Discharge Pathway Research Articles

Feasibility and safety of same-day discharge following single-port robotic-assisted laparoscopic prostatectomy.

The standard discharge pathway following robotic-assisted laparoscopic prostatectomy (RALP) involves overnight hospital admission. Models for same-day discharge (SDD) have been explored for multiport RALP, however, less is known regarding SDD for single-port RALP, especially in terms of patient experience. Patient enrollment, based on preoperative determination of potential SDD eligibility, commenced March 2020 and ended March 2021. Day-of-surgery criteria were utilized to determine which enrolled patients underwent SDD. Differences in preoperative characteristics and perioperative outcomes between patients undergoing SDD and patients undergoing standard discharge were evaluated. A prospectively administered questionnaire was designed to characterize patient-centered factors informing SDD perception. Fifteen patients underwent SDD and 36 underwent standard discharge. Overall mean ± SD age and BMI were 63.6 ± 7.0years and 29.7 ± 4.4kg/m2, respectively. Mean operative time was shorter in the SDD cohort than the standard discharge cohort (188min vs 217min, p = 0.011). A higher proportion of cases that underwent SDD were performed using the Retzius-sparing approach, 80% (12/15) vs 33% (12/36) in the standard discharge cohort (p = 0.005). Rates of 90day complication (p = 0.343), 90day readmission (p = 0.144), and 90day emergency department visits (p = 0.343) rates were all not significantly different between cohorts. Of questionnaire respondents undergoing standard discharge, 32% (8/25) cited pain as a reason for not undergoing SDD. With comparable outcomes to the standard discharge pathway, SDD is safe and effective in single-port RALP. Post-operative pain and perceptions of distance are implicated as patient-centered barriers to SDD; proactive pain management and patient education strategies may facilitate SDD.

361 EXPLORING THE EXPERIENCES OF HEALTHCARE PROFESSIONALS (HCPS) WORKING IN ACUTE STROKE DURING THE COVID-19 PANDEMIC: A QUALITATIVE STUDY

Abstract Background The COVID-19 pandemic had a significant impact on the delivery of stroke care internationally. The INAS (Irish National Audit for Stroke) report 2020, found that there was no significant disruption to stroke services as a result of the COVID-19 pandemic. Little is known about the experiences of Health-Care Professionals (HCPs) who were working in stroke care during the COVID-19 pandemic. This study explored the experiences of HCPs working in acute stroke care in an Irish hospital group during the COVID-19 pandemic. Methods A qualitative descriptive study was conducted. Using a combination of purposive and snowball sampling, 16 semi-structured interviews of healthcare professionals from six specialities (Medicine, Nursing, Physiotherapy, Occupational therapy, Speech and Language Therapy and Medical Social Work) in two model three hospitals and one model four hospital were conducted. Interviews were virtual. Analysis was completed using the Braun and Clarke six-step method. This research was approved by the Royal College of Surgeons Research Ethics committee and permission was secured from the Stroke Clinical lead at each site to conduct interviews. Results Two main themes emerged: (i) Disruption of the end-to-end acute stroke pathway and (ii) Opportunities of the pandemic to develop a new model of care. Theme (i) suggests challenges were experienced in emergency care, access to Stroke Units (SU) beds and multidisciplinary teams (MDT). In theme (ii) participants described opportunities in telemedicine, the development of new rehabilitation and existing Early Supported Discharge (ESD) pathways. Conclusion This study highlights the lived experience of HCPs, the disruption to the stroke pathway and the opportunities as a result of the pandemic. It demonstrates the need for further exploration of, telemedicine, alternative rehabilitation pathways in stroke care and the need for a wider stroke education programme for HCPs working outside stroke. Finally, this study highlights the unwavering resilience and empathy of HCPs working in Stroke.

