Malnutrition at Intensive Care Unit Admission Predicts Mortality in Emergency General Surgery Patients

Background: Emergency general surgery (EGS) patients are at an increased risk for morbidity and mortality compared with non‐EGS patients. Limited information exists regarding the contribution of malnutrition to the outcome of critically ill patients who undergo EGS. We hypothesized that malnutrition would be associated with increased risk of 90‐day all‐cause mortality following intensive care unit (ICU) admission in EGS patients. Materials and Methods: We performed an observational study of patients treated in medical and surgical ICUs at a single institution in Boston. We included patients who underwent an EGS procedure and received critical care between 2005 and 2011. The exposure of interest, malnutrition, was determined by a registered dietitian’s formal assessment within 48 hours of ICU admission. The primary outcome was all‐cause 90‐day mortality. Adjusted odds ratios were estimated by multivariable logistic regression models. Results: The cohort consisted of 1361 patients. Sixty percent had nonspecific malnutrition, 8% had protein‐energy malnutrition, and 32% were without malnutrition. The 30‐day readmission rate was 18.9%. Mortality in‐hospital and at 90 days was 10.1% and 17.9%, respectively. Patients with nonspecific malnutrition had a 1.5‐fold increased odds of 90‐day mortality (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.09–5.04; P = .009) and patients with protein‐energy malnutrition had a 3.1‐fold increased odds of 90‐day mortality (adjusted OR, 3.06; 95% CI, 1.89–4.92; P < .001) compared with patients without malnutrition. Conclusion: In critically ill patients who undergo EGS, malnutrition at ICU admission is predictive of adverse outcomes. In survivors of hospitalization, malnutrition at ICU admission is associated with increases in readmission and mortality.     

A Comprehensive Nutrition‐Focused Quality Improvement Program Reduces 30‐Day Readmissions and Length of Stay in Hospitalized Patients

Background: Although screening patients for malnutrition risk on hospital admission is standard of care, nutrition shortfalls are undertreated. Nutrition interventions can improve outcomes. We tested effects of a nutrition‐focused quality improvement program (QIP) on hospital readmission and length of stay (LOS). Materials and Methods: QIP included malnutrition risk screening at admission, prompt initiation of oral nutrition supplements (ONS) for at‐risk patients, and nutrition support. A 2‐group, pre‐post design of malnourished adults with any diagnosis was conducted at 4 hospitals: QIP‐basic (QIPb) and QIP‐enhanced (QIPe). Comparator patients had a malnutrition diagnosis and ONS orders. For QIPb, nurses screened all patients on admission using an electronic medical record (EMR)–cued Malnutrition Screening Tool (MST); ONS was provided to patients with MST scores ≥2 within 24–48 hours. QIPe had ONS within 24 hours, postdischarge nutrition instructions, telephone calls, and ONS coupons. Primary outcome was 30‐day unplanned readmission. We used baseline (January 1–December 31, 2013) and validation cohorts (October 13, 2013–April 2, 2014) for comparison. Results: Patients (n = 1269) were enrolled in QIPb (n = 769) and QIPe (n = 500). Analysis included baseline (n = 4611) and validation (n = 1319) comparator patients. Compared with a 20% baseline readmission rate, post‐QIP relative reductions were 19.5% for all QIP, 18% for QIPb, and 22% for QIPe, respectively. Compared with a 22.1% validation readmission rate, relative reductions were 27.1%, 25.8%, and 29.4%, respectively. Similar reductions were noted for LOS. Conclusions: Thirty‐day readmissions and LOS were significantly lowered for malnourished inpatients by use of an EMR‐cued MST, prompt provision of ONS, patient/caregiver education, and sustained nutrition support.     

Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone

Background: This study aimed to determine the agreement between the modified Nutrition Risk in Critically ill Score (mNUTRIC) and the Subjective Global Assessment (SGA) and compare their ability in discriminating and quantifying mortality risk independently and in combination. Methods: Between August 2015 and October 2016, all patients in a Singaporean hospital received the SGA within 48 hours of intensive care unit admission. Nutrition status was dichotomized into presence or absence of malnutrition. The mNUTRIC of patients was retrospectively calculated at the end of the study, and high mNUTRIC was defined as scores ≥5. Results: There were 439 patients and 67.9% had high mNUTRIC, whereas only 28% were malnourished. Hospital mortality was 29.6%, and none was lost to follow‐up. Although both tools had poor agreement (κ statistics: 0.13, P < .001), they had similar discriminative value for hospital mortality (C‐statistics [95% confidence interval (CI)], 0.66 [0.62–0.70] for high mNUTRIC and 0.61 [0.56–0.66] for malnutrition, P = .12). However, a high mNUTRIC was associated with higher adjusted odds for hospital mortality compared with malnutrition (adjusted odds ratio [95% CI], 5.32 [2.15–13.17], P < .001, and 4.27 [1.03–17.71], P = .046, respectively). Combination of both tools showed malnutrition and high mNUTRIC were associated with the highest adjusted odds for hospital mortality (14.43 [5.38–38.78], P < .001). Conclusion: The mNUTRIC and SGA had poor agreement. Although they individually provided a fair discriminative value for hospital mortality, the combination of these approaches is a better discriminator to quantify mortality risk.     

Relationship of Vitamin D Deficiency to Clinical Outcomes in Critically Ill Patients

Background: Despite the numerous disease conditions associated with vitamin D deficiency in the general population, the relationship of this deficiency to outcome in critically ill patients remains unclear. The objective of this study is to determine the burden of vitamin D deficiency in intensive care unit (ICU) patients and determine if it is associated with poor patient outcomes. Methods: The authors conducted an analysis of samples collected from a prospective study of 196 patients admitted to a medical/surgical ICU in a tertiary care hospital. They measured serum 25‐hydroxyvitamin D at admission and up to 10 days following admission and followed patients prospectively for 28‐day outcomes. Results: Of analyzable patients, 50 (26%) were deficient (≤30 nmol/L) and 109 (56%) were insufficient (>30 and ≤60 nmol/L). Baseline 25(OH)D levels decreased significantly in all patients after 3 days in the ICU and remained significantly lower through 10 days (P < .001). 25(OH)D status was not significantly associated with 28‐day all‐cause mortality (hazard ratio [HR], 0.89; 95% confidence interval, [CI] 0.37–2.24). Higher levels of 25(OH)D were associated with a shorter time‐to‐alive ICU discharge (HR, 2.11; 95% CI, 1.27–3.51). 25(OH)D‐deficient patients showed a nonstatistically significant trend toward a higher infection rate (odds ratio [OR], 3.20; 95% CI, 0.784–13.07; P = .11) compared with patients with sufficient levels of 25(OH)D. Conclusions: This study demonstrates significant decreases in vitamin D status over the duration of the patient's ICU stay. Low levels of vitamin D are associated with longer time to ICU discharge alive and a trend toward increased risk of ICU‐acquired infection.     

The Association of Changes in Physical Performance During Geriatric Inpatient Rehabilitation With Short-Term Hospital Readmission,Institutionalization, and Mortality: RESORT

ObjectivesGeriatric inpatient rehabilitation aims to restore function, marked by physical performance, to enable patients to return and remain home after hospitalization. However, after discharge some patients are soon readmitted, institutionalized, or may die. Whether changes in physical performance during geriatric rehabilitation are associated with these short-term adverse outcomes is unknown. This study aimed to determine the association of changes in physical performance during geriatric inpatient rehabilitation with short-term adverse outcomes.DesignObservational longitudinal study.Setting and ParticipantsGeriatric rehabilitation inpatients of the REStORing health of acutely unwell adulTs (RESORT) cohort study of the Royal Melbourne Hospital (Melbourne, Australia) were included.MethodsThe change from admission to discharge in the Short Physical Performance Battery (SPPB) score, balance, gait speed (GS), chair stand test (CST), and hand grip strength (HGS) were calculated and analyzed using logistic regression analysis with readmission, incidence of institutionalization, and mortality, and ≥1 adverse outcome within 3 months postdischarge.ResultsOf 693 inpatients, 11 died during hospitalization and 572 patients (mean age 82.6 ± 7.6 years, 57.9% female) had available physical performance data. Within 3 months postdischarge, 47.3% of patients had ≥1 adverse outcome: readmission was 20.8%, institutionalization was 26.6%, and mortality was 7.9%. Improved SPPB score, balance, GS, CST, and HGS were associated with lower odds of institutionalization and mortality. Improved GS was additionally associated with lower odds of readmission [odds ratio (OR) 0.35, 95% CI 0.16-0.79]. CST score had the largest effect, with a 1-point increase associating with 40% lower odds of being institutionalized (OR 0.60, 95% CI 0.42-0.86), 52% lower odds of mortality (OR 0.48, 95% CI 0.29-0.81), and a 24% lower odds of ≥1 adverse outcome (OR 0.76, 95% CI 0.59-0.97).Conclusions and ImplicationsImprovement in physical performance was associated with lower odds of short-term institutionalization and mortality indicating the prognostic value of physical performance improvement during geriatric inpatient rehabilitation.     

