Impact of valvular heart disease on hip replacement: a retrospective nationwide inpatient sample database study

Background To study the impact of valvular heart disease (VHD) on hip replacement, particularly the clinical impactions of aortic stenosis before total/partial hip arthroplasty. Methods This was a retrospective cohort study. Data on patients who had undergone hip replacement from 2005 to 2014 were extracted from the NIS database. Independent t test and chi-square test were used to analyze the essential characteristics of patients. Multivariate regression was used to estimate the correlation among demographics, comorbidities, complications, hospitalization costs, and time. Results VHD accounted for 5.56% and AS accounted for 0.03% of the patients before hip replacement surgeries. Patients with VHD before hip replacement are related to the following characteristics: female patients (odds ratio [OR] = 1.15 [1.12–1.18]), elective admission (OR = 0.78 [0.76–0.80]), Charlson Comorbidity Index ≥3 (OR = 1.06 [1.03–1.08]), large-volume hospitals (OR = 1.13 [1.1–1.2]), teaching hospitals (OR = 5 4.4 [2.9–6.7]), and hospital location in urban areas (OR = 1.22 [1.2–1.3]). In addition, VHD is a risk factor for mortality and some acute postoperative medical complications, such as acute cardiac event (OR = 2.96 [2.87–3.04]), acute pulmonary edema (OR = 1.13 [1.06–1.21]), acute cerebrovascular event (OR = 1.22 [1.16–1.74]), and acute renal failure (OR = 1.22 [1.17–1.27]). It also has an impact on DVT/PE (OR = 0.89 [0.8–0.99]). Patients with AS before hip replacement have basic demographic characteristics like those of hip replacement patients with valvular disease. Patients with AS are older than those without AS before surgery (OR = 3.28 [2.27–4.75) and are related to the following characteristics: female patients (OR = 1.92 [1.32–2.8]) and elective admission (OR = 0.51 [0.36–0.75]). The perioperative period is limited to acute postoperative complications, such as acute cardiac events (OR = 2.50 [1.76–3.53]) and acute hepatic failure (OR = 7.69 [1.8–32.89]). Both valvular diseases and AS are associated with a higher mortality rate and hospitalization cost. Conclusion VHD independently predicted mortality rate and surgical and medical complications after total/partial hip arthroplasty.

Urgent elective pathway service reconfiguration facilitates increased use of surgical adjuncts, improvement in survival trends, and reduced hospital stay for glioblastoma patients

Aims Glioblastomas (GB) are the most common and aggressive of intrinsic brain tumours. Median survival with maximal therapy is reported to be 14.6 months. Service reconfiguration at the Queen Elizabeth Hospital Birmingham (QEHB) has transformed the service for high grade brain cancer patients, including GB, from a predominantly emergency pathway based system to one of planned urgent-elective admissions consisting of: A. Patient-focused, consultant-led, research orientated “one stop shop” model of integrated outpatient neurosurgical oncology clinic B. Standardisation of urgent elective pathways C. Incorporation of neuro-surgical intra-operative adjuncts (neuro-monitoring, 5-ALA) into routine surgical practice for oncology. Using this model, we have reduced hospital length of stay (with associated financial savings), improved extent of resection and achieved a trend towards increased survival. Method We retrospectively identified patients with primary histological diagnoses of GB (WHO grade IV), who underwent surgery over a six year period, from 01/01/2014 to 31/12/2019, from the QEHB pathology database. Data was collected for demographics, surgical and oncological therapy, use of intra-operative adjuncts, emergency and elective admission status, year of admission, length of stay (LOS), and extent of resection (EOR) on first post-operative MRI scan from hospital databases. Survival was analysed using the Kaplan-Meier method and independent-samples median testing for survival. Proportion of patients undergoing resective surgery and admission status was calculated by year. Overall median survival was calculated and subgroup comparisons made of patients by: age, admission status, year of admission, biopsy or resection, oncology treatment. Hospital length of stay was calculated for patients by surgical procedure, admission pathways and compared across the year. Financial data taken from averages of inpatient episode costs were used to estimate cost savings. Results 610 patients underwent primary procedures for GB, of which 64 were still alive at time of analysis (02/02/2021). Median overall survival time was 9.53 months, this was greatest in patients who underwent resection with completion of Stupp protocol: 28.67 months (n=114). From 2014 to 2019, there has been an increase in elective admission rates (28.1% to 90.3%, p<0.001) and increased proportion of resective surgery (68.4% to 81.9%, p<0.001). There is a trend of improved survival from 2014 to 2019 (median 7.95 and 11.08 months, χ2=9.249, p=0.002). Increasing use of intra-operative adjuvants improved EOR (χ2 =31.064, p<0.001). Through improved urgent-elective admission rates, hospital length of stay has decreased by five days for craniotomies and six days for biopsies. Cost analysis of three cases demonstrated that reducing the LOS by one night alone result in an average cost saving of approximately £750 per patient per night. Conclusion Switching to a system of planned and urgent elective based admission, with standardisation of neuro-oncology patient pathways, increased use of intra-operative adjuncts, earlier oncology multidisciplinary input and outpatient review, has improved the extent of GB resection, led to shorter length of hospital stay associated with significant financial savings and achieved a trend towards increased overall survival.

