Using Quality Improvement Methodology to Increase Communication of Discharge Criteria on Rounds

OBJECTIVE: Clear communication about discharge criteria with families and the interprofessional team is essential for efficient transitions of care. Our aim was to increase the percentage of pediatric hospital medicine patient- and family-centered rounds (PFCR) that included discharge criteria discussion from a baseline mean of 32% to 75% over 1 year. METHODS: We used the Model for Improvement to conduct a quality improvement initiative at a tertiary pediatric academic medical center. Interventions tested included (1) rationale sharing, (2) PFCR checklist modification, (3) electronic discharge SmartForms, (4) data audit and feedback and (5) discharge criteria standardization. The outcome measure was the percentage of observed PFCR with discharge criteria discussed. Process measure was the percentage of PHM patients with criteria documented. Balancing measures were rounds length, length of stay, and readmission rates. Statistical process control charts assessed the impact of interventions. RESULTS: We observed 700 PFCR (68 baseline PFCR from July to August 2019 and 632 intervention period PFCR from November 2019 to June 2021). At baseline, discharge was discussed during 32% of PFCR. After rationale sharing, checklist modification, and criteria standardization, this increased to 90%, indicating special cause variation. The improvement has been sustained for 10 months. At baseline, there was no centralized location to document discharge criteria. After development of the SmartForm, 21% of patients had criteria documented. After criteria standardization for common diagnoses, this increased to 71%. Rounds length, length of stay, and readmission rates remained unchanged. CONCLUSION: Using quality improvement methodology, we successfully increased verbal discussions of discharge criteria during PFCR without prolonging rounds length.

Postoperative Antibiotics And Time To Reach Discharge Criteria After Appendectomy For Complex Appendicitis

Background: Postoperative antibiotic treatment is indicated for 3 – 5 days following appendectomy for complex appendicitis. However, meeting discharge criteria may allow for safe discontinuation of antibiotics and discharge. This study assessed the association between time to reach discharge criteria and duration of postoperative antibiotic use and length of hospital stay. Methods: This was a multicenter retrospective cohort study including patients who underwent appendectomy for complex appendicitis and received postoperative antibiotics for >24 hours. Main outcome measures were time to reach discharge criteria, duration of postoperative antibiotic use, length of hospital stay and postoperative infectious complications. Discharge criteria were defined as absence of fever (temperature ≤38°C) for 24 hours, ability to tolerate oral intake and pain controlled by oral analgesics.Results: A total of 124 patients were included between May 2014 and January 2015. Median time to reach discharge criteria was 2 days (interquartile range 1 – 3). Postoperative antibiotics duration and hospital stay were 5 (IQR 3 – 5) and 5 (IQR 4 – 6) days, respectively. Infectious complications occurred in 15 of 124 patients (12%) and was not different between patients reaching discharge criteria before or after 2 postoperative days.Conclusions: Discharge criteria were met by a median of 2 days after appendectomy for complex appendicitis. This suggests that postoperative antibiotics and hospital stay can be reduced without an increase in infectious complications. In daily practice this is not done, prescribed antibiotics are not reduced in total days given. Prospective studies that evaluate limited postoperative antibiotic use, based on these criteria, are necessary.

The impact of inhalation anesthetics on early postoperative cognitive function and recovery characteristics in Down syndrome patients: a randomized, double – blind study

