Warfarin Poisoning and Blunt Abdominal Trauma: A Rare Cause of Small Bowel Obstruction.

Intestinal intramural hematomas are a rare complication of blunt abdominal trauma in the setting of anticoagulation. A 52-year-old male presented to our surgical service with high-grade small bowel obstruction secondary to an extensive small bowel intramural hematoma requiring resection. The patient sustained a blunt abdominal assault several days earlier and workup revealed severe coagulopathy likely secondary to overexposure to a warfarin-based substance. Few cases have been reported on coagulopathic traumatic small bowel hematomas causing small bowel obstruction. Current literature suggests non-operative management can be used safely; however, operative intervention is warranted if there are signs of ischemia or perforation. This case highlights the importance of a high index of suspicion, thorough investigation, and prompt intervention to avoid significant morbidity in small bowel obstruction secondary to intramural traumatic hematoma.

Lean Lobectomy: Streamlining Video-Assisted Lobectomy to Increase the Value of Lung Cancer Care.

PURPOSE: A review of the outcomes of patients who received our video-assisted thoracic surgery (VATS) lung lobectomy in 2015 revealed long lengths of stay, inefficient care transitions, and overuse of resources. Focused process redesign offers a proven method for instituting improvement and changes in health care. We sought to use systems process improvement to streamline VATS lobectomies at our institution, and we targeted cost drivers to optimize quality of care and minimize overuse of resources. METHODS: We performed a retrospective review of perioperative practices between January 2015 and March 2016 for patients undergoing VATS lobectomy that helped establish a value stream map, used a granular cost database, and performed real-time analysis. We used an outcomes database, which allowed us to identify cost drivers, practice variability, and rent seeking. We implemented process redesign with constant review and formal value stream reanalysis at 6-month intervals over a 2-year period. RESULTS: We ultimately experienced an overall 187% reduction of time in the operating room (297 v 159 minutes). Our process redesign also resulted in significantly fewer chest x-rays per patient (mean, 6.7 v 2), laboratory draws (100% v 5.7%), and consultations (100% v 5.7%), which resulted in a 234% reduction in mean length of stay (4.4 v 1.88 days) and an overall cost reduction of 40%. These changes did not have a detrimental effect on patient outcomes: pulmonary complications (16.9% v 8.6%), cardiac complications (13.2% v 8.6%), and readmission rates (13.6% v 2.9%) all decreased. CONCLUSION: By using value stream analysis and process redesign methodologies, closely paired with highly granular cost and outcomes data, we were able to achieve significant improvements in patient outcomes and use of resources.