Early Hospital Discharge Research Articles

P486 Improving enhanced recovery after surgery (ERAS): the effect of a patient-centred mobile application on patient participation in colorectal surgery

Abstract Background Perioperative care in colorectal surgery is systematically established in the Enhanced Recovery After Surgery (ERAS) protocol. The ERAS protocol improved perioperative colorectal care in a multidisciplinary and multimodal manner, simulating early and safe hospital discharge. In general, compliance with the ERAS protocol is adequate; however, there is still room for improvement in compliance by actively involving patients in their recovery. The main objective of this study was to investigate whether compliance with selected items in the ERAS protocol could be improved by actively involving patients in the ERAS colorectal care pathway using a patient-centred mobile application. Methods This multicentre, randomised controlled trial was conducted in accordance with the CONSORT statement. Patients aged 18 years or older who underwent elective colorectal surgery and had a smartphone were included. Patients in the intervention group used a mobile application combined with an activity tracker to be guided and simulated through the ERAS pathway. Patients in the control group received standard care and wore an activity tracker to monitor their daily activities. The primary outcome was overall compliance with the selected active elements of the ERAS protocol. Secondary outcomes included length of hospital stay, number of complications, reintervention, and readmission rates, and patient-reported outcome measures (PROMs) such as quality of life, and patient satisfaction with received care. Results Between October 2019 and September 2022, 170 participants were enrolled and randomised to either the intervention (n=84) or control (n=86) groups. Thirty participants (17.6%) were lost to follow-up and 140 participants were included in the primary outcome analysis. Compliance with the selected active ERAS elements was 76.8% and 63.7% in the intervention and control groups, respectively (p<0.001). Complications or patient reported outcomes did not differ between the groups. Conclusion A patient-centred mobile application improved compliance with the active elements of the ERAS protocol. The implementation of this mobile application is recommended for patients undergoing elective colorectal surgery.

A new technique of duodenojejunostomy may reduce the rate of delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: The growth factor technique (with video)

BackgroundDespite various technical modifications, delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy. DGE results in longer hospital stay, higher cost, lower quality of life, and delay of adjuvant therapy. We have developed a modified duodenojejunostomy technique to reduce the incidence of DGE. Here we evaluate our 4-year experience with this technique. MethodsThis study evaluated consecutive patients who underwent pylorus-preserving pancreatoduodenectomy using the growth factor technique. It consists of performing a posterior seromuscular running suture with a zigzag stitch that stretches the jejunum and allows future growth of the anastomosis. This results in a longer jejunal opening. The angles at the edge of the duodenum are cut to accommodate the duodenal opening to the longer jejunum (the growth factor). The anterior seromuscular layer is then performed with interrupted sutures to accommodate the larger anastomosis. These patients were compared with a cohort of patients (n = 103) before the introduction of this new technique using propensity score matching. Results134 patients underwent pylorus-preserving pancreatoduodenectomy. Delayed gastric emptying occurred in only three patients (2.2%), one grade B and two grade C. Compared with the 103 patients in the control group with standard technique, the incidence of DGE was significantly higher (11.6%; P = 0.00318). The median hospital stay was also statistically longer in the control group (P = 0.048704). A similar trend was observed in the matched cohort; the proportion of patients who developed DGE was significantly (P = 0.005) lower in the growth factor technique group (2.1% vs. 12.9%). Hospital stay was significantly longer in the standard group (P = 0.008), and patients operated on with the standard technique resumed feeding later than those with the growth factor technique. ConclusionsThis study demonstrated that the new technique of duodenojejunostomy can reduce the incidence and severity of DGE and allow earlier hospital discharge. Comparative studies are still needed to confirm these preliminary results.

Establishment and external validation of neutrophil-to-lymphocyte ratio in excluding postoperative pancreatic fistula after pancreatoduodenectomy.

