Gianna Melillo

home

authors

gianna-melillo

revealed inconsistent findings on the effectiveness associated with interventions to reduce hospital length of stay (LOS) across all high-risk populations, underscoring important evidence gaps and the need for further research.

LOS is often used as a proxy for efficient hospital management, while reductions in LOS help improve bed turnover. This allows hospitals to match demand with capacity for elective and emergent admissions, intensive care unit (ICU) care, and interhospital transfers, researchers explained.

Numerous strategies to reduce LOS have been developed; however, a paucity of evidence exists when it comes to the effectiveness of interventions in unplanned hospitalizations, as opposed to elective admissions. This is especially true for populations at-risk for poor outcomes, including those with heart failure or older or medically complex patients.

To identify interventions aimed at reducing LOS among those at high risk of prolonged LOS, researchers conducted a systematic review of MEDLINE, PubMed, Embase, CINAHL, the Cochrane Library, and gray literature sources for studies published between 2010 to 2021. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study.

A total of 19 systematic reviews were included, of which 10 included a mix of study designs, 8 included only randomized clinical trials, and 1 included only retrospective cohort studies. Eight strategies to reduce LOS in high-risk populations were assessed: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth.

“Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure,” authors wrote, while “there were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk.” These could have included patients with housing instability, social isolation, limited English proficiency, or other factors.

Reviews also did not assess LOS interventions among those with substance use disorder or common chronic diseases.

Although analyses did find that for patients with heart failure, clinical pathways and case management were linked with reduced LOS , due to the heterogeneity across studies included, authors underscored the important roles local contexts and resources may play in streamlining care.

In addition, they found that “for patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations.”

Overall, this review showed no single intervention consistently reduced LOS in all high-risk populations.

“Future research assessing interventions for LOS reduction in high-risk populations or subpopulations should also consider implementation science measures to inform local adaption,” researchers concluded.

Articles

Interventions aimed at reducing hospital length of stay (LOS) among at-risk patients lack consistent efficacy, according to a systematic review. 

Are Hospital-Led Interventions Reducing LOS for High-Risk Populations?

This past week, health organizations across the United States took the CDC’s 

—stating fully vaccinated individuals can shed their face coverings in all outdoor and most indoor spaces—in stride, with some lauding the confirmation of data on vaccine effectiveness in community settings, and others strongly cautioning against relaxed transmission protocols.

The new guidance was announced on May 13, and specifically stated mask-wearing is still required for crowded indoor settings like health care facilities and on forms of public transportation. In addition, “fully vaccinated people should continue to follow any applicable federal, state, local, tribal, or territorial laws, rules, and regulations,” the guidance reads, while those who have not received a vaccine should still comply with all transmission mitigation efforts in place before the update.

 immediately put the new guidance into effect, others pumped the brakes and took time to assess the new recommendations prior to instituting any sweeping changes.

For hospitals and health systems, caution continues to take precedence.

The Society for Healthcare Epidemiology of America (SHEA) emphasized the importance of continued transmission mitigation efforts especially in health care facilities as measures begin to relax.

“SHEA is excited that epidemiological data has confirmed vaccine effectiveness in community settings in recent months. We agree with the recommendations relaxing requirements for post-exposure, and post-travel, quarantine and testing for fully vaccinated individuals,” the organization said in a 

“However, SHEA strongly cautions against relaxing transmission mitigation efforts, including masking in communities with ongoing high rates of transmission and within healthcare settings.”

According to the CDC, all health care personnel should continue following infection prevention and control recommendations, including universal masking in health facilities, to protect themselves and others from infection.

“For health care personnel, it is often not known whether patients have been vaccinated when they first arrive in need of care, and we provide care for many highly immunocompromised patients who may remain vulnerable to COVID-19 even after vaccination,” SHEA’s statement reads.

“The potential for exposure to SARS-CoV-2 [the virus which causes COVID-19] is not limited to direct patient care interactions since transmission can also occur through unprotected exposures in common areas to asymptomatic or pre-symptomatic co-workers or visitors, whose vaccination status may also not be known,” they stated.

In a similar vein, America’s largest nurses’ union, National Nurses United, condemned the CDC’s announcement and called on it to revise its guidance, stating it would jeopardize the health of frontline workers and the general public, and disproportionately impact people of color, 

 reports. Less than 40% of the country’s population is currently fully vaccinated.

"It's important for patients to know that this new guidance doesn't apply to health care settings,” 

 John C. O’Horo, MD, MPH, a critical care and infectious disease specialist at the 

. "We ask our patients and visitors to continue to wear masks and socially distance to protect our patients. Also, state and local government may continue to require masking, particularly in places with increasing cases and relatively low COVID-19 vaccination rates.”

