Actual Length Of Stay Research Articles

Analysing the Value of Intensive Care Unit Length of Stay Information Through Its Operational Performance

The increasing demand for Intensive Care Unit (ICU) beds requires efficient admission, discharge, and care processes. Although all such efforts require predictions of Length of Stay (LOS) values, it is unclear how accurate those predictions need to be. This study aims to investigate the relationship between accuracy level of LOS predictions and operational performance indicators. To model the ICU patient flows, a discrete event simulation model is developed. A linear function of actual and simulated LOS values is used to measure the accuracy level of the predictions. Multiple configurations of patient mix and patient waiting threshold were included in the simulation scenarios. Performance indicators are average waiting time of patients for an ICU bed and overall admission ratios. Further statistical tests were carried out to evaluate the significance of the results. Results suggest that inaccurate LOS predictions overestimated both average waiting time of patients for an ICU bed and overall admission rates. The gaps increased when more elective patients were included in the patient mix. Moreover, higher waiting thresholds (i.e. maximum amount of time a patient will wait for an ICU bed) yielded higher values in both performance indicators.

Do most premature babies get discharged by the expected date of delivery?

To compare the length of stay (LOS) against the expected date of delivery (EDD) and to describe mortality and LOS outcomes by gestational age (GA) categories over the years. Healthcare Cost and Utilization Project Kids' Inpatient database discharge records for years 2003, 2006, 2009, 2012, and 2016 were analyzed. For premature infants after inclusion-exclusion, actual, and calculated LOS were compared. Mortality and LOS outcomes were analyzed by GA and years. The majority (99%) of infants >28 weeks were discharged by EDD while, for neonate ≤28 weeks, about three-quarters (75%) of infants were discharged by calculated EDD. LOS is increasing while mortality is decreasing by GA categories in recent years. This is the largest study of mortality and LOS in the United States. Our study provides evidence-based numbers comparing actual LOS against EDD, which can be used in perinatal settings to counsel parents.

National Surgical Quality Improvement Program risk calculator validity in South Australian laryngectomy patients.

Assessing an individual patient's post-operative risk profile prior to laryngectomy for cancer is difficult. The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) risk calculator was developed to better inform preoperative decision-making. The calculator uses patient-specific characteristics to estimate the risk of experiencing post-operative complications within 30 days of surgery. We investigated the ACS-NSQIP risk calculator's performance for Australian laryngectomy patients. The ACS-NSQIP risk calculator was used to retrospectively calculate the 30-day post-operative predicted outcomes in patients who underwent laryngectomy for laryngeal, hypopharyngeal and thyroid cancers (with laryngeal involvement) in two institutions in South Australia. These data were compared against the actual mortality, morbidity, complications and length of stay (LOS) collected from a retrospective chart review. A total of 144 patients underwent surgical intervention for malignancies with laryngeal involvement. The median LOS was 25 days (range 13-197) compared to the predicted LOS of 6.5 days (range 3.5-12.5). Overall mortality was 2.78% with post-operative complications occurring in 63% of patients. The most common complication was wound infection, occurring in 33% of patients. Hosmer-Lemeshow plots demonstrated good agreement between predicted and observed rates for complications. The ACS-NSQIP risk calculator effectively predicted post-operative complication rates in South Australian laryngeal cancer patients undergoing laryngectomy. However, differences in predicted and actual LOS may limit the usefulness of the calculator's LOS predictions for Australian patients.

