Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 20
Filtrar
1.
J Trauma Acute Care Surg ; 88(4): 486-490, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32213787

RESUMO

BACKGROUND: With the recent birth of the Pennsylvania TQIP Collaborative, statewide data identified unplanned admissions to the intensive care unit (ICU) as an overarching issue plaguing the state trauma community. To better understand the impact of this unique population, we sought to determine the effect of unplanned ICU admission/readmission on mortality to identify potential predictors of this population. We hypothesized that ICU bounceback (ICUBB) patients would experience increased mortality compared with non-ICUBB controls and would likely be associated with specific patterns of complications. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2012 to 2015 for all ICU admissions. Unadjusted mortality rates were compared between ICUBB and non-ICUBB counterparts. Multilevel mixed-effects logistic regression models assessed the adjusted impact of ICUBB on mortality and the adjusted predictive impact of 8 complications on ICUBB. RESULTS: A total of 58,013 ICU admissions were identified from 2012 to 2015. From these, 53,715 survived their ICU index admission. The ICUBB rate was determined to be 3.82% (2,054/53,715). Compared with the non-ICUBB population, ICUBB patients had a significantly higher mortality rate (12% vs. 8%; p < 0.001). In adjusted analysis, ICUBB was associated with a 70% increased odds ratio for mortality (adjusted odds ratio, 1.70; 95% confidence interval, 1.44-2.00; p < 0.001). Adjusted analysis of predictive variables revealed unplanned intubation, sepsis, and pulmonary embolism as the strongest predictors of ICUBB. CONCLUSION: Intensive care unit bouncebacks are associated with worse outcomes and are disproportionately burdened by respiratory complications. These findings emphasize the importance of the TQIP Collaborative in identifying statewide issues in need of performance improvement within mature trauma systems. LEVEL OF EVIDENCE: Epidemiological study, level III.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Doenças Respiratórias/epidemiologia , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Pennsylvania/epidemiologia , Doenças Respiratórias/etiologia , Doenças Respiratórias/terapia , Estudos Retrospectivos , Fatores de Risco , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade
2.
J Intensive Care Med ; 35(10): 936-942, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31916876

RESUMO

In recent years, there has been an emphasis on evaluating the outcomes of patients who have experienced an intensive care unit (ICU) readmission. This may in part be due to the Patient Protection and Affordable Care Act's Hospital Readmission Reduction Program which imposes financial sanctions on hospitals who have excessive readmission rates, informally known as bounceback rates. The financial cost associated with avoidable bounceback combined with the potentially preventable expenses can result in unnecessary financial strain. Within the hospital readmissions, there is a subset pertaining to unplanned readmission to the ICU. Although there have been studies regarding ICU bounceback, there are limited studies regarding ICU bounceback of trauma patients and even fewer proven strategies. Although many studies have concluded that respiratory complications were the most common factor influencing ICU readmissions, there is inconclusive evidence in terms of a broadly applicable strategy that would facilitate management of these patients. The purpose of this review is to highlight the outcomes of patients readmitted to the ICU and to provide an overview of possible strategies to aid in decreasing ICU readmission rates.


Assuntos
Resultados de Cuidados Críticos , Unidades de Terapia Intensiva/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Insuficiência Respiratória/terapia , Ferimentos e Lesões/terapia , Fatores Etários , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Patient Protection and Affordable Care Act , Avaliação de Programas e Projetos de Saúde , Recidiva , Insuficiência Respiratória/etiologia , Fatores de Risco , Estados Unidos/epidemiologia , Ferimentos e Lesões/complicações
3.
J Surg Res ; 232: 553-558, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30463772

