Acute Length Of Stay Research Articles

Frailty in general medicine patients receiving geriatric medicine liaison services is predictive of adverse outcomes.

Frailty is in an increasing focus for acute care systems due to its association with adverse health outcomes. The Clinical Frailty Scale (CFS) is a judgement-based frailty assessment tool, which classifies the frailty status of older adults, but more research involving general medicine inpatients is necessary. The objectives of this study were to describe the predictive ability of CFS, administered by geriatric medicine trained nurses, for adverse outcomes including the following: acute unit and total length of stay (LOS), new nursing home (NH) admission, 12-month mortality and readmission within 30-day. Design Retrospective study. Participants Patients admitted under general medicine unit and seen by the geriatric medicine liaison team in one general hospital. Main Measure CFS. Of 394 patients included, 60% were mild-moderately frail, and 21% severely frail. In a multivariable analysis, patients classified as severely frail (CFS 7-9) had significantly high odds of death during admission (OR = 13.64), new NH admission (OR = 34.97) and acute LOS (OR = 1.74), compared to non-frail patients (CFS1-4). Mild-moderately frail (CFS 5-6) patients had significantly higher odds for new NH admission (OR = 4.36), acute unit LOS (OR = 1.49) and total LOS (OR = 1.61) compared to non-frail patients. In a Cox regression multivariable survival analysis, the severely frail had a sixfold significantly higher likelihood (HR = 6.19) of 12-month mortality, and the mild-moderately frail had a doubled likelihood (HR = 2.13), compared to the non-frail. The CFS has clinical utility for identifying general medicine older inpatients at-risk of various adverse outcomes.

Rehabilitation after surgery for hip fracture – the impact of prompt, frequent and mobilisation-focused physiotherapy on discharge outcomes: an observational cohort study

PurposeTo determine the relationship between three postoperative physiotherapy activities (time to first postoperative walk, activity on the day after surgery, and physiotherapy frequency), and the outcomes of hospital length of stay (LOS) and discharge destination after hip fracture.MethodsA cohort study was conducted on 437 hip fracture surgery patients aged ≥ 50 years across 36 participating hospitals from the Australian and New Zealand Hip Fracture Registry Acute Rehabilitation Sprint Audit during June 2022. Study outcomes included hospital LOS and discharge destination. Generalised linear and logistic regressions were used respectively, adjusted for potential confounders.ResultsOf 437 patients, 62% were female, 56% were aged ≥ 85 years, 23% were previously living in a residential aged care facility, 48% usually walked with a gait aid, and 38% were cognitively impaired prior to their injury. The median acute and total LOS were 8 (IQR 5–13) and 20 (IQR 8–38) days. Approximately 71% (n = 179/251) of patients originally living in private residence returned home and 29% (n = 72/251) were discharged to a residential aged care facility. Previously mobile patients had a higher total LOS if they walked day 2–3 (10.3 days; 95% CI 3.2, 17.4) or transferred with a mechanical lifter or did not get out of bed day 1 (7.6 days; 95% CI 0.6, 14.6) compared to those who walked day 1 postoperatively. Previously mobile patients from private residence had a reduced odds of return to private residence if they walked day 2–3 (OR 0.38; 95% CI 0.17, 0.87), day 4 + (OR 0.38; 95% CI 0.15, 0.96), or if they only sat, stood or stepped on the spot day 1 (OR 0.29; 95% CI 0.13, 0.62) when compared to those who walked day 1 postoperatively. Among patients from private residence, each additional physiotherapy session per day was associated with a -2.2 (95% CI -3.3, -1.0) day shorter acute LOS, and an increased log odds of return to private residence (OR 1.76; 95% CI 1.02, 3.02).ConclusionHip fracture patients who walked earlier, were more active day 1 postoperatively, and/or received a higher number of physiotherapy sessions were more likely to return home after a shorter LOS.

Is the level of consent to a national research registry associated with patient outcomes following traumatic spinal cord injury? A population-based study from the Rick Hansen Spinal Cord Injury Registry (RHSCIR).

