Background
This study highlights the multiple sources of delay along a hip fracture clinical pathway. The national recommendation is that ‘patients with a hip fracture should be admitted within 4 ...hours of arrival at the Emergency Department to which they first presented’.
Methods
Granular analysis and process mapping of all available hospital and ‘Irish Hip Fracture Database’ data for a 2-month period were used to highlight and compare causes of delay.
Discussion
We identified numerous sources of delay, occurring at every point along the pathway, emphasising the complexity of providing acute integrated care. There was no single stage that persistently contributed to the delay in the patient pathway. The focus is now to achieve marginal gains in each area. Increased staff and resources to the front line are a clear solution but this is complex to achieve.
The role of directional coronary atherectomy (DCA) in interventional cardiology remains uncertain. We report the Northern New England regional experience with DCA from 1991 to 1994. Data were ...collected on 11,178 patients having had an intervention on a single lesion in a single vessel (798 DCAs; 10,380 percutaneous transluminal angioplasties PTCA). The use of DCA increased from 1.8% of interventions in 1991 to 10% in 1994. Compared with PTCA, DCA patients were younger, more often men, had more 1-vessel disease and more coronary artery bypass surgery (CABG). DCA was more often used in the left anterior descending artery, in vein grafts, for restenoses, for subtotal occlusions, and with type A lesions. Angiographic success (96.7%) and clinical success (93%) were good. Adverse events were rare: mortality 0.9%, emergent CABG 2.2%, nonfatal myocardial infarction 2.8%. After adjusting for case-mix, there was no difference between DCA and PTCA for in-hospital mortality (odds ratio OR = 1.03, 95% confidence interval CI 0.44 to 2.43, p = 0.95) or need for emergent CABG (OR = 1.27, 95% CI 0.77 to 2.10, p = 0.34). Atherectomy patients were more likely to have a nonfatal myocardial infarction (OR = 2.0, 95% CI 1.26 to 3.20, p <0.01), to sustain an injury to the femoral or brachial artery (OR = 2.89, 95% CI 1.52 to 5.51, p <0.01), and to have a clinically successful procedure (OR = 1.37, 95% CI 1.01 to 1.88, p = 0.05). Our results support the relative safety and effectiveness of DCA as its use disseminated into the region.
We report the Northern New England regional experience with the use of directional coronary atherectomy from 1991 to 1993. Our results support the relative safety and effectiveness of directional coronary atherectomy as its use disseminated into the region.
