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Warner KN, Poulos RG, Cole AM, Nguyen TA, Un FC, Faux SG, Kohler F, Alexander T, Capell JT, Hilvert DR, O'Connor CMC, Poulos CJ. Re/connecting with "home": a mixed methods study of service provider and patient perspectives to facilitate implementing rehabilitation in the home for reconditioning. Disabil Rehabil 2024:1-11. [PMID: 39105538 DOI: 10.1080/09638288.2024.2386157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 07/20/2024] [Accepted: 07/25/2024] [Indexed: 08/07/2024]
Abstract
PURPOSE To explore the views of healthcare professionals and patients about the advantages and disadvantages of rehabilitation in the home (RITH) for reconditioning, and identify factors that should contribute to the successful implementation of a consensus-based RITH model for reconditioning. MATERIALS AND METHODS Interviews with 24 healthcare professionals and 21 surveys (comprising Likert scale and free text responses) of inpatients undergoing rehabilitation for reconditioning provided study data. Interpretive thematic analysis was used to analyse interview data; descriptive statistics analysed Likert scale responses; patient written responses assisted with the interpretation of themes developed from the interview data. RESULTS Two major themes were elicited in this study: the home is a physical setting and the home is a lived space. Advantages and disadvantages of RITH for patients, carers and healthcare professionals were identified within these themes. Appropriate patient selection; effective communication with patients and carers, and within RITH teams; adequate patient and carer support; ensuring the safety of patients and staff; and education of patients, carers and healthcare professionals are essential for the satisfactory implementation of RITH. CONCLUSION The concept of home shapes the delivery of RITH. Recognising the advantages and disadvantages of RITH highlights important considerations needed to successfully implement RITH for reconditioning.
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Affiliation(s)
- Kerry N Warner
- HammondCare, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Roslyn G Poulos
- HammondCare, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Andrew M Cole
- HammondCare, Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - Tuan-Anh Nguyen
- South Western Sydney Local Health District, Sydney, Australia
| | | | - Steven G Faux
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
- St Vincent's Hospital, Sydney, Australia
| | - Friedbert Kohler
- HammondCare, Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - Tara Alexander
- Australasian Rehabilitation Outcomes Centre, University of Wollongong, Wollongong, Australia
| | - Jacquelin T Capell
- Australasian Rehabilitation Outcomes Centre, University of Wollongong, Wollongong, Australia
| | | | - Claire M C O'Connor
- HammondCare, Sydney, Australia
- School of Psychology, University of New South Wales, Sydney, Australia
- Neuroscience Research Australia, Sydney, Australia
| | - Christopher J Poulos
- HammondCare, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
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Subramanian T, Song J, Kim YE, Maayan O, Kamil R, Shahi P, Shinn D, Dalal S, Araghi K, Asada T, Amen TB, Sheha E, Dowdell J, Qureshi S, Iyer S. Predictors of Nonhome Discharge After Cervical Disc Replacement. Clin Spine Surg 2024; 37:E324-E329. [PMID: 38954743 DOI: 10.1097/bsd.0000000000001604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 01/22/2024] [Indexed: 07/04/2024]
Abstract
STUDY DESIGN Retrospective review of a national database. OBJECTIVE The aim of this study was to identify the factors that increase the risk of nonhome discharge after CDR. SUMMARY OF BACKGROUND DATA As spine surgeons continue to balance increasing surgical volume, identifying variables associated with patient discharge destination can help expedite postoperative placement and reduce unnecessary length of stay. However, no prior study has identified the variables predictive of nonhome patient discharge after cervical disc replacement (CDR). METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent primary 1-level or 2-level CDR between 2011 and 2020. Multivariable Poisson regression with robust error variance was employed to identify the predictors for nonhome discharge destination following surgery. RESULTS A total of 7276 patients were included in this study, of which 94 (1.3%) patients were discharged to a nonhome destination. Multivariable regression revealed older age (OR: 1.076, P <0.001), Hispanic ethnicity (OR: 4.222, P =0.001), BMI (OR: 1.062, P =0.001), ASA class ≥3 (OR: 2.562, P =0.002), length of hospital stay (OR: 1.289, P <0.001), and prolonged operation time (OR: 1.007, P <0.001) as predictors of nonhome discharge after CDR. Outpatient surgery setting was found to be protective against nonhome discharge after CDR (OR: 0.243, P <0.001). CONCLUSIONS Age, Hispanic ethnicity, BMI, ASA class, prolonged hospital stay, and prolonged operation time are independent predictors of nonhome discharge after CDR. Outpatient surgery setting is protective against nonhome discharge. These findings can be utilized to preoperatively risk stratify expected discharge destination, anticipate patient discharge needs postoperatively, and expedite discharge in these patients to reduce health care costs associated with prolonged length of hospital stay. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | | | - Omri Maayan
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
| | | | | | - Daniel Shinn
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
| | | | | | | | | | - Evan Sheha
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
| | - James Dowdell
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
| | - Sheeraz Qureshi
