Admission Category Research Articles

Monodromy of monomially admissible Fukaya-Seidel categories mirror to toric varieties

Mirror symmetry for a toric variety involves Laurent polynomials whose symplectic topology is related to the algebraic geometry of the toric variety. We show that there is a monodromy action on the monomially admissible Fukaya-Seidel categories of these Laurent polynomials as the arguments of their coefficients vary that corresponds under homological mirror symmetry to tensoring by a line bundle naturally associated to the monomials whose coefficients are rotated. In the process, we introduce the monomially admissible Fukaya-Seidel category as a new interpretation of the Fukaya-Seidel category of a Laurent polynomial on (C⁎)n, which has other potential applications, and give evidence of homological mirror symmetry for non-compact toric varieties.

Association between child psychiatric emergency room outcomes and dimensions of psychopathology

ObjectiveTo determine the degree to which dimensional psychopathology predicts length of stay in an emergency department (ED) and need for hospital admission among children with psychiatric complaints. MethodElectronic health records of children age 4–17 years who presented to the ED of a large academic medical center were analyzed using a natural language processing tool to estimate Research Domain Criteria (RDoC) symptom scores. These scores' association with length of stay and probability of admission versus discharge to home were evaluated. ResultsWe identified 3061 children and adolescents who presented to the ED and were evaluated by the psychiatry service between November 2008 and March 2015. Median length of stay was 7.8 h (interquartile range 5.2–14.3 h) and 1696 (55.4%) were admitted to the hospital. Higher estimated RDoC arousal, cognitive, positive, and social domain scores were associated with increased length of stay in multiple regression models, adjusted for age, sex, race, private insurance, voluntary admission, and diagnostic categories. In similarly adjusted models, odds of hospital admission were increased by higher RDoC arousal and cognitive domain scores and decreased by higher negative domain scores. ConclusionsA natural language processing tool to characterize dimensional psychopathology identified features associated with differential outcomes in children in the psychiatric ED, most notably symptoms reflecting arousal and cognitive function. Methodologically, this in silico approach to risk stratification should facilitate precision psychiatry in children within the emergency setting.

The Impact of Pharmacy-specific Predictors on the Performance of 30-Day Readmission Risk Prediction Models.

Pharmacists are an expensive and limited resource in the hospital and outpatient setting. A pharmacist can spend up to 25% of their day planning. Time spent planning is time not spent delivering an intervention. A readmission risk adjustment model has potential to be used as a universal outcome-based prioritization tool to help pharmacists plan their interventions more efficiently. Pharmacy-specific predictors have not been used in the constructs of current readmission risk models. We assessed the impact of adding pharmacy-specific predictors on performance of readmission risk prediction models. We used an observational retrospective cohort study design to assess whether pharmacy-specific predictors such as an aggregate pharmacy score and drug classes would improve the prediction of 30-day readmission. A model of age, sex, length of stay, and admission category predictors was used as the reference model. We added predictor variables in sequential models to evaluate the incremental effect of additional predictors on the performance of the reference. We used logistic regression to regress the outcomes on predictors in our derivation dataset. We derived and internally validated our models through a 50:50 split validation of our dataset. Our study population (n=350,810) was of adult admissions at hospitals in a large integrated health care delivery system. Individually, the aggregate pharmacy score and drug classes caused a nearly identical but moderate increase in model performance over the reference. As a single predictor, the comorbidity burden score caused the greatest increase in model performance when added to the reference. Adding the severity of illness score, comorbidity burden score and the aggregate pharmacy score to the reference caused a cumulative increase in model performance with good discrimination (c statistic, 0.712; Nagelkerke R, 0.112). The best performing model included all predictors: severity of illness score, comorbidity burden score, aggregate pharmacy score, diagnosis groupings, and drug subgroups. Adding the aggregate pharmacy score to the reference model significantly increased the c statistic but was out-performed by the comorbidity burden score model in predicting readmission. The need for a universal prioritization tool for pharmacists may therefore be potentially met with the comorbidity burden score model. However, the aggregate pharmacy score and drug class models still out-performed current Medicare readmission risk adjustment models. Pharmacists have a great role in preventing readmission, and therefore can potentially use one of our models: comorbidity burden score model, aggregate pharmacy score model, drug class model or complex model (a combination of all 5 major predictors) to prioritize their interventions while exceeding Medicare performance measures on readmission. The choice of model to use should be based on the availability of these predictors in the health care system.

