scholarly journals The barts heart attack centre early discharge pathway:- a novel protocol for next day discharge after primary pci for ST-elevation myocardiai infarction

2021 ◽  
Vol 20 (Supplement_1) ◽  
Author(s):  
K Comer ◽  
O Casey-Gillman ◽  
E Moore ◽  
S Adey ◽  
S Mower
Keyword(s):  
Length Of Stay ◽  
Early Discharge ◽  
Low Risk ◽  
Successful Implementation ◽  
Primary Pci ◽  
Cardiac Events ◽  
Median Length ◽  
Post Discharge ◽  
Group 5

Abstract Funding Acknowledgements Type of funding sources: None. Introduction To respond to the challenges of COVID-19 and based on evidence confirming low rates of Major Adverse Cardiac Events (MACE) occurring between 24- and 48-hours post AMI (Acute Myocardial Infarction), we sought to design and implement a novel Early Hospital Discharge (EHD) pathway Aim The goal of the EHD protocol is to accurately and efficiently identify low-risk AMI patients who can be safely discharged between 24 and 48 hours after successful primary PCI, aiming to provide a  safe discharge for low risk patients, reduce length of stay  enhance the follow up of patients post AMI Methodology : Project was designed a QI project and patients were discharged with a structured follow up at 48 hours , 2 weeks and 8 weeks and with a interventional cardiologist at 3 months  Virtual follow up was conducted using a bespoke application enable a 2 way messaging and video consultation Patients with AMI are taken for primary PCI in an unselected manner which includes post cardiac arrest, intubated and ventilated patients Results :The median follow-up was 201 days (OQR: 98-268 days). In the early discharge group, there were 2 deaths (0.5%), both due to COVID-19 (both >30 days after d/c) with 0% cardiovascular mortality (comparator group 5% mortality, 2.5% cardiovascular  Overall, this resulted in a significant reduction in the overall length of stay for all patients presenting with STEMI undergoing primary PCI over the time period. The median length of stay was 3 days (IQR 2-5 days) from October 2019 to March 2020 before the pathway was introduced. Following the pathway introduction, from April 2020 to February 2021 the median length of stay was 2 days (1-4 days) (p < 0.0001), significantly reduced from pre pathway introduction Conclusion :Driven by the necessity to adapt to the pandemic, we report the safe and successful implementation of an early post MI discharge pathway with an integrated and structural multidisciplinary virtual follow up schedule.  This has shortened hospital admission times, decreasing the risk of nosocomial infections and optimised resource utilization, while at the same time enhancing the quality of post discharge care with high levels of patient satisfaction.

scholarly journals Analysis of risk scores and duration of hospital stay in prognosis of STEMI patients after pPCI

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
SR Thangasami ◽  
JS Prajapati ◽  
GL Dubey ◽  
VR Pandey ◽  
PM Shaniswara ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Hospital Stay ◽  
Early Discharge ◽  
Risk Scores ◽  
Timi Score ◽  
Study Population ◽  
Event Rates ◽  
Grace Score

