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1.
Artigo em Inglês | MEDLINE | ID: mdl-32044870

RESUMO

BACKGROUND: Trauma is the leading cause of non-obstetric death during pregnancy and is associated with an increased risk of maternal and fetal mortality. In an effort to improve the delivery of care to pregnant trauma patients, we developed an institutional multidisciplinary quality initiative designed to improve response times of non-trauma specialists and ensure immediate availability of resources. We hypothesized that implementation of a Perinatal Emergency Response Team (PERT) would improve time to patient and fetal evaluation and monitoring by the Obstetrics (OB) team, and improve both maternal and fetal outcomes. METHODS: We performed a 6-year (2012-2018) retrospective cohort analysis of consecutive pregnant trauma patients presenting to our University-affiliated, Level I Trauma Center. Patients in the pre-PERT cohort (prior to April 2015) were compared to a post-PERT cohort. Variables analyzed included patient demographics, mechanism of injury, injury severity score (ISS), and level of trauma activation. The main outcome measure was time to OB evaluation. Secondary outcomes included time to cardiotocometry, and mortality. RESULTS: Of 92 pregnant trauma patients, there were 50 patients (54.3%) in the pre-PERT cohort and 42 (45.7%) in the post-PERT group. Blunt injuries predominated (98.9%), with the most common mechanism being motor vehicle collisions (76.1%), followed by assaults (13%), and falls (6.5%). The mean time to obstetrical evaluation was 44 minutes in the pre-PERT cohort compared to 14 minutes in the post-PERT cohort (p = 0.001). There was a significant decrease in Level I (highest acuity) trauma activations pre- and post-PERT (46% vs. 21%, p=0.01), and the time to cardiotocography was significantly decreased post-PERT implementation (72 vs. CONCLUSION: Implementation of a multidisciplinary perinatal emergency response team (PERT) improves time to evaluation by the obstetrics team and time to cardiotocometry in the pregnant trauma patient. LEVEL OF EVIDENCE: IV STUDY TYPE: Retrospective review.

2.
Ann Vasc Surg ; 2019 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-31722245

RESUMO

BACKGROUND: Superficialization, the second stage of a two-stage brachiobasilic arteriovenous fistula (BB-AVF), can be performed under local (LA), regional (RA), or general anesthesia (GA). Given the numerous comorbidities in patients with end-stage renal disease (ESRD), our preference is to use RA or LA when feasible. Our goal was to review the success rate of RA and LA, need for conversion to GA, and cardiac morbidity and mortality for BB-AVF superficialization. METHODS: We performed a retrospective cohort analysis of patients who underwent BB-AVF creation with second-stage superficialization over a 4-year period. The primary outcome measures included need for conversion to GA, myocardial infarction (MI), and 30-day mortality. A secondary outcome was total operative time (time from preoperative briefing to the time the patient left the operating room). We analyzed the data using Fisher Exact test for categorical data and nonparametric analysis for continuous data. RESULTS: There were 42 patients who underwent BB-AVF superficialization. The median age was 56 years, with a mean body mass index of 29. Most patients were male (55%) and predominantly Hispanic/Latino (60%). RA was utilized in 35 patients (83%), LA in 5 (12%), and GA in 2 (5%). The conversion rate from RA to GA was 0% and was 20% (n = 1) from LA to GA. There were no postoperative MI or deaths. There was no significant difference in total operative time (219.6 min for RA, 234.5 min for LA, and 278 min for GA, (P = 0.37)). CONCLUSIONS: Local and/or regional anesthesia can be successfully used in the majority of patients undergoing BB-AVF superficialization. LA and RA are associated with negligible cardiac morbidity and mortality. Conversion from RA to GA is rare. Use of RA does not result in a longer total operative time.

3.
Am Surg ; 85(10): 1146-1149, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657312

RESUMO

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic (P < 0.001), had a higher incidence of preadmission antithrombotic therapy use (P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups (P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.


Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Tratamento de Emergência/efeitos adversos , Cálculos Biliares/cirurgia , Complicações Intraoperatórias/epidemiologia , Cirrose Hepática/complicações , Doença Aguda , Adulto , Fatores Etários , Ductos Biliares/lesões , Conversão para Cirurgia Aberta/estatística & dados numéricos , Tratamento de Emergência/métodos , Feminino , Fibrinolíticos/uso terapêutico , Cálculos Biliares/etiologia , Hemorragia/epidemiologia , Humanos , Incidência , Intestinos/lesões , Complicações Intraoperatórias/etiologia , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Segurança , Fatores Sexuais , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos
4.
Am Surg ; 85(10): 1189-1193, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657322

RESUMO

Paraesophageal hernia (PEH) repair is typically performed electively. Complex PEHs (obstructed or gangrenous) require more urgent repair and can have significant complications. Although elective repair is primarily laparoscopic, limited data are available on the use of laparoscopy for complex cases. Patients undergoing complex PEH repair were identified from the NSQIP database, and predictors of morbidity and mortality were compared for 2473 laparoscopic and 861 open repairs. Compared with the laparoscopic approach, emergent surgeries (36.7% vs 10.8%, P < 0.001) and preoperative sepsis (22.9% vs 7.4%, P < 0.001) were more common in the open group. Operative times were shorter for open repairs (152.6 vs 172.2 minutes, P = 0.03). However, open repair was associated with increased morbidity (28.2% vs 11%, P < 0.001) and mortality (5.2% vs 1.4%, P < 0.001), likely because of higher rates of preoperative comorbidities in the open group. On multivariable regression analysis, preoperative sepsis was associated with increased mortality and morbidity, whereas laparoscopic repair was associated with decreased morbidity. If laparoscopic repair can be safely completed, it is associated with decreased morbidity, despite longer operative times.


Assuntos
Doenças do Esôfago/cirurgia , Hérnia Hiatal/cirurgia , Herniorrafia/mortalidade , Laparoscopia/mortalidade , Idoso , Emergências/epidemiologia , Feminino , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Laparoscopia/efeitos adversos , Masculino , Morbidade , Duração da Cirurgia , Análise de Regressão , Sepse/epidemiologia
5.
Am J Surg ; 218(6): 1185-1188, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31551145

RESUMO

INTRODUCTION: The early identification of hemorrhagic shock may be challenging. The objective of this study was to examine the utility of a narrowed pulse pressure in identifying the need for emergent interventions following penetrating trauma. METHODS: In this 2.5-year retrospective study of adult patients with a penetrating mechanism, patients with a narrowed pulse pressure (<30 mmHg) were compared to those without. Main outcomes measures were the need for a massive transfusion or emergent operation. RESULTS: There were 957 patients, of which the majority were male (86%) and 55% presented with gunshot wounds. On multivariate analysis, a narrowed pulse pressure was associated with the need for massive transfusion (OR 3.74, 95% C.I. 1.8-7.7, p = 0.0003) and emergent surgery (OR 1.68, 95% C.I. 1.14-2.48, p = 0.009). CONCLUSIONS: A narrowed pulse pressure is associated with the presence of hemorrhagic shock and need for emergent interventions among patients with penetrating torso trauma.

6.
J Surg Educ ; 76(6): e132-e137, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31501067

RESUMO

PURPOSE: Women account for 21% of faculty positions in general surgery. In fields with lower female representation, female faculty receive lower evaluation scores by trainees compared to male faculty. At 42%, the female faculty representation in our general surgery department doubles the national average. We sought to determine if variations in faculty evaluations would be observed in a more gender-balanced general surgery program. METHODS: Two years of faculty teaching evaluations by residents in a general surgery residency program were collected from the MedHub system. Total 3277 resident evaluations of 26 faculty members (11 female, 15 male) were analyzed. Seven areas (scored 1-7, with 1 = needs improvement and 7 = outstanding) were examined. Chi-square test was used to compare the percentage of male and female faculty members who scored a 6 or 7 in each category, and multivariate logistic regression analysis was used to determine the association of gender with the evaluation score, while adjusting for the number of encounters between the trainee and the faculty member. RESULTS: There were no significant differences between male and female faculty in the "overall" evaluation score, nor in the "practice-based learning" and the "interpersonal and communication skills" categories. Female faculty had statistically significantly higher scores in "patient care", "professionalism," and "systems-based care" categories, whereas male faculty had higher evaluations in the "medical knowledge" category. CONCLUSION: In a general surgery residency program with a relatively gender-balanced faculty, there was no gender difference in the "overall" evaluation of faculty by residents. However, there were gender differences in specific domains. These findings suggest that gender balance in teaching faculty may help eliminate previously observed teaching evaluation bias in the traditionally male dominated fields.