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
| | - Sravisht Iyer
- Hospital for Special Surgery
- Weill Cornell Medicine, New York, NY
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Lequertier V, Wang T, Fondrevelle J, Augusto V, Polazzi S, Duclos A. Length of Stay Prediction With Standardized Hospital Data From Acute and Emergency Care Using a Deep Neural Network. Med Care 2024; 62:225-234. [PMID: 38345863 DOI: 10.1097/mlr.0000000000001975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Length of stay (LOS) is an important metric for the organization and scheduling of care activities. This study sought to propose a LOS prediction method based on deep learning using widely available administrative data from acute and emergency care and compare it with other methods. PATIENTS AND METHODS All admissions between January 1, 2011 and December 31, 2019, at 6 university hospitals of the Hospices Civils de Lyon metropolis were included, leading to a cohort of 1,140,100 stays of 515,199 patients. Data included demographics, primary and associated diagnoses, medical procedures, the medical unit, the admission type, socio-economic factors, and temporal information. A model based on embeddings and a Feed-Forward Neural Network (FFNN) was developed to provide fine-grained LOS predictions per hospitalization step. Performances were compared with random forest and logistic regression, with the accuracy, Cohen kappa, and a Bland-Altman plot, through a 5-fold cross-validation. RESULTS The FFNN achieved an accuracy of 0.944 (CI: 0.937, 0.950) and a kappa of 0.943 (CI: 0.935, 0.950). For the same metrics, random forest yielded 0.574 (CI: 0.573, 0.575) and 0.602 (CI: 0.601, 0.603), respectively, and 0.352 (CI: 0.346, 0.358) and 0.414 (CI: 0.408, 0.422) for the logistic regression. The FFNN had a limit of agreement ranging from -2.73 to 2.67, which was better than random forest (-6.72 to 6.83) or logistic regression (-7.60 to 9.20). CONCLUSION The FFNN was better at predicting LOS than random forest or logistic regression. Implementing the FFNN model for routine acute care could be useful for improving the quality of patients' care.
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Affiliation(s)
- Vincent Lequertier
- Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- INSA Lyon, Université Lumière Lyon 2, Université Claude Bernard Lyon 1, Université Jean Monnet Saint-Etienne, DISP UR4570, Villeurbanne, France
| | - Tao Wang
- Université Jean Monnet Saint-Etienne, INSA Lyon, Université Lumière Lyon 2, Université Claude Bernard Lyon 1, DISP UR4570, Roanne, France
| | - Julien Fondrevelle
- INSA Lyon, Université Lumière Lyon 2, Université Claude Bernard Lyon 1, Université Jean Monnet Saint-Etienne, DISP UR4570, Villeurbanne, France
| | - Vincent Augusto
- Mines Saint-Etienne, Univ. Clermont Auvergne, CNRS, CIS Center, Saint-Etienne, France
| | - Stéphanie Polazzi
- Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- Department of Health Data, Lyon University Hospital, Lyon, France
| | - Antoine Duclos
- Research on Healthcare Performance RESHAPE, Inserm U1290, Université Claude Bernard Lyon 1, Lyon, France
- Department of Health Data, Lyon University Hospital, Lyon, France
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Poulos RG, Cole AMD, Hilvert DR, Warner KN, Faux SG, Nguyen TA, Kohler F, Un FC, Alexander T, Capell JT, O'Connor CMC, Poulos CJ. Cost modelling rehabilitation in the home for reconditioning in the Australian context. BMC Health Serv Res 2024; 24:151. [PMID: 38291402 PMCID: PMC10826097 DOI: 10.1186/s12913-023-10527-2] [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: 05/09/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Inpatient rehabilitation services are challenged by increasing demand. Where appropriate, a shift in service models towards more community-oriented approaches may improve efficiency. We aimed to estimate the hypothetical cost of delivering a consensus-based rehabilitation in the home (RITH) model as hospital substitution for patients requiring reconditioning following medical illness, surgery or treatment for cancer, compared to the cost of inpatient rehabilitation. METHODS Data were drawn from the following sources: the results of a Delphi survey with health professionals working in the field of rehabilitation in Australia; publicly available data and reports; and the expert opinion of the project team. Delphi survey data were analysed descriptively. The costing model was developed using assumptions based on the sources described above and was restricted to the Australian National Subacute and Non-Acute Patient Classification (AN-SNAP) classes 4AR1 to 4AR4, which comprise around 73% of all reconditioning episodes in Australia. RITH cost modelling estimates were compared to the known cost of inpatient rehabilitation. Where weighted averages are provided, these were determined based on the modelled number of inpatient reconditioning episodes per annum that might be substitutable by RITH. RESULTS The cost modelling estimated the weighted average cost of a RITH reconditioning episode (which mirrors an inpatient reconditioning episode in intensity and duration) for AN-SNAP classes 4AR1 to 4AR4, to be A$11,371, which is 28.1% less than the equivalent weighted average public inpatient cost (of A$15,820). This represents hypothetical savings of A$4,449 per RITH reconditioning substituted episode of care. CONCLUSIONS The hypothetical cost of a model of RITH which would provide patients with as comprehensive a rehabilitation service as received in inpatient rehabilitation, has been determined. Findings suggest potential cost savings to the public hospital sector. Future research should focus on trials which compare actual clinical and cost outcomes of RITH for patients in the reconditioning impairment category, to inpatient rehabilitation.
