Shorter Length Of Stay Research Articles

Causes and length of stay of readmission among individuals with traumatic spinal cord injury: a prospective observational cohort study

BackgroundSecondary conditions may reduce function and participation in individuals with chronic Spinal Cord Injury (SCI). The knowledge of reasons for readmission to the hospital may be enlightening to prevent them and remodel the health services.Study designMulticenter prospective observational study of all consecutive readmissions of persons with SCI after rehabilitation completion.ObjectivesTo explore the characteristics of individuals with SCI readmitted to the hospital, the reasons for readmissions and the burden on hospitalization in terms of length of stay (LoS) for different conditions.Setting31 Italian specialized SCI centers.MethodsData on people with traumatic SCI readmitted to SCI centers were recorded about: age, sex, SCI level and severity group, geographical origin, readmission causes, clinical interventions during hospitalization, LoS and discharge destination. Linear and multiple logistic regression analyses were performed considering LoS (days) as dependent variable for correlations with independent variables. All tests were two-sided.ResultsAmong 1039 persons with traumatic SCI enrolled (mean age 46, males 85%, tetraplegia 43%), 59.09% of the readmissions were caused by urological problems, 39.74% by pressure injury and 35.41% by spasticity (68% readmitted for ≥2 causes, associated with longer LoS). The mean LoS was 48 days: pressure injury, rehabilitative needs, sexual, bowel, and pain problems were associated with longer and urological problems with shorter LoS. People from the South of the country were frequently (68%) readmitted to the northern centers.ConclusionsUrological problems, pressure injury and spasticity were the most frequent causes of re-hospitalization in individuals with traumatic SCI. The migration trend seeking SCI-specific treatments suggests geographic areas to which health care organizations need to pay more attention.

Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge

BackgroundWhile acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge. MethodsWe reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway (“ED cohort”) and admitted to the hospital (“admission cohort”), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge. ResultsOf 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001). ConclusionsAfter appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.

Short-term difference only in reported outcomes (PROMs) after anterior or posterior approach to total hip arthroplasty: a 4-year prospective multi-centre observational study

BackgroundThe direct anterior approach (DAA) in total hip arthroplasty (THA) may demonstrate better functional recovery compared to the posterior approach (PA).MethodsIn this prospective multi-centre study, patient-related outcome measures (PROMs) and length of stay (LOS) were compared between DAA and PA THA patients. The Oxford Hip Score (OHS), EQ-5D-5L, pain and satisfaction scores were collected at four perioperative stages.Results337 DAA and 187 PA THAs were included. The OHS PROM was significantly better in the DAA group at 6 weeks post-operatively (OHS: 33 vs. 30, p = 0.02, EQ-5D-5L: 80 vs. 75, p = 0.03), but there were no differences at 6 months and at 1 year. EQ-5D-5L scores were similar between both groups at all time points. LOS as inpatient was significantly different, in favour of DAA [median 2 days (IQR 2–3) vs. PA 3 (IQR 2–4), p ≤ 0.0001].ConclusionsPatients undergoing DAA THA have shorter LOS and report better short-term Oxford Hip Score PROMs at 6 weeks, but DAA did not convey long-term benefits over PA THA.

In meeting the increasing demands for total knee arthroplasty, can we achieve high levels of quality care in a small community hospital? A mixed-methods study.

Small community hospitals (SCHs) help meet the demand for total knee arthroplasty (TKA). This mixed-methods study compares outcomes and analyses of environmental differences following TKA at a SCH and a tertiary care hospital (TCH). Quantitative: A retrospective review of 352 propensity-matched primary TKA procedures at both a SCH and a TCH, based on age, body mass index, and American Society of Anesthesiologists class, was completed. Groups were compared by length of stay (LOS), 90-day emergency department visits, 90-day readmissions, reoperations, and mortality. Qualitative: Based on the Theoretical Domains Framework, seven prospective semistructured interviews were performed. Interview transcripts were coded and belief statements were generated and summarized by two reviewers. Discrepancies were resolved by a third reviewer. Quantitative: The average LOS for the SCH was significantly shorter than that for the TCH (2.0 ± 0.2 vs. 3.6 ± 2.7 days; p < 0.001), a difference that persisted following a subgroup analysis of ASA I/II patients (2.0 ± 0.2 vs. 3.2 ± 2.2; p < 0.001). There were no significant differences in other outcomes. Qualitative: The main themes that revolved around a higher case load for physiotherapy at the TCH resulted in patients waiting longer to be mobilized after surgery. Patient disposition also affected their discharge rates. Given the increasing demand for TKA, the SCH represents a viable option to increase capacity, while reducing LOS. Future directions to reduce LOS include addressing social barriers to discharge and patient prioritization for assessment by allied health services. When TKA is performed by the same set of surgeons, the SCH provides quality care with a shorter LOS and comparable with urban hospitals, and this can be attributed to the differences in resource utilization in the two hospital settings.

