A comparison of national immunization rates to immunization rates of Latino diabetic patients receiving clinical pharmacist interventions in a federally qualified community health centre (FQHC)

Background: The transition from hospital to home for older individuals can be complicated, as they are more likely to have complex health and/or social care needs. Several published studies have outlined positive outcomes from pharmacist-driven transition of care programs. At our four geriatric primary care clinics affiliated with a large academic medical center, there is no medication reconciliation process to evaluate a patient's medications after being discharged from the hospital to home. Objective: The objective of this pilot program was to demonstrate the need for a pharmacist-led transition of care medication reconciliation program within a geriatric primary care setting. Design: This is a retrospective evaluation of a pilot program that took place from July 1, 2022, to June 30, 2023, within 4 geriatric primary care clinics affiliated with a 523-bed, full-service medical and surgical acute care hospital. Electronic medical records (EMR) were utilized to identify patients who were discharged from the hospital within 24 to 72 hours to their homes. Documentation in the patient's EMR by the primary care clinic's clinical pharmacist contained confirmation of a hospital follow-up appointment, completion of medication reconciliation, notification to the provider for pharmacotherapy concerns, and patient counseling on medication changes. Information on number of patients requiring clinical pharmacist intervention prior to hospital follow-up appointment, intervention type, average number of medication discrepancies per patient, and percentage of hospital follow-up appointments with a medication reconciliation completed prior to visit were also documented. Setting: Four geriatric primary care clinics affiliated with a 523-bed, full-service medical and surgical acute care hospital in Gainesville, Florida. Patients, Participants: A total of 881 unique medication reconciliations were completed for this retrospective pilot program study. Patients were included if they were discharged from the hospital to home during that time period and were active patients of a provider at the primary care clinic. Patients were excluded if they were discharged from the hospital to another acute care facility (such as a skilled nursing facility, rehabilitation facility, or hospice), if the patient expired during their hospitalization, or if they were not an active patient of a provider at the primary care clinic. Intervention: A primary care clinical pharmacist reviewed each discharged patient's EMR from the hospital to reconcile their medications with the medication list within the patient's primary care EMR. A transitions of care medication reconciliation evaluation progress note was created for each patient discharged home for documentation. Within this note, the pharmacist documented the number of medication discrepancies, medications added, medications discontinued, and medications with dosage adjustments. The pharmacist would contact the patient to clarify any urgent medication concerns and confirm that they made the appropriate medication adjustments as instructed at discharge from the hospital. If the clinical pharmacist had additional pharmacotherapy concerns, they would contact the provider prior to the hospital follow-up appointment. This was counted as an intervention. The intervention type was classified into categories based on the issue as determined by the clinical pharmacist: new medication, medication omission, high-risk medication, clarify administration frequency, clarify dose, and other reasons. Methods: Data from EMRs identified patients discharged home from the hospital within the last 24-72 hours between July 1, 2022, and June 30, 2023. Medication reconciliation was documented in the patient's EMR. The following elements were included: confirmation of a hospital follow-up appointment, notification to the provider for pharmacotherapy concerns, and patient counseling on medication changes. Results: A total of 881 patient evaluations were included in this study; and these evaluations identified 4,895 medication discrepancies with an average of 5.5 discrepancies per patient. Prior to the hospital follow-up appointment, 267 patients (30.3%) required clinical pharmacist intervention. By the end of the study period, 96.3% of hospital follow-up appointments had a medication reconciliation completed by a clinical pharmacist prior to the visit. Conclusion: This pharmacist-led medication reconciliation program within a geriatric primary care setting confirms a gap in care during transition from hospital to home. It was able to identify medication discrepancies and educate patients about medication changes.

Purpose: Birth by cesarean delivery is a major public health issue with nearly one in three births delivered by cesarean section. Cesarean birth may be necessary to save mother or baby, but the rapid rise since 1996 without concomitant reduction in maternal and neonatal morbidity and mortality may indicate this mode of delivery may be over utilized. Cesarean births pose significant maternal and newborn health risks. Identification of factors that may contribute to reduction in the first cesarean birth in low-risk women who are nulliparous, term gestation, with single fetus in head down position (NTSV) is a health priority. The purpose of this study was two-fold: (1) to examine nursing assessment of fetal heart rate (FHR) tracing and their interventions (nursing surveillance) in response to identification of an FHR tracing consistent with category II pattern and (2) to identify whether nursing surveillance and frequency of category II patterns contribute to the risk of cesarean birth in NTSV women. Methodology: A descriptive, cross-sectional, correlational research design with purposive sample was used. Retrospective review of patient's electronic medical record was conducted for NTSV women who delivered at a large tertiary women's hospital between May and June 2013. Results: Statistically significant relationships were found between maternal age, admission BMI, induced labor, and cesarean birth. The odds of having a cesarean delivery was 12% (OR = 1.12) higher among women who had an increased number of nursing interventions within four hours prior to delivery. However, when examining the type of nursing intervention, none of the nursing interventions entered into the model were statistically significant as predictors of cesarean delivery. There was statistical significance between women who delivered vaginally and those who delivered by cesarean when examining nursing documentation of frequency of category II FHR tracing and nursing interventions. Conclusions: The primary aims of this research study were to examine if nursing identification of a category II FHR pattern and nursing interventions were predictors of cesarean birth. The presence of category II FHR pattern was not a predictor but frequency of nursing interventions was a statistically significant predictor when entered into a logistic regression model.

