Community Hospital Patients Research Articles

Risk of obstetric anal sphincter injuries at the time of admission for delivery: A clinical prediction model.

To develop and validate a model to predict obstetric anal sphincter injuries (OASIS) using only information available at the time of admission for labour. A clinical predictive model using a retrospective cohort. A US health system containing one community and one tertiary hospital. A total of 22 873 pregnancy episodes with in-hospital delivery at or beyond 21 weeks of gestation. Thirty antepartum risk factors were identified as candidate variables, and a prediction model was built using logistic regression predicting OASIS versus no OASIS. Models were fit using the overall study population and separately using hospital-specific cohorts. Bootstrapping was used for internal validation and external cross-validation was performed between the two hospital cohorts. Model performance was estimated using the bias-corrected concordance index (c-index), calibration plots and decision curves. Fifteen risk factors were retained in the final model. Decreasing parity, previous caesarean birth and cardiovascular disease increased risk of OASIS, whereas tobacco use and black race decreased risk. The final model from the total study population had good discrimination (c-index 0.77, 95% confidence interval [CI] 0.75-0.78) and was able to accurately predict risks between 0 and 35%, where average risk for OASIS was 3%. The site-specific model fit using patients only from the tertiary hospital had c-stat 0.74 (95% CI 0.72-0.77) on community hospital patients, and the community hospital model was 0.77 (95%CI 0.76-0.80) on the tertiary hospital patients. OASIS can be accurately predicted based on variables known at the time of admission for labour. These predictions could be useful for selectively implementing OASIS prevention strategies.

Sociodemographic Disparities in Access to Chemotherapy for Bladder Cancer.

We sought to evaluate sociodemographic disparities in access to neoadjuvant (NAC) and adjuvant (AC) chemotherapy in the United States and their effect on survival. The National Cancer Database was used to identify all patients from 2004 to 2016 eligible for NAC and AC. Univariate and multivariate logistic regression was performed to identify sociodemographic predictors associated with receipt of NAC and AC. Kaplan-Meier and Cox proportional hazard models were used for survival analysis. A total of 17,121 patients were eligible for NAC, and 18,962 for AC. Older (OR 0.94, P < .001), Medicare (OR 0.88, P=.047), Medicaid (OR 0.66, P=.001), uninsured (OR 0.47, P < .001), rural (OR 0.70, P=.042), and community hospital patients (OR 0.72, P < .001) were less likely to receive NAC. Older, (OR 0.95, P < .001), female (OR 0.79, P < .001), Medicaid (OR 0.71, P=.003), uninsured (OR 0.60, P=.001), and lower income patients (OR 0.86, P=.017) were less likely to receive AC. In NAC-eligible patients, older (HR 1.02, P < .001), Medicare (HR 1.11, P=.024), Medicaid (HR 1.25, P=.012), and community hospital patients (HR 1.09, P=.021) were at an increased risk of death. In AC-eligible patients, older (HR 1.01, P < .001), Black (HR 1.15, P=.011), Medicaid (HR 1.14, P=.042), lower income (HR 1.07, P=.038) and community hospital patients (HR 1.07, P=.021) were at an increased risk of death. Significant sociodemographic disparities currently exist in the United States in access to neoadjuvant and adjuvant chemotherapy for bladder cancer. Uninsured and Medicaid insurance status are the strongest predictors of not receiving chemotherapy. Efforts must be made to deliver this critical standard-of-care treatment to these patients.

Hospital factor and prognosis of COVID-19 in New York City, the United States of America: insights from a retrospective cohort study

