Community Hospital System Research Articles

S1610 The Impact and Utilization of Magnetic Resonance Cholangiopancreatography (MRCP) Amongst Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) in a Community Hospital System

S1610 The Impact and Utilization of Magnetic Resonance Cholangiopancreatography (MRCP) Amongst Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) in a Community Hospital System

Improvements in Clinical Cancer Care Associated with Integration of Personalized Medicine.

While adoption of personalized medicine (PM) continues to increase in clinical oncology, there is limited data connecting the level of PM adoption at a given institution to improved clinical outcomes for patients. The purpose of this study was to analyze the correlation between health care providers' scores on a previously described PM integration framework and two outcome measures: the use of targeted therapy and clinical trial enrollment. This study was conducted using real-world data (RWD) from the Syapse® Learning Health Network (LHN). The PM integration score for six community hospital systems in the LHN was calculated and subsequently correlated with the two outcome measures. Across six institutions, a strong correlation between PM integration score and targeted therapy use was observed in metastatic non-small cell lung cancer (mNSCLC) (R2 = 0.81), an indication with a significant number of approved targeted agents. Conversely, a strong correlation between PM integration score and clinical trial enrollment was observed in metastatic triple-negative breast cancer (TNBC) (R2 = 0.63), an indication with fewer marketed targeted therapies but an active targeted therapy pipeline. The results in these cases suggest that PM integration is a strong indicator of high-quality care practices for both utilization of targeted therapy in more mature PM indications (e.g., mNSCLC) and clinical trial enrollment in more emerging PM indications (e.g., TNBC).

EVALPAX: Evaluation of a pharmacist-driven protocol for nirmatrelvir/ritonavir prescribing in a community hospital system.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The purpose of this study was to evaluate pharmacist prescribing of nirmatrelvir/ritonavir to ensure this method of increasing access to treatment is safe and effective. This multicenter, retrospective observational study included patients receiving a prescription for nirmatrelvir/ritonavir by a physician, nurse practitioner (NP), physician assistant (PA), or pharmacist at an Indiana University (IU) Health West Central Region site over a 3-month period. Patients were divided into two groups: those who received nirmatrelvir/ritonavir prescribed by a pharmacist (the pharmacist prescribed group) and those who received nirmatrelvir/ritonavir prescribed by other providers (the physician/NP/PA prescribed group). Electronic health record (EHR) reviews were performed to assess the appropriateness of prescriptions based on the presence of risk factors and symptoms, day of symptom onset, and dosing. The primary endpoint was the overall appropriateness of nirmatrelvir/ritonavir prescriptions in the two study groups based on emergency use authorization inclusion and exclusion requirements. Secondary endpoints included appropriateness of nirmatrelvir/ritonavir dosing and medically attended visits or mortality within 30 days. Statistical analysis of the endpoints occurred post hoc utilizing the Fisher's exact test. A total of 259 patients were included in the pharmacist prescribed group and 265 patients in the physician/NP/PA prescribed group. Overall appropriate nirmatrelvir/ritonavir prescribing occurred in 258 patients (99.6%) and 232 patients (87.5%) in the pharmacist and physician/NP/PA prescribed groups, respectively (P < 0.0001). Nirmatrelvir/ritonavir dosing was appropriate in 256 patients (98.8%) and 240 patients (90.6%) in the pharmacist and physician/NP/PA prescribed groups, respectively (P < 0.0001). The 30-day rates of medically attended visits were similar between groups. No patients died within 30 days of treatment in either group. Pharmacist prescribing of nirmatrelvir/ritonavir may result in a higher likelihood of prescriptions meeting overall appropriateness criteria. Pharmacists represent an important healthcare professional resource to improve nirmatrelvir/ritonavir prescribing and utilization.

Central Nervous System Prophylaxis Utilization in Patients With Newly Diagnosed Diffuse Large B-Cell Lymphoma Within a Large Community Health System.

