Long-term Acute Care Facility Research Articles

Lessons for the next pandemic: analysis of the timing and outcomes including post-discharge decannulation rates for tracheostomy in severe COVID-19 respiratory failure.

COVID-19 patients with respiratory failure frequently require prolonged ventilatory support that would typically warrant early tracheostomy. There has been significant debate on timing, outcomes, and safety of these procedures. The purpose of this study was to determine the epidemiological, hospital, and post-discharge outcomes of this cohort, based on early (ET) versus late (LT) tracheostomy. Retrospective review (March 2020-January 2021) in a 5-hospital system of ventilated patients who underwent tracheostomy. Demographics, hospital/ICU length of stay (LOS), procedural characteristics, APACHE II scores at ICU admission, stabilization markers, and discharge outcomes were analyzed. Long-term decannulation rates were obtained from long-term acute care facility (LTAC) data. A total of 97 patients underwent tracheostomy (mean 61years, 62% male, 64% Hispanic). Despite ET being frequently performed during active COVID infection (85% vs. 64%), there were no differences in complication types or rates versus LT. APACHE II scores at ICU admission were comparable for both groups; however, > 50% of LT patients met PEEP stability at tracheostomy. ET was associated with significantly shorter ICU and hospital LOS, ventilator days, and higher decannulation rates. Of the cohort discharged to an LTAC, 59% were ultimately decannulated, 36% were discharged home, and 41% were discharged to a skilled nursing facility. We report the first comprehensive analysis of ET and LT that includes LTAC outcomes and stabilization markers in relation to the tracheostomy. ET was associated with improved clinical outcomes and a short LOS, specifically on days of pre-tracheostomy ventilation and in-hospital decannulation rates.

Predictors and outcomes of discharge to long-term acute care facilities after cardiac surgery

ObjectiveAn increasing number of patients with significant comorbidities present for complex cardiac surgery, with a subgroup requiring discharge to long-term acute care facilities. We aim to examine predictors and mortality after discharge to a long-term acute care facility. MethodsFrom January 1, 2015, to April 30, 2021, all adult cardiac surgeries were queried and patients discharged to long-term acute care facilities were identified. Baseline characteristics, procedures, and in-hospital complications were compared between long-term acute care facility and non–long-term acute care facility discharges. Random forest analysis was conducted to establish predictors of discharge to long-term acute care facilities. Kaplan–Meier survival analysis was used to determine probability of survival over 7 years. Multivariate regression modeling was used to establish predictors of death after long-term acute care facility discharge. ResultsOf 29,884 patients undergoing cardiac surgery, 324 (1.1%) were discharged to a long-term acute care facility. The long-term acute care facility group had higher rates of urgent/emergency operation (54% vs 23%; 10% vs 3%, P < .001) and longer mean cardiopulmonary bypass (167 vs 110 minutes, P < .001). By random forest analysis, emergency/urgent status, longer cardiopulmonary bypass duration, redo surgery, endocarditis, and history of dialysis were the most predictive of discharge to a long-term acute care facility. Although the non–long-term acute care facility group demonstrated greater than 95% survival at 6 months, Kaplan–Meier survival analysis showed 28% 6-month mortality in the long-term acute care facility cohort. Random forest analysis demonstrated that chronic lung disease and postoperative respiratory complications were significant predictors of death at 6 months after discharge to a long-term acute care facility. ConclusionsPatients with chronic lung and kidney disease undergoing prolonged procedures are at higher risk to be discharged to long-term acute care facilities after surgery with worse survival. Efforts to minimize postoperative respiratory complications may reduce mortality after discharge to long-term acute care facilities.

Effect of Atypical Sleep EEG Patterns on Weaning From Prolonged Mechanical Ventilation

Approximately one-third of acute ICU patients display atypical sleep patterns that cannot be interpreted by using standard EEG criteria for sleep. Atypical sleep patterns have been associated with poor weaning outcomes in acute ICUs. Do patients being weaned from prolonged mechanical ventilation experience atypical sleep EEG patterns, and are these patterns linked with weaning outcomes? EEG power spectral analysis during wakefulness and overnight polysomnogram were performed on alert, nondelirious patients at a long-term acute care facility. Forty-four patients had been ventilated for a median duration of 38days at the time of the polysomnogram study. Eleven patients (25%) exhibited atypical sleep EEG. During wakefulness, relative EEG power spectral analysis revealed higher relative delta power in patients with atypical sleep than in patients with usual sleep (53%vs41%; P< .001) and a higher slow-to-fast power ratio during wakefulness: 4.39 vs2.17 (P< .001). Patients with atypical sleep displayed more subsyndromal delirium (36%vs6%; P= .027) and less rapid eye movement sleep (4%vs11%total sleep time; P< .02). Weaning failure was more common in the atypical sleep group than in the usual sleep group: 91%vs45%(P= .013). This study provides the first evidence that patients in a long-term acute care facility being weaned from prolonged ventilation exhibit atypical sleep EEG patterns that are associated with weaning failure. Patients with atypical sleep EEG patterns had higher rates of subsyndromal delirium and slowing of the wakeful EEG, suggesting that these two findings represent a biological signal for brain dysfunction.

