Metropolitan Teaching Hospital Research Articles

"It's Just Really Important for us all to be on the Same Page": Qualitative Evaluation of Factors that Influence Written Mobility Communication.

Poor interdisciplinary team communication is a known barrier to increasing inpatient mobility. Understanding why and how clinicians from different disciplines communicate about mobility would help inform communication improvements. This qualitative interview study aimed to describe and explore clinician perceptions about written mobility communication, and perceived barriers and enablers to this communication. A rapid deductive qualitative approach was used to efficiently capture information for local improvement. Clinicians (physical therapists, nurses, physicians, and occupational therapists) working on 3 internal medicine wards in a metropolitan teaching hospital in Brisbane, Australia were purposefully sampled and invited to participate in individual interviews. Questions were based on the Consolidated Framework for Implementation Research. Interviews were recorded, transcribed, and analyzed using deductive and inductive thematic methods. From 17 interviews, key themes identified that written communication about patient mobility is important and valued by clinicians; clinicians learn documentation on the job, often from physical therapists; clinicians are not aware of organizational responsibility for mobility communication; multiple purposes for written communication contribute to multiple locations and inconsistency; and clinicians perceive that improvement would require a multi-disciplinary and multi-level approach. Suggestions for improvement included use of a common language, consistent use of existing bedside communication tools, and clearer responsibility for written communication about mobility. Written communication about patient mobility was valued by clinicians and a range of barriers to effective interdisciplinary communication identified. Clear professional roles and responsibility for written mobility communication is important. Suggestions for improvement included an interdisciplinary language supported by multi-disciplinary education and organizational governance. Written communication about patient mobility is recognized as critical to safe, high-quality hospital care. Our findings suggest that successful mobility communication improvements must involve multiple disciplines and include clear organizational governance to support staff training, clear role responsibilities, and quality monitoring.

Clinical Evaluation of Blood Culture Identification Gram-Positive Panel on Methicillin Resistant Gene Testing in a Large Metropolitan Teaching Hospital

Abstract Introduction The ePlex blood culture identification (BCID) gram-positive panel is a PCR-based approach used for the detection of common pathogens associated with bloodstream infections and corresponding antibiotic-resistance genes. One of the genes, mecA, is associated with methicillin, penicillin, and other penicillin-like-antibiotic-resistant gram-positive bacteria (GPB). It is unclear whether the BCID panel has predictive utility and accuracy in treating hospital infections due to GPB. This retrospective study attempts to determine the consistency and accuracy of BCID gene testing compared to more traditional susceptibility methods at a large public hospital. Method A search query was performed for all BCID results at one teaching hospital in a large metropolitan area for one year (2022). The query included demographic information, BCID results, culture results, and combined susceptibility data. The results were filtered to include only cases in which the mecA gene was detected. The filtered results were then analyzed to determine if the susceptibility results from the susceptibility platform (VITEK) were consistent with the expected susceptibility of the target gene, specifically for oxacillin and vancomycin. The susceptibility cutoff was set as >0.5 mcg/mL and <1 mcg/mL respectively, the standard threshold used at the institution. Results A total of 1211 culture results were obtained, of which the mecA gene was identified by BCID in 321 cases, along with the following GPB: Staphylococcus aureus, Staphylococcus epidermidis, and Staphylococcus sp. (not aureus). The corresponding cultures grew the following isolates: S. aureus, S. epidermidis, S. hominis, and S. haemolyticus. Of the 321 BCID results, 75 were identified as S. aureus. The isolates grew methicillin-resistant Staph aureus (MRSA) (69/75) 92%, while the typical S. aureus grew (6/75) in 8% of the isolates. In these cases, we compared susceptibility testing for both isolates as either sensitive or resistant, with a MIC of >0.5 mcg/mL for oxacillin to be designated as resistant, and <1 mcg/mL to be designated as sensitive to vancomycin. Of the 75 specimens, the concordance rate was 97% (73/75) for oxacillin and 100% (75/75) for vancomycin. The average receipt to verification turnaround time (TAT) was 36 hours for BCID results and 121 hours (about 5 days) for culture sensitivity results. Conclusion The results show that oxacillin resistance can be predicted by detecting S. aureus and the mecA gene using the BCID panel. However, the mecA gene can be identified in other GPB such as S. epidermidis, in which it should not be used to infer oxacillin or vancomycin susceptibilities. In the case of mecA and S. aureus detection by BCID, treating the patient as a MRSA infection may be appropriate before the susceptibilities have been performed. This approach can reduce the turnaround time for antimicrobial resistance reporting and improve antimicrobial stewardship efforts.

Nurse knowledge, attitudes, and barriers to pressure injuries: A cross-sectional study in an Australian metropolitan teaching hospital

Nurse knowledge, attitudes, and barriers to pressure injuries: A cross-sectional study in an Australian metropolitan teaching hospital

Early Electrophysiology in Suspected Acute Guillain-Barré Syndrome: A Prospective Study of Comprehensive Testing.

