Discharge Criteria Of Patients Research Articles

Patient outcomes after neonatal tracheotomy: A retrospective case-control study.

Patient outcomes after neonatal tracheotomy: A retrospective case-control study.

Prognostic Value of Integral Assessment of Congestion in Patients Hospitalized with Acute Decompensated Chronic Heart Failure

Background: Systemic congestion is the leading pathophysiological mechanism of decompensated heart failure (HF), and hospitalization and poor prognosis. Unfortunately, patients are discharged with residual congestion, possibly due to the lack of a clear strategy for its assessment. The existing criteria for discharge of patients from the hospital are more often based on a subjective assessment and poorly correlate with the state of hemodynamic stabilization, and the search for methods for detecting congestion remains relevant. Objective: The objective is to determine the prognostic value of an integrated assessment of congestion based on novel diagnostic methods in patients hospitalized with acute decompensated chronic HF (ADCHF). Methods: Single-center prospective study in 171 patients hospitalized with ADCHF. All patients underwent physical examination, paraclinical (laboratory and instrumental) investigations-N-terminal pro-brain natriuretic peptide (NT-proBNP) level, lung ultrasound, transient elastography (TE), bioimpedance vector analysis (BIVA) on admission and discharge. Clinical congestion was assessed in accordance with the HF Association consensus document. Clinical outcomes were assessed by structured telephone survey 1, 3, 6, 12 months after discharge. Combined rates of all-cause mortality and re-admissions were used as the study endpoint. Results: Patients hospitalized with ADCHF had the following congestion status at discharge as assessed by individual methods (TE, lung ultrasound, BIVA and NT-proBNP): The incidence of clinical residual Congestion I ranged 33%–39%, the incidence of subclinical congestion was 12%–24%, and patients with euvolemia accounted for 19%–32%. According to the integral assessment of hydration status, the incidences of clinical residual Congestion I, subclinical congestion, and euvolemia were 57%, 31% and 12%, respectively. The study has demonstrated a significant worsening of all congestion parameters with increasing number of methods (1–4) that had detected congestion. Patients with congestion detected at discharge by 2, 3, or 4 methods were at a significantly higher risk of all-cause mortality or readmission. TE + NT-proBNP had a higher prognostic value in regard to the risk of endpoint event, while the combination of all four methods was the most predictive. Conclusions: Patients hospitalized with ADCHF should undergo an integral assessment of residual and subclinical congestion at discharge. The introduction of integral congestion assessment into the routine practice will help identify patients with less favorable prognosis in terms of the risk of death and re-admission, as well as to enhance pharmacologic therapy and follow-up.

Committee report: Questionnaire survey on the treatment of COVID-19 in patients receiving dialysis therapy

BackgroundPatients with coronavirus disease 2019 (COVID-19) who receive dialysis therapy develop more severe disease and have a poorer prognosis than patients who do not. Although various data on the treatment of patients not receiving dialysis therapy have been reported, clinical practice for patients on dialysis is challenging as data is limited. The Infection Control Committee of the Japanese Society for Dialysis Therapy decided to clarify the status of treatment in COVID-19 patients on dialysis.MethodsA questionnaire survey of 105 centers that had treated at least five COVID-19 patients on dialysis was conducted in August 2021.ResultsSixty-six centers (62.9%) responded to the questionnaire. Antivirals were administered in 27.7% of facilities treating mild disease (most patients received favipiravir) and 66.7% of facilities treating moderate disease (most patients with moderate or more severe conditions received remdesivir). Whether and how remdesivir is administered varies between centers. Steroids were initiated most frequently in moderate II disease (50.8%), while 43.1% of the facilities initiated steroids in mild or moderate I disease. The type of steroid, dose, and the duration of administration were generally consistent, with most facilities administering dexamethasone 6 mg orally or 6.6 mg intravenously for 10 days. Steroid pulse therapy was administered in 48.5% of the facilities, and tocilizumab was administered in 25.8% of the facilities, mainly to patients on ventilators or equivalent medications, or to the cases of exacerbations. Furthermore, some facilities used a polymethylmethacrylate membrane during dialysis, nafamostat as an anticoagulant, and continuous hemodiafiltration in severe cases. There was limited experience of polymyxin B-immobilized fiber column-direct hemoperfusion and extracorporeal membrane oxygenation. The discharge criteria for patients receiving dialysis therapy were longer than those set by the Ministry of Health, Labor and Welfare in 22.7% of the facilities.ConclusionsOur survey revealed a variety of treatment practices in each facility. Further evidence and innovations are required to improve the prognosis of patients with COVID-19 receiving dialysis therapy.

