Unplanned Emergency Department Visits Research Articles

Impact of virtual care on planned rechecks in a pediatric emergency department: a quality improvement project.

In the absence of accessible urgent follow-up options, emergency physicians may use an in-person recheck (planned return visit) to the Emergency Department (ED) as a safety net for discharged patients. In-person rechecks require travel, triage, and waiting time for patients and families and contribute to ED census. Many of these visits do not result in further investigation or changes in management but can provide reassurance for the family and care providers. We aimed to reduce the volume of in-person rechecks to our ED through an urgent virtual follow-up process. We conducted a quality improvement project using iterative process mapping and Plan-Do-Study-Act cycles to develop and implement a new model of care for virtual rechecks. An interdisciplinary team tested and refined the virtual care process from December 2020 to June 2022. Outcome, process and balancing measures were tracked continuously and analyzed using statistical process control. Baseline data revealed that the majority of in-person rechecks were for young infants with bronchiolitis. Post-implementation of the new process, 50% of all virtual rechecks were for respiratory illnesses. Use of virtual rechecks increased steadily to an average of 6.5 per 1000 ED visits with 58% of all rechecks now completed virtually. The number of in-person rechecks did not decrease during the study period. Virtual rechecks triggered an in-person ED visit in 5.2% of virtual recheck instances. There was no increase in unplanned return ED visits or admissions after implementation of virtual rechecks. Virtual rechecks can be safely implemented to allow urgent reassessment of patients following an ED visit. Virtual rechecks could be a useful tool for addressing planned reassessments in the pediatric ED, especially during surges of respiratory illness.

Unplanned emergency department visits after mastectomy in Alberta: Informing a quality improvement initiative.

412 Background: Same day surgery (SDS) for mastectomy increased in Alberta from 1.7% to 73% in 2022, after implementation of a perioperative care pathway in 2016. However, unplanned visits to the emergency department (ED) remained high at 22-27% with <5% requiring readmission. Our study aims to explore factors associated with unplanned ED visits by 1) describing patients with unplanned ED visits within 30 days of mastectomy, and 2) exploring characteristics for unplanned ED visits from the patient perspective. Methods: A survey study was conducted of patients who underwent a mastectomy in Alberta between 07/01/2021 to 06/30/2022 by a general surgeon, and had an unplanned ED visit within 30 days. Patients were identified from the CIHI database; chart review was performed to confirm ED visit details. Patients were excluded if their presentation was unrelated to surgery. Survey questions evaluated 3 domains: medical, socioeconomic, and psychologic, as well as patient-reported experiences of post-operative care. Results: Of 549 patients who underwent mastectomy during the study period, 132 (24%) presented to ED within 30 days. The survey was sent to 87 patients meeting inclusion criteria; 38% responded. Average age was 56. Most patients had no comorbidities (30%) or 2+ (27%), and 85% had prior surgery. The majority (79%) had college education or higher. Treatment included neoadjuvant chemotherapy (24%), sentinel lymph node biopsy (39%), axillary dissection (12%), concurrent reconstruction (24%), and mastectomy alone (27%). Most patients had 2+ drains (70%). Many patients (38%) presented on a weekend, 50% stating the ED was the only choice available at the time. Comparatively, 22% reported being told to go, and 16% felt the ED was the best place for their problem. Patients were seen by an ED physician (89%), nurse (40%) and/or surgeon (28%). Most common reasons for ED visit were infection (38%) and drain concerns (38%). Re-operation and readmission rates were 25% and 19%, respectively. Overall, 84% felt prepared for surgery; only 15% felt uncomfortable with drain management. Patients identified peer support and wound information as areas lacking. While 78% of patients were mostly or very satisfied with surgery, difficulty accessing their surgical team post-operatively was reported as the main flaw. Conclusions: Our study cohort identified infection and drain concerns as the most common reason for unplanned ED visit after mastectomy. Overall, patients were satisfied with education and surgical care, but identified problems with accessing medical/surgical care after discharge. Future initiatives should focus on improved access to outpatient care, and education on post-mastectomy emergencies.

