Duration Of Stay Research Articles

Does weekend and out-of-hour duty affect the outcome of neurological emergencies in children? – A prospective observational study from Southern Nigeria

Abstract Background: There is a growing body of literature that suggests increased rates of morbidity and mortality for pediatric conditions admitted on a weekend compared with weekdays. Whether this association is seen in Nigerian children presenting with neurologic emergencies is not certain. Understanding the effect of weekend admission on the outcome of pediatric neurologic emergencies is important to allocate personnel and resources more efficiently. This study was conducted to determine whether weekend and out-of-hour duty affect the outcome of neurological emergencies in children. Subjects and Methods: This study used a cross-sectional analytic design over an 18-month period. Children aged 1 month–18 years presenting with neurologic emergencies were prospectively recruited over an 18-month period. The association between the dependent variable and independent variables was tested using the Chi-squared test and odds ratio. The level of statistical significance was accepted as P < 0.05. Results: A total of 146 children with neurologic emergencies were seen during the study period with 33.6% occurring on weekends. The average duration of stay (DOS) was 7.6 (±5.7) days. There was no difference in DOS between children based on the day of admission (P = 0.241) or the hour of admission (P = 0.155). Eleven (7.5%) of study subjects died during the study period. There was no difference in outcome based on day ([weekends – 6.1% vs. weekday – 8.2%] [P = 0.896]) or hour of admission ([out-of-hour – 7.3% vs. working hours – 7.7%] [P = 0.958]). Conclusions: Weekend and out-of-hour duty does not affect the outcome of neurological emergencies in children.

Gender differences in social environmental changes associated with smoking: a cross-sectional study from Chinese internal migrants

ObjectivesTo identify clues for women’s tobacco control, this study analyses the gender differences in social environmental changes associated with smoking and the interaction between the environment and individuals’ social integration.Design,...

An Optimized Machine Learning Model Accurately Predicts In-Hospital Outcomes at Admission to a Cardiac Unit

Risk stratification at the time of hospital admission is of paramount significance in triaging the patients and providing timely care. In the present study, we aim at predicting multiple clinical outcomes using the data recorded during admission to a cardiac care unit via an optimized machine learning method. This study involves a total of 11,498 patients admitted to a cardiac care unit over two years. Patient demographics, admission type (emergency or outpatient), patient history, lab tests, and comorbidities were used to predict various outcomes. We employed a fully connected neural network architecture and optimized the models for various subsets of input features. Using 10-fold cross-validation, our optimized machine learning model predicted mortality with a mean area under the receiver operating characteristic curve (AUC) of 0.967 (95% confidence interval (CI): 0.963–0.972), heart failure AUC of 0.838 (CI: 0.825–0.851), ST-segment elevation myocardial infarction AUC of 0.832 (CI: 0.821–0.842), pulmonary embolism AUC of 0.802 (CI: 0.764–0.84), and estimated the duration of stay (DOS) with a mean absolute error of 2.543 days (CI: 2.499–2.586) of data with a mean and median DOS of 6.35 and 5.0 days, respectively. Further, we objectively quantified the importance of each feature and its correlation with the clinical assessment of the corresponding outcome. The proposed method accurately predicts various cardiac outcomes and can be used as a clinical decision support system to provide timely care and optimize hospital resources.

Applying Clustering Methods to Develop an Optimal Storage Location Planning-Based Consolidated Picking Methodology for Driving the Smart Manufacturing of Wireless Modules

Picking operations is the most time-consuming and laborious warehousing activity. Managers have been seeking smart manufacturing methods to increase picking efficiency. Because storage location planning profoundly affects the efficiency of picking operations, this study uses clustering methods to propose an optimal storage location planning-based consolidated picking methodology for driving the smart manufacturing of wireless modules. Firstly, based on the requirements of components derived by the customer orders, this research analyzes the storage space demands for these components. Next, this research uses the data of the received dates and the pick-up dates for these components to calculate the average duration of stay (DoS) values. Using the DoS values and the storage space demands, this paper executes the analysis of optimal storage location planning to decide the optimal storage location of each component. In accordance with the optimal storage location, this research can evaluate the similarity among the picking lists and then separately applies hierarchical clustering and K-means clustering to formulate the optimal consolidated picking strategy. Finally, the proposed method was verified by using the real case of company H. The result shows that the travel time and the distance for the picking operation can be diminished drastically.

