Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project-Phase II Outcomes.

BACKGROUND: Our institution previously initiated a perioperative surgical home initiative to improve quality and efficiency across the hospital arc of care of primary total knee arthroplasty and total hip arthroplasty patients. Phase II of this project aimed to (1) expand the perioperative surgical home to include revision total hip arthroplasties and total knee arthroplasties, hip preservation procedures, and reconstructions after oncologic resections; (2) expand the project to include the preoperative phase; and (3) further refine the perioperative surgical home goals accomplished in phase I. METHODS: Phase II of the Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies project ran from July 2018 to July 2019. The evaluated arc of care spanned from the preoperative surgical consult visit through 90 days postoperative in the expanded population described above. RESULTS: Mean length of stay decreased from 2.2 days to 2.0 days (P < .001), 90-day readmission decreased from 3.0% to 1.6% (P < .001), and Press-Ganey scores increased from 77.1 to 79.2 (97th percentile). Mean and maximum pain scores and opioid consumption remained unchanged (lowest P = .31). Annual surgical volume increased by 10%. Composite changes in surgical volume and cost reductions equaled $5 million. CONCLUSION: Application of previously successful health systems engineering tools and methods in phase I of Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies enabled additional evolution of an orthopedic perioperative surgical home to encompass more diverse and complex patient populations while increasing system-wide quality, safety, and financial outcomes. Improved process and outcomes metrics reflected increased efficiency across the episode of care without untoward effects. LEVEL OF EVIDENCE: III Therapeutic.

Don't stress: a case report of regional anesthesia as the primary anesthetic for gynecologic surgery in a patient with mitochondrial myopathy and possible malignant hyperthermia susceptibility.

BACKGROUND: We aim to describe the evaluation and management of a patient with the uncommon combination of both mitochondrial myopathy and possible malignant hyperthermia susceptibility as an important source of information and as a valuable example of the role of regional anesthesia for patients with these diagnoses. CASE PRESENTATION: A 24 year old woman with a history of possible mitochondrial myopathy and possible malignant hyperthermia susceptibility presented for gynecologic surgery. Surgery was well tolerated with combined spinal epidural anesthesia as well as sedation with midazolam, ketamine, and fentanyl. CONCLUSIONS: Anesthetic management of patients with mitochondrial myopathy is challenging, made even more so with concurrent malignant hyperthermia susceptibility. This case adds an example to the literature of employing regional anesthesia as a safe approach to this complex care.

Finding the sweet spot: identification of optimal glucose levels in critically injured patients.

BACKGROUND: Conflicting data exist regarding optimal glycemic control in critically ill trauma patients. We therefore compared glucose parameters and outcomes among three different glycemic control regimens in a single trauma intensive care unit (ICU), hypothesizing that a moderate regimen would yield optimal avoidance of hyper- and hypoglycemia with equivalent outcomes when compared with a more aggressive approach. METHODS: We retrospectively reviewed 1,422 trauma patients with at least 3-day ICU stay and five glucose measurements from May 2001 to January 2010, spanning three nonoverlapping, sequential glucose control protocols: "relaxed," "aggressive," and "moderate." For each, we extracted mean blood glucose, hypoglycemic and hyperglycemic event frequency, and glucose variability and investigated their association with outcomes. RESULTS: Mortality was associated with elevated mean glucose (135.6 mg/dL vs. 126.2 mg/dL), more frequent hypoglycemic (2.67 ± 7 vs. 1.28 ± 5) and hyperglycemic (30.6 ± 28 vs. 16.0 ± 22 per 100 patient-ICU days) events, and higher glucose variability (37.1 ± 20 vs. 29.4 ± 20; all p < 0.001). Regression identified hyperglycemic episodes (p < 0.05) as an independent predictor of mortality. The "moderate" regimen had rare hyperglycemia, low glucose variability, and intermediate mean blood glucose range and frequency of hypoglycemia. Multiorgan failure and mortality did not differ between groups. CONCLUSIONS: Hyperglycemic events (glucose >180 mg/dL) most strongly predicted mortality. Of glucose control protocols analyzed, the "moderate" protocol had fewest hyperglycemic events. As outcomes were otherwise equivalent between "moderate" and "aggressive" protocols, we conclude that hyperglycemia can be safely avoided using a moderate glycemic control protocol without inducing hypoglycemia.

Cost-driven injury prevention: creating an innovative plan to save lives with limited resources.

BACKGROUND: Pedestrian injury costs >$20 billion annually. Countermeasures such as blinking crosswalks can be expensive but expectedly vital to injury prevention efforts. We aimed to create a new framework of cost-driven surveillance. The purpose of our study was to carry out a detailed analysis of the hospital cost and its relationship to location of pedestrian injury. Targeting identified "high cost areas" with effective countermeasures could save lives and be most cost-effective. Our hypothesis is that pedestrian injury creates a tremendous public funding burden and that hotspot sites can be mapped based on corresponding hospital costs. METHODS: We conducted a retrospective analysis of billing records of 694 auto versus pedestrian victims treated at Level I trauma center in our city in the sample year 2004. Total cost was computed using cost to charge ratios for hospital and ambulance fees and actual cost of professional fees. City district "price tags" were assigned per detailed patient cost data to corresponding spatial analysis of intersections. χ(2) analyses were conducted on demographic variables. Multiple regression analysis determined predictors of total cost. RESULTS: The total cost of injury was $9.8 million, whereas the total charge was $20.8 million. Ninety percent of victims resided in our City. Thirty-one percent were admitted and cost of their care accounted for 76% of the total. Admitted patients were older than nonadmitted patients (47 years vs. 38 years; t = 5.45; p = 0.00). Spatial analysis determined that of 11 city districts, three districts accounted for almost 50% of the total cost. Seventy-six percent of the total cost was publicly funded. The strongest predictors of cost were length of stay (â = 0.77; t(220) = 30.42; p = 0.000) and ventilator days (â = 0.51; t(220) = 6.69; p = 0.000). CONCLUSIONS: These findings provide a roadmap to target costly hot spots for city planning of preventive countermeasures. In a climate of limited resources, this kind of roadmap outlines the three regions that could most benefit from countermeasures from both an injury prevention and cost-containment standpoint. Cost-driven surveillance is useful in city strategic planning for cost-effective and life-saving pedestrian injury prevention.