Early Discharge Of Patients Research Articles

Investigating the Effects of Performing the Early Mobilization Protocol on Postoperative Hemorrhaging in Cardiac Surgery Patients

Background: Most adverse effects following cardiac surgery, including hemorrhaging, are related to immobility. The early mobilization of the patient in enhanced recovery after surgery (ERAS) can counteract these adverse effects. Despite the awareness, however, the protocol has a low performance rate due to numerous barriers. The present research aims to investigate the effectiveness of performing the early mobilization protocol on hemorrhaging in cardiac surgery patients. Methods: This research is a clinical trial study conducted in 2023-2024 at Ali Ibn AbiTalib Hospital in Zahedan, Iran, on 100 patients undergoing cardiac surgery. Purposive sampling was used based on the inclusion criteria. Hemorrhaging risk assessment in patients was evaluated according to the preoperative checklist. The early mobilization protocol was performed on day 2 after surgery on patients in the intervention group with mild to low risk of hemorrhage. The statistical tests of repeated measures, chi-square, and independent t-test were used for data analysis in SPSS 26. Results: There were no statistically significant variations in the demographic characteristics of patients in the intervention and control groups. The mean and standard deviation (SD) of the blood volume loss in patients over three different time periods (days 2, 3, and 4 after surgery) were 326.500±16.81, 69.300±11.41, and 51.200±3.82 in the intervention group, respectively, and 350.00±16.81, 325.00±11.41, and 82.10±3.82 in the control group, respectively, indicating the effectiveness of performing the early mobilization protocol (P ˂ 0.001). Conclusion: Performing the early mobilization protocol can reduce the volume of bleeding after cardiac surgery and the early discharge of patients, thus leading to reduced complications. Nurses as the main care providers in intensive care units play a key role in performing the protocol.

Driving in the Wrong Direction: Exploring the Unintended Consequences of an Early Discharge Program on Length of Stay in Hospital Setting.

Early discharge of patients has become standard work in acute care settings to reduce inpatient length of stay (LOS), improve patient flow, and reduce boarding in the emergency department (ED). Patient-level electronic health record data included discharge order entry time, discharge time, LOS, and diagnosis-related group geometric LOS (GMLOS). Additional unit-level data for ED boarding volumes and hours were included. Analyses were conducted at the hospital and unit levels where indicated. Patients with a discharge order by 9 am have longer mean hours from order to discharge than patients without a discharge order by 9 am (9.04 vs 2.48 hours, P < .001) ED boarding total ( R2 =46.2%, P ≤.001), percentage ( R2 =50.4%, P ≤.001), median minutes ( R2 =24.6%, P =.005), and total minutes ( R2 =40.8%, P ≤.001) all increased as discharge by 11 am performance improved. The mean LOS is longer for the discharge by 11 am group than the non-discharge by 11 am group -1.67; 95% CI, -2.03 to -1.28, P <.001). Discharge by 11 am patients had a LOS/GMLOS ratio 21.9% higher than the non-discharge by 11 am cohort (difference -0.31; 95% CI, -0.36 to -0.26, P < .001). Discharge order entry and release by 9 am and patient physically discharged by 11 am initiatives demonstrate a statistical increase in time from discharge order to discharge time, ED boarding, LOS, and observed-to-expected LOS.

Omadacycline for the treatment of skin and soft tissue infections.

To evaluate the current evidence on the use of omadacycline for the treatment of skin and soft tissue infections (SSTIs). This narrative review examines the available data on the pharmacology, clinical efficacy, safety profile, and comparative effectiveness of omadacycline in treating SSTIs, with a focus on its potential role in everyday clinical practice. Omadacycline is a viable option for outpatient therapy and early discharge in patients with SSTIs, particularly in frail populations and those undergoing chronic polypharmacotherapy. Emerging real-world evidence highlights its potential utility beyond approved indications, particularly for infections caused by multidrug-resistant microorganisms where treatment options are limited. However, further studies are needed to confirm its role in contexts beyond its current approvals.