Factors excluding postoperative pancreatic fistula (POPF), facilitating early drain removal and hospital discharge represent a novel approach in patients undergoing enhanced recovery after pancreatic surgery. This study aimed to establish the relevance of neutrophil-to-lymphocyte ratio (NLR) in excluding POPF after pancreatoduodenectomy (PD). A prospectively maintained database of patients who underwent PD at two high-volume centres was used. Patients were divided into three cohorts (training, internal, and external validation). The primary endpoints of this study were accuracy, optimal timing, and cutoff values of NLR for excluding POPF after PD. From 2012 to 2020, in a 2:1 ratio, 451 consecutive patients were randomly sampled as training (n = 301) and validation (n = 150) cohorts. Additionally, the external validation cohort included 197 patients between 2018 and 2020. POPF was diagnosed in 135 (20.8 per cent) patients. The 90-day mortality rate was 4.1 per cent. NLR less than 8.5 on postoperative day 3 (OR, 95 per cent c.i.) was significantly associated with the absence of POPF in the training (2.41, 1.19 to 4.88; P = 0.015), internal validation (5.59, 2.02 to 15.43; P = 0.001), and external validation (5.13, 1.67 to 15.76; P = 0.004) cohorts when adjusted for relevant clinical factors. Postoperative outcomes significantly differed using this threshold. NLR less than 8.5 on postoperative day 3 may be a simple, independent, cost-effective, and easy-to-use criterion for excluding POPF.

LAPAROSCOPIC RIGHT AND LEFT COLECTOMY: WHICH PROVIDES BETTER POSTOPERATIVE RESULTS FOR ONCOLOGY PATIENTS?

The laparoscopic approach considerably reduced the morbidity of colorectal surgery when compared to the open approach. Among its benefits, we can highlight less intraoperative bleeding, early oral intake, lower rates of surgical site infection, incisional hernia, and postoperative pain, and earlier hospital discharge. To compare the perioperative morbidity of right versus left colectomy for cancer and the quality of laparoscopic oncologic resection. Retrospective analysis of patients submitted to laparoscopic right and left colctomy between 2006 and 2016. Postoperative complications were classified using the Clavien-Dindo scale, 30 days after surgery. A total of 293 patients were analyzed, 97 right colectomies (33.1%) and 196 left colectomies (66.9%). The averageage was 62.8 years. The groups were comparable in terms of age, comorbidities, body mass index, and the American Society of Anesthesiology (ASA) classification. Preoperative transfusion was higher in the right colectomy group (5.1% versus 0.4%, p=0.004, p<0.05). Overall, 233 patients (79.5%) had no complications. Complications found were grade I and II in 62 patients (21.1%) and grade III to V in 37 (12.6%). Twenty-three patients (7.8%) underwent reoperation. The comparison between left and right colectomy was not statistically different for operative time, conversion, reoperation, severe postoperative complications, and length of stay. The anastomotic leak rate was comparable in both groups(5.6% versus 2.1%, p=0.232, p>0.05). The oncological results were similar in both surgeries. In multiple logistic regression, ASA statistically influenced the worst results (≥ III; p=0.029, p<0.05). The surgical and oncological results of laparoscopic right and left colectomies are similar, making this the preferred approach for both procedures.

The Effect of Early versus Traditional Hospital Discharge on Activities of Daily Living for Women Undergoing Elective Cesarean Section. An Observational Cohort Study

Background: Cesarean section is one of the most common surgeries performed worldwide and its consequences and complications represent a major public health concern. The policy of enhanced recovery after surgery has been implemented after cesarean section to optimize perioperative care. Enhanced recovery also aims to reduce the length of hospital stay, which might imply substantial healthcare savings. Rising hospital costs are one of the factors in early discharge. Patients & Methods: This was a prospective cohort study. 158 patients met the inclusion criteria of the study, 81 patients were discharged after 48 hours and 77 patients were discharged after 24 hours. All patients received the same postoperative care and instructions. All the study participants received a phone call 1, 3, and 5 days after discharge to objectively assess the activities of daily living through Katz index of independence in activities of daily living. All patients were offered a postpartum visit 1 week after discharge during which the wound was assessed by the Southampton wound assessment scale. Moreover, other maternal complications such as mastitis, puerperal sepsis, or pyelonephritis were assessed and cases who were readmitted were documented. Initiation of successful breastfeeding and neonatal readmission were reported as well. Results: 158 patients met the inclusion/exclusion criteria of the study. There was no significant difference between the two arms of the study regarding baseline characteristics. Katz index of independence showed that the resumption of activities of daily living after CS was similar in both arms of the study on days 1, 3 and 5 after discharge. Time till the passage of flatus and stool after the cesarean section was significantly shorter among the early discharge arm (9.31 VS 14.68, p value Conclusion: The policy of early discharge can be adopted in low-risk cases scheduled for elective uncomplicated CS provided that the mother and the neonate are in good general condition and proper instructions regarding red flag manifestations are given.

