Biomedical subjects

David L Berger

Publications and source records attributed to David L Berger.

12 recordsLinked to original sources

PubMed2006

INCOMING!--A web tracking application for PACU and post-surgical patients.

BACKGROUND: Capacity constraints necessitate improving hospital efficiency. An integrated real time system facilitating patient flow between the post-anesthesia care unit (PACU) and surgical ward would ease PACU workload by reducing the effort of discharging patients. METHODS: We developed INCOMING!, a web-based platform that monitors patient progress from the operating room to the PACU. INCOMING! integrates available data, automatically determining when a patient enters the PACU. An automated paging system alerts clinical unit managers to 'pull' their patients from the PACU after a set recovery period. General surgery patients were included in the INCOMING! system in late 2004 with paging added in mid-March 2005. Mean PACU length of stay was calculated for the intervention group (general surgery patients with INCOMING!) and compared to a control group (general surgery patients without INCOMING!) and an orthopedic surgery group before and after paging. RESULTS: The system successfully gathers data and generates automated pages when events occur. After paging, there was a significant difference between the orthopedic surgery control group and the general surgery intervention group (235 min versus 185 min, P = 0.001). The mean PACU LOS decreased in the INCOMING! intervention group by 26 min while the mean LOS increased by 28 min in the general surgery control group (P = 0.27). CONCLUSION: Pilot implementation demonstrates that INCOMING! performs the desired integration and automatic notification. Given the minimal cost and potential large gains from a wider deployment, we plan to implement the system for all PACU patients and all post-PACU care units.

Computer Systems↗

PubMed2006

Is right hemicolectomy for 2.0-cm appendiceal carcinoids justified?

HYPOTHESIS: We believe right hemicolectomy (RHC) is not necessary in patients with an appendiceal carcinoid greater than 2.0 cm. DESIGN: A retrospective review of patients with a histologically confirmed appendiceal carcinoid from April 1, 1980, to February 28, 2005, and an analysis of the literature. SETTING: Tertiary care referral center. PATIENTS: Forty-eight patients (34 females and 14 males) with a histologically confirmed diagnosis of appendiceal carcinoid were included in the study. Appendiceal carcinoid was diagnosed incidentally in all 48 patients. Patient ages ranged from 11 to 86 years (mean age, 41 years). Postoperative follow-up and disease-free survival were confirmed in 33 patients via medical record review. MAIN OUTCOME MEASURES: We assessed the relationship between survival, tumor size, and the role of RHC vs appendectomy alone. RESULTS: Four patients in our series underwent secondary RHC and lymph node dissection for tumors greater than 2.0 cm, and none had positive lymph nodes. Following review of the literature, we were unable to find any recent evidence of distant metastasis from carcinoids in patients already treated by appendectomy. There seem to be no conclusive data to support the notion that RHC confers a survival benefit over appendectomy for carcinoids greater than 2.0 cm. CONCLUSION: Appendiceal carcinoids greater than 2.0 cm can be managed effectively with simple appendectomy, given their low malignant potential and slow growth, obviating the need for RHC in this group of patients without affecting overall survival.

Adolescent↗

PubMed2006

Maximizing operating room and recovery room capacity in an era of constrained resources.

HYPOTHESIS: Three parallel processing operating rooms (ORs) (concurrent induction and turnover) with a dedicated 3-bed mini-recovery room (mini-postanesthesia care unit [PACU]) will optimize patient throughput and main PACU workload when compared with 4 traditional ORs or 4 parallel processing ORs. DESIGN: Statistical and mathematical models projected the impact of parallel processing on case throughput and PACU use. SETTING: Academic medical center with 48 traditional ORs using serial induction and turnover and 1 experimental OR, the operating room of the future, with parallel processing. PARTICIPANTS: All surgical cases from October 2002 through March 2004 (N = 49 887). INTERVENTIONS: A statistical model projected the duration of induction, surgery, turnover, and PACU stay for cases performed in a traditional OR (n = 48 667) based on the operating room of the future (n = 1220) experience. A fluid queuing model compared each combination using specific probability density functions. MAIN OUTCOME MEASURES: Each OR configuration was evaluated for case throughput and minutes of work sent to the PACU. RESULTS: Although all cases save OR time with parallel processing, only select surgeon-case combinations translate time saved into additional cases per day (26%). Without additional PACU slots, output from 4 parallel processing ORs further stresses the PACU. Three parallel processing ORs and a mini-PACU balances incremental volume by offsetting PACU utilization in 84% of cases. CONCLUSION: In a PACU-constrained environment, 3 parallel processing ORs with a mini-PACU configuration offers increased throughput and decreased PACU workload.