Surgical Treatment of Incompetent Perforator Veins by Subfascial Ligation

Background: Chronic venous ulceration of the leg is a common presentation in surgical clinics. Although, the majority of ulcers can be healed by simple compression. Some chronic ulcers with venous competencies require correction surgeries. We in the current study tried to study the role of Cockett and Dodd's operation of subfascial ligation of below-knee perforator veins in the treatment of varicose veins of the lower limbs. Methods: This cross-sectional study was done in the Department of General Surgery, Prathima Institute of Medical Sciences, Naganoor, Karimnagar. N=40cases of varicosities of the lower limbs with perforatorincompetence with or without saphenofemoral incompetence. The patients were treated with perforator ligationalone with the Cockett and Dodd method or in combination with the stripping procedure. Results: The clinical classification shows C5 healed venous ulcers and C6 active venous ulcers. 64% of cases belonged to these two categories and no case of C1 was found in our study. Perforator incompetence only was found in n=25 cases where perforator ligation alone was done given in table 4. In n=15 cases, perforator ligation and stripping with or without ligation of sphenopopliteal junction was done. The minimal mean duration of stay was 5.5 days the maximal mean duration of stay was 8.0 days. Conclusion: Open subfascial perforator ligation by Cockett and Dodd's procedure is a good procedure in the treatment of primary varicose veins with perforator incompetence. The rates of complications can be largely reduced by careful patient selection and skill full operative techniques. Follow-up of patients must be done at intervals for the development of new incompetent perforating veins and varicosities which may lead to the recurrence of ulcer formation.

Effects of Dance and Movement Therapy (DMT) versus Progressive Muscle Relaxation(PMR) on Depression among Elderly Residing in Selected Old Age Homes of Haryana: A Quasi Experimental Study

Depression is a universal health related problem which is increasing the life expectancy worldwide associatedwith morbidity and disability among elderly people. Elderly age group is a controversial issue as it is a naturalprocess which presents a unique challenge for every individual in society. The objectives of the study wereto assess and compare depression among elderly before and after administration of dance and movementtherapy and progressive muscle relaxation, to determine the relationship between depression and to find outthe association of depression with selected variables. Quantitative research approach, quasi experimentalnon equivalent control group pretest post test design was used to collect the data. Sixty participants (30DMT group, 30 PMR group) were enrolled for the study those who fulfilled the inclusion criteria by usingpurposive sampling technique. Homogeneity was checked by enrolling the participants. Data was collectedby using Geriatric Depression Scale (GDS) for assessing depression by interview technique. Analysis wasdone by applying non parametric test after K-S test to check normality of data. Thus findings of the studyshowed effectiveness of dance and movement therapy and progressive muscle relaxation on depression asthe calculated Friedman test Chi square value (DMT ?2 =51.44, p=0.00 and PMR ?2 =52.91, p=0.00) wassignificant at 0.05 in both groups. There was no any significant difference between DMT and PMR groupsin terms of depression. Depression among elderly was found to be statistically significant with duration ofstay in old age homes and history of chronic illness i.e (?=5.764, p=0.05) and (?=49.00, p=0.02) in DMTgroup, and depression among elderly was found to be statistically significant with history of chronic illnessi.e (?=49.00, p=0.04) in PMR group. Conclusion: Dance and movement therapy and Progressive musclerelaxation was effective in reducing depression among elderly as there was significant difference within thegroup.