The impact of central nervous system (CNS) prophylaxis in diffuse large B-cell lymphoma (DLBCL) is contentious. The CNS International Prognostic Index (IPI) calculator offers prognostic guidance in identifying those patients who may be at highest risk of disease progression or relapse to the CNS. However, it is unclear whether this tool has guided clinician decision-making in a real-world setting. Studies have suggested that CNS prophylaxis may not offer clinically significant benefit in terms of preventing CNS disease progression. Given this, we investigated the utilization of CNS prophylaxis within our own population and documentation of the CNS-IPI score. We retrospectively evaluated patients with newly diagnosed DLBCL between January 1, 2014, and December 31, 2017. Patients were assessed for receipt of CNS prophylaxis in the form of intrathecal (IT) chemotherapy and/or high-dose intravenous (IV) methotrexate. CNS-IPI scores were calculated for all patients who received CNS prophylaxis or those who experienced CNS disease. Long-term outcomes at five years from diagnosis included CNS progression/relapse and survival. Of 234 patients who met criteria, 20 (8.6%) received either IV methotrexate or IT chemotherapy; most received IT methotrexate. No patients in the IT prophylaxis group developed CNS disease, while two of eight IV methotrexate patients experienced CNS disease involvement. The incidence of CNS progression was 3.7% in the no prophylaxis group and 10% in those who received prophylaxis. This study revealed low utilization of CNS prophylaxis and CNS-IPI documentation in a community hospital system. Given large differences between groups, claims of CNS prophylaxis efficacy are unable to be made. CNS relapse rates were consistent with existing literature and promote continued evaluation of the utility of current CNS prophylaxis approaches in DLBCL. New unambiguously effective therapeutic approaches are needed and may encourage a higher rate of standardized use.

Universal genetic counseling in breast cancer patients significantly improves overall testing rates and improves completion rates in subpopulations.

The NCCN guidelines recommend genetic testing in those patients at increased risk of breast cancer in order to identify candidates for increased frequency of screening or prophylactic mastectomy. However, genetic testing may now identify patients who may benefit from recently developed targeted breast cancer therapy. In order to more widely identify these patients, we implemented genetic counseling for all patients diagnosed with breast cancer. In 2021, all patients evaluated within a Midwestern community hospital system diagnosed with breast cancer were offered genetic counseling. This group of patients was compared to a cohort of patients in 2021 who were offered genetic counseling based on NCCN guidelines. With Pearson's chi square, Fisher's Exact test, Mann-Whitney U, and multivariate regression as appropriate, individual demographic data and genetic testing completion between 2019 and 2021 were evaluated. A total of 973 patients were reviewed. 439 were diagnosed with breast cancer in 2019 and 534 in 2021. Demographics and stage at diagnosis (p = 0.194) were similar between years. Completion of genetic testing increased from 204 (46.5%) in 2019 to 338 (63.3%) in 2021 (p < 0.01) with the universal counseling protocol. Specifically, genetic testing completion increased significantly in older patients (p = 0.041) and patients receiving Medicare benefits (p = 0.005). The overall pathogenic variants found increased from 32 to 39 with the most common including BRCA2 (n = 11), CFTR (n = 9), CHEK2 (n = 8), BRCA1 (n = 6). Universal genetic counseling was related to a significant increase in genetic testing completion and an increase in pathogenic variants found among breast cancer patients, specifically in subpopulations which may have been previously excluded by traditional NCCN genetic testing screening guidelines.

Adoption and Clinical Outcomes of Fenestrated Endovascular Aneurysm Repair in a Regional, Multi-state Community Hospital System

Adoption and Clinical Outcomes of Fenestrated Endovascular Aneurysm Repair in a Regional, Multi-state Community Hospital System

Cardiac Extracorporeal Membrane Oxygenation in Community Cardiac Surgery Program: Are the Results Comparable?

