Reduction In Hospital Length Of Stay Research Articles

Minimally invasive direct coronary artery bypass: Anesthetic, monitoring, and pain control considerations

Objective: Minimally invasive direct coronary artery bypass (MIDCAB) provides many anesthetic challenges including monitoring, managing myocardial ischemia, and pain control. The objective was to evaluate the monitoring requirements and the potential benefits of preischemic conditioning and intrathecal morphine sulfate in MIDCAB patients. Design and Setting: This review was retrospective and unrandomized and was conducted at Allegheny University Hospitals, Allegheny General, Pittsburgh, PA. Participants: Sixty-four patients with single coronary artery lesions (>70% obstruction) underwent attempted MIDCAB during a 1-year period between November 1995 and November 1996. Seven patients required conversion to conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) and two patients required extended thoracotomy incisions. This report describes the remaining 55 patients who underwent MIDCAB. Interventions: Some of the MIDCAB patients received intrathecal morphine before anesthetic induction. Ischemic preconditioning was assessed in a subset of patients. Results: MIDCAB was performed in 55 of 64 patients. Transesophageal echocardiography (TEE) was used in all patients and a pulmonary artery catheter was used in 43% of patients. Esmolol was used in 25% of patients to reduce motion of the left ventricle (LV) during the left internal mammary artery (LIMA)-LAD anastomosis, but was used less often as the surgeons adapted to the use of a retractor that stabilized the ventricular wall adjacent to the site of the LIMA-LAD anastomosis. LAD occlusion caused reversible, regional systolic dysfunction by TEE in the anterior and apical LV segments. During LAD occlusion, nitroglycerin was used in 61% of patients and phenylephrine in 24%. Ischemic preconditioning did not prevent increases in systemic or pulmonary artery pressures during LAD occlusion. Most (85%) patients were extubated in the operating room. Intrathecal morphine decreased postoperative analgesic requirements. The mean hospital length of stay (LOS) was 4.0 ± 1.7 days (range, 1 to 10 days). Conclusions: MIDCAB may reduce hospital LOS for patients with single vessel coronary artery lesions when compared with median sternotomy with a LIMA-LAD graft performed on cardiopulmonary bypass. Pharmacologic heart rate control during the LIMA-LAD anastomosis is not critical with the use of a surgical retractor which diminishes ventricular motion. A single 5-minute test LAD occlusion did not protect against subsequent regional Ischemic dysfunction in our subset of patients with normal baseline function.

Prospective Evaluation of a Clinical Guideline Recommending Hospital Length of Stay in Upper Gastrointestinal Tract Hemorrhage

Upper gastrointestinal tract hemorrhage (UGIH) is a common and potentially life-threatening disorder. Resource utilization can vary without adverse effect on patient outcome. Clinical practice guidelines are a potential solution to reduce variation in practice while improving patient outcomes. To validate prospectively the safety, acceptability, and impact of a clinical practice guideline defining the medically appropriate length of stay (LOS) for patients hospitalized with UGIH. Prospective, controlled time-series study with an alternate-month design. Outcome surveyors and patients were blinded to study group allocation. GUIDELINE: A retrospectively validated scoring system using 4 independent variables: hemodynamics, time from bleeding, comorbidity, and esophagogastroduodenoscopy (EGD) findings to predict risk of adverse events. The quantitative risk for the low-risk subset was 0.6% (95% confidence interval [CI], 0.0%-2.0%) for subsequent complications and 0% (95% CI, 0.0%-0.9%) for life-threatening complications from this retrospective evaluation. A 1000-bed, not-for-profit, university-affiliated teaching hospital. Consecutive adult patients hospitalized for acute UGIH. Concurrent feedback of guideline recommendation (same-day hospital discharge) to physicians caring for patients at low risk for complication. No risk information was provided during control months. Seventy percent (209/299) of UGIH patients achieved low-risk status according to the guideline and were therefore potentially suitable for early discharge from the hospital. Providing real-time quantitative risk information (intervention group only) was associated with an increase in guideline compliance from 30% to 70% (P<.001) and a decrease in mean (SD) LOS from 4.6 (3.5) days to 2.9 (1.3) days (mean reduction of 1.7 days per patient; P<.001). No differences in complications, patient health status, or patient satisfaction were found when measured 1 month after discharge. An independent variable predicting decreased hospital LOS for low-risk UGIH patients was early EGD. Implementation of the clinical practice guideline safely reduced hospital LOS for selected low-risk patients with acute UGIH. Further prospective validation in other settings is warranted.

