Optimizing Hospital Resources Research Articles

ESTRATÉGIAS DE PREVENÇÃO DE LESÃO POR PRESSÃO EM PACIENTES ACAMADOS: O PAPEL DA ENFERMAGEM

Pressure injuries (PPI) represent a serious public health problem that affects bedridden patients, especially in hospital environments, and can cause complications such as infections and tissue necrosis. This article aims to propose the implementation of PI prevention strategies in bedridden patients, focusing on the role of nursing. The research aims to identify effective prevention practices, such as position changes, risk assessment and use of pressure relief devices. The methodology adopted was a bibliographic review of articles published in the last ten years, using databases such as PubMed, Scielo and LILACS. Expected results include reducing the incidence of PPL, improving the quality of nursing care and promoting preventive protocols based on scientific evidence. It is concluded that the rigorous adoption of these strategies could significantly contribute to improving patient health and optimizing hospital resources. The main strategies identified include changing position, using pressure relief devices and risk assessment. It is concluded that this management significantly reduces the incidence of LPP, improving the quality of nursing care and promoting patient health.

Point Prevalence Survey of HAIs as a key component of Infection Prevention and Control programs

Abstract Healthcare-Associated Infections (HAIs) are a global concern, requiring surveillance strategies as Point Prevalence Surveys (PPS) to estimate their burden and investigate associated risk factors for targeted interventions in high-risk areas. This study aims to assess the prevalence of HAIs, identify determinants and evaluate antimicrobial use in a teaching hospital in Rome. A PPS was carried out from June 19th to 23rd, 2023, in accordance with the European Centre for Disease Prevention and Control (ECDC) protocol for HAIs and antimicrobial use in European acute care hospitals (version 6.1). Pearson’s chi-squared test was employed to investigate correlations between potential risk factors and HAIs. The survey included 829 patients with an average age of 56.3 years (SD: ±24.6). Of these, 48.4% were female and over half had visited the hospital’s Emergency Department (53.7%). The prevalence of active HAIs was 8.7%, with 72 patients diagnosed. Furthermore, 51.0% of all patients received at least one systemic antimicrobial agent, and 16.7% of those treated had an HAI. Penicillins (39.7%) and third-generation cephalosporins (37.8%) were the most frequently prescribed antimicrobials. The primary HAIs were bloodstream infections (34.1%), followed by urinary tract (27.3%), surgical site (23.9%), lower respiratory tract (6.8%), and gastrointestinal infections (7.9%). Escherichia coli (13.2%), Staphylococcus aureus (9.2%), and Clostridium difficile (6.6%) were the most frequently isolated pathogens. Intensive Care Unit admission, use of medical device, recent antibiotic therapy and prior hospitalization or surgery significantly correlated (p < 0.05) with increased HAIs risk. The detected prevalence of HAIs is lower than the national rates observed in 2022 (10.2%), which have increased since 2016. HAIs surveillance is essential for developing effective infection prevention and control programs and for optimizing resource allocation in hospital settings. Key messages • Surveillance of Healthcare-Associated Infections is crucial for developing targeted Infection Prevention and Control programs and optimizing hospital resource allocation. • Point Prevalence Surveys offer essential information for assessing the burden of Healthcare-Associated Infections and directing intervention strategies in hospitals.

Early impact of treatment modifications adopted for acute lymphoblastic leukemia during SARS-CoV-2 pandemic; a single center experience and lessons for LMICs

Treatment modifications adopted during pandemic aimed at reducing infection, myelosuppression, and optimizing hospital resources. This study evaluated outcomes for pediatric patients with ALL who had treatment modifications during pandemic compared to historical cohorts at the National Cancer Institute, Cairo University, Egypt. Bi-directional cohort study included 378 patients. Treatment modifications included omission of specific drugs or adjusting chemotherapy schedules to 6-mercaptopurine/methotrexate. Median follow-up were 45.1 and 43.2 months, for cohorts (A) and (B), respectively. The three-year overall survival were 84.9% and 87.5% (p = .48) and three-year relapse free survival were 82.8% and 86.5% (p = .11) for cohorts (A) and (B), respectively. Infection-related mortality was 11% and 4.4% for cohorts (A) and (B), respectively (p = .03). Treatment modifications adopted during the pandemic did not adversely affect the outcome of patients with ALL and notably reduced infection-related deaths. Longer follow-up is warranted to validate these findings.