Anemia, Blood Transfusion, and Filter Life Span in Critically Ill Patients Requiring Continuous Renal Replacement Therapy for Acute Kidney Injury: A Case-Control Study.

Background Filter clotting is frequent during continuous renal replacement therapy (CRRT), which increases anemia risk. We studied anemia and blood transfusion in critically ill patients requiring CRRT for acute kidney injury and assessed the relationship between CRRT filter life span and PRBC transfusion. Methods A case-control study was conducted at a tertiary-care intensive care unit (ICU) where CRRT cases were matched with controls for age, gender, admission category, and severity of illness. Daily hemoglobin levels, blood transfusions, and life span of CRRT filter were noted. CCRT patients were categorized according to the median of the filter life span (20 hours). Results Ninety-five cases and 102 controls were enrolled. The hemoglobin level on admission was similar in the two groups, yet cases had significantly lower hemoglobin levels than controls (72.8 ± 15.3 versus 82.5 ± 20.7 g/L, p < 0.001) during ICU stay. Anemia <70 g/L occurred in 50% of cases and 19% of controls (p < 0.001). Most (56.3%) cases were transfused compared with 29.9% for controls (p < 0.001) with higher number of transfused packed red blood cell (PRBC) units in cases (2.6 ± 4.0 versus 1.5 ± 3.2 units per patient, p=0.03). Patients with shorter versus longer filter life had similar hemoglobin level in the first 7 days of CRRT with no difference in PRBC transfusion requirement. Prefilter heparin use and hemodialysis access location were not associated with longer filter life span. The mortality was similar in patients with shorter versus longer filter life. Conclusions CRRT in ICU was associated with larger drop in hemoglobin and more PRBC transfusion. Shorter (<20 hours) versus longer CCRT filter life was not associated with increased PRBC transfusion.

Effects of Early Enteral Glutamine Supplementation on Intestinal Permeability in Critically Ill Patients

ABSTRACTBackground and aimsEnteral administration of glutamine has been proposed as an effective recovery of intestinal barrier function. This amino acid has a modulating effect on the reducing bacterial translocation, which can influence immune functions of the intestine. The objective was to evaluate the effects of early enteral glutamine supplementation on intestinal permeability in critically ill patients.Materials and methodsA total of 80 critically ill patients older than 18 years were randomly assigned to one of two groups according to the stratified blocked randomization by age and admission category. Consecutive participants took enteral formula plus 0.3 g/kg/day glutamine powder or enteral formula plus maltodextrin during the ICU stay for a maximum of 10 days. Plasma glutamine, endotoxin, zonulin, and antiendotoxin immunoglobulin (Ig)G/IgM concentrations were measured on days 5 and 10 of intervention.ResultsOut of 80 participants, 36 patients in the glutamine group and 34 patients in the control group were included in the analysis of the outcomes. Enteral glutamine significantly reduced plasma zonulin concentration up to 40% during 10 days. This reduction was significantly greater compared with that of the placebo group (p<0.001). Endotoxin concentration decreased in both groups; this reduction was significantly greater in the glutamine group (p = 0.014). The antiendotoxin IgM and IgG antibody levels increased in the glutamine group but decreased in the control group (p <0.001). There were no significant differences in clinical outcomes between two groups.ConclusionEarly enteral glutamine supplementation led to a declined intestinal permeability in critically ill patients.How to cite this articleShariatpanahi ZV, Eslamian G, Ardehali SH, Baghestani AR. Effects of Early Enteral Glutamine Supplementation on Intestinal Permeability in Critically Ill Patients. Indian J Crit Care Med 2019;23(8):356–362.

