Decrease In Hospital Length Of Stay Research Articles

Use of a Cirrhosis Admission Order Set Improves Adherence to Quality Metrics and May Decrease Hospital Length of Stay.

Quality metrics for inpatient cirrhosis management have been created to improve processes of care. We aimed to improve adherence to quality metrics by creating a novel clinical decision support (CDS) tool in the electronic health record (EHR). We developed and piloted an alert system in the EHR that directs providers to a cirrhosis order set for patients who have a known diagnosis of cirrhosis or are likely to have cirrhosis. Adherence to process measures and outcomes when the CDS was used were compared with baseline performance before the implementation of the CDS. The use of the order set resulted in a significant increase in adherence to process measures such as diagnostic paracentesis (29.6%-51.1%), low-sodium diet (34.3%-77.8%), and social work involvement (36.6%-88.9%) ( P < 0.001 for all). There were also significant decreases in both intensive care and hospital lengths of stay ( P < 0.001) as well as in-hospital development of infection ( P = 0.002). There was no difference in hospital readmissions at 30 or 90 days between the groups ( P = 0.897, P = 0.640). The use of CDS in EHR-based interventions improves adherence to quality metrics for patients with cirrhosis and could easily be shared by institutions through EHR platforms. Further studies and larger sample sizes are needed to better understand its impact on additional outcome measures.

Pain Plan Implementation Effect: Analysis of Postoperative Opioid Use, Hospital Length of Stay, and Clinic Resource Utilization for Patients Undergoing Elective Spine Surgery.

The Pain Plan was developed collaboratively and implemented a unique systematic approach to reduce opioid usage in elective spine surgery. This was a retrospective cohort study comparing patients who underwent elective spine surgery before and after Pain Plan implementation. The Pain Plan was implemented on May 1, 2019. The experimental group comprised patients over the subsequent 1-year period with a Pain Plan (n = 319), and the control group comprised patients from the previous year without a Pain Plan (n = 385). Outcome variables include hospital length of stay (LOS), inpatient opioid use, outpatient opioid prescription quantities, number of clinic communication encounters, and communication encounter complexity. Patients were prospectively divided into three surgical invasiveness index subgroups representing small-magnitude, medium-magnitude, and large-magnitude spine surgeries. There was a statistically significant decrease in hospital LOS ( P = 0.028), inpatient opioid use ( P = 0.001), and the average number of steps per communication encounter ( P = 0.010) for Pain Plan patients and a trend toward decreased outpatient opioid prescription quantities ( P = 0.052). No difference was observed in patient-reported pain scores. Statistically significant decreases in inpatient opioid use were seen in large-magnitude (50% reduction, P < 0.001) and medium-magnitude surgeries (49% reduction, P < 0.001). For small-magnitude surgeries, there was no difference (1.7% reduction, P = 0.99). The median LOS for large-magnitude surgeries decreased by 38% (20.5-hour decrease, P < 0.001) and decreased by 34% for medium-magnitude surgeries (17-hour difference, P = 0.055). For small-magnitude surgeries, there was no significant difference ( P = 0.734). Outpatient opioid prescription quantities were markedly decreased in small-magnitude surgeries only. The total number of communication encounters was not statistically significant in any group. However, the number of steps within a communication encounter was significantly decreased ( P = 0.010), and staff survey respondents reported more efficient and effective postoperative pain management for Pain Plan patients. Pain Plan implementation markedly decreased hospital LOS, inpatient opioid use and outpatient opioid prescription quantities, and clinic resource utilization in elective spine surgery patients.

Low-Volume Bowel Preparation Is Associated With Reduced Time to Colonoscopy in Hospitalized Patients: A Propensity-Matched Analysis.

