Reduce Hospital Costs Research Articles

P-EGS05 Assessment of acute cholecystitis management during COVID-19 pandemic in comparison to the CholeQuic approach : A single centre experience

BackgroundAcute cholecystitis is an emergency condition, typically arising from gall bladder stones and often leading to unplanned surgical admissions to hospital. In the UK, gall stone disease accounts for approximately one third of all unplanned general surgical admissions. According to the The Royal College of Surgeons' Commissioning guidance, early management of acute cholecystitis in particular is the key to prevent further development of more serious complications that can lead to mortality (up to 10%). Therefore, urgent admission to secondary care and laparoscopic cholecytectomy are recommended once diagnosis is confirmed .Conservative management is not recommended as gallbladder inflammation often persists despite medical therapy which can lead to further attacks and risk of developing gall bladder perforation ( mortality in 30% of cases). Early laparoscopic cholecystectomy is also associated with reduced hospital costs and earlier recovery. During the first wave of COVID-19, the guidelines changed in order to limit the admission rates to free up spaces for possible COVID-19 infected patients. Crisis approach entailed conservative management with pain relief, antibiotics plus or minus cholecystostomy. However, reviews of this approach have not been widely published to assess the results and in turn planning our future management approach in case of other COVID-19 surge.MethodsOur study included all the patients diagnosed with acute cholecystitis who needed surgical intervention in one medical Centre in the UK. The time table of the study is divided into 3 periods the pre- COVID era from 16/12/2019 to 15/03/2020 (group I), then during the first lock down era from 16/03/2020 to 30/06/2020 (group II) and, finally after the ease of the lock down from 01/07/2020 to 02/09/2020 (group III).Pre- and post-lockdown time periods the CholeQuIC approach was followed while during the lockdown era, patients were initially treated conservatively followed by surgical managemnt in case of failure to improve. Laparoscopic cholecystectomy was performed, however, in difficult cases conversion to open surgery occurred.The primary outcome was to Compare and perform analysis of the three distinctive periods regarding, delayed presentation, the degree of operative difficulty, which was quantified by analysing the operative time, blood loss, rate of drain insertion and rate of conversion into open surgery. Furthermore, a review of unfavourable intra-operative findings such as extensive adhesion to surrounding organs, hydrops, empyema, gangrene, and/or perforation of the gallbladder was done. The post-operative results were also analysed, according to the length of hospital stay, and the rate of post-operative complications.Results Operative difficulty The mean operative time before the lockdown was 71.6 minutes while it was 81.0 and 78.0 minutes during and post COVID respectively. In terms of conversion to open, the rate reached 10.5 % during the lockdown, while the figures were 4.9% and 3.13% during the pre and after lockdown respectively. Moreover, intra peritoneal drains were used in more than one quarter of the patients (28.9%) during the lockdown era compared to 11.5 % and 12.5% pre and post the lockdown respectively. Considerable blood loss occurred in 10.5%. Intra-operative findings During the lockdown, 28.9 % exhibited extensive adhesions between the gall bladder and surrounding structures. This level is almost three times the percentage during the pre and post-lockdown time periods (8.2% and 9.4% respectively). As for gangrenous cholecystitis, it was 18.4 % during the lockdown, 6.6% before and 6.3% after the lockdown respectively. Post-operative results Before the lockdown the average LOS was 2.9 days which increased to 8.9 days during the lockdown, followed by a decrease to 2.4 days following the ease of lockdown. The lockdown era depicted the highest rate of post-operative complications (bile leakage 7.9%, missed stones 5.3% and duodenal injury 2.6 %). ConclusionsDuring crisis periods tough measures and decisions are made to deal with the situation, however, these decisions can lead to grave consequences on the medical staff and most importantly on patients. As shown in this study and supported by the previous studies, conservative management of acute cholecystitis led to serious complications as many patients were re-admitted for emergency surgery as a result of failure of the non-surgical approach. Moreover, delayed emergency surgery was associated with increased operative difficulties and higher percentage of serious intra and post-operative complications. All this led to longer hospital stay which can prove the failure of this approach. Unfortunately in our Unit, whilst closely studying acute gall bladder disease, we have found that the conservative approach appears to have back-fired and did the exact opposite. Therefore, we believe that there is nil to support conservative treatment of acute cholecystitis in our Unit. We believe that the evidence as displayed suggests that rapid surgery provides best outcome for individual patients and our system, perhaps especially when under strain for other reasons.

