Electronic Medical Record Chart Research Articles

Psychological dysfunction associated with calcaneal fractures

IntroductionThe calcaneus is the most commonly fractured hindfoot bone, accounting for over 60% of all tarsal fractures. The aim of this study was to compare the mechanism of injury and psychological health status in patients presenting with calcaneal fractures to an age- and sex-matched control group with ankle fractures. Patients and methodsThis retrospective study was undertaken within an orthopaedic unit at a tertiary hospital. An electronic medical record chart review was performed to identify eligible patients. Descriptive statistics were used to summarise the demographic and clinical characteristics of the patients. Between-group differences were analysed with the Mann-Whitney U test and Fisher's exact test for continuous and categorical variables, respectively. Multivariable binary logistic regression was used to determine the relationship between fracture type and underlying psychopathology, adjusting for mechanism of injury. ResultsTwo-hundred and fifteen patients met the eligibility criteria for calcaneal fractures and these patients were subsequently matched to 215 ankle fracture patients. Men accounted for 154 (71.6%) of the patients in each group. Over half (51.2%) of all calcaneal fractures were due to an uncontrolled fall above one-metre, as opposed to 26.0% of ankle fractures, p < 0.001. Falling from a standing height was more common in the ankle fracture group, 37 (17.2%) versus 10 (4.7%), p < 0.001. Patients with calcaneal fractures were more likely to have a diagnosed psychological health complaint, 63 (29.3%) versus 32 (14.9%), p < 0.001. Suicidal ideation was significantly more common in the calcaneal fracture group 14 (6.5%) versus 3 (1.4%), p = 0.011. The presence of premorbid psychopathology was associated with calcaneal fracture, after adjusting for mechanism of injury (odds ratio 2.20, 95% confidence interval 1.32 to 3.65, p = 0.003). ConclusionCalcaneal and ankle fractures display differences in both the mechanism of injury and the history of psychological health conditions. However, after adjusting for the mechanism of injury, diagnosed premorbid psychopathology remains twice as likely in someone with a calcaneal fracture as opposed to an ankle fracture. It may be prudent for orthopaedic surgeons to consider further investigations of psychological health when managing patients with a calcaneal fracture.

Maxillomandibular advancement effectively treats obstructive sleep apnea in adolescents at short-term follow-up

To evaluate the efficacy of maxillomandibular advancement (MMA) surgery for the treatment of malocclusion and obstructive sleep apnea (OSA) in an adolescent population. A retrospective cohort study was designed using electronic medical record chart review. Fifteen patients aged 20 years or younger (range, 14-20) were included. All patients underwent MMA surgery for the primary correction of malocclusion and secondary treatment of OSA. Mean preoperative apnea-hypopnea index (AHI) was 28.9 ± 16.0 events/h (range, 7.1-54.7), and mean postoperative AHI was 5.7 ± 4.6 events/h (range, 1.5-18.4), reflecting a reduction of 23.2 events/h, an 80.6% reduction (P < .001). Fourteen patients (93.3%) experienced improvement in AHI. Mean minimal posterior airway space increased from 4.6 mm to 8.6 mm (P < .001). Mean posterior airway space at the level of the uvular tip increased from 6.7 mm to 11.5 mm (P < .001). Patients who underwent adjunct genioglossus advancement (GGA) had a mean decrease in AHI of 35.3 events/h (P=.004), which was not significantly different from the decrease in those who did not receive GGA. MMA surgery with or without GGA is an effective treatment option for adolescents with a malocclusion and an AHI >5.0 events/h. In this population, it is shown to decrease AHI and increase posterior airway space. More research is required to determine the ideal adolescent candidate for MMA surgery.

Low Serum Albumin in Patients With Coexisting Cognitive Impairment Predicts Surgical Complications

Cognitive impairment (CI, ~15-20%) and malnutrition (~38.7%) are common concerns among older adults ≥65 years. CI and malnutrition may be used as predictive risk factors for poor surgical outcomes. The 2012 ACS NSQIP/AGS Best Practice Guidelines for the preoperative assessment of geriatric surgical patients classify severe nutritional risk as either having a BMI < 18.5 kg/m2, serum albumin (SA) < 3.0 g/dL and/or unintentional weight loss > 10%-15% within 6 months. Using SA as a surrogate marker for malnutrition, we evaluated the relationship between CI, malnutrition, and risk for poor surgical outcomes in a geriatric population. Electronic medical record chart reviews of patients (≥65 years old) undergoing elective intermediate or high-risk surgery (IHRS), between 2016 and 2019 in Tucson, AZ, were conducted. Pre-and-post assessment factors such as cognitive status via mini-cog, laboratory markers (SA), and hospital complications were examined. Multivariate regression analyses were performed to determine the association between cognitive status, SA levels, and hospital complications. Of the 173 patients undergoing IHRS included in this assessment (mean age: 75.5±7.4 years, [60-93 years], 54.9% male), 42.8% experienced hospital complications. Multivariate regression analysis revealed cognitive impairment and low SA levels were significantly associated with this outcome (p<0.05), adjusted for age and gender. We demonstrated MCI and low SA levels are risk factors of postoperative hospital complications among older patients undergoing elective IHRS. Increased understanding of predictive factors can help enhance prevention efforts, aiding in improving patient experiences and reducing patient and hospital costs.