68 Application of the Modified Hospital Length of Stay Predictor

Abstract Introduction Developing formulas to predict accurate length of stay (LOS) is challenging in burn patients as many complex variables can effect LOS. A recently published article in 2016 provided new formulas (NFs) to predict hospital LOS. Our goal is to compare our patients actual LOS (ALOS) to the NFs published, the traditional 1day/%TBSA rule, and to the hospital expected LOS (ELOS) based on patients CMI/DRGs. Methods Data was collected from Jan ‘16 to Dec ‘18 on all patients >18 years of age using NTRACS burn registry. We excluded deaths, non-burns, readmissions, any records with missing information, and any patients transferred to another acute care hospital. We performed multiple regression to examine the relationship between LOS with age, inhalational injury (INHINJ), and TBSA on all patients. We divided this population into three groups per the NFs recommendations: 1) INHINJ; 2) without INHINJ < 40 years old; 3) without INHINJ >40 years old. Using these three groups, we calculated the difference between ALOS to 1) the traditional LOS formula, 2) the NFs as established in the 2016 article, and to 3) the hospitals ELOS metrics. For acuity comparison, we also calculated average CMI in each study group. The NFs published are as follows: Results The multiple regression model with all three variables (Age, % TBSA, and INHINJ) produced R² = 0.321, F(3,883) = 139.23, p < .05. INHINJ, age, and TBSA had significant positive regression, indicating an increase or presence of all three variables will lengthen LOS. The regression equation is: LOS = (-3.93) +1.71(AGE) +1.11(TBSA) +15.81 (Inhalation). Every year increase in age increased LOS by 1.71 days. Every 1% increase in TBSA increased LOS by 1.11 days. Presence of INHINJ (0= no INHINJ; 1= INHINJ) increased LOS by 15.81 days. Table 1 depicts the mean ± SD of the difference in LOS (predicted - actual) for the three predictive models of LOS. Negative values indicate underestimation of LOS and positive values indicate overestimate of LOS. Conclusions Application of the predictive LOS formulas has underestimated LOS in this population, with the exception of the NFs to predict LOS on patients >40 years old without INHINJ. Furthermore, an R² value of 0.32 indicates that the variables utilized in this study do not account for 68% of the variation we see. This is further exemplified by the wide standard deviations, particularly in the INHINJ group. Applicability of Research to Practice Directly Applicable.

Estimating the neonatal length of stay for preterm babies in a saudi tertiary hospital

Introduction: The most frequent cause of morbidity and mortality in neonatal care units worldwide is prematurity. It represents the second leading cause of neonatal death after congenital anomalies and a significant determinant of newborn and infant morbidity. Objective: The objective is to have a local estimate of the length of stay (LOS) and risk of death for babies admitted to neonatal intensive care units, which facilitate planning and family counseling. Materials and Methods: This study is a retrospective review for all babies born at 23–36 weeks of gestational age (GA) and admitted to the neonatal unit from January 2010 to April 2019. We calculated the actual median LOS for babies and compared them with days to due date based on the GA and birth weight (BW). Results: There were 2913 babies born at 23–36 weeks GA admitted to the neonatal unit. In addition, the majority of babies (2845) did not require surgical intervention; only 61 babies did require surgical intervention. There was a negative correlation between the LOS median (interquartile range) and each of the GA or BW of the babies (LOS decreased as the week of GA and BW increased), while GA had a positive association with the BW. The total number of babies discharge from neonatal care was 2605 (89.7%). Conclusion: BW and GA are inherent factors that allow for a simple and objective prediction of the LOS in the neonatal unit, which can estimate on the 1st day of life.

27 Expanding Your Operational Toolkit: Using Computer Simulation to Improve Flow

Emergency department (ED) crowding has become a crisis for the U.S. health care system. Crowding often manifests as long waiting times for individual patients, extended overall length of stay (LOS), and high left-without-being seen (LWBS) rates. Hospitals and health care systems must invest in management strategies to address ED overcrowding and inpatient boarding. Computer simulation may be a cost-effective, efficient means to proactively identify and manage bottlenecks in patient care and excessive wait times or prolonged LOS. Simulation models are a novel tool to enhance prospective operational planning. We aimed to develop and validate a simulation model to estimate LOS in our ED. We then aimed to evaluate whether the simulation model could be used for operational planning by examining whether it could accurately predict the impact of planned operational changes. A high-fidelity, highly granular discrete event simulation (DES) model of patient flow through our ED was created in MedModel, a health care modeling operations software from the ProModel Corporation (Allentown, PA) that relies on queuing theory. This in silico model includes the entire ED, allowing visualization and analysis of multiple stages/queues during the patient flow through the ED. The model was developed using time stamps abstracted from the electronic health record (EHR): bed placement, RN assessment, MD assessment, and turnaround times (TOTs) for laboratory or imaging studies. Initial validation was performed by comparing system output LOS times to actual LOS values. The model was considered to be a valid predictor of LOS if simulated estimates were within a 5% margin of the actual LOS. After initial validation, the simulation was asked to model the impact of a dedicated inpatient holding unit. In the real world, a 15-bed ED pod was converted into a holding unit for admitted patients boarding in the ED awaiting inpatient bed assignment. LOS metrics were compared between simulation projections and actual data after implementation of this change. In this case, the model was considered valid if simulated estimates were within a 5% margin of the actual LOS and in the same direction of action. Initial validation of our simulation model confirmed that the model would predict LOS within 5% of real-world metrics. Simulated LOS was accurate, predicting LOS that was within 4.1% of actual LOS for all patients, and 0.8% of LOS for admitted patients. The simulation model also accurately predicted direction of impact on LOS for admitted patients following implementation of a 15-bed inpatient holding unit in the ED (Table 1). A DES simulation model is a valid tool to estimate LOS in the ED and can predict LOS following operational interventions (eg, implementation of an inpatient holding unit). Future work should test whether or not use of DES as an adjunct to standard decisionmaking improves operational metrics.Table 1Simulation model performance evaluating creation of inpatient holding unit.SimulationActual% DifferenceAdmit LOS, pre-implementation721 min726.4 min0.7%Admit LOS, post-implementation704 min715.8 min1.6% Open table in a new tab

