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Neef V, Himmele C, Piekarski F, Blum LV, Hof L, Derwich W, Holubec T, Meybohm P, Choorapoikayil S. Effect of using smaller blood volume tubes and closed blood collection devices on total blood loss in patients undergoing major cardiac and vascular surgery. Can J Anaesth 2024; 71:213-223. [PMID: 38191843 PMCID: PMC10884058 DOI: 10.1007/s12630-023-02643-8] [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: 03/06/2023] [Revised: 06/21/2023] [Accepted: 07/21/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Diagnostic laboratory tests are an integral part of managing hospitalized patients. In particular, patients in the intensive care units (ICUs) can experience a concerning amount of blood loss due to diagnostic testing, which can increase the risk developing iatrogenic anemia. Several interventions exist to curtail avoidable blood loss, for example computerized decision support, smaller phlebotomy tubes, and other blood conservation devices. Nevertheless, use of these interventions is not standardized. Therefore, the objective of our study was to quantify the daily phlebotomy volume taken from patients who had undergone major cardiac or vascular surgery. METHODS We estimated the number of blood analyses and volumes of drawn blood of 400 consecutive patients (≥ 18 yr) undergoing major cardiac or vascular surgery. The amount of blood saved using small-volume tubes and in combination with blood conservation device rather than standard-volume tubes was estimated for serum chemistry (serum), ethylenediaminetetraacetic acid (EDTA) tubes, sodium citrate coagulation (SCC) tubes, and arterial blood gas (ABG) analysis. RESULTS The mean total blood loss due to phlebotomy drawing using standard-volume tubes during hospitalization was 167.9 mL (95% confidence interval [CI], 158.0 to 177.8), 255.6 mL (95% CI, 226.5 to 284.6), and 695.3 mL (95% CI, 544.1 to 846.4) for patients undergoing cardiac surgery with a hospital length of stay (LOS) of 0-10, 11-20, and ≥ 21 days, respectively. The mean total blood loss due to phlebotomy during hospitalization was 80.5 mL (95% CI, 70.5 to 90.6), 225.0 mL (95% CI, 135.1 to 314.8 mL) and 470.3 mL (95% CI, 333.5 to 607.1) for vascular surgery patients with LOS 0-10, 11-20, and ≥ 21 days, respectively. Patients with at least a two-day stay at the ICU had a mean blood loss of 146.6 mL (95% CI, 134.6 to 158.6 mL) and those with ≥ 11 days incurred a loss of 1,428 mL (95% CI, 1,117.8 to 1,739.2). The use of closed blood collection device and small-volume tubes (serum, EDTA, SCC, and ABG) reduced blood loss by 82.8 mL for patients with an ICU stay of 2 days and up to 824.0 mL for patients with a ICU stay of ≥ 11 days. CONCLUSION Diagnostic laboratory tests are associated with significant patient blood loss, but are a modifiable risk factor. The use of small-volume tubes and closed blood collection devices decreases the volume of patient blood drawn for analysis and prevents blood waste.
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Affiliation(s)
- Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
| | - Chantal Himmele
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
| | - Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
| | - Lea V Blum
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
| | - Lotta Hof
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
| | - Wojciech Derwich
- Department of Vascular and Endovascular Surgery, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
| | - Tomas Holubec
- Department of Cardiovascular Surgery, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
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Yeshoua B, Bowman C, Dullea J, Ditkowsky J, Shyu M, Lam H, Zhao W, Shin JY, Dunn A, Tsega S, S Linker A, Shah M. Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review. BMJ Open Qual 2023; 12:bmjoq-2022-002128. [PMID: 36958791 PMCID: PMC10040017 DOI: 10.1136/bmjoq-2022-002128] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/05/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Over-ordering of daily laboratory tests adversely affects patient care through hospital-acquired anaemia, patient discomfort, burden on front-line staff and unnecessary downstream testing. This remains a prevalent issue despite the 2013 Choosing Wisely recommendation to minimise unnecessary daily labs. We conducted a systematic review of the literature to identify interventions targeting unnecessary laboratory testing. METHODS We systematically searched MEDLINE, EMBASE, Cochrane Central and SCOPUS databases to identify interventions focused on reducing daily complete blood count, complete metabolic panel and basic metabolic panel labs. We defined interventions as 'effective' if a statistically significant reduction was attained and 'highly effective' if a reduction of ≥25% was attained. RESULTS The search yielded 5646 studies with 41 articles that met inclusion criteria. We grouped interventions into one or more categories: audit and feedback, cost display, education, electronic medical record (EMR) change, and policy change. Most interventions lasted less than a year and used a multipronged approach. All five strategies were effective in most studies with EMR change being the most commonly used independent strategy. EMR change and policy change were the strategies most frequently reported as effective. EMR change was the strategy most frequently reported as highly effective. CONCLUSION Our analysis identified five categories of interventions targeting daily laboratory testing. All categories were effective in most studies, with EMR change being most frequently highly effective. PROSPERO REGISTRATION NUMBER CRD42021254076.
