Current Discharge Criteria Research Articles

Criteria for discharge of preterm infants from Canadian neonatal intensive care units.

Initial discharge from a neonatal intensive care unit (NICU) to home is a crucial milestone that impacts preterm infants, their families, and NICUs. Standardized discharge programs individualized for family needs can ensure a safe transfer of care to parents, decrease the length of stay and hospital costs, and improve parents' satisfaction. To assess the degree of variability in the current discharge criteria of preterm infants less than 34weeks' gestation among Canadian NICUs, explore different institution-specific guidelines and degree of adherence to the Canadian Paediatric Society (CPS) guidelines. A clinical representative of each of the 117 level 2-4 Canadian NICUs was contacted via email to participate in an anonymous survey link regarding the discharge criteria of preterm infants. Responders from ninety-eight NICUs (84%), representing all Canadian provinces, completed the survey. Most were nurse practitioners (43%) and neonatologists (31%) with > 5years of experience (87%). Level 3 and 4 NICUs represented 63% of responses. Units varied widely in many discharge criteria and in their adherence to CPS guidelines. Most of the units (81%) lack written discharge guidelines; 60% do not have a dedicated discharge coordinator, and 45% do not have a post-discharge clinic. Only 25% routinely teach parents CPR and only half of the surveyed units provide parental support programs. Conclusion: There is a significant heterogeneity in discharge practices of preterm infants among Canadian NICUs. This survey provides a basis for benchmarking and knowledge sharing. What is Known: • Discharging preterm infants from the NICU impacts preterm infants, their families, and NICUs. • All efforts should ensure a safe transfer of care to parents, decrease the length of stay, better utilize resources, and improve parents' satisfaction. What is New: • The discharge criteria of preterm infants vary widely among NICUs. • This survey provides benchmark information and exposes the need to better standardize discharge practices and the subsequent support for infants and parents.

Between-Limb Symmetry in ACL and Tibiofemoral Contact Forces in Athletes After ACL Reconstruction and Clearance for Return to Sport.

Background:Current return-to-sport (RTS) criteria after anterior cruciate ligament (ACL) reconstruction (ACLR) include demonstrating symmetry in functional and strength tests. It remains unknown if at the time that athletes are cleared to RTS, they exhibit between-limb symmetry in ACL and tibiofemoral contact forces or if these forces are comparable with those in uninjured athletes.Purposes:To (1) examine ACL and tibiofemoral contact forces in athletes who underwent ACLR and were cleared to RTS and (2) compare the involved leg to the healthy contralateral leg and healthy controls during functional tasks.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 26 male athletes who underwent ACLR were tested at the time of RTS during tasks that included single-leg vertical, horizontal, and side jumps; cutting maneuvers; and high-intensity running. We used an electromyography-constrained musculoskeletal modeling workflow to estimate ACL and tibiofemoral contact forces and compared the results with those of 23 healthy male participants.Results:The ACLR group presented no differences in peak tibiofemoral contact forces in the involved limb compared with the control group. However, there were significant between-limb differences mainly due to higher contact forces in the uninvolved (healthy) limb of the ACLR group compared with the control group. In the ACLR group, ACL forces were significantly higher in the uninvolved limb compared with the involved limb during cutting and running. Lateral contact forces were lower in the involved compared with the uninvolved limb, with large effect sizes during cutting (d = 1.14; P < .001) and running (d = 1.10; P < .001).Conclusion:Current discharge criteria for clearance to RTS after ACLR did not ensure the restoration of symmetric loading in our cohort of male athletes. ACL force asymmetry was observed during cutting and running, in addition to knee loading asymmetries on several tasks tested.

