Skilled Care Facility Research Articles

Use of interrupted time-series analyses in evaluating health economic outcomes following implementation of multilayer water-tight wound closure in a primary total joint arthroplasty population.

Aim: Total joint arthroplasty (TJA) with multi-layer, watertight closure (MLWC) using knotless barbed suture and 2-octyl cyanoacrylate plus polymer mesh tape was compared with conventional closure (CC) using Vicryl™ sutures and staples. Patients & methods: Electronic medical records of patients undergoing TJA (1574: total knee arthroplasty; 580: total hip arthroplasty; 13: unknown) from a single surgeon at a US hospital (CC 2011 to 2013; MLWC 2015 to 2020) were reviewed. Outcomes were length of stay (LOS), discharge to skilled nursing facility (SNF), 90-day surgical site infection (SSI) and 90-day readmission. Logistic regression controlled for baseline characteristics. Adjusted interrupted time series (ITS) analyses accounted for decreasing trends in LOS and SNF discharge over time. Results: Among 2167 TJA cases (mean [standard deviation] age 66.0 [9.7]years, 53.3% female), 906 received CC and 1261 received MLWC. Bivariate analysis showed no statistically significant differences in 90-day SSI rates; however, MLWC patients had 60% lower 90-day readmission rates (1.5 vs 3.8%, p<0.05), 44% lower LOS (1.4 vs 2.5days, p<0.05) and 40% lower discharge rates to a skilled care facility (8.5 vs 14.1%, p<0.05). Multivariable analyses showed CC patients were 2.45-times more likely to be readmitted within 90days, 1.88-times more likely to be discharged to SNF and had 1.67-times longer LOS compared with MLWC. ITS analyses showed a sharp decline in LOS (0.9days) and discharge to SNF (5.6% incidence) after implementation of MLWC, followed by no further changes for the remainder of the study period. Conclusion: MLWC was associated with ≥40% reduction in 90-day readmission, LOS and SNF discharge compared with TJA CC. LOS and discharge rate to SNF declined sharply after the implementation of MLWC.

A modified metaheuristic algorithm for a home health care routing problem with health team skill levels

Home Health Care (HHC) services have emerged as a result of the need to provide care to patients/people who cannot be treated in hospital due to their special conditions and/or need home care. The care and treatment processes provided by this service have been appreciated by researchers as they can be less expensive and just as effective than care provided by a hospital or a skilled care facility. HHC gains importance due to the increasing epidemic disease cases, the increase in the elderly population, etc. In this study, it is aimed to provide high quality service as well as minimizing travel costs by considering the constraints related to travel balancing and type of transportation vehicle. So, environmental and economic factors could be included in the model. The proposed Home Health Care Routing Problem with Health Team Skill Level (HTSL-HHCRP) model was coded in GAMS 24.2.1 software. A new hybrid method named as Genetic Algorithm Simulated Annealing-Marine Predators Algorithm (GASA-MPA) has been developed to solve the large dimensions of the problem. In hybrid approach, SA has been used with an initial point obtained by GA. On the other hand, feasibility of the neighborhood solutions is guaranteed by solving a constraint satisfaction problem via MPA. Test problems’ performance was analyzed using the Relative Deviation Index (RDI) evaluation criteria. In addition, the sensitivity of the results according to some parameters selected by scenario analysis was examined. Results confirm the efficiency of the GASA-MPA algorithm in terms of time and objective function. Furthermore, by addressing skill levels of the healthcare team, it is shown that the proposed algorithm performs better than more traditional evolutionary algorithms in HHCRP. The comparisons show that the proposed method outperformed the classical methods not only in terms of best solution, but also the Gap (%) and RDI values.

