Quality of Care and Cost-effectiveness: Optimizing Wound Care in the Netherlands.

OBJECTIVE: Previously, the authors implemented a "fast-track protocol" in the Netherlands to shorten the time to referral for patients when diagnostic testing was deemed necessary given suspicion of underlying pathology preventing wound healing. This subanalysis of the cross-sectional study presents the cost reduction of using that fast-track protocol. METHODS: The cross-sectional study data were collected at the Alrijne Wound Centre between January 2017 and January 2018 and included patients from two general practitioner practices and a large home-care organization who had a new occurrence of wounds. The cost-effectiveness analysis consisted of an analysis of the mean reduction in care, wound dressing materials, and reduction in unnecessary hospital referrals. RESULTS: In 2017, a total of 415 patients received wound care of the general practitioners or home-care organization. By using the "fast-track" protocol, costs were reduced in all areas. After extrapolation, the minimum mean cost reduction in wound care was €129,949,638; on wound dressings, it was €2,623,920, and on the reduction of unnecessary hospital referrals, the average recovery was €2,436,000. CONCLUSIONS: Prompt triage, analyses, and treatment of underlying causes by specialized doctors in a multidisciplinary setting offer enormous potential for cost savings. The conservative estimate is that approximately €135,000,000 to €293,000,000 can be saved in annual healthcare costs in the Netherlands using this protocol.

A contemporary assessment of devices for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): resource-specific options per level of care.

PURPOSE: Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as adjunct for temporary hemorrhage control in patients with exsanguinating torso hemorrhage is increasing. Characteristics of aortic occlusion balloons (AOB) are diverse and evolving as efforts are made to improve the technology. It is important to select a device that fits the requirements of the medical situation to minimize the risk of failure and complications. The aim of this study is to appraise guidance in the choice of an AOB in a specific situation. METHODS: We assessed 29 AOB for differences and outline possible advantages and disadvantages of each. Bending stiffness was measured with a three-point bending device. RESULTS: Diameter of the AOB ranged from 6 (ER-REBOA™) to 10 (Coda®-46) French. However, some need large-bore access sheaths up to 22 French (Fogarty®-45 and LeMaitre®-45) or even insertion via cut-down (Equalizer™-40). Bending stiffness varied from 0.08 N/mm (± 0.008 SD; Coda®-32) to 0.72 N/mm (± 0.024 SD; Russian prototype). Rescue Balloon™ showed kinking of the shaft at low bending pressures. The only non-compliant AOB is REBOA Balloon®. ER-REBOA™, Fogarty®, LeMaitre®, REBOA Balloon®, and Rescue Balloon™ are provided with external length marks to assist blind positioning. CONCLUSION: In resource-limited settings, a guidewire- and fluoroscopy-free, rather stiff device, such as ER-REBOA™, Fogarty®, and LeMaitre®, is warranted. Of these devices, ER-REBOA™ is the only catheter compatible with seven French sheaths and specifically designed for emergency hemorrhage control. Of the over-the-wire devices, Q50® has several features that facilitate use and reduce the risk of malplacement or vessel damage.

Acute Care Surgery Models Worldwide: A Systematic Review.

BACKGROUND: The Acute Care Surgery (ACS) model was developed as a dedicated service for the provision of 24/7 nontrauma emergency surgical care. This systematic review investigated which components are essential in an ACS model and the state of implementation of ACS models worldwide. METHODS: A literature search was conducted using PubMed, MEDLINE, EMBASE, Cochrane library, and Web of Science databases. All relevant data of ACS models were extracted from included articles. RESULTS: The search identified 62 articles describing ACS models in 13 countries. The majority consist of a dedicated nontrauma emergency surgical service, with daytime on-site attending coverage (cleared from elective duties), and 24/7 in-house resident coverage. Emergency department coverage and operating room access varied widely. Critical care is fully embedded in the original US model as part of the acute care chain (ACC), but is still a separate unit in most other countries. While in most European countries, ACS is not a recognized specialty yet, there is a tendency toward more structured acute care. CONCLUSIONS: Large national and international heterogeneity exists in the structure and components of the ACS model. Critical care is still a separate component in most systems, although it is an essential part of the ACC to provide the best pre-, intra- and postoperative care of the physiologically deranged patient. Universal acceptance of one global ACS model seems challenging; however, a global consensus on essential components would benefit any healthcare system.

