Day Hospital Research Articles

The day hospitals as preventive hospitalization of patients of able-bodied age

In accordance with the Russian Federal Law No. 350 of January 2019 the retirement age for Russians is increased for men from 60 up to 65 years, for women from 55 up to 60 years that requires implementation of organizational technologies of health-preserving, promotion of life and labor potential of population of late able-bodied age. In this regard, the role of day hospitals (DH) functioning directed at maximal possible prolongation of autonomous life and working capacity of elderly population increases. Besides, DH also presents additional reserve of optimization of medical care costs. The purpose of the study is to elaborate guidelines of improving activities of DH for population of late able-bodied age, for the purpose of preventive hospitalization. The study was organized on the basis of pilot medical organization of the Moscow Oblast, consisted of hospital of 600 beds and day hospital of 120 beds. The methods applied included sociological survey, expert judgment, statistical direct observation. The primary data was obtained from the forms of federal and sectorial statistical monitoring for 2014-2018. The analysis of medical documentation concerning pilot medical organization functioning during the year of the study was applied. The sociological surveys of patients of late able-bodied age (5 years before retirement according to the new legislation - men 60-65 years old, women 55-60 years old) who received treatment in day hospital. The results. The analysis of main indices of round-the-clock functioning in-patient and day hospitals in the Russian Federation in 2014-2018 established trend towards improvement of using hospital beds due to development of day hospital. However, bed capacity of hospitals is used ineffectively and experts assume that more than 1/3 of patients could receive medical care or aftercare in day hospitals. The experimental study of planning hospitalization of patients with chronic diseases at out-patient level demonstrated that 11.5% of population of able-bodied age need planned and preventive hospitalization in day hospital. The cost of treatment of patient with chronic pathology is 2-3 times lower in day hospital than in common hospital at the stage of exacerbation. It is reliable to apply at the out-patient level experience of planning hospitalization of patients with chronic pathology in day hospitals followed by performance control. The organization of functioning of day hospital and common hospital requires particular enhancement, including issues of succession, financing of the DS, the remuneration of medical personnel through effective contract determining interest of physician in early discharge of patient to aftercare in day hospital. The day hospital functioning is to be implemented in 2-3 turns. The day hospital is to be located in detached placement and the departments of base medical institution are to used in fullness. The day hospital is be used more actively for purpose of health preservation of population of late able-bodied age who. This contingent suffers of chronic pathology and is in need of preventive and health-promoting therapy in conditions of day hospital.

Program Expansion of a Day Hospital Dedicated to Manage Sickle Cell Pain

Background: Vaso-occlusive crisis (VOC) is the hallmark complication of sickle cell disease (SCD). The majority of SCD-related healthcare costs in the United States, estimated at $2.4 billion annually, is attributed to frequent emergency room (ER) visits and hospitalizations due to recurrent VOC (1-3). A day hospital (DH) dedicated to manage uncomplicated VOC reduces admission rates, decreases length of stay (LOS) for inpatient admissions, and saves hospital costs (4 , 5). Most DH programs have hours of operation from 9 am to 5 pm, and programs with extended hours are limited. The impact of extended hours of DH programs on patient care is less clear.Methods: The Comprehensive Sickle Cell Center at the University of Illinois at Chicago (UIC) started a DH program to manage uncomplicated VOC in 2009 that was open from 8 am-5 pm Monday through Friday. To improve patient access and decrease the burden on the ER, the hours of operation were increased to 8 am-11 pm in February, 2014. Data on VOC-related patient visits to the DH and ER and admissions to the inpatient floors for calendar years 2012- 2016 were collected from the electronic medical record and evaluated. Descriptive statistics, the Cochrane trend test and Jonckheere-Terpstra trend test were used for data analysis.Results: The number of the DH visits increased from 208 visits in to 1058 visits in 2016. The proportion of the DH visits compared to the ER visits during the same time period showed a trend of significant increase (p<0.0001; Figure 1A). The numbers of unique patients served in the DH (66 in 2012 to 164 in 2016) also had a greater progressive increase compared to in the ER (115 in 2012 to 185 in 2016) (p=0.0012; Figure 1B). With increasing utilization of the DH, the inpatient admission rate from the DH over the 5-year span decreased (24% in 2012 to 14% in 2016; p<0.0001) (Figure 2A). The LOS for inpatient admissions from either the ER or DH due to a VOC also significantly decreased after program expansion (p<0.0001) (Figure 2B).Summary: Here we show that expanding the operation hours of a DH program increased its utilization by SCD patients by almost 5-fold. This was accompanied by a decreased hospital admission rate from the DH and a decrease in LOS for inpatient admissions, which may represent significant cost savings. A major advertising campaign to promote the UIC Comprehensive Sickle Cell center during the same time period may also contribute to the increasing patient visits in both DH and ER, but the incremental increase in the DH utilization over the ED most likely reflects the impact of expanded hours in the DH. Further expansion of the DH program may offer more benefits to patients with SCD.Reference:1. K. L. Hassell, Am J Prev Med38, S512 (Apr, 2010).2. S. Lanzkron, C. P. Carroll, C. Haywood, Jr., Am J Hematol85, 797 (Oct, 2010).3. T. L. Kauf, T. D. Coates, L. Huazhi, N. Mody-Patel, A. G. Hartzema, Am J Hematol84, 323 (Jun, 2009).4. L. J. Benjamin, G. I. Swinson, R. L. Nagel, Blood95, 1130 (Feb 15, 2000).5. A. H. Adewoye, V. Nolan, L. McMahon, Q. Ma, M. H. Steinberg, Haematologica92, 854 (Jun, 2007). [Display omitted] DisclosuresHsu:AstraZeneca: Other: steering committee for HESTIA trial; Emmi: Other: consultant for Emmi. Gordeuk:Emmaus Life Sciences: Consultancy.

