Reduction In Median Length Research Articles

Changes in length of hospital stay for infective endocarditis - data from before and after the POET trial

Abstract Background The results from the Partial Oral Treatment of left-sided Endocarditis (POET) trial was published in August 2018 and established non-inferiority of a switch to oral step-down antibiotic treatment in stabilized patients with infective endocarditis (IE). However, data on length of hospital stay and safety following the POET trial are warranted. Purpose To examine the changes in length of hospital stay before and after POET publication. Further, to assess safety (relapse of bacteremia and 180 days of mortality) before and after POET publication. Methods By cross-linkage of Danish nationwide registries, patients with first-time IE caused by Streptococcus spp., Enterococcus faecalis, Staphylococcus aureus, or coagulase negative staphylococci from 2012-2021 were identified. Immediately following the publication of the POET trial, the POET criteria was implemented and used in Denmark. The study period was categorized according to publication date (before and after September 2018). Median length of hospital stay was examined according to calendar period. Mortality (from admission date) and relapse of bacteremia (after discharge) at 180 days of follow-up were examined with the Kaplan-Meier estimator and the Cumulative Incidence Function, respectively. Results We identified 3,008 patients before publication of the POET trial (median age 72.8 years) and 1,740 after the publication (median age 75.2 years) (p<0.0001). The burden of comorbidities was comparable between groups. The median length of hospital stay decreased by 8 days: 41 days (IQR: 29-49) before POET publication and 33 days (IQR: 21-44) after POET publication (p<0.0001 for difference), Figure 1. Similar reductions in length of hospital stay were seen across different microbiological etiologies and age groups. The reduction in length of hospital stay was most pronounced in non-surgically treated patients. The mortality from IE admission with a maximum of 180 days follow-up was 27.5% before POET publication and 28.3% after POET publication (p-value=0.41 for difference). The bacteremia relapse rate within 180 days was 3.5% before POET publication and 1.6% after POET publication (p-value=0.0002 for difference), Figure 2. Conclusion Following the POET trial, we found an 8 days reduction in median length of hospital stay with no change in mortality and an associated lower rate of relapse of bacteremia.

Implementing criteria-led discharge for acute admissions to facilitate the elective recovery from COVID-19: an example in acute tonsillitis

BackgroundHealthcare systems face unprecedented numbers of patients waiting for elective treatments in the wake of the COVID-19 pandemic. Hospitals must urgently optimise patient pathways and build capacity to meet the...

RACCE Study: Impact of an enhanced recovery after surgery program (ERAS) in the management of endometrial cancer: A single-center retrospective study

ObjectiveThis study evaluates the implementation of an ERAS program in the gynecological surgery department of Caen University Hospital and its impact on the management of endometrial cancer.The objective was to show its impact on the length of hospitalization of patients before and after its implementation. Patients and methodWe conducted a retrospective study including all women treated surgically for endometrial cancer at Caen University Hospital between January 1, 2015 and December 31, 2021. The ERAS program started in September 2017.We compared the pre-, intra- and postoperative characteristics of two groups: the first one concerning the period before the implementation of ERAS called « prior ERAS group » and the second one after implementation called « post ERAS group ». ResultsA total of 198 patients were included in our study. 139 patients were included after ERAS implementation. Our study shows that there is a significant reduction in median length of stay between the post ERAS and prior ERAS groups respectively 3 and 4 days (p = 0.004). There was also a reduction of time to resume ambulation (p < 0.001) and re-feeding (p < 0.001) for the post ERAS group compared to the prior ERAS group. Complication rates (p = 0.87) and readmission rates (p = 0.28) were not significant. Overall survival was not significant (p = 0.28). ConclusionERAS is a safe and effective method in the overall management of patients allowing an improvement in the quality of patient care and accelerating recovery to a previous physiological state. Finally, this results in a reduction in the patient's length of stay, without impacting morbidity and readmission rate.

Reconfiguration from emergency to urgent elective neurosurgery for glioblastoma patients improves length of stay, surgical adjunct use, and extent of resective surgery.

