Significant Reduction In Hospital Length Of Stay Research Articles

Lessons following implementation of a colorectal enhanced recovery after surgery (ERAS) protocol in a rural hospital setting.

Enhanced recovery after surgery (ERAS) programs have become increasingly popular in the management of patients undergoing colorectal resection. However, the validity of ERAS in rural hospital settings without intensive care facilities has not been primarily evaluated. This study aimed to assess an ERAS protocol in a rural surgical department based in Invercargill New Zealand. Ten years of prospectively collected data were analysed retrospectively from an ERAS database of all patients undergoing open, converted, or laparoscopic colorectal resections. Data were collected between two time periods: before the implementation of an ERAS protocol, from January 2011 to December 2013; as well as after the implementation of an ERAS protocol, from January 2014 to December 2020. The primary outcome measures were hospital length of stay (LOS) and LOS in the critical care unit (LOS-CCU). Secondary outcomes were compliance with ERAS protocol, mortality, readmission, and reoperation rates. A total of 118 and 558 colorectal resections were performed in the pre-ERAS and ERAS groups respectively. A statistically significant reduction in hospital LOS was achieved from a median of 8 to 7 days (P = 0.038) when comparing pre-ERAS to ERAS groups respectively. Furthermore, a significant reduction in re-operation rates was observed (7.6% vs. 3% in the ERAS group, P = 0.033) which was seen without a rise in readmission rates (13.6% vs. 13.6% in the ERAS group). The implementation of ERAS in a rural surgical setting is feasible, and these initial findings suggest ERAS adds value in optimizing the colorectal patient's surgical journey.

Expediting the TIA Workup (P6-5.024)

<h3>Objective:</h3> Reduction of length of stay (LOS) for transient ischemic attack (TIA) admissions at a public safety net community hospital. <h3>Background:</h3> Transient focal neurologic deficits are a common chief complaint among patients presenting to Emergency Department (ED). Admitting these patients is costly and increases utilization of limited hospital resources. Thus, the current national trend is to avoid admitting “low risk” TIA patients. The purpose of this study is to design a “TIA pathway,” in a public safety net hospital setting to expedite evaluation of these patients. <h3>Design/Methods:</h3> We based our TIA pathway protocol on work done by Boyle et al. We tailored our protocol, based on the socioeconomic needs of our patients (27.2% uninsured, 5.2% undomiciled), to further improve access to stroke care for our community. With ED collaboration, physician training was performed, including utilization of an order set and understanding guidelines for the TIA pathway and inpatient admission. TIA pathway utilization data and data from admitted TIA patients was gathered from the medical record and AHA Get with the Guidelines registry. In addition, safety data including adverse events, 30 day follow up, readmission, and outcomes were monitored and reviewed monthly by stroke leadership. <h3>Results:</h3> A total of 247 TIA cases were recorded in February 2020 through August 2022. The average LOS of patients admitted to the TIA pathway was 1.58 days, while the average LOS for patients admitted inpatient for TIA workup was 2.92 days. Since the inauguration of TIA pathway, we decreased bed utilization by 130 hospital days. <h3>Conclusions:</h3> A dedicated TIA pathway with well-constructed guidelines, order-sets, and physician education resulted in a significant reduction in hospital LOS for the initial evaluation of TIA patients. Follow up outcome studies will be performed to assess the safety and efficacy of an expedited TIA workup. <b>Disclosure:</b> Dr. Wen has nothing to disclose.

A novel, evidence-based, comprehensive clinical decision support system improves outcomes for patients with traumatic rib fractures.

