ObjectiveThe objective of this study was to explore the experiences from the period after the choice was made for palliative, non-operative management for geriatric patients with a hip fracture, to the most important factors in the process, as reported by a proxy.DesignSemistructured interviews were conducted between 1 August 2020 and 1 April 2021 to investigate by-proxy reported patient experiences of non-operative management after hip fracture. Interviews followed a topic guide, recorded and transcribed per word. Thematic analysis was used to identify themes in the data.Setting and participantsPatients were retrospectively identified from the electronic patient record. Relatives (proxies) of the patients who underwent palliative, non-operative management were contacted and were asked to participate in a semistructured interview and were named participants. The participants were proxies of the patients since patients were expected to be deceased during the timing of the interview.ResultsA total of 26 patients were considered eligible for inclusion in this study. The median age of the patients was 88 years (IQR 83–94). The 90-day mortality rate was 92.3%, with a median palliative care period of 11 days (IQR 4–26). A total of 19 participants were subjected to the interview. After thematic analysis, four recurring themes were identified: (1) the decision-making process, (2) pain experience, (3) patient–relative interaction and (4) the active dying.ConclusionsWith the introduction of shared decision-making in an acute setting for geriatric patients with hip fracture, proxies reported palliative, non-operative management as an acceptable and adequate option for patients with high risk of adverse outcomes after surgery. The emerged themes in palliative care for patients with hip fracture show great similarity with severe end-stage disease palliative care, with pain identified as the most important factor influencing comfort of the patient and their environment after hip fracture. Future research should focus on further improving targeted analgesia for these patients focusing on acute pain caused by the fracture.
Purpose To evaluate healthcare utilization and satisfaction with treatment before and after implementing direct discharge (DD) from the Emergency Department (ED) of patients with simple, stable musculoskeletal injuries. Methods Patients with simple, stable musculoskeletal injuries were included in two Dutch hospitals, both level-2 trauma centers: OLVG and Sint Antonius (SA), before (pre-DD-cohort) and after implementing DD (DD-cohort). With DD, no routine follow-up appointments are scheduled after the ED visit, supported by information leaflets, a smartphone application and a telephone helpline. Outcomes included: secondary healthcare utilization (follow-up appointments and X-ray/CT/MRI); satisfaction with treatment (scale 1–10); primary healthcare utilization (general practitioner (GP) or physiotherapist visited, yes/no). Linear regression was used to compare secondary healthcare utilization for all patients and per injury subgroup. Satisfaction and primary healthcare utilization were analyzed descriptively. Results A total of 2033 (OLVG = 1686; SA = 347) and 1616 (OLVG = 1396; SA = 220) patients were included in the pre-DD-cohort and DD-cohort, respectively. After DD, the mean number of follow-up appointments per patient reduced by 1.06 (1.13–0.99; p < 0.001) in OLVG and 1.07 (1.02–0.93; p < 0.001) in SA. Follow-up appointments reduced significantly for all injury subgroups. Mean number of follow-up X-rays per patient reduced by 0.17 in OLVG ( p < 0.001) and 0.18 in SA ( p < 0.001). Numbers of CT/MRI scans were low and comparable. In OLVG, mean satisfaction with treatment was 8.1 (pre-DD-cohort) versus 7.95 (DD-cohort), versus 7.75 in SA (DD-cohort only). In OLVG, 23.6% of pre-DD-cohort patients visited their GP, versus 26.1% in the DD-cohort, versus 13.3% in SA (DD-cohort only). Physiotherapist use was comparable. Conclusion This study performed in a large population and additional hospital confirms earlier pilot results, i.e., that DD has the potential to effectively reduce healthcare utilization, while maintaining high levels of satisfaction. Level of evidence II. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01835-5.
