Urban Teaching Hospital Research Articles

Delivery risks and outcomes associated with grand multiparity

Background There is limited recent US national data on risk for adverse outcomes associated with grand multiparity. Objective To examine the association between grand multiparity and severe maternal morbidity (SMM) and other adverse outcomes during delivery hospitalizations in the United States. Methods This repeat cross-sectional study evaluated delivery hospitalizations from 2000 through the third quarter of 2015 to women aged 15–54 in the National (Nationwide) Inpatient Sample database. Temporal trends in deliveries to women with grand multiparity were analyzed using the Cochran–Armitage trend test. The primary outcome studied was SMM, a composite of adverse outcomes defined by the Centers for Disease Control and Prevention. The exposure of interest was grand multiparity diagnosis during delivery hospitalization. Other adverse outcomes analyzed included placental abruption, preterm delivery, postpartum hemorrhage, disseminated intravascular coagulation, shock, hysterectomy, pulmonary edema and acute heart failure, transfusion of blood or blood products, hypertensive diseases of pregnancy, cesarean delivery, eclampsia, and acute renal failure. Log linear regression models were performed to determine the relationship between grand multiparity and adverse outcomes with measures of association demonstrated as unadjusted (RR) and adjusted risk ratios (aRR) with 95%CIs. Results From 2000 to 2015, there were an estimated 62,672,862 hospital deliveries with 386,019 deliveries in the setting of grand multiparity. The number of deliveries with a grand multiparity diagnosis increased over the study period from 4.2 per 1000 deliveries in 2000 to 8.6 per 1000 in 2015 (p < .01). Women with grand multiparity were more likely to be older, have comorbidities, be Hispanic or non-Hispanic Black, be from a lower ZIP code income quartile, have Medicaid insurance, and present to an urban teaching hospital for delivery (p < .01 for all). On univariable analysis, grand multiparity was associated with SMM (RR 1.27, 95%CI 1.23–1.32). However, in adjusted analyses accounting for hospital, clinical, and demographic factors, women with grand multiparity were at lower risk of SMM (aRR 0.93, 95%CI 0.89, 0.96). On analysis of individual adverse outcomes, grand multiparity was associated with a higher risk of placental abruption (RR 1.28, 95%CI 1.24–1.31), preterm delivery (RR 1.17, 95%CI 1.16–1.18), postpartum hemorrhage (RR 1.30, 95%CI 1.28–1.32), disseminated intravascular coagulation (RR 1.23, 95%CI 1.16–1.31), shock (RR 2.50, 95%CI 2.20–2.85), hysterectomy (RR 3.20, 95%CI 3.30, 3.41), pulmonary edema and acute heart failure (RR 1.33, 95%CI 1.24–1.42), and transfusion of blood or blood products (RR 1.74, 95%CI 1.70–1.79). Conversely, grand multiparity was associated with a lower risk of hypertensive diseases of pregnancy (RR 0.85, 95%CI 0.84–0.86), cesarean delivery (RR 0.96, 95%CI 0.95–0.96), and eclampsia (RR 0.69, 95%CI 0.60–0.79). There was no significant association between grand multiparity and acute renal failure. Conclusions Delivery hospitalizations with a grand multiparity diagnosis were not associated with increased risk for SMM in adjusted analysis. Grand multiparity was associated with increased risk for hysterectomy and shock although absolute increased risk for these complications was small.

COVID-19 Infection in Reproductive Age Group Females: Experience of a Tertiary Care Urban Teaching Hospital.

BackgroundThe objective of this study was to find out the effect, course of disease and management of the COVID-19 infection in pregnant women and compare it with non-pregnant population.MethodThis is a retrospective study done at Sardar Vallabhbhai Patel Institute of Medical Science and Research (SVPIMSR), Smt. NHL MMC, Ahmedabad, from April 1, 2020, to September 30, 2020. All COVID-19-positive patients were divided into two groups: group A was comprised of pregnant/postpartum and group B of non-pregnant patients.ResultA total of 709 women (Group A-205, Group B-504) were included in the study, In group A 90% of patients were asymptomatic, while in group B 48% asymptomatic patients. Group A had 5.9% and group B had 13.1% patients having comorbidities. In group A, smaller number of patients had raised inflammatory markers as compared to group B. Only 4% patients of group A showed significant changes on chest X-ray as compared to 16% in group B. Only 2.9% patients of group A required intensive care unit admission as compared to 10.31% patients of group B. Mean hospital stay of group A was 10.6 days, and that of group B was 12.1 days.ConclusionIn pregnancy, due to the physiological alterations in cardiovascular, respiratory and immune system, the pregnant women are vulnerable to infections. Although pregnancy is immunocompromised state, the severity of Coivd-19 disease is milder as compared to non-pregnant COVID-19-positive patients.

