Evaluating predictors of successful postoperative day 1 discharge following posterior fossa tumor resection

INTRODUCTION: Current trends in surgical neuro-oncology have shown that early discharges are both safe and feasible with shorter lengths of stay (LOS) associated with fewer thromboembolic complications, less hospital-acquired infections, reduced costs, and greater patient satisfaction. Traditionally, infratentorial tumor resections have been associated with longer LOS and limited data exists evaluating predictors of early discharge in these patients. The objective was to assess patients undergoing posterior fossa craniotomies for tumor resection and identify variables associated with a postoperative day 1 (POD1) discharge and determine any differences in outcomes and readmission rates. METHODS: A retrospective review of posterior fossa craniotomies for tumor resection at our institution was performed from 2011 to 2020. Laser ablations, craniotomies for non-tumoral pathologies, and biopsies were excluded. Complete demographic, clinical, surgical and postoperative data was collected for each patient. RESULTS: 173 patients were identified and 25 (14.5%) were discharged on POD1. Median length of stay was 6 days. The POD1 discharges had significantly better preoperative Karnofsky performance scores (p<0.001) and modified Rankin scores (p=0.002) and less frequently presented emergently (p=0.006) or with preoperative neurologic deficits (p=0.021). No statistically significant difference in 30-day readmissions and rates of PE, UTI, and DVT were found between the POD1 discharge cohort and those discharged later. Univariate logistic regression identified better preoperative functional status, elective admission, and lack of preoperative hydrocephalus as independent predictors of POD1 discharge however only the latter remained significant in the multivariable model (p=0.001). CONCLUSIONS: Discharging patients on POD1 is feasible following posterior fossa tumor resections and does not introduce any significant undue risk or result in higher readmissions. Although we found that the only independent predictor for a longer LOS was preoperative hydrocephalus, larger, prospective studies are needed to confirm these findings.

The Diabetes Transition of Hospital Care (DiaTOHC) Pilot Study: A Randomized Controlled Trial of an Intervention Designed to Reduce Readmission Risk of Adults with Diabetes

Hospital readmission within 30 days of discharge (30-day readmission) is a high-priority quality measure and cost target. The purpose of this study was to explore the feasibility and efficacy of the Diabetes Transition of Hospital Care (DiaTOHC) Program on readmission risk in high-risk adults with diabetes. This was a non-blinded pilot randomized controlled trial (RCT) that compared usual care (UC) to DiaTOHC at a safety-net hospital. The primary outcome was all-cause 30-day readmission. Between 10/16/2017 and 05/30/2019, 115 patients were randomized. In the intention-to-treat (ITT) population, 14 (31.1%) of 45 DiaTOHC subjects and 15 (32.6%) of 46 UC subjects had a 30-day readmission (p=0.88) while 35.6% DiaTOHC and 39.1% UC subjects had a 30-day readmission or ED visit (p=0.72). The Intervention:UC cost ratio was 0.33 (0.13-0.79)95%CI (p&lt;0.01). Among the 69 subjects with baseline HbA1c &gt;7.0% (53 mmol/mol), 30-day readmission rates were 23.5% (DiaTOHC) and 31.4% (UC, p=0.46) and composite 30-day readmission or ED visit rates were 26.5% (DiaTOHC) and 40.0% (UC, p=0.23). In this subgroup, the Intervention:UC cost ratio was 0.21 (0.08-0.58)95%CI (p=0.002). The DiaTOHC Program is feasible and may decrease combined 30-day readmission/ED visit risk as well as healthcare costs among patients with higher HbA1c levels.

Using Quality Improvement Methodology to Increase Communication of Discharge Criteria on Rounds

OBJECTIVE: Clear communication about discharge criteria with families and the interprofessional team is essential for efficient transitions of care. Our aim was to increase the percentage of pediatric hospital medicine patient- and family-centered rounds (PFCR) that included discharge criteria discussion from a baseline mean of 32% to 75% over 1 year. METHODS: We used the Model for Improvement to conduct a quality improvement initiative at a tertiary pediatric academic medical center. Interventions tested included (1) rationale sharing, (2) PFCR checklist modification, (3) electronic discharge SmartForms, (4) data audit and feedback and (5) discharge criteria standardization. The outcome measure was the percentage of observed PFCR with discharge criteria discussed. Process measure was the percentage of PHM patients with criteria documented. Balancing measures were rounds length, length of stay, and readmission rates. Statistical process control charts assessed the impact of interventions. RESULTS: We observed 700 PFCR (68 baseline PFCR from July to August 2019 and 632 intervention period PFCR from November 2019 to June 2021). At baseline, discharge was discussed during 32% of PFCR. After rationale sharing, checklist modification, and criteria standardization, this increased to 90%, indicating special cause variation. The improvement has been sustained for 10 months. At baseline, there was no centralized location to document discharge criteria. After development of the SmartForm, 21% of patients had criteria documented. After criteria standardization for common diagnoses, this increased to 71%. Rounds length, length of stay, and readmission rates remained unchanged. CONCLUSION: Using quality improvement methodology, we successfully increased verbal discussions of discharge criteria during PFCR without prolonging rounds length.

Outcomes of Patients With Hematologic Malignancies Who Received Inpatient Palliative Care Consultation

PURPOSE: Palliative care (PC) plays an established role in improving outcomes in patients with solid tumors, yet these services are underutilized in hematologic malignancies (HMs). We reviewed records of hospitalized patients with active HM to determine associations between PC consultation and length of stay, intensive care unit stay, 30-day readmission, and 6-month mortality compared with those who were not seen by PC. METHODS: We reviewed all oncology admissions at our institution between 2013 and 2019 and included patients with HM actively on treatment, stratified by those seen by PC to controls not seen by PC. Groups were compared using Wilcoxon rank-sum, chi-square, and Fisher's exact tests on the basis of the type and distribution of data. Multiple logistic regression models with stepwise variable selection methods were used to find predictors of outcomes. RESULTS: Three thousand six hundred fifty-four admissions were reviewed, among which 370 unique patients with HM were included. Among these, 102 (28%) patients saw PC, whereas the remaining 268 were controls with similar comorbidities. When compared with controls, PC consultation was associated with a statistically significant reduction in 30-day readmissions (16% v 27%; P = .024), increased length of stay (11.5 v 6 days; P < .001), increased intensive care unit admission (28% v 9%; P < .001), and increased 6-month mortality (67% v 15%; P < .001). These data were confirmed in multivariable models. CONCLUSION: In this retrospective study, more than two thirds of patients with HM did not receive PC consultation despite having similar comorbidities, suggesting that inpatient PC consultation is underutilized in patients with HM, despite the potential for decreased readmission rates.