Average Length Of Stay Research Articles

Association between physician-hospital integration and inpatient care delivery in accountable care organizations: An instrumental variable analysis.

To investigate the relationship between physician-hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure. The primary data were Massachusetts All-Payer Claims Database (2009-2013). Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013. Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician-hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date. Not applicable. The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician-hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, -15.1% to -5.9%). Corresponding estimates for 45 and 60 days were - 9.7% (95%CI, -14.2% to -4.9%) and - 9.6% (95%CI, -14.3% to -4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, -22.6% to -8.2%) but unrelated to 30-day readmission rate. Our instrumental variable analysis shows physician-hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.

Schizophrenia and schizoaffective disorder: Length of stay and associated factors.

Patients with schizophrenia and schizoaffective disorder often require longer admissions. To explore length of stay (LOS) and associated factors of patients with schizophrenia and schizoaffective disorder, admitted to a public sector specialised psychiatric hospital, over a 4-year period. The study was conducted at Tara Hospital in Johannesburg. A retrospective record review of 367 adult schizophrenia and schizoaffective disorder patients admitted between 01 January 2015 and 31 December 2018. Average LOS was calculated and the proportion of short-stay (< 30 days), medium-stay (31-90 days) and long-stay (> 90 days) admissions determined. Sociodemographic, clinical and admission outcome data were collected and analysed from a randomly selected subset of patients in each LOS category. Mean LOS was 128 days (median 87, interquartile range [IQR] 49-164, range 0-755 days). A significantly greater proportion had long-stay admissions (p < 0.001). Male gender (p = 0.018), being unmarried (p = 0.006), treatment resistant (p < 0.001) and on clozapine (p = 0.009) were factors found to have a significant association with long-stay admissions. Rates of unemployment (> 80%), comorbid substance use disorders (> 40%), medical illnesses (> 40%), antipsychotic polypharmacy (> 40%) and readmissions (> 80%) were high. Most (> 80%) were discharged. Long-stay admissions were frequently required for patients with schizophrenia and schizoaffective disorder admitted to Tara Hospital. This study highlights factors associated with long-stay admissions in patients with schizophrenia and schizoaffective disorder. More research is needed into whether increased access to community-based services, such as residential and daycare facilities, outpatient substance rehabilitation programmes and dual diagnosis clinics, could translate into shorter admissions, less frequent relapses and improved outcomes in this population.

Impact of an ICU bed capacity optimisation method on the average length of stay and average cost of hospitalisation following implementation of China’s open policy with respect to COVID-19: a difference-in-differences analysis based on information management system data from a tertiary hospital in southwest China

ObjectivesFollowing the implementation of China’s open policy with respect to COVID-19 on 7 December 2022, the influx of patients with infectious diseases has surged rapidly, necessitating hospitals to adopt temporary...

Standardized Criteria to Initiate External Ventricular Drain (EVD) Weaning in a Neurological Intensive Care Unit to Increase the Safety of EVD Discontinuation and Reduce the Need for a Shunt.

Introduction Patients with subarachnoid hemorrhages (SAH) with external ventricular drains (EVD) candevelop chronic hydrocephalus (HCP), requiring permanent cerebrospinal fluid (CSF) diversion via an external shunt. Two different strategies have been used to assess for dependence on EVD: 1) prompt closure, and 2) gradual weaning.Gradual weaning of EVDs is performed by increasing drainage resistance to outflow over days.However, when to start one strategy or the other is up to the physician. No uniform guidelines exist raising a question: Are standardized criteria necessary to initiate the EVD weaning process for SAH patients to increase the safety of EVD discontinuation and reduce the need for a shunt? This study shares criteria used to initiate EVD weaning that displayed increased safety of EVD discontinuation for patients with subarachnoid hemorrhage requiring EVD, particularly with regards to length of hospital stay (LOS), hospital-acquired infection rates, and ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement. Methods One hundred and fifty-one SAHpatients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non-aneurysmal nontraumatic SAH (naSAH) patients required EVD placement.A gradual EVD weaning protocol was initiated if patients met the following criteria: 1. The reason for EVD placement has resolved or is resolving, 2. The quantity of CSF output is <250mL over 24 hours, 3. Quality of CSF is nonbloody, 4. Intracranial Pressure (ICP) must be within normal limits, and 5. The patient must be neurologically stable. It was acceptable to initiate the weaning process when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing the drain (chamber) height by 5 millimeters of mercury every 24 hours if the criteria were met. Charts were reviewed for LOS, infection rates, and rate of VPS/ETV. Gender, age, race, wean failure incidence, Hunt-Hess scores, modified Fisher scores, and syndrome of inappropriate antidiuretic hormone/cerebral salt wasting (SIADH/CSW) rates were obtained. Results The average LOS for aSAH patients with EVD was 20.35 days. The incidence of VPS/ETV was 11%. A chi-square analysis revealed that aSAH patients had higher rates of VPS/ETV placement (p<0.001) and EVD wean failures (p<0.001) than naSAH patients. aSAH patients had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally. Conclusions Standardized criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provided a uniform approach to EVD management. Comparable infection rates and LOS for SAH patients requiring EVDs compared to national averages were found.

