Decreasing Length of Stay in Opioid Withdrawal

2021 ◽  
pp. 107839032110595
Author(s):  
Ansa George ◽  
Marian Baxter
Keyword(s):  
Length Of Stay ◽  
Performance Improvement ◽  
Opioid Withdrawal ◽  
Opiate Withdrawal ◽  
Inpatient Setting ◽  
Improvement Project ◽  
Industry Standard ◽  
Assessment And Treatment ◽  
Business Acumen

Introduction: In 2017, more than 1,200 opioid-related deaths were reported in Virginia, with slightly fewer in 2018, at 1,193 deaths. The current opioid crisis has placed a strain on an already limited number of mental health (MH) inpatient beds. The industry standard for assessment and treatment of opioid withdrawal symptoms, in the inpatient setting, is the Clinical Opiate Withdrawal Scale (COWS), and yet some units continue to utilize the Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) for this population. Aim: The purpose of this nurse-led performance improvement project was to implement COWS in the inpatient MH setting and improve length of stay (LOS) by 1 day. Method: In 2018, in a large federal teaching facility in the mid-Atlantic region, the COWS was implemented to replace the CIWA-Ar for opioid withdrawal, with the focus on decreasing LOS. Prior to implementation of COWS, LOS on the inpatient MH unit for opioid withdrawal was 8.6 days, which was higher than the ~6- to 7-day LOS for surrounding private sector hospitals. Individual electronic medical records were reviewed for LOS and completion of COWS and pertinent details were discussed daily with nursing staff and monthly with the interdisciplinary team. Baseline data were collected from April 2017 to March 2018, with data collection continuing through the project implementation, April to September 2018. Results: Completion of COWS on 100% of patients admitted with opioid withdrawal and a decrease in LOS from 8.6 to 4.7 days was found, a 45% reduction. Conclusion: The nurse-driven performance improvement project affected business acumen, through decreased LOS, as well as quality of care, through better symptom management.

Abstract 5918: Length of Stay for Acute Heart Failure: Effects of Cohorting Patients on Variability

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Mitchell Saltzberg ◽  
Maria Albert ◽  
Donna Mahoney ◽  
Lynne Bouffard ◽  
William Weintraub
Keyword(s):  
Heart Failure ◽  
Quality Of Care ◽  
Length Of Stay ◽  
Performance Improvement ◽  
Quality Care ◽  
Improvement Project ◽  
The Public ◽  
Graphical Displays ◽  
Wide Variability

Background: Quality metrics for heart failure (HF) are increasingly utilized as an indicator of quality care. Mean length of stay (LOS) is a commonly utilized metric that is made available to the public but variability in LOS is not reported. Efforts to cohort HF pts in the hospital improve quality of care but the effect on LOS is less well defined. Methods: As part of an ongoing performance improvement project at ChristianaCare, LOS was evaluated using standard descriptive statistics. A LOS distribution was also generated monthly to visualize LOS variability. Comparisons were made for HF pts cohorted on a dedicated HF unit (HFU) vs. all other units (Other) and by inclusion/exclusion of HF pts with prolonged LOS > 10 days to reduce the effects of outliers. Results: 71 % of all HF patients were discharged in < 5 days, 82 % in < 10 days. Mean LOS (March 07–March 08) for HF was 6.63 days overall (6.1 HFU vs. 7.2 other; p = 0.05). After exclusion of long LOS HF pts, mean LOS fell to 4.4 days (4.3 HFU vs. 4.5 Other; p = 0.06). Median LOS for all HF patients was 5.0 days regardless of location. The standard deviation of LOS was significantly lower for HFU patients (4.5 vs. 11.5 days, p < 0.02) The LOS graph (Graph 1) highlights the wide variability in LOS and how mean statistics may be misleading. Conclusions: Mean LOS can be misleading as a metric for quality of HF care provided as outliers significantly impact this value. Other statistics and graphical displays can more accurately reflect quality of care. In addition, cohorting of HF patients significantly reduces overall variability in LOS and suggests a more consistent approach to acute HF care.

