RESUMEN
Tertiary hospitals are increasingly called on by smaller hospitals and free-standing emergency rooms (ERs) to provide surgical care for complex patients. This study assesses patients transferred to an acute care surgery service. The ER and transfer center logs, as well as billing data, were reviewed for 12 months for all cases evaluated by acute care surgery. The charts were reviewed for demographics, comorbidities, and outcomes. A total of 111 transferred patients with complete data were identified, with 59 transferred from another hospital and 52 from a free-standing ER. The hospital transfer patients were older with more comorbidities, had a longer length of stay, and were more likely discharged to skilled care. There was no difference in the percent of patients requiring a procedure; however, significantly more procedures in the hospital transfer group were done by nonsurgical specialties Better infrastructure to monitor the impact of hospital transfers is warranted in the setting of the complex patient population transferred to tertiary hospitals.
Asunto(s)
Transferencia de Pacientes , Procedimientos Quirúrgicos Operativos , Atención Terciaria de Salud , Comorbilidad , Femenino , Investigación sobre Servicios de Salud , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana EdadRESUMEN
Withdrawal of care has increased in recent years as the population older than 65 years of age has increased. We sought to investigate the impact of this decision on our mortality rate. We retrospectively reviewed a prospectively collected database to determine the percentage of cases in which care was actively withdrawn. Neurologic injury as the cause for withdrawal, age of the patient, number of days to death, number of cases thought to be treatment failures, and the reason for failure were analyzed. Between January 2008 and December 2012, there were 536 trauma service deaths; 158 (29.5%) had care withdrawn. These patients were 67 (± 18.5) years old and neurologic injury was responsible in 63 per cent (± 5.29%). Fifty-two per cent of the patients died by Day 3; 65 per cent by Day 5; and 74 per cent Day 7. A total of 22.7 per cent (± 7.9%) could be considered a treatment failure. Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent. Trauma center mortality calculation does not account for care withdrawn. Treating an active, aging population, with advance directives, requires methodologies that account for such decision-making when determining mortality rates.
Asunto(s)
Mortalidad Hospitalaria , Privación de Tratamiento , Heridas y Lesiones/mortalidad , Factores de Edad , Anciano , Toma de Decisiones , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Centros Traumatológicos , Virginia/epidemiologíaRESUMEN
BACKGROUND: Ventilator-associated pneumonia (VAP) remains a major source of morbidity, mortality, and expense in the ICU despite therapies directed against it. STUDY DESIGN: A retrospective review of a prospectively developed performance-improvement project monitoring the incidence of VAP in two adjacent ICUs was conducted. In response to an excessive VAP rate, weekly multidisciplinary team meetings were instituted to review data, develop care protocols, and modify care routines. Protocol compliance was monitored daily and feedback provided weekly to the care teams. VAP rates were determined by the institutional Infection Control Committee and reviewed monthly with the ICU multidisciplinary team. Duration of the investigational period was 10 years. RESULTS: A standardized ventilator-weaning protocol was instituted with confirmed 95% use. Additional modifications of care, such as patient positioning, use of specific endotracheal tubes to minimize aspiration of supraglottic secretions, an oral-care regimen, and aggressive antibiotic stewardship were standardized, with a compliance rate >90%. VAP rates dropped from 12.8 per 1,000 patient-days in 1998 to 1.1 in 2007 in the burn trauma ICU and from 21.2 to <1 in the neurotrauma ICU in the same time frame. Also, mean ventilator length of stay decreased from 6 days to 4.2 and from 5.8 days to 4.75 simultaneously in the respective ICUs. Such performance improvement has been sustained since implementation of the program. CONCLUSION: A systematic, monitored program of standardized care protocols can markedly reduce VAP rate in the ICU.
Asunto(s)
Cuidados Críticos/normas , Neumonía Asociada al Ventilador/epidemiología , Quemaduras/terapia , Protocolos Clínicos , Hospitales de Enseñanza , Humanos , Incidencia , Unidades de Cuidados Intensivos , Intubación Intratraqueal , Tiempo de Internación , Higiene Bucal , Grupo de Atención al Paciente , Neumonía Asociada al Ventilador/prevención & control , Garantía de la Calidad de Atención de Salud , Estudios Retrospectivos , VirginiaRESUMEN
BACKGROUND: This study was designed to evaluate whether resident performance of placing central lines improved after simulation training on newly available partial-task simulators. METHODS: This study was designed as a prospective, randomized controlled trial of standard training versus simulated training using CentralLine Man (SimuLab, Seattle, WA, USA). After receiving a lecture on central line placement, all junior residents on the trauma rotation were randomized on a monthly alternating schedule. Equivalency of groups was determined with a self-reported survey. All lines placed by the participants were monitored, and data were collected on performance and complications. RESULTS: The 2 groups (n = 34; 21 standard and 13 simulated) were equivalent at baseline. The simulated training group had a significantly higher level of comfort and ability than the standard training group. The simulated group outperformed the standard group on 12 of the 15 specific variables monitored, although this did not reach statistical significance. There were significantly more complications in the standard group. CONCLUSIONS: Simulation for central line placement using a partial-task simulator does positively impact resident performance.