Health System Hospitals Research Articles

P-1515. Outcomes of Patients with Piperacillin/Tazobactam-Non-Susceptible and Ceftriaxone-Susceptible Enterobacterales Bacteremia

Abstract Background Piperacillin/tazobactam (TZP)-non-susceptible (NS) but third-generation cephalosporin (3GC)-susceptible (S) Escherichia coli and Klebsiella pneumoniae are increasingly reported in the clinical setting. This phenotype is associated with hyperproduction of β-lactamases, including TEM-1 and SHV-1. Tailoring therapy to a 3GC in these cases may decrease carbapenem use and promote antimicrobial stewardship. However, the optimal definitive β-lactam regimen for this phenotype is unknown. This retrospective case series describes the clinical outcomes and antibiotic prescribing in patients with TZP-NS and ceftriaxone (CRO)-S Enterobacterales bacteremia at a three hospital health system. Methods We identified patients >18 years of age hospitalized with TZP-NS and CRO-S E. coli, K. pneumoniae, Klebsiella oxytoca, and Proteus mirabilis bacteremia between February 2020 and March 2024. TZP-NS and CRO-S were defined per the 2024 Clinical and Laboratory Standards Institute (CLSI) susceptibility breakpoints: TZP-S if minimum inhibitory concentration (MIC) ≤ 8/4 mg/L, TZP-NS if MIC ≥ 16/4 mg/L; CRO-S if MIC ≤ 1 mg/L, CRO-NS if MIC ≥ 2 mg/L. We included only the first isolate per patient over the study period. Antibiotic data were collected for each patient during hospitalization. We defined empiric antibiotics as the agents with the longest duration of therapy (DOT) prior to susceptibilities. Composite clinical outcomes were 30-day all-cause mortality, or 30-day readmission/emergency department (ED) visit. Results Thirty-nine patients were included in the study (Table 1). The median number of different antibiotics patients received was 3 (interquartile range [IQR] 2-3), and the median total antibiotic DOT was 14 days (IQR 9.5-17.5 days) (Table 2). Thirteen patients experienced a clinical outcome (33.3%) (Table 3). Of the patients who experienced a clinical outcome, 46.2% (6/13) received ceftriaxone during tailored therapy (median 4.5 days, IQR 3.3-7.3 days). Conclusion In this case series, most patients received TZP empirically but were tailored to CRO upon culture susceptibility availability. Larger studies are necessary to elucidate if ceftriaxone is appropriate for definitive treatment of TZP-NS and CRO-S E. coli, K. pneumoniae, K. oxytoca, and P. mirabilis bacteremia. Disclosures All Authors: No reported disclosures

P-1463. Ceftaroline Versus Vancomycin for the Treatment of Complicated Skin and Soft Tissue Infections (cSSTIs): A Retrospective Cohort Study

Abstract Background Complicated skin and soft tissue infections (cSSTIs) caused by resistant pathogens like methicillin-resistant Staphylococcus aureus (MRSA) require effective treatment. Vancomycin is the standard-of-care for MRSA-associated cSSTIs, but its efficacy is questioned due to poor tissue penetration. Ceftaroline, an anti-MRSA cephalosporin with improved tissue penetration, may offer better outcomes. This real-world study compares the effectiveness of ceftaroline and vancomycin in treating cSSTIs. Methods A multicenter retrospective cohort study was conducted in five Memorial Health System hospitals from 2019-2023. Here we present an interim analysis of 90 patients per arm. Included were adults diagnosed with cSSTIs who received ≥48 hours of ceftaroline or vancomycin treatment and were discharged alive. Exclusions were patients with any concurrent infection at initial diagnosis, infections requiring prolonged therapy, combination therapy, pregnancy, or incarceration. The primary outcome was clinical cure rate. Secondary outcomes were hospital length of stay (LOS), 30-day readmission, 30-day recurrence, time to oral antibiotic switch, and nephrotoxicity. Multivariable logistic regression was used to assess the independent association between ceftaroline therapy and clinical cure, adjusting for confounders. Results Overall, 180 patients were included. For the ceftaroline and vancomycin groups, median (IQR) APACHE scores were 10.5 (6-13.8) and 8 (6-12) (p=0.09), and SOFA scores were 1 (0-2) and 0 (0-1) (p=0.03), respectively. Clinical cure rates were 93.3% for ceftaroline and 88.9% for vancomycin (p=0.43). Multivariate analysis showed ceftaroline is independently associated with clinical cure (p=0.04). For vancomycin and ceftaroline, median (IQR) LOS was 4 days (2-6) versus 10 days (6-14) (p< 0.01), and 30-day readmission rates were 7.8% and 18.9%, respectively (p=0.04). No significant differences in other outcomes were noted. Conclusion Interim analysis shows ceftaroline is associated with numerically higher clinical cure rates than vancomycin, despite higher disease severity in the ceftaroline group. Ceftaroline is an independent predictor of clinical cure. Further investigation is needed to compare the efficacy and safety of both treatments. Disclosures All Authors: No reported disclosures

