Difference In Hospital Length Of Stay Research Articles

Pulmonary specialist involvement in critical asthma in the pediatric intensive care unit: A retrospective review.

Asthma is one of the most common chronic diseases of childhood. There is a scarcity of published literature on critical asthma, considered acute asthma requiring pediatric intensive care unit (PICU) admission. The goal of this study was to describe the clinical care of children with critical asthma admitted to a single center PICU and to determine whether pulmonary medicine consultation during admission impacted outcomes. Retrospective chart review of known asthma patients aged 4-18 years admitted to a quaternary PICU between 01/2013 and 07/2019 for management of critical asthma. A total of 179 patients were enrolled with median age of 8 years. Median hospital length of stay (LOS) was 3.2 days and PICU LOS was 1.5 days. A total of 80 (44.7%) patients had a pulmonary medicine consultation. In the pulmonary medicine consultation group versus the no-pulmonary medicine consultation group, there was a significant difference in hospital LOS (4.16 vs. 2.86 days, p value <.0001) and PICU LOS (2.00 vs. 1.00, p value <.0001), escalation of controller medication (66% vs. 21%, p value <.0001), scheduled outpatient pulmonology follow-up (87.5% vs. 45.4%, p value <.0001), and receiving ≥3 courses of systemic steroids in the 12 months after discharge (32.2% vs. 14.7%). There was no difference in attendance of scheduled follow up appointments or in having ≥3 emergency room visits or admissions in the 12 months after discharge. Pulmonary medicine consultation during hospital admission may impact management of critical asthma by increasing escalation of controller medication and scheduled outpatient follow up.

Does the “July effect” of new trainees at teaching hospitals impact outcomes for patients hospitalized with heart failure? Real-world analyses of more than half a million US admissions

IntroductionThe “July effect” refers to the potential of adverse clinical outcomes related to the annual turnover of trainees. We investigated whether this impacts inpatient heart failure (HF) outcomes. MethodsData from all adults (≥18 years) admitted with a primary diagnosis of HF at US teaching hospitals from the 2012–2014 National Inpatient Sample were analyzed. Non-teaching hospital admissions were excluded. The primary outcome was in-hospital mortality. Secondary metrics included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic and linear regression models were used to adjust for confounders. Admissions were classified into 4 quarters (Q1–Q4), based on the academic calendar. Q1 and Q4 were designated to assess the effect of novice (July effect) versus experienced trainees, respectively. ResultsThere were 699,675 HF admissions during Q1 and Q4 in the study period. Mean age was 71 ± 15 years and 48% were females. There were 20,270 in-hospital deaths, with no difference between Q1 and Q4; crude odds ratio (OR) 1.00, 95% confidence interval (CI) 0.94–1.07, p = 0.95. After risk adjustment, there was no in-hospital mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, 95% CI 0.89–1.03, p = 0.23. There was no difference in hospital LOS or total cost; 5.8 versus 5.8 days, p = 0.66 and $13,755 versus $13,586, p = 0.46, in Q1 and Q4, respectively. ConclusionsIn this nationally representative sample, there was no evidence of a “July effect” on inpatient HF outcomes in the US. This suggests that HF patients should not delay seeking care during trainee transitions at teaching hospitals.

Meta-Analysis of New-Onset Atrial Fibrillation Versus No History of Atrial Fibrillation in Patients With Noncardiac Critical Care Illness

The incidence of new-onset secondary atrial fibrillation (NOSAF) is as high as 44% in noncardiac critical illness. A systematic review and meta-analysis were performed to evaluate the impact of NOSAF, compared with history of prior atrial fibrillation (AF) and no history of AF in noncardiac critically ill patients. Patients undergoing cardiothoracic surgery were excluded. NOSAF incidence, intensive care unit (ICU)/hospital length of stay (LOS), and mortality outcomes were analyzed. Of 2,360 studies reviewed, 19 studies met inclusion criteria (n=306,805 patients). NOSAF compared with no history of AF was associated with increased in-hospital mortality (risk ratio [RR] 2.06, 95% confidence interval [CI] 1.76 to 2.41, p <0.001), longer ICU LOS (standardized difference in means [SMD] 0.66, 95% CI 0.41 to 0.91, p <0.001), longer hospital LOS (SMD 0.31, 95% CI 0.07 to 0.56, p=0.001) and increased risk of long-term (>1 year) mortality (RR 1.76, 95% CI 1.29 to 2.40, p <0.001). NOSAF compared with previous AF was also associated with higher in-hospital mortality (RR 1.29, 95% CI 1.12 to 1.49, p <0.001), longer ICU LOS (SMD 0.37, 95% CI 0.03 to 0.70, p=0.03) but no difference in-hospital LOS (SMD -0.18, 95% CI -0.66 to 0.31, p=0.47). In conclusion, NOSAF, in the setting of noncardiac critical illness is associated with increased in-hospital mortality compared with no history of AF and previous AF. NOSAF (vs no history of AF) is also associated with increased long-term mortality.