Admission trends in pediatric isolated linear skull fracture across the United States.

Pediatric isolated linear skull fractures commonly result from head trauma and rarely require surgery, yet patients are often admitted to the hospital-a costly care plan. In this study, the authors utilized a national database to investigate trends in admission for skull fractures across the United States. Children younger than 18 years with isolated linear skull fracture, according to ICD-9 diagnosis codes in the Kids' Inpatient Database of the Healthcare and Utilization Project (HCUP), who presented between 2003 and 2016 were included. HCUP collected data in 2003, 2006, 2009, 2012, and 2016. Children with a depressed skull fracture, multiple traumatic injuries, and acute intracranial findings were excluded. Sample-level data were translated into population-level data by using an HCUP-specific discharge weight. Overall, 11,355 patients (64% males) were admitted to 1605 hospitals. National admissions decreased from 3053 patients in 2003 to 1203 in 2016. The mean ± SD age at admission also decreased from 6.3 ± 5.9 years to 1.2 ± 3.0 years (p < 0.001). The proportion of patients in the lowest quartile of median household income increased by 9%, while that in the highest income quartile decreased by 7% (p < 0.001). Admission was generally more common in the summer months (June, July, and August) and on weekdays (68%). The mean ± SD hospital length of stay decreased from 2.0 ± 3.1 days to 1.4 ± 1.4 days between 2003 and 2012, and then increased to 2.1 ± 6.8 days in 2016 (p < 0.001). When adjusted for inflation, the mean total hospital charges increased from $13,099 to $21,204 (p < 0.001). The greatest proportion of admissions was in the South (35%), and the lowest was in the Northeast (17%). The proportion of patients admitted to large hospitals increased (59% to 72%, p < 0.001), which corresponded to a decrease in patients admitted to small hospitals (16% to 9%, p < 0.001). Overall, the total proportion of admissions to rural hospitals decreased by 6%, and that to urban teaching centers increased by 15% (p < 0.001). Since 2003, no child has undergone a neurosurgical procedure or died as an inpatient. This study identified a general nationwide decrease in admissions for pediatric linear isolated skull fracture, but associated costs increased. Admissions became less common at smaller rural hospitals and more common at larger urban teaching hospitals. This patient population required no inpatient neurosurgical intervention after 2003.

The Impact of Hepatic Cirrhosis on Chronic Obstructive Pulmonary Disease in the United States: A Nationwide Analysis.

We aimed to study the impact of Hepatic Cirrhosis (HC) on chronic obstructive pulmonary disease (COPD).Our study is a retrospective cohort study using the 2016-2017 National Readmission Database (NRD). NRD is part of the Healthcare Cost and Utilization Project (HCUP), organized and supported by means of the Agency for Healthcare Research and Quality (AHRQ). Patients were included if they were 18 years or older and had a principal diagnosis of COPD based on International Classification of Diseases, Tenth Revision (ICD-10- CM) codes and had a secondary diagnosis of HC.A total of 505,004 patients were included in the study with a diagnosis of COPD, 6196 (1.23%) of whom had HC. HC was found to be more common amongst male patients between the ages of 50 and 65 years. Medicare beneficiaries with high comorbidity burden, lower socioeconomic status, and those who received treatment in a large urban teaching hospital also had higher rates of HC. Patients with HC and COPD correlated to an increase of in-hospital mortality (adjusted odds ratio (aOR: 2.21, p<0.001) and 30-day hospital readmission rate (aOR: 1.23, p<0.001) compared with patients without HC. The in-hospital mortality rate was higher during readmission compared with index admissions (5.01% versus 2.16%; p<0.001). In addition, HC was associated with higher morbidity including prolonged mechanical ventilation (aOR: 1.39, p<0.001), resource utilization with prolong length of stay (LOS) (adjusted mean difference (aMD: 0.51, p<0.001), higher total hospitalization charges (aMD: 4967, p<0.001), and costs (aMD: 1200, p<0.001). Both patient groups had similar odds of being intubated (aOR: 1.18, p-0.13), tracheostomy (aOR: 0.81, p-069) and bronchoscopy rates (aOR: 1.27, p-0.36). The most common causes of hospital readmission were found to be COPD with acute exacerbation (19.7%), sepsis, unspecified organism (6.0%, acute and chronic respiratory failure with hypoxia (4.2%), acute on chronic systolic heart failure (3.9%), and hepatic failure, unspecified coma (3.1%). Various autonomous prognosticators of readmission were sex (particularly female), alcohol dependence, LOS greater than 7 days, lower comorbidity burden, and discharge to short term hospital or against medical advice. On the other hand, males, patients without a history of alcohol dependence, greater comorbidity burden, and LOS fewer than 3 days, were less likely to be readmitted. We found that HC is related to higher in-hospital mortality, LOS, increased mechanical ventilation, resource utilization with prolonged LOS, hospital costs, odds of intubation, and tracheostomy and bronchoscopy rates. Our study aims to shed light on the impact of HC on COPD in hopes to improve future management.

