Hospitals, physicians need to be allies, not adversaries

The only way to bring hospital costs under control without sacrificing quality is to end the adversarial relationship between administration and physician staff, says Philip Hoggard. It's time to integrate the two camps into a shared organizational model that allocates risks and rewards fairly.     

HEDIS outcomes may not be the only ones you need to benchmark

The Foundation for Accountability (FACCT), a coalition of employers, is leading a trend away from process-oriented performance measures by generating patient-centered data sets for a variety of disease states, including asthma, diabetes, and depression. Many large employers, dissatisfied with the National Center for Quality Assurance's focus on cost, are pressuring managed care organizations to use the FACCT measures, which largely rely on patient self-reports about the care they receive. Some plans are using the data sets voluntarily, as a tool to better assess the quality of services they provide and to evaluate physician groups.     

Jejunostomy tube feedings should not be stopped in the perioperative patient

BACKGROUND: Anesthetic standard of care is to restrict oral intake for 8 hours before elective surgery. There is no research addressing appropriate preoperative discontinuation of jejunostomy tube (J-tube) feedings. We hypothesized that patients could be fed safely, via a J-tube, until the time of surgery. METHODS: Patients admitted to a Level I Trauma Center, having J-tubes and undergoing a nonabdominal operation, were prospectively evaluated. Group I patients received J-tube feedings until transport to the operating room. Group II patients had tube feedings discontinued for at least 8 hours before surgery. Data were compared using the Student's t test and contingency table analysis. Results: There were 46 patients in group I and 36 in group II. There was no incidence of aspiration. Patient groups did not differ in age, mortality, length of stay, injury severity score, or ventilator days. Group I patients had tube feedings discontinued for fewer hours before and after surgery than group II patients (before surgery: 1.40 +/- 1.20 vs 11.61 +/- 5.01, respectively; p < .001; after surgery: 2.99 +/- 7.49 vs 7.11 +/- 9.03, respectively; p = .043); received more kilocalories/ grams of protein on the day of surgery (group I vs group II, 1676.15/89.57 +/- 1133.21/38.04 vs 791.14/57.58 +/-498.66/79.87, respectively; p = .001/p = .032) and more kilocalories/grams of protein on the first postoperative day (group I vs group II, 1580.74/92.57 +/- 600.53/37.96 vs 1152.47/63.53 +/- 733.96/39.40, respectively; p = .006/p = .001). CONCLUSIONS: Patients receiving J-tubes who are undergoing nonabdominal operations may safely continue enteral nutrition at maximum protein and caloric intake until surgery.     

Transfer of the thermally injured patient

Treatment of a patient with a severe thermal injury differs greatly from that of a victim of multiple trauma: if there have been no other injuries, the burned patient will be transferred as soon as possible to a regional burns unit. Our suggested protocol highlights the differences and their management.     

Plaintiff in transfusion suit is not entitled to full insurance records

A New York judge has refused to give David Weiner, the survivor in a blood-transfusion case, access to the financial status of the hospital where the HIV-tainted blood was dispensed. Weiner demanded that the hospital provide information about pending and paid insurance claims for the period of time when his mother received two blood transfusions at Lenox Hill Hospital. When the hospital refused, Weiner sued Lenox Hill and the New York Blood Center on behalf of himself and as administrator of his mother's estate. However, a state Supreme Court justice for New York County refused Weiner's request and granted a protective order in favor of the hospital. The judge criticized other courts for engaging in judicial legislation to liberally interpret the state statute, CPLR 3101(f), which governs the discoverability of insurance information.     

Metronidazole need not be combined with an aminoglycoside when used for prophylaxis in elective colorectal surgery

A prospective randomized controlled study has compared prophylactic intravenous metronidazole alone with the combination of metronidazole and gentamicin in 100 patients having elective colorectal surgery. There was no significant difference in mortality, infection, dehiscence or postoperative stay between the antibiotic groups. Postoperative sepsis was almost entirely due to aerobic organisms but was associated with minimal morbidity. A significantly higher rate of anastomotic dehiscence and postoperative infection was seen where the quality of bowel preparation was judged to be poor.     

Transportation of the critically ill and injured patient

Transferring the seriously ill and injured is becoming a more formalized procedure in the UK. Whether from an accident site to medical care or between hospitals, the public expects that organized services are in place for safe patient transfer. As this is a developing subspeciality it is necessary to review the developments that have occurred over the previous 5 years.