Subacute Nursing Facility Research Articles

Abstract 280: Risk Factors in 90day Ischemic Stroke Readmissions

Introduction The purpose of this study is to conduct a retrospective Medicare Fee‐For‐Service medical claims analysis to identify risk factors associated with 30‐day and 90‐day readmissions in ischemic stroke patients. Methods The Centers for Medicare and Medicaid Services(CMS) Standard Analytic File(SAF) Limited Data Set(LDS) 100% Inpatient, Outpatient and Denominator files 2017‐2019 and ICD‐10‐CM diagnosis codes were used to identify ischemic stroke. Study Population includes all patients with an ischemic stroke inpatient admission in 2018 and were continuously enrolled with Medicare FFS for 1 year prior to and following their initial 2018 stroke admission. Factors considered in analysis include patient age, sex, geographic region, Medicaid dual eligibility, disability status prior to age 65, comorbidities, admission length of stay, discharge disposition, and hospital characteristics. Comorbidities were identified based on ICD‐10 codes on health claims for the full‐year preceding stroke and up to the index stroke hospitalization. We compared these factors among patients who were readmitted within 90‐days post initial stroke admission to those who were not admitted to identify risk factors for readmission Results Among the 200,058 patients discharged following an ischemic stroke in 2018, 25.9% (n=51,860) had an all‐cause 90‐day readmission. Fewer females and white individuals had a 90‐day readmission (53.5% female and 83.1% white in 90‐day population compared to 54.9% and 82.1% in study population). Discharge disposition of subacute nursing facility (SNF) represents 36.1% of the readmission population compared to 27.8% of the study population and 40.2% of those discharged home, in study population vs 36.0% of the readmission cohort. Characteristics that represent a larger portion of the 90‐day readmission cohort compared to the study population include disabled/ESRD (24.8% vs 20.6%) and dual eligible (26.9% vs 22.4%). Comorbidities with the greatest difference in prevalence between the 90‐day readmit and non‐readmit cohorts are coronary cardiac disease (60.48% prevalence in readmit cohort vs 52.62% in non‐readmit cohort), heart failure (37.85% vs 29.24%, diabetes 48.31% vs 42.08%), atrial fibrillation (40.45% vs 36.67%), and chronic kidney disease (39.82% vs 31.23%). In multivariate regression analysis, the factors independently associated with a greater risk of readmission within 90 days were hypercoagulation (1.359 [95%CI, 1.1274‐1.45]), opiod abuse and dependence (1.353 [95%CI, 1.238‐1.478]), chronic kidney disease (1.347 [95%CI, 1.316‐1.379]), liver disease (1.318 [95% CI, 1.26‐1.378]), and heart failure (1.282 [95%CI, 1.25‐1.315]). Conclusion Patient discharge disposition and comorbidities are driving factors in 90‐day readmissions following an ischemic stroke and differ from 30‐day readmissions. Idenfification of these risk factors will help inform the next phase of analysis to design data driven interventions to work towards reducing a large driver of healthcare cost.

Implications of COVID-19 on hip fracture care discharge locations during the early stages of the pandemic.

To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort. Retrospective cohort study. Academic medical center. Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020). Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility]. Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L). In COVID+ patients, 93% (13/14) were discharged to a facility, 62% (8/13) of whom passed away within 1 year of discharge. Of COVID+ patients discharged to an SNF, 80% (8/10) died within 1 year. Patients discharged to an SNF in 2020 were 1.8x more likely to die within 1 year compared with 2019 (P = 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes. All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic. III.

