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Biomedical subjects

Charles J Yowler

Publications and source records attributed to Charles J Yowler.

9 recordsLinked to original sources
PubMed2006

Improved outcome of adult blunt splenic injury: a cohort analysis.

BACKGROUND: The purpose of this study was to review our 15-year experience in the treatment of blunt splenic injury in adults. Our hypothesis was that the implementation of a change in practice, with stress on splenic preservation and splenic artery embolization for the management of splenic injury, would result in improved splenic salvage rates without negatively affecting mortality rates. METHODS: A retrospective cohort analysis was performed on all consecutive adults with blunt splenic injury who were admitted to a Level One Trauma Center. The cohorts were defined by 2 separate 7.5-year periods (1991-1998 and 1998-2005). RESULTS: Six hundred twenty-five patients with blunt splenic trauma were identified; 403 patients who were treated from 1998 to 2005 were compared with 222 patients whose cases had been reviewed previously (1991 to 1998). The present cohort differed in age (35 vs 40 years; P < .001) and injury severity score (27 vs 21; P < .0001). Nonoperative treatment was implemented in 136 patients (61%) in the initial cohort and 344 patients (85%) in the present cohort. The frequency of splenic artery embolization increased from 2.7% to 22.6% (P < .001). The success of nonoperative management increased from 77% to 96% (P < .001); the splenic salvage rate for all patients improved from 57% to 88% (P < .0001). Hospital mortality rates decreased from 12% to 6% (P < .001), and the mean hospital length of stay decreased from 15 to 9 days (P < .001). CONCLUSION: These results demonstrate that the success of nonoperative management and the splenic preservation for blunt injury has improved over time. This improvement correlated with a greater use of splenic artery embolization.

Adolescent↗
PubMed2005

Life after 80 hours: the impact of resident work hours mandates on trauma and emergency experience and work effort for senior residents and faculty.

BACKGROUND: The purpose of this study was to evaluate the impact of work hours mandates on (1) senior resident patient exposure and operating experience in trauma and emergency surgery and (2) faculty work effort. METHODS: We measured resident and faculty work on the trauma and emergency surgery services at our Level I trauma center during two comparable 6-month periods. Period 1 (July 1-December 31, 2002) had no call restrictions, separate trauma and emergency service resident call, and some overlap of faculty call responsibilities. Period 2 (July 1-December 31, 2003) had resident work hours compliance and complete integration of resident and faculty trauma and emergency call. Work hours were measured by surveys for faculty and residents. All data were collected prospectively. RESULTS: Resident exposure to trauma patients was similar during both time periods. Emergency surgery admissions declined during period 2; however, intensive care unit admissions increased. The number of operations performed by senior residents did not change; however, there was a shift in the median number of emergency surgery cases to more senior residents. Faculty work hours increased slightly despite a decrease in faculty call. CONCLUSION: Work hours compliance resulted in a 50% reduction in senior resident call and a 19% decrease in their work hours with no significant change in trauma/emergency patient care exposure or operative case load. Service call amalgamation reduced faculty call by 21% but did not result in a corresponding change in work hours or productivity.

Clinical Competence↗
PubMed2004

Nosocomial infections adversely affect the outcomes of patients with serious intraabdominal infections.

BACKGROUND: Patients with serious intraabdominal infections (IAI) who subsequently acquire nosocomial infections (NI) have been shown to have adverse outcomes. We evaluated factors that put patients at risk for developing NI and examined the effect of the NI on outcomes. METHODS: This study was a retrospective review of NI among 168 patients diagnosed with IAI over a seven-year period. RESULTS: Sixty-six patients (39.3%) developed 98 NI (23 urinary tract, 20 surgical site, 19 pneumonia, 14 bloodstream, 12 recurrent peritonitis, seven intravascular catheter-related, and three enteric). There were 35 males and 31 females. Patients with NI were older (56.0 +/- 18.3 vs. 47.0 +/- 15.6 years, p = 0.001), had a higher admission APACHE II score (10.7 +/- 6.1 vs. 7.5 +/- 5.1 points, p = 0.001), and more often had concomitant medical diagnoses (27.3% vs. 12.7%, OR = 2.57, 95% CI: 1.159-5.69, p = 0.018) than those who did not develop infection. Antimicrobial resistance among the IAI was higher in the NI group (19.7 vs. 5.9%, OR = 3.93, 95% CI: 1.41-10.93, p = 0.006). Patients who developed NI had an increased mortality rate (27.0% vs. 4.0%, OR = 8.87, 95% CI: 2.82-27.86, p < or = 0.0001), longer hospital stay (24.7 +/- 19.5 vs. 11.7 +/- 8.1 days, p < or = 0.0001), required more days of intravenous antibiotics (11.5 +/- 8.0 vs. 7.6 +/- 4.4 days, p < or = 0.0001), and were more likely to be admitted to an intensive care unit (54.5% vs. 25.5%, OR = 3.51, 95% CI: 1.82-6.77, p < or = 0.0001). Multivariate analysis demonstrated that antimicrobial resistance and an APACHE II score of > or = 10 independently predicted the development of a nosocomial infection. Age >/= 50 years, APACHE II score > or = 10, or the presence of a NI independently predicted death. CONCLUSIONS: The development of NI following treatment of an IAI significantly affects mortality, hospital length of stay, and treatment. Early recognition and treatment of these infections, combined with strategies to prevent NI, may be important to improve outcomes in this patient population.