Assessment of pulmonary oxygen toxicity in special operations forces divers under operational circumstances using exhaled breath analysis.

INTRODUCTION: The Netherlands Maritime Special Operations Forces use closed circuit oxygen rebreathers (O2-CCR), which can cause pulmonary oxygen toxicity (POT). Recent studies demonstrated that volatile organic compounds (VOCs) can be used to detect POT in laboratory conditions. It is unclear if similar VOCs can be identified outside the laboratory. This study hypothesised that similar VOCs can be identified after O2-CCR diving in operational settings. METHODS: Scenario one: 4 h O2-CCR dive to 3 metres' seawater (msw) with rested divers. Scenario two: 3 h O2-CCR dive to 3 msw following a 5 day physically straining operational scenario. Exhaled breath samples were collected 30 min before and 30 min and 2 h after diving under field conditions and analysed using gas chromatography-mass spectrometry (GC-MS) to reconstruct VOCs, whose levels were tested longitudinally using a Kruskal-Wallis test. RESULTS: Eleven divers were included: four in scenario one and seven in scenario two. The 2 h post-dive sample could not be obtained in scenario two; therefore, 26 samples were collected. GC-MS analysis identified three relevant VOCs: cyclohexane, 2,4-dimethylhexane and 3-methylnonane. The intensities of 2,4-dimethylhexane and 3-methylnonane were significantly (P = 0.048 and P = 0.016, respectively) increased post-dive relative to baseline (range: 212-461%) in both scenarios. Cyclohexane was increased not significantly (P = 0.178) post-dive (range: 87-433%). CONCLUSIONS: VOCs similar to those associated with POT in laboratory conditions were identified after operational O2-CCR dives using GC-MS. Post-dive intensities were higher than in previous studies, and it remains to be determined if this is attributable to different dive profiles, diving equipment or other environmental factors.

Prepared for Mission? A Survey of Medical Personnel Training Needs Within the International Committee of the Red Cross.

BACKGROUND: Humanitarian organizations such as the International Committee of the Red Cross (ICRC) provide worldwide protection and medical assistance for victims of disaster and conflict. It is important to gain insight into the training needs of the medical professionals who are deployed to these resource scarce areas to optimally prepare them. This is the first study of its kind to assess the self-perceived preparedness, deployment experiences, and learning needs concerning medical readiness for deployment of ICRC medical personnel. METHODS: All enlisted ICRC medical employees were invited to participate in a digital questionnaire conducted during March 2017. The survey contained questions about respondents' personal background, pre-deployment training, deployment experiences, self-perceived preparedness, and the personal impact of deployment. RESULTS: The response rate (consisting of nurses, surgeons, and anesthesiologists) was 54% (153/284). Respondents rated their self-perceived preparedness for adult trauma with a median score of 4.0 on a scale of 1 (very unprepared) to 5 (more than sufficient); and for pediatric trauma with a median score of 3.0. Higher rates of self-perceived preparedness were found in respondents who had previously been deployed with other organizations, or who had attended at least one master class, e.g., the ICRC War Surgery Seminar (p < 0.05). Additional training was requested most frequently for pediatrics (65/150), fracture surgery (46/150), and burns treatment (45/150). CONCLUSION: ICRC medical personnel felt sufficiently prepared for deployment. Key points for future ICRC pre-deployment training are to focus on pediatrics, fracture surgery, and burns treatment, and to ensure greater participation in master classes.