Day Of Admission Research Articles

WP2.5 - Impact of repeated phlebotomy in long-stay patients and patients requiring total parenteral nutrition

Abstract Introduction Blood tests are an essential for patient management. Repeated tests can be associated with harm. The study aimed to assess the consequences of repeated phlebotomy in patients with a long hospital stay or requiring total parenteral nutrition (TPN). Methods Retrospective data was collected from general surgical patients with a length of stay (LOS) of at least 14 days, over a period of 6 months. Biochemical parameters including haemoglobin were recorded on day of admission, day 14 and day 21. Complications following phlebotomy were also noted. Results 133 patients were identified. 84 patients had a LOS >21 days. The longest inpatient stay was 92 days. The most common pathologies were related to lower gastrointestinal disease at 45 cases. TPN was required in 35 cases. Average blood loss as a result of blood sampling was 325 ml/admission (105ml-850 ml), with associated average drop in haemoglobin of 20%. In 6 cases, haemoglobin dropped >40%. Rate of testing per admission length was 1every two days. (45 times as a peak) The most common complications noted were technical ( lab errors/ inadequate sampling). Other physical and psychological factors. A Full set of blood tests costs 150£. In our intervention, 4ml paediatric blood vacutainers (to 13 ml adult’s) were trialled in 10 cases. The results were very comparable. Potential 60% reduction in blood loss was noted. Conclusion careful clinical judgment and controlled approach with restricted practice towards phlebotomy is mandatory .It can be harmful, if not clinically required. Plus it’s expensive costs. Paediatric blood vacutainers can be a beneficial alternative in those requiring regular blood sampling.

EP278 - The undifferentiated general surgical take over 10 years: emergency imaging

Abstract Aims The undifferentiated emergency general surgical take in July 2013 and July 2023, at a District General Hospital, was reviewed with the aim of understanding increasing pressures on the surgical and radiology departments, and subsequently identifying areas in which we could adapt to facilitate these demands. Methods Patients were identified retrospectively if they had been cared for by the emergency general surgical team in July 2013 or July 2023. Further information was collected from electronic notes, with a focus on admission and initial imaging modalities. Patients were excluded if information was not available electronically. Results Of the 395 patients in July 2013, and 594 in July 2023, 55% and 61% respectively had imaging studies within 7 days of admission. 11% (n=44/395) of patients in 2013 had abdominal X-ray without further imaging, compared to 6% (n=33/594) in 2023. Computed Tomography (CT) use increased by 35%, whilst ultrasound scanning (USS) increased only by 11%. Time from admission to scans of all types has reduced from 0.79 days (+/-0.16, p=0.02) in 2013 to 0.60 (+/-0.1, p=0.02) days in 2023. Conclusion Overall volume of imaging has increased slightly, although the proportion of patients being scanned is largely unchanged, with subtle variation in preferred imaging modalities. CT is marginally more common, whilst USS remains mostly unchanged. The use of abdominal x-ray without subsequent imaging has decreased, demonstrating its reducing use in clinical judgement and reliance on alternative imaging techniques. Time from admission to scan of all kinds has reduced, despite increasing demands on radiology departments.

SP2.8 - The undifferentiated general surgical take over 10 years: emergency operating

Abstract Aims The aim of this study is to further understand the specific pressures on the department’s operating theatres and capacity, and to identify areas in which we could adapt to facilitate these demands, by reviewing the undifferentiated general surgical admissions in a District General Hospital in July 2013 and July 2023. Methods All patients seen by the emergency general surgical team in July 2013 and July 2023 were identified retrospectively. Data was gathered using electronic notes, to analyse admissions and surgeries within 30 days. Patients were excluded if there was insufficient information available. Results 26% (n=102/395) of all patients treated by emergency general surgical teams in July 2013 had surgery within 30 days. This proportion reduced to 23% (134/594) in July 2023, however overall volume has increased by 31%. The proportion of procedures performed on the day of admission has decreased from 10% to 7%. 3% of procedures were performed under local anaesthetic both in 2013 and 2023. Wait from admission to surgery has decreased from 2.84 days (+/-0.6, p=0.02) in 2013, to 1.9 days in 2023 (+/-0.83, p=0.02). Conclusions Although volume of procedures within the same 31-day period has increased throughout the 10 years, the proportion of patients that proceed to intervention has reduced marginally. This is reflected in the increasingly busy emergency operating lists throughout the country, with little change in resources to account for increasing volume. The rising proportion of patients managed conservatively may represent improving medical management of conditions, or more pragmatic management of frail patients.