Electrophysiologic changes in early Guillain-Barré Syndrome (GBS) can be nondiagnostic. Improved testing paradigms may improve hyperacute treatment. This work prospectively evaluated consecutive patients admitted to a metropolitan teaching hospital in Melbourne, Australia, with suspected acute GBS. We performed extensive neurophysiology at three different time points. Novel tests, including cutaneous silent periods, long latency reflexes, and contraction-induced H reflexes, were assessed. Twenty-three participants were studied, including 13 cases of acute GBS. In total, 69% of acute cases of GBS were accurately diagnosed on the first nerve conduction study using published neurophysiologic criteria, with serial studies rarely altering the GBS subtype classification. Antidromic and orthodromic upper limb sensory studies were diagnostically equivalent. A sural sparing pattern was seen in 77% of cases of GBS at the first test. Long latency reflexes and contraction-induced H reflexes testing were abnormal in most participants but were limited by muscle weakness in some. Cutaneous silent periods testing was unobtainable in approximately 50% of cases because of weakness and did not discriminate from mimic disorders. Abnormalities of long latency reflexes and contraction-induced H reflexes may be helpful where initial electrophysiology is nondiagnostic but are nonspecific. Cutaneous silent periods testing seems of limited value. Comprehensive testing provides diagnostic certainty in most cases of GBS from the very first study.

Frequency and potential causes of non-beneficial Code Blue activations at a metropolitan teaching hospital.

Code Blue activations in patients who are not for resuscitation (NFR) may be regarded as non-beneficial and may cause harm to patients, relatives and hospital staff. To estimate the prevalence of non-beneficial Code Blue calls in a metropolitan teaching hospital and identify modifiable factors that could be utilised to reduce these events. The study consisted of two parts: (i) a retrospective analysis of all Code Blue activations over a 12-month period using prospectively collected data. Non-beneficial activations were defined as calls made in patients with a NFR order in either the current or any previous hospital admissions and (ii) an anonymous voluntary survey of staff who were present at a Code Blue activation. There were 186 Code Blue activations over the study period, with 48 (25.8%) defined as non-beneficial. Such patients had more comorbidities, previous hospitalisations and greater levels of frailty. Most non-beneficial calls occurred on general wards and more than three-quarters of patients had been reviewed by a consultant prior to the call. The survey determined that despite ward staff having a considerable degree of resuscitation experience, there were deficiencies in understanding of Code Blue criteria, the resuscitation status of patients under their care and the interpretation of goals of care. Over a quarter of Code Blue calls were deemed non-beneficial. Improving the visibility of NFR status and staff understanding of patient goals of care are needed, along with timely, proactive documentation of NFR status by experienced clinicians.

Utilising an Allied Health Practitioner Capability Audit and Confidence Survey to Identify Implications for Telehealth Safety and Risk-A Chronicle of a Health Service Improvement Activity.

Whilst the benefits of telehealth were identified during the COVID-19 pandemic, we noted barriers to its use at a vital time. Through a health service improvement approach, we sought to increase allied health professional capability in telehealth, but we also sought to understand if there were risks associated with its use. We designed and implemented tools to evaluate allied health professional competence and confidence in using telehealth with private and public patients in a metropolitan teaching hospital setting. With an emphasis on technology capability, we undertook audits over three consecutive years (2020 to 2022) of allied health professional telehealth occasions of service reporting on compliance with the audit criteria and investigating staff confidence in undertaking telehealth sessions using a co-designed survey. The audit tool and confidence survey results were used to identify risk factors to telehealth service delivery using a Modified Health Failure Modes, Effects Analysis. Although confidence levels were relatively high among staff, confidence in managing safety factors and technology risks associated with telehealth were not initially verified by the audit findings. Remedial efforts resulted in service improvements in many identified risk factors, yet technology performance and its troubleshooting remained a primary variable in the ability of staff to comply with the requirements of the real-time audits. Health workers using telehealth should have training to engage safely and effectively in telehealth care and the technology.

Patients in isolation, their physical, environmental and mental health: An exploratory study.

