Implementation of an acute care emergency surgical service: a cost analysis from the surgeon's perspective.

BACKGROUND: Acute care surgical services provide comprehensive emergency general surgical care while potentially using health care resources more efficiently. We assessed the volume and distribution of emergency general surgery (EGS) procedures before and after the implementation of the Acute Care and Emergency Surgery Service (ACCESS) at a Canadian tertiary care hospital and its effect on surgeon billings. METHODS: This single-centre retrospective case-control study compared adult patients who underwent EGS procedures between July and December 2009 (pre-ACCESS), to those who had surgery between July and December 2010 (post-ACCESS). Case distribution was compared between day (7 am to 3 pm), evening (3 pm to 11 pm) and night (11 pm to 7 am). Frequencies were compared using the χ(2) test. RESULTS: Pre-ACCESS, 366 EGS procedures were performed: 24% during the day, 55% in the evening and 21% at night. Post-ACCESS, 463 operations were performed: 55% during the day, 36% in the evening and 9% at night. Reductions in night-time and evening EGS were 57% and 36% respectively (p < 0.001). Total surgeon billings for operations pre- and post-ACCESS were $281 066 and $287 075, respectively: remuneration was $6008 higher post-ACCESS for an additional 97 cases (p = 0.003). Using cost-modelling analysis, post-ACCESS surgeon billing for appendectomies, segmental colectomies, laparotomies and cholecystectomies all declined by $67 190, $125 215, $66 362, and $84 913, respectively (p < 0.001). CONCLUSION: Acute care surgical services have dramatically shifted EGS from nighttime to daytime. Cost-modelling analysis demonstrates that these services have cost-savings potential for the health care system without reducing overall surgeon billing.

CONTEXTE: La mise sur pied d'un service d'urgences chirurgicales permet d'offrir des soins de chirurgie générale d'urgence complets, tout en assurant une utilisation potentiellement plus efficiente des ressources en soins de santé. Nous avons évalué le volume et la distribution des interventions de chirurgie générale d'urgence (CGU) avant et après la mise sur pied d'un service de soins chirurgicaux d'urgence (SSCU) dans un hôpital de soins tertiaires canadien et mesuré son effet sur la facturation émise par les chirurgiens. MÉTHODES: Cette étude rétrospective cas­témoins réalisée dans un seul centre a comparé des patients adultes soumis à des interventions de CGU entre juillet et décembre 2009 (pré-SSCU) à ceux qui avaient subi une intervention chirurgicale entre juillet et décembre 2010 (post-SSCU). Nous avons comparé la distribution des cas entre les quarts de jour (de 7 heures à 15 heures), de soir (de 15 heures à 23 heures) et de nuit (de 23 heures à 7 heures). Nous avons utilisé le test χ2 pour comparer les fréquences. RÉSULTATS: Pendant la période pré-SSCU, 366 interventions de CGU ont été effectuées : 24 % durant le jour, 55 % durant la soirée et 21 % durant la nuit. Après la mise en place du SSCU, 463 opérations ont été effectuées : 55 % durant le jour, 36 % durant la soirée et 9 % durant la nuit. Les réductions observées au plan des CGU réalisées durant la nuit et la soirée ont été de 57 % et 36 %, respectivement (p < 0,001). La facturation totale soumise par les chirurgiens pour les interventions réalisées avant et après la mise en place du SSCU a été respectivement de 281 066 $ et de 287 075 $ : la rémunération a été de 6008 $ supérieure après la mise en place du SSCU, pour 97 cas additionnels (p = 0,003). L'analyse de modélisation des coûts a révélé qu'après la mise en place du SSCU, la facturation soumise par les chirurgiens pour les appendicectomies, les colectomies segmentaires, les laparotomies et les cholécystectomies a diminué de 67 190 $, 125 215 $, 66 362 $ et 84 913 $, respectivement (p < 0,001). CONCLUSION: Les services de soins chirurgicaux d'urgence ont considérablement modifié les interventions de CGU, les faisant passer des quarts de travail de nuit à ceux du jour. L'analyse de modélisation des coûts démontre que le SSCU recèle un potentiel d'économies pour le système de soins de santé sans réduire la facturation totale émise par les chirurgiens.

