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Correa-Agudelo E, Gautam Y, Mendy A, Mersha TB. Racial differences in length of stay and readmission for asthma in the all of us research program. J Transl Med 2024; 22:22. [PMID: 38178151 PMCID: PMC10768130 DOI: 10.1186/s12967-023-04826-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND This study addresses the limited research on racial disparities in asthma hospitalization outcomes, specifically length of stay (LOS) and readmission, across the U.S. METHODS We analyzed in-patient and emergency department visits from the All of Us Research Program, identifying various risk factors (demographic, comorbid, temporal, and place-based) associated with asthma LOS and 30-day readmission using Bayesian mixed-effects models. RESULTS Of 17,233 patients (48.0% White, 30.7% Black, 19.7% Hispanic/Latino, 1.3% Asian, and 0.3% Middle Eastern and North African) with 82,188 asthma visits, Black participants had 20% shorter LOS and 12% higher odds of readmission, compared to White participants in multivariate analyses. Public-insured patients had 14% longer LOS and 39% higher readmission odds than commercially insured patients. Weekend admissions resulted in a 12% shorter LOS but 10% higher readmission odds. Asthmatics with chronic diseases had a longer LOS (range: 6-39%) and higher readmission odds (range: 9-32%) except for those with allergic rhinitis, who had a 23% shorter LOS. CONCLUSIONS A comprehensive understanding of the factors influencing asthma hospitalization, in conjunction with diverse datasets and clinical-community partnerships, can help physicians and policymakers to systematically address racial disparities, healthcare utilization and equitable outcomes in asthma care.
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Affiliation(s)
- Esteban Correa-Agudelo
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Yadu Gautam
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Angelico Mendy
- Division of Epidemiology, Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tesfaye B Mersha
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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Azadeh-Fard N, Muchiri S, Pakdil F, Beazoglou H. Examining readmission rates of congestive heart failure patients in the United States between 2010 and 2017: Does length of stay matter? INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2157074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Nasibeh Azadeh-Fard
- Rochester Institute of Technology, Department of Industrial and Systems Engineering, Rochester, NY, USA
| | - Steve Muchiri
- Eastern Connecticut State University, Department of Economics, Willimantic, CT, USA
| | - Fatma Pakdil
- Eastern Connecticut State University, Department of Business Administration, Willimantic, CT, USA
| | - Hannah Beazoglou
- Eastern Connecticut State University, Department of Business Administration, Willimantic, CT, USA
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Mohr NM, Wu C, Ward MJ, McNaughton CD, Faine B, Pomeranz K, Richardson K, Kaboli PJ. Transfer boarding delays care more in low-volume rural emergency departments: A cohort study. J Rural Health 2022; 38:282-292. [PMID: 33644911 PMCID: PMC8715860 DOI: 10.1111/jrh.12559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals. METHODS A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas. FINDINGS A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs. CONCLUSIONS Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.
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Affiliation(s)
- Nicholas M. Mohr
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Emergency Medicine, University of Iowa Carver College of Medicine;,Department of Anesthesia, University of Iowa Carver College of Medicine
| | - Chaorong Wu
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, Iowa
| | - Michael J. Ward
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee;,Department of Emergency Medicine, Vanderbilt University Medical Center
| | - Candace D. McNaughton
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee;,Department of Emergency Medicine, Vanderbilt University Medical Center
| | - Brett Faine
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Kaila Pomeranz
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Kelly Richardson
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA
| | - Peter J. Kaboli
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Ippoliti R, Falavigna G, Zanelli C, Bellini R, Numico G. Neural networks and hospital length of stay: an application to support healthcare management with national benchmarks and thresholds. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:67. [PMID: 34627288 PMCID: PMC8502324 DOI: 10.1186/s12962-021-00322-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 09/23/2021] [Indexed: 11/25/2022] Open
Abstract
Background The problem of correct inpatient scheduling is extremely significant for healthcare management. Extended length of stay can have negative effects on the supply of healthcare treatments, reducing patient accessibility and creating missed opportunities to increase hospital revenues by means of other treatments and additional hospitalizations. Methods Adopting available national reference values and focusing on a Department of Internal and Emergency Medicine located in the North-West of Italy, this work assesses prediction models of hospitalizations with length of stay longer than the selected benchmarks and thresholds. The prediction models investigated in this case study are based on Artificial Neural Networks and examine risk factors for prolonged hospitalizations in 2018. With respect current alternative approaches (e.g., logistic models), Artificial Neural Networks give the opportunity to identify whether the model will maximize specificity or sensitivity. Results Our sample includes administrative data extracted from the hospital database, collecting information on more than 16,000 hospitalizations between January 2018 and December 2019. Considering the overall department in 2018, 40% of the hospitalizations lasted more than the national average, and almost 3.74% were outliers (i.e., they lasted more than the threshold). According to our results, the adoption of the prediction models in 2019 could reduce the average length of stay by up to 2 days, guaranteeing more than 2000 additional hospitalizations in a year. Conclusions The proposed models might represent an effective tool for administrators and medical professionals to predict the outcome of hospital admission and design interventions to improve hospital efficiency and effectiveness.
