RESUMO
BACKGROUND: Alternative methods for abdominal wall closure may be necessary after emergency laparotomy. The purpose of this study was to determine the morbidity and outcome of emergency fascial closure with polypropylene mesh. METHODS: A retrospective review was performed of all patients undergoing emergency fascial closure with polypropylene mesh from January 1990 to March 1994. RESULTS: Seventy patients were identified. Indications for mesh placement included visceral edema (40), infected/necrotic fascia (21), and planned reexploration (7). Enteric fistulas developed in five patients (7.1%). When omentum was interposed between intestine and mesh, the incidence of fistula was significantly reduced (0 of 51 vs 5 of 19, p < 0.01). Forty-two patients (60%) survived with wound closure, accomplished by skin flaps in 19 (45%), skin grafting in 11 (26%), and secondary healing in 6 (14%). The mesh was removed in six patients (14%). Complications of mesh extrusion and hernia occurred less often after skin flap closure compared with skin grafting or secondary healing (1 of 19 vs 9 of 17, p < 0.01). No mesh infection occurred. CONCLUSIONS: Polypropylene mesh placement is an effective alternative for abdominal closure after emergency laparotomy, even when intraabdominal sepsis is present. Fistulas associated with its use may be effectively eliminated by the interposition of omentum between bowel and mesh. Wound closure with full-thickness skin flaps is the preferred method for soft tissue coverage when mesh is used.
Assuntos
Traumatismos Abdominais/cirurgia , Músculos Abdominais/cirurgia , Doenças do Sistema Digestório/cirurgia , Laparotomia , Polietilenos , Polipropilenos , Telas Cirúrgicas , Traumatismos Abdominais/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Ruptura Aórtica/cirurgia , Doenças do Sistema Digestório/mortalidade , Emergências , Feminino , Humanos , Fístula Intestinal/epidemiologia , Fístula Intestinal/etiologia , Laparotomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Polietilenos/efeitos adversos , Polipropilenos/efeitos adversos , Estudos Retrospectivos , Telas Cirúrgicas/efeitos adversos , Deiscência da Ferida Operatória/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: Deep vein thrombosis (DVT) has been reported to occur in 20% to 40% of high-risk trauma patients if no prophylaxis is used. The purpose of this study was to determine the incidence of DVT and utility of a screening program in a high-risk group of trauma patients for whom routine DVT prophylaxis was utilized. PATIENTS AND METHODS: Of 3,154 trauma admissions over a 20-month period, 343 patients (10.9%) identified as high risk based on established criteria (prolonged bed rest, Glasgow coma score (GCS) of 7, spinal injury, lower extremity or pelvic fracture) were placed on a prospective surveillance protocol using color-flow duplex scanning and received thromboembolic prophylaxis. RESULTS: Twenty-three thromboembolic complications occurred, including 20 DVTs (5.8%) and 3 pulmonary emboli ([PE] 1%). Univariate analysis showed that the risk of DVT was related to age (52.6 + 19.9 years versus 38.1 + 18.5; P = 0.001), a longer hospital stay (31.4 versus 17.8 days; P = 0.001), or the presence of spinal fracture (12.6% versus 3.5%; P = 0.01). Discriminant function analysis revealed that length of stay, intensive care unit days, age, and GCS allowed correct classification of those who did not develop DVT in 97% of cases but was only correct in 15% of cases in predicting those who would develop DVT. Injury severity score (ISS) was not predictive in this multivariate analysis. Seventeen (85%) DVTs were unsuspected clinically. Study patients received an average of 3.5 studies at an overall charge of $313,330 to detect 17 clinically unsuspected DVTs (5%). This represents about 5% of the total bed charges for these patients, or $18,000 per DVT. CONCLUSIONS: These results suggest that standard use of DVT prophylaxis in a high-risk trauma population leads to a low incidence of DVT and that a screening protocol is effective in detecting unsuspected DVTs. Use of a surveillance protocol, however, may reduce but will not eliminate the incidence of pulmonary emboli in this patient population.
