RESUMO
OBJECTIVE: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. DESIGN: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members. METHODS: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM. RESULTS: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion. CONCLUSIONS: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.
Assuntos
Cuidados Críticos , Estado Terminal/terapia , Transfusão de Eritrócitos , Ferimentos e Lesões/terapia , Adulto , HumanosRESUMO
We present the case of a patient who sustained blunt liver trauma after a motor vehicle crash that was subsequently complicated by the development of a large biloma. Early use of computed tomography (CT) scan and HIDA (hepatobiliary iminodiacetic acid) imaging enabled the prompt identification and management of the problem.
Assuntos
Hepatopatias/diagnóstico , Fígado/lesões , Ferimentos não Penetrantes/complicações , Acidentes de Trânsito , Adulto , Bile , Humanos , Iminoácidos , Fígado/diagnóstico por imagem , Hepatopatias/etiologia , Masculino , Radiografia Abdominal , Cintilografia , Tomografia Computadorizada por Raios XRESUMO
A case report of isolated jejunal perforation secondary to a relatively unique mechanism of blunt thoracoabdominal trauma is presented. A thorough and concise review of the multimodal approach that may be necessary to diagnose such a rare clinical problem is discussed.
Assuntos
Traumatismos Abdominais/complicações , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/etiologia , Jejuno/lesões , Traumatismos Torácicos/complicações , Ferimentos não Penetrantes/complicações , Adulto , Serviço Hospitalar de Emergência , Feminino , Humanos , Exame FísicoRESUMO
OBJECTIVES: To implement an electronic laboratory utilization management system (laboratory expert system [LES]) to provide safe and effective reductions in unnecessary clinical laboratory testing. METHODS: The LES is a set of frequency filter subroutines within the Veterans Affairs hospital and laboratory information system that was formulated by an interdisciplinary medical team. RESULTS: Since implementing the LES, total test volume has decreased by a mean of 11.18% per year compared with our pre-LES test volume. This change was not attributable to fluctuations in outpatient visits or inpatient days of care. Laboratory cost savings were estimated at $151,184 and $163,751 for 2012 and 2013, respectively. A significant portion of these cost savings was attributable to reductions in high-volume, large panel testing. No adverse effects on patient care were reported, and mean length of stay for patients remained unchanged. CONCLUSIONS: Electronic laboratory utilization systems can effectively reduce unnecessary laboratory testing without compromising patient care.
Assuntos
Serviços de Laboratório Clínico/estatística & dados numéricos , Hospitais de Veteranos/organização & administração , Serviços de Laboratório Clínico/economia , Serviços de Laboratório Clínico/organização & administração , Redução de Custos , Hospitais de Veteranos/economia , Humanos , Laboratórios/economia , Laboratórios/organização & administração , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Estados Unidos , United States Department of Veterans AffairsRESUMO
Despite the challenges of implementing facilitative coaching, the Richard L. Roudebush VAMC staff succeeded in translating primary care medical home theory into process.
Assuntos
Rim/lesões , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnóstico por imagem , Acidentes de Trânsito , Serviço Hospitalar de Emergência , Humanos , Rim/diagnóstico por imagem , Rim/cirurgia , Masculino , Nefrectomia , Ferimentos não Penetrantes/cirurgia , Adulto JovemRESUMO
Traumatic abdominal wall hernia is a relatively uncommon finding secondary to blunt trauma. We report a unique case of laparoscopic diagnosis and immediate repair of a traumatic anterior abdominal wall hernia after blunt abdominal trauma.
Assuntos
Hérnia Ventral/cirurgia , Laparoscopia , Ferimentos não Penetrantes/cirurgia , Adulto , Fenômenos Biomecânicos , Feminino , Hérnia Ventral/diagnóstico , Hérnia Ventral/etiologia , Hérnia Ventral/fisiopatologia , Humanos , Ferimentos não Penetrantes/fisiopatologiaRESUMO
IMPORTANCE: In April 2009, an analysis of joint replacement surgical procedures at the Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, revealed that total hip and knee replacements incurred $1.4 million in non-Veterans Affairs (VA) care costs with an average length of stay of 6.1 days during fiscal year 2008. The Joint Replacement Program system redesign project was initiated following the Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain (VA-TAMMCS) model to increase efficiency, decrease length of stay, and reduce non-VA care costs. OBJECTIVE: To determine the effectiveness of Lean Six Sigma process improvement methods applied in a VA hospital. DESIGN, SETTING, AND PARTICIPANTS: Perioperative processes for patients undergoing total joint replacement were redesigned following the VA-TAMMCS model--the VA's official, branded method of Lean Six Sigma process improvement. A multidisciplinary team including the orthopedic surgeons, frontline staff, and executive management identified waste in the current processes and initiated changes to reduce waste and increase efficiency. Data collection included a 1-year baseline period and a 20-month sustainment period. MAIN OUTCOMES AND MEASURES: The primary endpoint was length of stay; a secondary analysis considered non-VA care cost reductions. RESULTS: Length of stay decreased 36% overall, decreasing from 5.3 days during the preproject period to 3.4 days during the 20-month sustainment period (P < .001). Non-VA care was completely eliminated for patients undergoing total hip and knee replacement at the Richard L. Roudebush Veterans Affairs Medical Center, producing an estimated return on investment of $1 million annually when compared with baseline cost and volumes. In addition, the volume of total joint replacements at this center increased during the data collection period. CONCLUSIONS AND RELEVANCE: The success of the Joint Replacement Program demonstrates that VA-TAMMCS is an effective tool for Lean and Six Sigma process improvement initiatives in a surgical practice, producing a 36% sustained reduction in length of stay and completely eliminating non-VA care for total hip and knee replacements while increasing total joint replacement volume at this medical center.