Large County Hospital Research Articles

Evaluation of an oncology diagnostic and screening clinic at a large safety net hospital.

94 Background: Increasingly, dedicated clinics have been established to expedite patients with suspicion of malignancy into cancer care. The Lyndon B. Johnson General Hospital (LBJGH) is part of the Harris County Hospital District (HCHD), serving the third largest county in the United States. A 2012 study at our institution found long mean ambulatory wait times for the diagnosis of breast, colon, and lung cancers (77.1 days, 65.4 days, and 70.8 days, respectively). The LBJGH Oncology Diagnostic and Screening clinic (DSC) was subsequently established to reduce ambulatory diagnostic times, decrease frequency of admissions, and improve patient outcomes. Our present study sought to establish the effectiveness of the DSC in bringing patients into care. Methods: The charts of 100 new patients seen in the DSC between August 2018 and November 2020 were reviewed. Demographic data, insurance status, date of referral to the DSC, date of first DSC visit, date biopsy or outside pathology ordered, date biopsy performed or outside pathology obtained, total number of visits to the DSC, and total time from initial DSC visit to initial oncology clinic visit were collected, as well as cancer stage upon arrival to the oncology clinic. The project was approved by the MD Anderson Quality Improvement Assessment Board and the Harris Health Quality Improvement Committee. Results: 57% of patients seen in the DSC were referred by the emergency department, and 23% by a PCP. The median time from referral to initial visit in the DSC was 19 days. 26% of patients had a known cancer diagnosis at the time of referral. The median time from biopsy ordered to performed was 39 days, and the median time from pathology requested to obtained was 23 days. The median total number of visits per patient to the DSC was 2. 48% of patients seen in the DSC were ultimately diagnosed with cancer, 29% had a benign condition, and 23% were lost to follow up. Of those patients with confirmed malignancy, 46% of patients had stage IV disease at their first oncology clinic visit. The average time from initial DSC visit to initial visit at the oncology clinic was 53 days. Conclusions: Establishment of an oncology DSC has improved the ambulatory wait time for entry into oncologic care from an average of approximately 70 days to an average of 53 days. However, almost half of patients referred from the DSC had stage IV disease at their initial oncology visit, indicating an urgent need to further expedite entry of these patients into oncologic care. Avenues for future quality improvement efforts include an expedited process to obtain outside pathology results, implementation of an “e-consult” option for PCPs to avoid unnecessary referrals, and a close analysis of insurance and financial barriers to entry into care. Reference: Mougalian SS, Wang J, Zarzour M et al. Feasibility and savings of a suspicion of cancer clinic at a large county hospital. JCO 2012; 30 (34 supplement): 104.

A comparison of acute pain management strategies after cesarean delivery

There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited. To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain. This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant. During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001). Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

Association Between Thyroid Hormones and Lipids Stratified by Race and Sex

It has been well-established that thyroid hormones play a role in cholesterol and lipoprotein metabolism. However, there is limited data assessing the variability in the association between thyroid hormones and lipids across sex and race. We hypothesized that thyroid dysfunction is associated with changes in lipids and lipoproteins with no substantial variability in this association between races and sex. The electronic medical record of a large county hospital in Dallas, TX was queried to obtain data on all patients who had lipid panels and thyroid function tests checked on the same day from 1/1/2013 to 1/1/2018. The results were stratified into hypothyroid (TSH greater than 4.5 mcIU/L and Free T4 less than 0.8 ng/dL), hyperthyroid (TSH less than 0.5 mcIU/L and Free T4 greater than 1.8 ng/dL) and normal (TSH between 0.5 and 4.5 mcIU/L, Free T4 between 0.8 and 1.8 ng/dL). Results consistent with subclinical thyroid disease were excluded from further analysis. There were 25,290 unique results for thyroid hormones and lipid panels checked on the same day. The results were further stratified by race and sex, and the relationship between thyroid function and lipids was assessed. The correlation coefficient (r) was compared between sexes within each race for the following variables: TSH vs HDL-C, TSH vs LDL-C, TSH vs Total Cholesterol, TSH vs triglycerides, FT4 vs HDL-C, FT4 vs LDL-C, FT4 vs Total Cholesterol, and FT4 vs triglycerides. Among black males with hypothyroidism, there was a notably stronger correlation when compared to black females in the relationship between TSH vs LDL-C, and TSH vs Total Cholesterol. Specifically, the correlation coefficient of TSH vs LDL-C among Black males with hypothyroidism was 0.582, compared to 0.133 among Black females with hypothyroidism (P=0.0053). Furthermore, the correlation coefficient of TSH vs Total Cholesterol among Black males was 0.567 compared to 0.184 among Black females (P=0.016). In contrast, no difference in any of the relationships between thyroid and lipids was demonstrated between sexes amongst Whites, Asians, and Hispanics. Overall, we found differences in Black patients compared to patients of other races with regards to the association between thyroid and lipids. Specifically, it was found that Black males with hypothyroidism had a stronger positive correlation in TSH vs LDL-C and TSH vs Total Cholesterol than Black females. This type of difference between sexes was not found amongst any other race. These findings suggest that thyroid dysfunction is associated with changes in lipids, and the way these changes manifest may vary depending on the race and sex. This further highlights the importance of checking lipid panels in patients with thyroid dysfunction. Further research is needed to more clearly characterize the variation that is seen in thyroid and lipid function amongst races.

