA) medical centers. Data from all hospitalizations were collected from January 2000 through December 2010. Blood bank data (including the type and volume of products administered) were available electronically from each hospital. These files were linked to inpatient data, which included ICD-9-CM diagnoses (principal and secondary) and procedures during hospitalization.

Statistical analyses were conducted using generalized linear models to evaluate trends over time. The unit of observation was hospitalization, with categorization by type. Surgical hospitalizations were defined as admissions in which any surgical procedure occurred, whereas medical hospitalizations were defined as admissions without any surgery. Alpha was set at 0.05, 2-tailed. All analyses were conducted in Stata/MP 14.1 (StataCorp, College Station, TX). The study received institutional review board approval from the VA Ann Arbor Healthcare System.

Results

From 2000 through 2010, there were 176,521 hospitalizations in 69,621 patients. Within this cohort, 6% were < 40 years of age, 66% were 40 to 69 years of age, and 28% were 70 years or older at the time of admission. In this cohort, 96% of patients were male. Overall, 13.6% of all hospitalizations involved transfusion of a blood product (12.7% RBCs, 1.4% platelets, 3.0% plasma).

Transfusion occurred in 25.2% of surgical hospitalizations and 5.3% of medical hospitalizations. For surgical hospitalizations, transfusion use peaked in 2002 (when 30.9% of the surgical hospitalizations involved a trans-fusion) and significantly declined afterwards (P < 0.001). By 2010, 22.5% of the surgical hospitalizations involved a transfusion. Most of the surgeries where blood products were transfused involved cardiovascular procedures. For medical hospitalizations only, there was no significant change in transfusion use over time, either from 2000 to 2010 (P = 0.126) or from 2002 to 2010 (P = 0.072). In 2010, 5.2% of the medical hospitalizations involved a transfusion.

Rates of transfusion varied by principal diagnosis (Figure 1). For patients admitted with a principal diagnosis of infection (n = 20,981 hospitalizations), there was an increase in the percentage of hospitalizations in which transfusions (RBCs, platelet, plasma) were administered over time (P = 0.009) (Figure 1). For patients admitted with a principal diagnosis of malignancy (n = 12,904 hospitalizations), cardiovascular disease (n = 40,324 hospitalizations), and other diagnoses (n = 102,312 hospitalizations), there were no significant linear trends over the entire study period (P = 0.191, P = 0.052, P = 0.314, respectively). Rather, blood utilization peaked in year 2002 and significantly declined afterwards for patients admitted for malignancy (P < 0.001) and for cardiovascular disease (P < 0.001).

The most common principal diagnoses for medical patients receiving any transfusion (RBCs, platelet, plasma) are listed in Table 1. For medical patients with a principal diagnosis of anemia, 88% of hospitalizations involved a transfusion (Table 1). Transfusion occurred in 6% to 11% of medical hospitalizations with malignancies, heart failure, pneumonia or renal failure (Table 1). A considerable proportion (43%) of medical patients with gastrointestinal hemorrhage received a transfusion.

Discussion

We also observed secular trends in the volume of RBCs administered. There was an increase in the percentage of hospitalizations in which 1 or 2 RBC units were used and a decline in transfusion of 3 or more units. The reduction in the use of 3 or more RBC units may reflect the adoption and integration of recommendations in patient blood management by clinicians,

which encourage assessment of the patients’ symptoms in determining whether additional units are necessary [7]. Such guidelines also endorse the avoidance of routine
administration of 2 units of RBCs if 1 unit is sufficient [8]. We have previously shown that, after coronary artery bypass grafting, 2 RBC units doubled the risk of pneumonia [9]; additional analyses indicated that 1 or 2 units of RBCs were associated with increased postoperative morbidity [10]. In addition, our previous research indicated that the probability of infection increased considerably between 1 and 2 RBC units, with a more gradual increase beyond 2 units [11]. With this evidence in mind, some studies at single sites have reported that there was a dramatic decline from 2 RBC units before initiation of patient blood management programs to 1 unit after the programs were implemented [12,13].

Medical patients who received a transfusion were often admitted for reason of anemia, cancer, organ failure, or pneumonia. Some researchers are now reporting that blood use, at certain sites, is becoming more common in medical rather than surgical patients, which may be due to an expansion of patient blood management procedures in surgery [16]. There are a substantial number of patient blood management programs among surgical specialties and their adoption has expanded [17]. Although there are fewer patient blood management programs in the nonsurgical setting, some have been targeted to internal medicine physicians and specifically, to hospitalists [1,18]. For example, a toolkit from the Society of Hospital Medicine centers on anemia management and includes anemia assessment, treatment, evaluation of RBC transfusion risk, blood conservation, optimization of coagulation, and patient-centered decision-making [19]. Additionally, bundling of patient blood management strategies has been launched to help encourage a wider adoption of such programs [20].

While guidelines regarding use of RBCs are becoming increasingly recognized, recommendations for the use of platelets and plasma are hampered by the paucity of evidence from randomized controlled trials [21,22]. There is moderate-quality evidence for the use of platelets with therapy-induced hypoproliferative thrombocytopenia in hospitalized patients [21], but low quality evidence for other uses. Moreover, a recent review of plasma transfusion in bleeding patients found no randomized controlled trials on plasma use in hospitalized patients, although several trials were currently underway [22].

Our findings need to be considered in the context of the following limitations. The data were from 3 VA hospitals, so the results may not reflect patterns of usage at other hospitals. However, AABB reports that there has been a general decrease in transfusion of allogeneic whole blood and RBC units since 2008 at the AABB-affiliated sites in the United States [2]; this is similar to the pattern that we observed in surgical patients. In addition, we report an overall view of trends without having details regarding which specific factors influenced changes in transfusion during this 11-year period. It is possible that the severity of hospitalized patients may have changed with time which could have influenced decisions regarding the need for transfusion.

In conclusion, the use of blood products decreased in surgical patients since 2002 but remained the same in medical patients in this VA population. Transfusions increased over time for patients who were admitted to the hospital for reason of infection, but decreased since 2002 for those admitted for cardiovascular disease or cancer. The number of RBC units per hospitalization decreased over time. Additional surveillance is needed to determine whether recent evidence regarding blood management has been incorporated into clinical practice for medical patients, as we strive to deliver optimal care to our veterans.

Corresponding author: Mary A.M. Rogers, PhD, MS, Dept. of Internal Medicine, Univ. of Michigan, 016-422W NCRC, Ann Arbor, MI 48109-2800, [email protected].

Funding/support: Department of Veterans Affairs, Clinical Sciences Research & Development Service Merit Review Award (EPID-011-11S). The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

Financial disclosures: None.

Author contributions: conception and design, MAMR, SS; analysis and interpretation of data, MAMR, JDB, DR, LK, SS; drafting of article, MAMR; critical revision of the article, MAMR, MTG, DR, LK, SS, VC; statistical expertise, MAMR, DR; obtaining of funding, MTG, SS, VC; administrative or technical support, MTG, LK, SS, VC; collection and assembly of data, JDB, LK.

Abstract

• Background: Although transfusion guidelines have changed considerably over the past 2 decades, the adoption of patient blood management programs has not been fully realized across hospitals in the United States.
• Objective: To evaluate trends in red blood cell (RBC), platelet, and plasma transfusion at 3 Veterans Health Administration (VHA) hospitals from 2000 through 2010.
• Methods: Data from all hospitalizations were collected from January 2000 through December 2010. Blood bank data (including the type and volume of products administered) were available electronically from each hospital. These files were linked to inpatient data, which included ICD-9-CM diagnoses (principal and secondary) and procedures during hospitalization. Statistical analyses were conducted using generalized linear models to evaluate trends over time. The unit of observation was hospitalization, with categorization by type.
• Results: There were 176,521 hospitalizations in 69,621 patients; of these, 13.6% of hospitalizations involved transfusion of blood products (12.7% RBCs, 1.4% platelets, 3.0% plasma). Transfusion occurred in 25.2% of surgical and 5.3% of medical hospitalizations. Transfusion use peaked in 2002 for surgical hospitalizations and declined afterwards (P < 0.001). There was no significant change in transfusion use over time (P = 0.126) for medical hospitalizations. In hospitalizations that involved transfusions, there was a 20.3% reduction in the proportion of hospitalizations in which ≥ 3 units of RBCs were given (from 51.7% to 41.1%; P < 0.001) and a 73.6% increase when 1 RBC unit was given (from 8.0% to 13.8%; P < 0.001) from 2000-2010. Of the hospitalizations with RBC transfusion, 9.6% involved the use of 1 unit over the entire study period. The most common principal diagnoses for medical patients receiving transfusion were anemia, malignancy, heart failure, pneumonia and renal failure. Over time, transfusion utilization increased in patients who were admitted for infection (P = 0.009).
• Conclusion: Blood transfusions in 3 VHA hospitals have decreased over time for surgical patients but remained the same for medical patients. Further study examining appropriateness of blood products in medical patients appears necessary.

Key words: Transfusion; red blood cells; plasma; platelets; veterans.

Transfusion practices during hospitalization have changed considerably over the past 2 decades. Guided by evidence from randomized controlled trials, patient blood management programs have been expanded [1]. Such programs include recommendations regarding minimization of blood loss during surgery, prevention and treatment of anemia, strategies for reducing transfusions in both medical and surgical patients, improved blood utilization, education of health professionals, and standardization of blood management-related metrics [2]. Some of the guidelines have been incorporated into the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, including: (a) don’t transfuse more units of blood than absolutely necessary, (b) don’t transfuse red blood cells for iron deficiency without hemodynamic instability, (c) don’t routinely use blood products to reverse warfarin, and (d) don’t perform serial blood counts on clinically stable patients [3]. Although there has been growing interest in blood management, only 37.8% of the 607 AABB (formerly, American Association of Blood Banks) facilities in the United States reported having a patient blood management program in 2013 [2].

While the importance of blood safety is recognized, data regarding the overall trends in practices are conflicting. A study using the Nationwide Inpatient Sample indicated that there was a 5.6% annual mean increase in the transfusion of blood products from 2002 to 2011 in the United States [4]. This contrasts with the experience of Kaiser Permanente in Northern California, in which the incidence of RBC transfusion decreased by 3.2% from 2009 to 2013 [5]. A decline in rates of intraoperative transfusion was also reported among elderly veterans in the United States from 1997 to 2009 [6].

We conducted a study in hospitalized veterans with 2 main objectives: (a) to evaluate trends in utilization of red blood cells (RBCs), platelets, and plasma over time, and (b) to identify those groups of veterans who received specific blood products. We were particularly interested in transfusion use in medical patients.

Methods

Participants were hospitalized veterans at 3 Department of Veterans Affairs (VA) medical centers. Data from all hospitalizations were collected from January 2000 through December 2010. Blood bank data (including the type and volume of products administered) were available electronically from each hospital. These files were linked to inpatient data, which included ICD-9-CM diagnoses (principal and secondary) and procedures during hospitalization.

Statistical analyses were conducted using generalized linear models to evaluate trends over time. The unit of observation was hospitalization, with categorization by type. Surgical hospitalizations were defined as admissions in which any surgical procedure occurred, whereas medical hospitalizations were defined as admissions without any surgery. Alpha was set at 0.05, 2-tailed. All analyses were conducted in Stata/MP 14.1 (StataCorp, College Station, TX). The study received institutional review board approval from the VA Ann Arbor Healthcare System.

Results

From 2000 through 2010, there were 176,521 hospitalizations in 69,621 patients. Within this cohort, 6% were < 40 years of age, 66% were 40 to 69 years of age, and 28% were 70 years or older at the time of admission. In this cohort, 96% of patients were male. Overall, 13.6% of all hospitalizations involved transfusion of a blood product (12.7% RBCs, 1.4% platelets, 3.0% plasma).

Transfusion occurred in 25.2% of surgical hospitalizations and 5.3% of medical hospitalizations. For surgical hospitalizations, transfusion use peaked in 2002 (when 30.9% of the surgical hospitalizations involved a trans-fusion) and significantly declined afterwards (P < 0.001). By 2010, 22.5% of the surgical hospitalizations involved a transfusion. Most of the surgeries where blood products were transfused involved cardiovascular procedures. For medical hospitalizations only, there was no significant change in transfusion use over time, either from 2000 to 2010 (P = 0.126) or from 2002 to 2010 (P = 0.072). In 2010, 5.2% of the medical hospitalizations involved a transfusion.

Rates of transfusion varied by principal diagnosis (Figure 1). For patients admitted with a principal diagnosis of infection (n = 20,981 hospitalizations), there was an increase in the percentage of hospitalizations in which transfusions (RBCs, platelet, plasma) were administered over time (P = 0.009) (Figure 1). For patients admitted with a principal diagnosis of malignancy (n = 12,904 hospitalizations), cardiovascular disease (n = 40,324 hospitalizations), and other diagnoses (n = 102,312 hospitalizations), there were no significant linear trends over the entire study period (P = 0.191, P = 0.052, P = 0.314, respectively). Rather, blood utilization peaked in year 2002 and significantly declined afterwards for patients admitted for malignancy (P < 0.001) and for cardiovascular disease (P < 0.001).

The most common principal diagnoses for medical patients receiving any transfusion (RBCs, platelet, plasma) are listed in Table 1. For medical patients with a principal diagnosis of anemia, 88% of hospitalizations involved a transfusion (Table 1). Transfusion occurred in 6% to 11% of medical hospitalizations with malignancies, heart failure, pneumonia or renal failure (Table 1). A considerable proportion (43%) of medical patients with gastrointestinal hemorrhage received a transfusion.

Discussion

We also observed secular trends in the volume of RBCs administered. There was an increase in the percentage of hospitalizations in which 1 or 2 RBC units were used and a decline in transfusion of 3 or more units. The reduction in the use of 3 or more RBC units may reflect the adoption and integration of recommendations in patient blood management by clinicians,

which encourage assessment of the patients’ symptoms in determining whether additional units are necessary [7]. Such guidelines also endorse the avoidance of routine
administration of 2 units of RBCs if 1 unit is sufficient [8]. We have previously shown that, after coronary artery bypass grafting, 2 RBC units doubled the risk of pneumonia [9]; additional analyses indicated that 1 or 2 units of RBCs were associated with increased postoperative morbidity [10]. In addition, our previous research indicated that the probability of infection increased considerably between 1 and 2 RBC units, with a more gradual increase beyond 2 units [11]. With this evidence in mind, some studies at single sites have reported that there was a dramatic decline from 2 RBC units before initiation of patient blood management programs to 1 unit after the programs were implemented [12,13].

Medical patients who received a transfusion were often admitted for reason of anemia, cancer, organ failure, or pneumonia. Some researchers are now reporting that blood use, at certain sites, is becoming more common in medical rather than surgical patients, which may be due to an expansion of patient blood management procedures in surgery [16]. There are a substantial number of patient blood management programs among surgical specialties and their adoption has expanded [17]. Although there are fewer patient blood management programs in the nonsurgical setting, some have been targeted to internal medicine physicians and specifically, to hospitalists [1,18]. For example, a toolkit from the Society of Hospital Medicine centers on anemia management and includes anemia assessment, treatment, evaluation of RBC transfusion risk, blood conservation, optimization of coagulation, and patient-centered decision-making [19]. Additionally, bundling of patient blood management strategies has been launched to help encourage a wider adoption of such programs [20].

While guidelines regarding use of RBCs are becoming increasingly recognized, recommendations for the use of platelets and plasma are hampered by the paucity of evidence from randomized controlled trials [21,22]. There is moderate-quality evidence for the use of platelets with therapy-induced hypoproliferative thrombocytopenia in hospitalized patients [21], but low quality evidence for other uses. Moreover, a recent review of plasma transfusion in bleeding patients found no randomized controlled trials on plasma use in hospitalized patients, although several trials were currently underway [22].

Our findings need to be considered in the context of the following limitations. The data were from 3 VA hospitals, so the results may not reflect patterns of usage at other hospitals. However, AABB reports that there has been a general decrease in transfusion of allogeneic whole blood and RBC units since 2008 at the AABB-affiliated sites in the United States [2]; this is similar to the pattern that we observed in surgical patients. In addition, we report an overall view of trends without having details regarding which specific factors influenced changes in transfusion during this 11-year period. It is possible that the severity of hospitalized patients may have changed with time which could have influenced decisions regarding the need for transfusion.

In conclusion, the use of blood products decreased in surgical patients since 2002 but remained the same in medical patients in this VA population. Transfusions increased over time for patients who were admitted to the hospital for reason of infection, but decreased since 2002 for those admitted for cardiovascular disease or cancer. The number of RBC units per hospitalization decreased over time. Additional surveillance is needed to determine whether recent evidence regarding blood management has been incorporated into clinical practice for medical patients, as we strive to deliver optimal care to our veterans.

Corresponding author: Mary A.M. Rogers, PhD, MS, Dept. of Internal Medicine, Univ. of Michigan, 016-422W NCRC, Ann Arbor, MI 48109-2800, [email protected].

Funding/support: Department of Veterans Affairs, Clinical Sciences Research & Development Service Merit Review Award (EPID-011-11S). The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

Financial disclosures: None.

Author contributions: conception and design, MAMR, SS; analysis and interpretation of data, MAMR, JDB, DR, LK, SS; drafting of article, MAMR; critical revision of the article, MAMR, MTG, DR, LK, SS, VC; statistical expertise, MAMR, DR; obtaining of funding, MTG, SS, VC; administrative or technical support, MTG, LK, SS, VC; collection and assembly of data, JDB, LK.

Abstract

• Background: Although transfusion guidelines have changed considerably over the past 2 decades, the adoption of patient blood management programs has not been fully realized across hospitals in the United States.
• Objective: To evaluate trends in red blood cell (RBC), platelet, and plasma transfusion at 3 Veterans Health Administration (VHA) hospitals from 2000 through 2010.
• Methods: Data from all hospitalizations were collected from January 2000 through December 2010. Blood bank data (including the type and volume of products administered) were available electronically from each hospital. These files were linked to inpatient data, which included ICD-9-CM diagnoses (principal and secondary) and procedures during hospitalization. Statistical analyses were conducted using generalized linear models to evaluate trends over time. The unit of observation was hospitalization, with categorization by type.
• Results: There were 176,521 hospitalizations in 69,621 patients; of these, 13.6% of hospitalizations involved transfusion of blood products (12.7% RBCs, 1.4% platelets, 3.0% plasma). Transfusion occurred in 25.2% of surgical and 5.3% of medical hospitalizations. Transfusion use peaked in 2002 for surgical hospitalizations and declined afterwards (P < 0.001). There was no significant change in transfusion use over time (P = 0.126) for medical hospitalizations. In hospitalizations that involved transfusions, there was a 20.3% reduction in the proportion of hospitalizations in which ≥ 3 units of RBCs were given (from 51.7% to 41.1%; P < 0.001) and a 73.6% increase when 1 RBC unit was given (from 8.0% to 13.8%; P < 0.001) from 2000-2010. Of the hospitalizations with RBC transfusion, 9.6% involved the use of 1 unit over the entire study period. The most common principal diagnoses for medical patients receiving transfusion were anemia, malignancy, heart failure, pneumonia and renal failure. Over time, transfusion utilization increased in patients who were admitted for infection (P = 0.009).
• Conclusion: Blood transfusions in 3 VHA hospitals have decreased over time for surgical patients but remained the same for medical patients. Further study examining appropriateness of blood products in medical patients appears necessary.

