Reduction In Hospital Length Of Stay Research Articles

Intravenous Lidocaine for Rib Fractures: Effect on Pain Control and Outcome.

Multimodal analgesia in rib fractures (RFs) is designed to maximize pain control while minimizing narcotics. Prior research with intravenous lidocaine (IVL) efficacy produced conflicting results. We hypothesized IVL infusion reduces opioid utilization and pain scores. A retrospective review of RF patients at an ACS-verified Level I trauma center from April 2018 to 2/2020 was conducted. Patients (pts) stratified as receiving IVL vs no IVL. Initial lidocaine dose: 1mg/kg/hr with a maximum of 3mg/kg/hr. Duration of infusion: 48h. Pain quantified by the Stanford Pain Score system (PS). Bivariate and multivariate analyses of variables were performed on SPSS, version 21 (IBM Corp). 414pts met inclusion criteria: 254 males and 160 females. The average age for the non-IVL = 67.4 ± 15.2 years vs IVL = 58.3 ± 17.1 years (P < .001). There were no statistically significant differences between groups for ISS, PS for initial 48h, and ICU length of stay (LOS). There was a difference in morphine equivalents per hour: non-IVL = 1.25 vs IVL = 1.72 (P = .004) and LOS non-IVL = 10.2+/-7.6 vs IVL = 7.82+/-4.94. By analyzing IVL pts in a crossover comparison before and after IVL, there was reduction in opiates: 3.01 vs 1.72 (P < .001) and PS: 7.0 vs 4.9 (P < .001). Stanford Pain Score system reduction in the IVL = 48.3 ± 23.9%, but less effective in narcotic dependency (27 ± 22.9%, P = .035); IVL pts had hospital cost reduction: $82,927 vs $118,202 (P < .01). In a crossover analysis, IVL is effective for reduction of PS and opiate use and reduces hospital LOS and costs. Patient age may confound interpretation of results. Our data support IVL use in multimodal pain regimens. Future prospective study is warranted.

Association between time to therapeutic INR and length of stay following mechanical heart valve surgery

Warfarin is the only oral anticoagulant approved for use following mechanical valve surgery (MeVS). Patients may experience prolonged hospital length of stay (LOS) following MeVS awaiting an appropriate warfarin effect. We aimed to determine whether an association exists between time to achieve the first therapeutic international normalized ratio (INR) and LOS following MeVS. Retrospective single center cohort study. We included consecutive adult patients undergoing elective MeVS from 2013 to 2018. Landmark analyses and multivariable regression with time-updated INR were used to estimate the association between time to therapeutic INR (TTI) and LOS. Among 384 patients (median age: 51 years, interquartile range [IQR]: 41-57; 58.3% male), the median TTI was 4 days (IQR: 2-5). Thirty seven percent of patients were discharged with a subtherapeutic INR, many on bridging anticoagulation or with an INR close to target. Those achieving therapeutic INR had an increased rate of hospital discharge (adjusted hazard ratio: 2.17; 95% confidence interval: 1.71-2.76; p < .0001). Attainment of a therapeutic INR anytime between postoperative Days 4 and 13 was significantly associated with a shorter LOS. Prolonged time to achieve a therapeutic INR was independently associated with prolonged LOS. Future strategies aimed at improving attainment of therapeutic INR following MeVS may reduce hospital LOS.

Examining patient specific factors associated with inpatient hospital length of stay for solid tumor oncology patients from low socioeconomic communities in Milwaukee, WI.