Effect of intraperitoneal instillation of dexmedetomidine or fentanyl as adjuvants to bupivacaine on fast tracking discharge criteria in patients undergoing ambulatory laparoscopic cholecystectomy: a randomised double-blind control trial

BackgroundPostoperative analgesia in laparoscopic cholecystectomy significantly affects the ambulation and discharge of the patient. This study compares fentanyl and dexmedetomidine as adjuvants to bupivacaine in intraperitoneal instillation after LC, in terms of their impact on ambulation, analgesic efficacy and recovery profile. Ninety patients were randomised into three groups with thirty patients in each group; group BF was administered 20 ml of 2 μg/kg fentanyl + 0.25% bupivacaine, group BD received 20 ml of 1μg/kg dexmedetomidine + 0.25% bupivacaine and group B received 20 ml of 0.25% bupivacaine only. After 8 h, Post-Anaesthesia Discharge Scoring System (PADS) scored for determining home readiness. Analgesic profile was assessed using Verbal Rating Scale and rescue analgesia requirement seen. Sedation was scored using Ramsay sedation scoring.ResultsGroup B had significantly higher VRS and rescue analgesia requirements whilst groups BF and BD had a similar analgesic profile. Ramsay sedation scores were significantly higher in group BD when compared to groups BF and B. However, the PADS score remained comparable in all three groups (P = 0.113). The trial was retrospectively registered with the clinical trial registry of India CTRI/2019/07/020466.ConclusionIntraperitoneal instillation of bupivacaine in combination with dexmedetomidine or fentanyl significantly reduces postoperative pain scores in comparison to bupivacaine alone, in patients undergoing ambulatory laparoscopic cholecystectomy. However, fentanyl may be preferred over dexmedetomidine, because it causes less sedation and achieves a better PADS score.

11 “Green Means Go”: Creation of a Discharge Checklist Tool for Patients with Bronchiolitis

Abstract Background A consistent and predictable discharge process is difficult to achieve, yet essential for good patient flow, appropriate resourcing, and safe patient care. At our institution, physicians predicted the estimated discharge date (EDD) for patients with bronchiolitis with 70.5% accuracy (January – March 2019). A key driver of this unpredictability is a lack of consensus on “medical discharge readiness” criteria across providers, which also has impacts on communication within the health care team and with patients and families. Objectives 1. To improve the ability to predict discharge date for patients with bronchiolitis by implementing a standardized medical discharge criteria checklist tool for one month (April 2019). 2. To more fully engage nurses in their patients’ care by improving transparency and accuracy of information about discharge. 3. To increase patient and family satisfaction with the discharge process. Design/Methods Meetings with key stakeholders determined drivers of discharge. Data on national practice variation in the management of patients with bronchiolitis was reviewed and informed the creation of a set of medical discharge criteria. Criteria were reviewed and accepted by the Division of Pediatric Medicine and presented to key stakeholders for feedback. Patient inclusion and exclusion criteria were developed. Feedback on the intervention was sought via surveys to physicians, nurses and patients/families. Results There was significant improvement (70.5% to 92.3%) in accuracy of predicting EDD with use of the medical discharge criteria checklist tool. There was also a reduction in length of stay. There were no patient bounce-backs to ED or patient readmissions. There was high satisfaction and support of the checklist tool from nursing and caregivers. Conclusion The development of standardized medical discharge criteria for patients with bronchiolitis is a safe and effective way to improve predictability, transparency, communication and patient flow, while enhancing engagement of the health care team and patient and family satisfaction. Its use is also associated with a reduced length of stay. Future directions include integrating the checklist tool into the electronic health record and moving towards a nurse-facilitated discharge process. Exploring and addressing non-medical barriers to discharge should also be a priority.