We examined the impact of consenting to the Rick Hansen Spinal Cord Injury Registry (RHSCIR) on outcomes: acute length of stay (LOS), in-hospital mortality, medical complications (pressure injuries and pneumonia), and the final discharge destination following a spinal cord injury (SCI) using the national RHSCIR dataset. A retrospective cohort study was conducted using RHSCIR participant data from 2014 to 2019. Participants approached for enrollment were grouped into 1) PC: provided full consent including community follow-up (CFU) interviews, 2) DWC: declined CFU interviews but accepted minimal data collection that may include initial/final interviews and/or those who later withdrew consent, and 3) DC: declined consent to any participation. As no data was collected for the DC group, descriptive, bivariate, and multivariable regression analysis was limited to the PC and DWC groups. Of 2811 participants, 2101 (74.7%) were PC, 553 (19.7%) were DWC, and 157 (5.6%) were DC. DWC participants had significantly longer acute LOS, more acute pneumonias/pressure injuries, and were less likely to be discharged home than PC participants. All these associations - except pneumonia - remained significant in the multivariable analyses. Not participating fully in RHSCIR was associated with more complications and longer hospital stays.

Introduction of enhanced weekend physiotherapy for patients with hip fracture is associated with improved early mobility outcomes.

To assess whether enhanced daily weekend physiotherapy (EWP) for patients with hip fracture was associated with improved clinical outcomes. We retrospectively analysed all previously ambulatory adults admitted with hip fracture to our tertiary hospital, comparing 'usual' ('control') care (09/19-03/20) to EWP (09/20-03/21). Outcomes included Day-7 mobility ≥20 m (primary), additional mobility measures, specified postoperative complications, new residential facility placement, acute length-of-stay (LOS) and 30-day death. Amongst 235 eligible patients (128 control, 107 EWP), 66% were female, mean age was 80.4 years (SD 10.5), 20% from residential care and 49% (114/235) were mobilising without aid at baseline (no between-group differences; all p ≥ .20). Median acute LOS was 10 days (IQR 6-15), total hospital LOS was 21 days (IQR 12-37) and 3% (n = 6) died by Day 30. Median Day-7 distance mobilised was 25 m (IQR 7-50) with EWP versus 10 m (3-40) (p = .06). No EWP patients developed pressure injury (0 vs. 6, p = .02); other outcomes were similar between groups. Adjusting for age, residence, baseline cognitive impairment, American Society of Anesthesiologist score and preadmission mobilisation without aids, EWP was independently associated with increased likelihood of mobilising ≥20 m at Day 7 (aOR 1.83, 95% CI 1.04-3.23, p = .03). Enhanced daily weekend physiotherapy was associated with improvement in early mobility, but not other outcomes assessed. These data would be strengthened by randomised controlled trial data exploring more intense physiotherapy, cost-benefit analysis and patient experience measures.

A Digital Respiratory Ward in Leicester, Leicestershire, and Rutland, England, for Patients With COVID-19: Economic Evaluation of the Impact on Acute Capacity and Wider National Health Service Resource Use.

The COVID-19 pandemic stressed global health care systems' acute capacity and caused a diversion of resources from elective care to the treatment of acute respiratory disease. In preparing for a second wave of COVID-19 infections, England's National Health Service (NHS) in Leicester, Leicestershire, and Rutland sought to protect acute capacity in the winter of 2020-2021. Their plans included the introduction of a digital ward where patients were discharged home early and supported remotely by community-based respiratory specialists, who were informed about patient health status by a digital patient monitoring system. The objective of the digital ward was to maintain acute capacity through safe, early discharge of patients with COVID-19 respiratory disease. The study objective was to establish what impact this digital ward had on overall NHS resource use. There were no expected differences in patient outcomes. A cost minimization was performed to demonstrate the impact on the NHS resource use from discharging patients into a digital COVID-19 respiratory ward, compared to acute care length of stay (LOS). This evaluation included all 310 patients enrolled in the service from November 2020 (service commencement) to November 2021. Two primary methods, along with sensitivity analyses, were used to help overcome the uncertainty associated with the estimated comparators for the observational data on COVID-19 respiratory acute LOS, compared with the actual LOS of the 279 (90%) patients who were not discharged on oxygen nor were in critical care. Historic comparative LOS and an ordinary least squares model based on local monthly COVID-19 respiratory median LOS were used as comparators. Actual comparator data were sourced for the 31 (10%) patients who were discharged home and into the digital ward for oxygen weaning. Resource use associated with delivering care in the digital ward was sourced from the digital system and respiratory specialists. In the base case, the digital ward delivered estimated health care system savings of 846.5 bed-days and US $504,197 in net financial savings across the 2 key groups of patients-those on oxygen and those not on oxygen at acute discharge (both P<.001). The mean gross and net savings per patient were US $1850 and US $1626 in the base case, respectively, without including any savings associated with a potential reduction in readmissions. The 30-day readmission rate was 2.9%, which was below comparative data. The mean cost of the intervention was US $223.53 per patient, 12.1% of the estimated gross savings. It was not until the costs were increased and the effect reduced simultaneously by 78.4% in the sensitivity analysis that the intervention was no longer cost saving. The digital ward delivered increased capacity and substantial financial savings and did so with a high degree of confidence, at a very low absolute and relative cost.

