Post-discharge Management Research Articles

Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study.

Background:Prolonged air leaks are increasingly treated in the outpatient setting, with patients discharged with chest tubes in place. We evaluated the incidence and risk factors associated with readmission, empyema development and further interventions in this patient population.Methods:We undertook a retrospective cohort analysis of all patients from 4 tertiary academic centres (January 2014 to December 2017) who were discharged home with a chest tube after lung resection for a postoperative air leak lasting more than 5 days. We analyzed demographics, patient factors, surgical details, hospital readmission, reintervention, antibiotics at discharge, empyema and death.Results:Overall, 253 of 2794 patients were analyzed (9.0% of all resections), including 30 of 759 from centre 1 (4.0%), 67 of 857 from centre 2 (7.8%), 9 of 247 from centre 3 (3.6%) and 147 of 931 from centre 4 (15.8%) (p < 0.001). Our cohort consisted of 56.5% men, and had a median age of 69 (range 19–88) years. Despite similar initial lengths of stay (p = 0.588), 49 patients (19.4%) were readmitted (21%, 0%, 23% and 11% from centres 1 to 4, respectively, p = 0.029), with 18 (36.7%) developing empyema, 11 (22.4%) requiring surgery and 3 (6.1%) dying. Only chest tube duration was a significant predictor of readmission (p < 0.001) and empyema development (p = 0.003), with a nearly threefold increased odds of developing empyema when the chest tube remained in situ for more than 20 days.Conclusion:Discharge with chest tube after lung resection is associated with serious adverse events. Given the high risk of empyema development, removal of chest tubes should be considered, when appropriate, within 20 days of surgery. Our data suggest a potential need for proactive postdischarge outpatient management programs to diminish risk of morbidity and death.

One-year readmission and mortality following ischaemic stroke by diabetes status, sex, and socioeconomic disadvantage: An analysis of 27,802 strokes from 2012 to 2017

ObjectiveWe estimated the 1-year incidence of readmission to hospital and 1-year all-cause mortality following ischaemic stroke (IS), by diabetes status, sex, and socioeconomic disadvantage. MethodsThis study included all individuals aged ≥30 years who were discharged from hospital following an IS between July 2012 and June 2017 in Victoria, Australia (n = 25,421). Individuals were followed from discharge until readmission (for all-causes, cardiovascular readmission, and readmission for IS) or death, censoring at 1-year of follow-up. ResultsThe 1-year cumulative incidence of all-cause readmission following an IS was 56.1% (95% CI: 55.5–56.7); 24% of first all-cause admission were attributed to cardiovascular disease. People with diabetes were at an excess risk of all-cause, cardiovascular, and IS readmission following an IS (adjusted sub-HRs: 1.13 [95% CI: 1.09–1.17], 1.14 [1.07–1.21], and 1.17 [1.06–1.29], for people with vs. without diabetes, respectively) and 1-year mortality (adjusted HR: 1.11 [1.03–1.19]). There was no significant difference between men and women in all-cause and cardiovascular readmission risk, while women were at higher risk of IS readmission (sub-HR: 1.10 [1.01–1.21] for women vs. men) and mortality (HR: 1.12 [1.05–1.20]). There was no relationship between socioeconomic disadvantage and risk of cardiovascular or IS readmission, while 1-year mortality risk did increase with increasing socioeconomic disadvantage (HR for most vs. least disadvantaged quintile: 1.15 [1.03–1.27]; ptrend = 0.006), and all-cause readmission risk decreased (sub-HR: 0.94 [0.90–0.99]; ptrend = 0.001). ConclusionsThere is a high risk of readmission following IS. Decreasing the readmission rate will require more complex interventions than solely improving post-discharge cardiovascular management.

Patient Perspectives on the Digitization of Personal Health Information in the Emergency Department: Mixed Methods Study During the COVID-19 Pandemic.