Collaborative Nursing and Nutrition Intervention Improves Unintentional Weight Loss at Emory Long Term Skilled Care Facility (Budd Terrace at Wesley Wood Campus)

Collaborative Nursing and Nutrition Intervention Improves Unintentional Weight Loss at Emory Long Term Skilled Care Facility (Budd Terrace at Wesley Wood Campus)

MP42-01 CLINICAL FACTORS ASSOCIATED WITH 90-DAY MORBIDITY FOLLOWING SURGICAL MANAGEMENT OF UROSYMPHYSEAL FISTULA

You have accessJournal of UrologyCME1 Apr 2023MP42-01 CLINICAL FACTORS ASSOCIATED WITH 90-DAY MORBIDITY FOLLOWING SURGICAL MANAGEMENT OF UROSYMPHYSEAL FISTULA Elizabeth Bearrick, Jayson Kemble, Samuel Broida, Matthew Houdek, and Boyd Viers Elizabeth BearrickElizabeth Bearrick More articles by this author , Jayson KembleJayson Kemble More articles by this author , Samuel BroidaSamuel Broida More articles by this author , Matthew HoudekMatthew Houdek More articles by this author , and Boyd ViersBoyd Viers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urosymphyseal fistula (USF) is a devastating complication associated with prostate cancer therapy treatment. Definitive surgical management including fistula decompression, removal of devitalized bone, and tissue interposition remain the gold standard. Early postoperative outcomes remain underreported. The aim of this study was to characterize 90-day morbidity and clinical characteristics associated with adverse outcomes. METHODS: A retrospective chart review of a single institutional database identified 54 patients who underwent operative treatment for USF. Clinical characteristics and 90-day morbidity were assessed. RESULTS: In total, 46/54 (85%) patients had a history of prior pelvic radiation. Cystectomy with urinary conduit was common (N=39, 72%) and 7 (13%) underwent a robotic approach. Discordance between intra and preoperative cultures was present in 34 (67%) including 10/21 (48%) with fungal growth. Median length of stay was 9 days (IQR 7-15), 90-day Clavien-Dindo grade ≥3 complications occurred in 19 (35%), including reoperation in 7 (13%) and rehospitalization in 11 (20%). Discharge to a skilled care facility was required in 5 (9%). At least one preoperative inflammatory marker (WBC, ESR, and CR) was available in 52 (96%) patients, and pre-op albumin was available in 38 (70%). Patients with a WBC >9.6×109/L while on pre-op antibiotic therapy were more likely (RR 1.60) to have culture discordance (93% vs 54%; p=0.019). Patients with pre-op ESR >28.0 mm/h (N=38) while on antibiotic therapy were more likely to have a longer hospital stay (10 days vs 6 days; p=0.007). Patients with a pre-op albumin <3.5g/dl (N=9) were more likely to have a prolonged hospital stay (13 days vs 8 days; p=0.03) or require discharged to skilled care (75% vs 18%, p=0.35). Those with CRP greater than 100.0mg/L had higher rates Clavien grade ≥3 complications (41% vs 11%, p=0.25). ESR >65 mm/h was associated with reintervention for osteomyelitis (83% vs 35%, p=0.36). CONCLUSIONS: Preoperative clinical features including ESR, CRP, WBC, and albumin are associated with an increased risk of morbidity following treatment of USF. Earlier identification of these patients may be useful to ascertain patients who could benefit from further preoperative optimization. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e566 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth Bearrick More articles by this author Jayson Kemble More articles by this author Samuel Broida More articles by this author Matthew Houdek More articles by this author Boyd Viers More articles by this author Expand All Advertisement PDF downloadLoading ...

Postsurgical Opioid Use Among Veterans Discharged to Skilled Care Facilities Compared to Veterans Discharged to Home After Orthopedic Surgery.

