Helping Hands for Blood Conservation Techniques and Perioperative Planning Part 7 May 2001
The List of Clinics with Special Blood Conservation Programs is by no means complete It does not take position as to the size of the clinic nor compare it with other clinics or make recommendations for some of them to be used in a special situation. Some of the clinics are small , others are big multidiciplinary Centers. But it tells us something about the special techniques used and the number of clinics using them , and it can help us to see where some of them can be found, and also gives an idea of the effectiveness of the methods. We doe not recommend any particular clinic nor doe we recommend any specific treatment.
Table of Contents Table of Contents...... 1 STARTING SPECIAL BLOOD CONSERVATION PROGRAMS ...... 6 Introduction...... 6 CLINICS WITH SPECIAL BLOOD CONSERVATION PROGRAMS ...... 10 1. AUSTRALIA...... 10 1) KALEEYA HOSPITAL MEDICAL CENTRE...... 10 Fremantle Kaleeya Hospital - East Freemantle 6158, WA, AT ...... 10 2. UNITED KINGDOM (UK)...... 11 A. Community Hospitals Group Plc...... 11 1) Ashtead Hospital...... 11 2) Duchy Hospital ...... 11 3) Fitzwilliam Hospital ...... 11 4) Mount Stuart Hospital...... 11 5) Oaks Hospital...... 11 6) Pinhill Hospital ...... 11 7) The Rivers Hospital ...... 11 8) Springfield Medical Centre...... 12 9) Winfield Hospital...... 12 10) The Yorkshire Clinic ...... 12 3. ISRAEL ...... 12 A. Holon ...... 12 1) Wolfson Medical Center ...... 12 4. SCHWEIZ...... 15 1. Clinique Cecil Lausanne ...... 15 1. Participating departments...... 16 a. Surgery ...... 16 b. Medicine...... 16 c. Obstetrics...... 16 5. SWEDEN...... 17 1. Sahlgrenska University Hospital Gothenburg...... 17 1. Participating departments...... 17 2. Participating doctors...... 17 2. Lund University Hospital Lund, Sweden...... 17 K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 2
1. Participating departments...... 17 2. Participating doctors...... 17 3. Linköping University Hospital Linköping, Sweden ...... 18 1. Participating departments...... 18 2. Participating doctors...... 18 4. Nu-Medical Service—Uddevalla Hospital Uddevalla, Sweden...... 18 1. Participating departments...... 18 2. Participating doctors...... 18 1) Uddevalla Hospital Orthopedic Clinic...... 18 The Brochure: ...... 18 a. MEASURES AVAILABLE AT UDDEVALLA HOSPITAL BLOODCONSERVATION TEAM .. 18 1. Anaesthesiological methods...... 19 Acute Haemodilution ...... 19 Cell Saver ...... 19 Separation of Plasma and Platelets...... 19 Platelet Gel ...... 19 Hypotensive Anaesthesia ...... 19 2. Intraoperative drugs ...... 19 Desmopressin (DDAVP)...... 19 Tranexamic Acid (TA) ...... 19 3. Surgical devices and supplies...... 19 Cautery (including Argon Beam Coagulator (ABC) ...... 19 Laser...... 19 Surgicel, Spongostan, Avitene,Tisseel ,Bone wax, Local Anaesthesia with Adrenaline...... 19 POSTOPERATIVE MEASURES...... 19 1. Continued blood loss postoperatively...... 19 - Cell Saver connected to drainage tube (Maximum 6 hours) ...... 19 - Antifibrinolytic Drugs (Desmopressin, Tranexamic Acid) ...... 20 - Consider early re-operation if blood loss is great...... 20 2. Postoperative anaemia to such a degree that blood transfusion is normally indicated ...... 20 - IV injection of Erythropoietin 10. 000 U/day...... 20 - Iron ( IM or IV) [ IM Jectofer 50mg Fe3+/ml , 1.5 mg/kg/day]...... 20 - [IV Venofer(follow instructions) 100-200mg/day(Adults)]...... 20 - IM injection of Vitamin B12 1mg/day ...... 20 - Oral administration of Folic Acid 5 mg x 2 /day...... 20 - Reduce Blood sampling to the minimum necessary...... 20 3. Life-threatening situations...... 20 - Consider Hyperbaric Oxygen Therapy (HBO)[Hyperbaric Chamber]...... 20 - Bettering Coagulation Status(Consider injection of Protamine if there is a...... 20 - definite association between bleeding and an exess Heparin dosage)...... 20 Contact persons at Uddevalla Hospital:...... 20 5. Uppsala Academic Hospital Uppsala, Sweden ...... 20 1. Participating department ...... 21 6. UNITED STATES OF AMERICA (U.S.A.)...... 21 I. ALABAMA...... 21 1) Brookwood Medical Center - Birmingham, AL, US ...... 21 2) DCH Regional Medical Center ...... 21 3) DCH Regional Medical Center - Tuscaloosa, AL, US...... 21 4) UAB Hospital...... 22 II. ARIZONA...... 26 1) St. Luke's Medical Center - Phoenix, AZ, US ...... 26 2) Tucson General Hospital - Tucson, AZ, US ...... 26 III. CALIFORNIA ...... 26 1) Alvarado Hospital Medical Center - San Diego, CA, US ...... 26 2) Anaheim General Hospital Information Services - Anaheim, CA, US ...... 27 3) Bloodless Healthcare Systems, Inc. Santa Ana Hospital Medical Center...... 28 4) Bloodless Healthcare Systems, Inc...... 28 Pediatric Bloodless Options...... 28 5) Brotman Medical Center - Culver City, CA, US ...... 28 6) Centinela Hospital Medical Center - Inglewood, CA, US ...... 30 K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 3
7) Coast Plaza Doctor's Hospital - Norwalk, CA, US ...... 30 8) Community Hospital of Los Gatos - Los Gatos, CA, US ...... 31 9) Corona Regional Medical Center - Corona, CA, US ...... 31 10) Desert Regional Medical Center - Palms Springs, CA, US ...... 31 11) Doctor's Medical Center - Modesto, CA, US...... 31 Articles: ...... 32 12) Encino-Tarzana North Hollywood Hospitals & Healthcare Network...... 32 a. Tarzana Location: Encino-Tarzana Regional Medical Center - Tarzana, CA, US ...... 33 b. Encion Location:...... 34 c. North Hollywood Location:...... 34 13) Fountain Valley Regional Hospital and Medical Center - Fountain Valley, CA, US ...... 34 14) French Hospital and Medical Center - San Luis, Obispo, CA, US ...... 35 15) Glendale Memorial Hospital and Health Center - Glendale, CA, US...... 35 16) Good Samaritan Hospital - Bakersfield, CA, US...... 35 17) Good Samaritan Hospital - Los Angeles, CA, US ...... 36 18) John F. Kennedy Memorial Hospital - Indio, CA, US ...... 37 19) John Muir Medical Center - Walnut Creek, CA, US ...... 37 20) Long Beach Community Medical Center - Long Beach, CA, US ...... 40 21) Presbyterian Intercommunity Hospital...... 40 22) San Ramon Regional Medical Center - San Ramon, CA, US...... 41 23) Sierra Vista Regional Medical Center - San Luis Obispo, CA, US ...... 42 24) St. Jude Medical Center - Fullerton, CA, US...... 43 25) St. Luke's Medical Center - Pasadena, CA, US...... 45 26) Temple Community Hospital - Los Angeles, CA, US ...... 45 27) Twin Cities Community Hospital - Templeton, CA, US ...... 46 28) USC University Hospital - Los Angeles, CA, US...... 46 29) USC Kenneth Norris Comprehensive Cancer Center and Hospital - Los Angeles, CA, US ...... 46 30) Valley Community Hospital - Santa Maria, CA, US ...... 46 31) Western Medical Center Anaheim - Anaheim, CA, US...... 46 32) Whittier Hospital Medical Center - Whittier, CA, US ...... 47 IV. COLORADO ...... 47 1) University Hospital - Denver, CO, US...... 47 V. CONNECTICUT ...... 49 1) Bridgeport Hospital - Bridgeport, CT, US ...... 49 2) Hartford Hospital - Hartford, CT, US ...... 50 VI. FLORIDA...... 51 1) Coral Gables Hospital - Coral Gables, FL, US ...... 51 2) Florida Medical Center - Fort Lauderdale, FL, US...... 51 3) Holy Cross Hospital...... 51 4) Jackson Memorial Hospital...... 53 5) St. Vincent's Medical Center...... 53 6) University General Hospital of Seminole ...... 53 7) Women's Hospital and Medical Center...... 53 8) University of Miami - Jackson Memorial Hospital / Memorial Center - Miami, FL, US...... 53 VII. GEORGIA...... 54 1) St. Joseph's Hospital - Savannah, GA, US ...... 54 VIII.HAWAII ...... 54 1)Palmetto General Hospital - Hi, , ...... 54 IX. ILLINOIS ...... 54 1) Northwest Community Hospital - Arlington Heights, IL, US...... 54 2) Our Lady of the Resurrection Medical Center - Chicago, IL, US...... 55 3) Illinois Center for Bloodless Medicine and Surgery at Proctor Hospital - Peoria, IL, US...... 56 X. INDIANA ...... 56 1) Winona Memorial Hospital - Indianapolis, IN, US...... 56 XI. KENTUCKY ...... 57 1) Audobon Regional Medical Center...... 57 2) Jewish Hospital ...... 57 XII. LOUISIANA ...... 57 1) Memorial Medical Center - New Orleans, LA, US...... 57 2) Sisters of Charity-St. Patrick Hospital - Lake Charles, LA, US...... 58 K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 4
XIII. MAINE ...... 58 1) Brighton Medical Center...... 58 XIV. MARYLAND ...... 58 1) Church Hospital Corporation ...... 58 XV. MASSACHUSETTS...... 58 1) University of Massachusetts Medical Center - Worcester, MA, US...... 58 XVI. MICHIGAN...... 58 1) Genesys Regional Medical Center - Grand Blanc, MI, US...... 58 2) Mercy Hospital - Detroit, MI, US ...... 58 3) St. Mary's Health Services - Grand Rapids, MI, US ...... 59 XVII. MINNESOTA...... 59 1) Hennepin County Medical Center - Minneapolis, MN, US ...... 59 XVIII. MISSOURI...... 61 1) Gulf Coast Medical Center - Biloxi, MS, US...... 61 XIX. MONTANA...... 61 1) St. Vincent's Hospital and Health Center - Billings, MT, US ...... 61 XX. NEBRASKA ...... 62 1) Saint Joseph Hospital at Creighton University Medical Center - Omaha, NE, US...... 62 XXI. NEW JERSEY ...... 62 1) Cooper Hospital-University Medical Center - Camden, NJ, US...... 62 2) The New Jersey Institute for the Advancement of Bloodless Medicine and Surgery at Englewood Hospital and Medical Center - Englewood, NJ, US ...... 64 3) Hackensack University Medical Center - Hackensack, NJ, US...... 65 4) UMDNJ-University Hospital ...... 65 XXII. NEVADA ...... 70 1) Lake Mead Hospital Medical Center - N. Las Vegas, NV, US...... 70 XXIII. NEW YORK ...... 70 1) Brookdale University Hospital Medical Center - Brooklyn, NY, US ...... 70 2) Buffalo General Hospital ...... 70 3) Long Island College Hospital...... 70 4) New York Methodist Hospital - Brooklyn, NY, US ...... 71 5) The New York Center for Bloodless Medicine and Surgery at the Long Island College Hospital - Brooklyn Heights, NY, US...... 71 6) Staten Island University Hospital - Staten Island, NY, US...... 71 7) The New York Hospital-Cornell Medical Center - New York, NY, US...... 71 8) Westchester Square Medical Center - Bronx, NY, US ...... 72 XXIV. OHIO ...... 72 1) Flower Hospital - Sylvania, OH, US...... 72 2) St. Vincent Charity Hospital and Columbia St. John West Shore - Cleveland, OH, US...... 72 3) The Cleveland Clinic Foundation - Cleveland, OH, US ...... 73 XXV. OKLAHOMA...... 73 1) Tulsa Regional Medical Center - Tulsa, OK, US...... 73 XXVI. OREGON...... 74 1) Emanuel Hospital and Health Ctr...... 74 2) Legacy Portland Hospitals Good Samaritan and Emanuel Children's - Portland, OR, US ...... 74 XXVII. PENNSYLVANIA ...... 76 1) Allegheny General Hospital - Pittsburgh, PA, US ...... 76 2) The Graduate Hospital ...... 78 3) The Center for Bloodless Medicine and Surgery, Pennsylvania Hospital - Philadelphia, PA, US 79 XXVIII. RHODE ISLAND ...... 79 1) Rhode Island Hospital - Providence, RI, US...... 79 XXIX. SOUTH CAROLINA...... 81 1) Roper Hospital - Charleston, SC, US...... 81 Articles...... 81 XXX. TENNESSEE ...... 82 1) St. Thomas Hospital - Nashville, TN, US...... 82 2) UT Bowld Hospital - Memphis, TN, US ...... 83 XXXI. TEXAS...... 84 1) Metropolitan Methodist Hospital - San Antonio, TX, US...... 84 2) Mission Hospital - Mission, TX, US...... 84 K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 5
3) Trinity Medical Center...... 84 4) Doctors Hospital of Dallas...... 85 5) American Medical International, Inc...... 86 a. Mid-Jefferson Hospital ...... 86 b. Park Place Medical Center...... 86 6) Sisters of Charity St. John Hospital - Nassau Bay, TX, US...... 86 7) Tenet Doctors Hospital - Dallas, TX, US...... 86 8) Tenet Park Place Med. Center & Mid Jefferson Hospital - Port Arthur, TX, US ...... 87 9) Tenet Park Plaza Hospital - Houston, TX, US...... 87 10) Trinity Medical Center - Carrollton, TX, US...... 87 XXXIII. PHILADELPHIA ...... 88 1) Center for Bloodless Medicine and Surgery - Graduate Hospital - Philadelphia, PA, US...... 88 XXVI. UTAH ...... 88 1) McKay-Dee Hospital Center - Ogden, UT, US...... 88 XXVII. WASHINGTON ...... 89 1) Kadlec Medical Center - Richland, WA, US ...... 89 2) Providence of Seattle Medical Center - Seattle, WA, US ...... 90 3) Puget Sound Hospital - Tacoma, WA, US ...... 94 4) Tri-City Regional Surgery Center - Richland, WA, US...... 95
K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 6
STARTING SPECIAL BLOOD CONSERVATION PROGRAMS
Introduction
(1) (1) Egger E TENET HOSPITALS LEADING WAY IN TREND TOWARD BLOODLESS SURGERIES. Health Care Strateg Manage 1999 Jan;17(1):17 (2) Trovarelli T, Kahn B, Vernon S TRANSFUSION-FREE SURGERY IS A TREATMENT PLAN FOR ALL PATIENTS. AORN J 1998 Nov;68(5):773-8, 780-4 Ortho Biotech, Cliffside Park, NJ, USA. Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal. (3) Bierbaum BE, Meehan JP BLOOD CONSERVATION IN TOTAL JOINT ARTHROPLASTY. Orthopedics 1998 Sep;21(9):989-90 New England Baptist Hospital, Boston, Mass, USA (4) Geier K PERIOPERATIVE BLOOD MANAGEMENT. Orthop Nurs 1998 Jan-Feb;17(1 Suppl):6-36; quiz 37-8 Webster Orthopaedic Medical Group, Oakland, California, USA. Perioperative blood management has evolved in recent years, and new approaches to blood conservation and replacement have dramatically changed the treatment of surgical patients. This article addresses the historical continuum of blood transfusions and describes current standards of practice in perioperative blood management in orthopaedic patients. Certain elective orthopaedic procedures lend themselves well to preoperative planning for blood loss. Since total joint arthroplasty can be associated with large volume blood loss, planning to replace lost blood is mandatory. Allogeneic, designated (or directed) donor, and autologous blood transfusion have been the standard of practice for blood replacement until very recently. Epoetin alfa, an FDA-approved treatment for anemia, can be administered perioperatively to total joint arthroplasty patients to help prevent the necessity of postoperative transfusion. Inspired by the infection risk associated with allogeneic blood transfusion, this development represents a growing trend in perioperative blood management of the orthopaedic patient. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 7
(5) Ward WF. THE DEVELOPMENT OF A HOSPITAL-BASED BLOODLESS SURGERY PROTOCOL. Erythropoiesis: 1998:8;102-111. Bloodless surgery describes the conduct of surgery without recourse of blood or blood products(Allogenic Blood).Reasons for the need of bloodless surgery differ from patient to patient and include contraindications to allogenic transfusion,such as blood group incompatibility or multiple antibodies.An increasingly important reason is that of personal choise,an example being the religious objection by Jehovah´s Witnesses.Legal and ethical considerations govern the conduct of bloodless surgery,based on the right of a competent person to refuse medical treatment,set against the apparently conflicting duty of the doctor to preserve life where possible,by all available means.Scientific principles have been established by which bloodless surgery may be made increasingly safe,based on new concepts and therapeutic tools for treatment of haemorrhage and anemia. Development of bloodless surgery protocols within hospitals enables continued research and also ensures that the needs of individual doctors and patients are met. There are now over 100 units with these protocols in the USA,a few in the UK and one in Australia. A hospital with a bloodless surgery protocol should be able to practice bloodless surgery effectively. This means regulary performing major surgery, and being backed up by speciality services such as intensiv care, pathology and haematology. It also needs specialiced equipment appropriate for use in bloodless surgery and educational programmes to enable medical staff to understand the principles and practice of bloodless surgery. The protocol must form an integral part of its policies and procedures. (6) Tapp A A TIMELY RISK MANAGEMENT RESOURCE. Can Nurse 1998 Feb;94(2):49-50 The Hospital Information Services program and the work of the HLC members has resulted in a significant increase in the number of physicians and institutions willing to co-operate with bloodless treatment of patients. Over a five-year period the number of physicians willing to co-operate in this matter has increased from 5,000 to more than 50,000 in 65 countries. This dramatic increase in the number of informed co-operative clinicians has also resulted in the development of more than 80 bloodless surgery and medical centres in various countries. (7) Maness CP, Russell SM, Altonji P,et al AORN J 1998 Jan;67(1):144-152 BLOODLESS MEDICINE AND SURGERY. Center for Bloodless Medicine and Surgery, Hartford Hospital, CT, USA. Our hospital is a center for bloodless medicine and surgery (CBMS). It is one of 56 such centers located in the United States. The mission of the center is to provide surgical and medical treatment without the administration of blood or blood-related products. Patients' rights to autonomy and self- determination are respected. Development of the CBMS program required the writing and implementation of specific guidelines, developing standards of care, revising existing policies and procedures, and educating staff members. The CBMS program is multifaceted and multidisciplinary. (8) Vernon S, Pfeifer GM ARE YOU READY FOR BLOODLESS SURGERY? Am J Nurs 1997 Sep;97(9):40-46 Center for Bloodless Medicine and Surgery, Columbia St. Vincent Charity Hospital, Cleveland, OH, USA. 'Bloodless' medicine and surgery is saving lives of individuals whose religious faith forbids blood transfusions. And the innovations it comprises are introducing new considerations to the nursing care of many patients undergoing complex operations.
K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 8
Jacques Belghiti: "Bloodless Surgery is a different Surgery."
(9) Langone J FEAR OF AIDS IS ONLY ONE REASON SOME DOCTORS ARE CALLING FOR BLOODLESS SURGERY. Time 1997 Fall;150(19):74-6 (10) Brecher ME, Monk T, Goodnough LT A STANDARDIZED METHOD FOR CALCULATING BLOOD LOSS. Transfusion 1997 Oct;37(10):1070-4 Department of Pathology, University of North Carolina, Chapel Hill, USA. BACKGROUND: The estimation of blood loss for a surgical procedure is both poorly reproducible and typically underestimated. Therefore, comparison of surgical transfusion outcomes such as blood loss and amount of blood transfused from one institution to another, or from one surgeon to another, is difficult. Recently, mathematical modeling has contributed to our understanding of transfusion strategies. STUDY DESIGN AND METHODS: A mathematical model of blood loss for a surgical hospitalization was developed on the basis of recently described mathematical principles for blood loss and hemodilution. The model was designed so that the calculation of blood loss would be based on easily measured factors such as the patient's blood volume, the number and type of red cell units transfused, the initial hematocrit, the discharge hematocrit, the transfusion trigger, the volume of intraoperatively salvaged blood transfused, and the amount of hemodilution performed. The calculated blood loss was then compared with the intraoperative blood loss actually estimated by the anesthesiologist in 250 consecutive patients who underwent radical retropubic prostatectomy. RESULTS: The mathematical equations were placed in a computer model to allow rapid calculation of a particular patient's blood loss. Figures were derived from the computer modelling to facilitate rapid manual calculation of the blood loss. There was a significant relation (p < 0.001) between the calculated blood loss for the hospitalization and the estimated intraoperative blood loss. However, the calculated blood loss was on average 2.1 times the intraoperative blood loss estimated by the anesthesiologist. CONCLUSION: The use of such mathematical modeling to rapidly estimate a patient's blood loss has the potential to allow ready, objective comparisons between sites and even surgeons. It also allows for a more judicial and informed decision as to what (if any) blood should be available or what blood-conservation techniques should be employed for a specific patient. (11) Zimmerman JE, Seneff MG, Sun X, Wagner DP, Knaus WA EVALUATING LABORATORY USAGE IN THE INTENSIVE CARE UNIT: PATIENT AND INSTITUTIONAL CHARACTERISTICS THAT INFLUENCE FREQUENCY OF BLOOD SAMPLING. Crit Care Med 1997 May;25(5):737-48 Department of Anesthesiology, George Washington University Medical Center, Washington, DC, USA. OBJECTIVES: To develop a predictive equation to estimate the frequency of blood drawing for intensive care unit (ICU) laboratory tests and to evaluate variations in ICU blood sampling practices after adjusting for patient and institutional factors. DESIGN: Prospective, inception, cohort study. SETTING: Forty-two ICUs in 40 hospitals, including 20 teaching and 17 nonteaching ICUs. PATIENTS: A consecutive sample of 17,440 ICU admissions, in which 14,043 blood samples were drawn for laboratory testing on ICU days 2 to 7. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient demographic, physiologic, and treatment data were obtained on ICU day 1; the type and number of blood samples for laboratory testing were recorded on ICU days 1 to 7. In the 42 ICUs, a mean of 16.2 blood samples were drawn for tests on ICU days 2 to 7, but varied between 23 samples in the teaching ICUs and 9.9 samples in nonteaching ICUs. Using only ICU day 1 patient data, we predicted the subsequent number of samples drawn on ICU day 2 (R2 = .26 across individual patients) and on ICU days 2 to 7 (R2 = .26 across individual patients). The most important determinants of the number of blood samples drawn on ICU days 2 to 7 were the ICU day 1 Acute K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 9
Physiology Score and admission diagnosis. After controlling for patient variables, hospital teaching status, number of beds, and location in the East and South were significantly (p < .05) associated with increased blood sampling on ICU day 2 and on ICU days 2 to 7. More frequent use of an arterial cannula and mechanical ventilation were also associated with increased blood sampling on subsequent days. CONCLUSIONS: The ability to adjust for patient and institutional variables and to predict the number of blood samples drawn for laboratory tests can allow ICUs to compare their practices with those of other units. When integrated into a continuous quality improvement process, this information can be used to identify and focus on opportunities for improving blood conservation and reducing excessive diagnostic testing. (12) Spray Major H. THE EMERGING ROLE OF BLOODLESS CENTERS Bloodless Medicine Surgery Conference 1996 Abstract/c 96 Currently there are over 50 Bloodless Centers in the United States and nearly 100 around the word.There are numerous reasons why there is a rapidly growing number of such centers. The appearance of Acquired Immune Deficiency Syndrome (AIDS) dramatically and irreversibly created a public reaction that demanded alternatives to blood transfusions. Subsequent to AIDS, additional blood-borne pathogens have been identified. This has led many physicians to the conclusion that blood transfusions are inherently dangerous. Clinical studies have linked blood transfusions to infections. In studies where patients received both autologous and homologous blood, patients receiving homologous blood exhibited an incidence of infectious complications that was approximately four times higher than in patients receiving autologous blood. Such data has encouraged the development of bloodless medicine and surgery. Furthermore, with the increased costs associated with testing blood for additional blood-borne pathogens, efforts to determine the real costs of blood transfusions have revealed that a unit of blood may actually cost more than $ 1000.00 when the direct costs, the costs of complications, and indirect costs are calculated. Simultaneous to these developments, new medical devices, new and improved techniques,and new pharmaceutical agents have come into existence that support the concept of Bloodless Medicine and Surgery Centers. The results have been dramatic. Although no controlled trial exists, data collected from 16 reports of the surgical outcome of a series of patients of the Jehovah's Witness faith who were not given transfusions for operations during which transfusions are typically given, supports the concept that approximately 0.5% to 1.5% of such operations are complicated by anemia resulting in death. The risk of not transfusing patients must be weighed against the cost, morbidity, and mortality that would be expected to accrue had these patients been transfused. Providing bloodless medicine and surgery is much more than just not administring blood to the patient. It means the physician(s) must be knowledgeable and experienced in the medical alternatives to allogenic blood. He or she must use these medical alternatives to aggressively treat the patient, thus providing a high quality of medical and surgical care. This will require continuing medical education and training. Bloodless medicine and surgery is becoming "the gold standard" . It also supports the patient's right of self-determination and bodily integrity. This reduces or eliminates confrontation and litigation. Indeed, the harbringer of future may have already arrived in the form of Bloodless Medicine and Surgery Programs. (13) Wilson JR, Gaedeke MK BLOOD CONSERVATION IN NEONATAL AND PEDIATRIC POPULATIONS. AACN Clin Issues 1996 May;7(2):229-37 Blood conservation in infants and children has benefits even beyond those seen with the adult populations. For instance, acquired blood borne diseases such as cytomegalovirus not only cause illness but also can have deleterious effects on the growth and development of infants and children. Decreasing blood transfusions is especially important in preventing sensitization over a lifetime, which may require further transfusion and even organ transplantation. A less striking benefit, but one equally as significant, is decreasing the occurrence of graft-versus-host disease when blood conservation negates the need for multiple transfusions. The limitation of alternative transfusion practices in children and infants increases the benefits of blood conservation. Autologous blood donation may be an alternative to allogeneic transfusion in older children, but is not possible with neonates who may be born anemic and who experience a normal physiologic anemia during the first 2 months of life. Critical care nurses are instrumental in helping blood conservation by understanding blood salvaging techniques, including correct collection techniques, noninvasive monitoring, evaluation of diagnostic sample needs, and administration of erythrocyte-stimulating factors. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 10
(14) Chernow B, Jackson E, Miller JA, Wiese J BLOOD CONSERVATION IN ACUTE CARE AND CRITICAL CARE. AACN Clin Issues 1996 May;7(2):191-7 Blood conservation has evolved into an important issue in hospital-based medicine. Increased awareness of and worry about transfusion-associated diseases have prompted a focus on this important area. New technologies, including continuous intraarterial monitoring devices, microchemical technologies, new drug development (recombinant human erythropoietin and aprotinin) and intraoperative salvage techniques have made the concept of clinically important blood conservation possible. In this article, the authors review clinically important areas regarding blood conservation, which are subsequently detailed in this issue of AACN Clinical Issues. Emphasis is placed on the need for blood conservation in acute and critical care practice and the technologies available to achieve this goal. (15) Robb N JEHOVAH'S WITNESSES LEADING EDUCATION DRIVE AS HOSPITALS ADJUST TO NO BLOOD REQUESTS. CMAJ 1996 Feb 15;154(4):557-60 Jehovah's Witness representatives have visited more than 10 Canadian medical schools and 200 hospitals in an attempt to educate future and practising physicians about nonblood medicine. The trend is becoming more popular since the advent of HIV, and there are now about 100 bloodless medicine and surgery centres around the world, including 52 in the US. However, a Jehovah's Witness spokesman says Canada is "conspicuously absent" from the list of countries that offer bloodless-medicine programs. Comment in: Can Med Assoc J 1996 Aug 1;155(3):275-6 CLINICS WITH SPECIAL BLOOD CONSERVATION PROGRAMS
In different Countries
1. AUSTRALIA
1) KALEEYA HOSPITAL MEDICAL CENTRE
Fremantle Kaleeya Hospital - East Freemantle 6158, WA, AT Contact: Bloodless Coordinator: Mr. Shannon Farmer Address: Cnr Staton & Wolsely Roads 15 Wolsely Rd. East Freemantle 6158, WA 6158 AT Phone: (08) 9339-1655 (08) 9319 1958 (fax) 800-810-713 (Within Australia) K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 11
011-618-9339-1655 (USA) WebSite: http://www.kaleeya.com.au Email: [email protected] Mailing Address: P.O. Box 723 Fremantle, WA. 6160 AUSTRALIA Kaleeya's programe is modelled on those successfully operating in the United States. In the short time it has been running, we have been in regular touch with our overseas counterparts. While other hospitals have the technology, we believe we are the first in Australia to have put together a team of quality professionals dedicated to its success. Our toll free number is 008-81-10713 2. UNITED KINGDOM (UK)
A. Community Hospitals Group Plc. Community Hospital Group is one of the leading independent providers of healthcare services in UK. The ten hospitals in the group provide high quality acute surgical healthcare services which include: ♦ Modern healthcare technology ♦ Consultants and Specialists covering most Surgical procedures ♦ Sympathetic, dedicated teams of healthcare professionals ♦ Privacy, and respect for the individual ♦ High standards of accomodation and catering services 1) Ashtead Hospital The Warren,Ashtea, Surrey KT21 2SB Tel No.(01372) 276161 Fax: (01372) 278704 2) Duchy Hospital Penventinnie Lane, Treliske, Truro, Cornwall TRI 3UP Tel No. (01872) 226100 Fax: (01872) 74590 3) Fitzwilliam Hospital Milton Way, South Bretton, Petersborough. Cambs PE3 9AQ Tel No: (01733) 261717 Fax: (01733) 332561 4) Mount Stuart Hospital St. Vincent's Road, Torquay, Devon T Q1 4UP Tel No: (01803) 313881 Fax: (01803) 314051 5) Oaks Hospital 120 Mile End Road, Colchester, Essex CO4 5XR Tel No: (01206) 752121 Fax: (012206) 852701 6) Pinhill Hospital Benslow Lane, Hitchin, Herts SG4 9QZ Tel No: (01462) 422822 Fax: (01462) 421968 7) The Rivers Hospital K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 12
Thomas Rivers Medical Centre, High Wych Road Sawbridgeworth,Herts CM21 0HH Tel No: (01279) 600282 Fax: (01279) 600212 8) Springfield Medical Centre Lawn Lane, Springfield, Chelmsford, Essex CM1 5GU Tel No: (01245) 461777 Fax: (01245) 450317 9) Winfield Hospital Tewkesbury Road, Gloucester GL2 9EE Tel No: (01452) 331111 Fax: (01452) 331200 10) The Yorkshire Clinic Bradford Road, Bingley, West Yorkshire BD 16 1TW Tel No: (01274) 560311 Fax: (01274) 551247 3. ISRAEL
A. Holon
1) Wolfson Medical Center (1) Matz A, Alis M, Charuzi I, Kyzer S THE ROLE OF LAPAROSCOPY IN THE DIAGNOSIS AND TREATMENT OF MISSED DIAPHRAGMATIC RUPTURE. Surg Endoscop 2000 Jun;14(6):537-539. Department of Surgery "B," Wolfson Medical Center, Holon, P.O.B. 5, Holon 58100, Israel and Sackler Faculty of Medicine, Background: Diaphragmatic rupture is one of the most commonly missed injuries in trauma cases. Traditionally, laparotomy or thoracotomy has been the treatment of choice for this condition. Methods: During the last 2 years, we treated three patients laparoscopically to address neglected diaphragmatic ruptures that caused herniation of the intraabdominal contents. Results: In all three cases, laparoscopy succeeded in identifying the diaphragmatic defect, so that the herniated viscera could be released and the defect repaired primarily or with a prosthesis. The intraoperative and the postoperative courses were uneventful; there were no significant complications. Conclusion: Laparoscopy has an important role in the surgical treatment of missed diaphragmatic ruptures. (2) Schachter P, Sorin V, Shimonov M, Rosen A, Czerniak A [LAPAROSCOPIC SURGERY IN TREATING HEPATIC CYSTS [ARTICLE IN HEBREW] Harefuah 2000 Apr 16;138(8):646-649. Dept. of Surgery A, Wolfson Medical Center, Holon. Solitary and multiple hepatic cysts are now more commonly found because of advances in imaging techniques. Most hepatic cysts are asymptomatic, but when they do cause symptoms they require surgical intervention. The advent of laparoscopy and of laparoscopic ultrasonography allow comprehensive evaluation and treatment of the cysts. 12 patients with hepatic cysts were treated laparoscopically. 8 with single cysts underwent successful subtotal cyst resection without signs of recurrence (up to 20 years of follow-up). 4 with polycystic liver disease underwent sub-total resection of superficial cysts. Deep cysts were unroofed and drained under laparoscopic ultrasound guidance. In this group, 1 experienced recurrence of symptoms and required partial hepatectomy of the involved segment. In another, a connection between a deep cyst and bile ducts was demonstrated and cystojejunostomy was performed. The laparoscopic approach in the management of patients with K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 13
liver cysts is effective and safe, and we recommend it as the procedure of choice for single hepatic cysts. In polycystic liver disease the procedure is much less successful. (3) Schachter P, Avni Y, Rosen A, Czerniak A [EVALUATION OF LAPAROSCOPY AND LAPAROSCOPIC ULTRASOUND IN PANCREATIC LESIONS]. [ARTICLE IN HEBREW] Harefuah 1999 Dec 15;137(12):593-597, and 680.! Dept. of Surgery A, Wolfson Medical Center, Holon. Pancreatic lesions present a diagnostic challenge. Even modern imaging techniques are not sensitive enough in determining resectability of pancreatic tumors. A substantial proportion of patients therefore undergo unnecessary surgical exploration. We determined the impact of laparoscopy and laparoscopic ultrasound (LAPUS) examinations on surgical decision-making in 60 patients with pancreatic lesions. Of 48 with solid pancreatic lesions, 22 were defined by LAPUS as having nonresectable tumors, while conventional imaging studies defined only 9 of them as such. 3 of these 9 underwent successful resections of the pancreatic mass. Surgical intervention was ruled out by LAPUS in 16 patients (33.3%) but 26 had resectable lesions of whom 25 underwent surgery. 3 of this group were found to have nonresectable tumors at surgery, a false-positive rate of 6.2%. Overall sensitivity of LAPUS in our series was 88%. In 12 patients with cystic pancreatic lesions LAPUS contributed significantly to the preoperative decision due to clear imaging of the cystic lesion. Additional information was obtained from ultrasound guided-biopsy of the cyst wall, as well as determination of tumor-marker levels in the cystic fluid aspirate. LAPUS contributed significantly to operative management in 58%. (4) Cohen AJ, Tamir A, Yanai O, Houri S, Schachner A INVERTED LEFT ATRIAL APPENDAGE PRESENTING AS A LEFT ATRIAL MASS AFTER CARDIAC SURGERY. Ann Thorac Surg 1999 May;67(5):1489-91 Department of Cardiovascular Surgery, Heart Institute, Wolfson Medical Center, Holon, Israel. [email protected] Inversion of the left atrial appendage can masquerade as a new left atrial mass. Failure to be aware of this entity can result in unnecessary diagnostic and therapeutic procedures. If the entity is diagnosed intraoperatively, treatment is simple with external reduction and ligation. (5) Lampl Y, Gilad R BILATERAL PTOSIS AND CHANGES IN STATE OF ALERTNESS IN THALAMIC INFARCTION. Clin Neurol Neurosurg 1999 Mar;101(1):49-52 Department of Neurology, Edith Wolfson Medical Center, Holon, Israel. Uni- or bilateral supranuclear ptosis is known to be caused by cerebral lesion. The exact anatomical cortical and subcortical basis is still undefined. We report a case of a patient developing bilateral ptosis with a left thalamic lesion. The bilateral ptosis was associated with transient changes in the state of alertness. We postulate that the thalamus, especially the anterior region, may have an influential role on the pathway from the cortex via the posterior branch of the internal capsule to the levator palpebrae superioris nuclei. (6) Cohen I, Rzetelny V SIMULTANEOUS IPSILATERAL PERTROCHANTERIC AND SUBCAPITAL FRACTURES. Orthopedics 1999 May;22(5):535-6 Orthopedic Department, E Wolfson Medical Center, Holon, Israel. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 14