Utilization of a Pediatric Sickle Cell Day Hospital By Patients with Sickle Cell Disease and Pain Events Is Associated with a Lower Rate of Inpatient Hospital Admission Compared to Utilization of the Pediatric Emergency Department

Introduction:Vaso-occlusive crisis (VOC) is a leading cause of morbidity in children with sickle cell disease (SCD) and is the most common reason for hospitalization. Frequent and prolonged hospitalization is a risk factor for development of acute chest syndrome and increased mortality, and also leads to decreases in school attendance and quality of life measures. Furthermore, inpatient care accounts for a large proportion of total disease-related costs.A sickle cell day hospital (DH) is an outpatient facility with several beds, staffed by hematology/oncology trained attending physicians, fellows, nurse practitioners and bedside nurses, all with expertise in caring for patients with SCD. The concept of the DH as an alternative to the emergency department (ED) for treatment of VOC has been explored in adults, with evidence for reduced hospitalization rate, superior pain relief and significant cost-savings. In pediatrics, there is limited data on the utility of a DH for VOC management.We hypothesize that pediatric patients with SCD presenting to our institution with acute VOC who are managed in the DH will have a lower rate of inpatient admission than those managed in the ED.Methods:We performed a retrospective chart review of children aged 4 to 21 years with HbSS, HbSC, HbSβ0- or β+- thalassemia who received initial treatment for uncomplicated VOC with IV opioids in the DH or ED at the Children's Hospital at Montefiore during three consecutive calendar years. Patients were excluded if they had any of the following at the time of presentation: pain score < 7, temperature > 38.0°C, decrease in oxygen saturation >2% below baseline or <92% on room air, new chest x-ray infiltrate, headache or other neurological symptoms, or evidence of splenic sequestration. Patients selected for the ED cohort were limited to those who presented during the hours when the DH was open. Additionally, patients transferred from the DH to the ED or vice versa at any time during the visit were excluded. We abstracted data from the charts of 60 unique patients for each site to allow for assessment of our primary outcome of need for inpatient admission at the time of initial visit, as well as secondary outcomes including time to initial and rescue doses of opioid analgesic. The study was approved by the Institutional Review Board at Montefiore Medical Center.Results:Data from 56 DH and 55 ED patients have been analyzed to date. In general, the cohorts had similar demographics, sickle cell disease status, and pain scores (Table 1), except for younger age in the DH cohort (median 12 years vs 13 years, p = 0.012). Patients who presented to the DH were significantly less likely to be admitted than patients who presented to the ED, with admission rates of 41.1% and 67.3%, respectively (p= 0.008) (Fig 1A). Admitted patients from each setting were further stratified by pain score at presentation (Fig 1B) and by hydroxyurea (HU) status as a surrogate marker of disease severity (Fig 1C). In patients with an initial pain score of 10, there was no significant difference in admission rate based on treatment location (DH 56% vs ED 72.7%, p= 0.362). In contrast, patients with an initial pain score of 7-9 were significantly less likely to be admitted from the DH than from the ED (29% vs 63.6%, p= 0.007). DH-managed patients were significantly less likely to be admitted regardless of HU status compared to ED-managed patients (on HU: 44.8% vs 77.8%, p= 0.036; not on HU: 37% vs 78.4%, p= 0.002).Secondary analyses showed a significant difference between the DH and ED in the median time to initial (Fig 2A) and rescue (Fig 2C) opioid doses (initial: 65 mins vs 76 mins, p= 0.044; rescue: 45 mins vs 123 mins, p < 0.001). This comparison was further stratified based on pain score at presentation, and demonstrated significantly longer median time to initial dose of opioid in the ED for those patients with initial pain score of 7-9 (78 mins vs 93 mins, p= 0.032 - Fig 2B), but no significant difference for those with initial pain score of 10. Time to rescue dose of opioid was significantly longer for patients seen in the ED, regardless of pain score (pain 7-9: median 43 mins vs 125 mins, p < 0.001; pain 10: median 65 mins vs 120 mins p= 0.006 - Fig 2D).Conclusions:A dedicated pediatric sickle cell day hospital is an effective setting for the management of uncomplicated acute VOC. Treatment in this setting is associated with decreased rates of inpatient admission and faster administration of appropriate analgesics. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Impact of day hospital care on adherence to psychiatric follow-up appointments and medications in patients with delusional disorder

