Mortality and Readmission Rates Among Patients With COVID-19 After Discharge From Acute Care Setting With Supplemental Oxygen.

Importance: To optimize patient outcomes and preserve critical acute care access during the COVID-19 pandemic, the Los Angeles County Department of Health Services developed the SAFE @ HOME O2 Expected Practice (expected practice), enabling ambulatory oxygen management for COVID-19. Objective: To assess outcomes of patients with COVID-19 pneumonia discharged via the expected practice approach to home or quarantine housing with supplemental home oxygen. Design, Setting, and Participants: This retrospective cohort study included 621 adult patients with COVID-19 pneumonia who were discharged from 2 large urban public hospitals caring primarily for patients receiving Medicaid from March 20 to August 19, 2020. Patients were included in the analysis cohort if they received emergency or inpatient care for COVID-19 and were discharged with home oxygen. Interventions: Patients receiving at least 3 L per minute of oxygen, stable without other indication for inpatient care, were discharged from either emergency or inpatient encounters with home oxygen equipment, educational resources, and nursing telephone follow-up within 12 to 18 hours of discharge. Nurses provided continued telephone follow up as indicated, always with physician back-up. Main Outcomes and Measures: All-cause mortality and all-cause 30-day return admission. Results: A total of 621 patients with COVID-19 pneumonia (404 male [65.1%] and 217 female [34.9%]) were discharged with home oxygen. Median age of these patients was 51 years (interquartile range, 45-61 years), with 149 (24.0%) discharged from the emergency department and 472 (76%) discharged from inpatient encounters. The all-cause mortality rate was 1.3% (95% CI, 0.6%-2.5%) and the 30-day return hospital admission rate was 8.5% (95% CI, 6.2%-10.7%) with a median follow-up time of 26 days (interquartile range, 15-55 days). No deaths occurred in the ambulatory setting. Conclusions and Relevance: In this cohort study, patients with COVID-19 pneumonia discharged on home oxygen had low rates of mortality and return admission within 30 days of discharge. Ambulatory management of COVID-19 with home oxygen has an acceptable safety profile, and the expected practice approach may help optimize outcomes, by ensuring right care in the right place at the right time and preserving access to acute care during the COVID-19 pandemic.

The Effect of Utilization Review on Emergency Department Operations.

STUDY OBJECTIVE: Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety-net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations. METHODS: In 2012, Los Angeles County + University of Southern California Medical Center implemented prospective use of computerized admission criteria. After implementation, only ED patients meeting primary review (diagnosis-based criteria) or secondary review (medical necessity as determined by an on-site emergency physician) were assigned inpatient beds. Data were extracted from electronic medical records from September 2011 through December 2013. Outcomes included operational metrics, 30-day ED revisits, and 30-day admission rates. Excluding a 6-month implementation period, monthly summary metrics were compared pre- and postimplementation with nonparametric and negative binomial regression methods. All adult ED visits, excluding incarcerated and purely behavioral health visits, were analyzed. The primary outcomes were disposition rates. Secondary outcomes were 30-day ED revisits, 30-day admission rate among return visitors to the ED, and estimated cost. RESULTS: Analysis of 245,662 ED encounters was performed. The inpatient admission rate decreased from 14.2% to 12.8%. Increases in discharge rate (82.4% to 83.4%) and ED observation unit utilization (2.5% to 3.4%) were found. Thirty-day revisits increased (20.4% to 24.4%), although the 30-day admission rate decreased (3.2% to 2.8%). Estimated cost savings totaled $193.17 per ED visit. CONCLUSION: The prospective application of utilization review software in the ED led to a decrease in the admission rate. This was tempered by a concomitant increase in ED observation unit utilization and 30-day ED revisits. Cost savings suggest that resources should be redirected to the more highly affected ED and ED observation unit, although more work is needed to confirm the generalizability of these findings.