(7) Cohen AJ, Arnaudov D, Zabeeda D, Schultheis L, Lashinger J, Schachner A NON-INVASIVE MEASUREMENT OF CARDIAC OUTPUT DURING CORONARY ARTERY BYPASS GRAFTING. Eur J Cardiothorac Surg 1998 Jul;14(1):64-9 Department of Cardiovascular Surgery, The Edith Wolfson Medical Center, Holon, Israel. OBJECTIVE: A new device, using whole body bioresistance measurements and a new equation for calculating stroke volume has been developed. Using this equation, an attempt was made to correlate whole body bioresistance cardiac output with thermodilution cardiac output in patients undergoing coronary artery bypass grafting. METHODS: Thirty-one adults undergoing elective coronary artery bypass grafting were studied prospectively. Simultaneous paired cardiac output measurements by whole body bioresistance and thermodilution were made at five time points during coronary artery bypass grafting: in anesthetized patients before incision (T1), after sternotomy (T2), after opening the pericardium (T3), ten min post bypass (T4), and in the intensive care unit (T5). The patients had a mean of three thermodilution cardiac outputs compared with a mean of three bioimpedance measurements at each time point. The bias and precision between the methods were calculated. RESULTS: There was good correlation between bioresistance cardiac output (nCO) and thermodilution cardiac output (ThCO) measurements in both groups for all recorded times. The patients' mean ThCO and nCO, as well as bias and precision between methods were calculated. Mean ThCO ranged between 4.14 and 5.06 l/min; mean nCO ranged between 4.12 and 4.97 l/ min. Bias calculations ranged between -0.072 and 0.104 l/min. Precision (2 SD) calculations ranged between 0.873 and 1.228 l/min for 95% confidence intervals. Pearson's correlation ranged from 0.919 to 0.938. CONCLUSIONS: Cardiac output measured with the new device correlates well with the thermodilution measurements of cardiac output during and immediately following coronary artery bypass grafting. The overall agreement between the two methods was good. The new device is an accurate non-invasive method of measuring cardiac output during coronary artery bypass grafting. (8) Levin S, Bennet AE, Levin D, Danielli L, Levin R, Sidi A MINIMALLY INVASIVE SURGICAL TREATMENT OF FEMALE STRESS URINARY INCONTINENCE. Int Urogynecol J Pelvic Floor Dysfunct 1998;9(6):405-8 Edith Wolfson Medical Center, Holon, Israel. The purpose of this study was to evaluate the safety and efficacy of a new minimally invasive surgical procedure for the treatment of female stress urinary incontinence (SUI). Four miniature bone anchors, each attached to a suture, are inserted transvaginally into the retropubic bone using an inserter on each side of the urethra without opening the vaginal mucosa. Tying the suture on each ipsilateral side creates colposuspension, as is the aim of previously described procedures such as the Marshall-Marchetti-Krantz. Sixty-one women (mean age 52+/-SD 9.9 years) with a mean follow-up of more than 12 months (range 12-30 months) were treated for SUI. Fifty patients (82%) are dry, 7 (14%) reported great improvement and 4 are considered surgical failures. The data presented suggest that our new minimally invasive procedure provides an effective treatment for female SUI. Its main advantages over other procedures are the transvaginal approach and short operating time. (9) Barda G, Bernstein D, Arbel-Alon S, Zakut H, Menczer J [GYNECOLOGIC PROBLEMS OF THE LOWER GENITAL TRACT IN CHILDREN AND YOUNG ADOLESCENTS]. [ARTICLE IN HEBREW] Harefuah 1997 Aug;133(3-4):84-6, 168 Dept of Gynecology and Obstetrics, Edith Wolfson Medical Center, Holon. Hospital records of 46 girls under the age of 17 years, hospitalized for lower genital tract problems in 1986-95 were reviewed. The most common conditions were results of unintentional injuries (43.5%), imperforate hymen (28.2%) and infections (19.6%). The median age for unintentional injuries was significantly lower than for other conditions (7.0 vs 11.4; p < 0.001). Most injuries were external and occurred during outdoor activities. Mean volume of estimated bloody fluid drained in those with imperforate hymen was greater when the diagnosis was made after the age of 12 (783 vs 433; not significant). It has been suggested that hematocolpos and hematometra should be prevented, but the possible unfavorable sequelae have not been documented. The relative order of frequency of the K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 15
various diagnostic groupings and the diagnoses of labial adhesions and imperforate hymen are specific for the age of the study group. (10) Haphtel L, Rephaeli Y, Zbida D, Rubin M [ANTERIOR RESECTION FOR RECTAL CARCINOMA IN AN ANEMIC JEHOVAH'S WITNESS]. [ARTICLE IN HEBREW] Harefuah 1996 Apr 15;130(8):517-8, 584, 583 Dept. of Surgery B, Wolfson Medical Center, Holon. Anterior resection is accepted treatment for tumors of the middle rectum, with mortality less than 5%. Since such surgery involves blood loss, blood transfusion is regarded as essential. We report a 69-year old anemic Jehovah's Witness who had a bleeding rectal tumor but who refused blood transfusion, despite a hemoglobin level of 4.8 g/dl. Anterior resection of the tumor was successfully performed without substantial blood loss. Her hemoglobin level was 5.8 g/dl on discharge. Jehovah's Witnesses do not oppose medical treatment nor do they practice faith healing. Instead, they seek good medical care but accept only proven medical alternatives to blood transfusions. Physicians, world-wide, are now successfully performing major surgery of all types on both adult and minor Witnesses. Due to their success in the use of alternatives, over 50 hospitals in North America, Europe and Australia have established "bloodless-surgery" centers to serve not only Jehovah's Witnesses but also a growing number of other patients who wish to avoid risks associated with blood transfusion. 4. SCHWEIZ
1. Clinique Cecil Lausanne Address: Avenue Ruchonnet 53 P.O.Box 330 CH-1001 Lausanne Phone: …………………...021/320 12 51 Fax: (Administration)…..0041-21-323 27 09 Fax Dir:………………….021/ 320 83 22 Articles: (1) Richoz B, Fankhauser H [CEREBRAL MAGNETIC RESONANCE IMAGING: INDICATIONS AND CONTRAINDICATIONS]. [ARTICLE IN FRENCH] Rev Med Suisse Romande 1997 Dec;117(12):931-945. Clinique Cecil Lausanne. (2) Dequesne JG TOTAL AND SUBTOTAL LAPAROSCOPIC HYSTERECTOMY. J Am Assoc Gynecol Laparosc 1996 Aug;3(4, Supplement):S9-S10. Endoscopic Center Clinique Cecil, 16, ch. des Croix-Rouges, CH-1007 Lausanne, Switzerland. The first laparoscopic hysterectomy was performed in our center in November 1990. From then until March 1994 I performed 107 procedures. The indications were the same as for abdominal hysterectomy, such as abnormal uterine bleeding (fibroids, adenomyosis), endometriosis, adhesions, and ovarian cysts, and to reduce uterine mobility. Concomitant surgery included vaporization or excision of endometriosis, unilateral or bilateral salpingectomy with or without oophorectomy, adhesiolysis, Burch procedure, and lymphadenectomy. Several techniques were used, including automatic stapling, bipolar coagulation, and suture of the uterine vessels. When the pathology was limited to the corpus uteri, a subtotal hysterectomy was performed with extraction through a posterior colpotomy. The mean uterine weight was 165 g. Operating time was 135 minutes, and K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 16
hospital stay was 3.2 days. Perioperative complications were one bladder injury (Burch) and two conversions for difficult hemostasis; no ureteral or bowel injury occurred. Postoperative complications were seven urinary infections, two vaginal hematomas, and one vaginal abscess. No thrombosis or embolism occurred. (3) Dequesne J [HYSTEROSCOPIC TREATMENT OF METRORRHAGIA AND INFERTILITY WITH THE ND YAG LASER]. [ARTICLE IN FRENCH] Arch Gynecol Obstet 1990;247.Suppl:S56-S64. Departement Laser, Clinique Cecil, Lausanne, Suisse. 1. Participating departments a. Surgery Cardio-vascular Surgery Thoracic Surgery Neurosurgery Ophtalmic Surgery Ear, Nose and Throat Surgery Maxillo-facial Surgery Plastic and Reconstructive Surgery Endoscopic Surgery Gynecological Surgery Genito-Urinary Surgery Orthopedic Surgery b. Medicine Oncology Cardiology Pneumology Neurology-Neuriphysiology Rheumatology Gastro-Enterology c. Obstetrics Normal Delivery, Cesarean Sections Birth Preparation Courses Postpartum Counselling Monitoring-Ultrasound Jacuzzi Physiotherapy Gymnastic Mother and Baby
The Clinic Cecil is pleased to offer a medico-chirurgical program to patients not wishing to receive blood, plasma or other derived substances. The aim of this program is to guarantee the highest standards of security, offering at the same time total respect of individual personal convictions. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 17
5. SWEDEN
1. Sahlgrenska University Hospital Gothenburg
Address: SE-413 45 Gothenburg, Sweden Phone Hospital Reception +46 (0)31 342 10 00 1. Participating departments
Participating departments Anaesthesia General Surgery (with 9 subspecialities) Gynaecology Obstetrics Oncology Orthopaedic Surgery Thoracic Surgery Transplantation Surgery 2. Participating doctors
Participating doctors About 120 doctors in 7 disciplines Pal Svendsen Address: Interventional Neruoradiology, Radiology Department PO Box 75037 Göteborg, SE S-40036 SE Phone: +46/31603206 +46/31825340 Fax Email: [email protected]
2. Lund University Hospital Lund, Sweden
Address: SE-221 85 Lund, Sweden Phone Hospital Reception +46 (0)46 17 10 00 1. Participating departments
Participating departments Anaesthesia Ear/Nose/Throat General Surgery Gynaecology Medicine 2. Participating doctors
Participating doctors About 15 doctors in 5 disciplines
K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 18
3. Linköping University Hospital Linköping, Sweden
Address: SE-581 85 Linköping, Sweden Phone Hospital Reception +46 (0)13 22 20 00 1. Participating departments
Participating departments Anaesthesia Ear/Nose/Throat Gastro-Enterologic Surgery Burn & Hand- and Plastic Surgery Jaw Surgery Neurosurgery Orthopaedic Surgery Spinal Surgery Thoracic Surgery Urology Vascular Surgery 2. Participating doctors
Participating doctors About 45 doctors in 11 disciplines
4. Nu-Medical Service—Uddevalla Hospital Uddevalla, Sweden
Address: SE-451 80 Uddevalla, Sweden Phone Hospital Reception +46 (0)522 920 00 1. Participating departments
Participating departments Anaesthesia General Surgery Orthopaedic Surgery 2. Participating doctors
Participating doctors About 10 doctors in 3 disciplines Note: The hospital has printed a brochure called Strategies in connection with operations in patients who for religious or other reasons do not want allogeneic blood transfusions 1) Uddevalla Hospital Orthopedic Clinic The Brochure: a. MEASURES AVAILABLE AT UDDEVALLA HOSPITAL BLOODCONSERVATION TEAM K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 19
STRATEGIES FOR OPERATIONS IN PATIENTS WHO,FOR RELIGIOUS OR OTHER REASONS,DO NOT WANT ALLOGENIC BLOOD TRANSFUSIONS ELECTIVE SURGERY 1.If the surgeon in question does not want to perform the operation, himself,he should help the patient contact a department or surgeon who is willing to perform the surgery.
2.If the surgeon agrees to perform the operation, he should undertake the following preoperative measures, in addition to the usual preoperative routines: -Complete coagulation status (if necessary, contact a haematologist,Coagulation Laboratory ) -Check the haemoglobin level (Hb). (If not adequate treat it , by all necessesary means) B. EMERGENCY SURGERY If the condition of the patient allows for it, another department or surgeon should be contacted, if the attending physician himself is hesitant to take care of the patient . 2. If the above is not possible, the attending physician has an obligation to take care of the patient himself. Intraoperative measures based of a list,should then be considered in consultation with an anaesthesiologist. The need for these measures depends on the general condition and cagulation stus of the patient, the extent of the surgical procedure and the risk of intra – and postoperative blood loss. The timing of the operation depends on the nature of the disease and the number of staff available at the Department of Anaesthesia. C. INTRAOPERATIVE MEASURES FOR BLOOD CONSERVATION AVAILABLE AT UDDEVALLA HOSPITAL 1. Anaesthesiological methods
Acute Haemodilution
Cell Saver
Separation of Plasma and Platelets
Platelet Gel
Hypotensive Anaesthesia 2. Intraoperative drugs
Desmopressin (DDAVP)
Tranexamic Acid (TA) 3. Surgical devices and supplies
Cautery (including Argon Beam Coagulator (ABC)
Laser
Surgicel, Spongostan, Avitene,Tisseel ,Bone wax, Local Anaesthesia with Adrenaline. POSTOPERATIVE MEASURES
1. Continued blood loss postoperatively
- Cell Saver connected to drainage tube (Maximum 6 hours) K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 20
- Antifibrinolytic Drugs (Desmopressin, Tranexamic Acid)
- Consider early re-operation if blood loss is great
2. Postoperative anaemia to such a degree that blood transfusion is normally indicated
- IV injection of Erythropoietin 10. 000 U/day
- Iron ( IM or IV) [ IM Jectofer 50mg Fe3+/ml , 1.5 mg/kg/day]
- [IV Venofer(follow instructions) 100-200mg/day(Adults)]
- IM injection of Vitamin B12 1mg/day
- Oral administration of Folic Acid 5 mg x 2 /day
- Reduce Blood sampling to the minimum necessary.
3. Life-threatening situations
- Consider Hyperbaric Oxygen Therapy (HBO)[Hyperbaric Chamber]
- Bettering Coagulation Status(Consider injection of Protamine if there is a
- definite association between bleeding and an exess Heparin dosage)
Contact persons at Uddevalla Hospital: Dr.------, Department of Anaesthesia Dr. Christer Strömberg , Department of Orthopedics Visiting adress : Fjällvägen 9 Post adress : Uddevalla sjukhus 451 80 UDDEVALLA, SWEDEN Telephon Nr : 0522-920 00 Reference: (4) HAGG O. BLOOD CONSERVATION TECHNIQUES IN SURGERY HOW CAN THE SURGEON LIMIT PERIOPERATIVE BLEEDING? THE EXAMPLE OF ORTOPEDIC SURGERY First Baltic Symposium April 18 and 19 , 1997, pp59-69, 5. Uppsala Academic Hospital Uppsala, Sweden
Address: SE-751 85 Uppsala, Sweden Phone Hospital Reception +46 (0)18 66 30 00 K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 21
1. Participating department
Participating department The Center for Thoracic Surgery 6. UNITED STATES OF AMERICA (U.S.A.)
I. ALABAMA
1) Brookwood Medical Center - Birmingham, AL, US Contact: Bloodless Coordinator: Shelbra Sublett Address: 2010 Brookwood Medical Center Drive Birmingham, AL 35209 US Phone: (205) 877-2357 Bloodless Program Articles: (1) No Authors Listed SUPPORTIVE CARE PATHWAY COMFORTS THE TERMINALLY ILL. Hosp Case Manag 1998 Apr;6(4):69-72. The supportive care pathway at Brookwood Medical Center in Birmingham, AL, is a different kind of pathway, de-emphasizing length of stay in favor of streamlining the care of terminally ill patients. The path differs from traditional pathway efforts in four respects: lack of tests and interventions, focus on both the patient and the family, utilization of phases of the dying process rather than days or hours, and a focus on the psychosocial, spiritual, and emotional aspects of care for the patient and family. The three phases of the pathway are admission (decision is made for palliative care), transition (symptom management), and terminal (peaceful death).
2) DCH Regional Medical Center 809 University Blvd. S. Tuscaloosa, Al 35401 (205) 759-7111-Hospital Articles: (1) Bourke B BEDSIDE MANNER. Healthc Ala 1997 Fall;10(3):8-11 Pastoral Care Services, DCH Regional Medical Center, AL, USA. The hospital setting can be a place of healing and hope for the future. Unfortunately, it can also be a site filled with pain and grief. How hospitals deal emotionally with patients, and others who experience trauma is an important aspect of overall care. The following is a look at the importance of compassionate care and how some Alabama hospitals tend to the emotional, psychological and spiritual needs of patients and their loved ones.
3) DCH Regional Medical Center - Tuscaloosa, AL, US Contact: Bloodless Coordinators: Angela Fulmer Eloise Webb Clinical Referral Consultant: Cathy Garth Medical Director: Dr. David Rice MD K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 22
Address: 809 University Blvd. E. Tuscaloosa, AL 35401 US Phone: 205-759-7967 800-266-4DCH (800-266-4324) 205-759-6031 Fax WebSite: http://www.dchhealthcare.com Email: [email protected]
4) UAB Hospital University Blvd. S Birmingham, Alabama (205) 934-6478 or (800) 822-6478 To make an appointment or for more information, please call (205) 934-9999 or (800) 822- 8816. After Hours Call (205) 934-3411 and ask for the Bloodless Surgery Program Coordinator UAB HOSPITAL continues its tradition of offering innovative medical care with the introduction of its Bloodless Medicine and Surgery Program. This innovative program was created to offer safe and medically proven alternatives to those adult patients who prefer to avoid blood transfusion during surgery. UAB Hospital enjoys an international reputation as one of the United States' premier medical facilities for providing excellent health care. Bloodless Surgery is designed to avoid or minimize bleeding during an operation so that transfusion of blood is not necessary. This can be achieved through usage of superior surgical and anesthetic techniques and a variety of pharmaceutical agents, all safe and medically established. A broad range of health care services, including highly specialized surgeries, are available. UAB's highly skilled physicians utilize state-of-the-art technologies and procedures to achieve this goal: ♦ CELL SAVER ♦ SKIN MONITOR ♦ ARGON BEAM COAGULATOR (ABC) ♦ VOLUME EXPANDERS ♦ SYNTHETIC ERYTHROPOIETIN ♦ LASER Articles: (1) Barber JW, King WD, Monroe KW, Nichols MH EVALUATION OF EMERGENCY DEPARTMENT REFERRALS BY TELEPHONE TRIAGE. Pediatrics 2000 Apr ;105(4 Pt 1):819-821. Department of Pediatrics, University of Alabama at Birmingham, USA. [email protected] OBJECTIVE: Telephone triage programs are becoming very common at children's hospitals across the nation. One of the proposed benefits of these programs is the more efficient use of health care resources by triaging patients to the appropriate level of health care. The purpose of this study is to examine the appropriateness of referrals to a pediatric emergency department (ED) by the Pediatric Health Information Line (PHIL), a hospital-based telephone triage program, versus all other sources of referrals. METHODS: A blinded Delphi rating system was used to review the physician's sheets of 133 consecutive ED referrals by PHIL for medical appropriateness. A total of 260 randomly selected control patients seen in the ED during the same period were similarly reviewed. If 2 of 3 pediatric emergency medicine physicians agreed that an ED visit was appropriate, then it was considered appropriate. A comparison of the 2 groups' ED appropriateness was made using a contingency table chi(2) test. An odds ratio with confidence limits was also calculated. Demographic data were collected K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 23
for both groups including age, race, gender, and insurance status. RESULTS: The PHIL group had an appropriateness rate of 80.2%, compared with 60.5% for the control group (chi(2) = 14.6369; odds ratio = 2.65; 95% confidence interval [1.5759,4.5008]). CONCLUSIONS: This demonstrated that for the period studied, PHIL referrals to the ED had a 33% higher rate of appropriateness than controls. This evidence supports telephone triage as an efficient gatekeeper for health care resources. (2) Rogers WJ, Canto JG, Barron HV, Boscarino JA, Shoultz DA, Every NR TREATMENT AND OUTCOME OF MYOCARDIAL INFARCTION IN HOSPITALS WITH AND WITHOUT INVASIVE CAPABILITY. INVESTIGATORS IN THE NATIONAL REGISTRY OF MYOCARDIAL INFARCTION. J Am Coll Cardiol 2000 Feb;35(2):371-379. University of Alabama Medical Center, Birmingham 35294, USA. [email protected] OBJECTIVES: We sought to determine the extent to which the capability of a hospital to perform invasive cardiovascular procedures influences treatment and outcome of patients admitted with acute myocardial infarction (AMI). BACKGROUND: Patients with AMI are usually transported to the closest hospital. However, relatively few hospitals have the capability for immediate coronary arteriography, percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG), should these interventions be needed. METHODS: The 1,506 hospitals participating in the National Registry of Myocardial Infarction 2 were classified according to their highest level of invasive capability: 1) none (noninvasive, 28.1%); 2) coronary arteriography (cath- capable, 25.2%); 3) coronary angioplasty (PTCA-capable, 7.4%); and 4) bypass surgery (CABG- capable, 39.2%). Treatment and in-hospital outcomes were assessed for 305,812 patients admitted from June 1994 through October 1996. Follow-up through 90 days was ascertained in a subset of 30,402 patients enrolled simultaneously in both the National Registry of Myocardial Infarction (NRMI) 2 and the Cooperative Cardiovascular Project (CCP). RESULTS: The proportion of patients receiving initial reperfusion intervention was only slightly higher at the more invasive hospitals (noninvasive 32.5%, cath-capable 31.2%, PTCA-capable 32.9% and CABG-capable 35.9%, p < 0.001 by chi-square statistic). Among thrombolytic recipients, median door-to-drug time interval differed little among hospital types and ranged from 42 to 45 minutes. At cath-capable, PTCA- capable and CABG-capable hospitals, coronary arteriography was performed in 32.9%, 37.4% and 64.9%, respectively, and PTCA in 0.0%, 5.1% and 31.4%, both p < 0.001 by chi-square statistic. The proportion of patients transferred out to other facilities was 51.0%, 42.2%, 39.9% and 4.4% (p < 0.0001) among noninvasive, cath-capable, PTCA-capable and CABG-capable hospitals, respectively. Among patients in the combined NRMI and CCP data set, mortality at 90 days postinfarction was similar among patients initially admitted to each of the four hospital types. CONCLUSIONS: Although patients with AMI admitted to hospitals without invasive cardiac facilities have a high likelihood of subsequent transfer to other facilities, their likelihood of receiving a reperfusion intervention at the first hospital, their door to thrombolytic drug intervals and their 90-day survival rates are similar to those of patients initially admitted to more invasively equipped hospitals. These data suggest that a policy of initial treatment of myocardial infarction at the closest medical facility is appropriate medical practice. Comment in: J Am Coll Cardiol 2000 Feb;35(2):380-1 (3) Morrisey MA, Alexander J, Burns LR, Johnson V THE EFFECTS OF MANAGED CARE ON PHYSICIAN AND CLINICAL INTEGRATION IN HOSPITALS. Med Care 1999 Apr;37(4):350-61 University of Alabama at Birmingham, Lister Hill Center for Health Policy, 35294-0022, USA. [email protected] OBJECTIVE: To empirically estimate the effects that managed care has had on physician and clinical integration in urban hospitals. DATA SOURCES: The 1993 Hospital-Physician Relationship Survey conducted for the Prospective Payment Assessment Commission, augmented with data from a variety of secondary sources. The entire 1,495 responding hospitals were used to construct measures of integration; 591 responding hospitals in urban areas were used for the managed care analysis. STUDY DESIGN: Factor analysis was used to reduce 23 integration variables into 5 physician and 3 clinical integration factors. Two-stage least-squares regression techniques were used K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 24
to estimate the effects of endogenous managed care. Models were estimated for all urban hospitals and for hospital subsets based upon ownership, multi-hospital system status, and teaching. PRINCIPAL FINDINGS: Other things equal, physician involvement in hospital management and governance increased with managed care involvement; to a lesser degree, the use of physician organization arrangements and other joint ventures also increased. Practice management and support services were lower in hospitals with high managed care activity. Larger hospitals, investor owned, system, and non-teaching hospitals had larger managed care revenues. Managed care revenues were lower in more concentrated hospital markets. CONCLUSIONS: The relationship between managed care and physician and clinical integration is relatively modest. Much of the realignment under managed care has been limited to certain types of efforts. Those efforts can best be described as foundation-building rather than comprehensive or fundamental. (4) Al-Mubarak N, Rogers WJ, Lambrew CT, Bowlby LJ, French WJ CONSULTATION BEFORE THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION. SECOND NATIONAL REGISTRY OF MYOCARDIAL INFARCTION (NRMI 2) INVESTIGATORS. Am J Cardiol 1999 Jan 1;83(1):89-93, A8 University of Alabama Medical Center, Birmingham, USA. Among 57,398 thrombolytic recipients in the National Registry of Myocardial Infarction 2, consultation with another physician was sought in 64% before initiating lytic therapy, although presenting features were typical, rather than atypical, in most patients. Consultation significantly delayed the administration of lytic therapy and was associated with increased hospital mortality. (5) Bittner V, Sanderson B, Breland J, Green D REFERRAL PATTERNS TO A UNIVERSITY-BASED CARDIAC REHABILITATION PROGRAM. Am J Cardiol 1999 Jan 15;83(2):252-5, A5 Department of Medicine, University of Alabama at Birmingham, 35294-0007, USA. [email protected] Referral rates to our cardiac rehabilitation program among patients hospitalized for coronary heart disease were computed over an 18-month period. Only 8.7% of eligible patients were referred, suggesting that more education targeting physicians, patients, and insurers is needed and barriers to participation must be systematically addressed. (6) Kilgore ML, Pacifico AD SHED MEDIASTINAL BLOOD TRANSFUSION AFTER CARDIAC OPERATIONS: A COST-EFFECTIVENESS ANALYSIS. Ann Thorac Surg 1998 May;65(5):1248-54 Department of Pathology, University of Alabama at Birmingham 35233-7331, USA. [email protected] BACKGROUND: Cardiac surgical patients consume a significant fraction of the annual volume of allogeneic blood transfused. Scavenged autologous blood may serve as a cost-effective means of conserving donated blood and avoiding transfusion-related complications. METHODS: This study examines 834 patients after cardiac operations at the University of Alabama Hospital. Data were collected on patients receiving unwashed, filtered, autologous transfusions from shed mediastinal drainage and those receiving allogeneic transfusions. The data were incorporated into clinical decision models; confidence intervals for parameters were estimated by bootstrapping sample statistics. Costs were estimated for transfusing both allogeneic and autologous blood. RESULTS: The study found a 54% reduction in transfusion risk or a mean reduction of 1.41 allogeneic units per case (95% confidence interval, 1.04 to 1.79 units). The process saved between $49 and $62 per case. CONCLUSIONS: The use of autologous blood has the potential to significantly reduce the costs and risks associated with transfusing allogeneic blood after cardiac operations. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 25
(7) Bronstein JM, Cliver SP, Goldenberg RL PRACTICE VARIATION IN THE USE OF INTERVENTIONS IN HIGH-RISK OBSTETRICS. Health Serv Res 1998 Feb;32(6):825-39 University of Alabama at Birmingham (UAB), School of Public Health, Department of Health Care Organization and Policy 35294-2010, USA. OBJECTIVE: To assess the relationship between clinical, demographic, and site-of-care factors and the use of tocolysis and corticosteroid therapy in the treatment of premature labor. DATA SOURCE: Secondary clinical and demographic data collected for the five-center March of Dimes Prematurity Prevention clinical trial, 1983-1986. STUDY DESIGN: We used logistic regression analysis in assessing the clinical, patient, and care site factors associated with the use of tocolysis and corticosteroid therapy during episodes of premature labor occurring to women enrolled in the trial. The two interventions were not subject to control in the trial, but were provided according to customary practice at the care site. DATA EXTRACTION: A total of 4,625 episodes of labor occurring before 37 weeks gestation were identified from either preterm labor or preterm delivery records recorded for the 33,792 women enrolled in the trial. PRINCIPAL FINDINGS: The use of tocolysis, an intervention that attempts to control premature labor contractions and that was widely used in high-risk obstetrics, varied almost exclusively by clinical factors. The use of corticosteroid therapy, a little used but effective intervention that reduces respiratory complications in premature infants, varied significantly by site of care and was used less frequently across sites and clinical conditions for minority group patients. CONCLUSION: This study confirms the premise that practice variation on the basis of nonclinical factors occurs more commonly for interventions where there is more uncertainty about clinical indications and effectiveness. The study also identifies another area of clinical care in which the use of aggressive and relatively uncertain interventions is provided less frequently to minority group patients. (8) Dean LS, George CJ, Roubin GS, Kennard ED, Holmes DR Jr, King SB 3rd, Vlietstra RE, Moses JW, Kereiakes D, Carrozza JP Jr, Ellis SG, Margolis JR, Detre KM BAILOUT AND CORRECTIVE USE OF GIANTURCO-ROUBIN FLEX STENTS AFTER PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY: OPERATOR REPORTS AND ANGIOGRAPHIC CORE LABORATORY VERIFICATION FROM THE NATIONAL HEART, LUNG, AND BLOOD INSTITUTE/NEW APPROACHES TO CORONARY INTERVENTION REGISTRY. J Am Coll Cardiol 1997 Apr;29(5):934-40 Department of Medicine, University of Alabama at Birmingham, 35294-0012, USA. [email protected] OBJECTIVES: We sought to determine the in-hospital clinical outcome and angiographic results of patients prospectively entered into the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention (NHLBI/NACI) Registry who received Gianturco-Roubin stents as an unplanned new device. BACKGROUND: Between August 1990 and March 1994, nine centers implanted Gianturco-Roubin flex stents as an unplanned new device in the initial treatment of 350 patients (389 lesions) who were prospectively enrolled in the NHLBI/NACI Registry. METHODS: Patients undergoing implantation of the Gianturco-Roubin flex stent were prospectively entered into the Gianturco-Roubin stent portion of the NHLBI/NACI Registry. Only subjects receiving the Gianturco-Roubin stent as a new device in an unplanned fashion are included. RESULTS: The mean age of the patient group was 61.8 years, and the majority of the patients were men. A history of percutaneous transluminal coronary angioplasty (PTCA) was present in 35.4% of the group, and 16.9% had previous coronary artery bypass graft surgery. Unstable angina was present in 67.7%. Double- or triple-vessel coronary artery disease was present in 55.4%, and the average ejection fraction was 58%. The presence of thrombus was noted in 7.3%, and 7.2% had moderate to severe tortuosity of the lesion. The angiographic success rate was 92%. Individual clinical sites reported that 66.3% of the stents were placed after suboptimal PTCA, 20.3% for abrupt closure and 13.4% for some other technical PTCA failure. Major in-hospital events occurred in 9.7% of patients, including death in 1.7%, Q wave myocardial infarction in 3.1% and emergency bypass surgery in 6%. Abrupt closure of a stented segment occurred in 3.1% of patients at a mean of 3.9 days. Cerebrovascular accident occurred in 0.3%, and transfusion was required in 10.6%. Vascular events with surgical K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 26
repair occurred in 8.6% of patients. CONCLUSIONS: Despite these complications, the use of this device for the treatment of a failed or suboptimal PTCA result remains promising given the adverse outcome of abrupt closure with conventional (nonstent) treatment. II. ARIZONA
1) St. Luke's Medical Center - Phoenix, AZ, US Contact: Director: Jan Wade Address: 1800 East Van Buren St. Phoenix, AZ 85006 US Phone: (602) 251-8333 Bloodless Program (888) 737-8573 (602) 251-8825 Fax Other Phone Numbers: (602) 251-8100 Hospital Articles: (1) Kerrigan JF, Aleck KA, Tarby TJ, Bird CR, Heidenreich RA FUMARIC ACIDURIA: CLINICAL AND IMAGING FEATURES. Ann Neurol 2000 May;47(5): Section of Child Neurology, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA. Fumaric aciduria (fumaric acidemia, fumarase deficiency) is a rare inborn error of metabolism caused by deficient activity of fumarate hydratase, one of the constituent enzymes of the Krebs tricarboxylic acid cycle. We describe the clinical and imaging features of this disease arising from a consanguineous pedigree in 8 patients in the southwestern United States. Thirteen patients have been previously described in the medical literature. Our patients presented with an early infantile encephalopathy with profound developmental retardation and hypotonia, and most experienced seizures. Previously unreported characteristics described here include structural brain malformations, dysmorphic facial features, and neonatal polycythemia. Magnetic resonance imaging showed multiple abnormalities, including diffuse polymicrogyria, decreased cerebral white matter, large ventricles, and open opercula. Fumaric aciduria should be included in the differential diagnosis of inborn errors of metabolism that cause cerebral malformations and dysmorphic features. The possibility that inborn errors of energy metabolism may cause structural malformations deserves increased recognition. (2) Heffner JE, Klein J CHEST IMAGING IN CRITICALLY ILL PATIENTS: ANALYSIS OF CLINICAL VALUE. Respir Care 1994 Jan;39(1):51-62. St Joseph's Hospital and Medical Center, Phoenix, AZ 85251.
