Admission Source Research Articles

P-1572. Epidemiology and Risk Factors for Altered Mental Status Induced by Urinary Tract Infections Amongst Elderly Hospitalized Patients

Abstract Background Elderly patients with urinary tract infections (UTIs) often present with atypical symptoms including altered mental status (AMS). Although UTI-induced AMS is typically reversible, these patients often experience complications and a longer hospital stay. There is a paucity of data on the incidence and risk factors for UTI-induced AMS in elderly patients. The purpose of this study was to describe the epidemiology and risk factors for AMS in elderly patients hospitalized with UTIs.Table 1.Bivariate Comparison of Baseline Characteristics between Patients with and without UTI-induced Altered Mental Status (AMS) χ2 test, Student’s t-test, or Fisher’s exact test for variable comparisons. Methods A retrospective study of hospitalized patients ≥ 70 years of age with a UTI at AtlantiCare Regional Medical Center between 1/2023-12/2023 was performed. Subjects with UTI were categorized in 2 groups, those with new onset UTI-induced AMS and those without AMS. Admitting providers determined the presence of AMS defined as new onset delirium or a significant change in mental status from baseline. Patients were excluded if they displayed evidence of AMS prior to their UTI or had a new comorbid condition at admission that could precipitate AMS. Data collection included patient demographics, body mass index, weight, admission source, comorbid conditions, presence of urinary instrumentation, and concurrent medications. Bivariate analyses were completed for baseline characteristics between patients with and without UTI-induced AMS. Log-binomial regression was performed to determine factors independently associated with the presence of UTI-induced AMS.Table 2.Baseline Characteristics Associated with UTI-induced Altered Mental Status (AMS) in the Log-Binomial Regression Analysis Results In total, 100 patients met the study criteria. The mean (SD) age was 74.8 (4.8) years, 54% were female, 15% were admitted from a long-term care facility, and 24% had an indwelling urinary catheter. Comparison of baseline characteristics between patients with and without UTI-induced AMS is shown in Table 1. In the log-binomial regression, female gender [risk ratio (RR) of 4.7, 95% CI: 1.6-13.8], presence of a urinary catheter (RR of 4.5, 95% CI: 1.6-13.0), and age ≥ 80 years (RR of 2.4, 95% CI: 1.1-5.1) were independently associated with UTI-induced AMS (Table 2). Conclusion Identified risk factors for UTI-induced AMS included female gender, presence of an indwelling urinary catheter, and age 80 years or greater. Further studies are warranted to determine the clinical implications and significance of these potential risk factors. Disclosures Joseph Reilly, B.S., Pharm.D., Melinta Therapeutics: Advisor/Consultant Thomas Lodise, Jr., Pharm.D., PhD, MERCK: Advisor/Consultant

P-1700. Benchmarking Clinical Outcomes by Antimicrobial Spectrum in Patients with Community-Acquired Pneumonia

Abstract Background Antimicrobial benchmarking provides insight into practice variation relative to peers and outcomes relative to projections. Incorporation of patient-level risk-adjustment amplifies the validity and utility of data generated. The Vizient Clinical Data Base (CDB) is a healthcare analytics platform incorporating granular patient-level data from over 1,100 US hospitals and can be used to benchmark patient outcomes. The CDB’s multi-variate 2023 Academic Medical Center Risk Model is validated to produce reliable estimates for patient outcomes. Methods The CDB evaluated length of stay (LOS) and mortality for hospital admissions for community-acquired pneumonia (CAP). Admissions in CY2023 were included when labeled with a principal ICD-10 code for bacterial pneumonia, adjudicated as present on admission, and when the admission source was an outpatient location. Compared to the observed LOS, the risk model computed expected LOS (eLOS) and produced an observed to expected (O:E) index; a similar O:E index was created for mortality. Those who received narrow-spectrum (NS) antimicrobials, defined as ceftriaxone plus either azithromycin (CA) or doxycycline (CD), or levofloxacin or moxifloxacin (FLQ) monotherapy, were compared to patients who received broad-spectrum (BS) therapy, defined as vancomycin plus either piperacillin/tazobactam (VPT) or cefepime (VCP). Admissions attributed to the NS cohort did not receive any doses of a BS (VPT/VCP) antimicrobial and vice versa. Admissions were limited to those with eLOS of 3-7 days to balance medical complexity between NS and BS cohorts and limit confounding amongst eLOS, morality estimates, and antimicrobial prescribing. Results A principal diagnosis of CAP was assigned to 46,585 admissions. The LOS index was < 1 for NS regimens, but > 1 for those receiving BS therapy (Table 1). All deviations were statistically significant. The mortality index was < 1 for all antimicrobial combinations; however, it was significantly lower than expected (p < 0.01) for NS regimens (CA 0.36; CD 0.27; FLQ 0.52), but not for VPT 0.81 or VCP 0.95 (p > 0.05). Conclusion After risk-adjusting for patient-level confounders impacting LOS and mortality, the use of NS antimicrobials for the treatment of CAP was associated with better outcomes than BS antimicrobials. Disclosures Kirthana Beaulac, PharmD, Abbvie: Honoraria Pratish C. Patel, PharmD, BCIDP, AAHIVP, VBI Vaccines: Stocks/Bonds (Public Company)