Clinical Outcomes Related to Protein Delivery in a Critically Ill Population

Objective: Optimal intake of energy and protein is associated with improved outcomes, although outcomes relative to protein intake are very limited. Our purpose was to evaluate the impact of prescribed protein delivery on mortality and time to discharge alive (TDA) using data from the International Nutrition Survey 2013. We hypothesized that greater protein delivery would be associated with lower mortality and shorter TDA. Methods: The sample included patients in the intensive care unit (ICU) ≥4 days (n = 2828) and a subsample in the ICU ≥12 days (n = 1584). Models were adjusted for evaluable nutrition days, age, body mass index, sex, admission type, acuity scores, and geographic region. Percentages of prescribed protein and energy intake were compared with mortality outcomes using logistic regression and with Cox proportional hazards for TDA. Results: Mean intake for the 4‐day sample was protein 51 g (60.5% of prescribed) and 1100 kcal (64.1% of prescribed); for the 12‐day sample, mean intake was protein 57 g (66.7% of prescribed) and 1200 kcal (70.7% of prescribed). Achieving ≥80% of prescribed protein intake was associated with reduced mortality (4‐day sample: odds ratio [OR], 0.68; 95% confidence interval [CI], 0.50–0.91; 12‐day sample: OR, 0.60; 95% CI, 0.39–0.93), but ≥80% of prescribed energy intake was not. TDA was shorter with ≥80% prescribed protein (hazard ratio [HR], 1.25; 95% CI, 1.04–1.49) in the 12‐day sample but longer with ≥80% prescribed energy in the 4‐day sample (HR, 0.82; 95% CI, 0.69–0.96). Conclusion: Achieving at least 80% of prescribed protein intake may be important to survival and shorter TDA in ICU patients. Efforts to achieve prescribed protein intake should be maximized.     

Thirty‐Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids

Background: Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30‐day readmissions for patients discharged with home parenteral support (HPS). Objective: Determine the rate of 30‐day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. Materials and Methods: Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. Results: Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter‐related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate (P = .41). According to univariable analysis, patients with an ostomy (P = .037), a small bowel resection (P = .002), a higher HPS volume at discharge (P < .001), and a shorter period between HPS consult and hospital discharge (P < .026) had a lower risk of 30‐day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30‐day readmission if they had a history of heart disease (P = .048) and for every 1‐unit increase in white blood cells (P = .026). Conclusions: Patients discharged with HPS have a high 30‐day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30‐day readmissions.     

Does Low Body Mass Index Predict the Hospital Mortality of Adult Western or Asian Patients?

Background: Some strategies for screening and assessment of malnutrition include a low but variable body mass index (BMI) cutoff, while others do not. The purpose of this systematic review was to investigate published data for Western and Asian hospital samples to determine how the prevalence of low BMI is associated with increased hospital mortality. Method: A PubMed search of the past 10 years (2006–2016) was conducted with the terms “BMI,” “malnutrition,” “adult,” “outcome,” and “hospital” or “ICU” for articles published in English. Studies that examined BMI levels among Western or Asian populations were included. Forest plots were constructed to determine the odds of hospital mortality in low versus normal BMI groups. Results: Twenty studies met inclusion criteria. The prevalence of BMI <18.5 kg/m² was greater in Asian (15%–20%) than Western (2%–7%) patient groups. In Western populations, BMI <18.5 kg/m² was so rare that most studies lacked power to evaluate outcomes. Hospital mortality among ICU patients was greater for patients with BMI <18.5 than those with BMI of 18.5–24.9 kg/m² (Western: odds ratio, 1.42 [95% CI, 1.33–1.50]; Asian: odds ratio = 1.78 [95% CI, 1.7–1.86]). Recommendations: BMI <18.5 kg/m² is a possible screening variable for malnutrition. Since low BMI was associated with increased mortality in Western and Asian patient groups, we suggest that all populations at risk based on low BMI undergo a full nutrition assessment with a validated method.     

Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review

Malnutrition is associated with poor clinical outcomes among hospitalized patients. However, studies linking malnutrition with poor clinical outcomes in the intensive care unit (ICU) often have conflicting findings due in part to the inappropriate diagnosis of malnutrition. We primarily aimed to determine whether malnutrition diagnosed by validated nutrition assessment tools such as the Subjective Global Assessment (SGA) or Mini Nutritional Assessment (MNA) is independently associated with poorer clinical outcomes in the ICU and if the use of nutrition screening tools demonstrate a similar association. PubMed, CINAHL, Scopus, and Cochrane Library were systematically searched for eligible studies. Search terms included were synonyms of malnutrition, nutritional status, screening, assessment, and intensive care unit. Eligible studies were case‐control or cohort studies that recruited adults in the ICU; conducted the SGA, MNA, or used nutrition screening tools before or within 48 hours of ICU admission; and reported the prevalence of malnutrition and relevant clinical outcomes including mortality, length of stay (LOS), and incidence of infection (IOI). Twenty of 1168 studies were eligible. The prevalence of malnutrition ranged from 38% to 78%. Malnutrition diagnosed by nutrition assessments was independently associated with increased ICU LOS, ICU readmission, IOI, and the risk of hospital mortality. The SGA clearly had better predictive validity than the MNA. The association between malnutrition risk determined by nutrition screening was less consistent. Malnutrition is independently associated with poorer clinical outcomes in the ICU. Compared with nutrition assessment tools, the predictive validity of nutrition screening tools were less consistent.     

A Cohort Study of Nutrition Practices in the Intensive Care Unit Following Abdominal Aortic Aneurysm Repair

Introduction: Enteral nutrition within 48 hours of intensive care unit (ICU) admission is recommended for the ICU population. Major vascular surgery patients have a higher incidence of pre‐ and postoperative malnutrition compared with the general surgical population. Our objectives were to determine if early feeding (within 48 hours of admission) is achievable and well tolerated, identify factors that predict early feeding, and determine if there is an association between early feeding and in‐hospital mortality among abdominal aortic aneurysm (AAA) repair patients. Methods: A retrospective cohort study was conducted among 145 postsurgical AAA repair patients admitted to the ICU within 48 hours of surgery. Kaplan‐Meier methods and Cox proportional hazard multiple regression were used to analyze the data. Results: Only 35 (24%) patients received early feeding. Patients were more likely to be fed early if they were male (adjusted hazard ratio [aHR] = 2.3; 95% confidence interval [CI], 0.8–6.7; P = .13), had endovascular AAA repair (aHR = 2.9; 95% CI, 1.4–6.2; P = .006), had less blood loss (<4 L) during surgery (aHR = 2.3; 95% CI, 0.7–7.2; P = .14), and had shorter length of ventilation (<48 hours) (aHR = 2.2; 95% CI, 1.1–4.8; P = .048). Of 44 patients fed via enteral nutrition (EN), 27 (61%) achieved nutrition adequacy (>80% EN goal) during ICU admission. After controlling for other factors, 14‐day mortality was not related to feeding time (aHR = 1.1; P = .88). Conclusion: Early feeding was achieved in a minority of patients following AAA repair, was related to type of surgery and duration of mechanical ventilation, and was tolerated as well as later introduced feedings. Randomized trials are needed to determine safety and benefits of early feeding in this patient group.     