The First 2 Years of Biosimilar Epoetin for Cancer and Chemotherapy-Induced Anemia in the U.S.: A Review from the Southern Network on Adverse Reactions.

Biosimilars are biologic drug products that are highly similar to reference products in analytic features, pharmacokinetics and pharmacodynamics, immunogenicity, safety, and efficacy. Biosimilar epoetin received Food and Drug Administration (FDA) approval in 2018. The manufacturer received an FDA nonapproval letter in 2017, despite receiving a favorable review by FDA's Oncologic Drugs Advisory Committee (ODAC) and an FDA nonapproval letter in 2015 for an earlier formulation. We discuss the 2018 FDA approval, the 2017 FDA ODAC Committee review, and the FDA complete response letters in 2015 and 2017; review concepts of litigation, naming, labeling, substitution, interchangeability, and pharmacovigilance; review European and U.S. oncology experiences with biosimilar epoetin; and review the safety of erythropoiesis-stimulating agents. In 2020, policy statements from AETNA, United Health Care, and Humana indicated that new epoetin oncology starts must be for biosimilar epoetin unless medical need for other epoetins is documented. Empirical studies report that as of 2012, reference epoetin use decreased from 40%-60% of all patients with cancer with chemotherapy-induced anemia to <5% of such patients because of safety concerns. Between 2018 and 2020, biosimilar epoetin use varied, increasing to 81% among one private insurer's patients covered by Medicare whose cancer care is administered with Oncology Analytics and to 41% with the same private insurer's patients with cancer covered by commercial health insurance and administered by the private insurer, to 0% in several Veterans Administration Hospitals, increasing to 100% in one large county hospital in California, and with yet-to-be-reported data from most oncology settings. We conclude that biosimilar epoetin appears to have overcome some barriers since 2015, although current uptake in the U.S. is variable. Pricing and safety considerations for all erythropoiesis-stimulating agents are primary determinants of biosimilar epoetin oncology uptake. IMPLICATIONS FOR PRACTICE: Few oncologists understand substitution and interchangeability of biosimilars with reference drugs. Epoetin biosimilar is new to the market, and physician and patient understanding is limited. The development of epoetin biosimilar is not familiar to oncologists.