Extracorporeal membrane oxygenation (ECMO) outcomes in small centers are commonly considered less favorable than in large-volume centers. New ECMO protocols and procedures were established in our regional community hospital system as part of a cardiogenic shock initiative. This retrospective study aims to evaluate the outcomes of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) in a community hospital system with cardiac surgery capability and assess whether protocol optimization and cannulation standards result in comparable outcomes to larger centers whether the outcomes of this new ECMO program at the community hospital setting were comparable to the United States averages. Our regional system comprises five hospitals with 1500 beds covering southwestern New Jersey, with only one of these hospitals having cardiac surgery and ECMO capability. In May 2021, the new ECMO program was initiated. Patients were screened by a multidisciplinary call, cannulated by our ECMO team, and subsequently treated by the designated team. We reviewed our cardiac ECMO outcomes over two years, from May 2021 to April 2023, in patients who required ECMO due to cardiogenic shock or as a part of extracorporeal cardiopulmonary resuscitation (ECPR). A total of 60 patients underwent cardiac ECMO, and all were VA ECMO, including 18 (30%) patients who required ECPR for cardiac arrest. The overall survival rate for our cardiac ECMO program turned out to be 48% (29/60), with 50% (22/42) in VA ECMO excluding ECPR and 39% (7/18) in the ECPR group. The hospital survival rate for the VA ECMO and ECPR groups was 36% (15/42) and 28% (5/18), respectively. The ELSO-reported national average for hospital survival is 48% for VA ECMO and 30% for ECPR. Considering these benchmarks, the hospital survival rate of our program did not significantly lag behind the national average. With protocol, cannulation standards, and ECMO management optimized, the VA ECMO results of a community hospital system with cardiac surgery capability were not inferior to those of larger centers.

Adoption and clinical outcomes of fenestrated endovascular aneurysm repair in a regional, multistate community hospital system

ObjectiveComplex endovascular abdominal aortic aneurysm (AAA) repair techniques have evolved over the last decade, yet patterns of physician and hospital system adoption of fenestrated endovascular aneurysm repair (FEVAR) remain poorly defined. We investigated clinical outcomes, use trends, and surgeon and hospital experience for FEVAR in a large community hospital system. MethodsWe conducted a retrospective cohort study of all FEVAR procedures within our 5-state hospital system between April 2012 and June 2021. AAA repair volumes (open, EVAR, and FEVAR) were captured at the hospital and surgeon levels using Current Procedural Terminology and International Classification of Diseases codes. Clinical and outcomes data were collected for FEVAR patients. To consider if surgeon or hospital experience influenced outcomes, sequential case number was used to divide patients into surgeon experience and hospital experience groups. Inverse probability weighted and generalized linear mixed models, adjusted for demographics and comorbidities, were built to examine risk-adjusted outcomes for surgeon and hospital experience groups. ResultsOf 3850 patients treated with AAA procedures of any kind between 2012 and 2021, 160 (4.2%) underwent FEVAR. FEVAR procedures were performed by 34 different surgeons at 12 hospitals, with intraoperative complications and unplanned adjunctive procedures occurring in 18.8% (n = 30) and 19.4% (n = 31) of patients, respectively. Among FEVAR patients, in-hospital mortality was 1.3% (n = 2) and postoperative morbidity was 16.9% (n = 27). Renal function decline occurred postoperatively in 5.1% of patients. Early (<30 day) postoperative endoleaks occurred in 15.3% of patients (n = 21). Target vessel patency was 95.6% on initial postoperative imaging. Surgeon and hospital experience had a small positive impact on outcomes after the first one to three cases. Significant decreases in operative time, fluoroscopy time, and estimated blood loss were observed with increased surgeon experience, relative to a surgeon's first case (P < .05). There were lower odds of intraoperative complications after a surgeon's first case (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.03-0.77, for cases 2-3) or after a hospital's first one to three cases (OR, 0.19; 95% CI, 0.04-0.89, for cases 4-8; OR, 0.12; 95% CI, 0.03-0.55 for cases 9-49). ConclusionsClinical outcomes of FEVAR across our hospital system compare favorably with previously published reports. Although system-wide FEVAR adoption increased 3-fold over the last decade, FEVAR continued to be performed by a minority of hospitals in our system. The results from this cohort demonstrate low rates of adverse events, high rates of technical efficiency, and a small impact of surgeon and hospital experience, thereby supporting this advanced endovascular technology as a safe, efficacious, and generalizable treatment alternative to open repair for patients with complex aortic anatomy.

Improving Compliance with Preoperative Nasal Povidone-Iodine to Prevent Surgical Site Infection in Vascular and Neurosurgery Services in a Community Teaching Hospital.