Quality improvement project to decrease unnecessary investigations in infants with bronchiolitis in Cork University Hospital

BackgroundBronchiolitis is a common reason for infants to present to the emergency department (ED). Clear evidence-based guidelines exist that recommend against routine radiological and laboratory investigations in this cohort. Despite...

Impact of Clinical Sepsis Phenotypes on Mortality and Fluid Status in Critically Ill Patients.

Sepsis is associated with high rates of in-hospital mortality, despite being the focus of medical research and public health initiatives for several years. The primary objective of this study was to determine the influence of septic phenotypes on rates of in-hospital mortality throughout intensive care unit (ICU) admission. Retrospective, single-center cohort study. Medical ICU of an academic medical center. Medical ICU patients admitted between January 2016 and August 2019 with a "sepsis alert" were screened for admitting diagnosis of "sepsis" or "septic shock." Patients were classified into one of four clinical sepsis phenotypes: multi-organ failure (MOF), respiratory dysfunction (RD), neurologic dysfunction (ND), or other patients (OP). An analysis of 320 patients was completed. In-hospital mortality was different between groups (P < 0.001). Patients with the MOF phenotype had the highest rate of mortality (48.4%), followed by the ND phenotype (39.7%), RD phenotype (20.8%), and OP phenotype (13.7%). There were differences in volume balances between phenotypes at 48 h (P = 0.001), 72 h (P < 0.001), and 96 h (P < 0.001) after hospital presentation, with the MOF and ND phenotypes having the largest volume balances at these time points. Ventilator-free days (P < 0.001) and ICU length of stay (LOS) (P = 0.030) were different between groups. There was no difference in hospital LOS (P = 0.479). This data supports the presence of marked intra-disease differences in septic patient presentation and correlation with clinical outcomes including mortality. Additionally, significantly more positive fluid balances were observed between survivors and non-survivors in some patient subsets. Using pragmatic clinical variables readily available to providers to classify patients into septic phenotypes has the propensity to guide treatment strategies in the future.

Use of Incentive Spirometry in Adults following Cardiac, Thoracic, and Upper Abdominal Surgery to Prevent Post-Operative Pulmonary Complications: A Systematic Review and Meta-Analysis

Background: Currently, consensus on the effectiveness of incentive spirometry (IS) following cardiac, thoracic, and upper abdominal surgery has been based on randomized controlled trials (RCTs) and systematic reviews of lower methodological quality. To improve the quality of the research and to account for the effects of IS following thoracic surgery, in addition to cardiac and upper abdominal surgery, we performed a meta-analysis with thorough application of the Grading of Recommendations Assessment, Development and Evaluation scoring system and extensive reference to the Cochrane Handbook for Systematic Reviews of Interventions. Objective: The objective of this study was to determine, with rigorous methodology, whether IS for adult patients (18 years of age or older) undergoing cardiac, thoracic, or upper abdominal surgery significantly reduces30-day post-operative pulmonary complications (PPCs), 30-day mortality, and length of hospital stay (LHS) when compared to other rehabilitation strategies. Methods: The literature was searched using Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and Web of Science for RCTs between the databases’ inception and March 2019. A random-effect model was selected to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Results: Thirty-one RCTs involving 3,776 adults undergoing cardiac, thoracic, or upper abdominal surgery were included. By comparing the use of IS to other chest rehabilitation strategies, we found that IS alone did not significantly reduce 30-day PPCs (RR = 1.00, 95% CI: 0.88–1.13) or 30-day mortality (RR = 0.73, 95% CI: 0.42–1.25). Likewise, there was no difference in LHS (mean difference = −0.17,95% CI: −0.65 to 0.30) between IS and the other rehabilitation strategies. None of the included trials significantly impacted the sensitivity analysis and publication bias was not detected. Conclusions: This meta-analysis showed that IS alone likely results in little to no reduction in the number of adult patients with PPCs, in mortality, or in the LHS, following cardiac, thoracic, and upper abdominal surgery.

