Inpatient Capacity Research Articles

Physician-led healthcare structures for patients in out-of-hospital intensive care nursing: a cross-sectional survey by the German Society for Out-of-Hospital Ventilation

Patients in out-of-hospital intensive care are usually provided with a tracheal cannula and often additionally receive mechanical ventilation. Less frequently, they receive non-invasive ventilation. Their potential to be weaned from the ventilator and to have their tracheostomy tubes removed must be evaluated twice per year from January 1, 2025 on. If there is a potential for weaning from mechanical ventilation or removal of the tracheostomy tube, referral to a specialized facility is required. The study aimed at characterizing the specialized institutions which can evaluate the potential of patients to be weaned from the ventilator and to have their tracheostomy tubes removed, and which can perform these tasks as well. Under the auspices of the German Interdisciplinary Society for Out-of-Hospital Ventilation (DIGAB) and with support from the Working group early neurological-neurosurgical rehabilitation (ENNR) a crosssectional online survey took place. Of 18 participating institutions, 11 (61.1%) were certified by professional societies representing neurorehabilitation, respiratory medicine, anaesthesiology and intensive care or paraplegiology. Most leading physicians were specialists in neurology, followed by pulmonology, anaesthesiology and paediatrics. Many professions with a variety of qualifications worked in these institutions. According to n=10 (55.6%) of the participating instituions, regional treatment capacities for patients from out-of-hospital intensive care, who need hospital admission for weaning from mechanical ventilation or a tracheal cannula, were not sufficient. About one third of the institutions offered televisits. Patients in out-of-hospital intensive care need interdisciplinary care, interconnecting out- and inpatient care structures due to medical complexity and participation restrictions. While interdisciplinary teams and a wide spectrum of diagnostic and therapeutic methods were provided in the participating institutions, their structure differed considerably. Quality criteria should be established for centres evaluating the patients' potential to be weaned from the ventilator and to have their tracheostomy tubes removed and performing weaning from mechanical ventilation and tracheal cannulas. Further research is needed to specify those criteria, to quantify inpatient treatment capacities for patients from out-of-hospital intensive care to be weaned from mechanical ventilation or tracheal cannulas,to evaluate the feasibility of weaning from mechanical ventilation and tracheal cannulas in an out-of-hospital setting and to understand the role of telemedicine in the treatment of patients in out-of-hospital intensive care.

Echocardiography In Acute Stroke - A Precious Resource

Abstract Background Echocardiography (Echo) is frequently utilized as part of the work up for ischemic stroke. National guidelines suggest using echo to assess for source of unexplained stroke “if detection of a structural cardiac abnormality would prompt a change of management”. This study aims to describe the use of Echocardiography post-stroke in Mayo University Hospital (MUH). Methods The study population was derived from a list of strokes admitted to MUH from July to December 2023 which was compiled by the Stroke ANP. The radiology system was consulted to assess time to echo and findings. Results 86 ischemic strokes were identified. 77 (89%) had echocardiography ordered as inpatient. 61 of 77 echoes ordered were filmed during admission. The mean wait for echo was 6.4 days. No PFO or LV thrombus was detected. In 52% (n=32) of echo’s performed for work up of aetiology of stroke there was no mention of intra-atrial septum (IAS) in the report. 24% had Modified Rankin Scale on discharge of 4 or above. Of these, 75% had echo ordered as inpatient despite 60% already having atrial fibrillation diagnosed. Conclusion Echocardiography appeared to be an over-utilised resource in ischemic strokes in MUH. The vast majority of patients with stroke, even if frail, elderly, or severely disabled, had echocardiography ordered despite national guidelines suggesting usage of echo only when diagnosis of structural heart disease was likely to change management. The intra-atrial septum wasn’t even mentioned in the majority of studies. The wait for echocardiography appears to be extending bed days for patients putting strain on hospital inpatient capacity and emergency departments. A more nuanced approach to ordering echo in the setting of acute stroke could be advocated for, this will take a collaborative effort between Cardiology and Stroke Medicine in order to prioritise that will most benefit from this precious resource.

Pediatric Inpatient Psychiatric Capacity in the US, 2017 to 2020

This cross-sectional study assesses US pediatric inpatient psychiatric capacity and identifies state-level variation in access to pediatric inpatient psychiatric beds.

