Adult Medical Patients Research Articles

The impact of the Centers for Disease Control and Prevention new surveillance definitions of ventilator-associated event on our clinical practice

ABSTRACT Objective Surveillance of ventilator-associated pneumonia is subjective, inaccurate, time-consuming, and does not predict outcomes. The Centers for Disease Control and Prevention (CDC) recommended the use of ventilator-associated event (VAE) definitions instead of ventilator-associated pneumonia (VAP) in 2013. Therefore, we evaluated this novel surveillance algorithm by comparing the results of our VAP and VAE methods. Material Methods We evaluated mechanically ventilated adult medical and surgical patients in our 13-bed intensive care unit (ICU). Nine patients diagnosed with VAP in 2018-2019 and 11 patients diagnosed with VAE in 2022-2024 were retrospectively evaluated. The impact of the new definitions on clinical processes such as days on the mechanical ventilator, duration of antibiotic use, ICU stay in determining infectious status was monitored. Results. Statistical analysis revealed that demographic and numeric data were similar in both VAP and VAE diagnosis groups (p

Debulking the Myth of the ‘Social’ Admission – A Retrospective Review of Acutely Admitted Medical Patients in Wexford General Hospital

Abstract Background “Acopia”, “social admission” and other synonymous terms are frequently provided reasons requiring admission to acute hospitals and represent a common encounter for the Geriatric clinician. These cases are usually so called when the patient’s social circumstances are felt to need urgent attention, yet their medical health has not acutely deteriorated. Such non-diagnostic labels often mask underlying complex medical issues which can have detrimental health outcomes if not addressed appropriately. Despite this, they persist in the vernacular of modern medicine with almost half of doctors, junior and senior, finding the term useful (43.5%) and acceptable as a diagnosis (30.9%)1. We sought to examine what percentage of adult medical patients admitted to an acute hospital did not have an appreciable medical cause for their presentation. Methods We conducted a retrospective review of 191 patients admitted under medical teams in Wexford General Hospital across a 13-day period. Inclusion criteria included adult patients admitted under a medical team from the Emergency Department. Exclusion criteria applied to any patient admitted from OPD or by non-medical specialities. Results 191 cases were analysed. The average age was 65.8, median age was 70 and majority were male (n=105, 55%). There were only 2 patients (1%) who had no acute medical concerns following medical review. In one, the patient’s home oxygen supply had run out and the intended delivery of oxygen had been delayed. Another patient required increased home care supports however their medical status had not changed. Conclusion Our findings suggest that most patients presenting to acute hospitals following a robust medical review will evidence an acute medical issue. Dismissive phrases such as “acopia” and “social admission” need to be challenged for the superficial assessment that they are, and this reductive approach must be expunged from clinical practice to avoid misdiagnosis and malpractice in the care of the older adult.

Abstract C130: Evaluation of key performance indicators of a community-focused patient navigation program in an outpatient cancer center

Abstract Background: In 2021, Dana-Farber Cancer Institute’s (DFCI) Cancer Care Equity Program (CCEP) implemented a Community-Focused Patient Navigation (CFPN) program to support adult medical oncology patients from historically marginalized groups by proactively identifying and addressing patients’ barriers to cancer treatment. The program has been sequentially implemented in five cancer treatment centers, gastrointestinal, breast, thoracic, and gynecologic oncology and hematologic malignancies with plans to expand further. The purpose of this analysis is to evaluate CFPN against key performance indicators (KPIs) in gastrointestinal oncology, where the program was implemented first. Methods: Patients included in the analysis met CFPN eligibility criteria: adult medical oncology patients from zip codes in the Greater Boston area with significant socio-economic disparities and who agreed to receive support from the patient navigator. Program KPIs included in the analysis were appointment no show rate, New Patient Intake Questionnaire (NPIQ) response rate, and social work encounter rate. A pre- post analysis was used to identify trends in the KPIs of interest among navigated patients from the start of the program in October 2021 through May 2024 compared to similar groups of patients seen one year prior to the launch of the program who would have met CFPN eligibility criteria if the program had existed at that time. The data were taken from the cancer center’s electronic medical record system and visualized in a dashboard. Results: Preliminary findings show a significant decrease in appointment no show rate from 4.07% to 2.29% (p<0.05) and an increase in NPIQ response rate from 20.97% to 34.74% (p<0.05) among all navigated patients after the program was implemented compared to one year prior to the program launch. While not statistically significant, there was an increase from 28.23% to 43.16% in the social work encounter rate for patients engaged with the patient navigator. Conclusion: Preliminary analysis of CFPN demonstrates a positive trend toward meeting KPIs in gastrointestinal oncology and reveals outcomes that will guide further quantitative and qualitative analysis to identify areas of programmatic success and improvement. Next steps include conducting a more in-depth quantitative analysis on additional KPIs, including patient retention rate, stratified by demographics. CCEP also plans to conduct a qualitative analysis to identify patient and care team perceptions of CFPN through focus groups and/or structured interviews. An abstract describing CFPN program design was accepted for online publication at ASCO. This project was undertaken as a Quality Improvement Initiative at DFCI, and as such was not formally supervised by the Institutional Review Board per policy. Citation Format: Sarah Pohl, Emma Green, Katherine Miller, Ludmila Svoboda, Magnolia Contreras, Christopher Lathan. Evaluation of key performance indicators of a community-focused patient navigation program in an outpatient cancer center [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C130.