To compare opioid use patterns among Veterans who were discharged to a skilled care facility vs home after orthopedic surgery at a VA hospital. We conducted a retrospective cohort study of Veterans who had orthopedic surgery at the XXXX between January 2018 and December 2021 and were followed by a transitional pain service. The principal outcome of interest was the time to stop opioid use after discharge from the hospital. Veterans not already on chronic opioid therapy who had orthopedic surgery at the XXXX and were followed by a transitional pain service. 448 patients were included in the study, of which 371 (83%) were discharged to home and 77 (17%) were discharged to a skilled care facility. Median days to opioid cessation were estimated using the Kaplan-Meier method with 95% CIs and compared with discharge disposition using a log-rank test. Time to opioid cessation following hospital discharge was compared to baseline characteristics using univariable and multivariable Cox proportional hazards models. Patients who were discharged to a skilled care facility used opioids for twice as long as those who were discharged home [median days (interquartile range)]: 22 (19, 26) vs 11 (10, 12), P < .001, respectively. When controlling for baseline characteristics in the multivariable analysis, discharge to a skilled care facility was significantly associated with continued opioid use at all time points [hazard ratio 0.63 (95% CI 0.44, 0.89), P= .009]. Veterans discharged to a skilled care facility after orthopedic surgery used opioids for twice as long as those who were discharged to home. As postsurgical pain management guidelines change to focus on nonopioid pain modalities and opioid reduction, skilled care providers should adapt those strategies for their facilities.

Colorectal Surgery Outcomes in the United States During the COVID-19 Pandemic

IntroductionThe purpose of this study was to assess colorectal surgery outcomes, discharge destination, and readmission in the United States during the COVID-19 pandemic. MethodsAdult colorectal surgery patients in the American College of Surgeons National Surgical Quality Improvement Program database (2019-2020) and its colectomy and proctectomy procedure-targeted files were included. The prepandemic time period was defined from April 1, 2019 to December 31, 2019. The pandemic time period was defined from April 1, 2020 to December 31, 2020 in quarterly intervals (Q2 April-June; Q3 July-September; Q4 October-December). Factors associated with morbidity and in-hospital mortality were assessed using multivariable logistic regression. ResultsAmong 62,393 patients, 34,810 patients (55.8%) underwent colorectal surgery prepandemic and 27,583 (44.2%) during the pandemic. Patients who had surgery during the pandemic had higher American Society of Anesthesiologists class and presented more frequently with dependent functional status. The proportion of emergent surgeries increased (12.7% prepandemic versus 15.2% pandemic, P < 0.001), with less laparoscopic cases (54.0% versus 51.0%, P < 0.001). Higher rates of morbidity with a greater proportion of discharges to home and lesser proportion of discharges to skilled care facilities were observed with no considerable differences in length of stay or worsening readmission rates. Multivariable analysis demonstrated increased odds of overall and serious morbidity and in-hospital mortality, during Q3 and/or Q4 of the 2020 pandemic. ConclusionsDifferences in hospital presentation, inpatient care, and discharge disposition of colorectal surgery patients were observed during the COVID-19 pandemic. Pandemic responses should emphasize balancing resource allocation, educating patients and providers on timely medical workup and management, and optimizing discharge coordination pathways.

Racial and Ethnic Disparities in Short-Stay Total Knee Arthroplasty

BackgroundThe purpose of this study was to understand racial and ethnic disparities in hospital-based, Medicare-defined outpatient total knee arthroplasty (TKA). We aimed to determine the following: 1) whether there are differences in preoperative characteristics or postoperative outcomes in outpatient TKA between racial/ethnic groups and 2) trends in outpatient TKA volume, based on race/ethnicity. MethodsThis was a retrospective cohort study of a large national database. Outpatient TKAs performed between 2012 and 2018 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were compared between White, Black, Asian, and Hispanic patients. ResultsOf 54,183 outpatient patients, 85.6% were White, 7.4% Black, 2.6% Asian, and 4.1% Hispanic. Black patients had the highest body mass index, and there were higher rates of diabetes among all minority groups (P < .001). All minority groups were more likely to be discharged to a rehabilitation or a skilled care facility compared to White patients (P < .001). Annual percentage increases in outpatient TKA were most pronounced for Asians and Hispanics and least pronounced among Blacks, when compared to White patients. ConclusionThe outcomes of outpatient TKA are impacted by risk factors that reflect underlying disparities in healthcare. As joint arthroplasties have come off the inpatient-only list and procedures move to ambulatory settings, these disparities will likely magnify and impact outcomes, costs, and access points. Extensive preoperative optimization and interventions that target medical and social factors may help to reduce these disparities in TKA and increase access among minority patients. Level of EvidenceIII, retrospective cohort study.