232 Background: In a retrospective analysis at the Medical College of Wisconsin’s Cancer Center, we identified longer inpatient length of stay (LOS) for patients residing in low-socioeconomic (SES) ZIP Codes in Milwaukee County compared to their high-SES counterparts in 2020 (7.3 days compared to 7.1 days). Under the auspices of American Society of Clinical Oncology’ Quality Training Program (QTP) initiative, this study examined specific factors related to prolonged LOS for solid tumor oncology patients. Methods: This analysis includes initial CY20 LOS medical record data for select patient service areas. Supplemental data includes disease registry data, diagnostic data, and SES data determined by patient ZIP Code. We identified patients 18 years and older with a diagnosis of common oncologic malignancies from 1/1/2020-12/31/2020 (breast, gastrointestinal (GI), genitourinary (GU), gynecologic (GYN), head and neck (H&amp;N), and lung cancers). Poisson regression models with robust standard errors were used to compare the LOS index (LOSi) between groups of patients based on race, SES group, primary payer, and BMI. Results: A total of 1,637 patients with solid tumor diagnosis admitted to hematology and oncology units were identified. The LOSi did not vary significantly by race (range 0.95 – 1.07, p = 0.40) or primary payer (range 0.99 – 1.04, p = 0.59), but lower SES groups tended to have longer LOSi, with LOSi ratio above 1 compared to high SES (low SES: 1.16, p = 0.2; medium-low SES: 1.24, p = 0.06). Among patients with breast cancer diagnosis, Black (LOSi = 1.24, p = 0.01), medium-low SES (LOSi = 1.46, p = 0.02), Medicaid (LOSi = 1.40, p = 0.00), underweight (LOSi = 1.66, p = 0.00), and overweight (LOSi = 1.23, p = 0.01) patients had slightly longer LOSi, with LOSi ratio above 1. Among patients with H&amp;N cancer diagnosis, Black patients (LOSi = 0.77, p = 0.02) had slightly shorter LOSi, with LOSi ratio below 1. The LOSi did not vary significantly by other factors for patients with H&amp;N cancer diagnosis or the other common oncologic malignancies evaluated. Conclusions: This study shows how patient-specific factors such as race, SES, primary payer, and BMI contribute to inpatient LOS. Healthcare systems may benefit by addressing patient-specific barriers and factors such as body mass index, SES and SDH, to reduce hospital LOS.

Interventions to Reduce Hospital Length of Stay in High-risk Populations

Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction. To identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS. Multiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide. Our searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days). This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.

Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

ObjectiveTo determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.DesignSystematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished)....

Enhanced recovery after surgery (ERAS®) protocol adapted to the Brazilian reality: a prospective cohort study for thoracic patients.

BackgroundIn Low-Middle Income Countries (LMICs), resource optimization and infrastructure availability are recurrently in debate. In order to assist the development and implementation of guidelines, LMICs often exemplify from High-Income Countries protocols. At the final, it will be: content adaption is often needed. In this study, we demonstrated the preliminary analysis of the Brazilian experience by adapting the ERAS® Protocol for thoracic surgery patients (PROSM).MethodsPatients’ data were extracted from the surgical group database that operated in the city of Sao Paulo. Patients’ data were organized for analysis after the institution’s ethics committee gave their approval. Patients’ variables were analyzed and compared to a control group. Subgroup analysis included patients without ICU Admission.ResultsPROSM patients had reduced ICU length of stay (LOS) (Mean of 0.3±0.58 days, 1.2±1.65 days, P=0.001), Hospital LOS (Mean of 1.6±1.32 days, 3.9±3.25 days, P=0.001) and Chest Drain duration (Median 1.0±1.00 days, 3.0±3.00 days, P=0.001). Analyses of patients that were not admitted to the ICU demonstrated reduced Hospital LOS and Chest drain duration. Cost analysis, such as procedure, daily, and post-surgical costs were also significantly lower towards PROSM group.ConclusionsThis study revealed important aspects for improvement of the delivered care quality and opportunity for expenditure management. We expect to assist more countries to improve knowledge under the implementation of enhanced protocols.

Effect of a perioperative immune-enhancing diet in clean-contaminated head and neck cancer surgery: A randomized controlled trial

BackgroundMalnutrition is a common problem in head and neck cancer patients and is associated with an increased risk of postoperative complications and prolonged length of hospital stay (LOS). The purpose of this study was to evaluate the effect of an immune-enhancing diet with supplementary arginine, glutamine, and fish oil in clean-contaminated head and neck cancer surgery. Materials and methodsA randomized controlled trial study in clean-contaminated head and neck cancer surgery patients was conducted. Patients undergoing surgery received either an immune-enhancing diet or hospital-prepared blenderized diet 7 days preoperatively and 14 days postoperatively. Clinical outcomes (mucocutaneous fistula, wound infection, general infection, LOS, and hospital costs) and nutritional parameters (body weight, prealbumin, transferrin, and albumin) were compared between the two groups. Results116 patients were included in the analysis, 60 in the immune-enhancing diet group and 56 in the blenderized diet group. There was a significant association between the immune-enhancing diet and the decrease in fistula rate (8.3 % vs. 23.2 %, p = 0.039), LOS (24 days vs. 29 days, p = 0.043), hospital costs (6312 US dollars vs. 7461 US dollars, p = 0.048), and higher prealbumin level on postoperative day 7 and 14 (p = 0.015 and 0.001, respectively) and transferrin level on postoperative day 14 (p = 0.047). In addition, the immune-enhancing diet also had a positive effect on body weight on postoperative day 14 (p = 0.028). However, there was no difference in nutrition-related adverse events between the two groups. ConclusionThe administration of a perioperative diet containing arginine, glutamine, and fish oil in clean-contaminated head and neck cancer surgery patients led to a significant reduction in mucocutaneous fistula, LOS, and hospital costs. Results also indicated improved nutritional status, including body weight, prealbumin, and transferrin levels.

