LOS Days Research Articles

5 The Predictive Capacity of ASA PS in Burn Patients

Abstract Introduction The four main prognostic models used to determine risk of burn mortality are the revised Baux (rBaux), Belgian Outcome in Burn Injury (BOBI), Abbreviated Burn Severity Index (ABSI), and quick Sequential Organ Failure Assessment (qSOFA). These models fail to factor in medical comorbidities. The ASA PS (American Society of Anesthesiologists Physical Status) is a simple scale incorporating severity of traumatic injury with comorbidities, which strongly predicts mortality in surgical patients. The purpose of this study is to determine whether the ASA PS is an adequate adjunct to measure burn severity. Methods All adults admitted to an ABA verified burn center from January 2016 to April 2019 with TBSA ≥10% who underwent surgery were reviewed. Demographics (age, gender, TBSA, race, ASA PS), vital signs (GCS, blood pressure, respiratory rate), and outcome variables (length of stay [LOS], mechanical ventilation [MV] days, and complications) were evaluated. rBaux, BOBI, ABSI, and qSOFA scores were calculated. The primary outcome was in-hospital mortality. After descriptive statistical analysis, mortality associations of the models were assessed by determining odds ratios. Firth’s logistic regression and area under the receiver operator curves determined the predictive utility of the prognostic scores. Results Of the 183 patients who fit inclusion criteria, median age was 44 years (30–57), and the majority (70%) were male. Median TBSA was 20%, 65% (n=118) had full thickness burns, 14% (n=25) had inhalation injury, and mortality was 9% (n=17). rBaux score was the best predictor of mortality (AUC=.84), ICU LOS (R2=.04), and MV days (R2=.06). For every 10-point increase in rBaux score, there was a 1.7 times increase in mortality (OR=1.7, CI 1.4–2.3, p< .00). The predicted ICU LOS increases from 2.8 to 31.4 days for the lowest and highest rBaux score quartiles. Compared to rBaux scores of 30–53, patients with scores of 54–70 had 4 times more MV days (CI 1.5–11, p< .00). The ASA PS was slightly inferior to rBaux in predicting mortality (AUC=.72), although not statistically significant (p=0.1). As ASA PS score went from I/II to III, III to IV, and IV to V/VI; mortality increased by 2.8 (OR=2.8, CI 1.5–5.5, p< .00). Conclusions rBaux is the best predictor of mortality, ICU LOS, and MV days although ASA PS also predicts mortality. Future studies should determine the combined predictive ability of ASA PS and rBaux. Applicability of Research to Practice rBaux and ASA PS scores can be used to determine risk of mortality in burn patients.

P058: Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: a retrospective cohort study

Introduction: Long-term immobility has detrimental effects for critically ill patients admitted to the intensive care unit (ICU) including ICU-acquired weakness. Early mobilization of patients admitted to ICU has been demonstrated to be a safe, feasible and effective strategy to improve patient outcomes. The optimal mobilization of trauma ICU patients has not been extensively studied. Our objective was to determine the impact of an early mobilization protocol on outcomes among trauma patients admitted to the ICU. Methods: We analyzed all adult trauma patients ( > 18 years old) admitted to ICU over a 2-year period prior to and following implementation of an early mobilization protocol, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared patient characteristics and outcomes (mortality, length of stay [LOS], ventilator days) between the pre- and post-implementation groups. Associations between early mobilization and clinical outcomes were estimated using binary and linear regression models. Results: Overall, there were 526 patients included in the analysis (292 pre-implementation, 234 post-implementation). The study population ranged in age from 18 to 92 years (mean age 49.0 ± 20.4 years) and 74.3% of all patients were male. The pre- and post-implementation groups were similar in age, sex, and injury severity. In-hospital mortality was reduced in the post-implementation group (25.3% vs. 17.5%; p = 0.031). In addition, there was a reduction in ICU mortality in the post-implementation group (21.6% vs. 12.8%; p = 0.009). We did not observe any difference in overall hospital LOS, ICU LOS, or ventilator days between the two groups. Compared to the pre-implementation period, trauma patients admitted to the ICU following protocol implementation were less likely to die in-hospital (OR = 0.52, 95% CI 0.30-0.91; p = 0.021) or in the ICU (OR = 0.40, 95% CI 0.21- 0.76, p = 0.005). Results were similar following a sensitivity analysis limited to patients with blunt or penetrating injuries. There was no difference between the pre- and post-implementation groups with respect to in-hospital LOS, ICU LOS, or the number of ventilator days. Conclusion: We found that trauma patients admitted to ICU during the post-implementation period had decreased odds of in-hospital mortality and ICU mortality. Ours is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol.