scholarly journals Effect of Clinical Opiate Withdrawal Scale Educational Intervention on Intensive Care Unite Nurses' Knowledge and Confidence

2021 ◽  
Author(s):  
Lauren Schneider
Keyword(s):  
Critical Care ◽  
Quality Improvement ◽  
Educational Intervention ◽  
The United States ◽  
Opioid Withdrawal ◽  
Quality Improvement Project ◽  
World Health ◽  
Opiate Withdrawal ◽  
Percentage Increase ◽  
Improvement Project

The opioid epidemic is a significant concern for the United States. Forty-eight and a half million Americans have either used illicit drugs such as heroin or have misused prescription opioid drugs. The exponential rise in opioid use increases the risk of opioid withdrawal, thus making opioid withdrawal assessment a top priority, especially for hospitalized individuals. The Clinical Opiate Withdrawal scale (COWS) is highly recommended to assess opioid withdrawal in hospitalized individuals and is well supported by the American Society of Addiction Medicine National Practice guideline and the World Health Organization. Despite the availability of reliable opioid withdrawal assessment scales, improper use and underuse of these scales are reported. Nurses education on the use of the COWS could address this gap. The purpose of this quality improvement project was to determine the effectiveness of an educational intervention concentrating on the COWS to improve critical care nurse’s knowledge and confidence in scale use. The quality improvement project utilized a pre-test, educational intervention and a posttest design. Twenty-eight out of the possible 60 critical care nurses participated in the quality improvement session. The mean scores on the pretest and post-test were 41.2 % and 83.5%, respectively. This showed a percentage increase in knowledge of 42.3. Furthermore, participants reported higher level of confidence in their ability to utilize the COWS. Receipt of COWS education could promote proper use of the scale. The advanced practice nurse can assist in establishing and implementing educational programs that focus on the importance of opioid withdrawal assessment through evidence-based practice.

Methadone Contrasted with Acetaminophen Codeine plus Clonidine: An Inpatient Pilot Study

2021 ◽  
Vol 10 ◽  
Author(s):  
Saeed Shoja Shafti
Keyword(s):  
Outcome Measures ◽  
Primary Outcome ◽  
Opioid Withdrawal ◽  
Withdrawal Symptoms ◽  
Opiate Withdrawal ◽  
Inpatient Setting ◽  
Substitution Treatment ◽  
Opioid Agonist ◽  
Opioid Substitution Treatment ◽  
Significant Difference

Introduction: The mainstay of pharmacological management of opioid dependence is opioid substitution treatment. Methadone is a long‐acting opioid agonist, which is used for detoxification and maintenance of opioid-dependent people. Objective: Objective of the present evaluation included a comparison between methadone and acetaminophen codeine plus clonidine for management of opioid withdrawal symptoms. Methods: All patients of an acute ward of a psychiatric hospital, who met dual diagnosis of primary psychiatric disorder plus opioid use disorder, were selected as accessible sample for the current evaluation. Duration of assessment was around elven months and the study was performed according to a single-blind plan. Among 96 patients, cases, who were using methadone, before their recent admission in hospital, continued their substitution treatment according to the recommended dosage and formulation till release (n = 42). The remaining group of patients, had been given acetaminophen codeine plus clonidine, as substitution treatment, during their inpatient management (n = 54). The primary outcome measures were the ‘Cross-Cutting Symptom Measure’ and the ‘Subjective Opiate Withdrawal Scale’, which were scored at baseline, week 1 and week 2. The study was performed according to the ‘per-protocol’ analysis, and the assessor was blind with respect to the said protocols. Results: while the mean total score of primary outcome measures decreased significantly in both groups, the between-group analysis did not show any significant difference between these two groups in a head-to-head analysis. Conclusion: Acetaminophen codeine plus clonidine was as good as methadone for management of opioid withdrawal symptoms in inpatient setting.