Associations between Early Surgery and Postoperative Outcomes in Elderly Patients with Distal Femur Fracture: A Retrospective Cohort Study

Previous literature has provided conflicting results regarding the associations between early surgery and postoperative outcomes in elderly patients with distal femur fractures. Using data from the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2019, we identified elderly patients who underwent surgery for distal femur fracture within two days of hospital admission (early surgery group) or at three or more days after hospital admission (delayed surgery group). Of 9678 eligible patients, 1384 (14.3%) were assigned to the early surgery group. One-to-one propensity score matched analyses showed no significant difference in 30-day mortality between the early and delayed groups (0.5% versus 0.5%; risk difference, 0.0%; 95% confidence interval, −0.7% to 0.7%). Patients in the early surgery group had significantly lower proportions of the composite outcome (death or postoperative complications), shorter hospital stays, and lower total hospitalization costs than patients in the delayed surgery group. Our results showed that early surgery within two days of hospital admission for geriatric distal femur fracture was not associated with a reduction in 30-day mortality but was associated with reductions in postoperative complications and total hospitalization costs.

Medical disputes and patient satisfaction in China: How does hospital management matter?

Satisfaction with healthcare may be captured by surveys of patients and staff, or in extreme cases, the number and severity of medical disputes. This study tries to investigate the relationship between satisfaction and hospital management as well as the role of good management in preventing medical disputes ex ante. We investigate this relationship using information on management practices collected from 510 hospitals in mainland China using the World Management Survey questionnaire and combined with medical malpractice litigation data and patient/staff satisfaction surveys. Multiple regression models were used to analyse the relationship between hospital management scores and medical litigation outcomes as well as patient and staff satisfaction during 2014-2016. An increase of one standard deviation in the management score was related to 13.1% (p<0.10) lower incidence of medical disputes, 12.4% (p<0.05) fewer medical litigations, and 51.3% (p<0.10) less compensation. Better management quality of hospitals was associated with higher inpatient satisfaction (p<0.05) and staff well-being (p<0.01). Improving hospital management could reduce hospital costs generated by lawsuits, reduce potential harm to patients, and improve patient and staff satisfaction, thus leading to a better patient-physician relationship.

The application value of metagenomic next-generation sequencing in children with invasive pneumococcal disease.

BackgroundA retrospective analysis was conducted to explore the sensitivity and specificity of metagenomic next-generation sequencing (mNGS) in blood, cerebrospinal fluid, and pleural effusion samples in children with invasive pneumococcal disease (IPD), and the impact of detection timing on prognosis and cost.MethodsChildren with IPD admitted to Hebei Children’s Hospital from 1 January 2017 to 1 March 2021 were allocated to 1 of 3 groups according to the clinical symptoms and lesions (Group 1: bacteremia; Group 2: meningitis; Group 3: pleurisy). Taking Alere BinaxNow® Streptococcus pneumoniae (S. pneumoniae) antigen detection and blood culture as the gold standard, receiver operating characteristic (ROC) was used to establish the diagnostic value of mNGS.ResultsA total of 96 cases were enrolled in the study, comprising Group 1 (n=65), Group 2 (n=17), and Group 3 (n=14). The positive rate of mNGS test was 62.5% (n=60), and the total coincidence rate was 75.0%. Delayed mNGS was found to have no significant effect on the 30-day survival rate; however, the species-specific read number (SSRN) of S. pneumoniae detected by mNGS in the early stage of the disease was higher, and it could significantly reduce the hospitalization days and costs (P<0.05).ConclusionsThe sensitivity and specificity of mNGS are high in the identification of S. pneumoniae in blood, cerebrospinal fluid, and pleural effusion samples, and the SSRN of S. pneumoniae is related to the interval from onset to sample collection. Early mNGS detection has no significant effect on the 30-day survival rate among children with IPD, but it can reduce hospitalization costs and duration.