P-289. Short-Duration vs. Long-Duration of Therapy for Hospital-Acquired or Ventilator-Associated Pneumonia due to Multi-Drug Resistant Pseudomonas aeruginosa

Abstract Background The duration of therapy for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP) due to non-lactose fermenter Gram-negatives bacilli including Pseudomonas aeruginosa (PsA) remains a topic of debate. Our study aimed to compare the efficacy of short-duration (≤8 days) to long-duration ( >8 days) therapy for HAP/VAP due to multi-drug resistant (MDR) or difficult-to-treat (DTR) PsA infection. Methods A two-center, retrospective cohort study was conducted from 5/2010 to 12/2022. We included all patients ≥18 years old with HAP or VAP due to MDR- or DTR-PsA in respiratory cultures who were treated for ≥72 hours. The primary outcome was a 30-day recurrence from the index culture, and the secondary outcomes were a 60-day recurrence, 30-day, and 60-day mortality from the index culture. Results Overall, 203 patients (short duration, n=91 and long duration, n=112) were included. Sixty-nine percent were male, and 58.6% were of African American descent. The mean (SD) for age and APACHE II score were 58.5 (15.8) and 23.9 (7.9), respectively. The common comorbidities were diabetes (39.9%), cerebrovascular disease (28.6%), and chronic obstructive pulmonary disease (24.1%). The primary admission source was a nursing home (44.8%). VAP was diagnosed in 53.0% of patients, with DTR-PsA accounting for 58.1% of all infections. Polymicrobial infection was present in 20.1% of the cases with Enterobactarales species present in all cases. Ceftazidime-avibactam and ceftolozane-tazobactam were used for treatment in 33.0% and 47.8%, respectively; combination therapy was used for 11.8% of cases. The 30-day recurrence was significantly lower in the long-duration therapy compared with the short-duration (5.4% vs. 15.9%, p = 0.017). Similarly, there was a lower 60-day recurrence rate in the long-duration group vs. short-duration group (8.9% vs. 24.4%, p=0.026). There were no significant differences in 30-day and 60-day mortality rates observed. Conclusion Prolonged duration ( >8 days) has resulted in lower recurrence rates of HAP/VAP caused by MDR/DTR PsA infection at 30 and 60 days. Although our study is insightful, a larger-scale study is necessary, and logistic regression should be conducted to determine the predictors of the significant differences in the primary outcome. Disclosures Kaylee E. Caniff, PharmD, BCIDP, T2Biosystems: Honoraria Michael J. Rybak, PharmD, PhD, MPH, Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Advisor/Consultant|Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Grant/Research Support|Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Speaker

Sepsis Epidemiology and Outcomes in Pediatric Intensive Care Unit of Alkhadra Hospital, Tripoli, Libya

Despite the various interventions and therapies that have been implemented to improve the quality of life for children with sepsis, the prevalence and death rates continue to increase. This issue is a major public health problem that requires the continuous improvement of the guidelines and the identification of new strategies. The aim of the study was to identify the prevalence and outcomes of severe sepsis among children admitted to the Pediatric Intensive Care Unit (PICU). This study was conducted in PICU of Alkhadra Hospital in 2023 as a hospital-based retrospective study. All children who were admitted to the PICU from 2017 to 2022 were included. Data was collected from hospital file records, which included the following: age of patient, gender, comorbidities of patients, and source of admission; origin of sepsis; type of PICU admission; primary site of infection; organ dysfunction present at screening; and patient outcomes. Of the 1284 total admissions to the PICU, 128 patients (9.96%) met the definition of sepsis. Most patients (78.9%) were less than 6 years old. Respiratory problems and congenital malformations were the most common co-morbidities, with reported rates of 18.8% and 10.2%, respectively. The emergency department was the most common source of admission (67.2%). Nearly all patients had good overall performance, whereas (21.1%) of the patients were in a coma. 77.3% discharged during the study, and 22.7% died. Although decreasing the incidence through preventive measures is ideal, early recognition and treatment of sepsis will decrease both short- and long-term complications and related mortality of at-risk infants and children.

Supporting long-term condition management: a workflow framework for the co-development and operationalization of machine learning models using electronic health record data insights.