Enhanced Screening and Research Data Collection via Automated EHR Data Capture and Early Identification of Sepsis.

Clinical research in sepsis patients often requires gathering large amounts of longitudinal information. The electronic health record can be used to identify patients with sepsis, improve participant study recruitment, and extract data. The process of extracting data in a reliable and usable format is challenging, despite standard programming language. The aims of this project were to explore infrastructures for capturing electronic health record data and to apply criteria for identifying patients with sepsis. We conducted a prospective feasibility study to locate and capture/abstract electronic health record data for future sepsis studies. We located parameters as displayed to providers within the system and then captured data transmitted in Health Level Seven® interfaces between electronic health record systems into a prototype database. We evaluated our ability to successfully identify patients admitted with sepsis in the target intensive care unit (ICU) at two cross-sectional time points and then over a 2-month period. A majority of the selected parameters were accessible using an iterative process to locate and abstract them to the prototype database. We successfully identified patients admitted to a 20-bed ICU with sepsis using four data interfaces. Retrospectively applying similar criteria to data captured for 319 patients admitted to ICU over a 2-month period was less sensitive in identifying patients admitted directly to the ICU with sepsis. Classification into three admission categories (sepsis, no-sepsis, and other) was fair (Kappa .39) when compared with manual chart review. This project confirms reported barriers in data extraction. Data can be abstracted for future research, although more work is needed to refine and create customizable reports. We recommend that researchers engage their information technology department to electronically apply research criteria for improved research screening at the point of ICU admission. Using clinical electronic health records data to classify patients with sepsis over time is complex and challenging.

Different Selection Processes, Different Outcomes? Comparing Labour Market Integration of Asylum Seekers, Resettled Refugees and Their Reunited Family Members in Finland

This study examines whether the different selection processes of asylum seekers, resettled refugees and their family members produce discrepancies to the employment trajectories in the host society. The labour market integration of the three refugee groups are analysed by using extensive longitudinal data from Finland during 2003-2015. The results show that, among males, family reunion migrants integrate faster than asylum seekers and resettled refugees. However, among females, resettled refugees integrate the fastest whereas family reunion migrants demonstrate the slowest integration. The overall small differences between admission categories are partly explained by discrepancies in observed characteristics such as age distribution among males and fertility patterns among females. The results do not support the hypothesis of positive self-selection of asylum seekers.

Stratification of stroke rehabilitation: Five-year profiles of functional outcomes.

Background:Stroke rehabilitation in inpatient setting requires high intensity of manpower and resources. Early stratification of patients with stroke could facilitate early discharge plan and reduce avoidable length of stay (LOS) in hospital. Stratification of patients with stroke in clinical setting is usually based on functional scores which are quite time-consuming and require a special training to complete the full score.Objective:The objective of the study was to explore whether Modified Functional Ambulation Category (MFAC) can serve as a stratification tool of patients with stroke in inpatient rehabilitation.Methods:This was a retrospective, descriptive study of the demographic, functional outcomes of patients with stroke in an inpatient rehabilitation center. A total of 2,722 patients completed a stroke rehabilitation program from 2011 to 2015 were recruited. The patients were divided into seven groups according to their admission MFAC. The between-group difference in LOS, functional outcomes at admission and discharge including Modified Rivermead Mobility Index (MRMI) and Modified Barthel Index (MBI) as well as MRMI gain, MRMI efficiency, MBI gain, and MBI efficiency were analyzed.Results:Subjects with admission categories of MFAC 2 and 3 had a highly significant () MRMI gain (6.2 and 6.6, respectively) and subjects with admission categories of MFAC 3 to 5 had highly significant () MRMI efficiency (0.34, 0.40, and 0.39, respectively). The subjects with admission categories of MFAC 2 to 5 had a highly significant () MBI gain (9.7, 10.2, 9.3, and 7.0, respectively) and the subjects with admission categories of MFAC 4 to 5 had a highly significant () MBI efficiency (0.70 and 0.72, respectively). The subjects with admission categories of MFAC 1 and 2 had a highly significant () LOS (27.7 and 26.6, respectively). MFAC profile was also established to represent the distribution of discharge MFAC of subjects according to their admission MFAC. The chance of subjects with admission categories of MFAC 1 and MFAC 2 progress to any kind of walker (MFAC 2) is 12.7% and 58.2%, respectively. The chance of subjects with admission MFAC 3, MFAC 4 and MFAC 5 progress to independent walker (MFAC 5) is 6.7%, 14.8%, and 50.3%, respectively. Both admission MFAC and admission MBI had strong correlations with discharge MFAC (, and , , respectively), discharge MRMI (, and , , respectively) and discharge MBI (, and , , respectively).Conclusion:This study showed that patients on admission with moderate disability in term of MFAC had the greatest mobility gain and basic activities of daily living (ADL) gain from inpatient stroke rehabilitation. Admission MFAC could be a stratification tool of patients with stroke in inpatient rehabilitation.

