Large Community Hospital Research Articles

Inspiring Leadership: How a Community Hospital Is Tackling Healthcare's Most Difficult Problems.

In the spring of 2022 - at the height of the COVID-19 pandemic - Halton Healthcare, a large community hospital corporation in southern Ontario, launched a brand-new leadership development program called "Inspiring Leadership" to support its workforce. Just one year later, the program is having a profound positive impact on the workforce with enhanced engagement and reduced turnover. By investging in people development, organizations can create a compelling employee value proposition, foster cross-continuum partnerships through Ontario Health Teams and community affiliates and, ultimately, advance their strategic objectives. In this article, we will describe the development of this unique program, its evaluation and its impact, with the intent of sharing this learning with other organizations so that they too might realize these benefits.

Scale development to measure the patient perception of patient-centered care of dentists in primary care settings of Thailand: a measurement invariance test

BackgroundPatient-centered care is essential for providing quality services thoroughly at the primary care level, but it is unclear and lacks measurement. This study aimed to develop a reliable and valid instrument to measure patient perception of patient-centered care in primary dental care in Thailand and test the measurement invariance between large and small community hospitals.MethodsThe initial set of 45 items for the patient perception of Patient-Centered Care of Dentist Scale (PCCDS-P version) was developed using a mixed-method approach, which included a literature review, a content validity test, cognitive interviews, and a pre-test. A multistage sampling strategy was used to recruit dental patients or their parents or caregivers from community hospitals across Thailand. Validity was examined through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Reliability was assessed using Cronbach's alpha coefficient and the intraclass correlation coefficient. Furthermore, a multi-group analysis was conducted to compare the responses of patients from large and small community hospitals.ResultsThree hundred thirty-six and One thousand one hundred sixty-seven samples were randomized for EFA and CFA, respectively. The final PCCDS-P version consists of 7 factors with satisfactory reliability and validity and is composed of 42 items: dentist-patient relationship, disease-illness, integrated care, communication, shared information and decision-making, holistic, and empathy and anxiety management. The CFA showed the model fit was consistent with the entire sample. The metric invariance analysis showed that the factor loadings were invariant across patient groups. Overall, Cronbach's alpha coefficient and intraclass correlation coefficient were satisfactory.ConclusionsThe newly developed PCCDS-P version is composed of seven domains with 42 items with good reliability and validity, and it indicated measurement invariance across patients in large and small community hospitals.

Prevalence of Hospital-Onset Bacteremia Pre- and Post-Implementation of a Needleless Blood Sampling Device From Existing Peripheral Catheters.

Repeated access of peripheral intravenous (IV) devices theoretically increases the risk of bacterial exposure. PIVO™ (VelanoVascular) is a needleless, single-use device that enables blood sampling from an existing peripheral IV. The goal of this retrospective observational exploratory study was to evaluate the influence of PIVO use on rates of hospital-onset bacteremia and fungemia (HOB) by comparing HOB rates in the year before and after PIVO introduction in hospitals implementing PIVO and over similar time periods in "control" hospitals with no PIVO. Two hospitals implementing PIVO (Hospital 1, a large community hospital; Hospital 2, a tertiary oncology center), and 71 control hospitals were included. During the 1-year period before and after PIVO introduction, HOB rates decreased in hospitals 1 and 2 by 31.9% and 41.8%, respectively. Control hospitals that did not use PIVO had a 12.4% decrease in HOB rates. Multivariable logistic regression analyses found that PIVO was associated with a lower risk (Hospital 1 odds ratio [OR]: 0.63; 95% CI, 0.42-0.94) or no change (Hospital 2 OR: 1.05; 95% CI, 0.72-1.52) in HOB rates. Control hospitals also showed no change in HOB rates between the 2 time periods. These data do not support concerns about increased risk of bacteremia with PIVO.

Prothrombin Complex Concentrate vs Factor VII for Refractory Bleeding in Cardiac Surgery

