Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs. DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding. Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients. Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage. Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents. 

/pdf/review-of-perioperative-outcomes-and-management-of-hip-26o5927y.pdf

Review of perioperative outcomes and management of hip fracture patients on direct oral anticoagulants

Introduction Orthopaedic trauma patients are at high risk of venous thromboembolism (VTE). As VTE prophylaxis has gradually raised public concerns, guidelines related to this topic have increased over time. However, the existing recommendations of thromboprophylaxis guidelines in orthopaedic trauma patients are still inconsistent, and the quality of the guidelines and recommendations for the topic still lacks comprehensive assessments. This review aims to critically appraise clinical practice guidelines for thromboprophylaxis in orthopaedic trauma patients. Methods and analysis We will conduct a comprehensive literature search up to 31 October 2022 in databases (PubMed, EMBASE, CINAHL, Web of Science, the Cochrane Library, etc), academic websites and guideline repositories. The quality of the guidelines and recommendations will be assessed by five reviewers independently using the Appraisal of Guidelines Research and Evaluation II instrument (AGREE-II) and the AGREE - Recommendation EXcellence (AGREE-REX). We will summarise the characteristics of the guidelines and compare the differences between these recommendations. Ethics and dissemination This study will follow the Declaration of Helsinki and has received approval from the Ethics Committee on Biomedical Research, West China Hospital, Sichuan University (ethics approval no. 2021-989). The results will be summarised as a paper, disseminated through peer-reviewed journals, and will help guide further research in the future. Protocol registration number CRD42021273405.

/pdf/quality-evaluation-of-clinical-practice-guidelines-for-gj6b927j.pdf

Quality evaluation of clinical practice guidelines for thromboprophylaxis in orthopaedic trauma based on AGREE II and AGREE-REX: a systematic review protocol

OBJECTIVES
Canadians are at an increased risk of outdoor slip and fall accidents during periods of ice and snow. The aim of this study was to create an index to alert the public of slippery outdoor conditions and promote pedestrian safety.


METHODS
Emergency department (ED) presentations from the four adult hospitals in Calgary, Alberta, Canada, over an 11-year period (January 2008‒December 2018) were extracted and filtered using the ICD-10 code W00 (fall due to ice and snow). Multivariable dispersion-corrected Poisson regression models were used to determine the variables most predictive of these presentations. Month of year, the presence of ice, snow on ground (per 10 cm), and interactions between ice and snow, all up to 3 days prior, were used to create the Slip and Fall Index (SFI).


RESULTS
The dataset included 14,977 slip and fall on ice/snow ED presentations. Females (57.36%, n = 8591) accounted for more presentations than males (42.64%, n = 6386). All months had a significant effect, either being predictive or protective of slip and falls on ice/snow. Current-day ice, snow on ground, and ice up to 3 days prior were predictive of increased presentations. Month and measurements of ice and snow can be input into the SFI, which generates the level of daily risk.


CONCLUSION
The SFI is the first Canadian index with the purpose of measuring the risk of having a slip and fall accident on ice/snow.

The Slip and Fall Index: Assessing the risk of slipping and falling on ice.

Aim: To evaluate patients’ and family members’ perceived support from light and color before, compared with after an evidence-based design (EBD) intervention at an emergency department (ED) using a validated instrument—the Light and Color Questionnaire (LCQ). Background: EDs offer acute care day and night. Thus, a supportive physical environment where light and color is crucial for how the milieu is experienced is vital. Research is limited on how care settings are perceived as supportive by users. Methods: Quasi-experimental evaluation of the refurbishing and remodeling of an ED by an expert group of nurse managers, nursing staff, nursing researchers and architects in south Sweden. LCQ includes dimensions “maximizing awareness and orientation,” “maximizing safety and security,” “supporting functional abilities,” “providing privacy,” “opportunities for personal control” (not for LCQ-Color), and “regulation and quality of stimulation.” LCQ was analyzed and compared in 400 surveys from 100 patients and 100 family members before the intervention and 100 patients and 100 family members after the intervention. Results: The LCQ total score significantly improved after the intervention for both patients and family members. Four of the six dimensions of LCQ Light subscale scores were significantly higher for family members, and three of the six dimensions were significantly higher for patients after the intervention. The LCQ Color subscale score showed significant improvements for all five dimensions for both patients and family members after the intervention. Conclusion: This study showed improved perceived support from light and color in the physical environment for patients and family members after an EBD intervention at an emergency department using a validated instrument—the Light and Color Questionnaire.

/pdf/the-perceived-support-from-light-and-color-before-and-after-128ot44x.pdf

The Perceived Support From Light and Color Before and After an Evidence-Based Design Intervention in an Emergency Department Environment: A Quasi-Experimental Study

OBJECTIVE
to assess the epidemiological profile of trauma patients from fall from the same level (FSL) and fall from an elevated level (FEL) during the COVID-19 pandemic, and to compare it with data from different levels of restriction (flags) and data prior to the pandemic.


METHOD
a cross-sectional study with a probability sample of the medical records of patients aged 18 years or older admitted to the emergency room due to falls, from June 2020 to May 2021. Epidemiological data, such as sex, age and injuries were analyzed, as well the current level of restriction. The three restriction periods were compared between then and the proportion of admissions due to falls was compared with the period from December 2016 to February 2018.


RESULTS
a total of 296 admissions were evaluated, 69.9% were victims of FSL and 30.1% of FEL. The mean age was 57.6 years, and 45.6% were over 60 years old. Admissions among men predominated, and 40.2% of patients required hospitalization. During the red flag period, there were proportionally more injuries to the head and neck (p=0.016), injuries to extremities (p=0.015) and neurological trauma (p<0.001). An average of 6.1, 6.3 and 5.2 admissions per day was obtained during the yellow, orange and red flag, respectively. There was a relative increase in falls when compared to the pre-pandemic period.