Ventilatory pressure parameters impact the association between acute gastrointestinal injury and all-cause mortality in mechanically ventilated patients

Acute gastrointestinal injury (AGI) is common in mechanically ventilated (MV) patients, but the potential association between ventilatory pressure parameters and AGI grade and their impact on mortality remains unclear. This study aimed to explore the association between ventilatory pressure parameters and AGI grade, and their interaction on all-cause mortality in MV patients. This study was a secondary analysis of a multicenter, prospective, observational study that enrolled adult patients with an expected duration of mechanical ventilation ≥ 48 h from 14 general intensive care units in Zhejiang Province between March and August 2014. The AGI grade was assessed daily on the basis of gastrointestinal symptoms, intra-abdominal pressures, and feeding intolerance in the first week of admission to the ICU. This study included 331 patients (69.2% men; mean age, 64.6 ± 18.9 years). Multivariate regression analysis showed that plateau pressure (Pplat) (OR 1.044, 95% CI 1.009–1.081, P = 0.013), serum creatinine (OR 1.003, 95% CI 1.001–1.006, P = 0.042) and APACHE II score (OR 1.035, 95% CI 1.021–1.072, P = 0.045) were independently associated with global AGI grade III/IV within 7 days of ICU admission. Moreover, global AGI grade (HR 2.228, 95% CI 1.561–3.182, P < 0.001), serum creatinine (HR 1.002, 95% CI 1.001–1.003, P = 0.012) and APACHE II score (HR 1.039, 95% CI 1.015–1.063, P = 0.001) were independently associated with 60-day mortality. In addition, there were significant (Pint ≤ 0.028) interactions of Pplat and DP with AGI grade in relation to 60-days mortality, whereas no interaction (Pint = 0.061) between PEEP and AGI grade on 60-days mortality was observed. In the presence of Pplat ≥ 19 cmH2O, the patients with AGI grade III/IV had 60-day mortality rate of 72.2%, significantly higher than those with AGI grade I/II (48.7%, P = 0.018), whereas there were no significant differences (27.9% vs. 33.7%, P = 0.39) in 60-days mortality between AGI grade I/II and III/IV among the patients with Pplat < 19 cmH2O. In comparison with Pplat, DP had a similar interaction (Pint = 0.028) with AGI grade on 60-day mortality. Ventilatory pressure parameters (Pplat and DP) are independent risk factors of AGI grade III/IV. Pplat and DP interact with AGI grade on 60-days mortality, highlighting the importance of optimizing ventilatory pressure parameters to improve gastrointestinal function and survival outcomes of MV patients.Trial registration: ChiCTR-OCS-13003824.

The neuronal biomarker NSE correlates with the volume of lung contusion in polytraumatized patients.