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Affiliation(s)
- Roslyn G Poulos
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Andrew M D Cole
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | | | - Kerry N Warner
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Steven G Faux
- St Vincent's Hospital, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Tuan-Anh Nguyen
- South Western Sydney Local Health District, Sydney, Australia
| | - Friedbert Kohler
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | | | - Tara Alexander
- Australasian Rehabilitation Outcomes Centre, University of Wollongong, Wollongong, Australia
| | - Jacquelin T Capell
- Australasian Rehabilitation Outcomes Centre, University of Wollongong, Wollongong, Australia
| | - Claire M C O'Connor
- HammondCare, Sydney, Australia
- School of Psychology, UNSW, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Christopher J Poulos
- HammondCare, Sydney, Australia.
- School of Population Health, UNSW, Sydney, Australia.
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Arora A, Demb J, Cummins DD, Callahan M, Clark AJ, Theologis AA. Predictive models to assess risk of extended length of stay in adults with spinal deformity and lumbar degenerative pathology: development and internal validation. Spine J 2023; 23:457-466. [PMID: 36892060 DOI: 10.1016/j.spinee.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/13/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND CONTEXT Postoperative recovery after adult spinal deformity (ASD) operations is arduous, fraught with complications, and often requires extended hospital stays. A need exists for a method to rapidly predict patients at risk for extended length of stay (eLOS) in the preoperative setting. PURPOSE To develop a machine learning model to preoperatively estimate the likelihood of eLOS following elective multi-level lumbar/thoracolumbar spinal instrumented fusions (≥3 segments) for ASD. STUDY DESIGN/SETTING Retrospectively from a state-level inpatient database hosted by the Health care cost and Utilization Project. PATIENT SAMPLE Of 8,866 patients of age ≥50 with ASD undergoing elective lumbar or thoracolumbar multilevel instrumented fusions. OUTCOME MEASURES The primary outcome was eLOS (>7 days). METHODS Predictive variables consisted of demographics, comorbidities, and operative information. Significant variables from univariate and multivariate analyses were used to develop a logistic regression-based predictive model that use six predictors. Model accuracy was assessed through area under the curve (AUC), sensitivity, and specificity. RESULTS Of 8,866 patients met inclusion criteria. A saturated logistic model with all significant variables from multivariate analysis was developed (AUC=0.77), followed by generation of a simplified logistic model through stepwise logistic regression (AUC=0.76). Peak AUC was reached with inclusion of six selected predictors (combined anterior and posterior approach, surgery to both lumbar and thoracic regions, ≥8 level fusion, malnutrition, congestive heart failure, and academic institution). A cutoff of 0.18 for eLOS yielded a sensitivity of 77% and specificity of 68%. CONCLUSIONS This predictive model can facilitate identification of adults at risk for eLOS following elective multilevel lumbar/thoracolumbar spinal instrumented fusions for ASD. With a fair diagnostic accuracy, the predictive calculator will ideally enable clinicians to improve preoperative planning, guide patient expectations, enable optimization of modifiable risk factors, facilitate appropriate discharge planning, stratify financial risk, and accurately identify patients who may represent high-cost outliers. Future prospective studies that validate this risk assessment tool on external datasets would be valuable.
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Affiliation(s)
- Ayush Arora
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Joshua Demb
- Division of Gastroenterology, Department of Medicine, University of California - San Diego, La Jolla, 9500 Gilman Drive, La Jolla, CA 92093, CA, USA
| | - Daniel D Cummins
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Matt Callahan
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, 400 Parnassus Ave, San Francisco, CA 94143, San Francisco, CA, USA
| | - Alekos A Theologis
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA.
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Poulos RG, Cole AM, Warner KN, Faux SG, Nguyen TA, Kohler F, Un FC, Alexander T, Capell JT, Hilvert DR, O'Connor CM, Poulos CJ. Developing a model for rehabilitation in the home as hospital substitution for patients requiring reconditioning: a Delphi survey in Australia. BMC Health Serv Res 2023; 23:113. [PMID: 36737750 PMCID: PMC9895972 DOI: 10.1186/s12913-023-09068-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Reconditioning for patients who have experienced functional decline following medical illness, surgery or treatment for cancer accounts for approximately 26% of all reported inpatient rehabilitation episodes in Australia. Rehabilitation in the home (RITH) has the potential to offer a cost-effective, high-quality alternative for appropriate patients, helping to reduce pressure on the acute care sector. This study sought to gain consensus on a model for RITH as hospital substitution for patients requiring reconditioning. METHODS A multidisciplinary group of health professionals working in the rehabilitation field was identified from across Australia and invited to participate in a three-round online Delphi survey. Survey items followed the patient journey, and also included items on practitioner roles, clinical governance, and budgetary considerations. Survey items mostly comprised statements seeking agreement on 5-point Likert scales (strongly agree to strongly disagree). Free text boxes allowed participants to qualify item answers or make comments. Analysis of quantitative data used descriptive statistics; qualitative data informed question content in subsequent survey rounds or were used in understanding item responses. RESULTS One-hundred and ninety-eight health professionals received an invitation to participate. Of these, 131/198 (66%) completed round 1, 101/131 (77%) completed round 2, and 78/101 (77%) completed round 3. Consensus (defined as ≥ 70% agreement or disagreement) was achieved on over 130 statements. These related to the RITH patient journey (including patient assessment and development of the care plan, case management and program provision, and patient and program outcomes); clinical governance and budgetary considerations; and included items for initial patient screening, patient eligibility and case manager roles. A consensus-based model for RITH was developed, comprising five key steps and the actions within each. CONCLUSIONS Strong support amongst survey participants was found for RITH as hospital substitution to be widely available for appropriate patients needing reconditioning. Supportive legislative and payment systems, mechanisms that allow for the integration of primary care, and appropriate clinical governance frameworks for RITH are required, if broad implementation is to be achieved. Studies comparing clinical outcomes and cost-benefit of RITH to inpatient rehabilitation for patients requiring reconditioning are also needed.
