Inpatient Observation Research Articles

Against the stream: intermittent nurse observations of in-patients at night serve no purpose and cause sleep deprivation.

This paper argues that intermittent nursing observations of in-patients at night do not reduce the risk of suicide or severe self-harm. Suicides between 23.00 h and 07.00 h are rare, and these overwhelmingly occur under intermittent observations. Such observation is purely a defensive intervention to document that a patient is safe at a particular time, as there is no engagement. For the large majority of in-patients, it has the unintended consequence of causing sleep deprivation. The intervention may cause harm to in-patients by making their disorder worse and increase their risk during the day. If patients are judged to be at immediate risk, then they should be placed on constant observation. If they are not, then optimising sleep is important for treating a psychiatric disorder and they should be placed on general observations.Declaration of interestNone.

Obstetricians’ knowledge and practices regarding the management of preeclampsia

Background: Preeclampsia affects over 4% of pregnancies in the United States. Management of preeclampsia is dependent on the severity of the condition and can range from expectant management to early delivery and inpatient observation. After publication of the hypertension in Pregnancy Task Force guidelines in 2013, little is known about their implementation and acceptance by practicing obstetricians and maternal-fetal medicine (MFM) specialists.Objective: To evaluate Obstetricians’ knowledge and practices regarding the management of preeclampsia.Methods: A prospective survey was administered to ob-gyns at three different hospital systems in the Northeastern United States to assess practices regarding preeclampsia management and prevention.Results: A total of 87 out of 130 providers completed and returned a questionnaire (66.9% response rate). Providers with a subspecialty in MFM made up 44.3% of the sample. 90.7% of respondents agreed that preeclampsia is a common diagnosis in their practice, while 85% agreed that aspirin is useful for reducing a patient’s risk of preeclampsia. 68.8% of providers reported not administering magnesium sulfate in labor to reduce seizure risk in patients with preeclampsia without severe features. Only 5.8% of providers reported using a preeclampsia prediction algorithm, all of whom were MFMs. Providers who specialized in MFM were more likely to prescribe aspirin for preeclampsia prevention in patients with chronic hypertension (26, 74.3% vs. 17, 39.5%, p = .002). MFM specialists were also more likely to counsel patients with abnormal biomarkers on the risk of preeclampsia (23, 69.7% vs. 15, 35.7%, p = .005).Conclusion: Efforts to inform practicing ob-gyns about the best practices for preeclampsia management and prevention have been largely successful, though there are still discrepancies between current recommendations and practice. Differences between general OBGYNs and MFM specialists were also significant with regards to practice. Given the acknowledgement of how common diagnoses of preeclampsia are in respondents’ practices, better education and distribution of guidelines on management of preeclampsia is needed.

Endoscopic Gastroplasty. Initial Experience.

Introduction: Less invasive endoscopic bariatric procedures are under development for the management of class I of obesity. The purpose of our study is to evaluate endoscopic gastroplasty (EG) using a suturing method, as well as the perioperative care and outcomes, during one-year period. Methods: This is a prospective single-center study over 17 patients using the EG under general anesthesia with overnight inpatient observation. The analyzed variables were: change in body weight; and adverse effects. In order to analyze correlations between BMI , and identify predictors for better weight loss after EG, we created 2 groups of patients: Group A (with BMI 35 and primary obesity - 10 patients) and Group B (with BMI 35 , or previous gastric balloon or bariatric surgery - 7 cases). Results: A total of 17 patients underwent endoscopic procedures for primary obesity or weight regain. All patients were female with a mean age of 38.7 years. The mean BMI was 34.8 kg/m2 (range: 30.8 - 44.1). There were no major intra-procedure adverse events or during the follow up. All patients were discharged on the 1st or 2nd day following the procedure and in the future the procedure will be proposed in ambulatory setting. Four patients (23.5 %) were complaining of moderate postprocedural pain for a mean period of time of 7.75 days (range 2-15 days) and two other patients complained about nausea and vomiting alleviated by the intravenous drugs. Of the 17 initial patients, 4 were available for 3-month of follow-up, 7 for 6-month, 3 for 9-month, and 3 completed the 12-month assessment with the mean EWL of 46.1 %. According to ASGE definition, 70.6 % (n= 12) of the 17 patients reached 25% of EWL. All patients in group A reached a successfully weight loss and the mean EWL was 72.4 %, but 5 out 7 patients in group B failed to achieve an EWL 25 %. Moreover, all patients who underwent previous bariatric surgery failed to achieve any results in term of weight loss following EG. Conclusions: Endoscopic gastroplasty represent a safe minimal invasive approach that can be considered as an effective and well tolerated procedure especially for primary obesity treatment. For patients with previous bariatric surgical procedures or with severe obesity the results are less favorable.