Strict patient isolation in hospital is associated with adverse health outcomes. However, there is a lack of high-quality evidence for effective interventions to improve safety and quality of care for these patients. To identify patient reported areas for improvement in the care of patients in hospital isolation and to determine the feasibility of collecting patient reported outcomes using validated tools. Design An exploratory mixed methods study. Setting A major metropolitan teaching hospital in Melbourne, Australia. Participants Patients in hospital isolation for transmissible infections. Data collection Data were collected by (1) phone interviews with patients in isolation and (2) seven validated measurement tools to assess cognition, loneliness, nutritional status, quality of life, anxiety and depression and physical activity. Data were collected between September and December 2021. Data analysis Interviews were transcribed and analysed using thematic analysis. Quantitative data were analysed descriptively including participant characteristics and outcome data. Participants identified areas for improvement including activities to decrease boredom, more contact with staff to mitigate loneliness and increase comfort care, and formalised communication about clinical treatment and discharge plan. Patients with gastrointestinal symptoms were happier to be alone. There were operational challenges within the health service including delays and miscommunication. Only 70% of the participants completed all questionnaires. This study identified areas for improvement in care of patients in isolation and demonstrated that collecting patient reported outcomes using validated tools was feasible. The results of this research will inform development of an intervention to manage adverse effects. Patients in hospital isolation require additional consideration to ensure that their needs are met to avoid adverse outcomes. The patient experience and comfort can be negatively affected when fundamental care is lacking. EQUATOR guidelines for Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR-RHS). Thirteen patients in hospital isolation agreed to participate in this study, sharing their experiences through interviews and assessment.

#1876 Pre-dialysis nutrition intervention is associated with delayed time to dialysis and survival after initiation of dialysis

Abstract Background and Aims Nutrition intervention (NI) is recommended in multidisciplinary pre-dialysis care as best evidence-based practice. NI aims to preserve kidney function, optimise nutritional status, attain optimal body weight/composition, and control complications and symptoms. However, understanding of its effectiveness on delaying dialysis and survival is limited. This study, Dietary Approaches to Manage Progressive and End stage Renal disease (DAMPER) study aimed to examine the effect of NI on time to dialysis and survival in patients attending a Kidney Disease Education Clinic (KDEC) and receiving structured NI from a dietitian. Method A retrospective clinical cohort study to examine patients who attended a KDEC at a metropolitan teaching hospital April 2002 through December 2019, followed up until December 2021. Associations of time to dialysis and mortality were compared between patients who received NI (NI group) and those who did not (no-NI group). Data were adjusted for baseline characteristics using Cox proportion hazard model, including age, gender, estimated glomerular filtration rate (eGFR), presence of co morbidities (e.g., diabetes mellitus, DM, peripheral vascular disease, PVD), and subjective global assessment (SGA) with score A=well-nourished, B or C=malnourished. Results 1138 patients attended the KDEC, 670 patients commenced dialysis and 538 met inclusion criteria for the study. 64.5% were male, median age 65 years (IQR 57–72), eGFR 15 mL/min/1.73 m2 (IQR 13–19), and prevalence of malnutrition (SGA=B and C) was 28.7%. 342 (63.6%) patients were in the NI group, only 84 (15.6%) had already commenced NI before KDEC. There was no statistical difference for the baseline age, gender, eGFR, PVD and DM (NS). However, prevalence of malnutrition was significantly higher in the non-NI group vs NI group (30.0% vs 28.1%, p = 0.002). By the end of the observation period, 503 (93.5%) patients had commenced dialysis, with 314/342 (91.8%) for the NI group vs 189/196 (96.4%) for the no-NI group (p = 0.037). The NI group reached dialysis significantly later compared to the no-NI group: 28.2 mo (95% CI 25.1–31.3) vs 18.8 mo (95% CI 15.7–22.0), respectively (log rank 0.000; hazard ratio [HR] 0.63; 95% CI 0.51–0.77; p = 0.000). Other factors significantly associated with time to dialysis were eGFR (p = 0.000) and PVD (p = 0.020). Age, gender, presence of malnutrition and diabetes were not associated with time to dialysis (NS). The NI-group was also associated with better survival compared to the no-NI group: time to mortality 116.6 mo (95% CI 106.1–127.2) vs 94.5 mo (95% CI 84.2-104.7), p = 0.001, respectively (log rank 0.005). None of these factors were independently associated with mortality (NS). Conclusion Structured pre-dialysis NI significantly delayed time to dialysis and reduced mortality risk in people with chronic kidney disease. Timely referral to NI is recommended in pre-dialysis care and KDEC provides an important platform for dietitians to initiate NI.

Abstract 3823: Clinical outcomes of uveal melanoma patients in the emergency department

