Interventions to Mobilize Elderly Patients and Reduce Length of Hospital Stay

For older people, and in particular frail older people, acute illness and hospitalization are associated with significant potential harm. One of the major drivers of iatrogenic harm in older adults is hospital-induced immobility, the so-called “pajama paralysis.” Older people in hospital are often confined to bed even after their acute illness has improved; not only by physical factors such as potentially unnecessary urinary catheters and monitoring equipment but also by the culture often found in hospital of keeping patients in bed for most of the day. Bed rest is associated with sarcopenia, infections, and greater length of stay, and early mobilization of patients is often overlooked as an intervention, despite being inexpensive and effective. In this article we review the evidence of the harm of unnecessary immobilization and discuss the innovations that have been developed to encourage a cultural shift away from pajama paralysis and toward early mobilization of older people in hospital.     

Management of Anemia in Patients with Inflammatory Bowel Disease (IBD)

Purpose of Review

Anemia is the most common complication as well as an extra intestinal manifestation of inflammatory bowel disease (IBD). It is associated with a significant impact on patient’s quality of life (QoL); as well it represents a common cause of frequent hospitalization, delay of hospital inpatient discharge and overall increased healthcare burden. In spite of all these, anemia is still often underdiagnosed and undertreated. Our aim in this review is to provide a pathway for physicians to help them achieve early diagnosis as well as timely and appropriate treatment of anemia which in turn would hopefully reduce the prevalence and subsequent complications of this condition among IBD patients.

Recent Findings

The etiology of anemia among IBD patients is most commonly due to iron deficiency anemia (IDA) followed by anemia of chronic disease. Despite this, more than a third of anemic ulcerative colitis (UC) patients are not tested for IDA and among those tested and diagnosed with IDA, a quarter are not treated with iron replacement therapy. A new algorithm has been validated to predict who will develop moderate to severe anemia at the time of UC diagnosis. While oral iron is effective for the treatment of mild iron deficiency-related anemia, the absorption of iron is influenced by chronic inflammatory states as a consequence of the presence of elevated levels of hepcidin. Also, it is important to recognize that ferritin is elevated in chronic inflammatory states and among patients with active IBD, ferritin levels less than 100 are considered to be diagnostic of iron deficiency. Newer formulations of intra-venous (IV) iron have a good safety profile and can be used for replenishment of iron stores and prevention of iron deficiency in the future.

Summary

Routine screening for anemia is important among patients with IBD. The cornerstone for the accurate management of anemia in IBD patients lies in accurately diagnosing the type of anemia. All IBD patients with IDA should be considered appropriate for therapy with iron supplementation whereas IV administration of iron is recommended in patients with clinically active IBD, or for patients who are previously intolerant to oral iron, with hemoglobin levels below 10 g/dL, and in patients who need erythropoiesis-stimulating agents (ESAs). As the recurrence of anemia is common after resolution, the monitoring for recurrent anemia is equally important during the course of therapy.

     

Hospital Length of Stay in Patients with Non-ST-segment Elevation Myocardial Infarction

PurposeSubstantial heterogeneity in hospital length of stay exists among patients admitted with non-ST-segment elevation myocardial infarction. Furthermore, little is known about the factors that impact length of stay.MethodsWe examined 39,107 non-ST-segment elevation myocardial infarction patients admitted to 351 Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines hospitals from January 1, 2007-March 31, 2009 who underwent cardiac catheterization and survived to discharge. Length of stay was categorized into 4 groups (≤2, 3-4, 5-7, and ≥8 days), where prolonged length of stay was defined as >4 days.ResultsThe overall median (25^th, 75^th) length of stay was 3 (2, 5) days. Patients with a length of stay of >2 days were older with more comorbidities, but were less likely to receive evidence-based therapies or percutaneous coronary intervention. Among the factors associated with prolonged length of stay >4 days were delay to cardiac catheterization >48 hours, heart failure or shock on admission, female sex, insurance type, and admission to the hospital on a Friday afternoon or evening. Hospital characteristics such as academic versus nonacademic or urban versus rural setting, were not associated with prolonged length of stay.ConclusionPatients with longer length of stay have more comorbidities and in-hospital complications, yet paradoxically, are less often treated with evidence-based medications and are less likely to receive percutaneous coronary intervention. Hospital admission on a Friday afternoon or evening and delays to catheterization appear to significantly impact length of stay. A better understanding of factors associated with length of stay in patients with non-ST-segment elevation myocardial infarction is needed to promote safe and early discharge in an era of increasingly restrictive health care resources.     