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Affiliation(s)
- Brandon Yeshoua
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Chip Bowman
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Jonathan Dullea
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Jared Ditkowsky
- Emergency Medicine, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Margaret Shyu
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Hansen Lam
- Department of Pathology and Laboratory Medicine, Icahn School of Medicine at Mount Sinai Lillian and Henry M Stratton-Hans Popper, New York, New York, USA
| | - William Zhao
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Joo Yeon Shin
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Andrew Dunn
- Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Surafel Tsega
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anne S Linker
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Manan Shah
- Department of Medicine, Mount Sinai, New York, New York, USA
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Trends in the national early warning score are associated with subsequent mortality – A prospective three-centre observational study with 11,331 general ward patients. Resusc Plus 2022; 10:100251. [PMID: 35620180 PMCID: PMC9127395 DOI: 10.1016/j.resplu.2022.100251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 10/25/2022] Open
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Sklarz T, Italiano A, Menon N, Correia C, Sharma E, Wu S, Hunter K, Roy S. Impact of Correcting Nutritional Deficiency Anemias in the Elderly on Hospitalizations, Falls, and Mortalities. J Hematol 2022; 10:233-245. [PMID: 35059085 PMCID: PMC8734490 DOI: 10.14740/jh926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background The incidence and prevalence of anemia increase with age, particularly in adults older than 65 years, and it is associated with a number of adverse health outcomes (AHO), particularly hospitalizations, falls and mortalities. Given that approximately one-third of these anemias are due to reversible causes, we studied whether the treatment of nutritional deficiency anemia (NDA), namely iron deficiency anemia (IDA), cobalamin deficiency anemia (CDA), and folate deficiency anemia (FDA), improves AHO; and explored whether each NDA had different AHO. Methods We reviewed electronic medical records of our internal medicine office patients aged 65 years or older, who had a diagnosis of anemia in a non-acute setting. Results Total 600 patients were included. Mean age was 75.2 years. Thirty-one point three percent had NDA (CDA 15.3%, IDA 12.3%, FDA 3.7%); and 68.7% had other anemias whom we categorized as non-nutritional deficiency anemias (NNDA), which included anemia of chronic disease (11.2%), myelodysplastic syndrome (6.2%), renal insufficiency anemia (5.7%) and unexplained anemia (45.6%). Even after adequate treatment, IDA group had significantly more hospitalizations (median, 25th - 75th: 2 (0 - 4) vs. 0 (0 - 1), P < 0.001), falls (median, 25th - 75th: 1 (0 - 3) vs. 0 (0 - 1), P < 0.001) and mortalities (10.8% vs. 3.4%, P = 0.011); CDA group had significantly more hospitalizations (median, 25th - 75th: 1 (0 - 2) vs. 0 (0 - 1), P = 0.007), but no difference in falls (median, 25th - 75th: 0 (0 - 1) vs. 0 (0 - 1), P = 0.171) and mortalities (7.6% vs. 3.4%, P = 0.083); and FDA group had significantly more hospitalizations (median, 25th - 75th: 1 (0 - 2) vs. 0 (0 - 1), P = 0.001), but no difference in falls (median, 25th - 75th: 0 (0 - 1) vs. 0 (0 - 1), P = 0.615) and mortalities (4.5% vs. 3.4%, P = 0.550), compared to the NNDA group. Age, Black race, higher number of comorbidities, presence of malignancy and use of direct oral anticoagulants were associated with increased odds of AHO in patients with NDA. Conclusions Compared to the patients with NNDA, patients with IDA had more hospitalizations, falls and mortalities even after adequate treatment; while patients with CDA and FDA had only more hospitalizations. Adequate treatment mitigated falls and mortalities in elderly patients with CDA and FDA.
