Biomarkers of Length of Stay On An Inpatient Eating Disorder Unit For Treatment of Anorexia Nervosa in Females

Background. Length of stay on an inpatient unit for treatment of anorexia nervosa (AN) is widely variable. Although previous research has used anthropometric and clinical variables and duration of illness to predict length of stay, there has been limited investigation of the predictive ability of biomarkers. Biomarkers, including those collected through a comprehensive metabolic panel (CMP) and appetite hormones, such as ghrelin and leptin, are impacted by disease presence and may play an etiological role in AN. Methods. Using a series of regression models, we retrospectively evaluated the associations of these putative biomarkers at admission with length of inpatient stay in 59 females receiving treatment on an inpatient eating disorder unit for anorexia nervosa. Results. Both lower levels of magnesium and higher active ghrelin levels at inpatient admission predicted length of stay. Conclusions. This research provides further evidence supporting both biological and psychological components of AN, identifying potential biomarkers that could aid in prospective prediction of treatment needs. Ghrelin monitoring throughout inpatient stays may aid clinicians in better predicting physical recovery and renourishment from AN and prepare for stepdown from an inpatient setting. Further research is necessary to replicate and extend these findings across treatment settings.

Addressing Transportation Insecurity Improves Attendance at Posthospitalization Appointments

BACKGROUND: Transportation influences attendance at posthospitalization appointments (PHAs). In 2017, our pediatric hospital medicine group found that our patients missed 38% of their scheduled PHAs, with several being due to transportation insecurity. To address this, we implemented a quality improvement project to perform inpatient assessment of transportation insecurity and provide mitigation with the goal of improving attendance at PHAs. METHODS: The process measure was the percentage of patients with completed transportation insecurity screening, and the outcome measure was PHA attendance. An interprofessional team performed plan-do-study-act cycles. These included educating staff about the significance of transportation insecurity, its assessment, and documentation; embedding a list of local transportation resources in discharge instructions and coaching families on using these resources; notifying primary care providers of families with transportation insecurity; and auditing PHA attendance. RESULTS: Between July 2018 and December 2019, electronic health record documentation of transportation insecurity assessment among patients on the pediatric hospital medicine service and discharged from the hospital (n = 1731) increased from 1% to 94%, families identified with transportation insecurity increased from 1.2% to 5%, and attendance at PHAs improved for all patients (62%–81%) and for those with transportation insecurity (0%–57%). Our balance measure, proportion of discharges by 2 pm, remained steady at 53%. Plan-do-study-act cycles revealed that emphasizing PHA importance, educating staff about transportation insecurity, and helping families identify and learn to use transportation resources all contributed to improvement. CONCLUSIONS: Interventions implemented during the inpatient stay to assess for and mitigate transportation insecurity led to improvement in pediatric PHA attendance.

Indwelling Pleural Catheters

Indwelling pleural catheters (IPC) are now being considered worldwide for patients with recurrent pleural effusions. It is commonly used for patients with malignant pleural effusions (MPE) and can be performed as outpatient based day care procedure. In malignant pleural effusions, indwelling catheters are particularly useful in patients with trapped lung or failed pleurodesis. Patients and care givers are advised to drain at least 3 times a week or in presence of symptoms i.e. dyspnoea. Normal drainage timing may lasts for 15–20 min which subsequently improves their symptoms and quality of life. Complications which are directly related to IPC insertion are extremely rare. IPC’s are being recently used even for benign effusions in case hepatic hydrothorax and in patients with CKD related pleural effusions. Removal of IPC is often not required in most of the patients. It can be performed safely as a day care procedure with consistently lower rates of complications, reduced inpatient stay. They are relatively easy to insert, manage and remove, and provide the ability to empower patients in both the decisions regarding their treatment and the management of their disease itself.