BackgroundAlthough the digitization of personal health information (PHI) has been shown to improve patient engagement in the primary care setting, patient perspectives on its impact in the emergency department (ED) are unknown.ObjectiveThe primary objective was to characterize the views of ED users in British Columbia, Canada, on the impacts of PHI digitization on ED care.MethodsThis was a mixed methods study consisting of an online survey followed by key informant interviews with a subset of survey respondents. ED users in British Columbia were asked about their ED experiences and attitudes toward PHI digitization in the ED.ResultsA total of 108 participants submitted survey responses between January and April 2020. Most survey respondents were interested in the use of electronic health records (79/105, 75%) and patient portals (91/107, 85%) in the ED and were amenable to sharing their ED PHI with ED staff (up to 90% in emergencies), family physicians (up to 91%), and family caregivers (up to 75%). In addition, 16 survey respondents provided key informant interviews in August 2020. Interviewees expected PHI digitization in the ED to enhance PHI access by health providers, patient-provider relationships, patient self-advocacy, and postdischarge care management, although some voiced concerns about patient privacy risk and limited access to digital technologies (eg, smart devices, internet connection). Many participants thought the COVID-19 pandemic could provide momentum for the digitization of health care.ConclusionsPatients overwhelmingly support PHI digitization in the form of electronic health records and patient portals in the ED. The COVID-19 pandemic may represent a critical moment for the development and implementation of these tools.

Neighborhood Socioeconomic Disadvantage Associated With Increased 90-Day Mortality Following Radical Cystectomy

ObjectiveTo examine relationships between neighborhood socioeconomic disadvantage and outcomes following radical cystectomy (RC). Materials and MethodsA retrospective single institution study of consecutive RCs performed for bladder cancer between 2011 and 2019. Major complications, mortality and survival outcomes were compared using Cochran-Armitage or Kruskal-Wallis tests. Cox proportional hazards models were used for time-to-event analyses. ResultsA total of 906 patients were included in analysis. Overall 90-day mortality was 2.98% (27/906). Ninety-day mortality rates observed in the least (first) and most (fourth) disadvantaged ADI quartiles were 0% (0/115) and 6.5% (12/185), respectively. Patients from the fourth quartile demonstrated worse overall survival and recurrence free survival than those in the first quartile. ADI quartile was positively associated with muscle invasive (P = .0006) and node positive (P = .042) disease. ADI percentile was an independent predictor for 90-day mortality (adjusted OR: 1.022, CI: 1.004-1.04, P = .015). ConclusionHigher rates of mortality and worse oncologic outcomes were observed for patients residing in the most disadvantaged quartile. ADI was associated with higher likelihood of 90-day mortality and may therefore be useful in patient counseling, risk stratification, and post-discharge management.

A National Survey of Outpatient Parenteral Antibiotic Therapy Practices

We conducted a national survey of pediatric infectious diseases (ID) clinicians on outpatient parenteral antibiotic therapy (OPAT) practices and post-discharge ID follow-up. Only 15% of sites required ID consultation for all OPAT. ID division resources for post-discharge care varied. Opportunities exist to increase ID involvement in post-discharge management of serious infections.

Pilot implementation of opioid stewardship measures using the national surgical quality improvement program-pediatric platform

IntroductionData surrounding optimal pediatric postoperative opioid prescribing are incomplete. The objective of this study was to leverage the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-P) and assess feasibility of added data collection surrounding pediatric perioperative pain management practices including opioid prescribing at discharge. MethodsNineteen (19) novel data elements were added to NSQIP-P data collection of selected patients, ages 5–18 years, who had undergone surgery at a single, free-standing children's hospital. Metrics around data abstraction and completion of variables were collected. Univariate analyses (using Chi-square or Wilcoxon Rank Sum tests) and multiple logistic regressions were performed to describe predictors of opioid prescribing at discharge and to monitor adherence to Food and Drug Administration (FDA) prescribing recommendations. ResultsMedian abstraction time of the novel variables decreased from 12 to 5 min per patient over 13 months with 94% variable completion rate. Of 878 patients, 302 (36.4%) were prescribed opioids at discharge. Factors associated with an opioid prescription included older age (p < 0.001), white race (p < 0.05), undergoing an orthopedic surgery (p < 0.001), and receiving a regional block perioperatively (p < 0.001). All opioid prescriptions met FDA guidelines with no patients receiving codeine, and 98% of patients receiving opioid prescriptions < 50 morphine milli-equivalents per day. ConclusionCollecting data on current pain management practices, opioid prescribing, and adherence to safety recommendations is feasible using the NSQIP-P with little added burden. Further expansion of data collection is needed to develop generalizable optimal prescribing practices for post-discharge pain management for children.

