The American journal of medicine
-
To perform a valid comparison of rates among surgeons, among hospitals, or across time, surgical wound infection (SWI) rates must account for the variation in patients' underlying severity of illness and other important risk factors. From January 1987 through December 1990, 44 National Nosocomial Infections Surveillance System hospitals reported data collected under the detailed option of the surgical patient surveillance component protocol, which includes definitions of eligible patients, operations, and nosocomial infections. Pooled mean SWI rates (number of infections per 100 operations) within each of the categories of the traditional wound classification system were 2.1, 3.3, 6.4, and 7.1, respectively. ⋯ The risk index score, ranging from 0 to 3, is the number of risk factors present among the following: (1) a patient with an American Society of Anesthesiologists preoperative assessment score of 3, 4, or 5, (2) an operation classified as contaminated or dirty-infected, and (3) an operation lasting over T hours, where T depends upon the operative procedure being performed. The SWI rates for patients with scores of 0, 1, 2, and 3 were 1.5, 2.9, 6.8, and 13.0, respectively. The risk index is a significantly better predictor of SWI risk than the traditional wound classification system and performs well across a broad range of operative procedures.
-
From July 1983 through June 1990, 319 patients with methicillin-resistant Staphylococcus aureus (MRSA) were identified at the University of California, Davis Medical Center. Initially, our goal was eradication of MRSA from the hospital flora. Our approach was: (a) immediate notification of all MRSA isolates by the microbiology laboratory; (b) strict isolation; (c) cohorting; (d) bathing patients with an iodophor; (e) surveillance cultures of patients and staff; (f) treatment of all colonized persons; and (g) strict isolation on readmission. ⋯ Since 1987, we have averaged only three new cases per month with one major MRSA outbreak. Annual cost savings of greater than $50,000 have been realized through the policy modifications. We conclude that the use of contact isolation with some modifications has saved time and money and has successfully controlled the spread of MRSA in our university hospital.
-
Aortoesophageal fistula (AEF) is a relatively rare but life-threatening cause of upper gastro-intestinal bleeding. The clinical characteristics of AEF are so unique that a presumptive bedside diagnosis can be made at the time of presentation. ⋯ We summarize our findings with respect to the etiology and clinical characteristics of AEF. Further, we discuss the diagnostic modalities that may be used to confirm the diagnosis, and the therapeutic modalities available to slow the hemorrhage, so as to allow time to correct the anatomic defect.
-
The do-not-resuscitate order: a comparison of physician and patient preferences and decision-making.
The purpose of this study was to compare the decision-making and preferences regarding do-not-resuscitate (DNR) orders of a group of family physicians with a group of out-patients from a family practice center. Complete results of the outpatient questionnaire were published in a previous study by the authors. ⋯ There are significant similarities and differences in the way physicians and patients make DNR decisions. It is important that physicians and their patients communicate in a timely manner about prognosis, values, and quality-of-life issues in order to make effective DNR decisions.
-
To further elucidate the clinical spectrum of alcoholic ketoacidosis (AKA). ⋯ AKA is a common disorder in chronic malnourished alcoholic persons. The acid-base abnormalities reflect not only the ketoacidosis, but also associated extracellular fluid volume depletion, alcohol withdrawal, pain, sepsis, or severe liver disease. Although the pathophysiology is complex, the syndrome is rapidly reversible and has a low mortality.