Emergency Department Readmission Research Articles

Short-Stay Arthroplasty is Not Associated With Increased Risk of 90-Day Hospital Returns

BackgroundWith the removal of total hip arthroplasty (THA) and total knee arthroplasty (TKA) from the inpatient-only list, medical centers are faced with challenging transitions to outpatient surgery. We investigated if short-stay arthroplasty, defined as length of stay (LOS) <24 hours, would influence 90-day readmissions and emergency department (ED) visits at a tertiary referral center. MethodsThe institutional database was retrospectively queried for primary TKAs and THAs from July 2015 to January 2018, resulting in 2,217 patients (1,361 TKA and 856 THA). Patient demographics, including age, gender, body mass index, and American Society of Anesthesiologists score were collected. LOS, disposition, cost of care, 90-day ED visits, and readmissions were identified through the institutional database using electronic medical record data. Univariable and multivariable models were used to evaluate rates of 90-day readmissions and ED visits based on LOS <24 hours vs ≥24 hours. ResultsLOS <24 h was associated with significant decreases in 90-day ED visits (P = .003) and readmissions (P = .002). After controlling for potential confounding variables with a multivariable model, a significant decrease in ED visits (P = .034) remained in the THA cohort alone. Within TKA and THA cohorts, LOS <24 h was associated with lower costs (P < .001). Eighteen percent of patients with ≥24 h LOS were discharged to skilled nursing or rehabilitation facilities. ConclusionIn this cohort, LOS <24 hours was associated with decreased 90-day readmissions, ED visits, and costs. With the goal of minimizing costs and maintaining patient safety while efficiently using resources, outpatient and short-stay arthroplasty are valuable, feasible options in tertiary academic centers.

An explanatory machine learning framework for studying pandemics: The case of COVID-19 emergency department readmissions

One of the major challenges that confront medical experts during a pandemic is the time required to identify and validate the risk factors of the novel disease and to develop an effective treatment protocol. Traditionally, this process involves numerous clinical trials that may take up to several years, during which strict preventive measures must be in place to control the outbreak and reduce the deaths. Advanced data analytics techniques, however, can be leveraged to guide and speed up this process. In this study, we combine evolutionary search algorithms, deep learning, and advanced model interpretation methods to develop a holistic exploratory-predictive-explanatory machine learning framework that can assist clinical decision-makers in reacting to the challenges of a pandemic in a timely manner. The proposed framework is showcased in studying emergency department (ED) readmissions of COVID-19 patients using ED visits from a real-world electronic health records database. After an exploratory feature selection phase using genetic algorithm, we develop and train a deep artificial neural network to predict early (i.e., 7-day) readmissions (AUC = 0.883). Lastly, a SHAP model is formulated to estimate additive Shapley values (i.e., importance scores) of the features and to interpret the magnitude and direction of their effects. The findings are mostly in line with those reported by lengthy and expensive clinical trial studies.

Emergency Department Visits Versus Hospital Readmissions Among Patients Hospitalized for Heart Failure

BackgroundWorsening heart failure (HF) often requires hospitalization but in some cases may be managed in the outpatient or emergency department (ED) settings. The predictors and clinical significance of ED visits without admission vs hospitalization are unclear. MethodsThe ASCEND-HF trial included 2661 US patients hospitalized for HF with reduced or preserved ejection fraction. Clinical characteristics were compared between patients with a subsequent all-cause ED visit (with ED discharge) within 30 days vs all-cause readmission within 30 days. Factors associated with each type of care were assessed in multivariable models. Multivariable models landmarked at 30 days evaluated associations between each type of care and subsequent 150-day mortality. ResultsThrough 30-day follow-up, 193 patients (7%) had ED discharge, 459 (17%) had readmission, and 2009 (76%) had neither urgent visit. Patients with ED discharge vs readmission were similar with respect to age, sex, systolic blood pressure, ejection fraction, and coronary artery disease, whereas ED discharge patients had a modestly lower creatinine (P < .01). Among patients with either event within 30 days, a higher creatinine and prior HF hospitalization were associated with a higher likelihood of readmission, as compared with ED discharge (P < .02). Landmarked at 30 days, rates of death during the subsequent 150 days were 21.0% for patients who were readmitted and 11.4% for patients discharged from the ED. Compared with patients who were readmitted, ED discharge was independently associated with lower 150-day mortality (adjusted hazard ratio 0.58, 95% confidence interval 0.36–0.92, P = .02). ConclusionsIn this cohort of US patients hospitalized for HF, worse renal function and prior HF hospitalization were associated with a higher likelihood of early postdischarge readmission, as compared with ED discharge. Although subsequent mortality was high after discharge from the ED, this risk of mortality was significantly lower than patients who were readmitted to the hospital.

