Adult Medical Care Research Articles

Burden of Device-Associated Infections in an Adult Medical and Surgical Intensive Care Units of a Tertiary Care Hospital in Egypt

Burden of Device-Associated Infections in an Adult Medical and Surgical Intensive Care Units of a Tertiary Care Hospital in Egypt

The benefits of non-invasive ventilation for Community-Acquired Pneumonia: A meta-analysis.

There is an observed international increase in NIV application as an alternative to endotracheal intubation in non-COPD patients admitted with community acquired pneumonia despite the lack of strong evidence for its use. The aim of this study is the meta-analysis of data from randomised-controlled trials on the effectiveness of non-invasive ventilation versus standard medical care in adults admitted with severe community-acquired pneumonia. Monthly electronic searches on CENTRAL and MEDLINE were performed between September 2017 and October 2019. Only randomized controlled-trials comparing non-invasive ventilation to standard medical care for the treatment of community-acquired pneumonia in adults were eligible for inclusion. The primary outcomes were the rate of endotracheal intubation (ETI) and the proportion of patients meeting the criteria of ETI as defined by the investigators. Secondary outcomes were the ICU and hospital mortality rate. Study eligibility was independently assessed by two investigators. The risk of bias of included studies was assessed using Cochrane's Risk of bias Tool. Four RCTs involving a total of 218 participants were eligible for inclusion. Results from the meta-analysis showed that NIV significantly reduced rate of ETI (RR = 0.46, 95% CI [0.26, 0.79]), the proportion of patients that met the criteria for ETI (RR = 0.28, 95% CI[0.16, 0.49]) and ICU mortality rate (RR = 0.3, 95% CI[0.09, 0.93]). No significant effect on hospital mortality rate was found (RR = 0.44, 95% CI [0.05, 3.67]). The authors rated quality of evidence based on GRADE criteria as 'Moderate' for the rate of intubation and proportion of patients meeting ETI criteria outcomes, but quality of evidence for ICU and hospital mortality rate as 'Low'. This study provides evidence supporting the use of NIV as potential means of avoiding endotracheal intubation and ICU mortality, in patients with acute respiratory failure due to CAP in the critical care setting. However, there is need for further larger international studies.

Yesterday a Child, Today a Grown-Up: Reflections on Family and Team Experience of an Abrupt, Non-Linear Transition from Pediatric to Adult Medicine (FR452)

•Describe system, provider and patient/family issues that affect the experience of young adults with serious illness as they transition from pediatric to adult medicine.•Explore challenges and strategies for providers and teams navigating this transition from both the pediatric and adult medicine perspective.•Reflect on the patient and family experience while navigating this transition and its impact on medical decision-making, end-of-life care and bereavement. For young adults living with serious illnesses, the transition from pediatrics to adult medical care can be challenging and traumatic, especially if this transition occurs alongside disease progression and complex decision making. Two pediatric palliative clinicians will share their experience preparing patients and families for this transition. For these clinicians, preparing patients is nuanced and complex, as family-centered care is a core tenant of pediatric medicine. Clinicians must establish rapport and trust-building during conversations regarding future planning and adjustment. Fostering independence in a patient whose physical function or coping are regressing can be challenging and the adolescent's perceived and legal level of autonomy can be conflicting. An adult palliative care clinician will share her experience supporting patients and families in this transition. Adult clinicians often feel unprepared to care for patients and families who are accustomed to pediatric care norms. Assuming this role often requires a paradigm shift and different approaches to communication, family dynamics, and shared decision-making. Additional challenges include lack of familiarity with traditionally “pediatric” illnesses, recognition of discordance between a patient's emotional and chronological maturity level, and navigation of intricacies around information-sharing. For patients and families, this transition can feel abrupt, arbitrary, and traumatic, as patients leave long-standing providers and meet new teams. One parent will share her family's experience of transitioning to the adult setting in the midst of cystic fibrosis disease progression. She will reflect on difficult decisions faced regarding lung transplantation possibilities, family relocation, long-term management of a multi-drug resistant bacterium and ultimately, end of life care and information sharing. She will highlight her daughter's increased physical and emotional vulnerability and corresponding need for increased familial involvement and support during this challenging time, particularly around medical decision-making. Panel and audience participants will have an opportunity to integrate emerging themes into best practice.

