The Association Between Pain and In-Hospital Complications and Duration of Stay After Colorectal Surgery

BackgroundPain is a subjective and multidimensional experience often inadequately managed following surgery. Postoperative pain has been shown to correlate with hospital length of stay (HLOS) and hospital complications. Given advancements in preemptive pain management approaches, reevaluation is necessary.AimsThe purpose of this study was to examine the association between postoperative pain intensity and HLOS and in-hospital complications among patients who underwent colorectal surgery, adjusted by sociodemographic and underlying medical variables.Setting and PatientsWe used electronic medical records. Data were collected from patients who underwent colorectal surgery at a large general hospital in Israel from January 2012 to December 2018.Design and MethodsThis is a retrospective cohort study. Information on HLOS, medical diagnoses, pain intensity, use of analgesics, postoperative infections, patient sociodemographic data, chronic diseases, functionality status, and source of admission were extracted from medical records. Logistic regression analysis was used for the final model, and HLOS and in-hospital complications were the major outcomes.ResultsWe enrolled 1,073 patients. Of them, 554 males (51.6%) with a mean age of 62.54 ± 16.55 years. The median postoperative pain score was 1.54 (interquartile range, 0.84; 2.16), and an in-hospital complication rate of 1.3% (n = 14). Postoperative pain was not associated with prolonged HLOS with adjustment to relevant independent variables (odds ratio, 1.399; 95% confidence interval, 0.759-2.578; p = .282). Contrarily, age, malignancy, assistance needed in activities of daily living, use of analgesic agents, and postoperative infection were risk factors for prolonged HLOS. Additionally, postoperative pain was not related to a higher risk of in-hospital complications.ConclusionsPain intensity post colorectal surgery was not a risk factor for extended HLOS or in-hospital complications. In contradistinction, tending to patient needs, adequate analgesic use, and reducing infection rates can shorten HLOS, improve health outcomes, and economize health care resources.     

Patient-related Risk Factors for Nausea and Vomiting With Standard Antiemetics in Patients With Cancer Receiving Carboplatin: A Retrospective Study

PurposeThis study aimed to identify patient-related risk factors for chemotherapy-induced nausea and vomiting (CINV) in patients with cancer receiving carboplatin in addition to standard antiemetics, using real-world data.MethodsIn this single-center, observational study, data from electronic medical records of consecutive patients with solid tumors who had received their first cycle of a carboplatin-based regimen and were treated with a 2- or 3-drug combination of antiemetics from January 2014 to January 2019 at Toranomon Hospital were retrospectively analyzed. The primary end point was the occurrence of a complete response (CR) within 5 days after the first cycle, which was defined as no vomiting and no use of rescue medication for CINV. A receiver operating characteristic curve, univariable, and multivariable logistic regression analyses were used.FindingsA total of 314 patients were evaluated in this study. The proportion of patients who had a CR in the overall, acute, and delayed phases was 76.8% (n = 241), 98.7% (n = 310), and 77.4% (n = 243), respectively. Similar to univariable logistic regression analysis, multivariable logistic regression analysis revealed that age ≥70 years and total dexamethasone dose ≥14.6 mg were significantly associated with a non-CR in the overall phase, whereas female sex, history of habitual alcohol intake, and history of smoking were not associated with a non-CR in the overall phase.ImplicationsOur study findings suggest that a patient age of <70 years and a total dexamethasone dose of <14.6 mg are high-risk factors for carboplatin-induced CINV     

