Correlation between Non-invasive Measurement of Carboxyhemoglobin and Bilirubin Level Measurement in Near- Term and Term Neonates as a Predictor of Neonatal Hemolysis

Background Neonatal hyperbilirubinemia is common in the neonatal period. Yet, serious pathological hyperbilirubinemia may cause kernicterus with detrimental neurologic sequalae. Carbon monoxide (CO) is the byproduct of the breakdown of heme, it is transported as carboxyhemoglobin to the lungs to be exhaled. Thus, carboxyhemoglobin levels increase as a result of hemolysis, and is therefore considered a sensitive index for the degree and severity of the subsequent hyperbilirubinemia. Objectives To correlate between non-invasive carboxyhemoglobin levels and bilirubin levels in near-term and tem neonates starting hour I of life. Subjects and methods A total of 100 near-term and term neonates were studied, by measuring carboxyhemoglobin by a Pulse CO-oximetry and serum bilirubin level (hour l) and transcutaneous bilirubin (TcB) hourly since birth for the I st 6 hours then every 6 hours till the time of discharge in a cross sectional case-control study. Results A cut off value of 4 for non-invasive carboxyhemoglobin with sensitivity of 81.25%, specificity of 95.24% was found to the earliest non-invasive predictor for subsequent jaundice. In patients with proven hemolysis, carboxyhemoglobin when compared to TcB was found to increase significantly in the first 3 hours of life more than TcB, stalting hour 4 till time of discharge it was increased yet statistically insignificant Conclusion We found that non-invasive carboxyhemoglobin is an effective early predictor for subsequent jaundice starting first hour of life. It can be used as a screening tool for hemolytic jaundice especially in hospitals with early discharge policy.

Audit of follow-up within 7 days on discharge from the mental health unit, Forth Valley Royal Hospital

AimsTo determine compliance with the new discharge policy of review within 7-days for all General Adult Psychiatry patients discharged from Forth Valley Royal Hospital.BackgroundIt is well established that there is an increased risk of suicide following discharge from Inpatient Psychiatric Wards. This risk is significantly increased in the first month, and particularly high in the first week.In their 2016 Guidance, NICE recommends follow-up within 7 days of discharge. It is not known whether seven day follow-up reduces suicide risk but it is clearly an opportunity for risk assessment and management during a particularly risky period.This standard was adopted by the General Adult Wards in Mental Health Unit at Forth Valley Royal Hospital in April 2019.MethodAll discharges from Wards 1, 2 and 3, Forth Valley Royal Hospital were reviewed during three distinct, month-long periods:November 2018 (prior to the introduction of the new discharge policy)May 2019 (shortly after the introduction of the new discharge policy)September 2019 (six months after the introduction of the new discharge policy)A list was obtained from Medical Records of all General Adult patients discharged in these periods. The paper and electronic records were checked for each patient, and the first scheduled care episode post discharge was taken as follow-up.ResultIn the1st round of audit (November 2018): 41 patients were discharged and 26 patients (64%) received follow-up within 7 days.In the 2nd round of audit (May 2019): 46 patients were discharged, 39 patients (84%) received follow-up within 7 days.In the 3rd round of the audit (September 2019), 50 patients were discharged and 49 (98%) received follow-up within 7 days.ConclusionThere has been a clear improvement in the provision of follow-up on discharge from the General Adult Psychiatry Wards in Forth Valley Royal Hospital.The new discharge policy was implemented in April 2019 and a “Discharge Pause” was introduced (initially a sticker, now an electronic form) to be completed by the medical team at the point when it was decided to discharge.Community Mental Health Teams have also been reminded of their need to facilitate seven day follow-up as a priority. A flowchart was produced in May 2019, which provided guidance as to who should provide the seven day follow-up.