Unmet nursing care needs on medical and surgical wards: A scoping review of patients' perspectives.

To review and synthesise research studies on surgical and medical inpatients' perceptions on unmet nursing care needs. Missed nursing care is a growing phenomenon that has been shown to adversely affect care outcomes-mainly in adult medical and surgical care settings. However, to date the aggregated and synthesised evidence of missed care comes from research that measures perceptions on missed care in surgical and medical settings from nurses, but not from the patients. Scoping review. In September 2018, three databases were searched: MEDLINE/PubMed, CINAHL and SCOPUS and papers were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were as follows: primary studies; published in peer-reviewed journals; in English or Italian; and regarding routine care provided to adult inpatients. Quality appraisal and a thematic analysis were conducted. Of the 1541 abstracts initially identified, 44 papers were included. Five themes emerged: "communication," "self-management, autonomy and education," "personal sphere," "essential physical care" and "emotional and psychological care." The majority of the unmet needs were related to the "personal sphere" and "emotional and psychological care." These unmet needs were not identified in previous literature on nurses' perspectives of missed care. Also, physical care deficits like oral hygiene were identified. It is important to take into account patients' perspectives. The themes focusing on patients' personal sphere, and emotional and psychological care, underline how patients need nurses to pay more attention to their cultural background, consider the person as a whole and for nursing care to be holistic and respectful of patients' dignity. This study intends to raise awareness amongst nurses and policymakers about the importance of addressing missed nursing care and unmet patients' needs in adult medical or surgical inpatient settings to ensure high-quality care and patient satisfaction.

Decline in Forced Expiratory Volume in 1 Second in Older Adults with Sickle Cell Disease Is Similar to Adults with Cystic Fibrosis

Introduction: In the current era of comprehensive medical care in adults with sickle cell anemia (SCA), median survival is 48 years of age (Blood, 2019 Feb 7;133(6):615-617) with cardiopulmonary disease being a major cause of mortality. Despite lung disease being a major cause of death in young adults with SCD, no evidence-based guidelines are available to follow adults with SCD with pulmonary function tests (PFT). In addition to lung disease being a major cause of earlier death, we demonstrated forced expiratory in 1 second percent predicted (FEV1%) was associated with increased probability of premature death (hazard ratio per % predicted 1.02; 95% confidence interval [CI] 1.00-1.04; p=0.037) in a prospective cohort of young adults with SCA (n=430), with a mean age of 32.6 years (Blood, 2015 vol. 126(13) pp. 1544-50). To provide additional evidence that lung function surveillance should be part of standard care for adults with SCD, we elected to compare the FEV1 volume loss in young adults with SCD to FEV1 volume loss in young adults with cystic fibrosis (CF). We selected CF because this disease is a well-established genetic disease where cardiopulmonary complications are the major cause of death. We tested the hypothesis that older adults with SCD (> 30 years of age) would have an absolute change per year in FEV1 similar to older adults with CF. If the results support the hypothesis, such a finding would provide additional evidence that monitoring decline in FEV1 in adults with SCD may lead to more targeted approaches for decreasing mortality. Method: In a retrospective cohort study design conducted at Vanderbilt University Medical Center, we evaluated the electronic records of adults with SCD and CF. Individuals with either disease must have had at least 2 pulmonary function tests (PFTs) to be included. The absolute change in the FEV1 values was analyzed and compared between the groups. Adults with SCD received PFT evaluation at least once every two years as standard care. Only the first PFT in each year was used for adults with CF and evaluation could not be done within eight weeks of a hospital admission. A multivariable mixed model regression analysis was used to predict change over time in at least 2 spirometry evaluations with a pre-specified set of covariates previously associated with FEV1 decline in SCD or CF. Results: A total of 180 and 234 adults with SCD and CF, respectively, with a mean age of 25.1 and 31.0 years, respectively, were included (see Table 1). The mean duration of follow up for adults with SCD and CF was 4.7 and 7.3 years, respectively. Using a multivariable mixed model regression analysis after adjusting for the statistically significant covariates (sex, SCD phenotype, and height for SCD; and sex, pancreatic insufficiency, and height for CF), the rate of FEV1 decline in individuals with SCD and CF over 30 years of age was 28 ml (p<0.001) and 30 ml (p<0.001) per year, respectively (p<0.001), These rates of decline were not different between the adults with SCD and CF (p=0.636), as shown in Figure 1. The rate of FEV1 change in individuals with SCD and CF between 18 and < 30 years of age was an increase of 10 ml per year (p=0.074) and a decrease of 64 ml per year (p<0.001), respectively (p=0.003). Conclusion: Our results provide clear evidence that adults > 30 years of age with SCD have a rate of decline of FEV1 similar in magnitude to adults with CF greater than 30 years of age. Our new findings, coupled with our prior results indicating that lower FEV1% predicted was associated with earlier mortality in young adults with SCD, provide clear evidence that surveillance of FEV1 decline is warranted and therapeutic trials are needed if we are going to address all of the risk factors for attenuated life-span in adults with SCD. Disclosures No relevant conflicts of interest to declare.