Assuntos
Trombose/prevenção & controle , Ferimentos e Lesões/complicações , Adulto , Idoso , Feminino , Preços Hospitalares , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Vigilância da População , Valor Preditivo dos Testes , Estudos Prospectivos , Embolia Pulmonar/prevenção & controle , Risco , Fatores de Risco , Tromboembolia/prevenção & controle , Trombose/diagnóstico por imagem , Trombose/economia , Trombose/etiologia , Fatores de Tempo , Ultrassonografia Doppler em Cores , Ferimentos e Lesões/diagnóstico por imagem , Ferimentos e Lesões/economiaRESUMO
BACKGROUND: The use of intraoperative endoscopy by surgeons can identify pathology and help determine the appropriate procedure to perform. However, residency training in endoscopy is often variable and unstructured. The purpose of this study was to determine the indications for and impact of intraoperative endoscopy performed at the time of general surgical procedures. METHODS: The records of all patients who underwent intraoperative endoscopy from January 1998 to December 1999 were reviewed. The indications for endoscopy, endoscopic findings, the impact of these findings on the operation performed, complications, and whether the patient was spared from undergoing a second procedure on a separate date were noted. RESULTS: A total of 107 intraoperative endoscopic procedures were performed in 103 patients. Excluding breast, endocrine, central line, and peritoneal dialysis catheter cases, endoscopy was utilized in 5.1% of all general surgery procedures performed during this time period. In 91 patients (88%), the endoscopic procedure was planned preoperatively; in 13 (12%), intraoperative findings dictated its use. The most common indications for endoscopy were identification of lesions and determination of extent of resection (n = 27); evaluation of rectal bleeding (n = 21); colonic evaluation in patients with perianal infections (n = 13); evaluation of extent of injury in trauma cases (n = 8); evaluation of pain (n = 6); evaluation of intestinal tract hemorrhage (n = 6); performance of procedures such as placement of a biliary stent, placement of a nasojejunal tube, or polypectomy (n = 5); and surveillance of chronic disease (n = 5). In 37 patients (36%), the endoscopic findings affected the operation performed. Sixty-nine patients (67%) were spared an endoscopic procedure at a second date, which would have required additional sedation or anesthesia. There were no complications related to endoscopy. CONCLUSION: Intraoperative endoscopy is a valuable tool that can be performed safely for multiple indications and is frequently of value in determining the operation to be performed. Surgical residents should be trained in the indications for endoscopic evaluation as well as the competent performance of such procedures.
Assuntos
Endoscopia/métodos , Cirurgia Geral/educação , Adulto , Idoso , Idoso de 80 Anos ou mais , Educação Médica Continuada/métodos , Educação Médica Continuada/tendências , Endoscopia/estatística & dados numéricos , Endoscopia/tendências , Feminino , Cirurgia Geral/tendências , Humanos , Período Intraoperatório/métodos , Masculino , Pessoa de Meia-IdadeRESUMO
Workers are at risk for a wide variety of occupational burns, secondary to thermal, electrical, or chemical sources. The diagnosis and management of common industrial burns is reviewed and outlined. Proper evaluation and management is necessary to minimize the disability that can result from these injuries.
Assuntos
Acidentes de Trabalho , Queimaduras/diagnóstico , Indústrias , Queimaduras/terapia , Queimaduras Químicas/diagnóstico , Queimaduras Químicas/terapia , Queimaduras por Corrente Elétrica/diagnóstico , Queimaduras por Corrente Elétrica/terapia , Humanos , MetalurgiaRESUMO
Standard diagnostic methods used to evaluate patients sustaining abdominal trauma result in non-therapeutic laparotomy rates ranging from 5 to 40 per cent depending upon the clinical situation. The purpose of this study was to assess the safety and efficacy of diagnostic laparoscopy in the identification of intra-abdominal injuries in stable trauma patients. Twenty-one hemodynamically stable adult patients underwent laparoscopy prior to laparotomy for blunt (n = 10) or penetrating (n = 11) trauma, and the findings from each procedure were directly compared. Laparoscopy was 100 per cent accurate in detecting the need for laparotomy, although a number of specific injuries were not identified. There were no complications related to the procedure. Emergency laparoscopy is safe and should be considered in hemodynamically stable trauma patients with indications for laparotomy based on standard diagnostic criteria in order to minimize the incidence of non-therapeutic laparotomy.