The prevalence of long-term conditions such as cardiovascular disease, chronic obstructive pulmonary disease (COPD), asthma, and diabetes mellitus is rising. These conditions are leading sources of premature mortality, hospital admission, and healthcare expenditure. Machine learning approaches to improve the management of these conditions have been widely explored, with data-driven insights demonstrating the potential to support earlier diagnosis, triage, and treatment selection. The translation of this research into tools used in live clinical practice has however been limited, with many projects lacking clinical involvement and planning beyond the initial model development stage. To support the move toward a more coordinated and collaborative working process from concept to investigative use in a live clinical environment, we present a multistage workflow framework for the co-development and operationalization of machine learning models which use routine clinical data derived from electronic health records. The approach outlined in this framework has been informed by our multidisciplinary team's experience of co-developing and operationalizing risk prediction models for COPD within NHS Greater Glasgow & Clyde. In this paper, we provide a detailed overview of this framework, alongside a description of the development and operationalization of two of these risk-prediction models as case studies of this approach.

Admission Patterns and Patient Outcomes in Intensive Care Delivery at a Rural Tertiary Hospital in Southern Nigeria: A Five-Year Retrospective Review.

Background Intensive care units (ICUs) play a vital role in managing critically ill patients, yet data on admission patterns and outcomes in rural healthcare settings, particularly in Nigeria, remain limited. Understanding these patterns is essential for improving patient care, especially in resource-limited, rural settings. This study aimed to investigate the admission and outcome patterns of patients admitted to the ICU at Irrua Specialist Teaching Hospital (ISTH), located in a rural part of Edo State, Nigeria. Method This was a retrospective study conducted at ISTH. Data on biodata, primary admission diagnosis, duration of admission, and patient outcomes were collected from the ICU register for all patients admitted to the ICU over a five-year period, from January 1, 2019, to December 31, 2023, and analyzed. Results During the five-year study period, there were 581 ICU admissions, of which 575 (99%) were included in the study after excluding six (1%) due to incomplete data. Among the patients, 297 (51.7%) were female. The young and middle-aged group (20-59 years) accounted for 60% (365) of admissions. Surgical cases comprised the majority of admissions at 57.9% (333), followed by medical cases at 25.9% (149) and obstetric/gynecologic casesat 16.2% (93). The most common sources of admission were general surgery (211, 36.7%), obstetrics (75, 13%), and neurosurgery (43, 7.5%), with the most frequent diagnoses being generalized peritonitis secondary to perforated viscus (102, 17.7%), bowel obstruction (36, 6.3%), preeclampsia/eclampsia (28,4.9%), traumatic brain injury (TBI) (27, 4.7%), and stroke (26, 4.5%). The overall mortality rate was 49.2%and was significantly associated with age, duration of admission, type of case, and subspecialty (p < 0.05). Conclusion The study highlights admission and outcome patterns that reflect the challenges faced in rural ICU settings. The high mortality rate highlights the need for improved critical care resources and targetedinterventions to improve outcomes of critically ill patients in similar resource-limited settings.

Bridging The Gap: Between an Older Adult Attending The Ambulatory Day Unit and An Acute Hospital Presentation

Abstract Background Older adults attending the ambulatory day units within the hospital group have a comprehensive geriatric assessment (CGA) completed. This identifies the older adult’s functional, physical, social, environmental and psychological baseline, in order to develop and implement a coordinated plan of care and follow up. The CGA is the gold standard in caring for older adults who are frail or at risk of frailty (HSE, 2016). The units are off site from the main hospital, therefore valuable information may not be available to the acute hospital. Valuable information from the CGA can provide the older adult’s functional and cognitive baseline and prevent unnecessary duplication of assessments and increased length of stay. Methods Plan-Do- Study-Act (PDSA) cycle was used. A questionnaire was produced to ascertain acute care staff’s understanding of; whether an older adult is attending the ambulatory unit? Would this information and a review by the RANP Gerontology be beneficial? A Registered Advanced Nurse Practitioner (RANP) Gerontology Pathway was developed. Education was provided to nursing, and the wider multidisciplinary team. An alert sheet was introduced and provided to older adult attending the ambulatory day units. The alert was for the older adult to produce, if attending or admitted to the acute hospital. This initiates the RANP pathway. Older adults are then seen by the RANP at source of admission. Clinic letters with baseline is documented in the Healthcare record, including advice plan and follow-up. Post-implementation questionnaire and verbal feedback were obtained. Results Positive feedback from older adults, family and staff. Avoidance of unnecessary duplication of assessments, data sharing, optimization of plan of care, treatment and rehabilitation potential. Effective discharge planning, reduction of unnecessary transfer to residential care. Conclusion Bridging the gap promotes positive outcomes: Reducing length of stay, positive impact on overall wellbeing, and an organizational cost containment.