BackgroundGlioblastoma (GB) is the most common intrinsic brain cancer and is notorious for its aggressive nature. Despite widespread research and optimization of clinical management, the improvement in overall survival has been limited. The aim of this study was to characterize the impact of service reconfiguration on GB outcomes in a single centre.MethodsPatients with a histopathological confirmation of a diagnosis of GB between 01/01/2014 and 31/12/2019 were retrospectively identified. Demographic and tumour characteristics, survival, treatment (surgical and oncological), admission status, use of surgical adjunct (5-aminolevulinic acid, intra-operative neuro-monitoring), the length of stay, extent of resection, and surgical complications were recorded from the hospital databases.ResultsFrom August 2018 the neurosurgical oncology service was reconfigured to manage high-grade tumours on an urgent outpatient basis by surgeons specializing in oncology. We demonstrate that these changes resulted in an increase in elective admissions, greater use of intra-operative adjuncts resulting in the improved extent of tumour resection, and a reduction in median length of stay and associated cost-savings.ConclusionsOptimizing neuro-oncology patient management through service reconfiguration resulted in increased use of intra-operative adjuncts, improved surgical outcomes, and reduced hospital costs. These changes also have the potential to improve survival and disease-free progression for patients with GB.

Impact of methicillin‐resistant Staphylococcus aureus polymerase chain reaction nasal swabs on vancomycin utilisation in patients admitted to the intensive care unit with respiratory infections

AbstractBackgroundMethicillin‐resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) screening has a negative predictive value as high as 96% for pneumonia. Using nasal PCR, care providers can detect the presence or absence of MRSA earlier and potentially decrease the duration of vancomycin therapy in patients with negative results.AimsThe primary objective was to assess the impact of MRSA nasal PCR on vancomycin length of therapy in patients admitted to the intensive care unit (ICU) with respiratory infections.MethodsThis was a retrospective, quasi‐experimental, uncontrolled before—after study, comparing patients receiving screening versus those who did not. Patients over the age of 18, admitted to ICU with respiratory infections who received at least one dose of vancomycin were included in this study. This investigation received exemption from the South Nassau Communities Hospital and Western Institutional Review Board (reference number SNCH‐E14) and was conducted in accordance with the tenets espoused in the Declaration of Helsinki.ResultsA total of 77 patients, 22 in the study group and 55 in the comparator group were included in the analysis. There was a reduction in median length of vancomycin therapy in the MRSA PCR group compared to the unscreened group (1.7 days vs. 6 days, IQR: 4.15 vs. 4.8, p &lt; 0.001). There was a reduction in median vancomycin levels performed (3 levels vs. 1 level, p = 0.619).ConclusionsThe use of nasal PCR screening for MRSA was associated with a reduction in median vancomycin length of therapy for patients admitted to the ICU with respiratory infections.

The impact of post-operative voiding trial on length of stay following laparoscopic hysterectomy: a prospective, randomized control trial

Objective: Same day discharge (SDD) is feasible following laparoscopic hysterectomy (TLH) in gynecologic oncology patients resulting in low complication and re-admission rates. Following vaginal surgery, backfill or active voiding trials have been shown to reduce hospital discharge with a catheter. The aim of this study is to determine if performing an active backfill voiding trial (AVT) vs. passive voiding trial (PVT) leads to expedited discharge following TLH. Methods: Subjects scheduled for SDD TLH were enrolled and randomized to an AVT or a PVT. The primary outcome was length of stay. Secondary outcomes include time to void, catheter replacement, admission to the extended recovery unity (ERU), post-operative pain, and complications. Results: 121 patients were randomized: 60 to an AVT and 61 to a PVT. There was a statistically significant reduction in median length of stay for patients undergoing an AVT vs. PVT (271.5 minutes vs. 329 minutes, P = 0.015). Median time to void was also decreased with an AVT vs. PVT (30 minutes vs. 289 minutes, P &lt; 0.001). There was no difference in median pain score (2), catheter replacement, peri-operative complications, or overnight admissions between the two groups. Conclusion: There is a significant reduction in time to void and total length of stay in patients randomized to a backfill voiding trial following TLH with no increased patient discomfort. While the numbers of post-operative admissions were low and underpowered to detect a difference in admission rate, these data will help to streamline post-operative care for SDD gynecologic oncology patients.

