Reduction In Average Length Research Articles

Effects of dough sheets resting on textural properties of long‐life noodles via moisture migration and gluten network development

SummaryNoodles are a popular staple food for many Asian populations. This study aimed to explore the effects of different resting temperatures (15, 25, 35, 45 °C) and humidity (65%, 75%, 85%, 95%) on the quality of long‐life noodles (LL noodles) by considering the moisture migration and microstructure of gluten network in dough sheets. According to results, at resting conditions (25 °C and 95% relative humidity), the dough sheet exhibited a shorter transverse relaxation time of tightly bound water (T21) and higher relative content (A21), which facilitated a tight combination between other components and water molecules. Additionally, a dense and uniform distribution of gluten network was achieved at 25 °C and 95%, due to a reduction in average length and width of gluten network lines, as well as to increased branching rate. Therefore, LL noodles were endowed with a lower cooking loss rate and higher water absorption rate, and the texture properties including chewiness, hardness, smoothness and elasticity were at optimal level. The present work demonstrated the possibility of using a resting at 25 °C and 95% humidity to enhance the uniformity of gluten network and texture of dough sheets and significantly improved the texture properties of LL noodles.

Improving patient outcomes while reducing readmissions with data analytics

As post-acute care spend continues to rise and the Centers for Medicare and Medicaid Services (CMS) moves forward with promoting both value-based and risk-bearing models of care, it is essential for accountable care organisations (ACOs), payers and hospital providers to take proactive measures to find innovative and data-driven strategies to meet the future demands of healthcare. Yet disparate electronic health record (EHR) systems between acute and post-acute providers continue to pose challenges in the ability to access live patient data across care settings, which enables clinical line of sight to manage both patient and population-level quality outcomes. Utilisation of an EHR-agnostic platform, which mitigates interoperability issues, can improve care transitions, provide data analytics to manage the patient care journey, foster seamless implementation of standardised care pathways and ultimately reduce total costs within post-acute networks by decreasing readmissions and length of stay. St. Joseph’s Health implemented such a data analytics platform and instituted a post-acute nurse navigator, social worker and care manager roles to manage their value-based patients in the postacute setting. As a result, their Medicare Shared Savings Plan ACO, Mission Health Coordinated Care, achieved a significant reduction in readmissions from 24 per cent to 17.8 per cent, as well as a total cost of care savings of US$1.6m in its first year. Currently, the readmission rate is down to 13.6 per cent, and there has also been a 3.2-day reduction in average length of stay. Owing to their successful post-acute strategy and programming, the project was scaled to include all patients in value-based contracts.

Number of drugs provided by the Pharmaceutical Benefits Scheme and mortality and hospital utilization in Australia, 2002–2019

We analyze the relationship between long-run changes in the drugs provided by the Pharmaceutical Benefits Scheme (PBS) and mortality and hospital utilization in Australia, by analyzing the correlation across diseases between the change in the number of drugs used to treat the disease provided and the subsequent change in mortality or hospital utilization from that disease.Our estimates indicate that diseases for which there were larger increases in the number of PBS drugs tended to have smaller subsequent growth in premature (before ages 85, 75, and 65) mortality. Diseases for which there was larger growth in the number of PBS drugs also tended to have smaller growth in the number of hospital days 2–10 years later. The reduction in the number of hospital days appears to be primarily attributable to a reduction in average length of stay.We estimate that the 1996–2013 increase in the number of PBS drugs was associated with a reduction in the number of years of life lost before age 85 in 2019 of 359,026, and that the 1994–2011 increase in the number of PBS drugs was associated with a reduction in the number of hospital days in 2019 of 2.48 million. A rough estimate of the cost per life-year before age 85 gained in 2019 from drugs previously added to the PBS is $AUS 1388.

