Hamilton Health Sciences Research Articles

Applying the Synergy Model to inform the nursing model of care in an inpatient and an ambulatory care setting: The experience of two urban cancer institutions, Hamilton Health Sciences and Grand River Regional Cancer Centre.

The incidence and prevalence of cancer continues to rise throughout Canada. Approximately one in two Canadians are expected to develop cancer at some point in their lives (Canadian Cancer Society, 2021). As the complexity and acuity of individuals with cancer increases, there is increased necessity to define the ideal nurse-to-patient ratio and patient caseload for nurses in specialized oncology settings. Two senior nurse leaders, faced with the need to determine the most appropriate model to inform the nursing model of care within their respective care areas, collaborated and decided to implement the Synergy Model. The Synergy Model is a professional practice model developed by the American Association of Critical Care Nurses (AACN). In the Synergy Model, nursing care reflects the integration of nurses' knowledge, skills, attitudes, competencies, and experience to meet the needs of patients and families (Curley, 2007). This model provides a framework for matching nursing resources based on patient care needs and has been adapted in various care settings. The model, however, has not been applied in a surgical oncology inpatient unit or in an oncology ambulatory care setting. Using a quality improvement methodology, the Synergy Model was piloted in these new areas and found to be effective. The Synergy Model can be utilized to determine the need for additional nursing resources with specialized oncology nurses and appropriate skill mix of intraprofessional nursing teams. It can also be used to assess adult oncology patients who present to the ambulatory systemic care suite for unscheduled care related to symptomatic concerns.

A22 PREVALENCE OF IRON DEFICIENCY AND SUPPLEMENTATION PRACTICES FOR PATIENTS ON HOME PARENTERAL NUTRITION

Abstract Background Iron deficiency (ID) is common in patients receiving parenteral nutrition (PN), likely due to a lack of iron in the PN formula. There is no clear consensus on how often serum iron should be tested or iron supplementation should be given, at which dose or route, in patients on long-term PN. Within the Hamilton Health Sciences (HHS) home PN (HPN) program, the prevalence of ID or iron deficiency anemia (IDA) is unknown. This knowledge will contribute to better iron prescribing practices with ultimate benefit on patient’s health. Aims To assess the prevalence of ID and IDA in patients enrolled in the HHS HPN Program. The secondary aim was to assess supplementation practices for patients enrolled in the HPN program according to gastrointestinal(GI) diagnosis and duration on PN. Methods We conducted a retrospective study including consecutive adult patients enrolled in the HHS-HPN program from January 2015 to November 2020. We collected data on demographics (age, sex, and GI diagnosis), iron supplementation (dose, duration, and route), and information related to iron-deficiency (hemoglobin, serum iron, ferritin, TIBC, and folate) at pre-set intervals (enrollment, 3, 6, 12, 18, 24, 30, 36, 48, 60 months) and last measured. ID was defined as ferritin ≤45μg/L or serum iron ≤9μmol/L. IDA was defined as hemoglobin <130g/L in men or <120g/L in women in the context of ID. Data were expressed as median (IQR) for continuous variables and n/N(%) for categorical variables. Chi2 was performed to assess differences between groups and logistic regression to assess predictors of ID and IDA. The analysis was conducted using SPSS software(v26). Results The analysis included 125 HPN patients (50 males, median age of 55 (40–65) years). Patients received PN for a median of 195 (83–521) days. The most common diagnoses were malignancy (36.8%) and inflammatory bowel disease (23.2%); the most common indications for HPN was short bowel (29.6%) and bowel obstruction (27.2%). Iron profiles were measured in 77% of patients. At enrollment, 42.2% of patients had ID and 38.9% had IDA. Only 13% of patients with ID and 22.8% with IDA had iron supplementation (Figure 1). A total of 38 patients received iron either oral or IV (oral=44.7% vs IV=55.3%; p=0.66). There was no correlation between low levels of serum iron or ferritin with iron supplementation (p=0.23, 0.45 respectively). Age, sex, diagnosis, or reason for PN did not correlate with ID or IDA at any time point. Conclusions Iron-deficiency and IDA are common in patients enrolled in the HHS HPN program independently of age, sex, diagnosis and reason for PN. Prospective studies are needed to implement the most effective way to ensure proper monitoring and treatment of iron deficiency in this population. Funding Agencies None

Abstract PO052: Uncovering the evolution of Glioblastoma proteome landscape from primary to the recurrent stage for development of novel diagnostic and predictive biomarkers

