Hospital Disposition Research Articles

564: ANALYSIS OF OBSTETRIC TRANSPORTS TO LABOR AND DELIVERY REQUIRING ESCALATION OF CARE TO THE ICU

Introduction: Severe maternal morbidity (SMM) is increasing. Prevention of maternal adverse outcomes requires prompt identification of the critically-ill patient requiring intensive care services (ICU). We aim to describe perinatal risk factors that are associated with obstetric transports that require escalation to the ICU after admission. Additionally we sought to illustrate the time intervals from labor and delivery (L&D) admission to the ICU as a marker for potential improvements in delays in care. Methods: This is a retrospective observational study of obstetric transports to a single tertiary medical center from 01/1/2017-12/31/2021. We included all patients transported to L&D. Patient transported directly to the ICU were excluded. Electronic medical records were used to collect demographics, obstetric and maternal risk factors, the time and indication for escalation to the ICU, and hospital length of stay (LOS). Results: A total of 1,855 obstetric transport patients were reviewed during the study period. Of these, 1,794 patients were directly admitted to L&D with 52 patients requiring escalation to the ICU during their admission. Asthma (26.9%), hypertension (21.2%) and diabetes (21.2%) were the most common maternal co-morbidities. The most common indication for ICU admission was acute respiratory failure (51%), followed by preeclampsia/eclampsia (19%), and cardiomyopathy (11.5%). Primary ICU interventions required were mechanical ventilation (59%) and vasopressors (42%). There was 1 maternal death. The time from L&D admission to ICU escalation was 35.6 hours with the median ICU LOS and total hospital LOS were 3 and 9.7 days, respectively. Conclusions: Transported obstetric patients admitted initially to L&D are still requiring ICU escalation. Delays in appropriate level of care can attribute to SMM and adverse perinatal outcomes. For this reason, obstetric-risk assessment tools are necessary in identifying the critically-ill obstetric patient to assist in determine the appropriate hospital disposition upon transfer.

1085: HYPERCHLOREMIA AND ACUTE KIDNEY INJURY IN PATIENTS WITH NONTRAUMATIC INTRACRANIAL HEMORRHAGE

Introduction: Hypertonic saline (HTS) is commonly used in patients with non-traumatic intracranial hemorrhage (ICH) as a prophylactic and therapeutic option for intracranial hypertension and/or cerebral edema. Hyperchloremia is often resulted an adverse event due to the accompanying chloride load. Among patients with subarachnoid hemorrhage, traumatic brain injury, and acute ischemic stroke, previous literature has demonstrated an association between hyperchloremia and acute kidney injury (AKI) incidence, length of stay (LOS), and even mortality. We sought to investigate this relationship in patients with non-traumatic ICH. Methods: This was a single-center, retrospective, cohort study comparing patients with and without hyperchloremia in the first 7 days of hospitalization. This was defined as a serum chloride level above 115 mEq/L. Primary outcome was incidence of AKI in the first 10 days of hospitalization, defined by having met any of either AKIN or RIFLE criteria. Secondary outcomes included ICU and hospital LOS, disposition status, and in-hospital mortality. All adult patients with non-traumatic ICH were included. Those who had CKD stage 3 or higher, baseline SCr > 2 mg/dL or chloride > 115 mEq/L, mannitol administration, and LOS < 72 hours were excluded. Results: A total of 133 patients were analyzed, 54 of which were in the hyperchloremia group. Baseline characteristics were similar between groups, except for chloride, Modified Early Warning score (MEWS), and ICH score. Incidence of AKI was found in 32.9% and 35.2% of the non-hyperchloremia and hyperchloremia groups, respectively (p=0.785). Patients with hyperchloremia had longer ICU LOS (7 vs. 5 days, p=0.006), lower rate of independent disposition (18.5% vs. 44.3%, p=0.001), and higher rate of mortality (38.9% vs. 15.2%, p=0.002). A logistic regression analysis was run to predict mortality risk using AKI, hyperchloremia, ICH score, and MEWS. ICH score was the only significant predictor of mortality (OR 2.25 (95% CI 1.40 -3.64), p=0.01). Conclusions: In non-traumatic ICH patients, we found no significant difference with AKI development between non-hyperchloremia and hyperchloremia groups. Baseline ICH score was predictive of mortality risk. Study limitations were its observational nature and lack of propensity score matching.

