Mean Hospital Length Of Stay Research Articles

End-stage renal disease and lower gastrointestinal bleeding-A propensity-matched analysis of nationwide inpatient sample.

We aim to determine the influence of lower gastrointestinal bleeding (LGIB) on mortality, morbidity, length of hospital stay and resource utilisation in end-stage renal disease (ESRD) patients. The National Inpatient Sample database (2016 &2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of ESRD and LGIB. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS) and total costs between propensity-matched groups of ESRD patients with LGIB versus ESRD patients. We identified 2187954 ESRD patients, of whom 242075 has LGIB, and 1945879 were ESRD patients. The in-hospital mortality was higher in ESRD with LGIB (OR 2.5, 95% CI 1.5-2.2; P=.00). ESRD with LGIB has higher odds of mechanical ventilation (OR 1.4, 95% CI 6.4-16.4; P=.00), and shock requiring vasopressor (OR 1.2, 95% CI 4.9-5.4; P=.002). Advanced age (OR 1.02 CI 1.02-1.03 P=.00), anaemia (OR 1.04 CI 1.59-1.91 P=.006), acute coronary syndrome (OR 1.8 CI 1.6-2.1, P=.00), acute respiratory failure (OR 1.29 CI 2.0-2.6, P=.00), mechanical ventilation (OR 1.9, CI 3.5-4.4, P=.00) and sepsis (OR 1.5, CI 4.1-5.08, P=.00) were identified as predictors of mortality in ESRD with LGIB. Mean LOS (10.8±14.9 vs 6.3±8.5, P<.01) and mean total charges (37054 $ vs 18080 $, P<.01) were also higher. In this propensity-matched analysis, ESRD with LGIB was associated with higher odds of in-hospital mortality, mechanical ventilation and shock requiring vasopressor. Mean LOS and resource utilisation were also higher.

Abstract 13302: The Depression and Anxiety Paradox Following Percutaneous Coronary Intervention: A National Inpatient Sample Analysis

Introduction: Depression and Anxiety are prevalent among patients with cardiovascular diseases. However, their impact on important clinical outcomes, such as length of hospital stay (LOS) and mortality, is incompletely understood. Objective: Examine the magnitude and impact of major depressive disorder (MDD) and anxiety on LOS and in-hospital mortality in patients with acute coronary syndrome (ACS) who undergo percutaneous coronary intervention (PCI). Hypothesis: Patients with MDD or anxiety will have poorer clinical outcomes after PCI. Methods: Data were obtained from the National Inpatient Survey (NIS). Admissions in 2017 with a primary diagnosis of ACS and undergoing PCI were identified based on ICD10 codes. Patients with MDD or anxiety were further delineated with ICD10 codes. The association between MDD or anxiety and LOS and in-hospital mortality was analyzed using linear and logistic regression models, respectively. Various sociodemographic (age, race, sex, income), clinical (history of hypertension, hyperlipidemia, stroke, peripheral artery disease, valvular heart disease, chronic kidney disease, anemia, obesity, smoking) and hospital-level (region, location, payer type) factors were adjusted for in the analysis. Results: Among 130,712 patients admitted for ACS who underwent PCI, the prevalence of MDD and anxiety were 8.7% (n=11,303) and 10.8% (n=14,066), respectively. Patients were on average aged 67 years (SD=13.5), 38% were females, and 73% non-Hispanic White. Overall, the mean LOS was 4.4 days (SD=5.4) and 4.7% of patients died while hospitalized. Patients with MDD (4.6 vs 4.4, p=0.001) or anxiety (4.7 vs 4.4, p=0.001) had longer LOS than those without these conditions. Contrary to our hypothesis, patients with MDD (OR: 0.82; 95% CI: 0.73-0.91) or anxiety (OR: 0.72; 95% CI: 0.64-0.79) had significantly lower odds of mortality than those without MDD or anxiety after adjusting for several factors of prognostic importance. Conclusions: Among ACS patients who underwent PCI, MDD and anxiety were associated with increased LOS but paradoxically lower in-hospital mortality. These findings reinforce the need for future investigations to evaluate the impact of psychological factors on clinical outcomes in ACS patients who undergo PCI.

Bariatric Enhanced Recovery Protocol: a Community Quality Perspective.

Bariatric enhanced recovery protocols can decrease length of stay (LOS) and hospital costs without compromising patient safety. Increased data is needed to compare patient outcomes before and after application of enhanced recovery pathways. We present a bariatric enhanced recovery protocol (BERP) at a community hospital. The objectives were to decrease hospital LOS and reduce schedule II substance use (medications with a high potential for abuse, potentially resulting in psychological or physical dependence), without compromising patient safety. This was a combined retrospective and prospective analysis of all patients undergoing bariatric surgery by two surgeons from September 2016 to April 2018. Mann-Whitney U, Pearson chi-square, and Fisher's exact tests were used to compare demographics, comorbidities, and outcomes. Two hundred patients were evaluated. Overall median (interquartile range) age was 43.0 (36.0-54.0) years and body mass index (BMI) was 45.0 (40.6-50.3) kg/m2. Pre-protocol mean hospital LOS was 2.3days while enhanced recovery protocol patients mean LOS was 1.4days (p < 0.001). Sixty-five percent of BERP patients were discharged on hospital day 1, while no patients prior to the protocol were discharged before hospital day 2. Only 9% of BERP patients were discharged with schedule II medications, compared to 100% of the pre-protocol patients (p < 0.001). Intraoperative, in-hospital, and 30-day complication rates were not statistically significant between the two groups. Community hospitals can reduce length of stay and narcotic prescribing without compromising safety-related outcomes. Significant reductions in the amount of schedule II medications can be achieved when using multimodal enhanced recovery protocol approaches.

