Differences In Admission Rates Research Articles

Hospital ownership and admission rates from the emergency department, evidence from Florida.

In light of Department of Justice investigations of for-profit chains for over-admitting patients, we sought to evaluate whether for-profit hospitals are more likely to admit patients from the emergency department. We used statewide visit-level inpatient and emergency department records from Florida's Agency for Healthcare Administration for 2007-2019. We calculated differences in admission rates between for-profit and other hospitals, adjusting for patient and hospital characteristics. We also estimated instrumental variables models using differential distance to a for-profit hospital as an instrument. Our main analysis focuses on patients ages 65 and older treated in hospitals that primarily serve adults. Adjusted admission rates among patients ages 65 and older were 7.1 percentage points (95% CI: 5.1-9.1) higher at for-profit hospitals in 2019 (or 18.8% of the sample mean of 37.8%). Differences in admission rates have remained constant since 2009. Our results are consistent with allegations that for-profit hospitals maintain lower admission thresholds to increase occupancy levels.

Natural Language Processing Identification of Symptoms in Emergency Department Visits in Patients Receiving Radiation

Patients undergoing radiotherapy (RT) for cancer often require emergency department (ED) attention with possible hospitalization. Designing strategies to mitigate hospital admissions requires understanding the causal symptoms to tailor interventional strategies. Natural language processing (NLP) has previously been shown to accurately identify documented symptoms and may help characterize factors contributing to admission. The objective of this study was to use NLP to identify documented symptoms during ED visits and their association with subsequent hospital admission of patients undergoing RT. A de-identified, single tertiary-care institution cohort of patients who received radiation between 2013 and 2022 was identified from the electronic health record using International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes. We applied a previously validated clinical Text Analysis and Knowledge Extraction System (cTAKES)-based NLP pipeline to extract Common Terminology Criteria for Adverse Events (CTCAE) encoded symptoms from ED encounter clinical notes. Chi-squared testing was used to compare demographics, and logistic regression was used to identify symptoms associated with subsequent admission from ED visits. We identified 14,007 patients who received radiation, of whom 270 (1.9%) experienced 302 ED visits during their radiation course. 141 (46.7%) of ED visits resulted in an admission. Among patients with an ED encounter, there were no differences in admission rates based on primary language (p = 0.771), sex (p = 0.824), marital status (p = 0.753), race (p = 0.222), or age (p = 0.123). In admitted patients, the top 5 symptoms were pain (94.3%), nausea (92.1%), vomiting (73.7%), constipation (70.9%), and weakness (63.8%). In patients who did not require admission, the most common symptoms were pain (84.5%), nausea (67.1%), vomiting (47.2%), headache (36.6%), and weakness (35.4%). The 10 symptoms most associated with admission from the ED based on logistic regression were malaise (OR 21.7, [95% CI 10.1 - 51.0]), lethargy (19.1, [8.5 - 51.3]), flushing (15.7, [8.6 - 30.4]), agitation (12.4, [3.5 - 78.7]), somnolence (10.3, [4.7 - 25.9]), fall (8.5, [3.7 - 23.2]), fatigue (7.8, [4.6 - 13.4]), constipation (6.9, [4.2 - 11.6]), nausea (5.8, [3.0 - 12.2]), and swelling (5.4, [3.3 - 9.1]). Admitted and non-admitted ED patients with cancer seen in the ED during radiotherapy are documented to experience similar symptoms, but certain symptoms are associated with a higher risk of hospital admission. NLP may offer a mechanism for early, automated identification to facilitate supportive interventions for patients at high risk for admission during radiotherapy.

Understanding the Clinical Profile and Hospitalisation Patterns of Residents From Aged Care Facilities: A Regional Victorian Hospital Study.

