In-hospital Resources Research Articles

Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis.

Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. The authors conducted a systematic review and meta-analysis evaluating the safety and outcome of admission to a step-down level of care or stroke unit (SU) compared to intensive care in adult patients with low-risk spontaneous ICH. PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials and observational cohort studies. The Mantel-Haenszel method or inverse variance, as applicable, was applied to calculate an overall effect estimate for each outcome by combining the specific risk ratio (RR) or standardized mean difference. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (CRD42023481915). The primary outcome examined was in-hospital mortality. Secondary outcomes were unfavorable short-term outcome, length of hospital stay, and (re)admission to the ICU. Five retrospective cohort studies involving 1347 patients were included in the qualitative analysis. Two of the studies had severity-matched groups. The definition of low-risk ICH was heterogeneous among the studies. Admission to an SU was associated with a similar rate of mortality compared to admission to an ICU (1.4% vs. 0.6%; RR 1.66; 95% confidence interval [CI] 0.24-11.41; P = 0.61), a similar rate of unfavorable short-term outcome (14.6% vs. 19.2%; RR 0.77; 95% CI 0.43-1.36; P = 0.36), and a significantly shorter mean length of stay (standardized mean difference - 0.87days; 95% CI - 1.15 to - 0.60; P < 0.01). Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.

Reducing the postpartum length of stay: Implications for emergency department presentations at a tertiary women's hospital.

Postpartum length of stay (LOS) in Australian hospitals has reduced over the past three decades. Although a reduction in LOS likely reduces hospital costs in the immediate postpartum period, there is concern that this is increasing the burden on emergency services, domiciliary staff and primary care providers. The aims were to determine whether the recent reduction in LOS at an Australian tertiary obstetric hospital resulted in a change in emergency department (ED) presentations by women in the first six weeks postpartum, and newborns within the first 28 days of life. We conducted a cross-sectional cohort study of all newborns ≤28 days of age and women ≤6 weeks postpartum who presented to the ED during four comparable time periods (2019-2022) at an Australian tertiary obstetric hospital. Logistic regression was used to determine the relationship between neonatal and maternal postpartum ED presentations and year of birth. Reduced postpartum LOS was associated with a significant increase in maternal and neonatal presentations to the ED (odds ratio (OR): 1.15 (95% confidence interval (CI): 1.08-1.23), and OR: 1.11 (95% CI: 1.03-1.19), respectively). For every 100 births, an extra six women and three neonates presented to the ED for postpartum care in 2022 compared with 2019. There was no difference in maternal or neonatal admissions throughout the study periods. The increase in maternal and neonatal ED presentations associated with reduced LOS should prompt reassessment of postnatal practice and encourage further research into allocation of in-hospital resources and postpartum education.

Outcomes of transcatheter edge-to-edge mitral valve repair with percutaneous coronary intervention vs. surgical mitral valve repair with coronary artery bypass grafting.

Patients with severe ischemic mitral regurgitation (IMR) may receive concurrent coronary artery bypass graft (CABG) with surgical mitral valve repair (SMVr) or percutaneous coronary stent implantation (PCI) with transcatheter edge-to-edge mitral valve repair (TMVr). However, there is no consensus on the management of severe IMR in this setting. We aimed to compare the outcomes of combined SMVr with CABG to concurrent TMVr with PCI among patients with IMR in the National Inpatient Sample (NIS) database. The National Inpatient Sample was queried for all patients diagnosed with IMR who underwent SMVr with CABG or TMVr with PCI during the years 2016-2018. Study outcomes included all-cause in-hospital mortality, periprocedural complications, and resources used. A total of 1,360 potentially eligible patients were included in the study. After 1:5 propensity score matching, 133 patients were classified in the SMVr + CABG group and 29 patients in the TMVr + PCI group. Adjusted mortality was higher in the TMVr + PCI group compared with the SMVr + CABG group (13.8% vs. 4.5%, P = 0.034). Perioperative complications were higher among patients who underwent SMVr + CABG including blood transfusions (29.3% vs. 6.9%, P = 0.01) and post-procedural cardiogenic shock (11.3% vs. 0%, P = 0.044). The cost of care was higher (USD$783548.80 vs. USD$331846.523, P = 0.001) and the length of stay was longer (17.9 vs. 15.44 days, P < 0.001) in the TMVr + PCI group. On multivariable analysis, age (OR, 1.039 [95% CI, 1.006-1.072]; P = 0.032), renal failure (OR, 3.465 [95% CI, 1.867-6.433]; P < 0.001), and liver disease (OR, 5.012 [95% CI, 2.578-9.686]; P < 0.001) were associated with in-hospital mortality. TMVr + PCI was associated with higher resource use and in-hospital mortality but with improved perioperative complications compared with SMVr + CABG.