Use of cardiac markers as assessed by outcomes analysis

This article will describe the outcomes studies that have been performed or are needed in related to biochemical markers in coronary artery diseases (CAD). Studies in five major areas are reviewed: the need for emergency department (ED) chest pain centers and the role of cardiac markers; impact of cardiac marker testing frequency on length of stay (LOS); interpretation of cardiac troponins T and I for risk stratification of cardiac patients with unstable angina (UA); serum markers for determining the success of intravenous thrombolytic therapy following acute myocardial infarction (AMI), and its role in rescue percutaneous transluminal coronary angioplasty (PTCA); and need and criteria for implementation of new cardiac tests. Chest pain centers reduce unnecessary admissions and costs for AMI rule outs. Laboratories must perform testing on a stat basis for rapid rule out of AMI. Stat testing will also result in a reduction in hospital LOS for patients who rule in for AMI. For UA patients, studies are needed to determine how results of cardiac markers can be used to improve cardiac outcomes. Serial measurements of myoglobin offer the earliest discrimination for successful reperfusion, and should be used if rescue PTCA becomes important therapeutically. New markers for early diagnosis are needed to complement tests such as myoglobin and CK-MB isoforms. Markers that assess early pathophysiologic events of AMI such as inflammation, thrombosis, and pre-necrosis ischemia have the most promise.

Outpatient high-dose chemotherapy with autologous stem-cell rescue for hematologic and nonhematologic malignancies.

A prospective study to determine the feasibility of high-dose chemotherapy (HDC) and autologous stem-cell rescue (ASCR) in the outpatient setting. One hundred thirteen consecutive patients underwent 165 cycles of HDC/ASCR for a variety of malignancies. HDC regimens were disease-specific. Initially, patients were hospitalized for HDC, discharged on completion, and maintained as outpatients unless toxicities required rehospitalization (subtotal outpatient transplantation [STOT]). Once this was established as safe, a total outpatient transplant (TOT) program was developed in which patients received all of the HDC, as well as supportive care, as outpatients. Patients who declined the outpatient programs received the same HDC and supportive care as inpatients. In 140 of 165 (85%) HDC cycles, patients agreed to participate in one of the outpatient transplant programs. Five patients in the STOT program could not be discharged from the hospital because of toxicities that developed during HDC; thus, 135 patients were monitored the outpatient setting, 95 (70%) of whom were never readmitted. The mean +/- SEM total hospital length of stay (LOS), including all readmissions and excess days after chemotherapy, was 18.33 +/- 5.06 days for patients who refused the outpatient program, 8.22 +/- 5.76 days for patients in the STOT program, and 2.81 +/- 7.66 days for those in the TOT program (P < .001). One treatment-related death occurred in each treatment setting: day 120 inpatient, day 17 STOT, and day 110 TOT. Outpatient management of HDC/ASCR is safe and acceptable for the vast majority of patients. The STOT program resulted in significant reduction in hospital LOS, while the TOT program appears equally safe and further reduces LOS. Hospitalization for HDC/ASCR is unnecessary in most patients.

