Acute Care Hospitals In California Research Articles

Outbreak of Burkholderia multivorans among patients at two acute-care hospitals in California, August 2021–July 2022

Background:Burkholderia multivorans are gram-negative bacteria typically found in water and soil. B. multivorans outbreaks among patients without cystic fibrosis have been associated with exposure to contaminated medical devices or nonsterile aqueous products. Acquisition can also occur from exposure to environmental reservoirs like sinks or other hospital water sources. We describe an outbreak of B. multivorans among hospitalized patients without cystic fibrosis at 2 hospitals within the same healthcare system in California (hospitals A and B) between August 2021 and July 2022. Methods: We defined confirmed case patients as patients without cystic fibrosis hospitalized at hospital A or hospital B between January 2020 to July 2022 with B. multivorans isolated from any body site matching the outbreak strain. We reviewed medical records to describe case patients and to identify common exposures. We evaluated infection control practices and interviewed staff to detect exposures to nonsterile water. Select samples from water, ice, drains, and sink splash zone surfaces were collected and cultured for B. multivorans in March 2022 and July 2022 from both hospitals. Common aqueous products used among case patients were tested for B. multivorans. Genetic relatedness between clinical and environmental samples was determined using random amplified polymorphic DNA (RAPD) and repetitive extragenic palindromic polymerase chain reaction (Rep-PCR). Results: We identified 23 confirmed case patients; 20 (87%) of these were identified at an intensive care unit (ICU) in hospital A. B. multivorans was isolated from respiratory sources in 18 cases (78%). We observed medication preparation items, gloves, and patient care items stored within sink splash zones in ICU medication preparation rooms and patient rooms. Nonsterile water and ice were used for bed baths, swallow evaluations, and ice packs. B. multivorans was cultured from ice and water dispensed from an 11-year-old ice machine in the ICU at hospital A in March 2022 but no other water sources. Additional testing in July 2022 yielded B. multivorans from ice and a drain pan from a new ice machine in the same ICU location at hospital A. All products were negative. Clinical and environmental isolates were the same strain by RAPD and Rep-PCR. Conclusions: The use of nonsterile water and ice from a contaminated ice machine contributed to this outbreak. Water-related fixtures can serve as reservoirs for Burkholderia, posing infection risk to hospitalized and immunocompromised patients. During outbreaks of water-related organisms, such as B. multivorans , nonsterile water and ice use should be investigated as potential sources of transmission and other options should be considered, especially for critically ill patients.Disclosures: None

Trends in emergency department visits associated with cannabis use among older adults in California, 2005-2019.

The use of cannabis among older adults is increasing in the United States. While cannabis use has been suggested to help alleviate chronic symptoms experienced by older adults, its potential adverse effects may lead to unintended consequences, including increased acute healthcare utilization related to its use. The objective of this study was to examine trends in cannabis-related emergency department (ED) visits in California. Using data from the Department of Healthcare Access and Information, we conducted a trend analysis of cannabis-related ED visits from all acute care hospitals in California from 2005 to 2019. For each calendar year, we determined the cannabis-related ED visit rate per 100,000 ED visits for adults aged ≥65 utilizing primary or secondary diagnosis codes. We estimated the absolute and relative changes in overall cannabis-related visit rates during the study period and by subgroup, including age (65-74, 75-84, ≥85), race/ethnicity, sex, payer/insurance, Charlson comorbidity index score, and cannabis-related diagnosis code. The cannabis-related ED visit rate increased significantly for adults aged ≥65 and all subgroups (p < 0.001). The overall rate increased from 20.7 per 100,000 visits in 2005 to 395.0 per 100,000 ED visits in 2019, a 1804% relative increase. By race/ethnicity, older Black adults had the highest ED visit rate in 2019 and the largest absolute increase while older males had a higher ED visit rate in 2019 and a greater absolute increase than older women. Older adults with a higher Charlson score had a higher ED visit rate in 2019 and a larger absolute increase during the study period. Cannabis-related ED visits are increasing among older adults in California and are an adverse effect of cannabis use. Asking about cannabis use and providing education about its use should be a part of routine medical care for older adults.

Association of the coronavirus disease 2019 (COVID-19) pandemic with the incidence of healthcare-associated infections in California hospitals.