Meeting the Needs: Description and Evaluation of an Alcohol Related Brain Damage (ARBD) Residential Rehabilitation Service

ABSTRACT To describe and evaluate a cost-effective, integrated model of service provision for people with Alcohol Related Brain Damage (ARBD). Participants identified by three large acute hospitals as having ARBD and suitable for recovery and rehabilitation were offered a 12-week recovery-focussed program at a residential unit. The unit is a collaboration between an NHS board, the local council, and a 3rd sector organization Participants’ pre-admission and post-admission medical data was gathered to analyze the effectiveness of the unit’s program on Emergency Department (ED) attendance and inpatient bed use. Improvement in cognition was measured by comparing the ACE-III results for all participants at admission and just prior to discharge from the program. Thirty-one participants met the inclusion criteria. Paired t-tests revealed the 12-week program overall significantly reduced attendance at ED, use of in-patient beds after discharge, and improved cognitive functioning. This integrated model of service provision provides clear benefits to residents’ cognitive functioning and to the NHS by freeing up inpatient beds and ED capacity. Therefore, it should be considered by commissioners when addressing the needs of people with ARBD.

Hospital design planning: unscheduled trauma ER visits impacting inpatient space allocation

ABSTRACT Medical healthcare planners need to align outpatient and inpatient design factors that affect hospital space allocation. The Emergency Departments (ED) design must be congruent with the inpatient platform design to limit bottlenecking of patient admissions. However, limited research deciphers the impact of unscheduled ED admissions and the effects on inpatient bed capacity to ensure facility capability. The current study utilizes a case study by comparing the use of space planning criteria of the Department of Defense (DoD) with similar Private healthcare organization departmental metrics to inform space allocation. This study established the significance of unscheduled ED visits metric on inpatient space allocation. Bed capacity was calculated by outlining specific metrics; namely: population at risk, Average Daily Patient Load (ADPL), Average Length of Stay (ALOS), Average Annual Workload, Annual Admissions, and Occupancy Rate that are necessary for the right-sized inpatient hospital designs with a trauma mission. By analyzing existing research, identifying key metrics, highlighting capacity gaps, and showcasing real-world impacts via a case study pilot model. Valuable insights and benefits allow medical planners and administrators to assess and incorporate unscheduled visits as a key factor that influences appropriate hospital facility sizing and resource allocation.

Care Patterns and Barriers to Outpatient Care for Adults With AML Following Intensive Chemotherapy at NCCN Member Institutions.

Prolonged hospitalization following intensive (re)induction chemotherapy for acute myeloid leukemia (AML), while standard, is costly and resource intense, limits inpatient bed capacity, and negatively impacts quality of life. Early hospital discharge (EHD) following completion of chemotherapy has proven safe as an alternative at select institutions, but is not widely implemented. From February 2023 through May 2023, the NCCN Best Practices Committee conducted a survey evaluating AML hospitalization patterns, care models, and barriers to EHD at its 33 member institutions. A total of 30 (91%) institutions completed the survey; two-thirds treat >100 patients with AML annually and 45% treat more than half of these with intensive chemotherapy. In the (re)induction setting, 80% of institutions keep patients hospitalized until blood count recovery, whereas 20% aim to discharge patients after completion of chemotherapy if medically stable and logistically feasible. The predominant reasons for the perceived need for ongoing hospitalization were high risk of infection, treatment toxicities, and lack of nearby/accessible housing. There was no significant association between ability to practice EHD and annual AML volume or treatment intensity patterns (P=.60 and P=.11, respectively). In contrast, in the postremission setting, 87% of centers support patients following chemotherapy in the outpatient setting unless toxicities arise requiring readmission. Survey responses showed that 80% of centers were interested in exploring EHD after (re)induction but noted significant barriers, including accessible housing (71%), transportation (50%), high toxicity/infection rate (50%), high transfusion burden (50%), and limited bed availability for rehospitalization (50%). Hospitalization and care patterns following intensive AML therapy vary widely across major US cancer institutions. Although only 20% of surveyed centers practice EHD following intensive (re)induction chemotherapy, 87% do so following postremission therapy. Given the interest in exploring the EHD approach given potential advantages of EHD for both patients and health care systems, strategies to address identified medical and logistical barriers should be explored.

Hospital in the Home: Nurse-Led Models of Care and Pathways.