The Platelet Millionaire: A Rare Cause of Thrombocytosis in an Adolescent

Objectives: Primary myelofibrosis is rare in pediatrics, often manifesting as persistent idiopathic thrombocytosis.Transitions from pediatric to adult medical care can be complicated by workup requiring invasive procedures. J.M., an 18-year-old healthy male, presented for excessive gingival bleeding after wisdom tooth extraction. Workup revealed persistent thrombocytosis to 1,165K, prompting a referral to hematology-oncology. A peripheral smear was notable for many platelets but normal RBC morphology. He had splenomegaly on abdominal ultrasound and a decreased von-Willebrand's activity to antigen ratio, suggesting acquired vWD. A bone marrow biopsy was advised; however, J.M. became lost to follow up for over 9 months owing to self-reported anxiety about the procedure. He remained asymptomatic in this interim until he re-presented to clinic for easy bruising, with no other evidence of bleeding at the time. The biopsy was pursued, revealing hypercellular marrow for age with left shifted granulocytic and erythroid maturation, abnormal megakaryocytes, and 3% blasts. This was consistent with primary early myelofibrosis (PMF), positive for MF-1, CALR, and TP53 mutations and negative for JAK2 and BCR-ABL. He was transitioned to adult hematology, maintained on baby aspirin, and referred for potential allogeneic hematopoietic stem cell transplant (HSCT). PMF is characterized by marrow fibrosis due to secretion of fibroblast growth factor by clonally proliferative megakaryocytes. It is a disease of adulthood, with 67 years being the median age at diagnosis. Only 100 cases have been reported in children, most of which are secondary to AML, ALL or other malignancies.1 Most patients present with complications of extramedullary hematopoiesis or bleeding.2 Diagnosis is suggested by a leukoerythroblastic picture on peripheral smear and confirmed with a bone marrow biopsy "dry tap" revealing marrow fibrosis.3 Prognosis in pediatric PMF is difficult to predict but outcomes tend to be worse;4 TP53 mutation is rare and based on limited adult studies may portend a poorer prognosis.5 Our young patient with this rare mutation was therefore referred for HSCT evaluation. Further complicating this case was J.M.'s anxiety, which delayed definitive diagnosis by biopsy. He only agreed to it when, at the med-peds clinic, the concept of local pain management was discussed. Anticipation of upcoming procedures by primary care physicians and close follow-up is especially important for patients transitioning from pediatric to adult providers. Disclosures No relevant conflicts of interest to declare.

Increasing Competence in Pressure Injury Prevention Using Competency-Based Education in Adult Intensive Care Unit.

There is a significant focus on pressure injury prevention to promote better patient outcomes and control health care cost. In 2016, the institution's pressure injury quarterly prevalence survey showed that two-thirds of the patients surveyed who developed unit-acquired pressure injury stage 2 and greater were in the adult intensive care units. The quality improvement project used a pre- and postintervention design. The adult medical intensive care unit (MICU) executed a competency-based education project to increase staff implementation of pressure injury prevention. Following initiation of competency-based education, staff documentation of pressure injury prevention implementation increased, and unit-acquired pressure injury stage 2 and greater rates were reduced. The use of a competency-based education program may be effective in increasing pressure injury prevention in the intensive care unit.

