Mean ICU Length Of Stay Research Articles

Implementing a Bedside Percutaneous Tracheostomy and Ultrasound Gastrostomy Team Reduces Length of Stay and Hospital Costs Across Multiple Critical Care Units in a 1500 Bed Tertiary Care Center.

Thousands of critically ill patients every year in the United States receive tracheostomy and gastrostomy procedures. Recent research has investigated the benefits of a combined team approach to these procedures, with associated decreases in length of stay (LOS) and hospital costs. This study's objective was to determine if implementing a bedside percutaneous tracheostomy and percutaneous ultrasound gastrostomy (PUG) team would reduce LOS and hospital costs. Design and Methods: This retrospective chart review compares the impact of implementing an ICU bedside percutaneous tracheostomy and PUG service team to the hospital's previous workflow (ie, pre-implementation). Inclusion criteria were adult patients with Ventilator Dependent Respiratory Failure (VDRF), a clinical indication for both procedures while admitted to the ICU and received both tracheostomy and gastrostomy procedures while admitted to the hospital. Pre- and post-implementation groups were compared across patients' demographics, clinical characteristics, and outcomes. ICU LOS, hospital LOS and total hospital costs were the primary outcome measures. Results: A total of 101 adult critically ill patients were included in the analysis; 49 patients were in the pre-implementation group and 52 patients in the post-implementation group (ie, PUG group). Patients in the PUG group had a significantly shorter mean ICU LOS and hospital LOS, 10.9- and 14.7-day reductions respectively (p = 0.010, p = 0.006). PUG group patients also had a significant reduction in total hospital costs, a per patient cost savings of $34 778 (p = 0.043). Conclusions: This study supports implementing a bedside percutaneous tracheostomy and PUG team to reduce LOS and total hospital costs in patients with VDRF.

Perioperative Anesthetic Considerations for Catheter-Based Pulmonary Vein Interventions in Fibrosing Mediastinitis

IntroductionFibrosing mediastinitis is a rare disease characterized by abnormal proliferation of fibrous tissue, causing compression, and narrowing of the airway, blood vessels and other mediastinal structures, including the pulmonary veins. Catheter based interventions are available palliative strategies. Due to the complex nature of the disease and the profound respiratory and hemodynamic sequela that may ensue, anesthetic management requires meticulous interdisciplinary planning. MethodsWe performed a retrospective descriptive study including patients with Fibrosing Mediastinitis undergoing catheter-based interventions for pulmonary vein stenosis from January 2020 to April 2024. A total of fourteen patients underwent chart review and we reported patient sex, preprocedural pulmonary artery pressures, comorbidities, lung isolation strategies, intra-procedural anesthestic complications, post procedural ICU admissions and length of stayResults: All patients underwent pulmonary vasculature angioplasty, with or without stent placement, under general anesthesia with lung isolation capabilities and echocardiogram guidance. 11 of 18 (61%) cases were uncomplicated. 4 of 18 (22%) required unanticipated postoperative ICU care, 2 (11%) in the setting of pulmonary hemorrhage, one due to hypoxic respiratory failure, and one due to difficult airway. One patient developed self-limiting postoperative hemoptysis in two different occasions and one patient developed a vascular access related complication. Mean hospital length of stay (LOS) was 2.6 days (0-13 days) and mean ICU LOS was 1.75 days (1-4 days). One patient presented 6-weeks postoperatively with massive hemoptysis likely secondary to PV rupture and passed away following a protracted ICU course. ConclusionPatients with FM can achieve successful intraprocedural outcomes by ensuring a comprehensive understanding of the disease, addressing significant anesthetic concerns and considerations, and engaging a multi-disciplinary team.

Comparative Outcomes for Microvascular Free Flap Monitoring Outside the Intensive Care Unit.