The Effect of Early Enteral Nutrition under the ERAS Model on Gastrointestinal and Immune Function Recovery in Patients Undergoing Gastric Tumor Surgery.

Patients with gastric malignant tumors usually undergo surgical treatment when indicated. Surgical intervention causes significant trauma and can lead to considerable stress responses in patients. These patients experience increased malnutrition along with reduced immune function, which ultimately leads to the occurrence of postoperative complications. Therefore, this study explored the effects of early enteral nutrition on gastrointestinal and immune function in patients undergoing gastric cancer surgery under the Enhanced Recovery After Surgery (ERAS) model, aiming to support early postoperative recovery. A retrospective analysis was conducted on the clinical data obtained from gastric tumors patients who underwent surgery in the Affiliated Hospital of Jiangsu University, between January 2019 and December 2022. Based on the gastrointestinal management approaches, the patients were divided into a control group (n = 92) and an observation group (n = 92). The control group received routine gastrointestinal management and parenteral nutrition support, while the observation group underwent early enteral nutrition support under the ERAS model. The initial postoperative flatulence, the first instance of eating, and the initial bowel movement, as well as serum nutritional indicators [albumin (Alb), prealbumin (PA), hemoglobin (Hb)], immune markers [immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA)], inflammatory markers [white blood cell (WBC), hypersensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6)] were evaluated at different time points before and after surgery. Furthermore, the incidence of postoperative complications (abdominal distension, diarrhea, and infection) and the length of post-surgery hospitalization were documented for both patient cohorts. The observation group showed shorter time to first postoperative flatus, earlier food consumption, and an advanced first bowel movement than the control group (p < 0.05). On the third day after surgery, the serum concentrations of Alb, PA, Hb, IgG, IgM, and IgA were diminished in both groups compared to their preoperative levels (p < 0.05). Moreover, on the 7th day after surgery, the serum levels of Alb, PA, Hb, IgG, IgM, and IgA increased in both groups compared to the 3rd day (p < 0.05) but remained lower than before surgery levels (p < 0.05). Additionally, the serum Alb, PA, Hb, IgG, IgM, and IgA levels were significantly higher in the observation group than in the control group on the 3rd and 7th postoperative days (p < 0.05). Three days following surgery, WBC, hs-CRP, and IL-6 levels were elevated in both groups compared to their preoperative levels (p < 0.05). On the 7th day after surgery, WBC, hs-CRP, and IL-6 levels decreased in both groups compared to the 3rd day after surgery (p < 0.05) but remained higher than preoperative levels (p < 0.05). Moreover, WBC, hs-CRP, and IL-6 levels were relatively lower in the observation group than in the control group on the 3rd and 7th postoperative days (p < 0.05). Furthermore, the observation group exhibited a decreased overall frequency of postoperative complications compared to the control group (p < 0.05), along with shorter hospitalization following the surgery (p < 0.05). Our findings indicate that early enteral nutrition under the ERAS model can better promote the recovery of gastrointestinal and immune functions in patients undergoing gastric tumor surgery while reducing postoperative complications and facilitating early discharge of patients.

Difficulties faced by three hospitals evacuated from the urgent protective action planning zone after the 2011 Fukushima Daiichi Nuclear power plant accident.