Tailoring nutrition therapy amid the COVID-19 pandemic: Does it work?

BackgroundThe COVID-19 pandemic has been a challenge for nutrition monitoring and delivery. This study evaluates clinical and nutritional characteristics of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and investigates the relationship between nutrition delivery and clinical outcomes.MethodsProspective observational study of adults admitted for >24 hrs to a tertiary-care hospital during a period of 2months. Data was collected on disease severity, energy, protein delivery and adequacy, use of mechanical ventilation (MV), hospital length of stay (LOS). Multivariate logistic regression models were used to determine the associations with mortality as the primary outcome.Results1083 patients: 69% male (n = 747), 31% females (n = 336), mean age 58.2 ± 12.8 with 26.6 ± 4.32 BMI were analysed. 1021 patients survived and 62 deaths occurred, with 183 and 900 patients in the ICU and ward, respectively. Inadequate calorie and protein delivery had significantly higher mortality than those with adequate provision (p < 0.001) among the ICU patients. In bivariate logistic regression analysis, inadequacy of energy and protein, disease severity, comorbidities ≥3, NRS score ≥3 and prone ventilation correlates with mortality (p < 0.001). In multivariate logistic regression analysis of the ICU patients, energy inadequacy (OR:3.6, 95%CI:1.25–10.2) and prone ventilation (OR:11.0, 95%CI:3.8–31.9) were significantly (p < 0.05) associated with mortality after adjusting for disease severity, comorbidities and MV days.ConclusionMost patients infected with SARS-CoV-2 are at nutrition risk that can impact outcome. Our data suggest that addressing nutritional adequacy can be one of the measures to reduce hospital LOS, and mortality among nutritionally risk patients.

How Much Benefit Can Patients Acquire from Enhanced Recovery After Surgery Protocols with Percutaneous Endoscopic Lumbar Interbody Fusion?

PurposeWe aimed to explore the role of enhanced recovery after surgery (ERAS) in patients who underwent percutaneous endoscopic lumbar interbody fusion (PELIF).Patients and MethodsWe performed a retrospective, observational, cohort study on 91 patients who underwent PELIF for degenerative disc disease. The primary outcomes were postoperative opioid consumption, hospital length of stay (LOS), and hospital cost.ResultsForty-six patients comprised the ERAS group, and 45 patients comprised the pre-ERAS group (control group). The groups had comparable demographic characteristics. Good compliance with the ERAS pathway was observed in the ERAS group. Patients in the ERAS group used significantly fewer morphine equivalents compared with the pre-ERAS group (25.0 vs 33.3, respectively; p = 0.017). Hospital LOS did not decrease significantly in the ERAS group compared with the pre-ERAS group (3.1days vs 3.4 days, respectively; p = 0.096). Likewise, there was no significant difference in hospital cost between the pre-ERAS group and the ERAS group ($10,598.60 vs $10,384.50, respectively; p = 0.468).ConclusionIn the present study, the benefit of ERAS in the context of PELIF was limited. Although a multidisciplinary ERAS protocol can improve analgesia and decrease opioid consumption, no significant reduction in hospital LOS and cost was observed.

Outcomes Following Implementation of a Hospital-Wide, Multicomponent Delirium Care Pathway.

