Decreased Length Of Hospital Research Articles

Quality of life in people with sickle cell disease treated with automated red blood cell exchange.

This review aims to explore the impact of sickle cell disease (SCD) on patients' quality of life (QoL) and the effectiveness of different transfusion modalities, particularly automated red blood cell exchange (aRBCX), in managing the factors that impact QoL. A systematic search was performed in PubMed to retrieve articles with data on QoL in SCD patients treated with aRBCX during the last 20 years. A targeted search for medical guidelines and a free search were added. When assessing the impact of the transfusion modality on the QoL of patients with SCD, some studies indicated an improvement in health-related QoL when using aRBCX while others reported no differences. The benefits of aRBCX include a decrease in length of hospital stay, pain-related hospitalizations and procedure time. The drawbacks of aRBCX were also identified, including an increased number of procedure-related complications (despite the overall number of complications showing no significant differences) and a more complex vascular access. Chronic red blood cell exchange favours psychosocial factors such as anxiety and social functioning, but the impact of using aRBCX in these parameters is not determined yet. aRBCX, known to be an efficient procedure to manage SCD, appears to be promising in improving patients' QoL. However, more comprehensive studies incorporating patient-reported outcomes are needed to fully understand the impact of different transfusion modalities on QoL in SCD patients. An integrated care approach, including psychological support and pain management, may further enhance QoL.

Clinical utility and impact of a diagnostic oncology clinic.

74 Background: Oncologists have expertise in the work-up and management of patients with a suspected diagnosis of cancer. Patients diagnosed with cancer during acute care hospitalization often have poorer outcomes than those diagnosed as outpatients. For these patients, time to appropriate cancer diagnosis, management of cancer-related symptoms, and timely initiation of treatment are key to improved outcomes. Outpatient new diagnosis clinics may improve patient outcomes by improving access to subspecialty care. Methods: Patients seen by the inpatient oncology consult service over a two-month period (8/1/23-8/31/23 and 10/1/23-10/31/23) were included in this analysis. Inpatient management of disease was defined as an invasive procedure to treat the disease or a complication of the disease, initiation of systemic anti-neoplastic treatment, or radiation therapy. Surveys regarding perceived barriers to timely outpatient oncology care were distributed to oncology fellows and attendings. A Diagnostic Oncology Clinic (DOC) was started 2/1/2024 with the goal to decrease time to first outpatient oncology by a median of 12 days to less than 10 days, decrease hospital length of stay (LOS), improve outpatient management of cancer related symptoms, and improve time to treatment. Results: A total of 95 patients were evaluated. 74 (78%) of patients had a new diagnosis of cancer. Most patients had gastrointestinal cancer (n = 40, 42%) or thoracic cancer (n = 24, 25%). 51 patients (53.7%) had metastatic disease. 48 patients (50.5%) had an ECOG performance status of 0 or 1 at the time of consultation. The median hospital LOS was 11 days (IQR, 5-19). 13 patients (13.7%) had an inpatient PET scan and 43 patients (45.3%) required inpatient management of their disease or disease-related complication. 57 patients (60%) were discharged home, 21 (22%) to an extended care facility, and 17 (18%) expired or transitioned to hospice. 35 patients (37%) were seen as new outpatients with a median time to visit of 12 days (IQR 7-20). The median time to initiation of anti-neoplastic therapy as an outpatient was 24 days (IQR 18-33). There were 29 survey respondents corresponding to a response rate of 69%. 16 (55%) felt that about half the time or less patients will have timely follow-up with an oncologist after discharge, and 19 (65%) felt half the time or less patients will have appropriate cancer-related symptom management after discharge. Conclusions: Most patients seen by the inpatient oncology consult service with a new diagnosis of cancer have advanced and symptomatic disease. Historically, there has been significant time to outpatient care and cancer-specific management led by an oncologist. Creation of a diagnostic oncology clinic may shift some diagnostic testing and symptom management from the inpatient to outpatient setting, decrease time to first outpatient visit, and improve provider workflow for a vulnerable patient population. Analysis of this intervention is ongoing.