RESUMO

BACKGROUND: While massive transfusion protocols (MTPs) are effective means of expeditiously delivering blood products to patients with exsanguinating hemorrhage, activation often occurs in cases with small blood volume deficits, leading to product wastage and overtransfusion. We sought to determine whether the additional implementation of a new protocol (called Rapid Release [RR]), which uses less resources, would result in decrease in blood product wastage. We hypothesized that RR would result in the reservation of MTPs for sicker patients and that blood product wastage would decrease. METHODS: All MTP activations 1.5 y pre-RR and 1.5 y post-RR were analyzed. Compared with MTP (six units packed red blood cells [pRBCs], six units fresh frozen plasma [FFP], six units platelets), RR only releases four units pRBCs and one unit FFP per activation. MTP resource utilization and wastage was compared before and after RR in trauma and nontrauma populations. P ≤ 0.05 was considered significant. RESULTS: One hundred nine MTPs were activated pre- (n = 48) to post-RR (n = 61), with 69 RRs activated in the post-RR period. Of these 69 RRs, 10 (14.5%) were eventually upgraded to MTP. Compared with the pre-RR group, significantly higher transfusion rates were observed for FFP and platelets. FFP wastage increased (pre: 0.65 ± 1.78 versus post: 3.46 ± 4.29; P < 0.001) over the study duration with no differences between the trauma and nontrauma populations. CONCLUSIONS: Contrary to our hypothesis, institution of the RR protocol resulted in higher mean wastage of FFP per activation despite the appropriateness of the RR protocol. Further efforts are warranted to refine the MTP to increase efficiency.


Assuntos
Transfusão de Sangue , Protocolos Clínicos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
4.
J Trauma Acute Care Surg ; 84(2): 295-300, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29194314

RESUMO

BACKGROUND: Hay-hole falls are a prevalent source of trauma among Anabaptists-particularly Anabaptist youth. We sought to decrease hay-hole falls in South Central Pennsylvania through the development and distribution of all-weather hay-hole covers to members of the at-risk Anabaptist community. METHODS: Following the creation of a rural trauma prevention syndicate, hay-hole cover prototypes co-designed and endorsed by the Pennsylvania Amish Safety Committee were developed and distributed throughout South Central Pennsylvania. Preintervention and postintervention surveys were distributed to recipients to gain an understanding of the hay-hole fall problem in this population, to provide insight into the acceptance of the cover within the community, and to determine the efficacy of the cover in preventing falls. RESULTS: A total of 231 hay-hole covers were distributed throughout eight rural trauma-prone counties in Pennsylvania. According to preintervention survey data, 52% of cover recipients reported at least one hay-hole fall on their property, with 46% reporting multiple falls (median fall rate, 1.00 [1.00-2.00] hay-hole falls per respondent). The median self-reported distance from hay-hole to ground floor was 10.0 (8.00-12.0) feet, and the median number of hay-holes present on-property was 3.00 (2.00-4.00) per respondent. Postintervention survey data found 98% compliance with hay-hole cover installation and no subsequent reported hay-hole falls. CONCLUSION: With the support of the Pennsylvania Amish Safety Committee, we developed a well-received hay-hole cover which could effectively reduce fall trauma across other rural communities in the United States. LEVEL OF EVIDENCE: Epidemiological study, Level III.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Ferimentos e Lesões/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Ferimentos e Lesões/epidemiologia
5.
J Trauma Acute Care Surg ; 84(2): 301-307, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29251704

RESUMO

BACKGROUND: Elderly trauma care is challenging owing to the unique physiology and comorbidities prevalent in this population. To improve the care of these patients, two practice management guidelines (PMGs) were implemented: high-risk geriatric protocol (HRGP), which triages patients based on injury patterns and comorbid conditions for occult hypotension, and the anticoagulation and trauma (ACT) alert, which is designed to streamline the care of geriatric trauma patients on anticoagulants. We hypothesized that both HRGP and ACT would decrease mortality and complications in geriatric trauma patients. METHODS: Geriatric blunt trauma patients (aged ≥65) presenting to our Level II center from January 2000 to July 2016 were extracted from the trauma registry. Do-not-resuscitate patients were excluded. The study period was divided into three phases: Phase 1, no PMGs in place (2000 to January 2006); Phase 2, HRGP only (February 2006 to February 2012); and Phase 3, HRGP + ACT (March 2012 to July 2016). Multivariate logistic regression models assessed adjusted mortality and complications during these phases to quantify the impact of these protocols. Statistical significance was set at p < 0.05. RESULTS: A total of 8,471 geriatric trauma patients met inclusion criteria. Overall mortality rate was 5.6% (Phase 1, 7.2%; Phase 2, 6.1%; Phase 3, 4.0%). No significant change in mortality was observed during Phase 2 with the HRGP only (adjusted odds ratio (OR), 0.98; 95% confidence interval, 0.73-1.34; p = 0.957); however, a significantly reduced OR of mortality was found during Phase 3 with the combination of both the HRGP and ACT (adjusted OR, 0.67; 95% confidence interval, 0.47-0.94; p = 0.021). No significant changes in incidence of complications was observed over the study duration. CONCLUSIONS: Geriatric trauma patients are not simply older adults. Improved outcomes can be realized with specific PMGs tailored to the geriatric trauma patients' needs. LEVEL OF EVIDENCE: Epidemiologic study, level III.


