Unplanned Emergency Department Research Articles

Does the sequence and timing of total shoulder arthroplasty relative to lower extremity arthroplasty influence postoperative complications?

BackgroundAs the number of total knee, hip, and shoulder arthroplasties increases, so do the number of patients requiring multiple arthroplasties in different joints. Evidence-based guidance on the sequence and timing of hip and knee arthroplasty (TJA) in total shoulder arthroplasty (TSA) patients is lacking. The objectives of the present study were to examine the relationship between the sequence and timing of these lower extremity arthroplasties on surgical and medical complications following TSA. MethodsPatients from the 100% Medicare dataset who underwent lower extremity Total Joint Arthroplasty (TJA) and TSA between 2005 and 2014 were identified. Patients were stratified into 6 groups: (1) patients who underwent TSA less than 3 months after TJA, (2) patients who underwent TSA between 3 months and 1 year after TJA, (3) patients who underwent TSA greater than 1 year after TJA, (4) patients who underwent TSA less than 3 months prior to TJA, (5) patients who underwent TSA between 3 months and 1 year prior to TJA, and (6) patients who underwent TSA greater than 1 year prior to TJA. Revision rate, indication for revision surgery, and medical complications of all groups were compared using a regression analysis. ResultsPatients who underwent TSA within 3 months prior to lower extremity TJA had a significantly higher incidence of revision shoulder surgery and unplanned emergency department visits within 90 days compared to all other groups (P < .05). These patients had higher rates of implant wear, periprosthetic lysis, and mechanical complications as the indication for revision compared to all other patients who also underwent revision surgery (P < .05). ConclusionTSA should be performed greater than 3 months before lower extremity TJA or at any point following lower extremity TJA to avoid the increased risk of revision surgery due to implant wear or lysis and increased rates of emergency room presentation. Level of evidenceLevel III

Institution-initiated text messaging can reduce unplanned emergency department visits after appendectomy

Background/PurposeThe purpose of this study was to reduce unplanned Emergency Department (ED) visits for minor complaints in children after appendectomy through proactive institution-driven communication and utilization of telehealth resources. MethodsWe developed a text messaging system to initiate communication with parents of postappendectomy patients and connect them with a telehealth visit or a phone call with a surgical provider as needed. Using descriptive statistics, chi square, and statistical process control analytics, we compared rates of postoperative ED visits for the 8 months pre- and post-implementation of the messaging system and summarized the feedback we received from patients. ResultsA total of 791 laparoscopic appendectomies were performed in two institutions (preintervention = 382, post-intervention = 409). The postoperative ED visit rate decreased from 5.8% preimplementation to 2.4% post-implementation (p = 0.02). Over one-fifth of families messaged (21.6%) had questions in the postoperative period. The majority expressed interest in a video visit (52.5%), while some preferred to speak with the surgeon's office (25%). Over 90% of respondents found the system helpful, and 4.9% opted out. ConclusionImplementation of a hospital-initiated text messaging system has the potential to reduce ED visits in the immediate postoperative period after appendectomy. This system can be scaled to include different surgeries across multiple disciplines. Level of EvidenceIII. Type of StudyClinical Retrospective Pre/Post Intervention Study.

Quality of Life After Elective Laparoscopic Sigmoidectomy for Symptomatic Uncomplicated Diverticular Disease.

Symptomatic uncomplicated diverticular disease (SUDD) is characterized by abdominal pain and altered bowel function and may affect quality of life. When symptoms are severe and conservative therapy is ineffective, surgical intervention becomes an option. This study aims to investigate quality of life after elective sigmoidectomy for patients affected by SUDD. Retrospective multicenter review of consecutive patients affected by SUDD that underwent elective laparoscopic sigmoidectomy from January 2015 to March 2018. SUDD was defined as the presence of diverticula with persistent localized pain and diarrhea or constipation without macroscopic inflammation. Quality of life was investigated using the Gastrointestinal Quality of Life Index questionnaire at baseline, and at 6 and 12 months after surgery. Readmissions, unplanned clinical examination, mesalazine resumption, and emergency department visit for abdominal symptoms were recorded. Fifty-two patients were included in the analysis. Gastrointestinal Quality of Life Index score at 6 months from surgery did not statistically differ from baseline (96±10.2 vs. 89±11.2; P>0.05), while patients reported a better quality of life at 12 months after surgery (109±8.6; P<0.05). Within the first year of follow-up, 3 patients (5.8%) were readmitted for acute enteritis, 8 patients (15.4%) had emergency room access for abdominal pain, and 8 patients had unplanned outpatients' medical examinations for referred lower abdominal pain and bowel changes. Mesalazine was resumed in 17.3% of patients. Elective laparoscopic sigmoidectomy for SUDD is safe and effective in improving quality of life, although in some cases symptoms may persist.