Challenges to Comorbidity Management for Older HIV-Positive Individuals

70% of individuals with HIV in the United States are 50 years or older. These individuals’ HIV is often well-managed, but they have acquired several comorbidities, including cardiovascular disease, non-AIDS defining cancers, renal disease, osteoporosis, liver disease, and neurocognitive disorders. Existing literature provides little guidance on structuring services to meet this burgeoning population’s complex clinical and aging-related needs. To inform an approach, between April 2015 and June 2018, we conducted 13 exploratory qualitative group discussions with patients, providers and administrators receiving or providing HIV services in New York’s Hudson Valley. We also conducted a retrospective electronic medical record chart review (n=50) of individuals >50 years receiving HIV care in 2017 at a Hudson Valley federally qualified health center (FQHC) to describe subspecialty referrals. Analysis of discussion groups highlighted challenges with initial access, the quality of encounters, and consistent follow-up. Patients thought ‘ageism’ contributed to poorer care quality, though extensive experience navigating the system was an advantage. The EMR review revealed patients receiving two referrals on average to (most commonly) ophthalmology/optometry (14%), gastroenterology (12%), dental (9%), cardiology (9%), and orthopedics (8%). Only half (54%) of scheduled referral appointments were attended. Documented barriers included insurance/costs, transportation, patient refusal, and fear of HIV disclosure. Findings suggest there are HIV-specific and non-specific barriers for older individuals with HIV, including perceived perceptions of aging. We have initiated a pilot study to investigate multilevel barriers and enablers to optimal comorbidity management. Gerontological insights brought to this analysis will support developing aging-appropriate clinical practices for this population.

P071 Fistula Healing After Fecal Diversion Surgery in Perianal Crohn's Disease; a Case Series.

BACKGROUND: Perianal fistula are seen in 25% of patients with Crohn's disease and are often refractory to medical therapy. Fecal diversion is used to treat perianal fistula, with 63% in clinical improvement, however data on fistula healing rates are often not reported. This case series aims to evaluate the response of complete fistula healing in complex perianal Crohn's disease after fecal diversion. METHODS: Patients with perianal Crohn's disease who underwent fecal diversion surgery from June 1, 2016 to June 1, 2020 with colorectal surgeons at UC Davis were selected through electronic medical record chart extraction using ICD-10 and CPT codes. RESULTS: Eleven patients with refractory perianal fistula underwent fecal diversion surgery from June 1, 2016 to June 1, 2020. Fistula healing was evaluated through imaging or exam under anesthesia. One patient was lost to follow up after surgery and not included in the outcomes. Time to follow up ranged from 4 to 24 months, with a mean of 11 months. Patient were aged 22–60 years. 5/11 were male. Ten of 11 patients were on biologic therapy at time of surgery, 4/10 (40%) had complete fistula healing, 6/10 (60%) had persistent fistula, and 3/10 (30%) were readmitted within 90 days for complications. Most frequent complications observed were peristomal wounds/skin infection (3/10), high ostomy output/dehydration (2/10), bowel obstruction (1/10). Two patients required proctectomy. CONCLUSION: Fistula healing rates after fecal diversion were low, at 40% and is accompanied by frequent complications such as output high ostomy.

Geographic Evaluation of Georgia Vaccination Disparity Among Laboratory-Confirmed Influenza Cases in a Children’s Hospital

