April 2002 Bulletin

Board approves advisory, position, statements new committee charges

The Boards of Directors of the American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons, meeting February 11-12 in Dallas took the following actions.

Position Statement on Use of Antibiotics was revised. The Advisory Statement on "The Use of Prophylactic Antibiotics in Orthopaedic Medicine and the Emergence of Vancomycin-Resistant Bacteria," first drafted in 1998, was reviewed by the Infections Committee, which agreed that current research on antibiotic allergy should be incorporated and appropriate references cited. Orthopaedic surgeons are among the frequent users of prophylactic antibiotics. Multiple bacterial species have developed resistance to these commonly used antibiotics. In addition to infections with methicillin-resistant organisms, vancomycin-resistant enterococci have occurred in orthopaedic patients. Enterococci are the second most common cause of nosocomial infection in the U.S.

In the Statement, the Academy makes five recommendations, falling into two categories—reduction in the use of vancomycin and measures to reduce the nosocomial spread of staphylococci and enterococci: "Vancomycin should be reserved for the treatment of serious infection with beta-lactam resistant organisms or for treatment of infection in patients with life-threatening allergy to beta-lactam antimicrobials.

"Hand washing with soap and water is highly effective and one of the simplest methods to prevent nosocomial spread. Used of water-less alcohol-based agents is highly effective and recommended in the absence of visible soiling.

"Patients infected with strains of VRE, VRSE or VISA require contact isolation.

"The identification of S. aureus sensitivity to vancomycin should be reported to state and local health departments and to CDC’s Epidemiology and Laboratory Branch, Division of Healthcare Quality Promotion (DHQP) at 1-800-893-0485. Confirmatory testing can be performed at DHQP laboratories. Assistance with epidemiological investigations may be helpful in identifying common sources of infections and means of halting transmissions.

"In the event that a patient with VISA is identified, all health care personnel and other patients who have had potential contact should have cultures of anterior nares and hands." For the full text of the statement, go to the AAOS website at http://www.aaos.org/ wordhtml/papers/advistmt/1016.htm

Advisory Statement on Implant Device Recalls approved. The Biomedical Engineering Committee developed an Advisory Statement on Implant Recalls to provide guidance for orthopaedic surgeons in response to two recent high profile manufacturer recalls of hip devices. The recall of orthopaedic implant devices and any subsequent revision surgery is a serious matter that requires the collaborative efforts of manufacturers, insurers and orthopaedic surgeons to ensure patient safety. "The American Academy of Orthopaedic Surgeons believes that patient safety must be the highest priority in cases of recalled implant devices, and care should be taken to confirm the device’s failure when considering revision surgery as a treatment option. The risks of re-operation are significant and must be carefully assessed and discussed with the patient before treatment is administered." The AAOS strongly encourages orthopaedic surgeons to:

The AAOS believes that clear communication between patients and physicians is essential when discussing the consequences of an implant recall. The orthopaedic surgeon should provide the patient with relevant information and pursue a course of shared decision-making regarding the treatment plan. The full text of the statement can be found on the AAOS web site at http://www.aaos. orghttp://www.aaos.org/wordhtml/papers/advistmt/1019.htm.

Advisory and Position Statements on Family Violence approved. The Task Force on Family Violence presented the two statements to reinforce the concept that this is an important issue and both the AAOS membership and the general public need to recognize that family violence is a public health problem. It leads to physical and psychological disability, death and loss of productivity. It can perpetuate itself through successive generations and contributes to the escalating health care costs in this country. Both the Advisory Statement and Position note that: "The AAOS believes family violence, in the form of child abuse, adult domestic violence and elder abuse, is a major public health problem in the United States. The Academy is committed to providing appropriate care to victims of family violence whether they present to an emergency department, orthopaedic office/clinic."

The Advisory Statement also endorses principles for orthopaedic surgeons regarding family violence, including become familiar with the diagnosis and treatment of family violence, referring patients to appropriate community resources, adhering to applicable state reporting laws and putting into place protocols to deal with victims of family violence. "The AAOS) believes that orthopaedic surgeons should become aware of and comply with state and/or local reporting laws. The Academy also believes that in cases of adult domestic violence, reports should only be made with the knowledge and consent of the victim, unless required by law, to reduce the probability of future harm to the victim." For the full text of the Advisory Statement, visit the AAOS web site at: http://www.aaos.org/wordhtml/papers/position/1020.htm.

For the full text of the Position Statement, go to: http://www.aaos.org/ wordhtml/papers/position/1156.htm.

Advisory Statement on Wrong Site Surgery revised. First approved in 1997, the Statement was changed to explicitly state that the operating orthopaedic surgeon should place his/her initials on the operative site. In light of recent publicity regarding medical errors, the Council on Health Policy and Practice felt it was important to clarify this important element of the statement. Additional language was added to emphasize the importance of communicating with the patient about this issue. The revised sections of the statement reads as follows: "Wrong-site surgery is preventable by having the surgeon, in consultation with the patient, place his or her initials on the operative site using a permanent marking pen and then operating through or adjacent to his initials" and "Consequently, eliminating wrong-site surgery means the surgeon places his or her initials on the operative site in a way that cannot be overlooked and in a manner that will be clearly incorrect if transferred to another body area prior to surgery."

In keeping with its Code of Ethics, the Academy believes that in any communication with the patient or patient’s family regarding the care rendered - particularly in relation to an untoward event such as wrong-site surgery - orthopaedic surgeons must be truthful in all circumstances. For the full text of the statement, visit the AAOS website at http://www.aaos.org/wordhtml/papers/advistmt/1015.htm.

Patient Safety Committee charges approved. At the December 2001 Board of Directors meeting, the Board approved the formation of the Patient Safety Committee. The mission of this committee is to promote orthopaedic patient safety and to reduce as completely as possible the potential of medical errors that could occur in orthopaedic practice. Second Vice President James Herndon, MD, presented—and the Board approved charges for the committee. Committee activities are expected to range from development of educational programs and advisory statements for MDs to creation of a curriculum on patient safety, public outreach, special alerts to members on breaking news regarding drug or device problems and collaboration with other professional societies.

Also approved were charges for a Tissue Banking Project Team of the Committee on Patient Safety. This group will be charged with interacting with government and tissue-bank accrediting organizations to asses good tissue practices, to survey and assess tissue-banking procedures used by registered tissue bank establishments relative to orthopaedic practice, and—as appropriate—to develop guidelines for safety initiatives in the use of tissue by orthopaedic surgeons.

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