Understanding the influences on hospital discharge decision-making from patient, carer and staff perspectives

BackgroundGaps in discharge planning are experienced by 41% of hospital patients in Australia. There is an established body of knowledge regarding the features of the discharge process that need to be improved to avoid subsequent hospital readmission and enhance the discharge experience. However, many of these studies have focused solely on factors related to unplanned hospital readmissions and there has been limited success in operationalising improvements to the discharge process. The aim of this study was to explore and describe the factors that influence the decision to discharge adult medical patients from hospital, from patient, carer and staff perspectives.MethodsA qualitative descriptive study was conducted in one acute medical ward in Melbourne, Australia. The study data were collected by observations of clinical practice and semi-structured interviews with patients, carers and staff. Participants were: i) English-speaking adults identified for discharge home, ii) patient carers, and iii) staff involved in the discharge process. Observation data were analysed using content analysis and interviews data were analysed using thematic analysis.ResultsTwenty-one discharges were observed, and 65 participants were interviewed: 21 patients, two carers, and 42 staff. Most patients (76%) were identified as being ready for discharge during morning medical rounds, and 90% of discharge decisions were made collaboratively by the medical team and the patient. Carers were observed to be notified in 15 discharges by the patient (n = 8), doctors (n = 4), or nursing staff (n = 3). Five themes were constructed from thematic analysis of interviews: Readiness for Home, Fragmented Collaboration, Health Literacy, Unrealistic Expectations, and Care beyond Discharge. A collaborative team and supportive carers were considered to enhance risk assessment and discharge planning, however fragmented communication between clinicians, and between clinicians and patients/carers was a barrier to discharge decision-making.ConclusionsOur study highlights the need for a more coordinated approach to discharge decision-making that optimises communication with patients and carers and multidisciplinary workflows and reduces fragmentation. The importance of patient-centred care and a personalised approach to care are well established. However, there is a need to design systems to customise the entirety of the patient journey, including the approach to discharge decision making.

Evaluation of hospital quality of care outcomes in a teaching hospital in Ethiopia: a retrospective database study

ObjectivesWe aimed to evaluate hospital mortality rates, readmission rates and length of hospital stay (LOS) among adult medical patients admitted to a teaching hospital in Ethiopia.DesignWe performed a retrospective study...

The evaluation of the quality of life in survivors of critical illness after discharge from Intensive Care Unit (ICU): A prospective cohort study

