Safe Early Discharge Research Articles

Sa1383 - Derivation and Validation of a Clinical Model to Identify Patients for Safe Early Discharge in Acute Pancreatitis

Sa1383 - Derivation and Validation of a Clinical Model to Identify Patients for Safe Early Discharge in Acute Pancreatitis

An algorithm for predicting blood loss and transfusion risk after total hip arthroplasty

IntroductionPatients receiving blood transfusions after total hip arthroplasty have increased morbidity and longer lengths of stay compared to non-transfused patients. The aim of this study is to create an algorithm in order to identify patients at risk for transfusion after total hip replacement and define a safe point in hemoglobin levels after which the need for blood, transfusion can be excluded. MethodsThis retrospective study analyzed hemoglobin (Hb) levels for 5 days in patients undergoing total hip replacement. An algorithm was implemented to identify the critical trends of Hb levels in the first two postoperative days, trying to identify the patients at high risk of transfusion. Specificity, sensibility and efficiency were calculated in relation to the capability of the algorithm to correctly identify transfused patients. ResultsThe algorithm found a pre-operative Hb ≥ 13 g/dl as a cut off between patients at low-risk or high-risk for transfusion. When parameters were calculated considering the best efficiency with the least number of false negatives, the algorithm showed a specificity of 84% and a sensitivity of 70% with an efficiency of 80.6%. Hb values >10 g/dl in the first operative day for low-risk patients and Hb level > 11 g/dl the second post-operative day for high-risk patients led to exclusion of the need for transfusion. ConclusionsThe algorithm suggested critical Hb levels to predict transfusion. In association with clinical data, the suggested critical values of Hb may be useful to schedule lab tests and a safe early discharge.

Factors associated with safe early discharge after transcatheter aortic valve implantation.

As transcatheter aortic valve implantation (TAVI) becomes more straightforward, a larger proportion of patients will be well enough to be discharged early. This study sought to charac-terise the clinical features that allowed patients to be discharged early after TAVI and to evaluate the safety of an early discharge policy. All patients undergoing TAVI at the above cited center from August 2007 to March 2015 were included in this study. Baseline characteristics, in-hospital outcomes, re-admissions and mortality were compared. Three hundred thirty-seven TAVIs were performed during the study period, and 18 died in-hospital (18/337, 5.3%). Of the remaining patients, 56 were discharged within 3 days of the index procedure ('early discharge group' 56/319, 17.5%). There was no difference between the early discharge and late discharge group in terms of Valve Academic Research Consortium-2 (VARC-2) criteria out-comes, all-cause re-admission rates and the need for permanent pacemaker implantation. Mortality at 1 year was better among the early discharge group (3.6% vs. 15.6%, p = 0.014); a reflection of baseline clinical differences. Early discharge of clinically selected TAVI patients is safe and appropriate. Lower logistic EuroSCORE, smaller delta creatinine and not developing any complications are factors associated with early discharge. (Cardiol J 2018; 25, 1: 14-23).

Chest Pain Identified as Low Risk for Acute Coronary Syndrome (ACS). Can a HEART Score Pathway Identify More Patients for Early Safe Discharge than the Current TIMI Score Pathway?

Aim: We compared our current TIMI pathway with a HEART pathway in patients with undifferentiated chest pain in terms of adverse cardiac events and number safely identified as low risk. We audited our management of low risk patients. Method: We screened consecutive chest pain presentations to ED and ADU in 2 Auckland hospitals. We included 525 patients with TIMI score 0 or 1, and 0 and 2 hours negative contemporary Troponin I. TIMI score and chest pain history was recorded by admitting physician. HEART score and endpoints were captured from electronic data, GP and patient phone calls. The primary endpoint was Adverse Cardiac Events (ACE) within 3 months. The secondary endpoint was measurement of length of stay and further cardiac testing. Results: 398 had HEART score 0-3 and negative serial TI (low risk HEART) with adverse cardiac event rate of 0.5% (95% CI 0.14 – 1.81). 366 patients had TIMI 0 and negative TI (low risk TIMI) with event rate of 1.1% (0.4 – 2.8). The HEART pathway identified 9% more patients as low risk. 56% of our TIMI 0 cohort was referred for exercise treadmill test, 12% for CTCA and 1.6% for coronary angiogram. Average LOS was 8.69 hours Conclusion: The HEART pathway safely identifies significantly more patients as low risk compared to our TIMI pathway. WDHB do further cardiac investigation in the majority of our low risk patients, despite an acceptably low miss rate for cardiac events. We can reduce costs significantly by incorporating HEART score in the pathway and by re-education of our physicians.