RETRACTED ARTICLE: Synergic deep learning based preoperative metric prediction and patient oriented payment model for total hip arthroplasty

In recent days, total hip arthroplasty (THP) become a very victorious process which relieve the pain and enhances its functioning. The main motive of the paper is to design and assess a synergic deep learning (SDL) for learning and predicting various metrics like duration of stay (DOS), discharge disposition (DD) and inpatient expenses for THA. The next motive is to develop a patient specific payment (PSP) model reporting the complexity level of the patient. By the use of 15 preoperative parameters from 78,335 THA patients for osteoarthritis from National Inpatient Sample and OME databases, the prediction of DOS, DS and inpatient expenses takes place. A set of two evaluation parameters namely accuracy and receiver operating characteristic curve is used for experimentation. In addition, a predictive uncertainty is employed. All patient refined comorbidity cohort for establishing the PSP model. The presented SDL model exhibited better learning with high trustworthiness, receptiveness, and validity in its prediction outcome. The presented model can be applied for the implementation of PSP model for tiered payments depending upon the case complexities.

Potential and Forms of Sustainable Village Tourism in Mizoram, Northeast India

This paper examines the potential and forms of sustainable village tourism in Mizoram, Northeast India. This study was conducted using both qualitative and quantitative approaches. Data was gathered from the primary and secondary sources. Tourism survey report of India 2018 for Mizoram was used to collect data on tourists’ inflow, purpose and duration of stay and level of accommodation from 2016 to 2018. A case study of village Sialsuk was conducted through household level survey using purposive random sampling method. The author surveyed 240 households (48%) of the village. The major questions were asked of on the main options of livelihoods and carrying capacity of village tourism. The result shows that Mizoram has the tremendous potential, as it has the number of villages, which has feasible climate, spectacular landscape, wilderness and abundance local food products and beverages. These abundance bases support for the sustainable village tourism. Meanwhile, tourists’ inflow is less in Mizoram. Further, accommodation, transportation and institutional facilities are insufficient. There are number of drivers, affecting development of village tourism in Mizoram and among them, the inner line permit and remoteness/inaccessibility of the villages are the main drivers. It is suggested that the inner line permit system should be abolished. Roads should be constructed, publicity of the tourists’ destination should be ensured and the tourism department should be strengthened so that the village tourism in Mizoram can be developed

Duration of Stay of Patients with Community-Acquired Pneumonia in Influenza Season.

There is a seasonal variation in the incidence of some infectious diseases. We analyzed the impact of influenza season (IS) on duration of stay (DOS) and some other characteristics of patients with community-acquired pneumonia (CAP). In our retrospective cohort study, we analyzed data of 369 patients with CAP. The mean patient age was 65.5±16.69 years, and 267 (72.4%) patients were male. There was no difference between patients with CAP admitted to hospital and intensive care unit during IS and non-influenza season (NIS) with respect to age, mortality, and DOS. There was no difference in leukocyte and neutrophil counts, C-reactive protein level, and erythrocyte sedimentation rate in different seasons. Although most comorbid disease rates were similar, only cancer, especially lung cancer, was more prevalent in NIS. Bilateral CAP confirmed using thorax computed tomography was more frequent in IS. Although more patients with bilateral pneumonias were hospitalized in IS, DOS was not different between IS and NIS.

Laparoscopic pancreatic resection-a review.

Contrary to many other gastrointestinal operations, minimal access approaches in pancreatic surgery have gained ground slowly. Laparoscopic distal pancreatectomy has gained wide acceptance. It is associated with reduced blood loss and shorter duration of stay (DOS) while oncologic results and morbidity are similar to open surgery. In recent years the number of laparoscopic pancreatoduodenectomies has also increased. While oncological outcome seems comparable to the open approach, operative times are longer while DOS and blood loss are reduced. One added advantage of the laparoscopic approach to pancreatic cancer seems to be that adjuvant treatment can start earlier. Minimal access total pancreatectomy, only reported in small numbers (mostly robot assisted), has also been shown to be feasible and safe. Enucleation (EN) of small pancreatic lesions is the most common tissue sparing resection. Although no reconstruction is necessary, the risk of pancreatic fistula is high, related to excision margins equal or smaller than 2 mm to the main pancreatic duct. Compared to the open approach, laparoscopic EN has shown comparable results in terms of morbidity, pancreatic function and fistula rate, with shorter operation times and faster recovery. Experience in robot assisted pancreatic surgery is increasing. However reports are still small in numbers, lacking randomization and mostly limited to dedicated centers. The learning curve for minimal access pancreatic surgery is steep. Low patient volume leads to longer DOS, higher costs and negatively impacts outcome.

