ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Reimbursement for trauma care based on prospective payment has not been satisfactory. The Health Care Financing Administration introduced four new Multiple Significant Trauma (MST) DRGs in 1991 with the intention of covering patients who have had at least two body sites injured. To determine the effect if any on reimbursement, a sample of patients who were assigned the new DRGs over a 5-month period were analyzed. The analysis compared the calculated reimbursement for these 49 patients based on their total accumulated charges, DRG weights, and the average Medicare dollar blend along with the additional weight factor specific for the study facility. This analysis was compared with an additional analysis determining the reimbursement performed on the same patient sample but with DRG weights determined from DRGs derived from the 1989 DRG GROUPER/FINDER. During the 5-month study period, 5.5% of the patients discharged from the hospital had sustained at least one injury covered by ICD-9-CM codes. Of these, 49 (3.9%) were classified into one of the four new MST DRGs. The majority of patients were male (75.5%), the mean age was 31.8 years, and the total charges accumulated were $1,809,192.23. The calculated DRG-based reimbursement was $1,183,495.40, or 65.5% of the total charges. In the second part of the study, using the DRGs available in 1989 for the same sample of patients, the DRG-based reimbursement was $691,437.72, or only 38.2% of the accumulated charges. The study suggests that the new MST DRGs apply to a very small percentage of trauma patients admitted to a level I trauma center, and that the DRGs are stil not specific enough to describe the extent and severity of the injuries sustained, but that the overall reimbursement for the patients assigned these DRGs has improved. Further investigation is needed to improve the identification of patients with above-average charges and the influence of such factors as complexity of injuries, barriers to discharge, and combinations of injuries on eventual reimbursement when prospective payment is used.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

The APACHE II scoring system has been promulgated as a useful tool in the assessment of the severity of injury and prognosis for acutely ill patients. The physiologic basis for stratification is weighted toward older patients with chronic medical conditions. Recently, the APACHE II system has been proposed as a method for determining diagnosis related group (DRG) reimbursement for individual trauma patients. The present study applied the APACHE II scoring system to 280 patients with blunt or penetrating trauma who had documented systolic blood pressures <90 mm Hg. Fifty-seven (20%) died of their injuries within the first 24 hours. APACHE II scores were recorded both in the emergency room (ED) and at 24 hours following admission. Injury Severity Scores (ISS), Revised Trauma Scores (RTS), and TRISSCAN were calculated. The APACHE II (n = 223) recorded at 24 hours (2.5 ± 0.2) was significantly less than that recorded in the ED (6.6 ± 0.3,p< 0.05, Mann-Whitney analysis). Using regression analysis, there was no correlation between APACHE II and ISS if recorded in the ED (r2= 0.06) or 24 hours following admission (r2= 0.08). APACHE II also demonstrated a poor correlation with the length of hospital stay (r2= 0.03 [ED], = 0.19 [24 hours]). Whereas APACHE II may be helpful in defining severity of disease among patients with acute-on-chronic medical conditions, the classification lacks an anatomic component, which is essential to assess the magnitude of acute injury in patients who are typically otherwise healthy.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Treatment principles for penetrating neck trauma are well described yet few exist for facial injuries. To help delineate these issues, we viewed our recent experience with gunshot wounds to the face. Since 1986 we have treated 100 patients with such injuries. Their mean age was 28.9 years (range, 12–77 years). There were 89 male patients and 11 female patients. Ninety-six patients were considered stable on initial examination. Yet 35 patients required urgent airway control in the ED; only two needed a surgical airway. Emergency angiography was performed in 37 patients; 19 vascular injuries were identified. Eleven required therapy for vascular injuries, five by neck exploration and six by embolization. In 15 patients the trajectory suggested an intracranial injury, i.e., across the base of the skull. Although 14 of 16 patients were awake and alert at examination, head CT scans demonstrated serious intracranial pathologic processes in 9 patients. Sixty-seven patients sustained bony injury, 19 patients a significant nonvascular soft-tissue injury, and 38 patients a significant neurologic injury (26 peripheral, one spinal and 20 cerebral injuries). Ultimately, 44% of all patients required some surgical treatment and 25% had a complication from their injury. Six patients died, three of CNS injury, one of exsanguination, and two of sepsis. The bony, soft tissue, nervous, and vascular anatomy make the management of gunshot wounds to the face challenging. Although initially stable, many patients require early airway control and urgent work-up for vascular and intracranial injuries. Early subspecialty input is helpful in delineating the often complex injury pattern and planning an optimal management strategy.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

