Establishing an alternative accommodation for stable hospitalised antepartum patients: barriers and challenges

BackgroundPatients in remote communities who risk premature delivery require transfer to a tertiary care centre for obstetric and neonatal care. Following stabilisation, many patients are candidates for outpatient management but cannot be discharged to their home communities due to lack of neonatal intensive care unit (ICU) support.ProblemWithout outpatient accommodation proximal to neonatal ICU, these patients face prolonged hospitalisation—an expensive option with medical, social and psychological consequences. Therefore, we sought to establish an alternative accommodation for out-of-town stable antepartum patients.MethodsQuality Improvement approaches were used to identify process strengths and opportunities for improvement on the antepartum ward in a tertiary care centre. Physician and patient surveys informed outpatient accommodation programme development by a multidisciplinary team. The intervention was implemented using a plan–do–study–act cycle. Barriers to patient discharge and enrolment in the programme were analysed by completing thematic and strengths–weaknesses–opportunities–threats (SWOT) analysis.ResultsPhysicians broadly supported safe outpatient management, whereas patients were hesitant to leave the hospital even when physicians assured safety. Our alternative accommodation was pre-existing and cost-effective, however, we encountered significant barriers. The physical space limited family visits and social interaction, lacked desired amenities,and the programme proved inconvenient to patients. The thematic and SWOT analysis identified aspects of the intervention which can be optimised to develop future actionable strategies.ConclusionThe utilisation of acute care beds is costly for the healthcare system and must be allocated judiciously. Patient needs, experience and health system barriers need to be considered when establishing alternative outpatient accommodations and strategies for stable antepartum patients.

Automated ICD Coding Using Deep Learning

ICD (international classification of diseases) is a system developed by the WHO in which every unique diagnosis and procedure has a unique code. It provides a standardized way to represent medical information and makes it sharable and comparable across different hospitals and countries. Currently, the task of assigning ICD codes to patient discharge summaries is performed manually by medical coders. Manual coding is costly, time consuming, and inefficient for huge data. So, the healthcare industry requires automated solutions to make the medical coding more efficient, accurate, and consistent. In this study, the automated ICD-9 coding is approached as a multi-label text classification problem. A deep learning system is presented to assign ICD-9 codes automatically to the patient discharge summaries. Convolutional neural networks and word2vec model are combined to automatically extract features from the input text. The best model has achieved 83.28% accuracy. The results of this research prove the usability of deep learning for multi-label text classification and medical coding.

An Interdisciplinary Dashboard to Streamline Medication Processing at Patient Discharge: A Quality Improvement Initiative

ABSTRACT Introduction The purpose of this quality improvement project was to develop and evaluate the use of an electronic medication request dashboard to reduce the amount of time required for medication processing and decrease time lost to workflow interruptions during patient discharge. Delayed discharges are associated with increased health care costs and adverse patient outcomes. Processing of medication requests at discharge contributes to these delays and to workflow interruptions for nursing and pharmacy staff at the project site. Electronic dashboards have been successfully implemented in multiple medical settings to streamline patient processing and enhance communication. Materials and Methods The Human Protections Office at Carl R. Darnall Army Medical Center (Fort Hood, TX) reviewed and approved the project with a non-human research determination. A multi-disciplinary workgroup with representatives from nursing, pharmacy, and health information technology (HIT) was formed to develop the dashboard. Based on a logic flow diagram of the desired communication, HIT created a medication request form and status dashboard using SharePoint and Nintex workflows. The dashboard was implemented for a 30-day pilot on a 25-bed medical/surgical nursing unit. The time required for medication processing, the time from discharge order to patient exit, the number of phone calls between nursing and pharmacy, and the usability of the medication request process were measured before and after implementation. The results were analyzed with descriptive statistics and evaluated for statistical significance with a P value ≤.05. Results With implementation of the dashboard, the average medication processing time decreased from 125 minutes to 48 minutes (P < .0001), and the average patient discharge time decreased from 137 minutes to 117 minutes (P = .002). The usability score of the medication request process increased from 40 to 87 for nursing (P < .0001) and from 62 to 85 for pharmacy (P = .003). The total number of voice calls between nursing and pharmacy decreased from 1,115 to 434, while the total time on voice calls decreased from 33 hours and 50 minutes to 13 hours and 19 minutes (P < .0001). Conclusions The electronic dashboard is an effective method to enhance interdisciplinary communication during patient discharge and significantly reduces medication processing times. However, despite the medication processing time decreasing by over an hour, the discharge time only decreased by 20 minutes. Additional investigation is needed to evaluate other contributors to delayed discharge. A key limitation of this study was the convenience sampling used over a 30-day pilot on a single unit. The process has since been adopted by the entire hospital, and additional analysis could better reveal the impact to the organization. This communication system shows high usability and reduces phone call interruptions for both nursing and pharmacy staff. Additionally, this technology could easily be applied to other communication pathways or request processes across military medicine.