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Affiliation(s)
- Roslyn G Poulos
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Andrew M Cole
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Kerry N Warner
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Steven G Faux
- School of Population Health, UNSW, Sydney, Australia
- St Vincent's Hospital, Sydney, Australia
| | - Tuan-Anh Nguyen
- South Western Sydney Local Health District, Sydney, Australia
| | - Friedbert Kohler
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | | | - Tara Alexander
- Australasian Rehabilitation Outcomes Centre, University of Wollongong, Wollongong, Australia
| | - Jacquelin T Capell
- Australasian Rehabilitation Outcomes Centre, University of Wollongong, Wollongong, Australia
| | | | - Claire Mc O'Connor
- HammondCare, Sydney, Australia
- School of Population Health, UNSW, Sydney, Australia
| | - Christopher J Poulos
- HammondCare, Sydney, Australia.
- School of Population Health, UNSW, Sydney, Australia.
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Arora A, Demb J, Cummins DD, Deviren V, Clark AJ, Ames CP, Theologis AA. Development and internal validation of predictive models to assess risk of post-acute care facility discharge in adults undergoing multi-level instrumented fusions for lumbar degenerative pathology and spinal deformity. Spine Deform 2023; 11:163-173. [PMID: 36125738 PMCID: PMC9768002 DOI: 10.1007/s43390-022-00582-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/27/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To develop a model for factors predictive of Post-Acute Care Facility (PACF) discharge in adult patients undergoing elective multi-level (≥ 3 segments) lumbar/thoracolumbar spinal instrumented fusions. METHODS The State Inpatient Databases acquired from the Healthcare Cost and Utilization Project from 2005 to 2013 were queried for adult patients who underwent elective multi-level thoracolumbar fusions for spinal deformity. Outcome variables were classified as discharge to home or PACF. Predictive variables included demographic, pre-operative, and operative factors. Univariate and multivariate logistic regression analyses informed development of a logistic regression-based predictive model using seven selected variables. Performance metrics included area under the curve (AUC), sensitivity, and specificity. RESULTS Included for analysis were 8866 patients. The logistic model including significant variables from multivariate analysis yielded an AUC of 0.75. Stepwise logistic regression was used to simplify the model and assess number of variables needed to reach peak AUC, which included seven selected predictors (insurance, interspaces fused, gender, age, surgical region, CCI, and revision surgery) and had an AUC of 0.74. Model cut-off for predictive PACF discharge was 0.41, yielding a sensitivity of 75% and specificity of 59%. CONCLUSIONS The seven variables associated significantly with PACF discharge (age > 60, female gender, non-private insurance, primary operations, instrumented fusion involving 8+ interspaces, thoracolumbar region, and higher CCI scores) may aid in identification of adults at risk for discharge to a PACF following elective multi-level lumbar/thoracolumbar spinal fusions for spinal deformity. This may in turn inform discharge planning and expectation management.
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Affiliation(s)
- Ayush Arora
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - Joshua Demb
- Division of Gastroenterology, Department of Medicine, University of California-San Diego, La Jolla, CA, USA
| | - Daniel D Cummins
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - Vedat Deviren
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | | | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA.
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Wu J, Misa O, Shiner CT, Faux SG. Targeted rehabilitation may improve patient flow and outcomes: development and implementation of a novel Proactive Rehabilitation Screening (PReS) service. BMJ Open Qual 2021; 10:bmjoq-2020-001267. [PMID: 33685858 PMCID: PMC7942267 DOI: 10.1136/bmjoq-2020-001267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 11/09/2022] Open
Abstract
Rehabilitation programmes can be delivered to patients receiving acute care (‘in-reach rehabilitation’) and/or those who have completed acute care but experience ongoing functional impairments (‘subacute rehabilitation’). Access to these programmes depends on a rehabilitation assessment, but there are concerns that referrals for this assessment are often triggered too late in the acute care journey. We describe a Proactive Rehabilitation Screening (PReS) process designed to systematically screen patients during an acute hospital admission, and identify early those who are likely to require specialist rehabilitation assessment and intervention. The process is based on review of patient medical records on day 5 after acute hospital admission, or day 3 after transfer from intensive care to an acute hospital ward. Screening involves brief review of documented care needs, pre-existing and new functional disabilities, the need for allied health interventions and non-medical factors delaying discharge. From May 2017 to February 2019, the novel screening process was implemented as part of a service redesign of the rehabilitation consultation service. Four thousand consecutive screens were performed at the study site. Of those ‘ruled in’ by screening as needing a rehabilitation assessment, 86.0% went on to receive inpatient rehabilitation interventions. Of those ‘ruled out’ by screening, 92.1% did not go on to receive a rehabilitation intervention, while 7.9% did receive some form of rehabilitation intervention. Of all patients accepted into a rehabilitation programme (n=516), PReS was able to identify 53.6% (n=282) of them before the acute care teams made a referral (based on traditional criteria). In conclusion, we have designed and implemented a systematic, PReS service in one metropolitan Australian hospital. The process described was found to be time efficient and feasible to implement in an acute hospital setting. Further, it appeared to identify the majority of patients who went on to receive formal inpatient rehabilitation interventions.