There is a trend towards nonintensive care unit (ICU) or specialty ward management of select patients. Here, we examine postoperative outcomes for patients transferred to a general ward following microvascular free flap (FF) reconstruction of the head and neck. Retrospective quality control study. Single tertiary care center. Consecutive patients who underwent FF of the head and neck before and after a change in protocol from immediate postoperative monitoring in the ICU ("Pre-protocol") to the general ward setting ("Post-protocol"). Outcomes included overall length of stay (LOS), ICU LOS, FF compromise, and postoperative complications. A total of 150 patients were included, 70 in the pre-protocol group and 80 in the post-protocol group. There were no significant differences in age, sex, comorbidities, tumor stage, or type of FF. Mean LOS decreased from 8.18 to 7.68 days (P = .4), and mean ICU LOS decreased significantly from 5.2 to 1.7 days (P < .01). There were no significant differences in postoperative or airway-related complications (P = .6) or FF failure rate (2.9% vs2.6%, P > .9). There was a non-significant increase in ancillary consults in the post-protocol group (45% vs 33%, P = .13) and a significant increase in rapid response team calls, a nurse-driven safety net for abnormal vitals or mental status (19% vs 3%, P = .003). We show the successful implementation of a protocol shifting care of FF patients from the ICU to a general ward postoperatively, suggesting management on the floor with less frequent flap monitoring is safe and conserves ICU beds. Additional teaching and familiarity with these patients may over time reduce the rapid response calls.

Same-day discharge after elective open arterial surgery

ObjectiveTo evaluate the feasibility of same-day discharge (SDD) after open peripheral arterial surgery (OAS) in a veteran population. MethodsThis is a single-center, retrospective study. Starting September 2021, veterans who underwent elective OAS were selectively chosen for planned SDD. Eligible procedures included popliteal artery aneurysm repair, common femoral/superficial femoral/popliteal artery endarterectomy ± concurrent endovascular intervention, bypass graft revision, femoral-femoral bypass, and axillofemoral bypass. All patients who underwent eligible procedures were compared across three eras based on the primary location of postoperative admission: intensive care unit era (ICUE, September 2016-December 2018), inpatient ward era (WARDE, January 2019-August 2021), and SDD era (SDDE, September 2021-December 2022). Demographics, comorbidities, indication for procedures, operative times, complications, readmissions, and length of stay (LOS) were analyzed. ResultsNinety-nine male patients underwent eligible procedures during the 6-year study period (ICUE: 32, WARDE; 41, and SDDE: 26). ICUE had higher rates of tobacco use (P = .04) with no differences in age or other comorbidities between the eras. Indications were claudication, bypass graft stenosis, popliteal aneurysm, ischemic rest pain, and tissue loss. Twenty patients were selected for SDD, and 18 were successfully discharged same day. Operative times were not significantly different between the eras. SDDE patients were more likely to undergo monitored anesthesia care (P = .04). The mean LOS was significantly lower in SDDE (0.54 days, P < .001) compared with WARDE (2.9 days) and ICUE (2.8 days). The mean ICU LOS was lower in SDDE (0.2 days, P <.001) compared with ICUE (1.1 days). There was no difference in postoperative complications (P = .30), reoperation (P = .51), or readmission rates (P = .35). ConclusionsSDD is safe and feasible after elective OAS in a veteran population with a low unplanned admission rate.

The impact of hypertonic saline on damage control laparotomy after penetrating abdominal trauma.

The inability to achieve primary fascial closure (PFC) after emergency laparotomy increases the rates of adverse outcomes including fistula formation, incisional hernia, and intraabdominal infection. Hypertonic saline (HTS) infusion improves early PFC rates and decreases time to PFC in patients undergoing damage control laparotomy (DCL) after injury. We hypothesized that in patients undergoing DCL after penetrating abdominal injury, HTS infusion would decrease the time to fascial closure as well as the volume of crystalloid required for resuscitation without inducing clinically relevant acute kidney injury (AKI) or electrolyte derangements. We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey's comparison, and student's t, and Fischer's exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution. Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37h ± 14.21 vs 59.05h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72h, peak sodium (Na) concentration (146.2mEq/L ± 2.94 vs 142.8mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days. HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm. Level III.

Outcomes of Patients With Sepsis and Septic Shock Requiring Source Control: A Prospective Observational Single-Center Study.

Prospective observational study from February 28, 2020, to March 31, 2021. Medical ICU of academic quaternary medical center. Two hundred five adult (≥18 yr) ICU patients. None. Patients were divided into a medical treatment group and a source control group. Patients requiring source control were further divided into early (intervention performed < 24 hr) and late (≥ 24 hr) source control groups. The primary outcomes were 30-day and ICU mortality. Secondary outcomes were ICU and hospital length of stay (LOS), days on mechanical ventilation, and need for renal replacement therapy. A total of 45.9% patients underwent source control. Of these, early source control was performed in 44.7% and late source control in 55.3% of patients. There was no significant difference in 30-day mortality or ICU mortality in the medical versus source control groups or in early versus late source control groups. Compared with the medical group, mean hospital LOS (11.5 vs 17.4 d; p < 0.01) and ICU LOS (5.2 vs 7.7 d; p < 0.01) were longer in the source control group. The hospital LOS (12.5 vs 21.4 d; p < 0.01) and ICU LOS (5.2 vs 9.7 d; p < 0.01) were also longer in patients who had delayed source control than in patients who had early source control. There were no significant differences in other outcomes. Although mortality was similar, patients who had delayed source control had a longer ICU and hospital LOS. Early source control may improve health care utilization in septic shock patients.

