Objective Templating of the acetabular cup size in Total Hip Replacement (THR) is normally done using conventional radiographs. As these are being replaced by digital radiographs, it has become essential to create a technique of templating using digital films. We describe a technique that involves templating the digital films using the universally available acetate templates for THR without the use of special software. Materials and methods Preoperative digital radiographs of the pelvis were taken with a 30 mm diameter spherical metal ball strapped over the greater trochanter. Using standard acetate templates provided by the implant company on magnified digital radiographs, the size of the metal ball (X mm) and acetabular cup (Y mm) were determined. The size of the acetabular cup to be implanted was estimated using the formula 30*Y/X. The estimated size was compared with the actual size of the cup used at surgery. Results Using this technique, it was possible to accurately predict the acetabular cup size in 28/40 (70%) of the hips. When the accuracy to within one size was considered, templating was correct in 90% (36/40). When assessed by two independent observers, there was good intra-observer and inter-observer reliability with intra-class correlation coefficient values greater than 0.8. Conclusion It was possible to accurately and reliably predict the size of the acetabular cup, using acetate templates on digital films, without any digital templates.

Accuracy of templating the acetabular cup size in Total Hip Replacement using conventional acetate templates on digital radiographs.

INTRODUCTIONInformed consent is an ethical and legal prerequisite for major surgical procedures. Recent literature has identified ‘poor consent’ as a major cause of litigation in trauma cases. We a...

The influence of process and patient factors on the recall of consent information in mentally competent patients undergoing surgery for neck of femur fractures

Objective:To study the perception of informed consent among various raters for thrombolysis in acute ischemic stroke patients receiving intravenous tissue plasminogen activator (IV-tPA). Methods:Twenty randomly selected videotaped telestroke consultations of acute stroke patients administered IV-tPA were retrospectively reviewed. Adequacy of informed consent was reviewed by five raters: a neurologist and emergency physician who routinely treat stroke, a medical risk management paralegal, a bioethicist, and a lay person. Raters assessed the quality of the informed consent presentation by the treating physician and the degree of understanding demonstrated by the patient/family authorizing consent. Factors associated with adequacy of consent were analyzed. Results: Consent was rated as adequately understood by the patient-family in 78.6% cases. Agreement between all five raters with regard to the patient-family understanding of consent was poor and also between the subgroups of non-physician and physician (all k < 0.20). Similarly, the quality of the physician consent process was poor for agreement between all five raters (kD 0.07) or between the subgroup of the three non-physician raters (kD 0.06) and fair between the two physician raters (kD 0.24). The legal reviewer and the bioethicist rated the physician consent process as being of lower quality than did the two physicians and the layperson. Conclusion: Despite high variability in the perception of informed consent among raters in this time-sensitive clinical situation, almost 80% of patients were rated by all reviewers as having adequate understanding of risks and benefits of tPA. This suggests the need for a standardized but brief tPA consent process that includes patient/family demonstration of understanding.

/pdf/variability-in-the-perception-of-informed-consent-for-iv-tpa-2w15xgulgl.pdf

Variability in the Perception of Informed Consent for IV-tPA during Telestroke Consultation

Background Obtaining informed consent in the clinical setting is an important yet challenging aspect of providing safe and collaborative care to patients. While the medical profession has defined best practices for obtaining informed consent, it is unclear whether these standards meet the expressed needs of patients, their families as well as healthcare providers. The authors sought to address this gap by comparing the responses of these three groups with a standardised informed consent paradigm. Methods Piloting a web-based ‘reverse’ simulation paradigm, participants viewed a video showing a standardised doctor engaging in an informed consent discussion. The scenario depicted a simulated patient with psychotic symptoms who is prescribed an atypical antipsychotic medication. 107 participants accessed the simulation online and completed a web-based debriefing survey. Results Survey responses from patients, family members and healthcare providers indicated disparities in information retention, perception of the doctor9s performance and priorities for required elements of the consent process. Conclusions To enhance existing informed consent best practices, steps should be taken to improve patient retention of critical information. Adverse events should be described in the short-term and long-term along with preventative measures, and alternative psychosocial and pharmacological treatment options should be reviewed. Information about treatment should include when the medication takes therapeutic effect and how to safely maintain the treatment. The reverse simulation design is a model that can discern gaps in clinical practice, which can be used to improve patient care.