P-916. Use of BCID2 on CSF in nosocomial CNS surgical site infections

Abstract Background Nosocomial intracranial infections, arising from surgical procedures or neuroinvasive devices like ventricular drains or shunts, present distinct risk factors and microbiologic etiologies compared to community-acquired meningitides. Pathogens typically include Staphylococcus spp., Gram-negative bacilli, and multidrug-resistant bacteria. The current diagnostic standard for nosocomial central nervous system (CNS) infections is cerebrospinal fluid (CSF) Gram stain and culture, but rapid molecular diagnostics could improve diagnosis and treatment, enhancing patient outcomes. This pilot study aimed to assess the validity of the BioFire® Blood Culture Identification Panel 2 (BCID2) panel used for blood culture positivity detection on CSF samples in patients presenting with nosocomial meningitis/ ventriculitis. Sensitivity and specificity were calculated, and patient characteristics and co-morbidities were reviewed. Microbiologic data comparing gold standard Gram stain and culture of CSF to BCID2 result. Methods Patients over 18, admitted to Thomas Jefferson University Health System hospitals between 4/1/2017 to 4/1/2024, were included if meeting Centers for Disease Control (CDC) criteria for intracranial infection or meningitis/ventriculitis. Positive CSF samples (n=30) from 28 patients with nosocomial infections included Gram-positive bacteria (13), Gram-negative bacteria (13), and fungi (4). Positive CSF samples included those positive on culture, while control samples (n=26) had negative cultures or cultures positive for Cutibacterium acnes, an organism not detected by the BCID2 panel. Results Across all positive CSF specimens, sensitivity for organism detection was 76.7%. When culture-positive samples were classified based on Gram Stain, samples with organisms detected on Gram Stain had a sensitivity of 94.7% compared to 45.5% for samples with no organisms seen. For samples with organisms detected on Gram Stain, sensitivity for Gram-negative organisms was 100% and 88.9% for Gram-positive organisms. Among all control specimens, specificity was 100%. Conclusion The ability to rapidly identify a pathogen is crucial for managing nosocomial CNS infections effectively. Our study found that the BCID2 panel offers a promising utility in the detection of nosocomial CNS infections through CSF analysis. Disclosures Matthew Pettengill, PhD, Cepheid: Grant/Research Support

P-406. Implementation of an Initial Specimen Blood Culture Diversion Device to Reduce Blood Culture Contamination: Lessons Learned

Abstract Background Blood culture (BCx) contamination (BCxC) leads to unnecessary antibiotic exposure, increased hospital stay, and cost. Despite best practices, our health system’s BCxC rates remain above the 1% benchmark. Implementation of an initial specimen diversion device (ISDD) have demonstrated reduced BCxC rates. 3,4 We assessed the impact of the Kurin Lock® ISDD on BCxC and vancomycin utilization in adult emergency departments (EDs), intensive care and step-down units (ICU/SD). Methods The Kurin Lock® was implemented in 3 Lifespan health system hospitals (The Miriam Hospital [TMH] ED October2022; Rhode Island Hospital [RIH] and Newport Hospital [NH] EDs January 2023, and in all 3 hospital’s ICU/SD units June 2023). We included adult BCx obtained by nurses (all hospitals) or phlebotomists (NH only). BCx were drawn per protocol; growth was monitored with the BioMérieux VIRTUO System. BCxC rates were calculated dividing the number of contaminated cultures (per CDC NHSN commensal list) by the total number of BCxs/month. Mean BCxC rates prior to Kurin Lock® implementation (6 months) and after implementation (subsequent months through December 2023), excluding the month of implementation, were compared using the Wilcoxon rank-sum test. An interrupted time-series analysis was performed using binomial regression models; vancomycin days of therapy (DOT) for ’bacteremia’ was analyzed using generalized linear models. Results Overall mean BCxC rates for all hospitals and locations decreased from 3% to 1.9% after ISDD implementation (P=0.009). This decline was observed in all EDs but only statistically significant in RIH ICUs/SDs. In the time-series analysis, an abrupt 65% decline in BCxC was observed immediately after implementation in all hospitals and locations (P = 0.04). Lower BCxC rates were sustained after 200 days in the ICUs/SDs and 400 days in the EDs; however, an upward trend was observed with time. Vancomycin DOT was not significantly different pre- vs. post-Kurin Lock® implementation (41/1000 patient days vs. 37/1000 patient days, P=0.9). Conclusion A sustained decline in BCxC is achievable with the Kurin Lock® ISDD in academic and community hospital settings. But consistent education on best practices is key to guarantee the efficacy and cost-effectiveness of this intervention. Disclosures Leonard Mermel, DO, ScM, Citius Pharmaceuticals: Advisor/Consultant|CorMedix Pharma: Advisor/Consultant|Destiny Pharma: Advisor/Consultant|Lightline Medical: Advisor/Consultant|Lightline Medical: Stocks/Bonds (Private Company)|Pristine Access Technologies: Advisor/Consultant|Pristine Access Technologies: Stocks/Bonds (Private Company)

