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PubMed2005

Clinical review: the Israeli experience: conventional terrorism and critical care.

Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for critically injured patients. To do so we have developed a highly flexible operational system for managing the general intensive care unit (GICU). The focus of this review will be on the organizational steps needed to provide operational flexibility, emphasizing the importance of forward deployment of intensive care unit personnel to the trauma bay and emergency room and the existence of a chain of command to limit chaos. A retrospective review of the hospital's response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical center's trauma registry and from GICU patient admission and discharge records. Patients are described with regard to the severity and type of injury. The organizational work within intensive care is described. Finally, specific issues related to the diagnosis and management of lung, brain, orthopedic and abdominal injuries, caused by bomb blast events associated with shrapnel, are described. This review emphasizes the importance of a multidisciplinary team approach in caring for these patients.

Abdominal Injuries↗
PubMed1999

[The use of computers and networking in the neurosurgical field].

Due to the improvements in computer and network technology, we are able to use medical information easily and safely on the network in medical institutions. In our department, we constructed and used an original Intranet with light fibers. The network links the outpatient room, ward, operation room, staff room and the examination room. Moreover, many computers and medical instruments are connected to the Intranet. Since our original Intranet has no connection with the outside network, we are able to access the patient's medical information safely. Using access management of identity and a password on the server, the client can present the medical information with sound and movie upon request of the patients and their families, medical students, nurses and doctors. Doctors can also search and input the patient's most recent medical information on a network database of every client. By linking the examination machine and operation aided instrument to the Intranet, we were able to forward the patient's medical information to the operation aided instrument easily and quickly. Furthermore, we will be able to perform tele-medicine and tele-operation in the near future: that is, the medical staff can guide the neurosurgical operation outside of the operation room with a microscope and computer view using picture mutual communication devices. By strict access to the management of our Intranet, we are able to use the medical information effectively for patient's treatment, operation, education and study on the network with no connection to the outside network.

Databases, Factual↗
PubMed2001

Pediatric PACS, Astrid Lindgren Children's Hospital at Karolinska Hospital, Stockholm, technical and practical aspects.

We present a filmless pediatric radiology department for the Stockholm area (1.8 million inhabitants) producing 50000 examinations per year. Seventy percent of the examinations are non scheduled, 50% are emergency cases out of office hours. The system is designed for high reliability operating with 99.7% uptime. A large number of daily conferences are held throughout the Children's Hospital at the various specialized departments, distributed through the intranet, with one pediatric radiologist attending. Instant reading is made in the majority of examinations and reports are available with images throughout the hospital including PC's at doctors rooms. The system uses conventional hardware and software with an open systems standard based approach. The system is highly appreciated by clinicians and has improved availability of radiology information.

Hospitals, Pediatric↗
PubMed2001

Are surgery training programs ready for virtual reality? A survey of program directors in general surgery.

BACKGROUND: The use of advanced technology, such as virtual environments and computer-based simulators (VR/CBS), in training has been well established by both industry and the military. In contrast the medical profession, including surgery, has been slow to incorporate such technology in its training. In an attempt to identify factors limiting the regular incorporation of this technology into surgical training programs, a survey was developed and distributed to all general surgery program directors in the United States. STUDY DESIGN: A 22-question survey was sent to 254 general surgery program directors. The survey was designed to reflect attitudes of the program directors regarding the use of computer-based simulation in surgical training. Questions were scaled from 1 to 5 with 1 = strongly disagree and 5 = strongly agree. RESULTS: A total of 139 responses (55%) were returned. The majority of respondents (58%) had seen VR/CBS, but only 19% had "hands-on" experience with these systems. Respondents strongly agreed that there is a need for learning opportunities outside of the operating room and a role for VR/CBS in surgical training. Respondents believed both staff and residents would support this type of training. Concerns included VR/CBS' lack of validation and potential requirements for frequent system upgrades. CONCLUSIONS: Virtual environments and computer-based simulators, although well established training tools in other fields, have not been widely incorporated into surgical education. Our results suggest that program directors believe this type of technology would be beneficial in surgical education, but they lack adequate information regarding VR/CBS. Developers of this technology may need to focus on educating potential users and addressing their concerns.

Clinical Competence↗
PubMed1993

Impact of a major hurricane on surgical services in a university hospital.