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Advances in the immediate management of ST elevation myocardial infarction (STEMI) have led to a dramatic decline in mortality and reduction in hospital length of stay (LOS). We analysed the prognostic value of selected risk models in STEMI treated with primary percutaneous coronary intervention (PPCI) and to identify additional parameters to strengthen risk scores in categorizing patients for safe early discharge and to identify parameters prolonging hospital stay. Purpose To assess parameters and risk scores to categorize patients for safe early discharge following STEMI and to assess the composite of death, MI, unstable angina (UA), stroke, unplanned hospitalization at the end of 30 days, 6 months and at 1year follow up. Methods The study included 222 patients, who were diagnosed as STEMI, treated with successful pPCI. The risk scores like TIMI score, GRACE score, ZWOLLE score, CADILLAC score were calculated for all patients from the baseline clinical data collected on admission. Routine blood investigations along with Brain natri-uretic peptide (BNP) were done for all patients. The entire cohort was divided into three groups on the basis of length of stay: ≤3 days (n = 150), 4–5 days (n = 47), and >5 days (n = 25). All-cause mortality and major cardiovascular events (MACEs) were assessed up to 1 year. Results The mean age group (yrs) of the study population was 53.92 ± 12.9. Patients in LOS <3 days had a mean age (yrs) of 52.41 ± 11.74, patients in LOS 4-5 days group had 54.19 ±13.59 and patient with LOS >5 days had 62.52 ± 15.32. The most important parameters that predicted hospital stay in our study are BNP levels OR: 1.003, 95% CI: 1.002-1.004, P < 0.001, GRACE score OR: 1.02 ,95% CI: 1.01-1.03, P < 0.001, TIMI score OR: 1.35, 95% CI: 1.18-1.55, P = 0.007, ZWOLLE score OR: 1.26, 95% CI: 1.16-1.37, P < 0.001, CADILLAC score OR: 1.24, 95% CI; 1.15-1.3: P < 0.001. 32 (14.4%) patients expired in the study population. 36% patients of LOS >5 days expired in 1year follow up with maximum mortality in the first 6 months. 56% of the patients in LOS > 5 days had an adverse cardiac event in 1 year follow up. Patients in LOS >5 days had increased event rates in 30 days,6 months and in 1 year follow up. Patients with LOS 4-5 days (30%) had increased event rates than patients in LOS < 3 days (19%).Unadjusted Kaplan Meir survival curves for 1 year mortality among hospital survivors showed a significant increase in mortality at 6 months in length of stay> 5 days group. (P value < 0.001). CONCLUSION Long hospital stay after PCI among patients with STEMI was associated with increased long-term all-cause mortality. Addition of BNP to this risk scores can better predict the course of hospital stay and adverse clinical outcomes in follow up. Long hospital stay may be used as a marker to identify patients at higher risk for long-term mortality. Abstract Figure. Kaplan meir survival curve

scholarly journals Early Discharge in Low-Risk Patients Hospitalized for Acute Coronary Syndromes: Feasibility, Safety and Reasons for Prolonged Length of Stay

PLoS ONE ◽  
2016 ◽  
Vol 11 (8) ◽  
pp. e0161493 ◽  
Author(s):  
Marie-Eva Laurencet ◽  
François Girardin ◽  
Fabio Rigamonti ◽  
Anne Bevand ◽  
Philippe Meyer ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Acute Coronary Syndromes ◽  
Early Discharge ◽  
Low Risk ◽  
Prolonged Length ◽  
Risk Patients ◽  
Coronary Syndromes

Abstract 17143: Shorter Length of Stay is Associated With Significantly Lower 30-day All-cause Readmission and 30-day All-cause Mortality in Older Medicare Beneficiaries Hospitalized for Heart Failure

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Cherinne Arundel ◽  
Ali Ahmed ◽  
Rahul Khosla ◽  
Charles Faselis ◽  
Charity Morgan ◽  
...  
Keyword(s):  
Heart Failure ◽  
Length Of Stay ◽  
Prospective Payment System ◽  
Early Discharge ◽  
Continuous Variable ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Medicare Beneficiaries ◽  
Post Discharge ◽  
All Cause Mortality

Background: A shorter hospital length of stay, encouraged by Prospective Payment System Act, may result in suboptimal care and early discharge. Heart failure (HF) is the leading cause for 30-day all-cause readmission. However, it is unknown whether hospitalized HF patients with a shorter length of stay may have higher 30-day all-cause readmission, the reduction of which is a goal of the Affordable Care Act. Methods: The 8049 Medicare beneficiaries hospitalized for HF and discharged alive from 106 U.S. hospitals (1998-2001) had a median length of stay of 5 days (interquartile, 4-8 days), of which 4272 (53%) had length of stay ≤ 5 days. Using propensity scores for length of stay 1-5 days, we assembled a matched cohort of 2788 pairs of patients with length of stay 1-5 and ≥6 days, balanced on 32 baseline characteristics. Results: 30-day all-cause readmission occurred in 19% and 23% of matched patients with length of stay 1-5 and ≥6 days, respectively (HR, 0.79; 95% CI, 0.70-0.89; Figure, left panel). When the length of stay of the 8049 pre-match patients was used as a continuous variable and adjusted for the same 32 variables, each day longer hospital stay was associated with a 2% higher risk of 30-day all-cause readmission (HR, 1.02; 95% CI, 1.01-1.03; p<0.001). Among matched patients, HR for 30-day HF readmission associated with length of stay 1-5 days was 0.84 (95% CI, 0.69-1.01; p=0.063). 30-day all-cause mortality occurred in 4.6% and 6.2% of matched patients with length of stay 1-5 and ≥6 days, respectively (HR, 0.73; 95% CI, 0.58-0.91; Figure, right panel). These associations persisted throughout 12 months post-discharge. Conclusions: Among hospitalized patients with HF, length of stay 1-5 days (vs. longer) was associated with significantly lower 30-day all-cause readmissions and all-cause mortality that persisted throughout first year post-discharge.

