30-day Emergency Department Visits Research Articles

Exparel and Outpatient Alveolar Bone Grafting: A Feasibility Study.

To examine the feasibility of outpatient alveolar bone grafting (ABG) using Exparel (bupivacaine liposome injectable suspension) for donor site analgesia. Retrospective, observational study. Single institution, 39-month retrospective review. In total, 21 patients with cleft alveolus were included in this study. In autologous outpatient ABG procedures using a mixed open harvest and Acumed trephine method to retrieve corticocancellous bone from the iliac crest, Exparel was injected in the donor site fascia. Postoperative data including length of stay, post anesthesia care unit narcotics delivered, and maximum pain scores were recorded. Successful outcomes were assessed by exploring 30-day complications, 30-day emergency department visits, 30-day readmissions, and ambulation at follow-up. The average hospital length of stay was 360.8 min. Four patients required overnight stay secondary to pain. The average doses of pain medications administered postoperatively were 198.4 mg acetaminophen, 9.3 mg ketorolac, 3.0 µg fentanyl, and 1.5 mg oxycodone. No patient reported 30-day complications secondary to donor site pain, 30-day emergency department visits, or 30-day readmissions, and there was only one case of wound dehiscence. All patients exhibited proper ambulation at follow-up and healed well from ABG. The use of Exparel for donor site analgesia in outpatient ABG procedures using corticocancellous grafts can result in adequate pain management and ambulation without an increased risk of complications and readmissions.

Effectiveness of Synchronous Postdischarge Contacts on Health Care Use and Patient Satisfaction : A Systematic Review and Meta-analysis.

Postdischarge contacts (PDCs) after hospitalization are common practice, but their effectiveness in reducing use of acute care after discharge remains unclear. To assess the effects of PDC on 30-day emergency department (ED) visits, 30-day hospital readmissions, and patient satisfaction. MEDLINE, Embase, and CINAHL searched from 2012 to 25 May 2023. Randomized and nonrandomized trials of PDC within 7 days. Two investigators independently screened articles and assessed risk of bias (ROB). Single reviewers extracted data, with verification by second investigators. Random-effects meta-analyses were done on outcomes shared by at least 3 studies, and the certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. Of 13 included studies (11 randomized trials [RTs]), 12 delivered PDCs via telephone. Three of 11 RTs were rated as having low ROB, with 1 rated high. Most PDC interventions (n = 10) consisted of single telephone contacts, often within 3 days. Eight studies focused on patients identified as higher-risk by the authors. There were no differences in 30-day ED use (5 RTs; 3054 patients; risk difference, 0.00 [95% CI, -0.02 to 0.03]; moderate certainty) or 30-day hospital readmissions (7 RTs; 7075 patients; risk difference, 0.00 [CI, -0.02 to 0.02]; moderate certainty) with PDC. Adherence and fidelity to PDC interventions were poorly described, and only 1 study investigated nontelephone PDC. Postdischarge contacts within 7 days of discharge were not associated with reductions in 30-day ED use or readmissions compared with usual care. Health systems should reconsider the utility of universal PDCs because multifaceted interventions targeting higher-risk patients may be necessary to reduce use of acute care after discharge. Department of Veterans Affairs. (PROSPERO: CRD42023465675).

Unplanned Postoperative Emergency Department Visits After Upper Extremity Fracture Surgery.

This study aimed to determine whether outpatient upper extremity fracture surgery was associated with increased postoperative emergency department (ED) visits and identify related risk factors. Retrospective cohort. This multicenter study was conducted within a single academic institution, encompassing two Level 1, two Level 2, and one Level 3 trauma centers. All patients >18 years of age who underwent upper extremity fracture surgery from 2015 to 2021 were included. Risk factors for postoperative ED visit that were investigated included age, sex, tobacco use, alcohol abuse, psychiatric diagnosis, Elixhauser comorbidity score, race, location of upper extremity fracture, surgical setting (inpatient vs. outpatient), upper extremity block, surgical specialty, and Area Deprivation Index. Variables with a P < 0.1 in bivariate analysis were included in a multivariable logistic regression to determine factors associated with a postoperative ED visit at 30 and 90 days. A total of 6315 patients with an average age of 51 ± 19 years were identified of whom 52% were women and 65% had outpatient surgery. Postoperatively, 188 patients (3.0%) presented to the ED within 30 days and 304 (4.8%) presented within 90 days. Thirty-seven percent of ED visits were directly related to the procedure, most commonly for pain (20%), cast issues (4.3%), and swelling (3.9%). At 30 days postoperatively, 2.8% of patients who underwent surgery in an outpatient setting and 3.4% of those who underwent inpatient surgery returned to the ED, with these rates increased to 4.4% and 5.6%, respectively, by 90 days. In multivariable analysis, outpatient surgery (odds ratio [OR]: 1.5, P = 0.030), tobacco use (OR: 2.1, P < 0.001), higher Elixhauser comorbidity scores (OR: 1.2, P < 0.001), non-White race (OR: 1.9, P < 0.001), elbow fractures (OR: 1.8, P = 0.016), and hand fractures (OR: 1.6, P = 0.046) were associated with 30-day ED visits. Outpatient surgery was associated with increased rate of 30-day ED visits. Patients who smoke, had increased number of comorbidities, or were non-White presented to the ED more frequently. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Regional Anesthesia for Wrist Fractures and Dislocations: Are We Really Blocking Opioid Prescribing?

