The Perioperative System: A New Approach to Managing Elective Surgery

A Perioperative Service has recently been introduced at Liverpool Hospital, a 460-bed university teaching hospital. This provides a co-ordinated system for managing all elective surgical patients from the time an admission is booked until hospital discharge. This paper describes the patient assessment, structure and staff requirements, benefits of and problems encountered with this service. The patient's preoperative preparation occurs before hospital admission. Where possible, patients are admitted on the day of procedure, either as a day-only patient, or a day-of-surgery patient. Patients are initially admitted to a specifically designed Perioperative Unit, adjacent to the Operating Theatre Suite. Patients do not enter the surgical wards until after their operation. Planning of the hospital discharge process commences at the time of booking for operation. Introduction of the Perioperative Service was staged process commencing in mid-1992. The hospital admits approximately 6,400 elective surgery cases each year. From July 1992 to December 1994, day-only patients were approximately 45% of these cases. Day-of-surgery admission patients increased from 6% to 35% of all cases over the same period. Appproximately 22% of elective surgical cases were seen in the Perioperative Clinic. As the Perioerative Service became fully operational, the average length of stay for elective surgical procedures fell. There has been a reduction in the areas of cancellations due to unavailablity of beds, inappropriate preparation of patients, and non-attendance of patients for booked procedures. Patient acceptance is high. The existence of a perioperative system facilitates the planning and management of elective surgery with maximum quality and efficiency.

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Increased length of inpatient stay and poor clinical coding: audit of patients with diabetes

JRSM Short Reports ◽

10.1258/shorts.2011.011100 ◽

2011 ◽

Vol 2 (11) ◽

pp. 1-6 ◽

Cited By ~ 9

Author(s):

Harriet Daultrey ◽

Erine Gooday ◽

Ketan Dhatariya

Keyword(s):

Length Of Stay ◽

Average Length ◽

University Teaching ◽

National Data ◽

Clinical Coding ◽

Existing Problems ◽

Average Length Of Stay ◽

Patients With Diabetes ◽

Foot Problems ◽

Discharge Summaries

Objectives People with diabetes stay in hospital for longer than those without diabetes for similar conditions. Clinical coding is poor across all specialties. Inpatients with diabetes often have unrecognized foot problems. We wanted to look at the relationships between these factors. Design A single day audit, looking at the prevalence of diabetes in all adult inpatients. Also looking at their feet to find out how many were high-risk or had existing problems. Setting A 998-bed university teaching hospital. Participants All adult inpatients. Main outcome measures (a) To see if patients with diabetes and foot problems were in hospital for longer than the national average length of stay compared with national data; (b) to see if there were people in hospital with acute foot problems who were not known to the specialist diabetic foot team; and (c) to assess the accuracy of clinical coding. Results We identified 110 people with diabetes. However, discharge coding data for inpatients on that day showed 119 people with diabetes. Length of stay (LOS) was substantially higher for those with diabetes compared to those without (± SD) at 22.39 (22.26) days, vs. 11.68 (6.46) ( P < 0.001). Finally, clinical coding was poor with some people who had been identified as having diabetes on the audit, who were not coded as such on discharge. Conclusion Clinical coding – which is dependent on discharge summaries – poorly reflects diagnoses. Additionally, length of stay is significantly longer than previous estimates. The discrepancy between coding and diagnosis needs addressing by increasing the levels of awareness and education of coders and physicians. We suggest that our data be used by healthcare planners when deciding on future tariffs.