Atrial fibrillation in critically ill patients who received prolonged mechanical ventilation: a nationwide inpatient report.

Background/AimsTo evaluate temporal trends of atrial fibrillation (AF) prevalence in critically ill patients who received prolonged mechanical ventilation (MV) in the United States.MethodsWe used the 2008 to 2014 National Inpatient Sample to compute the weighted prevalence of AF among hospitalized adult patients on prolonged MV. We used multivariable-adjusted models to evaluate the association of AF with clinical factors, in-hospital mortality, hospitalization cost, and length of stay (LOS).ResultsWe identified 2,578,165 patients who received prolonged MV (21.27% of AF patients). The prevalence of AF increased from 14.63% in 2008 to 24.43% in 2014 (p for trend < 0.0001). Amongst different phenotypes of critically ill patients, the prevalence of AF increased in patients with severe sepsis, asthma exacerbation, congestive heart failure exacerbation, acute stroke, and cardiac arrest. Older age, male sex, white race, medicare access, higher income, urban teaching hospital setting, and Western region were associated with a higher prevalence of AF. AF in critical illness was a risk factor for in-hospital death (odds ratio, 1.13; 95% confidence interval, 1.11 to 1.15), but in-hospital mortality in critically ill patients with AF decreased from 11.6% to 8.3%. AF was linked to prolonged LOS (2%, p < 0.0001) and high hospitalization cost (4%, p < 0.0001). LOS (−1%, p < 0.0001) and hospitalization cost (−4%, p < 0.0001) decreased yearly.ConclusionsThe prevalence of comorbid AF is increasing, particularly in older patients. AF may lead to poorer prognosis, and high-quality intensive care is imperative for this population.

Depression in females: comparison of patients visiting urban and rural teaching hospitals of Peshawar, Khyber Pakhtunkhwa

Introduction: Even though frequency of depression is documented globally, the spectrum of depression and its inciting factors in Pakistan are unique to the local cultural and social beliefs.&#x0D; Objective: To compare the status of depression and its provoking socio-cultural factors among urban and rural females attending selected hospitals of Peshawar.&#x0D; Materials &amp; Methods: A cross-sectional comparative study was conducted from March to May 2017 on 93 female patients attending two selected urban and rural teaching hospitals of Peshawar. Data were collected on Beck Depression Inventory through convenience sampling, and were analyzed for descriptive statistics by SPSS version 20. Comparisons were done by the Chi Square test and the Student’s T test keeping p≤0.05 as significant.&#x0D; Results: Out of 93 female patients, a final 89 females (53 urban and 36 rural) were included due to incomplete data entries. More urban females were in the normal, mild or borderline clinically depressed categories (38/53, 71.7%), compared to rural females (15/36, 41.7%), more of whom were in moderate, severe and extremely depressed categories (21/36, 58.3%); the difference was significant (p=0.025). Among the many factors leading to depression, there were significant differences in poor socio-economic status (p=0.011), illiteracy (p=0.003) and hostile in-laws (p=0.016), all of which were mainly due to females of rural area rather than urban females.&#x0D; Conclusion: Rural females suffered significantly greater depression compared to their urban counterparts related to poor socio-economic status, illiteracy, and hostile in-laws.&#x0D; Keywords: Depression; Anxiety; Stress; Female; Marriage; Domestic Violence.

Predicting the 30-day Adverse Outcomes of Non-Critical New-Onset COVID-19 Patients in Emergency Departments based on their Lung CT Scan Findings; A Pilot Study for Derivation an Emergency Scoring Tool

