Post-hospital Discharge Mortality Research Articles

Predictors of prolonged hospitalization of COVID-19 patients.

Despite the importance of hospital bed network during the pandemic, there are scarce data available regarding factors predictive of prolonged length of hospitalization of COVID-19 patients. We retrospectively analyzed a total of 5959 consecutive hospitalized COVID-19 patients in period 3/2020-6/2021 from a single tertiary-level institution. Prolonged hospitalization was defined as hospital stay > 21days to account for mandatory isolation period in immunocompromised patients. Median length of hospital stay was 10days. A total of 799 (13.4%) patients required prolonged hospitalization. Factors that remained independently associated with prolonged hospitalization in multivariate analysis were severe or critical COVID-19 and worse functional status at the time of hospital admission, referral from other institutions, acute neurological, acute surgical and social indications for admission vs admission indication of COVID-19 pneumonia, obesity, chronic liver disease, hematological malignancy, transplanted organ, occurrence of venous thromboembolism, occurrence of bacterial sepsis and occurrence of Clostridioides difficile infection during hospitalization. Patients requiring prolonged hospitalization experienced higher post-hospital discharge mortality (HR = 2.87, P < 0.001). Not only severity of COVID-19 clinical presentation but also worse functional status, referral from other hospitals, certain indications for admission, certain chronic comorbidities, and complications that arise during hospital stay independently reflect on the need of prolonged hospitalization. Development of specific measures aimed at improvement of functional status and prevention of complications might reduce the length of hospitalization.

Red cell distribution width is a potent prognostic parameter for in-hospital and post-discharge mortality in hospitalized coronavirus disease 2019 patients: a registry-based cohort study on 3941 patients

AimTo investigate clinical and prognostic associations of red cell distribution width (RDW) in hospitalized coronavirus disease 2019 (COVID-19) patients.MethodsWe retrospectively analyzed the records of 3941 consecutive COVID-19 patients admitted to a tertiary-level institution from March 2020 to March 2021 who had available RDW on admission.ResultsThe median age was 74 years. The median Charlson comorbidity index (CCI) was 4. The majority of patients (84.1%) on admission presented with severe or critical COVID-19. Patients with higher RDW were significantly more likely to be older and female, to present earlier during infection, and to have higher comorbidity burden, worse functional status, and critical presentation of COVID-19 on admission. RDW was not significantly associated with C-reactive protein, occurrence of pneumonia, or need for oxygen supplementation on admission. During hospital stay, patients with higher RDW were significantly more likely to require high-flow oxygen therapy, mechanical ventilation, intensive care unit, and to experience prolonged immobilization, venous thromboembolism, bleeding, and bacterial sepsis. Thirty-day and post-hospital discharge mortality gradually increased with each rising RDW percent-point. In a series of multivariate Cox-regression models, RDW demonstrated robust prognostic properties at >14% cut-off level. This cut-off was associated with inferior 30-day and post-discharge survival independently of COVID-19 severity, age, and CCI; and with 30-day survival independently of COVID severity and established prognostic scores (CURB-65, 4C-mortality, COVID-gram and VACO-index).ConclusionRDW has a complex relationship with COVID-19-associated inflammatory state and is affected by prior comorbidities. RDW can improve the prognostication in hospitalized COVID-19 patients.

Long-Term Outcomes in ICU Patients with Delirium: A Population-based Cohort Study.

Rationale: Delirium is common in the ICU and portends worse ICU and hospital outcomes. The effect of delirium in the ICU on post–hospital discharge mortality and health resource use is less well known.Objectives: To estimate mortality and health resource use 2.5 years after hospital discharge in critically ill patients admitted to the ICU.Methods: This was a population-based, propensity score–matched, retrospective cohort study of adult patients admitted to 1 of 14 medical–surgical ICUs from January 1, 2014, to June 30, 2016. Delirium was measured by using the 8-point Intensive Care Delirium Screening Checklist. The primary outcome was mortality. The secondary outcome was a composite measure of subsequent emergency department visits, hospital readmission, or mortality.Measurements and Main Results: There were 5,936 propensity score–matched patients with and without a history of incident delirium who survived to hospital discharge. Delirium was associated with increased mortality 0–30 days after hospital discharge (hazard ratio, 1.44 [95% confidence interval, 1.08–1.92]). There was no significant difference in mortality more than 30 days after hospital discharge (delirium: 3.9%, no delirium: 2.6%). There was a persistent increased risk of emergency department visits, hospital readmissions, or mortality after hospital discharge (hazard ratio, 1.12 [95% confidence interval, 1.07–1.17]) throughout the study period.Conclusions: ICU delirium is associated with increased mortality 0–30 days after hospital discharge.