Introduction Residents of residential aged care facilities (RACFs) are typically frailer than their community-dwelling counterparts. They often present to the emergency department (ED) with varied health issues, frequently leading to hospital admissions. These admissions can exacerbate patient frailty and strain the healthcare system. Despite global efforts to reduce ED presentations from RACFs, effective strategies still need to be discovered. This study examines the clinical profile and hospitalisation patterns of RACF residents in a regional Victorian town. Aims The study aimed to assess the prevalence of ED presentations and representations from RACFs, investigate the causes and outcomes of hospital admissions stemming from these presentations, and evaluate the prevalence of documented (advanced care directives) ACDs within this patient cohort. Methods Following ethical approval, we conducted a retrospective analysis of 467 ED presentations from 310 RACF patients admitted to Goulburn Valley Health's (GVH) ED from January to June 2022. We collected and examined data on demographics, ACD existence, ED presentation characteristics, and hospital admissions, classifying admission reasons into eleven groups. Statistical analysis was performed with GraphPad Prism and IBM SPSS, using inferential tests and logistic regression to assess readmission odds at a significance threshold of p<0.05. Results Our study encompassed 310 patients from multiple RACFs, yielding 467 ED presentations. These constituted 2.28% of total ED visits and 9.85% of those aged 65 and above. Most of the cohort were females (59.4%), aged between 79 and 91. About 98 patients presented multiple times, and 48.2% of presentations led to hospital admissions, with 6.2% of admitted patients succumbing during the hospital stay. A documented ACD was absent in 42.9% of the cohort. Statistically significant results include a correlation between male sex and an increased frequency of ED representations (p=0.0422) and a longer ED stay duration for admitted patients (p<0.0001). No significant associations were found between ACD presence and ED representations, ACD and sex, or between age and duration of stay in the ED. Age did not differ significantly among patients with single or multiple presentations or between patients with or without ACD. Regarding fall-related presentations, no significant sex-based difference in admission rates was found. The duration of stay between surgical and medical admissions was also statistically indifferent. Conclusion Our study highlights the significant utilisation of ED services by RACF residents, mainly males. The substantial percentage of these presentations resulting in hospital admissions underlines the critical nature of these visits. The absence of ACD in a significant portion of the cohort and the lack of its influence on the frequency of representations signal the need for further exploration. The results underline the ongoing challenge of meeting the complex healthcare needs of RACF residents and emphasise the importance of gender-specific interventions and efficient hospital utilisation strategies to optimise healthcare delivery in this population. Future studies should further investigate the underlying reasons for these findings to inform targeted strategies for reducing unnecessary ED visits and hospital admissions. Furthermore, fall-related presentations necessitate comprehensive ED assessments and integrated management approaches.

Health Resource Utilisation and Disparities: an Ecological Study of Admission Patterns Across Ethnicity in England Between 2017 and 2020

Background and AimThe COVID-19 pandemic highlighted adverse outcomes in Asian, Black, and ethnic minority groups. More research is required to explore underlying ethnic health inequalities. In this study, we aim to examine pre-COVID ethnic inequalities more generally through healthcare utilisation to contextualise underlying inequalities that were present before the pandemic.DesignThis was an ecological study exploring all admissions to NHS hospitals in England from 2017 to 2020.MethodsThe primary outcomes were admission rates within ethnic groups. Secondary outcomes included age-specific and age-standardised admission rates. Sub-analysis of admission rates across an index of multiple deprivation (IMD) deciles was also performed to contextualise the impact of socioeconomic differences amongst ethnic categories. Results were presented as a relative ratio (RR) with 95% confidence intervals.ResultsAge-standardised admission rates were higher in Asian (RR 1.40 [1.38–1.41] in 2019) and Black (RR 1.37 [1.37–1.38]) and lower in Mixed groups (RR 0.91 [0.90–0.91]) relative to White. There was significant missingness or misassignment of ethnicity in NHS admissions: with 11.7% of admissions having an unknown/not-stated ethnicity assignment and ‘other’ ethnicity being significantly over-represented. Admission rates did not mirror the degree of deprivation across all ethnic categories.ConclusionsThis study shows Black and Asian ethnic groups have higher admission rates compared to White across all age groups and when standardised for age. There is evidence of incomplete and misidentification of ethnicity assignment in NHS admission records, which may introduce bias to work on these datasets. Differences in admission rates across individual ethnic categories cannot solely be explained by socioeconomic status. Further work is needed to identify ethnicity-specific factors of these inequalities to allow targeted interventions at the local level.