The aim of this study was to evaluate the impact of regional anesthesia for the treatment of wrist fractures or dislocation on opioid prescription-filling patterns. Patients undergoing surgery for hand and wrist fractures or dislocations from 2010 to 2018 were identified by using a national insurance claims database. Patients were stratified by procedures conducted with and without regional anesthesia. Preoperative opioids were defined by a filled opioid prescription within 1 month prior to surgery, postoperative within 1 month following the surgery, and prolonged postoperative 3 to 6 months following surgery. Patients' demographic data, comorbidities, additional medications, 30-day emergency department (ED) visits, and hospital readmissions were analyzed. A total of 24 598 patients treated with and 115 199 patients treated without a regional nerve block for wrist fractures and dislocations were identified. Regional anesthesia was associated with greater postoperative opioid prescription but fewer prolonged postoperative prescriptions. There was an increased odds of all-cause 30-day ED visits but a decreased odds of 30-day hospital readmissions when patients received a regional nerve block prior to surgery. In this study, receiving regional anesthesia prior to surgical intervention for wrist fractures or dislocations was associated with increased filling of postoperative opioid prescriptions, but not prolonged postoperative opioid prescriptions. Additional investigation is needed to identify and implement nonnarcotic multimodal analgesia regimens that may help decrease usage of narcotic medications surrounding these procedures. Level III, retrospective cohort study.

Statin Use is Associated with Decreased Venous Thromboembolism Events Following Total Hip Arthroplasty: A Matched Retrospective Cohort Study.

Despite advances in surgical techniques and postoperative prophylactic protocols, venous thromboembolism (VTE) events remain an important source of morbidity following total hip arthroplasty (THA). Prior research in cardiology and other surgical fields has suggested that statin medications may have a protective effect against VTE. Our study aimed to: 1) Assess if preoperative statin use was associated with decreased rates of VTE following THA, and 2) conduct a subgroup analysis of statin intensity and VTE events. A total of 1,154 patients who had preoperative statin use for at least four weeks before surgery and who underwent primary THA at a large, urban academic center between January 1, 2012, and June 1, 2023, were identified. The 90-day postoperative VTE events, deep vein thrombosis (DVT), pulmonary embolism (PE), emergency department (ED) visits, reoperations, and readmission rates were collected from institutional coding software. Mortality rate in the 90-day postoperative period was also measured. Propensity matching was used to control for demographics and selected comorbidities. Preoperative statin use was associated with significantly lower rates of 90-day VTE events (Statin: 0.43% versus No-Statin: 1.13%, P = 0.047). There were no significant differences in 90-day PE, DVT, ED visit, readmission, or reoperation rates. There were no deaths within 90 days of THA in either group. Subgroup analysis of statin intensity revealed no significant differences in any outcomes measured between high-intensity, medium-intensity, and low-intensity statin groups. Preoperative statin use is associated with significantly lower rates of VTE events in the 90-day postoperative period following THA. Further research into the effect of statins on post-THA VTE is warranted.

Patient Race and Ethnicity are Associated with Higher Unplanned 90-Day Emergency Department Visits and Readmissions but not 10-year All-Cause Complications or Reoperations: A Matched Cohort Analysis of Primary Shoulder Arthroplasties

Patient Race and Ethnicity are Associated with Higher Unplanned 90-Day Emergency Department Visits and Readmissions but not 10-year All-Cause Complications or Reoperations: A Matched Cohort Analysis of Primary Shoulder Arthroplasties

Impact of same-day sleeve gastrectomy surgery on postoperative emergency department visits: analysis from the Michigan Bariatric Surgery Collaborative.

