Critical pathways intervention to reduce length of hospital stay

PURPOSE: Despite their popularity, critical pathways have been evaluated in only a few controlled studies. We evaluated the effectiveness of critical pathways in reducing length of hospital stay. SUBJECTS AND METHODS: We compared postoperative lengths of stay of patients who underwent coronary artery bypass graft (CABG) surgery, total knee replacement, colectomy, thoracic surgery, or hysterectomy before and after pathway implementation at a university hospital. For three procedures, changes in lengths of stay at neighboring hospitals without pathway programs were assessed for comparison. RESULTS: A total of 6,796 patients underwent one of the procedures during the study. The percentage of eligible patients managed on a critical pathway ranged from 94% for hysterectomy to 26% for colectomy. For most procedures, the postoperative length of stay was decreasing during the baseline period. After pathway implementation, the length of stay decreased 21% for total knee replacement, 9% for CABG surgery, 7% for thoracic surgery, 5% for hysterectomy, and 3% for colectomy (all P < 0.01). However, similar decreases were seen in the neighboring hospitals that did not have critical pathways or other specific efficiency initiatives. CONCLUSIONS: Critical pathways were associated with a rapid reduction in postoperative length of stay after all five study procedures. Secular trends at nearby hospitals, however, produced comparable reductions for the three procedures available for comparison. These findings raise questions about the effectiveness of critical pathways in a competitive environment.     

Continuous glucose monitoring as a tool to identify hyperglycaemia in non‐diabetic patients with acute coronary syndromes

Aim To explore the occurrence and the distribution of glucose excursions > 7.8 mmol/l by continuous glucose monitoring (CGM) in non‐diabetic patients admitted with acute coronary syndrome (ACS). Methods Twenty‐one non‐diabetic patients without baseline hyperglycaemia admitted for ACS wore a continuous glucose monitoring system (CGMS) for a median period of 45.6 h. Occurrence and 24‐h distribution of time spent with blood glucose > 7.8 mmol/l (TS > 7.8) were retrospectively investigated. Results CGMS data disclosed time spent > 7.8 in 17 patients, whereas only seven of them showed at least one capillary blood glucose test value above the threshold for the same time period. Glucose excursions were detectable earlier from CGMS data. Hyperglycaemia was detected most frequently in the morning, more than 2 h after breakfast. Conclusions CGM discloses early and frequent hyperglycaemia in non‐diabetic patients with ACS. Intensive glucose monitoring during the morning time period is the most efficient in screening for hyperglycaemia and could be a valuable guide to initiating insulin therapy and to further investigate outcomes in ACS.     

Strategies to reduce length of stay and costs associated with decompensated heart failure

Heart failure (HF) is a major medical problem in the United States, imposing significant economic burden on the health care system. Despite therapeutic advances, HF-associated morbidity and mortality continue to increase. Compliance with therapeutic guidelines for the management of chronic HF is far from ideal, increasing the likelihood that patients will experience multiple episodes of acute decompensated heart failure (ADHF) during the course of HF disease. Prevention, streamlined inpatient care, effective vasoactive therapy, and initiation of proven long-term therapies, including angiotensin-converting enzyme (ACE) inhibitors and beta-blockers, are all targets for improvement. Because of the chronic nature of heart failure, a successful disease management program for ADHF must also include effective outpatient care.     

Machine learning as a clinical decision support tool for patients with acromegaly

Pituitary - To develop machine learning (ML) models that predict postoperative remission, remission at last visit, and resistance to somatostatin receptor ligands (SRL) in patients with acromegaly...     

A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay

OBJECTIVES: To improve outcomes for cognitively impaired and delirious older adults. DESIGN: Pretest, posttest. SETTING: A university-affiliated hospital. PARTICIPANTS: Physicians and nurses in the emergency department (ED) and on an acute geriatric unit (AGU). INTERVENTION: Multifactorial and targeted to the processes of care for cognitively impaired and delirious older adults admitted to medicine service from the ED. MEASUREMENTS: Prevalence of delirium, admission to AGU, psychotropic medication use, hospital length of stay. RESULTS: Patient characteristics did not differ between baseline and the two outcome cohorts 4 and 9 months postintervention. Prevalence of delirium was 40.9% at baseline, 22.7% at 4 months (P<.002), and 19.1% at 9 months (P<.001). More delirious patients were admitted to the AGU than to non-AGU units at 4 months (P<.01) and 9 months (P<.01). Postintervention medication use in the hospital differed from baseline. Antidepressant use was greater at 4 months (P<.05). Benzodiazepine and antihistamine use were lower at 9 months (P>.01). Antidepressant and neuroleptic use were higher (P<.02) and antihistamine use was lower (P<.02) at 4 months on the AGU than for the baseline group. Benzodiazepine (P<.01) and antihistamine (P<.05) use were lower at 9 months. Each case of delirium prevented saved a mean of 3.42 hospital days. CONCLUSION: A multifactorial intervention designed to reduce delirium in older adults was associated with improved psychotropic medication use, less delirium, and hospital savings.     