BackgroundApril 22nd, 2020, New York City (NYC) was the epicenter of the pandemic of Coronavirus disease 2019 (COVID-19) in the US with differences of death rates among its 5 boroughs. We aimed to investigate the difference in mortality associated with hospital factors (teaching versus community hospital) in NYC.DesignRetrospective cohort study.MethodsWe obtained medical records of 6509 hospitalized patients with laboratory confirmed COVID-19 from the Mount Sinai Health System including 4 teaching hospitals in Manhattan and 2 community hospitals located outside of Manhattan (Queens and Brooklyn) retrospectively. Propensity score analysis using inverse probability of treatment weighting (IPTW) with stabilized weights was performed to adjust for differences in the baseline characteristics of patients initially presenting to teaching or community hospitals, and those who were transferred from community hospitals to teaching hospitals.ResultsAmong 6509 patients, 4653 (72.6%) were admitted in teaching hospitals, 1462 (22.8%) were admitted in community hospitals, and 293 (4.6%) were originally admitted in community and then transferred into teaching hospitals. Patients in community hospitals had higher mortality (42.5%) than those in teaching hospitals (17.6%) or those transferred from community to teaching hospitals (23.5%, P < 0.001). After IPTW-adjustment, when compared to patients cared for at teaching hospitals, the hazard ratio (HR) and 95% confidence interval (CI) of mortality were as follows: community hospitals 2.47 (2.03-2.99); transfers 0.80 (0.58-1.09)).ConclusionsPatients admitted to community hospitals had higher mortality than those admitted to teaching hospitals.

Prevalence of Psychiatric Diagnoses and Psychiatric Consultation Service Utilization on Inpatient Medical Units.

This practice improvement project sought to determine the prevalence of psychiatric diagnoses among patients admitted to a community hospital's inpatient medical units and which diagnoses were serviced by the hospital's psychiatric consultation service. Electronic medical record data on adult patients of five medical units admitted with a psychiatric condition between October 1, 2019, and December 31, 2019, were used. Psychiatric ICD-10 (International Classification of Diseases, 10th Revision) codes and diagnosis names extracted were categorized into seven major diagnostic groups. A total of 687 adult patients with 82 psychiatric ICD-10 codes were analyzed using descriptive statistics. Substance-related and addictive disorders were the most prevalent psychiatric diagnoses. Ninety-six percent (n = 658) of patients residing on medical floors with psychiatric disorders were hospitalized for a principal medical problem. Seventy-three cases received psychiatric consultations during their stay. Sixty percent (n = 44) of those cases had psychiatric disorders from two or more diagnostic categories. Multidisciplinary, team-based health care delivery models that include a psychiatric nurse can provide an effective approach to treat patients in community hospitals with multiple psychiatric and medical comorbidities. Hospitals could take a significant role in providing substance use disorder treatment and equipping medical nurses with training to competently care for patients with psychiatric disorders on medical units. Further research into the prevalence and impact of patients with co-occurring and multiple psychiatric diagnoses in community hospitals is needed to implement effective health care delivery models and provide appropriate treatment options in the community.

Efficacy and Safety of Ramucirumab/nab-paclitaxel for Previously Treated Advanced Gastric Cancer in Community Hospitals.

As the nanoparticle albumin-bound paclitaxel (nab-PTX) is free of ethanol and premedication, the duration of administration is shorter and patients can drive themselves to and from the hospital. In the 2018 Japanese gastric cancer treatment guidelines, ramucirumab (RAM) plus weekly nab-PTX is conditionally recommended for previously treated patients with advanced gastric cancer. Here, we retrospectively analysed the efficacy and safety of RAM+nab-PTX for such patients in community hospitals. From January 2018 to December 2019, 43 patients with metastatic and recurrent gastric cancer received RAM+nab-PTX treatment. Six patients (13.9%) were older than 80 years and 9 patients (20.9%) showed ECOG-PS 2. Progression-free survival (PFS), overall survival (OS), overall response rate (ORR), disease control rate (DCR), and adverse events (AEs) were reviewed retrospectively. Median PFS was 114 days (95% confidence interval [CI]: 84-190) and median OS was 297 days (95% CI: 180-398). ORR and DCR were 32.4% and 72.2%, respectively. The incidence rates of ≥grade 3 neutropenia and febrile neutropenia were 53.5% and 2.3%, respectively. No treatment-related deaths occurred. RAM plus nab-PTX combination therapy demonstrated manageable toxicity even patients who were elderly or had an ECOG-PS 2. This treatment is useful in community hospital settings.

The effect of the integrated delivery system in rural areas of China.