Abstract Purpose: Uveal melanoma is a rare ocular malignancy that has not been well characterized at a large scale. Specifically, uveal melanoma diagnosis and outcomes in the emergency department (ED) has not been characterized. Methods: The Nationwide Emergency Department Sample was queried from the last quarter of 2015 to 2019 to identify patients with a primary diagnosis of uveal melanoma. Multivariable logistic regression, with patient- and hospital-level characteristics as covariates, was used to identify factors associated with increased risk of inpatient admission. Results: From the last quarter of 2015 to 2019, there were 1,274 ED encounters with a primary diagnosis of uveal melanoma. Most patients were less than 11 years old (43.4%), male (51.1%), or a Medicaid beneficiary (37.8%), and most belonged to a family in the lowest income quartile (32.0%). The median age of these patients was 35 years (IQR: 2-64). Most patients presented to hospitals in the South (53.9%), with a Trauma Level I designation (51.4%), and most to a metropolitan teaching hospital (89.1%). The most common ED outcomes were same-day discharge (61.6%) and admission to the inpatient setting (31.2%). Patients presenting to Trauma Level I hospitals were most likely to be admitted (odds ratio [OR]=2.21; p=0.031). The factors that were most significantly associated with decreased odds of inpatient admission were: patients who were not charged for services (often due to charity) (OR=0.13; p=0.040), Medicaid beneficiaries (OR=0.27; p=0.031), and private insurance beneficiaries (OR=0.34; p=0.047). Among the admitted patients, patients can be discharged to home with self-care (76.2%) or with home-health care (14.9%) or can be transferred to an intermediate-care facility (8.1%). The mean hospital length of stay was 5.7±0.6 days. In-hospital mortality rate for admitted patients was very low (0.8%). Conclusion: Uveal melanoma patient outcomes are closely related to insurance status, indicating socioeconomic factors as a modulator of patient outcomes. Citation Format: Alice A. Beneke, Kamil Taneja, Lauren Ladehoff, Kevin Root, Eric Toloza. Clinical outcomes of uveal melanoma patients in the emergency department [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3823.

Abstract 6480: In-hospital mortality risk factors for uveal melanoma patients in the emergency department

Abstract Purpose: A considerable amount of uveal melanoma patients present to the emergency department (ED) for a complication related to their primary tumor. However, there is not much research into the primary reasons for these patients to present to the ED and their outcomes. Methods: The Nationwide Emergency Department Sample was queried from the last quarter of 2015 to 2019 to identify patients with a diagnosis of uveal melanoma. Multivariable logistic regression, with patient- and hospital-level characteristics as covariates, was used to identify factors associated with increased risk of in-hospital death. Results: From the last quarter of 2015 to 2019, there were 7,561 ED encounters with a secondary diagnosis of uveal melanoma. Most patients were at least 65 years of age (43.5%), male (52.5%), and a Medicare beneficiary (44.2%), or belong to a family in the 3rd income quartile (25.6%). The median age of these patients was 61 years (IQR: 32-74). Most patients presented to hospitals in the South (40.8%), with a Trauma Level I designation (47.2%), and to a metropolitan teaching hospital (72.6%). The most common diagnosis for presentation to the ED were the following general clinical categories: blood disorders (7.1%), genitourinary tract disorders (5.1%), infections (6.0%), respiratory diseases (9.0%), nervous system disorders (4.8%), endocrine/nutrition disorders (4.3%), and vascular disorders (8.3%). The rate of metastatic uveal melanoma was 5.8%. The rate of in-hospital mortality was 3.6%. In a multivariable logistic regression identified the following clinical categories as factors associated with a higher risk of in-hospital death: infections (odds ratio [OR]=10.22; p<0.001), metastases (OR=10.22; p<0.001), genitourinary tract disorders (OR=7.05; p<0.001), respiratory diseases (OR=3.31; p=0.031), and vascular disorders (OR=3.14; p=0.044). Nervous system, blood, and endocrine/nutrition disorders were not associated with a higher rate of in-hospital mortality. The only demographic variable associated with a higher risk of in-hospital death was being part of the top income quartile (OR=3.10; p=0.14). Conclusion: Physicians have to be mindful of different complications associated with uveal melanoma that can lead to presentation to the ED and possible in-hospital death. Specifically, physicians need to be mindful of infections, metastases, genitourinary tract disorders, respiratory diseases, and vascular disorders in these patients. Citation Format: Alice A. Beneke, Kamil Taneja, Lauren Ladehoff, Kevin Root, Eric Toloza. In-hospital mortality risk factors for uveal melanoma patients in the emergency department [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6480.