INNV-26. SERVICE RECONFIGURATION INTO AN URGENT ELECTIVE PATHWAY FOR THE MANAGEMENT OF GLIOBLASTOMA PATIENTS IMPROVES OUTCOMES, COSTS AND PATIENT EXPERIENCE AND ADJUNCT USE: A SINGLE CENTRE SIX YEAR REVIEW

Abstract BACKGROUND Glioblastomas (GB) are grade four gliomas, the most common form of neoplasms arising in the brain. GBs are known for their aggressiveness; despite widespread research, limited advances have been made to improve survival. Between 2014–2019, a service reconfiguration for suspected GB referrals within our centre has been achieved. We have gone from a predominantly emergency admission and surgery based service for GB, to an urgent elective admission pathway. This is backed by weekly MDTs, neuro-oncology specialist led clinics, with imaging and pre-assessment clinic as part of a one-stop-shop model. Improved planning through elective admissions has also helped us achieve increased use of intra-operative adjuncts, including neuro-monitoring and the use of 5-ALA. The aim of this study is to describe a single centre experience of improvements made across six years through a combination of service reconfiguration and an increase use of intra-operative adjuncts. METHODS Patients with histological confirmed, primarily diagnosed GBs between 01/01/2014 and 31/12/2019 were extracted from the pathology database. Information including survival, treatment (surgical, oncological) and use of adjunct, admission status, length of stay (LOS), extent of resection and surgical complications were extracted manually. Inpatient admission costs were estimated. RESULTS From 2014 to 2019, we achieved an increase in elective admissions (28.1% to 90.3%, p&amp;lt; 0.001), which has led to a greater proportion of patients undergoing resective surgery (68.4% to 81.9%, p= 0.041), reduction in median length of stay (9 to 3 days, p &amp;lt; 0.001) and deceased overall costs. An increased use of intra-operative adjuncts has improved the proportion of total and gross resections (p&amp;lt; 0.001). CONCLUSIONS A switch from emergency to a MDT-based, urgent pathway with increased use of intra-operative adjuncts has resulted in improved technical outcomes and cost savings for the trust. This change has high potential to improve survival in patients on further follow-up.

Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler

Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.

ValuedCare program: a population health model for the delivery of evidence-based care across care continuum for hip fracture patients in Eastern Singapore

BackgroundTo test a population health program which could, through the application of process redesign, implement multiple evidence-based practices across the continuum of care in a functionally integrated health delivery system and deliver highly reliable and consistent evidence-based surgical care for patients with fragility hip fractures in an acute tertiary general hospital.MethodsThe ValuedCare (VC) program was developed in three distinct phases as an ongoing collaboration between the Geisinger Health System (GHS), USA, and Changi General Hospital (CGH), Singapore, modelled after the GHS ProvenCare® Fragile Hip Fracture Program. Clinical outcome data on consecutive hip fracture patients seen in 12 months pre-intervention were then compared with the post-intervention group. Both pre- and post-intervention groups were followed up across the continuum of care for a period of 12 months.ResultsVC patients showed significant improvement in median time to surgery (97 to 50.5 h), as well as proportion of patients operated within 48 h from hospital admission (48% from 18.8%) as compared to baseline pre-intervention data. These patients also had significant reduction (p value < 0.001) of acute inpatient complications such as delirium, pneumonia, urinary tract infections, and pressure sores. VC program has shown significant reduction in median length of stay for acute hospital (13 to 9 days) as well as median combined length of stay for acute and sub-acute rehabilitation hospital (46 to 39 days), thus reducing the total duration of hospitalization and saving total hospital bed days. Operative and inpatient mortality, together with readmission rates, remained low and comparable to international Geriatric Fracture Centers (GFCs).ConclusionThe implementation of VC methodology has enabled consistent delivery of high-quality, reliable and comprehensive evidence-based care for hip fracture patients at Changi General Hospital. This has also reflected successful change management and interdisciplinary collaboration within the organization through the program. There is potential for testing this methodology as a quality improvement framework replicable to other disease groups in a functionally integrated healthcare system.

