Discharge Recommendations Research Articles

The effectiveness of an orthogeriatric service in Ain Shams University, Egypt: a quality improvement study

SummaryThis quality improvement study assessed the effectiveness of an orthogeriatric service regarding fracture care and outcomes in terms of time to surgery, length of hospital stay, postoperative pain score improvement, depression and treatment decisions. The findings showed a significant reduction in time to surgery and mean length of stay following the implementation of orthogeriatric services (OGS).IntroductionOsteoporosis is a metabolic bone disease prevalent amongst the elderly, more commonly females, and puts them at increased risk of fragility fractures. OGS are recommended as a model of best practice for primary and secondary fracture care.MethodsThis quality improvement study, conducted in our facility at Ain Shams University Hospital, Cairo, aimed to determine the effectiveness of an orthogeriatric service. We compared fracture care and outcomes before and after the implementation of OGS in terms of time to surgery, length of hospital stay, degree of postoperative pain score improvement, depression and treatment decisions. We included 128 patients aged 60 and above presenting to the emergency department with a fracture.ResultsWe found a significant reduction in the median time to surgery in the post-OGS group (p < 0.001) and a significant decrease in the mean length of stay in favour of the post-OGS group (p < 0.001). However, no significant difference was found between the two groups regarding the number of patients treated operatively, degree of postoperative pain improvement or susceptibility to depression.ConclusionSince the orthogeriatric service began, preliminary data have been encouraging, with significant reductions in time to surgery and length of stay. This along with preoperative medical optimisation and collaborative discharge recommendations has improved overall patient outcomes even though more research is needed.

Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: A Single-Institution Report.

Laparoscopic sleeve gastrectomy (LSG) is an effective weight-loss operation. Portomesenteric vein thrombosis (PMVT) is an important complication of LSG. We identified four cases of PMVT after LSG at our institution in women aged 36-47 with BMIs ranging from 44-48kg/m2. All presented 8-19 days postoperatively. Common symptoms were nausea, vomiting, and abdominal pain. Thrombotic risk factors were previous deep vein thrombosis and oral contraceptive use. Management included therapeutic anti-coagulation, directed thrombolysis, and surgery. Complications were readmission, bowel resection, and bleeding. Discharge recommendations ranged from 3-6 months of anticoagulation using various anticoagulants. No consensus was reached on post-treatment hypercoagulable work up or imaging. All cases required multi-disciplinary approach with Surgery, Interventional Radiology, and Hematology. As PMVT is a rare but potentially morbid complication of LSG, further development of tools that quantify preoperative thrombotic risk and clear guidance regarding use of anticoagulants are needed for prevention and treatment of PMVT following LSG.

Effectiveness of the 6-Minute Walk Test as a Predictive Measure on Hospital Readmission and Mortality in Individuals With Heart Failure

Purpose: To review the effect distance walked during the 6-minute walk test (6MWT) has on determining the risk of hospital readmission and mortality for individuals with heart failure. Methods: A comprehensive literature search of PubMed, CINAHL, MEDLINE, ProQuest, and Web of Science was performed from February 2021 through September 2021. Article screening and data extraction were completed by 2 authors (C.C. and M.M.). The Quality in Prognostic Studies (QUIPS) assessment tool was used by 3 authors (A.B., C.C., and M.M.) to determine the level of bias for each study. Results: Ten studies were included in this systematic review after inclusion and exclusion criteria were applied. Title (κ= 0.75, confidence interval [CI] 0.68-0.82), abstract (κ= 1, CI 1-1), and full-text (κ= 1, CI 1-1) screens were completed by 2 authors (C.C. and M.M.). Studies in this review included subjects with both acute and chronic heart failure diagnoses. Statistically significant results were reported in 7 of 10 research studies in reference to the distance walked during the 6MWT, hospital readmission, and mortality rates. In the included studies, 6MWT cut-off distances ranged from 200 to 468 m, predicting future hospitalization for subjects with heart failure. Conclusion: The 6MWT may be an effective and easily accessible tool in the acute care setting for physical therapists to estimate the risk of rehospitalization and mortality in the heart failure population and may help with determining discharge recommendations.