Integration of Inpatient and Residential Care In-Reach Service Model and Hospital Resource Utilization: A Retrospective Audit

ObjectiveIn parts of Australia, Residential In-Reach (RIR) services have been implemented to treat residential aged care (RAC) residents for acute conditions in their place of residence to avoid preventable hospital presentation. Our service was initiated in 2009 and restructured in 2014. We compared acute healthcare resource utilization (RIR activity and emergency hospital presentations) by RAC residents under 2 RIR models of care. DesignAcute RAC RIR service model of care was changed from existing nurse/emergency physician-led service to nurse/geriatrician-led service and incorporate inpatient liaison nurse consultant into the team. SettingRAC episodes and hospital presentations from a single tertiary referral hospital and its associated RAC RIR service. MethodsRetrospective audit comparing RIR activity, hospital presentations, and associated costs from 2 12-month periods, prior to and postimplementation. Data were expressed as a proportion of the total number of RAC beds in the hospital RIR catchment. ResultsAfter implementation of the new model of care, RIR episodes of care increased from 589 to 985 (15.3 vs 24.7 episodes/100 RAC beds, P < .001). Emergency department (ED) presentations fell from 1616 to 1478 (41.9 vs 37.2 presentations/100 RAC beds, P < .001). There were fewer unplanned ED presentations by RIR patients (2.4% vs 0.8%, = 0.03) and fewer 28-day ED re-presentations (16.8% vs 13.7%, P = .01) under the new model of care. ED cost [$AUD 30,830 vs $28,030/100 RAC beds ($USD 21,344 vs $19,407), P < .001] and inpatient admission costs [$145,607 vs $117,531/100 RAC beds ($USD 100,814 vs $81,380), P < .001] were each lower in the second period. Conclusions and ImplicationsIn the 12 months following implementation of the new model of care, an increase in RIR activity, and a decrease in ED presentations was observed. Further research is necessary to validate these retrospective findings and better evaluate clinical outcomes and consumer satisfaction of the service.

Patient Risk Profile for Unplanned 90-Day Emergency Department Visits Differs Between Total Hip and Total Knee Arthroplasty.

Numerous studies have explored 90-day readmissions following total joint arthroplasty; however, there is a paucity of literature concerning 90-day emergency department (ED) visits. The authors aimed to characterize the risk factors for ED presentations and to determine the primary reasons for return, hypothesizing that certain medical comorbidities would account for resource utilization. The institutional database was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were stratified based on return visits to the ED within 90 days postoperatively. Univariable and multivariable analyses were performed to determine the factors most predictive of ED return for each THA and TKA. A total of 10,479 procedures resulted in 1234 90-day ED visits made by 937 patients. Significant predictors of 90-day ED return after THA included black race, age older than 80 years, congestive heart failure, valvular heart disease, metastatic disease, peripheral vascular disease, alcoholism, drug use, depression, and discharge to a skilled nursing facility. In contrast, only black race, liver insufficiency, cancer, and pulmonary hypertension were predictive of ED return following TKA. The primary risk factors for ED return differ for THA and TKA, and this is not currently reflected in the medical severity diagnosis-related group system. Specifically, black patients with multiple comorbidities are at high risk for unplanned ED visits following THA. This should be considered in patient counseling and outreach programs when attempting to mitigate the postoperative risks and to decrease 90-day resource utilization in this patient population. [Orthopedics. 2020;43(5):295-302.].

Incidence and predictors of early and late hospital readmission after transurethral resection of the prostate: a population-based cohort study.

To evaluate the incidence and predictors of hospital readmission and emergency department (ED) visits in patients with benign prostatic hyperplasia treated by transurethral resection of the prostate (TURP). We conducted a retrospective cohort study using a linked administrative dataset from Calgary, Canada. Participants were men who underwent their first TURP procedure between 2015 and 2017. We examined patient demographics, and type of surgery (elective or urgent). Comorbidities were scored using the Charlson comorbidity index (CCI). The primary outcomes were unplanned hospital readmissions and ED visits at 30, 60 and 90 days after TURP. The secondary aim was to identify potential predictors across these groups. We identified 3059 men, most of whom underwent elective TURP (83%). The mean (sd) patient age was 71.0 (10.0) years. A total of 224 patients (7.4%) were readmitted to the hospital within 30days, 290 (9.5%) within 60days, and 339 (11.1%) within 90days of discharge. The frequency of return visits within 30, 60 and 90 days of TURP were 21.4%, 26% and 28.6%, respectively. The most responsible diagnoses for ED visit within 90days were haematuria (15.4%) and retention of urine (12.8%). Multivariable analysis showed that age (odds ratio [OR] 1.61, P < 0.001), surgery type (OR 2.20, P < 0.001), and CCI score (OR 2.03, P < 0.001) were independently associated with odds of readmission and ED visits at all time points. Older age, poorer health and urgent surgery predicted return to ED or readmission after TURP; efforts should be made to improve selection, counselling and preoperative optimization based on these risks.