Delirium is associated with poor clinical outcomes that could be improved with targeted interventions. To determine whether a multicomponent delirium care pathway implemented across seven specialty nonintensive care units is associated with reduced hospital length of stay (LOS). Secondary objectives were reductions in total direct cost, odds of 30-day hospital readmission, and rates of safety attendant and restraint use. This retrospective cohort study included 22,708 hospitalized patients (11,018 preintervention) aged ≥50 years encompassing seven nonintensive care units: neurosciences, medicine, cardiology, general and specialty surgery, hematology-oncology, and transplant. The multicomponent delirium care pathway included a nurse-administered delirium risk assessment at admission, nurse-administered delirium screening scale every shift, and a multicomponent delirium intervention. The primary study outcome was LOS for all units combined and the medicine unit separately. Secondary outcomes included total direct cost, odds of 30-day hospital readmission, and rates of safety attendant and restraint use. Adjusted mean LOS for all units combined decreased by 2% post intervention (proportional change, 0.98; 95% CI, 0.96-0.99; P = .0087). Medicine unit adjusted LOS decreased by 9% (proportional change, 0.91; 95% CI, 0.83-0.99; P = .028). For all units combined, adjusted odds of 30-day readmission decreased by 14% (odds ratio [OR], 0.86; 95% CI, 0.80-0.93; P = .0002). Medicine unit adjusted cost decreased by 7% (proportional change, 0.93; 95% CI, 0.89-0.96; P = .0002). This multicomponent hospital-wide delirium care pathway intervention is associated with reduced hospital LOS, especially for patients on the medicine unit. Odds of 30-day readmission decreased throughout the entire cohort.

Association of hospital characteristics with outcomes for pediatric neurosurgical accidental trauma patients.

In the pediatric population, few studies have examined outcomes for neurosurgical accidental trauma care based on hospital characteristics. The purpose of this study was to explore the relationship between hospital ownership type and children's hospital designation with primary outcomes. This retrospective cohort study utilized data from the Healthcare Cost and Utilization Project 2006, 2009, and 2012 Kids' Inpatient Database. Primary outcomes, including inpatient mortality, length of stay (LOS), and favorable discharge disposition, were assessed for all pediatric neurosurgery patients who underwent a neurosurgical procedure and were discharged with a primary diagnosis of accidental traumatic brain injury. Private, not-for-profit hospitals (OR 2.08, p = 0.034) and freestanding children's hospitals (OR 2.88, p = 0.004) were predictors of favorable discharge disposition. Private, not-for-profit hospitals were also associated with reduced inpatient mortality (OR 0.34, p = 0.005). A children's unit in a general hospital was associated with a reduction in hospital LOS by almost 2 days (p = 0.004). Management at freestanding children's hospitals correlated with more favorable discharge dispositions for pediatric patients with accidental trauma who underwent neurosurgical procedures. Management within a children's unit in a general hospital was also associated with reduced LOS. By hospital ownership type, private, not-for-profit hospitals were associated with decreased inpatient mortality and more favorable discharge dispositions.

The Content of Pre-habilitative Interventions for Patients Undergoing Repair of Abdominal Aortic Aneurysms and Their Effect on Post-Operative Outcomes: A Systematic Review

Patients requiring abdominal aortic aneurysm (AAA) repair are at risk of post-operative complications due to poor pre-operative state. Pre-habilitation describes the enhancement of functional capacity and tolerance to an upcoming physiological stressor, intended to reduce those complications. The ability to provide such an intervention (physical, pharmacological, nutritional, or psychosocial) between diagnosis and surgery is a growing interest, but its role in AAA repair is unclear. This paper aimed to systematically review existing literature to better describe the effect of pre-habilitative interventions on post-operative outcomes of patients undergoing AAA repair. EMBASE and Medline were searched from inception to October 2020. Retrieved papers, systematic reviews, and trial registries were citation tracked. Randomised controlled trials (RCTs) comparing post-operative outcomes for adult patients undergoing a period of pre-habilitation prior to AAA repair (open or endovascular) were eligible for inclusion. Two authors screened titles for inclusion, assessed risk of bias, and extracted data. Primary outcomes were post-operative 30 day mortality, composite endpoint of 30 day post-operative complications, hospital length of stay (LOS), and health related quality of life (HRQL) outcomes. The content of interventions was extracted and a narrative analysis of results undertaken. Seven RCTs with 901 patients were included (three exercise based, two pharmacological based, and two nutritional based). Risk of bias was mostly unclear or high and the clinical heterogeneity between the trials precluded data pooling for meta-analyses. The quality of intervention descriptions was highly variable. One exercise based RCT reported significantly reduced hospital LOS and another improved HRQL outcomes. Neither pharmacological nor nutritional based RCTs reported significant differences in primary outcomes. There is limited evidence to draw clinically robust conclusions about the effect of pre-habilitation on post-operative outcomes following AAA repair. Well designed RCTs, adhering to reporting standards for intervention content and trial methods, are urgently needed to establish the clinical and cost effectiveness of pre-habilitation interventions.