Surgical site infections (SSI) remain a cause of morbidity, prolonged hospitalization, surgical readmission, and death. Nasal colonization with methicillin-resistant Staphylococcal aureus is a frequent cause of device-related SSI and nasal mupirocin has been used for prevention. More recently, povidone-iodine nasal swabs have become an alternative. It is cheaper, ensures compliance and there are no concerns regarding antimicrobial resistance. However, its adoption was suboptimal in a community hospital system in southwestern Ohio, especially in neurosurgery and vascular surgery. Quality improvement techniques, including solicitation of stakeholder input, surgeons and perioperative nurses' education, and the use of reminders to order and administer the povidone-iodine nasal swabs improved physician ordering and nurse administration compliance, leading to fewer infections. The interventions continued after the project was completed, sustaining decreases in neurosurgery and vascular surgery, and fewer SSI through the first years of the pandemic. Despite the complexity of these surgeries, simple interventions were effective in addressing the problem.

Gynecologic Surgical Subspecialty Training Decreases Surgical Complications in Benign Minimally Invasive Hysterectomy

Study ObjectiveTo evaluate the impact of gynecologic subspecialty training on surgical outcomes in benign minimally invasive hysterectomies (MIH) while accounting for surgeon volume. DesignRetrospective cohort study of patients who underwent a MIH between 2014 and 2017. SettingSingle community hospital system. PatientsPatients were identified via CPT (Current Procedural Terminology) codes for MIH: vaginal, laparoscopic or robotic. Exclusion criteria included a gynecologic cancer diagnosis or concomitant major procedure at the time of hysterectomy. One thousand six hundred and thirty-one patients underwent a benign MIH performed by a gynecologic generalist or a subspecialist in Minimally-Invasive Gynecologic Surgery (MIGS), Urogynecology and Pelvic Reconstructive Surgery (URPS), or Gynecologic Oncology. 125 hysterectomies were vaginal, 539 were conventional laparoscopic, and 967 were robotic. InterventionsN/A Measurements and Main ResultsSurgical outcomes including intraoperative complications, operative outcomes, and postoperative readmissions and reoperations, were compared between generalists and subspecialists and stratified by surgeon volume status, with “high-volume” defined as performing 12 or more hysterectomies annually. Odds ratios for the primary outcome, Clavien-Dindo Grade III complications (which included visceral injuries, conversions, and reoperations within 90 days), were calculated to evaluate the impact of subspecialty training while accounting for surgeon volume status. 855/1631 (52.4%) MIH were performed by generalists and 776/1631 (47.6%) by subspecialists. High-volume generalists performed 618/1631 (37.9%) of MIH, 14.5% (237/1631) were performed by low-volume generalists. All subspecialists were high-volume surgeons; 38.1% of generalists were high-volume.The odds of a Clavien-Dindo Grade III complication was 0.39 (0.25-0.62) for hysterectomies performed by subspecialists compared to high-volume generalists after adjusting for potential confounding variables (p < .001). Subspecialists and high-volume surgeons had significantly lower incidence of visceral injuries, transfusions, blood loss over 500 mL, and conversions compared to generalists and low-volume surgeons, respectively. ConclusionBoth subspecialty training and high surgeon volume status are associated with a lower risk of surgical complications in benign MIH. Subspecialty training is associated with a reduction in surgical complications even after accounting for surgeon volume.

Incidence of short-term community hospital stays and clinical profiles of patients: the Finnish Community Hospital Cohort Study

Objective A community hospital system covers the entire population of Finland. Yet there is little research on the system beyond routine statistics. More knowledge is needed on the incidence of hospital stays and patient profiles. We investigated the incidence of short-term community hospital stays and the features of care and patients. Design Prospective observational study. Setting Community hospitals in the catchment area of Kuopio University Hospital in Finland. Subjects Short-term (up to one month) community hospital stays of adult residents. Main outcome measures The outcome was the incidence rate of short-term community hospital stays according to age, sex and the first underlying diagnoses. Results A number of 13,482 short-term community hospital stays were analyzed. The patients’ mean age was 77 years. The incidence rate of short-term hospital stays was 28.6 stays per 1000 person-years among residents aged <75 years and 419.0 among residents aged ≥75 years. In men aged <75 years, the hospital stay incidence was about 40% higher than in women of the same age but in residents aged ≥75 years incidences did not differ between sexes. The most common diagnostic categories were vascular and respiratory diseases, injuries and mental illnesses. Conclusions The incidence rate of short-term community hospital stays increased sharply with age and was highest among women aged ≥75 years. Care was required for acute and chronic conditions common in older adults. Implications Community hospitals have a substantial role in hospital care of older adults.