Institutional Audit on Percutaneous Nephrolithotomy

Background : Percutaneous nephrolithotomy (PCNL) is commonly used in the management of large upper renal tract stones. It is highly effective but carries a greater risk of significant morbidity than less invasive treatment options such as ureteroscopy or extracorporeal shock wave lithotripsy Aims and Objectives : To analyse contemporary PCNL practice within our institute with an emphasis on outcome measures, including stone free and reduced complication rates and compare our data with previously published series. Material and Methods : A prospective study was conducted in 145 patients from January 2015 to June 2016 in Department of Urology, Indira Gandhi Institute of Medical Sciences who underwent PCNL procedure as per standard protocols. Effectiveness was assessed by stone-free rates and safety according to complications including blood transfusion, fever, and sepsis rates Results : From January 2015 to June 2016, data on 145 patients who had PCNL procedures were collected. A total 17 of 145 procedures (11.7%) were for staghorncalculi, 84 (58%) for stones >2 cm, 41(28.3%) for stones 1–2 cm, and 3 (2.1%) for stones<1 cm. Complete stone clearance has been achieved in more than three fourth of the cases (76.6.%). Totally tubeless procedures were not associated with higher complication rates but did lead to a significant reduction in median length of stay (3 d vs 1.5 d; p <0.0001). Blood transfusion was required in 10 of 145 patients (6.4%). The incidence of postoperative fever was 19% and of sepsis was 4%. Conclusion : The PCNL data registry is a unique resource providing vital information on current practice and critical outcome data. Using the registry, endourologists can audit their practice against national outcome data for this benchmark procedure. It will help surgeons counsel patients during consent for this complex endourologic procedure about the possible outcome in their hands.

The safety and efficiency of a fast-track protocol for sleeve gastrectomy: a team approach.

Increasing numbers of morbid obese patients has led to increased numbers of bariatric procedures. Fast-track protocols are being developed to enhance the available resources, while maintaining a safe procedure. Reported results on safety merely apply to a mixed bariatric population. The objective was to evaluate safety and efficiency of the fast-track principles in patients undergoing sleeve gastrectomy. Retrospective observational study including patients undergoing primary sleeve gastrectomy at the Obesity Centre of the Catharina Hospital Eindhoven, the Netherlands. Conventional perioperative care (CC) (2008-2011) versus a fast-track protocol (FT) (2011-2013), using short-acting anesthetic agents, a multi-modal pain protocol to reduce opioids, and early mobilization. The main parameters for safety were intraoperative, early and late postoperative complications. Procedure time and hospital stay were used to evaluate efficiency. This study included 805 patients, 494 patients were subjected to the conventional care and 318 patients to fast-track protocol. A reduction of median operation time from 60 (CC) to 40 minutes (FT) (P<0.001) and a reduction in median length of hospital stay from three to two days (P=0.001), with a significant reduction in early postoperative complications (9.9% [CC] vs. 5% [FT], P=0.016) was achieved. The amount of late complications was comparable for both groups (5.1% [CC] vs. 4.4% [FT] [P=0.738]). Implementation of a fast-track protocol for sleeve gastrectomy is safe and efficient. It effectively reduces operation time and length of hospital stay, while improving postoperative outcome. This pleads for standard implementation of the fast-track protocol in sleeve gastrectomy.