Comparative study between the analgesic efficacy of adductor canal block alone and adductor canal with IPACK (interspace between popliteal artery and capsule of the knee) block for knee surgeries

ABSTRACT Background Knee surgeries are needed in a wide range of patients, from young athletes with anterior cruciate ligament injuries up to old patients with comorbidities presenting for arthroscopy up to total knee replacement procedures. The trend is fast track knee surgery with early ambulation and hospital discharge, so analgesic options of neuraxial blocks and main nerve blocks are less attractive due to the unavoidable muscle weakness. In this study, the benefit of pure sensory nerve block could be reached. Aim of the study To compare the postoperative range of motion and the analgesic efficacy of adductor canal block (ACB) alone against adductor canal with IPACK (interspace between popliteal artery and capsule of the knee) block in knee surgeries. Patients and methods The study is a randomized, prospective, comparative study where 50 patients subjected to knee surgeries were randomized into two groups: Group (A): patients in this group received ultrasound-guided ACB only; Group (AB): under ultrasound guide, patients in this group received a combined ACB and IPACK block at the start of surgery. Results Regarding pain control over the first 24hours following surgery, range of motion and walking distance; there were statistical differences between both groups. When demographic information such age, sex, BMI, and ASA scores were examined between the two groups, there was no statistically significant difference between them (p-value > 0.05). Additionally, there was no statistically significant difference between groups in terms of opioid needs or consumption. Conclusion Regardless of the good analgesic effect of ACB, patients who received a combination of ACB and IPACK blocks have experienced a better pain control, a wider range of motion and a longer walking distance following surgery when compared to patients who received ACB alone.

The Association of Elevated Lactate Level and Rate of Intensive Care Unit Admissions, Endoscopies, and Transfusion of Packed Cell in Patients with Acute Gastrointestinal Bleeding

Background: Management of patients with Gastrointestinal Bleeding (GIB) based on chronicity and severity of it can vary from outpatient medical therapy to intensive caring in life-threatening cases. Initial clinical management decision in patients presenting to emergency department with acute GIB is often based on identifying high- and low-risk patients. Patients with high risks of adverse outcomes, such as death or re-bleeding, are more likely to benefit from early, aggressive management, whereas patients with lower risks may be considered for early hospital discharge or even outpatient management. Serum lactate level is generally an indicator of the overall adequacy of peripheral oxygenation. In severe cases of acute GIB, the hemodynamic of the patients disturbs. In this study, we are evaluating whether higher serum lactate level is potentially a biomarker for predicting the future need for special management considerations.&#x0D; Methods: 168 patients with confirmed acute GIB have entered this study. The serum lactate level of participants was measured and documented as well as their demographic data and their medical history. The participants’ need for ICU admission, blood transfusion, emergent endoscopy, and mortality rate were documented and assessed prospectively.&#x0D; Results: Patients with higher levels of serum lactate levels were more admitted to the intensive care unit in the upcoming days. Anticoagulant use and abdominal pain prevalence were also significantly different in the study groups (p&gt;0.05). Other assessments were not statistically significant.&#x0D; Conclusion: Higher levels of serum lactate predict a higher probability of ICU admission in patients with acute GIB.