Emergency Surgery, Multimorbidity and Hospital-Free Days: A Retrospective Observational Study

IntroductionAnalyzing hospital-free days (HFDs) offers a patient-centered approach to health services research. We hypothesized that, within emergency general surgery (EGS), multimorbidity would be associated with fewer HFDs, whether patients were managed operatively or nonoperatively. MethodsEGS patients were identified using national Medicare claims data (2015-2018). Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set and stratified by treatment: operative (received surgery within 48 h of index admission) and nonoperative. HFDs were calculated through 180 d, beginning on the day of index admission, as days alive and spent outside of a hospital, an Emergency Department, or a long-term acute care facility. Univariate comparisons were performed using Kruskal–Wallis tests and risk-adjusted HFDs were compared between multimorbid and nonmultimorbid patients using multivariable zero-inflated negative binomial regression models. ResultsAmong 174,891 operative patients, 45.5% were multimorbid. Among 398,756 nonoperative patients, 59.2% were multimorbid. Multimorbid patients had fewer median HFDs than nonmultimorbid patients among operative and nonoperative cohorts (P < 0.001). At 6 mo, among operative patients, multimorbid patients had 6.5 fewer HFDs (P < 0.001), and among nonoperative patients, multimorbid patients had 7.9 fewer HFDs (P < 0.001). When length of stay was included as a covariate, nonoperative multimorbid patients still had 7.9 fewer HFDs than nonoperative, nonmultimorbid patients (P < 0.001). ConclusionsHFDs offer a patient-centered, composite outcome for claims-based analyses. For EGS patients, multimorbidity was associated with less time alive and out of the hospital, especially when patients were managed nonoperatively.

Electronic health record-based readmission risk model performance for patients undergoing outpatient parenteral antibiotic therapy (OPAT).

Outpatient Parenteral Antibiotic Therapy (OPAT) provides coordinated services to deliver parenteral antibiotics outside of the acute care setting. However, the reduction in monitoring and supervision may impact the risks of readmission to the hospital. While identifying those at greatest risk of hospital readmission through use of computer decision support systems could aid in its prevention, validation of such tools in this patient population is lacking. The primary aim of this study is to determine the ability of the electronic health record-embedded EPIC Unplanned Readmission Model 1 to predict all-cause 30-day hospital unplanned readmissions in discharged patients receiving OPAT through the Duke University Heath System (DUHS) OPAT program. We then explored the impact of OPAT-specific variables on model performance. This retrospective cohort study included patients ≥ 18 years of age discharged to home or skilled nursing facility between July 1, 2019 -February 1, 2020 with OPAT care initiated inpatient and coordinated by the DUHS OPAT program and with at least one Epic readmission score during the index hospitalization. Those with a planned duration of OPAT < 7 days, receiving OPAT administered in a long-term acute care facility (LTAC), or ongoing renal replacement therapy were excluded. The relationship between the primary outcome (unplanned readmission during 30-day post-index discharge) and Epic readmission scores during the index admission (discharge and maximum) was examined using multivariable logistic regression models adjusted for additional predictors. The performance of the models was assessed with the scaled Brier score for overall model performance, the area under the receiver operating characteristics curve (C-index) for discrimination ability, calibration plot for calibration, and Hosmer-Lemeshow goodness-of-fit test for model fit. The models incorporating maximum or discharge Epic readmission scores showed poor discrimination ability (C-index 0.51, 95% CI 0.45 to 0.58 for both models) in predicting 30-day unplanned readmission in the Duke OPAT cohort. Incorporating additional OPAT-specific variables did not improve the discrimination ability (C-index 0.55, 95% CI 0.49 to 0.62 for the max score; 0.56, 95% CI 0.49 to 0.62 for the discharge score). Although models for predicting 30-day unplanned OPAT-related readmission performed slightly better, discrimination ability was still poor (C-index 0.54, 95% CI 0.45 to 0.62 for both models). EPIC Unplanned Readmission Model 1 scores were not useful in predicting either all-cause or OPAT-related 30-day unplanned readmission in the DUHS OPAT cohort. Further research is required to assess other predictors that can distinguish patients with higher risks of 30-day unplanned readmission in the DUHS OPAT patients.