In radiological disasters, evacuating institutionalized individuals such as hospitalized patients and nursing home residents presents complex challenges. The Fukushima Daiichi Nuclear power plant (FDNPP) accident, triggered by the Great East Japan Earthquake (GEJE), exposed critical issues in evacuation planning. This case series investigates the evacuation difficulties encountered by three hospitals situated 20 to 30km from the FDNPP following the GEJE and FDNPP accident. Data collection involved reviewing records, stakeholder interviews and analyzing publicly available resources. Six key challenges emerged: acute phase influx-hospitals faced an abrupt surge in patients, including trauma victims and vulnerable individuals; initial discharge and transfers-coordinating patient discharges and transfers during the chaotic aftermath proved daunting; staff shortages-evacuation and personal factors lead to reduced staffing levels and strained hospital capabilities; infrastructure damage and logistics suspension-infrastructure issues, such as burst water pipes, halted gas supplies, and heavy oil shortage disrupted hospital operations; unclear evacuation criteria-ad hoc evacuation decisions underscored the lack of clear criteria; and limited preparation time-minimal preparation time hindered communication and planning. These findings underscore the need for robust disaster planning, resource management, and communication strategies to ensure the safety of patients and staff during radiological emergencies. Government interventions, early patient discharge, and improved medical record communication may alleviate the burden of evacuation. The lessons learned emphasize the importance of maintaining hospital functions in disaster-prone areas, particularly for vulnerable populations, and highlight the necessity for comprehensive community-wide disaster prevention planning.

Early Discharge Program After TAVI Based On Close Follow-up Supported by Telemonitoring Using Artificial Intelligence: the TeleTAVI Study

Abstract Introduction and objectives Evidence regarding the safety of early discharge following transcatheter aortic valve implantation (TAVI) is limited. The aim of this study was to evaluate the safety of very early (&amp;lt;24) and early discharge (24-48h) as compared to standard discharge (&amp;gt;48h), supported by the implementation of a voice-based virtual assistant using Artificial Intelligence (AI) and Natural Language Processing. Methods Single-arm prospective observational study that included consecutive patients who underwent TAVI in a tertiary hospital in 2023 and were discharged under an AI follow-up program. Primary end point was a composite of death, pacemaker implantation, readmission for heart failure, stroke, acute myocardial infarction, major vascular complications, or major bleeding, at 30-day follow-up. Results A total of 274 patients were included. 110 (40.1%) patients were discharged very early (&amp;lt;24h), 90 (32.9%) early (24-48h) and 74 (27.0%) were discharged after 48h. At 30-day follow-up no significant differences were found among patients discharged very early, early and those discharged after 48h for the primary endpoint (very early 9.1% vs early 11.1% vs standard 9.5%; p = 0.88). The AI platform detected complications that could be effectively addressed. The implementation of this follow-up system was simple and satisfactory for TAVI patients. Conclusions Early and very early discharge in patients undergoing TAVI, supported by close follow-up using AI, was shown to be safe. Patients with early and very early discharge had similar 30-day event rates compared to those with longer hospital stays. The AI system contributed to the early detection and resolution of complications.

A real-world, prospective, observational, investigator initiated trial to evaluate early discharge following Angio-Seal™ vascular closure device in patients undergoing percutaneous coronary intervention

BackgroundCardiac catheterization procedures such as percutaneous coronary intervention (PCI) are widely used but with complications of access site bleeding. Manual compression (MC)is the well accepted technique to control bleeding but time consuming (15-20 min); vascular closure devices (VCDs) are used increasingly as an alternative to MC and require <5 min for deployment.We aimed to document the real-world experience with a bioabsorbable collagen closure device (Angio-Seal™) with absorbable traction suture in patients undergoing PCI. ObjectiveThe primary objective was time (hours) to discharge from hospital after the procedure; to document the incidence of vascular access site complications, time to ambulation and time to hemostasis were the secondary objectives. MethodThis was a prospective, observational, investigator-initiated clinical trial wherein adult patients who underwent PCI procedure through femoral access route, with deployment of Angio-Seal™ femoral closure device were included. ResultsAmongst the 100 patients enrolled, 68 % were males. systemic hypertension (63 %), and type-2 diabetes mellitus (37 %) were the major comorbidities reported. Mean overall time from the end of procedure to hemostasis was 2.32 ± 0.99min. Time to ambulation was 156.08 ± 36.81min and to hospital discharge was 25.21 ± 4.49 h, One subject experienced hematoma. No other complications particularly pertaining to vascular access site were observed. ConclusionAngio-Seal™ is an effective and safe VCD and results in early ambulation, rapid hemostasis, and discharge in patients undergoing PCI.