Functional Optimization of Radionuclide Pairs in Theranostics of Prostate Cancer

The functional optimization of the composition of radiopharmaceutical pairs based on the prostatespecific membrane antigen (PSMA) for the radionuclide theranostics of castration-resistant prostate cancer was carried out. The analysis of radiation-physical and dosimetric characteristics of 9 radionuclides for diagnostic components of theranostic pairs and 6 radionuclides for therapeutic components is carried out. It was shown that positron-emitting radionuclides 18F and 68Ga should be considered optimal for the diagnosis and monitoring of the effectiveness of theranostics, and 177Lu beta-emitting radionuclide and 225Ac alphabeta-emitting radionuclide should be considered as the radionuclide therapy. The values of the total and organ radiation risks of secondary radiation-induced cancers in patients who have completed several courses of theranostics are calculated. It is shown that for 2 teranostic pairs based on 177Lu‑PSMA the radiation risk is higher than significant, while for 2 teranostic pairs based on 225Ac the risk falls within the range of a significant level. The calculated radiological criteria for discharge of patients after a course of theranostics from nuclear medicine departments show the fundamental possibility of performing an outpatient treatment regimen using any of the 4 considered theranostic pairs.

Do children need a longer time to shed SARS-CoV-2 in stool than adults?

SARS-CoV-2 can be shed in the stool of patients in the recovery phase. Children show a longer shedding time than adults. We analyzed the possible causes of this finding and recommend that a negative stool sample be included in a patient's discharge criteria.

Assessment of clinical judgment accuracy provided by emergency physicians in comparison with Peak Flowmetry in the severity and discharge criteria of patients with asthma attack

Introduction: In the emergency department, the decisions on admission or discharge are based on clinical symptoms and physical examinations. The aim of this study is to compare the assessment of emergency physician clinical judgment accuracy with the actual amount of peak expiratory flow rate (PEFR). Method: The present research was a cross-sectional study. In this study, 138 patients with asthma of the age of 18 to 55 years were enrolled. From admission to discharge, clinical signs and symptoms were investigated and recorded by emergency physicians and the severity of asthma was determined (mild, moderate, severe). In both stages (admission and discharge), the PEFR was measured by researcher and was compared with the severity of asthma, which are determined based on clinical symptoms and physical examination. Results: 37.7% of patients were male and the rest were females, and the mean age of participants was 49.84 years. The number of mild, moderate and severe asthma cases was 14, 36 and 88, respectively in peak flow meter. The number of mild, moderate and severe asthma cases was 37, 32 and 69, respectively in clinical judgment. In assessment of emergency physician clinical judgment accuracy in severity of asthma in comparison with peak flowmetry, the result was the kappa value of 0.231 (P <0.001). Conclusion: The study showed that clinical judgment of physicians in the emergency department is not a good prediction of severity of asthma.

Early discharge criteria in patients with acute bacterial skin and skin structure infections in a large tertiary-care teaching hospital in Florence, Italy

The study is aimed at retrospectively estimating the percentage of inpatients with severe acute bacterial skin and skin structure infections (ABSSSI) who met the early discharged (ED) criteria adapted from Nathwani et al. (Int J Antimicrob Agents. 2016 Aug;48(2):127-36) and to calculate the number of hospitalization days that could be potentially saved. A retrospective study was conducted in a tertiary care hospital in Florence, Italy. We included all patients admitted for cellulitis and post-surgical infections from 2014 to 2017. Demographic and clinical data were obtained from electronic medical records. We a priori defined the following as a risk factor for non-adherence (RFNA): active or on methadone intravenous drug users, homeless, migrants without health care assistance, and patients who need a caregiver to take prescribed medications. One hundred sixty-two subjects were enrolled. Of them, 94 (58.0%) were male, and 113 (69.7%) had cellulitis/erysipelas. A microbiological isolate was obtained in 51 patients (31.4%); Staphylococcus aureus was the most frequent (47%). Eighty-four (51.8%) were ED suitable, with 258 (49.0%) patient days potentially saved. Among the 78 not ED suitable patients, the most common reason for prolonged length of stay (LOS) was having at least one RFNA (34.6%). Fourteen (18.0%) had one RFNA. Half of the patients admitted in our hospital met the ED criteria with a sparing close to 50% in terms of hospitalization days. Unstable social and personal factors were the most frequent causes for prolonged LOS. In this selected subset of patients, more recent and easier to administer treatments, including long-acting agents, could be proposed.