Delays in inpatient colonoscopy are commonly caused by inadequate bowel preparation and result in increased hospital length of stay (LOS) and healthcare costs. Low-volume bowel preparation (LV-BP; sodium sulfate, potassium sulfate, and magnesium sulfate ) has been shown to improve outpatient bowel preparation quality compared with standard high-volume bowel preparations (HV-BP; polyethylene glycol ). However, its efficacy in hospitalized patients has not been well-studied. We assessed the impact of LV-BP on time to colonoscopy, hospital LOS, and bowel preparation quality among inpatients. We performed a propensity score-matched analysis of adult inpatients undergoing colonoscopy who received either LV-BP or HV-BP before colonoscopy at a quaternary academic medical center. Multivariate regression models with feature selection were developed to assess the association between LV-BP and study outcomes. Among 1,807 inpatients included in this study, 293 and 1,514 patients received LV-BP and HV-BP, respectively. Among the propensity score-matched population, LV-BP was associated with a shorter time to colonoscopy (β: -0.43 [95% confidence interval: -0.56 to -0.30]) while having similar odds of adequate preparation (odds ratio: 1.02 [95% confidence interval: 0.71-1.46]; P = 0.92). LV-BP was also significantly associated with decreased hospital LOS among older patients (age ≥ 75 years), patients with chronic kidney disease, and patients who were hospitalized with gastrointestinal bleeding. LV-BP is associated with decreased time to colonoscopy in hospitalized patients. Older inpatients, inpatients with chronic kidney disease, and inpatients with gastrointestinal bleeding may particularly benefit from LV-BP. Prospective studies are needed to further establish the role of LV-BP for inpatient colonoscopies.

Perceived control and length of stay post coronary artery bypass graft surgery

Background &amp; Aim: Patients undergoing CABG might have increased complications postoperatively, especially prolonging post-operative Length of Stay (LOS). Perceived Control (PC) affects LOS post CABG and complications among different cardiac populations. However, this relation is not well-studied post CABG. This study aimed to determine whether PC was an independent predictor of LOS among patients post CABG.&#x0D; Methods &amp; Materials: A prospective observational design was used. A consecutive sample consisted of 220 patients from four hospitals in Amman, Jordan, who underwent elective CABG between July 2020 and January 2021. PC was assessed using the Arabic Version of the Control Attitude Scale-Revised. LOS and other necessary information were retrieved from the patients' medical records. Data were analyzed using stepwise multiple regression.&#x0D; Results: 169 males and 51 females participated in this study. Age, female gender, as well as PC were found to be independent predictors for the hospital LOS. On the one hand, advanced age and female gender increased the hospital LOS, while higher levels of PC were protective. A one-year increase in age increased hospital LOS by 0.16 days, being female increased hospital LOS by 0.17 days, and a one-point increase in PC levels decreased LOS by 0.33 days. On the other hand, only female gender and PC were independent predictors for the ICU LOS. Similarly to hospital LOS, the female gender increased ICU LOS by 0.18 days while the one-point increase in PC decreased the ICU LOS by 0.21 days.&#x0D; Conclusion: PC was an independent predictor that affects LOS after CABG. Increasing PC among this population, especially females and the elderly, might improve outcomes of their CABG surgery decrease hospital's LOS and the resultant morbidity.

Early Postoperative Extubation is Associated with Shorter Hospitalization and Improved Short-Term Survival in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is associated with significant operative time, hospital resources, and morbidity. We examine factors associated with hospital length of stay (LOS) and early overall survival (OS) after CRS/HIPEC. Patients who underwent CRS/HIPEC were evaluated for factors associated with LOS. Institutional learning curve influence was addressed by comparing early vs late cohorts. Variables with P < .200 after univariate analysis were considered for inclusion in multivariate linear regression modeling. Independent factors associated with OS were evaluated using the Kaplan-Meier method. Seventy patients underwent CRS/HIPEC (mean age 52.3years, 64.3% female, and 68.6% Caucasian). Presence of any surgical complication was found in 26 (37.1%), 28 (40%) remained intubated postoperatively, and the mean Peritoneal Carcinomatosis Index (PCI) score was 14.4 (10.4). Mean intensive care unit and hospital LOS were 2.9days (2.3) and 9.6days (3.6), respectively. After adjusting for covariates, only shorter time to postoperative ambulation (regression coefficient .92, P = .001) and early extubation (regression coefficient -1.90, P = .018) were associated with decreased hospital LOS on multivariate analysis. Immediate postoperative extubation conferred an independent early survival benefit on Kaplan-Meier analysis (mean OS 714.8 vs 473.4days, P = .010). There was no difference in hospital LOS or OS between early and late cohorts. Early postoperative extubation and shorter time to ambulation are associated with decreased hospital LOS. Moreover, CRS/HIPEC patients extubated immediately postoperatively have an early survival benefit. Every effort should be made to achieve early postoperative extubation and mobilization in CRS/HIPEC patients.