Vulnerability and agency across treatment-seeking journeys for acutely ill children: how family members navigate complex healthcare before, during and after hospitalisation in a rural Kenyan setting

BackgroundChild mortality rates during hospitalisation for acute illness and after discharge are unacceptably high in many under-resourced settings. Childhood vulnerability to recurrent illness, and death, is linked to their families’ situations and ability to make choices and act (their agency). We examined vulnerability and agency across treatment-seeking journeys for acutely ill children and considered the implications for policy and practice.MethodA qualitative sub-study was embedded within the prospective CHAIN Network cohort study, which is investigating mechanisms of inpatient and post-hospital discharge mortality among acutely ill young children across a spectrum of nutritional status. Primary data were collected from household members of 20 purposively selected cohort children over 18 months through formal interviews (total n = 74), complemented by informal discussions and observations. Data were analysed using narrative and thematic approaches.ResultsTreatment-seeking pathways were often long and complex, particularly for children diagnosed as severely malnourished. Family members’ stories reveal that children’s carers, usually mothers, navigate diverse challenges related to intersecting vulnerabilities at individual, household and facility levels. Specific challenges include the costs of treatment-seeking, confusing and conflicting messaging on appropriate care and nutrition, and poor continuity of care. Strong power inequities were observed between family members and health staff, with many mothers feeling blamed for their child’s condition. Caregivers’ agency, as demonstrated in decision-making and actions, often drew on the social support of others but was significantly constrained by their situation and broader structural drivers.ConclusionTo support children’s care and recovery, health systems must be more responsive to the needs of families facing multiple and interacting vulnerabilities. Reducing incurred treatment costs, improving interpersonal quality of care, and strengthening continuity of care across facilities is essential. Promising interventions need to be co-designed with community representatives and health providers and carefully tested for unintended negative consequences and potential for sustainable scale-up.

Validation of the PROFUND index to predict early post-hospital discharge mortality.

The PROFUND index (PI) is a prognostic scale for polypathological patients at 12 months. The objective of the study was to validate the PI as a predictor of 1-year mortality in a current cohort of polypathological patients and analyse its prognostic usefulness in the short-term (1 month and 3 months) after discharge from Internal Medicine. We conducted a prospective observational study and all polypathological patients discharged from an Internal Medicine Department between 01 March 2016 and 28 February 2017 were enrolled. The variables recorded for each patient were age, sex, diseases and diagnostic categories defining patients as polypathological patients, PI at discharge, number of hospital admissions, length of stay, vital status at 1 year, and date and place of death if applicable. Follow-up lasted 1 year from the time of enrolment. Six hundred and ten polypathological patients were enrolled. Mortality was 41% and the patients who died were older, their length of stay was longer and their PI was higher compared with those who survived. The discrimination of the PI for predicting mortality was good, with a C-statistic of 0.718 [95% confidence interval (CI) 0.67-0.76]. In addition, a subgroup of patients with early mortality after discharge was identified, with a C-statistic of 0.74 (95% CI 0.67-0.80) at 30 days and 0.73 (95% CI 0.68-0.78) at 90 days. The PI is a valid tool for predicting early and 1-year mortality in polypathological patients after discharge from Internal Medicine.

Clinical outcomes in patients admitted to a hospitalist service exposed to an antimicrobial stewardship program \u2013 a retrospective matched cohort study

BackgroundGiven global issues with antimicrobial resistance and a need to optimize antimicrobial usage, antimicrobial stewardship (AS) programs are becoming a necessary component of hospitals and are increasingly mandated worldwide. It is important to evaluate these programs with respect to relevant clinical outcomes.MethodsAn AS program with a prospective audit and feedback service (PAF) of antimicrobial usage was initiated May 11, 2015 at our tertiary care center, for patients admitted under the hospitalist service. We conducted a retrospective matched cohort study. Patients assessed during the first year of this PAF were considered to be the exposed cohort and were compared to unexposed controls matched on gender, age and infectious diagnosis selected from patients who had been admitted under the hospitalist service prior to initiation of the PAF. Descriptive analysis was completed and a multivariate conditional logistic regression was performed to analyze differences between the exposed and control groups in terms of a composite endpoint of 30 day mortality, 30 day post hospital discharge mortality and hospital re-admission.ResultsA total of 348 patients were assessed and received PAF suggestions during the first year were compared to 827 matched control patients who did not receive PAF suggestions. Of 707 PAF suggestions made, the most common was to stop an antimicrobial (23%). A significantly lower (20.7% vs 28.8%, p = 0.008) composite endpoint was found in the group exposed to the PAF (OR 0.71 95%CI 0.52–0.97). This difference persisted when only patients with PAF suggestions that were completely or partially accepted were considered (18.6% vs 28.5%, p = 0.001) but was no longer significant when patients who had their ASP suggestions declined were analyzed (30.2% vs 26.7%, p = 0.610).ConclusionsIn this retrospective cohort study, patient admissions in which PAF recommendations were accepted had better clinical outcomes than matched historical controls managed in the absence of this AS service.