Blood transfusion is associated with increased risk of perioperative complications and prolonged hospital duration of stay among patients undergoing amputation

We evaluated the outcomes of patients undergoing major lower-extremity amputation who received packed red blood cell transfusion. Using the dataset of the National Surgical Quality Improvement Program (2005-2011), we examined 5,739 above-knee and 6,725 below-knee amputations. Patients were stratified by perioperative (preoperative, intraoperative, or postoperative) blood transfusion. Outcomes included perioperative mortality, myocardial infarction (MI), thromboembolism, and duration of stay (DOS) at the hospital. Adjusted comparisons of outcomes between transfused and not-transfused patients were performed by matching the 2 groups for age, smoking, diabetes, renal failure, coronary artery disease, classification of the American Society of Anesthesiologists, functional status, and procedure type. Multivariable logistic and gamma regression were used to examine associations between transfusion and outcomes. Of the 12,464 amputations in the study cohort 2,133 (17%) required transfusion. The majority of the cases were performed for critical limb ischemia (8,205 amputations; 66%) and the overall 30-days mortality was 9%. In both crude and matched cohorts, although perioperative mortality and cardiac complication rates were similar, transfusion was associated with a greater incidence of pneumonia (crude: 6.1% vs 3%, P < .001; matched: 5.9% vs 3.7%, P < .001), thromboembolism (2.5% vs 1.6%, P = .003; 2.5% vs 1.4%, P = .002) and longer DOS (18 ± 19 vs 13.6 ± 14.3 days, P < .001; 17.8 ± 18.4 vs 14.2 ± 14.5 days, P < .001). Multivariable adjustment for confounding variables in the crude cohort demonstrated that transfusion was independently associated with a greater odds of perioperative pneumonia (odds ratio [OR]:1.6; 95% confidence interval [CI]:1.3-2; P < .001), thromboembolism (OR 1.3, 95% CI 1.0-1.9, P = .09) and longer DOS (mean ratio: 1.1; 95% CI 1.1-1.6; P = .006). Among patients who had major lower-extremity amputation, perioperative transfusion independently predicted greater risks for perioperative pneumonia, thromboembolism, and prolonged hospital DOS.

Hierarchical remarshaling operations in block stacking storage systems considering duration of stay

This study proposes a strategy for steel plate storage systems in port terminals where steel plates are stored after being discharged from a vessel. Minimizing the rehandling operation or the number of relocations of plates on top of the plate to be retrieved is an essential requirement in the retrieval of steel plates from the storage system. One popular method to minimize the number of rehandling steps is to segregate the storage yard into several zones in which only plates with a remaining duration of stay (DOS) in a pre-specified range are stacked. When the retrieval time of a plate approaches, it is moved to the next zone corresponding to the plate’s remaining DOS at that time. This process is called “remarshaling.” This paper discusses how to optimize the classification of the zones so that the total number of remarshaling operations is minimized. Mathematical expressions for analyzing the remarshaling operation are derived, and the results of numerical experiments that use data from a steel plate storage warehouse are provided to explore interesting characteristics of optimal solutions.

A Survey of the Pain Management of Acute Painful Crisis among Patients with Sickle Cell Disease at Two Centres in Jamaica.

