Reduction In Hospital Length Of Stay Research Articles

Abstract 18511: Early Re-Implantation After Infected Device Extraction is Safe, Reduces Length of Stay and is Not Associated With a Higher Rate of Reinfection

Introduction: Cardiac implantable electronic device (CIED) infection often necessitates complete system removal (CSR) and eventual reimplantation. Concern for reinfection and other complication can delay reimplantation. We evaluated whether early reimplantation is safer, reduces length of stay (LOS) and predisposes to a higher reinfection rate than late reimplantation in patients undergoing CSR for CIED infection. Methods: We retrospectively reviewed data in 220 patients with CIED infection requiring CSR from 1995-2013 at a single academic medical center. We compared the incidence of major complications, wound dehiscence, and reinfection in patients undergoing early (≤ 48 hours) versus delayed (> 48 hours) reimplantation. A subgroup analysis in multi-drug resistant organism (MDRO) infections was performed. Results: A total of 97 patients were included. There were 43 patients reimplanted within 48 hours (88.4% men, mean age 69.0 yrs) and 54 patients reimplanted after 48 hours (77.8% men, mean age 65.1 yrs). There were more patients with initial systemic versus local infection in the delayed group (58.6% vs. 18.6%, p=0.0002). Reinfection after early reimplantation was not associated with a systemic presentation (40% vs. 50%, p=0.81). Early reimplantation did not portend a higher risk of major complications (4 vs. 1, p=0.10), wound dehiscence (1 vs. 0, p=0.26) or reinfection (5 vs.2, p=0.13). The findings were similar in early (n=18) versus delayed (n=19) reimplantation in patients with MDRO-positive infections (major complications: 2 vs.1, p=0.52, dehiscence: 0 vs.0, reinfection: 1 vs.1, p=0.97). Early reimplantation was associated with shorter hospital stay than delayed reimplantation (9.3 vs. 16.3 days, p=0.0005). Conclusions: In patients with CIED infection who have undergone CSR, including those with MDRO infections, early device reimplantation within 48 hours is safe, is not associated with a higher reinfection rate and reduces hospital LOS.

Editorial Commentary: Linking Process Measures to Outcome for Patients With Complicated Urinary Tract Infection: It's Complicated

Defining best practice and measuring compliance with standards for the management of infection is challenging. Quality indicators (QIs), many of which measure process, are being increasingly developed to address these challenges [1– 4], in some cases using a “bundle” approach where compliance is measured as “all or nothing” [5]. One could argue that these process measures end up measuring what can be measured rather than what should be measured [6]. It is therefore desirable to define clinical outcome measures that are sensitive to changes in the quality of care, for example to increased compliance with QIs. This presents significant challenges, but demonstrating links between process and outcome is necessary to convince clinicians and allow more meaningful external scrutiny [6]. Mortality, defined in a number of ways, is one of the most objective clinical outcome measures, but its application where an infection is associated with a low mortality rate, such as urinary tract infection (UTI), is limited. Very large sample sizes are required to demonstrate any significant changes and there is likely to be significant confounding by indication (the sickest patients who receive the best care are still most likely to die). Length of hospital stay (LOS), a continuous variable applicable to all patients, should theoretically be more sensitive to changes in practice. Although subject to numerous confounders, significant associations between increased guideline adherence and decreased LOS have been demonstrated in community-acquired pneumonia [7]. In this issue of Clinical Infectious Diseases, Spoorenberg and colleagues [8] report the findings of a large retrospective observational multicenter cohort study to evaluate whether adherence to a set of QIs defining appropriate antibiotic management for patients with complicated UTI was associated with LOS, the primary outcome measure. The 4 QIs were as follows: (1) perform a urine culture before starting treatment; (2) prescribe empirical treatment in accordance with the national guideline ([2B] prescribe empirical treatment in accordance with the local guideline); (3) switch from intravenous to oral treatment within 72 hours of starting treatment; and (4) tailor antibiotic treatment on the basis of culture results. Secondary outcome measures were intensive care unit (ICU) admission and in-hospital mortality. Adherence to the second (2B only) and third QI individually was associated with reduced adjusted LOS among patients qualifying for each indicator. There was also a reported statistically significant, stepwise reduction in LOS associated with increasing proportional adherence to applicable QIs. Assessment of the impact of QI adherence on ICU admission and inhospital mortality was limited by small numbers, although there was a reported significant association between prescribing in accordance with local guidelines and reduced ICU admissions. The strengths of this study include the large sample size and inclusion of patients from different settings. The quality indicators are rational and measurable and have been previously validated [1]. Using multilevel analysis is appropriate because discharge practices will differ by department and hospital independent of patient characteristics. However, the statistical analysis of LOS is often difficult due to nonnormal distribution, habitually including many outliers, [9] and it is not clear whether this was considered in the statistical modeling. Several other limitations also affect the interpretation and generalizability of the study findings. In all retrospective studies, case ascertainment bias is an important potential threat, Received and accepted 7 October 2013; electronically published 24 October 2013. Correspondence: Charis A. Marwick, PhD, Ninewells Hospital and Medical School, East Block, Dundee, Tayside, DD1 9SY, UK (c.z.marwick@dundee.ac.uk). Clinical Infectious Diseases 2014;58(2):170–2 © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/cid/cit690

