Reduction In Hospital Length Of Stay Research Articles

Can Emergency Medicine Ward Shorten Hospital Length of Stay in Patients with Nasogastric Tube Related Coffee Ground Aspirate?

Introduction The aim of this study was to determine whether elderly patients on nasogastric (NG) tube feeding who presented with coffee ground aspirate could be effectively and safely managed in a local setting of Emergency Medicine Ward (EMW). Method A retrospective study with data retrieved from all the cases admitted with a diagnosis of coffee ground aspirate or vomiting who were on NG tube feeding during three years before and after EMW was launched. Data including patient demographics, length of stay (LOS), types of pharmaceutical treatment received, need of upper endoscopy, in-hospital death and readmission rate within fourteen days were studied. Patients who were haemodynamically unstable, having melaena on per rectal examination, on warfarin or with underlying gastrointestinal malignancy were excluded. Results A total of 223 patients matching the studied criteria were included in the study, with 103 of them being admitted before the opening of EMW. For the 120 cases admitted after EMW was launched, 70 cases were admitted to EMW and 50 admitted to Medical Ward. The LOS for elderly patients on NG tube feeding presented with coffee ground aspirate was significantly shortened after EMW was launched (5.2 days vs. 4.2 days, p=0.046). In-hospital mortality and 14-day readmission rate were similar in the two studied period. Patients admitted to EMW and Medical Ward in the second study period were also analysed. Those admitted to EMW had a shorter LOS than those admitted to Medical ward during the same period (3.4 days vs. 5.3 days, p=0.001). Conclusion The establishment of EMW in local setting can achieve a significant reduction in hospital LOS without jeopardizing patient outcome for elderly patients who are on NG tube feeding presenting with coffee ground aspirate.

A Self-Paired Comparison of Perioperative Outcomes Before and After Implementation of a Clinical Pathway in Patients Undergoing Total Knee Arthroplasty

Clinical pathways commonly modify multiple variables and deviate from long-established clinical practices. Therefore, it is difficult to perform prospective, randomized clinical trials comparing "standard care" to the "new clinical pathway." The goal of this investigation was to examine the impact of clinical pathways implementation on perioperative outcomes and institutional costs in patients undergoing total knee arthroplasty (TKA). This before-and-after study evaluated patient clinical outcomes and economic costs after the implementation of institutional clinical pathway. The primary outcome was hospital length of stay (LOS). Clinical and economic outcomes were analyzed as continuous variables using paired t test. Fifty-four patients were identified for study inclusion. Patients undergoing their TKA after implementation of the clinical pathway had a significantly shorter hospital LOS (3.4 vs 4.4 days; P < 0.001). Patients reported significantly less postoperative pain, less postoperative confusion, and an easier time participating in physical therapy sessions after their second (after the clinical pathway implementation) TKA. Patients undergoing their TKA after the clinical pathway implementation had reduced total direct hospital costs ($956; 95% confidence interval, $233-$1785; P = 0.02). Our findings demonstrated that the use of a standardized clinical pathway reduced hospital LOS, improved clinical outcomes and patient satisfaction while reducing costs for identical surgical procedures.