Prediction of Length of Stay After Colorectal Surgery Using Intraoperative Risk Factors.

The primary objective of this study was to develop a length of stay (LOS) prediction model. Predicting the LOS is crucial for patient care, planning, managing expectations, and optimizing hospital resources. Prolonged LOS after colorectal surgery is largely influenced by complications, and an accurate prediction model could significantly benefit patient outcomes and healthcare efficiency. This study included patients who underwent colorectal surgery in 14 different hospitals between January 2016 and December 2020. Two distinct random forest models were developed: one solely based on preoperative variables (preoperative prediction model [PP model]) and the other incorporating both preoperative and intraoperative variables (intraoperative prediction model [IP model]). Both models underwent validation using 10-fold cross-validation. The discriminative power of the model was assessed using the area under the curve (AUC), and calibration was evaluated using a calibration curve. The 2 developed models were compared using DeLong test. A total of 2140 patients were included in the analysis. After internal validation, the PP model achieved an AUC of 0.75 (95% confidence interval [CI]: 0.73-0.77), and the IP model achieved an AUC of 0.84 (95% CI: 0.82-0.85). The difference in discrimination between the 2 models was statistically significant (DeLong test, P < 0.001). Both models exhibited good calibration. Incorporating intraoperative parameters enhances the accuracy of the predictive model for LOS after colorectal surgery. Improving LOS prediction can assist in managing the increasing number of patients and optimizing the allocation of healthcare resources.

Prediction of Patient Visit Levels Based on Type of Service at Patar Asih General Hospital Using the Monte Carlo Method

This study aims to predict the level of patient visits at RSU Patar Asih based on the type of service provided using the Monte Carlo method. The Monte Carlo method was chosen because of its ability to handle data variability and uncertainty that often arises in the context of patient hospital visits. The data used in this study includes the number of patient visits based on the type of service at RSU Patar Asih, such as health services for pregnant women, health services for postpartum mothers, health services for newborns, health services for toddlers, health services at primary education age, health services at productive age. , health services for the elderly, health services for people with hypertension, health services for people with diabetes mellitus, health services for people with serious mental disorders (ODGJ), health services for people suspected of having tuberculosis, health services for people at risk of being infected with the human immune system (HIV)during the period 2021, 2022, 2023.The prediction results from this simulation obtained an accuracy of 81.75%, providing a fairly accurate estimate of the level of patient visits in the future. These predictions can be used by hospital management for resource planning, such as medical staff allocation, drug and medical equipment inventory management, and operational scheduling. Thus, the results of this research have the potential to improve operational efficiency and overall quality of hospital services. It is hoped that this research can contribute to more effective and efficient hospital management through data-based predictions, thereby increasing patient satisfaction and optimizing hospital resources.

Left Ventricular Strain, Arch Angulation, and Velocity-Time Integral Ratio Improve Performance of a Clinical Pathway for Fetal Diagnosis of Neonatal Coarctation of the Aorta

Plain Language SummaryCoarctation of the aorta is challenging to diagnosis in fetal life. New fetal echocardiographic techniques have been developed to help predict the development of surgical coarctation of the aorta after birth but have not been externally validated or compared to each other. We sought to validate these metrics and compare their utility in predicting surgical coarctation of the aorta in a retrospective cohort of previously identified fetuses at risk for coarctation of the aorta. We found that among fetuses with prenatal concern for coarctation of the aorta, novel metrics were significantly different between surgical and non-surgical cases. Our results indicate that the incorporation of novel metrics can add diagnostic value for fetal coarctation of the aorta with higher specificity than previous high-risk criteria, without compromising the sensitivity of the low-risk group. The ability to identify fetuses at the highest risk for surgical coarctation may improve prenatal counseling, allow for more consistent surgical planning, and ultimately optimize hospital resource allocation.