Key words: Transfusion; red blood cells; plasma; platelets; veterans.

Transfusion practices during hospitalization have changed considerably over the past 2 decades. Guided by evidence from randomized controlled trials, patient blood management programs have been expanded [1]. Such programs include recommendations regarding minimization of blood loss during surgery, prevention and treatment of anemia, strategies for reducing transfusions in both medical and surgical patients, improved blood utilization, education of health professionals, and standardization of blood management-related metrics [2]. Some of the guidelines have been incorporated into the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, including: (a) don’t transfuse more units of blood than absolutely necessary, (b) don’t transfuse red blood cells for iron deficiency without hemodynamic instability, (c) don’t routinely use blood products to reverse warfarin, and (d) don’t perform serial blood counts on clinically stable patients [3]. Although there has been growing interest in blood management, only 37.8% of the 607 AABB (formerly, American Association of Blood Banks) facilities in the United States reported having a patient blood management program in 2013 [2].

While the importance of blood safety is recognized, data regarding the overall trends in practices are conflicting. A study using the Nationwide Inpatient Sample indicated that there was a 5.6% annual mean increase in the transfusion of blood products from 2002 to 2011 in the United States [4]. This contrasts with the experience of Kaiser Permanente in Northern California, in which the incidence of RBC transfusion decreased by 3.2% from 2009 to 2013 [5]. A decline in rates of intraoperative transfusion was also reported among elderly veterans in the United States from 1997 to 2009 [6].

We conducted a study in hospitalized veterans with 2 main objectives: (a) to evaluate trends in utilization of red blood cells (RBCs), platelets, and plasma over time, and (b) to identify those groups of veterans who received specific blood products. We were particularly interested in transfusion use in medical patients.

Methods

Participants were hospitalized veterans at 3 Department of Veterans Affairs (VA) medical centers. Data from all hospitalizations were collected from January 2000 through December 2010. Blood bank data (including the type and volume of products administered) were available electronically from each hospital. These files were linked to inpatient data, which included ICD-9-CM diagnoses (principal and secondary) and procedures during hospitalization.

Statistical analyses were conducted using generalized linear models to evaluate trends over time. The unit of observation was hospitalization, with categorization by type. Surgical hospitalizations were defined as admissions in which any surgical procedure occurred, whereas medical hospitalizations were defined as admissions without any surgery. Alpha was set at 0.05, 2-tailed. All analyses were conducted in Stata/MP 14.1 (StataCorp, College Station, TX). The study received institutional review board approval from the VA Ann Arbor Healthcare System.

Results

From 2000 through 2010, there were 176,521 hospitalizations in 69,621 patients. Within this cohort, 6% were < 40 years of age, 66% were 40 to 69 years of age, and 28% were 70 years or older at the time of admission. In this cohort, 96% of patients were male. Overall, 13.6% of all hospitalizations involved transfusion of a blood product (12.7% RBCs, 1.4% platelets, 3.0% plasma).

Transfusion occurred in 25.2% of surgical hospitalizations and 5.3% of medical hospitalizations. For surgical hospitalizations, transfusion use peaked in 2002 (when 30.9% of the surgical hospitalizations involved a trans-fusion) and significantly declined afterwards (P < 0.001). By 2010, 22.5% of the surgical hospitalizations involved a transfusion. Most of the surgeries where blood products were transfused involved cardiovascular procedures. For medical hospitalizations only, there was no significant change in transfusion use over time, either from 2000 to 2010 (P = 0.126) or from 2002 to 2010 (P = 0.072). In 2010, 5.2% of the medical hospitalizations involved a transfusion.

Rates of transfusion varied by principal diagnosis (Figure 1). For patients admitted with a principal diagnosis of infection (n = 20,981 hospitalizations), there was an increase in the percentage of hospitalizations in which transfusions (RBCs, platelet, plasma) were administered over time (P = 0.009) (Figure 1). For patients admitted with a principal diagnosis of malignancy (n = 12,904 hospitalizations), cardiovascular disease (n = 40,324 hospitalizations), and other diagnoses (n = 102,312 hospitalizations), there were no significant linear trends over the entire study period (P = 0.191, P = 0.052, P = 0.314, respectively). Rather, blood utilization peaked in year 2002 and significantly declined afterwards for patients admitted for malignancy (P < 0.001) and for cardiovascular disease (P < 0.001).

The most common principal diagnoses for medical patients receiving any transfusion (RBCs, platelet, plasma) are listed in Table 1. For medical patients with a principal diagnosis of anemia, 88% of hospitalizations involved a transfusion (Table 1). Transfusion occurred in 6% to 11% of medical hospitalizations with malignancies, heart failure, pneumonia or renal failure (Table 1). A considerable proportion (43%) of medical patients with gastrointestinal hemorrhage received a transfusion.

Discussion

We also observed secular trends in the volume of RBCs administered. There was an increase in the percentage of hospitalizations in which 1 or 2 RBC units were used and a decline in transfusion of 3 or more units. The reduction in the use of 3 or more RBC units may reflect the adoption and integration of recommendations in patient blood management by clinicians,

which encourage assessment of the patients’ symptoms in determining whether additional units are necessary [7]. Such guidelines also endorse the avoidance of routine
administration of 2 units of RBCs if 1 unit is sufficient [8]. We have previously shown that, after coronary artery bypass grafting, 2 RBC units doubled the risk of pneumonia [9]; additional analyses indicated that 1 or 2 units of RBCs were associated with increased postoperative morbidity [10]. In addition, our previous research indicated that the probability of infection increased considerably between 1 and 2 RBC units, with a more gradual increase beyond 2 units [11]. With this evidence in mind, some studies at single sites have reported that there was a dramatic decline from 2 RBC units before initiation of patient blood management programs to 1 unit after the programs were implemented [12,13].

Medical patients who received a transfusion were often admitted for reason of anemia, cancer, organ failure, or pneumonia. Some researchers are now reporting that blood use, at certain sites, is becoming more common in medical rather than surgical patients, which may be due to an expansion of patient blood management procedures in surgery [16]. There are a substantial number of patient blood management programs among surgical specialties and their adoption has expanded [17]. Although there are fewer patient blood management programs in the nonsurgical setting, some have been targeted to internal medicine physicians and specifically, to hospitalists [1,18]. For example, a toolkit from the Society of Hospital Medicine centers on anemia management and includes anemia assessment, treatment, evaluation of RBC transfusion risk, blood conservation, optimization of coagulation, and patient-centered decision-making [19]. Additionally, bundling of patient blood management strategies has been launched to help encourage a wider adoption of such programs [20].

While guidelines regarding use of RBCs are becoming increasingly recognized, recommendations for the use of platelets and plasma are hampered by the paucity of evidence from randomized controlled trials [21,22]. There is moderate-quality evidence for the use of platelets with therapy-induced hypoproliferative thrombocytopenia in hospitalized patients [21], but low quality evidence for other uses. Moreover, a recent review of plasma transfusion in bleeding patients found no randomized controlled trials on plasma use in hospitalized patients, although several trials were currently underway [22].

Our findings need to be considered in the context of the following limitations. The data were from 3 VA hospitals, so the results may not reflect patterns of usage at other hospitals. However, AABB reports that there has been a general decrease in transfusion of allogeneic whole blood and RBC units since 2008 at the AABB-affiliated sites in the United States [2]; this is similar to the pattern that we observed in surgical patients. In addition, we report an overall view of trends without having details regarding which specific factors influenced changes in transfusion during this 11-year period. It is possible that the severity of hospitalized patients may have changed with time which could have influenced decisions regarding the need for transfusion.

In conclusion, the use of blood products decreased in surgical patients since 2002 but remained the same in medical patients in this VA population. Transfusions increased over time for patients who were admitted to the hospital for reason of infection, but decreased since 2002 for those admitted for cardiovascular disease or cancer. The number of RBC units per hospitalization decreased over time. Additional surveillance is needed to determine whether recent evidence regarding blood management has been incorporated into clinical practice for medical patients, as we strive to deliver optimal care to our veterans.

Corresponding author: Mary A.M. Rogers, PhD, MS, Dept. of Internal Medicine, Univ. of Michigan, 016-422W NCRC, Ann Arbor, MI 48109-2800, [email protected].

Funding/support: Department of Veterans Affairs, Clinical Sciences Research & Development Service Merit Review Award (EPID-011-11S). The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

Financial disclosures: None.

Author contributions: conception and design, MAMR, SS; analysis and interpretation of data, MAMR, JDB, DR, LK, SS; drafting of article, MAMR; critical revision of the article, MAMR, MTG, DR, LK, SS, VC; statistical expertise, MAMR, DR; obtaining of funding, MTG, SS, VC; administrative or technical support, MTG, LK, SS, VC; collection and assembly of data, JDB, LK.

CASE A surgeon's story of patient loss

It was a Wednesday morning and Ms. M was my first case of the day. I knew her well, having delivered her 2 children. Now she had a 7-cm complex cyst on her right ovary, she was in pain, and she was possibly experiencing ovarian torsion. My resident took care of the paperwork, I met the patient in preop, answered her few questions, and reassured her husband that I would call him as soon as surgery was over. She was rolled to the operating room.

When I entered the OR, Ms. M was under general anesthesia, draped, and placed on the operating table in the usual position. I made a 5-mm incision at the umbilicus and inserted the trocar under direct visualization. There was blood and the camera became blurry. I removed the camera to clean it, and the anesthesiologist alerted me that there was sudden hypotension. I reinserted the camera and saw blood in the abdomen. I feared the worst—major vessel injury. I requested a scalpel and made a midline skin sub–umbilical incision, entered the peritoneal cavity, and observed blood everywhere. The massive transfusion protocol was activated and vascular surgery was called in. I could not find the source of the bleeding. Using a laparotomy towel I applied pressure on the aorta. The vascular surgeon arrived and pushed my resident away. He identified the source of the bleeding: The right common iliac artery was injured.

The patient coded, the anesthesiologist initiated CPR, bleeding continued, blood was being transfused, and after 20 long minutes of CPR the lifeless body of my patient could not hold any more. She was pronounced dead on the table.

At that moment, there were multiple victims: Ms. M lying on the surgical table; her family members, who did not know what was happening; and the surgical team members, who were looking at each other in denial and feeling that we had failed this patient, hoping that we would wake up from this nightmare.

Defining patient harm

Many patients experience harm each year because of an adverse medical event or preventable medical error.¹ A 2013 report revealed that 210,000 to 440,000 deaths occur each year in the United States related to preventable patient harm.² Although this fact is deeply disturbing, it is well known that modern health care is a high-risk industry.

Medical errors vary in terms of the degree of potential or actual damage. A “near miss” is any event that could have resulted in adverse consequences but did not (for example, an incorrect drug or dose ordered but not administered). On the other hand, an “adverse event” describes an error that resulted in some degree of patient harm or suffering.³

Related article:
Medical errors: Meeting ethical obligations and reducing liability with proper communication

For each patient who dies because of a medical error or a surgical complication, whether preventable or not, many clinicians are involved in the unfolding of the case. These events have a profound impact on well-intentioned, competent, and caring physicians, and they elicit intense emotional responses.⁴ When a patient experiences an unexpected adverse surgical outcome, the surgeons involved in their care may become “second victims.” They may feel that they have failed the patient and they second-guess their surgical skills and knowledge base; some express concern about their reputation and perhaps career choice.

Psychological responses. It is importantto understand this process to ensure a healthy recovery. Psychological responses to an adverse medical event include guilt; distress, anxiety, and fear; frustration and anger; feelings of insufficiency; and long-standing suffering. Clinicians who experienced an adverse medical event have reported additional psychological as well as physical symptoms in the aftermath of the event (TABLE 1).⁵

Risk factors. Certain factors are associated with a greater emotional impact of an adverse medical event, including⁶:

• severity of the harm or leaving permanent sequelae
• death of a healthy patient or a child (for example, from a motor vehicle accident)
• self-blame for the error
• unexpected patient death (for example, a catastrophic complication after a relatively benign procedure)
• physicians-in-training responsible for the patient
• first death under a clinician’s watch.

While most research in the field of medical error focuses on systems or process improvement, it is important not to neglect the individual and personal aspects of the clinicians involved in the event. The health care system must include care for our injured colleagues, the so-called second victims.

Read about the steps to recovery for the second victim.

Steps in recovery for the second victim

Based on a semistructured interview of 31 physicians involved in adverse events, Scott and colleagues described the following 6 stages of healing⁵:

Chaos and accident response. Immediately after the event, the physician feels a sense of confusion, panic, and denial. How can this be happening to me? The physician is frequently distracted, immersed in self-reflection.

Intrusive reflections. This is a period of self-questioning. Thoughts of the event and different possible scenarios dominate the physician’s mind. What if I had done this or that?

Restoring personal integrity. During this phase, the physician seeks support from individuals with whom trusted relationships exist, such as colleagues, peers, close friends, and family members. Advice from a colleague who has your same level of expertise is precious. The second victim often fears that friends and family will not be understanding.

Enduring the inquisition. Root cause analysis and in-depth case review is an important part of the quality improvement process after an adverse event. A debriefing or departmental morbidity and mortality conference can trigger emotions and increase the sense of shame, guilt, and self-doubt. The second victim starts to wonder about repercussions that may affect job security, licensure, and future litigation.

Obtaining emotional first aid. At this stage, the second victim begins to heal, but it is important to obtain external help from a colleague, mentor, counselor, department chair, or loved ones. Many physicians express concerns about not knowing who is a “safe person” to trust in this situation. Often, second victims perceive that their loved ones just do not understand their professional life or should be protected from this situation.

Moving on. There is an urge to move forward with life and simply put the event behind. This is difficult, however. A second victim may follow one of these paths:

• drop out—stop practicing clinical medicine
• survive—maintain the same career but with significant residual emotional burden from the event
• thrive—make something good out of the unfortunate clinical experience.

Related article:
TRUST: How to build a support net for ObGyns affected by a medical error

All these programs offer immediate help to any clinician in psychological distress. They provide confidentiality, and the individual is reassured that he or she can safely use the service without further consequences (TABLE 2).¹⁰

The normal human response to an adverse medical event can lead to significant psychological consequences, long-term emotional incapacity, impaired performance of clinical care, and feelings of guilt, fear, isolation, or even suicide. At some point during his or her career, almost every physician will be involved in a serious adverse medical event and is at risk of experiencing strong emotional reactions. Health care facilities should have a support system in place to help clinicians cope with these stressful circumstances.

Use these 5 strategies to facilitate recovery

1. Be determined. No matter how bad you feel about the event, you need to get up and moving.
2. Avoid isolation. Get outside and interact with people. Avoid long periods in isolation. Bring your team together and talk about the event.
3. Sleep well. Most symptoms of posttraumatic stress disorder occur at night. If you have trouble falling asleep or you wake up in the middle of the night with nightmares related to the event, attempt to regulate your body’s sleep schedule. Seek professional help if needed.
4. Avoid negative coping habits. Sometimes people turn to alcohol, cigarettes, food, or drugs to cope. Although these strategies may help in the short term, they will do more harm than good over time.
5. Enroll in activities that provide positive distraction. While the mind focuses on the traumatic event (this is normal), you need to get busy with such positive distractions as sports, going to the movies, and engaging in outdoor activities. Do things that you enjoy.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE A surgeon's story of patient loss

It was a Wednesday morning and Ms. M was my first case of the day. I knew her well, having delivered her 2 children. Now she had a 7-cm complex cyst on her right ovary, she was in pain, and she was possibly experiencing ovarian torsion. My resident took care of the paperwork, I met the patient in preop, answered her few questions, and reassured her husband that I would call him as soon as surgery was over. She was rolled to the operating room.

When I entered the OR, Ms. M was under general anesthesia, draped, and placed on the operating table in the usual position. I made a 5-mm incision at the umbilicus and inserted the trocar under direct visualization. There was blood and the camera became blurry. I removed the camera to clean it, and the anesthesiologist alerted me that there was sudden hypotension. I reinserted the camera and saw blood in the abdomen. I feared the worst—major vessel injury. I requested a scalpel and made a midline skin sub–umbilical incision, entered the peritoneal cavity, and observed blood everywhere. The massive transfusion protocol was activated and vascular surgery was called in. I could not find the source of the bleeding. Using a laparotomy towel I applied pressure on the aorta. The vascular surgeon arrived and pushed my resident away. He identified the source of the bleeding: The right common iliac artery was injured.

The patient coded, the anesthesiologist initiated CPR, bleeding continued, blood was being transfused, and after 20 long minutes of CPR the lifeless body of my patient could not hold any more. She was pronounced dead on the table.

At that moment, there were multiple victims: Ms. M lying on the surgical table; her family members, who did not know what was happening; and the surgical team members, who were looking at each other in denial and feeling that we had failed this patient, hoping that we would wake up from this nightmare.

Defining patient harm

Many patients experience harm each year because of an adverse medical event or preventable medical error.¹ A 2013 report revealed that 210,000 to 440,000 deaths occur each year in the United States related to preventable patient harm.² Although this fact is deeply disturbing, it is well known that modern health care is a high-risk industry.

Medical errors vary in terms of the degree of potential or actual damage. A “near miss” is any event that could have resulted in adverse consequences but did not (for example, an incorrect drug or dose ordered but not administered). On the other hand, an “adverse event” describes an error that resulted in some degree of patient harm or suffering.³

Related article:
Medical errors: Meeting ethical obligations and reducing liability with proper communication

For each patient who dies because of a medical error or a surgical complication, whether preventable or not, many clinicians are involved in the unfolding of the case. These events have a profound impact on well-intentioned, competent, and caring physicians, and they elicit intense emotional responses.⁴ When a patient experiences an unexpected adverse surgical outcome, the surgeons involved in their care may become “second victims.” They may feel that they have failed the patient and they second-guess their surgical skills and knowledge base; some express concern about their reputation and perhaps career choice.

Psychological responses. It is importantto understand this process to ensure a healthy recovery. Psychological responses to an adverse medical event include guilt; distress, anxiety, and fear; frustration and anger; feelings of insufficiency; and long-standing suffering. Clinicians who experienced an adverse medical event have reported additional psychological as well as physical symptoms in the aftermath of the event (TABLE 1).⁵

Risk factors. Certain factors are associated with a greater emotional impact of an adverse medical event, including⁶:

• severity of the harm or leaving permanent sequelae
• death of a healthy patient or a child (for example, from a motor vehicle accident)
• self-blame for the error
• unexpected patient death (for example, a catastrophic complication after a relatively benign procedure)
• physicians-in-training responsible for the patient
• first death under a clinician’s watch.

While most research in the field of medical error focuses on systems or process improvement, it is important not to neglect the individual and personal aspects of the clinicians involved in the event. The health care system must include care for our injured colleagues, the so-called second victims.

Read about the steps to recovery for the second victim.

Steps in recovery for the second victim

Based on a semistructured interview of 31 physicians involved in adverse events, Scott and colleagues described the following 6 stages of healing⁵:

Chaos and accident response. Immediately after the event, the physician feels a sense of confusion, panic, and denial. How can this be happening to me? The physician is frequently distracted, immersed in self-reflection.