Delivering Zonal Isolation between Reservoir Sublayers in Long, Horizontal 12 ¼-in. Hole Sections in Extended Reach Wells

Good cementing practices are required to achieve effective zonal isolation and provide long-term well integrity for uninterrupted safe production and subsequent abandonment. Zonal isolation can be attained by paying close attention to optimizing the drilling parameters, hole cleaning, fluid design, cement placement, and monitoring. In challenging extended reach wells in the UAE, different methods were employed to deliver progressive improvement in zonal isolation. Cementing the intermediate and production sections in the UAE field is challenging because of the highly deviated, long, open holes; use of nonaqueous fluids (NAFs); and the persistent problem of lost circulation. Compounding the problem are the multiple potential reservoirs; the pressure testing of the casing at high pressures after cement is set; and the change in downhole pressures and temperatures during production phases, which results in additional stresses. Hence, the mechanical properties for cement systems must be customized to withstand the downhole stresses. The requirement of spacer fluids with nonaqueous compatible properties adds complexity. Lessons learned from prior operations were applied sequentially to produce fit-for-purpose solutions in the UAE field. Standard cement practices were taken as a starting point, and subsequent changes were introduced to overcome specific challenges. These challenges included deeper 12 ¼-in. sections, which made it difficult to manage equivalent circulating densities (ECDs), and a stricter requirement of zonal isolation across sublayers in addition to required top of cement at surface. To satisfy these requirements, several measures were taken gradually: applying engineered trimodal blend systems to remain under ECD limits; pumping a lower-viscosity fluid ahead of the spacer; using NAF-compatible spacers for effective mud removal; employing flexible cement systems to withstand downhole stresses; and modeling the cement job with an advanced cement placement software to simulate displacement rates, bottomhole circulating temperatures, centralizer placement, mud removal and comply with a zero discharge policy that restricts the extra slurry volume to reach surface. To enhance conventional chemistry-based mud cleaning, an engineered scrubbing additive was included in the spacers with a microemulsion-based surfactant. The results of cement jobs were analyzed by playback in advanced evaluation software to verify the efficiency of the applied solutions. This continuous improvement response to changes in well design has resulted in a significant positive change in cement bond logs; a flexural attenuation measurement tool has been used to evaluate the lightweight slurry quality behind the casing, which has helped in enhancing the confidence level in well integrity in these challenging wells. The results highlight the benefit of developing engineering solutions that can be adapted to respond to radical changes in conditions or requirements.

New York City Jails: COVID Discharge Policy, Data Transparency, and Reform

During the early stages of the COVID-19 pandemic in 2020, Mayor Bill de Blasio ordered the release of New York City jail inmates who were at high risk of contracting the disease and at low risk of committing criminal reoffense. Using public information, we construct and analyze a database of nearly 350,000 incarceration episodes in the city jail system from 2014 - 2020. In concordance with de Blasio's stated policy, inmates discharged immediately after his order were at a lower risk of reoffense than inmates discharged during the same calendar week in previous years. The inmates in the former group were also slightly older, on average, than those in the latter group, although the overall age distributions of the two groups were quite similar. Additionally, the inmates of the former group had spent dramatically longer in jail than those in the latter group. With the release of long-serving inmates demonstrated to be feasible, we also examine how the jail population would have looked over the past six years had caps in incarceration been in place. With a cap of one year, the system would experience a 15% decrease in incarceration. With a cap of 100 days, incarceration would be just under 50% of the realized value. Because our results are only as accurate as New York City's public-facing jail data, we discuss numerous challenges with this data and suggest improvements. These improvements would address issues including inmate age, gender, and race. Finally, we discuss policy implications of our work, highlight some opportunities and challenges posed by incarceration caps, and suggest key areas for reform. It is striking that the de Blasio administration was able to identify inmates at low risk of reoffense and was willing to release them. Their success with discharge during the early stages of COVID-19 suggests that low-risk inmates could be discharged sooner in general.