10.
J Surg Educ ; 75(6): e91-e96, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30131281

RESUMO

OBJECTIVE: Identifying gaps in medical knowledge, patient management, and procedural competence is difficult early in surgical residency. We designed and implemented an end-of-year examination for our postgraduate year 1 residents, entitled Surgical Trainee Assessment of Readiness (STAR). Our objective in this study was to determine whether STAR scores correlated with other available indicators of resident performance, such as the American Board of Surgery in-training exam (ABSITE) and Milestone scores, and if they provided evidence of additional discriminatory value. STUDY DESIGN: Overall and component scores of the STAR exam were compared to the ABSITE and Milestone assessment scores for the 17 categorical residents that took the exam in 2016 and 2017. SETTING: Harbor-UCLA Medical Center, a university-affiliated academic medical center. PARTICIPANTS: Seventeen categorical general surgery residents. RESULTS: The STAR Total Test Score (ß = 2.77, p = 0.006) was an independent predictor of the ABSITE taken the same year, and components of the STAR were independent predictors of ABSITE taken the following year. The STAR Total Test Score was lowest in the 3 residents who had at least 1 low Milestone score assessed in the same year; and 2 of these 3 residents had at least 1 low Milestone score assigned the next year after STAR. Lastly, the Patient Care 1 and 2 Milestones assessed in the same year as STAR were uniformly scored as appropriate for level of training, yet the corresponding STAR component for those milestones demonstrated 3 residents as having deficiencies. CONCLUSIONS: We have created a multifaceted standardized STAR exam, which correlates with performance on the ABSITE and early milestone scores. It also appears to discriminate resident performance where milestone assessments do not. Further evaluation of the STAR exam with longer term follow-up is needed to confirm these initial findings.


Assuntos
Competência Clínica/normas , Cirurgia Geral/educação , Internato e Residência/normas , Fatores de Tempo , Apoio ao Desenvolvimento de Recursos Humanos , Estados Unidos
11.
Ann Surg Oncol ; 25(10): 2975-2978, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29956093

RESUMO

BACKGROUND: Sentinel lymph node biopsy (SLNB) historically involves a separate appointment in the Radiology Department to undergo injection of the radiocolloid tracer (RT) the day of, or prior to, surgery, which can lead to disruptions in scheduling. Furthermore, the patient must endure an additional procedure. In a pilot study, intraoperative injection of the RT was previously shown to be equally as effective as preoperative injection. This study evaluates the efficacy of this method in a large cohort and examines factors associated with failure of the RT to reach the axilla. METHODS: A retrospective review of patients who underwent SLNB between June 2010 and June 2017 was performed. All patients were injected immediately following intubation with sulfur colloid and blue dye, unless contraindicated. Operative records were reviewed to determine whether sentinel nodes were identified and if gamma counts were detected. Patient and tumor characteristics were examined to identify factors related to failed RT uptake in the axilla. RESULTS: In 7 years, 453 SLNBs were performed, with sentinel nodes being detected in 447 (98.7%) of these SLNBs. In the six cases where no nodes were detected, all had a prior ipsilateral axillary procedure. Sentinel nodes were undetectable with the gamma probe in 16 (3.5%) cases; a prior axillary procedure was the only statistically significant independent variable associated with this failure. CONCLUSION: Intraoperative injection of the RT is highly effective in the detection of sentinel nodes in clinically node-negative breast cancer patients. Eliminating the need for a preoperative injection of RT can avoid scheduling conflicts and decrease patient morbidity.