Assuntos
Traumatismos Abdominais/diagnóstico , Laparoscopia , Cuidados Pré-Operatórios , Ferimentos não Penetrantes/diagnóstico , Ferimentos Penetrantes/diagnóstico , Traumatismos Abdominais/cirurgia , Adolescente , Adulto , Idoso , Feminino , Humanos , Período Intraoperatório , Masculino , Lavagem Peritoneal , Reprodutibilidade dos Testes , Procedimentos Cirúrgicos Operatórios/métodos , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgiaRESUMO
Early recognition and treatment of necrotizing fasciitis (NF) is essential for survival. The diagnosis of primary or idiopathic NF may be particularly challenging because it occurs in the absence of a known causative factor or portal of entry for bacteria. Patients with NF treated between 1989 and 1993 were reviewed to determine the incidence, clinical features, bacteriology, and results of treatment in patients with idiopathic NF. Idiopathic NF occurred in nine (18%) of 51 patients, five men and four women, ranging in age from 21 to 67 years. Associated conditions included diabetes mellitus (4), alcoholism (3), remote infection (3), and pregnancy (2). NF affected the lower extremity in eight and the perineum in one patient. Pain and tenderness occurred in all patients, soft tissue gas was recognized in two, and the presence of erythema and edema was variable. Idiopathic NF was monomicrobial in seven (78%) patients, compared to 21 per cent of patients with secondary NF (P = 0.003). S. pyogenes was the causative organism in five of seven monomicrobial infections. Time from admission to operation was significantly longer (62.3 +/- 54.8 hours) in patients with idiopathic NF compared to patients with secondary NF (17.0 +/- 16.6 hours) (P = 0.001). Treatment included operative debridement (means = 3.3) and limb amputation (n = 1) to control infection. Three patients (33%) with idiopathic NF died. Primary or idiopathic NF is principally a monomicrobial infection usually caused by S. pyogenes that most commonly occurs in the extremities. Mortality is high but is comparable to secondary NF. It is important to recognize that NF may occur spontaneously, and it should be suspected in patients with unexplained soft tissue pain and tenderness.
Assuntos
Fasciite/diagnóstico , Fasciite/cirurgia , Adulto , Idoso , Alcoolismo/complicações , Amputação Cirúrgica , Antibacterianos/uso terapêutico , Infecções por Bacteroides/microbiologia , Desbridamento , Complicações do Diabetes , Fasciite/microbiologia , Fasciite/mortalidade , Feminino , Humanos , Infecções por Klebsiella/microbiologia , Perna (Membro) , Masculino , Pessoa de Meia-Idade , Períneo , Gravidez , Complicações na Gravidez , Estudos Retrospectivos , Infecções Estreptocócicas/microbiologia , Streptococcus pyogenes , Fatores de Tempo , Resultado do TratamentoRESUMO
Elderly patients with abdominal aortic aneurysms (AAA) may be deemed inoperable due to the presence of comorbid conditions. Presentation of these patients with acute rupture can then result in difficult ethical decisions regarding surgical treatment. Over six years, 80 patients were treated emergently for ruptured AAA. Of these patients, 26 (32.5%) had known aneurysms. This study was performed to determine outcome and factors affecting mortality in patients with known AAAs. There were no significant differences between known and unknown AAA groups with regard to operative risk. In the overall group (n = 80), patient delay in seeking treatment averaged 20.4 hours with a trend towards shorter times in those with known AAAs (13.8 hours) compared with the unknown group (23.6 hours; p = 0.09). Medical transport delay, however, was significantly shorter for patients with known AAA (124 minutes versus 230 minutes; p = 0.04). Overall mortality was 56 per cent (n = 45). Those patients with known AAAs had a higher mortality (69%; n = 18) than those with unknown AAAs (50%, n = 27) but this was not statistically significant (P = 0.10). In patients with known AAAs, operative death was related to patient delay, with an average delay in seeking medical advice of 21.3 hours in nonsurvivors compared with 8.6 hours in survivors (P = 0.04). No other risk or demographic factors correlated with mortality. Despite a known AAA, significant delay in seeking medical advice occurred, and this delay resulted in decreased survival. Patient education is imperative if nonoperative treatment is chosen.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Ética Médica , Seleção de Pacientes , Idoso , Idoso de 80 Anos ou mais , Aeronaves , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/mortalidade , Emergências , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Educação de Pacientes como Assunto , Complicações Pós-Operatórias , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Transporte de Pacientes , Resultado do Tratamento , Suspensão de TratamentoRESUMO