937-P: Multicenter application of EFR (Endocrine Final Recommendation) Note Embedded in EMR Improves the Accuracy of Diabetes Discharge Regimen in Hospitalized Patients with Diabetes

Patients with diabetes who are hospitalized often have changes in diabetes treatment regimen during hospitalization. In the ReCoDED study done at our institution, it was found that discharge instructions provided by Endocrine teams were not always accurately translated into discharge recommendations by primary teams. To address this issue, we implemented a “diabetes discharge recommendations note” (EFR Note) which clearly specifies discharge instructions for primary teams, which we embedded in the institution’s EMR in January 2019. Preliminary data evaluating the efficacy of the EFR Note at our academic center showed significantly improved accuracy in the discharge regimen. In this study, we investigated the patient data from two other centers, specifically inner-city community hospitals, from January to December 2021. We identified 40 patients through EMR for whom an EFR Note was utilized (EFR Group) and randomly selected 40 patients from the same centers for comparison (Control Group) . There were no significant differences in baseline characteristics between the two groups (All p values &amp;gt; 0.25) Results: We find that the accuracy of diabetes regimens provided by primary teams at discharge was significantly higher when EFR Note was utilized, relative to control (88% vs. 60%; χ2 (1) = 6.46, p = 0.011) . The most common error was incorrect insulin type/dosing, accounting for 76% of all errors. Insulin dosing errors were similarly less prevalent in the EFR Group relative to control (8% vs. 33%; χ2 (1) = 6.33, p = 0.012) . Conclusion: These results demonstrate that tools like EFR Note with specific instructions regarding discharge regimen can ameliorate deficiencies in discharge process. We plan to take steps to enhance awareness regarding the efficacy of EFR Note among endocrinology providers at multiple centers within our institution to facilitate a safer transition from inpatient to outpatient setting. Disclosure J.Lloyd: None. T.Abdulwahid: None. J.Levin: None. D.Pinkhasova: None.

Coordinating roles in the stoma care pathway: practical recommendations from France

Danièle Chaumier introduces recommendations for hospital discharge and community follow-up after ostomy formation, developed by the Strategic Healthcare Initiative for Easier Life Days (SHIELD)'s committee of multidisciplinary experts

Functional Status and Discharge Location of Patients Post–Left Ventricular Assist Devices Surgery in the Acute Care Setting

Purpose: Left ventricular assist devices (LVAD) are an alternative treatment for patients with heart failure. The purposes of this study were to describe patients immediately post-LVAD surgery, determine differences between functional outcome measures and discharge location, and the potential for initial Functional Status Score of the Intensive Care Unit (FSS-ICU) to assist in discharge recommendations. Methods: A retrospective study (n = 100) was conducted with the following data obtained: general demographics, FSS-ICU, ICU Mobility Scale (IMS), maximal ambulation distance, and discharge location. Patients were divided into 2 groups based on discharge location (home vs facility). Results: The mean age was 52.8 years, with 64% male. A significant improvement in all functional outcomes was observed from evaluation to discharge. Patients discharged home (76%) exhibited significantly higher FSS-ICU and IMS scores and tolerated out-of-bed activity and ambulation earlier. A score of 14 or higher on the initial FSS-ICU was predictive for discharge to home recommendation. Conclusion: Patients post-LVAD implantation exhibited low levels of functional mobility initially, yet were able to tolerate early activity. Patients discharged home had higher functional scores during the initial evaluation. Using the results of the FSS-ICU may assist in discharge recommendations; further research is needed.

Factors associated with febrile seizures among children

ObjectiveFebrile seizures are usually benign and are not presented with neurological manifestation. However, complex febrile seizures are presented with recurrence and might require meticulous management. The aim of this study was to evaluate the demographic, clinical, and laboratory parameters of children with febrile seizures and the correlation between these factors. MethodsIn this retrospective study, children presented with febrile seizure in 2019 presented (XXX) were included. Data based on their history, physical examination, and laboratory tests and discharge recommendations were recorded in a checklist. Data were computerized and statistically analyzed using SPSSv25. ResultsOf 77 patients were studied, the mean age of the patients was 29.4 ± 17.6. The mean duration of seizures was 5.09 ± 3.78 min and the mean temperature during seizures was 38.41 ± 0.83 °C. In 44 (57.14%) patients no cause of the fever was recorded. 10 (12.99%) patients had multiple seizures within 24 h 70 (90.91%) seizures ended without medication, and 5 (6.49%) patients were treated with diazepam. The gender of the patients was only correlated with white blood cells, p = 0.014. Other laboratory parameters did not show significant correlation with the gender, p > 0.05. The discharge recommendation was significantly correlated with recurrence within 24 h and type of seizure, p < 0.001, respectively. Lab parameters were significantly associated with family history, p = 0.036 and post-seizure drug, p = 0.005. ConclusionOur study showed that biochemical findings may not be suggestive of febrile seizures and recurrence of seizures and family history is associated with the course of treatment in terms of drugs and imaging.