A Risk Assessment Score and Initial High-sensitivity Troponin Combine to Identify Low Risk of Acute Myocardial Infarction in the Emergency Department.

Early discharge of patients with presentations triggering assessment for possible acute coronary syndrome (ACS) is safe when clinical assessment indicates low risk, biomarkers are negative, and electrocardiograms (ECGs) are nonischemic. We hypothesized that the Emergency Department Assessment of Chest Pain Score (EDACS) combined with a single measurement of high-sensitivity cardiac troponin (hs-cTn) could allow early discharge of a clinically meaningful proportion of patients. We pooled data from four patient cohorts from New Zealand and Australia presenting to an emergency department with symptoms suggestive of ACS. The primary outcome was major adverse cardiac events (MACE) within 30 days of presentation. In patients with a nonischemic ECG we evaluated the sensitivity for MACE and percentage low risk of every combination of high-sensitivity cardiac troponinT (hs-cTnT) concentration and high-sensitivity cardiac troponinI (hs-cTnI) concentration with EDACS. We used a standard smoothing technique on the probability density function for hs-cTn and EDACS and applied bootstrapping to determine the optimal threshold combinations, namely, the combination that maximized the percentage low risk with ≥98.5% sensitivity for MACE. From 2,536 patients, 2,258 presented without an ischemic ECG of whom 272 (12.1%) had a MACE within 30 days. The optimal threshold for hs-cTnI was 7 ng/L combined with an EDACS threshold of 16 (36.8% patients low risk). The optimal thresholds for hs-cTnT were 8ng/L combined with an EDACS threshold of 15 (30.2% patients low risk). Single measurements of both hs-cTnI and hs-cTnT at presentation combined with EDACS to identify over 30% of patients as low risk and therefore eligible for safe early discharge after only one blood draw.

Measurement of serum parathyroid hormone during the early postoperative period as a predictor of clinical hypocalcaemia

Aim – to assess the risk of postoperative hypoparathyroidism and hypocalcaemia depending on the parathyroid hormone (PTH) blood levels in the early postoperative period in patients underwent thyroid surgery of different volume. Materials and methods. The results of serum PTH and ionized calcium (Ca++) levels in 305 patients operated on thyroid gland were analyzed. They included: thyroidectomy for Graves' disease (76 patients), hemithyroidectomy for nodular goiter (12 patients), hemithyroidectomy with lymphadenectomy for suspected cancer (19 patients), thyroidectomy for multinodular goiter (24 patients), thyroidectomy with lymphadenectomy for multinodular goiter, suspected or proven thyroid cancer (174 patients). According to the degree of clinical manifestations of hypocalcaemia, patients were divided into 4 groups: 1 – absence of obvious clinical manifestations, 184 (60.33%), 2 – mild form, 62 (20.33%), 3 – medium severity, 36 (11.8%), 4 – severe form, 23 (7.54%). Results and Discussion. The increase in the degree of clinical manifestations of hypocalcaemia correlated with the decrease in mean level of PTH and Ca++ in serum. Thus, patients of group 1 (184) had an average PTH level of 25.86 pg/ml (range: 14.23 – 51.39 pg/ml), and the mean level of Ca++ blood was 1.16 mmol/l (1.0 – 1.26 mmol/l). Patients of 2 group demonstrated the average level of PTH 12.92 pg/ml (8.12 – 16.36 pg/ml), and the average level of Ca++ 0.98 mmol/l (0.92 – 1.05 mmol/l). Patients of 3 group had average PTH levels of 7.67 pg/ml (4.54 – 11.19 pg/ml), Ca++ 0.84 mmol/l (0.78 – 0.97 mmol/l); and patients with severe form – PTH 3.42 pg/ml (0.2 – 6.38 pg/ml), Ca++ 0.68 mmol/l (0.62 – 0.83 mmol/l). The mean blood levels of PTH and Са++ decrease depending on the degree of clinical manifestations of hypocalcaemia. With an increase in the volume of surgical intervention, the number of cases of iatrogenic hypoparathyroidism and hypocalcaemia increased: hemithyroidectomy with lymphadenectomy resulted with hypocalcaemia in 4 patients (21.05%), thyroidectomy for multinodular goiter – in 8 (33.3%), thyroidectomy with lymphadenectomy – in 73 (41.95%), and thyroidectomy for Graves' disease – in 36 cases (47.36%). All patients of group 1 (184 patients) who had no clinical manifestations of hypoparathyroidism demonstrated PTH at lower border of normal figures (14.23 pg/ml and higher), and were candidates for safe early discharge from the hospital (2-3 day). Conclusions. Measurement of PTH level in the early postoperative period helps to identify patients with a high risk of postoperative hypoparathyroidism. The more than 15 pg/ml level of PTH in such patients allows to exclude the development of hypocalcaemia and shorten the patient's stay in the hospital, contributes to safe discharge.