With the continuous development of modern society, the management of chronic diseases has become the focus of the medical community in China. In particular, diabetes is a chronic disease that cannot be ignored. China has built an integrated delivery system to deal with imminent health problems. The purpose of this study is to investigate the effects of integrated rural supply system in China. We selected 1,061 patients with diabetes from the Zhili Town Health Center's hospital information system. We tracked and studied their outpatient and inpatient expenses, treatment behaviors, incidence of complications, and satisfaction over 5 years. We compared the data collected from 2014 to 2019 to determine the trends of these four factors and the effects of the integrated delivery system for patients with diabetes. We found that the average costs for diabetes patients in outpatient and inpatient departments were increasing slightly every year. The number of patients in tertiary hospitals has decreased significantly, while the number of patients in community hospitals (primary hospitals) has increased, and the number of patients in secondary hospitals has remained relatively unchanged. Meanwhile, the expenses per visit were also lower over this period in hospitals at all levels. Diabetes complications have been increasing marginally, and there is a relatively high degree of satisfaction among patients and doctors in primary hospitals, which is rising. Considering the various needs of people in different stages of life, the integrated delivery system provides and manages continuous services such as health promotion, disease prevention, diagnosis, treatment, rehabilitation, and management through cooperation between institutions at different levels of the health system.

Preprocedural SARS-CoV-2 Testing to Sustain Medically Needed Health Care Delivery During the COVID-19 Pandemic: A Prospective Observational Study.

BackgroundWe implemented a preprocedural severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening initiative designed to sustain health care during a time when the extent of SARS-CoV-2 infection was unknown.MethodsThis was a prospective study of patients undergoing procedures at 3 academic hospitals in Pittsburgh, Pennsylvania (April 21–June 11), and 19 community hospitals across Middle/Western Pennsylvania and Southwestern New York (May 1–June 11). Patients at academic hospitals underwent symptom screening ≤7 days preprocedure, then SARS-CoV-2 nasopharyngeal polymerase chain reaction (PCR) testing 1–4 days preprocedure. A subset also underwent day-of-procedure testing. Community hospital patients underwent testing per local protocols. We report SARS-CoV-2 PCR positivity rates, impact, and barriers to testing encountered through June 11. PCR positivity rates of optional preprocedural SARS-CoV-2 testing for 2 consecutive periods following the screening initiative are also reported.ResultsOf 5881 eligible academic hospital patients, 2415 (41.1%) were tested (April 21–June 11). Lack of interest, distance, self-isolation, and nursing home/incarceration status were barriers. There were 11 PCR-positive patients (10 asymptomatic) among 10 539 patients tested (0.10%; 95% CI, 0.05%–0.19%): 3/2415 (0.12%; 95% CI, 0.02%–0.36%) and 8/8124 (0.10%; 95% CI, 0.04%–0.19%) at academic and community hospitals, respectively. Procedures were performed as scheduled in 40% (4/10) of asymptomatic PCR-positive patients. Positivity increased during subsequent coronavirus disease 2019 (COVID-19) surges: 54/34 948 (0.15%; 95% CI, 0.12%–0.20%) and 101/24 741 (0.41%; 95% CI, 0.33%–0.50%) PCR-positive patients from June 12–September 10 and September 11–December 15, respectively (P < .0001).ConclusionsImplementing preprocedural PCR testing was complex and revealed low infection rates (0.24% overall), which increased during COVID-19 surges. Additional studies are needed to define the COVID-19 prevalence threshold at which universal preprocedural screening is warranted.

