Hermann Hospital Research Articles

Post-Lung Transplantation Outcomes and Ex Vivo Histopathological Findings in Severe Post-Covid-19 Pulmonary Disease-A Single-Center Experience.

BackgroundA significant proportion of patients with severe and persistent coronavirus disease 2019 (COVID-19) require continuous ventilatory support and occasional extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS). Lung transplantation is a treatment option for patients who develop severe ARDS.MethodsOur lung transplant database was retrospectively reviewed for patients who underwent lung transplantation for COVID-19 pulmonary disease at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas, from January 2020 to March 2022. We evaluated outcomes of patients who were followed in our clinic at least 6 months post-transplant. Pretransplant patient characteristics, COVID-19-related treatment, histopathology results, and postdischarge course were evaluated.ResultsAmong a total of 13 lung transplant recipients, 6 consecutive patients were identified who had a minimum of 6 months of follow-up post–lung transplantation. The average age of patients was 55 years, with a male predominance. The median time to transplantation was 111 days. All 6 patients had significant postinfectious complications due to COVID-19 before transplant. Histopathological findings from explanted lungs showed a predominance of fibrotic change. There were no reported cases of rejection or graft dysfunction. 5 patients had minimal to no post-transplant infectious complications. One patient died 218 days post-transplant from infectious complications.ConclusionsFive out of six lung transplant recipients at our institution have demonstrated excellent long-term outcomes after index hospitalization, for a mean follow-up of 13 months post–lung transplantation. Lung transplantation for lung fibrosis due to COVID-19 is an acceptable salvage treatment option. Larger studies are warranted to confirm these findings.

Renal cell carcinoma in renal transplant recipients: Is there a role for screening?

10528 Background: Renal transplant (RT) recipients are at an increased risk of developing renal cell carcinoma (RCC), mainly due to iatrogenic immunosuppression and changes in immune surveillance. Most RCCs in RT recipients arises from the native kidney, but rarely may arise from the allograft. RCC post-RT can adversely affect allograft function and long-term survival. Screening for RCC in RT recipients is controversial and is not routinely done. Methods: We performed a retrospective chart review of RT recipients who underwent transplantation between January 1, 1999, and December 31, 2019. The following data were collected: Baseline demographic variables, cause of end-stage renal disease (ESRD), duration of dialysis prior to RT, type of RT (cadaveric vs. living donor), immunosuppressive regimen, site of RCC (native kidney vs transplanted kidney), time from RT to diagnosis of RCC, stage and Fuhrman grade, tumor histology, RCC treatment, and RCC-related mortality. RCC stage at diagnosis and survival were compared between patients who were screened versus those who were not. Results: Among 1998 RT recipients who underwent transplantation at Memorial Hermann Hospital (MHH) Texas Medical Center (TMC); 16 patients (0.8%) developed RCC. An additional 4 patients with RCC who underwent RT elsewhere but received follow up at MHH TMC were also included. Therefore, a total of 20 patients with post-RT RCC were identified, of whom 75% were men. Subject races included White (20%), Black (50%), Hispanic (20%), and Asian (10%). The median age was 56 years. Median duration of dialysis prior to RT was 36 months (range, 1–120). Median time to RCC diagnosis post-RT was 96 months (range, 16–312). Histologies included clear cell (75%), papillary (20%), and chromophobe (5%) RCC. RCC developed in the native kidney in 60% and in the allograft in 40% of the patients. Post-RT RCC patients were divided into those who underwent regular screening (n = 12) and no screening (n = 8). The regular screening group (n = 12) underwent ultrasound or computerized tomography annually or every 2 years. All of these patients had early-stage disease at presentation: stage I (n = 11) or II (n = 1). All patients who had RCC detected by screening were cured by nephrectomy (n = 10) or cryotherapy (n = 2). In patients who had no screening post RT, 37.5% had stage I, 25% had stage III, and 37.5% had stage IV RCC. Two patients with stage IV RCC died from metastatic disease. The RCC-related mortality was 0% in patients who were screened, compared to 25% in patients who had no screening. Conclusions: All RT recipients who had RCC diagnosed based on screening had an early diagnosis and no RCC-related mortality. Screening for RCC in RT recipients is an effective tool for early diagnosis and to reduce RCC-related mortality. Further research into the cost-effectiveness of screening is imperative.

