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Background and Purpose: Reduced mobility is a severe threat to the clinical outcomes and survival of elderly hip fracture patients. These patients generally struggle to comply with partial weight bearing, yet postoperative weight-bearing restrictions are still recommended by nearly 25% of surgeons. Therefore, we hypothesized that weight-bearing restrictions in elderly hip fracture patients merely leads to reduced mobility, while transposing full weight to the fractured extremity remains unaffected disregarding the prescribed aftercare., Patients and Methods: 41 equally treated patients with pertrochanteric fractures were enrolled consecutively in a maximum care hospital in a pre-post study design (level of evidence 2). A study group of 19 patients was instructed to maintain partial weight bearing (PWB), whereas the control group of 22 patients was instructed to mobilize at full weight bearing (FWB). All patients were asked to participate in a gait analysis using an insole force sensor (loadsol ® , Novel, Munich, Germany) on the fifth postoperative day., Results: The postoperative Parker Mobility Score in the PWB group compared to the FWB group was significantly reduced (3.21 vs. 4.73, p < 0.001). Accordingly, a significantly lower gait speed in the PWB group of 0.16 m/s vs. 0.28 m/s was seen (p = 0.003). No difference in weight bearing was observed in between the groups (average peak force 350.25 N vs. 353.08 N, p = 0.918), nor any differences in the demographic characteristics, ASA Score, Barthel Index or EQ5D., Interpretation: Weight-bearing restrictions in elderly hip fracture patients contributed to a loss of mobility, while no significant differences in loading of the affected extremity were observed. Therefore, postoperative weight-bearing restrictions in elderly hip fracture patients should be avoided, to achieve early mobilization at full weight bearing.

Purpose: Patients are sometimes admitted to intensive care units (ICU) after elective noncardiac surgery for advanced monitoring and treatments not available on a general postsurgical ward. However, patterns of ICU utilization are poorly understood. Our aims were to assess the incidence and determinants of ICU utilization after elective noncardiac surgical procedures., Methods: Population-based cohort study included adult patients who underwent 13 types of major elective noncardiac surgical procedures between 2006 and 2014 in Ontario, Canada. Primary outcome was early admission to ICU within 24 h after surgery. A prespecified analysis using multilevel logistic regression modeling separately examined patient- and hospital-level factors associated with early ICU admission within distinct groups of surgical procedures., Results: Early ICU admission occurred in 9.6% of the included 541,524 patients. Patients admitted early to ICU showed higher median age (68 vs. 65 years), burden of prehospital comorbidities (Charlson comorbidity index score ≥ 2, 33.1 vs. 10.4%), 30-day mortality rates (2.4 vs. 0.3%), and longer median postoperative hospital stays (6 vs. 4 days) than patients admitted to a ward. There was wide variation in proportions of patients admitted early to ICU across different surgery types (0.9% for hysterectomy to 90.8% for open abdominal aortic aneurysm repair) with generally low 30-day mortality across procedures (0.1-2.8%). Within individual procedures, there was wide interhospital variation in the range of early ICU admission rates (hysterectomy 0.07-14.4%, lower gastrointestinal resection 1.3-95%, endovascular aortic aneurysm 1.3-95.2%). The individual hospital where surgery was performed accounted for a large proportion of the variation in early ICU admission rates, with the median odds ratio ranging from 2.3 for hysterectomy to 21.5 for endovascular aortic aneurysm., Conclusions: There is a wide variation in early ICU admission across and within surgical procedures. The individual hospital accounts for a large proportion of this variation. Further research is required to identify the basis for this variation and to develop better methods for allocating ICU resources for postoperative management of surgical patients.

