147 resultados para hospital stay
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BACKGROUND & AIM: Immune-modulating nutritional formula containing arginine, omega-3 fatty acids and nucleotides has been demonstrated to decrease complications and length of stay in surgical patients. This study aims at assessing the impact of immune-modulating formula on hospital costs in gastrointestinal cancer surgical patients in Switzerland. METHOD: Based on a previously published meta-analysis, the relative risks of overall and infectious complications with immune-modulating versus standard nutrition formula were computed. Swiss hospital costs of patients undergoing gastrointestinal cancer surgery were retrieved. A method was developed to compute the patients' severity level, not taking into account the complications from the surgery. Incremental costs of complications were computed for both treatment groups, and sensitivity analyses were carried out. RESULTS: Relative risk of complications with pre-, peri- and post-operative use of immune-modulating formula was 0.69 (95%CI 0.58-0.83), 0.62 (95%CI 0.53-0.73) and 0.73 (95%CI 0.35-0.96) respectively. The estimated average contribution of complications to the cost of stay was CHF 14,949 (euro10,901) per patient (95%CI 10,712-19,186), independently of case's severity. Based on this cost, immune-modulating nutritional support decreased costs of hospital stay by CHF 1638 to CHF 2488 per patient (euro1195-euro1814). Net hospital savings were present for baseline complications rates as low as 5%. CONCLUSION: Immune-modulating nutritional solution is a cost-saving intervention in gastrointestinal cancer patients. The additional cost of immune-modulating formula are more than offset by savings associated with decreased treatment of complications.
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Introduction Sleep impairment is a common problem in older persons and is associated with adverse health and economic consequences. The most prescribed hypnosedatives in Switzerland are benzodiazepines, benzodiazepine-like hypnosedatives and clomethiazole. In the elderly persons, these medications have been associated with decreased cognitive performance, an increased risk of addiction and an increased risk of falls. The main aim of this study was to determine the prevalence, incidence and indications of hypnosedative prescriptions in older in-patients admitted to a Swiss university hospital. Furthermore, we planned to investigate the possible relationship between hypnosedatives' prescription and patients' falls during the hospital stay and we compared the prevalence of hypnosedative drugs' prescribing between geriatric and non-geriatric clinical wards.Materials & Methods This observational study included all patients aged 75 years or older admitted to a Swiss university hospital for 24 h or more. Prescription-related data were recorded every day for 26 consecutive days in the two geriatric wards, and twice, a week apart, in three non-geriatric wards.Results A total of 204 patients (mean age 84.7 ± 0.7 years, 66% women) were included. The prevalence of hypnosedative drugs prescription was 73% and the incidence was 28% on the two geriatric wards. The most common indications for a prescription on geriatric wards was insomnia (51%), followed by continuation of usual treatment (12%). The most frequently prescribed hypnosedative drug was clomethiazole (64% of the patients), followed by lorazepam (11%). We were not able to demonstrate any significant correlation between the number of hypnosedative drugs prescribed and the number of falls during hospital stay. The prevalence of hypnosedative drugs prescriptions was similar between geriatric and non-geriatric wards. The proportion of patients treated by at least one hypnosedative increased between hospital admission (32%) and discharge (45%).Discussions, Conclusion This study reveals a high prevalence of hypnosedative prescription in medical in-patients aged 75 years or older. Main indication was insomnia and the most frequently prescribed hypnosedative molecule was clomethiazole. Prescription incidence was also very high and the proportion of patients being prescribed a hypnosedative increased during hospital stay. Systematic interventions need to be integrated in order to reduce elderly inpatient exposure to treatments that are associated with adverse health outcomes.Conference information: ESCP 40th International Symposium on Clinical Pharmacy. Clinical Pharmacy: Connecting Care and Outcomes Dublin Ireland, 19-21 October 2011
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Infections remain the leading cause of death after major burns. Trace elements are involved in immunity and burn patients suffer acute trace element depletion after injury. In a previous nonrandomized study, trace element supplementation was associated with increased leukocyte counts and shortened hospital stays. This randomized, placebo-controlled trial studied clinical and immune effects of trace element supplements. Twenty patients, aged 40 +/- 16 y (mean +/- SD), burned on 48 +/- 17% of their body surfaces, were studied for 30 d after injury. They consumed either standard trace element intakes plus supplements (40.4 micromol Cu, 2.9 micromol Se, and 406 micromol Zn; group TE) or standard trace element intakes plus placebo (20 micromol Cu, 0.4 micromol Se, and 100 micromol Zn; group C) for 8 d. Demographic data were similar for both groups. Mean plasma copper and zinc concentrations were below normal until days 20 and 15, respectively (NS). Plasma selenium remained normal for group TE but decreased for group C (P < 0.05 on days 1 and 5). Total leukocyte counts tended to be higher in group TE because of higher neutrophil counts. Proliferation to mitogens was depressed compared with healthy control subjects (NS). The number of infections per patient was significantly (P < 0.05) lower in group TE (1.9 +/- 0.9) than in group C (3.1 +/- 1.1) because of fewer pulmonary infections. Early trace element supplementation appears beneficial after major burns; it was associated with a significant decrease in the number of bronchopneumonia infections and with a shorter hospital stay when data were normalized for burn size.
