Mandatory Consultation Research Articles

Evaluating the impact of a specialized and centralized online medical consultation system for paramedics: pilot study.

There are many limitations to utilizing on-duty emergency department (ED) physicians as Base Hospital Physicians for paramedic telephone consultations. We aimed to examine the impact of a specialized and centralized Online Medical Consultation program for paramedic consultations on system-relevant performance. This is a before-after study with concurrent control using health record review of audio recordings over a 6-month period before and after implementation of the Online Medical Consultation program. The primary outcome was the duration of paramedic consultation calls. The secondary outcomes included number of calls with orders that contradicted existing medical directives, number of calls with orders outside of paramedic scope of practice, number of calls with Base Hospital Physician requiring clarification on medical directives, and number of calls with Base Hospital Physician interrupting the paramedic during the call. We included 220 consultation calls. The patients' mean age was 54.5years. Most consultation calls (70.5%) were for mandatory consultations and 22.7% were voluntary. Most consultations were related to cardiac arrest (43.6%), combative patients (15.0%), and analgesia (13.6%). Before-after comparisons for total call duration showed that mean call duration decreased in Ottawa from 4:28 to 4:05min (p = 0.77) and decreased in Kingston from 4:50 to 4:13min (p = 0.49). There were no significant differences in our secondary outcomes. The Online Medical Consultation program was implemented and removed the responsibility of responding to online medical consultations for on-duty emergency physicians in Ottawa. The total call duration was not significantly different between groups. Additional time intervals and adherence to protocol benefits were also not statistically significant due to low baseline incidence.

Routine Infectious Diseases Consultations on a Pediatric Cardiac Unit to Improve Positive Blood Culture Management.

Bacteremia can be life-threatening, and highly medicalized patients, such as those with complex congenital heart disease, are at high risk. Infectious diseases (ID) consultation is associated with improved outcomes in bacteremia. We noted an opportunity for improvement in management of positive blood cultures in our cardiac care unit (CCU). We completed a quality improvement project that included a single plan-do-study-act cycle consisting of a policy of routine ID consultation for all positive blood cultures events in the CCU. Our outcome measure of interest was percentage of appropriately managed blood culture events, the process measure was percentage of blood culture events for which the ID service was formally consulted, and the balancing measure was number of individual patients for whom the ID service was formally consulted. Appropriate antimicrobial management was determined via chart review by an ID physician. Data were analyzed via run chart and simple statistics. Following the intervention, the rate of appropriately managed positive blood culture events increased from a baseline of 86% to 98%, and the rate of ID consultation for these events increased from 75% to 98%. A shift was noted in run charts for both the outcome and process measures. There was an increase in patients for whom the ID service was consulted throughout the entire study period. We successfully implemented mandatory ID consultations in a CCU to increase proportion of appropriately managed blood cultures. While this intervention cannot be universally applied, others may find it useful in selected scenarios.

Retailer Responses to Public Consultations on the Adoption of Takeaway Management Zones Around Schools: A Longitudinal Qualitative Analysis

Background: Takeaway food is often high in calories and served in portion sizes that exceed public health recommendations for fat, salt and sugar. This food is widely accessible in the neighbourhood food environment. As of 2019, of all local authorities in England (n=325), 41 had adopted urban planning-based interventions that can allow them to manage the opening of new takeaway outlets in ‘takeaway management zones around schools’ (known elsewhere as ‘exclusion zones’). Before adoption, local authorities undertake mandatory public consultation where responses objecting to proposals can be submitted. Evidence on common objections could be insightful for practitioners and policymakers considering this intervention. Methods: We included 41 local authorities that adopted a takeaway management zone around schools between 2009 and 2019. We identified and analysed objections to proposals submitted by or on behalf of food retailers and local authority responses to these. We used reflexive thematic analysis with a commercial determinants of health lens to generate themes, and investigated if and how objections and responses changed over time. Results: We generated four themes: The role of takeaways in obesity, Takeaway management zone adoption, Use and interpretation of evidence, and Managing external opinions. Despite not being implicated by the adoption of takeaway management zones around schools, planning consultants objected to proposals on behalf of transnational food retailers, however, independent takeaways did not respond. Objections attempted to determine the causes of poor diet and obesity, suggest alternative interventions to address them, undermine evidence justifying proposals, and influence perspectives about local authorities and their intervention. Objections consistently raised the same arguments, but over time became less explicit and expressed a willingness to partner with local authorities to develop alternative solutions. Conclusion: Objections to local authority proposals to adopt an urban planning intervention that can stop new takeaways opening near schools featured strategies used by other industries to delay or prevent population health intervention adoption. Practitioners and policymakers can use our findings when developing proposals for new takeaway management zones around schools. By using knowledge about their local context and addressing arguments against specific aspects of the intervention, they can pre-empt common objections.

