Total LOS Research Articles

Multi-Institutional Model to Predict Intensive Care Unit Length of Stay after Cardiac Surgery

Intensive care unit length of stay (ICU LOS) accounts for a large percent of inpatient cost following cardiac surgery. The Society of Thoracic Surgeons (STS) risk calculator predicts total LOS but does not discriminate between ICU and non-ICU time. We sought to develop a predictive model of prolonged ICU LOS. Adult patients undergoing STS index operations within a regional collaborative (2014-2021) were included. Prolonged ICU LOS was defined as ICU care for ≥72 hours postoperatively. A logistic regression model was utilized to develop a prediction model for the prolonged ICU LOS with pre-specified risk factors identified from our previous single center study. Internal prediction model validation was determined by bootstrapping resampling method. The prediction model performance was assessed by measures of discrimination and calibration. We identified 37,519 patients that met inclusion criteria with 11,801 (31.5%) patients experiencing prolonged ICU stay. From the logistic regression model, there were significant associations between prolonged ICU LOS and all pre-specified factors except sleep apnea (all p<0.05). MELD, preoperative intra-aortic balloon pump use, and procedure types were the most significant predictors of prolonged ICU LOS (all p<0.0001). Our prediction model had not only a good discrimination power (bootstrapped-corrected C-index=0.71) but also excellent calibration (bootstrapped-corrected mean absolute error=0.005). Prolonged ICU stay following cardiac surgery can be predicted with good predictive accuracy utilizing preoperative data and may aid in patient counseling and resource allocation. Through use of a state-wide database, the application of this model may extend to other practices.

Mapping forest phenological shift in Nilgiri Biosphere Reserve, Western Ghats: Response to climate change

In the present study, the spatiotemporal alterations in phenological metrics were analyzed in different forest types of Nilgiri Biosphere Reserve (NBR), Western Ghats, India with special reference to the impacts of changing climate on the forest phenology over two-phase periods (Phase 1: 2001–2010 and Phase 2: 2011–2020). Three phenological measures including the start/end/length of the season (SOS/EOS/LOS) were obtained using 16 days of MODIS Enhanced Vegetation Index (EVI) dataset over the two decades. The study exhibited a gradual delay in SOS during phase 1, and an advancing SOS during phase 2 in the tropical forests of NBR. Delayed EOS was observed in all forest types in NBR barring Moist Deciduous Forests (MDF) during phase 1, while opposite trend of advancing EOS was observed in deciduous forests (MDF and DDF: Dry Deciduous Forests), but delayed EOS was observed in evergreen forests (SEF: Semi Evergreen Forests and WEF: Wet Evergreen Forests) during phase 2. These variations in forest phenology are linked with an increase in annual mean temperature (0.01 °C year−1) along with a decrease in annual mean precipitation (3.97 mm year−1) during 1950–2018 as observed using IMD-based meteorological datasets. The results highlighted reduction in the total LOS with a delayed SOS and advanced EOS in NBR, which were prevalent during phase 1 conversely to phase 2 due to the varied intensity of changes in climatic conditions. However, disaggregating decade-long intervals into 5-year segments enables a finer resolution analysis of phenological trends. The study contributes to the development of long-term strategies for forest ecosystem restoration under the influence of global climate change by providing an insightful understanding of the non-systematic shifts in forest phenology attributed by rising warming impacts and erratic precipitation patterns.

Morbidity after accelerated enhanced recovery protocol for colon cancer surgery

Previous studies showed that accelerated enhanced recovery programs (ERPs) with discharge 1–3 days after colorectal surgery are feasible for specific patients without compromising patients’ safety. This study aimed to examine the incidence, severity, and treatment of complications after treatment according to an accelerated ERP (CHASE). This accelerated ERP consisted of adjustments in pre-, peri- and postoperative care. Patients treated according to the CHASE protocol were compared to a retrospective cohort of patients who received standard ERAS care. The primary outcome was the rate of severe complications. The overall complication rates were similar in both cohorts (CHASE 30.7% vs ERAS 31.4%, p = 0.958) as well as severe complications (CHASE 20.9% vs ERAS 21.4%, p = 0.950). Among the 113 patients with a complicated course, the readmission rate was significantly higher in the CHASE cohort (41.9% vs 21.4%, p = 0.020). LOS after readmission was longer in the CHASE cohort (p = 0.018), but the total LOS was shorter (4 versus 6 days, p = 0.001). This study demonstrates that accelerated recovery can be safe for ASA I-II patients and has the potential to become a standard of care. Moreover, the CHASE protocol proved to be beneficial in terms of total LOS for patients with complications.

