The Rothman Index predicts unplanned readmissions to intensive care associated with increased mortality and hospital length of stay: a propensity-matched cohort study.

BACKGROUND: Patients with unplanned readmissions to the intensive care unit (ICU) are at high risk of preventable adverse events. The Rothman Index represents an objective real-time grading system of a patient's clinical condition and a predictive tool of clinical deterioration over time. This study was designed to test the hypothesis that the Rothman Index represents a sensitive predictor of unanticipated ICU readmissions. METHODS: A retrospective propensity-matched cohort study was performed at a tertiary referral academic medical center in the United States from January 1, 2022, to December 31, 2022. Inclusion criteria were adult patients admitted to an ICU and readmitted within seven days of transfer to a lower level of care. The control group consisted of patients who were downgraded from ICU without a subsequent readmission. The primary outcome measure was in-hospital mortality or discharge to hospice for end-of-life care. Secondary outcome measures were overall hospital length of stay, ICU length of stay, and 30-day readmission rates. Propensity matching was used to control for differences between the study cohorts. Regression analyses were performed to determine independent risk factors of an unplanned readmission to ICU. RESULTS: A total of 5,261 ICU patients met the inclusion criteria, of which 212 patients (4%) had an unanticipated readmission to the ICU within 7 days. The study cohort and control group were stratified by propensity matching into equal group sizes of n = 181. Lower Rothman Index scores (reflecting higher physiologic acuity) at the time of downgrade from the ICU were significantly associated with an unplanned readmission to the ICU (p < 0.0001). Patients readmitted to ICU had a lower mean Rothman Index score (p < 0.0001) and significantly increased rates of mortality (19.3% vs. 2.2%, p < 0.0001) and discharge to hospice (14.4% vs. 6.1%, p = 0.0073) compared to the control group of patients without ICU readmission. The overall length of ICU stay (mean 8.0 vs. 2.2 days, p < 0.0001) and total length of hospital stay (mean 15.8 vs. 7.3 days, p < 0.0001) were significantly increased in patients readmitted to ICU, compared to the control group. CONCLUSION: The Rothman Index represents a sensitive predictor of unanticipated readmissions to ICU, associated with a significantly increased mortality and overall ICU and hospital length of stay. The Rothman Index should be considered as a real-time objective measure for prediction of a safe downgrade from ICU to a lower level of care.

General Surgery Residency and Emergency General Surgery Service Reduces Readmission Rates and Length of Stay in Nonoperative Small Bowel Obstruction.

BACKGROUND: Nonoperative management of adhesive small bowel obstruction (ASBO) results in resolution for the majority of patients. Previous studies have demonstrated that outcomes for patients with ASBO are improved when patients are admitted to a surgical service, but the effect of general surgery resident coverage is unclear. This study measures quality outcomes for patients with ASBO after the establishment of a new general surgery residency program. METHODS: An institutional review board-approved retrospective chart review of admissions for ASBO was conducted following the implementation of a protocol for ASBO nested within a newly developed resident-run emergency general surgery (EGS) service. Patients successfully treated without operative intervention were analyzed. RESULTS: During the study period, 612 patients were admitted for ASBO. After initiation of the residency, 74% of ASBO were admitted to a surgical service compared with 35% prior to residency (P < .01). Length of stay was reduced by 0.77 days (P = .016), average direct total cost per patient was reduced by 24% (P = .002), and 30-day readmissions were reduced by 35.7% (P = .046). There was no significant difference in mortality (1.4% vs 1.0%). DISCUSSION: Admission to a resident-run surgical service was associated with statistically significant improvement in outcomes for patients with ASBO. These data corroborate prior studies demonstrating the positive impact of residency programs on patient outcomes and provide additional evidence that general surgery residency programs improve outcomes for patients with surgical disease.

Large prepatellar glomangioma: A case report.

INTRODUCTION: Glomangiomas are rare, benign tumors derived from the glomus body, typically presenting with the classic triad of pain, tenderness to palpation, and hypersensitivity to cold. Most commonly they present as a solitary lesion in the extremities, especially subungual, but they may present elsewhere. PRESENTATION OF CASE: We describe the case of a large (64mm×59mm×41mm) glomangioma on the anteroinferior aspect of a healthy 49 year old male's knee. Symptoms included constant throbbing pain with intermittent stabbing sensations localized to the mass. The mass was evaluated first by magnetic resonance (MR) imaging and then by histopathology following excision. DISCUSSION: Although rare, clinical diagnosis of glomangiomas may be sufficient in typical cases, however in atypical cases, like the one discussed here, further evaluation is often necessary. Here MR findings were suggestive of a glomangioma with low to intermediate signal strength on T1 and mixed signal strength on T2. Intravenous gadolinium infusion demonstrated marked heterogeneous enhancement of the lesion, as well as serpiginous vascular malformations surrounding the lesion. Histopathology following excision confirmed a benign glomangioma depicting monomorphic small, round eosinophilic cells with minimal atypia which stained positive for smooth muscle actin, and negative for cytokeratin, S-100 and CK-34 via immunohistochemistry. CONCLUSION: The following case report details an atypical presentation of a benign glomangioma anterior to the knee in a patient experiencing chronic minor trauma to the area. Diagnosis was suggested by clinical presentation and MR imaging, and was confirmed histologically.