APPLICATION OF “FAST-TRACK” PATHWAY FOR VENTRICULAR TACHYCARDIA CATHETER ABLATION

<h3>Objective</h3> "Fast-track" pathway has been successfully applied in low- and intermediate-risk patients during catheter ablation. Catheter ablation is one of the treatment for patients suffering sustained ventricular tachycardia (VT). Patients with reduced cardiac function and patient presented with VT storm may have life threatening reduction in cardiac output. Using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for circulatory support during high-risk VT ablations can mitigate the risk of hemodynamic instability. The present study describes the application of "Fast-track" pathway in the high-risk patients underwent catheter VT ablation with and without ECMO support. <h3>Methods</h3> The study included patients undergoing catheter VT ablation between 2017 and 2022 at a high volume tertiary center in Israel. A prospective observational design was used. The patients were divided to two groups, Group I (non-ECMO group) and Group II (ECMO support group). In ECMO group cannulations was performed directly by the ECMO team, which include cardiac surgeon, perfusionist and operating nurse in the cardiac catheterization laboratory. Veno-arterial ECMO cannulations were inserted percutaneously using the Seldinger technique with ultrasound guidance. "Fast track" pathway defined as general Anesthesia or sedation using short-acting agent, early extubation, early decannulation (in ECMO group), early ICU discharge on Day 1 and early hospital discharge on Day 4. <h3>Results</h3> From the 87 procedures, Group I (non-ECMO) included 52 patients and Group II (ECMO support group) 35 patients."Fast-track" pathway was successful in 54.5% and 37.3%, respectively. On multiple logistic regression analysis, VT storm and ASA class IV-V were independent risk factors for failed "Fast-track" <h3>Conclusions</h3> "Fast-track" pathway may be safely applied in selected high-risk patients underwent VT ablation. Using ECMO support during catheter VT ablation should not exclude otherwise qualified candidates from consideration for "Fast-track" pathway.

Transcatheter closure of secundum atrial septal defects in Egyptian centers: immediate and short-term outcomes

Considered is the Atrial Septal Defect (ASD), with secundum ASDs being the most frequent. As known, in comparison to surgical approach, device closure of secundum ASD is less invasive, has few post-procedural complications, reduced anaesthesia risks, and has early hospital discharge. The present observational study discusses the outcome of the transcatheter closure of secundum ASD in Egyptian cardiac centres. The outcome included immediate and short-term results (up to one-year of intervention date).

Assessing the Safety of Discharging Patients Receiving High-Dose Methotrexate with Levels Greater Than 0.1 Umol/L