LENGTH OF HOSPITAL STAY OF ORTHOPAEDIC INPATIENTS IN A TERTIARY CARE TEACHING HOSPITAL IN NEPAL

Background: Length of Hospital Stay (LOHS) can have important effects on the cost of treatment and patient outcomes. The aim of this study was to determine the length of hospital stay among orthopaedic inpatients and assess its association with different socio-demographic and clinical factors. Methods: A retrospective study was conducted at College of Medical Sciences and Teaching Hospital, Nepal, wherein, clinical records of patients admitted and treated as inpatients between January and December 2019 were retrieved. Demographic data, diagnosis, treatment details, LOHS, co-morbidities, treatment modality and mode of payment were documented and data was analyzed using SPSS software 16.0. Median was calculated for skewed continuous data and frequency analysis was done for categorical variables. P value &lt;0.05 was considered statistically significant. Results: In a total of 1248 patients with mean age of 33.8±18.7 years, 72.4 % (n=904) were male. Most of them (34.9%, n=435) were students and majority (62.5%, n=780) were from outside Chitwan. The median LOHS was 5.0 (3.0–10.0) days. It was significantly greater in cases from outside Chitwan, those with trauma, infection, associated injury, and complications (p&lt;0.05). Moreover, there was significant difference in LOHS among various age quintiles, occupations, fracture types, modes of payment and treatment modalities (p&lt;0.05). However, LOHS did not differ significantly between patients with or without co-morbidity and gender (p&gt;0.05). Conclusions: This study identified that the LOHS was significantly associated with various clinico demographic factors except gender and co-morbidity. More studies can be conducted to assess the relationships further.

Evaluation of Dipeptidyl Peptidase-IV Inhibitor Use in Hospitalized Patients With Diabetes.

Glycemic control within goal blood glucose (BG) ranges is essential to minimize hospital complications for patients with type 2 diabetes mellitus (T2DM). Optimal treatment in the non-intensive care unit (ICU) setting includes a basal insulin containing regimen. Dipeptidyl peptidase-IV (DPP-IV) inhibitors have minimal hypoglycemia incidence and may be an appropriate bolus insulin replacement in the inpatient setting. To determine the effect of basal insulin plus DPP-IV inhibitor compared with basal plus bolus insulin in hospitalized patients with T2DM. This multicenter cohort study included adult patients with T2DM admitted to the non-ICU setting and prescribed either basal insulin plus DPP-IV inhibitor or basal plus bolus insulin. Propensity-score matching was performed for age, sex, Charlson Comorbidity Index, first BG reading during hospitalization, and hemoglobin A1C (A1C). The primary outcome was the difference in mean daily BG during hospitalization. Secondary outcomes included hospital length of stay (LOS), total daily dose (TDD) of insulin, hypoglycemic events, and mean daily BG in patients with an A1C >8%. A total of 105 patients were included in each group. Mean daily BG during hospitalization was lower in the basal insulin plus DPP-IV inhibitor group (199.3 ± 52.5 vs 213.6 ± 45.8 mg/dL; P = 0.04). There was a significant difference in hospital LOS (5 [interquartile range = 3-8] vs 6 [4-11] days; P = 0.02) and short-acting insulin TDD (11.6 ± 9.1 vs 20.5 ± 21.2 units; P < 0.001). No differences were observed in basal insulin TDD and hypoglycemia. There was no difference in mean daily BG in the subgroup analysis of patients with a A1C >8%. A significant difference in mean daily BG and hospital LOS was found with a basal insulin plus DPP-IV inhibitor regimen. Use of a DPP-IV inhibitor to replace bolus insulin in hospitalized patients with T2DM should be considered.

Impact of Initial eGlycemic Management System Dosing Strategy on Time to Target Blood Glucose Range.

Glucommander™ (GM), an electronic glycemic management system, was implemented across a multi-hospital health system as the standard of care for glycemic control. GM provides insulin dosing recommendations based on patient-specific blood glucose (BG) trends after providers select either a custom dose or weight-based multiplier as the initial dosing strategy for the first 24 hours. This study evaluated the impact of initial subcutaneous (SC) GM insulin dosing strategies on glycemic management. Non-intensive care unit patients treated with SC GM using either initial custom (based on provider discretion) or weight-based multiplier settings (0.3, 0.5, or 0.7 units/kg/day) were evaluated in this retrospective chart review. The primary endpoint was time to target BG range defined as time to first two consecutive in range point of care BG. Secondary endpoints included percentage of BG values in target range, percentage of orders following institutional recommendations, length of stay (LOS), average BG, and incidence of hypoglycemia and hyperglycemia. A review of 348 patients showed time to target BG was not significantly different between custom and multiplier groups (55 vs 64 hours, P = .07). Target BG was achieved in less than half of patients in both groups (47% vs 44%, respectively). There were no differences in hospital LOS, proportion of BG in target range, rates of hypo/hyperglycemia, and average BG. Custom initial SC GM insulin dosing settings showed a nonsignificant decrease in time to target BG range compared to pre-defined multiplier settings. Future studies evaluating the impact of compliance with institutional recommendations on BG control are warranted.