Background: Tonsillectomies (TE) in Germany are traditionally performed during inpatient hospital stays. Socioeconomic changes in the healthcare system have resulted in shorter hospital stays., Objectives: The aim of the study was to investigate whether a shorter hospital stay of 2 days leads to increased postoperative bleeding after TE. Factors affecting the duration of hospitalization were also studied., Materials and Methods: The relevant data of all patients (≥ 14 years) undergoing TE in the ENT Clinic of the Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, between 2011 and 2013 were recorded anonymously. Risk factors for bleeding after TE were analyzed. Additionally, patients who had a hospital stay of 2 days (since 2013) were compared with patients hospitalized for ≥ 3 days, and the influence of various risk factors on the length of hospital stay was analyzed., Results: During the study period 2011-2013, 376 procedures were performed and data from 213 patients was collected for analysis. Median patient age was 26 years (range 14-73 years). The rate of primary hemorrhage (up to 24 hours after TE) was 2% and the rate of secondary bleeding (later than 24 hours) was 24%. In 7% of patients with postoperative haemorrhage (primary and secondary) surgical hemostasis was performed. Male gender was associated with a significantly higher haemorrhage rate. Shortening postdischarge surveillance to only 2 days did not affect the postoperative bleeding rate., Conclusion: The duration of stationary monitoring following TE should not only be based on the rate of secondary bleeding, but also on patient comfort and safety. A shortening of postoperative monitoring to only 2 days had no effect on the haemorrhage frequency after TE and can therefore, be considered for adults who do not live alone and are within a reasonable distance to a hospital.

Purpose: Evidence of variation in mortality after surgery may indicate preventable postoperative death. We sought to determine if regional differences in outcome were present in surgical patients admitted to critical care in the UK., Methods: We extracted data on admission characteristics, case mix and outcome of all patients admitted to UK critical care units following surgery for the calendar year of 2009. We also used publicly held data on regional population, volume of surgery and bed provision. Multilevel regression analysis was used to adjust for the effects of case mix and regional critical care bed provision on acute hospital mortality., Results: A total of 16,147 patients admitted to critical care following surgery were included in this analysis. Median odds ratio (MOR) was used to describe regional-level variance in acute hospital mortality. Significant variation was identified (MOR 1.14; 95% CI 1.07, 1.28) and persisted following adjustment for case mix (MOR 1.10; 95% CI 1.04, 1.25) and regional critical care bed provision (MOR 1.09; 95% CI 1.04, 1.24). Critical care bed utilisation (surgical critical care admissions per 100,000 surgical procedures) seemed to better explain this observation (MOR 1.03; 95% CI 1.00, 29.26) and was associated with statistically significant reduction in mortality (OR 0.91; 95% CI 0.85, 0.97; p = 0.01)., Conclusion: Significant regional variation in hospital mortality for patients admitted to critical care following surgery was observed. Critical care bed utilisation seemed to better explain this observation and was associated with improved outcome.

Necrotizing enterocolitis (NEC) is a rare but catastrophic complication that may occur in newborns with congenital heart disease (CHD). In the preterm population, transfusion of red blood cells (RBCs) and use of RBCs with longer storage time have been independently associated with the development of NEC. To date, it is not known whether similar associations exist for the term newborn with CHD. This retrospective study identified the incidence of NEC among 1,551 newborns admitted to the authors' cardiac intensive care unit between 7 January 2002 and 7 January 2010. The study was limited to term newborns (>36 weeks gestation). To understand the impact of RBC transfusions on the development of NEC, a nested 2:1 matched case-control analysis was undertaken to compare RBC transfusion patterns between an age-matched group and a cardiac lesion-matched control group. In the study population, NEC developed in 45 term infants during the postoperative period. Of these 45 infants, 30 (66.7%) had single-ventricle heart defects, whereas 22 (48.8%) required surgery for aortic arch obstruction. The median patient age at NEC diagnosis was 21 days. The RBC transfusion rate was higher among the patients who experienced NEC (0.21/day) than among the control subjects (0.10/day) (p = 0.048). A multivariate analysis indicated that onset of NEC was associated with a greater number of RBC transfusions (odds ratio [OR] 1.83; 95% confidence interval [CI] 1.07-7.47; p = 0.045). The duration of RBC storage was not significantly longer in the NEC group (9 days) than in the control cohort (7 days) (p = 0.16). Increased exposure to RBC transfusions is associated with the development of NEC in term infants with CHD. Longer storage of RBCs does not appear to increase this risk. Although causality cannot be confirmed, these data prompt a careful review of RBC transfusion practices with this population.