Intrusive reflections. This is a period of self-questioning. Thoughts of the event and different possible scenarios dominate the physician’s mind. What if I had done this or that?

Restoring personal integrity. During this phase, the physician seeks support from individuals with whom trusted relationships exist, such as colleagues, peers, close friends, and family members. Advice from a colleague who has your same level of expertise is precious. The second victim often fears that friends and family will not be understanding.

Enduring the inquisition. Root cause analysis and in-depth case review is an important part of the quality improvement process after an adverse event. A debriefing or departmental morbidity and mortality conference can trigger emotions and increase the sense of shame, guilt, and self-doubt. The second victim starts to wonder about repercussions that may affect job security, licensure, and future litigation.

Obtaining emotional first aid. At this stage, the second victim begins to heal, but it is important to obtain external help from a colleague, mentor, counselor, department chair, or loved ones. Many physicians express concerns about not knowing who is a “safe person” to trust in this situation. Often, second victims perceive that their loved ones just do not understand their professional life or should be protected from this situation.

Moving on. There is an urge to move forward with life and simply put the event behind. This is difficult, however. A second victim may follow one of these paths:

• drop out—stop practicing clinical medicine
• survive—maintain the same career but with significant residual emotional burden from the event
• thrive—make something good out of the unfortunate clinical experience.

Related article:
TRUST: How to build a support net for ObGyns affected by a medical error

All these programs offer immediate help to any clinician in psychological distress. They provide confidentiality, and the individual is reassured that he or she can safely use the service without further consequences (TABLE 2).¹⁰

The normal human response to an adverse medical event can lead to significant psychological consequences, long-term emotional incapacity, impaired performance of clinical care, and feelings of guilt, fear, isolation, or even suicide. At some point during his or her career, almost every physician will be involved in a serious adverse medical event and is at risk of experiencing strong emotional reactions. Health care facilities should have a support system in place to help clinicians cope with these stressful circumstances.

Use these 5 strategies to facilitate recovery

1. Be determined. No matter how bad you feel about the event, you need to get up and moving.
2. Avoid isolation. Get outside and interact with people. Avoid long periods in isolation. Bring your team together and talk about the event.
3. Sleep well. Most symptoms of posttraumatic stress disorder occur at night. If you have trouble falling asleep or you wake up in the middle of the night with nightmares related to the event, attempt to regulate your body’s sleep schedule. Seek professional help if needed.
4. Avoid negative coping habits. Sometimes people turn to alcohol, cigarettes, food, or drugs to cope. Although these strategies may help in the short term, they will do more harm than good over time.
5. Enroll in activities that provide positive distraction. While the mind focuses on the traumatic event (this is normal), you need to get busy with such positive distractions as sports, going to the movies, and engaging in outdoor activities. Do things that you enjoy.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE A surgeon's story of patient loss

It was a Wednesday morning and Ms. M was my first case of the day. I knew her well, having delivered her 2 children. Now she had a 7-cm complex cyst on her right ovary, she was in pain, and she was possibly experiencing ovarian torsion. My resident took care of the paperwork, I met the patient in preop, answered her few questions, and reassured her husband that I would call him as soon as surgery was over. She was rolled to the operating room.

When I entered the OR, Ms. M was under general anesthesia, draped, and placed on the operating table in the usual position. I made a 5-mm incision at the umbilicus and inserted the trocar under direct visualization. There was blood and the camera became blurry. I removed the camera to clean it, and the anesthesiologist alerted me that there was sudden hypotension. I reinserted the camera and saw blood in the abdomen. I feared the worst—major vessel injury. I requested a scalpel and made a midline skin sub–umbilical incision, entered the peritoneal cavity, and observed blood everywhere. The massive transfusion protocol was activated and vascular surgery was called in. I could not find the source of the bleeding. Using a laparotomy towel I applied pressure on the aorta. The vascular surgeon arrived and pushed my resident away. He identified the source of the bleeding: The right common iliac artery was injured.

The patient coded, the anesthesiologist initiated CPR, bleeding continued, blood was being transfused, and after 20 long minutes of CPR the lifeless body of my patient could not hold any more. She was pronounced dead on the table.

At that moment, there were multiple victims: Ms. M lying on the surgical table; her family members, who did not know what was happening; and the surgical team members, who were looking at each other in denial and feeling that we had failed this patient, hoping that we would wake up from this nightmare.

Defining patient harm

Many patients experience harm each year because of an adverse medical event or preventable medical error.¹ A 2013 report revealed that 210,000 to 440,000 deaths occur each year in the United States related to preventable patient harm.² Although this fact is deeply disturbing, it is well known that modern health care is a high-risk industry.

Medical errors vary in terms of the degree of potential or actual damage. A “near miss” is any event that could have resulted in adverse consequences but did not (for example, an incorrect drug or dose ordered but not administered). On the other hand, an “adverse event” describes an error that resulted in some degree of patient harm or suffering.³

Related article:
Medical errors: Meeting ethical obligations and reducing liability with proper communication

For each patient who dies because of a medical error or a surgical complication, whether preventable or not, many clinicians are involved in the unfolding of the case. These events have a profound impact on well-intentioned, competent, and caring physicians, and they elicit intense emotional responses.⁴ When a patient experiences an unexpected adverse surgical outcome, the surgeons involved in their care may become “second victims.” They may feel that they have failed the patient and they second-guess their surgical skills and knowledge base; some express concern about their reputation and perhaps career choice.

Psychological responses. It is importantto understand this process to ensure a healthy recovery. Psychological responses to an adverse medical event include guilt; distress, anxiety, and fear; frustration and anger; feelings of insufficiency; and long-standing suffering. Clinicians who experienced an adverse medical event have reported additional psychological as well as physical symptoms in the aftermath of the event (TABLE 1).⁵

Risk factors. Certain factors are associated with a greater emotional impact of an adverse medical event, including⁶:

• severity of the harm or leaving permanent sequelae
• death of a healthy patient or a child (for example, from a motor vehicle accident)
• self-blame for the error
• unexpected patient death (for example, a catastrophic complication after a relatively benign procedure)
• physicians-in-training responsible for the patient
• first death under a clinician’s watch.

While most research in the field of medical error focuses on systems or process improvement, it is important not to neglect the individual and personal aspects of the clinicians involved in the event. The health care system must include care for our injured colleagues, the so-called second victims.

Read about the steps to recovery for the second victim.

Steps in recovery for the second victim

Based on a semistructured interview of 31 physicians involved in adverse events, Scott and colleagues described the following 6 stages of healing⁵:

Chaos and accident response. Immediately after the event, the physician feels a sense of confusion, panic, and denial. How can this be happening to me? The physician is frequently distracted, immersed in self-reflection.

Intrusive reflections. This is a period of self-questioning. Thoughts of the event and different possible scenarios dominate the physician’s mind. What if I had done this or that?

Restoring personal integrity. During this phase, the physician seeks support from individuals with whom trusted relationships exist, such as colleagues, peers, close friends, and family members. Advice from a colleague who has your same level of expertise is precious. The second victim often fears that friends and family will not be understanding.

Enduring the inquisition. Root cause analysis and in-depth case review is an important part of the quality improvement process after an adverse event. A debriefing or departmental morbidity and mortality conference can trigger emotions and increase the sense of shame, guilt, and self-doubt. The second victim starts to wonder about repercussions that may affect job security, licensure, and future litigation.

Obtaining emotional first aid. At this stage, the second victim begins to heal, but it is important to obtain external help from a colleague, mentor, counselor, department chair, or loved ones. Many physicians express concerns about not knowing who is a “safe person” to trust in this situation. Often, second victims perceive that their loved ones just do not understand their professional life or should be protected from this situation.

Moving on. There is an urge to move forward with life and simply put the event behind. This is difficult, however. A second victim may follow one of these paths:

• drop out—stop practicing clinical medicine
• survive—maintain the same career but with significant residual emotional burden from the event
• thrive—make something good out of the unfortunate clinical experience.

Related article:
TRUST: How to build a support net for ObGyns affected by a medical error

All these programs offer immediate help to any clinician in psychological distress. They provide confidentiality, and the individual is reassured that he or she can safely use the service without further consequences (TABLE 2).¹⁰

The normal human response to an adverse medical event can lead to significant psychological consequences, long-term emotional incapacity, impaired performance of clinical care, and feelings of guilt, fear, isolation, or even suicide. At some point during his or her career, almost every physician will be involved in a serious adverse medical event and is at risk of experiencing strong emotional reactions. Health care facilities should have a support system in place to help clinicians cope with these stressful circumstances.

Use these 5 strategies to facilitate recovery

1. Be determined. No matter how bad you feel about the event, you need to get up and moving.
2. Avoid isolation. Get outside and interact with people. Avoid long periods in isolation. Bring your team together and talk about the event.
3. Sleep well. Most symptoms of posttraumatic stress disorder occur at night. If you have trouble falling asleep or you wake up in the middle of the night with nightmares related to the event, attempt to regulate your body’s sleep schedule. Seek professional help if needed.
4. Avoid negative coping habits. Sometimes people turn to alcohol, cigarettes, food, or drugs to cope. Although these strategies may help in the short term, they will do more harm than good over time.
5. Enroll in activities that provide positive distraction. While the mind focuses on the traumatic event (this is normal), you need to get busy with such positive distractions as sports, going to the movies, and engaging in outdoor activities. Do things that you enjoy.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Take-Home Points

• In-office diagnostic needle arthroscopy is a minimally invasive, rapid method for identification of intra-articular joint pathology.
• Cost savings of a significant value can be realized to both the patient and healthcare system via small-bore needle arthroscopy as opposed to MRI.
• Diagnostic needle arthroscopy can lead to quicker identification of pathology than MRI.
• Diagnostic needle arthroscopy can reduce the number of undue "formal" surgical diagnostic arthroscopies.
• Standardization of image quality of small bore arthroscopy may pose benefits to the variable quality of MRI.

Patient satisfaction and healthcare costs have taken a leading role in today’s health care market. Patient satisfaction, often categorized as the "patient experience," can be measured on numerous levels, such as access to healthcare professionals and diagnostic testing, wait time for appointments, and timely test results. Furthermore, patients’ having a full understanding of their pathology and treatment options may correlate with their overall satisfaction. Some metrics are subjective, but procedure costs are objective.

The algorithm for treating patients who present with knee or shoulder pathology to an orthopedic office involves taking a thorough history, performing a physical examination, and, in many cases, obtaining diagnostic imaging. After arriving at a diagnosis, the physician plans the patient’s treatment. In most cases in which magnetic resonance imaging (MRI) is required, the process can take 2 to 3 weeks.¹

Surgical knee arthroscopy is one of the most common procedures in the United States.^2,3 Worldwide, more than 2 million knee arthroscopies are performed yearly.⁴ For most procedures, the decision to treat is based on physical examination findings, and the diagnosis is confirmed with MRI. MRI has 86% sensitivity and 91% specificity for diagnosing ligamentous and meniscal tears.⁵ However, regular use of MRI has led to increased healthcare expenditures and a larger financial burden for patients, which can delay diagnosis.⁶

Since 2000, MRI use in the United States has risen significantly—by 10% over a 10-year period.⁷ According to a 2013 population analysis, 107 in 1000 US inhabitants had an MRI yearly.⁸

MRI costs vary widely because of several factors, including state/regional consideration, scanning in a hospital or an independent facility, and use of contrast and arthrography. In a 2017 study of the variation in noncontrast MRI costs at 71 hospitals and 26 independent facilities in Iowa, Westermann and colleagues⁹ found that, excluding radiologist interpretation fees, the mean MRI technical component cost to consumers was US $1874 (SD, $694; range, $500-$4000).

Patient factors may preclude use of MRI (Table).

Small-bore needle arthroscopy is a cost-effective alternative diagnostic tool with efficacy and accuracy similar to those of MRI and standard arthroscopy for intra-articular pathologies.^6,11 The procedure is performed with a disposable handpiece equipped with an internal light source and optics; this handpiece attaches to a reusable tablet for ease of transportation and visualization (Figure 1).

In 2014, Voigt and colleagues⁶ reported a significant net healthcare system cost saving with use of a small-needle arthroscope for diagnostic testing. The saving was estimated at $115 million to $177 million for simple isolation of medial meniscus pathology—or, more specifically, for appropriate care after more accurate visualization with the diagnostic needle arthroscope coupled with a decrease in false positives compared with MRI use. Other factors include the economic impact of the patient’s lost work hours, often associated with the time off needed for the MRI and for the follow-up visit for review of results.

Methods

We retrospectively reviewed the patient charts for 200 in-office knee and shoulder diagnostic needle arthroscopies performed by 5 surgeons over a 12-month period and examined the costs. Medicare, Medicaid, worker’s compensation, self-pay, and motor vehicle cases were excluded to provide uniformity across commercial insurance payers. Only the reimbursement amounts for Current Procedural Terminology codes 29870 (diagnostic knee arthroscopy) and 29805 (diagnostic shoulder arthroscopy) were examined. Geographical differences in commercial payer reimbursements were considered. The 5 surgeons who submitted data for this study practice in different parts of the United States—the Northeast, the Mid-Atlantic, the Southeast, the Midwest, and the West Coast. Similarly, the costs of outpatient and inpatient MRI and MRA were reported by each physician based on regional rates. MRI reimbursement was considered only if the MRI magnet was 1.5 Tesla or stronger.

Results

We reviewed 200 (175 knee, 25 shoulder) in-office diagnostic needle arthroscopies of patients with commercial insurances. Average reimbursement was calculated across all commercial payers for both knee and shoulder arthroscopies (Figure 2).

For in-office diagnostic needle arthroscopy of the knee, average reimbursement was $628.92 (range, $340-$1391). For in-office diagnostic needle arthroscopy of the shoulder, average reimbursement was $492.38 (range, $471-$593). Outpatient MRI without contrast of the knee or shoulder averaged $1047 (range, $565-$2100) (Figure 3).

Discussion

Over the past decade, the combination of health and economics has often driven patient care and consumer demand. With rising deductibles and variations in secondary insurance carriers, patients often base healthcare decisions on their financial impact. Conversely, physicians are often in the difficult position of treating patients who are hesitant to obtain medical imaging out of financial concern. In addition, physicians and patients routinely are concerned about delays in care and timely reporting of test results. A patient’s ability to quickly obtain test results and start a course of definitive treatment may affect the patient’s perception of the overall healthcare experience with the physician, as has been noted in popular healthcare polls, such as Press-Ganey.¹³

Diagnostic needle arthroscopy performed in an office can yield a cost saving over MRI. Our review revealed in-office needle arthroscopy of the knee provided an average cost saving of $418.08 over standard MRI performed in an outpatient facility (Figure 3). That saving more than doubled, to $961.08, when MRI was performed in a hospital. Similarly, in-office needle arthroscopy of the shoulder provided an average cost saving of $554.62 over standard MRI. This saving also increased substantially, to $1097.62, over hospital MRI. An additional cost saving of $100 to $350 was found for knee or shoulder diagnostic needle arthroscopy over MRA.

Other factors affect the economic benefit of diagnostic needle arthroscopy over standard MRI. Having the procedure performed the same day as the presenting office visit can save the patient time and allow the physician to create a medical treatment plan sooner. In addition, the patient (and the insurance company) can save costs by avoiding a later office visit for review of MRI findings. Time spent going to MRI follow-up visits potentially can be analyzed as lost wages or as time lost from other segments of life. For the patient, this time can be defined as value hours. Last, there is a cost saving in avoiding nonoperative treatments in cases in which the initial definitive diagnosis would have called for surgical intervention. Accordingly, for patients who cannot undergo MRI, obtaining information on intra-articular pathology in the office may also decrease unnecessary "traditional" diagnostic arthroscopy in the operating room. Therefore, patients who do not require true formal arthroscopy to determine lack of pertinent intra-articular pathology can avoid unnecessary anesthesia, time off work, and associated healthcare expenses.

This study had several limitations. First, evaluating more cases would have increased the strength of the findings. Second, the large number of knee cases relative to shoulder cases may have been a by-product of the practice makeup of the surgeons rather than a matter of preference with this relatively new technology. However, the significant gap in cost savings between needle arthroscope and MRI cannot be discounted, and it provides a window on the potential cost savings the healthcare system can realize. Furthermore, analysis of payments made by the commercial payers in each state may have revealed a reimbursement fluctuation. The largest challenge in this study was the extreme variation in MRI costs. According to the literature, MRI of the upper or lower extremity ranges in cost from $500 to $4000.⁴ In addition, this cost is often negotiated between the patient and the MRI facility if the patient is willing to work outside insurance, which potentially can alter the overall average MRI cost.

The last points to consider are the reliability of users and the reproducibility of in-office diagnostic needle arthroscopy. Much as with true surgical arthroscopy and other diagnostic imaging practices, this procedure has a learning curve. We know that the number of successful diagnoses will increase with training and repetition, but so far there are no data on the number of procedures needed for proficiency. However, diagnostic needle arthroscopy images are of high quality and are static across users (Figures 5A, 5B). By contrast, the quality of MRI in the United States varies with the quality of the magnets used in individual facilities.

Conclusion

In-office diagnostic needle arthroscopy is a cost-effective and reproducible procedure with potential cost and quality-of-life benefits for commercial payers and patients. Although further study of long-term cost savings for the health care system is needed, significant value was realized in this 200-patient retrospective review. Minimum savings of $418 and $554.62 were realized for noncontrast knee and shoulder MRIs, respectively, in independent facilities. Those cost savings more than doubled in hospital-based facilities: $961.08 and $1097.62, respectively, for knee and shoulder noncontrast MRIs.

For More on In-office Arthroscopy...

Don’t miss Dr. Sean McMillan’s “Innovative Technique Update: In-Office Arthroscopy: My Technique and Results” at the upcoming Innovative Techniques® Knee, Hip, and Shoulder Course in Las Vegas. 29.5 CME/MOC available. Learn more

Take-Home Points

• In-office diagnostic needle arthroscopy is a minimally invasive, rapid method for identification of intra-articular joint pathology.
• Cost savings of a significant value can be realized to both the patient and healthcare system via small-bore needle arthroscopy as opposed to MRI.
• Diagnostic needle arthroscopy can lead to quicker identification of pathology than MRI.
• Diagnostic needle arthroscopy can reduce the number of undue "formal" surgical diagnostic arthroscopies.
• Standardization of image quality of small bore arthroscopy may pose benefits to the variable quality of MRI.

Patient satisfaction and healthcare costs have taken a leading role in today’s health care market. Patient satisfaction, often categorized as the "patient experience," can be measured on numerous levels, such as access to healthcare professionals and diagnostic testing, wait time for appointments, and timely test results. Furthermore, patients’ having a full understanding of their pathology and treatment options may correlate with their overall satisfaction. Some metrics are subjective, but procedure costs are objective.