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Affiliation(s)
- Jane Wu
- St Vincent's Health Australia Ltd, Darlinghurst, New South Wales, Australia
| | - Olivia Misa
- St Vincent's Health Australia Ltd, Darlinghurst, New South Wales, Australia
| | - Christine T Shiner
- St Vincent's Health Australia Ltd, Darlinghurst, New South Wales, Australia
| | - Steven G Faux
- St Vincent's Health Australia Ltd, Darlinghurst, New South Wales, Australia
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Warren KT, Liu L, Liu Y, Strawderman MS, Hussain AH, Ma HM, Milano MT, Mohile NA, Walter KA. Time to treatment initiation and outcomes in high-grade glioma patients in rehabilitation: a retrospective cohort study. CNS Oncol 2020; 9:CNS64. [PMID: 33112686 PMCID: PMC7737197 DOI: 10.2217/cns-2020-0018] [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] [Indexed: 11/21/2022] Open
Abstract
Aims: To investigate wait time (WT) for chemoradiation and survival in post-op high-grade glioma (HGG) patients admitted to inpatient rehabilitation compared with those discharged home. Materials & methods: A total of 291 HGG patients (14.4% grade III and 84.9% grade IV) were included in this retrospective cohort study. Patients were grouped by disposition following surgery. Results: Median length of stay was longer in acute inpatient rehabilitation facility (AIRF) patients (10d) compared with patients discharged home (3d). AIRF admission was associated with higher odds of excessive treatment delay. Median survival for AIRF patients less than for patients discharged home (42.9 vs 72.71 weeks). WT was not associated with survival even after adjusting for prognostic factors. Conclusion: HGG patients discharged to rehabilitation facilities have longer length of stay, longer WT and shorter survival compared with patients discharged home.
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Affiliation(s)
- Kwanza T Warren
- Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, NY 10032, USA
| | - Linxi Liu
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Yang Liu
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Myla S Strawderman
- Department of Biostatistics & Computational Biology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Ali H Hussain
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Heather M Ma
- Department of Physical Medicine & Rehabilitation, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA.,University of Rochester Medical Center-Wilmot Cancer Institute, Rochester, NY 14642, USA
| | - Nimish A Mohile
- University of Rochester Medical Center-Wilmot Cancer Institute, Rochester, NY 14642, USA.,Department of Neurology, University of Rochester Medical Center, Neuro-Oncology, Rochester, NY 14642, USA
| | - Kevin A Walter
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA.,University of Rochester Medical Center-Wilmot Cancer Institute, Rochester, NY 14642, USA.,Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY 14642, USA
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10
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Prediction calculator for nonroutine discharge and length of stay after spine surgery. Spine J 2020; 20:1154-1158. [PMID: 32179154 DOI: 10.1016/j.spinee.2020.02.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Following spine surgery, delays in referral to rehabilitation facilities leads to increased length of hospital stay (LOS), increases costs, more risk of hospital acquired complications, and decreased patient satisfaction. PURPOSE We sought to create a prediction calculator to determine the expected LOS after spine surgery and identify patients most likely to need postoperative nonhome discharge. The goal would be to facilitate earlier referral to rehabilitation and thereby ultimately shorten LOS, reduce costs, and improve patient satisfaction. STUDY DESIGN Retrospective. PATIENT SAMPLE We retrospectively reviewed all adult patients who underwent spine surgery for all indications between January and June 2018. OUTCOME MEASURES Length of stay and discharge disposition. METHODS Demographic variables, insurance status, baseline comorbidities, narcotic use, operative characteristics, as well as postoperative length of stay and discharge disposition data were collected. Univariable and multivariable analyses were performed to identify independent predictors of LOS and discharge disposition. RESULTS Two hundred fifty-seven patients were included. Mean age was 59 years, 46% were females, and 52% had private insurance vs 7% with Medicaid and 41% with Medicare. The most commonly performed procedure was lumbar fusion (31.9%). Mean LOS after surgery was 4.8 days and 18% had prolonged LOS >7 days. Age, insurance type, marriage status, and surgical procedure were significantly associated with LOS and discharge disposition. The final model had an area under the curve of 89% with good discrimination. A web based calculator was developed: https://jhuspine1.shinyapps.io/RehabLOS/ CONCLUSIONS: This study established a novel pilot calculator to identify those patients most likely to be discharged to rehabilitation facilities and to predict LOS after spine surgery. Our calculator had a high predictive accuracy of 89% compared to others in the literature. With validation this tool may ultimately facilitate streamlining of the postoperative period to shorten LOS, optimize resource utilization, and improve patient care.
