Frailty Cost: Economic Impact of Frailty in the Elective Surgical Patient.

BACKGROUND: Frailty in the surgical patient has been associated with increased morbidity, mortality, and failure to rescue. However, there is little understanding of the economic impact of frailty. STUDY DESIGN: A prospective database of elective surgery patients at an academic medical center was used to create a modified version of the Risk Analysis Index (RAI), a validated frailty index. This included 10,257 patients undergoing elective operations from 2016 to 2017. Patients were classified as not frail (RAI = 0), somewhat frail (RAI = 1 to 10), or significantly frail (RAI > 10). Cost, revenue, and income data were procured from the finance department. Univariate and multivariate analyses were performed. RESULTS: Frail patients were more likely to be older (65 years vs 50 years; p < 0.001) and inpatient (19% vs 36%; p < 0.001). General surgical, gynecologic, urologic, and cardiothoracic services operated on a higher percentage of significantly frail patients compared with orthopaedic, neurosurgical, and vascular (p < 0.001). On univariate analysis, frail patients were more likely to die (0% vs 0.4%; p < 0.001) and have increased length of stay (0.8 vs 2.1 days; p < 0.001), higher total cost ($6,934 vs $13,319), and lower net hospital income ($5,447 vs $3,129) (p < 0.001). On multivariate analysis, frailty was independently associated with increased direct cost (odds ratio [OR] 2.2; p < 0.001), indirect cost (OR 1.9; p < 0.001), total cost (OR 2.2; p < 0.001), and net income (OR 0.8; p < 0.001). Stratified by service line and inpatient vs outpatient status, frailty continued to be associated with increased direct cost, indirect cost, total cost, and decreased hospital income. CONCLUSIONS: Although a significant number of data exist on the impact of frailty in the surgical patient, the economic impacts have only limited description in the literature. Here we demonstrate that frailty, independent of age, has a detrimental financial impact on cost and hospital income in elective surgery.

Project IMPACT Pilot Report: Feasibility of Implementing a Hospital-to-Home Transition Bundle.

BACKGROUND AND OBJECTIVES: To improve hospital to home transitions, a 4-element pediatric patient-centered transition bundle was developed, including: a transition readiness checklist; predischarge teach-back education; timely and complete written handoff to the primary care provider; and a postdischarge phone call. The objective of this study was to demonstrate the feasibility of bundle implementation and report initial outcomes at 4 pilot sites. Outcome measures included postdischarge caregiver ability to teach-back key home management information and 30-day reuse rates. METHODS: A multisite, observational time series using multiple planned sequential interventions to implement bundle components with non-technology-supported and technology-supported patients. Data were collected via electronic health record reviews and during postdischarge phone calls. Statistical process control charts were used to assess outcomes. RESULTS: Four pilot sites implemented the bundle between January 2014 and May 2015 for 2601 patients, of whom 1394 had postdischarge telephone encounters. Improvement was noted in the implementation of all bundle elements with the transitions readiness checklist posing the greatest feasibility challenge. Phone contact connection rates were 69%. Caregiver ability to teach-back essential home management information postdischarge improved from 18% to 82%. No improvement was noted in reuse rates, which differed dramatically between technology-supported and non-technology-supported patients. CONCLUSIONS: A pediatric care transition bundle was successfully tested and implemented, as demonstrated by improvement in all process measures, as well as caregiver home management skills. Important considerations for successful implementation and evaluation of the discharge bundle include the role of local context, electronic health record integration, and subgroup analysis for technology-supported patients.

Bacterial contamination of cystic fibrosis clinics.

BACKGROUND: Respiratory pathogens from CF patients can contaminate inpatient settings, which may be associated with increased risk of patient-to-patient transmission. Few data are available that assess the rate of bacterial contamination of outpatient settings. We determined the frequency of contamination of CF clinics and the effectiveness of alcohol-based disinfectants in reducing hand carriage of bacterial pathogens. METHODS: We conducted a point prevalence survey and before-after trial in outpatient clinics at 7 CF centers. The study examined CF patients with positive respiratory cultures for Pseudomonas, Staphylococcus, Stenotrophomonas or Burkholderia species. Hand carriage and environmental contamination with respiratory pathogens were assessed during clinic visits (Part I) and the effectiveness of hand hygiene performed by CF patients (Part II) was determined using molecular typing of recovered isolates. RESULTS: In Part I (n=97), the contamination rate was 13.6%. Pseudomonas and S. aureus, including methicillin-resistant strains, were cultured from patients' hands (7%), the exam room air (8%), and less commonly, environmental surfaces (1%). In Part II (n=100), the hand carriage rate of pathogens was 13.5% and 4 participants without initial detection of pathogens had hand contamination when recultured at the end of the clinic visit. CONCLUSIONS: Respiratory pathogens from CF patients can contaminate their hands and the clinic environment, but the actual risk of patient-to-patient transmission in the outpatient setting remains difficult to quantify. These findings support several recommendations CF infection control recommendations including hand hygiene for staff and patients, contact precautions for certain pathogens, and disinfecting equipment and surfaces touched by patients and staff.

Association of bacterial infection and red blood cell transfusion after coronary artery bypass surgery.

BACKGROUND: Previous studies have shown an association between red blood cell transfusions (RBC) and bacterial infections following coronary artery bypass graft (CABG) surgery. We sought to assess whether there is an independent effect of RBC on the incidence of bacterial infections. METHODS: This was a prospective cohort study of 533 CABG patients over a 7-month period. Subjects were followed from time of CABG until 30 days postoperatively. Data were collected on patient and treatment characteristics, surgical management, and transfusion incidence. RESULTS: Seventy-five (14.1%) of 533 patients developed a bacterial infection. After controlling for patient and disease characteristics, invasive treatments, surgical time, and the transfusion of other substances, the adjusted rates of bacterial infection were 4.8% for no RBC transfusion, 15.2% with one to two units, 22.1% with three to five units, and 29.0% with greater than or equal to six units, (p(trend) < 0.001). Diabetes was the only patient or disease factor significantly associated with bacterial infection (p < 0.001). CONCLUSIONS: RBC transfusions were independently associated with a higher incidence of post-CABG bacterial infections. The risk of infection increased in proportion to the number of units of RBC transfused.