Abstract Glioblastoma (GBM) is characterized by extensive cellular and genetic heterogeneity. A wealth of literature describes the biology of primary GBM (p-GBM), but we currently lack an understanding of how GBM evolves through therapy to become a very different tumor at recurrence, which may explain why therapies against p-GBM fail to work in recurrent GBM (r-GBM). Therefore, to understand the evolution of r-GBM, we aimed to characterize patient-matched p-GBM and r-GBM proteome and identify potential therapeutic targets for r-GBM. We collected one of the world’s largest patient-matched p-GBM and r-GBM samples from the Hamilton Health Sciences for gene expression profiling, proteomic analyses and tissue microarray (TMA) construction. Nano-String analysis was performed for GBM subtype identification. Furthermore, patient demographics was generated for survival analysis. The top potential therapeutic targets for r-GBM were identified by proteomic analysis and were validated on TMA using immunohistochemistry. The essentiality of each protein in r-GBM were assessed using CRISPR KO studies and the top hit were selected for pre-clinical testing. 6798 proteins were detected by shotgun, label-free proteomic analyses. Differential expression analysis on the surface proteins revealed a distinct set of proteins overexpressed in r-GBM among which 7 proteins were selected as top potential therapeutic targets for r-GBM. Besides, the patients were grouped based on survival rate and the differential expression analysis revealed significantly enriched proteins and pathways in short-term survivors which cause aggressive phenotypes in GBM. In addition, consensus clustering identified five protein clusters which show distinction between primary vs recurrent tumors. Our data also strongly supports a preponderance of immune regulatory/suppressive genes as important drivers of r-GBM. This study resulted in identification of diagnostic and predictive biomarkers which is extremely complementary and instructive for the development of new poly-therapeutic paradigms for GBM patients at the recurrent level and will lead to improvement of patient’s survival. Citation Format: Nazanin Tatari, Shahbaz Khan, Julie Livingstone, Chitra Venugopal, Jennifer Chan, Cynthia Hawkins, John Provias, Jian-Qiang Lu, Kjetil Ask, Thomas Kislinger, Sheila Singh. Uncovering the evolution of Glioblastoma proteome landscape from primary to the recurrent stage for development of novel diagnostic and predictive biomarkers [abstract]. In: Proceedings of the AACR Virtual Special Conference on the Evolving Tumor Microenvironment in Cancer Progression: Mechanisms and Emerging Therapeutic Opportunities; in association with the Tumor Microenvironment (TME) Working Group; 2021 Jan 11-12. Philadelphia (PA): AACR; Cancer Res 2021;81(5 Suppl):Abstract nr PO052.

Antiplatelet therapy prescription patterns for acute coronary syndrome: a decade analysed

Abstract Background/Introduction Guidelines recommend dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and ticagrelor following acute coronary syndrome (ACS) regardless of management strategy. Despite this, prescription practices lag and appropriate DAPT is not utilized. Purpose We aimed to trend differences in P2Y12 inhibitor prescriptions between ACS patients managed with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). As well, we wanted to analyze the impact practice-changing trial publications, national guideline updates, and publicly funded drug coverage plans may have on prescription patterns. Methods From national databases, we obtained data for ACS patients in the province of Ontario, Canada between 2008 and 2018. Using an interrupted-time series with data aggregated monthly, we evaluated types of P2Y12 inhibitor prescribed at hospital discharge and changes to antiplatelet prescription patterns following publication of Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndrome (PLATO), Canadian Cardiovascular Society (CCS) antiplatelet therapy guidelines, and ticagrelor coverage by a publicly funded medication plan. Results We included 114,142 ACS patients; 49% underwent PCI and 8% required CABG. Between October 2008 and March 2018, the proportion of patients discharged on P2Y12 inhibitors increased from 73.4% to 87% (p<0.0001) for PCI patients and 11.4% to 31.4% (p<0.0001) for CABG patients. PLATO publication was associated with a 1.3% (p=0.002) monthly decline in clopidogrel prescriptions amongst PCI patients. The 2010 CCS antiplatelet therapy guidelines were associated with a 0.7% (p<0.0001) monthly decline in clopidogrel prescriptions amongst PCI patients. The approval of ticagrelor by publicly funded medication plan was associated with an increase in ticagrelor prescriptions within the first month (24.5%; p<0.0001) and a continued monthly increase (0.4%; p<0.0001) in PCI patients. The approval was also associated with an increase in monthly ticagrelor prescriptions (0.2%; p<0.0001) amongst CABG patients. The 2012 CCS antiplatelet therapy guidelines were associated with a decline in clopidogrel prescriptions within the first month (6.1%; p=0.003) and a monthly increase in ticagrelor prescriptions (0.3%; p=0.05) amongst PCI patients. Conclusion Drug coverage by a publicly funded medication plan and guideline updates had significant impact on P2Y12 inhibitor prescription practices. Despite improvements, P2Y12 inhibitor prescriptions for CABG patients are far behind PCI patients. Further research is necessary to address barriers to appropriate antiplatelet therapy in the ACS population. Antiplatelet Prescription Patterns Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): New Investigator Fund - Hamilton Health Sciences Foundation, Hamilton, Canada