Introduction: High-dose methotrexate (HD-MTX) remains a backbone therapy in a number of malignancies and is defined as a dose of greater than 500 mg/m2. HD-MTX requires supportive measures to minimize toxicity, particularly nephrotoxicity. MTX levels are followed to ensure adequate clearance of drug. Historically, patients were discharged with a MTX level of ≤0.05 umol/L. However, many single-center studies have shown that liberalizing the discharge level to <0.1 umol/L is safe and allows earlier hospital discharge. At NYU Langone Health (NYULH), many patients with stable renal function are discharged with a level of >0.1 umol/L, with supportive medications including oral leucovorin with or without sodium bicarbonate. The aim of our study is to confirm the safety of discharging patients with a MTX level of >0.1 umol/L. Methods/Results: This was a single center, retrospective, institutional-review board approved study of all adult patients who received HD-MTX in the inpatient setting, between January 1, 2017 and February 20, 2021. The primary endpoint was the incidence of renal injury post discharge from the HD-MTX admission. Outcomes were analyzed among three MTX level categories at discharge (>0.2 umol/L, 0.1-0.2 umol/L, <0.1 umol/L). If patients received more than one cycle of HD-MTX, each cycle was reported as an individual event. Baseline characteristics were reported based on the first infusion of each unique individual. Baseline renal insufficiency was defined as a creatinine clearance (CrCl) of less than 30 mL/min. Renal injury was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE, version 5.0). The first outpatient serum creatinine (SCr) documented in the patient chart post HD-MTX hospitalization was utilized to analyze renal injury. The study included 108 patients who received a total of 336 HD-MTX infusions. The primary indication for HD-MTX was central nervous system prophylaxis for diffuse large b-cell lymphoma or acute lymphoblastic leukemia. The most common HD-MTX doses were between 1,001-3,500 mg/m2 compared to 500-1,000mg/m2 and >3,500mg/m2 (p=0.0006). Four patients (4%) had baseline renal insufficiency. Of the 336 infusions, 49 (15%) infusions were categorized into MTX discharge level >0.2 umol/L, 145 (43%) into MTX 0.1-0.2 umol/L, and 142 (42%) into MTX <0.1 umol/L. Within the discharge category >0.2 umol/L, the median level was 0.28 umol/L (IQR, 0.22 - 0.37). The highest level was 1.04 umol/L at discharge. Patients were more likely to be discharged with oral leucovorin if they were discharged with a MTX level >0.1 umol/L (p<0.001). Similarly, patients were more frequently prescribed oral sodium bicarbonate if discharged with a MTX level >0.2 umol/L (p<0.001). There were 28 (8%) renal injury events, with no significant difference in renal injury occurring among the three MTX discharge level ranges. The renal injury events were primarily Grade 1. The median LOS in our study was statistically longer in the MTX <0.1 umol/L category (4 days, IQR 3-12) compared to the MTX 0.1-0.2 umol/L and >0.2 umol/L categories, 3 days (IQR 3-4) and 3.4 days, (IQR 3-4), respectively (p=0.023). There were 14 readmissions post HD-MTX hospitalization discharge. Two patients were admitted on two separate encounters after HD-MTX administration, leaving 12 unique patients. The primary reason for readmission was for myelosuppression, although all of these patients received other cytotoxic chemotherapy as part of the hyper-CVAD regimen. Two readmissions were after a MTX discharge level of >0.2 umol/L and 6 readmissions for both MTX discharge level of 0.1- 0.2 umol/L and <0.1 umol/L. Conclusion: Our study demonstrates that it is safe to discharge patients with a MTX level of >0.1 umol/L, with no difference in renal injury, and supporting shortened length of stay. Our data also suggest that it is safe to discharge a patient with a MTX level up to 0.4 umol/L, as our upper 75th quartile range was 0.37 umol/L, acknowledging supportive medications are prescribed. Limitations of this study include the retrospective nature of the study and heterogenous population. The length of stay data are confounded by other factors as well including multiday chemotherapy regimens, infections, and newly diagnosed malignancies. Our plan is to create an institutional protocol to outline the supportive care to support an early discharge of patients receiving HD-MTX. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 13274: The Safety of Early Discharge After Tavi in Northern and Rural Ontario Canada

Introduction: Early hospital (&lt;48hrs) discharge following transcatheter aortic valve implantation (TAVI) is an increasingly adopted practice. However, the safety of such an approach among patients residing in rural areas in Northern Ontario, including remote and medically underserved areas is lacking. Methods: After adapting the Vancouver 3M clinical pathway, all patients who underwent TAVI in Sudbury, Ontario were included in the analysis. The primary endpoint was all-cause mortality within 30 days. Secondary endpoints included procedural complications, post-TAVI length of hospital stay (LOS) and 30-day re-hospitalizations. Results: 165 patients underwent TAVI after adapting the Vancouver 3M clinical pathway. Mean age was 81 years (SD ± 8). Median STS-mortality score was 2.5% (IQR, 1.9-3.5). There was one in-hospital death (0.6%) with no 30 day mortality observed beyond hospital discharge. 11 patients (6.7%) required rehospitalization within 30 days, 3 of them for cardiac complaints. More over, after adoption of the 3M clinical pathway, the need for procedural mechanical ventilation and surgical vascular cut-down declined from 100% and 97% at baseline, to 6% and 2% respectively. Similarly, after adapting the 3M clinical pathway, the number of patients receiving TAVI on a given procedural day increased from two to three patients. Median post TAVI-LOS declined from 5 days (2-6 days) to 1 day (1-3 days). Conclusions: By transitioning to a 3M approach, our study has shown that early discharge after TAVI in Northern Ontario at a single lower-volume TAVI centre is feasible and safe, with favorable outcomes and improved hospital LOS. Furthermore, resource utilization improved with fewer patients requiring mechanical ventilation and surgical cut-down, leading to a downstream increase in the number of patients receiving TAVI on a given procedural day. This experience can potentially improve TAVI equity for underserved and vulnerable populations, reduce TAVI wait times and bridge variations in TAVI funding.

Dalbavancin in clinical practice in Spain: a 2 year retrospective study.

