Medical Floor Research Articles

Methods for Utilizing Multidisciplinary Team to Create Novel Visual Alarm Designs That Improve Recognition of Patient Decompensation and Alarm Response

The overwhelming number of alarms on medical center floors are false and nonactionable. This leads to delay in alarm response and adverse events. Furthermore, current alarm technology does not have the ability to display patient trends, it only displays one isolated patient event. This paper focuses on describing the methods for creating novel visual displays that incorporates alarm technology and patient decompensation events. Through a multi-disciplinary team approach, that is centered on human factors and system engineers, a novel visual display was created that integrated current alarm technology with patient data. The new displays were better able to predict decompensation and alarm validity. It is crucial to integrate partners from all facets of the medical community and from human factors and system engineering to form an accurate understanding and modeling of patients

Risky Business: Predicting patient mortality at a glance.

Clinicians are constantly forecasting patient trajectories to make critical point of care decisions intended to influence clinical outcomes. Little is known, however, about how providers interpret mortality risk against validated scoring systems. This research aims to understand how providers forecast mortality specifically for that of patients with sepsis. Defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, sepsis is commonly hard to diagnose, progresses rapidly, and lacks a "gold standard" test. Participants were nurses and doctors from the general medical and surgical floors of six different hospitals. Each was presented with ten different patient cases, categorized into low and high severity sepsis, and were asked about care decisions, along with estimations of mortality risk. The resulting data provides a unique look into the differences of risk forecasting between profession and patient severity.

Implanted Ports versus Peripheral Collection: A Comparison of Methods for Therapeutic Antibiotic Level Monitoring in Pediatric Patients with Cystic Fibrosis

Category/Date Emerging Knowledge for Clinical Practice Podium Presentations focusing on the Research Agenda Priority of Pediatric Research: Chronic Illness, Presented at NAPNAP's 40th National Conference on Pediatric Health Care, March 8, 2019, New Orleans, LA. Introduction Patients receiving treatment with certain antibiotics require frequent blood sampling to establish proper dosing and maintain a therapeutic level of the medicine in the blood. It is common for patients with cystic fibrosis to receive these medications via implantable ports. While withdrawing blood specimens from the implanted port for routine laboratory tests is a common practice, nursing practice is conflicted about the safety and accuracy of drawing antibiotic levels from implanted ports. The controversy is based on concern that drawing a specimen from the implanted port's reservoir will lead to falsely elevated serum antibiotic levels and negatively impact the ability to make accurate pharmacokinetic decisions. However, the literature is inconclusive on this subject. Researchers document varying results, use different blood sampling techniques, and do not differentiate between different types of central venous access devices. Background/Significance The extent of agreement between blood samples obtained from the same vascular access device through which the medication was administered and peripheral blood samples is unknown. This project attempts to clarify agreement between peripheral samples and those obtained from a specific type of vascular access device, the implanted port, and determine the clinical significance of any such differences. If levels drawn from implanted ports are to be used in dosing decisions, there is a clear clinical imperative to determine their accuracy; accurate drug levels are needed to ensure appropriate dosage and prevent adverse events. However, the evidence must be critically appraised and balanced with the desire to reduce avoidable suffering linked to repeated venipuncture. Objectives The primary objective is to determine if there are differences between tobramycin or vancomycin levels drawn from an implantable port, compared to those drawn peripherally among pediatric patients with cystic fibrosis undergoing inpatient antibiotic therapy. The secondary objective is to determine whether antibiotic levels drawn from implantable ports lead to dosing adjustments that would not occur with current standard practice (peripheral venipuncture). Methods/Design This is a prospective single-center observational study that compares antibiotic levels drawn from an implantable port to samples drawn peripherally in pediatric cystic fibrosis patients. Study approval was granted by the Baptist Health IRB. Inclusion criteria are patients aged 18 and under, admitted to an inpatient pediatric medical floor with a diagnosis of cystic fibrosis, an implantable port, and ordered therapy of vancomycin and/or tobramycin. For each participant, we analyze paired samples obtained concurrently from their implantable port and a peripheral blood draw. Research samples drawn from the implanted port were collected using a protocol that specifies the amount of saline flushed and blood wasted prior to sample collection. Results Overall, 20% of samples collected from implantable ports would lead to dosing discrepancies when compared with samples drawn via fingerstick or venipuncture. However, forty four percent of vancomycin levels drawn from implanted ports would lead to dosing discrepancies. The correlation of port and peripheral readings is quite high (r=0.907), but this does not mean that the two can be equated. It does suggest, however, that there is a statistical relation between the two that can be used to construct an adjustment to the port level that will more closely match the peripheral level. The only significant variable influencing ratio between peripheral and port values was lumen size, with smaller lumen (6 French) leading to larger differences. Conclusion The results demonstrate poor agreement between the two methods for collecting antibiotic levels, particularly when testing for vancomycin levels. Nurse practitioners prescribing and monitoring therapy with these medications should be alert for antibiotic level values that don't match dosing regimen. In addition, NPs should understand their institution's policies and practices surrounding central line blood sampling and ensure practices reduce the potential for residual drug within the lumen if levels are currently drawn from implanted ports. For NPs discussing port placement, ensure parents and patients are aware of potential for extra needlesticks as a possibility during therapy with antibiotics that require therapeutic drug level monitoring.