Two big bones, one big decision: When to fix bilateral femur fractures

PurposeFor polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. MethodsThe 2017–2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. Results1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. ConclusionEarly definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

929 Outcomes in Pediatric Spinal Cord Injuries Based on Time to Surgery

INTRODUCTION: Early surgery in individuals with traumatic spinal cord injury (SCI) has been associated with improved neurological recovery, lower risk of complications, and reduced resource utilization. Patient and healthcare-related factors may contribute to delay in surgery. This study aimed to determine factors contributing to longer time-to-surgery in pediatric patients with complete and incomplete SCI. METHODS: Patients with SCI were identified in the National Trauma Data Bank based on AIS codes. Patients who died in the ED or were transferred to another hospital were excluded. Procedure codes were used to identify patients who underwent spinal surgery. Patients were grouped by time to surgery less than or greater than 12 hours. RESULTS: 549 patients were identified with 235 incomplete and 314 complete SCI. 399 patients underwent surgery (177 incomplete; 222 complete). Of patients who underwent surgery, 55% of incomplete and 52% of complete SCI went to surgery after 12 hours. SCI patients with greater than 12-hour time-to-surgery had worse injury severity scores (32 vs 28, p &lt; 0.05). Additionally, ICU LOS, total ventilation days, and total LOS were longer. Time-to-surgery greater than 12 hours was statistically associated with unplanned ICU stay (incomplete), unplanned OR (complete), ventilator associated pneumonia (complete), and delirium (incomplete). Time-to-surgery was not significantly associated with race, gender, or mechanism of injury. pneumonia (complete), and delirium (incomplete). Time-to-surgery was not significantly associated with race, gender, or mechanism of injury. CONCLUSIONS: Greater time-to-surgery is associated with higher risk of complications and longer hospital stays in patients with complete and incomplete SCI in the pediatric population. This data raises the question as to whether earlier surgery could reduce complications.

Abstract WP33: Impact of Early Mobilization on Length of Stay in Acute Ischemic Stroke

Background: IV rt-tPA is standard of care in patients presenting within 4.5 hours of acute ischemic stroke (AIS) symptom onset. Despite its short half-life, concerns regarding the safety of early mobilization remain, which may delay patients’ time to rehabilitation evaluation. We previously demonstrated the safety of early mobilization, using stratification based on stroke severity. This study aims to compare time from mobility order to PT/OT evaluation and total length of stay between patients whose mobility orders were congruent with institutional guidelines to those with incongruent orders. Methods: This is a retrospective case-cohort study of AIS patients who received IV tPA and/or mechanical thrombectomy (MT), admitted to our center April 2018 to December 2019. Prior to this, a 24 hour bedrest protocol post-rtPA was in place. In April of 2018, a new mobility protocol was established stratifying bedrest time following tPA and/or MT to 1, 6, or 8 hours, based on NIHSS and clinical stability. All patients in this cohort (N=524) should have been assigned the new mobility protocol. For patients receiving both tPA and MT, the mobility assignment for thrombectomy was assessed. 37 patients were excluded from analysis due to missing data points. Results: A total of 384 patients received tPA only, with 89% (n=354) receiving congruent orderset. 59 patients received tPA and MT, and 74 received MT only. Mean LOS days for tPA only with congruent orderset was 5.33 + 5.76 (n=350) vs. 6.45 + 6.06 (n=55) with incongruent orders. Mean LOS days for MT only with congruent orders was 10.03 + 6.42 (n=58) vs. 10.28 + 7.64 (n=57) with incongruent orders. Mean time in hours from PT/OT order to evaluation for tPA only with congruent orders was 17.72 + 13.01 (n=341) vs. 32.63 + 29.45 (n=41) with incongruent orders. For MT only patients with a congruent orderset, mean hours from PT/OT order to evaluation was 33.74 + 16.91 (n=54), and 50.7 + 34.12 (n=47) for incongruent orders. Conclusions: There was an increase in both PT/OT order to evaluation time and total LOS for patients with incorrect orders. Following the early mobilization protocol leads to an earlier PT/OT evaluation and disposition.

Effectiveness and Safety of Postoperative Hospital at Home for Surgical Patients: A Cohort Study.

To determine the feasibility and effectiveness of a Hospital at Home (HaH) enabled early transfer pathways for surgical patients. HaH serves as a safe alternative to traditional hospitalization by providing acute care to patients in their homes through a comprehensive range of hospital-level interventions. To our knowledge, no studies have been published to date reporting a large cohort of early home-transferred patients after surgery through a HaH unit. Cohort study enrolling every patient admitted to the HaH unit of a tertiary hospital who underwent any of 6 surgeries with a predefined early transfer pathway and fitting both general and surgery inclusion criteria (clinical and hemodynamic stability, uncomplicated surgery, presence of a caregiver, among others) from November 2021 to May 2023. Protocols were developed for each pathway between surgical services and HaH to deliver the usual postoperative care in the home setting. Discharge was decided according to protocol. An urgent escalation pathway was also established. During the study period, 325 patients were included: 141 were bariatric surgeries, 85 kidney transplants, 45 thoracic surgeries, 37 cystectomies, 10 appendicectomies, and 7 ventral hernia repairs. The overall escalation of care during HaH occurred in 7.3% of patients and 30-day readmissions in 7%. Most adverse events were managed at home and the overall mortality was zero. The total mean length of stay was 8 days (interquartile range 2-14), and patients with HaH were transferred home 3 days (interquartile range 1-6) earlier than the usual pathway; a total of 1551 bed-days were saved. The implementation of early home transfer pathways for surgical patients through HaH is feasible and effective, with favorable safety outcomes.