BackgroundPerioperative bleeding remains an important complication of cardiac surgery. Current guidelines support goal-directed use of coagulation factor concentrates in refractory bleeding, but the optimal strategy is unclear. Four-factor prothrombin complex concentrate (4F-PCC) has theoretical advantages over recombinant activated factor VII (rFVIIa) because of expanded mechanistic targets and lower rates of adverse events, but comparative data are limited. MethodsWe pursued a retrospective cohort study assessing the implementation of an institutional treatment algorithm for refractory bleeding in cardiac surgery that mediated a practice change in preferred factor product from rFVIIa to 4F-PCC. All cardiac surgery patients at 2 large community hospitals who received 4F-PCC or rFVIIa during 2019-2020 were assessed for inclusion. The primary outcome was all-cause in-hospital mortality. ResultsA total of 42 patients met study criteria. Mortality was nonsignificantly lower in the 4F-PCC group (7.1% vs 28.6%; P = .16), as were median total blood products transfused (15 vs 25.5 units; P = .11), although median units of cryoprecipitate were significantly lower (0.5 vs 2 units; P = .01). Average factor product medication charge per patient was significantly lower in the 4F-PCC group ($9772 vs $50,293; P < .001). ConclusionsA 4F-PCC–based strategy for refractory bleeding in cardiac surgery was associated with reduced cryoprecipitate transfusion and medication costs without significant differences in inpatient mortality or total transfusion exposure. Trends toward decreased mortality and transfusions observed in this quality improvement study should be explored in larger prospective trials.

Effectiveness of a Multi-component Delirium Prevention Program Implemented on General Medicine Hospital Units: an Interrupted Time Series Analysis

BackgroundDelirium is among the most prevalent harmful events in hospitals that is associated with an elevated risk for severe outcomes such as functional decline, falls, longer length of stay, and increased mortality.ObjectiveTo evaluate the impact of the implementation of a multi-component delirium program on the prevalence of delirium and the incidence of falls among patients staying on general medicine inpatient hospital units.DesignA pre-post intervention study using retrospective chart abstraction and interrupted time series analysis.CohortPatients were selected from adult patients that stayed at least 1 day on one of the five general medicine units in a large community hospital in Ontario, Canada. A total of 16 random samples of 50 patients per month for 8 consecutive months pre-intervention (October 2017 to May 2018) and 8 months post intervention (January 2019 to August 2019) were selected for a total of 800 patients. There were no exclusion criteria.InterventionThe delirium program included multiple components: education of staff and hospital leadership, twice per day bed-side screen for delirium, non-pharmacological and pharmacological prevention, and intervention strategies and a delirium consultation team.MeasurementDelirium prevalence was assessed using the evidence-based delirium chart abstraction method, CHART-del. Demographic data as well as fall incidence were also collected.ResultOur evaluation showed that the implementation of a multicomponent delirium program led to a reduction in delirium prevalence and fall incidences. The reduction in both delirium and falls was the largest for patients in the ages between 72 and 83 years old and varied across inpatient units.ConclusionA multi-component delirium program to improve the prevention, recognition, and management of delirium reduces the prevalence of delirium and fall incidence among patients in general medicine units.

Opioid and Nerve Block Administration in Knee Arthroplasty: An Observational Retrospective Evaluation

AimsIncreasing opioid-related adverse events and deaths have amplified interest in non-opioid analgesic options. Peripheral nerve blocks (PNBs) are useful in pain management, especially in minimally invasive day surgeries. This evaluation sought to examine patterns of opioid use among adult patients undergoing total knee arthroplasty, stratified by use of PNBs. DesignA retrospective, observational design. SettingsA large tertiary medical center and community hospital in the Inland Northwest. Participants/SubjectsA dataset of 8,493 adult patients undergoing elective total knee arthroplasty, 3,432 of which received a PNB while 5,061 did not. MethodsA deidentified dataset was obtained to evaluate: (a) opioid use frequency, (b) average morphine milligram equivalents (MMEs) administered, (c) independent factors associated with opioid administration, and (d) time to first opioid administered in adults undergoing total knee arthroplasty while in the recovery room, stratified by use of PNBs. ResultsWhen controlling for general anesthesia, opioid use frequency was reduced when PNBs were administered (p < .05). The amount of MMEs consumed was 15 mg less in the group receiving a PNB (p < .001). In a linear regression model, PNBs reduced the MMEs consumed by 5 mg (p = .014). Time-to-first opioid was increased in patients receiving general anesthesia and PNBs with a hazards ratio of 0.70 (p < .001). ConclusionsPeripheral nerve blocks are an opioid-sparing technique in adult patients undergoing total knee arthroplasty. Clinical ImplicationsThe results confirm best practices regarding opioid-sparing PNBs. Postoperative opioids are appropriate, but regimens incorporating PNB administration for total knee arthroplasty help reduce opioid use.