Case management may reduce length of hospital stay in patients with recurrent admissions for chronic obstructive pulmonary disease

OBJECTIVES: The aim of the study was to determine whether the case management of patients with recurrent hospital admissions for chronic obstructive pulmonary disease (COPD) can reduce hospital days without reducing quality of life. METHODOLOGY: Sixteen subjects (mean forced expiratory volume in 1 second; FEV1 0.64 L) with at least four admissions for COPD in the previous 2 years were case managed by a clinical nurse specialist. Admissions and hospital bed days were recorded before and after the introduction of case management, and compared with data for 16 controls at another hospital who received usual care. Quality of life was measured serially in the case-managed group. RESULTS: In the first year of case management, the number of hospital bed days fell to eight per patient from 22 per patient in the previous year. This was mainly due to a reduction in the length of stay from 5.6 to 3.5 days. In the control group length of stay did not change. Admissions in both groups declined. Case-managed patients had a significant improvement in their quality-of-life scores. CONCLUSIONS: In a group of patients with severe COPD and recurrent admissions, case management reduced the number of days in hospital while improving the quality of life. These findings need to be confirmed in a randomized, controlled trial.     

Randomized trial of a noninvasive strategy to reduce hospital stay for patients with low-risk myocardial infarction

OBJECTIVES: This study evaluated the feasibility, pertinence and psychosocial repercussions of a noninvasive reduced hospital stay strategy (three days) for low-risk patients with acute myocardial infarction using simple clinical criteria and predischarge 24-h ambulatory ST-segment ischemic monitoring. BACKGROUND: Previous studies evaluating shorter stays for uncomplicated myocardial infarction have been limited by retrospective or nonrandomized design and overdependence on invasive cardiac procedures. METHODS: One-hundred twenty consecutive patients admitted with an acute myocardial infarction fulfilling low-risk criteria were randomized 2:1 to a short hospital stay (80 patients) or standard stay (40 patients). Short-stay patients with no ischemia on ST-segment monitoring were discharged on day 3, returning for exercise testing a week later. All analyses were on an intention-to-treat basis. RESULTS: Forty-one percent of all screened patients with acute myocardial infarction would have been medically eligible for the short-stay strategy. Seventeen patients (21%) were not discharged early because of ischemia on ST-monitoring or angina. Median initial hospital stay was halved from 6.9 days in the standard stay to 3.5 days in the short-stay group. At six months, median total days hospitalized were 7.5 in the standard stay and 3.6 in the short-stay group (p < 0.0001). Adverse events and readmissions were low and not significantly different, and there were 25% fewer invasive cardiac procedures in the short-stay group. Psychosocial outcomes, risk factor changes and exercise test results were similar in the two groups. CONCLUSIONS: This reduced hospital stay strategy for low-risk patients with acute myocardial infarction is feasible and worthwhile, resulting in a substantial and sustained reduction in days hospitalized. It is without unfavorable psychosocial consequences, appears safe and does not increase the number of invasive cardiac procedures.     

Pregnancy outcome in patients with raised blood glucose due to a heterozygous glucokinase gene mutation

Aim To assess determinants of fetal growth in the offspring of pregnant women with hyperglycaemia due to a heterozygous glucokinase (GCK) gene mutation. Methods Details of gestational age at delivery, fetal birth weight and maternal antenatal treatment were collected from patients and retrospective case note review of 82 offspring born to 42 women with GCK gene mutations and 31 offspring born to 13 unaffected normoglycaemic women with an affected partner. Fetal genotype was determined using direct sequencing from either a mouth swab or a blood sample. Results In mothers with GCK mutations, non‐mutation‐carrying offspring were heavier than mutation‐carrying offspring (corrected birth weight 3.9 ± 0.6 vs. 3.2 ± 0.8 kg; P < 0.001) and more likely to be macrosomic (> 4.0 kg; 39% vs. 7%, P = 0.001). There was no difference in corrected birth weight between offspring of insulin‐ and diet‐treated women (3.7 ± 0.7 vs. 3.8 ± 0.6 kg; P = 0.1), although insulin‐treated mothers delivered earlier (37.5 ± 1.7 vs. 38.9 ± 2.3 weeks; P < 0.001) due to increased obstetric intervention. Conclusions Offspring of women with GCK mutations are at increased risk of macrosomia and its obstetric consequences. Fetal birth weight is predominantly altered by fetal genotype and not treatment of maternal hyperglycaemia with insulin. This probably reflects the large effect of a fetal GCK mutation on fetal insulin secretion and the difficulty in reducing the regulated maternal glycaemia caused by a glucose sensing defect in people with GCK mutations.     

Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: a randomized controlled trial

PURPOSE: Patients with pneumonia often remain hospitalized after they are stable clinically, and the duration of intravenous antibiotic therapy is a rate-limiting step for discharge. The purpose of this study was to determine whether implementation of an evidence-based guideline would reduce the duration of intravenous antibiotic therapy and length of stay for patients hospitalized with pneumonia. METHODS: In a seven-site, cluster randomized clinical trial, we enrolled 325 control and 283 intervention patients who were admitted by one of 116 physician groups. Within site, physician groups were assigned randomly to receive a practice guideline alone (control arm) or a practice guideline that was implemented using a multifaceted strategy (intervention arm). The effectiveness of guideline implementation was measured by the duration of intravenous antibiotic therapy and length of stay; differences in the rates of discontinuation and hospital discharge were assessed with proportional hazards models. Medical outcomes were assessed at 30 days. RESULTS: Intravenous antibiotic therapy was discontinued somewhat more quickly in the intervention group (hazard ratio [HR] =1.23; 95% confidence interval [CI]: 1.00 to 1.52; P = 0.06) than in the control group. Intervention patients were discharged more quickly, but the difference was not statistically significant (HR = 1.16; 95% CI: 0.97 to 1.38; P = 0.11). Fewer intervention (55% [157/283]) than control (63% [206/325]) patients had medical complications during the index hospitalization (P = 0.04), with no differences in other medical outcomes, including mortality, rehospitalization, and return to usual activities, between treatment arms. CONCLUSIONS: The multifaceted guideline implementation strategy resulted in a slight reduction in the duration of intravenous antibiotic therapy and a nonsignificant reduction in length of stay, without affecting patient outcomes.     

Reducing hospital inpatient length of stay for patients with diabetes.

AIMS: To ascertain the effect of routine review by a diabetes nurse advisor on length of stay for medical and surgical inpatients with diabetes. METHODS: Inpatients with diabetes were identified prospectively from January 1997 until December 1998 (792 in 1997 and 819 in 1998). A new post of diabetes nurse advisor was introduced in January 1998 to optimize diabetes management. Length of stay was calculated retrospectively from hospital computer records. RESULTS: Median length of stay in 1997 was 11 days in medicine and 8 days in surgery. In 1998, the nurse advisor made 1936 visits to 819 patients; median length of stay fell to 8 days in medicine and 5 days in surgery (P < 0.001). Bed occupancy by patients with diabetes fell from 6.8 to 4.0%. Mean length of stay across the hospital remained unchanged. CONCLUSIONS: The introduction of a ward-based diabetes nurse advisor was associated with significant reductions in length of stay in inpatients with diabetes. Since this study was not a randomized study, other factors may have contributed to this change. However, the consistency of the reduction across specialities suggests the post itself had an important effect.     

Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma

STUDY OBJECTIVES: A decision instrument based on 5 clinical criteria has been shown to be highly sensitive in selecting patients who require cervical spine imaging after blunt trauma, while simultaneously reducing overall imaging. We examine the performance of this instrument in the elderly and explore some of the common features of geriatric cervical spine injury (CSI). METHODS: The National Emergency X-radiography Utilization Study (NEXUS) was a prospective, observational, multicenter study conducted at 21 geographically diverse centers. We analyzed the performance of the NEXUS decision instrument among patients at least 65 years of age. RESULTS: The study group consisted of 2,943 (8.6%) geriatric patients, representing 8.6% of the entire NEXUS sample. The rate of CSI was twice as great in these patients as it was in nongeriatric patients (4.59% versus 2.19%). Odontoid fractures were particularly common in geriatric patients, accounting for 20% of geriatric fractures compared with 5% of nongeriatric fractures. The frequency of patients meeting NEXUS criteria was similar in the 2 groups, with 14% of geriatric patients and 12.5% of nongeriatric patient classified as low risk. CSI occurred in only 2 low-risk geriatric patients, and these patients' injuries met our preset definition of a clinically insignificant injury. The sensitivity of the NEXUS decision instrument for clinically significant injury in the geriatric group was therefore 100% (95% confidence interval 97.1% to 100%). CONCLUSION: The prevalence of CSI, and especially odontoid fracture, is relatively increased among geriatric patients with blunt trauma. The NEXUS decision instrument can be applied safely to these patients, with an expected reduction in cervical imaging comparable with that achieved in nongeriatric patients.     

Factors related to the length of in-hospital stay of geriatric patients.