Hospital in the Home (HITH) model of care was developed to support the COVID-19 response and the need to deliver care in new ways to ensure secondary care services were free to deliver care to the sickest patients and not be overwhelmed by the COVID-19 patients needing hospital-level care. Intermediate Care Services, led by nursing and allied health stepped up to the challenge and collaborated on the development of the HITH model of care with defined pathways. This provided hospital-level acute health services in the home that was a clinically safe alternative option to inpatient care. The establishment of HITH released bed capacity and resources and therefore prevented the need for expanding hospital inpatient capacity at a time where resources and staff were constrained. Care delivery was achieved by utilising both in-person visits and telehealth. Technology supported the care delivery which allowed patients, whanau (family) and clinicians to be connected.

Functional capacity evaluation in acute isquemic patients

Abstract Background An acute ischemic event may cause a functional deterioration even in previously autonomous patients. The determination of functional capacity is relevant to determine health indicators for rehabilitation nursing care, allowing at the same time to determine the patient's functional status throughout their health-disease cycle and to prescribe exercise-based rehabilitation for home-based programs. The six-minute walking test is widely used in studies involving cardiac patients, however, reference values for ischemic population after immediate clinical stabilization are not known. Also the 6MWT has a prognostic value for cardiac patients, being of utmost importance to evaluate it, after clinical stabilization in order to properly determine goals for patient´s rehabilitation process. Aim Determine the functional capacity level of ischemic patients, by gender and type of event, after clinical stabilization using the 6-minute walking test. Methods Using the 6-minute walking test, the functional capacity of ischemic inpatients was evaluated at discharge, after clinical stabilization. Patients with acute coronary syndrome with and without ST-segment elevation were included. All patients were accompanied by the rehabilitation nursing team during the in-hospital stay period and performed phase 1 cardiac rehabilitation. The 6MWT was performed based on the 2016 ATS guidelines and the expected value of the distance covered was determined based on the Enright equation. The sample was divided by gender, taking into account their widely known differences in functional capacity and also by event, namely ST elevation and Non ST-segment elevation myocardial infraction. The profile of modifiable cardiovascular risk factors (CRF) was also evaluated, being considered the following: Hypertension, Dyslipidemia, obesity, tobacco, sedentary lifestyle and stress. Results A total of 303 patients were studied (229 male), with a mean age of 62 years (men) and 62 (women). About 36% of men and 7% of women were admitted with ST elevation Myocardial Infraction, with a mean number of cardiovascular risk factors (CVRF) of 3.2 in men and 3.9 in women. The most prevalent CVRF in females is dyslipidemia and sedentary lifestyle, while in males it is dyslipidemia. The sample was divided in two groups by type of event, namely ST-elevation (group A) and NonST-elevation (group B) and in each group, data was evaluated by gender. A statistically significant difference (p<0.01 for males and p<0.02 for female) was found between the value of the 6MWT performed (441.2 meters – males; 369.5 meters - females) compared to the value estimated by the equation (559.9 males; 482.8 female gender). There is a very significant difference between the expected value and the value actually covered in the walking test. It may be pertinent to define reference values for this typology of patients, so that their functional capacity can be properly measured.

Uneven primary healthcare supply of rural doctors and medical equipment in remote China: community impact and the moderating effect of policy intervention