Trends and Predictors of Short Length of Stay Following Transcatheter Aortic Valve Replacement

BackgroundMinimalist approaches to Transcatheter aortic valve replacement (TAVR) have allowed for improved efficiency in care of patients. We hypothesized that improved efficiencies in care process may have led to increased adoption of a one night length of stay (LOS) in this patient group. ObjectivesThe authors aimed to study temporal trends in short length of stay following TAVR. MethodsThis is a nationwide temporal trends study using the 2016–2019 National In Patient Sample (NIS) registry. Short stay was defined as LOS of one night or less. Trends in proportion of patients with short stay were obtained. A multivariate model to identify predictors of short stay was built after adjusting for confounders. Secondary analysis of temporal trends was stratified by presence or absence of major complications (major bleeding requiring transfusion or pacemaker implantation [PPMI]). ResultsA total of 217,110 patients were included in the weighted sample. The proportion of patients with short stay significantly increased for those with and without complications (Ptrend < 0.001). The morbidity burden, as defined by the proportion of patients with a Charlson comorbidity index (CCI) score of ≥2 and rate of major complications decreased significantly. On multivariate analysis short stay was predicted by male sex, white ethnicity, Southern/Western regions and lower CCI score. Patients with major bleeding requiring transfusion or PPMI were less likely to have short stay (aOR 0.23 and aOR 0.12, p < 0.001 respectively). ConclusionThere is a national trend towards shorter LOS following TAVR. There is a decrease in major post procedural complication rates from 2016 to 2019.

Simultaneous bladder augmentation and artificial urinary sphincter placement in children with neuropathic urinary incontinence. Is it safe to perform? Long-term results

Simultaneous performance of artificial urinary sphincter (AUS) placement and bladder augmentation (BA) in patients with neuropathic bladder is currently controversial. The aim of this study is to describe our very long-term results after a median follow-up of 17 years. A retrospective single-center case-control study was performed in patients with neuropathic bladder treated in our institution between 1994 and 2020, in whom AUS placement and BA were performed simultaneously (SIM group) or sequentially at different times (SEQ group). Demographic variables, hospital length of stay (LOS), long-term outcomes and postoperative complications were compared between both groups. A total of 39 patients (21 males, 18 females) were included, with a median age of 14.3 years. BA and AUS were performed simultaneously at the same intervention in 27 patients, and sequentially in different interventions in 12 cases, with a median of 18 months between both surgeries. No demographics differences were observed. SIM group had a shorter median LOS when compared to SEQ group, considering the two sequential procedures (10 vs. 15 days; p=0.032). Median follow-up was 17.2 years (interquartile range 10.3-23.9). Four postoperative complications were reported, 3 patients in SIM group and 1 case in SEQ group, with no statistically significant differences between them (p=0.758). Adequate urinary continence was achieved in more than 90% of patients in both groups. There are scarce recent studies comparing the combined performance of simultaneous or sequential AUS and BA in children with neuropathic bladder. The results of our study show a much lower postoperative infection rate than previously reported in the literature. It is a single-center analysis with a relatively small sample of patients although it is among the largest series published so far, and presents the longest long-term follow-up with more than 17 years of median follow-up time. Simultaneous BA and AUS placement appears safe and efficacious in children with neuropathic bladder, with shorter LOS and no differences in postoperative complications or long-term outcomes when compared to performing the two procedures sequentially at different times.