Effect of the population health inpatient Medicare Advantage pharmacist intervention on hospital readmissions: A quasi-experimental controlled study

BACKGROUND: The population health inpatient Medicare Advantage pharmacist (PHIMAP) intervention is a pharmacist-led, transitions-of-care intervention that aims to reduce hospital readmissions among Medicare Advantage beneficiaries. PHIMAP includes inpatient pharmacist participation in interdisciplinary rounds, admission and discharge medication reconciliation, pharmacy staff delivery of discharge medications to the bedside, personalized discharge medication lists and counseling, and communication with outpatient pharmacists through an electronic health record. OBJECTIVE: To evaluate the effect of the PHIMAP intervention on unplanned 30-day same-hospital readmissions among Medicare Advantage patients. METHODS: Those included were patients admitted to a large urban academic medical center between May 2018 and March 2020 who had a Medicare Advantage plan and were aged at least 18 years. A 2-group, quasi-experimental design was utilized. Control patients received the usual care, which included a best possible medication history and a postdischarge phone call. A multivariable logistic regression model was estimated to predict unplanned 30-day same-hospital readmissions. This study was a Hypothesis Evaluating Treatment Effectiveness study. RESULTS: In total, 884 patients were included. The majority were White (59.0%), non-Hispanic (87.7%), English speaking (90.5%), and older adults (median age, 75 years; interquartile range, 70-83 years). We detected no statistically significant association between the PHIMAP intervention and unplanned 30-day same-hospital readmissions (odds ratio [OR] = 0.91, 95% CI = 0.56-1.52). After adjusting for patient demographics and clinical covariates, significant predictors of 30-day readmissions included the number of emergency department/inpatient visits within 180 days prior to index admission (OR = 1.40, 95% CI = 1.11-1.77); discharge to a post-acute care facility, such as an inpatient rehabilitation facility, long-term acute care facility, or skilled nursing facility (OR = 1.69, 95% CI = 1.06-2.66); hospital length of stay in days (OR = 1.04, 95% CI=1.01-1.07); and the Agency for Healthcare Research and Quality Elixhauser Comorbidity Index score (OR = 1.01, 95% CI = 1.01-1.02). CONCLUSIONS: Significant predictors of readmissions among Medicare Advantage beneficiaries were consistent with greater illness severity, including a recent history of prior hospital utilization, a discharge to post-acute care facility (vs home), a longer length of hospital stay, and a higher comorbidity burden. Although we detected no statistically significant association between PHIMAP and unplanned 30-day same-hospital readmissions, differences in study group assignment based on the day of hospital discharge (weekend vs weekday) was a noted limitation of this study. Future studies of inpatient pharmacist-led interventions should plan to minimize the risk of selection bias due to differences in the time of patient discharge. DISCLOSURES: This study was supported in part by the National Institute on Aging under award number R01AG058911 (to Pevnick) and the UCLA Clinical Translational Science Institute (UL1 TR001881). The sponsor had no role in the design and conduct of the study, nor the writing of this report.

Abstract TP61: The Prevalence Of Psychiatric Symptoms Of Post-intensive Care Syndrome In Hemorrhagic Stroke Survivors Compared To Other Neurocritical Patients: Preliminary Findings

Background: Post-intensive care syndrome (PICS) consists of cognitive, psychiatric, and physical symptoms associated with intensive care unit (ICU) hospitalization. The occurrence of PICS in neurocritical patients is poorly characterized. We aimed to measure the prevalence of psychiatric symptoms of PICS including depression, anxiety, and post-traumatic stress disorder (PTSD) in hemorrhagic stroke (HS) and other neurocritical patients discharged to a long-term acute care facility. Methods: We reviewed patient data from January 2020 to December 2021 collected as a part of the virtual follow-up visits within 3 months after ICU discharge. Patients were excluded if the evaluation was not possible or denied. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9), anxiety with the General Anxiety Disorder-7 (GAD-7) tool, and PTSD with Post-traumatic Checklist for DSM-5 (PCL-5). PHQ-9 and GAD-7 scores of 5 and more were defined as depression and anxiety. PCL-5 scores of 33 and more were defined as PTSD. Univariate analysis was performed to examine the prevalence of PICS. Pearson’s chi-square test was used to determine the difference in PICS symptoms' prevalence among hemorrhagic stroke survivors and other neurocritical patients. Results: Of the 52 neurocritical patients that had a virtual clinic follow-up, 26 (50%) patients had complete and 11 (21%) incomplete evaluations for depression, anxiety, and PTSD. The prevalence of psychiatric symptoms in this population reached 77% with depression as the most prevalent symptom (61%). The most common neurologic diagnoses were hemorrhagic stroke (33%), acute ischemic stroke (15%), seizures (15%), and status epilepticus (10%). Among hemorrhagic stroke survivors, the prevalence of depression was 56%, anxiety 19%, and PTSD 1%. Other neurocritical patients in 63% of cases had depression, 21% had anxiety, and 9% had PTSD. The prevalence of psychiatric symptoms of PICS in the two groups was not significantly different. Conclusions: Psychiatric symptoms of PICS are as prevalent in hemorrhagic stroke survivors as in other neurocritical patients. Further research is warranted to better understand PICS in this population.

