Does the Implementation of Children's Hospital in the Home affect Health Outcomes for Children with Chronic Respiratory Conditions? A non-contemporary retrospective cohort comparison study

Objective To investigate whether the implementation of a Children’s Hospital in the Home (CHITH) service affects clinical and service outcomes for children with chronic respiratory conditions including cystic fibrosis and non-CF bronchiectasis. Study Design A non-contemporary retrospective cohort comparison study. Setting/Patients Children aged between 1 and 17.99 years who were admitted to Gold Coast University Hospital (GCUH) with a chronic respiratory condition for pulmonary optimisation were eligible. Methods A clinical audit was utilised to compare children with chronic respiratory conditions who were admitted to GCUH in (a) the 12 months prior to implementation of CHITH and (b) the 12-month period following the implementation of CHITH. Outcomes of interest included lung function; inpatient length of stay (days); duration on intravenous antibiotics and weight gain. Normally distributed data was compared using the t-test, while non-parametric data was analysed with the Mann-Whitney test. Results Data was analysed from 58 admissions, 27 (46.55%) of which occurred in the 12 months of traditional management and 31 (53.45%) in the 12 months following the implementation of the CHITH service. A statistically significant reduction in inpatient length of stay was noted following implementation of the CHITH service: 14.25 versus 6.0 days (p-value=0.0001). The pre-CHITH cohort had a non-significant mean improvement of 7.625% in their FEV1 (pred%) compared to 9.75% in the CHITH cohort (p-value=0.44). There was no significant difference in the secondary clinical outcomes. Conclusion The CHITH service provided equitable clinical outcomes for children with a chronic respiratory condition whilst significantly reducing inpatient length of stay.

Free Flap microvascular pharyngeal closure results in improved dysphagia-specific quality of life following total laryngectomy

Background Total laryngectomy (TL) as either a primary or salvage treatment strategy remains an effective oncologic operation in the management of laryngeal cancer. Dysphagia is the most common complication following TL and this has a significant impact on patients’ quality of life (QOL). Following removal of the larynx, a number of pharyngeal closure techniques exist. We aimed to evaluate the effect pharyngeal closure techniques have on dysphagia-specific QOL postoperatively. Methods We retrospectively reviewed patients who had undergone TL at our institution (2014–2019). Patients alive at the time of study were invited to complete the MD Anderson Dysphagia Inventory (MDADI). Outcomes were compared among Primary Closure (PC), Pedicled Pectoralis Major Myocutaneous Flap (PMMF) and Free Flap (FF) closure groups. Results There were 27 patients identified for inclusion. Eight patients (30%) underwent PC, 10 patients (37%) had PMMF-assisted closure and 9 patients (33%) underwent FF-assisted closure. Patients within the FF group scored consistently higher MDADI scores across all subscales (emotional, functional, physical, global) as well as composite MDADI score in comparison to the PC and PMMF groups. FF closure was associated with a reduced inpatient length of stay (LOS). Additionally, no significant differences in postoperative morbidity including rates of pharyngo-cutaneous fistula (PCF) were observed between groups. Conclusions We now advocate FF closure for our patients following salvage TL due to the improved dysphagia-specific QOL, reduced inpatient LOS and lack of additional surgical morbidity. Level of evidence, Level III, therapeutic/prognostic study.

Acute kidney injury associated with area under the curve versus trough monitoring of vancomycin in obese patients.

Vancomycin is a first-line agent used in the treatment of methicillin-resistant Staphylococcus aureus ; however, vancomycin is associated with acute kidney injury (AKI). Previous literature demonstrates decreased incidence of AKI using 24-hour area under the concentration-time curve (AUC 24 ) monitoring, but its safety is unknown in obese populations. Patients ≥18 years, with Body Mass Indices (BMI) ≥30 kg/m 2 , admitted between August 2015-July 2017 or October 2017-September 2019, who received vancomycin for ≥72 hours and had level(s) drawn within 96 hours of initiation were included. The primary outcome was incidence of AKI. Secondary outcomes included inpatient mortality rate, median inpatient length of stay, median vancomycin trough concentration, and median vancomycin AUC 24 . AKI was identified using the highest serum creatinine value compared to the value immediately prior to vancomycin initiation based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Overall, 1024 patients met inclusion criteria, with 142 out of 626 patients in the trough group and 65 out of 398 patients in the AUC 24 group meeting criteria for AKI (22.7% vs. 16.3%, p=0.008). Logistic regression of the data to account for confounding factors maintained significance for the reduction in incidence of AKI with AUC 24 monitoring compared to trough monitoring (p=0.010). Monitoring of vancomycin with AUC 24 was associated with a decreased risk of AKI when compared with trough monitoring in obese patients.