Introduction: Coronavirus Disease (COVID‐19) has become the most important global health issue, and chest computed tomography (CT) scan can help determine the severity of the infection. Objectives: This study aimed to provide an emergency scoring tool for predicting 30-day adverse outcomes in non-critical new-onset COVID-19 patients. Methods: This derivation study was conducted on new-onset COVID-19 patients presenting to the emergency department of an urban teaching hospital in Tehran, Iran, between 20 February and 20 March 2020. The total lobe severity score (TSS), age, history of comorbidities, and 30-day adverse outcomes (death, ICU admission or intubation) were taken into account to produce three prediction models. Results: Overall, 137 patients were included in the study. Their mean age was 59.9±16.8 years and 62% were male. The ground glass nodule, patch B/punctate ground-glass opacity, fibrous stripes, and air bronchogram sign with perihilar distribution, bilateral and ≥ 2 affected lobes were the most common findings. The mean TSS (model 1) was significantly higher in patients with an adverse outcome (9.4±3.2) compared to the discharged patients (7.2±3.3) (p&lt;0.001, AUC: 0.703, sensitivity: 64.4% and specificity: 74.1%). The optimal cut-off point of model 2 (TSS and age) had the following parameters: AUC: 0.721, sensitivity: 71.2% and specificity: 67.2%. The optimal cut-off point of model 3 (TSS, age, comorbidities) had: AUC: 0.755, sensitivity: 79.7% and specificity: 65.5%. The discrimination achieved with model 3 based on Bonferroni’s test was significantly better than that achieved with TSS (p&lt;0.001). Conclusion: TSS combined with age and history of at least one comorbidity had a better predictive value for adverse outcomes with a cut-off point above 8.

Predictors of Length of Stay and Cost of Hospitalization of Neonatal Abstinence Syndrome in the United States.

BackgroundThe incidence rate and economic burden of neonatal abstinence syndrome (NAS) are increasing in the United States (US). We explored the link between the length of stay (LOS) and hospitalization cost for neonatal abstinence syndrome in 2018.MethodsThis was a cross-sectional analysis of the 2018 national inpatient sample database. Newborn hospitalizations with neonatal abstinence syndrome and their accompanying comorbid conditions were identified using the International Classification of Diseases, 10th Edition diagnostic codes. Logistic regression was used to determine the impact of length of stay and the co-morbidities on inflation-adjusted hospital costs.ResultsThe incidence of neonatal abstinence syndrome was 7.1 per 1000 births (95% CI 6.8-7.3) in 2018. The majority had Medicaid (84.1%), with a neonatal abstinence syndrome incidence of 13.2 (95% CI: 12.8-13.6). In adjusted analysis, every one-day increase in length of stay increased the hospital cost by $1,685 (95% CI: 1,639-1,731). Neonatal abstinence syndrome hospitalizations with Medicaid had a longer length of stay by 1.8 days (95% CI: 0.5-3.1). Co-morbidities further increased the length of stay: seizures: 13.8 days; sepsis: 4.1 days; respiratory complications: 4.4 days; and feeding problems: 5.8 days. Those at urban teaching hospitals had a longer length of stay by 7.3 days (95% CI: 5.8-8.8). Co-morbidities increased hospital cost as follows: seizures: $71,380; sepsis: $12,837; respiratory complications: $8,268; feeding problems: $7,737. The cost of hospitalization at large bed-size hospitals and urban teaching was higher by $5,243 and $12,005, respectively.ConclusionThe incidence rate of neonatal abstinence syndrome remained high and was resource-intensive in 2018. Co-morbid conditions and hospitalization at urban teaching hospitals were major contributors to increased length of stay and hospital costs.

Prevalence, trends, and outcomes of atrial fibrillation in hospitalized patients with metastatic cancer: findings from a national sample.

BackgroundEpidemiological evidence regarding the link between cancer and atrial fibrillation (AF) are limited and outcomes of metastatic cancer comorbid with AF need to be elucidated.ObjectiveThis study aims to evaluate the prevalence, temporal trends, and outcomes of AF in hospitalized metastatic cancer patients.MethodsThe National Inpatient Sample (NIS) database was used to identify adult patients with metastatic tumors from 2003 to 2014. We analyzed the trends in AF prevalence, in‐hospital mortality, total cost, length of stay (LOS), and comorbidities pertaining to metastatic cancer. Multivariable‐adjusted models were used to evaluate the association of AF with clinical factors, in‐hospital mortality, total cost, and LOS.ResultsAmong 2,478,598 patients with metastatic cancer, 8.74% (216,737) were diagnosed with AF. The proportion of comorbid AF increased from 8.28% in 2003 to 10.06% in 2014 (p < 0.0001). Older age, white race, male, Medicare, higher income, larger hospital bed size, and urban teaching hospital were associated with higher AF occurrence. Among primary tumor sites, lung cancer experienced the highest odds of AF compared to other cancers. Patients with metastasis to lymph node and respiratory organ had higher odds of AF. In metastatic cancer, AF was associated with higher in‐hospital mortality (odds ratio: 1.48; 95% confidence interval: 1.43–1.54), 18% longer LOS, and 19% higher cost.ConclusionsAF prevalence in metastatic cancer continues to increase from 2003 to 2014. AF is linked to poorer prognosis and higher healthcare resource utilization. As the population ages, optimal preventive and treatment management strategies are needed for metastatic cancer comorbid with AF.

Systematic Debriefing for Critical Events Facilitates Team Dynamics, Education, and Process Improvement.

