Physical Restraint Usage in Hospitals Across the United States: 2011-2019.

Objective: To determine the change in rates of physical restraint (PR) use and associated outcomes among hospitalized adults. Patients and Methods: Using national inpatient sample databases, we analyzed years 2011-2014 and 2016-2019 to determine trends of PR usage. We also compared the years 2011-2012 and 2018-2019 to investigate rates of PR use, in-hospital mortality, length of stay, and total hospital charges. Results: There were 242,994,110 hospitalizations during the study period. 1,538,791 (0.63%) had coding to signify PRs, compared with 241,455,319 (99.3%), which did not. From 2011 to 2014, there was a significant increase in PR use (p-trend<.01) and a nonsignificant increase in PR rates from 2016-2019 (p-trend=.07). Over time, PR use increased (2011-2012: 0.52% vs 2018-2019: 0.73%; p<.01). Patients with PRs reported a higher adjusted odds for in-hospital mortality in 2011-2012 (adjusted odds ratio [aOR], 3.9; 95% CI, 3.7-4.2; p<.01) and 2018-2019 (aOR, 3.5; 95% CI, 3.4-3.7; p<.01). Length of stay was prolonged for patients with PRs in 2011-2012 (adjusted mean difference [aMD], 4.3 days; 95% CI, 4.1-4.5; p<.01) and even longer in 2018-2019 (aMD, 5.8 days; 95% CI, 5.6-6.0; p<.01). Total hospital charges were higher for patients with PRs in 2011-2012 (aMD, +$55,003; 95% CI, $49,309-$60,679; p<.01). Following adjustment for inflation, total charges remained higher for patients with PRs compared with those without PRs in 2018-2019 (aMD, +$70,018; 95% CI, $65,355-$74,680; p<.01). Conclusion: Overall, PR rates did not decrease across the study period, suggesting that messaging and promulgating best practice guidelines have yet to translate into a substantive change in practice patterns.

Outcomes among hospitalized patients with dementia and behavioral disturbances when physical restraints are introduced.

BACKGROUND: Physical restraint use among patients hospitalized with dementia and behavioral disturbances has not been studied nationally in the United States. METHODS: National Inpatient Sample database years 2016 through 2020 were used to compare physically restrained and unrestrained patients with dementia and behavioral disturbances. Multivariable regression analyses were used to assess patient outcomes. RESULTS: There were 991,605 patients coded for dementia with behavioral disturbances. Among these, physical restraints were used with 64,390 (6.5%) and not with 927,215 (93.5%). Patients in the restrained group were younger (mean age ± standard error: 78.7 ± 0.25 vs. 79.9 ± 0.34 ; p < 0.01) and more often male (59.0% vs. 45.8%; p < 0.01) compared to the unrestrained group. A higher proportion of Black patients were in the restrained group (15.2% vs. 11.8%; p < 0.01). Larger hospitals also made up a more significant proportion of restrained versus unrestrained patients (53.3% vs. 45.1%; p < 0.01). Those with physical restraints had longer lengths of stays (adjusted mean difference [aMD] = 2.6 days CI [2.2-3.0]; p < 0.01) and higher total hospital charges (aMD = $13,150 CI [10,827-15,472]; p < 0.01). There were similar adjusted odds for in-hospital mortality (adjusted odds ratio [aOR] = 1.0 [CI 0.95-1.1]; p = 0.28) and lower odds of being discharged to home after hospitalization (aOR = 0.74 [0.70-0.79]; <0.01) for patients with physical restraints compared to those without. CONCLUSION: Among patients hospitalized with dementia and behavioral disturbances, those with physical restraints had greater hospital resource utilization outcomes. Attempts to limit physical restraint use whenever possible may improve outcomes in this vulnerable population.

Inpatient outcomes comparing White and Black patients with obesity hospitalized for COVID-19 infection.

OBJECTIVE: Comparisons between Black and White patients with obesity hospitalized with COVID-19 have not been fully studied. We sought to determine outcomes differences between these two groups. METHODS: National Inpatient Sample database year 2020 was studied using multivariable regression to compare Black and White patients with obesity and COVID-19 infection. Outcomes were in-hospital mortality, length of stay, and hospital charges. RESULTS: 205,365 Black and White patients with obesity were hospitalized for COVID-19. 141,010 (68.6%) were White and 64,355 (31.3%) were Black. Black patients were younger (mean age [± standard error] 55.5 ± 0.14 vs. 62.1± 0.11; p < 0.01), more likely female (63.2% vs 50.9%; p < 0.01), and had lower mean comorbidity (Elixhauser score means [± standard error] 4.4 ± 0.02 vs. 4.6 ± 0.01; p < 0.01) than White patients. Black patients had lower odds of in-hospital mortality (adjusted Odds Ratio {aOR}=0.86 CI [0.77-0.97]; p = 0.01), longer hospital stays (adjusted Mean Difference {aMD}=0.32 days CI [0.14-0.51]; p < 0.01) and incurred higher, though non-significant hospital charges (aMD = $2,144 CI [-2270-+6560]; p = 0.34) than White patients. CONCLUSION: During the first year of the pandemic, Black patients with obesity and COVID-19 were less likely to die during the incident hospitalization but used greater hospital resources compared to White patients.

