Hospital-acquired Complications Research Articles

Implementation of a geriatric in-reach service improves acute surgical unit outcomes; a retrospective before-and-after study.

Australia's ageing population is challenging for surgical units and there is a paucity of evidence for geriatric co-management in acute general surgery. We aimed to assess if initiating a Geriatric Medicine in-reach service improved outcomes for older adults in our Acute Surgical Unit (ASU). The Older Adult Surgical Inpatient Service (OASIS) was integrated into ASU in 2021. We retrospectively reviewed all patients over age 65 admitted to ASU over a 12-month period before and after service integration with a length of stay (LOS) greater than 24 h. There was no subsequent truncation or selection. Primary outcomes were 30-day mortality, LOS, and 28-day readmissions. Secondary outcomes were discharge disposition, in-hospital mortality, and hospital-acquired complications (HACs). 1339 consecutive patients were included in each group, with no differences in baseline characteristics. There was a significant decrease in 28-day readmissions from 20.2% to 16.0% (P < 0.05), greatest in patients undergoing non-EL operative procedures (21.9% pre-OASIS vs. 12.6% post-OASIS; P < 0.05). Trends towards reduced 30-day mortality (7.17% vs. 5.90%; P = 0.211), in-hospital mortality (3.88% vs. 2.91%; P = 0.201), permanent care placement (7.77% vs. 7.09%; P = 0.843) and HACs (8.14% vs. 7.62%; P = 0.667) were seen, although statistical significance was not demonstrated. LOS remained unchanged at 4 days (P = 0.653). The addition of a geriatric in-reach service to a tertiary ASU led to a significant reduction in 28-day readmissions. Downtrends were seen in mortality, permanent care placement, and HAC rates, while LOS remained unchanged.

A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre-Post Feasibility Study.

Delirium is frightening for people experiencing it and their carers, and it is the most common hospital-acquired complication worldwide. Delirium is associated with higher rates of morbidity, mortality, residential care home admission, dementia, and carer stress and burden, yet strategies to embed the prevention and management of delirium as part of standard hospital care remain challenging. Carers are well placed to recognize subtle changes indicative of delirium, and partner with nurses in the prevention and management of delirium. To evaluate a Prevention & Early Delirium Identification Carer Toolkit (PREDICT), to support partnerships between carers and nurses to prevent and manage delirium. A pre-post-test intervention and observation study. Changes in carer knowledge of delirium; beliefs about their role in partnering with nurses and intended and actual use of PREDICT; carer burden and psychological distress. Secondary measures were rates of delirium. Participants were carers of Indigenous patients aged 45years and older and non-Indigenous patients aged 65years and older. Nurses implemented PREDICT, with a view to provide carers with information about delirium and strategies to address caregiving stress and burden. Participants included 25 carers (43% response rate) (n = 17, 68% female) aged 29-88 (M = 65, SD = 17.7years). Carer delirium knowledge increased significantly from pre-to-post intervention (p = < .001; CI 2.07-4.73). Carers' intent and actual use of PREDICT was (n = 18, 72%; and n = 17, 68%). Carer burden and psychological distress did not significantly change. The incidence of delirium in the intervention ward although not significant, decreased, indicating opportunity for scaling up. The prevention and management of delirium are imperative for safe and quality care for patients, carers, and staff. Further comprehensive and in-depth research is required to better understand underlying mechanisms of change and explore facets of nursing practice influenced by this innovative approach.

One-Year Recovery Among Survivors of Prolonged Severe COVID-19: A National Multicenter Cohort.