Severe injuries caused by accidents, like traumatic brain injury (TBI) or thoracic trauma (TT) continue to be the leading cause of death in younger people with relevant socio-economic impact. Fast and targeted diagnostics is essential for further therapy decisions and prognosis. The following study investigates NSE as a potential biomarker for lung injury after blunt TT. This is a retrospective analysis of prospectively collected data in a level-1 trauma center from 2014 to 2020. Serum levels of Neuron-specific Enolase (NSE) and Interleukins (IL-6, IL-10) in injured patients (n = 41) with isolated TT (AISthorax ≥ 3) compared to isolated TBI (AIShead ≥ 3) were assessed from day 0 to 5 after trauma. The extend of lung injury was quantified by Hounsfield scale in CT scans. 30 patients with TT (ISSmed = 20, age 50y ± 17, 83,3% male) and 11 patients with TBI (ISSmed = 25, age 54y ± 17,27,3% male) were included. After TT, NSE concentration increased initially after trauma with a peak value on the day of admission (8.51 ± 3.68 ng/ml) compared to healthy controls (4.51 ± 1.504 ng/ml, p < 0.001). Isolated thoracic trauma and TBI lead to equally strong NSE release ad the day of admission. There is a significant linear relationship (r = 0.636, p = 0.035) between serum NSE levels and severity of pulmonary contusion at the time of admission and after 24 hours. A significant NSE release after isolated thoracic trauma peaks on the day of admission. The extent of lung contusion volume (defined as alveolar parenchymal density) correlates with NSE serum concentration. Thus, NSE has predictive value for the extent of pulmonary contusion. However, according to these data, NSE seems to have no diagnostic value as a TBI biomarker in concomitant TT.

“Mucosal infection with tsukamurella species following nasal septum procedure: a rare case report”

Introduction and Importance: Tsukamurella species are rare, aerobic, Gram-positive bacteria known to cause infections, primarily in immunocompromised individuals. This case report presents a rare instance of a mucosal infection caused by Tsukamurella species following a nasal septum procedure in an immunocompetent patient. Case Presentation: A 51-year-old man with a history of multiple hereditary exostosis, allergic rhinitis, and recent nasal fracture repair presented with persistent fevers and low back pain. Postoperatively, he developed sinus pain and small oral lesions, initially treated with antibiotics for presumed sinusitis. Despite treatment, his fever persisted, leading to an emergency department visit. Laboratory tests indicated sepsis, but a CT scan of the sinuses showed no sinusitis. Despite broad-spectrum antibiotics, the patient’s fever continued. On admission day 9, nasal endoscopy and culture identified Tsukamurella species. The patient was treated with Augmentin, fluconazole, and levofloxacin, leading to resolution of symptoms and discharge with ongoing treatment. Clinical Discussion: Tsukamurella species are uncommon pathogens that are often associated with bacteremia in immunocompromised individuals. This case highlights the diagnostic challenges and importance of considering unusual pathogens in post-procedural infections, even in immunocompetent patients. Accurate identification and appropriate management are critical in improving outcomes for patients with Tsukamurella infections. Conclusion: This case underscores the need for vigilance in diagnosing rare infections like Tsukamurella, even in immunocompetent individuals. The successful resolution with combination therapy highlights the importance of appropriate antibiotic selection in managing such infections.

Optimal target mean arterial pressure for patients with sepsis-associated encephalopathy: a retrospective cohort study

BackgroundSepsis-associated encephalopathy (SAE) patients often experience changes in intracranial pressure and impaired cerebral autoregulation. Mean arterial pressure (MAP) plays a crucial role in cerebral perfusion pressure, but its relationship with mortality in SAE patients remains unclear. This study aims to investigate the relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients, providing clinicians with the optimal MAP target.MethodsWe retrospectively collected clinical data of patients diagnosed with SAE on the first day of ICU admission from the MIMIC-IV (v2.2) database. Patients were divided into four groups based on MAP quartiles. Kruskal-Wallis H test and Chi-square test were used to compare clinical characteristics among the groups. Restricted cubic spline and segmented Cox regression models, both unadjusted and adjusted for multiple variables, were employed to elucidate the relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients and to identify the optimal MAP. Subgroup analyses were conducted to assess the stability of the results.ResultsA total of 3,816 SAE patients were included. The Q1 group had higher rates of acute kidney injury and vasoactive drug use on the first day of ICU admission compared to other groups (P < 0.01). The Q1 and Q4 groups had longer ICU and hospital stays (P < 0.01). The 28-day and in-hospital mortality rates were highest in the Q1 group and lowest in the Q3 group. Multivariable adjustment restricted cubic spline curves indicated a nonlinear relationship between MAP and mortality risk (P for nonlinearity < 0.05). The MAP ranges associated with HRs below 1 for 28-day and in-hospital mortality were 74.6–90.2 mmHg and 74.6–89.3 mmHg, respectively.The inflection point for mortality risk, determined by the minimum hazard ratio (HR), was identified at a MAP of 81.5 mmHg. The multivariable adjusted segmented Cox regression models showed that for MAP < 81.5 mmHg, an increase in MAP was associated with a decreased risk of 28-day and in-hospital mortality (P < 0.05). In Model 4, each 5 mmHg increase in MAP was associated with a 15% decrease in 28-day mortality risk (HR: 0.85, 95% CI: 0.79–0.91, p < 0.05) and a 14% decrease in in-hospital mortality risk (HR: 0.86, 95% CI: 0.80–0.93, p < 0.05). However, for MAP ≥ 81.5 mmHg, there was no significant association between MAP and mortality risk (P > 0.05). Subgroup analyses based on age, congestive heart failure, use of vasoactive drugs, and acute kidney injury showed consistent results across different subgroups.Subsequent analysis of SAE patients with septic shock also showed results similar to those of the original cohort.However, for comatose SAE patients (GCS ≤ 8), there was a negative correlation between MAP and the risk of 28-day and in-hospital mortality when MAP was < 81.5 mmHg, but a positive correlation when MAP was ≥ 81.5 mmHg in adjusted models 2 and 4.ConclusionThere is a nonlinear relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients. The optimal MAP target for SAE patients in clinical practice appears to be 81.5 mmHg.