Induction mortality (IM) of acute myeloid leukemia (AML) patients treated with purine analogues-cytarabine-anthracycline at a general hospital.

e19019 Background: Cytarabine-anthracyclines (7+3) induction chemotherapy (IC)) has been the mainstay therapy for over four decades and it remains the standard AML IC regimen internationally. Triplet IC using purine analogues (fludarabine/cladribine) in combination with cytarabine and idarubicin (FIA/CLIA) is superior to the standard 7+3 regimen, but challenging to administer in general hospital settings due to myelosuppression. We reviewed AML IM rate in patients induced with (fludarabine/cladribine) combined with cytarabine and idarubicin (FIA/CLIA) at Memorial Hermann Hospital, Texas Medical Center (MHH at TMC). Patients and Methods: Of 44 AML reviewed records from January 2013 to January 2022, 40 received 5 days FIA/CLIA IC, and four 3-4 days due to age and comorbidities. For clinical characteristics see Table. Results: Median age was 51.5 years (range: 18-68). Three died before assessment. After 1 cycle the composite CR (CR+ CR i) was 82.9% (34/41) and 87.8% (36/41) after 2 cycles. MRD negative composite CR was 92%. Four patients had adverse risk cytogenetics and primary induction failure (modified FIA). 37% had febrile neutropenia. 25% had bacteremia with 15% requiring ICU admission and 4% mechanical ventilation. The 30-day induction mortality was 9%. Conclusions: FIA/CLIA has a higher CR rate than ‘3+7’ (which historically is 60%). The 30-day induction mortality in non-academic centers is about 30%. Given the fact that in AML achieving a CR is the most important factor to improve survival, with adequate treatment expertise, triplet IC regimen can be safely administered with a low induction mortality. [Table: see text]

External Validation of a Laboratory Prediction Algorithm for the Reduction of Unnecessary Labs in the Critical Care Setting

BackgroundUnnecessary laboratory tests contribute to iatrogenic harm and are a major source of waste in the health care system. We previously developed a machine learning algorithm to help clinicians identify unnecessary laboratory tests, but it has not been externally validated. In this study, we externally validate our machine learning algorithm. MethodsTo externally validate the machine learning algorithm that was originally trained on the Medical Information Mart for Intensive Care (MIMIC) III database, we tested the algorithm in a separate institution. We identified and abstracted data for all patients older than 18 years admitted to the intensive care unit at Memorial Hermann Hospital in Houston, Texas (MHH) from January 1, 2020 to November 13, 2020. Using the transfer learning style, we performed external validation of the machine learning algorithm. ResultsA total of 651 MHH patients were included. The model performed well in predicting abnormality (area under the curve [AUC] 0.98 for MIMIC III and 0.89 for MHH). The model performed similarly in predicting transitions from normal laboratory range to abnormal (AUC 0.71 for MIMIC III and 0.70 for MHH). The performance of the model in predicting the actual laboratory value was also similar in the MIMIC III (accuracy 0.41) and MHH data (0.45). ConclusionsWe externally validated the machine learning model and showed that the model performed similarly, supporting the generalizability to other settings. While this model demonstrated good performance for predicting abnormal labs and transitions, it does not perform well enough for prediction of laboratory values in most clinical applications.

Back to the Beginning: An Algorithmic Approach to Neonatal Myelomeningocele Repair.

Myelomeningoceles are formed by prenatal failure of neural tube closure and can cause hydrocephalus, motor abnormalities, and developmental delay. Although small defects are amenable to primary closure, larger defects often require complex reconstruction. Our goal was to identify factors associated with postoperative soft tissue complications and develop a systematic approach for myelomeningocele closure. A retrospective review was performed at the Children's Memorial Hermann Hospital from January 2013 to January 2019. Patients were identified using International Classification of Diseases, Ninth Revision/Tenth Revision , codes for myelomeningocele. Cohorts were stratified by reconstruction type and defect location. Primary outcomes were incidence of complications including cerebrospinal fluid leak, superficial and deep infection, and wound dehiscence. In addition, we developed an algorithm to standardize closure approach for patients with myelomeningoceles. A total of 172 patients with myelomeningocele were identified with 73 patients undergoing postnatal repair. Overall, 72% of defects were >5 cm. Defects were in the lumbar (9%), sacral (8%), and junctional (83%) regions. Overall, 30.1% patients underwent lumbar myofascial repair with 39.7% requiring fasciocutaneous flaps. Larger defects (>5 cm) were more likely to be closed with complex fasciocutaneous flaps (82.8% vs 66.0%, P = 0.11). No significant differences were observed in complication rates. In this series, patients with larger myelomeningoceles appear to benefit from complex flap closure. We propose a 5-layer closure for patients with myelomeningocele including the routine use of a myofascial layer. Cutaneous closure technique should be tailored based on specific defect characteristics as outlined in our algorithm. This approach streamlines myelomeningocele repair while optimizing outcomes and decreasing downstream complications.

182. Clinical Presentation of Patients with Staphylococcus lugdunensis Positive Blood Cultures After the Implementation of Rapid Molecular Blood Culture Diagnostics