The aim of this survey was to establish the pain management approaches to acute painful crisis (APC) in sickle cell patients at two healthcare facilities and to compare with available guidelines. A multi-centre observational survey of the management of APC in sickle cell patients was conducted. Data were collected at the Sickle Cell Unit (SCU), Tropical Medicine Research Institute (TMRI) and Accident and Emergency Department (A&E), University Hospital of the West Indies. One hundred episodes of uncomplicated APC involving 81 patients managed at the SCU clinic and 64 episodes at the A&E in a total of 28 patients were included in the data set. Drugs used at the SCU included oral morphine, codeine and paracetamol and intramuscular diclofenac. At the A&E, parenteral morphine and pethidine were most commonly used. At the SCU, the mean time to initiation of analgesics was 38 minutes (IQR 25 to 50 minutes); at the A&E, this was 111 minutes (IQR 50 to 150 minutes). At the SCU, the mean duration of stay (DOS) was 2.9 hours (IQR 1.9 to 3.8 hours) with 94% of the patients being discharged home. At the A&E, the mean DOS was 13.0 hours (IQR 8.3 to 16.9 hours) with 93% of the patients being discharged home. The A&E patient group contained multiple high frequency presenters. Documentation of pain severity scores was inconsistent. The findings of the survey indicate that the management of APC at the two centres is substantially different. Further study is required to investigate patient satisfaction, centre preference and analgesic therapy efficacy.

Can we improve duration of hospital stay in angioplasty treated ST-segment elevation acute myocardial infarction? The Zwolle risk score

Purpose: Optimal duration of stay (DS) in angioplasty (PCI) treated uncomplicated acute ST-segment elevation myocardial infarction (STEMI) remains undetermined. The Zwolle risk score (ZRS) is a simple tool which could help identify patients who can be safely discharged before 72h. We aimed to apply ZRS to our population and assess the variables influencing DS. Methods: 276 consecutive STEMI patients admitted for PCI were studied, between January 2009 and December 2010. ZRS, DS and 30-day mortality were obtained for all patients. Low risk was defined as ZRS≤3 and ROC curves were used for discriminative power. Results: In the 276 patients evaluated (mean age 62±13 years-old, 75% male, 20% Killip>1), ZRS median was 3 (IQR 1-4). 171 patients were classified as low risk. These patients were younger (57.1 vs. 67.6 years-old, p 1.2 mg/dL (37.2 vs 62.8% p=0.001). Total 30-day mortality was 4.7% (13 patients). ZRS correctly predicted this event in 93.7% of cases (C-statistic 0.937; CI95% 0.906-0.968). 30-day mortality, stratified by ZRS, was significantly different in the 2 groups (0 vs. 12.4% p<0.001, Fig.1), corresponding to a positive predictive value of 100% (CI95% 97.0-100%) for safe early discharge. In the low risk subset of patients, mean duration of stay was substantially lower (6.0 vs. 15.1 days, p<0.001). The need for additional revascularization (20 patients, 11.7%) was the most frequent cause for longer DS. ![Figure][1] Figure 1 Conclusions: In our population, a ZRS ≤3 had both high discriminative power and positive predictive value for safe early discharge, translating on the DS. A cost-benefit analysis is warranted to further assess the real impact of these results. [1]: pending:yes

Impact of a bronchiolitis clinical care pathway on treatment and hospital stay

Aim Bronchiolitis is a common lower respiratory tract infection of infancy where management has varied considerably in the past. The aim of the present study was to determine whether patient treatment and outcomes changed after introduction of a clinical care pathway. Methods Infants aged up to six months admitted to hospital with bronchiolitis were identified as part of an annual audit of bronchiolitis management between winters 2003/4 and 2010/11. High risk infants, e.g. infants born prematurely or with cardiac defects, were excluded. The primary outcome, duration of stay (DOS), was compared before and after the clinical pathway was introduced before the winter 2005/6. Secondary outcomes were proportion requiring nasogastric feeds, supplemental oxygen and readmission within a week of discharge. Results There were 382 infants identified, mean age 68 days, 55% were male and respiratory syncitial virus was detected in 84%. After the clinical pathway was introduced, the proportion of infants prescribed salbutamol fell from 50% to 10% (p Conclusions A clinical pathway for the management of acute bronchiolitis can be implemented in the hospital setting and the conservative approach, in particular cautious prescribing of bronchodilators, is not associated with prolonged duration of stay.