Neonatal Outcomes Associated With in Utero Exposure to Oxycodone, Overall and by Trimester of Exposure: A Retrospective Cohort Study

Oxycodone is commonly used by pregnant women for the treatment of pain. However, the potential risk associated with its use in pregnancy have not been robustly evaluated. The objective of this study was to examine neonatal outcomes associated with prenatal oxycodone exposure. State dispensing records were matched with midwives records to identify women who had been dispensed oxycodone during pregnancy (n=302). A matched comparison group of women who had been prescribed oxycodone prior to pregnancy was also identified (n=604). Hospital, mortality and congenital abnormality data were obtained for each mother-child dyad. Neonatal outcomes were examined for association with any exposure during pregnancy and trimester specific exposure, using generalized linear models. First trimester exposure was not associated with a significant increased risk of congenital anomalies (OR: 1.74 95%CI: 0.78, 3.87). Second trimester exposure to oxycodone was associated with reduction in average length of gestation (aCoef:-0.83, 95%CI: -1.26, -0.41) and birth weight (aCoef:-188, 95%CI: -299, -76). Second trimester exposure was also associated with an increased risk of very preterm birth (<32 weeks) (OR: 5.03, 95%CI: 1.95, 12.98) and admission to the special care nursery (aOR:1.99, 95%CI: 1.30, 3.03). Third trimester exposure to oxycodone was associated with a reduction in average length of gestation (aCoef:-0.33, 95%CI: -0.63, -0.02) compared with the comparison group. The use of oxycodone in pregnancy was not associated with an increased risk of congenital anomalies. However, oxycodone exposure was associated with a short period of gestation, preterm birth, and NAS, which likely contributed to a longer period of hospitalization following birth. PerspectiveThis article assesses the neonatal risks associated with prenatal exposure to oxycodone, providing clinicians and patients with important information on the safety of oxycodone in the treatment of pain in pregnancy.

Optimising Treatment Delivery and Reducing Length of Stay in an Adult In-Patient Unit

AimsLifetime prevalence of eating disorders worldwide is 8.4% (3.3–18.6%) for women and 2.2% (0.8–6.5%) for men and this prevalence has been increasing over time. Anorexia nervosa has become a greater burden on secondary care: Not only have admission rates increased, but so too have multiple admissions per person with Anorexia Nervosa. Conservative treatment approaches and long lengths of stay have both direct and indirect costs for patients, hinder access to the service for potential patients and reduce service cost effectiveness. Ramsay Clinic Hollywood is a voluntary, private ten bed adult eating disorder inpatient service in Perth, Western Australia (WA). It is the only inpatient eating disorder specialist service for people over the age of 16, in both the private and public sector in WA. Over the past eight years, our focus has been on optimizing treatment delivery to minimise time spent in hospital for individuals with anorexia. The aim of this study was to evaluate whether instituting a rapid refeeding protocol was effective in optimising treatment outcomes, such as rate of refeeding and reducing length of stay (LOS).MethodsA retrospective review of data collected for all inpatients from 2013–2019 was conducted. The outcomes evaluated were length of stay and number of readmissions.ResultsUtilising a rapid refeeding protocol successfully increased the rate of refeeding from 0.6kg/week to 1.5kg/week. This led to a reduction in average length of stay from 52 days in 2013 to 24 days in 2017. Concomitantly we have been able to double the number of patients admitted to the service/ year and reduce the number of readmissions/ patientsConclusionThese results suggest that it is possible to lower length of stay by increasing the rate of refeeding and this in turn allows more patients access to hospital care for their eating disorder.

Intermediate care units in progressive patient care model: a systematic literature review