Academic Medical Centers↗

PubMed2006

Financial and operational impact of a direct-from-PACU discharge pathway for laparoscopic cholecystectomy patients.

BACKGROUND: We assessed the operational and financial impact of discharging laparoscopic cholecystectomy (LC) patients directly from the postanesthetic care unit (PACU) in comparison with post-transfer discharge from a hospital bed in a busy academic hospital. METHODS: We retrospectively compared 6 months of performance (bed utilization; recovery room and hospital length of stay; complications; readmissions; hospital costs, revenue, and margin) after implementation of PACU discharges (case patients) to the corresponding 6 months in the prior year (control patients). RESULTS: After implementation, 66% of LC case patients were discharged on the day of surgery, compared with 29% in the control group (P < .05). Eighty percent of the day-of-surgery discharges were directly from the PACU. Shifting to PACU discharge saved 1 in-hospital bed transfer and 1 bed-day for each PACU discharge. Recovery room length of stay for PACU discharge patients was 26% longer than for hospital discharge patients (P = NS). Average hospital length of stay for all patients discharged on the day of surgery was 3.2 hours shorter (P < .05) for case patients (80% PACU discharge) than for control patients. There were no readmissions in the PACU discharge group and no difference in complications. While costs, revenue, and net margin for PACU discharge patients were reduced by 40% to 50% (P < .02) relative to floor discharge patients, the hospital's net margin for the combined case patient group was preserved relative to the control group. CONCLUSIONS: PACU discharge of LC patients significantly reduces bed utilization, decreases in-hospital transfers, and allows congested hospitals to better accommodate patient care needs and generate additional revenue.

Adult↗

PubMed2006

Increasing operating room efficiency through parallel processing.

OBJECTIVE: Because of rising costs and shrinking reimbursements, hospitals must continually find ways to improve efficiency and productivity. This study attempts to increase caseloads in ambulatory surgery operating rooms while maintaining patient satisfaction and safety. SUMMARY BACKGROUND DATA: In most hospitals, patients move through their operative day in a linear fashion, starting at registration and finishing in the recovery room. Given this pattern, only 1 patient may occupy the efforts of the operating room team at a time. By processing patients in a parallel fashion, operating room efficiency and patient throughput are increased while costs remain stable. METHODS: Patients undergoing hernia repairs under local anesthesia with intravenous sedation were divided into a control group and an experimental group. Patients in the control group received their local anesthesia in the operating room at the start of the surgery. The experimental group patients received their local anesthesia in the induction room by the surgeon while the operating room was being cleaned and set up. RESULTS: While operative time for the control group and the experimental group were nearly identical, the turnover time and the induction time were significantly shorter for the experimental group. The cumulative reduction in time during the operative day was sufficient to allow the addition of new operative cases. CONCLUSIONS: This study demonstrates a system of increasing operating room efficiency by changing patient flow rather than simply working to streamline existing steps. This increase in efficiency is not associated with the expansion of hospital budgets or a decrease in patient safety or satisfaction.

Ambulatory Surgical Procedures↗

PubMed2006

The effect of direct-from-recovery room discharge of laparoscopic cholecystectomy patients on recovery room workload.

Ambulatory laparoscopic cholecystectomy pathways move patients through the hospital without encountering delays caused by congested inpatient bed units. However, redirecting patients to a direct discharge pathway might not be beneficial if recovery capacity is further taxed by additional workload. In this study, we attempt to assess the operational impact on recovery room workload of directly discharging laparoscopic cholecystectomy patients to home. We conducted a retrospective case-control review of recovery room flow sheets to determine recovery room time and effort required for laparoscopic cholecystectomy patients. The study was restricted to patients of a single surgeon to minimize confounds from surgical technique. Fifty-seven case patients (May 1, 2004, through November 30, 2004), all managed with intent to directly discharge from the recovery room, were compared with control patients (n = 81) from the corresponding 6 months in the year before the direct-discharge plan. The times (mean; 95% confidence interval) to meet objective criteria for adequate pain control (3.5 minutes [2.1 to 5.9] versus 4.0 minutes [2.6 to 6.1]) and readiness for discharge from phase 1 recovery (8.1 minutes [4.8 to 13.6] versus 6.1 minutes [4.0 to 9.5]) were not different between the groups. The number and distribution of interventions documented in the recovery process were not different between groups, nor was there a difference in recovery room length of stay (158 minutes [138 to 182] versus 149 minutes [132 to 167]). In our study, recovery room records reveal little if any increased workload associated with the direct-to-home discharge of laparoscopic cholecystectomy patients.