IntroductionDay care programs have been extensively used to treat people with acute psychiatric disorders. Day hospitals (DH) can act as an alternative to admission in patients with acute symptoms, shorten the duration of admission, be useful for rehabilitation and maintenance care or enhance treatment in patients with poor adherence to outpatient care. Few research has been conducted in delusional disorder (DD).ObjectivesTo investigate whether DH care increases adherence with psychiatric appointments in patients with DD. To describe functions of partial hospitalization in DD.MethodsComparative study including DD patients who attended a DH (Group 1:n=12) versus patients who did not receive DH care (Group 2;n=7). Patients attending DH were classified into 3 groups according to the program function at referral. Adherence with outpatient follow-up appointments (primary outcome) and pharmacy refill data (secondary outcome) were assessed after discharge over a 6-month period (DH) and compared with group 2. For statistical analyses, non-parametric tests were performed.ResultsProgram function (DH): alternative to admission (n=4); shortening of admission (n=5) and enhancing outpatient treatment (n=3). Patients receiving DH care were more frequently referred from the inpatient unit or emergency department compared to those who did not attend DH (commonly referred from primary care services). No statistically significant differences were found between both groups in adherence to psychiatric appointments. Patients who attended DH showed higher compliance with antipsychotics (89.29% vs.72.62, p&lt;0.05).ConclusionsDH care may be a useful alternative to increase adherence with antipsychotics in DD patients with poor awareness of illness.Conflict of interestAGR has received honoraria, registration for congresses and/or travel costs from Janssen, Lundbeck-Otsuka and Angelini.

Mobile-Health Technologies for a Child Neuropsychiatry Service: Development and Usability of the Assioma Digital Platform.

We developed an m-Health platform to support clinical pathways in a child and adolescent neuropsychiatry unit. The Assioma platform was created for tablets, smartphones and PCs, to support data collection and clinical workflow, to promote constant communication between patients, caregivers and clinicians, and to promote active family involvement in day hospital (DH) procedures. Through the Assioma application for tablets, caregivers filled out an anamnestic questionnaire and explored contents on the DH procedures and neurodevelopmental conditions. The application for smartphones included an agenda function for the DH pathways. Through the application for desktops, clinicians could export anamnestic information in text and Excel formats, send real-time notifications, and push relative contents to families’ account. We tested the usability and satisfaction of the Assioma platform in a group of children, caregivers (N = 24) and clinicians (N = 6). Both families and clinicians gave high scores to almost all usability items. The overall satisfaction reached the highest levels at 50% satisfied for families and at 33% for clinicians. Our results indicate that the Assioma platform has the potential to optimize clinical pathways, increasing compliance and clinical efficiency, and to reduce in-person contacts supporting social distancing for clinical pathways, a crucial need during the COVID-19 pandemic.

The One Who Held Her Hand

The One Who Held Her Hand

Comparison among Three Different Steroid Therapies for Idiopathic Sudden Sensorineural Hearing Loss

Background and Objectives The optimal dose or type of systemic steroid for treating idiopathic sudden sensorineural hearing loss (ISSNHL) is unclear. Herein, we compare the efficacy of three steroid treatment protocols.Subjects and Method We reviewed the medical records of 140 adult ISSNHL patients from a tertiary medical center. The patients were divided into three groups based on their treatment regimen: Group 1 received intravenous 10 mg/day dexamethasone combined with intratympanic (IT) steroid injection, followed by prednisolone for 5 days after discharge; Group 2 received 10 mg/day dexamethasone for 5 days, followed by 5 mg/day for 5 days over a 10-day hospitalization period; and Group 3 received 10 mg/day dexamethasone combined with IT steroid injection during a 5-day hospital stay, followed by 5 mg/day dexamethasone for 5 days after discharge. The hearing thresholds were measured using an automatic audiometer at 0.5, 1, 2, 3, 4, and 8 kHz. Hearing recovery on Day 90 was categorized according to Siegel’s criteria.Results Univariate and multivariate analyses showed that patients in Group 3 had the lowest hearing thresholds, and the best results for speech reception threshold and speech discrimination scores. The impact of favorable thresholds in Group 3 was better among patients with a baseline average hearing threshold of ＜70 dB. Complete recovery was more likely in Group 3 than in the other groups, based on the odds ratios.Conclusion Administration of dexamethasone-based systemic steroid combined with IT steroid injection and a relatively long hospitalization period produced the most favorable result.