Infectious Diseases Consultation Reduces Antibiotic Duration for Uncomplicated Gram-Negative Bacteremia

Background: Unlike Staphylococcus aureus bacteremia, the impact of ID consultation for gram negative bacteremia (GNB) has not been well studied. Recent literature has supported shorter courses of antibiotics in adults with uncomplicated GNB. We examined duration of therapy for adult patients with uncomplicated GNB over a period of time during which ID consultation for GNB was made mandatory. Method: NorthShore University HealthSystem is a 4 hospital, 828 bed hospital system located in the northern suburbs of Chicago. Data were collected retrospectively from 1/1/2018 through 12/31/2021 for patients 18 years or older hospitalized with an uncomplicated bloodstream infection due to Escherichia coli, Klebsiella species or Proteus species. This study was approved by the Institutional Review Board. All sources of infection were included. Days of effective antibiotic therapy were extracted manually by two pharmacists and an infectious diseases physician. During the study period, two major changes occurred: 1) the Physician Practice Council of NorthShore University Healthsystem voted in favor of a mandatory ID consultation for GNB and 2) the ID division developed a treatment algorithm for GNB management with an emphasis on shorter antibiotic duration in uncomplicated cases. This study was divided into three time periods: Pre-ID consultation – 1/1/2018 – 8/31/2019; Transition – 9/1/2019 – 5/31/2020 (after mandatory ID consultation, before ID division consensus achieved); Post-ID Consensus – 6/1/2020 – 12/31/21. Primary outcome was duration of antibiotic therapy. Secondary outcomes included in-hospital all-cause mortality and 30 day readmission. Continuous variables were described using median and interquartile range, and categorical data using frequency and prevalence. Kruskal-Wallis rank sum test for continuous and χ2 for categorical variables was used to verify similarity among the pre-ID consultation, transition and post-ID consensus periods. The analysis was performed using Python. Result: 1026 patients were included in the study. Pathogens included 773 E. coli (75.4%), 193 Klebsiella species (18.8%) and 60 Proteus species (5.9%). Length of stay, 30 day readmission and in-hospital mortality were not statistically significantly different when comparing pre-ID consultation and post-ID consensus time periods. Total duration of therapy was statistically significantly shorter in the post-ID consensus period (p < 0.001). Conclusion: Mandatory ID consultation and development of an ID consensus approach can shorten antibiotic duration in uncomplicated GNB. Further analysis will explore timing of transition to oral therapy and syndromic differences.

The Moral Dilemma of Euthanasia Through the Eyes of the Medical Society in Bulgaria.

With the development of human society, the question of the value and inviolability of human life begins to occupy a central place in the various social strata and social structures. With the adoption of the Universal Declaration of Human Rights after the Second World War, the basic postulates protecting the right to inviolability of human life were laid. The question focused on euthanasia has been discussed in several European countries, such as Germany, Ireland, France, and Italy, leading to considerable interest in the medical community in Bulgaria. A prospective study was performed using approved sample cards, analyzing the general knowledge of the medical community in the Republic of Bulgaria about euthanasia and assisted suicide over a period of four months, between January 2023 and May 2023. In this process, 623 people were surveyed, and the questionnaire included several targeted questions through electronically generated samples on the Microsoft Forms platform. The target group had doctors with and without a specialty in various fields of hospital and pre-hospital care, dentists, and students from the fields of medicine and dentistry. The results show that the majority of medical professionals clearly state their positive opinion on the adoption of a law to legalize euthanasia in the Republic of Bulgaria, clearly taking into account the fact that the right to life has always been and always will be the most absolute and fundamental human right. Contrary to the above, it is implied that it is inevitably linked to a quality and fulfilling life without suffering. Identically, they also answered that a person should have the right to know exactly when to end his own life. The medical society in Bulgaria clearly shows its positive opinion regarding the idea that the different forms of euthanasia (active euthanasia and assisted suicide) should be defined as morally and legally permissible. Our research confirms the Bulgarian medical community's opinion that the subject of the problems of euthanasia and its legal regulation are already ripe for public discussion, similar to many other European countries. The actual issue of euthanasia as a conclusion raises several questions related to the process of acceptance of standard algorithms for action in such cases where the same action is legalized by law. It also includes the process of acceptance of strict regulations by the countries for the so-called negative phenomenon "death tourism" and several other administrative actions related to the mandatory registration of every case of euthanasia, the implementation of mandatory consultations with a psychiatrist and psychologist for patients seeking euthanasia as the only possible option, and providing possible alternatives regarding their illness. This is the unchangeable cornerstone for standardizing the legalization process and acceptance of "good death" in Bulgaria. In its essence, euthanasia creates both a social and an ethical conflict in our modern society, appearing at the same time as a kind of "stress test" for the health system.

Primary care physicians' experience of caring for children with parents with mental health illness: a qualitative study among French general practitioners and paediatricians