Reversal of Severe Multiorgan Failure Associated With Sickle Cell Crisis Using Plasma Exchange: A Case Series.

Red blood cell exchange (RBCE) is the standard of care for patients with sickle cell disease (SCD) who present with severe vaso-occlusive crisis (VOC). However, subsets of these critically ill patients have progressive multiorgan failure (MOF) despite RBCE therapy. The purpose of this case series is to describe the use of plasma exchange (PLEX) for the treatment of SCD-related MOF that is refractory to RBCE. A retrospective case review of patients with severe MOF from sickle cell crisis unresponsive to RBCE who underwent PLEX in a 14-bed adult medical intensive care unit (ICU) at a tertiary care university hospital over a 4-year time period. Key laboratory data including complete blood count, indices of hemolysis, and markers of organ failure were recorded before and after both RBCE and PLEX. Our primary objective is to evaluate the effectiveness of PLEX, in addition to RBCE, on organ dysfunction, laboratory indices, and mortality. Of the 7 patients, 6 survived. Of the patients who survived, all remained hemodynamically stable during PLEX sessions and showed both clinical and laboratory evidences of improvement in hemolysis and organ function. Average time from completion of first PLEX treatment to initial laboratory signs of organ failure reversal for patients who survived was 15.6 hours, the average length of stay in the ICU was 5.6 days, and the average total length of stay in the hospital was 14 days. Plasma exchange, in addition to RBCE, may be a novel synergistic treatment option to decrease risk of mortality in patients with refractory VOC and MOF.

Evaluation of Amiodarone Use for New-Onset Atrial Fibrillation in Critically Ill Patients With Septic Shock.

Objective: To describe the use of amiodarone in critically ill, septic shock patients experiencing new-onset atrial fibrillation (NOAF) during the acute resuscitative phase of septic shock. Methods: Single-center, retrospective review of adult medical or surgical intensive care unit (ICU) patients with septic shock and NOAF. All patients received amiodarone for NOAF during the acute resuscitative phase of septic shock. The cohort was analyzed via descriptive statistics. Associations between amiodarone exposure and clinical outcomes were analyzed via a Cox proportional-hazards model. An a priori defined sensitivity analysis of hospital survivors was also employed. Main Results: A total of 239 patients were included in the analysis. Patients had a median baseline Charlson Comorbidity Index of 4 (interquartile range [IQR]: 2-6) and were acutely ill with a median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 18 (IQR: 13-22) and an incidence of mechanical ventilation of 85%. In-hospital mortality was 56% with median ICU and hospital length of stay (LOS) of 9 and 15 days, respectively. Included patients received a median of 2760 (IQR: 1110-6415) mg of intravenous (IV) amiodarone during their ICU stay. Receipt of more than or equal to 2700 mg of amiodarone was identified as an independent factor associated with longer ICU LOS (hazard ratio [HR]: 1.30; 95% confidence interval [CI], 1.10-2.28). In a sensitivity analysis of hospital survivors (n = 105), receipt of more than or equal to 2700 mg of amiodarone remained independently associated with longer ICU LOS (HR: 1.64; 95% CI, 1.05-2.58). Conclusions: Exposure to more than or equal to 2700 mg of amiodarone in the setting of NOAF and septic shock is positively correlated with longer ICU LOS. Identifying opportunities to limit amiodarone exposure and address/resolve potential precipitating causes of NOAF in this clinical scenario may reduce the morbidity associated with septic shock.

ACOG Committee Opinion No. 768: Genetic Syndromes and Gynecologic Implications in Adolescents.

