Cost Savings of Frequent, Concise Skills Competency Training in the Emergency Department.

Nurse educators are confronted with ensuring skills competency and staff compliance to support the provision of safe and quality care. The ED setting presents additional challenges when conducting skills competency training. One military hospital's emergency department implemented a method of frequent, concise skills training sessions to overcome barriers unique to the ED setting; the same method was then implemented at a second military organization owing to the effectiveness of the training approach to increase staff compliance. This article outlines the methods for the implementation of frequent, concise skills training sessions, and it displays the cost savings and increased compliance experienced by the 2 health care organizations after the implementation of this frequent, concise skills training method.

Evaluation of Operative Waste in a Military Medical Center: Analysis of Operating Room Cost and Waste during Surgical Cases.

Operating rooms (ORs) contribute to at least 40 per cent of hospital costs. There is an existing cost waste in ORs for surgical devices that are opened without being used. There is a paucity of data evaluating the hospital cost of opened but unused OR supplies. The goal of this observational study is to examine the cost of opened but unused OR supplies for general surgery cases. We performed a quality improvement project of OR cost waste by observing 30 cases. Surgical cases of a senior surgeon who had been at the institution for more than five years were evaluated for items opened appropriately and whether the items are used. The cases evaluated ranged from open hernia repairs to robotic-assisted hernia repairs. We found that the cost of instruments opened but not used was $4528.18. Of the cases evaluated, we found that a range of 0 per cent to 27 per cent of total items were wasted, an average of 8.3 per cent. We found that for the open inguinal hernia case, there was minimal waste. The highest waste was among complex cases such as the robotic-assisted inguinal hernia with an average waste and cost of 15.8 per cent and $379. We found that on average for less complex cases such as open inguinal hernia repairs, $1.44 was potentially wasted per case, whereas for more complex cases up to $379 was wasted per case. We identified the outdated preference cards, lack of instrument knowledge, circulating nurse, and surgical technician distractions as reasons for contributing to waste.

Military Hospital Spending on Environmental Services and Inpatient Satisfaction Ratings.

EXECUTIVE SUMMARY: To assess the impact of military hospital expenditures on environmental services (EVS) on inpatient satisfaction, the authors collected Defense Health Agency TRICARE Inpatient Satisfaction Survey data from fiscal years 2011 through 2013, military hospital EVS spending and workload data, facility construction/renovation data, and military health system inpatient administrative claims data. Multivariate logistic regression for panel data was performed independently for medical/surgical and obstetric product lines and each satisfaction question. A statistically significant positive relationship was found between hospital EVS spending and patient satisfaction, with the highest expenditure levels generally exhibiting a greater association with satisfaction. Statistically significant increases in satisfaction with cleanliness were associated with higher levels of hospital expenditures on EVS.

Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain.

BACKGROUND: The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders. METHODS: A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables. RESULTS: The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70). CONCLUSION: Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.

Service Block Time Allocation in the US Army Medical Command.

Service block time allocation is a critical requirement for the optimization of patient throughput and access to care in the Surgical Services Service Line of the US Army Medical Command. The procedure complexity, volume, and diversity across 25 facilities create significant variation in service block time. This variation requires the involvement of both the informatics and leadership teams for block time allocation to be effective. This article describes our use of the Army's Surgery Scheduling System, which includes service block time as an embedded function, to develop a standardized process that helps ensure service block time is optimized. We also present guidelines for block time allocation and offer case studies that demonstrate the application of these guidelines.

What Patients Really Want: Optimizing the Military Preoperative Evaluation Clinic.

The idea of the preoperative anesthesia clinic as a means of examining and treating the patient so that he will arrive in the operating theater as strong and healthy as possible is well established in practice and literature.However, problems in clinic design and execution often result in high patient waiting times, decreased patient and staff satisfaction, decreased patient capacity, and high clinic costs. Although the details of clinic design, outcomes, and satisfaction have been extensively evaluated at civilian hospitals, we have not found corresponding literature addressing these issues specifically within military preoperative evaluation clinics. We find that changing to an appointment-based (versus walk-in) system and eliminating data collection step redundancies will likely result in lower wait times, higher satisfaction, lower per patient costs, and a more streamlined and resource-efficient structure.

Racial disparities in emergency general surgery: Do differences in outcomes persist among universally insured military patients?

BACKGROUND: Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care. METHODS: Five years (2006-2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care. RESULTS: A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13-1.35]; 90 days, 1.18 [1.09-1.28]; and 180 days, 1.15 [1.07-1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69-1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race. CONCLUSIONS: While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

[Organisational aspects of medical support for civilians employed in the Armed Forces in the military-medical institutions of the Ministry of Defence, deployed in Moscow].