Clinical Outcomes in Critically Ill Patients Associated With the Use of Complex vs Weight‐Only Predictive Energy Equations

Background: The energy intake goal is important to achieving energy intake in critically ill patients, yet clinical outcomes associated with energy goals have not been reported. Methods: This secondary analysis used the Improving Nutrition Practices in the Critically III International Nutrition Surveys database from 2007–2009 to evaluate whether mortality or time to discharge alive is related to use of complex energy prediction equations vs weight only. The sample size was 5672 patients in the intensive care unit (ICU) ≥4 days and a subset of 3356 in the ICU ≥12 days. Mortality and time to discharge alive were compared between groups by regression, controlling for age, sex, admission type, Acute Physiology and Chronic Health Evaluation II score, ICU geographic region, actual energy intake, and obesity. Results: There was no difference in mortality between the use of complex and weight‐only equations (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.86–1.15), but obesity (OR, 0.83; 95% CI, 0.71–0.96) and higher energy intake (OR, 0.65; 95% CI, 0.56–0.76) had lower odds of mortality. Time to discharge alive was shorter in patients fed using weight‐only equations (hazard ratio [HR], 1.11; 95% CI, 1.01–1.23) in patients staying ≥4 days and with greater energy intake (HR, 1.19; 95% CI, 1.06–1.34) in patients in the ICU ≥12 days. Conclusion: These data suggest that higher energy intake is important to survival and time to discharge alive. However, the analysis was limited by actual energy intake <70% of goal. Delivery of full goal intake will be needed to determine the relationship between the method of determining energy goal and clinical outcomes.     

The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.

OBJECTIVE: To determine mortality, morbidity, and costs attributable to surgical-site infections (SSIs) in the 1990s. DESIGN: A matched follow-up study of a cohort of patients with SSI, matched one-to-one with patients without SSI. SETTING: A 415-bed community hospital. STUDY POPULATION: 255 pairs of patients with and without SSI were matched on age, procedure, National Nosocomial Infection Surveillance System risk index, date of surgery, and surgeon. OUTCOME MEASURES: Mortality, excess length of hospitalization, and extra direct costs attributable to SSI; relative risk for intensive care unit (ICU) admission and for readmission to the hospital. RESULTS: Of the 255 pairs, 20 infected patients (7.8%) and 9 uninfected patients (3.5%) died during the postoperative hospitalization (relative risk [RR], 2.2; 95% confidence interval [CI95], 1.1-4.5). Seventy-four infected patients (29%) and 46 uninfected patients (18%) required ICU admission (RR, 1.6; CI95, 1.3-2.0). The median length of hospitalization was 11 days for infected patients and 6 days for uninfected patients. The extra hospital stay attributable to SSI was 6.5 days (CI95, 5-8 days). The median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected patients. The excess direct costs attributable to SSI were $3,089 (CI95, $2,139-$4,163). Among the 229 pairs who survived the initial hospitalization, 94 infected patients (41%) and 17 uninfected patients (7%) required readmission to the hospital within 30 days of discharge (RR, 5.5; CI95, 4.0-7.7). When the second hospitalization was included, the total excess hospitalization and direct costs attributable to SSI were 12 days and $5,038, respectively. CONCLUSIONS: In the 1990s, patients who develop SSI have longer and costlier hospitalizations than patients who do not develop such infections. They are twice as likely to die, 60% more likely to spend time in an ICU, and more than five times more likely to be readmitted to the hospital. Programs that reduce the incidence of SSI can substantially decrease morbidity and mortality and reduce the economic burden for patients and hospitals.     

Malnutrition May Worsen the Prognosis of Critically Ill Children With Hyperglycemia and Hypoglycemia

Objectives: To determine whether hyperglycemia and hypoglycemia are associated with higher mortality, longer length of intensive care unit (ICU) stay, and fewer ventilator‐free days in critically ill children while taking into account the clinical severity and nutrition status. Patients and Methods: A prospective observational cohort study was conducted on 221 children admitted to the ICU. Blood glucose levels were analyzed in the first 72 hours. Potential exposure variables for adverse prognosis included hyperglycemia (blood glucose >150 mg/dL), hypoglycemia (blood glucose ≤60 mg/dL), age <1 year, sex, nutrition status, the revised Pediatric Index of Mortality (PIM 2), and the Pediatric Logistic Organ Dysfunction (PELOD). Results: Of the patients, 47.1% were malnourished. Controlling for nutrition status, both hyperglycemia and hypoglycemia increased the risk of mortality in the malnourished patients compared with the well‐nourished ones. Adjusting for clinical severity, the odds ratio of mortality was higher in malnourished patients with hyperglycemia (odds ratio [OR], 3.98; 95% confidence interval [CI], 1.14–13.94; P = .03), whereas no significant associations were detected in the well‐nourished patients. After controlling for nutrition status, hypoglycemia was associated with longer length of ICU stay (OR, 6.5; 95% CI, 1.30–32.57; P < .01) and fewer ventilator‐free days (OR, 4.11; 95% CI, 1.26–13.40; P < .01) only in the malnourished group of patients. Conclusions: Compared with the well nourished, malnourished patients with hyperglycemia are at a greater risk of mortality, independent of clinical severity. Hypoglycemia was shown to be associated with mortality, longer length of ICU stay, and fewer ventilator‐free days only in malnourished patients.     