Post-operative neurosurgery outcomes by race/ethnicity among enhanced recovery after surgery (ERAS) participants

ObjectivePrior work reveals that Enhanced Recovery After Surgery (ERAS) programs decrease opioid use, improve mobilization, and shorten length of stay (LOS) among patients undergoing spine surgery. The impact of ERAS on outcomes by race/ethnicity is unknown. This study examined outcomes by race/ethnicity among neurosurgical patients enrolled in an ERAS program. MethodsPatients undergoing elective spine or peripheral nerve surgeries at a multi-hospital university health system from April 2017 to November 2020 were enrolled in an ERAS program that involves preoperative, perioperative, and postoperative phases focused on improving outcomes through measures such as specialty consultations for co-morbidities, multimodal analgesia, early mobilization, and wound care education. The following outcomes for ERAS patients were compared by race/ethnicity: length of stay, discharge disposition, complications, readmission, pain level at discharge, and post-operative health rating. We estimated the association between race/ethnicity and the outcomes using linear and logistic regression models adjusting for age, sex, insurance, BMI, comorbid conditions, and surgery type. ResultsAmong participants (n = 3449), 2874 (83.3%) were White and 575 (16.7%) were Black, Indigenous, and people of color (BIPOC). BIPOC patients had significantly longer mean length of stay compared to White patients (3.8 vs. 3.4 days, p = 0.005) and were significantly more likely to be discharged to a rehab or subacute nursing facility compared to White patients (adjusted odds ratio (95% CI): 3.01 (2.26–4.01), p < 0.001). The complication rate did not significantly differ between BIPOC and White patients (13.7% vs. 15.5%, p = 0.29). BIPOC patients were not significantly more likely to be readmitted within 30 days compared to White patients in the adjusted model (adjusted odds ratio (95% CI): 1.30 (0.91–1.86), p = 0.15) ConclusionBIPOC as compared to White ERAS participants in ERAS undergoing neurosurgical procedures had significantly longer hospital stays and were significantly less likely to be discharged home. ERAS protocols present an opportunity to provide consistent high quality post-operative care, however while there is evidence that it improves care in aggregate, our results suggest significant disparities in outcomes by patient race/ethnicity despite enrollment in ERAS. Future inquiry must identify contributors to these disparities in the recovery pathway.

Reader Response: Risk and Predictors of Depression Following Acute Ischemic Stroke in the Elderly.

We read with great interest the article by Mayman et al.1 that showed a 55% greater risk of poststroke depression (PSD) than postmyocardial infarction depression. We suggest additional information that can be helpful for clinicians and researchers. First, Mayman et al.1 provided a combined analysis of Medicare inpatient, outpatient, and subacute nursing facility data. Transient mood changes, such as adjustment disorder with depressed mood, can influence screening for clinical depression in acute settings.2 Some variability in PSD rates may be noted based on the specific evaluation setting—for example, an inpatient hospital, a rehab center, or an outpatient clinic.3,4 We suggest stratified PSD analysis in different settings or adding treatment settings as a covariate in the regression analysis.

Predictive value of discharge destination for 90-day outcomes among ischemic stroke patients eligible for endovascular treatment: Post-hoc analysis of DEFUSE 3

BackgroundThe endovascular treatment (ET) for acute ischemic stroke (AIS) is increasing among eligible patients. To help address care quality, administrative data sets are utilized but do not usually include formal outcome scales. We explore the predictive ability of discharge destination from acute hospitalizations for long-term disability among AIS patients eligible for ET within a clinical trial. MethodsWe analyzed publicly available data from the DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial. We evaluated patients who survived beyond the time of discharge from their acute hospitalizations. We calculated positive and negative predictive values and accompanying likelihood ratios for patients discharged to home, inpatient rehabilitation facility (IRF), or subacute nursing facility (SNF) for unfavorable outcome as defined by modified Rankin Scale (mRS) scores ≥3 at 90-days. ResultsOur final analysis included 127 patients (median age 67 [23–89] years, 51.2% men). There were 23.6% patients discharged home, 53.5% to IRF, and 22.8% to SNF. Approximately 61% of patients had 90-day post-stroke mRS scores ≥3. Patients discharged to SNF had the highest positive predictive value (93.1%) and positive likelihood ratio (8.77 [CI 95% 2.18–35.25]) for unfavorable outcome. Discharge to home had the highest negative likelihood ratio (2.09 [CI 95% 1.54–2.83]) for unfavorable outcome. ConclusionsAmong AIS patients eligible for ET within the DEFUSE 3 trial, discharge destination can provide high predictive value of 90-day functional outcomes. A discharge to SNF is highly predictive of long-term unfavorable outcomes.