Abstract 13403: Relationship Between Body Mass Index and In-hospital Outcomes After Percutaneous Coronary Intervention Among Patients With Acute Myocardial Infarction: A National In-Patient Analysis

Background: Body mass index (BMI), has been shown to be related to major adverse cardiovascular events, and overall mortality after percutaneous coronary intervention (PCI). However, the relationship between BMI, and important cardiovascular outcomes, as well as healthcare utilization have not been extensively explored in a national sample. Objectives: Examine the relationship between BMI and in-hospital mortality, cardiogenic shock, cardiac arrest, length of hospital stay (LOS), and cost of hospitalization. Methods: Adults who had a primary diagnosis of Acute Myocardial Infarction (AMI) who underwent a PCI were identified from the 2016 and 2017 National Inpatient Sample using ICD10 codes. BMI was classified BMI into: &lt;20 kg/m 2 , 20-29.9 kg/m 2 (reference), 30-34.9 kg/m 2 (Obesity class I), 35-39.9 kg/m 2 (Obesity class II) and ≥40 kg/m 2 (Obesity class III). Weighted multivariable logistic and linear regression models were used as appropriate. Results: Among 22,953 patients who had AMI and PCI done with reported BMI, 67.9% were male, and 76.2% were Non-Hispanic White. Compared to the reference group, obesity class I, II and III, showed an incremental higher odd of mortality, while patients with BMI &lt;20 kg/m 2 had non-significant lower odds of mortality (Table). Obesity class I and II had lower odds of cardiogenic shock compared to the reference group, while those in the extremes i.e. &lt;20 kg/m 2 and ≥40 kg/m 2 showed no significant difference (Table).The odds of cardiac arrest were not significantly different across the various BMI categories (Table). Obesity class III patients had significantly higher mean LOS and cost of hospitalization compared to the reference group (Table). Conclusion: Our study highlights the relationship between BMI and important clinical outcomes after PCI. These findings buttress the need for healthcare providers to identify high risk patients for worse outcomes after PCI and institute targeted interventions for improved clinical outcomes.

Outcomes of Clostridioides difficile in Patients with Vitamin D Deficiency: A Propensity-Matched National Inpatient Sample Analysis.

We aimed to determine in-hospital outcomes, length of hospital stay, and resource utilization in a contemporary cohort of Clostridioides difficile infection (CDI) and vitamin D deficiency (VDD). The National Inpatient Sample database for 2016 and 2017 was used for data analysis using International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) codes to identify the patients with the principal diagnosis of CDI and VDD. We assessed the all-cause in-hospital mortality, morbidity, length of hospital stay (LOS), and total costs between propensity-matched groups of CDI without VDD versus CDI with VDD. We identified 202,234 patients with CDI, 4515 of whom were patients with VDD and 197,719 of whom were without VDD. After propensity matching, there was no difference in the in-hospital mortality between the two groups (odds ratio [OR] 1.5, 95% confidence interval [CI] 0.58-4.3; P = 0.90). CDI with VDD has a higher odds of sepsis (OR 1.6, 95% CI 1.3-1.9; P = 0.0), and peritonitis (OR 1.6, 95% CI 1.4-3.8; P = 0.01). Mean LOS (5.9 ± 1.8 vs 5.4 ± 2, P < 0.01) and mean total charges ($11,500 vs $9971, P < 0.04) were higher in CDI with VDD. The factors affecting the LOS were acute coronary syndrome (P = 0.04), mechanical ventilation (P = 0.03), obesity (P = 0.004), acute kidney injury (P = 0.04), and sepsis (P = 0.05). In this large cohort in a propensity-matched analysis, VDD does not increase the in-hospital mortality in CDI. VDD increases the odds of complications with a higher LOS and resource utilization. These findings may be clinically relevant to guide clinicians to routinely monitor vitamin D status and supplement in patients at risk of CDI.

Risk factors for determining length of intensive care unit and hospital stays following correction of cervical deformity: evaluation of early severe adverse events.