Utilizing Enhanced Recovery After Surgery Pathway in Radical Cystectomy to Decrease Hospital Length of Stay: A Systematic Review

Utilizing Enhanced Recovery After Surgery Pathway in Radical Cystectomy to Decrease Hospital Length of Stay: A Systematic Review

152. Pain plan implementation decreases postoperative opioid use, hospital length of stay and clinic resource utilization for patients undergoing elective spine surgery

152. Pain plan implementation decreases postoperative opioid use, hospital length of stay and clinic resource utilization for patients undergoing elective spine surgery

Thoracic epidural-based Enhanced Recovery After Surgery (ERAS) pathway for Nuss repair of pectus excavatum shortened length of stay and decreased rescue intravenous opiate use.

PCA- and block-based enhanced recovery after surgery (ERAS) pathways have been shown to decrease hospital length of stay (HLOS) and opiate use following Nuss Repair for Pectus Excavatum (NRPE). No thoracic epidural-based ERAS pathway has demonstrated similar benefits. In this pre-post single-center study, data were retrospectively collected for patients ≤ 21years undergoing NRPE from May 2015 to August 2019. Univariate and multivariate methods were used to evaluate whether implementation of a thoracic epidural-based ERAS in April 2017 was associated with HLOS, opiate use, or pain scores. There were 110 patients: 35 pre- and 75 post-ERAS. HLOS decreased from median 4.8 (1.1) to 3.3 (0.6) days with ERAS (p < 0.001). Use of rescue intravenous opiates decreased from 35.3% pre- to 9.3% with ERAS (p = 0.013). When adjusted for baseline characteristics, ERAS was associated with a 1.3 ± 0.2day decrease in HLOS and 0.188 times the odds of rescue intravenous opiate use (p = 0.011). Pain scores, ED visits, and readmissions did not change with ERAS (p > 0.05). Implementation of a thoracic epidural-based ERAS following NRPE was associated with decreased HLOS and need for any rescue intravenous opiates without a change in pain scores, ED visits, or readmission.

656 Autologous Skin Cell Suspension is Associated with Decreased Hospital Length of Stay and Limited Surgical Interventions

Abstract Introduction Hospital length of stay is a measure of burn care quality and resource allocation. Traditionally, the average length of stay (LOS) for patients with burns is estimated at 1 day/% total body surface area (TBSA) although the 2016 American Burn Association National Burn Repository predicts closer to 3 days/%TBSA. Recent literature has shown that application of autologous skin cell suspension (ASCS) is associated with decreased hospital LOS and therefore is considered economically advantageous. Our study evaluated the LOS as it related to TBSA as well as the number of operations in patients treated with ASCS. Methods This is a single institution, retrospective review of burn patients at an American Burn Associated verified burn center admitted from August 2019 - August 2020 who underwent epidermal autografting. Patients were treated for partial thickness and full thickness burns either with epidermal grafting alone or in combination with widely meshed skin grafting. Demographics included age and sex of patient. The TBSA, LOS, number of operations, and re-admission rates were also collected. Results A total of 52 patients were included in the review. 73% were male with an average age of 42 years (range 15 months to 88 years. The patients were stratified into 4 different categories based on their burn TBSA: 0-10% (n=25), 11-20% (n=16), 21-30% (n=5), and &amp;gt;30% (n=6). The average number of operations increased with %TBSA (0-10%=1, 11-20%=1, 21-30%=2, &amp;gt;30%=4). The average LOS overall was 0.9 days/%TBSA (0-10%=1.0, 11-20%=0.7, 21-30%=0.9, &amp;gt;30%=0.8). Only one patient required re-admission after the first dressing takedown and underwent a second application of ASCS with subsequent healing. No patients required reconstructive surgery. Conclusions Burn patients treated with ASCS continue to demonstrate a decreased LOS/%TBSA and an overall decrease in the number of operations. The most significant impact may be noted as burn size increases.

