P-BN62 Predictive factors for subtotal cholecystectomy in delayed elective cholecystectomy after acute biliary presentation

Background Laparoscopic cholecystectomy is introduced as a treatment option for symptomatic gall bladder disease in 1987 and it is now the gold standard treatment for symptomatic gall bladder disease. The rate of conversion from laparoscopic to open ranges between 5 and 10% .The step of paramount importance in cholecystectomy is the clear identification of the cystic duct and artery, which in some situations can be difficult especially in presence of dense adhesions or severely inflamed gall bladder, increasing the risk for common bile duct (CBD) injury. The traditional response to encountering a difficult laparoscopic cholecystectomy procedure is to perform conversion to an open procedure but the open conversion has its drawbacks; The subtotal cholecystectomy has been shown to reduce the need for conversion to an open procedure, thus reducing complications associated with the open cholecystectomy. Studies have also shown that this procedure decreases the bile duct injury rate . Subtotal cholecystectomy rates increased nationally over the past decade. The aim of our study is to identify factors which could predict the need for a subtotal cholecystectomy in the acute biliary admission group having delayed elective Laparoscopic cholecystectomy ,hence proper planning in terms on theatre timing, expertise and patients consenting Methods We conducted a retrospective analysis of patients who had delayed elective laparoscopic subtotal cholecystectomy after admission with Acute Biliary disease and managed conservatively in a tertiary London hospital, between 01/03/2019-29/02/2020 We collected data for all patients whose primary diagnosis was either Acute Cholecystitis, Cholelithiasis, Ascending Cholangitis, Choledocholithiasis and Gallstone Pancreatitis, and analysed these in terms of patient demographics, , duration of index admission, laboratory and radiological results during the acute admission and need to intervention during the acute phase either as a drain (cholecystostomy) or ERCP during initial management. Data were collected from electronic patient records, regarding age, gender, indication for surgery, operative notes, preoperative gall bladder wall thickness on US scan, laboratory results during acute admission. BMI, other interventions such as endoscopic retrograde cholangiopancreatography (ERCP) and cholecystostomy Odds ratios were calculated to assess the risk of patients having a subtotal cholecystectomy. Results 243 patients presented between 01/03/19-29/02/2020 which acute biliary pathology – 95 Male and 148 Female, 230 patients had delayed elective laparoscopic cholecystectomy at least 6 weeks post-acute admission Of 230 laparoscopic cholecystectomies, 22 (9.56%) cases had a subtotal cholecystectomy 13(59.9%) patients were male patients, median age 72 (54.5%) had BMI more than 30 No open conversion. The indication for cholecystectomy in the subtotal group was as follows: Acute cholecystitis 12 (54.54%), Ascending cholangitis 4 (18.18%), Choledocholithiasis 3(13.63%), gall stone pancreatitis 1(4.5%), Cholelithiasis 2 (9.09%)The subtotal cholecystectomy group had Gall bladder wall thickness during index admission documented 4 (18.18%)patients had Gall bladder wall thickness less than 4 or equal 4 mm, 18(81.81%) patients had Gall bladder wall thickness more 4 mm. Odds ratios were calculated to assess the correlation between several characteristics and the likelihood of having a subtotal cholecystectomy in the delayed elective cholecystectomy, we concluded that Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm WCC > 15000 during acute admission, all increased the likelihood of having a subtotal cholecystectomy Conclusions Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm WCC > 15000 during acute admission all increased the likelihood of having a subtotal cholecystectomy. We recommend all these information should be documented during planning for laparoscopic cholecystectomy to allow proper theatre time planning and patient consenting for the possibility of having a subtotal cholecystectomy.

Dynamic SOFA score assessments to predict outcomes after acute admission of octogenarians to the intensive care unit

Background Identifying which octogenarians could benefit most from continuing critical care is challenging. We aimed to see if responses to therapies using the sequential organ failure assessment (SOFA) score on day 4 after unplanned admission to the intensive care unit (ICU) could be associated with short-term mortality. Methods In this prospective observational cohort study, data from 4 ICUs in a University Hospital included SOFA scores on admission and day 4, along with preadmission measurements of frailty, comorbidities, nutritional status and number of medications. Outcome measures included mortality and loss of autonomy on day 90 after admission. Results Eighty-seven critically ill patients aged 80 years or older with preadmission functional independence and no missing SOFA score data on day 4 were studied (primary analyses). The mortality rate on day 90 was 30%. In a univariate Cox model, the SOFA score on day 4 was significantly associated with mortality rate: hazard ratio = 1.18 per one-point increase, 95% confidence interval (CI), 1.08 to 1.28 (p<0.001). A SOFA score of 6 or more on day 4 could correctly classify 75% of patients who died on day 90, with a sensitivity of 54% and a specificity of 84%. After adjustment, the SOFA score on day 4, neurological failure on admission and the number of preadmission medications were significantly associated with mortality on day 90, with an area under the receiver operating characteristic curve of 0.81 (95% CI, 0.71 to 0.91). These findings were confirmed in a sensitivity analysis with 109 patients. Preadmission frailty was the only variable independently associated with loss of autonomy in the 49 surviving patients. Conclusion Measuring SOFA score on day 4 and preadmission frailty could help predict mortality and loss of autonomy on day 90 in octogenarians after their acute admission to the ICU.