Length of Stay and Discharge Disposition After Total Hip Arthroplasty: A Large Multicenter Propensity Matched Comparison of Robotic-Assisted and Manual Techniques

BackgroundRobotic-arm assistance continues to gain popularity in total hip arthroplasty (THA) for its potential to improve component placement accuracy and patient outcomes. Nonetheless, there is limited data on the impact of robotic-assisted THA (RA-THA) on hospital length of stay (LOS) and discharge location. This study thus aimed to compare LOS, discharge location, and readmission rate for propensity-matched cohorts of RA-THA versus manual THA (M-THA). MethodsA retrospective review of a multi-hospital database was performed to identify patients who underwent THA between January 2016 and December 2021 from surgeons who performed both RA-THA and M-THA at 77 geographically diverse hospitals. The RA-THA and M-THA cohorts were 1-to-1 matched based on patient sex, age, and body mass index, resulting in 8,536 patients per cohort. Insurance type, LOS, same-day discharge, discharge disposition, and 90-day all-cause readmission rate were compared using Mann-Whitney U and Chi-square tests. ResultsAverage LOS was significantly shorter for RA-THA patients (1.39 ± 0.85 days) than for M-THA patients (1.48 ± 0.91 days, P < .001). Compared to 5.6% of M-THA patients, 5.3% of RA-THA patients underwent same-day discharge (P = .38). There were statistically significant differences in discharge disposition between cohorts, with more RA-THA cases discharged home without home healthcare compared to M-THA (47.9 versus 45.5%, P = .001) and fewer RA-THA cases discharged to a skilled nursing facility compared to M-THA (5.6 versus 6.9%, P = .001). The 90-day all-cause readmission rate for RA-THA cases was 3.0%, compared to 3.4% for M-THA cases (P = .26). ConclusionsCompared to M-THA, RA-THA had a shorter average LOS, a similar percentage of patients with same-day discharge, fewer patients who had skilled nursing facility discharge, and a similar all-cause 90-day readmission rate. These results may be of interest to surgeons participating in bundled payment programs and engaging in cost savings.

Racial Disparity in Length of Stay Following Implementation of a Bariatric Enhanced Recovery Program

IntroductionEnhanced Recovery Programs (ERPs) mitigate racial disparities in postoperative length of stay (LOS) for colorectal populations. It is unclear, however, if these effects exist in the bariatric surgery population. Therefore, this study aimed to evaluate the racial disparities in LOS before and after implementation of bariatric surgery ERP. MethodsA retrospective cohort study was performed using data from a single institution. Patients undergoing minimally invasive sleeve gastrectomy or Roux-en-Y gastric bypass from 2017 to 2019 (pre-ERP) or 2020-2022 (ERP) were included. Chi-square, Kruskal–Wallis, and analysis of variance were used to compare groups, and estimated LOS (eLOS) was assessed via multivariable regression. ResultsSeven hundred sixty four patients were identified, including 363 pre-ERPs and 401 ERPs. Pre-ERP and ERP cohorts were similar in age (median 44.3 years versus 43.8 years, P = 0.80), race (53.4% Black versus 56.4% Black, P = 0.42), and preoperative body mass index (median 48.3 versus 49.4, P = 0.14). Overall median LOS following bariatric surgery decreased from 2 days pre-ERP to 1 day following ERP (P < 0.001). Average LOS for Black and White patients decreased by 0.5 and 0.48 days, respectively. However, overall eLOS remained greater for Black patients compared with White patients despite ERP implementation (eLOS 0.21 days, P = 0.01). ConclusionsImplementation of a bariatric surgery ERP was associated with decreased LOS for both Black and White patients. However, Black patients did have slightly longer LOS than White patients in both pre-ERP and ERP eras. More work is needed to understand the driving mechanism(s) of these disparities to eliminate them.