BackgroundUnequal access to primary healthcare (PHC) has become a critical issue in global health inequalities, requiring governments to implement policies tailored to communities’ needs and abilities. However, the place-based facility dimension of PHCs is oversimplified in current healthcare literature, and formulating the equity-oriented PHC spatial planning remains challenging without understanding the multiple impacts of community socio-spatial dynamics, particularly in remote areas. This study aims to push the boundary of PHC studies one step further by presenting a nuanced and dynamic understanding of the impact of community environments on the uneven primary healthcare supply.MethodsFocusing on Shuicheng, a remote rural area in southwestern China, multiple data are included in this village-based study, i.e., the facility-level healthcare statistics data (2016–2019), the statistical yearbooks, WorldPop, and Chinese GDP’s spatial distribution data. We evaluate villages’ PHC service capacity using the number of doctors and essential equipment per capita, which are the major components of China’s PHC delivery. The indicators describing community environments are selected based on extant literature and China’s planning paradigms, including town- and village-level factors. Gini coefficients and local spatial autocorrelation analysis are used to present the divergences of PHC capacity, and multilevel regression model and (heterogeneous) difference in difference model are used to examine the driving role of community environments and the dynamics under the policy intervention.ResultsDespite the general improvement, PHC inequalities remain significant in remote rural areas. The village’s location, aging, topography, ethnic autonomy, and economic conditions significantly influence village-level PHC capacity, while demographic characteristics and healthcare delivery at the town level are also important. Although it may improve the hardware setting in village clinics (coef. = 0.350), the recent equity-oriented policy attempts may accelerate the loss of rural doctors (coef. = − 0.517). Notably, the associations between PHC and community environments are affected inconsistently by this round of policy intervention. The town healthcare centers with higher inpatient service capacity (coef. = − 0.514) and more licensed doctors (coef. = − 0.587) and nurses (coef. = − 0.344) may indicate more detrimental policy effects that reduced the number of rural doctors, while the centers with more professional equipment (coef. = 0.504) and nurses (coef. = 0.184) are beneficial for the improvement of hardware setting in clinics.ConclusionsThe findings suggest that the PHC inequalities are increasingly a result of joint social, economic, and institutional forces in recent years, underlining the increased complexity of the PHC resource allocation mechanism. Therefore, we claim the necessity to incorporate a broader understanding of community orientation in PHC delivery, particularly the interdisciplinary knowledge of the spatial lens of community, to support its sustainable development. Our findings also provide timely policy insights for ongoing primary healthcare reform in China.

Disparities in Access to Outpatient Surgery Related to Removal of Procedures from Medicare's Inpatient Only List.

We assessed the shift from inpatient to outpatient surgical care related to changes to the Inpatient Only List in 2020 and 2021 compared to 2019. The extent to which procedures shift from the inpatient to outpatient setting following removal from Medicare's Inpatient Only List is unknown. Many health systems also encouraged a shift from inpatient to outpatient surgery during the COVID-19 pandemic. Assessing the relative change in outpatient surgical utilization for procedures removed from the Inpatient Only List during COVID-19 would provide empirical data on whether reimbursement policy changes or inpatient capacity needs during the pandemic were more likely to shift care from the inpatient to outpatient setting. We used administrative data from the PINC AI Healthcare Database across 723 hospitals to determine the within-facility relative change in outpatient vs inpatient procedural volume in 2020 and 2021 compared to 2019 using a multivariable conditional fixed-effects Poisson regression model. We also assessed whether outpatient surgical utilization varied by race and ethnicity. Using a multivariable linear probability model, we assessed the absolute change in risk-adjusted 30-day complication, readmission, and mortality rates for inpatient and outpatient surgical procedures. In 2020 and 2021 compared to 2019 respectively, there was a 5.3% (95% CI, 1.4% to 9.5%) and 41.3% (95% CI 33.1% to 50.0%) relative increase in outpatient elective procedural volume. Outpatient procedural volume increased most significantly for hip replacement which was removed from the Inpatient Only List in 2020 (increase in outpatient surgical utilization of 589.3% (95% CI, 524.9% to 660.3%)). The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement procedural volume increased by 271.1% (95% CI, 241.2% and 303.7%) for White patients and 29.5% (95% CI, 24.4% and 34.9%) for Black patients compared to 2019 levels. There were no consistent or large changes in 30-day complication, readmission, or mortality risk in 2020 and 2021 compared to 2019. There was a modest increase in elective outpatient surgeries and a pronounced increase in outpatient orthopedic surgeries which were removed from the Inpatient Only List during the COVID-19 pandemic. Utilization of outpatient surgical procedures was concentrated among White patients.

A data-driven newsvendor model for elective-emergency admission control under uncertain inpatient bed capacity.