The Clinic is asking patients and visitors to continue to wear masks and socially distance even if they are fully vaccinated, in an effort to protect patients with weakened immune systems.

The American Hospital Association (AHA), a national organization representing all types of hospitals and health care networks, had 

 from the CDC following the announcement of relaxed guidelines.

Staff, patients, residents and visitors should continue to wear masks in health care facilities, the CDC told the AHA. The Center directed facilities to continue to refer to its infection prevention and 

 when it comes to source control and physical distancing.

“We appreciate the fact that fully vaccinated people are likely to have sufficient protection to be able to remove their masks now in many other settings, which will likely encourage others to consider getting their vaccination,” said Nancy Foster, AHA’s vice president of quality and patient safety policy.

“At the same time, we recognize that patients in hospitals may be immunocompromised and thus, less likely to be able to fight off the virus if they are exposed. This is why CDC’s directive stipulates that masks and other precautions should still be used in hospitals and other health care settings.”

Following an announcement from the CDC that fully vaccinated individuals no longer need to wear masks in all outdoor and most indoor spaces, health systems and hospitals responded by continuing to encourage caution. 

How Have Health Systems, Hospitals Responded to the CDC's Relaxation of Mask Guidance?

The COVID-19 pandemic has shined a light on the physical and emotional risks healthcare workers face in addition to systemic inequities present prior to the health crisis.

In an effort to spark a national movement for change, a coalition of health system CEOs has devised and signed a 

 setting new safety standards for these workers. The Coalition consists of 10 health system CEOs from across the country committed to improving safety, well-being and equity for all who work in the healthcare field.

The Declaration expands the definition of safety to cover psychological and emotional well-being, states equity and anti-racism are core components of safety, and works to ensure safety by eliminating physical and verbal workplace violence, according to a recent 

To learn more about the Coalition’s formation and how it devised these principles, 

 spoke with Johnese Spisso, MPA, president of UCLA Health and CEO of UCLA Hospital System. Spisso is a co-founder of the CEO Coalition and also co-wrote the Declaration. 

 Can you discuss how the CEO Coalition came together? Has the group worked on initiatives in the past?

Well, certainly this past year has brought a lot of new issues forward in healthcare and as our role as employers for an incredibly dedicated and talented workforce in healthcare. The coalition was founded by 10 healthcare system CEOs from across the country. The founding healthcare systems are diverse in both the background, the region, and types of hospitals they lead. It represents academic medical centers, not-for-profit hospitals, and safety net facilities. The group of CEOs convened because we all shared a common commitment that we really cared deeply about the safety of our team members and wanted to help spark a movement to set new standards of safety for the nation. We recognize that the COVID-19 pandemic was amplifying and bringing visibility to safety issues for team members. It also particularly amplified the physical and emotional risks healthcare team members face, as well as systemic inequities. It gave us an opportunity to look at issues through a new lens and think about how we could bring all of this talent and energy together and create a movement that would be impactful.

The Declaration of Principles covers some areas that were workplace concerns before the pandemic—such as protecting healthcare workers from violence. Is the Coalition drawing on efforts that were in motion before COVID-19 to improve the health and safety of the workforce?

The Declaration of Principles was drafted and refined based on feedback from in-depth interviews and convening with the executives and CEOs over the course of three months in the early part of 2021. We relied on research and strived to understand what core principles underline team members' ability to feel and be safe at work, even prior to the COVID-19 pandemic—because a lot of these issues were there in the past. The CEO Coalition, we have the goal of turning that Declaration of Principles into action by collaborating with healthcare institutions to conduct research and identify a set of evidence-based practices and measures that help support the Declaration of Principles. So, there's still a lot of work to do.

The Principles discuss investments in technology to reduce mental and physical burdens for staff. This sounds like it could include everything from reducing time in front of screens to equipment to help move/transfer larger patients. What is the breadth of investment envisioned?

Are best practices emerging to deal with staff burnout? If so, what are they?

Yes, and we certainly have seen burnout and fatigue throughout this pandemic, and it's come in waves. I think starting out, not only were our staff worried about their own safety, they were also worried about the safety of their families when they were coming into work, and then taking care of patients and going back home, particularly early in the pandemic when we didn't have all the information that we needed about COVID-19. We've tried to make sure we can continue to support their health and well-being and their families' health and well-being as we navigate through the pandemic and provide that direct frontline care. We've tried to do a lot of wraparound services to support the staff going the extra mile for us. I think a lot of institutions have done this with support for meals, support for groceries, support for housing, support for childcare. We've also, here at UCLA health, we've run a variety of virtual and online wellness programs like mindfulness meditation, yoga, as well as reaching out and calling our staff and seeing how they're doing, particularly those who were working in our COVID-19 units.