Cold-stored whole blood platelet function is preserved in injured children with hemorrhagic shock.

Recent data demonstrate the safety of uncrossmatched cold-stored whole blood (WB) transfusion in pediatric trauma patients. The hemostatic capabilities of platelets within the cold-stored WB unit have been demonstrated via in vitro studies and animal models. However, platelet function has not been evaluated in pediatric recipients of cold-stored WB transfusions. Injured children, 2 years or older and 10 kg or greater with hemorrhagic shock received up to 30 mL/kg of cold-stored, low titer (<50) anti-A and -B, leukoreduced, group O- WB during their initial resuscitation. Patients were included if (1) they received WB and no conventional platelets, and (2) platelet count and thromboelastography maximum amplitude were measured both before and after transfusion. These data and relevant clinical outcomes (mortality, intensive care unit length of stay [LOS], hospital LOS and ventilator days) were compared to a historical cohort of pediatric trauma patients who received uncrossmatched red blood cells (RBC) and conventional room temperature platelets. Twenty-two children were included in the study; 14 in the component cohort versus 8 in the WB cohort. Neither posttransfusion platelet count (129 × 109/L vs. 135 × 109/L) nor function (thromboelastography maximum amplitude, 59.5 mm vs. 60.2 mm) differed significantly between children receiving cold-stored platelets within the WB unit versus children who received conventional warm platelets. Median (interquartile range) weight-adjusted platelet transfusion volume in the historical cohort was 4.6 (2.5-7.7) mL/kg vs. 2.4 (1.3-4.0) mL/kg in the WB cohort (p = 0.03). There was no difference between groups in age, race, mechanism of injury, Injury Severity Score, vital signs, and severe traumatic brain injury (TBI). Outcomes, including mortality, intensive care unit LOS, hospital LOS, and ventilator days, were not significantly different between groups. No difference was seen in posttransfusion platelet number or function in severely injured children receiving cold-stored WB platelets as compared to those receiving conventional room temperature-stored platelets. Larger cohorts are required to confirm these findings. Therapeutic, level IV.

A Pilot Study Using EMR (Electronic Medical Record) and BMT (Bone Marrow Transplant) Registry Data to Evaluate Health Service Utilization in BMT Patients with Depression and Comorbid Conditions at an Academic Cancer Center

Introduction and Objectives Depression has been shown to increase health service utilization in cancer patients. Using data from EMR and BMT Registry we evaluated the impact of depression and comorbidity in BMT patients at our center. Methods A retrospective review of EMR of autologous (AUTO) and allogeneic (ALLO) stem cell transplant patients in UCSD Moores Cancer Center from 2012 to 2017. All diagnoses were defined by ICD-9/ICD-10 codes. Between group differences were assessed by t-test and chi-square test. Negative binomial modeling was performed to evaluate predictors of length of stay in the hospital (LOS) and clinic visits. The analyses were adjusted for age, gender, cancer diagnosis, comorbid conditions, GVHD status (for ALLO patients only) and Charlson Comorbidity Index (CCI). Results A total of 731 patients of whom 22.3% had depression were identified: AUTO Patients (N = 472; 18% Depressed [85]); ALLO patients (N = 259; 30.1% depressed [78]). For the entire population, we compared depressed patients (n = 540) to non-depressed patients (n = 158). Significant differences were observed for LOS (days), clinic visits, and CCI: 59.58+/-49.48 vs. 40.28 (p For AUTO patients, the corresponding LOS, clinic visit, and CCI were 35.31+/-26.14 vs. 25.40+/-22.89 days (p = 0.002), 16.3+/-11.87 vs. 10.77+/-7.29 (p For AUTO patients, depression and infection were significant predictors for increased LOS and frequent clinic visits. For ALLO patients, significant predictors for increased LOS includes COPD and chronic GVHD which was a significant predictor for frequent clinic visits (Table 1). Conclusion Depression and comorbidities had a significant impact on health service utilization. Clinicians and health systems should recognize the importance of providing care in BMT patients with depression and managing comorbid conditions.

