Decreased Length Of Hospital 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.

Exceptional Cases of Spinal Cord Stimulation for the Treatment of Refractory Cancer-Related Pain

ObjectivesCancer pain has traditionally been managed with opioids, adjuvant medications, and interventions including injections, neural blockade, and intrathecal pump (ITP). Spinal cord stimulation (SCS), although increasingly used for conditions such as failed back surgery syndrome and complex regional pain syndrome, is not currently recommended for cancer pain. However, patients with cancer-related pain have demonstrated benefit with SCS. We sought to better characterize these patients and the benefit of SCS in exceptional cases of refractory pain secondary to progression of disease or evolving treatment-related complications. Materials and MethodsThis was a single-center, retrospective case series at a tertiary cancer center. Adults ≥18 years old with active cancer and evolving pain secondary to disease progression or treatment, whose symptoms were refractory to systemic opioids, and who underwent SCS trial followed by percutaneous implantation between 2016 and 2021 were included. Descriptive statistics included mean, SD, median, and interquartile range (IQR). ResultsEight patients met the inclusion criteria. The average age at SCS trial was 60.0 (SD: ±11.6) years, and 50% were men. Compared with baseline, the median (IQR) change in pain score by numeric rating scale (NRS) after trial was −3 (2). At an average of 14 days after implant, the median (IQR) change in NRS and daily oral morphine equivalents were −2 (3.5) and −126 mg (1095 mg), respectively. At a median of 63 days after implant, the corresponding values were −3 (0.75) and −96 mg (711 mg). There was no significant change in adjuvant therapies after SCS implantation at follow-up. Six patients were discharged within two days after implantation. Two patients were readmitted for pain control within the follow-up period. ConclusionsIn patients with cancer-related pain, SCS may significantly relieve pain, reduce systemic daily opioid consumption, and potentially decrease hospital length of stay and readmission for pain control. It may be appropriate to consider an SCS trial before ITP in select cases of cancer-related pain.

Enhanced recovery after surgery in liver transplantation: Challenges and feasibility.

BACKGROUNDEnhanced recovery after surgery (ERAS) started a revolution that changed age-old surgical stereotypical practices regarding the overall management of the surgical patient. In the last decade, ERAS has gained significant acceptance in the community of general surgery, in addition to several other surgical specialties, as the evidence of its advantages continues to grow. One of the last remaining fields, given its significant complexity and intricate nature, is liver transplantation (LT).AIMTo investigate the existing efforts at implementing ERAS in LT.METHODSWe conducted a systematic review of the existing studies that evaluate ERAS in orthotopic LT, with a multimodal approach and focusing on measurable clinical primary endpoints, namely length of hospital stay.RESULTSAll studies demonstrated a considerable decrease in length of hospital stay, with no readmission or negative impact of the ERAS protocol applied to the postoperative course. CONCLUSIONSERAS is a well-validated multimodal approach for almost all types of surgical procedures, and its future in selected LT patients seems promising, as the preliminary results advocate for the safety and efficacy of ERAS in the field of LT.

Frequency, associated factors, and associated outcomes of dysphagia following sepsis