Poor outcomes following transcranial gunshot wounds (TC-GSW) and the perception of significant financial loss have led some institutions to adopt a fatalistic attitude towards these patients. This study was undertaken to define those factors predictive of mortality following TC-GSW as well as to determine the costs and benefits associated with providing care to these individuals. We reviewed the medical records of 57 TC-GSW patients seen at our Level I Trauma Center between January 1990 and December 1992. Overall mortality was 75 percent, and was statistically associated with an admission Glasgow Coma Score of 4 or less, a respiratory rate of less than 10, and self-inflicted wounds. Complete financial information was available for 37 of the 57 patients. Reimbursements for this group were $306,156 and exceeded costs by $62,257. Organ donation efforts were successful in 44.2 per cent of the nonsurvivors (19/43), yielding 60 organs and 29 tissues for transplantation. Nonsurvivors who became organ donors were clinically and demographically indistinguishable from those in whom organs/tissues could not be retrieved. Despite the poor outcome following TC-GSW, vigorous resuscitation and stabilization is justified in all patients, in that nearly one half of nonsurvivors will become organ and/or tissue donors. Concerns regarding excessive monetary looses by treating facilities are unfounded.
Assuntos
Lesões Encefálicas/economia , Lesões Encefálicas/terapia , Ferimentos por Arma de Fogo/economia , Ferimentos por Arma de Fogo/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas/mortalidade , Criança , Pré-Escolar , Estudos de Coortes , Análise Custo-Benefício , Feminino , Previsões , Escala de Coma de Glasgow , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Mecanismo de Reembolso , Respiração , Ressuscitação , Estudos Retrospectivos , Suicídio , Taxa de Sobrevida , Doadores de Tecidos , Resultado do Tratamento , Ferimentos por Arma de Fogo/mortalidadeRESUMO
Our objective was to determine the incidence, management, and outcome of traumatic pancreatic injury. A retrospective review was performed of all patients with pancreatic injury admitted to two Level I trauma hospitals over a 10-year period. Comparisons were made with Chi square or Fisher's exact tests. Of 16,188 trauma admissions, 72 patients (0.4%) had pancreatic injury. The mean age was 30 years, and 30 patients (69%) were male. Mechanism of injury was gunshot in 32 (45%), blunt in 27 (37%), and stab wound in 13 (18%). The pancreas was involved in 1.1 per cent of patients with penetrating injuries compared to 0.2 per cent with blunt injuries (P < 0.01). There were 18 grade I (25%), 32 grade II (45%), 16 grade III (22%), and 5 grade IV (7%) injuries. Initial diagnosis was made intraoperatively in 63 patients and by computed tomography in 8. The mean injury grade was significantly lower on computed tomography compared to surgical exploration (0.4 vs 2.0; P < 0.05). Operative procedures included distal pancreatectomy in 23 (32%), exploration only in 22 (31%), external drainage in 13 (18%), pancreatorrhaphy in 4, internal drainage in 2, and proximal resection in 2. Mortality was 16.6 per cent and was not related to the mechanism or grade of injury. Mean Injury Severity Score and transfusion requirements were significantly greater in patients who died (P < 0.05). Morbidity occurred in 30 patients (42%), including pancreatic fistula (11%), pancreatitis (7%), and pancreatic pseudocyst (3%). Six patients (8%) developed intra-abdominal abscesses, and all had associated liver or intestinal injuries. In patients with grade I and II injuries, morbidity was higher with external drainage compared to exploration without drainage. Pancreatic injury is infrequent and is more often associated with penetrating trauma. Diagnosis is most commonly made by exploration and cannot be excluded by computed tomography. Drainage of low-grade injuries may not be necessary. Morbidity and mortality in patients with pancreatic trauma is significant and is primarily due to associated injuries.
