Discharge Options Research Articles

Identifying factors influencing emerging innovations in hospital discharge decision making in response to system stress: a qualitative study

BackgroundThe purpose of this qualitative study was to identify emergent rehabilitation innovations and clinician perceptions influencing their implementation and outcomes related to hospital discharge decision-making during the Coronavirus 2019 pandemic.MethodsRehabilitation clinicians were recruited from the Veterans Affairs Health Care System and participated in individual semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Data were analyzed using a rapid qualitative, deductive team-based approach informed by directed content analysis.ResultsTwenty-three rehabilitation clinicians representing physical (N = 11) and occupational therapy (N = 12) participated in the study. Three primary themes were generated: (1) Innovation: emerging innovations in discharge processes included perceived increases in team collaboration, shifts in caseload prioritization, and alternative options for post-acute care. (2) Recipients: innovations emerged as approaches to communicating discharge recommendations changed (in-person to virtual) and strong patient/family preferences to discharge to the home challenged collaborative goal setting; and (3) Context: the ability of rehabilitation clinicians to innovate and the form of innovations were influenced by the broader hospital system, interdisciplinary team dynamics, and policy fluctuations. Innovations described by participants included (1) use of technological modalities for interdisciplinary collaboration, (2) expansion of telehealth modalities to deliver care in the home, (3) changes in acute care case prioritization, and (4) alternative options for discharge directly to home.ConclusionsOur findings reinforce that rehabilitation clinicians developed innovative strategies to quickly adapt to multiple systems-level factors that were changing in the face of the COVID-19 pandemic. Future research is needed to assess the impact of innovations, remediate unintended consequences, and evaluate the implementation of promising innovations to respond to emerging healthcare delivery needs more rapidly.

Consensus paper on the assessment of adult patients with traumatic brain injury with Glasgow Coma Scale 13-15 at the emergency department: A multidisciplinary overview.

Traumatic brain injury (TBI) is a common reason for presenting to emergency departments (EDs). The assessment of these patients is frequently hampered by various confounders, and diagnostics is still often based on nonspecific clinical signs. Throughout Europe, there is wide variation in clinical practices, including the follow-up of those discharged from the ED. The objective is to present a practical recommendation for the assessment of adult patients with an acute TBI, focusing on milder cases not requiring in-hospital care. The aim is to advise on and harmonize practices for European settings. A multiprofessional expert panel, giving consensus recommendations based on recent scientific literature and clinical practices, is employed. The focus is on patients with a preserved consciousness (Glasgow Coma Scale 13-15) not requiring in-hospital care after ED assessment. The main results of this paper contain practical, clinically usable recommendations for acute clinical assessment, decision-making on acute head computerized tomography (CT), use of biomarkers, discharge options, and needs for follow-up, as well as a discussion of the main features and risk factors for prolonged recovery. In conclusion, this consensus paper provides a practical stepwise approach for the clinical assessment of patients with an acute TBI at the ED. Recommendations are given for the performance of acute head CT, use of brain biomarkers and disposition after ED care including careful patient information and organization of follow-up for those discharged.

336 Understanding the Unique Challenges Faced by Homeless Patients With Acute Traumatic Neurosurgical Injuries

INTRODUCTION: Homelessness is associated with high risk of acute neurotraumatic injury in the ∼600 000 Americans affected on any given night. METHODS: Adults hospitalized for acute neurotraumatic injuries between January 1, 2015, and December 31, 2020, were identified in this retrospective cross-sectional study at our Level 1 trauma center. We evaluated demographics, inhospital characteristics, discharge dispositions, readmissions, and adjusted readmission risk. RESULTS: Of 1308 patients, 8.5% (n = 111) were homeless on admission to neurointensive care. Compared with nonhomeless individuals, homeless patients were younger (P = .004), predominantly male (P = .003), and less frail (P = .003) but had similar presenting Glasgow Coma Scale scores (P = .85), neurointensive care unit stay time (P = .15), neurosurgical interventions (P = .27), and in-hospital mortality (P = .17). Nevertheless, homeless patients had longer hospital stays (11.8 vs 10.0 days, P = .02), more unplanned readmissions (15.3% vs 4.8%, P < .001), and more complications while hospitalized (54.1% vs 35.8%, P = .01), particularly myocardial infarctions (9.0% vs 1.3%, P < .001). Homeless patients were mainly discharged to their previous living situation (46.8%). Readmissions were primarily for acute-on-chronic intracranial hematomas (4.5%). Homelessness was an independent predictor of 30-day unplanned readmissions (odds ratio 2.41 [95% CI 1.33-4.38, P = .004]). CONCLUSIONS: Homeless individuals experience longer hospital stays, more inpatient complications such as myocardial infarction, and more unplanned readmissions after discharge compared with their housed counterparts. These findings combined with limited discharge options in the homeless population indicate that better guidance is needed to improve the postoperative disposition and long-term care of this vulnerable patient population.