When can I go home after my knee replacement? Factors affecting the duration of in-hospital stay after knee replacement.

Despite a sevenfold decline in the number of postoperative nights (21-3) after a total knee arthroplasty (TKA) over the last four decades, predictors of length of stay (LOS) are not fully understood. We attempted to ascertain these factors by analyzing a large cohort of patients. Prospectively collected data between January 2016 and March 2017 were retrospectively analyzed at our institute. Charts of 1663 consecutive, simple primary unilateral and bilateral TKAs were reviewed for the LOS excluding staggered bilateral, complex primary and revision knees. Preoperative variables [demographics, cash/credit status, historical, clinical, laboratory findings, Knee Society Function Scores and Oxford Knee Scores (OKSs)] were scrutinized by multivariate regression to identify significant factors affecting LOS and formulate model equations for patients and health caregivers. Results were incorporated into an iOS application, which was tested for accuracy. Among 1524 unilateral and 139 bilateral TKAs, mean LOS was 4.4 and 5.2days, respectively. Five factors, namely insurance, flexion/hyperextension deformity, preoperative OKS and a rheumatoid etiology, were significantly associated with prolonged LOS in unilateral knees. The impact of these independent variables on LOS could be calculated by: [Formula: see text]For bilateral cases, the only significant variable extending LOS was a low preoperative OKS and the equation is given as follows: [Formula: see text]The iOS-app-predicted LOS and actual LOS were similar (p > 0.05) for 115 prospectively operated knees. Poor preoperative OKS, rheumatoid etiology, flexion and hyperextension deformity and delays in insurance affected unilateral TKR LOS, while poor preoperative OKS alone affected LOS in bilateral cases.

Validation of the LACE readmission and mortality prediction model in a large surgical cohort: Comparison of performance at preoperative assessment and discharge time points

Study objectiveThe LACE index (Length of stay, admission Acuity, Charlson comorbidity index, and Emergency department visits within 6 months of current admission) is a practical tool designed to predict the risk of readmission or mortality within 30 days of hospital discharge. We sought to validate and examine its performance in a large surgical population at both the preoperative assessment and discharge time points. DesignRetrospective cohort study. SettingWe identified all admissions with a surgery or procedure at Vanderbilt University Medical Center (VUMC) between 2010 and 2015. PatientsA total of 192,670 admissions (age ≥ 18) were included in the study. InterventionsNone. MeasurementsLACE scores were calculated and analyzed with multivariable logistic regression. Discrimination was assessed with the c-statistic, calibration was assessed with calibration plots, and overall performance evaluated with the Brier score. Four models were created: admissions with any surgery or procedure, surgical admissions using actual length of stay (ALOS), surgical admissions using estimated length of stay (ELOS) and non-surgical procedural admissions. Main results192,670 admissions were included. The all admissions model c-statistic was 0.77 with a Brier score of 0.13. Surgical admissions with ALOS and ELOS had a c-statistic of 0.80, 0.82 and a Brier score of 0.10, 0.08 respectively. Non-surgical procedural admissions had a c-statistic of 0.76 and a Brier score of 0.14. Calibration for all models was adequate. ConclusionsThe LACE model for surgical and procedural admissions had good discrimination and adequate calibration. Analysis of the model applied to surgical admissions using ELOS demonstrated slightly better overall performance than ALOS, suggesting that LACE could be utilized for readmission risk stratification at the time of preoperative assessment.Clinical Trial and Registry URL: Not applicable.