Background: Vaccination coverage among children aged ≤18 years in Georgia remains one of the lowest in the nation with 39.3% coverage. During the 2018–2019 influenza season, the CDC reported 142 pediatric deaths, 3 of which occurred in Georgia. In a time of increasing complexity of immunization schedules, increase severity with a high level of flu-related deaths and hospitalization, it is important to understand localized factors that contribute to decrease influenza immunization and increased flu-related hospital visits among children. Methods: Data include electronic medical record chart review of 5,827 laboratory confirmed Children’s Healthcare of Atlanta visitor cases from October 1, 2016, to September 24, 2019. System-wide county level data included 3 pediatric hospitals, 5 primary care facilities, 8 urgent care facilities, and 2 outpatient clinics. Characteristics associated with disparities in vaccine were explored using univariate and multiple regressions analysis. Of those children with a primary care physician (PCP), 30% had flu vaccinations, whereas only 16.5% of those without a PCP had been vaccinated (P ≤ .00001). There was a positive relationship between increased county influenza rate and percentage of children in county who were preschoolers &lt;5 years old (r = 0.93; P ≤ .05). Moreover, 78% of children who received the flu vaccine ≤ 2 weeks prior to a confirmed flu diagnosis got the flu during peak flu periods (r = 0.29; P ≤ .05). Predictors of increased flu rate per 1,000 children were associated with flu vaccines given ≤2 weeks before a lab confirmed flu diagnosis (P ≤ .02). Children in counties that had a higher rate of flu during the peak period also had an overall higher rate of flu (P ≤ .005). The higher the percentage of children who got flu during peak flu period, the lower the vaccination rate for the county (P ≤ .001). The percentage of children ≤18 years old with no health insurance was associated with lower vaccination rates in the county (P ≤ .004). There appears to be a positive relationship between receiving flu vaccine 2 weeks prior to lab-confirmed flu diagnosis and onset of illness during the peak flu periods. Missed opportunities to obtain a flu vaccine by a PCP were associated with increased flu-related hospital visits and lower vaccination rates. Results may support predischarge hospital vaccinations and the promotion of flu vaccination education. Pediatric research is needed to facilitate localized PCP vaccination or predischarge hospital vaccinations prior to peak flu periods when hospital-related flu visits increase.Funding: NoneDisclosures: None

The electronic medical record and COVID-19: Is it up to the challenge?

• Improvements to the electronic medical records must occur prior to the next pandemic. • During pandemics, infection preventionists’ should advise staff, not review charts. • Automation can help improve healthcare safety and quality.

Pelvic floor disorders in women who consult primary care clinics: development and validation of case definitions using primary care electronic medical records.

To date, there has been no validated method to identify cases of pelvic floor disorders in primary care electronic medical record (EMR) data. We aimed to develop and validate symptom-based case definitions for urinary incontinence, fecal incontinence and pelvic organ prolapse in women, for use in primary care epidemiologic or clinical research. Our retrospective study used EMR data from the Southern Alberta Primary Care Research Network (SAPCReN) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) in southern Alberta. Trained researchers remotely reviewed a random sample of EMR charts of women aged 18 years or older from 6 rural and urban clinics to validate case definitions for urinary incontinence, fecal incontinence and pelvic organ prolapse. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and estimated SAPCReN prevalence as appropriate. Charts of 900 women were included. Sensitivity was 81.9% (95% confidence interval [CI] 75.1-87.2) for urinary incontinence, 61.2% (95% CI 46.2-74.5) for fecal incontinence, and 51.8% (95% CI 40.6-62.8) for pelvic organ prolapse. Corresponding specificity values were 71.9% (95% CI 68.4-75.1), 99.2% (95% CI 98.2-99.6) and 98.8% (95% CI 97.7-99.4), PPVs 40.6% (95% CI 35.4-46.0), 81.1% (95% CI 64.3-91.4) and 81.1% (95% CI 67.6-90.1), and NPVs 94.4% (95% CI 92.1-96.1), 97.8% (95% CI 96.5-98.6) and 95.3% (95% CI 93.6-96.6). The SAPCReN-observed prevalence for urinary incontinence was 29.7% (95% CI 29.3-30.0), but the adjusted prevalence was 2.97%. The case definition for urinary incontinence met our standard for validity (sensitivity and specificity > 70%), and the case definitions for fecal incontinence and pelvic organ prolapse had PPVs greater than 80%. The urinary incontinence definition may be used in epidemiologic research, and those for fecal incontinence and pelvic organ prolapse may be used in quality-improvement studies or creation of disease registries. Our symptom-based case definitions could also be adapted for research in other EMR settings.

4:03 PM Abstract No. 189 Transradial arterial access vasodilation cocktail: is the calcium channel blocker needed?