Acute-phase proteins as indicators of disease severity and mortality in COVID-19 patients

The aim of the study was to conduct of relationship of acute-phase proteins (APPs) with the severity of COVID-19 defined by National Institutes of Health and according to the criteria of MEWS scale, with the presence of a cytokine storm, oxygen therapy and patient survival. We enrolled 96 patients with COVID-19 and 30 healthy people. The samples were taken on the day of admission and after 9 days on average. Not only commonly used APPs such as CRP, procalcitonin and ferritin and also rarely assayed proteins such as transferrin, haptoglobin, α1-acid glycoprotein and α1-antitrypsin, were tested in the study. The levels of APPs depends on the severity of COVID-19 disease, on the presence of cytokine storm and used oxygen therapy. The greatest APPs changes occurred in the most advanced form of the disease, with the presence of a cytokine storm and the most intense oxygen therapy. The results obtained from MEWS scale were not consistent with National Institutes of Health scores. Studies in the second samples showed the quenching of the acute phase reactions and the effectiveness of oxygen therapy. Only two of the examined APPs i.e. procalcitonin and transferrin, differed between surviving and non-surviving patients, and these two predispose to the role of prognostic factors in Covid-19. In conclusion, the concentration of not all acute-phase proteins depends on the severity of COVID-19 disease, presence of cytokine storm, the used of oxygen therapy and only some of them (procalcitonin and transferrin) are related to the survival outcomes. Of the newly tested acute-phase proteins, only transferrin shows significance as a marker of disease severity and mortality in COVID-19 disease.

The Effect of Baricitinib and Corticosteroid Compared to that of Corticosteroid Monotherapy in Severely and Critically ill Patients with COVID-19: A Japanese Multicenter Inpatient Database Study.

BackgroundSystemic baricitinib and corticosteroids play important roles in treating severely and critically ill patients with coronavirus disease 2019 (COVID-19). However, the efficacy of the combination of baricitinib and corticosteroids compared to that of corticosteroid monotherapy in severely and critically ill hospitalized patients with COVID-19 remains unclear. MethodsWe analyzed severely and critically ill hospitalized patients with COVID-19 aged >18 years between January 1, 2020 and May 31, 2023, using a Japanese multicenter inpatient database. We performed propensity score matching to analyze the effect of the combination of baricitinib and corticosteroids within 2 days of hospital admission (combination group) on the 28-day and in-hospital mortality rates compared with those of corticosteroid monotherapy within 2 days of hospital admission (control group). Sensitivity analysis was performed using inverse probability weighting analysis and the generalized estimating equation method. ResultsThe eligible patients (n=7,433) were divided into a combination (n = 679) and a control group (n = 6,754). One-to-four propensity score matching analyses included 566 combination and 2,264 control group patients. There was no significant difference in 28-day (8.5% vs. 8.8%; risk difference, -0.3% [95% confidence interval, −2.9 to 2.3]) or in-hospital (11% vs. 10%; risk difference, 1.0 [−1.9 to 3.9]) mortality rates between 2 groups. The sensitivity analysis showed similar outcomes. ConclusionThis observational study, using a Japanese multicenter inpatient database, found that the combination of baricitinib and corticosteroid therapy did not improve the 28-day or in-hospital mortality rates in severely and critically ill patients with COVID-19 compared to corticosteroid monotherapy.