PHS80 - Contrasting Utilization of Inpatient Hospitalizations and Emergency Department Visits Between Medicaid and Commercially Insured Arkansans

Arkansas expanded Medicaid coverage for individuals with incomes ≤138% federal poverty level to provide commercial insurance (qualified health plans, QHPs) through premium assistance to non-frail individuals. We compared utilization of inpatient hospitalizations (IH) and emergency department (ED) visits between traditional Medicaid and QHP enrollees. Non-institutionalized, ambulatory, newly enrolled Arkansans aged 18-64 years between 2014-16, with at least 180 days of continuous enrollment in any two consecutive years in either Medicaid or QHP were studied. Two approaches were used: a) propensity score matching (PS) used demographics, Charlson comorbidity index, insurance region, and first-year’s census block median income; b) regression discontinuity (RD) based on a continuous health needs score assessed prior to the plan enrollment. Using PS, the rate (per 10,000 person-years) of IH in follow-up year-1 was higher (mean[SE]: 757.7[23.0] vs. 643.0[22.2], p<0.001), average LOS (days) was lower (year-1:4.7[0.2] vs. 6.2[0.2], p<0.001; year-2:4.4[0.2] vs. 6.2[0.4], p<0.001) in Medicaid vs. QHPs. Similarly, rates (per 100 person-years) of total ED visits (year-1:82.4[1.2] vs. 73.5[1.0], p<0.001; year-2:90.3[1.9] vs. 87.7[1.7], p=0.041), rates of emergent-ED visits (year-1:14.5[0.4] vs. 12.7[0.3], p<0.001; year-2:15.8[0.6] vs. 14.6[0.4], p=0.002), and rate of non-emergent-ED visits were higher (41.6[0.7] vs. 37.1[0.6], p<0.001) in Medicaid. Using RD, the rates of IH (year-1:1663.3[55.7] vs. 528.0[12.8], p<0.001; year-2:1478.0[58.4] vs. 557.3[14.8], p<0.001) and rate of non-emergent-ED visit in year-2 (60.4[1.5] vs. 27.8[0.4], p=0.042) were higher in Medicaid vs. QHPs, but differences in the average LOS (p=0.997), rates of total ED visits (p=0.085) and emergent-ED visits (p=0.415) were not statistically significant. Although enrollment in QHPs was associated with lower rates of IH, these rates increased in QHPs over time and were not materially different from Medicaid in the final year of follow-up. The rates of ED visits, and particularly non-emergent-ED visits, were higher for Medicaid, suggesting better access to physician-based office care in QHPs.

Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes

PurposeStudies suggest that “on-demand” radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied. Materials and methodsThis was a quasi-experimental, pre-post intervention study. Medical directors of two intervention ICUs requested pCXRs be ordered on an on-demand basis at one time point, without controlling or monitoring behavior or providing follow-up. ResultsA total of 11,994 patient days over 18months were included. Combined characteristics: Age: 56.7, 66% male, 96% survival, APACHE II 14 (IQR: 11–19), mechanical ventilation (MV) (occurrences)/patient admission: mean 0.7 (SD: 0.6; range: 0–5), duration (hours) of MV: 21.7 (IQR: 9.8–81.4) and ICU LOS (days): 2.8 (IQR: 1.8–5.6). Average pCXR rate/patient/day before was 0.93 (95% CI: 0.89–0.96), and 0.73 (95% CI: 0.69–0.77) after. Controlling for severity, daily pCXR rate decreased by 21.7% (p<0.001), then increased by about 3%/month (p=0.044). There was no change in APACHE II, mortality, and occurrences or duration of MV, unplanned re-intubations, ICU LOS. ConclusionsIn critically ill adults, pCXR reduction can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic intervention, without adversely affecting patient care, outside a controlled study.