843 A comparison of acute pain management strategies after cesarean delivery

To determine if a multimodal pain management regimen after cesarean delivery reduces the number of morphine milligram equivalents (MME) compared to traditional patient controlled opioid analgesia (PCA) while adequately controlling postoperative pain. This was a prospective inception cohort analysis of postoperative pain management for women undergoing cesarean delivery at a large county hospital during a transition from a traditional morphine PCA to a multimodal regimen that included scheduled NSAIDs and acetaminophen, with opioids as needed. Data was collected for a 6 week period before and after the transition. The primary outcome was postoperative opioid use defined as MME in the first 48 hours. Secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia, had a history of substance abuse disorder or who delivered in the first 4 weeks after the transition were excluded. Statistical analysis included Student’s t test, Wilcoxon rank sum and Hodges-Lehman shift. During the study period 878 women underwent cesarean delivery and 775 met inclusion criteria: 376 received the traditional PCA and 399 received the multimodal regimen. Implementation of a multimodal regimen resulted in a significant reduction in MME use in the first 48 hours (30 [16,45] MME vs 135 [88,177] MME, p<0.001, Figure). Compared to the traditional group, more women in the multimodal group reported a pain score ≤ 4 by 48 hours (88% vs 77%, p<0.001). There was no difference in time to discharge. Of women who planned to exclusively breastfeed, fewer used formula prior to discharge in the multimodal group as compared to the traditional group (9% vs 12%, p<0.001). Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in decreased opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

722 Perinatal outcomes among women living in at-risk areas identified by a community health needs assessment

As a recent Community Health Needs Assessment (CHNA) identified geographic areas within our county with substantial health disparities, the aim of this study was to evaluate maternal and infant outcomes within the region. We hypothesized that perinatal outcomes would differ for women living in areas with the higher social needs compared to those living in other regions of the county. This was a retrospective cohort study of pregnant women delivering at a large inner-city county hospital, which serves as the safety net hospital for the county. Perinatal outcomes were analyzed for women living within a target region of ten zip codes, identified during a recent CHNA, and compared to those women living outside the target region. Statistical analysis included student’s t-test, chi square, and logistic regression to adjust for demographics. Between January 2015 and July 2020, 66,936 women delivered at the county hospital. Of these, a total of 7,585 (11%) resided in the CHNA target region. The women living in the target region were younger (26.8 + 6.5 vs 27.9 + 6.4 years, p<.001), more likely to be black (37% vs 13%, p<.001), and had a higher BMI (33.3 + 7.0 vs 32.6 + 6.4 kg/m2,p <.001). The rates of preeclampsia and abruption were higher in the target region (Table). Adverse infant outcomes were also more common including preterm birth, neonatal ICU admission, and neonatal death. Increased risk for all maternal and neonatal adverse outcomes persisted after adjustment for age, race, and BMI (figure). Women living in areas with higher health disparity and more social needs identified in a recent CHNA are at greater risk of adverse perinatal outcomes. Efforts to improve obstetric outcomes in this at-risk area should focus on achieving health equity by eliminating social disparities through targeted education and outreach.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Magnetic Resonance Imaging of Diabetic Foot Osteomyelitis: Imaging Accuracy in Biopsy-Proven Disease

Magnetic resonance imaging (MRI) is the recommended diagnostic imaging technique for diabetic foot osteomyelitis (DFO). The gold standard to diagnose osteomyelitis is bone biopsy with a positive culture and/or histopathology finding consistent with osteomyelitis. The purpose of this study is to assess the accuracy of MRI readings in biopsy-proven diabetic foot osteomyelitis with a second read done by a blinded, expert musculoskeletal radiologist. A retrospective chart review of 166 patients who received a bone biopsy to confirm the diagnosis of a suspected DFO at a large county hospital between 2010 and 2014. A second, blinded musculoskeletal radiologist reviewed the images for accuracy, once the official reading was recorded. Imaging results were correlated with the final diagnosis of osteomyelitis determined by bone biopsy. In 17 of 58 patients (29.3%), the diagnosis of DFO by MRI was not confirmed by bone biopsy. There were 12 false positives and 5 false negatives. After the second expert read, there were 5 false positives and 4 false negatives. The overall accuracy was 84% for the second read. Our study demonstrated results comparable to the previously reported meta-analysis findings. There is a clear variation on the read of MRI that could lead to an incorrect diagnosis of DFO. An integrated approach with evaluation of clinical findings, communication with radiologist about the MRI results when indicated, and bone biopsy is warranted for accurate diagnosis management of DFO.

