Inpatient Consultation Research Articles

How to Effectively Utilize Consultation Codes: 2023 Updates

Consultation codes can be utilized by dermatologists in both the inpatient and outpatient setting. Updates to the inpatient and outpatient consultation code families went into effect January 1, 2023. Similar to the outpatient evaluation and management (E/M) codes, level of service is now determined solely based on either time on the date of the encounter or medical decision-making. Additionally, interprofessional consultation codes are time-based codes that can be utilized when assisting in the diagnosis and/or management of a patient without face-to-face contact.

Prospective Cohort Study on the Impact of Early Versus Late Inpatient Palliative Care on Length of Stay and Cost of Care.

Aim: To evaluate the impact of early vs late palliative care on (1) length of stay (LOS) in the context of expected LOS measures and (2) total cost of care to the hospital for each patient. Methods: A prospective cohort study was performed at a single large academic medical center on patients who received an inpatient palliative care consultation. The two cohorts were early palliative care (within 3days of admission) and late palliative care (after 3days of admission). Comparisons were made between patients' actual LOS, expected LOS, and total hospital costs between both cohorts. Results: Compared to the late palliative care cohort (N = 126), patients who received early palliative care (N = 68) had a significantly shorter LOS (P < .001) and also performed better compared to CMS-Expected LOS standards (Observed/Expected 3.1 vs 1.5 respectively; P < .001). Early palliative care patients also saw an average decline of $1431 in total costs 1-day pre/post consult as opposed to a more modest $403 decline in the later palliative care cohort (P < .001). Similarly, patients who received early palliative care had a $5839 decline in aggregated total 3-day costs, as opposed to a $1478 decline in those who received late palliative care (P < .001). Conclusions: In the competitive and rapidly evolving healthcare system, the opportunity to suppress costs and lower patient LOS has increasing importance. Our study strongly supports the implementation of earlier palliative care intervention to assist hospitals in approaching LOS targets and reducing patient costs.

Trends Following Implementation of an Otolaryngology Hospitalist Model in a Tertiary Care Setting.

The otolaryngology hospitalist (OH) model is an emerging paradigm for inpatient and acute patient care. This study presents encounter volume before and after the implementation of an OH service. Postimplementation trends are evaluated. Retrospective administrative and clinical database review. Tertiary care university hospital. This review includes 2 distinct time frames (2008-2012, 2014-2018), representing periods before and after OH implementation. The number of billed patient encounters is compared between these 2 periods using the hospital data warehouse. Additional data is evaluated for the postimplementation period, using a clinical database. Encounter type, the reason for consultation, procedures, and requesting service/location are described. After the OH implementation, there was a 451% increase in evaluation andmanagement encounters submitted for billing. Since the OH model inception, there was an overall increase in encounters (849-910), procedures performed (319-345), and operative cases (46-54) per year. Each inpatient consultation request generates one or more procedures on average. Common reasons for consultation include sinonasal pathology (20.3%), dysphonia/dysphagia (17.5%), and airway evaluation (15%). Critical Care (24%), Emergency Medicine (21%), and Hospital Medicine (21%) requested most of the Otolaryngology consults. Most consults were seen on the inpatient medical/surgical floor (46%), with the ICU (27%) and the Emergency Department (22%) being the next most common locations. The OH model is an evolving paradigm that is viable and offers timely, specialized care for patients in a hospital or acute care setting.