Correction of rigid cervical deformities can be associated with high complication rates and result in prolonged intensive care unit (ICU) and hospital stays. In this study, the authors aimed to examine the risk factors contributing to length of stay (LOS) in both the hospital and ICU following adult cervical deformity (ACD) surgery and to identify severe adverse events that occurred in this setting. A retrospective review of ACD patients who underwent posterior-based osteotomies for deformity correction from 2010 to 2019 was performed. Inclusion criteria were cervical kyphosis > 20° and/or cervical sagittal vertical axis (cSVA) > 4 cm. Multivariate analysis was used to identify risk factors independently associated with ICU and hospital LOS. A total of 107 patients were included. The mean age was 63.5 years, and 61.7% were female. Over half (52.3%) underwent 3-column osteotomies, while 47.7% underwent posterior column osteotomies. There was significant correction of all cervical parameters: cSVA (6.0 vs 3.6 cm, p < 0.001), cervical lordosis (8.2° vs -5.3°, p < 0.001), cervical scoliosis (6.5° vs 2.2°, p < 0.001), and T1-slope (40.2° vs 34.5°, p < 0.001). There were also reciprocal changes to the distal spine: thoracic kyphosis (54.4° vs 46.4°, p < 0.001), lumbar lordosis (49.9° vs 45.8°, p = 0.003), and thoracolumbar scoliosis (13.9° vs 11.1°, p = 0.009). Overall, 4 patients (3.7%) suffered aspiration-related complications, 3 patients (2.8%) experienced dysphagia requiring a feeding tube, and 4 patients (3.7%) had compromised airways, with 1 resulting in death. The mean ICU and hospital LOS were 2.8 days and 7.9 days, respectively. Multivariate analysis identified three factors independently associated with longer ICU LOS: female sex (3.0 vs 2.4 days, p = 0.004), ≥ 12 segments fused (3.5 vs 1.9 days, p = 0.002), and postoperative complication (4.0 vs 1.9 days, p = 0.017). These same factors were independently associated with longer hospital LOS as well: female sex (8.3 vs 7.3 days, p = 0.013), ≥ 12 segments fused (9.4 vs 6.2 days, p = 0.001), and complication (9.7 vs 6.7 days, p = 0.026). Posterior-based osteotomies are very effective for the correction of ACD, but postoperative hospital stays are relatively longer than those following surgery for degenerative disease. Risk factors for prolonged ICU and hospital LOS consist of both nonmodifiable (female sex) and modifiable (≥ 12 segments fused and presence of complication) risk factors. Additional multicenter prospective studies will be needed to validate these findings.

S3077 Acute Pancreatitis Without Early Imaging Changes Has Similar Outcomes to Those With Early Changes

INTRODUCTION: Increased use of abdominal computed tomography (CT) in the emergency department (ED) has led to a diagnostic dilemma where patients present with abdominal pain and lipase levels three times the upper limit of normal (ULN) while abdominal imaging may not support a diagnosis of acute pancreatitis (AP). This study seeks to determine whether early imaging findings are associated with change in clinical outcomes in AP patients. METHODS: The study is a single-center, retrospective cohort study with patients from 1/1/2016 to 12/31/2018 presenting to the ED and tested for serum lipase levels (N = 1464). Those with serum lipase of three times ULN (N = 209) and with CT imaging of the abdomen and pelvis with contrast performed in the ED were included in the cohort (N = 93). All charts were reviewed for repeat CT imaging, magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) during admission, bedside index for severity in AP (BISAP) score criteria, intensive care unit (ICU) admission, hospital length of stay (LOS), in-hospital mortality and hospital disposition. Outcome measurements consisted of RR of death, ICU admission, BISAP score >=2, BISAP >=3, inpatient ERCP and median length of hospital stay for patients with CT changes suggesting AP at ED presentation versus those patients with CT not notable for changes of AP. RESULTS: CT findings consistent with AP were associated with a RR for ICU admission of 1.47 [CI: 0.41-5.33, P = 0.55] , RR of 3.79 [CI:0.48-30.20, P = 0.21] for repeat inpatient CT imaging, RR of 0.95 [CI:0.48-2.33, P = 0.89] for MRCP, RR of 1.05 [CI:0.42-2.65, P = 0.91] for ERCP, RR of 0.32 [CI:0.03-3.36, P = 0.34] for death, RR of 0.63 [CI:0.09-4.29, P = 0.64] for non-home disposition, RR of 0.32 [CI:0.03-3.35, P = 0.34] for BISAP >=3, RR of 1.26 [CI:0.52-3.07, P = 0.61) for BISAP >=2. Difference in mean LOS for CT positive AP was 1.73 [CI:0.21-3.67, P = 0.08] 4.7 days versus 2.97 days in CT negative AP. CONCLUSION: Ninety-three out of 209 (44%) patients with lipase levels three times the ULN underwent CT imaging during ED assessment. Relative risk of ICU admission, difference in mean hospital LOS, risk of BISAP≥2 and BISAP≥3, risk of mortality and non-home disposition rate were all statically non-significant. These findings suggest that patients with early CT imaging not showing changes of AP have an unchanged clinical course. Therefore, they should be treated similarly as those with CT imaging displaying AP.