An Active In-Home Physician Model of Palliative Care and Its Resulting Performance Indicators Related to Home Deaths, Unplanned Emergency Department Visits and Unplanned Hospital Admissions.

Limited research has characterized team-based models of home palliative care and the outcomes of patients supported by these care teams. A retrospective case series describing care and outcomes of patients managed by the London Home Palliative Care Team between May 1, 2017 and April 1, 2019. The London Home Palliative Care (LHPC) Team care model is based upon 3 pillars: 1) physician visit availability 2) active patient-centered care with strong physician in-home presence and 3) optimal administrative organization. In the 18 month study period, 354 patients received care from the London Home Palliative Care Team. Most significantly, 88.4% (n = 313) died in the community or at a designated palliative care unit after prearranged direct transfer; no comparable provincial data is available. 21.2% (n = 75) patients visited an emergency department and 24.6% (n = 87) were admitted to hospital at least once in their final 30 days of life. 280 (79.1%) died in the community. These values are better than comparable provincial estimates of 62.7%, 61.7%, and 24.0%, respectively. The London Home Palliative Care (LHPC) Team model appears to favorably impact community death rate, ER visits and unplanned hospital admissions, as compared to accepted provincial data. Studies to determine if this model is reproducible could support palliative care teams achieving similar results.

Abstract 5769: Opioid prescription characteristics associated with frequent emergency department use among hospitalized cancer patients: a comparative cohort study

Abstract Background: Opioid use is associated with greater health resource utilization, namely unplanned emergency department (ED) visits. The purpose of this study was to characterize ED visit patterns by patients hospitalized for cancer based on their use of prescription opioids in the community. Design &amp; Methods: A prospective cohort study of cancer patients discharged from medical and surgical units at an academic health center in Montreal (Canada) between October 2014 and November 2016 was assembled. The main outcome was frequent ED use (≥4 ED visits) in the year following hospital discharge. Clinical information linked to health administrative claims from the provincial universal health care program (RAMQ) was used in multivariable logistic regression to model patient and opioid prescription characteristics, comparing frequent ED users to non-frequent ED users. Potential predictors included history of chronic pain condition, mental health diagnoses, type of cancer, receipt of radiotherapy/chemotherapy, medication history (previous use of opioids, history of antidepressant use, benzodiazepines), receipt of surgery during the hospitalization as well as characteristics of the discharge prescription (e.g: receipt of an opioid, presence of a multi-modal pain regimen). Results: A cohort of 1253 cancer patients discharged from the medical and surgical units was assembled. The mean age for these patients was 70.9 (11.8) and the most frequent cancers included 488 (38.9%) respiratory and 309 (24.6%) upper digestive cancer. Overall, 54% of cancer patients (n =654) had at least one ED visit in the year post-discharge. Of these, all had filled at least one opioid prescription during the follow-up period. Of patients with at least one ED visit in the one year post-discharge, 29% (n = 188) became frequent ED users. In adjusted multivariable logistic model, the strongest associations of frequent ED use were receipt of chemotherapy one year before their index hospitalization (odds ratio (OR) 1.67; 95% CI: 1.08 - 2.61) and respiratory cancer diagnoses (OR 1.69; 95% CI: 1.07 - 2.67). With respect to opioid prescribing, most the dispensations were for oxycodone (51.4%) and hydromorphone (33.6%). Patients receiving a daily dose &amp;gt;90 MME (morphine milligram equivalents) had an odds ratio of 2.24 (95% CI: 1.14- 4.40) of becoming frequent ED users. Those who filled more than one type of opioid during the follow-up were 1.81 times more likely to become repeated ED users (95% CI: 1.23 - 2.70). Conclusions: Cancer patients with higher opioid use after hospital discharge and active use of more than two different type of opioids within one year time of discharge are at higher risk of encoring unplanned health visits in the ER. A new approach to care planning and coordination is recommended to better monitor opioid prescribing practices and improve outcomes. Citation Format: Siyana Kurteva, Robyn Tamblyn, Ari Meguerditchian. Opioid prescription characteristics associated with frequent emergency department use among hospitalized cancer patients: a comparative cohort study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5769.

Outpatient surgery in patients with ankle fractures minimises hospital admissions and utilisation of healthcare resources.

PurposeThe recent outbreak of the novel coronavirus (SARS-CoV-2) has emphasised the need to minimise hospital admissions and utilisation of healthcare resources. The purpose of this study was to examine the outcomes of an outpatient surgery protocol for acute closed ankle fractures.MethodsIn this retrospective study, 262 patients underwent outpatient surgery for their closed ankle fractures at our level-1 trauma centre. A total of 196 patients met our inclusion criteria and were ultimately included in the final analysis. Our primary outcomes’ measures included post-operative admission to the emergency department within 30 days after surgery and unplanned hospital readmission within 30 days after surgery. Our secondary outcome measure included the incidence of surgical site infection (SSI) within 12 weeks after surgery.ResultsThirty-two patients (16.3%) had an unplanned emergency department visit within 30 days of fracture fixation and two patients (1.0%) required hospital readmission within 30 days of their surgery. Sixteen patients (8.2%) developed SSI, which included 11 (5.6%) superficial and five (2.6%) deep infections.ConclusionStrategic outpatient management of acute closed ankle fractures is associated with acceptable rates of unplanned emergency department visits, hospital readmissions, and SSIs. In the context of the recent SARS-CoV-2 outbreak, outpatient management of these injuries may aide in the mitigation of nosocomial infections and the preservation of finite healthcare resources.