Outcomes of a Colorectal Enhanced Recovery After Surgery Protocol Modified for a Diverse and Urban Community

IntroductionEnhanced recovery after surgery (ERAS) colorectal programs have been shown to improve the length of stay (LOS) without increasing hospital resource utilization at academic centers worldwide. A multidisciplinary ERAS protocol that includes preoperative, intraoperative, and postoperative management guidelines was recently implemented at our urban, racially diverse, and academically affiliated community hospital. A delivery option was provided to reduce barriers to care. Given our unique patient population, the objective of our study was to determine if improvements in outcomes were reproducible in our hospital. MethodsThis is a retrospective study of patients undergoing elective colectomy at New York-Presbyterian Queens Hospital between January 1, 2015, and December 31, 2020. Patient outcomes were compared between surgeries performed under standard practice (all colectomies prior to April 2017) and those performed after the implementation of the ERAS protocol. Demographic and perioperative data were abstracted from a prospectively derived database used to submit data to the National Surgical Quality Improvement Program. Additional data were obtained from chart review. ResultsSix hundred five elective colectomies were performed by 12 surgeons (range 1-228 cases) during the study period. Of these, 22 were performed open (41% followed ERAS), 467 were performed laparoscopically (57% followed ERAS), and 116 were performed robotically (74% followed ERAS). The average patient age was 64 y. Of which, 55% were male; 34% were Asian, 27% were non-Hispanic Caucasian, 27% were Hispanic, and 11% were Black or African American (all P-values > 0.05 for ERAS versus non-ERAS). Average duration of procedure was longer in the ERAS group (262 min versus 243 min, P = 0.04), although when stratified by procedure type, this relationship held true only for laparoscopic procedures. Hospital LOS was significantly shorter in the ERAS group (4.3 versus 5.4 d, P < 0.001) and this relationship held true for procedures performed both laparoscopically (4.2 versus 5.3 d, P = 0.01) and robotically (4.1 versus 5.1 d, P = 0.04). Of the ERAS group, patients who opted for delivery of ERAS components (n = 205) had the shortest LOS when compared to patients who picked up components (n = 91) or opted out of ERAS (n = 309) (4.1 versus 4.4 versus 5.2 d, P = 0.003). No significant differences were found for 30-d mortality, 30-d readmission, wound infection, or other postoperative complications (all P-values > 0.05). ConclusionsImplementation of an ERAS protocol in an urban, diverse, academically affiliated community hospital is associated with reductions in LOS for colectomies performed both laparoscopically and robotically. Facilitating ERAS compliance with a delivery option was also associated with improvements in hospital LOS. Preoperative nutrition supplementation was not associated with outcomes. No differences in mortality, readmission rates, or rates of postoperative complications were found.

Comparison of outcomes of the extended-view totally extraperitoneal rives-stoppa (eTEP-RS) and the intraperitoneal onlay mesh with defect closure (IPOM-plus) for W1-W2 midline incisional hernia repair-a single-center experience.

The eTEP technique is a new approach that has recently gained popularity in abdominal wall hernia surgery. This study aimed to compare the outcomes of the eTEP-RS and IPOM-plus procedures in W1 and W2 midline incisional abdominal wall hernia (IAWH) repairs performed by the same surgeon. Prospectively collected data of laparoscopic abdominal wall repairs performed on 61 patients with eTEP between November 2018 and April 2022 and on 67 patients with IPOM-plus between January 2016 and April 2022 were retrospectively analyzed. A total of 74 out of 128 patients, 30 in the eTEP-RS group and 44 in the IPOM-plus group, who underwent W1-W2 midline incisional hernia repair were included in the study. The mean follow-up was 24months in the eTEP-RS group and 45months in the IPOM-plus group. There was no statistically significant difference between the groups regarding age, sex, BMI, ASA score, or active smoking. No difference was seen between the two groups in terms of the mean defect area (MDA, 28.17cm2 vs. 27.41cm2, p = 0.84), but the mean mesh area (MMA) and mesh/defect (M/D) ratio were higher in the eTEP-RS group (404.11cm2 vs. 267.85cm2, p < 0.001 and 20.96 vs. 12.36, p = 0.004). In the eTEP-RS group, the hospital length of stay (LOS) (1.48days vs. 2.58days, p < 0.001) and pain on the first and 10th postoperative days were significantly lower (p < 0.001), while the operative time was significantly longer (204.07min vs. 88.33min, p < 0.001). There was no significant difference in terms of intraoperative complications (p = 0.56), seroma formation (p = 0.83), or recurrence (p = 0.83). The eTEP-RS technique has advantages over the IPOM-plus approach, such as a shorter LOS and less early postoperative pain with W1-W2 midline IAWH repair. However, the eTEP technique has a longer operative time.

