Establishing a laparoscopic bariatric program in a safety net hospital.

BACKGROUND: Most laparoscopic bariatric programs are situated in a community- or university-based hospital. The authors have recently initiated a program at a safety net hospital. This investigation hypothesizes that a laparoscopic bariatric program can be established at a safety net hospital with good clinical and financial results. METHODS: A laparoscopic bariatric program was initiated December 2002 at a safety net hospital. The program included a dedicated operative suite, an operative team, a bariatric unit, and a clinical pathway. The data for all the patients who underwent laparoscopic gastric bypasses up to June 2003 were analyzed. The patients were analyzed by type of insurance: government-sponsored insurance (G) or commercial insurance (C). RESULTS: There were 104 patients during this period. Their mean age was 40 years (range, 18-63 years), and their mean body mass index was 48 (range, 38-62). The median length of hospital stay was 2 days (mean, 3.9 days). Hypertension and diabetes were resolved for more than 80% of the patients. The average percentage of excess body weight loss was 73% after 1 year. There were no significant clinical differences between payor groups. The payor mix was 31% G and 69% C. The mean collection rates for hospital charges were 10% for G versus 53% for C (p < 0.0001). CONCLUSIONS: A laparoscopic bariatric program can be established in a safety net hospital with good clinical results. Findings showed that 1-year weight loss and comorbidity improvement/resolution compares favorably with those of other programs. Despite the overall poor payor mix of many safety net hospitals, a bariatric program can be established and can attract a high rate of commercially insured patients.

Blunt renal artery injury: incidence, diagnosis, and management.

Renal artery injury is a rare complication of blunt abdominal trauma. Increasing use of CT scans to evaluate blunt abdominal trauma identifies more blunt renal artery injuries (BRAIs) that may have otherwise been missed. We identified patients with BRAI to examine the incidence and to evaluate the current diagnosis and management strategies. Patients admitted from 1986 to 2000 at a regional Level I trauma center sustaining BRAI were evaluated. Patients undergoing revascularization or nonoperative management were followed for renovascular hypertension. Twenty-eight patients with BRAI were identified out of 36,938 blunt trauma admissions between 1986 and 2000 (incidence 0.08%). Most renal artery injuries were diagnosed by CT scans (93%) with seven confirmatory angiograms. Nine patients had nephrectomy (one bilateral), and three patients with unilateral injuries were revascularized. Sixteen were managed nonoperatively including one patient who had endovascular stent placement. Three patients died from shock and sepsis. Follow-up for all patients ranged from one month to 8 years. Two patients developed hypertension: one who was revascularized (33%) and one was managed nonoperatively (6%). The frequency of diagnosis of BRAI is increasing because of the increased use of CT. Nonoperative management of unilateral injuries can be successful with a 6 per cent risk for developing renovascular hypertension. The role of endovascular stenting is promising, and further study is necessary.

Pharmacoeconomics of aztreonam-clindamycin versus gentamicin-clindamycin in the treatment of penetrating abdominal injury.

STUDY OBJECTIVE: To evaluate the pharmacoeconomic implications of using aztreonam-clindamycin (A-C) versus gentamicin-clindamycin (G-C) from the perspective of the hospital and pharmacy directors. DESIGN: Pharmacoeconomic analysis performed at one of the sites participating in the prospective, randomized, double-blind, comparative, multicenter efficacy study. SETTING: Referral hospital with level 1 trauma center. PATIENTS: Eight-five adults with a suspected penetrating intraabdominal injury requiring laparotomy. INTERVENTIONS: Patients were randomized to receive aztreonam 2 g intravenously every 8 hours or gentamicin 2 mg/kg intravenous load followed by 5 mg/kg/day intravenously initially adjusted to peak concentrations of 6-8 micrograms/ml. All patients received clindamycin 900 mg intravenously every 8 hours. MEASUREMENTS AND MAIN RESULTS: Charge data were gathered from the hospital billing system and converted to cost data using an institutional cost:charge ratio of 0.6. Study drug and aminoglycoside monitoring costs were also calculated. Overall, 43 (97%) of 44 patients receiving A-C had a favorable clinical response compared with 35 (85.4%) of 41 receiving G-C (p = 0.052). The mean hospital cost of $66,336 for 7 infected patients was significantly higher than that of $8014 in 78 noninfected patients (p < 0.0001). Mean hospital costs of $12,058 and $13,742 for A-C and G-C groups, respectively, were not significantly different (p > 0.05) despite having only a single failure (total cost $162,666) in the A-C group. Similarly, mean pharmacy costs of $1411 and $1604, respectively, were not significantly different (p > 0.05). CONCLUSIONS: Hospital costs for infected patients with penetrating abdominal trauma exceed those of noninfected patients by 5-fold. Despite a lower infection rate in the A-C group, neither hospital nor pharmacy costs were significantly different compared with those in the G-C group.