Elective-emergency admission control referred to allocating available inpatient bed capacity between elective and emergency hospitalization demand. Existing approaches for admission control often excluded several complex factors when making decisions, such as uncertain bed capacity and unknown true probability distributions of patient arrivals and departures. We aimed to create a data-driven newsvendor framework to study the elective-emergency admission control problem to achieve bed operational efficiency and effectiveness. We developed a data-driven approach that utilized the newsvendor framework to formulate the admission control problem. We also created approximation algorithms to generate a pool of candidate admission control solutions. Past observations and relevant emergency demand and bed capacity features were modeled in a newsvendor framework. Using approximation algorithmic approaches (sample average approximation, separated estimation and optimization, linear programing-LP, and distribution-free model) allowed us to derive computationally efficient data-driven solutions with tight bounds on the expected in-sample and out-of-sample cost guaranteed. Tight generalization bounds on the expected out-of-sample cost of the feature-based model were derived with respect to the LP and quadratic programing (QP) algorithms, respectively. Results showed that the optimal feature-based model outperformed the optimal observation-based model with respect to the expected cost. In a setting where the unit overscheduled cost was higher than the unit under-scheduled cost, scheduling fewer elective patients would replace the benefit of incorporating related features in the model. The tighter the available bed capacity for elective patients, the bigger the difference of the schedule cost between the feature-based model and the observation-based model. The study provides a reference for the theoretical study on bed capacity allocation between elective and emergency patients under the condition of the unknown true probability distribution of bed capacity and emergency demand, and it also proves that the approximate optimal policy has good performance.

Towards 24/7 MRI: the effect of routine weekend inpatient MRI scanning on patient waiting times

BackgroundDemand for inpatient MRI outstrips capacity which results in long waiting lists. The hospital commenced a routine weekend MRI service in January 2023.AimThe aim of this study was to investigate the effect of a limited routine weekend MRI service on MRI turnaround times.MethodsWaiting times for inpatient MRI scans performed before and after the introduction of weekend MRI from January 1 to August 31, 2022, and January 1 to August 31, 2023, were obtained. The turnaround time (TAT) and request category for each study were calculated. Category 1 requests were required immediately, category 2 requests were urgent and category 3 requests were routine.ResultsThere was a 6% (n = 128) increase in MRI inpatient scanning activity in 2023 (n = 2449) compared to 2022 (n = 2322). There was a significant improvement in overall mean TAT for inpatient MRIs (p < .001) in 2023 (mean 65.2 h, range 0–555 h) compared to 2022 (mean 98.3 h, range 0–816 h). There was no significant difference in the mean waiting time for category 1 MRIs between 2022 and 2023. There was a significant improvement (p < .001) in mean waiting time in 2023 (mean 37.2 h, range 0–555) compared to 2022 (mean 55.4 h, range 0–816) for category 2 MRI. The mean waiting time for category 3 studies also significantly improved (p < .001) in 2023 (mean 93.4 h, range 1–2663) when compared to 2022 (mean 154.8, range 1–1706).ConclusionRoutine weekend inpatient MRI significantly shortens inpatient waiting times.

A forecasting tool for a hospital to plan inbound transfers of COVID-19 patients from other regions

BackgroundIn April 2021, the province of Ontario, Canada, was at the peak of its third wave of the COVID-19 pandemic. Intensive Care Unit (ICU) capacity in the Toronto metropolitan area was insufficient to handle local COVID patients. As a result, some patients from the Toronto metropolitan area were transferred to other regions.MethodsA spreadsheet-based Monte Carlo simulation tool was built to help a large tertiary hospital plan and make informed decisions about the number of transfer patients it could accept from other hospitals. The model was implemented in Microsoft Excel to enable it to be widely distributed and easily used. The model estimates the probability that each ward will be overcapacity and percentiles of utilization daily for a one-week planning horizon.ResultsThe model was used from May 2021 to February 2022 to support decisions about the ability to accept transfers from other hospitals. The model was also used to ensure adequate inpatient bed capacity and human resources in response to various COVID-related scenarios, such as changes in hospital admission rates, managing the impact of intra-hospital outbreaks and balancing the COVID response with planned hospital activity.ConclusionsCoordination between hospitals was necessary due to the high stress on the health care system. A simple planning tool can help to understand the impact of patient transfers on capacity utilization and improve the confidence of hospital leaders when making transfer decisions. The model was also helpful in investigating other operational scenarios and may be helpful when preparing for future outbreaks or public health emergencies.

Hospital capacities and response to COVID-19 pandemic surges in Iran: A quantitative model-based study.