Interprofessional Collaboration to Support Person-centered Care: Implementation of an Integrated Surgical Pathway for Complex Foot and Ankle Patients

Introduction: Traditionally foot and ankle patients have high medical and social complexities that require additional support and care navigation following surgery to improve transitions out of hospital into the community for recovery at home. We explored implementation of an integrated surgical pathway that included an interprofessional, centralized intake model for surgical consult, pre-operative mobility assessment to assess post-operative supports and potential barriers to successful discharge home, and creation of a partnership with transitional care, while providing person-centered care to improve patient experience and surgical recovery. &#x0D; Aims, Objectives and Methodology: Our objective was to develop and implement an integrated surgical pathway for complex foot and ankle patients to support seamless transitions in care from acute to recovery at home following surgery. &#x0D; A working group was formed with members spanning operational and clinical roles across the care continuum including: physiotherapist practitioner, surgeon administrative support, clinical managers, inpatient physiotherapists, social work, nurse practitioners and transitional care program managers. A 2-hour process mapping session was conducted outlining the current state surgical pathway and potential barriers to successful discharge were identified. Standard care path guidelines were developed with decision tree clinical resources to assist the care team in facilitating referrals to transitional care pre-operatively to ensure seamless transition for the patient after surgery. &#x0D; Highlights and Key Findings: The patient population supported by this integrated pathway were those with complex foot and ankle surgical procedures including: ankle and midfoot fusion, ligament reconstruction, ankle osteotomy, total ankle replacement and triple arthrodesis. Fairly equal distribution was seen between male and female (48% and 52% respectively), and the average age was 54 years. The addition of an interprofessional consult offered more robust patient education, pre and post surgical planning and expectation setting. A pre-op mobility assessment optimized post-operative care coordination. This was illustrated by a reduction in the acute length of stay from an average of 8.2 days in 19/20 to 3.4 days in 20/21. From 2018 to 2022 the discharge disposition of this patient cohort remained consistent with the majority of patients (66%) supported to return home with outpatient physiotherapy, 24% of patients were discharged home with homecare services coordinated and a small proportion (&lt;10%) were transferred to a transitional care, inpatient or residential care facility. Qualitative report from patient's revealed that supports provided eased anxiety and improved post-operative transitions home for recovery.&#x0D; Conclusions: Implementation of an integrated surgical pathway for complex foot and ankle patients that maximize pre-operative care planning and leveraging existing community partnerships, both in-home and institutional; enable the delivery of person-centred care, facilitating seamless transitions from acute care to community for patients while optimizing hospital resource utilization.&#x0D; Implications for applicability/transferability, sustainability and limitations: Expansion of collaborative integrated models that support additional orthopedic surgical patient populations from hospital to recovery within the community are critical in providing person-centered care. Sustainability of these models will rely on securing the resources required for pre-surgical patient education, expectation setting and care and resource planning for seamless post-operative transitions. &#x0D;

COVID-19 and the Genetics of Inflammation.

Interindividual variability in the clinical progression of COVID-19 may be explained by host genetics. Emerging literature supports a potential inherited predisposition to severe forms of COVID-19. Demographic and inflammatory characteristics of COVID-19 suggest that acquired hematologic mutations leading to clonal hematopoiesis (CH) may further increase vulnerability to adverse sequelae. This review summarizes the available literature examining genetic predispositions to severe COVID-19 and describes how these findings could eventually be used to improve its clinical management. A PubMed literature search was performed. Studies examining the significance of inherited genetic variation or acquired CH mutations in severe COVID-19 were selected for inclusion. Relevant genetic association data and aspects of study design were qualitatively assessed and narratively synthesized. Genetic variants affecting inflammatory responses may increase susceptibility to severe COVID-19. Genome-wide association studies and candidate gene approaches have identified a list of inherited mutations, which likely alter cytokine and interferon secretion, and lung-specific mechanisms of immunity in COVID-19. The potential role of CH in COVID-19 is more uncertain at present; however, the available evidence suggests that the various types of acquired mutations and their differential influence on immune cell function must be carefully considered. The current literature supports the hypothesis that host genetic factors affect vulnerability to severe COVID-19. Further research is required to confirm the full scope of relevant variants and the causal mechanisms underlying these associations. Clinical approaches, which consider the genetic basis of interindividual variability in COVID-19 and potentially other causes of critical illness, could optimize hospital resource allocation, predict responsiveness to treatment, identify more efficacious drug targets, and ultimately improve outcomes.