As adolescents with a genetic syndrome transition to adult medical care, they may be referred to obstetrician-gynecologists for routine preventive or contraceptive services, screening, or counseling for sexually transmitted infection, or for menstrual management. Although some genetic syndromes have no physical or intellectual impairment, others have significant ones; therefore, education and gynecologic care should be based on a patient's intellectual and physical capabilities. It is important to remember that adolescents with or without a genetic syndrome are sexual beings. Thus, education about reproductive health, expectations for fertility, and healthy relationships is important when treating patients with genetic syndromes. Obstetrician-gynecologists must respect patient autonomy and avoid coercion in any discussions with a patient, including decisions about contraceptive choices, sexual activity, and pregnancy planning. Most patients who have genetic syndromes and are neurotypical can tolerate routine gynecologic examinations in the office, when necessary. A patient should not be forced to have an examination or be restrained for an examination. Obstetric care of adolescents and women with genetic syndromes can pose challenges and often requires a multidisciplinary approach from the time pregnancy is contemplated through the postpartum period. When caring for an adolescent with a genetic syndrome, individual patient and guardian concerns, medical diagnoses associated with the specific genetic syndromes, and medication interactions should be considered. Obstetrician-gynecologists are encouraged to seek out additional resources and expertise when caring for adolescents with underlying genetic syndromes.

ACOG Committee Opinion No. 768 Summary: Genetic Syndromes and Gynecologic Implications in Adolescents.

As adolescents with a genetic syndrome transition to adult medical care, they may be referred to obstetrician-gynecologists for routine preventive or contraceptive services, screening, or counseling for sexually transmitted infection, or for menstrual management. Although some genetic syndromes have no physical or intellectual impairment, others have significant ones; therefore, education and gynecologic care should be based on a patient's intellectual and physical capabilities. It is important to remember that adolescents with or without a genetic syndrome are sexual beings. Thus, education about reproductive health, expectations for fertility, and healthy relationships is important when treating patients with genetic syndromes. Obstetrician-gynecologists must respect patient autonomy and avoid coercion in any discussions with a patient, including decisions about contraceptive choices, sexual activity, and pregnancy planning. Most patients who have genetic syndromes and are neurotypical can tolerate routine gynecologic examinations in the office, when necessary. A patient should not be forced to have an examination or be restrained for an examination. Obstetric care of adolescents and women with genetic syndromes can pose challenges and often requires a multidisciplinary approach from the time pregnancy is contemplated through the postpartum period. When caring for an adolescent with a genetic syndrome, individual patient and guardian concerns, medical diagnoses associated with the specific genetic syndromes, and medication interactions should be considered. Obstetrician-gynecologists are encouraged to seek out additional resources and expertise when caring for adolescents with underlying genetic syndromes.

Affordable and high-quality outpatient adult medical care

In low- and middle-income countries (LMIC) like Bangladesh, hospitalization-requiring care for all is usually adequately provided by public institutions for poorer, and private hospitals for wealthier citizens. In contrast, outpatient medical care and pharmaceuticals require out-of-pocket payments by patients. How to provide such services which are affordable and of effectively high-quality, has been difficult to define. With increasing non-communicable disease (NCD) case-burdens in cancer and cardiovascular diseases in LMIC/Bangladesh, addressing these service challenges is becoming more urgent. We have been working to provide medical care for women with breast problems and have identified in this setting the following components as critical to meeting this affordability/quality challenge: 1. Maximal use of information technology tools; 2. Increased paraprofessional staffing; 3. Diagnostic pathways and care guidelines which are evidence-based.; 4. Increased point-of-care diagnostic services; and 5. Implementational research. While broad societal issues of poverty, human rights, governance, and education strongly influence the quality of medical care, local systemic solutions are needed if the 2030 WHO Sustainable Development Goal of lowering morbidity and mortality from NCDs by one third, is to be met.
 Bangladesh J Medicine Jan 2019; 30(1) : 44-49

158. Medical Care of Unaccompanied Asylum-Seeking Adolescents At The Geneva University Hospitals, Switzerland : A Qualitative Study To Explore The Challenges of Their Transition To Majority