Epidemiology of traumatic brain injuries at a rural-serving Level II trauma center, 2004 - 2016

ABSTRACT Objective To describe the epidemiology of traumatic brain injury (TBI) and quantify rural and urban differences. Methods Patient characteristics, injury characteristics, imaging, and outcomes were extracted from the trauma registry of the level II trauma center at Essentia Health-St. Mary’s Medical Center, Duluth, MN, for patients admitted for a TBI from January 1, 2004, through December 31, 2016. Estimated relative risk (RR) per year, Wald 95% confidence intervals, and p-values were calculated. Results Of the 5,079 TBI admissions during the study period, just under half (2,510, 49.4%) resided in rural areas at the time of admission. Overall, there was a 3.8% unadjusted annual increase in TBI risk rom 2004–2016, with 2.9% and 4.7% annual increases among rural and urban U.S. residents, respectively. Rural residents had significant annual increases in risk of TBI admission resulting in 30-day post-discharge emergency department readmission and 30-day post-discharge combined inpatient/emergency department readmission of 35.2% and 22.4%, respectively. Conclusions We found that risk of rural resident TBI admission due to MVC was significantly greater than that for urban residents. Public health and medical interventions to decrease the rural/urban disparity are warranted, including public health campaigns to increase seat belt use, and supportive care post-discharge into rural communities.

Emergency department electric scooter injuries after the introduction of shared e-scooter services: A retrospective review of 3,331 cases.

To determine the frequency, characteristics, and use of resources related to electric scooter (e-scooter) injuries in the emergency department (ED) of a major metropolitan area hospital. We performed a retrospective review of all ED presentations related to e-scooter injuries at a level I trauma center between May 2017 and February 2020. We identified ED presentation data, injury-related data, patients' clinical course after evaluation, injury diagnosis, surgical procedures, and ED readmissions. A total of 3,331 patients with e-scooter injuries presented to the ED over a 34-month period. There was a 6-fold increase in e-scooter-related injuries presenting to the ED, from an average of 26.9 injuries per month before the introduction of shared e-scooter services in August 2018 to an average of 152.6 injuries per month after its introduction. The average injury rate during weekdays was 3.27 per day, with the majority of injuries occurring in the afternoon. The most common mechanism of injury was rider fall (79.1%). There were a total of 2,637 orthopedic injuries, of which 599 (22.7%) were fractures. A total of 296 (8.9%) patients were hospitalized following the initial ED admission, and 462 surgeries were performed within 7 days of ED arrival. The introduction of the shared e-scooter services is associated with a dramatic increase in e-scooter injuries presenting to the ED. E-scooter use carries considerably underestimated injury risks of high-energy trauma and misunderstood mechanisms of injuries. These injuries challenge the healthcare system, with a major impact on both EDs and surgical departments.