Critical Hypomagnesemia and Seizure Induced by Chronic Use of Proton Pump Inhibitors (PPIs)

Background: Chronic use of proton pump inhibitors (PPIs) may lead to severe hypomagnesemia, although it is a rare side effect. Hypomagnesemia related to PPIs use less reported compared to other side effects. Critically low magnesium level may lead to fatal seizure activity, which could lead to death if went undiagnosed. Case presentation: This is a report of a 49 yearold female with a history of gastroesophageal reflux disease (GERD) presented to our emergency department with a seizure activity and critically low magnesium level (< 0.5 mg/dL). Initially the patient was hemodynamically unstable, required intubation, and admitted to the medical intensive care unit (MICU). After further management in MICU, patient stabilized and transferred to the inpatient regular medical floor. Most of the potential common causes of her low magnesium level were thoroughly investigated and ruled out except for PPIs use (as she was a chronic user). The patient was advised to discontinue her PPIs and to use alternative medications because of lifethreatening side effect "hypomagnesemia"and based on the riskbenefit balance (as the risk overweight the benefits in this situation). No further hypomagnesemic episodes reported after the second admission to the ICU unit when PPIs were discontinued completely. Conclusion: Although PPIs use is beneficial for patients with GERD especially those with gastritis, but may lead to lifethreatening hypomagnesemia in rare occasions. Physicians should be aware of this side effect in all patients with chronic PPIs use. In addition, we recommend that patients who developed this rare side effec need to use alternative medications to prevent recurrence an fatal consequences. Further research is needed to determine the incidence and the association between the development of hypomagnesemia and the use of different types of gastric acid suppressants.

MON-004 The Effect of a Pharmacist Led Training Intervention on Reducing Inappropriate Use of Intravenous Levothyroxine in Hospitalized Patients

Background Approximately 88% of endocrinologists agreed that intravenous levothyroxine (IV T4) is not medically necessary in euthyroid patients if they are nothing by mouth (NPO) for less than 3 days. A prior 2013 retrospective database analysis at our institution revealed that a majority of IV T4 was prescribed inappropriately for NPO status. Therefore, we sought to develop an intervention to reduce inappropriate IV T4 use among hospitalized adults. Methods A training session was provided to clinical pharmacists and medical providers in areas with high IV T4 utilization rates (SICU, MICU, CICU, medical and surgical floors). Compelling reasons to use IV T4 were highlighted, including myxedema coma, cardiogenic shock, suspected malabsorption, or NPO status for >3 days. A retrospective 1-year database analysis was conducted after the intervention to assess IV T4 utilization rates and new onset of arrhythmias and troponin elevations among hospitalized patients. Rates of inappropriate use and adverse effects associated with T4 therapy were compared prior to and after the intervention with the chi-square test. Results Prior to the intervention, 76 patients (mean age 65 years) received IV T4 during the 6-month study period. Of these, 80% of IV T4 was prescribed inappropriately for NPO status at the cost of $38,423. Approximately 11% and 8% of these patients developed new onset arrhythmias and troponin elevations, respectively. After the intervention, 183 patients (mean age 61 years) received IV T4 at our institution during the 1-year study period. Of these, 56% of IV T4 was prescribed inappropriately for NPO status with no other compelling indication at the cost of $75,936. Approximately 20% and 12% of these patients developed new onset arrhythmias and troponin elevations, respectively. Approximately 31% of patients who had unwarranted IV T4 after the intervention had a history of atrial fibrillation, congestive heart failure, or coronary artery disease. The pharmacist led training intervention significantly reduced inappropriate use of IV T4 (p<0.05), however total cost and rates of new onset arrhythmia and troponin elevations did not significantly change (p>0.05). Conclusion A pharmacist led training intervention designed to educate providers and pharmacists about appropriate indications to use IV T4 among hospitalized adults led to a significant reduction in the use of inappropriate IV T4. Cost did not significantly change despite the reduction of inappropriate IV T4 use, likely due to rising drug prices. Despite a modest decrease in inappropriate IV T4 use, our institution aims to further reduce adverse effects, inappropriate use, and cost through a variety of quality control measures, such as implementing EMR order sets and/or restricting use of IV T4 subject to endocrinology approval.

