Community Hospital Setting Research Articles

A Clinical Monitoring Approach for Early Onset Sepsis: A Community Hospital Experience.

A serial clinical examination approach to screen late preterm and term neonates at risk for early onset sepsis has been shown to be effective in large academic centers, resulting in reductions in laboratory testing and antibiotic use. The implementation of this approach in a community hospital setting has not been reported. Our objective was to adapt a clinical examination approach to our community hospital, aiming to reduce antibiotic exposure and laboratory testing. At a community hospital with a level III NICU and >4500 deliveries annually, the pathway to evaluate neonates ≥35 weeks at risk for early onset sepsis was revised to focus on clinical examination. Well-appearing neonates regardless of perinatal risk factor were admitted to the mother baby unit with serial vital signs and clinical examinations performed by a nurse. Neonates symptomatic at birth or who became symptomatic received laboratory evaluation and/or antibiotic treatment. Antibiotic use, laboratory testing, and culture results were evaluated for the 14 months before and 19 months after implementation. After implementation of the revised pathway, antibiotic use decreased from 6.7% (n = 314/4694) to 2.6% (n = 153/5937; P < .001). Measurement of C-reactive protein decreased from 13.3% (n = 626/4694) to 5.3% (n = 312/5937; P < .001). No cases of culture-positive sepsis occurred, and no neonate was readmitted within 30 days from birth with a positive blood culture. A screening approach for early onset sepsis focused on clinical examination was successfully implemented at a community hospital setting resulting in reduction of antibiotic use and laboratory testing without adverse outcomes.

How Should Pediatric Residents Prepare for a Career in Pediatric Hospital Medicine?

How Should Pediatric Residents Prepare for a Career in Pediatric Hospital Medicine?

Total Ankle Arthroplasty Can Be Safely and Effectively Performed in the Community Hospital Setting: A Case Series of 65 Patients

The use of total ankle arthroplasty has expanded over the past decade, primarily due to improvements in implant design and survivorship that have significantly reduced the high failure rates observed in first-generation implants. A retrospective review of 65 consecutive patients undergoing primary total ankle arthroplasty with a single senior orthopedic surgeon in a community hospital from January 2014 to December 2019 was performed. All procedures were performed for end stage osteoarthritis, with the most common secondary diagnoses being Achilles contracture (23%), retained hardware (17%) and calcaneovalgus deformity (11%). Preoperatively, patients averaged 10.45 ̊ ± 10.00 ̊ of non-weightbearing dorsiflexion and 30.00 ̊ ± 8.79 ̊ of plantarflexion. Postoperatively, patients averaged 13.33 ̊ ± 7.62 ̊ dorsiflexion, and 25.48 ̊ ± 7.87 ̊ of plantarflexion. A total of 8 (12.3%) patients required reoperation, and average time to reoperation was 1.55 ± 1.58 years. Implant failure, defined as reoperation requiring prosthesis removal, occurred in 2 (3.1%) patients, with an average time to failure of 342 days (105 days in failure due to periprosthetic joint infection and 582 days in failure due to subsidence). Patients undergoing total ankle arthroplasty at our institution had a 12.3% reoperation rate, and a 96.9% implant survival rate over an average follow-up period of 2.42 years, results that compare favorably with previously reported outcomes. Based on these findings, we suggest that this procedure, which is often offered only in academic tertiary care facilities, can be safely and effectively performed by experienced surgeons in the community hospital setting.

312. Clinical Attributes and Risk Factors for In- Hospital Mortality among Covid-19 Patients in a Community Hospital Setting: A Propensity Matched Analysis