46 A Geriatric Emergency Department Evaluation Reduces Admissions and Decreases Hospital Length of Stay

46 A Geriatric Emergency Department Evaluation Reduces Admissions and Decreases Hospital Length of Stay

The Role of Preoperative Breathing Exercises in Reducing Postoperative Respiratory Complications in Coronary Artery Bypass Grafting: A Comparative Review of On-Pump and Off-Pump Techniques

Objectives: This review aims to evaluate the efficacy of preoperative breathing exercises in reducing postoperative respiratory complications, particularly respiratory failure, in patients undergoing CABG surgery. The review also compares the outcomes of these interventions in patients undergoing on-pump (ONCAB) versus off-pump (OPCAB) procedures. Methodology: A comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, and Cochrane Library, to identify studies that examined the impact of preoperative breathing exercises on respiratory outcomes in CABG patients. The review focused on randomized controlled trials (RCTs) that compared the effectiveness of these exercises in ONCAB and OPCAB settings. Results: The review identified several studies supporting the role of preoperative breathing exercises in reducing postoperative respiratory complications. These exercises, including diaphragmatic breathing, incentive spirometry, and deep breathing, were associated with improved pulmonary outcomes, such as reduced incidence of respiratory failure, shorter durations of mechanical ventilation, and decreased hospital length of stay. While the overall results were positive for both ONCAB and OPCAB patients, variations were observed based on the surgical technique and patient-specific factors. Conclusion: Preoperative breathing exercises are an effective intervention for reducing the risk of postoperative respiratory complications in CABG patients. The benefits were observed in both ONCAB and OPCAB procedures, with particular advantages noted in the ONCAB group due to the higher baseline risk. Further research is needed to optimize these interventions, considering the individualized nature of patient responses and the specific characteristics of each surgical technique.

Utilisation of a post-Fontan management pathway reduces chest tube drainage and hospital readmission rates.

Complications following the Fontan procedure include prolonged pleural drainage and readmission for effusions. To address these complications, a post-Fontan management pathway was implemented with primary goals of reducing chest tube duration/reinsertion rates and decreasing hospital length of stay and readmissions. Fontan patients were identified by retrospective chart review (2017-2019) to obtain baseline data for chest tube duration/reinsertion rates, hospital length of stay, and readmission rates for effusion. A post-Fontan management pathway was implemented (2020-2021) utilising post-operative vasopressin, nasal cannula oxygen until chest tube removal, and discharge regimen of three times daily diuretics, sildenafil, and afterload reducing medications. Patients were followed to evaluate primary outcomes. The pre- and post-pathway groups were similar in single ventricle morphology, demographics, and pre-operative haemodynamics. Forty-three and 36 patients were included in the pre- and post-pathway cohorts, respectively. There were statistically significant reductions in chest tube duration (8 vs. 5 days, p ≤ 0.001), chest tube output on post-operative day 4 (20.4 vs. 9.9 mL/kg/day, p = 0.003), and hospital readmission rates for effusion (13[30%] vs. 3[8%], p = 0.02) compared to baseline. There was an absolute reduction in hospital length of stay (11 vs. 9.5 days, p = 0.052). When combining average cost savings for the Fontan hospitalisations, readmissions for effusion, and cardiac catheterisations within 6 months of Fontan completion, there was a $325,144 total cost savings for 36 patients following pathway implementation. Implementation of a post-Fontan management pathway resulted in significant reductions in chest tube duration and output, and readmission rates for effusion in the perioperative period.

Temporal Trend in Hospitalization Among Patients With Congenital Heart Disease: ADanish Nationwide Study.

