Evaluation of the Clinical Impact of Thromboprophylaxis in Patients With COVID-19 Following Hospital Discharge

Background: Data are limited regarding the incidence of thromboembolism post-hospital discharge among COVID-19 patients. Guidelines addressing the role of extended thromboprophylaxis for COVID-19 patients are limited and conflicting. Objective: The purpose of this study was to evaluate the incidence of post-discharge thromboembolic and bleeding events and the role of thromboprophylaxis among COVID-19 patients. Methods: A retrospective analysis was conducted of hospitalized patients with symptomatic COVID-19 infection who were discharged from a University of Colorado Health (UCHealth) hospital between March 1, 2020, and October 31, 2020. The primary outcome was objectively confirmed thromboembolism within 35 days post-discharge. The main secondary outcome was the incidence of bleeding events within 35 days post-discharge. Outcomes were compared between those who received extended prophylaxis and those who did not. Results: A total of 1171 patients met the study criteria. A total of 13 (1.1%) of patients had a documented thromboembolic event and 10 (0.9%) patients had a documented bleeding event within 35 days post-discharge. None of the 132 patients who received extended prophylaxis had a thromboembolic event compared to 13 of 1039 who did not receive extended prophylaxis (0 and 1.3%, respectively; P = .383). The incidence of bleeding was higher among patients who received extended prophylaxis compared to those who did not (3.0% vs 0.6%, P = .019). Conclusions and Relevance: These results suggest that post-discharge extended prophylaxis may be beneficial for select COVID-19 patients, while carefully weighing the risk of bleeding. Application of our findings may assist institutions in development of thromboprophylaxis protocols for discharged COVID-19 patients.

Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study

Background Patients with substance use disorders are more likely than those without to have a self-directed hospital discharge, putting them at risk for poor health outcomes including progressing illness, readmissions, and death. Inadequate pain management has been identified as a potential motivator of self-directed discharge in this patient population. The objective of this study was to describe the association between acute pain and self-directed discharges among persons with opioid-related conditions; the presence of chronic pain in self-directed discharges was likewise considered. Methods We employed a large database of all hospitalizations at acute care hospitals during 2017 in the city of Philadelphia to identify adults with opioid-related conditions and compare the characteristics of admissions ending with routine discharge versus those ending in self-directed discharge. We examined all adult discharges with an ICD-10 diagnoses related to opioid use or poisoning and inspected the diagnostic data to systematically identify acute pain for the listed primary diagnosis and explore patterning in chronic pain diagnoses with respect to discharge outcomes. Results Sixteen percent of the 7972 admissions involving opioid-related conditions culminated in self-directed discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to complete a self-directed discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge. Conclusions These findings underscore the importance of pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.

Outcomes and Treatment Costs of Skilled Nursing Facility Patients with Pressure Injuries and Malnutrition

Skilled nursing facilities (SNF) provide care for individuals requiring skilled care while transitioning to a more permanent residence post hospitalization. This analysis shows that diagnosed malnutrition and pressure injuries (PI) adversely impact SNF patients’ health and recovery. Length of SNF stay, total charges, and discharge disposition were analyzed using SNF claims from 2016-2020 Centers for Medicare & Medicaid Services (CMS) Standard Analytical File databases. An average of 4.5% SNF patients had diagnosed PIs, and 4.9% had diagnosed malnutrition. Patients with diagnosed malnutrition were more likely to have PIs than patients without diagnosed malnutrition (11.9% vs 4.1%). Patients with PIs had higher charges ($12,304 vs. $10,937), were less likely to be discharged home (11.1% vs 18.9%), and more likely to be discharged to a hospital (15.8% vs 11.0%) or deceased (2.8% vs 1.6%). Patients with diagnosed malnutrition displayed a similar pattern for charges ($11,587 vs $10,969), and discharge to home (14.5% vs 18.8%), hospital (13.5 vs 11.1%) or deceased (2.8% vs 1.6%). Length of SNF stay did not differ between patients with and without PIs (18.5 vs 18.6) and was slightly shorter for patients with diagnosed malnutrition (17.3 vs 18.9). While higher probability of rehospitalization or death could impact these results, drivers behind these differences need further investigation. Because malnourished patients were more likely to have PIs and both PI and malnutrition are associated with poorer patient discharge outcomes and higher costs, efforts to identify malnutrition and implement proper nutrition interventions should be prioritized as part of SNF quality improvement initiatives.

