Abstract Background Patients may be discharged from the emergency department (ED) prior to final data from blood cultures. When positive, the ED provider must evaluate to determine next steps in caring for the patient. Up to 55% of positive blood cultures can be contaminants, and calling patients back to the ED may cause undue burden to the ED if no treatment or further evaluation is needed. We developed a toolkit to assist provider response to positive blood cultures for Staphylococcus aureus and Coagulase-negative staphylococci (CoNS) in patients discharged from the ED. It identifies which patients need to return to the ED (callback) and which do not (likely contaminant). Methods We conducted a multi-center, retrospective cohort study of patients with positive blood cultures with staphylococci from January 2019 through October 2022 resulting after discharge from 3 EDs. The objective was to compare the rate of callback to the ED in a retrospective cohort to the rate guided by adhering to a newly developed callback algorithm. The rate of actual callback to ED and the rate of callback to ED based on adhering to the algorithm was calculated with 95% Wilson score binomial confidence intervals (CIs). Asymptotic McNemar’s test was used to compare the paired binomial proportions, and the difference in the rates was estimated with 95% CI using the Newcombe square-and-add approach. Results Out of 188 patients discharged from the ED with the growth of staphylococci in the blood cultures, the rate of patient callback was 61.2% (115/188, 95% CI 55.2% to 66.8%), compared to the algorithm advised callback rate of 45.7% (86/188, 95% CI 39.9% to 51.7%). The difference between the actual callback and the algorithm-based callback rates was 15.4% (95% CI 9.8% to 20.9%, p< 0.001). Conclusion Implementation of an algorithm-based response to blood cultures can reduce unnecessary callbacks to the ED without compromising patient safety. Disclosures Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties

Abstract Background Appropriate antibiotic sequence (i.e. beta-lactam before vancomycin) may reduce early mortality in patients with bloodstream infections (BSIs). Herein, we describe the impact of a multifaceted stewardship initiative on the sequence of antibiotic administration across three hospitals. Methods We performed a pre-post analysis describing the impact of a multifaceted stewardship initiative from March 1, 2021 – May 22, 2022 (pre) and May 31, 2022 – Feb 12, 2023 (post) on the sequence of antibiotic administrations in adults > 18 years old with at least one positive blood culture who received vancomycin and a beta-lactam (i.e. cefepime, meropenem, or piperacillin-tazobactam) across three hospitals: a major university hospital and two community hospitals. Our initiative consisted of 1) a health-system wide adult beta-lactam order panel combining load and maintenance doses for select beta-lactams (Figure 1) 2) nursing administration instructions facilitating the appropriate sequential order of antibiotic administration (i.e. beta-lactam before vancomycin) (Figure 2) and 3) system-wide education to physicians, pharmacists, and nurses. The rate of beta-lactam first administration was compared between groups. Beta-lactam first rates were further stratified by hospital and antibiotic administration locations. Chi-square tests were used to compare rates between groups. Beta-Lactam Order Panel, Piperacillin-tazobactam Beta-Lactam First: Nursing Administration Instructions, Cefepime Results 361 patients were included for analysis: 224 pre- and 137 post-intervention. Piperacillin-tazobactam was the most common beta-lactam among studied patients (71.5%, Table 1). Beta-lactam first rates were already high at baseline, then higher post-intervention compared to pre-intervention (96.4% vs 93.8%, p = 0.283) (Table 2).Table 1.Receipt of Beta-Lactam Therapy in Adult Patients with Positive Blood CulturesTable 2.Sequence of Antibiotic Administration Conclusion A multifaceted initiative to promote beta-lactam before vancomycin administration increased adherence to this preferred practice in our health system, though baseline rates were high. Clinical decision support paired with system-wide education involving key stakeholders can help standardize appropriate antibiotic sequence. Future study could evaluate impact on a larger scale, on patient outcomes, and evaluate sustainability of beta-lactam first practice. Disclosures Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties

To evaluate the impact of a lay health worker support role in the inpatient setting. Healthcare systems are facing critical nursing and nurse assistant staffing shortages. These disciplines can be challenging to recruit and retain, leading healthcare leaders to identify innovative staffing models. Whereas lay health workers have been used in the community and low-income setting, there is scant evidence of their use in the inpatient setting. We implemented a lay health worker role, called Patient Attendant Service Aides (PASAs), on two medical/surgical units at a community hospital. A pre/post-implementation design was used for this study. An online survey was provided to nurses, nursing assistants, and PASAs on the two medical/surgical units to assess their satisfaction and perceptions of the role. Nursing quality metrics, patient satisfaction, and nursing and nursing assistant turnover were evaluated before and after implementing the role. The online survey showed that nurses and nursing assistants felt that PASAs helped offload their workload, allowing them to focus on nursing-related tasks. PASAs felt supported by the team and believed they were making a meaningful contribution to the unit. There were slight improvements in patient satisfaction, although not significant. There was a significant improvement in nursing turnover on Unit A, from 71.1% to 21.6% (p = 0.009). This is one of the first studies to evaluate the use of lay health workers in the inpatient setting; we found this role to be a feasible way to offload tasks from clinical staff. This role may serve as a pathway for workforce development, as several PASAs are now enrolled in nursing assistant training. Nurse managers may consider using lay health workers in the inpatient setting as they face severe clinical staff shortages.