The congenital heart disease (CHD) population is growing and aging. We aim to examine the impact by describing the temporal trend and causes of lifetime hospitalization burden among the CHD population. From the Danish National Patient Registry, 23 141 patients with CHD and their hospitalizations from 1977 to 2018 were identified, excluding patients with extracardiac malformation. Patients with CHD were categorized into major CHD and minor CHD, and each patient was matched with 10 controls by sex and year of birth. The rate of all-cause hospitalization increased over time from 28.3 to 36.4 hospitalizations per 100 person-years (PY) with rate difference (RD) per decade of 2.5 (95% CI, 2.0-3.1) hospitalizations per 100 PY for the patients with CHD, compared with the increase from 10.8 to 17.0 per 100 PY (RD per decade, 2.0 [95% CI, 1.8-2.2] per 100 PY) for the control group (RD for CHD versus control, P=0.08). The all-cause hospitalization rate remained constant for the major CHDs (RD per decade, -0.2 [95% CI, -1.2 to 0.9] per 100 PY) but increased for the minor CHDs (RD per decade, 5.2 [95% CI, 4.3-6.0] per 100 PY). For all patients with CHD, the cardiovascular hospitalization rate remained constant over time (RD per decade, 0.2 [95% CI, -0.3 to 0.6] per 100 PY) whereas the noncardiovascular hospitalization rate increased (RD per decade, 2.1 [95% CI, 1.6-2.7] per 100 PY). The length of all-cause hospital stays for all patients with CHD decreased from 2.7 (95% CI, 2.6-2.8) days per PY in 1977 to 1987 to 1.6 (95% CI, 1.6-1.7) days per PY in 2008 to 2018. Compared with previous decades, patients with CHD have an increasing hospitalization rate, similar to the general population, but a decreasing length of hospital stay. The increase in hospitalization rate was driven by noncardiovascular hospitalizations, with the patients with minor CHD being the key contributor to the increasing rate.

Cyclooxygenase 2 Inhibitors for Headache After Elective Cranial Neurosurgery: Results from a Systematic Review of Efficacy of Cyclooxygenase 2 Inhibitors for Headache After Acute Brain Injury.

Headache management after acute brain injury (ABI) is challenging. Although opioids are commonly used, selective cyclooxygenase 2 inhibitors (COXIBs) may be promising alternatives. However, concerns about cardiovascular effects and bleeding risk have limited their use. We aimed at summarizing available data on efficacy of COXIBs for headache management following ABI. A systematic review was conducted through MEDLINE and Embase for articles published through September 2023 (PROSPERO identifier: CRD42022320453). No language filters were applied to the initial searches. Interventional or observational studies and systematic reviews assessing efficacy of COXIBs for headache in adults with ABI were eligible. Article selection was performed by two independent reviewers using DistillerSR. Descriptive statistics were used for data analysis, and meta-analysis was unfeasible because of study heterogeneity. Of 3190 articles identified, 6 studies met inclusion criteria: 4 randomized controlled trials and 2 retrospective cohort studies, all conducted in elective cranial neurosurgical patients (total N = 738) between 2006 and 2022. Five studies used COXIBs in the intervention group only. Of the six studies, four found a reduction in overall pain scores in the intervention group, whereas one showed improvement only at 6h postoperatively, and one did not find significant differences. Pain scores decreased between 4 and 15%, the largest shift being from moderate to mild severity. Three studies found an overall opioid use reduction throughout hospitalization in the intervention group, whereas one reported a reduction at 12h postoperatively only. Opioid consumption decreased between 9 and 90%. Two studies found a decrease in hospital length of stay by ~ 1day in the intervention group. The one study reporting postoperative hemorrhage found a statistically nonsignificant 3% reduction in the intervention group. COXIBs may serve as opioid-sparing adjunctive analgesics for headache control after elective cranial surgery. Limited or no literature exists for other forms of ABI, and additional safety data remain to be elucidated.