Same-day discharge after sleeve gastrectomy (SDDSG) is being performed in select patient populations with increased regularity since2020. To evaluate the impact of SDDSG on emergency department (ED) visits. Academic and private practice bariatric surgery programs participating in a statewide quality improvement collaborative. Using a statewide bariatric specific data registry, all patients undergoing SDDSG between 2020 and 2023 were identified (n = 984). Rates of 30-day ED visits and complications were compared between SDDSG and a 2:1 propensity-matched cohort with a 1-2-day hospital length of stay (n = 1968). The mean age and body mass index of SDDSG patients were 41.7 years and 45.9, respectively. When compared to the matched cohort, SDDSG patients had higher rates of ED visits (9.2% versus 6.2%, P = .0029), were more likely to present to ED earlier (10.3 days versus 12.9 days, P = .0118), and were less likely to require hospital admission (87.8% versus 71.1%, P < .0037), even though the overall complication rates were similar (4.7% versus 3.7%, P = .2087). The most common reason for an ED visit after SDDSG was nausea, vomiting, and dehydration (58.9% versus 66.9%, P = .2294), and the most common day to present to the ED was Friday (20.0% versus 20.7%, P = .9061), which was similar between groups. Despite having similar complication rates, patients undergoing SDDSG were more likely to present to the ED after surgery when compared to a matched cohort of patients with a 1-2-day hospital stay.

Virtual Home Care for Patients With Acute Illness

Recent evolutions in clinical care and remote monitoring suggest that some acute illnesses no longer require intravenous therapy and inpatient hospitalization. To describe outcomes of patients receiving care in a new, outpatient, virtual, home-based acute care model called Safer@Home. This retrospective cohort analysis, conducted from September 1, 2022, through August 31, 2023, included 2466 patients treated at a safety net hospital in Los Angeles County for 10 core illnesses and 24 other acute illnesses for which patients are commonly hospitalized. Outpatient, home-based, acute care with virtual monitoring and clinic visits in lieu of inpatient or in-home care. The primary measure was hospital length of stay. Secondary measures included all-cause mortality, 30-day readmission, return urgent care visit rates, and return emergency department (ED) visit rates. Safer@Home provided care to 876 patients (mean [SD] age, 54.0 [14.5] years; 541 men [61.8%]) during the study period, compared with a cohort of 1590 patients (mean [SD] age, 52.3 [19.6] years; 901 men [56.7%]) with matching diagnoses who received standard, hospital-based care. Safer@Home patients had significantly shorter mean (SD) lengths of inpatient stay than the comparison cohort (1.3 [2.0] vs 5.3 [10.4] days; P < .001), totaling 3505 bed-days avoided (mean [SD], 4.0 [10.6] bed-days saved per patient), with no significant difference in all-cause mortality at last follow-up (2.6% [23 of 876] vs 4.0% [64 of 1590]; P = .07). Safer@Home patients and control patients also had no significant difference in the proportion experiencing 30-day hospital readmission (19.9% [174 of 876] vs 16.7% [266 of 1590]; P = .06). As intended, more Safer@Home than control patients had at least one 30-day return urgent care visit (37.3% [327 of 876] vs 5.2% [82 of 1590]; P < .001). In contrast, the Safer@Home and control cohorts did not significantly differ in experiencing at least one 30-day return ED visit (15.2% [133 of 876] vs 12.5% [199 of 1590]; P = .06). Safer@Home patients had significantly fewer mean (SD) total 30-day return ED visits per patient than control patients (0.19 [0.50] vs 0.21 [0.85]; P < .001). In this cohort study, patients receiving acute, virtual, home care with remote monitoring and as-needed return urgent care visits had markedly shorter hospital stays than patients receiving standard inpatient hospital care, with no significant increase in mortality, ED revisits, or return hospitalizations. This new care model is promising for systems that cannot staff Medicare-compliant hospital-at-home visits.

Outpatient Total Joint Arthroplasty at an Ambulatory Surgical Center: An Analysis of Failure to Launch

There has been a tremendous increase in same-day discharge (SDD) following primary total joint arthroplasty (TJA). Although the concept of failure to launch (FTL) has been recently investigated in hospital settings, there is a paucity of data in the ambulatory surgical center (ASC) context. This study aimed to examine the incidence and underlying causes of FTL within an ASC at a major academic medical center. A retrospective review from 2021 to 2024 was performed on all patients who underwent same-day surgery at our ASC after intentional selection and medical optimization per institutional protocols. The demographic information, incidence and source of FTL, 90-day readmissions, and reoperations/revisions were recorded. There were 1,974 patients who underwent primary TJA at the ASC during the study. There were nine patients who required direct hospital admission from the ASC (0.45%). This patient population had significantly increased American Society of Anesthesiologists score compared to patients who were discharged home. In addition, these patients had a significantly higher number of 90-day emergency department visits. Syncopal episodes were the most common reason for hospital admission from the ASC (66.7%), followed by nausea, seizures, and pain (all 11.1%). After review by attending orthopaedic surgeons and anesthesiologists, only two patients had potentially preventable medical causes for admission. Approximately, 99.6% of patients had successful SDD at our ASC, underscoring the importance of proper preoperative screening. Only 0.45% of patients required hospital admission, primarily attributed to hypotension and syncopal events. Interestingly, only two patients in our cohort experienced a potentially preventable instance of FTL. It is crucial that additional efforts be aimed at identifying patients at risk and implementing treatment strategies to prevent postoperative hypotension and syncopal events that may further improve SDD and outcomes in outpatient TJA in the ASC setting.