SUN-168 HAART-Induced Hyperglycemic Hyperosmolar Syndrome: A Rare Manifestation of HAART Therapy

Methods: Analysis of case report Objective: Increase awareness of Hyperglycemic complications secondary to HAART therapy) : 59-year-Old Hispanic Male with past medical History of pre-diabetes and recently diagnosed with HIV presented to the Emergency Department with the complaint of fatigue for 3 days associated with nausea for same duration. He denied any other complaints. Patient's blood glucose was 1900 mg/dl, serum bicarbonate level: 22, Blood pH: 7.38, serum acetone negative, and urine ketones negative. Serum osmolarity was 340 mmol/kg and HBA1c was 19%. Based on above laboratory Values, Diagnosis of Hyperglycemic Hyperosmolar Syndrome (HHS), was made and patient was admitted to Medical ICU started with Intravenous (IV) fluids and IV insulin Infusion. After normalization of blood sugar, patient transferred to the medical floor and provided with diabetic teaching and started on subcutaneous Insulin Injection. On review of past medical history, patient was diagnosed with HIV 6 weeks ago and was started with HAART therapy containing a Protease inhibitor (ritonavir) as one of drug in the combination therapy. Blood work 8 weeks ago showed HAB1C 6.2% and blood glucose 115 mg/dl showing temporal relation of the start of HAART therapy and sudden change in blood glucose and increased HBA1c. Infectious disease team was consulted and patient's HIV regimen was switched and Protease inhibitor ( Ritonavir) was stopped, Patient was discharged with a new HAART therapy and also subcutaneous Insulin. We followed the patient closely in outpatient management and over the course of 3 months, HBA1C and blood sugar came back to baseline and subcutaneous insulin was stopped. Conclusion 1. Protease inhibitors are commonly associated with Metabolic Syndrome. This is first case to our best of knowledge in which protease inhibitors has been linked to pure Hyperglycemic Hyperosmolar Syndrome. 2. Patients starting with HAART therapy should be further investigated for possible hyperglycemia secondary to protease Inhibitors. Abbreviation: HHS: Hyperglycemic Hyperosmolar Syndrome HAART: Highly Active Anti-Retroviral Therapy MICU: Medical Intensive Care Unit IVF: Intravenous Fluids

Student TXT.