405: A CASE OF CMV POLYRADICULOMYELITIS IN AN IMMUNOCOMPETENT PATIENT

Introduction: Cytomegalovirus (CMV) is a common virus. It can reside latent after primary infection and be reactivated at any time. Reactivation is most common in immunocompromised patients, though it can still occur in immunocompetent patients, often in the ICU in the setting of critical illness and typically limited to pneumonia or viremia. Neurologic infections are less common and primarily in immunocompromised patients. The following case is a unique presentation of polyradiculomyelitis in an immunocompetent patient, caused by CMV reactivation. Description: A 77-year-old male with hypertension was admitted for dyspnea and encephalopathy and treated for pneumonia. Lumbar puncture and head MRI were unremarkable. After 17 days, he was transferred to our institution and required mechanical ventilation for respiratory failure due to mucus plugging. After extubation two days later, he was noted to have new bilateral lower extremity flaccid paralysis and bowel incontinence. MRI revealed transverse myelitis from T6 through the conus medullaris, neuritis of all lumbar nerve roots, and significant cord edema. Repeat lumbar puncture was remarkable for CSF pleocytosis and positive CMV. Serum IgG was also positive for CMV. Findings were felt to be inconsistent with alternative diagnoses, such as multiple sclerosis, neuromyelitis optica, acute inflammatory demyelinating polyneuropathy, or Guillain-Barre. Ganciclovir, foscarnet, and dexamethasone were initiated. Patient ultimately required re-intubation and tracheostomy for inability to clear secretions. There was no improvement in his neurologic status by time of discharge to a long-term acute care facility. Discussion: Neurologic manifestations (meningitis, encephalitis, etc.) from CMV are usually only seen in immunocompromised patients. CMV causing a polyradiculomyelitis (besides the ascending paralysis associated with Guillain-Barre) is rare, especially so in this patient with a normal immune status. This case is uniquely relevant to the intensivist. The patient developed symptoms weeks after admission, indicating that it was likely his critical illness that put him at high risk for reactivation of a latent infection. Additionally, diffuse transverse myelitis placed him at high risk for respiratory compromise and irreversible respiratory failure.

A Case of Paraneoplastic NMOSD With Sarcoma and Unusual Cauda Equina Enhancement

Objective To describe a case of sarcoma associated with NMOSD presenting with myeloradiculitis. Background Neuromyelitis optica is a demyelinating disease of the CNS that predominantly affects the spinal cord and optic nerves. Reports of NMOSD occurring in the setting of cancer suggest that aquaporin-4 autoimmunity may have a paraneoplastic basis. Here, we describe a patient with metastatic sarcoma who tested positive for aquaporin-4 IgG consistent with NMOSD. Design/Methods 66-year-old man with left thigh soft tissue sarcoma with metastasis to the lungs admitted for 2-day history of urinary retention. Neurological exam showed bilateral lower extremity weakness, with decreased patellar reflexes. MRI spine showed cord swelling with enhancement from C6 downwards into the thoracic spine with associated syringohydromyelia and diffuse enhancement of the cauda equina. MRI brain was normal without abnormal enhancement in the optic nerves. CSF analysis demonstrated elevated protein and 0 oligoclonal bands. Was started on methylprednisolone 1 gram daily for 5 days empirically for transverse myelitis. Extensive serum and CSF workup for other causes of myelopathy including rheumatologic, infectious, and nutritional etiologies were unremarkable until NMO IgG antibody came back positive at 1:10000 titer. He had minimal clinical improvement after methylprednisolone course and so was started on plasmapheresis for five days. His weakness improved slightly but continued to have urinary retention. Discharged to a long-term acute care facility on prednisone 60 mg daily with intermittent bladder catheterization and plan for follow-up with Neuroimmunology. Results NA. Conclusions Myeloradiculitis has been reported with anti-MOG disease but is not a typical finding for NMO. We report this case to highlight this unusual finding. In addition, sarcoma is an uncommon cause of paraneoplastic syndromes and to our knowledge, this is the first report of sarcoma being associated with paraneoplastic NMOSD.

Abstract 288: Incidence And Outcomes Of In-hospital Cardiac Arrest Among Pulmonary Arterial Hypertension-related Hospitalizations In The United States

