Total Hospital Days Research Articles

Non-Variceal Upper Gastrointestinal Hemorrhage Is a Rare Complication After Percutaneous Coronary Intervention for Myocardial Infarction, but Has a Detrimental Effect on Mortality: A National Analysis Over 11 Months

Introduction: Non-variceal upper gastrointestinal hemorrhage (NVUGIH) is a feared complication after a percutaneous coronary intervention (PCI) for ST-elevation Myocardial infarction (STEMI) and non-STEMI. We sought to determine the incidence of NVUGIH after PCI among patients with STEMI or NSTEMI over an 11-month follow-up period, and its impact on mortality, morbidity and healthcare resource utilization using the largest national readmission database in the United States. Methods: This is a retrospective cohort study using the 2014 National Readmission Database (NRD). Inclusion criteria were: i) a principal diagnosis of STEMI or NSTEMI ii) An in-hospital PCI iii) Admission in January. Exclusion criteria were age less than 18 years and elective admission. All readmissions to any hospital for a principal diagnosis of NVUGIH within 11 months of the index admission were recorded for each patient. The primary outcome was incidence of NVUGIH. Secondary outcomes were 11-months mortality rate, and NVUGIH associated morbidity [prolonged mechanical ventilation (PMV) and shock] and resource utilization [length of stay (LOS) and total hospitalization costs and charges]. Independent risk factors for NVUGIH were also identified using multivariate logistic regression analysis. Results: 22,669 patients were included in the study. The mean age was 63.8 (63.4-64.1) years and 31.7% of patients were female. The 11-month incidence of NVUGIB was 1.6%. The onset of NVGIH was associated with an increase in 11-months mortality rate from 1.9% to 7.8% (adjusted OR: 1.94 (1.01-3.72, p=0.04). The proportion of patients with NVUGIH who developed shock was 6.2% (3.3%-11.3%), while those who required PMV was 1.9% (0.6% - 5.8%). The mean LOS for NVUGIH related readmissions was 5.1 (4.3-5.9) days, with an associated mean total hospitalization costs and charges of $10,492 ($9,169-$-11,815) and $41,030 ($34,766- $47,295), respectively. The total hospital days associated with NVUGIH related readmissions was 2,211 days, with a total healthcare in-hospital economic burden of $17.6 million. Independent predictors of NVUGIH were: female gender, charlson co-morbidity score, and LOS (Table 1). Conclusion: NVUGIH is an uncommon complication among patients who undergo PCI for STEMI or NSTEMI, with an 11-month incidence of 1.6%. However, the development of NVUGIH has a substantial impact on mortality, morbidity and in-hospital healthcare resource utilization in this patient population.532 Figure 1 No Caption available.

Rotation thromboelastometry (ROTEM) enables improved outcomes in the pediatric trauma population.

ObjectiveWe evaluated the role of rotation thromboelastometry (ROTEM) in managing acute traumatic coagulopathy in pediatric patients with trauma.MethodsA retrospective cohort of pediatric patients with trauma from six institutes was studied during a 10-year period from 2007 to 2017. The associations between ROTEM-guided, goal-directed coagulation therapy and clinical outcomes were determined.ResultsThree hundred thirty-two pediatric patients (age < 15 years) who were treated with ROTEM-guided, goal-directed coagulation therapy were matched to 332 control pediatric patients with conventional plasmatic coagulation tests. The ROTEM protocol was associated with a significant reduction in the interval for admission to acute traumatic coagulopathy treatment, less plasma transfusions in the first 24 hours of admission, and a favorable coagulopathy recovery. Furthermore, the median number of total hospital days was significantly shorter for patients who had the ROTEM protocol than for control patients.ConclusionsThere are significant favorable outcomes, including rapid acute traumatic coagulopathy treatment and a lower 24-hour blood product requirement, following ROTEM-guided, goal-directed coagulation therapy among pediatric patients with blunt trauma.

Relationship of American Spinal Injury Association Impairment Scale Grade to Post-injury Hospitalization and Costs in Thoracic Spinal Cord Injury.