Dalbavancin is approved for the treatment of acute bacterial skin and skin-structure infections (ABSSSIs) in adults. Its unique pharmacokinetic properties allow daily dosing to be avoided. The objective was to describe the sociodemographic and clinical characteristics of patients treated with dalbavancin in Spain, and to evaluate its effectiveness and safety in real-world settings. This non-interventional, retrospective, observational and multicentre study included patients who received at least one dose between 2018 and 2019 in seven Spanish hospitals. In total, 187 patients were included. The most common comorbidities were cardiovascular disease (27.4%) and diabetes mellitus (23.5%). Dalbavancin was used to treat osteoarticular infections (28.3%), ABSSSIs (22.5%), cardiovascular infections (20.9%) and catheter-related infections (18.2%). The most prevalent pathogens were Staphylococcus aureus (34.2%), CoNS (32.6%), and enterococci (12.8%). The main reason for use was early hospital discharge (65.8%). Most patients were treated with 1500 mg in a single dose (35.3%) and the median duration of treatment was 2 weeks. The treatment was clinically successful in 91.4% of cases. Six patients (3.2%) reported adverse events. Physicians agreed on the potential reduction of hospitalization days (85.3%). A subanalysis of patient characteristics and type of pathogen showed similar results in terms of efficacy and safety. Dalbavancin seems to be effective and safe as second-line treatment in severe Gram-positive infections. It improves treatment adherence and allows outpatient management. Furthermore, the effectiveness and safety profile are maintained against diverse microorganisms in Gram-positive infections and regardless of the patients' comorbidities at baseline, or age.

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

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

Effect of a light-darkness cycle on the body weight gain of preterm infants admitted to the neonatal intensive care unit

The Continuous bright light conditions to which premature infants are subjected while hospitalized in Neonatal Intensive Care Units (NICU) can have deleterious effects in terms of growth and development. This study evaluates the benefits of a light/darkness cycle (LDC) in weight and early hospital discharge from the NICU. Subjects were recruited from three participating institutions in Mexico. Eligible patients (n = 294) were premature infants who were hospitalized in the low-risk and high-risk neonatal units classified as stable. The subjects randomized to the experimental group (n = 150) were allocated to LDC conditions are as follows: light from 07:00 to 19:00 and darkness (25 lx) from 19:00 to 07:00. The control group (n = 144) was kept under normal room light conditions (CBL) 24 h a day. Main outcome was weight gain and the effect of reducing the intensity of nocturnal light in development of premature infants. Infants to the LDC gained weight earlier, compared with those randomized to CBL, and had a significant reduction in length of hospital stay. These results highlight those premature infants subjected to a LDC exhibit improvements in physiological development, favoring earlier weight gain and consequently a decrease in hospital stays. ClinicalTrials.gov; 02/09/2020 ID: NCT05230706.

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

Postpartum readmissions for hypertensive disorders in pregnancy during the COVID-19 pandemic