Abstract 2640: Clinical Characteristics and Risk Stratification in Symptomatic and Asymptomatic Patients with Brugada Syndrome - Multi-center Study in Japan-

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Masahiko Takagi ◽  
Yasuhiro Yokoyama ◽  
Kazutaka Aonuma ◽  
Naohiko Aihara ◽  
Masayasu Hiraoka
Keyword(s):  
Sudden Death ◽  
Risk Stratification ◽  
Brugada Syndrome ◽  
Clinical Characteristics ◽  
Low Risk ◽  
Cardiac Events ◽  
Asymptomatic Patients ◽  
Risk Patients ◽  
Qrs Duration

Background Neither the clinical characteristics nor risk stratification of symptomatic and asymptomatic patients with Brugada syndrome have been clearly determined. We compared clinical and ECG characteristics of symptomatic and asymptomatic patients with Brugada syndrome to identify new markers for distinguishing high- from low-risk patients. Methods A total of 216 consecutive individuals with Brugada syndrome (mean age 52±14 years, 197 males) were enrolled in the Japan Idiopathic Ventricular Fibrillation Study (J-IVFS). Clinical and ECG characteristics were compared among 3 groups of patients: VF group; patients with aborted sudden death and documented VF (N=34), Syncope (Sy) group; patients with syncope without documented VF (N=70), and Asymptomatic (As) group; subjects without symptoms (N=112). Comparisons were made among the 3 groups as well as between the symptomatic (VF/Sy) and asymptomatic (As) groups. Short-term prognosis was also compared among the 3 groups, and between the VF/Sy and As groups. Results 1) Clinical characteristics: incidence of past history of AF was significantly higher in the VF and Sy groups than in the AS group (26, 26, and 12 %, respectively; [p=0.04]), though no other clinical parameters differed among the groups. 2) On resting 12-lead ECG, r-J interval (interval from QRS onset to J point) in lead V2 and QRS duration in lead V6 were highest in the VF group (104, 98, and 92 msec in V2 [p<0.001]; 106, 103, and 94 msec in V6 [p<0.0001], respectively, VF vs. Sy vs. As). 3) Positive late potential and inducibility of VF by EPS did not differ in incidence among the 3 groups. 4) Clinical follow-up: during a mean follow-up of 36±16 months, incidence of cardiac events (sudden death and/or VF) was higher in the VF/Sy groups than in the As group (29, 8, and 0 %, respectively [p<0.001]). Multivariate analysis showed that the frequencies of r-J interval ≥ 90 msec in lead V2 and QRS duration ≥ 90 msec in lead V6 were significantly higher in patients with cardiac events (p=0.02, 0.02, respectively). Conclusions In symptomatic patients, prolonged ventricular depolarization in precordial leads of the ECG was prominent in the VF group, and this sign can be used to distinguish high- from low-risk patients with Brugada syndrome.

Abstract 17293: Functional Outcomes After Acute Pulmonary Embolism

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Yevgeniy Brailovsky ◽  
Siri Kunchakarra ◽  
Katerina Porcaro ◽  
Demetrios Doukas ◽  
Andrew Stiff ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Functional Capacity ◽  
Medical Center ◽  
Treatment Strategies ◽  
Low Risk ◽  
Continuous Variables ◽  
Post Discharge ◽  
6Mwt Distance ◽  
Acute Pe