Postoperative Hypertension: When Blood Pressure Cuff and Arterial Line Disagree

Hypertension is a commonly encountered condition by anesthesiologists yet there is no clearly defined approach to monitoring and managing blood pressure in the perioperative period. In this review, we focus on common dilemmas in perioperative management of hypertensive patients including preoperative evaluation and indications for postponement of elective procedures; appraise the commonly used modes of perioperative blood pressure monitoring; discuss acute hypertension in the postoperative period and the role of blood pressure in discharge criteria for patients in the post-anesthesia care unit; and we review the relevant pathophysiology of organ perfusion in chronic hypertension and the implication for postoperative blood pressure management in hypertensive patients.

Comparing low-dose bupivacaine with epidural volume extension to standard bupivacaine dosing for short obstetric procedures: a prospective, randomized study

Intrathecal bupivacaine's long duration of action can unnecessarily increase the time to meet Postanesthesia Care Unit (PACU) discharge criteria for patients undergoing short obstetric procedures. We sought to use a technique known as epidural volume extension (EVE) to determine if we could provide an adequate surgical block while significantly decreasing the time required to meet PACU discharge criteria for patients undergoing short obstetric procedures. Fifty participants were randomized into two groups. The control group received a 10 mg of 0.5% isobaric bupivacaine plus 15 µg of fentanyl injection in the intrathecal space via a combined spinal-epidural technique. The EVE group received a 5 mg of 0.5% isobaric bupivacaine plus 15 µg of fentanyl injection in the intrathecal space followed immediately by a 10 mL injection of sterile saline through the epidural needle for the EVE. Data were analyzed on 45 of the 50 patients. Time to meet PACU discharge criteria was significantly reduced in the EVE group when compared to the control group (50 vs. 135 minutes, P<0.001). The EVE group had a faster time to complete motor recovery when compared to the control group (66 vs. 181 minutes, P<0.001). Peak block height was similar in both groups at the time of surgery start (T5 vs. T5, P=0.44). The use of low-dose isobaric bupivacaine in combination with 10 mL of saline EVE allows for faster motor recovery and time to meet PACU discharge criteria in patients undergoing short obstetric procedures.

Outpatient Drain Management in Patients with Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) - Current Status in Germany

Postoperative pancreatic fistula (POPF) is a common complication after pancreatic surgery and is associated with extended hospitalisation, increased medical costs, and reduced quality of life. The aim of the present study was to assess the treatment of POPF in Germany, with a special focus on outpatient drain management in patients with clinically relevant POPF (CR-POPF). A questionnaire evaluating postoperative management once a CR-POPF is diagnosed - especially focusing on ambulatory drain management - was developed and sent to 211 German hospitals performing > 12 pancreatic operations per year. Statistical analysis was carried out using SPSS 21. The final response rate was 62% (n = 131). Outpatient drainage management is performed by most of the responding hospitals (n = 100, 76.3%). However, 30% of hospitals (n = 40) perform outpatient treatment only in 5% of their cases with clinically relevant POPF. There was no correlation between case load of the pancreatic centres and frequency of outpatient drain management. In general, discharge criteria for patients with drained POPF (n = 98, 74.8%), the drain management itself (n = 95, 72.5%) and criteria for drain removal (n = 74, 56.5%) are not standardised but made individually. In centres with standardised drain management criteria for drain removal, these criteria were drain volume < 20 ml (29.8%), no fluid collection (25.2%), no elevation of drain amylase/lipase (25.2%) and no specific symptoms (22.1%). This is the first survey in Germany evaluating outpatient drain management in patients with CR-POPF. Although the data in the literature are rare, the majority of German pancreatic surgeons perform outpatient drain management. However, discharge criteria, outpatient care and drain removal are standardised in only the minority of centres. Therefore, we recommend the evaluation of discharge criteria and a management algorithm for patients with drained CR-POPF to improve the perioperative course.