BACKGROUNDHypertensive disorders in pregnancy are one of the most common causes of readmission in the postpartum period. Because of the COVID-19 pandemic, early hospital discharge was encouraged for patients who were medically stable, because hospitalization rates among SARS-CoV-2–infected patients steadily increased in 2020. The impact of an early discharge policy on postpartum readmission rates among patients with hypertensive disorders in pregnancy is unknown.OBJECTIVEThis study aimed to compare the postpartum readmission rates of patients with hypertensive disorders in pregnancy before and after implementation of an early discharge policy owing to the COVID-19 pandemic.STUDY DESIGNThis was a quality improvement, retrospective cohort study of postpartum patients with antenatal hypertensive disorders in pregnancy who delivered and were readmitted because of hypertensive disorders in pregnancy at the New York University Langone Health medical center from March 1, 2019 to February 29, 2020 (control cohort) and from April 1, 2020 to March 31, 2021 (COVID-19 cohort). During the pandemic, our institution introduced an early discharge policy for all postpartum patients to be discharged no later than 2 days postpartum during the delivery admission if deemed medically appropriate. The reduction in postpartum length of stay was accompanied by the continuation of patient education, home blood pressure monitoring, and outpatient follow-up. The primary outcome was the comparison of the readmission rates for patients with postpartum hypertensive disorders in pregnancy. Data were analyzed using Fisher's Exact tests, chi-square tests, and Wilcoxon rank-sum tests with significance defined as P<.05.RESULTSThere was no statistical difference in the readmission rates for patients with postpartum hypertensive disorders in pregnancy before vs after implementation of an early discharge policy (1.08% for the control cohort vs 0.59% for the COVID-19 cohort). The demographics in each group were similar, as were the median times to readmission (5.0 days; interquartile range, 4.0–6.0 days vs 6.0 days; interquartile range, 5.0–6.0 days; P=.13) and the median readmission length of stay (3.0 days; interquartile range, 2.0–4.0 days vs 3.0 days; interquartile range, 2.0–4.0 days; P=.45). There was 1 intensive care unit readmission in the COVID-19 cohort and none in the control cohort (P=.35). There were no severe maternal morbidities or maternal deaths.CONCLUSIONThese findings suggest that policies calling for a reduced postpartum length of stay, which includes patients with hypertensive disorders in pregnancy, can be implemented without impacting the hospital readmission rate for patients with hypertensive disorders in pregnancy. Continuation of patient education and outpatient surveillance during the pandemic was instrumental for the outpatient postpartum management of the study cohort. Further investigation into best practices to support early discharges is warranted.

Once-a-Day Ceftriaxone-Amikacin Combination as Empiric Antibiotic Therapy to Enable Outpatient Management of Febrile Neutropenia in Children-16-Year Experience from a Single Institute.

Shailesh KanvindeBackground To enable outpatient department (OPD) management of febrile neutropenia (FN), we used once-a-day (OD) ceftriaxone-amikacin (CFT-AMK) as empiric antibiotic therapy. Our experience over 16-year period is presented. Methods This was a retrospective study conducted from January2002 to December2017. Inclusion criteria were <18 years of age, undergoing cancer chemotherapy, and having FN. Exclusion criteria were FN after palliative chemotherapy, bone marrow transplantation, or at diagnosis of malignancy. Empiric CFT-AMK was used in all, except those having respiratory distress, hypotension, altered sensorium, paralytic ileus, or clinical evidence of peritonitis. Admission criteria were age <1 year, acute myeloid leukemia (AML) chemotherapy, poor performance status, need for blood transfusions, convenience, insurance, or persistent fever >48 to 72 hours after CFT-AMK. Outcomes analyzed were response (defervescence within 48-72 hours), OPD management, antibiotic upgrade, and mortality. AML diagnosis, >7 days to absolute neutrophil count >0.5 × 10 9 /L, poor performance status, and malignancy not in remission were considered high-risk FN criteria. Results CFT-AMK was given in 877/952 (92.2%) FN episodes. Seventy-six percent had hematolymphoid malignancies. Response, antibiotic upgrade, and mortality were seen in 85.7 and 65.5% ( p < 0.0001), 15 and 45.5% ( p < 0.0001), and 0 and 2% ( p = 0.003) of low- and high-risk patients, respectively. Treatment was started in OPD in 52%, of which 21.6% required subsequent admission. Of those initially admitted, early discharge (hospital stay < 5 days) was possible in 24.6%. Forty-one percent episodes were managed entirely on OPD. Overall, 80% of low-risk and 42% of high-risk episodes received treatment wholly or partially on OPD. Conclusion Our results show empiric OD CFT-AMK allows OPD management for most of the low-risk and a proportion of high-risk FN following chemotherapy in children, without compromising clinical outcomes.

Development of the invasive candidiasis discharge [I Can discharge] model: a mixed methods analysis