The coronavirus 2019 (COVID-19) pandemic resulted in serious limitations for healthcare systems, and this study aimed to investigate the impact of COVID-19 surges on in-patient care capacities in Iran employing the Adaptt tool. Using a cross-sectional study design, our study was carried out in the year 2022 using 1-year epidemiologic (polymerase chain reaction-positive COVID-19 cases) and hospital capacity (beds and human resource) data from the official declaration of the pandemic in Iran in February 2020. We populated several scenarios, and in each scenario, a proportion of hospital capacity is assumed to be allocated to the COVID-19 patients. In most of the scenarios, no significant shortage was found in terms of bed and human resources. However, considering the need for treatment of non- COVID-19 cases, in one of the scenarios, it can be observed that during the peak period, the number of required and available specialists is exactly equal, which was a challenge during surge periods and resulted in extra hours of working and workforce burnout in hospitals. The shortage of intensive care unit beds and doctors specializing in internal medicine, infectious diseases, and anesthesiology also requires more attention for planning during the peak days of COVID-19.

Maintaining health-system functionality in response to the surge of COVID-19 cases due to the Omicron variant, Japan.

The Omicron variant of severe acute respiratory syndrome coronavirus 2 caused the largest surge of coronavirus disease (COVID-19) cases in Japan starting in the summer of 2022. We describe the mechanisms introduced to provide appropriate health care to all Omicron cases, provide appropriate health care to all non-COVID-19 patients, and protect health-care workers (HCWs) while providing necessary health services. Optimization of care for elderly patients was particularly important. Japan is home to 125 million people, of whom 28.6% are 65 years or older. Between January and June 2022, the country experienced 4.3 times more COVID-19 cases than in the previous 2years (7.3 million vs 1.7 million). To adjust care pathways, inpatient treatment capacity was increased, a home-based care system was established, and an on-site treatment scheme at long-term care facilities was started. Among essential health services, disruption of emergency care became most noticeable. Administrative and financial support was provided to hospitals with emergency departments to maintain emergency medical services. To protect HCWs while maintaining hospital services, flexible exemptions were introduced to enable those who became close contacts to return to work, and broadly targeted contact tracing and testing in case of nosocomial outbreaks were all helpful. As a result of the adjustments made to inpatient capacity and patient flow, bed occupancy for COVID-19 patients decreased, mostly because many patients were cared for at home or in temporary-care facilities. From this study, we extracted two essential lessons to aid in current and future health emergencies: how to balance the provision of acute medical care for elderly patients and maintain their well-being; and how to maintain essential health services.

Admission rates and clinical profiles of children and youth with eating disorders treated as inpatients before and during the COVID-19 pandemic in a German university hospital.

Children and youth at risk for mental health disorders, such as eating disorders (ED), were particularly affected by the COVID-19 pandemic, yet evidence for the most seriously affected and thus hospitalized youth in Germany is scarce. This crosssectional study investigated anonymized routine hospital data (demographic information, diagnoses, treatment modalities) of patients admitted (n = 2,849) to the Department of Child and Adolescence Psychiatry, Psychosomatics and Psychotherapy (DCAPPP) of a German University Hospital between 01/2016 and 02/2022. Absolute and relative number of inpatients with or without ED prior to (01/2016-02/2020) and during the COVID-19 pandemic (03/2020-02/2022) were compared. The effect of school closures as part of social lockdown measures for COVID-19 mitigation on inpatient admission rate was explored as it has been discussed as a potential risk factor for mental health problems in youth. During the COVID-19 pandemic, ED inpatient admission rate increased from 10.5 to 16.7%, primarily driven by Anorexia Nervosa (AN). In contrast to previous reports, we found no change in somatic and mental disorder comorbidity, age or sexratio for hospitalized youth with ED. However, we did observe a shortened length of hospital stay (LOS) for hospitalized youth with and without ED. In addition, non-ED admissions presented with an increased number of mental disorder comorbidities. In contrast to our hypothesis, school closures were not related to the observed increase in ED. In summary, the COVID-19 pandemic was associated with an increased rate of inpatient treatment for youth suffering from AN, and of youth affected by multiple mental disorders. Accordingly, we assume that inpatient admission was prioritized for individuals with a higher burden of disease during the COVID-19 pandemic. Our findings pinpoint the need for adequate inpatient mental health treatment capacities during environmental crises, and a further strengthening of child and adolescence psychiatry services in Germany.

Impact of the coronavirus disease 2019 pandemic on equity of access to hip and knee replacements: a population-level study.