Spinal Versus General Anesthesia in Contemporary Revision Total Knee Arthroplasties

BackgroundInterest in spinal anesthesia utilization in revision total knee arthroplasties (TKAs) is rising. This study investigated the pain control, length of stay (LOS), and complications associated with spinal versus general anesthesia in a single institution series of revision TKAs. MethodsWe identified 3,711 revision TKAs (3,495 patients) from 2001 to 2016 using our institutional total joint registry. There were 66% who had general anesthesia and 34% who had spinal anesthesia. Mean age, sex, and BMI were similar between groups at 67 years, 53% women, and 32, respectively. Data were analyzed using inverse probability of treatment weighted models based on propensity scores that accounted for patient and operative factors. Mean follow-up was 6 years (range, 2 to 17). ResultsPatients treated with spinal anesthesia required fewer postoperative oral morphine equivalents (OMEs) (P < .0001) and had lower numeric pain rating scale scores (P < .001). Spinal anesthesia was associated with shorter LOS (4.0 versus 4.6 days; P < .0001), less cases of altered mental status (AMS; Odds Ratio (OR) 2.0, P = .004), less intensive care unit (ICU) admissions (OR 1.6, P = .02), fewer re-revisions (OR 1.7, P < .001), and less reoperations (OR 1.4, P < .001). There was no difference in the incidence of VTE (P = .82), 30-day readmissions (P = .06), or 90-day readmissions (P = .18) between anesthetic techniques. ConclusionWe found that spinal anesthesia for revision TKAs was associated with significantly lower pain scores, reduced OME requirements, and decreased LOS. Furthermore, spinal anesthesia was associated with fewer cases of AMS, ICU admissions, and re-revisions even after accounting for numerous patient and operative factors. Level of EvidenceLevel III, Retrospective Comparative Study.

Identifying Risk Factors for Prolonged Length of Stay in Hospital and Developing Prediction Models for Patients with Cardiac Arrest Receiving Targeted Temperature Management.

Prolonged length of stay (LOS) following targeted temperature management (TTM) administered after cardiac arrest may affect healthcare plans and expenditures. This study identified risk factors for prolonged LOS in patients with cardiac arrest receiving TTM and explored the association between LOS and neurological outcomes after TTM. The retrospective cohort consisted of 571 non-traumatic cardiac arrest patients aged 18 years or older, treated with cardiopulmonary resuscitation (CPR), had a Glasgow Coma Scale score 8, or were unable to comply with commands after the restoration of spontaneous circulation (ROSC), and received TTM less than 12 hours after ROSC. Prolonged LOS was defined as LOS beyond the 75th quartile of the entire cohort. We analyzed and compared relevant variables and neurological outcomes between the patients with and without prolonged LOS and established prediction models for estimating the risk of prolonged LOS. The patients with in-hospital cardiac arrest had a longer LOS than those with out-of-hospital cardiac arrest (p = 0.0001). Duration of CPR (p = 0.02), underlying heart failure (p = 0.001), chronic obstructive pulmonary disease (p = 0.008), chronic kidney disease (p = 0.026), and post-TTM seizures (p = 0.003) were risk factors for prolonged LOS. LOS was associated with survival to hospital discharge, and patients with the lowest and highest Cerebral Performance Category scores at discharge had a shorter LOS. A logistic regression model based on parameters at discharge achieved an area under the curve of 0.840 to 0.896 for prolonged LOS prediction, indicating the favorable performance of this model in predicting LOS in patients receiving TTM. Our study identified clinically relevant risk factors for prolonged LOS following TTM and developed a prediction model that exhibited adequate predictive performance. The findings of this study broaden our understanding regarding factors associated with hospital stay and can be beneficial while making clinical decisions for patients with cardiac arrest who receive TTM.