Organ donation within the intensive care unit: A retrospective audit

BackgroundDespite many Australians supporting organ donation, national posthumous organ donation rates have not increased as expected over the last three decades. Little is known about the barriers to organ donation for patients in intensive care that meet the criteria for organ donation.ObjectiveThe aim of this study was to describe the characteristics of patients identified as potentially suitable for organ donation and to explore the variables associated with the success, or failure, of solid organ donation within the context of an Australian public hospital intensive care unit (ICU).MethodsA retrospective audit examined electronic records of 280 potential organ donors aged 18–80 years, admitted into the ICU between 1 July 2012 and 30 June 2016. Data extracted from three separate electronic hospital databases were amalgamated for analysis.ResultsOf the 280 potential organ donors identified, conversations with families of 182 (65%) patients resulted in their agreement to organ donation. Consent to organ donation was most often provided by the patient's spouse (65, 35.7%); however, only 63.7% (n = 116) were successful organ donors. The remaining 36.3% (n = 66) of patients did not donate organs for medical reasons. Compared with those who did not donate, the typical organ donor was significantly younger (M 49.9 years, p = 0.020), Australian-born (p = 0.031), and had a shorter length of ICU stay (M 64.9 h, p = 0.002). The most frequently donated organs were kidneys (103, 88.8%), lungs (59, 50.9%), and livers (52, 44.8%).ConclusionThis study provided insights into patient, family, and organisational factors contributing to the success of organ donation outcomes in the ICU. Two factors that adversely impacted donation outcomes were the following: (1) the family did not consent to organ donation on behalf of the patient and (2) consent was provided, but donation did not proceed for medical reasons. Although the focus on the consenting process has been raised, this study highlights the additional impact of medical suitability on rates of organ donation. Family members may experience significant disappointment after consent that may have repercussions on their health and also future donation considerations. This study also highlighted some deficiencies in the databases that, if addressed, could better inform organisational processes in the consent and support of those making decisions about consent.     

Utility of HEART Pathway in Identifying Low-Risk Chest Pain in Emergency Department

BackgroundChest pain is a common presenting symptom in the emergency department (ED). The HEART (history, electroencephalogram [ECG], age, risk factors, and troponin I) score, with addition of troponin at 3 h, helps to determine appropriate risk stratification of the patients.ObjectiveThis study evaluated the utility of the HEART pathway as a decision aid designed for risk stratification of patients with acute-onset chest pain for early and safe disposition.MethodsThis was a prospective observational study done in a tertiary care center. Focused history, 12-lead ECG, and baseline troponin I level on arrival and at hour 3 were recorded. Subjects were classified as low risk (HEART score 0–3) or high risk (HEART score ≥ 4). Patients with a HEART score of 0–3 with negative troponin I at 3 h were discharged and were followed up for major adverse cardiac events (MACEs) within 30 days of ED presentation.ResultsA total of 250 patients were screened for the study, of which 151 were included for the final analysis. One hundred and two patients (68%) were male and 54% of patients were younger than 45 years. HEART scores of 0 (n = 16), 1 (n = 43), 2 (n = 44), and 3 (n = 48) were observed. There was only 1 MACE (0.7%) in 30 days after ED discharge in the study population. The mean length of ED stay in the low-risk group was 4.5 h.ConclusionsLow-risk patients, as per the HEART pathway, can be discharged safely from the ED, which reduces ED stay and health care resource use.     

Weight and height documentation: Does ICU measure up?

BackgroundReliable assessment and documentation of weight and height are essential for the accurate delivery of many critical care interventions.MethodsWe conducted a 3-month retrospective, cross-sectional, single-centre audit to determine the prevalence of weight and height documentation in the clinical records of patients admitted to the intensive care unit (ICU) for the period from 3 months prior to hospital admission up to hospital discharge.ResultsOne hundred forty-one index ICU admissions were identified from October–December 2015 with 138 medical records available for analysis. Median (interquartile range) age was 64.5 (50.8–75.3) years, the majority were male (60.9%, 84/138), and the ICU admission Acute Physiology and Chronic Health Evaluation II score was 19.0 (14.0–25.0). Overall, weight and height were recorded in 90 (65.2%) and 63 (45.6%) patients, respectively. For elective postoperative admissions (n = 20), weight and height were recorded in 20 (100%) and 19 (95%) patients. For emergency medical and surgical admissions, 70 (59.3%) and 44 (37.2%) patients had weight and height recorded in both the 3-month period prior to hospital admission and the in-hospital period. A moderate, positive correlation was shown, r = 0.55, P < 0.001, with a longer hospital length of stay being associated with a greater number of weight and height records for each patient. In the emergency patient cohort, 81.7% (n = 215/263) of weight- and/or height-based interventions occurred before or during the ICU admission, of which 69.9% (n = 184/263) required consideration of ideal body weight.ConclusionMeasurement and medical record documentation of weight and height is infrequently performed in ICU patients. Given the clinical requirement for accurate measurement and documentation, further research to understand the barriers to perform and document this important process of care is necessary.     