How Standardization of Diagnosing and Treating Decompensated Heart Failure Affects Emergency Department and Hospital Length of Stay Across a Large Healthcare System

Introduction Heart failure (HF) affects more than 6 million Americans and is the most common discharge diagnosis-related group (DRG) among Medicare patients. As greater than 80% of these patients present via the emergency department (ED), it is imperative that decompensated HF (DHF) be differentiated from other medical conditions as quickly as possible to allow for efficient treatment initiation. In this study, we examined the effect of an ED HF protocol involving the triage, diagnosis, and management of DHF with the goal of improving diagnostic accuracy, time to initial diuresis, and length of stay (LOS). Methods : All patients diagnosed with DHF during an ED visit were studied over a 3-month period at two EDs across the Scripps Healthcare system. Quality metrics collected are listed in the accompanying table. Values were compared to a pre-intervention cohort that was treated for DHF at the same sites the year prior. Patients were evaluated in triage, and the HF protocol was initiated if the patient met screening criteria, which included specific complaints such as shortness of breath and/or leg swelling. Once initiated, “Code CHF” was announced. The protocol included a nurse-driven order set, medication reconciliation, and a prompt to the physician to utilize point of care ultrasound (POCUS). If DHF was diagnosed, a protocol dose of diuretic was ordered. The aforementioned metrics were then calculated post discharge. Results : A total of 485 patients were evaluated using the DHF protocol, and 377 patients were evaluated from the year prior. Mean door-to-diuretic (D2D) time decreased by 35 minutes. Mean ED LOS decreased by 1 hour and 34 minutes. Mean hospital LOS decreased by 5 hours. POCUS use increased by 23%. Lasix dose increased by a mean of 13 mg. Medication reconciliation did not change dramatically between the pre and post period. Conclusions/Discussion : This pilot study demonstrates that implementation of a HF protocol aimed at improving diagnostic accuracy and treatment of DHF is feasible in a real-world community ED. Crucially this translates into important quality, patient experience, and cost metrics. Our results are consistent with prior studies showing that a decrease in D2D time, and increase in initial diuretic dosing, are associated with improved LOS. While promising, the simultaneous implementation of several interventions makes it difficult to discern which had the biggest impact on improving the evaluated metrics. The question of sustainability and follow-up ED and hospital admissions is currently being assessed in follow up studies.

How can lean thinking improve ERAS program in bariatric surgery?

Enhanced recovery after bariatric surgery protocol (ERABS) decreased length of hospital stay (LOS) without influencing clinical outcomes. ERABS improved logistics aspects in operating room (OR) with OR time savings. Lean management was used to reorganize OR logistics and to improve its efficiency. This study analyzed clinical and OR logistic aspects in ERABS protocols. Retrospective analysis of prospectively maintained database of obese patients undergoing bariatric surgery from 2017 to 2019 was performed. Since September 2018, patients were treated with ERABS protocol (ERABS group). All patients treated with a standard protocol between January 2017 and September 2018 (control group) were compared to ERABS group. Preoperative (anthropometric data, surgical and medical history) and intraoperative (type of procedure) were analyzed in two groups. LOS was the primary outcomes parameter analyzed; complications, readmissions and reoperations within 30 days were the secondary outcomes. Logistic endpoints were evaluated in time saving and efficiency: surgical time, team work time and total anesthesia time. 471 patients underwent bariatric surgery: 239 patients (control group) compared to 232 patients (ERABS group). ERABS presented more previous surgical history rate (p = 0.04) compared to control group with difference of type of procedure performed (p < 0.001). Roux-en-Y gastric bypass was mainly procedure in both groups (61.1% in control group compared to 52.6% in ERABS groups). Mean LOS was shorter in ERABS (3.16days) compared to control group (4.81days) with no difference in clinical outcomes rate. All logistics endpoints showed a time savings in ERABS group compared to control group (surgical procedure, total anesthesia and team work time, p < 0.001). In multivariate analysis, LOS was associated to ERAS status (IRR 0.722; p < 0.0001), team work time (IRR 1.002; p = 0.002), surgical procedure time (IRR 1.002; p < 0.0001). ERAS status was not associated with complication neither readmission, but surgical procedure time was a factor associated with complication (IRR 1.011; p = 0.0008). This study confirmed that ERABS protocol is safe and a feasible alternative with improved LOS. OR reorganization and logistic efficiency achieved using lean management helped reduce all OR times and these are likely related to the improvement in LOS and complication.

Risk of major cardiovascular and cerebrovascular complications after elective surgery in patients with sleep-disordered breathing: A retrospective cohort analysis.