Postdischarge Unplanned Care Events Among Commercially Insured Patients With an Observation Stay Versus Short Inpatient Admission

Observation stays are composing an increasing proportion of unscheduled hospitalizations in the United States, with unclear consequences for the quality of care. This study used a nationally representative data set of commercially insured patients hospitalized from the emergency department (ED) to compare 30-day postdischarge unplanned care events after an observation stay versus a short inpatient admission. This was a retrospective analysis of ED hospitalizations using the 2015 Truven MarketScan Commercial Claims and Encounters data set. Adult observation stays and short inpatient hospitalizations of 2 days or less were identified and followed for 30days from hospital discharge to identify unplanned care events, defined as a subsequent inpatient admission, observation stay, or return ED visit. A propensity score analysis was used to compare rates of unplanned events after each type of index hospitalization. Among the propensity-weighted cohorts, patients with an index observation stay were 28% more likely to experience any unplanned care event within 30 days of discharge compared with those with a short inpatient admission (20.4% versus 15.9%; risk ratio 1.28; 95% confidence interval [CI] 1.21 to 1.34). Specifically, patients in the observation stay group had substantially higher rates of postdischarge observation stays (4.8% versus 1.9%; odds ratio 2.60; 95% CI 2.15 to 3.16) and ED revisits with discharge (11.1% versus 8.8%; odds ratio 1.26; 95% CI 1.21 to 1.44) compared with those in the inpatient group, but were less likely to be readmitted as inpatients (6.4% versus 7.2%; odds ratio 0.90; 95% CI 0.83 to 0.96). Commercially insured patients with an observation stay from the ED have a higher risk of postdischarge acute care events compared with similar patients with a short inpatient admission. Additional research is necessary to determine the extent to which quality of care, including care transitions, may differ between these 2 groups.

Short-term swallowing outcomes following type 1 laryngeal cleft injection

IntroductionInterarytenoid injection augmentation at the time of initial diagnostic endoscopy for aspiration and dysphagia may result in near-immediate improvement in swallowing function, potentially obviating the need for future formal endoscopic repair of type 1 laryngeal cleft. Interarytenoid injection augmentation may also address physiologic aspiration. Early treatment of type 1 laryngeal cleft may allow for expedited liberalization of feedings. The objective of this study was to evaluate the effect of interarytenoid injection augmentation (IIA) for type 1 laryngeal clefts (LC-1) on short-term swallowing function assessed by videofluoroscopic swallowing study (VFSS). MethodsThis was a retrospective cohort study of patients age ≤24 months with dysphagia on preoperative VFSS who underwent IIA with calcium hydroxyapatite for LC-1 during direct laryngoscopy and bronchoscopy from June to October 2017 at a tertiary care academic subspecialty hospital. Exclusion criteria included prior endoscopic or open LC repair (n = 1), gastrostomy tube dependence (n = 1), additional procedures at the time of IIA (supraglottoplasty, frenulectomy, n = 1). Children without postoperative VFSS within 30 days of injection were excluded (n = 2). Fifteen children met inclusion criteria for analysis. The primary endpoint was improvement in safely swallowed consistency as defined by recommendation to liberalize diet by at least a half-consistency (e.g. half-honey to nectar thick liquid). Secondary endpoints included clinical assessment of dysphagia and postoperative respiratory events. ResultsMedian [range] age at injection was 15.2 [7.7–24.3] months and 67% of patients were female (n = 10). The majority (13/15) of patients were full-term and 80% of patients (n = 12) had documented gastroesophageal reflux disease (GERD). Median time from injection to VFSS was 16 [9–29] days. Improvement in safely swallowed consistency was noted in 60% (n = 9) of patients. Aspiration completely resolved in two patients. Swallow function was unchanged in 40% of patients (n = 6); no patients experienced worsening dysphagia. No respiratory complications were documented during inpatient observation. ConclusionIIA is a safe procedure that may result in immediate improvement in dysphagia in select patients with LC-1. IIA does not address neurologic, developmental, or other anatomic etiologies of dysphagia. Additional studies are required to determine long-term efficacy of IIA on dysphagia and pulmonary complications, as well as the patient- and caregiver-related outcome measures.