The use of altered rapid response calling criteria in a tertiary referral facility

PurposeThe purpose of this study was to examine the current utilisation of altered rapid response calling criteria (ARRCCs) at a tertiary hospital.MethodsA retrospective review of all acute care admissions across 17 months was undertaken using the hospital administration system and electronic medical record to identify patients with ARRCCs. In patients with altered criteria, the type of alteration, frequency of rapid response calls, cardiac arrest, intensive care admission, and death in the hospital were identified. Comparisons were made using standard statistical methods.ResultsThe total hospital admissions numbered 45 912, with ARRCCs used in 768 (1.7%). Patients with an ARRCC during hospital admission were older (68.5 [55.5, 79.0] vs 59.0 [43.0, 72.0] years, p < 0.001) and had a significantly longer length of hospital stay (6.9 [3.0, 16.3] vs 2 [1, 5] days, p < 0.001).Compared with the total group of patient admissions, patients with ARRCCs more frequently triggered a rapid response team (9.0% vs 14.2%, χ²(1, n = 46 680) = 23.87, p < 0.001), more frequently suffered a cardiac arrest (0.2 vs 0.9%, χ²(1, n = 46 678) = 20.34, p < 0.001), more frequently died in the hospital (p < 0.001), and were less frequently discharged home (χ²(1, n = 46 680) = 43.91, p < 0.001).ConclusionPatients with an ARRCC stayed longer in the hospital and were at increased risk of cardiac arrest and death during hospitalisation. Further exploration of the role of ARRCCs in facilitating individualised care to meet the needs and treatment goals of each patient in the acute hospital setting is required.     

Improving Surgical Start Times by Improving Wayfinding

PurposeThis performance improvement project was undertaken to reduce costly delays in first-case, operating room (OR) start times.DesignTwo Plan, Do, Study, Act (PDSA) cycles.MethodsIn PDSA 1, student nurses observed 30 patients' paths of travel from hospital entrance to OR and documented time spent at key stopping points. Directional signs were placed after PDSA 1. PDSA 2 consisted of an electronic medical record (EMR) review of pre- and postsignage cases (n = 492 and n = 538 respectively).FindingsIn the initial PDSA cycle (n = 30), one reason for delay was the time patients spent finding the preoperative area (POA). Signage was placed at strategic points noted to confuse patients. PDSA cycle 2 found median presignage POA arrival times (34 minutes) were significantly higher than postsignage POA arrival times (20 minutes) (U = 51,618.0, z = −16.934, P < .001).ConclusionsDelayed wayfinding contributed to delayed OR starts but improved with appropriate signage.     

Attitudes Toward Influenza Vaccination Administration in the Emergency Department Among Health Care Providers: A Cross-Sectional Survey

IntroductionInfluenza is a burdensome and vaccine-preventable infectious disease. Lack of time was reported as a common barrier by Canadians who did not receive their influenza vaccine. Increasing convenient access to vaccination increases uptake, and a potential setting for vaccine administration is the emergency department, where long wait times are common.MethodsA cross-sectional survey to gauge health care provider support and perceived barriers and facilitators to delivering influenza vaccine was conducted at 1 emergency and trauma center in Halifax, Nova Scotia. Anonymous questionnaires were completed by a convenience sample of emergency nurses, physicians, and paramedics (n = 82).ResultsIn total, 86% (n = 68) of health care providers supported vaccination in the emergency department when sufficient staffing and resources were available. When asked to consider implementation of influenza vaccination in the emergency department based on current staffing and resources, only 59% (n = 48) supported making vaccination available. Most surveyed health care providers preferred screening for vaccination at triage (57%) and supported a nurse-initiated protocol for vaccine administration (74%). After Bonferroni correction, there was no significant association between preference for when to vaccinate and being a nurse or physician (χ²(2) = 6.208, P = 0.05). The highest risk patient groups with the lowest provider endorsement of vaccination were people involved in poultry culling (77%) and pregnant women (83%).DiscussionSurveyed health care providers were supportive of ED influenza vaccination. However, this study revealed additional barriers that need to be addressed to effectively launch such a program.     

