Do ward changes affect outcomes differently in people living with dementia?

PSY112 - Healthcare Resource Use (HRU) Associated with Severe Adverse Events (AES) Of Interest in Adults With Relapsed or Refractory (R/R) B-Precursor Acute Lymphoblastic Leukemia (All) In Eu-4 Countries

ObjectivesIntracranial pressure (ICP) monitoring is recommended for severe traumatic brain injuries (TBI) but some data suggests it may not improve outcomes. The objective was to investigate the effect of ICP monitoring among TBI.MethodsThis retrospective observational cohort study (1/1/2015–6/1/2020) included severe TBI patients. Outcomes [discharge destination, length of stay (LOS)] were compared by ICP monitoring and were stratified by GCS (3 vs. 4–8), α < 0.05.ResultsOf the123 patients who met inclusion criteria, 47% received ICP monitoring. There were baseline differences in the two groups characteristics, ICP monitored patients were younger (p = 0.02), had a subarachnoid hemorrhage less often (p = 0.04), and a subdural hematoma more often (p = 0.04) than those without ICP monitors. ICP monitored patients had a significantly longer median LOS (12 vs. 3, p < 0.01) than patients without monitoring. There was a trend towards more ICP monitored patients discharged home (40% vs. 23%, p = 0.06). Among patients with GCS = 3, ICP monitored patients had a longer LOS (p < 0.01) with no significant differences in discharge destinations. For those with a GCS of 4–8, ICP monitoring was associated with a longer LOS (p = 0.01), but fewer were discharged to a skilled nursing facility or long-term care (p = 0.01).ConclusionsFor TBI patients, ICP monitoring was associated with an increased LOS, with no significant differences in discharge destinations when compared to those without ICP monitoring. However, among only those with a GCS of 4–8, ICP monitoring was associated with a decreased proportion of patients discharged to a skilled nursing facility or long-term acute care .

BackgroundOutcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF.MethodsRetrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination.ResultsData were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination.ConclusionsMany factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

Older Adults with Epilepsy and COVID-19: Outcomes in a Multi-Hospital Health System

To test whether frailty, a novel measure of physiologic reserve, is associated with longer kidney transplant (KT) length of stay (LOS), and modifies the association between LOS and mortality. Better understanding of LOS is necessary for informed consent and discharge planning. Mortality resulting from longer LOS has important regulatory implications for hospital and transplant programs. Which recipients are at risk of prolonged LOS and its effect on mortality are unclear. Frailty is a novel preoperative predictor of poor KT outcomes including delayed graft function, early hospital readmission, immunosuppression intolerance, and mortality. We used registry-augmented hybrid methods, a novel approach to risk adjustment, to adjust for LOS risk factors from the Scientific Registry of Transplant Recipients (n = 74,859) and tested whether (1) frailty, measured immediately before KT in a novel cohort (n = 589), was associated with LOS (LOS: negative binomial regression; LOS ≥2 weeks: logistic regression) and (2) whether frailty modified the association between LOS and mortality (interaction term analysis). Frailty was independently associated with longer LOS [relative risk = 1.15, 95% confidence interval (CI): 1.03-1.29; P = 0.01] and LOS ≥2 weeks (odds ratio = 1.57, 95% CI: 1.06-2.33; P = 0.03) after accounting for registry-based risk factors, including delayed graft function. Frailty also attenuated the association between LOS and mortality (nonfrail hazard rate = 1.55 95% CI: 1.30-1.86; P < 0.001; frail hazard rate = 0.97, 95% CI: 0.79-1.19, P = 0.80; P for interaction = 0.001). Frail KT recipients are more likely to experience a longer LOS. Longer LOS among nonfrail recipients may be a marker of increased mortality risk. Frailty is a measure of physiologic reserve that may be an important clinical marker of longer surgical LOS.