Pattern of admission and outcome at a newly established sickle cell center in Nigeria

Background: Sickle cell disease (SCD) encompasses a group of autosomal recessive haemoglobinopathies whose genetic mutation leads to the replacement of glutamic acid by valine in position 6 of the beta-globin chain. Most of the world’s SCD burden is in Africa, where it is a major contributor to childhood morbidity and mortality. The study is aimed at determining the pattern of admission and outcome of patients seen at the sickle cell center Asaba, over a two-year period January 2022 to December 2023. Methods: This was a retrospective descriptive study of children with SCD admitted into the sickle cell center of the Asaba specialist hospital. Information obtained included age, gender, diagnosis, month and year of admission, and outcome. Descriptive statistics was used to describe the demographic characteristics and chi-square to assess their association. Results: A total of 338 children were seen, 34.5% of the patients were less than 5 years of age; males were 52.6% while 61.6% of the admission occurred during the rainy season. Vaso-occlusive crisis (80.6%) was the most common crisis seen; malaria (51.9%) was the prominent diagnosis made. Case fatality rate was 1.7%. Conclusions: SCD s remains a major source of admission and mortality in our environment. A comprehensive SCD care plan is needed to reduce the adverse consequences associated with this disease.

The effects of geometric factors on power generation performance in solar chimney power plants

This research aims to create an admissible source for specifying the relation between the plant's output power and specified geometrical parameters unique to each simulated chimney dimension. In the current study, the solar chimney output power has been studied considering 49 solar chimneys, including different collector diameters, chimney heights, and chimney diameters. The study employs the Ansys-CFX to simulate the numerical model for the unsteady k-ε turbulent flow for a vast number of geometries. The obtained results indicate that the velocity as the main factor in generating the output power has significantly improved by elevating the collector radius. The output power increased up to 50 % by elevating the collector radius and around 30 % by enhancing the chimney heights which cause an increase in airflow, temperature differentials. Moreover, increasing the chimney height has generally ascended the power plant system. Among all geometrical parameters, chimney radius had the least impact on solar chimney performance. The results indicate that the best ratio between collector radius and chimney height is 6 %–10 % to achieve the optimized output power. Our findings were verified with the available experimental setups.

The impact of hospital saturation on non-COVID-19 hospital mortality during the pandemic in France: a national population-based cohort study

BackgroundA previous study reported significant excess mortality among non-COVID-19 patients due to disrupted surgical care caused by resource prioritization for COVID-19 cases in France. The primary objective was to investigate if a similar impact occurred for medical conditions and determine the effect of hospital saturation on non-COVID-19 hospital mortality during the first year of the pandemic in France.MethodsWe conducted a nationwide population-based cohort study including all adult patients hospitalized for non-COVID-19 acute medical conditions in France between March 1, 2020 and 31 May, 2020 (1st wave) and September 1, 2020 and December 31, 2020 (2nd wave). Hospital saturation was categorized into four levels based on weekly bed occupancy for COVID-19: no saturation (< 5%), low saturation (> 5% and ≤ 15%), moderate saturation (> 15% and ≤ 30%), and high saturation (> 30%). Multivariate generalized linear model analyzed the association between hospital saturation and mortality with adjustment for age, sex, COVID-19 wave, Charlson Comorbidity Index, case-mix, source of hospital admission, ICU admission, category of hospital and region of residence.ResultsA total of 2,264,871 adult patients were hospitalized for acute medical conditions. In the multivariate analysis, the hospital mortality was significantly higher in low saturated hospitals (adjusted Odds Ratio/aOR = 1.05, 95% CI [1.34–1.07], P < .001), moderate saturated hospitals (aOR = 1.12, 95% CI [1.09–1.14], P < .001), and highly saturated hospitals (aOR = 1.25, 95% CI [1.21–1.30], P < .001) compared to non-saturated hospitals. The proportion of deaths outside ICU was higher in highly saturated hospitals (87%) compared to non-, low- or moderate saturated hospitals (81–84%). The negative impact of hospital saturation on mortality was more pronounced in patients older than 65 years, those with fewer comorbidities (Charlson 1–2 and 3 vs. 0), patients with cancer, nervous and mental diseases, those admitted from home or through the emergency room (compared to transfers from other hospital wards), and those not admitted to the intensive care unit.ConclusionsOur study reveals a noteworthy “dose-effect” relationship: as hospital saturation intensifies, the non-COVID-19 hospital mortality risk also increases. These results raise concerns regarding hospitals’ resilience and patient safety, underscoring the importance of identifying targeted strategies to enhance resilience for the future, particularly for high-risk patients.

Clinical Outcomes Following Operative and Nonoperative Management of Odontoid Fractures Among Elderly Individuals with Dementia.