scholarly journals National Trends in Emergency Department Care Processes for Acute Myocardial Infarction in the United States, 2005 to 2015

2020 ◽  
Vol 9 (20) ◽  
Author(s):  
Akshay Pendyal ◽  
Craig Rothenberg ◽  
Jean E. Scofi ◽  
Harlan M. Krumholz ◽  
Basmah Safdar ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Length Of Stay ◽  
Real World ◽  
The United States ◽  
Emergency Department Care ◽  
Care Processes ◽  
Ed Visits

Background Despite investments to improve quality of emergency care for patients with acute myocardial infarction (AMI), few studies have described national, real‐world trends in AMI care in the emergency department (ED). We aimed to describe trends in the epidemiology and quality of AMI care in US EDs over a recent 11‐year period, from 2005 to 2015. Methods and Results We conducted an observational study of ED visits for AMI using the National Hospital Ambulatory Medical Care Survey, a nationally representative probability sample of US EDs. AMI visits were classified as ST‐segment–elevation myocardial infarction (STEMI) and non‐STEMI. Outcomes included annual incidence of AMI, median ED length of stay, ED disposition type, and ED administration of evidence‐based medications. Annual ED visits for AMI decreased from 1 493 145 in 2005 to 581 924 in 2015. Estimated yearly incidence of ED visits for STEMI decreased from 1 402 768 to 315 813. The proportion of STEMI sent for immediate, same‐hospital catheterization increased from 12% to 37%. Among patients with STEMI sent directly for catheterization, median ED length of stay decreased from 62 to 37 minutes. ED administration of antithrombotic and nonaspirin antiplatelet agents rose for STEMI (23%–31% and 10%–27%, respectively). Conclusions National, real‐world trends in the epidemiology of AMI in the ED parallel those of clinical registries, with decreases in AMI incidence and STEMI proportion. ED care processes for STEMI mirror evolving guidelines that favor high‐intensity antiplatelet therapy, early invasive strategies, and regionalization of care.

scholarly journals 49 A Quality Improvement Project to Assess and Refine the Handover Process at Morning Trauma Meetings

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
S Sadiq ◽  
M Tahir ◽  
I Nur ◽  
S Elerian ◽  
A Malik
Keyword(s):  
Categorical Variables ◽  
Next Of Kin ◽  
Chi Square ◽  
Neck Of Femur ◽  
Improvement Project ◽  
Handover Process ◽  
Neck Of Femur Fracture ◽  
The Impact ◽  
Standard Operating Protocol

Abstract Introduction Poor handover between shifts can result in patient harm. This study was designed to evaluate the impact of implementing a handover protocol on the quality of information exchanged in the trauma handover meetings in a UK hospital. Method A prospective single-centre observational study was performed at an NHS Trust. Ten consecutive weekday trauma meetings, involving 43 patients, were observed to identify poor practices in handover. This data was used in conjunction with the Royal College of Surgeons’ recommendations for effective handover (2007) to create and implement a standard operating protocol (SOP). Following its implementation, a further 8 consecutive meetings, involving a further 47 patients, were observed. The data was analysed using t-test for quantitative variables and chi-square or Fisher’s exact tests for categorical variables. Results An improvement was demonstrated in multiple aspects of trauma handover including past medical history, injury date, results, diagnosis, consent, mark, and starvation status (all p &lt; 0.001). Subgroup analyses showed that handover of neck-of-femur fracture patients including information on baseline mobility (p = 0.04), Nottingham-Hip-Fracture Score (p = 0.01), next-of-kin discussion (p = 0.075) and resuscitation status (p = 0.001) all improved following the intervention. Conclusions These results demonstrate that the implementation of a well-structured handover protocol can improve the transmission of critical information in trauma meetings.