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Affiliation(s)
- Tammarah Sklarz
- Department of Medicine, Cooper University Health Care, Camden, NJ, USA
| | - Angelica Italiano
- Department of Medicine, Cooper University Health Care, Camden, NJ, USA
| | - Naveen Menon
- Department of Medicine, Cooper University Health Care, Camden, NJ, USA
| | - Caroline Correia
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Elena Sharma
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Samantha Wu
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Krystal Hunter
- Cooper Research Institute, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Satyajeet Roy
- Department of Medicine, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ, USA.,Division of General Internal Medicine, Cooper University Health Care, Cherry Hill, NJ 08034, USA
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Tiglis M, Cobilinschi C, Elena Mirea L, Emil Băetu A, Peride I, Paul Neagu T, Niculae A, Alexandru Checherită I, Marina Grintescu I. The Importance of Iron Administration in Correcting Anaemia After Major Surgery. J Crit Care Med (Targu Mures) 2021; 7:184-191. [PMID: 34722921 PMCID: PMC8519388 DOI: 10.2478/jccm-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/21/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Postoperative anaemia can affect more than 90% of patients undergoing major surgeries. Patients develop an absolute iron deficiency in the face of significant blood loss or preoperative anaemia and major surgery. Studies have shown the negative impact of these factors on transfusion requirements, infections, increased hospitalisation and long-term morbidities. AIM OF THE STUDY The research was performed to determine the correlation between intravenous iron administration in the postoperative period and improved haemoglobin correction trend. MATERIAL AND METHODS A prospective study was conducted to screen and treat iron deficiency in patients undergoing major surgery associated with significant bleeding. For iron deficiency anaemia screening, in the postoperative period, the following bioumoral parameters were assessed: haemoglobin, serum iron, transferrin saturation (TSAT), and ferritin, direct serum total iron-binding capacity (dTIBC), mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH). In addition, serum glucose, fibrinogen, urea, creatinine and lactate values were also collected. RESULTS Twenty-one patients undergoing major surgeries (52,38% were emergency and 47,61% elective interventions) were included in the study. Iron deficiency, as defined by ferritin 100-300 μg/L along with transferrin saturation (TSAT) < 20 %, mean corpuscular volume (MVC) < 92 fL, mean corpuscular haemoglobin (MCH) < 33 g/dL, serum iron < 10 μmol/L and direct serum total iron-binding capacity (dTIBC) > 36 μmol/L, was identified in all cases. To correct the deficit and optimise the haematological status, all patients received intravenous ferric carboxymaltose (500-1000 mg, single dose). Using Quadratic statistical analysis, the trend of haemoglobin correction was found to be a favourable one. CONCLUSION The administration of intravenous ferric carboxymaltose in the postoperative period showed the beneficial effect of this type of intervention on the haemoglobin correction trend in these groups of patients.
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Affiliation(s)
- Mirela Tiglis
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Emergency Clinical Hospital of Bucharest, BucharestRomania
| | - Cristian Cobilinschi
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Emergency Clinical Hospital of Bucharest, BucharestRomania
| | - Liliana Elena Mirea
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Emergency Clinical Hospital of Bucharest, BucharestRomania
| | - Alexandru Emil Băetu
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Emergency Clinical Hospital of Bucharest, BucharestRomania
| | - Ileana Peride
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Andrei Niculae
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Ioana Marina Grintescu
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Emergency Clinical Hospital of Bucharest, BucharestRomania
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Baig MM, GholamHosseini H, Afifi S, Lindén M. A systematic review of rapid response applications based on early warning score for early detection of inpatient deterioration. Inform Health Soc Care 2021; 46:148-157. [PMID: 33472485 DOI: 10.1080/17538157.2021.1873349] [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: 10/22/2022]
Abstract
AIM The aim of this study was to investigate the effectiveness of current rapid response applications available in acute care settings for escalation of patient deterioration. Current challenges and barriers, as well as key recommendations, were also discussed. METHODS We adopted PRISMA review methodology and screened a total of 559 articles. After considering the eligibility and selection criteria, we selected 13 articles published between 2015 and 2019. The selection criteria were based on the inclusion of studies that report on the advancement made to the current practice for providing rapid response to the patient deterioration in acute care settings. RESULTS We found that current rapid response applications are complicated and time-consuming for detecting inpatient deterioration. Existing applications are either siloed or challenging to use, where clinicians are required to move between two or three different applications to complete an end-to-end patient escalation workflow - from vital signs collection to escalation of deteriorating patients. We found significant differences in escalation and responses when using an electronic tool compared to the manual approach. Moreover, encouraging results were reported in extensive documentation of vital signs and timely alerts for patient deterioration. CONCLUSION The electronic vital signs monitoring applications are proved to be efficient and clinically suitable if they are user-friendly and interoperable. As an outcome, several key recommendations and features were identified that would be crucial to the successful implementation of any rapid response system in all clinical settings.