Debriefing is used in clinical settings to support interprofessional staff, improve processes, and identify educational needs. Nurses who lead debriefing sessions are empowered to improve processes. Nurse leaders identified the need for debriefing outside the critical care areas due to the rising acuity levels. Two nurse leaders developed a debriefing initiative in one urban teaching hospital following rapid responses, codes, and stressful situations. Nurses developed a Debriefing Facilitation Guide to collect qualitative aspects of clinical emergencies to improve processes, education, and team dynamics. Following each debriefing session, we deductively purposively coded the qualitative data into 3 a priori themes: the American Heart Association's team dynamics, process improvement, and educational opportunities. We identified opportunities for improvement for these themes during our first 54 debriefing sessions. Following each debriefing session, the debriefing nurse leader intervened on all educational and process improvement opportunities identified and facilitated positive team dynamics.

Evaluating a Pharmacist-Led Opioid Stewardship Initiative at an Urban Teaching Hospital

Deaths due to overdose from illicit drugs have risen in Canada, despite various community-led harm reduction programs. There have been limited pharmacist-led inpatient initiatives aimed at reducing opioid harm. The authors' group recently developed and implemented the Medication and Risk Factor Review, Optimize, Refer at Risk Patients, Educate and Plan (MORE) tool, a systematic checklist designed to help pharmacists follow and enhance the safety of in-hospital opioid prescribing. To evaluate the impact of a pharmacist-led opioid stewardship program utilizing the MORE tool in the care of patients at one tertiary teaching hospital. This study involved a review of health care records for patients admitted to general surgery and internal medicine clinical teaching units at a tertiary hospital between September 10 and December 31, 2018, for whom opioids were prescribed during the hospital stay. A descriptive data analysis was performed for patients who underwent assessment with the MORE tool. Of the 210 patients who met the initial eligibility criteria, including in-hospital opioid therapy for at least 3 days, 50 were assessed by a pharmacist using the MORE tool. For 40 (80%) of these patients, the pharmacist recommended an intervention, and 35 (87.5%) of these interventions were accepted by the prescriber. Among all 50 patients, the most common pharmacist interventions were adding or optimizing non-opioid pain medications (23 patients [46%]), decreasing opioid dose or frequency (15 patients [30%]), and adding a bowel regimen (9 patients [18%]). Most patients who underwent assessment by a pharmacist had risk factors for adverse events from opioid prescriptions and/or suboptimal orders and drug combinations. The MORE tool provided a guided approach for pharmacists to make targeted interventions aimed at improving opioid safety. A dedicated opioid stewardship pharmacist might be able to provide additional benefit.

Improving donor human milk collection in a hospital without a human milk bank: a quality improvement initiative at an urban tertiary-care teaching hospital

Feed intolerance and necrotising enterocolitis (NEC) are challenges while treating sick neonates. These can be reduced by giving human milk, but adequate availability of mother’s own milk or pasteurised donor...

Prophylactic colectomy for children with familial adenomatous polyposis: resource utilization and outcomes for open and laparoscopic surgery.

Laparoscopic approach for the surgical management of familial adenomatous polyposis (FAP) has become increasingly common for pediatric patients. The purpose of this study was to compare short-term outcomes and resource utilization between open and laparoscopic surgery for prophylactic colectomy in children with FAP. The Kids' Inpatient Database (2009 and 2012) was analyzed for children (age ≤20 years) with FAP that underwent prophylactic total colectomy or proctocolectomy. Patient demographics, treating hospital characteristics, hospital charges, and short-term outcomes were compared according to the surgical technique utilized (open versus laparoscopic). Overall, we identified 216 patients with FAP that underwent elective total colectomy, of which 95 cases were performed by open surgery and 121 were done laparoscopically. The majority of patients were treated at large, not-for-profit, urban teaching hospitals, and the median age was equal (16 years) in both groups. Complications that were more common for open procedures included accidental perforation or hemorrhage (4% vs. 0%, P=0.023), reopening of surgical site (3% vs. 0%, P=0.049), and pneumonia (3% vs. 0%, P=0.049). Simultaneous proctectomy was performed more commonly in the open cohort (91% vs. 71%, P<0.001) as well as ileostomy creation (74% vs. 49%, P<0.001). The median length of stay was similar in the open and laparoscopic groups (7 vs. 6 days, P=0.712). Median total hospital charges were also similar ($67,334 vs. $68,717, P=0.080). A laparoscopic approach for prophylactic colectomy can be safely performed in children with FAP, and total hospital charges are equivalent compared to open surgery. However, simultaneous proctectomy was performed less often with laparoscopic surgery.