Intercostal cryoablation during Nuss procedure: A large volume single surgeon's experience and outcomes

BackgroundRecent studies have shown intercostal cryoablation(IC) during the Nuss procedure decreases hospital length of stay(LOS) and opioid administration. However, few studies have also evaluated the risk of postoperative complications related to IC. MethodsWe performed a single center retrospective analysis of all patients who underwent Nuss procedure by one surgeon from 2/2016 to 2/2020, comparing intraoperative IC to other pain management modalities(non-IC). Primary outcomes were postoperative complications, hospital LOS, and opioid administration. Multivariate analysis was performed with outcomes reported as regression coefficients(RC) or odds ratios(OR) with 95% confidence interval. ResultsIC was associated with decreased hospital LOS (RC −1.91[−2.29 to −1.54], less hospital opioid administration (RC −4.28[−5.13 to −3.43]), and less discharge opioid administration (RC −3.82[−5.23 to −2.41]). With respect to postoperative complications, IC decreased the odds of urinary retention (OR 0.16[0.06 to 0.44]); however, increased the odds of slipped bars requiring reoperation (OR 36.65[5.04–266.39]). ConclusionsOur single surgeon experience controls for surgeon variability and demonstrates intraoperative IC for the Nuss procedure is an effective pain management modality that decreases hospital LOS and opioid use during hospitalization and at discharge; however, it is associated with increased odds of slipped bars requiring reoperation. Level of evidenceIII

The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction.

In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction. The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant. There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6mg MEQs [58.9, 112.8mg MEQs]. The APS cohort was 31.7mg MEQs [16.0, 55.3mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5days [4, 7days] versus 4days [4, 5days] in the APS group (p = 0.01). A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.

The Effect of Early Mobilization on ICU and Hospital Length of Stay and Its Impact on the Cost of Care in Post-Open Heart Surgery Patients: A Randomized Control Trial (RCT)

Introduction: Early Mobilization (EM) of patients in Intensive Care Unit (ICU) has received considerable attention in scientific literature over the past several years. It has been reported that EM decrease Hospital Length of Stay (LOS).

Hemoglobin Target and Transfusion Modality for Adult Patients With Sickle Cell Disease Acute Chest Syndrome.

Despite the importance of transfusion in treating sickle cell disease acute chest syndrome, the target hemoglobin and optimal modality for transfusion remain unknown. To compare hospital length of stay (LOS) in intensive care unit (ICU) patients with acute chest syndrome transfused to hemoglobin ≥ 8 g/dL versus patients transfused to hemoglobin < 8 g/dL; and to compare hospital LOS in acute chest syndrome patients treated with and without exchange transfusion. We performed a retrospective cohort study of all acute chest syndrome patients treated in the medical ICU at 2 tertiary care hospitals between January 2011 and August 2016 (n = 82). We compared median hospital LOS in patients transfused to hemoglobin ≥ 8 g/dL by the time of ICU transfer to the medical floor versus patients transfused to hemoglobin < 8 g/dL as well as patients who received exchange transfusion versus no exchange transfusion using Wilcoxon rank-sum tests. We modeled the association between hospital LOS and hemoglobin at ICU transfer to the medical floor using multivariable log-linear regression. Median hospital LOS was about half as long for patients transfused to hemoglobin ≥ 8 g/dL versus hemoglobin < 8 g/dL (8.0 versus 16.5 days, P = 0.008). There was no difference in LOS for patients treated with and without exchange transfusion. On average, a 1 g/dL increase in hemoglobin was associated with a 19.5% decrease (95% CI 10.8-28.2%) in LOS, controlling for possible confounding factors. Transfusion to a hemoglobin target ≥ 8 g/dL is associated with decreased hospital LOS in patients with acute chest syndrome. There was no difference in LOS between patients who received exchange transfusion and those who did not.