Understanding the long-term effects of severe COVID-19 illness on survivors is essential for effective pandemic recovery planning. Therefore, we investigated impairments among hospitalized adults discharged to long-term acute care hospitals (LTACHs) for prolonged severe COVID-19 illness who survived 1 year. The Recovery After Transfer to an LTACH for COVID-19 (RAFT COVID) study was a national, multicenter, prospective longitudinal cohort study. We included hospitalized English-speaking adults transferred to one of nine LTACHs in the United States between March 2020 and February 2021 and completed a survey. None. Validated instruments for impairments and free response questions about recovering. Among 282 potentially eligible participants who provided permission to be contacted, 156 (55.3%) participated (median age, 65; 38.5% female; 61.3% in good prior health; median length of stay of 57 d; 77% mechanically ventilated for a median of 26 d; 42% had a tracheostomy). Approximately two-thirds (64%) had a persistent impairment, including physical (57%), respiratory (49%; 19% on supplemental oxygen), psychiatric (24%), and cognitive impairments (15%). Nearly half (47%) had two or more impairment types. Participants also experienced persistent debility from hospital-acquired complications, including mononeuropathies and pressure ulcers. Participants described protracted recovery, attributing improvements to exercise/rehabilitation, support, and time. While considered life-altering with 78.7% not returning to their usual health, participants expressed gratitude for recovering; 99% returned home and 60% of previously employed individuals returned to work. Nearly two-thirds of survivors of among the most prolonged severe COVID-19 illness had persistent impairments at 1 year that resembled post-intensive care syndrome after critical illness plus debility from hospital-acquired complications.

Incidence and outcomes of in-hospital nutritional decline: A prospective observational cohort study in adult patients

Background and AimsHospital malnutrition is associated with higher healthcare costs and worse outcomes. Only a few prospective studies have evaluated trends in nutritional status during an acute stay, but these studies were limited by the short timeframe between nutrition assessments. The aim of this study was to investigate changes in nutritional status, incidence of hospital-acquired malnutrition (HAM), and the associated risk factors and outcomes in acute adult patients admitted for >14 days. MethodsA prospective observational cohort study was conducted in two medical and two surgical wards in a tertiary hospital in Brisbane, Australia. Nutrition assessments were performed using the Subjective Global Assessment at baseline (day eight) and weekly until discharge. Nutritional decline was defined as a change from well-nourished to moderate/severe malnutrition (HAM) or from moderate to severe malnutrition (further decline) >14 days after admission. ResultsOne hundred and thirty patients were included in this study (58.5% male; median age 67.0 years (IQR 24.4), median length of stay 23.5 days (IQR 14)). At baseline, 70.8% (92/130) of patients were well-nourished. Nutritional decline occurred in 23.8% (31/130), with 28.3% (26/92) experiencing HAM. Of the patients with moderate malnutrition on admission (n = 30), 16% (5/30) continued to decline to severe malnutrition. Improvement in nutritional status from moderate and severe malnutrition to well-nourished was 18.4% (7/38). Not being prescribed the correct nutrition care plan within the first week of admission was an independent predictor of in-hospital nutritional decline or remaining malnourished (OR 2.3 (95% CI 1.0–5.1), p = 0.039). In-hospital nutritional decline was significantly associated with other hospital-acquired complications (OR 3.07 (95% CI 1.1–8.9), p = 0.04) and longer length of stay (HR 0.63 (95% CI 0.4–0.9), p=0.044). ConclusionThis study found a high rate of nutritional decline in acute patients, highlighting the importance of repeated nutrition screening and assessments during hospital admission and proactive interdisciplinary nutrition care to treat or prevent further nutritional decline.

Dose-response relationships between body-mass index and pressure injuries occurrence in hospitalized patients: A multi-center prospective study

BackgroundPressure injuries (PIs) are one of the leading potentially preventable hospital-acquired complications associated with prolonged hospital length, poor quality of life and financial burden. The relationship between body mass index (BMI) and PIs occurrence is controversial. ObjectiveThe aim of this study was to further examine relationships between BMI and PIs occurrence in hospitalized patients. DesignA multi-center prospective study. Setting39 hospitals located in northwest China from April 2021 to July 2023. Participants175,960 hospitalized patients aged over 18 years were enrolled, and 170,800 patients were included in the final analysis. MethodsBMI and clinical characteristics were assessed at baseline. PIs assessment were performed by trained nurses, with data recorded for the presence, the location and stage of each PI. For staging PIs, the National Pressure Ulcer Advisory Panel（NPUAP） staging system were used. The multivariate logistic regressions analysis and restricted cubic splines (RCS) models were used to explore associations between BMI and PIs, adjusting for potential confounders. ResultsOf 175,960 participants, 5160 were excluded from analyses. The multivariate logistic regression model identified a positive relationship between under-weight BMI and risk of PIs occurrence (OR = 1.60, 95% CI:1.18–2.17). We also found U shaped association between BMI and PIs occurrence (non-linear P < 0.001). BMI less than 23 kg/m2 significantly increased risk of PIs, and there was a tendency to increase risk of PIs at BMI higher than 30 kg/m2. We stratified participants by sex to further investigate their association and found the risk of PIs increases substantially in women at BMI below 17 kg/m2 and in men at BMI below 23 kg/m2. ConclusionsThe present study indicated that there was an approximate U shaped relationship between BMI and PIs occurrence, and this association was potentially different between men and women.