Implementing a letter template to expedite specialty medication appeal letter submission

BackgroundPrior authorizations (PAs) for biologic medications, used to treat inflammatory bowel disease (IBD), are often denied by pharmacy benefits managers and can require a complex appeal process for patients to gain access to medication. ObjectiveThis quality improvement project evaluated the impact of implementing a standardized appeal letter template and customizable clinical rationale letter content on specialty pharmacist workflow and workload in an integrated hospital health system specialty pharmacy (HSSP) IBD clinic. Practice descriptionThis initiative was conducted in an IBD outpatient clinic at a tertiary academic medical center with an integrated HSSP whose specialty pharmacists work collaboratively with providers to manage specialty medications. Practice innovationA letter template was created in the electronic health record (EHR) for pharmacists to use when submitting appeal letters. The template automatically populates patient results from recent labs, imaging, and clinic visit notes as part of the appeal documentation. Clinical rationale letter content was developed for the most common appeal reasons using EHR functionality that allows the creation of standardized notes that can be shared among team members and customized at time of use. Evaluation methodAn analysis of 2 months of data preimplementation/postimplementation was conducted using descriptive statistics to report the number of appeals submitted, time from PA denial to appeal submission, and appeal approval rate. A pharmacist postimplementation satisfaction score was also collected. ResultsThe number of appeals submitted preimplementation (n = 73) and postimplementation (n = 73) was the same. Postimplementation, 89% of appeals were submitted within 3 days of PA denial compared to 29% preimplementation. PA approval rate was high (93%) preimplementation and postimplementation. Overall pharmacist satisfaction was 9.7 out of 10. ConclusionImplementation of an appeal letter template and standardized clinical rationale letter content in the EHR led to decreased time to appeal submission and high specialty pharmacist satisfaction.

Anesthesia Providers' Knowledge of Medication Interference with Hormonal Contraception: A Multisite Survey.

Sugammadex, aprepitant, and fosaprepitant are increasingly used perioperatively. These medications may interfere with the effectiveness of hormonal contraception. This study assessed anesthesia providers' use of sugammadex and aprepitant, their knowledge of interactions with hormonal birth control, and patient counseling practices to identify possible knowledge gaps or opportunities for practice improvement. In January 2023, an electronic survey was distributed to all anesthesia providers at Mayo Clinic sites (Mayo Clinic Rochester, Mayo Clinic Arizona, Mayo Clinic Florida, and Mayo Clinic Health System hospitals). The survey included 32 questions assessing providers' use of sugammadex and aprepitant, their knowledge of the medications' interactions with hormonal contraceptives (HC), their perceptions regarding education of these interactions during training, and their perioperative patient counseling practices. The collected data were analyzed using descriptive statistics. A total of 337 of 1092 (31%) providers completed the survey. While almost all respondents (324; 96%) knew that sugammadex may interfere with oral contraceptive effectiveness, only 158 (47%) knew about aprepitant's potential contraceptive interference. Only 176 providers (52%) knew the recommended duration for alternative contraceptive methods after use after sugammadex, and 119 providers (35%) knew the recommended duration after aprepitant exposure. Most respondents considered the interference of these perioperative drugs with HCs to be clinically relevant (sugammadex, 217, 64%; aprepitant, 191, 58%). Despite the common belief that the decision between these medications and alternatives should be shared between provider and patient, most providers reported rarely engaging in such shared decision-making (SDM) in practice. Most providers recognized the need for preoperative discussions on sugammadex (280, 83%) and aprepitant (257, 76%), yet 184 providers (73%) never or rarely discussed contraception use before surgery for aprepitant, and 135 (36%) never or rarely did so for sugammadex. Lastly, many providers believed that the interference between sugammadex, aprepitant, and HC was poorly taught during training. The results of this study highlight the need for increased education and awareness among anesthesia providers regarding drug interactions with HCs during the perioperative period. To facilitate SDM, it is imperative that providers discuss alternative medications and the potential need for additional contraception methods after drug administration and communicate the risks with patients preoperatively to enable informed and SDM. The patient's preferences should be accounted for, especially if they are unwilling or unable to use an alternative contraceptive for 7 to 30 days, thereby avoiding the complexities and burdens of altering birth control methods.