2) Tucson General Hospital - Tucson, AZ, US Contact: Bloodless Coordinator: Rita Klein Address: 3838 No. Campbell Ave. Tucson, AZ 85719 US Phone: (520) 318-6326 Hospital (520) 318-6326 Office (520) 318-6327 Fax III. CALIFORNIA
1) Alvarado Hospital Medical Center - San Diego, CA, US Center Contact: Healthcare Coordinator: K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 27
Rick Lopez Address: 6655 Alvarado Rd San Diego, CA 92120-5298 US Phone: 1 800-367-6643 (24 Hour Hotline) (619) 523-9009 (714) 201-9889 Articles: (1) Specht MD, Hofer JE, Valentine NK, Keturi J DEVELOPMENT AND IMPLEMENTATION OF A PERIOPERATIVE AUTOLOGOUS SERVICE PROGRAM. AORN J 1997 Sep;66(3):486, 489-492 Alvarado Hospital Medical Center, San Diego, USA. Several months after we initiated our PAS program, the AABB scrutinized our policy and procedure manual. At the same time, the JCAHO conducted an inspection of our blood bank and its standards. Both reviews were positive, which provided all of us involved in the PAS program with a tremendous sense of accomplishment. Each PAS team member played a significant role in the development and implementation of our PAS program. Thanks to the energy, enthusiasm, and support of perioperative nurses, surgeons, and hospital administrators, our PAS program has evolved into a high quality, efficient alternative to homologous blood transfusions in the perioperative setting.
2) Anaheim General Hospital Information Services - Anaheim, CA, US Contact: Bloodless Coordinator: Vince Jones Address: 8850 W. Ball Rd. Anaheim, CA 92804 US Phone: (714) 827-6700 Articles: (1) Ott RA, Gutfinger DE, Steedman R, Tanner TM, Hlapcich WL INITIAL EXPERIENCE WITH BEATING HEART SURGERY: COMPARISON WITH FAST-TRACK METHODS. Am Surg 1999 Nov;65(11):1018-1022. Department of Surgery, Anaheim Memorial Medical Center, California, USA. Cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) may increase postoperative complications in high-risk patients. The goal of this study is to retrospectively review a series of consecutive patients undergoing conventional CABG using a fast-track recovery method and to compare this series with the initial series of patients undergoing beating heart surgery using either the single-vessel minimally invasive approach or the off-pump multivessel bypass technique with a median sternotomy. One hundred fifty-eight consecutive patients underwent CABG. One hundred four patients underwent conventional CABG using CPB with a short-pump fast-track recovery method (Group A). Twenty-nine patients underwent a single-vessel bypass via a left anterior thoracotomy off pump [Group B, minimally invasive direct coronary artery bypass (MIDCAB)]. Twenty-five patients underwent multivessel CABG with a median sternotomy off pump (Group C). Short-pump fast-track (Group A) patients exhibited minimal complications and expedient recovery and received extensive revascularization. Off-pump multivessel patients (Group C) received fewer bypass grafts, had more preoperative comorbidity, and recovered as quickly as lower-risk fast-track short-pump patients (Group A). Single-vessel off-pump patients (Group B, MIDCAB) were younger elective patients and demonstrated no recovery advantage. The overall mortality was 1.8 per cent. The conversion rates from beating heart surgery to CPB for groups B and C were 10.3 and 16 per cent, respectively. The postoperative hospital length of stay for groups A, B, and C were 4.8+/-2.4, 3.9+/-1.8, and 5.2+/-2.3 days, respectively. Eliminating CPB is not as important as reducing exposure for minimizing operative risk. Beating heart surgery is an adjunct to conventional CABG with CPB. The off-pump multivessel bypass technique is best suited for high-risk patients requiring three grafts or fewer, whereas MIDCAB is best suited for single-vessel bypass that cannot be managed using interventional percutaneous techniques; however, the recovery advantage with MIDCAB is not K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 28
apparent. Patients requiring more than three bypass grafts should undergo conventional CABG with CPB.
3) Bloodless Healthcare Systems, Inc. Santa Ana Hospital Medical Center 1901 N. College Ave. Santa Ana, CA 92706 (714) 547-2565- Hospital WHAT IS BHS? It is a group of helthcare coordinators acting as a referral System to provide high quality medical services for your special needs. SERVICES PROVIDED BY BHS: Affiliated physicians and medical facilities offer a wide range of services for those people who object to blood transfusions for moral,religious or health reasons. Bloodless Healtcare Systems provides safe alternatives which help meet the needs of the patient and family. These alternatives are offered in all fields of medicine and surgery: Internal Medicine Cardiology Open heart Surgery Brain Surgery Spine Surgery Cancer and related Diseases Joint Replacement Pregnancy and Childbirth Infant and Childhood Diseases a.s.o. 24 hour hotline 1-800-367-6643 or 1-800-FOR-NO-HEMO and local (714) 641-5086
4) Bloodless Healthcare Systems, Inc. 1020 S. Anaheim Blvd. Suite 203 Anaheim, CA 92805 1-800-367-6643 - Hospital
Pediatric Bloodless Options We are pleased to announce the formation of the first pediatric team that respects the wishes of the parents avoiding the use of Blood or blood products as a part of their medical treatment for their children. This team is under the direction of Dr. H. Moore M.D. and Dr. V. Malhotra M.D. in collaboration with Fountain Valley Regional Hospital and Medical Center, Fountain Valley, California. To the best of our knowledge this is the first team of its kind in the country addressing this very delicate issue which has medico-legal implications. It is extremely important that all inquiries regarding this bold and new venture be directed through our 1-800-367-6643 Hot Line so that we can avoid court orders and other legal problems that might arise.* (Unlike adults with respecting your rights, children are different.) "In fact, very few physicians will give 100-percent assurance that they will not use blood under any cirumstances when treating a child. For medical and legal reasons, most doctors feel that they cannot give such a guarantee. Nevertheless, an increasing number want to provide care for the children, while going as far as they feel they can in respecting our whishes on blood." "Although adults generally have the right to accept or refuse medical treatment as they wish, parents are not free to refuse treatments considered necessary for their child's welfare even when their refusal is based on sincerely held religious beliefs."
5) Brotman Medical Center - Culver City, CA, US Contact: West Los Angeles Regional Bloodless Coordinator: Thomas W. Kanavos Address: 3828 Delmas Terrace Culver City, CA 90231-2459 US Phone: (800) 411-2262 Toll-Free (310) 202-4135 (310) 202-4125 Fax Articles: K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 29
(1) Marks LS, Ettekal B, Cohen MS, Macairan ML, Vidal J USE OF A SHAPE-MEMORY ALLOY (NITINOL) IN A REMOVABLE PROSTATE STENT. Tech Urol 1999 Dec;5(4):226-230. Urological Sciences Research Foundation, Brotman Medical Center, Culver City, California, USA. An easily removable prostate stent would be useful in various clinical situations but is not currently available. Thus, we studied the safety, tolerability, and ease of removal of a nitinol (nickel-titanium alloy) prostate stent in 10 men with symptomatic benign prostatic hyperplasia. The circular-coil stent becomes hourglass in shape following deployment, with the narrowest diameter approximately 35F. A working hypothesis was that the temperature-sensitive shape memory of nitinol would allow for its easy removal vis-a-vis other available stents. Using several modifications of a prototype insertion device, we found that the nitinol stents were easily inserted, retained their shape during retention periods of 1 to 4 weeks, caused no gross tissue reaction, and were removed easily with gentle traction after in situ cooling with iced saline lavage. Stent migration was observed in two patients, but otherwise, the stents were well tolerated. Nitinol prostate stents appear to fulfill a theoretical promise of being biologically inert, "superelastic," and pliable when cooled, allowing for easy removal. Further clinical investigation appears warranted. (2) Marks LS VALUE OF BALLOON DILATION IN TREATMENT OF YOUTHFUL PATIENTS WITH PROSTATISM. Urology 1992 Jan;39(1):31-38. Department of Surgery, Brotman Medical Center, Culver City, California. Forty-three youthful patients with uncomplicated prostatism were prospectively evaluated to test the safety and efficacy of transurethral balloon dilation (TUDP). Treatment consisted of cystoscopic placement of an intraprostatic balloon inflated to 25 mm diameter at 3 atm pressure for ten minutes. At longest follow-up (9.8 months, average; 3-24 months, range), 88 percent of patients were satisfied with overall treatment results. The average improvements in voiding symptom score and peak uroflow were 77 percent and 73 percent, respectively. Mean improvements over pretreatment levels were statistically significant at one month (p less than 0.01) and remained so for the entire follow-up period. No incontinence, impotency, retrograde ejaculation, sepsis, or serious bleeding developed. An intraprostatic fissure, which spared the bladder neck, was a uniform finding and the most likely mechanism of lasting action of TUDP. In the relief of uncomplicated prostatism in youthful patients, TUDP compares favorably with other treatment alternatives. (3) Stein M, Williams AJ, Grossman F, Weinberg AS, Zuckerbraun L CRICOPHARYNGEAL DYSFUNCTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Chest 1990 feb;97(2):347-352. Medical Service, Brotman Medical Center, Culver City. Dysphagia due to cricopharyngeal dysfunction is well known; however, there have been no previous data indicating an association between cricopharyngeal dysfunction and COPD. After observing marked cricopharyngeal dysfunction with aspiration in three patients who had frequent and severe exacerbations of COPD, we performed pharyngoesophageal examinations with videotaping in another 22 nonrandomized patients. Cineradiography or videofluoroscopic recording with capabilities of slow-motion and freeze-frame playback is mandatory, since the transit time of the bolus through the pharynx is rapid. Severe cricopharyngeal dysfunction was observed in 17 elderly patients with COPD. Deglutition disorders were elicited by careful questioning in 15 of these. In eight subjects, cricopharyngeal myotomy resulted in improvement of swallowing and complete or partial relief of acute exacerbations of respiratory distress. In one subject, myotomy relieved only the swallowing problem. The mechanism of cricopharyngeal dysfunction in elderly patients with COPD is unknown at this time, but may be related to gastroesophageal reflux, therapeutic agents, and/or alterations in pharyngoesophageal anatomic structures. We conclude that investigations for K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 30
swallowing disorders should be considered in patients with COPD who have frequent acute exacerbations of respiratory distress.
6) Centinela Hospital Medical Center - Inglewood, CA, US Contact: Coordinator: Jose A. Bretones Address: 555 East Hardy St. Inglewood, CA 90301 US Phone: (310) 419-2627 (310) 412-4566 Fax (310) 848-0633 Pgr. WebSite: http://www.tenethealth.com/centinela/ Email: [email protected] Phone: (310) 673-4660 xt. 7600 (Espanol) Articles: (1) Brau SA VIDEO ENDOSCOPIC SURGERY IN THE COMMUNITY HOSPITAL. Surg Laparosc Endosc 1994 Jun;4(3):222-224. Department of Surgery, Centinela Hospital Medical Center, Inglewood, CA 90307. After proper training and observation, I started performing laparoscopic cholecystectomy at the community hospital in August 1990. Since then, and after further advanced training, I have performed 172 procedures, including appendectomy, hernia repair, lysis of adhesions, retroperitoneal biopsy, paraesophageal hernia repair, exploration of the common bile duct, repositioning of CAPD catheters, and colon resection with excellent results. This experience confirms that video endoscopic surgery can become the approach of choice in the community for many of what today are still considered open procedures, without undue risk, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted. (2) Cook FF, Tibone JE, Redfern FC A DYNAMIC ANALYSIS OF A FUNCTIONAL BRACE FOR ANTERIOR CRUCIATE LIGAMENT INSUFFICIENCY. Am J Sports Med 1989 Jul-Aug;17(4):519-24 Centinela Hospital Medical Center Biomechanics Laboratory, Inglewood, California. A dynamic, in vivo, functional analysis of braces designed for ACL insufficiency has never been reported. In this study, 14 athletes who had arthroscopically proven absent ACLs were evaluated in the Biomechanics Laboratory at the Centinela Hospital Medical Center. None of the ligaments were repaired or reconstructed. Footswitch, high speed photography, and force place data were recorded while the athletes performed running and cutting maneuvers with and without their custom fitted C.Ti. braces (Innovation Sports, Irvine, CA). Cybex testing, KT-1000 evaluation, and radiographs were collected for each subject. Statistical analysis showed that while performing cutting maneuvers, braced limbs generated significantly increased shear forces compared to the same limb unbraced. During straight line running, braced limbs generated significantly less lateral and aft shear forces compared to the same limb unbraced. Running velocity increased while wearing a brace for most athletes, but this was not statistically significant. As expected, the sound limb generated significantly greater shear forces than the unbraced involved limb during most cutting maneuvers. Athletes who did not achieve 80% of the Cybex (Cybex, Division of Lumex, Ronkonkoma, NY) quadriceps torque of the sound limb generated significantly more forces during cutting maneuvers while wearing their braces. The cutting angle, approach time to the cut, and time on the force plate showed no significant differences during brace wear. We conclude that the C.Ti brace allows significantly better running and cutting performances for athletes who have torn ACLs. Athletes who have not achieved 80% of quadricep strength as measured by Cybex testing showed even more improvement while wearing their braces.
7) Coast Plaza Doctor's Hospital - Norwalk, CA, US Contact: Bloodless Coordinators: Ron Austin K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 31
Heidi Austin Medical Director: Aida Salatinjants MD Address: 13100 Studebaker Rd. Norwalk, CA 90650 US Phone: (800) NO-PLASMA (800) 667-5276 ext. 3350 (562) 868-3751 ext. 3350 Hospital (562) 929-3103 Fax Email: [email protected]
8) Community Hospital of Los Gatos - Los Gatos, CA, US Contact: Transfusion-Free Program Coordinator Glenna R. Aitken Medical Director Glenna R. Aitken, M.D., Anesthesiologist Address: 815 Pollard Rd Los Gatos, CA 95032 US Phone: (408)866-3822 Bloodless (800) 800-1684 (408)378-1848 Fax WebSite: http://www.tenethealth.com/LosGatos Email: [email protected]
9) Corona Regional Medical Center - Corona, CA, US Contact: Bloodless Coordinator: Jose Duran Se habla Espanol. Address: 730 Magnolia Ave. Corona, CA 91719 US Phone: (909) 737-4343
10) Desert Regional Medical Center - Palms Springs, CA, US Contact: Bloodless Coordinator: Bradford Ray Address: 1150 N. Indian Canyon Dr. Palms Springs, CA 92262 US Phone: 760 - 323 - 6311 Transfusion Free Program 760 - 323 - 6580 Fax 909 - 482 - 7326 Pager & Voice Program Specialties: Comprehensive Cancer Center Cardiology Cardiothoracic Surgery Neonatology OBGYN Regional Trauma Center National Leader in Orthopedic Surgery: (Joint Replacement, Spinal Surgery)
11) Doctor's Medical Center - Modesto, CA, US Contact: Bloodless Coordinator / Assistant Administrator: Katherine A. Medeiros Address: 1441 Florida Ave. P.O. Box 4138 Modesto, CA 95352 US Phone: 209-576-3601 209-576-3502 Bloodless 209-576-3680 Fax Email: [email protected] K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 32
Articles: (1) Brown J, Tompkins K, Chaney E, Donovan R FAMILY MEMBER RIDE-ALONGS DURING INTERFACILITY TRANSPORT. Air Med J 1998 Oct-Dec;17(4):169-73 Doctors Medical Center, Modesto, CA 95350, USA. INTRODUCTION: A significant portion of the Air Med Team (AMT) flight missions involves interfacility transport of the ill or injured to receiving facilities with comprehensive resources available for their care. In an effort to help meet the psychologic needs of our patients and their families, AMT developed a Family Member Ride-Along program that allows family members or significant others to accompany patients during interfacility transport. The purpose of this study was to evaluate the ride-along program from the perspective of the family member passenger (FMP) who has accompanied a patient during transport. METHODS: Thirty-one family member ride-alongs responded to a 10-item questionnaire using a scaled response. Questions were designed to evaluate the benefit of the ride-along program to patients and family members from the FMP perspective. RESULTS: All FMPs surveyed thought the program was beneficial to either themselves or the patients. Several benefits described by FMPs included the ability to offer emotional support to the patient, provide patient information to receiving physicians, and sign releases for medical treatment. During interfacility transports, FMPs did not hinder either patient care or transport safety. CONCLUSION: Our study shows that allowing FMPs to accompany patients during transport benefits both patients and family members. (2) Kettleman K CONTROLLING BONE PAIN. HOW TO KEEP NAUSEA AND OVERSEDATION OUT OF THE PICTURE. Nursing 1998 Nov;28(11):22 Doctors Medical Center, Modesto, Calif., USA. (3) Tumbarello C ULTRASOUND EVALUATION OF ABDOMINAL TRAUMA IN THE EMERGENCY DEPARTMENT. J Trauma Nurs 1998 Jul-Sep;5(3):67-72; quiz 79-80 Doctors Medical Center, Modesto, CA, USA. To review the use of ultrasound for assessment of abdominal trauma during the secondary assessment. Three current methods for evaluation of abdominal trauma will be outlined. The use of ultrasound in evaluation of patients with blunt abdominal trauma will be highlighted, including performance of test, time to test completion, strengths, and limitations. The use of serial examination utilizing focused abdominal sonography for blunt trauma (FAST) to evaluate hemoperitoneum will be presented (4) Broderick P PEDIATRIC VISION SCREENING FOR THE FAMILY PHYSICIAN. Am Fam Physician 1998 Sep 1;58(3):691-700, 703-4 University of California, Doctors Medical Center, Modesto 95352, USA
12) Encino-Tarzana North Hollywood Hospitals & Healthcare Network (1) No authors listed LAUNCHING A NEW RESOURCE CENTER. ENCINO-TARZANA REGIONAL MEDICAL CENTER, TARZANA, CA. Profiles Healthc Mark 1996 Mar-Apr;12(2):37-40 K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 33 a. Tarzana Location: Encino-Tarzana Regional Medical Center - Tarzana, CA, US Contact: Bloodless Coordinator: Jeff Jackman Address: 18321 Clark St. Tarzana, CA 91356 US Phone: 800-600-2276 818-609-2276 Bloodless 818-609-2288 Fax Email: [email protected] Hospital number: (818)881-0800 Articles: (1) Schifrin BS MEDICOLEGAL RAMIFICATIONS OF ELECTRONIC FETAL MONITORING DURING LABOR. Clin Perinatol 1995 Dec;22(4):837-54 Department of Maternal-Fetal Medicine, Encino-Tarzana Regional Medical Center, California, USA. Fetal heart rate patterns play a significant role in the modern day obstetric care. They also play a significant role in medicolegal allegations of negligence when the fetus suffers injury. Proper interpretation of the fetal monitor tracing is only one factor in the evaluation of the reasonableness of obstetric care. Appropriate care and optimal defense both derive from reasonable interpretation of pertinent clinical data, including the monitor strip, along with timely pursuit of a thoughtful, properly annotated, plan of care. (2) Asplund DJ, Hall SJ KINEMATICS AND MYOELECTRIC ACTIVITY DURING STAIR-CLIMBING ERGOMETRY. J Orthop Sports Phys Ther 1995 Dec;22(6):247-53 Encino-Tarzana Regional Medical Center, CA, USA. Stair-climbing ergometry has become a popular mode of aerobic exercise, yet little research on the biomechanics of stair-climbing ergometry has been reported. This study was conducted to evaluate kinematics and myoelectric activity in major agonist muscle groups over 22 minutes of stair-climbing ergometry at 75% of each subject's predicted VO2max. Data were captured over 30-second intervals beginning at 3.5, 9.5, 15.5, and 21.5 minutes of exercise. Multivariate analysis of variance for the kinematic variables revealed a significant (p < 0.05) change in hand placement from a higher to a lower position over time. Multivariate analysis of variance for the electromyographic values revealed a significant (p < 0.05) decrease in activity in the gluteus maximus and vastus lateralis between 3.5 and 9.5 minutes, representing an adjustment to the exercise workload. The normal range of motion and trunk angle values documented should prove helpful to fitness and rehabilitation specialists in prescribing stair-climbing ergometry. (3) Quinn P, Moinipanah R, Steinberg JM, Weathersbee PS SUCCESSFUL HUMAN IN VITRO FERTILIZATION USING A MODIFIED HUMAN TUBAL FLUID MEDIUM LACKING GLUCOSE AND PHOSPHATE IONS. Fertil Steril 1995 Apr;63(4):922-4 Encino-Tarzana Regional Medical Center. OBJECTIVE: To determine the effect of medium with or without glucose and phosphate on the fertilization and development of human oocytes. DESIGN: Sequential allocation of alternate patients to one of two treatment groups. SETTING: Private practice infertility programs. PATIENTS: Ten couples requesting treatment for infertility. INTERVENTIONS: Gametes from each couple were collected, washed, and incubated in one of two culture media under investigation. MAIN OUTCOME MEASURES: Number of oocytes collected, fertilized, cleaving, replaced, and implanting in each patient. Development of any supernumerary embryos to fully expanded blastocysts in vitro. RESULTS: There was a significant increase in the proportion of transferred embryos implanting in the group of patients whose gametes were handled in medium devoid of glucose and phosphate. All other comparisons of factors that may have influenced implantation rates between the two groups of K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 34
patients were not significantly different. CONCLUSIONS: High rates of fertilization, cleavage, implantation, and development of supernumerary human embryos to the blastocyst stage in vitro were obtained with a modified human tubal fluid medium containing ethylenediaminetetraacetic acid and glutamine but devoid of glucose and phosphate ions. A prospective randomized trial is necessary to evaluate the clinical significance of these observations. (4) Schifrin BS THE ABCS OF ELECTRONIC FETAL MONITORING. J Perinatol 1994 Sep-Oct;14(5):396-402 Department of Obstetrics, Gynecology, AMI Encino-Tarzana Regional Medical Center, Calif. There have been too many surrogates used to define fetal asphyxia and too many surrogates used to time fetal injury. Low Apgar scores and the need for prolonged resuscitation, by themselves, are inadequate criteria for the diagnosis of perinatal asphyxia or subsequent neurologic handicap. Even with the addition of a low cord pH and seizures, it is not possible to infer neurologic handicap. Furthermore, acidosis and depression at birth (which should be referred to as "perinatal asphyxia") cannot measure the duration and extent of any prenatal asphyxial encounter. Nor can we use the absence of one or more of these signs to exclude perinatal asphyxia as the cause of injury. We cannot refer to fetal asphyxia and injury therefrom without defining our criteria and describing the model of asphyxia being invoked. Because ischemia to the brain and other organs (that is, localized asphyxia), not systemic global asphyxia, appears to be the major precursor of human fetal injury it seems unreasonable to insist on systemic fetal asphyxia at any time to validate the timing or mechanism of fetal injury. Most hypoxic newborn infants are not injured and most injured newborn infants are not hypoxic. Furthermore, that a baby is injured as a result of hypoxia during labor does not mean that the hypoxia was preventable. FHR patterns, properly interpreted, may be one of the most reliable determinants of subsequent neurologic outcome and depending on the circumstances may provide insight into the timing and mechanism of neurologic injury.
b. Encion Location: 16237 Ventura Blvd. Encion, CA 91436 (818) 995-5000-Hospital c. North Hollywood Location: 12629 Riverside Dr. North Hollywood, CA 91607 (818) 980-9200-Hospital (818) 609-2288-Hospital FAX
13) Fountain Valley Regional Hospital and Medical Center - Fountain Valley, CA, US Contact: Vinod Malhotra, M.D. Medical Director Roland A. Martinez Bloodless Healthcare Coordinator/ Medical Research Analyst Joe Rodriquez Bloodless Coordinator Address: 17100 Euclid Street Fountain Valley, CA 92708-8010 US Phone: 714 - 966 - 7200 Hospital 714 NOBLOOD pager K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 35
800 - 252 – 2202 WebSite: http://www.fountainvalleyhospital.com/ Email: [email protected] Articles: (1) Yen RG, Giacopelli JA, Granoff DP, Smith SD NEW NONFUSION PROCEDURE FOR TALOCALCANEAL COALITIONS WITH A FIXED HEEL VALGUS. J Am Podiatr Med Assoc 1993 Apr;83(4):191-7 Fountain Valley Regional Hospital and Medical Center, CA. The authors present a case of bilateral middle facet talocalcaneal coalitions with peroneal spasm producing a fixed valgus heel. They introduce a corrective procedure used at the Fountain Valley Regional Hospital and Medical Center and discuss its application in podiatric surgery. Correction included resection of the synostosis and lateral opening wedge heterogenous bone graft in the calcaneus to redistribute the body's weight on the heel and centralized over the axis of the subtalar joint.
14) French Hospital and Medical Center - San Luis, Obispo, CA, US Contact: Bloodless Coordinator: Donna Earl R.N. Address: 1911 Johnson Ave. San Luis, Obispo, CA 93401 US Phone: 805-543-5353 805-542-6558 Bloodless 805-547-3657 Pager Email: [email protected] Other Hospital number:800-775-5335 ext.6558 Toll Free
15) Glendale Memorial Hospital and Health Center - Glendale, CA, US Contact: Coordinator: Helen L. Finger Address: 1420 S. Central Avenue Glendale, CA 91204 US Phone: (818) 502-1900 ext. 7629 (714) 669-4001 fax WebSite: http://www.1800bloodless.com/ Email: [email protected]
16) Good Samaritan Hospital - Bakersfield, CA, US Contact: Transfusion Free Coordinator: Cheryl Carter Address: 901 Olive Drive Bakersfield, CA 93308 US Phone: (805) 399-4461 (805) 399-4224 Fax (800) 660-0551CA only Articles: (1) deCastro RM BLOODLESS SURGERY: ESTABLISHMENT OF A PROGRAM FOR THE SPECIAL MEDICAL NEEDS OF THE JEHOVAH'S WITNESS COMMUNITY--THE GYNECOLOGIC SURGERY EXPERIENCE AT A COMMUNITY HOSPITAL. Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1491-8 Department of Obstetrics and Gynecology, Legacy Good Samaritan Hospital, Portland, USA. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 36
OBJECTIVE: My purpose was to describe the rationale behind the establishment of a hospital-based program instituted to enhance the health of the Jehovah's Witness community and to evaluate patient profiles and outcomes of gynecologic patients treated surgically at our institution, during the past 5 years, whose intake was through the Bloodless Surgery Program and who were not accepting of blood or most blood products. I further describe how a coordinated program dedicated to serving this particular population might improve outcomes and patient satisfaction. STUDY DESIGN: A retrospective review of the charts of 89 patients, all Jehovah's Witnesses, who were enrolled through the Bloodless Surgery Program and underwent gynecologic surgery involving at least 1 night's hospitalization at our institution between January 1, 1993, and December 31, 1997, was performed. A comparison of patient length of stay, hospital charges, and surgical blood loss, in a subset of 41 patients who underwent abdominal hysterectomy, with a cohort of patients not affiliated with the Jehovah's Witnesses or the Bloodless Surgery Program was performed. Data regarding patient satisfaction were obtained through surveys and are presented. RESULTS: Patients enrolled through the Bloodless Surgery Program and undergoing abdominal hysterectomy were significantly younger (average age 43.4 vs 47.7 years) and incurred significantly lower hospital charges (average cost $8754 vs $9539). No significant difference between the group studied and the control group could be found in average length of stay or the average change between preoperative and postoperative hemoglobin levels. Data from patient satisfaction surveys suggest a high level of satisfaction with the Bloodless Surgery Program. CONCLUSION: A program dedicated to the special needs of the Jehovah's Witness community can be instituted in a community-based hospital with no evidence of increased morbidity, as evidenced by length of stay, hospital charges, and surgical blood loss, in a gynecologic patient population. Development of such programs is associated with a high level of patient satisfaction and the potential for improved patient care.
17) Good Samaritan Hospital - Los Angeles, CA, US Contact: Bloodless Coordinator: Wayne Henderson Medical Director: Manuel Estioko, M.D. Address: 1225 Wilshire Blvd. Los Angeles, CA 90017-2395 US Phone: 800-977-7989 213-482-2744 Bloodless 213-977-2514 Dr. Estioko WebSite: http://www.goodsam.org/ Email: [email protected] (1) Gerspach JM, Bellman GC, Stoller ML, Fugelso P CONSERVATIVE MANAGEMENT OF COLON INJURY FOLLOWING PERCUTANEOUS RENAL SURGERY. Urology 1997 Jun;49(6):831-6 Kaiser Permanente Medical Center and Good Samaritan Hospital, Los Angeles, California, USA. OBJECTIVES: Colon injury during percutaneous renal surgery is rare and can result in significant morbidity. Our objective was threefold: (1) to identify risk factors for colon injuries; (2) to optimize prevention of such injuries; and (3) to devise a treatment strategy for optimal management of such colon injuries. METHODS: Between July 1990 and July 1995, all percutaneous renal procedures performed at three kidney stone centers were reviewed (Kaiser Permanente Medical Center, Los Angeles; Hospital of the Good Samaritan, Los Angeles; and University of California at San Francisco). In addition, a review of the pertinent literature was performed. RESULTS: Five patients who suffered colon injuries during percutaneous renal surgery were identified. All had undergone percutaneous nephrolithotomy, and all injuries were extraperitoneal. Mean age was 31 years (range 17 to 52). Three patients were considered lean, and the other two were of average body habitus. Four of 5 patients were male. Three injuries occurred on the left side and two on the right. Recognition of colon injury occurred postoperatively in 4 patients and intraoperatively in 1 patient. Presenting signs and symptoms included fever, fecaluria, abdominal pain, and leukocytosis. CONCLUSIONS: High K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 37
risk patients for colon injuries are young, lean males with minimal retroperitoneal fat, in whom a retrorenal colon is more likely. High risk patients should be accessed with a more superior and medial puncture. Retroperitoneal colon injuries can be successfully managed conservatively with early recognition and appropriate drainage of the urinary and intestinal tracts. A treatment algorithm is presented. (2) Cannom DS, Ruggio J SPECIALTY CARE AT THE CROSSROADS: ELECTROPHYSIOLOGY PRACTICE IN THE MANAGED-CARE ERA. Prog Cardiovasc Dis 1996 Mar-Apr;38(5):401-6 Good Samaritan hospital, Los Angeles, CA, USA. The economics of the managed-care era have declared that there is an o ver supply of specialists. Especially vulnerable to the changing marketplace are electrophysiologists whose technology is poorly understood by managed-care plans. To be successful, electrophysiology (EP) practices must develop strategies to contend with the new reality. Over the past decade, electrophysiologists at Good Samaritan Hospital (Los Angeles, CA) have worked with the leadership of a large managed-care organization (Family Health Plan [FHP]) to develop guidelines for clinical EP procedures that optimize clinical outcome and cost for EP procedures. The important elements of a successful guideline are that it be a distillation of the best current medical literature and that it be carefully followed and routinely improved. Using the guidelines developed for radiofrequency ablation, FHP found that it was cheaper ($21,166 v $26,448) for FHP patients drug-resistant to supraventricular tachycardia to undergo ablation than to be treated medically. This was for 14 months of care. In addition to the development and implementation of guidelines, a number of factors are important in developing a successful managed-care approach. The physicians should be the "high quality-low cost" provider, with demonstrable excellent clinical outcomes, low complication rates, and competitive pricing. In addition, there must be an efficient short-stay system, with a premium on personal service to the patient and family. Also important is a strong hospital partner as well as sophisticated marketing and contracting support. A new marketplace paradigm is upon us that calls for a change in practice style from that of a decade ago if electrophysiologists are to survive in the managed-care marketplace.