Outcome of Cancer Patients with an Unplanned Intensive Care Unit Admission: Predictors of Mortality and Long-term Survival.

Understanding the characteristics and outcomes of cancer patients with unplanned ICU admission is imperative for therapeutic decisions and prognostication purposes. To describe the clinical characteristics of patients with hematological and non-hematological malignancies (NHM) who require unplanned ICU admission and to determine the predictors of mortality and long-term survival. This retrospective study included all patients with cancer who had an unplanned ICU admission between 2011 and 2016 at a tertiary hospital in Saudi Arabia. The following variables were collected: age, gender, ICU length of stay (LOS), APACHE II score, type of malignancy, febrile neutropenia, source and time of admission, and need for mechanical ventilation (MV), renal replacement therapy (RRT), and treatment with vasopressors (VP). Predictors of mortality and survival rates at 28 days and 3, 6, and 12 months were calculated. The study included 410 cancer patients with 466 unplanned ICU admissions. Of these, 52% had NHM. The average LOS in the ICU was 9.6 days and the mean APACHE score was 21.9. MV was needed in 73% of the patients, RRT in 15%, and VP in 24%, while febrile neutropenia was present in 24%. There were statistically significant differences between survivors and non-survivors in the APACHE II score (17.7 ± 8.0 vs. 25.6 ± 9.2), MV use (52% vs. 92%), need for RRT (6% vs. 23%), VP use (42% vs. 85%), and presence of febrile neutropenia (18% vs. 30%). The predictors of mortality were need for MV (OR = 4.97), VP (OR = 3.43), RRT (OR = 3.31), and APACHE II score (OR = 1.10). Survival rates at 28 days, 3, 6, and 12 months were 52%, 28%, 22%, and 15%, respectively. The survival rate of cancer patients with an unplanned admission to the ICU remains low. Predictors of mortality include need for MV, RRT, and VP and presence of febrile neutropenia. About 85% of cancer patients died within 1 year after ICU admission.

244 The Inaugural “Century” of Mixed Reality in Cranial Surgery: Virtual Reality Rehearsal/Augmented Reality Guidance and Its Learning Curve in the First Single-Surgeon, 100-Case Series

INTRODUCTION: Virtual reality (VR) and augmented reality (AR), together called Mixed reality (MxR) gaining importance in Neurosurgery as it helps to select apporaches and identify key anatomic landmarks intraoperatively. METHODS: The first 100 consecutive cases of a single surgeon for which MxR was intended for use were retrospectivaly analyzed for specific contributions to the opeation. Seventeen cases in the study cohort were matched with historical non-MxR cases for comparison of outcome parameters. The cases in which MxR failed were plotted over time to determine the nature of the “learning curve.” RESULTS: The nadir of the blue line is at case 44. The inflection point of the trend line (black) occurred at approximately case 63.This provides some evidence of proficiency acquisition in between. MxR helped to limit the size of the opening in 44 cases, enhanced precise placement of the craniotomy in 64 cases, increased the guidance efficiency to target or marker in 58 cases, and protected anti-targets from surgical incursion in 12 cases. Cases where MxR had above-expectation performances will be highlighted. Comparing MxR cases with matching non-MxR, the average EBL (106.8 mL vs. 142.4 mL), LOS (5.4 d vs. 8.2 d) and surgery duration (218.4 mins. 252.8 min) were all smaller for the MxR group. However, no statistically significant differences were found for all three comparisons. CONCLUSIONS: MxR enhances surgical planning and can supplant probe-and-monitor navigation for efficient intraoperative guidance without additional time for surgery or hospitalization

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study.