Mechanical ventilation and mortality among 223 critically ill patients with coronavirus disease 2019: A multicentric study in Germany

BackgroundThere are large uncertainties with regard to the outcome of patients with coronavirus disease 2019 (COVID-19) and mechanical ventilation (MV). High mortality (50–97%) was proposed by some groups, leading to considerable uncertainties with regard to outcomes of critically ill patients with COVID-19.ObjectivesThe aim was to investigate the characteristics and outcomes of critically ill patients with COVID-19 requiring intensive care unit (ICU) admission and MV.MethodsA multicentre retrospective observational cohort study at 15 hospitals in Hamburg, Germany, was performed. Critically ill adult patients with COVID-19 who completed their ICU stay between February and June 2020 were included. Patient demographics, severity of illness, and ICU course were retrospectively evaluated.ResultsA total of 223 critically ill patients with COVID-19 were included. The majority, 73% (n = 163), were men; the median age was 69 (interquartile range = 58–77.5) years, with 68% (n = 151) patients having at least one chronic medical condition. Their Sequential Organ Failure Assessment score was a median of 5 (3–9) points on admission. Overall, 167 (75%) patients needed MV. Noninvasive ventilation and high-flow nasal cannula were used in 31 (14%) and 26 (12%) patients, respectively. Subsequent MV, due to noninvasive ventilation/high-flow nasal cannula therapy failure, was necessary in 46 (81%) patients. Renal replacement therapy was initiated in 33% (n = 72) of patients, and owing to severe respiratory failure, extracorporeal membrane oxygenation was necessary in 9% (n = 20) of patients. Experimental antiviral therapy was used in 9% (n = 21) of patients. Complications during the ICU stay were as follows: septic shock (40%, n = 90), heart failure (8%, n = 17), and pulmonary embolism (6%, n = 14). The length of ICU stay was a median of 13 days (5–24), and the duration of MV was 15 days (8–25). The ICU mortality was 35% (n = 78) and 44% (n = 74) among mechanically ventilated patients.ConclusionIn this multicentre observational study of 223 critically ill patients with COVID-19, the survival to ICU discharge was 65%, and it was 56% among patients requiring MV. Patients showed high rate of septic complications during their ICU stay.     

Unplanned postdischarge healthcare utilisation,discharge readiness,and perceived quality of teaching in mothers of neonates hospitalized in a neonatal intensive care unit: A descriptive and correlational study

BackgroundDischarge teaching has been positively associated with discharge readiness in various care settings and patient types. Association of discharge readiness with unplanned use of health services has not received as much attention in the neonatal intensive care unit (NICU) population, but has been negatively associated in parents of older children.ObjectivesThe objective of the study was to describe and assess relationships between maternal readiness for neonates' discharge, discharge teaching, and unplanned use of health services after discharge from an NICU.MethodsMothers from an NICU of a tertiary referral hospital in Switzerland completed the “Readiness for Hospital Discharge Scale” and the “Quality of Discharge Teaching Scale parental forms” in the 24 h preceding discharge. Telephone interviews evaluating the unplanned use of health services were conducted 28 days after discharge. Simple linear regressions and multiple regressions were used to explore the links between the readiness, perceived quality of discharge, and unplanned use of health services.ResultsOf the 71 participants, 75% (n = 53%) felt ready for discharge when asked directly, and for 60% (n = 42) of them, the amount of discharge teaching received was equal to or higher than that needed, but with high heterogeneity in scores. For 38% of mothers (n = 27), the expected support from the medical care of their child after discharge was deemed insufficient. In the month after discharge, unplanned use of health services occurred in 46% of the participants (n = 32). Perceived quality of teaching positively predicted readiness for discharge (R² = 0.24, p = 0.0004). Unplanned use of health services correlated neither with readiness nor with perceived teaching quality.ConclusionsAt discharge, mothers felt mostly ready and well prepared to go home. In the month after discharge, almost half used health services in an unplanned manner. Further exploration of reasons leading to this high rate of postdischarge healthcare utilisation is warranted.     