Assessment of outpatient chemotherapy and unplanned emergency department visits in a large community hospital system.

e18768 Background: Unplanned complications of outpatient chemotherapy can significantly affect patient oncologic outcomes, health, and increase cost of care. CMS rule OP-35 evaluates quality of care for Medicare patients by assessing the risk of emergency department (ED) visit within 30 days after outpatient chemotherapy administration. This study reviews this measure for all oncology patients treated in our community hospital setting. Methods: Patients treated between 02/2012 and 04/2021 were identified. Age at first chemotherapy administration, gender, cancer diagnosis, and chemotherapy regiment were evaluated. Chemotherapy was stratified into cytotoxic therapy, immunotherapy, targeted therapy, and endocrine therapy. ED visits were only those in our hospital system. 30-day risk of ED visit was calculated for individual chemotherapy administrations. Internal results were compared with our CMS OP-35 results for concordance. Results: There were 19,732 patients who received chemotherapy treatments between 02/2012 and 04/2021, with 262,379 chemotherapy administrations. Individual chemotherapy administration had 5.2% risk of a 30 day ED visit. Cumulative risk of a patient having a 30 day ED visit was 32.9%. From ED, patients had 61.2% rate of hospital admission, vs 24.8% rate for general ED population. By age at first chemotherapy administration, the risk of 30 day ED visit was 6.3% for age &lt; 18, 5.4% for age 18-64, and 5.9% for age &gt; = 65. Our rate was relatively stable between 2014 and 2020. Our corresponding CMS score was 5.5% in 2016, 5.5% in 2018, and 5.1% in 2019. By gender, the risk was 5.6% for male and 5.0% for female patients. By chemotherapy category, the risk was 5.9% for cytotoxic chemotherapy, 7.5% for immunotherapy, 4.2% for targeted therapy, and 5.2% for endocrine therapy. Carboplatin/paclitaxel was the most common drug combination administered, with 8.7% risk. Cytarabine/methotrexate combination had the highest risk at 57.0%. By ICD diagnosis, breast cancer accounted for most patients and most chemotherapy administrations, with 30 day ED visit risk of 3.6%. Multiple myeloma had the highest rate of chemotherapy administrations at 26.3 per patient and a risk of 4.0%, compared with 13.3 across the entire population. Stomach cancer had the highest risk of 30 day ED visit at 10.0%. Conclusions: The risk of 30 day unplanned ED visit was elevated in pediatric patients, and was similar in patients 18-64 and &gt; = 65 years of age, and corresponded well to our CMS OP-35 metric, despite only tracking internal ED visits. Immunotherapy had significantly elevated risk compared with cytotoxic therapy, while targeted therapy had the lowest risk of ED visit. There were significant differences depending on disease site. We have established a baseline, and developed a live dashboard in our electronic medical record to monitor this metric globally, and to intervene in patients at high risk of 30 day ED visit.

Effect of insulin resistance on CAC scores in cancer survivors.

e24056 Background: Many cancer (ca) survivors exhibit signs of insulin resistance (IR), an important risk factor for the development of coronary artery disease (CAD). Paramount in survivorship care is prevention of cardiovascular disease. Coronary artery calcium (CAC) scans offer a risk assessment of cardiovascular (CV) disease before cardiac damage has occurred. We investigated how IR affects CAC scores in cancer survivors. We hypothesized that CAC scores differ significantly between insulin-sensitive- and -resistant cancer survivors. Methods: We enrolled 90 cancer survivors of a large community hospital from March 2021 to January 2022 into this pilot study. Patients were subdivided into three groups: insulin-sensitive (IS), insulin-resistant/prediabetic and insulin-resistant/diabetic. Patients were tested for fasting insulin, -glucose, HgbA1c and lipids. Patients without evidence for prediabetes or diabetes also underwent an oral glucose tolerance test (oGTT). All patients received a CAC scan. Results: 32 patients were IS, 29 patients were IR/prediabetic and 29 patients were IR/diabetic. 17 CAC scans in the IS group, 6 CAC scans in the IR/prediabetic group and 5 CAC scans in the IR/diabetic group showed an Agatston score of 0. The p-value between the three groups was statistically significant ( p=0.005) where as the IR/prediabetic- and the IR/diabetic group did not differ statistically from each other. The mean MESA 10-year CHD risk with CAC was 7.8. There was a highly significant difference between the 3 groups: the IS group had a mean of 5.3, the IR/prediabetic group had a mean of 7.3, and the IR/diabetic group had a mean of 11.0 ( p &lt; 0.001). The two IR groups did not differ statistically (p=0.076). Conclusions: Our study showed that IR including prediabetes significantly increases the MESA 10-yr. CHD Risk with CAC in cancer survivors. Survivors with IR also have less frequent zero CAC scores than insulin-sensitive survivors. Survivors disproportionately exhibit insulin resistance, partly due to the association of certain types of cancer with IR. This trial highlights the importance of screening survivors for IR. Survivors diagnosed with IR should be screened for CAD more frequently than the general population. CAC scans are an inexpensive and efficient way of screening asymptomatic cancer survivors for CAD.