What Constitutes High Risk for Venous Thromboembolism? Comparing Approaches to Determining an Appropriate Threshold.

Guidelines recommend pharmacological venous thromboembolism (VTE) prophylaxis only for high-risk patients, but the probability of VTE considered "high-risk" is not specified. Our objective was to define an appropriate probability threshold (or range) for VTE risk stratification and corresponding prophylaxis in medical inpatients. Patients were adults admitted to any of 10 Cleveland Clinic Health System hospitals between December 2020 and August 2021 (N = 41,036). Hospital medicine physicians and internal medicine residents from included hospitals were surveyed between June and November 2023 (N = 214). We compared five approaches to determining a threshold: decision analysis, maximizing the sensitivity and specificity of a logistic regression model, deriving a probability from a point-based model, surveying physicians' understanding of VTE risk, and deriving a probability from physician behavior. For each approach, we determined the probability threshold above which a patient would be considered high-risk for VTE. We applied each threshold to the Cleveland Clinic VTE risk assessment model (CCM) and calculated the percentage of the 41,036 patients in our cohort who would be considered eligible for prophylaxis due to their high-risk status. We compared these hypothetical prophylaxis rates with physicians' observed prophylaxis rates. The different approaches yielded thresholds ranging from 0.3% to 5.4%, corresponding inversely with hypothetical prophylaxis rates of 0.2% to 75%. Multiple thresholds clustered between 0.52% to 0.55%, suggesting an average hypothetical prophylaxis rate of approximately 30%, whereas physicians' observed prophylaxis rates ranged from 48% to 76%. Multiple approaches to determining a probability threshold for VTE prophylaxis converged to suggest an optimal threshold of approximately 0.5%. Other approaches yielded extreme thresholds that are unrealistic for clinical practice. Physicians prescribed prophylaxis much more frequently than the suggested rate of 30%, indicating opportunity to reduce unnecessary prophylaxis. To aid in these efforts, guidelines should explicitly quantify high-risk.

Mood stabilizers for treatment of bipolar disorder in pregnancy and impact on neonatal outcomes.

Untreated bipolar disorder in pregnancy is associated with adverse maternal and neonatal outcomes. Despite advances in clinical management, there is concern among obstetric providers and patients about the safety of pharmacological agents for the treatment of bipolar disorder in pregnancy. Recent studies have shown atypical antipsychotics and lamotrigine to have a favorable safety profile; however, little information is published on lurasidone. The objective of this retrospective chart review was to evaluate pregnancy and neonatal outcomes in obstetric patients with bipolar disorder who are untreated, compared to those treated with lurasidone, other atypical antipsychotics, and lamotrigine at a tertiary teaching institution. This retrospective cohort study included neonates whose mothers had a diagnosis of bipolar disorder and were referred to the Maternal & Fetal Care Clinic with two documented visits after January 1, 2014, with delivery by October 31, 2017, within an SSM health-system hospital. In this study, women with untreated bipolar disorder (not on any mood stabilizer) in pregnancy had significantly higher rates of premature delivery and low birth weight compared to women on mood stabilizers of lamotrigine, lurasidone, and other atypical antipsychotics. No difference was observed for pregnancy or neonatal outcomes between patients taking any of the mood stabilizers. This study suggests that the use of lurasidone, other atypical antipsychotics, and lamotrigine have better neonatal outcomes than untreated bipolar disorder in pregnancy.

Observations of Ramadan fasting in the initial year after bariatric surgery

BackgroundRamadan is considered to be the holiest month of the Islamic religion. Hundreds of millions of Muslims practice the commitments of Ramadan, which include the abstinence from eating and drinking during daylight hours. Although there are exemptions to fasting for medical reasons, there is very limited guidance in terms of the safety of fasting in the postoperative period after bariatric surgery. ObjectivesTo assess outcomes and impact of fasting on patients who underwent bariatric surgery within the year leading up to Ramadan 2023. SettingCommunity hospital health system. MethodsRetrospective review of medical records and direct patient contact for 376 study participants. ResultsOf the 376 participants who underwent bariatric surgery in the year before Ramadan, only 8 patients (2.1%) reported they did not intend to fast during Ramadan. Patients who ended up having to break fasting were closer to their surgery date, at 4.3 months from surgery, than patients who were able to fast for the entire month of Ramadan, who were 5.1 months out from surgery. There was no difference between the number of patients needing to break fasting on the basis of what type of bariatric surgery they had performed. The number of patients needing to go to the emergency department and receive intravenous fluids was small, at 11 patients (2.9%), and these patients were also closer to surgery than those not needing to go to the emergency department or receive intravenous fluids. Side effects experienced during Ramadan, including abdominal pain, nausea/vomiting, and hypoglycemia, were more common in patients that were closer to their surgery, notably within 4 months of their surgery date. Patients who lost weight during Ramadan were closer to their surgery date at 4.9 months from surgery compared with those who maintained or gained weight, who were 7.0 months out from surgery. ConclusionsThere are a limited number of studies examining the safety and patient outcomes in those who fast for religious purposes after bariatric surgery. In this study, 376 participants who were within 1 year of undergoing surgery were followed throughout the month of Ramadan. Patients closer to surgery were more likely to break fasting, present to the emergency department, and experience side effects. However, the overall rate of complications was low, suggesting that fasting in the setting of a religious tradition in the carefully chosen patient with counseling and supervision may be a safe option.