Background Down syndrome (DS) is associated with intellectual disability. DS patients may be unable to cooperate and often require general anesthesia even for minor surgeries. Rapid recovery significantly contributes to fast-tracking. This prospective randomized, double - blind study investigates the impact of desflurane and sevoflurane on recovery and early postoperative cognitive function of these patients. Methods Forty-four patients undergoing dental surgery, were randomized to receive desflurane (DES-group) or sevoflurane (SEVO-group) for anesthesia maintenance. The primary outcome was postoperative cognitive function (Prudhoe Cognitive Function Test, PCFT) at 90 min and 4 h postoperatively. Secondary outcome measures were the time between volatile discontinuation and spontaneous breath, eye opening, extubation, orientation and response to commands, time to achieve an Aldrete score ≥ 9 in the Post-anesthesia Care Unit and time to fulfill discharge criteria (Post Anesthetic Discharge Scoring System, PADSS). Results At 90 min, PCFT scores significantly decreased from baseline in both groups. Nevertheless, at 4 h, in DES-group there was no significant change from baseline (p = 0.163), while in SEVO-group the decrease remained significant (p < 0.001). Desflurane was also found superior regarding recovery characteristics, such as time to eye opening (p = 0.021), spatial orientation (p = 0.004), response to commands (p = 0.004). Discharge criteria were met earlier in DES-group (p = 0.018 for Aldrete score / p < 0.001 for PADSS). Conclusions Desflurane was found superior to sevoflurane in terms of faster recovery and better preserved postoperative cognitive function in DS patients undergoing dental surgery. We suggest that desflurane, as part of a multimodal anesthetic approach, could be a useful agent to enhance early discharge from hospital of ambulatory patients with intellectual disability. Trial registration Registered with ClinicalTrials.gov (NCT02971254, principal investigator: E.G; November 2016).

Feasibility and Safety of Outpatient Thyroidectomy: A Narrative Scoping Review

BackgroundOutpatient thyroid surgery is gaining popularity as it can reduce length of hospital stay, decrease costs of care, and increase patient satisfaction. There remains a significant variation in the use of this practice including a perceived knowledge gap with regards to the safety of outpatient thyroidectomies and how to go about implementing standardized institutional protocols to ensure safe same-day discharge. This review summarizes the information available on the subject based on existing published studies and guidelines.MethodsThis is a scoping review of the literature focused on the safety, efficacy and patient satisfaction associated with outpatient thyroidectomies. The review also summarizes and editorializes the most recent American Thyroid Association guidelines.ResultsIn total, 11 studies were included in the analysis: 6 studies were retrospective analyses, 3 were retrospective reviews of prospective data, and 2 were prospective studies. The relative contraindications to outpatient thyroidectomy have been highlighted, including: complex medical conditions, anticipated difficult surgical dissection, patients on anticoagulation, lack of home support, and patient anxiety toward an outpatient procedure. Utilizing these identified features, an outpatient protocol has been proposed.ConclusionThe salient features regarding patient safety and selection criteria and how to develop a protocol implementing ambulatory thyroidectomies have been identified and reviewed. In conclusion, outpatient thyroidectomy is safe, associated with high patient satisfaction and decreased health costs when rigorous institutional protocols are established and implemented. Successful outpatient thyroidectomies require standardized preoperative selection, clear discharge criteria and instructions, and interprofessional collaboration between the surgeon, anesthetist and same-day nursing staff.

Early discharge after temporary epicardial pacing wire removal: a retrospective cohort study

Background/Aims Insertion of temporary epicardial pacing wires is a common procedure following cardiac surgery. Complications related to their removal, though rare, can be fatal. There are no nationally recognised guidelines on the removal of pacing wires or safe discharge thereafter. This study aimed to evaluate the safety of discharging stable cardiac surgery patients, who meet all other discharge criteria, within 4–24 hours of epicardial pacing wire removal. Methods A single-centre retrospective cohort study was conducted with all consecutive cardiac surgery patients who underwent temporary pacing wire insertion at a tertiary centre for cardiac surgery (n=250). Patient records were retrospectively reviewed to extract and collate variables related to the procedure, as well as acute and long-term adverse outcomes. Data were analysed using a variety of statistical tests, with P<0.005 being taken to indicate significance. Results No significant difference was observed in the incidence of acute (P=0.646) or long-term complications (P=0.118) between patients discharged before 24 hours after wire removal and those discharged later. Patients with moderate or severe resistance to removal were significantly more likely to experience acute complications (P<0.001). Patients with an international normalised ratio of >2 at removal showed significantly more long-term complications (40.9% vs 16.2%, P=0.02). Conclusions The practice of discharging patients within 24 hours after pacing wire removal, if all other discharge criteria are met, is safe. High resistance and an elevated international normalised ratio (>2) at the time of removal are independent predictors of acute and long-term complications. Such patients should be closely monitored after removal and might benefit from delayed discharge. Further research should be conducted to make this study's results more generalisable and to formulate guidelines to standardise practice.