The incidence of odontoid fractures among the elderly population has been increasing in recent years. Elderly individuals with dementia may be at increased risk for inferior outcomes following such fractures. Although surgical intervention has been maintained to optimize survival and recovery, it is unclear if this benefit extends to patients with dementia. We hypothesized that patients with dementia who were treated operatively for odontoid fractures would experience improved survival and lower rates of hospice admission but higher rates of delirium and of intensive interventions. We used Medicare claims data (2017 to 2018) to identify community-dwelling individuals with dementia who sustained type-II odontoid fractures. We considered treatment strategy (operative or nonoperative) as the primary predictor and survival as the primary outcome. The secondary outcomes consisted of post-treatment delirium, hospice admission, post-treatment intensive intervention, and post-discharge admission to a nursing home or a skilled nursing facility. In all models, we controlled for age, biological sex, race, Elixhauser Comorbidity Index, Frailty Index, admission source, treating hospital, and dual eligibility. Adjusted analyses for survival were conducted using Cox proportional hazards regression. Adjusted analyses for secondary outcomes were performed using generalized estimating equations. To address confounding by indication, we performed confirmatory analyses using inverse probability of treatment weighting. In this study, we included 1,030 patients. The median age of the cohort was 86.5 years (interquartile range, 80.9 to 90.8 years), 60.7% of the patients were female, and 90% of the patients were White. A surgical procedure was performed in 19.8% of the cohort. Following an adjusted analysis, patients treated surgically had a 28% lower hazard of mortality (hazard ratio, 0.72 [95% confidence interval (CI), 0.53 to 0.98]), but higher odds of delirium (odds ratio, 1.64 [95% CI, 1.10 to 2.44]). These findings were preserved in the inverse probability weighted analysis. We found that, among individuals with dementia who sustain a type-II odontoid fracture, surgical intervention may confer a survival benefit. A surgical procedure may be an appropriate treatment strategy for individuals with dementia whose life-care goals include life prolongation and maximizing quality of life in the short term following an injury. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Lost in transition: Impact of interhospital transfer on outcomes after emergency general surgery in the older adult population

BackgroundEmergency general surgery performed among patients over 65 years of age represents a particularly high-risk population. Although interhospital transfer has been linked to higher mortality in emergency general surgery patients, its impact on outcomes in the geriatric population remains uncertain. We aimed to establish the effect of interhospital transfer on postoperative outcomes in geriatric emergency general surgery patients. MethodsEmergency general surgery patients 65 years and older were identified with American College of Surgeons National Surgical Quality Improvement Program 2013 to 2019. Patients were categorized based on admission source as either directly admitted or transferred from an outside hospital inpatient unit or emergency department. The primary outcomes evaluated were in-hospital mortality, 30-day mortality, and overall morbidity. Propensity score matching was used to control for confounders, including age, race, comorbidities, and preoperative conditions. Kaplan-Meier survival analysis and the log-rank test were used to compare 30-day survival in the matched cohort. ResultsAmong the 88,424 patients identified, 13,872 (15.7%) were transfer patients. The median age was 74, and 53% were of female sex. Transfer patients had higher rates of comorbidities and preoperative conditions, including a higher prevalence of preoperative sepsis (21.8% vs 19.3%, P < .001) and ventilator dependence (6.4% vs 2.6%, P < .001). After propensity score-matched analysis, transferred patients exhibited higher rates of in-hospital mortality, 30-day mortality, and overall morbidity. Transfer patients were also less likely to be discharged home and more likely to be discharged to an acute care facility. Kaplan-Meier survival analysis confirmed a poorer 30-day survival in transferred patients. ConclusionInterhospital transfer independently contributed to overall mortality and morbidity amongst geriatric emergency general surgery patients. Further investigation into improved coordination between hospitals, tailored care plans, and comprehensive risk assessments are needed to help mitigate the observed differences in outcomes.

Higher mortality among off-hours versus regular-hours admissions to the cardiac intensive care unit (CICU): insights from the critical care cardiology trials network registry (CCCTN)