SO-2 Pancreatic cancer in HIV versus non-HIV population: Analysis of demographics, outcomes and healthcare utilization from a national sample

Pancreatic cancer (PC) is a highly fatal cancer with a dismal 5-year overall survival. With the advent of combined antiretroviral therapy, the lifespan of HIV patients has substantially improved and the incidence of non-AIDS-defining cancer is rising. PC remains rare in HIV and there is very little data about outcomes of PC in HIV versus non-HIV patients. We attempted to evaluate characteristics and outcomes, including healthcare utilization (HU), in patients with HIV-PC compared to non-HIV-PC using a national sample. United States Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS) (>7 million discharges/year) was queried to identify HIV and non-HIV-PC admissions between 2016-2018. We studied socio-demographic differences, medical comorbidities, mortality, length of stay (LOS), total hospital charges (THC). Secondary outcomes included sepsis, septic shock, neutropenia, anemia and malnutrition. Statistics were performed using the t-test, univariate and multinomial logistic regression. A total of 775 HIV-PC admissions and 317,415 non-HIV-PC admissions were identified, HIV-PC comprised 0.24% of all PC admissions. HIV-PC patients were significantly younger (mean age 59.9 vs 68.1, p<0.001) compared to non-HIV-PC. Proportion of patients over 65 years old was only 29.7% in HIV-PC group compared to 63.3% in non-HIV-PC group. HIV-PC patients were more likely to be men (71% vs 52%, p<0.0001), Black (52% vs 14%, p<0.0001), and less likely Caucasian (34% vs 71%, p<0.0001) compared to non-HIV-PC. HIV-PC were more likely to be treated at an urban teaching hospital (84.5% vs 76%, p=0.047) compared to non-HIV-PC but there was no difference in treating hospital bed size or zip-codes divided by income levels where patients hailed from. HIV-PC patients were less likely to be on private insurance and more likely to be on governmental sponsored insurance (p<0.001). The groups had similar rates of medical comorbidities including diabetes, CAD, COPD, heart failure, obesity and smoking. The HIV-PC group had significantly higher rates of chronic kidney disease (19% vs 12%, p=0.012) and dialysis (4.5% vs 0.86%, p<0.001) while non-HIV-PC showed higher rates of dyslipidemia (36% vs 25%, p=0.01) and hypertension (48% vs 39%, p=0.045). HIV-PC patients were also more likely to be malnourished (42% vs 34%, p=0.04) compared to non-HIV group. Rates of anemia, neutropenia, thrombocytopenia and sepsis were similar between groups. The mean LOS was higher in HIV-PC group (7.5 vs 6.1 days, p=0.001), THC were higher in HIV-PC group ($80,141 vs $66,361, p=0.02) but both differences were not significant when adjusted for patient and hospital demographics. A total 9% HIV-PC and 7.6% non-HIV-PC group died during hospitalization. While crude mortality was non-significant between groups, adjusted OR for mortality (aOR) was 0.43 (95%CI 0.24-0.76, p=0.004) when adjusted for patient demographics, hospital demographics and medical comorbidities. Pancreatic cancer occurred at a significantly younger age in HIV-PC patients compared to non-HIV-PC patients. Racial disparity followed the same trend as general HIV-infection. Adjusted mortality was lower in HIV-PC while most medical comorbidities, secondary outcomes and adjusted healthcare utilization was not significantly different between HIV and non-HIV groups with PC. HIV-positive status does not add significantly to the medical burden in patients with pancreatic cancer.

A Unified Approach to Quality From the Bedside to C-Suite and Back Again: Thoughts From the C-Suite on How to Achieve Value in Health Care.

The cost of a prolonged critical care admission is often the driver of the high cost of care. At a time when the health care system in the United States is absorbing an increasing percentage of the gross domestic product, an understanding of the value equation is essential. The pressure to provide high-quality care at a cost that the nation can shoulder unifies the bedside nurse and the C-suite to a common goal. The president, chief operating officer, and chief financial officer of a large urban teaching hospital were interviewed to provide some insight into how C-suite members view the value equation and the role of critical care nurses in achieving success.

Longer Length of Stay and No Chemotherapy Is Associated with Greater Likelihood of Death during Hospitalization in Patients with Diffuse Large B-Cell Lymphoma: An Analysis from the National Inpatient Sample (NIS)