Obesity Hypoventilation (Pickwickian) Syndrome – ”The Tip of an Iceberg” in Morbidly Obese Patients

ABSTRACT Obesity hypoventilation syndrome (OHS), also known as Pickwickian syndrome, is a combination of obesity (body mass index (BMI) &gt;30 kg/m2), daytime hypercapnia (arterial carbon dioxide tension &gt;45 mm Hg) and sleep-disordered breathing, after exclusion of other disorders that may cause alveolar hypoventilation. Management of OHS requires a multifaceted approach in the form of weight loss, treatment of existing co-illnesses, pulmonary rehabilitation, and Bi-level positive airway pressure (Bi-PAP) therapy. A 58-year-old lady with a BMI of 50 kg/m2 with symptoms of obstructive sleep apnea (OSA) and OHS presented to the hospital with respiratory distress. She gave a history of breathlessness, snoring, and sleep disturbances for the last 7 years. She was managed by a physician with a diagnosis of obstructive airway disease without further evaluation of sleep disturbance. On admission, she was started on non-invasive ventilation during her initial management. After 72 hours of admission, the patient became stable, and overnight polysomnography was performed to confirm the diagnosis of OHS. After confirmation of the diagnosis, she was started on Bi-PAP therapy along with other supportive therapy for 7 days. She was discharged after 10 days of admission with nocturnal Bi-PAP therapy at home and was enrolled in a comprehensive pulmonary rehabilitation program. Patient is on regular follow-up and has been doing well since then.

A composite risk assessment model for venous thromboembolism

ObjectiveVenous thromboembolism (VTE) is a preventable cause of hospitalization-related morbidity and mortality. VTE prevention requires accurate risk stratification. Federal agencies mandated VTE risk assessment for all hospital admissions. We have shown that the widely used Caprini (30 risk factors) and Padua (11 risk factors) VTE risk-assessment models (RAMs) have limited predictive ability for VTE when used for all general hospital admissions. Here, we test whether combining the risk factors from all 23 available VTE RAMs improves VTE risk prediction. MethodsWe analyzed data from the first hospitalizations of 1,282,014 surgical and non-surgical patients admitted to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. We used logistic regression to predict VTE within 90 days of admission using risk factors from all 23 available VTE RAMs. Area under the receiver operating characteristic curves (AUC), sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) were used to quantify the predictive power of our models. The metrics were computed at two diagnostic thresholds that maximized (1) the value of sensitivity + specificity-1; and (2) PPV and were compared using McNemar’s test. The Delong-Delong test was used to compare AUCs. ResultsAfter excluding those with missing data, 1,185,633 patients (mean age, 66 years; 93% male; and 72% White) were analyzed, of whom 33,253 (2.8%) had a VTE (deep venous thrombosis [DVT], n = 19,218, 1.6%; pulmonary embolism [PE], n = 10,190, 0.9%; PE + DVT, n = 3845, 0.3%). Our composite RAM included 102 risk factors and improved prediction of VTE compared with the Caprini RAM risk factors (AUC composite model: 0.74; AUC Caprini risk-factor model: 0.63; P < .0001). When the sum of sensitivity and specificity-1 was maximized, the composite model demonstrated small improvements in sensitivity, specificity and PPV; NPV was high in both models. When PPV was maximized, the PPV of the composite model was improved but remained low. The nature of the relationship between NPV and PPV precluded any further gain in PPV by sacrificing NPV and sensitivity. ConclusionsUsing a composite of 102 risk factors from all available VTE RAMs, we improved VTE prediction in a large, national cohort of >1 million general hospital admissions. However, neither model has a sensitivity or PPV that permits it to be a reliable predictor of VTE. We demonstrate the limits of currently available VTE risk prediction tools; no available RAM is ready for widespread use in the general hospital population.

