Rectal foreign body removal: increasing incidence and cost to the NHS.

INTRODUCTION: Insertion of foreign objects into the rectum is a well-described phenomenon and not an uncommon referral to the general surgeon on call. Although usually not life-threatening, there can be consequences following migration of the object or perforation of the large bowel. This study looks at the incidence of removal of foreign objects from the rectum over the last decade and the financial burden it presents to the NHS. METHODS: Hospital Episode Statistics for 2010-2019 were used to calculate the number of rectal foreign bodies that required removal in hospital. Data for age groups and genders have been compared. RESULTS: A total of 3,500 rectal foreign bodies were removed over the course of 9 years. Males accounted for 85.1% of rectal foreign bodies whilst 14.9% were females. This equates to 348 bed-days per annum. Admission peaks were observed in the second and fifth decades of life. CONCLUSION: This study shows that the incidence of rectal foreign bodies is higher in men and has been increasing over the period studied. Most foreign bodies can be removed trans-anally with the use of anaesthesia, with only a small proportion of patients requiring hospital stay over 24 hours (mean length of stay = 24 hours). Nearly 400 rectal foreign body removals are performed each year with an annual cost of £338,819, illustrating the effect this has on NHS resources.

Cost comparison and safety of emergency department conscious sedation for the removal of ear foreign bodies.

OBJECTIVES: The purpose of this study is to investigate the relative cost and safety of ear foreign body (FB) removal via conscious sedation in the emergency department. METHODS: A retrospective review of patients presenting from 2000 to 2015 to the emergency department at Mayo Clinic, Rochester, Minnesota was performed. 63 patients requiring sedation for ear foreign body removal were identified. Descriptive data, safety data, and costs were obtained for the study. RESULTS: There were no appreciable differences in patient safety outcomes and otologic outcomes in patients who received sedation in the emergency department or anesthesia in the operating room for FB removal. Cost analysis demonstrated increased cost associated with operating room utilization verses conscious sedation in the emergency department, with the greatest cost increase being in patients evaluated first in the emergency department and then sent to the operating room. CONCLUSIONS: Ear foreign body removal in the emergency department is shows a similar safety profile to removal in the operating room, but at a markedly lower cost. Emergency department conscious sedation should be considered a viable option in appropriately selected patients with this common problem given these results.

A Socio-Technical Exploration for Reducing & Mitigating the Risk of Retained Foreign Objects.

A Retained Foreign Object (RFO) is a fairly infrequent but serious adverse event. An accurate rate of RFOs is difficult to establish due to underreporting but it has been estimated that incidences range between 1/1000 and 1/19,000 procedures. The cost of a RFO incident may be substantial and three-fold: (i) the cost to the patient of physical and/or psychological harm; (ii) the reputational cost to an institution and/or healthcare provider; and (iii) the financial cost to the taxpayer in the event of a legal claim. This Health Research Board-funded project aims to analyse and understand the problem of RFOs in surgical and maternity settings in Ireland and develop hospital-specific foreign object management processes and implementation roadmaps. This project will deploy an integrated evidence-based assessment methodology for social-technical modelling (Supply, Context, Organising, Process & Effects/ SCOPE Analysis Cube) and bow tie methodologies that focuses on managing the risks in effectively implementing and sustaining change. It comprises a multi-phase research approach that involves active and ongoing collaboration with clinical and other healthcare staff through each phase of the research. The specific objective of this paper is to present the methodological approach and outline the potential to produce generalisable results which could be applied to other health-related issues.

Esophageal lesions following button-battery ingestion in children: Analysis of causes and proposals for preventive measures.

OBJECTIVES: To study recent cases of esophageal injury due to button-battery ingestion in children presenting in pediatric ENT emergency departments of the Paris area of France (Île-de-France region), in order to propose appropriate preventive measures. MATERIAL AND METHOD: A retrospective descriptive single-center study included all children under 15 years of age, presenting in pediatric ENT emergency departments between January 2008 and April 2014 for button-battery ingestion with esophageal impaction requiring emergency removal. RESULTS: Twenty-two boys and 4 girls, with a median age of 25 months, were included. Twenty-five of the 26 batteries had diameters of 20mm or more. Median esophageal impaction time was 7 hours 30 minutes (range, 2 to 72 hours). The complications rate was 23%. Mean hospital stay cost was €38,751 (range, €5130-119,737). The origin of the battery was known in 23 of the 26 cases: remote control without screw-secured compartment (42.3%), open battery pack (15.4%), children's toy (15.3%), camera (7.7%), watch (1 case) and hearing aid without screw-secured compartment (1 case). CONCLUSION: Esophageal lesions due to ingestion of button-batteries in children are almost always due to batteries larger than 20mm in diameter, mostly from devices with a poorly protected compartment, or batteries that are not individually packaged. These lesions cause serious complications in a quarter of cases and their management entails high health costs. Legislation requiring screw-secured compartments and individual blisters for batteries could have prevented 69.2% of the ingestions.