Mesh Exposure After Midurethral Sling Procedures Confers a High Risk of Persistent Stress Urinary Incontinence [ID: 1373885

INTRODUCTION: Stress urinary incontinence (SUI) affects between 4% and 35% of adult women. Midurethral slings (MUSs) are the gold standard for the treatment of SUI. Mesh exposure has been reported in 4.7–16.4% of patients who undergo MUS. It is unclear whether mesh exposure portends an increased risk of persistent SUI. The purpose of this study was to determine whether mesh exposure is associated with MUS failure/persistent SUI. METHODS: This was a retrospective cohort study from December 1, 2015 to January 1, 2022, of all patients who had a MUS procedure at a large community hospital. The primary outcome was persistent SUI at the 12-week postoperative appointment after MUS in patients with and without mesh exposure. RESULTS: A total of 456 patients underwent MUS procedure. The incidence of persistent SUI and mesh exposure was 6.4% and 8.8%, respectively. Twenty-five percent of patients with mesh exposure experienced persistent SUI, compared with 4.6% of patients without mesh exposure (P&lt;.0001). In univariable analysis, mesh exposure and postmenopausal status were associated with persistent SUI while asthma was associated with mesh exposure. In logistic regression, persistent SUI was 6.5 times higher in patients with MUS mesh exposure compared to those without mesh exposure (adjusted odds ratio 6.46, 95% CI 2.71–15.44). CONCLUSION: Mesh exposure is an independent risk factor for persistent SUI. Patients with mesh exposure are approximately seven times more likely to experience persistent SUI compared to patients without mesh exposure. Currently, there is insufficient evidence to recommend surgical revision of MUSs complicated by mesh exposure, and further studies are warranted.

Main Street, USA Enrollment: Community Hospital Recruitment Strategies for Diverse and Equitable Selection of Pregnant Participants in a Prospective Cohort Study [ID: 1377833

INTRODUCTION: The same factors contributing to disproportionately worse health outcomes are also barriers to inclusion in research for Black, Hispanic, and Indigenous patients. In this subanalysis of a large, multisite prospective cohort study of maternal plasma mRNA signatures and adverse pregnancy outcomes (APOs), we sought to determine whether equitable representation was aided by the inclusion of a large community hospital as an enrollment site. METHODS: Pregnant persons between 18 and 45 year old with a singleton pregnancy eligible to enroll in this IRB-approved prospective cohort study at Woman’s Hospital (Baton Rouge, Louisiana). A hybrid of indirect and direct recruitment strategies, bolstered by text message communication and gift card compensation, were deployed to facilitate enrollment that mirrored the community’s diversity. RESULTS: Two thousand five hundred twenty-two participants have been enrolled over 22 months (18% of the hospital’s eligible patient population): 41% of participants are Black, 9% are of Hispanic origin, 50% are White, and 9% Other race. This identically mirrors the demographics of the hospital obstetric patient population (38% Black, 7% Hispanic, 49% White, and 13% Other). CONCLUSION: Participants overall mirrored the diverse population served. Inclusion of study sites outside of the traditional academic setting is an effective strategy for promoting equitable access to clinical research, combating barriers to inclusion in research faced by the populations that are disproportionately affected by APOs.

Effect of insulin resistance on CAC scores in cancer survivors

BackgroundMany ca. survivors exhibit signs of IR, an important risk factor for the development of CAD. CAC scans offer a risk assessment of CV disease before cardiac damage has occurred. We investigated how IR affects CAC scores in cancer survivors.ObjectivesThe aim of this study was to show that CAC scores differ significantly between insulin-sensitive- and -resistant cancer survivors.MethodsWe enrolled 90 cancer survivors of a large community hospital from March 2021 to January 2022 into this pilot study. Patients were subdivided into three groups: insulin-sensitive (IS), insulin-resistant/prediabetic and insulin-resistant/diabetic. All patients received a CAC scan.Results70% of asymptomatic survivors overall and 81% of asymptomatic IR patients show CAD on CAC scans. 17 CAC scans in the IS group, 6 CAC scans in the IR/prediabetic group and 5 CAC scans in the IR/diabetic group showed an Agatston score of 0. The p-value between the three groups was statistically significant (p = 0.005) whereas the IR/prediabetic- and the IR/diabetic group did not differ statistically from each other. The mean MESA 10-year CHD risk with CAC was 7.8. There was a highly significant difference between the 3 groups (p < 0.001). The two IR groups did not differ statistically (p = 0.076).ConclusionsSurvivors with IR including prediabetes have less frequent zero CAC scores than insulin-sensitive survivors. Our study also showed that IR including prediabetes significantly increases the MESA 10-yr. CHD Risk with CAC in cancer survivors. This trial highlights the importance of screening survivors for IR and draws attention to the association of IR to CAC not only in diabetes but also in prediabetes. The high fraction of asymptomatic survivors with CAD is concerning and calls for further investigation. CAC scans are an inexpensive and efficient way of screening asymptomatic cancer survivors for CAD.