Introduction: Pulmonary embolism (PE) is associated with significant acute morbidity, mortality, and long term functional limitations. There is paucity of data on acute and short term functional assessment after acute PE. Hypothesis: Functional capacity will improve from baseline to follow up among patients with acute PE. Methods: We prospectively analyzed patients who underwent evaluation by the pulmonary embolism response team (PERT) at Loyola University Medical Center between 2016 and 2018. We included patients with acute PE who underwent six-minute walk test (6MWT) at discharge and during outpatient follow up (50±72 days post discharge). We collected demographic and clinical characteristics. We used paired sampled t-test to compare continuous variables. Results: Among the 204 patients evaluated by PERT, 38 patients (18.6%) underwent 6MWT at baseline and follow up. Patients were classified as low risk (6 patients), submassive (29 patients), and massive (3 patients). Mean age was 61.3±14.2, 50% were female, 60.5% were white, 26.3% were black, 29% had cancer, and 68.4% had concomitant DVT, mean BMI 36.4±10.3, and mean PESI score was 96.8+44.4. Overall the mean 6MWT distance increased significantly from a baseline of 726.9±73.7 feet to 1042±72.8 feet at follow up (p<0.001). Low risk (786±204 to 1115.8+177.6 p=0.63), Submassive (700.2±85 to 995.6±82.8 p<0.001), and Massive PE (859±261.7 to 1343.3±307 p=0.168) groups all demonstrated improvement in 6MWT distance. Conclusions: Functional capacity as measured by 6MWT significantly improved during follow up after acute PE. Future studies are needed to determine predictors of favorable functional outcome and best treatment strategies.

A cost analysis of febrile neutropenia management in Australia: ambulatory v. in-hospital treatment

2011 ◽  
Vol 35 (4) ◽  
pp. 491 ◽  
Author(s):  
Senthil Lingaratnam ◽  
Leon J. Worth ◽  
Monica A. Slavin ◽  
Craig A. Bennett ◽  
Suzanne W. Kirsa ◽  
...  
Keyword(s):  
Febrile Neutropenia ◽  
Cost Analysis ◽  
Ambulatory Care ◽  
Cost Effective ◽  
Early Discharge ◽  
Cost Structure ◽  
Low Risk ◽  
Sensitivity Analyses ◽  
Medical Complications

Background. Adult febrile neutropenic oncology patients, at low risk of developing medical complications, may be effectively and safely managed in an ambulatory setting, provided they are appropriately selected and adequate supportive facilities and clinical services are available to monitor these patients and respond to any clinical deterioration. Methods. A cost analysis was modelled using decision tree analysis, published cost and effectiveness parameters for ambulatory care strategies and data from the State of Victoria’s hospital morbidity dataset. Two-way sensitivity analyses and Monte Carlo simulation were performed to evaluate the uncertainty of costs and outcomes associated with ambulatory care. Results. The modelled cost analysis showed that cost savings for two ambulatory care strategies were ~30% compared to standard hospital care. The weighted average cost saving per episode of ‘low-risk’ febrile neutropenia using Strategy 1 (outpatient follow-up only) was 35% (range: 7–55%) and that for Strategy 2 (early discharge and outpatient follow-up) was 30% (range: 7–39%). Strategy 2 was more cost-effective than Strategy 1 and was deemed the more clinically favoured approach. Conclusion. This study outlines a cost structure for a safe and comprehensive ambulatory care program comprised of an early discharge pathway with outpatient follow-up, and promotes this as a cost effective approach to managing ‘low-risk’ febrile neutropenic patients. What is known about the topic? Febrile neutropenia is a common complication of chemotherapy for patients with cancer. There is high level evidence supporting the use of ambulatory care strategies to manage patients with febrile neutropenia who are deemed to be at low risk of developing medical complications. What does this paper add? This paper highlights a cost structure for an adequately equipped and cost-effective ambulatory care strategy suitable for Australian hospitals to manage patients with low-risk febrile neutropenia. What are the implications for practitioners? The strategy advocated in this paper affords eligible patients the choice of early discharge from hospital. It advocates for improved resource utilisation and expansion of outpatient services in order to minimise opportunity costs faced by cancer treatment facilities.

scholarly journals Cost conscious care: preoperative evaluation by a cardiologist prior to low-risk procedures

2019 ◽  
Vol 8 (2) ◽  
pp. e000481 ◽  
Author(s):  
Joseph Coffman ◽  
Thanh Tran ◽  
Troy Quast ◽  
Michael S Berlowitz ◽  
Sanders H Chae
Keyword(s):  
Length Of Stay ◽  
Statistical Significance ◽  
Preoperative Evaluation ◽  
Low Risk ◽  
Linear Regression Models ◽  
Cardiac Events ◽  
Preoperative Testing ◽  
Statistical Significance Testing ◽  
Adverse Cardiac Events ◽  
And Gender