259. A Prospective, Stewardship-Driven IV to PO Conversion in Uncomplicated Bacteremia

BackgroundRecent data has shown a transition to oral (PO) antibiotics (ABX) for definitive treatment of uncomplicated bacteremia has similar efficacy compared to continuation of intravenous (IV) ABX, and reduces hospital length of stay (LOS). The purpose of this study was to evaluate the safety and efficacy of an antimicrobial stewardship pharmacist-driven, IV to PO ABX transition in clinically stable patients with uncomplicated bacteremia, and to determine the impact on hospital LOS.MethodsThis was a prospective, interventional study with concurrent controls, conducted at Cedars-Sinai Medical Center between November 2019 and April 2020. For patient recruitment, a report of all positive inpatient blood cultures was reviewed daily. For patients meeting study criteria, the treating provider was contacted to recommend an IV to PO ABX transition. The treating provider was responsible for making the final determination on ABX therapy. Patients continuing IV ABX served as the comparator group to those transitioning to PO.The primary outcome of interest was a composite of: 30-day, all-cause mortality, 30-day readmission due to infectious- or ABX-related complications, or 30-day recurrent infection with the same organism recovered. The second outcome of interest was overall hospital LOS and hospital LOS after the definitive ABX regimen was established.ResultsA total of 117 patients were evaluated; 69 patients met criteria for inclusion in the study (46 PO ABX / 23 IV ABX). Overall, baseline characteristics were similar between the groups. No difference was observed in the 30-day composite outcome (1 in each group), but the median, overall hospital LOS was three days shorter in the PO group. Furthermore, hospital LOS after the definitive ABX regimen was established was four days shorter in the PO group. Based on the differences in hospital LOS observed, the intervention was estimated to have resulted in approximately $819,200 cost-avoidance during the study period.ConclusionSimilar to prior studies, our findings support the safety and effectiveness of an IV to PO ABX transition in clinically stable patients with uncomplicated bacteremia. Antimicrobial stewardship pharmacists can be leveraged to facilitate such a transition.Disclosures All Authors: No reported disclosures

Abstract 322: Post-cardiac Arrest Care Variations in Michigan Hospitals and Their Impact on Survival

Introduction: Targeted temperature management (TTM) is an important component of post cardiac arrest care. Current guidelines recommend deferring prognostic decisions for 72 hours post TTM. Most non survivors have care withdrawn and some hypothesize that early withdrawal of care adversely impacts survival. Our objective is to characterize hospital length of stay (LOS) post cardiac arrest, its relationship to survival and variation by hospitals using a statewide registry. Methods: We probabilistically linked out of hospital (OHCA) patients from 2014-2017 in a statewide Cardiac Arrest to Enhance Survival Registry (CARES) and the Michigan Inpatient Database (MIDB). We included resuscitated adult OHCA patients. To assess variation in LOS (arrival-death or discharge), those with &gt; 30 subjects/hospital were included. We abstracted subject demographics, arrest characteristics, in hospital care, and hospital LOS. Our outcome is survival to discharge. We define early death as hospital LOS&lt; 72 hours (LOS&lt;72). We calculated Pearson’s correlation coefficient (r) to characterize the relationship of LOS&lt;72 and patient survival. Results: We included 3,644 patients from 38 hospitals. They were predominately male (2160, 59.3%), mean age 62.4, 1716 (47.1%) received TTM, mean LOS was 6.1 days, and 1078 (29.6%) survived to discharge. Median LOS was longer in patients who were survivors (9.0 vs 2.0 days, p&lt;0.001). Median LOS was greater in patients who received TTM (5.0 vs 3.0 days, p&lt; 0.001) and almost half (1813, 49.8%) of all patients had a LOS &lt;72. We observed variation in LOS&lt;72 by hospitals (39.4% to 61.3%, Figure 1), and a negative relationship between LOC&lt;72 and survival (r = -0.36). Conclusion: We observed that nearly half of subjects had a LOS&lt;72, and a modest negative correlation of LOS&lt;72 and outcome. These data suggest that further work is needed to clarify whether early hemodynamic collapse or early withdrawal of care explains differences in hospital LOS and survival.