Personality predictors of emergency department post-discharge outcomes

Personality traits are important predictors of health behaviors, healthcare utilization, and health outcomes. However, we know little about the role of personality traits for emergency department outcomes. The present study used data from 200 patients (effective Ns range from 84 to 191), who were being discharged from the emergency department at an urban hospital, to investigate whether the Big Five personality traits were associated with post-discharge outcomes (i.e., filling prescriptions, following up with primary care physician, making an unscheduled return to the emergency department). Using logistic regression, we found few associations among the broad Big Five domains and post-discharge outcomes. However, results showed statistically significant associations between specific Big Five items (e.g., “responsible”) and the three post-discharge outcomes. This study demonstrates the feasibility of assessing personality traits in an emergency medicine setting and highlights the utility of having information about patients’ personality tendencies for predicting post-discharge compliance.

No Effect of Surgical Approach on Discharge Outcomes in Outpatient Total Hip Arthroplasty

Background: The interest in ambulatory total hip arthroplasty (THA) has increased recently due to a national focus on value-based care and improved rapid recovery protocols. Purpose: We sought to determine if surgical approach had an effect on discharge outcomes in outpatient THA. Methods: We performed a retrospective cohort study examining patients who underwent unilateral THA at a single institution using a standardized perioperative care pathway who were discharged home within 24 hours. In total, we compared 106 patients who underwent THA using the direct anterior approach (ATHA) and 90 patients who underwent THA using the posterior approach (PTHA). Univariate and multivariable analyses were used to compare time to ambulation, length of surgery, readmissions, and 90-day complications. Results:Time to ambulation in the ATHA and PTHA groups was 3.9 hours and 4.1 hours, respectively, and time to discharge was 5.9 hours and 6.0 hours, respectively. Length of surgery was shorter in the ATHA group than in the PTHA group (78 minutes vs 86 minutes, respectively). Complications occurred in 3 patients (3%) in the ATHA group vs 4 patients (4%) in PTHA group. In both groups, early ambulation (within 5 hours) predicted earlier time to discharge. Surgical approach was not associated with time to ambulation or time to discharge on multivariable analysis. Conclusion: In this retrospective study, outpatient THA was feasible in a well-selected population of patients undergoing anterior or posterior approaches. Further study is warranted.

Personality Predictors of Emergency Department Post-Discharge Outcomes

Personality traits are important predictors of health behaviors, healthcare utilization, and health outcomes. However, we know little about the role of personality traits for emergency department outcomes. The present study used data from 200 patients (effective Ns range from 84 to 191), who were being discharged from the emergency department at an urban hospital, to investigate whether the Big Five personality traits were associated with post-discharge outcomes (i.e., filling prescriptions, following up with primary care physician, making an unscheduled return to the emergency department). Using logistic regression, we found few associations among the broad Big Five domains and post-discharge outcomes. However, results showed statistically significant associations between specific Big Five items (e.g., “responsible”) and the three post-discharge outcomes. This study demonstrates the feasibility of assessing personality factors in an emergency medicine setting and highlights the utility of having information about patients’ personality tendencies for predicting post-discharge compliance.

SP3.1.14 NELA; what happens after discharge?

Aims NELA has been instrumental at improving perioperative care and 30–day mortality following emergency laparotomy (EmLap); long-term outcomes and follow-up are less well reported. This study aims to establish the unscheduled and scheduled service use of EmLap patients after discharge. Methods This is a single-centre service evaluation. Patients were included if they had an EmLap recorded from 2016-2019 at our local institute and were alive on discharge. Outcomes were 30-day readmission rate and outpatient follow-up. Results 944 patients were included. 11.9% re-presented to the surgical department within 30-days; 58.0% of these needed readmissions. The most common causes for re-presentation (n = 112) were management of a wound issue (15.2%), ongoing pain without evidence of complication (10.7%) and ongoing intra-abdominal sepsis (9.8%). 1-year survival was 81.4%. Of these (n = 856); 74.3% were invited to outpatients; DNA rate was 8.8%, with only 67.8% of patients having a follow-up review. Median time to follow up was 9 weeks. Patients were more likely to be invited for outpatient review if they had a new stoma (OR 2.56, 95% CI 1.81 – 3.56), and less likely if adhesiolysis was the primary procedure (OR 0.55, 95% 0.39-0.76). Patients who failed to attend an appointment were significantly younger (median age 53 vs. 60 years, p = 0.0033) and from more deprived areas (average WIMD 673.6 vs 977.3, p = 0.002). Conclusion This study demonstrates higher levels of unscheduled care and lower levels of scheduled care than expected. Care standards should be extended beyond the 30-day milestone to fully appreciate the morbidity associated from EmLap.