EP.TU.826Using Indocyanine Green (ICG) during laparoscopic bowel resections for elective cancer patients reduces anastomotic leaks and length of stay

Introduction Anastomotic leakage (AL) after colorectal surgery is associated with significant morbidity and mortality. Poor perfusion of bowel anastomosis is a significant contributing factor. ICG is a dye administered during laparoscopic surgery to assess bowel perfusion by fluorescent imaging – the aim of this study was to determine whether its use in our centre during elective laparoscopic colorectal cancer resections led to improved patient outcomes. Method Single-centre comparative study of all patients who underwent elective colorectal laparoscopic resections for cancer January 2019- January 2021. Primary outcome investigated was AL. Secondary outcomes: in-patient length of stay, clinical suspicion of AL and post-operative ileus. Cohorts compared with χ2 test. Results 25 patients had resections with ICG, 60 without. None in ICG group, and three in non-ICG group (5%) had AL; p-value 0.29. The ICG group were less likely to have CT for suspected anastomotic leak 12% vs 23.3%, p-value 0.29; and, post-operative ileus 5.3% vs 19.6%, p-value 0.09. Statistically significant reduction in mean inpatient length of stay when ICG used (4.0 days, 95% CI 3.3-4.7) compared to when not used (6.7 days, 95% CI 5.0-8.3). Conclusion Only a small number of previous studies have compared AL rates with and without ICG, finding that its use leads to a significant reduction in AL. While sample size small, our findings supports this. Using ICG also led to a significant reduction in inpatient length of stay. ICG fluorescence angiography is now established as our normal practice for all colorectal resections as a safe, innovative, simple technology.

Clinical characteristics of spinning-induced rhabdomyolysis and other causes of rhabdomyolysis: a comparative study

Introduction Spinning is an indoor stationary cycling programme that can cause severe rhabdomyolysis. We compared the clinical characteristics of spinning-induced exertional rhabdomyolysis (SER) with other exertional rhabdomyolysis (ER) and non-exertional rhabdomyolysis (NER). Methods This was a retrospective observational study of adult patients presenting with rhabdomyolysis to an emergency department from August 2018 to August 2019. Patients were classified as SER, ER or NER based on chart review. We compared patient demographics, serum creatine kinase (CK), transaminase and creatinine levels, admission rates, duration of hospitalisation and treatment prescribed. Results: 62 patients were analysed. SER patients were predominantly female (77% vs. 24% vs. 26%, p < 0.01), Chinese (100% vs. 47% vs. 79%, p < 0.01) and younger (mean age 27.7 vs. 34.6 vs. 59.4 years, p < 0.01) than those with ER and NER. The SER group had the highest CK level (20,000 vs. 10,465 vs. 6,007 U/L, p < 0.01) but the lowest mean serum creatinine level (53.5 vs. 80.9 vs. 143.5 μmol/L, p < 0.01) compared to the ER and NER groups. Admission rates were the highest in SER patients (100% vs. 57% vs. 90%, p < 0.01). SER mean inpatient length of stay was longer than ER but shorter than NER patients (4.3 vs. 1.9 vs. 6.0 days, p = 0.02). Conclusion: SER is a unique form of rhabdomyolysis. Predominantly seen in young, healthy women, it often presents with extremely high CK levels. However, the prognosis is good and the rate of complication is low with fluid treatment.

Addressing the disparities and the factors related to prolonged inpatient length of stay for solid tumor oncology patients during the COVID-19 pandemic: A narrative review

Solid tumor oncology treatments are primarily performed in the outpatient setting. However, hospitalizations are inevitable due to complications of cancer and treatment-related toxicities. With rising health care spending, the length of hospital stay (LOS) is increasingly considered a proxy for healthcare costs. There are several ongoing eff orts to abbreviate the inpatient LOS and ensure a safe and timely discharge to the outpatient setting. In addition to the acute illness and the associated comorbidities, various factors aff ect the LOS: social determinants of health (SDOH), nutritional status in cancer patients, and end-of-life issues. Furthermore, it is unclear how the institutional policies on social distancing and visitation during the current coronavirus disease (COVID-19) pandemic may impact the LOS. The purpose of this article is to review various factors and barriers that lead to longer LOS for solid tumor patients during the COVID-19 pandemic, and identify the critical areas of quality improvement.

