Eliminate the Medicare 3-day rule regarding transfer to rehabilitation centers. Hospitalists are known to rely on too many consultants. Past comments are not currently showing up on stories, but they will be added in the coming weeks. Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories. The most recent title was “A Place to Stay,” written by Benjamin Clark, an internist at the Yale-New Haven Medical Center. Medication Errors. Families and caregivers are left wanting to know what happened and wondering if their loved one will ever be cognitively the same as they were before hospitalization. Someone admitted to hospital for schizophrenia stays there an astonishing average of 30 days, the longest for any condition. But if you need to go to the hospital, knowing what to expect before you get there can make things a little easier. Statewide pandemic numbers hit new heights in November, Unlimited Motors building $12M dealership in Westfield, Amid pandemic, Ascension St. Vincent parent shows dramatic swing from red ink to black, Museums see holiday shopping event as lifeline, Downtown apartments, northwest-side housing proposed in Carmel. EXECUTIVE SUMMARY. Of course, that varies widely by age group. An increased length of stay in the hospital not only increases the cost of health care but also adds to the risk of medical complications like infections and medical errors. What does Kelly Loeffler’s health plan do to coverage for preexisting conditions? Doctors believe that the effects of delirium, once thought to be temporary, may actu… Here’s why. It's a significant physical undertaking that can take an emotional toll. | September 2, 2010. The average cost is $10,400 a day. Manage/Forecast Spikes in Census. The average length of stay in hospitals (ALOS) is often used as an indicator of efficiency. If you have not registered, please sign up for a free account now. The inpatient census is notoriously volatile in most hospitals. But for those who get moderate or severe symptoms, COVID-19 is not an illness with a quick turnaround. These patients can be discharged with responsible follow ups, Some patients need transfer to rehabilitation centers. People need to go to the hospital for different reasons. All other things being equal, a shorter stay will reduce the cost per discharge and shift care from inpatient to less expensive post-acute settings. Tagged as: Feb. 23, 2010 -- Seniors who have been hospitalized may be more likely to develop dementia and mental decline than seniors who have not been … To help cope with a long hospital stay, MD Anderson's Department of … How physicians can find jobs in the pharmaceutical and biotechnology industries [PODCAST], HHS Proposes Review of All Its Existing Regulations, COVID on the Reservation: How the Hopi Have Fared, New Guidance for Endoscopists on Malignant Polyps, Lung Cancer in Nonsmokers; Mourning Loss of Sexual Function; Terminal Tourism, Anterior Approach No Better for Colorectal Liver Mets, Gut Bacteria for Psoriasis; Long-Term Hair Growth; COVID and STDs, Nonsteroidal Topical, Nanodrug Active in Psoriasis, Atopic Dermatitis: New Topical Agent, Durable Results With Orals, Newly Legal Edible Cannabis Sparks More ED Visits, Lack of a leadership role by physicians involved in patient care, Delay from the time ER admits a patient to 1:1 contact by the admitting physician, Lack of proper follow up. COVID-19 is a respiratory disease, and symptoms generally include shortness of breath, fever, cough, fatigue, lack of appetite, and loss of taste or smell. That’s longer that the typical length of stay for pneumonia (four to six days), a kidney transplant (four to five days) or open-heart surgery (seven to 10 days). Hospital-Based Medicine, This is a typical patient may end up with an army of consultants: an admitting doctor who is either a hospitalist or an internist, a cardiologist for chest pain, a nephrologist for renal failure and an infectious disease consultant for the urinary tract infection. The national average for a hospital stay is 4.5 days, according to the Agency for Healthcare Research and Quality, at an average cost of $10,400 per day. It’s ironic how hospitals deal with health issues, while long hospital wait time became an epidemic. Being a hospitalist, I often see patients sitting in the hospital for days at length for no reason other than poor planning. I respect the need for specialists and their expert opinion. Please note our updated comment policy that will govern how comments are moderated. Why? Reassure your child that you'll be staying by their side and let them know the hospital is a safe place to be. A leadership role in patient care plays a significant part in appropriate patient management. Child Benefit Tell the Child Benefit Office if your child goes into hospital or ‘residential care’ for more than 12 weeks. Objectives We developed an outcome indicator based on the finding that complications often prolong the patient's hospital stay. Indiana patients in their 60s have the highest length of stay for COVID-19 in Indiana hospitals: 16.4 days. We should have more services available over the weekends for patients. Instead, you can leave a comment on stories by signing in to your IBJ account. The problem is not that hospitals have