Difference In Hospital Length Of Stay Research Articles

Pulmonary Embolism Response Teams-Evidence of Benefits? A Systematic Review and Meta-Analysis.

Background: Venous thromboembolisms constitute a major cause of morbidity and mortality with 60,000 to 100,000 deaths attributed to pulmonary embolism in the US annually. Both clinical presentations and treatment strategies can vary greatly, and the selection of an appropriate therapeutic strategy is often provider specific. A pulmonary embolism response team (PERT) offers a multidisciplinary approach to clinical decision making and the management of high-risk pulmonary emboli. There is insufficient data on the effect of PERT programs on clinical outcomes. Methods: We searched PubMed, Scopus, Web of Science, and Cochrane to identify PERT studies through March 2024. The primary outcome was all-cause mortality, and the secondary outcomes included the rates of surgical thrombectomy, catheter directed thrombolysis, hospital length of stay (HLOS), and ICU length of stay (ICULOS). We used the Newcastle-Ottawa Scale tool to assess studies' quality. We used random-effects models to compare outcomes between the pooled populations and moderator analysis to identify sources of heterogeneity and perform subgroup analysis. Results: We included 13 observational studies, which comprised a total of 12,586 patients, 7512 (60%) patients were from the pre-PERT period and 5065 (40%) patients were from the PERT period. Twelve studies reported the rate of all-cause mortality for their patient population. Patients in the PERT period were associated with similar odds of all-cause mortality as patients in the pre-PERT period (OR: 1.52; 95% CI: 0.80-2.89; p = 0.20). In the random-effects meta-analysis, there was no significant difference in ICULOS between PERT and pre-PERT patients (difference in means: 0.08; 95% CI: -0.32 to 0.49; p = 0.68). There was no statistically significant difference in HLOS between the two groups (difference in means: -0.82; 95% CI: -2.86 to 1.23; p = 0.43). Conclusions: This meta-analysis demonstrates no significant difference in all studied measures in the pre- and post-PERT time periods, which notably included patient mortality and length of stay. Further study into the details of the PERT system at institutions reporting mortality benefits may reveal practice differences that explain the outcome discrepancy and could help optimize PERT implementation at other institutions.

6431 Comparison of Diagnostic Scoring Systems for Myxedema Coma

Abstract Disclosure: K.S. Wei: None. A. Joyo: None. A.N. Lim: None. T.E. Angell: None. Introduction: Myxedema coma (MC) is a rare condition of severe hypothyroidism with high mortality. Diagnostic scoring systems exist, such as criteria by Popoveniuc et al. (2014) and Chiong et al. (2015), which both include categories of: “highly likely MC” (hlMC), “suggestive of MC” (sMC), and “unlikely MC” (uMC). Because few data support their clinical utility, we performed an analysis comparing these diagnostic criteria and associations with mortality and hospital measures. Methods: Patients with MC were included from a retrospective cohort of hospitalized adult patients with TSH greater than or equal to 10 mIU/L and free thyroxine (fT4) below the lower reference limit. Initial clinical diagnosis of MC was generally based on: hypothyroidism, precipitating illness, hypothermia, and altered mentation. Data collection included patient characteristics, mortality, ICU admission, and hospital length of stay (LOS). Patients were post-hoc categorized based on criteria of Popoveniuc and Chiong. Results: Of 386 initial patients, 25 patients had a clinical diagnosis of MC (median age = 60.1 years [IQR: 53.6-70.0]; 10/25 [40%] female). Median TSH was 58 mIU/L (IQR: 33.8-93.3) and median fT4 was 0.48 ng/dL (IQR: 0.16-0.68). All patients received IV levothyroxine and supportive care. Using Popoveniuc, 20/25 (80%) patients were hlMC and 5/25 (20%) were sMC. In contrast, using Chiong, 11/25 (44%) were hlMC, while 14/25 (56%) were sMC. No patient was considered uMC by either system. 10/25 (40%) patients were hlMC in both systems. 10/25 (40%) were hlMC in Popoveniuc but not Chiong, while only 1/25 (4%) was hlMC in Chiong but not Popoveniuc. Finally, 4/25 (16%) were not hlMC in either system. Mortality occurred in 3/25 (12%) patients, 2 of which were hlMC in Popoveniuc but not Chiong. There was a trend toward longer median hospital LOS in patients identified as hlMC vs not hlMC using Popoveniuc (11 days [IQR: 5.3-37.0] vs. 3.0 days [IQR: 2.0-17.5], p=0.07) but no statistically significant differences in hospital LOS were noted. There were no significant differences in ICU admission or LOS. Conclusion: Existing diagnostic scoring criteria of MC identified most patients but differed in their categorizations. Some cases of clinically diagnosed MC were not identified as hlMC by either scoring criteria. Criteria by Popoveniuc et al. appears to better capture patients most at risk for mortality and prolonged hospitalization. Presentation: 6/2/2024

Reducing Hospital Length of Stay and Hepatic Artery Thrombosis Rates for Children Receiving a Liver Transplant: A Single-Center Experience From 2000 to 2021.