A randomized retrospective analysis of patients who suffered trauma-related deaths over 36 months (May 1987-April 1990) was performed to study their utilization as candidates for organ and tissue harvesting. There were a total of 108 patients: 79 males, 29 females. The average age was 46.2 years; 38 (36%) of these patients were 65 years of age or older. Over 50% of fatalities were the result of motor vehicle crashes. There were 61 potential tissue donors. Forty-three were lost without documentation of a request for organ procurement. There were 23 patients with potentially salvageable organs: one candidate was lost without documentation of a request for organ procurement. Twenty-eight (26%) of the patients had support withdrawn; 16 were 65 years old or older. Brain death protocol was instituted in 17 (20%); organs were obtained from 70% of these patients. Reasons for failure of procurement after request by a physician included family refusal in seven cases, cardiopulmonary arrest during brain death protocol in two cases, and religious bias in one candidate. Twelve patients were organ donors: 10 patients were tissue donors. We conclude that the greatest source of underutilization lies in the failure to request tissue for harvesting, since there were noisolatedtissue donors. Pertinent information should be more widely distributed to physicians regarding candidacy for tissue donation. Further consideration of the adequacy of organs or tissue in relation to the candidates' age should be given, since patients aged 65 years and older can be a significant source of potential donor candidates. The potential for growth in procurement is significant for those patients who meet criteria for organ or tissue harvesting.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Pressure support ventilation (PSV) is a new ventilator modality that augments spontaneous inspiratory pressure with selected levels of positive airway pressure. There is presently considerable interest in its use in the management of critically ill, ventilator-dependent patients. The optimal method for application has not yet been established. This study investigated the effects of PSV on the oxygen cost of breathing (OCOB), a clinically applicable technique for quantitating the work of breathing. The OCOB and other bedside variables of pulmonary function were measured during PSV in ventilator-dependent patients where weaning was limited by an inability to sustain respiratory work. Nine studies were performed in 8 patients in the surgical intensive care unit. The OCOB, tidal volume (VT), respiratory rate (RR), and minute ventilation (&OV0312;E) were measured at various levels of pressure support. The OCOB was calculated from the difference in oxygen consumption (&OV0312;O2) during mechanical and spontaneous ventilation both at CPAP and with PSV. With increasing levels of PSV, the OCOB was observed to steadily decrease from 22% to 8% (p<0.001). There were also statistically significant increases in VTand decreases in RR. &OV0312;Eappeared not to be influenced. The results of this study suggest that the bedside measurement of the OCOB may be an accurate, simple, and reproducible method of titrating the level of applied pressure support in order to optimize respiratory work.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