Assuntos
Avaliação Geriátrica/métodos , Sistema de Registros , Centros de Traumatologia/estatística & dados numéricos , Triagem/normas , Ferimentos não Penetrantes/epidemiologia , Fatores Etários , Idoso , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Masculino , Razão de Chances , Pennsylvania/epidemiologia , Estudos Retrospectivos , Ferimentos não Penetrantes/diagnóstico
6.
Am Surg ; 82(12): 1203-1208, 2016 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-28234185

RESUMO

A growing body of literature indicates that beta-blocker administration after traumatic brain injury (TBI) is cerebroprotective, limiting secondary injury; however, the effects of preinjury beta blocker status remain poorly understood. We sought to characterize the effects of pre- and postinjury beta-blocker administration on mortality with subanalyses accounting for head injury severity and myocardial injury. In a Level II trauma center, all admissions of patients ≥18 years with a head Abbreviated Injury Scale Score ≥2, Glasgow Coma Scale ≤13 from May 2011 to May 2013 were queried. Demographic, injury-specific, and outcome variables were analyzed using univariate analyses. Subsequent multivariate analyses were conducted to determine adjusted odds of mortality for beta-blocker usage controlling for age, Injury Severity Score, head Abbreviated Injury Scale, arrival Glasgow Coma Scale, ventilator use, and intensive care unit stay. A total of 214 trauma admissions met inclusion criteria: 112 patients had neither pre- nor postinjury beta-blocker usage, 46 patients had preinjury beta-blocker usage, and 94 patients had postinjury beta-blocker usage. Both unadjusted and adjusted odds ratios of preinjury beta-blocker were insignificant with respect to mortality. However, postinjury in-hospital administration of beta blockers was found to significantly in the decrease of mortality in both univariate (P = 0.002) and multivariate analyses (P = 0.001). Our data indicate that beta-blocker administration post-TBI in hospital reduces odds of mortality; however, preinjury beta-blocker usage does not. Additionally, myocardial injury is a useful indicator for beta-blocker administration post-TBI. Further research into which beta blockers confer the best benefits as well as the optimal period of beta-blocker administration post-TBI is recommended.


Assuntos
Escala Resumida de Ferimentos , Antagonistas Adrenérgicos beta/administração & dosagem , Lesões Encefálicas Traumáticas/mortalidade , Traumatismos Cardíacos/mortalidade , Acidentes por Quedas/estatística & dados numéricos , Acidentes de Trânsito/estatística & dados numéricos , Adolescente , Antagonistas Adrenérgicos beta/farmacologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Esquema de Medicação , Feminino , Escala de Coma de Glasgow , Hospitalização , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Razão de Chances , Análise de Regressão , Fatores de Tempo
7.
Am Surg ; 81(4): 408-13, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25831189

RESUMO

In busy emergency departments (EDs), elderly patients on anticoagulation (AC) sustaining minor injuries who are triaged to a lower priority for evaluation are at risk for potentially serious consequences. We sought to determine if a novel ED protocol prioritizes workup and improves outcome. In a Pennsylvania-verified Level II trauma center, the ACT (AntiCoagulation and Trauma) Alert was implemented in March 2012. Triage parameters include: age 65 years or older, AC agents, Glasgow Coma Score (GCS) 13 or greater, and head trauma 24 hours or less. ACT Alerts are announced overhead in the ED and require assessment by an ED physician, nurse, and phlebotomist in 15 minutes or less. Furthermore, they necessitate Point of Care international normalized ratio (INR) 20 minutes or less and head computed tomography (CT) scan 30 minutes or less. Positive CT findings mandate trauma service consultation. ACT Alert patients from March to December 2012 were compared with ED patients 65 years or older, GCS 13 or greater, on AC with the same chief complaints as ACT Alerts from June 2011 to February 2012 (control). A P value ≤ 0.05 was considered significant. Of 752 study patients, 415 were ACT and 337 were controls. There were no significant differences between groups in age, elevated INR, or head bleeds. ACT patients had significantly shorter median times from ED arrival to INR (ACT 13 minutes vs control 80 minutes; P < 0.001) and to head CT (ACT 35 minutes vs control 65 minutes; P < 0.001). Of admitted patients, ACT had a significantly shorter median length of stay (LOS) (ACT 3.7 days vs control 5.0 days; P < 0.001). Although trends toward improved outcome were noted, no statistically significant differences were identified. The ACT Alert improves ED throughput and reduces hospital LOS while effectively identifying at-risk, mildly head injured geriatric patients on AC.