The long-term risks of venous thromboembolism among non-operatively managed spinal fracture patients: A nationwide analysis

IntroductionLong-term readmission data for venous thromboembolism (VTE) after spinal fractures is limited. We aimed to evaluate the 1-month and 6-month VTE readmission rates in non-operatively managed traumatic spinal fractures. MethodsAnalysis of the 2017 NRD. Adults (≥18 years) with a primary diagnosis of spinal fracture who were managed non-operatively were included. Patients that died on index admission, were on pre-injury anticoagulants, and those with spinal cord injuries were excluded. Outcomes were rates of DVT, PE, and VTE during index admission, and at 1-month and 6-months after discharge. Multivariate regression analysis was performed to identify independent predictors of 6-month readmission with VTE. Results41,337 patients were identified. Mean age was 61 ± 22 years, and the median ISS was 17[9–22]. Vertebral fractures were: 11% sacrococcygeal; 29% lumbar; 19% thoracic; 20% cervical; and 21% multiple levels. During the index admission, 392(0.9%) patients developed DVT, 281(0.7%) developed PE, and 601(1.5%) VTE. Within 1-month of discharge, 177(0.4%) patients were readmitted with DVT, 142(0.3%) with PE, and 268(0.6%) with VTE. Within 6-months of discharge, 352(0.9%) patients were readmitted with DVT, 250(0.6%) with PE, and 513(1.2%) with VTE. Among those who were readmitted within 6-months with VTE, mortality was 6.7%. On multivariate analysis, older age(OR = 1.01,p < 0.01), higher ISS(OR = 1.03,p < 0.001), thoracic level of spinal fracture(OR = 1.37,p = 0.04), and discharge to skilled nursing facility, rehabilitation center, or care facility(OR = 1.73,p < 0.001) were independently associated with 6-month readmission due to VTE. ConclusionsVTE risk and associated mortality remains high for 6-months after non-operatively managed traumatic spinal fracture. Further studies regarding optimal duration and choice of thromboprophylactic agents are warranted.

Investigating proficiency using a lift-type transfer support device for effective care: comparison of skilled and unskilled nursing homes

Purpose The purpose of the study was to investigate whether the sustained use of the "Hug," a "hugging" type robotic transfer support device, could increase the level of quality of care. Methods The effect of proficiency on using the device was examined in terms of time spent for transfer, ratio of transfers using the device, and range of targets. The results were compared between skilled care facilities that had used the device for >24 months and unskilled facilities. Results The time spent for transfer at the unskilled facility was 4.6 min (2nd week after introduction), was reduced to 3.0 min (5th week), and 1.5 min at the skilled facility. The usage ratio at the unskilled facility was 13% and 30% (2nd and 5th week, respectively), while it was 97% in the skilled facility. Further, we identified wider in the range of target care recipients in the skilled facility. Conclusion It takes time to master the use of Hug; however, its use was associated with many positive aspects, especially from the perspective of care recipients, e.g., better care, use of their own legs, and reduced time for transfers. These findings suggest that the widespread use of Hug would improve the quality of care. IMPLICATIONS FOR REHABILITATION Less physically burdened on the caregivers using Hug, they can afford to talk to the care recipients. Using recipient’s own legs during transfers, it prevents leg muscle disuse. As reduced time for transfers, recipients will have more opportunities to get out of bed.

Association of Language Barriers With Process Outcomes After Craniotomy for Brain Tumor.

