PubMed Health⌕ Search

Biomedical subjects

D E Weiland

Publications and source records attributed to D E Weiland.

At least 19 recordsLinked to original sources
PubMed1998

Choosing the best abdominal closure by meta-analysis.

BACKGROUND: Local custom, rather than evidence-based medicine, dictates how a surgeon closes abdominal wounds. Closures might be more secure if grounded on statistical data. MATERIALS AND METHODS: A meta-analysis of 12,249 patients with abdominal wound closures was made. Infections, hernias, and dehiscences were compared examining continuous versus interrupted closures, continuous (absorbable versus nonabsorbable), interrupted (absorbable versus nonabsorbable), and mass versus layered. RESULTS: Continuous absorbable closures showed more hernias (P = 0.0007). Dehiscences were significantly more with continuous nonabsorbable suture (P = 0.01). Interrupted nonabsorbable closures showed a higher incidence of hernias and dehiscences (P = 0.0002, P = 0.04). Mass closures produced significantly less hernias and dehiscences when compared with layered closures (P = 0.02, P = 0.0002). CONCLUSIONS: Continuous closures with nonabsorbable suture should be used to close most abdominal wounds. However, if infection or distention is anticipated, interrupted absorbable sutures are preferred. Mass closures are superior to layered closures.

Abdomen↗
PubMed1997

Why use clinical pathways rather than practice guidelines?

BACKGROUND: Financial pressures from managed care organizations, the government, and other "stakeholders" have resulted in the production of practice guidelines and clinical pathways. Clinical pathways involve all segments of a health care system and may prove to be more beneficial and less hazardous to patients and health care providers. METHODS: A historical narrative describing the development of clinical pathways by the Southwestern Surgical Congress (SWSC) and the Southeastern Surgical Congress (SESC) is made. The motivations, the benefits, and the hazards of both clinical pathways and practice guidelines are discussed. RESULTS: Clinical pathways have proven to reduce length of stay (LOS), complications, and cost, and provide increased patient satisfaction whereas practice guidelines from some specialties show improved quality of care when compared with nonspecialists. However, many practice guidelines are developed by specialists on "best practice" standards, and few have documented studies proving their effectiveness. CONCLUSIONS: Eleven clinical pathways were developed by the SWSC and the SESC and are in the process of revision and study for efficacy. They will be disseminated in the American Surgeon and on the SWSC web site for review and comment. In 1998, both congresses hope to publish the efficacy of selected pathways by describing their effect on LOS and charge for those diagnostic-related groups.

Critical Pathways↗
PubMed1997

Reduction of infectious complications and costs using temporary subcutaneous implantation of PD catheters.

A limited number of authors have demonstrated that temporary subcutaneous implantation of peritoneal dialysis catheters ("Moncrief") reduces infectious complications and increases catheter life expectancy. Two operations are required to use the Moncrief catheter as compared to only one operation when peritoneal dialysis catheters are exteriorized for immediate use ("Updike"). The questions arise, then, are these findings reproducible and which catheter is the most cost-effective? In an effort to support these premises, a retrospective review of 195 patients who received peritoneal dialysis catheters from 1991 to 1995 was undertaken. Demographics, complications, life expectancy analysis, and costs were compared between Moncrief and Updike catheters. There were no significant differences between the groups, and comparisons revealed a clinically evident and statistically significant decrease in the incidence of infections with Moncrief catheters. At both one- and two-year follow-up, Moncrief catheters demonstrated a significant increase in longevity as compared to the Updike catheters. Cost comparisons between the catheter systems revealed that if patients were not undergoing immediate dialysis, placement of a Moncrief catheter was more cost-effective. Conversely, if the patient was currently undergoing dialysis, placement of an Updike catheter was more cost-effective. However, sensitivity analysis revealed that shorter exteriorization times would make the Moncrief catheter the more cost-effective choice in this patient population. In conclusion, temporary subcutaneous implantation of peritoneal dialysis catheters significantly decreases the incidence of infectious complications, increases catheter life expectancy, and is the cost-effective choice for patients who will undergo peritoneal dialysis.

Catheters, Indwelling↗
PubMed1996

Does a full-time, 24-hour intensivist improve care and efficiency?

This article reviews the hypothesis that staffing with full-time intensive care physicians leads to improvements in the management of ICUs and in the outcome for ICU patients. Variations in the professional organization of critical care units in the United States are discussed. The advantages and disadvantages of open, closed, and transitional (comanagement) ICU organizational structures are presented.

Decision Making, Organizational↗
PubMed1995

Is academic managed care an oxymoron?

BACKGROUND: A review of 1993 data on length of stay (LOS) and charges for diagnosis-related group (DRG) 195 (complicated cholecystectomies) showed that Maricopa Medical Center charged more and had longer LOS than all other area hospitals. METHODS: Twenty DRG 195 charts were analyzed for the causes of the inefficiencies. The remaining cholecystectomy DRGs were similarly analyzed. RESULTS: Analysis of the charts for DRG 195 showed that 55% of the patients had laparoscopic conversions. Charges and LOS varied significantly because of the conversions, increased preoperative hospital days and increased operative times. Moreover, 30% of patients were more than 70 years old. Comparisons of other cholecystectomy DRGs showed similar inefficiencies, indicating a hospital system's problem. CONCLUSIONS: Diagnosis-related group delta analysis is a powerful performance improvement tool. Once problem areas are identified and corrected, monitoring prospective data produces rapid analysis of quality of care and cost improvements. The models can serve as a means for teaching hospitals to become more competitive and satisfy the Joint Commission on Accreditation of Healthcare Organizations requirements for patient-care improvements.

Adult↗
PubMed1989

Trauma malpractice claims related to trauma level designation.