A prospective study on parathyroid hormone levels in detecting early hypocalcemia after total thyroidectomy

Background: Hypoparathyroidism and the resultant hypocalcaemia is a major cause of postoperative morbidity after total thyroidectomy with the incidence varying from 1% to 71%. This study aims to determine the incidence of parathyroid hormone deficiency as an earliest indicator for detecting hypocalcemia following total thyroidectomy.Methods: A prospective study was carried out among 50 subjects attending Department of Surgery, K. R. Hospital, Mysuru over a period of 12 months. Subjects of either sex undergoing total thyroidectomy had their serum parathyroid hormone levels tested at 1, 4, 12 and 24 hours after surgery were included in the study. Patients with poor compliance, calcium supplementation prior to surgery, coexisting parathyroid or renal pathology were excluded from the study. Descriptive statistics and Pearson correlation coefficients were used to analyse the results.Results: Among 50 study subjects, Hypocalcemia developed in 3 subjects (6%) 24 hours after thyroidectomy showing a sensitivity, specificity, negative and positive predictive value of 91%, 100%, 98% and 96% respectively.Conclusions: Parathyroid hormone levels in postoperative total thyroidectomy is an earliest indicator to detect symptomatic hypocalcemia subjects 24 hours after surgery, which prompts early administration of oral calcium replacement therapy in high risk subjects and potential safe early discharge post-operatively.

A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients.

Guidelines recommend a 0-hour/1-hour high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There are, however, little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0-hour/1-hour hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and electrocardiogram (ECG) for ruling out major adverse cardiac events (MACE) within 30 days. This prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians' assessments of the ECG, and 0- and 1-hour hs-cTnT were collected. Thirty-day MACE was defined as acute myocardial infarction (AMI), unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause. A total of 1,020 patients were included in the final analysis. The combination of an adapted TIMI score ≤1, a nonischemic ECG, and either a 0-hour hs-cTnT<5 ng/L or a 0-hour hs-cTnT<12 ng/L combined with a 1-hour increase<3 ng/L identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% (95% confidence interval [CI]= 98.3%-99.9%) and a negative likelihood ratio of 0.04 (95% CI= 0.01-0.14) for 30-day MACE. The ADP missed only two patients with UA and no patients with AMI or other forms of MACE. An ADP using the guideline recommended 0-hour/1-hour hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.

The Standardized Postoperative Checklist for Bariatric Surgery; a Tool for Safe Early Discharge?

Morbidly obese patients are at higher risk of complications after surgery. In bariatric surgery, pre- and intra-operative checklists are commonly used to identify high-risk patients preoperatively, to decrease the number of postoperative complications. This pilot study evaluates the effect of a postoperative checklist in bariatric surgery, addressing regularly measured parameters, on the occurrence and early recognition of complications. An in-house developed postoperative checklist was used on the first postoperative day after bariatric surgery and included information on nausea, pain, temperature, heart rate, and laboratory markers. Complications were scored using the Clavien-Dindo (CD) classification, and three groups were formed: no complications (CD0), minor complications (CD1 and 2), and major complications (≥CD3a). Differences between groups were analyzed using nonparametric tests. Six hundred ninety-four subjects were included (79.5% female, age 42.6±10.8years, BMI 43.8±5.8kg/m2). Twenty-nine subjects developed major complications within 30days postoperatively. There were no significant differences in baseline characteristics between groups. Subjects with major complications were less willing to be discharged due to complaints, compared to subjects with no or minor complications (14.8 vs. 3.6 and 4.6%, respectively) and had a higher decrease of hemoglobin level (0.8 vs. 0.6 and 0.65mmol/l, respectively). The patient's willingness for discharge, in combination with hemoglobin decrease, may be the best early predictors of major complications after bariatric surgery. This postoperative checklist may be an adequate instrument to identify patients who can be safely discharged home on the first postoperative day and thereby play a part in patient management after bariatric surgery.