&#x0D; Background: Progressive patient care (PPC) has been defined as a systematic classification and segregation of patients based on their medical and nursing needs. Aim of the present research was to perform a systematic literature review about existing medical intermediate care unit organizational models and their performance strengths and weaknesses with a specific focus on Italian implementation, respect to US model.&#x0D; Methods: Databases PubMed, Cinahl, Google and Google Scholar were searched until September 2017. The search was limited to Italian and English studies. All study design are included in the review.&#x0D; Results: Ten studies were included in the review. The American studies showed, after the PPC reorganization, an increase in level of satisfaction and nursing care, a reduction in average length of stay, costs and tensions between nurses and an improvement in nurse-physician communication. An Italian study reported the results of a project carried out in three case studies (Forlì, Foligno and Pontedera hospital), redesigning hospital patient flow logistics around the concept of intensity of care: in all three cases, after the reorganization, an increase in bed occupancy rate (before: 71%,81%,65%; after: 78%,84%,82%, respectively) and in hospital case-mix complexity (average DRG weight - before: 0.99,1.07,1.12; after: 1.19,1.09,1.61, respectively) and a reduction in turn-over ratio (before: 2.5,1.4,2.8; after: 1.5,1.2,1.7, respectively) was recorded. Considering Italian healthcare professionals’ point of view, majority of internists supported a hospital remodeling according to PPC model.&#x0D; Conclusions: The PPC model, theorized in US, has found several applications in Italian regional realities. Improvements in quality of care, appropriateness and productivity in healthcare facilities, that adopted the PPC program, were observed.&#x0D;

Mindful Melody: feasibility of implementing music listening on an inpatient psychiatric unit and its relation to the use of as needed medications for acute agitation

BackgroundIn this quality improvement project, we set out to study the effectiveness and feasibility of using music as an adjunct or replacement for pharmacologic agitation management on an inpatient psychiatric unit. We hypothesized music intervention would not only assist in de-escalation/calming of agitated patients, but also reduce overall administration of PRN medications on the unit.MethodThe project included 172 volunteer participants over 6 months: Three months without music available and 3 months with a music de-escalation option. During the latter period, patients were given the option of selecting a preferred music genre and provided with wireless headphones for up to 30 min. The number of as needed (PRN) medications administered for agitation and anxiety (including oral, sublingual, and intramuscular routes) was compiled from raw data using pharmacy records. Patients and nurses were provided with self-report surveys regarding the music intervention.ResultsThe average weekly PRN medication administrations decreased significantly during the 3 months with music for both haloperidol (8.46 [+/− 1.79, p < 0.05] to 5.00 [+/− 1.44, p < 0.05] administrations/week) and olanzapine (9.69 [+/− 2.32, p < 0.05] to 4.62 [+/− 1.51, p < 0.05] administrations/week), compared to the 3 months prior to music implementation. There was a non-significant increase in administration of lorazepam (3.23 [+/− 1.09, p < 0.05] to 6.38 [+/− 2.46, p < 0.05] average administrations/week). The patient survey responses were 96% positive (non-neutral; either agree or strongly agree with calming effect). Nurses agreed that the project was easy to implement; 56% agreed that music helped to calm patients down. Other exploratory outcomes included observed reductions in average length of hospital stay and number of seclusion events.ConclusionMusic may play a significant role in reducing the utilization of PRN agitation medications on acute inpatient psychiatric units. More studies are needed to expand on these findings and explore the effect of PRN music on other therapeutic outcomes.Trial registrationProtocol registration NCT04514432, retrospectively registered on 08/13/2020.

64. Impact of a Duration Bundle on Antimicrobial Use in a Pediatric Hospital

BackgroundLimiting antibiotic durations to the shortest effective duration is a strong recommendation with moderate-quality evidence in the 2016 IDSA Antimicrobial Stewardship Program (ASP) guidelines. An ASP bundle including a decrease in antimicrobial automatic stop dates from 14 days to 10 days along with a guideline for standard durations for 48 specific indications was implemented at a tertiary pediatric hospital in November 2019. The purpose of this review and was to assess the impact of this ASP initiative on patient outcomes and hospital cost-savings by comparison of pre-intervention and post-intervention data.MethodsA set of antimicrobial duration recommendations for pediatric patients was created by the Antimicrobial Stewardship Program, Pediatric Hospital Medicine providers, and Infectious Disease providers specific to indication, agent, or pathogen. After education of medical care providers and distribution of the recommendations, automatic stop dates in the Electronic Medical Record (EMR) were updated from 14 days to 10 days for all antimicrobials. Concomitant advertising campaigns were shown on all hospital screensavers. Data were collected for a one month pre-intervention period of Nov.15 - Dec.15, 2018 including 133 patients and a one month intervention period of Nov.15 - Dec.15, 2019 including 125 patients.ResultsThe average length of stay decreased from an average of 8.3 days pre-implementation to 6.7 days (p=0.043) post implementation. The ratio of actual to recommended duration also decreased from 1.56 to 1.30 (p< 0.001) when comparing pre vs. post initiative. Balancing measures did not change for restarting treatment within 48 hours of stopping or readmission within 30 days for the same infection. The decrease in inpatient therapy translated to more than $10,000 per year in direct drug cost.ConclusionThis intervention lead to a significant reduction in average length of stay per admission and significantly reduced the secondary outcomes of the total duration of antimicrobial therapy and the ratio of actual duration compared to recommended duration. This lead to cost savings and decreased inappropriate antibiotic exposure.Disclosures All Authors: No reported disclosures