Evaluating the association of COVID-19 restrictions on discharge planning and post-discharge outcomes in the community hospital and Singapore regional health system.

The COVID-19 is a global health issue with widespread impact around the world, and many countries initiated lockdowns as part of their preventive measures. We aim to quantify the duration of delay in discharge to community from Community Hospitals, as well as quantify adverse patient outcomes post discharge pre and during lockdown period. We conducted a before-after study comparing the length of stay in Community Hospitals, unscheduled readmissions or Emergency Department attendance, patients' quality of life using EQ5D-5l, number and severity of falls, in patients admitted and discharged before and during lockdown period. The average length of stay in the lockdown group (27.77 days) were significantly longer than that of the pre-lockdown group (23.76 days), p = 0.003. There were similar proportions of patients with self-reported falls post discharge between both groups. Patients in the pre-lockdown group had slightly better EQ-5D-5l Index score at 0.55, compared to the lockdown study group at 0.49. Half of the patients in both groups were referred to Community Care Services on discharge. Our study would help in developing a future systematic preparedness guideline and contingency plans in times of disease outbreak and other similar public health emergencies.

Assessment of outpatient chemotherapy and unplanned emergency department visits in a large community hospital system.

e18768 Background: Unplanned complications of outpatient chemotherapy can significantly affect patient oncologic outcomes, health, and increase cost of care. CMS rule OP-35 evaluates quality of care for Medicare patients by assessing the risk of emergency department (ED) visit within 30 days after outpatient chemotherapy administration. This study reviews this measure for all oncology patients treated in our community hospital setting. Methods: Patients treated between 02/2012 and 04/2021 were identified. Age at first chemotherapy administration, gender, cancer diagnosis, and chemotherapy regiment were evaluated. Chemotherapy was stratified into cytotoxic therapy, immunotherapy, targeted therapy, and endocrine therapy. ED visits were only those in our hospital system. 30-day risk of ED visit was calculated for individual chemotherapy administrations. Internal results were compared with our CMS OP-35 results for concordance. Results: There were 19,732 patients who received chemotherapy treatments between 02/2012 and 04/2021, with 262,379 chemotherapy administrations. Individual chemotherapy administration had 5.2% risk of a 30 day ED visit. Cumulative risk of a patient having a 30 day ED visit was 32.9%. From ED, patients had 61.2% rate of hospital admission, vs 24.8% rate for general ED population. By age at first chemotherapy administration, the risk of 30 day ED visit was 6.3% for age &lt; 18, 5.4% for age 18-64, and 5.9% for age &gt; = 65. Our rate was relatively stable between 2014 and 2020. Our corresponding CMS score was 5.5% in 2016, 5.5% in 2018, and 5.1% in 2019. By gender, the risk was 5.6% for male and 5.0% for female patients. By chemotherapy category, the risk was 5.9% for cytotoxic chemotherapy, 7.5% for immunotherapy, 4.2% for targeted therapy, and 5.2% for endocrine therapy. Carboplatin/paclitaxel was the most common drug combination administered, with 8.7% risk. Cytarabine/methotrexate combination had the highest risk at 57.0%. By ICD diagnosis, breast cancer accounted for most patients and most chemotherapy administrations, with 30 day ED visit risk of 3.6%. Multiple myeloma had the highest rate of chemotherapy administrations at 26.3 per patient and a risk of 4.0%, compared with 13.3 across the entire population. Stomach cancer had the highest risk of 30 day ED visit at 10.0%. Conclusions: The risk of 30 day unplanned ED visit was elevated in pediatric patients, and was similar in patients 18-64 and &gt; = 65 years of age, and corresponded well to our CMS OP-35 metric, despite only tracking internal ED visits. Immunotherapy had significantly elevated risk compared with cytotoxic therapy, while targeted therapy had the lowest risk of ED visit. There were significant differences depending on disease site. We have established a baseline, and developed a live dashboard in our electronic medical record to monitor this metric globally, and to intervene in patients at high risk of 30 day ED visit.

Assessing Empiric Antimicrobial Therapy With the Modified Dundee Classification for Nonpurulent Skin and Soft Tissue Infections in a Community Hospital System.