Pediatric otolaryngology trends in patient care volume during covid-19: A survey study

PurposeTo assess changes in outpatient clinic, inpatient consult, and operative volumes among pediatric otolaryngologists in response to the COVID-19 pandemic. Materials and methodsAn online questionnaire was distributed to 535 active members of the American Society of Pediatric Otolaryngology from April 21, 2020, to May 4, 2020. The questionnaire assessed operative and clinical volumes during a two-week period between April 6, 2020, to April 20, 2020, while restrictions on elective surgery were in place, as compared to an average two-week period before the start of the COVID-19 pandemic. ResultsBoth outpatient clinic and inpatient consult visit volume decreased significantly during the Covid-19 period. Academic practitioners typically reported seeing fewer outpatient visits than their private practice counterparts. Operative case volume decreased significantly across all procedures and surgeries common to pediatric otolaryngology. One-third of surveyed surgeons reported no operative cases during the assessed period. ConclusionsPediatric otolaryngologists reported a severe reduction in operative volume, in-office visits, and inpatient consults during a time period at the peak of the 2020 Covid-19 outbreak. Many respondents saw no patients, nor operated in any capacity. This time period could have lasting effects on practitioner finances and trainee education.

Health Services in Huntington Disease: A Systematic Literature Review.

Clinical trials for Huntington disease (HD) have primarily focused on managing chorea and, more recently, the development of disease-modifying therapies (DMTs). Nonetheless, understanding health services among patients with HD is essential for assessing new therapeutics, development of quality metrics, and overall quality of life of patients and families with HD. Health services assess health care utilization patterns, outcomes, and health care-associated costs, which can help shape the development of therapeutics and aid in policies that affect patients with a specific condition. In this systematic literature review, we analyze data of published studies looking at causes of hospitalization, outcomes, and health care costs in HD. The search yielded 8 articles published in the English language and comprising data from the United States, Australia, New Zealand, and Israel. The most common cause of hospitalization among patients with HD was dysphagia or dysphagia-related complications (e.g., aspiration pneumonia or malnutrition), followed by psychiatric or behavioral symptoms. Patients with HD had more prolonged hospitalizations than non-HD patients, and it was most prominent among those with advanced disease. Patients with HD were more likely to be discharged to a facility. A small percentage received inpatient palliative care consultation, and behavioral symptoms were a primary cause of discharge to another facility. Interventions such as gastrostomy tube placement had associated morbidity, and it was common among patients with HD with a diagnosis of dementia. Palliative care consultation and specialized nursing care were associated with more routine discharges and fewer hospitalizations. In terms of cost, patients with HD with private and public insurances had the highest expenditure with more advanced disease, and expenses were associated with hospitalization and medication costs. In addition to DMTs, HD clinical trial development should also consider the leading causes of hospitalization, morbidity, and mortality in patients with HD, including dysphagia and psychiatric disease. No research study, to our knowledge, has systematically reviewed health services research studies in HD. Evidence from health services research is needed to evaluate the efficacy of pharmacologic and supportive therapies. This type of research is also critical in understanding health care costs associated with the disease and to better advocate and shape policies that can benefit this patient population.

Profile of Dermatology Consultations for Inpatients: The Scope for Telemedicine During the COVID-19 Pandemic and Beyond

Background: Attending dermatology consultations for inpatients is an integral part of the role of dermatologists inpatient care. Materials and Methods: A retrospective study was conducted at a large tertiary care hospital when the country, particularly the city, was severely affected by the COVID-19 pandemic. The aim was to study the profile of dermatology referrals for inpatients at the time of the COVID-19 pandemic and assessing the need for telemedicine in these inpatients. Results: A total of 341 dermatology consultations for 288 patients were received. Most of the consultations were from internal medicine (15.3%) and obstetrics and gynecology (8.7%). Around 65% of consultations were for new-onset (≤30 days) skin conditions while around 35% were for chronic (&gt;30 days) conditions. The most commonly seen conditions were superficial fungal infections (14.9%) followed by eczematous disorders (13.2%). On grading the level of urgency of the referrals, 34.4% required an immediate consultation, 41% required it within a week, 12.8% within 2–4 weeks, 8% within 1–3 months, and 3.8% after the pandemic settles. The need for urgent consultation was more in acute cases than in chronic cases (P = 0.00). 62.5% of the consultations could have been done by telemedicine. Conclusion: As a majority of the consultations were for common and straightforward skin conditions and could mostly be done on telemedicine, this study underlines the need for strengthening the telemedicine services for inpatients referrals during this COVID-19 pandemic and even beyond.