Molecular Features in the Diagnosis of Myeloid Neoplasms in Down Syndrome Patients Less Than Four Years of Age: Experience from a Single Institution

A novel score for transition success of pediatric rheumatology patients.

Objective: To investigate third-year undergraduate nursing students’ perceptions and views on being prepared for using patient electronic medical records (EMR) in clinical placement after using only paper-based documentation during their education program; and their opinion on the introduction of EMR in the university simulated learning environments to be work ready. Background: Contemporaneous clinical practice in many countries now requires nurses to competently use patient EMR including electronic observation and medication charts. However, Australia has been slow in introducing this learning into undergraduate nursing programs. For this reason, there is a knowledge gap examining nursing students’ viewpoints on learning EMR in their undergraduate program in preparation for the clinical environment and future registered nurses in Australia. Methods: All third-year students enrolled in the undergraduate nursing program at one regional metropolitan university in New South Wales (including three campuses) were invited to complete an electronic questionnaire. This survey included questions on the students’ perceptions on their confidence and preparedness using EMR in clinical practice based on their current paper-based learning in the university simulation laboratories; and their opinions on the benefits of integrating EMR learning into the undergraduate nursing curriculum. Results: Seventy third-year nursing students completed the questionnaire, a response rate of 13.2%. Most respondents (71.1%) did not feel prepared to use EMR in the clinical setting after only learning paper-based documentation and 81.7% did not feel confident accessing patients EMR the first time. Nearly all students (98.5%) believed they would be more confident using EMR initially in their clinical placements if there had been opportunity to practice using EMR in the university simulation laboratories. There was a significant difference with female participants perceived improved confidence accessing patients EMR, if EMR was integrated into the university simulated laboratories compared to the male participants (p=0.007). Conclusion: In this study, third year nursing students believed that learning to use an EMR program in the university simulated environment will increase their confidence and preparedness when on clinical placement and be work ready as registered nurses. Implications for research, policy and practice: This study showcases the importance of preparing nursing students for entering the workforce as confident and competent new graduate registered nurses and integrating health informatics and digital health technologies universities in undergraduate nursing programs in Australia. Future studies on Australian student’s experience with the introduction of an academic EMR program is recommended. What is already known about the topic? Using patient electronic medical records (EMR) is included in the nurse’s scope of practice in healthcare services worldwide. This scope of practice requires that nursing students learn the skills to use EMR in a safe environment. What this paper adds: Third year nursing students are not being prepared to use EMR in the clinical setting based on paper-based learning Majority of students identified the need to learn to use EMR in university simulation labs prior to clinical placement Effective integration of EMR into nursing undergraduate curriculum in Australia is essential

Trauma video review (TVR) involves reviewing video recordings of team-based trauma response to evaluate team performance, identify improvement opportunities, and assess procedures, but the feasibility of using TVR to gather medication-related information is unknown. We aimed to assess the feasibility of using TVR for data collection of medication-related variables for research and quality improvement by comparing and describing differences between TVR and electronic medical record (EMR) review. This was an observational study of level I/II trauma patients treated between November 2022 and March 2023. Patients with video recording started within 1 minute of arrival, at least 1 medication administered, and with pharmacist participation in care were included. The number of variables able to be collected by TVR or EMR review were compared and reported in the categories of medication administration, indicators of adverse drug events (ADEs), medication errors, and communication. The numbers and types of discrepancies between data collection modalities were quantified and described. Agreement between TVR and EMR review was assessed and reported as an intraclass correlation coefficient (ICC). Twenty-five patients were included; 758 and 1,011 variables collected by TVR and EMR review, respectively. In total, 689 variables were collected by both methods, and data collection modalities matched exactly in 4 of 25 patients (16%); ICC, 0.677 (moderate level of agreement). There were 46 (6.7%) discrepancies; 84% involved communication related variables. TVR missed more variables than EMR review, mostly medication errors and inability to assess ADEs but captured more communication-related variables. TVR and EMR review together offer a greater source of medication-related information for data collection compared to either alone. EMR review collected medication administration, ADE, and medication errors variables more often than TVR and TVR was better able to collect communication-related variables. When designing studies/quality improvement efforts related to medication use during trauma resuscitation (e.g., pharmacist impact on time to administration), combined data collection modalities should be used, when available.