Clinical and Organizational Impacts of Medical Ordering Settings on Patient Pathway and Community Pharmacy Dispensing Process: The Prospective ORDHOSPIVILLE Study

During the dispensing process of medical orders (MOs), community pharmacists (CPs) can manage drug-related problems (DRPs) by performing pharmacist interventions (PIs). There is little evidence that the PI rate is higher with MOs from hospitals (MOHs) than ambulatory (MOAs) settings, and their impact on the patient and community pharmacy is unknown. The primary objective of this study was to compare the MOH and MOA PI rates. The secondary objective was to describe PIs and their clinical and organizational impacts on patient and community pharmacy workflow. A total of 120 CPs participated in a prospective study. Each CP included 10 MOH and 10 MOA between January and June 2020. DRP and PI description and clinical and organizational impacts between MOH and MOA were assessed and compared. We analyzed 2325 MOs. PIs were significantly more frequent in MOH than in MOA (9.7% versus 4.7%; p < 0.001). The most reported PI was the difficulty of contacting hospital prescribers (n = 45; 52.2%). MOHs were associated with a longer dispensing process time and a greater impact on patient pathway and community pharmacy workflow than MOAs. Lack of communication between hospital and primary care settings partly explains the results. Implementation of clinical pharmacy activities at patient discharge could alleviate these impacts.

Outcomes and Treatment Costs of Skilled Nursing Facility Patients with Pressure Injuries and Malnutrition

Skilled nursing facilities (SNF) provide care for individuals requiring skilled care while transitioning to a more permanent residence post hospitalization. This analysis shows that diagnosed malnutrition and pressure injuries (PI) adversely impact SNF patients’ health and recovery. Length of SNF stay, total charges, and discharge disposition were analyzed using SNF claims from 2016-2020 Centers for Medicare & Medicaid Services (CMS) Standard Analytical File databases. An average of 4.5% SNF patients had diagnosed PIs, and 4.9% had diagnosed malnutrition. Patients with diagnosed malnutrition were more likely to have PIs than patients without diagnosed malnutrition (11.9% vs 4.1%). Patients with PIs had higher charges ($12,304 vs. $10,937), were less likely to be discharged home (11.1% vs 18.9%), and more likely to be discharged to a hospital (15.8% vs 11.0%) or deceased (2.8% vs 1.6%). Patients with diagnosed malnutrition displayed a similar pattern for charges ($11,587 vs $10,969), and discharge to home (14.5% vs 18.8%), hospital (13.5 vs 11.1%) or deceased (2.8% vs 1.6%). Length of SNF stay did not differ between patients with and without PIs (18.5 vs 18.6) and was slightly shorter for patients with diagnosed malnutrition (17.3 vs 18.9). While higher probability of rehospitalization or death could impact these results, drivers behind these differences need further investigation. Because malnourished patients were more likely to have PIs and both PI and malnutrition are associated with poorer patient discharge outcomes and higher costs, efforts to identify malnutrition and implement proper nutrition interventions should be prioritized as part of SNF quality improvement initiatives.

