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PubMed2003

Characteristics of bariatric surgery in an integrated VA Health Care System: follow-up and outcomes.

BACKGROUND: Since the 1991 NIH consensus conference, obesity surgery has been increasingly accepted as a form of therapy for morbid obesity. Approximately 40% of Veteran patients are obese and would potentially benefit from the operations. METHODS: Records were reviewed for all obesity operations performed at the Veterans Administration Greater Los Angeles Health Care System between January 1997 and April 2002. Morbidity, mortality, weight loss, and extent of follow-up were the outcomes measures assessed. RESULTS: Forty-six [11 Female (24%), 35 Male (76%)] patients underwent Roux-Y gastric bypass during the 63-month period we reviewed. There was one death from pulmonary hypertension unexpectedly encountered in the operating room. There was a single major complication: an anastomotic leak successfully treated with intravenous antibiotics. The Computerized Patient Record System contained extensive weight loss information, with dozens of weight measurements for these patients before and after surgery. Weight loss was sustained in all but 2 patients during the follow-up period. The only patients lost to follow-up were those referred from medical centers outside the boundaries of our integrated health care system. CONCLUSION: (1) The VA population has the opposite male/female ratio of populations reported in most weight loss studies. Because the health risks attributable to obesity are greater in males, the VA represents an important population to study that may benefit significantly from weight loss surgery. (2) Extensive clinical information available in the computerized medical record combined with frequent accession of health care resources by our patients resulted in a database rich in follow-up data for a population where long-term outcomes are traditionally difficult to obtain. (3) There was very low surgical morbidity and mortality in a high-risk population. This contrasts with the results of most volume-outcome studies and occurred in a low-volume hospital by a high-volume surgical and medical team. (4) Distinct patterns of weight loss were observed.

Delivery of Health Care, Integrated↗
PubMedDate not supplied

Real time signal processing in the clinical setting.

We routinely use a variety of real time signal acquisition, enhancement, and display techniques in the operating room to provide the surgeon with functional information. This enables reduction of surgical morbidity in cases which present a significant risk to the nervous system. Here we present regression based signal processing algorithms which produce considerable signal-to-noise-ratio enhancement with corresponding reduction in the time required to obtain an interpretable neurophysiological signal. We also present the approach we have applied to fault tolerance and distributed data display for our workstation cluster environment.

Algorithms↗
PubMed2000

Trauma patient outcome in an army Deployable Medical Systems environment compared with a medical center.

William Beaumont Army Medical Center is the second busiest trauma center in the Army. Recent facility renovations there necessitated the use of a temporary field hospital to serve as the Emergency Department, which included the initial evaluation and resuscitation of trauma patients by the trauma team. Although designed for the battlefield, the use of field medical equipment during renovation of military medical facilities is not a new concept. The MUST (Medical Unit Self-contained Transportable) and DEPMEDS (Deployable Medical Systems) have been used successfully during fixed-facility renovations. Previously described functions included inpatient services, outpatient care, and operating room facilities. However, no published information directly compares the use of these temporary structures with standard fixed facilities in the initial management of trauma patients. Trauma patients often present with complex concerns, are highly resource intensive, and their survival is dependent on efficient, timely care. We compared several aspects of patient outcome in the DEPMEDS versus the medical center.

Adolescent↗
PubMed1997

Monitoring the electrode position during acoustic neuroma surgery.

OBJECTIVE: To obtain information about the auditory brain stem responses during auditory brain stem implantation. SETTING: Operating room during acoustic neuroma surgery. METHODS: Electrical stimulation of the auditory system during acoustic neuroma surgery, by placement of a monopolar or bipolar electrode on the nerve or nerve entry zone of the brain stem, and monitoring of the evoked auditory brain stem responses (EABR) recorded from the scalp. In some patients, a multichannel silicon electrode array was placed at the foramen of Luschka. Biphasic rectangular current pulses were applied, and EABRs were recorded. RESULTS: Usually the derived potentials consisted of three peaks with a latency below 4 ms. Sometimes we got a complex of two or more peaks. The interpeak interval between the first and second peak was about 0.7 to 1.0 ms, independently of the stimulating electrode position, but the absolute latency of the first peak increased from a minimum of 0.7 ms stimulated at the foramen of Luschka to a maximum of 1.3 ms stimulated at the nerve.