Assessing preventable emergency department visits and hospitalizations following implementation of a high-touch program at an academic cancer center.

415 Background: Patients with cancer undergoing treatment are high utilizers of emergency department (ED) services and are at increased risk of hospitalization. A “high-touch” (HT) model of identifying and increasing communication with cancer patients at elevated risk of ED visits was implemented. The goal was to assess whether patients in the HT cohort had a reduced rate of unplanned ED visits and hospitalizations when compared to patients prior to implementation of the model. Methods: In this retrospective study (1/1/2018-4/1/2021), 51 patients on primarily palliative-intent treatment for their cancer were prospectively included in the HT group based on providers’ assessment of their risk of ED visits and malignancy-related complications. This group was compared to a similar cohort (n= 71) pre-implementation of the HT model. Data on baseline characteristics, malignancy type, reason for unplanned ED visits, and patient interaction with the oncology clinic immediately prior to ED visits were obtained, along with end-of-life outcomes including palliative measures. Each ED visit was also categorized as a potentially preventable or non-preventable visit, based on established criteria from Centers for Medicare and Medicaid Services (CMS). Results: While implementation of a HT program did not significantly decrease utilization, the percent of ED visits (p < 0.001) and hospitalizations (p = 0.002) for CMS-preventable reasons was notably higher in the HT cohort. Patients in the HT cohort also reached out to clinic providers significantly more frequently before visiting the ED (p < 0.001). Over half of patients in the HT cohort were seen by a palliative care physician in the inpatient setting within the last 6 months of life. Patients in both groups had similar high rates of dying at home or inpatient hospice versus dying in a hospital setting. Conclusions: Incorporation of a HT model of care in an oncology clinic may promote closer patient interaction with oncology providers prior to emergency department visits, but may come at the cost of increased medical utilization for otherwise CMS-preventable hospitalizations.[Table: see text]

Predictors and Outcomes of Unplanned Emergency Department Visits of ESRD Patients on Maintenance Hemodialysis in a Tertiary Hospital in Davao City

Predictors and Outcomes of Unplanned Emergency Department Visits of ESRD Patients on Maintenance Hemodialysis in a Tertiary Hospital in Davao City

Measuring substance use disorder (SUD) in commercial and Medicaid insured patients with cancer in Washington state.

177 Background: Studies have shown that SUDs not only impact cancer risk, treatment, and survivorship but also increase ED and hospital use. We sought to characterize SUD within Medicaid enrollees diagnosed with cancer in Washington state, hypothesizing thatMedicaid enrollees were more likely to be diagnosed with SUDs than commercial enrollees, and that patients with an SUD experienced higher rates of emergency department (ED) visits or inpatient (IP) stays during initial cancer treatment. Methods: We linked Washington State cancer registry records with claims data from two large commercial insurers and Medicaid. Eligibility criteria included patients under 65 diagnosed with a solid tumor between 2013-2021 who started systemic therapy within 6 months of diagnosis. SUD diagnoses were identified using codes from CMS’s hierarchical condition category for SUD in the 6 months following diagnosis. Chi-square tests were used to compare demographic characteristics of those with and without a SUD diagnosis. Multivariate logistic regressions were used to evaluate the association between SUD and likelihood of at least one ED visit or IP stay, after controlling for payer, sex, race, ethnicity, age, marital status, stage, cancer group, area deprivation index, and diagnosis year. Results: Among the 10,709 patients (6,680 Commercial, 3,718 Medicaid, 311 Multiple) who received systemic therapy, 7.2% had a SUD diagnosis. SUD patients were less likely to be Asian and more likely to be male, living without a partner, diagnosed at a later cancer stage, and living in more deprived areas. Medicaid patients had significantly higher rates of SUD than commercial-insured patients (14.3% vs 3.3%). Overall, 46.6% of cancer patients had an ED visit or IP stay. Patients with SUD had greater use of ED or IP visits than patients without SUD (70.1% and 44.8%, respectively). In the first 6 months of systemic therapy patients with SUD were significantly more likely to visit the ED or be admitted to IP (OR 2.12, 95% CI 1.79 - 2.50) than cancer patients without SUD. Conclusions: More than 1 in 7 Medicaid cancer patients in WA state has an identified SUD. SUD is associated with significant excess risk for ED/IP admissions during treatment. Accurate identification of SUD in patients is necessary prior to strategies aimed at mitigation of unplanned ED visits and hospitalizations during cancer care. Further research is needed on interventions that effectively reduce the risk during treatment.[Table: see text]