Exploring Longitudinal Cough, Breath, and Voice Data for COVID-19 Progression Prediction via Sequential Deep Learning: Model Development and Validation.

BackgroundRecent work has shown the potential of using audio data (eg, cough, breathing, and voice) in the screening for COVID-19. However, these approaches only focus on one-off detection and detect the infection, given the current audio sample, but do not monitor disease progression in COVID-19. Limited exploration has been put forward to continuously monitor COVID-19 progression, especially recovery, through longitudinal audio data. Tracking disease progression characteristics and patterns of recovery could bring insights and lead to more timely treatment or treatment adjustment, as well as better resource management in health care systems.ObjectiveThe primary objective of this study is to explore the potential of longitudinal audio samples over time for COVID-19 progression prediction and, especially, recovery trend prediction using sequential deep learning techniques.MethodsCrowdsourced respiratory audio data, including breathing, cough, and voice samples, from 212 individuals over 5-385 days were analyzed, alongside their self-reported COVID-19 test results. We developed and validated a deep learning–enabled tracking tool using gated recurrent units (GRUs) to detect COVID-19 progression by exploring the audio dynamics of the individuals’ historical audio biomarkers. The investigation comprised 2 parts: (1) COVID-19 detection in terms of positive and negative (healthy) tests using sequential audio signals, which was primarily assessed in terms of the area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity, with 95% CIs, and (2) longitudinal disease progression prediction over time in terms of probability of positive tests, which was evaluated using the correlation between the predicted probability trajectory and self-reported labels.ResultsWe first explored the benefits of capturing longitudinal dynamics of audio biomarkers for COVID-19 detection. The strong performance, yielding an AUROC of 0.79, a sensitivity of 0.75, and a specificity of 0.71 supported the effectiveness of the approach compared to methods that do not leverage longitudinal dynamics. We further examined the predicted disease progression trajectory, which displayed high consistency with longitudinal test results with a correlation of 0.75 in the test cohort and 0.86 in a subset of the test cohort with 12 (57.1%) of 21 COVID-19–positive participants who reported disease recovery. Our findings suggest that monitoring COVID-19 evolution via longitudinal audio data has potential in the tracking of individuals’ disease progression and recovery.ConclusionsAn audio-based COVID-19 progression monitoring system was developed using deep learning techniques, with strong performance showing high consistency between the predicted trajectory and the test results over time, especially for recovery trend predictions. This has good potential in the postpeak and postpandemic era that can help guide medical treatment and optimize hospital resource allocations. The changes in longitudinal audio samples, referred to as audio dynamics, are associated with COVID-19 progression; thus, modeling the audio dynamics can potentially capture the underlying disease progression process and further aid COVID-19 progression prediction. This framework provides a flexible, affordable, and timely tool for COVID-19 tracking, and more importantly, it also provides a proof of concept of how telemonitoring could be applicable to respiratory diseases monitoring, in general.

Early Determinants of Neurocritical Care Unit Length of Stay in Patients with Spontaneous Intracerebral Hemorrhage.