Quality of Life and its Determinants in Heart Failure Patients at a Major Tertiary Academic Center in Ontario, Canada

Background Heart failure (HF) greatly impacts quality of life (QoL). Objectives We evaluated QoL, its determinants and associations with major outcomes in HF patients at our institution, Hamilton Health Sciences (HHS), a tertiary academic centre in Ontario. Methods We enrolled 270 patients in a HF registry with standardized recording of data on demographics, social and educational status, living conditions, HF etiology, symptoms, comorbidities, physical exam, medication use, ECG, echocardiographic and biochemical measurements. QoL was measured using the KCCQ-12 questionnaire. Patients are followed prospectively and at the time of this analysis all patients had completed 6 months follow-up. Results Patients' mean age was 70.6±11.2 yrs, 32% were women, 55.6% were married, 25.6% lived alone, 74.4% were enrolled from the outpatient HF clinic and 25.6% during a HF hospitalization. Mean LVEF was 40.1%, 53.2% had HFrEF, 30.3% HFpEF and 16.5% HFmEF. The most common HF etiology was IHD, 48.1% had NYHA class III or IV functional status and 64.4% had 2 or more comorbidities. Average KCCQ-12 summary score was 57.5±27.7, consistent with fair disability level and overall good QoL. 14.1% had severe disability (KCCQ-12 score between 0 and 25) and 33.3% had little or no disability and excellent QoL (KCCQ-12 score between 76 and 100). HFpEF patients had on average a lower KCCQ-12 summary score than HFrEF patients (53.2±28.6 vs. 58.1±27.1, p=0.027) and a higher proportion had a score of 25 or lower consistent with severe disability (21.4% vs. 11.4%). In bivariate analysis lower KCCQ-12 summary score was associated with older age, inpatient status, living alone, NYHA class, time from diagnosis of HF, history of diabetes, COPD, total number of comorbidities, LVEF, heart rate and BMI. However, in multivariate analysis only NYHA class III or IV, inpatient status and COPD emerged as independent predictors of a lower KCCQ-12 summary score. Patients in the upper third of KCCQ-12 scores had the lowest rates of HF hospitalizations, all-cause hospitalizations, CV death, all-cause death and the composite of HF hospitalization and all-cause death. Conclusions Inspite of living with HF, many patients in our registry have fair disability level and good QoL. Patients with HFpEF had worse QoL than those with HFrEF. Advanced NYHA class, inpatient status and COPD were independent predictors of poorer QoL. We observed a strong association between the KCCQ-12 summary score and major CV outcomes.

Surveillance post-radiofrequency ablation for small renal masses: Recurrence and followup.

Small renal masses (SRMs), enhancing tumors <4 cm in diameter, are suspicious for renal cell carcinoma (RCC). The incidence of SRMs have risen with the increased quality and frequency of imaging. Partial nephrectomy is widely accepted as a nephron-sparing approach for the management of clinically localized RCC, with a greater than 90% disease-specific survival for stage T1a. Radiofrequency ablation (RFA) has been emerging as an alternative management strategy, with evidence suggesting RFA as a safe alternative for SRMs. We aimed to evaluate the time to recurrence and recurrence rates of SRMs treated with RFA at our institution. A retrospective review between October 2011 and May 2019 identified 141 patients with a single SRM treated with RFA at Hamilton Health Sciences and St. Joseph's Healthcare Hamilton. Patients with familial syndromes and distant metastases were excluded. Repeat RFAs of the ipsilateral kidney for incomplete ablation were not considered a new procedure. The primary variable measured was time from initial ablation to recurrence. A Cox proportional hazard regression model was used to identify possible prognostic variables for tumor recurrence defined a priori, including age, gender, mass size, RENAL nephrometry, and PADUA scores. The overall average age of our patients was 69.0±11.1 years, with 71.6% being male. Average tumor size was 2.6±0.8 cm. There were 22/154 total recurrences (15.6%) post-RFA. Median followup time was 67 (18-161) months. Those with new recurrences had median time to recurrence of 15 months and no recurrence beyond 53 months. Thirteen of 141 patients had residual disease (9.2%) and were identified within the first eight months post-RFA. The only prognostic variable identified as a predictor of residual disease was tumor size (hazard ratio 2.265; p<0.001). This study shows the risk of a new recurrence following RFA for SRMs is 6.4%. Most recurrences (9.2%) were a result of residual tumor at the ablation site identified within the first eight months post-RFA. No recurrences were identified beyond 53 months, with a total median followup time of 67 months. Tumor size alone, without need for complex scoring systems, may serve as a predictor of incomplete ablation following RFA and could be used to assist in shared decision-making on management strategies.