The purpose of the present study was to review a one-state experience (Arizona) with trauma malpractice claims as a function of hospital trauma level designation. A total of 191 cases covering 7 years was reviewed and analyzed. Three categories of treatment facilities were compared: American College of Surgeons-categorized Level I hospitals, all other hospitals, and outpatient treatment facilities. Only 22 percent of the malpractice claims were found in Level I facilities, whereas 58 percent were found in other hospitals and 20 percent came from outpatient facilities. Not surprisingly, the indemnity awards were more than two times higher in other hospitals than in Level I hospitals. However, the legal dollars spent in defense per claim were two times higher in Level I than either outpatient hospitals or outpatient treatment facilities, suggesting that Level I malpractice claims are more defensible. We have identified six areas of high potential liability and have made some suggestions for the reduction of risk management in those areas.

Arizona↗
PubMed1984

Prostaglandin E1 for alleviating symptoms of ergot intoxication: a case report.

A woman was admitted after ergotamine tartrate overuse for migraine headaches and her symptoms of arterial vasospasm were treated with PGE1, the first reported use of the vasodilator for ergot intoxication. The advantages of producing local vasodilatation without systemic effect, as well as inhibiting the formation of arterial microthrombi, suggest PGE1 as the agent of choice for relief of symptoms due to peripheral vasoconstriction caused by ergot. Treatment with PGE1 may allow sufficient collateral to preserve limb function and integrity, while awaiting remission of anatomic changes after withdrawal of ergot.

Adult↗
PubMedDate not supplied

Primary closure of fasciotomy incisions with a skin-stretching device in patients with burn and trauma.

Closure of fasciotomy wounds is often a clinical problem after successful management of compartment syndrome. Commonly, split-thickness skin grafts or regional composite grafts are used for fasciotomy closure. However, functional and cosmetic results would be improved if primary reapproximation of these wounds were more practical. The main obstacle that must be overcome is excessive tension on the wound edges. A recently developed skin-stretching device (Sure-Closure, Life Medical Sciences, Princeton, N.J.) allows large tissue defects to be closed with approximation of the wound edges. In this report we describe two patients in whom closure of the fasciotomy incisions was successfully accomplished with the skin-stretching device. These patients included an 11-month-old girl with a circumferential burn of the left arm, and a 42-year-old woman involved in a motor vehicle accident who sustained frostbite and crush injury to her left upper extremity without bone fractures. The skin-stretching device produced excellent functional and cosmetic wound closure results and eliminated the need for additional operative procedures.

Adult↗
PubMedDate not supplied

Rationale for 'early' percutaneous dilatational tracheostomy in patients with burn injuries.

Several investigators have cited the numerous complications that occur with conventional tracheostomies in patients with burn injuries. However, none of these studies included the technique of percutaneous dilatational tracheostomy, which has been shown to significantly decrease operative time, cost, perioperative, and long-term sequelae as compared to conventional tracheostomy. A retrospective analysis of 36 patients with burn injuries, from 1400 burn admissions, was conducted to compare conventional tracheostomy versus percutaneous dilatational tracheostomy. In this study, percutaneous dilatational tracheostomy resulted in significantly decreased operative times and cost compared to conventional tracheostomy. There were no major operative complications in either group, and alveolar-arterial oxygen gradients were improved in 71% of the patients with a tracheostomy. Percutaneous dilatational tracheostomy is an efficacious technique for airway management in patients with burn injuries. It can be safely performed at the bedside, at one fourth the cost of a conventional tracheostomy. Percutaneous dilatational tracheostomy may also benefit the patient with severe burns by decreasing alveolar-arterial oxygen gradients. Improved ventilatory mechanics might allow for a shorter duration of mechanical ventilation, thereby decreasing patient morbidity, hospital stay, and cost.

Adult↗
PubMedDate not supplied

Can there be mutual support between hospital marketing and continuous quality improvement?

Marketing the results of continuous quality improvement in hospitals builds a growing bank of loyal customers in an increasingly competitive and quality-oriented environment: If healthcare institutions want to survive and flourish, they must develop a lasting relationship with their customers. The long-term goal of CQI is to provide quality products and services. If marketing managers can sell these improved services, hospitals will build a solid client foundation.

Hospital Administration↗
PubMedDate not supplied

Using delta/DRG diagrams and decision tree analysis to select a cost-effective surgery for cholecystitis.

BACKGROUND AND OBJECTIVES: Many studies have attempted cost analysis of laparoscopic cholecystectomy as compared to open cholecystectomy. However, these analyses have included costs, charges, expenses, etc., and at times they have been used interchangeably. This paper demonstrates how DRG diagrams containing charges and length-of-stay, preoperative prediction of conversion rates, decision-tree construction and sensitivity analysis can be used to select the most cost-efficient operation for a given patient with cholecystitis. METHODS: A Delta DRG analysis for complicated cholecystectomy (DRG 195) showed the hospital to be an extreme outlier in both charges and length of stay. Record review indicated that 55% of the cases were converted laparoscopic cholecystectomies and the remainder were aged or younger patients with advanced disease. Chart and literature review determined the causes and the probability of conversion. Data were then placed into decision-tree and sensitivity analyses. The most cost-effective operation for a given probability of conversion was demonstrated. RESULTS: Three preoperative findings and combinations of each predicted conversion rates and analysis showed that the charge of laparoscopic cholecystectomy must be held below the range of $5,361-$13,084 to make routine laparoscopic cholecystectomy cost-effective. CONCLUSIONS: This method demonstrated that using Delta/DRG, decision-tree and sensitivity analysis offers physicians, hospitals and other health-care providers a method of evaluating the treatment of DRG categories to determine the most cost-effective management.

Cholecystectomy↗