Life on the farm-children at risk.

BACKGROUND: More than 1 million children live, play, and work on farms, surrounded by animals and machinery. This symbiotic relationship between work and home exposes children to unique risks. METHODS: Children presenting with a farm-related injury (November 1994 to August 2001, 82 months) were included. Trauma registry parameters included injury severity score (ISS); Glascow Coma Scale (GCS); time to presentation; season and day of injury; emergency room, intensive care unit, and total length of stay type; and mechanism of injury; and operations. RESULTS: A total of 1,832 pediatric trauma patients were evaluated. Ninety-four children were identified with farm-related injuries. Mean age was 10.75 years. Mean ISS was 7.38. Three children died. Four children wore protective equipment. Forty-four percent of injuries occurred during summer, 31% during spring, and 55% on weekends. Average time to initial presentation was 39 minutes. A total of 177 minutes elapsed before transfer to regional trauma center. Seventy-two children required admission. LOS was 0 to 28 days, mean, 2.76 days. Twenty-six children (28%) required operations. Injuries included dislocations/fractures (52%), lacerations/avulsions (38%), concussions (31%), contusions (30%), and burns (14%). Mechanism included animals (41%), falls (34%), motor vehicles (28%), all-terrain vehicles (20%), and firearms (4%). CONCLUSIONS: Farm injuries occur most commonly during weekends, summer, and spring months, resulting in significant morbidity. Most injuries required hospitalization. Unless unstable, initial transfer to a regional pediatric trauma center should result in the most cost-effective, prompt, and highest quality of care.

Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax.

Diaphragmatic injury with accompanying hernia is a well-documented complication associated with both penetrating and blunt trauma. It occurs in approximately 3% of abdominal injuries with a 2:1 ratio of penetrating to blunt trauma. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress six years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and foul-smelling purulent drainage. Work-up revealed incarcerated transverse colon in a diaphragmatic hernia. Celiotomy demonstrated necrotic colon in the chest with gross fecal contamination in both the chest and abdomen. The diaphragmatic defect was closed and a Hartmann's procedure performed. The patient did well postoperatively except for the development of an empyema, which resolved with conservative management. Our patient is the eleventh reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases including the diagnostic work-up, operative approach, and ex ected postoperative course of this unusual condition.

Driving quality through Hoshin planning.

BACKGROUND: Hoshin planning, which enables organizations to allocate resources to important improvement opportunities to achieve significant results from a continuous quality improvement (CQI) program, was implemented in 1994 at a 160-bed community-based, residential psychiatric center. IMPLEMENTATION: The management team identified 15 key functions of care and surveyed customers to determine the most important and least satisfactory functions. On the basis of these and other survey data, the team then identified the three top areas for improvement. One of these was admissions, which was low in customer satisfaction and which affected the performance of other functions. Staff input on improvement needs for each of these areas was collected, and teams were empowered to address process improvements. For example, a systemwide team was formed to decrease the time it took to complete an admission to the treatment center. REVIEW OF PROGRESS: The one-year assessment, which included resurvey of customers, showed that the admissions process was shorter, treatment planning was rescheduled to maximize staff and consumer (patient) input, and treatment units were addressing safety concerns. CONCLUSIONS: The Hoshin planning process allowed the organization to target resources, involve employees, and achieve significant results visible to its consumers. This process and the quality improvement process should be integrated from the beginning.

Treatment outcome and continuous quality improvement: two aspects of program evaluation.

Increasingly, various stakeholders from insurance companies to patients are demanding verification of treatment effectiveness. With this pressure for accountability, program evaluation is essential to the continued existence of psychiatric hospitals because it permits understanding the effects specific interventions or procedures have on the quality and effectiveness of care. Two inpatient aspects of program evaluation are treatment outcome and continuous quality improvement. This article describes the conceptual bases of both treatment outcome and continuous quality improvement, depicts their complementary characteristics, and suggests how these two aspects of program evaluation can be integrated.

Unit-based clinical and organizational indicators for residential treatment.

A psychiatric residential treatment center has developed a system for monitoring and evaluating the quality of care provided. Administrators of the nine residential treatment units of the Devereux Foundation's Edward L. French Center use a standard form to report on a number of uniform clinical and organizational indicators. The data are evaluated monthly by the utilization review committee, quarterly by the quality assurance committee, and semiannually and annually by other administrators, committees, and the foundation's board of trustees. This process has been an effective mechanism for identifying trends and patterns in client care, for improving client care, and for providing clues to relationships among organizational problems.