Abstract 6479: Metastases in uveal melanoma patients: Trends and risk factors

Abstract Purpose: Uveal melanoma has a high tendency to metastasize. Due to its rarity, there has not been large population studies that have demonstrated the effect of demographic variables on a patient’s risk to have metastases. Methods: The Nationwide Emergency Department Sample was queried from the last quarter of 2015 to 2019 to identify patients with a diagnosis of uveal melanoma. Multivariable logistic regression, with patient- and hospital-level characteristics as covariates, was used to identify factors associated with a higher chance of developing a metastasis and specific metastasis locations. Results: From the last quarter of 2015 to 2019, there were 7,561 ED encounters with a diagnosis of uveal melanoma. Of these patients, 5.8% had at least one metastasis. Most patients with a metastasis were at least 65 years of age (47.1%), male (54.4%), a Medicare beneficiary (45.2%), and belonged to a family in the highest income quartile (29.7%). The median age of these patients was 61 years (IQR: 32-74). Most patients presented to hospitals in the South (40.7%), with a Trauma Level I designation (56.1%), and to a metropolitan teaching hospital (72.9%). The most common sites of metastasis were liver (17.0%), brain (5.3%), and bone (2.0%). Multivariable logistic regression identified the following factors to be associated with increased risk of developing a metastasis: private insurance (odds ratio [OR]=1.62; p=0.012), highest income quartile (OR=2.30; p<0.001), and 2nd highest income quartile (OR=1.78; p=0.002). The following factors were associated with higher odds of developing a liver metastasis specifically: no-charge/charity work (OR=15.8; p=0.012), highest income quartile (OR=1.99; p=0.003), and second highest income quartile (OR=1.66; p=0.035). Presenting to a Trauma Level I hospital was associated with decreased risk of developing a liver metastasis (OR=0.57; p=0.016). Belonging to the highest income quartile was associated with a higher chance of developing a brain metastasis (OR=2.13; p=0.023) or a bone metastasis (OR=2.74; p=0.045). Among patients with a metastasis, the in-hospital mortality rate was 8.3%. Conclusion: Metastasis is an important complication to monitor in uveal melanoma patients. In this study, we have demonstrated that income and insurance status are factors that are associated with higher rates of metastases. Physicians should place special attention to these groups to ensure that metastases are minimized. Citation Format: Alice A. Beneke, Kamil Taneja, Lauren Ladehoff, Kevin Root, Eric Toloza. Metastases in uveal melanoma patients: Trends and risk factors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6479.

Development and validation of ‘Patient Optimizer’ (POP) algorithms for predicting surgical risk with machine learning

BackgroundPre-operative risk assessment can help clinicians prepare patients for surgery, reducing the risk of perioperative complications, length of hospital stay, readmission and mortality. Further, it can facilitate collaborative decision-making and operational planning.ObjectiveTo develop effective pre-operative risk assessment algorithms (referred to as Patient Optimizer or POP) using Machine Learning (ML) that predict the development of post-operative complications and provide pilot data to inform the design of a larger prospective study.MethodsAfter institutional ethics approval, we developed a base model that encapsulates the standard manual approach of combining patient-risk and procedure-risk. In an automated process, additional variables were included and tested with 10-fold cross-validation, and the best performing features were selected. The models were evaluated and confidence intervals calculated using bootstrapping. Clinical expertise was used to restrict the cardinality of categorical variables (e.g. pathology results) by including the most clinically relevant values. The models were created with logistic regression (LR) and extreme gradient-boosted trees using XGBoost (Chen and Guestrin, 2016). We evaluated performance using the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). Data was obtained from a metropolitan university teaching hospital from January 2015 to July 2020. Data collection was restricted to adult patients undergoing elective surgery.ResultsA total of 11,475 adult admissions were included. The performance of XGBoost and LR was very similar across endpoints and metrics. For predicting the risk of any post-operative complication, kidney failure and length-of-stay (LOS), POP with XGBoost achieved an AUROC (95%CI) of 0.755 (0.744, 0.767), 0.869 (0.846, 0.891) and 0.841 (0.833, 0.847) respectively and AUPRC of 0.651 (0.632, 0.669), 0.336 (0.282, 0.390) and 0.741 (0.729, 0.753) respectively. For 30-day readmission and in-patient mortality, POP with XGBoost achieved an AUROC (95%CI) of 0.610 (0.587, 0.635) and 0.866 (0.777, 0.943) respectively and AUPRC of 0.116 (0.104, 0.132) and 0.031 (0.015, 0.072) respectively.ConclusionThe POP algorithms effectively predicted any post-operative complication, kidney failure and LOS in the sample population. A larger study is justified to improve the algorithm to better predict complications and length of hospital stay. A larger dataset may also improve the prediction of additional specific complications, readmission and mortality.

Current Practices and Attitudes of Cardiac Nurses Regarding Cognitive Screening in Patients With Acute Coronary Syndrome

Cognitive impairment (CI) is common in patients with acute coronary syndrome (ACS) but is often undetected and may affect recovery and secondary prevention uptake. Nurses play a crucial role providing care for patients with ACS and promoting secondary prevention. This study aimed to explore current nursing practices and barriers regarding CI screening in patients with ACS. Cardiac nurses were recruited from three metropolitan teaching hospitals and two professional associations in Australia and undertook a 38-question purpose-built survey. A total of 95 nurses participated (mean age 38±13 years; 78% [n=74] female): 69 were registered nurses, and 48% had received CI training. Only 16% of nurses in our sample reported that they regularly screen for CI, and 23% reported that they never screen; however, 59% believed screening should be part of everyday practice. Nurses mostly screened when ward policy required admission/daily cognitive screening (34%) or when they suspected cognitive problems or decline (39%). Nurses in acute settings (vs non-acute) were nine times more likely to screen when adjusting for confounders. The typically used screening instruments assessed delirium/confusion and dementia but not milder CI. Common barriers to screening included communication difficulties, patients too unstable/unwell, time constraints requiring clinical care prioritisation, and being unaware of patients' normal cognition status. Screening practices for CI in the context of ACS were found to be suboptimal, with only 16% of nurses in our sample reporting regularly screening. The most used methods focus on screening for delirium. Given current practice, many CI cases will be missed, especially mild CI, which will negatively affect secondary prevention efforts. Further research is required to identify appropriate methods to implement routine screening within the nursing clinical workflow and establish a suitable screening tool.