Post-Operative Complications Associated with Long-Term NSAID or Long-Term Opioid Use Prior to Lumbar Spinal Fusion Surgery

ObjectiveLower back pain (LBP) has been implicated as a significant cause of chronic pain in the United States, often requiring analgesic use. In this study, we investigate the trends in long-term preoperative NSAID (LTN) and Opioid (LTO) use in patients with low back pain in the United States, and the resultant postoperative complications following lumbar fusion. MethodsIn this retrospective cohort study of patients with lumbar pathologies, multivariate population-based regression models were developed using the 2010–2017 National Readmission Database. Short-term complications (30-, 90-day) and long-term complications (180-, 300-day) were analyzed at readmission. ResultsOf patients diagnosed with LBP (N = 1427,190) we found a rise in LTO users and a fall in LTN users following 2015. We identified 654,264 individuals who received a lumbar spine fusion, of which 22,975 were LTN users and 11,213 were LTO users. LTO users had significantly higher total inpatient charges (p-value<0.0001) and LOS (p-value<0.0001), while LTN users had lower rates of acute infection (OR: 0.993, 95% CI: 0.987–0.999, p = 0.017) and acute posthemorrhagic anemia (OR: 0.957, 95% CI: 0.935–0.979, p < 0.001) at primary admission. Readmission analysis showed that LTN use had significantly lower odds of readmission compared to LTO use at all time points (p < 0.01 for all). LTN use had significantly higher odds of hardware failure (OR: 1.134, 95% CI: 1.039–1.237, p = 0.005) within 300-days of receiving a lumbar fusion. ConclusionsLTO users had significantly higher readmission rates compared to LTN. In addition, we found that LTN use was associated with significantly higher odds of hardware failure at long-term follow-up in patients receiving lumbar fusion surgery.

Health Care Resource Utilization (HCRU) and Cost of Management of Cytokine Release Syndrome (CRS) and Neurological Events (NEs) in Patients with R/R CLL/SLL Receiving Lisocabtagene Maraleucel (liso-cel) Treatment in the TRANSCEND CLL 004 Study

Background:Liso-cel is an autologous, CD19-directed, 4-1BB CAR T cell product administered at equal target doses of CD8 + and CD4 + CAR + T cells, which is currently being evaluated for treatment of patients with R/R CLL/SLL in the TRANSCEND CLL 004 study (NCT03331198). Initial study results suggested that a single infusion induced CRs or remission in patients with R/R CLL/SLL and had a manageable safety profile, with low to moderate incidence of severe CRS and NEs (Siddiqi T, et al. Lancet 2023). While the clinical consequences of CRS/NEs associated with CAR T cell therapies are well understood, limited data are available on the cost of management of these AEs. This analysis evaluated HCRU and estimated costs of managing CRS/NEs by grade in patients with R/R CLL/SLL who received liso-cel treatment in TRANSCEND CLL 004. Methods: Case report forms were analyzed from the trial database, capturing patient-level HCRU related to the management of CRS/NEs. Only patients that received liso-cel at a dose level of 100 × 10 6 CAR + T cells (dose level 2 [DL2]) and subsequently experienced treatment-emergent CRS and/or NEs were included in this study. Treatment-emergent AEs were defined as those initiated within a 90-day period of liso-cel administration. Costs for management of CRS/NEs were estimated using microcosting methodology. Relevant HCRU observed from the day of AE onset through resolution that was associated with the management of CRS/NEs per protocol management guidelines was identified; unit costs sourced from public databases were applied to each HCRU. Included HCRU categories were: facility (standard inpatient admission, ICU stay), diagnostics (laboratory, imaging), medications (tocilizumab, corticosteroids, vasopressors), and procedures (dialysis, intubation). Cost analyses were conducted from the United States (US) health care system perspective and adjusted to 2023 US dollars. Unit costs were obtained from the US Centers for Medicare &amp; Medicaid Services Hospital Outpatient Prospective Payment System, laboratory and physician fee schedules, IBM ® Micromedex ® RED BOOK ®, and literature. Descriptive statistical analyses stratified by AE severity grade and type of AE experienced were performed. Results: Ninety-four of 108 (87%) patients who received liso-cel at DL2 experienced CRS and/or NEs; 68 (72%) were grade ≤ 2 and 26 (28%) were grade ≥ 3. Overall, 44 (47%) patients had CRS only, 1 (1%) had NEs only, and 49 (52%) experienced both CRS and NEs. The study sample had a mean (standard deviation) age of 64.5 y (7.9) and were predominantly male (69%), White (84%), and non-Hispanic or Latino (90%). HCRU and total length of stay (LOS; the sum of inpatient and ICU stay days) are shown in the Table. All patients had an inpatient stay. ICU admissions only occurred among patients who experienced both CRS and NEs (10/49 [20%]) and were more common among patients with grade ≥ 3 (29%) compared with grade ≤ 2 (12%) AEs. Among patients who had an ICU admission, the median duration of an ICU stay was 5 days. Median total LOS increased with increasing AE severity for patients who had CRS only (grade 1, 5 days; grade 2, 9 days; grade 3, 15 days) and for patients who experienced both CRS and NEs (grade ≤ 2, 12 days; grade ≥ 3, 15 days). Overall, 68% and 62% of patients received tocilizumab and corticosteroids, respectively. Patients with grade ≥ 3 CRS and/or NEs had higher rates of utilization of medications, diagnostics, and procedures than those with grade ≤ 2 (Table). Additionally, patients who experienced both CRS and NEs had higher rates of utilization across all HCRU categories compared with those who experienced CRS or NEs only (Table). Estimated median management costs for CRS or NEs ranged from $14,638 (CRS only grade 1) to $46,802 (experienced both CRS and NEs with CRS or NEs grade ≥ 3) (Figure). Facility-related costs were the largest contributor to median total costs. Conclusions: While most patients treated with liso-cel at DL2 in TRANSCEND CLL 004 experienced CRS and/or NEs, they were primarily of low severity. HCRU and associated costs for management of CRS and/or NEs after liso-cel infusion increased with AE severity.Although everyone in this study required hospitalization, ICU admissions were rare and only observed among patients who experienced both CRS and NEs. Overall, costs of managing CRS and/or NEs were modest.