The utility of augmented teledermatology to improve dermatologist diagnosis of cellulitis: a cross-sectional study.

Dermatology consultation for cases of presumed cellulitis improves diagnostic accuracy and management. However, access to in-person consultation remains limited, a gap that could be filled with teledermatology. Augmented teledermatology may improve outcomes. In this cross-sectional study, 20 dermatologists (60% of whom reported conducting inpatient consults > 1month per year) reviewed 10 real-life cases representing either cellulitis or pseudocellulitis as diagnosed by in-person dermatology consultation. For each case, respondents recorded their diagnosis, confidence, and management decisions after viewing the history and standard teledermatology photos, the responses to a physician-reported cellulitis questionnaire, and finally thermal images. Overall mean diagnostic accuracy increased from 84 ± 4% with the history and physical to 89 ± 3% when adding a cellulitis questionnaire and thermal images (p = 0.23). Accuracy for cellulitis cases specifically significantly increased from 76 ± 6% to 88 ± 4% when adding a cellulitis questionnaire and thermal images (p = 0.049). Accuracy for pseudocellulitis was consistently ≥ 94%. Augmented teledermatology with a standardized questionnaire and thermal images improved diagnostic accuracy for cases of cellulitis and may increase physician confidence. Dermatologists were able to accurately diagnose regardless of experience with inpatient consults, increasing the pool of potential dermatologists who could diagnose cellulitis remotely.

Comparison of Psychiatric Service Utilization Prior, During, and After COVID-19 Lockdown: A Retrospective Cohort Study.

Background COVID-19 pandemic represents a significant risk factor for developing, relapsing, or exacerbating pre-existing mental health conditions. This negative impact on mental health results in increasing demand for psychiatric services. This study aimed to explore the effects of COVID-19 pandemic lockdown on the utilization of mental health services in three periods - prior, during, and after the lockdown - compared to the matched weeks in the previous years 2018 and 2019. Materials and Method In this retrospective cohort, quantitative, single-center study, data were collected from electronic medical records, including all patients with referrals\consultations to the psychiatric section prior, during, and after COVID-19 lockdown. Results In total, 2,454 patients were either referred to psychiatric outpatient clinics or needed consultation as inpatients during the study periods. Only 2,326 patients were included in our study. The total number of inpatient consultations was 1,410, with a statistically significant increase during the lockdown (p-value<0.001) and post-lockdown (p<0.016) in comparison to previous years. A significant reduction in outpatient referrals was observed during the lockdown (p=0.005) and post-lockdown period. Psychiatric disorders were identified in most patients (N=1,599), representing 65%, 54%, and 74% of patients in pre-lockdown, lockdown, and post-lockdown periods compared to 71%, 71%, and 76%, respectively, in the previous years. A total of 821 patients manifested symptoms of depression, constituting the largest proportion among all reasons for referral\consultations. The number of patients referred for substance/alcohol use disorders during the lockdown increased compared to patients in the same period in 2019. Suicidal behavior was identified in 70 patients across all study periods, with the lowest number observed in 2020. Conclusion Our findings indicate that during the COVID-19 lockdown, a significant increase in inpatient psychiatric services utilization was observed. Outpatient psychiatric service utilizations were significantly reduced. Implementation of evidence-based policy and protocol to guide mental health challenges in future health emergencies is needed.

Personalizing the Setting of Palliative Care Delivery for Patients with Advanced Cancer: "Care Anywhere, Anytime".