The association between opioid use disorder and skilled nursing facility acceptances: A multicenter retrospective cohort study.

Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs). To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted. A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD. OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD. The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD. This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.

Provider perceptions of challenges and facilitators to surgical care in unhoused patients: A qualitative analysis

BackgroundUnhoused patients have worse surgical outcomes than the general population. However, the drivers of this inequity have not been studied. MethodsWe conducted 26 semi-structured interviews of clinicians who care for patients with surgical disease, using a purposive sampling strategy to intentionally recruit participants with significant experience caring for unhoused patients across different roles. We used thematic analysis to analyze the resulting data. ResultsWe conducted 26 interviews: 11 with surgeons (42%), 8 with internal medicine physicians (30%), 2 with surgical advanced practice providers (8%), 3 with social workers or case managers (11%), and 2 with registered nurses (8%). One-third of the participants worked in either medical respite or street medicine programs. We identified 5 themes, each of which was most relevant at a distinct point along the spectrum of surgical care: (1) patients and clinicians face multiple challenges meeting preoperative requirements, (2) although surgeons do not make major operative decisions based on housing status, some take it into consideration for minor care decisions, (3) clinicians perceive that unhoused patients have negative postoperative experiences in the hospital, (4) discharge options for unhoused patients are commonly imperfect, which can lead to inadequate postoperative care, (5) challenges with formal communication between surgeons and non-surgeons are amplified when caring for unhoused patients. ConclusionClinicians who care for unhoused patients with surgical disease relayed multiple challenges throughout all phases of surgical care and relied on both formal and informal mechanisms to mitigate these challenges. There may be opportunities to intervene and improve access to surgical care for this vulnerable group.

INTERROGATING THE SKILLED NURSING STAYS OF HOMELESS AND SERIOUSLY ILL OLDER ADULTS

Abstract The culture change movement has fostered an intentional move away from restrictive ethos of care in hospitals, post-acute rehabilitation, and skilled nursing. However, for the millions in the United States who are uninsured, Medicaid-insured, or dual-eligible are less likely to access ‘deinstitutionalized’ healthcare environments. This presentation presents findings from a constructivist grounded theory study, Research and Supportive Care at Later-life for Unhoused People (RASCAL-UP), on the role of skilled nursing in the experiences of palliative care patients with histories of homelessness. Through provider interviews (n=30), field observations (n=12), and longitudinal chart documentation of a subset of homeless palliative care patients with stays in skilled nursing (n=13), this presentation will reflect on major findings: (1) barriers to skilled nursing entry; (2) successes and challenges in transitioning into skilled nursing residence; (3) acts of resistance to (re)institutionalization; and (4) discharge options and outcomes. Results showcase a need to fill the residential service gap between supportive housing and skilled nursing care and policy change that incentivizes consumer-directed practices for all.

Scaled TelePhysical Therapy Program a Promising Option for Post-acute Care of Lower-Extremity Arthroplasty Patients.