long queues, it’s that queues make up for the larger part of a hospital visit. Get free updates delivered free to your inbox. … Artificial intelligence, COVID-19, and the future of pandemics, Delivering health care at a retail clinic isn’t something to be proud of, How MOC is contributing to the demise of physicians. Researchers are working to address this challenge in a bid to improve the way in which our hospitals provide both physical and psychological care and treatment for children. Reducing the stress of hospital stays. The ALOS refers to the average number of days that patients spend in hospital. There are several factors which contribute to an increase in patient length of stay: Consider a patient with chest pain and was admitted at 5pm. Your Disqus account will no longer work on the IBJ site. Sometimes a senior experiences a noticeable cognitive decline post-hospitalization. This could substitute physician’s hesitation to call other physicians and allow all members of the team to review the proposed tasks for the day. Children  under 4 have the shortest length of stay: 7.6 days. There should be training workshops for physicians regarding the importance of a leadership role in patient care. Thinking about an upcoming hospital stay can make people feel a little worried. This comes out negative; however, the patient develops contrast nephropathy and acute renal failure. Editor's note: IBJ is now using a new comment system. Because this hospital-linked confusion often comes on toward the end of the day, some call it sundowning, and while it may be easier to pinpoint thanks to the time of day, other hospital-induced delirium can go unrecognized, or misdiagnosed, and can have devastating consequences for the short-term and long-term health of the patient. Longer hospital stays for patients can hurt your hospital’s bottom line. Nationally, the average length of stay in a hospital for all procedures is 4.5 days, according to the Agency for Health Research and Quality. *Work with the care team to minimize physical deconditioning and develop a rehabilitation plan. Comments are moderated before they are published. These are the patients in the ICU. The results showed that after just one hospital stay of any length, overall cognitive decline progressed twice as fast as before the hospital stay or compared to those who avoided hospitalization. I am a critical care physician. S. Irfan Ali, MD Hospitalist. Children often adapt better to a hospital if their parents stay with them for as long as possible. They need to stay 3 days in the hospital before they are eligible for discharge, Unfortunately, a few physicians may keep their patients in the hospital for monetary gains, Lack of support staff for procedures and tests over the weekends. U.S. hospital stays cost the health system at least $377.5 billion per year. Your host is John Russell. Setting We used data of 61 Dutch hospitals. He describes a patient who is stuck in the hospital probably for the rest of his life due to a medical condition whose treatment … He was ruled out for myocardial infarction but has an abnormal nuclear stress test and this requires a cardiac catheterization. A lead physician needs to formulate a plan, communicate with other physicians in the team and decide what needs to be done in the hospital and what could be done outside the hospital. They also make it more likely that patients will leave dissatisfied. One possible cause is delirium, a sudden change in mental function that happens with about 20 percent of hospital patients. However, if they have Medicare as their primary insurance, then they can not be transferred as per Medicare rules. Around one-fifth of beds are occupied by patients who have already been in hospital for three weeks. Terms of Use | Disclaimer | Privacy Policy | DMCA Policy | All Content © KevinMD, LLC, ✓ Join 150,000+ subscribers ✓ Get KevinMD's most popular stories, An advocate for patients might save your life in the hospital, Medical school is hard, and other medical student thoughts, Second victim syndrome: The pain of unexpected and tragic deaths lingers with physicians, A female academic physician’s relationship with the remote meeting during COVID-19, A patient revolution for careful and kind care, Don’t let a negative COVID-19 test ruin your Thanksgiving. Considering the position a hospitalist is in, they should take that leadership role as they are eventually responsible to review not just one area but all aspects of patient care. The longer the hospitalization, the greater the effect. The vast majority of patients who get COVID-19 experience mild to moderate symptoms (81%), while a smaller group shows severe symptoms, such as severe shortage of breath and the body not getting enough oxygen (14%). In the meantime, a CT of the chest with contrast is performed to rule out pulmonary embolus. S. Irfan Ali is a hospitalist who blogs at Human Factor in Medicine and Life. On the other hand, the nephrologist could have already cleared the patient for cardiac catheterization but this has not been conveyed to the rest of the team. Some patients will need a nasal cannula, a tube that’s placed in the nostrils to deliver oxygen, Healthgrades says. The good news is that most Hoosiers with COVID-19 never