Avoiding Sodium Polystyrene Sulfate (SPS) in Hyperkalemia

Hyperkalemia, defined as a concentration of potassium greater than 5.5 mEq/L in adults, is commonly found on labwork in the subacute nursing facility, often seen in the setting of kidney disease as a result of impaired excretion of potassium in the urine. Treatment is focused upon inducing potassium loss, often through use of loop diuretics such as furosemide. Sodium polystyrene sulfate (SPS) is often used; however, it carries with it significant associated risks and potential complications.

Intracerebral Hemorrhage Outcomes in the Very Elderly

Background: There is a paucity of outcomes data in patients over 80 years presenting with intracerebral hemorrhage (ICH). The primary aim of our study is to describe outcomes in this patient population. MethodRetrospective study of patients admitted with primary ICH from January 2012 to July 2018. Data were obtained from the Rush University Get With The Guidelines database; only patients 80 or above were included. ResultsA total of 1713 patients were screened and 220 patients met inclusion criteria. About 68.2% were female and mean age was 85.6 years old. Median ICH score on admission was 2 (IQR 1-3). Location of ICH included: deep (48.2%), lobar (40%), and cerebellum (9.5%). ICH etiologies included hypertensive (51.8%), cerebral amyloid angiopathy (26.8%), coagulopathy (5.9%), and the remaining were undetermined. CT angiograms were performed in 34.5% (n = 76) of patients; of these patients one arteriovenous malformation was identified. Patients underwent the following procedures: external ventricular drains (8.6%), decompression (3.6%), and ventriculoperitoneal shunts (1.8%). Tracheostomy and percutaneous gastrostomy placement were performed in 8.2%. About 4.5% had seizures and 1.5% were treated for status epilepticus. Disposition at hospital discharge included: subacute nursing facility ([SNF] 24.1%), acute rehabilitation (23.2%), hospice (18.2%), death (18.2%), home (11.8%), long-term acute care facility ([LTAC] 3.6%), and unknown (1%). Patients with an ICH score ≥2 on admission had a roughly 6 times higher chance of experiencing an unfavorable outcome (LTAC, SNF, or death), when compared to patients with lower ICH score. ConclusionsThis study shows that a significant proportion (35%) of ICH patients ≥80 years old have a good outcome, with discharge to home or to rehabilitation. Our data suggest that older patients with ICH presenting with supratentorial hemorrhages (volume < 30 cc) without intraventricular extension can have good outcomes despite their age.

1860 Use of NBT Gastrostomy Tubes as Replacement Jejunal Feeding Tubes

INTRODUCTION: For severely neurologically impaired patients, feeding tubes are a life-sustaining measure. While most patients can tolerate direct feeding into the stomach via nasogastric feeding tubes or gastrostomy feeding tubes, these options may be unhelpful or dangerous for patients with gastric retention or severe gastroesophageal reflux. For such patients, feeding through a jejunostomy may offer a safe alternative. However, when the tube needs to be replaced there are limited options. We review our experience of using non-balloon tip (NBT) gastrostomy replacement tubes as replacement jejunostomy tubes. CASE DESCRIPTION/METHODS: We searched procedure and follow-up reports from an individual gastroenterologist (JRE) from 03/2015 to 11/2018 for patients with jejunostomy feeding tubes at a single sub-acute nursing facility. All four jejunostomy patients on record had received 20 French NBT gastrostomy replacement tubes as replacement jejunostomy feeding tubes. The NBT tubes have a collapsible mushroom-shaped tip which is placed in the stoma with an obturator. We reviewed the patient records to determine if NBT replacement tubes effectively delivered nutrition and medication, whether they resulted in complications, and with what frequency the tubes needed replacement. DISCUSSION: The patients’ records show that the improvised replacement jejunal feeding tubes performed quite well. Available records show that the patients were fed jejunally for periods ranging from 47 to 168 weeks. Replacement NBT tubes lasted from 28 to 609 days. During this period, the only complication suffered was internal detachment of the mushroom tip, which occurred 5 times (4 of which in a single patient). In each of these cases however, the bowel remained unobstructed and the tips passed through the alimentary canal. Patients retained overall good health in spite of neurological impairment. For patients requiring feeding interventions, but lacking adequate gastric function, jejunostomy feeding is often needed if enteral feeding is to be maintained. While there is at present a dearth of equipment designed specifically for jejunal feeding tube replacement, our experience suggests that NBT gastrostomy tubes may constitute a viable option for patients with jejunostomy tubes. These mushroom-tip tubes remain in place without occluding the jejunum, they clog infrequently due to the wide lumen, and they represent a readily available and easy to place option for patients who need jejunostomy tube replacement.