Developing Strategies for Targeted Improvement of Perioperative Education for Postbariatric Surgery Body-Contouring Patients.

The quality of perioperative patient education impacts surgical outcomes, patient experiences, and resources needed to address patient concerns and unplanned visits. We examined patient inquiries and education materials to assess the quality of perioperative education and identify areas of targeted improvement for postbariatric surgery body-contouring procedures. We examined 100 consecutive postbariatric procedures at an academic center. Themes of patient-generated calls, e-mails, and electronic medical record portal messages during the perioperative period were identified via qualitative analysis. Understandability and actionability of perioperative educational resources were assessed using the Patient Education Materials Assessment Tool (PEMAT). Among 212 communications identified, 167 (79%) were postoperative. Common themes were concerns regarding the surgical site (38%), medications (10%), and activity restrictions (10%). One hundred thirty inquiries were resolved through patient re-education (57%), but 36 (16%) required in-person evaluation including 4 unplanned emergency department visits and 3 readmissions for surgical-site concerns. The PEMAT scores for institutional materials were fair for understandability (69%) and actionability (60%). American Society of Plastic Surgeons materials were more understandable (84%) but less actionable (40%). Patient queries can be leveraged as a source of qualitative data to identify gaps in perioperative education. High-yield topics, such as education regarding the surgical site and medications, can be targeted for quality improvement through better communication and potentially reduce the number of unnecessary visits. Using the PEMAT, we also identified how directly the education materials can be revised. Improving perioperative education can promote mutual understanding between patients and surgeons, better outcomes, and efficient resource utilization.

The oncology hospital at home: Health care utilization outcomes from the huntsman at home trial.

7000 Background: Unplanned hospitalizations and emergency department (ED) visits are common during cancer care. Providing acute hospital level care at home may add value by decreasing hospital and ED use. We conducted the first evaluation of an oncology Hospital-at-Home program, Huntsman at Home (H@H). Methods: The Huntsman Cancer Institute began H@H services in 2018 and accepts referral of cancer patients for acute-medical or post-surgical care at home. Patients are admitted who require continued acute level medical care after hospitalization or have emergent unstable symptoms related to treatment or disease progression that would otherwise require ED evaluation or hospitalization. Prospectively, patients referred to H@H from 8/2018 through 10/2019 were compared to a usual care comparison group (UC) drawn concurrently from patients living within the Salt Lake City metropolitan area who qualified for admission to H@H, but lived outside the service zip codes. Probability of H@H enrollment propensity scores were constructed via random forest from patient descriptors and health care utilization at admission. We used an intent-to-treat approach for analysis. Primary outcomes were hospitalizations, length of stay (LOS), ED visits and cumulative charges over 30 and 90 days post admission to either group. Comparisons were made by generalized linear models, stratified by tertiles of H@H vs. UC propensity score. Results: 367 patients, 169 H@H and 198 UC, were evaluated. The average age was 62 yrs, 85% were Caucasian, and 77% had stage IV cancer. Propensity score distributions were overlapping, demonstrating group comparability. A variety of cancers were represented; the most common being colon, gynecologic, prostate and lung cancers. Compared to UC, H@H patients were more likely to be female (61% vs 43%) and during the month prior to admission, showed a trend towards longer LOS if hospitalized (6.7 vs 5.5 days). During the first 30 days after admission, propensity stratified comparisons showed H@H patients with lower hospital LOS (mean reduction 1.19 days, p=0.022), 56% lower odds of unplanned hospitalizations (OR 0.44, p=0.001), 45% lower odds of ED visits (OR 0.55, p=0.037) and 50% lower cumulative charges (mean ratio 0.50, p&lt;0.001) compared to UC. Results over 90 days were similarly robust. Conclusions: In the first reported trial of an adult oncology Hospital at Home program, there was strong evidence for reduced hospitalizations, ED visits, and cost. Oncology Hospital at Home programs show promise for increased patient-centered care while simultaneously improving value.

A feasibility exploratory study of a novel modality of using patient-reported outcomes (PROsEXPLOR) in the real world.