Initial Prealbumin Level and Ability to Normalize Prealbumin Are Highly Predictive of Increased Mortality and Morbidity in Elderly Trauma Patients

SESSION TITLE: Infections in the ICU SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: To study the relationship between malnutrition and outcomes in elderly trauma patients. METHODS: A retrospective data analysis was performed on patients over the age of 65 with ISS greater than 10, admitted to the ICU for over 24 hours. Data obtained included: Age, Gender, RTS, ISS, ICU length of stay (ICU LOS), ventilator days, hospital length of stay (HLOS), survival, initial pre-albumin and ability to correct within 4 days. RESULTS: Of the 200 patients enrolled, patients were divided into 3 groups using initial prealbumin - 71 patients below 5 mg/dL, 101 patients 5-10 mg/dL, and 28 patients greater than 10 mg/dL. Of the 180 patients who were hospitalized for over 4 days, 128 patients achieved normalization of prealbumin while 52 did not. Mean age was 79.2 years. RTS was found to be decreased in patients with initial prealbumin below 5 mg/dL in comparison to the other groups (11.3 vs. 11.8 vs. 11.8, p = 0.0002), with greater ISS (25.1 vs. 18.8 vs. 19.7, p < 0.0001), ICU LOS (days) (11.3 vs. 3.9 vs. 3.0, p < 0.0001), ventilator days (7.9 vs. 0.8 vs. 0.1, p < 0.0001), HLOS (days) (17.4 vs 7.8 vs. 7.1, p < 0.0001) and decreased survival (66% vs. 95% vs. 100%, p < 0.0001). Patients with prealbumin corrected within 4 days had lower ISS (19.9 vs. 29.2, p < 0.0001), as well as reduction in ventilator days (0.9 vs. 10.1, p < 0.0001), ICU LOS (days) (4.2 vs. 13.8, p < 0.0001), HLOS (days) (8.3 vs. 21.3, p < 0.0001) and improved survival (94% vs. 63%, p < 0.0001). CONCLUSIONS: Patients with initial prealbumin below 5 mg/dL had worse clinical outcomes with regards to ICU LOS, HLOS, ventilator days and survival. Correction of prealbumin within 4 days was highly associated with improved outcomes. CLINICAL IMPLICATIONS: Initial prealbumin and ability to normalize is highly predictive of clinical outcomes. DISCLOSURE: The following authors have nothing to disclose: Krishna Akella, Sraavya Akella, Akella Chendrasekhar No Product/Research Disclosure Information

Traumatic colorectal injuries in children: The National Trauma Database experience

PurposeWe sought to utilize a nationwide database to characterize colorectal injuries in pediatric trauma. MethodsThe National Trauma Database (NTDB) was queried for all patients (age≤14years) with colorectal injuries from 2013 to 2014. We stratified patients by demographics and measured outcomes. We analyzed groups based on mechanism, colon vs rectal injury, as well as colostomy creation. Statistical analysis was conducted using t-test and ANOVA for continuous variables as well as chi-square for continuous variables. ResultsThere were 534 pediatric patients who sustained colorectal trauma. The mean ISS was 15.6±0.6 with an average LOS of 8.5±0.5days. 435 (81.5%) were injured by blunt mechanism while 99 (18.5%) were injured by penetrating mechanism. There were no differences between age, ISS, complications, mortality, LOS, ICU LOS, and ventilator days between blunt and penetrating groups. Significantly more patients in the penetrating group had associated small intestine and hepatic injuries as well as underwent colostomies. Patients with rectal injuries (25.7%) were more likely to undergo colonic diversion (p<0.0001), but also had decreased mortality (p=0.001) and decreased LOS (p=0.01). Patients with colostomies (9.9%) had no differences in age, ISS, GCS, transfusion of blood products, and complications compared to patients who did not receive a colostomy. Despite this, colostomy patients had significantly increased hospital LOS (12.1±1.8 vs 8.2±0.5days, p=0.02) and ICU LOS (9.0±1.7 vs 5.4±0.3days, p=0.02). ConclusionAlthough infrequent, colorectal injuries in children are associated with considerable morbidity regardless of mechanism and may be managed without fecal diversion. Level of evidenceIII. Study typeEpidemiology.

Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

We sought proof of concept of a Big Data Solution incorporating longitudinal structured and unstructured patient-level data from electronic health records (EHR) to predict graft loss (GL) and mortality. For a quality improvement initiative, GL and mortality prediction models were constructed using baseline and follow-up data (0-90 days posttransplant; structured and unstructured for 1-year models; data up to 1 year for 3-year models) on adult solitary kidney transplant recipients transplanted during 2007-2015 as follows: Model 1: United Network for Organ Sharing (UNOS) data; Model 2: UNOS & Transplant Database (Tx Database) data; Model 3: UNOS, Tx Database & EHR comorbidity data; and Model 4: UNOS, Tx Database, EHR data, Posttransplant trajectory data, and unstructured data. A 10% 3-year GL rate was observed among 891 patients (2007-2015). Layering of data sources improved model performance; Model 1: area under the curve (AUC), 0.66; (95% confidence interval [CI]: 0.60, 0.72); Model 2: AUC, 0.68; (95% CI: 0.61-0.74); Model 3: AUC, 0.72; (95% CI: 0.66-077); Model 4: AUC, 0.84, (95 % CI: 0.79-0.89). One-year GL (AUC, 0.87; Model 4) and 3-year mortality (AUC, 0.84; Model 4) models performed similarly. A Big Data approach significantly adds efficacy to GL and mortality prediction models and is EHR deployable to optimize outcomes.

Early extubation in pediatric heart surgery across a spectrum of case complexity: Impact on hospital length of stay and chest tube days

Early extubation is increasingly common in congenital heart surgery, but there are limited outcomes data across the spectrum of case complexity. We performed a retrospective review of 201 pediatric operations using cardiopulmonary bypass between 2012 and 2014. Patients extubated in the operating room or immediately on arrival to the ICU were compared to those extubated by traditional protocols. In-hospital mortality, major complications, need for re-intubation, hospital length of stay, and chest-tube days were compared between groups and by Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery (STAT) mortality category. Outcome measures of hospital length of stay and chest tube days were analyzed using multivariable regression modeling. Early extubation subjects were older, weighed more, had shorter bypass and aortic cross-clamp time, more often received caudal anesthesia, and had shorter hospital length of stay and fewer chest tube days. Subjects not extubated early had more chromosomal abnormalities, more preoperative co-morbidities, and had more major complications. Inhospital death, major complications, and re-intubation were rare outcomes for both groups across all STAT categories. Multivariable regression analysis showed that cardiopulmonary bypass time was a significant predictor of hospital length of stay and chest tube days. Hospital LOS and chest tube days were significantly lower for the early extubation group in both the unadjusted and adjusted analyses. Early extubation can be performed safely in congenital heart surgery across a spectrum of case complexity. No increased early mortality or re-intubation was observed with early extubation although there were important differences between the groups that merits further study. The potential benefits of early extubation include decreased hospital length of stay and fewer chest tube days, particularly in young children and patients with long bypass times.

Abstract: Even Better Than the Real Thing? The Use of Xenografting in Pediatric Patients with Scald Injury -- A Single-Institution, 10-Year Review