Is Tranexamic Acid Safe for Patients Who Have End-Stage Renal Disease Undergoing Total Joint Arthroplasty?

BackgroundTranexamic acid (TXA) is a renally-excreted antifibrinolytic commonly utilized in total joint arthroplasty (TJA). This study examined whether TXA administration affected clinical outcomes and kidney function in patients who had end-stage renal disease (ESRD) undergoing TJA or hemiarthroplasty. MethodsThrough a retrospective chart review, we identified 123 patients: 40 who underwent primary elective total knee arthroplasty (TKA; 65% received TXA), 34 who underwent primary elective total hip arthroplasty (THA; 52.9% TXA), and 49 who underwent nonelective THA or hemiarthroplasty (44.9% TXA) from January 2011 to February 2024. All patients had ESRD and/or were on dialysis, with no difference in percentage on dialysis between TXA groups (TKA: 65.4 versus 64.3%; THA: 55.6 versus 50.0%; nonelective/hemiarthroplasty: 86.4 versus 85.2%, P values ≥ 0.586). Demographic and perioperative characteristics, including preoperative hemoglobin, TXA administration, dose, and route of administration (ROA; intravenous, topical), were extracted. Pre- and postoperative (≤ 7 days) creatinine, perioperative transfusions, revisions, and 90-day emergency department (ED) visits, readmissions, and mortalities were recorded and compared between TXA groups. ResultsIn the total sample and all cohorts, change in pre- to postoperative creatinine and incidence of postoperative acute kidney injury (AKI), per Kidney Disease Improving Global Outcomes (KDIGO) guidelines, did not significantly differ based on receiving TXA (P values ≥ 0.159). Among patients receiving TXA, change in creatinine did not significantly differ by dose (P values ≥ 0.428) or ROA (P values ≥ 0.256). There were no statistically significant differences in 90-day ED visits, readmissions, or mortalities based on receiving TXA (P values ≥ 0.055). Thromboembolic events occurred in four patients (one TXA, three no TXA, P = 0.617), and perioperative transfusions occurred in two patients (one TXA, one no TXA, P = 0.882) in the nonelective/hemiarthroplasty cohort, with none in the elective cohorts. ConclusionsThe administration of TXA does not portend a significant increase in complications for patients who have ESRD undergoing TJA or hemiarthroplasty for fracture, suggesting TXA should not be contraindicated in this population.

Cervical Disc Arthroplasty Is Safe Across Various Obesity Levels

As surgical indications for cervical disc arthroplasty (CDA) continue to expand, a growing patient population is now becoming indicated for this procedure. Little is known about whether CDA is safe in the overweight and obese populations, and how this procedure compares to anterior cervical discectomy and fusion (ACDF) in this particular demographic. To evaluate the outcomes of CDA across varying levels of body mass indices and to compare these to ACDF. Retrospective cohort study. A total of 12,454 patients who underwent CDA and 45,513 patients who underwent ACDF between 2011 and 2020 were included in this study. The following data were observed for all cases: patient demographics, complications, revisions. The PearlDiver database was queried to identify all adults who underwent single-level CDA. Patients were stratified by body mass index (BMI), defined as Healthy Weight (<25kg/m2), Overweight (25-30kg/m2), Obese (30-40kg/m2), and Morbidly Obese (>40kg/m2). Patient demographics and comorbidities were compared before matching, and medical and surgical complications were compared after matching for age, sex, and Charlson Comorbidity Index (CCI). Similar comparative analyses were performed on all obese patients (>30kgm/2) who underwent single-level CDA and single-level ACDF. In total, 1907 Healthy Weight, 3295 Overweight, 5431 Obese, and 1821 Morbidly Obese patients were included. The mean age was between 45.43 and 47.41 years, 57.12% and 71.68% were female, and mean CCI was 1.16-1.73 across groups (all p<.001). Mean CCI (Healthy Weight=1.16, Overweight=1.31, Obese=1.47, Morbidly Obese=1.63) and rate of comorbidities, such as diabetes (19.19%, 25.74%, 37.51%, 48.65%), hypertension (45.20%, 56.18%, 69.21%, 76.22%), and hyperlipidemia (49.34%, 60.61%, 65.33%, 64.96%), generally increased with increasing BMI (p<.001). After matching, mean age was 44.59 years, 70.98% were female, and mean CCI was 1.07 for all groups. At 90 days postoperatively, medical complications, including infection, wound dehiscence, and readmissions, were comparable (p>.05). At 2 years postoperatively, anterior revision was higher in Healthy Weight patients (30.27%, 28.11%, 24.71%, 24.96%, p=.005) but other surgical complications, including dysphagia, dysphonia, and implant failure, were otherwise comparable (p>.05). Comparison of all obese patients across cervical procedures revealed higher rates of 90-day emergency department visits (ACDF=21.56% vs 16.65%, p<.001) and 1-year hardware removal (1.49% vs 0.81%, p=.002), wound exploration (0.73% vs 0.35%, p=.018), and posterior fusion (1.14% vs 0.44%, p<.001) and lower rates of anterior revision (18.82% vs 23.68%, p<.001) in ACDF patients compared to CDA patients. CDA may be safe across varying levels of obesity without any appreciable change in medical and surgical complications. In addition, single-level ACDF may result in higher complications than single-level CDA in the obese population.