Purpose: Currently, controversy exists with regard to the duration of bladder drainage and choice of catheter used in women who undergo radical hysterectomy. In this manuscript, we propose a novel approach to improving postoperative bladder care in women who undergo radical hysterectomy., Methods: This is a retrospective study of women who underwent Type 3 Piver radical hysterectomy in a gynaecological oncology centre in the United Kingdom from January 2009 to September 2011. We report the outcomes of removal of urinary catheter 48-72 h following radical hysterectomy., Results: Over a 32-month period, 30 women underwent radical hysterectomy. 19 (63.3 %) women underwent surgery for treatment of cervical cancer, 5 (16.7 %) women for management of endometrial cancer, 6 (20 %) women for other conditions. One patient underwent partial cystectomy at the time of radical hysterectomy and was not included in the analysis. Of the 29 patients, only five (17.2 %) were found to have urinary residuals greater than 100 ml following the removal of the indwelling catheter on the second postoperative day and required recatheterisation. 82.8 % of the patients had the catheter removed within 48-72 h postoperatively. None of these patients required re-admission with urinary retention., Conclusion: Removal of urinary catheter on the second postoperative day following radical hysterectomy is feasible and not associated with increased morbidity. This approach may be particularly useful to complement the introduction of laparoscopic and robotic surgical approaches for surgical management of cervical cancer.

Studies have shown improved perioperative outcomes after neonatal heart surgery at centers with greater surgical volumes. The impact of increasing distance from such centers on outcome after discharge has not yet been reported. Chart review and cross-sectional survey were performed on children discharged or transferred after undergoing neonatal congenital heart surgery as neonates (<30 days of age) from January 2005 to June 2006. The association of distance from center with mortality and adverse events was analyzed by univariate and multivariate regression and stratified by the Risk Adjustment for Congenital Heart Surgery-1 for complexity. Among 217 patients, those living further from the surgical center were smaller and older at surgery and more likely to be RACHS-1 class 6. Overall mortality was 8% (16 of 202) and was not associated with distance. Surveys were completed by 109 (54%) families with mean follow-up of 24 (± 3) months. Unplanned admissions after discharge and unplanned interventions occurred in 45% and 40% of patients, respectively. After adjusting for case complexity, living 90-300 min away from the surgical center was associated with fewer unplanned admissions compared with those living <90 min away. After neonatal cardiac surgery, adverse events were common. Distance from the surgical center was not associated with mortality, but it was associated with morbidity in a nonlinear fashion. This relation, its mediators, and its possible impact on mortality and later outcomes warrant further study to aid in planning appropriate patient follow-up.

Health service quality in Germany can be shown by the data from the external quality assurance program (BQS) but as these records are limited to the period of in-hospital stay no information about outcome after discharge from hospital can be obtained. Secondary routine administrative data contain information about long-term outcome, such as mortality, subsequent revision and the need for care following surgical treatment due to a hip fracture.Experiences in the use of secondary data dealing with treatment of hip fractures from the BQS are available in our department. In addition we analyzed routine administrative data from the health insurance companies Knappschaft Bahn-See and AOK in a cooperative study with the WidO (scientific institute of the AOK). These routine data clearly show a bias because of poor quality in coding as well as broad interpretation possibilities of some of the ICD-10 codes used.Consequently quality assurance using routine data is less valid than register-based conclusions. Nevertheless medical expertise is necessary to avoid misinterpretation of routine administrative data.