Background: Cardiac arrest is a known complication of Pulmonary arterial hypertension (PAH) often due to acute right heart failure and arrhythmias. However, data on trends in the incidence and in-hospital outcomes of in-hospital cardiac arrest (IHCA) among PAH-related hospitalizations in the US is limited. Hypothesis: IHCA incidence has declined and In-hospital outcomes improved among PAH-related hospitalizations. Methods: We identified hospitalizations with a primary diagnosis of PAH in the nationwide inpatient database between 2010 and 2019, using the appropriate international classification of disease codes. We extracted patients who underwent cardiopulmonary resuscitation for IHCA and evaluated temporal trends in the incidence and in-hospital outcomes using the Cochrane-Armitage test. Logistic regression was used to evaluate factors associated with odds of survival to hospital discharge. Results: We identified 18,772 PAH-related hospitalizations during the study period. The IHCA incidence rate was 1.8% with a mean age (SD) of 62 years (16) and females predominantly affected (62.8%). There was a non-significant decline in IHCA incidence rate between 2010 and 2019 (1.9% vs. 1.2%, P=0.08). The overall survival to hospital discharge rate was 30.4% and this increased significantly during the study period (26.7% vs 36.9%, P = 0.04). Most of the survivors were discharged to a long-term acute care facility (44.2%) and 18.% were discharged home without the need for home health care. Factors associated with lower odds of survival were age &gt; 65 years OR 0.97, 95% CI 0.96 - 0.98, P &lt; 0.001), acute right heart failure (OR 0.74, 95% CI 0.60 - 0.90, P&lt;0.001), acute respiratory failure (OR 0.20, 95% CI 0.16 - 0.24, P &lt; 0.001), and severe comorbidity index (OR 0.83, 95% CI 0.71-0.96, P &lt; 0.001). The presence of shockable rhythm (OR 1.67, 95% CI 1.31 - 2.26, P=0.03) and obesity (OR 1.33, 95% CI 1.02 - 1.72, P=0.03) were associated with higher odds of survival Conclusion: Though IHCA survival among resuscitated PAH-related hospitalizations improved during the 10-year study period in the US, only about 3 out of 10 patients still survive to hospital discharge. Additional studies are warranted to identify strategies that will improve resuscitation outcomes in these patients.

Abstract 289: Temporal Trends In The Incidence And Outcomes Of In-hospital Cardiac Arrest In Patients Hospitalized With Liver Cirrhosis In The Us: Analysis Of The Nationwide Inpatient Sample From 2010-2019

Introduction: Liver cirrhosis affects an estimated 1 in 400 adults in the US with significant morbidity and mortality. There is limited data on the incidence and outcomes of in-hospital cardiac arrest (IHCA) in liver cirrhosis-related hospitalizations. Methods: Using the appropriate international classification of disease codes, we queried the nationwide inpatient database to identify patients hospitalized with a primary diagnosis of liver cirrhosis who experienced IHCA and underwent cardiopulmonary resuscitation, between 2010 and 2019, We evaluated the temporal trends in the in-hospital outcomes using Cochrane -Armitage test, and factors associated with survival to hospital discharge using logistic regression analysis. Results: 7,091,054 weighted liver cirrhosis hospitalizations were identified during the study period. The IHCA incidence rate was 1.4% with a mean age (SD) of 59 years (12) and males were predominantly affected (59.9%). There was an upward trend in IHCA incidence during the study period (1.3% in 2010 to 1.5% in 2019, p &lt; 0.001). The overall survival to hospital discharge rate was 22.2%. No significant change in the mortality trend during the study period. Most of the survivors were discharged to a long-term acute care facility (46.4%) followed by home discharge without the need for home health (24.7%) and short-term acute facilities (12.6%). Factors associated with lower odds of survival to hospital discharge were age &gt; 65 years OR 0.71, 95% CI 0.67 - 0.75, P &lt; 0.001), Black (OR 0.94, 95% CI 0.91 - 0.99, P=0.012) and Hispanic race (OR 0.78, 95% CI 0.74 - 0.81, P &lt; 0.001), and severe comorbidity index (OR 0.63, 95% CI 0.59 - 0.65, P &lt; 0.001). Conclusion: Between 2010 and 2019, we found a slight increase in the IHCA incidence rate among patients hospitalized with liver cirrhosis. Only about one out of 5 patients survived hospital discharge, and this did not change during the study period. Low socioeconomic status and higher comorbidity burden were associated with lower odds of survival. More research is needed to identify strategies that may improve survival outcomes in IHCA among liver cirrhosis patients.

Initial hospital length of stay and long-term survival of patients successfully resuscitated using extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest.

The long-term outcomes of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory ventricular tachycardia/ventricular fibrillation (VT/VF) out-of-hospital cardiac arrest (OHCA) remain poorly defined. The purpose of this study was to describe the hospital length of stay and long-term survival of patients who were successfully rescued with ECPR after refractory VT/VF OHCA. In this retrospective cohort study, the length of index admission and long-term survival of patients treated with ECPR after OHCA at a single centre were evaluated. In a sensitivity analysis, survival of patients managed with left ventricular assist device (LVAD) implantation or heart transplantation during the same period was also evaluated. Between 1 January 2016 and 12 January 2020, 193 patients were transferred for ECPR considerations and 160 underwent peripheral veno-arterial extracorporeal membrane oxygenation cannulation. Of these, 54 (33.7%) survived the index admission. These survivors required a median 16 days of intensive care and 24 days total hospital stay. The median follow-up time of the survivors was 1216 (683, 1461) days. Of all, 79.6 and 72.2% were alive at 1 and 4 years, respectively. Most deaths within the first year occurred among the patients requiring discharge to a long-term acute care facility. Overall survival rates at 4 years were similar in the ECPR and LVAD cohorts (P = 0.30) but were significantly higher for transplant recipients (P < 0.001). This data suggest that the lengthy index hospitalization required to manage OHCA patients with ECPR is rewarded by excellent long-term clinical outcomes in an expert ECPR programme.