The specialty of palliative care has evolved over time to provide symptom management, psychosocial support, and care planning for patients with cancer throughout the disease continuum and in multiple care settings. This review examines the delivery and impact of palliative care in the outpatient, inpatient, and community-based settings. The article will discuss how these 3 palliative care settings can work together to optimize patient outcomes under a unifying model of palliative care "anywhere, anytime" and how to prioritize palliative care services when resources are limited. Many patients with advanced cancer receive care from each of the 3 branches of palliative care-outpatient, inpatient, and community-based settings-at some point along their disease trajectory. Early on, outpatient clinics provide longitudinal supportive care concurrent with active disease-modifying treatments. Telemedicine appointments can serve patients remotely to minimize their need to travel. When patients experience functional decline, community-based palliative care services can provide support and monitoring for patients at home. When patients develop acute symptomatic complications requiring admission, inpatient care consultation teams are essential for symptom management and goals-of-care discussions. For patients in severe distress, receiving care in a palliative care unit that provides intensive symptom control and facilitates complex discharge planning is ideal. Under a unifying model of palliative care designed to offer care "anywhere, anytime," the 3 branches of palliative care could work in unison to support each other, minimize gaps in care, and optimize patient outcomes.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

Introduction Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare. Methods We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. s and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes. Results Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples. Discussion Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

ALIGN-CARE: IMPLEMENTATION AND FEASIBILITY OF NEW GERIATRIC SURGERY CO-MANAGEMENT MODEL FOR PHYSICAL AND SOCIAL FRAILTY

Abstract Pre-operative geriatric evaluation in frail older patients that addresses both medical and psychosocial needs is often not completed prior to surgery, leaving frail older adults ill prepared for surgery. The ALIGN-CARE interprofessional co-management model uniquely serves to standardize care and coordination amongst the surgeon, geriatrician and social worker in ambulatory settings to allow a greater window of time to intervene for surgical optimization. Program elements include assessment of preoperative medications, functional status, cognition, nutrition, What Matters Most, advance care planning (ACP), and social determinants of health. Recommendations and action items from the geriatric-social work team are presented to surgeon and primary care physicians for follow-up and optimization. Program and process elements recorded in a REDCap database facilitate longitudinal evaluation of ALIGN-CARE model implementation feasibility. Initial data of 9 frail surgical oncology patients indicate increases in meaningful ACP discussions, patient-oriented decisions regarding surgery candidacy, and surgeon referrals for inpatient geriatric consultation post-operatively as a result of ALIGN-CARE. Current analyses to assess feasibility and quality of the program include thematic coding of program documents, semi-structured interviews of key stakeholders (surgeons, geriatricians, social workers, patients), and quantitative analysis of program outcomes, including uptake of program elements and process measures. Planned areas of analytic focus include workflow, cross-specialty coordination, and patient and primary care engagement and activation. We anticipate identifying specific barriers and facilitators of ALIGN-CARE implementation in our evaluation to aid the dissemination and upscaling of interprofessional co-management programs aimed to improve outcomes and quality of life for frail, older surgical patients.

Early palliative care consultation offsets hospitalization duration and costs for elderly patients with traumatic brain injuries: Insights from a Level 1 trauma center

We identified factors and outcomes associated with inpatient palliative care (PC) consultation, stratified into early and late timing, for patients over age 65 with traumatic brain injuries (TBI). Patients over age 65 presenting to a single institution with TBI and intracranial hemorrhage from January 2013-September 2020 were included. Patient demographics and various outcomes were analyzed. Inpatient PC consultation was uncommon (4 % out of 576 patients). Characteristics associated with likelihood of consultation were severe TBI (OR = 5.030, 95 % CI 1.096–23.082, p =.038) and pre-existing dementia (OR = 6.577, 95 % CI 1.726–25.073, p =.006). Average consultation timing was 8.6 (standard deviation ± 7.0) days. Patients with PC consults had longer overall (p =.0031) and intensive care unit (ICU) length of stays (LOS) (p <.0001), more days intubated (p <.0001) and higher costs (p =.0006), although those with earlier-than-average PC consultation had shorter overall (p =.0062) and ICU (p =.011) LOS as well as fewer ventilator days (p =.030) and lower costs (p =.0003). Older patients with TBI are more likely to receive PC based on pre-existing dementia and severe TBI. Patients with PC consultations had worse LOS and higher costs. However, these effects were mitigated by earlier PC involvement. Our study emphasizes the need for timely PC consultation in a vulnerable patient population.