SP8.2.5 Weekend Presentation to Emergency Surgical Units Results in Delayed Ultrasound Diagnosis and More Hospital Visits

Abstract Aims The principles of same day emergency care (SDEC) have been around early assessment, access to point of care testing and criteria led discharge. Supplementing clinical and biochemical assessment with ultrasound (USS) may not always achieve a diagnosis but still facilitates SDEC. Our 5-day SDEC USS service aims to achieve these objectives with only limited dedicated slots over the weekend and holidays. We present the results from our service, focusing on differences in outcomes in those who present on weekdays versus weekends. Methods Retrospective analysis of 558 patients who had USS between 2.2.21 and 12.4.21. Days from presentation to scan, number of re-presentations, and need for admission were compared. Results 402 patients presented in the weekday and 156 at the weekend. The proportion of patients having same day USS was higher for the weekday group (65% vs 26%; χ2 p &amp;lt; .001). The number of days to scanning was higher for weekend presenters (1.15 vs 0.38; Mann-Whitney p&amp;lt;0.001). There was no difference in admission rate on index presentation (weekday = 36% vs weekend = 37%; χ2 p = 0.74), however, the average number of total attendances during the study period was higher in those with an index presentation on a weekend (1.74 vs 1.55; Mann-Whitney p=.007). Conclusions Patients presenting at weekends have longer waits for USS, delaying diagnosis and discharge. Whilst admission rates on index presentation are not affected, access to SDEC USS at the weekend would allow for same-day discharge and fewer visits to hospital for patients.

Nationwide trends in emergency department utilisation for acute retinal ischaemia in the USA, 2011–2018

BackgroundGuidelines recommend urgent evaluation for transient monocular vision loss (TMVL) and retinal artery occlusion (RAO), but emergency department (ED) utilisation for these conditions is unknown.MethodsWe performed a retrospective longitudinal cross-sectional...

Efficacy of Telemedicine Utilization for Cardiac Outpatients' Care during the Pandemic of COVID-19: A Large Center Experience in the Wave of the Pandemic.

Introduction Synchronous telemedicine using teleconferencing may play a role in clinical care. In a tertiary care center, video conferencing-enhanced virtual clinics were established via a new application platform. They were introduced during COVID-19 pandemic to connect patients to trained health-care providers via a secured line. While maintaining patients' privacy, they were theorized to offer effective communications and continuous clinical care. In this cross-sectional cohort study, we ought to examine the impact of service and the assistance they may offer to cardiac patients in the outpatient setup. Methods A prospective cohort study looking at all video-conferencing virtual clinics' visits during the pandemic with primary focus on cardiac outpatient clinic, addressing primary endpoints of need for admission or emergency visits from cardiac demises during the pandemic and secondary endpoint of patient satisfaction based on patients' experiences. Results A total of 6000 live care video-based chats were made over 10 months period from March 10th, 2020, to January 30th, 2021, among which 277 patients were evaluated in the virtual cardiac clinic, of these 193 (69.7%) were males, with mean age of 48 ± 15.60 (22.3%), patients were requested to present to clinic for further evaluation and testing, 20 (7.2%) patients were asked to visit the emergency room, of whom 8 (2.8%) patients were hospitalized. All 8 were admitted for high-risk findings that require immediate medical attention, 4/8 underwent cardiac catheterization, mean duration of admission was 2 ± 1 days. When compared to regular walk-in care, there was a statistical difference in admission rate and emergency visits p = 0.001 and p = 0.0001, respectively, both were statistically higher in the virtual clinic. The satisfaction rate in a 5-scale grading system was 97% of 4 and above recommending the continuation of the service beyond pandemic time. Conclusions Video-enhanced virtual cardiology clinic works safely and efficiently during COVID-19 pandemic with a difference in admission rate and ER visits when compared to walk-in clinic. It can be used during nonpandemic time to reduce load on hospital and clinic crowdedness. It also decreases the chances of COVID-19 transmission indirectly by reenforcing physical distance.