Concomitant tacrolimus and ketorolac therapy in pediatric liver transplant recipients: Teaching old dogma new tricks.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ketorolac, are effective analgesic medications, but concerns for nephrotoxicity have limited their role for pain control following pediatric liver transplantation (LT). Calcineurin inhibitors (CNIs) and NSAIDs share a similar mechanism of nephrotoxicity, and concomitant administration is traditionally discouraged. A retrospective review of pediatric LT recipients was conducted between 1/1/2015 and 12/31/2019 at a single center. Patients were stratified based on receipt of ketorolac. The primary outcome was the incidence of acute kidney injury (AKI). Secondary outcomes included serum creatinine, urine output, estimated glomerular filtration rate, bleeding incidence, oral morphine milligram equivalents, and hospital length of stay (LOS). The incidence of AKI was similar between the two groups with 25.8% of patients in the ketorolac group versus 29.2% of patients in the nonketorolac group (p=.475) meeting criteria in the first 10days post-transplant. Opioid requirements were less in the ketorolac group (p<.001), who also demonstrated shorter LOS compared with nonketorolac patients (p=.033). Concurrent CNI and ketorolac use did not result in an increased incidence of AKI in the early post-LT period and resulted in significantly lower opioid requirements along with a decreased hospital LOS.

Bariatric Enhanced Recovery Protocol: a Community Quality Perspective.

Bariatric enhanced recovery protocols can decrease length of stay (LOS) and hospital costs without compromising patient safety. Increased data is needed to compare patient outcomes before and after application of enhanced recovery pathways. We present a bariatric enhanced recovery protocol (BERP) at a community hospital. The objectives were to decrease hospital LOS and reduce schedule II substance use (medications with a high potential for abuse, potentially resulting in psychological or physical dependence), without compromising patient safety. This was a combined retrospective and prospective analysis of all patients undergoing bariatric surgery by two surgeons from September 2016 to April 2018. Mann-Whitney U, Pearson chi-square, and Fisher's exact tests were used to compare demographics, comorbidities, and outcomes. Two hundred patients were evaluated. Overall median (interquartile range) age was 43.0 (36.0-54.0) years and body mass index (BMI) was 45.0 (40.6-50.3) kg/m2. Pre-protocol mean hospital LOS was 2.3days while enhanced recovery protocol patients mean LOS was 1.4days (p < 0.001). Sixty-five percent of BERP patients were discharged on hospital day 1, while no patients prior to the protocol were discharged before hospital day 2. Only 9% of BERP patients were discharged with schedule II medications, compared to 100% of the pre-protocol patients (p < 0.001). Intraoperative, in-hospital, and 30-day complication rates were not statistically significant between the two groups. Community hospitals can reduce length of stay and narcotic prescribing without compromising safety-related outcomes. Significant reductions in the amount of schedule II medications can be achieved when using multimodal enhanced recovery protocol approaches.

Effects of Preoperative Embolization on Juvenile Nasopharyngeal Angiofibroma Surgical Outcomes: A Study of the Kids' Inpatient Database.