Becoming a medical assistance in dying (MAiD) provider: an exploration of the conditions that produce conscientious participation

The availability of willing providers of medical assistance in dying (MAiD) in Canada has been an issue since a Canadian Supreme Court decision and the subsequent passing of federal legislation,...

P009: Quality improvement and implementation of urine culture follow up process

Background: The diagnosis of urinary tract infection (UTI) is made based on symptoms, urinalysis and urine culture. While simple urinary tract infections do not require routine culture, the Infectious Disease Society of America (IDSA) Guidelines state that complicated urinary tract infections should have urine cultures performed to determine which antibiotics are effective, as there is a higher risk of infection with resistant organisms. We hypothesized that the rate of urine cultures sent for complicated UTI is less than is recommended by the literature. Aim Statement: We aimed to implement a follow-up reporting system for Urinary Culture in patients diagnosed with complicated UTIs and raise our Urinary Culture rates in this population to 80% by June 2019. Measures &amp; Design: We performed a single-center chart review using Emergency Department (ED) charts of non-admitted patients. They were audited daily for two weeks to obtain a sample of patients who had a discharge diagnosis of urinary tract infection, pyelonephritis or cystitis. Charts capturing these diagnoses were assessed to see if a culture was clinically indicated and if it was ordered. Charts were screened for the presence of any of the following criteria indicating complicated UTI: known structural or functional abnormality of the urinary tract, genitourinary obstruction, pregnancy, immunosuppression, diabetes, indwelling or intermittent catheter use, fever, male patient, clinical pyelonephritis, antimicrobial failure, or transfer from a nursing home. Data was then compiled to determine culture rates in complicated and uncomplicated UTIs. This prevalence rate established the baseline performance in the ED which was used to inform the quality improvement project. Evaluation/Results: Over a two week period, 26 patients were discharged from the ED with a diagnosis of UTI, with 17 of these patients meeting criteria for complicated UTI. Only 6 of 17 complicated UTIs were sent for urine culture, therefore our pre-implementation culture rate was 35%. After initial data collection, a follow-up system was designed ensuring that urine culture and sensitivities results would be compiled and reviewed daily at Hamilton Health Sciences. This system was created with input from key stakeholders including department chiefs, core lab services, ED physicians and business clerks. A discrepancy form was created for documentation of culture result recognition and any required patient follow up ie. antibiotic change. In October 2019, the system had been implemented for a month, after which another chart review was completed. 27 cases were captured, 18 of which were complicated. The complicated culture rate had increased significantly from 35% to 72%. Discussion/Impact: In the ED, ordering of cultures for patients being discharged, regardless of type, is commonly associated with concern of result follow up, which may take up to 72 hours. This discrepancy system was implemented to ensure that all urine cultures ordered had appropriate follow up, thus supporting physicians in ordering cultures when indicated. The significant improvement in culture rate from 35% to 72% is balanced by one single culture of all 9 simple UTIs (11%). In PDSA cycle 2, we hope to increase rates to 90% by improving current challenges with the system.

P101: Seasonal variations in modes of presentation in ST elevation myocardial infarction

Introduction: For patients with ST-elevation myocardial infarction (STEMI), time is myocardium. The sooner STEMI patients receive a definitive intervention, the better their outcomes. The first point of contact with the healthcare system for STEMI patients is either via Emergency Medical Services (EMS), or self-transportation to an Emergency Department (ED). Despite a reduced time to definitive intervention, STEMI patients who use EMS have increased mortality compared to those who self-transport. In an effort to optimize STEMI care pathways, we characterized variations in modes of presentation of STEMI patients in our region. Methods: This study used a retrospective cohort design from a regional STEMI registry. Patients presenting to Hamilton Health Sciences between January 1, 2016, and December 31, 2018 meeting STEMI criteria were included in our analyses. Self-transport patients were analyzed from two academic EDs in Hamilton, Ontario. One hospital was PCI capable and the other, non-PCI capable. Patients transferred from other health regions were excluded from our analyses. Dichotomous variables were compared using χ2 tests. Group means were compared using the Student t-test. Results: Eight hundred and seventy-one patients were included in the analysis, including 675 EMS users, and 196 self-transporting to EDs. Patients self-transporting to EDs were younger (61.5 v. 64.6 y, p &lt; 0.002) and more often male (82.6 v. 69.2%, p &lt; 0.0002) compared to EMS users. There was a non-significant trend towards an increased rate of all STEMI patients self-transporting in the summer months compared to the winter (63 of 215 in summer v. 41 of 185 in winter, 29.3 v. 22.2%, p = 0.10). Comparative analysis between both hospitals yielded an increased rate of self-transportation to the PCI-capable hospital in the summer months compared to winter (46 v. 28, 23.2 v. 16.3%, p = 0.09), but not the other hospital (18 v. 13, 10.6 v. 8.3%, p = 0.57). The majority of self-transporting patients came from postal codes bordering each hospital, and the different rates of self-transportation between hospitals were not associated with recent specialist follow up at those sites. Conclusion: Seasonal trends in modes of presentation in STEMI patients may present an opportunity to optimize STEMI care pathways through resource utilization and patient education. A larger dataset and possible multicenter analysis should be done to determine if significance is obtained with larger sample size.

Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study

The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. In this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63·8%) were men, and 14 524 (46·5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71·9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27·5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88·7%] of 195 patients with open fractures; 426 [44·7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47·7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50·5%]), while Second Delays (delays in reaching care) were the least common (423 [5·4%]). Compared with other methods of transportation (eg, walking, rickshaw), ambulances led to delay in transporting patients with open fractures to a treating hospital (adjusted RR 0·66, 99% CI 0·46-0·93). Compared with patients with closed lower limb fractures, patients with closed spine (adjusted RR 2·47, 99% CI 2·17-2·81) and pelvic (1·35, 1·10-1·66) fractures were most likely to have delays of more than 24 h before admission to hospital. In low-income and middle-income countries, timely hospital admission remains largely inaccessible, especially among patients with open fractures. Reducing hospital-based delays in receiving care, and, in particular, improving interfacility referral systems are the most substantial tools for reducing delays in admissions to hospital. National Health and Medical Research Council of Australia, Canadian Institutes of Health Research, McMaster Surgical Associates, and Hamilton Health Sciences.

A100 ORAL VANCOMYCIN THERAPY FOR CLOSTRIDIOIDES DIFFICILE INFECTION AND RISK OF INFECTION WITH GRAM-NEGATIVE ORGANISMS

Abstract Background Vancomycin is the recommended first-line therapy for mild to severe Clostridioides difficile infection (CDI). However, oral vancomycin is associated with disruption of the indigenous microbiota, predisposing patients to overgrowth of endogenous pathogens such as vancomycin-resistant enterococci. Aims The primary objective of the study is to examine the effect of the treatment regimens of CDI on the risk of infection with gram-negative organisms in adult patients treated for CDI. Methods A retrospective cohort study of 319 adult patients treated for CDI at Hamilton Health Sciences in the year 2015. A multivariate logistic regression analysis was performed to determine if oral vancomycin-based therapy is associated with an increased risk of infection with gram-negative organisms after adjustment for other factors. Results Eighty-one patients were excluded because of recurrent episodes of CDI within the same year or missing information. 238 patients were included in the final analysis. 48 (20.2%) patients had positive culture for gram-negative organisms after onset of CDI. Urine was the most common source for gram-negative organisms (39/48, 81.3%) followed by blood (8/48,16.7%). The most common isolated gram-negative organisms were Escherichia coli (18/48, 37.5%) and Klebsiella pneumonia (9/48, 18.8%). The most common CDI treatment regimens were metronidazole monotherapy (137/238, 57.6%), vancomycin monotherapy (13/238, 5.5%), and combination therapy (88/238, 37.0%). Among patients who were treated with metronidazole monotherapy, vancomycin monotherapy, and combination therapy, 30(30/137, 21.9%), 3 (3/13,23.1%), and 15 (15/88, 17.1%) had positive culture for gram-negative organisms, respectively (P= 0.6). Ninety-seven (97/238,40.8%) patients had severe CDI, 40 (40/97, 41.2%) were treated with metronidazole monotherapy, 5(5/97, 5.2%) with vancomycin monotherapy, and 52 (52/97, 53.6%) with combination therapy. 26 (26/141,18.4%) and 22 (22/97, 22.7%) had positive culture for gram-negative organisms among patients with non-severe and severe CDI, receptively (P= 0.7). In the multivariate analysis, neither type of CDI treatment regimen (P=0.2, 95% CI 0.30–1.31) nor CDI severity (P=0.4, 95% CI 0.67–2.69) was associated an increased risk of infection with gram-negative organisms after CDI onset. Conclusions Contrary to the reported literature, we did not find that oral vancomycin-based CDI treatment was associated with increased risk of infection with gram-negative organisms. Funding Agencies None

Further reducing the rate of code blue calls through early warning systems and enabling technologies.