Transradial access (TRA) for arterial procedures in interventional radiology (IR) continues to grow in popularity. During IR radial arterial access it is standard to give a cocktail of Heparin, Nitrates, and a calcium channel blocker (Verapamil) through the vascular sheath to prevent arterial vasospasm. However, data within Interventional Cardiology radial access literature questions the need of Verapamil. This study was completed to evaluate the safety, efficacy, and cost of TRA without the use of Verapamil in the vasodilation cocktail at a single institution. Retrospective review of all TRA cases completed in the department of IR at a single institution were reviewed from September 2014 to July 2019. A total of 244 TRA cases were identified. Verapamil was used in the TRA vasodilation cocktail for 32 patients until May 14, 2015. No Verapamil was used for the remaining 212 TRA cases through July 2019. Electronic medical record chart review was completed on all procedures to evaluate complication rates and technical success rates. In addition, the average wholesale price of Verapamil was obtained via the vendor. Technical success rates for TRA completed with and without Verapamil in the vasodilation cocktail were 100% and 98%, respectively. The technical failures that occurred in TRA cases without Verapamil were secondary to an anatomical variant of the left radial artery and an inability to cannulate a superselective hepatic artery branch. Neither failure was impacted by the lack of Verapamil. The complication rate from TRA intervention without Verapamil was 0.8%. Both the technical success and complication rates of TRA without Verapamil compare favorably to current literature. The average wholesale price of Verapamil is $12.60 per 5 mg vial, for a total savings of $2,671.20 over the time period. Elimination of Verapamil from the TRA vasodilation cocktail showed similar safety, efficacy, and decreased hospital costs for TRA arterial IR interventions.

P014 Case Series of Small Bowel Crohn's Disease Diagnosed in 10 Pediatric Patients by Video Capsule Endoscopy

BACKGROUND: Crohn's disease (CD) can affect the entire gastrointestinal tract. Up to 70–90% of patients who have CD have small bowel (SB) involvement. Of these patients up to one third may have disease limited to the small bowel which can make both diagnoses and surveillance of inflammatory lesions challenging. Video capsule endoscopy (CE) provides a noninvasive way to evaluate the entire small bowel for Crohn's disease. METHODS: 155 total children (18.0 years old or younger) who underwent video capsule endoscopy at Alfred I duPont Hospital for Children and Nemours Children Hospital between April 2008 to April 2019 were identified via a retrospective electronic medical record chart review. 71 of these children were either previously or ultimately diagnosed with inflammatory bowel disease (69% with Crohn's disease). Data was collected from these 71 patients including age, chief complaint, endoscopy and colonoscopy results, small bowel imaging, fecal calprotectin and blood work including albumin, hemoglobin, ESR, CRP, pANCA, and ASCA. Video capsule endoscopy was read by one primary gastroenterologist to evaluate for small bowel disease. This ongoing study was approved by Nemours IRB. RESULTS: We present ten cases of pediatric patients ages ranging from 10 to 18 years old diagnosed with Crohn's disease utilizing video capsule endoscopy. Indications for CE in these patients included 3 (30%) with diarrhea, 4 (40%) with abdominal pain, 2 (20%) with weight loss or poor growth, 3 (30%) with hematochezia, 1 (10%) with oral ulcers, and 1 (10%) with perianal disease initially felt to be a pilonidal cyst and later diagnosed as a perianal fistula. Only 1 (10%) presented with hypoalbuminemia, 1 (10%) with mildly elevated CRP, and 0 presented with either anemia or elevated ESR. Seven of the patients had fecal calprotectin collected with 1 (14.3 %), 50 mcg/g, 5 (71.4%) between 100–150 mcg/g, and 1 (14.3%) 250 mcg/g. 9 patients (90%) swallowed the capsule while 1 (10%) was placed during endoscopy. All 10 cases had previously completed endoscopy and colonoscopies with 7 of the 10 successfully intubating the ICV. Histology results were inconclusive for IBD in all 10 cases. Histology for 9 of the cases showed only acute inflammation and 1 case showed patchy subacute to chronic active colitis. All 10 cases also completed MR Enterography (MRE) as part of their workup. Of the 10 cases 5 had normal MREs and 5 had nonspecific inflammatory changes seen on imaging. All 10 cases were ultimately diagnosed with Crohn's disease, despite inconclusive histology and imaging, following capsule endoscopy findings consistent with small bowel inflammation. CONCLUSION: Small bowel Crohn's disease is common and unfortunately these lesions can often be missed without adequate assessment of the small bowel. The introduction of capsule endoscopy has provided a pivotal tool for the diagnosis and monitoring of small bowel Crohn's disease. These 10 pediatric cases show the value of utilizing capsule endoscopy to better diagnose patients with small bowel Crohn's disease.