BackgroundParental psychiatric disorders can have a significant impact on child development and the parent-infant bond, with a high risk of attachment disorders. Early identification of difficulties in the parent–child relationship is essential to prevent consequences for the child. Childcare practitioners have a major role to play in this early detection process, through regular mandatory consultations during the first two years of a child's life. Thus, the aim of this study was to collect the experience of private practitioners in their care of children of parents with a mental health illness.MethodThis is a cross-sectional, observational, qualitative study. Data were collected by means of semi-structured interviews with eleven general practitioners and private paediatricians between February and July 2021 in Toulouse and its suburbs. We only included practitioners who had followed children of parents with a mental health illness. The interviews were recorded with the agreement of the participants, before being transcribed anonymously. The data were analysed with NVivo software using interpretative phenomenological analysis.ResultsThree main themes emerged from the results, which were further divided into several sub-themes. Addressing psychiatric disorders presents a risk for the therapeutic relationship. Practitioners express a need to preserve this relationship with the parent in joint care. Care is difficult and is permeated by the parents' emotional issues. Furthermore, practitioners face a conflict between their concerns for the parent–child bond and their desire not to stigmatise these families. They express a feeling of isolation in these follow-ups. This stressful care has a significant emotional impact on the doctors. Access to psychiatric training and multidisciplinary collaboration seem to be essential to improve the follow-up experience for practitioners, as these factors strengthen inter-professional connections.ConclusionPractitioners describe a parent-doctor relationship at risk, which is underpinned by the fear of care placement. This study illustrates the need to strengthen multidisciplinary work by promoting interprofessional exchanges, in order to improve the experience of practitioners in this care process. Addressing practitioners’ fear of discussing parental psychiatric illness is very important, so as not to delay the implementation of preventive actions that are likely to improve the developmental prognosis for children.

Clinical use of densitometric analysis of lung pathology and digital data processing programs for determining surgical tactics in phthisiosurgical patients with HIV status

Objective — to determine the possibilities of using densitometric indicators of computed tomography (CT) and digital software processing of CT data in lung pathology for the formulation of personalized treatment tactics for phthisiosurgical patients with concomitant HIV pathology, and to justify the indications for surgical treatment. 
 Materials and methods. A retrospective analysis was conducted on the results of the examination and treatment of 11 patients with specific tuberculous lesions of the lungs. Specific therapy was initiated 2—3 months after the initial visit to the medical institution, and immunochromatographic tests for HIV and hepatitis, which were performed in advance, yielded doubtful (questionable) or negative results. Patients underwent a general clinical examination, echocardiogram, fibrobronchoscopy with examination of bronchoalveolar lavage for Mycobacterium tuberculosis, and molecular genetic tests of sputum or bronchoalveolar lavage. Express tests for HIV, hepatitis B, and hepatitis C, as well as routine blood and urine tests, were carried out. The Aquilion TSX-101A Toshiba (Japan) tomography was used as the main research tool. Densitometric analysis of lung parenchyma was performed using DICOM-VIEWER PHILIPS in the areas of interest. Digital analysis of images obtained from CT slices was conducted using the Dragonfly program. 
 Results and discussions. The clinical manifestation of patients’ «radiological findings» was asymptomatic in 81.8 % of cases and mostly perceived as a «post COVID-19 syndrome». The analysis of the laboratory data did not indicate specific signs of the disease in 72.7 % of cases. The study of the verified focal lesions without signs of destruction of the lung parenchyma during densitometric analysis of CT revealed densities that characterize exudative processes in the lung parenchyma (0—15 HU), which is a characteristic sign of a specific inflammatory process in the context of HIV infection. Histologically, high activity of a specific inflammatory process was detected in operated patients. During digital software processing, we observed a shift in densitometric indicators that are characteristic of the exudative phase of inflammation. Situations of HIV-associated infection and alteration-exudative reactions were noted, which were 100 % determined by densitometric analysis and digital software processing of the chest CT scan. Six patients underwent surgery on (2 lobectomies, 1 combined resection and 3 sublobar resections). Among the non-operated patients, 3 experienced a recurrence of a specific inflammatory process, and 1 patient still exhibits significant morphological changes in the parenchyma.
 Conclusions. Densitometric analysis and digital software processing of CT scan allows you to objectify the patient's condition and reasonably prescribe personalized therapy. Identified patients with X-ray lesions of the lungs require a mandatory consultation with a thoracic surgeon and consideration of the issue of surgical treatment within 2—3 months after the start of specific therapy.

Konstytucja RP a egzorcyzmy

This article examines the determinants and consequences of the rite of exorcism from the constitutional law perspective. The study was limited to exorcism in the Roman Catholic Church due to its dominance in the religious composition of population in Poland. Exorcism is clearly a manifestation of religion, and it is argued that its performance should be subject to constraints justified by the need to protect the health and the right to humane treatment of the exorcised. Therefore, it is necessary to call for the establishment of legal restrictions, both preventive (mandatory medical consultation before performing the rite, mandatory medical examination for exorcists) and ex-post (ban on performing the rite on a given category of people). On the other hand, an absolute ban on exorcisms would violate the essence of the freedom to manifest religion and would not satisfy the requirements of proportionality.