Continued nucleic acid tests for SARS-CoV-2 following discharge of patients with COVID-19 in Lu’an, China

Background Studies have shown that discharged Coronavirus disease 2019 (COVID-19) patients have retested positive for SARS-CoV-2 during a follow-up RT-PCR test. We sought to assess the results of continued nucleic acid testing for SARS-CoV-2 patients in COVID-19 patients after they were discharged in Lu’an, China. Methods We conducted RT-PCR tests on sputum, throat swabs, fecal or anal swabs, and urine samples collected from 67 COVID-19 patients following discharge. Samples were collected on the 7th and 14th days following discharge. Patients testing positive on the 7th or 14th day were retested after 24 hours until they tested negative twice. Results Seventeen (17/67, 25.4%) discharged COVID-19 patients had a positive RT-PCR retest for SARS-CoV-2. Among them, 14 (82.4%) were sputum positive, five (29.4%) were throat swab positive, seven (41.2%) were fecal or anal swab positive, one (5.9%) was urine sample positive, five (29.4%) were both sputum and throat swab positive, four (23.5%) were both sputum and fecal test positive, and one (5.9%) was positive of all four specimens. The shortest period of time between discharge and the last positive test was 7 days, the longest was 48 days, and the median was 16 days. The proportion of positive fecal or anal swab tests increased from the third week. The median Cq cut-off values after onset were 26.7 after the first week, 37.7 the second to sixth week, and 40 after the sixth week. There were no significant differences between the RT-PCR retest positive group and the unrecovered positive group. Conclusions There was a high proportion of patients who retested positive for COVID-19. Discharge criteria have remained fairly consistent so we encourage regions affected by COVID-19 to appropriately amend their current criteria.

Prospective directions and problems of ensuring Radiation Safety in Radiation Medicine

The development of Radiation Medicine in the Russian Federation has resulted in the necessity to improve the regulatory and methodological support for ensuring Radiation Safety. Following the introduction of new diagnostics and therapy methods into practice, as well as the use of new radiopharmaceuticals, the actualization of radiation monitoring methods and the provision of radiological protection for patients, personnel and the public have become the most urgent tasks. Radionuclide therapy with new radiopharmaceuticals, which can be used in the day patient departments, is one of the promising directions in the development of Russian Radiation Medicine. The main tasks of ensuring Radiation Safety in the departments of radionuclide therapy are the regulation of radioactive waste management, the development of discharge criteria after the administration of radiopharmaceuticals and methods for Internal Dosimetry.

SARS-CoV-2 Viral Shedding and Transmission Dynamics: Implications of WHO COVID-19 Discharge Guidelines

The evolving nature of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has necessitated periodic revisions of COVID-19 patient treatment and discharge guidelines. Since the identification of the first COVID-19 cases in November 2019, the World Health Organization (WHO) has played a crucial role in tackling the country-level pandemic preparedness and patient management protocols. Among others, the WHO provided a guideline on the clinical management of COVID-19 patients according to which patients can be released from isolation centers on the 10th day following clinical symptom manifestation, with a minimum of 72 additional hours following the resolution of symptoms. However, emerging direct evidence indicating the possibility of viral shedding 14 days after the onset of symptoms called for evaluation of the current WHO discharge recommendations. In this review article, we carried out comprehensive literature analysis of viral shedding with specific focus on the duration of viral shedding and infectivity in asymptomatic and symptomatic (mild, moderate, and severe forms) COVID-19 patients. Our literature search indicates that even though, there are specific instances where the current protocols may not be applicable ( such as in immune-compromised patients there is no strong evidence to contradict the current WHO discharge criteria.