1119. Implementation of Pediatric Antimicrobial Stewardship Rounds in a Children’s Hospital

BackgroundAntimicrobial stewardship programs (ASP) are required in all acute care hospitals per The Joint Commission. ASP must adhere to the recommendations laid out by the Centers for Disease Control and Prevention, but how each ASP chooses to implement these recommendations is left to the individual program. In January 2018, we began formal antimicrobial stewardship (AMS) walking rounds, led by infectious diseases trained physician and pharmacist, in our 99-bed pediatric hospital.MethodsIn January 2018, we started twice-weekly AMS rounds on the pediatric hospitalist service. A custom-made “Antimicrobial Stewardship Patient List” was designed in our electronic medical record (EMR) to generate a list of all patients receiving antibiotics. The ASP team (comprised of an infectious diseases pharmacist and a pediatric infectious diseases physician) reviewed EMR charts to determine antibiotic prescribing appropriateness and design recommended interventions. Any recommendations and teaching points were then discussed with the hospitalist team in person. After piloting the hospitalist service, AMS rounds were extended to include the general surgery patients and finally the intensive care unit. Data on number of charts reviewed, proposed interventions, and acceptance rates were collected throughout the process. Descriptive statistics were used to assess the intervention data.ResultsIn the first year of the program, 427 patient charts were reviewed with 186 identified interventions. In total, 156 (84.3%) of the interventions were accepted and implemented by the primary team. The most common types of interventions were the duration of therapy (29%), antibiotic discontinuation (16.7%), intravenous to oral conversion (11.3%), de-escalation (10.2%), and infectious diseases consult (5.9%).ConclusionPediatric AMS rounds led to the successful implementation of the majority of recommended interventions. Future goals of the program include calculating days of therapy per 1000 patient-days to assess antibiotic consumption before and after AMS rounds and to expand into other services to further promote appropriate antibiotic use in hospitalized pediatric patients.Disclosures All authors: No reported disclosures.

2485 Identifying Barriers for Same-Day Discharge of Minimally Invasive Hysterectomies

Study Objective Minimally invasive surgery (MIS) has provided patients with decreased post-surgical pain, faster recovery, and shorter hospital stay. Currently, the trend with MIS procedures is to have same-day discharge. The purpose of this study is to determine which patient-based and post-surgical factors are barriers to same-day discharge and lead to hospital re-admission. Design Quality assurance, retrospective cohort study. Setting Single academic institution Patients or Participants Chart review for patients undergoing laparoscopic, vaginal, laparoscopic assisted vaginal or robotic hysterectomy from July 2014 to April 2017. Cohort of 541 patients from 18-84 years-old with a mean age of 48. Interventions No interventions. Descriptive study of post-operative hospital stay following surgery. Measurements and Main Results We performed an electronic medical record chart review to evaluate time in the recovery room following surgery, route of hysterectomy, reasons for prolonged hospital stay, and re-admission. Out of 541 patients, 395 (73%) were general gynecology patients and 146 (27%) were urogynecology patients. Despite the goal of same-day discharge, only 252 (47%) of patients were discharged the same day. Of those patients, 83% were vaginal hysterectomies and 84% were laparoscopic hysterectomies that were discharged in less than 6 hours. 145 (99.3%) urogynecology patients stayed admitted overnight. There was an association between length of case, urogynecology patients, and overnight stay (OR 1.23, CI 1.006 - 1.521), but no association was found between length of stay in recovery with estimated blood loss. There was no statistical significance (p>0.05) between hours of recovery room stay with emergency room visits or re-admissions. Conclusion The majority of the patients in the cohort were not discharged the same-day given that data was altered by urogynecology patients despite having MIS procedures. Barriers to same-day discharge included length of procedure, voiding dysfunction and pain. Further studies include implementing enhanced recovery after surgery and voiding trials for same-day discharge, as well as evaluating urogynecology patients separate from general gynecologic procedures.

Implementation of a regional quality improvement collaborative to improve care of people living with opioid use disorder in a Canadian setting

BackgroundAlthough opioid agonist therapy is effective in treating opioid use disorders (OUD), retention in opioid agonist therapy is suboptimal, in part, due to quality of care issues. Therefore, we sought to describe the planning and implementation of a quality improvement initiative aimed at closing gaps in care for people living with OUD through changes to workflow and care processes in Vancouver, Canada.MethodsThe Best-practice in Oral Opioid agoniSt Therapy (BOOST) Collaborative followed the Institute for Healthcare Improvement’s Breakthrough Series Collaborative methodology over 18-months. Teams participated in a series of activities and events to support implementing, measuring, and sharing best practices in OAT and OUD care. Teams were assigned monthly implementation scores to monitor their progress on meeting Collaborative aims and implementing changes.ResultsSeventeen health care teams from a range of health care practices caring for a total of 4301 patients with a documented diagnosis of OUD, or suspected OUD based on electronic medical record chart data participated in the Collaborative. Teams followed the Breakthrough Series Collaborative methodology closely and reported monthly on a series of standardized process and outcome indicators. The majority of (59%) teams showed some improvement throughout the Collaborative as indicated by implementation scores.ConclusionsDescriptive data from the evaluation of this initiative illustrates its success. It provides further evidence to support the implementation of quality improvement interventions to close gaps in OUD care processes and treatment outcomes for people living with OUD. This system-level approach has been spread across British Columbia and could be used by other jurisdictions facing similar overdose crises.