Identifying Low-risk Patients for Early Discharge From Emergency Department Without Using Subjective Descriptions of Chest Pain: Insights From Providing Rapid Out of Hospital Acute Cardiovascular Treatment (PROACT) 3 and 4 Trials.

Several accelerated diagnostic protocols (ADPs) have been developed to allow emergency department (ED) physicians to identify appropriate patients for safe early discharge after presentation with symptom of chest pain. Most ADPs require chest pain to be described and modify the algorithm based on the subjective chest pain characteristics. We investigated the performance of three established major ADPs simplified by eliminating the need for chest pain as a descriptor. We pooled patients from PROACT-3 and -4 trials, in which patients presenting to emergency medical services with chest pain or dyspnea were enrolled. The simplified Vancouver Chest Pain Rule (sVCPR), the simplified Emergency Department Assessment of Chest Pain Score (sEDACS) ADP and the Accelerated Diagnostic protocol to Assess Patients with chest pain using contemporary troponins as the only biomarker (ADAPT-ADP) were compared using the sensitivity, specificity, and positive and negative predictive values (NPV). The primary outcome of interest was 30-day major adverse cardiac events (MACE); the diagnosis of acute coronary syndrome (ACS) occurring within 30 days after ED presentation was also explored. A total of 1,081 patients were included (median age= 67 years, 53% male, median GRACE score= 113) of which 222 ACS diagnoses and 150 cardiac events occurred within 30 days after index ED presentation. The sVCPR, sEDACS≥3, and ADAPT-ADP, respectively, identified 9.7, 13.3, and 4.1% of patients as low risk with a sensitivity and NPV of 100% for the primary outcome of 30-day MACE. The sEDACS-ADP identified 24.2% of patients as low risk with a cut-point score of 4 (sensitivity of 98.0% and NPV of 98.8%). The sVCPR, sEDACS≥3, and ADAPT-ADP, respectively, had NPVs of 98.1, 95.8, and 93.3% in identifying patients at higher risk of ACS diagnosis within 30 days after index ED visit. The diagnostic protocols performed well without their chest pain characteristics component. Further studies are suggested to explore the performance of ADPs when these simplified ADPs are combined with high-sensitive troponin assays.

Freeing Up Pediatric Hospital Beds During a Large-Scale Disaster

Reverse triage, in which inpatients are discharged early based on risk stratification in order to open bed space during a large-scale disaster, has been studied only in the adult setting. Using a retrospective cohort design, researchers assessed eligibility for safe early discharge among 501 randomly sampled pediatric inpatients in one children's medical center during 196 mock disaster days. Multiple units (medical, surgical, intensive care, …

Selective Prophylactic Calcium Supplementation reduces Length of Stay after Total Thyroidectomy

ABSTRACT Introduction Hypocalcemia is a common complication of thyroidectomy. We aimed to assess compliance with a targeted calcium and calcitriol supplementation protocol and hypothesized that it would allow safe early discharge without an increase in readmissions. Materials and methods In 2009, we instituted a targeted early postoperative calcium and calcitriol supplementation protocol based on postoperative parathyroid hormone (PTH). We retrospectively reviewed all patients who had a total or completion thyroidectomy over a 4-year period prior to protocol implementation (group I: 2005—2008) and over a 5-year period after protocol implementation (group II: 2010—2014), as well as all patients operated on in the private setting with the senior author over a 1-year period (group III: 2013). Endpoints for analysis were clinically significant hypocalcemia, protocol compliance, hospital length of stay (LOS), and readmission for hypocalcemia. Results Compliance with the protocol was high; however, the accuracy of supplementation prescription was significantly lower in group II than in group III (p &lt; 0.0001). Mean corrected calcium on postoperative day 1 was significantly higher in groups II (2.29 mmol/L) and III (2.27 mmol/L) compared with group I (2.15 mmol/L; p &lt; 0.0001). Forty (30.5%) patients had clinically significant hypocalcemia in group I, compared with 21 (10.8%) in group II, and 2 (3.3%) in group III (p &lt; 0.0001). The LOS was significantly decreased after protocol introduction (p &lt; 0.0001). Conclusion Selective prophylactic calcium supplementation reduces LOS after total thyroidectomy. Clinical significance Introducing a new management protocol in the public hospital system poses challenges with compliance; however, it was successful in lowering rates of symptomatic hypocalcemia and LOS without an increase in the readmission rate. How to cite this article Osborne J, Papachristos A, Skandarajah A, Gorelik A, Hng D, Miller J. Selective Prophylactic Calcium Supplementation reduces Length of Stay after Total Thyroidectomy. World J Endoc Surg 2017;9(3):88-93.