450 Retrospective Analysis of Surgical Clerk-Ins Within the Acute Receiving Unit: A Quality Improvement Project

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
L Lee ◽  
A MacLeod ◽  
A Bradley
Keyword(s):  
Royal Infirmary ◽  
Improvement Project ◽  
Out Of Hours ◽  
Emergency Admissions ◽  
Vte Prophylaxis ◽  
Care Services ◽  
Documentation Quality ◽  
Patient Documentation ◽  
Patient Handovers

Abstract Introduction Accurate patient documentation at the ARU is vital to patient safety and ensuring smooth handovers to secondary care services. Because the nature of surgical treatment requires frequent patient handovers, and this increases the risk of miscommunication, we aimed to assess the quality of surgical clerk-ins and identify areas for improvement. Method Emergency admissions at the Dumfries Galloway Royal Infirmary were audited, looking at documentation quality under various clerk-in sections. Data was analysed before presentation to clinical governance. Results When 46 patient clerk-ins were examined, venous thromboembolism (VTE) prophylaxis plans were performed in only 24% of admissions - less than 1 in 4 patients. Comparing out-of-hours and in-hours patient documentation, much higher omission rates were identified in the out-of-hours documentation: in systemic enquiry (42 vs 100%) and family history (31% vs 66%). Conclusions These results brought to attention the effect of hospital admission timing on patient documentation quality, and the lack of VTE prophylaxis planning. In surgery, these plans are key to minimising risk of avoidable thromboembolic complications. A departmental meeting was convened to stress the importance of accurate and comprehensive clerk-ins to ARU doctors. Future audits could explore the factors influencing documentation quality for out-of-hours admissions, and ways to address these issues.

23 Nutritional Intake and Weight Change in Severely Burned Patients

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S20-S21
Author(s):  
Sandrine O Fossati ◽  
Beth A Shields ◽  
Renee E Cole ◽  
Adam J Kieffer ◽  
Saul J Vega ◽  
...  
Keyword(s):  
Wound Healing ◽  
Mass Loss ◽  
Performance Improvement ◽  
Body Mass ◽  
Total Body Surface Area ◽  
Nutritional Intake ◽  
Energy Deficit ◽  
Body Mass Loss ◽  
Improvement Project ◽  
Burn Care

Abstract Introduction Nutrition is crucial for recovery from burn injuries, as severe weight (wt.) loss can lead to impaired immunity and wound healing, infections, skin graft failure, and mortality. Previous studies recommended avoiding more than 10% wt. loss, as this level resulted in increased infection rates. However, wt. loss is often not quantifiable during the critical illness phase, with severe edema masking non-fluid related body wt. changes. Energy (kcal) deficits can be used to estimate wt. loss until the edema has resolved, but previous studies in non-burn patients indicate that actual wt. loss is less than the commonly used 3500 kcal per pound of fat (7700 kcal per kg of fat). The objective of this performance improvement project was to evaluate nutritional intake and the resulting dry wt. change in severely burned patients. Methods This performance improvement project was approved by our regulatory compliance division. We performed a retrospective evaluation on patients with at least 20% total body surface area (TBSA) burns admitted for initial burn care to our intensive care unit over a 7-year period. Patients who died or who had major fascial excisions or limb amputations were excluded. Patients who did not achieve a recorded dry wt. after wound healing were not included in this analysis. Retrospective data were collected, including sex, age, burn size, kcal intake, kcal goal per the Milner equation using activity factor of 1.4, admission dry wt., dry wt. after wound healing (defined as less than 10% TBSA open wound), and days to dry wt. after wound healing. Descriptive statistics and linear regression were performed using JMP. Significance was set at p&lt; 0.05. Results The 30 included patients had the following characteristics: 90% male, 30 ± 11 years old, 45% ± 15% TBSA burn. They received 2720 ± 1092 kcal/day, meeting 68% ± 24% kcal goal, and took approximately 53 ± 30 days from injury to achieve dry wt. after wound healing. These patients had wt. loss of 8 ± 8 kg from the kcal deficit of 69,819 ± 51,704 during this time period. The kcal deficit was significantly associated with wt. change [p &lt; 0.001, R2 = 0.49, wt. change in kg = (-0.000103 x kcal deficit) – 1]. This translates to one kg of body wt. loss resulting from 9709 kcal deficit. Conclusions This performance improvement project found that an energy deficit of approximately 9700 kcal in our patients equates to 1 kg of body mass loss (4400 kcal deficit equates to 1 pound of body mass loss). These findings are similar to wt. loss studies in other patient populations and contrary to the commonly used 3500 kcal per pound of fat (7700 kcal per kg of fat).