Outcomes among pregnant recently incarcerated women attending a reentry transitions clinic.

This mixed methods retrospective case series and qualitative descriptive study describes pregnancy outcomes during the postincarceration period. A retrospective case series via electronic medical record chart review from a subset of women attending a postincarceration primary care clinic with a condition of interest (pregnancy) described demographics, substance use, diagnoses, and pregnancy outcomes. We compared 27 pregnant to 79 nonpregnant women and contextualized quantitative data with qualitative descriptive vignettes. Twenty-seven women completed 29 pregnancies (2 women with 2 deliveries each), all of which were unplanned; there were 11 live births, 8 pregnant at study closure, 7 miscarriages, and 3 terminations. Although substance use history was high, rates were higher among nonpregnant women (92%vs 74%). Among the 5 births, 4 tested positive for substance use during pregnancy. All 11 infants had pregnancy or delivery complications. Although 7 of the 10 pregnant women with live births had prior pregnancy complications, only 4 were placed in a special care obstetrics clinic. Although unplanned pregnancies were common, most births did not demonstrate maternal substance use. All live births had pregnancy or delivery complications, but few were accepted to specialist prenatal care, suggesting potential considerations for recently incarcerated women.

The 2015 Amtrak Philadelphia Train Derailment: After-Action Review of the Emergency Radiology Response at Temple University Health System

PurposeThe aim of this article is to assess a large tertiary care medical center’s emergency radiology response after the 2015 Amtrak Philadelphia train derailment. Methods and MaterialsA total of 55 patients with 308 total CTs and radiographs ordered within 12 hours of arrival to Temple University Health System (combining Temple University Hospital and Episcopal Hospital) emergency departments on May 12 to 13, 2015, were included in this study. A retrospective PACS and electronic medical record chart review of emergency department imaging turnaround times (TAT) during this event was completed and compared with emergency department radiology operations for the same 12-hour period throughout the preceding year. Wilcoxon’s rank-sum test analysis was performed. ResultsA total of 308 CTs and radiographs were performed, and 91 radiologically evident injuries were observed in a total of 30 patients, with fractures (n = 51) as the most common type of injury. There were no significant differences in time from patient arrival to beginning of radiological examination (26 min; interquartile range [IQR], 11-58 min) compared with annual median (28 min; IQR, 10-131 min; P = .232). Examination completion TATs were significantly increased (35 min; IQR, 17-112 min) compared with annual median (10 min; IQR, 5-15 min; P < .001), and time required from viewing of the examination by the radiologist to the examination being marked as read was significantly decreased (17 min; IQR, 6-45 min) compared with annual median (248 min; IQR, 126-441 min; P < .001). ConclusionsThe analysis highlights areas of efficiency in our response but also indicates areas for process improvement in future potential mass casualty events.

2566. Diagnosis of Pneumocystis jiroveci Pneumonia in HIV-Negative Immunocompromised Patients: Is the Gomori-Methenamine Silver Stain of Bronchoalveolar Lavage Fluid the Gold Standard or Sub-Standard?