Association of Glucose Concentrations at Hospital Discharge With Readmissions and Mortality: A Nationwide Cohort Study.

Low blood glucose concentrations during the discharge day may affect 30-day readmission and posthospital discharge mortality rates. To investigate whether patients with diabetes and low glucose values during the last day of hospitalization are at increased risk of readmission or mortality. Minimum point of care glucose values were collected during the last 24 hours of hospitalization. We used adjusted rates of 30-day readmission rate, 30-, 90-, and 180-day mortality rates, and combined 30-day readmission/mortality rate to identify minimum glucose thresholds above which patients can be safely discharged. Nationwide cohort study including 843,978 admissions of patients with diabetes at the Veteran Affairs hospitals 14 years. The rate ratios (RRs) increased progressively for all five outcomes as the minimum glucose concentrations progressively decreased below the 90 to 99 mg/dL category, compared with the 100 to 109 mg/dL category: 30-day readmission RR, 1.01 to 1.45; 30-day readmission/mortality RR, 1.01 to 1.71; 30-day mortality RR, 0.99 to 5.82; 90-day mortality RR, 1.01 to 2.40; 180-day mortality RR, 1.03 to 1.91. Patients with diabetes experienced greater 30-day readmission rates, 30-, 90- and 180-day postdischarge mortality rates, and higher combined 30-day readmission/mortality rates, with glucose levels <92.9 mg/dL, <45.2 mg/dL, 65.8 mg/dL, 67.3 mg/dL, and <87.2 mg/dL, respectively. Patients with diabetes who had hypoglycemia or near-normal glucose values during the last day of hospitalization had higher rates of 30-day readmission and postdischarge mortality.

C-LACE2: computational risk assessment tool for 30-day post hospital discharge mortality

This paper describes a computational approach to assessing 30-day post-hospital discharge mortality risk. The idea of the constructed model is partially based on the popular LACE (Length of stay, Acuity, Comorbidities and Emergency visits) model, and combines elements of APACHE II (Acute Physiology and Chronic Health Evaluation) and IPEC (Inpatient Evaluation Center of Veterans Health Administration) mortality models. The resulting C-LACE2 model includes length of stay, acuity, comorbidities, selected lab values and medications. The process of construction of the model and its validation are presented in details. The constructed final model consists of 101 attributes, and its minimum version of 20 attributes. C-LACE2 has been constructed by applying machine learning methods to MIMIC III inpatient EHR data. The model achieved accuracy (AUC) of 0.779. Detailed analysis of the C-LACE2 model has been performed to check its sensitivity to inputs.

Heart failure, post-hospital mortality and renal function in Tanzania: A prospective cohort study

ObjectiveTo determine one-year, post-hospital mortality and the predictors of mortality in Tanzanian adults with heart failure (HF) compared to other admitted adults. MethodsIn this prospective cohort study we consecutively enrolled medical inpatients admitted during a 3-month period, screened for HF and followed until 12 months after hospital discharge. Standardized history, physical examination, echocardiography and laboratory investigations were obtained during hospital presentation. The primary outcome was one-year post-discharge mortality. The secondary outcome was in-hospital mortality. Cox regression adjusted for age and sex was used. ResultsDuring the study period, we enrolled 558 adults; 145 had HF and 107 of these survived until discharge. Patients with HF had a higher one-year post-hospital discharge mortality than all other diagnoses (62/107 (57.9%) vs 150/343 (43.7%), respectively, HR=1.57[1.13–2.18]). In-hospital mortality was similar. Markers of renal disease were more common in adults with HF (40/107 (37.4%) and were the strongest independent predictors of post-hospital mortality: low eGFR (HR=2.94[1.62–5.31]) and proteinuria (HR=2.03, [95%CI 1.13–3.66]). No patients discharged with the combination of low eGFR/proteinuria survived to the one-year endpoint. Of note, 79/145 (54.5%) of adults admitted with HF were newly diagnosed during hospital admission. ConclusionsOver half of adults discharged with HF died within 12months after discharge. Adults with HF had higher post-hospital mortality compared to other medical inpatients. Markers of renal disease were the strongest predictor of this mortality. Innovative interventions are needed to reduce post-hospital mortality in adults with HF and should focus on those with renal disease.