BACKGROUNDThe lifetime economic burden of thoracic spinal cord injury (SCI) is known to be high, but evidence of variability of costs in relation to the American Spinal Injury Association Impairment Scale (AIS) grade is limited.OBJECTIVETo estimate lifetime economic costs of hospitalization by AIS grade in thoracic SCI.METHODSUsing SCI Model Systems data from January 2000 to March 2016 from the National Spinal Cord Injury Statistical Center, we estimated mean total annual days of all-cause hospitalization by AIS grade among persons with thoracic SCI, based on assessments 1, 5, and 10 yr post-injury. We combined this information with secondary cost data and projections of life expectancy to estimate lifetime economic costs of hospitalization by AIS grade in persons aged 35 yr at time of thoracic SCI. Future costs were discounted to present value at 3% annually.RESULTSOne year post-injury, mean total annual days of hospitalization ranged from 2.1 for persons with AIS-D injuries to 5.9 for those who were AIS-A. Similar differences were noted 5 and 10 yr post-SCI. The estimated net present value of expected lifetime costs of hospitalization following thoracic SCI at age 35 yr was $321 534, $249 514, $188 989, and $68 120 (2015 US$) for AIS-A, AIS-B, AIS-C, and AIS-D injuries, respectively.CONCLUSIONPersons with less severe thoracic SCI, as reflected in AIS grade, spend fewer days in hospital over their lifetimes, leading to lower costs of inpatient care. Therapies improving AIS grade following thoracic SCI may provide cost savings in addition to addressing substantial unmet need.

Total hospital days, a novel composite endpoint, in patients undergoing pancreatic and hepatic surgery

Total hospital days, a novel composite endpoint, in patients undergoing pancreatic and hepatic surgery

External Fixation in the Emergency Department Is Equally Efficacious to Placement in the Operating Room

Category: Trauma Introduction/Purpose: Pilon and unstable ankle fractures are often treated initially with an external fixator (ex-fix) due to soft tissue concerns. Typically, the second stage involves open reduction internal fixation of the fracture as the definitive management. Ex-fix application in the emergency department (ED) has been described previously. We aimed to determine if an ex-fix applied in the ED would have any difference in rate of ex-fix revision, deep infection, and hospital length of stay when compared to an ex-fix that is applied in the operating room (OR). Methods: This is a retroscpective, case-cohort study performed at an urban, level-1 trauma center. Using CPT codes in our billing database, we identified all patients from 2011-2015 who had operative fixation of pilon (AO classification 43B or 43C) or unstable ankle fractures (AO classification 44C) and had application of an ex-fix (either ED or OR) prior to definitive fixation. Patients with open injury, those placed in ex-fix at outside institutions and those treated definitively with ex-fix were excluded. Results: Ninety-six patients met the inclusion criteria. Average age was 47 years and 54 (56%) were male. Thirty-three patients had ex-fix placed in the OR and 63 patients had ex-fix placed in the ED. Post-surgical complications (prominent implant, nonunion, deep infection, DVT, loss of reduction) were seen in 6/33 in the ED and 8/63 in the OR group (χ2=0.44, p=0.51). Deep infections occurred in 2/33 OR ex-fix and 5/63 ED ex-fix patients (χ2=0.137, p=0.71, OR= 1.4 [95% CI = 0.25 to 7.5]). Revision ex-fix for loss of reduction was performed 4/33 in the OR group and 10/63 in the ED ex-fix group (χ2=0.296, p=0.59). Mean length of stay was 14 days for the OR and 13 days for the ED group (p=0.35). Conclusion: We found no significant difference in post-surgical complications (surgical or infectious) or ex-fix revision rates for an ex-fix placed in ED compared to one placed in the OR. Total hospital days were similar in both groups. Prospective studies are needed to validate this method of provisional stabilization in the ED; however, these results indicate that the ED ex-fix is equally efficacious to an OR ex-fix.

Percutaneous transhepatic gallbladder drainage for different ASA grading of laparoscopic cholecystectomy in patients with acute cholecystitis

Objective To investigate the effect of percutaneous transhepatic gallbladder drainage (PTGBD) on different American Society of Anesthesiologists (ASA) grading of laparoscopic cholecystectomy in patients with acute cholecystitis. Methods The 324 patients with acute cholecystitis undergoing laparoscopic cholecystectomy who were hospitalized in Department of Hepatobiliary Surgery, Xianyang Central Hospital from March 2010 to December 2014 were enrolled in the retrospective analysis. According to the history of the patients with or without PTGBD before laparoscopic cholecystectomy, all patients were divided into 2 groups. One hundred and eighty four patients who underwent directly laparoscopic cholecystectomy were the control group, and the other 140 patients who underwent PTGBD+ elective laparoscopic cholecystectomy were the study group. The rates of conversion to laparotomy, total days of hospitalization, hospitalization days after cholecystectomy incidence, postoperative complications incidence, postoperative drainage were compared between two groups. The difference of clinical data between the two groups were compared under different ASA classification. Measurement data were expressed as (±s) and t-test were used for comparison between groups. Count data were compared by χ2 test. Results The rate of intraoperative laparotomy was 23.6%(33/140) in the study group and 20.7%(38/184) in the control group; the mean length of hospital stay was (7.3±3.3) days in the study group and (6.8±2.3) days in the control group; the postoperative complication rate was 2.8%(4/140) in the study group and 0.5%(1/184) in the control group; the abdominal cavity drainage rate was 80.0%(112/140) in the study group and 73.9%(136/184) in the control group; intraoperative laparotomy rate, postoperative hospital stay, postoperative complications incidence, and abdominal cavity drainage rate between the two groups had no significant difference (P>0.05). The total length of hospital stay was (17.6±4.4) days in the study group and (10.6±3.0) days in the control group, and there was a statistically significant difference between the two groups (P 0.05). Conclusions PTGBD has different effects on laparoscopic cholecystectomy in patients with different ASA grading of acute cholecystitis. PTGBD combined with laparoscopic cholecystectomy is a safe and effective method that can turn emergent operation intoselective operation. It is worthy of extensive application. Key words: Cholecystitis, acute; Cholecystectomy, laparoscopic; Percutaneous transhepatic gallbladder drainage