The Shoeshine Stand and the Renaissance of Primary Care.

Over the past century, family physicians have moved from small independently owned practices, many of them solo, to being employed by large hospital systems, corporate entities, or health systems. Today, almost three-quarters of all physicians are employed and the highest percentage of employed physicians are family physicians.This essay contrasts the elements of independent practice with employed practice as part of what has been lost in the past half century, but what might be regained if physicians demanded more autonomy and control over their practices.

A One-year Hospital System Review of Plasma Next-Generation Sequencing in a Mixed Population

Objective: To describe whether detecting plasma microbial cell-free DNA by next-generation sequencing (NGS) provided additional information compared to routine cultures or led to change in antimicrobial management. Design and setting: This is a retrospective cohort study evaluating NGS tests performed on patients who were admitted to an 11-acute care hospital health system in the greater Houston area between May 2022 and May 2023. Repeat tests on the same patient encounter were included if >7 days from previous test. Routine microbiology data was compared if test was collected within 7 days before or after NGS testing. Results: During the study period there were 135 unique patient encounters identified with an NGS order. Of which, 74.1% were ≥18 years of age and 46.7% were immunocompromised. A total of 143 NGS tests were ordered, with 4 not being run due to quality control issues. Out of 139 NGS tests completed, 76 (54.7%) were positive for at least one organism. When compared to routine testing, NGS alone was positive in 29 (20.9%) instances, routine testing alone was positive in 17 (12.2%) instances, both were positive in 44 (31.7%) instances, and both were negative in 49 (35.3%) instances. In the 44 instances that both NGS and routine testing were positive, 15 (34.1%) were concordant for all organisms. In total, NGS identified 92 more organisms (69 bacterial, 8 fungal, and 15 viral) compared to routine testing and routine testing identified 42 more organisms (28 bacterial, 6 fungal, 11 viral, and 1 parasite) compared to NGS. Fifty-six changes to antibiotic therapy were made within 48 hours of the NGS test resulting, with 16 of these changes being directly attributed to NGS test. Nine of these changes being escalations and seven being de-escalations. Conclusion: NGS may aid in determining further testing, earlier detection of pathogens, and detection of pathogens outside of routine testing resulting in direct changes to antimicrobials. However, results need to be interpreted with caution. NGS can miss pertinent pathogens and is difficult to interpret when commensal organisms are detected, both of which can lead to unnecessary testing or treatment. There is an absence of a clear algorithm for the use of NGS testing and the test comes with a high price and unclear utility. Further studies are needed to determine which patients may most benefit from NGS testing.

Real-world evaluation of an algorithmic machine-learning-guided testing approach in stable chest pain: a multinational, multicohort study.

An algorithmic strategy for anatomical vs. functional testing in suspected coronary artery disease (CAD) (Anatomical vs. Stress teSting decIsion Support Tool; ASSIST) is associated with better outcomes than random selection. However, in the real world, this decision is rarely random. We explored the agreement between a provider-driven vs. simulated algorithmic approach to cardiac testing and its association with outcomes across multinational cohorts. In two cohorts of functional vs. anatomical testing in a US hospital health system [Yale; 2013-2023; n = 130 196 (97.0%) vs. n = 4020 (3.0%), respectively], and the UK Biobank [n = 3320 (85.1%) vs. n = 581 (14.9%), respectively], we examined outcomes stratified by agreement between the real-world and ASSIST-recommended strategies. Younger age, female sex, Black race, and diabetes history were independently associated with lower odds of ASSIST-aligned testing. Over a median of 4.9 (interquartile range [IQR]: 2.4-7.1) and 5.4 (IQR: 2.6-8.8) years, referral to the ASSIST-recommended strategy was associated with a lower risk of acute myocardial infarction or death (hazard ratioadjusted: 0.81, 95% confidence interval [CI] 0.77-0.85, P < 0.001 and 0.74 [95% CI 0.60-0.90], P = 0.003, respectively), an effect that remained significant across years, test types, and risk profiles. In post hoc analyses of anatomical-first testing in the Prospective Multicentre Imaging Study for Evaluation of Chest Pain (PROMISE) trial, alignment with ASSIST was independently associated with a 17% and 30% higher risk of detecting CAD in any vessel or the left main artery/proximal left anterior descending coronary artery, respectively. In cohorts where historical practices largely favour functional testing, alignment with an algorithmic approach to cardiac testing defined by ASSIST was associated with a lower risk of adverse outcomes. This highlights the potential utility of a data-driven approach in the diagnostic management of CAD.