Abstract WP453: Intracerebral Hemorrhage Outcomes in the Very Elderly

Background: Intracerebral hemorrhage (ICH) outcomes have been well described, but there is a paucity of data regarding complications and outcomes in the “very elderly.” As the population ages the incidence of ICH in the very elderly will likely increase. Our objective is to describe ICH outcomes in this patient population that may assist in prognostication for this specific group. Methods: Retrospective study of patients admitted to the Neurosciences ICU at our tertiary care center with the diagnosis of primary spontaneous intracerebral hemorrhage from January 2012 to 2018. Only patients with age equal to or greater than 80 years old were included. Results: 1590 patients were initially screened, 187 patients met inclusion criteria. 66% were female and median age of all patients was 85 (80-92). Median ICH score on admission was 2 (IQR 1-3). Location of ICH included: lobar (39%), deep (51%), and cerebellum (10%). ICH etiologies included hypertensive (55%), amyloid angiopathy (25%), coagulopathy (5%), and the remaining 11% were other or unknown. Neurosurgical procedures included external ventricular drains (9%), ventriculoperitoneal shunts (2%) and decompression (4%). Five percent had seizures and an additional 1.5% were treated for status epilepticus. Tracheostomy and percutaneous gastrostomy placement performed in 8.5%. Thirty four percent of patients were designated as comfort measures and ICU mortality was 17%. Disposition at hospital discharge included: home (13%), acute rehabilitation (23%), subacute nursing facility (24%), long term acute care facility (4%), hospice (17%) and death (19%). The median ICU length of stay was 2 (range 0-30) days and median hospital stay was 5 (0-30) days. Patients with an ICH score &gt;1 on admission had a 6 times higher chance of experiencing an unfavorable outcome (LTAC, SNF or death), when compared to patients with lower ICH score. This persisted after correcting for age and sex (OR 3.02-11.2, p&lt;0.001) in a logistic regression prediction model. Conclusions: This study shows that a significant proportion (36%) of ICH patients &gt; 80 years old have a good outcome, with discharge to home or to rehab. ICH score &gt;1 on admission may be used to predict a poor outcome in this patient population, which varies from younger age groups.

Healthcare Utilization and Infection in the Week Prior to Sepsis Hospitalization.

To quantify healthcare utilization in the week preceding sepsis hospitalization to identify potential opportunities to improve the recognition and treatment of sepsis prior to admission. Retrospective study. Two large integrated healthcare delivery systems in the United States. Hospitalized sepsis patients. None. We quantified clinician-based encounters in each of the 7 days preceding sepsis admission, as well as on the day of admission, and categorized them as: hospitalization, subacute nursing facility, emergency department, urgent care, primary care, and specialty care. We identified the proportion of encounters with diagnoses for acute infection based on 28 single-level Clinical Classification Software categories. We also quantified the use of antibiotics over the same interval and used linear regression to evaluate time trends. We included a total of 14,658 Kaiser Permanente Northern California sepsis hospitalizations and 31,369 Veterans Health Administration sepsis hospitalizations. Over 40% of patients in both cohorts required intensive care. A total of 7,747 Kaiser Permanente Northern California patients (52.9%) and 14,280 Veterans Health Administration patients (45.5%) were seen by a clinician in the week before sepsis. Prior to sepsis, utilization of subacute nursing facilities remained steady, whereas hospital utilization declined. Primary care, specialty care, and emergency department visits increased, particularly at admission day. Among those with a presepsis encounter, 2,648 Kaiser Permanente Northern California patients (34.2%) and 3,858 Veterans Health Administration patients (27.0%) had at least one acute infection diagnosis. An increasing percentage of outpatient encounters also had infectious diagnoses (3.3%/d; 95% CI, 1.5%-5.1%; p < 0.01), particularly in primary and specialty care settings. Prior to sepsis hospitalization, the use of antibiotics also increased steadily (2.1%/d; 95% CI, 1.1%-3.1%; p < 0.01). Over 45% of sepsis patients had clinician-based encounters in the week prior to hospitalization with an increasing frequency of diagnoses for acute infection and antibiotic use in the outpatient setting. These presepsis encounters offer several potential opportunities to improve the recognition, risk stratification, and treatment prior to sepsis hospitalization.