Emergency Department Discharge of Pulmonary Embolus Patients.

BackgroundHospitalization for low‐risk pulmonary embolism (PE) is common, expensive, and of questionable benefit.ObjectiveThe objective was to determine if low‐risk PE patients discharged from the emergency department (ED) on rivaroxaban require fewer hospital days compared to standard of care (SOC).MethodsMulticenter, open‐label randomized trial in low‐risk PE defined by Hestia criteria. Adult subjects were randomized to early ED discharge on rivaroxaban or SOC. Primary outcome was total number of initial hospital hours, plus hours of hospitalization for bleeding or venous thromboembolism (VTE), 30 days after randomization. A 90‐day composite safety endpoint was defined as major bleeding, clinically relevant nonmajor bleeding, and mortality.ResultsOf 114 randomized subjects, 51 were early discharge and 63 were SOC. Of 112 (98.2%) receiving at least one dose of study drug, 99 (86.8%) completed the study. Initial hospital LOS was 4.8 hours versus 33.6 hours, with a mean difference of –28.8 hours (95% confidence interval [CI] = –42.55 to –15.12 hours) for early discharge versus SOC, respectively. At 90 days, mean total hospital days (for any reason) were less for early discharge than SOC, 19.2 hours versus 43.2 hours, with a mean difference of 26.4 hours (95% CI = –46.97 to –3.34 hours). At 90 days, there were no bleeding events, recurrent VTE, or deaths. The composite safety endpoint was similar in both groups, with a difference in proportions of 0.005 (95% CI = –0.18 to 0.19). Total costs were $1,496 for early discharge and $4,234 for SOC, with a median difference of $2,496 (95% CI = –$2,999 to –$2,151).ConclusionsLow‐risk ED PE patients receiving early discharge on rivaroxaban have similar outcomes to SOC, but fewer total hospital days and lower costs over 30 days.

Abstract P-162: PEDIATRIC INTENSIVE CARE UNIT (PICU) ADMISSIONS DUE TO PNEUMONIA COMPLICATED WITH PARAPNEUMONIC EFFUSION (PPE) OR PLEURAL EMPYEMA (PE) AT COSTA RICA’S (CR) NATIONAL CHILDREN’S HOSPITAL

Aims & Objectives: In Latin America, few studies analyzing children with pneumonia complicated with PPE or PE requiring PICU admission have been published. We describe the first study in Central America focusing on this subgroup of pts. Methods Retrospective descriptive study of ch <13 years who had a discharge diagnosis of pneumonia with PPE or PE who were admitted to the PICU of the only national pediatric tertiary referral teaching hospital of CR from Jan-1st-2006 to Jan-31st-2014. Results Among 121 pts with pneumonia complicated with PPE or PE, 46(38%) required PICU admission. 27(58.7%) were male; median age was 11(1–166) months. Median length of hospitalization in the PICU was 5(1–30) days, and total days in hospital for this group, 19(2–83) days. Mechanical ventilation was required in 43(93.5%) pts, with a mean duration of 6.9(1–30) days. A bacterial pathogen was identified in 33(71.7%) pts, being the 3 most common: Staphylococcus aureus 17(37%)(100% MRSA), Streptococcus pneumoniae 11(23.9%), and Streptococcus pyogenes 3(6.5%). Inotropic support was required in 23(50%) pts, transfusions in 28(60.9%), thoracocentesis 33(71.7%), chest tube insertion 37(80.4%), and decortication 14(30.4%). Septic shock occurred in 16(34.8%) pts. 3 (6.5%) pts died: 2 due to pneumococcal septic shock and 1 due to a culture-negative necrotizing pneumonia with abscess formation. Conclusions Although PICU admissions due to pneumonia complicated with PE or PPE in CR children is associated with significant morbidity, the mortality rate is low if compared with other countries. Due to the concerning high rates of MRSA isolates, antibiotic therapy against this pathogen should be initiated promptly in these pts.