Postinfusion Monitoring Health Care Resource Utilization and Costs By Site of Care Among Inpatients and Outpatients with Relapsed or Refractory Large B-Cell Lymphoma Who Received Second-Line Treatment with Lisocabtagene Maraleucel in the TRANSFORM and PILOT Clinical Trials

Background:CAR T cell therapy administration is often in an inpatient (IP) setting due to the possibility of severe AEs after infusion. Lisocabtagene maraleucel (liso-cel) is an autologous, CD19-directed, 4-1BB CAR T cell product administered at equal target doses of CD8 + andCD4 + CAR + T cells. Outpatient (OP) administration of liso-cel is feasible given trial-demonstrated low rates of grade ≥ 3 AEs that require hospitalization, including cytokine release syndrome and neurological events (Bachier CR, et al. J Clin Oncol 2020). Follow-up care in the OP setting may differ from that in an IP setting and may offer an opportunity to reduce AE management-related health care resource utilization (HCRU) and costs; limited data is published on this topic. Thus, this study assessed postinfusion monitoring HCRU and costs by site of care (ie, IP/OP) among patients with R/R large B-cell lymphoma (LBCL) treated with liso-cel as second-line (2L) therapy in TRANSFORM (NCT03575351) and PILOT (NCT03483103) clinical trials. Methods: A microcosting methodology was used to assess postinfusion monitoring-related HCRU identified from pooled TRANSFORM and PILOT case report forms and to estimate associated costs (excluding liso-cel acquisition costs) by site of care using a 6-month time frame, beginning on the liso-cel infusion date. HCRU data were analyzed in the 6 months after infusion, including facility (eg, number of standard IP and ICU hospitalizations and length of stay [LOS]), procedures (eg, dialysis or intubation/mechanical ventilation), diagnostics (eg, imaging or laboratory tests), and medication use (eg, tocilizumab or corticosteroids). Unit costs were then applied to each HCRU. Unit costs were assessed from the health care system perspective, derived from publicly available databases (eg, United States [US] Centers for Medicare &amp; Medicaid Services, Healthcare Cost and Utilization Project, and IBM ® Micromedex ® RED BOOK ®) or peer-reviewed literature, and adjusted to 2021 US dollars using the medical component of the Consumer Price Index. Patients were considered OP if discharged on the day of infusion or at the end of the observation period. Results: Among 150 patients treated with liso-cel, 111 (74%) were infused as IPs and 39 (26%) as OPs. Estimated median 6-month total postinfusion monitoring costs were $55,253 in the IP setting and $17,505 in the OP setting, reflecting a reduction of $37,748 for OP site of care (Figure). Among patients cared for in the OP setting who required subsequent hospitalization (19/39 [49%]), the median total LOS was 7 days shorter than patients cared for in the IP setting who required hospitalization (105/111 [95%]) (OP: 7 days [range, 1-33] vs IP: 14 days [range, 1-164]). Facility costs, especially hospitalizations, were the largest contributor to overall median 6-month costs in both the IP setting ($40,501; 73%) and the OP setting ($5697; 33%). The majority of total costs occurred in Month 1 postinfusion for patients in both settings. For patients receiving care in the IP setting, 78% ($42,864) of median costs were incurred within the first month after infusion; for OPs, 36% ($6295) of median costs were incurred within Month 1. Patients in the IP setting had higher rates of key HCRU than in the OP setting, respectively, for the following: standard IP hospitalizations (105/111 [95%] vs 19/39 [49%]), ICU admissions (10/111 [9%] vs 0/39 [0%]), any tocilizumab use (32/111 [29%] vs 5/39 [13%]), and any corticosteroid use (54/111 [49%] vs 17/39 [44%]). Patients in the OP setting had higher rates compared with the IP setting, respectively, for office visits (37/39 [95%] vs 87/111 [78%]) and intubation (2/39 [5%] vs 0/111 [0%]). Conclusions: Among patients with R/R LBCL treated with liso-cel in the 2L TRANSFORM and PILOT trials, estimated median 6-month postinfusion costs were 68% lower for patients cared for in the OP versus IP setting. These results are consistent with a previous analysis of patients treated with liso-cel in the third-line setting (Palomba ML, et al. Leuk Lymphoma 2021); and thus, further support that OP postinfusion monitoring and care may allow health care systems to optimize HCRU and costs for patients with LBCL who receive CAR T cell therapy.