Abstract Background New York City emerged as the Epicenter for Covid-19 due to novel Coronavirus SARS-CoV-2 soon after it was declared a Global Pandemic in early 2020 by the WHO. Covid-19 presents with a wide spectrum of illness from asymptomatic to severe respiratory failure, shock, multiorgan failure and death. Although the overall fatality rate is low, there is significant mortality among hospitalized patients. There is limited information exploring the impact of Covid-19 in community hospital settings in ethnically diverse populations. We aimed to identify risk factors for Covid-19 mortality in our institution. Methods We conducted a retrospective cohort study of hospitalized in our institution for Covid 19 from March 1st to June 21st 2020. It comprised of 425 discharged patients and 245 expired patients. Information was extracted from our EMR which included demographics, presenting symptoms, and laboratory data. We propensity matched 245 expired patients with a concurrent cohort of discharged patients. Statistically significant covariates were applied in matching, which included age, gender, race, body mass index (BMI), diabetes mellitus, and hypertension. The admission clinical attributes and laboratory parameters and outcomes were analyzed. Results The mean age of the matched cohort was 66.9 years. Expired patients had a higher incidence of dyspnea (P &amp;lt; 0.001) and headache (0.031). In addition, expired patients had elevated CRP- hs (mg/dl) ≥ 123 (&amp;lt; .0001), SGOT or AST (IU/L) ≥ 54 (p &amp;lt; 0.001), SGPT or ALT (IU/L) ≥ 41 (p &amp;lt; 0.001), and creatinine (mg/dl) ≥ 1.135 (0.001), lower WBC counts (k/ul) ≥ 8.42 (0.009). Furthermore, on multivariate logistic regression, dyspnea (OR = 2.56, P &amp;lt; 0.001), creatinine ≥ 1.135 (OR = 1.79, P = 0.007), LDH(U/L) &amp;gt; 465 (OR = 2.18, P = 0.001), systolic blood pressure &amp;lt; 90 mm Hg (OR = 4.28, p = .02), respiratory rate &amp;gt; 24 (OR = 2.88, p = .001), absolute lymphocyte percent (≤ 12%) (OR = 1.68, p = .001) and procalcitonin (ng/ml) ≥ 0.305 (OR = 1.71, P = .027) predicted in- hospital mortality in all matched patients. Conclusion Our case series provides admission clinical characteristics and laboratory parameters that predict in- hospital mortality in propensity Covid 19 matched patients with a large Hispanic population. These risk factors will require further validation. Disclosures All Authors: No reported disclosures

39. Impact of Antimicrobial Stewardship Interventions in a Community Hospital setting: An Interrupted Times Analysis

Abstract Background Community hospitals have fewer resources for antimicrobial stewardship programs (ASP) compared to larger tertiary hospitals. At our 312-bed community hospital, Long Island Jewish Forest Hills/Northwell, a combination of modified preauthorization, prospective audit feedback, and ASP education was implemented starting in August 2019 (Monday through Friday 9 am to 5 pm). Methods This retrospective study evaluated the impact of ASP interventions on the rate of targeted antimicrobial use over a 7 month pre- vs 7 month post- intervention period (Aug 2018 to Feb 2019 vs Aug 2019 to Feb 2020). Targeted antimicrobials included piperacillin-tazobactam, vancomycin, daptomycin, and carbapenems. The primary outcome was the monthly mean for overall targeted antimicrobial use measured by the rate of antimicrobial days per 1000 days present. Secondary outcomes were the individual rates of antimicrobial days per 1000 days present for each of the targeted antimicrobials, and the hospital’s overall standardized antimicrobial administration ratio (SAAR). Data were analyzed as a segmented regression of interrupted time series. Results Pre-intervention, there was an increasing trend (positive slope, p&amp;lt; 0.05) in the monthly mean, hospital SAAR, vancomycin and piperacillin-tazobactam use. Post-intervention, there was a significant change in slope for these same metrics, indicating a decrease in the mean use. Immediate impact of ASP interventions, measured by the difference in antibiotic use between the end of each intervention period, was visually evident in all cases except carbapenems (Fig. 1 through 4). The immediate impact on the overall monthly mean represented a significant reduction in the rate of antimicrobial days per 1000 days present, -12.72 (CI -21.02 to -4.42, P &amp;lt; 0.0066). The pre- vs post- ASP gap for all measures was negative and consistent with fewer days of antibiotic use immediately following intervention. Conclusion A targeted, multifaceted ASP intervention utilizing modified preauthorization, prospective audit feedback, and education significantly reduced antibiotic use in a community hospital. Disclosures All Authors: No reported disclosures

551. Remdesivir and Tocilizumab for the Treatment of Severe COVID-19 in a Community Hospital: A Retrospective Cohort Study