The relationship between Glasgow Prognostic Score and hospital duration in patients with inflammatory bowel diseases.

Both hypoalbuminemia and inflammation were common in patients with inflammatory bowel diseases (IBD), however, the combination of the two parameters on hospital duration re-mained unknown. This is a retrospective two-centre study performed in two tertiary hospitals in Shanghai, China. Serum levels of C-Reactive Protein (CRP) and albumin (ALB) were measured within 2 days of admission. Glasgow prognostic score (GPS), based on CRP and ALB, was calculated as follows: point "0" as CRP <10 mg/L and ALB ≥35 g/L; point "1" as either CRP ≥10 mg/L or ALB <35 g/L; point "2" as CRP ≥10 mg/L and ALB <35 g/L. Patients with point "0" were classified as low-risk while point "2" as high-risk. Length of hospital stay (LOS) was defined as the interval between admission and discharge. The proportion of low-risk and high-risk was 69.3% and 10.5% respectively among 3,009 patients (65% men). GPS was associated with LOS [β=6.2 d; 95% CI (confidence interval): 4.0 d, 8.4 d] after adjustment of potential co-variates. Each point of GPS was associated with 2.9 days (95% CI: 1.9 d, 3.9 d; ptrend<0.001) longer in fully adjusted model. The association was stronger in patients with low prealbumin levels, hypocalcaemia, and hypokalaemia relative to their counterparts. GPS was associated with LOS in IBD patients. Our results highlighted that GPS could serve as a convenient prognostic tool associated with nutritional status and clinical outcome.

Early specialised treatment for bipolar disorder: Long-term follow-up from the early intervention in affective disorders (EIA) randomised controlled trial.

It is unclear whether treatment early after onset in bipolar disorder may improve the long-term illness course. The early intervention in affective disorders (EIA) randomised controlled trial found that 2-years treatment in a specialised mood disorder clinic combining evidence-based pharmacological treatment with group psychoeducation improved clinical outcomes compared with standard treatment in patients with bipolar disorder discharged after their 1st, 2nd, or 3rd hospital admission. We aimed to assess the 16 years long-term outcomes after randomisation of the participants in the EIA trial. Data were obtained by linking nation-wide Danish population-based registers. All 158 participants of the EIA trial (Trial Registration Number NCT00253071) were followed from time of randomisation (2005-2009) to end of study (31 December 2021). The primary outcome was risk of psychiatric readmission. Secondary outcomes were total admissions and costs, medication use, intentional self-harm or suicide attempt or suicide, and socio-economic measures. The absolute mean risk of psychiatric readmission was 49.3% in the intervention group and 59.8% in the control group, with no statistically significant difference between the groups (b = -0.10, 95% CI: -0.26 to 0.047, p = 0.18). Compared with the control group, patients in the intervention group had numerically fewer total admission days (mean (SD) 44 (77) versus 62 (109)), lower total cost of psychiatric hospital admissions and hospital-based outpatient visits (mean (SD) 22,001 (36793) euros versus 29,822 (52671) euros) and higher use of lithium and antipsychotics, but the differences were not statistically significant. Fewer patients in the intervention group had an event of intentional self-harm or suicide attempt or suicide during follow-up (OR 0.25, 95% CI: 0.15-0.40, p < 0.001) compared with the control group and more patients in the intervention group used antiepileptics (OR 2.21, 95% CI: 1.08-4.60, p = 0.031). Analyses of very long-term outcomes of the EIA trial may potentially indicate a beneficial effect of the intervention at the long term but were likely underpowered to detect a more subtle effect and for most outcomes the differences between groups were not statistically significant.