A 5-year review of a trauma-trained hospitalist program for trauma patients: A matched cohort study

Level I trauma centers have requirements on the percentage of trauma patients admitted to either a trauma surgeon or surgical subspecialist; however, surgical resources are in steady decline. Therefore, a trauma system might better utilize its surgical resources if trained hospitalists admitted a larger percentage of mild to moderately injured trauma patients. The objective of this report is to provide a 5-year evaluation of a trauma medical service (TMED) at treating mild to moderately injured trauma patients. Adult trauma patients consecutively admitted to a Level I trauma center between January 2006 and December 2010 were analyzed. Patients admitted to trauma surgical services were matched 1:1 to those admitted to TMED, via propensity scores. Paired t tests examined differences in hospital duration of stay (DOS), and exact conditional logistic regression examined differences in the odds of having a delayed diagnosis, developing a complication, and dying. Of 1,202 TMED patients, 494 were matched; matched TMED patients had similar patient outcomes to nonmatched TMED patients. There were no differences between study groups in the mean hospital DOS, the proportion having a delayed diagnosis, or in the odds of dying in the hospital (P > .05 for all). The TMED group had a nominally higher complication rate (P = .12) owing to a higher rate of urinary tract infections. Since its inception, the TMED service has successfully and safely treated mild to moderately injured trauma patients, and decreased the dependency on trauma surgical services. Trauma centers might utilize declining surgical services more efficiently with the addition of trauma medical hospitalists.

Impact of a bronchiolitis clinical care pathway on treatment and hospital stay

Bronchiolitis is a common lower respiratory tract infection of infancy where management has varied considerably in the past. The aim of the present study was to determine whether patient treatment and outcomes changed after introduction of a clinical care pathway. Infants aged up to 6 months admitted to hospital with bronchiolitis were identified as part of an annual audit of bronchiolitis management between winters 2003/2004 and 2009/2010. The primary outcome, duration of stay (DOS), was compared before and after the clinical pathway was introduced before the winter 2005/2006. There were 328 infants identified, mean age 75 days, respiratory syncitial virus was detected in 89%. After the clinical pathway was introduced, the proportion of infants prescribed salbutamol fell from 50% to 8% (p < 0.001) and ipratropium bromide from 38% to 0% (p < 0.001) but the proportion prescribed antibiotics was unchanged. The median DOS was 79 h prior to the clinical pathway and 66 h afterwards (p = 0.010) but there was no difference in days where supplemental oxygen or nasogastric feeding was required. A clinical pathway for the management of acute bronchiolitis can be implemented in the hospital setting and the conservative approach, in particular not prescribing bronchodilators, is not associated with prolonged duration of stay.

Hospital costs associated with surgical site infections in general and vascular surgery patients

Although much has been written about excess cost and duration of stay (DOS) associated with surgical site infections (SSIs) after cardiothoracic surgery, less has been reported after vascular and general surgery. We used data from the National Surgical Quality Improvement Program (NSQIP) to estimate the total cost and DOS associated with SSIs in patients undergoing general and vascular surgery. Using standard NSQIP practices, data were collected on patients undergoing general and vascular surgery at a single academic center between 2007 and 2009 and were merged with fully loaded operating costs obtained from the hospital accounting database. Logistic regression was used to determine which patient and preoperative variables influenced the occurrence of SSIs. After adjusting for patient characteristics, costs and DOS were fit to linear regression models to determine the effect of SSIs. Of the 2,250 general and vascular surgery patients sampled, SSIs were observed in 186 inpatients. Predisposing factors of SSIs were male sex, insulin-dependent diabetes, steroid use, wound classification, and operative time (P < .05). After adjusting for those characteristics, the total excess cost and DOS attributable to SSIs were $10,497 (P < .0001) and 4.3 days (P < .0001), respectively. SSIs complicating general and vascular surgical procedures share many risk factors with SSIs after cardiothoracic surgery. Although the excess costs and DOS associated with SSIs after general and vascular surgery are somewhat less, they still represent substantial financial and opportunity costs to hospitals and suggest, along with the implications for patient care, a continuing need for cost-effective quality improvement and programs of infection prevention.