Clinical profile of rural community hospital inpatients in Sweden – a register study

Objective Patients in Sweden’s rural community hospitals have not been clinically characterised. We compared characteristics of patients in general practitioner-led community hospitals in northern Sweden with those admitted to general hospitals. Design Retrospective register study. Setting Community and general hospitals in Västerbotten and Norrbotten counties, Sweden. Patients Patients enrolled at community hospitals and hospitalised in community and general hospitals between 1 January 2010 and 31 December 2014. Outcome measures Age, sex, number of admissions, main, secondary and total number of diagnoses. Results We recorded 16,133 admissions to community hospitals and 60,704 admissions to general hospitals. Mean age was 76.8 and 61.2 years for community and general hospital patients (p < .001). Women were more likely than men to be admitted to a community hospital after age adjustment (odds ratio (OR): 1.11; 95% confidence interval (CI): 1.09–1.17). The most common diagnoses in community hospital were heart failure (6%) and pneumonia (5%). Patients with these diagnoses were more likely to be admitted to a community than a general hospital (OR: 2.36; 95% CI: 2.15–2.59; vs. OR: 3.32: 95% CI: 2.77–3.98, respectively, adjusted for age and sex). In both community and general hospitals, doctors assigned more diagnoses to men than to women (both p<.001). Conclusions Patients at community hospitals were predominantly older and women, while men were assigned more diagnoses. The most common diagnoses were heart failure and pneumonia. Our observed differences should be further explored to define the optimal care for patients in community and general hospitals. Key points The patient characteristics at Swedish general practitioner-led rural community hospitals have not yet been reported. This study characterises inpatients in community hospitals compared to those referred to general hospitals. • Patients at community hospitals were predominantly older, with various medical conditions that would have led to a referral to general hospitals elsewhere in Sweden. • Compared to men, women were more likely to be admitted to community hospitals than to general hospitals, even after adjustment for age. To the best of our knowledge, this pattern has not been reported in other countries with community hospitals. • In both community hospitals and general hospitals, doctors assigned more diagnoses to men than to women.

The effect of the integrated delivery system on managing hypertension in rural areas of China.

Since the implementation of the new medical reform in 2009, China has established and improved a series of medical security systems, established medical confederations based on four categories, and promoted the operation of the hierarchical diagnosis and treatment model. The purpose of this study is to analyze the effects of the matrix chronic diseases management platform developed from the integrated delivery system. To evaluate the effects of the matrix chronic diseases management platform developed from the integrated delivery system in China on expenses, medical seeking behaviors, compensation, and degree of satisfaction in hypertensive patients. A longitudinal and retrospective study was performed to investigate medical expenses, actual compensation ratios, medical behaviors, and the degree of satisfaction across different levels of medical institutions in hypertensive patients. A total of 7,037 patients with hypertension aged 36-99 from Zhili Town Health Center were selected based on the diagnostic criteria of the Guidelines for Prevention and Treatment of Hypertension in China. Data was collected from the hospital's database and systems, and questionnaires were distributed to patients who attended the Department of Cardiology. Outcomes included inspection and drug expenses in the outpatient and inpatient departments, actual reimbursement ratios, number of visits across different levels of hospitals, expenditure per visit, medical behaviors, complications of patients, and the degree of satisfaction of both patients and doctors in primary hospitals. The average cost for hypertensive patients was shown to be increasing year by year in the outpatient and inpatient departments. The number of patients in tertiary hospitals decreased significantly, while the number of patients in community hospitals (primary hospitals) increased, and the number of patients in secondary hospitals has remained almost unchanged. Furthermore, expenses per visit in hospitals across all levels also decreased during the study period. The primary complications of hypertension were cerebrovascular disease and coronary heart disease, which showed a slightly increasing trend. The degree of satisfaction of patients and doctors in primary hospitals was relatively high, and rose from 2014 to 2019. The matrix chronic diseases management platform developed from the integrated delivery system built in Huzhou No.1 Hospital had a positive effect on improving the reimbursement and satisfaction of patients with hypertension.

A Comparative Study on the Characteristics and Risk Factors among Hypertensive Patients in Referral and Community Hospitals

A Comparative Study on the Characteristics and Risk Factors among Hypertensive Patients in Referral and Community Hospitals

Use of Telemedicine to Improve Interfacility Communication and Aid in Triage of Patients with Intracerebral Hemorrhage: A Pilot Study