Determinants of Intensive Care Unit Length of Stay for Infants Undergoing Cardiac Surgery

Objective. The purpose of this study was to identify factors that influence postoperative intensive care unit length of stay (ICULOS) in infants less than 6 months of age undergoing congenital heart surgery. Methods. Records from a single institution, from January 2000 to December 2000, were reviewed. For analysis, surgical severity was characterized using an ordinal scoring system, the Aristotle Basic Complexity Score (ABCS; range 1–4). Results. Of 221 infants, 63 had elective surgery, that is, admission to the cardiac intensive care unit after surgery, and 158 had nonelective surgery with admission to the cardiac intensive care unit preoperatively. Elective vs. Nonelective groups differed: ABCS (median 2 vs. 3, P < .001), age at surgery (mean 110 + 10.5 vs. 27 + 3.7 days, P < .001), ICULOS (median 3.5 vs. 7 days, P < .000), and mortality (0% vs. 12.7%P < .0001). Step‐wise multiple regression was performed using the natural log of ICULOS as the dependent variable. Factors associated with longer ICULOS for all 221 patients included: increasing ABCS, preoperative organ‐system failure, total support time (= cardiopulmonary bypass time + deep hypothermic circulatory arrest time), total hours of postoperative ventilatory support, the need for postoperative cardiac catheterization, postoperative necrotizing enterocolitis, and postoperative nasogastric feeds. Higher preoperative weight and surgical repair vs. palliation were associated with a decrease in ICULOS. Conclusion. In conclusion, preoperative organ dysfunction, need for nasogastric feeding, and total support time may offer measurable variables useful in predicting that infant at greatest risk for extended ICULOS.     

Risk Stratification and Clinical Pathways to Optimize Length of Stay After Transcatheter Aortic Valve Replacement

BackgroundTranscatheter aortic valve replacement (TAVR) program experience and advances present opportunities to introduce minimalist clinical pathways. The purpose of this study was to determine the safety and feasibility of preprocedural individualized risk stratification for general anaesthesia and transesophageal echocardiography (GA/TEE) or awake TAVR and the postprocedural standard or rapid discharge TAVR clinical pathways.MethodsStandardized screening and multidisciplinary heart team consensus was used to evaluate individual periprocedural risk and requirements. Postprocedural clinical status and criteria guided the timing of discharge. We evaluated standardized TAVR outcomes and length of stay according to periprocedural practice and postprocedural trajectory.ResultsIn 144 consecutive patients who underwent TAVR in 2013 (mean age, 82.0 ± 7.1 years; 38.2% women; mean Society of Thoracic Surgeons score, 6.5% ± 4.1%), 101 (69.1%) were assigned to the GA/TEE protocol, whereas 43 (29.9%) were assigned to the minimalist awake TAVR protocol. Irrespective of mode of anaesthesia, 94 (65.3%) patients were discharged within the standard time, whereas 50 (34.7%) patients were suitable for rapid discharge. Overall outcomes at 30 days were 2.1% mortality, 1.4% stroke, and 2.1% life-threatening bleeding. Median length of stay was shortest in the awake TAVR group (2 days; interquartile range [IQR], 1-3 days) and rapid discharge group (2 days; IQR, 1-2 days) and longer in the GA/TEE and standard discharge (3 days, IQR, 3-4 days) groups.ConclusionsExcellent outcomes and decreased length of stay can be achieved with individualized risk stratification to select the optimal periprocedural practice and determine the timing of discharge. These findings should be further evaluated in a large long-term clinical study.     

Disability Impacts Length of Stay in General Internal Medicine Patients

BACKGROUND

Disability is prevalent among patients treated in Internal Medicine (IM), but its impact on length of inpatient stay (LOS) is unknown. Current systems of patient management and resource allocation are disease-focused with scant attention paid to functional impairment. Earlier studies in selected cohorts suggest that disability prolongs LOS.

OBJECTIVE

To investigate the relationship of disability with LOS in IM, controlling for comorbidity.

DESIGN

Prospective cohort study.

PATIENTS

We charted 448 patients from an IM team admitted between 2008 and 2012 for sociodemographic, disease, biochemical and functional characteristics. Each IM team is on duty for one month annually, and patients were hence recruited for one month each year.

MAIN MEASURES

Disability was measured using the Functional Independence Measure (FIM) recorded at discharge. Comorbidity was measured using the Charlson Comorbidity Index (CCI).

KEY RESULTS

Of the 448 patients, 57.4 % were male with mean age 68.6 years. The mean LOS was 9.58 days. The mean motor and cognitive FIM scores were 57.1 and 25.7, respectively. The mean CCI score was 2.69. Thirty-four percent had major social issues impacting discharge plans. The five most common diagnoses for admission were pneumonia (8.9 %), urinary tract infection (7.8 %), cellulitis (7.6 %), heart failure (7.1 %) and falls (6.0 %). Both cognitive and motor FIM scores were negatively correlated with longer LOS (P?<?0.001). On multivariate analysis, variables independently associated with longer LOS included the motor FIM score (P?<?0.001), presence of social issues such as caregiver unavailability (P?<?0.001), non-realistic patient expectations (P?=?0.001) and administrative issues impeding discharge (P?=?0.016).

