Successful Hospital Discharge Research Articles

‘Well, what are you going to do when you’re out there?’: a scoping review of successful hospital discharge for people with acquired disability and complex needs aged 18–65 years

‘Well, what are you going to do when you’re out there?’: a scoping review of successful hospital discharge for people with acquired disability and complex needs aged 18–65 years

A person-centred approach to help services and commissioners to improve the experience of people who are homeless and secure better sustainability.

Successful implementation of evidence-based services in health and social care depends largely on the fit of the services with the values and priorities of users who are shaping and participating in their delivery and use. When looking at the implementation of innovative specialist hospital discharge schemes for people who are homeless, there is a lack of knowledge on homeless people’s preferences and perspectives on receiving out-of-hospital care.
 In England, the Department of Health and Social Care, Ministry for Housing and Local Government and Ministry of Justice allocated £16 million to further develop and test out hospital care for people experiencing homelessness. The out-of-hospital care model programme is seeking to scale successful hospital discharge models that were shown to be effective and cost-effective in an earlier pilot programme adapting these for new contexts and circumstances post Covid-19.  Evaluation of the implementation of the out-of-hospital care model programme is currently underway in 17 local authority test sites across England. A specific component of the larger evaluation is aimed at capturing service users’ preferences for different types of specialist hospital discharge schemes.
 This is done using a flexible health economics tool for measuring choices in health and social care-related settings named discrete choice experiments (DCE). It measures preferences from individual decision-makers over alternative scenarios (or service provisions). Each alternative is described by several attributes (or characteristics) and the choices made between two or more competing scenarios subsequently determine how preferences are influenced by each attribute (eg, which attributes are valued as well as their relative importance). It can also provide a measure of the overall value attached to different alternatives (and identify optimal service provision that meets stakeholder requirements and have the best chance of sustainability in the long term). Hence a DCE survey has been developed to measure people’s preferences for what out-of-hospital care provides in terms of types of location of care, the professional who delivers most of their care, how often they receive care, how long they receive care after hospital discharge and rules about behaviour where they live.
 The attributes (characteristics) and their various levels were informed by our previous research. Webinar discussions regarding what stakeholders value about specialist services were used to validate and refine the attributes and levels. PPI stakeholders were also consulted on the development of the presentation, wording and format of the survey. Efficient experimental design techniques were applied to create the DCE questions. Due to the cognitive load involved in completing the survey, respondents are assisted in the completion of the questionnaire by members of the research team to secure responses from more than 250 people who are homeless. Data will be modelled using logit techniques and results will be ready for presentation in May 2023.
 Information on how service users value specialist hospital discharge schemes for people who are homeless is needed to better inform the implementation and development of the innovative out-of-hospital care model programme currently proposed in England at a national level. Identified learning will be shared at the conference.

SUCCESSFUL MYOCARDIAL REVASCULARIZATION IN A 92-YEAR-OLD FEMALE PATIENT: A CASE REPORT

Introduction. Patients with acute myocardial infarction should be treated with early revascularization. Patients over 73 years have a higher risk of infarct-related cardiogenic shock, which is a leading cause of lethality. Unfortunately, little is known about myocardial revascularization care for elderly people in Ukraine. We presented a 92-year-old lady with an acute chest pain case report, which was not revealed by analgesics.
 Important clinical findings. Coronary angiography revealed thrombotic occlusion of the distal segment of the left anterior descending artery (LAD) and floated thrombus in LAD mid-segment; stenosis of the left circumflex artery (LCx) close to the first obtuse marginal artery (OM1).
 The main diagnosis. Acute myocardial infarction with ST-segment elevation of the left ventricle anterior wall (anterior-STEMI). Calcific aortic valve disease, severe aortic valve stenosis, significant mitral and tricuspid valve regurgitation, pulmonary hypertension. Heart failure with reduced LVEF (<40%), NYHA class III symptoms.
 Intervention. The decision was to perform urgent stenting in LAD and balloon angioplasty in LCx. Successful hospital discharge was after 14 days.
 Conclusions. Take-away lessons: Elderly patients with acute myocardial infarction can be successfully treated in Ukraine. Age and comorbidities are not a contraindication for early myocardial revascularization.