The COVID-19 pandemic had innumerable impacts on healthcare delivery. In Canada, this included limitations on inpatient capacity, which resulted in an increased focus on outpatient surgery for non-emergent cases such as joint replacements. The objective of this study was to assess whether the pandemic and the shift towards outpatient surgery had an impact on access to joint replacement for marginalized patients. Data from Ontario's administrative healthcare databases were obtained for all patients undergoing an elective hip or knee replacement between January 1, 2018 and August 31, 2021. All surgeries performed before March 15, 2020 were classified as "pre-COVID," while all procedures performed after that date were classified as "post-COVID." The Ontario Marginalization Index domains were used to analyze proportion of marginalized patients undergoing surgery pre- and post-COVID. A total of 102,743 patients were included-42,812 hip replacements and 59,931 knee replacements. There was a significant shift towards outpatient surgery during the post-COVID period (1.1% of all cases pre-COVID to 13.2% post-COVID, p < 0.001). In the post-COVID cohort, there were significantly fewer patients from some marginalized groups, as well as fewer patients with certain co-morbidities, such as congestive heart failure and chronic obstructive pulmonary disease. The most important finding of this population-level database study is that, compared to before the COVID-19 pandemic, there has been a change in the profile of patients undergoing hip and knee replacements in Ontario, specifically across a range of indicators. Fewer marginalized patients are undergoing joint replacement surgery since the COVID-19 pandemic. Further monitoring of access to joint replacement surgery is required in order to ensure that surgery is provided to those who are most in need.

The successful and safe conversion of joint arthroplasty to same-day surgery: A necessity after the COVID-19 pandemic.

A key strategy to address system pressures on hip and knee arthroplasty through the COVID-19 pandemic has been to shift procedures to the outpatient setting. This was a retrospective cohort and case-control study. Using the Discharge Abstract Database and the National Ambulatory Care Reporting System databases, we estimated the use of outpatient hip and knee arthroplasty in Ontario, Canada. After propensity-score matching, we estimated rates of 90-day readmission, 90-day emergency department (ED) visit, 1-year mortality, and 1-year infection or revision. 204,066 elective hip and 341,678 elective knee arthroplasties were performed from 2010-2022. Annual volumes of hip and knee arthroplasties increased steadily until 2020. Following the start of the COVID-19 pandemic (March 1, 2020) through December 31, 2022 there were 7,561 (95% CI 5,435 to 9,688) fewer hip and 20,777 (95% CI 17,382 to 24,172) fewer knee replacements performed than expected. Outpatient arthroplasties increased as a share of all surgeries from 1% pre-pandemic to 39% (hip) and 36% (knee) by 2022. Among inpatient arthroplasties, the tendency to discharge to home did not change since the start of the pandemic. During the COVID-19 era, patients receiving arthroplasty in the outpatient setting had a similar or lower risk of readmission than matched patients receiving inpatient arthroplasty [hip: RR 0.65 (0.56-0.76); knee: RR 0.86 (0.76-0.97)]; ED visits [hip: RR 0.78 (0.73-0.83); knee: RR 0.92 (0.88-0.96)]; and mortality, infection, or revision [hip: RR 0.65 (0.45-0.93); knee: 0.90 (0.64-1.26)]. Following the start of the COVID-19 pandemic in Ontario, the volume of outpatient hip and knee arthroplasties performed increased despite a reduction in overall arthroplasty volumes. This shift in surgical volumes from the inpatient to outpatient setting coincided with pressures on hospitals to retain inpatient bed capacity. Patients receiving arthroplasty in the outpatient setting had relatively similar outcomes to those receiving inpatient surgery after matching on known sociodemographic and clinical characteristics.

Severe acute malnutrition promotes bacterial binding over proinflammatory cytokine secretion by circulating innate immune cells.

Children with severe acute malnutrition (SAM) have high infectious mortality and morbidity, implicating defects in their immune defenses. We hypothesized that circulating innate immune cells from children (0 to 59 months) hospitalized with SAM in Zambia and Zimbabwe (n = 141) have distinct capacity to respond to bacteria relative to adequately nourished healthy controls (n = 92). SAM inpatients had higher neutrophil and monocyte Escherichia coli binding capacity but lower monocyte activation and proinflammatory mediator secretion in response to lipopolysaccharide or heat-killed Salmonella typhimurium than controls. Among SAM cases, wasting severity was negatively associated with cytokine secretion, children with HIV had lower monocyte activation, and the youngest children released the least myeloperoxidase upon stimulation. Inpatient bacterial binding capacity and monocyte activation were associated with higher odds of persistent SAM at discharge, a risk factor for subsequent mortality. Thus, SAM shifts innate immune cell function, favoring bacterial containment over proinflammatory activation, which may contribute to health deficits after discharge.

