REBOA for Inter-Hospital Transfer: Are We Walking in the Dark?

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Impact of Race on Decision Making for Nursing Home Residents With Advanced Dementia: Can We Disrupt and Transform?

Despite 20 years of research and numerous experts and associations advocating a palliative approach to care for nursing home (NH) residents with advanced dementia, research consistently demonstrate striking and persistent racial differences in the use of burdensome interventions such as feeding tubes and hospital transfer. Most notable is that Black NH residents experience more burdensome interventions at the end of life. The reasons for these differences are poorly understood. The purpose of this study was to examine NH staff members’ perceptions of advance care planning with proxies of Black and White residents. We conducted thematic analysis of semi-structured interviews with 158 NH staff members gathered as part of the ADVANCE study. This is a large qualitative study in 13 NHs in 4 regions of the country aimed at explaining regional and racial factors influencing feeding tube and hospital transfer rates. We found that NH staff, regardless of region of the country, held several assumptions about Black proxies including: being attached or not wanting to let go; not wanting to talk about death, believing everything must be done; not wanting to play God; having large conflicted families, not trusting; putting on attitude, and tending not to use NHs. We found that these assumptions led some NH staff to feel that rather than engaging in shared decision making, they were engaged in a battle with proxies leading them to pick and choose their battles and at times even giving up trying. Whether these assumptions can be disrupted and transformed will be discussed.

No Increase in Short-Term Mortality Following COVID-19 Vaccination Among Nursing Home Residents

Reports of fatal adverse events following mRNA-based vaccination for COVID-19 in Norwegian nursing home (NH) residents have raised concern regarding vaccine safety in very old and frail persons. A limitation of these reports, however, is the absence of contemporaneous control groups, particularly given the high baseline mortality in this population. Using electronic health records’ data on resident deaths, hospital transfer, vaccination, and daily census from Genesis Healthcare, a large NH provider spanning 24 U.S. states, we compared 7-day mortality and hospitalization rates for vaccinated versus unvaccinated NH residents. Between December 18, 2020 and December 31, 2020, 7006 residents across 118 NHs were vaccinated with the first dose. Mortality and hospital transfer rates within 7 days of vaccination were compared to rates for: (1) unvaccinated residents in the same facility within 7 days of the vaccine clinic (n=4414), and (2) residents in 166 yet-to-be-vaccinated facilities between December 25, 2020 and January 1, 2021 (n=17,076). We excluded residents with a positive SARS-CoV-2 diagnostic test within 20 days prior to their 7-day observation window. Mortality rates per 100,000 residents were lower among vaccinated (587, 95%CI: 431, 798) versus unvaccinated residents within the same facilities (984, 95%CI: 705, 1382), and compared to residents in not-yet-vaccinated facilities (912, 95%CI: 770-1080), with overlapping 95% CIs. Hospital transfers were lower among vaccinated residents than in either comparison group, but with overlapping CIs. Our findings suggest that short term mortality rates appear unrelated to vaccination for COVID-19 in NH residents, and should dispel concerns raised by previous reports.

Regular feedback on inter-hospital transfer improved the clinical outcome and survival in patients with multiple trauma: a retrospective cohort study

Background Undertriage of major trauma patients is unavoidable, especially in the trauma system of rural areas. Timely stabilization and transfer of critical trauma patients remains a great challenge for hospitals with limited resources. No definitive measure has been proven to improve the outcomes of patients transferred with major trauma. The current study hypothesized that regular feedback on inter-hospital transfer of patients with major trauma can improve quality of care and clinical outcomes. Method This retrospective cohort study retrieved data of transferred major trauma patients with an injury severity score (ISS) > 15 between January 2010 and December 2018 from the trauma registry databank of a tertiary medical center. Regular monthly feedback on inter-hospital transfers was initiated in 2014. The patients were divided into a without-feedback group and a with-feedback group. Demographic data, management before transfer, and outcomes after transfer were collected and analyzed. Results A total of 178 patients were included: 69 patients in the without-feedback group and 109 in the with-feedback group. The with-feedback group had a higher ISS (25 vs. 27; p = 0.049), more patients requiring massive transfusion (14.49% vs. 29.36%, p = 0.036), and less patients with Glasgow Coma Scale ≤8 (30.43% vs. 23.85%, p < 0.001). After adjusting for confounding factors, the with-feedback group was associated with a higher rate of blood transfusion before transfer (adjusted odds ratio [aOR]: 2.75; 95% confidence interval [CI]: 1.01–7.52; p = 0.049), shorter time span before blood transfusion (− 31.80 ± 15.14; p = 0.038), and marginally decreased mortality risk (aOR: 0.43; 95% CI: 0.17–1.09; p = 0.076). Conclusion This study revealed that regular feedback on inter-hospital transfer improved the quality of blood transfusion.