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Affiliation(s)
| | - Hamid GholamHosseini
- School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Shereen Afifi
- School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Maria Lindén
- School of Innovation, Design and Engineering, Mälardalen University, Västerås, Sweden
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Hamid M, Naz A, Alawattegama LH, Steed H. The Prevalence of Anaemia in a District General Hospital in the United Kingdom. Cureus 2021; 13:e15086. [PMID: 34155456 PMCID: PMC8210626 DOI: 10.7759/cureus.15086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2021] [Indexed: 11/05/2022] Open
Abstract
Aim Investigating the prevalence of hospital-acquired anaemia in a United Kingdom (UK) secondary care setting to describe the level of appropriate management prior to discharge back to primary care. Design and settings An observational study of 13 medical and surgical wards in a UK district general hospital. Method Single-day examination of notes, blood results and drug charts, with a 30-day follow up, using pre-set definitions of anaemia and exclusion criteria. Results Two hundred and sixty-seven patients were included. Of them, 52% were anaemic on admission, 62.2% were anaemic on the study day, 16% had hospital-acquired anaemia and 49%-82% had no biochemical indices checked during the admission or in the last 12 months. Also, 53% of anaemic patients are being discharged without appropriate treatment, with over a third being under-investigated. Conclusion The prevalence of anaemia in a UK district general hospital is high. Causes of anaemia are complex, posing a potentially modifiable risk factor for falls, readmission and mortality.
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Affiliation(s)
- Mohammed Hamid
- General Surgery, University Hospital Birmingham National Health Service (NHS) Trust, Birmingham, GBR
| | - Aysha Naz
- Endocrinology, Diabetes and Metabolism, Royal Wolverhampton Hospital Trust, Wolverhampton, GBR
| | - Lakna H Alawattegama
- Orthopedics and Traumatology, Royal Wolverhampton Hospital Trust, Wolverhampton, GBR
| | - Helen Steed
- Gastroenterology and Hepatology, Royal Wolverhampton Hospital Trust, Wolverhampton, GBR
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Shiwani HA, Bilal M, Shahzad MU, Rodrigues A, Suliman JA, Soban M, Mirza S, Lotca N, Ruslan MR, Memon D, Arshad MA, Fatima K, Kamran A, Egom EE, Aziz A. A comparison of characteristics and outcomes of patients with community-acquired and hospital-acquired COVID-19 in the United Kingdom: An observational study. Respir Med 2021; 178:106314. [PMID: 33550150 PMCID: PMC7843030 DOI: 10.1016/j.rmed.2021.106314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/10/2021] [Accepted: 01/24/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Reports comparing the characteristics of patients and their clinical outcomes between community-acquired (CA) and hospital-acquired (HA) COVID-19 have not yet been reported in the literature. We aimed to characterise and compare clinical, biochemical and haematological features, in addition to clinical outcomes, between these patients. METHODS This multi-centre, retrospective, observational study enrolled 488 SARS-CoV-2 positive patients - 339 with CA infection and 149 with HA infection. All patients were admitted to a hospital within the University Hospitals of Morecambe Bay NHS Foundation Trust between March 7th and May 18th, 2020. RESULTS The CA cohort comprised of a significantly younger population, median age 75 years, versus 80 years in the HA cohort (P = 0·0002). Significantly less patients in the HA group experienced fever (P = 0·03) and breathlessness (P < 0·0001). Furthermore, significantly more patients had anaemia and hypoalbuminaemia in the HA group, compared to the CA group (P < 0·0001 for both). Hypertension and a lower median BMI were also significantly more pronounced in the HA cohort (P = 0·03 and P = 0·0001, respectively). The mortality rate was not significantly different between the two cohorts (34% in the CA group and 32% in the HA group, P = 0·64). However, the CA group required significantly greater ICU care (10% versus 3% in the HA group, P = 0·009). CONCLUSION Hospital-acquired and community-acquired COVID-19 display similar rates of mortality despite significant differences in baseline characteristics of the respective patient populations. Delineation of community- and hospital-acquired COVID-19 in future studies on COVID-19 may allow for more accurate interpretation of results.