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BACKGROUND: Hypercalcaemia has been shown to occur in about 20% of patients with major burns requiring prolonged intensive care unit (ICU) treatment, and it may be associated with renal failure. Having observed the early onset of hypercalcaemia, the study aimed to determine the frequency and timing of this condition in a European patient cohort. METHODS: A retrospective cohort study on a prospectively collected, computerised database of the 225 burn-injury ICU admissions between 2001 and 2007 was undertaken. The inclusion criteria included: burns >20% of the body surface area (BSA) or in-hospital stay >20 days. Hypercalcaemia was defined as an ionised plasma calcium (Ca(2+)) concentration >1.32 mmol l(-1) (or total corrected calcium=[Ca]c>2.55 mmol l(-1)). Four emblematic cases are reported in this article. RESULTS: A total of 73 patients met the inclusion criteria (age: 13-88 years, burns: 12-85% BSA): of these, 22 (30%) developed hypercalcaemia. The median time to the first hypercalcaemia value was 21 days. Only 11 patients had both high Ca(2+) and elevated [Ca]c (which remained normal in others). The risk factors of the disorder were burned surface (p=0.017) and immobilisation (fluidised bed use: p<0.05, duration: p=0.02) followed by burned BSA. Acute renal failure tended to be more frequent in hypercalcaemic patients (five (23%) vs. three (6%): p=0.11), while mortality was not increased. The disorder resolved with hydration and mobilisation in most cases: pamidronate was successful in three cases that were most severe. CONCLUSION: Hypercalcaemia and associated acute renal failure occur more frequently and earlier than previously reported. Determining the ionised Ca rather than the total Ca with albumin correction enables earlier detection of hypercalcaemia. Bisphosphonates are an effective treatment option in controlling severe hypercalcaemia and preventing bone loss.
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The risk of endometrial cancer in relation to cigarette consumption was evaluated in a hospital-based case-control study of breast and genital neoplasms conducted in Milan, northern Italy. For the present analysis, 357 women (cases) with histologically confirmed endometrial cancer were compared to a group of 1122 women (controls) admitted for a large spectrum of acute conditions unrelated to smoking or to any of the known or potential risk factors for endometrial cancer. Compared with never-smokers, the multivariate relative risk estimates were for current 0.45 [95% confidence interval (CI) = 0.30-0.70] and 0.86 (95% CI = 0.50-1.46) for ex-smokers. The negative association of endometrial cancer with current smoking was not influenced by menopausal status as well as by other major identified potential confounding factors, i.e. menstrual and reproductive history, body mass index, oral contraceptive or estrogen replacement therapy use and family gynecologic cancer history. However, there was no evidence of a dose-risk effect, since the relative risks were similar in moderate and heavy smokers. The present study confirms that smoking is less frequent in cases hospitalized for endometrial cancer than in a comparison group of patients with non-smoking-related acute conditions. This negative association is perhaps explained in terms of reduced estrogen levels in smokers, though the influence and the importance of some uncontrolled selection bias (due, for instance, to longer hospital stay of smokers even when admission diagnosis was for non-smoking-related conditions) cannot be ruled out.