Physician performance scores used to predict emergency department admission numbers and excessive admissions burden

BackgroundOvercrowding in hospitals is associated with a panoply of adverse events. Inappropriate decisions in the emergency department (ED) contribute to overcrowding. The performance of individual physicians as part of the...

Associations between pre-existing comorbidities and in-hospital cardiovascular events and mortality among COVID-19 patients in Bangladesh: a secondary analysis of a prospective cohort study

ObjectiveTo identify the associations of in-hospital cardiovascular events and mortality with pre-existing comorbidities and cardiovascular disease (CVD) risk factors among COVID-19 patients in Bangladesh without vaccine availability.DesignA secondary analysis of...

Does timing of tocilizumab administration affect mortality in COVID-19? A Scottish multicentre retrospective cohort study

BackgroundThe optimal timing of tocilizumab treatment during the disease course of COVID-19 has yet to be adequately defined in the context of randomised controlled trials and the effect of tocilizumab...

Nurse understaffing associated with adverse outcomes for surgical admissions.

Nurses play a crucial role in maintaining the safety of surgical patients. Few nurse staffing studies have looked specifically at surgical patients to examine the impact of exposure to low staffing on patient outcomes. A longitudinal patient analysis was conducted in four organizations in England using routine data from 213 910 admissions to all surgical specialties. Patients' staffing exposures were modelled as counts of understaffed registered nurse and nurse assistant days in the first 5 inpatient days. Understaffing was identified when staffing per patient-day was below the mean for the ward. Cox models were used to examine mortality within 30 days of admission and readmission within 30 days of discharge. Generalized linear models were used to investigate duration of hospital stay and occurrence of hospital-acquired conditions. Increased exposure to registered nurse understaffing was associated with longer hospital stay and increased risk of deep vein thrombosis, pneumonia, and pressure ulcers. This was also true for nurse assistant understaffing, but the effect sizes tended to be smaller. In the Cox models, there were similarly increased hazards of death for registered nurse understaffing (HR 1.09, 95% c.i. 1.07 to 1.12) and nurse assistant understaffing (HR 1.10, 1.08 to 1.13), whereas the effect size of registered nurse understaffing for readmission (HR 1.02, 1.02 to 1.03) was greater than that seen with nurse assistants (HR 1.01, 1.01 to 1.02). Understaffing by both registered nurses and nursing assistants is associated with increased risks of a range of adverse events, and generally larger effects are seen with registered nurse understaffing.

Subphenotypes of platelet count trajectories in sepsis from multi-center ICU data

Although thrombocytopenia on admission to the ICU is associated with increased in-hospital mortality in septic patients, the role of longitudinally measured platelet counts, which are dynamically changing, is unclear. We aimed to identify patterns of dynamic platelet count trajectories and evaluate their association with outcomes and thrombocytopenia in septic patients. We tested the longitudinal platelet trajectory patterns of sepsis patients within the first four days of ICU admission in the MIMIC-IV database and their association with 28-day mortality, and independently validated our findings in the eICU-CRD database. Statistical methods used included multivariate regression, propensity score analysis, doubly robust estimation, gradient boosting model, and inverse probability weighting to ensure the robustness of our findings. A total of 22,866 septic patients were included in our study. The trajectory analysis categorizes patients into ascending (AS), stable (ST), or descending (DS) patterns. The risk of 28-day mortality was increased in the DS patients (OR = 2.464, 95%CI 1.895–3.203, p < 0.001) and ST patients (OR = 1.302, 95%CI 1.067–1.589, p = 0.009) compared to AS patients. The AS patients had lower ICU length of stay (2.36 vs. 4.32, p < 0.001) and 28-day maximum SOFA scores (5.00 vs. 6.00, p < 0.001) than the DS patients, but had more ventilator-free days within 28 days than the DS group (26.00 vs. 24.00, p < 0.001). The mediating effect of thrombocytopenia was significant (p < 0.001 for the average causal mediation effect (ACME)). Longitudinal platelet trajectory was associated with risk-adjusted 28-day mortality among patients with sepsis and was proportionally mediated through thrombocytopenia.