Cochlear Implantation↗
PubMed2000

Identification of factors that disrupt negative air pressurization of respiratory isolation rooms.

OBJECTIVES: To investigate the airflow characteristics of respiratory isolation rooms (IRs) and to evaluate the use of visible smoke as a monitoring tool. METHODS: Industrial hygienists from the New York State Department of Health evaluated 140 designated IRs in 38 facilities within New York State during 1992 to 1998. The rooms were located in the following settings: hospitals (59%), correctional facilities (40%), and nursing homes (1%). Each room was tested with visible smoke for directional airflow into the patient room (ie, negative air pressure relative to adjacent areas). Information was obtained on each facility's policies and procedures for maintaining and monitoring the operation of the IRs. RESULTS: Inappropriate outward airflow was observed in 38% of the IRs tested. Multiple factors were associated with outward airflow direction, including ventilation systems not balanced (54% of failed rooms), shared anterooms (14%), turbulent airflow patterns (11%), and automated control system inaccuracies (10%). Of the 140 tested rooms, 38 (27%) had either electrical or mechanical devices to monitor air pressurization continuously. The direction of airflow at the door to 50% (19/38) of these rooms was the opposite of that indicated by the continuous monitors at the time of our evaluations. The inability of continuous monitors to indicate the direction of airflow was associated with instrument limitations (74%) and malfunction of the devices (26%). In one facility, daily smoke testing by infection control staff was responsible for identifying the malfunction of a state-of-the-art computerized ventilation monitoring and control system in a room housing a patient infectious with drug-resistant tuberculosis. CONCLUSION: A substantial percentage of IRs did not meet the negative air pressure criterion. These failures were associated with a variety of characteristics in the design and operation of the IRs. Our findings indicate that a balanced ventilation system does not guarantee inward airflow direction. Devices that continuously monitor and, in some cases, control the pressurization of IRs had poor reliability. This study demonstrates the utility of using visible smoke for testing directional airflow of IRs, whether or not continuous monitors are used. Institutional tuberculosis control pro grams should include provisions for appropriate monitoring and maintenance of IR systems on a frequent basis, including the use of visible smoke.

Air Pressure↗
PubMed2006

A prospective study of patient safety in the operating room.

BACKGROUND: To better understand the operating room as a system and to identify system features that influence patient safety, we performed an analysis of operating room patient care using a prospective observational technique. METHODS: A multidisciplinary team comprised of human factors experts and surgeons conducted prospective observations of 10 complex general surgery cases in an academic hospital. Minute-to-minute observations were recorded in the field, and later coded and analyzed. A qualitative analysis first identified major system features that influenced team performance and patient safety. A quantitative analysis of factors related to these systems features followed. In addition, safety-compromising events were identified and analyzed for contributing and compensatory factors. RESULTS: Problems in communication and information flow, and workload and competing tasks were found to have measurable negative impact on team performance and patient safety in all 10 cases. In particular, the counting protocol was found to significantly compromise case progression and patient safety. We identified 11 events that potentially compromised patient safety, allowing us to identify recurring factors that contributed to or mitigated the overall effect on the patient's outcome. CONCLUSIONS: This study demonstrates the role of prospective observational methods in exposing critical system features that influence patient safety and that can be the targets for patient safety initiatives. Communication breakdown and information loss, as well as increased workload and competing tasks, pose the greatest threats to patient safety in the operating room.

Communication↗
PubMedDate not supplied

The PACS committee: the all-important human element.