A Multidisciplinary Home Visiting Program for Children With Medical Complexity.

Given the high needs and costs associated with the care of children with medical complexity (CMC), innovative models of care are needed. Home-visiting care models are effective in subpopulations of pediatrics and medically complex adults, but there is no literature on this model for CMC. We describe the development and outcomes of a multidisciplinary program that provides comprehensive home-based primary care for CMC. Medical records from our institution were reviewed for patients enrolled in our program from July 2013 through March 2019. Demographics, clinical characteristics, and health care use were collected. We compared the differences in pre- and postprogram enrollment health care use using Wilcoxon signed rank test. We applied Cox proportional hazard models to examine the association between the time-dependent postenrollment health care use and numbers of home visits. We collected total claims data for a subset of our patients to examine total costs of care. We reviewed data collected from 121 patients. With our findings, we demonstrate that enrollment in our program is associated with reductions in average length of stay. More home visits were associated with decreased emergency department visits and hospitalizations. We also observed in patients with available cost data that total costs of care decreased after enrollment into the program. Our model has the potential to improve health outcomes and be financially sustainable by providing home-based primary care to CMC.

Burden of Pediatric Central Nervous System Infection and Cost-Benefit Simulation of Multiplex Polymerase Chain Reaction in Japan.

To investigate the clinical use of multiplex polymerase chain reaction (mPCR) in Japan, epidemiological and clinical data for central nervous infections are needed. Here, we report on the epidemiology and economic burden of central nervous system infections and a simulation of the cost-benefit analysis of the Filmarray® Meningitis/Encephalitis (FAME) test for possible clinical use in Japan. We performed FAME tests on samples from 27 patients with pleocytosis aged between 0 and 20 years seen in six community hospitals in Nara and Osaka prefectures. All clinical management procedures were performed without knowledge of the mPCR test results. We analyzed the clinical data and calculated the required reduction in average length of stay for the FAME test to be cost-beneficial. Among the 27 cases, the FAME test revealed causal pathogens in 13 cases (48.1%). The average medical and social costs per case were ¥299,118 ($2,719.2) and ¥171,768 ($1,561.5), respectively. The minimal needed reduction in average length of stay for the FAME test to be cost-beneficial was 0.32- 0.86 days per meningitis case. The result can be informative for evaluating the cost-effectiveness of the clinical use of the FAME test in Japan.

Enhanced recovery after liver surgery.

In a majority of cases, enhanced recovery after surgery program (ERP) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery. The program's preoperative, perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team. Having shown its merits in digestive surgery, ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail. The objective of this review was to evaluate the efficacy of ERP in liver surgery. This is a systematic narrative review of the literature on the efficacy of ERP in liver surgery by laparotomy or laparoscopy. Notwithstanding a number of studies (n=30: 5 randomized trials, 14 cohort studies and 11 meta-analyses) less sizable than with regard to digestive surgery in general and colorectal surgery in particular, analysis of the literature confirms that in liver surgery, ERP is associated with an overall decrease in complications by 30 to 60%, but without improvement in the rates of hospital readmission and postoperative mortality. All of the studies report a reduction in average length of stay (ALOS) by 2.3 days and in functional recovery, a more objective indicator than ALOS, by 2.5 days. As of now, the economic impact of the ERP programs in liver surgery is neither positive nor negative, the above-mentioned savings being counterbalanced by heightened costs for material and equipment. Laparoscopic surgery is independently associated with better outcomes in terms of complications, functional recovery and ALOS; that is why it is important to incorporate this surgical approach in ERP as often as possible. Given a lack of robust evidence, Prehabilitation, which is a preoperative optimization process leading to improved functional reserve, has yet to be assigned a place in ERP programs pertaining to liver surgery. Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader, a motivated multidisciplinary team, training courses and dedicated teaching sessions. ERP is a care improvement process that has a major play to play in organization of liver surgery, and its large-scale application is to be recommended.