The number of unaccompanied asylum-seeking adolescents (UASA) has increased in Switzerland in 2015, prompting medical teams to improve management of these young people and their transition towards adult medical care. About 5% of all UASA received in Switzerland are resettled in the region of Geneva. In 2015-2016, it locally represented a population group of 226 adolescents with numerous and complex health care needs (infectious and tropical diseases, nutritional deficiencies, long-standing illnesses and psychological distress). They all benefited from a medical check-up and follow-up by an adolescent medicine physician at the Geneva University Hospitals' Adolescents and Young Adults (AYA) Program. The aim of our project was to assess how this program prepared for the transition to the Adult Migrant Health (AMH) Program of the same hospitals. Semi-structured interviews were conducted from January to March 2017 with 6 health professionals (1 paediatrician, 1 physician in adolescent medicine, 1 Psychiatrist, 1 Psychologist, 1 Nurse and one adolescent physician working in private office) all working with unaccompanied minors in order to explore what preparations took place for minors reaching the age of majority. Interviews lasted in average 31 minutes and covered 5 main topics: 1) general information (previous professional experience with UASA, role in the transition), 2) medical and social situation of UASA before the age of 18, 3) anticipation of transition to majority, 4) challenges and opportunities of turning 18 and 5) proposals for better practice in the future. Health professionals are challenged when their patients reach majority by difficulties with network coordination, school integration and unadapted foster homes. The process of transition is described as an area of uncertainty. The need for continuity in health care was recognized; nevertheless the topic of the legal age and its consequences on the social status were rarely addressed in consultation, health professionals questioning themselves about the adequacy of their role in addressing this issue. Participants underlined the emotional consequences of this period of transition for these young people and worried about its impact on the most vulnerable. They also underlined that UASA should be considered in priority as proper adolescents before asylum seekers. This research identified the need to develop a structured medical and social transition program between the AYA Program and the AMH Program. The transition of care for young migrants is challenging for health professionals. An integrative and transversal understanding of this transition is needed, for instance by further exploring how the community responds to this transition and the impact on unaccompanied minors’ mental health. Health professionals need to address this transition during their consultation including social and legal aspects, before the age of 18, as part of the medical follow up. Results of this study allowed initiating changes, such as introducing a dedicated nurse as a link between the AYA and AMH programs and developing an interview grid to help health professionals evaluating medical and social challenges of former UASA transiting to their structures.

Drug utilization pattern in adult medical intensive care unit of a tertiary care hospital

Aims: This study aims to evaluate the drug utilization pattern in terms of Defined Daily Dose (DDD) in adult Medical Intensive Care Unit. Methods: In this prospective study conducted over a period of 8 months, data pertaining to all adult (age ≥18 years) patients' demography, diagnosis, treatment, and laboratory investigation were collected. The drugs were categorized by anatomical therapeutic classification, and their DDD was calculated. Results: A total of 452 patients were evaluated, of which 62.6% were males. The most common reason for hospitalization was cardiovascular disorder (21.4%), followed by respiratory disorder (21%) and central nervous disorder (20%). An average of 9.9 drugs was prescribed per patient. Nearly 52% of drugs were administered parenteral, 43% were oral and 5% were either nebulization or topical. Among the drugs prescribed, the most common drugs were pantoprazole, ondansetron, aspirin, furosemide, and atorvastatin and most common antimicrobials were ceftriaxone followed by piperacillin + tazobactam and metronidazole. Conclusions: Drug utilization produces an important impact on quantitative data for Intensive Care Unit patients and should be conducted regularly so as to understand the drug consumption as well as for protocol implementation to improve the quality of health care.

Sedation Variability Increases Incidence of Delirium in Adult Medical Intensive Care Unit Patients at a Tertiary Academic Medical Center.