Hospitals are facing an unprecedented level of change-with pressure from the general public to provide high-quality care and retain top talent by preventing burnout. How can they provide better patient care without overwhelming clinicians with more connected devices, alarming systems, and analytics solutions? Some challenges do not just cause harm to patients but they have a major economic impact on the financial health of the hospital. One problem for many hospitals is the growing number of "code blue" calls that warn clinicians a patient is in cardiac arrest. In this case study, you will learn the impacts of introducing an early warning system and its enabling technologies on Hamilton Health Sciences and why the underlying technology helped to produce positive results.

Prolonged EEGs in adult patients with a first unprovoked seizure: a prospective pilot study.

Definitions of epilepsy have changed to include a first unprovoked seizure with a high (>60%) risk of recurrence in the next 10 years. A single seizure and an epileptiform discharge on an EEG would suffice for this diagnosis. We hypothesized that an extended six-hour EEG in adult patients presenting with a first unprovoked seizure would demonstrate an increased yield of epileptiform discharges in comparison to a standard 30-minute EEG, and therefore higher rates of epilepsy diagnosis. Thirty-eight patients were recruited at Hamilton Health Sciences over six years and 36 underwent extended six-hour EEGs. Two of seven patients demonstrated epileptiform discharges on their EEG after only the first 30 minutes of recording, observed during sleep for both patients. This correlated to an overall increase of 5.56%, or a yield of 29%. A third more patients could benefit from early diagnosis with extended EEGs. The rate of epilepsy diagnosis based on EEG overall was superior to that of brain imaging (19% versus 6%). Given the limitations due to sample size in this study, a larger trial would be beneficial to confirm these findings.

Oral Antimicrobial Agents for Urinary Tract Infections Due to Enterobacteriales Species

Background Urinary tract infections (UTIs) due to Enterobacteriales continue to pose a challenge because of increasing resistance rate to antimicrobial agents. The aim of this study was to evaluate in vitro susceptibility of oral antimicrobial agents against urinary isolates of Enterobacteriales species in patients with suspected UTIs at Hamilton Health Sciences hospitals in 2016. Methods Positive urine cultures for Enterobacteriales species in all patients 18 years or older with diagnosis of UTIs from 2 acute care hospitals in 2016 were included. Susceptibility rates were calculated for first- and second-line oral antimicrobial agents commonly used to treat UTIs. Results A total of 2773 urinary isolates of Enterobacteriales species were included in the analysis. The rates of susceptibility to nitrofurantoin were 96.3% (1925/1999) and 46.9% (188/401), respectively, for Escherichia coli and Klebsiella pneumoniae. The rates of susceptibility to trimethoprim-sulfamethoxazole and ciprofloxacin were 73.9% (1478/1999) and 84% (337/401), and 72.3% (1446/1999) and 86.3% (346/401), respectively, for E. coli and K. pneumoniae. The rate of E. coli susceptibility to oral cephalosporins was approximately 83%. The proportions of Enterobacteriales isolates that produced extended-spectrum β-lactamases (ESBLs) for E. coli and K. pneumoniae were 11.6% (231/1999) and 11.2% (45/401), respectively. The rates of ESBLs E. coli susceptibility to nitrofurantoin, trimethoprim-sulfamethoxazole, and ciprofloxacin were 91.3% (211/231), 30.3% (70/231), and 16% (37/231), respectively. Conclusions Oral antimicrobial agents have a limited role as empiric treatment of UTIs due to antibiotic-resistant Enterobacteriales species, with the exception of nitrofurantoin for E. coli including ESBL-producing strains. Oral cephalosporins were the second most susceptible agents to E. coli.

Identifying Patterns of Inappropriate Plasma Transfusion Practices Using a Novel Multicenter Electronic Data Audit: Over 80 Percent of Plasma Transfused Is Inappropriate