Hurricane Hugo struck Charleston, South Carolina, on September 21, 1989. This report analyzes the impact this storm had upon surgical care at a university medical center. Although disaster planning began on September 17, hurricane damage by high winds and an 8.7-foot tidal surge led to loss of emergency power and water. Consequently, system failures occurred in air conditioning, vacuum suction, steam and ethylene oxide sterilization, plumbing, central paging, lighting, and refrigeration. The following surgical support services were affected. In the blood bank, lack of refrigeration meant no platelet packs for 2 days. In radiology, loss of electrical power damaged CT/MRI scanners and flooding ruined patient files, resulting in lost information. In the intensive care unit, loss of electricity meant no monitors and hand ventilation was used for 4 hours. In the operating room, lack of temperature and humidity control (steam, water, and suction supply) halted elective surgery until October 2. Ground and air transportation were limited by unsafe landing sites, impassable roads, and personnel exhaustion. Surgical planning for a major hurricane should include: 1) a fail-safe source of electrical power, 2) evacuation of as many critically ill patients as possible before the storm, 3) cancellation of all elective surgery, and 4) augmented ancillary service staffing with some, although limited, physician support.

Disaster Planning↗
PubMedDate not supplied

[Backache from exertion in health personnel of the Istituti Ortopedici Rizzoli in Bologna. A case-control study of the injury phenomenon in the 10-year period of 1987-1996].

Low-back (lumbosacral) injuries are known as one of more important occupational health problems in health care workers, because of high prevalence and impact of socioeconomic costs. To investigate the risk of low-back pain in hospital workers into the Istituti Ortopedici Rizzoli in Bologna (Italy), a retrospective study was carried out. The adapted study design was the matched (1:1 for age) case-control, enlisting the first injuries occurred in the hospital staff like cases, and personnel in force, matched for age and year of happened case, like controls. Information about diagnoses and occupational data was obtained from the current informative systems. Comparison with a control group suggests the validity of the work-relatedness of low-back pain in nursing and health aides (OR: 21.67; LC: 4.69-196.56), in nurses (OR: 20.21; LC: 4.81-177.95), in therapists (OR: 16.36; LC: 2.80-163.54) and in X-ray technicians (OR: 13.64; LC: 2.25-138.99). The risk of occupational injury is not homogeneously allocated into the hospital, and significatively prevails in the orthopaedic wards, in the plaster-rooms, in the operating blocks and in the sterilization plants. Specific manual handling were associated with an increased risk of back pain, while some non occupational factors like cigarette smoking, previous trauma leading to hospital admission, and number of children in female, were resulted weakly associated.

Adult↗
PubMed1991

Managing unofficial inventory: a piece of the materiel management foundation.

The implementation plan will remain the same: target an area of opportunity, measure and document the amount and value of the unofficial inventory, establish PAR levels, implement the use of hand-held terminals to assist in inventory control, and integrate inventory control with the implementation of new programs that will impact ordering, receiving, distribution, and invoicing. It is anticipated that the inventory in the main OR alone can be reduced by $1.5 million if we move forward with a stockless JIT system. This would reduce the days of inventory on hand from approximately 100 days to between 7 and 14 days. This could also mean a holding cost reduction of $150,000. The merit of reducing unofficial inventory is evident. Managing unofficial inventory is merely one piece of the successful materiel management foundation. The other foundation pieces include contract compliance and price negotiations, systematic methods of ordering products, and timely distribution of products to the end user. PHS cannot effectively move forward to a new, innovative materiel system for the future until we first measure, analyze, and document the present conditions. Once the foundation is laid by improving present business practices, then the framework of the structure can be designed and constructed. The goal is to implement a system that utilizes the full potential of people, equipment, logistics, and information so that our customers, the patient caretakers, do not have to worry about anything except the delivery of quality care.(ABSTRACT TRUNCATED AT 250 WORDS)

Electronic Data Processing↗
PubMed1990

Image processing by computer analysis--potential use and application in civil and criminal litigation.