Pediatric liver transplantation is a very resource-intensive therapy. This study aimed to identify the changes made between two epochs of management and analyze their influence on length of stay (LOS). Data from a single center were obtained from the liver transplant and Pediatric Intensive Care Unit (PICU) databases for 336 transplants (282 children) performed between 2000 and 2021. Transplants were analyzed in two epochs, before and after July 2012, representing a change in postoperative anticoagulation management. Differences in graft recipient demographics and perioperative management factors were compared between epochs. Multivariate regression was performed to identify the complications that correlated most strongly with hospital LOS. There was a difference in hospital LOS between Epoch 1 (Median = 31.7 days) and Epoch 2 (Median = 26.3 days) (p < 0.001), but not in PICU LOS (E1 Median = 7.3 days, E2 Median = 7.4 days; p = 0.792). Epoch 2 saw increased use of split grafts (60.6% of total), decreased pediatric end-stage liver disease (PELD) score at transplant (Average = 16.7; p < 0.001), decreased invasive ventilation time (Average = 4.48 days; p < 0.001), and decreased hepatic artery thrombosis (HAT) rates (E1 = 14.4%, E2 = 4.3%; p < 0.001) without an associated increase in bleeding rates. Hospital LOS has reduced in Epoch 2 due to refinements in intraoperative and postoperative management. There is increased emphasis on early extubation and increased use of noninvasive ventilatory techniques in Epoch 2. Split grafts have effectively expanded our graft donor pool and reduced transplant waitlist times.

Efficacy and Safety of Azvudine in Patients With COVID-19 in China: A Meta-Analysis of Observational Studies.

Azvudine (FNC) is a novel small molecule antiviral drug for treating COVID-19 that is available only on the Chinese market. Despite being recommended for treating COVID-19 by the Chinese guidelines, its efficacy and safety are still unclear. This study aimed to evaluate the protective effect of FNC on COVID-19 outcomes and its safety. We followed the PRISMA 2020 guidelines and searched the PubMed, Embase, Web of Science, Scopus, and China National Knowledge Infrastructure (CNKI) databases to evaluate studies on the effectiveness of FNC in treating COVID-19 in China, focusing on mortality and overall outcomes. Additionally, its impact on the length of hospital stay (LOHS), time to first nucleic acid negative conversion (T-FNANC), and adverse events was evaluated. The inclusion criterion was that the studies were published from July 2021 to April 10, 2024. This study uses the ROBINS-I tool to assess bias risk and employs the GRADE approach to evaluate the certainty of the evidence. The meta-analysis included 24 retrospective studies involving a total of 11 830 patients. Low-certainty evidence revealed no significant difference in mortality (OR = 0.91, 95% CI: 0.76-1.08) or LOHS (WMD = -0.24, 95% CI: -0.83 to 0.35) between FNC and Paxlovid in COVID-19 patients. Low-certainty evidence shows that the T-FNANC was longer (WMD = 1.95, 95% CI: 0.36-3.53). Compared with the Paxlovid group, low-certainty evidence shows the FNC group exhibited a worse composite outcome (OR = 0.77, 95% CI: 0.63-0.95) and fewer adverse events (OR = 0.63, 95% CI: 0.46-0.85). Compared with supportive treatment, low certainty shows FNC significantly reduced the mortality rate in COVID-19 patients (OR = 0.61, 95% CI: 0.51-0.74) and decreased the composite outcome (OR = 0.67, 95% CI: 0.50-0.91), and very low certainty evidence shows significantly decreased the T-FNANC (WMD = -4.62, 95% CI: -8.08 to -1.15). However, in very low certainty, there was no significant difference in LOHS (WMD = -0.70, 95% CI: -3.32 to 1.91) or adverse events (OR = 1.97, 95% CI: 0.48-8.17). FNC appears to be a safe and potentially effective treatment for COVID-19 in China, but further research with larger, high-quality studies is necessary to confirm these findings. Due to the certainty of the evidence and the specific context of the studies conducted in China, caution should be exercised when considering whether the results are applicable worldwide. PROSPERO number: CRD42024520565.

Standardized In-Bed Mobility Protocol to Increase Functional Outcomes in Pediatric Intensive Care Unit: A Pilot Randomized Controlled Trial

AbstractThe primary aim of this study is to determine whether a standardized in-bed mobility protocol involving an in-bed cycle ergometer in critically ill children increases functional outcomes as measured by the Functional Status Scale (FSS) and dynamometer measurements compared with patients participating in standard rehabilitation care. The secondary aim was to compare hospital length of stay (HLOS) between the two groups. This pilot randomized controlled trial (RCT) was conducted between April 2021 and December 2022. Eligible patients were randomized to the intervention group (up to 30 minutes of daily in-bed cycle ergometer use) or the control group (standardized rehabilitation care). During the study duration, 30 patients were randomized (13 in the control group and 17 in the intervention group). The difference in whole-body muscle strength measurements (enrollment vs. completion of study) was higher in the experimental group (3.68 lbs.) compared with the control group (1.5 lbs.). However, the difference between groups was not statistically significant (p = 0.18). Both the intervention group and the control group showed similar significant improvements in the FSS scores throughout the therapy, with no difference between the two groups. There was a significant positive correlation between exercise time and change in muscle strength (r = 0.75, p = 0.002). No difference in HLOS was detected in the study. Results from this pilot RCT suggest a trend toward benefits from using in-bed cycle ergometers. These devices may be an additional modality for preserving muscle function in critically ill children. Larger multicentric studies are needed for more conclusive evidence.

