Reducing Extended Hospital Lengths of Stay

In the United States, the costs of health care have become a major burden for the health care system. In order to address this problem, the hospitals of Syracuse, New York, developed programs to provide subacute and complex care. The Subacute programs provided patient transportation services for dialysis and other types of care outside hospitals. They also developed programs for services such as intravenous therapy in nursing homes. The Complex Care Programs, such as intravenous therapy and mental health services, have provided alternatives to extended care in hospitals. During the past five years, utilization of these programs has varied, declining between 2019 and 2022, and then increasing between 2022 and 2024. The programs have avoided the need for 1530 - 2974 patient days in hospitals. The programs saved the Syracuse hospitals approximately $600 per inpatient day. This amounted to savings of $918,000 - $1,784,400 per year. These programs demonstrated how relatively small mechanisms can save large amounts of health care resources.

Comparison of Mortality, Length of Stay, and Hospitalization Costs of Hospitalized COVID-19 Patients with Cardiac and Non-Cardiac Disease

Background: The COVID-19 pandemic has presented unprecedented challenges to global healthcare systems. As the pandemic unfolded, it became evident that certain groups of individuals were at an elevated risk of experiencing severe disease outcomes. Among these high-risk groups, individuals with pre-existing cardiac conditions emerged as particularly vulnerable. Objective: This study aimed to investigate the relationship between the length of stay, mortality, and costs of COVID-19 patients with and without a history of cardiac disease. Design: This retrospective study was conducted in Jam Hospital in Tehran, Iran, from March 21, 2021, to March 21, 2022. All patients with laboratory-confirmed COVID-19 who were hospitalized during this period were included. Results: A total of 500 COVID-19 patients were hospitalized, with 31.6% having a history of cardiac disease and 68.4% without any cardiac disease. Patients with cardiac disease were significantly older (median [range] age, 69.35 [37 - 94] years) compared to non-cardiac patients (54.95 [13 - 97] years) (p Conclusion: Patients with cardiac disease who are hospitalized with COVID-19 have a higher mortality rate, longer hospital stays, greater disease severity, ICU admission, and higher costs. Therefore, improved prevention and management strategies are crucial for these patients.

Correlation of serum albumin level on postoperative day 2 with hospital length of stay in patients undergoing emergency surgery for perforated peptic ulcer

BACKGROUND Perforated peptic ulcer(PPU)is a common emergency surgical condition and a significant cause of morbidity and mortality worldwide.While advances in surgical techniques have improved outcomes for patients with PPU,many factors still affect postoperative hospital stay and overall prognosis.One potential factor is the serum albumin(SA)level,a widely utilized marker of nutritional status that has been associated with length of stay and complications in various surgical procedures.AIM To clarify the correlation of SA level on postoperative day 2 with hospital length of stay(HLOS)in patients undergoing emergency surgery for perforated peptic ulcer(PPU).METHODS We retrospectively collected and analyzed clinical baseline data,including blood routine and SA levels,of patients who underwent emergency PPU surgery and postoperative treatment at the Lingnan Hospital,the Third Affiliated Hospital of Sun Yat-sen University between December 2012 and September 2021.Patients were grouped according to HLOS with 7 d as the cut-off value,and relevant indicators were analyzed using SPSS 26.0.RESULTS Of the 37 patients undergoing emergency surgery for PPU referred to our department,33 had gastric and 4 had duodenal ulcer perforation.The median HLOS was 10 d.There were 8 patients in the≤7-d group(median HLOS:7 d)and 29 patients in the>7-d group(median HLOS:10 d).The≤7-d group had markedly higher SA on postoperative day 2 than the>7-d group(37.7 g/L vs 32.6g/L;P<0.05).The SA level on postoperative day 2 was a protective factor for patients with HLOS>7 d(Odds ratio=0.629,P=0.015).The cut-off of SA on postoperative day 2 was 30.6g/L,with an area under the curve of 0.86 and a negative predictive value of 100%for the prediction of HLOS≤7 d.CONCLUSION The SA level on postoperative day 2 was associated with the HLOS in patients undergoing emergency surgery for PPU.The pre-and post-operative albumin levels should be monitored,and infusion of human SA should be considered in a timely manner.