Music during cataract surgery: effect on anxiety.

To determine the effect of playing patient-selected music intraoperatively on patient self-reported anxiety and the amount of sedative administered during cataract surgery. Yale New Haven Hospital health system, New Haven, Connecticut. Prospective, randomized, controlled clinical trial. Patients were randomized to either a music group or a control group, which had no music played. Patients were blinded to the purpose of the study. On postoperative day 1, patients were consented to participate in the study and asked to complete a 6-question Likert-style survey (modified from the State-Trait Anxiety Inventory) assessing anxiety at baseline and during surgery. Patients' intraoperative and postoperative vitals were recorded. The medication, dosage, and number of sedative injections given were also recorded. Paired t tests were used to assess for significant differences between the 2 groups. 107 patients (mean age 71.2 years) were enrolled in the study. There was no significant difference in baseline anxiety between the 2 groups. Patients randomized to the music group had significantly lower total self-reported anxiety (mean 5.98) than the control group (mean 7.13, P = .006). Moreover, patients exposed to music felt significantly less frightened, nervous, and confused during surgery ( P = .002, .007, and 0.017, respectively). There was no significant difference between the groups in number and dosage of sedatives given. Playing patient-selected music during cataract surgery is an effective way to decrease anxiety. Music directly affects patient experience and is an inexpensive, low-risk method of reducing patient anxiety during surgery.

Postoperative haemoglobin and anaemia-associated ischaemic events after major noncardiac surgery: A sex-stratified cohort study

Study objectiveTo determine the sex-specific associations between postoperative haemoglobin and mortality or complications reflecting ischaemia or inadequate oxygen supply after major noncardiac surgery. DesignA retrospective cohort study with prospective validation. SettingA large university hospital health system in China. PatientsMen and women undergoing elective major noncardiac surgery. Interventions and measurementsThe primary exposure was nadir haemoglobin within 48 h after surgery. The outcome of interest was a composite of postoperative mortality or ischaemic events including myocardial injury, acute kidney injury and stroke within hospitalisation. Main resultsThe study included 26,049 patients (15,757 men and 10,292 women). Low postoperative haemoglobin was a strong predictor of the composite outcome in both sexes, with the risk progressively increasing as the nadir haemoglobin concentration dropped below 130 g l−1 in men and 120 g l−1 in women (adjusted odds ratio [OR] 1.43, 95% CI 1.37–1.50 in men, and OR 1.45, 95% CI 1.35–1.55 in women, per 10 g l−1 decrease in postoperative nadir haemoglobin). Above these sex-specific thresholds, the change of nadir haemoglobin was no longer associated with odds of the composite outcome in either men or women. There was no significant interaction between patient sex and the association between postoperative haemoglobin and the composite outcome (Pinteraction = 0.673). Validation in an external prospective cohort (n = 2120) with systematic postoperative troponin and creatinine measurement confirmed our findings. ConclusionsPostoperative haemoglobin levels following major noncardiac surgery were nonlinearly associated with ischaemic complications or mortality, without any clinically important interaction with patient sex.

Short-chain fatty acids of various lengths differentially inhibit Klebsiella pneumoniae and Enterobacteriaceae species.