The modified Dundee classification has recently been validated in various studies for nonpurulent skin and soft tissue infections. This has yet to be applied in the United States and within community hospital settings to optimize antimicrobial stewardship and ultimately patient care. A retrospective, descriptive analysis was performed of 120 adult patients admitted to St. Joseph's/Candler Health System for nonpurulent skin and soft tissue infections between January 2020 and September 2021. Patients were classified into their modified Dundee classes, and frequencies of concordance of their empiric antimicrobial regimens with this classification scheme in the emergency department and inpatient settings were compared, along with possible effect modifiers and possible exploratory measures associated with concordance. Concordance with the modified Dundee classification for the emergency department and inpatient regimens was 10% and 15%, respectively, with broad-spectrum antibiotic use and concordance positively associated with illness severity. Due to substantial broad-spectrum antibiotic use, possible effect modifiers associated with concordance were unable to be validated, and overall no statistically significant differences among exploratory analyses across classification status were observed. The modified Dundee classification can help identify gaps in antimicrobial stewardship and excessive broad-spectrum antimicrobial usage toward optimizing patient care.

The Role of Human–Animal Bonds for People Experiencing Crisis Situations

Human-animal bonds, by providing social support, have been shown to improve the health and wellbeing of pet owners, especially those experiencing a crisis situation. The human-animal bond for people in crisis situations is complex and multifaceted, as it has shown to improve health, whilst it can also discourage people from seeking help, due to fears of leaving their pet behind. The purpose of the study is to capture and to assess the role of the human-animal bond for people in crisis situations. Semi-structured interviews were conducted with pet owners involved in the RSPCA NSW Community Programs (n = 13) in 2021 and 2022. The findings of the study indicate that the human-animal bond is highly valued by people experiencing crisis situations, that the human-animal bonds can affect people's ability to seek help or refuge, and that the human-animal bond helps people to recover after a crisis. The findings suggest that community crisis support services, prison systems, hospital systems, emergency housing, and government legislation should recognize and aim to preserve this bond to provide the best help for people experiencing crisis situations.

Assessing the Rate of Compliance with the Revised Sapporo/Sydney Criteria in Diagnosing Antiphospholipid Syndrome: A Multicenter Retrospective Analysis

Background: Antiphospholipid syndrome (APS) is a systemic autoimmune disease defined by thrombotic or obstetrical events in patients with persistent elevation of antiphospholipid antibodies (aPL) (Lim, 2013). The revised Sapporo/Sydney criteria has been adopted by most professional societies as a guidance to APS diagnosis. To be diagnosed with APS, a patient has to meet at least one clinical criteria and one laboratory criteria. Clinical criteria includes either vascular thrombosis or an adverse outcome during pregnancy. The lab criteria consist of the presence of one or more specified aPL, identified on two or more occasions, at least 12 weeks apart (Miyakis et al., 2006). Antibody testing in patients with suspected APS involves immunoassays for IgG and IgM antibodies to cardiolipin (aCL), and beta2-glycoprotein I (anti-β2GPI), as well as a functional assay for the lupus anticoagulant (LA) phenomenon (Miyakis et al., 2006). Testing asymptomatic individuals is not recommended and carries a significant rate of false positivity, given that up to 10% of healthy individuals may have transient aPL elevation (Vila et al., 1994). Furthermore, certain medications, infections, malignancies, autoimmune diseases, and rheumatologic diseases can also induce transient elevation of aPL antibodies without associated thrombotic complications, emphasizing the importance of repeated aPL measurements in the diagnosis (Lim, 2013; Rand & Wolgast, 2012). Weakly positive levels of aCL and anti-β2GPI antibodies should not be considered significant. Most authorities require Ab levels to be at or above the 99th percentile to be considered clinically significant (Rand & Wolgast, 2012). We aim to assess the compliance with revised Sapporo/Sydney criteria in diagnosing APS in our community hospital system. Methods: We conducted a multi-center, retrospective study among adult patients who were diagnosed with APS in a community healthcare system in southeast Michigan. Demographic and clinical characteristics were collected along with history of venous thrombosis, arterial thrombosis, pregnancy complications, aPL testing results and use of anticoagulants. We used SAS for exploratory data analysis and descriptive statistics. Results: A total of 781 patients were diagnosed with APS between August 2016 to December 2021 (table 1). The median age at diagnosis was 51.3 years (interquartile range 18-93 years). 639 (81.8%) patients were females and 142 (18.2%) were males. Majority of patients were white (n=563, 72.1%). 570 (73.0%) patients had history of venous or arterial thrombosis, 309 (49.9%) had pregnancy complications included in the revised Sapporo/Sydney criteria, and 211 (27.0%) had neither history of thrombosis nor pregnancy complications, not meeting the clinical criteria for APS diagnosis. 528 (67.6%) patients did not meet the laboratory criteria for the diagnosis (figure 1). Of these patients, 439 (83.1%) did not have a repeated testing of aPL antibodies.88 (16.7%) had weakly positive levels of aCL and anti-β2GPI antibodies, below the 99th percentile, and 1 (0.2%) had repeated antibodies testing in less than12 weeks. Out of 528 patients who did not meet the laboratory criteria, 321 (60.8%) were started on anticoagulants. Of these 321 patients, 135 (42%) did not have any history of thrombosis or other appropriate indication of anticoagulation, such as atrial fibrillation. Of 321 patients who were treated with anticoagulation, warfarin was the most prescribed accounting in 120 patients (37.4%). The remainder of patients (62%) were treated with apixaban, rivaroxaban or enoxaparin. Conclusion: Our results showed poor compliance with the current guidelines in both selecting the appropriate candidate for testing, and interpreting aPL testing results, leading to an alarmingly high rate of false diagnosis of APS. Obtaining a positive aPL test result in an otherwise disease-free individual can contribute to unnecessary anticoagulation and side effects including bleeding and increased cost burden to patients and families. Therefore, caution must be exercised while ordering aPL tests and adherence to current guidelines should be encouraged in the routine clinical settings. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

