Orthopaedic Mortality

Transcription

1 Orthopaedic Mortality Lessons from VASM Nigel Broughton Orthopaedic Surgeon, Peninsula Health AOA Rep on VASM

2 Colin Russell Founder of VASM Director of Surgery, Peninsula Health First Clinical Director of VASM 2007

3 What can we learn from VASM? Big picture Collecting patients together Analysing data Case histories Identifying themes

4 VASM/ANZASM has a lot of data Victoria has 4,905 cases, nearly 800 orthopaedic Nationally 30,196 cases 5,700 Orthopaedic

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6 National survey of mortality after elective hip and knee replacements Ruban Ambikaipalin and Nigel Broughton patients Causes of death Use of VTE prophylaxis

7 Hip and knee replacements in Australia Primary elective hip replacements 164,075 Primary elective knee replacements 263,388 (NJRR) Mortality 0.05% (1 in 2,000)

8 103 cases Operation THR 44 TKR 58 Bilateral TKR 1 Hospital: Private: 29 Public: 50 Unknown: 25 Gender Males 64 Females ASA Grade

9 AGE >90 Age in years

10 Causes of death Cardiac 54 Thromboembolic 16 Pneumonia 13 Respiratory failure 5 CVA 8 GI bleed/ischaemia 6 Hepatic/renal failure 2 AAA 1

11 Days Post Op to to to 29 > 30

12 Orthopaedic Deaths in Victoria 2014 Terminal care 41 Non-participant 53 Surgical Case Form pending 48 Assessment pending 24 Details available 209 Total 375

13 Admission diagnosis of 209 cases Neck of femur fractures 154 (74%) Other femoral fractures 15 (7%)

14 Admission diagnosis of 209 cases Neck of femur fractures 154 (74%) Other femoral fractures 15 (7%) OA hip/knee for elective TJRs 8 (4%)

15 Admission diagnosis of 209 cases Neck of femur fractures 154 (74%) Other femoral fractures 15 (7%) OA hip/knee for elective TJRs 8 (4%) Sepsis 10 (5%) Prosthetic 5 (THR 3, TKR 1, plate 1) Native 5 (Elbow 2, knee 2, shoulder 1)

16 Others Ankle #s 4 Spinal cases 3 Tibial #s 3 Humeral #s 2 Acetabular #s 2 Hip pain, no # 2 AVN in ESRF 1 Distal radius 1 Loose Moores 1 Multi trauma 1 Torn rotator cuff 1 Recurrent dislocation THR 1

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19 Agnotology Doubt is our product 1969 Robert Proctor 1995 The study of wilful acts to spread confusion and deceit

20 Examples of Agnotology Anti-vaccination information

21 Examples of Agnotology Anti-vaccination information Climate change sceptics

22 Examples of Agnotology Anti-vaccination information Climate change sceptics VTE prophylaxis sceptics

23 NHMRC CPG for the prevention of VTE in Australian Hospitals 2009 The science is wrong It s a conspiracy to inflate pharmaceutical companies profits Risk/benefit It s too much trouble

24 Arthroplasty Society of Australia 2010 Guidelines for Thromboembolic Prophylaxis after Hip and Knee Joint Replacement- Weighing Efficacy Against Risk A major focus of the Arthroplasty Society of Australia is to ensure that joint replacement surgery is made as safe as possible, particularly by putting in place measures to decrease the incidence of thromboembolic disease. After consideration of the current literature, this statement is a consensus opinion from this group of specialist joint replacement surgeons. When considering the varying effectiveness of the methods of prevention, the risks of the thromboembolic disease that we wish to prevent need to be weighed against the risks of complications caused by preventative measures. Several effective measures to prevent thromboembolic disease have low complication rates. These include the institution of early mobilization regimes, spinal anaesthetic, graduated compression stockings, foot pumps and sequential pneumatic compression boots. Use of one or more of these measures is strongly suggested. For some patients who have a higher risk of thromboembolic disease, additional measures by a pharmacological method may also be indicated. Pharmacological or chemical methods include the use of aspirin, warfarin, heparin, low molecular weight heparins (i.e. Clexane, Fragmin, etc.), fondoparinux and the melagatran group. While chemical prophylaxis has been shown to reduce rates of deep venous thrombosis, it may not alter the more important incidence of pulmonary embolism or sudden death from embolic disease following surgery. All of these pharmacological methods have, however, significantly higher complication rates, which include limb swelling, haematoma, bleeding from the surgical site, wound breakdown, joint stiffness, increased infection rates, remote bleeding episodes, stroke and even death. The use and duration of these additional means need to be carefully considered and thoroughly discussed with the patient in this context.

25 Thrombo-embolic prophylaxis: View of FLA (209 cases) Appropriate 189 Inappropriate 1 Could not assess 17 No comment 2

26 What thrombo-embolic prophylaxis was used? (209 cases) Heparin/Clexane 160 Aspirin 4 Warfarin 3 Rivaroxaban 2 Total 169 Seq comp 8 TEDs 4 Total 12 Inappropriate/withheld 18 No comment 9 Not considered 1

27 103 cases Clexane 78 Clexane and aspirin 10 Aspirin 6 Rivaroxaban 1 Warfarin 1 None 7

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29 Themes arising from Case Notes Recognition of the deteriorating patient More senior involvement Better interaction between ED and Ortho Delays to surgery

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32 Themes arising from Case Notes Use of calibration discs in NOF X-rays When to operate on patients on clopidogrel NFR documentation

33 How do we effect change? Advocate from the craft group Leadership support Access to means of communication

34 How do we effect change? Advocate from the craft group Leadership support Access to means of communication Local discussions Embrace the data don t shun it

35 What can VASM do to become more relevant to us? Have input from the AOA rep on all orthopaedic cases in the CNR booklets Separate out the Orthopaedic cases in the CNRs Identify Orthopaedic themes in the Annual Report

36 Where to now? Challenges Improvements Outcome measures

37 Thank you

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