Little is known about the independent association of language barriers on postoperative process outcomes after craniotomies. To evaluate the association of limited English proficiency (LEP) with length of stay (LOS), discharge disposition, hospitalization costs, and rate of 30-day readmission after craniotomy for brain tumor. This is a retrospective cohort study of adult patients who underwent craniotomies for brain tumor from 2015 to 2019 at a high-volume neurosurgical center. Multivariable logistic regression was used to evaluate the association of LEP with discharge disposition and 30-day readmission. Negative binomial regression was used to evaluate the association of LEP with LOS and hospitalization cost. Of the 2232 patients included, 7% had LEP. LEP patients had longer LOS (median [IQR] 5 [3-8] days vs 3 [2-5] days, P &lt; .001), higher costs of hospitalization (median [IQR] $27 000 [$21 000-$36 000] vs $23 000 [$19 000-$30 000], P &lt; .001), and were more likely to be discharged to skilled care facilities (37% vs 21%, P &lt; .001) compared with English proficient patients. In multivariable models, the association between LEP and longer LOS (incidence rate ratio 1.11, 95% CI 1.00-1.24), higher hospitalization costs (incidence rate ratio 1.13, 95% CI 1.05-1.20), and discharge to skilled care (OR 1.76, 95% CI 1.13-2.72) remained after adjusting for confounders. There was no difference in 30-day readmission rates by language status. LEP is an independent risk factor for extended LOS, higher hospitalization cost, and discharge to skilled care in neurosurgical patients who undergo craniotomy for brain tumor. Future research should seek to understand mediators of these observed disparities.

Evaluating the Impact of Community Gardening on Sense of Purpose for Persons Living with Dementia: A Cluster-Randomized Pilot Study.

Background:Gardening has been shown to have positive effects on persons living with dementia, but no studies have explored the effects of gardening on sense of purpose.Objective:Explore how gardening may influence sense of purpose for people with dementia.Methods:Ten residents with dementia diagnoses living in a skilled care facility participated in hour-long gardening sessions twice weekly at outdoor raised beds over a two-month duration. One group (n = 5) donated vegetables to a food pantry while the other (n = 5) harvested produce for personal use. Semi-structured interviews with participants and their caregivers conducted post-intervention were analyzed for themes.Results:Participants and caregivers reported biopsychosocial benefits of gardening, identifying four main themes: 1) Gardening outdoors provided specific physical benefits that improved quality of life; 2) Working on a project in a group setting improved mood and fostered a sense of community; 3) Gardening promoted reminiscence and reinforced a sense of self; 4) Gardening provided participants with a sense of purpose and pride.Conclusion:Gardening has biopsychosocial benefits for persons living with dementia, and there appears to be additive benefit linked to improved sense of purpose via charitable giving.

Understanding Psychosocial Dimensions of Geriatric Patients with Effective and Efficient Approach: Comprehensive and Contributing Factors

Aim: Background research looked at the demographics of senior patients with psychosocial difficulties around the world, as well as the impact of medical and psychiatric social workers on the old patients' recovery. Never before has the world's population been as mature as it is now. The research tool was ‘health status,' and psychological and social wellness were utilized to examine psychological difficulties connected with the gender of senior geriatric patients, as well as social problems. Increased mortality, prolonged length of stay, high rates of readmission, placement in a skilled care facility, delirium, and functional deterioration are all possible outcomes for the hospitalized senior. Individual patients and families, as well as the healthcare system as a whole, are affected by these outcomes in medical, emotional, and economic ways. Conclusion: Care for the aged must be approached in a specific psychological and functional context, in addition to disease-based management. In the case of approaching an elderly patient, a thorough geriatric assessment is essential.

Preparing for the New Normal: Chronicling the Impact of COVID-19 on Older Adults and Providers

COVID-19 and social distancing heralded an unprecedented change in the way older adults and health care providers live, work, socialize and manage their health. Early “calls-to-action” included the call for researchers to chronicle the impact of the COVID-19 pandemic on care of older adults to inform models of care and best practices in the new normal. This symposium explores the impact of COVID-19 on the health of older adults across the care continuum and healthcare delivery augmented by technology. The perspectives of older adults living in the community and providers who care for this population are highlighted. Additionally, there is a focus on the most vulnerable, those living in skilled care facilities and continuing care retirement communities. Fisher analyzes the key themes in 37 COVID-19 video communiques over 11 months at a continuing care retirement community. Sefcik explores coping strategies including outdoor activities among community-dwelling older adults. DiMaria-Ghalili examined patterns of physical and mental health, technology usage and loneliness in older adults, including those living in the community and a continuing care retirement community. Using longitudinal data and COVID-19 supplemental survey data from the National Health and Aging Trends Study, Huh-Yoo discusses disparities in online patient-provider communication and implications for the Post-COVID era. Coates discusses the facilitators and barriers perceived by interdisciplinary providers deploying telehealth during the COVID-19 pandemic and implications for healthcare delivery in older adults. The symposium will conclude with a discussion by Dr. Sefcik on the implications for research, practice and policy in the post COVID-19 era.