Trends in home treatment and early discharge of patients with low-risk pulmonary embolism

Abstract Background A strategy of ambulatory treatment or early discharge (≤ 48 hours) of patients with acute low-risk pulmonary embolism (PE) has been adopted by the most recent guideline recommendations. However, the adoption of such a change of paradigm in PE care in the ‘real-world’ clinical setting, outside the concept of prospective cohort (management) studies, remains unknown. Aims To determine the proportion of patients with PE who fulfill eligibility criteria for home treatment or early discharge, to investigate in how many of them such a management strategy is actually followed, and to discover differences in early complications between early or later discharge among low-risk patients. Methods We used two nationwide databases, the US Nationwide Emergency Department Sample (NEDS) and Nationwide Readmission Database (NRD), to identify patients with low-risk PE (absence of the following at presentation: haemodynamic instability, cor pulmonale, tachycardia, dyspnea, hypothermia, altered mental status, and fulfilment of the Hestia critieria). We investigated the proportion of patients that were discharged entirely at home, or discharged early (hospital stay £ 2 days) and their association with predictor variables. We also studied the 90-day occurrence of venous thromboembolism recurrence and major bleeding. Results From 2016 to 2020, there were 2,099,390 emergency department visits for PE (NEDS Database), with 641,621 (30.6%) classified as low-risk. Home treatment was documented in 20.3% of all cases, with 31.5% of low-risk PE cases being treated at home and an increasing trend over time (Figure 1A). Factors associated with home treatment for low-risk PE included younger age, female sex, and absence of comorbidities; home treatment was more frequent at university hospitals, non-metropolitan hospitals, and those with higher emergency department volumes (Figure 2A). In the NRD Database, there were 1,950,708 PE hospitalizations during the same period with 481,321 classified as low-risk (24.7%). An early discharge strategy was followed in 22.6% of all cases, increasing to 45.9% for low-risk PE admissions, with a rising trend observed from 2016 (Figure 1B). Factors associated with early discharge for low-risk PE included younger age, male sex, and absence of comorbidities; here, university hospitals and metropolitan hospitals were less likely to implement early discharge (Figure 2B). The 90-day incidence of VTE recurrence among low-risk patients was lower with early discharge (1.3% vs. 1.8%, p&amp;lt;0.001), as was major bleeding (1.5% vs. 2.8%, p&amp;lt;0.001). Conclusion Our results reveal an increasing implementation of early discharge and home treatment for low-risk PE across recent years. Factors influencing these strategies are related to demographics and hospital type. Early discharge was associated with favourable outcomes in the real-world setting, thus supporting the results of previously performed prospective cohort studies and randomized trials.Figure 1Figure 2

The Waiting 4 Surgery study: burden of in-hospital care

Abstract Introduction Patients with coronary artery and valvular diseases with surgical indication represent a significant proportion of hospitalizations. The Waiting 4 Surgery study (W4S) aims to better study this group of patients, their burden of hospital care and identify those with event-free admissions. Purpose In this work, we analyze both the economical and hospital-care burden of this group of patients. Methods Retrospective study of consecutive patients admitted between 2019 and 2021 with coronary artery and/or aortic valve diseases waiting for coronary artery bypass graft (CABG), aortic valve replacement (AVR; surgical or percutaneous) or both. Total admission time and the cost associated with the hospitalization were analyzed. For event-free hospitalization, the following events were considered: death, re-infarction, cardiac pulmonary arrest (CPA), stroke, ventricular tachycardia, acute heart failure (AHF), rest chest pain and reintroduction of intravenous (IV) drugs. We performed a secondary cost analysis for patients with event-free hospitalization after the first 5 days of admission. Results Total of 184 patients were included, mean age 67.9 years, 70.1% male, 71.2% submitted to CABG and 20.7% to AVR (6.5% to both). During admission 23.9% of patients reintroduced IV drugs, 20.1% had chest pain, 5.4% had AHF and 2.2% had CPA. No deaths, strokes of re-infarctions were observed. The total time of hospitalization was 3 259 patients/days, representing an occupation rate of 18.6% and a total cost of 1 898 447€ (10 318€/patient and 632 816€/year). Mean admission time was 17.6 days. Total cost for CABG and AVR patients was 1 479 613€ and 594 562€, respectively. Total of 115 patients had an event-free hospitalization (62.5%). The total time of event-free hospitalization was 1 650 patients/days, representing an occupation rate of 9.42% and a total cost of 979 710€ (6 575€/patient and 326 570€/year). Mean event-free admission time was 14.3 days. Total cost for CABG and AVR in event-free patients was 863 155€ and 223 258€, respectively. Conclusion The W4S study demonstrates the impact patients waiting for surgery represent in hospital care: a very high economic and logistic burden. The majority of patients showed an event-free admission, and identifying such patients for early discharge and ambulatory management together with surgical centers should be a priority.