429: TETANUS IN AN UNVACCINATED FIVE-YEAR-OLD AMISH CHILD

Introduction: Tetanus is a neurotoxin-mediated, vaccine-preventable disease caused by Clostridium tetani, rarely seen in developed nations. Affecting motor neurons and the autonomic nervous system, this disease is characterized by spastic paralysis, opisthotonos, and dysautonomia. We report the case of a five-year-old, unvaccinated male with tetanus. Description: A five-year-old, unvaccinated patient presented eight days post sheet metal laceration to his ankle. Medical care was sought after developing symptoms of back arching and the inability to open his mouth. His initial exam was consistent with opisthotonos and spastic rigidity of his extremities. He was empirically treated with clindamycin, ceftriaxone, metronidazole, tetanus immune globulin, and DTaP. He then went to the operating room for wound debridement and returned to the intensive care unit (ICU) intubated. ICU course was protracted and significant for requirement of intubation, mechanical ventilation, and 15 days of neuromuscular blockade therapy due to severe opisthotonos. Additional pharmacologic therapy for muscle relaxation included midazolam infusion, diazepam, and baclofen. Intermittent cessations in neuromuscular blockade resulted in endotracheal tube obstruction, hypoxia, and hypercarbia. On day 8, he developed dysautonomia with tachycardia, hypertension, and hyperthermia requiring initiation of dexmedetomidine infusion and external cooling followed by a magnesium infusion with a goal level of 4 mg/dL and dantrolene. His symptoms resolved by ICU day 15, with subsequent discontinuation of neuromuscular blockade and extubation. He was discharged home with good neurologic and neuromuscular function. Discussion: As illustrated by this case, management of spasms and dysautonomia can be difficult and often requires multimodal therapy. Current practice includes mechanical ventilation and neuromuscular blockade to support oxygenation and ventilation, preventing early mortality as the effects of the toxin resolve and new neuromuscular connections are formed. A paucity of evidence exists regarding management of tetanus associated dysautonomia, likely due to the low incidence and historically high early mortality rate. This case represents a strategy for treatment through successful recovery and hospital discharge.

Association between tocilizumab treatment of hyperinflammatory patients with COVID-19 in a critical care setting and elevated incidence of hospital-acquired bacterial and invasive fungal infections

BackgroundTocilizumab is an interleukin-6 inhibitor that reduces mortality and the need for invasive mechanical ventilation, while increasing the possibility of successful hospital discharge for hyperinflammatory patients with severe coronavirus disease 2019 (COVID-19). No increase in adverse events or serious infections has been reported previously.AimTo describe the characteristics and outcomes of patients with severe COVID-19 in critical care who received tocilizumab, and to compare mortality and length of hospital stay for patients who received tocilizumab (N=41) with those who did not (N=33).MethodsRetrospective review of data related to patients with COVID-19 who received tocilizumab in a critical care setting from 1st January to 31st December 2021.FindingsAmongst COVID-19 survivors, those who had received tocilizumab had longer intensive care unit (ICU) stays (median length 21 vs 9 days) and hospital stays (45 vs 34 days) compared with those who had not received tocilizumab. Thirty-day mortality (29% vs 36%; P=0.5196) and 60-day mortality (37% and 42%; P=0.6138) were not significantly lower in patients who received tocilizumab. Serious bacterial and fungal infections occurred at higher frequency amongst patients who received tocilizumab [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.04–6.86; P=0.042], and at significantly higher frequency than in non-COVID-19 ICU admissions (OR 5.26, 95% CI 3.08–9.00; P<0.0001).ConclusionsIn this single-centre study, patients in critical care with severe COVID-19 who received tocilizumab had a greater number of serious bacterial and fungal infections, but this may not have been a direct effect of tocilizumab treatment.

Continuity of Care and Successful Hospital Discharge of Older Veterans With Dementia.