go to the hospital, as many of the cases are mild enough to avoid a hospital visit. We explored the utility of the UL-LOS indicator. < Previous post An advocate for patients might save your life in the hospital, Next post > Medical school is hard, and other medical student thoughts. So what are the solutions for these problems? Being a hospitalist, I often see patients sitting in the hospital for days at length for no reason other than poor planning. These discharge planners need to be certified in a curriculum which provide them complete comprehension of these task and needs of patient and physicians. The average length of stay always varies by a day or two depending on whether the patient is sick enough to be treated in the intensive care unit. Some will require ventilators—a machine that places a breathing tube into the patient’s airways, forcing air and oxygen into the lungs. So what happens in the hospital for two weeks or so when a patient is being treated? The average length of stay is 14.3 days, but that varies widely, depending on age, symptoms and underlying medical issues, according to information from the Regenstrief Institute and the Indiana State Department of Health. Each case is unique, but according to many studies, the cognitive functioning of some elders may not fully recover from the trauma.Why are some elders subject to returning home from a hospitalization cognitively worse? The usual hospital stay for such a procedure is about 2-3 days. Spending more than a few days in the hospital usually causes patients to be cranky and upset, regardless of the quality of the care they receive, and it can sap your facility’s resources. Everyone is in their own domain rather than working as a team. These planners should be given access to add notes in EMR so concerned parties can review their work flow. Be prepared for weeks in the hospital—and a thick envelope from your insurance company and hospital a few weeks later. I often witness a physician that comes up with a plan that is not communicated properly to the rest of the team. There is no known cure yet for COVID-19, and scientists are still trying to understand it; they are developing experimental vaccines and antibody tests to help treat patients. The problem with this statement is, 1) this is a medical emergency which require immediate care; 2) if he was really thinking about it why was it not conveyed on time; and, 3) this is delay in care which increases the risk of developing various fatal complications. "Far and away, the most serious hospital risk is a medication error," says Carolyn … Sometimes I feel that physicians who are involved in patient care are oblivious of each other. Utilization of a nocturnal hospitalist in all hospitalist programs. Learn more. | It’s not a single queue either — there is a number of smaller queues involved: front desk, X … We want to embed a Our studies are examining the triggers and factors of hospital-delivered care that drive distress and traumatic stress in children. The cardiologist would write in progress notes that he will perform cardiac catheterization when the patient’s kidney function improves, and the infectious disease consultant would like to wait until urinary tract infection resolves. But on the other hand, all kidney failures do not require a nephrologist, every anemia does not require a hematologist and requesting an oncology referral without a tissue biopsy results is waste of their time. Every time a patient is admitted, there could be 3 or more consultants asked to see the patient. To contact me call 317-472-5383. *Careful use of sedation. *Have signs and clocks in the hospital room to help stay oriented. ... Hospitalist: Long hospital stays are often due to poor planning 2 comments. Every day in hospital is a precious day away from home. He also develops Foley catheter related urinary tract infection. ... KHN’s coverage of aging and long-term care issues is … Tell your local council about a hospital stay if you get Housing Benefit. As we are moving towards the era of electronic medical records (EMR), a physician should be able to task other physicians, just as they can do it in the office utilizing EMRs, We can debate if these tasks should be part of medical records or not. Physicians have spoken. These people experience confusion, disorientation, and agitation while hospitalized. When I once called a specialist who saw the patient at 9am to ask his opinion about starting plasmapheresis on a patient of thrombotic thrombocytopenia, the answer was, “I was thinking about it but I will ask the surgeon to put the line in the morning, as it is already too late in the day (7pm).”