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Introduction: Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic states (HHS) are acute metabolic complications of diabetes. Hypothesis: The objective of this study was to evaluate the impact of an institutional guideline and order set for hyperglycemic emergencies. Methods: This retrospective descriptive study of clinical practice evaluated adult patients admitted with a diagnosis of DKA or HHS. Two time periods were evaluated: phase 1 (PRE) assessed practice pre-guideline implementation from September 2007 to 2009 and phase 2 (POST) assessed post-guideline and order set introduction from February 2011 to April 2012. This study was approved by the IRB prior to data collection. The primary endpoint was hospital length of stay (LOS). Other endpoints included laboratory assessments, insulin administration metrics, hypoglycemia (<72 mg/dL), hypokalemia (<3.3 mmol/L), time to anion gap closure, and intensive care unit (ICU) LOS. Sample size was determined assuming a 25% reduction in hospital LOS given a 5% level of significance with 80% power. Results: A total of 172 patients (91 PRE and 81 POST) were included in the analysis with 56% of patients requiring admission to the ICU. There was no difference in the mean hospital LOS in the PRE vs. POST groups (5.2 ± 4 vs. 5.9 ± 8.6 days, p = 0.49). Mean ICU LOS was shorter in the POST group (64.8 ± 19 vs. 37.1 ± 74.8 hrs, p < 0.01). The POST group had an increase in the assessments for clearance of urinary ketones (18 vs. 33.3%, p = 0.03) and b-hydroxybutyrate (16 vs. 37%, p < 0.01). Both the frequency of point-of-care glucose testing (12.5 ± 4.6 vs. 15.1 ± 4.7, p < 0.01) and time to anion gap closure (13 ± 9 vs. 9.3 ± 7.4 hrs, p < 0.01) improved in the POST group. There was an increase in the number of patients in the POST group who received weight-based insulin bolus prior to initiation of infusion (25.5 vs. 95.1%, p < 0.01) with no difference in the number of patients experiencing hypoglycemia and hypokalemia. Conclusions: Implementation of an institutional guideline and order set for hyperglycemic emergencies demonstrated no difference in hospital LOS; however, improvements in ICU LOS and laboratory assessments were seen.

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Introduction: The risk for development of severe sepsis or septic shock (SS/SS) is a great concern in the cardiothoracic surgery patient population. The Surviving Sepsis Campaign has recommended sepsis bundles that have been shown to reduce mortality in patients with SS/SS. Our group has previously shown that using an early sepsis initiative in the surgical population as a whole has significant benefit; however, there is little data looking at the particularly vulnerable cardiothoracic surgery cohort. Hypothesis: We believe that implementation of an early sepsis initiative will improve outcomes in the cardiothoracic surgery patient population. Methods: A retrospective review of 460 patients receiving the diagnosis of SS/SS after undergoing cardiothoracic surgery during hospital admission from November of 2003 through December of 2009 was conducted at an academic medical center. Mortality, length of hospital stay (LOS), intensive care unit (ICU) days, and ventilator days were calculated for the pre-intervention (November 2003-December 2005, N=148) and post-intervention (January 2006-December 2009, N=312) groups. Statistical analysis was conducted using T-test for continuous variables and chi-squared analysis for categorical variables. A p-value of 0.05 or less was considered significant. Results: The in hospital mortality rate slightly decreased from 16.22% to 15.70% after implementation of the early sepsis initiative (p=0.892). LOS was reduced from a mean of 31.66 ± 34.38 days to 24.12 ± 25.12 days (p=0.018). ICU days decreased from 22.24 ± 35.80 days to 13.29 ± 23.71 days (p=0.008). Ventilator days were reduced from 16.71 ± 28.88 days to 9.03 ± 11.77 days (p=0.005). Conclusions: The results demonstrate that the implementation of early best practice sepsis initiative leads to significant reduction in hospital LOS, ICU days, and ventilator days in the cardiothoracic surgical patient population. However, there was not a significant decrease in mortality. This is in contrast to the larger surgical population, in which significant mortality benefit has been observed. There is a great need for additional studies in reducing mortality in the SS/SS cardiothoracic surgery cohort.

Effect of Physical Restraint Reduction on Older Patients’ Hospital Length of Stay