Optimal management of post-discharge postpartum hypertensive disorders of pregnancy: a quality improvement initiative.

Introduction: Postpartum hypertensive disorders of pregnancy occur in 2-5% of pregnancies. It is a major cause of urgent postpartum consultation and is associated with life-threatening complications. Our objective was to evaluate if local management of postpartum hypertensive disorders of pregnancy was congruent with expert recommendations. Methods: We conducted a quality improvement initiative through a retrospective single-centre cross-sectional study. All women over 18-year-old consulting emergently for hypertensive disorders of pregnancy in the first six weeks postpartum, from 2015 to 2020, were eligible. Results: We included 224 women. Optimal management of postpartum hypertensive disorders of pregnancy was observed in 65.0%. While diagnosis and laboratory work-up were excellent, adequate blood pressure surveillance and recommendations upon discharge of an outpatient postpartum episode (69.7%) did not meet expectations. Conclusion: Efforts should be targeted to improve discharge recommendations on optimal blood pressure surveillance after delivery for women at risk for hypertensive disorders of pregnancy and for postpartum hypertensive disorders of pregnancy in women treated as outpatients.

Differences in Postacute Rehabilitation Recommendations by Ethnicity at an Urban Comprehensive Stroke Center.

The aim of this study was to investigate differences in postacute rehabilitation discharge recommendations, actual disposition, and rehabilitation duration by ethnicity at an urban Joint Commission Comprehensive Stroke Center. This was a retrospective cohort study of adult acute stroke hospital admissions between January 1, 2016, and December 31, 2019 (n = 1717) who were discharged to home with or without outpatient therapy, inpatient rehabilitation facility, or skilled nursing facility (SNF). Lognormal and multinomial regressions were used to create statistical models evaluating ethnicity-related differences in discharge recommendation and disposition as well as rehabilitation duration while controlling for age, stroke type and severity, insurance type, and medical comorbidities; non-Hispanic white (NHW) patients served as the comparison group. Hispanic patients were less likely to have therapy recommendations of SNF, with a trend toward significance (P = 0.06), yet statistically more likely to have the actual disposition of SNF (P = 0.01) than NHW patients. There were no statistically significant differences comparing disposition rates for black and Asian patients to NHW patients for both inpatient rehabilitation facility and SNF. There was no statistically significant difference in rehabilitation duration for black or Hispanic patients compared with NHW patients. Hispanic patients were less likely to have therapy recommended SNF disposition, with a trend toward significance, but significantly more likely to have actual SNF disposition compared with NHW patients after acute stroke.

Abstract 58: Adherence To Discharge Rehabilitation Recommendations May Decrease Unplanned Care And Improve Patient Outcomes

Adherence to Discharge Rehabilitation Recommendations May Decrease Unplanned Care and Improve Patient Outcomes Introduction Unplanned episodes of care result in increased cost to patients and institutions. Minimal data exist correlating discharge recommendation by rehabilitation specialists to patient outcomes. We aimed to evaluate the discharge recommendation of rehabilitation team (physiatry, occupational and physical therapies) versus actual discharge location and their relationship of unplanned episodes of care and ninety day outcomes. Method: A single center retrospective analysis of Acute Ischemic Stroke (AIS) patients discharged from January to September 2020. We excluded those that were discharged to hospice and expired during the initial encounter. Our primary outcome was to examine unplanned care episodes in comparison to the adherence of the rehabilitation team’s discharge recommendation. The secondary outcome examined the 90 day modified Rankin Score in comparison to the discharge recommendations. Stepwise logistic regression and ordinal regression models were utilized to analyze primary and secondary outcomes. Results: A total of 544 patients were evaluated. After exclusions we included 385 patients; 301 (78.2%) followed the discharge recommendation. Agreement on discharge location between physiatry and therapy modalities was 85.7%. When physiatrist final recommendations were unavailable, agreement between occupational and physical therapy decreased to 83.9%. Patients who adhered to rehabilitation recommendations were less likely to experience unplanned care compared to patients who did not (23.7% vs. 28.6%), although the difference was not statistically significant; adjusted odds ratio (aOR) = 0.63 [95%CI, 0.36 - 1.10], p = 0.10. Similarly, patients adhering to recommendations experienced less disability at 90 days compared to those who did not, although the difference was not statistically significant; aOR = 0.64 [95%CI, 0.39 - 1.06], p = 0.08. Conclusion: When the patients followed the recommendations of the rehabilitation team, a trend was found towards a decrease in unplanned care and better outcomes. Findings suggest additional research is warranted.