Patients with invasive candidiasis (IC) have complex medical and infectious disease problems that often require continued care after discharge. This study aimed to assess echinocandin use at hospital discharge and develop a transition of care (TOC) model to facilitate discharge for patients with IC. This was a mixed method study design that used epidemiologic assessment to better understand echinocandin use at hospital discharge TOC. Using grounded theory methodology focused on patients given echinocandins during their last day of hospitalization, a TOC model for patients with IC, the invasive candidiasis [I Can] discharge model was developed to better understand discharge barriers. A total of 33% (1405/4211) echinocandin courses were continued until the last day of hospitalization. Of 536 patients chosen for in-depth review, 220 (41%) were discharged home, 109 (20%) were transferred, and 207 (39%) died prior to discharge. Almost half (46%, 151/329) of patients discharged alive received outpatient echinocandin therapy. Independent predictors for outpatient echinocandin use were osteomyelitis (OR, 4.1; 95% CI, 1.1–15.7; p = 0.04), other deep-seated infection (OR, 4.4; 95% CI, 1.7–12.0; p = 0.003), and non-home discharge location (OR, 3.9, 95% CI, 2.0–7.7; p < 0.001). The I Can discharge model was developed encompassing four distinct themes which was used to identify potential barriers to discharge. Significant echinocadin use occurs at hospital discharge TOC. The I Can discharge model may help clinical, policy, and research decision-making processes to facilitate smoother and earlier hospital discharges.

Comparison Between Outcome of Patients Following Saline Irrigation Versus Dry Mopping after Laparoscopic Cholecyetectomy

Background: Laparoscopic cholecystectomy is minimal invasive procedure of choice for diseases due to gall bladder diseases due to reduced morbidity, comfort and patient’s early hospital discharge. Studies showed stone spillage with its retrieval from the fossa of gall bladder can be done by irrigation or be mopping with surgical gauze. Aims: To Compare between outcome of patients following saline irrigation versus dry mopping after laparoscopic cholecystectomy. Methodology: This was a cross-sectional study conducted at Hanif hospital from July 2019- May 2022 after taking ethical committee review. The study was conducted on 214 patients. The inclusion criteria involved age&gt;18yrs till 60years either gender, with symptomatic gallstones. The patients with choledocholithiasis, immunocompromised, bleeding disorders were excluded. Results: Out of 214 patients enrolled in study mean age of patients was 42.63 ±5.7yrs . There was n=140:74 (65.4%: 34.6%) females: males. In 86% patients with laparoscopic cholecystectomy there was no complication of biliary spillage, while 14% patients experienced spillage of stones intraoperatively. All patients with dry mopping showed less postoperative pain and were discharged early from the hospital. However, the patients with wet irrigation had postoperative moderate pain. Surgical site infection was reported in 5 patients out of 15 patients with wet irrigation compared to dry mopping n=1 with prolonged hospital stay in patients with wet irrigation die to pain and surgical site infection. There was a statistical significant correlation when compared two groups with respect to hospital stay, postoperative pain, surgical site infection. P value-0.000. Conclusion: Our study has shown dry mopping to be better than wet irrigation in terms of increased postoperative pain, prolonged hospital stay &amp; statistical significant correlation in patients with spillage of stones intraoperatively. Keywords: Stones spillage, dry mopping, wet irrigation

Kolostomi Kapatılması Sonrası Erken Dönem Rektal Tüp Uygulamanın Barsak Peristaltizmine Etkisi

Objective: All surgeons performing colostomy closure strive to achieve early postoperative intestinal peristalsis in their patients. Early peristalsis following abdominal surgery leads to a shorter time to flatulence/defecation, thereby allowing early transition to oral feeding and early hospital discharge. The aim of this study was to investigate the effect of rectal tube applied after colostomy on intestinal peristalsis, time to first flatulence/defecation, and time to hospital discharge.&#x0D; Material and Methods: This retrospective study included 40 patients that underwent colostomy closure between September 2013 and October 2020. Age, gender, and indications for colostomy were reviewed for each patient. Patients were divided into two groups as patients who underwent and those who did not&#x0D; undergo rectal tube application. In both groups, time to first flatulence/defecation, time to oral feeding, and hospitalization period were recorded.&#x0D; Results: The 40 patients comprised 26 boys and 14 girls with a mean age of 3.46±2.11 years. Time to first flatulence/defecation and hospitalization periods were significantly shorter in patients that underwent rectal tube placement than in patients that did not undergo rectal tube placement (p=0.001).&#x0D; Conclusion: Rectal tube application following colostomy leads to early onset of intestinal peristalsis and a shorter time to flatulence/defecation, thereby allowing early transition to oral feeding and early hospital discharge.