Organisational aspects of medical support for civilians employed in the Armed Forces in the military-medical institutions of the Ministry of Defence, deployed in Moscow. To ensure social protection of the civilian personnel of the Armed Forces is one of the main tasks of the Ministry of Defence of the Russian Federation. In Moscow formed a territorial system of medical support of citizens who have the right for medical care in military medical institutions of the Ministry of Defence of the Russian Federation. Russian legislation does not provide the right for medical assistance provision to the civilian personnel of the Armed Forces in military medical institutions at the expense of funds allocated from the federal budget for the maintenance of the Ministry of Defence of the Russian Federation. The function of the physician in providing primary medical care performs primary care physician. Providing medical assistance to the civilian personnel of the Armed Forces of the Russian Federation in military medical institutions on the basis of their attachment to the clinics onlv the Russian Defence Ministrv. or in the direction of the clinics of Moscow.

La salud y la enfermedad en el Real Hospital de la Armada del Arsenal de la Carraca (1756-1821) / Health and disease in the Real Hospital de la Armada of the Arsenal de la Carraca (1756-1821)

En el primer cuarto del siglo XVIII se crea el Arsenal de la Carraca, considerado como el principal astillero de la Armada Española. La masiva llegada de operarios civiles y militares ante la oferta de trabajo, motivó un problema asistencial sanitario, que se solventó a través de una improvisada enfermería de madera y otros hospitales provisionales instalados en la Isla de León. Finalmente, en 1756 se pudo fundar el «Real Hospital del Arsenal de la Carraca». Este nosocomio tuvo un papel crucial en la epidemia de fiebre amarilla de 1800 y en los dos primeros años de la Guerra de la Independencia, hasta que en agosto de 1810 tuvo que ser desalojado ante el riesgo de bombardeo de las baterías francesas apostadas en Puerto Real, siendo reconvertido en un «hospital de sangre». No obstante, en la segunda grave epidemia de fiebre amarilla de 1819, el hospital tuvo que ser reactivado como en sus orígenes. Debido a la restructuración hospitalaria en la bahía de Cádiz, la Armada procedió a su extinción en el año 1821, tal y como muestra el documento que lo acredita encontrado en el Archivo General de Marina «Álvaro de Bazán». En este trabajo se exponen las vicisitudes sanitarias y humanas de este Real Hospital a lo largo de 65 años claves en la historia de España

In the first quarter of the 18th century the Arsenal de la Carraca was created and soon after considered the most important shipyard of the Spanish Navy. The massive arrival of military and civilian employees as a consequence of the job offered, brought about a health care problem. This trouble was resolved by an improvised wooden sickbay and other several provisional hospitals placed in La Isla de León. Finally, the Real Hospital del Arsenal de la Carraca was established in 1756. It played a crucial role in the 1800 Yellow Fever Epidemic and in the first two years of the War of Independence until August 1810, when it was forced to evict considering the risk of a bombardment by French batteries settled in Puerto Real; then it was retrained as a ‘blood hospital’. Nevertheless, the hospital was established as it was originally because of the second serious 1819 Yellow Fever Epidemic. As a result of that reorganization in the Bahia de Cádiz, the hospital was closed down by Spanish Navy in 1821, as it is demonstrated by its supporting document founded in the Archivo General de Marina ‘Álvaro de Bazán’. This work expounds the sanitary conditions and human mishaps of this Real Hospital over 65 key years in the Spanish history

Fever evaluation cost and time to treatment in the general surgery patient can be reduced by using a fever practice guideline.

OBJECTIVES: Evaluation of surgical patients with fever and leukocytosis (FAL) for an infection source often results in unnecessary laboratory and radiographic tests. The average cost of an FAL work-up ranges from $2200 to $5600. Lack of a systematic approach drives costs higher than necessary. We evaluated differences in time to treatment and costs using usual methods of FAL work-ups versus FAL work-ups using an established fever practice guideline (FPG). METHODS: In phase I, a retrospective electronic chart review was conducted for 82 adult surgery patients who underwent FAL work-ups to determine time from initial temperature presentation to fever treatment and total cost per fever evaluation. In phase II, an established FPG was applied to 30 intensive care unit patients from the original group of 82 using phase I data points. Differences in cost and time to treatment were compared using a paired t-test. RESULTS: Mean time to fever treatment decreased from 51.57 hours pre-FPG use to 11.23 hours afterward (p < 0.001), a 78% reduction in time to definitive treatment. Mean cost of FAL work-up decreased from $1,009.73 without FPG use to $399.00 with a 60% reduction in costs. CONCLUSIONS: Using a standardized FPG, FAL work-up time to treatment and cost can be significantly reduced.

Decreasing inpatient length of stay at a military medical treatment facility.

This article describes an evidence-based approach to decreasing the length of stay of inpatient adults on the medicine oncology ward of a large urban military medical center. A strong and diverse team was formed, which worked together for the length of the project. A formalized approach involving weekly discharge-planning meetings with a discharge advocate as the planner, coupled with solid documentation, was adopted. There was a decrease in the average length of stay on the inpatient wards, resulting in cost savings for the facility. This approach using strong evidence can overcome institutional challenges, with a positive impact on patient care.