The value of compassion: Healthcare savings of palliative care consults in trauma

BackgroundThe effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear. Study DesignWe interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared. Results140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01). Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01). Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01). Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01). Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group. Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01). Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01). ConclusionExpert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.

3 Continuous Renal Replacement Therapy for the Treatment of Burn Shock: A Post Hoc Analysis

IntroductionBurn shock is a consequence of burns that cover ≥20% TBSA and may be complicated by acute kidney injury, which is commonly treated with continuous renal replacement therapy (CRRT). However, early initiation of CRRT has not been clinically evaluated for the treatment of burn shock.MethodsData were obtained from the Renal Replacement Therapy in Severe Burns: A Multicenter Observational Study. In that study, baseline (t0) measurements were taken at the time of CRRT initiation and ~24 (t1) and ~48 (t2) hours thereafter. Patients were included in this analysis if they had ≥20% TBSA and began CRRT within 2 days of injury. Patients were categorized as Group A (began CRRT on same day as injury), Group B (began CRRT on day 1 postburn), and Group C (began CRRT on day 2 postburn). Outcomes measured at t0, t1, and t2 and hospital and ICU length of stay (LOS) were analyzed using generalized linear mixed models. Cox proportional hazards models were used to assess survival to hospital discharge (HD). All models were adjusted, e.g. for age, % full thickness, etc. Burn center was included as a random effect.ResultsMore than half of the 48 patients included were treated at just 2 burn centers. Timing of CRRT initiation varied by center, with all patients at one center starting CRRT on either the day of injury or the day after injury. Nearly 96% of patients had AKI at CRRT start and, of those, 22 were at stage 1 or 2. Patients generally had severe burns; Group A had more inhalation injuries and higher %TBSA, % full thickness, and Baux scores than Groups B and C. Shock index (SI) was persistently elevated across all 3 time points and did not vary by timing of CRRT initiation (p=0.37). Vasopressor dependency index (VDI) was also not associated with timing of CRRT initiation (p >0.99), although mean VDI for Groups B and C declined over time. For all 3 groups, fluid balance decreased from t0, but there were no differences among the groups (all p >0.30). Survival to HD was better for patients with lower TBSA (i.e. 20-49%) compared to those with TBSA ≥50% (hazard ratio=0.37; 95% CI=0.15-0.91). In contrast, timing of CRRT initiation was not associated with survival (p=0.73). Among patients that survived to HD, the mean hospital LOS was shorter for Groups A (13 days; p=0.01) and B (39 days; p=0.03) compared to Group C (131 days). Mean ICU LOS was also shorter for Groups A (13 days; p=0.01) and B (52 days; p=0.03) than for Group C (168 days).ConclusionsIn this analysis, earlier initiation of CRRT did not improve survival to hospital discharge. Nonetheless, starting patients on CRRT early may be advantageous for reducing ICU and hospital LOS for those patients that do survive.