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Affiliation(s)
- Haaris A Shiwani
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom; Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, United Kingdom.
| | - Muhammad Bilal
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Muhammad U Shahzad
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Alson Rodrigues
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Jehad A Suliman
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Muhammad Soban
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Shahzeb Mirza
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Nicoleta Lotca
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Mohammed R Ruslan
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Danyal Memon
- Our Lady of Lourdes Hospital, Drogheda, Louth, Ireland
| | | | - Kiran Fatima
- Khawaja Muhammad Safdar Medical College, Sialkot, Pakistan
| | - Asma Kamran
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, LA1 4RP, United Kingdom
| | - Emmanuel E Egom
- Egom Clinical & Translational Research Services Ltd., Dartmouth, Canada; Jewish General Hospital and Lady Davis Research Institute, Montreal, Quebec, Canada
| | - Abdul Aziz
- Royal Liverpool University Hospital, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, L7 8XP, United Kingdom
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Abstract
Objective To reduce diagnostic blood loss by using small volume tubes for routine laboratory testing throughout the hospital, as blood loss from laboratory testing can be substantial for patients and may lead to hospital-acquired anemia. Patients and Methods Diagnostic blood loss was evaluated in hospitalized patients between April 1, 2017, and June 1, 2018. The preintervention, during intervention, and postintervention mean diagnostic blood loss per hospitalized patient was compared across the floors and for each type of tube for hematology, basic metabolic panel, and coagulation tests. Mean hemoglobin levels, blood transfusions per hospitalized patient, and percent redraws were also compared. Results The total volume of blood drawn for all the 3 tests decreased across each implementation phase; however, only patients admitted to the transplant and critical care (T/CC) units had increased hemoglobin levels. In addition, there was a significant reduction in transfusions across implementation phases. The incidence risk ratio for transfusion reduced even more in patients admitted to the T/CC units. Finally, there was no significant difference in the overall percent redraws across all the units. Conclusion The use of small volume tubes in exchange for standard sized tubes markedly decreased diagnostic blood loss by 25.7% in all the units and 22.9% in the T/CC units. Also, the number of transfusions decreased across units, with the greatest decrease in the T/CC units. An increase in mean hemoglobin levels was observed specifically in patients admitted to the T/CC units, with no corresponding change in percent redraws across all the units.
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Gerry S, Bonnici T, Birks J, Kirtley S, Virdee PS, Watkinson PJ, Collins GS. Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology. BMJ 2020; 369:m1501. [PMID: 32434791 PMCID: PMC7238890 DOI: 10.1136/bmj.m1501] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To provide an overview and critical appraisal of early warning scores for adult hospital patients. DESIGN Systematic review. DATA SOURCES Medline, CINAHL, PsycInfo, and Embase until June 2019. ELIGIBILITY CRITERIA FOR STUDY SELECTION Studies describing the development or external validation of an early warning score for adult hospital inpatients. RESULTS 13 171 references were screened and 95 articles were included in the review. 11 studies were development only, 23 were development and external validation, and 61 were external validation only. Most early warning scores were developed for use in the United States (n=13/34, 38%) and the United Kingdom (n=10/34, 29%). Death was the most frequent prediction outcome for development studies (n=10/23, 44%) and validation studies (n=66/84, 79%), with different time horizons (the most frequent was 24 hours). The most common predictors were respiratory rate (n=30/34, 88%), heart rate (n=28/34, 83%), oxygen saturation, temperature, and systolic blood pressure (all n=24/34, 71%). Age (n=13/34, 38%) and sex (n=3/34, 9%) were less frequently included. Key details of the analysis populations were often not reported in development studies (n=12/29, 41%) or validation studies (n=33/84, 39%). Small sample sizes and insufficient numbers of event patients were common in model development and external validation studies. Missing data were often discarded, with just one study using multiple imputation. Only nine of the early warning scores that were developed were presented in sufficient detail to allow individualised risk prediction. Internal validation was carried out in 19 studies, but recommended approaches such as bootstrapping or cross validation were rarely used (n=4/19, 22%). Model performance was frequently assessed using discrimination (development n=18/22, 82%; validation n=69/84, 82%), while calibration was seldom assessed (validation n=13/84, 15%). All included studies were rated at high risk of bias. CONCLUSIONS Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. However, many early warning scores in clinical use were found to have methodological weaknesses. Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care. Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017053324.