The increasing economic pressure has resulted in strategies to use efficient treatment forms. The aim of our study was to evaluate to which extent the intermediate care unit (IMC-unit) relieves the intensive care unit and the wards. We analyzed: patient population, age, gender, admission criteria and the rate of patients with intensive nursing procedures between January 1, 2005 and December 31, 2007. The level of care was calculated according to the standard patient categories. The mean age amounted to 58.9 years. Intensive care patients made up 43.6% and patients from the emergency ward 36.6% of the total IMC-allocation. After IMC care 54.3% of all IMC-patients could be taken over by wards. The confused patients amounted to 27.5% and isolated patients 4.3%. The average care intensity amounted to 4.5 hours per patient daily and the mean length of stay in hospital was 9 days. Particularly the relief of nursing intensity and the possibility of primary treatment of severely injured persons reflect the requirements of IMC.

Background: This study is the first to document the quality of inpatient care provided to elderly patients with distal radius fracture in Germany., Patients and Methods: Inpatient care provided to 1,201 patients age 65 or older with isolated distal radius fracture was documented in a prospective cohort study conducted at 242 acute care clinics in Germany between January 2002 and September 2003., Results: The median patient age was 75, and nearly 90% of patients were female. Approximately 71% of patients were classified as ASA I or II, and 28% were ASA III. The most common comorbidity was arterial hypertension (60%). Seventy-five percent of patients were admitted on the day of the accident; of these, 63% had surgery on the same day, and 20% on the following day. The primary form of anaesthesia was general anaesthesia (55%). The predominant fracture management procedure was percutaneous K-wire osteosynthesis (56% of cases), followed by plate osteosynthesis (44%). The length of hospital stay after plate osteosynthesis (median 8.5 days) was more than twice as long as after K-wire osteosynthesis (median 4 days). The rate of postoperative complications typical of each procedure was around 10%. Roughly 90% of patients were discharged to home. Although evidence of osteoporosis was observed in 62% of women and 50% of men, only 7.9% of patients were prescribed osteoporosis-specific medication., Conclusions: Unexpected findings were the predominance of general anaesthesia and percutaneous K-wire osteosynthesis. Osteoporosis, affecting a majority of elderly women, is neglected in clinical practice. Good quality of care is reflected by the low rate of complications.

Objective: Concepts for optimal surgical treatment of the patient with blunt multiple injuries are being evaluated on the basis of the current literature., Methods: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system)., Results: The posttraumatic clinical course is divided into four different periods: acute-, primary-, secondary- und tertiary period. The first and second period are important for life saving surgery and the stabilization of major fractures. After the cardiorespiratory systems have been stabilized, the following priorities have been formulated: head, face, spine, abdomen, extremities. To restrict the degree of operative burden on the patient it appears to be necessary to limit the duration of initial surgery to less than 6 hours. In patients at high risk to develop posttraumatic complications-"borderline patients"-it appears safer to perform only temporary fixation of major fractures., Conclusions: Three different factors determine the clinical course after polytrauma: Trauma represents the first hit, followed by the therapy-induced burden (second hit). In addition, the third hit is represented by the individual response. An evaluation of the clinical status by immunologic monitoring can be performed in order to assess the patient's status.

Object: The aim of multimodal perioperative treatment concepts is to lower the extent of general complications after elective colonic resection and "traditional" perioperative therapy and to allow hospital discharge only a few days following the operation., Materials and Methods: In this prospective study, we examined a new perioperative treatment plan for accelerating postoperative recovery and evaluated the results. This so-called "fast-track" program employs combined thoracal peridural analgesia, forced mobilization, and rapid renourishment within the clinic., Results: Sixty-four consecutive patients with benign or malignant disease of the large intestine aged an average of 66 years (range 54-71) were operated on. Thirty received conventional resection and 34 were operated on laparoscopically and treated perioperatively using the fast-track program. The hospital diet was given in all cases on the 1st postoperative day, and the first bowel movement occurred on the 2nd day (range 2-3). The patients could be released on the 4th postresection day (range 4-5). General and local postoperative complications were observed in five patients each (8%), including two cases of anastomotic insufficiency., Conclusion: In colonic surgery, the "fast-track" method accelerated convalescence, lowered the number of general complications, and reduced the duration of hospital stay. Therefore, evaluation of "fast-track" concepts is warranted in other types of elective abdominal surgery.