The aim of this study was to evaluate factors predicting length of stay in hospital of geriatric patients. Study participants were 402 patients (183 males and 219 females) consecutively admitted to four geriatric wards located in Chieti, Perugia, Pescara and Prato, Italy. Information on potential predictors of length of stay was collected; in particular, we assessed the presence and severity of specific chronic medical conditions, level of physical function, cognitive status, and depressive symptoms. Moreover, information on family and social support was obtained. In general, participants were old, often cognitively impaired and physically disabled. Average length of stay ranged from 9.4 +/- 3.3 days (Perugia) to 14.1 +/- 7.2 days (Chieti), and was statistically different across centers (p < 0.001). None of the specific medical diagnoses was associated with different length of stay. However, higher comorbidity score (p < 0.001), living alone (p < 0.01), lower MMSE score (p = 0.03), and poor functional status (p = 0.05) were all associated with longer length of stay. When these variables were included in a multivariate model predicting length of stay, differences between centers were no longer statistically significant. Findings of this study show that specific medical diagnoses are not adequate instruments to estimate length of stay in geriatric units. Other assessment systems based on extension of the social network, comorbidity, and the cognitive as well as the functional level need to be developed.     

Comorbidity as a correlate of length of stay for hospitalized patients with acute chest pain

OBJECTIVE: To determine whether comorbid medical conditions as measured with the Charlson Comorbidity Index are independent correlates of length of stay after adjusting for other clinical and socioeconomic data. DESIGN: Prospective cohort study. SETTING: Urban teaching hospital. PATIENTS: All 1,261 patient aged 30 years or more who were admitted to this hospital after coming to the emergency department with acute chest pain between October 1990 and May 1992. MEASUREMENTS AND OUTCOMES: Clinical data including comorbid medical conditions used in the Charlson index were prospectively recorded by the evaluating physician at the time of admission or by a research nurse who was blinded to the subsequent events. History of myocardial infarction was excluded from the calculation of the Charlson index score. Charlson index scores were 0 to 1 for 921 patients (73%), 2 to 3 for 263 (21%), and greater than 3 for 77 (6%). Unadjusted mean (±SD) lengths of stay in these groups were 4.4±5.2, 5.2±5.9, and 7.5±9.3 days, respectively. In multiple linear regression analysis, compared with Charlson index scores of 0 to 1, scores of 2 to 3 and greater than 3 were significant (p<.01) independent correlates of the log transformation of length of stay after adjusting for clinical data from the initial presentation and subsequent course (modelR ²=.510). In an analysis restricted to the 795 patients without clinical complications, a Charlson index score greater than 3 was an independent correlate of length of stay compared with scores of 0 to 1 (p<.01). Individual comorbid conditions were not significant correlates of length of stay after controlling for Charlson index score. CONCLUSIONS: In this population of patients with acute chest pain, comorbidity as measured with the Charlson index was independently associated with length of stay after adjustment for other clinical data. After adjusting for the Charlson index, no separate comorbid condition was significantly correlated with length of stay. These findings suggest that the Charlson index can be used to adjust for comorbidities in analyses of length of stay for patients with this condition. From the Section for Clinical Epidemiology, the Division of General Medicine, the Cardiovascular Division, the Department Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass., and Iizuka Hospital, Iizuka, Japan. Supported by a grant from the Agency for Health Care Policy and Research (RO1 HS06452), Rockville, MD, and the Aso-Nesson Research Fund. Dr. Lee is an Established Investigator (9001119) of the American Heart Association.     

Hospital admissions, length of stay, charges, and in-hospital death among patients with systemic sclerosis

OBJECTIVE: To investigate population hospitalization rates to community hospitals for systemic sclerosis (SSc, scleroderma) and examine whether age, sex, race, and insurance status independently predict length of stay (LOS), hospital charges, and in-hospital death. METHODS: The 1995 Healthcare Cost and Utilization Project national inpatient sample was used to identify 3,621 SSc hospitalizations. Weighted age, sex, and race-specific frequencies were divided by population estimates to calculate hospitalizations per million people. Regression models were used to model LOS, charges, and in-hospital death with age, sex, race, and insurance serving as the primary independent variables. Covariates included numbers of diagnoses and procedures, whether or not the admission was a transfer from another hospital, and the presence of comorbid conditions. RESULTS: Population hospitalization rates were higher for non-whites compared to whites among those < 65, while rates were higher for whites compared to non-whites for those > or =65 years old. On average, non-whites were at least 10 years younger than whites. The mean LOS was 7.5 days, with whites' average LOS being 10% shorter than non-whites', and patients with public health insurance having approximately 9% longer LOS than those with private insurance. Charges averaged almost US$15,000 per hospitalization (median = $8,441), amounting to $280 million in community hospital charges in the U.S. in 1995. The overall in-hospital death rate was 7.1%. CONCLUSION: These patterns are consistent with a greater burden and increased severity of disease among non-whites under age 65 with Ssc.