Implementation Evaluation of an Early Notification Care Bundle for Patients with Hip Fracture (eHIP)

Introduction: Hip fracture in older adults results in significant mortality and is one of the costliest fall-related injuries. The Australian Commission for Quality and Safety in Health Care hip fracture clinical care standards consolidate the best available evidence for managing this patient group; however, uptake is variable. The aim of this study was to evaluate the implementation and effectiveness of a multidisciplinary early activation mechanism and bundle of care (eHIP) on patient and health service outcomes. Methods: This controlled pre- and post-test study was conducted from June 2019–June 2021 at a large regional hospital in Australia. We hypothesised that eHIP would result in at least 50% of hip fracture patients receiving six or more components of the ACSQHC Hip Fracture Clinical Care Standard. Secondary outcomes include hospital-acquired complication rates and acute treatment costs. Results: There were 565 cases included for analysis. After implementation of eHIP (the post-period), 88% of patients received a correct activation of the eHIP pathway, sustained over 12 months. The proportion of patients receiving the primary outcome of six or more components increased from 36% to 49%. Care at presentation (pain and cognitive assessment) increased by 23%, and unrestricted mobilisation within 24 h improved by 10%. Prescription of appropriate analgesia improved 10-fold (5.2–57%), and patients receiving the gold standard fascia iliaca block increased from 68% to 88%. Acute treatment costs did not significantly change. Discussion/Conclusion: eHIP, a hip fracture care program incorporating evidence-based behaviour change theory, resulted in sustained improvements to patient care as recommended by the ACSQHC Hip Fracture Clinical Care Standard.

Evaluation of a Novel Mechanical Venous Thromboembolism Compression Device in Trauma Patients: A Pilot Study.

Venous thromboembolism (VTE) is the fourth most common preventable hospital-acquired complication for hospitalized trauma patients. Mechanical prophylaxis, using sequential compression or intermittent pneumatic compression (IPC) devices, is recommended alongside pharmacologic prophylaxis for VTE prevention. However, compliance with device use is a barrier that reduces the effectiveness of mechanical prophylaxis. This study aimed to determine whether using the Movement and Compressions (MAC) system compared with an IPC device impacts compliance with mechanical VTE prophylaxis in trauma patients. This study used a before-and-after design with historical control at a Level II trauma center with a convenience sample of adult trauma patients admitted to the intensive care unit or acute care floor for at least 24h. We trialed the MAC device for 2 weeks in November and December 2022 with prospective data collection. Data collection for the historical control group occurred retrospectively using patients from a point-in-time audit of IPC device compliance from August and September of 2022. A total of 51 patients met inclusion criteria, with 34 patients in the IPC group and 17 patients in the MAC group. The mean (SD) prophylaxis time was 17.2h per day (4.0) in the MAC group and 7.5h per day (8.8) in the IPC group, which was statistically significant (p < .001). Our findings suggest that the MAC device can improve compliance with mechanical prophylaxis.

Which Demographic and Clinical Characteristics Can Better Predict the Length of Hospital Stay among Traumatic Patients? A Retrospective Single-Center, Registry-Based Study.