A novel nomogram for predicting 3-year mortality in critically ill patients after coronary artery bypass grafting

BackgroundThe long-term outcomes for patients after coronary artery bypass grafting (CABG) have been received more and more concern. The existing prediction models are mostly focused on in-hospital operative mortality after CABG, but there is still little research on long-term mortality prediction model for patients after CABG.ObjectiveTo develop and validate a novel nomogram for predicting 3-year mortality in critically ill patients after CABG.MethodsData for developing novel predictive model were extracted from Medical Information Mart for Intensive cart III (MIMIC-III), of which 2929 critically ill patients who underwent CABG at the first admission were enrolled.ResultsA novel prognostic nomogram for 3-year mortality was constructed with the seven independent prognostic factors, including age, congestive heart failure, white blood cell, creatinine, SpO2, anion gap, and continuous renal replacement treatment derived from the multivariable logistic regression. The nomogram indicated accurate discrimination in primary (AUC: 0.81) and validation cohort (AUC: 0.802), which were better than traditional severity scores. And good consistency between the predictive and observed outcome was showed by the calibration curve for 3-year mortality. The decision curve analysis also showed higher clinical net benefit than traditional severity scores.ConclusionThe novel nomogram had well performance to predict 3-year mortality in critically ill patients after CABG. The prediction model provided valuable information for treatment strategy and postdischarge management, which may be helpful in improving the long-term prognosis in critically ill patients after CABG.

Management of Acute Decompensated Heart Failure in Rural Versus Metropolitan Settings: An Australian Experience

Acute decompensated heart failure (ADHF) is the most common cause of hospital admission in patients over 65, with poorer outcomes demonstrated in rural versus metropolitan areas. The aim of this study was to compare the in-hospital and post-discharge management of ADHF patients admitted to rural versus metropolitan hospitals in Victoria. Data from the Victorian Cardiac Outcomes Registry, Heart Failure (VCOR-HF) project was used. This was a prospective, observational, non-randomised study of consecutive patients admitted to participating hospitals in Victoria, Australia, with ADHF as their primary diagnosis over four 30-day periods during consecutive years. All patients were followed up for 30 days post discharge. 1,357 patients (1,260 metropolitan, 97 rural) were admitted to study hospitals with ADHF during the study periods. Cohorts were similar in age (average 76.87±13.12 yrs) and percentage of male gender (56.4% overall). Metropolitan patients were more likely to have diabetes (44.4% vs 34.0%, p=0.046), kidney disease (65.8% vs 37.1%, p<0.01) and anaemia (31.9% vs 19.6%, p=0.01). There was no significant difference in length of stay between metropolitan and rural patients (7.49 vs 6.37 days, p=0.12). There was no significant difference between metropolitan and rural patients in 30-day rehospitalisations (19.1% vs 11.6%, p=0.07, respectively) and all-cause 30-day mortality (8.2% vs 4.1%, p=0.15, respectively). Metropolitan patients were significantly more likely to have seen their general practitioner (GP) (68.1% vs 53.2%, p<0.01) or attend an outpatient clinic (35.9% vs 10.6%, p<0.01) by 30 days. There was no significant difference in number of days to follow-up of any kind between groups. Referrals to a heart failure home visiting program remained low overall (19.9%). There was no significant difference in 30-day rehospitalisations or mortality between patients admitted to rural versus metropolitan hospitals. Geographical discrepancies were noted in follow-up by 30 days, with significantly more metropolitan patients having seen a doctor by 30 days post-discharge. Overall follow-up rates remain suboptimal.

Risk Factors for Revolving Door in Children and Adolescents with Psychiatric Disorders.

Revolving Door (RD) is a frequent phenomenon afflicting children and adolescents with psychiatric diagnoses. Nevertheless, risk factors for RD are still a matter of debate. To better understand RD phenomenon, we conducted a retrospective study on 224 children and adolescents (165 females and 59 males, aged 6–16 years) with a psychiatric hospitalization, taking the multiple risk factors together. At this aim, 108 patients with multiple hospitalizations and 116 patients with only one hospitalization were compared on demographic characteristics, clinical conditions, psychiatric ward stay, and post-discharge management factors. More than half of psychiatric patients were readmitted within three months of discharge. RD patients presented greater severity of illness, needed longer stays, and were more frequently placed in residential facilities than non-RD patients. Non-suicidal self-injurious and adoption were the main predictors of RD. Clinical instruments that detected behavioural and emotional symptoms, suicidal ideation severity, and level of impairment of the person’s functioning were useful to identify patients at high risk for RD. In conclusion, our findings pointed out that several risk factors have to be considered to better understand and, in the future, prevent RD phenomenon.