Critical incidents rates and types in Italian Intensive Care Units: A five-year analysis

ObjectiveTo describe rates and types of critical incidents in Intensive Care Units.Research methodologyA retrospective study in four intensive care units of an Academic Hospital located in the North-East of Italy. All critical incidents recorded in an incident reporting system database from 2013 to 2017 were collected.Results160 critical incidents emerged. The rate was 1.7/100 intensive care-patient admissions, and 2.86/1000 in intensive care-patient days. Nurses reported most of the critical incidents (n = 113, 70.6%). In 2013 there were 19 (11.9%) critical incidents which significantly increased by 2017 (n = 38, 23.7%; p = 0.034). The most frequent critical incidents were medication/intravenous fluids issues (n = 35, 21.9%) and resources and organisational management (n = 35, 21.9%). Less frequently occurring incidents concerned medical devices/equipment (n = 29, 18.1%), clinical processes/procedures (n = 18, 11.3%), documentation (n = 14, 8.8%) and patient accidents (n = 13, 8.1%). Rare incidents included behaviour, clinical administration, nutrition, blood products and healthcare associated infection.ConclusionOver a five-year period, documented incidents were steadily increasing in four Italian intensive care units. A voluntary incident reporting system might provide precious information on safety issues occurring in units. at both policy and professional levels.     

Prehospital supplemental oxygen for acute stroke – A retrospective analysis

ObjectiveBrief early administration of supplemental oxygen (sO₂) to create hyperoxia may increase oxygenation to penumbral tissue and improve stroke outcomes. Hyperoxia may also result in respiratory compromise and vasoconstriction leading to worse outcomes. This study examines the effects of prehospital sO₂ in stroke.MethodsThis is a retrospective analysis of adult acute stroke patients (aged ≥18 years) presenting via EMS to an academic Comprehensive Stroke Center between January 1, 2013 and December 31, 2017. Demographic and clinical characteristics obtained from Get with the Guidelines-Stroke registry and subjects’ medical records were compared across three groups based on prehospital oxygen saturation and sO₂ administration. Chi-square, ANOVA, and multivariate logistic regression were used to determine if sO₂ status was associated with neurological outcomes or respiratory complications.Results1352 eligible patients were identified. 62.7% (n = 848) did not receive sO₂ (“controls”), 10.7% (n = 144) received sO₂ due to hypoxia (“hypoxia”), and 26.6% (n = 360) received sO₂ despite normoxia (“hyperoxia”). The groups represented a continuum from more severe deficits (hypoxia) to less severe deficits (controls): mean prehospital GCS (hypoxia -12, hyperoxia - 2, controls - 14 p ≤ 0.001), mean initial NIHSS (hypoxia - 15, hyperoxia - 13, controls - 8 p < 0.001). After controlling for potential confounders, all groups had similar rates of respiratory complications and favorable neurological outcomes.ConclusionsHyperoxic subjects had no significant increase in respiratory complications, nor did they differ in neurologic outcomes at discharge when controlling for confounders. While limited by the retrospective nature, this suggests brief, early sO₂ for stroke may be safe to evaluate prospectively.     