18) John F. Kennedy Memorial Hospital - Indio, CA, US Contact: Bloodless Coordinator: Bradford Ray Address: 47-111 Monroe Street Indio, CA 92201 US Phone: (760) 775-8123 (909) 482-7326 (pager) Specialties: OB/GYN, Pediatric Neonatology. We have Physicians and Surgeons on Staff who have graduated from the OB/GYN University of Pittsburg
19) John Muir Medical Center - Walnut Creek, CA, US Contact: Bloodless Coordinator: Lisa Vencill Address: 1601 Ygnacio Valley Rd. Walnut Creek, CA 94598 US Phone: (925) 947-4466 (925)947-5380 Bloodless (925) 947-5372 Fax
John Muir Medical Center recognizes the need for patient autonomy and the patient's right to make choises about his or her healthcare. With that in mind, the staff has made a commitment to provide medical and surgical alternatives to their patients who wish to avoid blood transfusions. Call for more information. If you would like more information about physicians participatingin John Muir's Bloodless Surgery and Medical Program, call (510) 947-5380, Monday through Friday K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 38
between 9 a.m. and 4 p.m.. For information regarding the program, call (1)-(800)-883-3100. Specialized Medical Technique John Muir Medical Center's Staff has every device and technology available for bloodless surgery and medicine. Virtually every medical and surgical procedure performed at the medical center can be done using these techniques. Through this program, the meticulous surgical techniques of highly skilled physicians are paired with current medical technology. Medical Specialities and Surgical Procedures John Muir Medical Centers Bloodless Surgery and Medicine Program is equipped to pereform surgical and medical procedures within all the following specialities: Anesthesiology Cancer Hematology Internal Medicine Cancer Surgery Medical Oncology Chemotherapy Neurosurgery Ear, Nose and Throat Obstetrics Emergency Medicine Orthopedics General Surgery Urology Gynecology Heart Surgery Gastroenterology / Tumor / Endocrinology Vascular / Thoracic Surgery (1) Dann JJ OUTPATIENT ORAL AND MAXILLOFACIAL SURGERY: TRANSITION TO A SURGICENTER SETTING AND OUTCOME OF THE FIRST 200 CASES. J Oral Maxillofac Surg 1998 May;56(5):572-7 Department of Dentistry and Oral/Maxillofacial Surgery, John Muir Medical Center, Walnut Creek, CA, USA. Advances in techniques for perioperative management have reduced the morbidity associated with major oral and maxillofacial surgery. Simultaneously, pressures for cost control have affected patient access to surgical services. This report details the steps undertaken to effect a transition of major maxillofacial surgical procedures to an outpatient setting. Protocols for surgical, anesthetic, and postoperative management are described. Treatment outcomes for the first 200 cases are reported. Only 1% of cases required subsequent inpatient care and a less than 1% major revision rate was experienced. Articles: (1) Kelly CS PERINATAL COMPUTERIZED PATIENT RECORD AND ARCHIVING SYSTEMS: PITFALLS AND ENHANCEMENTS FOR IMPLEMENTING A SUCCESSFUL COMPUTERIZED MEDICAL RECORD. J Perinat Neonatal Nurs 1999 Mar;12(4):1-14 John Muir Medical Center, Walnut Creek, CA, USA. Interest in purchasing and installing a perinatal computerized patient record (CPR) and archiving system is growing in the United States as a result of increased patient satisfaction demands, cost containment, and quality improvement. Perinatal nurses are commonly charged with researching available computer software and hardware, making purchasing decisions, developing menus and forms, orienting users, and maintaining and upgrading systems. The decision to chart and archive by computer as well as installation and maintenance issues mandate that nurses increase their computer-related knowledge. The article reviews information related to CPR capabilities and rationales for purchase decisions, implementation and staff development issues, ergonomic and maintenance considerations, and realistic expectations of a CPR to provide perinatal nurses who are involved in purchasing, implementing, and maintaining these systems with a timely understanding of important elements that they need to know to make this effort successful. (2) Dann JJ OUTPATIENT ORAL AND MAXILLOFACIAL SURGERY: TRANSITION TO A SURGICENTER SETTING AND OUTCOME OF THE FIRST 200 CASES. J Oral Maxillofac Surg 1998 May;56(5):572-7 Department of Dentistry and Oral/Maxillofacial Surgery, John Muir Medical Center, Walnut Creek, CA, USA. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 39
Advances in techniques for perioperative management have reduced the morbidity associated with major oral and maxillofacial surgery. Simultaneously, pressures for cost control have affected patient access to surgical services. This report details the steps undertaken to effect a transition of major maxillofacial surgical procedures to an outpatient setting. Protocols for surgical, anesthetic, and postoperative management are described. Treatment outcomes for the first 200 cases are reported. Only 1% of cases required subsequent inpatient care and a less than 1% major revision rate was experienced. (3) Hansen KA IT'S NO ACCIDENT ... IT'S PREVENTABLE. J Emerg Nurs 1998 Feb;24(1):101-3 Injury Prevention Program, John Muir Medical Center, Walnut Creek, California, USA. (4) Pence M PATIENT-FOCUSED MODELS OF CARE. J Obstet Gynecol Neonatal Nurs 1997 May-Jun;26(3):320-6 Women's & Children's Services, John Muir Medical Center, Walnut Creek, CA 94598, USA. The structure and the process for delivering patient care will experience major changes during the next decade. Most hospitals have tried different alternatives, including restructuring, re-engineering, redesign, and the return to patient-focused care. Staffing strategies may successfully move nurses from total patient care to delegated, shared accountability. During their short stays, new parents and their neonates receive streamlined, intensely focused care from cross-trained workers in a patient- focused care environment. Each interaction becomes a meaningful and educational one, with the focal point being the mother and the family. Comment in: J Obstet Gynecol Neonatal Nurs 1998 Mar-Apr;27(2):125 (5) Baker MS, Armfield F PREVENTING POST-TRAUMATIC STRESS DISORDERS IN MILITARY MEDICAL PERSONNEL. Mil Med 1996 May;161(5):262-4 Navy Reserve Combat Zone 500 Fleet Hospital 21, John Muir Hospital and Trauma Center, Walnut Creek, CA, USA. Medical personnel in military units are highly vulnerable to post-traumatic stress disorder. They are removed from their conventional identity, stature, and social support system, and are deprived of a sense of control and physical comforts. They then must witness and immerse themselves in the gruesome results of warfare. Ideal training of medical personnel includes training intact units and functional teams, training on the deployment platform, and desensitizing with real casualty management. Using stress inoculation techniques prior to casualty handling, and providing for post- event debriefing (Critical Incidence Stress Debriefing), will reduce the incidence of combat casualty- induced stress disorders. (6) Reisetter J, Thistlethwaite D A LOOK AT OUR NEW EMERGENCY DEPARTMENT: JOHN MUIR MEDICAL CENTER, WALNUT CREEK, CALIFORNIA. J Emerg Nurs 1995 Aug;21(4):33A-34A (7) Baker MS ADVANCED TRAUMA LIFE SUPPORT: IS IT ADEQUATE STAND-ALONE TRAINING FOR MILITARY MEDICINE? Mil Med 1994 Sep;159(9):587-90 John Muir Hospital and Trauma Center, Walnut Creek, CA 94598-3194. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 40
Advanced Trauma Life Support (ATLS) is a 2-day course on handling the acutely injured patient. It has been developed by and is directed by the American College of Surgeons, and teaches a systematic approach to the care of the injured patient. It is relied upon as a teaching tool throughout the active and reserve military medical departments. This article will review its strengths and weaknesses, and will show that it is not an adequate "stand-alone" training tool. ATLS does not address the combat casualty, nor the combat scenario. Special courses must be utilized to train military medical providers for the conflicts and casualties of the future. (8) Herzog B, Felton B HEMOGLOBIN SCREENING FOR NORMAL NEWBORNS. J Perinatol 1994 Jul-Aug;14(4):285-9 John Muir Medical Center, Walnut Creek, California 94598. The spun hematocrit is a common screening test performed on normal newborn infants to determine anemia, and more commonly, polycythemia. Recently, the hemoglobin value obtained from the HemoCue system (HemoCue Inc.; Mission Viejo, Calif.) has gained popularity in the adult and outpatient pediatric population to screen blood for anemia. Although the machine is not in widespread use in hospitals, it is being used in blood banks and physician offices. The main advantage of using the HemoCue system versus a spun hematocrit is that specimen collection is safer. Universal precautions are used with all infants; however, a cut from a broken capillary tube places the health care worker at an increased risk of exposure to blood-borne pathogens. The HemoCue system is also a more rapid test that requires less blood. In addition, the machine is silent. This study was conducted to determine whether a hemoglobin values obtained with the HemoCue system could replace the spun hematocrit to screen for anemia and polycythemia in normal newborn infants. Fifty-four specimens were obtained from healthy, term newborn infants. The hematocrit and hemoglobin specimens drawn in the nursery and processed in the laboratory were compared. The hemoglobin was consistently one third the value of the hematocrit. There was a significant and systematic difference between the values obtained with the HemoCue in the nursery and the laboratory hematology analyzer. The HemoCue readings were slightly lower in all cases. (9) Benn A, Feldman T THE TECHNIQUE OF INSERTING AN INTRA-AORTIC BALLOON PUMP. INDICATIONS, CONTRAINDICATIONS, ADVICE FOR AVOIDING COMPLICATIONS. J Crit Illn 1992 Mar;7(3):435-45 John Muir Medical Center, Walnut Creek, California. The intra-aortic balloon pump (IABP) uses the timed inflation and deflation of a balloon placed in the descending aorta to augment coronary perfusion and reduce myocardial work. The IABP is useful in a number of settings, including acute myocardial ischemia, cardiogenic shock, and mechanical complications of acute myocardial infarction; it also provides support to perioperative patients. Because the device can be inserted percutaneously, mechanical circulatory support can be instituted rapidly Complications, most of which are reversible, occur in approximately 30% of patients.
20) Long Beach Community Medical Center - Long Beach, CA, US Contact: Healthcare Coordinator: Alexander Czerny Address: 1720 Termino Ave Long Beach, CA 92708 US Phone: (800) 367-6643 (24 hrs.) (562) 744-7527 (Pager) Email: [email protected] Medical Director: Dr. Mark I. Sander, Family Practice
21) Presbyterian Intercommunity Hospital 12401 Washington Blvd. Whittier, CA 90602 (310) 698-0811-Hospital K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 41
(1) Irwin C, Luciano K EASE YOUR MANAGEMENT WORKLOAD AND DEVELOP STAFF. Nurs Manage 1998 Nov;29(11):37-8 Presbyterian Intercommunity Hospital in Whittier, Calif., USA. A community hospital created a program where staff nurses work as house supervisors. The plan improves house supervisor coverage and provides opportunity for nursing staff development. (2) Ponce SR LESSONS LEARNED--THE BUCK STARTS IN ACCESS MANAGEMENT--NO MATTER WHERE IT IS! NAHAM Manage J 1998 Summer;24(5):19 Presbyterian Intercommunity Hospital, Whittier, CA, USA. (3) Alva D WANS ALL OVER THIS LAN. Healthc Inform 1994 Jul;11(7):38-40, 42 Presbyterian Intercommunity Hospital, Whittier, CA. (4) Reback JB THE WELL-STRUCTURED HOSPITAL-PHYSICIAN PARTNERSHIP. Healthc Forum J 1990 Sep-Oct;33(5):42-5 Cedars-Sinai Medical Center, Los Angeles. Presbyterian Intercommunity Hospital began its journey along the right path toward successful diversification when it decided to modify, rather than destroy, the legal structure of InterHealth (5) Tufts JC RESPIRATORY SERVICES DEPARTMENT AT PRESBYTERIAN INTERCOMMUNITY HOSPITAL. Respir Ther 1982 Nov-Dec;12(6):81-5 In 20 years, this department has grown from a small office with a staff of one to a facility staffed by 44 respiratory therapists and divided into four sections: respiratory therapy, respiratory laboratory, respiratory rehabilitation, and anesthesia. Computer programs complement the department's many services.
22) San Ramon Regional Medical Center - San Ramon, CA, US Contact: Transfusion-Free Med/Surg Coordinator: Mary-Kathryn Derr Andrew A. Knight, MD Chair, Department of Anesthesiology, Medical Director, Transfusion-Free Medicine & Surgery Program. Address: 6001 Norris Canyon Road San Ramon, CA 94583 US Phone: (800) 955-6606 (925) 275-8281Bloodless (925) 275-8396 fax WebSite: http://www.tenethealth.com/SanRamon/ Hospital number: (925) 275-9200 Articles: (1) Pettee D, Weckstein LN A SURVEY OF PARENTAL ATTITUDES TOWARD OOCYTE DONATION. Hum Reprod 1993 Nov;8(11):1963-5 Bay Area Fertility Medical Group, San Ramon Regional Medical Center, CA 94583. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 42
A questionnaire was sent to couples who had successfully completed oocyte donation cycles to survey their experiences and make suggestions to others considering this option. A majority of couples were successful in their first cycle, despite advanced maternal age or length of time attempting conception. A preference for non-anonymous arrangements was highlighted, despite the unknown long-term impact, and the importance of finding support was stressed. Respondents indicated no confusion about their role as parents of children conceived through oocyte donation. (2) Weckstein LN, Jacobson A, Galen D, Hampton K, Ivani K, Andres J IMPROVEMENT OF PREGNANCY RATES WITH OOCYTE DONATION IN OLDER RECIPIENTS WITH THE ADDITION OF PROGESTERONE VAGINAL SUPPOSITORIES. Fertil Steril 1993 Sep;60(3):573-5 Center for Reproductive Medicine, San Ramon Regional Medical Center, San Ramon, California. Pregnancy rates and implantation rates with oocyte donation in recipients 40 years of age and older were significantly lower than those obtained in recipients under the age of 40. This difference was eliminated when P vaginal suppositories were added to the luteal regimen in older recipients. Our experience suggests that uterine aging may play a role in the successful initiation of a pregnancy, but this may be overcome with the preparation of the uterus with P vaginal suppositories. (3) Newman CF, Capozza CM NUTRITIONAL SUPPORT IN HIV DISEASE. Caring 1991 Jul;10(7):28-36 San Ramon Regional Medical Center, Fremont, CA. As the management of HIV disease enters the realm of life-long treatment, rather than treatment for a terminal disease, nutrition becomes an important part of the treatment plan. Studies have shown a clear relationship between good nutritional status and the longevity of the AIDS patient.
23) Sierra Vista Regional Medical Center - San Luis Obispo, CA, US Contact: Bloodless Coordinator: Dennis Pall Address: 1010 Murray Ave. San Luis Obispo, CA 93406 US Phone: (800) 931-0070 (805) 546-7712 (805) 547-3187 pager Email: [email protected] Articles: (1) Olson EM, Duberg AC, Herron LD, Kissel P, Smilovitz D COCCIDIOIDAL SPONDYLITIS: MR FINDINGS IN 15 PATIENTS. AJR Am J Roentgenol 1998 Sep;171(3):785-9 Radiology Department, Sierra Vista Regional Medical Center, San Luis Obispo, CA 93405, USA. OBJECTIVE: MR imaging studies of 15 patients with documented vertebral column coccidioidomycosis infection were retrospectively reviewed to determine the MR imaging features of coccidioidal spondylitis. CONCLUSION: On MR imaging, coccidioidal spondylitis may be unifocal or multifocal. Involvement of an intervertebral disk, vertebral body marrow, and adjacent epidural and soft tissue is generally seen. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 43
(2) Kissel P, Youmans JR POSTTRAUMATIC ANTERIOR CERVICAL OSTEOPHYTE AND DYSPHAGIA: SURGICAL REPORT AND LITERATURE REVIEW. J Spinal Disord 1992 Mar;5(1):104-7 Sierra Vista Regional Medical Center, San Luis Obispo, California. Degenerative changes in the cervical spine can produce osteophytes and other hypertrophic abnormalities. Asymptomatic osteophytes of the anterior margins of the cervical vertebrae may occur in 20-30% of the population. Occasionally, dysphagia or dysphonia may be caused by such cervical osteophytes pressing against the esophagus or trachea. Recently, the authors treated a patient with posttraumatic dysphagia and dysphonia secondary to osteophytic spurring of the anterior cervical spine. This 43-year-old man presented 2 years after sustaining a flexion/extension soft tissue injury to his cervical spine. Radiographic studies depict the progression of his osteophyte growth, which resulted in surgical intervention to relieve his inability to swallow solid foods. One year follow-up studies demonstrate normal alignment and no instability. A search of the literature revealed approximately 75 previously reported cases of anterior osteophyte-induced dysphagia, with the majority secondary to diffuse idiopathic skeletal hyperostosis. The literature briefly mentions trauma as a possible etiology of anterior osteophytosis; however, our case is unique, as it documents the time course and progression of the pathologic process.
24) St. Jude Medical Center - Fullerton, CA, US Contact: Bloodless Coordinator: Linda Harper Address: 101 E. Valencia Mesa Dr. Fullerton, CA 92635 US Phone: 800-801-0701 714-992-3029 Fax (714) 992-3000 Ext.2580 Bloodless Programm Articles: (1) Tovar EA EXTRATHORACIC SUBCLAVIAN INTERNAL THORACIC ARTERY BYPASS GRAFTING. Ann Thorac Surg 1999 May;67(5):1485-7 Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, California, USA. [email protected] Interval development of a significant stenosis at the origin of the left internal thoracic artery (LITA) after this vessel has been used to revascularize the anterior descending coronary artery may be an indication for reoperation. We present an extrathoracic approach to bypass the proximal segment of the LITA that allows patients with this lesion a quick recovery, short hospital stay, and early resumption of normal activity (2) Tovar EA MINIMALLY INVASIVE APPROACH FOR PNEUMONECTOMY CULMINATING IN AN OUTPATIENT PROCEDURE. Chest 1998 Nov;114(5):1454-8 The Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, CA, USA. STUDY OBJECTIVE: To establish the effects of the use of a clinical pathway that includes a minimally invasive access among patients undergoing pneumonectomy. DESIGN: Prospective study from February to December of 1997. SETTING: A community hospital. PATIENTS: Five consecutive patients with a mean age of 60 years (range 43 to 74 years) with lung malignancies who required pneumonectomy. INTERVENTIONS: Clinical pathway based on patient education, a meticulous minimally invasive operation (oblique muscle-sparing minithoracotomy), intercostal K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 44
nerve cryoanalgesia, and a quick postoperative resumption of physical activity. RESULTS: All five patients were extubated in the operating room. They all had unrestricted shoulder mobility in the recovery room, and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation, and one patient was able to ambulate freely only a few hours after the procedure. Four patients were discharged the day after surgery, and one patient was discharged the same day of the operation. None required readmission related to the procedure. CONCLUSION: This initial experience seems to indicate that the application of this clinical pathway in patients undergoing pneumonectomy greatly accelerates their recovery and, for a select group of patients, converts it into an outpatient procedure. Comment in: Chest 1999 Jun;115(6):1753-5 (3) Tovar EA, Roethe RA, Weissig MD, Lillie MJ, Dabbs-Moyer KS, Lloyd RE, Patel GR MUSCLE-SPARING MINITHORACOTOMY WITH INTERCOSTAL NERVE CRYOANALGESIA: AN IMPROVED METHOD FOR MAJOR LUNG RESECTIONS. Am Surg 1998 Nov;64(11):1109-15 Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, California, USA. To decrease incisional pain, morbidity, and length of hospital stay (LOS) and, hopefully, to reduce costs, most surgical specialties have turned to minimally invasive procedures to access the body cavities during commonly performed operations. Video-assisted thoracic surgery (VATS) has emerged as the standard approach for a number of diagnostic and therapeutic procedures in thoracic surgery. Major lung resections (lobectomy, bilobectomy, and pneumonectomy), however, can be performed through an incision similar in size to the utility or access thoracotomy used in VATS to remove the specimen. The purpose of this study was to compare an oblique muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia with the standard posterolateral thoracotomy incision and VATS to perform major lung resections. Forty consecutive patients with bronchogenic carcinoma, operated on by a single surgeon, were chronologically divided into two groups, each with equivalent age, sex distribution, physiologic parameters, tumor size, and clinical stage. In addition, data were collected from a MEDLINE search of all published studies in which major lung resections were performed via VATS. The first group (group A, n = 20) underwent posterolateral thoracotomy to access the chest cavity, whereas the patients in the second group (group B, n = 20) underwent oblique minithoracotomy with intercostal nerve cryoanalgesia. Group B compared favorably with group A in LOS (P = 0.002), narcotic requirements (P = 0.001), morbidity (P = 0.042), and cost (P = 0.058). Group B also compared favorably with VATS major lung resection published data regarding LOS and morbidity. (4) Olmstead J EVALUATION AND MANAGEMENT OF THE PATIENT WITH ULCERATIVE COLITIS. Gastroenterol Nurs 1998 Jul-Aug;21(4):176-80 Endoscopy Department, St. Jude Medical Center, Fullerton, CA, USA. Ulcerative colitis is an inflammatory bowel disease that affects the large intestine. Ulcerative colitis is chronic and can be debilitating. The disease process waxes and wanes, which sometimes gives patients a false sense of cure. The endoscopy laboratory nurse is at the forefront to provide patients with education and offer community support resources. By educating the patient and introducing community outreach programs, the patient can learn to participate and be a partner with the provider in his or her healthcare management. The case study will help outline pertinent information for educating the patient in the management of ulcerative colitis. (5) Tovar EA, Roethe RA, Weissig MD, Lloyd RE, Patel GR ONE-DAY ADMISSION FOR LUNG LOBECTOMY: AN INCIDENTAL RESULT OF A CLINICAL PATHWAY. Ann Thorac Surg 1998 Mar;65(3):803-6 Department of Cardiothoracic Surgery, St Jude Medical Center, Fullerton, California, USA. [email protected] K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 45
BACKGROUND: Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained. METHODS: Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon's office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia. RESULTS: All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome. CONCLUSIONS: We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection. (6) Tovar EA, Blau N, Borsari A AXILLARY ARTERY-CORONARY ARTERY BYPASS GRAFTING. J Thorac Cardiovasc Surg 1998 Jan;115(1):242-3 Department of Cardiothoracic Surgery and Cardiology, St. Jude Medical Center, Fullerton, Calif., USA (7) Tovar EA, Borsari A, Landa DW, Weinstein PB, Gazzaniga AB VENTRICULOTOMY REPAIR DURING REVASCULARIZATION OF INTRACAVITARY ANTERIOR DESCENDING CORONARY ARTERIES. Ann Thorac Surg 1997 Oct;64(4):1194-6 Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, California, USA. [email protected] Optimal revascularization of the rare variant anomolous intracavitary left anterior descending coronary artery requires, by definition, entrance into the right ventricular cavity. We present a simple method to repair the ventriculotomy without risk of obliterating the left anterior descending coronary artery, septal perforators, or diagonal branches.
25) St. Luke's Medical Center - Pasadena, CA, US Contact: Bloodless Coordinator: Ronald Williams Address: 2632 East Washington Blvd. Pasadena, CA 91107-1411 US Phone: 800-311-3300 (626)791-6691 Bloodless (626) 791-6677 Fax 626.451.2267 Pgr Email: [email protected] Hospital number: (626)797-1141
26) Temple Community Hospital - Los Angeles, CA, US K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 46
Contact: Healthcare Coordinator: Arnold Avalos "Hablamos español" Address: 235 North Hoover Street Los Angeles, CA 90004 US Phone: 800-367-6643 (24 hour Hotline) (213) 397-5532 (Pager) Email: [email protected] Medical Director: Dr. Mark I Sanders, Family Practice.
27) Twin Cities Community Hospital - Templeton, CA, US Contact: Regional Director/Bloodless Coordinator Dennis Pall Address: 1100 Las Tablas Road Templeton, CA 93465 US Phone: 800 931-0070 (805) 547-3187 pager Email: [email protected]
28) USC University Hospital - Los Angeles, CA, US Contact: Bloodless Coordinator: Randy Henderson Address: 1500 San Pablo Los Angeles, CA 90033 US Phone: (323) 442-5261 Bloodless (800) USC-CARE (323) 442-8908 Fax WebSite: http://www.interknight.com/test/uscliver1999/facultystaff.html Email: [email protected]
29) USC Kenneth Norris Comprehensive Cancer Center and Hospital - Los Angeles, CA, US Contact: Bloodless Coordinator: Randy Henderson Address: 1441 East Lake Ave. Los Angeles, CA 90033-4585 US Phone: (800) 282-2273 (323)442-5261 Bloodless (323)442-8908 Fax Email: [email protected]
30) Valley Community Hospital - Santa Maria, CA, US Contact: Regional Director/Bloodless Coordinator Dennis Pall Address: 505 East Plaza Drive Santa Maria, CA 93454 US Phone: (800) 931-0070 (805) 547-3187 pager Email: [email protected]
31) Western Medical Center Anaheim - Anaheim, CA, US Contact: Healtcare Coordinator: Walter H. Bass Address: 1025 South Anaheim Blvd Anaheim, CA 92805 US Phone: 1800 367-6643 (24 hour Hotline) K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 47
(714) 563-0053 Email: [email protected]
32) Whittier Hospital Medical Center - Whittier, CA, US Contact: Healthcare Coordinator: Jorge Ortiz Medical Director: Dr. Stanley Kaller Address: 9080 Colima Rd Whittier, CA 90605 US Phone: 1 800 367-6643 (562) 465-9749 IV. COLORADO
1) University Hospital - Denver, CO, US Contact: Bloodless Coordinator: Judi Arias Address: 4200 East Ninth Ave. C-305 Denver, CO 80262 US Phone: 800-466-6633 (303)315-6385 Bloodless (303)315-8098 Fax Hospital number: (303)399-1211 University Hospital, the main teaching hospital of Colorado's premier academic medical center, is located in the heart of the campus of the University of Colorado Health Sciences Center ranked one of the top 20 academic medical centers in IV country. Along with a skilled medical and professional staff, the challenges of bloodless surgery call not only for surgeons with meticulous surgical techniques, but also for state-of-art medical technology. University Hospital's Technology includes: ♦ Cell Saver ♦ Skin Monitor ♦ Argon Beam Coagulator and Laser ♦ Synthetic Erythropoietin ♦ Volume Expanders We have built this Program on one basic principe: Respect for individual religious beliefs and medical preferences. You may prefer a bloodless treatment method for many reasons. For instance, you might feel more comfortable knowing that, with bloodless techniques, you don't risk infection of blood borne illnesses, such as hepatitis and HIV. Our goal in this program is to ensure access to high quality medical care that respects your personal or religious convictions. Our program includes virtually every medical and surgical procedure available, and we can provide medical care without transfusions to adult patients who request it. For more information on the University Bloodless Medicine and Surgery Program or to schedule an appointment, call 1-800-466-6633
Articles: K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 48
(1) Onstott AT HOSPITAL EXPLORES WINNING BALANCE IN PERIOPERATIVE EDUCATION. AORN J 1998 Sep;68(3):395-9 University Hospital, Denver, USA. [email protected] Although there are a number of education models used today that expose bachelor of nursing degree students to perioperative nursing, producing nursing graduates who have the education and experience needed to work in the demanding perioperative arena is a challenge for education facilities. The University of Colorado Health Sciences Center, Denver, has developed a perioperative education model that interfaces with one of the university's clinical sites, University Hospital, Denver, to achieve a winning balance between perioperative education and employment. The model provides nursing students with a realistic perspective of the OR and gives the employer an opportunity to thoroughly evaluate potential employees--beyond a resume and references. (2) Nehler MR, Taylor LM Jr, Lee RW, Moneta GL, Porter JM INTERPOSITION GRAFTING FOR REOPERATION ON THE COMMON FEMORAL ARTERY. J Vasc Surg 1998 Jul;28(1):37-42; discussion 42-4 Department of Surgery, University of Colorado Health Sciences Center, Denver 80262, USA. PURPOSE: This report details our experience with common femoral artery resection and Dacron interposition grafting in the management of vascular reoperations involving the common femoral artery. DESIGN: Retrospective review. SETTING: University teaching hospital. SUBJECTS: Consecutive reoperative patients who had common femoral artery interposition grafting for arteriosclerotic occlusive disease from 1986 to 1997. INTERVENTIONS: Common femoral artery resection and interposition grafting. MAIN OUTCOME MEASURES: Operative morbidity and mortality rates and long- term patency, limb salvage, patient survival, freedom-from-graft-infection, and freedom-from-reoperation rates. RESULTS: Ninety-nine common femoral arteries (16 bilateral) were resected and replaced with Dacron interposition grafts in 83 patients (50 male, 33 female; mean age, 65 years) who had had 237 previous ipsilateral common femoral artery operations (mean, 2.4 operations; range, 1-9 operations). Simultaneous infrainguinal bypass grafts were performed in 52 operations (53%), and 60 operations (61%) were performed in patients who had had previous ipsilateral proximal bypass grafts. Operative mortality was 2%, with a 14% rate of perioperative wound complications. Mean follow-up time was 22 months. One- and 3-year assisted primary patency rates for the interposition grafts were 90% and 77%, respectively. Both 1- and 3-year life-table-determined limb salvage rates were 95%. One- and 3-year life-table-determined freedom-from-reoperation rates were 74% and 43%, respectively. One- and 3-year life-table-determined freedom-from-infection rates were 99% and 92%, respectively. One- and 3-year life-table-determined survival rates were 82% and 73%, respectively. CONCLUSIONS: Common femoral artery resection and Dacron interposition grafting are safe, and they obviate many difficulties associated with reoperative common femoral artery surgery with satisfactory long-term results. (3) Bearman SI, Overmoyer BA, Bolwell BJ, Taylor CW, Shpall EJ, Cagnoni PJ, Mechling BE, Ronk B, Baron AE, Purdy MH, Ross M, Jones RB HIGH-DOSE CHEMOTHERAPY WITH AUTOLOGOUS PERIPHERAL BLOOD PROGENITOR CELL SUPPORT FOR PRIMARY BREAST CANCER IN PATIENTS WITH 4-9 INVOLVED AXILLARY LYMPH NODES. Bone Marrow Transplant 1997 Dec;20(11):931-7 Bone Marrow Transplant Programs of University of Colorado Health Sciences Center, Denver 80262, USA. Breast cancer patients with more than three involved axillary lymph have a high likelihood of relapse after adjuvant therapy. Early results of administration of high-dose chemotherapy (HDCT) and autologous peripheral blood progenitor cells (PBPC) to patients with primary breast cancer and > or = 10 involved axillary nodes have been encouraging. We performed a multicenter trial to determine whether HDCT could be safely administered to patients with primary breast cancer involving 4-9 axillary lymph K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 49
nodes. Fifty-four patients with stage II or III breast cancer and 4-9 involved axillary lymph nodes received doxorubicin-based induction chemotherapy, followed by high-dose cyclophosphamide (5.625 g/m2), cisplatin (165 mg/m2), and BCNU (450 mg/m2) and PBPC mobilized by sargramostim (GM- CSF) or filgrastim (G-CSF). After completion of HDCT, patients received radiation therapy to the chest wall or involved breast, plus tamoxifen. Survival and disease-free survival, time to engraftment, and charges associated with HDCT were determined. Plasma concentrations of BCNU were determined and plasma AUC(BCNU) was calculated. Fifty-four patients were evaluable for survival and relapse- free survival. Fifty-two patients received HDCT with PBPC support and were evaluable for toxicity. Fifteen patients (29%) developed late pulmonary drug toxicity, which resolved with a 10-week course of corticosteroids in all but one affected patient, who subsequently died of pulmonary toxicity. Ten patients relapsed a median of 426 days (range 86-1117 days) after the start of induction chemotherapy, seven of whom have died. Forty-three patients are alive and breast cancer-free at a median of 947 days (range 661-1730 days) after the start of therapy, including one patient who developed myelodysplastic syndrome 809 days after the start of HDCT. Actuarial 4-year survival and disease-free survival from the start of treatment are 84 and 71%, respectively. Mean plasma AUC(BCNU) was 400 (range 82-1255) microgxmin/ml and was not statistically different from that measured in historical controls who received 600 mg/m2 of BCNU. Combined hospital and physician charges for patients treated at the University of Colorado decreased from a mean of $125845 for the first four patients to $77126 for the final seven patients. We conclude that HDCT with autologous PBPC can be administered with acceptable safety to patients with primary breast cancer involving 4- 9 axillary lymph nodes. An ongoing, prospective randomized trial is evaluating the efficacy of HDCT for this patient group. (4) McGregor JA, French JI PRETERM BIRTH: THE ROLE OF INFECTION AND INFLAMMATION. Medscape Womens Health 1997 Aug;2(8):1 Department of Obstetrics and Gynecology, University of Colorado Health Sciences Center, Denver, Colo. Preterm birth is the leading preventable cause of neonatal morbidity. Evidence shows that common genitourinary infections, which can easily be treated, cause large numbers of babies to be born prematurely. Because of their biologically immature organs, these newborns require intensive neonatal care, which leads to excess hospital costs early in life (approximately $3000/day at the University of Colorado). Long term, these children require follow-up for a range of disabling conditions, such as cerebral palsy, mental retardation, blindness, and/or deafness. Inexpensive screening during pregnancy can detect such common infections as bacterial vaginosis, trichomoniasis, chlamydia, and urinary tract infection; prompt treatment of these infections can effectively reduce admissions for preterm labor evaluation and can lower preterm birth rates. Bacterial vaginosis, in particular, has been consistently associated with a significantly increased risk of preterm births. Selective use of antibiotics in women during preterm labor and premature rupture of membranes significantly reduces both preterm birth rates and the risk of complications--in particular, from group B streptococcus (GBS) infection--in both babies and mothers. Implementation of appropriate screening and treatment of bacterial vaginosis and other prevalent infections can dramatically reduce the excess morbidity and mortality of infants "born too soon" because of reproductive tract infection. V. CONNECTICUT
1) Bridgeport Hospital - Bridgeport, CT, US (1) Inayet N, Amoateng-Adjepong Y, Upadya A, Manthous CA RISKS FOR DEVELOPING CRITICAL ILLNESS WITH GI HEMORRHAGE. Chest 2000 Aug;118(2):473-478. Pulmonary and Critical Care Division, Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT. Study objectives: To define risk factors, identifiable on initial presentation, that predict subsequent physiologic derangements that are consistent with critical illness in patients presenting to hospital K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 50
with GI hemorrhage (GIH). DESIGN:: Observational, cohort study. SETTING:: Fourteen-bed medical ICU in a 300-bed community teaching hospital. PATIENTS:: One hundred ninety-three patients were studied during 199 separate hospital admissions for GIH. Methods and measurements: Demographic and physiologic variables were extracted from the medical records of patients admitted with GIH. Comprehensive data, from after 2 h in the emergency department to the time of discharge or death, were used to determine whether patients met established ICU admission criteria. Physiologic and demographic data from the initial 2-h period were then compared for patients who subsequently met and for those who did not meet ICU admission criteria. Independent predictors of meeting ICU admission criteria were identified using multiple logistic regression analyses. Sensitivity and specificity associated with the combined use of these predictors were assessed. RESULTS:: Thirty-four patients satisfied ICU admission criteria after the initial 2-h period in the emergency department. Sixty-five patients, including 29 of 34 patients who met ICU admission criteria, were actually admitted to the ICU. Among those who never fulfilled ICU admission criteria, the duration of hospital stay was longer for those admitted to the ICU than for those not admitted to ICU (6.6 +/- 0.6 days vs 5.2 +/- 0.3 days; p = 0.04). The admission prothrombin time (international normalized ratio > 1.2), hypotension (systolic BP < 90 mm Hg), acute neurologic changes, and initial APACHE (acute physiology and chronic health evaluation) II score ( >/= 15) were the best independent predictors for meeting the defined criteria for admission to ICU. The presence of one or more of these in the first 2 h of presentation was associated with a sensitivity of 88% and specificity of 74% for predicting subsequent critical instability. The area under the receiver operator characteristic curve for use of these four variables was 86% for predicting whether patients met ICU admission criteria. CONCLUSIONS:: Many patients with GIH were admitted to the ICU who never met local criteria for admission, and these patients experienced a significantly longer length of hospital stay than other, similarly ill patients. Coagulopathy, hypotension, neurologic dysfunction, and a higher ( >/= 15) APACHE II score in the first 2 h of hospitalization were the best independent predictors of the subsequent development of critical illness. (2) Bernstein LH, Qamar A, McPherson C, Zarich S EVALUATING A NEW GRAPHICAL ORDINAL LOGIT METHOD (GOLDMINER) IN THE DIAGNOSIS OF MYOCARDIAL INFARCTION UTILIZING CLINICAL FEATURES AND LABORATORY DATA. Yale J Biol Med 2000 Jul-Aug;72(4):259-268. Department of Pathology and Laboratory Medicine, Yale University School of Medicine, Bridgeport Hospital, Connecticut 06610, USA. OBJECTIVE: We used a new graphical ordinal logit method (GOLDminer) to assess a single cardiac troponin T (cTnT) analysis at the time of admission (first generation monoclonal; Roche BMC Corp., Indianapolis, Indiana), the character of chest pain, and electrocardiographic (ECG)findings in predicting the likelihood of acute myocardial infarction (AMI) in patients presenting with suspected myocardial ischemia. The final diagnosis of AMI was based on serial ECG findings and evolution of CKMB isoenzyme levels in conjunction with clinical findings. SUBJECTS: The study population consisted of 293 consecutive patients who presented at a mean of six hours after onset of chest pain or associated symptoms warranting a "rule-out" for AMI assessment to a university-affiliated community hospital. RESULTS: The odds-ratio for an elevated cTnT (> 0. 1 ng/ml) in AMI was 22.2:1. There was an association between typical chest pain and cTnT (chi square = 78.23, p < .0001) and between abnormal ECG findings and cTnT (chi square = 108, p < .0001). The cTnT yielded diagnostic benefit in addition to chest pain characteristics and ECG findings in AMI. We present the odds-ratios for the combined features in GOLDminer plots. CONCLUSION: We demonstrate how the odds-ratios for AMI are obtained after scaling continuous to ordinal the values for a single cTnT determination alone and with other features in patients presenting with chest pain.