Planning for Safe Hospital Discharge by Identifying Patients Likely to Fall After Discharge.

Acute care physical therapists recommend discharge locations and services in part to help prevent falls during post-discharge recovery. Therapists may use standardized tests to inform their recommendation decisions, but evidence linking test scores with fall risk after discharge is lacking. The primary purpose of this study was to explore the associations between Tinetti Performance-Oriented Mobility Assessment (POMA) and Activity Measure for Post-Acute Care Inpatient Mobility Short Form (AM-PAC IMSF) scores and falls in the first 30days after hospital discharge. Anticipating that agreement between therapist recommendations and discharge locations and services (discharge agreement), age, and sex could impact those associations, these factors were included in this investigation. In this observational cohort study, 258 hospitalized patients consented to medical record data extraction and answered a phone survey 30days after discharge to report whether they had experienced a fall since leaving the hospital. POMA and AM-PAC IMSF tests were administered for every patient. Participants' age, sex, diagnosis, last POMA score, last AM-PAC IMSF score, physical therapist discharge recommendations, actual discharge location and services, discharge date, and phone number were collected from their medical records. When analyzed alone, higher POMA scores were associated with lower odds of falling, but the association was not significant after adjustment for other factors. Neither AM-PAC IMSF scores, age, nor sex were associated with falls. Discharge agreement, however, was associated with 59% lower odds of falling after adjustment for other factors. Participants, who were discharged to the location with the services recommended by their physical therapist, were less likely to fall. Tinetti POMA and AM-PAC IMSF scores did not discriminate well participants who would fall. Findings in this study inform those involved in discharge planning on the value of implementing physical therapist recommendations in reducing fall risk after hospital discharge. If physical therapist discharge recommendations are implemented, patients are less likely to fall during the month after hospital discharge. Balance and mobility test scores may provide therapists valuable information, but they are limited in their ability to identify who will fall after discharge.

Minority status and 30-day readmission: a moderated mediation model of informal caregivers’ ensuring and explaining medical care during hospitalization and caregivers’ health literacy

Introduction: Studies have shown that informal caregivers help patients to understand informa¬tion during clinical encounters, adhere to discharge recommendations, and perform self-care tasks. There is also evidence that patients with informal caregiver have a lower risk of readmission compared with patients without an informal caregiver. Less is known about factors that may affect Informal Caregiver’s Ensuring and Explaining Medical Care (ICEEMC) during hospitalization and its impact on improved health outcomes, especially in different cultural groups. This study examined whether ICEEMC during hospitalization mediated the association between minority status of patients and 30-day readmissions. In addition, it was investigated whether levels of Health Literacy (HL) of caregivers moderated this mediated association.Methods: A prospective cohort study of 517 internal medicine patients, Hebrew (general population, coded as 0) and Russian, or Arabic native speakers (minority status, coded as 1), at a tertiary medical center in central Israel (2013 to 2014), who were accompanied by an informal caregiver. The in-hospital baseline questionnaire included sociodemographic, physical, mental, and functional health status [covariates]. In addition, it included questions about informal caregiver HL [moderator] and amount of ICEEMC (e.g., did he/she communicated with the health care team about the treatment; three items - 1: did not receive any help to 5: received help all the time) taken from the Informal Assistance and Support for Hospitalized Older Adults (ICHOA) instrument)) [mediator]. Information on 30-day readmissions [outcome], chronic conditions, and prior hospitalization [covariates] was retrieved from the healthcare organization’s data warehouse. Testing a moderated mediation model was conducted using Hayes PROCESS procedure, model 7.Results: A total of 95 patients (18.4%) were readmitted within 30 days. Logistic regression indicated that minority status was not associated with 30-day readmission when the mediator ICEEMC was not included (B=0.98; p&gt;0.05). However, moderated mediation analysis indicated significant direct (B=-1.08; p=0.003) and inconsistent indirect effect of minority status on readmission through high ICEEMC during hospitalization among patients who had informal caregivers with high HL level (Mediated effect (ME)=−0.62; CI= -1.07 to -0.29) but not among ones with low HL level (ME= 0.37; CI=-0.24 to 1.06).Discussions: These findings suggest that high level of informal caregivers' HL may be an essential factor in improving ICEEMC among minorities, which in turn improves their health outcomes by reducing 30-day readmissions.Conclusions: The association between patients’ minority status and 30-day readmission is mediated by ICEEMC during hospitalization and depends on high level of informal caregiver HL.Lessons learned: Our findings suggest that identifying informal caregivers with high HL levels at time of admission to the hospital and encouraging their involvement during patients’ hospital stay might be a useful strategy to improve transitions and reducing 30-day readmission, especially among minority patients.Limitations: Generalizability may be limited due to characteristics of the Israeli society. Nonetheless, health practices and outcomes of minority patients are challenging in various healthcare systems worldwide.Suggestions for future research: Future studies should explore these findings as an intervention study aimed at improving health practices and outcomes of minority patients.