Over the past several years there has been a dramatic increase in the implementation of telemedicine technology to aid in the delivery of care across community, inpatient, and emergency settings. This technology has proved valuable for acute life-threatening clinical scenarios. We aimed to pilot a novel neurosurgical telemedicine program within an academic tertiary care center to assist in consultation of patients with high-grade intracranial hemorrhage (ICH) (ICH score 4, 5). A quality improvement conceptual framework was developed. Subsequently, a process map and improvement interventions were created. Patients in community hospitals with high-grade ICH or pre-existing Do Not Resuscitate/Do Not Intubate orders with an admitting diagnosis of ICH triggered a TeleNeurosurgery consultation. Patients who met the inclusion criteria, with consent of their decision makers, were enrolled in the study. Post-encounter physician surveys were used to evaluate overall satisfaction with the implementation. This 18-month pilot study proved feasible, with an enrollment of 63.6% (n= 14 of 22) of patients who met criteria. All patients who were enrolled in the study and participated in TeleNeurosurgery consultation remained at the presenting facility for end-of-life care and palliative medicine consultation. Both community emergency physicians and subspecialists who performed the consultations reported satisfaction with the TeleNeurosurgery consultation process and a perceived benefit both to patients, families, and emergency medicine physicians. The program proved feasible and several areas in need of improvement within the health system were identified. Emergency physicians reported comfort with the process, program effectiveness, and improved access to care by implementation of this program.

Use of Transcervical Radiofrequency Ablation for Treatment of Uterine Fibroids

Study Objective The purpose of this video is to demonstrate the use of transcervical radiofrequency ablation (RFA) of uterine fibroids utilizing the Sonata Procedure. Design Case presentation Setting Academic affiliated community hospital Patients or Participants 51yo G5P4, with a history of abnormal uterine bleeding and fibroids, who previously underwent abdominal myomectomy and presented for further management. After thorough counseling, patient opted for the Sonata procedure. Interventions The Sonata device was deployed to the targeted ablation zone and radiofrequency energy was applied to a goal temperature of 105 degrees Celsius. Complete ablation of a type II anterior fundal uterine fibroid was achieved without any complications. Measurements and Main Results Patient tolerated the procedure well. She was discharged approximately 2 hours after her procedure. She did not require any narcotic pain medications upon discharge. Conclusion Transcervical radiofrequency ablation is a safe and effective alternative treatment option for management of uterine fibroids. It should be considered in patients who wish to avoid major surgery or are poor surgical candidates.

The Impact of an Enhanced Recovery after Surgery (ERAS) Protocol Implementation in a Community-Based Hospital.

Study Objective Does ERAS reduce opioid usage without adversely impacting patient satisfaction, length of stay (LOS) readmissions and complications? Design Retrospective quality care improvement study Setting Intercity community Hospital Patients or Participants Patients undergoing major Gynecologic surgery by Gynecologic oncology service. Interventions: ERAS protocol. For Minimally invasive Surgery (MIS) cases, gabapentin 24 hours prior to surgery was started, and was continued for 2 days postoperatively. Multimodal analgesia was used in the postoperative period. Measurements and Main Results Post ERAS implementation cases were compared with a cohort of consecutive patients undergoing major surgery 2 years prior to implementation. No significant differences in demographic, surgical or clinical characteristics were demonstrated. 174 cases were completed by MIS. LOS was similar before and after implementation (2.82 vs 2.71, p= 0.339), open cases had a longer LOS before ERAS (> 4 days in 16 (80%) vs 12 (63%, p=0.122). LOS for MIS before and after ERAS was no different (75.6% pre ERAS vs 78% after ERAS, p=0.339). After ERAS protocols, there was a significant decrease in amount of overall opioid usage (90 vs 61 P Conclusion ERAS was effective in decreasing the amount of opioid use at a large intercity community hospital.

Pre-Operative Predictors of Concurrent Choledocholithiasis in Patients With Acute Calculus Cholecystitis: An External Validity Analysis.