The Impact of Metabolic Syndrome on Microvascular Head and Neck Reconstruction: An ACS-NSQIP data analysis

BackgroundMetabolic syndrome (MetS) can predispose patients to poorer surgical outcomes. In this study, we sought to evaluate the impact of MetS on the postoperative outcomes of head and neck microvascular reconstruction. MethodsReview of the 2015–2019 NSQIP database identified 5,323 cases of microvascular reconstruction, of which 3,809 were head and neck cases. Of the included patients, 184 had MetS and 3625 did not. The groups were compared in terms of demographics and comorbidities. Postoperative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and nonhome discharge. ResultsThe MetS group had higher rates of medical complications (p<0.0001), sepsis (p=0.02), septic shock (p=0.01), and skilled care-discharge (p=0.0004). Analysis by flap type revealed that MetS patients receiving free skin flaps experienced higher rates of organ space infection (p=0.02), sepsis (p<0.0001), and lower home-discharge (p=0.01). In the free muscle group, superficial incisional infection (p=0.04), UTI (p=0.02), and septic shock (p=0.01) were higher in MetS patients. Stratification by surgical site showed that the occurrence of sepsis was significantly higher in the patients receiving microvascular flap reconstruction of the larynx (p=0.04) or tongue(p=0.03). Stratification of the MetS patients according to treatment for diabetes showed that patients receiving insulin experienced a higher rate of superficial incisional infection (p=0.04). A multivariate analysis verified significantly higher rates of medical complications (p<0.0001), sepsis (p=0.03) and septic shock (p=0.01) in the MetS group. ConclusionPatients with MetS undergoing head and neck microvascular reconstruction are at increased risk of postoperative medical complications, including sepsis and septic shock, and are more likely to be discharged to a skilled care facility. Surgical outcomes were found to depend on the type of flap and site of surgery.

Delirium and neuropsychological outcomes in critically Ill patients with COVID-19: a cohort study

ObjectiveTo characterise the clinical course of delirium for patients with COVID-19 in the intensive care unit, including postdischarge neuropsychological outcomes.DesignRetrospective chart review and prospective survey study.SettingIntensive care units, large academic...

Evaluation of Inappropriate COVID-19 RT-PCR Test Utilization at an Academic Medical Center.

BackgroundAn evolving COVID-19 testing landscape and issues with test supply allocation, especially in the current pandemic, has made it challenging for ordering providers. We audited orders of the Xpert® Xpress SARS-CoV-2 RT-PCR platform—the fastest of several other testing modalities available—to illuminate these challenges utilizing a multidisciplinary laboratory professional team consisting of a pathology resident and microbiology lab director.MethodsRetrospective review of the first five hundred Xpert® Xpress SARS-CoV-2 RT-PCR test orders from a 2-week period to determine test appropriateness based on the following indications: emergency surgery, emergent obstetric procedures, initial behavioral health admission, and later including discharge to skilled care facilities and pediatric admissions. Our hypothesis was that a significant proportion of orders for this testing platform were inappropriate.ResultsUpon review, a significant proportion of orders were incorrect, with 69.8% (n = 349, p < 0.0001) not meeting indications for rapid testing. Of all orders, 249 designated as emergency surgery were inappropriate, with 49.0% of those orders never proceeding with any surgical intervention; most of these were trauma related (64.6% were orders associated with a trauma unit).ConclusionsSignificant, pervasive inappropriate ordering practices were identified at this center. A laboratory professional team can be key to identifying problems in testing and play a significant role in combating inappropriate test utilization.

A mobile unit overcomes the challenges to monoclonal antibody infusion for COVID-19 in skilled care facilities.