947. Evaluating the Outcomes of Infectious Diseases Consultation on methicillin susceptible Staphylococcus aureus Bacteremia

Abstract Background In 2014, an institutional project was completed assessing outcomes of beta-lactams versus vancomycin in patients with MSSA bacteremia. This research led to the development and implementation of a new standard of care for Staphylococcus aureus bacteremia using a bundle set that included ID consultation. The purpose of this research is to evaluate the impact mandatory ID consultation had on patient outcomes since this bundle set was implemented at our institution. Methods This was a quasi-experimental, single center study of adults with MSSA bacteremia admitted from April 1, 2018 to August 31, 2021. In the instance of patients with multiple admissions with MSSA bacteremia, data from only the first admission was included in the final analysis. Patients were excluded if they had polymicrobial bacteremia or expired within 48 hours of admission. Patients were identified by utilizing reports generated from the pharmacy clinical decision support software of patients with at least one blood culture positive for MSSA. Patients in this list were further screened through manual chart review for inclusion and exclusion criteria. The primary endpoint of this study is inpatient mortality in the setting of MSSA bacteremia with and without an ID consultation. Inpatient mortality was defined as death by any cause during hospital admission. Secondary endpoints included time to bacterial clearance, ID consultation, and mortality. Results Of the patients included, only 42 percent of patients in the pre-bundle set group were treated with MSSA targeted therapy (beta-lactam), in comparison to 86 percent in the post-bundle set group. The difference in secondary outcomes was not statistically significant. For the primary outcome of inpatient all-cause mortality, a 10 percent difference was found between the pre and post-bundle set groups, 18% vs. 8% (p = 0.01). The multivariate regression analysis also confirmed that the presence of an ID consult had a significant relationship with decreased mortality (p = 0.01). Conclusion The all-cause mortality rate of adult patients with MSSA bacteremia significantly decreased after implementation of the Staphylococcus aureus bacteremia bundle set requiring an ID consultation. Disclosures All Authors: No reported disclosures.

948. Impact of a Multi-pronged Approach to Antimicrobial Stewardship on the Vascular Ward at a Tertiary Hospital

Abstract Background Up to 50% of inpatient antibiotic use may be inappropriate, and guideline concordance for antibiotic prescribing in surgical wards tends to be lower than medical wards. As such, our study describes a multi-pronged approach to antimicrobial stewardship (AMS) targeting a vascular ward and its impact on improving antibiotic use. Methods This is a quality improvement study at a tertiary hospital in British Columbia, Canada. All patients admitted to the vascular surgery ward for any vascular related issues and who received piperacillin-tazobactam or a carbapenem were included. Patients were excluded if admitted to the ward for < 48 hours. The primary outcome is appropriateness of carbapenem and piperacillin-tazobactam use in concordance with local policies. Secondary outcome is consumption of these agents. The pre-intervention period was March 2020 to June 2020. The AMS team prospectively reviewed included patients to establish the baseline level of appropriate antibiotic use. The intervention period was from July 2020 to February 2021. Aside from presentations to surgeons, the main intervention was regular audit and feedback to a nurse practitioner who rounds with the surgeons. Mandatory ID consultation for carbapenems was the last resort if AMS recommendations were not accepted. Results During the pre-intervention period, 19 out of 25 prescriptions (76%), either carbapenem or piperacillin-tazobactam, had appropriate indications. In the intervention period, 121 prescriptions were reviewed and the appropriateness level increased to 87% (Figure 1). Eleven mandatory ID consultations were generated. The mean days of therapy (DOT) per 1000 patient-days for carbapenem decreased from 94.6 to 56.6 for pre- and intervention periods, respectively. For piperacillin-tazobactam, the mean DOT per 1000 patient-days decreased from 209.9 to 138.5 for pre- and intervention periods. The reduced usage of piperacillin-tazobactam remained sustainable post-intervention (Figure 2). Figure 1:Summary of patient characteristics and outcomes during intervention period (July 2020 to February 2021)Figure 2:Usage of piperacillin-tazobactam from June 2019 to June 2021 Conclusion A multi-pronged approach, consisting of education, prospective audit and feedback to the surgical team, and mandatory ID consult in selected cases, is effective in decreasing inappropriate broad-spectrum antibiotic use on the vascular ward at a tertiary centre. Disclosures All Authors: No reported disclosures.

Paramedic Clinical Consults with a Paramedic or Nurse in an EMS Communications Center Compared to Traditional Online Physician Consults

Objectives In many emergency medical services (EMS) systems, a direct medical oversight physician is available to paramedics for mandatory and/or elective consultations. At the time of this study, a clinical support desk (CSD) was being implemented within the medical communications center of a provincial EMS system in addition to the physician resource. The CSD was initially staffed with a registered nurse or an advanced care paramedic. The objective of the current study was to compare CSD “peer to peer” consults versus physician consults with regards to consultation patterns, transport dispositions, and patient safety measures. Methods This retrospective cohort study analyzed 2 months before (September 1 to October 31, 2012) and 2 months after (September 1 to October 31, 2013) implementation of the CSD. In the before period, all clinical consults were fielded by the direct medical oversight physician. In the after period, consults were fielded by the physician, CSD or both. EMS databases were queried, and manual chart review and abstraction of audio recordings were done. Relapses back to EMS within 48 hours of non-transport were measured. Results 1621 consults were included, with 764 consults in the before period and 857 after (p = 0.02). The number of physician consults decreased from 764 before to 464 after (39.2%, p < 0.001), with the CSD taking 325 (37.9%) consults. The CSD was consulted more for police custody and trip destination. The physician was consulted more for cease resuscitation and clinical consults prior to medication administration. Overall non-transport rates were 595/764 before (77.9%), and 646/857 after (75.4%) (p = 0.2). Non-transports were 233/325 (71.7%) via the CSD, 364/464 (78.4%) via the physician, and 49/68 (72.1%) when both were involved (p = 0.07). Rate of relapse to EMS was similar before (25/524, 4.8%) and after (26/568, 4.6%) (p = 0.76), and between CSD (12/216, 5.5%) and physician consults (13/325, 4.0%) in the after period (p = 0.41). Conclusion The introduction of a novel “peer-to-peer” consult program was associated with an increased total number of consults made and reduced call volume for direct medical oversight physicians. There was no change in the patient safety measure studied.