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National University Hospital discharge survey in the Islamic Republic of Iran

Eastern Mediterranean Health Journal ◽

10.26719/2000.6.2-3.402 ◽

2000 ◽

Vol 6 (2-3) ◽

pp. 402-408

Author(s):

S. M. Reza Khatami ◽

S. K. Kamrava ◽

B. Ghatehbaghi ◽

M. Mirzazadeh

Keyword(s):

Health Care ◽

Length Of Stay ◽

Hospital Discharge ◽

Average Length ◽

Health Care Service ◽

Health Care Facilities ◽

University Hospital ◽

Occupancy Rate ◽

Bed Occupancy ◽

Average Length Of Stay

We aimed to determine the rate of hospital discharge, average length of stay and bed occupancy rate in different hospital wards around the country. The survey consisted of health care service activities from 452 university-related hospitals in the country with a total of 59 348 beds. Because of missing data, the use of 56 315 of these beds was analysed. The countrywide discharge rate was 68.32 patients/1000 population per year with an average length of stay of 3.60 days and a bed occupancy rate of 57.44%. The data could be used to design a framework for prediction of inpatient health care facilities needed in the future

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Rapid Response Team Activation After Major Hip Surgery: Patient Characteristics and Outcomes

10.21203/rs.3.rs-52563/v1 ◽

2020 ◽

Author(s):

Angus Pritchard ◽

Daryl Jones ◽

Rinaldo Bellomo ◽

Andrew Hardidge ◽

Ian Harley ◽

...

Keyword(s):

Odds Ratio ◽

Elective Surgery ◽

A Priori ◽

Rapid Response Team ◽

Patient Characteristics ◽

Rapid Response ◽

University Teaching ◽

Hip Surgery ◽

Surgery Patient ◽

Index Hospital

Abstract Background: Rapid Response Teams (RRT) are a critical care resource that reviews deteriorating patients within the hospital. Whilst contemporary literature has focused on outcomes of RRTs, little is known about the detailed perioperative course and characteristics of patients who require RRT activation after major hip surgery. We aimed to describe demographic, preoperative, surgical, anesthetic and postoperative characteristics of patients who required RRT activation after major hip surgery. We also sought to assess if these characteristics affected mortality during the index hospital admission. Methods: We reviewed a RRT database of adult patients undergoing orthopedic surgery at a university teaching hospital. We then retrospectively reviewed the medical records to extract a priori defined patient, preoperative, surgical, anesthetic and postoperative data of major hip surgery admissions between September 2014 and December 2017. Patients who survived the index hospital stay were compared to those who died.Results: Overall, 187 patients had a postoperative RRT activations. Mean (SD) age was 82.1 (11.6) years; 125 (67%) were female and most patients had at least one significant comorbidity: mean (SD) Charlson Comorbidity Index (CCI) of 5.6 (2.1). The majority of patients (68%) were frail, ASA class 3 or greater (91%) and underwent non-elective surgery (88%). Median (IQR) time from surgery to RRT activation was 29.4 hours (11.3:75.0), and 25 (13%) patients had unplanned admissions to ICU/HDU. Compared to patients who survived RRT activation, those who died displayed higher CCI [6.5 (1.8) vs. 5.5 (2.1); p=0.02], were more frail (80.1% vs. 56.5%; odds ratio 3.2; 95%CI: 1.2 to 8.1; p=0.03) and received less intraoperative opioids [median (IQR) intravenous morphine equi-analgesia 5.8 (0.1:8.2) mg vs. 11.7 (3.7:19.0) mg; p=0.03]. They were also more likely to receive an urgent medical review prior to RRT activation (62% vs 40%; odds ratio 2.4; 95%CI: 1.1 to 5.6; p=0.05).Conclusions: Death after RRT activation occurred in 1 out of 7 patients undergoing major hip surgery. Common patient characteristics included advanced age (>82 years), frailty, high CCI and emergency surgery. Further studies investigating perioperative surveillance teams in the identification of the high-risk patients before surgery, and deteriorating patients after major hip surgery, are warranted.

