The Frequency of, and Factors Associated with Prolonged Hospitalization: A Multicentre Study in Victoria, Australia

Nonlinear relationship between operational frequency and age in respiratory papillomatosis patients

BACKGROUND

Respiratory papillomatosis (RP) is a benign tumor that primarily affects the respiratory tract and is often caused by human papillomavirus (HPV). Patients typically require multiple surgeries. Recent studies suggest that age may significantly influence the frequency of surgeries, although specific research on this correlation remains limited.

METHODS

This study retrospectively analyzed data from 676 RP patients who underwent surgery between 2000 and 2022 at a specific hospital. Patients were divided into two groups: those over 18 years old and those 18 years old or younger. This study examined the impact of factors such as age, weight, length of hospital stay, and HPV infection on the number of operations. Smooth curve fitting and threshold effect analysis were employed to explore the nonlinear relationship between age and surgery frequency. Univariate and multivariate regression analyses, along with a generalized additive model, were used to investigate the associations between age and the number of surgeries.

RESULTS

This study analyzed data from 676 patients with respiratory papillomatosis and revealed a significant nonlinear relationship between age and the number of operations. The results revealed that younger patients, especially those under 18 years of age, needed more surgeries, with an average of 5.5 surgeries per year, whereas adult patients had an average of only 1.7 surgeries. Through generalized additive modeling, we established that 8.2 years is a critical inflection point; below this age, each additional year is associated with a decrease of 0.7 surgeries (95% CI [-0.8, -0.6], P < 0.001), whereas the frequency stabilizes above this age. Multivariable regression analysis further confirmed the significant impact of age on surgical frequency, maintaining this association even when adjusting for other variables (β= -2.16, 95% CI [-2.97, -1.36], P < 0.001).

CONCLUSION

Age is a crucial factor influencing the frequency of surgeries in RRP patients, with this effect being particularly pronounced in younger patients. Notably, below the critical age of 8.2 years, the number of surgeries increases significantly. This finding provides important insights for clinical practice, aiding in the development of more precise treatment strategies and prognostic assessments.

Emergency department and inpatient interhospital transfers for patients with status epilepticus

OBJECTIVE

Interhospital transfers for status epilepticus (SE) are common, and some are avoidable and likely lower yield. The use of interhospital transfer may differ in emergency department (ED) and inpatient settings, which contend with differing clinical resources and financial incentives. However, transfer from these two settings is understudied, leaving gaps in our ability to improve the hospital experience, cost, and triage for this neurologic emergency. We aimed to describe interhospital transfer for SE and examine the relationship between the site of transfer and hospital length of stay.

METHODS

We performed a cross-sectional study of adult patients with SE who underwent interhospital transfer using data from the State Emergency Department Databases and State Inpatient Databases of Florida (2016-2019) and New York (2018-2019). The primary outcome was discharge after undergoing transfer. Secondary outcomes were discharge within 1 day, discharge after 30 days, receipt of electroencephalography (EEG), and discharge disposition.

RESULTS

There were 10 461 encounters for SE. Of 1790 ED encounters without admission to the same hospital, 324 (18.1%) resulted in transfer. Of 8671 hospitalizations, 629 (7.3%) resulted in transfer. Patients transferred from the ED were younger, more likely were White, more likely were in a metro area, and had fewer medical comorbidities than patients transferred from the inpatient setting. The median time to discharge was 5 days (interquartile range [IQR] = 2.0-9.0) after ED transfer and 10 days (IQR = 4.0-20.0) after inpatient transfer. There were 58 (17.9%) patients who were discharged within 1 day after undergoing transfer from an ED. ED transfers had higher rates of discharge at 30 days and higher likelihood of undergoing EEG at the receiving hospital and being discharged home.

SIGNIFICANCE

A high proportion of patients with SE are discharged shortly after undergoing interhospital transfer, particularly those transferred from the ED. Understanding reasons for transfer is a crucial next step in triaging limited inpatient epilepsy resources and reducing costs associated with interhospital transfer.