A Retrospective Review of Red Blood Cell Transfusion Practices in a Rural Community Hospital System

Introduction: Anemia is associated with increased length of stay and mortality in hospitalized patients. Red blood cell (RBC) transfusions could be lifesaving intervention and are generally used as a stabilizing measure until underlying etiology of anemia is identified and corrected. However, RBC transfusions have several adverse effects which occasionally could be life-threatening, including transfusion associated infections, immunologic reactions, volume overload, electrolyte imbalances, and iron overload. The decision on RBC transfusions should be based on patient's clinical status and physician's judgment, supported by data from randomized trials. Methods: In efforts to improve RBC transfusion practices in Northern Arizona Healthcare (NAH) facilities, all RBC transfusions between 01/01/2021 and 03/31/2022 were evaluated. Based on randomized clinical trial data, the following RBC transfusion thresholds were considered: Hemoglobin (Hgb) <8 g/dL for hospitalized anemic patients with established cardiovascular disease (CVD) or undergoing surgery, and Hgb <7 g/dL in hemodynamically stable hospitalized patients. Transfusions in pediatric patients, active/suspected blood loss, anemia with hemodynamic instability and massive or recurrent transfusions were excluded from the analysis. For the purpose of this study, RBC transfusion was deemed to be unjustified in cases where only 1 unit of RBC could have been sufficient to raise Hgb level above the specified threshold, however >1 unit was used with no clear justification. Results: A total of 2756 units of RBC transfusions were analyzed in hospitalized patients ages 18-102 years. Three patient groups were identified based on the documented provider justification for RBC transfusions: 1) Hgb <7 g/dL, 2) Hgb <8 g/dL with established CVD or undergoing surgery, 3) "other" who did not meet criteria for the previous groups. In the "other" group, the justification was manually entered by the provider. In the Hgb <7 group, 2004 RBC units were transfused in 1019 patients. Of those, 1440 units were transfused for Hgb level of 6.0-6.9 g/dL in 837 patients, with 273 patients receiving 2-4 units of RBCs when 1 unit could have been sufficient to raise the Hgb level >7 g/dL. Therefore, 303 RBC units were considered unjustified. Also, 83 units were deemed unjustified as they were transfused in 72 patients with pre-transfusion Hgb of ≥7.0 g/dL. In the Hgb <8 group, a total of 711 units were transfused in 500 patients. In the CVD group, 401 units were transfused in 287 patients, of which 260 patients had a Hgb of 7.0-7.9 g/dL. Thirty-four of these patients received 2-3 units when 1 unit was deemed sufficient to increase Hgb >8 (35 unjustified units). Additionally, 5 patients received at least 1 unit of RBC when Hgb was ≥8.0 g/dL (6 unjustified units). In patients undergoing surgery, 213 patients received 310 units. Of those, 150 patients had a Hgb 7.0-7.9 g/dL, 23 of which received >1 units (23 unjustified units). In the group classified as "other", 41 units were transfused in 39 patients. Hgb levels in this group were between 6.7 to 13.3 g/dL. After further evaluation, 18 units transfused in 17 patients were deemed to be unjustified. Discussion: RBC transfusion practices were evaluated in two hospitals in a rural setting in Arizona. From a total of 2756 units, 468 (16.9%) were deemed to be unjustified. The majority of these cases were seen in the Hgb <7 group. This is the first evaluation of RBC transfusion practices at this institution and a stepping stone to implement measures to improve these practices in the future. The next step includes creating an order set module that would not only require providing justification for blood transfusion, but also confirmation of pre-transfusion and desired target Hgb levels. Additionally, it would implement a notification encouraging single unit transfusions when feasible to decrease transfusion associated adverse reactions and cost burden on patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Maternal telehealth: innovations and Hawai'i perspectives.