The gut microbiota is inextricably linked to human health and disease. It can confer colonization resistance against invading pathogens either through niche occupation and nutrient competition or via its secreted metabolites. Short-chain fatty acids (SCFA) are the primary metabolites in the gut as a result of dietary fiber fermentation by the gut microbiota. In this work, we demonstrate that the interaction of single-species gut commensals on solid media is insufficient for pathogen inhibition, but supernatants from monocultures of these commensal bacteria enriched in acetate confer inhibition against anaerobic growth of the enteric pathogen Klebsiella pneumoniae. The three primary SCFAs (acetate, propionate, and butyrate) strongly inhibit the intestinal commensal Escherichia coli Nissle as well as a panel of enteric pathogens besides K. pneumoniae at physiological pH of the cecum and ascending colon. This inhibition was significantly milder on anaerobic gut commensals Bacteroides thetaiotaomicron and Bifidobacterium adolescentis previously demonstrated to be associated with microbiota recovery after antibiotic-induced dysbiosis. We describe a general suppression of bacterial membrane potential by these SCFAs at physiological cecum and ascending colonic pH. Furthermore, the strength of bacterial inhibition increases with increasing alkyl chain length. Overall, the insights gained in this study shed light on the potential therapeutic use of SCFAs for conferring colonization resistance against invading pathogens in a dysbiotic gut.IMPORTANCERising antimicrobial resistance has made treatment of bacterial infections increasingly difficult. According to the World Health Organization, it has become a burgeoning threat to hospital and public health systems worldwide. This threat is largely attributed to the global rise of carbapenem-resistant Enterobacteriaceae in recent years, with common hospital-acquired pathogens growing increasingly resistant to last-line antibiotics. Antibiotics disrupt the homeostatic balance of the gut microbiota, resulting in the loss of colonization resistance against enteric pathogens. This work describes the ability of short-chain fatty acids (SCFAs) produced by gut microbiota to be effective against a wide panel of enteric pathogens without major impact on common gut commensal species. We also demonstrate a previously undescribed link between alkyl chain length and antibacterial effects of SCFAs. SCFAs, thus, hold promise as an alternative therapeutic option leveraging on the antimicrobial activity of these endogenously produced gut metabolites without disrupting gut microbiota homeostasis.

Abstract 33: An Innovative Digital Health Approach to Enhance Patient Engagement in Stroke Care

Introduction: Patient engagement (PE) is a crucial aspect of health management shown to improve adherence and outcomes. For patients with ischemic stroke (IS) and transient ischemic attack (TIA) PE holds significant value. Novel ways to engage IS/TIA patients and deliver personalized education may enhance knowledge, satisfaction, and adherence while potentially reducing recurrent stroke. Purpose: Develop and implement a stroke-specific 90-day digital health PE platform for IS/TIA patients discharged (DC) home from a Comprehensive Stroke Center (CSC). Utilizing the Twistle TM digital platform the initiative focuses on patient education and adherence. Methods: An expert panel (digital health operations, vascular neurologist, stroke-certified nurse practitioner) designed a 90-day program with 21 modules emphasizing education, adherence, communication, and 90-day mRS self-assessment. A pre-implementation survey assessed confidence to prevent stroke and knowledge of personalized risk factors, lifestyle modification, and medication in 14 IS/TIA patients (Mdn 21 days from DC), with 11 responses (73.3%). After pilot testing with 2 patients and feedback incorporation, 10 more patients were enrolled. A patient engagement and satisfaction survey was administered on day 20. Results: Assessment determined the program was feasible and compared pre-implementation and 20-day survey responses from participants (response rate 6/9). Post-implementation outcomes showed improved patient knowledge and confidence. Patients agreeing/strongly agreeing to having lifestyle modification knowledge increased from 64.6% (n=11) to 83.4% (n=6). Confidence in preventing another stroke/TIA rose from 27.3% (n=11) to 66.7% (n=6). Participants reported heightened engagement through digital messages (83.3%, 5/6), while one respondent (16.7%) remained neutral. Conclusions: Initial findings underscore the potential of digital health, delivered through platforms like Twistle TM , to enhance patient engagement and confidence post-IS/TIA. The program's successful launch suggests promise for expansion at the CSC and potentially across additional health system hospitals. The initiative holds potential for enhancing patient outcomes and well-being.

Severity-Driven Trends in Mortality in a Large Regionalized Critical Care Transport Service

ObjectiveThe epidemiology accompanying helicopter emergency medical services (HEMS) transport has evolved as agencies have matured and become integrated into regionalized health systems, as evidenced primarily by nationwide systems in Europe. System-level congruence between Europe and the United States, where HEMS is geographically fragmentary, is unclear. In this study, we provide a temporal, epidemiologic characterization of the largest standardized private, nonprofit HEMS system in the United States, STAT MedEvac. MethodsWe obtained comprehensive timing, procedure, and vital signs data from STAT MedEvac prehospital electronic patient care records for all adult patients transported to UPMC Health System hospitals in the period of January 2012 through October 2021. We linked these data with hospital electronic health records available through June 2018 to establish length of stay and vital status at discharge. ResultsWe studied 90,960 transports and matched 62.8% (n = 57,128) to the electronic health record. The average patient age was 58.6 years ( 19 years), and most were male (57.9%). The majority of cases were interfacility transports (77.6%), and the most common general medical category was nontrauma (72.7%). Sixty-one percent of all patients received a prehospital intervention. Overall, hospital mortality was 15%, and the average hospital length of stay (LOS) was 8.8 days ( 10.0 days). Observed trends over time included increases in nontrauma transports, level of severity, and in-hospital mortality. In multivariable models, case severity and medical category correlated with the outcomes of mortality and LOS. ConclusionIn the largest standardized nonprofit HEMS system in the United States, patient mortality and hospital LOS increased over time, whereas the proportion of trauma patients and scene runs decreased.

