Diagnosis related groups and the critically injured.

We reviewed the records of 59 patients with trauma treated in the surgical intensive care unit in 1983 to attempt to identify a diagnosis related group (DRG) modifier in order to eliminate major losses which would be incurred in caring for the critically injured. There were 22 females and 37 males. Payment based upon a DRG system would have resulted in hospital losses for the following subgroups: surgical treatment (n = 44) $1,348,009; no operation (n = 15) $125,085; length of stay (LOS) of more than ten days (n = 35) $1,124,778; LOS equal to or less than ten days (n = 24) $348,316; nonsurvivors plus LOS equal to or less than ten days plus operation (n = 12) $269,778, and survivor plus LOS greater than ten days plus operation (n = 29) $1,022,284. No useful modifier was identified for these subgroups using regression analysis. We believe that some immediate DRG modifier, based upon the total hospital charges (or costs if known) relationship to total DRG payments, should be created until further refinements in payment systems evolve. If some correction is not attempted, the considerable disadvantage which would result to participating hospitals may result in curtailing availability of effective long term intensive care unit trauma care at a time when the public is becoming aware of trauma systems and the improvement in survival seems to be a realizable goal.

The role of splenorrhaphy in splenic trauma.

Eighty-five cases of splenic trauma that were treated surgically from 1981 to 1983 were reviewed to define the exact role of splenorrhaphy. There were 73 male and 12 female patients with a mean age of 34 years. The mechanism of injury was blunt trauma in 51 and penetrating trauma in 34. The incidence of associated intraabdominal injury was 31 per cent and 79 per cent in blunt and penetrating trauma, respectively. Splenectomy was performed in 43 (51%) and splenorrhaphy in 42 (49%). Splenorrhaphy was performed in 19 (37%) who had blunt trauma and 23 (67%) who had penetrating trauma (P less than 0.01). Overall six patients died, three in the splenorrhaphy group (7.1%). Only one patient who had splenorrhaphy required reoperation for splenic hemorrhage. The authors conclude that about 50 per cent of all injured spleens in the patient population studied can be salvaged during laparotomy for splenic trauma, the splenic salvage rate is higher in penetrating trauma, and splenorrhaphy is a safe operation.

Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment.

In order to reassess the value of diagnostic peritoneal lavage (DPL) in patients with blunt abdominal trauma, we conducted a prospective study over a 15-month period involving 138 patients. There were 29 (28.3%) patients with positive DPL and 103 (71.7%) with negative DPL in this series. Of the 29 patients with positive DPL, 28 (96.5%) were found to have significant intra-abdominal injuries; 27 by exploratory laparotomy and in one case at autopsy. One patient with a grossly positive DPL had a negative exploratory laparotomy (3.4% false positive rate). All 109 patients with negative DPL were admitted. In only one case a significant intra-abdominal injury was demonstrated (0.9% false negative rate). The overall mortality in this series was 11.6% and there were no complications related to the DPL. Our results suggest that DPL is indeed an accurate indicator of significant intra-abdominal injuries in patients with blunt abdominal trauma.

Diagnosis-related groups and the salvagable trauma patient in the intensive care unit.

We reviewed 59 patients with trauma treated in the surgical intensive care unit (SICU) in 1983 comparing hospital charges with payments calculated from diagnosis-related groups (DRG). There were 37 male and 22 female patients with a mean age of 38.3 years. The mechanism of injury was blunt trauma in 42 and penetrating injury in 17 patients. The mean injury severity score (ISS) was 30.7 +/- 13.8 (mean plus or minus standard deviation). The duration of SICU care was 5.4 +/- 6.1 days. Over-all, 18 patients died. For the entire group, payment based upon a DRG system would have resulted in an over-all loss of $1,468,094.00 or $24,883.00 dollars per patient. Calculated DRG payments would have accounted for only 32.3 per cent of the total hospital charges. Calculated losses for 41 survivors would have been $1,098,431.00 dollars. Length of stay had a significant relationship to the calculated DRG payment (r = 0.69, p less than 0.001) but account for only 48 per cent of the variance. DRG only accounted for 26 per cent of the variance in charges despite a statistically significant relationship (r = 0.51, p less than 0.001). No statistically significant relationship was found between ISS and hospital charge by linear regression (r = 0.20, p greater than 0.01) or between ISS and DRG payment (r = 0.14, p less than 0.4). DRG as presently formulated would only pay one-third of total hospital charges for patients with trauma requiring SICU care. Present DRG payment schedules reflect neither the elements of care currently expended nor the modifiers necessary to adjust for acuity and severity. The ISS score would not be a useful modifier to correct DRG payment in this high cost group.

A prospective randomized study of moxalactam versus gentamicin and clindamycin in penetrating abdominal trauma.

We conducted a randomized, prospective study of moxalactam versus gentamicin plus clindamycin in 42 patients with penetrating abdominal trauma. Patients were randomized to receive intravenously either 2 grams of moxalactam every 12 hours or 80 milligrams of gentamicin every eight hours and 600 milligrams of clindamycin every six hours. Antibiotics were administered preoperatively and continued for a minimum of five days if hollow viscus injury occurred. For those without hollow viscus injury, only those patients receiving a minimum of three days of antibiotics were evaluated. A single intramuscular dose of 10 milligrams of vitamin K was also administered to all patients in the moxalactam group. There were 39 males and three females with a mean age of 33 years. Twenty patients received moxalactam and 22 received gentamicin plus clindamycin. The mechanism of injury was gunshot wound in 32 patients and stab wounds in ten patients. Eight patients in each group sustained injuries to the small intestine or colon, or both. The mean injury severity score was 22.6 and 21.2 in the single and double antibiotic regimen, respectively. The mean duration of antibiotic therapy was 5.8 and 7.0 days in the single and double antibiotic group, respectively. No infectious complications occurred in the moxalactam group whereas five infections occurred in four patients in the gentamicin plus clindamycin group (p less than 0.05). These infections included one intra-abdominal abscess, two wound infections and two episodes of necrotizing fasciitis of the wound and abdominal wall. There were no complications attributable to moxalactam therapy. The over-all mortality rate was zero per cent. The total pharmacy cost of a five day course of moxalactam plus a single dose of vitamin K is $204.67 compared with $226.00 for a similar course of gentamicin plus clindamycin. We conclude that: moxalactam is at least, if not more, effective in preventing infectious complications after penetrating abdominal trauma compared with gentamicin plus clindamycin; moxalactam is safe in the doses used when combined with vitamin K, and 3, moxalactam is more cost-effective than gentamicin plus clindamycin dual antibiotic therapy.