There is limited and conflicting data on whether sleep-disordered breathing (SDB) is associated with postoperative major cardiovascular and cerebrovascular events (MACCE), and mortality. To determine whether SDB is associated with increased risks of MACCE, mortality and length of hospital stay. Retrospective cohort analysis from the Nationwide Inpatient Sample. Adults who underwent elective abdominal, orthopaedic, prostatic, gynaecological, thoracic, transplant, vascular or cardiac surgery in the United States of America between 2011 and 2014. The study cohort included 1813 974 surgical patients, of whom 185 615 (10.2%) had SDB. Emergency or urgent surgical procedures were excluded. The incidences of MACCE, respiratory and vascular complications, in-hospital mortality and mean length of hospital stay were stratified by SDB. Linear and logistic regression models were constructed to determine the independent association between SDB and outcomes of interest. The incidences of MACCE [25.3 vs. 19.8%, odds ratio (OR) 1.20, P < 0.001] and respiratory complications (11.75 vs. 8.0%, OR 1.43, P < 0.001) were significantly higher in patients with SDB than in those without SDB. SDB was associated with higher rates of atrial fibrillation (14.7 vs. 10.8%, P < 0.001), other arrhythmias (6.0 vs. 5.4%, P < 0.001) and congestive heart failure (9.8 vs. 7.1%, P < 0.001). SDB patients had a lower rate of myocardial infarction (3.1 vs. 3.4%, OR 0.69, P < 0.001), lower mortality (0.6 vs. 1.3%, P < 0.001) and shorter length of hospital stay (4.8 vs. 5.2 days, P < 0.001). SDB was associated with increased risks of MACCE, and respiratory and vascular complications, but had a lower incidence of in-hospital mortality and shorter length of hospital stay.

Patient and Hospital Characteristics of Newborns with Neonatal Withdrawal Syndrome.

We sought to evaluate hospital resource usage patterns and determine risk factors for neonatal withdrawal syndrome (NWS) in the United States. Using the 2016 Kids' Inpatient Database (KID), we conducted a retrospective cross-sectional analysis of a nationally representative sample of neonates with NWS. The KID is the largest publicly available pediatric (20 years of age and younger) inpatient care database in the United States. We analyzed a stratified probability sampling of 3.1 million pediatric hospital discharges weighted to 6.3 million national discharges. Descriptive statistics for hospital and patient characteristics were identified and binary variables were analyzed using the Student t test. Multivariate regression was performed to assess the predictors of NWS. We excluded discharges if total cost or hospital length of stay (LOS) exceeded mean values by >3 standard deviations. Hospitalizations with NWS diagnosis were identified using the International Classification of Diseases, 10th Revision, Clinical Modification code P96.1 in any 1 of 30 discharge diagnostic fields. We estimated that 25,394 pediatric discharges were associated with an NWS diagnosis, totaling 403,127 inpatient days at a cost of $1.8 billion. Compared with non-NWS newborns, neonates with NWS had higher mean hospital charges ($71,540 vs $15,765), longer mean hospital stays (16 days vs 3 days), and a significantly higher proportion of low birth weight (7.2% vs 1.9%), feeding problems (19.0% vs 3.5%), respiratory diagnoses (5.6% vs 2.5%), and seizure (0.3% vs 0.1%). Among newborns with NWS, 53% were boys, 80.0% were white, 7.2% were black, 7.4% were Hispanic, and 5.3% were of other races. Hispanic neonates had the highest mean hospital charges and LOS of any other ethnic group ($123,749, 21 days). The largest proportion (83.0%) of NWS-related hospital stays were billed to Medicaid, followed by private insurance (10.3%) and self-pay (4.8%). More than one-third of NWS-related discharges (39.3%) occurred in areas with the lowest mean household annual income (≤$42,999) compared with 28.4% of neonates without NWS. Most NWS cases (53%) had ≥5 diagnoses, compared with 11% of non-NWS neonates. In the multivariate analysis, neonates with a birth weight <2500 g, feeding problems, respiratory diagnoses, seizure, >4 diagnoses, LOS >5 days, rural hospitals, Medicaid, and low-income households were significantly associated with NWS. There was a statistically significant mean hospital charge difference of $55,775 between NWS and non-NWS neonates. Since 2000, the number of infants treated for NWS in the US neonatal intensive care units has increased fivefold, accounting for an estimated $1.5 billion in annual hospital expenditures. The high hospital resource usage among NWS neonates raises the possibility that care for expectant mothers who use opiates and their newborns may be able to be delivered in a more efficient and effective manner. Because the majority of the study population was covered by Medicaid programs, state policy makers should be mindful of the impact the opioid crises continue to have on expectant mothers and their infants.

