Analysis of the effect of conversion from open to closed surgical intensive care unit.
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OBJECTIVE: To compare the effect on clinical outcome of changing a surgical intensive care unit from an open to a closed unit. DESIGN: The study was carried out at a surgical intensive care unit in a large tertiary care hospital, which was changed on January 1, 1996, from an open unit, where private attending physicians contributed and controlled the care of their patients, to a closed unit, where patients' medical care was provided only by the surgical critical care team (ABS or ABA board-certified intensivists). A retrospective review was undertaken over 6 consecutive months in each system, encompassing 274 patients (125 in the open-unit period, 149 in the closed-unit period). Morbidity and mortality were compared between the two periods, along with length-of-stay (LOS) and number of consults obtained. A set of independent variables was also evaluated, including age, gender, APACHE III scores, the presence of preexisting medical conditions, the use of invasive monitoring (Swan-Ganz catheters, central and arterial lines), and the use of antibiotics, low-dose dopamine (LDD) for renal protection, vasopressors, TPN, and enteral feeding. RESULTS: Mortality (14.4% vs. 6.04%, p = 0.012) and the overall complication rate (55.84% vs. 44.14%, p = 0.002) were higher in the open-unit group versus the closed-unit group, respectively. The number of consults obtained was decreased (0.6 vs. 0.4 per patient, p = 0.036), and the rate of occurrence of renal failure was higher in the open-unit group (12.8% vs. 2.67%, p = 0.001). The mean age of the patients was similar in both groups (66.48 years vs. 66.40, p = 0.96). APACHE III scores were slightly higher in the open-unit group but did not reach statistical significance (39.02 vs. 36.16, p = 0.222). There were more men in the first group (63.2% vs. 51.3%). The use of Swan-Ganz catheters or central and arterial lines were identical, as was the use of antibiotics, TPN, and enteral feedings. The use of LDD was higher in the first group, but the LOS was identical. CONCLUSIONS: Conversion of a tertiary care surgical intensive care unit from an open to closed environment reduced dopamine usage and overall complication and mortality rates. These results support the concept that, when possible, patients in surgical intensive care units should be managed by board-certified intensivists in a closed environment. (+info)
Evidence for validity of a health status measure in assessing short term outcomes of cholecystectomy.
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OBJECTIVE: To assess the validity of the Nottingham health profile (NHP) as an indicator of short term outcome of cholecystectomy. DESIGN: Prospective assessment of outcome. SETTING: One teaching hospital. Patients--161 consecutive patients admitted for cholecystectomy between January 1989 and September 1990. MAIN MEASURES: Patients' reported symptoms and self assessed NHP scores before cholecystectomy and at follow up at three and 12 months (76 patients); assessment before admission (19). RESULTS: Complete data were obtained preoperatively and at three months' follow up from 154 patients; seven did not respond to the follow up questionnaire. 76/84(90%) patients in the study 12 months or more answered the 12 month follow up questionnaire; eight did not respond. Significant changes in score before and at three months after the operation were observed for four of the six dimensions: energy (35.34 v 19.53, p < 0.0001), pain (27.38 v 9.8, p < 0.0001), sleep (26.99 v 17.51, p = 0.0002), and emotional reactions (16.12 v 7.56, p = 0.001). The mean scores for 76 patients followed up at three and 12 months showed little subsequent change. Scores in readmitted patients were all significantly higher, suggesting poor health. Patients with five reported symptoms had significantly worse scores for all dimensions. Scores were similar before cholecystectomy whether the questionnaire was completed before or after admission. CONCLUSION: The NHP is an appropriate tool for monitoring changes in health after cholecystectomy. (+info)
Total joint replacement: implication of cancelled operations for hospital costs and waiting list management.