The Key to Democracy: Mandatory Pre-Legislative Consultation

India’s policy of public consultation in the legislation process is currently not mandatory. The concept of pre-legislative scrutiny and inclusion of the public has proven to be an invaluable addition to the democratic process, and the absence of the same has led to instances of widespread protest and discontentment. The policy of pre-legislative scrutiny was introduced in 2014. However, certain bills passed post-2014 have witnessed public outcry over its lack of consultation and majority stakeholders’ adverse effects. This paper aims to highlight the importance of pre-legislative scrutiny and provide for a mandatory method to be followed while implementing a mandatory process of pre-legislative scrutiny. A democratic political structure is one that is based on the rule of law. Without the rule of law, there will be no political future. The aim of this paper is to examine the status of the rule of law in the current political environment, with the rule of law as the dependent variable and fundamental rights, inequality, an open parliament, and an autonomous judiciary as independent variables. The requisite data was gathered from written and online media in order to assess the rule of law. Only the rule of law and effective state institutions will enable a federal democratic republic to thrive.

Clinical impact of physician staffing transition in intensive care units: a retrospective observational study

BackgroundIntensivists play an essential role in improving the outcomes of critically ill patients in intensive care units (ICUs). The transition of ICU physician staffing from low-intensity ICUs (elective intensivist or no intensivist consultation) to high-intensity ICUs (mandatory intensivist consultation or a closed ICU) improves clinical outcomes. However, whether a transition from high-intensity to low-intensity ICU staffing affects ICU outcomes and quality of care remains unknown.MethodsA retrospective observational study was conducted to examine the impact of high- versus low-intensity staffing models on all-cause mortality in a suburban secondary community hospital with 400 general beds and 8 ICU beds. The ICU was switched from a high-intensity staffing model (high-former period) to low-intensity staffing in July 2019 (low-mid period) and then back to high-intensity staffing in March 2020 (high-latter period). Patients admitted from the emergency department, general ward, or operating room after emergency surgery were enrolled in these three periods and compared, balancing the predicted mortality and covariates of the patients. The primary outcome was all-cause mortality analyzed using hazard ratios (HRs) from Cox proportional hazards regression. An interrupted time-series analysis (ITSA) was also conducted to evaluate the effects of events (level change) and time.ResultsThere were 962 eligible admissions, of which 251, 213, and 498 occurred in the high-former, low-mid, and high-latter periods, respectively. In the matched group (n = 600), the all-cause mortality rate comparing the high-former period with the low-mid period showed an HR of 0.88 [95% confidence interval (CI), 0.56, 1.39; p = 0.58] and that comparing the high-latter period with the low-mid period showed an HR of 0.84 [95% CI, 0.54, 1.30; p = 0.43]. The result for comparison between the three periods was p = 0.80. ITSA showed level changes of 4.05% [95% CI, -13.1, 21.2; p = 0.63] when ICU staffing changed from the high-former to the low-mid period and 1.35% [95% CI, -13.8, 16.5; p = 0.86] when ICU staffing changed from the low-mid to the high-latter period.ConclusionThere was no statistically significant difference in all-cause mortality among the three ICU staffing periods. This study suggests that low-intensity ICU staffing might not worsen clinical outcomes in the ICU in a medium-sized community hospital. Multiple factors, including the presence of an intensivist, other medical staff, and practical guidelines, influence the prognosis of critically ill patients.

PSUN218 The Impact of Mandatory Pre-Operative Endocrinology Outpatient Consultation Before Elective Surgery in Patients with Diabetes Mellitus