Unplanned Emergency Department Visits Following Revision Total Joint Arthroplasty: Incidences, Risk Factors, and Mortalities

BackgroundThe incidence of unplanned emergency department (ED) visits following revision total joint arthroplasty is an indicator of the quality of postoperative care. The aim of this study was to investigate the incidences, timings, and characteristics of ED visits within 90 days after revision total joint arthroplasty. MethodsA retrospective review of 457 consecutive cases, including 254 revision total hip arthroplasty (rTHA) and 203 revision total knee arthroplasty (rTKA) cases, was conducted. Data regarding patient demographics, timings of the ED encounter, chief complaints, readmissions, and diagnoses indicating reoperation were analyzed. ResultsThe results showed that 41 patients who had rTHA (16.1%) and 14 patients who had rTKA (6.9%) returned to the ED within 90 days postoperatively. The incidence of ED visits was significantly higher in the rTHA group than in the rTKA group (P = .003). The most common surgery-related complications were dislocation among rTHA patients and wound conditions among rTKA patients. Apart from elevated calculated comorbidity scores, peptic ulcer in rTHA patients and cerebral vascular events and chronic obstructive pulmonary disease in rTKA patients might increase chances of unplanned ED visits. Patients who had ED visits showed significantly higher mortality rates than the others in both rTHA and rTKA cohorts (P = .050 and P = .008, respectively). ConclusionsThe ED visits within 90 days are more common after rTHA than after rTKA. Patients in both ED visit groups after rTHA and rTKA demonstrated worse survival. Efforts should be made to improve quality of care to prevent ED visits.

Trimethoprim-Sulfamethoxazole for Pediatric Osteoarticular Infections.

Trimethoprim-sulfamethoxazole (TMP-SMX) is active against most Staphylococcus aureus isolates but is not widely used for treatment of pediatric osteoarticular infections. This was a comparative effectiveness study of hospitalized patients ≤18 years treated with TMP-SMX versus other antibiotic regimens for acute osteoarticular infections between 2016 and 2021 at three hospitals using inverse probability of treatment weighted propensity score analysis. The primary outcome was treatment failure, a composite of unanticipated emergency department (ED) or outpatient visits, hospital readmissions, extension or change of antibiotic therapy due to inadequate clinical response, or death, all within 6 months after completing antibiotics. The secondary outcome was antibiotic-associated adverse events (AEs) within 6 months. The exposed group for the treatment failure analysis included children who received ≥7 days of TMP-SMX and did not experience treatment failure while on another antibiotic. Children receiving at least one dose of TMP-SMX were the exposed group for the AE analysis. 116 patients met eligibility criteria; 26 (22.4%) patients were classified into the TMP-SMX cohort and 90 (77.6%) into the other antibiotics cohort (most commonly clindamycin, vancomycin, and cefazolin). There was no significant difference in treatment failure between TMP-SMX and other antibiotics (43% vs 19%; 95% CI 0.9-10.4). More patients in the TMP-SMX cohort experienced an unplanned ED or outpatient visit (OR 4.8, 95% CI 1.3-17.8). There was no difference in hospital readmission, antibiotic change, or duration extension. Exposure to TMP-SMX was associated with more AEs (41% vs 19%, p=0.012). Treatment with TMP-SMX was not associated with greater clinical failure but was associated with more AEs compared to alternative agents for the treatment of pediatric acute osteoarticular infections.