702 Outcomes of COPD Patients with Burn Injuries at a Single Institution

IntroductionChronic obstructive pulmonary disease (COPD) is a condition with significant morbidity and mortality. In 2018, about 16 million adults in the United States reported a diagnosis of COPD based on data from the American Lung Association. Home oxygen is often used in more severe cases of COPD, and despite warnings against smoking while using home oxygen, many patients continue to sustain burn injuries. An existing diagnosis of COPD can further complicate management of a burn patient, especially if there is concomitant inhalation injury present. The objective of this study was to explore the outcomes of COPD patients admitted to our Burn Center.MethodsThis was a single-site, retrospective review using our institutional Burn Center registry. All adult patients with flame burns (18 years or older) admitted to our Burn Center between July 1, 2011 and June 30, 2020 who had a history of COPD with and without home oxygen use were included in this study. All adult patients with flame burns, who did not have a history of COPD, were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), ICU and ventilator days, and mortality.ResultsThere were a total of 4,397 patients with flame burns included in this study, and 515 of those patients were identified to have an existing diagnosis of COPD. The mean age of the COPD group was 45.1 years +/- 13.0 years, and the patient population was predominantly male (60.4%). The mean total body surface area (TBSA) involvement was 5.12% +/- 10.38%. Inhalation injury was present in 10.1% of patients with COPD and in 7.8% of those without COPD. The mean LOS for the COPD group was 11.9 days +/- 19.4 days and 13.4 days +/- 31.0 days for the non-COPD group. The mean ICU LOS for the COPD group was 11.2 days +/- 19.9 days and 18.0 days +/- 37.0 days for the non-COPD group. The mean number of ventilator days was 16.5 days +/- 35.4 days for the COPD group and 26.3 days +/- 42.0 days for the non-COPD group. The overall hospital mortality was 10.3% for the COPD group and 4.3% for the non-COPD group.ConclusionsThis study demonstrates that the overall hospital mortality was highest in the COPD group. Although hospital and ICU length of stay, as well as the number of ventilator days were higher in the non-COPD group, it remains clear that an existing diagnosis of COPD can negatively impact the outcomes of burn patients.

Influenza Vaccine Effectiveness in Preventing Severe Outcomes in Patients Hospitalized with Laboratory-Confirmed Influenza during the 2017-2018 Season. A Retrospective Cohort Study in Catalonia (Spain).

Seasonal influenza is a common cause of hospital admission, especially in older people and those with comorbidities. The objective of this study was to determine influenza vaccine effectiveness (VE) in preventing intensive care admissions and shortening the length of stay (LOS) in hospitalized laboratory-confirmed influenza cases (HLCI) in Catalonia (Spain). A retrospective cohort study was carried out during the 2017–2018 season in HLCI aged ≥18 years from 14 public hospitals. Differences in means and proportions were assessed using a t-test or a chi-square test as necessary and the differences were quantified using standardized effect measures: Cohen’s d for quantitative and Cohen’s w for categorical variables. Adjusted influenza vaccine effectiveness in preventing severity was estimated by multivariate logistic regression where the adjusted VE = (1 − adjusted odds ratio) · 100%; adjustment was also made using the propensity score. We analyzed 1414 HLCI aged ≥18 years; 465 (33%) were vaccinated, of whom 437 (94%) were aged ≥60 years, 269 (57.8%) were male and 295 (63.4%) were positive for influenza type B. ICU admission was required in 214 (15.1%) cases. There were 141/1118 (12.6%) ICU admissions in patients aged ≥60 years and 73/296 (24.7%) in those aged <60 years (p < 0.001). The mean LOS and ICU LOS did not differ significantly between vaccinated and unvaccinated patients. There were 52/465 (11.2%) ICU admissions in vaccinated cases vs. 162/949 (17.1%) in unvaccinated cases. Patients admitted to the ICU had a longer hospital LOS (mean: 22.4 [SD 20.3] days) than those who were not (mean: 11.1 [SD 14.4] days); p < 0.001. Overall, vaccination was associated with a lower risk of ICU admission. Taking virus types A and B together, the estimated adjusted VE in preventing ICU admission was 31% (95% CI 1–52; p = 0.04). When stratified by viral type, the aVE was 40% for type A (95% CI -11–68; p = 0.09) and 25% for type B (95% CI -18–52; p = 0.21). Annual influenza vaccination may prevent ICU admission in cases of HLCI. A non-significantly shorter mean hospital stay was observed in vaccinated cases. Our results support the need to increase vaccination uptake and public perception of the benefits of influenza vaccination in groups at a higher risk of hospitalization and severe outcomes.

Increasing Frailty, Not Increasing Age, Results in Increased Length of Stay Following Vestibular Schwannoma Surgery.