Insulation degradation and fracture cracks of mechanical impacted thermal‐ageing oil‐impregnated papers

In order to elucidate mechanical impacts affecting the insulation strength of thermal-ageing oil-impregnated pressboards, we perform mechanical degradation experiments of impacting forces that are represented as the winding-suffered stresses on thermal-ageing oil-paper insulation in transient short-circuit of transformer. Water content, degree of polymerisation (DP), partial discharge inception voltage and AC breakdown field strength are tested and analysed for diverse thermal-ageing levels. An analytical model of mechanical degradation is established by relating dielectric breakdown strength to mechanical impact. Mechanical impacts result in less water content in thermal-aging oil-impregnated pressboards while causing reduction and increment of DP, respectively, in mildly and severely aged oil-impregnated pressboards. Partial discharge inception voltage and dielectric breakdown strength vary significantly with the numbers of impact cycles, showing a maximum value under low-intensity impact and decreasing monotonously under high-intensity impact. High-intensity mechanical impacts will evidently exacerbate the thermal deterioration process of oil-impregnated pressboards, which is primarily attributed to cellulose fibre fractures in pressboard cracks produced by equivalent tensile stress of mechanical impacts. It is acceptable for mildly aged oil-impregnated pressboards to suffer low-intensity mechanical impacts that will alleviate insulation degradation by restraining partial discharge in smaller oil-gaps and prolonging breakdown discharge pathways along impact-caused cracks.

Febrile illness in high-risk children: a prospective, international observational study

To assess and describe the aetiology and management of febrile illness in children with primary or acquired immunodeficiency at high risk of serious bacterial infection, as seen in emergency departments in tertiary hospitals. Prospective data on demographics, presenting features, investigations, microbiology, management, and outcome of patients within the ‘Biomarker Validation in HR patients’ database in PERFORM, were analysed. Immunocompromised children (< 18 years old) presented to fifteen European hospitals in nine countries, and one Gambian hospital, with fever or suspected infection and clinical indication for blood investigations. Febrile episodes were assigned clinical phenotypes using the validated PERFORM algorithm. Logistic regression was used to assess the effect size of predictive features of proven/presumed bacterial or viral infection. A total of 599 episodes in 482 children were analysed. Seventy-eight episodes (13.0%) were definite bacterial, 67 episodes probable bacterial (11.2%), and 29 bacterial syndrome (4.8%). Fifty-five were definite viral (9.2%), 49 probable viral (8.2%), and 23 viral syndrome (3.8%). One hundred ninety were unknown bacterial or viral infections (31.7%), and 108 had inflammatory or other non-infectious causes of fever (18.1%). Predictive features of proven/presumed bacterial infection were ill appearance (OR 3.1 (95% CI 2.1–4.6)) and HIV (OR 10.4 (95% CI 2.0–54.4)). Ill appearance reduced the odds of having a proven/presumed viral infection (OR 0.5 (95% CI 0.3–0.9)). A total of 82.1% had new empirical antibiotics started on admission (N = 492); 94.3% proven/presumed bacterial (N = 164), 66.1% proven/presumed viral (N = 84), and 93.2% unknown bacterial or viral infections (N = 177). Mortality was 1.9% (N = 11) and 87.1% made full recovery (N = 522). Conclusion: The aetiology of febrile illness in immunocompromised children is diverse. In one-third of cases, no cause for the fever will be identified. Justification for standard intravenous antibiotic treatment for every febrile immunocompromised child is debatable, yet effective. Better clinical decision-making tools and new biomarkers are needed for this population.What is Known:• Immunosuppressed children are at high risk for morbidity and mortality of serious bacterial and viral infection, but often present with fever as only clinical symptom.• Current diagnostic measures in this group are not specific to rule out bacterial infection, and positivity rates of microbiological cultures are low.What is New:• Febrile illness and infectious complications remain a significant cause of mortality and morbidity in HR children, yet management is effective.• The aetiology of febrile illness in immunocompromised children is diverse, and development of pathways for early discharge or cessation of intravenous antibiotics is debatable, and requires better clinical decision-making tools and biomarkers.

Patient survey examining the experience of care of a hospital-based opt-out tobacco dependency treatment service (the CURE Project)

IntroductionTreating tobacco dependency in patients admitted to hospital is a key priority in the National Health Service long-term plan. This service evaluation assessed the perception, needs and experience of care...

IDENTIFYING SOCIAL FACTORS THAT MAY LIMIT EARLY DISCHARGE IN LOW-RISK ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

The implementation of the Zwolle Risk Score (ZRS) has been shown to effectively triage patients based on clinical and angiographic parameters to coronary care unit (high risk) or the general telemetry ward (low risk) following percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). With the utilization of early discharge pathways in low-risk STEMI, patients have been safely discharged within 48 hours. Growing concerns of resource scarcity have compelled a local interest in the development of an early discharge protocol in patients with minimal comorbidities and suitable social circumstances.