The Influence of Hospital Type, Insurance Type, and Patient Income on 30-Day Complication and Readmission Rates Following Lumbar Spine Fusion.

Several studies have shown that factors such as insurance type and patient income are associated with different readmission rates following certain orthopaedic procedures. The literature, however, remains sparse with regard to these demographic characteristics and their associations to perioperative lumbar spine fusion outcomes. The purpose of this study was to assess the associations between hospital type, insurance type, and patient median income to both 30-day complication and readmission rates following lumbar spine fusion. Patients who underwent primary lumbar spine fusion (n = 596,568) from 2010-2016 were queried from the National Readmissions Database (NRD). Incidence of 30-day complication and readmission rates. All relevant diagnoses and procedures were identified using International Classification of Disease, 9th and 10th Edition (ICD-9, 10) codes. Hospital types were categorized as metropolitan non-teaching (n = 212,131), metropolitan teaching (n = 364,752), and rural (n = 19,685). Insurance types included: Medicare (n = 213,534), Medicaid (n = 78,520), private insurance (n = 196,648), and out-of-pocket (n = 45,025). Patient income was divided into the following quartiles: Q1 (n = 112,083), Q2 (n = 145,755), Q3 (n = 156,276), and Q4 (n = 147,289), wherein quartile 1 corresponded to lower income ranges and quartile 4 to higher ranges. Statistical analysis was conducted in R. Kruskal-Wallis tests with Dunn's pairwise comparisons were performed to analyze differences in 30-day readmission and complication rates in patients who underwent lumbar spine fusion. Complications analyzed included infection, wound injury, hematoma, neurological injury, thromboembolic event, and hardware failure. 30-day readmission was significantly higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals and rural hospitals (P < .05). Patients from metropolitan teaching hospitals had significantly higher rates of infection (P < .001), wound injury (P < .001), hematoma (P = .018), and hardware failure (P < .002) compared to those treated at metropolitan non-teaching hospitals. Privately insured patients were significantly less likely to be readmitted at 30 days than those paying with Medicare or Medicaid (P < .01). Patients with private insurance also experienced significantly lower rates of hematoma formation than Medicare beneficiaries and out-of-pocket payers (P < .01), postoperative wound injury compared to Medicaid patients and out-of-pocket payers (P < .005), and infection compared to all other groups (P < .001). Patients in Quartile 4 experienced significantly greater rates of hematoma formation compared to those in Quartiles 1 and 2 and were more likely to experience a thromboembolic event compared to all other groups. Patients undergoing lumbar spine fusion at metropolitan non-teaching hospitals and paying with private insurance had significantly lower 30-day readmission rates than their counterparts. Complications within 30 days following lumbar spine fusion were significantly higher in patients treated at metropolitan teaching hospitals and in Medicare and Medicaid beneficiaries. Aside from a few exceptions, however, patient income was generally not associated with differential complication rates.

Race and Ethnicity and Emergency Department Discharge Against Medical Advice

Although discharges against medical advice (DAMA) are associated with greater morbidity and mortality, little is known about current racial and ethnic disparities in DAMA from the emergency department (ED) nationally. To characterize current patterns of racial and ethnic disparities in rates of ED DAMA. This cross-sectional study used data from the Nationwide Emergency Department Sample on all hospital ED visits made between January to December 2019 in the US. The main outcome was odds of ED DAMA for Black and Hispanic patients compared with White patients nationally and in analysis adjusted for sociodemographic factors. Secondary analysis examined hospital-level variation in DAMA rates for Black, Hispanic, and White patients. The study sample included 33 147 251 visits to 989 hospitals, representing the estimated 143 million ED visits in 2019. The median age of patients was 40 years (IQR, 22-61 years). Overall, 1.6% of ED visits resulted in DAMA. DAMA rates were higher for Black patients (2.1%) compared with Hispanic (1.6%) and White (1.4%) patients, males (1.7%) compared with females (1.5%), those with no insurance (2.8%), those with lower income (<$27 999; 1.9%), and those aged 35 to 49 years (2.2%). DAMA visits were highest at metropolitan teaching hospitals (1.8%) and hospitals that served greater proportions of racial and ethnic minoritized patients (serving ≥57.9%; 2.1%). Odds of DAMA were greater for Black patients (odds ratio [OR], 1.45; 95% CI, 1.31-1.57) and Hispanic patients (OR, 1.16; 95% CI, 1.04-1.29) compared with White patients. After adjusting for sociodemographic characteristics (age, sex, income, and insurance status), the adjusted OR (AOR) for DAMA was lower for Black patients compared with the unadjusted OR (AOR, 1.18; 95% CI, 1.09-1.28) and there was no difference in odds for Hispanic patients (AOR, 1.03; 95% CI, 0.92-1.15) compared with White patients. After additional adjustment for hospital random intercepts, DAMA disparities reversed, with Black and Hispanic patients having lower odds of DAMA compared with White patients (Black patients: AOR, 0.94 [95% CI, 0.90-0.98]; Hispanic patients: AOR, 0.68 [95% CI, 0.63-0.72]). The intraclass correlation in this secondary analysis model was 0.118 (95% CI, 0.104-0.133). This national cross-sectional study found that Black and Hispanic patients had greater odds of ED DAMA than White patients in unadjusted analysis. Disparities were reversed after patient-level and hospital-level risk adjustment, and greater between-hospital than within-hospital variation in DAMA was observed, suggesting that Black and Hispanic patients are more likely to receive care in hospitals with higher DAMA rates. Structural racism may contribute to ED DAMA disparities via unequal allocation of health care resources in hospitals that disproportionately treat racial and ethnic minoritized groups. Monitoring variation in DAMA by race and ethnicity and hospital suggests an opportunity to improve equitable access to health care.