Understand the frailty of vestibular schwannoma surgical patients and how frailty impacts clinical course. Retrospective Cohort. Single-tertiary academic hospital. All patients undergoing vestibular schwannoma surgery. The modified frailty index (mFI) was calculated for all patients undergoing surgery for vestibular schwannoma between 2011 and 2018. Patient demographics and medical history, perioperative course, and postoperative complications were obtained from the medical record. The primary endpoint was hospital length of stay (LOS). Secondary endpoint was postoperative complications. Basic statistical analysis was performed including multivariate linear regressions to determine independent predictors of LOS. There were 218 patients included and the mean age was 48.1 ± 0.9 (range 12-77). One-hundred ten patients were male (50.5%). The mean ICU LOS was 1.6 ± 0.1 days while mean total hospital LOS was 4.3 ± 0.2. There were 145 patients (66.5%) who were robust (nonfrail) with an mFI of 0, while 73 (33.5%) had an mFI of ≥1. Frailty (mFI≥2) was associated with longer hospital LOS compared with the prefrail (p = 0.0014) and robust (p = 0.0004) groups, but was not associated with increased complications (OR = 1.3; 95% CI: 0.5-3.7; p = 0.5925) or ICU LOS (p > 0.05). In multivariate analysis, increased mFI, and NOT increased age, was an independent risk factor for increased hospital LOS (p = 0.027). Increasing frailty, and not increasing age, is an independent risk factor for longer hospital LOS, but not for increased postoperative complications. Patients' frailty status may be useful preoperatively in counselling patients about postoperative expectations and frail vestibular schwannoma patients may require increased health spending costs given their increased hospital LOS.

Comparison of Outcomes of Severe Traumatic Brain Injury in 36,929 Patients Treated with or without Intracranial Pressure Monitoring in a Mature Trauma System

Severe traumatic brain injury (TBI) remains a major cause of morbidity and mortality with mortality rates reaching 35%. Intracranial pressure (ICP) monitoring is used to prevent secondary brain injury and death. However, while the association of elevated ICP and worsened outcomes is accepted, routine ICP monitoring has been questioned after the publication of several studies including the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure trial. We examined whether severe TBI patients in the trauma system of Pennsylvania fared better with or without ICP monitoring. We conducted a statewide retrospective analysis and included all TBI patients >18 years with an admission Glasgow Coma Scale (GCS) <9 from January 2000 through December 2017. The primary outcome was mortality. Secondary outcomes examined were intensive care unit length of stay (LOS) and discharge functional independence measure (FIM). A total of 36,929 patients matched our inclusion criteria and were included in the analysis. Of those, 6025 (16.3%) had ICP monitor placement. Mean ICU LOS was significantly higher in ICP-monitored patients (13.1 ± 11.6 days vs. 6.0 ± 10.8 days, P < 0.0001). Increasing age was a significant predictor of death (P < 0.0001). Mean FIM scores at discharge were significantly higher in patients without an ICP monitor (16.21 ± 4.91 vs. 9.53 ± 5.07, P < 0.0001). When controlling for injury severity score, GCS, age, and craniotomy, ICP monitoring conferred a hazard ratio of 0.85 (χ2= 32.63, P < 0.0001), a 25% reduction of in-hospital mortality compared with non-ICP-monitored patients. We found that ICP-monitored patients had a lower risk of in-hospital mortality. Our findings support the use of ICP monitors in eligible patients.

4 Optimizing Inpatient Management of Acute Pancreatitis: A Single Center Quality Improvement Project

INTRODUCTION: The management of acute pancreatitis has evolved over the last decade with emphasis on early adequate fluid resuscitation, early nutrition, and cholecystectomy prior to hospital discharge in gallstone pancreatitis. Adherence to these metrics reduces mortality, hospital length of stay (LOS), and overall healthcare utilization. We evaluated our institution's current performance and subsequently devised a strategy to improve adherence to quality metrics. METHODS: Patients hospitalized with acute pancreatitis between January, 2017 and October, 2018 were reviewed. Patient demographics, etiology and severity of pancreatitis, rate and type of IV fluid resuscitation, time to initiating nutrition, hospital LOS, ICU LOS, and hospital re-admission rates were examined. An EMR order set for inpatient management of acute pancreatitis was then designed and launched in December, 2018. Follow up data was collected until May, 2019. RESULTS: Our baseline data included 240 hospitalizations for acute pancreatitis of varying etiologies (Figure 1) and severity (Figure 2). The average patient age was 54.3 years and the average BMI was 28.3 (Figure 3). The mean hospital LOS was 6 days. ICU care was needed in 17% of cases. Mean ICU LOS was 4 days. The 30-day hospital re-admission rate was 14%. Adequate IV fluid resuscitation was given in only 25% of cases, with 20% receiving Lactated Ringer's (LR) solution. The average time to starting nutrition was 3 days. Cholecystectomy was performed prior to hospital discharge in 87% of mild gallstone pancreatitis cases. After launch, the EMR order set was used in 19 of 70 hospitalizations for acute pancreatitis (usage rate 27%). Among these patients, 79% received adequate fluid resuscitation, with 84% receiving LR. The average time to starting nutrition was 1.4 days. The mean hospital LOS was 4.4 days. No patients required ICU level care. CONCLUSION: Our baseline data revealed non-adherence to guideline recommendations of adequate fluid resuscitation with LR and early enteral feeding. By designing a customized EMR order set, we improved adequate fluid resuscitation from 25% to 79%, while reducing time to nutrition from 3 days to 1.4 days. Our average hospital LOS decreased from 6 days to 4.4 days, below the national average of 4.7 days. The advent of our EMR order set for acute pancreatitis has helped standardize management and improve outcomes thus far. Further work is needed to increase EMR order set utilization and continue data collection on patient outcomes.