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Affiliation(s)
- Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Timothy Bonnici
- Critical Care Division, University College London Hospitals NHS Trust, London, UK
| | - Jacqueline Birks
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Pradeep S Virdee
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Yao RQ, Wu GS, Xu L, Ma B, Lin J, Shi L, Tang HS, Yao YM, Xia ZF. Diagnostic blood loss from phlebotomy and hospital acquired anemia in patients with severe burns. Burns 2019; 46:579-588. [PMID: 31784239 DOI: 10.1016/j.burns.2019.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE The study was performed to estimate the diagnostic blood loss (DBL) volume during hospitalization and investigate its relationship with the development of moderate to severe hospital acquired anemia (HAA) and increased number of red blood cell (RBC) transfusion following extensive burns. MATERIALS AND METHODS This was a retrospective study of adult burned patients with total body surface area (TBSA) burn larger than 40%, who were admitted to burn center of Changhai hospital between January 2005 and December 2017. RESULTS We included a final number of 157 patients in the present study. Moderate to severe HAA within the fourth week postburn was developed in 46 of 121 patients who stayed over 28-day hospitalization. Patients with moderate to severe HAA had both significantly higher total DBL volume [245 (IQR: 183.75, 325.25) mL vs 168 (119, 163) mL ; P = 0.001] and DBL volume per day [10.22 (IQR: 8.57, 12.38) mL vs 6.63 (5.22, 10.42) mL/day; P = 0.005]. Logistic regression analysis revealed that both DBL volume per day and TBSA burn were independent risk factors for the development of moderate to severe HAA. CONCLUSIONS Severely burned patients appear to be prone to develop HAA during hospitalization. The DBL volume contribute to the occurrence of moderate to severe HAA, which might be a modifiable target for preventing HAA.
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Affiliation(s)
- Ren-Qi Yao
- Department of Burn Surgery, Changhai Hospital, Navy Medical University, Shanghai 200433, People's Republic of China; Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
| | - Guo-Sheng Wu
- Department of Burn Surgery, Changhai Hospital, Navy Medical University, Shanghai 200433, People's Republic of China
| | - Long Xu
- Department of Burn Surgery, Changhai Hospital, Navy Medical University, Shanghai 200433, People's Republic of China
| | - Bing Ma
- Department of Burn Surgery, Changhai Hospital, Navy Medical University, Shanghai 200433, People's Republic of China
| | - Jia Lin
- Department of Laboratory Diagnosis, Changhai Hospital, Navy Medical University, Shanghai 200433, People's Republic of China
| | - Lei Shi
- Department of Laboratory Diagnosis, Changhai Hospital, Navy Medical University, Shanghai 200433, People's Republic of China
| | - He-Shan Tang
- Department of Blood Transfusion, Changhai Hospital, Navy Medical University, Shanghai, People's Republic of China
| | - Yong-Ming Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China.
| | - Zhao-Fan Xia
- Department of Burn Surgery, Changhai Hospital, Navy Medical University, Shanghai 200433, People's Republic of China.
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12
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Bowman Z, Fei N, Ahn J, Wen S, Cumpston A, Shah N, Craig M, Perrotta PL, Kanate AS. Single versus double-unit transfusion: Safety and efficacy for patients with hematologic malignancies. Eur J Haematol 2019; 102:383-388. [PMID: 30664281 DOI: 10.1111/ejh.13211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Although hemoglobin thresholds for red blood cell (RBC) transfusion have decreased, double-unit RBC transfusion practices persist. We studied the effects switching from predominantly double-unit to single-unit RBC transfusions had on utilization and clinical outcomes for malignant hematology patients. METHODS Retrospective chart review compared malignant hematology patients before and after implementing single-unit RBC transfusion policy. Hemoglobin threshold was 8.0 g/dL for both groups. RBC utilization metrics included number of RBC units transfused, RBC units transfused per admission, and number of transfusion episodes. Clinical outcomes included length of stay, 30-day mortality, and outpatient RBC transfusion 30-days post-discharge. RESULTS Baseline hemoglobin was similar in both groups. The single-unit group was transfused with fewer RBC units per admission (5.1 vs 4.5, P = 0.01) than the double-unit group, but had more transfusion episodes per admission (4.1 vs 2.7, P < 0.001). After implementing single-unit policy, a 29% reduction in RBC utilization was observed. Mean hemoglobin at discharge was lower in the single-unit group (8.9 vs 9.5 g/dL, P = 0.005). No significant differences in length of stay or 30-day mortality were observed. CONCLUSION Transfusing malignant hematology patients with single RBC units is safe and efficacious. Electronic provider order systems facilitating RBC transfusion requests provide excellent adherence to transfusion policy.