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Ogink PT, Karhade AV, Thio QCBS, Gormley WB, Oner FC, Verlaan JJ, Schwab JH. Predicting discharge placement after elective surgery for lumbar spinal stenosis using machine learning methods. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1433-1440. [PMID: 30941521 DOI: 10.1007/s00586-019-05928-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/11/2019] [Accepted: 02/21/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE An excessive amount of total hospitalization is caused by delays due to patients waiting to be placed in a rehabilitation facility or skilled nursing facility (RF/SNF). An accurate preoperative prediction of who would need a RF/SNF place after surgery could reduce costs and allow more efficient organizational planning. We aimed to develop a machine learning algorithm that predicts non-home discharge after elective surgery for lumbar spinal stenosis. METHODS We used the American College of Surgeons National Surgical Quality Improvement Program to select patient that underwent elective surgery for lumbar spinal stenosis between 2009 and 2016. The primary outcome measure for the algorithm was non-home discharge. Four machine learning algorithms were developed to predict non-home discharge. Performance of the algorithms was measured with discrimination, calibration, and an overall performance score. RESULTS We included 28,600 patients with a median age of 67 (interquartile range 58-74). The non-home discharge rate was 18.2%. Our final model consisted of the following variables: age, sex, body mass index, diabetes, functional status, ASA class, level, fusion, preoperative hematocrit, and preoperative serum creatinine. The neural network was the best model based on discrimination (c-statistic = 0.751), calibration (slope = 0.933; intercept = 0.037), and overall performance (Brier score = 0.131). CONCLUSIONS A machine learning algorithm is able to predict discharge placement after surgery for lumbar spinal stenosis with both good discrimination and calibration. Implementing this type of algorithm in clinical practice could avert risks associated with delayed discharge and lower costs. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Paul T Ogink
- UMC Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Aditya V Karhade
- Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Quirina C B S Thio
- Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - William B Gormley
- Brigham and Women's Hospital - Harvard Medical School, Boston, MA, USA
| | - Fetullah C Oner
- UMC Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jorrit J Verlaan
- UMC Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Joseph H Schwab
- Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
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Warren N, Walford K, Susilo A, New PW. Emotional Consequences of Delays in Spinal Rehabilitation Unit Admission or Discharge: A Qualitative Study on the Importance of Communication. Top Spinal Cord Inj Rehabil 2018; 24:54-62. [PMID: 29434461 DOI: 10.1310/sci17-00026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Objective: To explore the influence of health communications on the emotional consequences of delays in transfer from acute hospital into a spinal rehabilitation unit (SRU) or delays in discharge from SRU. Methods: Semi-structured interviews were conducted in this exploratory, thematic qualitative research design in an SRU, Melbourne, Australia. Results: Six patients experienced delay in admission to (n = 4) or discharge from (n = 3) the SRU, with one person experiencing both an admission and discharge delay. Median admission delay was 41.5 days, primarily related to bed availability and staffing issues. Participants experiencing a delay in transfer from the acute hospital reported feelings of uncertainty, frustration, disappointment, and concern due to a perception that their functional recovery was compromised because of delayed access to specialist rehabilitation. Psychological issues were less common than emotional responses. One participant spent some of the delay period waiting for admission to the SRU in a non-spinal rehabilitation unit and reported no concerns about his recovery. Median discharge delay was 27 days, largely due to a wait in obtaining funding for equipment. Emotional and psychological responses to delayed discharge, particularly frustration, appeared to be influenced by having a sense of control over the discharge process. Conclusion: Patients' experiences during the delay periods partially mitigated the emotional and psychological consequences of a delayed admission or discharge on their psychological well-being. Locus of control, where participants reported being able to effect some influence on their situation, appeared to moderate their emotional state. The findings suggest that clinicians can draw on the concept of control to better support patients through periods of delay.
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Affiliation(s)
- Narelle Warren
- School of Social Sciences and Psychology Department, Alfred Hospital, Monash University, Victoria, Australia
| | - Karin Walford
- School of Psychological Science, Monash University, Victoria, Australia
| | - Annisha Susilo
- School of Psychological Science, Monash University, Victoria, Australia
| | - Peter Wayne New
- Spinal Rehabilitation Service, Caulfield Hospital, Alfred Health, Caulfield, Victoria, Australia.,Epworth-Monash Rehabilitation Medicine Unit, Southern Medical School, Monash University, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Victoria, Australia
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New PW, McDougall KE, Scroggie CPR. Improving discharge planning communication between hospitals and patients. Intern Med J 2016; 46:57-62. [PMID: 26439193 DOI: 10.1111/imj.12919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/27/2015] [Accepted: 09/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND A potential barrier to patient discharge from hospital is communication problems between the treating team and the patient or family regarding discharge planning. AIM To determine if a bedside 'Leaving Hospital Information Sheet' increases patient and family's knowledge of discharge date and destination and the name of the key clinician primarily responsible for team-patient communication. METHODS This article is a 'before-after' study of patients, their families and the interdisciplinary ward-based clinical team. Outcomes assessed pre-implementation and post-implementation of a bedside 'Leaving Hospital Information Sheet' containing discharge information for patients and families. Patients and families were asked if they knew the key clinician for team-patient communication and the proposed discharge date and discharge destination. Responses were compared with those set by the team. Staff were surveyed regarding their perceptions of patient awareness of discharge plans and the benefit of the 'Leaving Hospital Information Sheet'. RESULTS Significant improvement occurred regarding patients' knowledge of their key clinician for team-patient communication (31% vs 75%; P = 0.0001), correctly identifying who they were (47% vs 79%; P = 0.02), and correctly reporting their anticipated discharge date (54% vs 86%; P = 0.004). There was significant improvement in the family's knowledge of the anticipated discharge date (78% vs 96%; P = 0.04). Staff reported the 'Leaving Hospital Information Sheet' assisted with communication regarding anticipated discharge date and destination (very helpful n = 11, 39%; a little bit helpful n = 11, 39%). CONCLUSIONS A bedside 'Leaving Hospital Information Sheet' can potentially improve communication between patients, families and their treating team.