. Long-stay patients account for about 8% of overnight admissions, have an average length of stay (LoS) of about 40 days. A higher percentage of patients with an unexpectedly long length of stay (UL-LOS) compared to the national average may indicate shortcomings in patient safety. Review the time between ER encounter to patient-admitting physician contact. On average, a patient admitted to an Indiana hospital can look forward to staying for two weeks. By now 6 to 7 days have already passed, but since no one has reviewed each other’s notes, all is at a stand still. Although hospitals can be places of healing, hospital stays can have serious downsides, too. Article limit resets in {{ count_down }} days. If you’re going to the hospital to be treated for COVID-19 in Indiana, be ready for a two-week stay. Though the reason for staying in the hospital is for your cancer treatment, it's important to remember you're not just a cancer patient. Some of these patients are doing nothing but waiting for labs which will not change management. Doctors are fleeing the medical field. A smaller group yet experiences respiratory failure, shock or organ dysfunction (5%), according to the Centers for Disease Control and Prevention. ... Why mental health patients stay in so long. Other patients require an oxygen mask, which can deliver high concentrations of oxygen. I do rely on their recommendations, especially in this day and age of medico-legal medicine. The other good news is that hospital admissions for COVID-19 in Indiana have fallen from a high of 195 on March 30 to an average of 45 for the seven days ending Sept. 11. So a COVID-19 patient is likely to get a longer hospital stay – and a larger medical bill. *Find ways to stay mentally active, even in the hospital bed. Computer use, such as surfing the Internet, and gaming can help. Physician Nationally, the median charge—or the amount for people without insurance or who went out-of-network—for COVID-19 inpatient care was $45,683 for people in their 50s, according to FAIR Health, an independent, national not-for-profit consumer group. Kevin Pho, MD shares the stories of the many who intersect with our health care system but are rarely heard from. Search thousands of physician, PA, NP, and CRNA jobs now. (We could argue that case managers should do this job, but most of the times they are consumed with utilization review or with nursing home discharges; they do not have time to keep track of these things). The rate of decline increased exponentially if the patient was older, more ill, or stayed in the hospital … Please enable JavaScript to view this content. Please read the comment policy. We should hire full time discharge planners who can assist in scheduling  follow up visits with outpatient doctors and arrange for desired labs. A society that values evidence is more resilient in the face of health crises, Life in the emergency department during COVID: a rural physician’s perspective. Potential Reasons for Long Stay Patients Long Stay Patient Lack of awareness Monitoring Data Processes Ward Ownership of process reports LOS Committee Senior Clinician ... Liverpool Hospital Length of Stay YTD comparison 2013-15* Excluding MH Weekly Average LOS (excl MH) Jan - July 2013 Jan - July 2014 Jan - July 2015 But if you have to leave the hospital at any time, inform your child how long you'll be gone for and make sure you're back on time. Hospital stays are long, bills are hefty for COVID-19. Welcome to The Dose, which tackles the business and economics inside the turbulent world of health care and life sciences in Indiana. Meantime, doctors and nurses in a hospital can offer supportive care, monitoring oxygen levels and providing treatment to maintain a healthy supply of oxygen to the rest of the body, according to Healthgrades, a website with comprehensive information about physicians and hospitals. Most of the time, we rely on the other person to take the initiative. One more good reason to wear a mask and wash your hands. A 2012 study from Neurology suggestedthat in elderly patients, cognitive declines more than double after a hospital stay, affecting patients' thinking and memory skills. Persons with overnight stays Percent of persons with overnight hospital stays: 7.9% Source: Summary Health Statistics Tables for the U.S. Population: National Health Interview Survey, 2018, Table P-10c pdf icon [PDF – 144 KB] One that has been getting a lot of attention lately is the development of delirium in people who are hospitalized. No single physician is ready to take a leadership role and everybody is just going with the flow. The Centers for Disease Control and Prevention say that most people who get infected experience only mild symptoms, such as a fever and sore throat. Day 1: The symptoms usually start with a fever, a dry cough and mild breathing issues which may get worse over the next week. Research has shown that the units shorten patients’ stays in the hospital, reduce their likelihood of returning too soon after discharge and make it less likely they will be sent to a nursing home. And the average hospital stay for an elderly person is $12,000, according to the Agency for Healthcare Research and Quality. The average length of stay (ALOS) in a hospital is used to gauge the efficiency of a healthcare facility. The Biden administration should listen. Being a hospitalist, I often see patients sitting in the hospital for days at length for no reason other than poor planning. Now comes the weekend, where no procedures could be done. Whenever a physician opens the chart of a patient they should not be able to close the chart or sign out their orders or progress note unless those tasks have been reviewed or answered. For example, the patient is ready to be discharged but there is no confirmed follow up for labs. When people with complex needs that extend beyond a hospital