Abstract 275: Effects of Index Admission Length of Stay on Readmission Interval in Patients With Heart Failure

Background: Numerous quality improvement studies have attempted to identify variables that are predictive of repeat hospitalization in patients admitted with heart failure. The relationship between the length of hospital stay (LOS) during the index admission and the readmission risk in patients with heart failure has not been well investigated. Longer index LOS is likely in patients with multiple co-morbidities, which may also predict early readmission. Methods: The study included 720 patients with multiple admissions for heart failure to a single academic medical center between 2007-2016. Patients were stratified into four quartiles based on their LOS (days) during their initial admission. Demographic and clinical data were collected from charts. Results: The interquartile range of index admission LOS was 7 days. LOS of 1-7 days was observed in 439 patients (60.9%), 8-13 days in 175 (24.3%), 14-20 days in 58 (8.1%), and ≥21 days in 48 patients (6.7%). The longest re-admission interval of 553.5 (SD +/- 611) days was noted in patients with index admission LOS of 8-13 days, while the shortest re-admission interval of 329.1 (SD +/- 430.9) days was noted in patients with index admission LOS of ≥21 days (p=0.02). In comparison to patients with index admission LOS of 8-13 days, those admitted for 1-7 days had a readmission interval of 465.1 (SD +/- 630) days (p=0.11) and those admitted for 14-20 days lasted 444.7 (SD +/- 691.6) days (p=0.25). There were no significant differences in age, gender, race, tobacco use, or evidence-based medical treatment among the four groups. Insulin-dependent diabetes mellitus (IDDM) was more common in patients with increased index admission LOS of 14-20 days and ≥21 days (44.5% [26 of 58] and 47.9% [23 of 48], respectively), as compared to patients with LOS 1-7 days and 8-13 days (33.0% [145 of 439] and 28.6% [50 of 175], respectively, p=0.02). Similarly, chronic kidney disease (CKD) was more common in patients with LOS 14-20 days and ≥21 days (50% [29 of 58] and 56.3% [27 of 48], respectively). When adjusted for IDDM and CKD, the longest re-admission interval was still noted in patients with index admission LOS of 8-13 days, while the shortest re-admission interval was noted in patients with index admission LOS of ≥21 days (p=0.027). Conclusion: In our patients admitted with heart failure, 8 to 13-day index admission was associated with the longest readmission interval. It is possible that shorter index admission may not allow for sufficient medical optimization. This conclusion requires further study. While patients with prolonged index admission are more likely to have IDDM and CKD, these co-morbidities do not appear to result in shorter readmission intervals. There may be additional, currently not well investigated factors affecting readmission interval. Further research is needed to define optimal LOS and discharge criteria in patients admitted with a diagnosis of heart failure.

Facilitating emergency hospital evacuation through uniform discharge criteria

BackgroundThough hospitals' operational continuity is crucial, full institutional evacuation may at times be unavoidable. The study's objective was to establish criteria for discharge of patients during complete emergency evacuation and compare scope of patients suitable for discharge pre/post implementation of criteria. Basic proceduresStandards for patient discharge during an evacuation were developed based on literature and disaster managers. The standards were reviewed in a two-round Delphi process. All hospitals in Israel were requested to identify inpatients' that could be released home during institutional evacuation. Potential discharges were compared in 2013–2014, before and after formulation of discharge criteria. Main findingsConsensus exceeding 80% was obtained for four out of five criteria after two Delphi cycles. Average projected discharge rate before and after formulation of criteria was 34.2% and 42.9%, respectively (p<0.001). Variance in potential dischargeable patients was 31-fold less in 2014 than in 2013 (MST=8,452 versus MST=264,366, respectively; p<0.001). Differences were found between small, medium and large hospitals in mean rate of dischargeable patients: 52.1%, 41.5% and 42.2%, respectively (p=0.001). Principle conclusionsThe study's findings enable to forecast the extent of patients that may be released home during full emergency evacuation of a hospital; thereby facilitating preparedness of contingency plans.

Multi-center prospective evaluation of discharge criteria for hospitalized patients with Crimean-Congo Hemorrhagic Fever