Editorial Volume 17 Issue 4 – Assessing, treating and prognosticating from the front door

In our daily working lives, acute physicians strive to provide the best holistic care to our patients from the moment they arrive in hospital. Experienced healthcare professionals develop a gut feeling (generally recognised as the nagging internal voice of professional experience) about patients who may be more unwell than appearances suggest, or who may deteriorate despite showing signs of physiologically compensating quite well. The papers in this issue challenge us to examine how we prioritise, prognosticate and risk-stratify the patients we treat in acute medicine, how we remain cognisant and skilled in treating patients with more unusual acute medical conditions, and how we allocate resources in the NHS. There are many reasons for a patient to re-attend the Emergency Department (ED) in the days following a discharge. In the UK, these unplanned re-attendances are measured as a quality indicator, implying that patient’s return to the ED is due to a deficiency in the quality of their care. In this issue, Ludwig et al challenge this simplistic view by exploring the reasons why patients to come back to the ED and describe how these re-attendances can be ascribed to factors related either to the patient, the physician or the illness itself. Is there a reliable way to predict mortality and likelihood to require critical care at the point of admission? Two papers in this issue cover the subject of prognostication in acute medicine. Most acute medics are wary of transplanting illness-severity metrics from other disciplines and installing indiscriminately them in the ED and AMU. However, Holm and Brabrand have established that the Sequential Organ Failure Assessment (SOFA) score, a longtime staple of the Intensive Care Unit (ICU), can predict deterioration and death with acceptable accuracy in acute medical patients. This suggests that the SOFA score may inform treatment escalation plans and patient prioritisation at the ‘front door’. Bindraban et al have used the haematological indices of the full blood count develop an understanding of how front line tests may predict the patient journey. Whilst common sense suggests that those with the most abnormal blood test results at admission have worse outcomes, this paper quantifies and elaborates the relationship between the results on the computer screen and the patient in the hospital bed. When Grenfell Tower blazed in June 2017, the nearby AMUs cleared their beds as best they could and stood by to receive patients suffering with smoke-related injuries. Occurrences such as this remind us that the acute physician must be up to date with rare but important medical emergencies. In their review, Björkbom and Brabrand highlight the phenomenon smoke inhalation injury, and advise us that the period of in-patient observation should be slightly longer than we realise. “The most intense spending on acute health care in a lifetime occurs in the last few months of life”; from this statement Jones and Kellett lay out their argument that local mortality rates should inform and influence local healthcare spending. In an article that should provoke debate, they suggests significant adjustments in how financial resources are allocated, and how a national death registry could impact upon how the NHS spends its money.