Age, rehabilitation and surgery characteristics are re-injury risk factors for adolescents following anterior cruciate ligament reconstruction

ObjectivesTo examine the effect of age on post-ACLR rehabilitative outcomes and identify surgical/rehabilitative characteristics as ACL re-injury risk factors in adolescents. DesignCohort study. SettingChildren’s hospital. Participants273 adolescents with first-time ACLR. Main outcome measuresDemographics, injury history, surgery, and outcomes documented during post-ACLR physical therapy (PT) sessions were extracted from medical records. Effects of age on outcomes were examined using multivariate regression. ACL re-injury risk factors were identified using survival analysis with Cox regression. ResultsRe-injury was recorded in 47 patients (17.2%) with a median follow-up time of 3.1 years and median re-injury time of 13.4 months post-surgery. Younger age (Hazard-Ratio, HR = 1.264 per year decrease; P = 0.005), receiving surgery within 1 month post-injury (HR = 3.378 vs. >3 months; P = 0.012), starting PT within 3 days post-surgery (HR = 3.068; P = 0.022), and decreased number of PT sessions (HR = 1.118 per 3-session decrease; P = 0.010) increased re-injury risk. Although age was associated with re-injury risk, age was not associated with any outcome (P > 0.059). ConclusionAdolescents who are younger, receive surgery and post-surgery PT sooner, or attend fewer PT sessions may be at an increased re-injury risk. Younger patients achieved similar outcomes despite elevated re-injury risk. Current discharge criteria are inadequate in identifying high re-injury risk patients.

Saliva specimen complements anal swab in assessing patients with COVID-19 for discharge from hospital

ABSTRACT Since December 2019, coronavirus disease 2019 (COVID-19) caused by SARS coronavirus 2 (SARS-CoV-2) has spread and threatens public health worldwide. The recurrence of SARS-CoV-2 RNA detection in patients after discharge from hospital signals a risk of transmission from such patients to the community and challenges the current discharge criteria of COVID-19 patients. A wide range of clinical specimens has been used to detect SARS-CoV-2. However, to date, a consensus has not been reached regarding the most appropriate specimens to use for viral RNA detection in assessing COVID-19 patients for discharge. An anal swab sample was proposed as the standard because of prolonged viral detection. In this retrospective longitudinal study of viral RNA detection in 60 confirmed COVID-19 patients, we used saliva, oropharyngeal/nasopharyngeal swab (O/N swab) and anal swab procedures from admission to discharge. The conversion times of saliva and anal swab were longer than that of O/N swab. The conversion time of hyper sensitive-CRP was the shortest and correlated with that of CT scanning and viral detection. Some patients were found to be RNA-positive in saliva while RNA-negative in anal swab while the reverse was true in some other patients, which indicated that false negatives were inevitable if only the anal swab is used for evaluating suitability for discharge. These results indicated that double-checking for viral RNA using multiple and diverse specimens was essential, and saliva could be a candidate to supplement anal swabs to reduce false-negative results and facilitate pandemic control.

The Issue of Recurrently Positive Patients Who Recovered From COVID-19 According to the Current Discharge Criteria: Investigation of Patients from Multiple Medical Institutions in Wuhan, China.

The current discharge criteria for COVID-19 require that patients have two consecutive negative results for RT-PCR detection. Here, we observed that recurrently positive RT-PCR test results in patients with three consecutive negative results (3xNegRPos, 5.4%) were significantly decreased compared with those in patients with two consecutive negative results (2xNegRPos, 20.6%); such patients reported positive RT-PCR test results within 1 to 12 days after meeting the discharge criteria. These results confirmed that many recovered patients could show a positive RT-PCR test result, and most of these patients could be identified by an additional RT-PCR test prior to discharge.

Follow-up testing of viral nucleic acid in discharged patients with moderate type of COVID-19

To investigate the clinical outcome of patients with moderate type of coronavirus disease 2019 (COVID-19) after discharge by retesting viral nucleic acid. Seven patients with moderate COVID-19 met the discharge criteria enacted by National Health Commission were quarantined in hospital for 7 days, then continuously quarantined at home for 4 weeks after discharged. During the quarantined period, the symptoms and signs were documented, and sputum or nasal swab and feces samples were collected to test SARS-CoV-2 nucleic acid by RT-PCR method. There was no symptoms and signs during the quarantine period in all 7 patients. However, respiratory swabs from 3 patients were confirmed positive of SARS-CoV-2 nucleic acid at 5 to 7 days after they met the discharge criteria. There is a relatively high incidence of positive viral nucleic acid in patients met the discharge criteria, and it is suggested that patients met the current discharge criteria should be quarantined in hospital for another 7 days and the follow-up viral testing is necessary.