Surgical management of pleural complications in lymphangioleiomyomatosis

ObjectiveLymphangioleiomyomatosis (LAM) is a rare cystic lung disease occurring primarily in women. Pneumothorax and chylothorax are common pleural complications in LAM. We aim to explore various options in the surgical management of pleural disease in LAM. MethodsA retrospective chart review of all patients at the Center for LAM and Rare Lung Diseases at Columbia University was performed, and date, type, and indication for surgical procedure were collected. All patients with any cystic lung disease seen between January 1, 2000, and March 1, 2023, were included in the database. ResultsThe charts for 326 patients with possible LAM were reviewed, including 213 with confirmed LAM and 113 women with cystic lung disease consistent suspected to be LAM were reviewed. A total of 40.5% underwent surgical procedures at our institution or at referring hospitals. A total of 15.6% of patients underwent surgical lung biopsies. A total of 16.6% had a history of pneumothoraces, of whom 79.6% underwent chemical and/or mechanical pleurodesis, 14.8% required pleurectomy, and 7.4% were discharged with tunneled indwelling pleural catheters. We found that 5.6% of confirmed LAM patients have history of chylothorax, with thoracic duct ligation, thoracic duct embolization, pleurodesis, and pleurodesis with long-term tunneled indwelling pleural catheter placement all used as treatment strategies. ConclusionsHere we demonstrate the significant burden of pleural disease in patients with LAM. It is imperative that thoracic surgeons understand the high incidence of pneumothorax in this patient population. Tunneled indwelling pleural catheters are underutilized but provide long-term options for chylous management with long-term mechanical pleurodesis and a decrease in hospital length of stay.

Perioperative Management and Outcomes after Endovascular Mechanical Thrombectomy in Patients with Submassive (Intermediate-Risk) Pulmonary Embolism: A Retrospective Observational Cohort Study.

Pulmonary embolism (PE) embodies a large healthcare burden globally and is the third leading cause of morbidity and mortality worldwide. Submassive (intermediate-risk) PE accounts for 40% of this burden. However, the optimal treatment pathway for this population remains complex and ill-defined. Catheter-directed interventions (CDIs) have shown promise in directly impacting morbidity and mortality while demonstrating a favorable success rate, safety profile, and decreased length of stay (LOS) in the intensive care unit and hospital. This retrospective review included 22 patients (50% female) with submassive PE who underwent mechanical thrombectomy (MT). A total of 45% had a contraindication to thrombolytics, the mean pulmonary embolism severity index was 127, 36% had saddle PE, the average decrease in mean pulmonary artery pressure (PAP) was 7.2 mmHg following MT, the average LOS was 6.9 days, the 30-day mortality rate was 9%, the major adverse event (MAE) rate was 9%, and the readmission rate was 13.6%. A total of 82% had successful removal of thrombus during MT with no major bleeding complications, intracranial hemorrhage events, or device-related deaths. Acknowledging the limitation of our small sample size, our data indicate that MT in the intermediate-high-risk submassive pulmonary embolism (PE) cohort resulted in a decreased hospital length of stay (LOS) and in-hospital mortality compared to standard anticoagulation therapy alone.

Critical care innovations: navigating pain relief in intensive care: the role of regional anesthesia.

The purpose of this article is to provide an update of regional anesthesia and its applications in the critical care patient population. Regional anesthesia including blocks of the abdomen and thorax, head and neck, as well as upper and lower extremities can be used to alleviate pain and assist in managing life-threatening conditions such as cerebral vasospasm and ventricular storm in the ICU population. There have been many advances in these techniques including ultrasound-guidance with innovative approaches that allow for more superficial procedures that are safer for critically ill patients. Regional anesthesia can decrease hospital length of stay (LOS), prevent ICU admission, shorten ICU LOS, and increase ventilator free days and may have mortality benefits. Pain management in the ICU is an important and sometimes challenging aspect of patient care. Regional anesthetic techniques have more indications and are safe, versatile tools that should be incorporated into care of critically ill patients.

Perioperative Outcomes Using Single-Fire Stapler

BackgroundLaparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery performed worldwide. The Titan stapler aims to standardize the sleeve gastrectomy by eliminating inconsistencies and simplifying the procedure.MethodsA retrospective chart review was performed on all patients > 18 years of age undergoing LSG using the Titan. Pre-operative demographics, perioperative findings, and post-operative complications were all abstracted from the MBSAQIP database.ResultsA total of 807 LSG have been performed using the latest iteration of the Titan stapler since November 2022. Data from these patients was compared to 3829 patients who underwent LSG using a sequential staple firing technique from September 2016–September 2021. The median age of Titan patients was 42 years (IQR 33–52) compared to 44 years (IQR 35–54) for sequential firing. The median pre-operative BMI was 47.1 (IQR 43.5–52.1) for Titan versus 47.6 (IQR 43.1–53.3) for sequential staple firing. After propensity matching, operative duration was significantly less for the Titan. Titan patients had decreased hospital length of stay, experienced fewer 30-day readmissions, and had less post-operative nausea/vomiting. Post-op bleed rates were similar between the two cohorts. Weight loss at 6 months favored the sequential fire arm, but our preliminary data shows this difference diminishes at 1 year.ConclusionsHere we report our data on patients undergoing LSG using the latest Titan stapler. We show the device is safe, effective, and has resulted in an improvement in length of stay, readmissions, and post-operative nausea/vomiting. We also noted reduced operative time with this technique.Graphical