Awake breast cancer surgery: strategy in the beginning of COVID-19 emergency

IntroductionCOVID-19 is a declared worldwide pandemic. In our country, due to shortage of hospitals and beds in intensive care unit, oncological and breast cancer (BC) resources are temporarily shifted to COVID-19 patients. In addition, risk of cross-infections should be considered in these frail patients. To accomplish more surgical procedures and to reduce the length of hospital stay (LOS), fast track awake BC surgery should be implemented. The aim of the study is to estimate the effects of surgical shift in our facility during the early COVID-19 outbreak.Materials and methodsFrom 30th January 2020 to 30th of March 2020, 86 consecutive patients were retrospectively enrolled and divided into pre-COVID-19-BC and COVID-19-BC. Clinical parameters and anamnestic data were collected and analyzed. Surgical procedures, relative complications and type of anaesthesia were reported. The effect on surgical time (ST), operative room time (ORT) and length of stay (LOS) were described and examined.ResultsNo statistical difference was found in complications rate, clinical data and surgical procedures (p > 0.05). Awake breast conservative surgery (BCS) was the most frequent procedure in COVID-19-BC (p = 0.006). A statistically significant decrease in ORT and LOS was reported in COVID-19-BC (p = 0.040 and p = 0.0015 respectively), while comparable time resulted for ST (p = 0.976). Mean ORT and LOS reduction were 20.79 min and 0.57 hospital bed days.ConclusionIn the “COVID-19 era”, fast track awake breast surgery provides a reduction of ORT, LOS and potentially surgical treatment for a wider number of oncological patients.

Enhanced recovery after surgery (ERAS) protocol reduces LOS without additional adverse events in spine surgery

BackgroundEnhanced recovery after surgery (ERAS) protocols aim to reduce the physiological stress induced by surgery. These protocols are persistently associated with improved outcomes and reduced costs in several orthopaedic subspecialties. Recently, spine surgery has been explored in the literature as a potential and beneficial domain for ERAS protocols. The aim of this study was to compare the short-term postoperative spine surgery follow-up between patients who underwent the ERAS protocol and those who recovered conventionally. HypothesisThe ERAS protocol developed in our department since 2016 is beneficial to patients undergoing spinal surgery. Patients and methodsA retrospective analysis of data collected prospectively was performed to include all patients who underwent spinal surgery and went through the ERAS protocol in our clinic between January 2017 and January 2018. A control group was paired using a propensity score. Length of hospital stay (LOS), complications, rate of readmissions, postoperative pain, function and satisfaction were compared between the two groups. ResultsA total of 193 patients received the ERAS protocol during the study period. After pairing, 193 couples were selected resulting in a final database of 386 patients for the analysis. There was a significant difference in mean LOS, defined as the average number of days spent in hospital, between the two groups (ERAS group, mean LOS=2.6 days [median 2 days, range 1–7], control group mean LOS=4.4 days [median 4 days, range 2–14]; p<0.0001). Complications, rate of readmissions, postoperative pain, function and satisfaction were similar in the two groups. DiscussionThe ERAS protocol decreased hospital LOS, without resulting in additional adverse events after spinal surgery. These findings support the application of our ERAS protocol after spinal surgery. Level of evidenceIII, retrospective analysis.

Incidence and costs of cardiovascular events in Spanish patients with type 2 diabetes mellitus: a comparison with general population, 2015.

IntroductionCardiovascular (CV) disease affects a high percentage of patients with type 2 diabetes mellitus (T2DM), especially in the hospital setting, impacting on mortality, complications, quality of life and use of health resources. The aim of this study was to estimate the incidence, mean length of hospital stay (LOHS) and costs attributable to hospital admissions due to CV events in patients with T2DM versus patients without diabetes mellitus (non-DM) in Spain.Research design and methodsRetrospective observational study based on the Spanish National Hospital Discharge Database for 2015. Hospital admissions for patients aged ≥35 years with a diagnosis of CV death, non-fatal acute myocardial infarction (AMI), non-fatal stroke, unstable angina, heart failure and revascularization were evaluated. The International Classification of Diseases, Ninth Revision (250.x0 or 250.x2) coding was used to classify records of patients with T2DM. For each CV complication, the hospital discharges of the two groups, T2DM and non-DM, were precisely matched and the number of hospital discharges, patients, LOHS and mean cost were quantified. Additional analyses assessed the robustness of the results.ResultsOf the 276 925 hospital discharges analyzed, 34.71% corresponded to patients with T2DM. A higher incidence was observed in all the CV complications studied in the T2DM population, with a relative risk exceeding 2 in all cases. The mean LOHS (days) was longer in the T2DM versus the non-DM group for: non-fatal AMI (7.63 vs 7.02, p<0.001), unstable angina (5.11 vs 4.78, p=0.009) and revascularization (7.96 vs 7.57, p<0.001). The mean cost per hospital discharge was higher in the T2DM versus the non-DM group for non-fatal AMI (€6891 vs €6876, p=0.029) and unstable angina (€3386 vs €3304, p<0.001).ConclusionsPatients with T2DM had a higher incidence and number of hospital admissions per patient due to CV events versus the non-DM population. This generates a significant clinical and economic burden given the longer admission stay and higher costs associated with some of these complications.

Impact of right ventricular impairment on morbidity and mortality in takotsubo syndrome-a meta-analysis of observational trials.