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OBJECTIVE: To identify aspects of provision of total joint replacements which could be improved. DESIGN: 10 month prospective study of hospital admissions and hospital costs for patients whose total joint replacement was cancelled. SETTING: Information and Waiting List Unit, Musgrave Park Regional Orthopaedic Service, Belfast. PATIENTS: 284 consecutive patients called for admission for total joint replacement. MAIN MEASURES: Costs of cancellation of operation after admission in terms of hotel and opportunity costs. RESULTS: 28(10%) planned operations were cancelled, 27 of which were avoidable cancellations. Five replacement patients were substituted on the theatre list, leaving 22(8%) of 232 operating theatre opportunities unused. Patients seen at assessment clinics within two months before admission had a significantly higher operation rate than those admitted from a routine waiting list (224/232(97%) v 32/52(62%), x2 = 58.6, df = 1; p < 0.005). Mean duration of hospital stay in 28 patients with cancelled operations was 1.92 days. Operating theatre opportunity costs were 73% of the total costs of cancelled total joint replacements. CONCLUSION: Patients on long waiting lists for surgery should be reassessed before admission to avoid wasting theatre opportunities, whose cost is the largest component of the total costs of cancelled operations. (+info)
Need to measure outcome after discharge in surgical audit.
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OBJECTIVE: To assess the accuracy of outcome data on appendicectomy routinely collected as part of a surgical audit and to investigate outcome in the non-audited period after discharge. DESIGN: Retrospective analysis of audit data recorded by the Medical Data Index (MDI) computer system for all patients undergoing emergency appendicectomy in one year; subsequent analysis of their hospital notes and notes held by their general practitioners for patients identified by a questionnaire who had consulted their general practitioner for a wound complication. SETTING: One district general hospital with four consultant general surgeons serving a population of 250,000. PATIENTS: 230 patients undergoing emergency appendicectomy during 1989. MAIN MEASURES: Comparison of postoperative complications recorded in hospital notes with those recorded by the MDI system and with those recorded by patients' general practitioners after discharge. RESULTS: Of the 230 patients, 29 (13%) had a postoperative complication recorded in their hospital notes, but only 14 (6%) patients had these recorded by the MDI system. 189 (82%) of the patients completed the outcome questionnaire after discharge. The number of wound infections as recorded by the MDI system, the hospital notes, and notes held by targeted patients' general practitioners were three (1%), eight (3%), and 18 (8%) respectively. None of 12 readmissions with complications identified by the hospital notes were identified by the MDI system. CONCLUSIONS: Accurate audit of postoperative complications must be extended to the period after discharge. Computerised audit systems must be able to relate readmissions to specific previous admissions. (+info)
Transmyocardial laser revascularization: a qualitative systematic review.
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OBJECTIVE: To evaluate the status of transmyocardial laser revascularization (TMLR) from an evidence-based perspective to help hospitals make resource management decisions. STUDY DESIGN: Qualitative systematic review of the clinical literature. METHODS: We searched the reference databases MEDLINE, BIOSIS, EMBASE, SciSearch, and Current Contents to identify all articles related to TMLR published between January 1985 and March 1997. We collected, analyzed, and summarized clinical studies in evidence tables. RESULTS: The cumulative evidence available in the medical literature regarding the safety and effectiveness of TMLR encompasses approximately 2000 patients treated worldwide, primarily those with medically refractory angina. Preliminary data suggest that TMLR has an acceptable survival rate and effectively relieves angina in approximately 75% of patients. Data showing improved myocardial perfusion, cardiac function, or prognosis are inconclusive. The mechanism by which TMLR relieves angina is not yet known. CONCLUSIONS: Early evidence regarding TMLR suggests it will be useful for treating patients with end-stage coronary artery disease. Definitive recommendations await critical analysis of the results of ongoing randomized clinical trials, post-market surveillance studies, and third-party payer acceptance. (+info)
Relation of surgical volume to outcome in eight common operations: results from the VA National Surgical Quality Improvement Program.