Comparison of bronchodilator administration with vibrating mesh nebulizer and standard jet nebulizer in the emergency department

IntroductionProjects comparing bronchodilator response by aerosol devices in the ED are limited. Evidence suggests that the vibrating mesh nebulizer (VMN) provides 5-fold greater aerosol delivery to the lung as compared to a jet nebulizer (JN). The aim of this project was to evaluate a new nebulizer deployed in an Emergency Department. MethodsA quality improvement evaluation using a prospectively identified data set from the electronic medical record comparing all ED patients receiving aerosolized bronchodilators with the JN during September 2015 to those receiving aerosolized bronchodilators with the VMN during October 2015. Results1594 records were extracted, 879 patients received bronchodilators via JN and 715 patients via the VMN. Admission rates in the VMN group were 28.1% and in the JN group at 41.4%. The total albuterol dose administered was significantly lower in the VMN group compared to the JN (p<0.001). No patient in the VMN group required >5mg albuterol to control symptoms (85% of the VMN group received only 2.5mg) whereas dosing in the JN group was higher in some patients (with 47% receiving only 2.5mg). The use of VMN was also associated with a 13% (37min) reduction in median length of stay in the ED. ConclusionsThe VMN was associated with fewer admissions to the hospital, shorter length of stay in the ED and a reduction in albuterol dose. The device type was a predictor of discharge, disposition and amount of drug used. Randomized controlled studies are needed to corroborate these findings.

Clinical Care Guideline for Improving Pediatric Acute Musculoskeletal Infection Outcomes.

Acute pediatric musculoskeletal infections are common, leading to significant use of resources and antimicrobial exposure. In order to decrease variability and improve the quality of care, Children's Hospital Colorado implemented a clinical care guideline (CCG) for these infections. The purpose of this study is to evaluate clinical and resource outcomes PRE and POST this CCG. Retrospective chart review evaluated patients admitted to a large pediatric quaternary referral center (CHCO) diagnosed with acute osteomyelitis, septic arthritis, pyomyositis, and/or musculoskeletal abscess prior to and after guideline implementation. Primary outcomes included length of stay and overall antibiotic use, with additional secondary clinical, process, and therapeutic outcomes examined. 82 patients were identified in both the pre-CCG and post-CCG cohorts. There was a reduction in the median of all primary outcomes, including length of stay (0.6 median days decrease, P = .04), length of IV antibiotic therapy (4.9 median days decrease, P < .0001), and days of IV antibiotic therapy (6.4 median days decrease, P = .0004). Our median length of stay post-CCG was 4.9 days, the shortest reported length of stay for pediatric acute musculoskeletal infections to date. Additionally, there was a 24.5 hour reduction in median length of fever (P = .02), faster CRP normalization (P < .0001), 50% decrease in the number of related readmissions (P = .02), 34% decrease in central venous catheters placed (P < .0001), decreased time to first culture (P = .02), and 79% pathogen identification post-CCG (P = .056). Implementation of a CCG for acute musculoskeletal infections improves patient, process and resource outcomes.

Abstract PR623

Background & Objectives: Massive fluid shifts occur during ovarian cancer (OC) cytoreductive surgery (CRS), which is associated with increased morbidity. Goal directed therapy (GDT) for intra-operative fluid (IOF) has not been widely studied in OC; Only 2 studies showed reduction in median length of stay (LOS) and postoperative morbidity. Objective: To analyse the current IOF management in OC CRS and develop a prospective study comparing GDT versus standard fluid management and measure impact on hospital stay, post-operative morbidity and cost-effectiveness. Materials & Methods: Retrospective observational study using data from electronic medical records between December 2014 and May 2015. Results: Results: Forty-one patients underwent primary debulking surgery (PDS, n=15) or interval debulking (IDS, n=26). Median total IOF administration using standard approach was 5000 ml (crystalloids 3000 ml, colloid 2000 ml). Intra-operative acidosis occurred in 25 % patients, 29 % patients required intraoperative albumin infusion, 56 % required vasopressors on postoperative day 1 (POD1). There was no difference in mean IOF administration between PDS (longer duration of surgery or DOS) (5304 ml, DOS=627 min) vs. IDS (5215 ml, DOS=504 min). Cumulative fluid balance on POD1 was 2435 ml. The median LOS for PDS was 11 days vs. 8 days in IDS. In a later cohort of 4 patients (PDS=3, IDS=1) where GDT was initiated using stroke-volume variability (SVV), median IOF requirement was 8000 ml and no intra- operative acidosis occurred. Conclusion: GDT might give better guidance to replace IOF loss and maintain tissue perfusion in OC CRS.