There is still a controversial discussion in literature about the use of motor driven splints in knee surgery--as the principle of continuous passive motion, CPM. For this reason it seemed useful for an evaluation to look through the papers which were published since 1990. It was obvious, that negative results were published often before this year, but this papers are still quoted standard works. In medical data bases subito-doc.de, medscape.com, medica.de and zbmed.de 230 papers were found by search CPM, continuous passive motion and arthromot. Coincidentally there was a search for authors who were already quoted in other papers. 36 papers concerning CPM after knee surgery were utilized. The role of CPM regarding the range of motion, swelling, duration of hospital stay, use of analgesics, costs, postoperative manipulations, wound healing and thrombo embolic complications was evaluated. Although the results of this partial retrospective, partial prospective, sometimes randomized or double blinded studies are in contradiction, there can only be found a trend to better results. New clinical studies for evidence based guidelines in the handling of continuous passive motion after knee surgery are necessary.

The presented thromboprophylactic concept includes weight bearing and ankle motion as well as breathing therapy and drug prophylaxis (antiphlogistics, analgesic drugs, heparin). Routinely performed ultrasound screening of the deep veins (legs and pelvis) before release showed a low DVT incidence of 2.5% in a prospective clinical observation of 841 inpatients. Obesity, venous insufficiency, and a history of previous thromboembolic events were associated with a significantly increased risk of thrombosis (relative risk 4.1, 4,9, and 5.8, respectively) The duration of immobilization also had a relevant influence indicating that early postoperative physiotherapy in traumatology and orthopedic surgery has a widely underestimated thromboprophylactic effect.

Purpose: To determine current European practice in interventional radiology regarding nursing care, anesthesia, and clinical care trends., Methods: A survey was sent to 977 European interventional radiologists to assess the use of sedoanalgesia, nursing care, monitoring equipment, pre- and postprocedural care, and clinical trends in interventional radiology. Patterns of sedoanalgesia were recorded for both vascular and visceral interventional procedures. Responders rated their preferred level of sedoanalgesia for each procedure as follows: (a) awake/alert, (b) drowsy/arousable, (c) asleep/arousable, (d) deep sedation, and (e) general anesthesia. Sedoanalgesic drugs and patient care trends were also recorded. A comparison was performed with data derived from a similar survey of interventional practice in the United States., Results: Two hundred and forty-three of 977 radiologists responded (25%). The total number of procedures analyzed was 210,194. The majority (56%) of diagnostic and therapeutic vascular procedures were performed at the awake/alert level of sedation, 32% were performed at the drowsy/arousable level, and 12% at deeper levels of sedation. The majority of visceral interventional procedures were performed at the drowsy/arousable level of sedation (41%), 29% were performed at deeper levels of sedation, and 30% at the awake/alert level. In general, more sedoanalgesia is used in the United States. Eighty-three percent of respondents reported the use of a full-time radiology nurse, 67% used routine blood pressure/pulse oximetry monitoring, and 46% reported the presence of a dedicated recovery area. Forty-nine percent reported daily patient rounds, 30% had inpatient hospital beds, and 51% had day case beds., Conclusion: This survey shows clear differences in the use of sedation for vascular and visceral interventional procedures. Many, often complex, procedures are performed at the awake/alert level of sedation in Europe, whereas deeper levels of sedation are used in the United States. Trends toward making interventional radiology a clinical specialty are evident, with 51% of respondents having day case beds, and 30% having inpatient beds.