Self-referral to inpatient treatment program in a community mental health Centre in Central Norway: investigating the implementation, professionals\u2019 experiences and costs

BackgroundSelf-referral to inpatient treatment (SRIT) is built on user participation and patient autonomy. SRIT was conducted for patients with severe mental disorders in a Norwegian Community Mental Health Centre. The aims of the present study were to describe the implementation of SRIT, explore the professionals’ experiences of SRIT and assess the costs entailed.MethodsQualitative document analysis, interviews with professionals and quantitative analysis of register data from a randomized controlled trial were used.ResultsSRIT seemed to be implemented as intended. According to the professionals, SRIT allowed the patients to cope, be empowered, more active and responsible. Some professionals experienced increased responsibility for patients’ medication and for assessing health and suicide risks. SRIT did not reduce hospital costs. The professionals were satisfied with nurse-led SRIT treatment.ConclusionsSRIT appears to be a high-quality mental health service that empowers and activates patients. Nurse-led treatment may entail more efficient use of professional resources.In future implementations of SRIT, the efficient use of service resources and the administration of beds should be investigated. More flexible availability should be considered in line with the intentions behind SRIT, as well as ensuring adequate professional training in assessing health and suicide risk.

Short stay laparoscopic hysterectomy: An evaluation of feasibility and patient satisfaction.

Short-stay total laparoscopic hysterectomy (TLH) could lead to reduced hospital costs and decrease complications associated with hospitalisation such as hospital acquired-infection and venous thromboembolism. To evaluate the feasibility, safety and patient satisfaction of a novel short 'less than 23-hour' stay TLH protocol. Prospective cohort study, at Birmingham Women's Hospital, United Kingdom including eligible women undergoing TLH for benign indications or early stage cervical/endometrial cancer. Feasibility of discharge within 23-hours following TLH. Surgical complications and readmission rates were collected within 30-days of hysterectomy and patient's satisfaction was assessed at 6-weeks. Of the 128 eligible women, 104/128 women (81%) were discharged within 23-hours of admission, of which 62/104 or 60% (48.4% of the whole cohort) were discharged on the same day. Adenomyosis/fibroids, and previous caesarean sections were associated with a greater likelihood of stay beyond 23-hours (P<0.05). The overall complications rate was 13/128 (10%) with two grade-3 Clavien-Dindo intraoperative complications; one serosal bowel injury oversewn and one ureteric injury requiring reimplantation. The readmissions rate was 5/128 (4%). 94% of patients were 'happy' or 'very happy' with the pathway, although satisfaction was higher in short-stay patients (RR 1.2; 95% CI 0.95-1.94). Hospital discharge within 23-hours of TLH appears to be safe, feasible and acceptable to patients where a standardised, multidisciplinary care protocol is used. Our study is the first prospective case series in the UK reporting the safety and acceptability for performing laparoscopic hysterectomy as a 23-hour day case procedure.

Assessing the Performance of a New Artificial Intelligence-Driven Diagnostic Support Tool Using Medical Board Exam Simulations: Clinical Vignette Study.

BackgroundDiagnostic decision support systems (DDSS) are computer programs aimed to improve health care by supporting clinicians in the process of diagnostic decision-making. Previous studies on DDSS demonstrated their ability to enhance clinicians’ diagnostic skills, prevent diagnostic errors, and reduce hospitalization costs. Despite the potential benefits, their utilization in clinical practice is limited, emphasizing the need for new and improved products.ObjectiveThe aim of this study was to conduct a preliminary analysis of the diagnostic performance of “Kahun,” a new artificial intelligence-driven diagnostic tool.MethodsDiagnostic performance was evaluated based on the program’s ability to “solve” clinical cases from the United States Medical Licensing Examination Step 2 Clinical Skills board exam simulations that were drawn from the case banks of 3 leading preparation companies. Each case included 3 expected differential diagnoses. The cases were entered into the Kahun platform by 3 blinded junior physicians. For each case, the presence and the rank of the correct diagnoses within the generated differential diagnoses list were recorded. Each diagnostic performance was measured in two ways: first, as diagnostic sensitivity, and second, as case-specific success rates that represent diagnostic comprehensiveness.ResultsThe study included 91 clinical cases with 78 different chief complaints and a mean number of 38 (SD 8) findings for each case. The total number of expected diagnoses was 272, of which 174 were different (some appeared more than once). Of the 272 expected diagnoses, 231 (87.5%; 95% CI 76-99) diagnoses were suggested within the top 20 listed diagnoses, 209 (76.8%; 95% CI 66-87) were suggested within the top 10, and 168 (61.8%; 95% CI 52-71) within the top 5. The median rank of correct diagnoses was 3 (IQR 2-6). Of the 91 expected diagnoses, 62 (68%; 95% CI 59-78) of the cases were suggested within the top 20 listed diagnoses, 44 (48%; 95% CI 38-59) within the top 10, and 24 (26%; 95% CI 17-35) within the top 5. Of the 91 expected diagnoses, in 87 (96%; 95% CI 91-100), at least 2 out of 3 of the cases’ expected diagnoses were suggested within the top 20 listed diagnoses; 78 (86%; 95% CI 79-93) were suggested within the top 10; and 61 (67%; 95% CI 57-77) within the top 5.ConclusionsThe diagnostic support tool evaluated in this study demonstrated good diagnostic accuracy and comprehensiveness; it also had the ability to manage a wide range of clinical findings.