Anterior cervical discectomy and fusion versus posterior decompression in patients with degenerative cervical myelopathy: a systematic review and meta-analysis.

The optimal surgical approach for patients with multilevel degenerative cervical myelopathy (DCM) remains unknown. This systematic review and meta-analysis sought to compare anterior cervical discectomy and fusion (ACDF) versus posterior decompression (PD) in patients with DCM spanning ≥ 2 levels without ossification of the posterior longitudinal ligament. MEDLINE and PubMed were searched from inception to February 22, 2022. The primary outcomes were Neck Disability Index (NDI), SF-36 Physical Component Summary (PCS), modified Japanese Orthopaedic Association (mJOA) scale, visual analog scale (VAS), and EQ-5D scores. Secondary outcomes were operative bleeding, operative duration, hospital length of stay (LOS), postoperative morbidity (including hematoma, surgical site infection [SSI], CSF leakage, dysphagia, dysphonia, C5 palsy, and fusion failure), mortality, readmission, reoperation, and Cobb angle. Nineteen studies comprising 8340 patients were included, of whom 4118 (49.4%) and 4222 (50.6%) underwent ACDF and PD, respectively. The mean number of involved spinal levels was comparable between the groups (3.1 vs 3.5, p = 0.15). The mean differences (MDs) of the primary outcomes were the mean of each index in the ACDF group minus that of the PD group. At the 1-year follow-up, the MDs of the NDI (-1.67 [95% CI -3.51 to 0.18], p = 0.08), SF-36 PCS (2.48 [95% CI -0.59 to 5.55], p = 0.11), and VAS (-0.32 [95% CI -0.97 to 0.34], p = 0.35) scores were similar between the groups. While the MDs of the mJOA (0.71 [95% CI 0.27 to 1.16], p = 0.002) and EQ-5D (0.04 [95% CI 0.01 to 0.08], p = 0.02) scores were greater in the ACDF group, the differences were not clinically significant given the minimal clinically important differences (MCIDs) of 2 and 0.05 points, respectively. In the ACDF group, the MDs for operative bleeding (-102.77 ml [95% CI -169.23 to -36.30 ml], p = 0.002) and LOS (-1.42 days [95% CI -2.01 to -0.82 days], p < 0.00001) were lower, the dysphagia OR (11.10 [95% CI 5.43-22.67], p < 0.0001) was higher, and the ORs for SSI (0.43 [95% CI 0.24-0.78], p = 0.006) and C5 palsy (0.32 [95% CI 0.15-0.70], p = 0.004) were lower. The other outcomes were similar between the groups. Overall evidence according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was moderate. ACDF and PD are similar regarding functional outcomes. ACDF is beneficial in terms of less bleeding, shorter LOS, and lower odds of SSI and C5 palsy, while the procedure carries higher odds of dysphagia. The authors recommend individualized treatment decision-making.

Enhanced Recovery After Surgery Protocol in Bariatric Surgery Leads to Decreased Complications and Shorter Length of Stay.

Enhanced recovery after surgery (ERAS) programs have been shown in some specialties to improve short-term outcomes following surgical procedures. There is no consensus regarding the optimal perioperative care for bariatric surgical patients. The purpose of this study was to develop a bariatric ERAS protocol and determine whether it improved outcomes following surgery. An IRB-approved prospectively maintained database was retrospectively reviewed for all patients undergoing bariatric surgery from October 2018 to January 2020. Propensity matching was used to compare post-ERAS implementation patients to pre-ERAS implementation. There were 319 patients (87 ERAS, 232 pre-ERAS) who underwent bariatric operations between October 2018 and January 2020. Seventy-nine patients were kept on the ERAS protocol whereas 8 deviated. Patients who deviated from the ERAS protocol had a longer length of stay when compared to patients who completed the protocol. The use of any ERAS protocol (completed or deviated) reduced the odds of complications by 54% and decreased length of stay by 15%. Furthermore, patients who completed the ERAS protocol had an 83% reduction in odds of complications and 31% decrease in length of stay. Similar trends were observed in the matched cohort with 74% reduction in odds of complications and 26% reduction in length of stay when ERAS was used. ERAS protocol decreases complications and reduces length of stay in bariatric patients.