Effect of dynamic light at the coronary care unit on the length of hospital stay and development of delirium： a retrospective cohort study

Background Disturbed circadian rhythm is a potential cause of delirium and is linked to disorganisation of the circadian rhythmicity. Dynamic light （DL） could reset the circadian rhythm by activation of the suprachiasmatic nucleus to prevent delirium. Evidence regarding the effects of light therapy is predominantly focused on psychiatric disorders and circadian rhythm sleep disorders. In this study, we investi- gated the effect of DL on the total hospital length of stay （LOS） and occurrence of delirium in patients admitted to the Coronary Care Unit （CCU）. Methods This was a retrospective cohort study. Patients older than 18 years, who were hospitalized longer than 12 h at the CCU and had a total hospital LOS for at least 24 h, were included. Patients were assigned to a room with DL （n = 369） or regular lighting condi- tions （n = 379）. DL was administered at the CCU by two ceiling-mounted light panels delivering light with a colour temperature between 2700 and 6500 degrees Kelvin. Reported outcome data were： total hospital LOS, delirium incidence, consultation of a geriatrician and the amount of prescripted antipsychotics. Results Between May 2015 and May 2016, data from 748 patients were collected. Baseline charac- teristics, including risk factors provoking delirium, were equal in both groups. Median total hospital LOS in the DL group was 100.5 （70.8-186.0） and 101.0 （73.0-176.4） h in the control group （P = 0.935）. The incidence of delirium in the DL and control group was 5.4% （20/369） and 5.0% （19/379）, respectively （P = 0.802）. No significant differences between the DL and control group were observed in secon- dary endpoints. Subgroup analysis based on age and CCU LOS also showed no differences. Conclusion Our study suggests exposure to DL as an early single approach does not result in a reduction of total hospital LOS or reduced incidence of delirium. When delirium was diagnosed, it was associated with poor hospital outcome.

Comparison of the Length of Stay and Medical Expenditures among Japanese Hospitals for Type 2 Diabetes Treatments: The Box-Cox Transformation Model under Heteroscedasticity

In this paper, we analyzed length of stay (LOS) in hospitals and medical expenditures for type 2 diabetes patients. LOS was analyzed by the power Box-Cox transformation model when variances differed among hospitals. We proposed a new test and consistent estimator. We rejected the ho-moscedasticity of variances among hospitals, and then analyzed the LOS of 12,666 type 2 diabetes patients hospitalized for regular medical treatments collected from 60 general hospitals in Japan. The variables found to affect LOS were age, number of comorbidities and complications, introduced by another hospital, one-week hospitalization, 2010 revision, specific-hospitalization-period (SHP), and principal diseases E11.5, E11.6 and E11.7. There were surprisingly large differences in ALOS among hospitals even after eliminating the influence of characteristics and conditions of patients. We then analyzed daily medical expenditure (DME) by the ordinary least squares methods. The variables that affected DME were LOS, number of comorbidities and complications, acute hospitalization, hospital’s own outpatient, season, introduced by another hospital, one-week hospitalization, 2010 revision, SHP, time trend, and principal diseases E11.2, E11.4 and E117. The DME did not decrease after the SHP. After eliminating the influences of characteristics and conditions of patients, the differences among hospitals were relatively small, 12% of the overall average. LOS is the main determinant of medical expenditures, and new incentives to reduce LOS are needed to control Japanese medical expenditures. Since at least 99% of patients require medical care after leaving the hospital, systems that take proper care of patients for long periods of time after hospitalization are absolutely necessary for efficient treatment of diabetes.

Did the Revision of the Japanese Medical Payment System Work Properly?—An Analysis of Averages and Variances of Length of Hospital Stay for Type 2 Diabetes Patients by Individual Hospital

We evaluated the effects of the 2010 revision of the medical payment system on the length of stay (LOS). In this analysis, we assessed not only the average length of stay (ALOS), but also variance of LOS at individual hospitals. We used a dataset of 18,641 type 2 diabetes patients collected from 51 general hospitals. The variables found to affect LOS were age, comorbidities, complications, acute hospitalization, introduced by other hospitals, winter, one-week hospitalization, specific hospitalization period, and principal diseases coded E11.5, E11.6 and E11.7. Although the effect was marginal, the 2010 revision did reduce ALOS, and the reduction was larger as ALOS became longer. On the other hand, we did not find that the variance of LOS within hospitals became smaller. The results of the study suggest that new incentives and assistance to hospitals to help them make efficient use of medical information are needed.

