Biloma: a delayed complication of blunt hepatic injury.

We present the case of a patient who sustained blunt liver trauma after a motor vehicle crash that was subsequently complicated by the development of a large biloma. Early use of computed tomography (CT) scan and HIDA (hepatobiliary iminodiacetic acid) imaging enabled the prompt identification and management of the problem.

Isolated jejunal perforation after blunt thoracoabdominal trauma.

A case report of isolated jejunal perforation secondary to a relatively unique mechanism of blunt thoracoabdominal trauma is presented. A thorough and concise review of the multimodal approach that may be necessary to diagnose such a rare clinical problem is discussed.

Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital.

OBJECTIVES: To implement an electronic laboratory utilization management system (laboratory expert system [LES]) to provide safe and effective reductions in unnecessary clinical laboratory testing. METHODS: The LES is a set of frequency filter subroutines within the Veterans Affairs hospital and laboratory information system that was formulated by an interdisciplinary medical team. RESULTS: Since implementing the LES, total test volume has decreased by a mean of 11.18% per year compared with our pre-LES test volume. This change was not attributable to fluctuations in outpatient visits or inpatient days of care. Laboratory cost savings were estimated at $151,184 and $163,751 for 2012 and 2013, respectively. A significant portion of these cost savings was attributable to reductions in high-volume, large panel testing. No adverse effects on patient care were reported, and mean length of stay for patients remained unchanged. CONCLUSIONS: Electronic laboratory utilization systems can effectively reduce unnecessary laboratory testing without compromising patient care.

Using Facilitative Coaching to Support Patient Aligned Care Teams.

Despite the challenges of implementing facilitative coaching, the Richard L. Roudebush VAMC staff succeeded in translating primary care medical home theory into process.

Laparoscopic repair of blunt traumatic anterior abdominal wall hernia.

Traumatic abdominal wall hernia is a relatively uncommon finding secondary to blunt trauma. We report a unique case of laparoscopic diagnosis and immediate repair of a traumatic anterior abdominal wall hernia after blunt abdominal trauma.

Redesigning a joint replacement program using Lean Six Sigma in a Veterans Affairs hospital.

IMPORTANCE: In April 2009, an analysis of joint replacement surgical procedures at the Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, revealed that total hip and knee replacements incurred $1.4 million in non-Veterans Affairs (VA) care costs with an average length of stay of 6.1 days during fiscal year 2008. The Joint Replacement Program system redesign project was initiated following the Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain (VA-TAMMCS) model to increase efficiency, decrease length of stay, and reduce non-VA care costs. OBJECTIVE: To determine the effectiveness of Lean Six Sigma process improvement methods applied in a VA hospital. DESIGN, SETTING, AND PARTICIPANTS: Perioperative processes for patients undergoing total joint replacement were redesigned following the VA-TAMMCS model--the VA's official, branded method of Lean Six Sigma process improvement. A multidisciplinary team including the orthopedic surgeons, frontline staff, and executive management identified waste in the current processes and initiated changes to reduce waste and increase efficiency. Data collection included a 1-year baseline period and a 20-month sustainment period. MAIN OUTCOMES AND MEASURES: The primary endpoint was length of stay; a secondary analysis considered non-VA care cost reductions. RESULTS: Length of stay decreased 36% overall, decreasing from 5.3 days during the preproject period to 3.4 days during the 20-month sustainment period (P < .001). Non-VA care was completely eliminated for patients undergoing total hip and knee replacement at the Richard L. Roudebush Veterans Affairs Medical Center, producing an estimated return on investment of $1 million annually when compared with baseline cost and volumes. In addition, the volume of total joint replacements at this center increased during the data collection period. CONCLUSIONS AND RELEVANCE: The success of the Joint Replacement Program demonstrates that VA-TAMMCS is an effective tool for Lean and Six Sigma process improvement initiatives in a surgical practice, producing a 36% sustained reduction in length of stay and completely eliminating non-VA care for total hip and knee replacements while increasing total joint replacement volume at this medical center.

An exploratory study using data envelopment analysis to assess neurotrauma patients in the intensive care unit.

Patients with severe head trauma were studied retrospectively to determine if Data Envelopment Analysis (DEA) could successfully model patients early in their stay in an intensive care unit. Variables examined were cerebral perfusion pressure, body temperature, mean arterial pressure, serum osmolarity and pCO2. Unlike regression-based models that focus on mean values for the group, DEA evaluates each patient individually calculating an "efficiency" score based on a patient's ability to maximize output for a given set of physiologic inputs. Patients with high efficiency scores were found to have a better chance of making a full recovery than similarly injured patients that were inefficient. This approach needs further study but may offer physicians the opportunity to improve patient outcome subject to the manipulation of individual variables from the results of a DEA model rather than aiming for normal or average physiologic values.