Comparison of clinicopathological features and prognosis analysis between carcinoma in the remnant stomach and gastric cancer

To compare clinicopathological features and prognosis between patients with carcinoma in the remnant stomach (CRS) and with gastric cancer, and to investigate the prognostic factors in CRS patients. A retrospective cohort study was performed on clinicopathological data of 96 CRS patients (CRS group) and selected 440 patients with gastric cancer (GC group) treated at Harbin Medical University Cancer Hospital from January 1977 to December 2017. (1) undergoing gastrectomy; (2) diagnosed with CRS or gastric cancer through electronic gastroscopies and pathology; (3) without preoperative neoadjuvant radiotherapy or chemotherapy; (4) complete clinicopathological and follow-up data. The patients who died of other reasons or were lost during follow-up were excluded. Chi-square test and independent samples t-test were used to determine differences in clinicopathological factors between two groups. Survival analysis was conducted using the Kaplan-Meier method, and Log-rank test was used to compare survival difference between two groups. The prognosis of CRS patients was analyzed using Cox proportional hazards regression model. As compared to GC group, CRS group had a higher proportion of female [30.2%(29/96) vs. 13.2%(58/ 440), χ2=14.095, P=0.000], younger age [(56.4±10.1) years vs. (60.0±9.9) years, t=2.838, P=0.005], more distant metastasis and local organ infiltration [25.0%(24/96) vs. 16.1%(71/440), χ2=4.246, P=0.039; 64.6% (62/96) vs. 24.5% (108/440), χ2=58.331, P=0.000], lower prognostic nutritional index [(48.0±6.7) vs. (50.4±6.9), t=3.093, P=0.002], lower serum hemoglobin level [(115.0±24.7) g/L vs. (127.9±24.6) g/L, t=4.634, P=0.000], lower serum albumin level [(40.0±4.9) g/L vs. (41.2±5.0) g/L, t=2.038, P=0.042], and earlier occurrence of symptoms [(1.9±1.4) months vs. (3.7±3.2) months, t=5.431, P=0.000]. However, there were no statistically significant differences in TNM staging, postoperative hospital stay, and total hospitalization days between the two groups (all P>0.05). During follow-up, 24(25.0%) patients developed recurrence or distant metastasis and 68 (70.8%) patients died of tumor progression in CRS group, while 71(16.1%) patients developed recurrence or distant metastasis and 378(85.9%) patients died of tumor progression in GC group. The 5-year survival rate of CRS patients was 23.4%, which was higher than 15.0% of gastric cancer patients (P=0.032). Univariate analysis showed that the CRS patients with radical operation (P=0.000), earlier TNM stage (P=0.000), non-distant metastasis (P=0.022), serum hemoglobin level >130 g/L(P=0.013), and serum album level >40 g/L (P=0.042) had better prognosis. Multivariate analysis, enrolling above 5 factors, showed that TNM staging (HR=2.363, 95%CI: 1.478-3.776, P=0.000) and serum hemoglobin level >130 g/L(HR=0.449, 95%CI: 0.244-0.827, P=0.010) were independent factors influencing prognosis of CRS patients. Although CRS patients have better prognosis than gastric cancer patients, but local organ invasion and distant metastasis occurs more readily. TNM staging and serum hemoglobin level are independent prognostic factors for CRS patients.

Impact of patient-centred home telehealth programme on outcomes in heart failure

Background Telehealth is a promising intervention to reduce readmissions and healthcare-associated costs in patients with heart failure. Methods We performed a retrospective analysis of the impact of telehealth on 197 heart failure patients who had successfully completed one year of home telehealth monitoring following a heart failure admission as part of a clinically mandated programme at a Veterans Affairs Medical Center. Outcomes were compared both within the group (one year before and one year after home telehealth monitoring), and to a contemporary control cohort of 870 heart failure patients who were admitted but not enrolled in home telehealth. The following outcomes were analysed: admissions for any cause, heart failure admissions, total hospital days per patient, average length of stay per admission, urgent care and emergency room visits, and primary care visits. Results Both the home telehealth and control cohorts consisted of older male patients. Total hospital days per patient was significantly reduced by home telehealth monitoring in the home telehealth group (2.4 ± 3.5) in comparison to the previous year without monitoring (4.1 ± 4.6, p < 0.0001) and to the control group (3.8 ± 5.3, p < 0.001). A significantly lower admission rate (1.1 ± 1.6) and length of stay (5.7 ± 11.3 days) were observed during home telehealth monitoring within the home telehealth group compared to the prior year (1.6 ± 1.7, p < 0.05 and 9.5 ± 14 days, p < 0.01 respectively) but not in comparison with the control group (1.4 ± 2.0, p < 0.07). The home telehealth group also had a significantly lower length of stay when compared to the control group (5.7 ± 11.3 vs 9.0 ± 14.9, p < 0.01). The number of urgent care and emergency room visits, or primary care visits, was not significantly different during home telehealth monitoring as compared to the prior year. Conclusions Personalised and patient-centred home telehealth monitoring in heart failure patients was successful in reducing outcomes without an increase in outpatient and urgent care visits.