BackgroundSince the implementation of improved laboratory techniques, coagulase negative Staphylococcus (CoNS) have been routinely speciated to screen for S. lugdunensis (SL), which has led to increased identification. The objective of this study is to describe the characteristics of patients with SL positive blood cultures after the introduction of Verigene® Gram-Positive Blood Culture Nucleic Acid Test (BC-GP) in two large medical systems.MethodsRetrospective review of all blood culture isolates positive for SL from Memorial Hermann Hospital System (14 hospitals) and HarrisHealth System (two acute care hospitals) since implementation of BC-GP.ResultsBetween 2017 – 2021, 157 patients had SL positive blood cultures. 18 were eliminated as cultures were positive for bacteria other than CoNS, and 7 eliminated as patients were discharged prior to culture results. Of the remaining 132 patients, 39 (29.5%) were labelled contaminants by the treating physician and 93 were considered true bacteremia. Patients with hardware/implanted materials were more likely considered to have true bacteremia, while patients with other CoNS species in blood cultures were more likely considered contaminants. Only one death was attributed to SL bloodstream infection in the true bacteremia group. None of the deaths in the contaminated group were attributed to SL infection. Of the 93 patients labelled true bacteremia, the source was most frequently listed as central line associated bloodstream infection (17.2%), followed by skin/soft tissue infection (11.8%), and infective endocarditis (IE) (10.8%).Table 1. Characteristics of Patients with S. lugdunensis Positive Blood Cultures ConclusionIn our study, 29% of patients with positive blood culture for SL were deemed contaminants. Patients without hardwares or positive concomitant other CoNS species from the same blood culture were often considered as contaminated cases. The incidence of IE remains as high as 10.8% in those patients identified to have true bacteremia (7.6% overall in our cohort), although lower than previously reported cases. Careful evaluation is warranted in patients with positive SL blood culture to rule out severe infections and avoid unnecessary courses of antibiotic therapy. This study suggests that increased identification of SL may impact our understanding of its significance and pathogenicity over time.Disclosures All Authors: No reported disclosures

194. Antimicrobial Susceptibility Data of Staphylococcus lugdunensis After the Implementation of Rapid Molecular Blood Culture Diagnostics (Verigene® Gram-Positive Blood Culture Nucleic Acid Test)

Abstract Background S. lugdunensis is a coagulase negative staphylococci (CoNS) demonstrating high level pathogenicity. In contrast to other CoNS, S. lugdunensis (SL) remains susceptible to most antibiotics. Prior to the implementation of Verigene®, SL was identified by provider request only. We sought to describe the susceptibility data of SL isolated from blood culture after the implementation of multiplex PCR, as well as to determine the correlation of the mecA gene provided by Verigene® and oxacillin resistance. Methods Retrospective review of all blood culture isolates positive for SL from two major hospital systems, Memorial Hermann Hospital System (14 hospitals) and HarrisHealth System (two acute care hospitals) identified on Verigene® PCR. Multiple isolates detected from the same patients were excluded from this analysis. Memorial Hermann utilized Microscan®, and HarrisHealth utilized BD Phoenix® for susceptibility testing. Results Between 2017 – 2021, 157 patients were identified with SL positive blood cultures. Of them, 141 isolates had susceptibility data collected, which is summarized in table 1. Resistance rates were highest amongst clindamycin 97/141 (68.8 %) susceptible, erythromycin 98/141 (69.5%) susceptible, and oxacillin 120/141 (85.1%) susceptible. 127/141 (90.1%) of isolates were tested for mecA on Verigene®. 13 of 21 oxacillin resistant isolates were from pure culture, of these isolates, none had mecA detected. Conclusion In our study, clindamycin and erythromycin demonstrated similar susceptibility compared to prior studies in the literature, however oxacillin susceptibility rate was lower than expected at 85.1%, compared to 95.3% in a prior large-scale United States based study in 2017. Absence of mecA gene detection on multiplex PCR did not correlate with oxacillin susceptibility suggesting that oxacillin susceptibility cannot be accurately predicted by the use of multiplex PCR systems, such as Verigene®, as demonstrated in Table 2. Our study also suggested that increased prevalence of oxacillin resistant SL isolates may be emerging. Disclosures All Authors: No reported disclosures

845. Impact of the COVID-19 Pandemic on Routine HIV Screening in an Emergency Department

BackgroundThe Emergency Department (ED) at Memorial Hermann Hospital (MHH) - Texas Medical Center (TMC), Houston, Texas has a long established screening program targeted at detection of HIV infections. The impact of the COVID-19 pandemic on this screening program is unknown.MethodsThe Routine HIV screening program includes opt-out testing of all adults 18 years and older with Glasgow score > 9. HIV 4th generation Ag/Ab screening, with reflex to Gennius confirmatory tests are used. Pre-pandemic (March 2019 to February 2020) to Pandemic period (March 2020 to February 2021) intervals were compared. Results72,929 patients visited MHH_ED during the pre-pandemic period and 57,128 in the pandemic period, a 22% decline. The number of patients tested for HIV pre-pandemic was 9433 and 6718 pandemic, a 29% decline. When the pandemic year was parsed into first and last 6 months interval and compared to similar intervals in the year pre pandemic, 39% followed by 16% declines in HIV testing were found. In total, 354 patients were HIV positives, 209, (59%) in the pre-pandemic and 145 (41%) in the pandemic period.The reduction in new HIV infections found was directly proportional to the decline in patients visiting the MHH-ED where the percent of patients HIV positive was constant across intervals (2.21% vs 2.26%). Demographic and outcome characteristics were constant across the compared intervals.ConclusionThe COVID -19 pandemic reduced detection of new HIV infections by screening in direct proportion to the reduction in MHH-ED patient visits. The impact of COVID-19 pandemic decreased with duration of the pandemic.Disclosures All Authors: No reported disclosures