Utility of mental health and sleep screening questionnaires for patients admitted to a seizure monitoring unit

RationalePatients with seizure disorders have relatively high rates of comorbid psychological and sleep disorders. Because these can profoundly affect quality of life, early recognition and treatment are of potential benefit. As a quality improvement project, we evaluated the performance and utility of a set of mental health and sleep quality screening questionnaires in patients admitted to a VA seizure monitoring unit (SMU). MethodsQuestionnaires, including the Beck Depression Inventory-II (BDI-II), the post-traumatic stress disorder (PTSD) checklist (PCL), the Quality of Life in Epilepsy Inventory-31 (QOLIE-31), and the Pittsburgh Sleep Quality Index (PSQI), were administered to 100 patients admitted to the Portland VAMC SMU. Scored results were entered into the electronic medical record (EMR) within 72 h of hospital admission. We assessed how many patients exceeded questionnaire cutoff scores, and whether these patients had prior mental health or sleep diagnoses or evaluations within the six months preceding admission. Following hospital discharge, providers completed a survey regarding the utility of the questionnaire results. We also reviewed EMR documented mental health and sleep visits during the six months following the SMU admission. ResultsForty-seven patients (47.5%) exceeded the cutoff score for the BDI-II, including 15 without an admission diagnosis of depression, and 14 who had not seen a mental health provider in the previous six months. Similarly, 33 patients (33.3%) exceeded the cutoff score for the PCL, including nine without a diagnosis of PTSD. Scores on the BDI-II and PCL were highly correlated with the QOLIE-31 total score (r = 0.7). Seventy patients (70.7%) exceeded the cutoff score for poor sleep quality, and 37 did not have a sleep disorder diagnosis. Providers indicated that the questionnaire results were moderately or very helpful in most cases and influenced discharge recommendations to patients and referring providers in more than 50% of cases. Discharge recommendations for mental health or sleep follow-up were associated with EMR documented consultations within the six months following SMU admission. ConclusionsThe results suggest that a standard set of screening questionnaires can identify SMU patients at risk for mental health and sleep disorders, including patients not currently diagnosed or recently evaluated. Questionnaire results were perceived as helpful by providers and influenced discharge recommendations. Given that these disorders are treatable and have a major influence on health-related quality of life, the effort to collect and document this information is well justified.

OT Discharge Recommendations After Acute Stroke: Agreement Between Interprofessional Recommendations and Actual Discharge Setting

Abstract Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. In acute care, discharge planning is a primary role of OT for clients with arm impairment after stroke. Discharge planning accounts for many factors, including impairments, function, social supports, insurance, and the input of other disciplines. This research aimed to (1) determine the agreement in discharge recommendations between OT and physical therapy during acute hospitalization and (2) determine the agreement of OT recommendation and actual discharge setting for clients with arm impairment after stroke. Primary Author and Speaker: Nicole C. Lam Contributing Authors: Kimberly Erler, Jessica Ranford, Jessica D. Asiello, Kimberly Cortina, Natasha Frazier, Abigail Rude, Caitlin Sadlak, Helena Thorne, Rachel Collins, Erin E. Donovan, Sarah Norris, and David Lin

SARS-CoV-2 Viral Shedding and Transmission Dynamics: Implications of WHO COVID-19 Discharge Guidelines.