Kết quả điều trị phẫu thuật nội soi viêm ruột thừa ở phụ nữ mang thai tại Bệnh viện Đa khoa Tỉnh Thái Bình

TÓM TẮT Mục tiêu: Đánh giá kết quả điều trị phẫu thuật nội soi viêm ruột thừa ở phụ nữ mang thai tại bệnh viện Đa khoa tỉnh Thái Bình. Phương pháp nghiên cứu: Mô tả hồi cứu 35 trường hợp viêm ruột thừa ở phụ nữ mang thai được điều trị phẫu thuật nội soi. Kết quả: 100% bệnh nhân được mổ cắt ruột thừa nội soi. Thời gian phẫu thuật trung bình 50,7 ± 13,6 phút (30 - 70 phút). Thời gian phẫu thuật kéo dài hơn ở nhóm viêm phúc mạc ruột thừa (56,7 ± 8 (40 - 70) phút) so với viêm ruột thừa mà không có viêm phúc mạc (p < 0,05). Có 3 trường hợp phải chuyển viện do sốt, dọa sẩy thai, dọa đẻ non. Kết quả điều trị 91,4 % kết quả tốt; 8,6% kết quả trung bình, không có trường hợp nào thai phụ bị tử vong, không có thai nhi bị tử vong. Kết luận: Phẫu thuật nội soi ổ bụng có thể ứng dụng an toàn để điều trị viêm ruột thừa ở phụ nữ mang thai, với tỉ lệ tai biến và biến chứng thấp cho thai phụ và thai nhi. ABSTRACT THE RESULTS OF TREATING APPENDICITIS USING LAPAROSCOPIC SURGERY IN PREGNANT WOMEN IN THAI BINH PROVINCIAL GENERAL HOSPITAL Objective: To evaluate the results of appendicitis endoscopic surgical treatment in pregnant women at Thai Binh Provincial General Hospital. Method: Retrospective describe of 35 pregnant women diagnosed with appendicitis treated using laparoscopic surgery. Results: 100% of patients underwent laparoscopic appendectomy. Average surgery time 50,7 ± 13,6 minutes (30 - 70 minutes). Surgery time was longer in the group of appendicitis (56,7 ± 8 (40 - 70) minutes) compared with appendicitis without peritonitis (p < 0,05). There were 3 cases of hospital transfer due to fever, threat of miscarriage, threat of preterm birth. Results of treatment 91,4% of the results were good; 8,6% of the average results, no case of death of the pregnant woman, no death of the fetus. Conclusion: Abdomen endoscopic surgical treatment can be used to treat appendicitis in pregnant women with low rate of complications for both the women and fetus. Key words: Acute appendicitis, appendicitis in pregnant women

Abstract 1122‐000031: Reasons Thrombectomy Candidates Become Ineligible After Transfer for Treatment in a Hub‐And‐Spoke Telestroke Model

Introduction : The care of emergent large vessel occlusion (ELVO) stroke patients has been revolutionized by endovascular thrombectomy (EVT). Given its robust efficacy, it is crucial to optimize delivery to eligible patients. Within hub‐and‐spoke hospital system models, some patients first present to distant spoke hospitals and require transfer to hub hospitals for EVT. We sought to understand reasons EVT candidates become ineligible after transfer for treatment. Methods : Consecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre‐transfer CTA‐defined ELVO and Alberta Stroke Program Early CT Score ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90‐day functional independence (modified Rankin Scale, mRS ≤2). Results : 258 patients were identified with median age 70 years (IQR 60–81) and 50% female. 44% underwent EVT upon hub arrival, of which 87% achieved Thrombolysis in Cerebral Infarction 2b‐3 reperfusion. Compared to EVT‐eligible patients, ineligible patients were older (73 vs 68 years, p = 0.04), had lower NIH Stroke Scale (NIHSS, 10 vs 16, p<0.0001), longer LKW‐hub arrival time (8.4 vs 4.6 hours, p<0.0001), and received less IV alteplase (32% vs 45%, p = 0.04). The clinical reasons cited for becoming EVT ineligible upon hub arrival included large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion location (5%), subocclusive lesion (3%), and goals of care (3%). Becoming EVT ineligible independently reduced the odds of 90‐day functional independence (aOR = 0.26, 95%CI = 0.12,0.56; p = 0.001), even when controlling for age, NIHSS, and LKW‐hub arrival time. Conclusions : Approaches to increase EVT eligibility among ELVO transfers may improve long term outcomes. A primary reason for becoming EVT ineligible is infarct growth. Future studies should explore triaging patients directly to EVT‐capable hubs when feasible, improving inter‐hospital transfer times, supporting ischemic penumbra before EVT, and developing novel neuroprotective agents.

High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit

BackgroundMobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported.MethodsWe performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified.Results1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5–4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1–3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90–139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required.ConclusionsMSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.