63. PK-RNN-V: A Deep Learning Model for Vancomycin Therapeutic Drug Monitoring using Electronic Health Record Data

BackgroundTherapeutic drug monitoring (TDM) for vancomycin (VAN) with Bayesian models is recommended by national guidelines. However, limited data incorporating the models may hurt the performance. Our aim is to develop a novel deep learning-based pharmacokinetic model for vancomycin (PK-RNN-V) using electronic medical records (EHRs) data to achieve more accurate and personalized predictions for VAN levels.MethodsEHR data were retrospectively retrieved from Memorial Hermann Hospital System, comprising 14 hospitals in the greater Houston area. All patients who received VAN and had any VAN levels were eligible. Patients receiving hemodialysis and extracorporeal membrane oxygenation were excluded. Demographic data, vital signs, diagnostic codes, concomitant medications, VAN administration, and laboratory data were preprocessed as longitudinal data. VAN infusion, VAN level measurement, or each hospital day were the time steps for the models. The dataset was splited 70:15:15 for training, validation, and test sets. Our PK-RNN-V model predicted individual patient volume distribution (v) and VAN elimination (k) at each time step using an irregular timesteps GRU model. To compare, Bayesian models were developed from publicly available models, and tuned to feedback the first VAN level to update the v and k. (VTDM)ResultsA total of 12,258 patients with 195,140 encounters were identified from Aug, 2019 and March, 2020. After exclusion of 6,775 patients, 5,483 patients with 8,689 encounters were included. Table 1 summarized the characteristics of patients included in our study. 55,336 doses of VAN were administered with a median dosage of 1.0 gm. VAN levels were measured 18,588 times at various timings. The median VAN level was 14.7 mcg/mL Table 2 described the performance of our models and VTDM models. Our model exhibited better performance compared to VTDM model (RMSE: 5.64 vs. 6.57, respectively). Figure 1 shows example prediction curves of VAN levels from each model. ConclusionPK-RNN-V model is a novel approach to predict patient PK and VAN levels. Our results revealed promising performance of this model. Our model can take a wide range of real-world patient data into the model. Further studies are warranted for external validations and model optimizations. Disclosures All Authors: No reported disclosures

Study of Pediatric Operative Recreational Trauma: A Retrospective Analysis of Pediatric Sports-Related Facial Fractures.

In the United States, most school-aged children participate in some form of organized sports. Despite the advantages to social and physical development that organized sports may have, these activities also place a significant number of America's youth at risk for facial injuries. Pediatric facial fractures resulting from sports trauma are well documented within pediatric literature. Despite knowledge of the importance of safety equipment, there is a continued need for increased awareness about fracture patterns resulting from sports injuries to develop better strategies for their prevention. A retrospective review of all pediatric patients (age <18) who presented to Children's Memorial Hermann Hospital as a level 1 trauma between January 2006 and December 2015 with radiologically confirmed facial fractures was performed. Data regarding patient demographic information, mechanism of injury, facial fracture location, associated injuries, hospital course, and need for surgical intervention was collected. Of the 1274 patients reviewed, 135 (10.59%) were found to have facial fractures resulting from sports trauma and were included in our cohort. The median age was 14 with 77.8% of the cohort being male. The most common fractures identified were orbital (n = 75), mandibular (n = 42), nasal (n = 27), maxilla (n = 26). Fractures were more frequently related to involvement in baseball/softball and bicycling n = 46 and n = 31 respectively. Eighty-two (60.74%) patients required admission, 6 requiring ICU level care, 70 (51.85%) were found to require surgery. There were 14 patients who were found to have a concomitant skull fracture and 6 with TBI. There were no fatalities in this cohort of patients. Pediatric facial fractures occur in the same anatomic locations as adult facial fractures. However, their frequency, severity, and treatment vary because of important anatomical and developmental differences in these populations. Despite available knowledge on this subject and increased use of protective equipment, pediatric facial fractures continue to occur with similar distribution as historically described. While sports participation confers numerous benefits, it is vital that we continue researching pediatric facial trauma and associated fractures to develop protective equipment and protocols to mitigate the risks of these activities.