Standardization of Outpatient Care after CAR-T Therapy across a Large Cell Therapy Network- through Technology and Decentralized Virtual Nurses: Preliminary Results

Introduction: Shifting Chimeric Antigen Receptor T-cell (CAR-T) therapy to the outpatient setting may increase patient satisfaction and inpatient capacity, and reduce infection risk. Outpatient protocols require resources for patient management outside of clinic hours to be safe and effective. Our Transplant and Cellular Therapy Network (TCTN) leveraged wearable technology and decentralized nurses in four outpatient CAR-T programs. We sought to characterize patient adherence, time spent on patient monitoring, and clinical outcomes. Methods: Patients were deemed eligible for outpatient therapy if they were adults (18+ years), lived within 30-60 minutes of the treating hospital, had a 24/7 caregiver, and received CAR-T with known risks of developing cytokine release syndrome (CRS). The outpatient CAR-T program included enrollment into an FDA-cleared virtual care platform, daily engagement with virtual nurses for the duration of the program, and in-person clinic visits during the highest risk period (Days 1-14). The remote monitoring kit included a wearable device that continuously transmitted vital signs (pulse, respiratory rate, O 2 saturation and skin temperature), a tablet, axillary temperature patch and blood pressure (BP) cuff. Patients were asked to always wear the device outside of clinic visits, take a BP reading 3x/day, and complete surveys via the tablet. A multidisciplinary taskforce established clinical pathways for remote monitoring across sites and developed parameters for alarms, virtual nurse check-ins, and escalation of care to ER/clinic. Virtual nurses contacted patients based on vital sign trends, responded to patient concerns, and triaged in accordance with clinical pathways, escalating as appropriate. The virtual care platform, video and phone call logs with the virtual nurses, and clinical data were extracted for 40 patients between 2/20/23 and 6/15/2023. Inpatient admission, patient adherence, alarms, calls, and clinical metrics were summarized. Non-parametric measures were reported as median (IQR). Metrics for specific windows of time were reported for a subset of variables: wearable adherence (day vs. night) and alarms/calls during clinic hours (weekdays 8 am - 5 pm) vs. non- clinic hours. Adherence was derived from tasks/wear time completed vs. prescribed. Results: Forty patients (66 ± 12 years, 24 male) with diagnoses of Non-Hodgkin Lymphoma (75%), Plasma Cell Disorder (20%), or Acute Lymphoblastic Leukemia (5%) received CAR-T therapy [axi-cel (40%), liso-cel (25%), cilta-cel (20%), brexu-cel (12.5%), tisa-cel (2.5%)] and completed the outpatient CAR-T program. The median length of monitoring on the platform was 14.7 (10.4 - 27.6) days. Overall wearable adherence was 79 (67.7 - 87.9) %; 67 (48.7 - 83.4) % in the day and 89.1 (79.8 - 92.8) % at night. Median survey completion was 50 (7.7 - 80) % and BP compliance was 95 (69.8-100) %. Out of 717 patient days, 68.4% had 100% BP compliance (3 readings/day). There was a total of 780 alarms; 67% operational and 86% clinical alarms occurred during non-clinic hours (Table 1). The operational alarm rate was 0.5 and the clinical alarm rate was 0.6 per patient-day. 75% of patients triggered at least one operational and clinical alarm during their program. The virtual nurses engaged in 1102 calls through the tablet or phone (3.5 ± 3.4 mins). More than half of the calls were during non-clinic hours (63%) and 70% of calls were with a patient/care giver. Calls about a clinical alarm or clinical concern were 3x and 6.8x higher, respectively, during non-clinic hours. Twenty-seven patients required some level of hospital observation service and/or admission to the hospital; 25 patients developed CRS. Median duration from infusion to admission/observation was 5 (1-11) days. Median days to discharge was 5 (1-26). Of those admitted,10 patients were admitted to the ICU with a median stay of 5.5 (1-21) days. Conclusion: Our TCTN established a successful, integrated outpatient management process to ensure patient safety within the first 30 days post CAR T-Cell therapy. The virtual care platform and decentralized virtual nurses have enabled patients to recover safely with more time at home rather than in hospital. Future research will address patient and provider experiences and continue to expand on the safety and resource utilization of this integrated program.