Asthma Care Pathway Shortens Length of Hospitalization

Source: Hsu DP, Lee TJ, Barker JA. Outcome of pediatric inpatient asthma clinical pathway implementation in a military medical center. Mil Med. 2013; 178(4): e477-e482Investigators at San Antonio Military Medical Center sought to determine whether the implementation of a standardized inpatient asthma care pathway (ACP) decreased length of hospital stay (LOS). The ACP was designed using a combination of previously published assessment and care algorithms and included requirements for providing standardized asthma education to families and ensuring the scheduling of outpatient follow-up appointments prior to discharge. The ACP included a standardized assessment using the Pediatric Asthma Score (PAS), a validated measurement of severity of an acute asthma exacerbation (AAE). Initial medical management included corticosteroids, oxygen (if indicated), and inhaled bronchodilators, which were repeated every 20 minutes for 1 hour if not administered in the emergency department or outpatient clinic prior to admission. If a child’s clinical status, based on PAS scores (higher score = worse clinical status), did not improve or deteriorated, escalation of care included increased doses of albuterol and administration of subcutaneous epinephrine, terbutaline, or magnesium, with transfer to the ICU for patients with continued clinical deterioration. For children with low PAS scores, recommended management included decreased frequency of assessments and weaning of bronchodilators. Discharge criteria were also standardized in the pathway.The primary study outcome was LOS in children 2 to 18 years old hospitalized for an AAE. Secondary outcomes included use of recommended medications and provision of asthma education. Data on children hospitalized with an AAE in the 10 months following implementation of the ACP were compared to those in a historical control group of children admitted for an AAE in the 3 years prior to implementation.Data were abstracted from the medical records of 80 patients hospitalized for AAE after implementation of the ACP and 265 admitted prior to implementation. The average LOS decreased from 60.9 hours in the historical control group to 45.8 hours in the ACP group (P < .002). No patients in either study group required readmission within 72 hours of discharge. There was a significant increase in the use of subcutaneous epinephrine between the historical control group and the ACP group (1.13% vs 11.25%, P < .001). Adherence to guidelines for asthma education increased from 48% to 89% (P < .001) after implementation of the ACP.The authors conclude that implementation of an ACP is a useful tool to standardize and improve quality of care for children with AAE, and may decrease duration of hospitalization.Dr Sutter has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Suboptimal asthma management may result from inconsistent practices between medical providers, and a lack of specific practice pathways may lead to variability in provider choices for asthma therapy. Lack of adherence to recommended preventive and acute management recommendations has been associated with poor asthma control.1 Clinical practice algorithms for asthma are frequently used in the emergency department (ED) setting and may decrease the need for inpatient admissions.2 However, adherence to ACPs varies significantly, and providers may overestimate the frequency with which they follow such algorithms.3 Inpatient asthma management guidelines that include standardized clinical assessment tools and immediate management with corticosteroids and bronchodilators have been shown to decrease LOS.4Although the effects or adequacy of pre-admission management due to delayed implementation of the outpatient arm of the ACP was not evaluated in the current study, the prompt administration of bronchodilators every 20 minutes in admitted patients who had not received this treatment in the outpatient setting was considered a key component of immediate care for AAE. Although the authors did not separately analyze data for patients with symptoms severe enough to require subcutaneous epinephrine or other systemic therapies, they postulated that the statistically significant increased use of systemic beta-agonists contributed to the reduction in LOS. This suggestion is supported by findings in earlier studies that demonstrated reduced stays in children receiving early systemic beta-agonist therapy.5The authors emphasize the need for standardized asthma education and discharge planning that includes scheduled outpatient follow-up. While compliance with these standards significantly increased in this study, the study was limited by lack of follow-up to assess the effects of these interventions. Readmission within 72 hours did not occur in any of the pre- or postintervention patients. Subsequent need for readmission or outpatient care for acute symptoms was not evaluated in this study, though previous studies have demonstrated the positive effects of parent and patient asthma education on asthma control and need for ED visits for AAE. The results of this study need to be validated by studies with greater assessment of pre-admission management and more robust follow-up of patients after hospital discharge. Nonetheless, these findings argue for standardizing asthma care and including postdischarge education and follow-up in those pathways.

