scholarly journals LO073: Implementation of an ED atrial fibrillation and atrial flutter pathway decreases ED length of stay

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S55-S55
Author(s):  
D. Barbic ◽  
D.R. Harris ◽  
R. Stenstrom ◽  
C. Dewitt ◽  
J. Marsden ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Length Of Stay ◽  
Case Series ◽  
Primary Objective ◽  
Administrative Database ◽  
Retrospective Case ◽  
Chi Square ◽  
Referral Rates ◽  
Return Rates ◽  
Dependent Samples

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias presenting to the emergency department. A coordinated ED AFF electronic order-set and management pathway was developed in collaboration with cardiologists at our institution. The primary objective of this study was to compare the ED length of stay pre and post pathway implementation. Secondary objectives included comparison of the following outcomes pre and post-pathway (PRE & POST): AFF Clinic referral rates, ED return rates, and mortality. Methods: This was a retrospective case series of patients presenting to our quarternary care ED with AFF pre and post AFF pathway implementation. Cases were identified using an administrative database covering 120 000 annual ED visits. Trained research assistants and the primary investigator extracted data from the electronic medical record. 20% of all charts were double collected to ensure accuracy (k=0.85). Descriptive variables were described using counts, means, medians and confidence intervals. Chi-square statistics of dependent samples were calculated for the primary outcome. Results: We examined 307 cases of AFF presenting to our ED (n=130 PRE; n=177 POST). Demographic variables were similar PRE and POST: mean age (66.0 [95%CI 63.8-68.3] PRE; 65.0 [63.0-67.0] POST), % male (59.2% PRE; 59.3% POST), presenting rhythm (66.2% A.fib [58.0-74.3] A. flutter 29.2% [21.4-37.0] PRE; 61.0% A.fib [53.8-68.1] A. flutter 17.5% [11.9-23.1] POST), and CHADS2VASC score (2.1 [1.8-2.4] PRE; 1.9 [1.7-2.1] POST). The mean ED LOS decreased by 72.5 minutes (95% CI -22.9 to -122.1; P < 0.001). AFF clinic referral rates increased from 16.9% PRE to 25.4% POST (not significant). ED return rates within 30 days for AFF, CHF, major bleeding and CVA were unchanged. 30 day mortality rates were not statistically different (1.5% PRE vs. 2.8% POST). Conclusion: A coordinated ED AFF pathway was associated with a significant reduction in ED LOS without significant changes in ED return rates or mortality.

scholarly journals MP026: Implementation of an ED atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation in patients not previously on these medications

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S75-S75
Author(s):  
D. Barbic ◽  
D.R. Harris ◽  
R. Stenstrom ◽  
E. Grafstein ◽  
J. Marsden ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Case Series ◽  
Primary Objective ◽  
Administrative Database ◽  
Retrospective Case ◽  
Chi Square ◽  
Referral Rates ◽  
Return Rates ◽  
Atrial Fibrillation And Flutter ◽  
Dependent Samples

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias presenting to the emergency department. Without anticoagulation, AFF increases stroke risk; individuals with paroxysmal AFF have a similar prognosis. A coordinated ED AFF electronic order-set and management pathway was developed at our institution. The primary objective of this study was to measure rates of appropriate anticoagulation (AAC) on discharge from the ED for patients presenting with AFF not previously on antithrombotic or anticoagulant medications. Secondary objectives included comparison of the following outcomes pre and post-pathway (PRE & POST): AFF Clinic referral rates, ED return rates, and mortality. Methods: This was a retrospective case series of patients presenting to our quarternary care ED with AFF pre and post AFF pathway implementation. Cases were identified using an administrative database covering 120 000 annual ED visits. Trained research assistants and the primary investigator extracted data from the electronic medical record. 20% of all charts were double collected to ensure accuracy (k=0.85). Descriptive variables were described using counts, means, medians and confidence intervals. Chi-square statistics of dependent samples were calculated for the primary outcome. Results: We examined 307 cases of AFF presenting to our ED (n=130 PRE; n=177 POST). Demographic variables were similar PRE and POST: mean age (66.0 [95%CI 63.8-68.3] PRE; 65.0 [63.0-67.0] POST), % male (59.2% PRE; 59.3% POST), presenting rhythm (66.2% A.fib [58.0-74.3] A. flutter 29.2% [21.4-37.0] PRE; 61.0% A.fib [53.8-68.1] A. flutter 17.5% [11.9-23.1] POST), and CHADS2VASC score (2.1 [1.8-2.4] PRE; 1.9 [1.7-2.1] POST). The rate of AAC rose from 39.1% PRE to 77.8% POST (P < 0.01). AFF clinic referral rates increased from 16.9% PRE to 25.4% POST (not significant). ED return rates within 30 days for AFF, CHF, major bleeding and CVA were unchanged. 30 day mortality rates were not statistically different (1.5% PRE vs. 2.8% POST). Conclusion: The implementation of a coordinated ED AFF pathway was associated with significant improvements in the proportion of patients discharged with appropriate anticoagulation who had not previously been on antithrombotic or anticoagulant medications. ED return rates and mortality did not change significantly.