Hospital costs, length of stay and prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease

To examined the prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease (IBD) by comparing the diagnostic codes for these procedures in patients with IBD and a control group of patients. METHODSThe National Inpatient Sample database (NIS) is part of the Healthcare Cost and Utilization Project (HCUP), the largest publicly available inpatient healthcare database in the United States. The NIS samples about 20% of discharges from all community hospitals participating in HCUP, representative of more than 95% of the United States population, with approximately 7000000 hospitalizations reported annually. NIS contains data on diagnoses, procedures, demographics, length of stay (LOS), co-morbidities and outcomes. ICD-9-CM diagnostic codes for primary hospitalizations for arthroplasty of the hip or knee with a co-diagnosis of IBD [combining both Crohn’s disease (CD) and ulcerative colitis (UC)] were used to identify study subjects for cost and LOS analysis for NIS from 1999-2012. Statistical analysis: 1: 2 propensity score matching between IBD vs a control group based on following factors: Patient age, gender, race, total co-morbidities, # of procedures, admission type, insurance, income quartiles, and hospital bed size, location and hospital teaching status. Categorical variables were reported as frequency and compared by χ2 tests or Fisher’s exact tests. Individual 1:3 matching was also performed for patients carrying diagnostic codes for CD and for patients with the diagnostic code for UC. After matching, continuous variables were rcompared with Wilcoxon signed rank or Paired T-tests. Binary outcomes were compared with the McNemar’s test. This process was performed for the diagnosis of hip or knee arthroplasty and IBD (CD and UC combined). Prevalence of the primary or secondary diagnostic codes for these procedures in patients with IBD was determined from NIS 2007. RESULTSCosts and mortality were similar for patients with IBD and controls, but LOS was significantly longer for hip arthroplasties patients with IBD, (3.85 +/-2.59 d vs 3.68 +/-2.54 d, respectively, P = 0.009). Costs, LOS and survival from the procedures was similar in patients with CD and UC compared to matched controls. These results are shown in Tables 1-10. The prevalence of hip arthroplasty in patients with IBD was 0.5% in 2007, (170/33783 total patients with diagnostic codes for IBD) and was 0.66% in matched controls (P = 0.0012). The prevalence of knee arthroplasty in patients with IBD was 1.36, (292/21202 IBD patients) and was 2.22% in matched controls (P < 0.0001). CONCLUSIONCosts and mortality rates for hip and knee arthroplasties are the same in patients with IBD and the general population, while a statistical but non-relevant increase in LOS is seen for hip arthroplasties in patients with IBD. Compared to the general population, arthroplasties of the hip and knee are less prevalent in hospitalized patients with IBD.

Malnutrition as a predictor of prolonged length of hospital stay in patients with gynecologic malignancy: A comparative analysis

Objective To explore the consistency of the Patient-generated Subjective Global Assessment(PG-SGA)and Nutritional Risk Screening-2002(NRS-2002)for nutritional evaluation of patients with gynecologic malignancy and their predictive effect on the length of hospital stay(LOS).Methods We recruited 147 hospitalized patients with gynecologic malignancy from Nanfang Hospital in 2017.Their nutritional status was assessed using the PG-SGA and NRS-2002.The consistency between the two assessments was compared via the Kappa test.The relationship between malnutrition and LOS was analyzed using crosstabs and Spearman’s correlation.Results The PG-SGA demonstrated that 66.7%and 54.4%of patients scoring≥2 and≥4 were malnourished,respectively.Furthermore,the NRS-2002 indicated that 55.8%of patients were at nutritional risk.Patients with ovarian cancer had a relatively high incidence of malnutrition.However,this was only significant for patients who scored≥4 in the PG-SGA(P=0.001 and P=0.019 for endometrial carcinoma and cervical cancer,respectively).The PG-SGA and NRS-2002 showed good consistency in evaluating the nutritional status of patients with gynecologic malignancy(0.689,0.643 for PG-SGA score≥2,score≥4 and NRS-2002,respectively).Both the scores of PG-SGA and NRS-2002 were positively correlated with LOS.Furthermore,prolonged LOS was higher in patients with malnutrition than in those with adequate nutrition.Conclusion The PG-SGA and NRS-2002 shared a good consistency in evaluating the nutritional status of patients with gynecologic malignancy.Both assessments could be used as predictors of LOS.