Emergency surgical treatment of total anomalous pulmonary venous connection.

This study explored the strategy and effect of emergency surgical treatment for total anomalous pulmonary venous connection (TAPVC). From March 2009 to February 2020, 78 patients with TAPVC underwent emergency surgical correction. There were 51 males and 27 females. The median age was 39.5 days, and the median weight was 4.0 kg. Preoperative percutaneous oxygen saturation was 80.8% ± 4.5%. Of the cases investigated, seven died during the perioperative period; 16 had a delayed chest closure; 19 had early pulmonary vein obstruction; two had secondary tracheal intubation; one had a brain complication; and one had a third-degree atrioventricular block. Low weight, younger age, cardiopulmonary bypass time, and aortic cross-clamp time were identified as risk factors for early mortality. During the follow-up from 4 to 137 months, 12 cases did not respond to follow-up requests. Ten patients died within 1-6 months after discharge. One patient underwent reoperation due to pulmonary vein obstruction. The longer hospital stay after the operation and intensive care unit time were identified as risk factors for late mortality. Emergency surgery for severe TAPVC patients after admission achieved good short-term results. Prenatal diagnosis should be strengthened to save more patients. The higher late mortality rate of such patients indicates that post-dischargemanagement should be strengthened to reduce the occurrence of post-discharge deaths.

Supporting medicines management for older people at care transitions \u2013 a theory-based analysis of a systematic review of 24 interventions

BackgroundOlder patients are at severe risk of harm from medicines following a hospital to home transition. Interventions aiming to support successful care transitions by improving medicines management have been implemented. This study aimed to explore which behavioural constructs have previously been targeted by interventions, which individual behaviour change techniques have been included, and which are yet to be trialled.MethodThis study mapped the behaviour change techniques used in 24 randomised controlled trials to the Behaviour Change Technique Taxonomy. Once elicited, techniques were further mapped to the Theoretical Domains Framework to explore which determinants of behaviour change had been targeted, and what gaps, if any existed.ResultsCommon behaviour change techniques used were: goals and planning; feedback and monitoring; social support; instruction on behaviour performance; and prompts/cues. These may be valuable when combined in a complex intervention. Interventions mostly mapped to between eight and 10 domains of the Theoretical Domains Framework. Environmental context and resources was an underrepresented domain, which should be considered within future interventions.ConclusionThis study has identified behaviour change techniques that could be valuable when combined within a complex intervention aiming to support post-discharge medicines management for older people. Whilst many interventions mapped to eight or more determinants of behaviour change, as identified within the Theoretical Domains Framework, careful assessment of the barriers to behaviour change should be conducted prior to intervention design to ensure all appropriate domains are targeted.

The effects of WeChat follow-up management to improve the parents\u2019 mental status and the quality of life of premature newborns with patent ductus arteriosus

ObjectiveThis study aimed to explore the effect of WeChat follow-up management on improving the parents’ mental status and the quality of life of premature newborns with patent ductus arteriosus (PDA) after discharge.MethodsParticipants were randomly divided into an intervention group and a control group. WeChat was used in the intervention group for the postdischarge follow-up management, while the control group was managed traditionally. The psychological status and quality of life of the parents of the two groups were analyzed and compared.ResultsThe SAS and SDS scores in the intervention group at three months after discharge were significantly better than those at discharge, but there was no significant change in the control group. During the three-month follow-up, the SAS and SDS scores in the intervention group were significantly better than those in the control group. The WHOQOL-BREF scale scores in the intervention group were significantly better than those in the control group in physiology, psychology, social relations, and the environment. The total quality of life score in the intervention group was also significantly better than that in the control group. All patients in the intervention group were followed up as appropriate, while five patients in the control group were lost to follow-up. The incidence of pneumonia and feeding intolerance in the intervention group were significantly lower than those in the control group.ConclusionThe application of WeChat in the follow-up management of premature infants with PDA could alleviate parents’ anxiety and depression in taking care of their children at home and can improve their quality of life.

Diagnosis and Management of Heart Failure in Elderly Patients from Hospital Admission to Discharge: Position Paper.