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Affiliation(s)
- P W New
- Rehabilitation and Aged Care, Kingston Centre, Monash Health.,Epworth-Monash Rehabilitation Medicine Unit, Southern Medical School.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - K E McDougall
- Rehabilitation and Aged Care, Kingston Centre, Monash Health
| | - C P R Scroggie
- Rehabilitation and Aged Care, Kingston Centre, Monash Health
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Kothari AN, Yau RM, Blackwell RH, Schaidle-Blackburn C, Markossian T, Zapf MAC, Lu AD, Kuo PC. Inpatient Rehabilitation after Liver Transplantation Decreases Risk and Severity of 30-Day Readmissions. J Am Coll Surg 2016; 223:164-171.e2. [PMID: 27049779 DOI: 10.1016/j.jamcollsurg.2016.01.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Discharge location is associated with short-term readmission rates after hospitalization for several medical and surgical diagnoses. We hypothesized that discharge location: home, home health, skilled nursing facility (SNF), long-term acute care (LTAC), or inpatient rehabilitation, independently predicted the risk of 30-day readmission and severity of first readmission after orthotopic liver transplantation. STUDY DESIGN We performed a retrospective cohort review using Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases for Florida and California. Patients who underwent orthotopic liver transplantation from 2009 to 2011 were included and followed for 1 year. Mixed-effects logistic regression was used to model the effect of discharge location on 30-day readmission controlling for demographic, socioeconomic, and clinical factors. Total cost of first readmission was used as a surrogate measure for readmission severity and resource use. RESULTS A total of 3,072 patients met our inclusion criteria. The overall 30-day readmission rate was 29.6%. Discharge to inpatient rehabilitation (adjusted odds ratio [aOR] 0.43, p = 0.013) or LTAC/SNF (aOR 0.63, p = 0.014) were associated with decreased odds of 30-day readmission when compared with home. The severity of 30-day readmissions for patients discharged to inpatient rehabilitation were the same as those discharged home or home with home health. Severity was increased for those discharged to LTAC/SNF. The time to first readmission was longest for patients discharged to inpatient rehabilitation (17 days vs 8 days, p < 0.001). CONCLUSIONS When compared with other locations of discharge, inpatient rehabilitation reduces the risk of 30-day readmission and increases the time to first readmission. These benefits come without increasing the severity of readmission. Increased use of inpatient rehabilitation after orthotopic liver transplantation is a strategy to improve 30-day readmission rates.
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Affiliation(s)
- Anai N Kothari
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Analytics Research Group, Loyola University Medical Center, Department of Surgery, Maywood, IL
| | - Ryan M Yau
- One:MAP Analytics Research Group, Loyola University Medical Center, Department of Surgery, Maywood, IL
| | - Robert H Blackwell
- Department of Urology, Loyola University Medical Center, Maywood, IL; One:MAP Analytics Research Group, Loyola University Medical Center, Department of Surgery, Maywood, IL
| | | | - Talar Markossian
- Department of Public Health Sciences, Loyola University Chicago, Chicago, IL
| | - Matthew A C Zapf
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Analytics Research Group, Loyola University Medical Center, Department of Surgery, Maywood, IL
| | - Amy D Lu
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Analytics Research Group, Loyola University Medical Center, Department of Surgery, Maywood, IL
| | - Paul C Kuo
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Analytics Research Group, Loyola University Medical Center, Department of Surgery, Maywood, IL.
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Rosman M, Rachminov O, Segal O, Segal G. Prolonged patients' In-Hospital Waiting Period after discharge eligibility is associated with increased risk of infection, morbidity and mortality: a retrospective cohort analysis. BMC Health Serv Res 2015; 15:246. [PMID: 26108373 PMCID: PMC4480441 DOI: 10.1186/s12913-015-0929-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 06/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged, inappropriate hospital stay after patients' eligibility for discharge from internal medicine departments is a world-wide health-care systems' problem. Nevertheless, the extent to which such surplus hospital stays are associated with infectious complications, their time frame of appearance and their long-term implications was not previously addressed. METHODS We conducted a retrospective cohort analysis of patients experiencing an In-hospital Waiting Period (IHWP) after discharge eligibility in a single, tertiary hospital. RESULTS We screened the records of 245 patients out of which 104 patients fulfilled our inclusion criteria. The mean length of IHWP was 15.7 ± 4.79 day during which 9(8.7 %) patients died. The study primary composite end-point, in-hospital mortality or hospital acquired infection (pneumonia, UTI or sepsis) occurred in 32(31 %) patients. The most hazardous time was during the first 3 IHWP days: 63.7 % of patients experienced a complication and 44 % of the total complications occurred during this period. The occurrence of any complication during IHWP was associated, with statistical significance, with increased risk of mortality during the first year after IHWP initiation (HR = 6.02, p = 0.014). CONCLUSION Prolongation of hospital stay after patients are deemed to be discharged from internal medicine departments is associated with increased morbidity and mortality, mainly during the first surplus days of in-hospital stay. Efforts should be made to shorten such hospital stays as much as possible.