Robotic-assisted coronary artery bypass grafting: how I teach it.

The first robotic cardiac operation was performed more than two decades ago. This paper describes the distinct steps and components necessary for teaching robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB). It also provides a general overview of the surgical robotic setup and ways to troubleshoot potential complications. The focus of robotic training is not only on the surgeon but includes an entire dedicated cardiac team and administrative institutional support. This team approach ensures that R-MIDCAB can be performed safely and reproducibly. Meticulous planning, incremental learning, and teamwork are the main factors leading to program success and optimal patient outcomes. Robotic-assisted internal mammary artery (IMA) harvesting and coronary revascularization via a small, anterior mini-thoracotomy has provided an alternative to sternotomy in selected patients with coronary artery disease (CAD). Benefits include less postoperative atrial fibrillation, fewer blood transfusion, less time in the operating room (OR), less ventilatory support, fewer strokes, decreased intensive care unit stay and shortened postoperative length of stay all of which manifests as a decrease in institutional resource utilization. Recent data show that R-MIDCAB and hybrid coronary revascularization provides good long-term outcomes. In addition to patient satisfaction, there is an additional overall cost benefit to R-MIDCAB over traditional sternotomy coronary artery bypass grafting (CABG), secondary to decreased hospital length of stay. Robotically harvesting the IMA, operating on a beating heart, and performing anastomoses through a small incision all require advanced training and incremental learning. Increased experience generally leads to shortened surgical times and fewer complications.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality

A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed. To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors. MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021. Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes. Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome. The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality. Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant. In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

Development of a Complex Care Transition Team to Improve the Transition of Patients With Complex Care Needs to the Community.

Health care systems have historically struggled to provide adequate care for patients with complex care needs that often result in overuse of hospital and emergency department resources. Patients with complex care needs generally have increased expenses, longer length of hospital stays, an increased need for care management resources during hospitalization, and high readmission rates. Mayo Clinic in Arizona aimed to ensure successful transitions for hospitalized patients with complex care needs to the community by developing a complex care transition team (CCTT) program. With typical care management models, patients are assigned to registered nurse case managers and social workers according to the inpatient nursing unit rather than patient care complexity. Patients with complex care needs may not receive the amount of time needed to ensure an efficient and effective transition to the community setting. Furthermore, after transitioning to the community, patients with complex care needs often do not have access to care management resources if further care coordination needs arise. Acute care hospital in the US Southwest. The CCTT was composed of a registered nurse case manager, social worker, and care management assistant, with physician advisor support. The CCTT followed patients with complex care needs during their hospitalization and transition to the community for 90days after discharge. The number of inpatient admissions and hospital readmission rates were compared between 6months before and after enrollment in the CCTT program. Cost savings for decreased hospital length of stay, emergency department visits, and hospital readmissions were also determined. The CCTT selected patients according to a complex care algorithm , which identified patients who required high use of the health care system. The CCTT then followed this cohort of patients for an average of 90days after discharge. A total of 123 patients were enrolled in the CCTT program from July 1, 2019, to April 30, 2021, and 80 patients successfully graduated from the program. Readmission rates decreased from 51.2% at 6months before the intervention to 22.0% at 6months after the intervention. This reduced readmission rate resulted in a cost savings of more than $1 million. The outcomes resulting from implementation of the multidisciplinary CCTT highlight the need for a patient-specific approach to transitioning care to the outpatient setting. The patient social determinants of health that often contributed to overuse of health care resources included poor access to outpatient specialists, difficulty navigating the health care system due to illness or poor health literacy, and limited social support. The success of the CCTT program prompted the implementation of other specialty-specific pilot programs at Mayo Clinic in Arizona. The investment of time and resources, including dedicated personnel to follow patients with high hospital service usage, allows health care systems to reduce emergency department visits and hospital admissions and to provide patients with the best opportunity for success as they transition from the inpatient to outpatient setting.