Assuntos
Pâncreas/lesões , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo , Pâncreas/diagnóstico por imagem , Pancreatectomia , Complicações Pós-Operatórias , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Ferimentos por Arma de Fogo/diagnóstico por imagem , Ferimentos por Arma de Fogo/cirurgia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgia , Ferimentos Perfurantes/diagnóstico por imagem , Ferimentos Perfurantes/cirurgiaRESUMO
Colonic ischemia is an often fatal complication of abdominal aortic aneurysm (AAA) repair. In elective AAA repair, patency of the inferior mesenteric artery (IMA) has been shown to be an important contributing factor. The purpose of this study was to determine which clinical and operative factors are important in the development of colonic ischemia in ruptured AAA repair. A retrospective review of all patients treated for ruptured AAA over a 7-year period was performed. Of 101 patients who were treated for ruptured AAA, 71 (70 per cent) survived for longer than 24 hours postoperatively, and these patients are the basis for this study. Colonic ischemia, primarily left sided, was a common perioperative complication (n = 24; 35 per cent) requiring colectomy in 11 patients (44 per cent). It carried a 44 per cent mortality compared to 20 per cent in patients without this complication (P = 0.07). Colonic ischemia occurred more frequently in patients with preoperative shock (P = 0.01) and a greater intraoperative blood loss (P = 0.003), but showed no correlation with patient age, co-morbid medical conditions, laboratory values, time to operation, or treatment of the IMA. Most patients with postoperative bowel ischemia were found to have chronic IMA occlusion, including 8 of the 11 patients requiring colectomy. Revascularization would not be feasible in this group. Revascularization of patent IMAs had little effect on outcome. Of the 17 patent IMAs, 9 were reimplanted and 5 (55 per cent) developed bowel ischemia, two of which required colectomy. Eight were ligated and 3 (38 per cent) developed bowel ischemia, one requiring colectomy. The presence of preoperative shock is the most important factor predicting the development of colonic ischemia following ruptured AAA. The incidence of ischemia is not altered by the presence of a patent IMA or with attempts at IMA revascularization. Colonic ischemia remains a significant source of morbidity and mortality in these patients.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Colite Isquêmica/etiologia , Complicações Pós-Operatórias , Idoso , Aneurisma da Aorta Abdominal/complicações , Colectomia , Colite Isquêmica/complicações , Colite Isquêmica/fisiopatologia , Feminino , Humanos , Ligadura , Masculino , Artéria Mesentérica Inferior/fisiopatologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
Age, burn size, inhalation injury, and comorbid diseases are important factors in predicting survival of patients with burn injuries. These same factors are important in attempting to objectively define the point when burn care is futile. We reviewed the records of 3301 patients admitted to our Burn Center between January 1, 1986, and December 31, 1994. There were 114 deaths (3.45%), of which 44 occurred within the first few days of admission. Seventy patients died at a later date. A do-not-resuscitate with comfort-measures-only order was written on 33 patients (26.7%). We have developed objective criteria that include age, extent of burn, presence of inhalation injury, and major organ dysfunction to be applied in the determination of futility of further therapy, either at the time of admission or when patients develop progressive multi-organ system failure during the hospital course.
Assuntos
Queimaduras/terapia , Ordens quanto à Conduta (Ética Médica) , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Queimaduras/mortalidade , Criança , Pré-Escolar , Humanos , Lactente , Pessoa de Meia-IdadeRESUMO
Before 1988, survival of adults with burns > or = 75% total body surface area was uncommon in our burn unit. In 1988 a revised treatment plan for adult patients with burns > or = 75% was instituted. This plan included rapid disciplined eschar removal to fascia within 7 days, sequential meshed autografting with concomitant fresh allograft application, and early enteral feedings.