Background:Patients with diffuse large B-cell lymphoma (DLBCL) are routinely treated in the outpatient setting. However, those who experience toxicity from a new diagnosis, relapsed disease, or outpatient chemotherapy may require inpatient admissions. Occasionally, patients with relapsed disease or a new diagnosis require inpatient chemotherapy. There is limited data on which patients are more likely to receive chemotherapy in the hospital, and which patients are more likely to suffer fatal complications during hospitalization. We examined patient and hospital characteristics associated with receiving inpatient chemotherapy and death during hospitalization for adults with DLBCL using a large US national database.Methods:We obtained admission data for patients with DLBCL from the 2012 and 2013 Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). HCUP-NIS is a sampling of 20% of discharges from US hospitals, and provides weights that correspond to the total number of discharges represented by a single discharge in the dataset to provide national estimates. Utilizing existing variables in the HCUP-NIS database, including risk on the likelihood of dying, we performed univariate analysis of patient demographics associated with receipt of chemotherapy and death during hospitalization. We used multivariable logistic regression to identify predictors of death during hospitalization. The following factors were included: age, sex, income, insurance, number of chronic conditions, race, hospital type, region, length of stay (LOS), charges per day, and receipt of chemotherapy during the admission. All results apply the HCUP-NIS weights.Results:There were 10,860 admissions associated with DLBCL in 2012-2013. Median patient age was 70 years (IQR 59-78). Over half (55%) of admissions were of male patients. 3,170 (29%) of hospitalizations included administration of chemotherapy. Those who received chemotherapy in the hospital were younger (64 vs. 72 years, p<0.001), more often in urban teaching hospitals (p<0.001), had fewer chronic conditions (median 3.5 vs. 5.4, p<0.001), were more often male (31 vs. 27%, p=0.02), had private or Medicaid insurance (vs. Medicare, both p<0.001), and were less likely to have an “extreme likelihood of dying” per the HCUP-NIS database (4.9% vs. 11.4% p<0.001) than those who did not receive chemotherapy.575 (5.3%) of hospitalizations resulted in death. Patients who died during hospitalization were older (median 74.6 vs. 69.4 years, p<0.001), had an extreme likelihood of dying (66% vs. 6.3% p<0.001), had more chronic conditions (5.9 vs. 4.7, p<0.001), experienced longer LOS (7 vs. 4 days, p<0.001) and more charges per day ($8,241 vs. $6,127, p<0.001) compared to those who did not die. Patients who had not received chemotherapy during admission were more likely to die compared to those who received chemotherapy (6.6 vs. 2.2%, p<0.001). There was no difference in hospital type (rural/urban-nonteaching, vs. urban teaching), sex, geographic region, race, and income quartile among those who did vs. did not die during hospitalization.In multivariable regression, older age (OR 1.36 for 10-year increase, p=0.01) and longer LOS (OR 1.05, p<0.001were associated with higher odds of dying during hospitalization), while receiving chemotherapy (OR 0.36, p<0.001) was associated with lower odds of dying (Table).Conclusions:The majority of hospitalizations for patients with DLBCL did not include administration of chemotherapy. Those who received inpatient chemotherapy were generally younger and male, had less comorbidity, were admitted to urban teaching hospitals, and did not have Medicare insurance. A minority of hospitalizations resulted in death. Longer LOS and no receipt of chemotherapy were predictive of death during admission. Our data suggest that the majority of inpatient stays for DLBCL were unplanned admissions due to toxicity, and socio-demographics were not significant factors compared to clinical acuity in identifying who was at risk for death. [Display omitted] DisclosuresKumar:Celgene: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Research Funding.

National Trends and Disparities in the Diffusion of Laparoscopic Surgery for Children in the United States.

Background: Laparoscopic surgery has become the standard of care for many surgical treatments. The diffusion of laparoscopy has been investigated for adult patient populations but is still unknown for pediatric populations. This study sought to describe national trends in diffusion of laparoscopic surgery for common pediatric conditions and identify disparities in use of laparoscopic surgery. Study Design: A retrospective analysis of serial cross-sectional data was performed using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 1997 to 2016. Pediatric patients (ages ≤18) undergoing appendectomy, cholecystectomy, fundoplication, or inguinal hernia repair were identified. The diffusion of laparoscopy for each procedure was measured using the proportion of laparoscopic surgeries over years. Results: National trends demonstrate increases in the use of laparoscopy for children over the past two decades from 13.4% to 88.7% for appendectomy, from 82.6% to 94.9% for cholecystectomy, from 7.4% to 77.4% for fundoplication, and from 1.5% to 23.5% for repair of inguinal hernia (P < .001). Disparities in diffusion of laparoscopy were found from various pediatric populations, and the disparities varied by specific procedures and years. In particular, the proportion of laparoscopic appendectomy in 1997 was 11.3% at urban teaching hospitals and was 13.9% at rural hospitals (P = .01), while the proportions in 2016 increased to 90.8% at urban teaching hospitals versus 71.3% at rural hospitals (P < .001). Conclusions: Laparoscopy has become the standard surgical care for common pediatric surgical conditions. Widening disparities in use of laparoscopic surgery for pediatric populations appear between urban teaching hospitals and rural hospitals.