Effects of two anti-parkinsonian drugs on learning and memory processes in rats

Length of stay (LOS) after surgery for adult spinal deformity (ASD) is a critical period that allows for optimal recovery. Predictive models that estimate LOS allow for stratification of high-risk patients.A prospectively acquired multicenter database of patients with ASD was used. Patients with staged surgery or LOS >30 days were excluded. Univariable predictor importance ≥0.90, redundancy, and collinearity testing were used to identify variables for model building. A generalized linear model was constructed using a training dataset developed from a bootstrap sample; patients not randomly selected for the bootstrap sample were selected to the training dataset. LOS predictions were compared with actual LOS to calculate an accuracy percentage.Inclusion criteria were met by 653 patients. The mean LOS was 7.9 ± 4.1 days (median 7 days; range, 1–28 days). Following bootstrapping, 893 patients were modeled (653 in the training model and 240 in the testing model). Linear correlations for the training and testing datasets were 0.632 and 0.507, respectively. The prediction accuracy within 2 days of actual LOS was 75.4%.Our model successfully predicted LOS after ASD surgery with an accuracy of 75% within 2 days. Factors relating to actual LOS, such as rehabilitation bed availability and social support resources, are not captured in large prospective datasets. Predictive analytics will play an increasing role in the future of ASD surgery, and future models will seek to improve the accuracy of these tools.

Focused Resident Education and Engagement in Quality Improvement Enhances Documentation, Shortens Hospital Length of Stay, and Creates a Culture of Continuous Improvement

System-based practice with an emphasis on quality improvement (QI) is a recent initiative for the American College of Surgeons and a core-competency for surgical trainees. Few surgical training programs have a curriculum for hospital-based QI. Our vascular surgery service implemented several QI initiatives focused on decreasing length of stay (LOS) by targeting resident education and engagement. Residents were educated on terminology and processes impacting hospital and CMS QI metrics such as Medicare geometric mean LOS (CMS GMLOS) and diagnostic-related groups (DRG) with complication or comorbidity (CC/MCC) coding. LOS initiatives focused on identifying, tracking and removing avoidable perioperative delays, and improving accuracy of clinical documentation. Residents were given specific roles in QI initiatives and the impact on LOS was quantified. Patients' CMS GMLOS were compared to actual LOS during daily rounds, with confirmation that resident progress notes contained thorough and accurate documentation of diagnoses, comorbidities, and complications. Ten minutes during weekly preoperative conferences were dedicated to ongoing QI, with LOS metrics for the inpatient census presented by trainees and reviewed by attendings. Feedback was given addressing barriers to avoidable delays and impact on LOS. Data for July 2016-June 2017 (FY17) was compared to preimplementation baseline data (FY16) for vascular discharges overall. Accurate documentation of acuity was evaluated with in-depth review of notes and overall case mix index. Within the first year of implementation, overall vascular admissions demonstrated a 21% reduction in LOS, closing the gap between observed LOS and expected CMS GMLOS, from 2.1days to 0.5days on average. Documentation improved, with a shift in 24% of DRGs to accurately reflect CC/MCC. Overall case mix index increased by 10%, from 3.07 to 3.37. A culture of continuous quality improvement can be created with the establishment of a QI infrastructure that educates and involves trainees as stakeholders. Assigning discrete roles to increase resident accountability supports both formal and informal resident education that can substantially impact hospital benchmarking metrics.