Body Mass Index, Sex, and Age Are Predictors of Discharge to a Post-acute Care Facility Following Total Ankle Arthroplasty.

The utilization of total ankle arthroplasty (TAA) continues to increase. Discharge to a post-acute care (PAC) facility can increase patient morbidity and postoperative costs. The purpose of this study is to investigate the effects of age and body mass index (BMI) on discharge to a PAC facility and hospital length of stay (LOS) following TAA. A retrospective review of patients who underwent TAA from the National Surgical Quality Improvement Program (NSQIP) database was performed. Using overweight patients as the reference BMI group, sex- and age-adjusted log-binomial regression models were utilized to estimate risk ratios of BMI categories for being discharged to a PAC facility. A linear regression was utilized to estimate the effect of BMI category on hospital LOS. Obese patients had 1.36 times the risk of overweight patients (P = .040), and morbidly obese patients had 2 times risk of overweight patients (P = .001) of being discharged to a PAC facility after TAA. Men had 0.48 times the risk of women (P < .001). Compared with patients aged 18 to 44 years, patients aged ≥65 years had 4.13 times the risk (P = .012) of being discharged to a PAC facility after TAA. Relative to overweight patients, on average there was no difference in hospital LOS for underweight patients, but healthy weight patients stayed an additional 0.30 days (P=.003), obese patients stayed an additional 0.18 days (P = .011), and morbidly obese patients stayed an additional 0.33 days (P = .009). Men stayed 0.29 fewer hospital days than women (P < .001) on average. Women and patients who are obese or morbidly obese have a longer hospital LOS and an increased chance of being discharged to a PAC facility. Increasing age is also associated with an increased risk of being discharged to a PAC. These may be important factors when developing and discussing the postoperative plan with patients prior to TAA. Level III.

Clinical Outcomes of Protocolized Antibiotic Dosing in Critically Ill Surgical Patients With Bacteremia and Augmented Renal Clearance Compared With Critically Ill Surgical Patients Without Augmented Renal Clearance.

Background: Augmented renal clearance (ARC) is a phenomenon observed in critically ill patients, leading to supraphysiologic drug clearance and concern for suboptimal antibiotic concentrations. The purpose of this study was to compare the clinical outcomes of our institutional protocolized antibiotic dosing regimen in critically ill patients with bacteremia and ARC compared with critically ill patients without ARC. Patients and Methods: We performed a retrospective study comparing the efficacy of an institutional protocolized antibiotic dosing regimen in critically ill patients with bacteremia and ARC compared with critically ill patients without ARC. The primary end point was in-hospital mortality. Secondary outcomes were intensive care unit (ICU) mortality, days requiring mechanical ventilation, ICU length of stay (LOS), hospital LOS, development of drug resistance to index antibiotic agent, and documented clearance of blood cultures within 72 hours. Results: There were 75 patients included in this study. Twenty percent of patients in the ARC group died in the hospital versus 31% in the non-ARC group (p = 0.26). The results for the ARC group versus the non-ARC group for the secondary outcomes of ICU mortality (20% vs. 26%; p = 0.56), ICU LOS (14.7 days vs. 7 days; p = 0.07), hospital LOS (28.3 days vs. 21.6 days; p = 0.03), days requiring mechanical ventilation (14 days vs. 12 days; p = 0.49), duration of antibiotic therapy (7.5 days vs. 9.0 days; p = 0.39), documented clearance of blood cultures within 72 hours (41% vs. 33%; p = 0.56), and the development of drug resistance to the index antibiotic agent (0% vs. 0%; p > 0.99) were also calculated. Conclusions: Among critically ill patients with bacteremia and ARC, there was no difference in in-hospital mortality compared with critically ill patients without ARC. There was a difference in hospital LOS, with a shorter duration of stay for the non-ARC group. There was no development of multi-drug-resistant organisms in either group.

Tranexamic Acid in Hip Reconstructions in Children with Cerebral Palsy: A Double-Blind Randomized Controlled Clinical Trial.