Corticosteroids in critically ill patients: A narrative review.

Corticosteroids have been utilized in modern medicine for decades. Many indications have been investigated across various treatment settings with both benefit and harm observed. Given the instability of critically ill patients, the increased risk of corticosteroid-related complications, and the pervasive comorbidities, patients who receive corticosteroids must be carefully managed. Common critical care disease states in which corticosteroids have been studied and are routinely utilized include acute respiratory distress syndrome, adrenal insufficiency, angioedema, asthma, chronic obstructive pulmonary disease, community-acquired pneumonia, coronavirus disease 2019, septic shock, and spinal cord injury. Benefits of corticosteroids include an improvement in disease state-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality. The harm of corticosteroids is well documented through adverse effects that include, but are not limited to, hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness. Furthermore, corticosteroids are associated with increased health care costs through adverse effects as well as drug acquisition and administration costs. Given the assortment of agents, dosing, benefits, risks, and utilization in the critical care setting, there may be difficulty with identifying the appropriate places for use of corticosteroids in therapy. There currently exists no comprehensive report detailing the use of corticosteroids in the aforementioned disease states within the critical care setting. This narrative review sets out to describe these in detail.

Impact of an alcohol withdrawal screening and treatment protocol for hospitalized patients

IntroductionAlcohol Withdrawal Syndrome (AWS) is a potentially life-threatening complication of alcohol use disorder (AUD) that can be challenging to recognize in hospitalized patients. Our institution implemented universal AUD screening for all patients admitted to a non-critical care venue using the Prediction of Alcohol Withdrawal Severity Scale (PAWSS). At risk patients were then further assessed, utilizing the Glasgow Modified Alcohol Withdrawal Scale (GMAWS), and medicated according to a predetermined protocol. This study sought to determine whether this protocol decreased hospital length of stay, lowered the total benzodiazepine dose administered, and decreased adverse events attributable to AWS. MethodsThis retrospective cohort study was conducted over a 6-year period from 2014 to 2020. The study included patients with an ICD-10 code diagnosis of AWS and subsequently divided them into two groups: pre- and post-protocol introduction. Outcome measures were compared pre- versus post-protocol introduction. ResultsThere were 181 patient encounters pre- and 265 patient encounters post-protocol. There was no statistically significant difference in median length of stay between the two groups (2.956 days pre and 3.250 days post-protocol, p = 0.058). Post-protocol, there was a statistically significant reduction in median total benzodiazepine dose (13.5 mg and 9 mg lorazepam equivalents pre- and post-protocol, p < 0.001) and in occurrence of delirium tremens (7.7 % pre and 2.3 % post-protocol, p = 0.006). ConclusionProtocol implementation did not reduce length of stay in patients with AUD but was associated with a significant reduction in total benzodiazepine dose and, when adjusted, a non-statistically significant decrease in progression to delirium tremens in hospitalized patients, after applying Bonferroni adjustment.

Implementation of an Enhanced Recovery After Surgery Protocol for Cleft Palate Repair

Objective This study examines an Enhanced Recovery After Surgery (ERAS) protocol for patients with cleft palate and hypothesizes that patients who followed the protocol would have decreased hospital length of stay and decreased narcotic usage than those who did not. Design Retrospective cohort study. Setting The study takes place at a single tertiary children's hospital. Patients All patients who underwent cleft palate repair during a 10-year period (n = 242). Interventions All patients underwent cleft palate repair with the most recent cohort following a new ERAS protocol. Main Outcome Measures Primary outcomes included hospital length of stay and narcotic usage in the first 24 hours after surgery. Results Use of local bupivacaine during surgery was associated with decreased initial 24-hour morphine equivalent usage: 2.25 vs 3.38 mg morphine equivalent (MME) (P &lt; 0.01), and a decreased hospital length of stay: 1.71 days vs 2.27 days (P &lt; 0.01). The highest 24-hour morphine equivalent a patient consumed prior to the ERAS protocol implementation was 24.53 MME, compared with 6.3 MME after implementation. Utilization of the ERAS protocol was found to be associated with a decreased hospital length of stay: 1.67 vs 2.18 days (P &lt; 0.01). Conclusions Use of the proposed ERAS protocol may lead to lower narcotic usage and decreased length of stay.