Procedural sedation and analgesia versus nerve blocks for reduction of fractures and dislocations in the emergency department: A systematic review and meta-analysis.

Procedural sedation and analgesia (PSA) and peripheral nerve blocks (NBs) are techniques to manage pain and facilitate reduction of dislocated joints or fractures. However, it is unclear if either approach provides any distinct advantage in the emergency department (ED). The aim of this systematic review is to compare these 2 techniques on pain scores, adverse events, patient satisfaction, and length of stay (LOS) in the ED. We performed an electronic search of MEDLINE, EMBASE, and the Cochrane Library, and references were hand-searched. Randomized controlled trials (RCTs) comparing PSA with NBs for orthopedic reductions in the ED were included. Outcomes of interest included pain scores, adverse events, patient satisfaction, and LOS in the ED. A total of 2 reviewers independently screened abstracts and extracted data into a standardized form. The Cochrane risk-of-bias tool was used to evaluate study quality. The Grading of Recommendation Assessment Development and Evaluation approach was used to assess the certainty and strength of the evidence. Data on pain scores were pooled using a random-effects model and are reported as standardized mean differences (SMDs) with 95% confidence intervals (CIs). A total of 6 RCTs (n=256) were included in a qualitative review, and 4 RCTs (n=101) were included in the meta-analysis. There was no significant difference in pain scores between the PSA and NB groups (P=0.47; SMD, 0.45; 95% CI, -0.78 to 1.69; I2=0.94). There were less adverse events in the NB group (0%-3.3%) compared with the PSA group (0%-20%; n=256). LOS times were consistently shorter in the NB group (n=215). Patient satisfaction was comparable in both groups (n=196). Based on the available evidence, NBs performed by emergency physicians are as effective as PSA in managing pain during orthopedic reductions in the ED. NBs are associated with fewer adverse events and shorter LOS in the ED. The quality of evidence is low.

Operative versus percutaneous drainage with fibrinolysis for complicated pediatric pleural effusions: A nationwide analysis

Management of complicated pleural effusions and empyema using tube thoracostomy with intrapleural fibrinolysis versus surgical drainage has been debated for decades. However, there remains considerable variation in management with these approaches in the pediatric population. This study aims to compare the nationwide outcomes of pediatric patients with complicated pleural effusions. Patients <18 years old with a diagnosis of pleural effusion or empyema associated with pneumonia were identified from the Nationwide Readmissions Database (2016-2018). Demographics, hospital characteristics, and complications were compared among patients undergoing isolated percutaneous drainage (PD), percutaneous drainage with intrapleural fibrinolysis (PDF), or operative drainage (OD) using standard statistical tests. 5424 patients (age 4 [IQR 1-11] years) were identified with a pleural effusion or empyema who underwent percutaneous or surgical intervention. PD (22%) and OD (24%) were utilized more frequently than PDF (3%). Index complications, including bleeding and postprocedural air leak, were similar between groups. Those receiving PDF had lower index length of stay (LOS) and admission costs. Thirty-day and overall readmission rates were highest in patients receiving PD (15% and 24%) and OD (12% and 23%) versus PDF, all p<0.001. Those receiving OD had fewer readmission complications including recurrent effusion or empyema, pneumonia, and bleeding. Overall readmission cost was highest in those receiving PD (p=0.005). In this nationwide cohort, PDF was associated with lower index admission cost, shorter LOS and lower rates of readmissions compared to OD. This knowledge should be used to improve selection of these treatments in this patient population. Retrospective Comparative LEVEL OF EVIDENCE: III.