IntroductionPatients that are presented with acute calculus cholecystitis (AC) and elevated liver enzymes markers (LEM), often require evaluation for concurrent choledocholithiasis (CDL). Currently, evaluation guidelines follow the American Society of Gastroenterology Endoscopy (ASGE) recommendations.ObjectivesThe aim of the study was to externally validate both ASGE and the Chisholm predictors in a community hospital patient cohort.MethodsWe conducted a retrospective study of patients who presented to Ascension Saint John hospital with AC and elevated LEM over a period of two years. Sensitivity (SEN), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) were used to test the external validity of ASGE and Chisholm algorithms.ResultsA total of 132 patients’ charts were reviewed, and 87 patients included. Chisholm predictors SEN, SP, PPV and NPV were 50%, 82%, 18%, and 95% respectively versus 100%, 19%, 8%, 100% for the ASGE predictors model. In the ASGE module, SP and PPV can be significantly improved to 60% and 13%, respectively, by changing a few risk categories including age and LEM range.ConclusionsExternal validation of the Chisholm module in our patient cohort showed that it would lead to a low referral rate for unnecessary imaging and thus might be more cost-effective, especially when compared to current ASGE recommendations which would have a higher referral rate. On the other hand, current ASGE recommendations successively labeled all the patients with CDL, while the Chisholm module missed around 50 percent. We also observed that with the current ASGE module, the referral rate for further imaging and diagnostic tests can be possibly improved by adjusting a few of the predictors including the age and the abnormal liver transaminases range, but this observation is arbitrary and will need to be validated in a larger cohort study.

The Application Effect of Regional Family Doctor Contract Service Based on Internet Platform in the Management of Hypertensive Patients in Primary Hospital

Objective: To analyze the application effect of regional family doctor contract service based on Internet platform in the management of hypertension patients in community hospitals. Methods: Since June 2017, the Yetang Health Center has established a model of family doctors contracted chronic disease management based on the Internet platform under the guidance of the General Medical Department of the First People’s Hospital of Changshu City. The Internet platform for patient management was developed, and a regional data sharing center for hypertensive patients was established. The combination with the family doctor contract model enabled the effective management of hypertensive patients. In the 12 months before the model was implemented, 525 patients with hypertension were selected, and 2173 patients with hypertension after 12 months of implementation were included in the control group and the observation group. The differences in treatment compliance, selfmanagement rate and other indicators between the two groups were compared to analyze the application effect of the model. Results: Compliance, compliance rate, self-management rate and awareness rate of hypertensionrelated knowledge in the observation group were higher than those in the control group, and the difference was statistically significant (P &lt; 0.05). The total management cost, unit management cost and standard management cost of hypertension patients in the observation group were lower than those in the control group. The satisfaction rate of hypertension management in the observation group was 96.87% (2105/2173), which was higher than 63.05% (331/525) in the control group (P &lt; 0.05). The awareness rate of diagnostic criteria, risk factors, hazards and treatment methods of hypertension in the observation group was higher than that in the control group, and the difference was statistically significant (P &lt; 0.05). Conclusion: The regional family doctor contract service based on Internet platform can significantly improve the effectiveness and efficiency of community hospital management of hypertension patients, and it is also an effective way to reduce management costs and ensure patient satisfaction, which is worth further optimization and promotion.

2988 Patient Perceptions of Laparoscopic and Robotic Gynecologic Surgery

Study Objective To clarify the health literacy and needs of patients undergoing laparoscopic and surgery Design Survey Setting Urban community hospital Patients or Participants Patients waiting to undergo minimally invasive gynecologic surgery Interventions A 23 question survey was administered to patients waiting for Patients were educated on minimally invasive surgery after completing their survey. Measurements and Main Results 105 patients were surveyed. 51.4% of patients had heard of the term laparoscopy. However 63.8% of patients were familiar with the term robotic surgery. Only 36.2% had reported hearing these terms from their physician. Patients correctly answered 48.1% of questions that dealt with the benefits of minimally invasive Only 3.8% of patients thought that a robot worked autonomously during Conclusion There may be significant gaps between what clinicians discuss with their patients and what patients recall and comprehend. Further study is necessary to elucidate best practices for surgical consenting.