Comparison of face-to-face interaction and the electronic medical record for venous thromboembolism risk stratification using the 2005 Caprini score.

Acute Amnesia due to Isolated Mammillary Body Infarct

Introduction: Patients with decompensated end stage liver disease (ESLD) often have functional status limitations and a significant decrease in quality of life. The Palliative Performance Score (PPS) assesses functional status using five physical dimensions: ambulation, activity level, evidence of disease, self- care, oral intake, and level of consciousness. Patient's identified as having a PPS of 10-30% is defined as being totally bed bound and not able to care for themselves. The aim of this study is to determine if there a correlation between having a lower PPS score with a specific etiology of liver disease. Methods: We performed a retrospective analysis using a database of all inpatient consults performed by the Palliative Care service at our tertiary, urban liver transplant center from March 2006 to April 2015. Of 4394 consults, 294 were identified as ESLD patients. Patients with underlying liver malignancies were excluded. Patient age, ethnicity, admitting diagnosis, etiology of liver disease, reason for palliative care consult, PPS from palliative care consult, and length of hospital stay were identified. Etiology of liver disease was identified through review of the patient's electronic medical record. Those without identifiable etiology of liver disease were excluded. Results: A total of 125 ESLD patients with palliative care inpatient consults met inclusion criteria. The average PPS was 23.0% (95% CI 20.57-25.51). Of the patients included, 78.4% had a PPS of between 10-30% (n = 98). Alcohol was identified as the etiology of liver disease in 39.2% of patients (n = 49), viral etiologies were identified in 32% of patients (n = 40), while NASH was found in 12.5% (n = 10). In patients with a PPS of 10 to 30%, alcohol was the etiology in 40.8% (n = 40), viral etiologies were found in 29.5% (n = 29), NASH was the etiology in 7.1% (n = 7). In patients found to have a PPS of 10% (n = 55), alcohol was found to be the etiology of liver disease in 43.64% (n = 24) of patients, viral etiologies were 27.7% (n = 15), and NASH was the etiology in 5.5% (n = 3). Conclusion: Patient presenting with decompensated ESLD secondary to alcoholic liver disease have worse functional status compared to patients with other etiologies of liver disease. Additional attention to functional status and rehabilitation efforts should be targeted to this patient population.

Evaluation of a Presurgical Pregnancy Testing Protocol at an Ambulatory Surgery Center

Cerebral syphilitic gumma presenting with intracranial gumma and pathologic vertebrae fractures

Background: Although Clostridioides difficile infections (CDIs) are associated with significant morbidity and mortality, CDI disease burden may be underestimated if a high proportion of inpatients with diarrhea do not have stool specimens collected for CDI diagnostic testing. The objective of this study was to define the frequency of stool specimen collection and testing for CDI in adult hospitalized patients with diarrhea. Methods: A cross-sectional study was conducted in all 9 adult hospitals (total, 3,532 beds) in Louisville (adult aged ≥18 years; population 599,276) to identify patients with diarrhea and to observe the frequency of stool specimen collection for CDI diagnosis. For 7 consecutive days in December 2018, each ward was visited to identify new onset diarrhea (>3 loose stools in 24 hours) among Louisville adults: first via electronic medical record (EMR) review, then by nurse interviews, and finally by interviewing patients. For patients with diarrhea, research staff reviewed EMRs to determine whether a stool specimen was collected for CDI diagnosis, and they interviewed nurses about potential noninfectious causes of diarrhea. Results: Among 2,565 hospitalized adults (with 14,042 patient days), research staff identified 167 patients (47% men; median age, 64 years) with new onset diarrhea, 1.2 diarrhea cases per 100 patient days. Patients with diarrhea were initially ascertained by EMR review (50%), nurse interviews (42%) or patient interviews (8%); all cases identified by patient interviews were identified by nurses the following day (but many cases identified by nurses were never identified by EMR review). Nurses indicated that 67 cases had a potential noninfectious cause of diarrhea (eg, laxatives, feeding tube, colostomy, liquid diet, etc). Stool specimens were collected by hospital staff for CDI testing from 53 of 167 patients (32%) with diarrhea; 10 of 67 patients (15%) with diarrhea for whom nurses reported potential noninfectious causes of diarrhea (laxative use, enteric feeding, or gastric survey) in the past 24 hours; and 43 of 100 patients (43%) with diarrhea with no reported potential noninfectious causes of diarrhea. Stool collection frequency was similar on weekdays and weekends. Conclusions: The low frequency of CDI diagnostic testing of hospitalized patients with diarrhea indicates that CDI may be underdiagnosed in these hospitals and suggests, given that only 32% of patients with diarrhea had a stool specimen collected, that the CDI disease burden may be 3 times larger than currently appreciated. New-onset diarrhea occurred in >1% of patients each day; the most effective method for identifying patients with diarrhea was via nurse interviews.Funding: Pfizer Vaccines supported this study.Disclosures: Frederick Angulo, Kimbal D. Ford, Joann Zamparo, Elisa Gonzalez, Sharon Gray, David Swerdlow, and Catia Ferreira all report salary from Pfizer.