BackgroundGrowing evidence supports the use of remdesivir and tocilizumab for the treatment of hospitalized patients with severe COVID-19. The purpose of this study was to evaluate the use of remdesivir and tocilizumab for the treatment of severe COVID-19 in a community hospital setting.MethodsWe used a de-identified dataset of hospitalized adults with severe COVID-19 according to the National Institutes of Health definition (SpO2 < 94% on room air, a PaO2/FiO2 < 300 mm Hg, respiratory frequency > 30/min, or lung infiltrates > 50%) admitted to our community hospital located in Evanston Illinois, between March 1, 2020, and March 1, 2021. We performed a Cox proportional hazards regression model to examine the relationship between the use of remdesivir and tocilizumab and inpatient mortality. To minimize confounders, we adjusted for age, qSOFA score, noninvasive positive-pressure ventilation, invasive mechanical ventilation, and steroids, forcing these variables into the model. We implemented a sensitivity analysis calculating the E-value (with the lower confidence limit) for the obtained point estimates to assess the potential effect of unmeasured confounding.Figure 1. Kaplan–Meier survival curves for in-hospital death among patients treated with and without steroids The hazard ratio was derived from a bivariable Cox regression model. The survival curves were compared with a log-rank test, where a two-sided P value of less than 0.05 was considered statistically significant.Figure 2. Kaplan–Meier survival curves for in-hospital death among patients treated with and without remdesivir The hazard ratio was derived from a bivariable Cox regression model. The survival curves were compared with a log-rank test, where a two-sided P value of less than 0.05 was considered statistically significant.ResultsA total of 549 patients were included. The median age was 69 years (interquartile range, 59 – 80 years), 333 (59.6%) were male, 231 were White (41.3%), and 235 (42%) were admitted from long-term care facilities. 394 (70.5%) received steroids, 192 (34.3%) received remdesivir, and 49 (8.8%) received tocilizumab. By the cutoff date for data analysis, 389 (69.6%) patients survived, and 170 (30.4%) had died. The bivariable Cox regression models showed decreased hazard of in-hospital death associated with the administration of steroids (Figure 1), remdesivir (Figure 2), and tocilizumab (Figure 3). This association persisted in the multivariable Cox regression controlling for other predictors (Figure 4). The E value for the multivariable Cox regression point estimates and the lower confidence intervals are shown in Table 1.Figure 3. Kaplan–Meier survival curves for in-hospital death among patients treated with and without tocilizumab The hazard ratio was derived from a bivariable Cox regression model. The survival curves were compared with a log-rank test, where a two-sided P value of less than 0.05 was considered statistically significant.Figure 4. Forest plot on effect estimates and confidence intervals for treatments The hazard ratios were derived from a multivariable Cox regression model adjusting for age as a continuous variable, qSOFA score, noninvasive positive-pressure ventilation, and invasive mechanical ventilation.Table 1. Sensitivity analysis of unmeasured confounding using E-values CI, confidence interval. Point estimate from multivariable Cox regression model. The E value is defined as the minimum strength of association on the risk ratio scale that an unmeasured confounder would need to have with both the exposure and the outcome, conditional on the measured covariates, to explain away a specific exposure-outcome association fully: i.e., a confounder not included in the multivariable Cox regression model associated with remdesivir or tocilizumab use and in-hospital death in patients with severe COVID-19 by a hazard ratio of 1.64-fold or 1.54-fold each, respectively, could explain away the lower confidence limit, but weaker confounding could not.ConclusionFor patients with severe COVID-19 admitted to our community hospital, the use of steroids, remdesivir, and tocilizumab were significantly associated with a slower progression to in-hospital death while controlling for other predictors included in the models.Disclosures All Authors: No reported disclosures

485. Pediatrics Institutional COVID-19 Review

BackgroundCoronavirus disease (COVID-19) caused by SARS-COV2 represents global public health concern, with varied severity of illness in different ages and racial groups. This study aims to describe clinical presentation and outcomes in children aged 0-21 years in a community hospital setting in New Jersey.MethodsThis is a retrospective medical record review of pediatric patients (0-21 years) admitted to Saint Barnabas Medical Center between March 2020- December 2020 with confirmed diagnosis of COVID-19 infection. Diagnosis of COVID-19 infection is based on ICD-10 diagnosis code. Data was extracted from electronic medical records, including demographics, pre-existing conditions, presenting symptoms, treatments used and outcomes. ResultsWe identified 48 cases of pediatric COVID-19 patients at Saint Barnabas Medical Center during period of 03/20-12/20. Review of demographic data showed 29 patients (60%) were female, and 19 (40%) were male. Race distribution was 38% black, 17% white, 4 % Asian Indian, and 41% others/unknown. Age distribution was as follows: 40% >15 yrs, 15% 11-15 yrs, 15% 0-1 yrs, 13% 6-10 yrs, 13% 1-5 yrs, and 6% newborn. Fever (65%) was the most frequent symptom identified, followed by cough (31%), nausea/vomiting (29%), abdominal pain (19%), shortness of breath (17%), rash (15%), diarrhea (10%), headache (10%), myalgia/body-aches (8%), chest pain (6%), red eyes (6%), and loss of taste/smell (2%). Of 48 patients, 10 (21%) had positive chest X-ray findings of lung infiltrates or opacities, 4 (8%) had abnormal echocardiogram findings, and 1 (2%) had abnormal CT chest. 21 of 48 patients had underlying comorbid conditions, with Diabetes and Asthma being the most common. No deaths were reported. 8 of 48 COVID-19 patients were diagnosed with MIS-C. Of these MIS-C patients, 5 (63%) were male and 3 (38%) were female. 6 of 8 affected patients were black (75%). 50% of MIS-C patients were between 6-10 years. 3 of 8 patients (38%) had abnormal echocardiogram findings. ConclusionThis review supports clinical findings from other studies and also suggests certain racial ethnicities may be disproportionately impacted, which warrants further exploration to determine genetics vs environmental factors that lead to increased predisposition to severe illness.Disclosures All Authors: No reported disclosures

