Significant Differences In Admission Rates Research Articles

713 Mortality Benefit After Addition of Mid-level Support in Burn Intensive Care Unit

IntroductionBurn Intensive Care Units (BICU)s are resource-heavy and labor-intensive units with very sick patients. The removal of burns as a requirement from the surgical curriculum has decreased the number of rotating surgical trainees, but did not impact patient care needs. Our unit adopted an Advanced Practice Provider (APP) service model in fiscal year 2018 to provide consistent standardized clinical care, with surgical trainees rotating monthly, to mitigate the loss of residents over time. We aimed to critically evaluate the impact of an APP run BICU on mortality and quality improvement initiatives.MethodsPatients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted to the BICU between July 1, 2016 and June 30, 2020 were eligible for inclusion. All central line associated blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTI), ventilator associated pneumonias (VAP) and mortality rates were compared. Demographics, length of stay (LOS), co-morbid conditions and mortality were evaluated. Statistical analysis was performed with Students’ t-test, and chi-squared tests. Significance was accepted as p< 0.05.ResultsThere were no significant differences in admission rates over the study period. The number of CLABSIs significantly decreased each year (15 (2017), 6 (2018), 5 (2019), 3 (2020)). The number of CAUTIs significantly decreased ((13 (2017), 6 (2018), 1 (2019), 3 (2020)). The number of VAPs significantly decreased ((15(2017), 12 (2018), 7 (2019), 3 (2020)). Mortality was unchanged from 2017-2019 but significantly decreased in 2020 ((2.2% (2017), 2.4% (2018), 2.5% (2019), 0.9% (2020)).ConclusionsThere were no significant differences in admission rates over the study period. The number of CLABSIs significantly decreased each year (15 (2017), 6 (2018), 5 (2019), 3 (2020)). The number of CAUTIs significantly decreased ((13 (2017), 6 (2018), 1 (2019), 3 (2020)). The number of VAPs significantly decreased ((15(2017), 12 (2018), 7 (2019), 3 (2020)). Mortality was unchanged from 2017-2019 but significantly decreased in 2020 ((2.2% (2017), 2.4% (2018), 2.5% (2019), 0.9% (2020)).

Utilization of a Pediatric Sickle Cell Day Hospital By Patients with Sickle Cell Disease and Pain Events Is Associated with a Lower Rate of Inpatient Hospital Admission Compared to Utilization of the Pediatric Emergency Department