Decreased healthcare resource utilization associated with enhancement of a state graduated driver licensing law

ObjectiveIn 2007, Ohio implemented additional graduated driver licensing (GDL) provisions to restrict numbers of passengers and nighttime driving. This study evaluated the effects of Ohio's revised GDL law on hospital resource utilization among drivers and occupants involved in crashes with teen drivers ages 16–20 years. MethodsAnalysis of MVCs involving drivers ages 16–20 years in Ohio prior to GDL enhancement (2004–2006) and immediately following GDL enhancement (2008–2010) using linked crash and hospital data was performed. Descriptive statistics and population-based rates of emergency department (ED) visits and hospitalizations, and inpatient hospital charges and length of stay were compared. ResultsFollowing enactment of the 2007 GDL provisions, decreases were observed in the number of teen occupants and all-age occupants involved in crashes with drivers ages 16–17 years and 18–20 years. In the post-GDL enhancement period, ED visits declined by 22.2–39.9%, and inpatient hospitalizations declined by 54.4–62.5%. Total hospital charges for teen occupants in crashes with drivers ages 16–20 years decreased by $16.3–32.3 million, and for all-age occupants by $29.5–52.6 million. Decreases in total hospital charges occurred despite increases in mean hospital charges post-GDL enhancement. Total days of hospitalization in the post-GDL enhancement period declined by 60.4–67.7% among teen occupants and 55.5–63.2% among all-age occupants. ConclusionsThis study is the first to use linked data to evaluate the effects of GDL on healthcare resource utilization by teen drivers and their occupants. The post-GDL enhancement period was associated with reductions in MVC-related ED visits, inpatient hospitalizations, total hospital charges, and total days of hospitalization. Increases in mean inpatient hospital charges were noted and may indicate a reduction in minor injury crashes. Despite attempts to mitigate the confounding effects of the economy on teen driving, it is likely that economic influences are at least partially responsible for the observed decrease in healthcare resource utilization.

Changes in Socioeconomic Differences in Hospital Days With Age: Cumulative Disadvantage, Age-as-Leveler, or Both?

Length of hospital stay is inversely associated with socioeconomic status (SES). It is less clear whether socioeconomic disparities in numbers of hospital days diverge or converge with age. Longitudinal linked Finnish registry data (1988-2007) from 137,653 men and women aged 50-79 years at the end of 1987 were used. Trajectories of annual total hospital days by education, household income, and occupational class were estimated using negative binomial models. Men and women with higher education, household income, and occupational class had fewer hospital days in 1988 than those with lower SES. Hospital days increased between 1988 and 2007. For some age groups, higher SES was associated with a faster annual rate of increase, resulting in narrowing rate ratios of hospital days between SES groups (relative differences); the rate ratios remained stable for other groups. Absolute SES differences in numbers of hospital days appeared to diverge with age among those aged 50-69 years at baseline, but converge among those aged 70-79 years at baseline. The hypotheses that socioeconomic disparities in health diverge or converge with age may not be mutually exclusive; we demonstrated convergence/maintenance in relative differences for all age groups, but divergence or convergence in absolute differences depending on age.

Multi-drug resistant organism infections in a medical ICU: Association to clinical features and impact upon outcome

