Reduction of the Incidence of Amputation in Frostbite Injury With Thrombolytic Therapy
Hypothesis: Thrombolytic therapy will decrease the incidence of amputation when administered within 24 hours of exposure.
Design: Single institution retrospective review of clinical outcomes and resource use.
Setting: Burn unit of a tertiary academic referral center.
Patients: From 2001 to 2006, patients with severe frostbite admitted within 48 hours of injury underwent digital angiography and treatment with intra-arterial tissue plasminogen activator (tPA) if abnormal perfusion was demonstrated. These patients were compared with those treated from 1995 to 2006 who did not receive tPA.
Interventions: Tissue plasminogen activator vs traditional management of frostbite injury.
Main Outcome Measures: Number and type of surgery were recorded, along with amputations of digits (fingers or toes) and more proximal (ray, transmetatarsal, or below-knee) amputations. Resource utilization including length of stay, total costs, cost per involved digit, and cost per saved digit were analyzed.
Results: Thirty-two patients with digital involvement (hands, 19%; feet, 62%; both, 19%) were identified. Seven patients received tPA, 6 within 24 hours of injury. The incidence of digital amputation in patients who did not receive tPA was 41%. In those patients who received tPA within 24 hours of injury, the incidence of amputation was reduced to 10% (P < .05).
Conclusions: Tissue plasminogen activator improved tissue perfusion and reduced amputations when administered within 24 hours of injury. This modality represents the first clinically significant advancement in the treatment of frostbite in more than 25 years.
Bruen KJ, Ballard KJ, Morris SE, Cochran A, Edelman LS, Saffle JR
Practice-Based Learning and Improvement: A Curriculum in Continuous Quality Improvement for Surgery Residents
Hypothesis: Surgery residents can learn continuous quality improvement (CQI) principles within a structured curriculum and propose quality improvement projects.
Design: Curriculum within a surgical residency program.
Setting: A university surgical residency program with multiple hospital training sites.
Participants: Fifteen surgical residents during the dedicated research year.
Intervention: A curriculum in CQI that focuses on devising a quality improvement project.
Main Outcome Measures: Resident self-reported attitudes about quality improvement and implementation of resident-initiated quality improvement projects.
Results: Resident survey data demonstrated an improvement in knowledge, self-efficacy, and experiences within CQI. Fifteen individual residents, within smaller teams, created 4 quality improvement projects worthy of implementation.
Conclusions: A structured CQI curriculum can be successfully integrated into a general surgery residency program. Residents can learn the skill of constructing CQI project ideas within the framework of the plan-do-study-act cycle. Residents are eager to make improvements in their local system of residency. By giving them the tools to critically investigate systems improvement and a much needed ear to hear their concerns and suggestions for improvement, we found ways to potentially enhance patient care and developed ideas to improve the education of future surgeons. In doing so, we provided the residents with “buy-in” into their residency program, while addressing the competency of practice-based learning and improvement required by the Accreditation Council for Graduate Medical Education for resident education.
Canal DF, Torbeck L, Djuricich AM
Behavior and Analysis of 36-Item Short-Form Health Survey Data for Surgical Quality-of-Life Research
Hypothesis: Data from the 36-Item Short-Form Health Survey (SF-36) do not follow a normal distribution and should not be analyzed using parametric techniques. A novel type of analysis, top-box analysis, may add to the interpretation of these data.
Design: Review of SF-36 data from preoperative and postoperative patients.
Setting: Tertiary care hospital and clinic.
Patients: One thousand randomly selected preoperative and postoperative patients with a variety of surgical diseases completed the SF-36 (8 domains: physical functioning, role physical, role emotional, bodily pain, vitality, mental health, social functioning, and general health). The best possible score was 100; the worst possible score, 0. One item assessed “health transition.” The best score was 1; the worst score, 5. The health transition item and each domain were analyzed for mean with standard deviation, median, mode skewness, kurtosis, and normality. A “top-box” assessment was done by determining the frequency of patients scoring 100 in each domain or 1 in the health transition item. In addition, preoperative and postoperative scores were compared.
Results: The results for all 1000 questionnaires demonstrated that none of the domains had data that followed a normal distribution. The means, medians, and modes were different. Five domains had the mode and median at the top box.
Conclusions: The SF-36 data did not follow a normal distribution in any of the domains. Data were always skewed to the left, with means, medians, and modes different. These data need to be statistically analyzed using nonparametric techniques. Of the 8 domains, 5 had a significant frequency of top-box scores, which also were the domains in which the mode was at 100, implying that change in top-box score may be an informative method of presenting change in SF-36 data.
An Evidence-Based Perspective on Greetings in Medical Encounters
Background: Widely used models for teaching and assessing communication skills highlight the importance of greeting patients appropriately, but there is little evidence regarding what constitutes an appropriate greeting.
Methods: To obtain data on patient expectations for greetings, we asked closed-ended questions about preferences for shaking hands, use of patient names, and use of physician names in a computer-assisted telephone survey of adults in the 48 contiguous United States. We also analyzed an existing sample of 123 videotaped new patient visits to characterize patterns of greeting behavior in everyday clinical practice.
Results: Most (78.1%) of the 415 survey respondents reported that they want the physician to shake their hand, 50.4% want their first name to be used when physicians greet them, and 56.4% want physicians to introduce themselves using their first and last names; these expectations vary somewhat with patient sex, age, and race. Videotapes revealed that physicians and patients shook hands in 82.9% of visits. In 50.4% of the initial encounters, physicians did not mention the patient's name at all. Physicians tended to use their first and last names when introducing themselves.
Conclusions: Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names.
Makoul G, Zick A, Green M
Abstracts: In Other Archives Journals. Arch Facial Plast Surg. 2007;9(5):370-371. doi: