Early Discharge Rates Research Articles

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.

Safety and Effectiveness of the High-Sensitivity Cardiac Troponin HEART Pathway in Patients With Possible Acute Coronary Syndrome.

The HEART Pathway (History, Electrocardiogram, Age, Risk factors, Troponin) can be used with high-sensitivity cardiac troponin to risk stratify emergency department patients with possible acute coronary syndrome. However, data on whether a high-sensitivity HEART Pathway (hs-HP) are safe and effective is lacking. An interrupted time series study was conducted at 5 North Carolina sites in 26 126 adult emergency department patients being investigated for possible acute coronary syndrome and without ST-segment-elevation myocardial infarction. Patients were accrued into 16-month preimplementation and postimplementation cohorts with a 6-month wash-in phase. Preimplementation (January 2019 to April 2020), the traditional HEART Pathway was used with 0- and 3-hour contemporary troponin measures (Siemens). In the postimplementation period (November 2020 to February 2022), a modified hs-HP was used with 0- and 2-hour high-sensitivity cardiac troponin (Beckman Coulter) measures. The primary safety and effectiveness outcomes were 30-day all-cause death or myocardial infarction and 30-day hospitalizations. These outcomes and early discharge rate (emergency department discharge without stress testing or coronary angiography) were determined from health records and death index data. Outcomes were compared preimplementation versus postimplementation using χ2 tests and multivariable logistic regression to adjust for potential confounders. Preimplementation and postimplementation cohorts included 12 317 and 13 809 patients, respectively, of them 52.7% (13 767/26 126) were female with a median age of 54 years (interquartile range, 42-66). Rates of 30-day death or MI were 6.8% (945/13 809) postimplementation and 7.7% (948/12 317) preimplementation (adjusted odds ratio, 1.00 [95% CI, 0.90-1.11]). hs-HP implementation was associated with 19.9% (95% CI, 18.7%-21.1%) higher early discharges (post versus pre: 63.6% versus 43.7%; adjusted odds ratio, 2.22 [95% CI, 2.10-2.35]). The hs-HP was also associated with 16.1% (95% CI, 14.9%-17.3%) lower 30-day hospitalizations (postimplementation versus preimplementation, 31.4% versus 47.5%; adjusted odds ratio, 0.51 [95% CI, 0.48-0.54]). Among early discharge patients, death or myocardial infarction occurred in 0.5% (41/8780) postimplementation versus 0.4% (22/5383) preimplementation (P=0.61). hs-HP implementation is associated with increased early discharges without increasing adverse events. These findings support the use of a modified hs-HP to improve chest pain care.

Age-Based Trends in the Outcomes of Percutaneous Left Atrial Appendage Occlusion: Insights from a Real-World Database

The age-based trends in-hospital outcomes in patients with percutaneous left atrial appendage occlusion (LAAO) are unknown. Using the National Readmission Database from 2016 to 2019, patients who underwent LAAO were divided into 2 age groups: 60 to 79 and ≥80 years. The primary objective was to evaluate the age-based trends in the outcomes related to LAAO. The secondary objectives were to evaluate the mean cost and total cumulative cost of readmissions in both age groups in 2019. We identified 58,818 patients who underwent LAAO, of whom 36,964 (63%) were aged 60 to 79 years, and 21,854 (37%) were ≥80 years. The hospital mortality, pericardial complications, acute kidney injury, and in-hospital cardiac arrest did not change over time. The risk-adjusted postoperative stroke and bleeding requiring blood transfusion decreased in patients aged ≥80 years (p trend 0.03 for both outcomes). The length of stay decreased, and early discharge rates increased over time in both the unadjusted and risk-adjusted models in both age groups. The risk-adjusted 90-day readmission rates also decreased in patients aged ≥80 years. The inflation-adjusted cost did not change over time on the unadjusted and adjusted analyses. The total cumulative all-cause 90-readmission cost for both groups in 2019 was $31.7 million. Most outcomes after LAAO either improved or did not change from 2016 to 2019. Hospital mortality has remained <0.5% consistently since 2016. The risk-adjusted postoperative stroke, bleeding, and 90-day readmission rates improved in elderly vulnerable patients aged ≥80 years. The inflation-adjusted cost did not improve despite the decreasing length of stay and improving early discharge rates.

Enhanced Recovery after Surgery and Endometrial Cancers: Results from an Initial Experience Focused on Elderly Patients

Endometrial cancer is the fifth most common cancer among French women and occurs most frequently in the over-70-year-old population. Recent years have seen a significant shift towards minimally invasive surgery and Enhanced Recovery After Surgery (ERAS) protocols in endometrial cancer management. However, the impact of ERAS on endometrial cancer has not been well-established. We conducted a prospective observational study in a comprehensive cancer center, comparing the outcomes between endometrial cancer patients who received care in an ERAS pathway (261) and those who did not (166) between 2006 and 2020. We performed univariate and multivariate analysis. Our primary objective was to evaluate the impact of ERAS on length of hospital stay (LOS), with the secondary objectives being the determination of the rates of early discharge, post-operative morbidity, and rehospitalization. We found that patients in the ERAS group had a significantly shorter length of stay, with an average of 3.18 days compared to 4.87 days for the non-ERAS group (estimated decrease −1.69, p &lt; 0.0001). This effect was particularly pronounced among patients over 70 years old (estimated decrease −2.06, p &lt; 0.0001). The patients in the ERAS group also had a higher chance of early discharge (47.5% vs. 14.5% in the non-ERAS group, p &lt; 0.0001), for which there was not a significant increase in post-operative complications. Our study suggests that ERAS protocols are beneficial for the management of endometrial cancer, particularly for older patients, and could lead to the development of ambulatory pathways.

Safety and effectiveness of the short (0-1h) high sensitive troponin protocol in real-life practice

Aim Recent guidelines recommend the use of a short 0-1h high sensitive cardiac troponin (hs-cTn) algorithm in patients presenting with chest pain at the emergency department (ED). This retrospective observational study evaluates the safety and effectiveness of the new 0-1h hs-cTn I protocol in comparison with the standard 0-3h cTn I protocol for the diagnosis of acute myocardial infarction (AMI). Methods A total of two times 100 consecutive chest pain patients presenting at the ED in November/December 2018 (standard 0-3h cTn I group) and in November/December 2020 (short 0-1h hs-cTn I group) were enrolled. Decision making was based upon validated assay-specific cut-off values. Results The new 0-1h hs-cTn I protocol had a sensitivity of 100% (95% CI 83.2–100) and a negative predictive value of 100% to rule out AMI. The accuracy of rule-in was slightly lower with a specificity of 92.5% (95% CI 84.4–97.2). The overall protocol accuracy was 94% (95% CI 87.4–97.8) in the short 0-1h hs-cTn I group compared to 88% (95% CI 80.0–93.6) in the standard 0-3h cTn I group (p-value 0.14). The 0-1h hs-cTn I protocol was associated with a numerically higher rate of early hospital discharge compared to the conventional 0-3h cTn I protocol (47% versus 59%; p-value 0.09) and with a shorter median length of stay for those patients (mean 316 min versus 289 min; p-value 0.09). Conclusion The abbreviated protocol based on the 0-1h hs-cTn I assays is effective and safe for the exclusion of AMI at the ED.

Outpatient atrial fibrillation ablation: feasibility, safety and economic implications

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Catheter ablation of atrial fibrillation (CA-AF) is the most common ablation procedure in Spain. Purpose To analyze the feasibility of performing this procedure on an outpatient approach among patients undergoing scheduled to CA-AF. Methods We compared prospectively the results of all programmed CA-AF procedures in two consecutive periods: from April 1, 2018 to March 31, 2019 (conventional strategy CON-E]: discharge after at least one day of hospitalization, n=100) and from April 1, 2019 to December 31, 2021 (same-day discharge strategy [SDD-E] in which patients were referred for an outpatient procedure by intention to treat, n=320). We established a Primary Efficacy Objective (percentage of patients discharged on the same day in SDD-E), a Primary Safety Objective (cumulative incidence of urgent/unplanned care [UUC] in the 10 days following discharge) and a Secondary Objective (average cost per procedure including day hospital stay, hospitalization and UUC in the 10 days following discharge, using the most recent fees of the Spanish Public Health System). Results Primary Objective of Efficacy: in 358/380 procedures (94%) the patient was discharged within 12 hours after their arrival at the hospital (range of length of hospital stay: 7-10 hours). There was no difference in the early discharge rate between cryoablation vs. radiofrequency (94% vs. 95%; p=0.8). The reasons for patients being hospitalized after ablation in the same-day discharge strategy are displayed in Figure 1. Primary Objective of Safety: Twelve patients (12%) of the CON-E required urgency care within 10 days of discharge, compared to 53(14%) of the SDD-E (p=0.6), most of them due to recurrence of AF. Figure 2. Among SDD-E patients, one was hospitalizated due to severe groin haematoma on day 3 after discharge. The remaining 52 patients with UUC were discharged within 8 hours of arrival at the Medical Center. Secondary Objective: The SDD-E reduced hospital stays: 0 [Interquartilic Range: 0-0] vs. 1 [1-1] (p&amp;lt;0.001), resulting in lower cost per procedure: 552 euros (95% CI: 486-618) vs. 1738 euros (95% CI: 1172-1805) (p&amp;lt;0.001). Conclusions CA-AF can be performed with less than 12 hours of hospital stay in 94% of patients. Compared with the conventional strategy, SDD-E does not increase the rate UUC within 10 days of discharge and is associated with a significant reduction in cost per procedure.

Contemporary Trends, Characteristics, and Outcomes of Transcatheter Aortic Valve Implantation Among Extreme Elderly Patients

Transcatheter aortic valve implantation (TAVI) has been increasingly performed among extreme elderly patients with symptomatic severe aortic stenosis. We aimed to study the trends, characteristics, and outcomes of TAVI among extreme elderly. The National Readmission Database for the years 2016 to 2019 was queried for extreme elderly who underwent TAVI. Linear regression analysis was used to calculate the temporal trends in outcomes. A total of 23,507 TAVI extreme elderly admissions (50.3% women and 95.9% Medicare insurance) were included. The in-hospital mortality and all-cause 30-day readmissions were 2% and 15% and have been stable over years of analysis (p trend = 0.79 and 0.06, respectively). We evaluated complications, such as permanent pacemaker implantation (12%) and stroke (3.2%). Stroke rates did not decrease (3.4% vs 2.9% in 2016 and 2019 [p trend = 0.24]). The mean length of stay improved from 5.5 days in 2016 to 4.3 days in 2019 (p trend <0.01). The rates of early discharge (day ≤3) has improved from 49% in 2016 to 69% in 2019 (p trend <0.01). In conclusion, this nationwide contemporary observational analysis showed that TAVI was associated with low rates of complications in the extreme elderly. Transcatheter aortic valve implantation (TAVI) has been increasingly performed among extreme elderly patients with symptomatic severe aortic stenosis. We aimed to study the trends, characteristics, and outcomes of TAVI among extreme elderly. The National Readmission Database for the years 2016 to 2019 was queried for extreme elderly who underwent TAVI. Linear regression analysis was used to calculate the temporal trends in outcomes. A total of 23,507 TAVI extreme elderly admissions (50.3% women and 95.9% Medicare insurance) were included. The in-hospital mortality and all-cause 30-day readmissions were 2% and 15% and have been stable over years of analysis (p trend = 0.79 and 0.06, respectively). We evaluated complications, such as permanent pacemaker implantation (12%) and stroke (3.2%). Stroke rates did not decrease (3.4% vs 2.9% in 2016 and 2019 [p trend = 0.24]). The mean length of stay improved from 5.5 days in 2016 to 4.3 days in 2019 (p trend <0.01). The rates of early discharge (day ≤3) has improved from 49% in 2016 to 69% in 2019 (p trend <0.01). In conclusion, this nationwide contemporary observational analysis showed that TAVI was associated with low rates of complications in the extreme elderly.

Outcomes on an inpatient oncology service after the introduction of hospitalist comanagement.

Smilow Cancer Hospital (SCH) introduced hospitalist comanagement to the inpatient oncology service to address long lengths of stay and oncologist burnout. To determine the impact of hospitalists on inpatient quality outcomes and oncologist experience. Hospitalists were introduced to one of two inpatient oncology services at SCH. Patients were assigned to teams equally based on capacity. Outcomes on the oncologist-led, traditional service (TS) were compared with outcomes on the hospitalist service (HS) 6 months after program implementation. Outcomes included patient volume, length of stay (LOS), early discharge, discharge time, and 30-day readmission rate. Mixed linear or Poisson models that accounted for multiple admissions during the study duration were used. Oncologist experience was measured by survey. During the study period, there were 713 discharges, 400 from the HS and 313 from the TS (p = .0003). There was no difference in demographics or severity of illness (SOI) between services. Following adjustment for age, sex, race/ethnicity, cancer type, and discharge disposition, the average LOS was 4.71 on the HS and 5.47 on the TS (p = .01). Adjusted early discharge rate was 6.22% on the HS and 2.06% on the TS (p = .01). Adjusted mean discharge time was 3:45 p.m. on HS and 4:16 p.m. on TS (p = .009). There was no difference in readmission rates. Oncologists reported less stress (p = .001) and a better ability to manage competing responsibilities (p < .0001) while working on the HS. Hospitalist comanagement significantly improved LOS, early discharge, time of discharge, and oncologist experience without an increase in 30-day readmissions.

Ambulatory appendectomy for acute appendicitis: Can we treat all the patients? A prospective study of 451 consecutive ambulatory appendectomies out of nearly 2,000 procedures

BackgroundAcute appendicitis represents the leading cause of acute gastrointestinal disorders, but only a small series regarding ambulatory appendectomies are available. The aim of this study was to report the results of ambulatory (day-case) appendectomy for acute appendicitis in a large consecutive cohort and to improve selection criteria in order to extend the indications. MethodsAll appendectomy procedures for acute appendicitis (March 2013 to June 2020) were included retrospectively. Criteria to select patients eligible for ambulatory appendectomy were based on our clinico-radiological St-Antoine’s score ≥4. ResultsIn total, 1,730 consecutive patients had an appendectomy for acute appendicitis: 1,279 (74%) in conventional settings and 451 (26%) in ambulatory settings. In the conventional group, 360 (28%) patients had surgery deferred to the next morning, whereas in the ambulatory group, 309 patients (70%) were readmitted the next morning (P < .0001). In the ambulatory group, 376 (83%) patients satisfied the criteria (score ≥4), and 90.9% were discharged on postoperative day 0. Rates of unplanned consultation and readmission were not significantly different (5.1% vs 6.6% P = .243). Multivariate analysis of the entire cohort confirmed absence of radiological perforation as highly predictive of early discharge (odds ratio = 6.073). In our cohort, these patients had an early discharge rate of 86.4% compared to 90.2% in those with a St-Antoine’s score ≥4. Considering only radiological evidence of perforation as a selection criterion for ambulatory appendectomy, 581 more patients would be eligible for ambulatory surgery (+60%). ConclusionAmbulatory surgery for acute appendicitis based on St-Antoine’s score is safe. We propose to extend the indication for ambulatory management to all patients without radiological evidence of perforation.

Early Discharge from home health therapy services for people with Alzheimer’s Disease and Related Dementias

AbstractBackgroundPeople with Alzheimer’s Disease and Related Dementias (ADRD) experience barriers to accessing care that they need, including home health therapy services (physical, occupational, and speech therapy). Clinicians report difficulty engaging patients with ADRD in therapy sessions, especially during the later stages of the disease. There is limited information about how the existing barriers and challenges impact an individual with ADRD’s likelihood of being discharged from therapy services earlier than planned. The purpose of this study was to examine the relationship between early discharge from home health services and (a) dementia severity, (b) caregiver support, and (c) medication management.MethodThis retrospective study derived data from 100% national Medicare Home Health data files from October 1, 2016 through September 30, 2017. A cohort of 111,537 Medicare Fee‐for‐Service beneficiaries with ADRD was identified. A dementia severity categorization scale was used to classify individuals into one of six severity levels. Early discharge rates with associated 95% confidence intervals (CIs) were calculated for each patient characteristic. Multilevel logistic regression was used to estimate the relative risk (RR) of early discharge, by dementia severity level, caregiver support status, and level of medication assistance and adjusted for patient and clinical characteristics.ResultThe overall early discharge rate was 13.3% (13.1, 13.5). Individuals who were in the most severe ADRD stage were the only group that had an increased likelihood of being discharged early (1.163; 1.003‐1.344) amongst people with ADRD. However, individuals who required assistance with medication demonstrated a decreased likelihood of early discharge at all levels (0.828; 0.741‐0.924) There was no significant difference in likelihood for early discharge across caregiver support levels.ConclusionDespite a small increase in the most severe ADRD stage, the number of visits and the risk of early discharge was relatively consistent across severity stages. Further research is needed to assess whether the type and quality of services received varies across dementia stages. Individuals with ADRD who were independent with medication management had an increased likelihood of early discharge. Exploring this relationship in greater detail could inform clinician decisions about frequency and duration of care.

Role of Changing Procedural Characteristics Versus Changing Risk Profile in Age-Based Trends of Outcomes in Patients With Transfemoral Transcatheter Aortic Valve Replacement From 2012 to 2018: A Nationwide Analysis.

Background The trends in outcomes in patients who undergo transcatheter aortic valve replacement are well described in the literature. Some of these trends are driven by the decreasing risk profile of patients because of changing indications for transcatheter aortic valve replacement. We aimed to evaluate these trends in different age groups and quantify how much of these trends are driven by changes in procedural characteristics. Methods and Results Using the National Inpatient Sample from 2012 to 2018, we identified 204 230 adult patients who underwent transfemoral aortic valve replacement. The study's primary objective was to evaluate the changes in age-based trends in in-hospital mortality driven by changes in procedural characteristics over time. The secondary objectives were to evaluate similar trends in cardiac and noncardiac complications and resource use. Univariate and multivariate linear and logistic regression were used to obtain effect sizes. From 2012 to 2018, in-hospital mortality decreased from 1.8% to 0.79% in the age group 18 to 64 years, from 3.8% to 1.6% in the age group 65 to 80 years, and from 5.3% to 1.5% in the age group >80 years (P trend<0.01 for all age groups); these trends remained statistically significant on adjusted analysis except in patients aged 18 to 64 years. The other outcomes also showed variable trends over time. Length of stay, cost, and early discharge rates improved even after adjusting for comorbidities, which is likely attributable to improvement in procedural characteristics. Conclusions The changes in outcomes related to transcatheter aortic valve replacement are partly driven by changing patient risk profiles over time, but procedural characteristics have likely contributed to these trends in all age groups.

Minimally Invasive Valvular Surgery in the Elderly - Safety, Early Recovery, and Long-Term Outcomes.

For elderly people, the benefit of minimally invasive cardiac surgery (MICS) is unclear, so we evaluated the safety, recovery, and long-term survival in elderly MICS patients.Methods and Results: 63 propensity score-matched pairs of 213 consecutive patients (≥70 years old) who underwent mitral and/or tricuspid valve surgery between 2010 and 2020 (121 right mini-thoracotomies vs. 92 full sternotomies) were compared. The primary outcome was safety (composite endpoint of in-hospital death or major complication). Secondary outcomes were early ambulation and discharge to home. There were no differences between the groups for in-hospital death (3.2% vs. 0.0%, P=0.157) and primary outcome (14.3% vs. 17.5%, P=0.617). The rate of early ambulation (73.0% vs. 55.6%, P=0.048) and discharge to home (66.7% vs. 49.2%, P=0.034) were significantly higher in the mini-thoracotomy group. Major complication was an independent negative predictor of early ambulation for mini-thoracotomy but not for a conservative approach. Survival was 87.8±4.4% vs. 86.8±4.7% at 5 years, which was not significantly different. Similar safety but better recovery were observed for mini-thoracotomy, and long-term survival was comparable between groups. Major complication was a negative predictor of early ambulation after mini-thoracotomy. Careful preoperative risk stratification would enhance the benefits of MICS in elderly patients.

Oncology-hospitalist co-management: A model for efficient, high-quality care and education.

1 Background: Our inpatient oncology service at Smilow Cancer Hospital had long lengths of stay, high readmission rates and burnout among outpatient oncologists who rotated as inpatient attendings. With a proposal to improve length of stay by.25 days in the first year, the health system funded the integration of internal medicine hospitalists. Methods: Patients were randomly assigned to one of two oncology teams, allowing for real time outcome comparisons. Hospitalists were added to the Intervention Team and served as the primary attending with oncologists as consultants; Oncologists served as the primary attending on the Traditional Team. The intervention began in July 2021. Outcome metrics included LOS, readmission rate, case volume, early discharge rate, educational rankings, and oncologist satisfaction. A multidisciplinary steering group met to review data, study, and act on outcome metrics. Using Quality Improvement PDSA cycles, outcomes were reported at 3 months (PDSA 1), followed by improvement interventions; then reported again at 6 months (PDSA 2). Results: The Intervention Team achieved a 1.0-day reduction in LOS compared to Traditional team. There was no difference in Severity of Illness score in comparator groups, demonstrating no imbalance in patient population. The Intervention team cared for a 29% higher volume of patients and improved early discharge rate without an increase in readmissions from baseline. Oncologists reported a high level of satisfaction with the program. Housestaff overall educational rankings increased after the introduction of hospitalists (Table). Discussion: Hospitalist comanagement exceeded business plan LOS reduction target without compromise in quality or educational metrics. PDSA 1 identified need for role clarity among physicians, increased oncology teaching, and preservation of resident autonomy; PDSA 2 identified need for increased nursing-physician collaboration. Conclusions: Hospitalist comanagement can effectively reduce oncology LOS without adverse effect on readmission rates, educational outcomes, or oncologist satisfaction with care.[Table: see text]

Qualitative Subgenomic RNA to Monitor the Response to Remdesivir in Hospitalized Patients With Coronavirus Disease 2019: Impact on the Length of Hospital Stay and Mortality.

BackgroundThere is no reliable microbiological marker to guide the indication and the response to antiviral treatment in patients with COVID-19. We aim to evaluate the dynamics of subgenomic RNA (sgRNA) in patients with COVID-19 before and after receiving treatment with remdesivir.MethodsWe included consecutive patients admitted for COVID-19 who received remdesivir according to our institutional protocol and accepted to participate in the study. A nasopharyngeal swab for qRT-PCR was collected at baseline, and after 3 and 5 days of treatment with remdesivir. Genomic and sgRNA were analyzed in those samples and main co-morbidities and evolution were collected for the analyses. The main outcomes were early discharge (≤10 days) and 30-day mortality.ResultsA total of 117 patients were included in the study, from which 24 had a negative sgRNA at baseline with a 62.5% (15/24) of early discharge (≤10 days) and no deaths in this group. From the 93 remaining patients, 62 of them had a negative sgRNA at day 5 with 37/62 (59.6%) of early discharge and a mortality of 4.8% (3/62). In the 31 patients subgroup with positive sgRNA after 5 days of RDV, the early discharge rate was 29% (9/31) and the mortality rate was 16.1% (5/31). In the multivariable analyses, the variables associated with early discharge were negative sgRNA at day 3, and not needing treatment with corticosteroids or ICU admission.ConclusionsQualitative sgRNA could help monitoring the virological response in patients who receive remdesivir. Further studies are needed to confirm these findings.

Post-Operative Day Zero Discharge after Laparoscopic Appendectomy Does Not Worsen High-Yield Outcomes: A NSQIP Database Observational Study

Background: Post-operative day zero (POD-0) discharge after laparoscopic appendectomy for uncomplicated appendicitis has been studied primarily in single-center or pediatric studies. A larger study from a national sample addressing high-yield outcomes can update and supplement current literature and evaluate early discharge rates. Methods: This is a retrospective, observational National Surgical Quality Improvement (NSQIP) database study of laparoscopic appendectomies for uncomplicated appendicitis performed 2016–2019, with discharge POD-0 or post-operative day one (POD-1). Study outcomes included any or serious complication, unplanned readmission, and unplanned return to operating room (OR). Unadjusted outcomes comparisons were estimated via chi-square tests. Multivariate logistic regression models were constructed to adjust for potential confounders (sex, ethnicity, frailty, ASA score, tobacco use and diabetes). Results: A total of 25,629 patients were included in this analysis. More patients were discharged POD-1 (n = 15,229) than POD-0 (n = 10,440). Rate of any or serious complication was lower in patients discharged POD-0 than POD-1 (any complication: 2.0 vs. 2.8, p = 0.0002, serious complication: 1.4 vs. 2.1, p < 0.0001). Unplanned return to OR and unplanned readmission rates were not different between POD-0 and POD-1 discharged groups (p = 0.9 and p = 0.6, respectively). These findings were robust to adjustment for covariates in logistic regression modeling. Conclusions: This study found that unplanned readmission and other outcomes do not appear to be adversely affected by early discharge after laparoscopic appendectomy for uncomplicated appendicitis, confirming prior evidence on the topic in a large, national sample. It also found that early discharge does not appear to be used in most of these patients.

Impact of conductive disturbances on length of stay after TAVI: A single-centre retrospective study

Conductive disturbances remain the most frequent complication after TAVI. Management of conduction disturbances is highly variable among centres and impact length of stay (LOS). Recently, an expert consensus has been proposed in order to reduce their impact on LOS. To evaluate the impact of the expert consensus for the management of conductive disturbances to reduce LOS after TAVI. We retrospectively included patients who underwent a TAVI between January 1st, 2017 and December 31st, 2018. Patients who had a pacemaker before TAVI were excluded. ECG before, immediately after and the first two days after TAVI were analysed. According to the expert consensus, patients were classified in 5 groups: group 1 (normal ECG and no modification after TAVI), group 2 (pre-implantation right bundle branch block without modification after TAVI), group 3 (PR or QRS enlargement > 20 ms in patients with pre-existing conductive disturbances), group 4 (new onset left bundle blanch block), group 5 (High degree atrioventricular block or complete heart block during procedure). We assessed the proportion of patients early discharged (within 72 hours) among these 5 groups. During the studied period, 348 patients were included. The median LOS was 2 [2–4] days and 245 (71%) patients were discharged early. LOS were longer in groups 2, 3, 4 and 5. Patients in groups 3, 4 and 5 were discharged early in 62%, 65%, and 63% of cases respectively. In contrast, group 1 patients were discharged early in 77% of cases. Patients identified as having a high risk of delayed conductive disturbances by the consensus had longer LOS (5 [2.5–6.5] days with a lower rate of early discharge (39%) ( Table 1 ). This study confirm the impact of conductive disturbances on LOS. The consensus reduces their impact on LOS and allows early discharge in 71% of cases without other complications.

Trends, Outcomes, and Impact of Early Discharge Following Bariatric Surgery: a Retrospective MBSAQIP Analysis of 748,955 Patients.

Decreasing the length of stay following bariatric surgery can reduce pressure on hospitals and surgical costs and increase patient satisfaction. We examine trends in length of hospital stay following bariatric surgery and in post-operative complications. The 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was used to compile patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy. Patients were categorized into either early discharge (within one day of surgery) or late discharge, and patient and non-patient factors were compared between the two groups. A multivariable logistic regression was carried out to determine predictive factors for early discharge. We evaluated 748,955 patients, with 399,918 (53%) being discharged early. Patients discharged early were younger and had fewer associated medical problems. The rate of early discharge increased between 2015 and 2019 (42.1% in 2015 vs 62.0% in 2019), while complication rates decreased or were unchanged. Multivariable analysis revealed lower ASA classification (OR 1.07; CI 1.06-1.09; p < 0.0001) and operative year (2019 vs. 2015 OR 2.26; CI 2.22-2.29; p < 0.0001) to be independently associated with early discharge.Several factors including undergoing RYGB (OR 0.44 CI 0.44-0.45; p < 0.0001), and dialysis dependence (OR 0.50; CI 0.45-0.55; p < 0.0001) among others, were associated with reduced early discharge likelihood. There is a trend in bariatric surgery towards the practice of early discharge, which is safe for patients. Further work is needed to develop a set of criteria to determine which patients are best suited for this practice.

Early Discharge from a Newborn Nursery in the United States during the COVID-19 Pandemic

The COVID-19 pandemic changed birth hospitalization, with many hospitals implementing restrictions. Little is known about the impact of the COVID-19 pandemic on rates of early newborn discharge and length of stay (LOS). The primary objective was to compare rates of early discharge before and after the start of the COVID-19 pandemic. Secondary objectives included 28-day readmissions and LOS. A single-center retrospective cohort study was undertaken of all live newborns discharged from a well newborn nursery in the United States between 1 July 2015 and 18 June 2021. The pre-COVID-19 era was defined as 1 July 2015 to 29 February 2020, and the COVID-19 era as 1 March 2020 to 18 June 2021, based on the first case reported in our state. Early discharge was defined as less than or equal to 24 h. A total of 10,589 newborns were included: 8094 before and 2495 after the COVID-19 pandemic started. Overall, 43 newborns (0.41%) were discharged early. In the COVID-19 era, early discharges significantly increased from 0.23% (n = 19) to 0.96% (n = 24) (p &lt; 0.001). Median LOS declined from 52.0 (IQR, 43.0–64.0) to 45.0 (IQR, 37.0–56.0) hours (p &lt; 0.001). The 28-day readmission rate decreased from 2.3% (n = 182) to 1.3% (n = 33) (p &lt; 0.01). Since the start of the COVID-19 pandemic, the number of early discharges has significantly increased at our institution without an increase in readmissions. Additionally, overall decrease in length of stay for the birth hospitalization was observed. Potential reasons include changes in hospital unit policies including visitor limitations to reduce COVID-19 infection risk to patients and staff and/or parental concern for iatrogenic acquisition of the virus.

Association of early discharge with increased likelihood of hospital readmission in first four weeks for vaginally delivered neonates.

AimThe main aim was to determine whether hospital readmission rates by 28 days of age are elevated with early discharge (ED) in Finland. We sought to identify the causes and predictors of ED, readmission rates, admissions to the intensive care unit (ICU) and death.MethodsThe data of 333,321 infants were retrieved from nationwide registers. Vaginally delivered single infants at gestational ages (GAs) of ≥37+0, born in 2008–2015 and treated in any maternity ward in Finland, were included. ED was defined as discharge on the day of birth or after one night stay on the maternity ward.ResultsDuring the study period, the ED and hospital readmission rates increased. Low‐risk infants and those born in high population‐density areas were more likely to be discharged early. ED predicted hospital readmission but not ICU admission or death. The most common reason for readmission was jaundice, followed by infection. ED seemed not to predict severe cardiologic problems. Rather than ED, being born at 38+0–38+6 weeks’ GA significantly predicted ICU admission or death.ConclusionEarly discharge seems to be associated with increased hospital readmission. Birth at 38+0–38+6 weeks’ GA was a significant predictor of ICU admission or death, as opposed to early discharged infants.

Weak Transcranial Direct Current Effect on I Waves

Background: A single transcranial magnetic pulse over the motor cortex is known to generate repetitive descending activity along the corticospinal tract. With respect to the origin; the earliest volley is named direct wave and the subsequent activity forms indirect (I) waves. I waves are assumed to originate from corticocortical afferents; they can be modulated by several methods and are practical parameters for evaluating motor cortex excitability. Weak transcranial direct current stimulation (tDCS), which has been widely used in human studies since the early 2000s, is a noninvasive and painless modulatory method for studying cortical excitability. We aimed to investigate the modulatory effects of anodal and cathodal tDCS on I waves of healthy controls, as a component of the motor evoked potential response generator. Materials and Methods: Twelve healthy volunteers were enrolled in the study. One mA tDCS was applied for 10 min and; single motor unit (SMU) recording technique was used for the identification of I waves. Two conditions were analyzed for each SMU in both anodal and cathodal current polarities; before tDCS and after tDCS. Separate peristimulus time histograms were constituted for each condition. Total peak duration, early peak latency, early peak duration, and early peak discharge rate were calculated. Results: Total peak duration, early peak latency, and early peak duration did not differ between pre- and post-tDCS conditions in either polarity. However, I1 peak discharge rate was found to be significantly decreased after cathodal tDCS (P: 0.017) and increased after anodal tDCS (P: 0.003). Conclusion: Our results confirm polarity-specific effects of tDCS of the primary motor cortex on I waves. According to our knowledge, this is the first study evaluating modulatory effects of tDCS on I waves using SMU recording technique.