CONCLUSION

Disability predicts LOS in IM patients, and thus their comprehensive care should involve functional assessment. As social and administrative factors were also independently associated with LOS, there is a need to involve social workers and administrators in a multidisciplinary approach towards optimizing LOS.     

The Development of a Validated Instrument to Evaluate Bowel Function After Sphincter-Preserving Surgery for Rectal Cancer

PURPOSE Sphincter-preserving surgery is technically feasible for many rectal cancers, but functional results are not well understood. Therefore, the purpose of this study was to develop an instrument to evaluate bowel function after sphincter-preserving surgery.METHODS A 41-item bowel function survey was developed from a literature review, expert opinions, and 59 patient interviews. An additional 184 patients who underwent sphincter-preserving surgery between 1997 and 2001 were asked to complete the survey and quality-of-life instruments (Fecal Incontinence Quality of Life, European Organization for Research and Treatment of Cancer QLQ 30/Colorectal Cancer 38). A factor analysis of variance was performed. Test–retest reliability was evaluated, with 20 patients completing two surveys within a mean of 11 days. Validity testing was done with clinical variables (gender, age, radiation, length of time from surgery), surgical variables (procedure: local excision, low anterior resection, coloanal anastomosis), reconstruction (J-pouch, straight), anastomosis (handsewn, stapled), and quality-of-life instruments.RESULTS The survey response rate was 70.1 percent (129/184). Among the 127 patients with usable data, 67 percent were male, the median age was 64 (range, 38–87) years, and the mean time for restoration of bowel continuity after sphincter-preserving surgery was 22.9 months. Patients had a median of 3.5 stools/day (range, 0–30), and 37 percent were dissatisfied with their bowel function. Patients experienced a median of 22 symptoms (range, 7–32), with 27 percent reported as severe, 37 percent as moderate, and 36 percent as mild. The five most common symptoms were incomplete evacuation (96.8 percent), clustering (94.4 percent), food affecting frequency (93.2 percent), unformed stool (92.8 percent), and gas incontinence (91.8 percent). The factor analysis identified 14 items that collapsed into three subscales: FREQUENCY (α = 0.75), DIETARY (α = 0.78), and SOILAGE (α = 0.79), with acceptable test–retest reliability for the three subscales and total score (0.62–0.87). The instrument detected differences between patients with preoperative radiation (n = 67) vs. postoperative radiation (n = 15) vs. no radiation (n = 45) (P = 0.02); local excision (n = 10) vs. low anterior resection (n = 55) vs. coloanal anastomosis (n = 62) (P = 0.002); and handsewn (n = 18) vs. stapled anastomosis (n = 99) (P = 0.006). The total score correlated with 4 of 4 Fecal Incontinence Quality of Life (P < 0.01) and 9 of 17 European Organization for Research and Treatment of Cancer subscales (all P < 0.01).CONCLUSIONS Patients undergoing sphincter-preserving surgery for rectal cancer have impaired bowel function, and those treated with radiation, coloanal anastomoses, or handsewn anastomoses have significantly worse function. This reliable and valid instrument should be used to prospectively evaluate bowel function after sphincter-preserving surgery in patients undergoing rectal cancer therapy.Supported in part by a Limited Project Grant from The American Society of Colon and Rectal Surgeons Research Foundation, 2002.Presented at the meeting of The American Society of Colon and Rectal Surgeons in Dallas, Texas, May 8 to 13, 2004.     

Variation in Length of Stay and Outcomes among Hospitalized Patients Attributable to Hospitals and Hospitalists

BACKGROUND

There have been no prior population-based studies of variation in performance of hospitalists.

OBJECTIVE

To measure the variation in performance of hospitalists.

DESIGN

Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models.

SUBJECTS

131,710 hospitalized patients cared for by 1,099 hospitalists in 268 hospitals from 2006–2009.

MAIN MEASURES

We calculated, for each hospitalist, adjusted for patient and disease factors (case mix), their patients' average length of stay, rate of discharge home or to skilled nursing facility (SNF) and rate of 30-day mortality, readmissions and emergency room (ER) visits.

KEY RESULTS

In two-level models (admission and hospitalist), there was significant variation in average length of stay and discharge location among hospitalists, but very little variation in 30-day mortality, readmission or emergency room visit rates. There was stability over time (2008–2009 vs. 2006–2007) in hospitalist performance. In three-level models including admissions, hospitalists and hospitals, the variation among hospitalists was substantially reduced. For example, hospitals, hospitalists and case mix contributed 1.02 %, 0.75 % and 42.15 % of the total variance in 30-day mortality rates, respectively.