To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on the incidence of central-line-associated bloodstream infections (CLABSIs), Clostridioides difficile infections (CDIs), and methicillin-resistant Staphyloccocus aureus (MRSA) bloodstream infections (BSIs) in California acute-care hospitals. Retrospective cohort and before-and-after study. We compared standardized infection ratios (SIRs) for CLABSI, CDI, and MRSA BSI from the second half of 2020 to the second half of 2019. We performed interrupted time-series (ITS) analyses for these infections to assess departures from long-term trends. We also examined the association between the proportion of facility beds that were occupied by COVID-19 patients in May and June of 2020 and the incidence of infections using negative binomial models. In addition, we compared standardized antimicrobial administration ratios (SAARs) for the second halves of 2019 and 2020. We detected substantial and significant increases in the SIRs for CLABSI and MRSA BSI from 2019 to 2020. For the ITS analysis, CLABSI and had significant positive values for the pandemic onset level-change parameters, and CLABSI and MRSA BSI had significant positive values for the postinterruption slope-change parameters. We also detected a positive association between facility COVID-19 patient occupancy and CLABSI and MRSA BSI incidence. We did not detect associations with the onset of the pandemic or COVID-19 patient occupancy and CDI. The SAAR for all antibacterial drugs decreased slightly, but the SAAR for drugs with a high risk for CDI increased slightly. This study adds to a body of literature documenting increases in CLABSI and MRSA BSI incidence during the pandemic.

Geriatric Falls: Patient Characteristics Associated with Emergency Department Revisits.

IntroductionFalls are the leading cause of traumatic injury among elderly adults in the United States, which represents a significant source of morbidity and leads to exorbitant healthcare costs. The purpose of this study was to characterize elderly fall patients and identify risk factors associated with seven-day emergency department (ED) revisits.MethodsThis was a multicenter, retrospective, longitudinal cohort study using non-public data from 321 licensed, nonfederal, general, and acute care hospitals in California obtained from the Department of Healthcare Access and Information from January 1–December 31, 2017. Included were patients 65 and older who had a fall-related ED visit identified by International Classification of Diseases codes W00x to W19x. Primary outcome was a return visit to the ED within a seven-day window following the index encounter. Demographics collected included age, gender, ethnicity/race, patient payer status, Charlson Comorbidity Index (CCI), psychiatric diagnoses, and alcohol/substance use disorder diagnoses. We performed multivariate logistic regression to identify characteristics associated with seven-day ED revisit.ResultsWe identified a total of 2,758,295 ED visits during the study period with 347,233 (12.6%) visits corresponding to fall-related injuries. After applying exclusion criteria, 242,572 index ED visits were identified, representing 206,612 patients. Of these, 24,114 (11.7%) patients returned to an ED within seven days (revisit). Within this revisit population, 6,161 (22.6%) presented to a facility that was distinct from their index visit, and 4,970 (18.2%) were ultimately discharged with the same primary diagnosis as their index visit. Characteristics with the largest independent associations with a seven-day ED revisit were presence of a psychiatric diagnosis (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.69 to 1.80), presence of an alcohol or substance use disorder (OR 1.70; 95% CI 1.64 to 1.78), and CCI ≥ 3 (OR 2.79; 95% CI 2.68 to 2.90).ConclusionIn this study we identified 24,114 elderly fall patients who experienced a seven-day ED revisit. Patients with multiple comorbidities, a substance use disorder, or a psychiatric diagnosis exhibited increased odds of experiencing a return visit to the ED within seven days of a fall-related index visit. These findings will help target at-risk elderly fall patients who may benefit from preventative multidisciplinary intervention during index ED visits to reduce ED revisits.

Findings from healthcare-associated infections data validation attestation in California general acute-care hospitals

Background: Accurate and complete hospital healthcare-associated infection (HAI) data are essential to inform facility-level HAI prevention efforts and to ensure the validity and reliability of annual public reports. We implemented a validation attestation survey to assess and improve the HAI data reported by California hospitals via NHSN. Methods: The California Department of Public Health (CDPH) HAI Program invited all 401 general acute-care hospitals in California to participate in an annual HAI validation attestation survey in 2021. The survey was designed to be completed by the person with primary responsibility for HAI surveillance and reporting consistent with NHSN protocols and California laws. Survey questions addressed HAI reporting knowledge and practices and surgical procedures performed, and they included 3 hypothetical scenarios evaluating hospital application of HAI surveillance, decision making, and reporting methods. Results: We received responses from 345 hospitals (86%). For the 3 hypothetical scenarios, 171 hospitals (49.6%) correctly answered all 3 questions, 110 hospitals (31.9%) answered 2 questions correctly, 52 (15.1%) hospitals answered 1 question correctly, and 12 hospitals (3.5%) answered zero questions correctly. We did not detect a statistically significant association between facility type (ie, acute-care hospital, critical access hospital, long-term acute-care hospital, or rehabilitation hospital or unit) and the probability of getting all questions correct (Fisher exact P = .42). Of the 303 hospitals (88.0%) that perform at least 1 of the 28 surgical procedures reportable in California, 269 (88.8%) apply CDPH-recommended postoperative ICD-10 diagnosis flag codes to identify records that might indicate a possible surgical site infection (SSI). Moreover, ~289 (84.0%) hospitals confirmed that someone at their facility reviews CDPH quality assurance–quality control reports to verify the accuracy and completeness of their hospital’s reported HAI data. In 321 hospitals (93.0%) decisions about which infections are reported to NHSN are made solely by the infection preventionists or hospital epidemiologists, who are thoroughly familiar and follow NHSN protocol, definitions, and criteria. Conclusions: Most hospitals reported following best practices for evaluating records for SSIs; however, only half responded correctly to all 3 hypothetical scenarios. Our results highlight the need for ongoing education on HAI surveillance, decision making and reporting methods, and external HAI data validation in hospitals. This survey could serve as a model for other states that work with hospitals to improve HAI surveillance data and to ensure the integrity of public reports. Future research will link the results of this survey to NHSN validation audits.Funding: NoneDisclosures: None