Frailty as a predictor of negative outcomes in trauma patients with rib fractures

BackgroundIn patients with rib fractures, adverse outcomes are associated with number of rib fractures; however, studies suggest an association with frailty. We assessed whether frailty, measured using the Canadian Study of Health and Aging clinical frailty scale, was associated with adverse outcomes in this population. MethodsPatients ≥50 years admitted for rib fractures from July 2015 to June 2020 were retrospectively scored for frailty. Demographics, comorbidities, injury information, hospital course, and complications were collected. Univariate analyses were performed to assess significant differences between the fit, prefrail, and frail groups. The association between number of rib fractures and frailty with outcomes was determined. ResultsControlling for age, sex, Injury Severity Score, preadmission anticoagulant, injury mechanism, and comorbidities and nonchest Abbreviated Injury Scores showing significant differences, the number of rib fractures was associated with developing pneumonia (odds ratio = 1.197 [1.076–1.332]; P = .001), hospital length of stay (odds ratio = 1.066 [1.033–1.100], P < .001), mortality (odds ratio = 1.157 [1.048–1.278], P = .004), and discharge to long-term acute care facilities (odds ratio = 1.295 [1.084–1.546], P = .004). Frailty was associated with hospital length of stay (odds ratio = 1.659 [1.059–2.598], P = .027) and discharge to skilled nursing facilities (odds ratio = 5.282 [1.567–17.802], P = .007). ConclusionIn our population, the number of rib fractures was associated with respiratory complications and mortality. Frailty was associated with longer hospitalization and discharge to higher level of care.

ROLE OF VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN SALVAGE THERAPY FOR CENTRAL AIRWAY OBSTRUCTION: A CASE REPORT

ROLE OF VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN SALVAGE THERAPY FOR CENTRAL AIRWAY OBSTRUCTION: A CASE REPORT

Emphysematous Pyelonephritis, Emphysematous Cystitis, and Emphysematous Ureteritis: A Case Report

Emphysematous urinary tract infections (EUTIs) are rare, severe, and suppurative infections affecting various parts of the urinary tract. We report a case of a 75-year-old male presenting with hematuria and generalized weakness withuncontrolled diabetes mellitus (DM) and hypertension. He tested positive for COVID-19on the second day of hospital admission. A non-contrast-enhanced CT of the abdomen and pelvis revealed gas within the left renal parenchyma, walls of the left ureter, and urinary bladder, establishing the diagnosis of EUTIs. The patient was treated using intravenous antibiotics without any surgical intervention, and four weeks later was stable and transported tolong-term acute care (LTAC) facility. DM is the most common risk factor for the development of EUTIs and Escherichia coli is the most common causative pathogen.

Strangulated Paraesophageal Hernia Requiring Laparoscopic Total Gastrectomy

Introduction: Hiatal hernias are classified into four types.1 A type III hiatal hernia is a combination of types I and II where both the fundus and gastroesophageal junction herniate through the hiatus.2 Elective surgical repair is indicated for all types of symptomatic paraesophageal hernias. Emergency repair is indicated when a patient presents with associated obstruction, strangulation, uncontrolled bleeding, or perforation.3 In cases where gastric necrosis occurs, a gastrectomy may be required. A total gastrectomy can be performed either laparoscopically or open. A laparoscopic total gastrectomy has been shown to be a safe procedure with reduced length of stay but requires a well-trained laparoscopic team.4 This video illustrates a laparoscopic total gastrectomy for a necrotic stomach secondary to a gastric necrosis and perforation from an incarcerated paraesophageal hernia. Materials and Methods: A 74-year-old female presented to the emergency department with acute abdominal pain. CT of the abdomen and pelvis showed a type III hiatal hernia with intra-abdominal and intrathoracic free air. She was emergently taken to the operating room for a diagnostic laparoscopy. Intraoperatively, a large strangulated, necrotic, and perforated paraesophageal hernia involving >75% of the stomach was noted. The entire stomach was reduced with 4 cm of intra-abdominal esophagus. The distal esophagus was then transected. The duodenum was then transected distal to the pylorus. The gastric specimen was removed, and the patient was left in discontinuity because of multiple vasopressor requirements. The operation took 151 minutes with 75 mL of blood loss. Results: The patient was on multiple vasopressors throughout the case and transferred to the surgical intensive care unit for postoperative management. The patient underwent renal replacement therapy and was unable to be weaned from vasopressors. She developed severe sepsis-induced coagulopathy and was not medically stable for re-exploration the ensuing day. The patient remained on intravenous antibiotics and antifungals throughout this time. Owing to escalation of care and lack of thoracic surgery at this facility, the patient was transferred to a tertiary center. Over the next week, the vasopressors were discontinued. Bilateral chest tubes and abdominal drains were placed by interventional radiology. On postoperative day 21 from the index case, there was a change in the volume and color of the chest tube output and a CT chest showed an esophageal stump blowout. She subsequently underwent a right video-assisted thoracoscopic surgery wherein a mediastinal abscess was encountered and the distal esophagus was necrotic requiring further resection. On postoperative day 26, she returned to the operating room for placement of jejunostomy feeding tube; however, the abdomen was diffusely frozen and intra-abdominal abscesses were encountered. She remains in discontinuity without enteral access and was discharged to a long-term acute care facility. Conclusion: Strangulated paraesophageal hernias are rare but have significant morbidity when they occur. This case reinforces the need to repair paraesophageal hernias electively before severe complications. Despite the severity of the case, a laparoscopic approach was effective in performing a total gastrectomy in the acute phase and achieving source control. No competing financial interests exist. Runtime of video: 7 mins 4 secs Source: The source of the study was obtained from Trumbull Regional Medical Center. Authors have no conflict of interests or obligations from Trumbull Regional Medical Center. Patient Consent: Authors have received and archived patient consent for video recording and publication in advance of video recording of the procedure.