Limited utility of intraoperative frozen sections in primary malignant tumours involving long bones - A multicenter analysis of 475 cases

BackgroundIn the surgical removal of primary malignant tumours involving long bones, intraoperative frozen sections are used to ascertain the adequacy of tumour clearance. However, with the improved imaging modalities that provide better foreknowledge of the tumour extent, it is possible that the arduous task of performing frozen sections can be safely avoided. This would not only save procedural time but also reduce hospital costs. Presently, there are no clear guidelines regarding the modality required intraoperatively to assess tumour margins in these cases. Hence, in our retrospective multicentre analysis, we aimed at determining the usefulness of frozen sections in these cases. Materials and methodsOur study is a 3-centre retrospective analysis of 475 cases (513 tumour margins) involving the surgical removal of primary malignancies of long bones. The preoperative Magnetic Resonance Imaging (MRI) and intraoperative assessment of the split specimen of the tumours were used to determine marginal clearance in all the cases in addition to frozen sections in 410 of the margins. ResultsOf the 410 frozen sections (centres 1 and 2), only one margin was reported positive and another reported indeterminate. All other margins were reported negative. In the first case, a 2 cm additional bone-cut was done whereas in the second, the procedure was proceeded based on the intraoperative agreement without re-cutting the margin. All these margins were negative in the final histopathology. In addition, in Centre 3, where frozen sections were not available, all the 103 cases had negative margins in the final histopathology. ConclusionIn primary malignancies involving long bones, intraoperative decision making with the aid of MRI has been sufficiently accurate in identifying the required tumour margin without frozen sections. Hence, the added time and cost incurred by doing an additional procedure can be avoided in these cases.

Abstract 9362: A Quality Improvement Project to Optimize TEE Orders and Reduce Hospitalization Cost at a Large Volume Academic Hospital

Introduction: Appropriate use criteria (AUC) for indication of transesophageal echocardiography (TEE) were revised in 2011. Aim: To evaluate the appropriateness of TEEs ordered at Ochsner LSU Health Shreveport based on 2011 AUC guidelines and take necessary steps to optimize the TEE workflow and reduce hospitalization cost. Method: A retrospective analysis of the TEE case requests received by the echocardiography lab at Ochsner LSU Health Shreveport between March 1, 2020 and August 31, 2020 was carried out. Each TEE case request was classified as appropriate (A), inappropriate (I) or uncertain (U) based on the 2011 AUC guideline. TEE case requests were divided based on the ordering specialty as well as indications. Result: Among the total 372 case requests for TEE,189 (50.80%) were ordered by cardiologists and 183 (49.20%) were ordered by non-cardiologists. Out of the 189 orders by cardiologists, 184 (97.35%) were appropriate and 5 (2.65%) were inappropriate. Cardiologists ordered 123 TEEs for Atrial fibrillation/flutter evaluation/management, 33 for valvular evaluation, 10 for evaluation of mass/vegetation, 3 for atrial mass evaluation, 10 for CVA workup and 10 for other reasons. Among the total 183 TEE orders placed by non-cardiologists, 125 (68.31%) were appropriate and 58 (31.69%) were inappropriate. Specialty-wise, Neurology placed 78 TEE orders (54-A, 24-I), Hospital Medicine placed 59 orders (38-A, 21-I) while other specialties placed 46 orders (33-A, 13-I). Most common indications for TEE requests by non-cardiologists were for CVA workup (62-A, 30-I) and infective endocarditis workup (21-A, 13-I). Conclusion: 83% of all the TEE orders (309 out of 372) were appropriate. 97% (184 from 189) of the TEE orders by cardiologists were appropriate compared to 68% (125 from 183) orders by non-cardiologists. Following this result, medical providers were educated about the correct indications of TEE by educational presentation as well as distributing posters and pocket cards. Plan is to also evaluate the appropriateness of TEE orders post intervention phase. We believe that educating the physician providers can optimize the appropriate TEE requests, avoid unnecessary invasive procedures and reduce the hospitalization cost.