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Colonization and Infection With MRSA and CRKP and Its Result in an Increased Mortality Rate Within the Intensive Care and High-Dependency Units in Barbados

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.703 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s173-s174

Author(s):

Keisha Gustave

Keyword(s):

Intensive Care ◽

Length Of Stay ◽

High Mortality ◽

Average Length ◽

Cohort Analysis ◽

Health Concern ◽

Queen Elizabeth Hospital ◽

Surveillance Program ◽

Average Length Of Stay ◽

High Dependency

Background: Methicillin-resistant Staphylococcus aureus(MRSA) and carbapenem-resistant Klebsiella pneumoniae (CRKP) are a growing public health concern in Barbados. Intensive care and critically ill patients are at a higher risk for MRSA and CRKP colonization and infection. MRSA and CRKP colonization and infection are associated with a high mortality and morbidly rate in the intensive care units (ICUs) and high-dependency units (HDUs). There is no concrete evidence in the literature regarding MRSA and CRKP colonization and infection in Barbados or the Caribbean. Objectives: We investigated the prevalence of MRSA and CRKP colonization and infection in the patients of the ICU and HDU units at the Queen Elizabeth Hospital from 2013 to 2017. Methods: We conducted a retrospective cohort analysis of patients admitted to the MICU, SICU, and HDU from January 2013 through December 2017. Data were collected as part of the surveillance program instituted by the IPC department. Admissions and weekly swabs for rectal, nasal, groin, and axilla were performed to screen for colonization with MRSA and CRKP. Follow-up was performed for positive cultures from sterile isolates, indicating infection. Positive MRSA and CRKP colonization or infection were identified, and patient notes were collected. Our exclusion criteria included patients with a of stay of <48 hours and patients with MRSA or CRKP before admission. Results: Of 3,641 of persons admitted 2,801 cases fit the study criteria. Overall, 161 (5.3%) were colonized or infected with MRSA alone, 215 (7.67%) were colonized or infected with CRKP alone, and 15 (0.53%) were colonized or infected with both MRSA and CRKP. In addition, 10 (66.6%) of patients colonized or infected with MRSA and CRKP died. Average length of stay of patients who died was 50 days. Conclusions: The results of this study demonstrate that MRSA and CRKP cocolonization and coinfection is associated with high mortality in patients within the ICU and HDU units. Patients admitted to the ICU and HDU with an average length of stay of 50 days are at a higher risk for cocolonization and coinfection with MRSA and CRKP. Stronger IPC measures must be implemented to reduce the spread and occurrence of MRSA and CRKP.Funding: NoneDisclosures: None

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Temporal Changes in Central-Line–Associated Bloodstream Infection Time Between Events, 2017–2018 Versus 2015–2016

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1051 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s403-s404

Author(s):

Jonathan Edwards ◽

Katherine Allen-Bridson ◽

Daniel Pollock

Keyword(s):

Length Of Stay ◽

Patient Care ◽

Average Length ◽

Bloodstream Infections ◽

Central Line ◽

Significant Shift ◽

Care Hospital ◽

Average Length Of Stay ◽

Period 2 ◽

Hospital Bed

Background: The CDC NHSN surveillance coverage includes central-line–associated bloodstream infections (CLABSIs) in acute-care hospital intensive care units (ICUs) and select patient-care wards across all 50 states. This surveillance enables the use of CLABSI data to measure time between events (TBE) as a potential metric to complement traditional incidence measures such as the standardized infection ratio and prevention progress. Methods: The TBEs were calculated using 37,705 CLABSI events reported to the NHSN during 2015–2018 from medical, medical-surgical, and surgical ICUs as well as patient-care wards. The CLABSI TBE data were combined into 2 separate pairs of consecutive years of data for comparison, namely, 2015–2016 (period 1) and 2017–2018 (period 2). To reduce the length bias, CLABSI TBEs were truncated for period 2 at the maximum for period 1; thereby, 1,292 CLABSI events were excluded. The medians of the CLABSI TBE distributions were compared over the 2 periods for each patient care location. Quantile regression models stratified by location were used to account for factors independently associated with CLABSI TBE, such as hospital bed size and average length of stay, and were used to measure the adjusted shift in median CLABSI TBE. Results: The unadjusted median CLABSI TBE shifted significantly from period 1 to period 2 for the patient care locations studied. The shift ranged from 20 to 75.5 days, all with 95% CIs ranging from 10.2 to 32.8, respectively, and P < .0001 (Fig. 1). Accounting for independent associations of CLABSI TBE with hospital bed size and average length of stay, the adjusted shift in median CLABSI TBE remained significant for each patient care location that was reduced by ∼15% (Table 1). Conclusions: Differences in the unadjusted median CLABSI TBE between period 1 and period 2 for all patient care locations demonstrate the feasibility of using TBE for setting benchmarks and tracking prevention progress. Furthermore, after adjusting for hospital bed size and average length of stay, a significant shift in the median CLABSI TBE persisted among all patient care locations, indicating that differences in patient populations alone likely do not account for differences in TBE. These findings regarding CLABSI TBEs warrant further exploration of potential shifts at additional quantiles, which would provide additional evidence that TBE is a metric that can be used for setting benchmarks and can serve as a signal of CLABSI prevention progress.Funding: NoneDisclosures: None