The algorithm for treating patients who present with knee or shoulder pathology to an orthopedic office involves taking a thorough history, performing a physical examination, and, in many cases, obtaining diagnostic imaging. After arriving at a diagnosis, the physician plans the patient’s treatment. In most cases in which magnetic resonance imaging (MRI) is required, the process can take 2 to 3 weeks.¹

Surgical knee arthroscopy is one of the most common procedures in the United States.^2,3 Worldwide, more than 2 million knee arthroscopies are performed yearly.⁴ For most procedures, the decision to treat is based on physical examination findings, and the diagnosis is confirmed with MRI. MRI has 86% sensitivity and 91% specificity for diagnosing ligamentous and meniscal tears.⁵ However, regular use of MRI has led to increased healthcare expenditures and a larger financial burden for patients, which can delay diagnosis.⁶

Since 2000, MRI use in the United States has risen significantly—by 10% over a 10-year period.⁷ According to a 2013 population analysis, 107 in 1000 US inhabitants had an MRI yearly.⁸

MRI costs vary widely because of several factors, including state/regional consideration, scanning in a hospital or an independent facility, and use of contrast and arthrography. In a 2017 study of the variation in noncontrast MRI costs at 71 hospitals and 26 independent facilities in Iowa, Westermann and colleagues⁹ found that, excluding radiologist interpretation fees, the mean MRI technical component cost to consumers was US $1874 (SD, $694; range, $500-$4000).

Patient factors may preclude use of MRI (Table).

Small-bore needle arthroscopy is a cost-effective alternative diagnostic tool with efficacy and accuracy similar to those of MRI and standard arthroscopy for intra-articular pathologies.^6,11 The procedure is performed with a disposable handpiece equipped with an internal light source and optics; this handpiece attaches to a reusable tablet for ease of transportation and visualization (Figure 1).

In 2014, Voigt and colleagues⁶ reported a significant net healthcare system cost saving with use of a small-needle arthroscope for diagnostic testing. The saving was estimated at $115 million to $177 million for simple isolation of medial meniscus pathology—or, more specifically, for appropriate care after more accurate visualization with the diagnostic needle arthroscope coupled with a decrease in false positives compared with MRI use. Other factors include the economic impact of the patient’s lost work hours, often associated with the time off needed for the MRI and for the follow-up visit for review of results.

Methods

We retrospectively reviewed the patient charts for 200 in-office knee and shoulder diagnostic needle arthroscopies performed by 5 surgeons over a 12-month period and examined the costs. Medicare, Medicaid, worker’s compensation, self-pay, and motor vehicle cases were excluded to provide uniformity across commercial insurance payers. Only the reimbursement amounts for Current Procedural Terminology codes 29870 (diagnostic knee arthroscopy) and 29805 (diagnostic shoulder arthroscopy) were examined. Geographical differences in commercial payer reimbursements were considered. The 5 surgeons who submitted data for this study practice in different parts of the United States—the Northeast, the Mid-Atlantic, the Southeast, the Midwest, and the West Coast. Similarly, the costs of outpatient and inpatient MRI and MRA were reported by each physician based on regional rates. MRI reimbursement was considered only if the MRI magnet was 1.5 Tesla or stronger.

Results

We reviewed 200 (175 knee, 25 shoulder) in-office diagnostic needle arthroscopies of patients with commercial insurances. Average reimbursement was calculated across all commercial payers for both knee and shoulder arthroscopies (Figure 2).

For in-office diagnostic needle arthroscopy of the knee, average reimbursement was $628.92 (range, $340-$1391). For in-office diagnostic needle arthroscopy of the shoulder, average reimbursement was $492.38 (range, $471-$593). Outpatient MRI without contrast of the knee or shoulder averaged $1047 (range, $565-$2100) (Figure 3).

Discussion

Over the past decade, the combination of health and economics has often driven patient care and consumer demand. With rising deductibles and variations in secondary insurance carriers, patients often base healthcare decisions on their financial impact. Conversely, physicians are often in the difficult position of treating patients who are hesitant to obtain medical imaging out of financial concern. In addition, physicians and patients routinely are concerned about delays in care and timely reporting of test results. A patient’s ability to quickly obtain test results and start a course of definitive treatment may affect the patient’s perception of the overall healthcare experience with the physician, as has been noted in popular healthcare polls, such as Press-Ganey.¹³

Diagnostic needle arthroscopy performed in an office can yield a cost saving over MRI. Our review revealed in-office needle arthroscopy of the knee provided an average cost saving of $418.08 over standard MRI performed in an outpatient facility (Figure 3). That saving more than doubled, to $961.08, when MRI was performed in a hospital. Similarly, in-office needle arthroscopy of the shoulder provided an average cost saving of $554.62 over standard MRI. This saving also increased substantially, to $1097.62, over hospital MRI. An additional cost saving of $100 to $350 was found for knee or shoulder diagnostic needle arthroscopy over MRA.

Other factors affect the economic benefit of diagnostic needle arthroscopy over standard MRI. Having the procedure performed the same day as the presenting office visit can save the patient time and allow the physician to create a medical treatment plan sooner. In addition, the patient (and the insurance company) can save costs by avoiding a later office visit for review of MRI findings. Time spent going to MRI follow-up visits potentially can be analyzed as lost wages or as time lost from other segments of life. For the patient, this time can be defined as value hours. Last, there is a cost saving in avoiding nonoperative treatments in cases in which the initial definitive diagnosis would have called for surgical intervention. Accordingly, for patients who cannot undergo MRI, obtaining information on intra-articular pathology in the office may also decrease unnecessary "traditional" diagnostic arthroscopy in the operating room. Therefore, patients who do not require true formal arthroscopy to determine lack of pertinent intra-articular pathology can avoid unnecessary anesthesia, time off work, and associated healthcare expenses.

This study had several limitations. First, evaluating more cases would have increased the strength of the findings. Second, the large number of knee cases relative to shoulder cases may have been a by-product of the practice makeup of the surgeons rather than a matter of preference with this relatively new technology. However, the significant gap in cost savings between needle arthroscope and MRI cannot be discounted, and it provides a window on the potential cost savings the healthcare system can realize. Furthermore, analysis of payments made by the commercial payers in each state may have revealed a reimbursement fluctuation. The largest challenge in this study was the extreme variation in MRI costs. According to the literature, MRI of the upper or lower extremity ranges in cost from $500 to $4000.⁴ In addition, this cost is often negotiated between the patient and the MRI facility if the patient is willing to work outside insurance, which potentially can alter the overall average MRI cost.

The last points to consider are the reliability of users and the reproducibility of in-office diagnostic needle arthroscopy. Much as with true surgical arthroscopy and other diagnostic imaging practices, this procedure has a learning curve. We know that the number of successful diagnoses will increase with training and repetition, but so far there are no data on the number of procedures needed for proficiency. However, diagnostic needle arthroscopy images are of high quality and are static across users (Figures 5A, 5B). By contrast, the quality of MRI in the United States varies with the quality of the magnets used in individual facilities.

Conclusion

In-office diagnostic needle arthroscopy is a cost-effective and reproducible procedure with potential cost and quality-of-life benefits for commercial payers and patients. Although further study of long-term cost savings for the health care system is needed, significant value was realized in this 200-patient retrospective review. Minimum savings of $418 and $554.62 were realized for noncontrast knee and shoulder MRIs, respectively, in independent facilities. Those cost savings more than doubled in hospital-based facilities: $961.08 and $1097.62, respectively, for knee and shoulder noncontrast MRIs.

For More on In-office Arthroscopy...

Don’t miss Dr. Sean McMillan’s “Innovative Technique Update: In-Office Arthroscopy: My Technique and Results” at the upcoming Innovative Techniques® Knee, Hip, and Shoulder Course in Las Vegas. 29.5 CME/MOC available. Learn more

Take-Home Points

• In-office diagnostic needle arthroscopy is a minimally invasive, rapid method for identification of intra-articular joint pathology.
• Cost savings of a significant value can be realized to both the patient and healthcare system via small-bore needle arthroscopy as opposed to MRI.
• Diagnostic needle arthroscopy can lead to quicker identification of pathology than MRI.
• Diagnostic needle arthroscopy can reduce the number of undue "formal" surgical diagnostic arthroscopies.
• Standardization of image quality of small bore arthroscopy may pose benefits to the variable quality of MRI.

Patient satisfaction and healthcare costs have taken a leading role in today’s health care market. Patient satisfaction, often categorized as the "patient experience," can be measured on numerous levels, such as access to healthcare professionals and diagnostic testing, wait time for appointments, and timely test results. Furthermore, patients’ having a full understanding of their pathology and treatment options may correlate with their overall satisfaction. Some metrics are subjective, but procedure costs are objective.

The algorithm for treating patients who present with knee or shoulder pathology to an orthopedic office involves taking a thorough history, performing a physical examination, and, in many cases, obtaining diagnostic imaging. After arriving at a diagnosis, the physician plans the patient’s treatment. In most cases in which magnetic resonance imaging (MRI) is required, the process can take 2 to 3 weeks.¹

Surgical knee arthroscopy is one of the most common procedures in the United States.^2,3 Worldwide, more than 2 million knee arthroscopies are performed yearly.⁴ For most procedures, the decision to treat is based on physical examination findings, and the diagnosis is confirmed with MRI. MRI has 86% sensitivity and 91% specificity for diagnosing ligamentous and meniscal tears.⁵ However, regular use of MRI has led to increased healthcare expenditures and a larger financial burden for patients, which can delay diagnosis.⁶

Since 2000, MRI use in the United States has risen significantly—by 10% over a 10-year period.⁷ According to a 2013 population analysis, 107 in 1000 US inhabitants had an MRI yearly.⁸

MRI costs vary widely because of several factors, including state/regional consideration, scanning in a hospital or an independent facility, and use of contrast and arthrography. In a 2017 study of the variation in noncontrast MRI costs at 71 hospitals and 26 independent facilities in Iowa, Westermann and colleagues⁹ found that, excluding radiologist interpretation fees, the mean MRI technical component cost to consumers was US $1874 (SD, $694; range, $500-$4000).

Patient factors may preclude use of MRI (Table).

Small-bore needle arthroscopy is a cost-effective alternative diagnostic tool with efficacy and accuracy similar to those of MRI and standard arthroscopy for intra-articular pathologies.^6,11 The procedure is performed with a disposable handpiece equipped with an internal light source and optics; this handpiece attaches to a reusable tablet for ease of transportation and visualization (Figure 1).

In 2014, Voigt and colleagues⁶ reported a significant net healthcare system cost saving with use of a small-needle arthroscope for diagnostic testing. The saving was estimated at $115 million to $177 million for simple isolation of medial meniscus pathology—or, more specifically, for appropriate care after more accurate visualization with the diagnostic needle arthroscope coupled with a decrease in false positives compared with MRI use. Other factors include the economic impact of the patient’s lost work hours, often associated with the time off needed for the MRI and for the follow-up visit for review of results.

Methods

We retrospectively reviewed the patient charts for 200 in-office knee and shoulder diagnostic needle arthroscopies performed by 5 surgeons over a 12-month period and examined the costs. Medicare, Medicaid, worker’s compensation, self-pay, and motor vehicle cases were excluded to provide uniformity across commercial insurance payers. Only the reimbursement amounts for Current Procedural Terminology codes 29870 (diagnostic knee arthroscopy) and 29805 (diagnostic shoulder arthroscopy) were examined. Geographical differences in commercial payer reimbursements were considered. The 5 surgeons who submitted data for this study practice in different parts of the United States—the Northeast, the Mid-Atlantic, the Southeast, the Midwest, and the West Coast. Similarly, the costs of outpatient and inpatient MRI and MRA were reported by each physician based on regional rates. MRI reimbursement was considered only if the MRI magnet was 1.5 Tesla or stronger.

Results

We reviewed 200 (175 knee, 25 shoulder) in-office diagnostic needle arthroscopies of patients with commercial insurances. Average reimbursement was calculated across all commercial payers for both knee and shoulder arthroscopies (Figure 2).

For in-office diagnostic needle arthroscopy of the knee, average reimbursement was $628.92 (range, $340-$1391). For in-office diagnostic needle arthroscopy of the shoulder, average reimbursement was $492.38 (range, $471-$593). Outpatient MRI without contrast of the knee or shoulder averaged $1047 (range, $565-$2100) (Figure 3).

Discussion

Over the past decade, the combination of health and economics has often driven patient care and consumer demand. With rising deductibles and variations in secondary insurance carriers, patients often base healthcare decisions on their financial impact. Conversely, physicians are often in the difficult position of treating patients who are hesitant to obtain medical imaging out of financial concern. In addition, physicians and patients routinely are concerned about delays in care and timely reporting of test results. A patient’s ability to quickly obtain test results and start a course of definitive treatment may affect the patient’s perception of the overall healthcare experience with the physician, as has been noted in popular healthcare polls, such as Press-Ganey.¹³

Diagnostic needle arthroscopy performed in an office can yield a cost saving over MRI. Our review revealed in-office needle arthroscopy of the knee provided an average cost saving of $418.08 over standard MRI performed in an outpatient facility (Figure 3). That saving more than doubled, to $961.08, when MRI was performed in a hospital. Similarly, in-office needle arthroscopy of the shoulder provided an average cost saving of $554.62 over standard MRI. This saving also increased substantially, to $1097.62, over hospital MRI. An additional cost saving of $100 to $350 was found for knee or shoulder diagnostic needle arthroscopy over MRA.

Other factors affect the economic benefit of diagnostic needle arthroscopy over standard MRI. Having the procedure performed the same day as the presenting office visit can save the patient time and allow the physician to create a medical treatment plan sooner. In addition, the patient (and the insurance company) can save costs by avoiding a later office visit for review of MRI findings. Time spent going to MRI follow-up visits potentially can be analyzed as lost wages or as time lost from other segments of life. For the patient, this time can be defined as value hours. Last, there is a cost saving in avoiding nonoperative treatments in cases in which the initial definitive diagnosis would have called for surgical intervention. Accordingly, for patients who cannot undergo MRI, obtaining information on intra-articular pathology in the office may also decrease unnecessary "traditional" diagnostic arthroscopy in the operating room. Therefore, patients who do not require true formal arthroscopy to determine lack of pertinent intra-articular pathology can avoid unnecessary anesthesia, time off work, and associated healthcare expenses.

This study had several limitations. First, evaluating more cases would have increased the strength of the findings. Second, the large number of knee cases relative to shoulder cases may have been a by-product of the practice makeup of the surgeons rather than a matter of preference with this relatively new technology. However, the significant gap in cost savings between needle arthroscope and MRI cannot be discounted, and it provides a window on the potential cost savings the healthcare system can realize. Furthermore, analysis of payments made by the commercial payers in each state may have revealed a reimbursement fluctuation. The largest challenge in this study was the extreme variation in MRI costs. According to the literature, MRI of the upper or lower extremity ranges in cost from $500 to $4000.⁴ In addition, this cost is often negotiated between the patient and the MRI facility if the patient is willing to work outside insurance, which potentially can alter the overall average MRI cost.

The last points to consider are the reliability of users and the reproducibility of in-office diagnostic needle arthroscopy. Much as with true surgical arthroscopy and other diagnostic imaging practices, this procedure has a learning curve. We know that the number of successful diagnoses will increase with training and repetition, but so far there are no data on the number of procedures needed for proficiency. However, diagnostic needle arthroscopy images are of high quality and are static across users (Figures 5A, 5B). By contrast, the quality of MRI in the United States varies with the quality of the magnets used in individual facilities.

Conclusion

In-office diagnostic needle arthroscopy is a cost-effective and reproducible procedure with potential cost and quality-of-life benefits for commercial payers and patients. Although further study of long-term cost savings for the health care system is needed, significant value was realized in this 200-patient retrospective review. Minimum savings of $418 and $554.62 were realized for noncontrast knee and shoulder MRIs, respectively, in independent facilities. Those cost savings more than doubled in hospital-based facilities: $961.08 and $1097.62, respectively, for knee and shoulder noncontrast MRIs.

For More on In-office Arthroscopy...

Don’t miss Dr. Sean McMillan’s “Innovative Technique Update: In-Office Arthroscopy: My Technique and Results” at the upcoming Innovative Techniques® Knee, Hip, and Shoulder Course in Las Vegas. 29.5 CME/MOC available. Learn more

Take-Home Points

• Proper patient selection is critical as extensive postoperative rehabilitation is required to obtain an excellent outcome.
• Open and arthroscopic approaches are effective treatment options for elbow contractures.
• Elbow stability must be restored to obtain a successful outcome.
• Knowledge of neurovascular anatomy is essential to prevent neurologic complications.
• Prophylactic ulnar nerve release should be considered, especially in patients with limited flexion.

Elbow stiffness has several etiologies, posttraumatic being the most common. Elbow stiffness can have debilitating functional effects necessitating treatment. In a biomechanical study of normal elbow function, Morrey and colleagues¹ determined that a flexion extension arc of 100° (30°-130°) and a forearm rotation arc of 100° (50° pronation-50° supination) are required in 90% of activities of daily living. Similarly, elbow flexion of <105° was poorly tolerated, whereas patients could easier adapt to flexion contractures up to 40°.²

The goal of initial evaluation should be to establish the cause of the contracture and the patient’s functional demands and ability to cooperate in the extensive postoperative rehabilitation that is essential in achieving an excellent functional outcome. In a thorough clinical examination, the clinician must note skin, range of motion (ROM), ligamentous stability, and neurovascular structures and give special attention to ulnar nerve function and symptoms. Mid-arc pain suggests additional intra-articular pathology, as stiffness typically causes pain only at the limits of motion as osteophytes impinge and soft tissue is under maximal tension. Routine elbow radiographs are required in all cases, and computed tomography (CT) can be useful in evaluating osseous sources of contracture. Suspected ligamentous instability and cartilaginous defects particularly in the setting of mid-arc pain are best evaluated with magnetic resonance imaging.³

In this 5-point review, we evaluate treatment options as well as rehabilitation protocols in the management of elbow stiffness.

1 Anatomy of Contracture: The Usual Suspects

The cause of elbow stiffness is incompletely understood. Several posited contributing factors include biology, complex intra-articular anatomy, capsular distention favoring a flexed position, and tenuous postoperative fixation necessitating prolonged immobilization. Identifying intrinsic and extrinsic anatomical sources of stiffness can help guide treatment.⁴ Intrinsic pathology includes intra-articular malunion, osteophytes, loose bodies, and adhesions; extrinsic pathology includes soft-tissue contracture, heterotopic ossification, and extra-articular malunion.

Compared with the normal elbow, the capsule becomes thickened and fibrotic and thereby prevents motion. Severe contractures, and extension contractures in particular, may require release of the posterior medial capsule and the posterior medial collateral ligament (MCL) to regain motion. In a series of 42 patients with flexion <100°, Park and colleagues⁵ noted that all patients required release of the posterior band of the MCL to regain flexion. Other muscular impediments to motion include contracture of the brachialis and scarring of the triceps to the posterior humerus. Scarring of the triceps to the humerus can limit flexion.

In the posttrauma setting, intra-articular and extra-articular malunion must be considered. Extension malunion of the distal humerus can reduce flexion,⁶ and shortening with compromise of the olecranon and coronoid fossae can limit both flexion and extension.

Last, heterotopic ossification and osteophytes should be assessed as potential causes of limited ROM. Both the coronoid process and the olecranon can develop osteophytes, and their respective fossae should be assessed with CT. Posterior impingement is rare at the tip of the olecranon; it occurs because of "widening" of the olecranon by "Mickey Mouse ear" osteophytes and bony encroachment along the medial and lateral columns. Thus, the olecranon must be narrowed and the fossa widened and deepened.