2) Hartford Hospital - Hartford, CT, US Contact: Bloodless Coordinator: Suzanne Russell Address: 80 Seymour Street Hartford, CT 06102-5037 US Phone: (800) 684-3334 K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 51
(860) 545-4119 or (860) 293-5338 Pager (860) 545-5062 Fax Email: [email protected]
A coordinator of Hartford Hospital's Center for Bloodless Medicine and Surgery (CBMS) is available 24 hours a day for both scheduled and emergency admissions. The coordinator has a directory of physicians who are trained in the most advanced bloodless treatment techniques. But due to legal constraints, Hartford Hospital cannot guarantee that it will refrain from using blood when treating children.
To find out more to register with the Center for the Bloodless Medicine and Surgery Program at Hartford Hospital, please call: CBMS Program Coordinator at 1-800-684-3334. (1) Maness CP, Russell SM, Altonji P, Allmendinger P BLOODLESS MEDICINE AND SURGERY. AORN J 1998 Jan;67(1):144-52 Center for Bloodless Medicine and Surgery, Hartford Hospital, CT, USA. Our hospital is a center for bloodless medicine and surgery (CBMS). It is one of 56 such centers located in the United States. The mission of the center is to provide surgical and medical treatment without the administration of blood or blood-related products. Patients' rights to autonomy and self- determination are respected. Development of the CBMS program required the writing and implementation of specific guidelines, developing standards of care, revising existing policies and procedures, and educating staff members. The CBMS program is multifaceted and multidisciplinary.
VI. FLORIDA
1) Coral Gables Hospital - Coral Gables, FL, US Contact: Bloodless Coordinator: Humberto Perez Address: 3100 Douglas Rd. Coral Gables, FL 33134 US Phone: 305-441-6827 Bloodless (305) 461-6907 Fax Email: [email protected]
2) Florida Medical Center - Fort Lauderdale, FL, US Contact: Bloodless Coordinator: Paula Matlock Address: 5000 W. Oakland Park Blvd. Fort Lauderdale, FL 33313 US Phone: 954-730-2888 Email: [email protected]
3) Holy Cross Hospital 4725 N. Federal Hwy. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 52
Fort Lauderdale, FL 33308 (305) 771-8000-(Hospital) Articles: (1) Chard RR USING A CASE SCENARIO APPROACH TO EVALUATE AGE-SPECIFIC COMPETENCIES. AORN J 1998 Mar;67(3):634, 637-42 Holy Cross Hospital, Ft Lauderdale, Fla, USA. Age-specific competencies for staff members having direct patient contact is a requirement of the Joint Commission on Accreditation of Healthcare Organizations. This article addresses an annual competency evaluation of perioperative staff members relating to age-specific criteria. Several types of case scenarios were developed and given to staff members (eg, RNs, surgical technologists, OR assistants, postanesthesia care unit attendants) according to their specific job descriptions and responsibilities within the surgical services department. A case scenario format was used because of the variety of health care personnel and the ability to manipulate the scenarios according to the needs of patients, staff members, and the institution. The evaluation tools were meant to adequately assess staff members' abilities to care for patients throughout the life span. (2) Sieradzan R, Fuller AV A MULTIDISCIPLINARY APPROACH TO ENHANCE DOCUMENTATION OF ANTIBIOTIC SERUM SAMPLING. Hosp Pharm 1995 Oct;30(10):872, 874, 876-7 Holy Cross Hospital, Fort Lauderdale, FL 33308, USA. A procedure to improve interdepartmental communication and documentation of antibiotic serum sampling data for pharmacokinetic evaluation will be presented. A prospective audit by the Pharmacokinetic Service revealed that approximately 40% of all antibiotic serum levels were improperly drawn resulting in unsuitable specimens and erroneous serum concentrations or lacked sufficient data for pharmacokinetic analysis. A lack of communication and documentation between phlebotomy and nursing personnel was found to be the most significant source of potential error in serum sampling. Once the protocol for serum sampling was revised, less than 5% of antibiotic serum levels were found to be unsuitable for evaluation and interpretation. A continuous audit for procedural compliance identifies any source of potential sampling error and provides a means to improve the overall quality of a Pharmacokinetic Service. (3) Luceri RM, Zilo P, Habal SM, David IB COST AND LENGTH OF HOSPITAL STAY: COMPARISONS BETWEEN NONTHORACOTOMY AND EPICARDIAL TECHNIQUES IN PATIENTS RECEIVING IMPLANTABLE CARDIOVERTER DEFIBRILLATORS. Pacing Clin Electrophysiol 1995 Jan;18(1 Pt 2):168-71 Holy Cross Hospital, Fort Lauderdale, FL. Twenty-five patients with implantable cardioverter defibrillators (ICDs) implanted intrathoracically (group I) were compared with 25 patients who underwent implant using the nonthoracotomy approach (group II). All systems were implanted by the same medical team, in the same high volume implanting center. Indications for implantation were comparable in both groups. Patient characteristics were not statistically different with the exception of age (66-group I vs 71-group II; P < 0.05). Although left ventricular ejection fractions appeared to differ (32% vs 37%, respectively), this difference was not statistically significant (P = 0.06). ICD models used in group I were: Ventritex Cadence (16), Telectronics Guardian 4211 (2), Medtronic PCD (7); in group II they were: Ventritex Cadence (15), Guardian 4211 (2), and CPI 1600 (1). Total length of hospital stay was 16 +/- 6 days for group I versus 12 +/- 5 for group II (P < 0.05). Number of postoperative days in an intensive care unit was 3.2 +/- 2.8 for group I versus 0.5 +/- 0.6 for group II (P < 0.0001). Postoperative length of stay was 8.2 +/- 3.1 for group I versus 5.7 +/- 4.4 for group II (P < 0.001). Mean total hospital charges for the entire length of stay were $72,918 +/- $26,770 in group I versus $55,031 +/- $42,870 in group II, representing a mean reduction of 21% in global costs for group II patients. These data confirm that nonthoracotomy ICD K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 53
implantation in an experienced center is associated with significantly shorter hospital stays, a virtual elimination of the need for postoperative intensive care, and globally lower total hospital costs. In addition, the presence of a statistically older population in group II does not negate these beneficial effects.
4) Jackson Memorial Hospital 1660 NW 7th Ct. Miami, FL 33136 (305) 324-8111- Hospital
5) St. Vincent's Medical Center 1800 Barrs St. Jacksonville, FL 32204 (904) 387-7300-Hospital
6) University General Hospital of Seminole 10200 Seminole Blvd. P.O. Box 4005 Seminole, FL 36642 (813) 397- 5511- Hospital The Bloodless Medicine and Surgery Program at University General Hospital of Seminole is founded on one basic principle--respect for individual religious beliefs and medical preferences. This program includes virtually every medical and surgical procedure available. We have assembled a group of physicians trained in all subspecialities of helthcare who have made a special commitment to uphold the wishes of those who desire this service. In addition, our staff of nurses and technicians are skilled in providing bloodless medical and surgical care. Physician Referral Service at (813) 398-3307 between the hours 8:30 A.M. and5:00 P.M.!
7) Women's Hospital and Medical Center 9675 Seminole Blvd. P. O. Box 4001 Seminole, FL 34642 (813) 393- 4646- Hospital
At the University General Hospital of Seminole and Women's Hospital Medical Center we are committed to providing patients with high-quality health care
If you would like more information on the Bloodless Medicine & Surgery Program, and limitations where applicable, call (813) 398-3307.
8) University of Miami - Jackson Memorial Hospital / Memorial Center - Miami, FL, US Contact: Bloodless Coordinator: Diane Mitchell Address: 1611 12th Ave Miami, FL 33136-1094 US Phone: 305-585-7269 800-664-2533 WebSite: http://www.noblood-miami.com/ Email: [email protected] K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 54
VII. GEORGIA
1) St. Joseph's Hospital - Savannah, GA, US Contact: Bloodless Coordinator: Dr. Irving Victor Vice President of Medical Affairs Address: 11705 Mercy Blvd. Savannah, GA 31419 US Phone: (912) 927-5578 Office (912) 927-5188 Fax Program Specialties: Cardiology Orthopedics Neurosurgery (912) 925- 4100- Hospital VIII.HAWAII
1)Palmetto General Hospital - Hi, , Contact: N/A Address: 2001 W. 68th St. Hi, IX. ILLINOIS
1) Northwest Community Hospital - Arlington Heights, IL, US Contact: Bloodless Coordinator: Debby Dobbertin Address: 800 West Central Rd Arlington Heights, IL 60005-2392 US Phone: 847-618-1000 800-456-6970 (708) 259- 1000 - Hospital Articles: (1) Malone AJ UNENHANCED CT IN THE EVALUATION OF THE ACUTE ABDOMEN: THE COMMUNITY HOSPITAL EXPERIENCE. Semin Ultrasound CT MR 1999 Apr;20(2):68-76 Department of Radiology, Northwest Community Healthcare, Arlington Heights, IL 60005- 2392, USA. The "Great Mimicker," acute appendicitis, has finally found its match with the advent of rapid unenhanced computed tomography (RUCT). With little, if any, operator dependence, RUCT can be performed easily at any facility that has CT capabilities. With only minimal interpreter dependence, the examination is highly accurate in determining which patients with acute abdominal pain require further treatment and expenditure of resources. In this article we describe our experience, since devising the technique in 1991, with over 7,000 RUCT scans done on patients with acute abdominal pain, predominantly in the right lower quadrant. We show how RUCT is extremely useful and accurate, not only in the diagnosis of acute appendicitis, but in many other disease entities that mimic the "Great Mimicker." (2) Shetty MR, Reiman HM Jr TUMOR SIZE AND AXILLARY METASTASIS, A CORRELATIVE OCCURRENCE IN 1244 CASES OF BREAST CANCER BETWEEN 1980 AND 1995. Eur J Surg Oncol 1997 Apr;23(2):139-41 Department of Medical Oncology, Northwest Community Hospital, Arlington Heights, IL 60005, USA. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 55
A review of 1244 breast cancer cases from the Tumor Registry of Northwest Community Hospital between 1980 and 1995 was carried out to investigate the incidence of axillary metastasis. There were 442 patients (35.45%) with positive nodes. The small lesions were graded to ascertain if size and grade of small tumors can be used to predict axillary metastasis. One hundred and seventy-nine cases of < or = 1.0 cm were retrospectively reviewed by one pathologist. Tumors <0.4 cm had negative nodes. Those with nuclear and histologic grades of 1 had 3% positive nodes, the remainder had positive nodes ranging from 11% to 19%. Infiltrating duct cancers of nuclear grade 3, histologic grade 2, and positive nodes, showed a 40% mortality. Eighteen patients died in the 0.5-1.0 cm tumor size range, mostly of histologic grade 2 and nuclear grade 3. Nuclear and histologic grade 1 tumors with infiltrating duct cancers had negative nodes and showed a good prognosis. Based on this study, node dissection can be omitted in these patients and in those with tumors < or = 0.4 cm. For all other lesions, full axillary node dissection and detailed pathologic examination is still the gold standard for evaluating the axilla. Comment in: Eur J Surg Oncol 1997 Oct;23(5):466-7 (3) Baker N, Zeglen M ONE HOSPITAL'S EXPERIENCE WITH THE JCAHO'S IMSYSTEM. Healthc Inf Manage 1996 Spring;10(1):75-82 Northwest Community Hospital, Arlington Heights, IL, USA.
2) Our Lady of the Resurrection Medical Center - Chicago, IL, US Center Contact: Bloodless Coordinator: Jan Castro-Graziani Address: 5645 West Addison St. Chicago, IL 60634 US Phone: 800-327-3809 773-282-7000 Ext. 4083 773-794-4647 Fax WebSite: http://www.reshealth.org/ Articles: (1) Brooks BA, Massanari K IMPLEMENTATION OF NANDA NURSING DIAGNOSES ONLINE. NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION. Comput Nurs 1998 Nov-Dec;16(6):320-6 Our Lady of the Resurrection Medical Center, Chicago, Illinois, USA. [email protected] The authors describe the online implementation of the standardized nursing language of the North American Nursing Diagnosis Association (NANDA) nursing diagnoses at one 250-bed community hospital located in Chicago. A brief description of NANDA nursing diagnoses is provided along with a discussion of issues regarding implementation of these nursing diagnoses in a clinical information system. This system did not support online documentation of patient problems, therefore the challenge was to add documentation of patient problems to the system's software. This article focuses on the design and implementation of the nursing diagnoses computer screens, rather than focusing on the two problems we encountered during implementation--appropriate use of nursing diagnoses and the fit of nursing diagnoses with nursing interventions. Yet, the lessons learned in designing and implementing NANDA nursing diagnoses online may help others. (2) Carson HJ, Reddy V, Taxy JB PROLIFERATION MARKERS AND PROGNOSIS IN MERKEL CELL CARCINOMA. J Cutan Pathol 1998 Jan;25(1):16-9 Department of Pathology, Resurrection Medical Center, Chicago, IL 60631, USA. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 56
Merkel cell carcinoma (MCC) is a frequently aggressive primary cutaneous neuroendocrine malignancy. We investigated 3 cell proliferation markers which may be useful in predicting the aggressiveness of MCC: 1) p53, a tumor suppressor protein, 2) Ki-67, a marker of cell cycling, and 3) proliferating cell nuclear antigen (PCNA). Twenty patients with MCC were studied. The 3 cell proliferation markers were studied by immunoperoxidase. Clinical and immunoperoxidase results were tabulated according to recurrence or death from disease. Of the 20 patients, 10 experienced recurrence, and 10 did not. Seven tumors were positive for p53. We found correlations between recurrence and death in MCC patients, between p53 positivity and recurrence/death, and between p53 positivity and head/neck primary sites. We found no correlation with recurrence by gender or primary site. PCNA was positive in only 1 patient, while Ki-67 was positive in all patients, making these 2 markers unsuitable for predicting recurrence. Further clinical studies will be helpful to confirm and refine the application of this test. Prognostic information from such studies may be useful in planning observation and treatment for patients in the future. (3) Carson HJ, Pellettiere EV CLINICALLY-OCCULT MIXED CELLULARITY HODGKIN'S DISEASE WITH CHARCOT-LEYDEN CRYSTALS. Leuk Lymphoma 1996 Sep;23(1-2):153-7 Department of Pathology, Resurrection Medical Center, Chicago, IL 60631, USA. Charcot-Leyden crystals (CLC) are rarely described in tissue. Because of the derivation of CLC from eosinophils, and the antineoplastic functions that eosinophils effect, it is plausible that CLC in neoplastic tissue specimens may be significant. We recently encountered a case in which Hodgkin's disease and CLC were unexpectedly found. We reviewed 31 cases of Hodgkin's disease for CLC and sought relationships between CLC incidence and morbidity or mortality. While various grades of eosinophilia were represented, CLC were encountered only in the case reported. The role of eosinophils and CLC in Hodgkin's disease is enigmatic. With clinicopathologic correlations from additional patients, it may be determined that CLC play a role in the natural history or prognosis of Hodgkin's disease
3) Illinois Center for Bloodless Medicine and Surgery at Proctor Hospital - Peoria, IL, US Contact: Bloodless Coordinator: Ann Ulrich Address: 5409 N. Knoxville Peoria, IL 61614 US Phone: 800-522-3784 (Illiois only) (ext. 1005) 309-691-1005 Bloodless 309-689-6081 Fax Email: [email protected] Proctor's medical staff includes some of the finest medical specialists in the Midwest, representing more than 30 fields of medicine. The physicians and the staff at Proctor are committed to treating the whole person, believing this to be the most effective way to restore good health. Along with a skilled medical and professional staff, meeting the challenge of bloodless medicine and surgery requires state-of-art medical technology. Proctor's fully equipped nursing units provide continuous nursing care and personal attention to adult patients participating in the bloodless medicine and surgery program.
For more Information on the Illinois Center for Bloodless Medicine and Surgery at Proctor's Hospital, please call our toll free number, 1-800-522-3784 (in Il) or 309-691-1005. If you have financial questions or anticipate any difficulties meeting the payment of your bills, contact Patient Accounting at (309) 691-1080. X. INDIANA
1) Winona Memorial Hospital - Indianapolis, IN, US K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 57
Contact: Bloodless Coordinator: Marcus C. Mosely Address: 3232 N. Meridian St. Indianapolis, IN 46208 US Phone: 800-474-1611 317-725-1229 Pager Email: [email protected]
XI. KENTUCKY
1) Audobon Regional Medical Center One Audubon Plaza Drive Louisville, KY 40217 (502) 636-7111
2) Jewish Hospital 217 E. Chestnut St. Louisville, KY 40202 (502) 587-4011 - Hospital (1) Pallarito K LOUISVILLE REVS UP ITS RESEARCH ENGINE. Mod Healthc 1998 Aug 24;28(34):36-8, 40-1 It takes big bucks to attract the best brains in medical research. In Louisville, Ky., healthcare and political leaders are working together to lure research dollars. They include, from left, Alliant Health System CEO Stephen Williams, Louisville Mayor Jerry Abramson, Jewish Hospital HealthCare Services CEO Henry Wagner, Greater Louisville Inc. CEO Douglas Cobb and Kentucky Gov. Paul Patton. (2) No Authors Listed HOW TO BUILD A MAGNET. JEWISH HOSPITAL BUILT A $45 MILLION HEART AND LUNG CENTER AND THE PATIENTS CAME. Profiles Healthc Mark 1995 Nov-Dec;11(6):23-6 You might never have wondered how to build a magnet--unless that was a new heart and lung center that would be a "virtual magnet for physicians and patients." That's been the experience of Jewish Hospital in Louisville, Ky., and their new 14-story Rudd Heart and Lung Center. By the end of the year, it may be one of the top 10 centers for open heart surgeries in the country. What's the attraction? XII. LOUISIANA
1) Memorial Medical Center - New Orleans, LA, US Contact: Coordinator: Deborah Tooke Arceneaux Address: 301 N. Jefferson Davis Parkway New Orleans, LA 70119 US Phone: (877) 426-7766, toll-free (504) 483-5109 (504) 483-5104, fax Email: [email protected] K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 58
2) Sisters of Charity-St. Patrick Hospital - Lake Charles, LA, US Contact: Bloodless Coordinator: Marlene Kibodeaux Rayburn Address: 524 South Ryan Street Lake Charles, LA 70605 US Phone: (318) 491-7140 (888) 491-2888 (318) 430-5495 Fax Email: [email protected] XIII. MAINE
1) Brighton Medical Center 335 Brighton Ave. Portland, ME 04102 (207) 879-8000 - Hospital XIV. MARYLAND
1) Church Hospital Corporation 100 N. Broadway Baltimore, MD 21231 (410) 522-8000 - Hospital XV. MASSACHUSETTS
1) University of Massachusetts Medical Center - Worcester, MA, US Contact: Bloodless Coordinator: Heidi Waitkus BS, RN Address: 55 Lake Avenue North Worcester, MA 01655 US Phone: 508-856-2715 Bloodless 508-856-0011 508-856-4818 Fax Email: [email protected] XVI. MICHIGAN
1) Genesys Regional Medical Center - Grand Blanc, MI, US Contact: Physician Director: Address: One Genesys Parkway Grand Blanc, MI 48439 - 8066 US Phone: 810 - 606 - 6600 Hospital 888 - 606 - 6556 Toll Free 810 - 606 - 5522 Bloodless Surgery Program
2) Mercy Hospital - Detroit, MI, US Contact: Bloodless Coordinator: K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 59
Karen Scalici Address: 5555 Conner Ave. Detroit, MI 48213 US Phone: 313-328-2793 24Hr. Pager 313-579-4806 Bloodless 313-579-4000 Hospital Email: [email protected] Mercy Hospital is a 238-bed community hospital offering a variety of services. Less than a decade old, the hopital provides medical and surgical services. Less than a decade old, the hospital provides medical and surgical services including a 24-hour emergency room, renal(kidney) services, a Women's Health Center with complete Obstetrical care, pediatrics, and physical medicine and rehabilitation services. For more on our services, call (313) 579-4000 or (313) 579-4131) and Ask-A- Nurse ,our free physician referral service, at 1-800-368-2121
3) St. Mary's Health Services - Grand Rapids, MI, US Contact: Bloodless Coordinator: Linda Flory Address: 200 Jefferson St. S.E. Grand Rapids, MI 49503 US Phone: 800-968-3783 616-752-6644 Bloodless 616-752-6090 Hospital 616-774-6156 Fax XVII. MINNESOTA
1) Hennepin County Medical Center - Minneapolis, MN, US Contact: N/A Address: 701 Park Ave. S. Minneapolis, MN 55415 US Phone: 800-600-6015 612-347-6015 Bloodless 612-904-4297 Fax Articles: (1) Boucher TA, Lenz SK AN ORGANIZATIONAL SURVEY OF PHYSICIANS' ATTITUDES ABOUT AND PRACTICE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE. Altern Ther Health Med 1998 Nov;4(6):59-65 Department of Sociology, University of Minnesota, Minneapolis, USA. CONTEXT: A questionnaire was developed and administered by the Center for Addiction and Alternative Medicine Research, one of the research centers funded by the Office of Alternative Medicine. It was felt that information regarding mainstream medical usage and beliefs about alternative therapies might help to direct the focus of the center's research. OBJECTIVE: To examine the attitudes about and knowledge and practice of complementary and alternative medicine among physicians at a Midwestern teaching hospital. DESIGN: Two-part questionnaire. The first part requested demographic information, use of and familiarity with alternative therapies, research preferences, and general practice. The second part was designed for physicians with more experience in alternative modalities. PARTICIPANTS: 265 physicians working a minimum of 20 hours per week. Physicians were affiliated with the Hennepin Faculty Associates, which contracts its services exclusively to the Hennepin County Medical Center. RESULTS: A total of 109 responses were received, for a return rate of 40%. Most respondents predicted that the integration of alternative medicine at Hennepin County Medical Center would result in positive treatment, professional, and social outcomes. Physicians reported high rates of referrals to alternative practitioners, influenced in part by patients' demand and interest. Most (58.7%) respondents agreed that physicians should be knowledgeable about the most popular alternative therapies. CONCLUSIONS: The results suggest that the physicians of Hennepin County Medical Center are, if not supportive, at least open- K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 60
minded about the integration of complementary and alternative medicine. Standards of evidence must be rigorous to convince mainstream medical doctors of the safety and efficacy of alternative therapies. (2) Templeman DC, Gulli B, Tsukayama DT, Gustilo RB UPDATE ON THE MANAGEMENT OF OPEN FRACTURES OF THE TIBIAL SHAFT. Clin Orthop 1998 May;(350):18-25 Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, MN 55415, USA. A retrospective study of 133 open tibial fractures in 129 patients treated at the Hennepin County Medical Center between 1986 and 1993 was done. The results of the treatment protocol in this patient group is presented and the current classification schemes, prevention of infection, debridement, antibiotics, soft tissue reconstruction, fracture stabilization methods, bone grafting, and exchange nailing are discussed. Recent studies that have documented interobserver disagreement in the classification of open fractures underscore the difficulties encountered in the initial assessment and treatment of open tibial shaft fractures. Despite repetitive and aggressive debridement, a certain number of fractures will remain contaminated and become infected. Infection after these severe injuries is probably multifactorial, and its prevention requires that the surgeon diligently adhere to the imperatives of open fracture (3) Wagner JG, Leatherman JW RIGHT VENTRICULAR END-DIASTOLIC VOLUME AS A PREDICTOR OF THE HEMODYNAMIC RESPONSE TO A FLUID CHALLENGE. Chest 1998 Apr;113(4):1048-54 Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA. OBJECTIVE: To compare thermodilution right ventricular end-diastolic volume index (RVEDVI) and pulmonary artery occlusion pressure (Ppao) as predictors of the hemodynamic response to a fluid challenge. DESIGN: Prospective cohort study. SETTING: Medical ICU of a university- affiliated county hospital and medical-surgical ICU of a community hospital. PATIENTS: Twenty- five critically ill patients who had one or more clinical conditions that suggested the possibility of inadequate preload. INTERVENTIONS: Thirty-six fluid challenges. Fluid (saline or colloid) was administered rapidly until the Ppao rose by at least 3 mm Hg. When a patient underwent more than one fluid challenge, these were given on separate days and for different clinical indications. MEASUREMENTS AND RESULTS: Responders (n=20; > or = 10% increase in stroke volume [SV]) and nonresponders (n=16; <10% increase in SV) differed with respect to baseline Ppao (10.0+/-3.4 vs 14.2+/-3.6 mm Hg; p=0.001), but not with respect to baseline RVEDVI (105+/-31 vs 119+/-33 mL/m2; p=0.22). There was a moderate correlation between RVEDVI and fluid-induced change in SV (r=0.44); the relationship between Ppao and change in SV was stronger (r=0.58). A positive response to fluid was observed in 4 of 9 cases in which RVEDVI exceeded 138 mL/m2, a threshold value that has been suggested to reliably predict a poor response to fluid. CONCLUSION: RVEDVI was not a reliable predictor of the response to fluid. As a predictor of fluid responsiveness, Ppao was superior to RVEDVI. In an individual patient, adequacy of preload is best assessed by an empiric fluid challenge. Comment in: Chest 1998 Oct;114(4):1226-7 (4) Rao KV, Kasiske BL, Dahl DC, Danielson B, Ney A, Jacobs D, Odland M, Andersen RC LONG-TERM RESULTS AND COMPLICATIONS OF RENAL TRANSPLANTATION: THE HENNEPIN EXPERIENCE. Clin Transpl 1997;:119-24 Department of Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, USA. Approximately one sixth of patients receiving renal transplants have a functioning kidney beyond 20 years. Chronic rejection is the predominant cause of late allograft loss. Malignancy, cardiovascular K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 61
disease, hepatic failure, and infections are the major causes of late death. Early detection and control of the risk factors that contribute to patient death should favorably influence the long-term success of renal transplantation. (5) Leatherman JW, Ravenscraft SA LOW MEASURED AUTO-POSITIVE END-EXPIRATORY PRESSURE DURING MECHANICAL VENTILATION OF PATIENTS WITH SEVERE ASTHMA: HIDDEN AUTO-POSITIVE END-EXPIRATORY PRESSURE. Crit Care Med 1996 Mar;24(3):541-6 Department of Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA. OBJECTIVE: To describe the occurrence of low measured auto-end-expiratory pressure (auto-PEEP) during mechanical ventilation of patients severe asthma. DESIGN: Observational clinical study. SETTING: Medical intensive care unit of a university-affiliated county hospital. PATIENTS: Four mechanically ventilated patients with severe asthma who had low measured auto-PEEP despite marked increase in both peak and plateau airway pressures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Peak pressure, plateau pressure, and auto-PEEP were measured at an early time point, when airflow obstruction was most severe, and again at a later time after clinical improvement. Auto-PEEP was measured by the method of end-expiratory airway occlusion. From the early to the late point, there was a marked decrease in peak pressure (76 +/- 7 to 53 +/- 6 cm H2O; p<.001) and in plateau pressure (28 +/- 2 to 18 +/- 3 cm H2O; p<.001), but only minimal change in auto-PEEP (5 +/- 3 to 4 +/- 3 cm H2O). The difference between plateau pressure and auto-PEEP decreased between the early and late time points (23 +/- 1 to 14 +/- 1 cm H2O; p<.01), even though tidal volume was larger at the late time point. In three patients, low auto-PEEP and a large difference between plateau pressure and auto- PEEP was only seen after expiratory time was prolonged. In these three patients, prolongation of expiratory time resulted in a large decrease in measured auto-PEEP (14 +/- 4 to 5 +/- 4 cm H2O), but a much smaller change in plateau pressure (31 +/- 3 to 29 +/- 3 cm H2O). CONCLUSIONS: We conclude that measured auto-PEEP may underestimate end-expiratory alveolar pressure in severe asthma, and that marked pulmonary hyperinflation may be present despite low measured auto- PEEP, especially at low respiratory rates. This phenomenon may be due to widespread airway closure that prevents accurate assessment of alveolar pressure at end-expiration. Comment in: Crit Care Med 1996 Mar;24(3):379-80 (6) Stein WE THE HYPERBARIC MEDICINE FACILITY AT HENNEPIN COUNTY MEDICAL CENTER. Northwest Dent 1994 Sep-Oct;73(5):17-8 XVIII. MISSOURI
1) Gulf Coast Medical Center - Biloxi, MS, US Contact: Bloodless Coordinator: Melvin Satterfield Address: 180 Debuys Rd. Biloxi, MS 39531 US Phone: 601-385-9605 228-385-9605 Bloodless 228-388-0573 Fax XIX. MONTANA
1) St. Vincent's Hospital and Health Center - Billings, MT, US Contact: Bloodless Coordinator: Letitia Stuart Address: P.O. Box 35200 Billings, MT 59107 US Phone: 406-657-8865 (24 Hr) K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 62
406-855-9367 406-657-7583 Fax Hospital 406-657-7000 XX. NEBRASKA
1) Saint Joseph Hospital at Creighton University Medical Center - Omaha, NE, US Contact: Bloodless Coordinator: Darryl Gucwa Address: 601 North 30th St. Omaha, NE 68131 US Phone: 800-425-6638 424-449-5995 Bloodless 402-449-5646 Fax Email: [email protected] Hospital 402-449-4000 XXI. NEW JERSEY
1) Cooper Hospital-University Medical Center - Camden, NJ, US Contact: Bloodless Coordinator: Kathleen Yhlen Address: One Cooper Plaza Camden, NJ 08103-1489 US Phone: 609-342-2476 Bloodless 609-342-2000 Hospital 609-342-6803 Fax Email: [email protected] Articles: (1) Razi NM, Humphreys J, Pandit PB, Stahl GE PREDISCHARGE MONITORING OF PRETERM INFANTS. Pediatr Pulmonol 1999 Feb;27(2):113-6 Department of Pediatrics, Children's Regional Hospital at Cooper Hospital/University Medical Center, and University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School, Camden 08103, USA. The objectives of this study were: 1) to perform documented event-monitoring (DEM) for apnea (A, > or = 20 s) and bradycardia (B, < 80 beats per min for > or = 5 s) in premature infants prior to discharge, and 2) to examine the accuracy of nursing documentation (ND) of A and B. Forty-four stable preterm infants, with mean weights and gestational ages at birth (+/- SD) of 1,543 (+/- 365) g, and 30 (+/- 2) weeks, respectively, were studied using DEM for 9 (+/- 2) days prior to discharge. Differences in DEM and ND were analyzed by the z-test for proportions. There were 561 true events recorded by DEM: 56 were As and 505 were Bs. ND revealed 296 events, 190 As and 106 Bs. Of the 56 true As on DEM, only 21 (38%) were correctly reported by ND (P < 0.001, 95% confidence interval (CI) 0.44-0.81). Of the 505 true Bs on DEM, 153 (30%) were correctly reported by ND (P < 0.001, CI 0.63-0.76). When ND was compared with DEM, 174 (59%) of NDs were true events. Of the 106 As on ND, only 21 (20%) were true As on DEM (P < 0.001, CI 0.58-1). Of the 190 Bs on ND, 153 (80%) were true Bs on DEM (P < 0.001, CI 0.13-0.26). ND did not detect 6 of the 33 infants who had significant events on DEM, while 4 of the 11 who had events reported on ND did not have any on DEM. Thus, 10 infants were misclassified by ND (P < 0.01, CI 0.1-0.36). These results indicate that, compared to DEM, ND not only identified significantly fewer true As and Bs, but also misclassified a significant number of infants. We conclude that DEM performed prior to discharge for preterm infants at risk for apnea and bradycardia provides more objective and accurate information than ND. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 63
(2) Slotman GJ, Stein SC LAMINECTOMY COMPARED WITH LAPAROSCOPIC DISKECTOMY AND OUTPATIENT LAPAROSCOPIC DISKECTOMY FOR HERNIATED L5-S1 INTERVERTEBRAL DISKS. J Laparoendosc Adv Surg Tech A 1998 Oct;8(5):261-7 Department of Surgery, Cooper Hospital/University Medical Center, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School-Camden, 08103, USA. The objective of this study was to evaluate the clinical efficacy and cost effectiveness of inpatient and outpatient laparoscopic lumbar diskectomy (LLD) compared with laminectomy (LAM) in the surgical treatment of disabling L5-S1 disk herniation. Sixty-two adults underwent surgery for herniated L5-S1 intervertebral disks (31 LLD and 31 LAM). Operative blood loss (EBL) (milliliters), operative time (ORT) (minutes), hospital stay (LOS), and rehabilitation time to normal activity (REHAB) (days), recurrent symptoms, postoperative morbidity, percent pain free, and hospital patient charges were calculated. Thirty LLD patients (97%) had immediate relief of disk pain. Morbidity after LLD included transient urinary retention (one) and rectus hematoma (one). One LAM patient had a pseudomeningocele. Among patients observed for > or =6 months, with a median follow up time of 34 months, 22 of 25 LLD patients (88%) returned to normal activity, while 12 of the LAM group (52%) were disabled (p = 0.004). Functional outcome was improved by LLD for workers compensation patients followed > or =6 months, with 86% LAM disabled, vs. 10% LLD (p = 0.001). Sixteen LLD patients (52%) and 18 (58%) of the LAM group needed postoperative physical therapy. Four LLD patients recurred; three required reoperation. Four LAM patients had surgery for recurrent disk herniation. ORT was longer for LLD than LAM (210 vs. 158 minutes, median, p < 0.05). EBL and REHAB time were significantly reduced with LLD, vs. LAM. With a median follow- up of 34 months, 58% of LLD and 39% of LAM patients followed > or =6 months were pain free. Outpatient LLD (n = 9) reduced LOS (1 day vs. 2 days and 4 days, p < 0.01) and lowered patient charges ($4,405 vs. $5,723 and $7,192, p < 0.01) compared with inpatient LLD (n = 23) and LAM, respectively. LLD is a safe, cost-effective, minimally invasive alternative to LAM for treating herniated L5-S1 disks. Compared with LAM, LLD reduces EBL, LOS, REHAB time, and patient charges, improves function, and increases long-term pain relief. Cost effectiveness is optimized when LLD is performed as outpatient surgery. (3) Hewitt CW UPDATE AND OUTLINE OF THE EXPERIMENTAL PROBLEMS FACING CLINICAL COMPOSITE TISSUE TRANSPLANTATION. Transplant Proc 1998 Sep;30(6):2704-7 Department of Surgery, UMDNJ/Robert Wood Johnson Medical School, Cooper Hospital/University Medical Center, Camden, USA. (4) Tarnoff M, Atabek U, Goodman M, Alexander JB, Chrzanowski F, Mortman K, Camishon R, Pello M A COMPARISON OF LAPAROSCOPIC AND OPEN APPENDECTOMY. J Soc Laparoendosc Surg 1998 Apr-Jun;2(2):153-8 Department of Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Camden Cooper Hospital/University Medical Center, USA. BACKGROUND AND OBJECTIVES: To compare laparoscopic appendectomy with traditional open appendectomy. METHODS: Seventy-one patients requiring operative intervention for suspected acute appendicitis were prospectively compared. Thirty-seven patients underwent laparoscopic appendectomy, and 34 had open appendectomy through a right lower quadrant incision. Length of surgery, postoperative morbidity and length of postoperative stay (LOS) were recorded. Both groups were similar with regard to age, gender, height, weight, fever, leukocytosis, and incidence of normal vs. gangrenous or perforated appendix. RESULTS: Mean LOS was significantly shorter for patients with acute suppurative appendicitis who underwent laparoscopic appendectomy (2.5 days vs. 4.0 days, p < 0.01). Mean LOS was no different when patients classified K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 64
as having gangrenous or perforated appendicitis were included in the analysis (3.7 days vs. 4.1 days, P = 0.11). The laparoscopy group had significantly longer surgery times (72 min vs. 58 min, p < 0.001). There was no significant difference in the incidence of postoperative morbidity. CONCLUSIONS: Laparoscopic appendectomy reduces LOS as compared with the traditional open technique in patients with acute suppurative appendicitis. The longer operative time for the laparoscopic approach in our study is likely related to the learning curve associated with the procedure and did not increase morbidity. (5) Chuang LC, Sutton JD, Henderson GT IMPACT OF A CLINICAL PHARMACIST ON COST SAVING AND COST AVOIDANCE IN DRUG THERAPY IN AN INTENSIVE CARE UNIT. Hosp Pharm 1994 Mar;29(3):215-8, 221 Cooper Hospital/University Medical Center, Camden, NJ 08103. The authors performed a study to document the impact of a clinical pharmacist on cost saving and cost avoidance in an intensive care unit, and to evaluate the cost saving and avoidance to justify additional clinical pharmacist positions. Over 13 consecutive 5-day weeks, a clinical pharmacist with 50% teaching responsibility documented time spent and all interventions that impacted the cost of drug therapy. Both cost avoidance and cost saving were documented on change in route, change in dosage, change to another drug, discontinuation of therapy, discontinuation of therapeutic duplication, discontinuation of inappropriate therapy, notification of pharmacy of discrepancy, and improper drug-level monitoring avoidance. Cost analysis was calculated based on acquisition costs. The final cost saving was derived from adding cost avoided and cost saved minus pharmacist salary for the time spent in conducting the study. A total of 310 interventions were documented during the 13 weeks (65 days) of the study. The final cost saving was $79,723, which would extrapolate to an annual savings of $318,891. Although 31.3% of interventions involved change of dosage, interventions involving change to another drug (13.9%) had the largest economic impact ($62,527). The majority (85.4%) of the savings involved costs of medications saved (actual dollars saved rather than avoided). The authors concluded that the clinical pharmacist had a significant impact on the cost of drug therapy in the intensive care unit and that the cost of additional clinical pharmacist positions should be justified
2) The New Jersey Institute for the Advancement of Bloodless Medicine and Surgery at Englewood Hospital and Medical Center - Englewood, NJ, US Contact: Bloodless Coordinators: Sherri Ozawa Rom Rivera Noreen Scott Address: 350 Engle St. Englewood, NJ 07631 US Phone: 888-7NOBLOOD (888-766-2566) 201-894-3311 Hospital 201-541-2268 Fax WebSite: http://www.bloodlessmed.com Email: [email protected] (1) Dardik H THE SECOND DECADE OF EXPERIENCE WITH THE UMBILICAL VEIN GRAFT FOR LOWER-LIMB REVASCULARIZATION. Cardiovasc Surg 1995 Jun;3(3):265-9 Englewood Hospital, New Jersey, USA. Some 20 years have elapsed since the initial concept and development of the human umbilical vein graft. Experience with 1074 umbilical vein grafts forms the basis of this report as the indications for this prosthesis have been refined and its performance defined. In 1988, the author and colleagues published their 10-year experience with umbilical vein which described the results of 907 bypasses constructed in 715 patients (799 limbs). Over the past 5 years, the use of umbilical vein has decreased because of a commitment to autologous saphenous vein. A total of 167 additional umbilical vein K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 65
bypasses were performed at Englewood Hospital and Medical Center between 1985 and June 1993. Secondary patency rates for popliteal and crural reconstructions at 5 years showed a trend of continuous improvement--65% and 45% respectively compared with 57% and 33% as reported during the first decade of experience. Rates of infection, stenosis and pseudoaneurysm decreased and only two aneurysms have been discovered during this period. Umbilical vein is an acceptable alternative to the absent or deficient autologous vein. Patency rates are second only to autologous vein rates and the fear of failure due to aneurysm formation has not only been overstated, but also significantly exaggerated. (2) Kadar N LAPAROSCOPIC PELVIC LYMPHADENECTOMY IN OBESE WOMEN WITH GYNECOLOGIC MALIGNANCIES. J Am Assoc Gynecol Laparosc 1995 Feb;2(2):163-7 Department of Obstetrics and Gynecology, Englewood Hospital and Medical Center, Englewood, New Jersey, USA. Laparoscopic pelvic lymphadenectomy was performed successfully in 10 women weighing over 180 pounds (mean 212 lbs) in conjunction with simple (7) or radical (3) hysterectomy for carcinoma of the endometrium or cervix. Four patients had extensive lysis of adhesions in addition, and one had a myomectomy to allow access to the cul-de-sac. Mean operating time was approximately 4 hours (range 2.5-7 hrs), mean blood loss 1030 ml (range 300-2000 ml), and median hospital stay 3.5 days. The average number of lymph nodes recovered was 33 (range 11-49 nodes). It is concluded that obesity, even in the presence of other pelvic pathology, does not significantly limit the feasibility of pelvic lymphadenectomy. This finding is important to the laparoscopic management of women with endometrial carcinoma.