Assessment of Gender Disparities in Short-Term and Long-Term Outcomes Following Posterior Fossa Tumor Resection

IntroductionThe analysis of social determinants of health (SDOH) across different surgical populations is critical for the identification of health disparities and the development risk mitigation strategies among vulnerable patients. Research into the impact of gender on neurosurgical outcomes remains limited. The aim of the present study was to assess the effect of gender on outcomes, in a matched sample, following posterior fossa tumor resection, a high-risk neurosurgical procedure.MethodsTwo hundred seventy-eight consecutive patients undergoing posterior fossa tumor resection over a six-year period (June 07, 2013, to April 29, 2019) at a single academic medical system were retrospectively evaluated. Short-term outcomes included 30- and 90-day rates of emergency department (ED) visit, readmission, reoperation, and mortality. Long-term outcomes included mortality and reoperation for the duration of follow-up. Firstly, male and female patients in the entire pre-match sample were compared. Thereafter, coarsened exact matching was employed to control for confounding variables, matching male and female patients on key demographic factors - including history of prior surgery, median household income, and race, amongst others - and outcome comparison was repeated.ResultsIn both the entire pre-match sample and matched cohort analyses, no significant differences in adverse postsurgical events were discerned between the female and male patients when evaluating 30-day or 90-day rates of ED visit, readmission, reoperation, and mortality. There were also no differences in reoperation or mortality for the duration of follow-up.ConclusionGender does not appear to impact short- or long-term outcomes following posterior fossa tumor resection. As such, risk assessment and mitigation strategies in this population should focus on other SDOH. Further studies should assess the role of other SDOH within this population.

Comparative Cost Analysis of Ambulatory Versus In-Patient Endovascular Aortic Repair

We sought to compare the costs of ambulatory endovascular aneurysm repair (EVAR) compared to in-patient EVAR. Consecutive patients who had undergone elective EVAR between April 2016 and December 2018 at two academic centers were retrospectively reviewed. The patients had undergone either planned ambulatory EVAR or in-patient EVAR. The index visit, 30-day, and 1-year costs were compared according to the intended type of admission. The costs included operating room use, emergency department (ED) visits, readmissions, and reinterventions. The factors associated with increased costs were identified. The independent sample t test and Mann-Whitney U test were used for the comparisons, with P < .05 taken as significant. A total of 171 patients were identified. Most of the patients had undergone percutaneous EVAR (94%) under regional anesthesia (80%). Ambulatory EVAR was planned for 101 patients and was successful for 85 patients (84%). The ambulatory EVAR patients had had smaller aneurysm diameters (56.5 mm vs 59.1 mm; P = .011) and a shorter median length of stay (0.48 vs 1.33 days; P < .001). The ED visit, readmission, and reintervention rates were similar in the two groups for ≤1 year. Ambulatory EVAR was less expensive than in-patient EVAR at the index visit ($10,688 vs $12,397; P = .016) and during the perioperative period ($11,340 vs $12,931; P = .006). No differences were found in cost at 1 year ($11,745 vs $12,952; P = .065). The costs of the supportive services, including the laboratory and pharmacy, were less expensive for ambulatory EVAR. ED visits, readmissions, and reinterventions were associated with high 1-year EVAR costs, irrespective of admission type. In a Canadian multicenter experience, ambulatory EVAR costs were less than in-patient EVAR costs at 30 days but not at 1 year. Ambulatory EVAR clinical pathway implementation reduced the length of hospital stay and usage of hospital resources involving the laboratory and pharmacy. It did not result in increased ED visits, readmissions, or reinterventions.

Ambulatory Percutaneous Nephrolithotomy May Be Cost-Effective Compared to Standard Percutaneous Nephrolithotomy.