Admission Frailty Score Are Associated With Increased Risk of Acute Respiratory Failure and Mortality in Burn Patients 50 and Older.

Herein, we assessed the utility of the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS) to predict burn-specific outcomes. We hypothesized that frail patients are at greater risk for burn-related complications and require increased healthcare support at discharge. Patients 50 years and older admitted to our institution for burn injuries between July 2009 and June 2019 were included. Demographics, comorbidities, pre-injury functional status, injury and hospitalization information, complications (graft loss, acute respiratory failure, and acute kidney disease [AKI]), mortality, and discharge disposition were collected. Multivariate analyses were performed to assess the association between admission frailty scored using the CSHA-CFS and outcomes. P < .05 was considered significant. Eight-hundred fifty-one patients were included, 697 were not frail and 154 were frail. Controlling for Baux scores, sex, race, mechanism of injury, 2nd and 3rd degree burn surface, and inhalation injury, frailty was associated with acute respiratory failure (OR = 2.599 [1.460-4.628], P = .001) and with mortality (OR = 6.080 [2.316-15.958]; P < .001). Frailty was also associated with discharge to skilled nursing facility, rehabilitation, or long-term acute care facilities (OR = 3.135 [1.784-5.508], P < .001), and to hospice (OR = 8.694 [1.646-45.938], P = .011) when compared to home without healthcare services. Frailty is associated with increased risk of acute respiratory failure, mortality, and requiring increased healthcare support post-discharge. Our data suggest that frailty can be used as a tool to predict morbidity and mortality and for goals of care discussions for the burn patient.

Clinical epidemiology of carbapenem-resistant Enterobacterales in the Greater Houston region of Texas: a 6-year trend and surveillance analysis

ObjectivesCarbapenem-resistant Enterobacterales (CRE) remain an urgent public health priority in the United States. CRE poses a major threat to patients in healthcare and a potential risk to the community. This study examined the epidemiological trends, clinical, and microbiological data of CRE in the Greater Houston region of Texas. MethodsA multi-institutional retrospective observational study was conducted using surveillance data collected from 2015 to 2020. Predictors of incidence rates of CRE were determined by a negative binomial regression fit using a generalized estimation equation. ResultsOver a 6-year period, 4236 CRE cases were reported, of which Klebsiella pneumoniae accounted for 84.8%. The results show a steady increase in CRE cases, with a sharp rise since 2018. The majority of carbapenemase-producing Enterobacterales were Klebsiella pneumoniae carbapenemase (KPC)-producing (77.2%), followed by other rare carbapenemases, which includes OXA-48, NDM, IMP, VIM, coproduction of KPC with OXA-48, KPC with NDM, and NDM with OXA-48. Acute care hospitals (ACH) accounted for 68.5% of the source of CRE cases. The incidence rate of CRE cases reported from ACH and long-term acute care (LTAC) facilities was 1.16 times that of long-term care facilities (adjusted rate ratio [ARR] = 1.16, 95% confidence interval [CI]:1.04–1.30). The incidence rate of CRE among patients with indwelling devices was 15% (ARR = 0.85, 95% CI: 0.79–0.92) lower than that of patients without indwelling devices. ConclusionThe rise in the rate of CRE cases despite aggressive infection prevention and control strategies in the region is alarming. Evaluating and improving the current infection control strategies may be warranted.