Post-acute care for orthopedic surgery patients continues to evolve with the reduction in hospital length of stay (LOS), shift to ambulatory surgery, increased number of surgeries, and focus on value-based care. We sought to examine outcomes of a cohort of lower-extremity arthroplasty patients receiving telephysical therapy (TelePT) according to hospital LOS, as a means of exploring the viability of TelePT as a value-based discharge option. A retrospective review was conducted of patients who participated in our institution's HSS@Home TelePT program after undergoing primary unilateral hip or knee arthroplasty, unicondylar knee replacement, or hip resurfacing. Demographic data and outcomes such as hospital LOS, number of days between discharge and TelePT evaluation, number of TelePT visits, number of re-admissions, Hip dysfunction and Osteoarthritis Outcome (HOOS Jr.) or Knee injury and Osteoarthritis Outcome (KOOS Jr.) scores, and patient satisfaction scores were collected. Patients were divided into categories based on hospital LOS to help determine the versatility of program. In the 2814 patients included, we observed an average of 4.1 TelePT visits; 1% of patients were readmitted within 90 days, and 97% of patients were satisfied or highly satisfied. There was no difference in HOOS or KOOS Jr. scores at each follow-up time point, except for the 6-month HOOS Jr. scores. This retrospective study suggests that TelePT may be a viable option for care of lower-extremity arthroplasty patients in the post-acute setting, regardless of hospital LOS. As a discharge option, it may meet the needs of select patients to fill a gap in providing value-based care.

Understanding the Unique Challenges Faced by Homeless Patients With Acute Traumatic Neurosurgical Injuries.

Homelessness is associated with high risk of acute neurotraumatic injury in the ∼600 000 Americans affected on any given night. To compare care patterns and outcomes between homeless and nonhomeless individuals with acute neurotraumatic injuries. Adults hospitalized for acute neurotraumatic injuries between January 1, 2015, and December 31, 2020, were identified in this retrospective cross-sectional study at our Level 1 trauma center. We evaluated demographics, in-hospital characteristics, discharge dispositions, readmissions, and adjusted readmission risk. Of 1308 patients, 8.5% (n = 111) were homeless on admission to neurointensive care. Compared with nonhomeless individuals, homeless patients were younger ( P = .004), predominantly male ( P = .003), and less frail ( P = .003) but had similar presenting Glasgow Coma Scale scores ( P = .85), neurointensive care unit stay time ( P = .15), neurosurgical interventions ( P = .27), and in-hospital mortality ( P = .17). Nevertheless, homeless patients had longer hospital stays (11.8 vs 10.0 days, P = .02), more unplanned readmissions (15.3% vs 4.8%, P < .001), and more complications while hospitalized (54.1% vs 35.8%, P = .01), particularly myocardial infarctions (9.0% vs 1.3%, P < .001). Homeless patients were mainly discharged to their previous living situation (46.8%). Readmissions were primarily for acute-on-chronic intracranial hematomas (4.5%). Homelessness was an independent predictor of 30-day unplanned readmissions (odds ratio 2.41 [95% CI 1.33-4.38, P = .004]). Homeless individuals experience longer hospital stays, more inpatient complications such as myocardial infarction, and more unplanned readmissions after discharge compared with their housed counterparts. These findings combined with limited discharge options in the homeless population indicate that better guidance is needed to improve the postoperative disposition and long-term care of this vulnerable patient population.

Extracorporeal Life Support for Cardiogenic Shock in Octogenarians: Single Center Experience.

The age limit for the use of extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiac failure is not defined. The aim of the study was to evaluate the outcomes of octogenarians supported with ECMO due to cardiogenic shock. A retrospective review of consecutive elderly patients supported with ECMO during a 13-year period in a tertiary care center. Patient's demographic variables, comorbidities, perioperative data and outcomes were collected from patient medical records. Data of octogenarian patients were compared with the septuagenarian group. The main outcomes of the study was in hospital mortality, 6-month survival and 1-year survival after hospital discharge and discharge options. Multivariate logistic regression analysis was performed to identify the factors associated with hospital survival. Eleven patients (18.3%) in the elderly group were octogenarians (aged 80 years or above), and forty-nine (81.7%) were septuagenarians (aged 70-79 years). There were no differences except age in demographic and preoperative variables between groups. Pre ECMO SAVE, SOFA, SAPS-II and inotropic scores were significantly higher in septuagenarians than octogenarians. There was no statistically significant difference in hospital mortality, 6-month survival, 1 year survival or discharge options between groups. ECMO could be successfully used in selected octogenarian patients undergoing cardiac surgery to support a failing heart. An early decision to initiate ECMO therapy in elderly post-cardiotomy shock patients is associated with favorable outcomes.

Sources of Clinician Burnout in Providing Care for Underserved Patients in a Safety-Net Healthcare System.