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Affiliation(s)
- Zelia Bowman
- Department of Hematology/Oncology, West Virginia University, Morgantown, West Virginia
| | - Naomi Fei
- Department of Hematology/Oncology, West Virginia University, Morgantown, West Virginia
| | - Janice Ahn
- Department of Pathology, West Virginia University, Morgantown, West Virginia
| | - Sijin Wen
- Department of Biostatistics, School of Public Health, West Virginia University, Morgantown, West Virginia
| | - Aaron Cumpston
- Department of Pharmacy, West Virginia University Hospitals, Morgantown, West Virginia.,Alexander B. Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
| | - Nilay Shah
- Alexander B. Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
| | - Michael Craig
- Alexander B. Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
| | - Peter L Perrotta
- Department of Pathology, West Virginia University, Morgantown, West Virginia
| | - Abraham S Kanate
- Alexander B. Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
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13
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Derzon J, Alford A, Clarke N, Gross I, Shander A, Thurer R. Anemia Management and Audit Feedback Practices for Reducing Overuse of RBC Transfusion: A Laboratory Medicine Best Practice Systematic Review and Meta-Analysis. Am J Clin Pathol 2019; 151:18-28. [PMID: 30357323 DOI: 10.1093/ajcp/aqy123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives To evaluate the effectiveness of anemia management and audit with feedback practices in reducing overuse of RBC transfusion. Methods This review follows the Centers for Disease Control and Prevention's Laboratory Medicine Best Practice Systematic Review (A-6) method. We searched the literature and solicited unpublished studies on practices to reduce overuse of RBC transfusions as measured by reductions in units transfused and proportion of patients transfused. Results Thirteen studies on preoperative anemia management and three studies on audit feedback practices met inclusion criteria. Strength of evidence was high to moderate for reducing the number of units and proportion of patients transfused. Conclusions Preoperative anemia management reduces the proportion of patients transfused and units of RBCs transfused. Audit with feedback across cases, physicians, and/or service areas, as part of a continuous quality improvement practice, reduces the proportion of patients and units of RBCs transfused.
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Affiliation(s)
- James Derzon
- RTI International, Social, Statistical, and Environmental Sciences, Washington, DC
| | - Aaron Alford
- National Network of Public Health Institutes, Research and Evaluation, Washington, DC
| | | | | | - Aryeh Shander
- Englewood Hospital and Medical Center, Englewood, NJ
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14
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Michalak SS, Rupa-Matysek J, Gil L. Comorbidities, repeated hospitalizations, and age ≥ 80 years as indicators of anemia development in the older population. Ann Hematol 2018; 97:1337-1347. [PMID: 29633008 PMCID: PMC6018572 DOI: 10.1007/s00277-018-3321-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
Abstract
Anemia represents a common condition among the elderly; however, its prevalence and causes are not well known. This retrospective analysis was performed on 981 patients aged ≥ 60 in Poland over 2013-2014. The prevalence of anemia was 17.2% and increased with age. The predominant causes of anemia were the following: anemia of chronic disease (33.1%), unexplained anemia (28.4%), deficiency anemia (22.5%, including iron deficiency 13%), and chemo-/radiotherapy-induced anemia (8.9%). In the multivariate logistic regression model, factors increasing the risk of anemia were the following: age ≥ 80 years (OR 2.29; 95%CI 1.19-4.42; P = 0.013), the number of comorbidities (two diseases OR 2.85; 95%CI 1.12-7.30; P = 0.029, three diseases OR 6.28; 95%CI 2.22-17.76; P = 0.001, four diseases OR 4.64; 95%CI 1.27-17.01; P = 0.021), and hospitalizations (OR 1.34; 95%CI 1.13-1.58; P = 0.001). After a 2-year follow-up, the cumulative survival among patients without anemia in relation to the group with anemia was 90.76 vs. 78.08% (P < 0.001). In the multivariate model, anemia (HR 3.33, 95%CI 1.43-7.74, P = 0.005), heart failure (HR 2.94, 95%CI 1.33-6.50, P = 0.008), and cancer (HR 3.31, 95%CI 1.47-7.49, P < 0.004) were all significantly correlated with mortality. In patients ≥ 60 years, the incidence of anemia increases with age, number of comorbidities, and frequency of hospitalizations and has an adverse impact on survival.