Implementation of day of surgery admission for rectal cancer surgery in Ireland following a national centralisation programme.

Centralisation of rectal cancer surgery has altered the delivery of colorectal cancer care in Ireland. This has resulted in an increased demand for elective surgical beds in designated centres. This study aimed to assess if day of surgery admission (DOSA), in conjunction with implementation of a coordinated enhanced recovery pathway can reduce length of stay following elective rectal cancer resection. This is a retrospective review from a single institution. Our prospectively maintained Dendrite® Database was interrogated. Three time points were analysed across a 7-year period (2011, 2012, 2016). The first predates the introduction of a dedicated DOSA programme, the next was directly thereafter, and the final was 5-years post-implementation. These dates coincide with the centralisation of rectal cancer surgery to this centre. Outcomes included unadjusted length of stay and rates of DOSA pre-and post-implementation of the programme. The introduction of a DOSA pathway resulted in a fivefold increase in day of surgery admissions and a related 3-day reduction in average length of stay within a single year of implementation. This further improved in 2016, showing an almost 83% increase (15.90-98.50%) in day of surgery admission and a reduction in average length of stay from 16.4 to 12.4days when compared to 2011. Despite an increase in caseload of 54%, an estimated 272 bed days were saved. This demonstrated that DOSA is sustainable and highly effective in tackling the increased inpatient bed demands associated with the growing requirement for elective surgery.

Assessing sustainable supply chain enablers using total interpretive structural modeling approach and fuzzy-MICMAC analysis

PurposeThe purpose of this paper is to model the enablers of an integrated logistics. The integration is accounted for incorporating sustainability, thereby aiming in its theory building. Existing models have focused on enablers of sustainable supply chain independently which lacks a holistic view in understanding the integrated logistics for sustainable supply chain.Design/methodology/approachAn extensive literature review, expert opinion from both industry and academia based on questionnaire survey, is conducted to find the relevant enablers. The modeling of these enablers is done using total interpretive structural modeling (TISM). Finally, TISM along with its respective fuzzy-matriced impact croises multiplication applique (fuzzy-MICMAC) analysis is depicted.FindingsThe result of the survey and TISM model with its respective fuzzy-MICMAC has been used to evolve the mutual relationships among the important enablers of integrated logistics of consumer durables. The strategic factors obtained from TISM are integration and collaboration in the supply chain, vehicle type, and capacity; reduction in average length of haul; and real-time information system. Route selection and scheduling, reduction of fuel consumption, customer relationship management, green technology, cost reduction, etc., are some of the operational factors. Sustainable environment performance is obtained as the performance factor. Fuzzy-MICMAC is more responsive than the traditional MICMAC analysis.Research limitations/implicationsThe study has limitation for the development of a conceptual framework for integrated logistics in uncertain environments. So it can be extended by combining soft computing methodologies. There is a lack of mathematical quantification of the proposed model where the enablers of sustainability can be measured.Practical implicationsThe study on integrated logistics for sustainable supply chain is itself a new area to be explored, as very few studies on this relevant topic exist. The research concentrates on TISM for the integrated logistics and the movement of consumer durables through different distribution channels of a supply chain. The study has implications for practitioners, academicians, and policy makers. For practitioners, it provides a list of strategic factors, operational factors, and performance factors. For academicians, this methodology can be opted to conduct an exploratory study by identifying the essential enablers. For policy makers, the regulations can be developed using the above model.Originality/valueIt is an effort to model the important enablers and establish sustainability in integrated logistics of consumer durables.