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Comparison of Inpatient Standard-of-Care to Outpatient Oritavancin Therapy for Patients With Acute Uncomplicated Cellulitis

Journal of Pharmacy Practice ◽

10.1177/08971900211021258 ◽

2021 ◽

pp. 089719002110212

Author(s):

Brandy Williams ◽

Justin Muklewicz ◽

Taylor D. Steuber ◽

April Williams ◽

Jonathan Edwards

Keyword(s):

Hospital Readmission ◽

Average Length ◽

Hospital Readmissions ◽

Standard Of Care ◽

Economic Outcomes ◽

Day Hospital ◽

Outpatient Parenteral Antimicrobial Therapy ◽

Average Length Of Stay ◽

Observational Cohort ◽

The Difference

Background: Shifting inpatient antibiotic treatment to outpatient parenteral antimicrobial therapy may minimize treatment for acute bacterial skin and skin structure infections, including cellulitis. The purpose of this evaluation was to compare 30-day hospital readmission or admission due to cellulitis and economic outcomes of inpatient standard-of-care (SoC) management of acute uncomplicated cellulitis to outpatient oritavancin therapy. Methods: This retrospective, observational cohort study was conducted at a 941-bed community teaching hospital. Adult patients 18 years and older treated for acute uncomplicated cellulitis between February 2015 to December 2018 were eligible for inclusion. Information was obtained from hospital and billing department records. Patients were assigned to either inpatient SoC or outpatient oritavancin cohorts for comparison. Results: 1,549 patients were included in the study (1,348 in the inpatient SoC cohort and 201 in the outpatient oritavancin cohort). The average length of stay for patients admitted was 3.6 ± 1.5 days. The primary outcome of 30-day hospital readmission or admission due to cellulitis occurred in 49/1348 (3.6%) patients in the inpatient SoC cohort versus 1/201 (0.5%) in the outpatient oritavancin cohort (p = 0.02). The difference between costs and reimbursement was improved in the outpatient oritavancin group (p < 0.001). Conclusion: Outpatient oritavancin for acute uncomplicated cellulitis was associated with reduction in 30-day hospital readmissions or admissions compared to inpatient SoC. Beneficial economic outcomes for the outpatient oritavancin cohort were observed. Additional studies are required to confirm these findings.

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Hospital Microbiologic Culture Results to Predict the Use of Anti–methicillin-Resistant Staphylococcus aureus (MRSA)

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.521 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s40-s40

Author(s):

Hsiu Wu ◽

Tyler Kratzer ◽

Liang Zhou ◽

Minn Soe ◽

Jonathan Edwards ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Risk Adjustment ◽

