Clinical pathway for the Fontan patient to standardise care and improve outcomes

2020 ◽  
Vol 30 (9) ◽  
pp. 1247-1252
Author(s):  
Sarah M. Lagergren ◽  
Megan Jensen ◽  
Bryan Beaven ◽  
Suma Goudar
Keyword(s):  
Length Of Stay ◽  
Clinical Pathway ◽  
Patient Population ◽  
Fontan Procedure ◽  
Diuretic Therapy ◽  
The United States ◽  
Hospital Length Of Stay ◽  
Fluid Restriction ◽  
Fontan Patient ◽  
Improvement Project

AbstractIntroduction:The Fontan procedure is the final stage of surgical palliation for the children with functionally single ventricle anatomy. The post-operative medical management of this patient population can be variable and hospital length of stay prolonged. The purpose of this quality improvement project was to determine if the implementation of an evidence-based clinical pathway for post-operative management of the Fontan patient at a large Midwestern academic paediatric medical centre would standardise care and decrease length of stay.Materials and methods:The clinical pathway was developed using key components from three published pathways for the Fontan procedure from other paediatric institutions across the United States. Components of the clinical pathway included (1) supplemental oxygen until pleural drainage tubes are removed, (2) fluid restriction to 80% daily maintenance and a prescribed low-fat diet, (3) aggressive and standardised diuretic therapy while inpatient and (4) central venous access. The pathway was trialed using Plan-Do-Study-Act cycles in 2016, implemented in 2017 and sustained in 2018–2019. A retrospective electronic medical record review was performed to compare key outcomes from pre-pathway (2014–2015, 37 patients) with post-pathway implementation (2017–2018, 30 patients).Results:Adherence to the pathway was nearly 100% with a statistically significant decrease in length of stay from 12 to 9 days (p = 0.007) and no increase in readmissions.Conclusion:Standardising care can improve clinical and financial outcomes for the Fontan patient population without negatively impacting quality of care, thus providing a positive benefit to the healthcare institution, industry and patient.

30-Day Outcomes for Total Ankle Arthroplasty in Patients With Anemia

2021 ◽  
pp. 107110072110175
Author(s):  
Jordan R. Pollock ◽  
Matt K. Doan ◽  
M. Lane Moore ◽  
Jeffrey D. Hassebrock ◽  
Justin L. Makovicka ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Univariate Analysis ◽  
Hospital Length ◽  
Total Ankle Arthroplasty ◽  
Hospital Length Of Stay ◽  
Preoperative Anemia ◽  
Improvement Project ◽  
Average Hospital ◽  
Ankle Arthroplasty ◽  
Reoperation Rates

Background: While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty. Methods: A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia. Results: Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71). Conclusion: This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia. Level of Evidence: Level III, retrospective comparative study.

Prevalence and Inpatient Hospital Outcomes of Malignancy-Related Ascites in the United States

2020 ◽  
Vol 38 (1) ◽  
pp. 47-53
Author(s):  
Venkataraghavan Ramamoorthy ◽  
Muni Rubens ◽  
Anshul Saxena ◽  
Chintan Bhatt ◽  
Sankalp Das ◽  
...  
Keyword(s):  
United States ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
The United States ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
National Database ◽  
Hospital Outcomes ◽  
Inpatient Hospital ◽  
Male Sex

Objective: Malignancy-related ascites (MRA) is the terminal stage of many advanced cancers, and the treatment is mainly palliative. This study looked for epidemiology and inpatient hospital outcomes of patients with MRA in the United States using a national database. Methods: The current study was a cross-sectional analysis of 2015 National Inpatient Sample data and consisted of patients ≥18 years with MRA. Descriptive statistics were used for understanding demographics, clinical characteristics, and MRA hospitalization costs. Multivariate regression models were used to identify predictors of length of hospital stay and in-hospital mortality. Results: There were 123 410 MRA hospitalizations in 2015. The median length of stay was 4.7 days (interquartile range [IQR]: 2.5-8.6 days), median cost of hospitalization was US$43 543 (IQR: US$23 485-US$82 248), and in-hospital mortality rate was 8.8% (n = 10 855). Multivariate analyses showed that male sex, black race, and admission to medium and large hospitals were associated with increased hospital length of stay. Factors associated with higher in-hospital mortality rates included male sex; Asian or Pacific Islander race; beneficiaries of private insurance, Medicaid, and self-pay; patients residing in large central and small metro counties; nonelective admission type; and rural and urban nonteaching hospitals. Conclusions: Our study showed that many demographic, socioeconomic, health care, and geographic factors were associated with hospital length of stay and in-hospital mortality and may suggest disparities in quality of care. These factors could be targeted for preventing unplanned hospitalization, decreasing hospital length of stay, and lowering in-hospital mortality for this population.