Assuntos
Neoplasias da Mama/patologia , Carcinoma Ductal de Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Carcinoma Lobular/patologia , Biópsia de Linfonodo Sentinela , Coloide de Enxofre Marcado com Tecnécio Tc 99m , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/diagnóstico por imagem , Carcinoma Ductal de Mama/cirurgia , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Carcinoma Intraductal não Infiltrante/cirurgia , Carcinoma Lobular/diagnóstico por imagem , Carcinoma Lobular/cirurgia , Feminino , Seguimentos , Humanos , Período Intraoperatório , Linfonodos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Cuidados Pré-Operatórios , Cintilografia , Compostos Radiofarmacêuticos , Estudos Retrospectivos
12.
Am Surg ; 84(10): 1604-1607, 2018 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30747678

RESUMO

Historically, hernias were repaired before peritoneal dialysis (PD) catheter placement to obviate hernia complications, or after PD catheter placement once hernias became symptomatic or complicated. The aim of this study was to evaluate the outcomes and safety of combined hernia repair and PD catheter placement (HPD) compared with PD catheter placement alone. Within the NSQIP databases (2005-2014), 4406 patients who underwent PD catheter placement alone and 330 patients who underwent HPD were identified. Thirty-day outcomes were compared. Overall, HPD patients were older (61 vs 57 years, P < 0.001), male (72.4% vs 56.1%, P < 0.001), and more likely to have ascites (3.6% vs 1.0%, P < 0.001). Umbilical hernias (87.9%) were most commonly repaired. There was no significant difference in mortality, morbidity, superficial surgical site infection, deep SSI, organ/space SSI, readmission, or reoperation rates. HPD was associated with shorter length of stay (1.1 vs 1.7 days, P = 0.010) and longer mean operative time (66.1 vs 43.7 minutes, P < 0.001). On multivariate analyses, HPD was not an independent predictor of morbidity or mortality. In conclusion, HPD can be safely performed to prevent future complications and additional operations.


Assuntos
Hérnia Umbilical/cirurgia , Herniorrafia/métodos , Diálise Peritoneal/instrumentação , Cateterismo/métodos , Cateteres de Demora , Terapia Combinada , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Segurança do Paciente , Infecção da Ferida Cirúrgica/etiologia , Resultado do Tratamento
13.
Am Surg ; 84(10): 1626-1629, 2018 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30747683

RESUMO

Presently, there are no standardized guidelines regarding the necessity or timing of repeat head imaging in patients on antithrombotics (antiplatelet agents, warfarin, or novel oral anticoagulants) with suspected traumatic brain injury. This is a two-year single institutional retrospective analysis of patients with suspected traumatic brain injury on antithrombotic medications. Patients with a stable or negative repeat head CT were compared with patients who developed a new bleed or demonstrated progression of intracranial hemorrhage (ICH). Of 110 patients, 55 patients (50%) had a positive initial CT, two patients (1.8%) developed a new bleed after initially normal head CT, and 21 patients (19.1%) demonstrated worsening ICH. Patients with worsening or delayed ICH had a higher median Injury Severity Score (14 vs 5, P < 0.001), higher head/neck and face Abbreviated Injury Severity scores (both P < 0.05), and were more likely to be receiving combination therapy with warfarin and clopidogrel (4.3% vs 0%, P = 0.05). On multivariate analysis, lower face and head/neck Abbreviated Injury Severity scores were associated with a decreased risk for delayed or worsening hemorrhage (odds ratio = 0.21 and 0.46, respectively, P < 0.05). Repeat head CT in patients on a preinjury antithrombotic has a low yield. The use of combination therapy may result in an increased risk for delayed hemorrhage or hemorrhage progression.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico por imagem , Fibrinolíticos/efeitos adversos , Idoso , Anticoagulantes/efeitos adversos , Hemorragia Cerebral/induzido quimicamente , Progressão da Doença , Quimioterapia Combinada , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Los Angeles , Masculino , Inibidores da Agregação de Plaquetas/efeitos adversos , Retratamento/estatística & dados numéricos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Varfarina/efeitos adversos
14.
Am Surg ; 84(10): 1580-1583, 2018 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30747673

RESUMO

The rate of positive margins after breast conserving surgery (BCS) can be as high as 50 per cent, and optimal techniques for reducing rates of positive margins are presently debated. Our institution has previously demonstrated low rates of margin re-excision using a standardized approach to intraoperative selective margin excision for patients undergoing BCS. We hypothesized that this approach can be used for patients with ductal carcinoma In Situ (DCIS) and can yield similar rates when compared with invasive cancer. We performed a retrospective analysis of women with breast cancer who underwent BCS from January 2012 through July 2016 using our institution's standardized approach to selective margin resection. Of the 152 patients who underwent BCS, there were 30 (20%) with DCIS and 122 (80%) with invasive cancer. There was no statistically significant difference in re-excision rates for DCIS (13.3%) and invasive cancer (13.1%). Notably, the DCIS group had a larger mean lesion size (P = 0.00009); however, the lesion was visible on ultrasound more often in the invasive cancer group (P = 0.007). This standardized approach to intraoperative selective margin excision can produce similar rates of margin re-excision for DCIS and invasive cancer and may be a viable option for lowering re-excision rates for patients with DCIS.