Surgical treatment is indicated for hip dislocation in patients with cerebral palsy (CP), but it requires care due to the state of nutrition and associated clinical comorbidities. The use of resources that minimize blood loss and the need for blood transfusions are essential to avoid complications. Tranexamic acid (TXA) has been highlighted for orthopedic surgeries to control intraoperative bleeding; however, there is a lack of large studies for its use in hip surgeries in patients with CP. This study aims to evaluate the efficacy and safety of tranexamic acid to reduce bleeding in pediatric patients with cerebral palsy undergoing surgical treatment for hip instability. A sample of 31 patients with CP who underwent surgical treatment for hip dislocation (hip adductor stretching, varization osteotomy of the proximal femur and acetabuloplasty using the Dega technique) was randomly divided into groups: control (n = 10) and TXA (n = 21). Preoperative and 24 h hemoglobin concentrations, the length of hospital stay (LHS), and intraoperative bleeding (IB) were analyzed. TXA significantly reduced the IB (p = 0.02). The variance in hemoglobin concentration was lower for the TXA group, but without statistical significance (p = 0.06). There was no difference in LHS. Also, no statistical difference was observed for the number of transfusions (p = 0.08). The findings provide evidence of the effectiveness of TXA in decreasing intraoperative bleeding and its safety for use in pediatric patients with cerebral palsy.

Does phenobarbital reduce the hospital length of stay for patients suffering from severe alcohol withdrawal? A retrospective comparison of phenobarbital to lorazepam infusions

IntroductionData suggest that phenobarbital is as effective as benzodiazepines at managing withdrawal via its direct activation of the gamma-aminobutyric acid receptor and modulating glutamate-mediated stimulation of the N-methyl-D-aspartate receptor. There are little data evaluating the effect of phenobarbital on severe withdrawal syndromes. ObjectiveThe purpose of this study was to evaluate the effect of phenobarbital compared with protocolized, symptom-driven, benzodiazepine administration on hospital length of stay (LOS) in patients experiencing severe withdrawal. MethodsThis is a retrospective chart review of patients evaluated in the emergency department for the treatment of severe alcohol withdrawal syndrome, defined as a Clinical Institute Withdrawal Assessment for Alcohol – Revised score of 20 or greater during their visit. The primary outcome measure was the difference in hospital LOS between those receiving phenobarbital and those receiving continuous lorazepam infusions. Secondary outcomes include intensive care unit (ICU) admission, ICU LOS, need for mechanical ventilation, and incidence of oversedation. ResultsIn all, 298 patients met inclusion, with 131 treated with phenobarbital and 167 initiated on a lorazepam infusion. Hospital LOS was found to be statistically significantly greater in the lorazepam infusion cohort (7.6 ± 5.3 vs. 5.2 ± 4.5 days, P < 0.001) than the phenobarbital cohort. Patients treated with lorazepam were found to have increased admissions to the ICU (risk ratio [RR] 1.79 [95% CI 1.27–2.92]) and higher rates of oversedation (RR 1.71 [95% CI 2.09–4.25]). There were no differences in ICU LOS and need for mechanical ventilation. ConclusionData from this study suggest that phenobarbital may be associated with a decrease in hospital LOS in severe alcohol withdrawal and should be considered as an alternative to benzodiazepine infusions in these patients.

Body Mass Index is a Predictor of Discharge to a Post-Acute Care Facility Following Total Ankle Arthroplasty

Category: Ankle Introduction/Purpose: The utilization of total ankle arthroplasty (TAA) continues to increase, and identifying preoperative factors that influence postoperative outcomes after TAA may be valuable. The use of post-acute care (PAC) facilities has also grown substantially, and discharge to a PAC facility can increase patient morbidity and postoperative costs. The purpose of this study is to define the effect of BMI on discharge to a PAC facility and hospital length of stay (LOS) following TAA. Methods: We performed a retrospective review to identify a large cohort of adult patients who underwent TAA between 2006 - 2020 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Using overweight patients as the reference BMI group, we estimated a sex- and age- adjusted log-binomial regression model on BMI categories to estimate risk ratios to analyze the association between BMI and risk of being discharged to a PAC facility and/or hospital LOS. Results: Relative to overweight patients, obese patients had 1.47 times the risk (P=0.008), and morbidly obese patients had 2.26 times risk (P &lt; 0.001) of being discharged to a PAC facility after TAA. Males had 0.47 times the risk of females (P &lt; 0.001), and for each year older, patients had 1.07 times the risk (P &lt; 0.001) of being discharged to a PAC facility. There was no difference in hospital LOS for underweight patients, but healthy weight patients stayed an additional 0.29 days (P=0.004), obese patients stayed an additional 0.18 days (P=0.010), and morbidly obese patients stayed an additional 0.34 days (P=0.006). Males stayed 0.30 fewer hospital days than females (P &lt; 0.001), and for each year older, patients stayed 0.011 days longer (P &lt; 0.001). Conclusion: This study found that women and patients who are obese and morbidly obese have a greater LOS and chance to be discharged to a PAC facility. Increasing age is also associated with an increase in LOS and discharge to a PAC. These may be important factors when discussing the postoperative plan with patients prior to TAA.