Urinary tract injury during hysterectomy: Does surgeon specialty and surgical volume matter?

Ureteral injury is a known complication of hysterectomies. Recent studies have attempted to correlate surgeon volume and experience with incidence of urinary tract injuries during hysterectomies. Some studies have reported that as surgeon volume increases, urinary tract injury rates decrease. To our knowledge, no studies have assessed the relationship between surgeon subspecialty and the rate of urinary tract injury rates during minimally invasive hysterectomy. To determine the incidence of urinary tract injury between urogynecologists, gynecologic oncologists, and general gynecologists. The study took place from January 1, 2016 to December 1, 2021 at a large community hospital in Detroit, Michigan. We conducted a retrospective chart review of adult patients who underwent minimally invasive hysterectomy. After we identified eligible patients, the surgeon subspecialty was identified and the surgeon's volume per year was calculated. Patient demographics, medical history, physician-dictated operative reports, and all hospital visits postoperatively were reviewed. Urologic injury occurred in four patients (2%) in the general gynecologist group, in one patient (1%) in the gynecologic oncologist group, and in one patient (1%) in the urogynecologist group. When comparing high and low-volume surgeons, there was no statistically significant difference in urinary tract injury (1% vs 2%) or bowel injury (1% vs 0%). There were more complications in the low-volume group vs the high-volume group excluding urinary tract, bowel, or major vessel injury. High-volume surgeons had four (1%) patients with a complication and low-volume surgeons had 12 (4%) patients with a complication (P = 0.04). Our study demonstrated that there was no difference in the urinary tract injury rate in general gynecologists vs subspecialists, however our study was underpowered.

Abstract NS7: Time To Reversal Is Brain - A Retrospective Analysis Of Door To Needle Times Of Anticoagulation Reversal Agents In Intracranial Hemorrhage, A Single Center Retrospective Analysis

Objectives: Anticoagulant associated intracranial hemorrhage (AA-ICrH) accounts for 10-25% of all intracranial hemorrhages and anticoagulation (AC) at the time of the event more than doubles mortality risk. No guidelines for target times to treatment have been established for the administration of AC reversal agents despite their rapid onset of action. We evaluated AC reversal treatment times among patients with AA-ICrH presenting to a single large community hospital with institutional target times established in 2018. Methods: Retrospective chart review was performed for all AA-ICrH treated with reversal agents in Sarasota Memorial Hospital Comprehensive Stroke Center, Sarasota, Florida, between 2018-2021. Clinical and non-clinical variables were collected. Predictors with p&lt;0.20 in the univariate analysis were investigated further in a multivariable model. Results: We identified 175 patients, 60% male, 94% Caucasian. FXa inhibitors were used among 67%, warfarin 29% and dabigatran 4%. Half the cohort was treated with andexanet, 46% PCCs and 4% idarucizumab. Arriving via EMS, 70%, transfers from other facilities 14%, walk-ins 10%, and inpatients 6%. Overall, 62% arrived ≤3 hours from symptom onset, 52% and 20% presented under trauma alert (TA) and stroke alert (SA) protocols, respectively. Overall median [IQR] DTN and CTN times (in minutes) were 103 [69-182] and 81 [55-126] respectively, and order-to-needle time, 38 [31-46]. DTN and CTN times among EMS arrival were 98 [69-160] and 70 [54- 110], respectively, for walk-ins, 204 [144-262] and 88 [66-130], respectively (p&lt;0.05). DTN ≤90 and ≤60 minutes was seen in 69% and 38% of SA and 48% and 14% of TA, respectively. CTN ≤60 minutes was achieved in 58% of SA and 35% of TA. The only two significant independent predictors of faster DTN times were SA protocol on arrival and arrival mode (p&lt;0.001). Conclusions: Similar to ischemic strokes, arrival by EMS or under SA protocol was associated with faster DTN and CTN times for AC reversal therapies in patients presenting with AA-ICrH. Our institution’s proposed time goals for DTN ≤90 and CTN ≤60 minutes for &gt;75% of patients remained unmet. Nationally accepted target times for AC reversal therapies used in certified stroke centers could help achieve these goals.