https://jme.bmj.com/content/medethics/38/9/546.full.pdf

Enhancing informed consent best practices: gaining patient, family and provider perspectives using reverse simulation

Currently in Ireland, there is a lack of uniformity regarding the method in which the consent process is routinely documented. The purpose of this study was to evaluate the standard consent forms used in elective orthopaedic hospitals in Ireland. In addition, this paper explores the relevant guidelines from the UK and Ireland relating to consent documentation. Standard consent forms used in the 24 public hospitals that perform elective orthopaedic surgery were analysed and compared, based on the inclusion or exclusion of 22 unique consent-related items or statements selected by the authors. In addition, each form was analysed for format, word count, and readability. Within 24 hospitals with elective orthopaedic surgery, there were 21 unique consent forms being used. There was a mean inclusion of 9.5 of the 22 unique items per form with a standard deviation of 5.1 (range 2–18), indicating a wide discrepancy. For each unique consent-related item in the analysis, the mean rate of inclusion was 43.4% (SD 26.7%). The mean Flesch Reading Ease Score was 43.3. The format varied from 1 to 4 pages, with a word count of 109 to 1041 (mean 414.7). The findings demonstrate a lack of uniformity of both format and content amongst the consent forms currently being used in elective orthopaedic hospitals in Ireland. This paper supports the use of a nationally standardised consent documentation method in order to improve the efficiency of the consent process and ensure greater protection against litigation.

Consent documentation for elective orthopaedic surgery.

Consent plays a vital role in every aspect of medicine and surgery, facilitating the patient in making informed decisions about their treatment. The recently published Reference Guide to Consent, by the Department of Health (DH), notes that, although not a legal requirement, the completion of consent forms is good practice, particularly in interventions such as surgery. In addition, the Parliamentary and Health Service Ombudsman noted that a significant number of complaints about consent involved the complainant feeling that they did not fully understand what was going to happen. It was often found that there was no documentation to clarify what the patient was told, when and by whom. We have performed an audit of 71 randomly selected consent forms, elective and trauma cases within our district general hospital orthopaedics department. Our data demonstrate that a significant number of consent forms were incorrectly or insufficiently completed. This could not only leave the patient confused about their procedure but also leaves the doctor open to litigation, with little in the way of documentation support. Minor changes in consenting methods and more precise documentation could significantly improve patient experience and satisfaction.

https://jme.bmj.com/content/medethics/36/7/407.full.pdf

Quality of consent form completion in orthopaedics: are we just going through the motions?

Preoperative planning plays an important role in any surgical procedure and total hip replacement (THR) is no exception Templating of radiographs allows preoperative assessment of the correct size of implant to be used, lowers the risk of periprosthetic fracture, helps restore femoral offset and leg length, facilitates the optimisation of alignment and ensures the correct implants sizes are available All of these reduce the intraoperative pressures leading to the selection of incorrectly sized implants This study assessed whether there is adequate provision of the current NHS Picture Archiving and Communication Systems (PACS) to allow optimal digital templating for THRs Data were collected using a telephone questionnaire requesting information from the on-call orthopaedic SpR in 28 Greater London and surrounding area NHS Hospitals PACS were used in all 28 (100%) hospitals that were contacted Digital templating software was available in 14 (50%) hospitals Despite this, none of them performed digital templating regularly In the 50% that did have digital templating, this was not routinely done for the following reasons; only 3 (107%) allowed easy access to the software to the SpRs; only one SpR received formal training on how to use the system; only one hospital regularly used methods to accurately allow the software to assess magnification for accurate sizing (eg sizing balls) Digital PACS systems have made great improvements in the access of radiographs in the NHS In orthopaedic practice, however, we have shown that the benefit of digital templating is being overlooked within the NHS