Assuntos
Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Mastectomia Segmentar/métodos , Feminino , Humanos , Margens de Excisão , Pessoa de Meia-Idade , Radiografia Intervencionista , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Cirurgia Assistida por Computador/métodos
16.
Am Surg ; 83(10): 1054-1058, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-29391094

RESUMO

The objective of this study is to describe the contemporary management of proximal upper extremity and neck arterial injuries by comparing open and endovascular repair at a single institution. This is a retrospective study of 22 patients that sustained subclavian, axillary, and carotid artery injuries from 2011 to 2016 that were managed with open or endovascular repair. There were nine subclavian, eight axillary, and five carotid artery injuries of which 10 (45.5%) underwent endovascular repair and 12 (54.5%) underwent open repair. There was no statistically significant difference between the groups including injury severity score or preoperative hypotension. There were no deaths in the endovascular group, and three (25.0%) deaths in the open group. All patients in the endovascular group were discharged home. In the open group, seven (58.3%) patients had at least one inpatient complication with a mean of 1.1 (standard deviation 1.4) complications per patient. In the endovascular group, there were three (30.0%) patients with inpatient complications and a mean of 0.4 (standard deviation 0.7) complications per patient (P = 0.18). Endovascular management of nonaortic cervicothoracic arterial injuries was successfully performed in hypotensive patients and patients with other life threatening traumatic injuries. Further studies are warranted to look at long-term patency of these repairs and to help develop a protocol to guide decision-making in the management of cervicothoracic injuries.


Assuntos
Artéria Axilar/lesões , Lesões das Artérias Carótidas/cirurgia , Procedimentos Endovasculares , Artéria Subclávia/lesões , Lesões do Sistema Vascular/cirurgia , Adulto , Artéria Axilar/cirurgia , Lesões das Artérias Carótidas/mortalidade , Procedimentos Endovasculares/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Artéria Subclávia/cirurgia , Resultado do Tratamento , Lesões do Sistema Vascular/mortalidade
17.
Am Surg ; 83(10): 1117-1121, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-29391107

RESUMO

Necrotizing soft tissue infections (NSTIs) are aggressive infections requiring prompt diagnosis and extensive surgical debridement. Traditionally, patients undergo mandatory re-exploration to ensure adequacy of source control. The purpose of this study is to determine if re-exploration in the operating room is mandatory for all patients with NSTIs. An eight-year retrospective analysis of adult patients with NSTIs was performed comparing two groups: mandatory operative re-exploration versus operative re-exploration based on clinical examination findings. Outcomes measured included mortality, number of debridements, and length of stay (LOS). Twenty-two per cent of patients underwent a mandatory re-exploration. These patients were older, had a higher incidence of diabetes, and a longer duration of symptoms. There were no significant differences between groups with regard to the physical examination, severity of sepsis, time to repeat debridements, or in-hospital mortality, whereas LOS and the total number of debridements were increased in mandatory re-exploration. Bacteremia and septic shock were predictive of the need for further debridement in patients in the operative re-exploration based on clinical examination findings group. Mandatory re-exploration after initial debridement may not be necessary in all patients with NSTIs. Instead, bedside wound checks may be a safe strategy to determine the need for further operative debridement.