Lengthy hospitalization may lead to an increased hospital-acquired patient complication, including infections, as well as increased costs for both healthcare systems and patients. A few studies evaluated the impact of various clinical and demographic variables on patients' length of stay (LOS). Hence, in this study, we aimed to investigate the impact of various variables on traumatic patients' LOS. This is a retrospective single-center, registry-based study of traumatic patients admitted to Taleqani, a major trauma center in Kermanshah, Iran. A Minimal Dataset (MDS) was developed to retrieve traumatic data on demographic and clinical aspects. We used univariable and multiple quantile regression models to evaluate the association between independent variables, including ISS, GCS, and SBP, with LOS. LOS is practically defined as the time interval between hospital admission and discharge. The LOS durations have been presented as median (Q1 to Q3) hours. A p-value of <0.05 was considered statistically significant. A total of 2708 cases were included in this study, with 1989 (73.4%) of them being male. The median LOS was 87.00 (48.00 to 144.00) hours. When adjusted for systolic blood pressure (SBP), Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and cause of injury, the two characteristics of spine/back and multiple trauma were significantly associated with the higher LOS, with 43 (20.5 to 65.48) and 24 (10.39 to 37.60) hours more than extremities (P < 0.001 and P = 0.005). Besides, the patients admitted due to road traffic injuries (RTI) were discharged 16 and 41 hours later than falling and cutting/stabbing (P = 0.008 and < 0.001, respectively). Moreover, the patients with ISS≥16 and 9≤ISS≤15 had a median of 51 (21 to 80) and 34 (22 to 45) LOS hours more, compared to 1≤ISS≤8, respectively (P < 0.001). The trauma cases experiencing SBP ≤ 90 mmhg on admission had a median of 41 (20 to 62) hours more hospitalization period than those with SBP> 90 mmhg (P < 0.001). At last, the patients with GCS of 9 to 12 and GCS of 3 to 8 were hospitalized for 39 and 266 hours more than GCS of 13 to 15 (P < 0.001). Determining independent determinants of prolonged LOS may lead to better identifying at-risk patients on admission. Trauma care providers should consider the following risk factors for increased LOS: higher ISS, Lower GCS, and SBP, multiple trauma or spine injury, and trauma resulting from falling or cutting/stabbing. As a result, the impact of extended LOS might be reduced by intervening in the related influencing factors.

Factors affecting length of stay according to bronchopulmonary dysplasia severity: a nationwide cohort study in Korea.

Longer hospitalizations for preterm infants with bronchopulmonary dysplasia (BPD) delay developmental outcomes, increase the risk for hospital-acquired complications, and exert a substantial socioeconomic burden. This study aimed to identify factors associated with an extended length of stay (LOS) at different levels of severity of BPD. A cohort study was conducted using the Korean Neonatal Network registry of very low birth weight infants with BPD between 2013 and 2017 through retrospective analysis. A total of 4263 infants were diagnosed with BPD. For mild BPD, infants requiring surgical treatment for patent ductus arteriosus needed a longer LOS [eadjusted β coefficients (adj β) 1.041; 95% confidence interval (CI): 0.01-0.08] and hydrocephalus (eadj β 1.094; 95% CI 0.01-0.17). In moderate BPD, infants administered steroids or with intraventricular hemorrhage required a longer LOS (eadj β 1.041; 95% CI 0.00-0.07 and eadj β 1.271; 95% CI 0.11-0.38, respectively). In severe BPD, infants with comorbidities required a longer LOS: pulmonary hypertension (eadj β 1.174; 95% CI 0.09-0.23), administrated steroid for BPD (eadj β 1.116; 95% CI 0.07-0.14), sepsis (eadj β 1.062; 95% CI 0.01-0.11), patent ductus arteriosus requiring surgical ligation (eadj β 1.041; 95% CI 0.00-0.08), and intraventricular hemorrhage (eadj β 1.016; 95% CI 0.05-0.26). Additionally, the higher the clinical risk index score, the longer the LOS needed for infants in all groups. The factors affecting LOS differed according to the severity of BPD. Individualized approaches to reducing LOS may be devised using knowledge of the various risk factors affecting LOS by BPD severity.

Factors influencing the length of stay (LOS) undergoing robot-assisted thoracoscopic lung surgery in the setting of enhanced recovery after surgery (ERAS) protocol for pediatric patients: a retrospective study.