The impact of right ventricular impairment (RVI) on the morbidity and mortality of patients with Takotsubo syndrome (TTS) is well-debated. We conducted a meta-analysis to evaluate the mortality and morbidity risk associated with RVI compared with those without RVI in patients with TTS. A comprehensive search was performed in PubMed and Embase from inception to April 19, 2019. Our primary outcome of interest was in-hospital and long-term mortality. Other outcomes of interest were acute heart failure, left ventricular systolic function, tricuspid and mitral regurgitation, and length of hospital stay (LOS). We are reporting our outcomes as a cumulative odds ratio (OR). After an initial search, 10 studies with 1210 subjects were included in the quantitative analysis. Mean follow-up was 31months. The odds of in-hospital and long-term mortality in TTS patients with and without RVI were not significantly different (p = 0.13 and 0.40). In TTS patients without RVI, the odds of acute heart failure, and mitral and tricuspid regurgitation were significantly lower at an OR of 0.26 (p < 0.0001), 0.40 (p = 0.0001), and 0.52 (p = 0.02) respectively. TTS patients with RVI had significantly lower mean LVEF (34% vs 41%, p = 0.03) and numerically higher mean LOS (9.5days vs 7.6days, p = 0.52) compared with those without RVI. The presence of RVI represents a severe form of TTS disease spectrum, characterized by severely reduced LVEF, higher incidence of MR and presence of TR. Although there was a trend toward increased in-hospital and long-term mortality, RVI in TTS does not portend worse survival.

PMD44 HEALTHCARE RESOURCE UTILIZATION AND PAYMENTS AMONG PATIENTS RECEIVING TREATMENT FOR ACETABULUM FRACTURES

To estimate the healthcare resource utilization and medical payments among patients receiving treatment for acetabulum fractures in the United States. This retrospective cohort study included IBM® Marketscan® Commercial and Medicare databases. Adult patients (≥18 years) with a diagnosis of acetabulum fracture who received a treatment with an internal fixation device between 2010-2018 were included. The outcome measures included hospital length of stay (LOS), payments for the initial internal fixation hospitalization, and all-cause readmission and reoperation rates and their associated incremental payments over one-year post-acetabulum surgery. Generalized linear regression models controlling for demographic and clinical factors and method of least-squares means were used to calculate adjusted incremental payments for readmission and reoperation. A total of 1,929 patients in the commercial and 330 patients in Medicare databases were identified. The mean (standard deviation, SD) age of the cohort was 43.0 (14.2) years with 72.9% males in commercial and 75.8 (7.4) years with 57.3% males in Medicare. The mean (SD) hospital LOS were 11.6 (10.5) days and 10.4 (8.8) days and the mean payments for initial treatment hospitalization were $104,213 (119,693) and $49,353 (64,968) for commercial and Medicare populations respectively. Over the one-year post-surgery, the rates of readmission were 28.6% and 37.6% and the adjusted incremental payments were $67,871 and $53,830 for commercial and Medicare populations, respectively. The rates of reoperation were 7.7% and 13.3% and the adjusted incremental payments were $57,841 and $29,663 for commercial and Medicare populations, respectively. Patients receiving treatment for acetabulum fractures not only have long length of stay and burdensome medical payments for initial acetabulum procedure but also have high one-year readmission and reoperation rates and associated incremental payments. Treatment options that could reduce unplanned readmissions and reoperations representing significant potential cost savings to both the hospital and the health care system is warranted.

Open Reduction with Internal Fixation (ORIF) versus Hybrid Circular External Fixator (HCEF) as the Treatment of Choice for Bicondylar Tibial Plateau Fractures : A Systematic Review and Meta-Analysis

Bicondylar Tibial Plateu Fractures (BTPF) present a challenge in management due to the involvement of articular surface, resulting in high complication rate. This study aims to compare two treatments, Open Reduction with Internal Fixation (ORIF) and Hybrid Circular External Fixation (HCEF) as the choice of surgical procedure for BTPF that still controversial until now.Discussion:BTPF is a complex and challenging injury associated with severe bone and soft tissue damage which may result in severe morbidity and chronic complications. The minimally invasive procedure offered by HCEF preserves soft tissue and offers lower rate of deep infection. Furthermore, HCEF should be more considered as the treatment of choice for BTPF due to its shorter hospital LoS which may minimalize nosocomial infection risks and costs.Materials and Methods:A systematic review using Cochrane Library, PubMed, and Google Scholar was conducted based on PRISMA guideline. Inclusion criteria were studies comparing HCEF and ORIF of BTPF. Studies of only one surgical technique modality, Schatzker types I-IV Tibial Plateu Fractures, and case reports were excluded, resulting in six included studies. For the meta-analysis of hospital length of stay (LoS), random effect model was used for continuous outcomes using Review Manager 5.3.Results:Most common complications are nerve injuries, infection, and non/delayed union. Blood loss was higher in ORIF group, while both procedures have similar operation time and functional outcome. The mean hospital LoS for ORIF (n = 60) was 18.45, as for HCEF (n =63) was 8.325. There was significant difference in terms of hospital LoS between ORIF and HCEF (P =0.003).Conclusion:ORIF and HCEF carry similar operation time, functional outcome, union rate, and complication, though HCEF is more beneficial in terms of blood loss and hospital LoS.

