Estancias medias alargadas y grupos relacionados con el diagnóstico como indicadores de eficiencia en la gestión clínica

[Extensive normalization of the surgical discharge report. An efficient quality alternative]

OBJECTIVE

To improve the quality of the clinical information documents received by surgical patients when discharged from the Hospital.

MATERIAL AND METHODS

A preliminary analysis of the quality of the surgical discharge form (SDF) included information regarding the time of issue (provisional vs. definitive), legibility/standardization (typewritten, hand-written with or without a standardised format), technical quality (complete vs. incomplete) and retrievability (electronically storage or not). This analysis showed that 39% of the forms were either provisional, incomplete or were standardised formats (59%) or hand-written as a simple medical note (41%). We have redesigned the methodology for filling in the SDF and their storage using the resources available in our Hospital. We designated a common surgical secretary to fill in all the SDF and designed 81 standard formats in Word for all the surgical procedures. A consensus protocol was also developed with the different surgical departments for the completion, distribution and monitoring of the SDF. Finally we established a Windows-based computerised system for centralized storage/retrieval of the discharge forms that could be easily accessed by internet.

RESULTS

All the SDF are standardised and electronically stored. The patient receives a typewritten form at the time of discharge. The dates for the first surgical or outpatient review are included in 98% of the SDF from hospitalised patients and in 100% of the SDF from major ambulatory surgery patients. We did not reach the expected outcome for minor surgical procedures.

CONCLUSIONS

The extensive standardisation of the SDF, together with the new methods for completing them, has shown to be an efficient measure to maximise the quality of the clinical information given to the patient and to minimise the waiting time from the physician confirming discharge to the patient eventually leaving the hospital.

[Spontaneous pneumomediastinum: descriptive study of our experience with 36 cases]

Spontaneous pneumomediastinum is defined as a primary process characterized by the presence of air or gas in the mediastinum. We report all the cases of spontaneous pneumomediastinum diagnosed in our hospital between January 1996 and December 2004. We developed a protocol for data collection that included the following: medical history, triggers, signs, radiology, treatment, hospital stay, and complications. During this period we diagnosed 36 cases--25 men (69.4%) and 11 women (27.5%)--with a mean age of 36.8 years (range, 11-90 years) and a mean hospital stay of 8.56 days (range, 1-53 days). The most common clinical presentation was chest pain, either isolated (27%) or with associated dyspnea (19.4%). A triggering factor was identified for 14 patients (38.8%). There was no associated morbidity or mortality. In view of our findings, we concluded that spontaneous pneumomediastinum is an uncommon entity with considerable clinical variability and that correct diagnosis requires a high level of suspicion. Radiography provides the best evidence for diagnosis.

Neumomediastino espontáneo: estudio descriptivo de nuestra experiencia basada en 36 casos

El neumomediastino espontáneo se define como la presencia de aire o gas en el mediastino de forma primaria. Presentamos todos los casos de neumomediastino espontáneo hallados en nuestro hospital entre enero de 1996 y diciembre de 2004. Para ello, elaboramos un protocolo de recogida de datos que incluyó: antecedentes personales, desencadenantes, semiología, radiología, tratamiento, estancia y complicaciones. En este período diagnosticamos 36 casos —25 varones (69,4%) y 11 mujeres (27,5%)—, con una edad media de 36,8 años (rango: 11-90) y estancia media de 8,56 días (rango: 1-53). El cuadro clínico más habitual fue el dolor torácico, aislado (27%) o asociado a disnea (19,4%). En 14 pacientes (38,8%) hubo factor desencadenante. No hubo morbimortalidad asociada al proceso. Por todo ello, se concluye que el neumomediastino espontáneo es una entidad infrecuente, con gran variabilidad clínica, cuyo diagnóstico correcto exige un alto índice de sospecha, y la radiografía de tórax es la prueba idónea para ello.