[Marketing in the system of military-medical facilities].

Military medical facilities of the Ministry of Defence of the Russian, have received the right to provide additional services and have been involved in the sphere of market relations. The strong influence of market relations - an objective reality that must be used for the development of military medical institutions and improving quality of care.Effective commercial activity can improve capabilities of the military medical institutions. This requires constant study of market mechanisms to implement and develop their competitive advantage. The paper substantiates the need for the participation of military medical institutions in the provision of health services to the public on the terms of compensation incurred by financial institutions costs (paid medical services, medical assistance program of compulsory and voluntary health insurance). Taking into account the specifics of military medical institutions set out basic principles and recommendations have been implementing marketing approach in their management, the practical application of which will not only increase efficiency, but also create conditions to improve the financial and economic indicators. This knowledge will help the mechanism of functioning health care market and the rules of interaction of market counterparties.

What is the real cost of an overnight stay after an ambulatory general surgical procedure?

INTRODUCTION: Outpatient surgery is performed widely throughout the Army Medical Command (MEDCOM). It is common practice throughout Medical Command to admit barracks dwelling active duty service members (ADSMs) undergoing ambulatory surgical procedures for overnight observation. We hypothesized that overnight observation of these individuals has not prevented adverse outcomes that would have otherwise occurred if the patient had been discharged to the barracks. METHODS: We reviewed the postoperative course of all ADSMs undergoing ambulatory surgery with subsequent overnight hospital stay because of primary barracks residence. Procedures included hernia repair, lipoma excisions, and pilonidal cystectomies. Inclusion criteria were ADSMs who stayed overnight purely on the basis of their military barracks residence. RESULTS: 145 patients met our inclusion criteria. Their mean age was 23 ± 3.2, 90.9% were males. The mean hospital length of stay was 24 ± 11.4 hours. There were four (2.78%) postoperative complications, three patients with postoperative urinary retention, and one patient with mild bleeding from a pilonidal excision site, all within 8 hours postoperatively. No adverse outcomes were noted during the period of their hospitalization. CONCLUSION: Barracks dwelling ADSMs do not have adverse outcomes during their inpatient observational hospitalization. An outpatient escort would be sufficient to ensure adequate observation.

Usability study of a novel, self-lighted, disposable speculum: military applications.

STUDY DESIGN: Data collected from a postutilization questionnaire were used to evaluate the usability of the OfficeSPEC disposable vaginal speculum, specifically the effectiveness, efficiency, and acceptability, in clinical, hospital, and austere environments. RESULTS: Usability data analysis showed the OfficeSPEC speculum had an effectiveness rating of 4.6/5, efficiency rating of 4.5/5, and acceptability rating of 4.6/5; overall usability in deployed environments was favorable. The overall rankings were 3.4 for plastic, 4.2 for metal (p < 0.001), and 4.5 for OfficeSPEC (p < 0.001). Cost analysis of the OfficeSPEC placed the disposable speculum as a reasonable alternative with yearly cost of $129,200, compared to traditional metal ($209,100) and plastic ($319,175). CONCLUSION: By evaluating the OfficeSPEC speculum within a usability framework, it proved to be practical, viable alternative in all environments, particularly in the forward deployed environment.

Finally "deliberate by design": milestones in the delivery of health care for U.S. military family members.

The development of medical care for U.S. military families and retirees was serendipitous, a fortunate accident. The formal development of military family medical care required the evolution of three factors: the emergence of a standing army, frontiers to guard, and a peace to defend. These factors were first realized in the late 19th Century, and beginning at that point in U.S. history, seven key years highlight major milestones in the history of military family member medical care. At the same time, these years exemplify changing ideas of disease and of health care and how the physical design of clinics and hospitals reflects and impacts these ideas. The Fort Belvoir Community Hospital, which opens in 2011, exemplifies the Nation's best example of green hospital construction, patient and family centered care, and evidence-based design in a Culture of Excellence that demonstrates that military family medical care is finally "deliberate by design."

Casualties.

Privation and disease have mainly killed soldiers until very recently. Now that enemy action predominates, faster and better control of bleeding and infection before and during evacuation spares ever more lives today. This essay focuses on psychological war wounds, placing them in the context of military casualties. The surgeon's concepts of 'primary' wounds in war, and of would 'complications' and 'contamination', serve as models for psychological and moral injury in war. 'Psychological injury' is explained and preferred to 'Post-Traumatic Stress Disorder', being less stigmatizing and more faithful to the phenomenon. Primary psychological injury equates to the direct damage done by a bullet; the complications - for example, alcohol abuse - equate to hemorrhage and infection. Two current senses of 'moral injury' equate to wound contamination. As with physical wounds, it is the complications and contamination of mental wounds that most often kill service members or veterans, or blight their lives.