CONCLUSIONS
there was an absolute reduction in admissions of victims of falls in midst of the most restrictive period during the pandemic. However, when compared to pre-pandemic data, there was a relative increase in falls.

Influence of the COVID-19 pandemic on the epidemiological profile of the initial care of victims of falls.

Introduction Orthopaedic surgeons often speculate weather and season impact the nature and volume of surgical trauma. Little evidence exists to support this. We aimed to identify the relationship between weather conditions, time of year, surgical orthopaedic trauma volumes, after-hours surgery, and surgical wait times. Methods Unscheduled surgical orthopaedic cases were retrospectively reviewed at major adult hospitals in Calgary, Alberta, Canada, over an eleven-year period (2008–2018). Weather variables were gathered and a predictive model for ice was generated. Multivariable Poisson regression was used to determine the effect of weather and time of year on orthopaedic trauma volumes and after-hours surgery. Linear regression was used to investigate surgical wait times. Results 41,421 unscheduled orthopaedic trauma surgeries were analyzed against daily weather patterns. 49% of all surgery performed was for hip (26.4%) or ankle fractures (22.6%). Same day snow (p=0.002) and ice for two days prior (p=0.031; p=0.003) were significantly associated with increased overall trauma volumes. Same day snow (p Conclusion Winter and summer months as well as ice and daily snow contributed to the most significant increases in overall orthopaedic trauma volumes. On a snowy day in February with ice present for three consecutive days, trauma volumes increased as much as 71%. Despite this, resources dedicated to orthopaedic trauma are consistent throughout the year, which highlights the need to allocate resources for orthopaedic trauma surgery based on seasonal demands. We suggest our predictive model be used to guide the amount of operating room time reserved for orthopaedic trauma to better reflect expected volumes. This contrasts the current system which relies on after-hours surgeries and increased patient wait-times to compensate for increased orthopaedic trauma volumes. Since orthopaedic trauma can be predicted by weather patterns, interventions should aim to decrease weather-related orthopaedic trauma and reduce the burden prolonged wait times have on our system.

FROST: Factors Predicting Orthopaedic Trauma Volumes.

Background: Direct oral anticoagulants (DOACs) are rapidly replacing warfarin for therapeutic anticoagulation; however, many DOACs are irreversible and may complicate bleeding in emergent situations such as hip fracture. In this setting, there is a lack of clear guidelines for the timing of surgery. The purpose of this study was to evaluate the current practices of Canadian orthopedic surgeons who manage patients with hip fracture receiving anticoagulation. Methods: In January–March 2018, we administered a purpose-specific cross-sectional survey to all currently practising orthopedic surgeons in Canada who had performed hip fracture surgery in 2017. The survey evaluated approaches to decision-making and timing of surgery in patients with hip fracture receiving anticoagulation. Results: A total of 280 surgeons representing a mix of academic and community practice, seniority and fellowship training responded. Nearly one-quarter of respondents (66 [23.4%]) were members of the Canadian Orthopaedic Trauma Society (COTS). Almost three-quarters (206 [73.6%]) felt that adequate clinical guidelines for patients with hip fracture receiving anticoagulation did not exist, and 177 (61.9%) indicated that anesthesiology or internal medicine had a greater influence on the timing of surgery than the attending surgeon. A total of 117/273 respondents (42.9%) indicated that patients taking warfarin should have immediate surgery (with or without reversal), compared to 63/270 (23.3%) for patients taking a DOAC (p Conclusion: There is wide variability in Canada in the management of patients with hip fracture receiving anticoagulation. Improved multidisciplinary communication, prospectively evaluated treatment guidelines and focus on knowledge translation may add clarity to this issue. Level of evidence: IV.

/pdf/management-of-patients-with-hip-fracture-receiving-2st7vlyykv.pdf

Management of patients with hip fracture receiving anticoagulation: What are we doing in Canada?

Objectives: The aim of this study is to report the impact of public health measures (PHM), including their relaxation, on surgical orthopaedic trauma volumes. We hypothesize an initial reduction in orthopaedic trauma volumes during lockdown followed by a surge as Stages 1 and 2 of reopening progressed in Summer 2020. Methods: All unscheduled surgical orthopaedic trauma cases from March through August were retrospectively reviewed in Calgary, Alberta, Canada, from 2008 to 2020. Trauma volumes from 2008 to 2019 were used to model expected 2020 volumes, and multivariable Poisson regression was used to determine the effect of PHM on orthopaedic trauma volumes. Results: A total of 22,331 trauma orthopaedic surgeries were included. During lockdown, there was a significant decrease in trauma volume compared with expected (-14.2%, -25.7 to -10.5%, Pâ<â.001) and there were significantly fewer ankle fractures (-17.8%, -30.9 to -2.2%, Pâ=â.027). During reopening Stage 2, there was a significant increase in trauma volume (+8.9%, +2.2 to +16.1%, Pâ=â.009). There was no change in the incidence of polytrauma, hip fracture, or wrist fracture during the pandemic. Conclusions: This study provides the first report of a surge in trauma volumes as PHM are relaxed during the COVID-19 pandemic. The ability to predict decreases in trauma volumes with strict PHM and subsequent surges with reopening can help inform operating room time management and staffing in future waves of COVID-19 or infectious disease pandemics. Level of Evidence: Prognostic - Level III.

COVID-19 orthopaedic trauma volumes: a Canadian experience during lockdown and staged reopening.

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FROST: Factors Predicting Orthopaedic Trauma Volumes.

Management of patients with hip fracture receiving anticoagulation: What are we doing in Canada?

COVID-19 orthopaedic trauma volumes: a Canadian experience during lockdown and staged reopening.