400. Rehospitalization of Patients for Recurrent Clostridioides difficile Infection

Abstract Background Clostridioides difficile infection (CDI) is an important cause of morbidity and mortality, especially in patients with recurrent episodes and those requiring re-hospitalization. Decreasing recurrent CDI (rCDI) and re-hospitalization for rCDI are important outcomes. The purpose of our study was to evaluate the impact of specialty care from an infectious disease (ID) or gastroenterology (GI) provider, either during the admission of the primary episode or in a follow-up appointment within 30 days. Methods This was a single-center, retrospective, chart review at a tertiary medical center. All hospitalized patients with a positive stool test for C. difficile (CD) (GI panel PCR, FilmArray, Biofire, or CD PCR, Xpert CD assay, Cepheid) with or without an ICD-10 code Enterocolitis due to CD (A04.7, A04.71, A04.72) from January 2018 through December 2018 were reviewed. Demographic and clinical data at the time of diagnosis and up to 90 days after discharge were collected. Results Our criteria identified 602 patients. We excluded 27 patients who died while hospitalized and 104 patients classified as colonized from analysis. Most patients (410/471, 87%) were determined to have a primary CDI episode. After discharge, 57 (14%) patients developed rCDI and 40 patients (10%) died within 90 days of discharge. Among those with rCDI, 40% (23/57) of patients had to be re-hospitalized due to their recurrence. Those re-hospitalized for rCDI developed their recurrence sooner (40% within 45 days, p &amp;lt; 0.005) compared to patients with rCDI that were not re-hospitalized (Figure). ID/GI evaluated 173 of 471 (37%) patients during the index hospitalization or on hospital follow-up. Among patients evaluated by ID/GI, 10.4% had rCDI compared to the 13.8% with no ID/GI intervention. (p=NS). Only 3.5% (6/173) of patients evaluated by ID/GI were re-hospitalized vs 5.7% (17/298) of patients without ID/GI evaluation. (p=NS) Time to CDI recurrence in re-hospitalized patients Conclusion In our study, 40% of patients who had rCDI had to be readmitted for their rCDI. Recurrence occurred significantly earlier in patients who were re-hospitalized. Patients evaluated by ID or GI had a decreased rate of re-hospitalization. Inpatient consultation and timely follow up of hospitalized CDI patients should be studied prospectively to determine the impact on rCDI re-hospitalization. Disclosures Stuart Johnson, M.D., Ferring Pharmaceuticals: Membership on Ferring Publication Steering Committee|Ferring Pharmaceuticals: Employee|Summit Plc: Advisor/Consultant.

909. Impact of Implementing an IV to PO Antibiotic Treatment Protocol for Orthopedic Infections on Prescribing Habits and Health Utilization Outcomes