Modelling the substitutability of community, long-term, and hospital care and their impact on acute hospital length of stay in Ireland

Background: Within the context of reduced health expenditure and Government policy of transferring of care out of acute hospitals, this study models the supply of acute, community, and long-term care on acute hospital length of stay in Ireland. This study examines how different forms of acute and non-acute care often operate as substitutes for each other and that investment or changes in one area will have spillover effects on others. Understanding these substitution effects is vital in order reduce the demands on the expensive, strained acute hospital sector, and to provide a better model of integrated care within a healthcare system. Methods: This study uses data from the large administrative Hospital Inpatient Enquiry (HIPE) database (2010-2014), and other administrative databases to model the role acute and non-acute supply of care have on acute inpatient length of stay in Ireland. Longitudinal methods using both linear and count data models as well as multilevel modelling techniques are incorporated. Analyses were undertaken on both elective and emergency admissions, as well as specific populations where non-acute services may be most important, i.e. patients requiring rehabilitation. Results: This study finds that both the supply of acute hospital beds and staffing, and the non-acute supply of care impact acute hospital length of stay. Results from the hospital-level model found that a 10% of reduction in acute hospital beds led to a 5.6% reduction in average length of stay for inpatients in public hospital, with a larger reduction seen for emergency admissions (6.2%). Inequities also emerged; those with public insurance (a medical card) or not in a private bed being most sensitive to the reduction in acute bed supply. Considerable geographical differences in the supply of community care and long-term care were also observed. There was substantial evidence that poorer provision of non-acute services resulted in longer length of stay. These results highlight that non-acute and acute health services are often substitutable. Conclusion and discussion: The reduction in the supply of many healthcare services during a period of reduced healthcare expenditure impacted patient outcomes, including acute hospital length of stay. Both acute and non-acute healthcare supply impacted length of stay, with community services found to be substitutable for more expensive acute care. Greater awareness that changing the provision of both acute and non-acute care will impact patient outcomes will aid better models of integrated care. Better integration of acute and non-acute health may have highly beneficial effects on both patient outcomes and sustainability of services.

Relationship between ancient bridges and population dynamics in the lower Yangtze River Basin, China.

It has been suggested that population growth dynamics may be revealed by the geographic distribution and the physical structure of ancient bridges. Yet, this relationship has not been empirically verified. In this study, we applied the archaeological records for ancient bridges to reveal the population growth dynamics in the lower Yangtze River Basin in late imperial China. We investigated 89 ancient bridges in Yixing that were built during the Ming and Qing dynasties (AD1368–1911). Global Position System information and structure (length, width, and span) of those bridges was measured during our field investigations. Their distribution density was calculated by ArcGIS. The historical socio-economic dynamics of Yixing was inferred from the distribution and structure of ancient bridges. Based on the above information, the population growth dynamics in Yixing was projected. Our results show that 77 bridges were built in Yixing during the Qing dynasty, which is 6.41 times more than the number built during the Ming dynasty. In the Ming dynasty, bridges were built on pivotal routes; in the Qing dynasty, bridges were scattered across various places. Over the period, the density distribution of bridges shifted northwestward, while the average length and width of bridges decreased. The increasing number of bridges corresponded to population growth, largely attributable to massive clan migration from northern China during the Little Ice Age. The shift in the density distribution of bridges corresponded to the formation of settlements of large clans and the blossoming of Yixing Teapot handicrafts. The scattering and the reduction in average length and width of bridges was due to the dispersal of population and the associated formation of small settlements in the latter period. Our approach is innovative and robust, and could be employed to recover long-term historical population growth dynamics in other parts of China.

