Search

Background: Late afternoon hospital discharges are thought to contribute to admission bottlenecks. We previously described an intervention that resulted in a statistically significant increase in the discharge before noon (DBN) rate on 2 inpatient medicine units., Objective: To evaluate (1) the effect of an increased DBN rate on the admission arrival time and the number of admissions per hour and (2) the sustainability of our DBN initiative., Design: Pre-/postintervention retrospective analysis., Setting: Two acute-care inpatient medicine units in a tertiary care, urban, academic medical center., Patients: For the admission arrival time and admissions per hour analysis, all inpatients admitted to the medical units from June 1, 2011 to June 31, 2013. For the sustainability analysis, all patients discharged from July 1, 2013 to December 31, 2014., Intervention: A multidisciplinary intervention to increase the DBN rate., Measurements: Date and time of arrival to all inpatient sites, and discharge date and time of all patients from 2 inpatient medicine units., Results: Concurrent with our increase in DBN rate, we found a statistically significant change in the median arrival time of emergency department (ED) admissions and transfers from 5 pm to 4 pm. High-frequency admission peaks were statistically significantly reduced for ED admissions. The statistically significant increase in DBN rate is sustained at 35%., Conclusions: Increasing the DBN rate correlates with admissions arriving earlier in the day and reductions in high-frequency peaks of ED admissions. Statistically significant improvements in DBN rates are sustainable., (© 2015 Society of Hospital Medicine.)

Background: Late afternoon hospital discharges are thought to contribute to admission bottlenecks, overcrowding, and increased length of stay (LOS). In January 2012, the discharge before noon (DBN) percentage on 2 medical units was 7%, below the organizational goal of 30%., Objective: To sustainably achieve a DBN rate of 30% and to evaluate the effect of this intervention on observed-to-expected (O/E) LOS and 30-day readmission rate., Design: Pre-/post-intervention retrospective analysis., Setting: Two acute care inpatient medical units in an urban, academic medical center., Patients: All inpatients discharged from the units., Intervention: All staff helped create a checklist of daily responsibilities at a DBN kickoff event. We initiated afternoon interdisciplinary rounds to identify next-day DBNs and created a website for enhanced communication. We provided daily feedback on the DBN percentage, rewards for success, and real-time opportunities for case review., Measurements: Calendar month DBN percentage, O/E LOS, and 30-day readmission rate., Results: The DBN percentage increased from 11% in the 8-month baseline period to an average of 38% over the 13-month intervention (P = 0.0002). The average discharge time moved 1 hour and 31 minutes earlier in the day. The O/E LOS declined from 1.06 to 0.96 (P = 0.0001), and the 30-day readmission rate declined from 14.3% to 13.1% (P = 0.1902)., Conclusions: Our study demonstrates that increased DBN is an achievable and sustainable goal for hospitals. Future work will allow for better understanding of the full effects of such an intervention on patient outcomes and hospital metrics., (© 2014 Society of Hospital Medicine.)

Background: The clinical significance of occult hepatitis B virus (HBV) infection, defined as the presence of HBV DNA in individuals with HBV core antibodies (anti-HBc) in the absence of HBV surface antigen (HBsAg), is unclear in HIV-infected patients. This information is needed to determine the importance of detecting and treating occult HBV in this population., Objective: To determine if HIV-infected patients with occult HBV infection have an increased incidence of transaminitis., Study Design: We performed a cohort study among randomly selected HBsAg-/anti-HBc+ HIV-infected patients in the Penn CFAR Database and Specimen Repository. HBV DNA was qualitatively detected using a transcription-mediated amplification assay. Hepatic transaminase levels, the main study outcome, were collected at 6-month intervals from the time of occult HBV determination., Results: Among 97 randomly selected subjects without baseline transaminitis, 13 (13%) had occult HBV. These subjects more frequently had detectable HIV RNA. The 2-year incidence of transaminitis among HIV-infected subjects with occult HBV (50 events/100 person-years) was not significantly different from those without occult HBV (38 events/100 person-years; adjusted incidence rate ratio=1.36 [95% CI, 0.72-2.59])., Conclusions: Occult HBV did not increase the incidence of hepatic transaminitis over 2 years. Future studies should determine whether occult HBV is associated with other clinically important outcomes, particularly hepatocellular carcinoma.

Aim: To evaluate minimal fixation method with Kirschner's wires in the treatment of open fractures of the hand and foot short bones, caused by explosive devices., Method: There were 270 wounded persons with open fractures of hand and foot short bones, who were surgically treated at the Department of Surgery at the Osijek University Hospital. The stabilization of an unstable open fracture was performed with intramedullary positioned Kirschner's wires. In a few cases, satisfactory stabilization was achieved with Kirschner's wires positioned percutaneously alongside the wound and perpendicularly through the fracture. In the rest of the wounded, plaster immobilization was sufficient after surgical treatment and fracture reposition., Results: Among 270 persons with 412 open hand and foot bone fractures, 49% had fracture only in the feet, 27% only in the hands, and 24% in both hands and feet. Unstable short bone fractures were found in 56 patients (21%). Such fractures were stabilized with Kirschner's wires (n=71). In 58 patients (21%) partial hand and foot amputations had to be performed. Reconstructive operations to improve pseudarthrosis after minimal osteosynthesis were performed on 5 short bones (7%). Osteitis was found on four short bones (6%) after minimal osteosynthesis., Conclusion: Minimal osteosynthesis with Kirschner's wires is a reliable and adequate method of the treatment of open unstable short bone fractures caused by explosive devices.

Reconstruction of blood vessels after war injuries is mandatory for life and limb salvage. In an effort to prevent prolonged major bleeding and make reconstruction quicker and technically more comfortable, thigh pneumatic tourniquet occlusion was performed pre- and intraoperatively in eleven of 53 wounded with injuries of the arteries of the lower extremities during 1991/92 war against Croatia at the Department of Surgery, Osijek Clinical Hospital. This method benefits life and limb salvage under war conditions.