Digital templating in total hip arthroplasty in the NHS: ‘computer says no…’

Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock

Introduction: Preoperative planning plays an important role in any surgical procedure and total hip replacement (THR) is no exception. Templating of radiographs allows preoperative assessment of the correct size of implant to be used, lowers the risk of periprosthetic fracture, helps restore femoral offset and leg length, facilitates the optimisation of alignment and ensures the correct implants sizes are available. With the wide scale use of Picture Archiving and Communication Systems (PACS) in the National Health Service (NHS), the potential exists for faster and more accurate templating of THRs. Aim: In performing this study, we assessed whether there is adequate provision of the current NHS PACS to allow optimal digital templating for THRs. We also made comparison between the availability and overall ease of conventional versus digital templating. Methods: Data was collected using a telephone questionnaire requesting information from the on-call orthopaedic Specialist Registrar (SpR) in 28 Greater London and surrounding area NHS Hospitals. Data on the availability of PACS and the ability to template using hard-copy or digital templating was collected and analysed. Results: PACS were used in all 28 (100%) hospitals that were contacted. None performed conventional templating regularly and only 8 (28.6%) admitted to occasional templating. The predominant reason for this was difficulty in obtaining hard copies of x-rays in 12 (42.9%) hospitals, as well as lack of availability acetate templates, with 13 (46.4%) claiming that this was the case. Digital templating software was available in 14 (50%) hospitals. Despite this, none of them performed digital templating regularly. In the 50% that did have digital templating, this was not routinely done for the following reasons: only 3 (10.7%) allowed easy access to the software to the SpRs only one SpR received formal training on how to use the system only one hospital regularly used Methods: to accurately allow the software to assess magnification for accurate sizing (e.g. sizing balls) Discussion: Digital PACS systems have made great improvement in the access of radiographs in the NHS. With regards to orthopaedic practice, however, we have shown that the benefit of digital templating is being overlooked within the NHS.

Digital templating in total hip arthroplasty in the nhs: ‘computer says no…’


 
 
 The aim of this study was to analyse the necessity of routine group and saves (G+S) in patients undergoing laparoscopic cholecystectomies and to establish whether it would be safe to cease this practice. In doing so, we aim to reduce financial burden and workload, whilst maintaining safe clinical outcomes.
 
 
 
 This was a retrospective study into all consecutive patients that underwent an elective or emergency laparoscopic cholecystectomy in Royal Hampshire County Hospital (RHCH) from May 2019 - May 2021. IT systems and clinical notes were analysed to identify the quantity of pre-operative G+S samples sent, and the proportion of patients that required a postoperative blood transfusion.
 
 
 
 Over 24 months, 427 laparoscopic cholecystectomies were performed in RHCH, 70% of which were elective. In total, 682 G+S samples were processed (1.6/patient), resulting in a cost of £16504. Two patients received a postoperative blood transfusion (0.5%). One of these patients presented with an UGI bleed, whilst the other presented with a haemolytic crisis. They were therefore predictable, pre-operative conditions, for which a post-operative transfusion had been planned prior to surgery.
 
 
 
 In conclusion, this study suggests that performing routine G+S for all laparoscopic cholecystectomy patients has created an unnecessary workload and financial burden on this small DGH. Furthermore, during this 24 month, this practice had no clinical advantage. We therefore advise that sending pre-operative G+S samples should be a clinical decision made on a case-by-case basis, rather than a default for all patients.


/pdf/265-group-and-saves-for-laparoscopic-cholecystectomies-an-gsninrxv.pdf

265 Group and Saves for Laparoscopic Cholecystectomies: An Unnecessary Expense?

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