Do we need to reconsider the CMAM admission and discharge criteria?; an analysis of CMAM data in South Sudan

BackgroundWeight-for-height Z-score (WHZ) and Mid Upper Arm Circumference (MUAC) are both commonly used as acute malnutrition screening criteria. However, there exists disparity between the groups identified as malnourished by them. Thus, here we aim to investigate the clinical features and linkage with chronicity of the acute malnutrition cases identified by either WHZ or MUAC. Besides, there exists evidence indicating that fat restoration is disproportionately rapid compared to that of muscle gain in hospitalized malnourished children but related research at community level is lacking. In this study we suggest proxy measure to inspect body composition restoration responding to malnutrition management among the malnourished children.MethodsThe data of this study is from World Vision South Sudan’s emergency nutrition program from 2006 to 2012 (4443 children) and the nutrition survey conducted in 2014 (3367 children). The study investigated clinical presentations of each type of severe acute malnutrition (SAM) by WHZ (SAM-WHZ) or MUAC (SAM-MUAC), and analysed correlation between each malnutrition and chronic malnutrition. Furthermore, we explored the pattern of body composition restoration during the recovery phase by comparing the relative velocity of MUAC3 with that of weight gain.ResultsAs acutely malnourished children identified by MUAC more often share clinical features related to chronic malnutrition and minimal overlapping with malnourished children by WHZ, Therefore, MUAC only screening in the nutrition program would result in delayed identification of the malnourished children.ConclusionsThe relative velocity of MUAC3 gain was suggested as a proxy measure for volume increase, and it was more prominent than that of weight gain among the children with SAM by WHZ and MUAC over all the restoring period. Based on this we made a conjecture about dominant fat mass gain over the period of CMAM program. Also, considering initial weight gain could be ascribed to fat mass increase, the current discharge criteria would leave the malnourished children at risk of mortality even after treatment due to limited restoration of muscle mass. Given this, further research should be followed including assessment of body composition for evidence to recapitulate and reconsider the current admission and discharge criteria for CMAM program.

Coronavirus disease (COVID-19) in a paucisymptomatic patient: epidemiological and clinical challenge in settings with limited community transmission, Italy, February 2020.

Data concerning the transmission of the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) in paucisymptomatic patients are lacking. We report an Italian paucisymptomatic case of coronavirus disease 2019 with multiple biological samples positive for SARS-CoV-2. This case was detected using the World Health Organization protocol on cases and contact investigation. Current discharge criteria and the impact of extra-pulmonary SARS-CoV-2 samples are discussed.

Environmental Impact Assessment (EIA) of Effluents from Constructed Wetlands on Water Quality of Receiving Watercourses

The amount of animal manure produced in Flanders—Belgium by intensive animal farming generates a surplus that needs to be treated in order to achieve quality objectives set by the Nitrates Directive (91/676/EEC) and the European Water Framework Directive (2000/60/EU). After the physical separation and biological nitrification/denitrification processes, the liquid fraction of manure can be cost-efficiently and effectively treated by constructed wetlands (CWs). However, current discharge criteria limits do not evaluate whether nutrient loads from specific point sources (such as CWs) affect the water quality of their receiving waterway. Thus, we investigated whether a site-specific analysis, based on local environmental conditions, would yield more relevant discharge thresholds. In the present study, a standardized framework was developed for environmental impact assessment (EIA) of effluents from CWs on the water quality of receiving watercourses. This framework was tested as a case study on a manure treatment installation located in Langemark—Belgium. The effect of different impact scenarios on water quality and flow of the effluent and the receiving waterway was studied. Standardized EIA guidelines and sensitivity analyses were applied to determine the expected impacts of total nitrogen (TN), total phosphorous (P), chlorides (Cl−) and sulphates (SO4 2−) on the receiving watercourse. From this study, we concluded that the methodology currently applied requires adaptation when assessing the discharge from wetlands as current estimations of impact are overly conservative when compared with actual impact. In addition, results showed that expected impact might be mitigated by differentiating discharge limits between dry and wet periods.