Abstract Background The Oral versus Intravenous Antibiotics for Bone and Joint Infection Trial concluded that oral antibiotics administered during the first six weeks of therapy for orthopedic infections were non-inferior to parenteral antibiotics. Previously, we also conducted a retrospective cohort study of patients at our center with an orthopedic infection. Patients transitioned to oral therapy had significantly fewer adverse events and similar incidences of one year treatment failure compared to patients maintained on parenteral vancomycin. Methods To increase use of oral antibiotics for orthopedic infections, we created a protocol for changing IV to PO antibiotics prior to hospital discharge. We evaluated its effect on prescribing practices and healthcare utilization outcomes. Patients with an orthopedic infection were included if they were discharged within the 90-day pre- and post-protocol study periods, had an inpatient Infectious Disease consult, and were initiated on parenteral vancomycin while inpatient. The primary outcome compared the incidence of oral antibiotics prescribed at discharge. Secondary outcomes included incidence of adverse drug reactions, discharge dispositions, hospital length of stay, canceled follow-up appointments, unplanned readmissions, and early treatment failure. Results Fifty patients were included, 22 and 28 patients in the pre- and post-protocol groups, respectively. Twenty-three (82%) patients in the post-protocol group were prescribed oral antibiotics at discharge compared to 8 (36%) patients in the pre-protocol group. Twenty-three (82%) patients in the post-protocol group were discharged home compared to 13 (59%) patients in the pre-protocol group. Of note, 7 (25%) patients in the post-protocol group had early treatment failure compared to 1 (5%) patient in the pre-protocol group, and 8 (29%) patients in the post-protocol group compared to 4 (18%) patients in the pre-protocol group had an unplanned readmission. Conclusion Providing physicians with an oral antibiotic protocol for orthopedic infections significantly increased the number of oral antibiotic prescriptions at hospital discharge, but the higher rates of treatment failure observed after protocol implementation are concerning and warrant further investigation. Disclosures Russell J. Benefield, PharmD, BCPS-AQ ID, Paratek Pharmaceuticals: Grant/Research Support.

Social Risk Screening Changes Medical Decision-Making in a Complex Outpatient Pediatric Antibiotic Therapy Program.

Complex outpatient antibiotic therapy (COpAT) programs facilitate the treatment of serious infections at home, shorten inpatient stays, and improve patient satisfaction when compared to inpatient care [1]. However, COpAT delivery can be complicated by antibiotic side effects and vascular access problems, the management of which can become particularly difficult when attempted in the context of high social risk in the home and community [2]. The use of standardized social risk screening for optimizing infectious disease (ID) discharge plans is largely unexplored. We tested the feasibility and implementation of a novel social risk screening tool for COpAT and described alterations in care plans generated based on social risk information. A COpAT social risk screening tool was created by adapting publicly available social determinants of health screening toolkits [3, 4] to focus on social risks previously identified as prevalent in our patient population and relevant to our COpAT delivery system [5, 6] (Figure 1). From March to October 2019, the COpAT physician assistant assessed social risks for 29 of 40 (73%) consecutively eligible parents/caregivers. Results of social risk screening and COpAT modifications were documented in the patient’s EMR as a progress note. To assess changes made as a result of screening, we retrospectively compared the original COpAT plan by the inpatient consulting ID team to the final COpAT plan. We tabulated changes in COpAT plans using six predefined, a priori categories of change: (1) antibiotic use; (2) caregiver education; (3) COpAT follow-up plans; (4) social work referral; (5) new inpatient consultation; and (6) hospital length of stay. The study was deemed quality improvement and IRB oversight was waived.

Frequency of Acute Kidney Injury and Association With Mortality Among Extremely Preterm Infants