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Objective: Enhanced Recovery After Surgery (ERAS) clinical pathways in¦colorectal surgery are known to reduce postoperative complications leading¦to shortened hospital stay. However, the implementation of such an ERAS¦pathway requires time and financial investment. This study evaluates whether¦the savings related to the reduction in the length of stay (LOS) outweigh the¦costs of implementing an ERAS pathway.¦Methods: An ERAS pathway was implemented in our institution for colorectal¦surgery. The first 50 consecutive patients subjected to this ERAS pathway¦(ERAS group) were compared to 50 consecutive patients that were operated one¦year before its introduction (control group). Primary LOS, readmission within¦30 days, and total costs based on costs per day were compared. The mean costs¦per day were: 3,263 CHF for intensive care, 1,152 CHF for intermediate care,¦and 728 CHF for basic care.¦Results: Primary LOS was shorter in the ERAS group than in the control¦group: median 7 (interquartile range 5-12·25) versus 10 (7-18) days (P =¦0·0025). The readmission within 30 postoperative days was similar in both¦groups (2 patients each). In the ERAS group, the added primary LOS was¦485 days (379 in basic care, 99 in intermediate care, 7 in intensive care) compared¦to 706 days in the control group (533 in basic care, 146 in intermediate care,¦27 in intensive care). The total costs were significantly lower for the 50 ERAS¦patients compared to the control group: 412,801 CHF versus 644,317 CHF (P <¦0·01). Investments required for the 50 first ERAS patients were approximately¦83,544 CHF, including 348 working hours as well a full-time ERAS dedicated¦nurse. The overall cost saving was approximately 2,959 CHF per patient.¦Conclusion: Implementation of an ERAS pathway significantly reduced LOS¦after colorectal surgery. The financial investment to introduce and maintain¦such a pathway is clearly inferior to the cost-saving of reduced hospital stay.
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Major burns are characterized by an initial capillary leak, which requires fluid resuscitation for hemodynamic stabilization. While under resuscitation was the major cause of death until the 1980s, over resuscitation has become an important source of complications, including abdominal compartment syndrome, escharosis, impaired gas exchange with prolonged mechanical ventilation and hospital stay. Fluid over infusion started in the 1990s with an increasing proportion of the fluid delivered within the first 24 h being well above the 4 ml/kg/% burn surface area (BSA) according to the Parkland formula. The first alerts were published in the form of case reports of increased mortality due to abdominal compartment syndrome and respiratory failure. This paper analyses the causes of this fluid over infusion and the ways to prevent it, which include rationing prehospital fluid delivery, avoiding early administration of colloids and prevention by permissive hypovolemia.
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PURPOSE: Colonoscopy is reported to be a safe procedure that is routinely performed for the diagnosis and treatment of colorectal diseases. Splenic rupture is considered to be a rare complication with high mortality and morbidity that requires immediate diagnosis and management. Nonoperative management (NOM), surgical treatment (ST), and, more recently, proximal splenic artery embolization (PSAE) have been proposed as treatment options. The goal of this study was to assess whether PSAE is safe even in high-grade ruptures. METHODS: We report two rare cases of post colonoscopy splenic rupture. A systematic review of the literature from 2002 to 2010 (first reported case of PSAE) was performed and the three types of treatment compared. RESULTS: All patients reviewed (77 of 77) presented with intraperitoneal hemorrhage due to isolated splenic trauma. Splenic rupture was high-grade in most patients when grading was possible. Six of 77 patients (7.8Â %) were treated with PSAE, including the 2 cases reported herein. Fifty-seven patients (74Â %) underwent ST. NOM was attempted first in 25 patients with a high failure rate (11 of 25 [44Â %]) and requiring a salvage procedure, such as PSAE or ST. Previous surgery (31 of 59 patients), adhesions (10 of 13), diagnostic colonoscopies (49 of 71), previous biopsies or polypectomies (31 of 57) and female sex (56 of 77) were identified as risk factors. In contrast, splenomegaly (0 of 77 patients), medications that increase the risk of bleeding (13 of 30) and difficult colonoscopies (16 of 51) were not identified as risk factors. PSAE was safe and effective even in elderly patients with comorbidities and those taking medications that increase the risk of bleeding, and the length of the hospital stay was similar to that after ST. CONCLUSION: We propose a treatment algorithm based on clinical and radiological criteria. Because of the high failure rate after NOM, PSAE should be the treatment of choice to manage grade I through IV splenic ruptures after colonoscopy in hemodynamically stabilized patients.