Perceptions and Use of Safe Sleep Baby Boxes at Hospital Discharge by New Mothers.

A large community hospital in South Texas began distributing safe sleep baby boxes to reduce sudden unexplained infant death (SUID) in 2017. To describe safe sleep practices among new mothers who received a safe sleep baby box at hospital discharge. An information sheet containing a link to an online survey was mailed to all women who received a safe sleep baby box prior to discharge from the hospital from January 2018 to January 2019. N = 84 women participated. Most reported using the safe sleep baby box only during nap time (n = 62, 88.6%). Only 70.2% of participants reported that baby always slept their back (n = 59). Most reported their baby did not use a pacifier (n = 62, 73.8%), and many reported they were not breastfeeding their baby (n = 38, 45.2%). Many women were not using the safe sleep baby box as intended and were not following many of the other safe sleep guidelines. Nurses should ask their patients about plans for infant safe sleep after discharge to provide individualized education or recommend specific resources to address the family's needs.

1789. Current Antibiotic Prescription Practices in Hospitalized Patients with Acute Myeloid Leukemia (AML) and Febrile Neutropenia of Unknown Origin (FN-FUO): Data from a Large Tertiary Community Hospital

Abstract Background Optimal duration of empiric antibiotic therapy in hospitalized patients with febrile neutropenia of unknown origin (FN-FUO) remains controversial. Emerging evidence suggests that early discontinuation of antibiotics at 48-72 hours of apyrexia is safe regardless of neutrophil count. However, in the U.S., the adoption of this and other antibiotic use practices in these patients remains unstandardized and understudied, particularly in community hospitals. In this pilot study, we sought to evaluate current antibiotic prescription practices in our large community hospital in admitted patients with AML and FN-FUO. Methods We conducted a retrospective cohort study from January 1st, 2020 to December 16th, 2021. All patients admitted with a diagnosis of AML and febrile neutropenia (FN) were screened and those with FN-FUO, defined as no microbiological growth on blood, respiratory or urine cultures at 48 hours of first fever were included. Data on initial antibiotic choices, use of vancomycin and its congruence with IDSA guidelines, mean days of therapy (DOT), mean days of “excess” therapy (DOET), defined by days of antibiotics after &amp;gt;72 hours of apyrexia and total DOET were obtained by medical record review and descriptive analysis was performed. Results A total of 65 patients with FN were screened. After screening, 27 patients met criteria for inclusion and data from their hospital stay was obtained (Table 1). Cefepime was the preferred choice of initial intravenous β-lactam in 85% of cases and piperacillin-tazobactam was used in the remainder of cases. Vancomycin was used initially in 55% of cases out of which its use was considered to be incongruent with IDSA guidelines in 25% of cases. The most common reason for IDSA incongruent use of vancomycin was lack of documentation for its use. Mean DOT was 10 and mean DOET was 3 (Table 2). In total, we identified 87 excess days of antibiotic therapy in this cohort. Conclusion Little is known about antibiotic prescription practices in high risk FN-FUO patients in community hospitals. Our findings highlight potential concrete antibiotic stewardship targets and shortening this knowledge gap may help guide the development of interventions that have been previously shown to improve clinical outcomes in this overall underrepresented population. Disclosures All Authors: No reported disclosures.

1115: EVALUATION OF BIVALIRUDIN ANTICOAGULATION IN PATIENTS ON ECMO DUE TO COVID-19 RESPIRATORY FAILURE

Introduction: Patients supported on extracorporeal membrane oxygenation (ECMO) due to COVID-19 are at an increased risk of both thromboembolic complications and thrombocytopenia. Bivalirudin, a direct thrombin inhibitor, is increasingly being utilized for anticoagulation in the ECMO patient though there is largely a lack of literature within the COVID-19 population. The objective of our study was to evaluate the safety and efficacy of alternative anticoagulation with bivalirudin in patients on ECMO with COVID-19 respiratory failure. Methods: This was a non-interventional retrospective chart review conducted at a single center large community hospital between January 2020 – November 2021. We included both venovenous (VV) and venoarterial (VA) adult ECMO patients anticoagulated with bivalirudin that tested positive for COVID-19. Patients were excluded if their duration of ECMO cannulation was less than 48 hours. Descriptive statistical analyses were performed utilizing median with interquartile range and frequency with percent as appropriate. Results: Overall, 180 ECMO patients were included in the study. The duration of ECMO cannulation was 29 (9-54) days and our cohort experienced a 42% mortality rate. The rate of thrombotic events including in-circuit thrombosis, arterial and venous thrombotic events was 22%. The median initial platelet count on ECMO was 206 (157-274) and the median nadir was 85 (48-121). ELSO defined major bleeding occurred at a rate of 53% within this cohort. Conclusions: To our knowledge, this study describes the largest number of patients anticoagulated with bivalirudin for ECMO secondary to COVID-19. Our results suggest similar rates of thrombotic events compared to ELSO registry data. While the half-life of bivalirudin is short, clinicians should still be cautious of bleeding due to lack of a specific reversal agent. Retrospective studies with a comparator cohort, as well as randomized trials are warranted to further evaluate the selection of intravenous anticoagulants in the ECMO population with and without COVID-19.