Patient factors associated with survival after critical care interhospital transfer

ObjectiveTo identify the factors that predict mortality post-transfer and develop a comprehensive mortality prediction model capable of supporting pre-transfer decision making.Materials and methodsElectronic health record data from the Medical Transport Data Repository of a large health system hospital in Northeast Ohio that consists of a main campus and 11 affiliated medical centers. We retrospectively analyzed patient data from the referring hospital encounter prior to interhospital transfer. All patient data including diagnoses, laboratory results, medication, and medical and social history were analyzed to predict in-hospital mortality post-transfer. We employed a multi-method approach including logistic regression, gradient boosting, and multiple correspondence analysis to identify significant predictors of mortality as well as variables that are clinically useful to inform clinical decision support development. We identified all patients aged 21 and older that underwent critical care transfer in the health system between 2010 and 2017.ResultsWe found that age, laboratory results (albumin, INR, platelets, BUN, leukocyte, hemoglobin, glucose), vital signs (temperature, respirations, pulse, systolic blood pressure, pulse oximetry), and ventilator usage are the most predictive variables of post-interhospital transfer mortality. Using structured data from the EHR we achieved the same performance as APACHE IV within our health system (0.85 vs. 0.85). Lastly, mode of transport alone was not a significant predictor for the general population in any of the outcome models.ConclusionsOur findings provide a foundation for the development of decision support tools to guide transport referrals and identified the need for further inquiry to discern the role of mode of transport to enable future inclusion in decision support approaches. Further inquiry is needed to identify factors that differentiate patients not triaged as time-sensitive transfers but still require helicopter intervention to maintain or improve post-interhospital transfer morbidity and mortality.

Analysis of the performance of public and private hospitals serving the Brazilian Unified National Health System

This article aims to analyze the performance of the Brazilian Unified National Health System (SUS, acronym in Portuguese) hospital network based on the national databases of the Brazilian Hospital Information System (SIH, acronym in Portuguese) and the Brazilian National Registry of Health Establishments (CNES, acronym in Portuguese). The research used a set of indicators covering the production of admissions, the profile, quality and performance of care, associated with hospital size and legal nature. For data analysis, the Analysis of Variance with Tukey-Kramer test was used to highlight the differences between public and private hospitals, the moderation analysis to verify the effect of hospital size and the Pabon Lasso model to integrate the results. The results show that the increase in the number of beds influences the performance of the indicators differently for public and private hospitals. Public hospitals showed higher gains in scale efficiency with the increase in beds, whereas private non-profit hospitals showed a higher performance in the set of indicators and a more balanced performance in the different sizes. The application of the Pabon Lasso model showed that small hospitals, both public and private, perform poorly. It also showed that from medium-sized onwards, public and private hospitals perform well. However, each category displays particularities in its performance profile, reflecting a diversity of practices and operational results. This study thus confirms previous findings that hospital performance tends to improve as the number of beds increases, but also reveals that it varies significantly depending on the legal nature of these institutions.

Detecting Stroke at the Emergency Department by a Point of Care Device: A Multicenter Feasibility Study.

To evaluate if the Strokefinder MD 100 by Medfield Diagnostics AB can be used as a point of care device in overcrowded Emergency Departments (ED). We used the strokefinder MD 100 by Medfield Diagnostics AB in two Greek National Health System (NHS) Hospitals Emergency Departments. Our research protocol was approved by local scientific and ethics committees. We prospectively enrolled 71 adult patients from two NHS emergency departments in whom stroke was included as a differential diagnosis after triage. The feasibility of using the Strokefinder MD 100 by Medfield Diagnostics AB in various emergency department settings was evaluated through a structured questionnaire. The strokefinder MD 100 was used on 71 patients in various settings in the Emergency Department. In every case, the test was completed at the patient bedside without interfering with other ongoing and diagnostic and resuscitation procedures. There was no additional delay to patient care caused by performing the test when compared with current local Emergency Department practice and protocol. In almost 90% of the cases, a clear result was produced by the device. The Strokefinder MD 100 can be safely used as a point of care device by all trained healthcare professionals, in the most overcrowded emergency department, in various ED locations. Point of Care Systems, Cerebrovascular Stroke, Proof of Concept Study.