Abstract 16269: Does the “July Effect” Impact Heart Failure Outcomes? A Real-World Analysis of More Than Half a Million Nationwide Admissions

Background: The “July effect” is a well-described phenomenon in academic medicine, relating to the annual influx of new trainees. We examined whether the “July effect” impacts inpatient outcomes of admissions for heart failure (HF). Methods: Between 2012 and 2014, we included adult patients (≥18 years) with a primary diagnosis of HF, defined using ICD-9 codes, from the National Inpatient Sample. We excluded non-teaching hospitals. Primary endpoint was in-hospital mortality. Secondary endpoints included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic regression and adjusted odds ratio (OR) were used to adjust for confounders. Based on academic calendar, we classified admissions into 4 quarters (Q1-4). Q1 and Q4 were designated to assess the effect of novice (July effect) vs. seasoned trainees, respectively. Results: We identified 699,675 HF admissions during Q1 and Q4 over the study period. Mean age was 71 years and 48% were females. There were 20,270 in-hospital deaths (Q1 9,695 vs. Q4 10,575). After adjusting for confounders, there was no mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, p = 0.23 (Figure). Similarly, there was no difference in hospital LOS or total cost; 5.8 vs. 5.8 days, p = 0.66 and $13,755 vs. $13,586, p = 0.46, in Q1 and Q4, respectively. Conclusion: In the largest study to date, there was no evidence of a “July effect” on inpatient HF outcomes. This may be credited to the well-defined guidelines which facilitate safe patient care in these patients.

Evaluation of Dipeptidyl Peptidase-IV Inhibitor Use in the Inpatient Setting

Background: The American Diabetes Association recommends discontinuing non-insulin antihyperglycemic therapy during hospitalization and utilizing a basal insulin-containing regimen for patients with type 2 diabetes mellitus (T2DM). Limited research is available on the role of dipeptidyl peptidase-IV (DPP-IV) inhibitors in an inpatient real-world patient population. Objective: To determine the efficacy of DPP-IV inhibitor therapy in hospitalized patients with T2DM. Methods: Adult patients with T2DM and received at least one dose of DPP-IV inhibitor during hospitalization were included. The primary outcome was to determine the mean daily blood glucose (BG) readings in the overall patient population. Secondary outcomes included comparing study groups and evaluating mean daily blood glucose, hospital length of stay (LOS) and incidence of hypoglycemia. Results: One hundred and ninety-two patients were identified: 39 patients (20.3%) received DPP-IV inhibitor monotherapy, 104 (54.2%) received DPP-IV inhibitor plus oral antihyperglycemics and 49 (25.5%) received DPP-IV inhibitor plus insulin. Mean daily BG in the entire study population was 158.7 mg/dL (131-187.5). Mean daily BG was significantly different between groups (117 mg/dL [103.5-132.3] vs. 160.7 mg/dL [133-181.1] vs. 179.4 mg/dL [153.8-216.6]; (P < 0.001). Hypoglycemic events were higher in the DPP-IV inhibitor plus insulin group (2.6% vs. 3.8% vs. 16.3%; P = 0.008). There were no significant differences in hospital LOS (2 days [1-4] vs. 3 days [1-5] vs. 4 days [2-6.5]; P = 0.051). Conclusions: Inpatient DPP-IV inhibitor use was associated with mean daily BG within goal range. Administering DPP-IV inhibitors in the inpatient setting should be considered in hospitalized patients with controlled T2DM.