Outcomes for Hospitalized Aggressive and Violent Patients When Physical Restraints Are Introduced.

BACKGROUND: Hospital outcomes among patients acting aggressively or violently have not been extensively studied in the United States. OBJECTIVES: The aims of the study are to determine rates of physical restraint use among hospitalized patients who are aggressive/violent and to characterize associations with mortality and utilization metrics. DESIGN/SETTING/PARTICIPANTS: National Inpatient Sample databases from 2016 to 2019 were analyzed with multivariable regression to compare aggressive/violent patients in whom physical restraints were or were not used. MEASURES: Prevalence of physical restraint use, in-hospital mortality, length of stay, and total hospital charges were measures. RESULTS: A total of 40,309 hospitalized patients were coded as having aggressive/violent behavior, of whom 4475 (11.1%) were physically restrained. Physically restrained patients were younger (mean age ± standard error, 42.6 ± 0.64 versus 45.7± 0.41; P < 0.01), more frequently male (71.0% versus 65.4%; P < 0.01), and had less comorbidity (Charlson Index score >3: 7.9% versus 12.5%; P < 0.01) than unrestrained patients. Patients with physical restraints had higher odds of in-hospital mortality (adjusted odds ratio, 2.4, confidence interval [CI], 1.0-5.7; P = 0.04) and lower odds of being discharged to home (adjusted odds ratio, 0.46; CI, 0.38-0.56; P < 0.01) compared with unrestrained patients. Longer hospital stays (adjusted mean difference, 4.1 days CI, 2.1-6.0; P < 0.01) and higher hospitalization charges (adjusted mean difference, $16,996; CI, 6883-27,110; P < 0.01) were observed for those who were physically restrained. CONCLUSIONS: Physically restrained aggressive/violent patients had worse in-hospital outcomes compared with their unrestrained counterparts. Avoiding physical restraints whenever possible should be considered when managing this confrontational yet vulnerable patient population. When restraints are needed, providers must thoughtfully bear in mind heightened risks for worse outcomes.

Association of Obesity on Outcomes of Hospitalized Patients with Cerebral Palsy.

OBJECTIVE: Among hospitalized adults with cerebral palsy (CP), it is unknown whether obesity is associated with clinical and resource utilization outcomes. We sought to identify the association of obesity on clinical and resource utilization outcomes in this population. METHODS: This retrospective cohort study analyzed years 2016 and 2017 of the Nationwide Inpatient Sample database and examined hospitalized adults with CP. Regression analyses were used to evaluate mortality and resource utilization. RESULTS: In total, 154,219 adults with CP were hospitalized. Among them, 13,475 (8.7%) had a secondary diagnosis for obesity. Patients with obesity were older (mean age ± standard error of the mean: 49.9 ± 0.18 versus 44.7 ± 0.18 years, P < 0.01), a greater proportion were female (60.7% vs 43.2%, P < 0.01), and were more likely to be insured by Medicare (65.2% vs 56.2%, P < 0.01). Patients with obesity had higher comorbidity burdens (Charlson comorbidity score ≥ 3: 22.3% vs 9.8%, P < 0.01). Those with obesity had lower mortality rates (1.6% vs 2.4%; P < 0.01). After adjustment for confounders, mortality for patients with obesity remained lower (adjusted odds ratio 0.5, 95% confidence interval [CI] 0.4-0.7, P < 0.01). Hospital charges (adjusted mean difference $2499, 95% CI $6202-$1202, P = 0.18) and length of stay (adjusted mean difference 0.01 days; 95% CI -0.28 to 0.31, P = 0.93) were not significantly different between the groups. CONCLUSIONS: Obesity was associated with reduced mortality among adult patients in the hospital who had CP. This finding is consistent with the obesity paradox that has been observed repeatedly in patients with other chronic diseases. Further studies investigating hospitalized patients with CP are needed to corroborate these findings.