Traumatic chylothorax management post-coronary artery bypass grafting - A systematic review

IntroductionCoronary artery bypass graft (CABG) surgery is performed globally around 400,000 times annually. Despite its benefits, CABG can lead to complications, including chylothorax, a rare condition where chyle accumulates in the pleural cavity due to thoracic duct trauma. Currently, there are no international guidelines for traumatic chylothorax management post-CABG. This is the first systematic review to provide a comprehensive overview of the current state of management for chylothorax post-CABG.MethodsThis systematic review was conducted by searching EMBASE, Cochrane, Ovid and PubMed databases on 16 June 2024. The inclusion criteria focused on studies addressing post-CABG chylothorax management and reporting clinical outcomes. Data was extracted from 11 studies focusing on graft type, complications and management strategies.ResultsThis review included 11 case report studies with 14 cases of post-CABG chylothorax. Conservative management was attempted in all cases, with varying components such as total parenteral nutrition, nil by mouth, octreotide and low-fat diets. High-output chylothorax (>1000 mL/day) often necessitated surgical intervention after an average of 12.5 days of conservative management. Surgical approaches included thoracic duct ligation, embolisation and pleurodesis. Surgical ligation was effective in three cases, while thoracic duct embolisation was successful in one case.ConclusionsChylothorax post-CABG is managed initially with conservative strategies, but high-output cases often necessitate surgical intervention. This review highlights the need for standardised guidelines, regarding the timing of surgical escalation and the use of octreotide and somatostatin. Further research should focus on higher-powered studies to validate these findings and establish clinical guidelines for managing chylothorax post-CABG.

Outpatient parenteral antimicrobial therapy with carbapenems: A systematic review

OBJECTIVE

To review the literature on parenteral carbapenems in OPAT and present comprehensive evidence on their safety, efficacy, and stability.

METHODS

A systematic review following PRISMA guidelines was conducted through 17 January 2024, using PubMed, Embase, Web of Science, Scopus, and the Cochrane Library to find relevant articles.

RESULTS

Ertapenem (1 g QD) in OPAT showed high clinical (81-97%) and microbiological (67-90.9%) success rates. Ertapenem (1 g QD) was also comparable to piperacillin/tazobactam (3.375 g every 6 h) for complicated skin infections and superior to cefazolin (2 g every 8 h) and oxacillin (2 g every 4-6 h) for various infections. Ertapenem monotherapy, once daily, achieved an 81% clinical cure rate for urinary tract infections. Additionally, subcutaneous ertapenem in OPAT showed outcomes comparable to parenteral routes. Meropenem continuous infusion (CI) may also be considered safe and effective in selected patient populations; however, its use in OPAT as a CI is limited due to stability concerns.

CONCLUSION

Parenteral carbapenems are effective, and well-tolerated OPAT treatment options; nonetheless, further studies are warranted to optimize the stability and/or dosing regimens of meropenem and enable its wider use.

Impact of Non-Dialysis-Requiring Acute Kidney Injury on Survival Outcomes in Non-critically Ill Hospitalized Medical Patients in a Resource-Limited Setting: A Retrospective Cohort Study

Introduction The severe consequences of acute kidney injury (AKI) have been well-documented in high-risk patient populations. However, the effects of milder forms in non-critically ill patients remain understudied, particularly in resource-limited settings. While the risk of mortality associated with these cases is considered low, it can still lead to various complications including prolonged hospitalization, which may influence long-term renal and patient survival. Hence, the objective of this study was to study the impact of non-dialysis-requiring AKI (NDR-AKI) on survival outcomes of non-critically ill medical patients admitted to St. Paul's Hospital Millennium Medical College in Ethiopia during the period from July 2019 to January 2022. Methods A retrospective cohort study was conducted among 300 non-critically ill medical patients, 93 with NDR-AKI and 207 without AKI. Descriptive statistics, including frequency distributions and median survival times, were employed to summarize the data. Kaplan-Meier curves and the log-rank test were utilized to compare survival experiences of groups. A Cox proportional hazards survival model was fitted to estimate the impact of NDR-AKI on time to recovery. Adjusted hazard ratio (AHR) with 95% confidence interval (CI) was used to report findings. Results Two hundred four (68.0%) were discharged after improvement and the median recovery time was 16 days (95%CI: 13.5-18.5 days). Having NDR-AKI was associated with a 43% lower rate of achieving recovery (AHR=0.57, 95%CI=0.38, 0.84, p-value=0.004). Females were found to have a 1.41 times higher rate of recovery (AHR=1.41, 95%CI=1.03,1.94, p-value=0.033). Additionally, having tuberculosis (AHR=0.41, 95%CI=0.23,0.72, p-value=0.002) and being on anticoagulant (AHR=0.67, 95%CI=0.47,0.95, p-value=0.027) were associated with a 59% and 33% lower rate of recovery, respectively. Conclusion NDR-AKI significantly delays recovery compared to patients without AKI suggesting that even milder forms of AKI in non-critically ill patients can negatively impact patient outcomes. Early identification, prompt management, and addressing underlying causes are key to improving recovery and reducing long-term morbidity and mortality. Strict screening and monitoring of high-risk groups such as men, patients with tuberculosis, and those on anticoagulants is also crucial.