ObjectiveTo define clinical features associated with Intensive Care Unit (ICU) infections caused by multi-drug resistant organisms (MDRO) and their impact on patient outcome. DesignA single-center, retrospective case–control study was carried out between January 2010 and May 2010. SettingA medical ICU (MICU) in the United States. PatientsThe study included a total of 127 MDRO-positive patients and 186 MDRO-negative patients. InterventionsNo interventions were carried out. ResultsOut of a total of 313 patients, MDROs were present in 127 (41.7%). Based on the multivariate analysis, only infection as a cause of admission [OR 3.3 (1.9–5.8)]), total days of ventilation [OR 1.07 (1.01–1.12)], total days in hospital [OR 1.04 (1.01–1.07)], immunosuppression [OR 2.04 (1.2–3.5)], a history of hyperlipidemia [OR 2.2 (1.2–3.8)], surgical history [OR 1.82 (1.05–3.14)] and age [OR 1.02 (1.00–1.04)] were identified as clinical factors independently associated to MDROs, while the Caucasian race was negatively associated to MDROs. The distribution of days on ventilation, days in hospital and days of antibiotic treatment prior to infection differed between the MDRO-positive and MDRO-negative groups. The MDRO-positive patients showed a greater median number of days in hospital and days of antibiotic treatment before infection, with a greater median number of days in hospital, days of antibiotic treatment and days of ventilation after infection, compared to the MDRO-negative patients. The mortality rate was not significantly different between the two groups. Appropriate empirical antibiotic therapy was prescribed in 82% of the MDRO-positive cases – such treatment being started within 24h after onset of the infection in 68.5% of the cases. ConclusionDefining clinical factors associated with MDRO infections and administering timely and appropriate empirical antibiotic therapy may help reduce the mortality associated with these infections. In our hospital we did not withhold broad spectrum drugs as empirical therapy in patients with clinical features associated to MDRO infection. Our rate of appropriate empirical therapy was therefore high, which could explain the absence of excessive mortality in patients infected with MDROs.

Minimal Use of Opioids for Pain Relief in an Internal Medicine Department.

The objective of the study was to determine if pain control was adequate despite our policy of limited opioid use. In this observational cohort study, we reviewed 300 consecutive patient charts from an internal medicine department. We extracted demographic data, as well as the patients' primary diagnosis, pain on admission, daily pain evaluations (numerical rating score [NRS]), and treatment. Significant pain was defined as a score of ≥3 on the NRS. We determined the incidence of pain and pain control and reviewed the charts of those with an NRS ≥3 for ≥3 days to determine the need for opioid therapy. Of 1692 total hospitalization days in the 300 consecutive patients with a median age of 80 years (1st-3rd quartiles, 65-87 years) there were 204 days with complaints of pain (12.1%) and 149 days (8.8%) with reports of pain of ≥3 on the NRS. Overall, 28.3% (85 of 300) of the patients had significant pain during their hospitalization. Most of the pain, however, (80.0%, 68 of 85) was short-term (1-2 days) whether or not the patient received pain medication. Pain relief treatment in the hospital included opioids in 17 (5.7%, 95% confidence interval [CI] 3.5-8.9) and dipyrone in 36 (12%, 95% CI 8.8-16) of the 300 patients. Pain control was adequate in the seven patients with prolonged pain who did not receive opioids. There were only two patients discharged with prescriptions for opioids (0.7%, 95% CI 0.2-2.6). Significant pain is common in patients hospitalized in an internal medicine department, but the pain is mostly short term and pain control is adequate despite the restricted use of opioid therapy during hospitalization.

Benchmarking of aggregated length of stay after open and laparoscopic surgery for cancers of the digestive system.

BackgroundLength of hospital stay (LOS) may serve as a surrogate measure of healthcare quality and resource use, particularly when transfers of care and readmissions are accounted for. This study aimed to benchmark true hospital stay by measuring index, transfer and readmission stays across the range of digestive cancer surgery.MethodsA cohort study of all patients undergoing resection for cancer of the oesophagus, stomach, liver, pancreas, colon or rectum in 2012–2016 was undertaken. Index LOS, transfer and readmission stays were merged into an ‘aggregated’ length of stay (a‐LOS), and compared between organ sites and between open and minimal‐access approaches.ResultsIn total, 24 354 resections were reported (mean age of patients 68·3 years; 51·3 per cent were men). Resections were reported as laparoscopic for 9151 procedures (37·6 per cent), with a further 283 (3·0 per cent) described as converted to open surgery. Use of a‐LOS compared with standard LOS added a median of 5 days for pancreatoduodenectomy, 4 days for major liver resections, 3 days for oesophageal and gastric resections, and 2 days for minor liver, distal pancreatic and rectal resections.ConclusionOverall hospital stay across organ sites and procedures is better described by a‐LOS. The study benchmarks the use of total hospital days during the first 30 days in a universal healthcare system.