The public health resource utilization impact of airway foreign bodies in children.

OBJECTIVE: Quantify the resource utilization associated with airway foreign bodies in children in the United States using a national database and report observed trends over time. STUDY TYPE: Cross-sectional analysis of national inpatient database with weighted estimates. DATA SOURCE: The KID database (2000-2009). METHODS: ICD-9-DM codes for foreign body aspiration were used to identify patients to be included for investigation. Admission rates and charges were aggregated and compared among geographic region, location, and teaching hospital status. These factors were then also trended over time. RESULTS: From 2000 to 2009, airway foreign body diagnoses in children accounted for an estimated 4000 to 5000 admissions, resulting in a mean admission rate of 6.6 per 10,000 pediatric patients annually. Charges related to airway foreign bodies in children rose from a total of $93 million to $486 million in the observed period. There is an increasing trend over time of total charges per patient. Charges appear to be higher in urban locations and teaching hospitals. CONCLUSIONS: The public health and economic burden of pediatric airway foreign bodies appears to be rising. Further investigation may be helpful to examine factors that may be contributing to increasing charges and creating strategies to improve cost effectiveness, as well as why there seems to be increased resource utilization in urban locations and teaching hospitals.

Cost varies with procedure type in pediatric GI foreign bodies.

BACKGROUND/PURPOSE: In pediatric cases of ingested foreign bodies, gastrointestinal foreign bodies (GIFB) have distinct factors contributing to longer and more costly hospitalizations. METHODS: Patients admitted with ingested foreign bodies were identified in the Kids' Inpatient Database (1997-2009). RESULTS: Overall, 7480 cases were identified. Patients were most commonly <5years of age (44%), male (54%), and Caucasian (57%). A total of 2506 procedures were performed, GI surgical procedures (57%) most frequently, followed by GI endoscopy (24%), esophagoscopy (11%), and bronchoscopy - in cases of inhaled objects (9%). On multivariate analysis, length of stay increased when cases were associated with intestinal obstruction (OR=1.7), esophageal perforation (OR=40.0), intestinal perforation (OR=4.4), exploratory laparotomy (OR=1.9), and gastric (OR=2.9), small bowel (OR=1.5), or colon surgery (OR=2.5), all p<0.02. Higher total charges (TC) were associated with intestinal obstruction (OR=2.0), endoscopy of esophagus (OR=1.8), stomach (OR=2.1), or colon (OR=3.3), and exploratory laparotomy (OR=3.6) or surgery of stomach (OR=5.6), small bowel (OR=6.4), or colon (OR=3.4), all p<0.001. CONCLUSIONS: Surgical or endoscopic procedures are performed in approximately one third of GIFB cases. Associated psychiatric disorder or self-inflicted injury is seen in more than 20% of GIFB patients. Resource utilization is determined heavily by associated diagnoses and treatment procedures.

Glucagon Is a Safe and Inexpensive Initial Strategy in Esophageal Food Bolus Impaction.

BACKGROUND: Controversy exists about the utility of pharmacologic agents and endoscopic technique used for esophageal food bolus impaction. AIM: To evaluate the utility of glucagon and the technique used for endoscopic removal, including the rate of success and the adverse events of the techniques. METHODS: The database of the largest healthcare provider in southeastern Wisconsin was retrospectively reviewed for patients presenting with esophageal food bolus impaction. Data extracted included glucagon administration and its success rate, outcome of radiographic studies, and the endoscopic method of removal and adverse events associated with it, including 30-day mortality. RESULTS: A total of 750 patients were identified with food bolus impaction from 2007 to 2012. Glucagon was administered in 440 patients and was successful in 174 (39.5%). Endoscopic removal was performed in 470 patients and was successful in 469 (99.8%). The push technique was utilized in 209 patients, reduction in the bolus size by piecemeal removal followed by the push technique was utilized in 97 patients, and the pull technique was utilized in 107 patients. There were no perforations with endoscopic removal. Only 4.5% of the X-rays performed reported a possible foreign body within the esophagus. Glucagon was a significantly less-expensive strategy than endoscopic therapy (p < 0.0001). CONCLUSION: Glucagon is low cost, is moderately effective, and may be considered as an initial strategy. Endoscopic removal regardless of technique is safe and effective. The yield of radiography is poor in the setting of food bolus impaction.

The Hidden Costs of Reconciling Surgical Sponge Counts.