Genomic medicine in a community hospital setting

Clinical rapid genome sequencing (rGS), the sequencing and interpretation of variation in a patient's genome within ∼1 week, has helped to establish diagnoses and direct patient care in numerous studies, but has largely been restricted to an academic setting. In this volume of The Journal, Beuschel et al demonstrate that rGS is not only available in a community hospital but also directly affects patient care in this setting. In their retrospective analysis of 24 patients where a genetic diagnosis was suspected, or there was no clear explanatory cause of illness, medical management was altered in 67% of subjects as a result of rGS.

Clinical factors predictive of appropriate treatment in COPD: a community hospital setting

Background: Chronic obstructive pulmonary disease (COPD) is a common respiratory disease. The appropriate treatment according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline was 19-60%. However, there are limited data on predictors of appropriate treatment in patients with COPD. This study aimed to evaluate risk factors of appropriate treatment in patients with COPD according to the GOLD guideline in a real-world community setting. Methods: This is a retrospective study conducted at a community hospital. Inclusion criteria were adult patients diagnosed as COPD treated at a COPD clinic. The primary outcome was the appropriate treatment, defined by correct pharmacological treatment by the GOLD guideline according to the ABCD severity assessment. Clinical predictors of appropriate treatment were executed by stepwise multivariate logistic regression analysis. Results: 136 patients with COPD met the study criteria. Of those, 100 patients had inappropriate treatment according to the GOLD guideline. Three factors were independently associated with the appropriate treatment including number of admissions, modified Medical Research Council (mMRC) score, and CAT score. These factors had adjusted odds ratio of 3.11, 2.86, and 1.26, respectively. Causes of inappropriate treatment were unavailability of long-acting muscarinic antagonist (LAMA) (51 patients; 79.69%), treated by inhaled corticosteroid (ICS) alone (12 patients; 18.75%), and treated with only bronchodilator (1 patient; 1.56%). Conclusions: Appropriate COPD patients’ treatment according to the GOLD guideline was 26.47% in community setting. Factors associated with severity of COPD were associated with prescribing appropriate treatments.

PREVALENCE AND ASSOCIATED FACTORS IN THE DECLINE OF RENAL FUNCTION AMONG OUTPATIENTS ATTENDING A COMMUNITY HOSPITAL, CENTRAL THAILAND

Introduction: Chronic kidney disease (CKD) is recognized as global public health issue especially affecting developing countries including Thailand. The epidemiologic data in the decline of renal function and the risk factors among Thai patients especially in community hospital settings were limited.&#x0D; Methods: A cross-sectional study was conducted to identify the prevalence and associated risk factors in the decline of renal function among outpatients in Thaluang Community Hospital, Lop Buri Province, central Thailand, between November 1, 2018 and October 31, 2019. The decline in renal function was defined by glomerular filtration rate (GFR) &lt;60 mL/min/1.73m2. Multivariate logistic regression analysis was performed to obtain the adjusted odds ratios (AOR) and 95% confidence interval (CI) of the factors related to the decline of renal function.&#x0D; Results: A total of 874 outpatients participated in the study. The overall prevalence in the decline of renal function (eGFR &lt;60 mL/min/1.73m2) was 20.3% (95% CI; 17.5%-22.9%). Among male participants, the prevalence in the decline of renal function was 21.1% (95%CI; 16.7%-25.5%) while it totaled 19.7% (95%CI; 16.3%-23.1%) among females. The independent associated factors in the decline of renal function included greater age (AOR 1.07; 95% CI=1.05-1.09), history of NSAIDs used (AOR 2.97; 95% CI=1.85-4.79) and elevated pulse pressure (PP) &gt;75th percentile (AOR 1.64; 95% CI=1.07-2.53)&#x0D; Conclusion: We reported the prevalence in the decline of renal function among outpatients in a Thai community hospital which was comparable with the national level. Advanced age, history of NSAIDs used and PP were related to reduced kidney function. Therefore, effective health interventions should be conducted especially, appropriate NSAIDs used among outpatients.