S0533 Evaluating the Yield of EGD Performed as Clearance for TEE at Quaternary Referral Center and County Hospital

INTRODUCTION: Hoarseness, sore throat, odynophagia, and dysphagia are the most common complications following transesophageal echocardiography (TEE), but gastrointestinal (GI) tract perforation and bleeding have also been reported. Therefore, endoscopic evaluation prior to TEE is sometimes requested, particularly in those with history of GI disease and those with ongoing GI complaints. However, there are no published guidelines and very limited studies that offer insight on when an esophagogastroduodenoscopy (EGD) is needed before TEE. METHODS: This is a multi-site retrospective chart review of patients undergoing EGD prior to TEE. CPT codes were used to identify patients who underwent EGD prior to TEE from 10/1/2010 to 10/1/2019 at a quaternary referral center and a large urban county hospital. Medical records for patients ≥ 18 years of age were queried for demographic information along with the indications and findings from EGD and TEE. The presence of cirrhosis and its associated complications were documented along with MELD and Child-Pugh (CPT) score. The patients were classified based on whether the EGD was done as clearance for TEE and those who had diagnostic EGD within one year prior to TEE. RESULTS: In the year prior to the TEE, 26.6% of the EGDs done at the county hospital and 45.7% at the quaternary referral center were requested for clearance and Table 1 shows the differences in demographics and medical history between the two groups at each site. Patients requiring clearance EGD at the referral center, were more likely to be female with a history of cirrhosis, variceal bleed, and/or CPT score (P = 0.04, 0.0012, 0.0012, and 0.0013, respectively). This difference was not seen at the county hospital. The time lapse between EGD and TEE was shorter in the clearance group at both hospitals. Figure 1 shows the most common indications for EGD at each hospital which were not significantly different between groups (P = 0.134 and 0.23). None of the patients who underwent EGD clearance for TEE had endoscopic findings that precluded TEE.Table 1Figure 1CONCLUSION: EGD prior to TEE is more likely to be requested at a large referral hospital in patients with history of cirrhosis and variceal bleeding with an advanced CPT score. Due to the retrospective nature of this study, it is possible that we did not capture a small number of patients that underwent clearance EGD, but did not undergo TEE. Nonetheless, the results of this study do not show that EGD prior to TEE changes management.

My Unexpected Journey to Psychiatry

My Unexpected Journey to Psychiatry

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation).

Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life‐threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de‐escalation as a first‐line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.

Using Artificial Intelligence to Predict Surgical Shunts in Men with Ischemic Priapism.

Ischemic priapism is a urological emergency that requires prompt intervention to preserve erectile function. Characteristics that influence escalation to surgical intervention remain unclear. We identified factors and developed machine learning models to predict which men presenting with ischemic priapism will require shunting. We identified men with ischemic priapism admitted to the emergency department of our large county hospital between January 2010 and June 2019. We collected patient demographics, etiology, duration of priapism prior to intervention, interventions attempted and escalation to shunting. Machine learning models were trained and tested using R to predict which patients require surgical shunting. A total of 334 encounters of ischemic priapism were identified. The majority resolved with intracavernosal phenylephrine injection and/or cavernous aspiration (78%). Shunting was required in 10% of men. Median duration of priapism before intervention was longer for men requiring shunting than for men who did not (48 vs 7 hours, p=0.030). Patients with sickle cell disease as the etiology were less likely to require shunting compared to all other etiologies (2.2% vs 15.2%, p=0.035). Men with longer duration of priapism before treatment more often underwent shunting. However, phenylephrine injection and aspiration remained effective for priapism lasting more than 36 hours. Having sickle cell disease as the etiology of priapism was protective against requiring shunting. We developed artificial intelligence models that performed with 87.2% accuracy and created an online probability calculator to determine which patients with ischemic priapism may require shunting.

Adherence to ophthalmology referral, treatment and follow-up after diabetic retinopathy screening in the primary care setting

IntroductionTelemedicine-based diabetic retinopathy screening (DRS) in primary care settings has increased the screening rates of patients with diabetes. However, blindness from vision-threatening diabetic retinopathy (VTDR) is a persistent problem. This...

Decreased Outpatient Fluoroquinolone Prescribing Using a Multimodal Antimicrobial Stewardship Initiative.

BackgroundFluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system.MethodsIn an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics.ResultsTotal fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P < .01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P < .01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively.ConclusionA multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.