Abstract 21050: Long Term Survival and Neurological Status of Patients With Tracheostomy After Cardiac Arrest

Background: Overall survival and functional status is poor in patients that undergo a tracheostomy after respiratory failure. Little data exists on cardiac arrest (CA) patients’ in-hospital and long-term survival, and neurological status after tracheostomy. Methods: We retrospectively reviewed 509 consecutive patients that were more than 18 years of age, admitted to one of the intensive care units between 12/2007 and 12/2015, resuscitated following either in-hospital or out-of-hospital CA, and considered for targeted temperature management. Tracheostomy and other data was collected via chart review. Chi-square and Wilcoxon rank sum tests were used for analysis. Survival and Cerebral Performance Category score (CPC) at discharge and one year were compared between patients with and without tracheostomy. Results: Of 509 patients, 389 (76.4%) did not undergo a tracheostomy, 83 (16.3%) had new tracheostomies placed during the hospitalization, and 37 (7.3%) had pre-existing tracheostomy before the index cardiac event. In comparison to the non-tracheostomy group, the new tracheostomies patients had a greater number of in-hospital arrests with shorter duration of median return of spontaneous circulation, while the pre-existing tracheostomy group was older, worse CPC on admission, were mostly living in a subacute nursing facility, had lower rates of ventricular tachycardia/fibrillation as initial rhythm, and lower rates of therapeutic hypothermia. At the time of hospital discharge, there were 64/83 (77%) survivors in the new tracheostomy group, 104/389 (26.7%) in the non-tracheostomy, and 7/37 (19%) in the pre-existing tracheostomy group. Available one year data on 53 patients in the new tracheostomy group showed a 55% (n=29) survival rate, with neurological status as follows: {CPC 1: 7 (24%), CPC 2: 6 (21%), CPC 3: 8 (27.5%), CPC 4: 8 (27.5%)} compared to 66/81 (81%), {(CPC 1: 34 (51%), CPC 2: 15 (23%), CPC 3: 16 (24%), CPC 4: 1 (0.01%)} in the non-tracheostomy group (p=0.005). Conclusions: Cardiac arrest survivors that undergo a tracheostomy have reduced survival and poor neurological status at one year compared to those discharged without receiving a tracheostomy. Pre-existing tracheostomy patients suffer from high rates of in-hospital mortality.

Bundled Payments for Care Improvement: Boom or Bust?