Smokeless tobacco use is associated with a lower risk of perioperative complications and revision surgery after anatomic and reverse total shoulder arthroplasty compared to cigarette smokers

BackgroundNo prior study has separated the effects of smokeless tobacco from traditional cigarettes in patients undergoing anatomic total shoulder (aTSA) and reverse total shoulder arthroplasty (rTSA). Therefore, the purpose of this study was to evaluate the effects of smokeless tobacco on postoperative outcomes after aTSA and rTSA. MethodsA retrospective cohort study utilizing a large insurance database was conducted. Patients undergoing primary TSA with a minimum two-year follow-up were included. Smokeless tobacco only users, cigarette only users, and nontobacco users were propensity score matched based on demographic variables and comorbidities. Postoperative medical complications and surgery-specific complications were compared among groups. Patient groups were further stratified by surgical technique: aTSA or rTSA. Multivariable logistic regressions were employed to account for confounding variables. ResultsSmokeless tobacco use was not associated with increased risk of complications after TSA compared to nonusers. Cigarette use was associated with an increased risk of pneumonia (OR: 1.20), wound dehiscence (OR: 1.39), emergency department (ED) visits (OR: 1.40), and readmissions (OR: 1.12) within 90 days as well as infection (OR: 1.21), aseptic loosening (OR: 1.28), dislocation (OR: 1.27), fracture (OR: 1.30), and revision surgery (OR: 1.19) within 2 years compared to nonusers. After separating by surgical technique, smokeless tobacco use, after aTSA was associated with fewer 90-day ED visits (OR: 0.52), while cigarette only use was associated with increased risk of rotator cuff tear (OR: 1.17) and fracture (OR: 1.88) within two years compared to nonusers. Compared to cigarette smokers, smokeless tobacco users had significantly decreased risk of ED visits (OR: 0.40) within 90 days and implant removal (OR: 0.13) within two years of surgery. For rTSA, smokeless tobacco use was not associated with increased risk of complications compared to nonuser controls; however, cigarette use was associated with an increased risk of ED utilization (OR: 1.33) within 90 days as well as aseptic loosening (OR: 1.32) and irrigation and debridement (OR: 1.37) within two years. Smokeless tobacco use, when compared to cigarette users, was associated with significantly fewer shoulder dislocations (OR: 0.27) within two years. ConclusionSmokeless tobacco use was associated with a lower risk of complications compared to cigarette users and no difference compared to nonusers after aTSA and rTSA. These findings suggest that while all tobacco use, including smokeless tobacco and cigarettes, is best avoided prior to surgery, the risks associated with smokeless tobacco use may be less severe than those linked to cigarette smoking after aTSA and rTSA.

Machine Learning For Risk Prediction After Heart Failure Emergency Department Visit or Hospital Admission Using Administrative Health Data.

Patients visiting the emergency department (ED) or hospitalized for heart failure (HF) are at increased risk for subsequent adverse outcomes, however effective risk stratification remains challenging. We utilized a machine-learning (ML)-based approach to identify HF patients at risk of adverse outcomes after an ED visit or hospitalization using a large regional administrative healthcare data system. Patients visiting the ED or hospitalized with HF between 2002-2016 in Alberta, Canada were included. Outcomes of interest were 30-day and 1-year HF-related ED visits, HF hospital readmission or all-cause mortality. We applied a feature extraction method using deep feature synthesis from multiple sources of health data and compared performance of a gradient boosting algorithm (CatBoost) with logistic regression modelling. The area under receiver operating characteristic curve (AUC-ROC) was used to assess model performance. We included 50,630 patients with 93,552 HF ED visits/hospitalizations. At 30-day follow-up in the holdout validation cohort, the AUC-ROC for the combined endpoint of HF ED visit, HF hospital readmission or death for the Catboost and logistic regression models was 74.16 (73.18-75.11) versus 62.25 (61.25-63.18), respectively. At 1-year follow-up corresponding values were 76.80 (76.1-77.47) versus 69.52 (68.77-70.26), respectively. AUC-ROC values for the endpoint of all-cause death alone at 30-days and 1-year follow-up were 83.21 (81.83-84.41) versus 69.53 (67.98-71.18), and 85.73 (85.14-86.29) versus 69.40 (68.57-70.26), for the CatBoost and logistic regression models, respectively. ML-based modelling with deep feature synthesis provided superior risk stratification for HF patients at 30-days and 1-year follow-up after an ED visit or hospitalization using data from a large administrative regional healthcare system.