Early Exposure to Recommended Calorie Delivery in the Intensive Care Unit Is Associated With Increased Mortality in Patients With Acute Respiratory Distress Syndrome

Background: The Intensive Nutrition in Acute Lung Injury: Clinical Trial (INTACT), designed to evaluate outcomes of calorie delivery from acute respiratory distress syndrome (ARDS) diagnosis through hospital discharge, was stopped due to higher mortality in the intervention group. Post hoc analysis found timing and dose of calorie delivery influenced mortality. The objective of this retrospective cohort study was to determine if early vs late calorie exposure changed the hazard of death among a larger sample of patients with ARDS. Methods: Adult patients who met the eligibility criteria for INTACT but did not participate were included. Daily calorie delivery was collected from the date INTACT eligibility was determined to extubation or death. Cox proportional hazards regression was used to model the relationship between hazard of hospital death with average calorie exposure received over increasing study days and after day 7. Results: A total of 298 patients were included; overall mortality was 33%. Among patients who remained intubated at 1 week (n = 202), higher kcal/kg received from intensive care unit (ICU) days 1–6 increased hazards of subsequent death on days 7+ (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.01–1.06); kcal/kg received after ICU day 7 decreased the hazards of death on day 7+ (HR, 0.53; 95% CI, 0.33–0.84). Conclusions: Higher calorie exposure between ICU days 1 and 7 was associated with higher subsequent hazard of mortality, and provision of high‐calorie exposure after day 8 decreased the hazards of death.     

Impact of physician training level on emergency readmission within internal medicine

OBJECTIVES: The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine. METHODS: This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan-suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression. RESULTS: A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13-1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38-0.73). CONCLUSION: The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.     

Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization

Objectives. To determine the impact of unit‐level nurse staffing on quality of discharge teaching, patient perception of discharge readiness, and postdischarge readmission and emergency department (ED) visits, and cost‐benefit of adjustments to unit nurse staffing. Data Sources. Patient questionnaires, electronic medical records, and administrative data for 1,892 medical–surgical patients from 16 nursing units within four acute care hospitals between January and July 2008. Design. Nested panel data with hospital and unit‐level fixed effects and patient and unit‐level control variables. Data Collection/Extraction. Registered nurse (RN) staffing was recorded monthly in hours‐per‐patient‐day. Patient questionnaires were completed before discharge. Thirty‐day readmission and ED use with reimbursement data were obtained by cross‐hospital electronic searches. Principal Findings. Higher RN nonovertime staffing decreased odds of readmission (OR=0.56); higher RN overtime staffing increased odds of ED visit (OR=1.70). RN nonovertime staffing reduced ED visits indirectly, via a sequential path through discharge teaching quality and discharge readiness. Cost analysis projected total savings from 1 SD increase in RN nonovertime staffing and decrease in RN overtime of U.S.$11.64 million and U.S.$544,000 annually for the 16 study units. Conclusions. Postdischarge utilization costs could potentially be reduced by investment in nursing care hours to better prepare patients before hospital discharge.     

Metabolites Associated With Malnutrition in the Intensive Care Unit Are Also Associated With 28‐Day Mortality