Palliative Care Involvement in Patients Hospitalized in the United States with Aneurysmal Subarachnoid Hemorrhage.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) has a high mortality rate and significantly impacts survivors' quality of life. Objective: To assess impact of specialty palliative care services (sPCS) among patients hospitalized with aSAH. Design: A retrospective cohort study using the National Inpatient Sample (2017-2018). Setting/Subjects: U.S. adult patients hospitalized for aSAH with and without sPCS involvement. Measurements: Mortality and health care utilization variables. Results: Among 48,050 patients with aSAH, 12.7% received sPCS input. aSAH patients with sPCS were more likely to be sicker (higher National Inpatient Sample-subarachnoid hemorrhage [NIS-SAH] severity score, p < 0.01). Patients with sPCS had a 70% in-hospital mortality rate, whereas only 9% of the rest of this cohort died during the incident hospitalization (p < 0.01). Those with sPCS involvement had shorter lengths of stay (p < 0.05) and nonsignificantly lower hospital charges. Conclusion: sPCS involvement, inferred by International Classification of Diseases, 10th Revision (ICD-10) code Z51.5, was associated with shorter length of stay and lower hospital charges among survivors, but this did not meet prespecified statistical significance. There may be significant benefits to consulting sPCS for patients hospitalized with aSAH.

Severe vision impairment and blindness in hospitalized patients: a retrospective nationwide study.

BACKGROUND: Outcomes among hospitalized patients with severe vision impairment or blindness have not been extensively explored. This study sought to determine clinical and resource utilization outcomes in patients with severe vision impairment/blindness (SVI/B). Because obesity is very common among those who are hospitalized, we also sought to understand its impact among patients with SVI/B. METHODS: We conducted a retrospective study using the National Inpatient Sample for the year 2017; hospitalized adults with and without SVI/B were compared. In addition, for all patients with SVI/B, we compared those with and without obesity. Multiple logistic regression and linear analysis were used to evaluate mortality, disposition, length of stay, and hospital charges; the analyses were adjusted for multiple variables including age, sex, and race. RESULTS: 30,420,907 adults were hospitalized, of whom 37,200 had SVI/B. Patients with SVI/B were older (mean age ± SEM: 66.4 ± 0.24 vs. 57.9 ± 0.09 years, p < 0.01), less likely to be female (50 % vs. 57.7 %, p < 0.01), more frequently insured by Medicare (75.7 % vs. 49.2 %, p < 0.01), and had more comorbidities (Charlson comorbidity score ≥ 3: 53.2 % vs. 27.8 %, p < 0.01). Patients with SVI/B had a higher in-hospital mortality rate (3.9 % vs. 2.2 %; p < 0.01), and had lower odds to be discharged home after hospital discharge (adjusted Odds Ratio {aOR} =0.54, [Confidence Interval (CI) 0.51-0.58]; p < 0.01) compared to those without SVI/B. Hospital charges were not significantly different (adjusted Mean Difference {aMD} = $247 CI [-$2,474-2,929]; p = 0.85) but length of stay was longer (aMD = 0.5 days CI [0.3-0.7]; p < 0.01) for those with SVI/B. Patients with vision impariment who were also obese had higher total hospital charges compared to those without obesity (mean difference: $9,821 [CI $1,375-$18,268]; p = 0.02). CONCLUSIONS: Patients admitted to American hospitals in 2017 who had SVI/B had worse clinical outcomes and greater resources utilization than those without SVI/B. Hospital-based healthcare providers who understand that those with SVI/B may be at risk for worse outcomes may be optimally positioned to help them to receive the best possible care.

A Nationwide Study Examining Deafness Among Hospitalized Adults.

Background It is unknown whether hospital outcomes differ among nonspeaking deaf patients compared to those without this disability. Objective This article aims to compare clinical outcomes and utilization data among patients with and without deafness. Design This study used a retrospective cohort study. Setting and Participants The participants included Nationwide Inpatient Sample, year 2017, hospitalized adults with and without diagnostic codes related to deafness and inability to speak. Method Multiple logistic and linear regression were used to compare in-hospital outcomes. Results Thirty million four hundred one thousand one hundred seventeen adults were hospitalized, and 7,180 had deafness and inability to speak related coding. Patients with deafness were older (mean age ± SEM: 59.2 ± 0.51 vs. 57.9 ± 0.09 years, p = .01), and less likely female (47.0% vs. 57.7%, p < .01) compared to controls. Those with deafness had more comorbidities compared to the controls (Charlson comorbidity score ≥ 3: 31.2% vs. 27.8%, p < .01). Mortality was higher among deaf versus controls (3.6% vs. 2.2%; p < .01); this translated into higher adjusted odds of mortality (adjusted odds ratio = 1.7. [confidence interval (CI) 1.3-2.4]; p = .01). Deaf patients had lower odds of being discharged home compared to controls {aOR} = 0.6, (CI) 0.55-0.73]; p < .01. Length of stay was longer (adjusted mean difference = 1.5 days CI [0.7-2.3]; p < .01) and hospital charges were higher, but not significantly so (adjusted mean difference = $4,193 CI [-$1,935-$10,322]; p = .18) in patients with deafness. Conclusions Hospitalized nonspeaking deaf patients had higher mortality and longer hospital stays compared to those without this condition. These results suggest that specialized attention may be warranted when deaf patients are admitted to our hospitals in hopes of reducing disparities in outcomes. Supplemental Material https://doi.org/10.23641/asha.14336663.