BackgroundIdentifying dysphagia as a potential complication of sepsis may improve swallowing function and survival while decreasing hospital length of stay. ObjectivesOur goal was to determine the frequency of dysphagia in sepsis survivors on the 7th day after admission, as well as their associated factors and outcomes. MethodsThis single-centre, retrospective, observational study analysed data from sepsis survivors admitted to Okayama Saiseikai General Hospital from 2018 to 2019. Participants with sepsis were assigned to one of two study groups based on the presence or absence of dysphagia using the criterion of Functional Oral Intake Scale score <5 on the 7th day after admission. We used multivariate logistic regression to determine factors independently associated with dysphagia on the 7th day after admission. Multivariate logistic regression was also used to determine associations between groups and outcomes, including dysphagia on hospital discharge, direct discharge home (discharge of patients directly to their home), and total dependency (Barthel Index score ≤20) on hospital discharge. ResultsOne hundred one patients met the study inclusion criteria, 55 with dysphagia and 46 without dysphagia. Fasting period (adjusted odds ratio [AOR]: 1.31, 95% confidence interval [CI]: 1.07–1.59) and enteral tube feeding (AOR: 8.56, 95% CI: 1.95–37.5) were independently associated with the presence of dysphagia on the 7th day after admission. Dysphagia on the 7th day after admission was associated with dysphagia on hospital discharge (AOR: 46.0, 95%, CI: 7.90–268.3), a lower chance of direct discharge home (AOR: 0.03, 95% CI: 0.01–0.15), and a higher incidence of total dependency (AOR: 9.30, 95% CI: 2.68–32.2). ConclusionsWe found that dysphagia was commonly encountered post sepsis. Fasting period and enteral tube feeding were independently associated with dysphagia on the 7th day after admission. Dysphagia on the 7th day after admission was also associated with dysphagia on hospital discharge, nondirect discharge home, and dependency in activities of daily living at the time of hospital discharge.

Effect of OMT on Hospital Length of Stay in Elderly Patients with Pneumonia: A Meta-Analysis

Abstract Introduction: Pneumonia is an infection of the lungs that can be fatal. In elderly the average length of stay for patients over 65 is reported as 5.6 days. Multiple efforts have been made to decrease the length of stay of hospitalized patients to reduce the economic burden as well as improve the overall quality of life for patients. Through a meta-analysis, an analysis of whether OMT can improve outcomes in elderly patients by shortening length of hospital stay. Methods: A systematic review was conducted to identify studies which examined the effect of OMT on length of hospital stay in patients with pneumonia, aged 50 years and older, as compared to only receiving conventional care. A meta-analysis, an analysis of the results from the literature search was conducted. Results: OMT had a statistically significant decrease in hospital length of stay compared to those undergoing conventional treatment alone (P = 0.000995). A statistically significant overall mean difference effect size was −0.301 (Z score = 3.29, p = 0.001). Cochran’s Q test for heterogeneity supported homogeneity between the studies (p=0.428) as did the I2 of 0%. Conclusion: Meta-analysis favored the use of OMT in elderly patients hospitalized with pneumonia to significantly decreased the hospital length of stay compared to those undergoing standardized treatment. Based on these results, OMT should be utilized more in the hospital setting to reduce the length of stay in the hospital and reduced economic burden of days admitted in the hospital.

Novel advances in surgery for Gallstone Disease.

Examine recent advances in the treatment of patients with complex gallstone disease. Laparoscopic common bile duct exploration (LCBDE) has been shown to be an effective and safe treatment for choledocholithiasis, resulting in decreased hospital length of stay and costs when compared with ERCP plus laparoscopic cholecystectomy (LC). Novel simulator-based curricula have recently been developed to address the educational gap that has resulted in an underutilization of LCBDE. Patients with cholecystitis who are too ill to safely undergo LC have traditionally been treated with percutaneous cholecystostomy (PC). Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel definitive treatment for such patients and has been shown to result in decreased complications and hospital readmissions compared to PC. The management of symptomatic gallstone disease during pregnancy has evolved over the last several decades. While it is now well established that laparoscopic procedures under general anesthesia are safe throughout a pregnancy, recent studies have suggested that laparoscopic cholecystectomy during the third trimester specifically may result in higher rates of preterm labor when compared with non-operative management. Finally, indocyanine green (ICG) fluorescence cholangiography is a novel imaging modality that has been used during laparoscopic cholecystectomy and may offer better visualization of biliary anatomy during dissection when compared with traditional intraoperative cholangiography. A number of recent technological, procedural, educational, and research innovations have enhanced and expanded treatment options for patients with complex gallstone disease.

Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use

BackgroundFascia iliaca compartment block (FICB) has become a keystone technique for acute pain management in patients with hip and proximal femur fractures. ObjectivesTo demonstrate that administering FICB preoperatively to patients with hip or proximal femur fractures in the emergency department (ED) is likely to reduce opioid use and related complications, and to decrease hospital length of stay (LOS). MethodsAn unblinded study of adult patients with hip and proximal femur fractures who consented to receive an FICB with 30 cc of bupivacaine with epinephrine administered in the ED. We compared this group with a contemporaneous group of controls who only received systemic opioids. Over the course of approximately 6 months, main outcome measured between the two groups was amount of morphine equivalents given from block administration until 8 h after. We also compared complications such as delirium, constipation, and bleeding rates (oozing from injection site or hematoma formation). ResultsA total of 166 patients with hip and proximal femur fractures from August 12, 2018 to April 25, 2021; 81 received FICB plus systemic opioids, and 85 received only systemic opioids. Among the FICB group, morphine equivalents were reduced by 0.6 mg/h with no significant difference in LOS. A statistically significant difference in opioid-related adverse outcomes was found between the anticoagulated group vs. the no anticoagulation group. ConclusionsFICB is a safe and effective preoperative technique for initial pain management in patients with hip and proximal femur fractures, as it can also be used with additional systemic opioids. FICB administration may reduce systemic opioid use preoperatively, thus reducing opioid-related adverse effects with no significant impact on hospital LOS.

Structural changes in the Russian health care system: do they match European trends?

ВackgroundIn the last two decades, health care systems (HCS) in the European countries have faced global challenges and have undergone structural changes with the focus on early disease prevention, strengthening primary care, changing the role of hospitals, etc. Russia has inherited the Semashko model from the USSR with dominance of inpatient care, and has been looking for the ways to improve the structure of service delivery. This paper compares the complex of structural changes in the Russian and the European HCS.MethodsWe address major developments in four main areas of medical care delivery: preventive activities, primary care, inpatient care, long-term care. Our focus is on the changes in the organizational structure and activities of health care providers, and in their interaction to improve service delivery. To describe the ongoing changes, we use both qualitative characteristics and quantitative indicators. We extracted the relevant data from the national and international databases and reports and calculated secondary estimates. We also used data from our survey of physicians and interviews with top managers in medical care system.ResultsThe main trends of structural changes in Russia HCS are similar to the changes in most EU countries. The prevention and the early detection of diseases have developed intensively. The reduction in hospital bed capacity and inpatient care utilization has been accompanied by a decrease in the average length of hospital stay. Russia has followed the European trend of service delivery concentration in hospital-physician complexes, while the increase in the average size of hospitals is even more substantial. However, distinctions in health care delivery organization in Russia are still significant. Changes in primary care are much less pronounced, the system remains hospital centered. Russia lags behind the European leaders in terms of horizontal ties between providers. The reasons for inadequate structural changes are rooted in the governance of service delivery.ConclusionThe structural transformations must be intensified with the focus on strengthening primary care, further integration of care, and development of new organizational structures that mitigate the dependence on inpatient care.

Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes.

BACKGROUNDPercutaneous Endoscopic Gastrostomy (PEG) tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake. The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks, as half of patients with dysphagia improve within 2 wk. There are few studies comparing outcomes based on timing of PEG tube placement, and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities. AIMTo assess the safety of early (≤ 7 d post stroke) vs late (> 7 d post stroke) PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications. METHODSWe performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis, MO between January 2011 and December 2017. Patients were identified by keyword search of endoscopy reports. Mortality, peri-procedural complication rates, and post-procedural complication rates were compared in both groups. Predictors of morbidity and mortality such as protein-calorie malnutrition, presence of an independent cardiovascular risk equivalent, and presence of Systemic inflammatory response syndrome (SIRS) criteria or documented infection were evaluated by multivariate logistic regression.RESULTS154 patients had a PEG tube placed for dysphagia following a stroke, 92 in the late group and 62 in the early group. There were 32 observed deaths, with 8 occurring within 30 d of the procedure. There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant. Hospital length of stay was significantly less in patients with early PEG tube placement (12.9 vs 22.34 d, P < 0.001). Protein calorie malnutrition, presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications.CONCLUSIONEarly PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay. Given similar safety outcomes in both groups, early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.