Surgical Factors and Treatment Severity for Perioperative Complications Predict Hospital Length of Stay in Adult Spinal Deformity Surgery.

Retrospective review of prospectively collected multicenter registry data. The aim of this study was to determine whether surgical variables and complications as graded by treatment severity impact postoperative hospital length of stay (LOS). Surgical treatment can substantially improve quality of life for patients with adult spinal deformity (ASD). However, surgical treatment is associated with high complication rates, which may impact hospital LOS. Classifying complications by severity of subsequent treatment may allow surgeons to better understand complications and predict their impact on important outcome metrics, including LOS. Patients enrolled in a multicenter, prospectively enrolled database for ASD were assessed for study inclusion. Complications were graded based on intervention severity. Associations between LOS, complication intervention severity, and surgical variables (fusion length, use of interbody fusion, use of major osteotomy, primary versus revision surgery, same day vs. staged surgery, and surgical approach), were assessed. Two multivariate regression models were constructed to assess for independent associations with LOS. Of 1183 patients meeting inclusion criteria, 708 did not and 475 did experience a perioperative complication during their index hospitalization, with 660 and 436 included in the final cohorts, respectively. Among those with complications, intervention severities included 14.9% with no intervention, 68.6% with minor, 8.9% with moderate, and 7.6% with severe interventions. Multivariate regression modeling demonstrated that length of posterior fusion, use of major osteotomy, staged surgery, and severity of intervention for complications were significantly associated with LOS. Careful selection of surgical factors may help reduce hospital LOS following surgery for ASD. Classification of complications by treatment severity can help surgeons better understand and predict the implications of complications, in turn assisting with surgical planning and patient counseling.Level of Evidence: 4.

Demographic characteristics, clinical features, and optimal management of hospitalized patients with staphylococcal scalded skin syndrome.

Optimal management of staphylococcal scalded skin syndrome (SSSS) has not been established. Clindamycin may benefit patients via inhibition of ribosomal toxin production, but resistance patterns suggest penicillinase-resistant penicillins or cephalosporins should be the first line. Our goal was to describe demographic and clinical characteristics of SSSS patients at our institution, delineate bacterial resistance patterns, and examine outcomes of varying therapeutic strategies in SSSS. We performed a retrospective review of patients under the age of 18 with confirmed clinical SSSS diagnosis by the dermatology consult team at the University of North Carolina (UNC) Hospitals from January 2008 to April 2017. Median hospital and ICU length of stay (LOS) were compared using a Wilcoxon Rank Sum Test. We found 59 SSSS patients. Coverage with clindamycin and vancomycin versus absence of that combination was associated with shorter ICU LOS. Although trending toward reduced hospital LOS, this was not significantly altered with the use of vancomycin and clindamycin after adjustment for multiple comparisons. Individual use of either clindamycin or vancomycin did not significantly alter overall hospital or ICU LOS. Among 24 patients with a pathogen identified on culture, 18 (75.0%) revealed resistance to clindamycin, and 2 (8.3%) revealed MRSA. Clindamycin resistance is more prevalent in hospitalized SSSS patients compared to our pediatric outpatient population. The combination of vancomycin and clindamycin results in shorter ICU LOS. Individual use of clindamycin or vancomycin does not significantly reduce hospital or ICU LOS after adjustment for multiple comparisons.