1478. A Retrospective Review of Pseudomonas aeruginosa Infection in a Quarternary Intensive Care Unit: Epidemiology, Outcomes, and Antimicrobial Susceptibilities: 2013–2016

BackgroundPseudomonas aeruginosa (PA) is known to cause infection in the intensive care unit (ICU) and contribute to substantial morbidity and mortality. The objectives of this study were to describe the epidemiology, antimicrobial resistance and outcomes in critically ill patients with pseudomonal infection.MethodsPatients with PA isolated during ICU admission from 2013–2016 were identified using provincial microbiology data. Patients were classified as colonized or infected. Those with infection were reviewed for source of infection, patient characteristics, antimicrobial susceptibilities, appropriateness of empiric antimicrobial therapy and 30-day mortality. Independent predictors of mortality were identified using multivariable logistic regression.ResultsA total of 196 unique patients were culture-positive for PA. 140 (71%) were infected and included for analysis. Mean patient age was 55.4 years (18.4 SD) and 62% were male. Admission categories included medical (71%), surgical (20%), and trauma or neurological (9%). Mean APACHE II score at the time of ICU admission was 19.4 (9.8 SD). One hundred and twenty-six (90%) patients required invasive mechanical ventilation, 102 (73%) vasopressor support and 27 (19%) new initiation of renal replacement therapy. Thirty-two (23%) died within 30 days of ICU admission. The median ICU length of stay was 13 days (IQR 5–27). Median time to infection was 1 day (IQR 0–9). Sources were respiratory (66%) followed by skin/soft tissue (11%), urinary (10%), and blood (5%). Twenty (14%) isolates were multi-drug-resistant (MDR) and six (4%) were extensively drug resistant (XDR). There were no pan-resistant isolates. One hundred and one (52%) of infections were nosocomial. Empiric antimicrobial therapy was effective in 97 (69%) cases. On multivariable analysis liver disease (aOR 6.2, 95% CI 1.5–25.7; P = 0.01), malignancy (aOR 5.0, 95% CI 1.5–17.3; P = −0.01) and higher APACHE II score at the time of admission (aOR 1.1, 95% CI 1.0–1.1; P = 0.02), were independently associated with 30-day mortality.ConclusionPA in the ICU is associated with substantial mortality and is most commonly isolated from the respiratory tract. Existing malignancy, liver disease and higher APACHE II score at admission were independently associated with mortality.Disclosures All authors: No reported disclosures.

Effects of early enteral bovine colostrum supplementation on intestinal permeability in critically ill patients: A randomized, double-blind, placebo-controlled study.