Impact of profession and wards on moral distress in a community hospital.

Recently, a singular survey titled "Measure of Moral Distress-Healthcare Professionals," which addresses shortcomings of previous instruments, has been validated. To determine how moral distress affects nurses and physicians differently across the various wards of a community hospital. We distributed a self-administered, validated survey titled "Measure of Moral Distress-Healthcare Professionals" to all nurses and physicians in the medical/surgical ward, telemetry ward, intensive care units, and emergency rooms of a community hospital. A total of 101 surveys were included in the study. The mean Measure of Moral Distress-Healthcare Professionals score for all respondents was 143.0 (standard deviation = 79.8). The mean Measure of Moral Distress-Healthcare Professionals score was 1.75 greater for nurses than for physicians (92.5 vs 161.5, p < .001), and nurses were 2.52 times more likely to consider leaving their position due to moral distress (68% vs 27%). The mean Measure of Moral Distress-Healthcare Professionals score for moral distress was least prevalent in the medical/surgical ward (92.5, SD = 38.2) and highest in the telemetry ward (197.7, SD = 83.6). The intensive care unit ward had a mean Measure of Moral Distress-Healthcare Professionals score mildly greater than the emergency room. No participant identifying information or information connecting a survey response to an individual was collected. This study was approved by the Raritan Bay Medical Center's Institutional Review Board. This study provides insight into the level of moral distress in the community hospital setting. Telemetry nurses experience significantly more than nurses in other wards. Telemetry nurses typically manage patients sicker than medical/surgical wards, however do not have the resources of the critical care units. This scenario presents challenges for telemetry nurses and may explain their elevated moral distress. In community hospitals, telemetry nurses experience a considerably greater amount of moral distress compared to their colleagues in other wards. As measured by the Measure of Moral Distress-Healthcare Professionals questionnaire, moral distress continues to be higher among nurses compared to physicians.

Effect of Severe Acute Respiratory Syndrome Coronavirus 2 on Blood Product Utilization in the Community Hospital Setting

Abstract Introduction/Objective Blood products are a major expense for the laboratory, with an intricate balance between maintaining adequate supply and expiring products. Blood product wastage rates are typically less than 2%. The SARS-CoV-2 (SARS-CoV-2) pandemic has created a multifaceted challenge in blood utilization. Difficulties in predicting product usage, decreased supply, and transportation delays put hospitals at risk of increased blood product destruction. In this study, we analyze the effect of the SARS-CoV-2 pandemic on blood utilization in the community hospital setting, in order to develop improved laboratory management strategies for decreasing unit wastage. Methods/Case Report Quality indicators of blood utilization from 2012 to 2021 were retrospectively reviewed. Data was collected for packed red blood cells (pRBCs), platelets, and plasma. Units transfused, expired/destroyed, and total percent discarded were recorded for each month. Average transfusion and destruction rates were calculated for each product. Blood product utilization from 2020 was compared to years 2012-2019 using Pearson correlation, linear regression, and student paired t-tests. Results (if a Case Study enter NA) 1,042 units were reviewed. For pRBCs, there was a strong correlation between 2020 and increased destruction compared to 2012-2019 (R= 0.8, p=0.005). There was no significant change in pRBC transfusions in 2020 compared to 2018 and 2019 (p= 0.3, p= 0.2). There were fewer pRBC transfusions in 2020 compared to 2016 and 2017 (p= 0.006, p=0.01). For platelets, there was increased destruction in 2020 compared to 2012-2019 (p= 0.01-0.04) and no significant change in usage (p= 0.3-0.5). Conclusion During the 2020 SARS-CoV-2 pandemic, there was a significant increase in blood product wastage. There was no significant increase in transfused pRBCs or platelet units, suggesting the increased destruction was not due to an overall increase in transfusions. Blood products are a major cost for laboratory and further investigation of these findings is warranted to mitigate continued wastage.