Cholecystectomy, Laparoscopic↗

PubMed2005

Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients.

INTRODUCTION: Gastrointestinal (GI) complications following heart operation may be life-threatening. Systematic analysis of risk factors to allow early identification of patients at risk for GI complication may lead to the development of strategies to mitigate this complication as well as to optimize management after its occurrence. METHODS: Of 8709 consecutive patients undergoing heart operation during 7 years (1997-2003), 46 (0.53%) developed GI complications requiring surgical consultation. Preoperative, intraoperative, and postoperative predictors of complication and death were identified and compared with a control group. RESULTS: Significant (P < 0.05) preoperative predictors of complication were prior cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), type II heparin-induced thrombocytopenia, atrial fibrillation, prior myocardial infarction, renal insufficiency, hypertension, and need for intra-aortic balloon counter-pulsation. The most frequent serious GI complication was mesenteric ischemia, which developed in 31 (67%) patients. Twenty-two (71%) of these patients were explored, and 14 (64%) died within 2 days of heart operation. Of the 9 patients with mesenteric ischemia who were not explored, 7 (78%) died within 3 days of heart operation. Other complications included diverticulitis (5), pancreatitis (4), peptic ulcer disease (4), and cholecystitis (2). The mortality rate in this group of other diagnoses was lower (40%), and death occurred later (32 days) after heart operation (P = 0.03 compared with mesenteric ischemia). Predictors of death from GI complication included New York Heart Association (NYHA) class III and IV heart failure, smoking, chronic obstructive pulmonary disease, history of syncope, aspartate aminotransferase (AST) >600 U/L, direct bilirubin >2.4 mg/dL, pH < 7.30, and the need for >2 pressors. CONCLUSIONS: The most common catastrophic GI complication after cardiac surgery is mesenteric ischemia, which is frequently fatal. This complication may be a result of atheroembolization, heparin-induced thrombocytopenia, or hypoperfusion. Techniques to reduce the occurrence of and/or preemptively diagnosis postcardiotomy mesenteric ischemia are necessary to decrease its associated mortality.

Adult↗

PubMed2004

Improving team structure and communication: a key to hospital efficiency.

HYPOTHESIS: Improving team structure and heightening communication will help provide cost-effective and high-quality patient care for general surgery patients. DESIGN: This study surveys teamwork initiatives and their effects on specific variables related to patient care. PATIENTS: The study population comprised all patients admitted to the hospital's general surgery teams during 5 years 3 months. SETTING: Tertiary care hospital. INTERVENTIONS: A complete restructuring of the patient care team for general surgery patients admitted to the hospital. The intervention occurred midway through the study period. MAIN OUTCOME MEASURES: Mean length of stay for general surgery patients as a marker of team efficiency and a standardized patient satisfaction survey. RESULTS: The mean length of stay after initiation of the restructured care team was significantly shorter than before initiation. The significance was present despite a consistent patient acuity measure and was associated with a high patient satisfaction level. CONCLUSIONS: Restructuring the patient care team yielded a decreased mean length of stay while maintaining a high level of patient satisfaction. This analysis helps validate a hospital-wide initiative to maintain a high level of patient care while increasing patient volume.

Cost-Benefit Analysis↗

PubMed2003

Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection.

BACKGROUND: Patient care pathways have been developed for operative procedures with documented improvements in length of stay and cost without compromising outcome. The average hospital stay after colonic resection is 5 to 10 days. This study describes a clinical pathway for colon resections and examines patient outcome before and after institution of the pathway. METHODS: One hundred thirty-eight patients underwent elective colon resections at our institution by a single surgeon before (n = 52) and after (n = 86) introduction of a clinical pathway. Length of stay, postoperative complications, readmissions, and cost per patient were compared between the 2 groups. RESULTS: Mean total length of stay (+/- standard deviation [SD]) was less in the postclinical pathway patients (3.7 +/- 1.5 days) compared to preclinical pathway patients (6.6 +/- 3.3 days) (P <.001). When adjusted for age, sex, diagnosis, and type of operation, the difference in length of stay remains statistically significant (P <.001). There was 1 readmission in the prepathway group and 8 readmissions in the postpathway group. When the readmissions were added to the original admissions, the mean length of stay in the postpathway patients was 4.2 +/- 2.8 days and in the prepathway patients was 6.9 +/- 4.1 days (P <.001). The average cost per patient (+/- standard error of the mean), with readmission costs added, was 9310 +/- 5170 US dollars in the prepathway group and 7070 +/- 3670 US dollars in the postpathway group (P =.002). CONCLUSIONS: The institution of a clinical pathway for elective, open colon resections can be done safely with improvements in cost and length of stay.