Assuntos
Anticoagulantes/uso terapêutico , Traumatismos Craniocerebrais/diagnóstico , Tromboembolia/prevenção & controle , Centros de Traumatologia , Triagem , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Traumatismos Craniocerebrais/complicações , Feminino , Escala de Coma de Glasgow , Humanos , Tempo de Internação/tendências , Masculino , Pennsylvania , Estudos Retrospectivos , Fatores de Risco , Tromboembolia/complicações , Tomografia Computadorizada por Raios X
8.
J Trauma Acute Care Surg ; 78(2): 409-14, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25757130

RESUMO

BACKGROUND: To date, there are almost 500 accountable care organizations (ACOs) across the United States emphasizing cost-effective care. Readmission largely impacts health care cost; therefore, we sought to determine factors associated with geriatric trauma readmissions (recidivism) within our institution. METHODS: All admissions from 2000 to 2011 attributed to patients 65 years or older at our Level II trauma center, recently verified by Medicare as an ACO, were queried. Patients were classified as recidivist or nonrecidivist. The first admissions of recidivist patients were compared with the nonrecidivist admissions with respect to sex, age, race, primary insurance, admission Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), hospital length of stay, mechanism of injury (MOI), preexisting conditions, and discharge destination. Factors found to be significant predictors of recidivism in univariate analyses were subsequently incorporated into a multivariate logistic regression model. In addition, the second admission's MOI was compared with the first admission's MOI, and the proportion of first, second, and third admissions attributed to falls was calculated. A p < 0.05 was significant. RESULTS: Between 2000 and 2011, a total of 4,963 unique patients were admitted to the trauma center at 65 years or older. This population was composed of 287 recidivists (5.8%) and 4,676 nonrecidivists (94.2%). When placed in a multivariate logistic regression, female sex, admission GCS score of 15, history of head trauma, and preexisting pulmonary disease were identified as significant predictors of recidivism. A trend toward increasing proportion of injuries attributed to falls was found with each subsequent trauma admission (81.5% [234 of 287] of first admissions, 88.2% [253 of 287] of second admissions, and 90.5% [19 of 21] of third admissions). CONCLUSION: Our study identifies specific factors that should be targeted by social service and prevention resources to inhibit recidivism in the elderly. In the brave new world of ACOs, trauma centers must identify high-risk populations for the consumption of limited resources. LEVEL OF EVIDENCE: Care management study, level IV. Prognostic study, level III.


Assuntos
Organizações de Assistência Responsáveis , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Traumatismos Craniocerebrais/complicações , Feminino , Escala de Coma de Glasgow , Humanos , Pneumopatias/complicações , Masculino , Sistema de Registros , Fatores de Risco , Fatores Sexuais , Centros de Traumatologia , Estados Unidos
9.
Injury ; 46(1): 119-23, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25065652

RESUMO

INTRODUCTION: Approximately one in three older adults fall each year, resulting in a significant proportion of geriatric traumatic injuries. In a hospital with a focus on geriatric fall prevention, we sought to characterize this population to develop targeted interventions. As mild hyponatremia, defined as a serum sodium <135meq/L, has been reported to be associated with falls, unsteadiness and attention deficits, we hypothesized that hyponatremia is associated with falls in our geriatric trauma population. METHODS: Gender, age, pre-existing conditions (cardiac disease, diabetes, hematologic disorder, liver disease, malignancy, musculoskeletal disorder, neurological disorder, obesity, psychiatric disorder, pulmonary disease, renal disease, thyroid disease), mechanism of injury and admitting serum sodium level were queried for all geriatric trauma admissions from 2008 to 2011. Mechanism of injury was coded as falls admissions and non-falls admissions. Admitting serum sodium levels were coded as hyponatremic (<135mmol/L) and not hyponatremic (≥135mmol/L). RESULTS: Of the 2370 geriatric trauma admissions during the study period, there were 1841 (77.7%) falls admissions and 293 (12.4%) patients who were hyponatremic. Gender, age, neurological disorder, hematologic disorder, and hyponatremia were found to be significant predictors of falls in both univariate and multivariable analyses. CONCLUSION: Hyponatremic patients are significantly more likely to be admitted for a fall than non-hyponatremic patients, when adjusting for age, neurological disorder, and hematologic disorder. Consequently, hyponatremia identification and management should be an integral part of any geriatric trauma fall prevention programme. Additionally, if hyponatremia is found during a geriatric fall workup, it should be corrected prior to discharge and closely monitored by a primary care physician to prevent recurrent episodes of falls.