Abstract Funding Acknowledgements None. Background The outcomes of patients admitted to general intensive care units vary significantly according to the time of admission. Whether this applies to the CICU setting is unknown. Purpose We sought to determine if patient characteristics, admission source, critical care therapy utilization, and clinical outcomes differ according to whether CICU admission occurred during regular-hours or off-hours. Methods CCCTN is a multicenter prospective registry of consecutive admissions to CICUs in North America coordinated by the TIMI Study Group. For this analysis of admissions during calendar year 2022, "regular-hours" was defined as 7 a.m.- 7 p.m. Monday-Friday, and "off-hours" was defined as 7 p.m.- 7 a.m. on weekdays or at any time on Saturday or Sunday. Logistic regression analysis was used to adjust in-hospital mortality rates for admission time (on-hours vs. off-hours), age, sex, SOFA score, and cardiac arrest. Results Among 5238 CICU admissions, 2956 (56.4%) occurred during off-hours. Patient demographics (mean age: 67.0 years, 35.7% female, 51.1% white) and comorbidities were generally similar among off-hours and regular-hours admissions. The median SOFA score was 3.0 in both groups. Compared to regular-hours admissions, off-hours admissions were more likely to originate from the ED (39.9% vs. 29.4%, p&amp;lt;0.0001) and less likely to originate from a procedural area (24.5% vs. 41.8%, p&amp;lt;0.0001). ST-elevation MI was a more common admission diagnosis among off-hours vs. regular-hours admissions (19.2% vs. 16.4%, p=0.009). Primary CICU indications of respiratory insufficiency, unstable arrhythmia, cardiac arrest, and distributive/mixed shock were more common among off-hours admissions (Table). Mechanical ventilation, IV vasoactive therapy, and targeted temperature management (TTM) were utilized more frequently among patients admitted during off-hours. Median ICU (2.5 vs. 2.0d) and hospital length of stay (6.2 vs. 5.8d) were longer for off-hours admissions (both p&amp;lt;0.0001). Crude CICU mortality (11.4% vs. 8.5%, p=0.0005) and in-hospital mortality (15.6% vs. 11.7%, p&amp;lt;0.0001) were significantly higher among off-hours admissions (Figure). After adjustment, off-hours admission remained significantly associated with higher in-hospital mortality (OR 1.2, 95% CI 1.02 – 1.49, p=0.03). Conclusions Off-hours and regular-hours admissions to the CICU had similar baseline characteristics but differed significantly regarding source of admission, indication for admission, and utilization of critical care therapies. These differences were associated with worse clinical outcomes among off-hours admissions, which may suggest the need for more intensive staffing in CICUs during these times.FigureTable

A multi-center validation of the electronic health record admission source and discharge location fields against the clinical notes for identifying inpatients with long-term care facility exposure.

Residence or recent stay in a long-term care facility (LTCF) is an important risk factor for antibiotic-resistant bacterial colonization. However, absent dedicated intake questionnaires or resource-intensive chart review, ascertaining LTCF exposure in inpatients is challenging. We aimed to validate the electronic health record (EHR) admission and discharge location fields against the clinical notes for identifying LTCF-exposed inpatients. We conducted a retrospective study of 1020 randomly sampled adult admissions between 2016 and 2021 across 12 University of Maryland Medical System hospitals. Using study-developed guidelines, we categorized the following data for LTCF exposure: each admission’s history & physical (H&P) note, each admission’s EHR-extracted “Admission Source,” and (3) the EHR-extracted admission and discharge locations for previous admissions (≤90 days). We estimated sensitivities, with 95% CIs, of H&P notes and of EHR admission/discharge location fields for detecting “current” and “any recent” (≤90 days, including current) LTCF exposure. For detecting current LTCF exposure, the sensitivity of the index admission’s EHR-extracted “Admission Source” was 46% (95% CI: 35%–58%) and of the H&P note was 92% (83%–97%). For detecting any recent LTCF exposure, the sensitivity of “Admission Source” across the index and previous admissions was 32% (24%–41%), “Discharge Location” across previous admission(s) was 57% (47%–66%), and of the H&P note was 68% (59%–76%). The combined sensitivity of admission source and discharge location for detecting any recent LTCF exposure was 76% (67%–83%). The EHR-obtained admission source and discharge location fields identified 76% of LTCF-exposed patients compared to chart review but disproportionately missed currently exposed patients.

Outcome of Cancer Patients with an Unplanned Intensive Care Unit Admission: Predictors of Mortality and Long-term Survival.