Epidemiology of ophthalmic trauma in the United States from 2009–2018: A Nationwide Emergency Department Sample Analysis

PurposeTo determine the incidence, characteristics, disposition, and economic burden of emergency department (ED) visits for ophthalmic trauma in the United States (US). DesignRetrospective study. MethodsThe Nationwide Emergency Department Sample was used to calculate and characterize ED visits for ophthalmic trauma in the US from 2009 to 2018. Linear regression was used to estimate trends in annual incidence and mean inflation-adjusted ED charges. Logistic regression was used to assess variables associated with inpatient admission. ResultsThere were over 7.3 million ED visits for ophthalmic trauma in the US over the 10 years, with an annual incidence of 233 per 100,000 population. Patients were predominantly male (65 %), 21–44 years old (39 %), and from low-income households (56 %). Only 1 % of patients were hospitalized. Older age, male sex, metropolitan teaching hospitals, and trauma centers were associated with significantly higher odds of inpatient admission. The mean inflation-adjusted ED charge per visit more than doubled over the decade ($1,333 to $3,187) with total charges exceeding $14 billion. Superficial injuries (44 %) and eyelid/orbit wounds (20 %) accounted for the majority of visits. Orbital floor fractures (4 %) and open globe injuries (2 %) accounted for a minority of visits but were responsible for most admissions (49 % and 29 %, respectively) and the highest mean ED charge ($7,157 and $6,808, respectively). ConclusionsOphthalmic trauma represents an increasingly significant burden to EDs in the US. Preventive efforts should target young males from low socioeconomic backgrounds. Strategies to improve outpatient access and redirect non-urgent injuries may help alleviate costs.

NATIONWIDE DEMOGRAPHIC DISPARITIES IN UNITED STATES EMERGENCY DEPARTMENT VISITS IN PATIENTS WITH RHEGMATOGENOUS RETINAL DETACHMENT.

Within the evolving landscape of healthcare in the United States (US), delineating the demographic nuances and financial implications of emergent conditions, such as rhegmatogenous retinal detachment (RRD), is paramount. This study seeks to analyze the demographic and hospital billing amount/cost of service disparities in RRD visits to emergency departments (EDs) nationwide. We conducted a retrospective, cross-sectional, population-based study using International Classification of Diseases, 10th revision , and Current Procedural Terminology codes in the 2016 to 2019 Nationwide Emergency Department Sample databases to identify RRD visits. The analysis included demographics, hospital billing amount, and cost of service of RRD ED management. A total of 12,492 RRD encounters were identified with men constituting 64% and a prominent age group being 50 to 64 years (49.3%). Most patients (90%) were managed in metropolitan teaching hospitals, predominantly in the southern U.S. region (56.1%). Private insurance covered 45% of patients. Same-day RRD repair odds increased in November and December. Whites had a higher likelihood for same-day treatment. Hospital billing amount rose from $23,600 in 2016 to $30,354 in 2019, with stable mean total cost of service. Rhegmatogenous retinal detachment ED visit incidence did not show seasonal variation ( P = 0.819). Most patients with RRD in U.S, EDs were middle-aged men, with Whites more likely to receive same-day repair. There was no sex bias observed in same-day repair decision-making. Although hospital billing amount increased over the study period, total cost of service remained stable. The incidence of RRD ED visits showed no seasonal variation.

Clinical outcomes and predictors for 30-day readmissions of endoscopic retrograde cholangiopancreatography in the United States.