RATIONALE AND DESIGN OF A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, DOSE-COMPARISON SAFETY AND TOLERABILITY STUDY OF GRF6019 IN MILD-TO-MODERATE ALZHEIMER’S DISEASE

Published studies have demonstrated beneficial effects of IV administration of young human plasma on activity, locomotion, and cognition in old mice. Subsequent studies performed at Alkahest have confirmed these results and extended these findings to an investigational plasma protein fraction that showed beneficial effects lasting up to 3 months. Based on these robust preclinical data, a clinical study protocol was developed to assess the safety and tolerability of GRF6019, a proprietary plasma protein fraction manufactured by Grifols Therapeutics, Inc., in human subjects with Alzheimer's Disease (AD). In the proposed Phase 2 study, men and women 60 years or older with mild-to-moderate AD will be randomly allocated to receive multiple doses of either 100 mL or 250 mL of GRF6019. Approximately 40 subjects (20 randomized to each dose) will be recruited with the goal of obtaining ∼30 evaluable subjects. During dosing periods subjects will reside in inpatient observation units to facilitate safety evaluation. Subjects will undergo a screening visit, baseline visit, treatment visits, follow-up visits, and an end of study/early termination visit. Safety and tolerability assessments will occur at every visit. Neurocognitive and motor assessments will be performed at baseline and at periodic interim visits following dosing. The primary endpoints are safety, tolerability, and feasibility of the dosing regimen. Safety will be measured by the incidence of treatment-emergent adverse events. Tolerability will be measured by the number of subjects completing the week-8 follow-up visit and subjects completing the week-24 follow-up visit. Study feasibility will be measured by the number of subjects completing each infusion regimen. Secondary endpoints will assess potential effects on cognition using various established cognitive measures including the Alzheimer's Disease Assessment Scale-Cognitive Subscale. Exploratory endpoints include assessment of changes in composition and distribution of blood-based biomarkers and MR imaging. Robust preclinical evidence in rodents provides the foundation to test the translatability of these findings in humans. In this Phase 2 study, the safety, tolerability, and feasibility of multiple infusions of GRF6019 in subjects with AD will be assessed. Continued clinical development in AD will be informed by safety and efficacy data emerging from this trial.

Accuracy of Computed Tomography in Diagnosis of Intra-abdominal Injuries in Stable Patients With Anterior Abdominal Stab Wounds: A Systematic Review and Meta-analysis.

Workup for patients presenting to the emergency department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP); however, workup of stable, asymptomatic or nonperitoneal patients is not clearly defined. The objective was to evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intraabdominal injuries requiring therapeutic laparotomy (THER-LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient? We searched PubMed, Embase, and Scopus from their inception until May 2017 for studies on ED patients with AASW. We defined the reference standard test as LAP for patients who were managed surgically and inpatient observation in those who were managed nonoperatively. In those who underwent LAP, THER-LAP was considered as disease positive. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate the risk of bias and assess the applicability of the included studies. We attempted to compute the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) using a random-effects model with MetaDiSc software and calculate testing and treatment thresholds for CT scan applying the Pauker and Kassirer model. Seven studies were included encompassing 575 patients. The weighted prevalence of THER-LAP was 34.3% (95% confidence interval [CI]= 30.5%-38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were as follows: sensitivity= 50% to 100%, specificity= 39% to 97%, LR+= 1.0 to 15.7, and LR-= 0.07 to 1.0. The high heterogeneity (I2 >75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated. The articles revealed a high prevalence (8.7%, 95% CI= 6.1%-12.2%) of injuries requiring THER-LAP in patients with a negative CT scan and almost half (47%, 95% CI= 30%-64%) of those injuries involved the small bowel. In stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intraabdominal injuries.

External Validation of Six Pediatric Fever and Neutropenia Clinical Decision Rules.