Patient-reported outcomes (PROs) can help clinicians better evaluate chemotherapy and immunotherapy toxicity based on patient perspectives. In this exploratory study, we tested a simplified PRO questionnaire (sPQ) in routine clinical practice and patient satisfaction with this tool. We included 16 items related to the main toxicities of chemotherapy and immunotherapy to be filled in by patients. A baseline sPQ was completed by patients before starting treatment and then in the interval between courses for a total of 4 sPQs. Patients communicated the results to a data manager, who alerted the referral oncologist in case of replies differing from the basal or previous sPQ. According to the severity of symptoms, the patient was then referred to the team nurse, the general practitioner, or another specialist. A satisfaction survey was also completed. In a 3-month interval, 27 patients were enrolled. Fatigue and nausea were the most frequent symptoms reported as worsening during treatment. The oncologist was involved in the management of adverse events in 4 cases, home therapy variations were recommended by the dedicated nurse in 14 cases, additional visits were performed in 6 patients, and 1 patient was admitted to the oncology ward. None of the patients had unplanned visits to the emergency department or to the hospital. The sPQ was judged to be simple, useful, and satisfactory. Using sPQs in routine clinical practice was feasible and well-accepted by patients. PROs allowed us to recognize and promptly manage adverse events, reducing unplanned emergency department or hospital visits to zero.

Old and New Geriatric Screening Tools in a Belgian Emergency Department: A Diagnostic Accuracy Study.

To compare the diagnostic accuracy of the Identification of Seniors at Risk, the Flemish version of Triage Risk Screening Tool, and the interRAI Emergency Department Screener for predicting prolonged emergency department (ED) length of stay, hospitalization (following index ED stay), and unplanned ED readmission at 30 and 90 days among older (aged ≥70 years) community-dwelling adults admitted to the ED. Single-center, prospective, observation study. ED with embedded observation unit in University Hospitals Leuven (Belgium). A total of 794 patients (median age = 80 years; 55% female) were included. Study nurses collected data using semistructured interviews and patient record review during ED admission. Outcome data were collected with patient record review. Hospitalization (following index ED stay) and unplanned ED readmission at 30 and 90 days occurred in 67% (527/787) of patients and in 12.2% (93/761) and 22.1% (168/761) of patients, respectively. For all outcomes at cutoff 2, the three screening tools had moderate to high sensitivity (range = 0.71-0.90) combined with (very) low specificity (range = 0.14-0.32) and low accuracy (range = 0.21-0.67). At all cutoffs, likelihood ratios and interval likelihood ratios had no or small impact (range = 0.46-3.95; zero was not included) on the posttest probability of the outcomes. For all outcomes, area under the receiver operating characteristics curve varied in the range of 0.49 to 0.62. Diagnostic characteristics of all screening tools were comparable. None of the tools accurately predicted the outcomes as a stand-alone index. Future studies should explore the clinical effectiveness and implementation aspects of ED-specific minimum geriatric assessment and intervention strategies. J Am Geriatr Soc 68:1454-1461, 2020.

PL04: A randomized controlled trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury

Introduction: The emergency department (ED) is often the first point of health care contact for patients with mild traumatic brain injury (MTBI). Spontaneous resolution occurs in most patients within 7 days, yet 15-30% will develop post-concussion syndrome (PCS). Given the paucity of effective management strategies to prevent PCS and emerging evidence supporting exercise, the objective of this study was to evaluate the impact of prescribed early light exercise compared to standard discharge instructions for acute MTBI patients in the ED. Methods: This was a randomized controlled trial conducted in three Canadian EDs. Consecutive, adult (18-64 years) ED patients with a MTBI sustained within the preceding 48 hours were eligible for enrollment. The intervention group received discharge instructions prescribing 30 minutes of daily light exercise (e.g., walking), and the control group was given standard MTBI instructions advising gradual return to exercise following symptom resolution. Participants documented their daily physical activities and completed follow-up questionnaires at 7, 14, and 30 days. The primary outcome was the proportion of patients with PCS at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 30 days. Results: 367 patients were enrolled (control n = 184; intervention n = 183). Median age was 32 years and 201 (57.6%) were female. There was no difference in the proportion of patients with PCS at 30 days (control 13.4 vs intervention 14.6; Δ1.2, 95% CI: -6.2 to 8.5). There were no differences in median change of RPQ scores (control 14 vs intervention 13; Δ1, 95% CI: -1 to 4), median number of return health care provider visits (control 1 vs intervention 1; Δ0, 95% CI: 0 to 0), or median number of missed school or work days (control 2 vs intervention 2; Δ0, 95% CI: 0 to 1) at 30 days. There was a nonsignificant difference in unplanned return ED visits within 30 days (control 9.9% vs intervention 5.6%; Δ1, 95% CI: -1.4 to 10.3). Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35; Δ5, 95% CI: 2 to 15). Conclusion: To our knowledge, this is the first randomized trial of prescribed early light exercise for adults with acute MTBI. There were no differences in recovery or healthcare utilization outcomes. Results suggest prescribed early light exercise should be encouraged as tolerated at ED discharge following MTBI, but exercise prescription alone is not sufficient to prevent PCS.