Development of an Information Model for Storing Organ Donor Data Within an Electronic Medical Record

An accurate method of measuring primary care providers' tobacco counseling actions is needed for monitoring adherence to clinical practice guidelines. We compared three methods of measuring providers' tobacco counseling practices: electronic medical record (EMR) review, patient survey, and provider survey. We mailed a survey to 1,613 smokers seen by 114 Boston-area primary care providers during a 2-month period to assess what tobacco counseling actions had occurred at the visit (N = 766; 47% response rate). Smokers' reports were compared with the EMR and with their providers' self-reported usual tobacco counseling practices, derived from a provider survey (N = 110; 96% response rate). Patients reported receiving each counseling action more frequently than providers documented it in the EMR. Agreement between the patient survey and the EMR was poor for all 5A steps (kappa statistic = 0.01-0.22). Providers reported that they often or always performed each 5A action at a higher rate than indicated by EMR or patient report. However, providers who said they often or always performed individual 5A steps did not have consistently higher mean rates of EMR documentation or patient report than those who said they performed the 5A's less frequently. Little agreement was found among the three methods of measuring primary care providers' tobacco counseling actions. Implementing an EMR does not necessarily improve providers' documentation of tobacco interventions, but EMR adaptations that would standardize provider documentation of tobacco counseling might make the EMR a more reliable tool for monitoring providers' delivery of tobacco treatment services.

462 Background: Urgent fertility preservation (FP) represents a critical unmet need for patients of child-bearing potential undergoing cancer-directed therapies. A retrospective review of electronic medical record (EMR) based FP referrals placed prior to initiation of systemic cancer-directed therapies in patients aged 18-50 years, identified only 26 referrals to urology and 2 referrals to reproductive endocrinology during 2020. To address this issue, we conducted a division-wide survey to identify barriers to FP and designed and implemented a new FP referral EMR order set to facilitate timely fertility evaluation in patients about to begin cancer-directed therapy. Methods: We conducted a division-wide survey of faculty and fellows to identify barriers to FP (PDSA cycle 1), which identified that 50% of respondents did not know how to make a referral and 85% did not know the correct pre-requisite labs. Based on these results, we gathered multi-stakeholder input from reproductive endocrinology, urology, and stakeholders from different hematology/oncology disease groups to develop and design a common FP referral EMR order set (PDSA 2). The FP order set was tested and refined based on stakeholder input. Once the order set was implemented, we gave educational presentations at division-wide and disease group-specific conferences, placed informational flyers throughout the Cancer Center, and Cancer Center-wide communications via email to increase provider awareness (PDSA 3). The primary objective of the study was to increase in number of referrals for FP evaluation in patients aged 18-50 years undergoing cancer-directed therapy. We tracked number of FP referrals pre and post-intervention using EMR data. Results: In PDSA Cycle 2 and 3, the number of referrals increased further to 62 for urology and 35 for reproductive endocrinology. Of those referred, 35/97 (36.1%) were female. Regarding race/ethnicity, the largest percentage of patients referred identified as White and Asian with the lowest percentage being of Southwest Asian/North African or Black/African American (see Table 1). Conclusions: The development and implementation of a FP order set greatly increased the number of patients who underwent fertility evaluation prior to starting cancer-directed therapy. We did identify differences in groups with regards to referral rates with fewer women being referred, and fewer number of racial/ethnic minorities being referred. Further analysis is needed to identify potential areas of intervention to increase referrals and access to FP, particularly in under-represented groups.[Table: see text]