Associations Between Patient Neighborhood Characteristics and Inappropriate Antimicrobial Use

Background: Antimicrobials are among the most commonly prescribed medications in US hospitals; an estimated 50% of hospitalized patients receive an antimicrobial. Research has shown that antimicrobial prescriptions to vary by patient- and hospital-level factors; however, disparities by patient neighborhood characteristics have not been examined. We evaluated associations between hospital and neighborhood indicators of socioeconomic status (SES) and antimicrobial use (AU) for gram-positive bacterial infections (GPBs), and broad-spectrum use for community-acquired infections (BSCAs) and hospital-onset infections (BSHOs). Methods: This analysis was conducted among 86 acute-care hospitals in California that submitted AU data via the NHSN in 2019. Hospital-level AU was measured as standardized antimicrobial administration ratios (SAARs) calculated by dividing observed antimicrobial use by risk-adjusted predicted antimicrobial use for GPB, BSCA, and BSHO antimicrobial groupings and categorized as binary (&gt;1 or &lt;1); SAARs &gt;1 indicate potential inappropriate prescribing. California Office of Statewide Health Planning and Development 2018 data were used to obtain hospital characteristics and patient age, race or ethnicity, insurance, and comorbidities (defined by Charlson comorbidity index) for hospitalizations where AU may have been indicated, based on International Classification of Diseases Tenth Revision (ICD-10) diagnosis codes. The California Healthy Places Index (HPI) was used to obtain composite neighborhood SES indicators for each patient at the ZIP code level, measured as tertiles. Covariates were aggregated to the hospital level. Poisson regressions were used to evaluate the association between hospital and neighborhood SES indicators and SAAR scores, controlling for potential hospital-level confounders. Results: Among 86 hospitals included in the analysis, the mean patient age for hospitalizations where AU may have been indicated was 66 years, the proportion of white patients was 55%, and the mean proportion of Medi-Cal users was 19%. After adjusting for confounders including age, race or ethnicity, insurance status, comorbidities, and number of hospital beds; higher median values of patient SES had a protective effect against hospitals having GP SAAR scores &gt; 1 (relative risk [RR], 0.68; 95% CI, 0.50–0.93) but was not significantly associated with hospitals having BSCA SAAR scores &gt;1 (RR, 0.79; 95% CI, 0.62–1.02) or BSHO SAAR scores &gt;1 (RR, 0.80; 95% CI, 0.61–1.04). Conclusions: Considering SES in addition to summary antimicrobial use scores such as SAARs may help identify populations potentially at risk for inappropriate AU; however, patient-level information is still necessary to evaluate appropriateness of antimicrobial prescribing.Funding: NoDisclosures: None

Antimicrobial Stewardship in Acute-Care Hospitals: A Report of the California Healthcare-Associated Infections Honor Roll

Background: Antimicrobial stewardship has been demonstrated to improve patient outcomes and reduce unwanted consequences, such as antimicrobial resistance and Clostridioides difficile infection. The California Department of Public Health (CDPH) Healthcare-Associated Infection (HAI) Program developed an honor roll to recognize facilities with the goal of promoting antimicrobial stewardship programs and encouraging collaboration and research. Methods: The first open enrollment period in California was from August 1 to September 1, 2020, and was only open to acute-care hospitals (ACHs). Enrollment occurs every 6 months. Applicants completed an application and provided supporting documentation for bronze, silver, or gold designations. The criteria for the bronze designation were at least 1 item from each of CDC’s 7 core elements for ACHs. The criteria for silver were bronze criteria plus 9 HAI program prioritized items (based on published literature) from the CDC Core Elements and demonstration of outcomes from an intervention. The criteria for gold designation were silver criteria plus community engagement (ie, local work or collaboration with healthcare partners). Applications were evaluated in 3 phases: (1) CDPH reviewed core elements and documentation, (2) CDPH and external blinded antimicrobial stewardship experts reviewed outcomes as scientific abstracts, and (3) CDPH reviewed each program for overall effectiveness in antimicrobial stewardship and final designation determination. Designations expire after 2 years. Results: In total, 119 applications were submitted (30% of all ACHs in California), of which 100 were complete and thus were included for review. Moverover, 33 facilities were from northern California and 67 were from southern California. Also, 85 facilities were part of a health system or network, 14 were freestanding, and 1 was a district facility. Facility types included 68 community hospitals, 17 long-term acute-care (LTAC) facilities, 17 academic or teaching hospitals, 4 critical-access hospitals, and 4 pediatric hospitals. There was an even distribution of hospital bed size: 35 facilities had &lt;250 beds. The final designations included 19 gold, 35 silver and 43 bronze designations. There was 44% incongruency in applicants not receiving the designation for which they applied. Community hospitals were 63%–74% of all designations, and no LTACs received a gold designation. Moreover, 63% of hospitals with gold designations had &gt;250 beds, and 47% of hospitals with bronze designations had &lt;1 25 beds. Conclusions: The number of applicants was higher than expected because the open enrollment period occurred during the COVID-19 pandemic. This finding demonstrates the high importance placed on antimicrobial stewardship among ACHs. It also provides insight into how facilities are performing and collaborating and how CDPH can support facilities to improve their ASP.Funding: NoDisclosures: None