Purpose There is currently no consensus on nonoperative management in adult patients after a stable type B ankle fracture. The aim of this review is to compare a removable orthosis versus a cast regarding safety and functional outcome in the NOM of stable type B ankle fractures. Methods A systematic review and meta-analysis were performed using randomized clinical trials and observational studies. The methodological quality of the included studies was assessed with the methodological index for non-randomized studies instrument. Nonoperative management was compared using the number of complications and functional outcome measured using the Olerud and Molander Score (OMAS) or the American Academy of Orthopaedic Surgeons Ankle Score. Results Five studies were included. Two were randomized clinical trials, and three were observational studies, including a total of 516 patients. A meta-analysis showed statistically significant higher odds of developing complications in the cast group [odds ratio (OR), 4.67 (95% confidence interval (CI) 1.52–14.35)]. Functional outcome in OMAS did not vary significantly at 6 weeks, mean difference (MD) − 6.64 (95% CI − 13.72 to + 0.45), and at 12 weeks, MD − 6.91 (95% CI − 18.73 to + 4.91). The mean difference of functional outcome in OMAS at 26 weeks or longer was significantly better in the removable orthosis group; MD − 2.63 (95% CI − 5.01 to − 0.25). Conclusion Results of this systematic review and meta-analysis show that a removable orthosis is a safe alternative type of NOM, as complication numbers are significantly lower in the orthosis group. In addition, no statistically significant differences were found in terms of functional outcome between a removable orthosis and a cast at 6 and 12 weeks. The 6-week and the 26-week OMAS results show that in patients with stable type B ankle fractures, a removable orthosis is non-inferior to a cast in terms of functional outcome.
BACKGROUND To cope with the rising number of trauma patients in an already constrained Dutch healthcare system Direct Discharge (DD) has been introduced in over twenty-five hospitals in the Netherlands since 2019. With DD, no routine follow-up appointments are scheduled after the Emergency Department (ED) visit, and patients are supported by information leaflets, a smartphone application, and a telephone helpline. DD reduces secondary healthcare utilization, with comparable patient satisfaction and primary healthcare utilization. Currently, little is known about the experiences of in-hospital healthcare professionals with DD. OBJECTIVE The aim of this study was to explore the experiences of healthcare professionals with the DD protocol to enhance durable adoption and improve the protocol. METHODS A mixed-method study was conducted parallel to the implementation of DD in three hospitals. Data were collected through a pre-implementation survey, post-implementation survey, and semi-structured interviews. Quantitative data were reported descriptively, and qualitative data using thematic analysis. Outcomes included the Bowen feasibility parameters: implementation, acceptation, preliminary efficacy, demand, and applicability. Pre-implementation expectations were compared with post-implementation experiences. Healthcare professionals involved in the daily clinical care for patients with low-complex, stable injuries were eligible for this study. RESULTS Of the 217 eligible healthcare professionals, 128 started the primary survey, 37 completed both surveys, and 15 participated in semi-structured interviews. Healthcare professionals expressed satisfaction with the DD protocol (median 7.8, IQR 6.8 to 8.9), noting improved information quality and uniformity, reduced outpatient follow-up, and imaging. DD was perceived as safe in its current form, but a feedback system to reassure healthcare professionals that patients had recovered adequately was suggested to improve DD. The introduction of DD had varying effects on workload and job satisfaction among different occupations. Healthcare professionals expressed intentions to continue using DD due to increased efficiency, patient empowerment, and self-management. CONCLUSIONS Healthcare professionals perceive DD as an acceptable, applicable, safe, and efficacious alternative to traditional treatment. A numerical in-app feedback system (e.g., in-application communication tools or recovery scores) could alleviate healthcare professionals’ concerns about adequate recovery and further improve DD protocols. DD can reduce healthcare utilization, which is important in times of constrained resources. Nonetheless, both advantages and disadvantages should be considered while evaluating this type of treatment. In the future, clinicians and policymakers can use these insights to further optimize and implement DD in clinical practice and guidelines. CLINICALTRIAL not applicable to this study
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