Trajectories of Children's Executive Function After Traumatic Brain Injury

Executive functions are critical for school and social success. Although these functions are adversely affected by pediatric traumatic brain injury (TBI), recovery patterns are not well established. To examine 3-year trajectories of selected children's executive functions after TBI. This prospective cohort study was conducted from January 22, 2013, to September 30, 2015, with 3-year follow-up at the level I pediatric trauma centers Primary Children's Hospital in Salt Lake City, Utah and Children's Memorial Hermann Hospital in Houston, Texas. Study participants included children aged 2 to 15 years with TBI or orthopedic injury (OI) who were treated at the participating hospitals. Children were consecutively recruited and stratified by injury severity and age group. A total of 625 children consented and completed a baseline survey; 559 (89%) children completed at least 1 follow-up and composed the analysis cohort. It was hypothesized that recovery would differ by injury severity, age at injury, and sex. Data analyses were performed from June to October 2019. Growth curve models examined the pattern of change in the Emotional Control, Inhibit, Working Memory, and Plan-Organize subscales of the Behavior Rating Inventory of Executive Function (BRIEF) or BRIEF-Preschool. For all BRIEF subscales, higher scores indicate worse symptoms, and a score of 65 or greater represents clinical impairment. A total of 559 children (mean [SD] age, 8.6 [4.4] years; 356 boys [64%], 328 non-Hispanic White children [59%]) were included in the study: 155 (28%) children had mild TBI, 162 (29%) had complicated mild or moderate TBI, 90 (16%) had severe TBI, and 152 (27%) had OI. Growth curve trajectories varied by BRIEF subscale and injury severity. Overall, children with TBI did not return to their preinjury baseline, with a stepwise worsening of each outcome at 36 months by TBI severity compared with OI. Among children with severe TBI, trajectories accelerated fastest, indicating increased problems, from injury to 12 months for the Emotional Control (9.0 points; 95% CI, 6.0-11.9 points), Inhibit (3.6 points; 95% CI, 1.6-5.6 points), and Working Memory (7.0 points; 95% CI, 4.1-9.9 points) subscales. Their trajectories plateaued, with a secondary acceleration before 36 months for the Emotional Control and Working Memory subscales. Children with mild TBI had worse 36-month scores on all subscales except Inhibit compared with OI. Recovery patterns were similar for boys and girls. In this longitudinal cohort study of children with TBI, trajectory analysis revealed that some children worsen after a recovery plateau, suggesting a need for longitudinal reassessment beyond 1 year postinjury.

Hospital Consultation From Outpatient Clinicians for Medically Complex Children

Children with medical complexity (CMC) frequently experience fragmented care. We have demonstrated that outpatient comprehensive care (CC) reduces serious illnesses, hospitalizations, and costs for high-risk CMC. Yet continuity of care for CMC is often disrupted with emergency department (ED) visits and hospitalizations. To evaluate a hospital consultation (HC) service for CMC from their outpatient CC clinicians. Randomized quality improvement trial at the University of Texas Health Science Center at Houston with an outpatient CC clinic and tertiary pediatric hospital (Children's Memorial Hermann Hospital). Participants included high-risk CMC (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrolling in our clinic) receiving CC. Data were analyzed between January 11, 2018, and December 20, 2019. The HC included serial discussions between CC clinicians, ED physicians, and hospitalists addressing need for admission, inpatient treatment, and transition back to outpatient care. Usual hospital care (UHC) involved routine pediatric hospitalist care. Total hospital days (primary outcome), PICU days, hospitalizations, and health system costs in skeptical bayesian analyses (using a prior probability assuming no benefit). From October 3, 2016, through October 2, 2017, 342 CMC were randomized to either HC (n = 167) or UHC (n = 175) before meeting the predefined bayesian stopping guideline (>80% probability of reduced hospital days). In intention-to-treat analyses, the probability that HC reduced total hospital days was 91% (2.72 vs 6.01 per child-year; bayesian rate ratio [RR], 0.61; 95% credible interval [CrI], 0.30-1.26). The probability of a reduction with HC vs UHC was 98% for hospitalizations (0.60 vs 0.93 per child-year; RR, 0.68; 95% CrI, 0.48-0.97), 89% for PICU days (0.77 vs 1.89 per child-year; RR, 0.59; 95% CrI, 0.26-1.38), and 94% for mean total health system costs ($24 928 vs $42 276 per child-year; cost ratio, 0.67; 95% CrI, 0.41-1.10). In secondary analysis using a bayesian prior centered at RR of 0.78, reflecting the opinion of 7 experts knowledgeable about CMC, the probability that HC reduced hospital days was 96%. Among CMC receiving comprehensive outpatient care, an HC service from outpatient clinicians likely reduced total hospital days, hospitalizations, PICU days, other outcomes, and health system costs. Additional trials of an HC service from outpatient CC clinicians are needed for CMC in other centers. ClinicalTrials.gov Identifier: NCT02870387.

Persistence of Late Gadolinium Enhancement on Follow-Up CMR Imaging in Children with Acute Myocarditis.

Cardiac magnetic resonance (CMR) imaging is the gold standard non-invasive test for the diagnosis of acute myocarditis. Late gadolinium enhancement (LGE) on CMR imaging signifies myocardial fibrosis or scar but information on long-termfollow-up in pediatric patients is limited. The aim of this study is to evaluate the persistence of LGE in follow-up CMR imaging and highlight the need for serially following LGE after acute myocarditis in children. A retrospective review of the CMR images in pediatric patients less than 18years of age at Children's Memorial Hermann Hospital was performed from October 31, 2010, to December 31, 2017. The ages of the patients included in the study ranged from 10 to 17years. Out of 34 subjects, 12 subjects had a follow-up CMR imaging after the initial CMR imaging. Cardiac enzymes and inflammatory markers were elevated in all patients on initial presentation with normalization seen for all patients on follow-up testing. Baseline CMR imaging demonstrated depressed function in 50% of patients (6/12) with recovery of biventricular function seen in all except for one patient. LGE was detected in 10 out of 12 patients on baseline CMR and persisted in all on follow--up CMR imaging. Two patients did not have LGE at baseline CMR and had no evidence of LGE at follow-up CMR. Despite resolution of acute myocardial inflammation, LGE persisted in all of our study subjects. There is neither an agreement on time interval to perform follow-up CMR, nor on duration of follow-up. We recommend large-scale prospective CMR study for long-term follow-up evaluation of children after acute myocarditis.

