Barnes-Jewish West County Hospital

Background: In this quality improvement project, we examined whether two different frequencies for moving endotracheal tubes (ETT) in the intensive care unit setting resulted in different patient outcomes. The outcomes evaluated were skin breakdown or wound development resulting by ETT pressure injury. Methods: We collected data in two different medical ICUs, where in unit 1 ETT movement was scheduled to occur every 4 hours versus unit 2 where ETT movement was scheduled to occur every 2 hours. Respiratory therapists were scheduled to move ETT every 4 hours in both ICUs. In unit 2 the nursing staff was also scheduled to move the ETT 2 hours after the ETT was moved by the respiratory therapists. We only looked at data that was documented in our EMR. Our sample size (n) was 117 patients in unit 1 and 146 in unit 2. Patients were evaluated daily by respiratory therapists and nursing staff and three times weekly by the ICU wound nurse for any skin breakdown or wound development associated with the ETT. Results: The actual number of ETT movements documented in the EMR are shown in Table 1 below. We compared the number of EE movements with the T-test for the following data. The P value was 0.0019. This suggests that there was a statistically significant difference in the number of ETT movements that occurred between the two ICUs. The chi-square statistic is 0.1529. The P -value is 0.69. Hence the result is not significant. Meaning that both units’ data are similar in the context of skin breakdown and wound development Fisher Exact Test. Similarly, we can conclude the same by looking at the Fischer exact test. The Fisher exact test statistic value is 1. The result is not significant at P < .05. Conclusions: In conclusion, we can see that the frequency of skin breakdown or wound development was low in both ICUs. Moreover, more frequent movement of the ETT was not associated with better outcomes. However, we cannot be sure that compliance with moving ETT every 2 hours in unit 2 was achieved by the documented number of ETT movements recorded in unit 2.Table 1&nbsp;Unit 1Unit 2Mean5.536.76Std. Deviation2.073.88N117146Chi-Square&nbsp;NoYesRow TotalUnit 11131117Unit 21442146Column Totals2603263

aAssistant Professor of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri bDepartment of Orthopaedic Surgery Barnes-Jewish Hospital and Barnes-Jewish West County Hospital, St. Louis, Missouri Financial Disclosure: The author reports no conflicts of interest. Correspondence to Kimberly Ann Bartosiak, MD, Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, MSC, 8233-04-5505, Saint Louis, Missouri 63110 Tel: (+314) 362-0255; fax: (+314) 300-0835; e-mail: [email protected].

Reactive arthritis (ReA) following bacterial infection from the urogenital and gastrointestinal tract is widely described but is not typical post-viral infections. This report presents the second case of ReA after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the United States. A 45-year-old black male with chronic low back pain was hospitalized for 45 days with coronavirus disease 2019 (COVID-19), complicated due to the development of multiorgan failure managed with intubation, extracorporeal membrane oxygenation, and hemodialysis. He was subsequently discharged to an acute rehabilitation facility where he complained of new-onset pain in his shoulders, left elbow, and left knee three weeks after a negative SARS-CoV-2 test. He was readmitted from his acute rehabilitation facility due to recurrent fever and the development of a swollen, warm left knee. Laboratory studies at readmission showed elevated inflammatory markers, negative extensive infectious disease workup, and aseptic inflammatory left knee synovial fluid without crystals. Testing returned negative for most common antibodies seen in immune-mediated arthritides (e.g., rheumatoid arthritis, systemic lupus erythematosus), as well as for common respiratory and gastrointestinal tract pathogens responsible for viral arthritis. The multidisciplinary inpatient medical team deemed the clinical presentation and laboratory findings most consistent with ReA. The patient received a course of oral corticosteroids, followed by a second course due to the recurrence of symptoms weeks after initial treatment and recovery. The current body of medical literature on SARS-CoV-2 pathophysiology supports plausible mechanisms on how this infection may induce ReA. Such a scenario should be considered in the differential of COVID-19-recovered patients presenting with polyarthritis as prompt steroid treatment may help patient recovery.

To assess the impact of ambulatory surgery centers (ASCs) on rates of hospital-based outpatient procedures and adverse events. Twenty percent national sample of Medicare beneficiaries. A retrospective study of beneficiaries undergoing outpatient surgery between 2001 and 2010. Health care markets were sorted into three groups-those with ASCs, those without ASCs, and those where one opened for the first time. Generalized linear mixed models were used to assess the impact of ASC opening on rates of hospital-based outpatient surgery, perioperative mortality, and hospital admission. Adjusted hospital-based outpatient surgery rates declined by 7 percent, or from 2,333 to 2,163 procedures per 10,000 beneficiaries, in markets where an ASC opened for the first time (p<.001 for test between slopes). Within these markets, procedure use at ASCs outpaced the decline observed in the hospital setting. Perioperative mortality and admission rates remained flat after ASC opening (both p>.4 for test between slopes). The opening of an ASC in a Hospital Service Area resulted in a decline in hospital-based outpatient surgery without increasing mortality or admission. In markets where facilities opened, procedure growth at ASCs was greater than the decline in outpatient surgery use at their respective hospitals.

An approach to the valgus knee based on anatomic function of ligaments in flexion and extension consistently yields a knee that is balanced in flexion and extension when the implants have been positioned correctly. Two hundred thirty-one knees had a valgus deformity (range, 12 degrees-45 degrees) and were corrected with valgus alignment to 5 degrees by resecting the intact joint surfaces to match implant thickness. Femoral joint surfaces were aligned in 5 degrees valgus to the long axis of the femur and parallel to the epicondylar axis of the femur in flexion and extension. The tibial surfaces were aligned perpendicular to the long axis of the tibia. For knees that were tight in flexion and extension, the lateral collateral ligament and popliteus tendon were released. Those knees that remained tight only in extension had release of the iliotibial band. Posterior capsular release was done only when necessary for persistent lateral ligament tightness. Neither ligament advancement procedures nor varus or valgus stabilized implant systems were needed to achieve stability with this procedure. The knees with ligament releases all fell within a range of 4 degrees to 7 degrees mean varus and valgus laxity, and were not significantly different from one another. No cases of clinical instability occurred, and joint stability did not deteriorate with time.