713 Mortality Benefit After Addition of Mid-level Support in Burn Intensive Care Unit

IntroductionBurn Intensive Care Units (BICU)s are resource-heavy and labor-intensive units with very sick patients. The removal of burns as a requirement from the surgical curriculum has decreased the number of rotating surgical trainees, but did not impact patient care needs. Our unit adopted an Advanced Practice Provider (APP) service model in fiscal year 2018 to provide consistent standardized clinical care, with surgical trainees rotating monthly, to mitigate the loss of residents over time. We aimed to critically evaluate the impact of an APP run BICU on mortality and quality improvement initiatives.MethodsPatients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted to the BICU between July 1, 2016 and June 30, 2020 were eligible for inclusion. All central line associated blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTI), ventilator associated pneumonias (VAP) and mortality rates were compared. Demographics, length of stay (LOS), co-morbid conditions and mortality were evaluated. Statistical analysis was performed with Students’ t-test, and chi-squared tests. Significance was accepted as p< 0.05.ResultsThere were no significant differences in admission rates over the study period. The number of CLABSIs significantly decreased each year (15 (2017), 6 (2018), 5 (2019), 3 (2020)). The number of CAUTIs significantly decreased ((13 (2017), 6 (2018), 1 (2019), 3 (2020)). The number of VAPs significantly decreased ((15(2017), 12 (2018), 7 (2019), 3 (2020)). Mortality was unchanged from 2017-2019 but significantly decreased in 2020 ((2.2% (2017), 2.4% (2018), 2.5% (2019), 0.9% (2020)).ConclusionsThere were no significant differences in admission rates over the study period. The number of CLABSIs significantly decreased each year (15 (2017), 6 (2018), 5 (2019), 3 (2020)). The number of CAUTIs significantly decreased ((13 (2017), 6 (2018), 1 (2019), 3 (2020)). The number of VAPs significantly decreased ((15(2017), 12 (2018), 7 (2019), 3 (2020)). Mortality was unchanged from 2017-2019 but significantly decreased in 2020 ((2.2% (2017), 2.4% (2018), 2.5% (2019), 0.9% (2020)).

COVID-19: Highlighting Health Disparities in the Los Angeles Latinx Community.

Objective: Characterization of COVID-19 in the Latinx community is necessary for guiding public health initiatives, health system policy, clinical management practices, and improving outcomes. Our aim was to describe the socioeconomic background and clinical profile of patients with COVID-19 at a large public hospital in Los Angeles to improve health disparities leading to poor outcomes during the pandemic.Design, Setting and Participants: A single center retrospective cross-sectional study of all patients with a positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented to Los Angeles County (LAC)+University of Southern California (USC) Medical Center between March 15, 2020 and April 30, 2020.Methods: We describe patient characteristics, socioeconomic factors, laboratory findings, and outcomes of the first 278 patients to present to LAC+USC Medical Center with COVID-19.Results: Patients self-identified as Hispanic (82.4%) or non-Hispanic (17.6%). Hispanic patients presented later from symptom onset (6 days vs 3 days, P = 0.027) and had higher post-intubation mortality (40.9% vs. 33.3%, P = 1), intensive care unit (ICU) mortality (31.1% vs. 22.2%, P = 0.87), and overall mortality (11.1% vs 10.2%, P = 1). However, the difference in admission rates, mechanical ventilation rates, and overall mortality rates were not statistically significant. A majority of patients, 275/278 (98.9%), reported residency ZIP codes in areas of higher population density, higher percentage of Latinx, born outside the United States, lower median income, and lower high school graduation rate when compared to the rest of Los Angeles County. Regression analysis within the Hispanic cohort found that age, history of hypertension, history of diabetes, lactate dehydrogenase (LDH), and C-reactive protein (CRP) were predictors of mechanical ventilation and mortality.Conclusion: We show the Latinx community has been disproportionally affected by the pandemic in Los Angeles and we identified multiple socioeconomic and clinical characteristics that predispose this population to COVID-19 infection. This study highlights the need for change in local and national strategies to protect vulnerable communities during public health outbreaks.