Adult↗

PubMed2002

Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography.

HYPOTHESIS: Abandoning mandatory angiography in patients with blunt lower-extremity trauma and normal neurovascular examination results does not affect limb salvage. DESIGN: Retrospective, nonrandomized cohort study. Mean follow-up (31 of 52 patients) of 9.5 months (range, 0-96 months). SETTING: Single-institution, academic level I trauma center. PATIENTS: Medical records of patients presenting on an emergency basis with knee dislocation, distal femoral fractures, or proximal tibial fractures during a 20-year period were reviewed. Fifty-three injuries occurred in 52 patients. Patients were predominantly male (81%) and young (mean age, 32.7 years). Mechanisms and side of extremity injury, coincident injuries, and neurovascular status on admission were recorded. Hard signs of arterial insufficiency or compartment syndrome were identified. INTERVENTIONS: Angiographic findings and operative and nonoperative interventions were recorded to identify whether angiographic data would alter therapy dictated by clinical findings alone. MAIN OUTCOME MEASURES: Limb salvage rate and necessity for vascular surgical intervention based on angiographic data in patients with normal neurovascular examination results. RESULTS: Multiorgan trauma occurred in 11 patients. Pulses were normal in 35, absent in 16, and diminished or identified by Doppler signal in 2. Arterial insufficiency or compartment syndrome was present in 29%. Twenty-seven patients (28 limbs) underwent angiography at the discretion of the attending surgeon. Of 13 abnormal arteriograms, 2 occurred in patients with normal pulses and 11 in patients with abnormal examination results. Thirteen of 36 patients with normal pulses underwent angiography; none had clinically significant arterial injuries that necessitated intervention. No vascular interventions were necessary in 23 patients with normal pulses who did not undergo angiography (P<.001). Normal neurovascular status bore a 100% negative predictive value in determining the necessity of vascular intervention. CONCLUSIONS: Angiography is unnecessary in the routine evaluation of the patient with blunt lower-extremity trauma who presents with a normal neurovascular examination result and can be used selectively for patients with diminished pulses who lack associated indications for mandatory operative exploration.

Adult↗

PubMed2002

Airway risk in hospitalized trauma patients with cervical injuries requiring halo fixation.

OBJECTIVE: To identify the incidence and outcomes of emergent and semiemergent intubations in hospitalized trauma patients with cervical fractures and/or dislocations treated with halo fixation. SUMMARY BACKGROUND DATA: Intubating a trauma patient in halo fixation can be extremely difficult, with the potential for dire consequences. METHODS: The authors retrospectively reviewed the medical records of trauma patients with cervical injuries requiring halo fixation admitted to a level 1 trauma center between January 1992 and January 1997. The in-hospital need for emergent or semiemergent intubation was assessed and correlated with a variety of patient characteristics, including outcome. RESULTS: Of the 105 patients identified, 14 (13%) required an emergent or semiemergent intubation. Injury Severity Score, cardiac history, and intubation on arrival were significant indicators of the need for an in-hospital emergent or semiemergent intubation or reintubation. A total of seven deaths were reported, six of which were associated with an emergent or semiemergent in-hospital intubation. Although age did not appear significant in predicting the need for an emergent intubation, it was significant in predicting arrest-related deaths. A total of 17 tracheostomies were performed. Eight were considered "initial" in that they were performed before an emergent intubation, and nine were performed after an emergent intubation. Patients in the initial tracheostomy group did not differ in terms of the variables investigated from those who required an emergent intubation. None of the patients who underwent initial tracheostomy, however, had an airway emergency or died. CONCLUSIONS: A significant number of trauma patients treated with halo fixation ultimately require an in-hospital emergent or semiemergent intubation. Given the difficulty and potential lethality associated with these intubations, heightened vigilance regarding the airway is warranted. The authors recommend that early tracheostomy be considered in patients with a history of cardiac disease, especially when a high Injury Severity Score is present. Older patients (older than 60 years) are more at risk for arrest-related death and may also benefit from early tracheostomy.

Accidental Falls↗

PubMedDate not supplied

RFA for liver tumors: does it really work?

The use of radiofrequency ablation (RFA) is increasing in the treatment of both primary and metastatic hepatic tumors. However, the role of RFA has yet to be clearly defined in patients who are still considered amenable to surgical intervention. Future prospective studies are needed to define whether RFA can be used as an alternative to surgery in certain patient populations. In the interim, radiofrequency ablation technology will continue to advance and serve as both a palliative and potentially curative intervention for individuals with hepatic tumors.

Catheter Ablation↗