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Affiliation(s)
- Maya Rosman
- Department of internal medicine "T', Chaim Sheba Medical Center@, Ramat Gan, Israel.
| | - Orna Rachminov
- Department of Nursing Management, Chaim Sheba Medical Center@, Ramat Gan, Israel.
| | - Omer Segal
- Sackler faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Gad Segal
- Department of internal medicine "T', Chaim Sheba Medical Center@, Ramat Gan, Israel.
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Time-series analysis of the barriers for admission into a spinal rehabilitation unit. Spinal Cord 2015; 54:126-31. [PMID: 26099216 DOI: 10.1038/sc.2015.108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/17/2015] [Accepted: 05/25/2015] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN This is a prospective open-cohort case series. OBJECTIVES The objective of this study was to assess changes over time in the duration of key acute hospital process barriers for patients with spinal cord damage (SCD) from admission until transfer into spinal rehabilitation unit (SRU) or other destinations. SETTING The study was conducted in Acute hospitals, Victoria, Australia (2006-2013). METHODS Duration of the following discrete sequential processes was measured: acute hospital admission until referral to SRU, referral until SRU assessment, SRU assessment until ready for SRU transfer and ready for transfer until SRU admission. Time-series analysis was performed using a generalised additive model (GAM). Seasonality of non-traumatic spinal cord dysfunction (SCDys) was examined. RESULTS GAM analysis shows that the waiting time for admission into SRU was significantly (P<0.001) longer for patients who were female, who had tetraplegia, who were motor complete, had a pelvic pressure ulcer and who were referred from another health network. Age had a non-linear effect on the duration of waiting for transfer from acute hospital to SRU and both the acute hospital and SRU length of stay (LOS). The duration patients spent waiting for SRU admission increased over the study period. There was an increase in the number of referrals over the study period and an increase in the number of patients accepted but not admitted into the SRU. There was no notable seasonal influence on the referral of patients with SCDys. CONCLUSIONS Time-series analysis provides additional insights into changes in the waiting times for SRU admission and the LOS in hospital for patients with SCD.
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Sudarshan M, Feldman LS, St Louis E, Al-Habboubi M, Hassan MME, Fata P, Deckelbaum DL, Razek TS, Khwaja KA. Predictors of mortality and morbidity for acute care surgery patients. J Surg Res 2014; 193:868-73. [PMID: 25439507 DOI: 10.1016/j.jss.2014.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 08/19/2014] [Accepted: 09/04/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND As the implementation of exclusive acute care surgery (ACS) services thrives, prognostication for mortality and morbidity will be important to complement clinical management of these diverse and complex patients. Our objective is to investigate prognostic risk factors from patient level characteristics and clinical presentation to predict outcomes including mortality, postoperative complications, intensive care unit (ICU) admission and prolonged duration of hospital stay. METHODS Retrospective review of all emergency general surgery admissions over a 1-year period at a large teaching hospital was conducted. Factors collected included history of present illness, physical exam and laboratory parameters at presentation. Univariate analysis was performed to examine the relationship between each variable and our outcomes with chi-square for categorical variables and the Wilcoxon rank-sum statistic for continuous variables. Multivariate analysis was performed using backward stepwise logistic regression to evaluate for independent predictors. RESULTS A total of 527 ACS admissions were identified with 8.1% requiring ICU stay and an overall crude mortality rate of 3.04%. Operative management was required in 258 patients with 22% having postoperative complications. Use of anti-coagulants, systolic blood pressure <90, hypothermia and leukopenia were independent predictors of in-hospital mortality. Leukopenia, smoking and tachycardia at presentation were also prognostic for the development of postoperative complications. For ICU admission, use of anti-coagulants, leukopenia, leukocytosis and tachypnea at presentation were all independent predictive factors. A prolonged length of stay was associated with increasing age, higher American Society of Anesthesiologists class, tachycardia and presence of complications on multivariate analysis. CONCLUSIONS Factors present at initial presentation can be used to predict morbidity and mortality in ACS patients.
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Affiliation(s)
- Monisha Sudarshan
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Liane S Feldman
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Etienne St Louis
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Mostafa Al-Habboubi
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | | | - Paola Fata
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Dan Leon Deckelbaum
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Tarek S Razek
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Kosar A Khwaja
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada.
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New PW. Reducing process barriers in acute hospital for spinal cord damage patients needing spinal rehabilitation unit admission. Spinal Cord 2014; 52:472-6. [DOI: 10.1038/sc.2014.59] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 02/09/2014] [Accepted: 03/29/2014] [Indexed: 11/09/2022]
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