Continuation of Oral Antidiabetic Medications Was Associated With Better Early Postoperative Blood Glucose Control Compared to Sliding Scale Insulin After Total Knee Arthroplasty

BackgroundThis study evaluated blood glucose (BG), creatinine levels, metabolic issues, length of stay (LOS), and early postoperative complications in diabetic primary total knee arthroplasty (TKA) patients. It examined those who continued home oral antidiabetic medications and those who switched to insulin postoperatively. The hypothesis was that continuing home medications would lead to lower BG levels without metabolic abnormalities. MethodsPatients who had diabetes who underwent primary TKA from 2013 to 2022 were evaluated retrospectively. Diabetic patients who were not on home oral antidiabetic medications or who were not managed as an inpatient postoperatively were excluded. Patient demographics and laboratory tests collected preoperatively and postoperatively as well as 90-day emergency department visits and 90-day readmissions, were pulled from electronic records. Patients were grouped based on inpatient diabetes management: continuation of home medications versus new insulin coverage. Acute postoperative BG control, creatinine levels, metabolic abnormalities, LOS, and early postoperative complications were compared between groups. Multivariable regression analyses were performed to measure associations. ResultsA total of 867 primary TKAs were assessed; 703 (81.1%) patients continued their home oral antidiabetic medications. Continuing home antidiabetic medications demonstrated lower median maximum inpatient BG (180.0 mg/dL versus 250.0 mg/dL; P < .001) and median average inpatient BG (136.7 mg/dL versus 173.7 mg/dL; P < .001). Logistic regression analyses supported the presence of an association (odds ratio = 17.88 [8.66, 43.43]; P < .001). Proportions of acute kidney injury (13.5 versus 26.7%; P < .001) were also lower. There was no difference in relative proportions of metabolic acidosis (4.4 versus 3.7%; P = .831), LOS (2.0 versus 2.0 days; P = .259), or early postoperative complications. ConclusionsContinuing home oral antidiabetic medications after primary TKA was associated with lower BG levels without an associated worsening creatinine or increase in metabolic acidosis. Level III EvidenceRetrospective Cohort Study.

300 Older persons in early supported discharge: an exploration of their experiences

Abstract Background Early Supported Discharge (ESD) for Stroke is a complex intervention which enables people with new onset stroke to realise an accelerated discharge with rehabilitation in their home setting. ESD is supported with a robust evidence base, yet less is known about the specific experience of older adults. This paper aims to explore the experience and outcomes of patients over 65 years old in 2022 in a single stroke ESD site. Methods A password-encrypted database is held onsite, on which data for all ESD patients is inputted and updated during the time the patient is in the ESD service or shortly thereafter. The database was retrospectively reviewed to look at pertinent characteristics of the subgroup of ESD patients over 65 in 2022. Descriptive statistics were used to describe demographic details, functional outcomes, and predicted Length of Stay (LoS) saving in the acute hospital and LoS on the programme. Results Of 75 patients availing of ESD in the period, 47 were over 65 (62.6%). 63.8% of the over 65 cohort were female in contrast to 48% of the under 65 s. The Functional Independence Measure/Functional Assessment Measure (FIM/FAM) and Extended Activities of Daily Living (EADL) tools were used on admission and discharge. The FIM/FAM produced improvement score median of 6.08% and EADL, median score 12% among those over 65. The estimated LOS saving was the same across both groups (9.4 days). Average time on ESD programme was 29 days for this population, while those under 65 averaged at 46.6 days. Conclusion Older adults demonstrated functional gains in this ESD service, as measured by FIM/FAM and EADL measures, and they required less time in ESD than those under 65. Age did not influence acute LOS saving in this cohort. A larger review is indicated to determine trends over time and across ESD sites.