Introduction:Vaso-occlusive crisis (VOC) is a leading cause of morbidity in children with sickle cell disease (SCD) and is the most common reason for hospitalization. Frequent and prolonged hospitalization is a risk factor for development of acute chest syndrome and increased mortality, and also leads to decreases in school attendance and quality of life measures. Furthermore, inpatient care accounts for a large proportion of total disease-related costs.A sickle cell day hospital (DH) is an outpatient facility with several beds, staffed by hematology/oncology trained attending physicians, fellows, nurse practitioners and bedside nurses, all with expertise in caring for patients with SCD. The concept of the DH as an alternative to the emergency department (ED) for treatment of VOC has been explored in adults, with evidence for reduced hospitalization rate, superior pain relief and significant cost-savings. In pediatrics, there is limited data on the utility of a DH for VOC management.We hypothesize that pediatric patients with SCD presenting to our institution with acute VOC who are managed in the DH will have a lower rate of inpatient admission than those managed in the ED.Methods:We performed a retrospective chart review of children aged 4 to 21 years with HbSS, HbSC, HbSβ0- or β+- thalassemia who received initial treatment for uncomplicated VOC with IV opioids in the DH or ED at the Children's Hospital at Montefiore during three consecutive calendar years. Patients were excluded if they had any of the following at the time of presentation: pain score < 7, temperature > 38.0°C, decrease in oxygen saturation >2% below baseline or <92% on room air, new chest x-ray infiltrate, headache or other neurological symptoms, or evidence of splenic sequestration. Patients selected for the ED cohort were limited to those who presented during the hours when the DH was open. Additionally, patients transferred from the DH to the ED or vice versa at any time during the visit were excluded. We abstracted data from the charts of 60 unique patients for each site to allow for assessment of our primary outcome of need for inpatient admission at the time of initial visit, as well as secondary outcomes including time to initial and rescue doses of opioid analgesic. The study was approved by the Institutional Review Board at Montefiore Medical Center.Results:Data from 56 DH and 55 ED patients have been analyzed to date. In general, the cohorts had similar demographics, sickle cell disease status, and pain scores (Table 1), except for younger age in the DH cohort (median 12 years vs 13 years, p = 0.012). Patients who presented to the DH were significantly less likely to be admitted than patients who presented to the ED, with admission rates of 41.1% and 67.3%, respectively (p= 0.008) (Fig 1A). Admitted patients from each setting were further stratified by pain score at presentation (Fig 1B) and by hydroxyurea (HU) status as a surrogate marker of disease severity (Fig 1C). In patients with an initial pain score of 10, there was no significant difference in admission rate based on treatment location (DH 56% vs ED 72.7%, p= 0.362). In contrast, patients with an initial pain score of 7-9 were significantly less likely to be admitted from the DH than from the ED (29% vs 63.6%, p= 0.007). DH-managed patients were significantly less likely to be admitted regardless of HU status compared to ED-managed patients (on HU: 44.8% vs 77.8%, p= 0.036; not on HU: 37% vs 78.4%, p= 0.002).Secondary analyses showed a significant difference between the DH and ED in the median time to initial (Fig 2A) and rescue (Fig 2C) opioid doses (initial: 65 mins vs 76 mins, p= 0.044; rescue: 45 mins vs 123 mins, p < 0.001). This comparison was further stratified based on pain score at presentation, and demonstrated significantly longer median time to initial dose of opioid in the ED for those patients with initial pain score of 7-9 (78 mins vs 93 mins, p= 0.032 - Fig 2B), but no significant difference for those with initial pain score of 10. Time to rescue dose of opioid was significantly longer for patients seen in the ED, regardless of pain score (pain 7-9: median 43 mins vs 125 mins, p < 0.001; pain 10: median 65 mins vs 120 mins p= 0.006 - Fig 2D).Conclusions:A dedicated pediatric sickle cell day hospital is an effective setting for the management of uncomplicated acute VOC. Treatment in this setting is associated with decreased rates of inpatient admission and faster administration of appropriate analgesics. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Are Backyard Waterslides as Dangerous as Public Waterslides: A Review of 1,823 Head and Neck Injuries.

The purpose of this study was to describe the characteristics and compare the severity of head and neck injuries between public and backyard waterslides. This was a 20-year cross-sectional study of the National Electronic Injury Surveillance System. Injuries from waterslides were included in this study if they involved the head, face, eyeball, mouth, neck, or ear. Patient and injury characteristics were compared by the type of waterslide using chi-squared and independent sample tests. A total of 1823 injury reports were identified (39.8% backyard waterslides and 60.2% public waterslides). The mean age at the time of injury was 13.2 years, and the majority of patients were white (74.2%) males (55.1%). The most common primary diagnoses were laceration (28.4%) and internal organ injury (27.2%). A greater proportion of backyard injuries involved the head (P < 0.01) and resulted in concussions (P < 0.01) or fractures (P = 0.04). The overall admission rate from the ED was 3.5%, and no fatalities were noted. There were no significant differences in admission rates between injuries from backyard and public slides. Fatal or serious head and neck injuries appear to be uncommon with waterslide injuries. Backyard waterslides pose a greater likelihood of cranial injury, and this may relate to differences in riding habits between public and private waterslides.

Detection of Respiratory Pathogens Does Not Predict Risks After Outpatient Adenotonsillectomy.