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Background. Anastomotic leak remains a common and potentially deleterious complication after esophagectomy. Preoperative embolization of the left gastric artery and splenic artery (PAE) has been suggested to lower anastomotic leak rates. We present the results of our 5-year experience with this technique.Methods. All patients undergoing PAE before esophagectomy since introduction of this technique in 2004 were compared in a 1: 2 matched-pair analysis with patients without PAE. Matching criteria were type of anastomosis, neoadjuvant treatment, comorbidity, and age. Data were derived from a retrospective chart review from 2000 to 2006 that was perpetuated as a prospective database up to date. Outcome measures were anastomotic leak, overall complications, and hospital stay.Results. Between 2000 and 2009, 102 patients underwent esophagectomy for cancer in our institution with an overall leak rate of 19% and a mortality of 8%. All 19 patients having PAE since 2004 were successfully matched 1: 2 to 38 control patients without PAE; both groups were similar regarding demographics and operation characteristics. Two PAE (11%) and 8 control patients (21%) had an anastomotic leak, but the difference was statistically not significant (p = 0.469). Overall and major complication rates for PAE and control group were 89% versus 79% (p = 0.469) and 37% versus 34% (p = 1.000), respectively. Median intensive care unit and hospital stay were 3 versus 3 days (p = 1.000) and 22 versus 17 days (p = 0.321), respectively.Conclusions. In our experience, PAE has no significant impact on complications and anastomotic leak in particular after esophagectomy. (Ann Thorac Surg 2011;91:1556-61) (C) 2011 by The Society of Thoracic Surgeons
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Atrial septal defect (ASD) typically is asymptomatic in infancy and early childhood and elective defect closure usually is performed at an age between 4 - 6 years. Severe pulmonary hypertension (PHT) complicating an ASD is seen in adulthood and has only occasionally been reported in small children. A retrospective study was undertaken to evaluate the incidence of severe PHT complicating an isolated ASD and requiring early surgical correction in the fi rst year of life. 355 pediatric patients underwent treatment for an isolated ASD either surgically or by catheter intervention during a 10 year period (1996 - 2006) at two tertiary referral centers. 297 patients had secundum ASD and 58 primum ASD with mild to moderate mitral regurgitation. 8 infants were found with isolated ASD (six with secundum and two with primum ASD) associated with signifi cant PHT, accounting for 2.2% of all ASD patients in our centers. These 8 infants had invasively measured pulmonary artery pressures between 50 and 100% of systemic pressure. Median size of the ASD at the time of surgery was 14mm (7 - 20). They were operated in the fi rst year of life and had complicated postoperative courses requiring specifi c treatment for PHT for up to 16 weeks (median 12) postoperatively. Compared to ASD patients without PHT these infants had prolonged postoperative ICU stay of 5 - 9 days (median 8) and prolonged perioperative overall hospital stay of 8 - 32 days (median 15). Ultimate outcome in all 8 infants was good with persistent normalization of pulmonary pressures during mid-term follow-up of between 8 to 60 months (median 28). All other ASD patients had normal pulmonary pressures and mean age at defect closure was higher being 6.2 years for secundum ASD and 3.2 years for primum ASD. In conclusion, ASD is rarely associated with signifi cant PHT in infancy but then requires early surgery to normalize the prognosis of the patients.
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PURPOSE OF THE STUDY: This prospective study reports our preliminary results with local anaesthesia (LA) for carotid endarterectomy (CEA). MATERIAL AND METHODS: Twenty CEA in nineteen patients were performed using a three-stage local infiltration technique. CEA were performed through a short Duplex-assisted skin incision (median length: 55 mm) using a retro-jugular approach and polyurethane patch closure (median length: 35 mm). RESULTS: There were 13 men and 6 women with a mean age of 71.2 years. The indications of CEA were asymptomatic lesions in 11 cases, stroke in 7 cases and transient ischaemic attack in 2 cases. The median degree of internal carotid artery stenosis was 90%. One patient (5%) required an intraluminal shunt. There were no peri-operative deaths, stroke or conversion to general anaesthesia (GA). The median length of stay was 3 days. CONCLUSIONS: LA is a good alternative to GA. It can be used after a feasibility study and a short teaching procedure. In our centre, it is a safe and effective procedure associated with low morbidity, high acceptance by patients and a short hospital stay.
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BACKGROUND: Enhanced recovery protocols have been proven to decrease complications and hospital stay following elective colorectal surgery. However, these principles have not yet been reported for urgent surgery procedures. We aimed to assess our initial experience with urgent colectomies performed within an established enhanced recovery pathway. METHODS: In a prospective cohort study, all patients undergoing colonic resection between April 2012 and March 2013 were treated according to a standardized enhanced recovery protocol. Urgent surgeries were compared with the elective procedures with regards to baseline characteristics, compliance with enhanced recovery items, and clinical outcome. RESULTS: Patients (N = 28) requiring urgent colonic resection were included and compared with patients undergoing elective colectomy (N = 63). Overall compliance with the protocol was 57% for the urgent compared with 77% for the elective procedures (p = 0.006). The pre-operative compliance was 64 versus 96% (p < 0.001), the intra-operative compliance was 77 versus 86% (p = 0.145), and the post-operative compliance was 49 versus 67% (p = 0.015), for the urgent and elective resections, respectively. Overall, 18 urgent patients (64%) and 32 elective patients (51%) developed postoperative complications (p = 0.261). Median postoperative length of stay was 8 days in the urgent setting compared with 5 days in the elective setting (p = 0.006). CONCLUSIONS: Many of the intra-operative and post-operative enhanced recovery items can also be applied to urgent colectomy, entailing outcomes that approach the results achieved in the elective setting.