339 Does Shock Index, Pediatric Age-Adjusted Help Predict Mortality by Trauma Center Type?

Pediatric trauma patients can be seen at adult trauma centers (ATC), mixed pediatric and adult trauma centers (MTC), or pediatric trauma centers (PTC). Shock index, pediatric age-adjusted (SIPA) can be used to prospectively identify severely injured children. This study characterized the differences in mortality and hospital length of stay (LOS) amongst pediatric trauma patients with elevated SIPA at different trauma centers types. Pediatric patients (1-14 years) were queried from the 2013-2016 National Trauma Data Bank (NTDB). Patients with elevated SIPA (SIPA+) were included for analysis. The primary outcome was mortality. Secondary analyses included hospital length of stay. Unadjusted frequencies and multivariate regression analyses were performed. Out of 190,569 patients, 33,149 were SIPA+. The initial unadjusted odds ratio for mortality showed no significant difference at ATC OR 0.93 (95% CI 0.75, 1.17) or MTC OR 1.11 (95% CI 0.88, 1.39) when compared to PTC. The unadjusted mean hospital length of stay was 3.3 ± 6.97 days at ATC, 3.98 ± 7.17 days at MTC, and 3.64 ± 8.17 days at PTC. After controlling for age, race, sex, payment method, mean ISS, hospital teaching status, and number of hospital beds, amongst SIPA+ patients there was no significant difference in mortality at ATC OR 0.85 (95% CI 0.63, 1.13) and MTC OR 1.07 (95% CI 0.77, 1.47) when compared with PTC. There was also no significant difference in hospital LOS at ATC OR 0.78 (95% CI 0.56, 1.08) and MTC OR 0.93 (95% CI 0.65, 1.35) when compared with PTC. Severely injured children with elevated SIPA have no increased risk of mortality at ATCs or MTCs when compared to PTCs. This finding provides evidence for out-of-hospital systems to determine where severely injured pediatric trauma patients are transported for their initial trauma care.Tabled 1Adjusted Odds Ratios for SIPA+ PatientsType of Trauma CenterMortalityHospital LOSAdult Trauma CenterOR 0.85 (95% CI 0.63, 1.13)OR 0.78 (95% CI 0.56, 1.08)Mixed Trauma CenterOR 1.07 (95% CI 0.77, 1.47)OR 0.93 (95% CI 0.65, 1.35)Pediatric Trauma Center1; Reference1; Reference Open table in a new tab

Management of Nonoperative Diverticulitis : Is Surgical Admission Always Best?

Institutional pathways (IPs) allow efficient utilization of health care resources. Recent literature reports decreased hospital length of stay (LOS), complications, and costs with the admittance of surgical disease to surgical services. Our study aimed to demonstrate that admission to surgery for nonoperative, acute diverticulitis reduces hospital LOS, and cost, with comparable complication rates. In January 2017, we defined IPs for diverticulitis, mandating emergency department admission to a surgical service. Patients admitted from October 2015 to June 2016 (pre-protocol, control cohort) were compared with those admitted January 2017-September 2018 (post-protocol, IP cohort). Primary outcomes included hospital LOS, direct cost, indirect cost, total cost, and 30-day readmission. Student's 2-tailed t-test and chi-square analysis were utilized, with statistical significance P < .05. Nonoperative management of acute diverticulitis occurred in 62 (74%) patients in the control cohort. One hundred and eleven patients (85%) were admitted to the IP cohort. Patient characteristics were similar, except for a higher percentage of surgical patients utilizing private insurance and younger in age. Interestingly, no difference in hospital LOS (3.8 vs 4.7 days; P = 0.07), direct cost ($2639.44 vs $3251.52; P = .19), or overall cost ($5968.67 vs $6404.08, P = .61) was found between cohorts. Thirty-day readmission rates were comparable at 8% and 11% (P = .59). Institutional policy mandating admissions for patients receiving nonoperative management of diverticulitis to surgical services does not reduce hospital LOS or cost. This argues that admission to medical services may be an acceptable practice. This raises the question, is acute diverticulitis always a surgical issue?

General Anesthesia Leads to Increased Adverse Events Compared With Spinal Anesthesia in Patients Undergoing Unicompartmental Knee Arthroplasty

BackgroundThe volume of unicompartmental knee arthroplasty (UKA) has increased dramatically in recent years with good reported long-term outcomes. UKA can be performed under general or neuraxial (ie, spinal) anesthesia; however, little is known as to whether there is a difference in outcomes based on anesthesia type. The purpose of the present study is to compare perioperative outcomes between anesthesia types for patients undergoing primary elective UKA. MethodsPatients who underwent primary elective UKA from 2007 to 2017 were identified from the American College of Surgeons-National Surgical Quality Improvement Program Database. Operating room times, length of stay (LOS), 30-day adverse events, and readmission rates were compared between patients who received general anesthesia and those who received spinal anesthesia. Propensity-adjusted multivariate analysis was used to control for selection bias and baseline patient characteristics. ResultsA total of 8639 patients underwent UKA and met the inclusion criteria for this study. Of these, 4728 patients (54.7%) received general anesthesia and 3911 patients (45.3%) received spinal anesthesia. On propensity-adjusted multivariate analyses, general anesthesia was associated with increased operative time (P < .001) and the occurrence of any severe adverse event (odds ratio [OR], 1.39; 95% confidence interval [95% CI], 1.04-1.84; P = .024). In addition, general anesthesia was associated with higher rates of deep venous thrombosis (OR, 2.26; 95% CI, 1.11-4.6; P = .024) and superficial surgical site infection (OR, 1.04; 95% CI, 0.6-1.81; P < .001). Finally, general anesthesia was also associated with a reduced likelihood of discharge to home (OR, 0.72; 95% CI, 0.59-0.88; P < .001). No difference existed in postoperative hospital LOS or readmission rates among cohorts. ConclusionGeneral anesthesia was associated with an increased rate of adverse events and increased operating room times as well as a reduced likelihood of discharge to home. There was no difference in hospital LOS or postoperative readmission rates between anesthesia types.

