Surgical Stabilization of Rib Fractures Improves Outcomes in the Geriatric Patient Population

Introduction Rib fractures in the ≥65-year-old population have been shown to strongly influence mortality and pneumonia rates. There is a growing body of evidence demonstrating improvements in the geriatric patient’s survival statistics and respiratory performances after surgical stabilization of rib fractures (SSRF). We have observed a strong survival and complication avoidance trend in geriatric patients who undergo SSRF. The purpose of our study was to evaluate the outcomes of geriatric patients with rib fractures treated with SSRF compared to those who only receive conservative therapies. Methods We performed a retrospective review of our trauma registry analyzing outcomes of patients ≥65 years with rib fractures. Patients admitted from 2015 to 2019 receiving SSRF (RP group) were compared to a nonoperative controls (NO group) admitted during the same time. Bilateral fractures were excluded. Independent variables analyzed = ISS, mortalities, hospital days, ICU days, pleural space complications, and readmissions. Follow-up was 60 days after discharge. Group comparison was performed using Kolmogorov-Smirnov, Shapiro-Wilk, and Mann-Whitney U tests. Results 257 patients were analyzed: 172 in the NO group with mean age of 75 (65-10) and 85 in the RP group with mean age of 74 (65-96). Mean ISS = 13 (1-38) for the NO group and 20 (9-59) for the RP group ( P < .001). Mean hospital days = 8 (1-39) and 15 (3-49) in NO and RP groups, respectively. Mean ICU days = 10 (1-32) and 8 (1-11) in NO and RP groups, respectively. Deaths, pneumonia, readmissions, and pleural effusions in the NO group were statistically significant ( P < .01). Analysis of complications revealed 4 RP patients (4.7%) with respiratory complications out to 60 days and 65 NO patients (37.8%) ( P < .001). Conclusions Surgical stabilization of rib fractures appears to be associated with a survival advantage and an avoidance of respiratory-related complications in the ≥65-year-old patient population.

Current Status of Repeated Hospitalization in South Korea: Focused on Ambulatory Care Sensitive Conditions

Purpose: Repeated hospitalization could be a proxy of unnecessary or preventive admission in South Korea where barriers to hospitalization are relatively low. This study aimed to estimate the current status of repeated hospitalization due to ambulatory care sensitive conditions (ACSC) in South Korea.Methods: Using the National Health Information Database, repeated hospitalization databases were constructed in units of episodes for patients who had been admitted more than twice between January 2017 and December 2018. The number of hospitalizations, total in-hospital days, and total medical expenditure were calculated and compared by patient characteristics in both of the entire patient group and the ACSC patient group.Results: Of total hospitalization episodes, 26.6% reported repeated admission, and 6.7% of repeated hospitalization was due to ACSC. A total of 183,110 patients with ACSC had been admitted an average of 2.9 times and spent an average of KRW5,630,118. In other words, KRW1,309 billion had been spent for repeated hospitalization due to ACSC. The scale of medical expenditure was relatively large in the highest and lowest socioeconomic status.Conclusion: Repeated hospitalization for ACSC can be considered a simple and intuitive indicator when assessing unnecessary hospitalizations or evaluating healthcare policy.

Tocilizumab for Juvenile Takayasu Arteritis Complicated with Acute Heart Failure at Onset

Chronic heart failure caused by aortic valve regurgitation is a common complication of Takayasu arteritis (TA). However, fewer patients develop acute heart failure (AHF), and no specific treatment for AHF in TA has been established. We encountered a 12-year-old girl with TA who developed AHF at onset. We successfully treated her with intravenous methylprednisolone and tocilizumab. She developed palpitations and shortness of breath three weeks before admission. Her symptoms exacerbated rapidly and she finally entered the intensive care unit due to respiratory distress and tachycardia. Blood pressure measurements on the left arm and bilateral legs were paradoxically lower than that on the right arm. Chest X-ray revealed a severely enlarged heart. Contrast computed tomography showed an expanded aorta, aortic aneurysm, meandering, and irregular diameter of the aorta. The left ventricular ejection fraction (LVEF) was 20% on cardiac ultrasound. Her medical condition was finally diagnosed as TA with AHF. Along with inotropes and diuretics, methylprednisolone pulse therapy was administered on hospital days 2-4 and hospital days 12-14, followed by oral prednisolone. However, cardiac function was not notably improved. As intravenous cyclophosphamide therapy requires hydration and may exacerbate AHF, we initiated weekly subcutaneous tocilizumab treatment (162 mg/week) from hospital day 20. Inotropes were discontinued on hospital day 51 and her LVEF had gradually improved to 37.5% at discharge (day 63). As AHF in TA is presumed to be due to inflammation of the myocardium, tocilizumab could be a treatment option for TA with AHF.