Background: We hypothesized that metabolic profiles would differ in critically ill patients with malnutrition relative to those without. Materials and Methods: We performed a prospective cohort study on 85 adult patients with systemic inflammatory response syndrome or sepsis admitted to a 20‐bed medical intensive care unit (ICU) in Boston. We generated metabolomic profiles using gas and liquid chromatography and mass spectroscopy. We followed this by logistic regression and partial least squares discriminant analysis to identify individual metabolites that were significant. We then interrogated the entire metabolomics profile using metabolite set enrichment analysis and network model construction of chemical‐protein target interactions to identify groups of metabolites and pathways that were differentiates in patients with and without malnutrition. Results: Of the cohort, 38% were malnourished at admission to the ICU. Metabolomic profiles differed in critically ill patients with malnutrition relative to those without. Ten metabolites were significantly associated with malnutrition (P < .05). A parsimonious model of 5 metabolites effectively differentiated patients with malnutrition (AUC = 0.76), including pyroglutamine and hypoxanthine. Using pathway enrichment analysis, we identified a critical role of glutathione and purine metabolism in predicting nutrition. Nutrition status was associated with 28‐day mortality, even after adjustment for known phenotypic variables associated with ICU mortality. Importantly, 7 metabolites associated with nutrition status were also associated with 28‐day mortality. Conclusion: Malnutrition is associated with differential metabolic profiles early in critical illness. Common to all of our metabolome analyses, glutathione and purine metabolism, which play principal roles in cellular redox regulation and accelerated tissue adenosine triphosphate degradation, respectively, were significantly altered with malnutrition.     

Effect of Perioperative Probiotics and Synbiotics on Postoperative Infections After Gastrointestinal Surgery: A Systematic Review With Meta‐Analysis

Background: Bacterial infection following gastrointestinal surgery remains a common morbidity. The aim of this study was to estimate the effect of the perioperative use of probiotics and synbiotics on postoperative infections. Materials and Methods: We searched PubMed, Embase, and the Cochrane Library to identify pertinent randomized controlled trials (RCTs). The primary outcome was postoperative infection rate. The secondary outcomes were length of hospital and intensive care unit (ICU) stay, length of antibiotic therapy, and mortality. The pooled outcomes were calculated using random effects models. Results: Twenty‐eight RCTs involving 2511 patients were included in this systematic review. The incidence of infectious complications was lower among patients who received probiotics/synbiotics than among the controls (odds ratio [OR] = 0.35; 95% confidence interval [CI], 0.24–0.50), particularly regarding respiratory (OR = 0.44; 95% CI, 0.28–0.68), urinary tract (OR = 0.30; 95% CI, 0.16–0.55), and wound infections (OR = 0.58; 95% CI, 0.42–0.80). The lengths of hospital stay (mean difference [MD] = ?3.20; 95% CI, ?4.87 to ?1.54) and duration of antibiotic therapy (MD = ?3.40; 95% CI, ?4.67 to ?2.13) were shorter for patients who received probiotics/synbiotics than for controls. There were no significant differences in mortality (OR = 1.19; 95% CI, 0.52–2.74) or length of ICU stay (MD = ?0.46; 95% CI, ?1.07 to 0.14) between the compared groups. Conclusion: Probiotics and synbiotics may prevent postoperative infections in patients undergoing gastrointestinal surgery. However, the results need to be interpreted with caution due to the risk of bias in the included studies and the potential publication bias.     

Prognostic Value of Isolated Sarcopenia or Malnutrition–Sarcopenia Syndrome for Clinical Outcomes in Hospitalized Patients

Malnutrition–sarcopenia syndrome (MSS) is frequent in the hospital setting. However, data on the predictive validity of sarcopenia and MSS are scarce. We evaluated the association between sarcopenia and MSS and clinical adverse outcomes (prolonged length of hospital stay—LOS, six-month readmission, and death) using a prospective cohort study involving adult hospitalized patients (n = 550, 55.3 ± 14.9 years, 53.1% males). Sarcopenia was diagnosed according to the EWGSOP2, and malnutrition according to the Subjective Global Assessment (SGA). Around 34% were malnourished, 7% probable sarcopenic, 15% sarcopenic, and 2.5% severe sarcopenic. In-hospital death occurred in 12 patients, and the median LOS was 10.0 days. Within six months from discharge, 7.9% of patients died, and 33.8% were readmitted to the hospital. Probable sarcopenia/sarcopenia had increased 3.95 times (95% CI 1.11–13.91) the risk of in-hospital death and in 3.25 times (95% CI 1.56–6.62) the chance of mortality in six months. MSS had increased the odds of prolonged LOS (OR = 2.73; 95% CI 1.42–5.25), readmission (OR = 7.64; 95% CI 3.06–19.06), and death (OR = 1.15; 95% CI 1.08–1.21) within six months after discharge. Sarcopenia and MSS were predictors of worse clinical outcomes in hospitalized patients.