The PACS committee plays a crucial role in attaining successful outcomes from a PACS implementation. However, most radiology departments do not organize and manage their PACS committees well. This has resulted in poor outcomes and inability to realize projected benefits and return on investment. Ideally, there are two PACS committees: a high-level strategic committee that aligns the goals for the PACS with institutional initiatives, and an operational PACS committee that makes a hands-on approach to the project and manages the entire PACS program. The chairman of radiology, an assigned radiologist or the radiology administrator heads both PACS committees. The strategic PACS committee consists of senior people from information systems, strategic and operational planning, radiology, physicians, nursing, critical care, and other related departments in the hospital. The operational PACS committee consists of people directly involved in radiology operations including the chief of radiology, radiology administrator, technologists, file room manager and other personnel whose daily routines will be affected by the PACS implementation. The operational PACS committee manages the PACS program from initial planning through the post-installation period. Committee tasks include: developing an implementation plan, establishing goals and objectives, conducting a cost/benefits analysis, developing functional specifications, generating an RFP, managing vendor selection and contracting, preparing the site for installation, performing project management functions, conducting acceptance testing, overseeing training, and evolving the PACS operations to meet predicted outcomes.

Decision Making, Organizational↗
PubMed1997

Perioperative post graduate education.

This article describes post-graduate perioperative education in Australia at the Australian Catholic University and St. Vincent's Public Hospital: The Graduate Certificate in Perioperative Practice. The Australian Catholic University operates from eight campuses along the east coast of Australia. There are approximately 9000 students along with 1000 staff. The University consists of major faculties that all have clear relevance to the workplace-namely Arts and Sciences, Education and Health Sciences. Qualifications are offered at Certificate of Doctoral level studies in the areas of business, education, ethics, human movement, management, information systems, music, nursing, religion, social work and theology.

Australia↗
PubMed1988

[The information value of indices of the mathematical analysis of heart rhythm in noise exposure].

The effect of noise on the vegetative nervous system is well-studied. In a laboratory room simulating operator's box 6 subjects were exposed fourfold to white noise with intensity 95 dB/A. The indices of the cardiac rhythm were measured for 10 minutes, threefold, during all exposures, except the first. The measurements were before the beginning of the noise exposure, from the 5th to the 15th minute after starting and at the end (the exposure continues 135 min.). It was established that the effect of noise on the cardiac rhythm indices is most strongly expressed in the beginning. At the end of the exposure the traced indices show a tendency towards level off with the initial data. A conclusion is made that the nearly unknown, in our country, indices of the mathematical analysis of the cardiac rhythm possess high information concerning the noise hazard.

Adult↗
PubMed1990

Procedure codes: potential modifiers of diagnosis-related groups.

Proposals to make complexity-of-illness adjustments to the diagnosis-related group system have relied on secondary diagnosis codes and additional clinical information obtained from the hospital record. Another potential mechanism for modifying diagnosis-related groups involves the use of non-operating room procedure codes. The use of these codes has the advantage of reliably identifying costly subgroups of patients and thus the potential to provide for fairer compensation to hospitals caring for the sickest patients. There are a number of disadvantages, however, and therefore the criteria with which to evaluate procedures as potential modifiers are suggested.

Abstracting and Indexing↗
PubMed2005

Three-dimensional ultrasound imaging of breast cancer by a real-time intraoperative navigation system.

BACKGROUND: In order to achieve a good cosmetic result without increasing the risk of ipsilateral breast cancer recurrence after breast conserving surgery, it is very important to minimize the resection volume of the breast without compromising the negativity of the surgical margin. For this purpose, it is necessary to obtain precise information on tumor extension. We therefore developed a three-dimensional (3-D) ultrasound navigation system for breast cancer surgery, which can be performed in the operating room just before surgery. METHODS: We obtained 3-D breast tumor images by the 3-D ultrasound navigation system in 40 patients with primary breast cancer (stage 0-II) who underwent mastectomy or breast conserving surgery. The tumor size was measured in a coronal view of the 3-D tumor image and compared with the tumor size obtained from a pathological map of the tumor extension. RESULTS: We obtained 3-D tumor images in 38 patients (success rate=95%). The tumor size in the images showed a very strong correlation with the pathological tumor size (r=0.898). The difference in tumor size between the 3-D images and pathology was less than 1 cm in 29 tumors (76.3%) and less than 2 cm in 36 (94.7%). On the other hand, the difference in tumor size between palpation and pathology was less than 1 cm in 19 out of 38 tumors (50.0%) and less than 2 cm in 29 tumors (76.3%). The absolute difference between the 3-D images and pathology was significantly less than that between palpation and pathology (p=0.0197). CONCLUSIONS: Our 3-D ultrasound navigation system is useful in visualizing breast tumor extension and is more accurate than palpation. The system is expected to be helpful in deciding on the appropriate surgical margin in breast cancer surgery, resulting in a better cosmetic outcome without increasing the risk of surgical margin positivity.