A209 ASSESSMENT OF OUTCOMES OF PATIENTS ADMITTED WITH ACUTE, SEVERE ULCERATIVE COLITIS ON ESTABLISHED BIOLOGIC THERAPY: A SINGLE CENTRE RETROSPECTIVE ANALYSIS

Abstract Background Acute, severe, ulcerative colitis (ASUC) is associated with a high morbidity and mortality. Current guidelines recommend the initiation of high dose intravenous steroids, followed by anti-TNF therapy if a satisfactory therapeutic response is not rapidly achieved. However, guidelines are agnostic on how to manage patients who are admitted for ASUC despite being on established biologic therapy. Furthermore, short-term clinical outcomes in this population are not well characterized. Purpose The aim of this study is to assess the differences in short-term clinical outcomes in patients admitted with ASUC who are on established biologic therapy compared to those not on established biologic therapy. Method We conducted a retrospective chart review of patients admitted with ASUC to Mount Sinai Hospital (MSH) in Toronto, Ontario from January 2018 until December 2021. Patients were included if they were deemed to have a severe flare, defined as having 6 or more loose bowel movements per day with at least one of the following features: temperature of 38.0 Celsius, tachycardia, anemia, or elevated inflammatory markers. Included subjects were considered to be on established biologic therapy if they had a biologic within 56 days prior to admission, all other admitted subjects were included as controls. Our primary outcome was the difference in hospital length of stay (HLOS). We also contrasted duration of intravenous steroids, rates of surgical consultation, rates of in-hospital colectomy, and readmission rates within 90 days of discharge. Result(s) 130 charts were included in our study, 53 of which were patients on established biologic therapy, and 77 of which were patients not on established biologic therapy. The HLOS between the two groups was not significantly different, (7.23 days [established biologic therapy] vs.7.47 days [not on biologic therapy], p value = 0.77). Patients on established biologic therapy were more likely to receive an inpatient surgical consultation (33.96% vs 7.79%, p-value &amp;lt;0.001). However, rates of colectomy prior to discharge were not statistically different (1.89% vs 0%, p-value = 0.23). Patients on established biologic therapy were significantly more likely to be readmitted within 90 days of discharge (30.19% vs 12.99%, p-value = 0.016). Image Conclusion(s) Although there were no differences in HLOS and colectomy rates between the 2 groups, patients with ASUC on established biologic therapy were more likely to be readmitted within 3 months of discharge. Further work is required to define optimal medical management of persons admitted with ASUC who are failing biologic therapies. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

The Burden of Cerebral Venous Thrombosis in a Romanian Population across a 5-Year Period.

Health policies in transitioning health systems are rarely informed by the social burden and the incidence shifts in disease epidemiology. Cerebral venous thrombosis (CVT) is a type of stroke more often affecting younger adults and women, with higher incidences being reported in recent studies. A retrospective, hospital-based population study was conducted at Cluj-Napoca Emergency County Hospital across a 5-year period between 2017 and 2021. The overall incidence and the rates in distinctive gender and age groups were assessed. Length of hospital stay (LHS), modified Rankin score (mRS) and mortality at discharge and at 3 months were calculated. Fifty-three patients were included. The median age was 45 years, and 64.2% were women. In our population of 3,043,998 person-years, 53 CVT cases resulted in an incidence of 1.74 per 100,000 (95% CI 1.30-2.27). CVT incidence was higher in women (2.13 per 100,000, 95% CI 1.47-2.07). There was a statistically significant difference in LHS between patients with different intracranial complications (Kruskal-Wallis, p = 0.008). The discharge mRS correlated with increasing age (rs = 0.334, p = 0.015), transient risk factors (Fisher's exact test, p = 0.023) and intracranial complications (Fisher's exact test, p = 0.022). In addition, the mRS at 3 months was statistically associated with increasing age (rs = 0.372, p = 0.006) and transient risk factors (Fisher's exact test, p = 0.012). In-hospital mortality was 5.7%, and mortality at follow up was 7.5%, with higher rates in women (5.9% and 8.8%, respectively). Our findings may provide insight regarding the epidemiological features of certain patient groups more prone to developing CVT and its complications, informing local and central stakeholders' efforts to improve standards of care.

Impact of CSF Meningitis and Encephalitis Panel on Resource Use for Febrile Well-Appearing Infants.

To determine whether the BioFire FilmArray Meningitis/Encephalitis (ME) panel is associated with decreased resource use for febrile infants. The ME panel has a rapid turnaround time (1-2 hours) and may shorten length of stay (LOS) and antimicrobial use for febrile well-appearing infants. Retrospective cohort study of febrile well-appearing infants ≤60 days with cerebrospinal fluid culture sent in the emergency department from July 2017 to April 2019. We examined the frequency of ME panel use and its relationship with hospital LOS and initiation and duration of antibiotics and acyclovir. We used nonparametric tests to compare median durations. The ME panel was performed for 85 (36%) of 237 infants. There was no difference in median hospital LOS for infants with versus without ME panel testing (42 hours, interquartile range [IQR] 36-52 vs 40 hours, IQR: 35-47, P = .09). More than 97% of infants with and without ME panel testing were initiated on antibiotics. Patients with ME panel were more likely to receive acyclovir (33% vs 18%; odds ratio: 2.2, 95%: confidence interval 1.2-4.0). There was no difference in median acyclovir duration with or without ME panel testing (1 hour, IQR: 1-7 vs 4.2 hours, IQR: 1-21, P = .10). When adjusting for potential covariates, these findings persisted. ME panel use was not associated with differences in hospital LOS, antibiotic initiation, or acyclovir duration in febrile well-appearing infants. ME panel testing was associated with acyclovir initiation.