Clinical Profile and Sex-Specific Recovery With Cardiac Rehabilitation After Coronary Artery Bypass Grafting Surgery

BackgroundCardiac rehabilitation (CR) improves major adverse cardiac outcomes in patients recovering from myocardial infarction. CR influences outcomes through attenuation of cardiac risk factors, lifestyle changes, and biological effects on endothelial function. The clinical profile and sex-specific outcomes with CR after coronary artery bypass grafting (CABG) is less well defined.MethodsThis retrospective cohort study of consecutive patients undergoing elective or urgent CABG was performed between 2014 and 2016 at a single site. Patients requiring concomitant procedures were excluded. Patients received referral to a 12-week, 36-session CR program standardized through the health care system and tracked via electronic health records. Clinical data and complications during hospitalization were abstracted from Society of Thoracic Surgeons (STS) registry and matched with 12-months outcomes from electronic health records. Primary composite outcomes were mortality and STS-defined complications within 12 months after CABG. Kaplan-Meier plots for mortality were generated from conditional 6-month survival data.FindingsOf 756 patients undergoing CABG, 420 met the eligibility criteria (mean age, 66 years). Women (18%) had a similar cardiac risk profile to men except for a higher hemoglobin A_1c level and lower hematocrit before surgery. Women had similar extent of revascularization to men but had higher rates of intraoperative (30% vs 8%; p < 0.001) and postoperative blood transfusions (43% vs 29%; p = 0.014) compared with men. Only 66% of women qualified for direct discharge to home compared with 85% of men (p = 0.0003). Twelve-month mortality was 1.3% and 2%, respectively (p > 0.05). Half of the cohort got referred for CR, and 32% of men and 23% of women underwent CR. Twelve-month composite outcomes did not differ by referral to cardiac rehabilitation (odds ratio = 0.77; 95% CI, 0.36–1.64) or engagement with CR (odds ratio = 0.67; 95% CI ?0.05 to 0.086), adjusting for age, sex, body mass index, and diabetes. Kaplan-Meier analysis found no significant difference in survival between those who did and did not undergo CR. Men experienced increases in metabolic equivalents (38%, P = 0.014), grip strength (11%, P < 0.0001), and sense of physical well-being (40.9%, P < 0.0001), whereas women experienced increases in aerobic exercise duration (15.5%, P = 0.02) and a trend in improved sense for physical well-being (93.3%, P = 0.06).ImplicationsSex differences exist with CR after CABG. Future studies should confirm these findings in larger cohorts and corroborate the effect on endothelial function and other biological markers.     

Herpes associated erythema multiforme: A retrospective study

BackgroundErythema multiforme (EM), an acute dermatologic condition frequently encountered in the Emergency Department, classically presents with a targetoid rash. We reviewed all recent EM cases seen at the LAC-USC County Hospital in order to ascertain the proportion of Herpes associated EM (HAEM) cases and to inform the diagnostic workup of these patients.MethodsICD-9 and ICD-10 codes were used to extract a list of EM cases at our institution from 2013 to 2019. Two non-blinded abstractors screened records to confirm an EM diagnosis and entered patient data utilizing a standardized data abstraction form. Cohen's kappa statistic was used to measure inter-rater reliability on various variables. Kappa (κ) values ranged from 0.803 to 1.0.Results70 pediatric and 56 adult EM patients were included in the study. A likely etiology was ascribed to 63% of pediatric and adult EM cases. Pediatric EM was most commonly attributed to upper respiratory infection (URI) (n = 23; 33%), Mycoplasma pneumoniae infection (n = 5; 7%), and medications (n = 4; 6%). Adult EM was most commonly attributed to HSV infection (n = 11; 20%), medications (n = 5; 9%), URIs (n = 4; 7%), and other infections (n = 4; 7%).ConclusionHSV-1/2 serologic testing should be considered in most EM patients to potentially prevent repeated ED visits. In EM cases not clearly attributable to herpes or drug exposure, physicians can consider further workup: Mycoplasma serology, nasal PCR, and a respiratory viral panel in pediatric patients. Identification of an etiologic cause may suggest a different treatment approach and prevent mislabeling of medication allergies in patient charts.