Reducing Length of Stay for Patients with Acute Myeloid Leukemia Receiving Inpatient High-Dose Cytarabine Consolidation Chemotherapy

BackgroundFor patients receiving high dose cytarabine (HiDAC) at the University of Virginia Health System between 10/2019 and 10/2020, median length of stay (LOS) from time of clinic appointment to hospital discharge exceeded the expected standard treatment time (119.4 hours vs 112 hours). Despite the final dose of chemotherapy being scheduled for completion by 9:00 am on the planned day of discharge, only 50% of patients receiving HiDAC were successfully discharged by 12:00 pm (3 hours post-chemotherapy completion). Though there are no national standards for duration of inpatient stay for planned chemotherapy, LOS that extends beyond the standard treatment time results in increased cost, overutilization of hospital resources, delayed admissions for future patients, and patient dissatisfaction.MethodsA multidisciplinary team of licensed providers, pharmacists, and nurses was formed. Due to inconsistency in admission times, the team focused on the percentage of patients discharged by 12:00 pm as a surrogate marker for LOS. The aim was to increase the percentage of patients discharged by 12:00 pm to 65%. Reviewing the baseline data revealed an unstable process with a 3-sigma XmR statistical process control chart. The team developed current and ideal process state maps, a Pareto chart, and a priority matrix to determine an action plan. The most common identified causes for delay in discharge included: lack of standardized discharge checklist, discharge order placed after 10:00 am, medications dispensed from the outpatient pharmacy after 11:00 am, licensed providers not prioritizing patients who were pending discharge, and medication reconciliation not completed prior to day of discharge.ResultsFrom 10/2020 to 5/2021, the first PDSA cycle focused on standardizing the discharge process to correct the instability in the process. A discharge checklist was created based on the ideal process map, which allowed providers to have a consistent process at discharge. A 3-sigma XmR chart demonstrated a newly stable process and an increase in percentage of patients discharged by 12:00 pm to 58% (14 of 24). The second PDSA cycle from 6/2021 to 8/2021 addressed the high impact/easy effort interventions identified in the priority matrix: providers completed medication reconciliation the day before discharge, prioritized seeing HiDAC discharge patients first during morning rounds, and ensured discharge orders were placed prior to completion of the last chemotherapy infusion. Following these interventions, the percentage of patients discharged by 12:00 pm increased to 66% (4 of 6).ConclusionsUsing quality improvement methodology, a multidisciplinary team developed an action plan for patients receiving HiDAC that has increased the percentage of patients discharged by 12:00 pm. This outcome may lead to decreased length of stay, reduced hospitalization costs, and increased bed availability for other hematology/oncology patients. Further PDSA cycles are planned and will focus on the pharmacy medication delivery service, and continuous evaluation of the process is ongoing. [Display omitted] DisclosuresEl Chaer: Amgen: Honoraria, Research Funding.

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.

AMBULATORY PULMONARY ARTERY PRESSURE MONITORING REDUCES COSTS AND IMPROVES OUTCOMES IN SYMPTOMATIC HEART FAILURE: A SINGLE-CENTER CANADIAN EXPERIENCE