Background: Coronavirus disease 2019 (COVID-19) changed the practice of medicine in America. During the March 2020 lockdown, elective cases were canceled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing aPCNL against standard PCNL (sPCNL). Materials and Methods: Ninty-eight patients underwent PCNL at Indiana University Methodist Hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of emergency department (ED) visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included cost analysis and stone-free rates (SFRs). Propensity score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results: Ninety-eight patients underwent PCNL during the study period (sPCNL = 75 and aPCNL = 23). After propensity score matching, 42 patients were available for comparison (sPCNL = 19 and aPCNL = 23). We found no difference in 30-day ED visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327 ± 442 per case. SFRs were higher for aPCNL compared with sPCNL. Conclusions: aPCNL appears safe to perform and does not have a higher rate of ED visits or readmissions compared with sPCNL. aPCNL may also be cost-effective compared with sPCNL.

Victims of Violence and Post-Discharge Adverse Events: A Prospective Modified Trauma Quality Improvement Program (TQIP) Study.

IntroductionTrauma patients frequently return to an emergency department (ED) soon after discharge; often for non-urgent reasons. Social factors contribute to higher ED usage. At present, there is no standardized system for reporting of ED visits and readmissions among trauma care. We hypothesized that victims of violent crime suffer from many early post-discharge adverse events that has not been captured by current methods.MethodsWe prospectively consented and enrolled injured patients from January 1st, 2019 to December 31st, 2019. We documented 30-day post-discharge events using post-discharge phone calls and detailed chart abstraction. Patients were categorized as victims of violence (VV) or unintentional traumatic injury (UT).ResultsDuring the study period, 444 patients were enrolled. Fifty-one (11.5%) were victims of violence and 393 (88.5%) experienced unintentional injuries. The VV patients were younger (40.10 vs 60.36; p<0.0001), and more predominantly male (92.16% vs 57.51%; p<0.0001). Total injury severity score (ISS), critical care length of stay (LOS), and total LOS were similar. VV patients were more likely discharged home (70.59% vs 55.47%; p=0.0403). They were significantly more likely to return to an emergency department (47.06% vs 23.16%; p<0.0005) and had more total number of ED visits per patient. Readmission rates, however, were not different (21.57% vs 16.28%; p=NS). The VV patients more frequently were underinsured (72.5%, vs 20.6%, p<0.005).DiscussionVictims of violence presented to the ED significantly more often, despite similar injury scores, LOS, and being of younger age. Of these patients, only 26.2% of ED presentations resulted in readmission, suggesting the majority of patient complaints may have been able to be managed in an office-based setting. VV had significantly more underinsured or subsidized patients. Victims of violence are vulnerable and may benefit from more resources provided in the early post-discharge period.

A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses™.

Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.

Association of perioperative hypotension with subsequent greater healthcare resource utilization

Study objectiveDetermine if perioperative hypotension, a modifiable risk factor, is associated with increased postoperative healthcare resource utilization (HRU). DesignRetrospective cohort study. SettingMulticenter using the Optum® electronic health record database. PatientsPatients discharged to the ward after non-cardiac, non-obstetric surgeries between January 1, 2008 and December 31, 2017 with six months of data, before and after the surgical visit. Interventions/ExposurePerioperative hypotension, a binary variable (presence/absence) at an absolute MAP of ≤65-mmHg, measured during surgery and within 48-h after, to dichotomize patients with greater versus lesser hypotensive exposures. MeasurementsShort-term HRU defined by postoperative length-of-stay (LOS), discharge to a care facility, and 30-day readmission following surgery discharge. Mid-term HRU (within 6 months post-discharge) quantified via number of outpatient and emergency department (ED) visits, and readmission LOS. Main results42,800 distinct patients met study criteria and 37.5% experienced perioperative hypotension. After adjusting for study covariates including patient demographics and comorbidities, patients with perioperative hypotension had: longer LOS (4.01 vs. 3.83 days; LOS ratio, 1.05; 95% CI, 1.04–1.06), higher odds of discharge to a care facility (OR, 1.18; 95% CI, 1.12–1.24; observed rate 22.1% vs. 18.1%) and of 30-day readmission (OR, 1.22; 95% CI, 1.11–1.33; observed rate 6.2% vs. 5.0%) as compared to the non-hypotensive population (all outcomes, p < 0.001). During 6-month follow-up, patients with perioperative hypotension showed significantly greater HRU regarding number of ED visits (0.34 vs. 0.31 visits; visit ratio, 1.10; 95% CI, 1.05–1.15) and readmission LOS (1.06 vs. 0.92 days; LOS ratio, 1.15; 95% CI, 1.07–1.24) but not outpatient visits (10.47 vs. 10.82; visit ratio, 0.97; 95% CI, 0.95–0.99) compared to those without hypotension. There was no difference in HRU during the 6-month period before qualifying surgery. ConclusionsWe report a significant association of perioperative hypotension with an increase in HRU, including additional LOS and readmissions, both important contributors to overall medical costs.