Factors Associated With Emergency Department Visits Among Patients Receiving Publicly-Funded Homecare Services: A Retrospective Chart Review From Southern Taiwan Regional Hospital.

The public health strategy of increasing access to comprehensive home or community-based healthcare services and emergency home visits is intent on reducing the overcrowding of emergency departments. However, scientific evidence regarding the association between home-based healthcare services and emergency department uses is surprisingly insufficient and controversial so far. The present retrospective study identified the risk factors for emergency department visits among patients receiving publicly-funded homecare services. The personal demographic and medical information, caregiver characteristics, and behaviours related to homecare services and emergency department visits from the medical records and structured questionnaires of 108 patients who were recipients of integrated homecare services in a regional hospital in southern Taiwan between January 1, 2020, and December 31, 2020, were collected. After screening the potential predictor variables using the preliminary univariate analyses, the multivariate logistic regression with best subset selection approach was conducted to identify best combination of determinants to predict unplanned emergency department utilizations. Best subset selection regression analysis showed Charlson Comorbidity Index (odds ratio (OR)=1.33, 95% CI=1.05 to 1.70), male caregiver (OR=0.18, 95% CI=0.05 to 0.66), duration of introducing homecare services (OR=0.97, 95% CI=0.95 to 1.00), working experience of dedicated nurses (OR=0.89, 95% CI=0.79 to 0.99) and number of emergency department utilizations within previous past year before enrollment (OR=1.54, 95% CI=1.14 to 2.10) as significant determinants for unplanned emergency department visits. The present evidence may help government agencies propose supportive policies to improve access to integrated homecare resources and promote appropriate care recommendations to reduce unplanned or nonurgent emergency department visits among patients receiving homecare services.

Investigating Factors Associated with Postmastectomy Emergency Department Visits: A Population-Based Analysis.

In 2016, a multi-pronged pathway was implemented across 13 hospitals to improve the mastectomy perioperative care experience with one objective being to safely allow same day surgery mastectomy. While the pathway successfully increased same day mastectomy rates from 1.7 to 73.0%, the rate of postoperative emergency department (ED) visits remained high at >20%, despite focused interventions to enhance perioperative support. To investigate potential factors associated with high postoperative ED visits following mastectomies in Alberta, Canada. Data was collected using the Discharge Abstract Database and the National Ambulatory Care Reporting System database. Eligible patients included all women over 18 years old who underwent a mastectomy province-wide between 2004 and 2020. Patient demographics were collected. Primary outcome of interest was ED visit within 30 days of mastectomy. Univariate and multivariable analyses were performed to identify independent predictors for post-operative ED visits. A total of 19,974 patients had mastectomy during the study period, of which 4590 (23%) had an ED visit within 30 days of surgery. Independent factors associated with ED visits were increasing age, overnight stay mastectomy, reconstruction, certain comorbidities, and living rurally. Post-operative ED visits remain high despite initiating a province-wide surgical pathway in 2016 which emphasizes patient education and improved perioperative care and supports. Currently, the majority of ED visits are manageable in non-emergent settings. Patient populations at higher risk for ED visits groups may benefit from additional targeted support and resources to reduce unplanned ED visits.

Assessment of outpatient chemotherapy and unplanned emergency department visits in a large community hospital system.