Access to maternal-fetal medicine (MFM) subspecialty services is a critical part of a healthcare system that optimizes pregnancy outcomes for women with complex medical and obstetrical disorders. Healthcare services in the State of Hawai'i consist of a complicated patchwork of independently run community health clinics and hospital systems which are difficult for many pregnant patients to navigate. Maternal telehealth services have been identified as a solution to increase access to subspecialty prenatal services for women in rural communities or neighboring islands, especially during the COVID-19 pandemic. Telehealth innovations have been rapidly developing in the areas of remote ultrasound, hypertension management, diabetes management, and fetal monitoring. This report describes how telehealth innovations are being introduced by MFM specialists to optimize care for a unique population of high-risk patients in a remote area of the world such as Hawai'i, as well as review currently available telemedicine technologies and future innovations.

EP01.04-004 Overcoming the Barriers to Lung Cancer Screening using a Systemwide Approach

The lung cancer screening program (LCSP) at St. Elizabeth Healthcare (SEHC), a 1,191 bed Northern Kentucky community hospital system, began in 2013. Over 22,000 low-dose CT lung cancer screens have been performed. From 2015 through 3Q 2021, 2,498 lung cancers were diagnosed systemwide. ASPIRED, a Screening Program with Impactful Results from Early Detection, reviews that experience. 325 (13.0%) were diagnosed by screening and 2,173 (87.0%) were non-screened. The non-screened cohort was queried to determine how many additional individuals could have been screened, as per 2015 CMS criteria, identifying barriers and failures to meet eligibility.

Fecal microbiota transplantation may reduce the mortality of patients with severe and fulminant Clostridioides difficile infection compared to standard-of-care antibiotics in a community hospital.

Clostridioides difficile infection (CDI) is known for significant morbidity and mortality. Fecal microbiota transplantation (FMT) is an effective therapy for recurrent and resistant CDI. However, its impact on the mortality rate of patients with severe and fulminant CDI has not been rigorously studied yet. We aimed to evaluate the effectiveness of FMT on the mortality rate of patients with severe or fulminant CDI in a community hospital system. Our study included 106 inpatients with severe or fulminant CDI. Both standard-of-care (SOC) and FMT were provided to 14 (13.2%) patients (the FMT group). SOC antibiotics alone were provided to 92 (86.8%) patients, out of whom 28 patients were included via propensity score matching in a 2:1 ratio (the SOC group). The primary outcome was defined as the composite end-point of mortality during admission, within 30 and 90 days after discharge, and discharge with comfort measures only. Each component was a secondary end-point. The primary outcome rate in the FMT group was 7.1% (1/14) compared to 25.0% (7/28) in the SOC group. Univariate analysis demonstrated that FMT decreases mortality (odds ratio[OR] 0.08, 95% confidence interval [CI] 0.01-0.58, P=0.01). However, multivariate regression did not show statistical significance (OR 0.15, 95% CI 0.01-2.53, P=0.19), possibly due to the small sample size. FMT may decrease the mortality of patients with severe and fulminant CDI. Large studies are needed to validate these findings.