Four-year assessment of a day hospital-inn program as an alternative to inpatient hospitalization

The authors report on a new system of care in which all patients who require psychiatric hospitalization are admitted to a day hospital with an inn and an intensive care unit. Data on use of services, length of stay, recidivism, security, medical emergencies, staff accidents, and seclusion and restraint over a 4-year period suggest that the new delivery system provides care which is at least as effective as the previous system of care. Evidence is presented that the new system offers certain advantages, including less seclusion and restraint, fewer episodes of escape, and substantial cost savings.     

Laparoscopic Roux-en-Y gastric bypass: results and learning curve of a high-volume academic program

HYPOTHESIS: Laparoscopic Roux-en-Y gastric bypass is a complex procedure performed on a high-risk patient population. Good results can be attained with experience and volume. DESIGN: Retrospective study. SETTING: Tertiary care academic hospital. PATIENTS: Seven hundred fifty consecutive morbidly obese patients undergoing surgery from March 1998 to April 2004. INTERVENTIONS: All patients underwent laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOME MEASURES: Perioperative deaths and complications. RESULTS: The patient population was 85% women and had a mean body mass index of 47 kg/m2 (range, 32-86 kg/m2). The overall complication rate was 15% and the mortality was 0.3%. For the first 100 cases, the overall complication rate was 26% with a mortality of 1%. This complication rate decreased to approximately 13% and was stable for the next 650 patients. The incidence of major complications has also decreased since the first 100 cases. Leak decreased from 3% to 1.1%. Small-bowel obstruction decreased from 5% to 1.1%. Overall mean operating time was 138 minutes (range, 65-310 minutes). It decreased from 212 minutes for the first 100 cases to 132 minutes for the next 650 and 105 minutes (range, 65-200 minutes) for the last 100 cases. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is a technically difficult operation. This review of a large series in a high-volume program demonstrated that the morbidity and mortality could be reduced by 50% with experience. The results are similar to those reported from other major centers. In addition, as reported elsewhere, the learning curve for this procedure may be 100 cases.