Determining the Impact of Platelet-rich Plasma Therapy on Short-‎term Postoperative Outcomes of Pediatric ‎Tonsillectomy Patients in Egypt

Background: Tonsillectomy is considered one of the most common major operations performed in pediatric population. Unfortunately, tonsillectomy is often associated with severe pain that may delay the patient discharge and influence his ability to return to the normal daily activities together with a 2–4% risk of hemorrhage. Among promising healing promoting agents is Platelet-rich plasma (PRP). It is considered as a potential adjuvant therapy improving the healing of surgical wounds and contains multiple growth and healing factors that are released upon their activation. Methods: This was a prospective randomized controlled study carried on forty patients who underwent tonsillectomy alone or adenotonsillectomy. In each patient, PRP was used on one side " test side " and other side was used as a control. The test side was randomly allocated in all patients, so the results will be of the 40 patients, total sides 80, (test side 40; 20 right side and 20 left side). Results: Our results revealed that mucosal healing was noted to be better in PRP treated side, particularly on 5th and 10th post-operative day, with documented less incidence of secondary post-operative hemorrhage. Pain scores were less on the PRP treated side through the post-operative period, but were statistically significant only on the 5th day postoperative. Conclusions: The preliminary results from this study, supported by literature, have revealed that PRP was beneficial in the amelioration of post-tonsillectomy pain, improvement of healing and bleeding risk in pediatric tonsillectomy patients.

Implementation of Electronic Patient Discharge: A Successful Strategy to Increase Hospital Bed Capacity During the COVID-19 Pandemic

Background: The ongoing COVID-19 pandemic increased the need for inpatient beds, indicating the need for hospitals to increase the efficiency of beds. Objectives: This study aimed to increase hospital bed capacity using the implementation of Electronic Patient Discharge (EPD). Methods: This qualitative-quantitative study was conducted in a tertiary care hospital using the pre-and post-intervention designs, and the main outcome was patient discharge time. By applying the Six Sigma model, including definition, measurement, analysis, improvement, and control, the patient discharge process was assessed and improved by some interventions such as EPD. All hospitalized patients with COVID-19 from 21 March 2020 to 22 July 2021 were examined for the post-intervention. In addition, data were collected from the hospital information system (HIS). Results: By the use of EPD, patient discharge time decreased to 47.70% (from 10.19 h to 5.33 h) (P < 0.000). According to the Sigma level, the yield and defects per million opportunities of the discharge process also increased to 55%. Conclusion: Six Sigma methodology can be an effective change management tool to improve discharge time to cover the demand created during pandemics. According to the results of the present study and the obtained saved time, one bed is added to the hospital capacity for every five discharges.

720. Efficacy of Nifurtimox + Eflornithine in the Treatment of African Trypanosomiasis. Systematic Review

Background Sleeping sickness is an infectious disease transmitted mainly by the Trypanosoma Brucei, with the tsetse fly as a vector. The condition has two stages: The hemolymphatic and the meningo-encephalitic stage. The second stage is caused mainly by the Trypanosoma Brucei Gambiense. The treatment of the second stage has changed from melarsoprol, eflornithine, to now nifurtimox-eflornithine (NECT). This systematic review will focus on the efficacy and the toxicity of the medication. Methods We use PRISMA and MOOSE protocol for this review. On figure 1, we detail the methodology used for the extraction of information from the systematic review. To assess the study's bias, we used Cochrane Collaboration’s tool for risk assessment of the clinical trials and the Robins I tool for the observational studies. Results We collected four clinical trials and two observational studies after an extensive search. Three clinical trials showed that NECT was non-inferior to eflornithine with the following cure rates (NECT VS eflornithine): 1) 96.3% vs. 94.1% ; 2) 90.9% vs. 88.9%; 3) 91.6% vs. 96.5%. An additional clinical trial revealed that the proportion of patient discharge from the hospital was 98.4% (619/629); 95% CI [97.1%; 99.1%]). The two observational studies discussed the pharmacovigilance of the drug and toxicity related to NECT. In one study, patients treated with NECT, 589 (86%) experienced at least one adverse effect (AE) during treatment, and 70 (10.2%) experience serious AE. On average, children experienced fewer AEs than adults. In the other study at least one AE was described in 1043 patients (60.1%), and Serious AE was reported in 19 patients (1.1% of treated), leading to nine deaths (case fatality rate of 0.5%). The major limitations of the studies were the lack of blinding because most of them were open-label. Also, there was heterogenicity in the definition of the outcomes in the observational studies. PRISMA Flow Chart Conclusion NECT is not inferior to eflornithine, and the proportion of patients discharged from the hospital alive showed favorable results. The observational studies revealed a high frequency of AE. However, NECT is more convenient and safe than Eflornithine and Melarsoprol. Disclosures All Authors: No reported disclosures