OUTCOMES OF IN-HOSPITAL CARDIAC ARREST IN PATIENTS WITH IDIOPATHIC PULMONARY FIBROSIS: A NATIONWIDE ANALYSIS OF 800,000 PATIENTS

OUTCOMES OF IN-HOSPITAL CARDIAC ARREST IN PATIENTS WITH IDIOPATHIC PULMONARY FIBROSIS: A NATIONWIDE ANALYSIS OF 800,000 PATIENTS

Current status of reimbursement practices for remote monitoring of cardiac implantable electrical devices across Europe.

Remote monitoring (RM) of cardiac implantable electrical devices (CIEDs) is currently proposed as a standard of care for CIEDs follow-up, as recommended by major cardiology societies worldwide. By detecting a series of relevant device and patient-related parameters, RM is a valuable option for early detection of CIEDs' technical issues, as well as changes in parameters related to cardio-respiratory functions. Moreover, RM may allow longer spacing between in-office follow-ups and better organization of in-hospital resources. Despite these potential advantages, resulting in improved patient safety, we are still far from a widespread diffusion of RM across Europe. Reimbursement policies across Europe still show an important heterogeneity and have been considered as an important barrier to full implementation of RM as a standard for the follow-up of all the patients with pacemakers, defibrillators, devices for cardiac resynchronization, or implantable loop recorders. Indeed, in many countries, there are still inertia and unresponsiveness to the request for widespread implementation of RM for CIEDs, although an improvement was found in some countries as compared to years ago, related to the provision of some form of reimbursement. As a matter of fact, the COVID-19 pandemic has promoted an increased use of digital health for connecting physicians to patients, even if digital literacy may be a limit for the widespread implementation of telemedicine. CIEDs have the advantage of making possible RM with an already defined organization and reliable systems for data transmissions that can be easily implemented as a standard of care for present and future cardiology practice.

EMS Non-Transport of Low-Risk COVID-19 Patients

Objectives: COVID-19 infections in the community have the potential to overwhelm both prehospital and in-hospital resources. Transport of well-appearing patients, in the absence of available emergency department treatment capacity, increases strain on the hospital and EMS system. In May of 2020, the Connecticut Office of EMS issued a voluntary, EMS-initiated, non-transport protocol for selected low-risk patients with symptoms consistent with COVID-19. We evaluated the implementation of this non-transport protocol in a mixed urban/suburban EMS system. Methods: We conducted a retrospective review of contemporaneously recorded quality improvement documentation for uses of the Connecticut COVID-19 non-transport protocol by EMS clinicians within our EMS system during two implementations: from 12/14/2020 to 5/1/21, and again from 1/3/22 to 2/18/22, which coincided with large COVID-19 case surges in our region. Results: The vast majority of patients treated under the non-transport protocol were not reevaluated by EMS or in our emergency departments in the subsequent 24 hours. There was reasonable adherence to the protocol, with 83% of cases appropriate for the non-transport protocol. The most common reasons for protocol violations were age outside of protocol scope (pediatric patients), failure of documentation, or vital signs outside of the established protocol parameters. We did not find an increased 24-hour ED visit rate in patients who were inappropriately triaged to the protocol. Of patients who had ED visits within 24 hours, only two were admitted, none to higher levels of care. Conclusion: Within this small study, EMS clinicians in our system were able to safely and accurately apply a non-transport protocol for patients presenting with symptoms consistent with COVID-19. This is consistent with previous literature suggesting that EMS-initiated non-transport is a viable strategy to reduce the burden on health systems.