1885. Experience using combined antigen and RT-PCR tests for COVID-19 diagnosis at a Veterans Affairs (VA) Health Care System during the Omicron surge

Abstract Background Combining rapid antigen and RT-PCR tests optimizes detection of COVID-19 compared with either test alone. Therefore, coincident with the Omicron surge, in November 2021, the Atlanta VA Health Care System (AVAHCS) initiated combination testing for all patients admitted from the emergency department (ED) to the inpatient wards. We retrospectively compared test performance for all patients with combination testing performed at AVAHCS, assessed impact of combination testing on ED disposition, and reviewed clinical characteristics of those admitted from the ED with discordant results. Methods We assessed concordance of antigen (Abbott BinaxNOW®) and RT-PCR (either Cepheid GeneXpert® or Roche cobas® 6800) tests performed within 24 hours of each other (i.e., combination test-pairs) for any patient during November 25, 2021–January 27, 2022, and calculated test characteristics of the antigen test using RT-PCR as the gold standard. For those patients evaluated in the ED who had discordant results, we determined ED disposition then performed standardized medical record reviews for those admitted to ascertain clinical history and hospital course and disposition. Combination Antigen and RT-PCR Testing Algorithm for Patients in the Emergency Department, Atlanta VA Healthcare System Results Of 836 combination test-pairs, 112 (13%) were discordant, of which 111 were antigen-negative/RT-PCR positive. Sensitivity of the antigen test was 50%, specificity was 100%, positive predictive value 99%, and negative predictive value was 85%. Of 68 patients evaluated in the ED who had antigen-negative/RT-PCR positive results, 21 (31%) were admitted, of whom 17 (81%) had COVID-19-related symptoms at time of ED evaluation. Of the 21 admitted patients, all were admitted to a COVID isolation unit, 20 (95%) had ≥1 chronic comorbidity, 12 (57%) had not completed vaccination, 14 (67%) received COVID-19-specific treatment while inpatient, 6 (29%) received care in an intensive care unit, 17 (81%) discharged home, and 1 (5%) died during hospitalization. Flow Diagram of Initial Analysis Flow Diagram of ED Discordant Results Characteristics of Discordant Hospitalized Patients Conclusion The sensitivity of antigen testing was 50% compared to RT-PCR among patients tested across AVAHCS, consistent with published literature. Combination testing facilitated earlier diagnosis, isolation, and treatment of some patients hospitalized from the ED, likely preventing nosocomial transmission. Disclosures All Authors: No reported disclosures.

79 Impact of COVID-19 wave 3 paediatric inpatient unit closures on transfers to tertiary care paediatric hospital

Abstract Background During Wave 3 of the COVID-19 pandemic, 15 community hospital paediatric inpatient units (comprising 167 beds) in Toronto were directed to close by the Greater Toronto Area (GTA) Hospital Incident Management System (IMS) Command Centre to increase adult inpatient bed capacity. All paediatric patients from closed inpatient units were redirected to a single tertiary care paediatric hospital, which increased capacity to accommodate these additional patients through activation of surge plans, while community hospitals redeployed resources to fill much needed gaps in adult care. Objectives The objective was to describe patient characteristics of all transfers during the closure to explore the impact of community paediatric inpatient unit closures on transfers to the tertiary hospital. Design/Methods A chart review of all transferred patients was conducted during the mandated closure and subsequent reopening. Transfers excluded ICU-level transfers as these were not impacted by IMS mandated closures. All transfers were categorized as requiring tertiary care (i.e. would typically be transferred) or not requiring tertiary care (i.e. only transferred due to the closure). Variables collected included sending hospital, admitting diagnosis, patient age, hospital disposition, and length of stay. Data was collected until the last paediatric unit reopened. Quality improvement project approval was granted by the institution. Results A total of 858 patients were transferred to the tertiary hospital during the 67 day closure; of those, 530 were transferred solely to increase adult bed capacity (i.e. were categorized as patients requiring non-tertiary care). The majority of patients were admitted to general paediatrics (52%), and 39% went to a surgical inpatient unit. Most patients (68%) admitted had a length of stay between 24 and 72 hours. A third of patients admitted were under 2 years old, and a third were over 12 years old. The top three diagnoses for admission were infections, gastrointestinal issues, and general surgery. Two-thirds (60%) of transfers from closed sites came from three sites. Conclusion More than half of the transfers occurred solely due to the mandated closures, and transfers returned to a stable volume once all sites re-opened. The GTA hospital system was able to respond to the mandated closure effectively through clear high-level communication, escalation processes and structures as well as responsive, real-time problem solving. Closures increased potential adult inpatient capacity by 6740 bed days and demonstrated an unprecedented system-wide approach to the provision of integrated paediatric care across the region.