Care transitions are frequent among patients with dementia. This study aimed to estimate the impact of continuity of care (COC) on successful community discharge after hospitalization. National Veterans Health Administration data linked to Medicare claims in fiscal years 2014-2015. Community-dwelling older veterans with dementia with an acute hospitalization were included (n = 31,648). COC was measured by the Bice-Boxerman Continuity of Care (BBC) index (0-1). Association of COC before hospitalization on successful community discharge was examined separately among veterans discharged to the community directly and through post-acute care facilities. Veterans with a 0.1 higher BBC were 4.6% (p = .06) more likely to have successful direct community discharge; but BBC had no demonstrable effect when discharge was through post-acute care facilities. Better COC may have impact at improving successful direct community discharge, although the effect is small and the type I error rate (statistical significance) was 6%.

Capturing rich person-centred discharge information: exploring the challenges in developing a new model

PurposeCapture, consumption and use of person-centred information presents challenges for hospitals when operating within the scope of limited resources and the push for organisational routines and efficiencies. This paper explores these challenges for patients with Acute Coronary Syndrome (ACS) and the examination of information that supports successful hospital discharge. It aims to determine how the likelihood of readmission may be prevented through the capturing of rich, person-specific information during in-patient care to improve the process for discharge to home.Design/methodology/approachThe authors combine four research data collection and analysis techniques: one, an analysis of the patient record; two, semi-structured longitudinal interviews; three, an analysis of the patient's journey using process mining to provide analytics about the discharge process, and four, a focus group with nurses to validate and confirm our findings.FindingsThe authors’ contribution is to show that information systems which support discharge need to consider models focused on individual patient stressors. The authors find that current discharge information capture does not provide the required person-centred information to support a successful discharge. Data indicate that rich, detailed information about the person acquired through additional nursing assessments are required to complement data provided about the patient's journey in order to support the patients’ post-discharge recovery at home.Originality/valuePrior research has focused on information collection constrained by pre-determined limitations and barriers of system design. This work has not considered the information provided by multiple sources during the whole patient journey as a mechanism to reshape the discharge process to become more person-centred. Using a novel combination of research techniques and theory, the authors have shown that patient information collected through multiple channels across the patient care journey may significantly extend the quality of patient care beyond hospital discharge. Although not assessed in this study, rich, person-centred discharge information may also decrease the likelihood of patient readmission.

Development of salient medication reminders to facilitate information transfer during transition from inpatient to primary care: the Delphi process

ObjectiveTransitional care is important to successful hospital discharge. Providing patients with a clear and concise summary of medication-related information can help improve outcomes, in particular, among older adults. The present...

Cardiovascular Disease and Severe Hypoxemia Are Associated With Higher Rates of Noninvasive Respiratory Support Failure in Coronavirus Disease 2019 Pneumonia.

Retrospective cohort study to describe rates of high-flow oxygen delivered through nasal cannula and/or noninvasive positive pressure ventilation success (live discharge without endotracheal intubation). Fine-Gray subdistribution hazard models were used to identify patient characteristics associated with high-flow oxygen delivered through nasal cannula and/or noninvasive positive pressure ventilation failure (endotracheal intubation and/or in-hospital mortality). One large academic health system, including five hospitals (one quaternary referral center, a tertiary hospital, and three community hospitals), in New York City. All hospitalized adults 18-100 years old with coronavirus disease 2019 admitted between March 1, 2020, and April 28, 2020. None. A total of 331 and 747 patients received high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation as the highest level of noninvasive respiratory support, respectively; 154 (46.5%) in the high-flow oxygen delivered through nasal cannula cohort and 167 (22.4%) in the noninvasive positive pressure ventilation cohort were successfully discharged without requiring endotracheal intubation. In adjusted models, significantly increased risk of high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation failure was seen among patients with cardiovascular disease (subdistribution hazard ratio, 1.82; 95% CI, 1.17-2.83 and subdistribution hazard ratio, 1.40; 95% CI, 1.06-1.84, respectively). Conversely, a higher peripheral blood oxygen saturation to Fio2 ratio at high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation initiation was associated with reduced risk of failure (subdistribution hazard ratio, 0.32; 95% CI, 0.19-0.54, and subdistribution hazard ratio 0.34; 95% CI, 0.21-0.55, respectively). A significant proportion of patients receiving noninvasive respiratory modalities for coronavirus disease 2019 acute hypoxemic respiratory failure achieved successful hospital discharge without requiring endotracheal intubation, with lower success rates among those with comorbid cardiovascular disease or more severe hypoxemia. The role of high-flow oxygen delivered through nasal cannula and noninvasive positive pressure ventilation in coronavirus disease 2019-related acute hypoxemic respiratory failure warrants further consideration.