In case of concomitant ligament instability, we prefer to reconstruct the ligament first, and then perform contracture release as a staged procedure. We favor a staged approach because the rehabilitation regimens for instability and contracture release are diametrically opposed: Instability requires immobilization, and contracture release requires immediate motion. Last, incision placement and ulnar nerve management are crucial in minimizing the potential complications of the second procedure.

2 Nonoperative Treatment

In the absence of significant bony impediments to motion—such as heterotopic ossification or malunion—initial treatment should commence with nonoperative therapy. Therapy should be initiated as soon as concern for stiffness arises in order to prevent contracture. Initial nonoperative treatment can also serve as an important litmus test of postoperative adherence. Adequate patient relaxation is crucial in avoiding co-contracture resisting stretching forces. Passive ROM exercises use sustained force to allow time-dependent stress relaxation to increase tissue length as well as fatigue antagonist muscles. In addition, hold-and-relax techniques apply isometric resistance to induce relaxation of antagonist muscles.⁷ Active ROM should emphasize triceps isolation and elbow extension to prevent scarring of the triceps to the posterior humerus.

Corrective splinting can be an effective adjuvant to physiotherapy. Static progressive turnbuckle splints was described as an effective treatment for both elbow flexion and extension contractures, effecting an average 43° increase in elbow motion in a series of 15 patients.⁸ Similarly, Gelinas and colleagues⁹ noted improvement among 22 patients treated with turnbuckle splinting for an average of 4.5 months. In addition, serial extension splints may be used in the treatment of elbow flexion contractures.

3 Open Contacture Release and Surgical Approach

When nonoperative therapies fail to restore the functional arc of motion, patients with flexion contractures or extension contractures of >30° may be indicated for contracture release. Surgical approach should be determined by meticulous preoperative planning that notes prior incisions and CT findings. It can be helpful to organize common offending structures and their effects on flexion and extension (Table).

A medial over-the-top approach uses the medial supracondylar ridge as a landmark, subperiosteally reflecting the brachialis anteriorly.¹⁰ The ulnar nerve is neurolyzed and protected posteriorly. The flexor-pronator mass is split distally and elevated along with the brachialis as a single sleeve of muscle. The coronal plane of dissection should be the anterior half of the lateral epicondyle to avoid injury to the MCL. Large Bennett or Hohmann retractors can hinge on the lateral border of the humerus and provide clear visualization of the anterior capsule and the ulnohumeral joint. Exposure of the radiocapitellar joint is possible, but this joint is very deep in the operative field, and caution should be taken excising the anterolateral capsule because of the risk of radial nerve injury. The ulnar nerve can be temporarily transposed anteriorly to dissect posteriorly along the supracondylar ridge of the humerus. The triceps is reflected off the distal humerus. Occasionally, the posterior band of the MCL must be resected in severe extension contractures. If possible, the anterior bundle should be preserved. With this approach, the anterior capsule, distal humerus, coronoid process, posterior MCL, posterior capsule, and triceps can be addressed. The zone anterior to the radial head and the anterolateral and posterolateral capsule cannot be safely exposed with a medial approach. As described by Wada and colleagues,¹¹ a primarily medial approach resulted in an average 64° increase in arc of motion.

4 Arthroscopic Contracture Release and Technique

Recently, arthroscopic elbow contracture release, a technically demanding but effective treatment option, has gained popularity. Knowledge of neurovascular anatomy is a prerequisite to the prevention of devastating neurologic complications (ulnar, median, and radial nerve transections have been described^14,15). Relative contraindications include extensive heterotopic ossification, ulnar nerve transposition, and limited arthroscopic experience. Functional improvements as well as average 26° to 42° increases in arc of motion have been described with arthroscopic release.^16-18 In thin-framed patients with dense elbow capsular scarring (severe loss of elbow motion with hard block) and small joint space, arthroscopic release and particularly arthroscope insertion are notoriously difficult.

The patient may be placed in the prone, lateral decubitus, or supine position, depending on surgeon preference (Figure 5). Before surgery, portals and the ulnar nerve should be carefully outlined.¹⁹

We prefer to start by entering the posterior compartment and using the shaver to create a working space. All bone work and resectioning should be performed before capsular resection. After the joint and the olecranon fossa are identified, soft-tissue and bony débridement of the olecranon and the fossa can be performed. Care should be taken to protect the ulnar nerve when the posteromedial corner or medial gutter is approached.

5 Additional Considerations

After surgery, the elbow is immobilized in maximal extension and supination with an anterior splint, and therapy is initiated either immediately or after temporary immobilization.^16,19,20 Regional anesthesia is crucial in obtaining adequate pain control and establishing an immediate postoperative therapy program. The utility of continuous passive motion (CPM) in postoperative protocols is controversial. A retrospective case-control study of 32 patients matched on age, diagnosis, and contraction severity found no benefit of CPM use, and increased costs and hospital length of stay, leading the authors to recommend against CPM use.²⁰

Neurovascular risks are associated with both open and arthroscopic elbow contracture release. Particularly concerning is the risk of traction ulnar neuropathy, described in upward of 20% of patients.²¹ Anatomical studies have found decreases in cubital tunnel and ulnar nerve area as elbow flexion increases with corresponding increased intraneural pressure,²² leading some authors to recommend prophylactic ulnar nerve release with limited preoperative flexion.¹⁵ Nevertheless, despite transposition, ulnar nerve symptoms were noted in 8 of 40 patients who underwent open contracture release for posttraumatic loss of elbow flexion.⁵ In a retrospective review of 164 open and arthroscopic elbow contracture releases, Williams and colleagues²¹ noted an 8.1% rate of postoperative new-onset ulnar nerve symptoms. The rate of ulnar neuropathy was nonsignificantly elevated among patients with preoperative flexion of <100° (15.2% vs 3.7%; P = .057). Recently, a retrospective review of 564 consecutive arthroscopic contracture releases found a significantly higher rate of delayed-onset ulnar neuritis among patients without prophylactic ulnar nerve decompression or transposition (11% vs 3%; P < .001).²³ Further analysis revealed that, compared with decompression, ulnar nerve transposition did not offer additional benefit but was associated with a significantly higher rate of wound complications (19% vs 4%; P = .03). We favor prophylactic release, particularly in the setting of preoperative extension contracture. For open contracture release from the lateral approach, however, we do not routinely release the ulnar nerve unless there were preoperative symptoms.

Although open and arthroscopic contracture releases can provide durable outcomes in the setting of painless elbow stiffness, options are more limited in the treatment of the painful stiff elbow. Total elbow arthroplasty remains an option in low-demand elderly patients but is not without significant risk of complications.²⁴ In addition, durability concerns and postoperative restrictions make total elbow arthroplasty less attractive to younger patients. Interposition arthroplasty may be indicated as a salvage procedure in the treatment of a young or high-demand patient with a stiff painful elbow.²⁵ Elbow stability is crucial in obtaining a successful outcome, and data on optimal graft choices are limited.

Conclusion

Elbow stiffness, a common complication of trauma, significantly impairs activities of daily living. Early after trauma, therapy should be initiated to prevent contracture. In the absence of symptomatic arthritis, both open and arthroscopic contracture releases are effective surgical treatments in properly selected and motivated patients. Although more research is needed to establish the optimal surgical approach, severity and anatomical cause of contracture should guide decisions as to which approach to use. Having a thorough understanding of neurovascular anatomy and of prophylactic ulnar nerve decompression in the setting of limited preoperative flexion can mitigate complications.

Take-Home Points

• Proper patient selection is critical as extensive postoperative rehabilitation is required to obtain an excellent outcome.
• Open and arthroscopic approaches are effective treatment options for elbow contractures.
• Elbow stability must be restored to obtain a successful outcome.
• Knowledge of neurovascular anatomy is essential to prevent neurologic complications.
• Prophylactic ulnar nerve release should be considered, especially in patients with limited flexion.

Elbow stiffness has several etiologies, posttraumatic being the most common. Elbow stiffness can have debilitating functional effects necessitating treatment. In a biomechanical study of normal elbow function, Morrey and colleagues¹ determined that a flexion extension arc of 100° (30°-130°) and a forearm rotation arc of 100° (50° pronation-50° supination) are required in 90% of activities of daily living. Similarly, elbow flexion of <105° was poorly tolerated, whereas patients could easier adapt to flexion contractures up to 40°.²

The goal of initial evaluation should be to establish the cause of the contracture and the patient’s functional demands and ability to cooperate in the extensive postoperative rehabilitation that is essential in achieving an excellent functional outcome. In a thorough clinical examination, the clinician must note skin, range of motion (ROM), ligamentous stability, and neurovascular structures and give special attention to ulnar nerve function and symptoms. Mid-arc pain suggests additional intra-articular pathology, as stiffness typically causes pain only at the limits of motion as osteophytes impinge and soft tissue is under maximal tension. Routine elbow radiographs are required in all cases, and computed tomography (CT) can be useful in evaluating osseous sources of contracture. Suspected ligamentous instability and cartilaginous defects particularly in the setting of mid-arc pain are best evaluated with magnetic resonance imaging.³

In this 5-point review, we evaluate treatment options as well as rehabilitation protocols in the management of elbow stiffness.

1 Anatomy of Contracture: The Usual Suspects

The cause of elbow stiffness is incompletely understood. Several posited contributing factors include biology, complex intra-articular anatomy, capsular distention favoring a flexed position, and tenuous postoperative fixation necessitating prolonged immobilization. Identifying intrinsic and extrinsic anatomical sources of stiffness can help guide treatment.⁴ Intrinsic pathology includes intra-articular malunion, osteophytes, loose bodies, and adhesions; extrinsic pathology includes soft-tissue contracture, heterotopic ossification, and extra-articular malunion.

Compared with the normal elbow, the capsule becomes thickened and fibrotic and thereby prevents motion. Severe contractures, and extension contractures in particular, may require release of the posterior medial capsule and the posterior medial collateral ligament (MCL) to regain motion. In a series of 42 patients with flexion <100°, Park and colleagues⁵ noted that all patients required release of the posterior band of the MCL to regain flexion. Other muscular impediments to motion include contracture of the brachialis and scarring of the triceps to the posterior humerus. Scarring of the triceps to the humerus can limit flexion.

In the posttrauma setting, intra-articular and extra-articular malunion must be considered. Extension malunion of the distal humerus can reduce flexion,⁶ and shortening with compromise of the olecranon and coronoid fossae can limit both flexion and extension.

Last, heterotopic ossification and osteophytes should be assessed as potential causes of limited ROM. Both the coronoid process and the olecranon can develop osteophytes, and their respective fossae should be assessed with CT. Posterior impingement is rare at the tip of the olecranon; it occurs because of "widening" of the olecranon by "Mickey Mouse ear" osteophytes and bony encroachment along the medial and lateral columns. Thus, the olecranon must be narrowed and the fossa widened and deepened.

In case of concomitant ligament instability, we prefer to reconstruct the ligament first, and then perform contracture release as a staged procedure. We favor a staged approach because the rehabilitation regimens for instability and contracture release are diametrically opposed: Instability requires immobilization, and contracture release requires immediate motion. Last, incision placement and ulnar nerve management are crucial in minimizing the potential complications of the second procedure.

2 Nonoperative Treatment

In the absence of significant bony impediments to motion—such as heterotopic ossification or malunion—initial treatment should commence with nonoperative therapy. Therapy should be initiated as soon as concern for stiffness arises in order to prevent contracture. Initial nonoperative treatment can also serve as an important litmus test of postoperative adherence. Adequate patient relaxation is crucial in avoiding co-contracture resisting stretching forces. Passive ROM exercises use sustained force to allow time-dependent stress relaxation to increase tissue length as well as fatigue antagonist muscles. In addition, hold-and-relax techniques apply isometric resistance to induce relaxation of antagonist muscles.⁷ Active ROM should emphasize triceps isolation and elbow extension to prevent scarring of the triceps to the posterior humerus.

Corrective splinting can be an effective adjuvant to physiotherapy. Static progressive turnbuckle splints was described as an effective treatment for both elbow flexion and extension contractures, effecting an average 43° increase in elbow motion in a series of 15 patients.⁸ Similarly, Gelinas and colleagues⁹ noted improvement among 22 patients treated with turnbuckle splinting for an average of 4.5 months. In addition, serial extension splints may be used in the treatment of elbow flexion contractures.

3 Open Contacture Release and Surgical Approach

When nonoperative therapies fail to restore the functional arc of motion, patients with flexion contractures or extension contractures of >30° may be indicated for contracture release. Surgical approach should be determined by meticulous preoperative planning that notes prior incisions and CT findings. It can be helpful to organize common offending structures and their effects on flexion and extension (Table).

A medial over-the-top approach uses the medial supracondylar ridge as a landmark, subperiosteally reflecting the brachialis anteriorly.¹⁰ The ulnar nerve is neurolyzed and protected posteriorly. The flexor-pronator mass is split distally and elevated along with the brachialis as a single sleeve of muscle. The coronal plane of dissection should be the anterior half of the lateral epicondyle to avoid injury to the MCL. Large Bennett or Hohmann retractors can hinge on the lateral border of the humerus and provide clear visualization of the anterior capsule and the ulnohumeral joint. Exposure of the radiocapitellar joint is possible, but this joint is very deep in the operative field, and caution should be taken excising the anterolateral capsule because of the risk of radial nerve injury. The ulnar nerve can be temporarily transposed anteriorly to dissect posteriorly along the supracondylar ridge of the humerus. The triceps is reflected off the distal humerus. Occasionally, the posterior band of the MCL must be resected in severe extension contractures. If possible, the anterior bundle should be preserved. With this approach, the anterior capsule, distal humerus, coronoid process, posterior MCL, posterior capsule, and triceps can be addressed. The zone anterior to the radial head and the anterolateral and posterolateral capsule cannot be safely exposed with a medial approach. As described by Wada and colleagues,¹¹ a primarily medial approach resulted in an average 64° increase in arc of motion.

4 Arthroscopic Contracture Release and Technique

Recently, arthroscopic elbow contracture release, a technically demanding but effective treatment option, has gained popularity. Knowledge of neurovascular anatomy is a prerequisite to the prevention of devastating neurologic complications (ulnar, median, and radial nerve transections have been described^14,15). Relative contraindications include extensive heterotopic ossification, ulnar nerve transposition, and limited arthroscopic experience. Functional improvements as well as average 26° to 42° increases in arc of motion have been described with arthroscopic release.^16-18 In thin-framed patients with dense elbow capsular scarring (severe loss of elbow motion with hard block) and small joint space, arthroscopic release and particularly arthroscope insertion are notoriously difficult.

The patient may be placed in the prone, lateral decubitus, or supine position, depending on surgeon preference (Figure 5). Before surgery, portals and the ulnar nerve should be carefully outlined.¹⁹

We prefer to start by entering the posterior compartment and using the shaver to create a working space. All bone work and resectioning should be performed before capsular resection. After the joint and the olecranon fossa are identified, soft-tissue and bony débridement of the olecranon and the fossa can be performed. Care should be taken to protect the ulnar nerve when the posteromedial corner or medial gutter is approached.

5 Additional Considerations

After surgery, the elbow is immobilized in maximal extension and supination with an anterior splint, and therapy is initiated either immediately or after temporary immobilization.^16,19,20 Regional anesthesia is crucial in obtaining adequate pain control and establishing an immediate postoperative therapy program. The utility of continuous passive motion (CPM) in postoperative protocols is controversial. A retrospective case-control study of 32 patients matched on age, diagnosis, and contraction severity found no benefit of CPM use, and increased costs and hospital length of stay, leading the authors to recommend against CPM use.²⁰

Neurovascular risks are associated with both open and arthroscopic elbow contracture release. Particularly concerning is the risk of traction ulnar neuropathy, described in upward of 20% of patients.²¹ Anatomical studies have found decreases in cubital tunnel and ulnar nerve area as elbow flexion increases with corresponding increased intraneural pressure,²² leading some authors to recommend prophylactic ulnar nerve release with limited preoperative flexion.¹⁵ Nevertheless, despite transposition, ulnar nerve symptoms were noted in 8 of 40 patients who underwent open contracture release for posttraumatic loss of elbow flexion.⁵ In a retrospective review of 164 open and arthroscopic elbow contracture releases, Williams and colleagues²¹ noted an 8.1% rate of postoperative new-onset ulnar nerve symptoms. The rate of ulnar neuropathy was nonsignificantly elevated among patients with preoperative flexion of <100° (15.2% vs 3.7%; P = .057). Recently, a retrospective review of 564 consecutive arthroscopic contracture releases found a significantly higher rate of delayed-onset ulnar neuritis among patients without prophylactic ulnar nerve decompression or transposition (11% vs 3%; P < .001).²³ Further analysis revealed that, compared with decompression, ulnar nerve transposition did not offer additional benefit but was associated with a significantly higher rate of wound complications (19% vs 4%; P = .03). We favor prophylactic release, particularly in the setting of preoperative extension contracture. For open contracture release from the lateral approach, however, we do not routinely release the ulnar nerve unless there were preoperative symptoms.

Although open and arthroscopic contracture releases can provide durable outcomes in the setting of painless elbow stiffness, options are more limited in the treatment of the painful stiff elbow. Total elbow arthroplasty remains an option in low-demand elderly patients but is not without significant risk of complications.²⁴ In addition, durability concerns and postoperative restrictions make total elbow arthroplasty less attractive to younger patients. Interposition arthroplasty may be indicated as a salvage procedure in the treatment of a young or high-demand patient with a stiff painful elbow.²⁵ Elbow stability is crucial in obtaining a successful outcome, and data on optimal graft choices are limited.

Conclusion

Elbow stiffness, a common complication of trauma, significantly impairs activities of daily living. Early after trauma, therapy should be initiated to prevent contracture. In the absence of symptomatic arthritis, both open and arthroscopic contracture releases are effective surgical treatments in properly selected and motivated patients. Although more research is needed to establish the optimal surgical approach, severity and anatomical cause of contracture should guide decisions as to which approach to use. Having a thorough understanding of neurovascular anatomy and of prophylactic ulnar nerve decompression in the setting of limited preoperative flexion can mitigate complications.

Take-Home Points

• Proper patient selection is critical as extensive postoperative rehabilitation is required to obtain an excellent outcome.
• Open and arthroscopic approaches are effective treatment options for elbow contractures.
• Elbow stability must be restored to obtain a successful outcome.
• Knowledge of neurovascular anatomy is essential to prevent neurologic complications.
• Prophylactic ulnar nerve release should be considered, especially in patients with limited flexion.