Analysis of Length of Stay (LOS) Data from the Medical Records of Tertiary Care Hospital in Saudi Arabia for Five Diagnosis Related Groups: Application of Cox Prediction Model

Background: One of the main objectives of hospital managements is to control the length of stay (LOS). Successful control of LOS of inpatients will result in reduction in the cost of care, decrease in nosocomial infections, medication side effects, and better management of the limited number of available patients’ beds. The length of stay (LOS) is an important indicator of the efficiency of hospital management by improving the quality of treatment, and increased hospital profit with more efficient bed management. The purpose of this study was to model the distribution of LOS as a function of patient’s age, and the Diagnosis Related Groups (DRG), based on electronic medical records of a large tertiary care hospital. Materials and Methods: Information related to the research subjects were retrieved from a database of patients admitted to King Faisal Specialist Hospital and Research Center hospital in Riyadh, Saudi Arabia between January 2014 and December 2016. Subjects’ confidential information was masked from the investigators. The data analyses were reported visually, descriptively, and analytically using Cox proportional hazard regression model to predict the risk of long-stay when patients’ age and the DRG are considered as antecedent risk factors. Results: Predicting the risk of long stay depends significantly on the age at admission, and the DRG to which a patient belongs to. We demonstrated the validity of the Cox regression model for the available data as the proportionality assumption is shown to be satisfied. Two examples were presented to demonstrate the utility of the Cox model in this regard.

Hospital Length of Stay Reduction: A Long-Term Study

This study evaluated length of stay reduction for adult medicine and adult surgery in the combined hospitals of Syracuse, New York between 1998 and 2016. The study was based on the All Patients Refined Severity of Illness System. Through this approach, it controlled for changes in the degree of illness of hospital populations. The study data indicated that reductions in adult medicine and adult surgery stays in the Syracuse hospitals between 1998 and 2012 reduced the annual number of excess days compared with severity adjusted national averages by 49,000, or an average daily census of 134.2. It appeared that the shift to reimbursement by discharges initiated by Medicare was a major cause of these reductions. The impact of this change was accompanied by length of stay reduction initiatives by the Syracuse hospitals, especially relating to long-term care. Between January-April 2012 and 2016, additional reductions brought the lengths of stay for adult medicine and adult surgery in the combined Syracuse hospitals close to the national average. The study suggested that remaining opportunities for length of stay reductions in Syracuse involved patients with high severity of illness and those discharged to nursing homes.

Reducing Hospital Lengths of Stay: A Five-Year Study

Hospital length of stay reduction is an important mechanism for improving the outcomes and efficiency of care. This study evaluated the impact of length of stay reduction in the hospitals of Syracuse, New York. Between 2015 and 2020, length of stay reduction saved 7106 inpatient days for adult medicine, and 10,605 patient days for adult surgery in the hospitals. At a conservative late stay rate of $600 per day, $4,263,600 was eliminated for adult medicine and $6,363,000 was eliminated for adult surgery between 2015 and 2020. The study data suggested that the numbers of days saved were the greatest for patients with Major and Extreme severity of illness. At the community level, length of stay reduction can support the efforts of health care providers to free inpatient capacity for patients with Coronavirus and other conditions. It can also generate the efficiency needed to reimburse the costs of care.

Reducing Hospital Lengths of Stay in the Epidemic

The need for efficiency has been a major challenge for hospitals in the United States. The efficiency of these providers is directly related to their inpatient lengths of stay. The coronavirus epidemic has challenged the ability of hospitals in the United States to reduce stays and provide efficient care. This study described the impact of the epidemic on inpatient lengths of stay in the hospitals of Syracuse NY between March-November 2020 compared with the same periods in previous years. It demonstrated that, during this period, adult medicine lengths of stay increased by 4.5 percent and adult surgery stays increased by 5 - 6 percent. These increases were not large;however, they challenged the ability of hospitals to provide efficient care at a time when additional capacity was needed to deal with the epidemic. The results of the study suggested that the coronavirus epidemic should not limit the effectiveness of hospital programs that support efficiency and protect needed health care resources at the community level.