Importance: Plasma is frequently transfused to patients who are bleeding or require an invasive procedure and have a deficiency of coagulation factors. Despite published guidelines delineating optimal plasma use, two recent audits have suggested that over 50% of the plasma transfused is unnecessary. Inappropriate utilization of plasma has numerous adverse consequences for the recipient, as well as the health care system. Objective: To determine the proportion of inappropriate plasma use with a multicenter electronic data audit and identify focused areas for intervention to reduce inappropriate use. Setting: 3 tertiary care academic sites across Ontario, Canada: Hamilton Health Sciences Centre (Hamilton, Ontario), Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario). Participants: All adult inpatients receiving plasma during the time period January 1, 2017 and December 31, 2017. Design: Four areas of inappropriate plasma use in adult patients were defined: (1) patients with a normal INR &amp;lt;1.5 and who were not actively bleeding or moderate bleeding only (1 unit RBC transfused within 24 hours before or after plasma transfusion or 20 g/L drop in hemoglobin); (2) elevated INR &amp;gt;1.5, without active bleeding or procedures in 6 hours after plasma transfusion (1 calendar day when time of procedure was not available); (3) no INR drawn before or after plasma infusion; (4) inappropriate non-therapeutic plasma dose of plasma (≤ 2 units) . Results: A total 4,385 plasma transfusion events occurred in 1,844 inpatient admissions. Appropriate indication and dosing was found in 813 (18.5%) of the events. Inappropriate compliance occurred in 3,572 (81.5%) of the events: 608 (13.9%) events occurred in the pre-specified criteria (1-3) above; inappropriate dosing alone occurred in 1,583 (36.1%) events; and, a combination of inappropriate dosing in addition to any 1-3 pre-defined categories occurred in 1,381 (31.5%) transfusion events. Patients transfused with a documented INR (81.5%) in the 24 hours preceding plasma transfusion had a mean INR value 1.8+1.7 (INR + SD). The mean overall reduction after 1-24 hours of plasma transfusion was -0.5+1.6 . Conclusions and Relevance: A significant amount of plasma is transfused inappropriately, leading to potential patient harm, significant unnecessary costs, and diversion of plasma away from fractionation impacting the supply of intravenous immunoglobulin. This study will inform a large quality improvement study aimed at reducing unnecessary plasma transfusion. Disclosures Heddle: Novartis: Research Funding. Arnold:Principia: Consultancy; Bristol-Myers Squibb: Research Funding; Novartis: Honoraria, Research Funding; Rigel: Consultancy, Research Funding. Hsia:Amgen: Honoraria; Jansen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees.

Physical activity and sedentary behaviour in children with spina bifida.

To describe active and sedentary time in children with spina bifida and to compare their physical activity on weekdays versus weekends. In this exploratory cross-sectional study, data from 13 Canadian and 22 Dutch children with spina bifida (14 females, 21 males; mean age 10y 11mo, standard deviation [SD] 3y 6mo, range 5y 6mo-18y; Hoffer classification distribution: community [n=28], household [n=3], non-functional [n=3], and non-ambulator [n=1]) were analysed. Objective measures of physical activity and sedentary behaviour were obtained by using ActiGraph or Actiheart activity monitors. Data for the participants wearing the ActiGraph were compared with age- and sex-matched controls that were developing typically using independent-samples t-tests. Activity data collected on weekdays was compared to those on weekends. ActiGraph data demonstrated children with spina bifida spent more time sedentary (mean [SD] 49.5min/h [5.78]) and less time in moderate to vigorous physical activity (mean [SD] 2.33min/h [1.61]) compared with the typically developing group (mean [SD] 41.0min/h [5.76] and 5.46min/h [2.13], p=0.001 and p<0.001 respectively). For both ActiGraph- and Actiheart-derived data, physical activity and sedentary time were not significantly different between weekdays and weekends. Children with spina bifida have reduced levels of physical activity and increased sedentary behaviour, with no statistical differences seen between weekdays and weekends. Several methodological issues related to activity monitoring warrant consideration when choosing the appropriate method to quantify physical activity and sedentary behaviour. Reduced levels of physical activity and sedentary time were quantified in children with spina bifida. Objective quantification of physical behaviour in ambulatory and non-ambulatory school-aged children with spina bifida is possible.

Is Blood Urea Concentration an Independent Predictor of Positive Endoscopic Findings in Presumed Upper Gastrointestinal Bleeding?

Background: The test characteristics of blood urea concentration in the identification of upper gastrointestinal bleeding (UGIB) or high-risk endoscopic lesions have not been clearly determined. This study aimed to elucidate if urea independently correlates with the presence of positive endoscopic findings in cases of presumed UGIB and understand the diagnostic value of this parameter when assessing a patient with potential UGIB. Methods: A retrospective cohort study was conducted at Hamilton Health Sciences hospitals examining patients who had upper endoscopy for presumed UGIB. Contingency tables were generated to determine the test characteristics of urea at different thresholds for prediction of UGIB. A crude OR was calculated for odds of bleeding being identified on endoscopy based on varying thresholds of urea, and adjusted ORs were calculated using logistic regression modelling. Results: Variables significantly associated with detecting a source of GI bleeding at endoscopy included increase in urea (OR 1.06, 95% CI 1.01–1.09), male gender (OR 2.02, 95% CI 1.08–3.77), presence of melena (OR 2.37, 95% CI 1.06–5.33), and hematemesis (OR 3.88, 95% CI 1.70–8.83), when adjusted for other covariates. The odds of identifying UGIB at endoscopy in patients with urea ≥10 mmol/L was 3.73 (95% CI 1.90–7.31) times higher than for patients with urea <10 mmol/L. Conclusion: Urea level is an independent predictor of positive endoscopic findings in presumed UGIB, and urea ≥10 mmol/L may be a useful threshold to help guide clinicians towards clinically significant bleeding that could warrant early endoscopic evaluation.