BackgroundResidents of nursing homes and long‐term care facilities are at increased risk for severe coronavirus disease‐19 (COVID‐19) but may not be able to access monoclonal antibody therapies offered at outpatient infusion centers due to frailty and logistical issues. We describe a mobile monoclonal antibody infusion program for patients with COVID‐19 in skilled nursing facilities and provide descriptive data on its outcomes.DesignRetrospective cohort study.SettingCollaboration between Mayo Clinic and skilled nursing facilities in Southeast Minnesota was developed to administer anti‐spike monoclonal antibodies under the FDA Emergency Use Authorization.ParticipantsSeventy five residents of skilled nursing facilities at high risk of COVID‐19 complications.ExposureEmergency use treatment with bamlanivimab and casirivimab–imdevimab.MeasurementsHospitalization and medically attended visits.ResultsThe mobile infusion unit, staffed by Mayo Clinic Infusion Therapy registered nurses and supported by the skilled nursing facility staff, infused anti‐spike monoclonal antibodies to 45 of 75 patients (average age, 77.8 years) in December 2020. The infusions occurred at an average of 4.3 days after COVID‐19 diagnosis. Fourteen days after infusion, there were no deaths, two emergency department visits, and three hospitalizations, for a combined event rate of 11.1%. There was one reported adverse event.ConclusionThe implementation of a mobile infusion unit embedded in a collaborative process resulted in rapid infusion of monoclonal antibodies to high‐risk COVID‐19 patients in skilled nursing facilities, who would otherwise be unable to access the novel therapies. The therapies were well tolerated and appear beneficial. Further study is warranted to explore the scalability and efficacy of this program.

A history of Clostridioides difficile infection portends infection recurrence and worse outcomes after stoma reversal

BackgroundClostridioides difficile infection is reported to occur after 2.2% of colorectal operations and is associated with longer length of hospital stay, greater overall healthcare cost, and significant morbidity and mortality. The incidence of Clostridioides difficile infection is greatest after elective stoma reversal. The purpose of this study was to evaluate the effect of prior Clostridioides difficile infection on patients undergoing stoma reversal. We hypothesized that patients with a history of Clostridioides difficile infection who underwent stoma reversal will be at an increased risk of postoperative Clostridioides difficile infection compared with patients without a history of Clostridioides difficile infection. MethodsThis was an observational cohort study of patients undergoing elective stoma reversal surgery by colorectal surgeons at a single academic institution during a 10-year period. A prospectively maintained institutional database was queried to identify 454 patients who underwent stoma reversal surgery between January 1, 2007 and December 31, 2017. The primary outcomes were Clostridioides difficile infection after stoma reversal and time to Clostridioides difficile infection after bowel refunctionalization. Secondary outcomes included postoperative complications, length of hospital stay, discharge destination, and 30-day readmission rate. Univariate and multivariable logistic regression analyses were conducted to identify factors associated with Clostridioides difficile infection after stoma reversal. ResultsA total of 445 patients were identified who underwent elective stoma reversal, 42 of whom had a history of Clostridioides difficile infection before the stoma reversal. There were no significant differences in patient age, number of days diverted, or use of perioperative antibiotics between patients with and without a history of Clostridioides difficile infection. The incidence of postreversal Clostridioides difficile infection was 23.4% in patients with a history of Clostridioides difficile infection compared with 9.6% in patients with no Clostridioides difficile infection history (P = .004); however, time to Clostridioides difficile infection after reversal did not differ. History of Clostridioides difficile infection was also associated with greater risk of postoperative complications (26.2% vs 9.4%, P < .01), increased length of stay (3 vs 5 days postoperatively, P < .01), increased likelihood of discharge to a skilled-care facility (11.9% vs 6.2%, P < .01), and readmission (13.7 vs 31.0%, P < .01) within 30 days. In a multivariable logistic regression model, history of Clostridioides difficile infection, increased length of hospital stay, and discharge to a skilled facility were associated with increased risk of Clostridioides difficile infection after reversal, while proton pump inhibitors use was associated with decreased risk of Clostridioides difficile infection. ConclusionPatients with a prior history of Clostridioides difficile infection who underwent stoma reversal exhibited higher rates of postoperative Clostridioides difficile infection and were at greater risk of postoperative complications, discharge to a skilled facility, and 30-day readmission. Furthermore, research into interventions aimed at improving outcomes in this unique, high-risk population is needed.