Standardization of surgical care in a high-volume center improves survival in resected pancreatic head cancer

BackgroundDurable clinical gains in surgical care are frequently reliant on well-developed standardization of practices. We hypothesized that the standardization of surgical management would result in improved long-term survival in pancreatic cancer. MethodsSeventy-seven consecutive, eligible patients representing all patients who underwent pancreaticoduodenectomy and received comprehensive, long-term postoperative care at the University of Florida were analyzed. Patients were divided into prestandardization and poststandardization groups based on the implementation of a pancreatic surgery partnership, or standardization program. ResultsStandardization resulted in a reduction in median length of stay (10 vs 12 days; P = .032), as well as significant gains in disease-free survival (17 vs 11 months; P = .017) and overall survival (OS; 26 vs 16 months; P = .004). The improvement in overall survival remained significant on multivariate analysis (hazard ratio = .46, P = .005). ConclusionsStandardization of surgical management of pancreatic cancer was associated with significant gains in long-term survival. These results suggest strongly that management of pancreatic head adenocarcinoma be standardized likely by regionalization of care at high performing oncologic surgery programs.

Multidisciplinary, multi-modal nutritional care in acute hip fracture inpatients – Results of a pragmatic intervention

Malnutrition is highly prevalent and resistant to intervention following hip fracture. This study investigated the impact of individualised versus multidisciplinary nutritional care on nutrition intake and outcomes in patients admitted to a metropolitan hospital acute hip fracture unit. A prospective, controlled before and after comparative interventional study aligning to the CONSORT guidelines for pragmatic clinical trials. Randomly selected patients receiving individualised nutritional care (baseline) were compared with post-interventional patients receiving a new model of nutritional care promoting nutrition as a medicine, multidisciplinary nutritional care, foodservice enhancements, and improved nutrition knowledge and awareness. Malnutrition was diagnosed using the Academy of Nutrition and Dietetics criteria. Fifty-eight weighed food records were available for each group across a total of 82 patients (n=44, n=38). Group demographics were not significantly different with predominantly community dwelling (72%), elderly (82.2 years), female (70%), malnourished (51.0%) patients prone to co-morbidities (median 5) receiving early surgical intervention (median D1). Multidisciplinary nutritional care reduced intake barriers and increased total 24-henergy (6224 vs. 2957kJ; p<0.001) and protein (69.0 vs. 33.8g; p<0.001) intakes, reduced nutritional deterioration over admission (5.4 vs. 20.5%; p=0.049), and increased discharge directly back to the community setting (48.0 vs. 17.6%; p=0.012). Trends suggested a reduction in median length of stay (D13 vs. D14). Inpatient mortality remained low across groups (5.2%, 2.3%). Multidisciplinary nutritional care improves nutrition intake and outcomes in acute hip fracture inpatients. Similar pragmatic study designs should be considered in other elderly inpatient populations perceived resistant to nutritional intervention.