S1507 Disconnected Pancreatic Duct Syndrome: To Drain or Not to Drain?

INTRODUCTION: Disconnected pancreatic duct syndrome (DPDS) is an uncommon complication of pancreatitis resulting in cellular necrosis and destruction of viable pancreatic tissue surrounding the duct, typically within the head or body of the pancreas. CASE DESCRIPTION/METHODS: 63-year-old male with a past history remarkable for recurrent acute necrotizing pancreatitis of unknown etiology presented with acute onset and progressively worsening abdominal pain. The patient had significant 15-year alcohol consumption history, but last ingestion was 2 years prior. He was recently discharge from a 10-day hospitalization for a previous “flare” in his pancreas that was managed conservatively. Abdominal exam is remarkable for mild to moderate tenderness throughout with moderate to severe tenderness in the epigastric and bilateral upper quadrants. Laboratory workup revealed an elevated lipase (115IU/L). CT abdomen/pelvis showed evolution of severe necrotizing pancreatitis, a large 15 cm necrotic collection replacing the pancreas neck and body, and residual enhancing pancreatic parenchymal tissue of the tail suggestive of DPDS. However, there was no fluid surrounding the disconnected pancreatic tail segment to be drained. Conservative management was recommended of the sterile necrosis as the patient was without signs of sepsis. DISCUSSION: DPDS, as the name suggests, occurs when the pancreatic duct becomes interrupted and typically occurs secondary to pancreatitis, whether that is from an acute necrotizing type, chronic relapsing type, or pancreatic fistula formation. The prevalence of this condition is unknown but estimated to occur in up to 23% of acute necrotizing pancreatitis cases. In our patient, findings of a necrotic collection replacing the pancreas neck and body with residual enhancing of the pancreatic tail was most easily seen on contrast-enhanced CT scan; however, ERCP or MRCP are other possible imaging modalities. Presence of DPDS makes the management of pancreatitis more complex and recurrence rates of DPDS can be as high as 30%. If the pancreatic duct is disrupted and there is accumulating fluid surrounding the disconnected segment of pancreas, the success rate of conservative management is usually minimal. Early pancreatic debridement or drainage is rarely helpful and is complicated by intra-abdominal hypervascularity and altered anatomy. Urgent drainage is indicated if the patient has worsening symptoms or septic signs attributable to infection of the fluid collection.Figure 1.: Contrast-enhanced computed tomography of the abdomen and pelvis demonstrating evolution of severe necrotizing pancreatitis with development of a large dominant 15 cm necrotic collection (yellow arrow) essentially replacing the pancreas neck and body. Residual enhancing pancreatic parenchymal tissue in the tail (red arrow) is highly suggestive of disconnected pancreatic duct syndrome.