Negative Binomial ◽

Average Length ◽

Negative Binomial Regression ◽

Drug Resistant ◽

Gram Positive ◽

Average Length Of Stay ◽

Control And Prevention ◽

Hospital Characteristics

Background: To provide a standardized, risk-adjusted method for summarizing antimicrobial use (AU), the Centers for Disease Control and Prevention developed the standardized antimicrobial administration ratio, an observed-to-predicted use ratio in which predicted use is estimated from a statistical model accounting for patient locations and hospital characteristics. The infection burden, which could drive AU, was not available for assessment. To inform AU risk adjustment, we evaluated the relationship between the burden of drug-resistant gram-positive infections and the use of anti-MRSA agents. Methods: We analyzed data from acute-care hospitals that reported ≥10 months of hospital-wide AU and microbiologic data to the National Healthcare Safety Network (NHSN) from January 2018 through June 2019. Hospital infection burden was estimated using the prevalence of deduplicated positive cultures per 1,000 admissions. Eligible cultures included blood and lower respiratory specimens that yielded oxacillin/cefoxitin–resistant Staphylococcus aureus (SA) and ampicillin-nonsusceptible enterococci, and cerebrospinal fluid that yielded SA. The anti-MRSA use rate is the total antimicrobial days of ceftaroline, dalbavancin, daptomycin, linezolid, oritavancin, quinupristin/dalfopristin, tedizolid, telavancin, and intravenous vancomycin per 1,000 days patients were present. AU rates were modeled using negative binomial regression assessing its association with infection burden and hospital characteristics. Results: Among 182 hospitals, the median (interquartile range, IQR) of anti-MRSA use rate was 86.3 (59.9–105.0), and the median (IQR) prevalence of drug-resistant gram-positive infections was 3.4 (2.1–4.8). Higher prevalence of drug-resistant gram-positive infections was associated with higher use of anti-MRSA agents after adjusting for facility type and percentage of beds in intensive care units (Table 1). Number of hospital beds, average length of stay, and medical school affiliation were nonsignificant. Conclusions: Prevalence of drug-resistant gram-positive infections was independently associated with the use of anti-MRSA agents. Infection burden should be used for risk adjustment in predicting the use of anti-MRSA agents. To make this possible, we recommend that hospitals reporting to NHSN’s AU Option also report microbiologic culture results.Funding: NoneDisclosures: None

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Biased and unbiased estimation of the average length of stay in intensive care units in the Covid-19 pandemic

Annals of Intensive Care ◽

10.1186/s13613-020-00749-6 ◽

2020 ◽

Vol 10 (1) ◽

Cited By ~ 2

Author(s):

Nathanael Lapidus ◽

Xianlong Zhou ◽

Fabrice Carrat ◽

Bruno Riou ◽

Yan Zhao ◽

...

Keyword(s):

Intensive Care ◽

Length Of Stay ◽

Average Length ◽

Parametric Method ◽

Estimation Methods ◽

Unbiased Estimation ◽

Bed Occupancy ◽

Average Length Of Stay ◽

Discharged Patients ◽

First Admission

Abstract Background The average length of stay (LOS) in the intensive care unit (ICU_ALOS) is a helpful parameter summarizing critical bed occupancy. During the outbreak of a novel virus, estimating early a reliable ICU_ALOS estimate of infected patients is critical to accurately parameterize models examining mitigation and preparedness scenarios. Methods Two estimation methods of ICU_ALOS were compared: the average LOS of already discharged patients at the date of estimation (DPE), and a standard parametric method used for analyzing time-to-event data which fits a given distribution to observed data and includes the censored stays of patients still treated in the ICU at the date of estimation (CPE). Methods were compared on a series of all COVID-19 consecutive cases (n = 59) admitted in an ICU devoted to such patients. At the last follow-up date, 99 days after the first admission, all patients but one had been discharged. A simulation study investigated the generalizability of the methods' patterns. CPE and DPE estimates were also compared to COVID-19 estimates reported to date. Results LOS ≥ 30 days concerned 14 out of the 59 patients (24%), including 8 of the 21 deaths observed. Two months after the first admission, 38 (64%) patients had been discharged, with corresponding DPE and CPE estimates of ICU_ALOS (95% CI) at 13.0 days (10.4–15.6) and 23.1 days (18.1–29.7), respectively. Series' true ICU_ALOS was greater than 21 days, well above reported estimates to date. Conclusions Discharges of short stays are more likely observed earlier during the course of an outbreak. Cautious unbiased ICU_ALOS estimates suggest parameterizing a higher burden of ICU bed occupancy than that adopted to date in COVID-19 forecasting models. Funding Support by the National Natural Science Foundation of China (81900097 to Dr. Zhou) and the Emergency Response Project of Hubei Science and Technology Department (2020FCA023 to Pr. Zhao).