Severity of Coronavirus Disease 2019 Hospitalization Outcomes and Patient Disposition Differ by Disability Status and Disability Type.

Systemic inequities may place people with disabilities at higher risk of severe coronavirus disease 2019 (COVID-19) illness or lower likelihood to be discharged home after hospitalization. We examined whether severity of COVID-19 hospitalization outcomes and disposition differ by disability status and disability type. In a retrospective analysis of April 2020-November 2021 hospital-based administrative data among 745 375 people hospitalized with COVID-19 from 866 US hospitals, people with disabilities (n = 120 360) were identified via ICD-10-CM codes. Outcomes compared by disability status included intensive care admission, invasive mechanical ventilation (IMV), in-hospital mortality, 30-day readmission, length of stay, and disposition (discharge to home, long-term care facility (LTCF), or skilled nursing facility (SNF). People with disabilities had increased risks of IMV (adjusted risk ratio [aRR]: 1.05; 95% confidence interval [CI]: 1.03-1.08) and in-hospital mortality (1.04; 1.02-1.06) compared to those with no disability; risks were higher among people with intellectual and developmental disabilities (IDD) (IMV [1.34; 1.28-1.40], mortality [1.31; 1.26-1.37]), or mobility disabilities (IMV [1.13; 1.09-1.16], mortality [1.04; 1.01-1.07]). Risk of readmission was increased among people with any disability (1.23; 1.20-1.27) and each disability type. Risks of discharge to a LTCF (1.45, 1.39-1.51) or SNF (1.78, 1.74-1.81) were increased among community-dwelling people with each disability type. Severity of COVID-19 hospitalization outcomes vary by disability status and type; IDD and mobility disabilities were associated with higher risks of severe outcomes. Disparities such as differences in discharge disposition by disability status require further study, which would be facilitated by standardized data on disability. Increased readmission across disability types indicates a need to improve discharge planning and support services.

Opioid Utility and Hospital Outcomes Among Inpatients Admitted With Osteoarthritis and Spine Disorders.

The aim of the study is to evaluate opioid analgesic utilization and predictors for adverse events during hospitalization and discharge disposition among patients admitted with osteoarthritis or spine disorders. This is a retrospective study of 12,747 adult patients admitted to six private community hospitals from 2017 to 2020. Opioid use during hospitalization and risk factors for hospital-acquired adverse events and nonhome discharge were investigated. The total number of patients using opioids decreased; however, the daily morphine milligram equivalent use for patients on opioids increased from 2017 to 2020. Increased odds of nonhome discharge were associated with older age, Medicaid, Medicare insurance, and increased lengths of stay, increased body mass index, daily morphine milligram equivalent, and electrolyte replacement in the osteoarthritis group. In the spine group, older age, Black race, Medicaid, Medicare, no insurance, increased Charlson Comorbidity Index, lengths of stay, polypharmacy, and heparin use were associated with nonhome discharge. Adverse events were associated with increased age, lengths of stay, Medicare, polypharmacy, antiemetic, and benzodiazepine use in the osteoarthritis group and increased Charlson Comorbidity Index, lengths of stay, and electrolyte replacement in the spine group. Despite the decreasing number of patients using opioids over the years, patients on opioids had an increased daily morphine milligram equivalent over the same period.

Spinal level and cord involvement in the prediction of sepsis development after vertebral fracture repair for traumatic spinal injury.