Comparative efficacy of nebulization with 3% hypertonic saline and 0.9% normal saline in the management of acute bronchiolitis

Background: There is a dearth of therapeutic modalities for the management of bronchiolitis in children. Objective: The objective of the study was to compare the improvement in clinical severity scores and the length of hospital stay (LOS) among children with bronchiolitis nebulized with either 3% hypertonic saline (HS) or 0.9% normal saline (NS). Materials and Methods: A total of 360 hospitalized patients of age 1–24 months, diagnosed as a case of acute bronchiolitis of moderate severity, were randomized to receive either 4 ml of 3% HS (Group A) or 4 ml of 0.9% NS (Group B) along with 1.5 mg of epinephrine in each arm, at 4 hourly intervals till the patients were ready for discharge. Appropriate statistical analysis was carried out using the collected data. Results: All the baseline characteristics were similar in both the groups. There was a significant (p=0.0011) reduction of 13 h (12.2%), i.e., from 4 days 23 h in Group B (NS) to 4 days 10 h in Group A in the mean LOS and significant difference (p=0.0001) in the clinical severity score was noted from the 2nd day onward in Group A as compared to Group B. No adverse events were observed or reported by the treating medical team or the patients’ caregiver in both the study groups. Conclusion: Nebulization with 3% HS is superior to 0.9% NS nebulization in infants with clinically diagnosed acute bronchiolitis.

Trends in Hospitalization and Inpatient Outcomes of Behçet's Disease: A Nationwide Inpatient Sample Study.

ObjectiveAfter an extensive review of the literature, we discovered that no study had addressed trends in hospitalization for people with Behçet's disease (BD). Hence, in this study, we explore multiple variables in patients with BD in the US for the year 2016.MethodsWe analyzed the data relating to hospitalized patients for the year 2016 using the National Inpatient Sample (NIS) database with a listed discharge diagnosis of BD based on the International Classification of Diseases, 10th Revision (ICD-10) diagnosis code M35.2. The mean age in years, alive discharges, lumbar puncture procedures, type of hospital, the Charlson Comorbidity Index (CCI), comorbidities, mean length of stay (LOS) and factors affecting it, and total cost and charges for the admissions were analyzed. A p-value of <.05 was considered statistically significant.ResultsA total of 2,605 discharges with the diagnoses of BD were identified among 35.7 million overall discharges in 2016. Among patients hospitalized with underlying BD, the majority were white and female. The mean hospital LOS was 5.57 ± 0.37 days, which is higher than in the general population and statistically significant (5.57 days vs 4.62 days; p: 0.009). Mean LOS in patients undergoing lumbar puncture was 8.54 ± 2.91 days. Patients with BD had lower medical comorbidity burden (16.9% with a CCI of ≥3) vs the general population (24.67% with a CCI of ≥3) (p: 0.00). Medical comorbidities with a statistically significant difference in their prevalence in the two groups were renal disease, dementia, peptic ulcer disease, heart failure, rheumatologic disorders, malignancy, and dyslipidemia.ConclusionIncreased awareness about this rare condition in an inpatient setting will help in the early identification of the disease and associated complications. This will help caregivers to provide quality care in a timely manner, thereby decreasing the morbidity, mortality, LOS, and hospital costs associated with BD.

Prediction calculator for nonroutine discharge and length of stay after spine surgery

BACKGROUND CONTEXTFollowing spine surgery, delays in referral to rehabilitation facilities leads to increased length of hospital stay (LOS), increases costs, more risk of hospital acquired complications, and decreased patient satisfaction. PURPOSEWe sought to create a prediction calculator to determine the expected LOS after spine surgery and identify patients most likely to need postoperative nonhome discharge. The goal would be to facilitate earlier referral to rehabilitation and thereby ultimately shorten LOS, reduce costs, and improve patient satisfaction. STUDY DESIGNRetrospective. PATIENT SAMPLEWe retrospectively reviewed all adult patients who underwent spine surgery for all indications between January and June 2018. OUTCOME MEASURESLength of stay and discharge disposition. METHODSDemographic variables, insurance status, baseline comorbidities, narcotic use, operative characteristics, as well as postoperative length of stay and discharge disposition data were collected. Univariable and multivariable analyses were performed to identify independent predictors of LOS and discharge disposition. RESULTSTwo hundred fifty-seven patients were included. Mean age was 59 years, 46% were females, and 52% had private insurance vs 7% with Medicaid and 41% with Medicare. The most commonly performed procedure was lumbar fusion (31.9%). Mean LOS after surgery was 4.8 days and 18% had prolonged LOS >7 days. Age, insurance type, marriage status, and surgical procedure were significantly associated with LOS and discharge disposition. The final model had an area under the curve of 89% with good discrimination. A web based calculator was developed: https://jhuspine1.shinyapps.io/RehabLOS/ CONCLUSIONSThis study established a novel pilot calculator to identify those patients most likely to be discharged to rehabilitation facilities and to predict LOS after spine surgery. Our calculator had a high predictive accuracy of 89% compared to others in the literature. With validation this tool may ultimately facilitate streamlining of the postoperative period to shorten LOS, optimize resource utilization, and improve patient care.