Preoperative CHA2DS2-VASc Score Predicts Postoperative Atrial Fibrillation after Lobectomy

2018 ◽  
Vol 67 (02) ◽  
pp. 125-130 ◽  
Author(s):  
Charles Lee ◽  
David Strauss ◽  
Lauren Stone ◽  
Jill Stoltzfus ◽  
Matthew Puc ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Nonsmall Cell Lung Cancer ◽  
Postoperative Atrial Fibrillation ◽  
Multivariable Logistic Regression Analysis ◽  
Cutoff Score ◽  
Pulmonary Lobectomy ◽  
Retrospective Case ◽  
Chi Square ◽  
Significant Independent Predictor ◽  
Increased Risk

Background Postoperative atrial fibrillation (POAF) affects 10 to 20% of noncardiac thoracic surgeries and increases patient morbidity and costs. The purpose of this study is to determine if preoperative CHA2DS2-VASc score can predict POAF after pulmonary lobectomy for nonsmall cell lung cancer. Methods Patients with complete CHA2DS2-VASc data who underwent lobectomies from January 2007 to January 2016 at a single institution were analyzed in a retrospective case–control study using a prospective database. An independent samples t-test was used to compare the mean CHA2DS2-VASc scores of POAF and non-POAF groups. A multivariable logistic regression analysis (MVA) evaluated the independent contribution of variables of the CHA2DS2-VASc score in predicting POAF. Chi-square test with univariate odds ratios (ORs) was used to determine a statistically significant cutoff score for predicting POAF. Results Of 525 total patients, 82 (15.6%) developed POAF (mean CHA2DS2-VASc score: 2.7) and 443 (84.4%) did not develop POAF (mean score: 2.3). Mean difference between these groups was significant at 0.43 (p = 0.01; 95% confidence interval [CI]: 0.09–0.76). In the MVA, significant predictors of POAF were age 65 to 74 years (adjusted OR [aOR] = 2.45; 95% CI: 1.31–4.70; p = 0.006) and age ≥75 years (aOR = 3.11; 95% CI: 1.62–5.95; p = 0.0006). Patients with CHA2DS2-VASc scores ≥5 had significantly increased OR for POAF (OR = 2.59; 95% CI: 1.22–5.50). Conclusions Preoperatively calculated CHA2DS2-VASc score can predict POAF in patients undergoing pulmonary lobectomy. Age is the most statistically significant independent predictor, and patients with scores ≥5 have significantly increased risk. Trials for POAF prophylaxis should target this population.

Efficacy, Outcomes, and Alignment Following Isolated Fibular Sesamoidectomy via a Plantar Approach

2019 ◽  
Vol 40 (12) ◽  
pp. 1375-1381 ◽  
Author(s):  
Samuel E. Ford ◽  
Christopher R. Adair ◽  
Bruce E. Cohen ◽  
W. Hodges Davis ◽  
J. Kent Ellington ◽  
...  
Keyword(s):  
Pain Relief ◽  
Functional Outcome ◽  
Case Series ◽  
Office Visit ◽  
Administrative Database ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Tertiary Referral Center ◽  
Flexion Strength