Despite understanding the associated adverse outcomes, identifying hospitalized patients at risk for sepsis is challenging. The authors aimed to characterize the epidemiology and clinical risk of sepsis in patients who underwent vertebral fracture repair for traumatic spinal injury (TSI). The authors conducted a retrospective cohort analysis of adults undergoing vertebral fracture repair during initial hospitalization after TSI who were registered in the National Trauma Data Bank from 2011 to 2014. Of the 29,050 eligible patients undergoing vertebral fracture repair, 317 developed sepsis during initial hospitalization. Of these patients, most presented after a motor vehicle accident (63%) or fall (28%). Patients in whom sepsis developed had greater odds of being male (adjusted OR [aOR] 1.5, 95% CI 1.1-1.9), having diabetes mellitus (aOR 1.5, 95% CI 1.11-2.1), and being obese (aOR 1.9, 95% CI 1.4-2.5). Additionally, they had greater odds of presenting with moderate (aOR 2.7, 95% CI 1.8-4.2) or severe (aOR 3.9, 95% CI 2.9-5.2) Glasgow Coma Scale scores and of having concomitant abdominal injuries (aOR 1.9, 95% CI 1.5-2.5) but not cranial, thoracic, or lower-extremity injuries. Interestingly, cervical spine injury was significantly associated with developing sepsis (OR 1.4, 95% CI 1.1-1.8), but thoracic and lumbar spine injuries were not. Spinal cord injury (OR 1.9, 95% CI 1.5-2.5) was also associated with sepsis regardless of level. Patients with sepsis were hospitalized approximately 16 days longer. They had greater odds of being discharged to rehabilitative care or home with rehabilitative care (OR 2.4, 95% CI 1.8-3.2) and greater odds of death or discharge to hospice (OR 6.0, 95% CI 4.4-8.1). Among patients undergoing vertebral fracture repair, those with cervical spine fractures, spinal cord injuries, preexisting comorbidities, and severe concomitant injuries are at highest risk for developing postoperative sepsis and experiencing adverse hospital disposition.

The Evolving Needs of Children Hospitalized for Eating Disorders During the COVID-19 Pandemic.

Throughout the COVID-19 pandemic, there has been an increase in hospital admissions for adolescents with eating disorders (EDs). However, there is a paucity of information on how this increase has affected hospitalization courses and disposition planning. We sought to describe the changes in hospitalizations for EDs at our institution during the pandemic. We reviewed charts of patients admitted to our academic medical center for nutritional restoration from January 1, 2017, to June 30, 2021. We report differences in patient characteristics and hospitalization courses using descriptive statistics and Poisson regression. We reviewed charts for 85 patients for 108 hospital admissions. Admissions increased from 1.4 per month prepandemic to 3.6 per month during the pandemic (P < .001). Most patients were female (91%), White (79%), had private insurance, (80%) and had restrictive eating behaviors (97%). During the pandemic, we found (1) an increase in the average length of stay (12.6 days vs. 18.0 days) with younger age associated with longer length of stay (P < .001); (2) more patients requiring psychotropic medication management (11% vs 31%, P = .01); and (3) fewer patients discharged from the hospital with outpatient therapy (43% vs 24%, P = .03). In addition to an increase in hospital admissions for ED management during the pandemic, our study highlights the evolving needs of ED patients during their hospitalizations. The implications of longer admissions with higher acuity at discharge represent areas where appropriate adaptations in inpatient management and disposition planning may improve the quality of care for ED patients.

The Use of Nitric Oxide as a Rescue Modality for Severe Adult Acute Respiratory Distress Syndrome Patients, Including COVID-19, in Critical Care Rotor Transport: A Retrospective Community Outcome Study