Enhanced Recovery Pathway Reduces Hospital Stay and Opioid Use in Microsurgical Breast Reconstruction: A Single-Center, Private Practice Experience.

This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care resource utilization. A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol. Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar ( p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar ( p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly ( p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly ( p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements ( p < 0.001) and length of stay ( p < 0.001). ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay. Therapeutic, III.

Systematic Review of Ostomy Care Pathways.

To evaluate if ostomy care pathways improve outcomes for adults anticipating or living with an ostomy. In this systematic review, the authors searched the MEDLINE, CINAHL, Cochrane Central, and EMBASE databases. Studies were included if they met the following criteria: written in English, targeted adults anticipating or currently living with an ostomy, evaluated the impact of two or more components of an ostomy care pathway, and included one or more of the pertinent outcomes (patient satisfaction, hospital length of stay, hospital readmission rates, and staff satisfaction). Details recorded included design, setting, descriptions of intervention and control groups, patient characteristics, outcomes, data collection tools, effect size, and potential harms. Of 5,298 total records, 11 met the inclusion criteria: 2 randomized controlled trials and 9 nonrandomized studies. The overall quality of the studies was low. Of the four studies that examined patient satisfaction, all studies reported improvement or positive satisfaction rates. Of the six studies that evaluated hospital length of stay, five noted a decrease in length of stay. Of the eight studies that evaluated hospital readmission rates, five found a reduction in hospital readmission rates. No studies reported on staff satisfaction. Ostomy care pathways included preoperative education and counseling, postoperative education and discharge planning, and outpatient home visits and telephone follow-ups. Ostomy care pathways may contribute to patient satisfaction and decrease both hospital length of stay and hospital readmission rates. However, higher-quality literature is needed to be confident in the effectiveness of ostomy care pathways.

The Emergent General Surgical Patient: Evaluation Patterns in the Emergency Department.

IntroductionEmergency general surgery patients represent a growing segment of general surgical admissions and national healthcare burden. A paucity of literature exists evaluating the work-up of these patients presenting to the Emergency Department (ED), particularly possible evaluation differentials between emergency physicians and physician assistants or advanced practice registered nurses (PA/ APRNs). The purpose of this study was to evaluate differences in ED work-up of general surgical patients between emergency physicians and PA/APRNs.MethodsA retrospective review was conducted of patients presenting to the ED with the chief complaint of abdominal pain. Demographic data, evaluating provider, laboratory and imaging tests, diagnostic data, and disposition were obtained.ResultsPatient median age was 53.5 years, with 49% male and 81.6% Caucasian. Emergency physicians saw the majority (61.2%) of patients. Emergency physicians saw older patients (62.0 vs. 45.5 years; p = 0.017), and more patients that were anemic (28.3% vs. 14.3%) or with elevated creatinine levels (46.7% vs. 25.7%). There was no significant difference between groups for time in the ED (6.1 ± 2.4 vs. 5.7 ± 2.6 hours; p = 0.519), time to surgical consult (3.4 vs. 3.3 hours; p = 0.298), or time to the operating room (29.5 vs. 12.0 hours; p = 0.075). Patients seen by emergency physicians had a longer length of hospital stay (4.5 vs. 2 days; p = 0.002).ConclusionsTime in the ED and time to surgical consult did not vary between groups although patients first seen by emergency physicians had potentially higher acuity. Decreased hospital length of stay in patients seen by PA/APRNs may reflect disease-specific differences.