Analyzing the 20-year declining trend of hospital length-of-stay in European countries with different healthcare systems and reimbursement models

The study aims to investigate the last 20-year (2000-2019) of hospital length of stay (LOS) trends and their association with different healthcare systems (HS) among 25 European countries. A panel dataset was created using secondary data from Eurostat and Global Burden of Disease study databases, with dependent and control variables aggregated at the national level over a period of 20 years. A time trend analysis was conducted using a weighted least squares model for panel data to investigate the association between LOS, HS models [National Health Service (NHS), National Health Insurance, Social Health Insurance (SHI), and Etatist Social Health Insurance], healthcare reimbursement schemes [Prospective Global Budget (PGB), Diagnosis Related Groups (DRG), and Procedure Service Payment (PSP)], and control variables. The study showed a reduction of average LOS from 9.20 days in 2000 to 7.24 in 2019. SHI was associated with a lower LOS compared to NHS (b = - 0.6327, p < 0.05). Both DRG (b = 1.2399, p < 0.05) and PSP (b = 1.1677, p < 0.05) reimbursement models were positively associated with LOS compared to PGB. Our results confirmed the downward trend of LOS in the last 20 years, its multifactorial nature, and the influence of the SHI model of HS. This could be due to the financial incentives present in fee-for-service payment models and the role of competition in creating a market for healthcare services. These results offer insight into the factors influencing healthcare utilization and can inform the design of more effective, efficient, and sustainable HS.

Length of hospital stay and associated factors among adult surgical patients admitted to surgical wards in Amhara Regional State Comprehensive Specialized Hospitals, Ethiopia

INTRODUCTION

Hospitals across the country are facing increases in hospital length of stay ranging from 2% to 14%. This results in patients who stay in hospital for long periods of time being three times more likely to die in hospital. Therefore, identifying factors that contribute to longer hospital stays enhances the ability to improve services and quality of patient care. However, there is limited documented evidence on factors associated with longer hospital stays among surgical inpatients in Ethiopia and the study area.

OBJECTIVE

This study aimed to assess the length of hospital stay and associated factors among adult surgical patients admitted to surgical wards in Amhara Regional State Comprehensive Specialized Hospitals, Ethiopia, 2023.

METHODS

An institutional-based cross-sectional study was conducted among 452 adult surgical patients from April 17 to May 22, 2023. Data were collected based on a pretested, structured, interviewer-administered questionnaire, medical record review, and direct measurement of BMI. Study participants were selected using a systematic random sampling technique. The collected data were cleaned, entered into EpiData version 4.6.0 and exported to STATA version 14 for analysis. Binary logistic regression analysis was used. Variables with a p value <0.05 in the multivariable logistic regression analysis were considered statistically significant.

RESULTS

In the current study, the prevalence of prolonged hospital stay was 26.5% (95% CI: 22.7, 30.8). Patients referred from another public health facility (AOR = 2.65; 95% CI: 1.14, 6.14), hospital-acquired pneumonia (AOR = 3.64; 95% CI: 1.43, 9.23), duration of surgery ≥110 minutes (AOR = 2.54; 95% CI: 1.25, 5.16), being underweight (AOR = 5.21; 95%CI: 2.63, 10.33) and preoperative anemia (AOR = 3.22; 95% CI: 1.77, 5.86) were factors associated with prolonged hospital stays.

CONCLUSION

This study found a significant proportion of prolonged hospital stays among patients admitted to surgical wards. Patients referred from another public health facility, preoperative anemia, underweight, duration of surgery ≥110 minutes, and hospital-acquired pneumonia were factors associated with prolonged hospital stay. Early screening and treatment of anemia and malnutrition before surgery can shorten the length of stay.