Traumatic rib fractures are associated with high morbidity and mortality. Clinical decision support systems (CDSS) have been shown to improve adherence to evidence-based (EB) practice and improve clinical outcomes. The objective of this study was to investigate if a rib fracture CDSS reduced hospital length of stay (LOS), 90-day and 1-year mortality, unplanned ICU transfer, and the need for mechanical ventilation. The independent association of two process measures, an admission EB order set and a pain-inspiratory-cough score early warning system, with LOS were investigated. The CDSS was scaled across nine US trauma centers. Following multiple imputation, multivariable regression models were fit to evaluate the association of the CDSS on primary and secondary outcomes. As a sensitivity analysis, propensity score matching was also performed to confirm regression findings. Overall, 3,279 patients met inclusion criteria. Rates of EB practices increased following implementation. On risk-adjusted analysis, in-hospital LOS preintervention versus postintervention was unchanged (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 0.97-1.15, p = 0.2) but unplanned transfer to the ICU was reduced (odds ratio, 0.28; 95% CI, 0.09-0.84, p = 0.024), as was 1-year mortality (hazard ratio, 0.6; 95% CI, 0.4-0.89, p = 0.01). Provider utilization of the admission order bundle was 45.3%. Utilization was associated with significantly reduced LOS (IRR, 0.87; 95% CI, 0.77-0.98; p = 0.019). The early warning system triggered on 34.4% of patients; however, was not associated with a significant reduction in hospital LOS (IRR, 0.76; 95% CI, 0.55-1.06; p = 0.1). A novel, user-centered, comprehensive CDSS improves adherence to EB practice and is associated with a significant reduction in unplanned ICU admissions and possibly mortality, but not hospital LOS. Therapeutic/Care Management; Level III.

How Much Benefit Can Patients Acquire from Enhanced Recovery After Surgery Protocols with Percutaneous Endoscopic Lumbar Interbody Fusion?

PurposeWe aimed to explore the role of enhanced recovery after surgery (ERAS) in patients who underwent percutaneous endoscopic lumbar interbody fusion (PELIF).Patients and MethodsWe performed a retrospective, observational, cohort study on 91 patients who underwent PELIF for degenerative disc disease. The primary outcomes were postoperative opioid consumption, hospital length of stay (LOS), and hospital cost.ResultsForty-six patients comprised the ERAS group, and 45 patients comprised the pre-ERAS group (control group). The groups had comparable demographic characteristics. Good compliance with the ERAS pathway was observed in the ERAS group. Patients in the ERAS group used significantly fewer morphine equivalents compared with the pre-ERAS group (25.0 vs 33.3, respectively; p = 0.017). Hospital LOS did not decrease significantly in the ERAS group compared with the pre-ERAS group (3.1days vs 3.4 days, respectively; p = 0.096). Likewise, there was no significant difference in hospital cost between the pre-ERAS group and the ERAS group ($10,598.60 vs $10,384.50, respectively; p = 0.468).ConclusionIn the present study, the benefit of ERAS in the context of PELIF was limited. Although a multidisciplinary ERAS protocol can improve analgesia and decrease opioid consumption, no significant reduction in hospital LOS and cost was observed.

Outcomes with perioperative fat emulsions containing omega-3 fatty acid: A meta-analysis of randomized controlled trials

Results of a meta-analysis of data from clinical studies comparing patient outcomes and hospital length of stay (LOS) in surgical patients receiving fish oil (FO)-containing i.v. fat emulsions (IVFEs) versus non-FO-containing IVFEs are presented. Computerized searches of the MEDLINE, Embase, and Coch rane CENTRAL databases were performed in August 2014 to identify English-language articles on randomized controlled trials (RCTs) comparing FO-containing and non-FO-containing IVFEs in adult surgical patients receiving parenteral nutrition. Selected articles were analyzed for methodological and publication bias and study heterogeneity (I2 statistic). Data from 19 RCTs (total n = 1,167) were included in the meta-analysis. Compared with use of non-FO-containing IVFEs (products based in soybean oil [SO], medium-chain triglycerides, or olive oil), use of FO-containing IVFEs was associated with reduced infectious morbidity (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.30-0.65; p < 0.0001; I2 = 0%); the effect size was greatest for FO-containing versus SO-based IVFEs. Relative to use of SO-based IVFEs, use of FO-containing IVFEs was associated with a significant reduction in hospital LOS (weighted mean difference, -2.70 days; 95% CI, -3.60 to -1.79 days; p < 0.00001; I2 = 0%). The results of the meta-analysis indicated that FO-containing IVFEs could improve infectious morbidity and LOS. The overall effect of reducing infectious morbidity and LOS was found to be the greatest in comparison with the SO-based IVFEs.