e18768 Background: Unplanned complications of outpatient chemotherapy can significantly affect patient oncologic outcomes, health, and increase cost of care. CMS rule OP-35 evaluates quality of care for Medicare patients by assessing the risk of emergency department (ED) visit within 30 days after outpatient chemotherapy administration. This study reviews this measure for all oncology patients treated in our community hospital setting. Methods: Patients treated between 02/2012 and 04/2021 were identified. Age at first chemotherapy administration, gender, cancer diagnosis, and chemotherapy regiment were evaluated. Chemotherapy was stratified into cytotoxic therapy, immunotherapy, targeted therapy, and endocrine therapy. ED visits were only those in our hospital system. 30-day risk of ED visit was calculated for individual chemotherapy administrations. Internal results were compared with our CMS OP-35 results for concordance. Results: There were 19,732 patients who received chemotherapy treatments between 02/2012 and 04/2021, with 262,379 chemotherapy administrations. Individual chemotherapy administration had 5.2% risk of a 30 day ED visit. Cumulative risk of a patient having a 30 day ED visit was 32.9%. From ED, patients had 61.2% rate of hospital admission, vs 24.8% rate for general ED population. By age at first chemotherapy administration, the risk of 30 day ED visit was 6.3% for age < 18, 5.4% for age 18-64, and 5.9% for age > = 65. Our rate was relatively stable between 2014 and 2020. Our corresponding CMS score was 5.5% in 2016, 5.5% in 2018, and 5.1% in 2019. By gender, the risk was 5.6% for male and 5.0% for female patients. By chemotherapy category, the risk was 5.9% for cytotoxic chemotherapy, 7.5% for immunotherapy, 4.2% for targeted therapy, and 5.2% for endocrine therapy. Carboplatin/paclitaxel was the most common drug combination administered, with 8.7% risk. Cytarabine/methotrexate combination had the highest risk at 57.0%. By ICD diagnosis, breast cancer accounted for most patients and most chemotherapy administrations, with 30 day ED visit risk of 3.6%. Multiple myeloma had the highest rate of chemotherapy administrations at 26.3 per patient and a risk of 4.0%, compared with 13.3 across the entire population. Stomach cancer had the highest risk of 30 day ED visit at 10.0%. Conclusions: The risk of 30 day unplanned ED visit was elevated in pediatric patients, and was similar in patients 18-64 and > = 65 years of age, and corresponded well to our CMS OP-35 metric, despite only tracking internal ED visits. Immunotherapy had significantly elevated risk compared with cytotoxic therapy, while targeted therapy had the lowest risk of ED visit. There were significant differences depending on disease site. We have established a baseline, and developed a live dashboard in our electronic medical record to monitor this metric globally, and to intervene in patients at high risk of 30 day ED visit.

Injury-related emergency department visits and unplanned readmissions are associated with worse long-term mental and physical health

BackgroundThe risk factors for unplanned emergency department (ED) visits and readmission after injury and the impact of these unplanned visits on long-term outcomes are not well understood. We aim to: 1) describe the incidence of and risk factors for injury-related ED visits and unplanned readmissions following injury and, 2) explore the relationship between these unplanned visits and mental and physical health outcomes 6–12 months post-injury. MethodsTrauma patients with moderate-to-severe injury admitted to one of three Level-I trauma centers were asked to complete a phone survey to assess mental and physical health outcomes at 6–12 months. Patient reported data on injury-related ED visits and readmissions was collected. Multivariable regression analyses were performed controlling for sociodemographic and clinical variables to compare subgroups. ResultsOf 7,781 eligible patients, 4675 were contacted and 3,147 completed the survey and were included in the analysis. 194 (6.2%) reported an unplanned injury-related ED visit and 239 (7.6%) reported an injury-related readmission. Risk factors for injury-related ED visits included: younger age, Black race, a lower level of education, Medicaid insurance, baseline psychiatric or substance abuse disorder and penetrating mechanism. Risk factors for unplanned injury-related readmission included younger age, male sex, Medicaid insurance, substance abuse disorder, greater injury severity and penetrating mechanism of injury. Injury-related ED visits and readmissions were associated with significantly higher rates of PTSD, chronic pain and new injury-related functional limitations in addition to lower SF-12 mental and physical composite scores. ConclusionsInjury-related ED visits and unplanned readmissions are common after hospital discharge following treatment of moderate-severe injury and are associated with worse mental and physical health outcomes.

Outpatient Non-operative Management of Uncomplicated Acute Appendicitis: A Non-inferiority Study

IntroductionNon-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis.MethodsThe study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon’s preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay.Results30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (p = 0.327). OutNOM was non-inferior to inNOM with a risk difference of—3.80% 97.5% CI (− 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1–4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (p < 0.001).ConclusionsOutpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.