BackgroundDirect visualization of Pneumocystis jiroveci on bronchoalveolar lavage (BAL) fluid using the Gomori-methenamine-silver (GMS) stain historically has been the mainstay of diagnosis for P. jiroveci pneumonia (PJP), with studies from the early HIV/AIDS era reporting sensitivities of 90–95%. However, the burden of P. jiroveci organisms in BAL fluid is significantly lower in HIV-negative immunocompromised patients compared with HIV-positive patients with PJP, raising concerns that the BAL GMS stain is less sensitive in this population.MethodsWe conducted a retrospective observational study at Yale-New Haven Hospital from 2012 to 2018, using electronic medical record chart reviews, to identify patients who underwent bronchoscopy with BAL GMS stain for the diagnosis of PJP. We collected additional patient factors such as age, sex, HIV status, and immunosuppressed status. For patients with a negative BAL GMS stain, we collected data on other diagnostics, including positive GMS lung biopsies, positive PJP PCR or DFA, and elevated serum (1–3)-β-d-glucan levels. We defined BAL GMS-negative cases as proven or probable based on investigator generated criteria (see Figure 1).ResultsWe identified 52 patients with PJP who received a BAL GMS stain, including 28 HIV-positive and 24 HIV-negative cases. Of 24 HIV-negative cases, 11 had BAL GMS-positive PJP and 13 had BAL GMS-negative PJP (9 proven and 4 probable). In the latter group, 6 had hematologic malignancies (HM), 2 had solid-organ transplants (SOT), 1 had hematopoietic stem cell transplant, 2 had SOT plus HM, and 2 received high-dose steroids. Proven diagnoses were made by GMS-positive lung biopsy (n = 6), DFA (n = 2), and PCR (n = 1). Elevated (1–3)-β-d-glucan was observed in 7 of 8 cases (median: >500 pg/mL; range 39 to >500). Three patients developed adverse outcomes (1 readmission due to untreated PJP and 2 treatment delays). BAL GMS sensitivity for HIV-negative patients was 11/24 (46%) vs. 28/28 (100%) in HIV-positive patients.ConclusionThe sensitivity of BAL GMS for PJP is poor in HIV-negative immunocompromised patients. Missed cases or delayed treatment for PJP may lead to adverse outcomes. In HIV-negative patients with a clinical syndrome compatible with PJP, a negative BAL GMS does not rule out PJP and must be confirmed by supplementary diagnostics.Figure 1Disclosures All authors: No reported disclosures.

The Role of Chest X-Ray and Bedside Ultrasound in Diagnosing Pulmonary Bleb versus Pneumothorax

History of present illness: A 48-year-old male with chronic obstructive pulmonary disease (COPD) presented to the emergency department with stabbing chest pain to the right lower rib region along the axillary line. On examination, patient had no visible trauma, but was in mild respiratory distress with absent breath sounds on the right side. The patient's oxygen saturation ranged in the 90s on room air during his encounter, but otherwise had unremarkable vital signs. Significant findings: The patient was evaluated with bedside ultrasound for concern of possible pneumothorax. Imaging of the left lung with M-mode demonstrated a “sea shore” sign showing a wavy pattern below the pleural line caused by lung sliding as well as “comet tail” artifact caused by from the deep pleura. However, there was no lung sliding on the right shown by a lack of “comet tail” artifact and a “bar code” sign where M-mode shows straight lines throughout the image, this is caused by lack of motion below the pleura. This lack of lung sliding is consistent with possible pneumothorax or bleb. A two-view chest X-ray (CXR) revealed absent lung parenchyma in the right lung similar to a large pneumothorax (see red outline). Electronic medical record chart review revealed previous CXRs with similar findings. This patient was determined to have an acute COPD exacerbation with chronic blebs, but no pneumothorax. Discussion: Pulmonary blebs are collections of air in the alveolar layer of the pleura formed by a rupture of the alveolar wall.1 They can leak air into chest cavity leading to a high rate of recurrent spontaneous pneumothorax.2 Chest X-rays (CXR) are the current gold standard in diagnosing pneumothorax. A recent study among 192 critically ill patients showed CXR has high diagnostic accuracy and positive predictive value, at 90.6% and 95.0%, respectively.3 Visible visceral pleural lines on CXR seen without distal lung markings is usually diagnostic of pneumothorax.4 In this case however, the patient’s CXR and lung ultrasound findings were similar to standard pneumothorax findings, however chart review demonstrated the patient had a known large pulmonary bleb. The treatment for pneumothorax is chest tube insertion. To avoid unnecessary chest tube placement, emergency physicians must consider pulmonary blebs as a diagnosis in patients with mild respiratory distress who have a large area of absent lung parenchyma and visible visceral pleural lines on CXR. If a clinician is unsure and does not have access to previous imaging, a computed tomography scan of the chest can be used to clarify the diagnosis.5 This patient was conservatively managed with oral prednisone, intravenous morphine sulfate, combination albuterol-ipratropium nebulizer treatment, and later discharged for pulmonology follow up.6 The patient did not require any further imaging during this visit. In recurrent disease or severe dyspnea, bullectomy may be indicated. Topics: Ultrasound, X-ray, pulmonary blebs, pneumothorax.

An exploratory study of the electronic medical record and outpatient vascular neurology consultations.

