Journal of the American College of Surgeons
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Lean is a management system designed to enhance productivity by eliminating waste. Surgical practice offers many opportunities for improving efficiency. Our objective was to determine whether systematic implementation of lean thinking in an academic otolaryngology operating room improves efficiency and profitability and preserves team morale and educational opportunities. ⋯ Application of lean management techniques to a single operating room and surgical service improved operating room efficiency and morale, sustained resident education, and can provide considerable financial gains when scaled to an entire academic surgical suite.
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Comparative Study
Open repair of blunt thoracic aortic injury remains relevant in the endovascular era.
Thoracic endovascular aneurysm repair (TEVAR) has been a major advance in the treatment of blunt thoracic aortic injury (BTAI), although many patients still undergo open repair. This study was undertaken to evaluate outcomes with open repair and TEVAR for BTAI. ⋯ TEVAR and open repair should be viewed as complementary rather than competing modalities for the treatment of BTAI. Having both available allows selection of the most appropriate management technique for each patient, with subsequent improvement in outcomes.
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Multicenter Study Controlled Clinical Trial
Early platelet dysfunction: an unrecognized role in the acute coagulopathy of trauma.
Our aim was to determine the prevalence of platelet dysfunction using an end point of assembly into a stable thrombus after severe injury. Although the current debate on acute traumatic coagulopathy has focused on the consumption or inhibition of coagulation factors, the question of early platelet dysfunction in this setting remains unclear. ⋯ In this study, we show that platelet dysfunction is manifest after major trauma and before substantial fluid or blood administration. These data suggest a potential role for early platelet transfusion in severely injured patients at risk for postinjury coagulopathy.
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Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted. ⋯ There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.
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The measurement of hospital quality based on outcomes requires risk adjustment. The c-statistic is a popular tool used to judge model performance, but can be limited, particularly when evaluating specific operations in focused populations. Our objectives were to examine the interpretation and relevance of the c-statistic when used in models with increasingly similar case mix and to consider an alternative perspective on model calibration based on a graphical depiction of model fit. ⋯ In the present study, we demonstrate how the c-statistic can become less informative and, in certain circumstances, can lead to incorrect model-based conclusions, as case mix is restricted and patients become more homogenous. Although it remains an important tool, caution is advised when the c-statistic is advanced as the sole measure of a model performance.