The Scope of Hospital-Based Simulation.

Healthcare simulation has expanded dramatically; however, little is known about the scope of simulation in acute care hospitals. A descriptive, cross-sectional online survey was used. Participants included nurse executives from acute care hospitals in California. Most organizations (96%) used simulation primarily for education, 37% used simulation for health system integration and systems testing, 30% used it for error investigation, 15% used it for research, and 15% used it for patient/family education. Organizations have a substantial opportunity to increase the scope of simulation beyond education to include systems integration, clinical systems testing, and other translational simulation activities. This targeted focus on patient safety and quality will allow hospitals to improve financial performance and maximize scarce resources.

Transjugular Intrahepatic Portosystemic Shunts Reduce Variceal Bleeding and Improve Survival in Patients with Cirrhosis: A Population-Based Analysis

PurposeTo investigate from a population health perspective the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation on recurrent variceal bleeding and survival in patients with cirrhosis. Materials and MethodsPatients with cirrhosis who presented to outpatient and acute-care hospitals in California (2005–2011) and Florida (2005–2014) with variceal bleeding comprised the study cohort. Patients entered the study cohort at their first presentation for variceal bleeding; all subsequent hospital encounters were then evaluated to determine subsequent interventions, complications, and mortality data. ResultsA total of 655,577 patients with cirrhosis were identified, of whom 42,708 (6.5%) had at least 1 episode of variceal bleeding and comprised the study cohort. The median follow-up time was 2.61 years. A TIPS was created in 4,201 (9.8%) of these patients. There were significantly greater incidences of coagulopathy (83.9% vs 72.8%; P < .001), diabetes (45.5% vs 38.8%; P < .001), and hepatorenal syndrome (15.3% vs 12.5%; P < .001) in TIPS recipients vs those without a TIPS. Following propensity-score matching, TIPS recipients were found to have improved overall survival (82% vs 77% at 12 mo; P < .001) and a lower rate of recurrent variceal bleeding (88% vs 83% recurrent bleeding–free survival at 12 months,; P < .001) than patients without a TIPS. Patients with a TIPS had a significant increase in encounters for hepatic encephalopathy vs those without (1.01 vs 0.49 per year; P < .001). ConclusionsTIPS improves recurrent variceal bleeding rates and survival in patients with cirrhosis complicated by variceal bleeding. However, TIPS creation is also associated with a significant increase in hepatic encephalopathy.

Emergency departments: The economic engine of hospitals – Evidence from California

BackgroundIt is important that policy makers, emergency physicians, hospital administrators, and health system planners understand the expanded role of hospital emergency departments (EDs). ObjectivesWe sought to document the expanded role hospital EDs and their economic impact on overall hospital activity between 2002 and 2017. MethodsThis is a retrospective analysis of hospital ED capacity, utilization, and financial data from all general acute care hospitals in California (2002 through 2017). We calculate changes in ED capacity, annual ED visits and admissions through the ED, and the share of total hospital charges associated with ED generated utilization. ResultsEDs now account for well over half of all inpatient admissions to the hospital and ED outpatient visit volume has also grown substantially over time. By 2017 EDs within California's general acute care hospitals generated 67% of the total hospital economic activity (as measured by charges), up from 40% in 2002. ConclusionOverall, our data reveal that EDs are now the economic engine of hospitals and play a much larger role in the overall health care system, suggesting many unexplored policy, manpower, market, and health system design implications for further research.