Drug Burden Index Is a Modifiable Predictor of 30-Day Hospitalization in Community-Dwelling Older Adults With Complex Care Needs: Machine Learning Analysis of InterRAI Data

BACKGROUND

Older adults (≥65 years) account for a disproportionately high proportion of hospitalization and in-hospital mortality, some of which may be avoidable. Although machine learning (ML) models have already been built and validated for predicting hospitalization and mortality, there remains a significant need to optimize ML models further. Accurately predicting hospitalization may tremendously affect the clinical care of older adults as preventative measures can be implemented to improve clinical outcomes for the patient.

METHODS

In this retrospective cohort study, a data set of 14 198 community-dwelling older adults (≥65 years) with complex care needs from the International Resident Assessment Instrument-Home Care database was used to develop and optimize 3 ML models to predict 30-day hospitalization. The models developed and optimized were Random Forest (RF), XGBoost (XGB), and Logistic Regression (LR). Variable importance plots were generated for all 3 models to identify key predictors of 30-day hospitalization.

RESULTS

The area under the receiver-operating characteristics curve for the RF, XGB, and LR models were 0.97, 0.90, and 0.72, respectively. Variable importance plots identified the Drug Burden Index and alcohol consumption as important, immediately potentially modifiable variables in predicting 30-day hospitalization.

CONCLUSIONS

Identifying immediately potentially modifiable risk factors such as the Drug Burden Index and alcohol consumption is of high clinical relevance. If clinicians can influence these variables, they could proactively lower the risk of 30-day hospitalization. ML holds promise to improve the clinical care of older adults. It is crucial that these models undergo extensive validation through large-scale clinical studies before being utilized in the clinical setting.

Postoperative Gait Performance Following Pertrochanteric Fractures Is Influenced by the Preoperative Condition of the Gluteal Muscles

Introduction Amid an increasing number of patients with pertrochanteric fractures, early prediction of postoperative gait potential could reduce unnecessary rehabilitation and hospitalization. The relationship between preoperative gluteal muscle condition and postoperative gait outcomes remains unclear. The gluteal muscles are crucial for mobility, and their cross-sectional area (CSA) and fatty infiltration are indicators of physical function. Preoperative computed tomography (CT) provides quantitative data on muscle CSA and density, measured in Hounsfield Units (HU). This study aimed to identify which preoperative muscle index, CSA, BMI-adjusted CSA, or muscle density, best predicts postoperative gait ability. We hypothesized that a higher adjusted CSA and muscle density in the gluteus muscles would be associated with superior gait performance. Materials and methods Preoperative assessments included radiographs and CT scans. Patients under 75, with less than four weeks of follow-up, prior contralateral hip surgery, prefracture immobility, male patients, high-energy trauma, or conditions impairing physical performance were excluded. Gait performance was evaluated four weeks postoperatively, classifying patients into two groups: the 'parallel bar group,' requiring parallel bars, and the 'walker group,' walking independently. Patients underwent CM nailing. Preoperative CT scans measured the CSA and muscle density of the gluteus maximus and medius. Measurements were taken from the non-injured side to avoid interference from the fracture. Muscle borders were manually traced, and the CSA and muscle density in HU were calculated. Results Out of 81 patients, 49 met the inclusion criteria (mean age: 87). The patients were divided into the 'parallel bar group' (n=19) and the 'walker group' (n=30) based on postoperative gait performance. No significant differences in age, weight, height, or fracture laterality were observed between groups. The mean (and standard deviation (SD)) of CSA for the gluteus maximus in the 'parallel bar group'/in the 'walker group' was 2211.8 ± 469.8 mm²/2440.0 ± 586.2 mm², respectively (p=0.15), and for the gluteus medius, it was 1751.7 ± 415.2mm²/1869.1 ± 448.3mm², respectively (p=0.36). The mean (and SD) muscle density for the gluteus maximus in the 'parallel bar group'/in the 'walker group' was 13.6 ± 12.7 HU / 20.6 ± 13.0 HU (p=0.07), and for the gluteus medius, it was 25.2 ± 8.4 HU/31.8 ± 10.1 HU, respectively (p=0.02). The ROC curve identified a 30.9 HU cut-off for gluteus medius density, with sensitivity and specificity of 60.7% and 78.9%. The mean (and SD) of BMI-adjusted CSA for the gluteus maximus in the 'parallel bar group'/ in the 'walker group' was 116.4 ± 26.8 m²/106 kg/124.3 ± 29.2 m²/106 kg, respectively (p=0.35), and for the gluteus medius, it was 93.3 ± 27.2 m²/106 kg/95.4 ± 21.3m²/106kg, respectively (p=0.78). Conclusion This study analyzed preoperative CT images of women aged 75 and older with pertrochanteric fractures, comparing gluteal muscle CSA and density with postoperative walking ability. The gluteus medius density was significantly higher in the superior gait group, with a cut-off value of 30.9 HU. However, no significant differences were found in the gluteus maximus density, CSA, or BMI-adjusted CSA. These findings partially support the hypothesis, emphasizing the importance of muscle evaluation in predicting postoperative gait performance.