S690 “Does the Early Bird Catch the Worm?” Prognostic Value of Early Endoscopic Intervention in GI Bleed Patients

Introduction: Early endoscopic intervention (within 6 hours of admission) in patients with gastrointestinal bleeding (GIB) increases overall mortality but does not improve the mortality, length of stay (LOS), or transfusion requirement in lower GIB, while reducing the LOS in upper GIB. We aimed to study the prognosis of patients undergoing endoscopic intervention in < 1 day compared to ≥ 1 day. Methods: This is a single-center retrospective cohort analysis of patients admitted to Intermediate unit and ICU with GIB as their primary diagnosis (03/2015 – 03/2021). Medical records of patients above 18 years of age were reviewed for baseline characteristics and lab values. Charlson comorbidity index (CCI), Glasgow Blatchford Score (GBS), AIMS 65, ABC, quick Sequential Organ Failure Assessment (qSOFA) scores on admission were calculated. Patients were compared according to time to scope i.e., < 1 day vs. ≥ 1 day. Outcome variables assessed included hospital LOS, 30-day mortality, and 90-day readmission rate. Pearson Chi-square and Mann Whitney U were applied to compare groups. Results: Out of 212 patients admitted with GIB, 196 (92.5%) underwent endoscopic intervention in ≥ 1 day and 16 (7.5%) within 1 day. Baseline characteristics are illustrated in (Table). Patients scoped ≥ 1 day had higher PRBCs transfused (median 3 vs. 2; p< 0.01) and less frequently received antibiotics (15.3% vs. 37.5%, p< 0.01). None of the scores (GBS, AIM-65, qSOFA, CCI, and ABC) were significantly different between two groups (p-value >0.05). Median (interquartile range (IQR)) of the scores according to time to scope i.e., < 1 day vs. ≥ 1 day is as follows: 14.5 (8.3,15.8) vs. 12.0 (9.0, 14.0); AIM-65: 1.0(0.0, 1.0) vs. 1.0(1.0,2.0); qSOFA: 0.5 (0.0,1.0) vs. 0.0(0.0,1.0); CCI: 4.5(1.5,6.8) vs. 5.0(3.0,6.0); ABC: 0.0(0.0,1.0) vs. 0.0(0.0,0.0). There was no significant difference in hospital LOS and 30-day mortality. However, 90-day readmission rate were higher in patients who underwent endoscopic intervention < 1 day (p=0.04). Conclusion: Comparable risk stratification scores indirectly indicate equivalent severity of GIB between the two groups on presentation. According to our study, early endoscopic intervention does not significantly impact the LOS and 30-day mortality, but increases 90-day readmission rates. Further studies, primarily a prospective analysis, should be pursued to determine whether early endoscopic intervention should be avoided in certain scenarios. Table 1. - Illustrating the comparison of baseline characteristics, medical history, end organ damage (troponin leak and AKI), management, hospital length of stay, 30-day mortality, and 90-day readmission rates, between the patients who underwent endoscopic intervention in less than one day compared to one or more day Time to scope Less than 1 day (n =16) Equal to or greater than 1 day (n=196) p-value Age, mean ± SD (median, IQR) 61.19 ±13.01(57.00,52.50-74.25) 66.80±15.12 (67.50, 56.00-78.00) ns Gender Male 8 (50.0%) 113(57.6%) ns Female 8 (50.0%) 83(42.4%) Race Caucasian 10(62.4%) 126 (64.3%) Black 4(25.0%) 28(14.3%) ns Hispanic 1(6.3%) 27(13.7%) Other including data unavailable 1(6.3%) 15(7.7%) History of HTN 7 (43.8%) 123 (63.1%) ns History of DM 4 (25.0%) 49 (25.0%) ns History of CAD 3 (18.8%) 128 (65.3%) ns History of HF 1(6.2%) 52(26.5%) ns History of CKD 4(25.0%) 49(25.0%) ns History of Liver disease 5(31.3%) 33 (16.9%) ns History of DVT/PE 0 (0.0%) 22 (11.2%) ns History of atrial fibrillation 1(6.2%) 49(25.0%) ns Personal history of GI tract cancer 1 (6.3%) 16 (8.2%) ns Family history of GI tract cancer 0 (0.0%) 10 (5.3%) ns Use of NSAIDs 1(6.2%) 27(14.1%) ns Use of anticoagulants 1 (16.3%) 69 (35.6%) < 0.05 Use of antiplatelets 0(0.0%) 68(35.1%) < 0.01 Use of PPI at home 5(31.3%) 64(33.3%) ns History of smoking 7 (46.6%) 88 (46.1%) ns History of alcohol 9 (60%) 81 (42.4%) ns History of drug use 0 (0.0%) 8 (4.3%) ns NSTEMI/STEMI 0(0.0%) 15(2.6%) ns AKI 3 (18.8%) 62 (31.6%) ns Antibiotics 6 (37.5%) 30 (15.3%) < 0.01 PRBc transfused: Median (IQR) 2(1,3) 3(2,4) < 0.01 No. of patients intubated 2(12.5%) 13(6.63%) ns No. of patients ICU 7(43.7%) 15(7.7%) ns IU 9(56.3%) 80(92.3%) Source of GI Bleed Upper 13(81.2%) 131(77.9%) Lower 0 (0.0%) 31(18.4%) ns Both 3 (18.8%) 6(3.6%) Hospital length of stay, mean ± SD (median, IQR) 5.63 ± 4.47(4.00,3.00-7.00) 6.34 ±4.20(5.00,4.00-8.00) ns Alive at 30 days 15 (93.7%) 174(88.8%) ns 90-day readmission due to GI Bleed 7 (43.8%) 41 (21.4%) 0.04 HTN – Hypertension; DM – Diabetes mellitus; CAD – Coronary artery disease; HF – Heart Failure; CKD – Chronic Kidney Disease; DVT – Deep venous thrombosis; PE – Pulmonary embolism; AF – Atrial Fibrillation; NSAIDs – Non steroidal anti-inflammatory drugs; PPI – Proton Pump Inhibitors; AKI – Acute Kidney Injury; PRBC – Packed Red Blood Cells; ICU – Intensive care unit; IU – Intermediate unit.