ObjectiveSevere acute respiratory distress syndrome (ARDS) mortality increases in smaller outlying facilities, and patients (especially those diagnosed with coronavirus disease 2019 [COVID-19]) are often “stuck” at these facilities. These patients are on maximal ventilator settings and are often in the prone position. Our purpose was to show that with the use of inhaled nitric oxide (iNO), a “community-based” rotor wing critical care transport (CCT) team can safely, consistently, and effectively transport these extremely precarious patients to the tertiary care that is needed. MethodsThis was a retrospective database review of 50 patients (39 patients with COVID-19) transported between 2017 and 2021 in whom iNO was brought to the bedside and initiated by the rotor wing critical care transport team. The review included patient demographics, vital signs, and ventilator settings from the sending hospital, in-flight, and the receiving hospital. We reviewed the transition from transport to venovenous extracorporeal membrane oxygenation (if applicable), hospital disposition, and length of stay from the receiving hospital side. Concerning the actual transport, we reviewed the mode of transport, the sending facility size, and the distances covered. ResultsUpon arrival at the sending facilities, we found severely ill patients with almost half (46%) in the prone position or recently transitioned from a prone position within the last 2 hours. Eighty-six percent were pharmaceutically paralyzed, and 44% were in shock. There was a younger and heavier predominance with an average age of 44 years and an average weight of 103 kg. Thirty-nine patients were diagnosed with COVID-19. The other 11 had a mix of non–COVID-19 ARDS, pulmonary embolism, and pulmonary edema. The patients presented from 27 different community hospitals. Forty-four percent were from small referring hospitals that had less than 200 beds. Twenty-eight patients were transported by a Bell 407 helicopter, 18 with an Airbus H135 helicopter, and 4 by ground ambulance. Forty-one percent of patients were transported within 25 miles, and 4 patients were transferred from > 100 miles away. All 50 patients were safely transported without significant deterioration or significant pulmonary pressure increases. Thirty-seven patients were placed on venovenous extracorporeal membrane oxygenation (34 of those patients cannulated within 2 hours of arrival). The overall mortality rate was 27%, and the COVID-19 mortality rate was 24%. ConclusioniNO retrieval for severe ARDS can be safely and effectively completed within the COVID-19 population and the nonacademic community setting using helicopters prevalent in the global air medical industry (Bell 407 and Airbus H135).

Acute respiratory distress syndrome after in-hospital cardiac arrest

ObjectiveAcute respiratory distress syndrome (ARDS) after out-of-hospital cardiac arrest is common and associated with worse outcomes. In the hospital setting, there are many potential risk factors for post-arrest ARDS, such as aspiration, sepsis, and shock. ARDS after in-hospital cardiac arrest (IHCA) has not been characterized. MethodsWe performed a single-center retrospective study of adult patients admitted to the hospital between 2014–2018 who suffered an IHCA, achieved return of spontaneous circulation (ROSC), and were either already intubated at the time of arrest or within 2 hours of ROSC. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days following ROSC. Outcomes included alive-and-ventilator free days across 28 days, hospital length-of-stay, hospital mortality, and hospital disposition. ResultsOf 203 patients included, 146 (71.9%) developed ARDS. In unadjusted analysis, patients with ARDS had fewer alive-and-ventilator-free days over 28 days with a median of 1 (IQR: 0, 21) day, compared to 18 (IQR: 0, 25) days in patients without ARDS (p = 0.03). However, this association was not significant after multivariate adjustment. There was also a non-significant longer hospital length-of-stay (15 [IQR: 7, 26] vs 10 [IQR: 7, 22] days, p = 0.25; median adjusted increase in ARDS patients: 3 [95% CI: −2 to 8] days, p = 0.27) and higher hospital mortality (53% vs 44%, p = 0.26; aOR 1.6 [95% CI: 0.8–2.9], p = 0.17) in the ARDS group. ConclusionAmong IHCA patients, almost three-quarters developed ARDS within 3 days of ROSC. As in out of hospital cardiac arrest, post-IHCA ARDS is common.

Association of care by a non-medical intensive care unit provider team with outcomes of medically critically ill patients.

To determine the association of boarding of critically ill medical patients on non-medical intensive care unit (ICU) provider teams with outcomes. A retrospective cohort study. ICUs in a tertiary academic medical center. Patients with medical critical illness. None. We compared outcomes for critically ill medical patients admitted to a non-medical specialty ICU team (April 1 - August 30, 2020) with those admitted to the medical ICU team (January 1, 2018 - March 31, 2020). The primary outcome was hospital mortality; secondary outcomes were hospital length of stay (LOS) and hospital disposition for survivors. Our cohort consisted of 1241 patients admitted to the medical ICU team and 230 admitted to non-medical ICU teams. Unadjusted hospital mortality (medical ICU, 38.8% vs non-medical ICU, 42.2%, p=0.33) and hospital LOS (7.4 vs 7.4days, p=0.96) were similar between teams. Among survivors, more non-medical ICU team patients were discharged home (72.6% vs 82.0%, p=0.024). After multivariable adjustment, we found no difference in mortality, LOS, or home discharge between teams. However, among hospital survivors, admission to a non-medical ICU team was associated with a longer LOS (regression coefficient [95% CI] for log-transformed hospital LOS: 0.23 [0.05,0.40], p=0.022). Certain subgroups-patients aged 50-64years (odds-ratio [95% CI]: 4.22 [1.84,9.65], p=0.001), with ≤10 comorbidities (0-5: 2.78 (1.11,6.95], p=0.029; 6-10: 6.61 [1.38,31.71], p=0.018), without acute respiratory failure (1.97 [1.20,3.23], p=0.008)-had higher mortality when admitted to non-medical ICU teams. We found no association between admission to non-medical ICU team and mortality for medically critically ill patients. However, survivors experienced longer hospital LOS when admitted to non-medical ICU teams. Middle-aged patients, those with low comorbidity burden, and those without respiratory failure had higher mortality when admitted to non-medical ICU teams.