Recombinant human bone morphogenetic protein-2 versus iliac crest bone graft in anterior cervical discectomy and fusion: Dysphagia and dysphonia rates in the early postoperative period with review of the literature

Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a growth factor utilized to stimulate bone development in several clinical scenarios. Although the U.S. Food and Drug Administration approved this therapeutic modality for only two applications, it is frequently used off-label in anterior cervical discectomy and fusion (ACDF) procedures as an alternative to iliac crest bone graft (ICBG), the prior standard of care. This usage has been a source of controversy in the medical community due to evidence of increased rates of postoperative edema and dysphagia. This retrospective cohort study investigates two groups of 200 patients having undergone ACDF, one using rhBMP-2 and the other using ICBG, to evaluate the incidence of complications in the early postoperative period. A significant reduction in average length of stay was found in the rhBMP-2 cohort (1.40days) compared to the ICBG cohort (1.85days) as well as a significantly increased rate of dysphagia (25.5% in rhBMP-2 vs. 15% in ICBG; p=0.01). An increased rate of dysphonia was observed among patients undergoing revision surgery (25.0%) compared to primary surgery (1.6%), but stratification by number of levels, gender, and smoking status yielded no differences in complication rates. Our evaluation of two large cohorts along with review of the literature on the topic sheds light on potential benefits and risks of rhBMP-2 in ACDF procedures. Further investigation is warranted to determine if clinical gains outweigh the potential harms of rhBMP-2 use in this setting.

Preemptive Ethanol Lock Therapy in Pediatric Hematology/Oncology Patients With Catheter-Associated Bloodstream Infection: Impact on Length of Stay, Cost, and Catheter Salvage.

Background. Ethanol lock therapy (ELT) with systemic antimicrobial therapy is a promising therapy for catheter-related infection (CRI). The impact of ELT timing on treatment efficacy and costs is unknown. Procedures. A prospective study was conducted in the Hematology/Oncology Unit at the Children’s Hospital of Michigan. Patients with suspected CRI were randomized to Preemptive ELT arm or Rescue ELT arm after positive culture. Results. Five cases in Preemptive arm and 9 in Rescue arm had a confirmed CRI. All cases cleared infection with line salvage with no adverse events due to ELT or recurrence within 14 days. Our data showed a trend toward 36% reduction in average hospital costs and 40% reduction in average length of stay in Preemptive arm over Rescue arm. Conclusion. Although a small study, our data on preemptive ELT with systemic antimicrobial therapy suggest a potentially important treatment strategy in reducing length of stay as well as hospital costs.

To treat NAS, use mother‐infant bond; results include reduced use of morphine, length of stay, and costs

Infants born to mothers who are in treatment for opioid use disorders with methadone are sometimes born with neonatal abstinence syndrome (NAS), a constellation of symptoms associated with opioid withdrawal. The old way of treating these infants — and the current way in many institutions — is to put them in the neonatal intensive care unit (NICU) and treat them with gradually decreasing doses of morphine. But keep out of the NICU, standardize nonpharmacologic care, and empower parents, and what do you get? A reduction in the percentage of infants treated with morphine from 98% to 14%, a reduction in average length of stay (ALOS) from 22.4 to 5.9 days, and a decrease in costs from $44,824 to $10,289. That is what researchers at Yale New Haven Children's Hospital discovered when they implemented novel “plan‐do‐study‐act” cycles in 2010 in response to a dramatic increase in the number of infants born there who had been exposed to methadone in utero (a 74% increase from 2003 to 2009).

Reduction in resource utilization and increase in patient satisfaction two years after implementation of Perioperative Surgical Home

Introduction: Perioperative Surgical Home (PSH) provides coordinated, team-based care that is patient-centered, designed to guide patients efficiently through the surgical experience. We applied several changes to our anesthesia practice during 2014 and evaluated outcomes for all orthopedic major joint replacement surgeries completed in 2015. Since this was a quality improvement/utilization study, we were granted approval from our institutional review board to retrospectively review these data.Methods: We conducted a utilization review of all 1,356 patients who received total knee, hip, or shoulder joint replacement from 4 major surgical providers in 2015. Preoperative evaluation was limited and focused to each patient’s unique medical conditions. Additionally, we reduced intraoperative fluid use, reduced continuous femoro-sciatic nerve or brachial plexus blocks by increasing the administration of single-shot regional blocks, limited transfusion, and minimized urinary catheter use. We improved pain consult response time and provided timely discharges.Results: We noted 9% reduction in preoperative imaging per case, 22% decrease in average number of tests per case, 87% fewer average units of red blood cell used per case, and a 0.4 day reduction in average length of stay (LOS). Patient satisfaction data showed constant improvement in pain management, and doctor communication.Conclusions: Numerous small modifications to patient care collectively contributed to these progressive observed changes in patient outcomes from quarter to quarter.