The evolving nature of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has necessitated periodic revisions of COVID-19 patient treatment and discharge guidelines. Since the identification of the first COVID-19 cases in November 2019, the World Health Organization (WHO) has played a crucial role in tackling the country-level pandemic preparedness and patient management protocols. Among others, the WHO provided a guideline on the clinical management of COVID-19 patients according to which patients can be released from isolation centers on the 10th day following clinical symptom manifestation, with a minimum of 72 additional hours following the resolution of symptoms. However, emerging direct evidence indicating the possibility of viral shedding 14 days after the onset of symptoms called for evaluation of the current WHO discharge recommendations. In this review article, we carried out comprehensive literature analysis of viral shedding with specific focus on the duration of viral shedding and infectivity in asymptomatic and symptomatic (mild, moderate, and severe forms) COVID-19 patients. Our literature search indicates that even though, there are specific instances where the current protocols may not be applicable ( such as in immune-compromised patients there is no strong evidence to contradict the current WHO discharge criteria.

Predictors of Parent Behavioral Engagement in Youth Suicide Discharge Recommendations: Implications for Family-Centered Crisis Interventions.

The number of youth presenting to Emergency Departments (EDs) with psychiatric chief complaints has almost doubled in the last decade. With pediatric patients, ED brief interventions and discharge recommendations necessitate meaningful parental engagement to optimize youth safety and support. This study examined parent-level factors (stigmatizing attitudes, self-efficacy beliefs, distress symptoms, and illness-related stressors) in relation to parents' behavioral engagement (i.e., participation in and follow-through with best practice discharge recommendations). In this short-term prospective study, participants were 118 parent-youth (aged 11-18) dyads (57% female) recruited from a psychiatric ED. Parents' behavioral engagement was measured with parent- and youth-self report at 2-week follow-up. Parents' self-reported anxious and depressive symptoms, insomnia, stress, and stigmatizing attitudes were not related to engagement 2weeks later. Higher parental self-efficacy beliefs were significantly associated with greater engagement in standard discharge recommendations. Implications for maximizing parent implementation of clinical recommendations during a youth suicide crisis are discussed.

Diabetes Medication Reconciliation at Hospital Discharge

Background: During hospital discharge, patients are at high risk for medication discrepancies as they transition from hospital to home. This study aims to evaluate the prevalence of medication errors at hospital discharge for diabetes medications in patients who received an endocrinology consultation for diabetes and explore interventions to improve the accuracy of discharge medication reconciliation. Methods: All patients (n=3018) who received an endocrinology consultation for diabetes at a tertiary care medical center from October 2017 to December 2019 were included. A retrospective chart review was performed to collect the following information on each patient: primary service from which the patient was discharged, hospital site, month and year of discharge date, and whether each patient’s medication reconciliation for diabetes medications at hospital discharge was in agreement with the inpatient diabetes team’s recommendations. Patients who were discharged on medications discordant from those recommended by the inpatient diabetes service were subcategorized into three groups: 1) one medication incorrect 2) more than one medication incorrect and 3) the primary service did not notify the consult team of patient’s discharge or request final recommendations for diabetes medications prior to discharge. Based on the findings of this study, an educational intervention was implemented in November 2019 to the Hospital Medicine services regarding diabetes discharge medication reconciliation. Results: Of the 3018 patients who received an endocrinology consultation for diabetes at a tertiary university medical center, 2279 patients (76%) were discharged on correct medications, 165 patients (5%) were discharged with one incorrect medication, 443 patients (15%) were discharged with more than one incorrect medication, and 121 patients (4%) were discharged without final discharge recommendations from the diabetes service. There was no significant variation based on discharging service or month of the year. After an educational intervention was implemented in November 2019 to the Hospital Medicine service on the existence and use of a comprehensive diabetes discharge order set, the percentage of patients discharged on correct medications improved to 92% (11/12 patients) compared to prior 81% (44/54 patients). Conclusion: Despite detailed discharge medication recommendations including patient education detailing the recommended regimen by the endocrinology diabetes service, a significant number of patients were discharged by providers across all services on diabetes medications discrepant with the diabetes service’s recommendations. Educational efforts improved the rate of correct medications at discharge on the Hospital Medicine service, and additional educational interventions with other services may be helpful in improving medication reconciliation accuracy.