Transitions: Stepping Forward with Trust By Pamela FriesenFigureI remember the day of graduation from my BSN program and the joy of finally reaching my long-awaited goal of entering the nursing profession. There were tears of sadness in leaving classmates who had become family, but also the anticipation of the next steps. I moved to a new city, successfully passed the State Board (NCLEX) exam, and started my first job on a medical floor. I was transitioning from being a student to working as a practicing nurse. The first three months were tough with making many adjustments to the role of an RN, feeling inadequate to apply my new knowledge, and trying to settle into a different living environment. The next years brought more changes: beginning nursing positions, going back to school, moving to another state (culture shock), and launching a career in nursing education. As one who doesn't particularly like change, these transitions were challenging, but were also periods of incredible personal growth. How do we deal with transitions, these passages from what is familiar and comfortable to what is unknown and maybe frightening? Through the years, I have learned much from Old Testament characters. Joshua is a favorite. In the book of Numbers, the children of Israel were facing the transition from decades of slavery in Egypt to freedom in a new, unknown land God had promised. God directed Moses to send 12 spies to scope out this unseen territory; Joshua and Caleb were among those 12. When they returned, the spies described the bountiful land they had seen, but also reported that the cities were strongly fortified and the giants too powerful to conquer. Joshua's and Caleb's response stood in contrast to the other 10 scouts. “Let's go at once to take the land...We can certainly conquer it!” (Numbers 13:30, NLT). Later, as Joshua guided this unruly people, he maintained complete trust in God's power, eventually leading them into their new homeland. He was one of the few who successfully made the transition. His faith made reaching the goal possible. My response to transitions has varied—sometimes embracing the change and looking forward to new challenges, and at other times being reluctant and shrinking back like the 10 spies, wondering if God really meant it when he said, “I will never leave you nor forsake you” (Hebrews 13:5, ESV). There are no easy answers for how to handle life's passages, but we find God's directive in Joshua 1:9 as the source of hope and inspiration during change: “...Be strong and courageous! Do not be afraid and discouraged. For the LORD your God is with you wherever you go” (NLT). Joshua was one who stepped forward courageously, believing God was going to give him everything he needed to succeed in his work. God wants us to walk with him into new challenges and phases of life. As we keep moving forward with him, he gives us strength, courage, and freedom from fear. Like Joshua, I am facing a transition. Thirty-two years have passed since the beginning of my nursing education and experiencing the joy of working with undergraduate and graduate students. Now, I'm entering a new phase called retirement! Just as I encountered many unknowns as I entered nursing practice and then nursing education, I again face an uncharted chapter. God promised to go with me, to be faithful to me, and to bring new meaning and purpose that will be equally fulfilling. Encouragement for Transitions “Trust in the LORD with all your heart; do not depend on your own understanding. Seek his will in all you do, and he will show you which path to take” (Proverbs 3:5-6, NLT). “I can do all things through him who strengthens me” (Philippians 4:13, ESV). “Jesus Christ is the same, yesterday, today and forever” (Hebrews 13:8, NLT). Farewell from Pam Friesen In this transition out as column coeditor, I want to thank the JCN staff for the privilege of these 10 years in my role with Student TXT. I also express sincere gratitude to Maureen Juarez, Bernita Missal, and Julie De Haan for their partnership in this venture. What a joy it has been to encourage students, nurses in practice, and faculty to share their meaningful stories.

Hand Carried Ultrasound Utilization in Acute Heart Failure Patients, Does It Correlate with Physical Examination?

Purpose Evaluation of intravascular volume is an essential component of clinical management of acute heart failure (HF) patients. Correlation between physical examination and ultrasound measurements has not been well studies and was the focus of this investigation. Methods We prospectively studied patients admitted to the medical floor with acute heart failure exacerbation between January 2017 to October 2018. Assessment of volume status by physical examination (PE) was performed by heart failure team, and classified patient's volume status into (0- euvolemic, 1- Mildly overloaded, 2- Moderately overloaded, 3- Severely overloaded), then central venous pressure (CVP) was measured using hand carried US (assessment of inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Spearman's correlation was used to correlate between PE findings and US-estimated CVP. Finally, the distribution of CVP for each PE category was provided (Figure). Results A total of 186 (Age 64±15,42% females) patients were included during study duration. (34%) patients had HF with preserved ejection fraction (HFpEF), and 104 (66%) patients had HF with reduced ejection fraction (HFrEF). The correlation between PE and US-estimated CVP was moderate at best (rho=0.41, p Conclusion Physical exam is moderately correlated with US-estimated CVP and is unreliable in directing therapy for acute HF exacerbation. Further investigations are needed to integrate hand carried US in the daily management of heart failure patients.