3) Hackensack University Medical Center - Hackensack, NJ, US Contact: Nurse Manager: Jo Valenti, R.N. Address: 30 Prospect Ave. Hackensack, NJ 07601 US Phone: 877-BLOODLS Toll Free 201-996-2000 Hospital 201- 996-3962 Fax attn: Jo Valenti
WebSite:http://www.humed.com/bloodless.html Pager: 973- 591-5818 for Emergencies
4) UMDNJ-University Hospital Newark 07103-2406, New Jersey, USA (1) 888-BLD-LESS or (253-5377) University of Medicine and Dentistry of New Jersey (UMDNJ) Hospital is a ultra-modern 466-bed facility that serves as the primary teaching hospital of the University of Medicine and Dentistry-New Jersey Medical School. In addition to providing a complete array of inpatient services and the widest range of outpatient services in the state, University Hospital serves as a referral center for specialized treatment in the areas of Trauma; Neurology and Neurosurgery; Liver Disease and Transplantation; Ophtalmology; High Risk Pregnancies and Newborns; and Spinal Cord Injuries among others. Edwin A. Deitch is Medical Director Professor and Chair, Departement of Surgery (1) DeLisa JA, Jain SS, Kirshblum S, Christodoulou C EVIDENCE-BASED MEDICINE IN PHYSIATRY: THE EXPERIENCE OF ONE DEPARTMENT'S FACULTY AND TRAINEES. Am J Phys Med Rehabil 1999 May-Jun;78(3):228-32 Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School, Newark 07103-2406, USA. Evidence-based medicine is regarded by many as the new paradigm in medical practice. Sixty-seven medical school faculty and trainees in a physical medicine and rehabilitation department were surveyed with regard to training and competence in the use of evidence-based medicine techniques. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 66
The majority of subjects in the present study supported the use of evidence-based medicine techniques, although a number of the respondents indicated that they lacked adequate training or competence in their use. It is suggested that medical schools and physiatry residency programs provide a greater emphasis on training in evidence-based medicine. Recommendations are provided that individuals can use to develop a systematic strategy to keep up with the rapidly expanding medical literature. (2) Leviton A, Paneth N, Reuss ML, Susser M, Allred EN, Dammann O, Kuban K, Van Marter LJ, Pagano M HYPOTHYROXINEMIA OF PREMATURITY AND THE RISK OF CEREBRAL WHITE MATTER DAMAGE. J Pediatr 1999 Jun;134(6):706-711 Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston; Michigan State University, East Lansing; Bellevue Research Foundation, Niskayuna, New York; Columbia University, New York, New York; Harvard School of Public Health, Boston; New England Medical Center, Boston; Tufts University School of Medicine, Boston; Brigham and Women's Hospital, Boston; St. Peter's Medical Center, New Brunswick, New Jersey; Robert Wood Johnson Medical School, New Brunswick; Babies' Hospital, New York; St Luke's-Roosevelt Medical Center, New York; Lincoln Hospital, Bronx, New York; New York Hospital, New York; Cornell Medical School, New York; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; UMDNJ-New Jersey Medical School, Newark, New Jersey. The other Developmental Epidemiology Network Investigators are listed at the end of this article. OBJECTIVE: Infants with hypothyroxinemia of prematurity (HOP) are at increased risk for neurodevelopmental dysfunction. Infants born near the end of the middle trimester are also at increased risk for an echolucency (EL) in the cerebral white matter, which reflects white matter damage and is the cranial ultrasound abnormality that best predicts neurodevelopmental dysfunction. We postulated that some of the increased risk of neurodevelopmental problems associated with HOP reflects an increased risk of EL.Study design: We studied 1414 infants weighing 500 to 1500 g who were born at 4 medical centers between 1991 and 1993. The infants had thyroxine blood levels measured during the first weeks of life, at least 1 of 3 cranial ultrasound scans performed at specified postnatal intervals, and their own and their mother's hospital charts reviewed. Infants were classified by whether or not their first thyroxine level placed them in the lowest quartile among all infants in this sample (ie, <67.8 nmol/L, our definition of HOP, equivalent to <5.3 mug/dL). RESULTS: After adjusting for such potential confounders as low gestational age and measures of illness severity, infants with HOP had twice the risk of EL as their peers with higher thyroxine levels. CONCLUSION: Our findings are consistent with the hypothesis that a "normal" blood thyroxine level protects infants born near the end of the middle trimester against the risk of cerebral white matter damage. (3) Pandit HB, Spillert CR, Shih RD DETERMINATION OF HYPERCOAGULABLE STATE IN ACUTE BRONCHOSPASM. J Am Osteopath Assoc 1999 Apr;99(4):203-6 Department of Surgery, UMDNJ-New Jersey Medical School, Newark, USA. The issue of hypercoagulability in acute asthmatic attacks is controversial. This may be due to lack of an appropriate test to monitor overall coagulation. Current hematologic tests do not account for the cellular fraction of blood that has procoagulant activity. Our study uses a clotting assay called the modified recalcification time test that is performed with whole blood to ensure the contribution of all chemical and cellular mediators in the coagulation process, particularly tissue factor. Venous blood samples were obtained from 12 adult patients with acute exacerbation of asthma or chronic obstructive pulmonary disease and compared with samples from 12 age-matched healthy control subjects. By use of the modified recalcification time, the presence of a relative hypercoagulable state was demonstrated in patients with acute bronchospasm. Furthermore, there is an identifiable difference in modified recalcification time value between the patients with acute attacks who required hospital admission versus those discharged from the emergency department. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 67
(4) Martino K, Merrit S, Boyakye K, Sernas T, Koller C, Hauser CJ, Lavery R, Livingston DH PROSPECTIVE RANDOMIZED TRIAL OF THORACOSTOMY REMOVAL ALGORITHMS. J Trauma 1999 Mar;46(3):369-71; discussion 372-3 Department of Surgery, UMDNJ-New Jersey Medical School, Newark, USA. INTRODUCTION: The preferred chest tube (CT) removal algorithm has not yet been established. The purpose of this study was to determine which technique, water seal or suction, allowed for shorter CT duration. In addition, the recurrent pneumothorax (PTX) rate, the need for CT reinsertion, and the total number of chest x-ray films (CXR) were determined. METHODS: Prospective randomized trial of 205 trauma patients, older than 15 years of age, requiring tube thoracostomy for blunt and penetrating trauma. Patients requiring mechanical ventilation more than 24 hours were excluded from the study. Informed consent was obtained from all patients. Chest tubes were randomized for removal when output was less than 150 mL/24 hours, CXR revealed no significant PTX, and no air leak was present. Patients in the water seal group were disconnected from low wall suction and a CXR was obtained 6 to 8 hours later. Chest tubes in the no water seal group were disconnected from wall suction and pulled immediately. All tubes were removed by using standard protocol with patients at maximal inspiratory effort. A follow-up CXR was obtained after removal. RESULTS: Of the 205 patients, 93 patients (45 %) were randomized to the water seal group and 112 patients (54%) to the no water seal group. Four patients in the water seal group developed a PTX before CT removal and were considered treatment failures. After CT removal, repeat PTX was seen in 13 patients in the water seal group and in 9 patients in the no water seal group. However, seven patients in the no water seal group required CT reinsertion compared with one in the water seal group (p<0.05). Average number of CXR in the water seal group was 6.5 compared with 5.5 radiographs in the no water seal group. There was no difference in chest tube duration or hospital length of stay between groups for either all patients or only those patients with isolated chest injuries. Patients who required another CT had a hospital length of stay twice that of patients who did not. CONCLUSIONS: It is possible that patients in the no water seal group did not have sufficient time for a possible PTX to evolve, which resulted in a larger and more significant PTX requiring another CT. Although there was no difference in chest tube duration between the no water seal and water seal groups, a short trial of water seal appears to allow occult air leaks to become clinically apparent and reduces the need for another CT. (5) Melchiorre PJ ACUTE HOSPITALIZATION AND DISCHARGE OUTCOME OF NEUROLOGICALLY INTACT TRAUMA PATIENTS SUSTAINING THORACOLUMBAR VERTEBRAL FRACTURES MANAGED CONSERVATIVELY WITH THORACOLUMBOSACRAL ORTHOSES AND PHYSICAL THERAPY. Arch Phys Med Rehabil 1999 Feb;80(2):221-4 Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey, Medical School, Newark, NJ, USA. OBJECTIVES: To identify the acute hospital discharge functional status achieved and the amount of physical therapy (PT) and occupational therapy (OT) received by neurologically intact patients with thoracolumbar vertebral fractures managed only by bracing with a custom-molded thoracolumbosacral orthosis (TLSO). These patients would be expected to ambulate independently soon after receiving their TLSOs unless they had concomitant lower extremity injuries, but they may need assistance with lower extremity activities of daily living. DESIGN: Retrospective study. SETTING: Urban, level I trauma center. PATIENTS: Twenty-seven subjects who sustained one or more thoracolumbar fractures, were neurologically intact, and were managed nonoperatively with a custom-molded TLSO. OUTCOME MEASURES: Median time to TLSO arrival, start of PT, number of PT sessions, time to ambulate independently from admission, and length of stay (LOS). RESULTS: Median time to TLSO arrival was 2 days, start of PT was 4 days, number of PT sessions was one, time to ambulate independently from admission was 3(1/2) days, and LOS was 5 days. Subjects with lower extremity fractures required significantly (p < .037) more PT sessions to achieve independent ambulation than those without lower extremity fractures. Almost 89% of the subjects ambulated independently with or without an assistive device at discharge. Fifty-nine percent of subjects were discharged home the day they cleared PT for independent ambulation. Only 11% of K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 68
the subjects received OT. CONCLUSIONS: A majority of neurologically intact patients with thoracolumbar fractures managed conservatively with a TLSO ambulate independently after receiving one or two sessions of PT and can be discharged home on the same day of PT clearance. Patients with lower-extremity fractures need more PT to achieve independent ambulation. The consequences of a minority of these patients being evaluated and seen by OT are not fully known. Future research may be able to document the need for more OT services. (6) Goodman ER, Kleinstein E, Fusco AM, Quinlan DP, Lavery R, Livingston DH, Deitch EA, Hauser CJ ROLE OF INTERLEUKIN 8 IN THE GENESIS OF ACUTE RESPIRATORY DISTRESS SYNDROME THROUGH AN EFFECT ON NEUTROPHIL APOPTOSIS. Arch Surg 1998 Nov;133(11):1234-9 Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark 07103, USA. [email protected] OBJECTIVE: To evaluate the role of interleukin 8 (IL-8) in the regulation of neutrophil (PMN) apoptosis in normal plasma and plasma from patients with early, fulminant acute respiratory distress syndrome (ARDS). DESIGN: Experimental study using cultured human PMNs. SETTING: University hospital, level I trauma center. PARTICIPANTS: Plasma was obtained from 6 patients with early, fulminant posttraumatic ARDS (mean Injury Severity Score, 26). All samples were drawn within 24 hours after injury. Plasma was also taken from 13 healthy control subjects. These controls were also used as sources of PMNs. MAIN OUTCOME MEASURES: Effect of early, fulminant ARDS and normal plasma on spontaneous apoptosis, CD16, and CD11-b expression in PMNs in vitro; levels of IL-8 in plasma; correlation of extracellular IL-8 concentration with rate of PMN apoptosis; and effect of IL-8 blockade on PMN apoptosis, CD16, and CD11-b expression in ARDS and normal plasma. RESULTS: Plasma from patients with early, fulminant ARDS inhibited spontaneous PMN apoptosis at 24 hours (35%+/-5% vs 54%+/-5%; P=.01). Neither CD16 nor CD1l- b differed significantly between the 2 groups. The mean plasma level of IL-8 in patients with early, fulminant ARDS was 359+/-161 pg/mL vs 3.0+/-0.4 pg/mL in healthy controls (P<.05). Interleukin 8 inhibited apoptosis in plasma-free medium at low doses (1-50 pg/mL) but had no significant effect at higher doses (100-5000 pg/mL) (P<.05). Interleukin 8 blockade with monoclonal antibody suppressed apoptosis in normal plasma (28%+/-5% with monoclonal antibody vs 51%+/-5% without monoclonal antibody; P=.008) but not in plasma from patients with early, fulminant ARDS (29%+/-5% with monoclonal antibody vs 34%+/-6% without monoclonal antibody; P=.67). It had no effect on CD16 or CD11-b expression in either plasma. CONCLUSIONS: Plasma from patients with early, fulminant ARDS contains soluble factors that inhibit PMN apoptosis in vitro. Low levels of IL-8 inhibit PMN apoptosis in normal plasma. Although plasma levels of IL-8 are markedly elevated in early, fulminant ARDS, IL-8 is not directly responsible for the antiapoptotic effect of plasma from patients with early, fulminant ARDS. (7) Cathcart CS, Dunican A, Halpern JN PATTERNS OF DELIVERY OF RADIATION THERAPY IN AN INNER-CITY POPULATION OF HEAD AND NECK CANCER PATIENTS: AN ANALYSIS OF COMPLIANCE AND END RESULTS. J Med 1997;28(5-6):275-84 Department of Radiology, UMDNJ-New Jersey Medical School, University Hospital, Newark 07103, USA. A retrospective analysis of survival rate of patients treated for head and neck cancers in a radiation oncology department at an innercity hospital (UMDNJ, Newark, NJ) was performed. Eligible patients received either postoperative or definitive radiation therapy and had no distant metastases. The records of patients treated from 1984-1989 were screened and 78 met the above criteria. Total dose of radiation, fraction size, number of fractions given, and overall duration of treatment were determined. Tumor registry data was used to evaluate patient status. Two patients who died prior to completing radiation treatments were excluded and seven patients were lost to follow up. Therefore, the outcomes and treatments of 69 patients were analyzed. There were two categories of noncompliant patients, those whose treatment duration was in excess of 20% of the prescription, and those whose treatments were discontinued against medical advice. The overall five year survival of K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 69
the compliant group was 38%, and 12% for the noncompliant group (p < 0.05). The mean survival time for the compliant group was 24.2 months and 12.6 months for the noncompliant group (p < 0.05). Forty-seven per cent of the patients were compliant. Compliant rates for men and women were 46% and 48%, respectively. African-Americans, who made up 71% of the patients analyzed, had a compliance rate of 45%. Caucasians, who made up 22%, had a compliance rate of 47%. The stage at presentation, and therefore prognosis, did not alter compliance rates. Sixty-nine per cent of the patients analyzed had stage III or stage IV disease. This patient group had a compliance rate of 48%, which did not statistically differ from the earlier stage patient group which had a compliance rate of 54%. The length of patient survival from head and neck cancer is related to compliance to radiation treatment. Compliance appears to be directly related to better overall survival and mean survival time. Compliance to treatment does not seem to depend on patient sex, race, or prognosis. (8) Campagnolo DI, Esquieres RE, Kopacz KJ EFFECT OF TIMING OF STABILIZATION ON LENGTH OF STAY AND MEDICAL COMPLICATIONS FOLLOWING SPINAL CORD INJURY. J Spinal Cord Med 1997 Jul;20(3):331-4 Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School, Newark 07103-2406, USA. This retrospective study examines length of acute hospital stay (LOS) and the development of medical complications in 64 patients with cervical, thoracolumbar or cauda equina injuries divided into two groups according to whether they underwent spinal stabilization < 24 hours after injury or > 24 hours after injury. The mean length of stay for the early stabilization group was 37.5 days (SD +/- 34.2) and for the late stabilization group 54.7 days (SD +/- 40.1). This difference was statistically significant by Mann Whitney U test (Z = 2.53, P = 0.01). There was no statistically significant difference between the early and the late groups with respect to the occurrence of common medical complications. There was a statistically significant difference in age in the early group (mean of 32.4 years) versus the late group (mean of 41.9 years) (t = 2.36, P = 0.02); however we do not feel that this age difference is clinically significant. There was not a statistically significant difference between the early group (17.9, SD = +/-7.2) and the late group (21.3, SD = +/- 8.3) (t = 1.71, p = 0.10) in mean injury Severity Scores (ISS). Also the correlation between length of stay and ISS scores was not significant (r = 0.18, P = 0.2). Timing of spinal stabilization appears to be an important factor in the management of spinal cord injury survivors. Our limited retrospective study suggests that when spinal stabilization is indicated, performance < 24 hours after injury is associated with a significantly shorter length of stay in the hospital. We suspect this is due to earlier mobilization of the patient. Medical complication rates were not significantly affected. (9) Livingston DH, Capko DM, Elcavgae J, Raina S, Machiedo GW, Rush BF Jr LAPAROSCOPIC CHOLECYSTECTOMY IN THE INNER-CITY HOSPITAL. Am Surg 1994 Dec;60(12):971-4 Department of Surgery, UMDNJ-New Jersey Medical School, Newark 07103. Laparoscopic cholecystectomy (LCCY) has become the treatment of choice for patients undergoing elective CCY. Inner-city hospitals treat a large number of patients with advanced or acute disease, and the ability to perform LCCY in this patient population is unclear. The records of the first 107 patients undergoing LCCY were reviewed. There were 96 women and 11 men with a mean age of 42 years (range 14-86 years). Twenty-seven (42%) of the patients were admitted through the emergency room and were operated upon urgently, whereas 35 (58%) underwent elective LCCY. More than two-thirds of the patients were either uninsured or covered by Medicaid. In the urgent group, 38% had gallstone pancreatitis, 41% had abnormal LFTs, and 26% had a WBC > 13,000. A total of 70% of these patients were discharged within 48 hours after LCCY. The conversion rate was 9% and was similar between urgent and elective LCCY. In summary, acute biliary tract pathology accounted for one-half of the patients undergoing LCCY in our hospital. In conclusion, LCCY can be performed in this group of patients with low morbidity, especially if the need for liberal conversion to open CCY is recognized. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 70
XXII. NEVADA
1) Lake Mead Hospital Medical Center - N. Las Vegas, NV, US Contact: N/A Address: 1409 E. Lake Mead Blvd. N. Las Vegas, NV 89030 US Phone: 702-657-5719 Bloodless 702-649-7711 Hospital 702-657-5540 Fax XXIII. NEW YORK
1) Brookdale University Hospital Medical Center - Brooklyn, NY, US Contact: Bloodless Coordinator: Dr. Thomas Crimi, MD Coordinator: Shawn Gates, CP Address: 1 Brookdale Plaza Room #727 Brooklyn, NY 11212 US Phone: (718) 240-5843 (718) 240-5367, fax (917) 433-8585, pager Specialty: Acute Normovolemic Hemodilution
2) Buffalo General Hospital 100 High St. Buffalo, NY 14203 (716) 845-5600-Hospital (1) James DM AN INTEGRATED MODEL FOR INNER-CITY HEALTH-CARE DELIVERY: THE DEACONESS CENTER. J Natl Med Assoc 1998 Jan;90(1):35-9 Department of Family Practice, State University of New York at Buffalo 14208, USA. Under the auspices of the Buffalo General Hospital and the faculty of medicine of the State University of New York at Buffalo, a comprehensive delivery system for primary care has been established in a local inner-city neighborhood. At the Deaconess Family Medicine Center, located within an inner-city location of Buffalo, New York, several divisions have been integrated to provide comprehensive patient-oriented primary care. These divisions include a primary care clinic, an urgent care clinic, a substance abuse clinic, and a community pediatrics clinic. Professional services are provided by attending physicians and residents. The horizontal integration of these four divisions is in turn vertically integrated with the tertiary care teaching hospital inpatient and obstetrical services, providing a continuum of patient care. The horizontal integration serves as an entry point for patients to enter the hospital's health-care system, while the vertical integration capability serves to capture any specialized referrals or inpatient needs. This article discusses the structure of the center, with special reference to service integration, service delivery, and patient capture; medical education; and the place of integrated units in the strategic plan of a tertiary care hospital.
3) Long Island College Hospital 340 Henry St. Brooklyn, NY 11201 (718) 780-1000 - Hospital K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 71
(1) Newman LA, Alfonso AE AGE-RELATED DIFFERENCES IN BREAST CANCER STAGE AT DIAGNOSIS BETWEEN BLACK AND WHITE PATIENTS IN AN URBAN COMMUNITY HOSPITAL. Ann Surg Oncol 1997 Dec;4(8):655-62 Department of Surgery, Long Island College Hospital, Brooklyn, New York, USA. BACKGROUND: Breast cancer mortality is significantly higher among black patients compared to white patients. Black women are reportedly at increased risk for early-onset breast cancer. Our goal was to evaluate stage distribution relative to age among black and white breast cancer patients in an institution with a relatively high minority patient population. METHODS: We evaluated 425 patients diagnosed with breast cancer between 1990 and 1994: 56% white, 34% black, the remainder were other ethnicities. Patients were stratified by age: under 50 years versus 50 and older. Socioeconomic status was estimated by utilization of medical care in the private-practice setting versus the public clinic. RESULTS: Significantly more black patients were younger at diagnosis compared to white patients (32% vs. 20%; p = 0.008). There was a significantly more advanced stage distribution among the younger black patients, but not among the older black patients. Most of the black and white patients received private-practice care. CONCLUSIONS: These age-related differences in breast cancer stage distribution between black and white patients (which appeared independent of socioeconomic status) indicate that more aggressive screening and public education programs directed toward younger black women is warranted, and they lend support to the possibility of ethnicity-related variation in primary tumor biology
4) New York Methodist Hospital - Brooklyn, NY, US Contact: Bloodless Surgery Coordinator: Rebecca Flood, R.N. Address: 506 Sixth Street Brooklyn, NY 11215 US Phone: 1-888-622-6448 718-780-3000 WebSite: http://www.nym.org Email: [email protected].
5) The New York Center for Bloodless Medicine and Surgery at the Long Island College Hospital - Brooklyn Heights, NY, US Contact: Bloodless Coordinator: Emily Rossi Address: 339 Hicks Street Brooklyn Heights, NY 11201 US Phone: 1-888-299-6625
6) Staten Island University Hospital - Staten Island, NY, US Contact: Bloodless Coordinator: Valerie Haskell R.N. Address: 475 Seaview Avenue Staten Island, NY 10305 US Phone: 1-888-682-5663 718-226-6792 Bloodless 718-226-6467 Fax
7) The New York Hospital-Cornell Medical Center - New York, NY, US Contact: Bloodless Coordinator: Doctor Todd Rosengart Address: 525 East 68th St. New York, NY 10021 US K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 72
Phone: 800-822-2694 Referral Service 212-746-5150 Bloodless 212-746-8828 Fax Email: [email protected] Hospital 212-746-5454 Office 212-746-5155
8) Westchester Square Medical Center - Bronx, NY, US Contact: Bloodless Coordinator: Debra Conti-Abreu Director: Dr. Rudolph Nisi, MD Address: 2475 St. Raymond Avenue Bronx, NY 10461 US Phone: (718) 430-4380 Email: [email protected] XXIV. OHIO
1) Flower Hospital - Sylvania, OH, US Contact: Bloodless Coordinator: Barbara Gocke Address: 5200 Harroun Road Sylvania, OH 43560 US Phone: (419) 824-1222 (800) 866-1827 (Toll Free from OH and Michigan) (419) 882-2342 (Fax) Email: [email protected] [email protected]
2) St. Vincent Charity Hospital and Columbia St. John West Shore - Cleveland, OH, US Contact: Bloodless Coordinators: Sharon Vernon Irene Kopen Address: 2351 East 22nd St. Cleveland, OH 44115 US Phone: 800-SVC-HOPE 216-861-6200 x2404 216-694-4614 Fax Hospital 216-861-6200 The Center for bloodless Medicine and Surgery at St. Vincent Charity Hospital offers a team approach to the provision of quality medical care without the use of blood transfusions. These alternatives to non-blood treatment are available to any patient upon request.
At St. Vincent Charity Hospital, patient care provided by The Bloodless Center staff includes these specialities: # Anesthesiology # Cardiology # Ear, Nose & Throat # Emergency Medicine # Gastroenterology # General Surgery # Gynecology # Hematology # Internal Medicine # Neurosurgery K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 73
# Open Heart Surgery # Ophtalmology # Orthopedics # Urology # Vascular/ Thoracic Surgery A fully-equipped nursing unit provides round-the-clock nursing care to bloodless medical and surgical patients. Modern Medical Technology Supplementing the efforts of the Center's experienced staff is stat-of-the-art medical equipment. Technological resources available at St. Vincent Charity Hospital Include: • Cell Saver • Electrosurgical Coagulator • Hyperbaric Chamber • Skin Monitoring • Synthetic Erythropoietin • Volume Expanders • For more information on The Bloodless Center or to schedule an appointment, call our 24-hour hotline at 1-800-SVC-HOPE. Our nurse coordinators can help you select a physician or answer medical questions. The Center for Bloodless Medicine and Surgery 1 - 800 - SVC - HOPE
(1) Vernon S, Pfeifer GM ARE YOU READY FOR BLOODLESS SURGERY? Am J Nurs 1997 Sep;97(9):40-6; quiz 47 Center for Bloodless Medicine and Surgery, Columbia St. Vincent Charity Hospital, Cleveland, OH, USA. 'Bloodless' medicine and surgery is saving lives of individuals whose religious faith forbids blood transfusions. And the innovations it comprises are introducing new considerations to the nursing care of many patients undergoing complex operations.