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Affiliation(s)
- Roberto Ippoliti
- Faculty of Business Administration and Economics, Bielefeld University, Bielefeld, North Rhine-Westphalia, Germany.
| | - Greta Falavigna
- Research Institute on Sustainable Economic Growth (IRCrES), National Research Council of Italy (CNR), Moncalieri, TO, Italy
| | - Cristian Zanelli
- Quality and Management Control Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, AL, Italy
| | - Roberta Bellini
- Quality and Management Control Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, AL, Italy
| | - Gianmauro Numico
- Medical Oncology Unit, Azienda Ospedaliera Santa Croce e Carle, Cuneo, CN, Italy
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5
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Abuzied Y, Maymani H, AlMatouq B, AlDosary O. Reducing the Length of Stay by Enhancing the Patient Discharge Process: Using Quality Improvement Tools to Optimize Hospital Efficiency. GLOBAL JOURNAL ON QUALITY AND SAFETY IN HEALTHCARE 2021; 4:44-49. [PMID: 37260536 PMCID: PMC10229011 DOI: 10.36401/jqsh-20-27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/16/2020] [Indexed: 06/02/2023]
Abstract
Introduction Delays in the discharging process can affect hospital efficiency. Improving patient flow in acute care hospitals is an essential issue that hospital management and research aim to achieve. Admission volume and LOS for hospitalized patients in the medical specialties department was examined at a tertiary care center in Riyadh, Saudi Arabia, to explore practical approaches to reduce the LOS. We aimed to identify and manage reasons for the delay in discharging patients from the medical specialties department at a tertiary care center in Saudi Arabia. Methods Admission and discharge data for hospitalized patients were collected from 2016-2018. In 2017, a FOCUS (find, organize, clarify, understand, select)-PDSA (plan, do, study, act) quality improvement method was used to improve the discharge processes, with specific measurable targets per year. The number of readmissions and mortality rates decreased significantly after the intervention was implemented, suggesting an improvement in the quality of treatment and the process of admission and discharge. Results Despite gradual increases in admissions from 2016 to 2018, the mean LOS decreased significantly between 2016 and 2018, from 9.16 to 7.47 days (p < 0.001). The number of readmissions and mortality rates decreased after the intervention was implemented in 2017, suggesting an improvement in the process of admission and discharge. Conclusion The LOS can be reduced by implementing a quality improvement intervention, driven by a multidisciplinary committee involving healthcare personnel, to facilitate the optimal discharge mechanism through available hospital resources and services.
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Affiliation(s)
- Yacoub Abuzied
- Department of Nursing, Rehabilitation Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hassan Maymani
- Department of Medical Specialties, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Basim AlMatouq
- Department of Medical Specialties, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Oweida AlDosary
- Department of Medical Specialties, Main Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
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Gamboa-Antiñolo FM. Organizational determinants of hospital stay: increasing hospital efficiency. Intern Emerg Med 2020; 15:925-927. [PMID: 32253573 DOI: 10.1007/s11739-020-02305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
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Numico G, Bellini R, Zanelli C, Ippoliti R, Boverio R, Kozel D, Davio P, Aiosa G, Bellora A, Chichino G, Ruiz L, Ladetto M, Polla B, Manganaro M, Pistis G, Gemme C, Stobbione P, Desperati M, Centini G. Organizational determinants of hospital stay: establishing the basis of a widespread action on more efficient pathways in medical units. Intern Emerg Med 2020; 15:1011-1019. [PMID: 31907767 DOI: 10.1007/s11739-019-02267-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/18/2019] [Indexed: 12/16/2022]
Abstract
Given the high hospital costs, the increasing clinical complexity and the overcrowding of emergency departments, it is crucial to improve the efficiency of medical admissions. We aimed at isolating organizational drivers potentially targetable through a widespread improvement action. We studied all medical admissions in a large tertiary referral hospital from January 1st to December 31st, 2018. Data were retrieved from the administrative database. Available information included age, sex, type (urgent or elective) and Unit of admission, number of internal transfers, main ICD-9 diagnosis, presence of cancer among diagnoses, surgical or medical code, type of discharge, month, day and hour of admission and discharge. National Ministry of Health database was used for comparisons. 8099 admissions were analyzed. Urgent admissions (80.5% of the total) were responsible for longer stays and were the object of the multivariate analysis. The variables most influencing length-of-stay (LOS) were internal transfers and assisted discharge: they contributed, respectively, to 62% and 40% prolongation of LOS. Also, the daily and weekly kinetics of admission accounted for a significant amount of variation in LOS. Long admissions (≥ 30 days) accounted for the 15.5% of total bed availability. Type of discharge and internal transfers were again among the major determinants. A few factors involved in LOS strictly depend on the organizational environment and are potentially modifiable. Re-engineering should be focused on making more efficient internal and external transitions and at ensuring continuity of the clinical process throughout the day and the week.
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Affiliation(s)
- Gianmauro Numico
- Department of Medicine and Medical Oncology Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Via Venezia 16, 15121, Alessandria, Italy.
| | - Roberta Bellini
- Quality and Management Control Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Cristian Zanelli
- Quality and Management Control Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Roberto Ippoliti
- Department of Business, Administration and Economics, University of Bielefeld, Bielefeld, Deutschland
| | - Riccardo Boverio
- Emergency Department Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Daniela Kozel
- General and Medical Direction, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Piero Davio
- Internal Medicine Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Giuseppe Aiosa
- Internal Medicine Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Aldo Bellora
- Geriatric Medicine Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Guido Chichino
- Infectious Diseases Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Luigi Ruiz
- Neurology Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Marco Ladetto
- Hematology Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Biagio Polla
- Respiratory Medicine Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Marco Manganaro
- Nephrology Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Gianfranco Pistis
- Cardiology Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Carlo Gemme
- Gastroenterology Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Paolo Stobbione
- Rheumathology Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Massimo Desperati
- General and Medical Direction, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Giacomo Centini
- General and Medical Direction, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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Oberlin M, Andrès E, Behr M, Kepka S, Le Borgne P, Bilbault P. [Emergency overcrowding and hospital organization: Causes and solutions]. Rev Med Interne 2020; 41:693-699. [PMID: 32861534 DOI: 10.1016/j.revmed.2020.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/14/2020] [Accepted: 05/05/2020] [Indexed: 10/23/2022]
Abstract
Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.