IntroductionThe information of discharge criteria in patients with Crimean-Congo Hemorrhagic Fever (CCHF) is limited. In this study, we aimed to determine the clinical and laboratory parameters used in discharging the patients by the experienced centers. Materials and methodsThe study was done in 9 reference centers of CCHF from May 1, 2015 to December 1, 2015 and included laboratory-confirmed patients with CCHF. The study was prospective, observational and non-interventional. ResultsThe study included 260 patients. Mean age was 51.3 ± 16.3 years; 158 (60.8%) were male. Mean hospital stay was 7 ± 2.6 days. The decision of discharging was taken considering clinical and laboratory findings. On discharge, no patients had fever or hemorrhage. The patients were followed-up clinically and a repeat CCHF PCR was not studied. All centers considered the following criteria for discharge: no fever and hemorrhage, improvement in clinical findings and laboratory studies. For all patients except one, platelet count was >50,000/mm3 and had a tendency to increase.Prothrombin time and international normalized ratio (INR) were normal in 258 (99.6%) and 254 (98.1%) patients respectively. Alanine aminotransferase (ALT) was either normal or not higher than 10-fold and had a tendency to decrease in 259 (99.6%) patients. ALT and aspartate aminotransferase (AST) levels were not taken as discharge criteria with priority. During 30 days following the discharge, complication, relapse, or secondary transmission were not reported. ConclusionsThe discharging practice of the centers based on clinical and laboratory parameters seems safe considering no complications, relapses, or secondary infection thereafter. Current discharge practice of the centers composed of no fever and hemorrhage, improvement in clinical findings, platelet count of either >100,000/mm3 or >50,000/mm3 with a tendency to increase, and normal bleeding tests can be used as the criteria of discharge.

소아치과의사의 진정법 사용에 대한 실태조사

본 연구는 대한소아치과학회 산하 진정법 교육연구위원회가 진정법에 대한 가이드라인의 제정과 향후 정기적인 진정법교육 프로그램을 만들기 위해 시행하였다. 진정법을 사용하는 소아치과 회원 215명에게 2014년 2월 메일로 설문을 보내어 한달간 응답한 111명의 자료를 수집하여 분석하였다. 진정법은 어린이의 행동조절을 위해 선택되어, 3~4세 어린이(78%)에게 주로 사용되었다. 치료시간은 1~2시간(74.8%)이 많으며, 전악 치료(76.6%)가 주로 이루어지고 있었다. Chloral hydrate(CH) 50~70 mg/kg, hydorxyzine(Hx) 1~2 mg/kg, midazolam 근주(Mida IM) 0.1~0.2 mg/kg가 선호하는 진정법약제의 용량이었다. 진정법 시 선호하는 진정법 약제의 조합은 CH+Hx+<TEX>$N_2O/O_2$</TEX>(67.6%), CH+Hx+Mida 점막하투여(SM)+<TEX>$N_2O/O_2$</TEX>(29.7%), Mida IM+<TEX>$N_2O/O_2$</TEX>(23.4%) 등으로, 추가투여는 48%에서 행해지며 주로 Midazolam을 사용하고 있었다. 진정법 시 부작용을 경험한 응답자는 87.5%로, 주로 오심과 구토, 과흥분, 호흡저하 및 호흡곤란, 비틀거림 등이며, 약 20%만 정기적인 응급처치 교육을 받고 있었다. 진정법 후 환자 퇴원기준에 대해 응답자들은 명확한 퇴원기준의 부족과 추천하는 퇴원기준을 따르고 있지 않았다. 응답자의 86%가 진정법 코스에 대해 흥미를 가지고 있었으며, 진정법 코스에서 배우고 싶은 내용은 주로 응급 시 대처법과 안전한 약물용량 등 이었다. 소아치과에서의 진정법 사용은 환자안전을 최우선으로 고려하여야 하며, 의료사고예방을 위한 evidence-based 진료가 필요하다. 따라서, 대한소아치과학회는 진정법 가이드라인 및 응급처치에 대한 술기교육의 체계를 갖추어 소아치과의사들에게 제공할 필요가 있다. The aim of this study was to establish the appropriate guidelines in the sedation techniques and to organize the continuing education programs for the sedation in future under the direction of Committee on Sedation, Education and Research under the Korean Academy of Pediatric Dentistry(KAPD). The surveys on the sedation technique were performed on 111 organizations which practices the sedation and responded to the survey via online and e-mail by February 2014. The collected survey were analyzed. The purpose of sedation was mainly to manage the children's behavior and its uses were primarily on 3~4 years old children. The most frequent duration of treatment was 1~2 hours to treat both maxillary and mandible. The preferred dosages of sedative drugs were chloral hydrate(CH) 50~70 mg/kg, hydorxyzine(Hx) 1~2 mg/kg, and intramuscular midazolam(Mida IM) 0.1~0.2 mg/kg. The preferred combination of the sedative drugs were CH + Hx + <TEX>$N_2O/O_2$</TEX>(67.6%), CH + Hx + Mida submucosal administration (SM) + <TEX>$N_2O/O_2$</TEX>(29.7%), and Mida IM + <TEX>$N_2O/O_2$</TEX>(23.4%). The administration of additional sedatives was carried out at 48%, mainly using Midazolam. 87.5% of the respondents experienced the adverse effects of the sedation such as vomiting/retching, agitation during recovery, subclinical respiratory depression, staggering, and etc. Among them, only 20% periodically retrain the emergency management protocol. About the discharge criteria for patients after the sedation, the respondents either showed a lack of clear criteria or did not follow the recommended discharge criteria. 86% of the respondents expressed the interests in taking a course on the sedation and they wanted to learn mostly about the sedation-related emergency management, the safe dosage of the sedative drugs, and etc. The use of sedation in pediatric dentistry must be consider a patient's safety as top priority and each dentist must show the evidence of sound practices for the prevention of any possible medical errors. Therefore, KAPD must establish the proper sedation guidelines and it needs to provide the systematic technical training program of sedation-related emergency management for pediatric dentists.