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Affiliation(s)
- Sylwia Sulimiera Michalak
- Faculty of Medicine and Health Sciences, University of Zielona Góra, Zielona Góra, Poland
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Szamarzewskiego 84, 60-569, Poznań, Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Szamarzewskiego 84, 60-569, Poznań, Poland.
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Szamarzewskiego 84, 60-569, Poznań, Poland
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15
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Hueth KD, Jackson BR, Schmidt RL. An Audit of Repeat Testing at an Academic Medical Center: Consistency of Order Patterns With Recommendations and Potential Cost Savings. Am J Clin Pathol 2018; 150:27-33. [PMID: 29718090 DOI: 10.1093/ajcp/aqy020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To evaluate the prevalence of potentially unnecessary repeat testing (PURT) and the associated economic burden for an inpatient population at a large academic medical facility. METHODS We evaluated all inpatient test orders during 2016 for PURT by comparing the intertest times to published recommendations. Potential cost savings were estimated using the Centers for Medicare & Medicaid Services maximum allowable reimbursement rate. We evaluated result positivity as a determinant of PURT through logistic regression. RESULTS Of the evaluated 4,242 repeated target tests, 1,849 (44%) were identified as PURT, representing an estimated cost-savings opportunity of $37,376. Collectively, the association of result positivity and PURT was statistically significant (relative risk, 1.2; 95% confidence interval, 1.1-1.3; P < .001). CONCLUSIONS PURT contributes to unnecessary health care costs. We found that a small percentage of providers account for the majority of PURT, and PURT is positively associated with result positivity.
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Affiliation(s)
- Kyle D Hueth
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
| | - Brian R Jackson
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
- ARUP Laboratories, Salt Lake City, UT
| | - Robert L Schmidt
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
- ARUP Laboratories, Salt Lake City, UT
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16
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Nguyen OK, Makam AN, Clark C, Zhang S, Das SR, Halm EA. Predicting 30-Day Hospital Readmissions in Acute Myocardial Infarction: The AMI "READMITS" (Renal Function, Elevated Brain Natriuretic Peptide, Age, Diabetes Mellitus , Nonmale Sex , Intervention with Timely Percutaneous Coronary Intervention, and Low Systolic Blood Pressure) Score. J Am Heart Assoc 2018; 7:e008882. [PMID: 29666065 PMCID: PMC6015397 DOI: 10.1161/jaha.118.008882] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/19/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Readmissions after hospitalization for acute myocardial infarction (AMI) are common. However, the few currently available AMI readmission risk prediction models have poor-to-modest predictive ability and are not readily actionable in real time. We sought to develop an actionable and accurate AMI readmission risk prediction model to identify high-risk patients as early as possible during hospitalization. METHODS AND RESULTS We used electronic health record data from consecutive AMI hospitalizations from 6 hospitals in north Texas from 2009 to 2010 to derive and validate models predicting all-cause nonelective 30-day readmissions, using stepwise backward selection and 5-fold cross-validation. Of 826 patients hospitalized with AMI, 13% had a 30-day readmission. The first-day AMI model (the AMI "READMITS" score) included 7 predictors: renal function, elevated brain natriuretic peptide, age, diabetes mellitus, nonmale sex, intervention with timely percutaneous coronary intervention, and low systolic blood pressure, had an optimism-corrected C-statistic of 0.73 (95% confidence interval, 0.71-0.74) and was well calibrated. The full-stay AMI model, which included 3 additional predictors (use of intravenous diuretics, anemia on discharge, and discharge to postacute care), had an optimism-corrected C-statistic of 0.75 (95% confidence interval, 0.74-0.76) with minimally improved net reclassification and calibration. Both AMI models outperformed corresponding multicondition readmission models. CONCLUSIONS The parsimonious AMI READMITS score enables early prospective identification of high-risk AMI patients for targeted readmissions reduction interventions within the first 24 hours of hospitalization. A full-stay AMI readmission model only modestly outperformed the AMI READMITS score in terms of discrimination, but surprisingly did not meaningfully improve reclassification.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Christopher Clark
- Office of Research Administration, Parkland Health & Hospital System, Dallas, TX
| | - Song Zhang
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Sandeep R Das
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
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