Impact of a Standardized Clinical Pathway for Suspected and Confirmed Ileocolic Intussusception.

Clinical pathways for specific diagnoses may improve patient outcomes, decrease resource utilization, and diminish costs. This study examines the impact of a clinical pathway for emergency department (ED) care of suspected and confirmed pediatric ileocolic intussusception. Our multidisciplinary team designed an intussusception clinical pathway and implemented it in a tertiary children's hospital ED in October 2016. Process measures included the proportion of patients who underwent abdominal radiography, had laboratory studies, received antibiotics, or required admission following reduction of intussusception. The primary outcome measure was the cost per encounter. Balancing measures included unplanned ED visits within 72 hours of discharge. Data analyzed compared 24 months before and 21 months following pathway implementation. After pathway implementation, the use of abdominal radiography in patients with suspected intussusception decreased from 50% to 12%. In patients with confirmed intussusception, laboratory studies decreased from 58% to 25%, antibiotic use decreased from 100% to 2%, and hospital admissions decreased from 100% to 12%. The average cost per encounter for confirmed intussusception decreased from $6,724 to $2,975. There was a small increase in unplanned returns to the ED within 72 hours but no increase in readmissions after pathway implementation. Implementation of a standardized ED pathway for the management of suspected and confirmed pediatric ileocolic intussusception is associated with a reduction in abdominal radiographs, improved antibiotic stewardship, reduction in laboratory studies, fewer inpatient admissions, and decreased cost, with no compromise in patient safety.

MP15-06 INDICATIONS FOR STENT OMISSION AFTER URETEROSCOPIC LITHOTRIPSY: A PROSPECTIVE TRIAL FROM THE REGISTRY FOR STONES OF THE KIDNEY AND URETER (RESKU)

You have accessJournal of UrologyStone Disease: Surgical Therapy III (MP15)1 Apr 2020MP15-06 INDICATIONS FOR STENT OMISSION AFTER URETEROSCOPIC LITHOTRIPSY: A PROSPECTIVE TRIAL FROM THE REGISTRY FOR STONES OF THE KIDNEY AND URETER (RESKU) Robert Fisher*, Kaitlan Cobb, David Friedlander, David Bayne, Seth Bechis, Helena Chang, Thomas Chi, Brian Duty, Jonathan Harper, Ian Metzler, Mathew Sorensen, Marshall Stoller, David Tzou, and Roger Sur Robert Fisher*Robert Fisher* More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , David FriedlanderDavid Friedlander More articles by this author , David BayneDavid Bayne More articles by this author , Seth BechisSeth Bechis More articles by this author , Helena ChangHelena Chang More articles by this author , Thomas ChiThomas Chi More articles by this author , Brian DutyBrian Duty More articles by this author , Jonathan HarperJonathan Harper More articles by this author , Ian MetzlerIan Metzler More articles by this author , Mathew SorensenMathew Sorensen More articles by this author , Marshall StollerMarshall Stoller More articles by this author , David TzouDavid Tzou More articles by this author , and Roger SurRoger Sur More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000840.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stent complications including pain, infection and discomfort are a significant source of emergency room visits in the post-operative period. Per AUA Guidelines, placement of a ureteral stent following ureteroscopy (URS) is at the urologist’s discretion. The risk/benefit calculation for routine use of ureteral stents following uncomplicated URS is controversial. We performed a multi-institutional study to investigate if ureteral stent omission is safe following URS compared to routine stenting. METHODS: From November 2018 to June 2019, a stent omission protocol was instituted at 5 academic centers for patients undergoing URS with laser lithotripsy and/or basketing by 6 fellowship trained endourologists. Inclusion criteria included: age ≥18 years, solitary ureteral stone ≤10 mm, total renal stone burden ≤15 mm with largest stone ≤10cm. Patients were excluded for solitary kidney or if a ureteral access sheath was used without pre-stenting. Data was collected prospectively via ReSKU (The Registry for Stones of the Kidney and Ureter) and was retrospectively reviewed. Analyzed outcomes included event rates of patient phone calls, unplanned emergency department or clinic visits, and unplanned operation. Bivariate differences in categorical and continuous variables between stented and unstented groups were examined using the Pearson's chi-squared and the students t-test, respectively. RESULTS: A total of 344 URS procedures were performed and 134/344 (39.0%) patients met inclusion criteria for ureteral stent omission. Of these candidates, 90 subjects (67%) had their stents omitted, while 44 (33%) deviated from the stent-less protocol. Deviation from the stent protocol did not vary by institution (20% vs. 37.5% vs. 60% vs. 50% vs. 40%; P>0.05). The total event rate (phone call, ED, OR, or clinic) was 19.1% for subjects with a stent versus 20.0% for subjects with a stent omitted (P>0.05); with the majority (30.7%) of these events being phone calls. CONCLUSIONS: In a multi-center prospectively collected study involving 344 individuals undergoing URS for nephrolithiasis, there was a similar proportion of stented and unstented subjects who called, presented to the ED or clinic, or required a return trip to the operating room following uncomplicated ureteroscopy for stone disease. Our findings suggest that ureteral stents can be safely omitted in properly selected adult patients. Source of Funding: National Institutes of Health grant (NIH P20-DK-116193). © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e206-e206 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert Fisher* More articles by this author Kaitlan Cobb More articles by this author David Friedlander More articles by this author David Bayne More articles by this author Seth Bechis More articles by this author Helena Chang More articles by this author Thomas Chi More articles by this author Brian Duty More articles by this author Jonathan Harper More articles by this author Ian Metzler More articles by this author Mathew Sorensen More articles by this author Marshall Stoller More articles by this author David Tzou More articles by this author Roger Sur More articles by this author Expand All Advertisement PDF downloadLoading ...