A comparison of robotic enhanced-view totally extraperitoneal approach versus trans-abdominal retro-muscular approach for midline ventral hernias.

The evolution of midline ventral hernia repair has progressed from the open Rives-Stoppa technique to minimally invasive robotic approaches, notably the trans-abdominal retromuscular (TARM) and enhanced-view Totally Extraperitoneal (eTEP) methods. This study compares these two robotic techniques in repairing medium-sized midline ventral hernias. A retrospective comparative study of electronic medical records from 2015 to 2021 was conducted on patients undergoing robotic TARM or eTEP at NYU Langone Hospital-Long Island. Data on demographics, comorbid conditions, surgical history, intraoperative details, hernia characteristics, and postoperative outcomes were analyzed. Both eTEP and TARM groups exhibited comparable outcomes regarding operative duration, hernia defect size, and overall complications. However, notable differences were observed in patients' BMI, implanted mesh area, mesh composition, and fixation techniques across the groups. The TARM group required a longer hospital stay (median: 1day) in contrast to the eTEP group (median: 0days). Additionally, eTEP patients indicated reduced postoperative pain scores (median: 2) compared to TARM (median: 3), with both differences being statistically significant (p < 0.001). The robotic eTEP approach is associated with lower post-operative pain scores, decreased hospital length of stay, and larger areas of mesh implantation as compared to the TARM approach. Other variables are largely comparable between the two techniques. Level III.

Nurses' knowledge and beliefs on pain management practices with hospitalised persons living with dementia: A qualitative descriptive study.

To understand nurses' knowledge, beliefs and experiences affect pain management practices in hospitalised persons living with dementia (PLWD). Naturalistic inquiry using qualitative descriptive design. Semi-structured interviews were conducted with 12 registered nurses who worked in one acute care hospital in Southern California from October to November 2022. Data were analysed using content analysis to identify themes. Two themes were developed: improvising pain assessment, which included how pain was documented, and administration hesitancy referring to nurse's concerns about PLWD's confusion. Nurses described the challenges of assessing pain in hospitalised PLWD particularly if they were non-verbal and/or demonstrating responsive behaviours. Nurse's years of experience, dementia stigma, and their unconscious biases affected nurses' pain management practices. The study findings highlight the complex challenges of pain management in hospitalised PLWD that are exacerbated by nurses' knowledge deficits, negative stereotypical beliefs, dementia stigma and unconscious biases towards older people that contributes to undermanaged pain in hospitalised PLWD. A comprehensive strategy using an implementation framework is needed to address nurse's knowledge gaps, unconscious bias, dementia stigma and techniques that enhance communication skills is suggested. Building a foundation in these areas would improve pain management in hospitalised PLWD. Improving pain management in hospitalised PLWD would improve the quality of life, decrease hospital length of stay, prevent readmissions, and improve nurse satisfaction. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ). Improving pain management in hospitalised PLWD would prevent long term confusion, episodes of delirium and improve quality of life as they recover from their acute illness for which they required hospital care.

Neighborhood child opportunity is associated with hospital length of stay following pediatric burn injury

IntroductionPediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI) is a well-validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children. MethodsWe performed a single-institution retrospective review of pediatric (<16 years) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay. Results2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 %) and low (n = 566, 29.2 %) COI neighborhoods. The proportion of non-Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 %) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 %) (p < 0.01). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 ± 4.1 vs. 3.2 ± 4.9 vs. 3.3 ± 4.8 vs. 2.8 ± 3.5 vs. 3.2 ± 8.1) (p = 0.02). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45–0.56). ConclusionChildren from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns. Type of studyRetrospective study Level of evidenceLevel III