A study on causes of re-admission to surgical intensive care unit and risk factors analysis of their prognosis

To evaluate the causes of readmission of patients to surgical intensive care unit (SICU), and the risk factors involved in their prognosis. Among 7381 SICU patients admitted between January 2009 and February 2012, clinical data of 178 patients readmitted to the SICU were analyzed retrospectively and assessed by univariate and multiple step wise regression analysis. The SICU readmission rate was 2.41% (178/7381). Among 178 patients readmitted to SICU, 39.89% (71/178) of them were over 70 years old in age, and 46.07% (82/178) of readmission to SICU occurred within 48 hours after their first SICU discharge. The death rate of readmitted patients was 37.08% (66/178). At discharge from SICU and at readmission, the acute physiology and chronic health evaluation II (APACHEII) score in death group (n=66) was higher than that in survivor group (n=112, 9.15±4.13 vs. 7.74±3.62, 18.47±5.67 vs. 12.99±6.32, P<0.05 and P<0.01). At readmission, Glasgow coma score (GCS) was lower than that in survive group (10.88±4.37 vs. 12.37±2.68, P<0.01). Respiratory and operation related complications were the most common causes of SICU readmission. The incidence of sepsis, septic shock and multiple organ dysfunction syndrome(MODS) in death group was obviously higher than that in survivor group (22.7% vs. 7.1%, 19.7% vs. 7.1%, 10.6% to 0 respectively, all P<0.05). The APACHEII score and complicating MODS at time of SICU readmission were found to be the independent risk factors of death as shown by multiple step wise regression analysis (t=5.0163, P=0.0000; t=2.3641, P=0.0192). The study indicated that the criteria for discharge of patients from SICU should be strictly controlled in line with patients' condition. It is very important to actively monitor the APACHEII score and GCS score, to control both respiratory and operation related complications in order to reduce the re-admission rate of the patients to SICU.

Evaluating the effectiveness of a discharge protocol for children with advanced appendicitis

BackgroundIn 2006, an evidence-based protocol for the management of children with appendicitis was established at our institution. Discharge criteria for patients with advanced appendicitis were based on a combination of clinical parameters and laboratory values. The purpose of this study is to evaluate the utility of laboratory values in guiding patient management with a discharge protocol for advanced appendicitis. Materials and methodsWe reviewed charts of patients with advanced appendicitis as defined by the surgeon intraoperatively from 2008–2009. We evaluated the sensitivity and specificity of the laboratory values at discharge for predicting postoperative intra-abdominal abscess (IAA) formation using a receiver operator curve. A logistic regression analysis was performed to identify predictors of IAA formation. ResultsWe identified 450 patients (mean age 8.9 ± 3.9 y). The postoperative IAA rate was 25%. The sensitivity and specificity for developing an abscess with a white blood cell count >12,000/UL were 52% and 82%, respectively (AUC 0.72, 95% CI 0.67–0.78, P < 0.001). The sensitivity and specificity for bands >3% were 47% and 70% (AUC 0.60, 95% CI 0.53–0.67, P = 0.002), respectively. On logistic regression analysis, an elevated white blood cell count was independently associated with an increased likelihood of a postoperative IAA (OR 1.27, 95% CI 1.19–1.35, P < 0.001). ConclusionsThe absence of leukocytosis is useful for identifying children with a decreased risk of postappendectomy IAA formation who otherwise meet clinical discharge parameters. A band count is not as predictive of risk. The use of laboratory evaluation as a component of discharge criteria in advanced appendicitis can stratify a subset of patients who are at increased IAA risk and may benefit from continued antibiotic therapy.