Impact of preoperative uni- or multimodal prehabilitation on postoperative morbidity: meta-analysis.

Postoperative complications occur in up to 43% of patients after surgery, resulting in increased morbidity and economic burden. Prehabilitation has the potential to increase patients' preoperative health status and thereby improve postoperative outcomes. However, reported results of prehabilitation are contradictory. The objective of this systematic review is to evaluate the effects of prehabilitation on postoperative outcomes (postoperative complications, hospital length of stay, pain at postoperative day 1) in patients undergoing elective surgery. The authors performed a systematic review and meta-analysis of RCTs published between January 2006 and June 2023 comparing prehabilitation programmes lasting ≥14 days to 'standard of care' (SOC) and reporting postoperative complications according to the Clavien-Dindo classification. Database searches were conducted in PubMed, CINAHL, EMBASE, PsycINFO. The primary outcome examined was the effect of uni- or multimodal prehabilitation on 30-day complications. Secondary outcomes were length of ICU and hospital stay (LOS) and reported pain scores. Twenty-five studies (including 2090 patients randomized in a 1:1 ratio) met the inclusion criteria. Average methodological study quality was moderate. There was no difference between prehabilitation and SOC groups in regard to occurrence of postoperative complications (OR = 1.02, 95% c.i. 0.93 to 1.13; P = 0.10; I2 = 34%), total hospital LOS (-0.13 days; 95% c.i. -0.56 to 0.28; P = 0.53; I2 = 21%) or reported postoperative pain. The ICU LOS was significantly shorter in the prehabilitation group (-0.57 days; 95% c.i. -1.10 to -0.04; P = 0.03; I2 = 46%). Separate comparison of uni- and multimodal prehabilitation showed no difference for either intervention. Prehabilitation reduces ICU LOS compared with SOC in elective surgery patients but has no effect on overall complication rates or total LOS, regardless of modality. Prehabilitation programs need standardization and specific targeting of those patients most likely to benefit.

Predictive Analysis of Hospital Stay after Caesarean Section: A Single-Center Study.

Caesarean section (CS) rate has seen a significant increase in recent years, especially in industrialized countries. There are, in fact, several causes that justify a CS; however, evidence is emerging that non-obstetric factors may contribute to the decision. In reality, CS is not a risk-free procedure. The intra-operative, post-pregnancy risks and risks for children are just a few examples. From a cost point of view, it must be considered that CS requires longer recovery times, and women often stay hospitalized for several days. This study analyzed data from 12,360 women who underwent CS at the "San Giovanni di Dio e Ruggi D'Aragona" University Hospital between 2010 and 2020 by multiple regression algorithms, including multiple linear regression (MLR), Random Forest, Gradient Boosted Tree, XGBoost, and linear regression, classification algorithms and neural network in order to study the variation of the dependent variable (total LOS) as a function of a group of independent variables. We identify the MLR model as the most suitable because it achieves an R-value of 0.845, but the neural network had the best performance (R = 0.944 for the training set). Among the independent variables, Pre-operative LOS, Cardiovascular disease, Respiratory disorders, Hypertension, Diabetes, Haemorrhage, Multiple births, Obesity, Pre-eclampsia, Complicating previous delivery, Urinary and gynaecological disorders, and Complication during surgery were the variables that significantly influence the LOS. Among the classification algorithms, the best is Random Forest, with an accuracy as high as 77%. The simple regression model allowed us to highlight the comorbidities that most influence the total LOS and to show the parameters on which the hospital management must focus for better resource management and cost reduction.

Impact of Fluid Balance on Intensive Care Unit Length of Stay in Critically Ill Trauma Patients.

There is significant data in the medical and surgical literature supporting the correlations between positive volume balance and negative outcomes such as AKI, prolonged mechanical ventilation, intensive care unit and hospital length of stay and increased mortality. This single-center, retrospective chart review included adult patients identified from a Trauma Registry database. The primary outcome was the total ICU LOS. Secondary outcomes include hospital LOS, ventilator-free days, incidence of compartment syndrome, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT), and days of vasopressor therapy. In general, baseline characteristics were similar between groups with the exception of mechanism of injury, FAST exam, and disposition from the ED. The ICU LOS was shortest in the negative fluid balance and longest in the positive fluid balance group (4 days vs 6 days, P = .001). Hospital LOS was also shorter in the negative balance group than that of the positive balance group (7 days vs 12 days, P < .001). More patients in the positive balance group experienced acute respiratory distress syndrome compared to the negative balance group (6.3% vs 0%, P = .004). There was no significant difference in the incidence of renal replacement therapy, days of vasopressor therapy, or ventilator-free days. A negative fluid balance at seventy-two hours was associated with a shorter ICU and hospital LOS in critically ill trauma patients. Our observed correlation between positive volume balance and total ICU days merits further exploration with prospective, comparative studies of lower volume resuscitation to key physiologic endpoints compared with routine standard of care.

EFFECTS OF SARS COVID-19 POSITIVITY STATUS ON VENOUS THROMBOSIS AND PULMONARY EMBOLISM RATES IN TRAUMA PATIENTS.