Fever and neutropenia (FN) clinical decision rules (CDRs) are recommended to help distinguish children with cancer at high and low risk of severe infection. The aim of this study was to validate existing pediatric FN CDRs designed to stratify children with cancer at high or low risk of serious infection or medical complication. Pediatric CDRs suitable for validation were identified from a literature search. Relevant data were extracted from an existing data set of 650 retrospective FN episodes in children with cancer. The sensitivity and specificity of each of the CDR were compared with the derivation studies to assess reproducibility. Six CDRs were identified for validation: 2 were designed to predict bacteremia and 4 to predict adverse events. Five CDRs exhibited reproducibility in our cohort. A rule predicting bacteremia had the highest sensitivity (100%; 95% confidence interval (CI): 93%-100%) although poor specificity (17%), with only 15% identified as low risk. For adverse events, the highest sensitivity achieved was 84% (95% CI: 75%-90%), with specificity of 29% and 27% identified as low risk. A rule intended for application after a 24-hour period of inpatient observation yielded a sensitivity of 80% (95% CI: 73-86) and specificity of 46%, with 44% identified as low risk. Five CDRs were reproducible, although not all can be recommended for implementation because of either inadequate sensitivity or failure to identify a clinically meaningful number of low-risk patients. The 24-hour rule arguably exhibits the best balance between sensitivity and specificity in our population.

The frequency and management of seizures during psychological treatment among patients with psychogenic nonepileptic seizures and epilepsy.

Growing evidence suggests that psychological treatments are effective for improving outcomes in both epilepsy and psychogenic nonepileptic seizures (PNES). However, the risk of in-session seizures may cause concerns about safety and about seizures disrupting treatment. This study explores the risk of in-session seizures in patients with epilepsy and those with PNES, the timings of seizures during psychological therapy, and the responses of therapists to seizures. Consecutive patients with epilepsy or PNES attending 2 neurology centers in the United Kingdom for psychological treatment to help with their seizure disorders were studied. Information about seizures during outpatient psychological therapy sessions was gathered using a 12-item pro forma. Ninety-seven patients with epilepsy and 195 with PNES were evaluated. One in 32 patients with epilepsy and 1 in 8 with PNES had at least 1 in-session seizure. A seizure occurred in 1 in 136 treatment sessions provided to patients with epilepsy, and 1 in 36 sessions provided to those with PNES. The risk of in-session seizures was significantly greater in patients with PNES than in patients with epilepsy (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.3-15.2). Seizures tended to occur in the first half of treatment programs and individual sessions and only disrupted sessions briefly. Only one patient with PNES required in-patient observation not involving overnight admission. In-session seizures do occur and are much more common in patients with PNES than in those with epilepsy. Seizures rarely caused major disruption to psychological treatment, and could almost invariably be managed by the treating therapist without help from additional medical staff. Nonetheless, this research suggests that psychological therapy providers should anticipate the occurrence of in-session seizures and have safe management plans in place. The greater frequency of in-session seizures in PNES may add to our understanding of the mechanisms triggering these seizures.

Alcohol intoxication in emergency medicine

Every year more than 100,000 people with an alcohol intoxication are admitted to German hospitals. Many of them refuse inpatient observation or treatment. Therefore the physician in charge at the emergency room has to decide, how to proceed. The capacity to consent has to be judged, especially if the patient insists on being discharged. In this context the risks of injuries, complicated alcohol withdrawal, aggressive and suicidal behavior must be evaluated. In this article the juridical aspects and the necessary mental and physical assessments especially in case of discharge of the patient against medical advice are presented. Essential aspects are summarized in checklists.

Reducing rates of operative intervention for pediatric post-tonsillectomy hemorrhage.