Association between changes in potentially inappropriate medication use and adverse outcomes during hospitalization in older adults: A retrospective study

PURPOSE

To evaluate the association between the change in the number of PIMs in older adults during hospitalization and adverse outcomes.

METHODS

This retrospective cohort study was conducted in the internal medicine wards of a tertiary teaching hospital between May and December 2017. 3,460 patients (77.5±8.4 years, 60.4% male) were enrolled, and 206 patients died during hospitalization. PIMs were defined using the Beers Criteria as suggested by the American Geriatrics Society. Adverse outcomes studied were functional decline (a loss in 1 or more activities of daily living from admission to discharge), prolonged length of stay (LOS) (≥14 days), and mortality.

RESULTS

2258 patients (65.3%) had increasing PIMs during hospitalization. They tended to be younger (77.0±8.3 versus 78.5±8.5 years, p<0.001) and had lower numbers of PIMs at admission (0.4±0.8 versus 0.8±1.1, p<0.001). Increasing PIM use was strongly associated with greater functional decline (aOR 1.36, 95%CI 1.01-1.67, p=0.005), prolonged LOS (aOR 3.47, 95%CI 2.71-4.44, p<0.001) and higher mortality rate (aOR 2.68, 95%CI 1.75-4.12, p<0.001), even after adjusting for all covariates. We observed a strong association between adverse outcomes and increasing PIMs in older adults during hospitalization (p for trend <0.001).

CONCLUSIONS

Older adults with increasing PIMs during hospitalization were at greater risk for functional decline, prolonged LOS, and mortality, especially in those with three or more PIMs. Further studies are needed to better understand the complex interactions and to evaluate the effectiveness of intervention programs to lower PIM number and improve discharge outcomes for patients who had increasing PIM use during hospitalization.

Association of the Number of Teeth With Physical Function and Length of Hospital Stay After Hip Fracture Surgery: A Prospective Observational Study at a Tertiary Hospital in Japan

OBJECTIVES

Although lower-extremity muscle strength is associated with physical function, there are challenges in assessing the muscle strength of patients after hip surgery due to pain or limited cognitive function. The number of teeth is a characteristic that can be easily examined. Although the relationship between the number of teeth and physical function has been reported in recent years, there are no reports examining the relationship with prognosis in patients with hip fractures. Therefore, this study aimed to investigate the relationship between the number of teeth and physical function and length of hospital stay after hip fracture surgery and to evaluate the predictive efficacy of the number of teeth on postoperative prognosis.

METHODS

This prospective cohort study was conducted in a tertiary clinical care facility. Patients aged ≥65 years who underwent hip surgery were included. A total of 101 patients (mean age: 85.1±8.0 years) were included. The factor analyzed was the number of teeth at admission. Patients were divided into two groups according to the number of teeth: those with ≥20 and those with ≤19 teeth. The outcomes were knee extension muscle strength-to-weight ratio at two weeks postoperatively and the length of hospital stay. A multiple regression analysis was performed to determine the association between the two groups.

RESULTS

Of 101 patients, 79 (78.2%) had ≤19 teeth, whereas 22 (21.8%) had ≥20 teeth. The mean muscle strength-to-weight ratio and length of hospital stay were 0.26±0.11 kgf/kg and 57.5±31.4 days, respectively. Multiple regression analysis revealed that the number of teeth was significantly associated with the muscle strength-to-weight ratio (β=-0.26, p=0.04) but not with the duration of hospitalization (β=0.17, p=0.09).

CONCLUSIONS

We suggest that assessment of the number of teeth at admission may be a useful predictor of patient physical function.