Assuntos
Acidentes por Quedas/prevenção & controle , Avaliação Geriátrica/métodos , Hiponatremia/sangue , Prevenção de Acidentes , Acidentes por Quedas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Hiponatremia/complicações , Hiponatremia/fisiopatologia , Masculino , Razão de Chances , Admissão do Paciente , Prevalência , Recidiva , Fatores de Risco , Fatores Sexuais
10.
Am Surg ; 81(12): 1279-83, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26736168

RESUMO

Geriatric living facilities have been associated with a high rate of falls. We sought to develop an innovative intervention approach targeting geriatric living facilities that would reduce geriatric fall admissions to our Level II trauma center. In 2011, a Trauma Prevention Taskforce visited 5 of 28 local geriatric living facilities to present a fall prevention protocol composed of three sections: fall education, risk factor identification, and fall prevention strategies. To determine the impact of the intervention, the trauma registry was queried for all geriatric fall admissions attributed to patients living at local geriatric living facilities. The fall admission rate (total fall admissions/total beds) of the pre-intervention period (2010-2011) was compared with that of the postintervention period (2012-2013) at the 5 intervention and 23 control facilities. A P value < 0.05 was considered statistically significant. From 2010 to 2013, there were 487 fall admissions attributed to local geriatric living facilities (intervention: 179 fall admissions; control: 308 fall admissions). The unadjusted fall rate decreased at intervention facilities from 8.9 fall admissions/bed pre-intervention to 8.1 fall admissions/bed postintervention, whereas fall admission rates increased at control sites from 5.9 to 7.7 fall admissions/bed during the same period [control/intervention odds ratio (OR), 95% confidence interval (CI) = 1.32, 1.05-1.67; period OR, 95%CI = 1.55, 1.18-2.04, P = 0.002; interaction of control/intervention group and period OR 95% CI = 0.68, 0.46-1.00, P = 0.047]. An aggressive intervention program targeting high-risk geriatric living facilities resulted in a statistically significant decrease in geriatric fall admissions to our Level II trauma center.


Assuntos
Acidentes por Quedas/prevenção & controle , Avaliação Geriátrica/métodos , Hospitalização/estatística & dados numéricos , Medição de Risco/métodos , Acidentes por Quedas/estatística & dados numéricos , Idoso , Feminino , Seguimentos , Humanos , Masculino , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos
11.
J Intensive Care Med ; 30(3): 151-5, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24212599

RESUMO

BACKGROUND: Although the Leap Frog intensivist staffing model has been shown to improve outcomes in the intensive care unit (ICU), to date, no one has examined the effect of an intensivist model in a dedicated trauma ICU. With stricter adherence to evidence-based protocols and 24-hour availability, we hypothesized that a mature intensivist model in a trauma ICU would decrease mortality. METHODS: Level II trauma center trauma ICU admissions 2006 to 2011. The ICU care provided by 6 trauma intensivists. Two periods were compared: early (2006-2008) and mature (2009-2011). Patients matched on age, Injury Severity Score (ISS), preexisting conditions, and so on in a univariate analysis, with significant variables placed in a logistic regression model, with mortality as the outcome. RESULTS: A total of 3527 patients (2999 excluding do not resuscitate status) were reviewed. Age ≥65 (odds ratio [OR] 2.38, P < .001), ISS ≥17 (OR 3.3, P < .001), coagulopathy (OR 1.64, P = .004), and anemia (OR 1.73, P = .02) were independent predictors of mortality. Multivariate logistic model encompassing these factors found no statistically significant differences in mortality across the 6-year period. The ICU efficiency showed significant improvements in terms of ventilator days (30.1% EARLY vs 24.4% MATURE; P < .001), decreases in mean consultant use per patient (0.55 ± 0.85 EARLY vs 0.40 ± 0.74 MATURE; P < .001), and increase in number of bedside procedures per patient (0.09 ± 0.48 EARLY vs 0.40 ± 0.74 MATURE; P < .001 CONCLUSIONS: Our mature intensivists staffing model shows improvement in ICU throughput (ventilator days, ICU days, decreased consultant use, and increased bedside procedures) but no survival benefit. Further improvements in overall trauma mortality may lie in the resuscitative and operative phase of patient care.