0811 Periodic Limb Movements In Patients With Dysautonomia

Abstract Introduction Periodic Limb Movements in Sleep (PLM) have been thought to result in increase in sympathetic tone in sleep, tachycardia, elevated systolic blood pressure and therefore elevation in risk of cardiovascular disease. However, evidence of a direct causative relationship has been elusive. We discuss the presence of PLM in patients with dysautonomia, proposing that autonomic dysfunction may be either a causative factor for PLM or share common pathogenesis with PLM. Methods Three patients with dysautonomia, referred to the TIRR Memorial Hermann Hospital neurological sleep disorders center with varying sleep-related symptoms were studied with polysomnography, recorded under AASM guidelines. PLM were scored using standard criteria described in the AASM scoring manual. Results The three patients described all carried a diagnosis of dysautonomia, diagnosed by tilt table testing. The first patient was an 18 year old woman with complaints of palpitations during sleep and frequent arousals. Her PLM index was 49.8. Serum ferritin level was pending. The second patient was a 35-year-old woman who complained of nonrestorative sleep. Polysomnogram demonstrated a PLM index of 17.6. Ferritin level was 36 ng/mL. The third patient was a 34-year-old woman with insomnia who was also found to have a PLM index of 15.1. Her serum ferritin level was 24. She underwent therapeutic iron infusions and experienced substantial improvement in subjective sleep quality. None of the patient described symptoms of restless legs syndrome or had any bleeding disorders to explain low ferritin levels. Conclusion The patients described above all were relatively healthy young women with symptoms of dysautonomia and disturbed sleep. It would be unusual for young individuals to present with PLM which are commonly associated with advancing age. In at least one patient, iron infusions improved sleep quality dramatically. Work needs to be done to establish relationship between autonomic imbalance and PLM, suggesting that the previously thought unidirectional relationship, [i.e. PLM causing change in sympathetic tone] may actually be bidirectional. Support None

Abstract WP455: Memorial Hermann Hospital System Stroke Coordinators: Working as One

Background: Many hospital stroke programs fail to meet or maintain the certification requirements of The Joint Commission (TJC) as a Primary Stroke Center (PSC) or Comprehensive Stroke Center (CSC). The most common reason is the absence of a dedicated stroke program coordinator. There are opportunities for improvement to promote stroke coordinator growth and retention. Purpose: We created The Memorial Hermann Hospital System Stroke Coordinator Alliance to combine resources, reduce workload, and support stroke coordinators in order to promote adherence to best practice and maintain TJC stroke certification. Methods: The Memorial Hermann Hospital System Stroke Coordinator Alliance was developed in 2015. It includes 14 nurses who represent 11 acute care hospitals within a large hospital system in Houston (Figure1). Four of the hospitals are CSCs, five are PSCs, and two are not certified. Monthly meetings are conducted to create standardized access to resources, stroke coordinator orientation, education, medical power plans, process improvement, and data development. Coordinator work groups, a central email and shared drive, biweekly data meetings, and a buddy system were created to reduce work load, improve electronic communication, and streamline data review procedures. A partnership was created to onboard new coordinators and to prepare for mock and real time survey visits. In 2018 data abstraction was standardized across hospitals with use of a homegrown database Stroke Program Registry (REGIS). Results: Of the 14 Stroke Coordinators in place during fiscal years 2015 - 2019, retention was 100%. A total of 19 stroke surveys were completed and recognized as successful by The Joint Commission. A total of 17,148 stroke patients were received with PSC measures averaging greater than 95% and CSC measures above 90%. Conclusion: Implementing program development support for stroke coordinators improves retention and quality care in a high volume stroke system.