Multidisciplinary management of worsening heart failure (HF) in the elderly improves survival. To ensure patients have access to adequate care, the current HF and French health authority guidelines advise establishing a clearly defined HF patient pathway. This pathway involves coordinating multiple disciplines to manage decompensating HF. Yet, recent registry data indicate that insufficient numbers of patients receive specialised cardiology care, which increases the risk of rehospitalisation and mortality. The patient pathway in France involves three key stages: presentation with decompensated HF, stabilisation within a hospital setting and transitional care back out into the community. In each of these three phases, HF diagnosis, severity and precipitating factors need to be promptly identified and managed. This is particularly pertinent in older, frail patients who may present with atypical symptoms or coexisting comorbidities and for whom geriatric evaluation may be needed or specific geriatric syndrome management implemented. In the transition phase, multi-professional post-discharge management must be coordinated with community health care professionals. When the patient is discharged, HF medication must be optimised, and patients educated about self-care and monitoring symptoms. This review provides practical guidance to clinicians managing worsening HF in the elderly.

Feasibility and effectiveness of a multidimensional post-discharge disease management programme for heart failure patients in clinical practice: the HerzMobil Tirol programme.

It remains unclear whether transitional care management outside of a clinical trial setting provides benefits for patients with acute heart failure (AHF) after hospitalization. We evaluated the feasibility and effectiveness of a multidimensional post-discharge disease management programme using a telemedical monitoring system incorporated in a comprehensive network of heart failure nurses, resident physicians, and secondary and tertiary referral centres (HerzMobil Tirol, HMT), METHODS AND RESULTS: The non-randomized study included 508 AHF patients that were managed in HMT (n = 251) or contemporaneously in usual care (UC, n = 257) after discharge from hospital from 2016 to 2019. Groups were retrospectively matched for age and sex. The primary endpoint was time to HF readmission and all-cause mortality within 6months. Multivariable Cox proportional hazard models were used to assess the effectiveness. The primary endpoint occurred in 48 patients (19.1%) in HMT and 89 (34.6%) in UC. Compared with UC, management by HMT was associated with a 46%-reduction in the primary endpoint (adjusted HR 0.54; 95% CI 0.37-0.77; P < 0.001). Subgroup analyses revealed consistent effectiveness. The composite of recurrent HF hospitalization and death within 6months per 100 patient-years was 64.2 in HMT and 108.2 in UC (adjusted HR 0.41; 95% CI 0.29-0.55; P < 0.001 with death considered as a competing risk). After 1year, 25 (10%) patients died in HMT compared with 66 (25.7%) in UC (HR 0.38; 95% CI 0.23-0.61, P < 0.001). A multidimensional post-discharge disease management programme, comprising a telemedical monitoring system incorporated in a comprehensive network of specialized heart failure nurses and resident physicians, is feasible and effective in clinical practice.

What Happens after Hospital Discharge? Deficiencies in Medication Management Encountered by Geriatric Patients with Polypharmacy.

This study aimed to describe post-discharge medication self-management by geriatric patients with polypharmacy, to describe the problems encountered and to determine the related factors. In a multicenter study from November 2019 to March 2020, data were collected at hospital discharge and two to five days post-discharge. Geriatric patients with polypharmacy were questioned about medication management using a combination of validated (MedMaIDE) and self-developed questionnaires. Of 400 participants, 70% did self-manage medication post-discharge. Patients had a mean of four different deficiencies in post-discharge medication management (SD 2.17, range 0–10). Knowledge-related deficiencies were most common. The number of medicines and the in-hospital provision of medication management by nurses were significant predictors of post-discharge medication management deficiencies. In addition to deficiencies in knowledge, medication-taking ability and obtaining medication, non-adherence and disrupted continuity of medication self-management were common in geriatric patients with polypharmacy post-discharge. Improvements in in-hospital preparation could avoid medication self-management problems at home.