161 THE ROLE OF THE GERIATRIC DAY HOSPITAL DURING THE COVID 19 PANDEMIC

BackgroundThe geriatric day hospital (GDH) provides outpatient medical, nursing and rehabilitation care to older adults. Historically the main focus has been on rehabilitation. This project’s objective was to evaluate how the GDH adapted during the COVID-pandemic to provide acute medical care to older adults.MethodsThis is a pre and post COVID-19 comparative study. Referral source, multidisciplinary-team input and admission rates were evaluated for all new patient referrals from April 1st to May 31st 2019 (pre-pandemic) and compared to April 1st to May 31st 2020 (during-pandemic). This service evaluation project was approved by the local Research and Innovation Office.ResultsThere was a 37.7% reduction in the number of new patient referrals for 2020 compared to 2019, p < 0.00; Geriatric medicine referrals reduced by 46.5%, emergency department referrals reduced by 61.5%; community referrals increased 15-fold[AL1]. There were no differences in patients referred in terms of gender (p = 0.069), mean age (80.9(SD7.6) vs 79.1(SD6.6), p = 0.092), median conditions (5(IQR3.75–7) vs 6(IQ4–8), p = 0.329) and median medications (8(IQR5–11) vs 8 (IQR5.25–9), p = 0.600). Those referred pre-pandemic were frailer according to the clinical frailty score; median 5(IQR5–6) vs 5(IQR4–6), p = 0.013. In 2020, there was a significant reduction in referrals for physiotherapy (72.9% vs 37.3%, p < 0.001), occupational therapy (58.5% vs 37.8%, p = 0.005) and social work (47.5% vs 26.7%, p = 0.004). Clinical nutrition and speech and language remained the same, 16.1% vs 12%, p = 0.430 and 9.3% vs 12%, p = 0.552, respectively. In 2020, patients referred had significantly fewer attendances; median 4(IQR2–7) vs 3(IQR1–5), p = 0.002. There was no difference in admission rates between 2019 and 2020 (3.3% vs 7.9%, p = 0.149).ConclusionDuring the COVID-Pandemic, the GDH evolved to provide more acute ambulatory medical care to avoid admissions. The GDH continues to adapt as the pandemic evolves and older adults needs change. Further comparative analysis will be required.

EP.FRI.5 Defining measurable data points for Emergency Surgical care

Abstract Aims Service provision and assessing the impact of future innovations can best be assessed by accurate data collection. Methods We have devised a simple dataset and implemented prospective data collection detailing patient referral source and outcome (consecutive days from 19.08.20 to 06.01.21) of Acute Surgical admissions. Results 2706 patient episodes. Conclusions These baseline figures demonstrate referral source and outcomes. Traditional Emergency Department referrals via the Surgical Registrar result in a noticeable difference in admission rates compared with novel pathways such as ASU Direct which allows admission from ED without discussion. These data are essential to facilitate proper evaluation of service delivery, the impact of novel pathways and would allow units to compare / combine results.

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

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

Variation in Rates of Hospital Admission from the Emergency Department Among Medicare Patients at the Regional, Hospital, and Physician Levels

Rates of admission from the emergency department (ED) vary widely across regions of the country, hospitals within regions, and physicians within hospitals. Our objective was to determine the extent to which variation in admission decisions was described by differences in admission rates at these 3 levels. This understanding will serve to better target interventions to modify rates of admission where appropriate. In this cross-sectional observational cohort study, we analyzed Medicare fee-for-service claims for ED visits from 2012 to 2015 in a 20% random sample of beneficiaries. We first estimated the total regional-, hospital-, and physician-level variations in rates of admission and their proportions of the total variation after adjusting for patient and each level's covariates. We then estimated the extent to which each level's characteristics accounted for variation at that respective level. Our study sample included 5,778,218 visits with 45,491 physicians at 3,480 EDs across 306 hospital referral regions. The mean rate of admission was 38.9% and ranged from 21.4% to 53.0% for physicians at the 10th and 90th percentile of the distribution, respectively. The residual (unexplained) variations at the regional, hospital, and physician levels were 13.3% (95% confidence interval [CI], 11.2 to 15.5%), 60.1% (57.1 to 62.9%), and 26.7% (26.4 to 26.9%), respectively. Regional, hospital, and physician characteristics accounted for 9.1% (95% CI, -5.6 to 23.8%), 51.1% (48.8 to 53.5%), and 2.7% (1.3 to 4.1%), respectively, of the explained variation at their respective levels. Within-area variation, both across hospitals within a region and across physicians within a hospital, is a more substantial component of observed variation in admission rates from the ED than regional level variation. These findings suggest that variation in admission rates is at least in part related to institutional norms and cultures as well as heterogeneity of physician decisionmaking within hospitals, both of which could be targets of interventions to modify rates of admission.