The present study considers patients with spontaneous intracerebral hemorrhage (ICH) admitted to the neurocritical care unit (NCCU) through the Emergency Department (ED). It aims to identify patient-specific clinical variables that can be assessed on presentation and that are associated with prolonged NCCU length of stay (LOS). A cross-sectional, single-center, retrospective analysis of ICH patients directly admitted from the ED to the NCCU over an 8-year period was performed. Patients' demographics, clinical exam characteristics, serum laboratory values, intubation status, and neurosurgical procedures at presentation were recorded. Head computed tomography scans obtained on presentation were reviewed. LOS was calculated based on the number of midnights spent in the NCCU. Prolonged LOS was determined using a change point analysis, adopting the method of Taylor which utilizes CUMSUM charts and bootstrap analysis. A decision tree model was trained and validated to identify reliable variables associated with prolonged LOS. Two hundred and five patients with ICH were analyzed. Prolonged LOS was calculated to be a stay that exceeds 8days; 68 patients (33%) had a prolonged LOS in NCCU. Median LOS did not differ between survivors and patients who died in hospital. Clinical variables explored through the decision tree model were intubation status, neurosurgical intervention (EVD, decompression or evacuation within 24h from presentation), and components of the ICH score: age, GCS, hematoma volume, the presence of intraventricular hemorrhage (IVH), and infratentorial location. The model accuracy was 0.8 and AUC was 0.83 (95% CI 0.78-0.89). We propose an ICH-LOS model based on neurosurgical intervention, intubation status and GCS at presentation to predict prolonged LOS in the NCCU in patients with ICH. This simple clinical tool, if prospectively validated, could help with medical planning, contribute to patient care-directed conversations, assist in optimizing hospital resource utilization, and, more importantly, motivating patient-specific interventions aimed at optimizing outcomes and decreasing LOS.

Evaluation of medication errors in electronic medical prescriptions and proposal for correction

Worldwide, the annual cost associated with medication errors is estimated at US$ 42 billion or almost 1% of the total global health expenditure. In Brazil, analysis and measures to minimize these errors has not been well studied. Thus, the present study identified the errors in electronic medical prescriptions and proposed strategies to minimize such errors. A total of 1980 medical prescriptions were analyzed in a hospital, with 196 beds and 11 sectors located in Votuporanga, SP, Brazil. The errors were listed: Via, Frequency, Time, Duplication, Absence, Diluents, Dose, Medication, and Infusion. The statistical analysis was applied, with a significance level at 5%. The 2621 found errors correspond to 49.49% of the prescriptions analyzed; 23.68% contained only one prescription error, 11.06% had two errors, and 14.75% included three or more errors. After the evaluation stage, some errors were corrected, and some improvements were suggested. The correction of dose error decrease of 68% and 30% occurred in the consumption of two drugs. For the correction of diluents and time errors, an assertiveness was generated in all the prescriptions analyzed. A cycle of continuous improvement is proposed for the indicators of medical prescription errors based on four main principles of planning, performing, analyzing, and correcting. The starting point for this process should always be the diagnosis of the main prescription errors. This cycle should be applied annually to reduce prescription errors, thus, offering better treatment to patients and optimizing hospital resources.

Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days.

Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated. Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay. In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children ( P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday ( P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay. DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient's closest family. Understanding limitations of the patient's insurance may help plan DC destination. Optimizing hospital resources when available should be a focus. Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team's overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.

Accurate Prediction of Congenital Heart Surgical Length of Stay Incorporating a Procedure-Based Categorical Variable.

There is increasing demand for the limited resource of Cardiac ICU care. In this setting, there is an expectation to optimize hospital resource use without restricting care delivery. We developed methodology to predict extended cardiac ICU length of stay following surgery for congenital heart disease. Retrospective analysis by multivariable logistic regression of important predictive factors for outcome of postoperative ICU length of stay greater than 7 days. Cardiac ICU at Boston Children's Hospital, a large, pediatric cardiac surgical referral center. All patients undergoing congenital heart surgery at Boston Children's Hospital from January 1, 2010, to December 31, 2015. No study interventions. The patient population was identified. Clinical variables and Congenital Heart Surgical Stay categories were recorded based on surgical intervention performed. A model was built to predict the outcome postoperative ICU length of stay greater than 7 days at the time of surgical intervention. The development cohort included 4,029 cases categorized into five Congenital Heart Surgical Stay categories with a C statistic of 0.78 for the outcome ICU length of stay greater than 7 days. Explanatory value increased with inclusion of patient preoperative status as determined by age, ventilator dependence, and admission status (C statistic = 0.84). A second model was optimized with inclusion of intraoperative factors available at the time of postoperative ICU admission, including cardiopulmonary bypass time and chest left open (C statistic 0.87). Each model was tested in a validation cohort (n = 1,008) with equivalent C statistics. Using a model comprised of basic patient characteristics, we developed a robust prediction tool for patients who will remain in the ICU longer than 7 days after cardiac surgery, at the time of postoperative ICU admission. This model may assist in patient counseling, case scheduling, and capacity management. Further examination in external settings is needed to establish generalizability.