Clinical Characteristics and Long-Term Outcomes of Midaortic Syndrome

Midaortic syndrome (MAS) is a rare congenital or acquired condition marked by segmental or diffuse stenosis of the distal thoracic and/or abdominal aorta and its branches. The optimal approach to medical or interventional management of MAS and long-term outcomes in adults are not well defined. We reviewed MAS cases to characterize the natural history of aortic disease, identify prognostic factors, and evaluate the durability of invasive interventions. We conducted a retrospective review of patients with MAS who presented to Memorial Hermann Hospital and Baylor College of Medicine between 1997 and 2018. We categorized cases according to demographic and clinical manifestations, etiologies, the extent of aortic involvement, interventions, and vascular outcomes. We identified a cohort of 13 patients with MAS. The etiology of MAS was identified in 6 cases, including genetic syndromes (neurofibromatosis type 1 (2/13), Williams syndrome (1/13), fibromuscular dysplasia (2/13), and Takayasu arteritis (1/13)). Mean age at first documented clinical event was 25.2 (2-67) years, but cases with genetic etiologies presented significantly younger (18.2years). The most common primary anatomic site was the suprarenal and infrarenal aorta (zones 5-8). Extra-aortic locations involved the renal (4/13), celiac (3/13), and superior mesenteric (3/13) arteries. Clinical manifestations included hypertension (13/13), claudication (9/13), and postprandial abdominal pain (5/13). All patients with available follow-up data underwent at least one surgical or endovascular intervention (range: 1-8). Postoperative complications included renal failure requiring postdischarge hemodialysis and respiratory failure. There were no deaths in long-term follow-up. MAS is a complex vasculopathy with substantial variability in clinical presentation and anatomic distribution. Extensive disease frequently requires multiple invasive interventions and results in refractory hypertension, which may predict subsequent clinical events. A multidisciplinary approach with long-term monitoring is essential for preservation of end-organ function and quality of life in this debilitating disease.

Improving Care of Pediatric Behavioral Health Patients and Employee Safety through Quality Collaborative Participation

Background: With limited behavioral health placements, our hospital houses behavioral health patients for extended periods of time. Without a dedicated behavioral health unit and full-time behavioral health staff members, there was no consistent process for the management and care of pediatric behavioral health patients in our facility, a children’s hospital within an adult hospital, within a larger system. This led to patient and employee harm. A review of employee injury reports and days away restricted/transferred (DART) events related to behavioral patients found 5 total reports, 2 DART events, 64 lost days, and 146 restricted days (210 DART days total) between June 2017 and June 2018 (Fig. 1). Methods: Our interdisciplinary behavioral health team created a standardized room safety/preparation checklist, established a template and process for daily individualized safety plans based on the patient’s assigned safety classification, and developed a formalized process for the management of these patients. The facility also supported de-escalation training for all pediatric staff members, providing additional behavioral health education and resources for pediatric nurses and providers. Simultaneously, our facility joined the SPS Employee/Staff Safety: Patient Behavioral Events group. This provided a venue to share our progress and learn from other organizations. Results: After the process rollout in June 2018, 91% of behavioral health patients had individualized safety plans created, ensuring continuity between caregivers and as patients transfer units, and no serious patient harm has been reported. Postintervention employee injury report and DART results between June 2018 and June 2019 were 11 reports received, 1 DART event, 3 lost days, and 28 restricted days (31 DART days total) (Fig. 1). The interdisciplinary team has implemented a process to review pediatric behavioral health cases twice monthly to monitor progress and address opportunities. Our campus adult and system partners have adopted some of these best practices and we continue to share information to spread best practices across both the pediatric and adult population.Fig. 1.: Children's Memorial Hermann Hospital Employee Safety Reported Events and Days Away Restricted/Transferred (DART) Days, June 2017-September 2019/. Graph shows number of events reported per month and number of staff days from work or restricted per month related to violence caused by a behavioral health patient. Preintervention (June 2017 and June 2018), staff reported 5 events, 3 of which were OSHA recordable (TRIR) and 2 of which sustained injuries, resulting in 64 total lost days (days away) and 146 restricted days (210 DART days total). Postintervention between June 2018 and June 2019, 11 event reports were received (a 120% increase). One event was OSHA recordable (a 66% decrease) with the employee reporting sustaining injuries, which resulted in 3 lost days (a 95% decrease), and 28 restricted days (an 80% decrease), for a total of 31 DART days reported (an 80% decrease). CMHH, Children's Memorial Hermann Hospital; DART, days away restricted/transferred; OSHA, Occupational Safety and Health Administration; TRIR, Total Recordable Incident Rate.Conclusions/Implications: Through our safety classification and daily safety plans, we have improved the standardization of care for our behavioral health patients. These interventions have reduced variability in care among caregivers and nursing units and provided a process for providers and nursing staff members to communicate and coordinate care for these patients. Decreased variability and improved coordination of care has led to improved competency in caring for this patient population as evidenced by decreased patient and staff member harm. We learned that data collection and regular retrospective chart audits help ensure compliance and timely course correction, stakeholder buy-in is crucial for a project of this magnitude, and the project must be scoped appropriately to continue moving toward goals.