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Affiliation(s)
- M Oberlin
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France.
| | - E Andrès
- Service de Médecine Interne, Diabète et Maladies métaboliques, Hôpitaux Universitaires de Strasbourg, Clinique Médicale B - HUS, 1 porte de l'Hôpital, 67000 Strasbourg, France; Unité INSERM EA 3072 « Mitochondrie, Stress oxydant et Protection musculaire », Faculté de Médecine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
| | - M Behr
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France
| | - S Kepka
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France
| | - P Le Borgne
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France; Unité INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médeine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
| | - P Bilbault
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France; Unité INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médeine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
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Berg KM, Donnino MW, Andersen LW, Moskowitz A, Grossestreuer AV. Acute respiratory compromise on hospital wards: Association between recent ICU discharge and outcome. Resuscitation 2019; 144:40-45. [PMID: 31513866 PMCID: PMC7371260 DOI: 10.1016/j.resuscitation.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/15/2019] [Accepted: 09/01/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Acute respiratory compromise (ARC), respiratory distress requiring emergent assisted ventilation, has a mortality of 20-40%. The relationship between recent discharge from an intensive care unit (ICU) and outcomes of patients suffering ARC on hospital wards is not well known. We hypothesized that a significant percentage of ARC events would occur in patients recently discharged from an ICU, that these patients would have worse outcomes than those without prior ICU stays, and that weekend ICU discharge would be associated with higher than expected post-ICU ARC frequency. METHODS Using the Get-With-The-Guidelines-Resuscitation ARC registry, we included adult, index ARC events occurring on hospital wards. Our primary analysis used multivariable logistic regression accounting for clustering by hospital to examine the association between prior ICU discharge and survival after an ARC event. RESULTS Of 11,800 ARCs, 937 (8%) occurred within two calendar days and 1010 (9%) >two calendar days after an ICU discharge. Patients with ICU discharge within two days had higher survival compared to those with no prior ICU stay (odds ratio 1.28 (95% CI: 1.11-1.48, p = 0.001)). Survival was not different in those with an ICU discharge more than two days prior and no prior ICU stay. Patients with ARC within two days of ICU discharge were not more likely to have left the ICU on a weekend. CONCLUSIONS Contrary to our hypothesis, discharge from an ICU within two calendar days was associated with better odds for survival compared to no prior ICU discharge or ICU discharge more than two days prior.
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Affiliation(s)
- Katherine M Berg
- Divsion of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.
| | - Michael W Donnino
- Divsion of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Lars W Andersen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Ari Moskowitz
- Divsion of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Anne V Grossestreuer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Martin BJ, McBrien A, Marchak BE, Atallah J, Al Aklabi M, Mackie AS. Predicting Post-Fontan Length of Stay: The Limits of Measured Variables. Pediatr Cardiol 2019; 40:1208-1216. [PMID: 31230092 DOI: 10.1007/s00246-019-02134-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Abstract
Post-operative length of stay (LOS) is an important metric for both healthcare providers and patients and their families. Predicting LOS is a challenge as it is sensitive to multitudinous patient and system factors. All subjects undergoing a Fontan from 1996-2016 who survived to hospital discharge were included. Details about the pre-operative status, operative conduct, and post-operative course of each patient were obtained. The association between patient characteristics and post-Fontan LOS were determined using stepwise multivariable regression models. Of 320 subjects who underwent a Fontan, 314 (98.1%) survived to hospital discharge. Median age at Fontan was 3.3 years (IQR 2.8, 4.0) and the most common underlying diagnosis was hypoplastic left heart syndrome (106, 33.8%). Median post Fontan LOS was 11 days (IQR 8, 17). Univariable risk factors for longer LOS included number of previous surgeries, post-Glenn LOS, cardiopulmonary bypass time, post-operative chylothorax, and failure to extubate in the operating room (all p < 0.05). In multivariable models, number of previous operations, extubation in the operating room, and postoperative complications predicted LOS (R2 = 0.5185 for full model). The proportion of patients discharged on week days (14.7-18.8% per day) was significantly higher than the proportion discharged on weekend days (5.1-9.9% per weekend day). Pre-operative variables have limited use in predicting post-Fontan length of stay. The most important predictors of post-operative LOS are extubation in the operating room and the occurrence of post-operative complications. However, a significant proportion of variability in LOS was not explained by available measurable variables.
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Affiliation(s)
- Billie-Jean Martin
- Department of Cardiothoracic Surgery, Falk Building, Stanford University, 870 Quarry Road, CV-225, Stanford, CA, 94304-5407, USA.
| | - Angela McBrien
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - B Elaine Marchak
- Department of Anesthesia, University of Alberta, Edmonton, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | | | - Andrew S Mackie
- Department of Pediatrics, University of Alberta, Edmonton, Canada
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Rocha HAL, Santos AKLDC, Alcântara ACDC, Lima CSSDC, Rocha SGMO, Cardoso RM, Cremonin JR. Bed management team with Kanban web-based application. Int J Qual Health Care 2018; 30:708-714. [PMID: 29767742 DOI: 10.1093/intqhc/mzy108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/29/2018] [Indexed: 01/05/2023] Open
Abstract
Objective To measure the effectiveness of the bed management process that uses a web-based application with Kanban methodology to reduce hospitalization time of hospitalized patients. Design Before-after study was performed. Setting The study was conducted between July 2013 and July 2017, at the Unimed Regional Hospital of Fortaleza, which has 300 beds, of which 60 are in the intensive care unit (ICU). It is accredited by International Society for Quality in Healthcare. Population Patients hospitalized in the referred period. Intervention Bed management with an application that uses color logic to signal at which stage of high flow the patients meet, in which each patient is interpreted as a card of the classical Kanban theory. It has an automatic user signaling system for process movement, and a system for monitoring and analyzing discharge forecasts. Main Outcome Measures Length of hospital stay, number of customer complaints related to bed availability. Results After the intervention, the hospital's overall hospital stay time was reduced from 5.6 days to 4.9 days (P = 0.001). The units with the greatest reduction were the ICUs, with reduction from 6.0 days to 2.0 (P = 0.001). The relative percentage of complaints regarding bed availability in the hospital fell from 27% to 0%. Conclusion We conclude that the use of an electronic tool based on Kanban methodology and accessed via the web by a bed management team is effective in reducing patients' hospital stay time.
