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Chirurgie bij de trauma‐patiënt : kwaliteit door beschikbaarheid
Guy PutzeysOrthopedie
AZ Groeninge Kortrijk Voormalig voorzitter BOTA
Voorzitter AO Belux
Symposium : Traumatologie in het operatiekwartier: van chaos naar structuur Vrijdag 13/3/2015
overview
II. orthopedic traumatology
III. orthopedic trauma operating room
I. Background: trauma in Belgium
IV. casus
V. Conclusion
2. psychological shock or severe distress from experiencing a disastrous event outside the range of usual experience
Trauma : definition
1. physical : a body wound or shock produced by physical injury
• No internationally recognised standard definition
Major trauma
• Regional : admission to an intensive care unit ; Injury Severity Score (ISS) over 12, urgent surgery , life‐changing injury …
Traumachain
Pre hospital•Bystander first aid• Emergency service dispatch
•Roadside criticalintervention
•Transport toappropriate unit
In hospital• Early resuscitation•Rapid diagnosis• Early specialist intervention• Intensive care•hospitalisation
Post hospital•Revalidation•Ambulatory
Plaats van ongeval•Ambulancier•Spoedarts•Spoed VPK
Spoed•spoed VPK •Spoedarts •brevet•akutist•Urgentist
•Chirurg•Orthopedisch chirurg
•Neurochirurg•Vaat/thorax•Abdominaal•Urologisch•traumachirurg
Radiologie•Rx vpk•radioloog
OK•Operatie VPK•Algemeen•trauma•Anesthesist•chirurg
IZ•IZ VPK•Intensivist•chirurg
Afdeling•Afdeling VPK•chirurg
Revalidatie •Rev VPK•Rev artsen•chirurg
INFRASTR
CAREGIVER
Traumasystem Definition :
‐ organized, coordinated care of “major “trauma ‐ geographical‐ Complete chain of trauma‐care ( prehosp revalidation)‐ integrated in the public health‐care
Traumachain
Network design
deliver the patient rapidly and safely to the
Principle 1
Principle 2
Evolve care models and pathways
Principle 3
Registration
Regional Network design major trauma
Major Trauma Centre (level 1)
Trauma Unit (level 2)
Local Emergency Hospital (level 3)
3 types of hospital:
Major Trauma in England:Odds of survival
2008-9 2009-10 2010-11 2011-12 2012-13
1.6
1.3
1.0
0.6
0.3
Odds ratioof survival
year
0.92
1.09 1.06
TARN
All hospitalsISS 8+All age groupsN=62,290
MTN live
1.20
1.31
2013-14
p = 0.04
Economisch
The development of a strong trauma program is clearlyone of the most important facets of successful business development.Several recent publications have demonstrated that well run trauma services can generate significant profits for both the hospital and the surgeons involved.
Trauma Program DevelopmentPeter L. Althausen, MD, MBA J Orthop Trauma 2014
Trauma in Belgium
clinician driven
surgical societies with exclusive interest in trauma
scientific organisations personaland/or
• BESEDIM : belgian society of emergency and disaster medicine
• BOTA: belgian orthopaedic trauma association ( orthop. + MST surgeons)• BTS: belgian trauma society ( surgeons)• AOTrauma: international society ( orthop. surgeons andtrauma‐surgeons)
Non‐surgical society
February 2010
“Current services for people who suffer major trauma are not good enough.”