Effect of single-dose dexmedetomidine on postoperative recovery after ambulatory ureteroscopy and ureteric stenting: a double blind randomized controlled study

BackgroundAmbulatory surgery has recently gain popularity, as it is a good method of optimizing hospital resources utilization. To support ambulatory surgery, anaesthetic goals now revolve around patients’ early recovery with minimal pain and nausea, expedient discharge home and prompt resumption of activities of daily living. In this study, we evaluated the effect of a single pre-induction dose of dexmedetomidine on anaesthetic requirements, postoperative pain and clinical recovery after ambulatory ureteroscopy andureteric stenting under general anaesthesia.MethodsSixty patients were randomised to receive IV dexmedetomidine 0.5 μg.kg-1 (Group DEX, n = 30) or IV saline (Group P, n = 30). General anaesthesia was maintained with Sevoflurane: oxygen: air, titrated to BIS 40–60. Pain intensity, sedation, rescue analgesics, nausea/vomiting and resumption of daily activities were recorded at 1 h, and postoperative day (POD) 1–5.ResultsGroup DEX patients had significant reduction in sevoflurane minimum alveolar concentration (MAC), mean (SD) DEX vs. Placebo 0.6 (0.2) vs. 0.9 (0.1), p = 0.037; reduced postoperative resting pain at 1 h (VAS 0–10) (mean (SD) 1.00 (1.84) vs. 2.63 (2.78), p = 0.004), POD 1 (mean (SD) 1.50 (1.48) vs. 2.87 (2.72), p = 0.002), POD 2 (0.53 (0.97) vs. 1.73 (1.96), p = 0.001) and POD 3 (0.30 (0.75) vs. 0.89 (1.49), p = 0.001). DEX patients also had less pain on movement POD 1 (3.00 (2.12) vs. 4.30 (3.10), p = 0.043) and POD 2 (2.10 (1.98) vs. 3.10 (2.46), p = 0.040), with higher resumption of daily activities by 48 h compared to placebo, 87% vs. 63%, p = 0.04.ConclusionsWe conclude that a single dose of dexmedetomidine was a useful adjuvant in reducing MAC and postoperative pain (at 1 h and POD 1–3), facilitating faster return to daily activities by 48 h.Trial registrationThe Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12617001120369, 31st July 2017, retrospectively registered.

Optimizing Hospital Resource Utilization in Bariatric Readmission.

Background and Objectives:The prevalence of patients with a history of bariatric surgery is climbing. Medical and surgical questions arising in this patient population may prompt them to present to the nearest emergency department (ED), irrespective of that facility's experience with bariatric surgery. The emergency physician is the first to evaluate patients with a history of bariatric surgery who present with abdominal symptoms. As a quality improvement project aimed at reducing resource utilization, we sought to determine which patients presenting to the ED could be treated in an outpatient setting in lieu of hospital admission.Methods:We conducted a retrospective review of bariatric patients admitted from our ED with abdominal symptoms, including abdominal pain, nausea, vomiting, dysphagia, obstruction, and hematemesis. We collected the following variables: type of bariatric operation, admission and discharge diagnoses, and all interventions performed during admission.Results:One hundred sixty-nine patients (76.1%) had a history of laparoscopic Roux-en-Y gastric bypass. The time from bariatric operation to presentation averaged 42 ± 4.63 (SD) months. The most common symptom was abdominal pain (80.2%). Ninety-four percent of patients underwent invasive management via upper endoscopy, laparoscopy, or laparotomy. The most common postprocedural diagnoses were stricture, bowel obstruction, inflammatory findings, and cholecystitis.Conclusion:Most patient encounters resulted in invasive management (204/282; 72.3%). The subset of these patients requiring endoscopic evaluation or therapy (37.7%) may be suitable for outpatient management if appropriate measures are available for rapid follow-up and procedural scheduling.