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Affiliation(s)
- Hermano Alexandre Lima Rocha
- Community Health Department, Federal University of Ceará, Rua Prof Costa Mendes, 1608, 60.430-130, Fortaleza, Ceará, Brazil.,Public Health, Centro Universitário Unichristus, ISEC. R. João Adolfo Gurgel, 133, Cocó, Fortaleza, CE
| | - Ana Kelly Lima da Cruz Santos
- Research Unit Department, Hospital Regional Unimed Fortaleza. Av. Visconde do Rio Branco, 4000-São João do Tauape, Fortaleza-CE, Fortaleza, Ceará, Brazil
| | - Antônia Celia de Castro Alcântara
- Research Unit Department, Hospital Regional Unimed Fortaleza. Av. Visconde do Rio Branco, 4000-São João do Tauape, Fortaleza-CE, Fortaleza, Ceará, Brazil
| | - Carmen Sulinete Suliano da Costa Lima
- Research Unit Department, Hospital Regional Unimed Fortaleza. Av. Visconde do Rio Branco, 4000-São João do Tauape, Fortaleza-CE, Fortaleza, Ceará, Brazil
| | | | - Roberto Melo Cardoso
- Research Unit Department, Hospital Regional Unimed Fortaleza. Av. Visconde do Rio Branco, 4000-São João do Tauape, Fortaleza-CE, Fortaleza, Ceará, Brazil
| | - Jair Rodrigues Cremonin
- Research Unit Department, Hospital Regional Unimed Fortaleza. Av. Visconde do Rio Branco, 4000-São João do Tauape, Fortaleza-CE, Fortaleza, Ceará, Brazil
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Au J, Horwood C, Hakendorf P, Thompson C. Similar outcomes for general medicine patients discharged on any day of the week. Intern Med J 2018; 49:380-384. [PMID: 30129263 DOI: 10.1111/imj.14083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/18/2018] [Accepted: 08/11/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hospital congestion is worsened by fewer patients being discharged on the weekend than on weekdays. Weekend admissions fare worse in hospital than weekday admissions. Understanding the fate of patients discharged on the weekend, or any particular weekday, may help optimise hospital discharge processes. AIM To determine the effects of weekend and specific weekday discharges on adverse outcomes (mortality and readmission to hospital). METHODS Electronic records were used to identify unplanned admissions to two large public hospitals across a 5-year period. Day of week of discharge, the inpatient length of stay, unplanned readmissions and mortality rate were determined. RESULTS There was a significant reduction in discharges on the weekend (49%), particularly for patients who were older or with significant comorbidity (P < 0.001). Adjusting for these differences, there was no difference in readmission and mortality between weekday and weekend discharges within two (OR 0.97; 95% CI 0.83-1.14; P < 0.76) or seven (OR 0.91; 95% CI 0.82-1.01; P < 0.07) days of discharge. By 30 days, there were significantly fewer adverse outcomes for those discharged on the weekend (OR 0.89; 95% CI 0.83-0.96; P < 0.001). There was no difference in adverse outcome rates for patients discharged on Mondays, Wednesdays or Fridays. CONCLUSION Fewer patients are discharged on the weekend and these are typically younger, less complex patients. Patients discharged on the weekend fare similarly or better than those discharged on a weekday. Therefore, a push to discharge more patients on the weekend could improve hospital efficiency without compromising patient care.
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Affiliation(s)
- John Au
- Department of General Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Chris Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, South Australia, Australia
| | - Paul Hakendorf
- Department of Clinical Epidemiology, Flinders Medical Centre, South Australia, Australia
| | - Campbell Thompson
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Masselot P, Chebana F, Bélanger D, St-Hilaire A, Abdous B, Gosselin P, Ouarda TBMJ. Aggregating the response in time series regression models, applied to weather-related cardiovascular mortality. THE SCIENCE OF THE TOTAL ENVIRONMENT 2018; 628-629:217-225. [PMID: 29438931 DOI: 10.1016/j.scitotenv.2018.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/04/2018] [Accepted: 02/02/2018] [Indexed: 06/08/2023]
Abstract
In environmental epidemiology studies, health response data (e.g. hospitalization or mortality) are often noisy because of hospital organization and other social factors. The noise in the data can hide the true signal related to the exposure. The signal can be unveiled by performing a temporal aggregation on health data and then using it as the response in regression analysis. From aggregated series, a general methodology is introduced to account for the particularities of an aggregated response in a regression setting. This methodology can be used with usually applied regression models in weather-related health studies, such as generalized additive models (GAM) and distributed lag nonlinear models (DLNM). In particular, the residuals are modelled using an autoregressive-moving average (ARMA) model to account for the temporal dependence. The proposed methodology is illustrated by modelling the influence of temperature on cardiovascular mortality in Canada. A comparison with classical DLNMs is provided and several aggregation methods are compared. Results show that there is an increase in the fit quality when the response is aggregated, and that the estimated relationship focuses more on the outcome over several days than the classical DLNM. More precisely, among various investigated aggregation schemes, it was found that an aggregation with an asymmetric Epanechnikov kernel is more suited for studying the temperature-mortality relationship.