Burnout among clinicians is common and can undermine quality of care, patient outcomes, and workforce preservation, but sources of burnout or protective factors unique to clinicians working in safety-net settings are less well understood. Understanding these clinician experiences may inform interventions to reduce burnout. To describe clinician perspectives on sources of burnout in a safety-net healthcare system. Semi-structured interviews were conducted with clinicians from multiple disciplines who provided care at a safety-net healthcare system from October 2018 to January 2019. Transcripts were analyzed using thematic analysis. Forty clinicians (25 female and 15 male; mean [SD] age, 41 [9.1]) participated, including physicians, social workers, advanced practice providers, nurses, psychologists, physical and occupational therapists, and other healthcare professionals. Themes and subthemes that reflected clinician experiences, burnout, and workload expectations. Five themes emerged: limited resources (entrenched social injustices, brokenness of the US healthcare system, precarious discharge options, and "revolving door" readmissions), barriers to building trust with patients (chasm of communication, addressing fear and mistrust, and being exposed to threats), administrative requirements (criticism hampering meaningful care, assuming extra workloads, bureaucratic burden), compassion fatigue (confronting traumatic situations, persistent worry about patient safety and welfare, witnessing mistreatment and stigmatization, overextending and overinvesting, withdrawing and shutting down, blaming self and career crisis), and advocacy as a counterbalance to burnout (solidarity when helping underserved communities, fervent advocacy, and patient gratitude). Among clinicians who provide care in a safety-net healthcare system, sources of burnout included limited resources, barriers to building trust with patients, administrative requirements, and compassion fatigue, but clinicians remained driven by their desire to advocate for patients. Policy-level interventions which increase funding to safety-net healthcare systems to bolster existing resources and staffing, create peer-support and wellness programs, and support advocacy efforts may mitigate burnout.

Hôpital Montfort's Postnatal Care-at-Home Program: An Innovative Model for Early Postnatal Care.

The Montfort Postnatal Care-at-Home (MPCH) Program is an innovative, integrated physician, nurse and midwifery model of care that offers an early hospital discharge option to families. The MPCH Program provides care and support to families throughout their transition from hospital to home. The program has the potential to improve families' experiences and maternal-newborn health outcomes, and provides a safety net to families 24/7 during the first seven days postpartum at home. This model transforms how postnatal care is delivered, and has the potential to improve the flow of the birthing unit and the unit capacity and reduce acute care hospital costs.

Responding to stakeholder needs to engage rehabilitation professionals in the delivery of evidence-based health programming for adults with osteoarthritis.

Although there are many evidence-based programs that promote healthy lifestyles and symptom modification for people with osteoarthritis, their delivery in rehabilitation clinical settings in the United States is limited. These programs can be a primary component of treatment or a discharge option to facilitate long-term mobility and pain management. The purpose of this perspective article is to describe a delivery model that brings one arthritis-appropriate, evidence-based intervention, the Arthritis Foundation's Walk With Ease program, to older adults seeking physical therapy related to their osteoarthritis. We embedded program delivery into a Doctor of Physical Therapy curriculum using a student health coaching approach and partnering with physical therapy clinics and other community agencies for participant referrals. This model of delivery is cost-effective, sustainable, and provides outcomes that meet goals of the national agenda for osteoarthritis. The model provides benefits for students in health professions education programs, community organizations and rehabilitation clinics, and adults living with osteoarthritis.

Should older people ever be discharged from hospital at night?

The discharge of older people from hospital at night is a topical and emotive issue that has recently gained media attention in New Zealand and the United Kingdom, including calls to prevent it occurring. With growing pressures on hospital capacity and ageing populations, normative aspects of hospital discharge are increasingly relevant. This paper therefore addresses the question: Should older people (say, over eighty years old) ever be discharged home from hospital during the night? Or given safety concerns, should regulation against the night-time discharge of older people be put in place? Employing a principlist lens to bioethics, this paper considers key principles or values involved, including discharge safety concerns, personal preference and consent, the risk of remaining in hospital, and broader considerations around discharge policy. These points act as a possible framework for further research and discussion of normative aspects of hospital discharge. Overall, this paper argues that while discharge safety concerns must be properly acknowledged and addressed, it can still sometimes be appropriate for an older person to leave hospital at night. The option of night-time discharge should therefore remain open to people of all ages.

