Jeremiah Newsom, MD, MSPH

Background: IBP is very common and associated with increased length of stay and cost of care. Many nonmodifiable risk factors have been identified such as socioeconomic status, male gender, and increased age, but no studies have been done to look at modifiable risk factors such as medication use, timing of colonoscopy, and diet before colonoscopy. Furthermore, no studies have been done to assess the effects of these modifiable factors on IBP.

Study design: Retrospective cohort study using multivariate logistic regression analysis.

Setting: Cleveland Clinic Hospitals in Ohio and Florida.

Synopsis: Records of 8,819 patients (aged greater than 18 years) undergoing colonoscopy at Cleveland Clinic between January 2011 and June 2017 were reviewed. They found that 51% had IBP. Modifiable risk factors, including opiate use within 3 days of colonoscopy, colonoscopy performed before noon, and solid diet the day before colonoscopy, were associated with IBP. After adjustment for these variables, they found the rates of IBP were reduced by 5.6%. They also found that patients who had IBP had increased length of stay by 1 day (6 days vs. 5 days; P less than .001). This translates into 494 unnecessary hospital days or approximately $1 million dollars in unnecessary costs based on the number of patients (almost 9,000).

This study was performed in a single institution so it may be difficult to extrapolate to other institutions. Further studies need to be performed using multicenter institutions to assess accuracy of data.

Bottom line: Liquid diet or nothing by mouth (NPO) 1 day prior to colonoscopy, performing colonoscopy before noon, and avoiding opioids 3 days prior to colonoscopy are modifiable risk factors that may decrease the rate of inadequate bowel preparations in hospitalized patients.

Citation: Garber A et al. Modifiable factors associated with quality of bowel preparation among hospitalized patients undergoing colonoscopy. J Hosp Med. 2019;5:278-83.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

Background: IBP is very common and associated with increased length of stay and cost of care. Many nonmodifiable risk factors have been identified such as socioeconomic status, male gender, and increased age, but no studies have been done to look at modifiable risk factors such as medication use, timing of colonoscopy, and diet before colonoscopy. Furthermore, no studies have been done to assess the effects of these modifiable factors on IBP.

Study design: Retrospective cohort study using multivariate logistic regression analysis.

Setting: Cleveland Clinic Hospitals in Ohio and Florida.

Synopsis: Records of 8,819 patients (aged greater than 18 years) undergoing colonoscopy at Cleveland Clinic between January 2011 and June 2017 were reviewed. They found that 51% had IBP. Modifiable risk factors, including opiate use within 3 days of colonoscopy, colonoscopy performed before noon, and solid diet the day before colonoscopy, were associated with IBP. After adjustment for these variables, they found the rates of IBP were reduced by 5.6%. They also found that patients who had IBP had increased length of stay by 1 day (6 days vs. 5 days; P less than .001). This translates into 494 unnecessary hospital days or approximately $1 million dollars in unnecessary costs based on the number of patients (almost 9,000).

This study was performed in a single institution so it may be difficult to extrapolate to other institutions. Further studies need to be performed using multicenter institutions to assess accuracy of data.

Bottom line: Liquid diet or nothing by mouth (NPO) 1 day prior to colonoscopy, performing colonoscopy before noon, and avoiding opioids 3 days prior to colonoscopy are modifiable risk factors that may decrease the rate of inadequate bowel preparations in hospitalized patients.

Citation: Garber A et al. Modifiable factors associated with quality of bowel preparation among hospitalized patients undergoing colonoscopy. J Hosp Med. 2019;5:278-83.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

Background: IBP is very common and associated with increased length of stay and cost of care. Many nonmodifiable risk factors have been identified such as socioeconomic status, male gender, and increased age, but no studies have been done to look at modifiable risk factors such as medication use, timing of colonoscopy, and diet before colonoscopy. Furthermore, no studies have been done to assess the effects of these modifiable factors on IBP.

Study design: Retrospective cohort study using multivariate logistic regression analysis.

Setting: Cleveland Clinic Hospitals in Ohio and Florida.

Synopsis: Records of 8,819 patients (aged greater than 18 years) undergoing colonoscopy at Cleveland Clinic between January 2011 and June 2017 were reviewed. They found that 51% had IBP. Modifiable risk factors, including opiate use within 3 days of colonoscopy, colonoscopy performed before noon, and solid diet the day before colonoscopy, were associated with IBP. After adjustment for these variables, they found the rates of IBP were reduced by 5.6%. They also found that patients who had IBP had increased length of stay by 1 day (6 days vs. 5 days; P less than .001). This translates into 494 unnecessary hospital days or approximately $1 million dollars in unnecessary costs based on the number of patients (almost 9,000).

This study was performed in a single institution so it may be difficult to extrapolate to other institutions. Further studies need to be performed using multicenter institutions to assess accuracy of data.

Bottom line: Liquid diet or nothing by mouth (NPO) 1 day prior to colonoscopy, performing colonoscopy before noon, and avoiding opioids 3 days prior to colonoscopy are modifiable risk factors that may decrease the rate of inadequate bowel preparations in hospitalized patients.

Citation: Garber A et al. Modifiable factors associated with quality of bowel preparation among hospitalized patients undergoing colonoscopy. J Hosp Med. 2019;5:278-83.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

 

Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?

Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.

Study design: Cluster randomized clinical trial.

Setting: A 2,000-bed urban medical center in Taipei, Taiwan.

Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.

Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.

Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
 

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

 

Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?

Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.

Study design: Cluster randomized clinical trial.

Setting: A 2,000-bed urban medical center in Taipei, Taiwan.

Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.

Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.

Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
 

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

 

Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?

Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.

Study design: Cluster randomized clinical trial.

Setting: A 2,000-bed urban medical center in Taipei, Taiwan.

Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.

Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.

Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
 

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

 

Clinical question: Is hospital acquired anemia associated with increased postdischarge adverse outcomes?

Background: Hospital acquired anemia (HAA) is defined as the development of anemia during the course of a hospitalization when starting with a normal hemoglobin on admission. The incidence of HAA is at least 25% when using the last hemoglobin prior to discharge as the index value. HAA is felt to be potentially preventable and usually iatrogenic due to phlebotomy.

Study design: Observational cohort study.

Setting: Six northern Texas hospitals.

Synopsis: There were 11,309 index hospitalizations with a median hematocrit value on admission of 40.6 g/dL. The authors defined HAA as a normal hematocrit value within the first 24 hours of admission and a hematocrit value lower than the WHO sex-specific cut points at the time of discharge: mild HAA (hematocrit greater than 33% and less than 36% in women, greater than 33% and less than 40% in men), moderate HAA (greater than 27% and less than 33%), and severe HAA (less than 27%). Mild HAA occurred in 21.6% of patients, with 10.1% of patients developing moderate HAA, and 1.4% developing severe HAA (85% underwent major procedure, diagnosis of hemorrhage or coagulation/hemorrhagic disorder). Predictors of developing moderate/severe HAA included undergoing a major diagnostic or therapeutic procedure, female sex, elective admission, hospital LOS, BUN to creatinine ratio greater than 20:1, and serum creatinine on admission. Development of severe HAA was associated with a 41% increase in the odds of 30-day readmission and a 39% increase in the odds of the composite outcome (30-day mortality and 30-day readmission).

Bottom line: Severe HAA had significant increased odds of 30-day readmission and mortality, but might not be as preventable as initially thought given the frequency of major procedures and hemorrhage in those that developed severe HAA.

Citation: Makam AN, Nguyen OK, Clark C, Halm EA. Incidence, predictors, and outcomes of hospital-acquired anemia. J Hosp Med. 2017;12(5):317-22.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

 

Clinical question: Is hospital acquired anemia associated with increased postdischarge adverse outcomes?

Background: Hospital acquired anemia (HAA) is defined as the development of anemia during the course of a hospitalization when starting with a normal hemoglobin on admission. The incidence of HAA is at least 25% when using the last hemoglobin prior to discharge as the index value. HAA is felt to be potentially preventable and usually iatrogenic due to phlebotomy.

Study design: Observational cohort study.

Setting: Six northern Texas hospitals.

Synopsis: There were 11,309 index hospitalizations with a median hematocrit value on admission of 40.6 g/dL. The authors defined HAA as a normal hematocrit value within the first 24 hours of admission and a hematocrit value lower than the WHO sex-specific cut points at the time of discharge: mild HAA (hematocrit greater than 33% and less than 36% in women, greater than 33% and less than 40% in men), moderate HAA (greater than 27% and less than 33%), and severe HAA (less than 27%). Mild HAA occurred in 21.6% of patients, with 10.1% of patients developing moderate HAA, and 1.4% developing severe HAA (85% underwent major procedure, diagnosis of hemorrhage or coagulation/hemorrhagic disorder). Predictors of developing moderate/severe HAA included undergoing a major diagnostic or therapeutic procedure, female sex, elective admission, hospital LOS, BUN to creatinine ratio greater than 20:1, and serum creatinine on admission. Development of severe HAA was associated with a 41% increase in the odds of 30-day readmission and a 39% increase in the odds of the composite outcome (30-day mortality and 30-day readmission).

Bottom line: Severe HAA had significant increased odds of 30-day readmission and mortality, but might not be as preventable as initially thought given the frequency of major procedures and hemorrhage in those that developed severe HAA.

Citation: Makam AN, Nguyen OK, Clark C, Halm EA. Incidence, predictors, and outcomes of hospital-acquired anemia. J Hosp Med. 2017;12(5):317-22.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

 

Clinical question: Is hospital acquired anemia associated with increased postdischarge adverse outcomes?

Background: Hospital acquired anemia (HAA) is defined as the development of anemia during the course of a hospitalization when starting with a normal hemoglobin on admission. The incidence of HAA is at least 25% when using the last hemoglobin prior to discharge as the index value. HAA is felt to be potentially preventable and usually iatrogenic due to phlebotomy.

Study design: Observational cohort study.

Setting: Six northern Texas hospitals.

Synopsis: There were 11,309 index hospitalizations with a median hematocrit value on admission of 40.6 g/dL. The authors defined HAA as a normal hematocrit value within the first 24 hours of admission and a hematocrit value lower than the WHO sex-specific cut points at the time of discharge: mild HAA (hematocrit greater than 33% and less than 36% in women, greater than 33% and less than 40% in men), moderate HAA (greater than 27% and less than 33%), and severe HAA (less than 27%). Mild HAA occurred in 21.6% of patients, with 10.1% of patients developing moderate HAA, and 1.4% developing severe HAA (85% underwent major procedure, diagnosis of hemorrhage or coagulation/hemorrhagic disorder). Predictors of developing moderate/severe HAA included undergoing a major diagnostic or therapeutic procedure, female sex, elective admission, hospital LOS, BUN to creatinine ratio greater than 20:1, and serum creatinine on admission. Development of severe HAA was associated with a 41% increase in the odds of 30-day readmission and a 39% increase in the odds of the composite outcome (30-day mortality and 30-day readmission).

Bottom line: Severe HAA had significant increased odds of 30-day readmission and mortality, but might not be as preventable as initially thought given the frequency of major procedures and hemorrhage in those that developed severe HAA.

Citation: Makam AN, Nguyen OK, Clark C, Halm EA. Incidence, predictors, and outcomes of hospital-acquired anemia. J Hosp Med. 2017;12(5):317-22.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.