We had a recent commentary submitted that said one challenge of ensuring adequate staff is the lack of slots in nursing education programs. Has this problem come up at UCLA Health?

How will the Coalition measure the success of implementing the Principles?

That's a really important point. I think, as we bring forward new work to make sure it is having the impact that is desired, and I think that as we look at the CEO coalition, we'll be successful if healthcare team members' safety, as defined in the Declaration of Principles, is measurably improved within one to two years. Our vision is to build momentum by gaining the support of CEOs across the country to help demonstrate the importance of the issue, and specifically around those three pillars that we've defined for our healthcare system nationally. Those are the emotional and psychological safety, the health justice, and the physical safety. We also hope then, that we can use that work and those measured improvements to influence health policy, funding, and culture to create a safer experience for all who work in healthcare, and to keep our healthcare workforce on the job longer in their careers.

Chief Healthcare Executive™ discusses the CEO Coalition's new Declaration of Principles aimed at improving healthcare worker safety with Coalition co-founder and Declaration co-author Johnese Spisso, MPA.

Johnese Spisso on the CEO Coalition's Efforts to Improve Healthcare Worker Safety 

The majority of patients with COVID-19 who received home-based 

 did not require care escalation to a traditional hospital setting, according to study findings published in 

. This finding was consistent even if patients were older or obese.

As the COVID-19 pandemic forced health care systems to rapidly transform care to meet patient demand, Atrium Health implemented the Atrium Health Hospital at Home (AH-HaH) program early on to deliver home-based hospital-level care to increase the system’s bed capacity. The non-profit health system provides care to patents in North Carolina and Georgia.

To determine which AH-HaH patients were at increased risk for care escalation to traditional facilities, researchers conducted a retrospective cohort study of adults aged 18 and older who received treatment via the AH-HaH program between March and November 2020.

“Patients who the evaluating provider would otherwise have admitted to the brick-and-mortar facility who had safe living situations and clinical stability at admission” were eligible to participate in AH-HaH, authors wrote.

The program included telephonic access to nurses, daily in-home visits from paramedics, and virtual visits with a hospitalist, among other services. Baseline covariates and treatment information for each patient were collected via electronic health records.

Of the 391 eligible patients, 53% were female, 43% were White, and patients had a median age of 56 years. In addition, the median length of AH-HaH stay was three days. Analyses revealed:

84 patients (21%) were transferred to a brick-and-mortar facility within 14 days (median time to transfer, 2.2 days [interquartile range, 0.8 to 3.3 days])

Among hospital admissions, 33 required intensive care, 11 required mechanical ventilation, and there were 11 in-hospital deaths (causes included organ failure and shock)

Higher oxygen saturation was associated with decreased odds of transfer (odds ratio [OR], 0.87 [95% CI, 0.81-0.93]), whereas higher comorbidity burden was associated with increased odds of transfer (OR 1.12 [95% CI, 0.99-1.26])

Respiratory aberrations (such as low oxygen saturation, supplemental oxygen ≥3 L/min, and high respiratory rate) and tachycardia at enrollment were frequently observed among patients who required immediate care escalation

High-risk chronic conditions (such as hypertension and diabetes) were common among patients who required nonimmediate care escalation

Overall, approximately one in five patients were admitted within 14 days. Researchers hypothesized the lack of an independent association between older age or obesity and transfer may be due to providers being more cautious about enrolling these patients into the program.

“Although not statistically significant, race/ethnicity and area-level deprivation warrant additional research given established COVID-19 health disparities and possible bias due to home-based AH-HaH eligibility criteria,” they added.

The retrospective nature of the study, which was conducted at a single health system, marks a limitation, while its relatively small sample size could limit identification of significant risk factors for care escalation.

“Nevertheless, this study provides practical initial evidence to help inform patient selection guidelines as health systems and payers increasingly leverage hospital-at-home as a standard care delivery option,” researchers concluded.

A study identifies factors that put patients with COVID-19 receiving home-based care at risk for care escalation. 

Gianna Melillo

Articles

Are Hospital-Led Interventions Reducing LOS for High-Risk Populations?

How Have Health Systems, Hospitals Responded to the CDC's Relaxation of Mask Guidance?

Johnese Spisso on the CEO Coalition's Efforts to Improve Healthcare Worker Safety

Identifying Factors Linked to COVID-19 Care Escalation From In-Home to Hospital