The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform.

On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery. This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery. A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform. Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.

Y-012. Metformin changes serum cytokines in pregnant women with polycystic ovary syndrome

Determine if perioperative hypotension, a modifiable risk factor, is associated with increased postoperative healthcare resource utilization (HRU).Retrospective cohort study.Multicenter using the Optum® electronic health record database.Patients discharged to the ward after non-cardiac, non-obstetric surgeries between January 1, 2008 and December 31, 2017 with six months of data, before and after the surgical visit.Perioperative hypotension, a binary variable (presence/absence) at an absolute MAP of ≤65-mmHg, measured during surgery and within 48-h after, to dichotomize patients with greater versus lesser hypotensive exposures.Short-term HRU defined by postoperative length-of-stay (LOS), discharge to a care facility, and 30-day readmission following surgery discharge. Mid-term HRU (within 6 months post-discharge) quantified via number of outpatient and emergency department (ED) visits, and readmission LOS.42,800 distinct patients met study criteria and 37.5% experienced perioperative hypotension. After adjusting for study covariates including patient demographics and comorbidities, patients with perioperative hypotension had: longer LOS (4.01 vs. 3.83 days; LOS ratio, 1.05; 95% CI, 1.04–1.06), higher odds of discharge to a care facility (OR, 1.18; 95% CI, 1.12–1.24; observed rate 22.1% vs. 18.1%) and of 30-day readmission (OR, 1.22; 95% CI, 1.11–1.33; observed rate 6.2% vs. 5.0%) as compared to the non-hypotensive population (all outcomes, p < 0.001). During 6-month follow-up, patients with perioperative hypotension showed significantly greater HRU regarding number of ED visits (0.34 vs. 0.31 visits; visit ratio, 1.10; 95% CI, 1.05–1.15) and readmission LOS (1.06 vs. 0.92 days; LOS ratio, 1.15; 95% CI, 1.07–1.24) but not outpatient visits (10.47 vs. 10.82; visit ratio, 0.97; 95% CI, 0.95–0.99) compared to those without hypotension. There was no difference in HRU during the 6-month period before qualifying surgery.We report a significant association of perioperative hypotension with an increase in HRU, including additional LOS and readmissions, both important contributors to overall medical costs.

Impact of a medico-pharmaceutical follow-up and an optimized communication between hospital and community on the readmission to the emergency department for an adverse drug event: URGEIM, study protocol for a randomized controlled trial

BackgroundAdverse drug events (ADE) represent one of the main causes of admission to emergency department (ED). Their detection, documentation, and reporting are essential to avoid readmission.We hypothesize that a pharmacist-initiated multidisciplinary transition of care program combining ED pharmacist contribution and medications’ data transfer between inpatient and outpatient caregivers will reduce emergency visits related to ADEMethod/designThis is a prospective, open-label, randomized controlled trial. The primary aim of the study is 6-month ED readmission related to the same ADE. Three hundred forty-six adult patients with an ADE detected by a binomial pharmacist-physician will be recruited from the ED of an University Hospital and will be randomized in two groups: [1] experimental group (multidisciplinary transition of care program and medications’ data transfer between inpatient and outpatient caregivers) and [2] control group (usual care). Patients will be followed up over a period of 6 months. Endpoints will be carried out blindly of the randomization arm. The primary endpoint is the rate of patients who had at least one readmission in the ED for the same reason at 6 months (data collected during a phone call with the patient and the general practitioner). Trials registered NCT03725046.DiscussionThe trial results will have implications for the role of the clinical pharmacist in an emergency department. If successful, the intervention could be considered for implementation across other hospitals.Trial registrationClinicalTrials.govNCT03725046. Registered on 30 October 2018