Outcomes and Cost Comparison of Percutaneous Endovascular Aortic Repair versus Endovascular Aortic Repair With Open Femoral Exposure

BackgroundThe objective of this study was to assess cost differences between patients who underwent percutaneous endovascular aortic repair (PEVAR) and open surgical femoral exposure in elective endovascular aortic repair (EVAR) of abdominal aortic aneurysms. Materials and methodsAn IRB-approved single center retrospective analysis of patients who underwent elective EVAR for abdominal aortic aneurysms from 2009 to 2016 was performed. One hundred patients were selected with 50 patients who underwent PEVAR and 50 patients who underwent open surgical femoral exposure. Patient demographics, procedural variables, and hospital outcomes were collected and compared. Primary outcomes assessed used in cost calculations included operating time (OR time), hospital length of stay (LOS), and intensive care unit stay (ICU LOS). Extrapolated cost differences were based on known, published cost multipliers for the primary outcomes observed. ResultsPatients undergoing PEVAR had significant reduction in mean OR time (113.9 min versus 144.9 min, P < 0.001), mean ICU LOS (19.7 h versus 28.9 h, P = 0.094), and overall LOS (28.3 h versus 33.1 h, P = 0.020). There was no statistically significant difference in access related complications, although there was a trend toward less complication rates with PEVAR (0% versus 5%, P = 0.056). Calculated cost of procedures based on mean ICU LOS, hospital LOS, and OR time, showed significant reduction in mean hospital costs with PEVAR ($16,628.5 versus $21,705.8, P < 0.001). Multiple linear regression analysis demonstrated an overall 23% cost reduction with PEVAR. ConclusionsPrior reports comparing PEVAR versus EVAR with open femoral exposures have shown improvement in overall patient time to ambulation and other hospital metrics such as LOS with PEVAR. There is, however, a paucity of overall cost comparison data regarding PEVAR. In this study, adoption of PEVAR was seen to significantly reduce OR times (19%) and overall hospital LOS (50%). The outcomes observed ultimately translated into significant reduction in hospital costs.

Patients Who Underwent Surgery for Blunt Abdominal Aortic Injury Have Higher Risk of Perioperative Mortality, Pneumonia, and Longer Hospital Length of Stay

Introduction: Blunt abdominal aorta injury (AAI) is uncommon and not well studied. This study is intended to determine the outcomes of patients with blunt AAI that were managed conservatively and with surgery. Methods: Adults patients (>18 years) with blunt AAI were identified in National Trauma Databank (NTDB) (2002-2012) using ICD-9 th and CPT codes. Patients with AAI secondary to penetrating injury were excluded. Patients were divided into two groups based on treatment modality (surgery versus observation). Outcomes including perioperative mortality, morbidity and length of stay (LOS) were compared across the groups. Multivariable analysis was performed to adjust for possible confounding factors. Results: There were 975 patients with blunt AAI that were identified and included in the study cohort. Majority of the patients were male (71.9%), mean age was 47 years, and overall mortality was 31%. 202 patients (21%) required surgery while 773 (79%) were managed conservatively. Among the patients who underwent surgery, 81% (n=163) had open surgery and remaining endovascular surgery (n=39). Patients who require surgery had higher injury severity score (ISS) (36.6 vs. 33.5, p=.004), and different mechanism of injury (fall 6% vs. 12.4%, motor vehicle accident 79% vs. 77.6%, p=.009). Perioperative mortality (39.6% vs. 28.2%. p=.002), pneumonia (14.4% vs. 8.4%, p=.011), and amputation (5% vs. 1%, p<.001) were significantly higher in patients who required surgery. Mean hospital LOS (17 vs. 12.4 days, p<.001) and mean ICU LOS (9.9 vs. 6.1 days, p<.001) were also significantly longer in patients that underwent surgery. Patients who were treated with endovascular repair had similar ISS to open repair but had significantly lower risk of mortality (30.8% vs. 41.7%, p=.003). However, those who underwent endovascular repair had higher risk of pneumonia (23.1% vs. 12.3%, p=.005) and amputation (7.7% vs. 4.3%, p=<.001). In multivariable analysis, surgery was independently associated with risk of perioperative mortality (OR 1.8, 95% CI 1.2-2.7, p=.009) and pneumonia (OR 1.8, 95% CI 1.1-3.0, p=.02). Other factors associated with mortality were age (OR 1.1, p<.001) and ISS (OR 1.1, p<.001). Conclusion: Patients with blunt abdominal aortic injury have significant mortality and morbidity. Up to 20% of patients with more severe injuries required surgical repair, and have significantly higher mortality, pneumonia and required longer length of stay compared to those were managed conservatively. Endovascular repair can be associated with better survival than open repair.