The aims of this study were to determine the frequency of rebleeding in patients admitted for observation after presentation for nonactive hemorrhage in the post-tonsillectomy period, compare rebleeding rates between patients managed with observation versus initial operative control, and describe the complication profile associated with observation as a management strategy for post-tonsillectomy bleeding. Case series with retrospective review of patients. Patients presenting from September 1, 2013 to August 31, 2015 for post-tonsillectomy hemorrhage to a tertiary pediatric care center were evaluated for inclusion in the study. Inclusion criteria included patients ≤18 years of age without active bleeding at the time of the initial examination. Proportions were compared using χ2 and Fisher exact tests, whereas continuous data were compared using the Wilcoxon rank sum test. Of 3,866 tonsillectomy patients, 285 (7.4%) presented with concern for oropharyngeal bleeding in the postoperative period, of whom 224 were admitted for nonactive bleeding. Of patients with nonactive bleeding, 203 (90.6%) were managed with observation and 21 (9.4%) with operative intervention. Rate of rebleeding was 26/203 (12.8%) after inpatient observation and 3/21 (14.3%) after operative intervention (P = 1.000). Frequency of rebleeding requiring operative control in patients undergoing initial observation was 14/203 (6.9%). In our pilot study, rates of rebleeding in patients observed for nonactive post-tonsillectomy hemorrhage was not statistically different than those managed with initial operative exploration. Although preliminary in nature, our data suggest observation may have comparable safety and efficacy when compared to operative management for pediatric patients presenting with nonactive post-tonsillectomy bleeding. Further data collection to establish an optimal management algorithm is ongoing. 4 Laryngoscope, 1958-1962, 2018.

Assessment of Time to Hospital Encounter after an Initial Hospitalization for Heart Failure: Results from a Tertiary Medical Center.

Background Hospital inpatient readmissions for patients admitted initially with the primary diagnosis of heart failure (HF) can be as high as 20–25% within 30 days of discharge. This, however, does not include admissions for observations or emergency department (ED) visits within the same time frame and does not show a time-dependent hospital encounter following discharge after an index admission. We present data on time-dependent hospital encounter of HF patients discharged after an index admission for a primary diagnosis of HF. Methods The study recruited patients from 2 hospitals within the same health system. 500 consecutive admissions with the ICD diagnosis of HF were reviewed by inclusion and exclusion screening criteria. The 166 eligible remaining patients were tracked for post hospital discharge encounters consisting of hospital admissions, observation stays, and ED visits. Only those with a primary diagnosis of heart failure were included. Demographics were recorded on all patients. Days until hospital inpatient readmissions or hospital encounters were displayed in Kaplan–Meier plots. Results A total of 166 patients met inclusion criteria (mean age 79.3 years, males 54%). For the first 90 days following the index admission, there were a total of 287 follow-up visits (1.7 per patient), 1158 total hospitalization days (2.6 per visit, 7.0 per patient, and 8.6 per 100 days at risk), and 21 deaths (12.7%). At 30 days, 25% and 52% of patients had an inpatient readmission or a hospital encounter, respectively. The median time to inpatient readmission was 117 days and to hospital encounter was 27 days. Conclusion Time-dependent excess days in acute care (unplanned inpatient admission, outpatient observation, and ED visit) rather than 30-day hospital inpatient readmission rate is a more realistic measure of the intensity of care required for HF patients after index admission.

A Retrospective 10-Year Analysis of Water Absorbent Bead Ingestion in Children.

Aim This retrospective case series was designed to evaluate the clinical experience of pediatric patients who had ingested water absorbent beads (WABs) and review the relevant literature. Materials and Methods A retrospective chart analysis of 21 children who were admitted to the emergency service or outpatient clinic with complaints of swallowing WABs during a 10-year period was performed. The patients were divided into two groups: 6 patients who were hospitalized and 15 patients who were observed as outpatients for groups 1 and 2, respectively. All data were screened with respect to presentation, age, gender, clinical and radiological findings, modalities of treatment, and follow-up. Results All patients were asymptomatic with uneventful outcomes. Laboratory studies, X-ray, and ultrasound examinations revealed normal results. None of the patients underwent surgery or other medical procedures. Gastrointestinal system obstruction or any other pathological findings were not detected after WAB ingestion. No complications were identified during follow-up. Discussion This first clinical study showed that asymptomatic patients do not require inpatient observation and laboratory investigations, X-ray, and ultrasound. However, results of the present study cannot be generalized to children of all ages due to the few cases of bowel obstruction reported to date in small children.