Physical restraints are often used to prevent falls and to secure medical devices in older people in hospitals. Restraint reduction has been advocated on the grounds that physical restraints have negative psychological effects and are not effective in preventing falls. The potential effect of restraint reduction on length of hospital stay (LOS) has not been investigated. This study was undertaken to compare the average length of stay of older patients in a convalescent medical ward setting before and after a restraint reduction program. This is a retrospective study. A convalescent hospital in Hong Kong. This study included 2000 patient episodes. The use of physical restraint, LOS, and clinical outcomes of randomly selected patient episodes in the year before and after the implementation of a restraint reduction program were compared. The clinical outcomes included Modified Functional Ambulatory Categories and modified Barthel index. Subgroup analysis was performed on those with confusion as defined by dementia diagnosis, low abbreviated mental test score, or abnormal mental domain of Norton Score. A total of 958 and 988 patient episodes admitted to 10 medical wards in a convalescent hospital in 2007 and 2009 were examined. There were no significant differences in the baseline characteristics of patients in the 2 years. With the implementation of the restraint reduction scheme, the rate of physical restraint use declined significantly from 13.3% in 2007 to 4.1% in 2009 for all patients. The average LOS of patients was significantly lower in the year after the implementation of restraint reduction (19.5 ± 20.7 versus 16.8 ± 13.4 days in 2007 and 2009 respectively, P < .001). On subgroup analysis, the reduction in LOS was significant in the cognitively impaired patients (23.0 ± 26.5 to 17.8 ± 15.0 days in 2007 and 2009 respectively, P < .001), but not in the cognitively normal patients. There were no significant differences between the 2 years in the incidence of fall, mobility, and activities of daily living on discharge. Physical restraint reduction was associated with significant reduction in average length of stay in convalescent medical wards, especially in the cognitively impaired patients.

Open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery ERAS® programme (ORANGE II – Trial): study protocol for a randomised controlled trial

BackgroundThe use of lLaparoscopic liver resection in terms of time to functional recovery, length of hospital stay (LOS), long-term abdominal wall hernias, costs and quality of life (QOL) has never been studied in a randomised controlled trial. Therefore, this is the subject of the international multicentre randomised controlled ORANGE II trial.MethodsPatients eligible for left lateral sectionectomy (LLS) of the liver will be recruited and randomised at the outpatient clinic. All randomised patients will undergo surgery in the setting of an ERAS programme. The experimental design produces two randomised arms (open and laparoscopic LLS) and a prospective registry. The prospective registry will be based on patients that cannot be randomised because of the explicit treatment preference of the patient or surgeon, or because of ineligibility (not meeting the in- and exclusion criteria) for randomisation in this trial. Therefore, all non-randomised patients undergoing LLS will be approached to participate in the prospective registry, thereby allowing acquisition of an uninterrupted prospective series of patients. The primary endpoint of the ORANGE II trial is time to functional recovery. Secondary endpoints are postoperative LOS, percentage readmission, (liver-specific) morbidity, QOL, body image and cosmetic result, hospital and societal costs over 1 year, and long-term incidence of incisional hernias. It will be assumed that in patients undergoing laparoscopic LLS, length of hospital stay can be reduced by two days. A sample size of 55 patients in each randomisation arm has been calculated to detect a 2-day reduction in LOS (90% power and α = 0.05 (two-tailed)).The ORANGE II trial is a multicenter randomised controlled trial that will provide evidence on the merits of laparoscopic surgery in patients undergoing LLS within an enhanced recovery ERAS programme.Trial registrationClinicalTrials.gov NCT00874224.

Propensity score analysis evaluating preoperative glucocorticoid administration in elective colectomy

BackgroundPreoperative glucocorticoid (GC) administration attenuates the physiological response to surgery and improves clinical outcomes. However, GC use is not yet universally implemented. A propensity score analysis was performed to evaluate preoperative GC use in elective colectomy. MethodsA retrospective review of prospectively collected data was conducted for all patients who had undergone elective colectomy within an established Enhanced Recovery After Surgery (ERAS) programme at our institution from January 2006 to 2010. Demographic data, surgery type, glucocorticoid administration and clinical outcomes including complication rates and length of hospital stay (LOS) were investigated. Univariate and propensity score analyses were conducted with statistical significance identified as p ≤ 0.05. ResultsThere were 253 patients included in the analysis, of which 146 received preoperative GC. There were significant baseline differences between those who received GC and those who did not in male gender (GC: 56 (38%); non-GC: 58 (54%); p = 0.02) and American Society of Anesthesiologists (ASA) III (GC: 40 (27%); non-GC: 43 (40%); p = 0.04). On univariate analysis, there were no significant differences in the incidence of total complications, major complication, anastomotic leak and infectious complication. On propensity score analysis, preoperative GC administration was found to be independently associated with a reduction in LOS (GC: 5; Non-GC: 6; p = 0.04). ConclusionPreoperative GC administration is associated with a reduction in LOS without an increase in postoperative complications.