Three-Year Experience of a Multidisciplinary Central Nervous System Clinic Model for Radiation Oncology and Neurosurgery (RADIANS) in a Community Hospital Setting

As academic centers partner and establish healthcare systems with community hospitals, delivery of subspecialty, multidisciplinary care in community hospital settings remains a challenge. Improving outcomes for central nervous system (CNS) disease is related to integrated care between neurosurgery (NS) and radiation oncology (RadOnc) specialties. Our multidisciplinary community hospital-based clinic, RADIANS, previously reported high patient approval of simultaneous evaluation with NS and RadOnc physicians. Three-year experience is now reported. Prospectively collected clinical and demographic patient data over three years was done, and surveys administered. Descriptive statistics reported as mean and percentages for patient characteristics, diagnosis, treatment and outcomes. Between August 2016 and August 2019, 101 patients were evaluated. Mean age and distanced traveled was 61.2 years, and 54.9 miles, respectively. Patient Satisfaction Score was 4.79 (0-5 Scale, 5-very satisfied). Most common referral source was medical oncologists. Seventy-two patients had malignant CNS disease (brain mets 28; spine mets 27; both 6; primary brain 9; primary spine 2), 29 had benign CNS disease. Post-evaluation treatment: radiation therapy (RT) only (n=29), neurosurgery (NS) only (n=16), both RT and NS (n=22), and no RT/NS intervention (n=34). Fractionated stereotactic radiosurgery was most common RT delivered; craniotomy with tumor resection was most common NS performed. Treatment outcomes: local control=61/67 (91%); radiation necrosis or radiation-induced myelitis=2/51 (3.9%). The RADIANS multidisciplinary community hospital-based CNS clinic model is first of its kind to be reported, continuing strong patient approval at extended follow-up. Data indicates the model serves as a regional referral center, delivering evidence-based treatment modalities for complex CNS disease in community hospital settings, yielding high rates of local control and low rates of grade 3 or 4 radiation-induced toxicity.

Evaluation of albumin use in a community hospital setting: A retrospective study looking at appropriate use and prescribing patterns.

Albumin has been shown to be safe and effective in clinical practice for a wide variety of indications. The purpose of this medication use evaluation is to quantify the use of albumin in the community hospital setting based on indication and prescribing department. This study is a retrospective, single-center, chart review over a 6-month period of 186 patients aged 18 and older who were treated with IV human albumin 5% or 25% at a single 202-bed community hospital setting from February 1, 2020, to August 1, 2020. A chart review was completed for each patient and the data collected included date of albumin administration, the ordering provider, the specialty of the provider, the indication for albumin as stated in the order, patient notes, crystalloid therapy use prior to albumin, albumin strength, the presence of acute or chronic renal, hepatic or respiratory disorders, and lab values denoting renal and hepatic function. Appropriate albumin use was determined utilizing criteria which included FDA labeled indications, the Surviving Sepsis Campaign, and existing literature. A total of 186 patients received albumin 5% or 25% IV solution at least once during the study period. The study population was 52.2% female, and the average age was 68 years. Of the patients selected for the study, 23 (11.6%) had chronic hepatic disease, and 37 (18.7%) had chronic renal disease. The top indications for which albumin was administered were sepsis or septic shock (25.3%), hypotension or hypovolemia (19.4%), intra-dialytic hypotension (13.4%), fluid support in surgery (10.8%), and nephrosis or nephropathy (10.8%). The departments with highest albumin use during this study period were critical care (41%), nephrology (28%), and surgery (17%). Overall, albumin was used for an appropriate indication in 126 out of 186 patients (67.7%). We found that albumin was most utilized for sepsis and septic shock, hypovolemia and hypotension, and intradialytic hypotension in our community hospital setting and it was most frequently ordered by critical care, nephrology, and surgical departments. Further research could determine if this trend is seen in other community hospital settings.

Association of the FRAIL scale with rehabilitation outcomes in the community hospital setting.

Frailty is associated with adverse health outcomes and can be measured using the FRAIL scale. In Singapore, its use has been studied in tertiary hospitals but not in community hospitals. A tool to predict rehabilitation outcomes would allow for better risk stratification and allocation of resources. We aimed to determine whether the FRAIL scale is associated with rehabilitation outcomes in patients admitted to the community hospital setting, where post-acute care and rehabilitation are primarily delivered. This was a retrospective cohort study. The FRAIL scale was utilised to screen 560 older adults who were admitted to a community hospital for rehabilitation. Data were analysed to determine the relationship between baseline characteristics and frailty status, with rehabilitation outcome measures of absolute functional gain, rehabilitation effectiveness, rehabilitation efficiency, length of stay and discharge destination. The combined score of the FRAIL scale showed significant negative association with absolute functional gain (P < 0.001), rehabilitation effectiveness (P < 0.001) and rehabilitation efficiency (P < 0.001), whereas it was positively associated with increased length of stay (P < 0.05) and a need for continued support in increased care settings (P < 0.001). Individual components of the FRAIL scale, in particular, the 'fatigue', 'ambulation' and 'loss of weight' components, appeared to be highly associated with rehabilitation effectiveness and efficiency, especially among pre-frail patients. The utility of the FRAIL scale as an indicator of frailty status and its association with rehabilitative outcomes in the post-acute care setting were demonstrated. Moreover, the FRAIL scale may better predict the rehabilitative progress of pre-frail patients.