Kielland’s rotational forceps delivery: comparison of maternal and neonatal outcomes with pregnancies delivering by non-rotational forceps

We compared complications in pregnancies that had Kielland’s rotational forceps delivery (KRFD) with non-rotational forceps delivery (NRFD). Maternal outcomes included post-partum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS); neonatal outcomes included admission to neonatal intensive care unit (NICU), 5-minute Apgar scores <7, hypoxic ischaemic encephalopathy (HIE), jaundice, shoulder dystocia and birth trauma. The study population included 491 (2.1%) requiring KRFD, 1,257 (5.3%) requiring NRFD and 22,111 (93.0%) that had SVD. In pregnancies with NRFD compared to KRFD, there was higher incidence of OASIS (8.5% vs. 4.7%; p = .006) and a non-significant increased trend for PPH (15.0% vs. 12.4%; p = .173). There was no significant difference in rates of admission to NICU (p = .628), 5-minute Apgar score <7 (p = .375), HIE (p = .532), jaundice (p = .809), severe shoulder dystocia (p = .507) or birth trauma (p = .514). Our study demonstrates that KRFD has lower rates of maternal complications compared to NRFD whilst the rates of neonatal complications are similar. IMPACT STATEMENT What is already known on this subject? Kielland’s rotational forceps is used for achieving vaginal delivery in pregnancies with failure to progress in second stage of labour secondary to fetal malposition. The use of Kielland’s forceps has significantly declined in the last few decades due to concerns about an increased risk of maternal and neonatal complications, despite the absence of any major studies demonstrating this increased risk. What do the results of this study add? There are some studies which compare the risks in pregnancies delivering by Kiellands forceps with rotational ventouse deliveries but there is limited evidence comparing the risks of rotational with non-rotational forceps deliveries. Our study compares the major maternal and neonatal complications in a large cohort of pregnancies undergoing rotational vs. non-rotational forceps deliveries. What are the implications of these findings for clinical practice and/or further research? The results of our study demonstrate that maternal and neonatal complications in pregnancies delivering by Kielland’s rotational forceps undertaken by appropriately trained obstetricians are either lower or similar to those delivering by non-rotational forceps. Consideration should be given to ensure that there is appropriate training provided to obstetricians to acquire skills in using Kielland’s forceps.

The Effect of Body Mass Index on Presentation of COVID-19 amongst Heart Transplant Recipients: A Multi-Institutional Study

PurposeCharacteristics and outcomes of heart transplant (HT) recipients who contract coronavirus (SARS-CoV-2) have been poorly described. The current study was undertaken to better understand the risk obesity may pose in this patient populationMethodsA prospectively-maintained Trans-CoV-VAD Registry containing HT recipients at 11 participating institutions who presented with SARS-CoV-2 were reviewed. Presenting characteristics, hospitalization rates, ventilator & intensive care unit usage, and mortality were queried. Patients were grouped by body mass index (BMI) into obese (BMI≥30 k/m2) and non-obese cohorts (BMI<30 kg/m2). Comparisons between groups were made utilizing chi-squared, Fisher's exact, and Mann-Whitney U-tests. Multivariable logistic regression models were utilizedResultsAcross all centers, 85 HT recipients who tested positive for SARS-CoV-2 were identified, of whom 26 (31%) were obese. Median time from HT to diagnosis was 4.6 (1.8-13.8) years. No differences in age (57 vs 60 p 0.85) or female gender (31% vs 24% p 0.5) were noted between obese and non-obese patients. On presentation, obese patients were more symptomatic with higher rates of cough (76% vs 48% p 0.02), dyspnea (62% vs 41% p 0.09), diarrhea (60% vs 35% p 0.03), and headache (35% vs 14% p 0.03). No differences in rates of admission (62% vs 64% p 0.8), ICU presentation (44% vs 35% p 0.6) or need for mechanical ventilation were noted (38% vs 22% p 0.2). More secondary infections were noted amongst obese patients (32% vs 13% p 0.04). On follow-up, mortality was similar between groups (12% vs 9% p 0.7). On multivariable modeling, BMI was not associated with increased adjusted odds of hospital/ICU admission or mechanical ventilation (p>0.10)ConclusionAcute presentations of SARS-CoV-2 amongst HT recipients carry significantly higher mortality over the general population. Obesity appears to impact presenting symptoms and secondary infections, but does not strongly impact ICU requirements or mortality