Underutilization of laparoscopy for ovarian surgeries in the pediatric population: A nationwide analysis

PurposeOophorectomy and ovarian detorsion are some of the most frequent operations performed in the female pediatric population. Despite the advent of laparoscopy, many surgeons continue to utilize open surgical approaches in these patients. This study sought to compare nationwide trends and postoperative outcomes in laparoscopic and open ovarian operations in the pediatric population. MethodsFemales less than 21 years old who underwent ovarian operations (oophorectomy, detorsion, and/or drainage) from 2016 to 2017 were identified from the Nationwide Readmissions Database. Patients were stratified by surgical approach (laparoscopic or open). Hospital characteristics and outcomes were compared using standard statistical tests. ResultsThere were 13,202 females (age 17 [14–20] years) who underwent open (59%) or laparoscopic (41%) ovarian operations. The most common indications for surgery were ovarian mass (48%), cyst (36%), and/or torsion (19%) for which oophorectomy (88%), detorsion (26%), and drainage (13%) were performed most frequently. The open approach was utilized more frequently for oophorectomy (95% vs. 77% laparoscopic) and detorsion (33% vs. 16% laparoscopic), both p < 0.001. A greater proportion of laparoscopic procedures were performed at large (67% vs. 61% open), teaching (82% vs. 76% open) hospitals in patients with private insurance (47% vs. 42% open), all p < 0.001. Patients undergoing open procedures had significantly higher index length of stay (LOS) and rates of wound infections. Thirty-day and overall readmission rates, as well as overall readmission costs, were higher in patients who received open surgeries. ConclusionsDespite fewer overall complications, decreased cost, fewer readmissions, and shorter LOS, laparoscopic approaches are underutilized for pediatric ovarian procedures. Type of StudyRetrospective Comparative. Level of EvidenceLevel III.

Comparative effectiveness of anesthetic technique on outcomes after lumbar spine surgery: a retrospective propensity score-matched analysis of the National Surgical Quality Improvement Program, 2009–2019

BackgroundThe impact of anesthetic technique on spine surgery outcomes is controversial. Using a large national sample of patients, we compared outcomes after lumbar decompression under regional anesthesia (RA: spinal or...

1234 IMPROVING HEART FAILURE MANAGEMENT WITHIN HOSPITAL AT HOME

Abstract Introduction Heart failure (HF) is a common problem managed in our West Lothian multi-disciplinary hospital at home (HaH) service, however significant variation in practice was noted with considerable resource implications. We aimed to standardise and improve this by developing a dedicated protocol. Methods We developed a protocol to guide the assessment and management of HF within HaH. We collected baseline (n=25) and follow-up data (n=10) after protocol introduction from patients referred to HaH with heart failure. Outcomes reviewed included anticipatory care planning (ACP) decisions, length of stay (LOS) and treatment strategy. We held staff education sessions and surveyed staff confidence regarding HF management. Results ACP discussion rates improved after protocol introduction, with decision rates improving for both escalation of care (28% to 80%) and resuscitation (44% to 60%). LOS reduced after protocol introduction (mean 6.3 days to 5.9 days). Titration of oral diuretics alone (71%) was associated with a shorter LOS (mean 5.4 days) compared to IV (29%, mean 8.1 days), with no difference in 28 day outcome. In those with HF with reduced ejection fraction, the rates of beta-blocker prescription increased (57% to 80%) however ACE-inhibitor prescription decreased (29% to 20%). Use of add-on therapy (e.g. thiazide diuretics) increased (12% to 30%) with a decrease in complication rates (12% to 0%). All staff found the protocol helpful with an improvement in confidence levels. Conclusions Through introducing a standardised protocol, we observed an improvement in anticipatory care discussion rates and a trend towards shorter LOS. Oral diuretic titration was less resource intensive without an adverse impact on outcome. Future plans include ongoing education and data collection, trialling a joint multi-disciplinary meeting with cardiology for discussion of complex patients and embedding a treatment strategy of oral diuretic titration with a ‘discharge with planned review' approach in appropriate patients.