The effect of rapid exome sequencing on downstream health care utilization for infants with suspected genetic disorders in an intensive care unit

PurposeThis study aimed to compare downstream utilization of medical services among critically ill infants admitted to intensive care units who received rapid exome sequencing (ES) and those who followed alternative diagnostic testing pathways. MethodsUsing propensity score–weighted regression models including sex, age at admission, and severity indicators, we compared a group of 47 infants who underwent rapid ES with a group of 211 infants who did not receive rapid ES. Utilization and cost indicators were compared between cohorts using negative binomial models for utilization and two-part models for costs. ResultsAfter controlling for patients’ sociodemographic and clinical characteristics, we found no statistically significant difference in outpatient visits, hospitalizations, intensive care unit or total length of stay, or length of stay–associated costs between the cohorts at 12- or 26-month follow-up. Similarly, there was no evidence of higher utilization or costs by the ES group when infants who died were removed from the analysis. ConclusionWhen examining utilization during and beyond the diagnostic trajectory, there is no evidence that ES changes frequency of outpatient visits or use of in-hospital resources in critically ill infants with suspected genetic disorders.

Patient disposition using the Emergency Severity Index: a retrospective observational study at an interdisciplinary emergency department

ObjectivesEarly patient disposition is crucial to prevent crowding in emergency departments (EDs). Our study aimed to characterise the need of in-house resources for patients treated in the ED according to...

Presentations with reported methamphetamine use to an urban emergency department in Switzerland.

The stimulant methamphetamine (e.g., "crystal meth") is a commonly abused drug in many parts of the world and can cause significant health problems. The present study aims to describe presentations with reported methamphetamine use at an urban emergency department (ED) in Switzerland, to investigate prevalence, patterns and susceptible groups. Retrospective study at the ED of the University Hospital of Bern, Switzerland. Cases from June 2012 to July 2019 were retrieved from the electronic patient database using full-text terms and were categorised into three groups based on patient history: "acute", if patients presented within 72 hours of last reported use, "chronic" in cases of regular use but not within the previous 72 hours, and "past" in cases of discontinued consumption. Cases with a positive methamphetamine urine drug screening test with no further information available were described separately. During the study period, 40 cases were categorised as "acute". Among those, the mean age was 29.5 years (standard deviation [SD] 8.7), 75% (n = 30) were male, and agitation (n = 11, 28%), hypertension (n = 11, 28%), tachycardia (n = 11, 28%), sleep disturbances (n = 10, 25%) and aggression (n = 8, 20%) were the most common symptoms. Most patients (n = 22, 55%) were medically discharged, but 35% (n = 14) were admitted to a psychiatric clinic. Most (n = 33, 82.5%) were polydrug users, with alcohol, cocaine and cannabis being the most frequent co-used substances. The "chronic" group included 37 cases. Those patients were mostly male (n = 26, 70%), with a mean age of 31 years (SD 11.0), and 46% (n = 17) presented because of psychiatric symptoms, such as psychosis, depression or aggression. Of the 45 cases in the "past" group (mean age of 30 years, SD 8.6), 69% (n = 31) were male, and 49% (n = 22) and 24% (n = 11), respectively, had medical and psychiatric symptoms as the reason for admission. Of 61 cases with a positive urine drug screening test as the sole indicator of methamphetamine use, 19 patients reported MDMA use (cross-reactivity with methamphetamine in the urine immunoassay used). In the 42 remaining cases, it was unclear if the positive result was due to unreported methamphetamine use or cross-reactivity. Most patients with reported methamphetamine use were young and male, with signs of sympathomimetic arousal and/or psychiatric symptoms. Although ED visits with reports of methamphetamine use appear to be uncommon, consumption-related health problems can require significant pre- and in-hospital resources.

The Creation of Telelactation During the COVID-19 Crisis

The COVID-19 pandemic led to shortened hospital stays for postpartum women and their newborns, thus limiting traditional inhospital education, resources, and support systems. The goal of the telelactation program at Northwell Health is to provide remote lactation consultations via audiovisual technology, thereby supporting the breastfeeding process in postpartum women and providing breastfeeding support to them in the comfort of their own homes. Studies have shown that telelactation offers a service that rivals inperson care and is often more convenient for postpartum woman and less costly, and it encourages self-efficacy.