Abstract Introduction A multi-departmental quality improvement initiative by endocrinology, internal medicine, surgery, and anesthesia became effective, making it the standard of care to call for an outpatient endocrinology consult for diabetic patients undergoing elective surgery in our hospital. Aim We tested our hypothesis that mandatory endocrinology consults prior to elective surgery decreases negative outcome parameters in patients with poorly controlled diabetes. Material and Method: Patients with diabetes mellitus (T2DM) who had an HbA1C 8% and above and who were planned to have elective surgery were seen by Endocrinology Service as an outpatient before the surgery date and were cleared until fasting glucose is less than 200 mg/dl or HbA1c is less than 8%. Retrospective analysis of 64 inpatient elective T2DM surgical patients, with no endocrine consults from 09/2019-12/2019 (Group I), comparing with 51 inpatient elective T2DM surgical patients from 09/2020-12/2020, with endocrine consults prior to surgery (Group II). Exclusion criteria: Emergency surgical patients and patients who received endocrine consults prior to surgery from September – December 2019. Primary outcome measure: Average capillary glucose, length of stay (LOS), the number of patients with hypoglycemic episodes (&amp;lt;70 mg/dl), hypoglycemia rate (number of glucose readings less than 70 mg/dl/the total number of capillary glucose measurements), readmission rate and infection rate. Mainly non-parametric statistical tests were utilized. Results There were 64 patients without endocrinology consult in 2019 (Group I) and 51 patients with endocrinology consult in 2020 (Group II). Although it was a mandatory policy, only 11 out of 51 patients were consulted to endocrinology. There was no difference in baseline characteristics of age, gender, average HbA1c, and type of surgery between the two groups. Average glucose during hospital stay, the number of patients who had hypoglycemia (13% versus 6%), average LOS, readmission within 30 days and postoperative infection rate were not statistically different between Group I and II. In Group I hypoglycemic events were 2% of all the capillary glucose measurements performed (17 hypoglycemia out of 852) and in Group II hypoglycemic events were %0.5 (3 out of 653) of all the capillary glucose measurements performed during surgical admission (p&amp;lt;0.05). The number of hypoglycemic events were lower with preoperative endocrine consults. Limitations of this study include fewer elective surgeries in 2020 due to Covid-19. Conclusion The number of hypoglycemic events were lower in patients with diabetes and preoperative mandatory endocrinology consultation. There was no difference in average glucose, LOS, the number of subjects with hypoglycemia, readmission or infection rate. The study should be repeated after more education about mandatory preoperative endocrinology consults to surgeons is delivered and after the COVID pandemic is over, when there are no restrictions on elective surgery. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ODP216 Interventional Study To Reduce The Readmission Rate In Type 1 Diabetics Hospitalized For Diabetic Ketoacidosis

Abstract Introduction Diabetic ketoacidosis (DKA) is an emergency associated with a high mortality rate. 25% of DKA readmissions in the U. S. A are preventable and they lead to an increase in the mortality rate and the length of the hospital stay with each new admission. In our study, we set out to decrease the DKA readmission rate at our hospital which is a community teaching hospital by assessing the predictors of readmission in adults with type 1 diabetics hospitalized for DKA. Methods The study was an interventional study conducted between February 2021 and May 2021. All the type 1 diabetics who were on insulin and had DKA admissions in the past three months were included in the study. After a literature review of the risk factors of DKA readmission, a questionnaire was designed to gather information from the patients. The ABCD (A: age; B: behavioral health; C: coverage; D: drug/alcohol abuse) score was used for DKA readmission risk assessment on admission. The insulin delivery technique of the patients was assessed and proper training on the technique was given before discharge. All the DKA admissions received mandatory endocrinology consult and the note template of the endocrinology consult note in the electronic medical record system was modified to let the primary team know about the discharge instructions, medications, and follow-up appointments in detail. Patients were followed up with a telehealth visit in a week and physical endocrinology clinic follow-up 3 weeks after discharge. Results Our study included 69 patients admitted with a diagnosis of DKA. The average HbA1C in the study was 11.8. Predictors of readmission were female sex (Hazard Ratio [HR]: 1.74, 95% CI: 1.64 - 1.80, p&amp;lt;0. 001), hypertension (HR: 1.98, 95% CI: 1.80 - 1.95, p&amp;lt;0. 001), discharge against medical advice (HR: 1.74, 95% CI: 1.53 - 1.96, p&amp;lt;0. 001). The readmission rate at the hospital was 20.8% initially and dropped to 13.7% after the interventions. 78% of the population were administering insulin the wrong way. The 'ABCD' score of the patients had a statistically significant correlation with the readmission rate. A difference in difference study model was used to assess the significance of the interventions on the readmission rate. Linear regression was run with significant R square, F- test values. Conclusions The study revealed that the major risk factors for readmission were lower socioeconomic status, co-morbidities, poor health literacy, and drug abuse. The study highlighted the importance of inpatient education, specialty care, better discharge instructions, coordination of care, and post-discharge support to reduce the DKA readmission rate. Presentation: No date and time listed