Intermittent Phosphate Usage for Pediatric Diabetic Ketoacidosis in the Setting of a Phosphate Shortage

2019 ◽  
pp. 001857871986764
Author(s):  
Christopher T. Campbell ◽  
Sarah Gattoline ◽  
Brian Kelly
Keyword(s):  
Length Of Stay ◽  
Diabetic Ketoacidosis ◽  
Group Versus ◽  
Potassium Phosphate ◽  
Hospital Length Of Stay ◽  
Continuous Group ◽  
Continuous Administration ◽  
Improvement Project ◽  
Total Phosphate ◽  
Number Of Patients

Purpose: Hypophosphatemia during pediatric diabetic ketoacidosis (DKA) is often replaced through a continuous infusion of intravenous (IV) fluids with potassium phosphate. In 2012, during an IV potassium phosphate shortage, providers were directed to oral replacement strategies to restrict IV products to those patients with severe hypophosphatemia. Intermittent oral and IV as needed doses for low phosphate levels replaced continuous administration in pediatric DKA. The purpose of this quality-improvement project was to determine whether the implemented IV phosphate restrictions resulted in less IV phosphate usage with no change in clinically relevant outcomes. Methods: In a retrospective chart analysis, pediatric patients less than 18 years of age admitted with a DKA diagnosis from June 2011 to December 2016 were divided into 2 groups: continuous and intermittent phosphate administration. Patients were excluded if they received both therapies. The primary outcome was the difference in IV phosphate administered. Secondary outcomes included the following: total phosphate received, the number of patients requiring as needed doses, phosphate levels at admission and discharge from pediatric intensive care unit (PICU), hospital length of stay, and PICU length of stay. Results: Phosphate restrictions resulted in a significantly lower usage of IV phosphate products in the intermittent group versus the continuous group (38.5 vs. 0 mmol, P < .0001). While total phosphate replacement was similar, intermittent phosphate administration was also associated with significantly lower minimum and discharge phosphate levels. Conclusions: During a phosphate salt shortage, restriction of continuous phosphate replacement in pediatric DKA management can reduce the amount of IV phosphate products used without any clinically meaningful change in outcomes.

The Impact of BMI on Adult Blunt Trauma Outcomes

2019 ◽  
Vol 85 (12) ◽  
pp. 1354-1362
Author(s):  
Rahman Barry ◽  
Milad Modarresi ◽  
Rodrigo Aguilar ◽  
Jacqueline Sanabria ◽  
Thao Wolbert ◽  
...  
Keyword(s):  
United States ◽  
Mortality Rate ◽  
Length Of Stay ◽  
Blunt Trauma ◽  
Nationwide Inpatient Sample ◽  
The United States ◽  
Mortality Rates ◽  
Hospital Length Of Stay ◽  
Obese Patients ◽  
The Impact

Traumatic injuries account for 10% of all mortalities in the United States. Globally, it is estimated that by the year 2030, 2.2 billion people will be overweight (BMI ≥ 25) and 1.1 billion people will be obese (BMI ≥ 30). Obesity is a known risk factor for suboptimal outcomes in trauma; however, the extent of this impact after blunt trauma remains to be determined. The incidence, prevalence, and mortality rates from blunt trauma by age, gender, cause, BMI, year, and geography were abstracted using datasets from 1) the Global Burden of Disease group 2) the United States Nationwide Inpatient Sample databank 3) two regional Level II trauma centers. Statistical analyses, correlations, and comparisons were made on a global, national, and state level using these databases to determine the impact of BMI on blunt trauma. The incidence of blunt trauma secondary to falls increased at global, national, and state levels during our study period from 1990 to 2015, with a corresponding increase in BMI at all levels ( P < 0.05). Mortality due to fall injuries was higher in obese patients at all levels ( P < 0.05). Analysis from Nationwide Inpatient Sample database demonstrated higher mortality rates for obese patients nationally, both after motor vehicle collisions and mechanical falls ( P < 0.05). In obese and nonobese patients, regional data demonstrated a higher blunt trauma mortality rate of 2.4% versus 1.2%, respectively ( P < 0.05) and a longer hospital length of stay of 4.13 versus 3.26 days, respectively ( P = 0.018). The obesity rate and incidence of blunt trauma secondary to falls are increasing, with a higher mortality rate and longer length of stay in obese blunt trauma patients.