Pharmacist involvement with antiepileptic therapy for status epilepticus in the emergency department

BackgroundDespite there being an estimated 50,000–150,000 emergency department (ED) visits per year related to status epilepticus, there are limited data regarding pharmacist involvement in patient care. The purpose of this study was to evaluate differences in time to antiepileptic drug (AED) administration and appropriate AED use and dose when a pharmacist was present or not. MethodsRetrospective, single-center, observational study of adult status epilepticus patients presenting to the ED between January 2018 through July 2020. The primary outcome was time to AED administration. Secondary outcomes included occurrence of appropriate AED selection and dose, escalation of care, length of stay (LOS), and 30-day mortality. Wilcoxon rank-sum was used for continuous variables and nominal data was analyzed by Chi-square or Fisher's Exact test, as appropriate. ResultsTwenty patients were included; 13 in the pharmacist-present and seven patients in the no-pharmacist-present groups. Median time to first and second AED was 26 min (IQR 17–177) versus 37 min (IQR 21–206), p = 0.58, and 51 min (IQR 30–221) versus 171 min (IQR 99–433), p = 0.07, in the pharmacist-present and no-pharmacist-present groups, respectively. Although there was no difference between groups for appropriate AED selection, those in the pharmacist-present group received a higher median dose of lorazepam equivalents (2.5 mg [IQR 2–4] vs 2 mg [IQR 2–2]; p = 0.04) and were more likely to receive at least 4 mg of lorazepam equivalents (38% vs 0%; p = 0.11). There were no differences in hospital LOS or 30-day mortality. ConclusionPharmacist presence during status epilepticus patient management was associated with a clinically significant reduction in time to administration of AEDs. Medication doses were more guideline adherent and more patients received a lorazepam dose of at least 4 mg compared to when a pharmacist was not present.

Outcomes of Cytomegalovirus Viremia Treatment in Critically Ill Patients With COVID-19 Infection.

BackgroundPatients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU) have poor outcomes and frequently develop comorbid conditions, including cytomegalovirus (CMV) reactivation. The implications of CMV reactivation in this setting are unknown. We aimed to investigate if treatment of CMV viremia improved in-hospital mortality in ICU patients with COVID-19.MethodsIn this single-center retrospective study, we analyzed clinical outcomes in patients diagnosed with COVID-19 pneumonia and CMV viremia admitted to an ICU from March 1, 2020, to April 30, 2021, who either received treatment (ganciclovir and/or valganciclovir) or received no treatment. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were total hospital length of stay (LOS), ICU LOS, requirement for extracorporeal membrane oxygenation (ECMO) support, duration of mechanical ventilation (MV), and predictors of in-hospital mortality.ResultsA total of 80 patients were included, 43 patients in the treatment group and 37 in the control group. Baseline characteristics were similar in both groups. CMV-treated patients were more likely to test positive for CMV earlier in their course, more likely to be on ECMO, and received higher total steroid doses on average. In-hospital mortality was similar between the 2 groups (37.2% vs 43.2.0%; P = .749). There was no significant difference in hospital LOS, though CMV-treated patients had a longer ICU LOS.ConclusionsTreatment of CMV viremia did not decrease in-hospital mortality in ICU patients with COVID-19, but the sample size was limited. CMV viremia was significantly associated with total steroid dose received and longer ICU stay.