CONCLUSIONS

There is significant variation among hospitalists in length of stay and discharge destination of their patients, but much of the variation is attributable to the hospitals where they practice. The very low variation among hospitalists in 30-day readmission rates suggests that hospitalists are not important contributors to variations in those rates among hospitals.     

Liver Injury Among Japanese Patients Treated Using Prophylactic Enoxaparin After Colorectal Surgery

Digestive Diseases and Sciences - Enoxaparin, a low molecular weight heparin, has been used to prevent thrombotic events during major surgery without increasing the rate of hemorrhage. On the other...     

Depressive Symptoms Predict Anti-tumor Necrosis Factor Therapy Noncompliance in Patients with Inflammatory Bowel Disease

Digestive Diseases and Sciences - Noncompliance in use of anti-tumor necrosis factor (anti-TNF) therapy in patients with moderate-to-severe inflammatory bowel disease (IBD) can be a factor in...     

Using the AUDIT-PC to Predict Alcohol Withdrawal in Hospitalized Patients

BACKGROUND

Alcohol withdrawal syndrome (AWS) occurs when alcohol-dependent individuals abruptly reduce or stop drinking. Hospitalized alcohol-dependent patients are at risk. Hospitals need a validated screening tool to assess withdrawal risk, but no validated tools are currently available.

OBJECTIVE

To examine the admission Alcohol Use Disorders Identification Test-(Piccinelli) Consumption (AUDIT-PC) ability to predict the subsequent development of AWS among hospitalized medical-surgical patients admitted to a non-intensive care setting.

DESIGN

Retrospective case–control study of patients discharged from the hospital with a diagnosis of AWS. All patients with AWS were classified as presenting with AWS or developing AWS later during admission. Patients admitted to an intensive care setting and those missing AUDIT-PC scores were excluded from analysis. A hierarchical (by hospital unit) logistic regression was performed and receiver-operating characteristics were examined on those developing AWS after admission and randomly selected controls. Because those diagnosing AWS were not blinded to the AUDIT-PC scores, a sensitivity analysis was performed.

PARTICIPANTS

The study cohort included all patients age ≥18 years admitted to any medical or surgical units in a single health care system from 6 October 2009 to 7 October 2010.

KEY RESULTS

After exclusions, 414 patients were identified with AWS. The 223 (53.9 %) who developed AWS after admission were compared to 466 randomly selected controls without AWS. An AUDIT-PC score ≥4 at admission provides 91.0 % sensitivity and 89.7 % specificity (AUC?=?0.95; 95 % CI, 0.94–0.97) for AWS, and maximizes the correct classification while resulting in 17 false positives for every true positive identified. Performance remained excellent on sensitivity analysis (AUC?=?0.92; 95 % CI, 0.90–0.93). Increasing AUDIT-PC scores were associated with an increased risk of AWS (OR?=?1.68, 95 % CI 1.55–1.82, p?<?0.001).

CONCLUSIONS

The admission AUDIT-PC score is an excellent discriminator of AWS and could be an important component of future clinical prediction rules. Calibration and further validation on a large prospective cohort is indicated.     

Predictors of Hospital Length of Stay in Patients with Exacerbations of COPD: A Cohort Study

Background

Various studies have tried to delimit the predictors of hospital length of stay (LOS) for patients with exacerbated chronic obstructive pulmonary disease (eCOPD), but have been disadvantaged by certain limiting factors.

Objective

Our goal was to prospectively identify predictors of LOS in these patients and to validate our results.

Design

This was a prospective cohort study.

Participants

Subjects were patients with eCOPD who visited 16 hospital emergency departments (EDs) and who were admitted to the hospital.

Main Measures

Data were recorded on possible predictor variables at the ED visit, on admission and 24 hours later, during hospitalization, and on discharge. LOS and prolonged LOS (≥ 9 days, considering the 75th percentile of LOS in our sample) were the outcomes of interest. Multivariate multilevel linear and logistic regression models were employed.

Results

A total of 1,453 patients were equally divided between derivation and validation samples. The hospital variable was the best predictor of LOS. Multivariate predictors of LOS, as log-transformed variables, were the hospital, baseline dyspnea and physical activity levels and fatigue at 24 hours, intensive care or intensive respiratory care unit admission, the need for antibiotics, and complications during hospitalization. Predictors of prolonged LOS were also the hospital, baseline dyspnea and fatigue at 24 hours, ICU or IRCU admission, and complications during hospitalization (AUC: 0.77). Models were validated in the validation sample (AUC: 0.75).

Conclusions

We identified a number of modifiable factors, including baseline dyspnea, physical activity level, and hospital variability, that influenced the LOS of patients with eCOPD who were admitted to the hospital.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3129-x) contains supplementary material, which is available to authorized users.KEY WORDS: COPD exacerbations, Admission, Prospective cohort study, Predictive factors