<h3>BACKGROUND</h3> Pulmonary artery pressure (PAP) monitoring with the CardioMEMS device reduces heart failure (HF) hospitalizations and improves quality of life in NYHA Class III HF. The aim of this study was to evaluate the CardioMEMS device in a real-world Canadian HF cohort and explore its economic impact. <h3>METHODS AND RESULTS</h3> 21 patients with NYHA Class III HF underwent CardioMEMS implantation at Foothills Medical Centre, Calgary, Alberta. Baseline, 3, 6, 9, and 12-month assessments of laboratory parameters, hemodynamics, 6-minute walk test (6-MWT) and Kansas City Cardiomyopathy Questionnaire (KCCQ12) scores were prospectively collected. Healthcare costs for the 1-year pre and post-implant were collected from administrative databases. Of 21 patients, 19 patients had useable data (1 unsuccessful implant, 1 pressure dampening due to small implant artery). There were no procedural complications. Mean age was 68.9 years, 45% were female, 10% HFpEF. Of those with HFrEF, mean LVEF at baseline was 31%. Over a mean follow-up of 10 months, there was an 85% reduction in HF ER visits (p=0.0003), 83% reduction in HF hospitalizations (p < 0.001), 79% decrease in all-cause hospitalizations (p=0.0006), 41% decrease in HF clinic visits (p=0.034), and a 151% increase in nurse clinician calls (p < 0.0001) observed. KCCQ-12 scores and 6-MWT at baseline vs. last follow-up were 45.7 vs. 47.1 (p=0.76) and 364.4 vs. 402.3 m (p=0.59), respectively. NT-proBNP and mean PAP at baseline vs. last follow-up were 2277.2 vs. 1509.9 pg/mL (p=0.28) and 31.5 vs. 24.4 mmHg (p=0.0024), respectively. NYHA class improved at least one class in 74% of patients. Fourteen patients have completed 1 year of follow-up. Table 1 outlines healthcare utilization costs 1-year pre and post-implant (n=14). Total measurable HF-related spending pre-implantation was $324 795. The cost of measurable HF spending in the year post-implantation was $108 763. When considering device cost, the net cost at 1-year was $386 558, equating to an additional $4 412 per patient. <h3>CONCLUSION</h3> CardioMEMS remote monitoring demonstrated reductions in PA pressures, hospitalizations, ER visits, clinic visits and improvement in NYHA class in NYHA III HF. There was no significant difference in KCCQ12 scores, 6MWT or NT-proBNP limited by short duration of follow up. Cost-parity was nearly achieved at 1-year post-implantation, driven predominantly by a significant reduction in hospitalization costs. Though further economic evaluation is needed, these results support the use of ambulatory PA pressure monitoring as a cost-effective method of HF management in a publicly funded healthcare system.

Significant hospitalization cost savings to the payer with a pharmacist-led mobile health intervention to improve medication safety in kidney transplant recipients

This was an economic analysis of a 12-month, parallel arm, randomized controlled trial in adult kidney recipients 6 to 36months posttransplant (NCT03247322). All participants received usual posttransplant care, while the intervention arm received supplemental clinical pharmacist-led medication therapy monitoring and management, via a smartphone-enabled mHealth app, integrated with risk-based televisits. Hospitalization charges were captured from the study institution accounts payable and non-study institution hospitalization charges were estimated using multiple imputation. Multivariable modeling was used to assess the impact of the intervention on charges. The intervention significantly reduced rates of hospitalization (1.08 per patient-year in the control arm vs 0.65 per patient-year in the intervention arm, p=.007). The control arm had estimated hospitalization costs of $870,468 vs $390,489 in the intervention arm. Modeling demonstrated a 49% lower hospitalization charge risk in the intervention arm (RR 0.51, 95% CI 0.28-0.91; p=.022). From a payer or societal perspective, the net estimated cost savings, after accounting for intervention delivery costs, was $368,839, with a return on investment (ROI) of $4.30 for every $1 spent. These results demonstrate that a mHealth-enabled, pharmacist-led intervention significantly reduced hospitalization costs for payers over a 12-month period and has a positive ROI.

Effects of Branched-chain Amino Acids on Nutritional Metabolism and Pharmacoeconomics in Patients with Severe Abdominal Trauma.

To observe the influences of branched-chain amino acids (BCAAs) on nutrition metabolism and prognosis of patients with severe abdominal trauma; at the same time, to analyze and evaluate the pharmacoeconomics of it. A total of 75 severe abdominal trauma patients were recruited from June 2016 to December 2017 and randomly divided into control group and observation group. After surgery and basic treatment, parenteral nutrition support therapy with iso-nitrogen and iso-calorie of both groups was administered. Meanwhile, an equivalent of 8.5% (18AA-II) and 10% (20AA) compound AA injection was administrated to the control and observation groups, respectively. The nitrogen balance, serum protein level and plasma amino spectrum of the patients were observed before and after treatment. Besides, the hospital stay, survival rate, complications, adverse reactions and hospitalization costs were also compared. After a 7-day course treatment, the nitrogen balance level of the two groups was significantly improved, but no significant difference was found between them. In addition, the serum protein level and plasma amino spectrum of the two groups was generally improved when compared to before treatment. Compared with the control group, the level of albumin and transferrin in the observation group was improved significantly after treatment, while no difference in plasma amino spectrum was found between the two groups. Moreover, the cost analysis showed remarkably reduced hospitalization costs in the observation group. To a certain degree, BCAAs could improve the nutritional metabolism and prognosis of patients with severe abdominal trauma, and have good cost-effectiveness.