THE PREVENTION OF CARDIOVASCULAR COMPLICATIONS AFTER CORONARY STENTING IN PATIENTS WITH UNSTABLE ANGINA AND RESISTANCE TO ANTIPLATELET AGENTS

Objective: the aim of the study was evaluation of the clinical significance of high residual platelet reactivity in patients with unstable angina and coronary arteries stenting in the inpatient and outpatient monitoring and development of optimal ways of correction of this condition.Material and Methods: the study included 131 patients with unstable angina after coronary stenting. The main group represented 78 patients (UA) underwent dynamic observation of platelet aggregation (Multiplate aggregometer) on the inpatient and outpatient observations (7 day, 1 month, 6 months, 12 months, 18 months) to identify primary and secondary resistance to antiplatelet agents with subsequent correction of antiplatelet therapy. The control group consisted of 53 patients with standard therapy with antiplatelet agents without control of platelet aggregation. All patients were performed: general blood analysis, biochemical blood analysis with determination of the level of TnI, C-reactive protein, myeloperoxidase, von Willebrand factor, and fibrinogen; the test of thrombin generation, also ECG, EchoCG, 24-hour ECG monitoring, coronary angiography. The Republican Scientific and Practical Center Cardiology, Minsk, BelarusResults: the results of our study showed a reduction in sensitivity to clopidogrel at 24,4% of patients with UA and stenting of the coronary arteries, of which the original clopidogrel in 7,7% of patients, generic clopidogrel 16,7% pts. Reduced sensitivity to acetylsalicylic acid was detected in 17,9% of individuals with UA. Laboratory resistance to ASA and/or clopidogrel increased the relative risk of recurrent cardiovascular events more than 4 times [CI 2,9; 5,6] during the 18 months of observation in comparison with a group of pts with no signs of resistance to antiplatelet agents.Conclusions: execution of aggregatogram to patients with unstable angina and stenting of the coronary arteries allows to identify patients with high residual platelet reactivity, to correct of antiplatelet therapy and to reduce the number of repeat cardiovascular events in patients with signs of laboratory resistance to antiplatelet agents.

Low molecular weight heparin as an anticoagulation strategy for left-sided ablation procedures.

This quality improvement study was implemented to demonstrate consistent and reliable post procedure anticoagulation for patients undergoing left-sided ablations. We evaluated the safety and efficacy of anticoagulation practice during a transition from anticoagulation with overnight infusion of unfractionated heparin to a single subcutaneous injection of low molecular weight heparin. Outcomes for patients who received unfractionated heparin from January 2014 to October 2014, were compared with outcomes of patients who received low molecular weight heparin from October 2014 to October 2015. Complications prepractice and postpractice change were documented and compared to establish confidence in the practice change and confirm the safety of the anticoagulation therapy management. There were no differences in the type or frequency of complications/adverse events demonstrated between the patients who had received unfractionated heparin for anticoagulation prophylaxis and those who received low molecular weight heparin. No thromboembolic events were reported or documented with either anticoagulation strategy. After confidence in the safety and efficacy of the practice change was established, a decision was made to discharge patients home the same day as there procedure, effectively reducing inpatient bed days and overall costs. Administration of low molecular weight heparin provides predictable anticoagulation and equally safe as unfractionated heparin when administered to patients post left-sided ablation. A secondary gain has been reduction of procedural costs by elimination of the previously required inpatient observation stay.

Abstract 21095: Medical Emergency Team (MET) Criteria in the Intensive Care Unit Setting