Decreasing Hospital Length of Stay for Bronchiolitis by Using an Observation Unit and Home Oxygen Therapy

Pediatric observation units (OUs) offer the opportunity to safely and efficiently care for common illnesses previously cared for in an inpatient setting. Home oxygen therapy (HOT) has been used to facilitate hospital discharge in patients with hypoxic bronchiolitis. It is unknown how implementation of a hospitalwide bronchiolitis treatment protocol promoting OU-HOT would affect hospital length of stay (LOS). To test the hypothesis that using OU-HOT for bronchiolitis would decrease LOS. Retrospective cohort study at Primary Children's Medical Center, Salt Lake City, Utah. Uncomplicated bronchiolitis patients younger than 2 years admitted during the winter seasons of 2005 through 2011. Implementation of a new bronchiolitis care process encouraging use of an OU-HOT protocol. Mean hospital LOS, discharge within 24 hours, emergency department (ED) bronchiolitis admission rates and ED revisit/readmission rates, and inflation-adjusted cost. A total of 692 patients with bronchiolitis from the 2010-2011 bronchiolitis season were compared with 725 patients from the 2009-2010 season. Implementation of an OU-HOT protocol was associated with a 22.1% decrease in mean LOS (63.3 hours vs 49.3 hours, P < .001). Although LOS decreased during all 6 winter seasons, linear regression and linear quantile regression analyses for the 2005-2011 LOS data demonstrated a significant acceleration in the LOS decrease for the 2010-2011 season after implementation of the OU-HOT protocol. Discharges within 24 hours increased from 20.0% to 38.4% (P < .001), with no difference in ED bronchiolitis admission or ED revisit/readmission rates. After implementation of the OU-HOT protocol, the total cost per admitted case decreased by 25.4% ($4800 vs $3582, P < .001). Implementation of an OU-HOT protocol for patients with bronchiolitis safely reduces hospital LOS with significant cost savings. Although widespread implementation has the potential for dramatic cost savings nationally, further studies assessing overall health care use and cost, including the impact on families and outpatient practices, are needed.

Effects of introducing an enhanced recovery after surgery programme for patients undergoing open hepatic resection

ObjectivesEnhanced recovery after surgery (ERAS) protocols are coming to represent the standard of care in many surgical procedures, yet data on their use following hepatic surgery are scarce. The aim of this study was to review outcomes after the introduction of an ERAS programme for patients undergoing open hepatic resection. MethodsA retrospective review of patients undergoing open hepatic resection from March 2005 to June 2011 was carried out. The primary outcome measure was total hospital length of stay (LoS) (including readmissions). Principles associated with enhanced recovery after surgery were documented and analysed as independent predictors of hospital LoS. ResultsA total of 120 patients underwent 128 consecutive hepatic resections, 84 (65.6%) of which were performed in patients with underlying colorectal metastases and 64 (50.0%) of which comprised major hepatic resections. The median hospital LoS was reduced from 6 days to 3 days from the first to the fourth quartiles of the study population (P = 0.021). The proportion of patients suffering complications (26.6%) remained constant across the series. Readmissions increased from the first quartile (none of 32 patients) to the fourth quartile (seven of 32 patients) (P = 0.044). Following multivariate analysis, only the development of a complication (P < 0.001), total postoperative i.v. fluid (P = 0.003) and formation of an anastomosis (P = 0.006) were independent predictors of hospital LoS. conclusionsAn ERAS programme can be successfully applied to patients undergoing open hepatic resection with a reduction in hospital LoS, but an increase in the rate of readmissions.

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.