176 - Outpatient-Based Autologous Stem Cell Transplantation: Feasible, Safe and Cost-Effective Approach

Given the improvements in the supportive care, autologous hematopoietic stem cell transplantation (AHSCT) could be performed in outpatient basis, for selected patients (pts), offering the benefit of shorter hospitalization, less exposure to hospital pathogens, saving nosocomial beds, demonstrating thus not only a safe but also a cost-effective profile. To evaluate the feasibility and safety of this approach, we performed 29 AHSCTs on outpatient basis, in a total of 22 pts, previously diagnosed with Hodgkins lymphoma (n = 5) or Multiple Myeloma (n = 17); 7 pts underwent AHSCT twice in the context of a tandem transplant program. Six were females and 16 males aged of a median 51 (27-68) ys. The eligibility criteria for the outpatient AHSCT, were the standard clinical and laboratory tests, plus psychosocial evaluation, patient's compliance assessment, 24 hours caregiver availability, timely access to the hospital and signed informed consent. The conditioning regimen consisted from single agent Melphalan of 200 (n = 21) or 140 mg/m2 (n = 8), graft infusion and supportive care were given in an allocated room. The antimicrobial, antifungal and antiviral prophylaxis was administered from day -2 and filgrastim 5 mcg/kg from day +5 till neutrophils recovery. If no infection was documented the antimicrobial and antifungal prophylaxis were discontinued upon stable neutrophils recovery while antiviral prophylaxis was continued for 10-12 months. Patients were evaluated daily or every 2 days in the outpatient clinic. The criteria for admission were fever >38oC, intractable nausea/vomiting or diarrhea, mucositis needing total parenteral nutrition and any other toxicity WHO > grade 3. The median day for neutrohils >1000/mm3 was 11(11-18) and for platelets >20000/ mm3 was 11(0-21); in 2 pts platelets never dropped lower than 25000/mm3. Totally, 14 admissions were required, 9 for inability for food/fluid uptake due to severe mucositis, 4 for febrile neutropenia and 1 for engraftment syndrome. The infections successfully treated with broad spectrum antibiotics and no pt was admitted to intensive care unit. For the whole 29 ASCTs, the total hospitalization days were 65 (median:1, range 0-9), while for the 14 admissions the median hospitalization days were 5 (1-9), which favorably compares with the average of 14 hospitalization days for a single “conventional” ASCT. No other toxicities (WHO > 3) were observed. All pts are alive, 7 (2-33) months post AHSCT. Our data indicate that the outpatient-ASCT is a feasible and safe approach provided a caregiver availability, close pts evaluation and adequate supportive care. Keeping in mind the nosocomial complications and the potential high cost of the prolonged hospitalization, it seems that the outpatient ASCT offers lower risk of infections and significant cost saving compared to the “convetional” inpatient ASCT approach.

Impact of a Home-Based Palliative Care Program for Advanced Heart Failure (QI816)

•Describe an interdisciplinary home-based palliative care pilot program for patients with advanced heart failure.•Discuss preliminary outcomes of home-based palliative care intervention on acute care utilization and satisfaction. Transitions LifeCare partnered with a community hospital to offer home-based palliative care (HBPC) to patients with advanced heart failure (HF). These patients were identified by the hospital as high utilizers of services. HBPC provided symptom management, psychosocial support, advance care planning, and patient education. Evaluate the impact of HBPC support on hospital utilization and quality of care. This is a case series of 20 patients with advanced HF who were high utilizers of healthcare resources. Initial HBPC consultation occurred within 7 days of hospital discharge and care continued for 4-6 weeks. A nurse-directed interdisciplinary team provided physical assessment, symptom management, medication reconciliation, advance care planning, and psychosocial support. The Quality Data Collection Tool for Palliative Care was used to collect symptom management data and the FAMCARE-2 was used to assess family satisfaction. Data were collected for hospital utilization in the 90 days leading up to the intervention and compared to utilization during the pilot. Hospital admissions declined by 52.4%, from 14.7 per 30 days to 7 per 30 days (p = 0.001). Hospital days decreased by 53.8%, from 86.7 per 30 days to 40 per 30 days (p = 0.04). Total ICU usage decreased 100%, from 9.7 per 30 days to 0 per 30 days (p = 0.01). Overall symptom burden decreased, and 40% of patients had a change in code status or advance directives. This HBPC program significantly reduced hospital admissions, total hospital days and ICU utilization for the participants while reducing symptom burden. Expanding this HBPC program would provide high quality care to patients and cost savings to the partnering hospital. Based on average hospital costs of HF admissions in NC, this could represent a savings of up to $8,000 per patient for this 30-day period.

Hospitalization and medical cost of patients with elevated serum N-terminal pro-brain natriuretic peptide levels.