PO-679-06 SAME DAY DISCHARGE AND 30 DAY READMISSION AFTER ATRIAL FIBRILLATION ABLATION BEFORE AND DURING THE COVID-19 PANDEMIC IN A TWO HOSPITAL HEALTHCARE SYSTEM

COVID-19 pandemic has significantly changed cardiac electrophysiology (EP) practices, specifically directed at decreasing length of hospital stay and increasing same day discharge after EP procedures including Atrial Fibrillation (AF) ablation. However, the safety of these practices needs to be assessed.

Peri-Operative Warfarin Protocol to Decrease Length of Stay After Left Ventricular Assist Device Implantation

<h3>Purpose</h3> A limitation to left ventricular assist device (LVAD) implantation is cost with fixed reimbursement rates for the LVAD implantation hospitalization regardless of hospital length of stay and costs. Patients must have a therapeutic INR on warfarin prior to discharge which can take days and delay discharge. The purpose of this study is to evaluate the impact of a peri-operative warfarin protocol on decreasing length of stay during index LVAD implantation. <h3>Methods</h3> This is a retrospective single center study of adult patients undergoing LVAD implantation between January 1, 2019 and December 31, 2020. Patients who died during the admission were excluded. Patients in the intervention group (INT) underwent LVAD between January 1-December 31, 2020. The peri-operative warfarin protocol included pre-operative vitamin K dosing according to INR, initiation of warfarin by post-operative day (POD) 3, and warfarin titration scheme. The historical control group (CON) included patients receiving LVADs between January 1-December 31, 2019. Warfarin start date was at the discretion of providers. All patients had a goal INR of 2-3. Endpoints included length of stay, post-operative warfarin start date, time to therapeutic INR, warfarin dosing requirements, pre-operative vitamin K dosing and bleeding complications. <h3>Results</h3> Seventy-seven patients were included; n=41 (53.2%) CON and n=36 (46.8%) INT. Total hospital length of stay was 35 [26,43] days in the CON group compared to 27.5 [24,35] days in the INT group (p=0.095). Warfarin was started earlier in the INT group (POD 5.5 [2.8,7.0]) compared to the CON group (POD 8 [6,14]) (p=0.004). Time to therapeutic INR remained the same between the two groups with a median of 6 days. Pre-operative vitamin K decreased from 15 [10,15] mg in the CON group to 5 [0.0,11.3] mg in the INT group (p=<0.001). There was no increase in bleeding with the peri-operative warfarin interventions: 8 bleeds in the CON group and 4 bleeds in the INT group. <h3>Conclusion</h3> Initiating warfarin earlier post-operatively may help decrease hospital length of stay after LVAD implantation without increasing bleeding events.

Mobile Medical Clinics in the United States Post-Affordable Care Act: An Integrative Review.

Despite changes brought about by the 2010 Affordable Care Act (ACA), millions of individuals are still unable to access health care in the United States. Mobile medical clinics have been an invisible force of care delivery for vulnerable and marginalized populations for decades; however, little is known about their impact post-ACA. Guided by the Anderson Behavioral Model, the purpose of this article was to review and critique the state of the current literature about mobile medical clinics in the United States since 2010. Following Whittemore and Knafl's integrative review methodology, the search was conducted in 6 databases and delivered 1934 results; 341 articles were removed as duplicates. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, 2 independent reviewers screened and adjudicated the remaining titles, abstracts, and full-texts, yielding 12 articles in the final review. The Mixed Methods Appraisal Tool (MMAT) was used to evaluate the quality of the articles. Studies revealed variation in quality, study design, and location; and diversity of chronic diseases and populations addressed (eg, children with asthma, complementary alternative medicine use with children, adults with diabetes and hypertension, patients with chronic disease with an emphasis on the patient experience, utilization patterns in migrant farmers). Mobile medical clinics provide care for the prevention, treatment, and management of chronic illness and their wide geographic spread confirms their broad use across the United States. They provide a return on investment through emergency room avoidance, decreasing hospital length of stay, and improving chronic disease management.

Quality Improvement Project to Reduce Opioid Use in Patients Undergoing Cesarean Birth.