Background: Admission to the Intensive Care Unit (ICU) constitutes a substantial psychophysical burden for patients and their relatives. Individuals who are critically ill and receive care in the ICU frequently exhibit numerous physical and mental issues stemming from the primary ailment, its complications, and subsequent treatments. Aim: This study aimed to assess the quality of life (QoL) for ICU patients in the first and third month after ICU discharge and identify any issues arising from their ICU hospitalization. Method and Material: This was a prospective cohort study. The study participants were adult medical or surgical patients admitted to ICUs in three public hospitals in the region of Attica in Greece, from August 2020 to December 2021. The short form (SF)-36 was used to measure QoL. Data collection was performed through telephone interviews during the first and third month after ICU discharge. Results: The study included 43 patients. The mean age was 59.63±13.06 years. The average value of the two main categories in the 1st month was: Physical health: 53.72 ± 15.92, and Mental health: 69.03 ± 26.02, while in the 3rd month, it was 62.42 ± 20.45 and 72.81 ± 16.47, respectively. The duration of mechanical ventilation, high-flow oxygen therapy, and spontaneous breathing in days seemed to be correlated with the “Physical Functioning”, “Pain”, and “Limitation of the role due to Physical health” subscales of SF-36, respectively (p-value <0.05). The total length of hospitalization seemed to have a statistically significant weak negative correlation with "Physical Function" and "Physical Health" subscales (p-value<0.05). Conclusions: An improvement in patients’ QoL was demonstrated three months after discharge from the ICU.

Impact of Clinical Decision Support with Mandatory versus Voluntary Venous Thromboembolism Risk Assessment in Hospitalized Patients.

Background Venous thromboembolism (VTE) causes significant preventable morbidity and mortality in hospitalized patients. Assessing VTE risk is essential to initiating appropriate prophylaxis and reducing VTE outcomes. Studies show that computerized clinical decision support (CDS) can improve VTE risk assessment (RA), prophylaxis, and outcomes but few examined the effectiveness of specific design features. From 2008 to 2016, University of Michigan Health implemented CDS for VTE prevention in four stages, which alternated between voluntary and mandatory RA using the 2005 Caprini model and generated inpatient orders for risk-appropriate prophylaxis based on CHEST guidelines. This cross-sectional study evaluated the impact of mandatory versus voluntary RA on VTE prophylaxis and outcomes for adult medical and surgical patients admitted to the health system. Methods Interrupted time series analysis was conducted to evaluate the trend in smart order set-recommended VTE prophylaxis by CDS stage. Logistic regression with CDS stage as the primary independent variable was used in pairwise comparisons of VTE during hospitalization and within 90 days post-discharge for mandatory versus voluntary RA. Adjusted odd ratios (ORs) were calculated for total, in-hospital, and post-discharge VTE. Results In this study of 223,405 inpatients over 8 years, smart order set-recommended prophylaxis increased from 65 to 79%; it increased significantly when voluntary RA in Stage 1 became mandatory in Stage 2 (10.59%, p < 0.001) and decreased significantly when it returned to voluntary in Stage 3 (-11.24%, p < 0.001). The rate increased slightly when mandatory RA was reestablished in Stage 4 (0.23%, p = 0.935). Adjusted ORs for VTE were lower for mandatory RA versus adjacent stages with voluntary RA. The adjusted OR for Stage 2 versus Stage 1 was 14% lower ( p < 0.05) and versus Stage 3 was 11% lower ( p < 0.05). The adjusted OR for Stage 4 versus Stage 3 was 4% lower ( p = 0.60). These results were driven by changes in in-hospital VTE. By contrast, the incidence of post-discharge VTE increased in each successive stage. Conclusion Mandatory RA was more effective in improving smart order set-recommended prophylaxis and VTE outcomes, particularly in-hospital VTE. Post-discharge VTE increased despite high adherence to risk-appropriate prophylaxis, indicating that guidelines for extended, post-discharge prophylaxis are needed to further reduce VTE for hospitalized patients.

Integration of patient navigation into clinical operations of an outpatient cancer center.

e23091 Background: Recognizing the critical importance of expanding access to high-quality, integrated cancer care, Dana-Farber Cancer Institute’s (DFCI) Cancer Care Equity Program developed a multi-year plan to integrate a centralized, systems-based patient navigation (PN) program focused on supporting adult medical oncology patients from historically marginalized groups. The goal was to proactively address patients’ socio-economic, emotional, and structural barriers to attending medical appointments and adhering to cancer treatment plans through care coordination, physical accompaniment, and resource provision. Methods: Inclusion of the new program in DFCI’s operating goals supported prioritization of the work across the cancer center. A multidisciplinary workgroup developed standard operating procedures grounded in evidence-based approaches while leveraging existing clinical operations. The Freeman Navigation Model informed PN scope of work with a focus on historically marginalized communities. DFCI’s Community Health Needs Assessment guided the decision to prioritize patients from zip codes with significant disparities related to social determinants of health. Utilization of electronic health records for PN documentation ensured effective communication with care teams and enabled accurate and consistent data collection and reporting. Alignment of the program’s measurement strategy with national PN metrics and development of a data dashboard allowed for ongoing monitoring and evaluation. Results: The program was implemented sequentially in five cancer treatment centers: gastrointestinal, breast, thoracic, and gynecologic oncology as well as hematologic malignancies. 517 patients were contacted and 1,736 barriers to cancer care were addressed at time of analysis. Preliminary findings from the first cancer treatment center suggest a decreased no show rate in the second year of the program. Conclusions: The multidisciplinary approach to integrating an evidence-based PN program into clinical operations supported general adoption among care teams and timely replication across cancer types. The infrastructure developed for the program could potentially support implementation of Centers for Medicare and Medicaid Services reimbursement for PN services. Next steps include confirming preliminary findings in a larger sample, conducting a cost-benefit analysis, and expanding the program across the clinical enterprise. [Table: see text]