Functional Outcome Prediction After Spinal Cord Injury Using Ensemble Machine Learning

ObjectivesTo establish a machine learning model to predict functional outcomes after SCI with Spinal Cord Independence Measure (SCIM) using features present at the time of rehabilitation admission. Study DesignA retrospective, single-center study. The following data were collected from the medical charts: age, sex, acute length of stay (LOS), level of injury, American Spinal Injury Association Impairment Scale (AIS), motor scores of each key muscle, Upper Extremity Motor Score (UEMS), Lower Extremity Motor Score (LEMS), SCIM total scores, and subtotal scores on admission and discharge. Based on the multivariate linear regression analysis, age, acute LOS, UEMS, LEMS, and SCIM subtotal scores were selected as features for machine learning algorithms. Random forest, support vector machine, neural network, and gradient boosting were used as the base models and combined using ridge regression as a metamodel. SettingA spinal center in Tokyo, Japan. ParticipantsParticipants were individuals with SCI admitted to our hospital from March 2016 to October 2021 for the first rehabilitation after the injury. They were divided into 2 groups: training (n=140) and testing (n=70). InterventionsNot applicable. Main Outcome MeasuresThe root-mean-square error (RMSE), R2, and Mean Absolute Error (MAE) were used as accuracy measures. ResultsRMSE, R2, and MAE of the meta-model using the testing group were 9.7453, 0.8835, and 7.4743, respectively, outperforming any other single base model. ConclusionsOur study revealed that functional prognostication could be achieved using machine-learning methods with features present at the time of rehabilitation admission. Goals can be set at the beginning of rehabilitation. Moreover, our model can be used to evaluate advanced medical treatments, such as regenerative medicine.

Evaluation of the use of methylprednisolone and dexamethasone in asthma critically ill patients with COVID-19: a multicenter cohort study

BackgroundPrevious studies have shown mortality benefits with corticosteroids in Coronavirus disease-19 (COVID-19). However, there is inconsistency regarding the use of methylprednisolone over dexamethasone in COVID-19, and this has not been extensively evaluated in patients with a history of asthma. This study aims to investigate and compare the effectiveness and safety of methylprednisolone and dexamethasone in critically ill patients with asthma and COVID-19.Methods The primary endpoint was the in-hospital mortality. Other endpoints include 30-day mortality, respiratory failure requiring mechanical ventilation (MV), acute kidney injury (AKI), acute liver injury, length of stay (LOS), ventilator-free days (VFDs), and hospital-acquired infections. Propensity score (PS) matching, and regression analyses were used.ResultsA total of one hundred-five patients were included. Thirty patients received methylprednisolone, whereas seventy-five patients received dexamethasone. After PS matching (1:1 ratio), patients who received methylprednisolone had higher but insignificant in-hospital mortality in both crude and logistic regression analysis, [(35.0% vs. 18.2%, P = 0.22) and (OR 2.31; CI: 0.56 – 9.59; P = 0.25), respectively]. There were no statistically significant differences in the 30-day mortality, respiratory failure requiring MV, AKI, acute liver injury, ICU LOS, hospital LOS, and hospital-acquired infections.ConclusionsMethylprednisolone in COVID-19 patients with asthma may lead to increased in-hospital mortality and shorter VFDs compared to dexamethasone; however, it failed to reach statistical significance. Therefore, it is necessary to interpret these data cautiously, and further large-scale randomized clinical trials are needed to establish more conclusive evidence and support these conclusions.