Proactive Psychiatric Consultation Services Reduce Length of Stay for Admissions to an Inpatient Medical Team

Some studies suggest intensive psychiatric consultation services facilitate medical care and reduce length of stay (LOS) in general hospitals. To compare LOS between a consultation-as-usual model and a proactive consultation model involving review of all admissions, rapid consultation, and close follow-up. LOS was compared in an ABA design between a 33-day intervention period and 10 similar control periods, 5 before and 5 after the intervention, on an internal medical unit. During the intervention period, a staff psychiatrist met with the medical team each weekday, reviewed all admissions, provided immediate consultation as needed, and followed all cases throughout their hospital stay. Time required for initial case review was brief, 2.9 ± 2.2 minutes per patient (mean ± S.D.). Over 50% of admissions had mental health needs: 20.3% were estimated to require specialist consultation to avoid potential delay of discharge. The consultation rate for the intervention sample was 22.6%, significantly greater than in the control sample, 10.7%. Mean LOS was significantly shorter in the intervention sample, 2.90 ± 2.12 versus 3.82 ± 3.30 days, and the fraction of cases with LOS > 4 days was significantly lower, 14.5% versus 27.9%. A rough cost benefit analysis was favorable with at least a 4.2 ratio of financial benefit to cost. Psychiatric review of all admissions is feasible, indicates a high incidence of mental health barriers to discharge, identifies more necessary consultations than typically requested, and results in earlier consultation. A proactive consultation model can reduce hospital LOS.

Improving Patient Flow in Acute Coronary Syndromes in the Face of Hospital Crowding

BackgroundThe current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease. ObjectiveTo measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS. MethodsPrimary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post- availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death. ResultsIn the post-implementation period there was a 30% (95% confidence interval [CI] 36–44%) reduction in admissions to telemetry with a 33% (95% CI 26–39%) reduction in ED LOS and a 20% (95% CI 7–34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p=0.001). ConclusionThe focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS.

Readmission and Length of Stay After Total Hip Arthroplasty in a National Medicare Sample

Evaluation of hospital readmissions after total hip arthroplasty may help improve patient safety and cost reduction. This study investigates the rates and reasons for readmission as well as length of hospital stay (LOS) for 1802 total hip arthroplasty patients from 2002 to 2007. Data were abstracted from the Medicare Patient Safety Monitoring System. The overall 30-day rate of readmission was 6.8%. There was no difference in readmission rate from 2002 to 2004 (7.1%) to 2005 to 2007 (6.3%) (odds ratio, 0.90; 95% confidence interval, 0.63-1.30; P = .58). The overall mean LOS was 4.2 ± 2.2 days. There was a significant reduction in LOS from 2002 to 2004 (4.4 ± 2.5 days) to 2005 to 2007 (3.8 ± 1.7 days) (odds ratio, 1.28; 95% confidence interval, 1.25-1.31; P < .0001). The most common causes for readmission were cardiac related. A reduction in LOS was not associated with an increase in the rate of readmission in this sample. Efforts to optimize cardiac status before discharge may lead to lower rates of readmission in the future.

Decreased Length of Stay After TKA Is Not Associated With Increased Readmission Rates in a National Medicare Sample