Two Weeks Versus One Week of Maximal Patient-Intensivist Continuity for Adult Medical Intensive Care Patients: A Two-Center Target Trial Emulation.

To compare outcomes for 2 weeks vs. 1 week of maximal patient-intensivist continuity in the ICU. Retrospective cohort study. Two U.S. urban, teaching, medical ICUs where intensivists were scheduled for 2-week service blocks: site A was in the Midwest and site B was in the Northeast. Patients 18 years old or older admitted to a study ICU between March 1, 2017, and February 28, 2020. None. We applied target trial emulation to compare admission during an intensivist's first week (as a proxy for 2 wk of maximal continuity) vs. admission during their second week (as a proxy for 1 wk of maximal continuity). Outcomes included hospital mortality, ICU length of stay, and, for mechanically ventilated patients, duration of ventilation. Exploratory outcomes included imaging, echocardiogram, and consultation orders. We used inverse probability weighting to adjust for baseline differences and random-effects meta-analysis to calculate overall effect estimates. Among 2571 patients, 1254 were admitted during an intensivist's first week and 1317 were admitted during a second week. At sites A and B, hospital mortality rates were 25.8% and 24.2%, median ICU length of stay were 4 and 2 days, and median mechanical ventilation durations were 3 and 3 days, respectively. There were no differences in adjusted mortality (odds ratio [OR], 1.01 [95% CI, 0.96-1.06]) or ICU length of stay (-0.25 d [-0.82 d to +0.32 d]) for 2 weeks vs. 1 week of maximal continuity. Among mechanically ventilated patients, there were no differences in adjusted mortality (OR, 1.00 [0.87-1.16]), ICU length of stay (+0.06 d [-0.78 d to +0.91 d]), or duration of mechanical ventilation (+0.37 d [-0.46 d to +1.21 d]) for 2 weeks vs. 1 week of maximal continuity. Two weeks of maximal patient-intensivist continuity was not associated with differences in clinical outcomes compared with 1 week in two medical ICUs.

Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial.

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500.

Causes for 30-day readmissions and accuracy of the LACE index in regional Victoria, Australia.

Clinicians and funders continue to search for ways to reduce costs without sacrificing quality of care. Ongoing research should focus on innovative care models that identify patients at high-risk for hospitalisation and thereby reduce healthcare costs. This study examined readmission rates, comorbidity profiles and the performance of the LACEi (Length of stay, Acuity of admission, Charlson Comorbidity Index, ED admissions in the previous 6 months index) to predict the risk of 30-day readmissions in a regional population. Furthermore, we tested a novel clinician-orientated classification for the causes of 30-day readmissions. Using a nested case-control design, data were extracted from administrative health records using 30-day readmission status as the outcome. We defined cases as discharges within 30 days before readmission and controls without a discharge within 30 days before admission between 1 July 2020 and 30 June 2022. The study was conducted at South West Healthcare in Victoria, Australia. All adult medical patients were discharged alive from the facility. We excluded planned readmissions, surgical and obstetric admissions, dialysis, transfers to alternative facilities and discharges against medical advice. Thirty-day readmission rate, comorbidity profile for all admissions, LACEi for all admissions, the performance of the LACEi in our setting and the causes leading to readmission using a clinician-orientated classification tool. Comorbidity burden, male sex and age > 65 years were associated with increased readmission risk but not length of stay. The LACEi demonstrated modest predictive ability to identify high-risk patients for readmissions (area under the receiver operating characteristic curve = 0.59). Additional variables were needed to increase accuracy. The novel classification identified 42% of readmissions as potentially avoidable. Our study identified comorbidity burden, male sex and age ≥ 65 years as critical indicators for readmission risk. Although the LACEi showed moderate predictive ability, additional variables were needed for increased accuracy. Over 40% of readmissions were potentially avoidable, and nearly two thirds occurred within 14 days of discharge from the hospital.