Nutrition care processes from intensive care unit admission to inpatient rehabilitation: A retrospective observational study

ObjectivesExtended duration of nutrition interventions in critical illness is a plausible mechanism of benefit and of interest to inform future research. The aim of this study was to describe nutrition processes of care from intensive care unit (ICU) admission to discharge from inpatient rehabilitation. MethodsThis was a single-center retrospective study conducted at a health care network in Melbourne, Australia. Adult patients in the ICU >48 h and discharged to inpatient rehabilitation within 28 d were included. Dietitian assessment data and nutrition impacting symptoms were collected until day 28. Data are presented as n (%), mean ± SD or median (interquartile range). ResultsFifty patients were included. Of the 50 patients, 28 were men (56%). Patients were 65 ± 19 y of age with an Acute Physiology And Chronic Health Evaluation II score 15.5 ± 5.2. ICU length of stay (LOS) was 3 d (3–6), acute ward LOS was 10 d (7–14), and rehabilitation LOS was 17 d (8–37). Patients assessed by a dietitian and days to assessment in ICU, acute ward, and rehabilitation were 43 (86%) and 1 (0–1); 42 (84%) and 1 (1–3), and 32 (64%) and 2 (1–4) d, respectively. Oral nutrition was the most common mode: 40 (80%) in the ICU and 48 (96%) on the acute ward and rehabilitation. There was at least one nutrition impacting symptom reported in 44 patients (88%). ConclusionsRehabilitation LOS was longer than in the ICU or acute wards, yet patients in rehabilitation were assessed the least by a dietitian and time to assessment was longest. Symptoms that impact nutrition intake were common; nutrition interventions beyond the acute care setting in critical illness need investigation.

Effect of inpatient rehabilitation facility care on ninety day modified Rankin score in ischemic stroke patients

ObjectiveTo determine Inpatient Rehabilitation Facility (IRF) treatment effect on modified Rankin Scale (mRS) scores at 90 days in acute ischemic stroke (AIS) patients. Materials and methodsThis prospective cross-sectional study included 738 AIS patients admitted 1/1/2018-12/31/2020 to a Comprehensive Stroke Center with a Stroke Rehabilitation program. We compared outcomes for patients who went directly home versus went to IRF at hospital discharge: (1) acute care length of stay (LOS), (2) National Institutes of Health Stroke Scale (NIHSS) score, (3) mRS score at hospital discharge and 90 days, (4) the proportion of mRS scores ≤ 2 from hospital discharge to 90 days. ResultsAmong 738 patients, 499 went home, and 239 went to IRF. IRF patients were more likely to have increased acute LOS (10.7 vs 3.9 days; t-test, P<0.0001), increased mean NIHSS score (7.8 vs 4.8; t-test, P<0.0001) and higher median mRS score (3 vs 1, t-test, P<0.0001) compared to patients who went home. At 90 days, ischemic stroke patients who received IRF care were more likely to progress to a mRS ≤ 2 (18.7% increase) compared to patients discharged home from acute care (16.3% decrease). Home patients experienced a one-point decrease in mRS at 90 days compared to those who received IRF treatment (median mRS of 3 vs. 2, t-test, P<0.05). ConclusionsIn ischemic stroke patients, IRF treatment increased the likelihood of achieving mRS ≤ 2 at 90 days indicating the ability to live independently, and decreased the likelihood of mRS decrease, compared with patients discharged directly home after acute stroke care.

COVID-19 is associated with increased care needs and a decreased likelihood of returning home following a hip fracture: The IMPACT frailty study.