Does minimally invasive oesophagectomy provide a benefit in hospital length of stay when compared with open oesophagectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: 'in patients undergoing oesophagectomy, does a minimally invasive approach convey a benefit in hospital length of stay (LOS), when compared to an open approach?' A total of 647 papers were identified, using an a priori defined search strategy; 24 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and key results are tabulated. Of the studies identified, data from two randomized controlled trials were available. The first randomized study compared the use of open thoracotomy and laparotomy versus thoracoscopy and laparoscopy. Those undergoing minimally invasive oesophagectomy (MIO) left hospital on average 3 days earlier than those treated with the open oesophagectomy (OO) technique (P = 0.044). The other randomized trial, which compared thoracotomy with thoracoscopy and laparoscopy, demonstrated a reduction of 1.8 days in the LOS when employing the MIO technique (P < 0.001). With the addition of the remaining 22 non-randomized studies, comprising 3 prospective and 19 retrospective cohort studies, which are heterogeneous with regard to their design, study populations and outcomes; data are available representing 3173 MIO and 25 691 OO procedures. In total, 13 studies (including the randomized trials) demonstrate a significant reduction in hospital LOS associated with MIO; 10 suggest no significant difference between techniques; and only 1 suggests a significantly greater length of stay associated with MIO. The only two randomized trials comparing MIO and OO demonstrated a reduction in length of stay in the MIO group, without compromising survival or increasing complication rates. All bar one of the non-randomized studies demonstrated either a significant reduction in length of stay with MIO or no difference. The benefit in reduced length of stay was not at the cost of worsened survival or increased complications, and conversion rates in all studies were low.

Increased Severity of Clostridium difficile Infection (CDI) Is Associated With Increased Mortality in Hospitalized Patients: A Single-Center Retrospective Cohort Study

Introduction: CDI is associated with significant morbidity and mortality in hospitalized patients. We studied whether severity according to the Infectious Diseases Society of America (IDSA) 2010 guidelines had any effect on hospital based outcomes. Furthermore, we investigated whether adherence to these guidelines with respect to treatment had any effect on the same outcomes. Methods: Setting: Single-center retrospective cohort study conducted at an acute care facility for the period of April 1, 2012 to December 31, 2014.t Patients: Hospitalized adults with diarrhea that tested positive for CDI by polymerase chain reaction (PCR) assay, identified through the infection control committee's database. Exclusion criteria: Initiation of CDI therapy before hospitalization; lack of treatment for CDI; diagnosis and discharge from the emergency room; patients treated with intravenous metronidazole before diagnosis for non-CDI indications; and incomplete data. Definitions: Severity was categorized by IDSA guidelines. CDI treatment was classified as guideline adherent if treatment provided was with the correct antibiotic(s), route(s), and dosage(s). Non-adherence was defined as any of the following: incorrect antibiotic(s), route(s), and/or dosage(s). Primary outcomes: All cause in-hospital mortality. Secondary outcomes: Hospital length of stay (LOS) and intensive care unit (ICU) LOS Statistical Analysis: Multivariable logistic and linear regression analyses (SPSS Version 19) Results: 341 cases were identified, 53 were excluded, and 288 were analyzed. Severity of CDI was associated with increased mortality, hospital LOS and ICU LOS on univariate and multivariate analysis. Adherence to guidelines was observed in 43% of cases. Non-adherence was more common in the severe uncomplicated and complicated cases. On univariate analysis, adherence was associated with a trend towards reduced mortality (11% vs 6%, p = 0.1) and ICU LOS (2.2 vs 1.3 days, p = 0.1), and a significant reduction in hospital LOS (7.2 vs 5.4 days, p = 0.04). This did not reach significance on multivariate analysis. Conclusion: In our cohort, severe cases of CDI were associated with worse hospital outcomes. We showed that adherence to treatment guidelines improved these outcomes, but the adherence rate was less in the more severe cases. Our data suggest that implementation of the guidelines in severe cases of CDI could reduce mortality and LOS.Table 1: Severity of CDI (IDSA) and OutcomesTable 2: Outcomes for Adherence to IDSA Guidelines

Parenteral glutamine supplementation in critical illness: a systematic review.