Discharging to the Street: When Patients Refuse Medically Safer Options

The ethical obligation to provide a reasonably safe discharge option from the inpatient setting is often confounded by the context of homelessness. Living without the security of stable housing is a known determinant of poor health, often complicating the safety of discharge and causing unnecessary readmission. But clinicians do not have significant control over unjust distributions of resources or inadequate societal investment in social services. While physicians may stretch inpatient stays beyond acute care need in the interest of their patients who are experiencing homelessness, they must also consider the implications of using an inpatient hospital bed for someone without the attendant level of medical need. Caring for patients in an inpatient setting when they no longer require acute care means fewer beds for acute care patients. And when a patient who is experiencing homelessness declines a medically safer option such as a skilled nursing facility, then clinicians may be faced with the sole option of discharge to the street, which raises troubling questions of nonmaleficence and social justice. Here we investigate the different forms of injustice that play out when patients are discharged to the street, and offer a map of the interwoven ethical responsibilities of clinicians, hospitals, and skilled nursing facilities.

Suicide maternel périnatal : comment prévenir ?

The sixth report of the National Confidential Survey on Maternal Deaths provides insights into the frequency, risk factors, causes, adequacy of care, and preventability of maternal deaths occurring in 2013-2015 in France. The method developed ensures an exhaustive identification and a confidential analysis of maternal deaths. It was organized in three steps. 1) All deaths occurring during pregnancy or up to 1 year after its end, whatever the cause or mode of termination, being considered 2) A pair of volunteer assessors (midwives, gyneco-obstetricians, anesthesiologists, psychiatrists) was in charge of collecting the information (history of the woman, course of her pregnancy, circumstances of the event that led to the death and management); 3) Review and classification of deaths by the National Committee of Experts on Maternal Mortality which made a collective judgment on the cause of death, on the adequacy of the care provided, and on what could been done to avoid the death depending on the existence of circumstances that could have prevented the fatal outcome. The operation of the committee has been enriched by new resources to further explore these cases. Specifically, a module of the survey questionnaire, the recruitment of psychiatrists whose contribution allows relevant documentation of the suicides, and the participation of a psychiatrist as an associate expert for the analysis of the appropriateness of the management and the variable determining factors of these cases. Suicide becomes one of the two main causes of maternal mortality, (the other cause being cardiovascular pathologies), with 35 suicides on the triennium among the 262 maternal deaths, that is to say 13.4% of maternal deaths, about 1 per month. In this population, the average age of women who died by suicide was 31.4years. The majority of the women were born in France, 68% were prima parous, and in 9% of cases suicide followed a twin pregnancy. Psychiatric history was known in 33.3% of the suicidal mothers, and 30.3% had a history of psychiatric care that was unknown to the maternity team.43% of the women had psychosocial vulnerability factors, a history of violence, and eviction from the home and/or financial difficulties. In 23% of the cases, the time of occurrence of these suicides was within the first 42days postpartum, and in 77% between 43 days and one year after birth with a median delay of 126days. Only one suicide occurred during pregnancy. Maternal suicides were mostly violent deaths. Suboptimal care was present in 72% of cases, where 91% of potentially preventable deaths related to a lack of multidisciplinary management and/or inadequate interaction between the patient and the health care system. Among these potentially avoidable deaths, we were able to distinguish: women whose psychiatric pathology was known and for whom multidisciplinary management was not optimal, and women whose psychiatric pathology was not known or was not present-for whom it was rather a matter of a failure to detect and identify the signs, particularly by obstetric care providers or general emergency services. Based on the analysis of the cases, strong messages were identified, with the aim of optimizing management: -The screening by structured questioning of psychiatric history from the moment of registration in the maternity ward, repeated at each consultation throughout the pregnancy. -The reassessment of the psychological and somatic state through an early postnatal interview at one month; -The identification of warning symptoms, with screening tools for depression. If necessary, a further recourse to the psychologist and/or psychiatrist of the maternity hospital, organisation of a home hospitalization, and a private midwife to provide a link in the pre- and postpartum period. This, in addition to the earliest possible care in the PMI (Maternal and Infantile Protection, of the French social care system), appointments with mental health professionals,and the link with the attending physician; -The implementation of a coordinated care pathway in case of a known psychiatric pathology with pre conception counselling. This includes a multidisciplinary collaboration, an adaptation of psychotropic treatment, management of comorbidities referral to specialized perinatal psychopathology teams, prenatal meeting with the pediatrician of the maternity hospital, anticipation of the birth, postpartum and discharge options, liaison sheet established for the organization of the delivery and postpartum, and a regular written transmissions between the intervening parties throughout the care; -The generalization of medico-psycho-social staffs, in maternity wards, for all situations identified as at risk. In addition to the need for training and increased awareness on psychological issues during the perinatal period and on the different pathologies encountered by adult mental health professionals and front-line workers, it is necessary to encourage the development of resources in the country. Particularly, joint child psychiatrist-adult psychiatrist consultations at the territorial level, responsible for being resource contacts for maternity wards and local care professionals, as well as the promotion of case pathway referrals.