The association between fracture and short-term adverse health outcomes among children with cerebral palsy

BackgroundChildren with cerebral palsy (CP) have a high risk of fracture; yet, little is known about their post-fracture health outcomes. A fracture is an unplanned event in contrast to surgeries or procedures where there is a pre-operative period to optimize body composition and health and planned post-operative follow-up care. Fractures may be associated with significant outcomes due to the unplannable nature and reactionary care. The objective of this study was to determine if fractures were associated with an increased rate of short-term adverse health outcomes among children with CP, and if these associations were dependent on age. MethodsThis retrospective cohort study used commercial claims from 01/01/2001–12/31/2018. The primary cohort was children 2–18 years old with CP and an incident fracture (CP + Fx). Comparison cohorts were propensity score matched 1:1 to CP + Fx on demographic and health-related indicators: CP without fractures (CPw/oFx); without CP with (w/oCP + Fx) or without (w/oCPw/oFx) a fracture. The incidence rate (IR) and IR ratios (IRR) of 30-day and 31–90-day pneumonia and 90-day emergency department (ED) visit were estimated. Cox regression tested for effect modification by age and sex. ResultsThe CP + Fx cohort (n = 1670) had higher IRs of 30-day pneumonia (IRR range, 1.53–4.54) and 90-day ED visit (IRR range, 1.45–2.37) (all P < 0.05), and higher IRs of 31–90-day pneumonia but this did not reach statistical significance (IRR, 1.41 to 2.32, all P > 0.05). Notably, there was evidence of effect modification by age. The rate of 30-day pneumonia became more problematic for CP + Fx with older age relative to comparison cohorts and for 90-day ED visit compared to CPw/oFx. The rate of 90-day ED visit for CP + Fx was more problematic at younger ages compared to w/oCP + Fx. ConclusionsFractures among children with CP were associated with an increased rate of short-term pneumonia and ED visit, which was more problematic with older age.

General versus disease-specific medical oncology consults and impact on inpatient quality of care.

321 Background: Hospitalization is a time of crisis for patients and caregivers. Subspeciality oncologists may bring more timely, effective support compared to a general oncologists. Attendings, fellows and advance practice providers (APPs) may benefit from focused expertise for consultative care and education. Methods: Subspeciality oncology consults launched July 2023, with consults staffed by 4 oncologists from: 1) breast 2) head and neck/thoracic 3) gastrointestinal and 4) genitourinary/melanoma. Previously, 3 oncologists staffed all patients, regardless of primary malignancy. Throughout the study period, oncologists were supported by at least 1 fellow or 1 APP. Using Epic and Tableau, we collected LOS, time to consult (TTC), ICU rate, hospice referral rate, 30-day readmission, 30-day emergency department (ED) visit data. Using Qualtrics, we collected fellow, attending, and APP satisfaction feedback pre- and post-intervention. Data was analyzed using R-4.40. Oncologists, fellows, and APPs completed Qualtrics surveys pre- and post-intervention regarding their experience. Results: Subspeciality oncology consults were associated with a significant decrease in LOS, TTC, and ICU rate. Median LOS decreased by 2.0 days (P&lt;0.001), with median TTC decreasing by 1.0 hour (P=0.003). ICU rate decreased from 27.5% to 16.4% (P&lt;0.001). There was no difference in hospice referrals or 30-day ED visits. A significant increase in 30-day readmission during post-intervention was observed (Table). Oncologists reported a high level of satisfaction with the program. Oncologist, fellow, and APP overall experience and educational rankings increased after the introduction of subspeciality consults. Inpatient productivity measured by wRVU increased by 30% following the intervention, without associated changes to outpatient productivity. Conclusions: Transition to a subspeciality oncology consult model improved inpatient quality of care, as well as clinician experience. Additionally, inpatient productivity increased without decrease in outpatient metrics. Subspeciality medical oncology consultation can improve inpatient quality of care, education, clinician satisfaction and productivity. Subspeciality oncology consult outcomes. General Consults (Baseline)* Subspeciality Consults (Intervention) P-value Median TTC (Hours) 4.0 (1.5-6.0)** 3.0 (0-5.0)** P=0.003 Median LOS (Days) 7.0 (4.0-13.0)** 5.0 (3.0-10.0)** P&lt;0.001 ICU Rate 148 (27.5%) 161 (16.4%) P&lt;0.001 Hospice Referral Rate 56 (10.4%) 95 (9.7%) 0.655 30-Day Readmission Rate 136 (25.3%) 301 (30.7%) 0.028 30-Day ED Rate 157 (29.2%) 315 (32.1%) 0.247 *Baseline data reflects outcomes for general oncology consult staffing, prior to initiation of subspeciality consult model (pre-intervention). **Interquartile Range (IQR).