LO27: System outcomes associated with an emergency department clinical decision unit

Introduction: A clinical decision unit (CDU) is an area within the emergency department (ED) that allows for protocol-driven treatment &amp;amp; observation of patients who may not require hospital admission, but are not ready for discharge after initial assessment &amp;amp; treatment. A CDU was established at BC Children’s Hospital in 2014 as a means to optimize hospital resource utilization. Preliminary administrative data review revealed a return to ED (RTED) rate of 15% following a CDU stay, 2-3 times the RTED rate reported in the literature. Whether this is the expected cost of reducing hospital admissions remains unclear. Research exploring the underlying reasons for RTED following a CDU stay is limited. Objectives: Following a CDU stay, to describe 1) disposition outcome distribution; 2) underlying reasons for RTED; and 3) the proportion of potentially preventable RTED. Methods: Retrospective cohort study of all ED visits with a CDU stay from Jan 1, 2015 to Dec 31, 2015. Health records data was extracted &amp;amp; entered into standardized online forms by trained research assistants, then blindly reviewed by two investigators to determine a) the most probable cause of each RTED &amp;amp; b) the number of RTED that were clinically unnecessary. Results: Of the 1696 index CDU visits, 1503 (89%) were discharged home. However, 139 (9%) had ≥1 associated RTED. Among these, 48 (35%) were deemed clinically unnecessary (89% agreement, Kappa=0.79) &amp;amp; therefore potentially preventable. The most common reason (88%) for unnecessary RTED was mismatch between expected natural progression of disease (not requiring further medical assessment or treatment) &amp;amp; families’ understanding of disease symptom range &amp;amp; duration. In 90% of these cases, anticipatory guidance regarding natural progression of disease was not communicated to parents upon discharge. Among the remaining 1364 (91%) that did not return, 750 had an initial visit total ED length of stay of &amp;gt;8 hours, thus were considered averted hospitalizations attributable to the CDU. Conclusion: The CDU has had a positive impact on patient &amp;amp; system outcomes through the prevention of several inpatient admissions. However, we observed a relatively large proportion of RTED, 35% of which were clinically unnecessary &amp;amp; 27% of which had inadequate discharge instructions. This highlights opportunities to further optimize the effectiveness of the CDU through quality improvement initiatives focusing on the ED discharge process.

PREDICTION TOOL FOR CONGENITAL HEART SURGERY LENGTH OF STAY

Background: In response to increasing demand to optimize hospital resource use, we developed a methodology to predict extended length of stay (LOS) in the cardiac intensive care unit (CICU) following surgery for congenital heart disease. Methods: Patients undergoing congenital heart surgery at

Abstract 248: Substance Abuse is Associated with Observation Status of Patients with Heart Failure at an Urban Academic Medical Center

Background: More than 80% of patients presenting to the emergency department (ED) with acute decompensated heart failure (ADHF) are admitted and categorized as either observation (OBS) or inpatient (IP) post discharge using Interqual criteria (severity of illness and intensity of service). Identifying patient characteristics upon admission to determine OBS or IP status may optimize hospital resource utilization. Purpose: To determine patient characteristics upon admission that are associated with the categorization (OBS vs IP) for patients with ADHF presenting to the ED of an urban academic medical center. Methods: Retrospective medical record review of 172 randomly selected adult patients from 2013 who presented to the ED with ADHF. Patients had been categorized as OBS vs IP after discharge based on Interqual Criteria. Based on the literature, we identified variables traditionally associated with an admitting diagnosis for heart failure (HF) including: symptoms (shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, and lower extremity edema), physiologic measures (B-type natriuretic peptide and blood pressure), and patient characteristics (number of co-morbidities, type of HF- HF with reduced ejection fraction vs HF with preserved ejection fraction, 30 day readmission rate, gender, ethnicity, and history of substance abuse within the past 12 months). Chi square tests and student t-tests were used to compare variables between groups. Results: Of the 172 ADHF patients, 76% (n=131) were categorized as IP and 24% (n=41) were OBS. The majority of patients were African American (n = 130, 75.6%), female (n = 101, 58.7%) and had HF with a reduced ejection fraction (n = 99, 57.6%). There were no significant differences between the OBS and IP groups in terms of symptoms, B-type natriuretic peptide levels, blood pressure, number of co-morbidities, type of HF, 30 day readmission rate, gender, ethnicity, or socio-demographic characteristics. A history of substance abuse was more common among the OBS group versus the IP group ( p = 0.013). Conclusions: In this single center retrospective medical record review comparing the categorization of patients presenting to the ED with ADHF as OBS vs IP, we found no difference in the traditional clinical variables between groups. However, a history of substance abuse was associated with the patient being categorized as OBS. Substance abuse may be an important non-traditional variable to consider in resource utilization.