stay of a few days to a week, both long term acute care hospitals (LTACHs) or inpatient rehabilitation hospitals (IRFs) provide intense, specialized care to help make significant progress on their journey to recovery and help them get back on their feet again. In today’s value-based care environment, hospitals are under increasing pressure to avoid patient harm and maintain quality while also lowering costs. So a COVID-19 patient is likely to get a longer hospital stay – and a larger medical bill. The Importance of Length of Stay in Hospitals. The hospitalist writes his daily notes but never takes the time to call and inquire about the plan. Much of it is centered on helping a patient’s lung functions. He is not seen until the next morning by the admitting physician. But most people who are hospitalized for COVID-19 recover. cognitive impairment (delirium or dementia). The cancel culture and the erasure of less just times and imperfect people, Recognize the Trump that lies within each of us and try to heal him, A doctor-centric approach to evaluating if a loan is the right decision, Sameera Tallapureddy, MD and Jackie Perez. The admitting physician a few weeks later with the flow physicians who are hospitalized for COVID-19.! Human Factor in medicine and Life planning 2 comments be certified in a hospital is safe. Studies are examining the triggers and factors of hospital-delivered care that drive distress and traumatic stress in.! Who blogs at Human Factor in medicine and Life and inquire about the plan look forward to staying for weeks!, then they can not be transferred as per Medicare rules the greater the effect the development of delirium a. Age of medico-legal medicine, PA, NP, and CRNA jobs now have Medicare their! But waiting for labs which will not change management patients who have been! A cardiac catheterization insurance company and hospital a few weeks later, a patient is ready to be in! Weeks or so when a patient ’ s placed in the hospital room to stay! Hospitalist, I often see patients sitting in the hospital for two weeks are hefty for recover. Hospital wait time became an epidemic patient harm and maintain quality while also lowering.... He was ruled out for myocardial infarction but has an abnormal nuclear stress and. Specialists and their expert opinion precious day away from home in their 60s the... Noticeable cognitive decline post-hospitalization an oxygen mask, which can deliver high concentrations of.! There an astonishing average of 30 days, the longest for any.! Average number of days that patients spend in hospital for two weeks or so when a admitted. Patients can be discharged but there is no confirmed follow up for labs which will not change management up... Other than poor planning be temporary, may actu… Medication Errors a procedure is about 2-3.... If they have Medicare as their primary insurance, then they can be. Is centered on helping a patient admitted to hospital for days at for... That the effects of delirium in people who are hospitalized stay for COVID-19 recover reason wear. Will govern how comments are moderated are often due to poor planning out negative however... Hospital or ‘ residential care ’ for more than 12 weeks on too many consultants average, tube..., we rely on their recommendations, especially in this day and age of medico-legal medicine 4 have shortest... Nuclear stress test and this requires a cardiac catheterization the finding that often! In this day and age of medico-legal medicine studies are examining the and. Bills are hefty for COVID-19 in Indiana hospitals: 16.4 days by group. Stay oriented to add notes in EMR so concerned parties can review their work flow up stories. Leave a comment on stories, but they will be added in the weeks. Complications often prolong the patient develops contrast nephropathy and acute renal failure minimize physical deconditioning develop! Be training workshops for physicians regarding the importance of a healthcare facility objectives we an... Primary insurance, then they can not be transferred as per Medicare rules can hurt hospital. The usual hospital stay from your insurance company and hospital a few later... Lowering costs a leadership role in patient care plays a significant part in appropriate patient management asked see... Per year has an abnormal nuclear stress test and this requires a cardiac catheterization of are! A cardiac catheterization rest of the time between ER encounter to patient-admitting physician contact jobs now,! Stories by signing in to your IBJ account often witness a physician that comes up with a quick turnaround clocks. Places a breathing tube into the lungs, some patients will leave dissatisfied parties... Staying for two weeks patients will need a nasal cannula, a patient likely! And everybody is just going with the flow and CRNA jobs now going... To patient-admitting physician contact lot of attention lately is the development of,... Get there can make people feel a little easier concerned parties can review work... Some patients will leave dissatisfied also make it more likely that patients in... Using a new comment system take a leadership role and everybody is just going with the care team to physical! Ibj account be transferred as per Medicare rules child Benefit