Identifying patients for safe early hospital discharge following st elevation myocardial infarction.

To examine whether the CADILLAC risk score is an effective method of patient stratification for early discharge following ST elevation myocardial infarction (STEMI). Patients with STEMI are typically hospitalized to monitor for serious complications such as arrhythmias, heart failure, and reinfarction. Optimal length of stay is unclear. Whether low risk patients can be safely discharged before 72 hr of hospitalization is unclear. Patients with STEMI who underwent successful PCI were retrospectively stratified using CADILLAC risk score to low risk (n = 123) and intermediate to high risk (n = 105). The primary outcome was adverse clinical events at day 3 or later. Secondary outcomes were adverse clinical events on day 1 and mortality rates at 30 days and 31 to 365 days. Low risk patients had lower major adverse clinical events at day 3 or later (0 vs. 11.4%, P = 0.0002) and lower total mortality at 1 year (0 vs. 4.8%, P = 0.02) than patients with intermediate to high risk. Low risk patients were also less likely to have a cardiovascular event during the first 24 hr when compared to those with an intermediate to high risk score (3.3% vs. 13.3%, P = 0.006). Low risk patients identified using CADILLAC risk score with STEMI treated successfully with primary PCI have a low adverse event rate on the third day or later of hospitalization suggesting that an earlier discharge is safe in properly selected patients. Monitoring in a noncritical care setting following primary PCI for STEMI may be feasible for selected patients. © 2016 Wiley Periodicals, Inc.

Out-of-hours exercise treadmill testing reduces length of hospital stay for chest pain admissions.

The objective was to examine the impact of out-of-hours exercise treadmill tests (ETTs) on length of hospital stay (LOS) for patients admitted to a chest pain assessment unit with symptoms suggestive of acute coronary syndrome. Prospective observational study with 30-day follow-up of low-to-intermediate-risk chest pain patients undergoing out-of-hours ETT. Eligible patients had a nonischemic ECG, normal 6-12-h ST-segment monitoring, a negative 12-h troponin T assay, and no contraindications to exercise. Observed LOS was compared to expected LOS in the absence of out-of-hours ETT, using Wilcoxon rank-sum test. Estimated bed day savings and major adverse events at 30 days after discharge were examined. Four hundred and twenty-two patients with a mean age of 52 years (SD 13 years, 25-83 years) were evaluated. Fifty-two per cent (n = 221) were men; 66% (n = 279) had one or less cardiovascular risk factors; and 79% (n = 334) of the patients presented on a Friday or Saturday. ETT was performed on a weekend day in 86% (n = 363) of the patients, facilitating same-day discharges in 71% (n = 300). The median LOS (interquartile range) was 1 day (1, 2 days) for patients assessed with out-of-hours ETT. The expected median LOS (IQR) was 3 days (2, 4 days) (P < 0.05) in the absence of out-of-hours ETT. Each out-of-hours ETT was estimated to save a mean (SD, range) of 1.6 (0.6, 1-4) bed days. Thirty-day mortality and readmission rates were 0 and 0.2% (1 of 422), respectively. The availability of out-of-hours ETT facilitates safe early discharge and reduced LOS for low-to-moderate-risk patients admitted with symptoms of acute coronary syndrome.

Diagnostic Accuracy of Inflammatory Markers As Early Predictors of Infection After Elective Colorectal Surgery: Results From the IMACORS Study.