Retained surgical sponges are serious adverse events that can result in negative patient outcomes. The primary method of prevention is the sponge count. Searching for sponges to reconcile counts can result in inefficient use of OR time. The purpose of this descriptive study was to estimate the cost of nonproductive OR time (ie, time spent not moving forward with the surgical procedure) spent reconciling surgical sponge counts and the cost of using radiography to rule out the presence of retained sponges. We included 13,322 patient surgeries during a nine-month period. Perioperative personnel required from one to 90 minutes of additional time to reconcile each of 212 incorrect/unresolved counts. The total annualized cost of OR time spent searching for sponges and ruling out the presence of potentially retained sponges using radiography was $219,056. These costs should be included in comprehensive cost analyses when considering alternatives to supplement the surgical count.

Safe and effective management of esophageal coins in children with bougienage.

BACKGROUND: Coins are the foreign body most commonly ingested in infants and children. Coins retained in the esophagus require intervention to prevent complications. Management of retained esophageal coins remains variable both between and within institutions. We hypothesize that the incorporation of bougienage in the management of pediatric esophageal coins is safe and more cost-effective compared with traditional management strategies that use endoscopy. METHODS: We conducted a retrospective review of infants and children diagnosed with an esophageal foreign body managed at Children's Hospital of Wisconsin between January 2003 and June 2012. Pediatric otolaryngologists (ear-nose-throat, ie, ENTs) or pediatric surgeons manage all children with esophageal foreign bodies in a prospective call schedule that alternates weekly. RESULTS: During an 8.5-year period, 1,642 children were diagnosed with esophageal foreign bodies and 518 had a retained coin. For esophageal coins, ENT managed 218 cases and pediatric surgery managed 300. ENTs preferentially used endoscopy for coin removal, whereas pediatric surgeons used either endoscopy or esophageal bougienage for selected children meeting specific criteria. Bougienage was successful at advancing the coin into the stomach in 94% of patients, and endoscopy was successful at removing the coin from the esophagus in 100% of patients. The mean duration of stay was 0.6 days for endoscopy by ENT, 0.6 days for endoscopy by pediatric surgery, and 0.1 days for bougienage (P < .05). The median hospital charge was $4,593 for endoscopy by ENT, $5,379 for endoscopy by pediatric surgery, and $579 for bougienage (P < .05). There were 3 complications each in the endoscopy group for ENT and pediatric surgery. There were no complications in children undergoing bougienage. CONCLUSION: This is the first case series evaluating the management of children with esophageal coins using a prospective assignment to endoscopy versus endoscopy or bougienage. Our data support bougienage as a safe and cost-effective treatment for managing retained esophageal coins in selected children.

Retained foreign bodies: risk and outcomes at the national level.

BACKGROUND: Retained foreign bodies (RFB) after operative interventions are linked to an increased risk of morbidity and mortality, and represent a medico-legal liability. We aimed to identify associated risk factors and outcomes related to iatrogenic RFB in the United States. STUDY DESIGN: A cross-sectional analysis was performed on all interventions that resulted in a secondary diagnosis of RFB in the Nationwide Inpatient Sample (NIS) from 2003 to 2009. Comparative controls were randomly selected from patients who underwent similar procedures. RESULTS: We identified 3,045 cases of RFB, and 12,592 controls were included. The majority of incidents, 968 (31.8%), were reported after gastrointestinal interventions. Risk of RFB was higher in teaching hospitals (odds ratio [OR] 1.31, 95% CI [1.19, 1.45], p < 0.001). For abdominopelvic procedures, patients admitted with traumatic injuries did not demonstrate a higher risk of RFB compared with electively admitted patients (OR 1.70, 95% CI [0.94, 3.07], p = 0.08). However, for procedures unrelated to abdominopelvic surgery, patients admitted for trauma had a lower risk (OR 0.62, 95% CI [0.50, 0.78], p < 0.001). Obesity (BMI ≥ 30 kg/m(2)) and older age (≥ 65 years) were significantly associated with a higher risk only for abdominopelvic procedures (p < 0.01 for both). Retained foreign bodies were associated with a higher average cost of health services ($26,678.00 ± $769.69 vs $12,648.00 ± $192.80, p < 0.001). CONCLUSIONS: Retained foreign bodies have unfavorable and nationally tangible clinical and economic outcomes. The risk profile for RFB at the national level seems to demonstrate an association with demographic and clinical factors including nature of the procedure, type of admission, and trauma status. Teaching hospitals are associated with a higher risk. Targeted efforts toward identified high-risk populations are needed to avoid these morbid and costly complications.

The national cost burden of bronchial foreign body aspiration in children.