State Member Board Briefs

The number of opioid prescriptions in Alabama have fallen for an eighth consecutive year, according to a report released by the American Medical Association on September 8, 2022. Additional data released in the report also showed that: Opioid prescriptions in Alabama decreased 41.6% from 2012–2021. From 2020–2021, opioid prescriptions in the state declined 1.6%, marking the eighth consecutive year the number of opioid prescriptions in Alabama has dropped.The dosage strength of opioid prescriptions fell 52.7% from 2012–2021 and dropped 6.5% between 2020–2021.Prescriptions of naloxone to treat patients at risk of an opioid overdose rose 851% between 2012–2021 and 35.4% from 2020–2021.Physicians and other healthcare professionals accessed the state’s Prescription Drug Monitoring Program more than 5.5 million times in 2021, an increase of three percent from 2020. Healthcare providers who dispense opioids in Alabama must report the information to the Prescription Drug Monitoring Program to help physicians detect the abuse and misuse of prescriptions.The Medical Association of the State of Alabama was one of the first medical associations in the country to offer a continuing education course to train physicians on safely and effectively prescribing opioids. Since 2009, more than 8,000 prescribers in Alabama have completed the course.“Alabama physicians are advancing the fight against the opioid crisis by continuing to reduce the number and potency of prescribed opioids in our state, and by furthering our education on opioids,” said Dr. Julia Boothe, President of the Medical Association of the State of Alabama. “While we are making good progress in these areas under a physician’s control, Alabama is in a worsening overdose epidemic due primarily to illicitly manufactured fentanyl, which is found in more than 75% of counterfeit pills and other substances. No community is safe from this poison.”Source: Alabama State Medical Board of Medical Examiners and Medical Licensure Commission Announcement, September 8, 2022The Medical Board of California recently took a significant step in updating its Guidelines for Prescribing Controlled Substances, last updated in November 2014. The Board released a draft of its updated guidelines on its website and solicited input from stakeholders at a July 14, 2022, Interested Parties Meeting.After considering all the feedback and incorporating proposed changes from stakeholders where appropriate, the task force and Board staff plan to present the revised guidelines to the Board at a future Board meeting.The Board’s revised guidelines now place the decision of what to prescribe to patients solely on the physician and the needs of the patient. The guidelines highly encourage physicians to document their prescription decisions in the patient’s medical record and keep the records up to date.The guidelines also incorporate legislation such as the mandatory consultation of Controlled Substance Utilization Review and Evaluation System (CURES) before prescribing schedule II–IV controlled substances, and the requirement to prescribe all controlled substances, with certain exemptions, electronically.Source: Medical Board of California News, Volume 161, Second Quarter EditionOregon Psilocybin Services (OPS) is a new section housed within the Oregon Health Authority (OHA) Public Health Division’s Center for Health Protection. OPS will implement Ballot Measure 109, which was passed in November 2020 and directs the OHA to license and regulate the manufacturing, transportation, delivery, sale, and purchase of psilocybin products, as well as the provision of psilocybin services.OPS will begin accepting applications for licensure in early 2023. Until then, the section is in a development period, working to build the nation’s first regulatory framework for psilocybin services.Source: Oregon Health Authority websiteVirginia Governor Glenn Youngkin has appointed 5 new members to the Board of Medicine. They are Peter Apel, MD (6th Congressional District), Randy Clements, DPM (Roanoke), Hazem Elariny, MD (8th Congressional District), William Hutchens, MD (11th Congressional District), and Krishna Madiraju, MD (10th Congressional District). The 5 members whose terms have expired and have rotated off the Board are Jim Arnold, DPM, Amanda Barner, MD, Milly Rambhia, MD, Brenda Stokes, MD and Khalique Zahir, MD.The Virginia Board of Medicine has selected Blanton Marchese, Citizen member from Midlothian as President, David Archer, MD, OB/GYN, from Norfolk as Vice-President, and Alvin Edwards, PhD, from Charlottesville as Secretary-Treasurer.Source: Virginia Board of Medicine Board Briefs #94, April 2022

Allokation von einmalig zu applizierenden Arzneimitteln bei Kindern in globalen Compassionate Use-Programmen

ZusammenfassungCompassionate Use beschreibt die Anwendung zulassungsüberschreitender Arzneimittel für Patient*innengruppen, die an einer lebensbedrohlichen oder zu einer schweren Behinderung führenden Erkrankung leiden, ohne dass eine alternative Therapieoption besteht. An Ärzt*innen vorbei werden solche Programme ausschließlich von Pharmaunternehmen initiiert, was viele ethische Konflikte mit sich bringt. Eine neue Dimension erreichte das 2020 gestartete Programm für Onasemnogenum abeparvovecum zur Therapie von Spinaler Muskelatrophie bei Kindern, welches die Krankheit nach nur einmaliger Gabe stoppen sollte. Die globale Allokation von nur 100 zur Verfügung gestellten Dosierungen per Losverfahren stellte ein Novum bei der Allokation in Compassionate Use-Programmen dar und wurde vielfach kritisiert. Diese Arbeit untersucht mögliche alternative Allokationsprinzipien auf das Beispiel von Onasemnogenum abeparvovecum. Für jedes in Frage kommende Prinzip der Allokation medizinischer Güter bestehen Aspekte, die im Hinblick auf die drängende Zeit und die globale Verteilung bedacht werden müssen. Dies lässt einige Prinzipien wie First-Come-First-Served vernachlässigbar erscheinen. Verbliebene Prinzipien werden hierarchisch geordnet, um einen Algorithmus abzuleiten, der eine Alternative zum Losverfahren darstellen kann. Eine Kombination von Teilnahmebereitschaft bei Forschung, Dringlichkeit und Erfolgsaussicht (bezogen auf die Existenz supportiver Therapieoptionen) kann in ähnlichen Fällen bei zukünftigen globalen Compassionate Use-Programmen bei Kindern erwogen werden. Da universelle Algorithmen nur schwer definierbar sind, sollten Allokationskriterien in jedem Fall durch ein unabhängiges Expert*innengremium diskutiert werden. Sowohl die Konstitution eines solchen Gremiums sowie deren verpflichtende Konsultierung sind gefordert, um für Entlastung aller Beteiligten zu sorgen und Willkür vorzubeugen.