The image processing by computer analysis has established a data base for applications in the industrial world. Testing has proved that the same system can provide documentation and evidence in all facets of modern day life. The medicolegal aspects in civil and criminal litigation are no exception. The primary function of the image processing system is to derive all of the information available from the image being processed. The process will extract this information in an unbiased manner, based solely on the physics of reflected light energy. The computer will analyze this information and present it in pictorial form, with mathematical data to support the form presented. This information can be presented in the courtroom with full credibility as an unbiased, reliable witness. New scientific techniques shown in the courtroom are subject to their validity being proven. Past imaging techniques shown in the courtroom have made the conventional rules of evidence more difficult because of the different informational content and format required for presentation of these data. I believe the manner in which the evidence can now be presented in pictorial form will simplify the acceptance. Everyone, including the layman, the judge, and the jury, will be able to identify and understand the implications of the before and after changes to the image being presented. In this article, I have mentioned just some of the ways in which image processing by computer analysis can be useful in civil and criminal litigation areas: existing photographic evidence; forensic reconstruction; correlation of effect evidence with cause of evidence; medical records as legal protection; providing evidence of circumstance of death; child abuse, with tracking over time to prevent death; investigation of operating room associated deaths; detection of blood at the scene of the crime and on suspected objects; use of scales at the scene of the crime; providing medicolegal evidence beyond today's technology; and a new theory and technique on using polygraph information in litigation. I am sure that the professionals in the forensic field will be able to think of many more applications where the image processing by computer analysis tool will be able to provide solutions to complex problems. The next time you say to yourself, "I wish they would have preserved this," or, "It's too bad they didn't do an autopsy," think of this new tool that is available to help you get the documentation and answers that will stand up to the scrutiny of the civil and criminal litigation system.

Accidents, Traffic↗
PubMedDate not supplied

Management of shotgun wounds: do we need classification systems?

BACKGROUND: Shotguns cause a wide variety of injuries, depending on the weapon-victim distance and the type of the gun and pellets. It has been suggested that the probability of significant internal injuries cannot be predicted using physical examination alone, and several wound classification systems have been proposed to facilitate clinical decision-making. OBJECTIVE: To evaluate the sensitivity of clinical examination and assess the role of a new classification system to detect significant injuries caused by shotguns. PATIENTS AND METHODS: The medical records of 56 consecutive patients admitted to a Level I trauma center with shotgun wounds from January 1994 to December 1996 were reviewed. Clinical examination was the main tool to select patients for emergency operation or nonoperative management. Wounds were classified by the number of body areas (abdomen, chest, head and neck, extremities) involved: grade I involved more than two areas, grade II two adjacent areas, and grade III one area. RESULTS: Twelve patients had type I wounds, 25 had type II wounds, and 19 had type III wounds. Nineteen major operations for intrathoracic, intra-abdominal or peripheral vascular injuries were done on 16 patients, as well as 10 orthopedic, ophthalmological and urological procedures and three emergency room thoracotomies,. No differences were found in the incidence of operations, morbidity, mortality, or length of hospital stay among the three groups. Clinical examination was 100% sensitive and 93% specific in identifying the presence of significant organ injuries and need for emergency operation. Three patients had unnecessary abdominal explorations because they received anesthesia for other procedures and could not be reliably followed up clinically. CONCLUSIONS: Clinical examination is the most reliable tool to identify patients who require emergency operation after shotgun wounds. Classification systems provide only crude information and do not predict reliably the presence of significant internal injuries.

Adolescent↗
PubMed2003

[Modern operating room management in the workflow of surgery. Spectrum of tasks and challenges of the future].

The operating unit is one of the cost-intensive facilities in a surgical clinic with a pacemaking function for most of the internal procedures. The power of performance of the operating unit is based on the cooperation of all disciplines and professions involved. The key to management of the operating unit is not only to coordinate the daily procedures, but also to interact with support personnel. To ensure successful OR management, the internal structure of the OR must fit the clinical tasks and the available quantity of personnel in each profession must be coordinated. Sufficient utilization of resources and equipment must be guaranteed without cost-intensive over-capacities and patient flow must be orientated to OR capacities. The development of such a business structure requires the management to clearly define the goal, to know the actual on-site data in detail with regard to the idiosyncratic workings of each specialty and to clearly assign the competence of each member of the team working in the OR. Coordination of the operating unit is the main task of OR management, which must ensure the following: transparent and coordinated schedule management in the various operative specialties, goal-directed changes of the schedule with incorporation of emergencies, as well as effective organization of staff. In order to realize these tasks, it is reasonable to implement interdisciplinary rules of procedures. In addition, the assignment of a neutral decision-making body within the OR and the creation of an information center for all OR personnel. The challenge of OR organization in the future is to implement more effective documentation systems and active controlling within the OR. One can ensure adequate utilization of resources in the OR with prospectively oriented planning. Better transparency of operations in the OR contributes to increased efficiency. Implementation of quality management is the foundation for a successfully operating surgical hospital. Not only the productivity of individual members of the staff, but also the precise documentation of the quality of results will become important parameters in a successful surgical hospital, whose nucleus is the OR.