Assuntos
Queimaduras/mortalidade , Queimaduras/terapia , Adulto , Idoso , Queimaduras/cirurgia , Desbridamento , Nutrição Enteral , Feminino , Hidratação , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente/normas , Estudos Retrospectivos , Transplante de Pele , Transplante Homólogo , CicatrizaçãoRESUMO
Burn centers are under continuing pressures to lower costs and maintain quality of care. One method of achieving this goal is to integrate inpatient and outpatient care in the burn unit. In 1991, our unit instituted an on-site outpatient clinic that was expanded significantly in 1996. The clinic is staffed by the inpatient personnel and allows for 24-hour availability and accommodation of all nurse and physician visits. The number of outpatient visits has increased from 1604 in 1992 to 4728 in 1996, despite a 33% reduction in registered nurse staffing during this time. From 1990 to 1996, the average length of inpatient stay for burns of 0% to 5% total burn surface area (TBSA), 6% to 10% TBSA, and 11% to 15% TBSA has decreased from 7.5 to 3.7 days, 10.3 to 7.7 days, and 16.6 to 11.8 days, respectively. Complete integration of inpatient and outpatient burn care can be achieved. An expanded on-site outpatient facility leads to optimal continuity of care, outpatient management of a larger percentage of burn injuries, and a shift in census from the inpatient to outpatient settings.
Assuntos
Unidades de Queimados/organização & administração , Queimaduras/terapia , Ambulatório Hospitalar/organização & administração , Unidades de Queimados/economia , Unidades de Queimados/estatística & dados numéricos , Controle de Custos , Prestação Integrada de Cuidados de Saúde , Humanos , Tempo de Internação/estatística & dados numéricos , Ohio , Ambulatório Hospitalar/economia , Ambulatório Hospitalar/estatística & dados numéricosRESUMO
Lower extremity amputations are occasionally required after high-voltage electric and deep thermal burns. The extensive loss of skin and soft tissue after these injuries may make it difficult to fashion below-knee amputation that will readily tolerate a prosthesis. We have found an osteocutaneous pedicle fillet flap of the foot useful in the salvage of below-knee amputation after severe burn injury. Three patients have undergone this procedure after burn injury, 1 with burn secondary to high-voltage electric injury and 2 after deep thermal burns. All became ambulatory with artificial prostheses. There were no postoperative infections and no need for further revisions. The osteocutaneous pedicle fillet flap of the foot has proven to be a reliable form of below-knee stump coverage in patients with extensive soft tissue necrosis after burn injury.
Assuntos
Cotos de Amputação/cirurgia , Amputação Cirúrgica/métodos , Queimaduras por Corrente Elétrica/cirurgia , Traumatismos do Pé/cirurgia , Retalhos Cirúrgicos , Acidentes de Trânsito , Adulto , Membros Artificiais , Queimaduras por Corrente Elétrica/complicações , Seguimentos , Traumatismos do Pé/etiologia , Traumatismos do Pé/reabilitação , Humanos , Escala de Gravidade do Ferimento , Joelho , Perna (Membro) , Masculino , Pessoa de Meia-Idade , Terapia de Salvação , Resultado do Tratamento , Cicatrização/fisiologiaRESUMO
Many patients with minor burn wounds will initially be evaluated in an emergency department (ED) and incur unnecessary costs that could be avoided through a direct referral to a burn center. In June 1997, use of an ED burn triage protocol was begun at our hospital. Adults with uncomplicated burns that covered more than 1% and less than 15% of total body surface area (TBSA) and children with burns that covered more than 1% and less than 10% of TBSA were to be triaged directly to the outpatient clinic of the burn center without registering in the ED. From 1996 to 1997, 653 patients were seen in the ED for burn injuries. Approximately 500 patients fit the present criteria for direct triage to the burn center. Since the triage protocol began, the percentage of patients triaged to the burn center has increased from 27% in the first month of use (July 1997) to 73% in December 1997. At least 33% of ED patients were eligible by protocol but not triaged. The average ED visit time for these patients was 103 minutes versus 44 minutes for patients who were sent directly to the burn clinic. An estimated $125,000 per year decrease in charges would occur with use of the protocol. Implementation of an ED triage protocol leads to avoidance of emergency room visits for the majority of patients with minor burn injuries, which results in more efficient, less expensive, faster care.