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.

scholarly journals Quantifying the Effects of Vibration on Medicines in Transit Caused by Fixed-Wing and Multi-Copter Drones

Drones ◽  
2021 ◽  
Vol 5 (1) ◽  
pp. 22
Author(s):  
Andrew Oakey ◽  
Tim Waters ◽  
Wanqing Zhu ◽  
Paul G. Royall ◽  
Tom Cherrett ◽  
...  
Keyword(s):  
Road Transport ◽  
Uv Spectra ◽  
Frequency Spectra ◽  
Vibration Measurements ◽  
British Pharmacopoeia ◽  
Medical Products ◽  
Industry Standard ◽  
The Stability ◽  
In Transit

The concept of transporting medical products by drone is gaining a lot of interest amongst the medical and logistics communities. Such innovation has generated several questions, a key one being the potential effects of flight on the stability of medical products. The aims of this study were to quantify the vibration present within drone flight, study its effect on the quality of the medical insulin through live flight trials, and compare the effects of vibration from drone flight with traditional road transport. Three trials took place in which insulin ampoules and mock blood stocks were transported to site and flown using industry standard packaging by a fixed-wing or a multi-copter drone. Triaxial vibration measurements were acquired, both in-flight and during road transit, from which overall levels and frequency spectra were derived. British Pharmacopeia quality tests were undertaken in which the UV spectra of the flown insulin samples were compared to controls of known turbidity. In-flight vibration levels in both the drone types exceeded road induced levels by up to a factor of three, and predominant vibration occurred at significantly higher frequencies. Flown samples gave clear insulin solutions that met the British Pharmacopoeia specification, and no aggregation of insulin was detected.

scholarly journals Quality of life in multiple sclerosis: The differential impact of motor and cognitive fatigue

2021 ◽  
Vol 7 (1) ◽  
pp. 205521732199604
Author(s):  
Sabina David Ruban ◽  
Claudia Christina Hilt ◽  
Thor Petersen
Keyword(s):  
Quality Of Life ◽  
Multiple Sclerosis ◽  
Short Form ◽  
Cross Sectional Study ◽  
University Hospital ◽  
Cognitive Fatigue ◽  
Cross Sectional ◽  
Impact Scale ◽  
Assessment And Treatment

Background Multiple sclerosis is a chronic disease leading to reduced quality of life. Objectives To investigate whether motor and cognitive fatigue impact differently on aspects of quality of life among patients with multiple sclerosis, independently from bodily disability. Methods 79 patients with multiple sclerosis from Aalborg University Hospital, Denmark were included in an observational, cross-sectional study. Each subject completed two separate questionnaires regarding fatigue (Fatigue Scale for Motor and Cognitive Functions and Modified Fatigue Impact Scale) and one regarding quality of life (Short Form 36). Disability was measured with the Expanded Disability Status Scale (EDSS)-scores obtained from patient records. Results All fatigue scores were significantly correlated to all areas of quality of life (p < 0,05). This remained significant after adjustment for age, disease duration and EDSS-score. When looking at each type of fatigue separately, cognitive fatigue correlated mainly with mental health aspects of quality of life and motor fatigue with physical health areas of quality of life. Conclusion Increased motor and cognitive fatigue lead to a differential reduction in physical and mental quality of life, independently of bodily disability. This underlines the importance of proper assessment and treatment of fatigue among patients with multiple sclerosis.

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