Sequentially Updated Discharge Model for Optimizing Hospital Resource Use and Surgical Patients’ Satisfaction

The ability to estimate cardiac surgical patients' length of stay (LOS) and discharge to a continuing care facility (nonhome discharge) may allow earlier discharge planning and optimal use of limited hospital resources. We developed a sequentially updated tool for postoperative discharge planning. Using preoperative, intraoperative, and postoperative day (POD) 2 and POD 4 variables, we created and validated a model to predict early discharge (less than 4 days), standard discharge (5 to 8 days), delayed discharge (9 to 14 days), late discharge (more than 15 days), and nonhome discharge. When predicting LOS, model accuracy using preoperative variables alone had a C-statistic of 0.80, but improved with sequential addition of intraoperative and POD 2 (0.87) and POD 4 variables (0.89). At 48 hours, the strongest predictors of longer LOS were higher preoperative creatinine, elevated blood urea nitrogen, lower postoperative albumin, atrial fibrillation, and longer intensive care unit stay. On POD 4, the strongest predictors were red blood cell transfusion, lower postoperative albumin, white blood cell transfusion, longer intensive care unit stay, and readmission to the intensive care unit. For nonhome discharge, however, preoperative variables alone produced a highly predictive model (C-statistic 0.88), and sequential addition of intraoperative and POD 2 (C-statistic 0.91) and POD 4 data (C-statistic 0.90) did not significantly improve it. This sequentially updated model of postoperative LOS can be used by the discharge planning team to identify both patients imminently ready for discharge and patients with a high likelihood of nonhome discharge, with the goals of decreasing unnecessary hospital days, managing patients' expectations, and engaging patients early in the discharge process.

At-home Management of Adult Patients Following Consolidation Chemotherapy for Acute Myeloid Leukemia

Background: Consolidation chemotherapy for adult patients with acute myeloid leukemia (AML) who have achieved a complete response after induction treatment is associated with prolonged, severe neutropenia and a high incidence of infections. In our center, patients were historically followed up during the neutropenic period at the day care unit, usually every 2 or 3 days, where they had routine laboratory tests, blood transfusions, central venous catheter management and medical checkups. Since this strategy was associated with a high incidence of febrile episodes that lead to hospital readmissions with some patients dying due to infectious complications, we designed a specific program for patients with AML receiving consolidation therapy including a specialized at-home management. Patients and Methods: Since March 2011, all consecutive patients with AML without significant co-morbidities or active febrile complications who received consolidation chemotherapy and lived within 60 minutes of the hospital were included in the at-home program (AHP). During the neutropenic period, a specialized nurse took care of every patient daily, either visiting the patient at home or by phone. A record of the vital signs, routine laboratory tests, central venous catheter management and administration of intravenous medication was kept regularly by the nurse. Antibiotic prophylaxis consisted of oral levofloxacin (500 mg daily), oral posaconazole (200 mg, three times per day) and intravenous ceftriaxone during the neutropenic ( Results: Up until February 2014, 29 out of 31 (94%) patients were included in the AHP, with a total of 60 episodes. Only 2 patients were excluded from the program, one because of lack of informed consent and the other due to an active febrile complication. The control group consisted of 40 out of 42 (98%) patients (56 episodes in total), who received consolidation treatment following the standard outpatient from May 2004 to March 2011. Median duration of severe neutropenia was of 11 (4-34) days in the AHP group compared with 18 (2-55) days in the control group (p Conclusion: At-home management after administration of consolidation therapy in adult patients diagnosed with AML is feasible in most patients. It is associated to a lower incidence of febrile complications and readmissions, contributing to increase safety for patients and optimizing hospital resources. Disclosures No relevant conflicts of interest to declare.