Percutaneous Nephrolithotomy in the United Kingdom: Results of a Prospective Data Registry

BackgroundPercutaneous nephrolithotomy (PCNL) is commonly used in the management of large upper renal tract stones. It is highly effective but carries a greater risk of significant morbidity than less invasive treatment options such as ureteroscopy or extracorporeal shock wave lithotripsy. ObjectiveEvaluate the current practice and outcomes of PCNL using a national prospective data registry. Design, setting, and participantsAll surgeons undertaking PCNL in the United Kingdom were invited to submit data to an online registry. MeasurementsEffectiveness was assessed by stone-free rates and safety according to complications including blood transfusion, fever, and sepsis rates. Results and limitationsSince January 2010, data on 987 patients who had 1028 PCNL procedures were collected. A total of 299 of 1012 procedures (30%) were for staghorn calculi, 299 (30%) for stones >2cm, 329 (33%) for stones 1–2cm, and 89 (9%) for stones <1cm. There were no significant differences in rates of failed access or complications according to whether a urologist or radiologist obtained renal access. There was a nonsignificant trend to a higher transfusion rate with balloon dilatation (7 of 222 [3.2%]) compared with serial dilatation (2 of 245 [0.8%]) of the renal tract (p=0.093). Totally tubeless procedures were not associated with higher complication rates but did lead to a significant reduction in median length of stay (3 d vs 1.5 d; p<0.0001). Intraoperatively, 78% of patients were believed to be stone free, which was confirmed in 68% with postoperative imaging. Blood transfusion was required in 24 of 968 patients (2.5%). The incidence of postoperative fever was 16% and of sepsis was 2.4%. ConclusionsThe PCNL data registry is a unique resource providing vital information on current practice and critical outcome data. Using the registry, endourologists can audit their practice against national outcome data for this benchmark procedure. It will help surgeons counsel patients during consent for this complex endourologic procedure about the possible outcome in their hands.

Evaluation of the impact of implementation of a Medical Assessment and Planning Unit on length of stay

The Medical Assessment and Planning Unit (MAPU) model provides a multidisciplinary and 'front end loading' approach to acute medical care. The objective of this study was to evaluate the impact of a 10-bed MAPU in Royal Melbourne Hospital (RMH) on hospital length of stay. A pre-post study design was used. Cases were defined as all general medical patients admitted to the RMH between 1 August 2003 and 31 January 2004. MAPU patients were defined as general medical patients who had been discharged from RMH MAPU unit as part of their RMH inpatient admission. Historical controls were defined as all general medical patients admitted to the RMH between 1 August 2002 and 31 January 2003. There was a reduction in median length of stay that did not reach statistical significance. During the study period, median emergency department length of stay for MAPU patients was 10.3 h compared with 13.2 h for non-MAPU patients who were admitted directly to general wards. The reductions in length of stay are likely to be of clinical significance at the emergency department (ED) level. The MAPU model also contributes to providing care appropriate care for older admitted patients.

Impact of rapid in situ hybridization testing on coagulase-negative staphylococci positive blood cultures

To evaluate the impact of the rapid differentiation of Staphylococcus aureus from coagulase-negative staphylococci (CoNS) in blood cultures using peptide nucleic acid fluorescence in situ hybridization (PNA FISH) on vancomycin usage, length of patient hospital stay and hospital costs. This was a retrospective, cost-effective analysis of PNA FISH in its initial 3 month implementation period in 2004 in a 650 bed academic medical centre. Blood cultures with Gram-positive cocci in clusters (GPCC) that were negative for S. aureus using the PNA FISH assay were compared with an untested control group in the same period that had similar illness severity and location. We evaluated the effectiveness of the early identification of CoNS by ruling out S. aureus in conjunction with an antimicrobial team (AMT) on antimicrobial therapy, patient length of stay and hospital costs. A total of 139 blood cultures positive with GPCC had PNA FISH results while 84 in the control group did not. Evaluable criteria were met in 53 patients in the PNA FISH group and 34 in the control group. When comparing the results obtained from using the PNA FISH assay with those for the control group, there was a significant reduction in median length of hospital stay from 6 to 4 days (P < 0.05, CI 0.95-1.87) and a trend towards less vancomycin usage with a decrease in associated hospital costs of approximately Dollars 4000 per patient. The PNA FISH assay is rapid, accurate and reliable and in association with an AMT could decrease hospital length of stay in patients with CoNS bacteraemia in non-intensive care unit settings and prevent excessive vancomycin usage.