Introduction : COVID-19-induced coagulopathy (CIC) can increase the risk of thromboembolism without underlying clotting disorders, even when compared with other respiratory viruses. Trauma has a known association with hypercoagulability. Trauma patients with concurrent COVID-19 infection potentially have an even greater risk of thrombotic events. The purpose of this study was to evaluate venous thromboembolism (VTE) rates in trauma patients with COVID-19. Methods : This study reviewed all adult patients (≥18 years of age) admitted to the Trauma Service from April through November 2020 for a minimum of 48 hours. Patients were grouped based off COVID-19 status and compared for inpatient VTE chemoprophylaxis regimen, thrombotic complications defined as deep vein thrombosis, pulmonary embolism, myocardial infarction, and cerebrovascular accident, intensive care unit (ICU) length of stay, hospital length of stay, and mortality. Results : A total of 2,907 patients were reviewed and grouped into COVID-19-positive (n = 110) and COVID-19-negative (n = 2,797) groups. There was no difference in terms of receiving deep vein thrombosis chemoprophylaxis or type, but a longer time to initiation in the positive group ( P = 0.0012). VTE occurred in 5 (4.55%) positive and 60 (2.15%) negative patients without a significant difference between the groups, as well as no difference in type of VTE observed. Mortality was higher ( P = 0.009) in the positive group (10.91%). Positive patients had longer median ICU LOS ( P = 0.0012) and total LOS ( P < 0.001). Conclusion : There were no increased rates of VTE complications between COVID-19-positive and -negative trauma patients, despite a longer time to initiation of chemoprophylaxis in the COVID-19-positive group. COVID-19-positive patients had increased ICU LOS, total LOS, and mortality, which are likely due to multifactorial causes but primarily related to their underlying COVID-19 infection.

Impact of obesity on postoperative outcomes in patients undergoing esophagectomy for resectable esophageal cancer.

327 Background: The prevalence of obesity (Body Mass Index&gt;30kg/m^2) is rising in the western world and is a risk factor for gastrointestinal malignancy. It is considered a risk factor for poor surgical outcomes including impaired wound healing and venous thromboembolism. Dysphagia is a late sign of esophageal cancer and is associated with pre-operative malnutrition and weight loss. However, the true impact of obesity on outcomes after esophagectomy is controversial. This analysis investigates the impact of pre-operative obesity on outcomes following esophagectomy for esophageal cancer. Methods: All patients with recorded pre-treatment BMI, who underwent surgery from January 2005 to June 2022 at a single tertiary, specialist cancer centre in the United Kingdom (UK), were included in this study. Demographic details including BMI and tumour staging (TNM classification) were collected, as well as total length of inpatient and critical care admission (LOS), 30- and 90- day mortality. Statistical analyses were performed on the R platform. Results: A total of 401 patients (348 male, 53 female) underwent resectional surgery for esophageal cancer; 132 (32.9%) were of normal BMI (18.5-24.9kg/m^2), 162 (40.1%) were overweight (BMI of 25-29.9kg/m^2), and 108 (26.9%) were obese (BMI&gt;30kg/m^2). The mean BMI for obese patients was 33.6kg/m^2 and mean age was 62.5 years in this cohort. Laparoscopic Ivor-Lewis esophagectomy was the commonest procedure performed on obese patients (57/108, 52.3%). When all patients were categorised into healthy BMI, overweight or obese cohorts, there was no statistically significant difference in post-operative complications at Clavien-Dindo grade II or lower, (p=0.500) or grade IIIa or higher (p=0.201). Furthermore, there was no statistically significant difference in total inpatient LOS (p=0.503), length of critical care admission (p=0.358), 30-day (p=0.836) or 90-day mortality (p=0.691). Conclusions: Obesity is not significantly associated with increased risk of postoperative complications, LOS, 30- or 90-day mortality in patients undergoing esophagectomy for cancer. The increasing uptake of minimally invasive surgery for esophageal cancer resections may also be associated with favourable surgical outcomes being achieved in patients with BMI&gt;30kg/m^2.

Clinical Outcomes of a Newly Instituted Hospital at Home Program During the COVID19 Pandemic.