In this study we sought to investigate the effect of early enteral bovine colostrum supplementation on intestinal permeability in intensive care unit (ICU)-hospitalized patients. A total of 70 ICU-hospitalized adult patients were randomly assigned to receive a bovine colostrum supplement or placebo according to the stratified blocked randomization by age and admission category. Plasma endotoxin and zonulin concentrations were measured on days 5 and 10 of intervention. Out of 70 participants, 32 patients in the colostrum group and 30 patients in the control group were included in the final analysis of the outcomes. Plasma endotoxin concentration decreased significantly in the colostrum group on the 10th day (P < 0.05). Furthermore, plasma levels of zonulin reduced in the colostrum group significantly compared with the placebo group (P < 0.001).The incidence of diarrhea was significantly lower in the colostrum group than in the control group (P = 0.02). Our results provide evidence that bovine colostrum supplementation may have beneficial effects on intestinal permeability and gastrointestinal complications in ICU-hospitalized patients. Further studies are needed to investigate the exact mechanism of action of these effects.

Here and Gone: Rapid Transfer From the General Care Floor to the PICU.

Children admitted to the general care floor sometimes require acute escalation of care and rapid transfer (RT) to the PICU shortly after admission. In this study, we aim to investigate the characteristics of RTs and the impact RTs have on patient outcomes, including PICU length of stay (LOS), mortality, and emergency transfer defined as critical care interventions occurring within 1 hour on either side of transfer to the PICU. We conducted a 2-year, single-center, retrospective analysis including all patients admitted to the general care floor of a tertiary children's hospital that were subsequently transferred to the PICU, with attention to those transferred within 4 hours of admission, meeting criteria as RTs. Patient-level data and outcomes were tracked. Statistical summaries were stratified by RT or non-RT strata and between-strata comparisons were performed. Significant univariate factors were entered into a multivariate logistic regression model and reduced with statistical significance required for final model inclusion. Of 450 patients with an unplanned PICU transfer, 105 (23.3%) experienced RTs. Significant factors in the reduced multivariate logistic regression model associated with decreased risk for RT were increased baseline Pediatric Overall Performance Category (P = .046) and PICU origin of admission (P = .012). RT patients had shorter PICU LOSs (2.8 vs 5.5 days, P < .001) compared with non-RT patients despite a higher rate of emergency transfer (15.2% vs 7.5%, P = .018) and no difference in mortality (P = .741). In this study, we demonstrate RTs have an increase in emergency transfer rate but no apparent risk of increased PICU LOS or mortality.

The male immigrant–native employment gap in Sweden: migrant admission categories and human capital

Despite having a celebrated labor market integration policy, the immigrant–native employment gap in Sweden is one of the largest in the OECD. From a cross-country perspective, a key explanation might be migrant admission group composition. In this study we use high-quality detailed Swedish register data to estimate male employment gaps between non-EU/EES labour, family reunification and humanitarian migrants and natives. Moreover, we test if differences in human capital are able to explain rising employment integration heterogeneity. Our results indicate that employment integration is highly correlated with admission category. Interestingly, differences in human capital, demographic and contextual factors seem to explain only a small share of this correlation. Evidence from auxiliary regressions suggests that low transferability of human capital among humanitarian and family migrants might be part of the story. The article highlights the need to understand and account for migrant admission categories when studying employment integration.

Reclassifying by highest complexity operation rather than first operation influences mortality after pediatric heart surgery

ObjectiveTo evaluate the effect on mortality of reclassifying patients undergoing pediatric heart reoperations of varying complexity by operation of highest complexity instead of by first operation. MethodsData from the Virtual Pediatric Systems Database on children aged < 18 years who underwent heart surgery (with or without cardiopulmonary bypass) were included (2009-2015). Only patients who underwent reoperations during the same hospitalization were included. Patients were classified based on the first cardiovascular operation (the index operation), and on the complexity of the operation (the operation with the highest Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery [STAT] mortality category of each hospital admission) performed. ResultsOf 51,047 patients (73 centers), 22,393 met inclusion criteria. Using index operation as the classifying operation, the number of patients classified in the STAT 1 category increased by approximately 2.5 times compared with the highest-complexity operation (index, 7,077 and highest complexity, 2,654). In contrast, when the highest-complexity classification was used, we noted an increase in the number of patients in other STAT categories. We also noted higher mortality in all STAT categories when patients were classified by index operation instead of by highest complexity (index vs highest STAT category 1, 0.6% vs 0.2%; category 2, 2.4% vs 0.8%; category 3, 3.1% vs 2.1%; category 4, 5.8% vs 5.6%; and category 5, 16.7% vs 16.5%). ConclusionsThis study demonstrates differences in the reported number of patients and reported mortality in each STAT category among children undergoing various heart reoperations during the same hospitalization by classifying patients based on index operation compared with the operation of highest complexity.