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Aims: To analyze the current literature on combined endoscopic-laparoscopic resection of colon polyps and to compare this new approach to standard laparoscopic colonic resection for polyps not suitable for endoscopic resection. Results: Several studies demonstrated that with a combined endoscopic-laparoscopic approach, polyps were successfully resected in 82-91% with a low morbidity of 3-10% and a short hospital stay of 1-2 days. Segmental laparoscopic resection was necessary in only 9-12%, but had a conversion rate to open surgery of 15% with an average hospital stay of 6-11 days. A cancerous polyp was found in 6-13% after a combined approach, with lymph node metastasis in 6%. Recurrent polyps after a combined endoscopic-laparoscopic resection seem to be rare, but follow-up of most studies is short and incomplete. Conclusion: Combined endoscopic-laparoscopic resection of colon polyps is feasible, safe, and has a high success rate. Malignant lesions can be treated laparoscopically during the same operation, avoiding the need for a second procedure, and with good long-term oncologic outcome.
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We reviewed the records of 108 patients who had a tracheostomy performed over a 10-year period from July 1979 to April 1989. Median age at tracheostomy was 6 months (1 week-15 years). Indications for surgery were acquired subglottic stenosis (31.4%), bilateral vocal cord paralysis (22.2%), congenital airway malformations (22.2%) and tumours (11.1%). No epiglottis and no emergency situation had to be managed by tracheostomy. Operation was uneventful in all, but 8 patients (7.4%) developed a pneumothorax in the postoperative period. Twenty-one (19.5%) had severe complications during the cannulation period (tube obstruction in 11 patients with cardiorespiratory arrest in 4; dislocation of the tube in 6 patients). Fifteen patients (13.8%) had severe complications after decannulation (2 had a cardiorespiratory arrest); all 15 had to be recannulated. At the end of the study period 85 patients (78.7%) were successfully decannulated with a median period of tracheostomy of 486 days (8 days-6.6 years). The median hospital stay was 159 days (13 days-2.7 years). All patients could be discharged. Eight patients (7.4%) died but no death was related to tracheostomy. In summary the mortality rate is lower than reported in previous reviews and tracheostomy is a safe operation even in small children but cannula-related complications may lead to life-threatening events. The management of tracheostomized small children and infants in a highly staffed and monitored intensive care unit has allowed better handling of complications and has resulted in a reduction in cannula-related deaths.
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Objective. Collaborative quality improvement programs have been successfully used to manage chronic diseases in adults and acute lung complications in premature infants. Their effectiveness to improve pain management in acute care hospitals is currently unknown. The purpose of this study was to determine whether a collaborative quality improvement program implemented at hospital level could improve pain management and overall pain relief. Design.To assess the effectiveness of the program, we performed a before-after trial comparing patient's self-reported pain management and experience before and after program implementation. We included all adult patients hospitalized for more than 24 hours and discharged either to their home or to a nursing facility, between March 1, 2001 and March 31, 2001 (before program implementation) and between September 15, 2005 and October 15, 2005 (after program implementation). Setting.A teaching hospital of 2,096 beds in Geneva, Switzerland. Patients.All adult patients hospitalized for more than 24 hours and discharged between 1 to 31 March 2001 (before program) and 15 September to 15 October 2005 (after program implementation). Interventions.Implementation of a collaborative quality improvement program using multifaceted interventions (staff education, opinion leaders, patient education, audit, and feedback) to improve pain management at hospital level. Outcome Measures.Patient-reported pain experience, pain management, and overall hospital experience based on the Picker Patient Experience questionnaire, perceived health (SF-36 Health survey). Results.After implementation of the program only 2.3% of the patients reported having no pain relief during their hospital stay (vs 4.5% in 2001, P = 0.05). Among nonsurgical patients, improvements were observed for pain assessment (42.3% vs 27.9% of the patients had pain intensity measured with a visual analog scale, P = 0.012), pain management (staff did everything they could to help in 78.9% vs 67.9% of cases P = 0.003), and pain relief (70.4% vs 57.3% of patients reported full pain relief P = 0.008). In surgical patients, pain assessment also improved (53.7.3% vs 37.6%) as well as pain treatment. More patients received treatments to relieve pain regularly or intermittently after program implementation (95.1% vs 91.9% P = 0.046). Conclusion.Implementation of a collaborative quality improvement program at hospital level improved both pain management and pain relief in patients. Further studies are needed to determine the overall cost-effectiveness of such programs.