Context: The COVID19 pandemic stressed U.S. health systems beyond their capacity and created worsening clinical outcomes. Hospital a Home (HaH) programs were utilized infrequently prior to pandemic. The Acute Care at Home Waiver was introduced in 2020 to facilitate the creation of HaH programs with a goal of promoting treatment in the home setting. A potential alternative approach to creating rapid inpatient level health system capacity is providing hospital-level care at home to substitute for inpatient hospitalization. The overall impact on clinical outcomes of a HaH program in patients with COVID19 is not well understood. Objective: To compare clinical outcomes of a HaH program versus usual hospital care for patients admitted for COVID19. Study Design: Matched case-control retrospective chart review. Setting or Dataset: Academic medical center. Population studied: Patients admitted with COVID19 and subsequently enrolled into the HaH program from February 1, 2021 to January 31, 2022. Patients aged <18 were excluded from consideration for enrollment. A case-control sample was matched on age, gender, and severity of illness. A total of 200 patients (100 HaH and 100 control) were included for analysis. Outcome Measures: Primary outcome: 30-day readmissions, Secondary outcomes: Inpatient length of stay (iLOS) defined as length of stay in the physical hospital, total length of stay (tLOS) (sum of iLOS and HaH program days), time to readmission, and 30-day emergency department visits. Results: Analysis included 200 patents. The mean age was 50.4. The sample was 55% female. 48.5% were black, 43.5% were white, and 8% were other races. Compared with usual care patients, HaH patients had no difference in 30-day readmissions (11% vs. 14%, p=0.648), mean days to readmission (9.0 vs. 11.8, p=0.201), or return ED visits (17% vs. 20%, p=0.701). Inpatient LOS (5.7 vs. 9.4 days, p=0.005) was shorter in the HaH group. Total LOS (13.0 vs. 9.4 days, p<0. 001) was longer in the HaH group. Conclusions: The HaH program was associated with no difference in readmissions, time to readmission, or return ED visits compared to usual hospital care. HaH programs were associated with shorter inpatient length of stays, but longer total length of stays. In surge times, HaH programs could potentially reduce iLOS and increase bed capacity. Future studies should look to evaluate the economic impact of HaH programs and investigate the drivers of the increased tLOS.

OGBN P12 Minimising the systemic effects of an oesophageal leak following high risk myotomy repair using Prophylactic Endoluminal Vacuum Therapy (EVT) - time for a change?

Abstract Background Endoluminal Vacuum Therapy (EVT) continues to gain momentum as a first line treatment for oesophageal perforations. Outside the emergency setting there is growing interest in using EVT prophylactically to protect high-risk elective oesophageal repairs. We present a case which demonstrates the benefit of prophylactic EVT in preventing extraluminal contamination, mediastinitis and sepsis following elective oesophageal surgery. Methods An 80-year-old female underwent laparoscopic Hellers Myotomy and Dor Fundoplication for Type 2 Achalasia following worsening symptoms including weight loss despite nutritional optimisation. She had multiple prior balloon dilatations without long term symptom control and remained frail, with a performance status of 0 and an ASA 2. During surgery the oesophageal myotomy was challenging due to extensive scarring. Endoscopy was performed on completion of the myotomy to confirm adequacy and a 1cm oesophageal perforation at 38cm was noted. Primary repair was performed with 5 interrupted 3/0 maxon sutures. An ad-hoc EVT device was constructed using V.A.C granufoam (KCI) sutured to the end of an 18Fr nasogastric tube, and placed intraluminally in the oesophagus across the repair. Continuous negative pressure of 75mmHg was applied. Post operatively the patient was kept nil by mouth and received parenteral nutrition. Her clinical and biochemical parameters were monitored, and the progress of her oesophageal repair was assessed endoscopically. Results The first post-operative endoscopy was performed at day 4. On visual inspection a full thickness oesophageal defect was seen at the proximal aspect of the oesophageal repair. There was no associated leak cavity or other endoscopic evidence of extraluminal contamination. A further ad-hoc EVT device was constructed and placed intraluminally in the oesophagus across the suture repair and oesophageal wall defect. A second endoscopy was performed on day 10 post-operative and the oesophageal defect had completely healed. Despite having a documented full thickness oesophageal wall defect the patient remained clinically well throughout her post-operative recovery with no clinical signs of sepsis. The highest recorded CRP was 131 and WCC was 12.7 on day 1 and day 8 respectively. At no point was a higher level of care or input required than the general surgical ward. Her total LOS was 14 days. Conclusions A leak following elective oesophageal surgery is a serious complication which may result in mediastinitis, sepsis and death. This case demonstrates the utility of prophylactic EVT in reducing the impact of an oesophageal leak in patients where breakdown of the oesophageal repair occurs. Without prophylactic EVT in this case, we are certain the breakdown of the oesophageal repair would have resulted in a significant oesophageal leak with mediastinitis and sepsis which an 80-year-old patient with limited physiological reserve may not have survived. While prophylactic EVT is not a substitute for sound surgical technique, it should be considered in high-risk patients undergoing elective oesophageal surgery to reduce or prevent the septic hit consequent to an oesophageal leak if breakdown of an oesophageal repair occurs.

P102. Chronological comparison of existing frailty indices to predict complications throughout the postoperative course following adult spinal deformity surgery