Objectives/HypothesisTo determine whether the presence of detectable upper respiratory infections (URIs) at the time of adenoidectomy/adenotonsillectomy is associated with increased morbidity, complications, and unexpected admissions.Study DesignProspective double‐blinded cohort.MethodsIn this prospective cohort study, nasopharyngeal swabs were obtained intraoperatively from 164 pediatric patients undergoing outpatient adenoidectomy/tonsillectomy with or without pressure equalization tubes (PETs) and were analyzed with PCR for the presence of 22 known URIs, including SARS‐CoV‐2. Surgeons and families were blinded to the results. At the conclusion of the study, rates of detectable infection were determined and intraoperative and postoperative events (unexpected admissions, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, and postoperative presentation to an emergency department) were compared between infected and uninfected patients.ResultsOf the 164 patients (50% male, 50% female, ages 8 mo‐18 y), 136 patients (82.9%) tested positive for one or more URI at the time of surgery. Forty one patients (25.0%) tested positive for three or more URIs concurrently, and 11 (6.7%) tested positive for five or more URIs concurrently. There were no significant differences in admission rates, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, or postoperative presentation to an emergency department between positive and negative patients. No patients tested positive for SARS‐CoV‐2.ConclusionsA recent positive URI test does not confer any additional intraoperative or postoperative risk in the setting of outpatient adenoidectomy/tonsillectomy in healthy patients. There is no utility in preoperative URI testing, and delaying surgery due to a recent positive URI test is not warranted in this population.Level of Evidence3 Laryngoscope, 131:E2074–E2079, 2021

Psychiatric admissions from crisis resolution teams in Norway: a prospective multicentre study

BackgroundCrisis resolution teams (CRTs) provide intensive alternative care to hospital admission for patients with mental health crises. The aims of this study were to describe the proportions and characteristics of patients admitted to in-patient wards from CRTs, to identify any differences in admission practices between CRTs, and to identify predictors of admissions from CRTs.MethodsA naturalistic prospective multicentre design was used to study 680 consecutive patients under the care of eight CRTs in Norway over a 3-month period in 2005/2006. Socio-demographic and clinical data were collected on the patients, and on the organization and operation of the CRTs. Logistic regression analysis for hierarchical data was used to test potential predictors of admission at team and patient level.ResultsOne hundred and forty-six patients (21.5%) were admitted to in-patient wards. There were significant differences in admission rates between the CRTs. The likelihood of being admitted to an in-patient ward was significantly lower for patients treated by CRTs that operated during extended opening hours than CRTs that operated during office hours only. Those most likely to be admitted were patients with psychotic symptoms, suicidal risk, and a prior history of admissions.ConclusionsExtended opening hours may help CRTs to prevent more admissions for patients with moderately severe and relapsing mental illnesses. Patients with severe psychosis seem to be difficult to treat in the community by Norwegian CRTs even with extended opening hours.

Epidemiology of Pediatric Critically-ill Patients Presenting to the Pediatric Emergency Department

This study aimed to analyze the epidemiologic patterns of pediatric critically-ill patients presenting to the emergency department (ED) and the etiologies of intensive care unit (ICU) admission of different age groups.This retrospective study of all children aged less than 18 years presenting with critical illnesses to the ED was conducted in a tertiary medical center in Taiwan from 2003 to 2007. All patients transferred to the ICU from the ED were included without distinction. Demographic data of critically-ill children admitted to the ED and ICU were analyzed. Etiologies of the ICU admissions were analyzed by various age groups.There were 2978 critically-ill children admitted to the ICU from the ED. In 120 pediatric patients with out-of-hospital cardiac arrest, cases with pulseless electrical activity or ventricular fibrillation had higher successful CPR rates than patients with asystole (both p<0.05). In patients admitted to ICUs, complications from the perinatal period, respiratory system diseases, accidental injuries and poisoning were the predominant etiologies respectively in young children (42.5%), school-aged children (38.5%), and adolescents (47.9%). Moreover, the most common of which was respiratory distress syndrome in neonates followed by bacterial pneumonia and status epilepticus.Epidemiologic analysis may provide primary clinicians to identify significant differences in admission rates based on different etiologies of various age groups.