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Affiliation(s)
- Pierre Masselot
- Institut National de la Recherche Scientifique, Centre Eau-Terre-Environnement, Québec, Canada.
| | - Fateh Chebana
- Institut National de la Recherche Scientifique, Centre Eau-Terre-Environnement, Québec, Canada
| | - Diane Bélanger
- Institut National de la Recherche Scientifique, Centre Eau-Terre-Environnement, Québec, Canada; Centre Hospitalier Universitaire de Québec, Centre de Recherche, Québec, Canada
| | - André St-Hilaire
- Institut National de la Recherche Scientifique, Centre Eau-Terre-Environnement, Québec, Canada
| | - Belkacem Abdous
- Université Laval, Département de Médecine Sociale et Préventive, Québec, Canada
| | - Pierre Gosselin
- Institut National de la Recherche Scientifique, Centre Eau-Terre-Environnement, Québec, Canada; Centre Hospitalier Universitaire de Québec, Centre de Recherche, Québec, Canada; Institut National de Santé Publique du Québec (INSPQ), Québec, Canada
| | - Taha B M J Ouarda
- Institut National de la Recherche Scientifique, Centre Eau-Terre-Environnement, Québec, Canada
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Albabtain IT, Alsuhaibani RS, Almalki SA, Arishi HA, Alsulaim HA. Outcomes of common general surgery procedures for patients discharged over weekends at a tertiary care hospital in Saudi Arabia. Ann Saudi Med 2018; 38:105-110. [PMID: 29620543 PMCID: PMC6074366 DOI: 10.5144/0256-4947.2018.105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hospitals usually reduce staffing levels and services over weekends. This raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk of adverse events post-discharge. OBJECTIVES To assess the outcomes of common general surgery procedures for patients discharged over weekends, and to identify the key predictors of early readmission. DESIGN Retrospective cohort study. SETTING A tertiary care center. PATIENTS AND METHODS Patients discharged from general surgery services during the one-year period between January and December 2016 after cholecystectomy, appendectomy, or hernia repairs were included. Patient demographic information, comorbidities, and complications as well as admission and follow-up details were collected from electronic medical records. MAIN OUTCOME MEASURES Outcomes following weekend discharge, and the predictors of early readmission. SAMPLE SIZE 743 patients. RESULTS The operations performed: 361 patients (48.6%) underwent a cholecystectomy, 288 (38.8%) an appendectomy, and 94 (12.6%) hernia repairs. A significantly lower number of patients were discharged over the weekend (n=125) compared to those discharged on weekdays (n=618). Patients discharged during the weekend were younger, less likely to have chronic diseases, and had a significantly shorter average length of stay (LOS) (median 2 days, IQR: 1, 4 vs. median 3 days, IQR: 1, 5, P=.002). Overall, the 30-day readmission rate was 3.2% (n=24), and weekend discharge (OR=2.25, 95% CI 0.52-9.70) or any other variable did not predict readmission in 30 days. However, 14-day post-discharge follow-up visits were significantly lower in the weekend discharge subgroup (83.1% vs. 91.2%, P=.006). CONCLUSION Weekend discharge was not associated with higher readmission rates. Physicians may consider discharging post-operative patients over a weekend without an increased risk to the patient. Day of discharge, length of stay and increased patient age are not predictors of early readmission. LIMITATIONS Single-center study and retrospective. CONFLICT OF INTEREST None.
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Affiliation(s)
| | | | - Sami A Almalki
- Dr. Sami Abdulrahman Almalki, College of Medicine,, King Saud bin Abdulaziz University for Health Sciences,, PO Box 6247, Riyadh 12936,, Saudi Arabia, T: +966555987922,
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Hemiparetic Positioning of Patients With Hemiplegia. J Dr Nurs Pract 2017; 10:129-134. [DOI: 10.1891/2380-9418.10.2.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Nature and scope of the project: Patients with hemiplegia may develop pain, decreased strength, sensation, and tone impacting functional ability of the affected arm when patients are not positioned correctly. The purpose of this quality improvement (QI) project was to evaluate improvements in the function of patients with hemiplegia in a rehabilitation hospital after implementing a hemiparetic positioning program. Project implementation: Education on hemiparetic positioning developed by an interdisciplinary team was offered to all nursing and therapy staff over a 1-month with follow-up and written materials. Evaluation criteria: The outcome measures for this project were Functional Independence Measurement (FIM) scores. Changes in FIM scores of patients hospitalized 3 months before the project were compared with a sample hospitalized after the project to see if outcomes improved. Outcomes: The sample consisted of 91 (pre-QI = 27, post-QI = 64) hospitalized patients with hemiplegia. All patients had significant improvements in FIM scores from admission to discharge. There were no significant differences observed between the groups on FIM change scores using Mann–Whitney U test: transfers from bed/chair/wheelchair (z = −.822, p = .411), upper body dressing (z = −.104, p = .917), lower body dressing (z = −1.120, p = .263), and toileting (z = −1.259, p = .208).
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16
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Gopakumar S, Tran T, Luo W, Phung D, Venkatesh S. Forecasting Daily Patient Outflow From a Ward Having No Real-Time Clinical Data. JMIR Med Inform 2016; 4:e25. [PMID: 27444059 PMCID: PMC4974453 DOI: 10.2196/medinform.5650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 05/29/2016] [Accepted: 06/21/2016] [Indexed: 11/23/2022] Open
Abstract
Background: Modeling patient flow is crucial in understanding resource demand and prioritization. We study patient outflow from an open ward in an Australian hospital, where currently bed allocation is carried out by a manager relying on past experiences and looking at demand. Automatic methods that provide a reasonable estimate of total next-day discharges can aid in efficient bed management. The challenges in building such methods lie in dealing with large amounts of discharge noise introduced by the nonlinear nature of hospital procedures, and the nonavailability of real-time clinical information in wards.