Background: The purpose of this study was to evaluate patients for intermediate-term pain relief, functional outcome, and changes in hallux alignment following isolated, complete fibular sesamoidectomy via a plantar approach for sesamoid-related pain recalcitrant to conservative treatment. Methods: A retrospective query of a tertiary referral center administrative database was performed using the Current Procedural Terminology code 28135 for sesamoidectomy between 2005 and 2016. Patients who underwent an isolated fibular sesamoidectomy were identified and contacted to return for an office visit. The primary outcome measure was change in visual analog pain score at final follow-up. Secondary measures included satisfaction, hallux flexion strength, hallux alignment, pedobarographic assessment, and postoperative functional outcome scores. Patients who met the 2-year clinical or radiographic follow-up minimum were included. Ninety fibular sesamoidectomies were identified. Thirty-six sesamoidectomies met inclusion criteria (median 60-month follow-up). The average patient was 36 years old and underwent sesamoidectomy 1.1 years after initial diagnosis. Results: Median visual analog scale scores improved 5 (6 to 1) points at final follow-up ( P < .001). Final postoperative mean hallux valgus angle did not differ from preoperative values (10.5 degrees/8.5 degrees, P = .12); similarly, the intermetatarsal angle did not differ (8.0 degrees/7.9 degrees, P = .53). Eighty-eight percent of patients would have surgery again and 70% were “very satisfied” with their result. Hallux flexion strength (mean 14.7 pounds) did not differ relative to the contralateral foot (mean 16.1 pounds) ( P = .23). Among the full 92 case cohort, 3 patients underwent 4 known reoperations. Conclusion: Fibular sesamoidectomy effectively provided pain relief (median 5-year follow-up) for patients with sesamoid pathology without affecting hallux alignment. Level of Evidence: Level IV, retrospective case series.

scholarly journals TP6.1.2 Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Kirsten Boyd ◽  
Nicholas Bradley ◽  
Elizabeth Cannings ◽  
Himanshu Wadhawan ◽  
Michael Wilson ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Open Cholecystectomy ◽  
Bile Leak ◽  
Case Series ◽  
Retrospective Case ◽  
Open Conversion ◽  
Subtotal Cholecystectomy ◽  
Change In Practice ◽  
Group A ◽  
Group B

Abstract Aim Laparoscopic subtotal cholecystectomy is a safe strategy to avoid bile duct injury when a critical view of safety cannot be obtained. This technique may result in fewer open conversions and was introduced in our DGH in 2013. This study describes the change in practice at our centre following introduction of subtotal cholecystectomy. Method Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date; 2009-2012 (Group A) and 2013-2019 (Group B). These groups represent pre- (Group A) and post- (Group B) introduction of laparoscopic subtotal cholecystectomy. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic sub-total and lap-converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. Results There were 4248 cases; 1387 in Group A, and 2861 in Group B. The rate of open conversions was higher in Group A than Group B (4.7% vs. 2.8%, p = 0.003). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.3% vs. 92.8%, p = 0.013). In the subtotal group (n = 114, 3.9% of Group B); 14 (12.3%) patients had bile leak requiring ERCP, 6 (5.3%) underwent re-laparoscopy for inadequate biliary drainage, and median LOS was 2 days. Conclusion Laparoscopic subtotal cholecystectomy has proven to be a safe technique at our centre, reducing the rate of open conversion and length of stay, with a low rate of reintervention for bile leak.

scholarly journals Clinical Outcomes With Continuous Nafcillin Infusions in Children

2017 ◽  
Vol 22 (4) ◽  
pp. 261-265
Author(s):  
Chad A. Knoderer ◽  
Lauren C. Karmire ◽  
Kristen R. Nichols
Keyword(s):  
Length Of Stay ◽  
Clinical Outcomes ◽  
Treatment Success ◽  
Tertiary Care ◽  
Primary Objective ◽  
Retrospective Case ◽  
Lengths Of Stay ◽  
Pediatric Study ◽  
Retrospective Case Study ◽  
Microbiological Cure

OBJECTIVES The primary objective of this study was to describe the clinical outcomes of continuous nafcillin infusion in pediatric patients. METHODS This was a retrospective case study performed at a freestanding, tertiary care children's hospital. Subjects were included if they were at least 30 days old and had received more than 1 dose of nafcillin by continuous infusion (CI) between January 1, 2009, and December 31, 2012. Clinical and microbiological data were extracted from the medical record. Documented adverse events potentially associated with nafcillin were recorded. Treatment success was defined by any one of the following outcomes without the presence of conflicting data: microbiological cure, prescriber-documented treatment success, or normalization of abnormal clinical or laboratory parameters. RESULTS Forty subjects with a median of 9 (interquartile range [IQR], 2.3–12) years of age were included. Median length of stay (in days) for all indications observed was 7 (IQR, 5–21.8) days. Extended lengths of stay, indicated by ≥10 days, were more common in cases of endocarditis, skin and soft tissue infection, and bacteremia. Adverse reactions were documented in 20% of patients. CONCLUSIONS In this pediatric study, overall treatment success was observed in 92.5% of patients. Microbiological cure was documented in 91.3% of patients by using follow-up cultures. Length of stay may be positively impacted by CI nafcillin. Continuously infused nafcillin appears to be an acceptable alternative to intermittently infused nafcillin in children. Further studies are needed to address the question of whether clinical outcomes of CI nafcillin are superior to those of conventional infusion.