Immediate post‐anaesthesia recovery 2013

1. After general, epidural or spinal anaesthesia, all patients should be recovered in a specially designated area (henceforth 'post-anaesthesia care unit', PACU) that complies with the standards and recommendations described in this document. 2. The anaesthetist must formally hand over the care of a patient to an appropriately trained and registered PACU practitioner. 3. Agreed, written criteria for discharge of patients from the PACU to the ward should be in place in all units. 4. An effective emergency call system must be in place in every PACU and tested regularly. 5. No fewer than two staff (of whom at least one must be a registered practitioner) should be present when there is a patient in a PACU who does not fulfil the criteria for discharge to the ward. 6. All registered practitioners should be appropriately trained in accordance with the standards and competencies detailed in the UK National Core Competencies for Post Anaesthesia Care. 7. All patients must be observed on a one-to-one basis by an anaesthetist or registered PACU practitioner until they have regained control of their airway, have stable cardiovascular and respiratory systems and are awake and able to communicate. 8. All patients with tracheal tubes in place in a PACU should be monitored with continuous capnography. The removal of tracheal tubes is the responsibility of the anaesthetist. 9. There should be a specially designated area for the recovery of children that is appropriately equipped and staffed. 10. All standards and recommendations described in this document should be applied to all areas in which patients recover after anaesthesia, to include those anaesthetics given for obstetric, cardiology, imaging and dental procedures, and in psychiatric units and community hospitals. Only registered PACU practitioners who are familiar with these areas should be allocated to recover patients in them as and when required. 11. Patients' dignity and privacy should be respected at all times but patients' safety must always be the primary concern. When critically ill patients are managed in a PACU because of bed shortages, the primary responsibility for the patient lies with the hospital's critical care team. The standard of nursing and medical care should be equal to that in the hospital's critical care units. Audit and critical incident reporting systems should be in place in all PACUs.

Discharge criteria should be validated in patients who undergo ambulatory gynecologic surgery

To the editor: Ambulatory surgery has rapidly increased in recent years due to the request of patients and the increase in the cost of inpatient health services [1]. Patients who undergo ambulatory surgery usually receive general anesthesia or local anesthesia with sedation. Studies have reported that these types of anesthesia can impair cognitive and psychomotor performance [2-4]. The impairment of cognitive and psychomotor performance may threaten the safety of patients who undergo ambulatory surgery because patients are often discharged 2 to 3 hours post-operatively. Therefore, discharge criteria have been devised to ensure patient safety [2]. Gynecologic surgeries such as loop electrosurgical excisional procedure (LEEP) are usually performed as ambulatory surgery. However, there is no study addressing the usefulness of discharge criteria in patients who undergo ambulatory gynecologic surgery. Recently, we adopted the modified Korttila discharge criteria (MKDC) [5] as an element of clinical pathway of LEEP in our institute. Approximately 2 to 3 hours after LEEP, a nurse evaluated the patient using the MKDC. If the patient passed all the MKDC, the patient was discharged without notification to physicians. If the patient did not pass all the MKDC, the nurse notified the results of the MKDC to physicians, who in turn made the discharge decision. Between 3 and 7 days after discharge, the head nurse of the gynecology ward called by telephone the patient and asked whether or not the patient revisited the hospital after discharge due to medical problems. Ninety-nine patients were evaluated using the MKDC and 96 patients passed all elements of the MKDC. One and two patients failed the 10th and 12th elements of the MKDC, respectively. The patient who failed the 10th element of the MKDC (discharge order) was not discharged because the frozen biopsy of the LEEP specimen reported an invasive cervical cancer. Two patients who failed the 12th element of the MKDC (accompanying escort) were discharged with precautions. None of 98 patients who were discharged on the day of surgery revisited the hospital due to medical problems. Sixteen of 17 nurses completed the evaluation using MKDC within 5 minutes and responded that use of the MKDC is necessary to ensure the safety of patients. We think that every institute and physician has their own discharge criteria for patients who undergo ambulatory gynecologic surgery. However, we believe that validated discharge criteria should be developed to ensure the safety of patients and to protect ourselves from potential lawsuits.