Introduction: Leiomyomas are common benign tumours of the female pelvis with growth and extension not limited to pelvis. The occurrence of solitary or multiple nodules are initially asymptomatic except when it is occurring within the cavity of the uterus. Symptoms would however develop with time if not properly treated or ignored, which could lead to live-threatening complications. Case Presentation: This is a report of a 48-year-old woman with neglected leiomyoma who presented with an enormous abdominal distension due to massive cystic degeneration of the leiomyoma mimicking an ovarian tumor. An abdominal ultrasound scan performed revealed a large solid-cystic abdominal mass on which account an exploratory laparotomy where total abdominal hysterectomy left salpingectomy and bilateral oophorectomy was performed. The histopathology report of the tumour revealed it was a benign fibromyoma (leiomyoma) with degenerative changes. The ovaries and left tube were all normal. Conclusion: Leiomyoma though a benign tumour, can grow disproportionately and undergo degenerative changes if neglected. This can result in life-threatening sequelae, mimicking a malignant tumour.

Clozapine carries a US boxed warning for severe neutropenia, and strict monitoring is required through the FDA's Risk Evaluation and Mitigation Strategy (REMS) program. Patients with confirmed diagnosis of COVID-19 are also at risk for neutropenia. For patients on clozapine, the diagnosis of this novel virus may require an increase in the frequency of scheduled ANC monitoring. A case report of moderate neutropenia following COVID-19 diagnosis that required an increase in the frequency of ANC monitoring in a patient on long-term clozapine treatment is discussed. A 33-year-old white man with schizophrenia had been on clozapine for more than 2 years, with an ANC monitoring schedule once every 4 weeks. The patient was admitted to the hospital for worsening aggressive behavior. On day 11 of hospital admission, he tested positive for COVID-19. Five days following this diagnosis, the patient's ANC dropped from 2.2/L to 0.8/L. This decrease led to daily ANC labs and the clozapine regimen being held for 1 day. Throughout the patient's admission adjustments were made to the frequency of lab monitoring based on fluctuations in his ANC levels. There have been limited case reports on patients receiving clozapine experiencing neutropenia following the diagnosis of COVID-19. To the authors knowledge, this is the first case report from the United States that specifically discusses the required changes to ANC monitoring. Patients on clozapine who test positive for COVID-19 may be at an even greater risk for neutropenia, compared with clozapine patients without COVID-19. Increasing the frequency of ANC monitoring should be considered in the weeks following the diagnosis to ensure that clozapine treatment can be safely adjusted, or even discontinued.

Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment for alcohol withdrawal syndrome (AWS). Currently, existing research offers only modest guidance on the safety and effectiveness of phenobarbital in managing AWS in hospital settings. The study objective was to assess if a phenobarbital protocol for the treatment of AWS reduces respiratory complications when compared to a more traditionally used benzodiazepine protocol. A retrospective cohort study analyzing adults who received either phenobarbital or benzodiazepine-based treatment for AWS over a 4-year period, 2015-2019, in a community teaching hospital in a large academic medical system. A total of 147 patient encounters were included (76 phenobarbital and 71 benzodiazepine). Phenobarbital was associated with a significantly decreased risk of respiratory complications, defined by the occurrence of intubation (15/76 phenobarbital [20%] vs. 36/71 benzodiazepine [51%]) and decreased incidence of the requirement of six or greater liters of oxygen when compared with benzodiazepines (10/76 [13%] vs. 28/71 [39%]). There was a significantly higher incidence of pneumonia in benzodiazepine patients (15/76 [20%] vs. 33/71 [47%]). Mode Richmond Agitation Sedation Scale (RASS) scores were more frequently at goal (0 to -1) between 9 and 48 h after the loading dose of study medication for phenobarbital patients. Median hospital and ICU length of stay were significantly shorter for phenobarbital patients when compared with benzodiazepine patients (5 vs. 10 days and 2 vs. 4 days, respectively). Parenteral phenobarbital loading doses with an oral phenobarbital tapered protocol for AWS resulted in decreased risk of respiratory complications when compared to standard treatment with benzodiazepines.