Objectives The aim of the study is to evaluate the effect of preoperative vascular embolization (PVE) on juvenile nasopharyngeal angiofibroma (JNA) surgical outcomes using a national pediatric hospitalization database. Methods The health care cost and utilization project Kids' Inpatient Database was queried for all cases of operative management of JNA between the years of 1997 and 2016. Cases were stratified based on whether the patient received PVE. A multiple linear regression was used to predict the effect of PVE on hospital length of stay (LOS) and total cost while controlling for patient demographic factors and comorbidities. The odds ratio (OR) of receiving a perioperative blood transfusion was computed using a binary logistic regression for PVE patients. Results A total of 473 patients who underwent JNA surgical resection in this time period were identified. The use of PVE has increased from 0% in 1997 to 66% of all cases by 2016. PVE was found to decrease LOS by 1 day ( p = 0.036) and decrease the odds of needing a perioperative blood transfusion (OR = 0.511, p = 0.041). Patients receiving PVE were charged an additional $35,600 ( p < 0.001), but recent data in 2016 indicate that hospital costs for PVE are decreasing. Conclusion PVE of JNA is becoming increasingly prevalent. Embolization results in decreased hospital LOS and lower odds of needing blood transfusions. While embolization increases the cost of management, this trend should be re-evaluated as this procedure is becoming more widespread.

The Use of Periorbital Steroids to Reduce Postoperative Swelling in Fronto-orbital Advancement: An Analysis of Outcomes

PURPOSE: Marked facial swelling is a known consequence following fronto-orbital advancement (FOA), which can result in prolonged eye closure, patient discomfort, and postoperative hospitalization. There are limited reports on the efficacy and safety of periorbital steroids to help reduce facial swelling in craniofacial surgery, which has become standard practice at some centers. The purpose of this study is to compare outcomes with and without the use of periorbital steroids in patients undergoing FOA. METHODS: A retrospective chart review of patients who underwent FOA at Seattle Children’s Hospital between January 2012 and December 2019 was completed. All procedures were performed by 2 senior surgeons (R.A.H. and C.B.B.) in conjunction with a pediatric neurosurgeon. All patients received pre-, intra-, and postoperative care via a standardized clinical care pathway. In the periorbital steroid cohort, triamcinolone was administered as an injection into the subcutaneous tissues or soaked in gelfoam and placed in the frontal/periorbital region before closure of the scalp. Statistical significance between outcomes measures was determined using a 2-tailed unpaired Student’s t test or chi-square test as appropriate. RESULTS: A total of 167 patients were included in this study (80 control, 87 periorbital steroid). The majority of these patients underwent FOA for isolated metopic synostosis (52.1%) followed by multisuture synostosis (23.9%) and isolated unicoronal synostosis (18%). 15.6% of patients had craniosynostosis as part of a diagnosed craniofacial syndrome. The average postoperative length of stay following FOA was 4.3 ± 2.0 days. Criteria for discharge including adequate PO intake, appropriate pain control, removal of the surgical drain, and improvement in facial swelling with opening of at least 1 eye. The use of periorbital steroids resulted in a statistically significant decrease in the hospital length of stay (LOS) compared with controls for isolated metopic (12.5 hours; P = 0.031) and unicoronal (12 hours; P = 0.015) craniosynostosis; there was no statistically significant difference in LOS for multisuture craniosynostosis (5.2 hours; P = 0.329). There was a significantly higher rate of surgical site infection in patients who received periorbital steroids compared to controls (10.2% versus 2.5%; P = 0.041). All of these complications represented scalp wound infections requiring operative intervention. Ninety-one percent of patients required hospital readmission with an average LOS of 17.6 days and 36% required subsequent revision cranioplasty. There was no association between specific suture involvement, craniofacial syndrome, or age at FOA with infectious complications. CONCLUSIONS: The use of periorbital steroids has been reported in the literature to reduce facial swelling and shorten convalescence following FOA. This study demonstrates that there is a statistically significant decrease in hospital LOS with the use of periorbital steroids in isolated suture craniosynostosis. However, it is associated with a significantly higher rate of infectious complications requiring operative intervention, extended hospital readmissions, prolonged antibiotic therapy, and secondary reconstruction.