Elbow stiffness has several etiologies, posttraumatic being the most common. Elbow stiffness can have debilitating functional effects necessitating treatment. In a biomechanical study of normal elbow function, Morrey and colleagues¹ determined that a flexion extension arc of 100° (30°-130°) and a forearm rotation arc of 100° (50° pronation-50° supination) are required in 90% of activities of daily living. Similarly, elbow flexion of <105° was poorly tolerated, whereas patients could easier adapt to flexion contractures up to 40°.²

The goal of initial evaluation should be to establish the cause of the contracture and the patient’s functional demands and ability to cooperate in the extensive postoperative rehabilitation that is essential in achieving an excellent functional outcome. In a thorough clinical examination, the clinician must note skin, range of motion (ROM), ligamentous stability, and neurovascular structures and give special attention to ulnar nerve function and symptoms. Mid-arc pain suggests additional intra-articular pathology, as stiffness typically causes pain only at the limits of motion as osteophytes impinge and soft tissue is under maximal tension. Routine elbow radiographs are required in all cases, and computed tomography (CT) can be useful in evaluating osseous sources of contracture. Suspected ligamentous instability and cartilaginous defects particularly in the setting of mid-arc pain are best evaluated with magnetic resonance imaging.³

In this 5-point review, we evaluate treatment options as well as rehabilitation protocols in the management of elbow stiffness.

1 Anatomy of Contracture: The Usual Suspects

The cause of elbow stiffness is incompletely understood. Several posited contributing factors include biology, complex intra-articular anatomy, capsular distention favoring a flexed position, and tenuous postoperative fixation necessitating prolonged immobilization. Identifying intrinsic and extrinsic anatomical sources of stiffness can help guide treatment.⁴ Intrinsic pathology includes intra-articular malunion, osteophytes, loose bodies, and adhesions; extrinsic pathology includes soft-tissue contracture, heterotopic ossification, and extra-articular malunion.

Compared with the normal elbow, the capsule becomes thickened and fibrotic and thereby prevents motion. Severe contractures, and extension contractures in particular, may require release of the posterior medial capsule and the posterior medial collateral ligament (MCL) to regain motion. In a series of 42 patients with flexion <100°, Park and colleagues⁵ noted that all patients required release of the posterior band of the MCL to regain flexion. Other muscular impediments to motion include contracture of the brachialis and scarring of the triceps to the posterior humerus. Scarring of the triceps to the humerus can limit flexion.

In the posttrauma setting, intra-articular and extra-articular malunion must be considered. Extension malunion of the distal humerus can reduce flexion,⁶ and shortening with compromise of the olecranon and coronoid fossae can limit both flexion and extension.

Last, heterotopic ossification and osteophytes should be assessed as potential causes of limited ROM. Both the coronoid process and the olecranon can develop osteophytes, and their respective fossae should be assessed with CT. Posterior impingement is rare at the tip of the olecranon; it occurs because of "widening" of the olecranon by "Mickey Mouse ear" osteophytes and bony encroachment along the medial and lateral columns. Thus, the olecranon must be narrowed and the fossa widened and deepened.

In case of concomitant ligament instability, we prefer to reconstruct the ligament first, and then perform contracture release as a staged procedure. We favor a staged approach because the rehabilitation regimens for instability and contracture release are diametrically opposed: Instability requires immobilization, and contracture release requires immediate motion. Last, incision placement and ulnar nerve management are crucial in minimizing the potential complications of the second procedure.

2 Nonoperative Treatment

In the absence of significant bony impediments to motion—such as heterotopic ossification or malunion—initial treatment should commence with nonoperative therapy. Therapy should be initiated as soon as concern for stiffness arises in order to prevent contracture. Initial nonoperative treatment can also serve as an important litmus test of postoperative adherence. Adequate patient relaxation is crucial in avoiding co-contracture resisting stretching forces. Passive ROM exercises use sustained force to allow time-dependent stress relaxation to increase tissue length as well as fatigue antagonist muscles. In addition, hold-and-relax techniques apply isometric resistance to induce relaxation of antagonist muscles.⁷ Active ROM should emphasize triceps isolation and elbow extension to prevent scarring of the triceps to the posterior humerus.

Corrective splinting can be an effective adjuvant to physiotherapy. Static progressive turnbuckle splints was described as an effective treatment for both elbow flexion and extension contractures, effecting an average 43° increase in elbow motion in a series of 15 patients.⁸ Similarly, Gelinas and colleagues⁹ noted improvement among 22 patients treated with turnbuckle splinting for an average of 4.5 months. In addition, serial extension splints may be used in the treatment of elbow flexion contractures.

3 Open Contacture Release and Surgical Approach

When nonoperative therapies fail to restore the functional arc of motion, patients with flexion contractures or extension contractures of >30° may be indicated for contracture release. Surgical approach should be determined by meticulous preoperative planning that notes prior incisions and CT findings. It can be helpful to organize common offending structures and their effects on flexion and extension (Table).

A medial over-the-top approach uses the medial supracondylar ridge as a landmark, subperiosteally reflecting the brachialis anteriorly.¹⁰ The ulnar nerve is neurolyzed and protected posteriorly. The flexor-pronator mass is split distally and elevated along with the brachialis as a single sleeve of muscle. The coronal plane of dissection should be the anterior half of the lateral epicondyle to avoid injury to the MCL. Large Bennett or Hohmann retractors can hinge on the lateral border of the humerus and provide clear visualization of the anterior capsule and the ulnohumeral joint. Exposure of the radiocapitellar joint is possible, but this joint is very deep in the operative field, and caution should be taken excising the anterolateral capsule because of the risk of radial nerve injury. The ulnar nerve can be temporarily transposed anteriorly to dissect posteriorly along the supracondylar ridge of the humerus. The triceps is reflected off the distal humerus. Occasionally, the posterior band of the MCL must be resected in severe extension contractures. If possible, the anterior bundle should be preserved. With this approach, the anterior capsule, distal humerus, coronoid process, posterior MCL, posterior capsule, and triceps can be addressed. The zone anterior to the radial head and the anterolateral and posterolateral capsule cannot be safely exposed with a medial approach. As described by Wada and colleagues,¹¹ a primarily medial approach resulted in an average 64° increase in arc of motion.

4 Arthroscopic Contracture Release and Technique

Recently, arthroscopic elbow contracture release, a technically demanding but effective treatment option, has gained popularity. Knowledge of neurovascular anatomy is a prerequisite to the prevention of devastating neurologic complications (ulnar, median, and radial nerve transections have been described^14,15). Relative contraindications include extensive heterotopic ossification, ulnar nerve transposition, and limited arthroscopic experience. Functional improvements as well as average 26° to 42° increases in arc of motion have been described with arthroscopic release.^16-18 In thin-framed patients with dense elbow capsular scarring (severe loss of elbow motion with hard block) and small joint space, arthroscopic release and particularly arthroscope insertion are notoriously difficult.

The patient may be placed in the prone, lateral decubitus, or supine position, depending on surgeon preference (Figure 5). Before surgery, portals and the ulnar nerve should be carefully outlined.¹⁹

We prefer to start by entering the posterior compartment and using the shaver to create a working space. All bone work and resectioning should be performed before capsular resection. After the joint and the olecranon fossa are identified, soft-tissue and bony débridement of the olecranon and the fossa can be performed. Care should be taken to protect the ulnar nerve when the posteromedial corner or medial gutter is approached.

5 Additional Considerations

After surgery, the elbow is immobilized in maximal extension and supination with an anterior splint, and therapy is initiated either immediately or after temporary immobilization.^16,19,20 Regional anesthesia is crucial in obtaining adequate pain control and establishing an immediate postoperative therapy program. The utility of continuous passive motion (CPM) in postoperative protocols is controversial. A retrospective case-control study of 32 patients matched on age, diagnosis, and contraction severity found no benefit of CPM use, and increased costs and hospital length of stay, leading the authors to recommend against CPM use.²⁰

Neurovascular risks are associated with both open and arthroscopic elbow contracture release. Particularly concerning is the risk of traction ulnar neuropathy, described in upward of 20% of patients.²¹ Anatomical studies have found decreases in cubital tunnel and ulnar nerve area as elbow flexion increases with corresponding increased intraneural pressure,²² leading some authors to recommend prophylactic ulnar nerve release with limited preoperative flexion.¹⁵ Nevertheless, despite transposition, ulnar nerve symptoms were noted in 8 of 40 patients who underwent open contracture release for posttraumatic loss of elbow flexion.⁵ In a retrospective review of 164 open and arthroscopic elbow contracture releases, Williams and colleagues²¹ noted an 8.1% rate of postoperative new-onset ulnar nerve symptoms. The rate of ulnar neuropathy was nonsignificantly elevated among patients with preoperative flexion of <100° (15.2% vs 3.7%; P = .057). Recently, a retrospective review of 564 consecutive arthroscopic contracture releases found a significantly higher rate of delayed-onset ulnar neuritis among patients without prophylactic ulnar nerve decompression or transposition (11% vs 3%; P < .001).²³ Further analysis revealed that, compared with decompression, ulnar nerve transposition did not offer additional benefit but was associated with a significantly higher rate of wound complications (19% vs 4%; P = .03). We favor prophylactic release, particularly in the setting of preoperative extension contracture. For open contracture release from the lateral approach, however, we do not routinely release the ulnar nerve unless there were preoperative symptoms.

Although open and arthroscopic contracture releases can provide durable outcomes in the setting of painless elbow stiffness, options are more limited in the treatment of the painful stiff elbow. Total elbow arthroplasty remains an option in low-demand elderly patients but is not without significant risk of complications.²⁴ In addition, durability concerns and postoperative restrictions make total elbow arthroplasty less attractive to younger patients. Interposition arthroplasty may be indicated as a salvage procedure in the treatment of a young or high-demand patient with a stiff painful elbow.²⁵ Elbow stability is crucial in obtaining a successful outcome, and data on optimal graft choices are limited.

Conclusion

Elbow stiffness, a common complication of trauma, significantly impairs activities of daily living. Early after trauma, therapy should be initiated to prevent contracture. In the absence of symptomatic arthritis, both open and arthroscopic contracture releases are effective surgical treatments in properly selected and motivated patients. Although more research is needed to establish the optimal surgical approach, severity and anatomical cause of contracture should guide decisions as to which approach to use. Having a thorough understanding of neurovascular anatomy and of prophylactic ulnar nerve decompression in the setting of limited preoperative flexion can mitigate complications.

Take-Home Points

• Restore proper anatomic parameters; compare to the other side.
• Don't forget about the DRU joint.
• CT can aide in identifying subtle articular depression and severe comminution to change operative management.
• Remember, there still is a role for external fixators; an alternative remains an internal spanning plate.
• Respect the soft tissues, which can aide in reduction, however don't leave the operating room without feeling confident about your fixation.

Distal radius fracture (DRF), a common fracture, accounts for almost one sixth of all emergency department visits.¹ With the advent of emerging technologies and refined technique, treatment options for DRFs have evolved. Although controversy remains regarding nonoperative vs operative treatment of DRFs in the elderly,^2,3 select situations (open injuries, complex high-energy injuries, young age) warrant definitive fixation. Previously, internal fixation options were limited. Current technologies include locked fixed-angle plating, fragment-specific fixation, and locked variable-angle plating. These modalities aid in achieving and maintaining more anatomical fixation. This article summarizes tips, tricks, and planning for definitive external and internal fixation of complex DRFs.

Anatomical Considerations and Classification

The wrist joint, part of the complex articular network that begins at the forearm and ends at the distal interphalangeal joint, is the foundation for fine- and gross-motor skills. Understanding the anatomy of this network can provide a valuable roadmap for operative reconstruction.

At the wrist level, the radius bears most of the weight-bearing, and in some studies exhibits up to 80% of the load.^1,4 The triangular distal radius bears this weight through a biconcave articular surface with facets for the lunate and scaphoid separated by an anteroposterior ridge.^5-7 The radius also articulates with the ulnar head at the sigmoid notch to form the distal radioulnar (DRU) joint. Restoring the relationships of the DRU joint, the triangular fibrocartilage complex, and the ulnar variance is of paramount importance.^1,8,9

Classical teaching calls for restoration of radial inclination to about 23°, volar tilt to 11° to 12°, and radial length to about 11 mm. Especially regarding volar tilt and radial length, however, cadaveric and clinical studies have found more variance, leading to use of the contralateral extremity as an operative template, particularly when closed reduction thought to be adequate deviates significantly from these parameters.^1,4,7

DRF classification based on these principles has led to abundant representation in the literature.^10-13 Many authors have focused on fracture lines, comminution degree, articular surface violation, and other anatomical or radiographic characteristics of DRF classification and operative fixation approach.^10-13 In 2001, Fernandez⁹ proposed a classification system focused on energy or mechanism of injury. In comparisons,¹⁴ the Fernandez system had the highest interobserver reliability—higher than that of AO (Arbeitsgemeinschaft für Osteosynthesefragen).

Considerations for Operative Treatment: Column Theory

In the restoration of anatomical alignment in complex DRFs, it is important to consider the 3 joints and the 3 columns—radial, intermediate, and ulnar (Figure 1). [[{"fid":"201864","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":""}}}]]In addition, parallels between the distal radius and the tibial plateau can be considered because of similarities in operative goals. Restoration of mechanical axis, length, alignment, rotation, and articular surfaces is paramount.¹⁵ Considering multiple surgical approaches to address "bicolumnar injuries" and reconstructing the "simpler" columnar injury first are common principles.¹⁶

The goals of fracture fixation at the wrist are the same as at any other joint: anatomical reduction, stable fixation, and early range of motion (ROM). Column restoration can result in consistent achievement of those goals. Intuitively, there is a close correlation between anatomical alignment and functional results.¹⁷ Rebuilding the structural foundation of the columns with respect to buttressing and restoring the 3 radial articulations with the ulna, scaphoid, and lunate can consistently yield restoration of length, inclination, and tilt (Figure 2). [[{"fid":"201865","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"2"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":""}}}]]Next, we discuss the options available and how to use each to an advantage, individually or in hybrid constructs.

External Fixation: Is There Still a Role?

In the setting of highly comminuted, complex fractures, external fixation with Kirschner wires (K-wires) is a reasonable choice, with restoration of motion and strength within 75% to 80% of the uninjured wrist.¹⁸ In a 2-year study of 113 patients with comminuted metaphyseal DRFs randomly assigned to either external fixation or casting, Kreder and colleagues¹⁹ found a trend toward better clinical, functional, and radiographic outcomes with external fixation with or without K-wire fixation. There was improved restoration of radial length and palmar tilt with external fixation. A study of unstable DRF in patients with osteoporosis found that redisplacement was more common after treatment with a cast than after treatment with an external fixator.²⁰ Although closed reduction and casting continue to have a role in the treatment of DRF, Kreder and colleagues¹⁹ found that remanipulation was necessary in at least 9% of cases. According to a meta-analysis²¹ of the literature on DRF treatment, 4 articles directly address the question of the superiority of external fixation over closed reduction and casting, and 3 of the 4 found more favorable radiographic and functional outcomes with external fixation.

External fixation is useful in treating complex DRFs with metaphyseal comminution. It can also be effective in the presence of simple articular involvement without depression of the joint surface. External fixation devices can span areas of soft-
tissue injury and are useful as manipulation tools in achieving anatomical reduction. Although external fixation is effective, its complications include pin-tract infection, nerve injury, loss of reduction, and loss of digital ROM. In a meta-analysis, Li-hai and colleagues²² found that external fixators had a complication rate of 30.9%. With this technique, it is important to avoid midcarpal distraction, excessive ulnar deviation, and excessive palmar flexion. Papadonikolakis and colleagues²³ found that distraction of as little as 2 mm to 5 mm significantly affected the function of the flexor digitorum superficialis at the metacarpophalangeal joint. Over-distraction in wrist flexion can lead to lengthening of the extensor tendons and loss of full digital ROM. Excessive flexion and ulnar deviation can lead to median nerve compression and associated symptoms, as well as poor extensor and radial tendon length. In addition, prolonged distraction in excessive flexion combined with swelling and inflammation during fracture healing causes digital stiffness and contracture.²³ Biomechanical studies have found that proximal pin placement in the radius, along with distal pin fixation in 6 metacarpal cortices through the second and third metacarpals, helps provide the strongest fixation.²⁴

As for technique, pins are placed in the second metacarpal and radial shaft. With respect to the radius, the incision is made just proximal to the edge of the abductor pollicis longus muscle in the "bare area." Ideal pin placement is between the extensor carpi radialis longus and the extensor carpi radialis brevis, with care taken to avoid the radial sensory nerve, which lies between the extensor carpi radialis longus and the brachialis and emerges 9 cm proximal to the radial styloid.²⁵ Next, a 2.5-cm to 3-cm incision is made over the palpable edge of the index metacarpal near the base. During drilling, the guide is placed at intersecting 45° angles, and the distal pin is placed 2 cm to 3 cm from the proximal pin. The proximal metacarpal pin is placed at the base of the metacarpal. The second metacarpal pin can also be placed first, with the external fixator used to judge proximal placement of the radial pin within the bare area.

Various supplements to external fixation have positive outcomes. Wolfe and colleagues¹⁸ found that using K-wires with the external fixation construct added stability in flexion/extension, radial/ulnar deviation, and rotational motion. They noted that fixation stability may depend more on the augmentation to fixation than on the external fixator itself. In a prospective, randomized trial, Moroni and colleagues^26,27 found that, compared with standard pins, hydroxyapatite-coated pins had higher extraction torque, which was associated with improved fixation. When combined with external fixation, calcium phosphate cement also provided additional stability, allowing the bone filler to help maintain articular reduction and cortical continuity.^28,29

External fixation has its disadvantages and complications. It can be bulky, and theoretically it contributes to higher rates of stiffness in the wrist and fingers.^30-32 Higher rates of pin-site infection have been reported, along with hardware failure and associated loss of reduction, in patients treated with external fixation (Figures 3A-3C).^31-33[[{"fid":"201866","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"3"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"3":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":""}}}]]In addition, joint overdistraction can adversely affect the length-tension curve and contribute to potential reflex sympathetic dystrophy, which can be devastating (Figures 4A, 4B).^1,21,31,33 Despite these complications, external fixation remains a powerful tool in the treatment of high-energy DRFs. [[{"fid":"201867","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"4"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"4":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":""}}}]]In many cases, authors who compared open reduction and internal fixation (ORIF) with external fixation found no significant differences in outcome scores or function.^31-34 In a meta-analysis of 917 patients, Margaliot and colleagues³³ found no differences in pain, grip strength, wrist ROM, or radiographic parameters. More recently, in prospective randomized trials, both Egol and colleagues³¹ and Grewal and colleagues³⁴ compared hybrid external fixation with ORIF, and, though early outcomes favored ORIF, 1-year follow-up comparisons were even, and there were no significant differences. These consistently reproducible results reaffirm keeping external fixation in the orthopedic toolbox.

Definitive Reconstruction With ORIF

Early nonlocked dorsal plating options for DRF fixation had unacceptable rates of plate failure, poor cosmesis, and extensor tendon complications.^17,35-37 Subsequent technologic advances—multiple approaches, lower profile plating, and rigid, fragment-specific fixation—have allowed even the most complex fracture patterns to be addressed (Table). In malunited fractures, bone graft may not be required if the fracture is extra-articular and treated with a volar locking plate. [[{"fid":"201868","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"5"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"5":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":""}}}]]Other options include corticocancellous autograft from the iliac crest, hydroxyapatite synthetic grafts, and osteoconductive bone graft substitutes, such as bone morphogenic proteins. In addition, healing times are similar in cases, regardless of whether a graft was used.³⁸

Involvement of the radial and intermediate columns should be addressed first. Although some may prefer a single volar plate, others may use fragment-specific fixation to buttress a comminuted radial styloid (in orthogonal fashion) and/or a dorsal ulnar fragment to restore the intermediate column and thereby fully restore the radial articular surface.^39,40 Typically, restoring the radial and intermediate columns for radial articular reduction subsequently and simultaneously restores the majority of radial height and length. After the radial and intermediate columns are reduced and stabilized, the need for ulna column fixation can be determined. Important factors in ulna column restoration are severe osteoporosis and ulna head and/or neck comminution. Significant comminution throughout the metaphysis of both the radius and the ulna may also warrant stabilizing the ulna with internal fixation. Finally, any DRU joint instability noted on examination should also favor fixing the ulnar side.

