Ten years Siriraj’s experience of wound infection rate at the third post-operative day or the day of discharge in appendicitis pediatric patients.

Objective: Primary: To find the wound infection rate at the third postoperative day 3 or the day of discharge from Siriraj Hospital, Bangkok, Thailand. Secondary: To find factors that might cause postoperative wound infection: age, body weight, mean time of the first wound dressing, duration of abdominal pain before operation, pre-diagnosis antibiotic administration, duration of anesthesia and operation, and type of suture material. Methods: Retrospective reviews of medical records of the division of pediatric surgery diagnosed appendicitis from 1997-2006 were used to form the study group. Data collected included personal profile, abdominal pain before diagnosed appendicitis, medication used before being diagnosed, type and duration of preoperative antibiotics, operative time, time in operating room, length of stay, time of the first dressing after operation, and wound infection were collected. Data were collected to be analyzed for descriptive and analytic method between the wound infection group and the no wound infection group and between the complicated (ruptured or gangrenous) appendicitis and the non complicated (acute or acute suppurative) appendicitis groups. Results: There were 433 patients. Appendectomy wounds were opened in the third operative day or the day of discharge in 109 patients. Two wound separations, 1 wound infection and 8 wounds that had discharge were found. The average time of first wound dressing after operation was 64.31 hours. Three out of 4 wound infections were diagnosed after discharge from the hospital. The average time in the operating room was longer in the wound infection group compared with the uninfected group (P = 0.042). Patients with complicated appendicitis had more incidence of wound infection than patients with non complicated appendicitis (P = 0.015). Compared between the non complicated and the complicated appendicitis group, the age and bodyweight of the complicated group were lower than the other group (P = 0.009 and 0.05, respectively). Patients with complicated appendicitis had a longer duration of abdominal pain before being diagnosed with appendicitis and a longer length of stay (LOS) (P <0.001). Conclusion: Wound infection is rarely diagnosed at the third operative day or the day of discharge. Complications from wound dressing, including wound separation and psychological problems, were more common than the wound infection that was detected at that time. Patients with the wound infection spent a longer time in the operating room. The patients with complicated appendicitis were younger and had a lower bodyweight. They had a longer duration of abdominal pain before admission, had a longer length of hospital stay, and had more incidence of wound infection compared with the non complicated group.

The cost analysis using the clinical practice guideline and cost minimization analysis in orthopaedic inpatients under universal coverage policy admitted to Siriraj Hospital.

Objective: The hospital revenues are decreasing from the government policy in the universal coverage while increasing the hospital expenses . The cost analysis is a very important tool for the strategic plan in the hospital expenses reduction with standard quality. This study wanted to investigate the cost of 12 orthopaedic diseases using the clinical practice guideline (CPG) at maximum length of stay (LOS) and to compare the cost before and after utilization management in cost minimization analysis in orthopaedic inpatients under the universal coverage policy. Methods: Part 1, The CPG with maximum LOS was studied in detail and the cost analysis was performed using the formula C = S+I+X+P+O+L+A+R while C = unit service cost/case, S = service cost, I = instrument cost, X= X-ray cost, P = prosthetic cost, O = operating cost, L = laboratory cost, A = anesthetic cost, R = recovery room cost. Part 2, the cost minimization analysis (CMA) before and after utilization management was studied in 2 groups. Group A consisted of 236 cases which were studied after utilization management from June 1, 2003 to February 24, 2005. Group B consisted of 89 cases from June 1, 2002 to May 31, 2003 which were studied before utilization management was introduced in the department. The cost of both groups were compared. Results: The cost of the 12 orthopaedic diseases ranged from 13,036.10 baht/case for 3 days LOS in club foot surgery to 99,532.73 baht/case for 21 days LOS in total hip replacement surgery. The reduction of 1 day LOS reduces the service cost by an average 1,844.26 baht. The CMA found that after utilization management in group A, the CMA in the average cost reduction was 3,274.45 baht/case with an average 2.07 days reduction in length of stay. Both groups had the same outcomes. Conclusion: The cost analysis was done in 12 orthopaedic diseases using CPG. The usefulness with cost reduction was found after implementation of utilization management.

Medical utilization review by indicators “ORTHOPAEDICS” in orthopaedic inpatients under universal coverage policy admitted to Siriraj Hospital.

Objective: Utilization review is very important especially in universal coverage policy. In Siriraj Hospital the utilization review began in 2002, and the Department of Orthopaedic Surgery developed the indicators “ORTHOPAEDICS” to assess the appropriateness of medical utilization. This study is designed to study the effectiveness of medical utilization review by using indicators “ORTHOPAEDICS” in orthopaedics, public inpatients under universal coverage policy in terms of expenses, the appropriateness, length of hospital stay and the satisfaction of the patients. Methods: 301 orthopaedic inpatients were divided in 2 groups: Group A included 149 patients, 100 men and 49 women. Their average age was 32.7 years old. From June 1, 2003 – May 31, 2004, each patient was prospectively reviewed regarding their daily utilization in terms of expenses, appropriateness of medical utilization by using indicators “ORTHOPAEDICS”. Their length of hospitalization was measured, as well as and their satisfaction evaluated. Group B was the control which included 152 patients, 98 men and 54 women. Their average age was 34.8 years old. No intervention was performed and the data was collected only in expenses and the length of hospital stay for each patient retrospectively from June 1, 2002– May 31, 2003. The expenses and the length of hospital stay of both groups were compared and analyzed. The appropriateness in Group A was studied by using indicators “ORTHOPAEDICS” which were: O = Operation; R = Relative weight rate; T = Type of treatment; H = Hospital stay; O = Occurrence of complication; P = procedures; A = admission; E = expenses; D = drugs; I = Investigation; C = Care map according to CPG of 12 diseases; S = Satisfactions score from 0-10 minimum to maximum, by asking the patients about the satisfaction in term of results of treatment. Results: The total expenses per patient in group A was 24,566.74 baht but in group B was 30,484.53 baht. The expense in group A was 5,917.79 baht reduction which was statistically significant difference (P<0.05). The average length of hospital stay in group A was 8.24 days, whereas in group B was 10.93 days. It reduced 2.69 days after utilization review was implemented. The appropriateness of utilization was found in the procedures, drugs and investigation without inappropriateness (0%). The inappropriateness in admission was 26.9% because the physician forgot to take blood examination and laboratory investigation before admission and it was done in the ward without any effect the treatment. And the average satisfaction score in group A was 9.6. Conclusion: “ORTHOPAEDICS” was useful and helpful indicator to significantly reduce the expense per patient and the length of hospitalization without reducing patient satisfaction and quality of treatment.