Do postoperative telemedicine interventions with a communication feature reduce emergency department visits and readmissions?-a systematic review and meta-analysis.

Emergency department (ED) visits and readmissions after surgery are common and represent a significant cost-burden on the healthcare system. A notable portion of these unplanned visits are the result of expected complications or normal recovery after surgery, suggesting that improved coordination and communication in the outpatient setting could potentially prevent these. Telemedicine can improve patient-physician communication and as such may have a role in limiting unplanned emergency department visits and readmissions in postoperative patients. Major electronic databases were searched for randomized controlled trials and cohort studies in surgical patients examining the effect of postoperative telemedicine interventions with a communication feature on 30-day readmissions and emergency department visits as compared to current standard postoperative follow-up. All surgical subspecialties were included. Two independent reviewers assessed eligibility, extracted data, and evaluated risk of bias using standardized tools. Our primary outcomes of interest were 30-day ED visits and readmissions. Our secondary outcomes were patient satisfaction with the intervention. 29 studies were included in the final analysis. Fourteen studies were RCTs, and the remaining fifteen were cohort studies. Eighteen studies reported 30-day ED visit as an outcome. There was no overall reduction in 30-day ED visit in the telemedicine group (RR: 0.89, 95%CI: 0.70-1.12). Twenty-two studies reported 30-day readmission as an outcome. The overall pooled estimate did not show a difference in this outcome (RR: 0.90, 95%CI: 0.74-1.09). Fifteen studies reported a metric of patient satisfaction regarding utilization of the telemedicine intervention. All studies demonstrated high levels of satisfaction (> 80%) with the telemedicine intervention. This review fails to demonstrate a clear reduction ED visits and readmissions to support use of a telemedicine intervention across the board. This may be in part explained by significant heterogeneity in the proportions of potentially preventable visits in each surgical specialty. As such, targeting interventions to specific surgical settings may prove most useful.

Postoperative Admission of Adult Craniotomy Patients to the Neuroscience Ward Reduces Length of Stay and Cost.

The neurointensive care unit (NICU) has traditionally been the default recovery unit after elective craniotomies. To assess whether admitting adult patients without significant comorbidities to the neuroscience ward (NW) instead of NICU for recovery resulted in similar clinical outcome while reducing length of stay (LOS) and hospitalization cost. We retrospectively analyzed the clinical and cost data of adult patients undergoing supratentorial craniotomy at a university hospital within a 5-yr period who had a LOS less than 7 d. We compared those admitted to the NICU for 1 night of recovery versus those directly admitted to the NW. The NICU and NW groups included 340 and 209 patients, respectively, and were comparable in terms of age, ethnicity, overall health, and expected LOS. NW admissions had shorter LOS (3.046vs 3.586 d, P<.001), and independently predicted shorter LOS in multivariate analysis. While the NICU group had longer surgeries (6.8vs 6.4 h), there was no statistically significant difference in the cost of surgery. The NW group was associated with reduced hospitalization cost by $3193 per admission on average (P<.001). Clinically, there were no statistically significant differences in the rate of return to Operating Room, Emergency Department readmission, or hospital readmission within 30 d. Admitting adult craniotomy patients without significant comorbidities, who are expected to have short LOS, to NW was associated with reduced LOS and total cost of admission, without significant differences in postoperative clinical outcome.