Assessment of the distal ulna in these complex fractures goes beyond the involvement of an ulnar styloid fracture. Typically, fractures at the base of the ulnar styloid have been reported to have little clinical relevance, including a low incidence of associated DRU joint problems.^41-43 Decisions to address the ulnar column are largely swayed by any instability found on DRU joint testing, as laxity caused by severe comminution can dictate the need for distal ring fixation to provide support. Even in the presence of a high-energy fracture in severely osteoporotic bone, the argument can be made to prevent instability by supporting the ulnar column. Stabilization of the ulnar articular surface can also be made more facile by creating an easier "A" fracture pattern (per AO classification) from a complex "C" to further aid in achieving efficient anatomical reduction. After preoperative planning is completed, depending on which columns need to be addressed, several surgical approaches can be considered to achieve maximum exposure and soft-tissue mobilization in order to successfully complete the operative fixation goals.

Volar Approach

An approach is selected for ideal exposure of a facile environment for definitive fixation. Access to the radial column can be gained with the extended flexor carpi radialis (FCR) approach. This approach allows visualization and removal of the appropriate deforming forces on the radial column to allow for fracture reduction by "opening the book," similar to that of tibial plateau reconstruction.^44,45 It may be prudent to perform a preincision Allen test as well as a preoperative DRU joint examination for comparison after ORIF is complete. Compared with the classic Henry approach near the distal radius, going through the volar sheath of the FCR avoids many of the perforating radial artery branches. Avoiding stripping the radial artery of its surrounding fat and lymphatics prevents postoperative "cold intolerance." Retracting the FCR ulnarly and then incising the dorsal FCR sheath provide ready access to the pronator quadratus after collective ulnar mobilization of both the FCR and the flexor pollicis longus.⁴⁴ In addition, for work near the distal FCR sheath, care must be taken to avoid the branch of the palmar cutaneous nerve that emerges about 5 cm proximal to the wrist flexion crease.⁴⁶

Once at the level of the pronator quadratus, an "L-shape" incision can be made to reflect the muscle off the radius. Care must be taken when working too distal to avoid transection of the inserting volar wrist ligaments.⁴⁴ Leaving a cuff for repair of the pronator remains controversial. In a recent case-control series, however, Hershman and colleagues⁴⁷ did not find significant differences in function or complication rate in patients with and without repair. After reflection, adequate exposure of the radial column should be achieved. Ready access to the radial styloid for orthogonal plating can be obtained by releasing the brachioradialis, which simultaneously releases one of the primary fracture deforming forces.⁴⁴ With this incision and exposure, if needed, dorsal bone grafting can be achieved from the volar side; however, care must be taken to protect the first dorsal compartment.⁴⁸ The cutaneous branch of the median nerve may be at risk with this exposure, but avoiding dissection ulnar to the FCR tendon can help to reduce this risk.⁴⁹

Before surgery, if the fracture pattern dictates a more ulnar approach, we prefer the extended carpal tunnel approach. Using the plane between the palmaris longus and the flexor digitorum superficialis medially and the FCR laterally, the extended carpal tunnel approach provides an obvious release of the flexor retinaculum but, more important, allows for extensile access to the sigmoid notch, the DRU joint, and the ulnar column.

Dorsal Approach

The dorsal approach is necessary in a few select cases. With a focus on fragment-specific fixation, presence of a significant dorsal ulnar fragment should warrant a dorsal approach.⁵⁰ In addition, in select, rare cases in which volar access is limited or unavailable, dorsal access is the only option.⁵⁰ Finally, if direct articular visualization is required, the dorsal approach typically is favored as the stronger radiocarpal ligaments found on the volar side are maintained.

Access should begin with an incision centered over the dorsal distal radius; a safe access point is just ulnar to the Lister tubercle. On incision of the retinaculum through a full-thickness excision, the third dorsal compartment is opened and the extensor pollicis longus (EPL) mobilized, fully exposing the dorsal distal radius. Work can be performed on either side of the EPL between the second and fourth dorsal compartments. Exposure typically is not an issue because of the pliable soft tissue of the dorsum, with ready access from styloid to styloid.⁴⁴ Here, low-profile plates and/or mini-fragment-specific plate options should be used to minimize potential tendon damage.⁵¹ Care must also be taken to avoid damaging the radiocarpal or scapholunate ligaments.⁴⁹ On closure, the retinaculum is repaired primarily; however, though some proponents advocate relocating the EPL tendon into its groove, we prefer leaving the EPL free within the surrounding soft tissue to reduce tension and promote unhindered excursion. The dorsal approach, though controversial and used inconsistently, should remain an important tool in anatomical restoration, especially in cases of complex fracture patterns.

Conclusion

Controversy still marks the lack of consensus on deciding which DRF treatment is optimal. Some investigators question moving away from external fixation and cite the lack of significantly better data relative to ORIF.^21,52 The same proponents note that the only advantage over external fixation is earlier return to function and cite reports of tendon rupture and complications with both dorsal and volar fixation options.^34,53-58 Other investigators find that operative treatment generally does not provide a significant improvement over nonoperative treatment.⁵⁹

With the advent of lower profile locked plating, fragment-specific fixation, and variable-angle devices, comparative clinical trials are finding it difficult to keep up.^60-64 Results from ongoing prospective randomized trials like ORCHID (Open Reduction and Internal Fixation Versus Casting for Highly Comminuted Intra-Articular Fractures of the Distal Radius; 500 patients >65 years old, 15 centers) will provide more definitive answers about ideal treatment.⁶⁵

Anatomical restoration involves a versatile array of fragment fixation and reconstruction. Careful preoperative planning and a consistent approach to restoring the radial, intermediate, and ulnar columns, along with a proper surgical approach, are ideal. Many advances in internal fixation have been exceedingly helpful. Use of external fixation, especially in a bridging fashion with or without supplementation, is still valuable in many situations.

Take-Home Points

• Restore proper anatomic parameters; compare to the other side.
• Don't forget about the DRU joint.
• CT can aide in identifying subtle articular depression and severe comminution to change operative management.
• Remember, there still is a role for external fixators; an alternative remains an internal spanning plate.
• Respect the soft tissues, which can aide in reduction, however don't leave the operating room without feeling confident about your fixation.

Distal radius fracture (DRF), a common fracture, accounts for almost one sixth of all emergency department visits.¹ With the advent of emerging technologies and refined technique, treatment options for DRFs have evolved. Although controversy remains regarding nonoperative vs operative treatment of DRFs in the elderly,^2,3 select situations (open injuries, complex high-energy injuries, young age) warrant definitive fixation. Previously, internal fixation options were limited. Current technologies include locked fixed-angle plating, fragment-specific fixation, and locked variable-angle plating. These modalities aid in achieving and maintaining more anatomical fixation. This article summarizes tips, tricks, and planning for definitive external and internal fixation of complex DRFs.

Anatomical Considerations and Classification

The wrist joint, part of the complex articular network that begins at the forearm and ends at the distal interphalangeal joint, is the foundation for fine- and gross-motor skills. Understanding the anatomy of this network can provide a valuable roadmap for operative reconstruction.

At the wrist level, the radius bears most of the weight-bearing, and in some studies exhibits up to 80% of the load.^1,4 The triangular distal radius bears this weight through a biconcave articular surface with facets for the lunate and scaphoid separated by an anteroposterior ridge.^5-7 The radius also articulates with the ulnar head at the sigmoid notch to form the distal radioulnar (DRU) joint. Restoring the relationships of the DRU joint, the triangular fibrocartilage complex, and the ulnar variance is of paramount importance.^1,8,9

Classical teaching calls for restoration of radial inclination to about 23°, volar tilt to 11° to 12°, and radial length to about 11 mm. Especially regarding volar tilt and radial length, however, cadaveric and clinical studies have found more variance, leading to use of the contralateral extremity as an operative template, particularly when closed reduction thought to be adequate deviates significantly from these parameters.^1,4,7

DRF classification based on these principles has led to abundant representation in the literature.^10-13 Many authors have focused on fracture lines, comminution degree, articular surface violation, and other anatomical or radiographic characteristics of DRF classification and operative fixation approach.^10-13 In 2001, Fernandez⁹ proposed a classification system focused on energy or mechanism of injury. In comparisons,¹⁴ the Fernandez system had the highest interobserver reliability—higher than that of AO (Arbeitsgemeinschaft für Osteosynthesefragen).

Considerations for Operative Treatment: Column Theory

In the restoration of anatomical alignment in complex DRFs, it is important to consider the 3 joints and the 3 columns—radial, intermediate, and ulnar (Figure 1). [[{"fid":"201864","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":""}}}]]In addition, parallels between the distal radius and the tibial plateau can be considered because of similarities in operative goals. Restoration of mechanical axis, length, alignment, rotation, and articular surfaces is paramount.¹⁵ Considering multiple surgical approaches to address "bicolumnar injuries" and reconstructing the "simpler" columnar injury first are common principles.¹⁶

The goals of fracture fixation at the wrist are the same as at any other joint: anatomical reduction, stable fixation, and early range of motion (ROM). Column restoration can result in consistent achievement of those goals. Intuitively, there is a close correlation between anatomical alignment and functional results.¹⁷ Rebuilding the structural foundation of the columns with respect to buttressing and restoring the 3 radial articulations with the ulna, scaphoid, and lunate can consistently yield restoration of length, inclination, and tilt (Figure 2). [[{"fid":"201865","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"2"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":""}}}]]Next, we discuss the options available and how to use each to an advantage, individually or in hybrid constructs.

External Fixation: Is There Still a Role?

In the setting of highly comminuted, complex fractures, external fixation with Kirschner wires (K-wires) is a reasonable choice, with restoration of motion and strength within 75% to 80% of the uninjured wrist.¹⁸ In a 2-year study of 113 patients with comminuted metaphyseal DRFs randomly assigned to either external fixation or casting, Kreder and colleagues¹⁹ found a trend toward better clinical, functional, and radiographic outcomes with external fixation with or without K-wire fixation. There was improved restoration of radial length and palmar tilt with external fixation. A study of unstable DRF in patients with osteoporosis found that redisplacement was more common after treatment with a cast than after treatment with an external fixator.²⁰ Although closed reduction and casting continue to have a role in the treatment of DRF, Kreder and colleagues¹⁹ found that remanipulation was necessary in at least 9% of cases. According to a meta-analysis²¹ of the literature on DRF treatment, 4 articles directly address the question of the superiority of external fixation over closed reduction and casting, and 3 of the 4 found more favorable radiographic and functional outcomes with external fixation.

External fixation is useful in treating complex DRFs with metaphyseal comminution. It can also be effective in the presence of simple articular involvement without depression of the joint surface. External fixation devices can span areas of soft-
tissue injury and are useful as manipulation tools in achieving anatomical reduction. Although external fixation is effective, its complications include pin-tract infection, nerve injury, loss of reduction, and loss of digital ROM. In a meta-analysis, Li-hai and colleagues²² found that external fixators had a complication rate of 30.9%. With this technique, it is important to avoid midcarpal distraction, excessive ulnar deviation, and excessive palmar flexion. Papadonikolakis and colleagues²³ found that distraction of as little as 2 mm to 5 mm significantly affected the function of the flexor digitorum superficialis at the metacarpophalangeal joint. Over-distraction in wrist flexion can lead to lengthening of the extensor tendons and loss of full digital ROM. Excessive flexion and ulnar deviation can lead to median nerve compression and associated symptoms, as well as poor extensor and radial tendon length. In addition, prolonged distraction in excessive flexion combined with swelling and inflammation during fracture healing causes digital stiffness and contracture.²³ Biomechanical studies have found that proximal pin placement in the radius, along with distal pin fixation in 6 metacarpal cortices through the second and third metacarpals, helps provide the strongest fixation.²⁴

As for technique, pins are placed in the second metacarpal and radial shaft. With respect to the radius, the incision is made just proximal to the edge of the abductor pollicis longus muscle in the "bare area." Ideal pin placement is between the extensor carpi radialis longus and the extensor carpi radialis brevis, with care taken to avoid the radial sensory nerve, which lies between the extensor carpi radialis longus and the brachialis and emerges 9 cm proximal to the radial styloid.²⁵ Next, a 2.5-cm to 3-cm incision is made over the palpable edge of the index metacarpal near the base. During drilling, the guide is placed at intersecting 45° angles, and the distal pin is placed 2 cm to 3 cm from the proximal pin. The proximal metacarpal pin is placed at the base of the metacarpal. The second metacarpal pin can also be placed first, with the external fixator used to judge proximal placement of the radial pin within the bare area.

Various supplements to external fixation have positive outcomes. Wolfe and colleagues¹⁸ found that using K-wires with the external fixation construct added stability in flexion/extension, radial/ulnar deviation, and rotational motion. They noted that fixation stability may depend more on the augmentation to fixation than on the external fixator itself. In a prospective, randomized trial, Moroni and colleagues^26,27 found that, compared with standard pins, hydroxyapatite-coated pins had higher extraction torque, which was associated with improved fixation. When combined with external fixation, calcium phosphate cement also provided additional stability, allowing the bone filler to help maintain articular reduction and cortical continuity.^28,29

External fixation has its disadvantages and complications. It can be bulky, and theoretically it contributes to higher rates of stiffness in the wrist and fingers.^30-32 Higher rates of pin-site infection have been reported, along with hardware failure and associated loss of reduction, in patients treated with external fixation (Figures 3A-3C).^31-33[[{"fid":"201866","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"3"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"3":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":""}}}]]In addition, joint overdistraction can adversely affect the length-tension curve and contribute to potential reflex sympathetic dystrophy, which can be devastating (Figures 4A, 4B).^1,21,31,33 Despite these complications, external fixation remains a powerful tool in the treatment of high-energy DRFs. [[{"fid":"201867","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"4"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"4":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":""}}}]]In many cases, authors who compared open reduction and internal fixation (ORIF) with external fixation found no significant differences in outcome scores or function.^31-34 In a meta-analysis of 917 patients, Margaliot and colleagues³³ found no differences in pain, grip strength, wrist ROM, or radiographic parameters. More recently, in prospective randomized trials, both Egol and colleagues³¹ and Grewal and colleagues³⁴ compared hybrid external fixation with ORIF, and, though early outcomes favored ORIF, 1-year follow-up comparisons were even, and there were no significant differences. These consistently reproducible results reaffirm keeping external fixation in the orthopedic toolbox.

Definitive Reconstruction With ORIF

Early nonlocked dorsal plating options for DRF fixation had unacceptable rates of plate failure, poor cosmesis, and extensor tendon complications.^17,35-37 Subsequent technologic advances—multiple approaches, lower profile plating, and rigid, fragment-specific fixation—have allowed even the most complex fracture patterns to be addressed (Table). In malunited fractures, bone graft may not be required if the fracture is extra-articular and treated with a volar locking plate. [[{"fid":"201868","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"5"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"5":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":""}}}]]Other options include corticocancellous autograft from the iliac crest, hydroxyapatite synthetic grafts, and osteoconductive bone graft substitutes, such as bone morphogenic proteins. In addition, healing times are similar in cases, regardless of whether a graft was used.³⁸

Involvement of the radial and intermediate columns should be addressed first. Although some may prefer a single volar plate, others may use fragment-specific fixation to buttress a comminuted radial styloid (in orthogonal fashion) and/or a dorsal ulnar fragment to restore the intermediate column and thereby fully restore the radial articular surface.^39,40 Typically, restoring the radial and intermediate columns for radial articular reduction subsequently and simultaneously restores the majority of radial height and length. After the radial and intermediate columns are reduced and stabilized, the need for ulna column fixation can be determined. Important factors in ulna column restoration are severe osteoporosis and ulna head and/or neck comminution. Significant comminution throughout the metaphysis of both the radius and the ulna may also warrant stabilizing the ulna with internal fixation. Finally, any DRU joint instability noted on examination should also favor fixing the ulnar side.

Assessment of the distal ulna in these complex fractures goes beyond the involvement of an ulnar styloid fracture. Typically, fractures at the base of the ulnar styloid have been reported to have little clinical relevance, including a low incidence of associated DRU joint problems.^41-43 Decisions to address the ulnar column are largely swayed by any instability found on DRU joint testing, as laxity caused by severe comminution can dictate the need for distal ring fixation to provide support. Even in the presence of a high-energy fracture in severely osteoporotic bone, the argument can be made to prevent instability by supporting the ulnar column. Stabilization of the ulnar articular surface can also be made more facile by creating an easier "A" fracture pattern (per AO classification) from a complex "C" to further aid in achieving efficient anatomical reduction. After preoperative planning is completed, depending on which columns need to be addressed, several surgical approaches can be considered to achieve maximum exposure and soft-tissue mobilization in order to successfully complete the operative fixation goals.

Volar Approach

An approach is selected for ideal exposure of a facile environment for definitive fixation. Access to the radial column can be gained with the extended flexor carpi radialis (FCR) approach. This approach allows visualization and removal of the appropriate deforming forces on the radial column to allow for fracture reduction by "opening the book," similar to that of tibial plateau reconstruction.^44,45 It may be prudent to perform a preincision Allen test as well as a preoperative DRU joint examination for comparison after ORIF is complete. Compared with the classic Henry approach near the distal radius, going through the volar sheath of the FCR avoids many of the perforating radial artery branches. Avoiding stripping the radial artery of its surrounding fat and lymphatics prevents postoperative "cold intolerance." Retracting the FCR ulnarly and then incising the dorsal FCR sheath provide ready access to the pronator quadratus after collective ulnar mobilization of both the FCR and the flexor pollicis longus.⁴⁴ In addition, for work near the distal FCR sheath, care must be taken to avoid the branch of the palmar cutaneous nerve that emerges about 5 cm proximal to the wrist flexion crease.⁴⁶

Once at the level of the pronator quadratus, an "L-shape" incision can be made to reflect the muscle off the radius. Care must be taken when working too distal to avoid transection of the inserting volar wrist ligaments.⁴⁴ Leaving a cuff for repair of the pronator remains controversial. In a recent case-control series, however, Hershman and colleagues⁴⁷ did not find significant differences in function or complication rate in patients with and without repair. After reflection, adequate exposure of the radial column should be achieved. Ready access to the radial styloid for orthogonal plating can be obtained by releasing the brachioradialis, which simultaneously releases one of the primary fracture deforming forces.⁴⁴ With this incision and exposure, if needed, dorsal bone grafting can be achieved from the volar side; however, care must be taken to protect the first dorsal compartment.⁴⁸ The cutaneous branch of the median nerve may be at risk with this exposure, but avoiding dissection ulnar to the FCR tendon can help to reduce this risk.⁴⁹

Before surgery, if the fracture pattern dictates a more ulnar approach, we prefer the extended carpal tunnel approach. Using the plane between the palmaris longus and the flexor digitorum superficialis medially and the FCR laterally, the extended carpal tunnel approach provides an obvious release of the flexor retinaculum but, more important, allows for extensile access to the sigmoid notch, the DRU joint, and the ulnar column.