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Affiliation(s)
- Shivapratap Gopakumar
- Centre for Pattern Recognition and Data Analytics, Deakin University, Geelong Waurn Ponds, Australia.
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Pitzul KB, Wodchis WP, Carter MW, Kreder HJ, Voth J, Jaglal SB. Post-acute pathways among hip fracture patients: a system-level analysis. BMC Health Serv Res 2016; 16:275. [PMID: 27430219 PMCID: PMC4950780 DOI: 10.1186/s12913-016-1524-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 07/07/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines suggest that rehabilitation after surgery is imperative to return patients to pre-morbid function. However, post-acute care (which encompasses rehabilitation) is currently delivered in a multitude of settings, and there is a lack of evidence with regards to which hip fracture patients should use which post-acute settings. The purpose of this study is to describe hip fracture patient characteristics and the most common post-acute pathways within a 1-year episode of care, and to examine how these vary regionally within a health system. METHODS This study took place in the province of Ontario, Canada, which has 14 health regions and universal health coverage for all residents. Administrative health databases were used for analyses. Community-dwelling patients aged 66 and over admitted to an acute care hospital for hip fracture between April 2008 and March 2013 were identified. Patients' post-acute destinations within each region were retrieved by linking patients' records within various institutional databases using a unique encoded identifier. Post-acute pathways were then characterized by determining when each patient went to each post-acute destination within one year post-discharge from acute care. Differences in patient characteristics between regions were detected using standardized differences and p-values. RESULTS Thirty-six thousand twenty nine hip fracture patients were included. The study cohort was 71.9 % female with a mean age of 82.9 (±7.5SD). There was significant variation between regions with respect to the immediate post-acute discharge destination: four regions discharged a substantially higher proportion of their patients to inpatient rehabilitation compared to all others. However, the majority of patient characteristics between those four regions and all other regions did not significantly differ. There were 49 unique post-acute pathways taken by patients, with the largest proportion of patients admitted to either community-based or short-term institutionalized rehabilitation, regardless of region. CONCLUSIONS The observation that similar hip fracture patients are discharged to different post-acute settings calls into question both the appropriateness of care delivered in the post-acute period and health system expenditures. As policy makers continue to develop performance-based funding models to increase accountability of institutions in the provision of quality care to hip fracture patients, ensuring patients receive appropriate rehabilitative care is a priority for health system planning.
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Affiliation(s)
- Kristen B. Pitzul
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
| | - Walter P. Wodchis
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
| | - Michael W. Carter
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Department of Mechanical and Industrial Engineering, University of Toronto, 5 King’s College Road, Toronto, Ontario M5S3G8 Canada
| | - Hans J. Kreder
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Department of Surgery, University of Toronto, 2075 Bayview Avenue., MG-365, Toronto, Ontario M4N3M5 Canada
| | - Jennifer Voth
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
| | - Susan B. Jaglal
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
- />Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
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Herzer KR, Chen Y, Heinemann AW, González-Fernández M. Association Between Time to Rehabilitation and Outcomes After Traumatic Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:1620-1627.e4. [PMID: 27269706 DOI: 10.1016/j.apmr.2016.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine the relations between time to rehabilitation after spinal cord injury (SCI) and rehabilitation outcomes at discharge and 1-year postinjury. DESIGN Retrospective cohort study. SETTING Facilities designated as Spinal Cord Injury Model Systems. PARTICIPANTS Patients (N=3937) experiencing traumatic SCI between 2000 and 2014, who were 18 years or older, and who were admitted to a model system within 24 hours of injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rasch-transformed FIM motor score at discharge and 1-year postinjury, discharge to a private residence, and the Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence and Mobility scores at 1-year postinjury. RESULTS After accounting for health status, a 10% increase in time to rehabilitation was associated with a 1.50 lower FIM motor score at discharge (95% confidence interval [CI], -2.43 to -0.58; P=.001) and a 3.92 lower CHART Physical Independence score at 1-year postinjury (95% CI, -7.66 to -0.19; P=.04). Compared to the mean FIM motor score (37.5) and mean CHART Physical Independence score (74.7), the above-mentioned values represent relative declines of 4.0% and 5.3%, respectively. There was no association between time to rehabilitation and discharge to a private residence, 1-year FIM motor score, or the CHART mobility score. CONCLUSIONS Earlier rehabilitation after traumatic SCI may improve patients' functional status at discharge.
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Affiliation(s)
- Kurt R Herzer
- Medical Scientist Training Program, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Yuying Chen
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL
| | - Allen W Heinemann
- Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago, Chicago, IL; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Goldman J, Reeves S, Wu R, Silver I, MacMillan K, Kitto S. A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning. J Interprof Care 2016; 30:217-25. [PMID: 26852628 DOI: 10.3109/13561820.2015.1072803] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patient discharge is a key concern in hospitals, particularly in acute care, given the multifaceted and challenging nature of patients' healthcare needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and microlevel practices. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers' perspectives, behaviours, and interactions regarding discharge. Data collection involved observations, interviews, and document analysis. Approximately 65 hours of observations were undertaken, 23 interviews were conducted with healthcare providers, and government and hospital discharge documents were collected. Data were analysed using a directed content approach. The findings indicate the existence of a medically dominated division of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.