Analysis of charges associated with diagnosis of nosocomial pneumonia: can routine bronchoscopy be justified?

Many ventilated trauma patients thought to have nosocomial pneumonia have pulmonary contusion or systemic inflammatory response syndrome with tracheobronchial colonization. Fiberoptic bronchoscopy with quantitative culture techniques of protected specimen brush (PSB; threshold 10(3) cfu/mL) or bronchoalveolar lavage (BAL; threshold 10(5) cfu/mL) can potentially eliminate the false positive cultures of the upper airway seen with routine sputum aspirates (RS). However, bronchoscopy is expensive, and routine use may not be cost effective. This prospective study evaluated the patient charges associated with bronchoscopy and quantitative cultures compared with RS for the diagnosis of nosocomial pneumonia. Specimens were obtained by RS, PSB, and BAL from the lower airway in 107 trauma patients (136 sets of triplicate cultures). All patients had clinical evidence suggestive of pneumonia (fever, leukocytosis, purulent sputum, abnormal roentgenographic findings). Typical oral flora were considered contaminants; no gram-negative specimens were excluded. Mean age was 40 years and mean ISS was 29. Seventy-eight percent had blunt injuries, 22% penetrating, and 42% had chest injuries. The incidence of nosocomial pneumonia according to each method was: RS-73%; PSB-34%; BAL-25%. Considering all charges involved (bronchoscopy, equipment, microbiologic analysis, and antibiotics), and based on a 14-day course of ceftazidime and vancomycin, the charges for PSB were 58% of RS, and charges for BAL were 43% of RS. We conclude that the charges associated with bronchoscopy are high, but can be offset by antibiotic savings. Side effects of unnecessary antibiotic therapy would be avoided. Further study is needed to determine the efficacy of PSB or BAL in trauma patients.

A prospective analysis of diagnostic laparoscopy in trauma.

OBJECTIVE: This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed. SUMMARY BACKGROUND DATA: Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps. METHODS: Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy. RESULTS: Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol. CONCLUSIONS: DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management.

Trauma center imaging problems: proposed solution with picture archiving communication systems.

Radiologic support for trauma center activities presents special problems that are discussed. This article proposed the use of a picture archiving communication system (PACS) as a potential solution. A sample PACS for this purpose is described to illustrate this approach.

Drug use in a trauma intensive-care unit.

Medication prescribing patterns and costs of specific drug therapies in a trauma intensive-care unit (TICU) were studied. Demographic data and total drug use (scheduled, p.r.n., and single-dose medications) were recorded for all patients admitted to a TICU whose length of stay exceeded 24 hours. Scheduled and p.r.n. medications were categorized into major drug classes for purposes of analysis. Cost estimates were calculated for all scheduled medications. Correlations were made between demographic variables, injury severity indices, drug use, and length of stay by using simple linear regression. A one-way ANOVA was used to compare drug use between the trauma types. For the 278 patients who met the inclusion criteria, the mean +/- S.D. number of drugs prescribed was 9.1 +/- 6.5. Scheduled medications accounted for 58% of total drug use. Mean +/- S.D. duration of scheduled drug therapy was 5.0 +/- 4.8 days. Age (by decade), injury severity score, trauma score, and length of stay correlated with total and scheduled drug use per patient. Drug use (total, scheduled, and p.r.n.) did not differ significantly by trauma type. Antimicrobial therapy, stress ulcer prophylaxis, and bronchodilator therapy accounted for more than 66% of all scheduled drugs used; total cost estimates for these three drug categories exceeded $47,000 over the six-month study period. Analgesics, antipyretics, sedatives, and muscle relaxants constituted nearly 75% of all p.r.n. drug orders. Drug use in the TICU was extensive. The drug categories identified in this study may be useful in future cost containment efforts and initiation of drug use evaluations.