1151: CARDIAC ARREST OUTCOMES AND TIME OF DAY: A SINGLE-CENTER STUDY

Introduction: Previous studies of in-hospital cardiac arrest have shown lower survival rates in arrests which occur during the night time hours. These statistics have held true when looking at aggregate data throughout the hospital as well as specifically in the ICU. The majority of prior analyses have been on registry data from a wide range of facilities, including both academic teaching and community hospitals. This study looks at sentinel arrests occurring in the ICU of a community hospital primarily staffed by advanced practice providers overnight with emergency physician code team backup. Methods: This retrospective, observational analysis of a Code Blue database looked at the survival to hospital discharge of adult patients who received either CPR or defibrillation while in the ICU between January 1st, 2015 – December 31st 2019 based on timing of arrest (0700 – 1859, 1900 – 0659). Binary logistic regression was utilized to assess the relationship between time of day and survival to discharge, as well as chance of ROSC. Multivariable logistic regression was performed utilizing age, gender, initial rhythm, comorbidities, use of vasoactive medications as well as ventilatory status at time of arrest. Results: Over the 5-year period there were 219 Code Blue events meeting the prespecified criteria, of these 118 (54%) occurred during the night hours while 101 (46%) occurred during the day. Survival was 23/118 (19.5%) on nights and 29/101 (28.7%) on days. After adjusting for confounders there was no significant association between an arrest occurring between the hours of 0700 – 1859 p=0.173 OR 1.69[CI 95% 0.79 – 3.6] and survival to hospital discharge. The unadjusted analysis demonstrated an OR 0.24[CI 95% 0.15 - 0.38] of survival if the arrest occurred during this timeframe. An initial shockable rhythm exhibited a positive effect on survival p=0.011 OR 3.7[CI 95% 1.36 – 10.07], while acute kidney injury p=0.012 OR 0.36 [CI 95% 0.17 – 0.8] and the use of vasoactive medications p= < 0.001 OR 0.19 [CI 95% 0.09 – 0.44] at the time of arrest were associated with a negative outcome. Conclusions: When adjusted for confounding factors there was no difference in cardiac arrest outcomes based on time of day in the ICU of a large community hospital staffed by advanced practice providers at night.

Emergency Surgery in a Large Urban Area Community Hospital During SARS-CoV-2 Pandemic: An Analysis on Acute Appendicitis

Background: The literature highlights a decrease in surgical treated appendicitis with an increased severity during the COVID-19 pandemic. The aim of this study was to analyze the effect of COVID lockdown on the population with appendicitis comparing clinical-pathologic data and outcome in two matching period (prepandemic and pandemic era). Methods: A retrospective analysis of patients admitted to two community urban hospital in Rome with diagnosis of acute appendicitis (AA) before and after the COVID-19 pandemic was performed. We compared patients patients with acute appendicitis in three groups named A (pre-COVID), B (early pandemic), and C (late pandemic). We evaluate the differences between the three groups in terms of onset of symptoms and severity, procedure difficulty, conversion rate, and short-term outcome. Results: A total of 310 patients were identified. The time interval from onset of symptoms to arrival in the emergency department was significantly longer in both pandemic group; there was also a significantly longer time to surgery comparing to group A. The risk of complicated AA was higher in both pandemic groups. A significantly higher grade of difficulty was detected in both COVID-groups. However, no differences were observed in conversion rate. Postoperative complications rate showed no significant difference among all three groups. No patients was tested positive for SARS-CoV-2 postoperatively. Conclusion: AA treatment was comparable to pre-COVID period in-hospital presurgery stay and early postoperative outcome. With an accurate respect of pandemic protocol is possible to maintain a high and safe standard of care for patients with acute appendicitis.

