Background Nearly 30% of patients with newly formed ileostomies require hospital readmission from severe dehydration or associated complications. This contributes to significant morbidity and rising ...healthcare costs associated with this procedure. Our aim was to design and pilot a novel program to decrease readmissions in this patient population. Study Design An agreement was established with Visiting Nurse Health System (VNHS) in March 2015 that incorporated regular home visits with clinical triggers to institute surgeon-supervised corrective measures aimed at preventing patient decompensation associated with hospital readmissions. Thirty-day readmission data for patients managed with and without VNHS support for 10.5 months before and after implementation of this new program were collected. Results Of 833 patients with small bowel procedures, 162 were ileostomies with 47 in the VNHS and 115 in the non-VNHS group. Before program implementation, VNHS (n = 24) and non-VNHS patients (n = 54) had similar readmission rates (20.8% vs 16.7%). After implementation, VNHS patients (n = 23) had a 58% reduction in hospital readmission (8.7%) and non-VNHS patient hospital readmissions (n = 61) increased slightly (24.5%). Total cost of readmissions per patient in the cohort decreased by >80% in the pilot VNHS group. Conclusions Implementation of a novel program reduced the 30-day readmission rate by 58% and cost of readmissions per patient by >80% in a high risk for readmission patient population with newly created ileostomies. Future efforts will expand this program to a greater number of patients, both institutionally and systemically, to reduce the readmission-rate and healthcare costs for this high-risk patient population.
Objective Surgical simulation is an important adjunct in surgical education. The majority of operative procedures can be simplified to core components. This study aimed to quantify a cadaver-based ...simulation course utility in improving exposure to fundamental maneuvers, resident and attending confidence in trainee capability, and if this led to earlier operative independence. Design A list of fundamental surgical procedures was established by a faculty panel. Residents were assigned to a group led by a chief resident. Residents performed skills on cadavers appropriate for PGY level. A video-recorded examination where they narrated and demonstrated a task independently was then graded by attendings using standardized rubrics. Participants completed surveys regarding improvements in knowledge and confidence. Setting The course was conducted at the Emory University School of Medicine and the T3 Laboratories in Atlanta, GA. Participants A total of 133 residents and 41 attendings participated in the course. 133 (100%) participating residents and 32 (78%) attendings completed surveys. Results Resident confidence in completing the assigned skill independently increased from 3 (2-3) to 4 (3-4), p < 0.01. Residents stated that a median of 40% (interquartile range: 20%-60%) of procedures were performed for the first time in the course, and the same number had been performed only in the course. The percentage of skills attendings believed residents could perform independently increased from 40% (40%-60%) to 60% (60%->80%), p < 0.04. Attendings were more likely to grant autonomy in the operating room after this exercise (4 3-5). Conclusions A cadaveric skills course focused on fundamental maneuvers with objective confirmation of success is a viable adjunct to clinical operative experience. Residents were formally exposed to fundamental surgical maneuvers earlier as a result of this course. This activity improved both resident and attending confidence in trainee operative skill, resulting in increased attending willingness to grant a higher level of autonomy in the operating room.
Background Variable gastric morphology has been identified on routine upper gastrointestinal series after laparoscopic sleeve gastrectomy. This test might give us useful information beyond the ...presence of leak and obstruction. The aim of this study is to standardize a morphologic classification of gastric sleeve based on water-soluble contrast upper gastrointestinal series, and to determine possible clinical implications. Study Design One hundred morbidly obese patients underwent laparoscopic sleeve gastrectomy and had routine upper gastrointestinal on postoperative day 1 or 2. Images were reviewed by 4 radiologists who were blinded to outcomes, and sleeve shape was classified as upper pouch, lower pouch, tubular, or dumbbell. Inter-observer agreement was calculated. Clinical outcomes including weight loss, satiety control, and reflux symptoms were recorded. Comparisons were determined by 1-way ANOVA and t -test. Results Mean age was 46 ± 12 years and mean BMI was 45.1 ± 6 kg/m2 . Overall inter-observer agreement level for the sleeve shape classification was 76.3%. Sleeve shapes were tubular in 37%, dumbbell in 32%, lower pouch in 22%, and upper pouch in 8%. Mean excess body weight loss at 1, 3, and 6 months was 16.8%, 29.9%, and 39.1%, respectively. Excess body weight loss was not associated with sleeve shape. Mean hunger score was 213 ± 97, and patients with dumbbell shape had higher hunger scores (p = 0.003). Mean reflux score was 5.7 ± 8. Upper pouch shape was associated with greater severity of reflux symptoms (p = 0.02). Conclusions This study suggests a standardized radiographic classification of gastric sleeve morphology. Although sleeve shape is not correlated with weight loss, gastric sleeves with retained fundus result in lower satiety control and higher severity of reflux symptoms. An adequate resection of the gastric fundus might avoid this potential complication.