Patients with fibromyalgia have increased risk of 90-day postoperative adverse events following arthroscopic rotator cuff repair

BackgroundArthroscopic rotator cuff repair (RCR) is a common surgical intervention for symptomatic rotator cuff tears when conservative management fails. Understanding the potential correlation of short- and longer-term outcomes associated with defined comorbidities can help with patient selection, counseling, and related care pathways. The association of fibromyalgia, one potential comorbidity, with outcomes following RCR has not been reported in the literature. MethodsPatients with and without fibromyalgia diagnosed prior to undergoing RCR were identified from the PearlDiver Mariner161 database between 2016 and April 30, 2022, using Current Procedural Terminology (CPT) codes. Exclusion criteria were age less than 18 years, a diagnosis of neoplasm, trauma, or infection within 90 days prior to surgery, and postoperative records of fewer than 90 days. Patients with and without fibromyalgia were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI).Ninety-day adverse events were assessed. Severe adverse events were defined as the occurrence of sepsis, surgical site infection, cardiac events, deep vein thrombosis, or pulmonary embolism. Minor adverse events were defined as the occurrence of wound dehiscence, urinary tract infection, pneumonia, transfusion, hematoma, or acute kidney injury. Also identified was the occurrence of any adverse event, emergency department (ED) visits, and readmission. These outcomes were compared with multivariate analysis. One-year revisions were assessed with Kaplan-Meier curves and compared with the log-rank test. ResultsIn total, 295,169 RCR patients were identified, of which fibromyalgia was noted for 12,366 (4.2%). Following matching, the final cohort sizes for those with and without fibromyalgia were 11,387 and 45,354 respectively.Diagnosis of fibromyalgia was independently associated with increased risk of all individual adverse events as well as aggregated incidence of severe, minor, and any adverse events (p<0.0001 for all). Additionally, patients with fibromyalgia had independently 90-day increased odds of ED utilization (p<0.0001). There was no statistically significant difference in reoperation between the cohorts within 1 year of surgery. Discussion and ConclusionFibromyalgia was associated with significantly increased 90-day postoperative adverse events and ED visits. These findings are relevant in surgical planning but are also balanced by a lack of difference in one-year revisions.

A pilot study testing a new transition of care model from hospital to the community for Hispanic/Latino adults with diabetes to reduce emergency department visits and hospital re-admissions

BackgroundHispanic/Latino populations have the second highest prevalence of diabetes (12.5%) among ethnic minority groups in the USA. They also have higher rates of uncontrolled diabetes and diabetes-related complications. Approximately 29% of diabetes care costs are attributed to inpatient hospital care. To reduce hospital length of stay and re-admission rates for diabetes, the American Diabetes Association (ADA) recommends a “structured discharge plan tailored to the individual patient with diabetes.” However, limited research exists on the feasibility and applicability of a transition of care model specifically tailored for the Hispanic/Latino population.MethodsWe conducted a 2-year pilot study to develop a practical, patient-centered, and culturally competent transition of care (TOC) model for Hispanic/Latino adults with diabetes discharged from the hospital to the community. Feasibility outcomes included recruitment rates, questionnaire completion rates, adherence to a 30-day post-discharge phone call, and resource needs and utilization for study implementation. Participant-centered outcomes included 30-day post-discharge emergency department (ED) visits, 30-day post-discharge unplanned re-admissions, follow-up visits within 2 weeks of discharge, and patient satisfaction with the TOC model.ResultsTwelve participants were enrolled over the study period, with weekly enrollment ranging from 0 to 4 participants. Participants’ average age in years was 47 (± 11.6); the majority were male (85%), and 75% had type 2 diabetes. Recruitment involved the support of 4 bilingual staff. The estimated time to review the chart, approach participants, obtain informed consent, complete questionnaires, and provide discharge instructions was approximately 2.5 h. Of the 10 participants who completed the 30-day post-discharge phone call, none had ED visits or unplanned hospital re-admissions within 30 days post-discharge, and all had a follow-up with a medical provider within 2 weeks.ConclusionsImplementing a patient-centered and culturally competent TOC model for Hispanic/Latino adults with diabetes discharged from the hospital to the community is feasible when considering key resources for success. These include a bilingual team with dedicated and funded time, alignment with existing discharge process and integration into the Electronic Medical Record (EMR) systems.

Complications and revision rates after total shoulder arthroplasty are similar between patients with and without diabetes mellitus.