Accuracy of Published Indications for Predicting Use of Damage Control During Laparotomy for Trauma

BackgroundAlthough studies have identified published indications that experts and practicing surgeons agree indicate use of damage control (DC) laparotomy, it is unknown whether these indications predict use of the procedure in practice. Materials and methodsWe conducted a diagnostic performance study of the accuracy of a set of published appropriateness indications for predicting use of DC laparotomy. We included consecutive adults that underwent emergent laparotomy for trauma (2011-2016) at Memorial Hermann Hospital. ResultsWe included 1141 injured adults. Two published preoperative appropriateness indications [a systolic blood pressure (BP) persistently <90 mmHg or core body temperature <34°C] produced moderate shifts in the pretest probability of conducting DC instead of definitive laparotomy. Five published intraoperative appropriateness indications produced large and often conclusive changes in the pretest probability of conducting DC during emergent laparotomy. These included the finding of a devascularized or completely disrupted pancreas, duodenum, or pancreaticoduodenal complex; an estimated intraoperative blood loss >4 L; administration of >10 U of packed red blood cells (PRBCs); and a systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during operation. Most indications that produced large changes in the pretest probability of conducting DC laparotomy had an incidence of 2% or less. ConclusionsThis study suggests that published appropriateness indications accurately predict use of DC laparotomy in practice. Intraoperative variables exert greater influence on the decision to conduct DC laparotomy than preoperative variables, and those indications that produce large shifts in the pretest probability of conducting DC laparotomy are uncommonly encountered.

1407. Potential Impact of the Biofire® Film Array Meningitis and Encephalitis (ME) Panel in Reducing Repeat Lumbar Punctures in Patients with Meningitis and Encephalitis

BackgroundThe Biofire® FilmArray Meningitis Encephalitis (FAME) is a multiplex polymerase chain reaction (PCR) test can rapidly detect up to 14 pathogens that cause meningitis and encephalitis. The impact on preventing repeat lumbar punctures to obtain more diagnostic studies is currently unknown.MethodsPatients admitted to Memorial Hermann Hospital (MHH) between July 2018-February 2019 with community-acquired symptoms of meningitis or encephalitis, CSF with white blood cell count >5 cells/mm3, and with leftover CSF at the MHH microbiology laboratory were eligible for the study. Testing FAME was performed after discharge for specimens that had not been centrifuged, had a volume of ≥200 μL, were appropriately stored, and were collected by lumbar puncture (LP) for evaluation of suspected meningitis/encephalitis.ResultsOf 1,382 CSF specimens screened, 70 (5.0%) met the criteria and were tested with FAME. The majority was adults (72.8%), non-Caucasian (68.6%), male (60%), immunocompetent (75.7%) and had a meningitis presentation (75.7%). Mean age was 36.9 years (1 mo-89 years). The mean duration between CSF collection and any PCR result done in the hospital was 60 hours. Fifteen patients (21.4%) required 25 repeat LPs [13 (86.6%) for additional testing (7 (53.8%) pediatric patients) and 2 (13.3%) for cryptococcal meningitis assessment]. The FAME could have prevented repeat LPs in 86.6% of patients. Five of the 13 repeat LP (38.4%) FA ME showed a pathogen [VZV (2), HSV 1 (1), HHSV-6 (1), Neisseria meningitidis (1)]. Of 46 tests with negative FA ME, acyclovir therapy was started in 22 (47.8%) with a mean of 6 doses dispensed. 38 (26.6%) patients were discharged with an unknown etiology of whom FA ME was positive in 8 (21%) [HSV2 (37.5%), VZV (25%), Enterovirus (25%) and HSV1 (12.5%)]. PCR was ordered in the hospital for only 4 (50%) of these patients.ConclusionThe FAME identified an etiology in 21% of patients with meningitis and encephalitis symptoms discharged with an unknown etiology. A total of 18.5% of patients required a repeat LP for additional testing. FAME testing offers an avenue for reducing the burden of repeat LPs and duration of unnecessary anti-infective therapy while increasing diagnostic yield.Disclosures All authors: No reported disclosures.

Utilizing Data to Improve Sepsis Identification in Targeted Populations

Background: Children’s Memorial Hermann Hospital (CMHH) joined the Improving Pediatric Sepsis Outcomes (IPSO) collaborative in July 2016 with successful data importation beginning Summer 2017. At the beginning of the collaborative, generalized triage screening provided a 30% positive screening rate, and the baseline mortality at 30 days per 1,000 admissions for patients admitted from the Emergency Center (EC) to the pediatric intensive care unit was 0.67. Extensive data analysis revealed that 37% of the patients seen in the emergency department with intent to treat and 100% of attributable deaths related to sepsis at CMHH were identified as complex chronic children who were technology dependent. Methods: Based on the collected data and variable regression analysis utilizing Six Sigma methodology, the problem was defined as the risk for sepsis in the chronic complex patient population who are technology dependent indicated the need for accurate screening. As part of the IPSO collaborative goals of increasing early identification, the CMHH IPSO team worked with the EC nurses to create a triage algorithm to improve the identification of sepsis in this population (Fig. 1). Education was done, and Plan–Do–Study–Act cycle implementation began in January 2018 with the final rollout of the algorithm in the EC of March 2018. Results: Accurate screening of this population increased from a mean of 30%–75% after intervention, resulting in a decrease in mortality for inpatients admitted from the EC to the pediatric intensive care unit to zero/1,000 through the last reported data cycle of December 2018 (Fig. 2). Conclusion: Utilization of data analysis resulted in a defined problem and a targeted intervention resulting in the elimination of sepsis attributed mortality in the targeted population.Fig. 1.: Sepsis triage algorithm.Fig. 2.: Sepsis mortalities per 1,000 admissions—day 3.