Predicting length of stay with assessment of motor and process skills in subjects with acquired brain injury

ABSTRACT Background The Functional Independence Measure (FIM) is a well-established predictor of length of stay (LOS) for rehabilitation. The Assessment of Motor and Process Skills (AMPS) is a more in-depth construct for measuring activities of daily living (ADL) and may therefore be a valuable adjunct when predicting LOS. This paper aimed to investigate AMPS as a candidate predictor of LOS in a statistical model including FIM. Methods A cohort study of 647 patients with acquired brain injuries admitted for rehabilitation. LOS was analyzed in a multiple regression model with the motor and process/cognitive domains of AMPS and FIM. Results Independence in ADL process ability and FIM cognition were associated with 31% (p < 0.001) and 38% (p < 0.001) shorter LOS, respectively, relative to patients needing total assistance. Independence in ADL motor ability was associated with a 26% (p = 0.002) shorter LOS, whereas FIM motor was not a predictor. Conclusions The AMPS predicts LOS for rehabilitation at a level that is at least as good as that of FIM. Conducting the AMPS early in the course of inpatient rehabilitation provides clinicians and managers with valuable information for planning LOS.

Spinal Intradural Extramedullary Tumors: A Retrospective Analysis on Ten-Years' Experience of Minimally Invasive Surgery and a Comparison with the Open Approach.

Spinal intradural extramedullary (ID-EM) tumors are pathologies widely treated through a classical open approach. However, minimally invasive surgery is gaining traction as a comparable treatment option because it carries less morbidity and may reduce healthcare costs.This study aimed to compare the clinical and functional outcomes of open versus minimally invasive approaches for patients with ID-EM tumors. We performed a retrospective analysis on prospectively collected data from patients with ID-EM tumors submitted to surgery. Baseline features and operative variables were compared, including surgery duration and estimated blood loss (EBL). Postoperative data covered tumor histology, length of stay (LOS), complication(s), and neurological status (Medical Research Council (MRC) scale) at the last follow-up.In total, 46 patients were included: 30 (65.2%) operated through an open approach and 16 (34.8%) through a minimally invasive surgical (MIS) approach. The predominant histology type was schwannomas (43.5%). Lesions more frequently affected the lumbar spine (34.8%). The tumor dimensions were similar in both cohorts. The minimally invasive approach was on average 76.7 min faster and correlated positively with less EBL (140 mL less than that of the open approach). Patients in the MIS group had shorter LOSs (5.63 days vs. 17.27 days) and had fewer postoperative complications. No significant difference in functional outcome was found.MIS is as effective as the traditional approach in achieving comparable functional outcomes, with advantages such as shorter surgery durations, less blood loss, and shorter hospital LOSs.

Reduced Time to Procedure for Gastrointestinal Bleeding After Warfarin Reversal With Four-Factor Complex Concentrate as Compared to Plasma.

Bleeding is a serious adverse effect of vitamin K antagonists (VKAs). Anticoagulation reversal is required in some acute cases. This is usually accomplished by plasma transfusion or four-factor prothrombin complex concentrate (4F-PCC). The aim of this study was to gain insight into the clinical course of patients with gastrointestinal (GI) bleeding who require VKA reversal. Medical records were collected from two centers from patients who presented to the emergency department (ED) for GI bleeding and received 4F-PCC or plasma for VKA reversal between January 2015 and December 2020. ED, hospital, intensive care unit (ICU) length of stay (LOS) as well as time from admission to GI procedure were determined. 4F-PCC patients (n = 49) as compared to plasma (n = 63) patients were found to have a greater number of comorbidities (average of 4.2 vs. 2.7 comorbidities/patient) and more ICU admissions (47% vs. 21%). Time to GI procedure was significantly decreased in the 4F-PCC group (median (interquartile range (IQR)) 19.47 (9.23 - 30.25) vs. 27.88 (21.38 - 45.00) h; P = 0.01). When adjusting for comorbidities, differences in time to GI procedures were also significant in favor of 4F-PCC regardless of any comorbidities (P = 0.014), in atrial fibrillation (P = 0.045) and in hypertension (P = 0.02). The 4F-PCC patients had shorter LOS in the ED and ICU. Our study demonstrated that compared to plasma, 4F-PCC was utilized in more acutely ill patients with higher rates of comorbidities and ICU admission. Nevertheless, the patients who received 4F-PCC had faster access to GI procedure and shorter ED and ICU LOS.