THE FORGOTTEN TRUTH ABOUT COMMON COLD FORMULATIONS’ POTENTIAL TO CAUSE WIDE COMPLEX TACHYCARDIA AND SEIZURES

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: First-generation antihistamines: diphenhydramine and doxylamine are readily available over the counter medications. These drugs are commonly used as sleep aids, cold, and allergy medications due to their anticholinergic and anti-histamine effects. Here we present a 19-year-old female, who presented to the hospital after an intentional overdose of over the counter cold medications. This case serves to remind us of the potential for life-threatening arrhythmias associated with these medications. CASE PRESENTATION: We present a 19-year-old-year-old female with a past medical history of depression, dissociative identity disorder, and multiple suicide attempts who called EMS after reporting an intentional overdose of unknown quantities of Nyquil, Unisom, and Benadryl. Daily Ativan was her only home medication. En route to the hospital, she had two witnessed tonic-clonic seizures, which resolved after two doses of Ativan. On admission, she was alert but irritable, easily startled, and confused. She had no cardiac or respiratory symptoms. Vital signs were stable except for heart rates in the 160s. Initial EKG showed a wide complex tachycardia, a left bundle branch block and left axis deviation. Troponins were negative. She was given a dose of physostigmine, several bicarbonate pushes, and eventually started on a sodium bicarbonate infusion. Due to worsening mental status and upper extremity myoclonic jerks concerning for ongoing seizures, she was intubated for airway protection. After 5 hours of sodium bicarbonate infusion, the wide complex tachycardia resolved. During her 10-day hospital stay, she developed hypokalemia and metabolic alkalosis, which resolved after potassium supplementation and cessation of bicarbonate infusion respectively. In addition, she developed rhabdomyolysis and lactic acidosis both of which resolved after fluid resuscitation. The patient continued to have intermittent myoclonic jerks and new vertical nystagmus. EEG did not show seizure activity. Her mental status returned to baseline. EKG remained in normal sinus rhythm and she was finally discharged with close psychiatry follow up. DISCUSSION: We present a patient who overdosed on first-generation anti-histamines resulting in a wide complex tachyarrhythmia and seizures. Cardiac arrhythmias develop due to increased excitability, slowed conduction of the fast inward sodium current as well as QT interval prolongation. Antagonism at the H1 receptor mediates seizure activity. Management should be focused on early pattern recognition, sodium bicarbonate, and anti-epileptic therapy. CONCLUSIONS: Although widely used and easily available, over the counter formulations are an increasingly rare but possible cause of life-threatening arrhythmias and seizures if taken in large amounts. It is imperative that patients be educated on the potential side effects of these commonly prescribed medications. Reference #1: Joshi, Ajay K., et al. “Case of Polymorphic Ventricular Tachycardia in Diphenhydramine Poisoning.” Journal of Cardiovascular Electrophysiology, vol. 15, no. 5, 2004, pp. 591–593., doi:10.1046/j.1540-8167.2004.03173.x Reference #2: Su, Mark, and Matthew Goldman . “Anticholinergic Poisoning.” UpToDate, 2019, www.uptodate.com/contents/tricyclic-antidepressant-poisoning?topicRef=305&source=see_link#H15. DISCLOSURES: No relevant relationships by Andre Gabriel, source=Web Response No relevant relationships by Jasmin Hundal, source=Web Response No relevant relationships by Brenda Nyatanga, source=Web Response

Current state of the cardiology bed fund in the Russian Federation and its dynamics during 2010–2018

Aim. To assess the current state of the cardiology bed fund in round-the-clock and day-patient facilities in the Russian Federation and the efficiency of its use in 2010–2018.Materials and methods. Using the method of descriptive statistics, the data from the Federal Statistical Observation Forms (No. 30, 47 and 14DS) were analyzed in order to assess the current state and dynamics of the use of cardiology beds during the 2010–2018 period.Results. The absolute number of cardiology hospital beds in Russia in 2018 amounted to 49,578 beds, which number was lower than in 2010 by 5,899 beds. The absolute number of cardiology beds in day-patient facilities of all hospital types increased by 169 beds and equaled 4,019 beds. The provision of the Russian population with round-the-clock hospital cardiology beds decreased from 3.88 per 10,000 population in 2010 to 3.38 in 2018 (–12.9%). The provision of the population with cardiology beds in day-patient facilities in hospitals providing inpatient care increased by 19.6% (from 0.12 to 0.14 per 10,000 population) in 2010–2018. This indicator decreased by 11.5% (from 0.15 to 0.14 per 10,000 population) in day-patient facilities in medical organizations providing outpatient care in 2014–2018. In Russia, the hospitalization rate in round-the-clock cardiology departments increased from 9.3 per 1000 population in 2010 to 10.8 in 2018 (+16.1%). The average length of patient stay in round-the-clock cardiology departments decreased from 13.1 days to 9.7 days (–26.0%), with the indicator of bed turnover growing by 29.2%. The mortality rate decreased by 3.6% (from 1.96% in 2010 to 1.89% in 2018).Conclusion. The total number of patients treated in cardiology beds of both round-the-clock and day-patient facilities was 266,311 people higher in 2018 compared to 2010, out of which 89.6% (236,004 people) were treated in round-the-clock hospital facilities and 10.4% (27,307 people) — in hospitals providing outpatient care. At the same time, the absolute number of round-the-clock hospital beds decreased. As a result, the rate of substituting treatment at round-the-clock hospital facilities with that at outpatient medical organizations remains insignificant.