Adult↗
PubMed2002

Burns with multiple trauma.

The purpose of this study was to determine the incidence, mechanisms, and outcomes of management in patients with multisystem trauma and associated burn injury. A retrospective review was performed of patients admitted with combined burns and trauma from 1990 through 1999. Mechanism of injury, extent of burns, associated injuries, Injury Severity Score (ISS), and patient outcomes were identified. There were 2,845 burn and 19,418 trauma admissions. Fifty-six patients (2.0% and 0.29% respectively) had combined burns and trauma. Mean ISS was 21.7 and average percentage total body surface area was 16.2. Associated injuries included fractures in 32, complex soft-tissue injury in 20, head injury in 11, and abdominal trauma in seven. Mechanism of injury was industrial in 19, motor vehicle accident in 16, house fire in 13, high voltage in six, and other in three. Skin grafting was required in 33 of 56 patients (59%). Six of 56 patients died. Mean ISS was 19.0 in survivors compared with 46.2 in nonsurvivors. The combination of burns with multiple system trauma is uncommon. Fractures are the most frequent associated injury, and the majority of patients will require skin grafting in their burn treatment. Outcomes with appropriate management are favorable and are primarily dependent on the degree of associated trauma.

Adolescent↗
PubMed2002

Early and late outcome of bedside percutaneous tracheostomy in the intensive care unit.

To simplify long-term airway management in critically ill patients the feasibility of performing percutaneous tracheostomy (PT) in the intensive care unit (ICU) was investigated from August of 1997 to March of 2000. Bedside PT was considered for patients with positive end-expiratory pressure <10 cm H20, no previous tracheostomy, no anatomic distortion of the tracheal region, and no other indication to go to the operating room. Indication for tracheostomy, duration of endotracheal intubation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, morbidity, and mortality were determined. Patients were prospectively followed until decannulation or for a minimum of 3 months. PT was performed in the ICU in 71 patients. Indications for PT were: acute respiratory failure (41), airway protection (26), and maxillofacial trauma (four). Mean duration of intubation before PT was 14 days (range 5-35 days). Average APACHE II score was 14 (range 3-28). Morbidity from PT included: early (two) and late (one) bleeding from the tracheostomy, early cuff leak (one), and self-decannulation (one). Sixteen patients died of causes unrelated to PT. Forty-five patients were decannulated after an average of 57 days (range 9-170 days); two noted a minor voice change. PT can be performed in the ICU with minimal morbidity eliminating the need for an operating room, the risks of patient transport, and the costs associated with each.

Adolescent↗
PubMedDate not supplied

Comparative study of two systems of delivering supplemental protein with standardized tube feedings.

Burn patients often require protein supplementation for their nutritional support. Although these are often added to a commercial formula, published standards recommend a 4-hr hang time for manipulated open-system formulas in comparison with 24 hr for unopened closed systems. We hypothesized that use of standard closed-system formulas with the addition of protein flushes via the feeding tube twice daily would reduce nursing time and increase satisfaction. A pilot study included a time study comparing the two methods and a nursing satisfaction questionnaire. Management of an open system consistent with national standards took almost twice as much nursing time daily as the closed system with supplemental protein flushes (36.6 +/- 17.1 min vs 18.6 +/- 3.6 min; P =.051). Sixteen of 17 nurses preferred the closed system with protein flush. The results of this study were used to support expansion of the protocol change throughout the hospital.

Bacterial Infections↗
PubMedDate not supplied

The burn nursing shortage: a burn center survey.

The Membership Advisory Committee of the American Burn Association sponsored a survey of burn units in North America to review the issue of nursing staffing, to which 124 of 133 (93%) of the burn centers identified responded. Sixty-two percent had experienced a nursing shortage, and the 77 of 124 units with current vacancies had an average of 4.6 positions open. Licensed practical nurses, aides, and nonlicensed caregivers provide direct patient care in 83% of the units. Ten of 124 units had identified adverse patient outcomes because of staff shortages in their quality assurance programs. Areas identified by two surveys that require further development are nursing acuity systems applicable to burn units and burn nursing educational programs.

Burn Units↗
PubMedDate not supplied

A prospective study of the impact of a critical care pharmacist assigned as a member of the multidisciplinary burn care team.

A critical care clinical pharmacy specialist was assigned to the burn center to make scheduled rounds with the physicians and to attend the weekly multidisciplinary burn team rounds. A prospective 6-month study was completed to 1) determine the clinical impact of the pharmacist's interventions and 2) quantify cost savings generated by these interventions. Prospective data concerning clinical interventions by the pharmacist were collected during a 6-month period. Each intervention was independently reviewed by two attending burn surgeons to determine its importance. A total of 165 interventions in 76 patients were documented. Following an independent review of each intervention by burn surgery attendings, 121 of 165 interventions were felt to have improved overall patient care, 42 of 165 prevented possible drug-related toxicity or organ dysfunction, 1 of 165 prevented a possible life-threatening event, and only 1 of 165 was considered insignificant. Drug changes suggested by the pharmacist resulted in a savings of Dollars 11,081.14 for the 6-month period. The integration of the critical care pharmacist into clinical rounds results in significant cost avoidance and improves overall patient care.

Burn Units↗