Abstract TP264: Analysis of Emergency Department Code Stroke Activations at a Large County Hospital: Real World Experience

Introduction: Code strokes are activated to rapidly mobilize hospital resources directed at stroke care. Activations for non-strokes and stroke mimics can divert attention away from patients with acute stroke or delay care of other medical emergencies. There is a drive to reduce door to treatment times in acute ischemic stroke (AIS) without a universal triage method to accurately recognize stroke. We looked at the most common reasons for activation of a code stroke in a quality improvement effort to increase the yield of correctly identifying AIS treatment. Methods: Retrospective review of prospectively collected emergency department (ED) code stroke activations between January - December 2018 at our institution. Reasons for code stroke activations, patient demographics, exam and MRI findings, and discharge and neurologist diagnoses were reviewed. Results: A total of 523 patients were activated as an ED code stroke. One hundred forty (26.8%) were discharged with a cerebrovascular-related diagnosis (20.1% AIS, 1.2% TIA, and 5.6% ICH). The average age of all acute cerebrovascular pathology is 61.5 years and the gender were found to be 57.1% male. The non-stroke group had an average age of 51.8 years and were 44.1% male. The average NIHSS of the entire cerebrovascular cohort was 9.1 (7.8 in AIS, 15.1 in ICH) compared with 4.6 in the non-stroke group. The most frequent non-stroke diagnosis was related to non-neurologic medical emergencies (25.3%), headaches and migraine (14.6%), psychiatric diagnoses (14.1%), recrudescence of prior symptoms (9.1%), and other neurologic emergencies (8.4%). Conclusion: In an era of increased treatment expectations, accurate detection of AIS is key. Current activation criteria and screening tools have a low sensitivity and specificity for AIS. They are often complex for the non-neurologist and inconsistently applied during a code stroke. In conclusion, an overwhelming majority of code strokes are not related to AIS and represent other non-neurologic medical emergencies. A simpler more accurate triage method is needed.

868 Coils and Dermabond: A Large County Hospital Experience With Gastric Varices

INTRODUCTION: Bleeding from gastric varices (GV) is associated with high mortality and morbidity. EUS-guided injection of coils, cyanoacrylate glue or both is an emerging modality for treatment of gastric varics. We present our experience using EUS injection of coils (Nester Embolization Coil; Cook Medical) and 2-Octyl-cyanoacrylate (Dermabond) glue in the treatment of bleeding gastric varices in a large county hospital setting. METHODS: Medical records of consecutivepatients undergoing EUS guided treatment of gastric varices with glue and coils between mth/yer to mth/year were reviewed.Patient characteristics were recorded including presence of cirrhosis, variceal characteristics (size, location), and intervention type. Outcomes included technical success (defined as deployment of glue and coils inside the varix with cessation of blood flow on Doppler evaluation), rebleeding events, and subsequent one month follow up were recorded. RESULTS: Total of 16 patients were treated with EUS guided injection of coils and/or glue. Three (18.8%) had active bleeding and four (25%) had stigmata of recent bleeding at the index endoscopy. The remaining 9 (46.2%) had history of bleeding from gastric varices. 15/16 patients were treated with both coils and glue injection. One patient with small varices was treated with glue injection alone. Technical success was achieved in all 16 (100%) patients. None of the patients had active bleeding at the end of the procedure. The mean number of coils inserted was 3.9 and the mean volume of glue injected was 2.1 mL. Rebleeding, defined as having repeat endoscopy for gross gastrointestinal bleeding, occurred in 3 patients within one month of the initial EUS. In one patient, rebleeding was from gastric varices and was again treated with coils and glue injection. There were no significant adverse events including pain or embolization of glue or coils. One patient had extrusion of coils into the lumen of the stomach with no active bleeding identified. CONCLUSION: In this series, we demonstrate the high technical success and efficacy of EUS guided coil and glue injection in treatment of bleeding or secondary prophylaxis of gastric varices.