Classical and disease-specific quality indicators in glioma surgery – Development of a quality checklist to improve treatment quality in glioma patients

Background There is a pressing demand for more accurate, disease-specific quality measures in the field of neurosurgery. Aiming at most adequately measuring and reflecting the quality of glioma therapy, we developed a novel quality indicator bundle in form of a checklist for all patients that are treated operatively for glioma. Methods On the basis of possible glioma-specific quality indicators retrieved from the literature and quality guidelines, a multidisciplinary team developed a checklist containing 13 patient-need-specific outcome measures. Subsequently, the checklist was prospectively applied to a total of 78 patients compared with a control group consisting of 322 patients. A score was generated based on the maximum of quality measures achieved. Results Significant improvements in quality after prospectively introducing the checklist were achieved for supplemental physical and occupational therapy during inpatient stay (89.4% vs. 100%, p= 0.002), consultation of a social worker during inpatient stay (64% vs. 92.3%, p< 0.001), psycho-oncological screening (14.3% vs. 70.5%, p< 0.001), psycho-oncological consultation (31.1% vs. 82.1%, p< 0.001), and consultation of the palliative care team (20% vs. 40%, p= 0.031). Overall, after introduction of the checklist one third (n= 23) of patients reached best-practice measures in all categories, and over half of the patients (n= 44) achieved above 90% with respect to the outcome measures. Conclusions Aiming at ensuring comprehensive, consistent and timely care of glioma patients the implementation of the checklist for routine use in glioma surgery represents an efficient, easily reproducible and powerful tool for significant improvements.

Pyopneumopericarditis from a gastropericardial fistula: a case report

Background Pyopneumopericarditis is a very rare diagnosis that requires prompt recognition and urgent treatment. It denotes the presence of pus and air in the pericardium with associated inflammation of the fibrous pericardial sac. Case summary A 49-year-old gentleman was admitted with pyopneumoperciarditis on a background of a previous uncomplicated Roux-en-Y gastric bypass surgery performed 7 years prior. He underwent emergency surgery for an omental patch repair of an ulcer perforation involving the diaphragm and pericardium. His inpatient stay was complicated by persistent seropurulent output from the pericardial drain, loculated pleural effusion, and deconditioning. Discussion Management is extrapolated from the literature regarding purulent pericarditis. This condition albeit rare, requires swift recognition as without treatment mortality approaches 100%. Colchicine is an important adjunctive therapy postoperatively to prevent constrictive physiology.

Traditional Medicare Spending on Inpatient Episodes as Hospitalizations Decline

OBJECTIVE: To describe Medicare inpatient episode spending trends between 2009 and 2017 as inpatient use declined among traditional Medicare beneficiaries. METHODS: Inpatient episodes included claims for all traditional Medicare inpatient, outpatient, and Part D services provided during the 30 days prehospitalization, the inpatient stay, and the 90 subsequent days. We describe the mean number of episodes per 1000 beneficiaries, mean episode-related spending per beneficiary, and mean spending per episode for all beneficiaries and for specific populations and types of episodes. Spending measures are reported with and without adjustment for payment rate increases over the study period. RESULTS: The number of inpatient-initiated episodes per 1000 beneficiaries declined by 18.2% between 2009 and 2017 from 326 to 267. After adjusting for payment rate increases, Medicare spending per beneficiary on episode-related care declined by 8.9%, although spending per episode increased by 11.4% over this period. Between 2009 and 2017, all subgroups defined by age, sex, race, or Medicaid status experienced declines in inpatient use accompanied by decreased overall episode-related spending per beneficiary and increased spending per episode. Larger declines in the number of episodes per 1000 beneficiaries were seen among episodes that began with a planned admission (28.8%) or involved no use of post–acute care services (23.9%). When comparing admissions according to medical diagnosis, the largest decline occurred for episodes initiated by a hospitalization for a cardiac or circulatory condition (31.8%). CONCLUSION: Medicare inpatient episodes per beneficiary decreased, but spending decreases due to declining volume were offset by increased spending per episode.