There is a trend toward decreasing length of hospital stay (LOS) after TKA although it is unclear whether this trend is detrimental to the overall postoperative course. Such information is important for future decisions related to cost containment. We determined whether decreases in LOS after TKA are associated with increases in readmission rates. We retrospectively reviewed the rates and reasons for readmission and LOS for 4057 Medicare TKA patients from 2002 to 2007. We abstracted data from the Medicare Patient Safety Monitoring System. Hierarchical generalized linear modeling was used to assess the odds of changing readmission rates and LOS over time, controlling for changes in patient demographic and clinical variables. The overall readmission rate in the 30days after discharge was 228/4057 (5.6%). The 10 most common reasons for readmission were congestive heart failure (20.4%), chronic ischemic heart disease (13.9%), cardiac dysrhythmias (12.5%), pneumonia (10.8%), osteoarthrosis (9.4%), general symptoms (7.4%), acute myocardial infarction (7.0%), care involving other specified rehabilitation procedure (6.3%), diabetes mellitus (6.3%), and disorders of fluid, electrolyte, and acid-base balance (5.9%); the top 10 causes did not include venous thromboembolism syndromes. We found no difference in the readmission rate between the periods 2002-2004 (5.5%) and 2005-2007 (5.8%) but a reduction in LOS between the periods 2002-2004 (4.1±2.0days) and 2005-2007 (3.8±1.7days). The most common causes for readmission were cardiac-related. A reduction in LOS was not associated with an increase in the readmission rate in this sample. Optimization of cardiac status before discharge and routine primary care physician followup may lead to lower readmission rates.

Does Preoperative Anemia Adversely Affect Colon and Rectal Surgery Outcomes?

Complications associated with blood transfusions have resulted in widespread acceptance of low hematocrit levels in surgical patients. However, preoperative anemia seems to be a risk factor for adverse postoperative outcomes in certain surgical patients. This study investigated the National Surgical Quality Improvement Program (NSQIP) database to determine if preoperative anemia in patients undergoing open and laparoscopic colectomies is an independent predictor for an adverse composite outcome (CO) consisting of myocardial infarction, stroke, progressive renal insufficiency or death within 30 days of operation, or for an increased hospital length of stay (LOS). Hematocrit levels were categorized into 4 classes: severe, moderate, mild, and no anemia. From 2005 to 2008, the NSQIP database recorded 23,348 elective open and laparoscopic colectomies that met inclusion criteria. Analyses using multivariable models, controlling for potential confounders and stratifying on propensity score, were performed. Compared with nonanemic patients, those with severe, moderate, and mild anemia were more likely to have the adverse CO with odds ratios of 1.83 (95% CI 1.05 to 3.19), 2.19 (95 % CI 1.63 to 2.94), and 1.49 (95% CI 1.20 to 1.86), respectively. Patients with a normal hematocrit had a reduced hospital LOS, compared with those with severe, moderate, and mild anemia (p < 0.01). A history of cardiovascular disease did not significantly influence these findings. This large multicenter database analysis suggests that the presence of severe and moderate and even mild preoperative anemia is an independent risk factor for complications and a longer hospital stay after colon surgery.

Does the Introduction of Thoracoscopic Lobectomy Reduce Hospital Length of Stay? Initial Results From the Green Lane Cardiothoracic Unit

Does the Introduction of Thoracoscopic Lobectomy Reduce Hospital Length of Stay? Initial Results From the Green Lane Cardiothoracic Unit

The Impact of Emergency Medicine Ward in Acute Intoxication Management

Background The Emergency Medicine Ward (EMW) was established in Caritas Medical Centre (CMC) in November 2007 under the management of emergency physicians. With the support from the psychiatric team and medical social workers, it provided effective management for intoxicated patients as an alternative to traditional inpatient service. Objective The aim of this study was to evaluate the impact of the EMW in the management of acute intoxication. Method A retrospective comparative study with data retrieved from all admitted intoxicated and suspected intoxicated patients was carried out over two separate half-year periods in 2007 and 2008, before and after the establishment of the EMW. Data on patient demographics, reason of exposure, substance involved, treatment, psychiatric service offered, clinical outcome, hospital length of stay (LOS) and 28-day hospital re-admission were compared. Results A total of 316 intoxicated patients were admitted to CMC with 165 in the 2007 group and 151 in the 2008 group. Both groups shared similar basic epidemiological data. There was a marked reduction in hospital LOS from 80.1 hours to 45.9 hours (p&lt;0.01), a markedly increased proportion of patients receiving psychiatric service from 47.9% to 71.5% (p&lt;0.01) and a significant decline in the access time of psychiatric assessment from 27.4 hours to 10.6 hours (p&lt;0.05). There were no statistically significant difference in treatment, patient clinical outcome and 28-day hospital re-admission. Conclusions The establishment of EMW achieved a significant reduction in hospital LOS of intoxicated patients without jeopardizing patient outcome. The results also illustrate that EMW can provide a good platform for the integration of psychiatric service for these patients.