BackgroundPreoperative testing before low-risk procedures remains overutilised. Few studies have looked at factors leading to increased testing. We hypothesised that consultation to a cardiologist prior to a low-risk procedure leads to increased cardiac testing.Methods and results907 consecutive patients who underwent inpatient endoscopy/colonoscopy at a single academic centre were identified. Of those patients, 79 patients (8.7%) received preoperative consultation from a board certified cardiologist. 158 control patients who did not receive consultation from a cardiologist were matched by age and gender. Clinical and financial data were obtained from chart review and hospital billing. Logistic and linear regression models were constructed to compare the groups. Patients evaluated by a cardiologist were more likely to receive preoperative testing than patients who did not undergo evaluation with a cardiologist (OR 47.5, (95% CI 6.49 to 347.65). Specifically, patients seen by a cardiologist received more echocardiograms (60.8% vs 22.2%, p<0.0001) and 12-lead electrocardiograms (98.7% vs 54.4%, p<0.0001). There was a higher rate of ischaemic evaluations in the group evaluated by a cardiologist, but those differences did not achieve statistical significance. Testing led to longer length of stay (4.35 vs 3.46 days, p=0.0032) in the cohort evaluated by a cardiologist driven primarily by delay to procedure of 0.76 days (3.14 vs 2.38 days, p=0.001). Estimated costs resulting from the longer length of stay and increased testing was $10 624 per patient. There were zero major adverse cardiac events in either group.ConclusionPreoperative consultation to a cardiologist before a low-risk procedure is associated with more preoperative testing. This preoperative testing increases length of stay and cost without affecting outcomes.

scholarly journals 607. Identifying Intervention Opportunities to Prevent Readmissions during OPAT

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S365-S365
Author(s):  
Michael J Swartwood ◽  
Claire E Farel ◽  
Nikolaos Mavrogiorgos ◽  
Renae A Boerneke ◽  
Ashley Marx ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Infectious Diseases ◽  
Median Time ◽  
Care Coordination ◽  
Multidisciplinary Team ◽  
Primary Care Providers ◽  
Care Providers ◽  
Post Discharge ◽  
Icd 10

Abstract Background Patients receiving outpatient parenteral antimicrobial therapy (OPAT) experience high rates of unplanned readmissions. To inform interventions that may reduce risk of unplanned readmissions during OPAT, we examined the frequency and reasons for readmission in a large cohort of OPAT patients. Methods We analyzed data on all patients enrolled in UNC’s OPAT program from February 2015-February 2020. Patients were evaluated by an infectious diseases (ID) physician prior to OPAT enrollment, discharged with &gt;14 remaining days of prescribed therapy, and received care coordination and systematic monitoring by an ID pharmacist. We abstracted EHR data into a REDCap database to ascertain information on each patient’s OPAT course and readmission details: length of stay, primary ICD-9-CM/ICD-10-CM diagnosis code associated with readmission, and reason for readmission from clinical notes. Diagnosis codes and notes were adjudicated and summarized by a multidisciplinary team. Results Among 1,165 OPAT courses, 19% resulted in at least one readmission during therapy, lasting for a median length of stay of 5 days. Among those patients who were readmitted during OPAT, the median time from OPAT start to readmission was 17 days (interquartile range, IQR: 8-29 days). 66% of readmissions preceded the scheduled follow-up appointment during OPAT (median time to scheduled follow-up was 27 days, IQR: 15-35 days). 55% of readmissions were unrelated to OPAT diagnosis. Based on ICD-9-CM/ICD-10-CM code classifications, the most common infectious diseases-related reasons for readmission were worsening OPAT infection (18%), OPAT-related adverse drug reaction (12%), and new infection (11%). Conclusion One-fifth of OPAT courses resulted in readmission during therapy. Half of readmissions were associated with OPAT or other infection, and half were for other reasons. Earlier post-discharge follow-up by a multidisciplinary team (including primary care providers, case management, and OPAT) might prevent infection-related readmissions for OPAT patients. Future work should also address the need for enhanced care coordination with non-infectious disease providers to manage OPAT patients. Disclosures All Authors: No reported disclosures

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