Quantitative assessment of psychomotor recovery after sedation and analgesia for outpatient EGD.

Sedation and analgesia are routinely used to improve patient tolerance for GI endoscopy. Currently, assessment of postprocedure recovery uses cardiovascular and respiratory parameters but not psychomotor function. The two aims of this study were to determine degree of psychomotor recovery after conscious sedation for endoscopy when patients meet established discharge criteria, and to identify a sensitive method of testing psychomotor recovery, and thereby provide meaningful predictions regarding the ability of patients to return to daily activities. Outpatients undergoing elective EGD were recruited. Four psychometric tests were used to establish baseline psychomotor function before sedation and analgesia: Critical Tracking, Manual Dexterity, Multiple-Choice Reaction Time, and Letter Cancellation. Meperidine and midazolam were administered intravenously per standard nomogram. The tests were repeated immediately after the procedure and at 15-minute intervals until patients were deemed ready for discharge by recovery room personnel. Discharge criteria included an Aldrete discharge score of 10 and the ability to ambulate unhindered and carry on a simple conversation. Recovery personnel were blinded to psychometric test results. Psychomotor scores at discharge were compared with baseline scores to determine percent recovery. Thirty-one patients (12 men, 19 women; mean age 43 years, range 18-72 years) were enrolled. When Aldrete discharge criteria were met, the average psychomotor recovery was only 60% to 70% compared with baseline. At the time of discharge, average psychomotor recovery was 86.5% of baseline. Letter Cancellation and Multiple-Choice Reaction Time had the highest sensitivity in detecting depression of psychomotor function versus baseline, with mean recovery of, respectively, 64% and 63% (p < 0.0001). Psychomotor function remains significantly impaired when patients reach an Aldrete discharge score of 10. The Letter Cancellation test was most sensitive in detecting psychomotor impairment and recovery. Incorporating psychometric tests with current discharge criteria may identify patients who are better able to resume normal daily activities without supervision.

Quantitative assessment of psychomotor recovery after sedation and analgesia for outpatient EGD

Background: Sedation and analgesia are routinely used to improve patient tolerance for GI endoscopy. Currently, assessment of postprocedure recovery uses cardiovascular and respiratory parameters but not psychomotor function. The two aims of this study were to determine degree of psychomotor recovery after conscious sedation for endoscopy when patients meet established discharge criteria, and to identify a sensitive method of testing psychomotor recovery, and thereby provide meaningful predictions regarding the ability of patients to return to daily activities. Methods: Outpatients undergoing elective EGD were recruited. Four psychometric tests were used to establish baseline psychomotor function before sedation and analgesia: Critical Tracking, Manual Dexterity, Multiple-Choice Reaction Time, and Letter Cancellation. Meperidine and midazolam were administered intravenously per standard nomogram. The tests were repeated immediately after the procedure and at 15-minute intervals until patients were deemed ready for discharge by recovery room personnel. Discharge criteria included an Aldrete discharge score of 10 and the ability to ambulate unhindered and carry on a simple conversation. Recovery personnel were blinded to psychometric test results. Psychomotor scores at discharge were compared with baseline scores to determine percent recovery. Results: Thirty-one patients (12 men, 19 women; mean age 43 years, range 18-72 years) were enrolled. When Aldrete discharge criteria were met, the average psychomotor recovery was only 60% to 70% compared with baseline. At the time of discharge, average psychomotor recovery was 86.5% of baseline. Letter Cancellation and Multiple-Choice Reaction Time had the highest sensitivity in detecting depression of psychomotor function versus baseline, with mean recovery of, respectively, 64% and 63% ( p < 0.0001). Conclusions: Psychomotor function remains significantly impaired when patients reach an Aldrete discharge score of 10. The Letter Cancellation test was most sensitive in detecting psychomotor impairment and recovery. Incorporating psychometric tests with current discharge criteria may identify patients who are better able to resume normal daily activities without supervision. (Gastrointest Endosc 2002;56:810-6.)

Significant cognitive and motor deficits are not detected by current discharge criteria for ambulatory upper GI endoscopy

Significant cognitive and motor deficits are not detected by current discharge criteria for ambulatory upper GI endoscopy