3) The Cleveland Clinic Foundation - Cleveland, OH, US Contact: Jonathan H. Waters, M.D. Paul Potter, M.D. Address: 9500 Euclid Ave. E31 Cleveland, OH 44195 US Phone: (216)444-2200 (216)444-6343 Dr. Waters (216)444-6154 Dr. Potter WebSite:http://www.ccf.org/ Fax: 216-444-9247
XXV. OKLAHOMA
1) Tulsa Regional Medical Center - Tulsa, OK, US Contact: N/A Address: 744 West Ninth St. Tulsa, OK 74127 US Phone: 800-637-1195 918-599-1799 Bloodless 918-587-2561 Hospital K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 74
(1) Willems S EMPLOYEE EMPOWERMENT THROUGH TEAM BUILDING AND USE OF PROCESS CONTROL METHODS. Top Health Inf Manage 1998 Feb;18(3):32-9 Tulsa Regional Medical Center, OK, USA. The article examines the use of statistical process control and performance improvement techniques in employee empowerment. The focus is how these techniques provide employees with information to improve their productivity and become involved in the decision-making process. Findings suggest that at one Mississippi hospital employee improvement has had a positive effect on employee productivity, morale, and quality of work. XXVI. OREGON
1) Emanuel Hospital and Health Ctr. 281 N. Gantenbein Ave. Portland, OR 97210 (503) 280-3200 - Hospital (1) Curran TJ, Foley MI, Swanstrom LL, Campbell TJ LAPAROSCOPY IMPROVES OUTCOMES FOR PEDIATRIC SPLENECTOMY. J Pediatr Surg 1998 Oct;33(10):1498-500 Legacy Emanuel Children's Hospital, Portland, OR, USA. BACKGROUND: Pediatric laparoscopic splenectomy is a relatively new surgical procedure with a limited number of reports comparing its outcomes to that of the open procedure. The authors have minimized the invasiveness of our procedure by using only three ports and have described the technique as well as compared it with the open method. METHODS: A retrospective review of seven laparoscopic splenectomies (LS) using a three port technique were compared with seven open splenectomies (OS) performed for similar indications at a single children's hospital. RESULTS: The average age in the LS group was 8.7 years compared with 8.9 years for OS, (P value not significant), and the average weights were also similar. The indications for splenectomy were hereditary spherocytosis, idiopathic thrombocytopenic purpura, sickle cell anemia, and splenic cyst. All splenectomies were performed safely with an average estimated blood loss of 41 mL for LS and 34 mL for OS (P value not significant). Operative time averaged 147 minutes for LS and 86 minutes for OS (P < .05). LS patients recovered more rapidly and were discharged home on a median of postoperative day (POD) 2 versus POD 4 for OS (P < .05). LS patients received significantly less total amount of intravenous pain medication with an average of 0.18 mg/kg of morphine sulfate versus 0.8 mg/kg for OS (P< .05). Total hospital charges were higher for LS with an average of $10,899 versus $8,275 for OS (P < .05). CONCLUSIONS: Laparoscopic splenectomy currently is a safe procedure, offering better cosmesis, much less pain, and a shorter hospital stay compared with the traditional open procedure. The more sophisticated equipment and time needed to carry out the procedure led to a modestly increased hospital cost.
2) Legacy Portland Hospitals Good Samaritan and Emanuel Children's - Portland, OR, US Contact: Medical Director: Dr. David Rosencrantz Bloodless Coordinator: MaryAnn Knauss Address: 1015 N.W. 22nd Ave. Portland, OR 97210 US Phone: (503) 413-8396 Bloodless (800)733-9952 (503)413-6095 Fax K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 75
Email: [email protected] Articles: (1) deCastro RM BLOODLESS SURGERY: ESTABLISHMENT OF A PROGRAM FOR THE SPECIAL MEDICAL NEEDS OF THE JEHOVAH'S WITNESS COMMUNITY--THE GYNECOLOGIC SURGERY EXPERIENCE AT A COMMUNITY HOSPITAL. Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1491-8 Department of Obstetrics and Gynecology, Legacy Good Samaritan Hospital, Portland, USA. OBJECTIVE: My purpose was to describe the rationale behind the establishment of a hospital-based program instituted to enhance the health of the Jehovah's Witness community and to evaluate patient profiles and outcomes of gynecologic patients treated surgically at our institution, during the past 5 years, whose intake was through the Bloodless Surgery Program and who were not accepting of blood or most blood products. I further describe how a coordinated program dedicated to serving this particular population might improve outcomes and patient satisfaction. STUDY DESIGN: A retrospective review of the charts of 89 patients, all Jehovah's Witnesses, who were enrolled through the Bloodless Surgery Program and underwent gynecologic surgery involving at least 1 night's hospitalization at our institution between January 1, 1993, and December 31, 1997, was performed. A comparison of patient length of stay, hospital charges, and surgical blood loss, in a subset of 41 patients who underwent abdominal hysterectomy, with a cohort of patients not affiliated with the Jehovah's Witnesses or the Bloodless Surgery Program was performed. Data regarding patient satisfaction were obtained through surveys and are presented. RESULTS: Patients enrolled through the Bloodless Surgery Program and undergoing abdominal hysterectomy were significantly younger (average age 43.4 vs 47.7 years) and incurred significantly lower hospital charges (average cost $8754 vs $9539). No significant difference between the group studied and the control group could be found in average length of stay or the average change between preoperative and postoperative hemoglobin levels. Data from patient satisfaction surveys suggest a high level of satisfaction with the Bloodless Surgery Program. CONCLUSION: A program dedicated to the special needs of the Jehovah's Witness community can be instituted in a community-based hospital with no evidence of increased morbidity, as evidenced by length of stay, hospital charges, and surgical blood loss, in a gynecologic patient population. Development of such programs is associated with a high level of patient satisfaction and the potential for improved patient care. (2) Sheley RC, Semonsen KG, Quinn SF HELICAL CT IN THE EVALUATION OF RENAL COLIC. Am J Emerg Med 1999 May;17(3):279-82 Department of Radiology, Legacy Good Samaritan Hospital and Medical Center, Portland, OR 97210, USA. This study assessed the clinical effectiveness of unenhanced helical (spiral) computed tomography (CT) for evaluation of patients presenting with symptoms of renal colic. Two hundred patients with symptoms and signs of renal colic (flank or groin pain, hematuria) were imaged. Unenhanced CT was performed using 5-mm collimation with a pitch of 1.5 to 1.8. Image reconstruction was performed at 3-mm intervals. Exam time was approximately 5 minutes. The financial charge at the study institution was the same as for an intravenous urogram. Clinical follow-up was performed by review of available medical records and patient interviews. The sensitivity for detecting clinically relevant ureteral and bladder calculi was 0.862 (0.95 confidence interval [CI] 0.771 to 0.927), the specificity was 0.914 (0.95 CI 0.837 to 0.962), and the accuracy was 0.89 (0.95 CI 0.833 to 0.931). Helical CT is an effective technique in the evaluation of suspected acute urinary tract obstruction. (3) Wagar P, Ritzman D IMPROVING PATIENT CARE, CUTTING HOSPITAL COSTS. A PROCESS IMPROVEMENT SYSTEM. Hosp Top 1995 Winter;73(1):35-7 Good Samaritan Hospital and Health Care Center, Dayton, OH, USA. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 76
Today's healthcare managers all find themselves confronted with the dilemma of finding ways to reduce costs while simultaneously improving the quality of patient care. Working with management consultants, cross-functional teams at Good Samaritan Hospital carried out a four-step process to reduce the average length of stay for knee and hip replacement surgery from twelve to seven days. The improvements are saving the hospital an estimated $800,000 a year.
XXVII. PENNSYLVANIA
1) Allegheny General Hospital - Pittsburgh, PA, US Contact: Bloodless Director: Kay Williams Address: 312 E. North Ave. Pittsburgh, PA 15212 US Phone: (877) 284-2100 (412) 359-8787 Articles (1) Benoit RM, Cohen JK, Miller RJ Jr COMPARISON OF THE HOSPITAL COSTS FOR RADICAL PROSTATECTOMY AND CRYOSURGICAL ABLATION OF THE PROSTATE. Urology 1998 Nov;52(5):820-4 Department of Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA. OBJECTIVES: To compare the hospital costs of radical prostatectomy (RP) and cryosurgical ablation of the prostate (CSAP). METHODS: All patients who underwent either RP or CSAP at Allegheny General Hospital during an 18-month period beginning in January 1995 were included in this study. Hospital costs were generated for each case, and a chart review was undertaken for each patient. Costs were obtained from the hospital accounting office and divided into 11 categories, including total costs. Pretreatment grade, clinical stage, and prostate-specific antigen level were obtained from the patient's chart. Noncost information such as length of stay, number of operating room units charged, and patient age were also obtained from the hospital record. RESULTS: Sixty- seven men underwent RP and 114 men underwent CSAP during the study period. Average hospital costs were $4150 for men undergoing CSAP and $5660 for men undergoing RP, a difference of 27.2% (P < 0.001). The difference in hospital costs was almost completely explained by the difference in room costs ($682 for CSAP and $2348 for RP). Length of stay was 1.1 days for CSAP and 3.5 days for RP. Average operating room costs were higher for CSAP ($2309) than for RP ($ 1326). Conclusions: As costs become an ever more critical factor in healthcare, the costs of various treatment options for clinically localized prostate cancer will become as important as clinical outcomes in deciding appropriate treatment. From a strictly financial perspective, CSAP is a viable treatment option for clinically localized prostate cancer. (2) Magovern JA, Benckart DH, Landreneau RJ, Sakert T, Magovern GJ Jr MORBIDITY, COST, AND SIX-MONTH OUTCOME OF MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS GRAFTING. Ann Thorac Surg 1998 Oct;66(4):1224-9 Division of Thoracic Surgery, Allegheny University Hospitals, Allegheny General, and Allegheny University of the Health Sciences, Pittsburgh, PA 15212, USA. BACKGROUND: Minimally invasive direct coronary artery bypass grafting (MIDCABG) promises to reduce the morbidity of coronary bypass, but this has not been proved. METHODS: This retrospective study compares the morbidity, mortality, cost, and 6-month outcome of patients less than 80 years old undergoing elective left internal mammary artery to left anterior descending artery K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 77
bypass grafting via MIDCABG (n = 60) or sternotomy (n = 55) between January 1995 and December 1996. There were no differences between the groups in mean age, sex distribution, or preoperative risk level. The left internal mammary artery was mobilized from the fifth costal cartilage to the subclavian artery in all patients. The anastomoses were done with a beating heart in the MIDCABG group and with cardioplegic arrest in the sternotomy group. RESULTS: There were no operative deaths in either group. The MIDCABG patients had a lower transfusion incidence (10/60 [17%] versus 22/55 [40%]; p< or =0.02) and a shorter postoperative intubation time (2.1+/-4.2 versus 12.6+/-9 hours; p< or =0.0001). One patient in each group was reexplored for bleeding. Three sternotomy patients (3/55, 5%) required ventilatory support for greater than 48 hours, but no MIDCABG patient was ventilated for more than 24 hours. Median postoperative length of stay was 4 days for MIDCABG and 7 days for sternotomy. Estimated hospital costs were $11,200+/-3100 for MIDCABG and $15,600+/-4200 for CABG (p < 0.001). The reduced morbidity and cost of MIDCABG was found mostly in high-risk patients. At 6-month follow-up, 5 MIDCABG patients (5/60, 8%) had evidence of recurrent ischemia involving the left anterior descending artery, primarily the result of anastomotic stricture. CONCLUSIONS: This analysis shows that MIDCABG reduces the initial morbidity and cost of coronary bypass, but some patients require subsequent reintervention. Long-term follow-up is needed before MIDCABG can be judged better than traditional bypass, but the initial results are promising, especially in high-risk patients. (3) Gretebeck RJ, Shaffer D, Bishop-Kurylo D CLINICAL PATHWAYS FOR FAMILY-ORIENTED DEVELOPMENTAL CARE IN THE INTENSIVE CARE NURSERY. J Perinat Neonatal Nurs 1998 Jun;12(1):70-80 Department of Pediatrics, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA. The physiologic and neurodevelopmental benefits of developmentally sensitive nursing care for high- risk infants have been well documented. The remaining challenge is to find ways to introduce developmental care principles into busy intensive care nurseries. The article discusses the development of three clinical pathways designed around five areas for developmental intervention: environmental organization, structuring of nursing care, feeding, family involvement, and family education. Each pathway incorporated developmental principles appropriate for a different level of care; the level III pathway was designed for acutely ill or very premature infants, the level II pathway for infants recovering from acute illness or older premature infants, and the level I pathway for full-term infants. Introduction of the developmental care pathways had an immediate positive impact in the tertiary level intensive care nursery at Allegheny General Hospital. (4) Bailes JE, Poole CC, Hutchison W, Maroon JC, Fukushima T UTILIZATION AND COST SAVINGS OF A WIDE-AREA COMPUTER NETWORK FOR NEUROSURGICAL CONSULTATION. Telemed J 1997 Summer;3(2):135-9 Department of Neurosurgery, Allegheny University of the Health Sciences, Allegheny General Hospital, Pittsburgh, PA, USA. BACKGROUND AND OBJECTIVE: Telemedicine systems offer many potential advantages for health care delivery. Most reports have centered on the delivery of primary and medical subspecialty care rather than on its impact on patient care and the potential for cost savings. In 1993, we implemented NeuroLink, a wide-area teleradiology network for delivery of specialty care in neurologic surgery at Allegheny General Hospital (AGH). This study was designed to determine the potential cost savings of such a network. METHODS: We prospectively reviewed 100 consecutive telemedicine neurosurgical consultations from 20 western Pennsylvania community hospitals participating in the NeuroLink network. Data related to referring hospital, diagnosis, disposition of the patient, and mode of transportation were reviewed. To determine the potential cost savings, the differential of hospital-based charges between AGH and western Pennsylvania primary hospitals was calculated based on an average length of stay (LOS), patient bed costs, and transportation charges. RESULTS: Of the 100 patients, 33 did not require transfer to a tertiary facility but were instead managed at the community hospital as a direct result of the remote diagnosis and image review disclosing that neurosurgical procedures or intensive care were not required. Cost analysis, comparing the average LOS at AGH with that of the average community hospital, including transportation, showed savings of $502,638. CONCLUSION: Our neurosurgical wide-area computer K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 78
network has led to more appropriate transfer of patients to a tertiary facility and significant estimated cost savings.
2) The Graduate Hospital 1800 Lombard St. Philadelphia, PA 19146 (215) 893-2000 - Hospital The Graduate Hospital is a 330-bed tertiary care facility with a medical staff of over 550 physicians and 115 residents and fellows who are proficient in more than 40 specialized medical and surgical disciplins. The overall mission of the hospital is to provide the finest medical care to the patients in our community. In fulfilling our mission, we believe it is vital that we continuously meet the needs of our entire community. In a culturally diverse society such as ours, that includes providing medical and surgical care to adult patients who choose to exercice their rights to refuse blood transfusion and blood components. To be able to provide such an option to all patients who request it, we offer our Bloodless Care Program. To accommodate the wishes and needs of these individuals, The Graduate Hospital has assembled a comprehencive team of health care professionals - physicians, surgeons, registred nurses, technical and support staff - who believe that complete, effective health care should be avilable to all in accordance with their religious beliefs and personal preferences. In addition, we offer the most advanced, state-of-the-art equipment and technology available to successfylly meet the challenge of bloodless medicine and surgery.
When you are admitted, please help us by specifically mentioning that you are choosing to be treated through Graduat's Bloodless Care Program. For more informnations on The Graduate Hospital Bloodless Care Program, or for assistance in contacting one of our participating physicians, please call the Bloodless Care Program Coordinator at (215) 893-2086.
(1) Bauer TW, Morris JB, Lowenstein A, Wolferth C, Rosato FE, Rosato EF THE CONSEQUENCES OF A MAJOR BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY. J Gastrointest Surg 1998 Jan-Feb;2(1):61-6 Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. Bile duct injury is perhaps the most feared complication of laparoscopic cholecystectomy. The focus of this study was on the immediate and short-term outcome of patients who have undergone repair of major bile duct injuries with respect to hospital stay, perioperative interventions, and reoperations. The records of patients who underwent surgery at three academic hospitals in Philadelphia (Hospital of the University of Pennsylvania, Thomas Jefferson University Hospital, and Graduate Hospital) from 1990 to 1995 for repair of a major biliary injury following laparoscopic cholecystectomy were reviewed. A major biliary injury was defined as any disruption (including ligation, avulsion, or resection) of the extrahepatic biliary system. Small biliary leaks not requiring surgery were excluded. Thirty-two patients sustained major bile duct injuries. The injury was recognized immediately in 10 patients. The remaining 22 patients had pain (59%), jaundice (50%), and/or fever (32%) as the symptom heralding the injury. Bismuth classification was as follows: 13% of patients were class I, 63% were class II, 7% were class III, 7% were class IV, and 10% were class V. Biliary reconstruction included a Roux-en-Y hepaticojejunostomy in 30 patients and two were primary repairs. There was one postoperative death from multiorgan system failure. The mean length of hospital stay after repair was 17 +/- 8 days. Over a mean follow-up period of 11.5 +/- 10.5 months, 11 patients (38%) required 19 emergency readmissions, most commonly for cholangitis. Five patients (17%) required postoperative balloon dilatation for biliary stricture. At follow-up 18 patients (62.0%) remain asymptomatic with normal liver function, eight (28%) are experiencing episodic cholangitis, and three (10%) are asymptomatic with persistently elevated liver function values. The consequences of a major biliary tract injury following laparoscopic cholecystectomy include a K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 79
complex operative repair resulting in a lengthy postoperative stay with an increased risk of death, an excessive number of perioperative diagnostic and therapeutic studies, frequent readmissions (often as emergencies), and a lifelong risk of restricture. The "cost" to these patients remains enormous. (2) No Authors Listed GHS (GRADUATE HEALTH SYSTEM) LINKS REGIONAL NETWORK OF CARE. Health Manag Technol 1995 Jan;16(1):20-2, 24, 26 Philadelphia-based Graduate Health System is implementing technology that will ultimately change the way physicians practice medicine, according to Harold Cramer, chairman and chief executive officer of GHS. The new technology centers around an electronic medical record, consensus protocols, outcomes measurement and electronic medical library resources. (3) Becker BF, Cramer H, Easley D, Nathanson P, Neeson R, Raney J, Samuelson C, Ummel S CEO SUMMIT. THE NEW DELIVERY & FINANCING REALITIES. PART III OF III. Hosp Health Netw 1994 Aug 20;68(16):38-40, 42 In cooperation with McManis Associates Inc., Washington, Hospitals & Health Networks recently convened a summit on the integration of financing and delivery in health care. This installment is the third of a three-part series on lessons learned by those on the front lines of integration activity. The session was designed and facilitated by senior associates at McManis. Among the issues summit participants discussed in the second segment: What level of understanding do purchasers have of the factors that differentiate quality in health care services? Can provider-driven integrated delivery systems compete with insurer-driven ones? And what happens when a large integrated delivery system merges with a dominant insurer, as happened in the Philadelphia market? Can that model be successfully replicated in other markets? In this final segment, participants talk about whether providers' deep connections to their communities will add value in a reformed delivery system; how incentives might be aligned among all the players in integrated networks and organizations; how the concept of community focus might be redefined under systems integration; and the process involved in preparing for constant, accelerated change. The second segment concluded with comments about the assets providers and insurers bring to integrated health systems, and whether the merger experience of Graduate Health System and QCC/Independence Blue Cross could be replicated in other markets or not.
3) The Center for Bloodless Medicine and Surgery, Pennsylvania Hospital - Philadelphia, PA, US Contact: Bloodless Coordinator: Kay Williams Office Manager: Michael Columbus Address: 301 South 8th Street Suite 3C-2 Philadelphia, PA 19107 US Phone: (888) 451-6060 (215) 829-6504 Bloodless (215) 829-5460 Fax WebSite: http://www.pahosp.com/services/bdy5b22.html We encourage you to contact us with any questions or comments. Email Contact: Kay Williams: [email protected] Michael Columbus: [email protected] Program Specialties: Stem Cell Transplants OB-GYN Cardiac Surgery Neonatology Oncology Orthopedic Surgery Lung Transplant
XXVIII. RHODE ISLAND
1) Rhode Island Hospital - Providence, RI, US Contact: Lifespan Health Connection Address: 593 Eddy St. Providence, RI 02903 US Phone: 401-444-4800-Hospital 401-5070 Office K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 80
401-444-4814 Fax (1) Soares RL Jr, Monchik J, Migliori SJ, Amaral JF LAPAROSCOPIC ADRENALECTOMY FOR BENIGN ADRENAL NEOPLASMS. Surg Endosc 1999 Jan;13(1):40-2 Department of Surgery, Rhode Island Hospital/Brown University, Providence RI 02903, USA. BACKGROUND: Since first reported in 1992, laparoscopic adrenalectomy has been used to remove a wide variety of adrenal neoplasms. Indications for use of this technique have not been clearly defined, nor has it been demonstrated to be more cost effective than open adrenalectomy. METHODS: A retrospective comparison was made of 19 consecutive laparoscopic and open adrenalectomies performed in patients with benign adrenal neoplasms in a tertiary-care university teaching hospital over a 3-year period. RESULTS: The two groups were well matched for side of tumor and age. Laparoscopic adrenalectomy was completed in 11 of 12 patients in whom it was attempted. The laparoscopic group had significantly smaller tumor size; shorter operative time, postoperative ileus, and postoperative stay; and decreased operative blood loss and postoperative narcotic requirement. There were no significant differences between groups for operating room or hospital charges. CONCLUSIONS: Laparoscopic adrenalectomy is cost effective and should be the preferred treatment for patients with small benign adrenal neoplasms. (2) O'Brien GM, Shapiro MJ, Woolard RW, O'Sullivan PS, Stein MD "INAPPROPRIATE" EMERGENCY DEPARTMENT USE: A COMPARISON OF THREE METHODOLOGIES FOR IDENTIFICATION. Acad Emerg Med 1996 Mar;3(3):252-7 Division of General Internal Medicine, Rhode Island Hospital, Providence 02903, USA. OBJECTIVE: To determine the level of agreement between the rates of "inappropriate" ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness. METHODS: Ambulatory adult patients seen at one urban, university-based teaching hospital ED between 8 AM and midnight during select days from April to June 1994 were assessed regarding the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90-question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 non-emergent complaints that have been used by managed care providers and previously published (TRIAGE), 2) use of ten explicit criteria (e.g., need for parenteral medication) from prior publications (EXPLICIT), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (PHYS). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores. RESULTS: Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of "inappropriate" visits using the three definitions were TRIAGE, 58%; PHYS, 47%; and EXPLICIT, 42%. Of those deemed "inappropriate" by the EXPLICIT criteria, 81% also were judged as "inappropriate" by the TRIAGE criteria, and 72%, by the PHYS criteria. Of those patients deemed "inappropriate" by the TRIAGE criteria, 59% also were judged as "inappropriate" by the EXPLICIT criteria, and 66%, by the PHYS criteria. Levels of agreement (kappas) were TRIAGE/EXPLICIT, 0.39; TRIAGE/PHYS, 0.42; and EXPLICIT/PHYS, 0.42. CONCLUSION: There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts "inappropriate" ED visits. Comment in: Acad Emerg Med 1996 Mar;3(3):189-91 Comment in: Acad Emerg Med 1996 Nov;3(11):1071-3 K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 81
XXIX. SOUTH CAROLINA
1) Roper Hospital - Charleston, SC, US Contact: Bloodless Coordinator: Loretta Humes Medical Director Dr. Stanley Wilson Address: 316 Calhoun St. Charleston, SC 29401 US Phone: 843-724-2399 Bloodless 800-868-4916 843-720-8304 Fax Email: [email protected] Hospital 843-724-2000 (after hours ask for nursing administrator)
Articles (1) Fitzgerald RH Jr, Decker M CONSERVATION BREAST THERAPY AT ROPER HOSPITAL: THE EARLY EXPERIENCE. J S C Med Assoc 1996 Nov;92(11):455-7 Roper Hospital, Charleston, SC 29301, USA. The preliminary analysis, done at five years, of the initial population of women treated at Roper Hospital with the intention of breast preservation is consistent with and not at variance with results from larger series and institutions. Fifty patients are available for analysis from five to 12 years following breast irradiation. One has recurred in the treated breast. One has had a contralateral primary carcinoma. Forty-nine (98 percent) have had no recurrence of their primary breast lesion and none developed metastases. Comment in: J S C Med Assoc 1996 Nov;92(11):473-4 (2) Pacult A, Gratzick G, Voegele D, Worthington C, Quinn G, Utsey T SURGICAL CLIPPING OF DIFFICULT INTRACRANIAL ANEURYSMS USING DEEP HYPOTHERMIA AND TOTAL CIRCULATORY ARREST. South Med J 1993 Aug;86(8):898-902 Roper Hospital, Charleston, SC. Intracranial aneurysms often present a challenging problem for the neurosurgeon. A variety of techniques have been developed to deal with these lesions. Several subspecialists are frequently involved in such treatment. We present our experience in a community hospital using a previously described technique of hypothermic cardiac arrest and barbiturate cerebral protection. (3) Strong JW, Worsham GF, Baker AS, Hawk JC 3d, Austin RM FINE-NEEDLE ASPIRATION CYTOLOGY OF AN ENDOMETRIOID-LIKE VARIANT OF YOLK SAC TUMOR. Diagn Cytopathol 1992;8(6):600-4 Department of Pathology, Roper Hospital, Charleston, SC 29401. A 36-year-old male with a history of immature teratoma and embryonal carcinoma of the testis was admitted to the hospital for abdominal pain and fever. A CT scan revealed a large right abdominal mass. The patient's serum alpha-fetoprotein (AFP) was 46.8 ng/ml (reference < 25 ng/ml). Fine- needle aspiration (FNA) of the mass revealed malignant glandular cells. Chemotherapy was instituted, followed by resection of the large abdominal mass. The tumor was grossly encapsulated, consisting of large areas of necrotic, hemorrhagic tissue surrounded by smaller, multiloculated cysts. Microscopically, the tumor had a villoglandular pattern and variably stratified tall columnar cells. A prominent feature of the columnar cells was supranuclear and subnuclear vacuolization. Intracytoplasmic PAS-positive, diastase-resistant hyaline globules were occasionally present. AFP by immunoperoxidase was prominent within the tumor. This recurrence of the previously diagnosed testicular teratoma with embryonal carcinoma represents a yolk sac tumor with components strongly resembling endometrioid carcinoma, a variant only recently described in eight cases of ovarian origin (Clement et al.: Am J Surg Pathol 1987; 11(10):767-778). We believe this is the first reported case of K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 82
an endometrioid-like variant of testicular yolk sac tumor and also the first report of the FNA cytology findings in this variant. (4) Flanders E, Hinnant JR AMBULATORY SURGERY POSTOPERATIVE WOUND SURVEILLANCE. Am J Infect Control 1990 Oct;18(5):336-9 Roper Hospital, Charleston, SC 29401.
XXX. TENNESSEE
1) St. Thomas Hospital - Nashville, TN, US Contact: Bloodless Coordinator: Almeda Golson Address: 4220 Harding Rd. Nashville, TN 37202 US Phone: (800) 298-3200 (615) 298-3200 (615) 386-2111 Articles: (1) Anderson JT, Watson M, Hilleman D CARDIOVASCULAR RISK FACTOR SCREENING AND INTERVENTION IN AFRICAN AMERICAN ADULTS. J Health Care Poor Underserved 1997 Aug;8(3):322-44 Cardiac Health and Rehabilitation program, St. Thomas Heart Institute, Nashville, TN 37205, USA. The Cardiac Health and Rehabilitation program of St. Thomas Hospital in Nashville, Tennessee, has developed a project to assess the effectiveness of a community-based cardiovascular risk assessment and intervention program directed at African American adults. The specific aim of this program is to assess the feasibility of implementing a community-based cardiovascular disease risk factor reduction program directed at African American adults. Its ultimate goal is to be able to teach African American adults cost-efficient, simple methods of exercise, nutrition, and weight management; smoking cessation; and blood pressure control. The program is expected to raise the African American community's awareness of the importance of modifiable cardiovascular disease risk factors and their effect on cardiac morbidity and mortality. The program is also expected to be able to evaluate the success of cardiovascular disease risk factor intervention and patient satisfaction with the program. (2) Tomichek RC, Shields JA, Zimmerman RE TRANSESOPHAGEAL ATRIAL PACING (TAP) FOR SINUS BRADYCARDIA DURING CORONARY ARTERY BYPASS GRAFTING: COMPARISON OF TAP TO INTERMITTENT BOLUS GALLAMINE. J Cardiothorac Vasc Anesth 1995 Jun;9(3):259-63 Division of Cardiac Anesthesia, St. Thomas Hospital, Nashville, TN, USA. OBJECTIVE: To assess the relative efficacy of a pacing esophageal stethoscope and intermittent boluses (40 mg) of gallamine in correcting sinus bradycardia (SB) during coronary artery surgery. DESIGN: The study was prospective, randomized, and controlled. SETTING: A community hospital. PARTICIPANTS: Fifty patients scheduled for elective coronary artery surgery. INTERVENTIONS: The patients were randomly allocated to receive treatment for an SB (less than 60 BPM) with either transesophageal atrial pacing (TAP) or gallamine. MEASUREMENTS AND MAIN RESULTS: Heart rate, blood pressure, and systemic hemodynamics were measured. The electrocardiogram was K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 83
monitored for rate, rhythm, and conduction abnormalities. Twenty-four of the 25 TAP patients could be paced at a rate of 70 BPM after SB. Cardiac index increased from 1.90 to 2.56 L/min/m2. In the gallamine group, heart rate was increased from 50 to 66 BPM, but cardiac index only increased to 2.2 L/min/m2, and 2 patients developed nodal rhythms. Eight of these patients had peak heart rates over 80 BPM, and two were over 90 BPM. CONCLUSIONS: The ability to reliably and precisely control heart rate was superior with TAP compared with intermittent bolus dosing with gallamine. (3) Sprouse MW A REALISTIC APPROACH FOR GAINING PHYSICIAN SUPPORT OF QA. J Qual Assur 1990 Jul-Aug;12(3):12-7 St. Thomas Hospital, Nashville, TN.
2) UT Bowld Hospital - Memphis, TN, US Contact: Coordinator: Sue Pulliam Address: 951 Court Avenue Memphis, TN 38103-2998 US Phone: 800- 531-2342 901- 448-7805 Bloodless 901- 448-7974 Fax WebSite: http://www.utmedicalgroup.com/utbowld/bloodless-care-program.html Hospital 901-448-4000 Articles: (1) Self TH, Kelso TM, Arheart KL, Morgan JH, Umberto Meduri G NURSES' PERFORMANCE OF INHALATION TECHNIQUE WITH METERED-DOSE INHALER PLUS SPACER DEVICE. Ann Pharmacother 1993 Feb;27(2):185-7 Department of Pharmacy Services, UT Bowld Hospital, University of Tennessee Medical Center, Memphis 38103. OBJECTIVE: To determine if nurses could correctly use a metered-dose inhaler plus spacer (MDI- spacer) device after a brief description and demonstration of proper use by a clinical pharmacist. DESIGN: Pretest, educational intervention, posttest. SETTING: University hospital. PARTICIPANTS: Twenty-three nurses. INTERVENTIONS: Nurses were asked to use the MDI- spacer (Aerochamber) and were scored using a nine-point checklist (pretest). Educational intervention by the clinical pharmacist consisted of a five-minute discussion and correct demonstration of the device. Nurses were then asked to use the device again (posttest). MAIN OUTCOME MEASURES: Pre- and posttest scores. RESULTS: Total scores were improved after the educational intervention (66 percent pretest vs. 88 percent posttest, p = 0.0001). In an item analysis, four of the nine steps had improved significantly. CONCLUSIONS: A brief discussion and demonstration of correct use of MDI-spacers is effective in improving nurses' skill in using the device. (2) Joe RH, Kellermann A, Arheart K, Ellis R, Self T EMERGENCY DEPARTMENT ASTHMA TREATMENT PROTOCOL. Ann Pharmacother 1992 Apr;26(4):472-6 UT Bowld Hospital, Memphis, TN 38103. OBJECTIVE: The purpose of this study was to determine if a brief educational intervention (INT) on the treatment of acute asthma improved prescribing patterns of internal medicine residents in an emergency department (ED). Additional objectives were to determine if optimal therapy reduced length of stay (LOS) in the ED and to determine if discharge prescribing patterns could be improved. DESIGN: Nonrandomized, single-blind INT study. SETTING: A large, urban, county-owned, university-affiliated ED. PATIENTS AND OTHER PARTICIPANTS: Eight internal medicine residents in each of three study periods; numbers of adult asthmatics for each period were: control group, 129 (Nov-Dec 1989); INT group A, 82 (Jan-Feb 1990); and INT group B, 139 (Nov-Dec 1990). INTERVENTIONS: INT consisted of a ten-minute verbal presentation, a three-page summary of the K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 84
literature, and a posted protocol in the ED. Control data were collected prior to any INT. Prescribing patterns were covertly evaluated in each of the three study periods. Because discharge prescribing of long-term antiinflammatory therapy with inhaled corticosteroids was not improved in group A, emphasis on this point was added for group B. MAIN OUTCOME MEASURES: Percentage of patients who received desired acute and discharge therapies and LOS for each study period. RESULTS: Increased prescribing of desired acute therapy in the ED was seen in both INT groups. For discharge prescribing, the INT was partially successful. Reduced LOS was not found for the INT groups. CONCLUSIONS: A brief INT effectively improves prescribing of optimal acute therapy of asthma in the ED, yet does not appear to reduce LOS. Further strategies are needed to impact on therapy prescribed at discharge from the ED.