S2299 Mysterious Bleeding in a Patient With Roux-en-Y Gastrectomy

Introduction: Obscure gastrointestinal bleeding (GIB) accounts for 5% of admissions for GIB. Management of recurrent obscure GIB is problematic and costly, requiring repeat hospitalizations, various imaging modalities and multiple endoscopies with bleeding often ceasing at time of endoscopy, only to recur at a later time. Angiography can be diagnostic and therapeutic, but may be complicated by kidney damage and ischemia. Nuclear medicine bleeding scan is time consuming and often unreliable. Surgical intervention is a last resort, carries significant morbidity, and may not be a permanent solution as in the case of bleeding from angioectasias. Case Description/Methods: A 39 year old woman with gastric bypass 15 years ago initially presented to outside hospital with reports of rectal bleeding and anemia requiring transfusions. At that time, ileocolonoscopy and push enteroscopy were performed, and were unrevealing for etiology of bleeding. She presented to our institution a month later with same complaints. Nuclear bleeding scan suspected bleeding in the colon; repeat colonoscopy was again unrevealing. Small bowel capsule endoscopy was planned, but patient returned to the hospital with symptomatic anemia (Hgb 4.9 g/dL) and rectal bleeding. CT-angiography was unrevealing. After a discussion with the patient, endoscopy with heparin provocation was planned. After colonoscope was advanced into terminal ileum, IV Heparin 10,000u was administered. Terminal ileum and colon were carefully examined with two passes of the scope; no blood or etiology of bleeding identified. Push enteroscopy was then performed up to jejuno-jejunal anastomosis, where fresh blood was encountered. Active oozing from large bed of vascular ectasias was apparent. Protamine Sulfate 50mg IV was administered and ectasias were treated with Argon Plasma Coagulation and hemoclips placement with successful cessation of bleeding. The patient was discharged home and had no further hospitalizations for GIB. Discussion: Heparin provocation has been used in rare cases of obscure GIB to provoke bleeding and identify responsible site at time of endoscopy. This is useful in patients with recurrent overt obscure bleeding, especially in poor surgical candidates. Heparin provocation has been controversial due to fear of inducing a life-threatening bleed. However, as this case demonstrates, such procedures can be performed safely and effectively even in a community hospital setting with proper preparation and use of Protamine to reverse anticoagulation effects.Figure 1.: 1. J-J anastomosis filled with blood 2. J-J anastomois with active bleeding 3. Status post treatment with cautery and hemoclip placement.

S3371 Diagnostic Efficacy of Endoscopic Ultrasound-Guided Fine-Needle Biopsy (EUS-FNB) in the Evaluation of Solid Pancreatic Neoplasms: A Community Hospital Experience