Planejamento nutricional da alta hospitalar: breve revisão da literatura e proposta de instrumento de avaliação

Introduction: Due to its frequency and potential consequences, malnutrition is a worrisome condition in the hospital environment, especially in the case of adults admitted to intensive care units and others at high risk; malnutrition is associated with a higher risk of morbidity and mortality, prolonged hospital stay, higher frequency of readmissions, and increased costs. Although the absence of a planning for hospital discharge can aggravate these consequences, there are no guidelines for nutritional planning for hospital discharge that can be widely adopted in Brazil. Methods: A panel of experts was convened to assess the most relevant topics in the literature related to hospital discharge planning, discuss their experience in this regard, and propose an instrument that could guide and justify the importance of planned and safe nutrition discharge. Results: An organized and explicit discharge plan brings clinical and nutritional benefits to the patient, as well as advantages for family members and the health-care service. Nutritional care and better communication and guidance from the multiprofessional team prepare the patient and family members to reduce length of hospital stay and may avoid readmissions. Discharge planning requires the development of an individualized plan, as well as the education of the patient, family and caregivers; the nutritional care plan is inserted in the discharge plan. Based on these considerations, we propose an instrument that aims to systematize the nutritional discharge through the collection of the most relevant information related to the nutritional risk and the therapeutic approach to this risk, standardizing the communication with the patient, their caregivers, and the health-care team. Conclusions: The instrument presented here should be tested in clinical practice, and it is hoped that it can allow a better follow-up of the patient’s journey, leading to a more successful hospital discharge.

Patients undergoing urgent trans-aortic valve implantation suffer from an increased mortality rate

Abstract Introduction Information on the outcome of urgent Transcatheter valve implantations (TAVI) is scarce, but available data suggest that it could be a reasonable option for the treatment of decompensated severe aortic valve stenosis. The prospects of an all-comer urgent population, however, are unknown. Here we report our experience with clinically indicated urgent TAVI implantation in an unselected patient population with severe aortic valve stenosis (AS). Purpose To compare the outcome of patients undergoing urgent or elective TAVI and to identify potential predictors of outcome. Methods A retrospective, single centre study of AS patients undergoing femoral or apical TAVI between 01. 01.2013 and 30.09.2018 was performed. Demographic information, medical history, clinical and procedural data were collected from the local electronic database. Urgent implantation was defined as accelerated, in-hospital patient preparation and urgent device placement following an acute admission. Survival was investigated with Kaplan-Meier survival analysis and log-rank test. Regression analysis was performed to identify possible predictors of mortality. Results During the study period TAVI was performed in 631 patients, of whom 53 (8.4%) underwent urgent TAVI. In the case of urgent procedures, the median admission-to-procedure time was 18 [10–29] days. Age, gender and the prevalence of diabetes mellitus, chronic obstructive lung disease (COPD) and a glomerular filtration rate of ≤30ml/min was comparable among the groups. Patients in the urgent group had a lower BMI (26 [23–28] vs. 27 [24–30]; p&amp;lt;0.05), had more frequently an ejection fraction &amp;lt;30% (30% vs 4%p&amp;lt;0.001) and a higher Euroscore II (5.3 [3.4–10.9]% vs 2.9 [1.7–4.5]%; p&amp;lt;0.001). The rate of apical implantation and post-operative stroke, pacemaker implantation and renal failure did not differ between the groups. Urgent patients, however, needed longer post-procedural hospitalization (6 [4–9] vs 4 [3–6] days; p&amp;lt;0.001) and had higher in-hospital (11.3% vs 3,1%; &amp;lt;0.001) and one-year mortality rates (28.3% vs 8.5%; p&amp;lt;0.001). Urgency was an independent predictor of overall one-year mortality (HR 3.0, p=0.001) and worsened the survival of the individuals who were discharged from the hospital (out-of-hospital mortality at one-year; HR 2.8, p=0.011), but had no effect on in-hospital mortality. In-hospital mortality was mainly determined by apical access (OR 3.1; p=0.016) and major post-operative stroke (OR 8.8.; p=0.006), with both worsening overall 1-year survival too (HR 1.8 for apical access and 4.8 for stroke; p&amp;lt;0.05). Mortality after a successful hospital discharge was increased not only by urgency (HR 2.8, p=0.011), but by COPD (HR 2.1; p=0.04) and prolonged post-operative hospitalization (HR 1.05/day; p=0.001) as well. Conclusion Stabilizing AS patients can mitigate the effect of urgency on peri-procedural survival. Urgency remains, however, an important determinant of one-year TAVI outcome. Funding Acknowledgement Type of funding source: None