573 Interfacility Transfers for Burn Patients with Concomitant Traumatic Injuries

IntroductionBurn patients with concomitant traumatic injuries suffer increased morbidity and mortality. Complex care coordination for these patients often requires interfacility transfers. We sought to examine the outcomes for traumatically injured burn patients to identify the occurrence and associated reasons for trauma system transfers in this group.MethodsThe National Trauma Data Bank was examined from years 2007 to 2016 for 6,565,577 patients with traumatic, burn, and concomitant burn & traumatic injuries to evaluate demographic data, ED and hospital dispositions, length of ICU stay, ventilator days, mortality, and interfacility transfers. There were 5,068 patients with both traumatic and burn injuries, 145,890 patients with burn injuries, and 6,414,619 patients with traumatic injuries. Non-parametric Kruskal Wallis, analysis of variance, chi-square, Mann Whitney, and T-tests were utilized for comparisons.ResultsPatients were 69.1% male in the trauma/burn, 67.1% male in the burn, and 62.2% male in the trauma groups (P< 0.001). Trauma/burn patients were more often admitted to the ICU from the ED at 35.5% compared to 27.1% for burn and 19.4% for trauma (P< 0.001). ICU stay was longer for trauma/burn patients at 5.00 median days (IQR 2.00, 15.00) versus 3.00 (IQR 1.00, 10.00) for burn and 3.00 (IQR 1.00, 5.00) for trauma (P< 0.001). Trauma/burn patients had more ventilator days at 3.00 median days (IQR 1.00, 11.75) compared to 2.00 (IQR 1.00, 9.00) for burn and 2.00 (IQR 1.00, 7.00) for trauma (P< 0.001). Trauma/burn patients had increased mortality at 4.9% versus 2.5% for burn and 3.2% for trauma (P< 0.001). For hospital disposition, trauma/burn patients required more interfacility transfers 2.5% compared to 1.7% for burn and 1.3% for trauma (P< 0.001). For level 1 trauma centers, 5.5% of trauma/burn, 7.1% of burn, and 0.5% of trauma patients required interfacility transfers. For level 2 trauma centers, 29.1% of trauma/burn, 47.0% of burn, and 2.8% of trauma patients required interfacility transfers.ConclusionsAmong level 1 and level 2 trauma centers, patients with only burns and burn patients with concomitant traumatic injuries required more interfacility transfers, and level 2 trauma centers required more interfacility transfers for all patients.

Epidemiology of Firearm Injury in Children at US Trauma Centers

Epidemiology of Firearm Injury in Children at US Trauma Centers

Significant variations in preoperative fluid resuscitation volumes delivered to elderly hip fracture patients at six level 1 trauma centers: an observational descriptive study.

Objective:To describe the variations in administration of preoperative (preop) fluids and in the volumes of fluid administered among geriatric hip fracture patients requiring surgical repair.Design:Observational descriptive.Setting:Six Level 1 trauma centers.Patients:A total of 595 patients aged ≥65 with ICD-10 codes indicating hip fracture and surgical repair were identified. Of these, 87.9% (n = 525) received preop fluid. The median volume of preop fluid delivered was 1500 mL (IQR: 1000–2250 mL).Intervention:None.Main Outcome Measures:Receipt of preop fluids; median volume of fluid received.Results:Receipt of preop fluid was significantly different by inter-hospital transfer, facility, BMI, hospital length of stay, and postop fluid volume. Age, sex, time to surgery, time to ambulation, and hospital disposition were not associated with preop fluid. There were significant differences in median preop fluid volumes by facility and postop fluid volume.Conclusion:This descriptive study of current practices among geriatric trauma patients with isolated hip fractures revealed significant differences in the use of preop fluid resuscitation and the resuscitation volumes administered. Treating facility may be the most substantial source of variation highlighting the need for a guideline on fluid resuscitation. These observed variations may be a result of patient characteristics or provider discretion and should be evaluated further.