Variability in sedation may increase the incidence of delirium and mortality, as well as increased intensive care unit (ICU) and hospital lengths of stay (LOS), despite mean Richmond Agitation Sedation Scale (RASS) scores at goal. Coefficient of variation (CV) can be used to represent variability with a higher ratio indicating increased variability. Do patients with an increased variability in sedation, as evaluated by CV in RASS, have an increased incidence of delirium? We conducted a retrospective chart review of adult medical ICU patients requiring mechanical ventilation (MV) for ≥24 hours between January and April 2013. Patients were excluded if intubated at an outside hospital, neuromuscularly blocked, suffering from anoxic brain injury, or had a goal RASS of -4 or -5. Outcomes assessed included the presence of delirium, as evaluated by the Confusion Assessment Method, RASS, CV in RASS, duration of MV, ICU, and hospital LOS, and survival. Of 45 included patients, 32 experienced delirium during their ICU admission and 13 did not. The groups were similar at baseline. There was no difference in mean RASS when comparing the delirium and nondelirium groups (-1.6 ± 1.3 vs. -1.8 ± 0.8, respectively; P = 0.61). Patients with delirium had a greater CV in RASS (0.3 ± 0.135 vs. 0.2 ± 0.105; P = 0.02), a longer MV duration [4 (2-8) vs. 3 (2-3) days; P = 0.045], and a trend toward increased ICU LOS [8 (5-12.25) vs. 4 (3-8) days; P = 0.096], but no difference in hospital LOS [13 (10-25) vs. 18 (9-39) days; P = 0.83] and survival (71.9% vs. 69.2%; P = 1.0). Medical ICU patients with delirium had a higher CV in RASS compared with patients without delirium, suggesting that greater variability in sedation may increase the incidence of delirium. Patients with delirium also had a greater duration of MV and a trend toward longer ICU LOS.

Variables Correlating to Transition of Care for the Bleeding Disorder Population at the University of California San Francisco

Background An effective and coordinated process of transitioning adolescents with bleeding disorders from pediatric to adult medical care is essential for maintaining continuity of care and establishing a lifelong medical support system. Barriers to transition among people with a bleeding disorder (PWBD) at the University of California San Francisco (UCSF) are currently unknown.Objective The purpose of this study is to collect and evaluate data on potential demographic, clinical and socioeconomic determinants of the length of time to transition among PWBD at UCSF.Methods A retrospective chart review of 60 patients with bleeding disorders born between 1982 and 1996 was conducted to collect baseline demographic, clinical and socioeconomic data. The data was analyzed using a two-tailed t-test to determine factors associated with length of time to transition.Results Of the 60 total patients included in this analysis, 15 were lost to follow-up. The average length of time to transition for the 45 patients who completed transition into adult care was 1.31 years, and the average age at transition was 22 years old. We analyzed various determinants of length of time to transition that fell into five categories: demographics, socioeconomic status, disease severity, level of independence and adherence to recommended care. Females trended toward a longer average time to transition of 1.93 years compared to 1.13 years for males (p=0.08). One variable had a statistically significant correlation to length of time to transition. Patients prescribed a factor product had a significantly shorter time to transition of 0.85 years compared to 2.13 years for patients not prescribed a factor product (p=0.0009). Of the 45 patients who completed transition into adult care, 62% were prescribed a factor product.Conclusions Our study demonstrated that prescription of a factor product, which is likely an indicator of a greater disease severity, is correlated with time to transition. Our univariate analysis did not indicate that demographics, socioeconomic status, level of independence or adherence to recommended care related to length of time to transition. The results of this study are preliminary and further analysis is required to better understand the barriers to transition that exist among PWBD at UCSF. DisclosuresLesh:Bayer: Membership on an entity's Board of Directors or advisory committees, Other: International Nursing Advisory Board 2017. Tobase:Partners: Consultancy, Honoraria.