Successful Reduction in the Heart Failure Length of Stay through Standardized Management

Background As the focus to decrease in-hospitalization medical expenses increases, length of stay (LOS) has become a focal point of analysis particularly in the heart failure (HF) population. This is a reasonable goal as HF is the leading cause of hospital admission in patients older than 65 years old and research has shown that shorter LOS is associated with better outcomes. The purpose of this project was to standardize the management of HF patients and to decrease the HF average length of stay (ALOS) by one day. Method In this single center observational study, five areas of potential improvement were identified: Initial Furosemide dosage, early involvement of cardiology team, utilization of a standardized HF order set, multi-disciplinary rounding and close monitoring from the nursing staff. The data showed that the majority of the HF patients were receiving Furosemide 40mg or less as the first dose in the Emergency Department (ED) which was associated with a two day increase in the length of stay, as compared to those receiving 60mg and higher. Furthermore, the data also showed low utilization of the HF order set, and lack of early cardiology consultation. Process benchmarking revealed an opportunity to restructure the multidisciplinary rounds to give focus on the progression of care. Review of literature uncovered the need to restructure the responsibilities of the HF nurse coordinator to support the initiative. Based on the identified opportunities, a HF management algorithm was created to standardize the approach. A HF nurse was appointed to oversee and promote these 5 key areas of focus. Results Improvements in the aforementioned processes, utilization of at least Furosemide 60mg in the ED increased from 22% to 67% in six months. Furthermore, order set utilization increased from 32% to 81% and cardiology consult increased from 75% to 95% both within a few months. These enhancements resulted in a 1.04 day reduction in the ALOS. In HF admissions, ALOS decreased from 7.72 days (2016) to 6.68 days (01/2017 - 07/2017). A true measure of this improvement is the LOS index which is the ratio of actual LOS over expected LOS. HF LOS index steadily trended down from 1.42 (01/2017) to 1.1 in (6/2017) (Vizient data). Conclusion In conclusion, the expansion of these five key milestones were the fundamental drivers in lowering the LOS by more than 1 day.

Assessment of the NSQIP Surgical Risk Calculator in Predicting Microvascular Head and Neck Reconstruction Outcomes

This study evaluated the accuracy of the Surgical Risk Calculator (SRC) of the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) in predicting head and neck microvascular reconstruction outcomes. Retrospective analysis. Tertiary medical center. A total of 561 free flaps were included in the analysis. The SRC-predicted 30-day rates of postoperative complications, hospital length of stay (LOS), and rehabilitation discharge were compared with the actual rates and events. The SRC's predictive value was examined with Brier scores and receiver operating characteristic area under the curve. A total of 425 myocutaneous, 134 osseous (84 fibula, 47 scapula, and 3 iliac crest), and 2 omental free flaps were included in this study. All perioperative complications evaluated had area under the curve values ≤0.75, ranging from 0.480 to 0.728. All but 2 postoperative complications had Brier scores >0.01. SRC-predicted LOS was 9.4 ± 2.38 days (mean ± SD), which did not strongly correlate with the actual LOS of 11.98 ± 9.30 days ( r = 0.174, P < .0001). The SRC is a poor predictor for surgical outcome among patients undergoing microvascular head and neck reconstruction.

Predictive Modeling of Length of Hospital Stay Following Adult Spinal Deformity Correction: Analysis of 653 Patients with an Accuracy of 75% within 2 Days

Length of stay (LOS) after surgery for adult spinal deformity (ASD) is a critical period that allows for optimal recovery. Predictive models that estimate LOS allow for stratification of high-risk patients. A prospectively acquired multicenter database of patients with ASD was used. Patients with staged surgery or LOS >30 days were excluded. Univariable predictor importance ≥0.90, redundancy, and collinearity testing were used to identify variables for model building. A generalized linear model was constructed using a training dataset developed from a bootstrap sample; patients not randomly selected for the bootstrap sample were selected to the training dataset. LOS predictions were compared with actual LOS to calculate an accuracy percentage. Inclusion criteria were met by 653 patients. The mean LOS was 7.9 ± 4.1 days (median 7 days; range, 1-28 days). Following bootstrapping, 893 patients were modeled (653 in the training model and 240 in the testing model). Linear correlations for the training and testing datasets were 0.632 and 0.507, respectively. The prediction accuracy within 2 days of actual LOS was 75.4%. Our model successfully predicted LOS after ASD surgery with an accuracy of 75% within 2 days. Factors relating to actual LOS, such as rehabilitation bed availability and social support resources, are not captured in large prospective datasets. Predictive analytics will play an increasing role in the future of ASD surgery, and future models will seek to improve the accuracy of these tools.

