A novel evidence-based predictor tool for hospitalization and length of stay: insights from COVID-19 patients in New York city.

Predictive models for key outcomes of coronavirus disease 2019 (COVID-19) can optimize resource utilization and patient outcome. We aimed to design and internally validate a web-based calculator predictive of hospitalization and length of stay (LOS) in a large cohort of COVID-19-positive patients presenting to the Emergency Department (ED) in a New York City health system. The study cohort consisted of consecutive adult (> 18 years) patients presenting to the ED of Mount Sinai Health System hospitals between March 2020 and April 2020, diagnosed with COVID-19. Logistic regression was utilized to construct predictive models for hospitalization and prolonged (> 3 days) LOS. Discrimination was evaluated using area under the receiver operating curve (AUC). Internal validation with bootstrapping was performed, and a web-based calculator was implemented. From 5859 patients, 65% were hospitalized. Independent predictors of hospitalization and extended LOS included older age, chronic kidney disease, elevated maximum temperature, and low minimum oxygen saturation (p < 0.001). Additional predictors of hospitalization included male sex, chronic obstructive pulmonary disease, hypertension, and diabetes. AUCs of 0.881 and 0.770 were achieved for hospitalization and LOS, respectively. Elevated levels of CRP, creatinine, and ferritin were key determinants of hospitalization and LOS (p < 0.05). A calculator was made available under the following URL: https://covid19-outcome-prediction.shinyapps.io/COVID19_Hospitalization_Calculator/ . This study yielded internally validated models that predict hospitalization risk in COVID-19-positive patients, which can be used to optimize resource allocation. Predictors of hospitalization and extended LOS included older age, CKD, fever, oxygen desaturation, elevated C-reactive protein, creatinine, and ferritin.

Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I

INTRODUCTION The unnecessary overuse of ED services in the United States leads to an estimated wasteful spending of $38 billion yearly. The burden of these visits is multiplied in pandemics and times of crisis, such as the COVID-19 pandemic, during which ED resources may already be overwhelmed. Post-operative Emergency Department (ED) visits following suboccipital decompression in CM-1 patients are not well described. METHODS A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. Pre-operatively and post-operatively prior to hospital discharge, patients are counselled extensively on activity restrictions after surgery, incision care, expectations of severe headache and neck stiffness for the first few weeks after surgery, the variability in degree and timing of symptom improvement from patient to patient, and the proper intake of analgesics, as prescribed. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS). RESULTS In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%). Concentration disturbance at presentation was the only factor significantly associated with a post-operative ED visit (P = .023). The occurrence of a post-operative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted OR of CCOS≥13 = 0.35, P = .021;adjusted OR of CCOS≥14 = 0.38, P = .016). CONCLUSION Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of post-operative ED visits, which are mostly due to pain-related complaints, despite preoperative and postoperative counselling. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of post-operative ED service utilization are warranted.

Scoring System to Triage Patients for Spine Surgery in the Setting of Limited Resources: Application to the Coronavirus Disease 2019 (COVID-19) Pandemic and Beyond.

BACKGROUND: As of May 4, 2020, the coronavirus disease 2019 (COVID-19) pandemic has affected >3.5 million people and touched every inhabited continent. Accordingly, it has stressed health systems worldwide, leading to the cancellation of elective surgical cases and discussions regarding health care resource rationing. It is expected that rationing of surgical resources will continue even after the pandemic peak and may recur with future pandemics, creating a need for a means of triaging patients for emergent and elective spine surgery. METHODS: Using a modified Delphi technique, a cohort of 16 fellowship-trained spine surgeons from 10 academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. Three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. Sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high-priority elective, or low-priority elective scheduling. RESULTS: The devised scoring system included 8 independent components: neurologic status, underlying spine stability, presentation of a high-risk postoperative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. The resultant calculator was deployed as a freely available Web-based calculator (https://jhuspine3.shinyapps.io/SpineUrgencyCalculator/). CONCLUSIONS: We present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. We believe that our scoring system, although not all encompassing, has potential value as a guide for triaging spine surgical cases during the COVID pandemic and post-COVID period.