Economic implications of an early postoperative enteral feeding protocol.

OBJECTIVE: To study the cost-effectiveness of an early postoperative feeding protocol for patients undergoing bowel resections. DESIGN: A nonrandomized, prospective, clinical trial. Surgeons elected to participate in the treatment arm before the study's outset. SUBJECTS/SETTING: Treatment (n = 66) and control (n = 159) patients were admitted to a nonprofit general teaching hospital in the Texas Medical Center for similar diagnoses and subsequent bowel resections during an 18-month period. INTERVENTION: Treatment patients who met specific inclusion criteria had a jejunal feeding tube placed during surgery. Tube feedings were initiated within 12 hours after surgery. Control patients who met the same inclusion criteria received usual care. OUTCOMES: A successful outcome was defined as a patient developing no postoperative infection. The average cost of a nosocomial infection is presented. Variable direct and total costs (fixed plus variable) are compared between patient groups. STATISTICAL ANALYSIS: Mean cost was adjusted for rate of success in each patient group according to an analytic model. The mean cost difference between groups was analyzed by independent-samples t tests. Nonparametric Mann-Whitney rank sum tests were used to determine the cost significance of a nosocomial infection. RESULTS: The average variable direct cost savings per successful treatment patient was $1,531, which required an additional variable cost of $108.30 for the dietitian's time. The protocol resulted in a total cost savings of $4,450 per success in the treatment group. CONCLUSION: An early postoperative enteral feeding protocol as part of an outcomes management program for patients undergoing bowel resection is cost-effective.

A case-control evaluation of treatment efficacy: the example of magnesium sulfate prophylaxis against eclampsia in patients with preeclampsia.

Randomized trials are the optimal approach for evaluations of treatment efficacy but may not always be feasible. We study the adequacy of the case-control design in evaluating efficacy in a situation where the investigated therapy, namely the administration of magnesium sulfate for the prevention of eclampsia in patients with preeclampsia, has a suspected strong protective effect. A total of 66 cases of eclampsia were ascertained from among deliveries occurring between 1977 and 1992 at two hospitals in Houston, Texas. Randomly selected preeclamptic controls were matched to cases based on hospital and month of delivery. Magnesium sulfate administration prior to seizure occurrence had a strong protective effect against eclampsia in patients with preeclampsia (OR, 0.02; 95% CI, 0.01-0.05). This protective effect remained when controls were stratified by the degree of severity of preeclampsia (mild-to-moderate OR, 0.03, 95% CI, 0.01-0.09 and severe OR, 0.005; 95% CI, 0.0005-0.04) and when cases were stratified by the timing of the first seizure (antepartum and intrapartum seizures OR, 0.01; 95% CI, 0.003-0.05 and postpartum seizures OR, 0.03; 95% CI, 0.005-0.15). The effect also remained after adjustment for other important predictors in a multivariate logistic regression model (OR, 0.11; 95% CI, 0.03-0.38). The results of this study are in support of a recent randomized trial on the efficacy of magnesium sulfate as a prophylactic agent against eclampsia. Although there are serious potential sources of bias in this study, the magnitude of the protective effect of magnesium sulfate minimizes the likelihood that this effect can be explained by bias. Observational studies could be appropriate complements or alternatives to randomized trials in situations where a strong treatment effect is expected.

Balloons, beds, and breakdown. Effects of low-air loss therapy on the development of pressure ulcers in cardiovascular surgical patients with intra-aortic balloon pump support.

There is limited research related to pressure ulcers in the ICU patient population and even less has focused on patients who have undergone cardiovascular surgery and IABP support. The objective of this article was to determine the incidence of pressure ulcers in the postoperative CVS patient with IABP support and to determine if LAL therapy was more effective in the prevention of pressure ulcers in this patient population. In a quasiexperimental design, a convenience sample of 36 adults was used. Patients who were placed on IABP support the day of surgery were enrolled into the study within 24 hours of admission to the cardiovascular recovery room. Data collection was daily for 4 days and continued if the patient developed a pressure ulcer. Final measurements were obtained on the day of hospital discharge. Instruments used were demographic data form, APACHE II, Patient Identification for Rotation Therapy, and the Braden Scale. The most common surgical patient in this pilot underwent aortocoronary bypass with IABP support. Pressure ulcers developed in 9 of 36 (25%) patients for a total of 17 ulcers. Patients who developed pressure ulcers were generally older, had a history of cerebrovascular disease, renal insufficiency, a higher APACHE II score, and Braden score of 9 on POD 1. In addition, these patients generally had a lower hemoglobin level, higher serum creatinine level, and an altered level of consciousness on POD 1. The results suggest that LAL therapy does make a difference in the prevention of pressure ulcers in the aortocoronary bypass patient with IABP support.