Abstract PR331

Background & Objectives: Total Knee Arthroplasty (TKA) is a common surgical procedure for patients with end stage joint disease [1]. Poorly controlled pain in the post-operative setting is associated with higher levels of opioid use and opioid related adverse effects, immobility, morbidity, longer hospital admissions, and decreased overall patient satisfaction [2]. There is no current gold standard for pain reduction in the post-operative time period. One narcotic alternative, intravenous acetaminophen, was first commercialized in Europe in 2002 and has subsequently been approved by the FDA. Preliminary studies have found it safe and efficacious for decreasing post-operative pain, including TKA. We plan to perform a three arm study comparing the clinical advantages of a periarticular liposomal bupivacaine injection versus a standardized knee injection cocktail previously described versus this same knee injection cocktail with the addition of intravenous acetaminophen on decreasing opioid related side effects without sacrificing expected levels of analgesia. The main study endpoints will be a Visual Analogue Score (VAS) Pain score and Opioid Related Symptoms Distress Scale (OR-SDS). Additional endpoints will include Total Morphine Equivalents (TME) administered, Actual Length of Stay, Active Knee Range of Motion, and Discharge location. Materials & Methods: This will be a randomized, prospective, single-center clinical trial to evaluate the efficacy of three treatment methods on reducing pain in patients undergoing a TKA. The study will involve 141 patients divided evenly into three treatment arms. All patients in this study will be treated with the standardized spinal anesthesia, the standardized adductor canal block, 10 mg of dexamethasone intravenously, and four postoperative doses of IV ketorolac (15 mg every eight hours for forty-eight hours). The Standardized Spinal Anesthesia After it is washed with epinephrine, between 1.4 ml to 2 ml of hyperbaric bupivacaine will be drawn into the syringe (with dosage dependent on the height of patient and duration of surgery). The Standardized Adductor Canal Block Periarticular Liposomal Bupivacaine Injection Treatment Group Standardized Knee Cocktail Treatment Group IV Acetaminophen Plus Standardized Knee Cocktail Treatment Group Results: The results of the 141 currently enrolled patients will be reported after statistical analysis. Conclusion: The result of the 141 currently enrolled patients will be reported after statistical analysis with conclusions to follow.

Do Heart Failure Pathways Decrease Length of Stay and Conservable Days and Leverage Organization Efficiencies?

Background and Significance: Congestive heart failure CHF) is a common, chronic disease that significantly impacts patient outcomes, efficient patient management and health care economics. At a two site hospital corporation in Ontario, Canada, CHF is one of the top admission diagnoses and leading outlier in terms of length of stay (LOS) and conservable days. In the fiscal year April 1, 2012 to March 31, 2013, quarterly audits demonstrated poor compliance with CHF pathway and standardized order set use. Aim: Mixed method study/quality initiative to review CHF pathway use and determine if heart failure pathways decrease LOS, conservable days and leverage organization efficiencies. Methodology: A mixed methods approach was taken.: 1) staff surveys to identify CHF pathway awareness and barriers to use, 2) Secondary data analysis on a) site specific chart audits of CHF pathway/order set compliance b) CHF admission/discharge data to examine LOS, expected length of stay (ELOS), and conservable days. Data Analysis/Results: Pearson’s chi-square determined responses to question 5 (use CHF pathway regularly) were statistically significant between sites, χ2 (1) = 7.07, p = .008, with 54.1% of Site 2 respondents indicating yes compared with 21.4% of Site 1 respondents. Tests of ANOVA revealed no significant differences between patient age or ELOS between sites. Actual LOS was significantly different between sites, F (1, 498) = 6.20, p = .013, with average LOS at Site 1 (M = 10.05 days, SD = 9.32 days) greater than Site 2 (M = 7.73 days, SD = 11.03). An ANOVA with site as independent variable and conservable days as dependent variable, revealed significant difference between sites, F (1, 498) = 7.78, p = .006, with Site 2 reporting a statistically significant decreased number of mean conservable days (M = -1.15, SD = 4.59) compared with Site 1 (M = .08, SD = 5.23). All analyses were conducted with SPSS, Version 22 (IBM Corp., 2013). Conclusion/Implications: This study provided some evidence that CHF pathways may decrease LOS and conservable days and leverage organization efficiencies. This has the potential to be of critical significance to an overburdened health care system and further research should be undertaken. These results must be interpreted with caution as the reliance on secondary data analysis and survey responses prevents the determination of causation.