scholarly journals Minimally Invasive Lateral Corpectomy of the Thoracolumbar Spine: A Case Series of 20 Patients

2020 ◽  
pp. 219256822094529
Author(s):  
Hai Le ◽  
Joshua Barber ◽  
Eileen Phan ◽  
Richard K. Hurley ◽  
Yashar Javidan
Keyword(s):  
Length Of Stay ◽  
Minimally Invasive ◽  
Thoracolumbar Spine ◽  
Case Series ◽  
Retroperitoneal Approach ◽  
Adjacent Segment ◽  
Retrospective Case ◽  
Spinal Reconstruction ◽  
Retrospective Case Series ◽  
Estimated Blood Loss

Study Design: Retrospective case series. Objective: To report our experience with corpectomy of the thoracolumbar (TL) spine through a minimally invasive lateral retropleural or retroperitoneal approach. Methods: This is a retrospective case series of 20 consecutive patients who underwent minimally invasive TL corpectomy and spinal reconstruction. Electronic medical records were reviewed for demographic, operative, and clinical outcome data. Results: Between 2015 and 2019, 20 consecutive cases of minimally invasive TL corpectomy were performed, comprising 12 men (60%) and 8 women (40%) with a mean age of 54.3 years. Indications for surgery were infection (n = 6, 30%), metastatic disease (n = 2, 10%), fracture (n = 6, 30%), and calcified disc herniation (n = 6, 30%). Partial and complete corpectomy was performed in 5 patients (25%) and 15 patients (75%), respectively. Mean operative time and estimated blood loss was 276.2 minutes and 558.4 mL, respectively. Mean length of stay from admission and surgery were 14.6 and 11.4 days, respectively. Mean length of stay from surgery for elective cases was 4.2 days. Mean follow-up time was 330.4 days. Visual analogue scale score improved from 7.7 to 4.5 ( P < .01). There were a total of 3 postoperative complications in 2 patients, including 1 mortality for urosepsis. One patient had revision spinal surgery for adjacent segment disease. Conclusions: Corpectomy and reconstruction of the TL spine is feasible and safe using a minimally invasive lateral retropleural or retroperitoneal approach. Since this is a relatively new technique, more studies are needed to compare the short- and long-term radiographic and clinical outcomes between minimally invasive versus open corpectomy of the TL spine.

The Role of Endoscopic Sinus Surgery in Children Undergoing External Drainage of Non-Medial Subperiosteal Orbital Abscess

2020 ◽  
pp. 194589242095379
Author(s):  
Stephen R. Chorney ◽  
Adva Buzi ◽  
Mark D. Rizzi
Keyword(s):  
Endoscopic Sinus Surgery ◽  
Case Series ◽  
Primary Objective ◽  
Acute Sinusitis ◽  
Sinus Surgery ◽  
Symptom Duration ◽  
Retrospective Case ◽  
Orbital Abscess ◽  
Significant Difference ◽  
Subperiosteal Orbital Abscess

Background The extent of surgery required in the management of pediatric non-medial subperiosteal orbital abscess (SPOA) due to medically refractory complicated acute sinusitis is unknown. Objectives The primary objective is to compare operative outcomes of children treated with combined endoscopic sinus surgery (ESS) and external orbital drainage (EOD) versus those treated with EOD alone. Methods Retrospective case series from a tertiary children’s hospital analyzing outcomes in children requiring surgical management for acute sinusitis complicated by non-medial SPOA between November 2007 and September 2019. Results Sixteen children with a mean age of 9.4 years (95% CI: 7.3–11.4) met inclusion. Eleven (68.8%) underwent combined EOD and ESS, while five (31.2%) underwent EOD alone. Groups were similar in age, symptom duration, white blood cell count, C-reactive protein level, intraocular pressure, Lund-Mackay score, and abscess volume. There was no significant difference in median length of stay between patients treated with a combined approach versus those treated by EOD alone. Cultures identified non-beta-hemolytic Streptococcus species in 56.3% of patients, with Streptococcus intermedius representing the most common organism in 37.5%. In one case, ESS identified a pathogen not acquired via concomitant EOD, which did influence management. No child required a subsequent surgical procedure and there were no operative complications. Conclusions The addition of ESS in the management of pediatric non-medial SPOA was not associated with a statistically different duration of hospitalization. Cultures from concomitant ESS rarely aided in diagnosis or antibiotic therapy. Further study should delineate the indications for ESS in these cases.

scholarly journals Enhanced recovery after anterior resection: earlier leak diagnosis and low mortality in a case series