Reducing length of stay for patients with acute myeloid leukemia receiving inpatient high-dose cytarabine consolidation chemotherapy.

257 Background: For patients receiving high dose cytarabine (HiDAC) at University of Virginia (UVA) Health between 10/2019 and 10/2020, median length of stay (LOS) from time of clinic appointment to hospital discharge was 119.35 hours. Standard treatment time should be 112 hours from premedication to end of chemotherapy. There are no national standards for duration of inpatient stay for planned chemotherapy, but only 50% of these patients were discharged after noon (over 3 hours post-chemotherapy completion). LOS that extends beyond the standard treatment time results in increased cost, overutilization of hospital resources, delayed admissions for future patients, and patient dissatisfaction. Methods: A multidisciplinary team comprised of licensed providers, pharmacists, and nurses was formed. The team focused on percentage of patients discharged by noon as a surrogate marker for LOS due to inconsistency of admission times; the aim was to increase patients discharged by noon to 65%. Reviewing the baseline data revealed an unstable process with a 3-sigma X-bar statistical process control chart. The team developed current and ideal process state maps, a Pareto chart, and a priority matrix to determine an action plan. The most common identified causes for delay in discharge included: lack of standardized discharge checklist, discharge order placed after 10 am, medications dispensed from the outpatient pharmacy after 11 am, licensed providers not prioritizing discharge patients, and medication reconciliation not completed prior to day of discharge. Results: From 10/2020 to 5/2021, the first PDSA cycle focused on standardizing the discharge process to correct the instability in the process. A discharge checklist was created based on the ideal process map, which allowed the providers to have a consistent process at discharge. 3-sigma Xbar chart demonstrated a now stable process and an increase of patients discharged by noon to 58%. During the second PDSA cycle starting in 6/2021, providers completed medication reconciliation the day before discharge, prioritized HiDAC discharges first during rounds, and ensured discharge orders were placed by completion of the last chemotherapy bag. Data collection is ongoing, and will be analyzed by August 2021. Future tests of change are planned to focus on the pharmacy medication delivery service. Hospital LOS has also decreased after the first PDSA cycle. Conclusions: Using quality improvement methodology, a multidisciplinary team developed an action plan for patients receiving HiDAC which to date has increased the percentage of patients discharging by noon and decreased length of stay. This outcome may lead to reduce hospitalization costs and increase bed availability for other oncology patients. Further PDSA cycles are scheduled and continuous evaluation of the process is ongoing.

The influence of antenna gain and beamwidth used in OSSEUS in the screening process for osteoporosis

Applications on electromagnetic waves in the field of biotelemetry have increased in the latest years, being used to prevent, diagnose, and treatment of several diseases. In this context, biotelemetry allows minimally invasive monitoring of the physiologic, improving comfort and patient care and significantly reducing hospital costs. Aiming to assist the mineral bone density classification, through a radio frequency signal (RF), for a later diagnosis of osteoporosis, Osseus was proposed in 2018. This equipment is a combination of the application of techniques and concepts of several areas such as software, electrical, electronic, computational, and biomedical engineering, developed at a low cost, with easy access to the population, and non-invasive. However, when placed on evaluation, potential improvements were identified to increase the stability of Osseus operation. It is proposed the implementation of improvements in the antennas used by Osseus, aiming its miniaturization, improvement in the reception of the RF signal, and better stability of the equipment's operation. Then, two antennas were built, one of which was used as a project for the second, which is an array. The array showed significant improvements in the radiation parameters relevant to the application, being a candidate to replace the antennas currently in use at Osseus.

Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units.

The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.