Incidence and Risk Factors of Hospital-Acquired Pressure Ulcers Following Total Hip Arthroplasty: A Retrospective Nationwide Inpatient Sample Database Study

BackgroundThe occurrence of hospital-acquired pressure ulcers (HAPUs) is disturbing and costly, leading to a variety of adverse effects. The objective of this study was to examine the incidence and risk factors of HAPUs following total hip arthroplasty (THA) using a large-scale national database. MethodsA retrospective database analysis was performed based on Nationwide Inpatient Sample (NIS) from 2005-2014. Patients who underwent THA were included. Patient demographics, hospital characteristics, length of stay (LOS), total charges during hospitalization, in-hospital mortality, preoperative comorbidities, and perioperative complications were assessed.ResultsA total of 592,174 THAs were captured from the NIS database. The general incidence of HAPUs after THA was 0.05%, with a fluctuating trend annually. Patients suffered from HAPUs were older, less likely through elective admission, more likely in large hospital, more usage of Medicare, and less possibly paying via Private insurance compared to the nonaffected individuals. Additionally, the occurrence of HAPUs was associated with more preoperative comorbidities, longer LOS, extra total charges, and higher in-hospital mortality. Risk factors of HAPUs included advanced age (≥75 years), large hospital, multiple comorbidities (n≥3), diabetes with chronic complications, drug abuse, liver disease, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disorders, psychoses, chronic renal failure, peptic ulcer disease, and weight loss. Besides, HAPUs were associated with inflammatory arthritis and femoral neck fracture (compared with primary/secondary osteoarthritis), frailty/senility, osteoporosis, acute renal failure, pneumonia, postoperative delirium, urinary tract infection, deep vein thrombosis, sepsis/septicemia, wound dehiscence/non-healing surgical wound, periprosthetic joint infection, and mechanical prosthesis-related complications. Both elective admission and Private insurance were detected as protective factors. ConclusionsIt is beneficial to study the risk factors of HAPUs after THA to ensure the preventive management and optimize consequences although a really low incidence was identified.

Preparation of children for elective surgery and hospitalisation: A parental perspective

Parents play a central role in the preparation of their child for hospitalisation and surgery. This research examined the parental perspective on educating their child for an elective admission to hospital for surgery. The study employed a qualitative descriptive design and sampled eight parents from a private hospital in Dublin, Ireland, prior to their child’s discharge, after ear, nose and throat surgery. A thematic analysis revealed four themes: how parents educate themselves about surgery and hospital, factors influencing parent’s decisions on the quantity of information to share, sources of education about hospitalisation and aspects of hospitalisation not discussed by parents. Findings indicated that although the internet was used as a general source of information, parents relied more on information provided by the hospital. Parents used their child’s age, individual needs and level of autonomy to determine what information to communicate. Specific areas that parents found difficult to communicate included pain and fasting. This research highlights the need for hospitals to invest and support the delivery of parental education for children prior to surgery. Clarification of the children’s nurses’ role in the development, implementation and evaluation of education programmes that support education delivery in the home by parents is also warranted.

Can multiple sclerosis nurses help reduce non-elective admissions? An analysis of a service delivery audit

Background: It has been identified that nearly one-in-five people with multiple sclerosis (MS) have been admitted to hospital as a non-elective admission in 2018–2019. The average national stay is 7.7 days, at an average cost of £2844. Emergency hospital admissions for people with multiple sclerosis are rising nationally. Method: The authors conducted a 12-month audit of non-elective admissions across two clinical sites, comparing and contrasting the data gathered with national Hospital Episode Statistics. The outcome of the data collection influenced changes in local service delivery. Findings: The most common reasons identified for non-elective admissions related to MS were associated with respiratory issues (4255 admissions), with the most common single cause being urinary tract infections (2960 admissions). Bladder and bowel issues combined also accounted for 3550 admissions in 2018/19. Conclusion: The data identified urinary tract infections and sepsis as the largest presentation of non-elective MS admissions to both trusts. Certain recommendations have been made that will contribute to the improvement of service delivery and better quality care.