Paediatric major incident simulation and the number of discharges achieved using a major incident rapid discharge protocol in a major trauma centre: a retrospective study

ObjectivesHospitals have the responsibility of creating, testing and maintaining major incident (MI) plans. Plans emphasise readiness for acceptance of casualties, though often they neglect discharge planning and care for existing inpatients to make room for the sudden influx.After collaboration and design of a discharge policy for a paediatric MI, we aimed to establish the number of beds made available (primary outcome) to assess potential surge and patient flow. We hypothesised that prompt patient discharge would improve overall departmental flow. Flow is vital for sick patients awaiting admission, for those requiring theatre and also to keep the emergency department clear for ongoing admissions.Method and settingA simulated MI was declared at a London major trauma centre. Five paediatric priority 1 and 15 priority 2 and priority 3 patients were admitted. Using live bed boards, staff initiated discharge plans, and audits were conducted based on hospital bed occupancy and discharge capacity. The patients identified as dischargable were identified and folllowed up for 7 days.ResultsTwenty-nine ward beds were created (42% of the total capacity). Handwritten summaries just took 13.3% of the time that electronic summaries took for the same patients by the same doctor. In-hospital transfers allowed five critically injured children into paediatric intensive care unit (PICU), and creation of a satellite PICU allowed for an additional six more if needed.ConclusionWe increased level 3 capacity threefold and created 40% extra capacity for ward patients. A formalised plan helped with speed and efficiency of safe discharge during an MI. Carbon copy handwritten discharge letters allowed tracking and saved time. Robust follow-up procedures must be in place for any patients discharged.

464 - SURVEY OF THE ADEQUACY OF HOSPITAL DISCHARGE LETTERS FROM OLDER ADULT MENTAL HEALTH (OAMH) WARDS IN A SCOTTISH HEALTH REGION

Background:One form of communication deficiency leading to patient harm is failure to keep colleagues informed and to share appropriate levels of clinical information. The production of discharge letters is a clinical and professional requirement, deficiencies of which contribute to clinical risks, while failure to observe standards may be a focus of medico-legal enquiry.Objectives:To examine the adequacy of clinical discharge letters from the OAMH inpatient wards in one Scottish Health region (Fife, population 370,000) against the 14-day discharge policy, with focus on medication advice and follow-up arrangements.Methods:All discharge notifications from the five OAMH wards were examined retrospectively against the electronic records and case-files for the 7-month period ending 31st January 2020.Results:169 discharge notifications inclusive of 14 deaths were reduced to 123 after excluding brief inter-ward transfers. Female:male ratio of 1.05:1; average age 77 (range 60 -99) years, average inpatient duration 120 (range 2-934) days. There was no identified discharge letter in 20.3%. Direct admissions from Care Homes died more often (30%) than those admitted directly from home (2%), presumably a reflection of greater frailty. 29% patients were discharged to (19% admitted from) Care Homes. 59% patients had dementia, 20% an affective disorder, 7% a psychotic disorder, with 20% having multiple diagnoses. Antidepressants were the commonest (49%) regularly prescribed psychotropic medication on discharge both for those with (47%) or without (52%) dementia. 32% of all patients (25% in dementia) were discharged on antipsychotics, often without advice on monitoring, prescribing restrictions or risks. The 98 verified letters took 27 (range 0-168) days to verify, 67% failing the production-time standard. 53% discharges had multiple follow-up arrangements. Variabilities were noted in letter production according to the discharge ward (range 53-100%) and between consultant teams (verification rates 50-100%) where delays ranged 6-109 days and ability to produce letters within the standard ranged from 0-92% (average 33%).Conclusions:There appear significant failings in the timely transfer of clinical details between OAMH inpatient services and primary care services in this region that require intervention to minimise clinical risk and maximise patient safety. There were identified factors that are amenable to quality improvement.