BackgroundAcute kidney injury (AKI) is defined as oliguria or rise in serum creatinine but oliguria alone as a diagnostic criterion may over-diagnose AKI.ObjectivesGiven the association between fluid overload and AKI, we aimed to determine if positive fluid balance can complement the known parameters in assessing outcomes of AKI.DesignProspective observational study.SettingTeaching hospital in Vancouver, Canada.Patients111 consecutive patients undergoing elective cardiac surgery from January to April 2012.MeasurementsOutcomes of cardiac surgery intensive care unit (CSICU) and hospital length of stay (LOS) in relation to fluid balance, urine output and serum creatinine.MethodsAll fluid input and output was recorded for 72 hours post-operatively. Positive fluid balance was defined as >6.5 cc/kg. Daily serum creatinine and hourly urine output were recorded and patients were defined as having AKI according to the AKIN criteria.ResultsOf the patients who were oliguric, those with fluid overload trended towards longer LOS than those without fluid overload [CSICU LOS: 62 and 39 hours (unadjusted p-value 0.02, adjusted p-value 0.58); hospital LOS: 13 and 9 days (unadjusted p-value: 0.05, adjusted p-value: 0.16)]. Patients with oliguria who were fluid overloaded had similar LOS to patients with overt AKI (change in serum creatinine ≥ 26.5 µmol/L), [CSICU LOS: 62 and 69 hours (adjusted p value: 0.32) and hospital LOS: 13 and 14 days (adjusted p value: 0.19)]. Patients with oliguria regardless of fluid balance had longer CSICU LOS (adjusted p value: 0.001) and patients who were fluid overloaded in the absence of AKI had longer hospital LOS (adjusted p value: 0.02).LimitationsSingle centre, small sample, LOS as outcome.ConclusionsOliguria and positive fluid balance is associated with a trend towards longer LOS as compared to oliguria alone. Fluid balance may therefore be a useful marker of AKI, in addition to urine output and serum creatinine.

Background: Discharge planning is a major component of stroke care. Early prediction of hospital disposition may increase efficient delivery of health care by initiating appropriate discharge planning and shortening length of stay (LOS). Purpose: To identify admission factors that are associated with longer LOS and discharge to non-home setting. Methods: In this retrospective analysis of Get With The Guidelines-Stroke data from five stroke centers of the Mount Sinai Health System in New York City from 1/1/2010 to 12/31/2015, chi-square and logistic regression analyses were used to test for admission factors associated with discharge to non-home setting. Linear regression was used to test for factors associated with LOS. Admission NIH Stroke Scale Score (NIHSS) was analyzed as a continuous variable; other covariates included demographics, medical risk factors, and weekend admission. Results: Among 7829 patients, mean age was 70.6 years (SD 14.8); 47.5% were male; 36.8% were non-Hispanic white, 28.1% non-Hispanic black, 10.9% Hispanic; 75.9% had hypertension, 35.6% diabetes, 37.4% dyslipidemia, 22.5% coronary artery disease, 16.6% atrial fibrillation, and 24.8% prior stroke. Factors independently associated with reduced odds of discharge home were higher admission NIHSS, per point increase (OR 0.83; 95% CI 0.82-0.85), age (OR 0.97 per year; 0.97-0.98), non-Hispanic black race (OR 0.74; 0.64-0.86), and diabetes (OR 0.75; 0.66-0.85). Factors associated with longer LOS were higher admission NIHSS (0.32 day longer LOS per point increase, 95% CI 0.29-0.35; p&lt;0.0001), non-Hispanic black (1.43, 0.93-1.93; p&lt;0.0001), Hispanic (1.06, 0.39-1.73; p&lt;0.0001), and atrial fibrillation (0.55, .004-1.09; p=0.048) but not age (p=0.26) or diabetes (p=0.15). Conclusions: Several admission factors (NIHSS, age, race-ethnicity, and diabetes) were associated with discharge to non-home setting. Early identification of these patients may help initiate proper discharge planning. Hispanic ethnicity and atrial fibrillation, but not age or diabetes, were associated with longer LOS. Future research is required into why Hispanic patients, compared to non-Hispanic whites, have longer LOS despite similar discharge to home rates.

Patterns of Inpatient Care and Outcomes for Multiple Myeloma in 2014: A National Inpatient Sample Analysis

Hepatocellular carcinoma (HCC) is an important complication of cirrhosis. Our aim was to assess the inpatient economic and mortality of HCC in the USA METHODS: Five cycles of Nationwide Inpatient Sample (NIS) conducted from 2005 to 2009 were used. Demographics, inpatient mortality, severity of illness, payer type, length of stay (LoS) and charges were available. Changes and associated factors related to inpatient HCC were assessed using simple linear regression. Odds ratios and 95% CIs for hospital mortality were analysed using log-linked regression model. To estimate the sampling variances for complex survey data, we used Taylor series approach. SAS(®) v.9.3 was used for statistical analysis. From 2005 to 2009, 32,697,993 inpatient cases were reported to NIS. During these 5 years, primary diagnosis of HCC increased from 4401 (2005), 4170 (2006), 5065 (2007), 6540 (2008) to 6364 (2009). HCC as any diagnosis increased from 68 per 100,000 discharges (2005) to 99 per 100,000 (2009). However, inpatient mortality associated with HCC decreased from 12% (2005) to 10% (2009) (P < 0.046) and LoS remained stable. However, median inflation-adjusted charges at the time of discharge increased from $29,466 per case (2005) to $31,656 per case (2009). Total national HCC charges rose from $1.0 billion (2005) to $2.0 billion (2009). In multivariate analysis, hospital characteristic was independently associated with decreasing in-hospital mortality (all P < 0.05). Liver transplantation for HCC was the main contributor to high inpatient charges. Longer LoS and other procedures also contributed to higher inpatient charges. There is an increase in the number of inpatient cases of HCC. Although inpatient mortality is decreasing and the LoS is stable, the inpatient charges associated with HCC continue to increase.