Adding nebulized corticosteroids to systemic corticosteroids for acute asthma in children: A systematic review with meta‐analysis

To evaluate the evidence for the efficacy of inhaled corticosteroids (ICSs) in addition to SCs compared to SCs alone in children with acute asthma in the emergency department (ED) or during hospitalization. Five electronic databases were searched. All randomized clinical trials that compared ICS (via nebulizer or metered dose inhaler) plus SC (oral or parenteral) with placebo (or standard care) plus SC were included without language restriction. Two reviewers independently reviewed all the studies. The primary outcomes were hospital admission and hospital length of stay (LOS), and secondary outcomes were readmissions during follow-up, ED-LOS, lung function, asthma clinical score, oxygen saturation, and heart and respiratory rates. Nine studies (n = 1473) met the inclusion criteria. In all the studies, the ICS was budesonide. Compared to SC alone, adding budesonide to SC did not affect hospitalization rate, but decreased hospital LOS by more than 1 day (MD = -29.08 hours [-39.9 to -18.3]; I2 = 0%, P = < .00001). Moreover, adding budesonide significantly improved the acute asthma severity score among patients at ED. Compared to SC alone, adding budesonide to SC does not affect the hospitalization rate, but decreases the LOS and improves the acute asthma score in children in an ED setting.

Development of a Web-Based Nonoperative Small Bowel Obstruction Treatment Pathway App

An electronic pathway for the management of adhesive small bowel obstruction (SBO) was built and implemented on top of the electronic health record. The aims of this study are to describe the development of the electronic pathway and to report early outcomes. The electronic SBO pathway was designed and implemented at a single institution. All patients admitted to a surgical service with a diagnosis of adhesive SBO were enrolled. Outcomes were compared across three time periods: (1) patients not placed on either pathway from September 2013 through December 2014, (2) patients enrolled in the paper pathway from January 2017 through January 2018, and (3) patients enrolled in the electronic pathway from March through October 2018. The electronic SBO pathway pulls real-time data from the electronic health record to prepopulate the evidence-based algorithm. Outcomes measured included length of stay (LOS), time to surgery, readmission, surgery, and need for bowel resection. Comparative analyses were completed with Pearson's chi-squared, analysis of variance, and Kruskal-Wallis tests. There were 46 patients enrolled in the electronic pathway compared with 93 patients on the paper pathway, and 101 nonpathway patients. Median LOS was lower in both pathway cohorts compared with those not on either pathway (3 days [range 1-11] vs. 3 days [range 1-27] vs. 4 days [range 1-13], p = 0.04). Rates of readmission, surgery, time to surgery, and bowel resection were not significantly different across the three groups. It is feasible to implement and utilize an electronic, evidence-based clinical pathway for adhesive SBOs. Use of the electronic and paper pathways was associated with decreased hospital LOS for patients with adhesive SBOs.

The survival benefit of low molecular weight heparin over unfractionated heparin in pediatric trauma patients

IntroductionVenous thromboembolism (VTE) prophylaxis in pediatric patients is controversial and is mainly dependent on protocols derived from adult practices. Our study aimed to compare outcomes among pediatric trauma patients who received low molecular weight heparin (LMWH) compared to those who received unfractionated heparin (UFH). MethodsWe performed 2 years (2015–2016) retrospective analysis of the Pediatrics ACS-TQIP database. Pediatric trauma patients (age ≤17) who received thromboprophylaxis with either LMWH or UFH were included. Patients were stratified into three age groups. Analysis of each subgroup and the entire cohort was performed. Outcome measures included VTE events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), hospital and ICU length of stay (LOS) among survivors, and mortality. Propensity score matching was used to match the two cohorts LMWH vs UFH. ResultsA matched cohort of 1,678 pediatric trauma patients was analyzed. A significant difference in survival, DVT events, and in-hospital LOS was seen in the age groups above 9 years. Overall, the patients who received LMWH had lower mortality (1.4% vs 3.6%, p<0.01), DVT (1.7% vs 3.7%, p<0.01), and hospital LOS among survivors (7 days vs 9 days, p<0.01) compared to those who received UFH. There was no significant difference in the ICU LOS among survivors and the incidence of PE between the two groups. ConclusionLMWH is associated with increased survival, lower rates of DVT, and decreased hospital LOS compared to UFH among pediatric trauma patients age 10–17 years. Level of EvidenceLevel III Prophylactic. Study TypeProphylactic.