After observing the effectiveness of Enhanced Recovery After Surgery (ERAS) protocols for gynecological surgery patients, an interdisciplinary team initiated a quality improvement project with an ERAS protocol to minimize opioid use of patients undergoing elective cesarean birth. Secondary outcomes during the three-month project included decreasing the patient's length of stay and inpatient care costs. We used the Lean Six Sigma methodology and measured aggregated patient outcomes of opioid use, length of hospital stay, and total cost. In addition, we incorporated the ERAS protocol into the electronic health record. Results showed a reduction use of morphine milligram equivalents of opioids, a slight decrease in length of hospital stay, and no change in the inpatient costs. The team recognized that implementation of an ERAS protocol is a best practice to reduce opioid use in patients undergoing a cesarean birth and decided to permanently include it in patient care processes.

21 Decreasing Preparation Time of Full-thickness Engineered Constructs: Seeding Dermal Allografts with Non-cultured Keratinocytes

IntroductionEarly wound closure reduces risk of infection and fluid loss, which can reduce mortality and decrease length of hospital stay. The most common challenge associated with rapid wound closure in patients with large, full-thickness (FT) burns is lack of available donor skin. Tissue engineering can generate significant amounts of tissue for grafting but requires specialized facilities and up to three weeks of culture, substantially increasing time to closure.Off-the-shelf technologies that do not require ex vivo culture of cells represent a major advance in wound care. Point-of-care cell spray technology isolated using an autologous cell harvesting device (ACHD) allows for immediate application of a cell suspension to the wound bed, eliminating specialized laboratory equipment and culture of skin cells. The goal of this project was to assess the ability of freshly isolated skin cells harvested using ACHD or traditional laboratory techniques to regenerate epithelium on engineered dermal tissue, in an effort to decrease time required for preparation of FT engineered skin.MethodsDermal allografts were made by seeding collagen scaffolds with human dermal fibroblasts. Human surgical discard tissue was collected with IRB approval. Split-thickness skin (0.008”) was harvested from the discard tissue and cells were isolated using ACHD or via standard laboratory procedures following epidermal separation. Cell suspensions were seeded on the dermal allografts and cell populations were assessed histologically using H&E and Fontana-Masson’s, and via immunohistochemistry for Ki67, ColIV, ColVII, keratin 15, and involucrin. Advanced phenotyping of the cell suspension isolated using ACHD was assessed using flow cytometry.ResultsIsolation of cells using ACHD required 8-fold less preparation time and resulted in a different ratio of cell constituents. ACHD yielded suspensions comprised predominantly of keratinocytes (60-75%), fibroblasts (25-40%), and melanocytes (1-3%). Advanced phenotyping indicates subpopulations of keratinocytes including epidermal stem cells, activated keratinocytes, and proliferating keratinocytes. The standard laboratory protocol resulted in a keratinocyte suspension (96-99%) with melanocytes (1-3%) and no fibroblasts. Both cell suspensions were capable of epidermal regeneration with greater pigment and slightly higher numbers of proliferative cells and epidermal stem cells with the ACHD.ConclusionsThe results suggest non-cultured cell sprays have the potential to regenerate bioengineered dermal allografts in the absence of a split-thickness skin graft. Additionally, ACHD offers a significant time advantage to laboratory-based procedures in the preparation of cell-spray.

Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria.

