Purpose: The Rehabilitation Department at the University of Tennessee Medical Center in Knoxville, Tennessee, changed its staffing model in an effort to increase efficiency and reduce hospital length of stay (LOS) without compromising safety for patients undergoing total joint arthroplasty (TJA). This study was designed to reveal effects of extended physical therapy (PT) coverage on TJA patient safety and LOS at our hospital. Methods: Our study is a retrospective chart review including 775 patients. After a staffing change involving the addition of an evening PT shift, we gathered data on patients with TJA in 2 groups: (1) before staffing change and (2) after staffing change. We examined the percentage of patients in each group who received a day of surgery (DOS) PT evaluation and tracked each group's incidence of adverse events and hospital LOS. We then compared outcomes between groups. Results: The percentage of Patients who received a DOS PT evaluation increased from 64.5% prestaffing change to 97.0% poststaffing change. Hospital LOS decreased from 2.30 days (SD = 0.9) in the prestaffing change group to 2.16 days (SD = 0.8) in the poststaffing change group, with no difference in incidence of adverse events between groups. The frequency of adverse events tracked in this study was only 6.6% in each group, indicating that the greater frequency of DOS PT evaluations did not increase the incidence of adverse events or compromise patients' safety. Conclusions: A staffing change involving extended PT evening coverage resulted in a higher percentage of patients with TJA receiving a DOS PT evaluation, no increase of adverse events, and a statistically significant decrease in hospital LOS.

This study reports on the successful use of a protective boot in a patient with diabetic foot disease

rarity of this condition prompts me toAt midnight on 9 June, 1962, I was called to the Wagga Wagga Base Hospital to a 49-year-old woman with a "ruptured prolapse." She stated that seven years ago a vaginal hysterectomy had been performed and some time later she had developed a vaginal prolapse. That evening, whilst washing dishes at the sink, she coughed and then felt something warm and moist come down the "front passage." On examination I found 2 to 3 feet of small bowel protruding from the vagina and resting on a sterile towel. Although this was then five hours after the incident and she had travelled by car some 60 miles, she was in good condition and in no way shocked. At operation an hour later, the vagina was cleaned with C.T.A.B. and the bowel washed with saline. The serosa of the bowel was grossly reddened, but on withdrawing a further 3 inches of proximal and distal bowel there were no necrotic areas, so it was returned to the abdomen. The vault of the vagina had a transverse laceration about an inch and one-half in length. The vault was brought down to the introitus, the peritoneum separated from this, and the sac closed high up with a running suture. The medial margins of the levators ani were dissected from the bladder in front to the rectum behind and drawn together with interrupted chromic catgut. This was further inturned by a layer of interrupted sutures drawing the fascia overlying the levator, thus forming a keel in the pelvic floor in the sagittal direction. The most anterior stitch was tied to the uppermost vaginal stitch. The perineal body was also repaired to complete the colpocleisis. At the end of operation she had a short but functional vagina.Her post-operative course was marred by an aching sensation in the rectum at about the ninth post-operative day. Rectal examination revealed the firm anterior repair, but there was a smooth, soft, non-tender swelling in the curve of the sacrum. This subse-THE record the following case :-quently increased in size, almost obstructed the rectum and then subsided. Having die covered no such mass on the night of admission I concluded that one of my stitches must have pierced a vessel lying on the superior surface of the levator ani. Because she was lying in bed after operation blood tracked posteriorly, lateral to the rectum and then descended in the hollow of the sacrum between the 2 margins of the ilio-coccygeus muscle to lie behind the rectum as a haematoma. This liquefied, increased in size and then absorbed spontaneously.