Unplanned 120-Day ED Visits and Readmission Rates Following Common Stone Procedures

ObjectiveTo quantify emergency department (ED) visits and hospital admissions (HA) after common urologic stone procedures including ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCL) which are a concern of payors, providers, and patients. Materials and MethodsThis is a retrospective cohort study using claims data from the IBM MarketScan Commercial and Medicare Supplement databases. Adults with a urologic stone diagnosis and no history of stone procedure in prior 12 months who underwent stone procedures between 2012 and 2017 were included. All-cause ED visits and HA were evaluated during 30, 60, 90, and 120-day periods following the index urologic stone procedure. ResultsA total of 166,287 patients were included in the analytic cohort. For inpatient-indexed procedures, cumulative ED visits rates following stone procedure at 120 days was 18.8% for URS, 19.2% for SWL, and 23.6% for PCL. A similar trend was observed with ED visit rates, following outpatient indexed procedures at 120 days with a cumulative rate of 14.2% of SWL patients, 14.9% of URS patients, and 17.3% of PCL. A similar trend was found when examining HA. ED and HA rates increased steadily through the 120-day time period. ConclusionRates of ED visits and HA following common stone procedures continue to rise at least up to 120 days following the index procedure whether in the outpatient or inpatient settings. While rates of unplanned care are similar for URS and SWL, patients undergoing PCL return to the hospital at higher rates.

Direct-to-Implant Versus 2-Stage Breast Reconstruction: Which Technique Is Better? An Analysis of 104 Patients at a Single Institution.

Two-stage (TS) implant-based reconstruction is the most commonly performed method of reconstruction after mastectomy. A growing number of surgeons are offering patients direct-to-implant (DTI) reconstruction, which has the potential to minimize the number of surgeries needed and time to complete reconstruction, as well as improve health care utilization. However, there are conflicting data regarding the outcomes and complications of DTI, and studies comparing the 2 methods exclusively are lacking. Patients undergoing implant-based reconstruction after mastectomy within a large interstate health system between 2015 and 2019 were retrospectively identified and grouped by reconstruction technique (TS and DTI). The primary outcomes were a composite of complications (surgical site occurrences), health care utilization (reoperations, unplanned emergency department visits, and readmissions), and time to reconstruction completion. Risk-adjusted logistic and generalized linear models were used to compare outcomes between TS and DTI. Of 104 patients, 42 underwent DTI (40.4%) and 62 underwent TS (59.6%) reconstruction. Most demographic characteristics, and oncologic and surgical details were comparable between groups ( P > 0.05). However, patients undergoing TS reconstruction were more likely to be publicly insured, have a smoking history, and undergo skin-sparing instead of nipple-sparing mastectomy. The composite outcome of complications, reoperations, and health care utilization was higher for DTI reconstruction within univariate (81.0% vs 59.7%, P = 0.03) and risk-adjusted analyses (odds ratio, 3.78 [95% confidence interval [CI], 1.09-13.9]; P < 0.04). Individual outcome assessment showed increased mastectomy flap necrosis (16.7% vs 1.6%, P < 0.01) and reoperations due to a complication (33.3% vs 16.1%; P = 0.04) in the DTI cohort. Although DTI patients completed their aesthetic revisions sooner than TS patients (median, 256 days vs 479 [ P < 0.01]; predicted mean difference for TS [reference DTI], 298 days [95% CI, 71-525 days]; P < 0.01), the time to complete reconstruction (first to last surgery) did not differ between groups (median days, DTI vs TS, 173 vs 146 [ P = 0.25]; predicted mean difference [reference, DTI], -98 days [95% CI, -222 to 25.14 days]; P = 0.11). In this cohort of patients, DTI reconstruction was associated with higher complications, reoperations, and health care utilization with no difference in time to complete reconstruction compared with TS reconstruction. Further studies are warranted to investigate patient-reported outcomes and cost analysis between TS and DTI reconstruction.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis

Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events. All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated. 438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p=0.04). The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries. Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

Predicting the Risks of Aggressive-Intent Chemotherapy Toxicity in Older Patients With Lymphoma: A Prospective Observational Pilot Study

IntroductionLymphoma is a disease of older patients and while treatment is subtype specific, curative or aggressive intent combination chemotherapy is often recommended. However, there has been limited evidence on which to base treatment decisions for older adults. Our objectives were to assess the utility of risk stratification measures and serial functional tests in predicting chemotherapy toxicity and as well the feasibility of conducting these in older adults undergoing chemotherapy for lymphoproliferative disorders. Materials and MethodsThis prospective cohort study recruited lymphoma patients 70 years or older planned for systemic chemotherapy. The Cancer and Aging Research Group (CARG) risk stratification tool and Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) were calculated at baseline. The Clinical Frailty Scale (CFS), Charlson Comorbidity Index score, grip strength and gait speed test, and toxicity events, were assessed at baseline and serially throughout treatment. Sarcopenia was calculated on CT scans at baseline, midway through treatment, and 1-month after completion of therapy. The primary endpoint was to assess the feasibility of applying these measures in busy ambulatory clinics. These measures were also correlated with clinical outcomes including ≥grade 3 adverse events (AEs), hospitalizations and emergency department visits, dose changes or delays, and overall survival. ResultsIn total, 30 patients were enrolled (mean age 78.1 ± 6.4 years), of whom 20 were treated with curative intent. A total of 16 patients (53%) experienced grade ≥3 AEs, 9 (56%) of which led to a chemotherapy delay. On univariable analyses, CFS score, a high CARG score, medium to high CRASH score, and the gait speed were associated with grade ≥3 AEs, while only CFS remained significant on multivariable analysis. On univariable analysis, patients with a medium to high risk CRASH score were more likely than low risk patients to have an unplanned emergency department visit or hospitalization. ConclusionsThe CFS seems to predict toxicity in this cohort study, with gait speed, CARG and CRASH scores being potentially additional predictive methods of evaluation.

North American multicentre evaluation of a same-day discharge protocol for minimally invasive colorectal surgery using mHealth or telephone remote post-discharge monitoring.

Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up. A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3days. A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up. A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.

Rate and Predictors of Acute Care Encounters in the First Month After Stroke

ObjectivesThe purpose of this quality improvement project is to understand the burden of acute care, including inpatient readmission and emergency department (ED) visits, in the month following hospital discharge after stroke. Materials and MethodsWe identified patients discharged from our hospitals between 2015 and 2018 with any stroke diagnosis who had an unplanned readmission or ED visit within the first month after discharge, and those who had primary care (PC) visits before or after their stroke. Patients were compared regarding demographics, clinical characteristics, and PC visits. Independent predictors of acute care encounters were examined using logistic regression. ResultsA total of 166 patients (19%) had an acute care encounter one month after discharge. Eighty-eight (10%) patients were readmitted and 78 (9%) patients had an ED visit. Encounter diagnoses were different between the two groups; inpatient readmission had more frequent acute stroke/TIA and pneumonia/pulmonary indications, while ED visits had more non-specific neurologic symptoms and more frequent cardiovascular complaints. Independent predictors of any acute care encounter and inpatient readmission were younger age, longer length of stay (LOS), and lack of PC visit after discharge. Predictors of ED visits were the same except for LOS. Conclusions30-day acute care encounters after stroke hospitalization are common, affecting 19% of patients and usually occurring in the first week after discharge. Post discharge PC visit was associated with a decreased need for acute care. Efforts should be made to facilitate a PC visit within a week after discharge, especially in high risk patients.