We aimed to assess 30-day readmissions of endoscopic retrograde cholangiopancreatography (ERCP) in the United States. The National Readmission Database was utilized from 2016 to 2020 to identify 30-day readmissions of ERCP. Hospitalization characteristics and outcomes were compared between index hospitalizations and readmissions. Predictors of 30-day readmission and mortality were also identified. Between 2016 and 2020, 885 416 index hospitalizations underwent ERCP. Of these, 88 380 (10.15%) were readmitted within 30days. Compared to index hospitalizations, 30-day readmissions had higher mean age (63.76 vs 60.8years, P<0.001) and proportion of patients with Charlson Comorbidity Index (CCI) score ≥3 (48.26% vs 29.91%, P<0.001). Sepsis was the most common readmission diagnosis. Increasing age, male gender, higher CCI scores, admissions at large metropolitan teaching hospitals, cholecystectomy on index hospitalization, biliary stenting, increasing length of stay (LOS) at index admission, post-ERCP pancreatitis, post-ERCP hemorrhage, and gastrointestinal tract perforation were independent predictors of 30-day readmissions. Furthermore, 30-day readmissions had higher odds of inpatient mortality (4.42% vs 1.66%, aOR 1.9, 95% CI: 1.79-2.01, P<0.001) compared to index hospitalizations. However, we noted a shorter LOS (5.78 vs 6.22days, mean difference 1.2, 95% CI: 1.12-1.28, P<0.001) and lower total hospital charge ($71 076 vs $93 418, mean difference $31 452, 95% CI: 29 835-33 069, P<0.001) for 30-day readmissions compared to index hospitalizations. Increasing age, higher CCI scores, increasing LOS, biliary stenting, and post-ERCP hemorrhage were independent predictors of inpatient mortality for 30-day readmissions. After index ERCP, the 30-day remission rate was 10.15%. Compared to index hospitalizations, 30-day readmissions had higher odds of inpatient mortality.

Experiences of redeployment by haemodialysis nurses during the COVID-19 pandemic: a hermeneutic phenomenological approach

Background Redeployment of healthcare workers is one of the strategies that has been successfully used to manage increased workload and shortage of staff during the COVID-19 pandemic. However, little is known about how best to do this in the pandemic and beyond. The purpose of this study was to explore the lived experiences of haemodialysis nurses who were redeployed across five haemodialysis units affiliated with a large metropolitan teaching hospital in Australia during the COVID-19 pandemic. Design Qualitative design utilizing a hermeneutic (interpretive) phenomenology approach. Methods: Interviews were conducted in March 2022 among nurses who had been redeployed to other haemodialysis units during the COVID-19 pandemic (N = 16). Audiotaped interviews were transcribed verbatim and analysed independently by two researchers following specific steps of hermeneutic phenomenological analysis. Results Five themes were derived from the analyses. These were: (1) Nurses’ immediate reaction; (2) Barriers to redeployment; (3) Benefits of redeployment; (4) Local and organisational support and (5) Opportunities for improvement. Conclusions Redeployment of nurses across different haemodialysis units is associated with personal and organisational benefits and number of barriers that need to be addressed. Future studies should explore the long-term effects of redeployment due to the COVID-19 pandemic on haemodialysis nurses and other healthcare workers.

Accuracy of medication labels on community pharmacy-prepared dose administration aids: An observational study

BackgroundHospital prescribers often use the labels on multicompartment compliance aids or monitored dosage systems, known in Australia as dose administration aids (DAAs), as a trusted source of information about patients' medication regimens taken in the community. AimThe primary aim was to explore the prevalence and nature of labelling incidents on community pharmacy-prepared DAAs. MethodsA convenience sample of 100 adult patients admitted to a metropolitan teaching hospital who used a community pharmacy-prepared DAA at home was recruited. Patients were excluded if their DAAs were not brought to hospital. As part of usual care, a pharmacist took a best possible medication history (BPMH) using multiple information sources. This ‘gold standard’ BPMH was compared to the regimen listed on the DAA summary label and the DAA contents. The primary outcome was the percentage of patients whose DAA summary label(s) had one or more incidents for DAA packed medications. DAA label incident was defined as incorrect, missing or illegible/ambiguous medication name, strength, dose or dose-form when compared to the BPMH and DAA contents. Secondary outcomes were compliance with best-practice guidelines for labelling DAAs; and percentage of patients with a DAA packing error. ResultsThe 100 patients used 110 DAAs, packed by 75 community pharmacies. Four (4.0%) patients had no medication summary label on their DAAs. Of the 96 patients whose DAA(s) had a summary label, 82 (85.4%) had one or more summary label incidents. The most prevalent incidents were ‘illegible, ambiguous or missing medication details’, ‘truncated medication name’ and ‘omission of a medication’. The most prevalent guideline non-compliance was not including generic medication names (68% DAA-packed medications). Two DAA packing errors were identified. ConclusionA high prevalence of DAA labelling incidents was identified. Improved DAA labelling software functionality, more robust pharmacy procedures and pharmacy staff education are required.