Ball, Colleen T.

Abstract Background: Home telemonitoring has been shown to reduce 30-day readmissions patients at high risk for return to the hospital. The reason for this remains unclear. The aim of this study was to explore the association of nurse contact with 30-day hospital readmission in these high risk patients. Methods: This study was a subgroup analysis from a prior randomized control comparing home telemonitoring for readmission for 30 days to usual care at discharge. Patients randomized to the home telemonitoring who had vital signs outside a preset range, triggered an alert flag for the monitoring nurse, which generated a contact to the patient. We compared patients who had at least one nurse contact to those who had none to see if the contact reduced the rate of readmissions in patients being monitored. Results: Of 449 patients, 292 (65.0%) received 1 or more telemonitoring flags. Single variable and multivariable logistic regression models exploring the association of flag type with hospital 30-day readmission did not find any statistically significant associations of telemonitoring flags with hospital 30-day readmission (all unadjusted P≥0.13, all adjusted P≥0.18). Conclusion: While post-hospitalization home telemetry has been shown to reduce 30-day readmission, our subset analysis did not show that the nurse contact was the factor that reduced readmission in these patients. Trial registration: ClinicalTrials.gov identifier: NCT02136186, registration date May 12, 2014.

ObjectiveTo validate a new baseline estimated glomerular filtration rate (NB‐GFR) formula in a cohort of robotic‐assisted partial nephrectomies (RAPN).MethodsNB‐GFR = 35 + preoperative GFR (× 0.65) – 18 (if radical nephrectomy) – age (× 0.25) + 3 (if tumor size >7 cm) – 2 (if diabetes). NB‐GFR was calculated in 464 consecutive RAPN from a single surgeon cohort. 143 patients were excluded secondary to insufficient eGFR follow up. We analyzed NB‐GFR accuracy utilizing the last observed eGFR 3–12 months post RAPN. Categorical variables were summarized with the frequency and percentage of patients. Numerical variables were summarized with the median, 25th percentile, and 75th percentile.ResultsThe mean difference between observed and predicted NB‐GFR was 4.6 ml/min/1.73m2 (95% CI −6.9 to 16.1 ml/min/1.73m2). There was a pattern of higher observed NB‐GFRs being underestimated by the NB‐GFR equation while lower observed NB‐GFRs were overestimated by the NB‐GFR equation. The NB‐GFR formula had a high level of accuracy with 98.8% of predicted NB‐GFRs falling within 30% of the observed NB‐GFR (95% CI 86.8% to 99.5%). The median and interquartile range of the difference between observed and predicted NB‐GFR was 3.9 ml/min/1.73m2 (IQR 0.7 to 8.2 ml/min/1.73m2). The sensitivity, specificity, positive predictive value, and negative predictive value for the ability of predicted NB‐GFR to identify those with an observed NB‐GFR <60 ml/min/1.73m2 after RAPN was 98%, 92%, 88%, and 99%, respectively.ConclusionThe NB‐GFR equation developed with partial and radical nephrectomy cohorts is accurate in predicting post‐operative eGFR 3–12 months following RAPN.

IMPORTANCE: Aggressive fluid resuscitation remains a cornerstone of the Surviving Sepsis Campaign (SSC) guidelines, but there is growing controversy regarding the recommended 30 mL/kg IV fluid dosage. It is contended that, in selected patients, this volume confers an increased risk of volume overload without either concomitant benefit or strong evidence in support of the recommended IV fluid dosage. OBJECTIVES: Assessment of practice patterns and their impact on patient outcomes following the surviving sepsis guidelines for fluid resuscitation. DESIGN: Large, multisite retrospective cohort study. SETTING AND PARTICIPANTS: The retrospective study included all adult patients who presented to the emergency department at one of 19 different Mayo Clinic sites throughout the Midwest, Southeast, and Southwest from August 2018 to November 2020 with suspected sepsis. MAIN OUTCOMES AND MEASURES: Eight-thousand four-hundred fourteen patients suspected to have sepsis were assessed regarding fluid resuscitation and outcomes among patients receiving 30 mL/kg IV fluid dosing compared with patients who did not. Patient demographics and clinical information were collected via electronic health records. Patients were divided into two cohorts: those who received 0–29.9 mL/kg of IV fluid and those who received 30.0+ mL/kg of IV fluid. Statistical analyses were performed to evaluate the impact of fluid dose on in-hospital death, 30-day mortality, ICU admission after diagnosis, dialysis initiation after diagnosis, ventilator use, vasopressor use, as well as ICU and hospital length of stay. RESULTS: We observed lower in-hospital mortality and 30-day mortality risk in the 30+ mL/kg dosing group. Increased fluid dosage did, however, carry a much greater chance of ICU admission. Most patients (72% after propensity score weighting) in our population received less than 30 mL/kg fluid (based on ideal body weight). CONCLUSIONS AND RELEVANCE: IV fluid dosing for sepsis resuscitation greater than 30 mL/kg was associated with decreased risk of in-hospital mortality, 30-day mortality, and reduced risk of requiring mechanical ventilation. Our data does ultimately seem to support the SSC recommendation.

Objectives Palliative Medicine involvement in MICU patients have improved length of stay and mortality, but with varying effects on specific patient decision outcomes, such as, advance care planning. These studies have utilized Palliative Medicine later in the hospital or ICU course, with some evidence showing that earlier involvement resulted in better results. The purpose of this study was to evaluate the benefits of early (within 24 hours) palliative care consultation in medical ICU (MICU) patients to clinical and satisfaction outcomes. Methods An unblinded randomized study performed in the MICU in one academic hospital in the USA. Ninety-one adult patients admitted to MICU received a Palliative care medicine consultation within 24 hours as the intervention. Measurements and results Ninety-one patients admitted to the MICU underwent randomization with 50 patients randomly assigned to receive Palliative Medicine consultation and 41 patients randomly assigned to receive standard-of-care based on predefined criteria. The median satisfaction score was 23 points higher for the patients in the intervention group (P < .001). The median length of MICU stay was 5 days shorter in the intervention group compared to the control group (95% CI; 1 day to 18 days, P = .018). Advance care planning was completed in the hospital for 34% of patients in the intervention arm and 12% of patients in the controls arm (absolute risk difference 22%, 95% CI 4% to 37%, P = .016). Conclusion Early Palliative Medicine consultation within 24 hours of MICU admission showed significant benefits to patients by improving satisfaction and decreasing length of stay. This study provides evidence that Palliative Medicine involvement earlier in the course of severe disease is important. Further studies in other types of intensive care units (neurological and Cardiovascular) are necessary to determine their impact.