Psychiatric hospital length of stay (LOS) is not affected solely by socio-clinical factors but also by legal procedures. This study examined the associations between legal procedures and LOS. Data from 521 patients with psychiatric illnesses hospitalized over 2013-2015 were analyzed. Logistic regression was used to evaluate the predictors of longer (> 14 days) or prolonged (> 30) LOS with socio-clinical factors and legal procedures including court-ordered interventions (assisted outpatient treatment, medication over objection, and retention). Longer LOS occurred in 246 patients and 99 had prolonged LOS. Legal procedures affected 57 patients, with 11 assisted outpatient treatments, 39 cases of medication over objection, and 16 retentions. Longer LOS was significantly associated with six factors including older age, unmarried status, non-Hispanic race, risk of violence, schizophrenia, and legal procedures. Legal procedures had the strongest association. Longer/prolonged LOS yielded qualitatively similar associations. Among 521 psychiatric inpatients, approximately 11% were mandated to receive interventions/procedures by the courts. Court-ordered legal procedures were strongly associated with longer LOS. Mental health providers may consider legal procedures for patients at high treatment/medication noncompliance risk as early as patient admission to inpatient units to prevent, intervene or prepare for a longer or prolonged LOS.

We describe the incidence and etiology of fever and the relationship between fever characteristics and outcome in children with severe traumatic brain injury (TBI). We conducted a retrospective study of children <14 years and with Glasgow Coma Scale (GCS) score of <9 admitted to a level I pediatric trauma center intensive care unit (PICU) between 1998 and 2003. We examined whether fever characteristics were associated with poor outcome (hospital discharge GCS score <13 and discharge disposition of either death or discharge to a skilled nursing facility). PICU length of stay (LOS) and hospital LOS were also examined. Data are presented as means and medians (SD), and P < 0.05 reflects significance. Ninety-three records were reviewed. Patients were 5.7 (SD 4.1) years old, 70% were male, and the average admission GCS score was 5. Mortality rate was 14%. Forty-eight (52%) patients had fever, and 23 (48%) of those patients had infectious fever. Each additional febrile episode was associated with a twofold higher risk of patients having a hospital discharge GCS score of <13 (odds ratio 2.4, 95% confidence interval 1.2-5.0) and having a 0.4-day longer PICU LOS (P < 0.001). Patients with infectious fever had a 0.9-day longer PICU LOS (P < 0.001). Patients with any fever in the PICU had an increased HLOS (0.9 days; P < 0.001). Our data suggest that in severe pediatric TBI, both fever and infection were common, and both were associated with longer LOS. Patients with higher fever burden had poor hospital discharge GCS score.

Associations between low health literacy (HL) and adverse health outcomes have been well documented in the outpatient setting; however, few studies have examined associations between low HL and in-hospital outcomes. To compare hospital length of stay (LOS) among patients with low HL and those with adequate HL. Hospital-based cohort study. Academic urban tertiary-care hospital. Hospitalized general medicine patients. We measured HL using the Brief Health Literacy Screen. Severity of illness and LOS were obtained from administrative data. Multivariable linear regression controlling for illness severity and sociodemographic variables was employed to measure the association between HL and LOS. Among 5540 participants, 20% (1104/5540) had low HL. Participants with low HL had a longer average LOS (6.0 vs 5.4 days, P < 0.001). Low HL was associated with an 11.1% longer LOS (95% confidence interval [CI], 6.1%-16.1%; P < 0.001) in multivariate analysis. This effect was significantly modified by gender (P = 0.02). Low HL was associated with a 17.8% longer LOS among men (95% CI, 10.0%-25.7%; P < 0.001), but only a 7.7% longer LOS among women (95% CI, 1.9%-13.5%; P = 0.009). In this single-center cohort study, low HL was associated with a longer hospital LOS. The findings suggest that the adverse effects of low HL may extend into the inpatient setting, indicating that targeted interventions may be needed for patients with low HL. Further work is needed to explore these negative consequences and potential mitigating factors.