This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. Therapeutic/Care Management; Level III.

Risk factors for unfavorable outcome after spontaneous intracerebral hemorrhage in elderly patients

BackgroundSpontaneous intracerebral hemorrhage (SICH) of the elderly is a devastating form of stroke with a high morbidity and economic burden. There is still a limited understanding of the risk factors for an unfavorable outcome where a surgical therapy may be less meaningful. Thus, the aim of this study is to identify factors associated with unfavorable outcome and time to death in surgically treated elderly patients with SICH. MethodsWe performed a single-center retrospective study of 70 patients (age > 60 years) with SICH operated between 2008 and 2020. Functional outcome was assessed by modified Rankin Scale. Various clinical and neuroradiological variables including type of neurosurgical treatment, anatomical location of hemorrhage, volumetry and distribution of hemorrhage were assessed. Univariate and multivariate logistic regression models were performed. Length of stay (LOS) and hospital costs are presented. ResultsThe overall mortality (mean follow-up time of 22 months) in this study was 32/70 patients (45.71%), 30-days mortality was 8/70 (11.42%), and 12-months mortality was 22/70 (31.43%). Average LOS was 73.5 days with a median of 58, 766 € estimated in hospital costs per patient. Multivariate analysis for 12-months mortality was significant for intraventricular hemorrhage (IVH) (p = 0.007, HR = 1.021, 95% CI = 1.006 – 1.037). ROC analysis for 12-months mortality for IVH volume >= 7 cm3 presented an are under the curve of 0.658. ConclusionsWe identified IVH volume > 7 cm3 as an independent prognostic risk factor for mortality in elderly patients after SICH. This may help clinicians in decision-making for this critical and growing subgroup of patients.

Analyzing the 20-year declining trend of hospital length-of-stay in European countries with different healthcare systems and reimbursement models

The study aims to investigate the last 20-year (2000–2019) of hospital length of stay (LOS) trends and their association with different healthcare systems (HS) among 25 European countries. A panel dataset was created using secondary data from Eurostat and Global Burden of Disease study databases, with dependent and control variables aggregated at the national level over a period of 20 years. A time trend analysis was conducted using a weighted least squares model for panel data to investigate the association between LOS, HS models [National Health Service (NHS), National Health Insurance, Social Health Insurance (SHI), and Etatist Social Health Insurance], healthcare reimbursement schemes [Prospective Global Budget (PGB), Diagnosis Related Groups (DRG), and Procedure Service Payment (PSP)], and control variables. The study showed a reduction of average LOS from 9.20 days in 2000 to 7.24 in 2019. SHI was associated with a lower LOS compared to NHS (b = − 0.6327, p < 0.05). Both DRG (b = 1.2399, p < 0.05) and PSP (b = 1.1677, p < 0.05) reimbursement models were positively associated with LOS compared to PGB. Our results confirmed the downward trend of LOS in the last 20 years, its multifactorial nature, and the influence of the SHI model of HS. This could be due to the financial incentives present in fee-for-service payment models and the role of competition in creating a market for healthcare services. These results offer insight into the factors influencing healthcare utilization and can inform the design of more effective, efficient, and sustainable HS.

Do Laparoscopic Colorectal Procedures Need Fluid Optimization?

BACKGROUND: Goal-directed fluid therapy (GDFT) with hemodynamic monitoring may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in enhanced recovery after surgery protocols (ERAS) setting. AIMS: We predicted different fluid and vasoactive drug consumption during the procedure and less complications in the group of patients, where invasive hemodynamic monitoring was used. METHODS: Two groups of patients undergoing elective laparoscopic colorectal surgery were compared: A control group (CG), with standard hemodynamic monitoring, and a study group, (SG) with invasive hemodynamic monitoring and appropriate intraoperative interventions. We compared differences in intraoperative fluid consumption, length of hospital stay (LOS) and post-operative morbidity. RESULTS: A group of 29 patients in SG had similar average intraoperative fluid balance (+438 mL) as 27 patients in CG (+345 mL) p = 0.432. Average LOS was 8 days (±4) in SG and 6 days (±1) in CG (p = 0.124). Acute renal failure, anastomotic dehiscence, and indication for antibiotic treatment were predictors of statistically significant prolongation of hospital stay 3rd day after surgery, but independent of SG. CONCLUSION: Since no differences between the groups were shown in overall fluid and vasoactive drug consumption, we conclude that GDFT is not needed in laparoscopic colorectal surgery, when ERAS is followed.