BackgroundPrior to the introduction of intravenous (IV) drip infusion, most IV drugs were delivered in a syringe bolus push. However, intravenous drip infusions subsequently became the standard of care. Puerto Rico is the largest supplier of IV fluid bags and in the aftermath of Hurricane Maria, there was a nationwide fluid bag shortage. This shortage required stewardship measures to maintain the operation of the self-administered outpatient parenteral antimicrobial therapy (OPAT) program at Parkland Health.MethodsParkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV syringe bolus push (IVP) instead of an IV-drip infusion. Medications deemed appropriate were transitioned to IVP. The hospital EMR was used to identify patients discharged to the OPAT clinic using all methods of parenteral drug delivery. Data was collected for patient demographics, patient satisfaction, and clinical outcomes. Finally cost of care was calculated for IVP and IV drip administration. ResultsOne-hundred and thirteen self-administered IVP and 102 self-administered IV drip treatment courses were identified during the study period. Individuals using IVP had a statistically significant decrease in hospital length of stay. Patient satisfaction was greater with IVP and IVP saved 504 liters of normal saline resulting in a savings of $43,652 over 6 months. The 30-day readmission rate and mortality were similar.ConclusionThe abrupt IV fluid shortage following a natural disaster led to implementation of a high value care model that improved efficiency, reduced costs, and did not affect safety or efficacy.

Trauma Prevalence and Resource Utilization During 4 COVID-19 "Surges": A National Analysis of Trauma Patients From 92 Trauma Centers.

IntroductionWe aim to assess the trends in trauma patient volume, injury characteristics, and facility resource utilization that occurred during four surges in COVID-19 cases.MethodsA retrospective cohort study of 92 American College of Surgeons (ACS)-verified trauma centers (TCs) in a national hospital system during 4 COVID-19 case surges was performed. Patients who were directly transported to the TC and were an activation or consultation from the emergency department (ED) were included. Trends in injury characteristics, patient demographics & outcomes, and hospital resource utilization were assessed during four COVID-19 case surges and compared to the same dates in 2019.ResultsThe majority of TCs were within a metropolitan or micropolitan division. During the pandemic, trauma admissions decreased overall, but displayed variable trends during Surges 1-4 and across U.S. regions and TC levels. Patients requiring surgery or blood transfusion increased significantly during Surges 1-3, whereas the proportion of patients requiring plasma and/or platelets increased significantly during Surges 1-2. Patients admitted to the hospital had significantly higher Injury Severity Score (ISS) and mortality as compared to pre-pandemic during Surge 1 and 2. Patients with Medicaid or uninsured increased significantly during the pandemic. Hospital length of stay (LOS) decreased significantly during the pandemic and more trauma patients were discharged home.ConclusionsTrauma admissions decreased during Surge 1, but increased during Surge 2, 3 and 4. Penetrating injuries and firearm-related injuries increased significantly during the pandemic, patients requiring surgery or packed red blood cells (PRBCs) transfusion increased significantly during Surges 1-3. The number of patients discharged home increased during the pandemic and was accompanied by a decreased hospital length of stay (LOS).

Continued Increase in Cost of Care Despite Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Introduction:Previous studies have demonstrated decreased hospital length of stay (LOS) for children undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).Methods:Hospitalization event data from the Kids Inpatient Database were queried for all PSF events for AIS performed in 2009, 2012, and 2016 using diagnosis and surgical codes. Data were subdivided into two groups: pre–enhanced recovery after surgery (ERAS) (2009 and 2012) and post-ERAS (2016). The primary outcome variables were LOS and total treatment charge (adjusted for 2020 inflation). Univariate and multivariate analysis were performed to identify differences in outcome variables.Results:A total of 12,010 unique hospitalization events were identified, 74% female, mean 14.3 years. There was a decrease in LOS (pre-ERAS: 5.4 ± 4.0 versus 4.3 ± 3.2 days, P < 0.0001) with an increase in adjusted total treatment charge (pre-ERAS $193,544.4 ± $108,116.1 versus $200,469.1 ± $110,112.6; P = 0.0013). Pre-ERAS, male sex, smaller hospital, and non-Medicaid insurance were predictive of longer LOS, whereas pre-ERAS, older age, non-White race, male sex, hospital outside the Northeast, and non-Medicaid insurance were predictive of higher treatment costs.Discussion:There continues to be a significant decrease in LOS for PSF hospitalization events for AIS; however, total treatment charges continue to rise. Future research should investigate potential factors influencing total treatment charges after PSF for AIS.