03:18 PM Abstract No. 153 The influence of IVC filters on the rate of pulmonary embolism in cancer patients with deep venous thrombosis: a population-based study

Inferior vena cava (IVC) filters are placed to reduce pulmonary embolism (PE) in patients with lower extremity deep venous thrombosis (DVT). The purpose of this population based study was to evaluate the influence of IVC filters in the prevention of PE for cancer patients with DVT. Using administrative data from all discharges from acute care hospitals in California (2005-2011) and Florida (2005-2014), cancer patients with DVT were identified. All subsequent hospital visits for these patients were evaluated for the placement of an IVC filter, the development of PE, as well as bleeding and venous thrombosis risk factors. The influence of IVC filter placement on PE rates was estimated using a propensity score matching algorithm. A total of 89,041 cancer patients with DVT were identified who accounted for 289,233 inpatient hospital encounters. These patients comprised the study cohort. Of the total 24,470 (27.4%) patients who underwent IVC filter placement, 85.3% (20,875) underwent IVC filter placement within 30 days of initial DVT diagnosis. IVC filter patients had higher rates of bleeding risk factors including intracranial hemorrhage (2.6% vs 1.6% P < 0.001), lower GI bleed (8.1% vs 4.4%, P < 0.001), and hematuria (5.6% vs 3.4%, P < 0.001). In addition, IVC filter patients had higher rates of proximal DVT (53.9% vs 41.6%, P < 0.001) as well as the thrombosis risk factors of metastatic disease (47.7 vs 35.8%, P < 0.001) and coagulopathies (15.8% vs 12.3%, P < 0.001). After the initial DVT presentation, a total of 1,944 (2.2%) patients were diagnosed with PE. Adjusting for risk factors and anticoagulation use by a propensity matching algorithm, patients who received an IVC filter were noted to have a significantly improved PE-free survival at 6, 12, and 24 months relative to those who did not receive an IVC filter (96.6% vs 94.4%, 95.5% vs 92.3%, 94.0% vs 89.7%, P < 0.001). In cancer patients with DVT and bleeding risk factors, IVC filter placement is associated with an improved rate of PE-free survival.Tabled 1IVC filterNo IVC filterP ValuePatients (N)24,47065,571Age (median in years)7070NSGender (% female)50.750.6NSRace (%)NS White70.170.1 Black11.811.3 Hispanic14.114.1Intracranial hemorrhage (%)2.6%1.6%< 0.001Upper GI bleed (%)1.8%0.7%< 0.001Lower GI bleed (%)8.1%4.4%< 0.001Hematuria5.6%3.4%< 0.001Proximal DVT (%)53.9%41.6%< 0.001Metastatic disease (%)47.7%35.8%< 0.001Coagulopathy (%)15.8%12.3%< 0.001 Open table in a new tab

Hospital Volume and Operative Mortality for General Surgery Operations Performed Emergently in Adults.

This study aimed to answer 2 questions: first, to what degree does hospital operative volume affect mortality for adult patients undergoing 1 of 10 common emergency general surgery (EGS) operations? Second, at what hospital operative volume threshold will nearly all patients undergoing an emergency operation realize the average mortality risk? Nontrauma surgical emergencies are an underappreciated public health crisis in the United States; redefining where such emergencies are managed may improve outcomes. The field of trauma surgery established regionalized systems of care in part because studies demonstrated a clear relationship between hospital volume and survival for traumatic emergencies. Such a relationship has not been well-studied for nontrauma surgical emergencies. Retrospective cohort study of all acute care hospitals in California performing nontrauma surgical emergencies. We employed a novel use of an ecological analysis with beta regression to investigate the relationship between hospital operative volume and mortality. A total of 425 acute care hospitals in California performed 165,123 EGS operations. Risk-adjusted mortality significantly decreased as volume increased for all 10 EGS operations (P < 0.001 for each); the relative magnitude of this inverse relationship differed substantially by procedure. Hospital operative volume thresholds were defined and varied by operation: from 75 cases over 2 years for cholecystectomy to 7 cases for umbilical hernia repair. Survival rates for nontrauma surgical emergencies were improved when operations were performed at higher-volume hospitals. The use of ecological analysis is widely applicable to the field of surgical outcomes research.