2019 ◽  
Vol 101 (7) ◽  
pp. 495-500
Author(s):  
N D’Souza ◽  
PD Robinson ◽  
G Branagan ◽  
H Chave
Keyword(s):  
Intensive Care ◽  
Length Of Stay ◽  
Anastomotic Leak ◽  
Anterior Resection ◽  
Enhanced Recovery ◽  
Treatment Options ◽  
Case Series ◽  
Admission Rate ◽  
District General Hospital ◽  
Chi Square

Introduction Early detection and treatment of anastomotic leak may mitigate its consequences. Within an enhanced recovery setting, the subtle signs of a leak can be more apparent. There are multiple treatment options for anastomotic leak following anterior resection. This study aimed to determine when leaks are diagnosed in enhanced recovery, and whether the choice of intervention affects outcomes. Materials and methods We conducted a retrospective study of a prospectively maintained database of complications of anterior resections for rectal cancer in a district general hospital in the UK. Data were extracted on day of leak diagnosis, length of stay, intensive care admission, mortality and ileostomy reversal rate. Statistical analysis was performed using Student’s t, Mann–Whitney U and chi square tests. Results A total of 323 patients underwent anterior resection for colorectal cancer between 1 January 2007 and 1 October 2015. The leak rate was 10.8% (35/323). Patients were diagnosed in hospital with leaks on median day 4 compared with day 11 for patients diagnosed with leaks after readmission from home (P < 0.001). Defunctioned patients diagnosed with a leak had a longer median length of stay (24 vs 18.0 days, P = 0.31) but were more frequently managed non-operatively (100% vs 19.0%, P < 0.001) and had a lower admission rate to intensive care (9.5% vs 42.9%, P = 0.02) than patients who were not defunctioned at time of resection. Overall mortality from anastomotic leak was 2.9% (1/35). Ileostomies were reversed in 73.5% of patients (25/34). Discussion Enhanced recovery enables early diagnosis of leaks following anterior resection. Defunctioning of patients with anastomotic leak lowers mortality.

scholarly journals Characteristics, complications and outcomes among 1549 patients hospitalised with COVID-19 in a secondary hospital in Madrid, Spain: a retrospective case series study

BMJ Open ◽  
2020 ◽  
Vol 10 (11) ◽  
pp. e042398
Author(s):  
Eva Jiménez ◽  
Mario Fontán-Vela ◽  
Jorge Valencia ◽  
Ines Fernandez-Jimenez ◽  
Elena Alba Álvaro-Alonso ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Case Series ◽  
Case Fatality ◽  
Median Length ◽  
Retrospective Case ◽  
Retrospective Case Series ◽  
Hospitalised Patients ◽  
Number Of Patients ◽  
Case Series Study ◽  
Secondary Hospital

ObjectivesTo describe demographic, clinical, radiological and laboratory characteristics, as well as outcomes, of patients admitted for COVID-19 in a secondary hospital.Design and settingRetrospective case series of sequentially hospitalised patients with confirmed SARS-CoV-2, at Infanta Leonor University Hospital (ILUH) in Madrid, Spain.ParticipantsAll patients attended at ILUH testing positive to reverse transcriptase-PCR on nasopharyngeal swabs and diagnosed with COVID-19 between 1 March 2020 and 28 May 2020.ResultsA total of 1549 COVID-19 cases were included (median age 69 years (IQR 55.0–81.0), 57.5% men). 78.2% had at least one underlying comorbidity, the most frequent was hypertension (55.8%). Most frequent symptoms at presentation were fever (75.3%), cough (65.7%) and dyspnoea (58.1%). 81 (5.8%) patients were admitted to the intensive care unit (ICU) (median age 62 years (IQR 51–71); 74.1% men; median length of stay 9 days (IQR 5–19)) 82.7% of them needed invasive ventilation support. 1393 patients had an outcome at the end of the study period (case fatality ratio: 21.2% (296/1393)). The independent factors associated with fatality (OR; 95% CI): age (1.07; 1.06 to 1.09), male sex (2.86; 1.85 to 4.50), neurological disease (1.93; 1.19 to 3.13), chronic kidney disease (2.83; 1.40 to 5.71) and neoplasia (4.29; 2.40 to 7.67). The percentage of hospital beds occupied with COVID-19 almost doubled (702/361), with the number of patients in ICU quadrupling its capacity (32/8). Median length of stay was 9 days (IQR 6–14).ConclusionsThis study provides clinical characteristics, complications and outcomes of patients with COVID-19 admitted to a European secondary hospital. Fatal outcomes were similar to those reported by hospitals with a higher level of complexity.

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