PD34-02 NATURAL HISTORY OF RESIDUAL FRAGMENTS AFTER AGGRESSIVE URETEROSCOPY AND FRAGMENT RETRIEVAL

You have accessJournal of UrologyStone Disease: Surgical Therapy V (PD34)1 Apr 2020PD34-02 NATURAL HISTORY OF RESIDUAL FRAGMENTS AFTER AGGRESSIVE URETEROSCOPY AND FRAGMENT RETRIEVAL Ryan L. Steinberg*, Brett A. Johnson, Igor Sorokin, Alaina Garbens, Vishnuvardhan Ganesan, Joseph Crivelli, Abdulhadi Akhtar, Jodi Antonelli, and Margaret Pearle Ryan L. Steinberg*Ryan L. Steinberg* More articles by this author , Brett A. JohnsonBrett A. Johnson More articles by this author , Igor SorokinIgor Sorokin More articles by this author , Alaina GarbensAlaina Garbens More articles by this author , Vishnuvardhan GanesanVishnuvardhan Ganesan More articles by this author , Joseph CrivelliJoseph Crivelli More articles by this author , Abdulhadi AkhtarAbdulhadi Akhtar More articles by this author , Jodi AntonelliJodi Antonelli More articles by this author , and Margaret PearleMargaret Pearle More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000905.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Follow-up of patients with residual fragments (RFs) after ureteroscopy (URS) for upper tract stones has shown that the occurrence of stone-related events is common. Short-term follow up of a cohort with RFs detected by CT after URS revealed that 41% of patients experienced a stone-related event (SE) at a mean follow-up of 16 months. We have continued to follow these patients with RFs to determine intermediate outcomes. METHODS: Between December 2015 and February 2017, 167 patients (209 renal units, RUs) underwent URS for renal and ureteral calculi and were imaged with CT at 6-8 weeks post-operatively. Patients were evaluated at subsequent office visits with imaging studies and/or contacted by phone to determine the occurrence of stone events attributable to their RFs. A stone event was defined as spontaneous stone passage, symptoms requiring emergency department (ED) visit, surgical intervention, or stone growth. Patients with RFs of any size were included for analysis. Stone-event free survival (SEFS) was determined by the Kaplan Meier analysis and risk factors for an event were identified by logistic regression. RESULTS: A total of 73 patients (87 RUs) had RFs after URS with a median follow-up of 29 months (IQR 22-34). The mean number of RFs per patient on post-operative CT was 2.1 ± 1.5 and mean largest fragment size was 3.7 ± 2.0 mm. SE occurred in 47% of RUs (41/87). Unplanned ED or clinic visits occurred in 13%, a secondary stone surgery was required in 17%, and 17% of patients experienced spontaneous stone passage. The median time to SE was 20 months (IQR 7-26). Neither size (p=0.11) nor location (p=0.816) of the residual fragment predicted a stone event. Bilateral procedures were associated with an increased risk of a stone event (OR 3.2, CI 1.4 – 7.8, p=0.01), while increasing age (OR 0.3, CI 0.1 – 0.8, p=0.01) and male gender (OR 0.9, CI 0.91– 0.98, p<0.01) were protective on multivariable analysis. By Kaplan-Meier analysis, SEFS was 74% at 24 months year and 58% at 30 months post-operatively (Figure). CONCLUSIONS: With longer follow up, nearly half of patients left with RFs after URS will experience a SE, rates comparable to those following SWL. Better patient selection for URS and new ways to enhance stone free rates after URS are essential to improve outcomes. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e711-e712 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan L. Steinberg* More articles by this author Brett A. Johnson More articles by this author Igor Sorokin More articles by this author Alaina Garbens More articles by this author Vishnuvardhan Ganesan More articles by this author Joseph Crivelli More articles by this author Abdulhadi Akhtar More articles by this author Jodi Antonelli More articles by this author Margaret Pearle More articles by this author Expand All Advertisement PDF downloadLoading ...

Screening for Frailty in Older Emergency Patients and Association with Outcome.