Together All To (Bid) Adieu (TATA) (Seamless Discharge Process)

The discharge process is a crucial step in patient care, often marred by delays, communication breakdowns, and other bottlenecks, leading to decreased patient satisfaction. This article emphasizes the need for seamless discharge planning, which begins at admission and continues throughout the patient's stay. Nursing staff play a critical role in ensuring a smooth discharge, coordinating various tasks from communicating discharge timelines to arranging for necessary equipment and medications. By following well-planned strategies, such as early discharge preparation, patient and family education, and timely return of medications, healthcare professionals can enhance the patient’s experience and ensure a positive conclusion to their hospital stay.

Association of robotic surgery with early discharge, readmission, and complications in elective colectomy: an analysis of NSQIP data from 2012 to 2021.

Background Early discharge (ED) after colectomy has become a target outcome for multiple reasons, but the factors associated with ED are not well characterized. This study investigated the factors associated with ED and evaluated the impact of ED on overall outcome. Methods Data from ACS-NSQIP were used to identify patients who underwent non-emergent colectomy from 2012 to 2021. ED was defined as length of stay ≤ 2days. Unpaired t-tests, chi-square tests and adjusted multivariate logistic regression modeling were used to estimate associated factors for ED. Bounceback readmission was defined as readmission within 7days of discharge. Results In this cohort of 282,490 patients, 43,137 (15.3%) met the criteria for ED. Robotic colectomy (OR 14.35; 95% CI [13.63-15.12]) was more strongly associated with ED than any other patient characteristic, including laparoscopic colectomy (6.82 [6.51-7.14], ref open colectomy). ED vs. non-ED patients had lower rates of 30-day (5.84 vs. 10.37%, p < 0.01) and bounceback (3.56 vs. 5.75%, p < 0.01) readmissions, overall complications (5.65 vs. 18.63%, p < 0.01) and post-discharge complications (4.21 vs. 7.49%, p < 0.01). Conclusions Robotic surgery was the variable most strongly associated with ED, with greater odds of ED compared to both laparoscopic and open colectomy. Patients who had ED after robotic surgery had lower rates of complications and readmission compared to non-ED patients.

Evaluation of an intervention to decrease length of stay in children with low-risk febrile neutropenia

Abstract Background Febrile neutropenia is one of the most common serious complications of myelosuppressive chemotherapy. For this reason, pediatric oncology patients with FN have traditionally been admitted to the hospital and started on empiric intravenous antibiotics. However, not all FN patients are at high risk of developing subsequent complications, and a low-risk group exists that could safely be discharged early. Methods A retrospective study of 194 FN episodes presenting in pediatric oncology patients at St. Jude Children’s Research Hospital. Outcomes of FN episodes were studied and compared before and after early discharge guidelines for low-risk febrile neutropenic (LRFN) were implemented at St. Jude on May 6, 2020. Results Total length of hospital stay was similar in the pre- and post-intervention groups (median 4 [IQR 3,6] vs. 4 [IQR 3,7] days, P = 0.443). Differences in adverse outcomes were insignificant between the pre- and post-intervention cohorts, with only two ICU admissions after the first 24 hours inpatient in the post-intervention group, one new positive blood culture (&amp;gt; 24 hours – 14 days of admission) in each group, and 36.2% versus 21% new fever after resolution of initial fever in pre- and post-intervention cohorts respectively. Cumulative antibiotic use between the pre- and post-intervention groups was statistically insignificant (median 13.5 [IQR 22.8,8] vs. 14 [IQR 22,9] days, P = 0.537), whereas Levofloxacin use was significantly longer in the post-intervention cohort versus the pre-intervention cohort (median 0 [IQR 0,4] vs. 0 [IQR 0,0] days, P = &amp;lt;0.001). Conclusion The implementation of guidelines for early discharge of LRFN patients showed no reduction in hospital stay. Understanding the optimal strategy for effectiveness of guideline implementation is crucial to improve quality and efficiency of care.