Patient and Hospital Characteristics Associated with Increased Length of Stay for Patients with Acute Myeloid Leukemia (AML): An Analysis from the 2012 National Inpatient Sample (NIS)

INTRODUCTION Recent changes in healthcare policies implemented as per the Affordable Care Act (ACA) have resulted in providers and hospitals seeking ways to optimize resource utilization and improve patient outcomes. Length of stay (LOS) after surgery has increasingly been used as a surrogate for resource utilization. In the current study, we investigated factors associated with longer LOS after surgery for grade 1 spondylolisthesis. METHODS We queried the Quality Outcomes Database for patients with grade 1 lumbar degenerative spondylolisthesis undergoing a surgical intervention between July 2014 and June 2016. Only those patients enrolled in a multi-side study investigating the impact of fusion on clinical and patient reported outcomes (PROs) among patients with grade 1 spondylolisthesis were evaluated. A multivariable (MV) proportional odds regression model was fitted to determine factors associated with longer LOS. RESULTS A total of 608 patients undergoing surgery were identified (555 single-level, 53 2-level surgeries). Median LOS was 3 d (IQR: 2-4 d). On MV analysis, factors found to be independently predictive of longer LOS included nonroutine home discharge (home with healthcare: OR: 3.5 (1.9-6.8); postacute care: OR: 9.6 (5.2-17.7)), higher baseline ODI (interquartile OR: 1.44 (1.21-1.86)), longer operative time (OR: 1.98 (1.56-2.51), 2-level surgery (OR: 2.91 (1.37-6.21), ref = 1-level surgery); assisted ambulation (OR: 1.9 (1.1-3.3)) and higher American Society of Anesthesiologists (ASA) score (OR: 1.6 (1.1-2.3) while decompression alone (OR: 0.05 (0.03-0.09)), anterior/lateral approaches (OR: 0.25 (0.11-0.56, ref = posterior) and use of MIS (OR: 0.42 (0.30-0.59) were associated with shorter length of stay. Predictor importance analysis revealed that type of surgery (decompression vs fusion), discharge disposition, operative time, use of Minimally invasive spine surgery (MIS) and surgical approach were the top predictors determining duration of stay. CONCLUSION These results from a multi-site study of patients undergoing surgery for grade I spondylolisthesis indicate that patients undergoing fusion, discharged to nonhome, with longer operative time and posterior surgical approaches may have longer LOS. Type of surgery and discharge destination are top predictors determining length of stay.

The purpose of this study was to determine factors, including day of week of hospital admission, associated with delay to surgery (DTS) and increased length of stay (LOS) in patients with hip fractures. Retrospective. Level I Trauma Center. Six hundred thirty-five consecutive patients admitted to a single hospital between January 1999 and July 2006 aged 65 years or older with a hip fracture (OTA 31) were identified retrospectively from an orthopaedic database. Demographic data, American Society of Anesthesiologists (ASA) score, hospital admission and discharge dates, the date of surgery, and details of any preoperative cardiac testing were extracted from the hospital record. These data were used to identify the day of week for hospital admission and to calculate days for DTS and hospital LOS. Linear regression was used to identify independent variables associated with DTS and increased LOS. All patients underwent surgical treatment of a hip fracture (OTA 31). Factors affecting DTS and LOS. Independent factors associated with DTS included the day of week for hospital admission, ASA score, and the need for preoperative cardiac testing. Patients admitted Thursday through Saturday had longer DTS (mean, 2.2-2.7 days) than did patients admitted other days (mean, 1.7-1.8). DTS increased for increasing ASA: 1.4 days for ASA 2, 2.0 days for ASA 3, and 3.0 days for ASA 4. Those requiring preoperative cardiac testing had an increased number of days to surgery (mean, 3.2 days) than those without (mean, 1.7 days). Independent factors associated with increasing hospital LOS included ASA, the need for preoperative cardiac testing, male gender, and day of admission. LOS increased for increasing ASA: 6.3 days for ASA 2, 8.1 days for ASA 3, and 10.1 days for ASA 4. Those requiring preoperative cardiac testing had an increased LOS (mean, 9.4 days) than those without (mean, 7.3 days). Male patients had a longer LOS (mean, 9.8 days) than did females (mean, 7.3 days). Patients admitted on Thursday or Friday (mean, 8.5-9.1 days) had longer LOS than those admitted on other days (mean, 7.3-7.9 days). This is the first study to consider and identify the day of admission and need for preoperative cardiac tests as determinants of DTS and LOS for geriatric patients with hip fracture. Relative scarcity of weekend hospital resources, when present, may be responsible for these delays. This study also confirms that patient medical condition as measured by ASA affects both DTS and LOS. Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.