Impact of Valvular Heart Disease on Hip Replacement: A Retrospective Nationwide Inpatient Sample Database Study

BackgroundTo study the impact of valvular heart disease (VHD) on joint replacement, particularly the clinical impactions of aortic stenosis before total/partial hip arthroplasty. MethodsThis was a retrospective cohort study. Data on patients who had undergone joint replacement from 2005 to 2014 were extracted from the NIS database. Linear regression was used to analyze the essential characteristics of patients. Multivariate regression was used to estimate the correlation among demographics, comorbidities, complications, hospitalization costs, and time.ResultsOf the hip replacement surgeries, VHDs accounted for 5.56% and aortic stenosis (AS) accounted for 0.03% before surgery. VHD patients are related to the following characteristics: female patients (odds ratio [OR]=1.15 [1.12–1.18]), elective admission (OR=0.78 [0.76–0.80]), Charlson Comorbidity Index ≥3 (OR=1.06 [1.03–1.08]), large-volume hospitals (OR=1.13 [1.1–1.2]), teaching hospitals (OR=5 4.4 [2.9–6.7]), and hospital location in urban areas (OR=1.22 [1.2–1.3]). In addition, VHD is a risk factor for mortality and some acute postoperative medical complications, such as acute cardiac event (OR=2.96 [2.87–3.04]), acute pulmonary edema (OR=1.13 [1.06–1.21]), acute cerebrovascular event (OR=1.22 [1.16–1.74]), and acute renal failure (OR=1.22 [1.17–1.27]). It also has an impact on DVT/PE (OR=0.89 [0.8–0.99]). Patients with AS before hip replacement have basic demographic characteristics similar to those of TJA patients with valvular disease. Patients with AS are older (≥80 years) than those without AS before surgery (OR=3.28 [2.27–4.75) and have the following characteristics: female patients (OR=1.92 [1.32–2.8]) and elective admission (OR=0.51 [0.36–0.75]). The perioperative period is limited to acute postoperative complications, such as acute cardiac events (OR=2.50 [1.76–3.53]) and acute hepatic failure (OR=7.69 [1.8–32.89]). Both valvular diseases and AS are associated with a higher mortality rate and hospitalization cost. ConclusionValvular heart disease (VHD) independently predicted mortality rate and surgical and medical complications after total/partial hip arthroplasty.

The prevalence rates and sequelae of delirium at age older than 90 years

Objective Although age and pre-existent dementia are robust risk factors for developing delirium, evidence for patients older than 90 years is lacking. Therefore, this study assesses the delirium prevalence rates and sequelae in this age group. Method Based on a Diagnostic and Statistical Manual (DSM)-5, Delirium Observation screening scale (DOS), and Intensive Care Delirium Screening Checklist (ICDSC) construct, in this prospective cohort study, the prevalence rates and sequelae of delirium were determined in 428 patients older than 90 years by simple logistic regressions and corresponding odds ratios (ORs). Results The overall prevalence delirium rate was 45.2%, with a wide range depending upon specialty: intermediate and intensive care services (83.1%), plastic surgery and palliative care (75%), neurology (72%), internal medicine (69%) vs. dermatology (26.5%), and angiology (14.5%). Delirium occurred irrespective of age and gender; however, pre-existent dementia was the strongest delirium predictor (OR 36.05). Delirious patients were less commonly admitted from home (OR 0.47) than from assisted living (OR 2.24), indicating functional impairment. These patients were more severely ill, as indicated by emergency (OR 3.25) vs. elective admission (OR 0.3), requirement for intensive care management (OR 2.12) and ventilation (OR 5.56–8.33). At discharge, one-third did not return home (OR 0.22) and almost half were transferred to assisted living (OR 2.63), or deceased (OR 47.76). Significance of results At age older than 90 years, the prevalence and sequelae of delirium are substantial. In particular, functional impairment and pre-existent dementia predicted delirium and subsequently, the loss of independence and death were imminent.

Healthcare strain and intensive care during the COVID-19 outbreak in the Lombardy region: a retrospective observational study on 43,538 hospitalized patients

ABSTRACTBackgroundDuring the spring of 2020, the SARS-CoV-2 epidemic has caused significant resource strain in hospitals of Lombardy, Italy, with the demand for intensive care beds for COVID-19 patients exceeding the overall pre-crisis capacity. In this study, we evaluate the effect of healthcare strain on ICU admission and survival.MethodsWe used data on 43,538 patients admitted to a hospital in the region between February 20 and July 12, 2020, of which 3,993 (9.2%) were admitted to an ICU. We applied logistic regression to model the probability of being admitted to an ICU and the probability of survival among ICU patients. Negative binomial regressions were used to model the time between hospital and ICU admission and the length of stay in ICU.ResultsDuring the period of highest hospital strain (March 16 – April 22), individuals older than 70 years had a significantly lower probability of being admitted to an ICU and significantly longer times between hospital and ICU admission, indicating elective admission due to constrained resources. Healthcare strain did not have a clear effect on mortality, with the overall proportion of deaths declining from 52.1% (95%CI 49.8-54.5) for ICU patients admitted to the hospital before March 16, to 43.4% (95%CI 41.5-45.6) between March 16 and April 22, to 27.6% (95%CI 20.0-35.2) after April 22.ConclusionsThese data demonstrate and quantify the adoption of elective admission to ICUs during the peak phase of the SARS-CoV-2 epidemic in Lombardy. However, we show that for patients admitted to ICUs, clinical outcomes progressively improved despite the saturation of healthcare resources.