Immediate Effects of Urgent Reorganisation of Emergency Department-Based Treatment Pathway in Nonperforated Appendicitis: A Retrospective Study

Background Acute appendicitis is a global disease and a very common indication for emergency surgery worldwide. The need for hospital resources is therefore constantly high. The administration in Kanta-Häme Central Hospital, Southern Finland, called for an urgent reorganisation due to shortage of hospital beds at the department of general surgery. According to it, postoperative treatment pathway of patients with nonperforated acute appendicitis was ordered to take place in the Emergency Department (ED). The aim of this study was to assess whether this reorganisation affected the length of in-hospital stay (LOS) and the 30-day complication rate.Methods This is a retrospective pre- and post-intervention analysis. After the reorganisation, most patients with nonperforated appendicitis were followed postoperatively at the 24-hour observation unit of the ED instead of surgical ward. Patients operated during the first three months after the reorganisation were compared to those operated during the three months before it. A case met inclusion criteria if there were no signs of appendiceal perforation during surgery. Exclusion criteria comprised age <18 years and perforated disease. Results During the study period, appendicectomy was performed on 112 patients, of whom 62 were adults with nonperforated appendicitis. Twenty-seven of the included patients were treated before the reorganisation, and 35 after it. Twenty of the latter were followed only at the ED. Postoperative LOS decreased significantly after the reorganisation. Median postoperative time till discharge was 15.7 hours for all patients after the reorganisation compared to 24.4 hours before the reorganisation (standard error 6.2 hours, 95% confidence interval 2.3–15.2 hours, p < 0.01). There were no more complications in the group treated postoperatively in the ED. Conclusions Early discharge of patients with nonperforated appendicitis after enforced urgent reorganisation of the treatment pathway in the ED observation unit is safe and feasible. Shifting the postoperative monitoring and the discharge policy of such patients to the ED – instead of the surgical ward – occurred in the majority of the cases after the reorganisation. This change may spare resources as in our series it resulted in a significantly shorter LOS without any increase in the 30-day complication rate.

Impact on Early Discharge After Emergency Department-Based Treatment Pathway in Nonperforated Appendicitis: A Retrospective Study

Background Acute appendicitis is a global disease and a very common indication for emergency surgery worldwide. The need for hospital resources is therefore constantly high. The administration in Kanta-Häme Central Hospital, southern Finland, called for an urgent reorganisation due to shortage of hospital beds at the department of general surgery. Treatment pathway of nonperforated acute appendicitis was moved into Emergency Department (ED). The aim of this study was to assess whether it affected the length of in-hospital stay (LOS) and the 30-day complication rate.MethodsThis is a retrospective pre- and post- intervention analysis. After the reorganisation, most postoperative patients with nonperforated appendicitis were followed at the 24-hour observation unit of the ED instead of the surgical ward. Patients operated during the first three months after the reorganisation were compared to those operated during the three months before it. A case met inclusion criteria if there were no signs of appendiceal perforation during surgery. Exclusion criteria comprised age <18 years and perforated disease. ResultsDuring the study period, appendicectomy was performed on 112 patients, of whom 62 were adults with nonperforated appendicitis. Twenty-seven of the included patients were treated before the reorganisation, and 35 after it. Twenty of the latter were followed only at the ED. LOS decreased significantly after the reorganisation. Median postoperative time till discharge was 15.67 hrs for all patients after the reorganisation and 13.13 hrs for those exclusively followed at the ED, compared to 24.42 hrs before the reorganisation (standard error 6.2 hrs, 95% confidence interval 2.3–15.2 hrs, p < 0.01). There were no more complications in the group treated postoperatively in the ED. ConclusionsEarly discharge from the ED observation unit after appendicectomy for nonperforated appendicitis in adults is safe and feasible. Shifting the postoperative monitoring and the discharge policy of such patients to the ED – instead of the surgical ward – occurred in the majority of the cases after the reorganisation. This change may spare resources as in this series it resulted in a significantly shorter LOS without any increase in the 30-day complication rate.