The diagnosis of pulmonary embolism (PE) may be difficult to establish in trauma patients, particularly those who are unresponsive or mechanically ventilated. Based on a prior retrospective study, we hypothesized that patients monitored by continuous pulse oximetry who experienced a 10% or greater sudden sustained drop in arterial oxygen saturation (Sao2) without a change in static lung compliance (Cst) were most likely to have had a PE. We followed Sao2in 972 patients admitted to our trauma ICU during the 18-month period ending in December 1990. Forty-eight patients (5%) with Sao2changes, but no Cst changes, were evaluated for suspected PE using pulmonary arteriography (PA). Of these, 21 (44%) had a positive PA study. All patients with a positive PA had either clear chest roentgenograms or no change in underlying pulmonary pathologic processes. Of the remainder, 26 had evidence of a new pathologic entity on chest roentgenograms and only one patient had a Sao2decrease, no change in Cst, and a negative PA. All mechanically ventilated trauma patients should have Sao2monitored continuously. Patients with a >10% drop in Sao2with no change in Cst and no new roentgenographic chest findings should undergo PA. Based on our experience, this approach would yield a sensitivity, specificity, and predictive value of 100%, 99.9%, and 95%, respectively, for the diagnosis ofclinically significantPE.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Many surgeons advocate repair of venous injuries to prevent the sequelae of venous ligation. Since 1986, we have treated 74 patients with 79 venous injuries of the lower extremity or pelvis. There were 68 men and six women with a mean age of 29.2 years (range, 16–62 years). The mechanisms of injury were gunshot wounds in 61 patients, stab wounds in 11 patients, and shotgun wounds and blunt trauma in one patient each. Forty-eight injuries were treated by ligation; 31 injuries were treated by repair. Repairs inclucded two interposition grafts, eight end-to-end repairs, 16 venorrhaphies, and five vein patches. In addition, we developed a venous injury staging system (VIS), which ranged from grade I (less than 50% laceration) to grade IV (complete interruption with soft-tissue injury). Patient age, mechanism, location of injury, associated injuries, and incidence of arterial injury were not different between the patients treated by ligation and those treated by repair. Patients treated with venous ligation had a greater VIS (mean, 3.45 vs. 2.0), a greater incidence of shock (71% vs. 39%), and higher transfusion requirements (9.23 vs. 4.82 units). Postoperative morbidity rates were identical, however. There was no increase in the need for fasciotomy in patients treated with venous ligation. Eighty-six percent of the patients treated by ligation were totally free of edema at discharge. The others had only mild edema that did not interfere with daily activities at discharge and follow-up. Ligation is a safe alternative to repair in patients with injuries to the lower extremities or pelvis. There is no increase in postoperative morbidity, need for fasciotomy, or leg edema. It is especially useful in the management of patients for whom prolongation of surgical time is unsafe.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

A 1990 national survey of 66 closed trauma centers across 14 states was conducted to ascentain the factors that promoted closure. Data from 44 facilities, or 67% of the centers identified, indicate that inadequate financing and physican participation were comonplace. The findings support the work of other investigators and demonstrate that uncompensated care, inadequate reimbursement, high operating costs, and lack of physician support all adversel affect trauma care in both urban and suburban settings.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Hospital-based helicopter services from a German (GER) and an American (AMR) university-affiliated trauma center were reviewed. All patients with multiple injuries transported via helicopter from the scene to the trauma centers during a 1-year period were included. The patients were comparable regarding mechanism of injury, age, flight times, mean ISS, ISS distribution, and number of severe injuries per body region (patients with AIS score > 3 for head, thorax, and abdomen). Overall mortality was 21 of 221 (9.5%) for GER and 21 of 186 (11.3%) for AMR (NS). Survivor-based TRISS analysis yieldedZstatistics of +2.459 for GER (p< 0.025) and +1.049 for AMR (NS). M statistics were 0.89 for GER, 0.874 for AMR; the W statistic +1.35 for GER. There were nine unexpected survivors (Ps < 0.50) for GER and six for AMR. There was a significantly higher (p< 0.01) number of early deaths (<6 hours) in AMR (12; ISS = 56) than in GER (four; ISS = 64). Analysis of the prehospital data demonstrated significant differences in the mean volume of IV fluids infused: 1800 mL, GER; 825 mL, AMR (p< 0.05); rate of intubation: 82 of 221 (37.1%) GER; 24 of 186 (13.4%) AMR (p< 0.001); and thoracic decompressions: 20 of 221 (9.1%) GER; 1 of 186 (0.5%) AMR (p< 0.001). Prehospital care in the GER system is directed on scene by a trauma surgeon member of the flight crew compared with a nurse/ paramedic team with remote medical control in the AMR system. Compared with an AMR trauma system, the GER system demonstrated improved overall outcome as measured by survivor-based TRISSZstatistics. More favorable GERZstatistics are, in part, related to fewer early deaths. With the on-scene experience and judgment of a trauma surgeon, the GER aeromedical system provided more aggressive prehospital resuscitation, particularly in the areas of airway and ventilation management.

ISSN:0022-5282    

出版商:OVID    

年代:1992

数据来源: OVID