There is wide variability in the conclusions of studies examining the effects of diabetes mellitus (DM) on outcomes of shoulder arthroplasty (SA). The objective of this study was to determine if there are differences in complication profiles between patients with DM and those without undergoing anatomic and reverse total SA. A retrospective review of patients undergoing SA in a single center from January 2014 to December 2019 was performed. Patients were then stratified into two cohorts, patients with controlled DM (mean hemoglobin A1C < 7%) and those without. Outcomes analyzed included intraoperative complications, postoperative complications, and revision surgery rates. Emergency department (ED) visits and hospital readmissions within 30 days were also recorded. A total of 595 patients underwent SA. No significant difference was found between the diabetes (n = 151) and control group (n = 444) with regard to length of stay (P = .168), complications (P = .286), infection rate (P = .977), 30-day ED visits (P = .789), and readmissions (P = .230). The average time to revision was 26.8 months in the diabetes group and 26.6 months in the control group (P = .989). Following SA patients with controlled DM showed no increased risk of postoperative infection, ED visitation,hospital readmission, and revision surgery rate when compared to non-diabetics. Level III-retrospective cohort.

Implementation and impact of a surgical dashboard on pediatric tonsillectomy outcomes: A quality improvement study.

In pediatric tonsillectomy management, the consistent tracking of surgical outcomes and adherence to guidelines are vital. This study explores how a surgical dashboard can serve as a tool in research analysis, translating AAO-HNSF guidelines into measurable performance improvements. Using a prospective registry from three pediatric hospitals, a Tableau dashboard was constructed to graphically visualize key demographic and postoperative outcomes (including intensive care unit [ICU] utilization, 30-day emergency department (ED) visits, and postoperative bleed rates) in children undergoing tonsillectomy from 2020 to 2024. From the dashboard data, a retrospective cohort study analyzing 6767 tonsillectomies was conducted from January 2, 2020, to June 20, 2023. Patients were categorized into low-risk, OSA-only (by ICD-10 codes), and high-risk groups based on comorbidities. Logistic regression identified factors influencing ED revisits and unplanned nursing calls. Three quality initiatives were assessed: preoperative school absence notes, perioperative dexamethasone recording, and post-tonsillectomy parental education. A total of 2122 (31%) were low-risk, 2648 (39%) were OSA-only, and 1997 (30%) high risk. Risk factors that increased the likelihood of ED visits were high-risk comorbidities (OR = 1.46; 95% CI = 1.24-1.74; p < 0.001) and older age (OR = 1.05; 95% CI = 1.03-1.08; p < 0.001). Risk factors that increased the likelihood of an unplanned nursing communication were high-risk comorbidities (OR = 1.53; 95% CI = 1.34-1.75; p < 0.001), older age (OR = 1.03, 95% CI = 1.01-1.04; p = 0.001), and Medicaid insurance (OR = 1.25; 95% CI = 1.09-1.43; p = 0.002). Postoperative bleed control was generally comparable between the groups, at 2.8% (low risk), 2.7% (OSA), 3.2 (high risk) (p = 0.651). The dashboard aided in data collection, data visualization, and data analysis of quality improvement initiatives, effectively translating guidelines into tangible measures to enhance care. NA.

Extending emergency care beyond discharge: Piloting a virtual after care clinic.

Many unscheduled return visits to the emergency department (ED) stem from insufficient access to outpatient follow-up. We piloted an emergency medicine-staffed, on-demand, virtual after care clinic (VACC) as an alternative for discharged ED patients. Prospective cohort study of discharged ED patients who scheduled VACC appointments within 72hoursof index ED visit. We performed descriptive analyses and compared risks of ED return at 72hours and 30 days between patients who did/did not attend their appointment. From March to December 2022, 309 patients scheduled VACC appointments and 210 (68%) attended them. Patients who scheduled appointments were young (median 37 years), non-Hispanic white (80%), females (75%) with a primary care physicians (PCP) (90%), and commercial insurance (72%). Most VACC visits reinforced ED testing and/or treatment (64%) or adjusted medications (26%). VACC attendees were less likely to return to the ED within 72h (3.3%vs. 13.1%; risk difference 9.3% [95% confidence interval, CI 2.7%‒19.8%]) and 30 days (16.2%vs. 30.3%; risk difference 14.1% [95% CI 3.8%‒24.4%]) compared to those who scheduled but did not attend a VACC appointment.VACC attendance was associated with lower odds of 72-h (adjusted odds ratio [aOR] 0.0; 95% CI 0.0‒0.4) and 30-day (aOR 0.4; 95% CI 0.2‒0.7) return ED visits. In this pilot study, younger, white, female, commercially insured patients with a PCP preferentially scheduled VACC appointments. Among patients who scheduled VACC appointments, those who attended their appointments were less likely to return to the ED within 72hours and 30 days than those who did not.