Small bowel obstruction managed without hospital admission: A safe way to reduce both cost and time in the hospital?

BACKGROUND: Small bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes. METHODS: We reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission. RESULTS: In total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18). CONCLUSION: Management of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.

Survey of medical center employees' willingness and availability to donate blood in support of a civilian warm fresh whole blood program.

OBJECTIVES: In military settings, utilizing warm fresh whole blood (WFWB) was associated with reduced mortality; however, there are multiple challenges for administering WFWB to civilians. The authors aimed to determine barriers to hospital employees emergently donating to civilian WFWB programs. METHODS: We surveyed hospital employee willingness to donate emergently, familiarity with blood donation, and queried baseline demographics. The electronic survey was disseminated to a random sample of employees. Descriptive and univariate analyses were performed. RESULTS: Three thousand surveys were sent; 883 were returned (28 percent). The majority of respondents were female (n = 630, 71 percent). Respondent familiarity with WFWB donation included very/somewhat familiar (n = 381, 43 percent) and somewhat-not/not-at-all familiar (n = 356, 40 percent). Most were definitely or somewhat willing to emergently donate (n = 660, 75 percent). Four hundred and sixty would drive from home to donate (52 percent). The majority worked day-time shifts (n = 754, 85 percent). In regards to donation history, 366 (41 percent) had donated blood more than ten times, but 138 (16 percent) had never donated. Barriers to emergent donation were identified (55 percent), with the most common being childcare responsibilities (n = 242; 27 percent). CONCLUSIONS: Hospital employees are willing to donate WFWB emergently, but program implementation must address donor availability and logistical barriers. Future research should assess feasibility of a civilian WFWB program by determining regulatory challenges, development of a quality system for emergency donations, assessment of optimal workforce structure, potential impact to the general blood inventory, as well as patient and community perspectives regarding untested blood units.

Autonomic and Enteric Nervous System Dysfunction May Play a Role in Hyperemesis Gravidarum.

BACKGROUND: Nausea and vomiting, seen in 70-85% of all pregnancies, becomes intractable in hyperemesis gravidarum (HG). We aimed to investigate the relationship between HG and autonomic nervous system functioning and gastric electrical activity. METHODS: Twenty-seven pregnant patients, 21 with HG and six normal, were studied with sympathetic adrenergic; percent vasoconstriction (%VC) and postural adjustment ratio (PAR); parasympathetic vagal cholinergic functions by R-to-R intervals (RRIs), a total autonomic score; and enteric nervous system measured by electrogastrography (EGG). RESULTS: Significant differences were found in parasympathetic measures (RRI for HG 29.98 ± 2.95 vs. control 40.91 ± 2.38, P < 0.05); sympathetic PAR was significantly lower in patients (PAR for HG 24.5 ± 5.0 vs. 67.6 ± 11.4 for controls, P < 0.01); mean total autonomic score was significantly lower in HG (131.75 ± 9.61 vs. 196.87 ± 12.8, P < 0.05). EGG results were borderline different (normal < 3.3, HG 3.4 vs. controls 3.0, P = 0.07). CONCLUSION: Autonomic and enteric nervous system dysfunction may play a role in the pathophysiology of HG.