Therapeutics for Vancomycin-Resistant Enterococcal Bloodstream Infections

Vancomycin-resistant enterococci (VRE) are common causes of bloodstream infections (BSIs) with high morbidity and mortality rates. They are pathogens of global concern with a limited treatment pipeline. Significant challenges exist in the management of VRE BSI, including drug dosing, the emergence of resistance, and the optimal treatment for persistent bacteremia and infective endocarditis. Therapeutic drug monitoring (TDM) for antimicrobial therapy is evolving for VRE-active agents; however, there are significant gaps in the literature for predicting antimicrobial efficacy for VRE BSIs. To date, TDM has the greatest evidence for predicting drug toxicity for the three main VRE-active antimicrobial agents daptomycin, linezolid, and teicoplanin. This article presents an overview of the treatment options for VRE BSIs, the role of antimicrobial dose optimization through TDM in supporting clinical infection management, and challenges and perspectives for the future.

Prevalence and predictors of prolonged length of stay among patients admitted under general internal medicine in a tertiary government hospital in Manila, Philippines: a retrospective cross-sectional study

BACKGROUND

Prolonged hospitalization leads to poorer health outcomes and consumes limited hospital resources. This study identified factors associated with prolonged length of stay (PLOS) among internal medicine patients admitted in a tertiary government hospital.

METHODS

We reviewed the medical records of 386 adult patients admitted under the primary service of General Internal Medicine at the Philippine General Hospital from January 1 to December 31, 2019. PLOS was defined as at least 14 days for emergency admissions or 3 days for elective admissions. Sociodemographics, clinical characteristics, admission- and hospital system-related factors, disease-specific factors, outcome on the last day of hospitalization, and hospitalization costs were obtained. We determined the proportion with PLOS and reviewed reasons for discharge delays. We conducted multiple logistic regression analyses to assess associations between various factors and PLOS.

RESULTS

The prevalence of PLOS is 19.17% (95% CI 15.54, 23.42). Positive predictors include being partially dependent on admission (aOR 2.61, 95% CI 0.99, 6.86), more co-managing services (aOR 1.26, 95% CI 1.06, 1.50), and longer duration of intravenous antibiotics (aOR 1.36, 95% CI 1.22, 1.51). The only negative predictor is the need for intravenous antibiotics (aOR 0.14, 95% CI 0.04, 0.54). The most common reason for discharge delays was prolonged treatment. The median hospitalization cost of patients with PLOS was PHP 77,427.20 (IQR 102,596).

CONCLUSIONS

Almost a fifth of emergency admissions and a quarter of elective admissions had PLOS. Addressing factors related to predictors such as functional status on admission, number of co-managing services, and use of intravenous antibiotics can guide clinical and administrative decisions, including careful attention to vulnerable patients and judicious use of resources.

Hospital length of stay prediction for general surgery and total knee arthroplasty admissions: Systematic review and meta-analysis of published prediction models

Objective

Systematic review of length of stay (LOS) prediction models to assess the study methods (including prediction variables), study quality, and performance of predictive models (using area under receiver operating curve (AUROC)) for general surgery populations and total knee arthroplasty (TKA).

Method

LOS prediction models published since 2010 were identified in five major research databases. The main outcomes were model performance metrics including AUROC, prediction variables, and level of validation. Risk of bias was assessed using the PROBAST checklist.

Results

Five general surgery studies (15 models) and 10 TKA studies (24 models) were identified. All general surgery and 20 TKA models used statistical approaches; 4 TKA models used machine learning approaches. Risk scores, diagnosis, and procedure types were predominant predictors used. Risk of bias was ranked as moderate in 3/15 and high in 12/15 studies. Discrimination measures were reported in 14/15 and calibration measures in 3/15 studies, with only 4/39 externally validated models (3 general surgery and 1 TKA). Meta-analysis of externally validated models (3 general surgery) suggested the AUROC 95% prediction interval is excellent and ranges between 0.803 and 0.970.

Conclusion

This is the first systematic review assessing quality of risk prediction models for prolonged LOS in general surgery and TKA groups. We showed that these risk prediction models were infrequently externally validated with poor study quality, typically related to poor reporting. Both machine learning and statistical modelling methods, plus the meta-analysis, showed acceptable to good predictive performance, which are encouraging. Moving forward, a focus on quality methods and external validation is needed before clinical application.