OBJECTIVES/HYPOTHESIS: Foreign body aspiration (FBA) continues to be a concerning pediatric problem, accounting for thousands of emergency room visits and more than 100 deaths each year in the United States. The costs incurred with hospitalizations and procedures following these events are the focus of this study. STUDY DESIGN: Retrospective review. METHODS: The Nationwide Inpatient Sample from 2009 to 2011 was analyzed, and all cases with pediatric bronchial foreign body aspirations (International Classification of Diseases-9 codes: 934.0, 934.1, 934.8, and 934.9) were reviewed. Cases were analyzed to determine type of foreign body aspiration, procedural interventions performed, duration of inpatient stay, mortality rate, complications, and posthospitalization disposition. The median length of hospital stay and total costs associated with aspiration events were determined. RESULTS: An estimated 1,908 ± 273 pediatric bronchial FBA patients were admitted annually over the 3-year period (mean age, 3.6 ± 0.3 years; 61.3% ± 1.9% male). The ratio of foreign object aspiration to food aspiration was 5:3. Overall, 56%.0 ± 3.6% of the patients underwent a bronchoscopic procedure for foreign body removal; of those, 41.5% ± 2.5% had a foreign body removed at the time of the endoscopy. The hospital mortality rate associated with bronchial aspiration was 1.8% ± 0.4%; and 2.2% ± 0.5% of patients were diagnosed with anoxic brain injury. The median length of stay was 3 days (25th-75th interquartile range, 1-7 days).The median charges and actual costs per case were $20,820 ($10,800-$53,453) and $6,720 ($3,628-$16,723), respectively. CONCLUSION: The annual overall inpatient cost associated with pediatric bronchial foreign-body aspiration is approximately $12.8 million. Combined, the rate of death or anoxic brain injury associated with pediatric foreign body is approximately 4%. LEVEL OF EVIDENCE: 2C.

Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.

BACKGROUND: Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. STUDY DESIGN: Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. RESULTS: Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. CONCLUSIONS: Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology.

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review.

PURPOSE: Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS. METHODS: A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs. RESULTS: There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS. CONCLUSION: Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.

Emergency care of esophageal foreign body impactions: timing, treatment modalities, and resource utilization.

Esophageal foreign body impaction (EFBI) often requires urgent evaluation and treatment, but characteristics of emergency department (ED) care such as timing of presentation and therapeutic procedures and costs of care are unknown. We aimed to study health-care utilization for patients with EFBI presenting to the ED. Cases of EFBI from 2002 to 2009 were identified by querying three different databases from the University of North Carolina Hospitals for all records with ICD-9 CM code 935.1: 'foreign body in the esophagus.' Charts were reviewed to confirm EFBI and extract pertinent data related to the ED visit, including time of presentation, length of ED stay, medications administered, type of procedure performed, characteristics of procedures, and time to therapeutic procedure. Hospital charges for EFBI encounters and consult fees were determined from the Physicians' Fee Reference 2010, and were compiled to estimate costs. Of the 548 cases of EFBI identified, 351 subjects (64%) presented to the ED. A total of 118 (34%) patients received a medication to treat EFBI, which was only effective in 8% of those patients. Two hundred ninety (83%) subjects underwent a procedure including esophagogastroduodenoscopy (EGD) (n=206) or ear, nose, and throat surgery (ENT)-performed laryngoscopy/esophagoscopy (n=138). Admission to the hospital occurred in 162 (46%) of cases. There was no relationship between ED arrival time and time-to-procedure or total time in ED. There was also no significant relationship between delivery of ED medications and likelihood of undergoing a procedure, or between ED arrival time and delivery of medications. The charges associated with a typical EFBI episode ranged from $2284-$6218. In conclusion, the majority of patients with EFBI at our institution presented to the ED. Medical management was largely ineffective. A therapeutic procedure was required to clear the EFBI in most patients. Time of ED arrival made no difference in time-to-procedure, indicating that gastroenterology and ENT specialists recognize the urgency of treating EFBI regardless of time of day.

A study of the bioengineered surgical sponge.

The postoperatively retained foreign body (PORFB) can induce complications leading to the need for follow-up surgery to ensure its removal, to treat or prevent the formation of an abscess, and to minimize the risk of death for the patient and liability for the surgeon and hospital. The most common cause of PORFB complications is the surgical sponge. Previously, PORFB prevention was focused on improved efficiency in RFB counting; however, because of the inability to entirely eliminate human error, cost, and the potentially unproven patient outcome improvement, new approaches have been sought. We examined the use of a novel bioengineered, biodegradable sponge (BSS) to reduce the risk of complications due to PORFBs, thus potentially improving patient outcomes.