EP.TU.170Audit to assess the management of patients presenting with lower gastrointestinal (LGI) bleeds in the Trust

Aims To identify presentations of LGI bleeds, assimilate learning and make appropriate recommendations to improve management in hospital. Methods 336 patients with ‘PR bleed’ on their coding summary in 2019 were identified. Data obtained through eCare and EDM was analysed as outlined: Results 69% were emergency presentations of LGI bleed and the remaining 31% were elective admissions. 5% of emergency LGI bleed patients were discharged on the same day as compared to 97.4% of elective patients. The remaining 80% of emergency patients went on to have outpatient investigations. Positive cases included haemorrhoids, inflammatory bowel disease and diverticulitis. Conclusions All emergency presentations occurred during inpatient stay creating disparities in manner of presentation and duration of admission between cohorts. However, outcomes between the cohorts were broadly similar, suggesting absence of significant disparities in management. Colonoscopy is the gold standard diagnostic investigation in LGI bleeds however, flexible-sigmoidoscopy can be considered in under 50’s. 80% of patients had a colonoscopy during admission as per guidelines. No reasoning was documented for patients who underwent other methods of investigation as first-line, thus creating a need for improved documentation when deviating from guidelines. Recommendation to re-audit in 1 year to assess changes.

EP.WE.190Post-operative Hypocalcaemia: Analysis of factors influencing and predicting hypocalcaemia post total thyroidectomy

Aims Hypocalcaemia is a severe complication post total thyroidectomy leading to increased morbidity, length of inpatient stay and associated costs. The leading cause is damage or de-vascularisation of the parathyroid glands intra-operatively however this is not always easy to identify and is usually inadvertently performed. Prompt identification of patients likely to become severely hypocalcaemia is difficult for clinicians but is of interest as timely management of hypocalcaemia in these patients is crucial to reduce length of stay and worsening/development of symptoms. Methods A retrospective audit of 42 patients who were admitted for a total thyroidectomy at a district general hospital was performed. Data was collected on demographics, indication, post-operative diagnosis and pre- and post- electrolyte levels and calcium supplementation. Results Eight patients were identified with severe hypocalcaemia post operatively. Age, indication, post-operative diagnosis or pre-operative electrolyte levels were not statistical significant predictors of post-operative hypocalcaemia. Percentage difference between pre and immediate post-operative calcium levels was a significant predictor of subsequent severe hypocalcaemia and increased length of inpatient stay (p < 0.05). Conclusions Reducing patient morbidity and length of stay is of crucial importance to clinicians and patients alike. Commonly post-operative calcium levels are interpreted independently to determine need of supplementation. However, using pre-operative calcium levels in conjunction with the immediate post-operative levels has lead to a better prediction of patients likely to suffer from this complication. We theorise that prospectively identifying these patients and starting treatment early as appropriate will lead to improved patient outcomes.

EP.FRI.510 The Management of Hyperkalaemia in Acute General Surgical Inpatients

Aims Hyperkalaemia is very common in hospitalised patients especially in peri-operative settings. It is associated with increased length of stay, morbidity and mortality. Here we review the management of hyperkalaemia in emergency surgery inpatients compared to the recommended national guidelines. With the identification of any gaps, we will introduce a new protocol to standardize practice as the basis of our educational intervention. Methods A retrospective observational study of adult surgical inpatients between July and December 2020. 20 patients with a K+ >5.5 during their inpatient stay were identified. Data on their clinical management was extracted from their electronic data record and handover database and analysed. Results Of the 20 patients identified, 13 had mild (5.5-6), 3 moderate (6-6.5) and 4 severe (>6.5) hyperkalaemia. Mortality was 0 and 100% of patients with K + ≥6.5 received timely emergency treatment in line with guidelines. However, there was a wide variation in the type of treatment given with 100% of cases not aligning with current guidelines. Additionally, in only 40% of cases was the hyperkalaemia documented and only 20% of patients received an ECG; a recommendation even in mild cases. Conclusions There is a need to standardise practice in the clinical management of hyperkalaemia and align with recent, validated guidance. A clear and easily accessible algorithm reinforced by an educational intervention to junior doctors may improve the management of high potassium in surgical inpatients and improve outcomes. Following this intervention, the standard will be re-audited.