INTRODUCTION: Scald injuries remain the most common type of burn in children, but best practices continue to evolve. Over 250,000 children are burned each year in the United States, and 100,000 of these are scald burns.1 The use of Xenografting in burns has been described as early as 1880,2 followed by the description of split- or intermediate-thickness skin grafts in 1929.3 Depending on depth of injury, management can range from non-operative wound care to excision and autografting. In 2004, we introduced xenografting for intermediate partial-thickness wounds at our institution. We report our 10-year experience with pediatric scald burns, comparing Xenografting to Autografting. METHODS: Using prospectively collected data submitted to the National Burn Repository, verified by individual chart review, we identified all patients < 18 years old, admitted to our burn center, who sustained scald burns from 2004–2013. Patients were divided into three cohorts, based on wound closure method (Autograft, Xenograft, Non-Op) and compared by two tailed t-test and chi-square analysis. RESULTS: 1867 children with scald burns were admitted from 2004–2013. Compared to Autografting, patients who underwent xenografting had a similar TBSA, but lower incidence of hospital-acquired infections (HAIs), shorter ICU and facility stays, less expensive hospitalizations, and decreased development of hypertrophic scar formation or need for reconstruction. However compared to the Non-Op group, Xenografting patients had a larger TBSA, higher cost, and LOS. CONCLUSIONS: Xenografting appears to be a reasonable option for patients with partial-thickness scald injuries. The cost, LOS, HAIs, and ICU days for the Xenografting cohort fell in-between the Non-Op and Autografting cohorts, as would be expected. While non-operative management may be appropriate for small/superficial burns, and Autografting may be required for large/deep burns, xenografting provides rapid wound closure. Xenografting also permits earlier hospital discharge, reduces need for reconstruction, and should strongly be considered as first line therapy for intermediate-depth pediatric scald injuries. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. “Pediatric Burns Fact Sheet”; The Burn Foundation. http://www.burnfoundation.org/programs/resource.cfm?c=1&a=12. Feb 3rd, 2015. 2. Lee EW. Zoografting in a burn case. Boston Med Surg 1880;103:260. 3. Diegidio P. Chapter 1: The Use and Uses of Large Split Skin Grafts of Intermediate Thickness by Blair VP, and Brown JB (1929) in 50 Studies Every Plastic Surgeon Should Know. Edited by C.S. Hultman. CRC Press, Taylor & Francis Group; Boca Raton, FL (2014).

Implementing a Simple Process for Pre-op Bathing in the Cardiovascular Surgery Population

ISSUE: Urinary Tract Infections [UTIs] are a leading cause of lost treatment opportunities, severe clinical outcomes such as sepsis and shock and increases in patient length of stay [LOS] in the rehabilitation population. PROJECT: Our objectivewas to identify opportunities to reduce UTIs, especially in patients who have indwelling Foley Catheters [FCs]. A UTI Task Force was formed; Study design included a random sampling of patients within the rehabilitation hospital setting who had indwelling FC. National Healthcare Safety Network [NHSN] surveillance definitions for CAUTI were utilized. From 2008 e 2010 biostatical analysis reviewed 150 subject cases. The UTI Task Force interventions included: patient related factors (gender and neurogenic bladder), caregiver related factors (hand washing and device insertion techniques), and system related factors (policies, review policies, competencies, nurse rounding, physician orders and antibiotic usage). RESULTS: At the conclusion of the study there was a 30% decrease in the Number of UTIs in patients who had indwelling catheters (baseline period n1⁄4 156 and intervention period n1⁄4 109) with cost savings of $47,329. Contributing factors placing patients at risk of infection showing statistical significance were: FC usage greater than 6 days (p-value 0.0001) and bladder not fully emptied (pvalue 0.0033). Reducing FC-associated UTIs also shortened the LOS by 53.7% (41 LOS days with FC-associated UTIs as compared to 19 LOS days without UTI) a net decrease in LOS of 22 days.

A perioperative cost analysis comparing single-level minimally invasive and open transforaminal lumbar interbody fusion