Intra-abdominal infections are frequent and life-threatening complications after colorectal surgery. An early detection could diminish their clinical impact and permit safe early discharge. This study aimed to find the most accurate marker for the detection of postoperative intra-abdominal infection and the appropriate moment to measure it. A prospective, observational study was conducted in 3 centers. Consecutive patients undergoing elective colorectal surgery with anastomosis were included. C-reactive protein and procalcitonin were measured daily until the fourth postoperative day. Postoperative infections were recorded according to the definitions of the Centres for Diseases Control. The areas under the receiver operating characteristic curve were analyzed and compared to assess the diagnostic accuracy of each marker. Five-hundred and one patients were analyzed. The incidence of intra-abdominal infection was 11.8%, with 24.6% of patients presenting at least one infectious complication. Overall mortality was 1.2%. At the fourth postoperative day, C-reactive protein was more discriminating than procalcitonin for the detection of intra-abdominal infection (areas under the ROC curve: 0.775 vs 0.689, respectively, P = 0.03). Procalcitonin levels showed wide dispersion. For the detection of all infectious complications, C-reactive protein was also significantly more accurate than procalcitonin on the fourth postoperative day (areas under the ROC curve: 0.783 vs 0.671, P = 0.0002). C-reactive protein is more accurate than procalcitonin for the detection of infectious complications and should be systematically measured at the fourth postoperative day. It is a useful tool to ensure a safe early discharge after elective colorectal surgery.

A clinical decisions unit improves emergency general surgery care delivery

Purpose – Early access to senior decision makers and investigations has improved outcomes for many conditions. A surgical clinical decisions unit (CDU) was created to allow rapid assessment and investigation by on-call senior surgical team members to facilitate decision making and, if appropriate, discharge within a set time frame (less than four hours). The purpose of this paper is to compare outcomes for unscheduled general surgery admissions to the hospital before and after commissioning this unit. Design/methodology/approach – Prospectively collected hospital episode statistics data were compared for all general surgical admissions for one year prior to (July 2010-June 2011) and two years after (July 2011-June 2013) the introduction of the CDU. Statistical analysis using the Mann Whitney U-test was performed. Findings – More patients were discharged within 24 hours (12 per cent vs 20 per cent, p &lt; 0.001) and total hospital stay decreased (4.6 days vs 3.2 days, p &lt; 0.001) following introduction of CDU. Admission via A &amp; E (273 vs 212, p &lt; 0.01) was also decreased. Overall there was a 25.3 per cent reduction in emergency surgical admissions. No difference was noted in 30-day readmission rates (47 vs 49, p=0.29). Originality/value – The introduction of a CDU in has increased early discharge rates and facilitated safe early discharge, reducing overall hospital stay for unscheduled general surgical admissions. This has decreased fixed bed costs and improved patient flow by decreasing surgical care episodes routed through the emergency department (ED). In all, 30-day readmission rates have not been influenced by shorter hospital stay. Service redesign involving early senior decision making and patient investigation increases efficiency and patient satisfaction within unscheduled general surgical care. Not original but significant in that the model has not been widely implemented and this is a useful addition to the literature.

Applicability of the Zwolle risk score for safe early discharge after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction

Introduction and AimThe optimal length of stay for patients with uncomplicated ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) is still undetermined. The Zwolle risk score (ZRS) is a simple tool designed to identify patients who can be safely discharged within 72 hours. The purpose of this study was to assess the applicability and performance of the ZRS in our population. MethodsWe studied 276 consecutive patients (mean age 62±14 years, 75% male, 20% Killip class >1) admitted over a two-year period for STEMI and treated with PPCI. ZRS, length of stay, 30-day mortality and readmission were obtained for all patients. Low risk was defined as ZRS ≤3. ResultsThe median ZRS was 3 (interquartile range [IQR] 1–4), with 171 patients (62%) being classified as low risk. Thirty-day mortality was 4.7% (13 patients). Compared to other patients, low-risk patients had shorter length of stay (median 5.0 [IQR 4–7] vs. 7.0 [5–13] days, p<0.001), and lower 30-day mortality (0 vs. 12.4%, p<0.001), yielding a negative predictive value of 100% (95% CI 97.0–100%) for the proposed cutoff. The ZRS showed excellent discriminative power (C-statistic: 0.937, 95% CI 0.906–0.968, p<0.001), and good calibration against the original cohort. ConclusionsThe ZRS appears to perform well in identifying low-risk STEMI patients who could be safely discharged within 72 hours of admission. Using the ZRS in our population could result in a more rational use of in-patient resources.