Implementation of a Preoperative Anemia Management Clinic in a Tertiary Academic Medical Center

Background:Preoperative anemia is commonly encountered with a reported incidence of 5-75% in elective presurgical populations. Anemia is an independent risk factor for perioperative morbidity and mortality and is a strong predictor of perioperative blood transfusion. Approximately 50% of all blood transfusions occur in the perioperative setting and transfusions are a significant financial burden for healthcare institutions. Although preoperative anemia management has been shown to reduce transfusion requirements and improve perioperative outcomes, the optimal delivery model for this service remains unclear. We describe the implementation of a novel preoperative anemia management clinic (AMC) workflow and report patient volume trends since its implementation in Jan 2015 at the University Of Iowa Hospitals & Clinics.Methods:We identified patients undergoing elective high blood loss (HBL) surgical procedures (defined as predicted blood loss >500 cc) with a preoperative hemoglobin (Hb) <12 g/dl as the target population for preoperative anemia management. We identified HBL procedures by ICD codes using information derived from our institutional maximum surgical blood-ordering schedule (MSBOS), intraoperative estimated blood loss (EBL) data from the electronic medical record (EMR) and surgical provider input. In calendar year 2014, 3262 elective HBL surgical patients were identified, out of which 452 (13.9%) received perioperative red cell transfusions. 232 (51.3%) of these patients had a preoperative Hb <12 g/dl. 61 (26%) of these patients were transfused 1 unit PRBCs, 62 (27%) were transfused 2 units and the remaining 109 (47%) patients were transfused > 2 units. Assuming 1- 2 unit transfusions were preventable by preoperative anemia managment, the calculated cost savings to the institution by avoiding these transfusions was estimated to be $200,000/year, not including potential improvement in length of stay. Using these data as baseline, a business plan for an AMC was presented to and approved by our hospital administration. An outpatient clinic was initiated in a temporaray location in early 2015 and later moved to a permanent location with infusion capabilities in August 2015 with two full time staff including a nurse practitioner and a medical assistant supervised by a nurse manager and a medical director. To streamline workflow, a stepwise algorithm for diagnosis and management of anemia was created by a multidisciplinary team that included Hematology, Anesthesiology, Surgery, Internal Medicine, Nursing and Pharmacy. We established referral mechanisms primarily from surgical clinics via automatic EMR alerts for elective HBL procedures linked to case scheduling through the EMR and secondarily through direct outpatient consultations.Results:We observed an overall trend of reduction in the percentage of patients transfused perioperatively in the two quarters following implementation of the preoperative AMC compared with the preceding quarterly intervals since Jan 2014 (Figure). In the same time period we observed a steady increase in number of patient visits to the AMC and number of iron infusions administered. Patient visits and iron infusions more than doubled in the first two quarters of 2016 compared to same time period in 2015 (594 vs 195 and 366 vs 124 respectively). There was a significant reduction in average length of stay (2.78 days) for patients who received transfusions after an AMC visit compared with patients who were not seen in the AMC.Conclusions:Implementation of a structured preoperative anemia management clinic (AMC) with an automatic referral workflow is feasible at a large academic medical center and appears to result in reductions in blood transfusions and hospital length of stay. The heterogeneity of our surgical population and the short timespan since implementation of the AMC are limitations of this analysis. We have ongoing efforts to minimize system errors in our referral mechanisms (ie appropriate EMR alerts to surgeons) and enhance surgical provider education to maximize preoperative anemia management opportunities. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.