A three-year retrospective multi-center study on time to surgery and mortality for isolated geriatric hip fractures

BackgroundThere are multiple reports on the effect of time to surgery for geriatric hip fractures; it remains unclear if earlier intervention is associated with improved mortality, hospital length of stay (HLOS), or cost. MethodsThis was a multi-center retrospective cohort study. Patients (≥65y.) admitted (1/14-1/16) to six level 1 trauma centers for isolated hip fractures were included. Patients were dichotomized into early (≤24 h of admission) or delayed surgery (>24 h). The primary outcome was mortality using the CDC National Death Index. Secondary outcomes included HLOS, complications, and hospital cost. ResultsThere were 1346 patients, 467 (35%) delayed and 879 (65%) early. The early group had more females (70% vs. 61%, p < 0.001) than the delayed group. The delayed group had a median of 2 comorbidities, whereas the early group had 1, p < 0.001. Mortality and complications were not significantly different between groups. After adjustment, the delayed group had no statistically significant increased risk of dying within one year, OR: 1.1 (95% CI:0.8, 1.5), compared to the early group. The average difference in HLOS was 1.1 days longer for the delayed group, when compared to the early group, p-diff<0.001, after adjustment. The average difference in cost for the delayed group was $2450 ($1550, $3400) more expensive per patient, than the early group, p < 0.001. ConclusionsThe results of this study provide further evidence that surgery within 24 h of admission is not associated with lower odds of death when compared to surgery after 24 h of admission, even after adjustment. However, a significant decrease in cost and HLOS was observed for early surgery. If causally linked, our data are 95% confident that earlier treatment could have saved a maximum of $1,587,800. Early surgery should not be pursued purely for the motivation of reducing hospital costs. Level of evidenceLevel III.

1400. Impact of a Multiplex Polymerase Chain Reaction Meningitis/Encephalitis Panel and Antimicrobial Stewardship Bundle on Antimicrobial Use in Patients with Suspected Meningitis or Encephalitis

BackgroundOptimal treatment of meningitis relies on prompt diagnostic evaluation and initiation of appropriate antimicrobials. The meningitis/encephalitis panel (MEP) is a multiplex rapid polymerase chain reaction, with the ability to detect 14 community-acquired pathogens in 1 hour. The purpose of this study was to evaluate impact of the MEP on de-escalation of antimicrobials in adult inpatients with suspected meningitis at a large community teaching hospital.MethodsThis single-center retrospective quasi-experimental pre/post study included adults admitted for ≥48 hours and initiated on antimicrobial therapy for suspected meningitis. Those with healthcare-associated meningitis, immunosuppression, initiation of antimicrobials >8 hours prior to lumbar puncture (LP), and use of antimicrobials for another indication were excluded. The pre-group included patients admitted prior to MEP introduction. The post-group included patients with the MEP performed. An antimicrobial stewardship bundle consisting of a meningitis order set, provider education, and use of a real-time meningitis alert in clinical decision support software was also implemented in the post-group. The primary outcome was percentage of patients experiencing antimicrobial de-escalation ≤48 hours after LP. Secondary outcomes included time to de-escalation, total duration of antimicrobial therapy (DOT), and hospital length of stay (LOS).ResultsA total of 45 patients were included in the study (23 pre-group and 22 post-group). Baseline characteristics were similar between groups. The percentage of patients experiencing de-escalation of antimicrobials ≤ 48 hours after LP increased by 44% in the post-group (82% vs. 38%, P = 0.005). The overall median time to de-escalation of antimicrobials decreased by 35 hours [11.1 (IQR 5.6, 17.6) vs. 46.1 (IQR 18.4, 66.5); P = 0.002] and the median time to de-escalation after LP decreased by 38 hours [13.6 (IQR 8.3, 20.3) vs. 51.6 (IQR 44.2, 69.8); P < 0.001]. No statistically significant difference in hospital LOS or total DOT was seen.ConclusionImplementation of the MEP and antimicrobial stewardship bundle increased the percentage of patients de-escalated in 48 hours and decreased the time to de-escalation. However, this did not impact the total DOT or hospital LOS.Disclosures All authors: No reported disclosures.