Mini-laparatomy radical cysto-prostatectomy for urinary bladder carcinoma

Introduction: Open radical cysto-prostatectomy (RCP) is the gold standard for invasive urinary bladder cancer in male. Though minimal invasive technique like laparoscopic or robotic assisted surgery is gaining popularity for surgical management in developed countries, open mini laparotomy is equally effective with similar oncological outcome and morbidity result. Our study aims to evaluate the feasibility of Mini-laparotomy RCP with ileal conduit (IC) or neobladder.&#x0D; Methods: This is a descriptive cross-sectional study of 25 patients conducted from October 2016 to December 2019. Nineteen patients had muscle invasive urinary bladder cancer (MIBC), four had multifocal high grade non-muscle invasive bladder cancer (NMIBC) and two were BCG failure patients. Nineteen patients underwent RCP with IC and six with RCP and ileal Neobladder. We analyzed technical difficulty, operative time, blood loss, peri-operative complication for minilaparotomy RCP.&#x0D; Results: The mean age of patients was 63.2 years (46-81years). The mean operative time was 274 minute (180-420 minutes) with mean blood loss of 470 ml (300-2000 ml). Mean post-operative ileus was observed for 2.8 days (2-4 days). All patients stayed in the hospital for mean days of 12.84 (7 to 25 days). All patients were mobilized early with mean intensive care unit (ICU) stay of 2.52 days. Mean lymph node extraction was 17.6. Two patients died of renal failure and hyperosmolar diabetes mellitus.&#x0D; Conclusion: Minilaparatomy RCP is a feasible option in terms of early recovery with acceptable morbidity without compromising the oncological principles.

Narrative Inquiry on Experience of Mentally Ill Patients in Psychiatric Day Hospital Care

Narrative Inquiry on Experience of Mentally Ill Patients in Psychiatric Day Hospital Care

Sa2003 CLOSURE OF ENDOSCOPIC SUBMUCOSAL DISSECTION DEFECTS WITH ENDOSCOPIC SUTURING TO PREVENT ADVERSE EVENTS

Endoscopic submucosal dissection (ESD) enables en bloc removal of gastrointestinal epithelial lesions but can leave behind a large defect. These defects can result in adverse events such as delayed bleeding, delayed perforation, abdominal pain, or fever. Monitoring for these adverse events may necessitate observation in the hospital for several days. While prophylactic defect closure with clips has been well-described, there are little data regarding the use of endoscopic suturing to close these defects. The aim of this study therefore was to examine the safety and efficacy of endoscopic suturing in closing ESD defects to prevent adverse events and potentially avoid post-procedure hospitalization. In this single-center prospective study, endoscopic suturing was performed to close ESD defects after ESD in the stomach or rectum. Suturing was performed in the antegrade position starting from the edge most distal to the scope insertion site (12 o’clock position), moving from left (10 o’clock position) to right (2 o’clock position), right to left (8 o’clock position), left to right (4 o’clock position) before ending at the edge most proximal (6 o’clock position) to the scope insertion site (Figure). Surveillance endoscopies were performed to evaluate for recurrence/residual tissue and healing of the resection scar. Summary statistics were used to describe patient, lesion, and procedure characteristics as well as adverse event outcomes. In total, 31 patients (mean age 65.6, 71% male) received endoscopic suturing after gastric (58.1%) or rectal (41.9%) ESD (Table). The most common lesion pathology was adenocarcinoma (22.6%) followed by adenomas with high-grade dysplasia (19.4%) and low-grade dysplasia (19.4%). The mean dissection time was 54.8 minutes and the mean suturing time was 13.4 minutes. Significant intraprocedural bleeding occurred in 2 (6.5%) cases with no instances of intraprocedural perforation. Same-day discharge occurred in 58.1% of patients with a mean length of stay of 1 day in those who required overnight admission. There were no instances of delayed bleeding or delayed perforation. Surveillance endoscopy was performed at a mean of 143.9 days with no recurrences or residual tissue found. In this prospective study, endoscopic suturing offered a safe and efficacious method of closing ESD defects after gastric and rectal ESD without significantly prolonging procedure time. There were no instances of delayed bleeding or delayed perforation and over half of the patients were able to be discharged the same day. Larger, randomized studies will be needed to compare endoscopic suturing with other techniques of defect closure and evaluate its cost-effectiveness.TablePatient, lesion, and procedure characteristics and patient outcomesView Large Image Figure ViewerDownload Hi-res image Download (PPT)

The effects of focused resolution model on anxiety level in patients undergoing cataract surgery