Children in the London: Inpatient Care in a Voluntary General Hospital.

The presence of children in English voluntary hospitals during the eighteenth century has only recently come under academic scrutiny. This research examines the surviving admission records of the London Hospital, which consistently record inpatient ages, to illuminate the hospital stays of infant and child patients and examine the morbidity of children during the long eighteenth century. Traumatic cases were the most common category of admission. The proportion of trauma cases admitted to the London Hospital was higher than in provincial English child patient cohorts, potentially reflecting the differential risks faced by rural and urban children. In most cases of traumatic injury the inpatients stayed in hospital long enough for significant fracture healing to have occurred. Understanding the conditions surrounding children's admission to hospital, their length of stay, the result of their stay, and which medical issues drove their parents or guardians to seek medical attention for them are critical to illuminating the morbidity of children during the long eighteenth century.

Immigrant category of admission and the earnings of adults and children: how far does the apple fall?

Immigrants in many Western countries have experienced poor economic outcomes. This has led to a lack of integration of child immigrants (the 1.5 generation) and the second generation in some countries. However, in Canada, child immigrants and the second generation have on average integrated very well economically. We examine the importance of Canada’s admission classes to determine if there is an earnings benefit of the selection under the economic classes to (1) the Adult Arrival immigrants and (2) the Child Arrival immigrants (1.5 generation) once old enough to enter the labour market. We employ unique administrative data on landing records matched with subsequent income tax records that also allows for the linking of the records of Adult Arrival parents and their Child Arrival children. We find, relative to the Family Class, the Adult Arrivals in the Skilled Worker category have earnings that are 29% higher for men and 38% higher for women. These differences persist even after controlling for detailed personal characteristics such as education and language fluency at 21% for men and 27% for women. Child Arrival immigrants landing in the Skilled Worker Class have earnings advantages (as adults) over their Family Class counterparts of 17% for men and 21% for women. These Child Arrival Skilled Worker advantages remain at 9% for men and 14% for women after controlling for child characteristics, the Principal Applicant parent’s characteristics, and the parent’s subsequent income in Canada.

Medical Versus Surgical ICU Obese Patient Outcome: A Propensity-Matched Analysis to Resolve Clinical Trial Controversies.

To determine the short- and long-term mortality of obese ICU patients following medical as opposed to surgical admission and the relation between obesity and mortality. Retrospective analysis of prospectively collected data, using a propensity score-matched analysis of patients with medical or surgical admission. One French mixed medical-surgical ICU. Critically ill obese patients (body mass index ≥ 30 kg/m) and nonobese patients admitted during a 14-year period. None. Seven-hundred ninety-one obese patients and 4,644 nonobese patients were included, 338 (43%) and 2,367 (51%) medical and 453 (57%) and 2,277 (49%) surgical obese and nonobese patients, respectively. Mortality was significantly higher in medical than in surgical obese patients in ICU (25% vs 12%; p < 0.001) and up to 365 days (36% vs 18%; p < 0.001) post ICU admission. One-to-one propensity score matching generated 260 pairs with well-balanced baseline characteristics. After matching on propensity score, mortality was still significantly higher in medical patients both in the ICU (21% vs 13%; p = 0.03) and up to 365 days (30% vs 20%; p = 0.01) post ICU admission. Obesity was not significantly associated with mortality both in univariate analysis (140 obese patients [15%] in the dead group vs 651 [14%] in the alive group; p = 0.72) and multivariate analysis (odds ratio, 1.09 [95% CI, 0.86-1.38]; p = 0.49) after adjustment for Simplified Acute Physiology Score II, age, category of admission, history of cardiac disease, and history of respiratory disease. After careful matching, the data suggest that ICU mortality in obese population was higher in the medical group than in the surgical group and remains significantly higher 365 days post ICU admission.