Health Care Costs and Resource Utilization Among Patients With Crohn’s Disease With and Without Perianal Fistula

Background Perianal fistula (PAF), a complication of Crohn’s disease (CD), is associated with substantial economic costs and poor prognosis. We determined prevalence of PAF CD in the United States and compared costs and health care resource utilization (HRU) of PAF CD patients with matched non-PAF CD patients. Methods This was a retrospective cohort study of claims data from the IBM MarketScan Commercial Database from October 1, 2015, to September 30, 2018. Eligible patients were aged 18 to 89 years with ≥2 CD diagnoses. Patients with PAF CD had ≥1 PAF diagnosis or procedure code and were matched with non-PAF CD patients. Cumulative prevalence of PAF CD in the US population was calculated across total patients in MarketScan. All-cause and gastrointestinal (GI)-related costs and HRU were compared between groups using a generalized linear model (GLM). Results Cumulative 3-year prevalence of PAF was 7.70% of patients with CD (N = 81,862) and 0.01% of the US population. Among PAF CD (n = 1218) and matched non-PAF CD (n = 4095) patients, most all-cause costs and HRU were GI-related. Mean total all-cause and GI-related health care costs per patient and per year for PAF CD were $85,233 and $71,612, respectively, vs $40,526 and $29,458 for non-PAF CD (P &lt; .0001). Among PAF CD vs non-PAF CD patients, GLM-adjusted proportions of patients with GI-related inpatient, outpatient, or pharmacy visits, mean GI-related inpatient length of stay, and mean GI-related surgeries were higher (P &lt; .0001 for all comparisons). Conclusions Costs and HRU are significantly higher for patients with PAF CD vs non-PAF CD patients, highlighting the economic burden of the disease.

The impact of inpatient bed capacity on length of stay

Objective Large reductions in inpatient length of stay and inpatient bed supply have occurred across health systems in recent years. However, the direction of causation between length of stay and bed supply is often overlooked. This study examines the impact of changes to inpatient bed supply, as a result of recession-induced healthcare expenditure changes, on emergency inpatient length of stay in Ireland between 2010 and 2015. Study design We analyse all public hospital emergency inpatient discharges in Ireland from 2010 to 2015 using the administrative Hospital In-Patient Enquiry dataset. We use changes to inpatient bed supply across hospitals over time to examine the impact of bed supply on length of stay. Linear, negative binomial, and hospital–month-level fixed effects models are estimated. Results U-shaped trends are observed for both average length of stay and inpatient bed supply between 2010 and 2015. A consistently large positive relationship is found between bed supply and length of stay across all regression analyses. Between 2010 and 2012 while length of stay fell by 6.4%, our analyses estimate that approximately 42% (2.7% points) of this reduction was associated with declines in bed supply. Conclusion Changes in emergency inpatient length of stay in Ireland between 2010 and 2015 were closely related to changes in bed supply during those years. The use of length of stay as an efficiency measure should be understood in the contextual basis of other health system changes. Lower length of stay may be indicative of the lack of resources or available bed supply as opposed to reduced demand for care or the shifting of care to other settings.

Pain management consultation for acute pancreatitis: impact on length of stay and opioid utilization

Aim: The purpose of the study was to understand the impact of a pain management consult for acute pancreatitis patients on their inpatient length of stay, morphine milligram equivalences (MMEs) and pancreatitis severity. Materials & methods: Adult patient data were extracted from the electronic health records from 1 October 2016 to 31 December 2018. Results & conclusion: Of 277 patients with a single acute pancreatitis hospitalization, 23 had a pain consultation (treatment group), whereas 254 did not (control group). There were statistically significant differences in median length of stay, median MME total and median MME per day between the treatment and control groups with comparable severity and pain scores (6.8 vs 3.1 days, 196.5 vs 33.8 MMEs, 30.9 vs 12.1 MMEs, respectively, p < 0.0001). This study emphasizes the complexity of pain management and the importance of further research in the field.