Relation Between Body Composition, Systemic Inflammatory Response, and Clinical Outcomes in Patients Admitted to an Urban Teaching Hospital with COVID-19.

ABSTRACTBackgroundCOVID-19 has been associated with cases of severe respiratory illness, admissions to intensive therapy units (ITUs), and high mortality rates.ObjectivesThe aim of the present study was to examine the relation between computed tomography- body composition (CT-BC) measurements, systemic inflammation, and clinical outcomes in those with COVID-19.MethodsPatients who presented to our institution between March 17 and May 1, 2020, with a positive PCR test for COVID-19 or characteristic radiological changes, were assessed for inclusion. Data collected included general demographic details, clinicopathological variables, poGPS, NLR , CT-BC measurements, and clinical outcomes including ITU admission and 30-d mortality, of those admitted.ResultsSixty-three patients met the study inclusion criteria. Forty-two patients (67%) were aged ≥70 y, 30 (47.6%) were male and 34.9% ( n = 22) had a poGPS ≥1. ITU admission was significantly associated with a high VFA ( P < 0.05). Thirty-day mortality was associated with high VFA (P < 0.05) and low SMI (P < 0.05).ConclusionsSarcopenia in the presence of obesity was associated with clinical outcomes including greater 30-d mortality.

Timing of Oversedation Events Following Opiate Administration in Hospitalized Patients

Background: Unintended overdoses of opiate medications are potentially lethal events. Monitoring patients for oversedation is fundamental to ensuring safe use of opiates, and the timing of this evaluation is guided by the onset of action, time to max effect and duration of action of the opiate. The study’s aim was to describe the timing of oversedation in relation to the predicted duration of action of the administered opiate. Methods: This study was conducted as a retrospective review of all opiate-related oversedation events during a 2-year period involving patients admitted to an urban teaching hospital. Results: Of the 53 opiate-related oversedation events evaluated, 47% occurred after the predicted maximal duration of action of the administered opiate. Conclusion: Opiate-induced oversedation routinely occurs after predicted based upon duration of action. The study findings have profound implications upon nursing practice regarding duration of time required to monitor for opiate-induced oversedation. J Clin Med Res. 2021;13(5):304-308 doi: https://doi.org/10.14740/jocmr4498

Analysis of outcomes and disposition in hospitalized patients with head and neck cancer over 15 years.

e18021 Background: The care of hospitalized head and neck cancer patients often involves a multidisciplinary approach. The trends, outcomes and disposition in hospitalized patients with head and neck cancer in United States for the past two decades has not been well characterized. This retrospective study involves analysis of the demographics, outcomes and disposition of these patients and their trend over 15 years. The presence of medical comorbidities and the relationship to inpatient mortality was also studied. Methods: Hospitalization data from the National Inpatient Sample database was analyzed for the years: 2000 to 2014. Patients with head and neck cancer were identified using ICD-9 codes. Demographic features such as age, gender, race, geographical location, hospital size, hospital location, insurance etc. were analyzed. The trend of mortality was analyzed for the study period of 15 years. A sub-analysis of associated comorbidities was also performed in patients who have died during hospitalization. Univariate analysis was initially performed followed by multivariate analysis and logistic regression to identify risk factors associated with mortality. Results: An estimated 145,262 hospitalizations involving patients with head and neck cancer from 2000 to 2014 were studied and it showed a gradual yearly increment in hospitalization. 41% of the hospitalizations were in the 50-64 years age group. There was a 2:1 male preponderance. Caucasians constituted 60% followed by African Americans at 10%. A majority of the hospitalizations occurred in large sized hospitals and urban teaching hospitals. The mean length of stay was 6.4 days but 38% of the hospitalizations involving 2-5 days of stay. The inpatient mortality rate was 4.6% and it down trended over the past 15 years with statistical significance (p &lt; 0.05). Inpatient mortality was highest in the &gt; 80 years age group. Of note, inpatient mortality was equal between both the genders. Mortality was highest in the groups with a length of stay below 2 days and above 11 days. 58% of the discharges did not need any special services while 21% of the discharges involved home health care. The most common comorbidities were smoking and hypertension while &lt; 1% of morbid obesity was observed. Multivariate analysis showed malnutrition, ESRD, cirrhosis, stroke and CHF were significant risk factors (ORs: 1.6, 1.94, 2.18, 2.2 and 1.78 respectively). Conclusions: Mortality in hospitalized patients with head and neck cancer has improved over the past 15 years. Inpatient mortality was high in the very elderly and in female patients (compared to the male preponderance upon admission). Malnutrition, cardiac/liver/renal dysfunction and stroke were significant risk factors for inpatient mortality. Strategies to mitigate inpatient mortality in these patients need to factor the above risk factors during their in-hospital management.