Understanding the characteristics and outcomes of cancer patients with unplanned ICU admission is imperative for therapeutic decisions and prognostication purposes. To describe the clinical characteristics of patients with hematological and non-hematological malignancies (NHM) who require unplanned ICU admission and to determine the predictors of mortality and long-term survival. This retrospective study included all patients with cancer who had an unplanned ICU admission between 2011 and 2016 at a tertiary hospital in Saudi Arabia. The following variables were collected: age, gender, ICU length of stay (LOS), APACHE II score, type of malignancy, febrile neutropenia, source and time of admission, and need for mechanical ventilation (MV), renal replacement therapy (RRT), and treatment with vasopressors (VP). Predictors of mortality and survival rates at 28 days and 3, 6, and 12 months were calculated. The study included 410 cancer patients with 466 unplanned ICU admissions. Of these, 52% had NHM. The average LOS in the ICU was 9.6 days and the mean APACHE score was 21.9. MV was needed in 73% of the patients, RRT in 15%, and VP in 24%, while febrile neutropenia was present in 24%. There were statistically significant differences between survivors and non-survivors in the APACHE II score (17.7 ± 8.0 vs. 25.6 ± 9.2), MV use (52% vs. 92%), need for RRT (6% vs. 23%), VP use (42% vs. 85%), and presence of febrile neutropenia (18% vs. 30%). The predictors of mortality were need for MV (OR = 4.97), VP (OR = 3.43), RRT (OR = 3.31), and APACHE II score (OR = 1.10). Survival rates at 28 days, 3, 6, and 12 months were 52%, 28%, 22%, and 15%, respectively. The survival rate of cancer patients with an unplanned admission to the ICU remains low. Predictors of mortality include need for MV, RRT, and VP and presence of febrile neutropenia. About 85% of cancer patients died within 1 year after ICU admission.

Understanding Pathways into Care-homes using Data (UnPiCD study): a two-part model to estimate inpatient and care-home costs using national linked health and social care data

BackgroundPathways into care-homes have been under-researched. Individuals who move-in to a care-home from hospital are clinically distinct from those moving-in from the community. However, it remains unclear whether the source of care-home admission has any implications in term of costs. Our aim was to quantify hospital and care-home costs for individuals newly moving-in to care homes to compare those moving-in from hospital to those moving-in from the community.MethodsUsing routinely-collected national social care and health data we constructed a cohort including people moving into care-homes from hospital and community settings between 01/04/2013-31/03/2015 based on records from the Scottish Care-Home Census (SCHC). Individual-level data were obtained from Scottish Morbidity Records (SMR01/04/50) and death records from National Records of Scotland (NRS). Unit costs were identified from NHS Scotland costs data and care-home costs from the SCHC. We used a two-part model to estimate costs conditional on having incurred positive costs. Additional analyses estimated differences in costs for the one-year period preceding and following care-home admission.ResultsWe included 14,877 individuals moving-in to a care-home, 8,472 (57%) from hospital, and 6,405 (43%) from the community. Individuals moving-in to care-homes from the community incurred higher costs at £27,117 (95% CI £ 26,641 to £ 27,594) than those moving-in from hospital with £24,426 (95% CI £ 24,037 to £ 24,814). Hospital costs incurred during the year preceding care-home admission were substantially higher (£8,323 (95% CI£8,168 to £8,477) compared to those incurred after moving-in to care-home (£1,670 (95% CI£1,591 to £1,750).ConclusionIndividuals moving-in from hospital and community have different needs, and this is reflected in the difference in costs incurred. The reduction in hospital costs in the year after moving-in to a care-home indicates the positive contribution of care-home residency in supporting those with complex needs. These data provide an important contribution to inform capacity planning on care provision for adults with complex needs and the costs of care provision.

Epidemiology of Craniomaxillofacial Fractures Over a 5-year Period at a Midwestern Level 1 Trauma Center Serving a Large Rural Population

Though the epidemiology of craniomaxillofacial (CMF) fractures has been well documented at urban hospitals, the characteristics of these fractures in rural hospitals have not been well studied. The purpose of this study is to report on the epidemiology of CMF fractures at a regional Level 1 trauma center serving a large rural population in central Illinois. This is a retrospective cohort study at a community-based regional tertiary referral center that serves a predominantly rural population. Inclusion criteria comprised patients with radiologically confirmed CMF fractures between 2015 and 2019. Patients with incomplete medical records were excluded. Predictor variables included demographics (age, admission source, race, and sex) and etiology of CMF fracture (assault/domestic violence, all-terrain vehicle/off-road, falls, farm-related, motor vehicle collisions, gunshot wound, and others). The primary outcome variable was the CMF anatomic location including nasal bone, orbit, mandible, malar/maxillary, and other CMF fractures. The covariates are not applicable. Descriptive statistics were used to summarize a sample of the population characteristics. Wilcoxon ranked sign tests and χ2 tests of independence were used to assess for statistically significant associations between select variables of interest. Statistical significance was defined as P<.05. Between 2015 and 2019, a total of 2,334 patients presented to the emergency department with a CMF fracture. After applying the inclusion/exclusion criteria, the final sample was composed of 1,844 patients for the management of 2,405 CMF fractures. The majority of patients were male(62.0%) and young adults (aged 18-39) had the highest number of CMF fractures (819) relative to all other age groups. The most common fracture etiology was fall(37.3%), and nasal bone fractures represented the most common fracture location(41.6%). χ2 analyses revealed statistically significant associations between the anatomic location of CMF fracture incurred, and differing categories of age, admission source, race, sex, and etiology. Our study shows that patients seen at our Midwestern Level 1 trauma center are more likely to present with nasal bone and malar/maxillary fractures due to falls. In studies based in urban centers, patients are likely to present with orbital and mandibular fractures due to falls and assault.