Introduction: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) plays a crucial role in the early diagnosis of pancreatic cancer. Majority of EUS procedures are performed in tertiary care centers, and data from community hospitals is limited. Our goal was to assess EUS-FNB performance and its diagnostic efficacy in a community hospital setting and compare it with specialized centers. Methods: We reviewed electronic health records of patients who underwent EUS-FNB procedure for solid pancreatic lesions at MedStar Southern Maryland Hospital Center between 2019-2020. All cases underwent EUS with linear array echoendoscope, and FNB was performed by an experienced gastroenterologist using a 22-gauge Franseen tip needle. Pathologist performed rapid onsite evaluation (ROSE). EUS impression was correlated with final cytology diagnosis. Follow-up data were obtained on all neoplastic cases by reviewing surgical pathology reports and medical oncology notes. Results: We had 38 patients who underwent EUS-FNB, of which 17 were males and 21 were females. Age group 43-90 years (mean: 66 years). Number of FNA passes 2-6 (average: 3.6). Pancreatic lesions size range 0.8-5.8 cm (mean: 2.8 cm). ROSE was performed on 35/38 cases (92.1%), of which 30/35 cases (85.7%) were deemed adequate. Location of the pancreatic lesions: 20 head, 2 neck 2, 1 uncinate process, 8 body, and 7 tail. By cytology, 20 cases were neoplastic, 12 non-neoplastic, and 6 non-diagnostics. EUS impression was accurate in 18/20 (90%) neoplastic cases (18 adenocarcinomas, 1 Intraductal papillary mucinous neoplasm, and 1 neuroendocrine tumor), and the remaining 2 (10%) cases had initial incorrect EUS impression of pancreatitis. Of 12 non-neoplastic cases on cytology only 7 precisely correlated with EUS impression. The 6 cases deemed non-diagnostic by cytology were excluded from statistical analysis. The overall discrepancy rate between cytology and EUS was 21.9% (7/32) (Table). Conclusion: Calculated sensitivity, specificity, positive predictive value, and negative predictive value for EUS-FNB were 90%, 67%, 82%, and 80%, respectively. The calculated statistical measures of EUS-FNB's performance from our community hospital (sensitivity of 90%) are comparable to published data from larger specialized centers. With a diagnostic efficacy of 90% and higher tissue yield on EUS-FNB, the technique can be safely performed in community hospitals for appropriately triaging patients to specialized centers for a higher level of care as needed.Table 1.: Correlation between Endoscopic Ultrasound (EUS) Impression, Cytology Diagnosis, and Final Diagnostic Surgical Resection/ Medical Oncology. Footnotes: ROSE: Rapid On-site Evaluation; IPMN: Intraductal Papillary Mucinous Neoplasm.

Provider Comfort with Prescribing HIV Pre-Exposure Prophylaxis to Adolescents.

In the United States, Black and Latinx youth remain disproportionately affected by HIV. Oral antiretroviral pre-exposure prophylaxis (PrEP) is a proven effective HIV prevention strategy. PrEP is approved for use in people younger than the age of 18 years, but little is known about provider comfort and preparedness with prescribing it to adolescents. In this study, physicians provide their perspectives on the facilitators and barriers to PrEP access among adolescents. Focus groups (n = 23) were conducted with pediatric and family practitioners practicing in an urban community hospital setting to assess PrEP awareness and receptivity to use among adolescents. Most providers were unfamiliar with clinical guidelines for PrEP use, especially in determining adolescent candidates for PrEP use, including appropriate dosing regimen and follow-up procedures. Overall, providers had low intent on prescribing PrEP, citing concerns about consent, medication adherence, and appropriateness of primary care providers in prescribing and managing adolescent PrEP use. Strategies that will address provider education and comfort in prescribing PrEP to adolescents are required to increase PrEP access and uptake among communities disproportionally affected by HIV.

Head and Neck Free Flap Reconstruction in an Academic versus a Community Setting.

Head and neck free flap reconstructions are complex procedures requiring extensive resources, and have the potential to be highly morbid. As such, it is imperative that they should be performed in an appropriate setting, optimizing outcomes while limiting morbidity. The aim of this study is to identify any disparities in the treatment outcomes of patients undergoing head and neck free flap reconstruction by a single surgeon in an academic versus a community hospital setting. A retrospective review of all patients who underwent head and neck free flap reconstruction for any indication by a single surgeon from 2009 to 2019 was conducted. All surgeries were performed at one of two hospitals: one academic medical center and one community hospital. Demographics and rates of partial or complete flap failure, medical complications, surgical complications, mortality, and other secondary outcomes were compared between the two settings. Ninety-two patients who underwent head and neck free flap reconstruction were included. Fifty-seven (62%) of free flap reconstructions were performed in the academic medical center, while 35 (38%) were performed in the community hospital. There were no significant differences in complete flap loss, either intraoperative or postoperative (p = 0.5060), partial flap loss (p = 0.5827), postoperative surgical complications (p = 0.2930), or medical complications (p = 0.7960) between groups. The in-hospital mortality rate was 0% (n = 0) at the university hospital as compared with 5.7% at the community hospital (p = 0.0681). The mean operative time was 702.3 minutes at the university hospital and 606.3 minutes at the community hospital (p = 0.0080). Head and neck free flap surgery can be performed safely in either an academic or a community setting, with no difference in primary outcomes of surgery. Preferential selection of either treatment setting should be based on consideration of patient needs and availability of auxiliary specialty services.

What are the benefits and harms of interventions to increase patient and family involvement in the escalation of care for community health and hospital settings?

What are the benefits and harms of interventions to increase patient and family involvement in the escalation of care for community health and hospital settings?