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OBJECTIVE: To examine, in the Veterans Health Administration (VHA), the relation between surgical volume and outcome in eight commonly performed operations of intermediate complexity. SUMMARY BACKGROUND DATA: In multihospital health care systems such as VHA, consideration is often given to closing low-volume surgical services, with the assumption that better surgical outcomes are achieved in hospitals with larger surgical volumes. Literature data to support this assumption in intermediate-complexity operations are either limited or controversial. METHODS: The VHA National Surgical Quality Improvement Program data on nonruptured abdominal aortic aneurysmectomy, vascular infrainguinal reconstruction, carotid endarterectomy (CEA), lung lobectomy/pneumonectomy, open and laparoscopic cholecystectomy, partial colectomy, and total hip arthroplasty were used. Pearson correlation, analysis of variance, mixed effects hierarchical logistic regression, and automatic interaction detection analysis were used to assess the association of annual procedure/specialty volume with risk-adjusted 30-day death (and stroke in CEA). RESULTS: Eight major surgical procedures (68,631 operations) were analyzed. No statistically significant associations between procedure or specialty volume and 30-day mortality rate (or 30-day stroke rate in CEA) were found. CONCLUSIONS: In VHA hospitals, the procedure and surgical specialty volume in eight prevalent operations of intermediate complexity are not associated with risk-adjusted 30-day mortality rate from these operations, or with the risk-adjusted 30-day stroke rate from CEA. Volume of surgery in these operations should not be used as a surrogate for quality of surgical care. (+info)
Estimating prevalence of alcohol abuse and dependence in one general hospital: an approach to reduce sample selection bias.
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Prevalence estimates of alcohol abuse or dependence in general hospitals are often limited to single wards, small data collecting periods or insufficient diagnostic procedures. Therefore, the present study aimed to ascertain alcohol abuse or dependence in one general hospital, to compare prevalence data for all the 11 wards and 6 intake months, to establish if screening is sufficient or if a two-step diagnostic procedure is needed, and to determine whether information for an alcohol diagnosis on suspicion is available. A sample of 1309 medical or surgical in-patients were screened by questionnaires or medication for withdrawal, and, if screening-positive, were interviewed with the alcohol section of a standardized psychiatric interview. In screening-negative patients, a diagnosis on suspicion was given if medication to treat withdrawal had been used, or if there was evidence of single criteria of alcohol dependence, somatic disorders from alcohol drinking, raised laboratory parameters on grounds of alcohol drinking or of self-reported high alcohol consumption. Of the medical and surgical in-patients, 20.7 and 16.0% respectively were alcohol abusers or dependents, with a range of prevalence rates of alcohol abuse or dependence among wards of 11.1-32.9% and among intake months between 11.3 and 28.7%. Of the medical department in-patients, 1.9%, and of the surgical in-patients, 2.1%, were screened as false-positive cases. In addition, 5.5% of the medical and 12.0% of the surgical patients were given a diagnosis on suspicion. It is concluded that all general wards and different intake months should be taken into account when estimating prevalence of alcohol abuse or dependence in a general hospital. (+info)
Institutional volumes and coronary angioplasty outcomes before and after the introduction of stenting.
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CONTEXT: An increasing number of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) are receiving coronary stents. OBJECTIVES: To assess whether the introduction of coronary stenting has changed hospital mortality or same-admission coronary artery bypass grafting (CABG) and whether the hospital's procedure volume affects these outcomes. DESIGN: Observational study using hospital claims. SETTING: Nonfederal hospitals that performed PTCA in California in 1993 and 1996. PATIENTS: 35,350 patients who underwent PTCA in 1993 (before the introduction of stenting) and 43,040 patients who had PTCA in 1996 (43% of whom received stents). MEASUREMENTS: Hospital stenting volumes for 1996 were divided into terciles; total PTCA procedures per year were categorized as low (< or = 200), medium (201 to 400), or high (> 400). Outcome variables included hospital death and coronary artery bypass grafting (CABG) performed during the same admission. Patients with a principal diagnosis of acute myocardial infarction (AMI) were analyzed separately from those without such a diagnosis. RESULTS: From 1993 to 1996, the characteristics of patients undergoing PTCA did not change substantially. The use of same-admission CABG decreased by 13% (from 6.0% to 5.2%; P = 0.008) in the AMI group and by 30% (from 3.7% to 2.6%; P < 0.001) in the no-AMI group. Hospital mortality did not change significantly in either group. Procedure volume was not related to hospital mortality. However, rates of same-admission CABG were significantly lower at hospitals with high annual stenting volumes than at low-volume centers (1.3% vs. 2.3% among patients in the no-AMI group; P < 0.001). CONCLUSIONS: Hospital mortality rates after PTCA have not changed considerably since the introduction and diffusion of coronary stenting. However, rates of same-admission CABG have decreased in recent years and are lowest at hospitals with high procedure volumes. (+info)