Impact of Infectious Disease Consultation on S. aureus Bacteremia Mortality

Objective: This study evaluated the impact of a hospital policy requiring infectious disease (ID) consultation and follow-up from an antimicrobial stewardship (AMS) pharmacist-driven team on S. aureus Bacteremia (SAB) patient mortality and improved clinical outcomes. Methods: This retrospective study included adult inpatients with SAB from 1 August 2016 to 30 May 2018 (pre-policy) and June 1 2018 to 29 February 2020 (post-policy). The primary outcome variable was in-hospital mortality, and secondary outcomes were 30-day readmission rate, acute kidney injury (AKI) at discharge, stay length, and adherence to evidence-based treatment. Results: The final sample included 435 patients for analysis. Management by non-ID physicians was associated with an 8.1 increased likelihood of mortality while hospitalized (CI 95%, 3.701–17.569). Overall mortality was reduced from 11% (n = 25) pre-policy to 6% (n = 13) after policy implementation (p = 0.07). Patients with antibiotics managed by non-ID physicians were 3 times more likely to be readmitted within 30 days. Those with a history of being immunocompromised (64% vs. 36%), or cardiovascular disease (56% vs. 44%), and patients whose providers followed guidelines (23% vs. 7%) were more likely to be discharged with AKI. Policy implementation reduced non-consultant cases from 11% to 0%. Conclusion: A policy of mandatory ID consultation with pharmacist-driven AMS review to ensure compliance can improve patient mortality, 30-day readmission rates, and clinical outcomes.

Pharmacy naloxone codispensing: A mixed methods study of practices and perspectives under a statewide standing order program

BackgroundIn a previous statewide naloxone purchase trial conducted in Massachusetts, we documented high levels of naloxone accessibility, upon patient request, under the state’s naloxone standing order (NSO) program. Equally important for reducing overdose mortality rates is expanding naloxone access via codispensing alongside opioid prescription and syringe purchases at pharmacies. ObjectiveTo understand naloxone codispensing from the perspective of pharmacists under the Massachusetts NSO program. MethodsThe study used a mixed methods design involving 3 focus groups and a quantitative survey. Participants in both the focus groups (N = 27) and survey (N = 339) were licensed Massachusetts pharmacists. Focus groups were conducted at 3 separate professional conferences for pharmacists. The survey was conducted using a stratified random sample of 400 chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. Quantitative and qualitative analyses examined current policies, practices, and attitudes regarding naloxone codispensing for patients at risk of opioid overdose. ResultsMost pharmacists (69%) reported that they, their pharmacy, or both promoted codispensing alongside opioid prescriptions. A majority promoting naloxone codispensing did so for patients prescribed high opioid dosages (80%); fewer promoted codispensing for patients also prescribed benzodiazepines (20%). Facilitators to codispensing were pre-existing relationships between pharmacists and prescribers, mandatory pharmacist consultation, and universal naloxone promotion to all patients meeting certain criteria. Barriers to codispensing were pharmacists’ concerns about offending patients by initiating a conversation about naloxone, insufficient technician training, workflow and resource constraints, and misconceptions surrounding naloxone. We found no substantive differences in outcomes between chain and independent pharmacies. ConclusionWe documented several facilitators and barriers to naloxone codispensing in Massachusetts pharmacies. Areas amenable to intervention include increased training for front-line pharmacy technicians, mandatory pharmacist consultation for opioid-prescribed patients, workflow reorganization, and addressing stigma concerns on the pharmacist end.

The impact of intensive care unit physician staffing change at a community hospital.

Objectives:A high-intensity staffing model has been defined as either mandatory intensivist consultation or a closed intensive care unit in which intensivists manage all aspects of patient care. In the current climate of limited healthcare resources, transitioning to a closed intensive care unit model may lead to significant improvements in patient care and resource utilization.Methods:This is a single-center, retrospective cohort study of all mechanically ventilated intensive care unit admissions in the pre-intensive care unit closure period of 1 October 2014 to 30 September 2015 as compared with the post-intensive care unit closure period of 1 November 2015 to 31 October 2016. Patient demographics as well as outcome data (duration of mechanical ventilation, length of stay, direct costs, complications, and mortality) were abstracted from the electronic health record. All data were analyzed using descriptive and inferential statistics. Regression analyses were used to adjust outcomes for potential confounders.Results:A total of 549 mechanically ventilated patients were included in our analysis: 285 patients in the pre-closure cohort and 264 patients in the post-closure cohort. After adjusting for confounders, there was no significant difference in mortality rates between the pre-closure (40.7%) and post-closure (38.6%) groups (adjusted odds ratio = 0.82; 95% confidence interval = 0.56–1.18; p = 0.283). The post-closure cohort was found to have significant reductions in duration of mechanical ventilation (3.71–1.50 days; p < 0.01), intensive care unit length of stay (5.8–2.7 days; p < 0.01), hospital length of stay (10.9–7.3 days; p < 0.01), and direct hospital costs (US $16,197–US $12,731; p = 0.009). Patient complications were also significantly reduced post-intensive care unit closure.Conclusion:Although a closed intensive care unit model in our analysis did not lead to a statistical difference in mortality, it did demonstrate multiple beneficial outcomes including reduced ventilator duration, decreased intensive care unit and hospital length of stay, fewer patient complications, and reduced direct hospital costs.