Ventilation time and LOS in ICU and thus fast-track potential is not affected by low or moderate sufentanil administration - a randomized study

Background. Progressive cost containment as well as a more efficient use of resources has resulted in a growing interest in fast-track cardiac surgery. Ventilation time and length of stay (LOS) in the ICU are important factors in early patient mobilization and patient turnover. Early extubation is usually considered one of the main steps in fast-track pathways1. The application of fast-track protocols, have demonstrated a shorter postoperative ventilation time and reduced use of resources in cardiac surgery patients. Different protocols have been proposed to achieve this, but the impact of different regimes, drugs and logistics is still debated and the question of effect, applicability, quality and safety is still open. We hypothesized that a protocol with half our standard dose of Sufentanil and double dose of Propofol would reduce ventilation time and LOS in ICU. Methods. Sixty cardiac surgery patients were randomized to “standard” dose sufentanil (bolus 1 mg/kg and propofol 1.8 mg/kg/ h) or “low” dose (bolus 0.5 mg/kg and propofol 3.6 mg/kg/h). Depth of anaesthesia was monitored with BIS, aiming at BIS below 50 during surgery. The primary endpoints were ventilation time and eligible time to discharge from ICU. Secondary outcomes were actual LOS in ICU and quality of recovery. Results. The groups were fully comparable in selected demographics and perioperative parameters. The use of sufentanil and propofol were significantly different between groups. There was no difference in ventilation time (191 vs 204 minutes) or the eligible ICU discharge time (11.3 vs 10.5) between the groups. The propofol infusion was significantly higher (2.76 mg/kg/h) than the stipulated dose (1.8 mg/kg/h) in the “standard” group (P o 0.0001.). Conclusion. Both regimes were useful in keeping the patient on the desired anaesthesia level. Regarding the fast-track potential, we could not demonstrate a faster turnover in patients receiving significantly less opioids during anaesthesia.

Perioperative risk factors for early intensive care delirium following cardiac surgery

fast-track cardiac surgery protocols leading to early discharge from the ICU. Early extubation is usually considered one of the main steps in fast-track pathways1 and studies have demonstrated that the application of fast-track anaesthesia resulted in decreased ventilation time. Length of stay (LOS) in the ICU is an important report tool in research and logistics and one of the main factors limiting operating room utilization in cardiac surgery. However, LOS in ICU is not a fully objective measure as patient discharge besides medical factors may be guided by logistics and policy and thus more objective measures are warranted. The need for a faster ICU turnover due to increased demand and reduced resources has led to a continuous search for factors which can reduce the LOS in the ICU2.The present study compares two randomized fast-track protocols with focus on ventilation time, eligible time to discharge from ICU and patient quality of recovery. Method. Sixty cardiac surgery patients acting as control groups from two randomized studies, (nominated A, 2015 and B, 2013) concerning different aspects of fast-track protocols. The control patients in the two studies were treated equally in relevant parameters. The primary endpoints were ventilation time and eligible time to discharge from ICU and secondary outcomes were actual LOS in ICU and quality of recovery. Results. The patient groups were fully comparable in selected demographics and peroperative parameters. The median ventilation time decreased from study B 261 (216-372) to 205 min (139-279) in study A (P1⁄40.019; Mann-Whitney test). The mean eligible time to discharge was not different being 11.4 (8.4-14.6) and 10.5 (6.6-13.6) (P1⁄40.387) respectively nor was the actual median discharge time (21.2 (19.1-23.1) vs 20.4 (18.6-22.1) h) (P1⁄40.234). The quality of recovery evaluated by ICU scores showed statistically significant higher total scores in study A (figure). Higher scores in individual parameters were found in pain and diuresis while sedation scores were lower the first 10 postoperative hours in patients from study A. Conclusion. A reduction in ventilation time was seen between control individuals from the two studies. However the shorter ventilation time did not lead to shorter eligible or actual discharge time and we found some indications of poorer patient quality during recovery. OP-46

Association Between Patient and Emergency Department Operational Characteristics and Patient Satisfaction Scores in a Pediatric Population.