A prolonged length of stay (LOS) after surgery may result in higher hospital costs and hospital-acquired complications. This study aims to identify the risk factors associated with a prolonged hospital stay after robot-assisted thoracoscopic lung surgery for pediatric patients in the context of enhanced recovery after surgery. The data for this retrospective study were collected from pediatric patients undergoing robot-assisted thoracoscopic lung surgery. Patients were divided into two subgroups based on median postoperative LOS (Group I: LOS > median 5 days and Group II: LOS ≤ median 5 days). Logistic regression analysis was used to identify the potential factors associated with increased LOS. This study included 241 patients, 71 (29.46%) with an LOS of >5 days. The proportion of older children was significantly higher in Group I than that in Group II (P=0.004). Patients in Group I were more likely to experience a longer duration of anesthesia and surgery (P<0.001). They also had significantly higher rates of pneumonia, pleural effusion, and liver function damage (P<0.05). Several factors were identified to be associated with an increased LOS after robot-assisted thoracoscopic lung surgery: age >6 years [odds ratio (OR) =3.214, 95% confidence interval (CI): 1.464-7.502, P=0.004], surgery duration >100 min (OR =2.138, 95% CI: 1.296-4.387, P=0.005), intra-albumin (OR =13.778, 95% CI: 1.470-129.116, P=0.022), and blood loss >5 mL (OR =2.184, 95% CI: 1.082-4.409, P=0.029). The results revealed that older age, longer surgery duration, use of intra-albumin, and more blood loss predict longer postoperative hospital stay in pediatric patients with congenital lung lesions after robot-assisted thoracoscopic lung surgery.

Reliable Prediction of Discharge Disposition Following Cervical Spine Surgery With Ensemble Machine Learning and Validation on a National Cohort.

A retrospective cohort study. The purpose of this study is to develop a machine learning algorithm to predict nonhome discharge after cervical spine surgery that is validated and usable on a national scale to ensure generalizability and elucidate candidate drivers for prediction. Excessive length of hospital stay can be attributed to delays in postoperative referrals to intermediate care rehabilitation centers or skilled nursing facilities. Accurate preoperative prediction of patients who may require access to these resources can facilitate a more efficient referral and discharge process, thereby reducing hospital and patient costs in addition to minimizing the risk of hospital-acquired complications. Electronic medical records were retrospectively reviewed from a single-center data warehouse (SCDW) to identify patients undergoing cervical spine surgeries between 2008 and 2019 for machine learning algorithm development and internal validation. The National Inpatient Sample (NIS) database was queried to identify cervical spine fusion surgeries between 2009 and 2017 for external validation of algorithm performance. Gradient-boosted trees were constructed to predict nonhome discharge across patient cohorts. The area under the receiver operating characteristic curve (AUROC) was used to measure model performance. SHAP values were used to identify nonlinear risk factors for nonhome discharge and to interpret algorithm predictions. A total of 3523 cases of cervical spine fusion surgeries were included from the SCDW data set, and 311,582 cases were isolated from NIS. The model demonstrated robust prediction of nonhome discharge across all cohorts, achieving an area under the receiver operating characteristic curve of 0.87 (SD=0.01) on both the SCDW and nationwide NIS test sets. Anterior approach only, age, elective admission status, Medicare insurance status, and total Elixhauser Comorbidity Index score were the most important predictors of discharge destination. Machine learning algorithms reliably predict nonhome discharge across single-center and national cohorts and identify preoperative features of importance following cervical spine fusion surgery.

Total laryngectomy and readmission: causes, rates and predictors

BackgroundTotal laryngectomy (TL) is a complex procedure, and patients undergoing TL are at high risk for readmission, which exposes them to hospital-acquired complications. Readmission rate is a metric for quality of care. We aimed to identify the rate, causes, and predictors of hospital readmission within 60 days after discharge following TL.MethodsThis is a 12-year retrospective study where we included all patients undergoing TL in a single tertiary care center between 2008 and 2022. Patient charts were reviewed for demographics, comorbidities, and causes for readmission.ResultsOf 83 patients who underwent TL, 12 (14.50%) were readmitted within 60 days. Common causes were surgical site infection (33.33%) and mucocutaneous fistula (25%). Significant predictors for readmission were tobacco use (P = 0.003), African ethnicity (P = 0.004), being unmarried (P < 0.001), lower preoperative serum albumin (P < 0.001), higher preoperative TSH (P = 0.03), higher preoperative neutrophil count (P = 0.035), higher American Society of Anesthesiology (ASA) score (P = 0.028), and higher Cumulative Illness Rating Scale (CIRS) score (P = 0.029).ConclusionOne in every seven patients were readmitted following TL. Frequent causes include wound infection and fistulas. Predictors include preoperative hypoalbuminemia, hypothyroidism, African ethnicity, being unmarried, tobacco use, and a higher baseline burden of comorbidities. Such factors can be targeted to reduce hospital readmission rates.