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Introduction: The utility of in-house night intensivist coverage remains controversial with conflicting data on its ability to affect ICU metrics. We investigated the effect of a dedicated night critical care service on ICU length of stay (LOS) and mortality before and after the addition of an in-house night critical care attending at a tertiary referral, university hospital with a Level 1 Trauma Center. Methods: After an IRB exemption, we queried the hospital’s database to evaluate adult ICU LOS and mortality data before and after implementation. In-house attending night critical care coverage of at least 15 nights per month began in July 2011, and complete night coverage began in September 2011. Monthly data were counted as prior to the change (October 2009 until June 2011) and post-change (July 2011 to February 2013). Night critical care involves one attending acting as critical care backup on all 72 adult ICU beds. This attending is available and actively involved in resident critical care consultations, procedural supervision and resuscitative care management. No other new ICU initiatives were begun during this interval. Patient demographics, mortality index based on UHC 2012 risk adjustment, and ICU LOS were evaluated using t-tests and Wilcoxon’s rank sum respectively. Results: Total patients included in the study were 10,876, 50% prior to the June 2011 implementation date. Mean expected mortality using 2012 UHC Risk Model was 0.207 prior to June 2011 and 0.227 post implementation for our ICU populations. Mean (±SD) ICU LOS was 4.8 ± 9.3 days prior to July 2011, and 3.9 ± 4.5 thereafter. The overall LOS improvement was 0.8 days [95% CI 0.6–1.1]. LOS decrease per unit: Medical ICU 0.75 days (p<0.01); Neurosurgical ICU 0.22 days (p=0.33); Trauma- Surgical ICU 1.03 days (p<0.01). Overall our ICU UHC mortality index decreased 0.3 from 1.35 to 1.05 (95% CI:0.07–0.53; p<0.01). Conclusions: At our institution implementation of a single, actively involved, night intensivist significantly shortened ICU LOS and reduced mortality.

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Introduction: Insulin infusion therapy (IIT) is commonly used in the hospital setting to manage diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Clinical evidence suggests that both hypoglycemia and glycemic variability experienced while on insulin infusions negatively impacts patient outcomes. To address these concerns our institutional DKA protocol was revised to include evidence-based targets for glycemic control and to emphasize wide safety thresholds via use of an online infusion rate calculator embedded within the electronic medical record. Extensive, targeted outreach efforts were also employed to increase staff education about the new protocol. The aim of this study was to characterize the impact of a conservative-correction DKA protocol on the prevalence of hypoglycemic events, glycemic variability, and hospital length of stay. Methods: This single-center, retrospective cohort study incorporated a before-after design and included all adult patients admitted with a DKA or HHS diagnosis and initiated on a continuous insulin infusion. Outcome data was collected on 100 subjects in the pre-protocol group (October 2010 – October 2012) and 38 subjects in the post-protocol group (March 2013 – July 2013). The primary endpoint was hospital length of stay (LOS) in hours. Other endpoints included mean absolute glucose change (mg/dL/hr), hypoglycemia (blood glucose < 70 mg/dL), severe hypoglycemia (blood glucose < 40 mg/dL), and ICU LOS. Sample size was determined assuming a 25% reduction in hospital LOS with an alpha of 0.05 and power of 80%. Descriptive statistics, Fischer’s exact test, and the paired student t-test were used. Results: A total of 138 subjects with 3187 blood glucose readings were evaluated. Seventy-five (54.3%) of these subjects required admission to the ICU. There was a significant reduction in the risk of hypoglycemia (35% vs. 2.6%) and severe hypoglycemia (4% vs. 0%) when compared to the pre-protocol group. The average number of extreme glucose variability episodes, defined as mean absolute glucose change > 100 mg/dL/hr, were also notably decreased after protocol implementation (3.2 per patient vs. 1.7 per patient). Hospital and ICU length of stay were reduced by 20% and 27% respectively, suggesting that a conservative-correction approach does not delay ketosis resolution or time to discharge. Conclusions: This preliminary data support the hypothesis that a conservative-correction approach to DKA management is safe and effective in minimizing the risk of hypoglycemia and glycemic variability without impacting hospital length of stay.