During 18 months' period of war in northeastern Croatia 38 wounded with injuries of lower extremity arteries were operated on in Osijek Department of Surgery demanding the use of substitute conduit for vascular reconstruction; 26 synthetic prosthesis and 12 vein grafts were applied. Ankle-brachial index and life-table method were used for the construction of the initial and cumulative limb salvage rate at 40 months. Cumulative graft patency and limb salvage rates for synthetic grafts was 87.67% +/- 6.9 and for vein grafts 91.67% +/- 8.0 respectively and did not differ significantly for both synthetic prosthesis and autologous vein grafts.

During 18 months of the 1991-1992 war against Croatia, 14 persons wounded by antipersonnel mines were admitted to the Department of Surgery at Osijek University Hospital. Twelve had injury of the calcaneal region. Kirschner wires were used for minimal osteosynthesis. Delayed wound closure was performed 14 to 21 days after injury. The methods used were delayed direct closure, split skin-thickness graft, or microvascular free flaps. Osteitis did not develop, and all patients walked with full weight after 1 year.

During 18 months of the 1991-1992 war against Croatia, 4425 injured were treated at the Department of Surgery, Osijek University Hospital. Among them 46 had tendon injuries, 20 with tendon laceration and 26 with total rupture. In 12 wounded primary repair was performed, 4 of an extensor tendon, 7 of a flexor tendon and 1 of both flexor and extensor. Four patients with primary flexor tendon repair had a good functional result. In other 34 no primary repair was done. Good function was achieved in 18 cases.

During the war against Croatia in 1991-1992, 85 wounded with war injuries of major vessels in the extremities were admitted to the Department of Surgery, Osijek Clinical Hospital. These 85 included 13 (15.3%) wounded with injuries of the popliteal artery. In 12 cases an allograft was used as a substitute conduit. One early thrombosis and two infections occurred. Two amputations had to be performed because of massive soft tissue destruction and infection in the leg tissue. Our experience shows that an allograft is an acceptable choice for popliteal artery reconstruction in a highly contaminated war wound.

During the war in Croatia, the surgical department of Osijek Hospital was the place of primary and definitive surgical management of the wounded from the city of Osijek and the entire northeastern region of Croatia. Our surgical experience with the management of war injuries of major extremity vessels, collected from May 2, 1991, through April 12, 1992, is reviewed. During that time, 60 wounded were admitted to the hospital with injuries of major blood vessels of the extremities, all of them directly from the battlefield or from the streets of Osijek. The method of surgical treatment depended on the type of vascular injury and associated injuries. Our methods were arterial injury reconstruction and monitoring of the early results when autogenous vein grafts or synthetic prostheses were used. The results indicate that one should not resist using synthetics for reconstruction of arterial injuries in a highly contaminated area.

A four-year-old girl who sustained an explosive injury to the femoral artery and vein underwent vascular reconstruction. An allograft was used as a substitute conduit for both the artery and the vein. Eight months after reconstruction there was no pulse deficit and decrease in systolic blood pressure, nor were there any signs of venous obstruction.

In the period of aggression of the Federal Army and Serbian paramilitary forces on the City of Osijek and its surrounding, beginning in the summer of 1991, 4036 wounded were treated at the Department of Surgery, Osijek General Hospital. Extremity injuries were documented in 3889 patients, including 959 bone fractures. The majority of patients had wounds caused by highly destructive explosives filled with metal fragments of different shapes and dimensions, and having sharp and uneven edges. One hundred and forty wounded were treated by external fixators. In 102 patients this mode of fixation was applied for gun- and explosive-related long bone fractures of the lower extremities. External fixator for the upper and forearm fractures was used in 38 cases. During this period, different types of external fixators were used and experience in this work has been gained. Stability of both open and unstable bone fractures of the extremities, caused by explosive devices, has been obtained by the external fixation mostly in one plane, regardless of the type of external fixator used. The advantages of use of external fixators of the types Instrumentarija Zagreb 1 and 2 for the treatment of long bone fractures has been emphasized as well as the possibility of the subsequent corrections owing to the technical construction of the bone spike. The usefulness of the longitudinal bar of the AO/ASIF fixator for the healing of fractures of the upper leg with subsequent callus formation is also stressed. The same stability has been achieved by the CMC fixator. The external fixators of a type Zagreb 2 have been a satisfactory treatment for forearm fractures as well.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphologic and osteogenetic changes of the hip joint in patients with coxarthrosis were studied. Examination included 224 patients treated and operated on Department of Orthopaedics, Clinic Hospital Osijek. Coxarthrosis was proved in 331 hips, 183 cases (55,29%) referred to a secondary and 148 844,71%) to primary arthrosis. Osteogenetic changes on the head of femur were found in 148 x-rays (44,71%). The upper osteophyte of the head of femur was found in 79 x-rays of the hip (22,36%) but lower osteophyte of the head of femur only in 26 cases (7,85%). In 48 x-rays (14,50%) osteophytes were found both on the upper and lower sides of the head of femur. 217 x-rays of hips (65,56%) proved the existence of medial cervial osteophyte, according to frequency mostly type 1. Osteophyte of the roof of acetabulum were expressed on 158 x-rays (44,73). The double bottom of the acetabulum was studied on several measurement levels and showed from 0,24 to 2,35 mm observed from cranial to caudal measurement levels. The studies proved that the patients with coxarthrosis experienced a number of morphological and osteogenetic changes on the head and neck of femur as well as on the acetabulum. Their features on x-rays will depend on the cause and degree of the development of coxarthrosis.