RESOURCE UTILIZATION AMONG NEONATOLOGISTS IN A UNIVERSITY CHILDREN'S HOSPITAL. ▴ 1123

Objective. We studied factors affecting length of hospital stay and resulting hospital charges among patients managed by two separate groups of neo- natologists in the same academic health science center. Design. Retrospective analysis of clinical and finan- cial data base information. Methods. Neonatal intensive care was provided in the same acute care nursery in a large university chil- dren's hospital by: (1) neonatologists in a full-time aca- demic division (group A) and (2) a group associated with a private managed care organization (group B). Clinical and financial parameters of all neonates admitted in fiscal year 1994 were compared for the two provider groups. Stepwise regression analysis was used to evalu- ate factors influencing hospital charges and length of hospital stay (LOS) and to adjust for differences in clin- ical variables between the two groups. Results. Group A physicians provided care for 340 infants, while 137 were treated by those of group B. Group A included older patients, more outborns, more level III patients, more sepsis, more intermittent positive pressure ventilation, and more patent ductus arteriosus. The incidence of transient tachypnea of the newborn was higher among group B patients. Hospital charges were primarily determined by LOS, which was similar for the two groups. When the data were corrected for differences in risk and patient acuity, however, a significant relation- ship between physician group and LOS was demon- strated, with LOS being an average of 7.8 days shorter for group A. A net reduction of $3 114 969 in hospital charges might have been realized had group A physicians pro- vided care for all study patients. Conclusions. Hospital charges were determined by LOS. In this setting, academic neonatologists produced shorter LOS and comparable clinical outcomes, despite caring for a population at greater risk. The reduction in LOS could have resulted in more than $3.1 million in annualized savings had the academic group provided care for all of the study patients. Pediatrics 1997;99(6). URL: http://www.pediatrics.org/cgi/content/full/99/6/e2; resource utilization, hospital changes, length of stay, neo- natologists. ABBREVIATIONS. LOS, average length of hospital stay; PDA, patent ductus arteriosus. Steep increases in health care costs over the past decade have stimulated demands for cost contain- ment, particularly among large corporate purchasers of group health insurance. Numerous strategies for controlling health care costs have been marketed under the concept of managed care. Data are lacking regarding the impact of these market-driven health care strategies on children, particularly the care of the neonate. Academic health science center hospitals, includ- ing children's hospitals and their associated medical school faculty, often are depicted as being unable to deliver cost-effective health care. 1 Such institutions are deemed costly because of high rates of uncom- pensated care and cost shifting, personnel-intense and technology-oriented delivery systems, and their central role in development of innovative (and ex- pensive) new medical techniques. Patient care by medical school physicians is viewed as costly, and possibly inefficient, in comparison to the private sec- tor because of participation of physicians in training, detailed laboratory testing, and unwillingness to consider approaches that may compromise per- ceived standards of care. The high cost of neonatal intensive care is of particular concern. Despite the rhetoric surrounding these issues, little objective in- formation is available concerning the cost of neonatal care provided by academic physicians compared with physicians associated with managed care orga- nizations. Indicators most commonly used to analyze re- source utilization are hospital charges and length of hospital stay (LOS). Recent publications have em- phasized LOS as the primary determinant of cost of neonatal care 2,3 because of its relationship to low birth weight. Reduced costs have been demonstrated in association with nursery strategies that reduce LOS. 4,5

Upper gastrointestinal hemorrhage clinical guideline—Determining the optimal hospital length of stay

Physicians lack objective outcome data to define the medically appropriate length of stay (LOS) for patients hospitalized with acute upper gastrointestinal hemorrhage (UGIH), resulting in wide variations in resource utilization and quality of care. A clinical practice guideline with the ability to assign relative risk for adverse events is proposed. A comprehensive scoring system was derived from the literature by using four variables; hemodynamics, time from bleeding, comorbidity, and esophagoduodenoscopy findings. The discriminatory ability, potential safety, and impact on resource utilization of the clinical practice guideline was measured in a retrospective, observational study. Seventy percent of UGIH patients (349 of 500) achieved low-risk status according to the guideline, and, were therefore potentially suitable for early discharge from the hospital. If low-risk patients were discharged based upon the guideline, mean (+/- SD) hospital LOS would have been decreased from 4.8 +/- 2.4 days to 2.7 +/- 1.4 days; mean reduction was 2.1 bed-days per patient (95% CI 1.8 to 2.3, P <0.001). LOS would have increased in 4% of cases. Adopting the guideline's recommendation of early discharge would have resulted in a 0.6% (95% CI 0.07 to 2.1) complication rate, with no worsening of quality of care, as judged by implicit review. The proposed clinical practice guideline may safely reduce hospital LOS for selected low-risk patients with acute UGIH. Moreover, it also may reduce premature discharge of high-risk patients prone to life-threatening events.