Traumatic vs non-traumatic spinal cord lesions: comparison of neurological and functional outcome after in-patient rehabilitation

Retrospective comparative study of 2 years duration. To compare neurological and functional outcome and length of stay of persons with traumatic vs non-traumatic spinal cord lesion (SCL) after in-patient rehabilitation. Neurological rehabilitation department of a tertiary research center in Bangalore, Karnataka, India. Seventy-six in-patients with spinal cord lesion: traumatic (38 patients, M/F=34:4) and non-traumatic (38 patients, M/F=16:22) were admitted for in-patient multidisciplinary neurorehabilitation. ASIA impairment scale, duration of stay (DOS), and admission and discharge--Barthel Index scores in both the groups were recorded, compared and analyzed. ASIA impairment scale scores were significantly higher in non-traumatic group both at admission and discharge (P=0.020 and 0.017), respectively, showing lesser impairment in non-traumatic group. DOS for rehabilitation was higher for traumatic group as compared to non-traumatic group (65.97+/-47.66 vs 60.68+/-45.69 days), although statistically not significant (P>0.05). Barthel Index scores were 28.68+/-17.15 vs 27.63+/-14.96 at admission and 54.21+/-25.10 vs 51.44+/-19.86 at discharge in traumatic and non-traumatic groups, respectively. All patients (n=76) showed significant improvement in Barthel Index (P=0.000), but no statistically significant difference (P>0.05) was recorded between the two groups, both at admission and at discharge. Orthoses was required significantly more frequently (P=0.043) in traumatic SCL group. The study showed that despite more impairment in persons with traumatic spinal cord lesion, there was statistically no significant difference in the length of stay and the functional outcome between persons with traumatic and non-traumatic spinal cord lesion after in-patient rehabilitation.

Environmental impact of accelerated clinical care in a high-volume center

"Fast-track" surgery, involving multimodal care, improves efficiency and short-term outcomes in patients undergoing bowel resection. The sustainability of the benefits and the "drag" effect on non-participating surgeons through changed nursing and resident practice is undetermined. 297 consecutive elective colon resections (DRG149) within three study periods (pre-change, immediate post-change, long-term post-change) were retrospectively reviewed. Two surgeons began to "fast-track" their patients in 1999 independently from the other surgeons in the hospital. Surgeons were grouped into "fast-track surgeons," "high-volume surgeons," (>/=10 cases per year) and "low-volume surgeons," (<10 cases per year). Comparisons of duration of stay (DOS), readmission rates, and mortality were made for each of three time periods and surgeon groups. Trends were also compared with unrelated hospital non-colectomy control groups (uncomplicated craniotomy DRG 001 and pancreatic surgery DRG 192) and to a colectomy control group from a statewide database (DRG 149). Mean DOS for colon resection significantly decreased among the "fast-track" surgeons and among all the other surgeons in the hospital, from 6.3 +/- 0.3 days, down to 3.7 +/- 0.1 days. We found no significant difference in mortality or readmission rates between the study periods. 15% of the cases were performed laparoscopically, and the improvements in outcome were independent of surgical technique. Control group analyses demonstrated that the environmental impact on outcome was independent of hospital-wide or regional improvement efforts. Implementation of a new practice pattern in a shared environment leads to improved outcomes for patients of other surgeons within the same environment. Dissemination and cross-pollination of new methods through resident, nurse, and case manager practice pattern modification creates a favorable force for change and this impact is sustained over a 3-year period.