Emergency Department Waiting Times in an Israeli Children's Hospital During Times of Military Conflict.

During military conflicts in southern Israel, many families moved north, and hospitals and primary care clinics under threat of missile attacks referred their patients to hospitals outside the combat zone, causing overcrowding of the emergency departments (ED). The study objective is to examine the effect of military conflicts on ED waiting time in a children's hospital outside the combat zone. A retrospective cohort study of patients admitted between January 2011 and December 2015 was conducted. Multivariable regression was used to examine the effect of age, gender, triage category, arrival time, weekday, and period of admission (peacetime and time of military conflict) on waiting time. Totally, 79,825 children were admitted in peacetimes and 3,058 in times of military conflict. Factors that most influenced shorter waiting times were triage category 1 (change in waiting time: -25.5%; 95% confidence interval: -29.3 to -21.7) or triage category 2 (change in wait time: -21.8%; 95% confidence interval: -23.7 to -20.05). Arriving during times of military conflict did not influence ED waiting time (p=0.18). ED waiting times during times of peace and times of military conflict were 38 min of interquartile range (21-65) and 38 min of interquartile range (22-65), respectively. In this report of a large cohort of patients, waiting times were similar during periods of peace and periods of military conflict. The findings suggest that the 2012 and the 2014 military conflicts did not influence ED waiting times in a hospital outside the combat zone, despite the population shift that occurred during these conflicts. This study is the first to examine the association between periods of military conflict and ED waiting time in children.

National Quality Assurance &amp; Improvement System (NQAIS) – Medicine

Introduction: Length of stay varies by hospital, admission type, diagnosis and clinical team, while waiting lists, emergency department throughput and delayed discharges generate frustration for patients and health professionals. The National Acute Medical Programme (NAMP) was established in 2010 by the Royal College of Physicians of Ireland and the Health Service Executive (HSE) to enable: - Swifter access to senior decision makers - Swifter access to investigations and interventions - Reduced overnight admissions - Shorter average length of stay (AvLOS) - Optimal use of Acute Medical Assessment Unit (AMAU) NQAIS Medicine: NQAIS Medicine supports NAMP and hospitals to re-engineer care delivery based on interdisciplinary co-operation using timely and relevant data. The system was developed by Health Intelligence, Health & Wellbeing, Health Service Executive, in collaboration with NAMP and OpenApp. It is deployed under the governance framework of the Joint NQAIS (Surgery & Medicine) Steering Group. NQAIS Medicine is a web-enabled, role-based quality assurance and improvement system providing an evidence base to inform decisions. Innovative “diamond” plots (simplified box and whisker) and trend plots in easily understood “ribbons” are displayed by hospital (or group), admission category, diagnosis and clinical team. Patient profiles (age, co-morbidity, admission day/time etc.) can be flexibly explored. Selected records can be identified for chart review. The predictive impact of meeting targets are summarised by the novel computation of the potential “number of beds freed per day” which could be made available for other patients. The Clinical Classification System (CCS) - Agency for Healthcare Research & Quality (AHRQ) - converts the principal (admission) diagnosis into clinically meaningful groups. The Charlson Index is used to convert secondary diagnoses into a “complexity” score. AvLOS and readmission rates are dynamically analysed in the context of data-driven targets: AvLOS per CCS diagnosis as achieved by top quartile (Irish) teams; 50%+ all acute medical admissions should be routed via the AMAU of whom 25% should be discharged home. AvLOS is computed for each CCS nationally in the context of its trim point - national 75%ile + 3 X (25% – 75%ile). If the target AvLOS is achieved and AMAU usage optimised, the potential impact is translated into simple summary metrics - beds used within, close to and off target. These metrics identify and prioritise processes in hospital most likely to reveal potential learning and reengineering opportunities for using beds for other patients. Implementation: A train-the-trainers approach within hospital groups, guided by a national training team, supports the national deployment of the system. NQAIS Medicine combines science and art to provide detailed but very understandable feedback to unequivocally identify areas for review. Modest meeting of targets would transform a system struggling to cope with increasing demands. The successful implementation of NAMP, using NQAIS Medicine as a continuous improvement enabler, requires sustained focus and commitment from clinicians and management alike. The system is currently being deployed to all acute hospital in Ireland, and is being extended to encompass surgery and other domains within a single system referred to as NQAIS Clinical.