The primary aim was to evaluate the impact of COVID-19 on frailty in patients surviving a hip fracture. Secondary aims were to assess impact of COVID-19 on (i) length of stay (LoS) and post-discharge care needs, (ii) readmissions, and (iii) likelihood of returning to own home. This propensity score-matched case-control study was conducted in a single centre between 01/03/20-30/11/21. A 'COVID-positive' group of 68 patients was matched to 141 'COVID-negative' patients. 'Index' and 'current' Clinical Frailty Scale (CFS) scores were assigned for frailty at admission and at follow-up. Data were extracted from validated records and included: demographics, injury factors, COVID-19 status, delirium status, discharge destination, and readmissions. For subgroup analysis controlling for vaccination availability, the periods 1 March 2020-30 November 2020 and 1 February 2021-30 November 2021 were considered pre-/post-vaccine periods. Median age was 83.0years, 155/209 (74.2%) were female and median follow-up was 479days (interquartile range [IQR] 311). There was an equivalent median increase in CFS in both groups (+1.00 [IQR 1.00-2.00, p=0.472]). However, adjusted analysis demonstrated COVID-19 was independently associated with a greater magnitude change (Beta coefficient [β] 0.27, 95% confidence interval [95% CI] 0.00-0.54, p=0.05). COVID-19 in the post-vaccine availability period was associated with a smaller increase versus pre-vaccine (β -0.64, 95% CI -1.20 to -0.09, p=0.023). COVID-19 was independently associated with increased acute LoS (β 4.40, 95% CI 0.22-8.58, p=0.039), total LoS (β 32.87, 95% CI 21.42-44.33, p<0.001), readmissions (β 0.71, 95% CI 0.04-1.38, p=0.039), and a four-fold increased likelihood of pre-fracture home-dwelling patients failing to return home (odds ratio 4.52, 95% CI 2.08-10.34, p<0.001). Hip fracture patients that survived a COVID-19 infection had increased frailty, longer LoS, more readmissions, and higher care needs. The health and social care burden is likely to be higher than prior to the COVID-19 pandemic. These findings should inform prognostication, discharge-planning, and service design to meet the needs of these patients.

The Impact of Rapid PCR Testing for Viral Respiratory Infections on Acute Admissions From the Emergency Department and Inpatient Length of Stay.

Diagnosing influenza and respiratory syncytial virus (RSV) with conventional multiplex respiratory viral polymerase chain reaction (PCR) takes 24-72 hours compared with under two hours for recently available rapid PCR tests. We investigated the impact of rapid diagnosis of acute respiratory viral infection on admission odds from the emergency department (ED) and acute inpatient length of stay (LOS), as well as concordance between the rapid and conventional PCR tests used at our institution. Single-center retrospective cohort study of patients presenting to the ED with influenza-like illness. We compared the odds of admission and acute LOS in patients investigated with rapid PCR, those investigated with conventional PCR, and those investigated with both tests. Multivariable logistic regression was used to assess the odds of admission, while linear regression was used to assess LOS. There was no significant change in the odds of admission among patients who received the rapid PCR compared to conventional PCR (odds ratio: 1.01, 95% confidence interval [CI]: 0.50-2.02; p = 0.96). There was also no significant difference in LOS of admitted patients who received rapid PCR testing (regression coefficient: -0.32, 95% CI: -1.75 to 1.12; p = 0.66). The rapid PCR test used at our institution yielded fully concordant results with conventional PCR testing. Rapid PCR testing is as sensitive as conventional PCR testing for the diagnosis of influenza and RSV but is neither associated with a significant impact on admission nor inpatient LOS. Further research is needed to assess the impact of rapid testing on isolation room use.

809 USE OF NEW MOBILITY SCORE AND A TRANS-DISCIPLINARY APPROACH TO REDUCE HOSPITAL LOS, RETURN TO ORIGINAL RESIDENCE, AND MORTALITY

IntroductionThe National Hip Fracture Database indicated Guy’s and St Thomas’ Trust ranked in the fourth quartile nationally with reference to hospital length of stay (LOS), return to original residence (ROR), and mortality in hip fracture patients in 2018. This quality improvement project aimed to improve and maintain these key factors via a two-stage process.MethodsStage one involved implementation of four key interventions through a trans-disciplinary focus group, comprising ortho-geriatricians, orthopaedic surgeons, physiotherapists (PT), occupational therapists (OT), nursing staff, and a transfer of care navigator (TCN). Firstly, the New Mobility Score (NMS) was employed as a tool to guide estimated length of stay. Secondly, use of preoperative OT assessment allowed early evaluation of patient expectations concerning discharge planning. Third, facilitation of the discharge process was optimised by the recruitment of a TCN. Lastly, attendance of a senior orthogeriatrician during the daily board round was established. Stage two involved education of new members of the trans-disciplinary team to ensure that the key interventions listed above were maintained on hip fracture patients.ResultsFollowing stage one, average acute hospital LOS and overall LOS decreased from 20.1 to 15.1 days and 22.4 to 18.3 days, respectively. Rate of ROR within 120 days of discharge improved from 72.4% to 86.9%, while mortality rates fell from 7.1 to 3.4. Following stage two, overall LOS improved to 17.1 days, while acute LOS and mortality were maintained at 15.6 and 3.9 days, respectively. While ROR fell to 82.8%, this remained higher than the national average at 69.9%.ConclusionsUtilisation of NMS and multi-disciplinary input effectively improved ROR, while reducing length of hospital stay and mortality rates in hip fracture patients. Education of new members of the trans-disciplinary team allowed sustained improvement despite challenges faced during the COVID-19 pandemic.