Older people have a high incidence of adverse outcomes after urgent care presentation. Identifying high-risk older patients early is key to targeting interventions at those patients most likely to benefit. This study used the Frailsafe three-point screening questions amongst older Emergency Department (ED) attendees. Consecutive unplanned ED attendances in patients aged ≥75 were assessed for Frailsafe status. The primary outcome was mortality at 180 days. A Frailsafe screen was completed in 356 patients, of whom 194/356 (54.5%) were Frailsafe positive. The mean age was 85.8 for Frailsafe screen positive and 82.2 for Frailsafe screen negative patients (p < 0.001). A positive Frailsafe screen was a predictor of death within 180 days of presentation to the ED and remained so after adjustment (AOR = 3.23, 95% CI 1.45–7.19, p = 0.004). A positive Frailsafe screen was an independent predictor of a new care home admission at 180 days (AOR = 8.95, 95% CI 2.01–39.83, p = 0.004). A positive Frailsafe screen was also predictive of a number of secondary outcomes, such as length of stay of >28 days (AOR 3.42, 95% CI 1.41–8.31, p = 0.007) and re-attendance within 30 days of discharge after admission (OR = 2.73, 95% CI 1.27–5.88, p = 0.01). Frailsafe screen results independently predict a range of outcomes amongst older ED attendees.

Payer effects of personalized preventive care for patients with diabetes.

To examine the effects of MD-Value in Prevention (MDVIP) enrollment on Medicare expenditures and utilization among fee-for-service (FFS) beneficiaries with diabetes over a 5-year period. We obtained participating physician and beneficiary enrollment lists from MDVIP and Medicare FFS claims data through the Virtual Research Data Center to compare changes in outcomes, before and after enrollment dates, with those of nonenrolled beneficiaries receiving primary care in the same local market. We employed propensity score matching to identify comparison beneficiaries similar in observed characteristics and preenrollment trends. Individual fixed effects were used to control for time-consistent differences between treatment and comparison populations. We found that enrollment is statistically associated with reductions in outpatient expenditures, Medicare expenditures in year 5, emergency department (ED) utilization, and unplanned inpatient admissions, accompanied by significant increases in evaluation and management visits and expenditures. Total Medicare expenditures over the 5-year period, as well as all inpatient admissions, were not statistically different between the MDVIP and comparison groups. Our finding of reduced unplanned inpatient admissions and ED utilization supports the previous findings regarding MDVIP enrollees. We did not find significant changes in overall third-party expenditures, although savings were estimated in year 5, the last year of observation, and may occur later. Our approach, however, strengthens controls for baseline characteristics of the population and uses a comparison population drawn from the same markets who do not experience the loss of their primary care physician at the time of enrollment.

Supporting at-risk older adults transitioning from hospital to home: who benefits from an evidence-based patient-centered discharge planning intervention? Post-hoc analysis from a randomized trial

BackgroundSubgroups of older patients experience difficulty performing activities of daily living (ADL) following hospital discharge, as well as unplanned hospital readmissions and emergency department (ED) presentations. We examine whether these subgroups of “at-risk” older patients benefit more than their counterparts from an evidence-based discharge planning intervention, on the following outcomes: (1) independence in ADL, (2) participation in life roles, (3) unplanned re-hospitalizations, and (4) ED presentations.Trial design and methodsThis study used data from a randomized control trial involving 400 hospitalized older patients with acute and medical conditions, recruited through 5 sites in Australia. Participants receive either HOME, a patient-centered discharge planning intervention led by an occupational therapist; or a structured in-hospital consultation. HOME uses a collaborative approach for goal setting and includes pre and post-discharge home visits as well as telephone follow-up. Characteristics associated with higher risks of adverse outcomes were recorded and at-risk subgroups were created (mild cognitive impairment, walking difficulty, comorbidity, living alone and no support from family). Independence in ADL and participation in life roles were assessed with validated questionnaires. The number of unplanned re-hospitalizations and ED presentations were extracted from medical files. Linear regression models were conducted to detect variation in response to the intervention at 3-months, according to patients’ characteristics.ResultsAnalyses revealed significant interaction effects for intervention by cognitive status for unplanned re-hospitalization (p = 0.003) and ED presentations (p = 0.021) at 3 months. Within the at-risk subgroup of mild cognitively impaired, the HOME intervention significantly reduced unplanned hospitalizations (p = 0.027), but the effect did not reach significance in ED visits. While the effect of HOME differed according to support received from family for participation in life roles (p = 0.019), the participation observed in HOME patients with no support was not significantly improved.ConclusionsFindings show that hospitalized older adults with mild cognitive impairment benefit from the HOME intervention, which involves preparation and post-discharge support in the environment, to reduce unplanned re-hospitalizations. Improved discharge outcomes in this at-risk subgroup following an occupational therapist-led intervention may enable best care delivery as patients transition from hospital to home.Trial registrationThe trial was registered before commencement (ACTRN12611000615987).