Enhanced Recovery 2.0 - Same Day Discharge With Mobile App Follow-up After Minimally Invasive Colorectal Surgery.

To investigate the feasibility of SDD protocol with postdischarge follow-up using a mobile phone app in patients undergoing elective minimally-invasive colectomy. Discharge before gastrointestinal recovery and use of mobile health technology for remote follow-up may allow for SDD after minimally-invasive colectomy within an ERP. Adult patients undergoing elective laparoscopic colectomy or loop ileostomy reversal from February 2020 to November 2020 were screened for eligibility. Patients were eligible if they lived within a 30-minute drive from the hospital, had an adequate support system at home, and owned a smart phone. Patients were discharged from the recovery room on the day of surgery based on set criteria with postdischarge remote follow-up using a mobile application. Feasibility was defined as discharge on the day of surgery without emergency department (ED) visit or readmission within the first 3 days. 30-day complications, ED visits, and readmissions were compared to a non-SDD historical cohort (May 2019-March 2020) also remotely followed-up using the same mobile phone app (standard ERP group). A total of 48 patients were recruited to SDD, of which 77% were discharged on the day of surgery without subsequent ED visit in the first 72 hours. There were 11 patients that could not be discharged, including 7 for failure of discharge criteria and 4 for intraoperative complications/concerns. Overall 30-day complications in the SDD group (17%) was similar to the standard ERP group (15%, P = 0.813). ED visits (SDD10% vs standard ERP8%, P = 0.664) and readmissions (6% vs 4%, P = 0.681) were also similar. Findings from this study support the feasibility of a SDD protocol in select patients undergoing minimally-invasive colorectal resection. SDD colectomy protocols may represent the next evolution of ERP and postoperative recovery.

Emergency department: risk stratification in the elderly

Background &amp; aims. The older adults have very frequent access to the Emergency Department (ED). The aim of this study is to explore the ability of some geriatric screening tools validated for the ED to predict outcomes (mortality, hospitalization, ED readmission and institutionalization) at 6 months.Methods. Older adults consecutively admitted to Cagliari University’s ED between May and December of 2017 were enrolled. In ED older patients were screened with three tools: Identification of Seniors at Risk tool (ISAR); Triage Risk Screening Tool (TRST); International Resident Assessment Instrument Emergency Department Screener (InterRAI ED Screener). At 6 months patients were contacted by phone to verify: mortality, ED readmission, hospital admission, and institutionalization.Results. Of the 421 patients (median age 77, Interquartile Range 71-83; 55.8% women) enrolled, 72.4% were positive at the ISAR, 50.1% at the TRST; moreover 44.9% of enrolled subjects needed a urgent geriatric evaluation at the InterRAI ED Screener. The dead subjects had ISAR, TRST and InterRAI ED Screener with greater severity compared to the alive ones. The ISAR and the TRST were also more severe in subjects who had ED readmission, while those hospitalized, in addition to the ISAR, had the more severe Inter- RAI ED Screener. However, applying stepwise logistic regression, of the three tools used, only the ISAR was a predictor for hospitalization (OR = 1.23; CI = 1.03- 1.48; P = 0.02; AUC = 0.63).Conclusions. The association of ISAR and InterRAI ED Screener may be useful in ED to intercept both critical issues typical of the elderly, and the need and priority of the geriatric evaluation.

Potentially Inappropriate Medication Usage in Older Adults in a Tertiary Academic Medical Center Emergency Department