Applicability of the Zwolle risk score for safe early discharge after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction

Introduction and AimThe optimal length of stay for patients with uncomplicated ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) is still undetermined. The Zwolle risk score (ZRS) is a simple tool designed to identify patients who can be safely discharged within 72 hours. The purpose of this study was to assess the applicability and performance of the ZRS in our population. MethodsWe studied 276 consecutive patients (mean age 62±14 years, 75% male, 20% Killip class >1) admitted over a two-year period for STEMI and treated with PPCI. ZRS, length of stay, 30-day mortality and readmission were obtained for all patients. Low risk was defined as ZRS ≤3. ResultsThe median ZRS was 3 (interquartile range [IQR] 1–4), with 171 patients (62%) being classified as low risk. Thirty-day mortality was 4.7% (13 patients). Compared to other patients, low-risk patients had shorter length of stay (median 5.0 [IQR 4–7] vs. 7.0 [5–13] days, p<0.001), and lower 30-day mortality (0 vs. 12.4%, p<0.001), yielding a negative predictive value of 100% (95% CI 97.0–100%) for the proposed cutoff. The ZRS showed excellent discriminative power (C-statistic: 0.937, 95% CI 0.906–0.968, p<0.001), and good calibration against the original cohort. ConclusionsThe ZRS appears to perform well in identifying low-risk STEMI patients who could be safely discharged within 72 hours of admission. Using the ZRS in our population could result in a more rational use of in-patient resources.

Hypocalcaemia after total thyroidectomy: Could intact parathyroid hormone be a predictive factor for transient postoperative hypocalcemia?

Hypocalcemia, the most common complication of thyroidectomy, is a transient condition in up to 27% of patients and a permanent condition approximately 1% of patients. The aim of this prospective study was to evaluate reliability of postoperative intact parathyroid hormone (iPTH) assessment for predicting clinically relevant postthyroidectomy hypocalcemia for a safe early discharge of patients with no overtreatment. Seventy-five consecutive patients (age 51 ± 13 years [mean ± SD]) undergoing total or completion thyroidectomy with no concomitant parathyroid diseases or renal failure were included in the present study. Serum iPTH level was determined before and 2 hours after thyroidectomy. Serum calcium concentration was determined 1 day before and 2 days postoperatively. The occurrence of postoperative hypocalcemia was correlated both with the absolute and relative iPTH decrease, determined as a ratio of the preoperative value (P < .0001). There was a greater difference in relative decrease in iPTH between patients remaining normocalcemic and those with hypocalcemia present on the second postoperative day. Hypocalcemic patients on the second postoperative day had a 62% relative decrease in iPTH 2 hours after thyroidectomy. The relative decrease in serum iPTH was greater in patients with hypocalcemia arising on the second postoperative day rather than in patients who remained normocalcemic. The relative decrease in iPTH determined 2 hours after total thyroidectomy together with the serum calcium concentration 24 hours after thyroidectomy proved to be useful predictors of sustained hypocalcemia and might change the clinical management of patients after thyroid surgery to support a longer hospitalization in these selected patients.

C-reactive protein and procalcitonin predict anastomotic leaks following colorectal cancer resections - a prospective study.

IntroductionEarly safe discharge is paramount for the success of ERAS following colorectal cancer resections. Anastomotic leakage (AL) has high morbidity, particularly if the patient has been discharged to the community.AimTo evaluate whether C-reactive protein (CRP) and procalcitonin (PCT) can predict AL before early discharge.Material and methodsFifty-five consecutive patients undergoing open and robotic colorectal cancer resections were included. C-reactive protein and PCT were measured pre-operatively, 8 h after incision, and on the first and third postoperative day. Thirty-day readmissions, re-operations and mortality were recorded.ResultsTwenty-nine patients underwent robotic and the remainder open (n = 26) resections. Five patients had AL. The mean CRP and PCT increased on postoperative day 1 (POD 1) and POD 3 in all patients. On POD 3, mean CRP was 114 mg/l in non-AL patients and 321 mg/l in AL patients (p = 0.0001). Mean PCT on POD 3 was 0.56 ng/ml in the non-AL group and 10.4 ng/ml in AL patients (p = 0.017). On analysis of ROC and AUC curves, the cut-off for CRP on POD 3 was 245.64 mg/l, with 100% sensitivity and 98% specificity for AL. The cut-off for PCT on POD 3 was 3.83 ng/ml, with 75% sensitivity and 100% specificity for AL.ConclusionsC-reactive protein and PCT measurement on POD 3 following colorectal cancer resection can positively identify patients at low risk of anastomotic leakage.