A Narrative Review of Trauma Care Delivery in India: Challenges and Opportunities

It is estimated that the cost of road accidents in India is around 3% of the Gross Domestic Product of the country. On average, 400 persons die daily in road accidents in India, and cities, such as New Delhi and the national capital region are on the top of the list of road accident causalities. Based on the Basilica agreement, the Indian government has initiated various policy changes and infrastructure development along the national highways which include the redesign of blindspots on the roads and the infliction of heavy penalties for the violation of traffic rules and compliances. On the academic front, the Indo-US Emergency Medicine forum has inaugurated an academic college for emergency medicine in India that cooperates with various government and private healthcare providers and policymakers for the improvement of emergency/trauma care delivery. Lately, few business schools and healthcare educational institutes have focused on interdisciplinary training and research centers in the area of emergency care delivery. Policymakers are also proactively working with various organizations to implement new rules and compliance mechanisms. This prospective study entails a detailed review of the literature using keywords in the PubMed journals, news articles, and media reports. Authors encountered studies in the area of trauma care delivery in India and other countries in their comprehensive field research. Almost 100% of the cases were medico-legal and only one case out of 100 was an insured patient. Furthermore, 87% of the cases were new and only 13% were review cases. Based on the conducted analysis, the number of accidents reduced across the country after the implementation of the New Motor Vehicle Act in the year 2019. It is worth mentioning that, the government launched awareness programs for the public as well. Some of the major challenges identified included lack of coordination and institutional mechanisms for an integrated emergency care delivery, poor referral processes, inadequate ambulance services, lack of third-party coordination, and poor in-hospital resources, particularly in public healthcare organizations. Apart from these, there was an acute shortage of trained emergency medicine experts at all levels. Trauma care delivery is a complex issue and its accomplishment requires good coordination and collaboration among stakeholders. The study identified various challenges and opportunities for the improvement of trauma care delivery in India. There is an immense need and opportunity for the modification of the emergency care delivery system through the introduction of appropriate changes in the transportation policy, emergency care delivery models, institutional mechanisms, such as referral process, and appropriate resource allocation at different levels of care delivery system.

Geriatric Assessment and In-Hospital Economic Cost of Elderly Patients With Acute Coronary Syndromes

Elderly patients with acute coronary syndromes (ACS) are at higher risk for complications and health care resources expenditure. No previous study has assessed the specific contribution of frailty and other geriatric syndromes to the in-hospital economic cost in this setting. Unselected patients with ACS aged ≥75 years were prospectively included. A comprehensive geriatric assessment was performed during hospitalisation. Hospitalisation-related cost per patient was calculated with an analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in Euros (2019). The contribution of geriatric syndromes and clinical factors to the economic cost was assessed with a linear regression method. A total of 194 patients (mean age 82.6 years) were included. Mean length of hospital stay was 11.3 days. The admission-related economic cost was €6,892.15 per patient. Most of this cost was attributable to hospital length of stay (77%). The performance of an invasive strategy during the admission was associated with economic cost (p=0.008). Of all the ageing-related variables, comorbidity showed the most significant association with economic cost (p=0.009). Comorbidity, disability, nutritional risk, and frailty were associated with the hospital length of stay-related component of the economic cost. The final predictive model of economic cost included age, previous heart failure, systolic blood pressure, Killip class at admission, left main disease, and Charlson index. Management of ACS in elderly patients is associated with a significant economic cost, mostly due to hospital length of stay. Comorbidity mostly contributes to in-hospital resources expenditure, as well as the severity of the coronary event.