Background: The Beers Criteria® medications are potentially inappropriate medications (PIMs) recommended by the American Geriatric Society to be avoided or used with caution in adults 65 years and older. The usage of PIMs in the emergency department (ED) setting is not well characterized. Objectives: The purpose of this study is to evaluate the usage of PIMS in the ED. Methods: This is a single center retrospective observational study of a random sample of patients aged 65 and older who presented to the ED during a 6-month timeframe. The primary outcome was the incidence of ED readmissions in patients administered or prescribed a PIM compared with patients who were not prescribed or administered a PIM. Secondary outcomes included ED length of stay (LOS) and hospital admission. Results: Out of 192 patients, there was a total of 58 patients (30.2%) in the PIM group and 134 patients (69.8%) in the No PIM group. ED re-presentation within 30 days occurred in 10 patients (17%) in the PIM group vs 26 patients (19%) in the No PIM group (p = 0.88). The median ED LOS was 227 minutes vs 208 minutes (p = 0.1679). Hospital admission within 30 days occurred in 4 patients (7%) in the PIM group and 13 patients (10%) in the No PIM group (p = 0.725). Conclusions: This analysis did not show statistically significant differences between patients who received a PIM compared to those who received an alternative medication with regard to re-presentation, admission, and ED LOS. ED LOS trended towards being longer in the PIM group.

Immune Checkpoint Inhibitor-Induced Hypophysitis in Renal Cell Carcinoma: Two Contrasting Case Presentations

Background: Increasing use of immune checkpoint inhibitor (ICI) therapy for malignancy has led to rising incidence of ICI-mediated endocrinopathies. We describe two varying cases of patients with renal cell carcinoma (RCC) who presented with ICI-mediated hypophysitis. Cases: Patient A: A 72 year old female with RCC (T1bN0M0) diagnosed after an incidental renal mass was found on CT scan following a motor vehicle accident. After nephrectomy, she received 5 cycles of nivolumab (6/2019 to 10/2019). One month later, she presented in severe DKA and was diagnosed with ICI-mediated diabetes (low c-peptide, negative autoantibodies). ICI therapy was stopped. In 4/2020, she experienced a drastic reduction in her insulin requirement (~30 units/day of basal/bolus insulin to ~6 units/day of basal insulin only). She had a primary care visit for fatigue, nausea, and anorexia. Biochemical evaluation showed hyponatremia, normokalemia, normoglycemia, and no acid-base disorder. One week later, she presented to the emergency department (ED) with worsening symptoms. She was hypotensive (94/56 mmHg), hyponatremic (129 mmol/L), normokalemic, and azotemic. Cosyntropin stimulation test (CST) showed an inappropriate response [ACTH <5 pg/ml; cortisol response of 0.4 to 8.1 µg/dl]. Brain MRI showed a partially empty sella. She was diagnosed with secondary adrenal insufficiency (AI) due to hypophysitis and started on steroid replacement. A repeat CST after 3 months did not show HPA axis recovery. Her presentation is unique because she developed secondary AI six months after nivolumab therapy. Patient B: A 43 year old female with RCC (T4N1M1) who received 4-cycles of ipilimumab and nivolumab (11/2019 to 1/2020). One month later, she presented to the ED with hypotension, anorexia, and fatigue. Biochemical evaluation showed severe DKA. She was diagnosed with ICI-mediated diabetes (low c-peptide, negative autoantibodies) and started on basal/bolus insulin. Her ICI-therapy was stopped. One month later, she was readmitted for hypotension and severe headaches and found to have hyponatremia (131 mmol/L), normokalemia, hyperprolactinemia (29 ng/ml), cortisol 4.5 µg/dl (previous random cortisol a month earlier was 33 µg/dl). Pituitary gland was normal on MRI. She was presumed to have secondary AI due to hypophysitis and started on steroid replacement. A CST performed after 3 months showed ACTH <5 pg/ml and cortisol response of 3.5 to 4.5 µg/dl. Her case was a usual presentation of ICI-mediated secondary AI as it occurred within 1-2 months of stopping ICI therapy. Conclusion: As we continue to learn about ICI-mediated endocrinopathies, it is imperative to document the variation in timing of presentation. ICI-mediated hypophysitis can present at any time after the initiation of therapy. Given this variation, there is need for routine screening and early treatment of hypophysitis to reduce ED visits and readmission rates.