No independent associations between physical activity and clinical outcomes among hospitalized patients with moderate to severe COVID-19

Background:Regular physical activity(PA)has been postulated to improve,or at least maintain,immunity across the life span.However,the link between physical(in)activity and coronavirus disease 2019(COVID-19)remains to be established.This small-scale prospective cohort study is nested within a randomized controlled trial aimed to investigate the possible associations between PA levels and clinical outcomes among hospitalized patients with moderate to severe COVID-19.Methods:Hospitalized patients with COVID-19(mean age:54.9 years)were recruited from the Clinical Hospital of the School of Medicine of the University of Sao Paulo(a quaternary referral teaching hospital)and from Ibirapuera Field Hospital,both located in Sao Paulo,Brazil.PA level was assessed using the Baecke Questionnaire of Habitual Physical Activity.The primary outcome was hospital length of stay.The secondary outcomes were mortality,admission to the intensive care unit(ICU),and mechanical ventilation requirement.Results:The median hospital length of stay was 7.0§4.0 days,median§IQR;3.3%of patients died,13.8%were admitted to the ICU,and 8.6%required mechanical ventilation.Adjusted linear regression models showed that PA indices were not associated with hospital length of stay(work index:b=-0.57(95%confidence interval(95%CI):-1.80 to 0.65),p=0.355;sport index:b=0.43(95%CI:-0.94 to 1.80),p=0.536;leisure-time index:b=1.18(95%CI:-0.22 to 2.59),p=0.099;and total activity index:b=0.20(95%CI:-0.48 to 0.87),p=0.563).None of the PA indices were associated with mortality,admission to the ICU,or mechanical ventilation requirement(all p>0.050).Conclusion:Among hospitalized patients with COVID-19,PA did not independently associate with hospital length of stay or any other clinically relevant outcomes.These findings should be interpreted as meaning that,among already hospitalized patients with more severe forms of COVID-19,being active is a potential protective factor likely outweighed by a cluster of comorbidities(e.g.,type 2 diabetes,hypertension,weight excess)and older age,suggesting that the benefit of PA against the worsening of COVID-19 may vary across stages of the disease.

Efficacy of peritoneal drainage in very-low-birth-weight neonates with Bell’s stage II necrotizing enterocolitis:A single-center retrospective study

BACKGROUND Currently,pediatric surgeons are challenged by a lack of consensus on the optimal management strategy(conservative or surgical)for children with Bell’s stage II necrotizing enterocolitis(NEC).AIM To evaluate the clinical efficacy of peritoneal drainage in very-low-birth-weight(VLBW)neonates with modified Bell’s stage II NEC.METHODS This was a retrospective analysis of 102 NEC(modified Bell’s stage II)neonates born with VLBW who were treated at the Fujian Children’s Hospital(Fujian Branch of Shanghai Children’s Medical Center)between January 2017 and January 2020;these included 24 cases in the peritoneal drainage group,36 cases in the exploratory laparotomy group,and 42 cases in the conservative treatment group.RESULTS The general characteristics were comparable in the three groups(P>0.05).Compared with conservative treatment,peritoneal drainage was associated with significantly shorter fasting time,abdominal distension relief time,fecal occult blood(OB)negative conversion time,and reduced hospital length of stay(HLOS)(P<0.05 for all).Despite some advantages of peritoneal drainage over conservative treatment in terms of cure,conversion to laparotomy,intestinal perforation,intestinal stenosis,and abdominal abscess rates,the differences were not statistically significant(P>0.05).Compared to exploratory laparotomy,the fecal OB negative conversion time was significantly shorter in the peritoneal drainage group(P<0.05);similarly,the exploratory laparotomy group showed longer fasting time,abdominal distension relief time,HLOS,and higher complication rate compared to peritoneal drainage group,but the between-group differences were not statistically significant(P>0.05).CONCLUSION Peritoneal drainage,an easy-to-operate procedure,can improve the clinical symptoms of VLBW neonates with Bell’s stage II NEC and help reduce the HLOS.

Recent Developments in Health Care Utilization at the Community Level

Recent developments in health care have changed hospital utilization at the community level. This study provided examples of these changes in the metropolitan area of Syracuse, New York. The study demonstrated that percent differences in discharges between the two time periods for both services changed little. For adult medicine, percent differences ranged between 16.5 and 18.0 percent while percent differences in adult surgery ranged from 23.25 to 24.93 percent. This information suggested that reductions in discharges during the five year period had stabilized. Most of these changes were associated with the movement of patients from inpatient to ambulatory care services. The largest numbers of these patients were associated with orthopedic surgery. They resulted from the movement of these patients who were at low severity of illness to ambulatory care settings. The study also identified increases in hospital lengths of stay for adult medicine and adult surgery between January-September 2019 and 2023 in the Syracuse hospitals. Adult medicine stays increased by 23.6 percent, from 4.84 to 5.98 days. Adult surgery stays increased by 25.5 percent, from 5.41 to 6.79 days.