Factors associated with prolonged hospitalization of patients with corona virus disease (COVID-19) in Uganda: a retrospective cohort study

INTRODUCTION

Identification of factors predicting prolonged hospitalization of patients with coronavirus disease (COVID-19) guides the planning, care and flow of patients in the COVID-19 Treatment Units (CTUs). We determined the length of hospital stay and factors associated with prolonged hospitalization among patients with COVID-19 at six CTUs in Uganda.

METHODS

We conducted a retrospective cohort study of patients admitted with COVID-19 between January and December 2021 in six CTUs in Uganda. We conducted generalized linear regression models of the binomial family with a log link and robust variance estimation to estimate risk ratios of selected exposure variables and prolonged hospitalization (defined as a hospital stay for 14 days or more). We also conducted negative binomial regression models with robust variance to estimate the rate ratios between selected exposures and hospitalization duration.

RESULTS

Data from 968 participants were analyzed. The median length of hospitalization was 5 (range: 1-89) days. A total of 136/968 (14.1%: 95% confidence interval (CI): 11.9-16.4%) patients had prolonged hospitalization. Hospitalization in a public facility (adjusted risk ratio (ARR) = 2.49, 95% CI: 1.65-3.76), critical COVID-19 severity scores (ARR = 3.24: 95% CI: 1.01-10.42), and malaria co-infection (adjusted incident rate ratio (AIRR) = 0.67: 95% CI: 0.55-0.83) were associated with prolonged hospitalization.

CONCLUSION

One out of seven COVID-19 patients had prolonged hospitalization. Healthcare providers in public health facilities should watch out for unnecessary hospitalization. We encourage screening for possible co-morbidities such as malaria among patients admitted for COVID-19.

Preadmission assessment of extended length of hospital stay with RFECV-ETC and hospital-specific data

Background

Patients who exceed their expected length of stay in the hospital come at a cost to stakeholders in the healthcare sector as bed spaces are limited for new patients, nosocomial infections increase and the outcome for many patients is hampered due to multimorbidity after hospitalization.

Objectives

This paper develops a technique for predicting Extended Length of Hospital Stay (ELOHS) at preadmission and their risk factors using hospital data.

Methods

A total of 91,468 records of patient’s hospital information from a private acute teaching hospital were used for developing a machine learning algorithm relaying on Recursive Feature Elimination with Cross-Validation and Extra Tree Classifier (RFECV-ETC). The study implemented Synthetic Minority Oversampling Technique (SMOTE) and tenfold cross-validation to determine the optimal features for predicting ELOHS while relying on multivariate Logistic Regression (LR) for computing the risk factors and the Relative Risk (RR) of ELOHS at a 95% confidence level.

Results

An estimated 11.54% of the patients have ELOHS, which increases with patient age as patients < 18 years, 18–40 years, 40–65 years and ≥ 65 years, respectively, have 2.57%, 4.33%, 8.1%, and 15.18% ELOHS rates. The RFECV-ETC algorithm predicted preadmission ELOHS to an accuracy of 89.3%. Age is a predominant risk factors of ELOHS with patients who are > 90 years—PAG (> 90) {RR: 1.85 (1.34–2.56), P:  < 0.001} having 6.23% and 23.3%, respectively, higher likelihood of ELOHS than patient 80–90 years old—PAG (80–90) {RR: 1.74 (1.34–2.38), P:  < 0.001} and those 70–80 years old—PAG (70–80) {RR: 1.5 (1.1–2.05), P: 0.011}. Those from admission category—ADC (US1) {RR: 3.64 (3.09–4.28, P:  < 0.001} are 14.8% and 70.5%, respectively, more prone to ELOHS compared to ADC (UC1) {RR: 3.17 (2.82–3.55), P:  < 0.001} and ADC (EMG) {RR: 2.11 (1.93–2.31), P:  < 0.001}. Patients from SES (low) {RR: 1.45 (1.24–1.71), P:  < 0.001)} are 13.3% and 45% more susceptible to those from SES (middle) and SES (high). Admission type (ADT) such as AS2, M2, NEWS, S2 and others {RR: 1.37–2.77 (1.25–6.19), P:  < 0.001} also have a high likelihood of contributing to ELOHS while the distance to hospital (DTH) {RR: 0.64–0.75 (0.56–0.82), P:  < 0.001}, Charlson Score (CCI) {RR: 0.31–0.68 (0.22–0.99), P:  < 0.001–0.043} and some VMO specialties {RR: 0.08–0.69 (0.03–0.98), P:  < 0.001–0.035} have limited influence on ELOHS.