Association between surgical wait time and hospital length of stay in primary total knee and hip arthroplasty.

AimsIn countries with social healthcare systems, such as Canada, patients may experience long wait times and a decline in their health status prior to their operation. The aim of this study is to explore the association between long preoperative wait times (WT) and acute hospital length of stay (LoS) for primary arthroplasty of the knee and hip.MethodsThe study population was obtained from the provincial Patient Access Registry Nova Scotia (PARNS) and the Canadian national hospital Discharge Access Database (DAD). We included primary total knee and hip arthroplasties (TKA, THA) between 2011 and 2017. Patients waiting longer than the recommended 180 days Canadian national standard were compared to patients waiting equal or less than the standard WT. The primary outcome measure was acute LoS postoperatively. Secondarily, patient demographics, comorbidities, and perioperative parameters were correlated with LoS with multivariate regression.ResultsA total of 11,833 TKAs and 6,627 THAs were included in the study. Mean WT for TKA was 348 days (1 to 3,605) with mean LoS of 3.6 days (1 to 98). Mean WT for THA was 267 days (1 to 2,015) with mean LoS of 4.0 days (1 to 143). There was a significant increase in mean LoS for TKA waiting longer than 180 days (2.5% (SE 1.1); p = 0.028). There was no significant association for THA. Age, sex, surgical year, admittance from home, rural residence, household income, hospital facility, the need for blood transfusion, and comorbidities were all found to influence LoS.ConclusionSurgical WT longer than 180 days resulted in increased acute LoS for primary TKA. Meeting a shorter WT target may be cost-saving in a social healthcare system by having shorter LoS.Cite this article: Bone Jt Open 2021;2(8):679–684.

Impact of time to first antimicrobial dose on length of stay and 30-day hospital readmission in patients with lower limb cellulitis

There have been efforts to promote timely antimicrobial administration for patients with sepsis, but the importance for other infections is uncertain. This study analysed whether time to first antimicrobial dose (TFAD) in patients with lower limb cellulitis influenced outcome measures such as acute length of stay (LOS) in hospital and 30-day hospital readmission rates for cellulitis. Medical records of patients admitted with lower limb cellulitis or erysipelas over a 15-month period (1 May 2019 to 30 November 2019 and 1 March 2020 to 31 October 2020) were reviewed. Patients requiring intensive care unit (ICU) admission were excluded. The TFAD was the difference (in minutes) between the emergency department triage time and the time that the antimicrobial was first recorded as administered. Analysis included log-transformed linear regression (for LOS) and logistic regression (for 30-day readmission with cellulitis), controlling for confounders where possible. The study included 282 patients with lower limb cellulitis. The median TFAD was 177 min (interquartile range, 98-290 min). Linear regression suggested a weak association between TFAD and LOS (P=0.05; adjusted R2=0.01), which was non-significant after adjusting for confounders (P=0.18). There were too few patients readmitted within 30 days with cellulitis for meaningful analysis. After controlling for confounders, no association between increased TFAD and increased acute LOS was identified for patients with lower limb cellulitis who did not require ICU admission (i.e. without septic shock). Conclusions could not be made for 30-day readmission rates for cellulitis.

Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit.

Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N= 957) requiring packed red blood cell transfusion between January 2015 and December 2015. In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p= 0.02) and LOS in patients with chronic blood loss (β1 .8.26, 95% CI 4.09-12.43; p< 0.01). A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

Factors associated with discharge destination following inpatient functional rehabilitation in patients with traumatic spinal cord injury.