Goals of Parents Whose Infant Is in the Neonatal Intensive Care Unit: An Explorative Study.

The aim of many neonatal intensive care units (NICU) today is to promote a family-centered practice that addresses parental concerns and needs. However, the specific goals of parents are often unaddressed by the healthcare team. The aim of this study was to understand the goals of parents whose infant was in the NICU to enhance collaboration and communication between parents and health professionals. A written questionnaire was disseminated to parents whose infant was in the NICU at the Kingston Health Sciences Centre. A thematic analysis of the goals was completed to identify key emergent themes and their implications. A total of 23 questionnaires were disseminated to parents and 13 (57%) were returned. Returned questionnaires were most often completed by the mother (n = 9, 70%), and a total of 40 goals were recorded. Three key emergent themes were identified, which included feeding and weight gain, eliminating medical equipment, and successful hospital discharge. Understanding the goals of parents whose infant was in the NICU can enhance communication between parents and their healthcare team, thus aiding the implementation of a family-centered practice. Future larger sample sizes studies across several NICUs would increase the generalizability of results and garner a larger volume of data to establish significant trends between specific infant and parent demographic data and the associated goals.

Prediction of early discharge after gynaecological oncology surgery within ERAS.

Enhanced recovery after surgery programs (ERAS) have been proven to decrease the length of hospital stay without increasing readmission rates or complications. However, the patient and operative characteristics that improve the chance of a successful early hospital discharge are not well established. The aim of this study was to design a nomogram which could be used before surgery, using the characteristics of patients, to establish who could benefit from early discharge (POD ≤ 2days). This observational study has been prospectively conducted. All the included patients were referred for surgical treatment of gynecologic cancer. We defined two sub-groups of patients on surgical procedure characteristics: isolated procedures (hysterectomy or lymphadenectomy) and combined procedures (at least the association of two procedures). 230 patients were enrolled during the study protocol. 83.9% of patients were treated with a minimally invasive surgery (MIS). 159 patients (69.1%) were discharged on or before POD 2. On multivariate analysis, the surgical approach (open surgery vs. laparoscopy, OR  0.02 (95% CI [0-0.07]), p < 0.001) and the type of surgery (combined procedure versus isolated procedure, OR  0.41 (95% CI [0.18-0.91]), p = 0.028) were found to be significant predictors of increased hospital stay. A nomogram has been built for the purpose of predicting eligible patients for early post-operative discharge based on the multivariate analysis results (AUC = 0.86, 95% CI [0.81-0.92]). The use of MIS for isolated procedures in oncologic indications constitutes an independent factor of early discharge in a setting of ERAS. These promising preliminary results still require to be validated on a prospective cohort.

Short-term mechanical circulatory support for severe primary graft dysfunction following orthotopic heart transplant.