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Affiliation(s)
- Joanne Goldman
- a Centre for Quality Improvement and Patient Safety, Faculty of Medicine , University of Toronto , Toronto , Ontario , Canada
| | - Scott Reeves
- b Centre for Health & Social Care Research , Kingston University & St. George's, University of London , London , UK
| | - Robert Wu
- c Division of General Internal Medicine, Toronto General Hospital, University Health Network, and Department of Medicine, Faculty of Medicine , University of Toronto , Toronto , Ontario , Canada
| | - Ivan Silver
- d Centre for Addiction and Mental Health, Department of Psychiatry, Faculty of Medicine , University of Toronto , Toronto , Ontario , Canada
| | - Kathleen MacMillan
- e School of Nursing, Dalhousie University , Halifax , Nova Scotia , Canada
| | - Simon Kitto
- f Department of Innovation in Medical Education, Faculty of Medicine , University of Ottawa , Ottawa , Ontario , Canada
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Drew B, Angeli F, Dave K, Pavlova M. Impact of patients' healthcare payment methods on hospital discharge process: evidence from India. Int J Health Plann Manage 2015; 31:e158-74. [PMID: 26349851 DOI: 10.1002/hpm.2310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 07/06/2015] [Indexed: 11/08/2022] Open
Abstract
This study investigates the impact of patients' payment methods on hospitals' discharge process. Patients' payment methods, particularly the use of third-party payers, are documented to impact hospitals' behavior. However, evidence is still missing on how differences across payment categories affect hospital discharge, a complicated and poorly standardized process. Data are derived from a single case study carried out in 2014 at the Mazumdar Shaw Medical Center at the Narayana Health City Campus in Bangalore, India. A mixed-method approach has been adopted. First, process mapping for different payment categories was conducted using unstructured interviews with staff and on-the-floor observations. Second, linear regression analysis was applied on a sample of 1000 discharges that occurred in January 2014 to investigate the impact of patients' payment categories on discharge turnaround time. The qualitative evidence highlights substantial variation in the discharge process across payment categories. Regression analyses reveal that the sequential process used to discharge community health insurance patients results in a significantly shorter discharge turnaround time and that cash-paying patients do not experience any significantly shorter discharge duration. For hospital managers, this study provides important evidence that patient utilization of a third-party payer does not hamper hospital efficiency. This finding should also encourage policy makers and third-party payers to work towards expanding the medical insurance system, particularly in India and particularly community-based schemes. At the same time, our findings document a strong fragmentation of discharge processes, which should spur hospitals and third-party payers to cooperate in order to set standards and minimize disruptions to patient flows. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Federica Angeli
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | | | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Toomath R, Szecket N, Poole P. Author reply. Intern Med J 2015; 45:593. [DOI: 10.1111/imj.12737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/06/2015] [Indexed: 11/29/2022]
Affiliation(s)
- R. Toomath
- Auckland City Hospital; General Medicine; Auckland New Zealand
| | - N. Szecket
- Auckland City Hospital; General Medicine; Auckland New Zealand
| | - P. Poole
- Auckland City Hospital; General Medicine; Auckland New Zealand
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Shanley LA, Lin H, Flores G. Factors associated with length of stay for pediatric asthma hospitalizations. J Asthma 2014; 52:471-7. [DOI: 10.3109/02770903.2014.984843] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hakkennes S, Lindner C, Reid J. Implementing an inpatient rehabilitation Saturday service is associated with improved patient outcomes and facilitates patient flow across the health care continuum. Disabil Rehabil 2014; 37:721-7. [PMID: 25052101 DOI: 10.3109/09638288.2014.939772] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To evaluate the effectiveness of the introduction of a Saturday inpatient rehabilitation service in improving patient outcomes and facilitating hospital access and flow. METHODS A quasi-experimental study with a historical comparison group is presented. Data were evaluated for the 477 patients admitted and discharged in the 6 months following the implementation (October 2012-March 2013) of the service and 499 patients in the historical control group (April 2012-September 2012). RESULTS Prior to the introduction of the service median number of patients admitted on a Saturday was 0 (range 0-3), post-implementation the median number of patients admitted on a Saturday increased to 2 (range 0-5), this difference was statistically significant (Z = -3.61, p < 0.001). Median regression modelling demonstrated that, after adjusting for admission Functional Independence (FIM) score, gender, length of stay (LOS) and age, there was a small but significant increase in discharge FIM scores (median increase 2.28, p = 0.027) for those patients admitted in the post-implementation phase. There was no such effect of the service on LOS. CONCLUSIONS The implementation of the Saturday inpatient rehabilitation service was associated with improved patient outcomes and supported an increase in patient flow throughout the organization as evidenced by an increased number of Saturday patient admissions. IMPLICATIONS FOR REHABILITATION Inpatient rehabilitation services do not operate in isolation; they are a critical link in the healthcare continuum. There is a mounting body of evidence that the introduction of weekend rehabilitation services has a positive impact on patient outcomes. To maximize health outcomes, access to critical services and patient flow, organizations and staff need to move away from the long-standing 5-day/week inpatient rehabilitation model and start transitioning to a model that incorporates weekend therapy services.
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Rabin E, Kocher K, McClelland M, Pines J, Hwang U, Rathlev N, Asplin B, Trueger NS, Weber E. Solutions to emergency department 'boarding' and crowding are underused and may need to be legislated. Health Aff (Millwood) 2013; 31:1757-66. [PMID: 22869654 DOI: 10.1377/hlthaff.2011.0786] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The practice of keeping admitted patients on stretchers in hospital emergency department hallways for hours or days, called "boarding," causes emergency department crowding and can be harmful to patients. Boarding increases patients' morbidity, lengths of hospital stay, and mortality. Strategies that optimize bed management reduce boarding by improving the efficiency of hospital patient flow, but these strategies are grossly underused. Convincing hospital leaders of the value of such solutions, and educating patients to advocate for such changes, may promote improvements. If these strategies do not work, legislation may be required to effect meaningful change.