Appointments and Schedules↗
PubMed1987

Postoperative complications: factors of significance to anaesthetic practice.

In an attempt to define what factors are important to the development of postanaesthetic complications, the data from a nine-year prospective study of anaesthetic practice in a large tertiary care institution were evaluated. A model of anaesthetic morbidity dependent upon factors of patient illness, surgical practice, anaesthetic technique and physician experience, and duration of anaesthesia was developed. Postoperative anaesthetic morbidity was defined as any anaesthetic-related complication which, in the opinion of the follow-up nurse, was associated with prolonged hospitalization or documented compromise of the patient. Using a multiple logistic regression, ASA physical status was a risk factor for postoperative complications (odds ratio = 1.95) but the number of preoperative conditions and age were not. The type of surgical procedure, classified by site or by degree of trauma, did not influence postanaesthetic complication rates. The duration of anaesthetic exposure was an important determinant of risk (odds ratio = 2.53), with complications increasing with the length of anaesthetic time. As to factors under control of the anaesthetist those patients experiencing operating room complications (odds ratio = 3.36) or those receiving pure spinal (odds ratio = 5.53) or narcotic techniques (odds ratio = 2.14) had higher risks of postoperative complications. Finally, it would appear that the greater the experience of the anaesthetist the less the risk of postoperative problems (odds ratio = 0.52).

Anesthesia↗
PubMed2002

Overseeing organizations: configuring action and its environment.

Despite the widespread deployment of CCTV through most major cities and towns in great Britain, and the importance of surveillance to contemporary debates within the social sciences, there remains relatively little detailed research concerned with the practical use of these technologies in the workplace. In this paper, we examine how personnel in the operation rooms in London Underground use CCTV and related equipment to identify problems and events and to develop a co-ordinated response. In particular, we consider how personnel configure scenes to make sense of and interpret the conduct of the travelling public in organizationally relevant ways, and how they shape the ways in which both passengers and staff see and respond to each others' actions. In addressing how personnel constitute the sense and significance of CCTV images, we reflect on the development of information processing systems which are designed to automatically detect conduct and events.

Humans↗
PubMed1996

The interactive use of magnetoencephalography in stereotactic image-guided neurosurgery.

OBJECTIVE: To expand the use of magnetoencephalography (MEG) functional mapping in the operating room as well as preoperatively, a method of integrating the MEG sensorimotor mapping information into a stereotactic database, using computed tomographic scans, magnetic resonance imaging scans, and digital angiography, was developed. The combination of functional mapping and the stereotactic technique allows simultaneous viewing of the spatial relationship between the MEG-derived functional mapping, the radiological/structural anatomic characteristics, and the pathological abnormality. METHODS: MEG data were collected using a MAGNES II Biomagnetometer and were incorporated into the COMPASS frame-based and REGULUS frameless stereotactic systems. The transformation process, by calculating a translational vector and a rotation matrix, integrates functional and anatomic information that is then directly available intraoperatively in the stereotactic database. This procedure was employed in 10 patients undergoing computer-assisted stereotactic volumetric resections for lesions involving the sensorimotor cortex. The principles of coregistration and coordinate transformation are reviewed in the context of preoperative functional mapping. We introduce innovations to apply these techniques to intraoperative stereotactic systems. RESULTS: Tests of the accuracy of the intraoperative integration of functional information in patients and calibration phantoms indicated close agreement with earlier preoperative methods. The intraoperative availability of functional information was a significant aid to the surgeon because it provided more accurate information on the location of functional tissue than could be derived solely by radiological criteria. CONCLUSION: The real-time availability of functional mapping information in an interactive fashion can reduce surgical risk and minimize functional morbidity. Within the ever-expanding realm of functional mapping and image-guided neurosurgery, further progress and integration of these methods is critical for resection of lesions involving eloquent cortex.

Adult↗
PubMed1992

Invasive and noninvasive cardiovascular imaging in the child and fetus.