Assuntos
Eficiência Organizacional , Mortalidade Hospitalar , Unidades de Terapia Intensiva/organização & administração , Admissão e Escalonamento de Pessoal/organização & administração , Fatores Etários , Eficiência Organizacional/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Logísticos , Modelos Organizacionais , Cobertura de Condição Pré-Existente , Estudos Retrospectivos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/mortalidade
12.
J Trauma Acute Care Surg ; 77(1): 89-94, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24977761

RESUMO

BACKGROUND: Little is known about nursing care's impact on trauma outcomes. The Magnet Recognition Program recognizes hospitals for quality patient care and nursing excellence based on objective standards. We hypothesized that Magnet-designated trauma centers would have improved survival over their non-Magnet counterparts. METHODS: All 2009 to 2011 admissions to Pennsylvania's Level I and II trauma centers with more than 500 admissions during the study period (10 Magnet and 17 non-Magnet hospitals) were extracted from the Pennsylvania Trauma Systems Foundation State Registry. A logistic regression model with mortality as the dependent variable included the following variables: Magnet status, age, sex, admitting temperature, logit transformation of mortality probability predicted by the Trauma Mortality Prediction Model (TMPM-ais), systolic blood pressure, mechanism of injury, paralytic drug use, and Glasgow Coma Scale motor (GCSm) score. RESULTS: A total of 73,830 patients from the Pennsylvania Trauma Outcome Study database met inclusion criteria for this study. The Magnet and non-Magnet hospital groups were statistically indistinguishable with respect to level of designation, medical school association, surgical residency programs, in-house surgeons, and urban locations. Patients admitted to a Magnet hospital had a significantly decreased odds of mortality when compared with their non-Magnet counterparts (odds ratio, 0.83; 95% confidence interval, 0.70-0.99; p = 0.033), when controlling for numerous factors. Overall, the model has outstanding discrimination with a receiver operating characteristic curve of 0.93. CONCLUSION: Admission to a Magnet-designated hospital is associated with a 20% reduction in mortality. We believe that the Magnet program's attention to nursing competence has important consequences for trauma patients, as reflected in the improved survival rates in trauma patients admitted to Magnet-designated hospitals. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III. Care management study, level IV.


Assuntos
Recursos Humanos de Enfermagem Hospitalar/normas , Centros de Traumatologia/normas , Ferimentos e Lesões/mortalidade , Adulto , Distinções e Prêmios , Competência Clínica , Humanos , Modelos Logísticos , Razão de Chances , Pennsylvania
13.
J Trauma Acute Care Surg ; 73(2): 511-5, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23019680

RESUMO

BACKGROUND: This study aimed to determine the relative "weight" of risk factors known to be associated with venous thromboembolism (VTE) for patients with trauma based on injuries and comorbidities. METHODS: A retrospective review of 16,608 consecutive admissions to a trauma center was performed. Patients were separated into those who developed VTE (n = 141) versus those who did not (16,467). Univariate analysis was performed for each risk factor reported in the trauma literature. Risk factors that were shown to be significant (p < 0.05) by univariate analysis underwent multivariate analysis to develop odds ratios for VTE. The Trauma Embolic Scoring System (TESS) was derived from the multivariate coefficients. The resulting TESS was compared with a data set from the National Trauma Data Bank (2002-2006) to determine its ability to predict VTE. RESULTS: The multivariate analysis demonstrated that age, Injury Severity Score, obesity, ventilator use for more than 3 days, and lower-extremity trauma were significant predictors of VTE in our patient population. The TESS was from 0 to 14, with the best prediction for those patients with a score of more than 6 (sensitivity, 81.6%; specificity, 84%). Overall, the model had excellent discrimination in predicting VTE with a receiver operating characteristic curve of 0.89. The VTE rates for TESS in the National Trauma Data Bank data set were similar for all integers except for 3 and 4, in which the VTE rates were significantly higher (3, 0.2% vs. 0.6%; 4, 0.4% vs. 1.0%). CONCLUSION: The TESS provides an objective measure of classifying VTE risk for patients with trauma. The TESS could allow informed decision making regarding prophylaxis strategies in patients with trauma.