Assessment of groundwater discharge pathways in a till-dominated coastal aquifer

Study regionMabou Harbour located in Cape Breton Island, Nova Scotia, Canada, is representative of the many natural harbours throughout the Maritime region of Canada as the surrounding landscape is overlain by glacial deposits, predominantly composed of glacial till. Study focusUnderstanding the pathways facilitating groundwater flow and associated solute transport to the ocean is key for developing conceptual hydrogeologic models for coastal watersheds and for informing coastal zone management. Most local-scale field and modelling submarine groundwater discharge (SGD) studies have been conducted in high-permeability formations given the likely importance of SGD in these coastal settings. This study investigates direct (SGD) and indirect (seaward stream baseflow) groundwater discharge from a till dominated coastal aquifer using a combination of field measurements (river flow and baseflow separation, seepage meter measurements, and water temperature analysis) and a calibrated 3D numerical groundwater flow model. New hydrological insights for the regionResults show that seaward stream baseflow greatly exceeds direct SGD to the ocean on the scale of the full harbour watershed (96.1% vs. 3.9 of total groundwater discharge). Particle tracking shows that the vast majority of SGD originates in the subcatchment immediately surrounding the harbour with limited intermediate or regional flow. The shorter flow paths and residence times for direct SGD results in less opportunity for natural attenuation processes and may have implications for groundwater-borne contamination to this harbour.

Reexamining the Role of Postoperative ICU Admission for Patients Undergoing Elective Craniotomy: A Systematic Review.

The standard-of-care for postoperative care following elective craniotomy has historically been ICU admission. However, recent literature interrogating complications and interventions during this postoperative ICU stay suggests that all patients may not require this level of care. Thus, hospitals began implementing non-ICU postoperative care pathways for elective craniotomy. This systematic review aims to summarize and evaluate the existing literature regarding outcomes and costs for patients receiving non-ICU care after elective craniotomy. A systematic review of the PubMed database was performed following PRISMA guidelines from database inception to August 2021. Included studies were published in peer-reviewed journals, in English, and described outcomes for patients undergoing elective craniotomies without postoperative ICU care. Data regarding study design, patient characteristics, and postoperative care pathways were extracted independently by two authors. Quality and risk of bias were evaluated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence tool and Risk Of Bias In Non-Randomized Studies-of Interventions tool, respectively. In total, 1,131 unique articles were identified through the database search, with 27 meeting inclusion criteria. Included articles were published from 2001 to 2021 and included non-ICU inpatient care and same-day discharge pathways. Overall, the studies demonstrated that postoperative non-ICU care for elective craniotomies led to length of stay reduction ranging from 6 hours to 4 days and notable cost reductions. Across 13 studies, 53 of the 2,469 patients (2.1%) intended for postoperative management in a non-ICU setting required subsequent care escalation. Overall, these studies suggest that non-ICU care pathways for appropriately selected postcraniotomy patients may represent a meaningful opportunity to improve care value. However, included studies varied greatly in patient selection, postoperative care protocol, and outcomes reporting. Standardization and multi-institutional collaboration are needed to draw definitive conclusions regarding non-ICU postoperative care for elective craniotomy.

Optimising the balance of acute and intermediate care capacity for the complex discharge pathway: Computer modelling study during COVID-19 recovery in England.

ObjectivesWhile there has been significant research on the pressures facing acute hospitals during the COVID-19 pandemic, there has been less interest in downstream community services which have also been challenged in meeting demand. This study aimed to estimate the theoretical cost-optimal capacity requirement for ‘step down’ intermediate care services within a major healthcare system in England, at a time when considerable uncertainty remained regarding vaccination uptake and the easing of societal restrictions.MethodsDemand for intermediate care was projected using an epidemiological model (for COVID-19 demand) and regressing upon public mobility (for non-COVID-19 demand). These were inputted to a computer simulation model of patient flow from acute discharge readiness to bedded and home-based Discharge to Assess (D2A) intermediate care services. Cost-optimal capacity was defined as that which yielded the lowest total cost of intermediate care provision and corresponding acute discharge delays.ResultsIncreased intermediate care capacity is likely to bring about lower system-level costs, with the additional D2A investment more than offset by substantial reductions in costly acute discharge delays (leading also to improved patient outcome and experience). Results suggest that completely eliminating acute ‘bed blocking’ is unlikely economical (requiring large amounts of downstream capacity), and that health systems should instead target an appropriate tolerance based upon the specific characteristics of the pathway.ConclusionsComputer modelling can be a valuable asset for determining optimal capacity allocation along the complex care pathway. With results supporting a Business Case for increased downstream capacity, this study demonstrates how modelling can be applied in practice and provides a blueprint for use alongside the freely-available model code.