Socioeconomic health disparities in pediatric traumatic brain injury on a national level.

Low socioeconomic status is a determinant of pediatric traumatic brain injury (TBI) incidence and severity. In this study, the authors used National (Nationwide) Inpatient Sample (NIS) data to evaluate socioeconomic and health disparities among children hospitalized after TBI. This retrospective study identified pediatric patients aged 0 to 19 years with ICD-9 codes for TBI in the NIS database from 2012 to 2015. Socioeconomic variables included race, sex, age, census region, and median income of the patient residential zip code. Outcomes included mechanism of injury, hospital length of stay (LOS), cost, disposition at discharge, death, and inpatient complications. Multivariate linear regressions in log scale were built for LOS and cost. Logistic regressions were built for death, disposition, and inpatient complications. African American, Hispanic, and Native American patients experienced longer LOSs (β 0.06, p < 0.001; β 0.03, p = 0.03; β 0.13, p = 0.02, respectively) and increased inpatient costs (β 0.13, p < 0.001; β 0.09, p < 0.001; β 0.14, p = 0.03, respectively). Females showed increased rates of medical complications (OR 1.57, p < 0.001), LOS (β 0.025, p = 0.02), and inpatient costs (p = 0.04). Children aged 15 to 19 years were less likely to be discharged home (OR 3.99, p < 0.001), had increased mortality (OR 1.32, p = 0.03) and medical complications (OR 1.84, p < 0.001), and generated increased costs (p < 0.001). The study results have demonstrated that racial minorities, females, older children, and children in lower socioeconomic groups were at increased risk of poor outcomes following TBI, including increased LOS, medical complications, mortality, inpatient costs, and worse hospital disposition. Public education and targeted funding for these groups will ensure that all children have equal opportunity for optimal clinical outcomes following TBI.

Safety of a Novel Obstructive Sleep Apnea Triage Tool for Postoperative Orthopedic Surgery Patients

PurposeThe purpose of this quality improvement project is to provide a tool for effective and safe triage of postoperative patients in the postanesthesia care unit with known or suspected obstructive sleep apnea (OSA) at an academic orthopedic hospital in New York City. DesignThe structure of this project was observational after implementation of a novel OSA triage tool. MethodsResults were reported from a single center experience in a hospital where there was no existing standard assessment tool consistently used to triage patients with either known or suspected OSA in the postoperative period. Adult patients who underwent orthopedic surgery between October 2018 and February 2020 and who had a known or suspected history of OSA were included. After admission to the postanesthesia care unit (PACU) and upon meeting their modified Aldrete criteria or after 2 hours had elapsed, the PACU primary provider used the OSA triage tool to assess whether the patient had a high or low risk of respiratory deterioration after discharge from the PACU related to OSA. Patients without high-risk criteria were discharged from the PACU to a medical/surgical unit. For patients with high-risk criteria, the PACU provider requested critical care consultation to determine each patient's appropriate hospital disposition upon PACU discharge. FindingsOver the course of the study period, 216 patients were evaluated using the OSA triage tool: 53.2% of the cohort was male, median BMI was 36.3 kg/m2, and 80.1% had a prior diagnosis of obstructive sleep apnea. Patients underwent a variety of orthopedic surgeries with 23.6% having undergone hip surgery, 51.4% knee surgery, 13.4% spine surgery, 9.7% shoulder surgery, and 1.9% foot or ankle surgery. Notably, with the use of this tool, only 12.5% of patients met criteria for critical care consult and 91.7% were admitted to the floor from the PACU. Rapid response for respiratory complications were not observed in any of the patients. There were only three patients who required critical care evaluation after PACU discharge. An anonymous survey completed by PACU nurse practitioners and anesthesiologists revealed a 96.8% self-reported satisfaction with OSA triage tool. ConclusionWe demonstrated that use of a OSA triage tool in the single-center orthopedic PACU at NYULH is potentially a safe and effective method of triaging patients with known or suspected OSA to acute care beds versus higher levels of care.