The impact of routine post-anesthesia care unit extubation for pediatric surgical patients on safety and operating room efficiency

PurposeMaximizing operating room (OR) efficiency is essential for hospital cost containment and effective patient throughput. Little data is available regarding the safety and efficacy of extubation of children in the post-anesthesia care unit (PACU) by a nurse rather than in the OR. We sought to evaluate the impact of a long-standing practice of PACU extubation upon airway complications and OR efficiency. MethodsThe records of 1930 children who underwent inguinal hernia repair, laparoscopic appendectomy or pyloromyotomy at a children's hospital between July, 2018 and June, 2020 were reviewed. Extubations were performed in the OR only when the PACU was inadequately staffed or during the early months of the Covid-19 pandemic. Cases in which there was a deep extubation, a PACU hold was in effect or a patient went directly to an inpatient unit from the OR were excluded. Intra- and post-operative time metrics were recorded and emergency airway interventions were assessed. Results1747 operations were evaluated. Time from the end of the procedure to leaving the OR ranged from 4.1 to 4.8 min when extubation was done in the PACU and was 6–9 min less than with OR extubation. (see table). There were 23 airway events (1.5% of all cases) after PACU extubation that necessitated only brief bag-mask ventilation. There were no cases of re-intubation. ConclusionsIn a large population of children undergoing diverse surgical procedures, post-anesthesia care unit extubation was safe and resulted in rapid transfer of patients from the operating room after completion of their operation. Time saved because of shorter operating room times reduces hospital costs and can allow for increased throughput. Extubation in the post-anesthesia care unit may not only be as safe as operating room extubation, but may result in fewer serious airway events as patients may be less likely to have their endotracheal tube removed prematurely. Level of evidenceTreatment Study, Level III

Mobile Applications in Clinical and Perioperative Care for Anesthesia: Narrative Review.

BackgroundThe increasing use of smartphones by providers and patients alike demonstrates that digital health utilizing mobile applications has the potential to transform perioperative care and education in anesthesia.ObjectiveThis literature review describes the current scope of the use of mobile applications in anesthesiology.MethodsLiterature was searched using PubMed, Scopus, and clinicaltrials.gov for articles published from January 1, 2010, through April 1, 2020. Only English language studies were included. Articles were included if they examined the use of a mobile health application in the setting of anesthesia or the perioperative (immediate preoperative, intraoperative, and postoperative) period. Studies were excluded if they explored video interventions or did not examine the feasibility or efficacy of the mobile app.ResultsWe included 29 articles, and three areas of clinical functionality were identified: patient-centered care (preoperative, intraoperative, and postoperative), systems-based improvement, and medical education. Several studies demonstrate the feasibility and reliability of mobile apps in these areas, but many are only tested for efficacy in simulated environments or with small patient samplesConclusionsMobile health applications show promise in improving communication between anesthesiologists, improving workflow efficiency, enhancing medical education, and reducing hospital costs. However, there is a need for validation and improvement before full implementation by the provider, patients, and hospital systems. Future studies are needed to demonstrate meaningful health outcomes to create guidelines and recommendations specific to the application of mobile technology to health care.

The Impact of Nurse Navigator-Led Preoperative Education on Hospital Outcomes Following Posterolateral Lumbar Fusion Surgery

Beyond the spine-specific pathology, patient factors such as associated medical and psychosocial conditions, understanding of the treatment process, and the degree of patient activation-defined as the ability of the individual to utilize the available information and actively engage in making their healthcare decisions-can influence outcomes after posterolateral lumbar fusion (PLF) surgery. A retrospective observational cohort study of 177 patients undergoing PLF at a single institution was conducted. Patient demographics, medical and psychosocial risk factors, and outcomes were compared between patients who attended a nurse navigator-led group preoperative education course and those who did not. Patients attending the course were younger, more likely to undergo one-level fusion, less likely to undergo 5- or more-level fusion, and had less comorbidity burden as measured by the hierarchical condition categories score. No differences in psychosocial risk factors were observed between groups. Course attendees had a significantly shorter length of stay (2.12 vs. 2.60 days, p = .042) and decreased average hospital cost (U.S. $10,149 vs. U.S. $14,792, p < .001) than those who did not attend; no differences in other outcomes were observed. After controlling for differences in risk factors, patients enrolled in a preoperative education course demonstrated a statistically significant reduction in hospital cost (β=-4,143, p < .001). Preoperative education prior to PLF surgery may reduce hospital cost, possibly through increased patient activation. Given the relatively high prevalence of psychosocial risk factors in this and similar patient populations, optimizing patient activation and engagement is important to achieve high value care. Based on our findings, nurse navigator-led preoperative education appears to be valuable in this patient population and should be included in enhanced recovery protocols.