Dorsal Approach

The dorsal approach is necessary in a few select cases. With a focus on fragment-specific fixation, presence of a significant dorsal ulnar fragment should warrant a dorsal approach.⁵⁰ In addition, in select, rare cases in which volar access is limited or unavailable, dorsal access is the only option.⁵⁰ Finally, if direct articular visualization is required, the dorsal approach typically is favored as the stronger radiocarpal ligaments found on the volar side are maintained.

Access should begin with an incision centered over the dorsal distal radius; a safe access point is just ulnar to the Lister tubercle. On incision of the retinaculum through a full-thickness excision, the third dorsal compartment is opened and the extensor pollicis longus (EPL) mobilized, fully exposing the dorsal distal radius. Work can be performed on either side of the EPL between the second and fourth dorsal compartments. Exposure typically is not an issue because of the pliable soft tissue of the dorsum, with ready access from styloid to styloid.⁴⁴ Here, low-profile plates and/or mini-fragment-specific plate options should be used to minimize potential tendon damage.⁵¹ Care must also be taken to avoid damaging the radiocarpal or scapholunate ligaments.⁴⁹ On closure, the retinaculum is repaired primarily; however, though some proponents advocate relocating the EPL tendon into its groove, we prefer leaving the EPL free within the surrounding soft tissue to reduce tension and promote unhindered excursion. The dorsal approach, though controversial and used inconsistently, should remain an important tool in anatomical restoration, especially in cases of complex fracture patterns.

Conclusion

Controversy still marks the lack of consensus on deciding which DRF treatment is optimal. Some investigators question moving away from external fixation and cite the lack of significantly better data relative to ORIF.^21,52 The same proponents note that the only advantage over external fixation is earlier return to function and cite reports of tendon rupture and complications with both dorsal and volar fixation options.^34,53-58 Other investigators find that operative treatment generally does not provide a significant improvement over nonoperative treatment.⁵⁹

With the advent of lower profile locked plating, fragment-specific fixation, and variable-angle devices, comparative clinical trials are finding it difficult to keep up.^60-64 Results from ongoing prospective randomized trials like ORCHID (Open Reduction and Internal Fixation Versus Casting for Highly Comminuted Intra-Articular Fractures of the Distal Radius; 500 patients >65 years old, 15 centers) will provide more definitive answers about ideal treatment.⁶⁵

Anatomical restoration involves a versatile array of fragment fixation and reconstruction. Careful preoperative planning and a consistent approach to restoring the radial, intermediate, and ulnar columns, along with a proper surgical approach, are ideal. Many advances in internal fixation have been exceedingly helpful. Use of external fixation, especially in a bridging fashion with or without supplementation, is still valuable in many situations.

Take-Home Points

• Restore proper anatomic parameters; compare to the other side.
• Don't forget about the DRU joint.
• CT can aide in identifying subtle articular depression and severe comminution to change operative management.
• Remember, there still is a role for external fixators; an alternative remains an internal spanning plate.
• Respect the soft tissues, which can aide in reduction, however don't leave the operating room without feeling confident about your fixation.

Distal radius fracture (DRF), a common fracture, accounts for almost one sixth of all emergency department visits.¹ With the advent of emerging technologies and refined technique, treatment options for DRFs have evolved. Although controversy remains regarding nonoperative vs operative treatment of DRFs in the elderly,^2,3 select situations (open injuries, complex high-energy injuries, young age) warrant definitive fixation. Previously, internal fixation options were limited. Current technologies include locked fixed-angle plating, fragment-specific fixation, and locked variable-angle plating. These modalities aid in achieving and maintaining more anatomical fixation. This article summarizes tips, tricks, and planning for definitive external and internal fixation of complex DRFs.

Anatomical Considerations and Classification

The wrist joint, part of the complex articular network that begins at the forearm and ends at the distal interphalangeal joint, is the foundation for fine- and gross-motor skills. Understanding the anatomy of this network can provide a valuable roadmap for operative reconstruction.

At the wrist level, the radius bears most of the weight-bearing, and in some studies exhibits up to 80% of the load.^1,4 The triangular distal radius bears this weight through a biconcave articular surface with facets for the lunate and scaphoid separated by an anteroposterior ridge.^5-7 The radius also articulates with the ulnar head at the sigmoid notch to form the distal radioulnar (DRU) joint. Restoring the relationships of the DRU joint, the triangular fibrocartilage complex, and the ulnar variance is of paramount importance.^1,8,9

Classical teaching calls for restoration of radial inclination to about 23°, volar tilt to 11° to 12°, and radial length to about 11 mm. Especially regarding volar tilt and radial length, however, cadaveric and clinical studies have found more variance, leading to use of the contralateral extremity as an operative template, particularly when closed reduction thought to be adequate deviates significantly from these parameters.^1,4,7

DRF classification based on these principles has led to abundant representation in the literature.^10-13 Many authors have focused on fracture lines, comminution degree, articular surface violation, and other anatomical or radiographic characteristics of DRF classification and operative fixation approach.^10-13 In 2001, Fernandez⁹ proposed a classification system focused on energy or mechanism of injury. In comparisons,¹⁴ the Fernandez system had the highest interobserver reliability—higher than that of AO (Arbeitsgemeinschaft für Osteosynthesefragen).

Considerations for Operative Treatment: Column Theory

In the restoration of anatomical alignment in complex DRFs, it is important to consider the 3 joints and the 3 columns—radial, intermediate, and ulnar (Figure 1). [[{"fid":"201864","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 1.","field_file_image_credit[und][0][value]":""}}}]]In addition, parallels between the distal radius and the tibial plateau can be considered because of similarities in operative goals. Restoration of mechanical axis, length, alignment, rotation, and articular surfaces is paramount.¹⁵ Considering multiple surgical approaches to address "bicolumnar injuries" and reconstructing the "simpler" columnar injury first are common principles.¹⁶

The goals of fracture fixation at the wrist are the same as at any other joint: anatomical reduction, stable fixation, and early range of motion (ROM). Column restoration can result in consistent achievement of those goals. Intuitively, there is a close correlation between anatomical alignment and functional results.¹⁷ Rebuilding the structural foundation of the columns with respect to buttressing and restoring the 3 radial articulations with the ulna, scaphoid, and lunate can consistently yield restoration of length, inclination, and tilt (Figure 2). [[{"fid":"201865","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"2"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 2.","field_file_image_credit[und][0][value]":""}}}]]Next, we discuss the options available and how to use each to an advantage, individually or in hybrid constructs.

External Fixation: Is There Still a Role?

In the setting of highly comminuted, complex fractures, external fixation with Kirschner wires (K-wires) is a reasonable choice, with restoration of motion and strength within 75% to 80% of the uninjured wrist.¹⁸ In a 2-year study of 113 patients with comminuted metaphyseal DRFs randomly assigned to either external fixation or casting, Kreder and colleagues¹⁹ found a trend toward better clinical, functional, and radiographic outcomes with external fixation with or without K-wire fixation. There was improved restoration of radial length and palmar tilt with external fixation. A study of unstable DRF in patients with osteoporosis found that redisplacement was more common after treatment with a cast than after treatment with an external fixator.²⁰ Although closed reduction and casting continue to have a role in the treatment of DRF, Kreder and colleagues¹⁹ found that remanipulation was necessary in at least 9% of cases. According to a meta-analysis²¹ of the literature on DRF treatment, 4 articles directly address the question of the superiority of external fixation over closed reduction and casting, and 3 of the 4 found more favorable radiographic and functional outcomes with external fixation.

External fixation is useful in treating complex DRFs with metaphyseal comminution. It can also be effective in the presence of simple articular involvement without depression of the joint surface. External fixation devices can span areas of soft-
tissue injury and are useful as manipulation tools in achieving anatomical reduction. Although external fixation is effective, its complications include pin-tract infection, nerve injury, loss of reduction, and loss of digital ROM. In a meta-analysis, Li-hai and colleagues²² found that external fixators had a complication rate of 30.9%. With this technique, it is important to avoid midcarpal distraction, excessive ulnar deviation, and excessive palmar flexion. Papadonikolakis and colleagues²³ found that distraction of as little as 2 mm to 5 mm significantly affected the function of the flexor digitorum superficialis at the metacarpophalangeal joint. Over-distraction in wrist flexion can lead to lengthening of the extensor tendons and loss of full digital ROM. Excessive flexion and ulnar deviation can lead to median nerve compression and associated symptoms, as well as poor extensor and radial tendon length. In addition, prolonged distraction in excessive flexion combined with swelling and inflammation during fracture healing causes digital stiffness and contracture.²³ Biomechanical studies have found that proximal pin placement in the radius, along with distal pin fixation in 6 metacarpal cortices through the second and third metacarpals, helps provide the strongest fixation.²⁴

As for technique, pins are placed in the second metacarpal and radial shaft. With respect to the radius, the incision is made just proximal to the edge of the abductor pollicis longus muscle in the "bare area." Ideal pin placement is between the extensor carpi radialis longus and the extensor carpi radialis brevis, with care taken to avoid the radial sensory nerve, which lies between the extensor carpi radialis longus and the brachialis and emerges 9 cm proximal to the radial styloid.²⁵ Next, a 2.5-cm to 3-cm incision is made over the palpable edge of the index metacarpal near the base. During drilling, the guide is placed at intersecting 45° angles, and the distal pin is placed 2 cm to 3 cm from the proximal pin. The proximal metacarpal pin is placed at the base of the metacarpal. The second metacarpal pin can also be placed first, with the external fixator used to judge proximal placement of the radial pin within the bare area.

Various supplements to external fixation have positive outcomes. Wolfe and colleagues¹⁸ found that using K-wires with the external fixation construct added stability in flexion/extension, radial/ulnar deviation, and rotational motion. They noted that fixation stability may depend more on the augmentation to fixation than on the external fixator itself. In a prospective, randomized trial, Moroni and colleagues^26,27 found that, compared with standard pins, hydroxyapatite-coated pins had higher extraction torque, which was associated with improved fixation. When combined with external fixation, calcium phosphate cement also provided additional stability, allowing the bone filler to help maintain articular reduction and cortical continuity.^28,29

External fixation has its disadvantages and complications. It can be bulky, and theoretically it contributes to higher rates of stiffness in the wrist and fingers.^30-32 Higher rates of pin-site infection have been reported, along with hardware failure and associated loss of reduction, in patients treated with external fixation (Figures 3A-3C).^31-33[[{"fid":"201866","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"3"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"3":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Figure 3.","field_file_image_credit[und][0][value]":""}}}]]In addition, joint overdistraction can adversely affect the length-tension curve and contribute to potential reflex sympathetic dystrophy, which can be devastating (Figures 4A, 4B).^1,21,31,33 Despite these complications, external fixation remains a powerful tool in the treatment of high-energy DRFs. [[{"fid":"201867","view_mode":"medstat_image_flush_right","attributes":{"class":"media-element file-medstat-image-flush-right","data-delta":"4"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"4":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Figure 4.","field_file_image_credit[und][0][value]":""}}}]]In many cases, authors who compared open reduction and internal fixation (ORIF) with external fixation found no significant differences in outcome scores or function.^31-34 In a meta-analysis of 917 patients, Margaliot and colleagues³³ found no differences in pain, grip strength, wrist ROM, or radiographic parameters. More recently, in prospective randomized trials, both Egol and colleagues³¹ and Grewal and colleagues³⁴ compared hybrid external fixation with ORIF, and, though early outcomes favored ORIF, 1-year follow-up comparisons were even, and there were no significant differences. These consistently reproducible results reaffirm keeping external fixation in the orthopedic toolbox.

Definitive Reconstruction With ORIF

Early nonlocked dorsal plating options for DRF fixation had unacceptable rates of plate failure, poor cosmesis, and extensor tendon complications.^17,35-37 Subsequent technologic advances—multiple approaches, lower profile plating, and rigid, fragment-specific fixation—have allowed even the most complex fracture patterns to be addressed (Table). In malunited fractures, bone graft may not be required if the fracture is extra-articular and treated with a volar locking plate. [[{"fid":"201868","view_mode":"medstat_image_flush_left","attributes":{"class":"media-element file-medstat-image-flush-left","data-delta":"5"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"5":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Table.","field_file_image_credit[und][0][value]":""}}}]]Other options include corticocancellous autograft from the iliac crest, hydroxyapatite synthetic grafts, and osteoconductive bone graft substitutes, such as bone morphogenic proteins. In addition, healing times are similar in cases, regardless of whether a graft was used.³⁸

Involvement of the radial and intermediate columns should be addressed first. Although some may prefer a single volar plate, others may use fragment-specific fixation to buttress a comminuted radial styloid (in orthogonal fashion) and/or a dorsal ulnar fragment to restore the intermediate column and thereby fully restore the radial articular surface.^39,40 Typically, restoring the radial and intermediate columns for radial articular reduction subsequently and simultaneously restores the majority of radial height and length. After the radial and intermediate columns are reduced and stabilized, the need for ulna column fixation can be determined. Important factors in ulna column restoration are severe osteoporosis and ulna head and/or neck comminution. Significant comminution throughout the metaphysis of both the radius and the ulna may also warrant stabilizing the ulna with internal fixation. Finally, any DRU joint instability noted on examination should also favor fixing the ulnar side.

Assessment of the distal ulna in these complex fractures goes beyond the involvement of an ulnar styloid fracture. Typically, fractures at the base of the ulnar styloid have been reported to have little clinical relevance, including a low incidence of associated DRU joint problems.^41-43 Decisions to address the ulnar column are largely swayed by any instability found on DRU joint testing, as laxity caused by severe comminution can dictate the need for distal ring fixation to provide support. Even in the presence of a high-energy fracture in severely osteoporotic bone, the argument can be made to prevent instability by supporting the ulnar column. Stabilization of the ulnar articular surface can also be made more facile by creating an easier "A" fracture pattern (per AO classification) from a complex "C" to further aid in achieving efficient anatomical reduction. After preoperative planning is completed, depending on which columns need to be addressed, several surgical approaches can be considered to achieve maximum exposure and soft-tissue mobilization in order to successfully complete the operative fixation goals.

Volar Approach

An approach is selected for ideal exposure of a facile environment for definitive fixation. Access to the radial column can be gained with the extended flexor carpi radialis (FCR) approach. This approach allows visualization and removal of the appropriate deforming forces on the radial column to allow for fracture reduction by "opening the book," similar to that of tibial plateau reconstruction.^44,45 It may be prudent to perform a preincision Allen test as well as a preoperative DRU joint examination for comparison after ORIF is complete. Compared with the classic Henry approach near the distal radius, going through the volar sheath of the FCR avoids many of the perforating radial artery branches. Avoiding stripping the radial artery of its surrounding fat and lymphatics prevents postoperative "cold intolerance." Retracting the FCR ulnarly and then incising the dorsal FCR sheath provide ready access to the pronator quadratus after collective ulnar mobilization of both the FCR and the flexor pollicis longus.⁴⁴ In addition, for work near the distal FCR sheath, care must be taken to avoid the branch of the palmar cutaneous nerve that emerges about 5 cm proximal to the wrist flexion crease.⁴⁶

Once at the level of the pronator quadratus, an "L-shape" incision can be made to reflect the muscle off the radius. Care must be taken when working too distal to avoid transection of the inserting volar wrist ligaments.⁴⁴ Leaving a cuff for repair of the pronator remains controversial. In a recent case-control series, however, Hershman and colleagues⁴⁷ did not find significant differences in function or complication rate in patients with and without repair. After reflection, adequate exposure of the radial column should be achieved. Ready access to the radial styloid for orthogonal plating can be obtained by releasing the brachioradialis, which simultaneously releases one of the primary fracture deforming forces.⁴⁴ With this incision and exposure, if needed, dorsal bone grafting can be achieved from the volar side; however, care must be taken to protect the first dorsal compartment.⁴⁸ The cutaneous branch of the median nerve may be at risk with this exposure, but avoiding dissection ulnar to the FCR tendon can help to reduce this risk.⁴⁹

Before surgery, if the fracture pattern dictates a more ulnar approach, we prefer the extended carpal tunnel approach. Using the plane between the palmaris longus and the flexor digitorum superficialis medially and the FCR laterally, the extended carpal tunnel approach provides an obvious release of the flexor retinaculum but, more important, allows for extensile access to the sigmoid notch, the DRU joint, and the ulnar column.

Dorsal Approach

The dorsal approach is necessary in a few select cases. With a focus on fragment-specific fixation, presence of a significant dorsal ulnar fragment should warrant a dorsal approach.⁵⁰ In addition, in select, rare cases in which volar access is limited or unavailable, dorsal access is the only option.⁵⁰ Finally, if direct articular visualization is required, the dorsal approach typically is favored as the stronger radiocarpal ligaments found on the volar side are maintained.

Access should begin with an incision centered over the dorsal distal radius; a safe access point is just ulnar to the Lister tubercle. On incision of the retinaculum through a full-thickness excision, the third dorsal compartment is opened and the extensor pollicis longus (EPL) mobilized, fully exposing the dorsal distal radius. Work can be performed on either side of the EPL between the second and fourth dorsal compartments. Exposure typically is not an issue because of the pliable soft tissue of the dorsum, with ready access from styloid to styloid.⁴⁴ Here, low-profile plates and/or mini-fragment-specific plate options should be used to minimize potential tendon damage.⁵¹ Care must also be taken to avoid damaging the radiocarpal or scapholunate ligaments.⁴⁹ On closure, the retinaculum is repaired primarily; however, though some proponents advocate relocating the EPL tendon into its groove, we prefer leaving the EPL free within the surrounding soft tissue to reduce tension and promote unhindered excursion. The dorsal approach, though controversial and used inconsistently, should remain an important tool in anatomical restoration, especially in cases of complex fracture patterns.

Conclusion

Controversy still marks the lack of consensus on deciding which DRF treatment is optimal. Some investigators question moving away from external fixation and cite the lack of significantly better data relative to ORIF.^21,52 The same proponents note that the only advantage over external fixation is earlier return to function and cite reports of tendon rupture and complications with both dorsal and volar fixation options.^34,53-58 Other investigators find that operative treatment generally does not provide a significant improvement over nonoperative treatment.⁵⁹

With the advent of lower profile locked plating, fragment-specific fixation, and variable-angle devices, comparative clinical trials are finding it difficult to keep up.^60-64 Results from ongoing prospective randomized trials like ORCHID (Open Reduction and Internal Fixation Versus Casting for Highly Comminuted Intra-Articular Fractures of the Distal Radius; 500 patients >65 years old, 15 centers) will provide more definitive answers about ideal treatment.⁶⁵

Anatomical restoration involves a versatile array of fragment fixation and reconstruction. Careful preoperative planning and a consistent approach to restoring the radial, intermediate, and ulnar columns, along with a proper surgical approach, are ideal. Many advances in internal fixation have been exceedingly helpful. Use of external fixation, especially in a bridging fashion with or without supplementation, is still valuable in many situations.