Neonatal acute kidney injury (AKI) is common and associated with morbidity and mortality. The temporal relationship between AKI and critical illness, as well as the frequency of AKI definition components (urine output and serum creatinine [sCr] concentration change), are unknown in extremely low-birth-weight (ELBW) (<1000 g), extremely preterm (<29 weeks' completed gestational age [GA]) infants. To measure the frequency of AKI from birth to death or discharge with attention to the definition components as well as the temporal relationship of AKI to critical illness and death. A single-center, multiyear, retrospective cohort study was conducted at an academic level IV neonatal intensive care unit between January 1, 2012, and January 1, 2020. Participants included inborn ELBW and infants at 22 to 28 weeks' completed GA with confirmed congenital anomalies who survived 12 hours or more. Extremely preterm birth and ELBW. The primary outcome was AKI frequency. The timing, severity, and criteria for AKI were measured. The temporal relationship between AKI, organ dysfunction, and outcomes were quantified using odds ratios (ORs), logistic regression, and Shapley Additive Explanations. Acute kidney injury recognition, imaging, pediatric nephrology consultation, and follow-up were determined. A total of 436 infants (52% male; 44% Black) met the inclusion criteria (median BW, 725 g; median GA, 25.7 wk). Acute kidney injury was common in the first week of life (44%), primarily based on the change in the sCr concentration criterion (88%), and negatively associated with GA (OR, 0.69; 95% CI, 0.60-0.78), but positively associated with antecedent critical illness (OR, 1.17; 95% CI, 1.12-1.23), severe intraventricular hemorrhage (OR, 1.86; 95% CI, 1.12-3.08), late-onset sepsis (OR, 1.03; 95% CI, 1.02-1.03), and mortality (OR, 2.77; 95% CI, 1.63-4.72). Acute kidney injury had negligible clinical contribution to death within the model (Shapley Additive Explanation, <0.5% change to outcome) relative to antecedent patient-concentration organ dysfunction (6%-15% change). Among infants with severe AKI, recognition (32%), nephrology inpatient consultation (16%), and outpatient follow-up (9%) were not common. In this cohort study of ELBW infants, AKI was common in the first week of life, inversely associated with GA, and followed organ (primarily cardiovascular) dysfunction. Acute kidney injury considered as the primary pathway to mortality was rare, and amelioration of AKI to modify death was not well supported.

Piloting an Advanced Neuroimmunology Elective for Neurology Residents

Objective To describe the creation of an Advanced Neuroimmunology elective for residents with a special interest in clinical neuroimmunology. Background There has been a dramatic change in the landscape of neuroimmune conditions with the discovery of new pathogenic autoantibodies, disease modifying therapies and wider availability of multidisciplinary care systems for patients. Most residencies do offer exposure to multiple sclerosis but with increasing interest in neuroimmunology and autoimmune neurological conditions, there is a gap in resident education to meet needs of this changing landscape. Design/Methods A curriculum for advanced neuroimmunology (NI) was developed for residents with special interest in clinical neuroimmunology. This two-week elective consisted of rotations through NI and affiliated multidisciplinary clinics to increase exposure to immune mediated neurological illnesses, appreciate their heterogeneity, and aid multi-disciplinary approach. Department experts in various disease states related to neuroimmunology were contacted and based on interest and resident elective time, a schedule was set up for rotations through neuroinfectious diseases, pulmonary sarcoidosis clinic, neuro-oncology, neuropathology and rheumatology. An additional expectation was to work with the fellow on inpatient consults that came in through the 2 weeks. In addition to multiple sclerosis/neuroimmunology division didactics, residents are encouraged to attend other affiliated department conferences as well as present at interdepartmental meetings, such as neuro-rheumatology conference. Results The availability of this elective allowed increased exposure to neuroimmunological conditions outside the typical Multiple Sclerosis elective at UTHealth. It also has allowed for additional inter-departmental collaboration clinically. Since the initial pilot elective, more residents have requested this as an elective and will be surveyed about their experience. Conclusions There is an unmet need for MS and NI subspecialists. Exposure to the broad spectrum of neuroimmunological conditions through multi-disciplinary collaborations during residency is instrumental to ensure future specialists have the foundations to adapt to this rapidly advancing field.

OD2-3 The effect of inpatient palliative care consultation on aggressiveness of antibiotic use at the end of life among patients with terminal cancer

OD2-3 The effect of inpatient palliative care consultation on aggressiveness of antibiotic use at the end of life among patients with terminal cancer

Pediatric dental residents' on-call experience.