Use of Acute Psychiatric Hospitalisation: A Study of the Factors Influencing Decisions to Arrange Acute Admission to Inpatient Mental Health Facilities

Background: Human decision-making involves a complex interplay of intra- and inter-personal factors. The decisions clinicians make in practise are subject to a wide range of influences. Admission to a psychiatric hospital is a major clinical intervention, but the decision-making processes involved in admissions remain unclear.Aims: To delineate the range of factors influencing clinicians' decisions to arrange acute psychiatric admissions.Methods: We undertook six focus groups with teams centrally involved in decisions to admit patients to hospital (crisis resolution home treatment, liaison psychiatry, approved mental health practitioners and consultant psychiatrists). The data were analysed using qualitative thematic analysis.Results: Our analysis of the data show a complex range of factors influencing decision-making that were categorised as those related to: (i) clinical and risk factors; (ii) fear/threat factors; (iii) interpersonal dynamics; (iv) contextual factors.Conclusions: Decisions to arrange acute admission to hospital are not just based on an appraisal of clinical and risk-related information. Emotional, interpersonal and contextual factors are also critical in decision-making. Delineating the breadth of factors that bear on clinical decision-making can inform approaches to (i) clinical decision-making research, (ii) the training and supervision of clinicians, and (iii) service delivery models.

Prevention of AcuTe admIssioN algorithm (PATINA): study protocol of a stepped wedge randomized controlled trial

Background The challenges imposed by ageing populations will confront health care systems in the years to come. Hospital owners are concerned about the increasing number of acute admissions of older citizens and preventive measures such as integrated care models have been introduced in primary care. Yet, acute admission can be appropriate and lifesaving, but may also in itself lead to adverse health outcome, such as patient anxiety, functional loss and hospital-acquired infections. Timely identification of older citizens at increased risk of acute admission is therefore needed. We present the protocol for the PATINA study, which aims at assessing the effect of the ‘PATINA algorithm and decision support tool’, designed to alert community nurses of older citizens showing subtle signs of declining health and at increased risk of acute admission. This paper describes the methods, design and intervention of the study. Methods We use a stepped-wedge cluster randomized controlled trial (SW-RCT). The PATINA algorithm and decision support tool will be implemented in 20 individual area home care teams across three Danish municipalities (Kerteminde, Odense and Svendborg). The study population includes all home care receiving community-dwelling citizens aged 65 years and above (around 6500 citizens). An algorithm based on home care use triggers an alert based on relative increase in home care use. Community nurses will use the decision support tool to systematically assess health related changes for citizens with increased risk of acute hospital admission. The primary outcome is acute admission. Secondary outcomes are readmissions, preventable admissions, death, and costs of health care utilization. Barriers and facilitators for community nurse’s acceptance and use of the algorithm will be explored too. Discussion This ‘PATINA algorithm and decision support tool’ is expected to positively influence the care for older community-dwelling citizens, by improving nurses’ awareness of citizens at increased risk, and by supporting their clinical decision-making. This may increase preventive measures in primary care and reduce use of secondary health care. Further, the study will increase our knowledge of barriers and facilitators to implementing algorithms and decision support in a community care setup. Trial registration ClinicalTrials.gov, identifier: NCT04398797. Registered 13 May 2020.

Anticholinergic Cognitive Burden in Older People Over Acute Admission

Objective To evaluate the change of geriatric anticholinergic cognitive burden (ACB) over acute admission for fall, fracture, or altered mental status (AMS) with a secondary endpoint of associated 30-day all-cause readmission. Design Retrospective, single-center chart review. Setting An academic, 636-bed level-I trauma and tertiary care hospital in Texas. Patients, Participants Participants at least 65 years of age admitted for acute fall, fracture, or AMS between January 1, 2014, and August 31, 2018. A total of 265 participants were included; average age was 83 years, with 56% female. Main Outcome Measures Change in ACB of home medications from hospital admission to discharge. Results At admission, ACB averaged 2.6 with 43.4% of participants having clinically significant scores, defined as ACB greater than or equal to 3. Overall, ACB decreased by 0.1 by discharge with 63.8% and 13.9% of participants having no change and increases in their ACB over admission, respectively. Clinically significant anticholinergic burden at discharge was significantly associated with 30-day all-cause readmission (P<0.001). Conclusions Anticholinergic burden in older people admitted for fall, fracture, or AMS is not consistently intervened upon in this acute care setting. Strategies to optimize deprescribing in this setting are needed.

Anticholinergic Cognitive Burden in Older People Over Acute Admission

OBJECTIVE: To evaluate the change of geriatric anticholinergic cognitive burden (ACB) over acute admission for fall, fracture, or altered mental status (AMS) with a secondary endpoint of associated 30-day all-cause readmission.<br/> DESIGN: Retrospective, single-center chart review.<br/> SETTING: An academic, 636-bed level-I trauma and tertiary care hospital in Texas.<br/> PATIENTS, PARTICIPANTS: Participants at least 65 years of age admitted for acute fall, fracture, or AMS between January 1, 2014, and August 31, 2018. A total of 265 participants were included; average age was 83 years, with 56% female.<br/> MAIN OUTCOME MEASURES: Change in ACB of home medications from hospital admission to discharge.<br/> RESULTS: At admission, ACB averaged 2.6 with 43.4% of participants having clinically significant scores, defined as ACB greater than or equal to 3. Overall, ACB decreased by 0.1 by discharge with 63.8% and 13.9% of participants having no change and increases in their ACB over admission, respectively. Clinically significant anticholinergic burden at discharge was significantly associated with 30-day all-cause readmission (P<0.001).<br/> CONCLUSIONS: Anticholinergic burden in older people admitted for fall, fracture, or AMS is not consistently intervened upon in this acute care setting. Strategies to optimize deprescribing in this setting are needed.