A nurse-led cardiovascular disease prevention clinic

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Bayer Background Patients who present to our hospital with a vascular event receive appropriate preventative measures and are discharged to Primary Care without further specialist review. We have initiated a Cardiovascular Disease Prevention Clinic to provide specialist review for all patients at one year following their index event. Purpose This project was undertaken to assess the implementation of guideline-directed preventative treatment within our current patient pathway, thereby establishing the need for, and the likelihood of benefiting from a secondary care specialist clinic. Methods The medical notes of all patients on our angiography database over a 6 month period were scrutinised. This included the majority of patients diagnosed with acute coronary syndromes [ACS] and symptomatic coronary artery disease [CAD] over this period. Patients with confirmed atheromatous CAD were screened for clinical features that would put them at high risk of recurrent events. These risk factors were identified in recent landmark trials[1,2] and include: diabetes, eGFR &amp;lt;60, age &amp;gt;65 years, multi-vessel disease, recurrent events within 3 years, and heart failure. Of the high risk patients, those whose management was deemed suboptimal were invited to attend the clinic that is nurse led, protocol driven, with a Consultant available for advice. All appointments were conducted via telephone in view of COVID precautions. Patients were assessed according to guideline targets for cardiovascular risk factors[3,4,5]. Lifestyle habits were reviewed with appropriate guidance provided for the patient. Results 833 patients were screened, of which 175 patients fulfilled the above criteria and so invited to the clinic. 2 patients declined the appointment. Table 1 summarises the guideline targets not achieved by the high risk cohort. 132 patients (75.8%) met the criteria for consideration for DOAC[6]. Of these, 80 (60%) had a relative bleeding contraindication or declined therapy. 155 (88.6%) met the criteria for consideration for longer-term P2Y12i[7]. Of these 139 (89.7%) had relative bleeding contraindications or declined therapy. Interventions implemented at this clinic are summarised in Table 2. All patients were given advice with regard to lifestyle modification strategies. Conclusion The discharge pathway for patients diagnosed with ACS and symptomatic CAD includes cardiologist prescribing, cardiac rehabilitation nurse review and primary care follow-up. Despite this, we showed that a significant number of patients with CAD and at high risk of recurrent events failed to achieve secondary prevention targets at one year following their index event. A specialist CVD prevention follow-up clinic can result in significant improvements in patient management over and above the usual standard of care and we should anticipate a reduction in cardiovascular events as a result of this. A nurse led clinic with prescribing protocols based on current guidelines is a successful clinic model.

Salt Transport Under Tide and Evaporation in a Subtropical Wetland: Field Monitoring and Numerical Simulation

AbstractTidal wetland ecosystems are sensitive to porewater salinity dynamics. However, it is unclear how salts move and distribute in these wetlands, particularly how the salts accumulated by evaporation get removed from the wetland soil, so that the salinity levels may stabilize to accommodate vegetation. We conducted a combined field and modeling study to identify the porewater flow and salinity patterns in a subtropical wetland subjected to tidal inundation and evaporation. Measured and simulated salinity contours indicated the formation of hypersaline porewater plumes in the upper intertidal zone and the fresher porewater zones with salinity close to that of seawater near the creek and in the supratidal zone. Simulations indicated the discharge of the hypersaline upper intertidal porewater to the creek with a discharge pathway developed under the fresher near‐creek porewater zone, and this was further confirmed by the field‐observed significant salinity gradient under the creek. Our model suggested that both water and salt discharge from the wetland soil occurred predominantly at the creek bank and creek bed. The porewater discharge is more intensive through the creek bank than the creek bed, while the salt discharge across both the creek bank and creek bed was comparable due to the much higher salinity level under the creek bed. Salt discharge driven by density gradients and tidal‐induced porewater circulation provides a mechanism for removing salts accumulated in the upper intertidal zone due to evaporation and could prevent salt flat formation and marsh plants dieback.

Increased Complications in Octogenarians Undergoing Same-Day Discharge following Total Knee Arthroplasty: A Matched Cohort Analysis.