Effects of patients’ hospital discharge preferences on uptake of clinical decision support

The Centers for Medicare and Medicaid Services identified unplanned hospital readmissions as a critical healthcare quality and cost problem. Improvements in hospital discharge decision-making and post-discharge care are needed to address the problem. Utilization of clinical decision support (CDS) can improve discharge decision-making but little is known about the empirical significance of two opposing problems that can occur: (1) negligible uptake of CDS by providers or (2) over-reliance on CDS and underuse of other information. This paper reports an experiment where, in addition to electronic medical records (EMR), clinical decision-makers are provided subjective reports by standardized patients, or CDS information, or both. Subjective information, reports of being eager or reluctant for discharge, was obtained during examinations of standardized patients, who are regularly employed in medical education, and in our experiment had been given scripts for the experimental treatments. The CDS tool presents discharge recommendations obtained from econometric analysis of data from de-identified EMR of hospital patients. 38 clinical decision-makers in the experiment, who were third and fourth year medical students, discharged eight simulated patient encounters with an average length of stay 8.1 in the CDS supported group and 8.8 days in the control group. When the recommendation was “Discharge,” CDS uptake of “Discharge” recommendation was 20% higher for eager than reluctant patients. Compared to discharge decisions in the absence of patient reports: (i) odds of discharging reluctant standardized patients were 67% lower in the CDS-assisted group and 40% lower in the control (no-CDS) group; whereas (ii) odds of discharging eager standardized patients were 75% higher in the control group and similar in CDS-assisted group. These findings indicate that participants were neither ignoring nor over-relying on CDS.

Transcatheter Aortic Valve Implantation During the COVID-19 Pandemic

Transcatheter aortic valve implantation (TAVI) outcomes during the coronavirus disease 2019 (COVID-19) pandemic have not been fully evaluated and some structural programs in the world have been suspended during this period. We sought to evaluate and compare clinical outcomes in patients undergoing TAVI in pandemic versus nonpandemic era. In a single center, we compared 198 TAVI patients performed during 2019 to 59 patients performed during the COVID-19 pandemic period (March 1st to June 30th, 2020). Primary outcome was procedural success according to VARC criteria and 30-day mortality rates. VARC-defined procedural success was high in both groups (93.3% vs 96.6%; p = 0.53). There were no differences in any vascular complications (26% vs 19%; p = 0.3), permanent pacemaker implantation (11.8% vs 15.3%; p = 0.63), and length of hospital stay (5.2 vs 4.2 days; p = 0.29). Thirty-day mortality was similar (3% vs 3.4%; p = 1.0). We had no documented COVID-19 disease in our patients during follow up. In conclusion, TAVI procedures can be performed effectively and safely during the COVID-9 pandemic, using a minimalist approach, early discharge, and by maintaining proper use of personal protective equipment.

Pragmatic Recommendations for Tracheostomy, Discharge, and Rehabilitation Measures in Hospitalized Patients Recovering From Severe COVID-19 in Low- and Middle-Income Countries.

ABSTRACTNew studies of COVID-19 are constantly updating best practices in clinical care. However, research mainly originates in resource-rich settings in high-income countries. Often, it is impractical to apply recommendations based on these investigations to resource-constrained settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for tracheostomy, discharge, and rehabilitation measures in hospitalized patients recovering from severe COVID-19 in LMICs. We recommend that tracheostomy be performed in a negative pressure room or negative pressure operating room, if possible, and otherwise in a single room with a closed door. We recommend using the technique that is most familiar to the institution and that can be conducted most safely. We recommend using fit-tested enhanced personal protection equipment, with the fewest people required, and incorporating strategies to minimize aerosolization of the virus. For recovering patients, we suggest following local, regional, or national hospital discharge guidelines. If these are lacking, we suggest deisolation and hospital discharge using symptom-based criteria, rather than with testing. We likewise suggest taking into consideration the capability of primary caregivers to provide the necessary care to meet the psychological, physical, and neurocognitive needs of the patient.