52739 Trauma Care in Nigeria and Recommendations for Sustainable Improvement to Nigeria’s Trauma Care System: A Systematic Literature Review

ABSTRACT IMPACT: This work highlighs the significant burden of Trauma in Nigeria and will help inform policy decisions on improving Nigeri’s current Trauma care system OBJECTIVES/GOALS: To evaluate trauma care delivery at the pre-hospital, hospital and health systems level in Nigeria in order to identify the burden of trauma, gaps in the delivery of trauma care, and interventions, implemented or recommended, to improve upon the limitations to trauma care delivery. METHODS/STUDY POPULATION: A two-concept search - one being trauma and the other being Nigeria - of the Pubmed (Medline) and Embase databases, in addition to Global Index Medicus and grey literature was performed between September 2018 and September 2019. The search yielded 3,970 articles that underwent title screening and 331 articles that underwent abstract screening. 101 articles were identified for full text screening and the majority were extracted for inclusion into the review. The extracted literature was grouped into 4 categories - articles outlining the burden of trauma in Nigeria, and articles outlining the delivery of trauma care at the pre-hospital, hospital and health systems level. RESULTS/ANTICIPATED RESULTS: Results were classified as an identified challenge or an intervention, recommended or implemented, to address Nigeria’s trauma care system. There was a highlighted need for pre-hospital infrastructure, training of frontline providers, continued competency assessments of frontline providers, in-hospital diagnostic resources, and trauma care surveillance systems to guide health policy. DISCUSSION/SIGNIFICANCE OF FINDINGS: There is a significant burden of trauma in Nigeria. Coordinated interventions and policies at the pre-hospital level, the hospital level, as well as the health systems level are needed in order to address the gaps in Nigeria’s current trauma care system.

Patients Undergoing Primary Total Joint Arthroplasty with Primary Hypercoagulable States.

ObjectiveTo analyze perioperative complications, resource consumption, and inpatient mortality of patients who receive total joint arthroplasty (TJA) with a concomitant diagnosis of a primary hypercoagulable state (PHS). The following questions were posed in the present paper. First, do patients undergoing TJA with PHS have increased risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and periprosthetic joint infection (PJI)? Second, what other in‐hospital complications are more likely among PHS patients undergoing TJA? Third, do TJA patients with PHS usually consume greater in‐hospital resources? Fourth, do PHS patients suffer higher mortality rates compared to non‐PHS patients? Finally, have PHS patients received proper anticoagulant management in past arthroplasties?MethodsThe National Inpatient Sample (NIS) database for the years between 2003 and 2014 was searched to identify patients undergoing primary TJA. Patients with PHS were identified with the ICD‐9‐CM code 289.81. The χ2‐test, the Pearson test, and adjusted multivariate regression analysis were performed to evaluate the difference and odds ratios between the positive and negative diagnosis groups.ResultsFrom 2003 to 2014, a total of 2,044,356 patients were identified in the NIS as undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) in the United States. A total of 4664 patients (0.2%) were identified as having PHS. Compared with the non‐PHS group, TJA patients with PHS had a higher risk of DVT (THA: odds ratio [OR] = 8.343, 95% CI: 5.362–12.982, P < 0.001; TKA: OR = 4.712, 95% CI: 3.560–6.238, P < 0.001) but did not have increased risk of PE (THA: OR = 1.306, 95% CI: 0.48–3.555, P = 0.602; TKA: OR = 1.143, 95% CI: 0.687–1.903), and only PHS patients in the THA group had higher risks of inpatient mortality (OR = 3.184, 95% CI: 1.348–7.522, P = 0.008) and periprosthetic joint infection (OR = 3.343, 95% CI: 1.084–10.879, P = 0.036). In addition, PHS patients had extended length of stay, higher total costs, and increased risks of certain other complications, such as peripheral vascular disease, hemorrhage, and thrombophlebitis.ConclusionIn the present study, PHS patients had higher risks of DVT, greater in‐hospital resource consumption, and certain other perioperative complications. However, PHS was not associated with increased risk of PE in TJA patients in the United States between 2003 and 2014. While potential hazards of PHS have already been recognized, the present study revealed additional concerns and demonstrated that further improvements in the perioperative management of patients with hereditary hypercoagulable disorders are essential.

Rheumatoid Arthritis Versus Osteoarthritis in Patients Receiving Revision Total Knee Arthroplasty in the United States: Increased Perioperative Risks? A National Database-Based Propensity Score-Matching Study.