PWE-105 Long term survival of cirrhotics following icu admission – a subgroup of patients with 'resilient' cirrhosis

<h3>Introduction</h3> Patients with cirrhosis who are admitted to the ICU are considered to have a poor prognosis. Previous studies have sought to identify markers of high predictive value in patients who will not survive their critical care stay. These studies have focused upon early prognosis, rather than longer term survival. We sought to validate previously described outcome predictors and review long-term survival in a cohort of cirrhotic patients admitted to ICU. <h3>Method</h3> We performed a retrospective analysis of cirrhotic patients admitted to adult ICU, University Hosptial of Wales (Cardiff, UK) between 2009–14. Admission information was collated from the Intensive Care National Audit and Research Centre database. Child-Pugh, Model for End-stage Liver Disease-Na (MELD-Na) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were derived from data on admission to critical care. Statisical analyses were conducted with SPSS. <h3>Results</h3> One hundred and fifty one cirrhotics (2.8% of all critical care admissions) were admitted to the ICU with a mean age of 54 (range 22–80) and a male preponderance (65.6%). The predominant aetiology was alcoholic liver disease (ALD, 107/151, 70.9%). The reasons for ICU admission were variceal bleed 29.8%; sepsis 25.2%; decompensation 13.9%;non variceal bleed 5.3% and other 26%. ICU mortality was 43.7% for the 151 patients. Mean follow up after ICU discharge was 788 days (range 26–1722). Hyponatraemia (p &lt; 0.001), coagulopathy (p = 0.02), APACHE II (p = 0.004) and MELD-Na scores (p &lt; 0.0001) were significantly associated with mortality. Patients diagnosed as decompensation with no obvious underlining precipitant had a worse prognosis than those with precipitants (e.g. variceal bleeding, sepsis) which was maintained at follow up (p = 0.05). Child’s A, B and C stage patients had a mean overall survival of 1274, 976 and 690 days respectively (p = 0.01). Seventy-eight patients were discharge from hospital. Only 6 of these patients died, all with Child’s B liver disease. Only attending outpatient follow up clinic was associated with increased survival (p = 0.01 1373 v 1668 days). <h3>Conclusion</h3> Nearly half of all cirrhotics admitted to the ICU die before discharge, and two thirds of all patients have alcohol as an aetiological factor, emphasising the burden on our society. As expected, commonly used scoring systems predict short-term outcome, but often do not reflect long-term survival. Cirrhotics who survive the challenge of ICU admission seem to have quite marked physiological resilience and capacity for recovery with a good long term prognosis. Interestingly only patients with Child’s B cirrhosis continued to demonstrate a post-hospital discharge mortality, warranting further investigation for underlying reasons. <h3>Disclosure of interest</h3> None Declared.

Effectiveness of an inpatient smoking cessation program

Inpatient smoking cessation may increase the success of quitting smoking post-hospital discharge. Using a quasiexperimental study design, use of cessation methods, mortality, self-reported abstinence, and quit status 6 months post-hospital discharge were measured to assess the effectiveness of an inpatient smoking cessation program. Subjects were interviewed by telephone 6 months post-hospital discharge. Outcomes for patients who were seen by the inpatient smoking cessation counselor were compared to consecutive patients who were not seen by the counselor. Electronic medical records (EMRs) and administrative data were used to construct baseline measures, comorbidity covariates, pharmaceutical use rates during hospitalization, readmission, and mortality outcomes. Multivariate methods included logistic regression and survival analysis. At baseline, the study groups varied by mean age, length of stay (LOS), comorbidity index, cardiovascular diagnosis, and acuity. At 6 months post-hospital discharge, the intent to treat estimate for point prevalence abstinence was 16% in the intervention group compared to 10% in the comparison group (P = 0.02) while self-reported quit status in the intervention group was 44% vs. 30% in the comparison group (P = 0.00). The intervention group used more nicotine replacement therapy (NRT) than the comparison group both in-hospital and following discharge. Crude post-hospital discharge mortality was significantly less in the intervention group (0.02) than in the comparison group (0.04). A multivariate survival model, controlling for baseline imbalances, showed a significantly reduced mortality in the intervention group (hazard ratio [HR] = 0.37; P = 0.04). Inpatient smoking cessation programs effectively improve quit outcomes, NRT use, and mortality post-hospital discharge.