Fast-track Colorectal Surgery Program Reduces Hospital Length of Stay

This study compared outcomes of a fast-track postoperative program implemented for patients undergoing laparoscopic colorectal surgery on 2 surgical units to patients receiving traditional postoperative care following laparoscopic colorectal surgery prior to implementation of the fast-track program. The primary aim was to determine if there was a significant difference in length of stay and 30-day readmission rates between the 2 groups. The secondary aim was to examine whether patients on the fast-track program were able to successfully tolerate early diet, early ambulation, and minimal use of drains. The study was conducted at a large Midwestern hospital. A retrospective medical record review was done on 100 patients who underwent laparoscopic colorectal surgery on the fast-track program for data pertaining to the research questions. Additionally, a medical record review was done for comparison on 100 matched controls based on age, sex, surgeon, and surgical procedure who received traditional postoperative care following laparoscopic colorectal surgery. A statistical significant difference of 1 day was found between patients receiving traditional care and patients on the fast-track program. Readmission rates between the 2 groups were not statistically significantly different. : Overall, patients undergoing laparoscopic colorectal surgery on a fast-track program discharged 1 day sooner than patients on traditional recovery programs. Patients successfully followed the fast-track program. Fast-track programs in colorectal surgery reduce length of stay and could be considered for other surgical populations.

Odontoid Fractures in the Elderly: Should We Operate?

: Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach. : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. Patients were then grouped according to treatment, early-OP (< or =3 days posttrauma), late-OP (>3 days), or non-OP treatment. Patient characteristics that were evaluated and compared among the three groups included age, Injury Severity Score, preexisting conditions, and the type of odontoid fracture. Outcomes evaluated included in-hospital mortality, ventilator days, hospital length of stay (HLOS), need for tracheostomy and percutaneous endoscopic gastrostomy (PEG), and the complications of urinary tract infection (UTI), deep vein thrombosis (DVT), and pneumonia. Differences among groups were tested using analysis of variance, Students t test, chi, and Fishers exact test. : The non-OP patients were significantly older than either operative group (mean, 82.4 for non-OP; 77.4 for early-OP; and 76.4 for late-OP; p = 0.006 non-OP compared with either operative group). Injury Severity Score, number of preexisting conditions, mechanism of injury, and distribution of type of odontoid fractures were similar among all three groups. There was no statistically significant difference in mortality among the three groups (11.7% early-OP, 8.7% late-OP, and 17.6% non-OP). There was also no difference among all three groups with respect for the need for tracheostomy and PEG and the development of UTI or pneumonia. However, there were significantly less DVTs in the non-OP group compared with the early-OP group (2.9% vs. 17.6%, p = 0.02). The percentage of patients discharged to a skilled nursing facility was similar among all three groups. The non-OP group had a significant decrease in both ventilator days and HLOS when compared with the operative groups. Only 2.9% of non-OP patients returned for OP for nonunion of the odontoid fracture. : Despite being an older population, elderly patients with odontoid fracture who were managed non-OP had similar mortality, UTI, and pneumonia rates compared with their younger counterparts who underwent OP. The need for tracheostomy and PEG and discharge disposition was similar among all three groups. Elderly patients with odontoid fracture managed non-OP had a reduction in HLOS and ventilator days compared with either operative group and less DVT compared with the early operative group. Based on these results, non-OP management should be given strong consideration in elderly patients with traumatic odontoid fractures.

The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre

Unintended harm to patients in operating theatres is common. Correlations have been demonstrated between teamwork skills and error rates in theatres. This was a single-institution uncontrolled before–after study of the...

Containing costs and containing bugs: are they mutually exclusive?