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More skilled clinical management of COVID-19 patients modified mortality in an intermediate respiratory intensive care unit in Italy

Respiratory Research ◽

10.1186/s12931-021-01613-2 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Giovanna E. Carpagnano ◽

Giovanni Migliore ◽

Salvatore Grasso ◽

Vito Procacci ◽

Emanuela Resta ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Severe Acute Respiratory Syndrome ◽

Clinical Management ◽

Average Length ◽

Limited Attention ◽

Average Length Of Stay ◽

Before And After ◽

Respiratory Intensive Care Unit ◽

Transferred Patients

Abstract Background Some studies investigated epidemiological and clinical features of laboratory-confirmed patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) the virus causing coronavirus disease 2019 (COVID-19), but limited attention has been paid to the follow-up of hospitalized patients on the basis of clinical setting and the expertise of clinical management. Methods In the present single-centered, retrospective, observational study, we reported findings from 87 consecutive laboratory-confirmed COVID-19 patients with moderate-to-severe acute respiratory syndrome hospitalized in an intermediate Respiratory Intensive Care Unit (RICU), subdividing the patients in two groups according to the admission date (before and after March 29, 2020). Results With improved skills in the clinical management of COVID-19, we observed a significant lower mortality in the T2 group compared with the T1 group and a significantly difference in terms of mortality among the patients transferred in Intensive Care Unit (ICU) from our intermediate RICU (100% in T1 group vs. 33.3% in T2 group). The average length of stay in intermediate RICU of ICU-transferred patients who survived in T1 and T2 was significantly longer than those who died (who died 3.3 ± 2.8 days vs. who survived 6.4 ± 3.3 days). T Conclusions The present findings suggested that an intermediate level of hospital care may have the potential to modify survival in COVID-19 patients, particularly in the present phase of a more skilled clinical management of the pandemic.

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The incidence of pneumonia in the paediatric population in Poland in light of the maps of health needs

Journal of Public Health ◽

10.1007/s10389-021-01503-3 ◽

2021 ◽

Author(s):

Joanna Lange ◽

Jerzy Kozielski ◽

Kinga Bartolik ◽

Paweł Kabicz ◽

Tomasz Targowski

Keyword(s):

Average Length ◽

Age Groups ◽

Paediatric Population ◽

Incidence Rates ◽

Education Development ◽

Average Length Of Stay ◽

Significant Difference ◽

Social Fund ◽

Hospital Deaths ◽

Reported Data

Abstract In Poland, no statistical data are available concerning the analysis of the incidence of pneumonia in inpatient children. The requirement for these data results mainly from the need to prepare systemic and economic solutions. Aim This study aimed to use reported data for evaluating pneumonia incidence rates among hospitalised children and other parameters in various age groups. Subject and methods A detailed analysis was performed as part of the Operational Programme Knowledge Education Development co-financed by the European Social Fund. Services reported to the National Health Fund in 2014 were considered, including pneumonia incidence among hospitalised children and mortality in specific age groups. Results In 2014, a total of 68,543 children were hospitalised for pneumonia (68% of all hospitalisations for acute respiratory diseases). Within each of the analysed age groups, boys were hospitalised more frequently. Irrespective of the place of residence, infants were most commonly hospitalised. It was observed that there was a significant difference between the incidence rate of pneumonia among hospitalised children in all analysed groups depending on the province. The average length of stay was 7.29 days, with infants requiring the longest stays (7.96 days), and 1.8% of children were rehospitalised within 30 days due to recurrence of pneumonia. The most commonly coded pathogens responsible for pneumonia included Mycoplasma pneumoniae, Streptococcus pneumoniae and Chlamydia spp. A total of 19 inpatient hospital deaths in the course of pneumonia were reported. Conclusions Based on our findings, it is warranted to utilize epidemiological knowledge for the planning of an appropriate level of service commissioned both in outpatient and inpatient facilities as well as for the estimation of institutional and staff needs necessary to secure these services.

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