Nocturnal hemodialysis increases arterial baroreflex sensitivity and compliance and normalizes blood pressure of hypertensive patients with end-stage renal disease.

BACKGROUND: Impaired neural control of heart rate, elevated arterial stiffness, and hypertension place patients with end-stage renal disease (ESRD) at increased risk of cardiovascular mortality. Nocturnal hemodialysis (6 x 8 hours/week), a more intense program than conventional hemodialysis (3 x 4 hours/week), lowers blood pressure and restores brachial dilator responses to hyperemia and nitrates. METHODS: We hypothesized that nocturnal hemodialysis would increase arterial baroreflex sensitivity for heart rate of hypertensive ESRD patients by an afferent vascular mechanism. Ten consecutive hypertensive ESRD patients (age 42 +/- 4) (mean +/- SEM) receiving conventional hemodialysis were studied before and 2 months after conversion to nocturnal hemodialysis. Regression slopes relating RR interval responses to rises or falls in systolic blood pressure were averaged to derive spontaneous baroreflex sensitivity for heart rate for each patient, and the stroke volume/pulse pressure ratio was used to estimate total arterial compliance. RESULTS: Dialysis dose (Kt/V per session) increased from 1.2 +/- 0.05 to 2.1 +/- 0.1 (P < 0.05). Despite withdrawal of antihypertensive medications (from 2.9 to 0.1 drugs/patient), nocturnal hemodialysis lowered systolic blood pressure (from 143 +/- 4 to 120 +/- 6 mm Hg) (P= 0.001). Both baroreflex sensitivity (from 4.76 +/- 1.1 msec/mm Hg to 6.91 +/- 1.1 msec/mm Hg) (P= 0.04) and total arterial compliance (from 0.98 +/- 0.13 mL/mm Hg to 1.43 +/- 0.2 mL/mm Hg) (P= 0.02) were higher following conversion to nocturnal hemodialysis. Increases in baroreflex sensitivity correlated with increases in stroke volume/pulse pressure (r= 0.845, P= 0.002). CONCLUSION: These findings are consistent with the concept that nocturnal hemodialysis increases baroreflex sensitivity via greater afferent baroreceptor responsiveness to pulsatile pressure. A more favorable risk profile, due to enhanced baroreflex regulation of the circulation and vascular compliance, may translate into lower cardiovascular event rates in ESRD patients receiving nocturnal hemodialysis.

Early radiation-induced endothelial cell loss and blood-spinal cord barrier breakdown in the rat spinal cord.

Using a rat spinal cord model, this study was designed to characterize radiation-induced vascular endothelial cell loss and its relationship to early blood-brain barrier disruption in the central nervous system. Adult rats were given a single dose of 0, 2, 8, 19.5, 22, 30 or 50 Gy to the cervical spinal cord. At various times up to 2 weeks after irradiation, the spinal cord was processed for histological and immunohistochemical analysis. Radiation-induced apoptosis was assessed by morphology and TdT-mediated dUTP nick end labeling combined with immunohistochemical markers for endothelial and glial cells. Image analysis was performed to determine endothelial cell and microvessel density using immunohistochemistry with endothelial markers, namely endothelial barrier antigen, glucose transporter isoform 1, laminin and zonula occludens 1. Blood-spinal cord barrier permeability was assessed using immunohistochemistry for albumin and (99m)Tc-diethylenetriamine pentaacetic acid as a vascular tracer. Endothelial cell proliferation was assessed using in vivo BrdU labeling. During the first 24 h after irradiation, apoptotic endothelial cells were observed in the rat spinal cord. The decrease in endothelial cell density at 24 h after irradiation was associated with an increase in albumin immunostaining around microvessels. The decrease in the number of endothelial cells persisted for 7 days and recovery of endothelial density was apparent by day 14. A similar pattern of blood-spinal cord barrier disruption and recovery of permeability was observed over the 2 weeks, and an increase in BrdU-labeled endothelial cells was seen at day 3. These results are consistent with an association between endothelial cell death and acute blood-spinal cord barrier disruption in the rat spinal cord after irradiation.