Implementing and Evaluating a Discharge Before Noon Initiative in a Large Tertiary Care Urban Hospital.

BACKGROUND: Discharging clinically ready patients before noon on their discharge day may influence overall discharge process quality, emergency department (ED) boarding times, and length of stay (LOS). This study evaluated the effectiveness of a discharge before noon (DBN) initiative. METHODS: Many DBN components were refined or added during a pilot, including incorporating the DBN process into daily rounds, an electronic tracking system, and other elements for possible DBN patients such as a car service when appropriate and expedited lab results and physical therapy consults. DBN was evaluated through a retrospective pre-post study (12-month periods). Study patients were from Maimonides Medical Center's medicine units. Kaplan-Meier estimates and a log-rank test characterized and compared the discharge time probabilities in pre-DBN and post-DBN groups. Log-logistic accelerated failure time (AFT) analysis assessed the influence of DBN on discharge time. Secondary analyses examined the relationship between LOS and readmission within 30 days for any cause and DBN. RESULTS: The percentage of patients discharged before noon increased from 5.0% to 11.4% pre/post-DBN (p < 0.001). The AFT analysis estimated that post-DBN patients had discharge times 41.5% earlier (p < 0.001). DBN as an independent factor was not associated with LOS or subsequent readmissions within 30 days for any cause. Despite an increase in the percentage of patients admitted during the daytime (8:00 a.m. to 5:00 p.m.), the median ED boarding time increased by 41 minutes in post-DBN patients (p < 0.001). CONCLUSION: The DBN initiative was associated with an increased percentage of patients discharged before noon. Further research is needed to identify strategies that reliably improve discharge timeliness while reducing ED boarding.

Dalbavancin Use in the Emergency Department Setting.

Background: Although dalbavancin's (DBV's) long half-life and one-time dosing strategy confer ideal administration in the ambulatory setting, the optimal role of DBV in the management of acute bacterial skin and skin structure infections (ABSSSIs) remains to be elucidated. Objectives: The primary objective of this study was to compare treatment outcomes of ABSSSI between patients who received DBV in the emergency department (ED) as part of standard care versus patients who received DBV as part of a telehealth program. Methods: This was a retrospective cohort study evaluating patients who received DBV at 3 urban EDs. The primary end point was the incidence of ABSSSI recurrence. Secondary outcomes included need for hospital admission and ED length of stay (LOS; in hours). Results: A total of 65 ABSSSI treatment courses were included; 42 were included in the telehealth criteria (TC) cohort and 23 in the initial criteria (IC) cohort. There were 14% (6/42) infection recurrences in the TC cohort and 22% (5/23) in the IC cohort, with median time to recurrence being 4 and 14 days, respectively. Median ED LOS was significantly shorter in the TC (5 vs 25 hours, P < 0.05). Numerically fewer individuals in the TC cohort required inpatient admission (0 vs n = 2, 9%). Conclusion and Relevance: Our results suggest that patients may be safely administered DBV in an ED setting, with telehealth follow-up. Providing structured patient selection criteria is an effective method of assisting ED providers in selecting appropriate DBV candidates to limit potential recurrences and readmissions.

Bending the cost curve: time series analysis of a value transformation programme at an academic medical centre.

BACKGROUND: Reducing costs while increasing or maintaining quality is crucial to delivering high value care. OBJECTIVE: To assess the impact of a hospital value-based management programme on cost and quality. DESIGN: Time series analysis of non-psychiatric, non-rehabilitation, non-newborn patients discharged between 1 September 2011 and 31 December 2017 from a US urban, academic medical centre. INTERVENTION: NYU Langone Health instituted an institution-wide programme in April 2014 to increase value of healthcare, defined as health outcomes achieved per dollar spent. Key features included joint clinical and operational leadership; granular and transparent cost accounting; dedicated project support staff; information technology support; and a departmental shared savings programme. MEASUREMENTS: Change in variable direct costs; secondary outcomes included changes in length of stay, readmission and in-hospital mortality. RESULTS: The programme chartered 74 projects targeting opportunities in supply chain management (eg, surgical trays), operational efficiency (eg, discharge optimisation), care of outlier patients (eg, those at end of life) and resource utilisation (eg, blood management). The study cohort included 160 434 hospitalisations. Adjusted variable costs decreased 7.7% over the study period. Admissions with medical diagnosis related groups (DRG) declined an average 0.20% per month relative to baseline. Admissions with surgical DRGs had an early increase in costs of 2.7% followed by 0.37% decrease in costs per month. Mean expense per hospitalisation improved from 13% above median for teaching hospitals to 2% above median. Length of stay decreased by 0.25% per month relative to prior trends (95% CI -0.34 to 0.17): approximately half a day by the end of the study period. There were no significant changes in 30-day same-hospital readmission or in-hospital mortality. Estimated institutional savings after intervention costs were approximately $53.9 million. LIMITATIONS: Observational analysis. CONCLUSION: A systematic programme to increase healthcare value by lowering the cost of care without compromising quality is achievable and sustainable over several years.

Linezolid-resistant, vancomycin-resistant Enterococcus faecium infection in patients without prior exposure to linezolid.

We describe 2 patients without prior exposure to linezolid who were infected with closely related strains of linezolid- and vancomycin-resistant Enterococcus faecium (LRVREF) that may have been hospital acquired. Polymerase chain reaction amplification of the domain V region of the 23S ribosomal RNA gene demonstrated the presence of the G2576U mutation previously reported to be associated with linezolid resistance. Nosocomial transmission of LRVREF is an ominous sign and underscores the importance of meticulous infection-control measures.