Predicting 90-Day Prognosis in Ischemic Stroke Patients Post Thrombolysis Using Machine Learning.

(1) Objective: This study aimed to construct a machine learning model for predicting the prognosis of ischemic stroke patients who underwent thrombolysis, assessed through the modified Rankin Scale (mRS) score 90 days after discharge. (2) Methods: Data were sourced from Qatar's stroke registry covering January 2014 to June 2022. A total of 723 patients with ischemic stroke who had received thrombolysis were included. Clinical variables were examined, encompassing demographics, stroke severity indices, comorbidities, laboratory results, admission vital signs, and hospital-acquired complications. The predictive capabilities of five distinct machine learning models were rigorously evaluated using a comprehensive set of metrics. The SHAP analysis was deployed to uncover the most influential predictors. (3) Results: The Support Vector Machine (SVM) model emerged as the standout performer, achieving an area under the curve (AUC) of 0.72. Key determinants of patient outcomes included stroke severity at admission; admission systolic and diastolic blood pressure; baseline comorbidities, notably hypertension (HTN) and coronary artery disease (CAD); stroke subtype, particularly strokes of undetermined origin (SUO); and hospital-acquired urinary tract infections (UTIs). (4) Conclusions: Machine learning can improve early prognosis prediction in ischemic stroke, especially after thrombolysis. The SVM model is a promising tool for empowering clinicians to create individualized treatment plans. Despite limitations, this study contributes to our knowledge and encourages future research to integrate more comprehensive data. Ultimately, it offers a pathway to improve personalized stroke care and enhance the quality of life for stroke survivors.

A comparative study between surgical cut down and percutaneous closure devices in management of large bore arterial access

BackgroundCompared to conventional open surgery, minimally invasive catheter-based procedures have less post procedural complications. Transcatheter aortic valve implantation (TAVI) and endovascular aneurysm repair (EVAR) require large bore arterial access. Optimal site management of large bore arterial access is pivotal to reduce the hospital-acquired complications associated with large bore arterial access. We wanted to compare surgical cutdown versus percutaneous closure devices in site management of large bore arterial access.MethodsParticipants planned for TAVI or EVAR with large bore arterial access more than 10 French were included, while participants with history of bypass surgery, malignancies, thrombophilia, or sepsis were excluded. A consecutive sample of 100 participants (mean age 74.66 ± 2.65 years, 61% males) was selected, underwent TAVI or EVAR with surgical cutdown (group 1) versus TAVI or EVAR with Proglide™ percutaneous closure device (group 2).ResultsThe incidence rate of hematoma was significantly lower in group 2 versus group 1 (p = 0.014), the mean procedure time (minutes) and the median hospital stay (days) were significantly higher in group 1 versus group 2 (t(98) = − 2.631, p = 0.01, and U = 2.403, p = 0.018, respectively), and the c-reactive protein pre-procedure and the c-reactive protein post-procedure were significantly lower in group 2 versus group 1 (U = -2.969, p = 0.003, and U = -2.674, p = 0.007, respectively).ConclusionsOur study showed a lower incidence rate of large bore arterial access complications as hematoma, a shorter procedure time, and a shorter hospital stay with percutaneous closure devices compared to surgical cutdown.

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals

BackgroundInternational evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).MethodsWe conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017–2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors.ResultsOf 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45–0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients.ConclusionOur findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

Implementing a Screen-Clean-Hydrate bundle of care for improving swallow screening, oral health, and hydration in acute stroke: Protocol for a Type 2 hybrid-effectiveness pre-post study.