Background contextEmerging literature suggests superior clinical short- and long-term outcomes of MIS (minimally invasive surgery) TLIFs (transforaminal lumbar interbody fusion) versus open fusions. Few studies to date have analyzed the cost differences between the two techniques and their relationship to acute clinical outcomes. PurposeThe purpose of the study was to determine the differences in hospitalization costs and payments for patients treated with primary single-level MIS versus open TLIF. The impact of clinical outcomes and their contribution to financial differences was explored as well. Study design/settingThis study was a nonrandomized, nonblinded prospective review. Patient sampleSixty-six consecutive patients undergoing a single-level TLIF (open/MIS) were analyzed (33 open, 33 MIS). Patients in either cohort (MIS/open) were matched based on race, sex, age, smoking status, medical comorbidities (Charlson Comorbidity index), payer, and diagnosis. Every patient in the study had a diagnosis of either degenerative disc disease or spondylolisthesis and stenosis. Outcome measuresOperative time (minutes), length of stay (LOS, days), estimated blood loss (EBL, mL), anesthesia time (minutes), Visual Analog Scale (VAS) scores, and hospital cost/payment amount were assessed. MethodsThe MIS and open TLIF groups were compared based on clinical outcomes measures and hospital cost/payment data using SPSS version 20.0 for statistical analysis. The two groups were compared using bivariate chi-squared analysis. Mann-Whitney tests were used for non-normal distributed data. Effect size estimate was calculated with the Cohen d statistic and the r statistic with a 95% confidence interval. ResultsAverage surgical time was shorter for the MIS than the open TLIF group (115.8 minutes vs. 186.0 minutes respectively; p=.001). Length of stay was also reduced for the MIS versus the open group (2.3 days vs. 2.9 days, respectively; p=.018). Average anesthesia time and EBL were also lower in the MIS group (p<.001). VAS scores decreased for both groups, although these scores were significantly lower for the MIS group (p<.001). Financial analysis demonstrated lower total hospital direct costs (blood, imaging, implant, laboratory, pharmacy, physical therapy/occupational therapy/speech, room and board) in the MIS versus the open group ($19,512 vs. $23,550, p<.001). Implant costs were similar (p=.686) in both groups, although these accounted for about two-thirds of the hospital direct costs in the MIS cohort ($13,764) and half of these costs ($13,778) in the open group. Hospital payments were $6,248 higher for open TLIF patients compared with the MIS group (p=.267). ConclusionsMIS TLIF technique demonstrated significant reductions of operative time, LOS, anesthesia time, VAS scores, and EBL compared with the open technique. This reduction in perioperative parameters translated into lower total hospital costs over a 60-day perioperative period. Although hospital reimbursements appear higher in the open group over the MIS group, shorter surgical times and LOS days in the MIS technique provide opportunities for hospitals to reduce utilization of resources and to increase surgical case volume.

Epidemiology, Management and Outcome Of Priapism In Children and Adolescents With Sickle Cell Disease: A Pediatric Health Information System Database Analysis

BackgroundPriapism is a known but largely understudied complication of sickle cell disease (SCD). The epidemiology of priapism in children and adolescents with SCD is not well characterized especially the pattern of hospitalization. Data are scarce about the role of blood transfusion and surgical therapies in the management of priapism in SCD. Recent expert opinion questions the efficacy of blood transfusion and recommends early urological interventions in these patients (Merritt et al. Can J Emerg Med 2006, Kato GJ. J Sex Med. 2012). As hospitalization consumes lots of economic resources, we studied the trend and outcome of hospitalization for priapism in children with SCD over the last decade. MethodsWe used the Pediatric Health Information System (PHIS), an electronic database of children's hospitals in the US. Patients ≤ 21 years of age with SCD from 33 hospitals from 2000-2011 were analyzed. SCD, priapism and all related conditions were identified by ICD-9 codes. We examined patient demographics, timing of hospitalizations, treatment details, RBC transfusion (simple and exchange transfusion), and urologic procedures (including aspiration and irrigation of corpus cavernosum, corpora cavernosa-corpus spongiosum shunt and corpora-saphenous shunt) and hospital charges. With the inherent skewness of the length of stay and cost data, we used non-parametric analysis when comparing summary statistics. Given the level of over-dispersion, a negative binomial model was used to determine adjusted length of stay and cost. A p-value <.05 was considered statistically significant. ResultsFrom 2000 to 2011, there were 7929 unique male pediatric patients with SCD identified. Among these 465 (5.9%) patients had a diagnosis of priapism and accounted for 1069 priapism related hospitalizations. Overall, the number of new sickle cell patients with priapism getting hospitalized remained stable (Figure 1A). The demographic and baseline characteristics of these patients are shown in Figure 1B. In 63% (673/1069) of the priapism related hospitalizations, patients received conservative treatment whereas blood transfusion, urologic procedures or both were performed in 25.2% (269/1069), 6.6% (71/1069) and 5.2% (56/1069) of the hospitalizations respectively. Five percent (51/1069) of priapism related hospitalizations required ICU care, 1% (15/1069) required mechanical ventilation and there was no in-hospital mortality. Average length of stay for priapism related hospitalization was 3.8 days. Multivariate regression analysis showed that the presence of VOC, ACS, blood transfusion, and urologic procedures were independently associated with increased length of stay and costs (Table 1). Multivariate analysis showed neither transfusion nor urologic procedures were associated with neurological complications observed during priapism related hospitalizations. [Display omitted] Table 1Predictors of length of stay and hospital costs in priapism related hospitalizationsVariableLength of Stay (LOS)Total Hospital CostCoefficientStd. Errorp-valueAdjusted LOS (days)CoefficientStd. Errorp-valueAdjusted Cost (in $1000 dollars)ACS0.4030.101<.00015.840.6640.130<.000117.25VOC0.3790.060<.00015.770.2530.1010.01214.04No Transfusion/Procedurereference----3.57reference----8.04Transfusion-only0.3340.069<.00014.990.4740.107<.000112.91Procedure-only0.2570.0980.0094.610.3570.1110.001311.49Both Transfusion/Procedure0.5730.106<.00016.330.8950.141<.000119.67 ConclusionsIn our largest pediatric in-patient sickle cell cohort, the prevalence of priapism was 5.9%. New inpatient diagnoses of priapism among children with SCD remained constant overtime as previously reported in adult SCD population (Chrouser et al. Am J Surg 2011). Majority of our patients received conservative treatment and urologic procedures were utilized infrequently, again consistent with adult literature. Both blood transfusion and urologic procedures were associated with increased length of stay and costs but not with neurological complications. There is a strong need for prospective, multi-institutional trials to define the role of blood transfusions, surgical procedures and other novel therapies to improve the outcome. Disclosures:No relevant conflicts of interest to declare.