IntroductionThe potential benefit of parenteral glutamine (GLN) supplementation has been one of the most commonly studied nutritional interventions in the critical care setting. The aim of this systematic review was to incorporate recent trials of traditional parenteral GLN supplementation in critical illness with previously existing data.MethodsAll randomized controlled trials of parenterally administered GLN in critically ill patients conducted from 1997 to 2013 were identified. Studies of enteral GLN only or combined enteral/parenteral GLN were excluded. Methodological quality of studies was scored and data was abstracted by independent reviewers.ResultsA total of 26 studies involving 2,484 patients examining only parenteral GLN supplementation of nutrition support were identified in ICU patients. Parenteral GLN supplementation was associated with a trend towards a reduction of overall mortality (relative risk (RR) 0.88, 95% confidence interval (CI) 0.75, 1.03, P = 0.10) and a significant reduction in hospital mortality (RR 0.68, 95% CI 0.51, 0.90, P = 0.008). In addition, parenteral GLN was associated with a strong trend towards a reduction in infectious complications (RR 0.86, 95% CI 0.73, 1.02, P = 0.09) and ICU length of stay (LOS) (WMD –1.91, (95% CI -4.10, 0.28, P = 0.09) and significant reduction in hospital LOS (WMD -2.56, 95% CI -4.71, -0.42, P = 0.02). In the subset of studies examining patients receiving parenteral nutrition (PN), parenteral GLN supplementation was associated with a trend towards reduced overall mortality (RR 0.84, 95% CI 0.71, 1.01, P = 0.07).ConclusionsParenteral GLN supplementation given in conjunction with nutrition support continues to be associated with a significant reduction in hospital mortality and hospital LOS. Parenteral GLN supplementation as a component of nutrition support should continue to be considered to improve outcomes in critically ill patients.

Can Emergency Medicine Ward Shorten Hospital Length of Stay in Patients with Nasogastric Tube Related Coffee Ground Aspirate?

Introduction The aim of this study was to determine whether elderly patients on nasogastric (NG) tube feeding who presented with coffee ground aspirate could be effectively and safely managed in a local setting of Emergency Medicine Ward (EMW). Method A retrospective study with data retrieved from all the cases admitted with a diagnosis of coffee ground aspirate or vomiting who were on NG tube feeding during three years before and after EMW was launched. Data including patient demographics, length of stay (LOS), types of pharmaceutical treatment received, need of upper endoscopy, in-hospital death and readmission rate within fourteen days were studied. Patients who were haemodynamically unstable, having melaena on per rectal examination, on warfarin or with underlying gastrointestinal malignancy were excluded. Results A total of 223 patients matching the studied criteria were included in the study, with 103 of them being admitted before the opening of EMW. For the 120 cases admitted after EMW was launched, 70 cases were admitted to EMW and 50 admitted to Medical Ward. The LOS for elderly patients on NG tube feeding presented with coffee ground aspirate was significantly shortened after EMW was launched (5.2 days vs. 4.2 days, p=0.046). In-hospital mortality and 14-day readmission rate were similar in the two studied period. Patients admitted to EMW and Medical Ward in the second study period were also analysed. Those admitted to EMW had a shorter LOS than those admitted to Medical ward during the same period (3.4 days vs. 5.3 days, p=0.001). Conclusion The establishment of EMW in local setting can achieve a significant reduction in hospital LOS without jeopardizing patient outcome for elderly patients who are on NG tube feeding presenting with coffee ground aspirate.

The Impact of Emergency Medicine Ward in Acute Intoxication Management

Background The Emergency Medicine Ward (EMW) was established in Caritas Medical Centre (CMC) in November 2007 under the management of emergency physicians. With the support from the psychiatric team and medical social workers, it provided effective management for intoxicated patients as an alternative to traditional inpatient service. Objective The aim of this study was to evaluate the impact of the EMW in the management of acute intoxication. Method A retrospective comparative study with data retrieved from all admitted intoxicated and suspected intoxicated patients was carried out over two separate half-year periods in 2007 and 2008, before and after the establishment of the EMW. Data on patient demographics, reason of exposure, substance involved, treatment, psychiatric service offered, clinical outcome, hospital length of stay (LOS) and 28-day hospital re-admission were compared. Results A total of 316 intoxicated patients were admitted to CMC with 165 in the 2007 group and 151 in the 2008 group. Both groups shared similar basic epidemiological data. There was a marked reduction in hospital LOS from 80.1 hours to 45.9 hours (p&lt;0.01), a markedly increased proportion of patients receiving psychiatric service from 47.9% to 71.5% (p&lt;0.01) and a significant decline in the access time of psychiatric assessment from 27.4 hours to 10.6 hours (p&lt;0.05). There were no statistically significant difference in treatment, patient clinical outcome and 28-day hospital re-admission. Conclusions The establishment of EMW achieved a significant reduction in hospital LOS of intoxicated patients without jeopardizing patient outcome. The results also illustrate that EMW can provide a good platform for the integration of psychiatric service for these patients.

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

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