Learning from Haiti Creighton, Francis X, BSc; Leeds, Ira L, BA; Master, Viraj A, MD ...
The Lancet (British edition),
06/2011, Letnik:
377, Številka:
9782
Journal Article
Recenzirano
In May, 2010, a 37-year-old woman, displaced from Port-au-Prince after the January earthquake, presented to Hôpital St Thérèse in Hinche, Haiti, with a 2-year history of a slowly growing abdominal ...mass with associated dyspepsia, intermittent abdominal pain, anorexia, and weight loss. Diagnostic ultrasonography is a recognised, costeff ective aid for procedure-based care in under-resourced areas of the world.1,2 However, access to ultrasonography in these settings is limited.3,4 While we were in Haiti, ultrasonography also aided in the evaluation of soft-tissue masses, peritoneal disease, and uterine pathology.
Abstract Background Ligation of the significantly injured infrarenal inferior vena cava (IVC) is an accepted practice in the setting of damage control surgery. This is a report of inpatient ...management, outcomes, and long-term follow-up in 25 patients after IVC ligation. Methods The records of patients with injuries to the IVC treated in an urban level I trauma center from 1995 to 2008 were reviewed. Demographics, injury severity, and outcome data were recorded. In addition, outpatient records were reviewed and telephone interviews were conducted to assess for the presence and severity of long-term sequelae. Results One hundred patients had IVC injuries, and 25 (25%) underwent ligation. Location of injury was infrarenal in 54 patients, suprarenal in 21, retrohepatic in 15, and suprahepatic in 10. Twenty-two of 54 (41%) injuries to the infrarenal IVC and 3 of 21 (14%) injuries to the suprarenal IVC were ligated. Patients who underwent ligation had a significantly higher Injury Severity Score (ISS) (22 vs 15, P < .001), a higher transfusion requirement (26 U vs 12 U, P < .001), a longer hospital length of stay (78 days vs 26 days, P = .02), a longer intensive care unit length of stay (24 days vs 9 days, P < .001), and a higher mortality (59% vs 21%, P < .001). Ten of 13 early survivors of infrarenal IVC ligation received early below knee fasciotomy. Three other patients with normal compartment pressures were treated expectantly without development of a compartment syndrome. The 1 survivor of suprarenal ligation had below knee fasciotomies and had normal renal function by 1 month post injury, despite an initial creatinine elevation from .7 mg/dL to 3.2 mg/dL. Ten (40%) patients with IVC ligation survived to hospital discharge (9 infrarenal, 1 suprarenal), and long-term follow-up data are available in 8 patients (7 infrarenal, 1 suprarenal). At an average of 42 months (11–117 months), no patient has significant lower extremity edema or dysfunction. Conclusions (1) Ligation of the infrarenal IVC is an acceptable damage control technique, although it remains associated with a high mortality. Ligation of the suprarenal IVC may be done, if necessary, although few survivors of this technique exist. (2) Early fasciotomy is generally required, but occasional patients may be treated expectantly, based on measurements of compartment pressures. (3) Long-term sequelae in survivors of IVC ligation for trauma are rare.