Hospital costs and cost implications of co-morbid conditions for patients with single ventricle in the period through to Fontan completion

BackgroundPatients undergoing palliative surgeries for single-ventricle conditions are affected by multiple comorbidities or non-cardiac conditions. The prevalence, costs and the cost implications of these conditions have not been assessed. MethodsAdministrative costing records from four hospitals in Australia and New Zealand were linked with the Fontan registry database to analyze the inpatient resource use for co-morbid or non-cardiac conditions. Inpatient costing records from the birth year through to Fontan completion were available for 156 patients. The most frequent primary diagnoses were hypoplastic left heart syndrome (33%), double inlet left ventricle (13%), and tricuspid atresia (12%). ResultsDuring the staged surgical treatment period, children had a mean of 10±6 inpatient admissions and spent 85±64days in hospital. Among these admissions, 3±5 were for non-cardiac conditions, totaling 21±41 inpatient days. Whilst cardiac surgeries were the major reason for resource use (77% of the total cost), other cardiac care that is not surgical contributed 5% and non-cardiac admissions 18% of the total cost. The three most prevalent non-cardiac diagnostic admission categories were ‘Respiratory system’, ‘Digestive system’, and ‘Ear, nose, mouth and throat’, affecting 28%, 21% and 34% of the patients respectively. Multivariate regression estimated that admissions for each of these categories resulted in an increased cost of $34,563 (P=0.08), $52,438 (P=0.05) and $10,525 (P=0.53) per patient respectively for the staged surgical treatment period. ConclusionsNon-cardiac admissions for single-ventricle patients are common and have substantial resource implications. Further research assessing the causes of admission and extent to which admissions are preventable is warranted.

Linking hospital and immigrant landing data to understand patterns of hospital use among refugees in Canada

ABSTRACT&#x0D; ObjectivesIn Canada, refugees represent between 10% and 15% of the total immigrant annual in-take of immigrants. Refugees are generally admitted with different selection criteria and have different settlement challenges which may lead to higher health risk, compared to other categories of immigrants. The purpose of this study is to use linked hospital and immigrant landing data to report hospitalization rates among refugees arriving to Canada between 1980 and 2006 with special focus on those from refugee-dominant source areas, namely Poland and Vietnam, and the Middle East.&#x0D; ApproachData from the 2006/07-2008/09 Discharge Abstract Database (DAD) were linked to the 1980-2008 Immigrant Landing File (ILF) to identify hospitalizations among immigrants by category of admission. Age-standardized hospitalization rates (ASHR) for overall causes (excluding pregnancy), and for selected causes are derived for refugees overall and by specific source country. Rates are compared with those for the Canadian-born population and with economic class immigrants from the same source country.&#x0D; ResultsOverall, refugees had substantially lower overall ASHR compared with the Canadian-born population (494 per 10,000, 95% CI, 487, 500 vs 891 per 10,000, 95% CI, 890, 892, retrospectively). Among refugees, those who landed in Canada (refugee claimants) had the highest ASHR (539, 95% CI 524,555), especially for circulatory disease. Among refugee-dominant areas, Government-assisted refugees from the Middle East tended to have higher ASHR at levels comparable with that of the Canadian born population (for circulatory disease). Refugees had higher rates of hospitalization compared with their economic class counterparts, except among those from Poland.&#x0D; ConclusionRefugees, like other immigrants, generally had lower hospitalization rates compared with the Canadian born population, but the heterogeneity within groups reveals specific vulnerability for certain types of health care use.