Adult↗
PubMed2007

Home injuries mortality: sensitivity and specificity analysis of different data sources and operative definitions.

UNLABELLED: The aim of this longitudinal study was to test different operational definitions of home accident mortality. METHODS: The sources of data were the Emergency Information System, hospital discharge reports and the mortality registry of the Lazio Region, 2000-2001. We selected all emergency room visits for unintentional traumas that occurred at home. A 9-month follow-up was performed to calculate mortality rates. A sensitivity analysis of in-hospital mortality, deaths within 30 days and deaths from home accident E-codes was performed. A gold standard definition of home accident-related deaths was proposed. RESULTS: We observed 598 home accident-related fatalities (29.1% of all the deaths found in the follow-up study). In-hospital mortality, deaths within 30 days and deaths for home accident E-codes had sensitivity values of 63.4%, 63.4% and 59.4%, respectively; positive predictive values were 78.1%, 67.1% and 100%, respectively. CONCLUSIONS: The best operational definition of home injury was based on in-hospital mortality, while mortality based on E-codes reported on death certificates was lacking. In order to measure the real burden of home injuries, hospital and mortality data must be integrated.

Accidents, Home↗
PubMed1991

Operating room satellite pharmacies: demographics, services and implementation.

OR (operating room) satellite pharmacies are still a relatively new addition to the system of pharmacy-coordinated drug distribution. For the last ten years, however, hospitals creating OR satellite pharmacies have found that they provide improved service, reduced inventory, better narcotic control and more efficient drug delivery. Hospital Pharmacy and the OR Satellite Pharmacy Bulletin published a questionnaire to obtain information about OR satellite pharmacies from those actively involved in their planning, implementation, and operation. The questionnaire covered three major areas: demographics, functions and services. This article summarizes the results.

Centralized Hospital Services↗
PubMed2006

Emergent CSCW systems: the resolution and bandwidth of workplaces.

In any collaborative work settings, people naturally develop physical tools and associated work processes that support the management of the interdependencies in information, materials, and social needs. Field studies of management of operating rooms pointed out that collaborative work is supported by an infrastructure that is composed of mostly non-computerized, physical components. The supporting infrastructure is jointly maintained and exploited, with constantly evolving patterns of usage, in response to complexity of coordination needs and the uncertain environment. To represent status and plans, users seem to invent structures based both on idiosyncratic preferences and on negotiated symbols. The fluidity and ease of restructuring workplaces to support collaborative work may be explained in part by the high resolution and bandwidth of workplaces: a large number of ways in which workers could structure their work and a high capacity to convey rich information and meanings quickly to collaborators. We argue that to support health care workers, designers of computer supported cooperative work (CSCW) systems should learn how the physical and perceptual properties of workplaces are exploited, and that CSCW systems should be designed to allow maximum freedom of restructuring and reconfiguring as part of workplaces to enhance bandwidth and resolution of representation and communication.

Cooperative Behavior↗
PubMed1997

Treatment of liver injuries at level I and level II centers in a multi-institutional metropolitan trauma system. The Midwest Trauma Society Liver Trauma Study Group.