Conclusions

Relying on the preadmission assessment of ELOHS helps identify those patients who are susceptible to exceeding their expected length of stay on admission, thus, making it possible to improve patients’ management and outcomes.

Scenarios to Improve the Patient Experience Time in a Tertiary Academic Hospital Using Simulation

Background Shortening the patient experience time (PET) in the emergency department (ED) improves patient quality and satisfaction and reduces mortality and morbidity. Worldwide, the PET target in the ED is ≤ 6 hours; however, the PET awaiting admission to inpatient Medicine at Hamad General Hospital (HGH) in the Qatar State, through ED is currently 15.3±6.4 (mean ± SD) hours. Aim Identify solutions to reduce the PET duration at HGH-ED to the international target. Method A cohort study was done using the Discrete-event simulation (DES) model, utilizing a commercial simulation software package (Process Model Inc., Utah, version 5.2.0). One-year data, January 1, 2019 - December 30, 2019, was analyzed and found to follow seven subprocesses. The duration of each subprocess was recorded, and the average time was calculated. A computer simulation scheme was developed for all the subprocesses of the actual PET duration. The simulated PET was validated, and scenarios were proposed and assessed for each subprocess separately and in combination, A constructed simulatory design using an iterative process involving a construction model. This model starts with the logical organization of submitted tasks based on their cycle times. A subject-matter expert interview was conducted to determine the appropriateness and frequency of actions. The duration of each activity in the considered process was defined using a triangular distribution. Results The actual PET duration for the Medical Department was 15.3±6.4 (mean + SD) hours. The three most prolonged PET subprocess durations were in the referral to internal medicine, the decision to admit, and finding a free bed; these represent 17.9%, 53.8%, and 16.7% of the PET, respectively. Adding two physicians to each shift, which shortens the subprocess of the decision to admit, reduced the PET duration by 27.5%. Moreover, creating a new admitting team (unit) that takes care of new patients admitted to the ED reduced PET duration by another 12.5%. Combining these two scenarios reduced the average PET duration to only 10.2±0.5 hours. In addition to these scenarios, the PET can be further decreased to six hours by increasing the number of inpatient beds. Conclusions The simulated scenarios indicated that restructuring the medical teams, adding two physicians to each shift, and creating an admissions team dedicated to the ED would reduce the total PET duration to 10.2 hours, Furthermore, PET's further reduction to six hours is predictable by increasing the bed number.

Predictors of Vancomycin-Resistant Enterococcus spp. Intestinal Carriage among High-Risk Patients in University Hospitals in Serbia

The predictors of intestinal carriage of vancomycin-resistant Enterococcus spp. (VRE) among high-risk patients in the counties of the Southeast Europe Region are insufficiently investigated, yet they could be of key importance in infection control. The aim of the study was to identify risk factors associated with fecal VRE colonization among high-risk inpatients in university hospitals in Serbia. The study comprised 268 inpatients from three university hospitals. Data on patient demographics and clinical characteristics, length of hospital stay, therapy, and procedures were obtained from medical records. Chi-squared tests and univariate and multivariate logistic regressions were performed. Compared to the hemodialysis departments, stay in the geriatric departments, ICUs, and haemato-oncology departments increased the risk for VRE colonization 7.6, 5.4, and 5.5 times, respectively. Compared to inpatients who were hospitalized 48 h before stool sampling for VRE isolation, inpatients hospitalized 3–7, 8–15, and longer than 16 days before sampling had 5.0-, 4.7-, and 6.6-fold higher risk for VRE colonization, respectively. The use of cephalosporins and fluoroquinolones increased the risk for VRE colonization by 2.2 and 1.9 times, respectively. The age ≥ 65 years increased the risk for VRE colonization 2.3 times. In comparison to the University Clinical Centre of Serbia, the hospital stays at Zemun and Zvezdara University Medical Centres were identified as a protector factors. The obtained results could be valuable in predicting the fecal VRE colonization status at patient admission and consequent implementation of infection control measures targeting at-risk inpatients where VRE screening is not routinely performed.