Same-day discharge pathways in total knee arthroplasty (TKA) are gaining popularity as a means to increase patient satisfaction and reduce overall costs, but these pathways have not been thoroughly evaluated in potentially at-risk populations, such as in patients ≥80 years old. The purpose of this study was to compare 90-day complications and mortality following same-day discharge after primary TKA in patients ≥80 years old and those <80 years old. Patients who underwent unilateral primary TKA, were discharged on postoperative day 0, and had a minimum 90-day follow-up were identified in a national insurance claims database (PearlDiver Technologies) using Current Procedural Terminology code 27447. These patients were stratified into two cohorts based upon age: (1) nonoctogenarians (<80 years old) and (2) octogenarians (≥80 years old). These cohorts were propensity matched based upon sex, Charlson comorbidity index, and obesity status. Univariate analysis was performed to determine differences in 90-day complications and mortality between the two cohorts. In total, 1,111 patients were included in each cohort. Both cohorts were successfully matched, with no observed differences in matched parameters for demographics or comorbidities. There was no significant difference in 90-day mortality between the two cohorts (p = 0.896). However, octogenarians were at significantly increased risk of postoperative atrial fibrillation (20.8 vs. 10.4%; p < 0.001), nonatrial fibrillation arrhythmias (8.4 vs. 5.6%; p = 0.009), pneumonia (4.5 vs. 2.2%; p = 0.002), stroke (3.1 vs. 1.7%; p = 0.037), heart failure (10.5 vs. 7.5%; p = 0.012), and urinary tract infection (UTI; 14.3 vs. 9.4%; p < 0.001) compared with the nonoctogenarian cohort. Relative to matched controls, octogenarians were at significantly increased risk of numerous 90-day medical complications following same-day primary TKA, including cardiopulmonary complications, stroke, and UTI. Clinicians should be cognizant of these complications and counsel patients appropriately when electing to perform same-day TKA in the octogenarian population.

Assessment of Spatio-Temporal Variability of Faecal Pollution along Coastal Waters during and after Rainfall Events

More than 80% of wastewaters are discharged into rivers or seas, with a negative impact on water quality along the coast due to the presence of potential pathogens of faecal origin. Escherichia coli and enterococci are important indicators to assess, monitor, and predict microbial water quality in natural ecosystems. During rainfall events, the amount of wastewater delivered to rivers and coastal systems is increased dramatically. This study implements measures capable of monitoring the pathways of wastewater discharge to rivers and the transport of faecal bacteria to the coastal area during and following extreme rainfall events. Spatio-temporal variability of faecal microorganisms and their relationship with environmental variables and sewage outflow in an area located in the western Adriatic coast (Fano, Italy) was monitored. The daily monitoring during the rainy events was carried out for two summer seasons, for a total of five sampling periods. These results highlight that faecal microbial contaminations were related to rainy events with a high flow of wastewater, with recovery times for the microbiological indicators varying between 24 and 72 h and influenced by a dynamic dispersion. The positive correlation between ammonium and faecal bacteria at the Arzilla River and the consequences in seawater can provide a theoretical basis for controlling ammonium levels in rivers as a proxy to monitor the potential risk of bathing waters pathogen pollution.

Gas Leakage From Shallow Ponding Magma and Trapdoor Faulting at Sierra Negra Volcano (Isabela Island, Galápagos)

AbstractWe report on new volcanic gas composition results acquired in October 2017 at Minas de Azufre, a persistent fumarolic field topping the resurgent Sierra Negra caldera, in the Galápagos archipelago. Our results indicate that the Minas de Azufre fumaroles are moderately hydrous (52–64 mol.% H2O) and rich in CO2 (35–46 mol.%), with total sulfur (ST) being 21–35 times less abundant than CO2. SO2, the most abundant S species, is released at an average rate of 19 ± 9 tons/day. Using a volatile saturation model that provides the composition of magmatic gases at equilibrium with western Galápagos basaltic melt (48 wt. % SiO2) in the 400–0.1 MPa pressure range, we infer that Minas de Azufre fumarolic emissions consist of a mixture of (a) magma‐derived gases coexisting with a melt at ∼50–60 MPa and (b) shallow meteoric water. We thus propose that the fumaroles are supplied by outgassing of magma stored in a ∼2 km deep sill‐like reservoir underneath the caldera floor, and that the trapdoor fault system at the western margin of the resurgent caldera block acts as a preferential pathway for magmatic gas ascent and surface discharge. Our results thus suggest that, in contrast to the majority of the volcano‐hosted hydrothermal systems worldwide, Minas de Azufre releases a relatively pristine magmatic gas.