The imaging technologies available for evaluating congenital cardiac disorders continue to evolve. In noninvasive areas such as color Doppler echocardiography, more sophisticated questions are being asked of the techniques: investigators want not just diagnostic information about the fetus or newborn, but fundamental predictors of prognosis. An improved understanding of the tradeoffs between magnetic resonance imaging and echocardiography for pediatric patients has evolved, and ultrasound technology has invaded invasive areas such as the operating room (with transesophageal echoscopes) and the catheterization laboratory, where it is used to guide therapeutic catheterizations; and angiography. Lastly, the newest technique, intravascular imaging, now appears applicable for pediatric patients and may yield new insights about interventional catheterization procedures, as well as about changes in the circulatory system in preoperative or postoperative congenital heart disease patients.

Cardiac Catheterization↗
PubMed1990

[Analysis of data management in anesthesia from an ergonomic viewpoint].

In the perioperative phase the anesthetist has to manage an increasing amount of knowledge, information and data. Using a system-ergonomic approach we can define three types of data management (DM): Exploratory DM, Operative DM, Concluding DM. The preliminary examination of the patient is Exploratory DM. Data are collected and recorded. Here, a well structured form prevents things being forgotten, provides forgetting anything. Help from electronic devices is not available. Control of anaesthesia is based on Operative DM. The anesthetist is part of an ongoing process. He investigates and records a situation based on his knowledge and experience and a prompt reaction to untoward circumstances may be necessary. Today's workplace provides insufficient support for this task. Data presentation is unstructured and distributed around the workplace which produces potentially dangerous overloading in critical situations. It is necessary to view the work layout as an integrated whole. The data being displayed must be hierarchically structured and appropriate to the situation. Concluding DM involves summarising data and information on completion of a process in ways appropriate to specific purposes. With this the anesthetist completes an anaesthesia and transfers the patient to the next unit, e.g. to the recovery room. He has to fill in several forms for clinical and statistical reasons. Electronic aids are available only for parts of some tasks. The goal should be a multifunctional summary satisfactory for clinical and statistical purposes, most aspects of which are created automatically by a computer system.

Anesthesiology↗
PubMed1999

Medical record innovations that can improve physician productivity.

Medical records are the fulcrum of patient care activities. They represent the primary reference point with respect to the patient's medical status and long-term planning. A significant portion of the patient care dollar is invested in the medical record document and its handling. The most critical part of this process takes place in the physician's examination room during the patient encounter. The use of SmartCharts is a way to expedite the chart generation process and improve the quality and consistency of the source information from which all future care and plans are generated. The process removes a substantial portion of the human memory cycle that is needed for chart development and improves the encounter process by exploring the full range of diagnostic signs and symptoms that are associated with a preselected diagnosis or patient problem. The system is designed for stand-alone operation or insertion into an already-functioning electronic medical record system.

Decision Support Systems, Clinical↗
PubMed1997

Emergency Health Care Information System for Bucharest-Romania.

The Emergency Health Care Information System (EHCIS) in Bucharest provides information about the whole activity of Dispatch Emergency Ambulance Service and Emergency Receiving Room of the 7 Hospitals, providing emergency health care in Bucharest over a MAN (Metropolitan Area Network). In each of these places a local network is located, containing a database server ORACLE. The link among LANs is made via switched lines. The Hospitals collect information only about emergency cases. The microstation represents station for emergency teams of Emergency Ambulance Service of Bucharest (EASB), distributed in all 6 districts of Bucharest. The system is structured accordingly with the working-groups existing in Dispatch, microstations and hospitals: registration operators (phone-operators) for administer the emergency requests/calls; a location for the medical coordinator which must to choose, in few seconds, the emergency team, accordingly with the case emergency degree; radio-operators which communicate with the teams in the field; a location for the manager of Dispatch, in order to provide a full-set of real-time medical and resources information; a registration operator at each microstation; a registration operator at each hospital. The data are registered in the ORACLE database on the central server. The client/server architecture assures the real time communication among all these locations. The system works 7 days/week, 24 hours/day.

Ambulances↗
PubMed1976

Theatre utilization analysis.

A method of analysing operating theatre utilization is presented as a management information system applicable to medical administration.The operating theatre plant represents an item of considerable expenditure in a hospital budget. This aspect of hospital activity requires maximized utilization to ensure an appropriate cost benefit. Extraction of information in such a form provides a basis for exact comparisons of performance of the personnel involved and determining needs for additional resources.

Hospital Records↗