Abstract WP223: Ischemic and Hemorrhagic Stroke in Native Americans

Introduction: Stroke is a leading cause of morbidity and mortality in the United States, affecting an estimated 15 million people each year. Native Americans (NAs) account for 1.5% of the population. Several recent studies have focused on how stroke affects minority groups. However, existing data on stroke in NAs are extremely limited. We aimed to characterize the demographic and clinical characteristics of this population and identify predictors of in-patient mortality. Methods: We evaluated claims data from acute care hospitals in California between 2005-2011. California has the largest NA population in the United States. Validated ICD-9 codes were used to identify first time primary ischemic (AIS) and hemorrhagic stroke (ICH) admissions and ascertain comorbidities and in-hospital mortality. We used univariate and multivariate logistic regression to compare baseline characteristics across race/ethnic groups and to identify independent predictors of in hospital mortality. Results: We identified 283,107 first time strokes in California between 2005 and 2011, including 234,471 AIS (83%) and 48,636 ICH (17%). Of these, 851 (0.3%) were NAs (Age 66 [SD14], female sex 444 [53%]), including 698 AISs (82%) and 153 (18%) ICHs. For AIS, NAs had intermediate prevalence of relevant vascular risk factors, including history of smoking (15% vs 18% in Blacks and 11% in Whites, p&lt;0.001) and diabetes (46% vs 48% in Hispanics and 26% in Whites, p&lt;0.001). NAs with AIS were the least likely to receive palliative care (1% vs 4% in Whites, p&lt;0.001). In ICH, NAs had the second highest proportion chronic kidney disease (13% vs. 17.5% in Blacks and 8.1% in Whites, p&lt;0.001) and the highest proportion of diabetes (41% vs. 37% in Hispanics and 21% in Whites, p&lt;0.001). In-hospital mortality was similar to other minorities (4% and 26% for AIS and ICH, respectively; all p&gt;0.2). In both AIS and ICH, predictors of in hospital mortality were similar to other minority groups. Conclusions: Native Americans constitute an important yet understudied minority population in stroke. NA have high prevalence of modifiable risk factors including diabetes and smoking.

Substance Use, Homelessness, Mental Illness and Medicaid Coverage: A Set-up for High Emergency Department Utilization.

IntroductionFrequent users of emergency departments (ED) account for 21–28% of all ED visits nationwide. The objective of our study was to identify characteristics unique to patients with psychiatric illness who are frequent ED users for mental health care. Understanding unique features of this population could lead to better care and lower healthcare costs.MethodsThis retrospective analysis of adult ED visits for mental healthcare from all acute care hospitals in California from 2009–2014 used patient-level data from California’s Office of Statewide Health Planning and Development. We calculated patient demographic and visit characteristics for patients with a primary diagnosis of a mental health disorder as a percentage of total adult ED visits. Frequent ED users were defined as patients with more than four visits in a 12-month period. We calculated adjusted rate ratios (aRR) to assess the association between classification as an ED frequent user and patient age, sex, payer, homelessness, and substance use disorder.ResultsIn the study period, 846,867 ED visits for mental healthcare occurred including 238,892 (28.2%) visits by frequent users. Patients with a primary mental health diagnosis and a co-occurring substance use diagnosis in the prior 12 months (77% vs. 37%, aRR [4.02], 95% confidence interval [CI] [3.92–4.12]), homelessness (2.9% vs 1.1%, odds ratio [1.35], 95% [CI] [1.27–1.43]) were more likely to be frequent users. Those covered by Medicare (aRR [3.37], 95% CI [3.20–3.55]) or the state’s Medicaid program Medi-Cal (aRR [3.10], 95% CI [2.94–3.25]) were also more likely to be frequent users compared with those with private insurance coverage.ConclusionPatients with substance use disorders, homelessness and public healthcare coverage are more likely to be frequent users of EDs for mental illness. Substance use and housing needs are important factors to address in this population.

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

Hospital care for children is becoming more concentrated, with interhospital transfer occurring more frequently even for common conditions. Condition-specific analysis is required to determine the value, costs, and consequences of this trend. To describe the capabilities of transferring and receiving hospitals and to determine how often children transferred after an initial diagnosis of abdominal pain or appendicitis require higher levels of care. Retrospective cohort analysis using the 2 most recent available inpatient and emergency department administrative data sets from all acute care hospitals in California from 2010 to 2011 and Florida, Massachusetts, and New York from 2013 to 2014. Data were analyzed between February and June 2018. All patients younger than 18 years with a primary diagnosis of abdominal pain or appendicitis who underwent an interhospital transfer and whose care could be matched through unique identifiers were included. Outcomes after hospital transfers, classified into encounters with major surgical procedures, imaging diagnostics, and no major procedures. Pediatric Hospital Capability Index of transferring and receiving hospitals. There were 465 143 pediatric hospital encounters for abdominal pain and appendicitis, including 53 517 inpatient admissions and 15 275 transfers. Among them, 4469 could be matched to encounters in receiving hospitals. The median (interquartile range) age of this cohort was 10 (7-14) years, with 54.8% female (2449 patients), 40.9% male (1830 patients), and 4.3% unreported sex (190 patients). The increase in capability at the receiving hospital compared with the transferring hospital was large (median [interquartile range] change in Pediatric Hospital Capability Index score, 0.70 [0.54-0.82]), with 9.2% of hospitals (57) with very high capability (Pediatric Hospital Capability Index score >0.77) receiving 80.8% of the total transfers (3610). Diagnostic imaging was undertaken in the care of 710 transferred patients (15.9%) and invasive procedures were performed in 2421 patients (54.2%), including 2153 appendectomies. No imaging or surgery was required in the care of 1338 transfers (29.9%). In this study, interfacility transfers of patients with appendicitis and abdominal pain were concentrated toward high-capability hospitals, and about 30% of patients were released without apparent intervention. These findings suggest an opportunity for improving care and decreasing cost through better interfacility coordination, such as standardized management protocols and telemedicine with high-capability hospitals. Further research is needed to identify similar opportunities among other common conditions.