Assuntos
Desbridamento , Reoperação , Infecções dos Tecidos Moles/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Necrose/diagnóstico , Necrose/mortalidade , Necrose/cirurgia , Estudos Retrospectivos , Infecções dos Tecidos Moles/diagnóstico , Infecções dos Tecidos Moles/mortalidade
18.
Am Surg ; 82(10): 894-897, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27779968

RESUMO

With constant changes in health-care laws and payment methods, profitability, and financial sustainability of hospitals are of utmost importance. The purpose of this study is to determine the relationship between surgical services and hospital profitability. The Office of Statewide Health Planning and Development annual financial databases for the years 2009 to 2011 were used for this study. The hospitals' characteristics and income statement elements were extracted for statistical analysis using bivariate and multivariate linear regression. A total of 989 financial records of 339 hospitals were included. On bivariate analysis, the number of inpatient and ambulatory operating rooms (ORs), the number of cases done both as inpatient and outpatient in each OR, and the average minutes used in inpatient ORs were significantly related with the net income of the hospital. On multivariate regression analysis, when controlling for hospitals' payer mix and the study year, only the number of inpatient cases done in the inpatient ORs (ß = 832, P = 0.037), and the number of ambulatory ORs (ß = 1,485, 466, P = 0.001) were significantly related with the net income of the hospital. These findings suggest that hospitals can maximize their profitability by diverting and allocating outpatient surgeries to ambulatory ORs, to allow for more inpatient surgeries.


Assuntos
Administração Financeira de Hospitais/organização & administração , Planejamento em Saúde/economia , Centro Cirúrgico Hospitalar/economia , Procedimentos Cirúrgicos Operatórios/economia , California , Bases de Dados Factuais , Economia Hospitalar , Feminino , Humanos , Modelos Lineares , Masculino , Análise Multivariada , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Papel (figurativo) , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos
19.
Am Surg ; 82(10): 926-929, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27779975

RESUMO

The population of the United States is predicted to age dramatically over the next few decades; as such older patients will comprise an increasing proportion of the injured populations. Due to multiple comorbidities and frailty, the old and very old are at greater risk for mortality than younger patients. To identify predictors of inhospital mortality in these patients, we performed a retrospective cohort study at our Level 1 trauma center. Between April 2009 and October 2014, we identified 193 trauma patients aged 80 years and older admitted to the intensive care unit. The mean age was 86 years old (4.9) and a majority of patients were white (57%) and male (54%). Univariate analysis found Injury Severity Score (P < 0.01), initial Glasgow Coma Scale (P < 0.01), admission pH (P = <0.01), admission lactate (P < 0.01), the need for mechanical ventilation (P < 0.01), and Geriatric Trauma Outcome Score (P < 0.01) to be predictors of mortality. Multivariate analysis identified length of mechanical ventilation [odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.60-0.90, P < 0.01], admission lactate (OR = 1.74, 95% CI = 1.21-2.51, P < 0.01), and the need for mechanical ventilation (OR = 18.2, 95% CI = 3.33-99.8, P < 0.01) as independent predictors of mortality. These predictors can help guide clinical decisions and should prompt early discussion of goals of care. The association between mechanical ventilation and mortality is confounded by withdrawal of care.


Assuntos
Avaliação Geriátrica , Mortalidade Hospitalar , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade , Fatores Etários , Idoso de 80 Anos ou mais , Análise de Variância , Estudos de Coortes , Comorbidade , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Análise de Sobrevida , Centros de Traumatologia , Estados Unidos , Ferimentos e Lesões/terapia
20.
Am J Surg ; 212(6): 1096-1100, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27780558

RESUMO

BACKGROUND: The objectives of this study were to examine the incidence and severity of early acute respiratory distress syndrome (ARDS) according to the Berlin Definition and to identify risk factors associated with the development of early post-traumatic ARDS. METHODS: A 2.5-year retrospective database of adult trauma patients who required mechanical ventilation for greater than 48 hours at a level 1 trauma center was analyzed for variables predictive of early (<48 hours after injury), mild, moderate, and severe ARDS and in-hospital mortality. RESULTS: Of 305 patients, 59 (19.3%) developed early ARDS: mild, 27 (45.8%); moderate, 26 (44.1%); and severe, 6 (10.1%). Performance of an emergent thoracotomy, blunt mechanism, and fresh frozen plasma administration were independently associated with the development of early ARDS. ARDS was not predictive of mortality. CONCLUSIONS: Trauma patients with blunt mechanism, who receive fresh frozen plasma, or undergo thoracotomy, are at risk of developing early ARDS.


Assuntos
Síndrome do Desconforto Respiratório do Adulto/epidemiologia , Ferimentos e Lesões/complicações , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Centros de Traumatologia , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia
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