Clinical decision support in the EHR is an innovation that can support guideline adherence in acute myocardial infarction. Cardiac rehabilitation referral and left ventricular systolic function assessment are part of evidence-based clinical practice guidelines associated with reduced morbidity and mortality following acute myocardial infarction. Effective clinical decision support is sustained by evidence-based principles for design and implementation. This quality improvement project evaluated the impact of practice advisories designed using principles of effective clinical decision support design to improve performance of left ventricular systolic function assessment and ambulatory referral to cardiac rehabilitation for patients hospitalized with acute myocardial infarction. Performance in cardiac rehabilitation referral and left ventricular systolic function assessment was measured for a 3-month interval pre- and post-intervention. Pre-implementation, cardiac rehabilitation referral or valid documented reason for non-referral was 80.3%. Rehabilitation referral or documented valid reason for non-referral increased to 98.4% post-implementation (P < .001). Left ventricular systolic function assessment increased from 94.2% to 100% following clinical decision support implementation (P = .120). This quality improvement project supports the positive impact of effective clinical decision support design and implementation to improve outcomes for patients hospitalized with acute myocardial infarction.

Introduction: Some women with uterine leiomyoma can experience life threatening complications during pregnancy. These leiomyomas are usually large and their associated symptoms were either neglected before the onset of the pregnancy or surgical treatment may have been rejected earlier by the patient. Case Presentation: Three cases of antepartum myomectomy are reported in this paper. They had severe abdominal pains not responding to medical treatment with gross abdominal distention. Additionally, they had severe life-threatening symptoms including right hypochondria pain and shallow breath in case no.2 and intestinal obstruction in case no.3, an acute surgical complication which could not be resolved by conservative management. All three patients had successful antepartum myomectomy using a new flap techinique not previously described in the literature on reported cases of myomectomy during pregnancy. All the patients recovered successfully from the operation and their pregnancies continued to delivery of their babies at term by caesarean section. Cases no.1 and 2 presented in this report were managed in health facilities in Tamale, Northern Region in 2019. Case no.3 was managed in Accra at the Greater Accra Regional Hospital in 2022. Conclusion: Pregnant women may present with life threatening complications of leiomyomas, antepartum myomectomy can be considered and successfully performed to improve quality of life or prevent maternal mortality. The procedure for the myomectomy in such situation may not be routine but a special approach is required to avoid fatal complications for both mother and foetus.

Professional medical associations (PMAs) have an essential role in advancing medical care and health. PMAs promote skills training, clinical standards, and other important educational activities. Most often, PMAs are not-for-profit entities that rely upon funding from industry to help cover the costs of these valuable activities. Equally important, innovation and progress in surgery require physician collaboration with industry throughout the product development process. SAGES has opined that, with appropriate Conflict of Interest (COI) disclosure and management processes, PMA educational activities can be both scientifically and ethically sound. SAGES has developed and implemented comprehensive and stringent processes for managing potential COI within the organization, at the annual meeting, and in developing educational offerings. This document reviews the SAGES COI processes and results 2009-2021. Implementation of the SAGES COI disclosure and management processes reduced the reported perceived incidence of bias at the annual meeting from 4.4-6.2% (2008-2010) to 1.2-2.2% (2011-2013). Recent comparison of reported disclosures revealed a rise in number of speakers with financial relationships and an increase in reporting of disclosures in presentations without an associated increase in need for conflict resolution by the COI committee. Despite good overall adherence to COI policies, SAGES was recently cited for non-compliance with ACCME standards related to inclusion of faculty with ownership interest. This experience highlighted the potential for discordance in the interpretation of whether disclosures relate to specific CME content. SAGES COI processes have since been updated to reflect the more stringent 2020 ACCME Standards that exclude speakers and planners with ownership interest from any CME activity. The SAGES experience with disclosure and mitigation of financial relationships highlights the challenges of validating the accuracy of physician disclosures and establishing the relevance of financial relationships to the content of accredited educational activities. SAGES will continue to streamline its COI disclosure process with specific focus on aligning all financial disclosures among the various reporting platforms.

Daily chlorhexidine gluconate (CHG) bathing is a well-supported intervention to reduce patient's risk of central line associated bloodstream infection (CLABSI); however, compliance with this practice is suboptimal. One major barrier is patient refusals of CHG bathing. The purpose of this project was to implement tailored interventions to mitigate this barrier. The specific aims were to reduce patient refusals, increase compliance with CHG bathing, and evaluate CLABSI rates and nursing staff's knowledge of CHG bathing. Iterative Plan-Do-Study-Act (PDSA) cycles were implemented over the course of 6 months. Run charts were used to identify signals of improvement. Interventions included printed educational flyers for staff and patients, educational sessions, an electronic learning module, and a "badge buddy." We saw a reduction in the median percentage of patient refusals documented, from 23% to 8% after the PDSA cycles. Documentation compliance with CHG bathing increased only slightly from 46% to 47%. CLABSI rates decreased 6% from 0.69 to 0.65. Using interventions tailored to the clinical setting can impact patient outcomes. Other health care systems should consider implementing PDSA cycles to improve evidence-based practices. Using PDSA cycles can result in a reduction in patient refusal documentation, and may slightly improve CHG bathing compliance and CLABSI rates.