Burden of Substance Abuse-Related Admissions to the Medical ICU

Admissions to the ICU related to alcohol, prescription drugs, and illicit drugs are shown to be widespread and costly. In 1993, a study revealed 28%of ICU admissions at Johns Hopkins Hospital were related to substance abuse and accrued 39%of costs. Since then, health-care expenditures have increased, and substance abuse treatment admissions have risen. We conducted a study to provide updated data on ICU utilization and costs related to licit and illicit abuse at a large county hospital in Indianapolis, Indiana. All admissions to the medical ICU at Eskenazi Hospital from March to October 2017 were reviewed. Demographics, reason for admission, relation to substance abuse and specific substance, ICU and hospital length of stay, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, mortality, insurance status, and hospital charges were collected based on chart review. A total of 611 admissions generated $74,587,280.35 in charges. A total of 25.7%of admissions related to substance abuse accounted for 23.1%of total charges. Illicit drugs were 13%of total admissions, generating 11%of charges. Alcohol-related admissions were 9.5%of total admissions, generating 7.6%of charges. Prescription drugs were 2.9%of admissions, generating 4.2%of charges. Of the substance abuse admissions, patients were generally men and 40 to 64 years of age, with longer ICU stay, higher APACHE II scores, and higher mortality. Substance abuse admissions make up almost a one-quarter of resources used by our ICU. Patients tend to be younger and sicker with a higher risk of death. Identifying and accurately describing the landscape of this current health crisis will help us take appropriate action in the future.

Awareness of relative CT utilization among peers is not associated with changes in imaging requests among emergency department providers in a large county hospital.

The purpose of this quality improvement initiative was to study the effect of providing scorecards to emergency department providers to assess its effect on changes in utilization. CT of the abdomen and pelvis, CT angiogram of the chest for pulmonaryembolism, and CT of the head were targeted due to ordering variability, cost, and radiation exposure. The utilization rate for each provider was assessed for emergency department providers. Following this, providers were given scorecards regarding their utilization as well as their relative utilization compared with each other. Utilization was then monitored following the intervention to assess the effect of the scorecard on ordering practices. No significant effect on the utilization of these 3 exams was found after the scorecard intervention. Providing scorecards to make emergency department providers aware of their relative utilization does not significantly alter ordering behavior. Incentive-based systems may be required in order to lessen overutilization of these 3 commonly ordered radiology procedures in the emergency department.

The Fuel Gauge: A Simple Tool for Assessing General Surgery Resident Well-Being

Resident well-being is an increasingly relevant issue in medical education; however, there is no consensus on how to best measure well-being. The "fuel gauge," is a simple, easy-to-use tool developed to measure resident well-being and previously applied in an Internal Medicine Residency Program at our institution. The current study sought to evaluate its acceptability and usefulness in a surgery program. Weekly fuel gauge data was retrospectively collected from August 2017 through December 2018 along with resident Postgraduate Year designations. This study was conducted at a single, large general surgery residency program that rotates through a variety of hospitals, including a University hospital, a large county hospital, a Veterans Affairs hospital, and a freestanding Children's hospital. Categorical general surgery residents at every level of training as well as preliminary interns and off service intern rotators from urology, oral and maxillofacial surgery, and otolaryngology were eligible for the study. Fuel gauge submissions which did not denote a score were excluded from analysis. Out of 130 residents, 103 (79.2%) completed at least 1 fuel gauge assessment with a weekly mean response rate of 41.5%. Low scores were submitted by 39.8% of resident participants. Narrative feedback was provided in 6.2% of submissions with increased length associated with decreased fuel gauge score. The fuel gauge was well accepted by a large general surgery program with no decline in participation rates over the study period. The tool provided residents with a direct line of communication with their program's administration, and a feasible way for the program director's office to monitor and identify residents who were struggling with regard to their well-being.

Can physicians detect hyperkalemia based on the electrocardiogram?