Assuntos
Queimaduras/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Triagem/economia , Adulto , Idoso , Unidades de Queimados/economia , Queimaduras/economia , Controle de Custos , Serviço Hospitalar de Emergência/economia , Feminino , Custos de Cuidados de Saúde , Preços Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Healthcare organizations have historically separated outpatient from inpatient facilities. In order to streamline the continuity of high quality care, an outpatient burn clinic was established on our inpatient burn center in 1991. Management of the outpatient clinic required alternate staffing patterns and supply allocation plus training in managed care and third party payors. Budget decisions and health care trends affected the number of full time equivalents (FTEs). Between 1990 and 1998, a 33% RN FTE reduction occurred with an overall 22% decrease in total inpatient care providers. Clinic positions were allocated as patient volume and workload data could justify additional staff. Enhanced flexibility in assignment and use of personnel with varying skill levels led to efficient integration of inpatient and outpatient care with an overall reduction in RN FTEs. The purpose of this study is to review the changes in nursing management strategies required by this consolidation.
Assuntos
Unidades de Queimados/organização & administração , Ambulatório Hospitalar/organização & administração , Unidades de Queimados/estatística & dados numéricos , Custos de Cuidados de Saúde , Humanos , Capacitação em Serviço , Tempo de Internação/estatística & dados numéricos , Programas de Assistência Gerenciada/organização & administração , Recursos Humanos de Enfermagem Hospitalar/educação , Recursos Humanos de Enfermagem Hospitalar/provisão & distribuição , Ohio , Avaliação de Resultados em Cuidados de Saúde , Ambulatório Hospitalar/estatística & dados numéricos , Admissão e Escalonamento de Pessoal , Revisão da Utilização de Recursos de Saúde , Recursos Humanos , Carga de TrabalhoRESUMO
The proper function of peritoneal dialysis (PD) catheters can be compromised by catheter malposition, fibrin clot, or omental wrapping. The purpose of this study was to determine the efficacy of laparoscopy in the treatment of malfunctioning PD catheters. All patients undergoing laparoscopy for catheter dysfunction at MetroHealth Medical Center in Cleveland, Ohio, from 1991 to 1995, were reviewed. Twenty-six laparoscopies were performed in 22 patients, for malfunction occurring an average of 3.9 months following insertion (range 0.5-18 months). Omental and/or small below wrapping as present in all but three cases. Lysis of adhesions was required in 19 of 26 cases, with repositioning only in seven. Eight patients had failed attempts at stiff wire manipulation prior to laparoscopy. Perioperative complications occurred in seven cases, consisting of temporary dialysate leakage (2), enterotomy (1), and early reocclusion (4). Repeat laparoscopy was successful in three of these four reocclusions. The overall success rate (catheter function > 30 days after laparoscopy) was 21/22 (96%). Laparoscopy is highly accurate and effective in the management of peritoneal dialysis catheter dysfunction and results in prolongation of catheter life.
Assuntos
Cateteres de Demora , Falência Renal Crônica/cirurgia , Laparoscópios , Diálise Peritoneal Ambulatorial Contínua/instrumentação , Adulto , Idoso , Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Anomalies of the biliary ductal system are not uncommon, and are of variable clinical significance. A case is reported of an extremely unusual variation, with the cystic duct entering the left hepatic duct. Preoperative delineation of the anomaly in this patient by endoscopic retrograde cholangiography assisted in the subsequent performance of a safe laparoscopic cholecystectomy. Awareness of potential biliary variations is one factor in avoidance of ductal injuries during laparoscopic surgery.