Assuntos
Escala de Gravidade do Ferimento , Tromboembolia Venosa/classificação , Tromboembolia Venosa/epidemiologia , Ferimentos e Lesões/epidemiologia , Adulto , Distribuição por Idade , Idoso , Estudos de Coortes , Comorbidade , Intervalos de Confiança , Técnica Delphi , Feminino , Seguimentos , Humanos , Incidência , Traumatismos da Perna/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Obesidade/epidemiologia , Razão de Chances , Valor Preditivo dos Testes , Sistema de Registros , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Distribuição por Sexo , Análise de Sobrevida , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia
14.
J Trauma Acute Care Surg ; 73(2): 435-40, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22846952

RESUMO

BACKGROUND: Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury. We have developed the high-risk geriatric protocol (GP) that seeks to identify high-risk geriatric patients. We hypothesized that a high-risk GP would improve outcome in this select group of patients. METHODS: Patients from 2000 to 2010 were included. Patients 65 years or older who met high-risk GP based on comorbidities and/or physiologic parameters were compared with those patients who had not received GP before its implementation as well as other non-GP patients. This protocol includes a geriatric consultation, as well as a lactate levels, arterial blood gas levels, and echo test to assess for occult shock. Age, trauma activation, preexisting conditions, Injury Severity Score, Revised Trauma Score, and mortality were reviewed. Univariate and multivariate analyses were conducted to identify factors predictive of mortality. RESULTS: A total of 3,902 patients were evaluated. Patients receiving GP were less likely to die (odds ratio, 0.63 [0.39-0.99], p = 0.046). For all patients, there was a dramatic increase in mortality for those patients older than 75 years. CONCLUSION: The GP, adjusted for other covariates, significantly reduced mortality in our patient population. Thus, this study confirms the overall effectiveness of our GP, which is hallmarked by prompt identification of those patients with occult shock and a multidisciplinary care of the aged population.


Assuntos
Mortalidade Hospitalar/tendências , Equipe de Assistência ao Paciente/organização & administração , Triagem , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Estudos Transversais , Feminino , Avaliação Geriátrica , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Melhoria de Qualidade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Gestão da Segurança , Análise de Sobrevida , Centros de Traumatologia , Resultado do Tratamento , Ferimentos e Lesões/diagnóstico
15.
J Trauma Acute Care Surg ; 72(2): 381-4, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22327980

RESUMO

BACKGROUND: Temporary inferior vena cava filters (IVCF) are uniquely suited for trauma patients in whom the high risk of venous thromboembolism is transient. Currently, few "retrievable filters" are actually retrieved, with most published series documenting a retrieval rate between 20% and 50%. We sought to determine whether we could achieve a higher rate of retrieval with an improved process of care. METHODS: All permanent and temporary filters were entered prospectively into a dedicated filter registry. Within 60 days of filter placement, all temporary filter patients were contacted by a trauma case manager to evaluate ongoing venous thromboembolism risk. Low-risk patients were then evaluated by radiology for removal of the IVCF. If appropriate, removal of the IVCF was scheduled. Initial contacts with patients were made by telephone. If unsuccessful with phone contact, family members, rehabilitation facility, and social work were all contacted to obtain the most recent phone number and address. A follow-up letter was sent to the patient with follow-up visit instructions. Finally, if prior contact measures did not work, a certified letter was sent to the last known address. RESULTS: Between 2006 and 2009, of 7,949 trauma admissions, 420 (5.2%) met indications for filter placement. Of those, 160 were available for removal and 94 were successfully removed (59%). CONCLUSIONS: A retrieval rate of 59% can be achieved with an explicit process of care emphasizing disciplined follow-up. LEVEL OF EVIDENCE: III.