ObjectiveAlthough there is no consensus on how to use an electrocardiogram (ECG) in patients with hyperkalemia, physicians often obtain it in the acute setting when diagnosing and treating hyperkalemia.The objective of this study is to evaluate if physicians are able to detect hyperkalemia based on the ECG. MethodsThe study was conducted at a large county hospital with a population of end stage renal disease (ESRD) patients who received hemodialysis (HD) solely on an emergent basis. Five hundred twenty eight ECGs from ESRD patients were evaluated. The prevalence of hyperkalemia was approximately 60% in this cohort, with at least half of them in the severe hyperkalemia range (K ≥ 6.5 mEq/L). ResultsThe mean sensitivity and specificity of the emergency physicians detecting hyperkalemia were 0.19 (± 0.16) and 0.97(± 0.04) respectively. The mean positive predictive value of evaluators for detecting hyperkalemia was 0.92 (±0.13) and the mean negative predictive value was 0.46 (± 0.05). In severe hyperkalemia (K ≥ 6.5 mEq/L), the mean sensitivity improved to 0.29 (± 0.20), while specificity decreased to 0.95 (±0.07). ConclusionAn ECG is not a sensitive method of detecting hyperkalemia and should not be relied upon to rule it out. However, the ECG has a high specificity for detecting hyperkalemia and could be used as a rule in test.

MON-613 Lipid Abnormalities In Thyroid Dysfunction.

The relationship between thyroid hormone levels and lipid disorders was first described decades ago when physicians relied on laboratory data from older assays. From these studies, the association between thyroid hormone levels and low-density lipoprotein-cholesterol (LDL-C) was well established. However, little data exists assessing the relationship between modern thyroid assays and lipid levels as well as lipoproteins other than LDL-C. We hypothesized that thyroid dysfunction affects all lipids and lipoproteins with substantial variability between patients. We queried the electronic medical records of a large county hospital in Dallas, TX assessing all patients who had thyroid function tests (TSH and Free T4) and lipid panels done on the same day from 1/1/2013 to 1/1/2018. We stratified test results into hypothyroid (TSH > 4.5 mcIU/L and Free T4 < 0.8 ng/dL), hyperthyroid (TSH < 0.5 mcIU/L and Free T4 > 1.8 ng/dL) and normal (0.5 ≤ TSH ≤ 4.5 mcIU/L, 0.8 ≤ Free T4 ≤ 1.8 ng/dL). Results consistent with subclinical hyper- and hypothyroidism were excluded. Each group was analyzed and compared for triglycerides, total cholesterol, HDL-C, non-HDL-C and LDL-C levels. Our query identified 25,290 unique results for thyroid hormones and lipid panels checked on the same day. Of these, 2,918 (11.5%) were hypothyroid (mean TSH 41 mcIU/L, Free T4 0.6 mcIU/L), 1,152 (4.5%) were hyperthyroid (mean TSH 0.08 mcIU/L, FT4 2.7 mcIU/L), and 23,332 (92.2%) were normal (mean TSH 2.0 mcIU/L, FT4 1.2 mcIU/L). Overall, the hypothyroid group had the highest levels of lipids/lipoproteins: total cholesterol mean (SD) hypothyroid 232 (93) vs normal 186 (51) vs hyperthyroid 155 (42) mg/dL, p < 0.001; LDL-C 126 (49) vs 103 (36) vs 83 (31) mg/dL, p < 0.001; non-HDL-C 179 (91) vs 133 (46) vs 107 (36) mg/dL, p < 0.001; triglycerides median (IQR) 163 (114, 273) vs 123 (118, 184) vs 101 (78, 144) mg/dL, p < 0.001. HDL-C was slightly lower in both hypothyroid and hyperthyroid groups: 49 (19) vs 51 (16) vs 47 (16), p < 0.001. Among the hypothyroid, 8% (n = 229) had triglycerides levels ≥ 1000 mg/dL, and 10% (n = 284) had LDL-C ≥ 190 mg/dL without increased triglycerides. Our results confirm that thyroid dysfunction affects all lipids and lipoproteins: all but HDL-C were increased in hypothyroidism and decreased in hyperthyroidism. Additionally, we found that among hypothyroid patients, variability may exist in the lipid response to thyroid hormone. Some patients developed hypertriglyceridemia, placing them at risk for pancreatitis, while other patients were found to have severe hypercholesterolemia, potentially increasing their risk of coronary artery disease. Our results reinforce the need to check all hypothyroid patients for abnormalities in lipid and lipoproteins. Additional work is required to understand why a variability in lipid response may exist.