Risk Factors for Discharge to a Non-Home Destination and Reoperation Following Outpatient Total Hip Arthroplasty (THA) in Medicare-Eligible Patients.

Introduction:The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only (IO) list in January 2020. Given this recommendation, we analyzed Medicare-eligible patients undergoing outpatient THA to understand risk factors for nonroutine discharge, reoperations, and readmissions.Materials and Methods:The 2015-2018 American College of Surgeons–National Surgical Quality Improvement Program database was queried using Current Procedural Terminology code 27130 for Medicare eligible patients (≥ 65 years of age) undergoing outpatient THA. Postoperative discharge destination was categorized into home and non-home. Multivariate logistic regression models were used to evaluate risk factors associated with non-home discharge disposition. Secondarily, we evaluated rates and risk factors associated with 30-day reoperations and readmissions.Results:A total of 1095 THAs were retrieved for final analysis. A total of 108 patients (9.9%) experienced a non-home discharge postoperatively. Patients were discharged to rehab (n = 47; 4.3%), a skilled care facility (n = 47; 4.3%), a facility that was “home” (n = 8; 0.7%), a separate acute care facility (n = 5; 0.5%), or an unskilled facility (n = 1; 0.1%). Independent factors for a non-home discharge were American Society of Anesthesiologists Class >II (odds ratio [OR] 2.74), operative time >80 minutes (OR 2.42), age >70 years (OR 2.20), and female gender (OR 1.67). Eighteen patients (1.6%) required an unplanned reoperation within 30 days. A total of 40 patients (3.7%) required 30-day readmissions, with 35 readmissions related to the original THA procedure. Independent risk factors for 30-day reoperation were COPD (OR 5.85) and HTN (OR 5.24). Independent risk factors for 30-day readmission were HTN (OR 4.35) and Age >70 (OR 2.48).Discussion:The current study identifies significant predictors associated with a non-home discharge, reoperation, and readmission in Medicare-aged patients undergoing outpatient THA.Conclusion:Providers should consider preoperatively risk-stratifying patients to reduce the costs associated with unplanned discharge destination, complication or reoperation.

A Fall Within 3 Months Before Total Joint Arthroplasty is Associated With Adverse Outcomes in Elderly Patients

BackgroundFalls are associated with morbidity and death in the elderly. The consequences of falls after total joint arthroplasty (TJA) are known, but the consequences of preoperative falls are unclear. We assessed associations between preoperative fall history and hospital readmission rates and discharge disposition after primary TJA. MethodsWe queried the National Surgical Quality Improvement Program Geriatric Pilot Project for cases of primary total hip arthroplasty (THA) (n = 3671) and total knee arthroplasty (TKA) (n = 6194) performed between 2014 and 2018 for patients aged ≥65 years. Patient characteristics, comorbidities, functional status indicators, and 30-day outcomes were compared among patients with falls occurring within 3 months, from >3 to 6 months, and from >6 to 12 months before surgery, and patients with no falls in the year before surgery. The timing of falls was assessed for independent associations with hospital readmission and discharge to a skilled care facility (SCF). Alpha = 0.05. ResultsPatients who fell within 3 months before surgery had greater odds of SCF discharge (for THA, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.8-3.4; for TKA, OR 1.8, 95% CI 1.4-2.3) and hospital readmission (for THA, OR 1.8, 95% CI 1.1-3.0; for TKA, OR 2.4, 95% CI 1.6-3.5) compared with the no-fall cohort. No such associations were observed for the other two fall cohorts. ConclusionFalls within 3 months before primary TJA are associated with SCF discharge and readmission for patients aged ≥65 years. Fall history screening should be included in preoperative evaluation. Level of EvidenceIII.