The Commission on Dental (CODA) requires that pediatric dentistry training programs provide residents with clinical experiences in oral-facial injury and emergency care, as well as interprofessional patient care through hospital dentistry. These standards are often met through pediatric dental residents being on-call for children's hospitals. The aim of this study was to describe the on-call experience of pediatric dental residents at two urban children's hospitals. This cross-sectional descriptive study collected and analyzed data on the number, type, and time and date distributions of on-call pages received by pediatric dental residents over a 36-month study period. A total of 737 on-call pages were received. Each pediatric dental resident responded to 70 pages on average during their training. The most common reason for pages being received was inpatient consultation and oral-facial trauma. The mean number of pages received did not vary by year, month, or day of the week. There was a statically significant difference in the mean number of pages received by the hour of the day. Having an on-call pediatric dental service in pediatric dentistrytraining programs is a meaningful way of exposing pediatric dental residents to oral-facial trauma, hospital dentistry, and interprofessional care.

Understanding Hydroxyurea Utilization in Sickle Cell Disease: Exploring Patient and Provider Attitudes and Beliefs

Introduction Hydroxyurea (HU), a first line sickle cell disease (SCD) modifying drug, has a 22%-48% utilization rate, according to national estimates (Lanzkron 2006, Stettler 2015, Knisely 2020). There are numerous factors identified as barriers to adherence of hydroxyurea such as access to care (Badawy 2017). Given the high frequency of SCD inpatient admissions at the University of Chicago Medical Center (UCMC) and thus the limited opportunity for outpatient care where disease modifying therapies can be initiated, we proposed a quality improvement project to monitor HU education and usage during inpatient encounters. Methods Our project was reviewed by the UCMC Institutional Review Board and approved to meet quality improvement (QI) determination. To address the question of HU initiation in SCD during inpatient encounters, we surveyed key stakeholders including patients with SCD and providers. We identified consecutive patients with SCD who were either established with primary care or hematology at UCMC (n=197) and distributed our deidentified survey through a REDCap secure link to patients with active email accounts (n=135). We designed a provider survey eliciting knowledge, beliefs, and perspectives on HU use in SCD and distributed this through REDCap to 182 frontline providers. We analyzed the data qualitatively, identifying patterns and common themes from aggregate responses and free text answers. Results The patient survey response rate was 31% (n=42/135). Forty-five percent (n=18) of patients agreed that they missed follow up appointments due to admissions. Approximately half of patient respondents indicated they were not taking HU (n=19). Additionally, of those patients, 72% (n=14) indicated they would be willing to deal with the side effects of HU if it improved their SCD symptoms and 32% (n=6) said they would consider initiation of HU during an inpatient encounter. Patient respondents cited the benefits of HU, including improving quality of life (33%; n=13), preventing pain episodes (43%; n=17), improving mortality (18%; n=7), and helping prevent hospitalizations (36%; n=14). In terms of further education, 35% (n=14) of patient respondents indicated they would like to learn more about HU. 88% (n=35) indicated they would like to learn more about other disease modifying therapies. The provider survey response rate was 73% (n=132/182), of whom, 40% (n=52) were IM or Med/Peds residents, 28% (n=37) were medicine attendings, and 11% (n=15) were Hematology/Oncology faculty or fellows. 98% (n=129) of respondents overall agreed that HU initiation should be offered to patients with SCD during inpatient encounters and that the benefits of HU in SCD outweighed the potential harms. Providers requested tools to facilitate prescribing HU during inpatient encounters, including bundled orders ("orderset") within the EMR (55%; n=73), an option for inpatient SCD consult services (28%; n=37), education sessions and materials (45%; n=59), and a linked outpatient hematology referral system (58%; n=77). Conclusion: Results from our patient survey demonstrate an unmet need for expanding access to HU into inpatient encounters and providing access to other disease modifying therapies and potential cures. Providers would be comfortable with initiation and monitoring of HU during inpatient SCD encounters. To facilitate this, providers request additional education and process resources. Results from both surveys inform a plan to address disparities in HU utilization rates among patients with SCD at UCMC, in addition to providing opportunities to enhance SCD care overall. The path forward will include building curricula for providers, educational handouts on disease modifying therapies for patients, generating a HU prescribing orderset embedded in the EMR, and innovating a SCD inpatient consult service at UCMC.