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Affiliation(s)
- Elaine Rabin
- Department of Emergency Medicine at Mount Sinai School of Medicine in New York City, USA.
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Bastiampillai T, Schrader G, Dhillon R, Strobel J, Bidargaddi N. Impact of a psychiatric unit's daily discharge rates on emergency department flow. Australas Psychiatry 2012; 20:117-20. [PMID: 22461658 DOI: 10.1177/1039856211432458] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate relationships between time spent in the emergency department (ED) in patients requiring admission to the psychiatric ward, the day of the week of presentation and the daily number of discharges from the psychiatric ward. METHOD Retrospective analysis of patient flow as a function of day of week, time of day (a.m., p.m.), number of patients requiring admission and number of ward discharges over a one-year period, for all mental health related presentations to the ED of the Queen Elizabeth Hospital in Adelaide, South Australia, before their admission to the psychiatric inpatient facility. RESULTS The time spent by patients in the ED waiting for admission to the psychiatric ward was significantly greater on weekends. There were significantly fewer discharges from the psychiatric ward during weekends compared with weekdays. The average time spent by patients in the ED requiring admission to the psychiatric ward for those days when there were vacant beds was 17.9 hours (SD=14.5). More people presented to the ED with a psychiatric diagnosis in the afternoons. There was a significant inverse correlation between the time spent by patients in the ED requiring admission to the psychiatric ward per day and the number of discharges from the psychiatric ward per day. CONCLUSION These findings demonstrate that patient flow is significantly slower on weekends because of fewer discharges from the ward, leading to longer times spent in the ED before ward transfer. Waiting times in the ED were very substantially greater than the proposed 4-hour target even when vacant beds were available, raising considerable doubt about that target being realistic for psychiatric patients.
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Szecket N, Wong HJ, Wu RC, Berman HD, Morra D. Implementation of a continuous admission model reduces the length of stay of patients on an internal medicine clinical teaching unit. J Hosp Med 2012; 7:55-9. [PMID: 21954169 DOI: 10.1002/jhm.926] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/25/2011] [Accepted: 03/17/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND Optimizing hospital operations is a critical issue facing healthcare systems. Reducing unnecessary variation in patient flow is likely to improve efficiency and optimize capacity for hospital inpatients. The objective of this study was to determine whether changing admissions, from a "bolus" system to a "drip" system, would result in a smoothed daily discharge rate, and reduce the length of stay of patients on a General Internal Medicine clinical teaching unit over a period of 1 year. METHODS We conducted a retrospective analysis of the General Internal Medicine inpatient service at Toronto General Hospital for the 6-month periods from March to August during 2 consecutive years. Length of stay distributions and daily discharge rate variations were compared between the 2 study periods. RESULTS There were a total of 2734 discharges, 1446 occurring in the pre-change period, and 1288 in the post-change period. There was overall smoothing of the daily discharge rates, and a reduction of 0.3 days in median length of stay in the post-change period (P = 0.0065). CONCLUSIONS Restructuring the admission system to achieve constant daily admissions to each care team resulted in a smoothing of daily discharge rates and improved operational efficiency with shorter lengths of stay.
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Affiliation(s)
- Nicolas Szecket
- General Internal Medicine, Center for Innovation in Complex Care, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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An evidence-based case for the value of social workers in efficient hospital discharge. Health Care Manag (Frederick) 2011; 30:242-6. [PMID: 21808176 DOI: 10.1097/hcm.0b013e318225e1dd] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A study was undertaken to make an evidence-based case for the value of social workers in efficient discharge of patients from acute care hospitals and to assist hospital managers in making informed staffing decisions. Hospital administrative databases from March 1 to November 30, 2008, were used for the analysis of inpatient discharges on days when social workers were on vacation compared with days fully staffed with social workers. Two performance measures, daily discharge rate and average length of stay, were evaluated. During the study period, 1825 patients were discharged from the General Internal Medicine inpatient service. Team discharge rates were significantly lower on social work vacation Fridays versus regular Fridays. In contrast, the average length of stay for patients discharged on social work vacation Fridays was significantly shorter than that for patients discharged on regular Fridays. It was concluded that daily discharge rate better quantified the role of social work in patient discharge. More generally, these results provide preliminary support for the need for adequate social work staffing in timely and efficient patient discharge.
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Excellent hospital care for all: open and operating 24/7. J Gen Intern Med 2011; 26:1050-2. [PMID: 21499824 PMCID: PMC3157523 DOI: 10.1007/s11606-011-1715-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 03/22/2011] [Accepted: 03/24/2011] [Indexed: 10/18/2022]
Abstract
Nights and weekends are the times when most people are admitted to the hospital. They are also synonymous with reduced staffing levels and fewer specialized diagnostic, procedural, and treatment options. Indeed, there is increasing evidence suggesting that patient care is compromised during these times. Equally important is the inefficient use of capital investments during nights and weekends, and inappropriate utilization of hospital beds caused by poor weekend discharge flexibility. We believe that these findings should be of concern not just to hospital care providers, but across care settings and to the general public. In this perspective article, we highlight how our current office-hours system of running hospitals threatens the lives of our sickest, most vulnerable patients, describe solutions currently implemented in hospitals that may alleviate this disparity, and discuss challenges to wider scale implementation.
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Vermeulen MJ, Ray JG, Schull MJ. In reply. Ann Emerg Med 2010. [DOI: 10.1016/j.annemergmed.2010.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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