Resident loneliness, social isolation and unplanned emergency department visits from supportive living facilities: a population-based study in Alberta, Canada

BackgroundSupportive living (SL) facilities are intended to provide a residential care setting in a less restrictive and more cost-effective way than nursing homes (NH). SL residents with poor social relationships may be at risk for increased health service use. We describe the demographic and health service use patterns of lonely and socially isolated SL residents and to quantify associations between loneliness and social isolation on unplanned emergency department (ED) visits.MethodsWe conducted a retrospective cohort study using population-based linked health administrative data from Alberta, Canada. All SL residents aged 18 to 105 years who had at least one Resident Assessment Instrument-Home Care (RAI-HC) assessment between April 1, 2013 and March 31, 2018 were observed. Loneliness and social isolation were measured as a resident indicating that he/she feels lonely and if the resident had neither a primary nor secondary caregiver, respectively. Health service use in the 1 year following assessment included unplanned ED visits, hospital admissions, admission to higher levels of SL, admission to NH and death. Multivariable Cox proportional hazard models examined the association between loneliness and social isolation on the time to first unplanned ED visit.ResultsWe identified 18,191 individuals living in Alberta SL facilities. The prevalence of loneliness was 18% (n = 3238), social isolation was 4% (n = 713). Lonely residents had the greatest overall health service use. Risk of unplanned ED visit increased with loneliness (aHR = 1.10, 95% CI: 1.04–1.15) but did not increase with social isolation (aHR = 0.95, 95% CI: 0.84–1.06).ConclusionsLonely residents had a different demographic profile (older, female, cognitively impaired) from socially isolated residents and were more likely to experience an unplanned ED visit. Our findings suggest the need to develop interventions to assist SL care providers with how to identify and address social factors to reduce risk of unplanned ED visits.

Safety and Efficacy of Postoperative Indwelling Popliteal Nerve Catheters for Outpatient Charcot-Marie-Tooth Surgery.

Outpatient surgical deformity correction for Charcot-Marie-Tooth (CMT) disease is limited by effective postoperative pain control. Our previous institutional protocol for foot and ankle surgery in this population included preoperative single-injection nerve blocks, but patients often experienced uncontrolled pain when the block wore off postoperative day 0 or 1, resulting in high opioid requirements and unplanned emergency department visits. The use of ultrasonography-guided continuous nerve catheters in CMT patients has not previously been studied. We aimed to prospectively investigate the safety and efficacy of ultrasonography-guided indwelling popliteal catheters in CMT patients undergoing outpatient foot deformity correction surgery. Twenty CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasonography-guided popliteal catheters. This series included 24 total outpatient procedures; 4 were staged bilateral. Indwelling popliteal catheters were maintained on discharge, providing continuous infusion until postoperative day (POD) 3, and then self-discontinued. Patients were prescribed oxycodone 5 mg (60-80 pills) as needed for breakthrough pain. Outcomes collected included daily pain scores (0-10), an opioid pill count on POD 14, and patient satisfaction ratings. Neurologic evaluation by 5-point 10g Semmes-Weinstein monofilament testing was performed preoperatively and on POD 14. There were no observed catheter-site infections or hematomas. Nine of the patients had pre-existing sensory deficits involving at least 2 areas on the 5-point monofilament test. Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative pain scores were typically low, with median values (interquartile ranges [IQRs]) of 3.5 (2.0-5.0) on POD 1, 2.5 (2.0-5.0) on POD 2, and 2.5 (1.0-3.75) on POD 3. At POD 14, pain was 1.0 (0-1.0). Patients consumed a median of 25 oxycodone pills (IQR 8-43) over 2 weeks, less than half the prescribed number. Patient satisfaction was high. All patients reported they would choose to have a nerve catheter again for a similar surgery. This cases series demonstrated that regional anesthesia using ultrasonography-guided indwelling popliteal catheters was safe and effective for pain control in CMT patients undergoing outpatient foot and ankle surgery. Opioid consumption was comparable to published rates following major bony procedures, and no patients required emergent treatment or hospital admission for uncontrolled pain. No new sensory deficits were detected and patients with underlying sensory deficits remained unchanged. Patients were highly satisfied. Level IV, case series.