1764. The Gut: A Veiled Reservoir for Multidrug-resistant Organisms (MDROs) Below the Tip of the Iceberg

BackgroundClinical culture results are sometimes used to estimate the burden of multidrug-resistant organisms (MDROs) in hospitals. The association between positive clinical culture results and prevalence of MDROs in the gut is incompletely understood.MethodsRectal swab or stool samples were collected daily from adult medical intensive care unit (MICU) patients and cultured for target MDROs using selective media between January 2017 and January 2018 at Rush University Medical Center, a 676-bed tertiary-care center in Chicago. Resistance mechanisms were confirmed by phenotypic methods and/or polymerase chain reaction. Clinical culture results during MICU stay were extracted from the hospital information system. Target MDROs included vancomycin-resistant Enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL), carbapenem-resistant Pseudomonas aeruginosa (CRPA) and carbapenem-resistant Acinetobacter baumannii (CRAB). Patients with either a study or clinical culture positive for a target MDRO were analyzed.ResultsWe collected 5,086 study samples from 1,661 unique admissions (1,419 patients) and included here data from 413 unique admissions (397 patients) with completed microbiologic analysis. Median (IQR) patient age was 65 (51–75) years and length of MICU stay was 3 (3–4) days. A total of 156 (37.8%) patients had a target MDRO detected from a study sample at any point; 57 (36.5%) patients had >1 MDRO detected. Overall prevalence of these MDROs was found to be 22.5% VRE, 6.5% CRE, 19.8% ESBL, 4.4% CRPA, and 0.7% CRAB. New MDRO acquisition was observed in 58 (14.6%) patients (figure). Once a target MDRO was detected in a study sample, 82.2% of subsequent study samples were positive for that MDRO. Only 13 (5.8%) patients had a positive clinical culture for any target MDRO during their MICU stay (table).ConclusionClinical cultures capture only the tip of the resistance iceberg and alone are insufficient to guide MDRO-targeted prevention strategies. Universal infection prevention measures are an alternative that may be preferred in settings where overall prevalence of MDROs is moderate or high and patients may be colonized with >1 MDRO. Disclosures All authors: No reported disclosures.

Diabetes mellitus at the interface between pediatric and adult medicine

Patients with chronic diseases manifesting in childhood, such as type1 diabetes, need to make an optimal transition from pediatric to adult medical care. This or transitionis achallenge for patients and their treatment teams, since metabolic control is often unstable at this time of life. Additional factors like the social environment, as well as concomitant diseases, also need to be taken into account and often represent hurdles to optimal therapy. Transition is an important process to guarantee good self-management of diabetes therapy and good outcomes in the long term. This review provides an overview and recommendations on the topic of transition in diabetes.

Development and Initial Psychometric Properties of a Questionnaire to Assess Competence in Palliative Care: Palliative Care Competence Framework Questionnaire.

Although the provision of palliative care (PC) is fundamental to the role of the physician, little research has assessed the competence of trainee and experienced physicians in PC. To describe the development of a competence questionnaire and assess the level of competence of medical doctors in Ireland to provide PC to individuals with life-limiting conditions and their families. A survey-based cohort study was employed using a questionnaire based on the Palliative Care Competence Framework, developed specifically for this study. The sample was accessed via the Royal College of Physicians of Ireland. All specialties in adult medical care and direct patient contact were included. A pilot study demonstrated comprehensiveness and ensured face validity. In the main study, all subscales showed internal reliability and evidence of a normal distribution. Strong correlation was noted between knowledge and behavior while moderate correlations were noted between attitudes and behavior and attitudes and knowledge, respectively. As expected, palliative-trained participants scored significantly higher in attitudes, behavior, and knowledge. The study provides baseline data on the level of competence of PC of doctors working in Ireland. The study also offers a novel assessment tool that has the potential to be used for future research.

A Long Way from Transfer to Transition: Challenges for Pediatric and Adult Nephrologists

Significant advances in the diagnosis and medical care of children with chronic kidney disease (CKD) are major reasons for the better survival rates of children and adolescents with CKD than the survival rates reported in previous decades. These patients are reaching adulthood, and therefore require a transition to adult medical care. This transition phase is well-recognized to be associated with considerably increased morbidities and medical problems, such as non-adherence, graft loss after transplantation, and loss to follow-up. Low adherence increases morbidity and medical complications and contributes to poorer qualities of life and an overuse of the health care system. However, these tragic outcomes may be avoidable through a structured and well-defined transition program. In the last decade, there has been increasing interest to resolve these medical and psychological problems that occur during the transfer of young adult patients from pediatric to adult renal units. The aims of a successful transition from pediatric to adult medical care include enhancing the individual development of better healthcompetence and stabilizing, or even improving, the state of health. This review will focus on various aspects of the transition phase of adolescents who have CKD or who underwent kidney transplantation from pediatric to adult nephrology care. Key words: Transition; Transplantation; Chronic kidney disease (CKD); Children