The impacts of rheumatoid arthritis (RA) on perioperative risks among patients undergoing revision total knee arthroplasty (rTKA) have not been investigated yet. Thus, we hypothesized that patients with RA sustained increased perioperative risks and higher resource consumption burdens as compared to patients with osteoarthritis (OA) during the perioperative period. The National Inpatient Sample (NIS) database was used to compare the demographic characteristics, major in-hospital complications, resource consumptions, and in-hospitalization mortality between patients with RA and OA after rTKA. A 1:1 propensity score-matching, χ2 test, independence-sample T-test, and logistic regression analysis were done in statistical analyses to answer our hypotheses. 4.3% (6363/132,405) of rTKA patients were diagnosed with RA. They tended to be women and received revision for infection but with similar ages as compared to patients with OA. Except for acute postoperative anemia (odds ratio [OR] = 1.196), blood transfusion (OR = 1.179), prolonged hospitalization (OR = 1.049), and higher total cost (OR = 1.145), patients with RA sustained decreased odds of acute renal failure (OR = 0.804) and urinary complications (OR = 0.467). Besides, the other observed in-hospital complications showed no differences between patients with RA and OA. Despite consuming greater in-hospital resources, patients with RA did not suffer increased odds of most in-hospital complications and in-hospital mortality for a revision TKA during the perioperative period. Compared with patients with OA, patients with RA sustained equivalent perioperative risks in the United States between 2002 and 2014.

Patient with heart failure: importance to treat valvular diseases.

COVID-19 pandemic is causing an unprecedented burden on healthcare resources and this includes treatment of heart failure and valvular heart diseases (VHD). Percutaneous procedures have broadened the number of patients with VHD who could be treated. However, COVID-19 pandemic has challenged their implementation. The risk of in-hospital infection, resources reallocation, reduced access to hospital caused a substantial delay of VHD treatment with an increased risk of clinical worsening and mortality. Now, the pandemic is not ended and subsequent waves are likely. Reorganization of our healthcare resources is needed, including a proper algorithm for patients’ prioritization, based on the severity of their valve disease, their life expectancy, complexity of the intervention, and the resources available. A wider use of telemedicine for patients’ selection and follow-up and any measurement that can shorten the duration of the hospital stay must be adopted. Patients’ and healthcare staff screening for COVID-19 and all needed procedures to prevent infection will continue to be mandatory. Percutaneous procedures, compared to surgery, are associated with a lower risk of infection and a lower need for in-hospital resources, including a shorter duration of hospital stay. This may favour their adoption when the risk of viral infection is high.

COVID-19 Pandemic and Its Impact on Neurosurgery Practice in Malaysia: Academic Insights, Clinical Experience and Protocols from March till August 2020.

The newly discovered coronavirus disease 2019 (COVID-19) is an infectious disease introduced to humans for the first time. Following the pandemic of COVID-19, there is a major shift of practices among surgical departments in response to an unprecedented surge in reducing the transmission of disease. With pooling and outsourcing of more health care workers to emergency rooms, public health care services and medical services, further in-hospital resources are prioritised to those in need. It is imperative to balance the requirements of caring for COVID-19 patients with imminent risk of delay to others who need care. As Malaysia now approaches the recovery phase following the pandemic, the crisis impacted significantly on neurosurgical services throughout the country. Various emergency measures taken at the height of the crisis may remain as the new normal in the provision of neurosurgical services and practices in Malaysia. The crisis has certainly put a strain on the effective delivery of services and as we approach the recovery era, what may have been a strain may prove to be a silver lining in neurosurgical services in Malaysia. The following details are various measures put in place as the new operational protocols for neurosurgical services in Malaysia.

