常规外科手术程序和实施围手术期外科家庭方案对患者再入院医院的选择
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Readmissions to Different Hospitals After Common Surgical Procedures and Consequences for Implementation of Perioperative Surgical Home Programs
背景与目的
我们考虑是否应该针对急性外科手术资源建立更多的优先信息共享：（1）在出院时（如果适用）转移患者的专业护理设施或住院康复医院，（2）当再住院事件发生在不同的医院。而从这两个来源获取和存储数据用于围手术期手术家庭活动是不同的; 根据国家和卫生系统，两者都可能面临挑战。
方 法
通过使用2013年美国全国住院数据库，我们研究了美国国家平均住院时间（LOS）≥3天的手术诊断相关组（DRG）和每个医院因医疗保险严重性DRG的出院病例≥100次且≥10个医院。
结 果
在全国范围内，16.15％（95％置信区间[CI]，15.14％-17.22％）的出院患者是处于“不在家”（即转移到专业熟练的护理设施或住院康复医院）。在30天内，出院患者的0.88％（0.82％-0.95％），再入院所选择的医院与原来做手术的医院不同，在所有的出院患者中，让其“不在家”与“在家”相比，患者在30天内再入院且选择的医院与之前手术的医院不是同一个医院有更大的可能性（2.11,95％CI，1.96-2.27 ; P<.0001）。在某种程度上，这是因为让其“不在家”与再入院有更大的可能性（1.90,95％CI，1.82-1.98;P<.0001）。此外，在30天之内再入院的一部分出院患者中让其“不在家”与“在家”的情况相比，再入院选择的医院与进行手术的医院为同一医院的可能性更大（1.20,95％CI，1.111.31;P<.0001）。医院的DRG平均住院时间（LOS）与重新入院到不同医院的可能性没有关联（P=.82）。医院平均住院时间（LOS）每天降低的优势比为1.01（95％CI，0.91-1.12）
结 论
希望展示围手术期手术家庭措施的价值或计算风险承担合同的部门和医院应确保其信息优先权包括获得有关临床护理设施（如专业护理设施）资源使用的准确数据。虽然大约四分之一的再入院患者所选择的医院是不同于手术进行的医院，但只要得到认可，获得这些丢失的数据就不那么重要了。
原始文献摘要
Panigrahi A K, Yeaton-Massey A, Bakhtary S, et al. A Standardized Approach for Transfusion Medicine Support in Patients With Morbidly Adherent Placenta[J]. Anesthesia & Analgesia, 2017
PURPOSE:The incidence of placenta accreta (PA) has increased from 0.8 to 3.0 in 1000 pregnancies, driven by increased rates of cesarean deliveries (32.2% in 2014) of births in the United States. The average blood loss for a delivery complicated by PA ranges from 2000 to 5000 mL, frequently requiring substantial transfusion medicine support. We report our own institutional multidisciplinary approach for managing such patients, along with transfusion medicine outcomes, in this setting over a 5-year period.
METHODS: We reviewed records for patients referred to our program in placental disorders from July 1, 2009, to July 1, 2014. A placental disorders preoperative checklist was implemented to ensure optimal management of patients with peripartum hemorrhage.
RESULTS:Of 136 patients whose placentas were reviewed postpartum, 21 had PA, 39 had microscopic PA, 17 had increta, 17 had percreta, and 42 had no accreta (of which 11 had placenta previa). For each subtype, the percentage of patients receiving blood products were 71% (PA), 28% (microscopic PA), 82% (increta), 82% (percreta), and 19% (no accreta). Among patients with PA or variants, 89% of patients with PA or variants underwent postpartum hysterectomy, compared to only 5% of patients with no or microscopic PA.
CONCLUSION:
Based on our experience and on the fndings of our retrospective analysis, patients presenting with either antepartum radiological evidence or clinical suspicion of morbidly adherent placenta will beneft from a standardized protocol for clinical management, including transfusion medicine support. We found that massive hemorrhage is predictable when abnormal placentation is identifed predelivery and that blood product support is substantial regardless of the degree of placental invasiveness. The protocol at our institution provides immediate access to suffcient volumes and types of blood products at delivery for patients at highest risk for life-threatening obstetric hemorrhage. Therefore, for patients with a diagnosis of morbidly adherent placenta scheduled for planned cesarean delivery with possible hysterectomy, a programmatic checklist that mobilizes a multidisciplinary team, including proactive transfusion medicine support, represents best practices.
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