Weekends admitted adult medical patients have higher in-hospital mortality in Ethiopia: An implication for quality improvement.

Weekend effect' is a term used to describe the increased mortality associated with weekend emergency admissions to hospitals compared with admissions on weekdays. This effect was not investigated in Ethiopia among adult patients admitted to hospitals. We aimed to find out whether the weekend effect exists in the country's a teaching hospital. The study was conducted among adult medical patients admitted at Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia, from September 2020 to September 2023. We extracted the data from the electronic medical records, and those with missed outcomes, length of hospital stays, and diagnosis were excluded. We used a multivariable logistic regression model to determine the association between the outcome and risk factors. The Cox proportional hazard model was utilized to establish the correlation between admission times and mortality risk incidence. Statistical significance was determined using a P value of less than 0.05. The Kaplan-Meier curve was utilized to estimate the risk of in-hospital mortality over the duration of the hospital stay. A of 5564 patients were admitted to medical wards (n = 5001) and intensive care unit (ICU) (n = 563) during the study periods. In binary multivariable analysis, weekend medical wards and ICU admitted adult medical patients had a 38% (AOR, 1.38, 95% CI, 1.17, 1.65) and 50% (AOR, 1.50, 95% CI, 1.02, 2.20) higher in-hospital mortality compared weekdays admitted patients, respectively. The cumulative mortality risk incidence was higher among medical ward-admitted patients (AHR, 1.26, 95% CI, 0.09, 1.46, P value = 0.051) and significantly higher among ICU-admitted adult patients (AHR, 1.28, 95% CI, 1.21, 1.75, P value = 0.01) during the weekends. There was no statistically significant mortality difference among night versus day or office hours versus off-office hours admitted patients. Moreover, we did identify significant differences in the duration of hospital stays between weekends and weekdays. In this study, weekend-admitted adult medical patients in wards or ICUs have higher in-hospital mortality rates. This underscores a need for comprehensive nationwide data to improve weekend admitted patients' quality of care and treatment outcomes.

Impact of changes in antihypertensive medication on treatment intensity at hospital discharge and 30 days afterwards.

Little is known about the cumulative effect of changes in antihypertensive medications on treatment intensity. This study analyzed how changes in antihypertensive medications affect the intensity of antihypertensive treatment at hospital discharge and 30days afterwards. A prospective observational study of 299 hospitalized adult medical patients with antihypertensive therapy was conducted. The effect of medication changes on treatment intensity was evaluated by the Total Antihypertensive Therapeutic Intensity Score (TIS). At discharge, antihypertensive medications were changed in 62% of patients (184/299), resulting in a very small median reduction in TIS of -0.16. Treatment intensity was reduced more with increasing number of antihypertensive medications at admission, whereas it increased with elevated inpatient systolic blood pressure. Thirty days after discharge, antihypertensive medications were changed in 37% of patients (88/239) resulting in a median change in TIS of -0.02. Among them, 90% (79/88) had already undergone a change at discharge. The change in treatment intensity after discharge was inversely correlated with a change at discharge. Changes in antihypertensive medication frequently occurred at discharge but had a minimal impact on the intensity of antihypertensive treatment. However, these adjustments exposed patients to further medication changes after discharge, evidencing the need for treatment reassessment in the first month post-discharge.

Head-to-head comparison of 19 prediction models for short-term outcome in medical patients in the emergency department: a retrospective study

IntroductionPrediction models for identifying emergency department (ED) patients at high risk of poor outcome are often not externally validated. We aimed to perform a head-to-head comparison of the discriminatory performance of several prediction models in a large cohort of ED patients.MethodsIn this retrospective study, we selected prediction models that aim to predict poor outcome and we included adult medical ED patients. Primary outcome was 31-day mortality, secondary outcomes were 1-day mortality, 7-day mortality, and a composite endpoint of 31-day mortality and admission to intensive care unit (ICU).The discriminatory performance of the prediction models was assessed using an area under the receiver operating characteristic curve (AUC). Finally, the prediction models with the highest performance to predict 31-day mortality were selected to further examine calibration and appropriate clinical cut-off points.ResultsWe included 19 prediction models and applied these to 2185 ED patients. Thirty-one-day mortality was 10.6% (231 patients), 1-day mortality was 1.4%, 7-day mortality was 4.4%, and 331 patients (15.1%) met the composite endpoint. The RISE UP and COPE score showed similar and very good discriminatory performance for 31-day mortality (AUC 0.86), 1-day mortality (AUC 0.87), 7-day mortality (AUC 0.86) and for the composite endpoint (AUC 0.81). Both scores were well calibrated. Almost no patients with RISE UP and COPE scores below 5% had an adverse outcome, while those with scores above 20% were at high risk of adverse outcome. Some of the other prediction models (i.e. APACHE II, NEWS, WPSS, MEWS, EWS and SOFA) showed significantly higher discriminatory performance for 1-day and 7-day mortality than for 31-day mortality.ConclusionsHead-to-head validation of 19 prediction models in medical ED patients showed that the RISE UP and COPE score outperformed other models regarding 31-day mortality.

Remote monitoring after hospital discharge.

561 Background: Strategies to improve transitions from the hospital to home for patients with cancer are considered an important component of quality, patient-centered care in oncology. CMS evaluates cancer hospital performance based on the 30-day unplanned hospital readmission rate, and this measure has been endorsed by the National Quality Forum. Nationally, the 30-day readmission rate for oncology patients ranges from 19%-27%. These readmissions come at high psychosocial, physical, and financial costs for patients and caregivers. A remote monitoring intervention that includes frequent contacts with the patient is likely to be effective in improving this transition. Methods: We evaluated the feasibility, acceptability, and perceived value of a mobile health intervention to monitor and manage symptoms of adult medical oncology patients discharged from an NCI-designated cancer center to home. Patients were monitored for 10 days, which is the median time to readmission for an oncology patient. The technology supporting the program included: 1) a patient portal enabling daily electronic patient-reported outcomes assessments; 2) alerts for concerning symptoms; 3) an application to allow staff to review and trend symptom data; 4) a secure platform to support communications and televisits between staff and patients; 5) an advanced feedback report to provide just-in-time patient symptom education. Feasibility and acceptability were evaluated through engagement (goal: &gt;50% response rate) and symptom alerts and perceived value was measured through a patient engagement survey that included a net promoter score (how likely the patient is to recommend the program to similar patients; goal &gt;0.70). Results: Between January 1, 2021 to December 31, 2022, the program enrolled 2,258 medical oncology patients (median age: 63 years, 55% female). Patients with gastrointestinal (25%) and thoracic (19%) malignancies were the most prevalent diagnoses. Of those enrolled, 66% of patients participated in home remote monitoring by self-reporting symptom data and 49% of patients generated a severe symptom alert. The most prevalent severe symptom alerts were pain (24%), constipation (7%), and fatigue (7%). Patients expressed a great deal of satisfaction with the intervention with a net promoter score of 0.86. In preliminary analysis, we found that 30-day readmission decreased by 3% (from 33% to 30%) representing savings of $2.3 - $5.8 MM annually. Conclusions: A remote monitoring program after discharge was feasible, acceptable, and perceived to be of value by oncology patients discharged from a cancer center. Future work will evaluate the value of a remote symptom monitoring platform in decreasing readmissions.