Inferior Vena Cava Filter Use at a Large Community Hospital: A Cross-Sectional Analysis

Introduction: Inferior vena cava (IVC) filters are considered among patients who have sustained a recent lower extremity deep vein thrombosis (DVT) and/or pulmonary embolism (PE) with a contraindication to anticoagulation. IVC filter use has risen in recent decades despite a lack of data on the effectiveness of IVC filters in reducing venous thromboembolism (VTE)-related mortality. Moreover, IVC filters may be associated with significant morbidity, including filter migration, IVC thrombosis, and fatal bleeding. Prolonged insertion of an IVC filter risks endothelialization which renders later attempts at removal ineffective, and raises the risk of complications. In this study, we aimed to characterize the pattern of IVC filter use at a large community-based hospital. Specifically, we characterized the indications for IVC filter insertion, rates of IVC filter removal, and filter-associated complications. Methods: A retrospective cohort study of adult patients (>18 years) who received an IVC filter between January 1, 2005 - February 28, 2022 at Windsor Regional Hospital (WRH), which is a large community-based hospital with academic affiliations in Southwestern Ontario, Canada. Data were collected using RedCAP software and analyzed using descriptive methods. Results: To date, we have reviewed 89 patient charts from 2019-2022. Patients with IVC filters inserted through WRH were most often male (58.4%) with a median age of 68 years. The most common indications for IVC filters included recent VTE (DVT and/or PE within 3 months) and active bleeding (43.8%), and recent VTE with a need for anticoagulation interruption for surgery (32.6%). Approximately 21% (19 patients) of IVC filters were inserted for indications outside recommended guidelines, including: need for interruption of anticoagulation in patients with a remote history of VTE (31.6%) or prior to surgery (15.8%), recent VTE & active bleed but anticoagulant therapy not discontinued (21.1%), surgical prophylaxis (10.5%), recent VTE & risk of bleeding with no active bleed (10.5%), failure of anticoagulation (5.3%), and massive PE with residual DVT (5.3%). Only 34.8% of patients had successful removal of their IVC filter with an average of 1.2 attempts at filter removal per patient. At least 4 patients (4.5%) have experienced complications relating to their IVC filter, including IVC thrombotic occlusion (50%) and IVC filter migration (50%). Conclusions: Approximately 21% of IVC filters were inserted for indications that fall outside of current guidelines at a large community-based hospital in Ontario, Canada. Moreover, 65% of IVC filters were not removed which is consistent with rates reported in other studies, and significantly raises the risk of IVC filter complications. Given that the majority of patient care occurs in the community setting, further efforts are needed to understand patterns of IVC filter use at other community hospitals. As well, our findings further support the need for development of concrete guidelines on indications for IVC filter use and monitoring practices. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The data and the reality: urine cultures and emergency medicine physicians.

The IDSA has published guidelines for the treatment of urinary tract infections, recommending limiting treatment to symptomatic patients and pregnant females. Our objective is to elucidate current practice patterns among emergency physicians (EPs) in treating positive urine cultures in various clinical situations. This study employed a cross-sectional design utilizing a questionnaire addressing nine common scenarios encountered by EPs in the follow-up of a positive urine culture. The questionnaire was conducted using RedCap and distributed via email to current and former physicians and residents across our hospital network. Demographic information included years of training and practice setting. For each of nine clinical scenarios, Physicians were asked if they would treat with antibiotics. Results were then analyzed by tabulating percentage of responses and 95% confidence intervals. Of 120 respondents, 40.8% worked in academic centers with emergency medicine residencies, 37.5% in large community hospitals, and 20.67% in small community hospitals. Responses came from 14 residents, 33 attendings < 5years out of training, 23 attendings 5-9years out of training, 37 attendings 10-20years out of training, and 13 attendings > 20 beyond training. Asymptomatic young women were treated by 34.2% (95% CI 25.91-43.46%) while asymptomatic elderly women were treated by 50% (95% CI 40.79-59.21%) of EPs. All EPs (95% CI 96.13-100%) chose to treat a symptomatic male and 99.2% (95% CI 94.77-99.96%) chose to treat an asymptomatic pregnant female. Elderly females after a fall were treated by 63.3% (95% CI 54-71.8%) of EPs while elderly males with confusion and a fall were treated by 96.7% (95% CI 91.18-98.93%). Asymptomatic males with a chronic Foley catheter were treated by 28.2% (95% CI 20.67-37.4%) of EPs and 46.7% (95%CI 37.59-55.97%) would treat an asymptomatic middle-aged female with diabetes. Finally, 92.5% (95% CI 85.85-96.3%) of EPs chose to treat an asymptomatic kidney transplant patient. EPs in varied training stages and practice settings have significant practice variation in the treatment of positive urine cultures, particularly in the geriatric population, often prescribing antibiotics to patients where clear, specific and data-driven IDSA guidelines suggest treatment is unnecessary and potentially harmful.