Improving nutrition practices for postoperative high-risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre- and post-protocol intervention outcome study.

Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra- and postoperative complications requiring high-dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high-risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High-Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant. We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre- and post-intervention groups. Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line-associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90-day and 1-year mortality (P = 0.56, P = 0.35). This single-center, QI pre- and post-protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.

Topical hemostatic application on staple line in laparoscopic sleeve gastrectomy: a single-surgeon experience.

Laparoscopic sleeve gastrectomy (LSG) is a common bariatric procedure with low complication rates. Several hemostatic agents have been used to reduce staple line bleeding, but its impact is unclear. The primary endpoint of this study was to compare the early (30-day) complications comparing oxidized regenerated cellulose (ORC) and fibrin sealant (FS) application on the staple line. The secondary endpoints were to compare the need for postoperative blood transfusion, postoperative blood work values of hemoglobin (Hb), white blood cell (WBC), C-reactive protein (CRP), drain output volume and hospital length of stay (LOS). A retrospective analysis of all patients who underwent LSG between January and October 2021 was performed. Subjects were divided into two groups according to the use of ORC versus FS on the staple line. Early postoperative complications, Hb level, WBC count, and drain output volume were compared between groups. A total number of 77 patients were included: 27 in the ORC-group and 50 in the FS-group. No major complication was recorded in both groups. There was no significant difference in the need for blood transfusion, Hb value, and drain output volume on postoperative day (POD) 1 and 2. There was a significantly higher WBC count in the ORC-group on POD 1 and 2. There was no difference in hospital LOS between the groups. The use of FS and ORC was associated with a comparable low rate of bleeding. ORC causes an increased WBC count postoperatively, but this showed no clinical relevance.

Abstract WP125: Methamphetamine Associated Psychosis In Acute Stroke

Introduction: Methamphetamine, an addictive stimulant, may lead to psychosis of which little is known about the impact in acute stroke. Despite its short half-life, we hypothesize that methamphetamine use in acute stroke is associated with the development of psychosis and extends hospital length of stay (LOS). Methods: Single-center retrospective analysis (2016-2019) of consecutive adult patients admitted for acute ischemic stroke, intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (SAH), and transient ischemic attack (TIA) with methamphetamine detected on urine drug screen and were compared to those who did not. Psychosis was defined as disturbed thoughts or perceptions with abnormal psychomotor behavior. Psychosis onset and duration, clinical characteristics, total hospitalization time and intensive care unit (ICU) LOS, as well as psychotic treatment interventions were documented. Results: 138 patients were admitted for acute cerebrovascular events (87 ischemic strokes, 40ICH, 7 SAH, 2 TIAs). 69 patients tested positive for methamphetamine (68% male; mean age 53(range 26-68)) and were compared to 69 who did not (65% male, mean age 64 (range 30-93).Despite no differences in having any psychiatric illness history, 25% (17/69) of methamphetamine users experienced psychosis compared to only 3% (2/69) who did not test positive (p &lt;0.0002). Although there was no statistical difference in hospital LOS (3.6 days in methamphetamine positive versus 2.9 days ( p =.113)), substance use abusers had significantly longer ICU stays (48 hours versus 24 hours; p =.006). NIHSS and ICH Scores were not statistically different between those who tested positive or negative for methamphetamine. Conclusions: Methamphetamine use is strongly associated with developing psychosis and when present, leads to longer ICU stay.

Does 3D Printing-Assisted Acetabular or Pelvic Fracture Surgery Shorten Hospitalization Durations among Older Adults?

Acetabular or anterior pelvic ring fractures are rare but extremely complicated and challenging injuries for orthopedic trauma surgeons. Three-dimensional (3D) printing technology is widely used in the management of these two fracture types for surgical benefits. Our study aimed to explore whether 3D printing-assisted acetabular or pelvic surgery is beneficial in terms of shortening the length of hospital stay (LHS) and intensive care unit (ICU) stay (ICU LS) for older patients. This retrospective study included two groups of 76 participants over 60 years old who underwent operations with (n = 41) or without (n = 35) guidance by 3D printing. The Mann–Whitney U test was used to analyze continuous variables. Chi-square analysis was applied for categorical variables. Univariable and multivariable linear regression models were used to analyze the factors associated with LHS. The median LHS in the group without 3D printing assistance was 16 (12–21) days, and the median ICU LS was 0 (0–2) days. The median LHS in the group with 3D printing assistance was 17 (12.5–22.5) days, and the median ICU LS was 0 (0–3) days. There was no significant difference in LHS associated with 3D printing assistance vs. that without 3D printing among patients who underwent open reduction and internal fixation for pelvic or acetabular fractures. The LHS positively correlated with the ICU LS whether the operation was 3D printing assisted or not. For fracture surgery in older patients, in addition to the advancement of surgical treatment and techniques, medical teams require more detailed preoperative evaluations, and more personalized medical plans regarding postoperative care to achieve the goals of shortening LHS, reducing healthcare costs, and reducing complication rates.