A clinical prediction model for safe early discharge of patients with an infection at the emergency department

BackgroundEvery hospital admission is associated with healthcare costs and a risk of adverse events. The need to identify patients who do not require hospitalization has emerged with the profound increase in hospitalization rates due to infectious diseases during the last decades, especially during the COVID-19 pandemic. This study aimed to identify predictors of safe early discharge (SED) in patients presenting to the emergency department (ED) with a suspected infection meeting the Systemic Inflammatory Response Syndrome (SIRS) criteria. MethodsWe conducted a prospective cohort study on adult non-trauma patients with a suspected infection and at least two SIRS criteria. We defined SED as hospital discharge within 24 h (e.g. direct ED discharge or rapid ward discharge) without disease-related readmission to our hospital or death during the first seven days. A prediction model for SED was developed using multivariate logistic regression analysis and tested with k-fold cross-validation. ResultsWe included 1381 patients, of whom 1027 (74.4 %) were hospitalized for longer than 24 h or re-admitted within seven days and 354 (25.6 %) met SED criteria. Parameters associated with SED were relatively young age, absence of comorbidities, living independently, yellow or green triage urgency, lack of ambulance transport or general practitioner referral, normal clinical impression scores, and risk scores (i.e., qSOFA, PIRO, MEDS, NEWS, and SIRS), normal vital sign measurements and absence of kidney and respiratory failure. The model performance metrics showed an area under the curve of 0.824. The validation showed a minimal drop in performance and indicated a good fit. ConclusionWe developed and validated a model to identify patients with an infection at the ED who can be safely discharged early.

JTH in Clinic: management of low-risk pulmonary embolism

Pulmonary embolism (PE) is a common cardiovascular disease diagnosis in emergency departments that can be associated with significant morbidity and mortality. One of the first steps after diagnosing PE is to risk stratify for adverse outcomes using risk scores such as PE Severity Index and European Society of Cardiology risk scheme. While intermediate- and high-risk PE patients should be admitted to the hospital, there is increasing evidence to support early discharge and home-based anticoagulation therapy for low-risk patients. The Hestia criteria encompass many of the clinicians’ considerations for who may be suitable for early discharge, considering both medical and social factors. Additionally, professional guidelines have provided algorithms on determining which low-risk patients may be suitable. Despite this, low-risk acute PE patients are still often admitted for inpatient treatment. In this review, we present a case-based approach on how to risk stratify and evaluate patients who may be good candidates for early discharge and home therapy.

Preliminary Insights Into Early Ambulation and Hemostasis After Atrial Fibrillation Ablation Using the Perclose Vascular Closure Device.

The introduction of the Perclose vascular closure device (VCD) for atrial fibrillation (AF) ablation procedures in Japan is expected to facilitate early ambulation. The study population comprised 554 patients undergoing AF ablation, of whom 377 successfully underwent Perclose VCD deployment at the end of the procedure. At 4 h after the procedure, 94% (353/377 patients) achieved early hemostasis and 57% (213/377 patients) achieved early ambulation. Notably, 0.5% (2/377 patients) developed acute deep vein thrombosis. The Perclose VCD demonstrated promising efficacy in achieving early hemostasis, potentially facilitating early ambulation and discharge in appropriate patients.