Assessing Effects of Sediment Delivery to Coral Reefs: A Caribbean Watershed Perspective

Coral reefs in the western Atlantic and Caribbean are deteriorating primarily from disease outbreaks, increasing seawater temperatures, and stress due to land-based sources of pollutants including sediments associated with land use and dredging. Sediments affect corals in numerous ways including smothering, abrasion, shading, and inhibition of coral recruitment. Sediment delivery resulting in deposition and water quality deterioration can cause degradation at the spatial scale of corals or entire reefs. We still lack rigorous long-term studies of coral cover and community composition before, during and after major sediment stress, and evidence of recovery after watershed management actions. Here we present an overview of the effects of terrestrial sediments on corals and coral reefs, with recent advances in approaches to watershed assessment relevant to the delivery of sediments to these ecosystems. We present case studies of northeastern Caribbean watersheds to illustrate challenges and possible solutions and to draw conclusions about the current state of knowledge of sediment effects on coral reefs. With a better understanding of erosion and the pathways of sediment discharge to nearshore reefs, there is the increased potential for management interventions.

Deciphering CO2 Reduction Reaction Mechanism in Aprotic Li–CO2 Batteries using In Situ Vibrational Spectroscopy Coupled with Theoretical Calculations

The aprotic Li–CO2 battery represents a sustainable technology by virtue of energy storage capability and CO2 recyclability. However, the CO2 reduction reaction (CO2RR) mechanism underpinning the operation of Li–CO2 batteries is not yet completely understood. Herein, using in situ surface-enhanced Raman spectroscopy coupled with density functional theory calculations, we obtain direct spectroscopic evidence of the CO2RR (i.e., CO2–, CO, and Li2CO3) and propose a surface-mediated discharge pathway (i.e., 2Li+ + 2CO2 + 2e– → CO + Li2CO3) in Li–CO2 batteries. We also highlight the significant effect of the electrocatalysts’ near-Fermi-level d-orbital states on the CO2RR activity through a systematic comparative study of model electrocatalysts. Moreover, deep CO2RR via “4Li+ + 3CO2 + 4e– → 2Li2CO3 + C” may be difficult to proceed because of the sluggish chemical steps involved (e.g., dimerization of two CO2– intermediates). This work provides molecular insights into the CO2RR mechanism in a Li+-aprotic medium and will be beneficial for next-generation Li–CO2 batteries.

Referring hospital involvement in early discharge post transcatheter aortic valve implantation: the TAVI (R-) EXPRES program

Aim: Over the past decade, transcatheter aortic valve implantation (TAVI) has matured into a valid treatment strategy for elderly patients with severe aortic stenosis. TAVI programs will grow with its adoption in low-risk patients. The aim of this study was to evaluate safety and feasibility of early discharge protocols, either home or back to a referring hospital. Methods: Consecutive patients undergoing TAVI between July 2017 and July 2019 were stratified into three discharge pathways from TAVI center: (1) early home (EXPRES); (2) early transfer to referring hospital (R-EXPRES); and (3) routine discharge (standard). Baseline, procedural, and 30-day outcomes were prospectively collected and compared per discharge pathway. Results: In total, 22 (5%) patients were enrolled in the EXPRES cohort [median age 78 (IQR: 73-81); mean Society of Thoracic Surgeons (STS) 2.4% ± 1.5%], 121 (29%) in the R-EXPRES cohort [median age 81 (IQR: 77-84); mean STS 4.3% ± 2.8%], and 269 (65%) in the routine discharge cohort [median age 80 (IQR: 75-85); mean STS 4.4% ± 3.1%]. EXPRES patients trended to be younger (P = 0.13) and had lower STS (P = 0.02). Early clinical outcome was similar through the different pathways including re-hospitalization rate. Median length of stay was one day longer for R-EXPRES vs. routine discharge patients [5 (IQR: 4-7) vs. 4 (IQR: 3-6); P &lt; 0.01]. Median length of stay (LOS) was two days (IQR: 1-3 days) for EXPRES patients. Conclusion: Early discharge pathways home and to referral hospitals are safe and help streamline TAVI programs. LOS in referring hospitals may be further reduced.