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Introduction: Medical emergency teams (METs) utilize a multidisciplinary strategy to better anticipate and prevent in-hospital morbidity and mortality. In general, the responsibilities of the team include diagnosing clinical problems, initiating therapy, and when appropriate, triaging patients to higher levels of care. However, there are no specific guidelines as to who should lead METs, thus the composition of these teams varies among institutions. Hypothesis: The objective of our study was to compare patient outcomes when the MET at a tertiary academic medical center was lead by emergency medicine physicians to critical care medicine trained intensivists. Methods: We conducted a retrospective study comparing the rate of intubation, intensive care unit (ICU) admission, and all-cause hospital mortality in a three month interval when the MET was staffed solely by emergency medicine physicians (interval A, October 1, 2010-December 31, 2010) to a three month interval (interval B, April 1, 2011-June 30 2011) when the MET was staffed by either emergency medicine physicians or intensivists. Results: The MET was activated 391 times during interval A and 390 times during interval B. There was no difference between the intervals in rate of intubation (7.4% vs 7.4%, p=0.36) or mortality (20.7% vs 21%, p=0.35). However, there was a lower rate of ICU admissions in interval B by 68.2% (45% vs 14.6%, p<0.01). This decline could not be explained by physician specialty since there was no significant difference in admission rate between the two groups (13.8% by emergency medicine physicians and 16.8% by intensivists, p=0.20). The difference could also not be explained by severity of illness since the mean APACHE II score for all patients admitted to the ICU was 73.5 during interval A and 70.7 during interval B. Conclusions: Our study shows that the specialty of the physicians leading METs does not impact the rate of intubation or mortality. Interestingly, we observed a significant decline in the ICU admission rate between the two study intervals which could not explained by physician specialty or severity of illness. Informal surveys of MET members suggested that through experience, the team was spending more time and effort managing patients on the floors and had improved communication with the primary services. However, prospective and long term studies are needed.

The Role of Negative CT of the Abdomen and Pelvis in the Decision to Admit Adults From the Emergency Department After Blunt Trauma

Computed tomography (CT) is widely used in the initial evaluation of blunt trauma patients and is associated with a high rate of negative imaging. A described benefit of negative imaging is prompt discharge. This study examined a single level 1 trauma center to determine whether adult blunt trauma patients are discharged from the emergency department (ED) after negative CT of the abdomen and pelvis (CT AP). The authors retrospectively created a data set of adult blunt trauma patients who received CT AP in the ED from August to November 2003. Statistical analysis of admission rates on the basis of positivity or negativity on CT AP was performed to determine if the test influenced admission rates. Additional subgroup analysis was made between the patients admitted with negative CT AP and those who were discharged from the ED. Two thirds (316/469) had negative CT AP. Whereas 80.4% of the patients (254/316) with negative CT AP were admitted, 98.0% (148/151) with positive CT AP were admitted, a statistically significant difference in admission rate (P < .0001). The vast majority (208/254, 81.9%) of patients with negative CT AP were admitted for extra-abdominal injuries. There was no statistical difference in the characteristics of a subgroup of 45 patients who were admitted without any documented injuries from the group discharged from the ED in terms of age, gender, comorbidity, Glasgow Coma Scale score, or intoxication. Under current practice, negative CT AP after blunt trauma results in a statistically significant decrease in admissions.