SP5.7 - Identifying patients for safe early discharge following robotic colorectal resection: can C reactive protein levels help?

Abstract Aims Current enhanced recovery protocols are mainly based on outcomes from laparoscopic surgery and do not factor in the reduced stress response seen in robotic surgery. We report our centre’s seven-year experience in managing patients undergoing robotic colorectal resections and aim to define cut-offs for inflammatory markers to allow early and safe discharge of these patients. Methods A retrospective single-centre UK study including patients who underwent robotic colorectal resections with primary anastomosis from 01/02/2015 to 28/02/2022. Serial white cell counts and C-reactive protein (CRP) levels from postoperative day 1 to 5 were used as surrogate markers for assessing inflammatory response. Anastomotic leak was defined as evidence of disruption on imaging or on direct visualisation at return to theatre. Results In total, 200 patients were included based on our inclusion criteria. Overall, 19 patients (9.5%) had anastomotic leaks postoperatively. Postoperatively, a higher day 3, 4, and 5 white cell count and CRP were seen in patients with anastomotic leak. ROC curve analysis revealed a day 3 CRP of &amp;lt; 95.5 mg/L had a sensitivity of 94.4% in predicting no anastomotic leak with an AUC of 0.842. In our study, 94/200 patients met this cut-off and could have been safely discharged from hospital at day 3. Conclusion A day 3 CRP of &amp;lt; 95.5 mg/L was found to be a sensitive marker in ruling out anastomotic leak in patients undergoing robotic colorectal resection which is lower than the threshold described in the literature for open/laparoscopic procedures. Enhanced recovery protocols need to be redesigned to factor in the relative reduction in inflammatory response conferred by robotic surgery.

Safety and factors associated with early discharge in revisional laparoscopic Roux-en-Y gastric bypass: analysis of the MBSAQIP database.

Improvements in bariatric surgery outcomes have prompted policy initiatives that explore shifting bariatric surgery toward outpatient procedures. While the safety of early discharge after primary laparoscopic Roux-en-Y gastric bypass (LRYGB) has been reported, its safety for revisional LRYGB remains uncertain. Our study aimed to investigate the safety and patient factors associated with early discharge in patients undergoing revisional LRYGB compared with primary LRYGB. We identified adult patients who underwent primary and revisional LRYGB from 2020 to 2022 in the MBSAQIP database. Patients discharged early, i.e., same-day discharge (SDD) and next-day discharge (NDD) were compared to inpatients. Outcomes included 30-day complications (minor = Clavien-Dindo 1-2; major = Clavien-Dindo 3-4), mortality, readmissions, and reoperations. Multivariable logistic regression models adjusting for patient demographics, comorbidities, and operative time were fitted to assess the study outcomes. SDD rate was similar after primary (3,422/137,406; 2.5%) and revisional LRYGB (781/32,721; 2.4%), while NDD rate was higher in primary LRYGB (59.8% vs 54.7%, respectively; p < 0.001). SDD patients had lower odds of major complications compared to inpatients following primary (2% vs 7%, aOR: 0.30, 95%CI 0.24-0.38) and revisional LRYGB (3.7% vs 9.3%, aOR: 0.43, 95%CI 0.29-0.62, respectively). NDD patients had similarly lower odds of morbidity outcomes. ASA Classification IV/V was associated with lower odds of SDD compared to Class I/II (Primary: 0.9% vs. 3%, aOR: 0.61, 95% CI 0.48-0.78; Revisions: 0.9% vs. 3%, aOR: 0.24, 95%CI 0.10-0.55). Early discharge after revisional LRYGB, particularly after an overnight stay, can be accomplished safely in carefully selected patients. However, SDD rates remain low limiting its safety assessment. Further, almost half of the patients stay more than 48h in the hospital suggesting that policy initiatives toward outpatient management after bariatric surgery may be inappropriate for this patient population.