Objective To explore the effect of focused solution on anxiety level in patients undergoing cataract surgery. Methods From November 2016 to April 2017, 100 cases of cataract surgery patients in the day ward of Henan Provincial People's Hospital were selected and divided into the intervention group and the control group according to the table of random numbers, 50 cases of each group.The control group received routine cataract care, and the intervention group, on the basis of the control group, applied focused solution mode to provide psychological guidance to the patients 1 day before the operation, 1 morning after the operation and 1 week after the operation.Anxiety levels in the two groups were compared at different time periods. Results There was no significant difference in preoperative anxiety between the two groups(P>0.05). In the morning of operation day and 1 week after operation, the difference in anxiety value between the two groups was statistically significant(P<0.05). Conclusions The focused resolution model can help ease anxiety levels in patients undergoing cataract surgery. Key words: Cataract; Anxiety; Focused resolution model

Recovering autonomy is a key advantage of home-based immunoglobulin therapy in patients with myositis

Immunoglobulins are 2nd or 3rd-line treatments in dermatomyositis (DM) or polymyositis (PM) refractory to high-dose corticosteroids and immunosuppressants. Immunoglobulins (2 g/kg/mo) are usually administered intravenously (IVIg) once a month and the patients stay at hospital for a few days. Recently, subcutaneous injections (SCIg) were proposed 2 to 3 times per week, in some dysimmune diseases. SCIg are administered at home preferably by the patient or by a nurse. We investigated the needs and attitudes of DM and PM patients with experience of IVIg and SCIg.Seven patients (6 PM and 1 DM) from a single center participated in a focus group (N = 6) or underwent in-depth interview (N = 1). Six had the experience of both IVIg at hospital and SCIg at home; 1 has received only IVIg at hospital. Verbatim was recorded and transcribed for further content analysis and computer-aided textual analysis.Clinical profiles and stories were heterogeneous. At diagnosis, muscle weakness, severe pain, and fatigue were at the forefront of patients' complaints impairing daily life. Patients reported considerable improvement with immunoglobulins. SCIg were described as easy, less disruptive for daily life, well tolerated, and less time-consuming. SCIg self-administration at home restored the feeling of autonomy and control.Interviews of DM and PM patients revealed that recovering autonomy and control was a central advantage of home-based SCIg that were efficient, well tolerated, and perceived as a good compromise between treatment burden and efficacy.

200 Evaluation of Nutrition Service Provision in a Day Hospital Setting

Abstract Background Malnutrition, frailty and functional impairment adversely impact individuals and should be considered simultaneously in rehabilitation. Individuals in a Day Hospital (DH) setting require a multidisciplinary approach to rehabilitate and nutrition plays a fundamental role in improving patient outcomes. The aim of this study was to establish the nutritional profile of the patients attending the DH and to measure this against current dietetic referral criteria. Methods A prospective quality improvement analysis of older adults attending the DH was conducted. Nutritional status, using the mini nutritional assessment short-form, demographic and biochemical information was collected from nursing notes and the software Key. Frailty scores were assigned using Rockwood Clinical Frailty Scale. Nutrition service provision was evaluated in relation to the priority rating system for DH Patients. Results Nearly two-thirds of the 57 patients were malnourished (17.5%) or at risk (45.6%), 1 in 4 (26.3%) was obese. Most patients were frail (77.2%). 45.6% of patients were referred to clinical nutrition services. 90% of malnourished patients and 53.8% of those at risk were referred to dietetic services. Patients were seen at 4 ± 2.45 weeks after referral, 19.2% of patients were seen on time. Patients with underweight or obese BMI classifications were at greater risk of malnutrition and frailty. Those referred to the DH for falls review were nutritionally poorer and physically frailer. Conclusion This study highlights the need for a focused nutritional service in this environment. Revision of dietetic referral criteria and streamlining strategies are required to provide quality, timely intervention to those who need it most.

246 A Clinical Audit of Detection and Management of Sarcopenia in Older Persons’ Specialist Rehabilitation Services in an Academic Teaching Hospital

Abstract Background Sarcopenia, characterised by progressive loss of muscle mass and strength, is associated with increased morbidity, mortality and poorer quality of life. International and European clinical practice guidelines on diagnosis and management of sarcopenia suggest the algorithm: Find Cases through screening, Assess Strength with validated outcome measures, Confirm Diagnosis with muscle quantity analysis and Determine Severity with validated physical performance measures (PPMs). Treatment recommendations include progressive resistance training (PRT) and a protein-rich diet. This audit aimed to investigate our specialist gerontological services’ adherence to these guidelines. Methods Using a custom-designed audit tool, patient medical records (PMRs) were reviewed in two inpatient rehabilitation wards and one Day Hospital (DH). Patients were included if under the care of a geriatrician and reviewed two or more times by a physiotherapist. Results Thirty PMRs were reviewed (18 DH, 12 inpatient). 0% of patients were screened for sarcopenia using a validated screening tool. 83.3% (n=15) of DH patients and 33.3% (n=4) of inpatients underwent a validated strength assessment. 0% of patients underwent muscle quantity analysis. 66.6% (n=12) of DH patients and 33.3% (n=4) of inpatients had validated PPMs performed. Probable sarcopenia was identified in 75% of DH and 100% of inpatients who had PPMs conducted. PRT was prescribed in 94% (n=17) and 50% (n=6) of DH patients and inpatients respectively. 16.6% (n=3) of DH patients and 75% (n=9) of inpatients were referred for nutritional assessment. 100% (n=9) of patients assessed by clinical nutrition were prescribed a high-protein/high-calorie diet. Conclusion This audit demonstrates limitations in identifying and managing sarcopenia as per the most recent international and European clinical practice guidelines. It is recognised that a multi-disciplinary approach is required to improve adherence to these guidelines. A multi-disciplinary sarcopenia management pathway is being implemented to facilitate this. Re-audit is planned to ensure the effectiveness of this pathway.