BackgroundPatients with heart failure (HF) are reportedly at high risk for ‘all-cause’ re-hospitalization. A biomarker for HF, N-terminal pro-brain natriuretic peptide (NT-proBNP), enables to simply detect patients with possible HF (pHF). We examined the hospitalization and medical cost of Japanese patients detected by an elevated serum NT-proBNP, and also evaluated the effects of institutional team approaches for HF on their all-cause hospitalizations.MethodsWe retrospectively extracted all adult patients with serum NT-proBNP ≥400 pg/ml measured between January and March 2012 in Hiroshima University Hospital as pHF-positive patients. We studied their all-cause hospitalization records during the past 3-year period. We also extracted all pHF-negative patients with NT-proBNP <400 pg/ml and studied as well. In the pHF-positive patients followed for 3 years after starting interprofessional team approaches to prevent the onset and exacerbation of HF in the hospital, we compared the hospitalization and medical cost between the 3-year periods before and after the start of the team approaches.ResultsWe enrolled 432 pHF-positive and 485 pHF-negative patients with one or more hospitalization records. Compared to the pHF-negative patients, the pHF-positive patients had longer total hospitalization days (median [interquartile range], 30 [13–58] versus. 18 [8–39], p <0.0001) and higher total medical cost for hospitalizations (2.42 [1.07–5.08] versus. 1.80 [0.79–3.65] million yen, p <0.0001). A subset of 303 pHF-positive patients was followed for 3 years after starting the team approaches, and we found that both total hospitalization days (30 [13–57] to 8 [0–31]) and medical cost for hospitalizations (2.59 [1.37–5.05] to 0.76 [0–2.38] million yen) showed marked reduction in them.ConclusionsPatients with an elevated serum NT-proBNP have longer hospitalizations and higher costs for all-cause hospitalizations than those without. Institutional team approaches for HF may reduce them.

Assessment of Time to Hospital Encounter after an Initial Hospitalization for Heart Failure: Results from a Tertiary Medical Center.

Background Hospital inpatient readmissions for patients admitted initially with the primary diagnosis of heart failure (HF) can be as high as 20–25% within 30 days of discharge. This, however, does not include admissions for observations or emergency department (ED) visits within the same time frame and does not show a time-dependent hospital encounter following discharge after an index admission. We present data on time-dependent hospital encounter of HF patients discharged after an index admission for a primary diagnosis of HF. Methods The study recruited patients from 2 hospitals within the same health system. 500 consecutive admissions with the ICD diagnosis of HF were reviewed by inclusion and exclusion screening criteria. The 166 eligible remaining patients were tracked for post hospital discharge encounters consisting of hospital admissions, observation stays, and ED visits. Only those with a primary diagnosis of heart failure were included. Demographics were recorded on all patients. Days until hospital inpatient readmissions or hospital encounters were displayed in Kaplan–Meier plots. Results A total of 166 patients met inclusion criteria (mean age 79.3 years, males 54%). For the first 90 days following the index admission, there were a total of 287 follow-up visits (1.7 per patient), 1158 total hospitalization days (2.6 per visit, 7.0 per patient, and 8.6 per 100 days at risk), and 21 deaths (12.7%). At 30 days, 25% and 52% of patients had an inpatient readmission or a hospital encounter, respectively. The median time to inpatient readmission was 117 days and to hospital encounter was 27 days. Conclusion Time-dependent excess days in acute care (unplanned inpatient admission, outpatient observation, and ED visit) rather than 30-day hospital inpatient readmission rate is a more realistic measure of the intensity of care required for HF patients after index admission.

Distracción mandibular ósea: resultados del postoperatorio inmediato

IntroductionMandibular distraction osteogenesis is a relatively new surgical technique to relieve mandibular lengthening airway obstruction in patients with mandibular hypoplasia. It has revolutionised the management of defects in the field of craniofacial surgery, and the procedure has become widely accepted in hospitals worldwide. GoalsTo describe the evolution and rate of complications in the immediate postoperative period following mandibular distraction osteogenesis in the Mother and Child Hospital of Granada, Andalusia's referral hospital for this technique. Material and methodsDescriptive observational study of children who underwent mandibular distraction in the period between 2006 and 2016. A total of 20 patients were included. The data were analysed with the statistical package SPSS Statistics 20. ResultsThe children required admission to ICU for a median of 5.5 days (2-9), the total days of hospital stay were a median of 8 (4.25 to 14). A total of 10 patients (50%) developed a fever. Enteral nutrition was established, on average, at 2 days after surgery. ConclusionsPatients with Pierre Robin sequence may have severe retro/micrognathia causing them symptoms including from difficulty in air entry to obstructive apnoea, in which case mandibular distraction is the treatment of choice. After this intervention the postoperative period should be in ICU for airway management and other care. According to the data presented, we conclude that the postoperative period is short and with a low rate of complications.