MO359ASSOCIATIONS BETWEEN RENAL FUNCTION TRAJECTORIES AFTER 3 MONTHS ACUTE KIDNEY INJURY AND LONG-TERM RENAL OUTCOMES

Abstract Background and Aims Renal function recovery after acute kidney injury (AKI) is associated with patient outcomes. The study objectives were to assess the patterns of AKI recovery within 6 months following discharge for AKI and subsequent incidence of chronic dialysis. Method A retrospective cohort of 234,867 hospitalized adult patients was examined for AKI between January 1, 2010, and December 31, 2017 in the largest healthcare delivery system in Taiwan. Renal function recovery at 3- and 6-month post discharge, incident chronic kidney disease and chronic dialysis initiation were analyzed over 7 years of follow-up. Renal recovery was defined by &amp;lt; 1.5× baseline SCr (prior to the hospitalization). Independent associations between renal function recovery patterns and renal outcomes was assessed by Cox proportional hazard model controlling for potential confounders, and subdistribution hazard ratio (SHR) with [95% CI] was analysed for competing risk of early death. Results Among 3 months AKI survivors (n=24,132), 14.28% (n=3,430) did not recovery back to baseline, and 16% of recovery did not sustain. Three distinct renal function recovery continuums at 6 months post hospital discharge were: persistent non-recovery (10.18%), non-recovery (14.33%), and recovery (75.5%). Comparing to survivors without AKI (n=50,387), the impact of renal recovery continuum on chronic dialysis initiation varied by patient’s baseline renal disease (SHR was 2.82 [95%CI, 2.42-3.28] in CKD, and 0.8 [95%CI, 0.27-2.38] for non-CKD. Persistent non-recovery was significantly associated with a greater increased risk of chronic dialysis than non-recovery in any patients with AKI. Comparing to patients with sustained AKI recovery, risk of CKD onset increased 5-fold in persistent non-recovery and 3-fold risk in non-recovery. Conclusion The continuum of AKI recovery post 6 months is associated with increased risk of chronic dialysis, particularly in patients with baseline CKD. These study results suggested that patients ever with AKI should receive close renal function monitoring for post-discharge management.

A Hospitalist-Led Fracture Liaison Service Improves Care of Hip Fracture Patients

Background: Osteoporosis care traditionally falls to outpatient primary care providers despite the fact that over 300,000 elderly patients are hospitalized yearly with hip fractures in the United States. Internal medicine hospitalists are often involved in the co-management of their care on surgical teams and are skillful in osteoporosis recognition and management. Objective: A hospitalist-led Fracture Liaison Service (FLS) was established to provide improved care of hospitalized patients with hip fractures. Methods: A retrospective evaluation of inpatient and post-discharge management of patients admitted with low-impact hip fractures was performed before (8/17-2/18) and after (8/19 - 2/20) launch of the hospitalist Fracture Liaison Service (H-FLS). Results: Eighty-nine patients were admitted with a hip fracture in post-launch period compared to 73 admitted prior. 74% vs 11% of eligible patients (based on adequate renal function and vitamin D stores) were discharged with anti-osteoporosis medications (p<0.001), 82% vs 38% were discharged with vitamin D/calcium supplements (p<0.001), 22% vs 5% underwent a DXA scan after discharge (p<0.05) and 65% vs 0% were referred to outpatient osteoporosis-specific care at discharge (p<0.001). Conclusion: A hospitalist-led FLS is a unique approach to osteoporosis care that significantly improved quality metrics for elderly patients with osteoporotic hip fractures including initiation of anti-osteoporosis medication and bone density imaging. Outpatient follow-up data are needed to evaluate adherence to this initial management over time.

Post-discharge antithrombotic management and clinical outcomes of patients with new-onset or pre-existing atrial fibrillation and acute coronary syndromes undergoing coronary stenting: Follow-up data of the MATADOR-PCI study

Background. Patients with concomitant atrial fibrillation (AF) and acute coronary syndromes (ACS) do not seem to receive proper antithrombotic therapies and present high rates of adverse clinical events. Methods. We analyzed the follow-up data of the prospective, nationwide MATADOR-PCI registry. We assessed the use of antithrombotic strategies and the incidence of major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) at 6 months, in patients with new-onset or pre-existing AF admitted for ACS and treated with percutaneous coronary intervention (PCI). Results. Out of the 588 patients enrolled in the registry and discharged alive (287 with pre-existing and 301 with new-onset AF), data at 6 months were obtained for 579 (98.5%) patients. Compared to hospital discharge, the rate of triple antithrombotic therapy was significantly reduced (from 76.4% to 23.6% and from 53.8% to 23.6%; both p<0.0001) while dual antithrombotic therapy (DAT) increased (from 11.8% to 56.3% and from 5.8% to 30.9%; both p<0.0001) at follow-up, in patients with pre-existing and new-onset AF, respectively. Among patients with a class IA indication to receive oral anticoagulation therapy (OAT), it was prescribed in 91% and 88% of patients with pre-existing and 64% and 62% of new-onset AF, at discharge and follow-up, respectively. At 6 months from discharge the overall rate of MACE was 8.4% and 7.6% (p=0.75), while NACE occurred in 10.8% vs 10.0% (p=0.74) of patients with pre-existing or new-onset AF, respectively. Conclusions. At follow-up, DAT was the most used antithrombotic strategy for both patients with pre-existing and new-onset AF with concomitant ACS. These two groups of patients presented comparable rates of MACE and NACE at 6 months.