Initiation of a Candida Auris Screening Program at a Large, Academic Medical Center

Background Candida auris is an emerging, multi-drug resistant, fungal pathogen known to cause facility-wide outbreaks, significant mortality, and is environmentally persistent. Rapid identification and isolation of this fungus prevents it from becoming normal flora in the local community. Methods The screening program began on January 25, 2021, at a large, urban, academic medical center. All patients transferred from high-risk facilities (long term acute care (LTAC), acute care, skilled nursing facilities, and nursing homes) from local counties, were screened for Candida auris. Initial screenings were tested via culture. On March 8, 2021, we began screening with a polymerase chain reaction test, which turned around results within one business day. Collection technique of each screening specimen followed guidance from the Centers for Disease Control and Prevention. Patients were placed on contact isolation until results finalized negative. Education was provided to both the healthcare worker and the patient. Partners within Information Technology were able to automate the screening program so that an alert would fire to the nurse in the Emergency Department or Transfer Center for patients meeting high-risk criteria. Results Screening results between 1/25/21 to 3/7/21 resulted in no positive cultures. Between 3/8/21 – 8/31/21, 195 patients were screened for Candida Auris. Three patients resulted positive, for a rate of 1.5%, over the course of 6 months. All positives had recent history of LTAC residency. These results demonstrated a lack of widespread local community transmission of Candida Auris. Conclusions In collaboration with the state health department, we were able to narrow our screening program to only patients directly transferred from LTAC facilities or resided at LTACs within 60 days, thus reducing the need for isolation, impediments to bed flow, and cost for lab testing, all without sacrificing public health. Candida auris is an emerging, multi-drug resistant, fungal pathogen known to cause facility-wide outbreaks, significant mortality, and is environmentally persistent. Rapid identification and isolation of this fungus prevents it from becoming normal flora in the local community. The screening program began on January 25, 2021, at a large, urban, academic medical center. All patients transferred from high-risk facilities (long term acute care (LTAC), acute care, skilled nursing facilities, and nursing homes) from local counties, were screened for Candida auris. Initial screenings were tested via culture. On March 8, 2021, we began screening with a polymerase chain reaction test, which turned around results within one business day. Collection technique of each screening specimen followed guidance from the Centers for Disease Control and Prevention. Patients were placed on contact isolation until results finalized negative. Education was provided to both the healthcare worker and the patient. Partners within Information Technology were able to automate the screening program so that an alert would fire to the nurse in the Emergency Department or Transfer Center for patients meeting high-risk criteria. Screening results between 1/25/21 to 3/7/21 resulted in no positive cultures. Between 3/8/21 – 8/31/21, 195 patients were screened for Candida Auris. Three patients resulted positive, for a rate of 1.5%, over the course of 6 months. All positives had recent history of LTAC residency. These results demonstrated a lack of widespread local community transmission of Candida Auris. In collaboration with the state health department, we were able to narrow our screening program to only patients directly transferred from LTAC facilities or resided at LTACs within 60 days, thus reducing the need for isolation, impediments to bed flow, and cost for lab testing, all without sacrificing public health.

110 Does Discharge to a Post-acute Facility Predispose Burn Patients to a Deterioration of Their Wounds?

IntroductionThe care of burn injuries requiring hospitalization is complex and highly specialized. In-hospital treatment results in discharging patients with stabilized, but unhealed wounds with the need for ongoing care. The expectation is that wounds continue to heal without complication. For patient who are unable to be discharged home, disposition is frequently dictated by finance and payor source. Post-acute facilities such as Skilled Nursing facilities (SNF), Acute Rehabilitation Centers (ARC) and Long-term Acute Care facilities (LTAC) are utilized. The purpose of this study was to evaluate the wound healing in patients being sent to SNF and ARC.MethodsA retrospective chart review of patients discharged to a SNF or ARC over a one-year period was performed. Photographic review was done comparing photos from the first clinic visit to those from hospital discharge. Wounds were designated as “Improved” (IM) or “Worsened/No Change” (W/NC) by a single burn surgeon.ResultsOf the 963 charts reviewed, 719 patients suffered burn injuries, and of these 127 were discharged to post-acute facilities, 54 were either discharged to a LTAC or did not have photos available for review at their first clinic visit. Thus 73 were evaluable. The majority, 51% (n=37) worsened or showed no change (W/NC) and 49% (n=36) improved (IM). All patients returned to clinic within the first 2 weeks of discharge. There were no significance differences for age, gender, BMI, comorbidities, substance abuse, living situation, ICU days, ventilator days, length of stay, number of surgeries, payor source or facility type (SNF vs ARC). Mean TBSA was greater in IM 13.99% vs W/NC 8.31% (p=0.018). There were no significant differences between groups for mechanism, although IM was more likely to have suffered a flame/flash injury (n=20) and W/NC contact burns (n=21). A total of 30 different facilities were utilized for discharge.ConclusionsDespite having smaller burn injuries, the majority of patients worsened if discharged to a post-acute facility. No patient factors were identified that were associated with worsening/no change in wound status at the first clinic visit post discharge. Given the number of discharge facilities utilized, we were unable to analyze the relationship between specific facilities and outcomes. The magnitude of the problem warrants further investigation. A Quality Improvement project is being developed to further identify areas for intervention.