Red blood cell distribution width levels predict prolonged hospital stay for infants after cardiopulmonary bypass surgery

Background Thered cell distribution width(RDW)is a parameter that reflects the heterogeneity of red blood cell volume and size,and it is commonly used in the diagnosis of anemia in patients.RDW may serve as a predictor of the postoperative prognosis of surgical patients in the intensive care unit.This study evaluated the predictive capability of RDW for outcomes in infants after cardiopulmonary bypass surgery.Methods A retrospective cohort study was conducted at Guangdong Provincial People's Hospital enrolling infants(≤1 year)who underwent cardiac surgery between January 2019 and April 2019.The infants were divided into two groups based on their preoperative RDW levels(<14.5% and≥14.5%).The primary outcome measured was the prolonged hospital stay post-operation.The association between RDW levels and prolonged hospital length of stay was evaluated using multivariate Logistic regression,presenting the adjusted odds ratio with a 95%confidence interval(CI).Additionally,interaction and subgroup analyses were performed to assess the consistency of these correlations.Results A total of 186 infants were included in the study.After adjusting for potential confounders,multivariate logistic regression models demonstrated a significant association between RDW and prolonged length of stay(LOS)in hospital when treated as a continuous variable(change per 1SD,OR:1.50,95%CI:1.06-2.11,P=0.021).Categorizing RDW as a variable revealed that higher RDW levels(≥14.5%)were significantly associated with an increased risk of prolonged LOS compared to lower levels(<14.5%)(OR:9.72,95%CI:2.87-32.91,P<0.001).Receiver operating curves(ROC)analysis showed that RDW levels exhibited relatively higher diagnostic value for predicting prolonged LOS(AUC=0.697,95%CI:0.617-0.776,P<0.05).Stratified analyses further showed that depending on the variable testing,an association between higher RDW levels and prolonged hospital length of stay in different subgroups was observed.Conclusions Elevated RDW levels in infants undergoing cardiac surgery involving cardiopulmonary bypass may signify prolonged recovery periods.

Role of peripheral eosinophilia in acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND Eosinophil counts are a promising guide to systemic steroid administration for chronic obstructive pulmonary disease(COPD).AIM To study the role of peripheral eosinophilia in hospitalized patients with acute exacerbation of COPD(AECOPD).METHODS From January 2014 to May 2017,patients with AECOPD hospitalized in Taipei Tzu Chi Hospital were retrospectively stratified into two groups according to their peripheral eosinophil count:The EOS group(eosinophil count≥2%)and the non-EOS group(eosinophil count<2%).Demographics,comorbidities,laboratory data,steroid use,length of hospital stay,and COPD-related readmissions were compared between the groups.RESULTS A total of 625 patients were recruited,with 176 patients(28.2%)in the EOS group.The EOS group showed a lower prevalence of infection,lower cumulative doses of prednisolone equivalents,shorter length of hospital stay,and higher number of COPD-related readmissions than the non-EOS group.There were significantly linear correlations between eosinophil percentage and number of readmissions and between eosinophil percentage and length of hospital stay P<0.001,and a lower percent-predicted value of forced expiratory volume in one second(FEV1)were associated with shorter time to first COPD-related readmission[adjusted hazard ratio(adj.HR)=1.488,P<0.001;adj.HR=0.985,P<0.001,respectively].CONCLUSION The study findings suggest that the EOS group had the features of a shorter length of hospital stay,and lower doses of systemic steroids,but more frequent readmissions.The EOS group and lower percent-predicted FEV1 values were risk factors for shorter time to first COPD-related readmission.

Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity

BACKGROUND The optimal timing of endoscopic retrograde cholangiopancreatography(ERCP)in acute cholangitis(AC) is uncertain,especially in patients with AC of varying severity.AIM To report whether the timing of ERCP is associated with outcomes in AC patients with different severities.METHODS According to the 2018 Tokyo guidelines,683 patients who met the definite diagnostic criteria for AC were retrospectively identified.The results were first compared between patients receiving ERCP ≤ 24 h and>24 h and then between patients receiving ERCP ≤ 48 h and>48 h.Subgroup analyses were performed in patients with grade Ⅰ,Ⅱ or Ⅲ AC.The primary outcome was 30-d mortality.Secondary outcomes were intensive care unit(ICU) admission rate,length of hospital stay(LOHS) and 30-d readmission rate.RESULTS Taking 24 h as the critical value,compared with ERCP>24 h,malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group(5.2% vs 11.5%).The proportion of cardiovascular dysfunction(11.2% vs 2.6%),respiratory dysfunction(14.2% vs 5.3%),and ICU admission(11.2% vs 4%)in the ERCP ≤ 24 h group was significantly higher,while the LOHS was significantly shorter(median,6 d vs 7 d).Stratified by the severity of AC,higher ICU admission was only observed in grade Ⅲ AC and shorter LOHS was only observed in grade Ⅰ and Ⅱ AC.There were no significant differences in 30-d mortality between groups,either in the overall population or in patients with grade Ⅰ,Ⅱ or Ⅲ AC.With 48 h as the critical value,compared with ERCP>48 h,the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group(81.5% vs 68.3%).The ERCP ≤ 48 h group had significantly lower 30-d mortality(0 vs 1.9%) and shorter LOHS(6 d vs 8 d).Stratified by AC severity,lower 30-d mortality(0 vs 6.1%) and higher ICU admission rates(22.2% vs 10.2%) were only observed in grade Ⅲ AC,and shorter LOHS was only observed in grade I and Ⅱ AC.In the multivariate analysis,cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality.CONCLUSION ERCP ≤ 48 h conferred a survival benefit in patients with grade Ⅲ AC.Early ERCP shortened the LOHS in patients with grade Ⅰ and Ⅱ AC.

Improvement of gastric emptying by enhanced recovery after pancreaticoduodenectomy

BACKGROUND： Enhanced recovery after surgery（ERAS） has improved postoperative outcomes particularly in colorectal surgery. This study aimed to assess compliance with an ERAS protocol and evaluate its effect on postoperative outcomes in patients undergoing pancreaticoduodenectomy. METHODS： Fifty patients who had received conventional peri operative management from 2005 to 2009（conventional group）were compared with 75 patients who had received perioperative care with an ERAS protocol（fast-track group） from 2010 to2014. Mortality, complications, readmissions and length of hospital stay were evaluated and compared in the groups.RESULTS： Compliance with each element of the ERAS pro tocol ranged from 74.7% to 100%. Uneventful patients had a significant higher adherence to the ERAS protocol（87.5% vs40.7%; P〈0.001）. There were no significant differences in de mographics and perioperative characteristics between the two groups. Patients in the fast-track group had a shorter time to remove the nasogastric tube, start liquid diet and solid food pass flatus and stools, and remove drains. No difference was found in mortality, relaparotomy, readmission rates and over all morbidity. However, delayed gastric emptying and length of hospital stay were significantly reduced in the fast-track group. The independent effect of the ERAS protocol in reduc ing delayed gastric emptying and length of hospital stay was confirmed by multivariate analysis.CONCLUSION： ERAS pathway was feasible and safe in improving gastric emptying, yielding an earlier postoperative recovery, and reducing the length of hospital stay.

Safety of Overnight Hospitalization after Transurethral Resection of Prostate

Background: Monopolar transurethral resection of prostate has long been a standard method of managements of benign prostatic hyperplasia. The safe and superior efficacy of transurethral resection of prostate (TURP) always argues strongly for maintaining it as the primary mode of therapy for patients with benign prostatic hyperplasia (BPH). There is a trend toward early catheter removal after transurethral resection of prostate (TURP) even to the extent of performing it as a day case. We explored the safety and feasibility of early catheter removal and discharging the patient without catheter after TURP. Materials and methods: Forty patients who underwent monopolar TURP were included in a prospective study. The decision to remove catheters on the first morning after surgery was based on the color of the catheter effluent, absence of clots, normal vital signs and adequate urine output. Patients who voided successfully were discharged on the same day as catheter removal. Results: Among the forty patients whose catheters were removed on first postoperative day, 38 patients (95%) voided successfully, and were discharged on the same day. However, two out of forty patients (5%) were recatheterized due to urethral discomfort during micturition. The catheter was removed on the next day. Mean overall duration of catheterization was 18.36 hours, and overall length of patient hospitalization was 21.68 hours. Conclusions: Overnight hospitalization and early catheter removal after transurethral prostatectomy are an appropriate, safe and effective way of patient care with minimal morbidity.