XXXI. TEXAS
1) Metropolitan Methodist Hospital - San Antonio, TX, US Contact: Bloodless Coordinator: James Reinhardt Address: 1310 McCullough Ave. San Antonio, TX 78212-9960 US Phone: 800-882-5663 (210) 971-2200 - Hospital 210-208-2908 Bloodless 210-208-2915 Fax WebSite: http://www.mhshealth.com/facilities/metro/index.html
2) Mission Hospital - Mission, TX, US Contact: Bloodless Coordinator: Howard Swift Medical Director: Javier Murillo Address: 900 South Bryan Road Mission, TX 78572 US Phone: (956) 580-9000 Email: [email protected]
3) Trinity Medical Center 4343 N. Josey Lane Carrollton, TX 75010 (214) 492-1010 - Hospital Trinity Medical Center is a fully accredited, 149-bed acute care facility and medical campus conveniently located in Carrollton at the intersection of Hebron Parkway and North Josey Lane. The Medical campus also includes thre Professional Buildings, a pharmacy. a 180-bed skilled nursing facility and the Trinity Easter Seal Society for Children. Our medical staff is comprised of more than 335 physicians, representing 37 specialities. Together, the hospital and the immediate environs represent a complete, sophisticated medical campus that is designed to meet the growing and changing needs of our community. Trinity Medical Center is owned by the Metrocrest Hospital Authority and operated by National Medical Ebterprises Inc. , one of the nation's largest healthcare services companies. At Trinity Medical Center we realize that you cannot plan ahead for all things in life. Sometimes medical situations arise that need immediatew attention. The staff at the Bloodless Medicine and Surgery Program is available to you 24 hours a day, seven days a week. If you need to schedule a K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 85
surgery, have an emergency or just have questions you need answered call the program coordinator at Trinity Medical Center. Our staff is here to help. WHEN YOU NEED US, CALL: (800) 999-5075 or (214) 492-1010 Articles: (1) Punzi HA, Novrit BA THE TREATMENT OF SEVERE HYPERTENSION WITH TRANDOLAPRIL, VERAPAMIL, AND HYDROCHLOROTHIAZIDE. TRANDOLAPRIL/VERAPAMIL MULTICENTER STUDY GROUP. J Hum Hypertens 1997 Aug;11(8):477-81 Trinity Hypertension Research Center, Trinity Medical Center, Carrollton, TX 75010, USA. A multiple drug regimen consisting of trandolapril, verapamil and hydrochlorothiazide (HCTZ) were sequentially added in an open-label evaluation of patients with severe hypertension. Ninety patients (58 white and 32 black patients) were titrated on one or more drugs and followed for a 19- week maintenance period. Statistically significant (P = 0.001) mean (+/-s.d.) decreases in supine diastolic blood pressure (DBP) were 9.0 (+/-9.3) mm Hg for trandolapril, 13.9 (+/-11.0) mm Hg for the trandolapril + verapamil (TV) combination, and 19.0 (+/-12.3) mm Hg when hydrochlorothiazide was added to the combination. The decrease in BP observed on TV combination therapy plus HCTZ was significantly (P = 0.001) greater than the decrease observed for the TV combination, which was significantly (P = 0.001) greater than the decrease observed for trandolapril monotherapy. Clinical responder rates were 44.8%, 56% and 77.7% for trandolapril monotherapy, trandolapril + verapamil combination therapy and triple therapy, respectively. Black and white patients had similar response rates, but black patients appeared to benefit more from the addition of HCTZ; 20% of black patients achieved a post- treatment supine DBP <90 mm Hg compared to 12.8% of white patients. This study demonstrates that the addition of verapamil to trandolapril has an additive effect on BP that is maintained throughout the day. (2) Frankel G, Kantipong M SIXTEEN-MONTH EXPERIENCE WITH VIDEO-ASSISTED EXTRAPERITONEAL LAPAROSCOPIC BLADDER NECK SUSPENSION. J Endourol 1995 Jun;9(3):259-64 Department of Urology, Trinity Medical Center, Carrollton, TX, USA. After an extensive favorable experience with the Lapides-Ball open retropubic bladder neck suspension, we chose to perform this operation laparoscopically. We describe video-assisted extraperitoneal laparoscopic bladder neck suspension (VELBNS), in which we employ a single laparoscopic cannula and a laparoscopic bladder suspension set for suturing and simultaneously use video-assisted cystoscopy and laparoscopy for precise suture placement. Over 16 months, we operated on 70 patients with stress urinary incontinence secondary to hypermobility of the urethra. We describe the patient evaluation and selection and the surgical principles and techniques. Five procedures were converted to open operations because of bladder lacerations (two cases) or inability to dissect the space of Retzius because of scar tissue (three cases). At 3 months, 4 patients had unresponsive de novo urgency incontinence, and 61 patients were dry and without protection. One patient had a recurrence at 6 months that was corrected by open surgery. All 12 patients seen at 1 year were dry. We intend to survey our patients annually to obtain long-term results
4) Doctors Hospital of Dallas 9440 Poppy Dr. Dallas, TX 75218 (214) 324-6640 – Hospital Articles: K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 86
(1) Weld L DEVELOPING A CARDIAC CATHETERIZATION EDUCATION PROGRAM. J Cardiovasc Nurs 1997 Jan;11(2):47-57 Department of Nursing, Doctors Hospital, Dallas, Texas, USA. This article describes the establishment of a coordinated education program for patients having a cardiac catheterization. The article focuses on developing the program content, instructional aids, and the education of the staff doing the actual patient education for this group of patients and their families
5) American Medical International, Inc. Articles (1) Lutz S NME, AMI TO MERGE. Mod Healthc 1994 Oct 17;24(42):2-3 By agreeing to buy American Medical International in a $3.3 billion deal, National Medical Enterprises sets its sights on becoming an 84-hospital chain with $5.3 billion in annual revenues. But the deal also will bring $2.5 billion in debt and $150 million in fees. (2) Nemes J O'LEARY-LED COST-CUTTING AIDS FINANCIAL TURNAROUND AT AMI. Mod Healthc 1992 Dec 14;22(50):48-9 Wall Street analysts are giving Robert O'Leary good grades for his first year as chief executive at American Medical International. Mr. O'Leary, who joined the Dallas-based hospital chain in July 1991, has spent the past year and a half recruiting his own team of senior executives and implementing a new agenda for the company. But it's his aggressive cost-cutting and the bottom-line improvements that have earned him the highest marks. a. Mid-Jefferson Hospital 27th St. Nederland, TX 77627 (409) 727-2321 -Hospital b. Park Place Medical Center 3050 39th St. Port Arthur, TX 77640 (409) 983-4951 - Hospital
6) Sisters of Charity St. John Hospital - Nassau Bay, TX, US Contact: Program Coordinator Jessica Varisco Address: 1830 St John Drive Nassau Bay, TX 77058 US Phone: (888) 411-7527 281-333-8878 Transfusion Free 281-291-0941 Fax Hospital 281-333-5303
7) Tenet Doctors Hospital - Dallas, TX, US Contact: Bloodless Coordinator: Audrey Bingham Address: 9440 Poppy Dr. Dallas, TX 75218 US Phone: 800-436-8181 214-324-6224 Transfusion Free 214-324-6228 (fax) K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 87
Hospital 214-324-6100
8) Tenet Park Place Med. Center & Mid Jefferson Hospital - Port Arthur, TX, US Contact: Sharon Miller CCRN Cynthia Ballou CRTT/RCP Address: P.O. Box 1648 Port Arthur, TX 77641-9971 US Phone: 800-344-0014
9) Tenet Park Plaza Hospital - Houston, TX, US Contact: Bloodless Coordinator: Lawrence Johnson Address: 1313 Hermann Dr. Houston, TX 77004 US Phone: 800-527-1551 713-527-5950 713-523-3821 Fax Email: [email protected] Hospital 713-527-5000
10) Trinity Medical Center - Carrollton, TX, US Contact: Bloodless Coordinator: Mary Anne Rouch Address: 4343 N. Josey Ln. Carrollton, TX 75010 US Phone: 972-394-2292 Transfusion Free 800-999-5075 972-394-2239 Fax Email: [email protected] Hospital 972-492-1010 Articles: (1) Punzi HA, Novrit BA THE TREATMENT OF SEVERE HYPERTENSION WITH TRANDOLAPRIL, VERAPAMIL, AND HYDROCHLOROTHIAZIDE. TRANDOLAPRIL/VERAPAMIL MULTICENTER STUDY GROUP. J Hum Hypertens 1997 Aug;11(8):477-81 Trinity Hypertension Research Center, Trinity Medical Center, Carrollton, TX 75010, USA. A multiple drug regimen consisting of trandolapril, verapamil and hydrochlorothiazide (HCTZ) were sequentially added in an open-label evaluation of patients with severe hypertension. Ninety patients (58 white and 32 black patients) were titrated on one or more drugs and followed for a 19- week maintenance period. Statistically significant (P = 0.001) mean (+/-s.d.) decreases in supine diastolic blood pressure (DBP) were 9.0 (+/-9.3) mm Hg for trandolapril, 13.9 (+/-11.0) mm Hg for the trandolapril + verapamil (TV) combination, and 19.0 (+/-12.3) mm Hg when hydrochlorothiazide was added to the combination. The decrease in BP observed on TV combination therapy plus HCTZ was significantly (P = 0.001) greater than the decrease observed for the TV combination, which was significantly (P = 0.001) greater than the decrease observed for trandolapril monotherapy. Clinical responder rates were 44.8%, 56% and 77.7% for trandolapril monotherapy, trandolapril + verapamil combination therapy and triple therapy, respectively. Black and white patients had similar response rates, but black patients appeared to benefit more from the addition of HCTZ; 20% of black patients achieved a post-treatment supine DBP <90 mm Hg compared to 12.8% of white patients. This study demonstrates that the addition of verapamil to trandolapril has an additive effect on BP that is maintained throughout the day. (2) Frankel G, Kantipong M SIXTEEN-MONTH EXPERIENCE WITH VIDEO-ASSISTED EXTRAPERITONEAL LAPAROSCOPIC BLADDER NECK SUSPENSION. J Endourol 1995 Jun;9(3):259-64 Department of Urology, Trinity Medical Center, Carrollton, TX, USA. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 88
After an extensive favorable experience with the Lapides-Ball open retropubic bladder neck suspension, we chose to perform this operation laparoscopically. We describe video-assisted extraperitoneal laparoscopic bladder neck suspension (VELBNS), in which we employ a single laparoscopic cannula and a laparoscopic bladder suspension set for suturing and simultaneously use video-assisted cystoscopy and laparoscopy for precise suture placement. Over 16 months, we operated on 70 patients with stress urinary incontinence secondary to hypermobility of the urethra. We describe the patient evaluation and selection and the surgical principles and techniques. Five procedures were converted to open operations because of bladder lacerations (two cases) or inability to dissect the space of Retzius because of scar tissue (three cases). At 3 months, 4 patients had unresponsive de novo urgency incontinence, and 61 patients were dry and without protection. One patient had a recurrence at 6 months that was corrected by open surgery. All 12 patients seen at 1 year were dry. We intend to survey our patients annually to obtain long-term results. (3) Peterson JL MULTI-INSTITUTIONAL PRIVILEGING: A PILOT DEMONSTRATION PROJECT OF THE UNITED STATES NAVY AND THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS. Mil Med 1992 Nov;157(11):604-8 Trinity Medical Center, Carrollton, TX 75010. The U.S. Navy and the Joint Commission on Accreditation of Healthcare Organizations have undertaken a 3-year multi-institutional privileging project. The concept involves granting privileges in one Navy facility that are recognized throughout the system during the staff appointment period. It entails: (1) use of specialty-specific standardized privilege lists, (2) designation of one authority at a time to grant the appointment with privileges, (3) use of a single credentials file during the practitioner's career, and (4) medical staff bylaws applicable to the entire system. The concept is potentially useful in other armed services, the Veterans Administration, and some civilian systems. XXXIII. PHILADELPHIA
1) Center for Bloodless Medicine and Surgery - Graduate Hospital - Philadelphia, PA, US
Contact: Coordinators: Randal Thomas - Lead Lawrence Birch Paul Johnson Patrick Fremont Christopher Tabbert Address: 1800 Lombard St. Philadelphia, PA 19146 US Phone: (800) 472-3277 (215) 893-2135 (215) 893-2190 direct Fax: 893-7197
XXVI. UTAH
1) McKay-Dee Hospital Center - Ogden, UT, US Contact: Director: Jo-Ann Boggess, RN Address: 3939 Harrison Blvd. Ogden, UT 84409 US WebSite: http://www.ihc.com/mckay-dee Email: [email protected] Articles: K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 89
(1) Young MP, Gooder VJ, Oltermann MH, Bohman CB, French TK, James BC THE IMPACT OF A MULTIDISCIPLINARY APPROACH ON CARING FOR VENTILATOR-DEPENDENT PATIENTS. Int J Qual Health Care 1998 Feb;10(1):15-26 Critical Care Department, McKay-Dee Hospital Center, Ogden, UT 84403, USA. OBJECTIVE: To determine the clinical and financial outcomes of a highly structured multidisciplinary care model for patients in an intensive care unit (ICU) who require prolonged mechanical ventilation. The structured model outcomes (protocol group) are compared with the preprotocol outcomes. DESIGN: Descriptive study with financial analysis. SETTING: A twelve-bed medical-surgical ICU in a non-teaching tertiary referral center in Ogden, Utah. STUDY PARTICIPANTS: During a 54 month period, 469 consecutive intensive care patients requiring mechanical ventilation for longer than 72 hours who did not meet exclusion criteria were studied. INTERVENTIONS: A multidisciplinary team was formed to coordinate the care of ventilator-dependent patients. Care was integrated by daily collaborative bedside rounds, monthly meetings, and implementation of numerous guidelines and protocols. Patients were followed from the time of ICU admission until the day of hospital discharge. MAIN OUTCOME MEASURES: Patients were assigned APACHE II scores on admission to the ICU, and were divided into eight diagnostic categories. ICU length of stay, hospital length of stay, costs, charges, reimbursement, and in-hospital mortality were measured. RESULTS: Mortality in the preprotocol and protocol group, after adjustment for APACHE II scores, remained statistically unchanged (21-23%). After we implemented the new care model, we demonstrated significant decreases in the mean survivor's ICU length of stay (19.8 days to 14.7 days, P= 0.001), hospital length of stay (34.6 days to 25.9 days, P=0.001), charges (US$102500 to US$78500, P=0.001), and costs (US$71900 to US$58000, P=0.001). CONCLUSIONS: Implementation of a structured multidisciplinary care model to care for a heterogeneous population of ventilator-dependent ICU patients was associated with significant reductions in ICU and hospital lengths of stay, charges, and costs. Mortality rates were unaffected. (2) Richins S, Holmes M WAITING FOR SATISFACTION. J Healthc Manag 1998 May-Jun;43(3):281-5 McKay-Dee Hospital Center, Ogden, UT, USA. This case study documents McKay-Dee Hospital Center's search for a solution for low patient satisfaction scores concerning wait times for surgery patients entering McKay-Dee's Same Day Department. Unable to expand to an appropriate size for present patient flow, the operating room/recovery room committee reviewed data on patient wait times at a physician level to determine an alternate solution to expansion. Data were gathered and refined, definitions were interpreted, and various steps in the scheduling processes were delineated, clarifying several issues that affected patient wait times. By studying the data in a committee setting rather than focusing on the human aspect, detrimental patterns such as late schedule changes and "catch-all procedures" were identified and logical solutions were suggested. In this manner, preoperative wait time targets were appropriately set, surgeons and staff were counseled, and surgical scheduling became more accurate. The result was a dramatic rise in patient satisfaction scores concerning preoperative wait times. XXVII. WASHINGTON
1) Kadlec Medical Center - Richland, WA, US Contact: Bloodless Coordinator: Johnean Hansen C.R.C.P. Address: 888 Swift Blvd. Richland, WA 99352 US Phone: 509-946-4611 Hospital 800-780-6067 Ext. 2817 Bloodless 509-942-2750 Fax Articles: K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 90
(1) Hadeed A, Siegel S NEWBORN CARDIAC ARRHYTHMIAS ASSOCIATED WITH MATERNAL CAFFEINE USE DURING PREGNANCY. Clin Pediatr (Phila) 1993 Jan;32(1):45-7 KADLEC Medical Center, Richland, Washington 99352.
2) Providence of Seattle Medical Center - Seattle, WA, US Contact: Bloodless Coordinator: Bernice Goldstien Address: 500 17th Avenue Seattle, WA 98122 US Phone: (206) 320-2358 (888) 662-4166 (206) 320-2245, fax Email: [email protected] Articles: (1) Sasajima T, Bhattacharya V, Wu MH, Shi Q, Hayashida N, Sauvage LR MORPHOLOGY AND HISTOLOGY OF HUMAN AND CANINE INTERNAL THORACIC ARTERIES. Ann Thorac Surg 1999 Jul;68(1):143-8 The Hope Heart Institute, Providence Seattle Medical Center, and Department of Surgery, University of Washington School of Medicine, 98122, USA. BACKGROUND: We evaluated human and canine internal thoracic arteries (ITAs) to determine whether the latter is valid for studies relevant to clinical use. METHODS: We studied 19 human ITAs obtained from 1 female and 14 male victims of recent fatal accidents who had no evidence of cardiovascular disease (mean age = 39+/-19 years; range = 15 to 79 years), and ITAs of 21 randomly- selected mongrel dogs of both sexes, weighing 18-40 kg (average = 24.3+/-5.7 kg). Specimens were fixed in formalin at a controlled pressure of 120 mm Hg, before extensive assessment that included intimal thickening, condition of the internal elastic lamina, and number of medial elastic lamellae and vasa vasorum. RESULTS: The canine morphology and histology were similar to the human ITAs, but there was no intimal hyperplasia, and the media and adventitia were thinner (ITAs of humans older than 40 years had significant increases in medial thickness, as well as in overall length). Morphologically and histologically, the left and right canine ITAs were almost completely the same. CONCLUSIONS: Canine ITAs are valid for bilateral comparative studies and are a useful tissue source and model for clinically-relevant experimental studies. (2) Jett GK PHYSIOLOGY OF NONPULSATILE CIRCULATION: ACUTE VERSUS CHRONIC SUPPORT. ASAIO J 1999 May-Jun;45(3):119-22 Department of Cardiovascular Surgery, Providence Seattle Medical Center, Washington, USA. Mammals seem to be able to adapt to nonpulsatile circulation. For chronic support, pressure and flow, not the presence of a pulse, are the major requirements to sustain normal organ function. Pulsatile flow, however, seems to offer advantages over nonpulsatile flow for acute support in maintaining lymphatic flow, decreasing systemic vascular resistance, improving peripheral and pulmonary capillary perfusion, and reversing shock. These advantages may not be seen with chronic support with adaptation to nonpulsatile flow. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 91
(3) Shi Q, Wu MH, Sauvage LR CLINICAL AND EXPERIMENTAL DEMONSTRATION OF COMPLETE HEALING OF POROUS DACRON PATCH GRAFTS USED FOR CLOSURE OF THE ARTERIOTOMY AFTER CAROTID ENDARTERECTOMY. Ann Vasc Surg 1999 May;13(3):313-7 Hope Heart Institute, Providence Seattle Medical Center, WA 98122, USA. A clinical porous Dacron patch graft used for closure after carotid endarterectomy was explanted 24 hr postmortem during autopsy. There had been no TIAs or stroke postoperatively, and the cause of death was congestive heart failure. The graft had been implanted for 25 months. The specimen had a very clean surface, was completely incorporated by full-wall tissue ingrowth, and the flow surface was covered with well-organized neointima containing endothelial cells and smooth muscle cells, as confirmed by immunological studies. For comparison, animal experiments were performed. In both the clinical and experimental specimens the carotid patches were patent without neointimal compromise of the lumen, and their healing patterns were similar, with endothelium on the flow surface. (4) Bhattacharya V, Ghali R, El-Massry S, Saad E, Zammit M, Rodriguez D, Spencer MP, Sauvage LR A CLINICAL COMPARISON OF DACRON PATCH CLOSURE OF SMALL-CALIBER CAROTIDS COMPARED WITH PRIMARY CLOSURE OF LARGE-CALIBER CAROTIDS AFTER ENDARTERECTOMY. Am Surg 1999 Apr;65(4):378-82 The Hope Heart Institute, The Providence Seattle Medical Center, and University of Washington School of Medicine, 98122, USA. The objective was to study results of carotid endarterectomies performed between 1975 and 1991, comparing primary closure to Dacron patch closure. This was a retrospective study. Data from patient follow-up by physical examination, chart review, and Duplex study were used. Scan data were obtained in 92 of the primary cases, at a mean of 5 years postoperatively, and in 63 of the patch cases, at a mean of 4.1 years postoperatively. During this period, 269 endarterectomies were closed primarily and 101 were closed with a knitted Dacron patch. Twenty patients in the primary group and nine patients with patch closure were lost to follow-up, which extended for up to 12.5 years, with a mean of 4.7 +/- 3.6 years. No acute closures, infections or aneurysms developed in either group. Perioperative stroke incidence was 4.1 per cent for primary closure and 3.0 per cent for the patch group (P > 0.05). Late stenosis occurred in 17.3 per cent of the primary group and 11.1 per cent of the patch closure group (P > 0.05). Five-year survival was 76.2 per cent in the primary group, compared with 79.2 per cent for patch closure. Late stroke incidence was 2.8 per cent in the primary group and 3.3 per cent in the patch closure group. Results of smaller (< or = 3.5 mm) carotid arteries closed with knitted Dacron patches are equivalent to those of larger carotid arteries closed primarily. (5) Scranton PE Jr THE COST EFFECTIVENESS OF STREAMLINED CARE PATHWAYS AND PRODUCT STANDARDIZATION IN TOTAL KNEE ARTHROPLASTY. J Arthroplasty 1999 Feb;14(2):182-6 Department of Orthopedics, Providence Medical Center, Seattle, Washington, USA. The orthopaedic department at Providence Medical Center, Seattle, Washington, instituted a streamlined care pathway and product standardization for total knee arthroplasty (TKA) in July 1995. The goal was to reduce operating room time and to streamline the care pathway for a safe, expedited hospitalization of patients. The hospital staffs standardized nursing orders, cut the instrument systems from 13 to 4 sets, and coordinated the expedited care pathway. Fifty-two consecutive primary TKAs were compared prepathway to 77 consecutive primary TKAs postpathway. The average length of stay declined 1.9 days from 5.1 to 3.2. The tourniquet time declined from 61 minutes to 56 minutes. The average dollar charges were $1,063 less. There were no infections in either group. The manipulation rate for adhesions declined 37%. K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 92
(6) Jett GK LEFT VENTRICULAR APICAL CANNULATION FOR CIRCULATORY SUPPORT. J Card Surg 1998 Jan;13(1):51-5 Department of Cardiovascular Surgery, Providence Seattle Medical Center, Washington 98122, USA. Circulatory support is occasionally needed for postcardiotomy low output. The left atrium may not be accessible for inflow cannulation. This article describes cannulation of the left ventricular apex for circulatory support. (7) Shi Q, Rafii S, Wu MH, Wijelath ES, Yu C, Ishida A, Fujita Y, Kothari S, Mohle R, Sauvage LR, Moore MA, Storb RF, Hammond WP EVIDENCE FOR CIRCULATING BONE MARROW-DERIVED ENDOTHELIAL CELLS. Blood 1998 Jul 15;92(2):362-7 Department of Surgery, The Hope Heart Institute and Providence Medical Center, Seattle, WA 98122, USA. It has been proposed that hematopoietic and endothelial cells are derived from a common cell, the hemangioblast. In this study, we demonstrate that a subset of CD34(+) cells have the capacity to differentiate into endothelial cells in vitro in the presence of basic fibroblast growth factor, insulin- like growth factor-1, and vascular endothelial growth factor. These differentiated endothelial cells are CD34(+), stain for von Willebrand factor (vWF), and incorporate acetylated low-density lipoprotein (LDL). This suggests the possible existence of a bone marrow-derived precursor endothelial cell. To demonstrate this phenomenon in vivo, we used a canine bone marrow transplantation model, in which the marrow cells from the donor and recipient are genetically distinct. Between 6 to 8 months after transplantation, a Dacron graft, made impervious to prevent capillary ingrowth from the surrounding perigraft tissue, was implanted in the descending thoracic aorta. After 12 weeks, the graft was retrieved, and cells with endothelial morphology were identified by silver nitrate staining. Using the di(CA)n and tetranucleotide (GAAA)n repeat polymorphisms to distinguish between the donor and recipient DNA, we observed that only donor alleles were detected in DNA from positively stained cells on the impervious Dacron graft. These results strongly suggest that a subset of CD34+ cells localized in the bone marrow can be mobilized to the peripheral circulation and can colonize endothelial flow surfaces of vascular prostheses. (8) Overand PT, Teply JF VASOPRESSIN FOR THE TREATMENT OF REFRACTORY HYPOTENSION AFTER CARDIOPULMONARY BYPASS. Anesth Analg 1998 Jun;86(6):1207-9 Department of Cardiac Anesthesiology, Providence Medical Center, Seattle, Washington, USA. Comment in: Anesth Analg 1999 Mar;88(3):695 (9) Ghali R, Palazzo EG, Rodriguez DI, Zammit M, Loudenback DL, DeMuth RP, Spencer MP, Sauvage LR TRANSCRANIAL DOPPLER INTRAOPERATIVE MONITORING DURING CAROTID ENDARTERECTOMY: EXPERIENCE WITH REGIONAL OR GENERAL ANESTHESIA, WITH AND WITHOUT SHUNTING. Ann Vasc Surg 1997 Jan;11(1):9-13 Hope Heart Institute, Providence Medical Center, Seattle, WA 98122, USA. To determine whether continuous transcranial Doppler (TCD) can significantly alter therapeutic conduct during carotid endarterectomy, a retrospective study of 117 carotid endarterectomies was done. There was no perioperative mortality; one perioperative stroke was recorded in a patient who was symptomatic preoperatively. Continuous TCD of the ipsilateral middle cerebral artery (MCA) was attempted in 99 cases, and successful in 90; nine patients (9.1%) had inadequate temporal K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 93
windows for MCA access. MCA velocities and emboli were recorded before and during carotid cross- clamping, and on clamp release. There were no significant velocity differences between the patients with regional and general anesthesia, and patients with and without carotid shunts, but there was a statistically significant difference in the total number of emboli (air and particulate transients) noted for the shunted and nonshunted patients after clamp release: 12.7 versus 23.6, respectively (p = 0.05). There was no significant difference when particulate and air microemboli were compared. During surgery TCD identified residual flow of less than 40% in the MCA in 17 patients (18.8%). TCD also identified hyperperfusion in two patients, shunt abnormalities in three patients, and influenced postop treatment in four patients, one of whom was returned to surgery. TCD is an important tool for identifying patients who would benefit from a shunt, preventing hyperperfusion, identifying postop emboli, and detecting technical errors. (10) Levinson MM, Fooks GS CORONARY GRAFTING USING A TEMPORARY INTRALUMINAL SHUNT INSTEAD OF HEART-LUNG BYPASS. Ann Thorac Surg 1995 Dec;60(6):1800-1 Division of Cardiothoracic Surgery, Providence Hospital and Medical Center, Seattle, Washington, USA. The application of a temporary intraluminal shunt is presented as a technique to prevent ischemia when coronary grafting is performed without cardiopulmonary bypass. This simple maneuver expands the indications for coronary grafting without cardiopulmonary bypass. (11) Johansen K RUPTURED ABDOMINAL AORTIC ANEURYSM: HOW SHOULD RECENT OUTCOME STUDIES IMPACT CURRENT PRACTICES? Semin Vasc Surg 1995 Jun;8(2):163-7 Office of Surgical Education, Providence Medical Center, Seattle, WA 98124, USA. (12) Bailet JW, Sercarz JA, Abemayor E, Anzai Y, Lufkin RB, Hoh CK THE USE OF POSITRON EMISSION TOMOGRAPHY FOR EARLY DETECTION OF RECURRENT HEAD AND NECK SQUAMOUS CELL CARCINOMA IN POSTRADIOTHERAPY PATIENTS. Laryngoscope 1995 Feb;105(2):135-9 Pacific Medical Center at Providence, Seattle, WA 98122, USA. Positron emission tomography (PET) has recently proved to be highly sensitive in detecting known extracranial head and neck squamous cell carcinomas when compared to computed tomography and magnetic resonance imaging (MRI). The ability of PET to detect early subclinical recurrent squamous cell malignancies in patients who received primary radiotherapy was evaluated. A new PET-MRI coregistration technique was used to determine precise anatomic tumor location, enabling directed biopsies to confirm the presence of malignancy, and to plan additional therapeutic strategies. Ten patients underwent PET evaluation with intravenous [18F]-fluorodeoxyglucose and received postradiotherapy MRI scans. In all cases, PET accurately detected the presence of recurrent disease despite negative or equivocal MRI scans and indeterminate clinical examinations. PET appears to be highly effective in detecting early recurrent head and neck squamous cell malignancies in postirradiated patients. (13) Spencer MP, Thomas GI, Nicholls SC, Sauvage LR DETECTION OF MIDDLE CEREBRAL ARTERY EMBOLI DURING CAROTID ENDARTERECTOMY USING TRANSCRANIAL DOPPLER ULTRASONOGRAPHY. Stroke 1990 Mar;21(3):415-23 Providence Medical Center, Seattle, Washington. The purpose of our study was to define the signal characteristics and clinical circumstances associated with emboli detected in the middle cerebral artery using 2-MHz pulsed transcranial K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 94
Doppler ultrasound in patients undergoing carotid endarterectomy. Signals designating emboli were transients displaying harmonic qualities the signatures of which were clearly different from those of mechanical and electronic artifacts. We reviewed the audio/video tape recordings from 91 patients for signals of air bubble emboli occurring upon release of common carotid artery crossclamps; recordings from 35 patients (38%) demonstrated air bubble emboli. Transients with signatures identical to those of air bubble emboli were also discovered when bubbles in the bloodstream were improbable; we defined these transients as representing formed-element emboli. Such signals were found in recordings from 24 patients (26%), and they occurred before (both spontaneously and upon common carotid artery compression), during, and after surgical dissection. Signals indicating formed-element emboli were associated with intraluminal platelet thrombus, with ulcerations in the carotid artery, and with transient ischemic attacks or stroke. Most postoperative formed-element emboli did not cause symptoms but, when persisting for hours, they were associated with strokes and cerebral infarction. This Doppler ultrasound method of detecting emboli will be useful in the study of stroke mechanisms and as a clinical test to guide the medical and surgical treatment of patients at risk of stroke. (14) Harris MR, Huseby JS PULMONARY COMPLICATIONS FROM NASOENTERAL FEEDING TUBE INSERTION IN AN INTENSIVE CARE UNIT: INCIDENCE AND PREVENTION. Crit Care Med 1989 Sep;17(9):917-9 Department of Nursing, Providence Medical Center, Seattle, WA 98124. We prospectively evaluated 71 nasoenteral feeding tube insertions in critically ill patients and found a 4% incidence of pulmonary complications. All pulmonary complications occurred in tracheally intubated patients. To prevent these complications, we developed an enteral feeding tube insertion technique using a 26-Fr red rubber catheter as an introducer for a 8-Fr feeding tube. This technique is easy to perform by hospital staff and well tolerated by patients. No pulmonary complications occurred in 31 subsequent feeding tube insertions.
3) Puget Sound Hospital - Tacoma, WA, US Contact: Bloodless Coordinator: Gary Butler Address: 215 South 36th St. Tacoma, WA 98408 US Phone: 800-309-6354 253-756-9545 Bloodless 253-756-2450 Fax Email: [email protected] P. O. Box 11412 (206) 474-0561 - Hospital Articles: (1) Best CE A PREDICTION MODEL OF PERFORMANCE IN LEVEL II FIELDWORK IN PHYSICAL DISABILITIES. Am J Occup Ther 1994 Oct;48(10):926-31 School of Occupational Therapy and Physical Therapy, University of Puget Sound, Tacoma, Washington. OBJECTIVES. A prediction model of performance in physical disabilities fieldwork was generated with grades received in the occupational therapy curriculum and in prerequisite courses. METHOD. Grades included those from functional anatomy, neuroanatomy, physical disabilities lecture, physical disabilities clinic, and prerequisite anatomy and physiology courses. Sampling was done collectively over graduated occupational therapy classes from 1987 to 1992 at the University of Puget Sound. A multiple regression analysis was performed and prediction equations were generated for each subscale of the Fieldwork Evaluation for the Occupational Therapist. Equations for combinations of the subscale categories were also produced. RESULTS. Adjusted R2 values were found to be less K.R Part 7 of Helping Hands of Blood Conservation Techniques, May 2001 Page 95
than 10% in all equations. CONCLUSION. This poor ability of grades to predict fieldwork performance suggests that future investigation be focused on variables other than grades. Such variables might include student motivation, rapport between the student and fieldwork supervisor, and hospital experience in physical disabilities. (2) Lindsey SE SYSTEMS COLLABORATE FOR A HEALTHIER COMMUNITY. A COMMUNITY HEALTH ADVISORY BOARD FOCUSES ON IMMUNIZATION. Health Prog 1994 Jan-Feb;75(1):64-7 Franciscan Health System, Tacoma, WA. The Community Health Advisory Board (CHAB), Pierce County, WA, involves four healthcare systems--Franciscan Health System, MultiCare Medical Center, Group Health Cooperative of Puget Sound, and Good Samaritan Hospital--that have joined forces with other providers in an innovative attempt to better serve their community. An evaluation by representatives of New York University's Hospital Community Benefit Standard Program prompted St. Joseph Medical Center, Tacoma, WA, to bring major providers together in a coordinated effort that could reach community residents in need. At their first meeting in November 1992, CHAB members agreed on a purpose: to facilitate collaboration between healthcare providers throughout the county to develop programs and services that improve the health status of community residents. In January 1993 CHAB members selected a "quick success" project: a program aimed at increasing immunization levels to 90 percent for two- year-old children in the county. In February 1993 CHAB members committed the "best and brightest" to the Immunization Task Force, naming experts in planning, nursing, community health, education, and marketing. When the Immunization Task Force assessed the project, they realized that the "quick success" program would not be accomplished so quickly. CHAB has had to address underlying problems to make higher immunization levels sustainable. In March 1994 members will evaluate the immunization program's process, status, and structure; data on immunization levels; and the group's demonstrated ability to cooperate.
4) Tri-City Regional Surgery Center - Richland, WA, US Contact: Bloodless Coordinator: Johnean Hansen C.R.C.P. Address: 1096 Goethals Avenue Richland, WA 99352 US Phone: (509) 942-2817 Related Links: Kadlec Medical Center