Stroke clinical guidelines recommend care processes that optimize patient outcomes and minimize hospital-acquired complications. However, audits and surveys illustrate that recommended care is not always consistently or thoroughly implemented. This paper outlines the methods for implementing and evaluating a new bundle of care. Screen-Clean-Hydrate bundles together recommendations from the Australian Clinical Guidelines for Stroke Management and supplements these with evidence-informed best practice from the literature for: swallow screening within 4 h of presentation to hospital (Screen); oral health assessment and delivery of oral care (Clean); and hydration assessment and management (Hydrate). The study is a pre-post Type 2 hybrid effectiveness/implementation design with an embedded process evaluation, which will be conducted in two acute stroke units in a capital city of Australia. The integrated-Promoting Action on Research Implementation in Health Services (iPARIHS) framework will be used to guide study design, conduct, and evaluation. Clinical effectiveness will be measured by rates of hospital-acquired complications and proxy measures of cost (length of stay, procedure costs) for 60 patient participants pre- and postimplementation. Implementation outcomes will focus on acceptability, feasibility, uptake and fidelity, and identification of barriers and enablers to implementation through staff interviews, medical record audits, and researcher field notes. Due to its design as a hybrid effectiveness/implementation study, once completed, the study will provide information on both intervention and implementation effectiveness, including details of successful and unsuccessful multidisciplinary implementation strategies. This will inform a larger multisite effectiveness/implementation trial for future upscale, leading to improved compliance with stroke guidelines and therefore stroke outcomes.

Outcomes ofcompleted quality activities inan Australian tertiary hospital, 2015-2019.

Quality activities including quality assurance and quality improvement are an integral part of safety and quality governance for hospitals. Previous studies identified that (i) majority are for quality assurance and knowledge-acquiring purposes and (ii) adherence to the quality cycle as well as impact on patient-related outcomes at the hospital level are unclear, neither associated with costs. This study aims to (i) assess adherence to the quality cycle for quality activities in a large Australian tertiary hospital; (ii) report outcomes of quality activities at the hospital level, including impact on patient-related outcomes measured by the occurrence of hospital-acquired complications; and (iii) estimate time and costs for data collection. This quantitative study utilized three data sources. First is the hospital's electronic quality management system, Governance, Evidence, Knowledge and Outcome that identifies completed quality activities over a 5-year period; second is Tableau dashboards for hospital-acquired complication performance; third is Microsoft Teams Forms used to capture time of data collection for bedside observations and retrospective notes reviews. Median sample size and median hourly rates in 2018 were used for calculations. A total of 1768 quality activities were completed over a 5-year period representing an average of 353 quality activities per year, of which 87.8% were initiated by clinicians and 12.2% planned and coordinated by safety and quality or equivalent. The activity reports indicated that less than a fifth (17.1%) brought about improvement in process measures and only 7.1% improved outcome measures. Two-thirds of the quality activities (66.3%) provided recommendations based on their findings, but evidence of action plan was available in 14.1% of the reports only. No association was found between the number of activities completed and overall hospital-acquired complication performance. Retrospective data collection (64.7%) was common. The estimated time and cost for data collection averaged at 3490h/year, equivalent to 1.8 full-time employees, for a cost of $171 000 at the nursing rate (A$49.0), $280 000 at the medical rate (A$79.5), and $200 000 at the Health Service Union rate (A$58.9). Most quality activities were clinician-initiated. Implementing change and achieving and sustaining improvement were the two challenging stages in the quality cycle. No clear association was observed between activities completed and improvement in patient-related outcomes although some improvement in processes. A paradigm shift may be needed to engineer quality activities in hospitals to be more outcome-oriented. Opportunities exist for hospitals to consider how quality activities can be organized to maximize returns from investment.

Delirium and Its Association with Short- and Long-Term Health Outcomes in Medically Admitted Patients: A Prospective Study.

Delirium is highly prevalent among elderly hospitalized patients in various healthcare settings. This study aimed to assess the impact of delirium on short- and long-term health outcomes. A prospective cohort included medically ill patients (≥65 years) admitted to a tertiary healthcare facility. Delirium was screened using the 3-Minute Diagnostic confusion assessment method (3D-CAM). During hospitalization, 53.8% (n = 153/284) had delirium. Patients with delirium had a longer length of hospital stay (LOS) (7 vs. 5 days; p < 0.01) compared to patients without delirium. Delirium caused a higher frequency of high-dependency unit (HDU) or intensive care unit (ICU) admission (p < 0.01) and an increased incidence of hospital-acquired complications, including infections (p = 0.03), pressure injuries (p = 0.01), and upper gastrointestinal bleeding (p < 0.01). Inpatient all-cause mortality was higher in patients with delirium than those without delirium (16.3% vs. 1.5%; p < 0.01). Patients with delirium had higher rates of 90-day all-cause mortality (25.4% vs. 8.4%; p < 0.01) and 1-year all-cause mortality (35.9% vs. 16%; p < 0.01) compared to patients without delirium. Patients with delirium exhibited shorter survival periods at 90 days and 1 year compared to patients without delirium with a hazard ratio (HR) = 3.41, 95% CI: 1.75-6.66, p < 0.01 and HR = 2.64, 95% CI: 1.59-4.37, p < 0.01, respectively. Delirium is associated with serious short-term and long-term clinical consequences. Early recognition, prevention, and targeted interventions addressing reversible risk factors are crucial. Further research is warranted to explore effective strategies for delirium management in general medical wards.