Primary graft dysfunction (PGD) is a devastating complication and the most common cause of early death following a heart transplant. The goal of this study was to report our experience of using mechanical circulatory support to manage severe PGD. Following 208 heart transplants performed between January 2007 and May 2017, 14 (6.7%) patients presented with severe PGD. We provided haemodynamic support using the following approaches: a venoarterial extracorporeal membrane oxygenation device, left ventricular assist device, right ventricular assist device and biventricular assist device. Primary complications included severe PGD, which resulted in hospital deaths and late survival. The mean follow-up was 3.7 ± 2.7 years. Fourteen (6.7%) heart transplant recipients presented with severe PGD. Seven patients received a venoarterial extracorporeal membrane oxygenation device; 1 patient received a left ventricular assist device; 4 patients received a right ventricular assist device; and 2 patients received a biventricular assist device. Mean device support and explantation times were 4.7 ± 2 and 6.3 ± 2 days, respectively. Weaning with cardiac recovery was successful in 57.1% of the patients. The hospital mortality rate was 50%. Postoperative causes of morbidity included renal failure that necessitated dialysis in 28.5%, surgical re-exploration due to postoperative bleeding in 57.1%, pneumonia in 28.5%, sepsis in 14.2%, sternal wound infection in 14.2% and mediastinitis in 7.1% of the patients, respectively. There were no deaths following hospital discharge or later follow-up appointments. Mechanical support devices such as venoarterial extracorporeal membrane oxygenation specifically offer a reliable therapeutic approach. Recognizing the relatively high number of deaths in-hospital, patients who have cardiac recovery and a successful hospital discharge can expect a favourable late outcome.

Outcomes of mechanical support in a pediatric lung transplant center.

Pediatric lung transplantation is a lifesaving option for patients with end stage lung disease, although the scarcity of suitable donor organs results in long wait times and increased waitlist mortality. Many pediatric centers consider mechanical ventilatory support, such as long-term invasive ventilation and ECMO, a contraindication to lung transplantation. We hypothesized that current survival rates and outcomes for patients on mechanical ventilatory support in the pre-transplant period were not remarkably different. In our retrospective analysis we included patients between the ages of 0-21 years listed for lung transplantation from deceased donors between 2007 and 2014 at our institution. One-year survival outcomes were compared between three groups of patients: (i) patients bridged to transplant on ECMO (n = 6, 1-year survival = 67%); (ii) patients needing mechanical ventilation (either through endotracheal intubation or tracheostomy) but not ECMO (n = 12, 1-year survival = 75%); and (iii) patients who did not need endotracheal ventilation, tracheostomy, or ECMO (n = 25, 1-year survival = 88%). Comparison of outcomes of transplanted patients between these three groups were not statistically different in terms of successful hospital discharge and 1-year survival rates (P > 0.05). We believe that "bridging" the end-stage lung disease patient with long-term mechanical ventilation and/or ECMO support is a reasonable option in selected patients until suitable donors become available. Pediatr Pulmonol. 2017;52:360-366. © 2016 Wiley Periodicals, Inc.

Predictors of early discharge after open gynecological surgery in the setting of an enhanced recovery after surgery protocol.

Enhanced recovery after surgery (ERAS) protocols have been proven to decrease length of hospital stay without increasing readmission rates or complications. However, patient and operative characteristics that improve the chance of successful early hospital discharge are unknown. The aim of this study was to determine the characteristics of patients undergoing open gynecological surgery in an ERAS protocol who could be discharged home by postoperative day 3. A retrospective review was performed on patients undergoing laparotomy by a single surgeon and managed by an ERAS protocol between January 2008 and April 2013. Data collection on patient characteristics, hospitalization and post-discharge details was performed prospectively. Patients successfully discharged home on or by day 3 (early discharge) were compared to patients who had a longer admission (late discharge). During the study period, 454 consecutive patients were identified and included in the study. No patients were excluded. A total of 335 patients (73.8%) were successfully discharged home within 3 days. After adjusting for age and Eastern Cooperative Oncology Group performance score, patients with early discharge were significantly less likely to have a malignancy (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.36-0.97; P=0.038), intensive care unit admission (OR, 0.59; 95%CI, 0.36-0.97; P = 0.046), vertical midline incision (OR, 0.28; 95%CI, 0.07-0.82), complications (OR, 0.21; 95%CI, 0.09-0.49; P=0.0003), or FIGO Stage III or IV disease (OR, 0.39; 95%CI, 0.23-0.67; P = 0.001). Prior abdominal surgery, body mass index>25 and lymph node dissection did not significantly influence length of hospital stay. Malignancy, advanced-stage disease, intensive care unit admission, vertical midline incision and perioperative complications are significantly associated with longer hospital stay in patients managed by an ERAS protocol.