Experimental characterization of a small-scale solar Organic Rankine Cycle (ORC) based unit for domestic microcogeneration

The integration of a Micro-Organic Rankine Cycle (ORC) power unit with conventional solar flat plate collectors ensures the simultaneous fulfillment of electricity and domestic hot water (DHW) demands. Due to the variability of the solar source, despite the introduction of a thermal storage unit, the plant is subject to severe off design operating conditions. A small-scale ORC-based was designed, built and fully tested, to experimentally assess the performance and operating robustness of the plant in steady and dynamic off-design condition. The unit is fed by hot water from a 135 L reservoir. Dedicated electric heaters (12 kW each one) reproduce the thermal availability from 15 m2 of standard solar thermal collectors for domestic applications. The test bench underwent an extensive experimental assessment in both stationary conditions of the hot source and in presence of a variable thermal load at the evaporator. Due to the plant architecture and components, the control of the unit is based on the variation of the mass flow rate of the working fluid (R245fa) matching the thermal equilibrium at the evaporator in each operating condition of the system. The variation of the flow rate, in fact, must fit with thermal power available. The off-design steady state assessment allows the understanding of the wide operability of the plant (17–62 g/s), with power and efficiency varying between 150 and 500 W and 2.4–4%, respectively. The dynamic testing of the pilot unit points out the plant consistency and robustness to severe off-design operation, mostly due to the 1 kW scroll expander, very suitable for time-varying operating conditions. Both the option of a full discharge of the thermal energy of the reservoir and the option of a split discharge to the evaporator were investigated and provided a clear indication on the CHP feasibility when no addition of thermal energy takes place at the reservoir. It was observed that during a complete reservoir thermal discharge, the plant works for 3000–3300 s continuously, with a slow power decrease from 500 W to 100 W. Considering the thermal energy recharging time, the plant could be averagely operated up to 7 times during the day if a partial discharge was performed. Each plant activation lasts 900 s producing a power ranging from 500 W to 200 W. This operating strategy allows to cover up to 11.2% of the whole electric energy yearly required by an average European household.

Timing of Maternal Discharge after Cesarean Delivery and Risk of Maternal Readmission.

Despite legislation and hospital policies (present in some institutions) mandating a minimum length of stay in an effort to decrease the frequency of hospital readmissions, the effectiveness of this approach remains uncertain.We hypothesized that following cesarean delivery (CD), the rates of maternal readmission or unscheduled health care visits are lower in patients discharged on postoperative day (POD) 3 or ≥4 as compared with those discharged earlier on POD 2. This is a secondary analysis of a multicenter randomized trial comparing adjunctive azithromycin for unscheduled CD to prevent infection. Groups were compared based on the duration of hospitalization measured in days from delivery (POD 0) to day of discharge and categorized as POD 2, 3, and ≥4. The primary outcome was the composite of any maternal postpartum readmission, unscheduled clinic, or emergency room (ER) visit, within 6 weeks of delivery. Secondary outcomes included components of the primary outcome and neonatal readmissions. We excluded women with hypertensive disorders of pregnancy and infections diagnosed prior to POD 2. A total of 1,391 patients were included. The rate of the primary outcome of any readmission increased with POD at discharge: 5.9% for POD 2, 9.4% for POD 3, and 10.9% for POD ≥4 group (trend for p = 0.03). The primary outcome increased with later discharge (POD ≥4 when compared with POD 2). Among components of the composite, ER and unscheduled clinic visits, but not maternal readmissions, increased with the timing of discharge for patients discharged on POD ≥4 when compared with POD 2. Using logistic regression, discharge on POD 3 and on POD ≥4 was significantly associated with the composite (adjusted odds ratios [aOR] 2.6, 95% confidence interval [CI] [1.3-5.3]; aOR 2.9, 95% CI [1.3-6.4], respectively) compared with POD 2. The risk of maternal readmission composite following uncomplicated but unscheduled CD was not lower in patients discharged home on POD 3 or ≥4 compared with patients discharged earlier (POD 2). · Risk of maternal readmission is higher in patients discharged on POD 3 or 4 compared with POD 2.. · No significant differences by the timing of discharge were observed for any neonatal readmissions.. · Timing of discharge should include an individualized approach with the option of discharge by POD 2..