We report on the results of a country-wide survey of people’s perceptions of issues relating to the conservation of biodiversity and ecosystems in India. Our survey, mainly conducted online, yielded ...572 respondents, mostly among educated, urban and sub-urban citizens interested in ecological and environmental issues. 3160 “raw” questions generated by the survey were iteratively processed by a group of ecologists, environmental and conservation scientists to produce the primary result of this study: a summarized list of 152 priority questions for the conservation of India’s biodiversity and ecosystems, which range across 17 broad thematic classes. Of these, three thematic classes—“Policy and Governance”, “Biodiversity and Endangered Species” and “Protection and Conservation”—accounted for the largest number of questions. A comparative analysis of the results of this study with those from similar studies in other regions brought out interesting regional differences in the thematic classes of questions that were emphasized and suggest that local context plays a large role in determining emergent themes. We believe that the ready list of priority issues generated by this study can be a useful guiding framework for conservation practitioners, researchers, citizens, policy makers and funders to focus their resources and efforts in India’s conservation research, action and funding landscape.
Background
Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught ...with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations.
Methods and procedures
An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student’s t-tests.
Results
Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (
P
< 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4–80.8% post-implementation (
P
< 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes.
Conclusion
Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.
OBJECTIVE:To determine the relationship between complications after 3 common general surgery procedures and per-episode hospital finances.
BACKGROUND:With impending changes in health care ...reimbursement, maximizing the value of care delivered is paramount. Data on the relative clinical and financial impact of postoperative complications are necessary for directing surgical quality improvement efforts.
METHODS:We reviewed the medical records of patients enrolled in the American College of Surgeonsʼ National Surgical Quality Improvement Program who underwent pancreaticoduodenectomy, hepatectomy, and colectomy at a single academic institution between September 2009 and August 2012. Clinical outcomes data were subsequently linked with hospital billing data to determine hospital finances associated with each episode. We describe the association between postoperative complications, hospital length of stay, and different financial metrics. Multivariable linear regression modeling tested linear association between postoperative outcomes and cost data.
RESULTS:There was a positive association between the number of surgical complications, payments, length of stay, total charges, total costs, and contribution margin for the three procedures. Multivariable models indicated that complications were independently associated with total cost among the selected procedures. Payments increased with complications, offsetting increased costs.
CONCLUSIONS:In the current fee-for-service environment, the financial incentives are misaligned with quality improvement efforts. As we move to a value-driven method of reimbursement, administrators and health care providers alike will need to focus on improving the quality of patient care while remaining conscious of the cost of care delivered. Reducing complications effectively improves value.
OBJECTIVE To analyze postoperative outcomes, morbidity, and mortality following enterocutaneous fistula (ECF) takedown. DESIGN, SETTING, AND PATIENTS Retrospective review of the complete medical ...records of patients who presented to a single tertiary care referral center from December 24, 1987, to June 18, 2010, and subsequently underwent definitive surgical treatment for ECF originating from the stomach, small bowel, colon, or rectum. MAIN OUTCOME MEASURES Postoperative fistula recurrence and mortality. RESULTS A total of 153 patients received operative intervention for ECF. Most ECFs were referred to us from outside institutions (75.2%), high output (52.3%), originating from the small bowel (88.2%), and iatrogenic in cause (66.7%). Successful ECF closure was ultimately achieved in 128 patients (83.7%). Six patients (3.9%) died within 30 days of surgery, and overall 1-year mortality was 15.0%. Postoperative complications occurred in 134 patients, for an overall morbidity rate of 87.6%. Significant risk factors for fistula recurrence were numerous, but postoperative ventilation for longer than 48 hours, organ space surgical site infection, and blood transfusion within 72 hours of surgery carried the most considerable impact (relative risks, 4.87, 4.07, and 3.91, respectively; P < .05). Risk of 1-year mortality was also associated with multiple risk factors, the most substantial of which were postoperative pulmonary and infectious complications. Closure of abdominal fascia was protective against both recurrent ECF and mortality (relative risks, 0.47 and 0.38, respectively; P < .05). CONCLUSIONS Understanding risk factors both associated with and protective against ECF recurrence and postoperative morbidity and mortality is imperative for appropriate ECF management. Closure of abdominal fascia is of utmost importance, and preventing postoperative complications must be prioritized to optimize patient outcomes.
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