Prehospital factors associated with out-of-hospital cardiac arrest outcomes in a metropolitan city: a 4-year multicenter study

BackgroundPrehospital factors play a vital role in out-of-hospital cardiac arrest (OHCA) survivability, and they vary between countries and regions. We investigated the prehospital factors associated with OHCA outcomes in a single metropolitan city in the Republic of Korea.MethodsThis study included adult medical OHCA patients enrolled prospectively, using data from the citywide OHCA registry for patients registered between 2018 and 2021. The primary outcome was survival to hospital discharge. Multivariable logistic regression analysis was conducted to determine the factors associated with the study population’s clinical outcomes, adjusting for covariates. We performed a sensitivity analysis for clinical outcomes only for patients without prehospital return of spontaneous circulation prior to emergency medical service departure from the scene.ResultsIn multivariable logistic regression analysis, older age (odds ratio [OR] 0.96; 95% confidence interval [CI] 0.95–0.97), endotracheal intubation (adjusted odds ratio [aOR] 0.29; 95% [CIs] 0.17–0.51), supraglottic airway (aOR 0.29; 95% CI 0.17–0.51), prehospital mechanical chest compression device use (OR 0.13; 95% CI 0.08–0.18), and longer scene time interval (OR 0.96; 95% CI 0.93–1.00) were negatively associated with survival. Shockable rhythm (OR 24.54; 95% CI 12.99–42.00), pulseless electrical activity (OR 3.11; 95% CI 1.74–5.67), and witnessed cardiac arrest (OR 1.59; 95% CI 1.07–2.38) were positively associated with survival. In the sensitivity analysis, endotracheal intubation, supraglottic airway, prehospital mechanical chest compression device use, and longer scene time intervals were associated with significantly lower survival to hospital discharge.ConclusionsRegional resuscitation protocol should be revised based on the results of this study, and modifiable prehospital factors associated with lower survival of OHCA should be improved.

Effect of sepsis protocol in inpatient departments triggered by Ramathibodi Early Warning Score (REWS) on treatment processes

Background: Sepsis needs to be more focused on the effect of patient management at the ward level. We aimed to evaluate the effect of implementing the sepsis protocol triggered by the Ramathibodi Early Warning Score (REWS) on treatment processes in inpatients with new-onset sepsis. Methods: We conducted a prospective observational study among adult medical patients admitted to the general wards. A 25-month pre-protocol period was assigned as a control, and a 14-month protocol period was allocated to a protocol group. An inpatient sepsis protocol comprised a nurse-initiated sepsis protocol with REWS ≥2 plus suspected infection, prompt antibiotic, lactate measurement, and fluid resuscitation. Primary outcomes were the achievement of sepsis treatment processes, including the resuscitation and management bundle, namely: 1) the percentage of patients who were taken for the initial laboratory workup for sepsis, especially lactate and blood culture taking before antibiotics; 2) the percentage of patients who received appropriate antibiotics; 3) the percentage of patients who received optimal fluid resuscitation and management; 4) the percentage of patients who performed inferior vena cava ultrasound; 5) the percentage of patients who received steroid and vasopressor drugs; 6) "time-to-antibiotic," the duration from diagnosis of sepsis to receiving antibiotic treatment; 7) "time-to-optimal intravenous fluid management;" 8) "time-to-transfer to ICU. Results: 282 patients were evaluated (141 pre-implementation, 141 post-implementation); 94.7% of patients with sepsis had REWS ≥2. More patients in the protocol period had a lactate measurement and fluid management (89 [63.1%] vs. 44 patients [31.2%], p&lt;0.001 and (50 [35.4%] vs. 22 patients [15.6%], p&lt;0.001, respectively). More patients in the protocol period received antibiotics within 1 hour than in the pre-protocol period (80 [56.7%] vs. 53 patients [37.6%], p=0.001). The time to antibiotic treatment (mean, SD) in the protocol period was shorter than that in the pre-protocol period (81.7 [77.86] vs. 138.22 [145.17], p=0.007). The length of the intensive care unit (ICU) stay was shorter in the protocol period (8 d [3, 16.5] vs. 10 d [5, 20.5], p=0.011). The two groups did not differ in in-hospital mortality, length of hospital stay, or time-to-transfer to the ICU. Conclusions: Implementing an in-hospital sepsis protocol was associated with significant improvement in sepsis treatment processes, namely lactate measurement, starting antibiotic treatment within 1 hour, fluid management, and a shorter length of ICU stay.