Pulmonary Mechanics Following Albuterol Therapy in Mechanically Ventilated Infants with Bronchiolitis

Background and aims. Bronchiolitis is a common cause of critical illness in infants. Inhaled β2-agonist bronchodilators are frequently used as part of treatment, despite unproven effectiveness. The purpose of this study was to describe the physiologic response to these medications in infants intubated and mechanically ventilated for bronchiolitis. Materials and methods. We conducted a prospective trial of albuterol treatment in infants intubated and mechanically ventilated for bronchiolitis. Before and for 30 minutes following inhaled albuterol treatment, sequential assessments of pulmonary mechanics were determined using the interrupter technique on repeated consecutive breaths. Results: Fifty-four infants were enrolled. The median age was 44 days (25–75%; interquartile range (IQR) 29–74 days), mean hospital length of stay (LOS) was 18.3 ± 13.3 days, mean ICU LOS was 11.3 ± 6.4 days, and mean duration of mechanical ventilation was 8.5 ± 3.5 days. Fifty percent (n = 27) of the infants were male, 81% (n = 44) had public insurance, 80% (n = 41) were Caucasian, and 39% (n = 21) were Hispanic. Fourteen of the 54 (26%) had reduction in respiratory system resistance (Rrs) that was more than 30% below baseline, and were defined as responders to albuterol. Response to albuterol was not associated with demographic factors or hospitalization outcomes such as LOS or duration of mechanical ventilation. However, increased Rrs, prematurity, and non-Hispanic ethnicity were associated with increased LOS. Conclusions. In this population of mechanically ventilated infants with bronchiolitis, relatively few had a reduction in pulmonary resistance in response to inhaled albuterol therapy. This response was not associated with improvements in outcomes.

S9 Feasibility of establishing a Regional Weaning Unit in Scotland: modelling resource implications and costs

IntroductionIntensive care (ICU) admission is usually mandatory for patients requiring mechanical ventilation (MV). A proportion of patients require prolonged MV (PMV). In other countries, specialised weaning units allow stable PMV...

Impact of a Hospital-Acquired/Ventilator-Associated/Healthcare-Associated Pneumonia Practice Guideline on Outcomes in Surgical Trauma Patients

Evidence-based guidelines for managing nosocomial pneumonia were published in 2005. Subsequently, our surgical critical care service developed and implemented an adaptation of this guideline for use in our surgical trauma intensive care unit (STICU). This study examined outcomes for two STICU cohorts treated for pneumonia before and after guideline implementation. A total of 130 charts were evaluated. The guideline cohort (GC) consisted of 65 patients with pneumonia managed by the surgical critical care service. These patients were prospectively identified for inclusion if they met specified clinical criteria for pneumonia diagnosis. The historical control cohort was identified retrospectively using ICD-9 coding. The primary outcome measure was ICU length of stay (LOS). Secondary outcome measures included overall LOS, mechanical ventilation days, mortality, and total cost of admission. The study was designed to have 80% power to detect a 1-day decrease in mean ICU LOS in a multivariable regression analysis. Descriptive differences were compared using two-sample t tests for continuous variables and chi for categorical variables. Baseline characteristics were not significantly different between cohorts. The multivariable regression analysis indicated a mean decrease of 4.6 days, 9.5 days, and 3.9 days for ICU LOS, overall LOS, and mechanical ventilation days, respectively, in the GC, with an expected mean cost reduction per admission of $23,322 (all significant at p <or= 0.0001). There was a 5% difference in hospital mortality in favor of the GC, but this difference was not statistically significant. The STICU pneumonia practice guideline significantly improved outcomes and cost of care.