Non-index hospital re-admissions after hospitalisation with acute myocardial infarction and geographic remoteness, New South Wales, 2005-2020: a retrospective cohort study.

To examine the frequency of re-admissions to non-index hospitals (hospitals other than the initial discharging hospital) within 30 days of admission with acute myocardial infarction in New South Wales; to examine the relationship between non-index hospital re-admissions and 30-day mortality. Retrospective cohort study; analysis of hospital admissions (Admitted Patient Data Collection) and mortality data (Registry of Births, Deaths and Marriages). Adults admitted to NSW hospitals with acute myocardial infarction re-admitted to any hospital within 30 days of discharge from the initial hospitalisation, 1 January 2005 - 31 December 2020. Proportion of re-admissions within 30 days of discharge to non-index hospitals, and associations of non-index hospital re-admissions with demographic and initial hospitalisation characteristics and with 30-day and 12-month mortality, each by residential remoteness category. Of 168 097 people with acute myocardial infarction discharged alive, 28 309 (16.8%) were re-admitted to hospital within 30 days of discharge, including 11 986 to non-index hospitals (42.3%); the proportion was larger for people from regional or remote areas (50.1%) than for people from major cities (38.3%). The odds of non-index hospital re-admission were higher for people with ST-elevation myocardial infarction, for people whose index admissions were to private hospitals, who were transferred between hospitals or had undergone revascularisation during the initial admission, were under 65 years of age, or had private health insurance; the influence of these factors was generally larger for people from regional or remote areas than for those from large cities. After adjustment for potential confounders, non-index hospital re-admission did not influence mortality among people from major cities (30-day: adjusted odds ratio [aOR], 1.09; 95% confidence interval [CI], 0.99-1.20; 12-month: aOR, 0.98, 95% CI, 0.93-1.03), but was associated with reduced mortality for people from regional or remote areas (30-day: aOR, 0.81; 95% CI, 0.70-0.95; 12-month: aOR, 0.88; 95% CI, 0.81-0.96). The geographically dispersed Australian population and the mixed public and private provision of specialist services means that re-admission to a non-index hospital can be unavoidable for people with acute myocardial infarction who are initially transferred to specialised facilities. Non-index hospital re-admission is associated with better mortality outcomes for people from regional or remote areas.

Outpatient parenteral antibiotic therapy in non-cystic fibrosis lung transplant recipients: characteristics, efficacy and safety.

Bacterial isolation is associated with worse outcomes after lung transplantation (LTx), and successful bacterial eradication is shown to improve long-term survival and pulmonary function. Outpatient Parenteral Antibiotic Therapy (OPAT) may be an effective therapeutic modality for bacterial eradication post-LTx. A single-center, retrospective analysis of OPAT characteristics, efficacy, safety, and costs in non-cystic fibrosis LTx recipients. A total of 156 OPAT courses (from June 2019 to December 2022) were evaluated in 108 distinct LTx recipients. OPAT mainly consisted of dual antibiotic therapy (69%) for pulmonary bacterial isolation (97%), mostly Pseudomonas aeruginosa (66%). Successful eradication at 3 months post-OPAT was achieved in 71%. Eradication rate was significantly higher in patients treated after the first post-operative year (79%), compared to patients within the first year (61%) (p = 0.017). Eradication rate was similar for multidrug resistance (eradication rate 61%) versus no multidrug resistance (74%) (p = 0.116). Spirometry remained stable at 90 days post-OPAT. A statistically significant, but clinically negligible, increase in serum creatinine at 90 days post-OPAT was observed (1.33mg/dL vs. 1.39mg/dL, p < 0.001), yet unrelated to the antibiotic regimen used. OPAT-related hospital admissions occurred in 13% and line-related adverse events in 6%. Median number of hospitalization days saved per OPAT-course was 10 days (range 2-92), accounting for a total of 1841 avoided admission days and an estimated net cost reduction of 47% per treatment course. OPAT is an effective and safe therapeutic modality for bacterial eradication post-LTx, associated with a significant reduction in hospitalization days and treatment costs.