LB 02.2 Prevention of Symptomatic Venous Thromboembolism with LowMolecular-Weight Heparin in Hospitalized Older Adult Medical Patients: A Randomized Placebo-Controlled Trial

LB 02.2 Prevention of Symptomatic Venous Thromboembolism with LowMolecular-Weight Heparin in Hospitalized Older Adult Medical Patients: A Randomized Placebo-Controlled Trial

Comparison of intensive care unit liberation bundle adherence prior to and during the COVID‐19 pandemic: A retrospective cohort study

AbstractThe intensive care unit (ICU) liberation (A–F) bundle is recommended by the Society of Critical Care Medicine guidelines as standard supportive care. Significant deviations were made to providing bundled care during the coronavirus disease 2019 (COVID‐19) pandemic. The objective of the study is to describe how COVID‐19 affected bundle adherence at a single academic medical center. This is a retrospective cohort study of adult medical ICU patients on mechanical ventilation (MV) for at least 48 h and an ICU stay of at least 7 days. Patients were separated into three cohorts based on ICU admission date and COVID‐19 status from April 2019 to March 2021; pre‐pandemic (pre‐COV), pandemic COVID‐19 negative (COV‐neg), and pandemic COVID‐19 positive (COV‐pos). Primary outcomes were median average daily bundle adherence over 7 days and daily complete bundle adherence. Secondary outcomes were individual bundle component adherence rates and patient outcomes. A total of 67 patients were included. Median average daily bundle adherence (pre‐COV 68.6% vs. COV‐neg 51.4% vs. COV‐pos 32.6%; p &lt; 0.001), median number of days with complete adherence (pre‐COV 1 [interquartile range (IQR) 0–1] vs. COV‐neg 0 [IQR 0–0] vs. COV‐pos 0 [IQR 0–0]; p &lt; 0.001), and percentage of patients with any day of complete bundle adherence (pre‐COV 78.6% vs. COV‐neg 14.3% vs. COV‐pos 7.1%) were different among groups and individual bundle component adherence varied. Also, median duration of MV (pre‐COV: 6.3 days [IQR 5.6–9], COV‐neg: 8.9 days [IQR 7.6–14], COV‐pos: 11.6 days [IQR 8.4–21], p = 0.01) and median days alive and free from MV up to Day 30 (pre‐COV: 23 [IQR 21–24], COV‐neg: 20 [IQR 15–22], COV‐pos: 18 [IQR 7–21], p = 0.015) were significantly different between groups. ICU A–F bundle adherence was significantly reduced during the COVID‐19 pandemic in patients with and without COVID‐19 infection.

Sex differences in clinical presentation and mortality in emergency department patients with sepsis

Background There is growing awareness that sex differences are associated with different patient outcomes in a variety of diseases. Studies investigating the effect of patient sex on sepsis-related mortality remain inconclusive and mainly focus on patients with severe sepsis and septic shock in the intensive care unit. We therefore investigated the association between patient sex and both clinical presentation and 30-day mortality in patients with the whole spectrum of sepsis severity presenting to the emergency department (ED) who were admitted to the hospital. Materials and methods In our multi-centre cohort study, we retrospectively investigated adult medical patients with sepsis in the ED. Multivariable analysis was used to evaluate the association between patient sex and all-cause 30-day mortality. Results Of 2065 patients included, 47.6% were female. Female patients had significantly less comorbidities, lower Sequential Organ Failure Assessment score and abbreviated Mortality Emergency Department Sepsis score, and presented less frequently with thrombocytopenia and fever, compared to males. For both sexes, respiratory tract infections were predominant while female patients more often had urinary tract infections. Females showed lower 30-day mortality (10.1% vs. 13.6%; p = .016), and in-hospital mortality (8.0% vs. 11.1%; p = .02) compared to males. However, a multivariable logistic regression model showed that patient sex was not an independent predictor of 30-day mortality (OR 0.90; 95% CI 0.67–1.22; p = .51). Conclusions Females with sepsis presenting to the ED had fewer comorbidities, lower disease severity, less often thrombocytopenia and fever and were more likely to have a urinary tract infection. Females had a lower in-hospital and 30-day mortality compared to males, but sex was not an independent predictor of 30-day mortality. The lower mortality in female patients may be explained by differences in comorbidity and clinical presentation compared to male patients. KEY MESSAGES Only limited data exist on sex differences in sepsis patients presenting to the emergency department with the whole spectrum of sepsis severity. Female sepsis patients had a lower incidence of comorbidities, less disease severity and a different source of infection, which explains the lower 30-day mortality we found in female patients compared to male patients. We found that sex was not an independent predictor of 30-day mortality; however, the study was probably underpowered to evaluate this outcome definitively.