Implementation of a transition of care pathway for low-risk patients presenting to the emergency department with venous thromboembolism

Inpatient management of low-risk patients with venous thromboembolism (VTE) places a large resource burden on the healthcare system. Adult patients diagnosed with deep vein thrombosis (DVT) or pulmonary embolism (PE) in the emergency department (ED) have historically been hospitalized and treated with therapeutic anticoagulation. However, over the last two decades, outpatient treatment of patients with acute DVT and low risk PE has become increasingly accepted as an effective and safe option for patients given the low risk of short-term clinical deterioration. The purpose of this project was to establish a transition of care (TCM) program for patients with acute VTE presenting to the ED. The primary goals for the project included better quality patient follow-up in the Vascular Medicine Nurse Practitioner (NP) within one week and medication adherence. The second goal was increasing appropriate ED discharges for patients with low-risk VTE. Outcome metrics include the rate of early discharge of low-risk patients with VTE, follow-up in the Vascular Medicine NP clinic, and anticoagulant adherence.

Are Routine Postoperative Hemoglobin Tests Justified in All Patients Who Undergo Total Hip Arthroplasty Due to a Displaced Femoral Neck Fracture?

Background: Total hip arthroplasty (THA) is a standard treatment for a displaced femoral neck fracture in the elderly. In contemporary healthcare, there is a global shift towards fast-track treatment modalities, prioritizing early hospital discharge for patients. Consequently, routine postoperative blood tests may become redundant, offering significant time and cost savings. We aim to evaluate postoperative hemoglobin levels in trauma-related THA cases and identify patient profiles for whom these tests hold significance. Methods: A retrospective review of 176 THA procedures performed between 2018 and 2022, focusing on individuals undergoing THA for displaced femoral neck fractures. Multivariable logistic regression analysis was employed to identify factors associated with postoperative hemoglobin levels below 8.5 g/dL. Results: Of the 176 patients included, 109 (61.9%) were women and the mean age was 69.09 ± 8.13 (range 27 to 90) years. The majority of the patients underwent surgery within 48 hours of admission. The mean preoperative hemoglobin (Hb) level was 13.1 ± 1.4 g/dL, while the mean postoperative Hb level was 10.5 ± 1.2 g/dL. Only six patients (3.41%) exhibited postoperative Hb levels of ≤8.5 g/dL. No significant associations were found between postoperative Hb levels ≤ 8.5 and any demographic, surgical, or medical characteristics. Conclusions: Our findings suggest that routine postoperative blood count testing may not be necessary for most patients undergoing THA for displaced femoral neck fractures, particularly those without complications or significant comorbidities.

Unlocking the Potential of the HEART Pathway: Predicting MACE and Facilitating Nurse-Physician Collaboration in Chest Pain Unit.

The HEART pathway serves as a tool for predicting major adverse cardiac events (MACE) among patients presenting with acute chest pain, aiding in early discharge of low-risk patients and reducing unnecessary cardiac investigations. This study aimed to evaluate physician-nurse reliability of the HEART pathway. Moreover investigates the efficacy of HEART pathway to predict 3-month MACE in patients with acute chest pain. We conducted a prospective study on 97 patients experiencing acute chest pain. A team of three professionals - a nurse, a cardiology resident, and a cardiology attending physician - performed risk stratification. We assessed inter-rater reliability among the raters as well as explored 3-month MACE outcomes. Excellent pairwise agreements were found between the raters. Overall agreement among raters was excellent, with an ICC of 0.84 (95% CI: 0.73 - 0.97). The HEART pathway score exhibited strong predictive power (AUC: 0.85) for 3-month MACE. At a cut-off score of 4, sensitivity, specificity, and negative predictive values were 87.5%, 58.9%, and 95.8%, respectively. The HEART pathway score effectively predicts 3-month MACE in patients with acute non-traumatic chest pain. Moreover, the high agreement among the attending physician, the resident physician, and the nurse suggests that nurses could use this tool, potentially reducing the workload on physicians.