Elevated Troponin: A Marker for Noncardiac Complications After Resection of Head and Neck Cancers.

To examine if troponin positivity (TP) in patients who undergo head and neck cancer mucosal resections (HNS) predicts noncardiac complications (NCC). Major HNSs are arduous operations that place stress on the patient's hemodynamic system. TP after noncardiac surgery previously has been shown in up to 25% of patients, which may signal cardiac complications (CC) or NCC. Although CC after HNS has been observed, no study has investigated the relationship of TP to NCC. All patients who underwent HNS at a tertiary-care cancer center from July 2014 to July 2016 were included and underwent postoperative troponin measurements as part of an institutional cardiac protocol. Comparative and multivariate regression analysis were used to compare TP and troponin-negative (TN) patients for NCC. One hundred seventy-two patients underwent HNS. Of those, 15% developed TP during the postoperative period. There was no significant difference between TP and TN for gender, tumor-node-metastasis staging, Charlson comorbidity index, and smoking status. Risk of NCC in TP was 73.1% versus 28.1% in TN (P < 0.001). A significant difference (P < 0.05) in wound complications, length of hospital stay (LOHS), and incidence of pneumonia was found between both groups. Nonparametric testing confirmed significant difference in pneumonia (Z = -3.469, P = 0.001) and LOHS (-3.110, P = 0.002). Multivariate regression analysis confirmed a significant difference in LOHS independent of CC (R2 = 0.122, P < 0.0001). TP is not an uncommon occurrence after HNS and is associated with statistically significant increases in wound complications, LOHS, and pneumonia. However, the overall significance of these findings remains unclear, and further research is warranted to determine if outcomes may be improved by closely monitoring these patients for TP. 4 Laryngoscope, 130:2148-2152, 2020.

The effect of supplementation of vitamin D in neurocritical care patients: RandomizEd Clinical TrIal oF hYpovitaminosis D (RECTIFY).

Hypovitaminosis D is prevalent in neurocritical care patients, but the potential to improve patient outcome by replenishing vitamin D has not been investigated. This single-center, double-blinded, placebo-controlled, randomized (1:1) clinical trial was designed to assess the effect on patient outcome of vitamin D supplementation in neurocritical care patients with hypovitaminosis D. From October 2016 until April 2018, emergently admitted neurocritical care patients with vitamin D deficiency (≤ 20 ng/ml) were randomized to receive vitamin D3 (cholecalciferol, 540,000 IU) (n = 134) or placebo (n = 133). Hospital length of stay (LOS) was the primary outcome; secondary outcomes included intensive care unit (ICU) LOS, repeat vitamin D levels, patient complications, and patient disposition. Exploratory analysis evaluated specific subgroups of patients by LOS, Glasgow Coma Scale (GCS) score, and Simplified Acute Physiology Score (SAPS II). Two-hundred seventy-four patients were randomized (intent-to-treat) and 267 were administered treatment within 48 hours of admission (as-treated; 61.2% of planned recruitment) and monitored. The mean age of as-treated patients was 54.0 ± 17.2 years (56.9% male, 77.2% white). After interim analysis suggested a low conditional power for outcome difference (predictive power 0.12), the trial was halted. For as-treated patients, no significant difference in hospital LOS (10.4 ± 14.5 days vs 9.1 ± 7.9 days, p = 0.4; mean difference 1.3, 95% CI -1.5 to 4.1) or ICU LOS (5.8 ± 7.5 days vs 5.4 ± 6.4 days, p = 0.4; mean difference 0.4, 95% CI -1.3 to 2.1) was seen between vitamin D3 and placebo groups, respectively. Vitamin D3 supplementation significantly improved repeat serum levels compared with placebo (20.8 ± 9.3 ng/ml vs 12.8 ± 4.8 ng/ml, p < 0.001) without adverse side effects. No subgroups were identified by exclusion of LOS outliers or segregation by GCS score, SAPS II, or severe vitamin D deficiency (≤ 10 ng/ml). Despite studies showing that vitamin D can predict prognosis, supplementation in vitamin D-deficient neurocritical care patients did not result in appreciable improvement in outcomes and likely does not play a role in acute clinical recovery.Clinical trial registration no.: NCT02881957 (clinicaltrials.gov).