Assisted ambulation to improve health outcomes for older medical inpatients (AMBULATE): study protocol for a randomized controlled trial

BackgroundHospitalized older adults spend as much as 95% of their time in bed, which can result in adverse events and delay recovery while increasing costs. Observational studies have shown that general mobility interventions (e.g., ambulation) can mitigate adverse events and improve patients’ functional status. Mobility technicians (MTs) may address the need for patients to engage in mobility interventions without overburdening nurses. There is no data, however, on the effect of MT-assisted ambulation on adverse events or functional status, or on the cost tradeoffs if a MT were employed. The AMBULATE study aims to determine whether MT-assisted ambulation improves mobility status and decreases adverse events for older medical inpatients. It will also include analyses to identify the patients that benefit most from MT-assisted mobility and assess the cost-effectiveness of employing a MT.MethodsThe AMBULATE study is a multicenter, single-blind, parallel control design, individual-level randomized trial. It will include patients admitted to a medical service in five hospitals in two regions of the USA. Patients over age 65 with mild functional deficits will be randomized using a block randomization scheme. Those in the intervention group will ambulate with the MT up to three times daily, guided by the Johns Hopkins Mobility Goal Calculator. The intervention will conclude at hospital discharge, or after 10 days if the hospitalization is prolonged. The primary outcome is the Short Physical Performance Battery score at discharge. Secondary outcomes are discharge disposition, length of stay, hospital-acquired complications (falls, venous thromboembolism, pressure ulcers, and hospital-acquired pneumonia), and post-hospital functional status.DiscussionWhile functional decline in the hospital is multifactorial, ambulation is a modifiable factor for many patients. The AMBULATE study will be the largest randomized controlled trial to test the clinical effects of dedicating a single care team member to facilitating mobility for older hospitalized patients. It will also provide a useful estimation of cost implications to help hospital administrators assess the feasibility and utility of employing MTs.Trial registrationRegistered in the United States National Library of Medicine clinicaltrials.gov (# NCT05725928). February 13, 2023.

A novel risk score for predicting prolonged length of stay following pediatric kidney transplant.

Kidney transplants (KT) are accepted as the kidney replacement therapy of choice for children with kidney failure. The surgery itself may be more difficult especially in small children, and often leads to significant hospital stays. There is little research on predicting prolonged length of stay (LOS) in children. We aim to examine the factors associated with prolonged LOS following pediatric KT to help clinicians make informed decisions, better counsel families, and potentially reduce preventable causes of prolonged stay. We retrospectively analyzed the United Network for Organ Sharing database for all KT recipients less than 18years old between January 2014 and July 2022 (n = 3693). Donor and recipient factors were tested in univariate and multivariate logistic analysis using stepwise elimination of non-significant factors to create a final regression model predicting LOS longer than 14days. Values were assigned to significant factors to create risk scores for each individual patient. In the final model, only primary diagnosis of focal segmental glomerulosclerosis, dialysis prior to KT, geographic region, and recipient weight prior to KT were significant predictors of LOS longer than 14days. The C-statistic of the model is 0.7308. The C-statistic of the risk score is 0.7221. Knowledge of the risk factors affecting prolonged LOS following pediatric KT can help identify patients at risk of increased resource use and potential hospital-acquired complications. Using our index, we identified some of these specific risk factors and created a risk score that can stratify pediatric recipients into low, medium, or high risk groups. A higher resolution version of the Graphical abstract is available as Supplementary information.