Retrospective review of data from a prospective database of a Level 1 trauma center. This project aims to identify factors collected during the acute and rehabilitative care following a traumatic spinal cord injury (TSCI) associated with success and failure to return home after inpatient intensive functional rehabilitation (IFR). Level 1 trauma center specialized in TSCI care in Montreal, Canada. All eligible patients from our prospective database were separated into two groups according to discharge destination following IFR. Clinical variables collected during the acute and rehabilitative care as well as demographic variables were compared between patients who managed to return home (Group 1) and those who were discharged elsewhere (Group 2). Multivariable regression analyses were conducted with variables that were significant at the univariate level. Out of the 193 patients included, 22 (11%) failed to return home following IFR. Six variables were associated with failure to return home at the univariate level: longer acute length of stay (LOS), longer rehabilitation LOS, living alone, higher neurological level of injury, having comorbidities, and having a pressure injury (PI) during acute care. Three variables remained significant at the multivariate level: living alone, increasing acute LOS and presenting a high cervical (C1-C4) neurological level of injury. It is important that acute care clinicians recognize the aforementioned factors early after TSCI in order to optimize patients for community reintegration.

Impact of a family medicine-based transitional care intervention on readmission and length of stay: a pilot study

Transitional care interventions, often led by hospital specialists, have mixed impact on reducing readmissions. Interventions led by family physicians may be more promising. The objective of this study was to evaluate the impact of a family-medicine-based intervention in reducing the incidence of emergency department (ED) visits, hospital readmissions and the length of stay (LOS) of older patients. A quasi-experimental pilot-study was conducted at a Family Medicine Group (FMG) in Montreal. Thirty-five patients discharged from the FMG-affiliated hospital between July 2014-2015 were compared to 68 historical controls discharged from the same hospital one year prior. Inclusion criteria were: 65+ years, rostered at FMG, high-risk of readmission; and discharged to home/senior residence. Patients’ charts were reviewed to determine a composite outcome of all-cause rates of acute hospital use (ED visit/hospital readmissions) and LOS at 30, 60, 90 and 180-days post-discharge. We found no statistically significant differences in acute hospital use rates between groups. LOS was statistically significantly shorter at 90- and 180-days for patients compared to controls: Incidence Rate Ratio (95% Confidence Interval) at 90-days: 0.66 (0.64-0.69) and at 180-days: 0.49 (0.43-0.55). Our study provides support to the impact of a family-medicine-based transitional care intervention in reducing the LOS of vulnerable older patients readmitted to hospital.

Patients from residential aged care with hip fractures-Does discharge destination from acute care affect outcomes?

The aim of this study was to describe the demographics of patients from residential aged care facilities (RACFs) who underwent fixation of hip fracture and to compare 12-month functional and mortality outcomes for those returning to their RACF with those admitted to a subacute facility (SAF) following their acute hospital stay. A retrospective review was undertaken of all patients from a RACF with high-level care needs admitted to Alfred Hospital, Melbourne, for fixation of hip fracture in 2014-2015. Data including demographic and hospital event details, length of stay (LOS), discharge destination and 12-month functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), were collected. Factors related to discharge destination and outcomes were analysed. Ninety patients from a RACF were included in this study, with 68 patients (76%) returning to their RACF and 22 (24%) admitted to a SAF after acute hospital stay. Those discharged to a SAF had an average LOS at this facility of 20.79days (SD 8.02). The SAF group also had a longer acute LOS (7days IQR 5-10, compared to 6days IQR 4-7.5) but there was no difference between groups at 12months in terms of mortality or function, with 50% of all patients deceased at this time point (n=40) and the remaining 40 patients (50%) reporting a poor functional outcome. Mobility status during acute and subacute stay, and 12-month functional and mortality outcomes were similar in both groups irrespective of discharge destination, with the influence of cognition and concomitant medical issues currently unknown. Further research is required to evaluate the efficacy of current hip fracture models of care, the factors that influence clinician discharge planning decision-making and to interrogate new models of care that support rehabilitation and complex medical management in RACFs.