Preventing iatrogenic HCV infection: A quantitative risk assessment based on observational data in an Egyptian hospital.

When compliance with infection control recommendations is non-optimal, hospitals may play an important role in hepatitis C (HCV) transmission. However, few studies have analyzed the nosocomial HCV acquisition risk based on detailed empirical data. Here, we used data from a prospective cohort study conducted on 500 patients in the Ain Shams hospital (Cairo, Egypt) in 2017 with the objective of identifying (i) high-risk patient profiles and (ii) transmission hotspots within the hospital. Data included information on patient HCV status upon admission, their trajectories between wards and the invasive procedures they underwent. We first performed a sequence analysis to identify different hospitalization profiles. Second, we estimated each patient's individual risk of HCV acquisition based on ward-specific prevalence and procedures undergone, and risk hotspots by computing ward-level risks. Then, using a beta regression model, we evaluated upon-admission factors linked to HCV acquisition risk and built a score estimating the risk of HCV infection during hospitalization based on these factors. Finally, we assessed and compared ward-focused and patient-focused HCV control strategies. The sequence analysis based on patient trajectories allowed us to identify four distinct patient trajectory profiles. The risk of HCV infection was greater in the internal medicine department, compared to the surgery department (0·188% [0·142%-0·235%] vs. 0·043%, CI 95%: [0·036%-0·050%]), with risk hotspots in the geriatric, tropical medicine and intensive-care wards. Upon-admission risk predictors included source of admission, age, reason for hospitalization, and medical history. Interventions focused on the most at-risk patients were most effective to reduce HCV infection risk. Our results might help reduce the risk of HCV acquisition during hospitalization in Egypt by targeting enhanced control measures to ward-level transmission hotspots and to at-risk patients identified upon admission.

Determinants of Mortality of Patients Admitted to the Intensive Care Unit at Debre Berhan Comprehensive Specialized Hospital: A Retrospective Cohort Study.

The provision of intensive care services is advancing globally. However, in resource-limited settings, it is lagging far behind and intensive care unit mortality is still higher due to various reasons. This study aimed to assess determinants of mortality among medical patients admitted to the intensive care unit. A five-year facility-based retrospective Cohort Study was conducted. A total of 546 medical patients admitted to the intensive care unit from March 2017 to February 2022 were included. Document review using a structured questionnaire was implemented to collect data. Data entered into Epi Data were analyzed by STATA and summarized using frequency tables and graphs. Binary and multivariate logistic regression analyses were performed to identify determinants of mortality. The overall mortality was 35.9%. Approximately half of the deaths were attributed to septic shock, congestive heart failure, severe community-acquired pneumonia, and stroke. The most common immediate cause of death was cardio-respiratory arrest. Source of admission, GCS level at admission, duration of ICU stay, treatment with inotropes, septic shock, and retroviral infection status were found to have a statistically significant association with ICU mortality. This study revealed a significantly higher mortality rate among patients admitted to the intensive care unit. Early identification and admission of patients to the intensive care unit are important factors that could decrease mortality. Patient selection is essential since some patients with a high likelihood of mortality might not benefit from intensive care unit admission in an area with high resource limitations.

An explainable machine learning approach for hospital emergency department visits forecasting using continuous training and multi-model regression

Background and ObjectiveIn the last years, the Emergency Department (ED) has become an important source of admissions for hospitals. Since late 90s, the number of ED visits has been steadily increasing, and since Covid19 pandemic this trend has been much stronger. Accurate prediction of ED visits, even for moderate forecasting time-horizons, can definitively improve operational efficiency, quality of care, and patient outcomes in hospitals. MethodsIn this paper we propose two different interpretable approaches, based on Machine Learning algorithms, to accurately forecast hospital emergency visits. The proposed approaches involve a first step of data segmentation based on two different criteria, depending on the approach considered: first, a threshold-based strategy is adopted, where data is divided depending on the value of specific predictor variables. In a second approach, a cluster-based ensemble learning is proposed, in such a way that a clustering algorithm is applied to the training dataset, and ML models are then trained for each cluster. ResultsThe two proposed methodologies have been evaluated in real data from two hospital ED visits datasets in Spain. We have shown that the proposed approaches are able to obtain accurate ED visits forecasting, in short-term and also long-term prediction time-horizons up to one week, improving the efficiency of alternative prediction methods for this problem. ConclusionsThe proposed forecasting approaches have a strong emphasis on providing explainability to the problem. An analysis on which variables govern the problem and are pivotal for obtaining accurate predictions is finally carried out and included in the discussion of the paper.