Assessment of Between-Hospital Variation in Readmission and Mortality After Cancer Surgical Procedures

Although current federal quality improvement programs do not include cancer surgery, the Centers for Medicare & Medicaid Services and other payers are considering extending readmission reduction initiatives to include these and other common high-cost episodes. To quantify between-hospital variation in quality-related outcomes and identify hospital characteristics associated with high and low performance. This retrospective cohort study obtained data through linkage of the California Cancer Registry to hospital discharge claims databases maintained by the California Office of Statewide Health Planning and Development. All 351 acute care hospitals in California at which 1 or more adults underwent curative intent surgery between January 1, 2007, and December 31, 2011, with analyses finalized July 15, 2018, were included. A total of 138 799 adults undergoing surgery for colorectal, breast, lung, prostate, bladder, thyroid, kidney, endometrial, pancreatic, liver, or esophageal cancer within 6 months of diagnosis, with an American Joint Committee on Cancer stage of I to III at diagnosis, were included. Measures included adjusted odds ratios and variance components from hierarchical mixed-effects logistic regression analyses of in-hospital mortality, 90-day readmission, and 90-day mortality, as well as hospital-specific risk-adjusted rates and risk-adjusted standardized rate ratios for hospitals with a mean annual surgical volume of 10 or more. Across 138 799 patients at the 351 included hospitals, 8.9% were aged 18 to 44 years and 45.9% were aged 65 years or older, 57.4% were women, and 18.2% were nonwhite. Among these, 1240 patients (0.9%) died during the index admission. Among 137 559 patients discharged alive, 19 670 (14.3%) were readmitted and 1754 (1.3%) died within 90 days. After adjusting for patient case-mix differences, evidence of statistically significant variation in risk across hospitals was identified, as characterized by the variance of the random effects in the mixed model, for all 3 metrics (P < .001). In addition, substantial variation was observed in hospital performance profiles: across 260 hospitals with a mean annual surgical volume of 10 or more, 59 (22.7%) had lower-than-expected rates for all 3 metrics, 105 (40.4%) had higher-than-expected rates for 2 of the 3, and 19 (7.3%) had higher-than-expected rates for all 3 metrics. Accounting for patient case-mix differences, there appears to be substantial between-hospital variation in in-hospital mortality, 90-day readmission, and 90-day mortality after cancer surgical procedures. Recognizing the multifaceted nature of hospital performance through consideration of mortality and readmission simultaneously may help to prioritize strategies for improving surgical outcomes.

Current Trends and Practices of Intensive Care Unit Visitations.

Few topics have existed for decades and created as much of a debate as when discussing appropriate visitation policies for patients. Studies have continued to document the conflicted opinions of nurses to commit to fully open visiting hours for various reasons. Family members are very definite in their desire to be at their loved one's bedside. To review the visiting policies of acute care hospitals in California and compare them to the American Association of Critical-Care Nurses recommendations. This descriptive study collected data from California acute care hospital websites about critical care visiting hours to assess visiting hours and the type, age, and number of visitors. Review of 363 hospital websites demonstrated a wide variation in policies when listed. Those that did post their visitation rules had no consistent policies regarding visiting hours or age, relationship, or number of visitors. Hospital visitation policies in California are inconsistent and not evenly enforced. They do not reflect current evidence and practice guidelines. Ethics require the nurses to advocate for their patient. In this role, nurses need to become proactive in implementing policy changes in their institution based on current evidence and practice guidelines.

193 Emergency Department Patients With Cancer: How Do Outcomes at National Cancer Institute-Designated Hospitals Compare to the General Population?