“”””identifying poor practice,the Department of Health and NHS have taken very little actionto improve major trauma care”
The Department of Health and NHSmust get a grip of coordinating servicesh trauma networks…..…if they are to prevent unnecessary deaths”
II. Orthopedic trauma‐care in Belgium
Ter plaatse•Ambulancier•Spoedarts•Spoed VPK
Spoed•VPK •Spoedarts •brevet•akutist•Urgentist•Chirurg•Orthopedisch chirurg
•Neurochirurg•Vaat/thorax•Abdominaal•Urologisch•traumachirurg
Radiologie•Rx vpk•radioloog
OK•Operatie VPK•Algemeen•trauma•Anesthesist•chirurg
IZ•IZ VPK•Intensivist•chirurg
Afdeling•Afdeling VPK•chirurg
Revalidatie •Rev VPK•Rev artsen•chirurg
Orthopedic trauma surgery
Orthopedicsurgeon
General surgeon
Importance of trauma for orthopedics in Belgium
• Data AZG ( 1000‐bed hospital, 10 orthopedicsurgeons) :
Aantal jaar
traumazaal Campus VL
2010 1071 3671
2011 1028 3797
2012 1024 4085
2013 1141 4213
2014 1074 4039
25 tot 30% of our job
operations hipfracture AZG
prothese Nagel‐schroef
Plaat‐schroef
totaal
2011 115 112 28 255
2012 104 126 17 247
2013 107 140 24 271
2014 108 134 22 264
Need for an Orthopaedic trauma roomdedicated orthopaedic operating room (DOOR)
a daily, daytime unbooked operating room reserved for the treatment of patients with nonemergent orthopaedic trauma and staffed with experienced orthopaedicpersonnel
Definition:
Emergency operating room
efficient and cost‐effective operations
extra flexibility with direct and indirect cost
optimum patient care
Literature1. Elder GM, Harvey EJ, Vaidya R, et al. The effectiveness of orthopaedic trauma
theatres in decreasing morbidity and mortality: a study of 701displaced subcapitalhip fractures in two trauma centres. Injury. 2005
4. Min W, Wolinsky PR. The dedicated orthopedic trauma operating room. J Trauma. 2011
2. Bhattacharyya T, The value of the dedicated orthopaedic trauma operating room. J Trauma. 2006 . (shorter operative times for femoral roddings )
3. Wixted J. The effect of an orthopedic trauma room on after‐hours surgery at a level one trauma center. J Orthop Trauma. 2008.
6. Timothy T. Roberts, MD Dedicated Orthopaedic Operating Rooms: Beneficial toPatients with femoral neck fractures and Providers Alike J Orthop Trauma Jan 2015
5. Althausen PL Operating room efficiency: benefits of an orthopaedic traumatologist at a level II trauma center. J Orthop Trauma. 2014
• decrease night time surgery • improve morbidity and mortality rates • decrease complication rates • decreased operative times• increase personal and professional lifestyles • improve physician recruitment • increase surgeon retention• a greater proportion of cases done by fellowshiptrainedtraumatologists.
Value of DOOR :
Complexity orthopaedic trauma surgery
• Surgical technique• Surgical team• Implants• Infrastructure• Operation table• Imaging ……
An art in itself …
Many types of very specific implants
0
10
20
30
40
50
60
Mathys Thahyti Biomet DePuy
2011
2012
2013
2014
2015
0
20
40
60
80
100
IMHS PFNa Gamma
2011
2012
2013
2014
2015
• Emergency operating room (OR) access 24/7/365• OR availability for orthopaedic trauma cases Mon through Sat 7 AM–5 PM.• Orthopaedic OR nursing staff lead for organizing implants,instruments, etc.• One physician assistant (PA)/orthopaedic trauma surgeon FTE• sufficient image intensifiers and trained radiology technicians• Funded call support coverage (ie, stipend)• implant systems IM nailing, exfix, plating, and arthroscopy• CME• Clinic follow‐up • Commitment from emergency department physician leadershipto increase orthopaedic injury triage capabilities• a research coordinator in level I and level II centers
Requirements of an orthopaedic trauma service :
AAOS / OTA ASSOCIATION POSITION STATEMENT
In return :
• Quality assurance direction and leadership• Must have hospital indemnification• Morbidity and mortality conferences• Responsibility for call schedule coverage and making the call schedule• Commitment to limit variation in implant usageThis can substantially reduce direct costs
• Explore gain sharing/comanagement agreements• Serve on committee for new products and orthobiologics• Continuing medical education leadership and involvementfor OR staff, staff physicians, floor nurses, and clinic staff
• Include structured fracture conferences for trauma panelmembers to share cases
• Regular review of fiscal impact of the service with hospitaladministration
Conclusie: dringend nood aan
Orthopedisch traumatoloog binnen dienst orthopedie
Traumasysteemketentraumateamtraumazaaltrauma verpleegkundigen