The overall health care costs for managing patients with community-acquired pneumonia (CAP) in U.S. hospitals is burdensome. While pharmacy costs comprise only a minor proportion of these costs, hospital length of stay (LOS) is the greatest contributor. Infections due to antimicrobial-resistant pathogens are also associated with increased overall health care cost. Therefore, strategies that aim to minimize antimicrobial resistance and reduce hospital LOS may have the greatest impact in reducing overall health care costs in managing patients with CAP. To evaluate how antimicrobial resistance can impact health care costs associated with CAP and review strategies to minimize the risk of resistance development while promoting appropriate antimicrobial therapy (including optimized dosing) and decreasing hospital LOS. Antimicrobial resistance can increase the risk of clinical failure and result in higher overall health care costs. Further development of antimicrobial resistance during therapy should, therefore, be minimized. This can be achieved through optimized antimicrobial dosing strategies- using a higher dose of concentration-dependent agents or prolonged infusion of time-dependent agents - that increase the probability of attaining pharmacokinetic-pharmacodynamic targets for eradication of the pathogen and hence successful clinical outcomes. Decreasing LOS must be a priority when attempting to reduce hospital costs. Active intravenous-to-oral switch therapy has been shown to effectively reduce LOS. Appropriate short-course regimens may also offer the opportunity for effective treatment while reducing or eliminating unnecessary antimicrobial exposure that not only reduces the potential for drug-related adverse events, but may also minimize the selection of resistant organisms. Clinical failure and antimicrobial resistance can significantly increase the cost of managing patients with CAP, primarily by increasing LOS. Therefore, strategies should be employed to minimize the risk of resistance development and reduce LOS. These include early appropriate therapy, optimized dosing based on pharmacodynamic principles, and efficient IV-to-PO switch therapy when appropriate.

Does PC Consultation Reduce Hospital Length of Stay? (317-C)

Does PC Consultation Reduce Hospital Length of Stay? (317-C)

Targeted individual exercise programmes for older medical patients are feasible, and may change hospital and patient outcomes: a service improvement project

BackgroundThe aim of this project was primarily to assess the feasibility of individual exercise programs for older hospitalised patients at risk of functional decline, and secondarily to evaluate impact on discharge outcomes.MethodsDesign: Cohort service improvement projectSetting: 500 bed acute metropolitan hospitalSubjects: Patients aged 70 and older admitted to Flinders Medical Centre under the general medical, aged care and respiratory units from June to November 2006, at intermediate or high risk of functional decline, and able to commence exercise within 48 hours of admissionIntervention: Functional Maintenance Program (FMP); an individually tailored exercise program to maintain functional mobility, prescribed and progressed by a physiotherapist, and supervised by an Allied Health Assistant (AHA), provided in addition to usual physiotherapy careOutcome measures: Feasibility (number of admissions suitable, commencing and complying with FMP). Impact (length of hospital stay (LOS), Aged Care Assessment Team (ACAT) referrals and approvals, hospital readmissions within 28 days, and functional mobility (Elderly Mobility Scale))Data Analysis: Descriptive and logistic regression analysisResultsOf 1021 admissions of patients aged 70 or older to general medical, aged care and respiratory units, 22% (n = 220) were identified within 48 hours as suitable for FMP: 196 (89%) commenced FMP within 48 hours of admission (FMP patients); 24 (11%) received usual physiotherapy (usual care patients). Feasibility of individually tailored exercise programs for older medical patients was supported by high uptake (89%), low withdrawal (17%) shown by those who commenced FMP, and good compliance with exercise sessions (70%). Logistic regression analysis showed a statistically significant decreased likelihood of referral for nursing home admission (OR = 0.228, 95% CI 0.088–0.587) and decreased likelihood of approval for admission to residential care (OR = 0.307, 95% CI 0.115–0.822) in favour of FMP. Although trends of an average 15.7% LOS reduction, 8% fewer readmissions and improved functional mobility were demonstrated in favour of FMP patients, these results were not statistically significant.ConclusionIt is feasible to identify older medical patients likely to benefit from an exercise program to maintain functional abilities, and to commence within 48 hours of admission.