LO67: Alcohol-related emergency department visits by youth aged 12-24: demographics and resource utilization at Kingston Health Sciences Centre

Introduction: Recent evidence shows an increase in alcohol-related emergency department (ED) visits among youth. We sought to quantify the impact of ED visits (type and frequency, patient characteristics and resource use) related to alcohol in our centre. Methods: This was a chart review of patients aged 12-24 with alcohol-related ED visits between Sept 2013-Aug 2017. The National Ambulatory Care Reporting System (NACRS) database was searched for visits alcohol related ICD-10 codes. The Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) database was also searched using the keyword alcohol. Duplicate visits were removed. Visits were excluded if patients had a history of psychosis, were held in the ED for psychiatric assessment, were homeless, were inmates from a correctional institute, if alcohol use was not mentioned and for complaints of sexual assault/intimate partner violence. Data was abstracted by two reviewers using a standard form with predetermined variables. Differences were resolved with third party adjudication. Interrater reliability of the reviewers was assessed with Kappa scores through duplicate review of 10% of randomly selected charts. A further 10% were assessed by a 3rd reviewer for extraction accuracy. Results: 3,256 ED visits were identified with 777 removed via predefined exclusion criteria. 2,479 visits were reviewed with a male predominance (54.3%). More than half of all patients (50.9%) arrived via ambulance. Assigned CTAS levels were Resuscitation: 1% Emergent: 9.9% Urgent: 48.2% Less Urgent: 35.7% Non-Urgent: 4.2% (missing 1%). The median LOS was 2.9 hrs (IQR 1.8-4.6). All visits were subclassified into mutually exclusive categories: injury (51.8%), acute intoxication (45.1%) and mental health issue (3.2%). Males were more likely to present with injury (62.4% vs 42.6%, p &lt; 0.01). Females were more likely to present with acute intoxication (53.3% vs 46.7%, p &lt;0.01) and mental health issues (59.5% vs 40.5%, P = 0.01). ED resource use was notable: 483 (19.4%) had imaging tests and 1216 (49.1%) had some medical intervention (blood test, fluids or medication). 57 (2.3%) patients were admitted and there was one death from an alcohol related MVC. Conclusion: Alcohol-related ED visits by youth are common in our centre and utilize substantial prehospital and in-hospital resources. Identification of effective harm reduction strategies should be a research priority.

Implementing individualized care plans in high-risk oncology patients: A team-based model to increase hospice utilization.

64 Background: In the era of increasing therapeutic options and complexity of disease, some cancer patients (pts) continue aggressive treatment even within days of death. Previous studies report 30-66% of pts do not receive hospice or palliative services in the last month of life and many are enrolled in hospice &lt; 3 days before death. Quality measures are endorsed by ASCO, National Quality Forum, and Oncology Care Model to increase hospice utilization. It is shown that pts enrolled in hospice have increased survival time with reduced in-hospital resources. These benefits increase the longer pts are in hospice. We hypothesize early identification of high risk pts by a multidisciplinary group and formulation of a care plan will prompt early discussion for hospice eligibility, increasing referrals to hospice and the number of days spent in hospice. Methods: As reported (ASCO 2018, Abst 6547), an Interdisciplinary Care Team (ICT) was created with palliative medicine and oncology physicians, nurses, and social workers. Twice monthly pts with high utilization over a 60-day period were identified. Care plans (CP) were created using a team based approach with parallel input from outpatient teams. CP was communicated back to the primary team. Results: 112 pts were discussed over 24 months; 39 pts died with a solid tumor malignancy and this was our study cohort. 85% pts (33/39) were referred to or had a hospice discussion and 82% pts (27/33) enrolled. 6 pts declined and 6 acutely died. Of the 27 pts that entered hospice 78% (21/27) were enrolled &gt; 3 days and 22 % (6/27) &lt; 3 days. Average number days in hospice was 19.7 (median 11) for all who entered hospice. In the subgroup that were enrolled for &gt; 3 days, average number days was 25 (median 21). 62% pts (17/27) entered hospice within 60 days of ICT meeting and CP. Conclusions: Early identification of high-utilizing cancer patients along with review by ICT may correlate with early recognition of hospice eligibility, enrollment, and therefore greater number days spent in hospice. This increases hospice utilization allowing patients and families to experience the full benefit of hospice-directed care. Further interventions should be explored in optimizing transitions of care.

Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury.

The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma. This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds. 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744min]; general [n = 27 (15%); 90min]; vascular [n = 19 (10%); median 53min]; thoracic [n = 19 (10%); 646min]; and neurosurgery [n = 4 (2%); 198min]. The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack. Assistance Publique-Hôpitaux de Paris.