A pilot study of intensive intervention using a novel trismus device.

PURPOSE: Trismus secondary to head and neck neoplasm treatment impacts upon quality of life, nutrition, oral hygiene, and dentition. Current treatment options for trismus apply unquantified force to the jaw, and in many cases, the device costs are prohibitive. This study aimed to prospectively evaluate the impact of a novel trismus device. METHOD: This single arm cohort study prospectively evaluated the impact of a novel trismus device on maximal incisal opening (MIO), trismus-related function and quality of life scores. Seventeen patients diagnosed with trismus were recruited to undergo a 10-week program using a novel device. The effect of the intervention was assessed by comparing pre- vs post-intervention validated measures. RESULT: A significant improvement in MIO was observed post the 10-week intervention period (12.6 mm). This was associated with an improvement in patient reported trismus symptomology including quality of life, swallowing, speech, and jaw pain. CONCLUSIONS: This pilot study demonstrates the feasibility of a novel device in the treatment of trismus. Further evaluation of this device is warranted to assess efficacy, safety, and cost-effectiveness in a larger cohort with appropriate controls.

A 5-year time study analysis of emergency department patient care efficiency.

STUDY OBJECTIVES: We conducted a 5-year time study analysis of emergency department patient care efficiency. Our specific aims were (1) to calculate the main ED patient care time intervals to identify areas of inefficiency, (2) to measure the effect of ED and inpatient bed availability on patient flow, (3) to quantitatively assess the effects of administrative interventions aimed at improving efficiency, and (4) to evaluate the relationship between waiting times to see a physician and the number of patients who leave without being seen (LWBS) by a physician. METHODS: Seven 1-week ED patient flow time studies were conducted from September 1993 to July 1998 using identical study design and methodology. Patients presenting with complaints of chest pain, abdominal pain, vaginal bleeding, and extremity injury were included to represent the level of severity of patient conditions seen in our Los Angeles County hospital ED. The calculated time intervals representing the main phases of evaluation and treatment were (1) triage presentation to completion of registration, (2) completion of registration to ED treatment area entry, (3) ED treatment area entry to initial medical assessment, (4) triage presentation to initial medical assessment, (5) initial medical assessment to disposition order, and (6) disposition order to patient discharge from the ED. Total ED lengths of stay (LOS) were also calculated as overall measures of efficiency. Time intervals were compared depending on the availability of ED and hospital inpatient beds. The effects of administrative interventions on the specific time intervals were assessed. The relationship between the median waiting time to see a physician and the number of LWBS patients was evaluated. Administrative interventions were implemented by a special interdepartmental continuous quality improvement committee. Interventions were aimed at specific sources of delay and inefficiency identified by the time studies. RESULTS: Eight hundred twenty-six patients were included in the 7 time studies. The unavailability of ED and inpatient beds was associated with significant delays. There was a significant reduction of the median total ED LOS from 6.8 hours to 4.6 hours over the first 5 periods, presumably resulting from the administrative interventions. Median total ED LOS, however, increased from 4.6 hours to 6.0 hours during the last 2 periods, possibly as a result of an increase in our ED patient census and reductions in both nursing and physician staffing imposed by the recent Los Angeles County fiscal crisis. The number of LWBS patients was closely correlated to waiting time to see a physician ( r =0.79, beta=5.20, P =.033). CONCLUSION: Time studies are an effective method of identifying areas of patient care delay. In our ED, targeted administrative interventions apparently reduced the total ED LOS and improved overall efficiency. Despite initial decreases in ED LOS, efficiency appeared to be adversely affected by reductions in nursing and physician staffing and increases in our patient census. The strength of the relationship between waiting times to see a physician and the number of LWBS patients suggests that decreasing waiting times may reduce the number of LWBS patients.

The effect of surgical theatre head-gear on air bacterial counts.

The wearing of disposable head-gear in operating theatres is currently recommended for scrubbed and non-scrubbed staff. However, there is little evidence of its effectiveness as an infection control measure in casual or non-scrubbed theatre staff. The effect of head-gear on bacterial air counts was studied, using six volunteers, in a sealed room, with and without ventilation. Using a Casella slit sampler and a SAS Air Sampler, air counts ranged from 0.08 to greater than 2.9 colony forming units (cfu) m-3. The wearing of head-gear was not associated with a reduction in air counts but counts were lower with ventilation. We recommend that non-scrubbed staff no longer wear head-gear as effective ventilation probably counteracts any possible increased bacterial shedding. Scrubbed staff should continue to wear disposable head-gear because of their proximity to the operative field.

Theatre over-shoes do not reduce operating theatre floor bacterial counts.

Occasional staff or visitors to operating theatres are usually requested to don over-shoes as this is perceived to reduce bacterial floor colony counts. However, this entails some expense and considerable inconvenience. Using disposable surface contact plates floor bacterial counts were measured four times a day at five different sites during the 5 normal working days of one 2-week period in a general operating theatre when over-shoes were worn and one 2-week period when over-shoes were not worn. There was no significant difference in the mean bacterial floor colony counts between the two periods according to sampling times or sites. As in Intensive Therapy units, over-shoes should no longer be used in general operating theatres.