BackgroundAs early implementors of the Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) initiative, our private practice sought to compare our readmission rates, post-acute care utilization, and length of stay for the first year under BPCI compared to baseline data. MethodsWe used CMS data to compare total expenditures of all diagnosis-related groups (DRGs). Medicare patients who underwent orthopedic surgery between 2009 and 2012 were defined as non-BPCI (n = 8415) and were compared to Medicare BPCI patients (n = 4757) who had surgery in 2015. Ninety-day post-acute events including inpatient rehabilitation facility or subacute nursing facility admission, home health (HH), and readmissions were analyzed. ResultsThe median expenditure for non-BPCI patients was $22,193 compared to $19,476 for BPCI patients (P < .001). Median post-acute care spend was $6861 for non-BPCI and $5360 for BPCI patients (P < .001). Compared to non-BPCI patients, BPCI patients had a lower rate of subacute nursing facility admissions (non-BPCI 43% vs 37% BPCI; P < .001), inpatient rehabilitation facility admissions (non-BPCI 3% vs 4% BPCI; P = .005), HH (non-BPCI 79% vs 73% BPCI; P < .001), and readmissions (non-BPCI 12% vs 10% BPCI; P = .02). Changes in length of stay for post-acute care were only significant for HH with BPCI patients using a median 12 days and non-BPCI using 24 days. ConclusionThe objective of BPCI was to improve healthcare value. Through substantial efforts both financially and utilization of human resources to contain costs with clinical practice guidelines, patient navigators, and a BPCI management team, the expenditures for CMS were significantly lower for BPCI patients.

Improving Patient Safety through High Reliability Organizations

Preventable medical errors result in the loss of 200,000 lives per year with associated financial and operational burdens on organizations and society. Widespread preventable patient harm occurs despite increases in healthcare regulations. High reliability organization theory contributes to improved safety and may potentially reverse this trend. This single case study explored the introduction of a safety culture and subsequent improvements in patient safety in a reliability-seeking organization. Fourteen participants from a subacute nursing facility were selected using purposeful sampling criterion. Data were collected through participant interviews, document reviews, and group observation. Five themes emerged from an analysis of collected data including process standardization, checks and redundancy, authority migration, communication, and teamwork. The themes uncovered the need for extensive education and training, communication, and teamwork to improve patient safety. The results of the study may be useful to improve safety and enhance leadership to promote a culture of safe patient care.

Factors Influencing Discharge Destination After Total Hip Arthroplasty: A California State Database Analysis.

Introduction:With this growing demand, the length of stay for total hip arthroplasty (THA) procedures has decreased, and as a trade-off, we have seen a higher utilization of extended care facilities (ECFs). Both trends have significant economic implications on the health care system, and predicting the discharge destinations of THA patients would help policy makers plan for future health expenditures. We performed a retrospective data analysis of a large patient database to determine which variables are significant in predicting discharge destinations of THA patients.Methods:We used the California Hospital Discharge data set of the year 2010, collected and provided by the Office of Statewide Health Planning and Development. The data set includes information about patient demographics, insurance type, diagnoses and procedures, and patient disposition. The study cohort included 14 326 patients. Discharge to home was the reference category. Discharge to ECF and discharge to home with home care were the 2 additional alternatives.Results:In all, 46.9% of patients were discharged home with home health care, followed by 29.6% to ECF, and 23.5% to home without care. Discharge to ECF was more likely for patients with more comorbidities and a higher age. The strongest predictors were Medicaid and black or Asian race. Medicare relative to private payer was a strong predictor of ECF discharge. Male gender was the only factor that lowered the risk of discharge to ECF. The strongest predictor for discharge to home with home care was black race relative to whites. Medicaid lowered the risk of home care, and gender did not matter.Conclusion:This study serves to provide insight on which patient characteristics influence discharge destination after THA. Race, insurance, and morbidity were highly significant factors on patient discharge destination to a subacute nursing facility.

Cost Benefit Analysis of Topical Tranexamic Acid in Primary Total Hip and Knee Arthroplasty

The purpose of this study was to provide a cost–benefit analysis of topical tranexamic acid (TXA) in primary total hip and knee arthroplasty patients. A retrospective cohort of 591 consecutive patients, 311 experimental and 280 control, revealed a transfusion rate reduction from 17.5% to 5.5%, increased postoperative hemoglobin, and decreased delta hemoglobin without an increase in adverse events (all P<0.001). This led to saving $83.73 per patient based on transfusion costs alone after accounting for the cost of TXA. Hospital disposition to home compared to subacute nursing facility was also significantly increased by 9.3% (P<0.02). We conclude that topical TXA reduces transfusion rate, increases home disposition, and reduces cost in primary hip and knee arthroplasty.