Individual and contextual predictors of emergency department visits among community-living older adults: a register-based prospective cohort study

ObjectivesTo examine the extent to which contextual factors explain emergency department (ED) visits and ED revisits, additional to that explained by individual factors.DesignA register-based prospective cohort study.SettingSwedish region of Dalarna.ParticipantsParticipants...

Abstract WP157: Outcomes Of Reversible Cerebral Vasoconstriction Syndrome: Analysis Of The National Inpatient Sample Databases, 2016-2018

Introduction: Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe headaches accompanied by reversible segmental vasoconstriction of cerebral arteries. Ischemic and hemorrhagic stroke are considered major complications of RCVS. We aimed to assess outcomes of RCVS patients with and without stroke, and to compare presentation with ischemic or hemorrhagic stroke. Methods: Data was extracted from the National Inpatient Sample (NIS) spanning 2016 to 2018. All adult patients diagnosed with RCVS were identified using ICD-10 codes after excluding patients with a concurrent diagnosis of primary angiitis. Measured outcomes included adverse events during hospitalization and discharge disposition. Standard bivariate statistical tests were applied to compare groups. Results: Of 3170 patients (mean age 48.0±15.7 years; 73.3% female) who were admitted with the diagnosis of RCVS, 1565 patients (49.4%) had no stroke and 1605 patients (50.6%) presented with stroke. In patients who presented with stroke, 375 patients (26.1%) had only ischemic stroke and 1060 (73.9%) presented with only hemorrhagic stroke. Rates of routine discharge were higher in patients with no stroke (75.4% vs 57.9%, p&lt;0.001) versus those presenting with stroke (Table). In patients who presented with stroke, rates of percutaneous gastrostomy (PEG) placement were higher in ischemic stroke group compared to patients with hemorrhagic stroke (5.3% vs 2.4%, p=0.004), whereas rates of ventilation/intubation were higher in patients with hemorrhagic stroke (10.8% vs 4.0%, p=0.001). Routine discharge was more frequent in RCVS patients presenting with hemorrhagic rather than ischemic stroke (66.0% vs 48.0%, p&lt;0.001). Conclusions: More than half of patients admitted with a diagnosis of RCVS presented with stroke. RCVS patients presenting with ischemic stroke have higher rates of PEG placement and lower rates of routine discharge than those presenting with hemorrhagic stroke.

A national analysis on complications and readmissions for adult cerebral palsy patients undergoing primary spinal fusion surgery.

Retrospective National Database Study. Surgical intervention with spinal fusion is often indicated in cerebral palsy (CP) patients with progressive scoliosis. The purpose of this study was to utilize the National Readmission Database to determine the national estimates of complication rates, 90-day readmission rates, and costs associated with spinal fusion in adult patients with CP. The 2012-2015 NRD databases were queried for all adult (age ≥ 19years) patients diagnosed with CP (ICD-9: 333.71, 343.0-4, and 343.8-9) undergoing spinal fusion (ICD-9: 81.00-08). 1166 adult patients with CP (42.7% female) underwent spinal fusion surgery between 2012 and 2015. 153 (13.1%) were readmitted within 90days following the primary surgery, with a mean 33.8 ± 26.5days. Mean hospital charge of the primary admission was $141,416 ± $157,359 and $167,081 ± $145,416 for the non-readmitted and readmitted patients, respectively (p = 0.06). The mean 90-day readmission charge was $72,479 ± $104,100. Most common complications with the primary admission included UTIs (no readmission vs. readmission: 7.6% vs. 4.8%; p = 0.18), respiratory (6.9% vs. 5.6%; p = 0.62), implant (3.8% vs. 6.0%; p = 0.21), and paralytic ileus (3.6% vs. 3.2%; p = 0.858). Multivariate analyses demonstrated the following as independent predictors for 90-day readmission: comorbid anemia (OR: 2.8; 95% CI: 1.6-4.9; p < 0.001), coagulopathy (2.9, 1.1-8.0, 0.037), perioperative blood transfusion (2.0, 1.1-3.8, 0.026), wound complication (6.4, 1.3-31.6, 0.023), and transfer to short-term hospital versus routine disposition (4.9, 1.0-23.3, 0.045). Quality improvement efforts should be aimed at reducing rates of infection related complications as this was the most common reason for short-term complications and unplanned readmission following surgery.

A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias?

BackgroundEmergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias. MethodA nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016–2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05. ResultsA total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001). ConclusionSurgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.