Enhanced Recovery After Surgery can Improve Patient Outcomes and Reduce Hospital Cost of Gastrectomy for Cancer in the West: A Propensity-Score-Based Analysis

BackgroundData on ERAS for gastrectomy are scarce, and the majority of the studies come from Eastern countries. Patients in the West are older and suffer from more advanced tumors that impair their clinical condition and often require neoadjuvant treatment. This retrospective study assessed the feasibility and safety of an Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy in a Western center.MethodsWe conducted a single-center study of 351 patients operated for gastric cancer: 103, operated from January 2015 to December 2016, followed the standard pathway, while 248, operated from January 2017 to December 2019, followed the ERAS program. The primary outcomes considered were length of hospital stay (LOS) and direct costs. Secondary outcomes were 90-day morbidity and mortality, readmission rate, and compliance with ERAS items. A propensity score (PS) was built on confounding variables.ResultsCompliance with ERAS items after the program was ≥ 70%. Univariable analysis evidenced a 2-day median reduction in LOS and a median cost reduction of €826 per patient in the ERAS group. PS-based multivariable analysis confirmed a significant, 2-day decrease in median LOS and a €1097 saving after ERAS introduction. Ninety-day mortality decreased slightly in ERAS group, while complications and readmissions did not change significantly. When complications were included in the multivariable analysis, ERAS retained its significance, although the effects on LOS and cost were blunted to a median reduction of 1 day and €775, respectively.ConclusionsERAS for gastrectomy improved patients’ recovery and reduced hospital costs without changes in morbidity, mortality, or readmission.

People With Hematological Malignancies Treated With Bone Marrow Transplantation Have Improved Function, Quality of Life, and Fatigue Following Exercise Intervention: A Systematic Review and Meta-Analysis.

For people with hematological malignancies treated with bone marrow transplantation (BMT), this systematic review aimed to identify, evaluate, and synthesize the evidence examining the effect of exercise training on the outcomes of exercise capacity, health-related quality of life (HRQoL), and hospital length of stay (LOS) and to identify any difference in the effect on people treated with allogeneic versus autologous transplantation. Five electronic databases were systematically searched from inception to December 5, 2020. Prospective studies with a comparator group, with or without randomization, were included if they investigated the effects of an exercise intervention compared with usual care or another intervention in adults who had a hematological malignancy and were undergoing BMT. Primary outcomes of interest were functional exercise capacity and HRQoL; secondary outcomes included strength, fatigue, hospital LOS, and feasibility. Only randomized controlled trials were included in the meta-analyses. Risk of bias was evaluated using the Physiotherapy Evidence Database or Newcastle-Ottawa Scale; the quality of evidence for meta-analyses was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Twenty-four randomized controlled trials and 3 prospective nonrandomized experimental trials were included (n = 2432). There was moderate-quality evidence that exercise improves functional exercise capacity (mean difference [MD] = 29 m; 95% CI = 12.59 to 45.4), global HRQoL (MD = 3.38 points; 95% CI = 0.37 to 6.39), and fatigue (MD = 2.52 points; 95% CI = 0.42 to 4.63) and low-quality evidence for reduced hospital LOS (MD = 2.07 days; 95% CI = 0.43 to 3.72). These effects were more pronounced in recipients of allogeneic transplantation. No serious adverse events were associated directly with exercise in the included studies. Exercise is safe and improves outcomes, including functional exercise capacity, HRQoL, and hospital LOS in adults undergoing BMT. The results of this systematic review support the implementation of exercise programs in adults undergoing BMT, particularly recipients of allogeneic transplantation.

Economic analysis of the use of video laryngoscopy versus direct laryngoscopy in the surgical setting.

Aim: Compared with direct laryngoscopy (DL), video laryngoscopy (VL) offers clinical benefits in routine and difficult airways. The health economic benefit of VL versus DL for routine tracheal intubation remains unknown. Materials & methods: This analysis compared VL and DL health economic outcomes, including total inpatient costs, length of hospital stay (LOS), postoperative intensive care unit (ICU) admission and incidence of procedurally associated complications. Results: Patients with VL had decreased inpatient cost (US$1144-5891 across eight major diagnostic categories [MDC]); >1-day LOS reduction in five MDC; reduced odds for postoperative ICU admission (0.04-0.68) and reduced odds of respiratory complications in three MDC (0.43-0.90). Conclusion: Video laryngoscopy may lower total costs, reduce LOS and decrease the likelihood of postoperative ICU admission.

Clinical and Economic Outcomes Associated With Use of Liposomal Bupivacaine Versus Standard of Care for Management of Postsurgical Pain in Pediatric Patients Undergoing Spine Surgery.