The effect of limited English proficiency on admission rates from a pediatric ED: Stratification by triage acuity

The objectives of this study were to determine the effect of Limited English Proficiency (LEP) visits and acuity status on admission rates from a pediatric ED. A retrospective cohort study was performed using a fully computerized medical record, which includes information on language spoken, triage acuity, and disposition. Data was collected on all patient visits from July 2002 to November 2002 from a tertiary-care pediatric ED. Admission rates and acuity status for LEP and non-LEP patients were compared. A total of 13,585 patient visits were identified, of which 12,416 fit the study criteria. There were 244 LEP patient visits, of which 206 were Spanish-speaking. There were 12,172 English-speaking patient visits. Compared with English-speaking visits, LEP visits were more likely to be triaged as high acuity (25.8% vs. 16.1%, P < .001). LEP patients were more likely to be admitted to the hospital (22.1% vs. 13%, P < .001). For high- and low-acuity patients, no significant differences in admission rates were seen between LEP and English-speaking patients. In contrast, moderate-acuity LEP visits showed a significantly increased admission rate compared to moderate acuity English visits (22.5% vs. 12.4%, P = .005). Similar trends were seen among Spanish-speaking LEP patients. Differences in medical disposition from the ED were found between English-speaking and LEP patient visits. There were higher rates of admission for LEP patients, particularly among moderate-acuity visits. This highlights disparities of care for this vulnerable population.

Are diagnostic testing and admission rates higher in non–english-speaking versus english-speaking patients in the emergency department?

Study Objective: To determine whether non–English-speaking patients who present to an emergency department have more diagnostic tests ordered, higher admission rate, and longer length of stay in the ED than English-speaking patients for 2 common complaints, chest pain and abdominal pain. Methods: This prospective, comparative, observational study was conducted at a public hospital ED. The study group was composed of 324 patients (172 non–English-speaking and 152 English-speaking) presenting with nontraumatic abdominal pain (148) or chest pain (176). The main outcome measures were admission rates, length of stay in the ED, and diagnostic test and procedure ordering. Results: The mean age for the total sample was 45.8±15.5 years (range 14 to 87 years); 45.4% (147/324) of the patients were male. For the non–English-speaking patients, the language distribution was Spanish (31.0%), other (9.0%), Cantonese (5.9%), Hindi (2.5%), Mien (1.5%), Arabic (1.9%), Russian (0.9%), Mandarin (0.6%), and Korean (0.3%). The admission rate was 37.8% for English-speaking patients versus 42.8% for non–English-speaking patients in the total sample (mean difference in proportions 5%, 95% confidence interval [CI] –6% to 16%; 34.2% for English-speaking versus 9.1% for non–English-speaking patients presenting with abdominal pain, mean difference in proportions 5%, 95% CI –11% to 21%) and 40.9% for English-speaking versus 45.8% for non–English-speaking patients presenting with chest pain (mean difference in proportions 5%, 95% CI –10% to 20%). Power was 80% to detect a 15% difference in admission rates at an α value of.05. There was no statistically significant difference in ordering of diagnostic tests between the non–English-speaking and English-speaking patients with chest pain. Non–English-speaking patients with abdominal pain had 5 tests ordered more often than English-speaking patients. The mean difference in proportions (with 95% CIs) for these tests were CBC count 18.4% (5.1% to 31.7%), serum electrolytes 17.9% (3.8% to 31.9%), urinalysis 20.0% (4.5% to 35.6%), ECG 23.4% (8.6% to 38.2%), and abdominal computed tomographic scan 10.9% (1.0% to 20.8%). There was no statistically significant difference between English-speaking and non–English-speaking patients for ED length of stay in the total sample (mean difference 29.8, 95% CI –37.5 to 97.1 minutes; for the abdominal pain subgroup, mean difference 19.5, 95% CI –74.6 to 113.5 minutes; and for the chest pain subgroup, mean difference 37.9, 95% CI –58.0 to 133.8 minutes). Conclusion: Significantly more tests are ordered for non–English-speaking patients with abdominal pain in the ED, including 3 times as many abdominal computed tomographic scans. There is no increase in test ordering with non–English-speaking patients with complaints of chest pain in the ED. When comparing English-speaking and non–English-speaking patients, there were no statistically significant differences in admission rates or length of stay in the ED. [Waxman MA, Levitt MA. Are diagnostic testing and admission rates higher in non–English-speaking versus English-speaking patients in the emergency department? Ann Emerg Med. November 2000;36:456-461.]