A prospective study of 91 patients undergoing both computed tomography and peritoneal lavage following blunt abdominal trauma.

Recent reports comparing computed tomography of the abdomen (CTA) and diagnostic peritoneal lavage (DPL) following trauma have been contradictory. A 10-month prospective study was conducted at our trauma center comparing both methods. Criteria for entry into the study included suspected blunt abdominal trauma without indication for immediate laparotomy, with either equivocal abdominal examination, diminished sensorium, or neurologic deficit. Ninety-one patients meeting these criteria underwent CTA followed by DPL. CTA was performed using both oral and intravenous contrast; DPL was performed by the open technique with RBC greater than 100,000 mm3 or WBC greater than 500 mm3 as criteria for a positive examination. CTA was interpreted initially by available radiology staff and residents and retrospectively reviewed by an experienced tomographer blind to DPL and surgical results. Twenty patients in whom either test was positive underwent laparotomy; all others were admitted for observation and/or extra-abdominal surgery. Laparotomy revealed 26 organs injured in the 20 patients explored at admission; none of the observed patients required delayed laparotomy. The results of CTA and DPL were compared to the findings at laparotomy or the clinical course of those not explored. The sensitivity, specificity, and accuracy for initial CTA were 60%, 100%, and 91%; for review CTA 85%, 100%, and 97%; for DPL 90%, 100%, and 98%. We conclude that: even with experienced examiners, CTA offers no diagnostic advantage over DPL in blunt trauma; because of relative costs, we do not recommend the routine application of CTA; CTA is a reliable alternative when circumstances prevent the performance of DPL.

Vascular trauma to the extremities and lower neck: initial assessment with intravenous digital subtraction angiography.

Rapid assessment of a patient with possible major peripheral vascular injury is essential to preserve limb function. Intravenous digital subtraction angiography (IV DSA) allows rapid evaluation of these patients without the need for intraarterial examination. We report our experience in 295 vessels studied by IV DSA for the evaluation of possible traumatic arterial injury to the extremities or neck. Of our study population requiring angiography (469 patients), 63.4% were appropriate candidates for IV DSA. Of the vessels studied by IV DSA, 93.6% required no further radiologic evaluation. A normal appearance on IV DSA study indicates no major vascular injury; patients with positive studies may proceed to surgery without further interventional assessment.

Management of perforating colon trauma: randomization between primary closure and exteriorization.

During a 44 month trial, 268 patients with wounds of the colon were entered into a prospective, randomized, nonblinded study. Consideration for primary closure demanded that: preoperative shock was never profound, blood loss was less than 20% of estimated normal volume, no more than two intra-abdominal organ systems had been injured, fecal contamination was minimal, operation was begun within eight hours, and wounds of colon and abdominal wall were never so destructive as to require resection. Once such criteria had been satisfied, colon wound management was dictated by last digit in the randomly assigned hospital number; odd indicated primary closure; even, exteriorization of the wound or primary closure with protection by a proximal vent. Results obtained in 139 determinant patients eligible for randomization revealed that primary closure (67 patients) had a lower infection rate of the incision (48% vs S7%, p > 0.05) and a still lower infection rate for the abdomen proper (15% vs 29%, p < 0.05) on comparison to the 72 patients with a randomized colostomy. Morbidity otherwise for the randomized colostomy was tenfold greater than if a primary closure had been performed. Average postoperative stay was six days longer (p < 0.01) if a colostomy had been created, exclusive of subsequent hospitalization for colostomy closure; while the total extra cost for management of the colon wound by colostomy was approximately $2,700.00. Although immediate mortalities were identical, one late death occurred following colostomy closure. These data not only confirm the safety of primary closure for colon wounds in selected cases, but also indicate that such should become the preferred method of treatment whenever specific criteria have been met.