Background: Approximately 60% of hospitalized children undergoing surgery experience at least 1 day of moderate-to-severe pain after surgery. Pain following spine surgery may affect opioid exposure, length of stay (LOS), and costs in hospitalized pediatric patients. This is a retrospective cohort analysis of pediatric patients undergoing inpatient primary spine surgery.Objectives: To examine the association of opioid-related and economic outcomes with postsurgical liposomal bupivacaine (LB) or non-LB analgesia in pediatric patients who received spine surgery.Methods: Premier Healthcare Database records (January 2015–September 2019) for patients aged 1–17 years undergoing inpatient primary spine surgery were retrospectively analyzed. Outcomes included in-hospital postsurgical opioid consumption (morphine milligram equivalents [MMEs]), opioid-related adverse events (ORAEs), LOS (days), and total hospital costs. A generalized linear model adjusting for baseline characteristics was used.Results: Among 10 189 pediatric patients, the LB cohort (n=373) consumed significantly fewer postsurgical opioids than the non-LB cohort (n=9816; adjusted MME ratio, 0.53 [95% confidence interval (CI), 0.45–0.61]; P<0.0001). LOS was significantly shorter in the LB versus non-LB cohort (adjusted rate ratio, 0.86 [95% CI, 0.80–0.94]; P=0.0003). Hospital costs were significantly lower in the LB versus non-LB cohort overall (adjusted rate ratio, 0.92 [95% CI, 0.86–0.99]; P=0.0227) mostly because of decreased LOS and central supply costs. ORAEs were not significantly different between groups (adjusted rate ratio, 0.84 [95% CI, 0.65–1.08]; P=0.1791).Discussion: LB analgesia was associated with shorter LOS and lower hospital costs compared with non-LB analgesia in pediatric patients undergoing spine surgery. The LB cohort had lower adjusted room and board and central supply costs than the non-LB cohort. These data suggest that treatment with LB might reduce hospital LOS and subsequently health-care costs, and additional cost savings outside the hospital room may factor into overall health-care cost savings. LB may reduce pain and the need for supplemental postsurgical opioids, thus reducing pain and opioid-associated expenses while improving patient satisfaction with postsurgical care.Conclusions: Pediatric patients undergoing spine surgery who received LB had significantly reduced in-hospital postsurgical opioid consumption, LOS, and hospital costs compared with those who did not.

Prehabilitation in Paediatric Orthopaedic Surgery Reduces Hospital Length of Stay

Prehabilitation in Paediatric Orthopaedic Surgery Reduces Hospital Length of Stay

Enhanced Recovery After Surgery Pathway for Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion Decreases Length of Stay and Opioid Consumption.

Opioid requirements in the perioperative period in patients undergoing lumbar spine fusion surgery remain problematic. Although minimally invasive surgery (MIS) techniques have been developed, there still remain substantial challenges to reducing length of hospital stay (LOS) because of postoperative opioid requirements. To study the effect of implementing an enhanced recovery after surgery (ERAS) pathway in patients undergoing a 1-level MIS transforaminal lumbar interbody fusion (MIS TLIF) at our institution. We implemented an ERAS pathway in patients undergoing an elective single-level MIS TLIF for degenerative changes at a single institution. Consecutive patients were enrolled over a 20-mo period and compared with a pre-ERAS group prior to the implementation of the ERAS protocol. The primary outcome was LOS. Secondary outcomes included reduction in morphine milligram equivalent units (MME), pain scores, postoperative urinary retention (POUR), and incidence of postoperative delirium. Patients were compared using the chi-square and Welch's 2-sample t-tests. A total of 299 patients were evaluated in this study: 87 in the ERAS group and 212 in the pre-ERAS group. In the ERAS group, there was a significant reduction in LOS (3.13± 1.53vs 3.71± 2.07 d, P=.019), total admission MME (252.74± 317.38vs 455.91± 498.78 MME, P=.001), and the number of patients with POUR (48.3%vs 65.6%, P=.008). There were no differences in pain scores. This is the largest ERAS MIS fusion cohort published to date evaluating a single cohort of patients in a generalizable manner. This ERAS pathway has shown a substantial decrease in LOS and opioid requirements in the immediate perioperative and postoperative period. There is further work to be done to evaluate patients undergoing other complex spine surgical interventions.