Health system costs and days in hospital for colorectal cancer patients in New South Wales, Australia

Introduction Colorectal cancer (CRC) care costs the Australian healthcare system more than any other cancer. We estimated costs and days in hospital for CRC cases, stratified by site (colon/rectal cancer) and disease stage, to inform detailed analyses of CRC-related healthcare. Methods Incident CRC patients were identified using the Australian 45 and Up Study cohort linked with cancer registry records. We analysed linked hospital admission records, emergency department records, and reimbursement records for government-subsidised medical services and prescription medicines. Cases’ health system costs (2020 Australian dollars) and hospital days were compared with those for cancer-free controls (matched by age, sex, geography, smoking) to estimate excess resources by phase of care, analysed by sociodemographic, health, and disease characteristics. Results 1200 colon and 546 rectal cancer cases were diagnosed 2006–2013, and followed up to June 2016. Eighty-nine percent of cases had surgery, chemotherapy or radiotherapy, and excess costs were predominantly for hospitalisations. Initial phase (12 months post-diagnosis) mean excess health system costs were $50,434 for colon and $60,877 for rectal cancer cases, with means of 16 and 18.5 excess hospital days, respectively. The annual continuing mean excess costs were $6,779 (colon) and $8,336 (rectal), with a mean of 2 excess hospital days each. Resources utilised (costs and days) in these phases increased with more advanced disease, comorbidities, and younger age. Mean excess costs in the year before death were $74,952 (colon) and $67,733 (rectal), with means of 34 and 30 excess hospital days, respectively–resources utilised were similar across all characteristics, apart from lower costs for cases aged ≥75 at diagnosis. Conclusions Health system costs and hospital utilisation for CRC care are greater for people with more advanced disease. These findings provide a benchmark, and will help inform future cost-effectiveness analyses of potential approaches to CRC screening and treatment.

Evaluation of Early Discharge after Intensive Induction Chemotherapy in Adults with Acute Myeloid Leukemia

Background: Acute myeloid leukemia (AML) patients who require intensive induction chemotherapy are traditionally hospitalized for the duration of neutropenia to monitor for treatment-related toxicities. On average, AML patients are hospitalized for 33.7 days during first induction treatment (Sacks et al Clin Ther 2018). Prolonged hospitalizations are associated with substantial costs, increased risk for nosocomial infections, and significant declines in physical function and quality of life. Several studies have evaluated the impact of early discharge prior to neutrophil recovery, however current evidence has not clearly defined the ideal patient characteristics or described the optimal time post-induction to safely discharge patients. At our institution, we established a "STREAMLINE (Safe TRansition with Early-discharge in Acute Myeloid Leukemia INtensivE-induction) Protocol" to evaluate patients for early discharge following induction chemotherapy. Objective: To determine the optimal time after induction chemotherapy to safely discharge AML patients. Methods: Retrospective, single-institution review of adult AML patients who received intensive induction chemotherapy from January 1, 2017 to December 31, 2019. The STREAMLINE criteria for early discharge (Table 1) was retrospectively applied at discharge timepoint-1 (DT1) and discharge timepoint-2 (DT2). DT1 was defined as within 24 hours following completion of induction therapy and DT2 was defined as within 24 hours after performance of first bone marrow biopsy after induction therapy. Each patient served as his/her own control to compare actual length of hospitalization to the length of hospitalization if the patient had been discharged at DT1 and/or DT2. The primary outcome was number of hospital days saved if discharged at DT1 compared to DT2. Secondary outcomes included proportion of patients who met STREAMLINE criteria, incidence and time to first complication that would require hospital readmission for patients who met criteria, overall days of hospitalization, and overall survival at 30 and 60 days. Results: A total of 284 patients met inclusion criteria and were assessed for early discharge. Eighty-nine patients (31.3%) met the STREAMLINE criteria for early discharge with 51 (57.4%) at DT1, 19 (21.3%) at DT2, and 19 (21.3%) at DT1 and DT2. Baseline demographics of the study population are described in Table 2. Of the 195 patients (68.7%) ineligible for early discharge, 118 (60.5%) were ineligible due to an active medical issue or laboratory parameter not met, 60 (30.8%) due to age, 9 (4.6%) due to poor performance status, and 8 (4.1%) due to history or evidence of heart failure. The most common laboratory or active medical issues that led to ineligibility were the need for intravenous anti-infectives (34.9%), fever within 48 hours of discharge timepoint (29.3%), and transfusion dependence (24.5%). Study outcomes are summarized in Table 3. In the 70 patients who met STREAMLINE criteria at DT1, 60 (94.3%) experienced an event that would require hospital readmission (Figure 1). The most common were neutropenic fever (42.9%), proven infection (31.4%), and re-induction therapy (7.1%). The median time to readmission event was 6 days [interquartile range (IQR) 3-10]. Based on early discharge at DT1, median length of hospitalization was 26 days (IQR 19-33) with a median 6 days saved (IQR 2-9.8). In the 38 patients who met STREAMLINE criteria at DT2, 26 (68.4%) experienced an event that would require hospital readmission (Figure 1). The most frequent were neutropenic fever (28.9%), re-induction therapy (18.4%), and proven infection (13.2%). The median time to readmission event was 3 days (IQR 2-5). Based on early discharge at DT2, the median length of hospitalization was 25.5 days (IQR 22-40) with a median 3 days saved (IQR 1-5). Overall, early discharge at DT1 was predicted to save a total of 468 days compared to a total of 165 days at DT2. In all patients who met STREAMLINE criteria (n=89), overall survival at 30- and 60-days post-induction therapy was 100%. Conclusions: Early discharge at DT1 was predicted to save a greater number of hospital days compared to DT2, however DT1 was associated with higher readmission events. These findings suggest that early discharge is safe and feasible in AML patients who receive intensive induction therapy. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Patient Health Outcomes following Dialysis Facility Closures in the United States