Cardiovascular prevention and rehabilitation for patients with ventricular assist device From exercise therapy to long-term therapy Part II: Long-term therapy

Over the years left ventricular assist devices (VADs) have become more durable and reliable, smaller, simpler, easier to implant and more comfortable. The extensive experience now acquired shows successful hospital discharge with VAD use. We are entering an era in which long-term mechanical circulatory support will play an increasing role in the approach to end-stage heart failure (HF); at the same time, the extension of VADs into destination therapy has revealed the limitations of our understanding of these populations. This second paper on cardiovascular prevention and rehabilitation for patients with left VADs will deal with the management of patients outside the highly specialized HF centers and surgical setting, with particular focus on postoperative patient management. Outpatient management of VAD patients is time-intensive, and a multidisciplinary approach is ideal in long-term care. Although the new devices have definite advantages over the older pumps, some challenges still remain, i.e. infection, stroke, device thrombosis, gastrointestinal bleeding, recurrent HF symptomatology with or without multisystem organ failure, and occurrence of ventricular arrhythmias.

Predicting survival following non-invasive ventilation for hypercapnic exacerbations of chronic obstructive pulmonary disease

Non-invasive ventilation (NIV) has revolutionised the management of hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD). We wished to evaluate factors related to its overall success in the 'real-life' setting. A retrospective analysis of patients receiving NIV for a hypercapnic exacerbation of COPD was performed. Demographics, laboratory data, blood gases and outcomes (hospital discharge or in-patient death) were extracted and subsequently analysed to identify factors relating to its overall success or failure. Over 6 years, 240 patients (mean age 70 years), received NIV with mean pH and pCO(2) prior to NIV 7.24 and 10.4kPa respectively; of these, 167 survived to hospital discharge with a median age (70 vs. 74; p = 0.02) lower than non-survivors. Absolute values of pH and pCO(2) (higher and lower respectively) prior to NIV and at 1 h were both associated with successful hospital discharge. An improvement (p = 0.02) in pH within an hour of receiving NIV - but not pCO(2) - was associated with surviving to hospital discharge. Of all laboratory data assessed, only baseline urea was significantly (p = 0.021) associated with a successful outcome. Younger patients with a lower urea, higher pH and lower pCO(2) at baseline and who demonstrate an improvement in pH within 1 h, are more likely to have a successful outcome when given NIV for a hypercapnic exacerbation of COPD on an unselected basis. Prospective studies evaluating many other parameters are now required to help identify patients in whom NIV is likely to be successful.

Left Ventricular Assist Device Support as a Bridge to Recovery in Young Children

Left ventricular assist device (LVAD) experience and follow-up data in children are limited. We report the deployment and successful weaning from LVAD in young children with severe heart failure (HF). From 2004--2009, 13 children suffering from HF were placed on LVAD. All presented with a dilated left ventricle (LV) with severely reduced contractility, secondary to myocarditis, atrial arrhythmia or idiopathic HF. This study reports their outcomes and longitudinal follow-up. Of 13 young children with HF (ages 1 month--6 years; mean 19.2 months) placed on LVAD: eight weaned to recovery and successful hospital discharge, one was transplanted and four died. Echo follow-up in the weaned patients (mean age 22.1 months) revealed significant improvements from pre-LVAD measurements: LV end-diastolic dimension (LVED) mean z-score decreased from +4.8 to +0.95 (P < .001); fractional shortening (FS %) improved from a mean of 9.3% to 33% (P < .001); and the degree of mitral regurgitation (MR) significantly improved (P < .05). Time to LVAD deployment from HF diagnosis was more likely to be less than 30 days in the successfully weaned patients (100%) than patients who died or were transplanted (20%); P = .007. LVAD support can be utilized as a bridge to recovery in young children with HF. Following LVAD weaning, children sustain improvements in LV size, function and degree of MR. LVAD deployment less than 30 days from HF diagnosis improves the likelihood of successful weaning and illustrates that children with acute etiologies of HF are more likely to achieve recovery.

TCT-426: Primary Angioplasty Can Achieve Successful Early Hospital Discharge Following Myocardial Infarction

TCT-426: Primary Angioplasty Can Achieve Successful Early Hospital Discharge Following Myocardial Infarction