587 Methadone and Morphine for Outpatient CO2 Laser Pain Management

Abstract Introduction Burn reconstruction with CO2 laser is now very popular. Providing adequate analgesia is imperative for large total body surface area (TBSA) resurfacing. CO2 lasers’ cause significant pain during the procedure and pain similar to that of a severe sunburn post-operatively. Thus, adequate analgesia that provides peri-operative and post discharge management without delaying discharge is beneficial. At our institution, we use a multimodal analgesic preoperative and intra-operative approach to deal with this issue. The preoperative intervention utilizes a novel approach of oral methadone for older children and avoids the use of intra-operative morphine as a preemptive measure for pain management. The purpose of this outcomes review was to determine if our peri-operative analgesic practices were effective in controlling peri-operative pain. Methods After corporate IRB review, this project was undertaken as a quality improvement initiative and was not formally supervised by an institutional review board. A chart review of all patients who received CO2 laser treatment (CLT) was conducted. Using a Donabedian model for outcomes measure, postoperative and pre-discharge observational pain scores (scale 1–10), peri-operative analgesics, demographics, percent burn treated, incidents of rescue medication before discharge home, time to discharge and adverse reactions were collected. Results 74 patients were reviewed (47 male, 27 female), ages 4 to 30, average age 17. Average percent body surface area treated was 17.5%. Out of 74 cases, 18 received intra-operative morphine and 56 received oral methadone pre-operatively. All patients received routine intra-operative ketorolac and lidocaine/prilocaine cream, based on weight. In the PACU there were 2 recorded rescue doses of morphine in the morphine group and 0 in the methadone group. There was one post- operative recorded observational pain score of 5 in the methadone group and one each of 3 and 8 in the morphine group, both of which received rescue morphine. There were no differences in mean times to discharge between groups. Observational pain scores were 0 for both groups at discharge. Chi square analysis showed no statistical difference between groups. No adverse outcomes (respiratory arrest or readmission for pain) were recorded in either group. Conclusions Both pre-operative oral methadone and intra-operative morphine are effective in controlling peri-operative pain in our children undergoing laser surgery. Categorical age differences and low group sizes may have contributed to outcomes and should be considered in the next review.

Effects of mobile messenger counseling on case management success for individuals engaging in self-harm or suicide attempts who were discharged from emergency departments

ObjectivePostdischarge case management for self-harm or suicide attempters often fails; therefore, this study aimed to investigate the effects of mobile messenger counseling (MMC) on the postdischarge case management results among this patient group.MethodsA retrospective analysis was done with data collected from March 2015 to February 2020 that included self-harm or suicide attempters who had visited a Korean emergency department and were discharged. If patients consented, postdischarge case management and MMC were conducted from March 2017. The primary outcome was the rate of successful case management, which reflects the patients either connecting to a local psychiatric healthcare center or undergoing a follow-up at a neuropsychiatric outpatient department at least once following discharge. Using univariate and multivariate logistic regression analyses, we evaluated MMC’s effects on these patients’ postdischarge case management.ResultsOf 913 patients, 604 participated in this study. In terms of successful case management, the MMC group showed a significantly higher rate than the non-MMC one (28.3% vs. 16.1%, P=0.001). A multivariate analysis demonstrated that access to postdischarge MMC (odds ratio, 2.149; 95% confidence interval, 1.357–3.403; P=0.001) and giving consent for case management while in the emergency department were significantly associated with successful case management (odds ratio, 8.917; 95% confidence interval, 5.610–14.173; P<0.001).ConclusionThe use of MMC for self-harm or suicide attempters is associated with higher case management success rates by increasing their chances of connecting to a psychiatric healthcare center or a neuropsychiatric outpatient department.