Emergency departments (EDs) are seeing an increase in the importance of patient satisfaction scores, yet little is known about their association with patient and operational characteristics. This study aimed to identify patient and operational characteristics associated with patient satisfaction scores. This was a retrospective analysis of data from Press Ganey patient satisfaction surveys of pediatric patients (<18 years) and their families, discharged from the ED of a single, academic, pediatric ED from December 2009 to May 2013. A linear mixed-effects regression model was used to identify significant associations while taking the clustering within patients and physicians into account. Outcome variables included scores for overall experience (0-10), wait time to be seen by a provider (0-100), and likelihood to recommend (0-100). The ED characteristics considered included daily census, proportion of left without being seen, average length of stay (LOS), and total boarding hours, as well as time of day by shift, door-to-room time, and discharge LOS. Patient characteristics included patient age, sex, race, person completing survey, survey language, survey method (mailed or online), payer type, mode of arrival, distance to hospital, weekend or weekday visit, and difference of patient-reported LOS to actual LOS. Only statistically significant variables were included in the final model. A total of 810 pediatric surveys were included for analysis. The overall mean (SD) was 8.7 (2.0) for overall experience, 84.0 (23.5) for waiting time to be seen by a provider, and 90.1 (22.2) for likelihood to recommend. The score for overall experience was highly correlated with likelihood to recommend (r = 0.90) and less strongly correlated with score for waiting time (r = 0.58). In the final models, increased door-to-room time was associated with a significant decrease in scores for all 3 outcome variables. In addition, a difference between perceived and actual LOS (>2 hours) was significantly associated with lower scores in overall experience and likelihood to recommend, whereas surveys completed online had higher scores for waiting time to see a provider compared with mailed. Emergency departments looking to increase satisfaction scores should focus efforts on decreasing door-to-room times.

Does one score fit all? Measuring risk in ulcerative colitis

BackgroundThe American College of Surgeons Surgical Risk Calculator was developed to improve risk stratification and surgical quality but has not been studied at the institutional level for specific disease states, like ulcerative colitis (UC). MethodsUC patients undergoing colorectal resection had predicted risk calculator data compared with actual outcomes for length of stay (LOS), complications, reoperation, and death. Main outcome measures were the difference in actual vs predicted outcomes. ResultsSeventy patients were evaluated. The actual and predicted mean LOS was identical, but not representative of the actual LOS picture, which had 10 LOS outliers (14.3%). The actual incidence of any complication (P < .001) and major complications (P < .001) was higher than predicted. The most common complications actually encountered-intrabdominal abscess (14.3%), postoperative ileus (7.2%), and anastomotic leak (5.7%), were not even calculated by the tool. ConclusionsFor UC, the calculator poorly evaluates relevant risks, complications, and is greatly impacted by outliers. These limitations caution use for surgical quality reporting and determining specific patient outcomes, at least in UC.

Remifentanil Compared With Sufentanil Does Not Enhance Fast-Track Possibilities in Cardiac Surgery—A Randomized Study

Progressive cost containment has resulted in a growing interest for fast-track cardiac surgery. Ventilation time and length of stay (LOS) in the intensive care unit (ICU) are important factors in patient turnover, a more efficient use of resources, and early patient mobilization. However, LOS in ICU is not an objective measure because, in addition to medical factors, patient discharge may be guided by logistics and policy, and thus more objective measures are warranted. The authors hypothesized that remifentanil compared with sufentanil would reduce ventilation time and LOS in the ICU and that remifentanil would have beneficial effects on the overall quality of recovery. A randomized, prospective study. Sixty patients scheduled for elective coronary artery bypass grafting with or without aortic valve replacement. A university hospital. Patients were assigned randomly to receive either remifentanil or sufentanil combined with propofol. Patients with ejection fraction<0.3, myocardial infarction within the last 4 weeks, diabetes, and severe pulmonary or arterial hypertension were excluded. The primary outcome variables were ventilation time and time to eligibility of discharge from the cardiac recovery unit. Secondary outcomes were actual LOS in the cardiac recovery unit and quality of recovery. The groups were comparable in selected demographics and perioperative parameters. There were no differences in ventilation time or eligible ICU discharge time between the groups. Remifentanil patients received more morphine than did the sufentanil patients during recovery (20 mg v 10 mg; p = 0.040). No difference was found in pharmacologic support or use of a pacemaker. In a fast-track protocol, remifentanil did not seem to be superior to a standard moderate- to high-dose sufentanil regimen.