BackgroundOngoing changes to reimbursement of United States dialysis care may increase the risk of dialysis facility closures. Closures may be particularly detrimental to the health of patients receiving dialysis, who are medically complex and clinically tenuous.MethodsWe used two separate analytic strategies—one using facility-based matching and the other using propensity score matching—to compare health outcomes of patients receiving in-center hemodialysis at United States facilities that closed with outcomes of similar patients who were unaffected. We used negative binomial and Cox regression models to estimate associations of facility closure with hospitalization and mortality in the subsequent 180 days.ResultsWe identified 8386 patients affected by 521 facility closures from January 2001 through April 2014. In the facility-matched model, closures were associated with 9% higher rates of hospitalization (relative rate ratio [RR], 1.09; 95% confidence interval [95% CI], 1.03 to 1.16), yielding an absolute annual rate difference of 1.69 hospital days per patient-year (95% CI, 0.45 to 2.93). Similarly, in a propensity-matched model, closures were associated with 7% higher rates of hospitalization (RR, 1.07; 95% CI, 1.00 to 1.13; P=0.04), yielding an absolute rate difference of 1.08 hospital days per year (95% CI, 0.04 to 2.12). Closures were associated with nonsignificant increases in mortality (hazard ratio [HR], 1.08; 95% CI, 1.00 to 1.18; P=0.05 for the facility-matched comparison; HR, 1.08; 95% CI, 0.99 to 1.17; P=0.08 for the propensity-matched comparison).ConclusionsPatients affected by dialysis facility closures experienced increased rates of hospitalization in the subsequent 180 days and may be at increased risk of death. This highlights the need for effective policies that continue to mitigate risk of facility closures.

PERILAKU CARING PERAWAT DIMASA PANDEMI COVID-19 DI RUMAH SAKIT UMUM DAERAH KOTA MAKASSAR

The purpose of the study: to find out the description of the caring behavior of nurses in the ward of the Makassar City General Hospital. Methods: This study used a descriptive survey using a non-probability sampling technique, namely consecutive sampling. The sample in this study was 77 people according to the inclusion criteria and exclusion criteria. Collecting data using a questionnaire Care Q (the Nurse Behavior Caring Study) based on the opinion of Larson (1998, in Watson 2004). Questionnaire sheet. Results: The results showed that the caring behavior of nurses at the Makassar City General Hospital in general was mostly good (79.2%). , explanation and facilities (79.9 %), comfort (79.9 %), trusting relationship (71.4 %). Discussion: In the application of caring behavior nurses need to integrate various dimensions of caring behavior which include readiness and willingness, explanations and facilities, comfort, mutual trust relationships to improve the quality of nursing services which have an impact on increasing patient satisfaction and decreasing hospital days. Conclusion: Nurse caring behavior in Makassar City General Hospital in general is mostly good Suggestion: Nurses are expected to cultivate a culture of caring for patients by reminding each other among colleagues to improve the quality of nursing services