Effectiveness of a Multidisciplinary Limb Preservation Program in Reducing Regional Hospitalization Rates for Patients With Diabetes-Related Foot Complications.

This study evaluated the toe and flow model (TFM), a limb preservation program led by podiatric surgeons in Alberta, Canada, for its impact on hospitalization rates and length of stay (LOS) in patients with diabetic foot complication (DFC). Diabetes, a leading cause of non-traumatic lower extremity amputations (LEAs) in Canada, often results in diabetic foot ulcers (DFUs), a major cause of infection, amputation, and hospitalization. TFM has reportedly reduced amputation rates by 39% to 56%. The study analyzed Alberta's health database from 2007 to 2017, focusing on diabetes patients aged 20 and above. It included patients with various DFCs and compared outcomes in regions using TFM and standard of care (SOC). The study also examined data from two major cities, one with TFM and the other without, including rural referrals to Calgary and Edmonton. The data were normalized for the diabetic population and analyzed using a standard Student's t-test. TFM regions showed significantly lower hospitalization rates (p = 1.22E-12) than SOC regions. Over 11 years, TFM maintained lower average and median LOS by 0.13 and 0.26 days, respectively. TFM access reduced hospitalization risk by up to 30%, and patients in TFM regions had a 21% shorter LOS compared to SOC regions. Despite similar demographics and healthcare systems, the TFM region benefited from a dedicated multidisciplinary program and comprehensive limb preservation services. The study shows that TFM effectively reduces hospitalizations and LOS for DFCs, with significantly better outcomes in the TFM region than in SOC regions.

O147: Use of the National Consultant Information Programme to evaluate surgical practice in England for rectal prolapse repair, identifying points of variation for improvement and the impact of the Covid-19 pandemic

Abstract Introduction Using the National Consultant Information Programme (NCIP) tool to extract and analyse data surrounding rectal prolapse repair procedures, to identify key trends and variation. Analysing data across a 4-year period to evaluate how the Covid-19 pandemic impacted current surgical practice. Methods NCIP compiles hospital episode statistics data gathered by NHS analysts. Data is categorised by key metrics including length of stay (LOS), procedure approach, deprivation score and pseudonymised provider. Data is for elective procedures in patients 17+ and has been contextualised by recent available literature. Results Of the 6702 procedures, 65.8% (4413) were carried out in the first time period, 1st April 2018 to 31st March 2020. Abdominal prolapse repair increased from 37.0% of procedures in the first 2 years, to 42.4% in the second period (1st April 2020 to 31st March 2022). Perineal approach decreased from 45.6% of procedures to 41.1% in the second period. 87.7% of patients were female. Most procedures were open (77.7%). Average LOS was 2.5 days and was highest in laparoscopic assisted procedures (5.38), 2.33 in open procedures. From 141 providers, the top 15 did 100-218 procedures each across the 4 years. 24 providers performed 15 or less, while 5 performed only 1 repair. Mortality within 90 days was 0.81% in the first data period and increased to 1.1% in the second. Conclusion Data suggests an impact on procedure numbers due to Covid-19, but not on approach type. Significant observed variation between provider approach and procedure count invites further research into reasons behind this.

The effect of surgical time on perioperative complications in adolescent idiopathic scoliosis cases. A propensity score analysis.

Posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) can be lengthy and complication-ridden. The aim of this study was to evaluate the effect of surgical time on perioperative complications in this procedure when controlling for confounding variables with propensity score analysis. This was an IRB-approved review of electronic health records from 2010 to 2019 at a single tertiary care children's hospital. Patients undergoing PSIF were grouped into "short" (< 6h) or "long" (≥ 6h) surgical time groups. Outcome measures were estimated blood loss (EBL), cell saver transfusions, packed red blood cell (pRBC) transfusions, length of stay (LOS), intraoperative monitoring (IOM) alerts, hematocrit, ICU transfer, neurologic loss, surgical site infection, and 90-day readmissions. We controlled for age, sex, BMI, curve severity, number of segments fused, and surgeon factors. After propensity score matching there were 113 patients in each group. The short surgical time group had lower EBL (median 715, IQR 550-900 vs median 875, IQR 650-1100cc; p < 0.001), received less cell saver blood (median 120, IQR 60-168 vs median 160, IQR 97-225cc; p = 0.001), received less intraoperative pRBCs (median 0, IQR 0-0 vs median 0, IQR 0-320, p = 0.002), had shorter average LOS (4.8 ± 1.7 vs 5.4 ± 2.5days; p = 0.039), and fewer IOM alerts (4.3% vs 18%, p = 0.003). Patients with shorter surgical times had less blood loss, received less transfused blood, had a shorter LOS, and fewer IOM alerts compared to patients with longer surgical times. Surgical times < 6h may have safety and efficacy advantages over longer times. III.

The use of a psychiatric overflow unit in a large urban community hospital to improve process outcomes

BackgroundThe United States is experiencing a mental health (MH) crisis with limited resources to meet demands. We established a 5-bed psychiatric overflow unit (POU) within the emergency department (ED) as a care alternative. ObjectiveDetermine the clinical utility and safety of a POU in care delivery to patients in a MH crisis compared to the main ED (controls). MethodsRetrospective study using data from electronic health record/chart review [October 1, 2021–May 31, 2022 (POU established January 2022)] for all ED patients ≥12 years admitted with MH crisis. Per triage nurse, patients for potential hospital admission were POU admitted when medically cleared. Clinical utility definition: ED length of stay (LOS); patient safety definition: return to ED within 72 ​h for same complaint. ResultsPatients (n ​= ​919; POU ​= ​302, main ED ​= ​617) were 61.4% male, mean age 39.7 ​± ​15.6 years, 84.2% ESI 2, 61.7% admitted/transferred, average ED LOS was 932.3 ​± ​804.7 ​min and no returns within 72 ​h. POU had longer ED LOS (1058.7 ​± ​736.5 vs 884.6 ​± ​824.6, P ​< ​0.0001) but no differences among admitted/transferred patients comparing POU vs controls (P ​> ​0.05); Among discharged patients POU compared to main ED had a longer mean ED LOS (819.9 ​± ​779.8 vs 486.4 ​± ​577.3, P ​< ​0.0001); Removal of police escort patients did not change POU ED LOS (P ​< ​0.05). ConclusionsAn ED POU, staffed with behavioral health nurses, had equivocal safety and clinical utility as the main ED potentially providing an alternative care-delivery option when ED space and MH resources are limited.

Differences in inpatient performance of public general hospitals following implementation of a points-counting payment based on diagnosis-related group: a robust multiple interrupted time series study in Wenzhou, China

ObjectivesThis study measures the differences in inpatient performance after a points-counting payment policy based on diagnosis-related group (DRG) was implemented. The point value is dynamic; its change depends on the...

Robotic-enhanced hybrid ablation for persistent and long-standing atrial fibrillation: Early assessment of feasibility, safety, and efficacy

ObjectivesTo assess feasibility, safety, and early efficacy of robotic-enhanced epicardial ablation (RE-EA) as first stage of a hybrid approach to patients with persistent (PsAF) and long-standing atrial fibrillation (LSAF). MethodsSingle-center, retrospective analysis of patients with documented PsAF and LSAF who underwent RE-EA followed by catheter-guided endocardial ablation. Postoperatively, patients were monitored for major adverse events and underwent rhythm follow-up at 3 and 12 months. ResultsBetween January 2021 and June 2023, we performed RE-EA in 64 patients (73.5% male, CHA2DS2-VASc 2.7 ± 1.6, BMI 34.1 ± 6.3 kg/m2). Mean AF preoperative duration and left atrial volume index were, respectively, 85 months and 47.5 mL/m2. Through the robotic approach, the intended lesion set was completed in all patients without cardiopulmonary bypass support, conversion to thoracotomy/sternotomy, blood transfusions, or perioperative mortality. The average LOS was 1.7 days, with only 1 patient requiring intensive care unit admission and >65% of patients discharged within 24 hours. At follow-up, 2 (3.1%) patients experienced new left pleural effusion or hemidiaphragm paralysis requiring treatment. There were no readmissions related to AF, stroke, thromboembolic events, or deaths. The mean interval between the epicardial and endocardial stages of the procedure was 5.9 months. Rhythm follow-up showed AF resolution in 73.4% and 71.9% of patients at 3 and 12 months, respectively. ConclusionsRE-EA is a feasible and safe, first-stage approach for the treatment of patients with PsAF and LSAF. It improves exposure of the intended targets, favors short hospital stay, and facilitates return to activity with satisfactory AF treatment in the short term.