Knowledge of cardiovascular disease in South African HIV-positive surgical patients – A pilot survey

Background: Medical and surgical HIV-positive patients are at risk of cardiovascular disease (CVD). Surgical patients are admitted to hospital for a few days around the time of their surgeries, allowing sufficient opportunity for health promotion interventions. Health promotion could improve CVD knowledge and encourage lifelong healthy behaviours. However, this approach requires that baseline CVD knowledge first be established. This study sought to determine the knowledge of CVD in HIV-positive South African (SA) surgical patients. Methods: This was a prospective pilot survey of HIVpositive surgical patients who attended a tertiary hospital in Durban, South Africa, between 1 October 2016 and 31 March 2017. Patients completed 2 questionnaires: (1) a demographic characteristics questionnaire, and (2) a CVD knowledge questionnaire (identifying risk factors and signs/symptoms of myocardial infarction and stroke). All data were analysed using descriptive statistical methods. Results: The study sample consisted of 39 HIV-positive surgical patients. Correct responses for the items on the CVD knowledge questionnaire ranged between 0.0% and 61.5% for risk factors, and between 0.0% and 89.7% for signs/symptoms. Conclusion: Knowledge of CVD risk factors and signs/ symptoms in this study was less than desirable. Levels of CVD knowledge are likely a function of educational attainment.

Lean Management: organizational innovations in hematological Day-Hospitals

Background. Lean Thinking is a management method which, despite its industrial origins, has spread in health-care environment too.&#x0D; Objective. To describe the path followed and the results reached implementing Lean Thinking in four case studies. &#x0D; Methods. Such case studies were conducted in as many hematological Day-Hospitals (DHs), located in Central-Italy. At the beginning of each study, the DH internal processes, activity volumes and patient flows were analyzed and satisfaction questionnaires were administered to both operators and patients. Based on the returned questionnaires, deficiencies were focused on; for each deficiency data was collected and objectives defined. Following such definitions, analysis of inefficiency causes was performed and countermeasures were identified. In the final meeting the results were assessed and monitoring/maintenance methods were defined. All these steps were supported by Lean Thinking instruments for analysis and solution. &#x0D; Results. Activity organization and patient satisfaction improved everywhere. Time losses and workloads imbalances were minimized in two DHs, particularly through higher standardization in the management of clinical-administrative documents. In another DH, the output capacity of the hospital pharmacy and the workflows in DH were aligned with respect to the course of the day, so reducing delays in the delivery of therapies. Appointment planning was improved in the fourth DH, standardizing time slots (15-minutes) necessary for each therapy, so optimizing the number of beds and chairs used.&#x0D; Conclusions. Poor management of health care facilities can affect efficiency, security and quality of services provided. Lean Thinking is a valid method to address such problems. &#x0D; (HTA &amp; Market Access)

Evaluation of Symptoms and Alexithymia in Psychiatric Patients: A Naturalistic Longitudinal Study in a Day Hospital

ABSTRACT This study aimed to examine the effectiveness of a time-limited (10 months), combined individual and group treatment in a Day Hospital (DH) setting. Participants (N = 73) completed measures of general symptoms and alexithymia. We hypothesized improvements in these symptoms at the end of the overall therapeutic treatment. Results showed significant improvement in ability to identify and describe emotions and feelings, and in general symptoms. Differences in age and personality disorders were found at the end of the treatment: younger patients had less difficulty in identifying emotions, and psychotic patients have higher difficulty to describe feelings compared to patients with personality disorders. Furthermore, patients with schizophrenia had lower pathological symptoms compared to patients with mood disorders. This naturalistic longitudinal study demonstrates that DH treatments in group setting increase the patient‘s ability to symbolize and to connect their symptoms to thought and emotions.