Introduction: MET criteria are widely used in the hospital setting to provide an early warning system to facilitate escalation of care. We aimed to determine the proportion of RMH Intensive Care Unit (ICU) patients who have met MET call criteria within several separate 24-hour snapshot periods. The RMH ICU has over 2500 admissions per year (73.6% emergency admissions), with a mean age of 56.4 years, a mean length of stay of 79.6 hours, a mean APACHE 3 score 58.9, and an overall ICU mortality of 8%. Methods: This prospective study collected information retrospectively from a convenience sample, during the period from 01/03/2017 to 08/06/2017. Snapshots were collected at a set time by review of all the current RMH ICU inpatient observation charts, on separate occasions at least two days apart. Observation charts were examined for the prior 24 hours of data, or fewer hours if the patient had been more recently admitted to the ICU. Each of these discrete episodes was examined to determine whether or not specific MET criteria had been met. MET criteria occurring multiple times within one episode were not additionally recorded. The data below is from 10 separate days of data collection. Results: Over 10 separate snapshots examining 237 patient episodes, 230 observation charts could be reviewed. Of the 230 patients, 147 were mechanically ventilated (63.9%), while 116 were receiving vasopressor/inotrope infusions (50.4%). Of the 230 patients, 177 (77%) met at least one MET call criteria in the previous 24-hour period. The most common MET criterion was a spontaneous respiratory rate of <8 breaths/minute (87/230, 37.8%); 86 of these 87 patients were mechanically ventilated. Other MET criteria detected were systolic blood pressure <90 mmHg (60/230, 26.1%), respiratory rate >30 breaths/minute (55/230, 23.9%), heart rate >130 beats/minute (32/230, 13.9%), and pulse oximetry saturation <90% (27/230, 11.7%). 175 of the patients (76.1%) had adjusted daily physiological aims recorded on their observation charts. Conclusions: ICU patients commonly meet standard MET criteria. Unadjusted MET criteria by themselves cannot be used to activate an escalation of care in Intensive Care.

THE DASH PROJECT ‐ AN INTERVENTION AIMED AT CHANGING PHYSICIANS’ PRACTICE OF INPATIENT OBSERVATION FOLLOWING ANTIBIOTIC DE‐ESCALATION IN UNCOMPLICATED COMMUNITY ACQUIRED PNEUMONIA

RespirologyVolume 22, Issue S3 p. 226-226 APSR Poster Abstracts THE DASH PROJECT - AN INTERVENTION AIMED AT CHANGING PHYSICIANS’ PRACTICE OF INPATIENT OBSERVATION FOLLOWING ANTIBIOTIC DE-ESCALATION IN UNCOMPLICATED COMMUNITY ACQUIRED PNEUMONIA First published: 23 November 2017 https://doi.org/10.1111/resp.13207_362Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume22, IssueS3Supplement: 22nd Congress of the Asian Pacific Society of Respirology, International Convention Centre, Sydney, Australia, 23–26 November 2017November 2017Pages 226-226 RelatedInformation

On the hands of patients with Clostridium difficile: A study of spore prevalence and the effect of hand hygiene on C difficile removal

The prevalence of Clostridium difficile spores was assessed in 48 observations of infected inpatients. Participants were randomized to hand hygiene with either alcohol-based handrub or soap and water. C difficile was recovered in 14.6% of pre-hand hygiene observations. It was still present on 5 of these 7 participants after hand hygiene (3/3 using alcohol-based handrub; 2/4 using soap and water).

Hospital admission unnecessary for successful uncomplicated radiographic reduction of pediatric intussusception

PurposeAfter radiologic reduction, patients with ileocolic intussusception are often admitted. We hypothesize that discharge of stable patients after 4 h of emergency department (ED) observation does not result in an increase of adverse outcomes. MethodsWe retrospectively reviewed pediatric patients with ileocolic intussusception between 2011 and 2016, managed with either 24-h inpatient or 4-h ED observation. Outcomes included length of stay, adverse outcomes, and total hospital charges. ResultsFifty-one patients were managed with ED observation and 79 with inpatient observation. Recurrence rates, time to recurrence, and adverse outcomes were similar in both protocols. Total recurrence rates for ED observation was 15% versus 14% for inpatient observation. ED observation reduced time in the hospital by 26.8 h (4.9 versus 31.7 h). ConclusionDischarging patients following uncomplicated hydrostatic reduction of ileocolic intussusception after a 4-h observation period does not result in an increase in adverse outcomes.