77 Post-ERCP Pancreatitis Rates and NSAID Use in a Community Hospital

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) has been consistently used for more than 50 years as a diagnostic and therapeutic procedure in pancreaticobiliary diseases. However, its use is associated with several adverse effects including bleeding, cholangitis, pancreatitis, intestinal perforation, and death. Of these, post-ERCP pancreatitis (PEP) is the leading cause of morbidity and mortality with an estimated incidence of 1.6–15%. Endoscopic techniques, patient characteristics, and the hospital setting have been noted to put patients at higher risk of developing PEP. Williams et al. reported a significantly increased risk of PEP in community hospitals compared to university hospitals. Rectal NSAIDs, including diclofenac and indomethacin, have shown promising results in several high-quality clinical trials and meta-analysis, especially in high-risk patients. More recent trials failed to show a significant reduction of PEP after NSAID use. There is scant data on the efficacy of rectal NSAIDs in higher risk patients in community hospitals. The aim of this study is to determine if there is an increased risk of PEP in a community hospital and if the use of rectal NSAIDs for high-risk patients is beneficial within a community hospital. METHODS: After obtaining IRB approval, the charts of every adult patient admitted to a Wichita, KS community hospital for ERCP in a 2-year time period were reviewed. Primary endpoint was percentage of patients developing PEP. Secondary endpoints included NSAID use in high-risk individuals (Table 1) and the change in incidence of PEP in this group with the use of rectal NSAID. RESULTS: 422 patients underwent ERCP during the study period. Of these, about 212 (50.2%) were noted to have at least 1 high risk factor to develop PEP. 24 (5.6%) of the patients received rectal NSAIDs, of which 10 patients were noted to be high-risk for PEP. 9 patients (2.1%) developed PEP during the study time period. Of the nine patients, 3 patients were high risk and did not receive any NSAIDs. The use of NSAIDs did not cause a significant reduction in PEP in the high-risk group (p-value 0.7) or overall (P-value 0.66). CONCLUSION: PEP rates in a community hospital setting have not been well established. Our study reports an incidence of 2.1%, comparable to the PEP incidence described in academic trials. Despite the unstandardized use of rectal NSAIDs noted in the study population, there appears to be no significant benefit in their use overall or in the high-risk population.

Communities as ‘renewable energy’ for healthcare services? a multimethods study into the form, scale and role of voluntary support for community hospitals in England

ObjectiveTo examine the forms, scale and role of community and voluntary support for community hospitals in England.DesignA multimethods study. Quantitative analysis of Charity Commission data on levels of volunteering and...

STATIN THERAPY PRIOR TO SEPTIC SHOCK IS ASSOCIATED WITH A REDUCED RISK OF ARDS

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: A potential benefit of statins in reducing the risk of acute respiratory distress syndrome (ARDS) was shown in a septic shock animal model, however, this effect hasn’t been replicated in patients after they have developed ARDS. We aimed to evaluate the effect of statin therapy prior to admission in patients with septic shock on the risk of developing ARDS METHODS: A retrospective cohort of patients with septic shock in a community hospital ICU from December 2013 to December 2014 was complied. Patients who met criteria for septic shock were included. ARDS was defined based on the Berlin Criteria. Statin use prior to admission was determined from the home medication list. Demographic, clinical and laboratory data were collected. ARDS, ICU and hospital length of stay, and ventilator days were defined as outcomes. A multivariate regression analysis was employed with statin prior to admission as the independent variable, and ARDS as the dependent variable RESULTS: Of the 128 included patients, 61% were female, 71% were white, and the mean age was 67 years.The most common causes of septic shock were: intra-abdominal infection 34%, pneumonia 31%, and urinary tract infection 20%. In our sample, 56% of patients required mechanical ventilation, and the overall mortality was 50%. A total of 22% met criteria for ARDS with a mean PaFiO2 ratio of 128 (SD 67). Prior to admission 33% of patients were taking a statin. Patients taking statins were more likely to be older (73.7 +/- 10 vs 64.4 +/- 18; p=0.002), have diabetes mellitus (59% vs 40%; p=0.033), take aspirin (50% vs 19%; p<0.001), take beta blockers (47.6% vs 26%; p=0.013), have higher serum albumin levels (2.6 g/dL +/- 0.76 vs 2.1 +/- 0.74), and less likely to have cirrhosis (0% vs 12%; p=0.021). Patients taking a statin were less likely to develop ARDS (7% vs 29%; p=0.005). In the subset of patients on statins prior to admission, there was no significant difference in incidence of ARDS based on continuation of statin upon admission to the ICU (4.2% vs 11%; p=0.387). When controlling for age, gender, race, diabetes, aspirin, beta blockers, cirrhosis, pneumonia, albumin level, and lactate level, statin use prior to admission was associated with a significantly decreased risk of ARDS (OR 0.18; p=0.03). Statin use prior to admission was not associated with a significant reduction in length of stay (12.8 +/- 13.2 vs 15.4 +/- 16.1; p=0.365), ICU length of stay (4.7 +/- 4.8 vs 6.0 +/- 6.3; p=0.244), or ventilator days (3.1 +/- 5.6 vs 3.8 +/- 5.7; p=0.528). CONCLUSIONS: Statin therapy prior to septic shock was associated with a significantly decreased risk of developing ARDS in this retrospective cohort of community hospital patients CLINICAL IMPLICATIONS: Statins appear to reduce the risk of ARDS when patients have been taking them prior to developing septic shock. Further research into the mechanism by which statins modulate the pathogenesis of ARDS is warranted DISCLOSURES: No relevant relationships by Andres Chacon, source=Web Response No relevant relationships by Elie Donath, source=Admin input No relevant relationships by Brian Garnet, source=Web Response No relevant relationships by Mehdi Mirsaeidi, source=Web Response No relevant relationships by Juan Teran Plasencia, source=Web Response no disclosure on file for Adam Wellikoff