Modelling of Irrigation Return Flow in Unconfined Aquifer of Dharoi Command in Mehsana District of Gujarat, India

Surface water flow and subsurface flow have traditionally been investigated separately and simulators have been developed over the years, to model each of these systems. Growing interest in conjunctive water management, and need for simulations of surface/subsurface flow and their interactions has lead to the linking of models of the respective domains. This study from Dharoi command area, using MODFLOW, showed pertaining to the second layer of the calibrated model. The first layer is a thin soil cover layer of about 3 m uniform thickness. Top layer is kept under unconfined water table condition, where as the next layer is given the scope of transforming between water table to confined state and vice versa depending upon the fluctuation of the computed water level with respect to the bottom boundary of the top layer. No recharge and discharge options other than a single boundary condition of average May water level in the extreme north-east grid has been allowed. This calibration is based upon matching the observed and computed average gradient of the water table (hydraulic gradient) and nothing to do with matching the point to point values of the observation wells as that could lead to misappropriation in respect of hydrologic condition. Over all gradient of the water table in the area of interest is computed as 0.23 m per km in comparison to an observed hydraulic gradient of 0.3 m per km. The rivers such as Sabarmati downstream of Dharoi dam and up to Bijapur, Rupen and Pushpawati are activated in the transient run. Conductance value is considered as 0.0001 m/sec for all the rivers. proximity of the second layer under unconfined state. Comparisons of water levels in selected locations. Overall match between the trends and the point values indicate that the calibrated model transient run can be considered as base case and various options can be studied with this model. Visual MODFLOW is very effective to know the present scenario of ground water flow, water level of aquifer, wells, also point values indicate that the calibrated model transient run can be considered as base case and various options can be studied with this model. Visual MODFLOW is very effective to know the present scenario of ground water flow, water level of aquifer, wells, also distribution of spatial recharge, specific yield distribution. It gives very close result to the observed value.

Local conditions and the economic feasibility of urban wastewater recycling in irrigated agriculture: Lessons from a stochastic regional analysis in California

AbstractUsing treated wastewater for crop irrigation could help mitigate water scarcity. We examine the feasibility of this strategy focusing on the role of local conditions, such as the costs and benefits of alternative wastewater discharge options, and adaptability of agricultural production to water quantity and quality changes. Our approach accounts for uncertainties in the availability of natural water resources and regulatory constraints concerning wastewater discharge. Our analysis of a region in Southern California finds reuse for crop irrigation unwarranted; however, utilizing that practice to support agriculture in the region is economically inexpensive. A sensitivity analysis reveals that diversified agriculture and limitations on the safe and remote discharge of treated wastewater are strong incentives for reuse in agricultural irrigation.

Optimal Ways of Unloading and Loading Operations under Arctic Conditions

Usually, loading and unloading of cargo ships takes place in ports that are equipped with the infrastructure necessary to carry out such operations. In the Arctic, often a helicopter is the only way to get the cargo to the right place. Finding the optimal geographic location for unloading a ship using helicopters is an important task. It is necessary to create a support system for making the right decisions in such situations. Mathematical modeling has been used to find the geographical location that ensures the most favorable and quickest delivery of cargo from a vessel to its destination, using a helicopter. A criterion has also been found in which the search for the optimum point is a more rational way of unloading the vessel compared to other discharge options. The maps of the economic benefits of loading and unloading operations in this model have been developed. Using the example of the developed model, it is shown that during the transportation of goods in Ob Bay, significant economic and temporary advantages can be obtained. The developed model can be extended to the case of cargo delivery not only in the Arctic conditions, but also where the transport infrastructure is insufficiently developed.