PHP24 - Economic Burden of Inpatient Post-Admission Dehydration – Retrospective Database Analysis in Us

• PAD has a potential to add significant burden to hospital costs and resources. • Adopting strategies aimed at avoiding PAD may help in reducing hospital cost and resource burden and may improve patient outcomes. All patients:  Post-matching 86,398 pairs were identified.  Economic outcomes: • Mean total cost were significantly higher for the PAD group compared to NPAD group($33,945 vs. $22,380, p<0.0001). • Mean costs associated with room & board, central supply, surgery, pharmacy and other miscellaneous departments were also significantly higher for PAD group(all p<0.0001).  Clinical outcomes: • Compared to NPAD group, PAD group had higher mean LOS days(12.9 vs. 8.2, p<0.001) • PAD group also had a higher incidence of CAUTI(0.6 vs. 0.5%) and in-hospital mortality(8.6% vs. 7.8%) (both p<0.05). Sub-group analysis: • 50.2% of PAD patients were surgical patients. • The results for sub-group analysis were also significant for total costs(Medical patients: $22,065 vs. 15,700; Surgical patients: $45,728 vs. $32,091) and LOS days(Medical patients: 11.4 vs. 8.3; Surgical patients: 14.3 vs. 11.4) (all p<0.05).

PTH-126 A Functional Model of of a ‘Seven Day Acute Gastroenterology Service’: Looking Beyond Out-Of-Hours Endoscopy

IntroductionEarly involvement and management by specialists has been shown to have a favourable impact on outcomes in a number of acute medical conditions. Increased patient mortality at weekends has also...

Decreasing ICU LOS, VAP Rates, and Mechanical Ventilator Days Using an Electronic Standardized Wean Screening Tool by the Respiratory Therapist

Decreasing ICU LOS, VAP Rates, and Mechanical Ventilator Days Using an Electronic Standardized Wean Screening Tool by the Respiratory Therapist

Comparison of costs of photodynamic therapy and radiofrequency ablation for management of dysplasia in Barrett's oesophagus: the Aintree experience

IntroductionRecent NICE guidelines suggest offering endoscopic ablative therapy to patients with high-grade dysplasia and intra-mucosal oesophageal carcinoma as an alternative to surgery. Both Photodynamic therapy (PDT) and Radiofrequency ablation (RFA)...

S163 The ‘Obesity Paradox’ in chronic obstructive pulmonary disease

Poor nutritional status in chronic obstructive pulmonary disease (COPD) is associated with increased mortality independently of disease-severity (Collins et al).1 Epidemiological studies have suggested a protective role of obesity against...

P80 Pre-operative assessment of children undergoing scoliosis surgery

IntroductionHistorically, assessment of operative risk in children prior to scoliosis surgery has been largely based on pre-operative lung function testing. Children having scoliosis surgery suffer from a wide range of...