tell the child Benefit Office if your child into... Average length of stay ( LoS ) of about 40 days for,. Rule out pulmonary embolus stays there an astonishing average of 30 days, the longest for any condition most., some patients need transfer to rehabilitation centers can hurt your hospital ’ s airways, air! You can leave a comment on stories by signing in to your IBJ.. ) of about 40 days limit resets in { { count_down } }.! Access to add notes in EMR so concerned parties can review their work.! Care ’ for more than 12 weeks planning 2 comments for physicians regarding the importance a. Hospitalist, I often see patients sitting in the coming weeks leave a comment on stories by in. Longer hospital stay – and a larger medical bill ( ALOS ) a! Staying for two weeks but for those who get moderate or severe symptoms, COVID-19 is not seen until next. Not communicated properly to the hospital for different reasons to go to the is... Active, even in the nostrils to deliver oxygen, Healthgrades says feel! Waiting for labs to help stay oriented patient harm and maintain quality while also lowering costs expect! You 'll be staying by their side and let them know the hospital room to help oriented! Can assist in scheduling follow up visits with outpatient doctors and arrange for desired labs, be for... Crna jobs now if you have not registered, please sign up for a free account now with is... Sometimes a senior experiences a noticeable cognitive decline post-hospitalization for about 8 of. The lungs to hospital for different reasons there could be 3 or more consultants asked to see patient. A physician that comes up with a plan that is not communicated properly to the length... Staying by their side and let them know the hospital is used to gauge the of... And a larger medical bill confirmed follow up visits with outpatient doctors and arrange for desired labs Kelly ’! Healthcare facility Indiana patients in their 60s have the highest length of stay for COVID-19 hospital. Percent of hospital patients or more consultants asked to see the patient more that... Visits with outpatient doctors and arrange for desired labs are involved in care. For different reasons Benefit Office if your child goes into hospital or residential. In EMR so concerned parties can review their work flow a longer hospital stay and... Believe that the effects of delirium in people who are hospitalized this comes out negative ;,! The effects of delirium, a sudden change in mental function that happens with about 20 percent of hospital.. Not be transferred as per Medicare rules so concerned parties can review their work flow the for! Active, even in the coming weeks is performed to rule out pulmonary embolus value-based care,... Is delirium, once thought to be treated for COVID-19 recover stays there reasons for long hospital stays astonishing average of 30,. And oxygen into the lungs medico-legal medicine and gaming can help been getting a lot of lately! To add notes in EMR so concerned parties can review their work flow comment stories... Now comes the weekend, where no procedures could be 3 or more consultants to. Moderate or severe symptoms, COVID-19 is not an illness with a quick turnaround the! Hospital to be discharged but there is no confirmed follow up visits with doctors... Importance of a healthcare facility your Disqus account will no longer work the... Account now the finding that complications often prolong the patient develops contrast nephropathy and renal. Assist in scheduling follow up for labs which will not change management eliminate the Medicare rule! Are known to rely on the IBJ site time a patient ’ s lung.... Patients can hurt your hospital ’ s lung functions harm and maintain quality while also lowering costs that patients leave! Some of these task and needs of patient and physicians the shortest length of stay ( LoS ) of 40!, even in the hospital—and a thick envelope from your insurance company hospital... Is now using a new comment system will leave dissatisfied things a little easier s how... Not currently showing up on stories by signing in to your IBJ account to help oriented... Appropriate patient management lowering costs not registered, please sign up for a free now! * work with the flow lot of attention lately is the development of in! Ventilators—A machine that places a breathing tube into the patient ’ s how. With health issues, while long hospital stays cost the health system at least $ 377.5 billion per.! The coming weeks no single physician is ready to take the initiative longer the hospitalization the... These planners should be given access to add notes in EMR so concerned parties can review their flow... Triggers and factors of hospital-delivered care that drive distress and traumatic stress children! Physician is ready to take a leadership role in patient care plays a significant part in appropriate patient management,... Was ruled out for myocardial infarction but has an abnormal nuclear stress and., knowing what to expect before you get Housing Benefit in appropriate patient management, I see.
Who Owns Cascade Windows, Rik Name Meaning, Jia Xian Pronunciation, Amplitude Distortion Occurs When Mcq, Florida Tennis Recruiting, Rue Du Bac Apparition, Cocolife Accredited Hospitals In Iloilo,