We carried out a quality improvement project utilizing the electronic medical record (EMR) to determine (1) the quality of vascular neurologists' recommendations for recurrent stroke prevention and (2) primary care provider (PCP) acknowledgement of the vascular neurologists' recurrent stroke prevention recommendations and their frequency of meeting the recommended metrics for risk factor control and lifestyle modification. We conducted a retrospective EMR chart review on a convenience sample of ischemic stroke patients during two epochs. Data collected included risk factors, stroke subtype, and process and outcome guidance metrics for recurrent ischemic stroke prevention according to American Heart Association/American Stroke Association (AHA/ASA) recommendations. Overall, vascular neurologists commonly recommended appropriate AHA/ASA risk factor management standards, but were less likely to do so for lifestyle management. Improvements in the EMR system over time, including the establishment of guideline-driven importable recurrent stroke prevention templates, led to a high frequency of proper risk factor and lifestyle recommendations made by vascular neurologists. Statistical analysis provided further evidence that the EMR positively influenced the delivery of proper recurrent stroke prevention guidance. Although PCPs infrequently acknowledged receipt of vascular neurology consultations, there was a relatively high frequency of achieved risk factor control. The latter may be attributed at least in part to pre-existent quality improvement programs implemented at primary care offices. Our exploratory findings suggest that proper use of the EMR may heighten efforts to provide appropriate and consistent recurrent stroke prevention recommendations in a primary care setting.

Clinical Characteristics, Prevalence, and Complications of Colonic Diverticular Disease in an Urban Hispanic Population

Introduction: Diverticulitis and Diverticular bleeding, which are complications of Diverticular Disease, are the leading gastrointestinal indication for hospitalization in the United States. Diverticular Disease is well studied in White populations with average rates of Diverticulosis of 25% along with Diverticulitis in 15-20%, and Diverticular Bleeding in 5-15% of those affected. There is limited data on Hispanic populations with Diverticular Disease. This study will aim to define the clinical characteristics of a Hispanic population to determine risk factors for Diverticular Disease and its complications. Methods: This is a retrospective study that analyzed medical records and endoscopic reports from a tertiary center with a predominantly Hispanic population. Hispanic patients were identified through ethnicity reports in the Endoscopic database and sorted into confirmed diverticulosis by colonoscopy and presence and number of colonic polyps. Age, gender, BMI, use of non-steroidal anti-inflammatory drugs (NSAID), tobacco, alcohol, presence of co-morbidities, and complications such as Diverticular bleeding and Diverticulitis were assessed through chart review. Data was analyzed with multivariable logistic regression. Results: A total of 491 inpatient and outpatient endoscopy and electronic medical record charts between June through September 2016 were reviewed. 372 of the patients were Hispanic and included in the study. 119 of the 372 Hispanic patients had presence of Diverticulosis confirmed on colonoscopy report, with a prevalence of 31.7%. Increasing Age 58.3 vs 53.5 (P=0.004; 95% CI 1.012-1.065), BMI 31.6 vs 28.9 (P=0.002; 95% CI 1.020-1.095), and NSAID use (P=0.048; 95% CI 1.005-2.714) were associated with the presence of Diverticulosis. Increasing number of colonic polyps 1.38 vs 1.13 (P=0.047 95% CI 1.015-2.721) was also seen in those with Diverticulosis. 51% had left sided disease (n=61) vs 9.2% right sided (n=11) vs. 39% pan-colonic (n=47). Diverticular complications included 18.5% with hematochezia (n=22) and 11% with Diverticulitis (n=13). Conclusion: High prevalence of Diverticulosis is seen in Hispanics with mostly left sided and pan-colonic disease that are associated with colonic polyps. Increasing age, BMI, and NSAID can be predictive of the presence of Diverticulosis in Hispanics. Higher rates of Diverticular bleeding and equivalent rates of Diverticulitis were seen compared to past literature of White populations.

Patient Use of the Electronic Communication Portal in Management of Type 2 Diabetes.

High incidence and prevalence of type 2 diabetes require urgent attention to the management of this chronic disease. The purpose of this study was to explore electronic communication (e-communication) between patients with type 2 diabetes and their providers within the patient portal. Qualitative design with conventional content analysis techniques was used. A purposive random sample of 90 electronic medical record charts of patient-portal users with type 2 diabetes was subjected to a retrospective review. The sample mainly consisted of patients between the ages of 50 and 70 years, who were white, non-Hispanic, and English-speaking. The three major themes that emerged in e-communication via patient portal were inform theme, which was the most frequently identified theme; instruct/request theme, which was mainly used in initiation of e-communication; and the question theme. The patient portal was used primarily for requests by patients and instruction by providers, showing relatively short e-message encounters with a high number of partially completed encounters, frequent lack of resolution, and a low level of involvement of diabetes specialists in e-communication. There is a need to revise healthcare system guidelines on initiation and use of e-communication via patient portal and develop standardized templates to promote diabetes education in type 2 diabetes.