742 Disparities in emergency care for underserved women during the first year postpartum

Disparities in mortality disproportionately impact Black women during the first postpartum year. Readmission for morbidities is used as a measure to decrease mortality and to date, has not been evaluated for women presenting to the emergency department (ED) up to one year postpartum. The aim of this study was to determine if there are differences in rates of admission from the ED according to race and ethnicity among a cohort of underserved women presenting to the ED during the first postpartum year. We performed a retrospective cohort study of all Black and Hispanic postpartum women who delivered and sought emergency care in the Harris Health system between 3/2012 and 3/2020. Patients, comorbidities, and diagnoses were identified by ICD-10 codes. A propensity score analysis matched Black to Hispanic patients based on maternal age, body mass index, comorbidity and reason for ED visit. Conditional logistic regression was used to calculate odds ratios for admission to the hospital following ED evaluation. There were 47,976 patients who delivered during the study period; 41,237 (86%) were Black or Hispanic. Of the 6,204 Black patients, 1,059 (17.1%) sought care at the ED compared to 4,379 of the 35,033 (12.5%) Hispanic women (p< .001). 1,049 Black women (99.1%) were matched to a Hispanic woman. Black patients were significantly less likely to be admitted to the hospital following ED evaluation compared to matched Hispanic patients (OR 0.65; 95% CI 0.49-0.85). Repeat ED visits accounted for 7.7% of total visits among Black women and 8.2% of total visits among Hispanic women (p=.38). Within our matched cohort of underserved women seeking care at a county health facility within 1 year of delivery, Black patients were significantly less likely to be admitted compared to Hispanic patients. These results indicate a potential missed opportunity for interventions that could influence the disparate rate of maternal death among Black women.

Symptomatic, functional and service utilization outcomes of migrants with a first episode of psychosis.

Certain migrant groups have been identified as being at increased risk of developing a psychotic disorder, but there is limited research on the outcomes for migrants who develop a first episode of psychosis (FEP). We investigated symptomatic outcomes (remission and relapse rates), functional outcomes (occupational status and relationships) and service utilization (hospital admission and engagement). Young people, aged between 15 and 24, who presented with FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen between 01.01.11 and 31.12.16 were included. Place of birth was recorded at the time of presentation. To determine remission, symptoms were scored at three-month intervals using the short-form Scale for the Assessment of Positive Symptoms. A total of 1220 young people presented with FEP over the six-year period (mean age = 19.6 ± 2.8). Of these, 58.1% were male and 24.0% were first-generation migrants. While there was no difference in overall rates of admission after presentation, migrants were more likely to have an involuntary admission after presentation (31.4% vs. 24.6%, aHR = 1.54, 95% CI [1.19, 2.01]) and this risk was greatest for African migrants (HR = 1.98, 95% C.I. [1.37, 2.86]. The rates of remission and relapse were similar in migrants and those born in Australia and there was no difference in functional outcomes, such as employment rates at follow-up. The outcomes for migrants who experience FEP appear to be largely similar to those for the Australian-born population. Our finding that a greater rate of involuntary admission for migrants at presentation supports existing literature and needs further exploration to improve clinical care.