There is a growing recognition of the unique challenges encountered while providing emergency care to cancer patients. We have recently presented data describing why these patients present to the ED and have explored patient characteristics that are most likely to require a repeat ED visit within 7 days. Here, we designed a study to investigate if there is a difference in outcomes when patients are seen at an emergency department affiliated with a National Cancer Institute (NCI)-designated hospital versus the general community. We performed a retrospective cohort study to investigate cancer-related ED visits from all licensed non-military acute care hospitals in California using a non-public statewide database. We queried cancer-related ED visits for patients ≥18 years of age during the 2016 calendar year and recorded ED admission and discharge diagnoses, cancer types, and medical comorbidities. Bounce-back visits were defined as ED return visits within 7 days of a preceding ED discharge. Visits were categorized based on whether the ED was in the general community, or affiliated with 1 of 8 NCI-designated cancer centers in California (City of Hope, UC Irvine, UCLA, UCSD, USC, UCSF, Stanford, or UC Davis). Cancer types were defined and categorized using primary and secondary ICD-10 codes as designated by the NCI. In 2016 there were 103,523 cancer-related ED visits that met our inclusion criteria. At NCI-designated hospital EDs (NCI EDs), 4,297 patients comprised 5,501 index visits. Interestingly, the 7-day bounce-back rate at NCI EDs was slightly higher than at general community EDs (GC EDs), 18.1% versus 17.6%. There was no significant difference in the types of cancers that were seen at GC EDs versus NCI EDs. The most common diagnoses among all ED bounce-backs were septicemia, abdominal symptoms, and other cancer-related pain. One stark difference was the rate of septicemia, which was present in 6.1% of GC ED revisits versus 3.8% of NCI ED revisits. The rate of admission upon bounce-back to a GC ED was 36.6% b 40.3% at an NCI ED, while the rate of mortality during that admission was higher for GC EDs (8.7% versus 6.5%). Interestingly, the Charlson Comorbity Index Score, which accounts for cardiopulmonary disease, diabetes, and liver disease in addition to cancer, was significantly higher among patients at GC EDs compared to NCI EDs (CMI Score of 3+ in 53.3% versus 42.8%). These data highlight interesting differences in the characteristics of bounce-backs among cancer patients seen at NCI EDs versus GC EDs. The slightly higher rate of bounce-backs at NCI EDs may be due to a combination of treating more aggressive cancers and being more comfortable with discharging potentially sick patients. The fact that sepsis was less common on repeat visits at NCI EDs perhaps suggests that these EDs are more proficient at identifying sepsis on the index visit. Although the rate of admission upon bounce-back was higher at NCI EDs, they had a lower mortality during that admission, suggesting either a higher level of care provided at those NCI hospitals, or that those sicker patients were more appropriately identified during the index visit. We hope that by further studying these differences in outcomes at NCI EDs, we can identify appropriate strategies for treating these cancer patients in the general community on their index visit.

Does the meaningful use of electronic health records improve patient outcomes?

While Electronic Health Records (EHRs) hold the promise of improving patient outcomes, past research on their efficacy has yielded inconsistent results. In this study, we overcome several drawbacks of past research by examining not just partial versus full adoption, but the impact of meaningful assimilation of EHRs as mandated by the HITECH (Health Information Technology for Economic and Clinical Health) Act. Detailed patient-level data from acute-care hospitals in California, coupled with relevant data from several other sources, is used to conduct our analysis. After controlling for self-selection bias, our results show that overall length of stay (LOS) is reduced by 3%, on average, for all patients who undergo treatment at hospitals that are meaningful-use assimilated, relative to patients at hospitals that have fully adopted EHRs. The magnitude of this reduction is increased for patients with greater comorbidity complexity and greater coordination complexity. In addition, we find an overall decrease in readmission. We do not find such benefits among full adopters of EHRs. Thus, our study provides empirical evidence that instead of merely adoption, assimilation of EHRs at a hospital-wide level can improve the efficiency with which patients are treated, with benefits from such an assimilation being far more pronounced for patients with a greater degree of health complexities. These are important findings, because hospitals are struggling to deliver quality care to their sickest patients without severe cost overruns. Recommendations from our study point to a path forward in meeting this challenge.

Lower Postsurgical Mortality for Individuals with Dementia with Better-Educated Hospital Workforce.

To investigate whether care in a hospital with more nurses holding at least a Bachelor of Science in Nursing (BSN) degree is associated with lower mortality for individuals with Alzheimer's disease and related dementias (ADRD) undergoing surgery ADRD. Cross-sectional data from 2006-07 Medicare claims were linked with the Multi-State Nursing Care and Patient Safety Survey of nurses in 4 states. Adult, nonfederal, acute care hospitals in California, Florida, New Jersey, and Pennsylvania (N=531). Medicare beneficiaries aged 65 and older with and without ADRD undergoing general, orthopedic, or vascular surgery (N=353,333; ADRD, n=46,163; no ADRD, n=307,170). Thirty-day mortality and failure to rescue (death after a complication). Controlling for hospital, procedure, and individual characteristics, each 10% increase in the proportion of BSN nurses was associated with 4% lower odds of death (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.93-0.98) for individuals without ADRD, but 10% lower odds of death (OR=0.90, 95% CI=0.87-0.94) for those with ADRD. Each 10% increase in the proportion of nurses holding a BSN degree or higher was associated with 5% lower odds of failure to rescue (OR=0.95, 95% CI=0.92-0.98) for individuals without ADRD but 10% lower odds of failure to rescue (OR=0.90, 95% CI=0.87-0.94) for those with ADRD. Individuals undergoing surgery who have coexisting ADRD are more likely to die within 30 days of admission and die after a complication than those without ADRD. Having more BSN nurses in the hospital improves the odds of good outcomes for all individuals and has a much greater effect in individuals with ADRD.