Runoff and discharge pathways of microplastics into freshwater ecosystems: A systematic review and meta-analysis

Although many studies have focused on the importance of littering and (or) illegal dumping as a source of plastic pollution to freshwater, other relevant pathways should be considered, including wastewater, stormwater runoff, industrial effluent/runoff, and agricultural runoff. Here, we conducted a meta-analysis focused on these four pathways. We quantified the number of studies, amount and characteristics of microplastics reported, and the methods used to sample and measure microplastics from each pathway. Overall, we found 121 studies relevant to our criteria, published from 2014 to 2020. Of these, 54 (45%) quantified and characterized microplastics in discharge pathways. Although most focused on wastewater treatment plant effluent (85%), microplastic concentrations were highest in stormwater runoff (0.009 to 3862 particles/L). Morphologies of particles varied among pathways and sampling methods. For example, stormwater runoff was the only pathway with rubbery particles. When assessing methods, our analysis suggested that water filtered through a finer (&lt;200 um) mesh and of a smaller volume (e.g., 6 L) captured more particles, and with a slightly greater morphological diversity. Overall, our meta-analysis suggested that all four pathways bring microplastics into freshwater ecosystems, and further research is necessary to inform the best methods for monitoring and to better understand hydrologic patterns that can inform local mitigation.

Where to next? An exploration of patients with disability and complex needs who leave acute care hospitals via an interim discharge pathway.

Objective To examine the characteristics and circumstances of admitted patients with disability who require individualised supports to leave hospital and who experience interim discharge arrangements. Methods The study used a retrospective exploratory design. Medical chart reviews of patients with disability who required funded support to leave hospital were conducted. The records of 224 patients admitted to one of three hospital facilities in South-East Queensland, Australia, between May 2017 and January 2020 were reviewed. Information about hospital facility, demographic characteristics, disability type, support needs, discharge destination, and reasons for interim discharges were extracted for analysis. Results Forty of 224 patients were discharged to an interim destination. Inter-hospital transfers were the most common interim discharge arrangement. Being divorced or separated was the only demographic variable associated with having an interim discharge arrangement for admitted patients with disability. More patients with disability who experienced an interim discharge required accommodation supports and behavioural supports compared to patients who were not involved in interim discharges. Conclusions Patients with disability with minimal informal support and who rely on a sophisticated mix of individualised supports to leave hospital may be more susceptible to interim discharge arrangements. Early identification of these patients and formal mechanisms for ensuring continuous coordination of ongoing transitions and supports is critical to avoid sub-optimal outcomes. Future research is needed to capture a complete picture of the series of transitions of interim discharged patients with disability leaving acute care facilities and the quality of their supports and outcomes.

Barriers to Implementation of a Same-Day Discharge Pathway for Holmium Laser Enucleation of the Prostate

ObjectiveTo investigate perceived barriers to successful same-day discharge (SDD) after holmium laser enucleation of the prostate (HoLEP) from the perspective of surgical and nursing staff members. MethodsA 17-question survey was administered to intraoperative and postoperative surgical staff in June 2021 after a six-month period of implementing a SDD HoLEP pathway with same-day catheter removal. McNemar's and Stuart-Maxwell tests were performed for statistical analysis. ResultsSurveys were completed by 30 respondents. The majority of respondents had less than 5 years of surgical experience (63%). Almost all respondents (96%) felt that HoLEP patients could be discharged safely on day of surgery. Overall, 60% felt that HoLEP had a lower risk of post-operative bleeding compared to other transurethral surgeries. There was a significant decrease in number of respondents that felt apprehensive when comparing initiation of SDD HoLEP pathway to 6-months post-implementation (43% vs 7%, P = .003). The most common factors causing apprehension both pre- and post-implementation included: degree of hematuria (43% vs 40%, P = .56), risk of failure of trial of void (40% vs 30%, P = .26), and risk of readmission or unplanned emergency department (ED) visit (33% vs 30%, P = .48). There was a significant decrease in the number of respondents who were apprehensive about lack of experience with SDD after HoLEP comparing pre- and post-implementation (20% vs 0%, P = .01). ConclusionWhile staff report initial apprehension regarding implementation of a SDD HoLEP pathway, adequate support to intraoperative and postoperative teams helps build experience that alleviates these concerns.