The impact of post-operative voiding trial on length of stay following laparoscopic hysterectomy: a prospective, randomized control trial

Objective: Same day discharge (SDD) is feasible following laparoscopic hysterectomy (TLH) in gynecologic oncology patients resulting in low complication and re-admission rates. Following vaginal surgery, backfill or active voiding trials have been shown to reduce hospital discharge with a catheter. The aim of this study is to determine if performing an active backfill voiding trial (AVT) vs. passive voiding trial (PVT) leads to expedited discharge following TLH. Methods: Subjects scheduled for SDD TLH were enrolled and randomized to an AVT or a PVT. The primary outcome was length of stay. Secondary outcomes include time to void, catheter replacement, admission to the extended recovery unity (ERU), post-operative pain, and complications. Results: 121 patients were randomized: 60 to an AVT and 61 to a PVT. There was a statistically significant reduction in median length of stay for patients undergoing an AVT vs. PVT (271.5 minutes vs. 329 minutes, P = 0.015). Median time to void was also decreased with an AVT vs. PVT (30 minutes vs. 289 minutes, P &lt; 0.001). There was no difference in median pain score (2), catheter replacement, peri-operative complications, or overnight admissions between the two groups. Conclusion: There is a significant reduction in time to void and total length of stay in patients randomized to a backfill voiding trial following TLH with no increased patient discomfort. While the numbers of post-operative admissions were low and underpowered to detect a difference in admission rate, these data will help to streamline post-operative care for SDD gynecologic oncology patients.

Are Backyard Waterslides as Dangerous as Public Waterslides: A Review of 1,823 Head and Neck Injuries.

The purpose of this study was to describe the characteristics and compare the severity of head and neck injuries between public and backyard waterslides. This was a 20-year cross-sectional study of the National Electronic Injury Surveillance System. Injuries from waterslides were included in this study if they involved the head, face, eyeball, mouth, neck, or ear. Patient and injury characteristics were compared by the type of waterslide using chi-squared and independent sample tests. A total of 1823 injury reports were identified (39.8% backyard waterslides and 60.2% public waterslides). The mean age at the time of injury was 13.2 years, and the majority of patients were white (74.2%) males (55.1%). The most common primary diagnoses were laceration (28.4%) and internal organ injury (27.2%). A greater proportion of backyard injuries involved the head (P < 0.01) and resulted in concussions (P < 0.01) or fractures (P = 0.04). The overall admission rate from the ED was 3.5%, and no fatalities were noted. There were no significant differences in admission rates between injuries from backyard and public slides. Fatal or serious head and neck injuries appear to be uncommon with waterslide injuries. Backyard waterslides pose a greater likelihood of cranial injury, and this may relate to differences in riding habits between public and private waterslides.

Mortality Rates in Transplant Recipients and Transplantation Candidates in a High-prevalence COVID-19 Environment.

The risk of COVID-19 infection in transplant recipients (TRs) is unknown. Patients on dialysis may be exposed to greater risk of infection due to an inability to isolate. Consideration of these competing risks is important before restarting suspended transplant programs. This study compared outcomes in kidney and kidney/pancreas TRs with those on the waiting list, following admission with COVID-19 in a high-prevalence region. Audit data from all 6 London transplant centers were amalgamated. Demographic and laboratory data were collected and outcomes included mortality, intensive care (ITU) admission, and ventilation. Adult patients who had undergone a kidney or kidney/pancreas transplant, and those active on the transplant waiting list at the start of the pandemic were included. One hundred twenty-one TRs and 52 waiting list patients (WL) were admitted to hospital with COVID-19. Thirty-six TR died (30%), while 14 WL patients died (27% P = 0.71). There was no difference in rates of admission to ITU or ventilation. Twenty-four percent of TR required renal replacement therapy, and 12% lost their grafts. Lymphocyte nadir and D-dimer peak showed no difference in those who did and did not die. No other comorbidities or demographic factors were associated with mortality, except for age (odds ratio of 4.3 [95% CI 1.8-10.2] for mortality if aged over 60 y) in TR. TRs and waiting list patients have similar mortality rates after hospital admission with COVID-19. Mortality was higher in older TRs. These data should inform decisions about transplantation in the COVID era.