Malnutrition in Hospitalized Adults With Cerebral Palsy.

BACKGROUND: Malnutrition among hospitalized adults with cerebral palsy (CP) has not been extensively explored. We sought to identify impacts of malnutrition on clinical and resource outcomes among hospitalized adults with CP. METHODS: This retrospective cohort study surveyed years 2016 and 2017 from the National Inpatient Sample database. Regression models evaluated mortality and resource utilization. RESULTS: 154,219 adults with CP were hospitalized. Among them, 21,064/154,219 (13.5%) had malnutrition. Patients with and without malnutrition were similar in age (mean age ± SEM, 45.1 ± 0.30 vs 45.2 ± 0.18 years; P = .70). Patients with malnutrition were more likely male (12,175/21,604 [57.8%] vs 72,929/133,155 [54.8%], P < .01) and had higher comorbidity scores (Charlson comorbidity score ≥ 3; 2,464/21,064 [11.7%] vs 14,380/133,155 [10.8%]; P = .01). Mortality rates were higher among patients with malnutrition (905/21,064 [4.3%] vs 2,796/21,064 [2.1%], P < .01), and they had higher odds for mortality (adjusted odds ratio [aOR] = 2.1; CI, 1.7-2.5; P < .01). Those with malnutrition were less likely discharged home (aOR = 0.52; CI, 0.48-0.56; P < .01). Hospital charges were higher (adjusted mean difference [aMD] = +$42,540; CI, $36,934-48,146; P < .01) and length of stay longer (aMD = +4.3 days; CI, 3.9-4.7; P < .01) among patients with malnutrition. CONCLUSION: Malnutrition in hospitalized patients with CP is associated with increased mortality and hospital resource utilization. Flagging these patients as being "high risk" when they are hospitalized may result in heightened attentiveness about clinical outcomes in this vulnerable population.

Clinical outcomes among morbidly obese patients hospitalized with diabetic foot complications.

The aim of the study is to investigate effects of morbid obesity on patients hospitalized with diabetic foot ulcers and infections (DFU/Is). This retrospective cohort study of hospitalized adults investigated patients with a principal diagnosis of DFU/Is, and compared outcomes based on weight. The primary outcome was lower limb amputations. Secondary outcomes included in-hospital mortality, morbidity (sepsis and discharge disposition), resource utilization (length of stay [LOS] and total hospitalization charges). Multivariate analyses adjusted for confounders. A total of 31 730 admissions were included; 14% were morbidly obese. Patients with morbid obesity had overall lower rates of amputations (adjusted odds ratio [aOR]: 0.60; 95% confidence interval [CI]: 0.45-0.80). There was no difference in mortality rates between those who were morbidly obese and the non-morbidly obese patients (aOR: 3.89 [95% CI: 0.79-19.30]). Combined data from 2010 to 2014 have found higher odds of sepsis in morbidly obese patients compared with non-morbidly obese patients after adjusting for confounders (aOR: 1.49 [1.09-2.02], P = 0.01). Patients with morbid obesity were less likely to be discharged to home (aOR: 0.82 [95% CI: 0.70-0.95]), had longer LOS (adjusted mean difference [aMD]: 0.47 [95% CI: 0.13-0.81]) and higher hospital charges (aMD: $3205 [95% CI: $3373-$6037]). Despite having lower amputation rates compared to those who are not morbidly obese, patients with morbid obesity hospitalized for DFU/Is succumbed to sepsis more frequently and had less favourable utilization metrics. Specialized care pathways may be needed to enhance the value of care delivered to this high-risk population.

Oral Rehydration Therapy and Feeding Replaces Total Parenteral Nutrition: A Clinical Vignette.

A 27-year-old patient with spina bifida and a high output loss of water and electrolytes from her ileostomy was successfully liberated from dependency on total parenteral nutrition and intravenous fluid and electrolyte replacement by the use of a rice-based oral rehydration therapy (ORT). This allowed her to return home to the care of her mother. We suggest that ORT can be effective in the context of modern high-technology settings, as well as in resource-poor situations.