Examining Canada's return visits to the emergency department after a concussion.

The purpose of this study was to identify 1) the proportion of patients discharged from the emergency department (ED) with a diagnosis of concussion and return within 14 days, and 2) the characteristics that prompt a return. A health records review was conducted on adult patients with a discharge diagnosis of a concussion who accessed care through Hamilton Health Sciences EDs and Urgent Care Centre in 2016. Subsequent data were collected from those who returned to the ED within 14 days. Clinical characteristics of returners were compared to those of non-returners. Of the 389 patients included in the study, 38 (10%) returned within 14 days. Patients who sustained a concussion in a sport-related context or were referred to a specialized clinic were less likely to return (p = 0.03). Those who suffered an assault-related concussion were more likely to return (p = 0.01). Of those who did return, 42% received a CT scan with normal results, and 42% were given new discharge instructions. Approximately 10% of patients diagnosed with a concussion in a Canadian hospital setting returned to the ED within 14 days of their index visit. Our study suggests the opportunity to reduce this burden to both the healthcare system and the patient through careful discharge instructions outlining anticipated symptoms following a concussion (specifically, headache) or referral to a concussion clinic.

Extended venous thromboembolism prophylaxis after abdominopelvic cancer surgery: a retrospective review.

Extended prophylaxis against venous thromboembolism (vte) after abdominal or pelvic cancer surgery with low molecular weight heparin (lmwh) is recommended by multiple guidelines. The primary objective of the present study was to assess adherence to that guideline recommendation at tertiary care centres within Hamilton Health Sciences (hhs). Given that an estimated 70% of the study population would be expected to receive extended prophylaxis, a sample size of 105 patients was calculated. Patients who had undergone abdominal or pelvic surgery for cancer from March 2012 to December 2015 were identified, and data were collected from electronic health records. The primary outcome was prescription of extended vte prophylaxis. Of 105 patients, only 3 received extended vte prophylaxis. Those 3 patients had serous carcinoma of the uterus, transitional cell carcinoma of the bladder, and cecal cancer. Of the 3 patients, 2 were followed by the thrombosis service while in hospital; none of the other 102 patients received any form of extended vte prophylaxis. Based on multiple randomized controlled trials, guidelines suggest lmwh prophylaxis for up to 4 weeks after major abdominal or pelvic cancer surgery. Despite those recommendations, postoperative extended vte prophylaxis is not commonly prescribed at hhs facilities. Next steps will include identification of barriers and an examination of how those barriers could be addressed. Failure to use prophylaxis is not consistent with evidence-based guidelines and is placing patients at risk of vte.

Electronic Procedural Reporting for Colonoscopy; Challenges (Discrepancies) in Data Entry and Report Generation

Aims: Computerized reporting systems that generate standardized endoscopy reports are available and facilitate easy retrieval of data for quality assurance review. We aim to compare the accuracy of extracted database fields in our reporting system (endoPRO) for key measures of quality to the final edited endoscopy report for colonoscopy procedures. Methods: In a retrospective analysis, we compared data retrieved from endoPRO to the final colonoscopy reports at Hamilton Health Sciences (HHS). The data included demographics, indications for procedures, bowel prep quality, findings, extent of exam, and recommendations. Discrepancies, changes or missing information pertaining to key quality indicators for colonoscopies were recorded. Results: In total, 1843 colonoscopy procedures were done at HHS from January to March 2010, and reports for 592 colonoscopies, randomly selected, were analyzed for this study. Discrepancies were seen in: Indication – 34 cases (5.7%), Assistants present during colonoscopy – 94 cases (15.9%), Quality of bowel preparation – 35 cases (5.9%), Findings & impressions – 38 cases (6.4%) including polyps, inflammation, diverticulosis and haemorrhoids. Conclusions: Our study demonstrates the variability between data found in patients’ final colonoscopy reports and data retrieved from the endoscopy databases. Structured endoscopy reporting and the use of databases facilitate quality assurance but editing of procedure reports after structured data entry compromises accuracy of the data in key quality measures. Inaccurate or incomplete data recording will compromise the enhancements in quality assurance that would accrue otherwise from regular audit processes.