A Multidisciplinary Minimally Invasive Approach Is Necessary for the Contemporary Management of Esophageal Diverticula.

Background: Esophageal diverticula were traditionally treated with open surgery, which is associated with significant morbidity and mortality rates. Management has shifted to minimally invasive approaches with several advantages. We examine outcomes in patients with esophageal diverticula treated with minimally invasive techniques by a multidisciplinary surgical team at a single center. Materials and Methods: A retrospective review of a prospectively maintained database was performed for patients who underwent minimally invasive surgery for esophageal diverticula at our institution from June 2010 to December 2022. Primary outcomes were 30-day morbidity and mortality rates. Secondary outcomes were symptom resolution, length of stay (LOS), readmission, and need for reintervention. Results: A total of 28 patients were identified. Twelve patients had pharyngeal diverticula, 7 patients had midesophageal diverticula, and 9 patients had epiphrenic diverticula. Thirty-day morbidity and readmission rates were 10.7% (3 patients), 1 pharyngeal (sepsis), 1 midesophageal (refractory nausea), and 1 epiphrenic (poor oral intake). There were no esophageal leaks. Average LOS was 2.3 days, with the pharyngeal group experiencing a significantly shorter LOS (1.3 days versus 3.4 days for midesophageal, P < .01 versus 2.8 days for epiphrenic, P < .05). Symptom resolution after initial operation was 78.6%. Reintervention rate was 17.9%, and symptom resolution after reintervention was 100%. There were no mortalities. Conclusion: This study demonstrates that esophageal diverticula can be repaired safely and efficiently when performed by a multidisciplinary team utilizing advanced minimally invasive endoscopic and robotic surgical techniques. We advocate for the management of this rare condition at a high-volume center with extensive experience in foregut surgery.

Late-week Multilevel Anterior Cervical Discectomy and Fusion Associated With Increased Length of Stay.

Retrospective analysis of clinical data from a single institution. To assess the day of surgery during the week as a possible predictor of length of stay (LOS) following anterior cervical discectomy and fusion (ACDF). Surgeries later in the week may result in longer LOS and higher costs for joint arthroplasty, yet this is unclear following spine surgery. Procedures performed later in the week may lead to weekend admissions when there are limited services that may contribute to an extended LOS. We attempt to identify associations between day of surgery and LOS, readmission, and complications following single- and multilevel ACDF. Patients at a single institution undergoing ACDF by 7 primary surgeons in both orthopedic and neurosurgery spine departments between 2015 and 2019 were retrospectively reviewed. Patients were stratified by surgery day at either the beginning (Monday/Tuesday) or end (Thursday/Friday) of the week and by single- or multilevel ACDF. Surgery for trauma, infections, adjacent level disease, or revision were excluded. Patient demographics, Charlson Comorbidity Index (CCI), LOS, postoperative complications, and readmission rates were assessed. Six hundred fifty-two patients underwent ACDF. For single-level ACDF, 222 were reviewed, with 112 having surgery at the beginning and 110 at the end of the week. For multilevel ACDF, 431 were reviewed, with 192 having surgery at the beginning and 239 at the end of the week. No differences in pre- or postoperative variables were determined for single-level ACDF. Despite no differences in pre-operative variables, CCI, operative duration, or number of levels, late-week multilevel ACDF had longer average LOS (2.8±3.0 days) compared to early-week surgery (2.0±2.0 days) ( P =0.018). Late-week multilevel ACDF was associated with an increased LOS, as it may prove beneficial to surgical planning. This conflicts with previous reports that day of week was not associated with LOS following ACDF. III.