Race Impacts Outcomes of Patients With Firearm Injuries

2020 ◽  
Vol 86 (9) ◽  
pp. 1113-1118
Author(s):  
Heather Peluso ◽  
John D. Cull ◽  
Marwan S. Abougergi
Keyword(s):  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Prolonged Mechanical Ventilation ◽  
The United States ◽  
Traumatic Shock ◽  
Hospital Length Of Stay ◽  
Firearm Injuries ◽  
Black Patients ◽  
Hospitalization Costs

Background To study the relationship between race and outcomes of patients with firearm injuries hospitalized in the United States. Methods The 2016 National Inpatient Sample was used. Patients were included if they had a principal diagnosis of firearm injury. Exclusion criteria were age <16 years and elective admissions. The primary outcome was in-hospital mortality. Secondary outcomes were morbidity (traumatic shock, prolonged mechanical ventilation, acute respiratory distress syndrome [ADRS], and ventilator-associated pneumonia [VAP]), and resource utilization (length of stay and total hospitalization charges and costs). Results The sample included 31 335 patients; 52% were Black and 29% were Caucasian. The mean age was 32 years and 88% were male. Black patients had lower odds of mortality (adjusted odds ratio (aOR): 0.41 (95% CI: 0.32-0.53), P < .01). However, compared with Caucasians, Blacks had higher mean total hospitalization charges (adjusted mean difference (aMD) : $14 052 (CI: $1469-$26 635), P = .03) and costs (aMD: $3248 (CI: $654-$5842), P = .01) despite similar mean length of stay (aMD: 0.70 (CI: −0.05-1.45), P = .07). Both racial groups had similar rates of traumatic shock (aOR: 0.91 (0.72-1.15), P = .44), prolonged mechanical ventilation (aOR: 0.82 (0.63-1.09), P = .17), ARDS (aOR: 1.18 (0.45-3.07), P = .74) and VAP (aOR: 1.27 (0.47-3.41), P = .63). Discussion Black patients with firearm injuries had a lower adjusted odds of in-hospital mortality compared with other races. However, despite having a similar hospital length of stay and in-hospital morbidity, -Black patients had higher total hospitalization costs and charges.

scholarly journals PT Achievement in Public Hospitals and Its Effect on Outcomes

Geriatrics ◽  
2019 ◽  
Vol 4 (4) ◽  
pp. 58
Author(s):  
Jessica S. Morton ◽  
Alex Tang ◽  
Michael J. Moses ◽  
Dustin Hamilton ◽  
Neville Crick ◽  
...  
Keyword(s):  
Physical Therapy ◽  
Length Of Stay ◽  
Medical Center ◽  
Therapy Group ◽  
Academic Medical Center ◽  
Early Mobilization ◽  
The United States ◽  
Public Hospitals ◽  
Hospital Length Of Stay ◽  
Discharge Disposition

The demand for TKA continues to rise within the United States, while increasing quality measures and cost containment became the basis of reimbursement for hospital systems. Length of stay is a major driver in the cost of TKA. Early mobilization with physical therapy has been shown to increase range of motion and decrease complications, but with mixed results in regards to length of stay. We postulate that initiating physical therapy on post-operative day zero will decrease length of stay in an urban public hospital. Retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period. Groups who underwent post-operative day zero therapy were compared with those who initiated physical therapy on post-operative day one. Length of stay was the primary outcome. Patient demographic characteristics and discharge disposition were also collected. There were 98 patients in the post-operative day-one physical therapy cohort and 58 in the post-operative day zero physical therapy group. Hospital length of stay was significantly decreased in the post-operative day zero physical therapy group. (p < 0.01) There was no difference in discharge disposition between the two groups.

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