262. Pediatric Antibiotic Use in the Duke Antimicrobial Stewardship Outreach Network

BackgroundThe Duke Antimicrobial Stewardship Outreach Network (DASON) was established in 2013 to provide antimicrobial stewardship resources to community hospitals in the Southeast. Pediatric patients in community hospitals may benefit from antimicrobial stewardship program (ASP) activities.MethodsAntibacterial use (AU) was reviewed using the DASON Antimicrobial Stewardship Assessment Portal, which includes filters for National Healthcare Safety Network (NHSN) unit types. We performed a retrospective review of AU in pediatric units from January 1 to December 31, 2017. AU was summarized by days of therapy (DOT) and percent of total DOT for specific unit types and agents. AU rates were reported by DOT/1,000 patient-days.ResultsA total of 41 pediatric units were included from the 28 hospital DASON cohort: 11 Neonatal Critical Care or Step Down Nurseries, eight Pediatric Medical/Surgical Wards, and 22 Well Baby Units. There were no pediatric (non-neonatal) critical care or oncology units. A total of 21,731 antibiotic DOT were attributable to pediatric units, accounting for 1.6% of all AU in the cohort. These include 5,585 (26%) DOT in Neonatal Critical Care (level II/III) Units, 4,898 (23%) in Pediatric Medical/Surgical Units, 3,910 (18%) in Well Baby Units, 3,307 (15%) in Neonatal Critical Care (level III) Units, 3,217 (15%) in Step Down Neonatal Nurseries (level II), and 814 (4%) in Pediatric Medical Wards. Ampicillin (7,229 DOT, 33%), gentamicin (6,320 DOT, 29%), ceftriaxone (1,750 DOT, 8%), and vancomycin (1,462, 7%) were the most common antibiotics administered.AU rates were 219 DOT/1,000 patient-days in children when compared with 979 in adults. Unit-specific rates ranged from 65 (Well Baby Units) to 1,081 DOT/1,000 patient-days (Pediatric Medical/Surgical Units). Rates in level II and III nurseries ranged from 302 to 697 DOT/1,000 patient-days.ConclusionPediatric patients accounted for a small proportion of AU in community hospitals. AU rates on pediatric medical/surgical units were comparable with adult units. Although rates were lower in neonatal units, these units accounted for 75% of pediatric AU. Antibiotic exposure in the neonatal period has been associated with short- and long-term outcomes, including necrotizing enterocolitis, obesity, and atopy. This population would benefit from a dedicated focus from community hospital ASPs.Disclosures All authors: No reported disclosures.