Assuntos
Procedimentos Clínicos , Remoção de Dispositivo/estatística & dados numéricos , Traumatismo Múltiplo , Embolia Pulmonar/prevenção & controle , Filtros de Veia Cava , Veia Cava Inferior , Adolescente , Adulto , Idoso , Técnica Delphi , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Fatores de Risco
17.
Am J Surg ; 202(4): 382-6, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21816386

RESUMO

BACKGROUND: The aim of this study was to determine if prolonged immobility and tissue injury from a prehospital entrapment would place patients at higher risk for in-hospital venous thromboembolism (VTE) complications. It was hypothesized that entrapment would increase in-hospital VTE. METHODS: All consecutive trauma admissions over a 10-year period were retrospectively reviewed. Patients were divided into those who were entrapped according to defined prehospital criteria for entrapment and those who were not entrapped. The complications of deep vein thrombosis and pulmonary embolism were noted. RESULTS: There were 15,159 patients admitted between 1999 and 2008. Of these, 1,176 met the criteria for prehospital entrapment. Those patients who met the criteria for entrapment had a significant risk for developing both deep vein thrombosis (P < .001, χ(2) test) and pulmonary embolism (P = .005, Fisher's exact test). Multiple logistic regression analysis revealed entrapment to be a significant contributing risk factor to the development of VTE (odds ratio, 1.54; P = .04). CONCLUSIONS: Patients with prehospital entrapment are at higher risk for VTE. These results mandate aggressive VTE prophylaxis in patients with histories of prehospital entrapment.


Assuntos
Imobilização/efeitos adversos , Embolia Pulmonar/epidemiologia , Tromboembolia Venosa/epidemiologia , Ferimentos e Lesões/complicações , Adulto , Idoso , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Embolia Pulmonar/etiologia , Sistema de Registros , Estudos Retrospectivos , Tromboembolia Venosa/etiologia
18.
Healthc Q ; 13(4): 40-7, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-24953808

RESUMO

This article presents a framework for thinking about the key questions that need to be answered to develop new policy and program-relevant knowledge that can be used to make more informed decisions. It is a primer for administrators, policy makers and others about how to identify the knowledge they need to make decisions regarding new or existing programs. The article covers three related dimensions in evaluation: types of evaluations, key domains of inquiry and generic research questions. While the questions are generic, they can be readily adapted to any new and/or existing healthcare program evaluation. Examples of how the generic questions can be adapted to primary healthcare clinics and home care are presented.


Assuntos
Tomada de Decisões , Administração de Serviços de Saúde , Avaliação de Programas e Projetos de Saúde/métodos , Política de Saúde , Serviços de Saúde , Serviços de Assistência Domiciliar/organização & administração , Atenção Primária à Saúde/organização & administração
19.
Healthc Q ; 12(1): 38-47, 2, 2009.
Artigo em Inglês | MEDLINE | ID: mdl-19142062

RESUMO

Given the recent economic climate and increasing costs in the Canadian healthcare system, we must ensure that we are getting the best value for money possible. This article presents new findings and a broad weight of evidence to make the case that it is possible to obtain better value for money in our healthcare system by adopting models of integrated care delivery for seniors and others with ongoing care needs.


Assuntos
Prestação Integrada de Cuidados de Saúde , Enfermagem Geriátrica/economia , Idoso , Canadá , Atenção à Saúde , Prestação Integrada de Cuidados de Saúde/economia , Serviços de Assistência Domiciliar/economia , Serviços de Assistência Domiciliar/estatística & dados numéricos , Humanos , Programas Nacionais de Saúde , Casas de Saúde/economia , Casas de Saúde/estatística & dados numéricos
20.
Gerontologist ; 44(3): 389-400, 2004 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15197293

RESUMO

PURPOSE: This paper reports on Canadian research that examined the cost effectiveness of home care for seniors as a substitute for long-term institutional services. DESIGN AND METHODS: Two Canadian cities were included in the research: Victoria, British Columbia, and Winnipeg, Manitoba. The research computes the costs of formal care and informal care in both settings and ensures comparable groups of clients in both settings by comparing individuals at the same level of care. RESULTS: The results reveal that costs were significantly lower for community clients than for facility clients, regardless of whether costs only to the government were taken into account or whether both formal and informal costs were taken into account. When informal caregiver time is valued at either minimum wage or replacement wage, there was a substantial jump in the average annual costs for both community and facility clients relative to when informal caregiver time was valued at zero. IMPLICATIONS: Nevertheless, the results reveal that home care is significantly less costly than residential care even when informal caregiver time is valued at replacement wage.


Assuntos
Custos de Cuidados de Saúde , Serviços de Assistência Domiciliar/economia , Instituição de Longa Permanência para Idosos/economia , Casas de Saúde/economia , Idoso , Análise de Variância , Colúmbia Britânica , Análise Custo-Benefício , Humanos , Assistência de Longa Duração , Manitoba
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...