OBJECTIVE: The development of trauma systems and trauma centers has had a major impact on the fate of the critically injured patient. However, some have suggested that care may be compromised if too many trauma centers are designated for a given area. As of 1987, the state of Missouri had designated six adult trauma centers, two Level I and four Level II, for the metropolitan Kansas City, Mo, area, serving a population of approximately 1 million people. To determine whether care was comparable between the Level I and II centers, we conducted a concurrent evaluation of the fate of patients with a sentinel injury, hepatic trauma, over a 6-year period (1987-1992) who were treated at these six trauma centers. METHODS: All patients during the 6-year study period who suffered liver trauma and who survived long enough to be evaluated by computerized tomography or celiotomy were entered into the study. Patients with central nervous system trauma were excluded from analysis. Information concerning mechanism of injury, RTS, Injury Severity Score (ISS), presence of shock, liver injury scoring, mode of treatment, mortality, and length of stay were recorded on abstract forms for analysis. Care was evaluated by mortality, time to the operating room (OR), and intensive care unit (ICU) and hospital length of stay. RESULTS: Over the 6-year period 300 patients with non-central nervous system liver trauma were seen. Level I centers cared for 195 patients and Level II centers cared for 105. There was no difference in mean ISS or ISS > 25 between Level I and II centers. Fifty-five (28%) patients arrived in shock at Level I centers and 24 (23%) at Level II centers. Forty-eight patients (16%) died. Thirty-two (16%) died at Level I centers, and 16 (15%) died at Level II centers. Twenty of 55 patients (36%) in shock died at Level I centers, and 11 of 24 (46%) died at Level II centers (p = 0.428). Forty-three patients (22%) had liver scaling scores of IV-VI at Level I centers, and 10 (10%) had similar scores at Level II centers (p < 0.01). With liver scores IV-VI, 22 of 43 (51%) died at Level I centers and 10 of 14 (71%) died at Level II centers (p = 0.184). There was no difference in mean time or in delays beyond 1 hour to the OR for those patients in shock between Level I and II centers. There was a longer ICU stay at Level II centers (5.0 +/- 8.3 vs. 2.8 +/- 8.4 days, p = 0.04). This difference was confined to penetrating injuries. There was no difference in hospital length of stay. CONCLUSIONS: In a metropolitan trauma system, when Level I and II centers were compared for their ability to care for victims of hepatic trauma, there was no discernible difference in care rendered with respect to severity of injury, mortality, delays to the OR, or hospital length of stay. It was observed that more severe liver injuries were seen at Level I centers, but this did not seem to significantly affect care at Level II centers. There was a longer ICU stay observed at Level II centers owing to penetrating injuries, possibly because there were fewer penetrating injuries treated at these facilities. Although the bulk of patients were seen at Level I centers, care throughout the system was equivalent.

Adult↗
PubMedDate not supplied

Positron emission tomography: a first-hand experience.

In July 1999, the University of Kansas Hospital installed a positron emission tomography (PET) scanner and added PET to the imaging technologies it offers patients and physicians. The new service is managed by the nuclear medicine section in the department of radiology. Plans are being implemented now to install a cyclotron in March 2000. Prior to installation of the scanner, a radiation area survey was performed in the space being considered for the PET unit. We also needed to address other critical considerations, including the manufacturer's requirements for construction of the scanner room, special electrical needs, and how the system would connect to our existing information network. It is important to work closely with your chief financial officer and chief operations officer from the beginning of the purchasing process so that these administrators have up-to-date, supportive information about PET and the progress of the installation. We made use of a variety of promotional techniques to market the new service, including broadcast e-mail, an open house for potential referring physicians, postings on the nuclear medicine Web site and communication through the local media. We also worked with the major insurance providers that utilize our hospital to educate them about PET and its benefits. In addition, we trained our own billing staff about procedures that optimize reimbursement for PET. In March 2000, University of Kansas Hospital will install the first cyclotron in the state, enabling us to generate the drugs used for PET scanning and potentially to add targets for research PET radiopharmaceuticals.

Computer Communication Networks↗
PubMedDate not supplied

Improving radiology in surgery.

The time has come to reevaluate the use of films of substandard quality obtained from outdated radiography equipment. The authors recommend that surgical subspecialists, orthopedic surgeons, emergency room physicians, gastroenterologists, or whoever employs radiology in the operating room ensure that technological progress in radiology be transferred to the surgical area. The mobile C-arm image amplifier with television fluoroscopy and single-image storage device should be considered for orthopedic surgery and ER rooms. More sophisticated equipment is required for operative cholangiography and operative angiography.

Data Display↗