<h3>BACKGROUND CONTEXT</h3> The comparison of various frailty indices and their ability to predict complications after ASD surgery has not been investigated. <h3>PURPOSE</h3> Assess whether certain frailty indices have predictability of complication rates following ASD surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective. <h3>PATIENT SAMPLE</h3> A total of 689 ASD patients. <h3>OUTCOME MEASURES</h3> Complication rates, clinical outcomes, cost-utility. <h3>METHODS</h3> Operative ASD patients with baseline (BL) and 2-year (2Y) data were included. Four frailty indices were used for comparison: Passias et al modified ASD frailty index (mFI), Miller et al ASD frailty index (FI-ASD), the ACS-NSQIP 5-Factor frailty index (ACS-FI5), and the FRAIL Scale (PMID:29792992). Patients were stratified into not frail (NF), frail (F) and severely frail (SF). Associations of the indices with EBL, op time, complications, hospital-acquired conditions (HAC: UTI, DVT/PE, SSI), reoperations, SICU stay, and LOS were compared using one-way ANOVA, logistic and linear regression analyses. <h3>RESULTS</h3> There were 421 ASD patients included (Age: 60.4, BMI: 28.0, CCI: 1.9). Total cohort complication rates: 71% any comp, 27% major (68% were surgical, 32% medical), 35% minor, 25% intraoperative, 18% mechanical, 22% underwent reoperation. Upon presentation, severely frail patients were much more likely to present with a severe ODI (OR: 16, [7.2-29.8]). All four indices significantly correlated with intraop details and comps. During hospital stay, all four indices correlated to SICU time and total LOS. Only FRAIL Scale correlated with SICU admission rate (OR: 1.2, [1.03-8.8]), while no index was predictive of comps prior to discharge (all p>.05). ASD-FI had the strongest correlation with periop comps, including HACs (OR: 1.2, [1.1-6.3]), any (OR: 1.2, [1.02-7.3]) and major comps (OR: 1.5, [1.1-4.7]). When assessing 2Y comps, logistic regression analysis demonstrated correlation between ASD-FI, mFI, and FRAIL Scale indices and any comps, major comps and reoperation. However, mFI was the only correlate for all 2Y comps (any, major, minor, mech, reop), along with highest OR for predicting mechanical comps (OR: 1.6, [1.3-1.9]). Clinically, ASD-FI SF group had the greatest improvement (ODI,SRS-Total), while mFI SF had lowest rates of improvement. Given their higher complication rates, this translated to higher cost per QALY by 2 years for SF pts when stratified by mFI (p<.001). <h3>CONCLUSIONS</h3> Frailty imposes a significant burden on adult spinal deformity patients from the moment of presentation through cost-utility at two years. Assessing frailty by different measures demonstrated meaningful differences in complications and outcomes. These findings highlight the impact of frailty stratification during surgical planning to effectively assess the risk of patients undergoing corrective surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Protocolized management of pediatric complicated appendicitis leads to improved outcomes.

We aimed to evaluate a complicated appendicitis clinical practice guideline at our institution. Records were compared before and after protocol implementation. We standardized an ED consult pathway, antibiotic use and need for early appendectomy (EA) versus interval appendectomy (IA). We evaluated demographics, clinical characteristics, and outcomes. Subgroup analysis was performed to compare patients with small abscess treated with IA pre-protocol versus similar patients treated by EA post-protocol. In total 246 patients were reviewed (Pre-protocol = 152, Post-protocol = 94). Pre-protocol early appendectomy rate was 51% versus 82% on post-protocol patients. There were no differences in demographics. Post-protocol the use of preoperative imaging significantly decreased (Pre 92% vs. 56%, p = 0.0001), as well as the use of discharge antibiotics (Pre 93% vs. Post 27%, p = 0.0001) with no change in abscess rate. Overall, post-protocol patients had fewer total CT scans performed (Pre 40% vs. Post 28%, p = 0.03) and decreased total length of stay (Pre 7.7 vs. Post 6.5days, p = 0.049). On subgroup analysis, post-protocol EA with no or small abscess had lower median number of admissions, decreased total LOS (Pre IA 9days vs. Post EA 5days, p = 0.00001) and fewer complications (Pre IA 42% vs. EA 22%, p = 0.022). The establishment of a standardized pediatric complicated appendicitis protocol may lead to improved outcomes and resource utilization. Patients presenting with no or small abscess may be the least likely to benefit from interval appendectomy. Level III.

SP4.1.14 Single centre experience in managing acute appendicitis during COVID-19 pandemic

BackgroundGiven the pressure of COVID pandemic, the UK Intercollegiate guidance encouraged a move towards non-operative or open appendicectomy management of acute appendicitis. The aim of the study was to assess the approaches used to manage acute appendicitis and their outcomes during pandemic peak and after it.MethodsThis was a single-centre retrospective study, 2-observer data collection. We collected and analysed data on acute appendicitis management approaches (surgical and non-surgical) and patient outcomes were compared during the peak of the pandemic (04-2020 to 06-2020) and post-peak (07-2020 to 09-2020) periods.Results190 patients - (peak – 88, F:M=1.09, median age – 30.5) and post-peak 102 (F:M=1.12, median age -31)). There were no significant differences for APPY risk score, ASA grade, comorbidities between the groups. There was more diagnostic imaging performed during the peak of the pandemic (peak 71.6%, post-peak – 56.9%) (p = 0.035 X2=4.431). Comparison between managing patients during peak and post-peak showed that approaches were the following: conservative (14.8% vs 14.7%, P = 0.998), laparoscopic appendicectomy (65.3% vs 96.6% P = <0.001), open appendicectomy (34.7% vs 3.4% P = <0.001). There was no significant difference in postoperative complications (Clavien-Dindo II-IIIb), readmission to hospital, or total LoS (median=3 days) between the groups (p > 0.05). Median LoS for patients treated conservatively was 1 day. Only 1 patient developed COVID postoperatively, the mortality was 0%. ConclusionsTreatment strategies adapted and modified in COVID peak were effective and safe in managing acute appendicitis. Laparoscopic surgery remained a safe practice even in the peak of COVID pandemic.