IS IT MANIA, DELIRIUM, OR CATATONIA? A CASE SERIES ON DELIRIOUS MANIA IN OLDER ADULTS

Introduction Delirium can be thought of as acute brain failure and is characterized by a disturbance in attention and awareness as well as cognition which develops over a short period of time. It is a serious condition that is associated with high morbidity and mortality, particularly in critically ill patients. Although delirium has been described for thousands of years, it is frequently overlooked and the pathophysiology remains poorly understood. Our understanding of the different presentations of delirium continues to evolve. Delirious mania was studied in 1849 by Bell, with a 75% mortality in the cohort investigated. Although there has been over a century and a half since that description, there continue to be limited diagnostic criteria and treatment guidelines for delirious mania. Methods Case series, systematic literature review Results Case Identification: Cases of delirious mania have been identified and described in the literature. Delirious mania is characterized with the typical disturbances in attention, awareness, and cognition along with mania and psychosis. In one of the first attempts to define the condition, Bell proposed that there was no association with prior mental or systemic disorder. Multiple case studies since then have described an acute onset of a delirious and manic state in the absence of a history of bipolar or depressive disorder. Past history of a personal or family history of psychiatric conditions such as bipolar illness or a depressive disorder may provide diagnostic guidance and help identify a primary psychiatric disturbance. In older adults with mania or psychosis, delirium must be considered in the differential as they often have compromised reserve capacities and are prone to developing delirium from conditions that may not be deliriogenic in younger adults. We describe two cases that we believe reflect delirious mania in patients that were previously diagnosed with mania stemming from a psychiatric disorder. Treatment: A case series (with patients aged 50-67) by Karmacharya et al. (2008) put forth electroconvulsive therapy (ECT) as the definitive treatment for delirious mania. They also found that clozapine, quetiapine, lithium, and valproate which may otherwise have been prescribed in a manic episode were not first line treatments. The medications, even when helpful, took an unacceptably long time to work. Curiously, high dose benzodiazepines have also been found to be effective which has led to the association with catatonia. . One of the cases illustrates prolonged recovery while on clozapine, but did not require a high dose of benzodiazepines for rapid improvement despite being in a similar age range. Much like previous case reports, our cases also help to illustrate the overlap of the symptoms of hyperactive delirium with mania and catatonia, particularly in older adults. Conclusions The cases described illustrate characteristics of delirious mania in patients with a previously diagnosed psychiatric history. They highlight the importance of comparing the patient's current episode to previous psychiatric presentations. Both cases were originally thought to be due to mania, hence warranting admission to psychiatric units. However, they were found to have a large and complicated medical component to their illness. The initial admission to psychiatric units delayed treatment of their serious medical illnesses and may have contributed to a prolonged hospital stay. The argument can be made to manage these patients on a medical floor with psychiatric services given the critical nature of the medical presentation and more immediate access to life supporting interventions. These cases reiterate the need for formal diagnostic criteria to aid in the early diagnosis of delirious mania. This research was funded by Non-applicable

Determining Insulin Dose at the Time of Discharge in A High-Risk Population: is There Room for Improvement?

To evaluate the adequacy of the insulin dose prescribed at hospital discharge in a high-risk population and assess patient characteristics that influence insulin dose requirement in the immediate postdischarge period. This was a retrospective study conducted at Parkland Health System. We included all patients admitted to a medical floor who received an insulin prescription at discharge and had at least one follow-up visit within 6 months of discharge. All data were extracted by a detailed manual review of each electronic medical record. At the postdischarge follow-up (N = 797, median 33 days from discharge), 60% of patients required an insulin dose adjustment; 47% of the patients required a dose decrease. Significant predictors of a decrease insulin requirement postdischarge included (multiple regression beta coefficient [95% confidence interval]): newly diagnosed diabetes, -12.7 (-17.7, -7.7); ketosis-prone diabetes, -8.4 (-15, -1.8); glycated hemoglobin A1c (HbA1c), <10% (86 mmol/mol) -7.0 (-11.4, -2.6); discharge insulin total daily dose, -5.3 (-9.3, -1.3); and metformin prescription, -4.9 (-8.4, -1.3). An insulin dose adjustment (most commonly a decrease) was necessary shortly after discharge in more than half of our patients. A better model to estimate insulin dose at discharge is needed along with short-term follow-up after discharge for insulin titration. A pre-emptive insulin dose reduction at discharge should be considered for patients with newly diagnosed diabetes, ketosis-prone diabetes, metformin prescription, and those with HbA1c <10% at presentation. DKA = diabetic ketoacidosis; HbA1c = glycated hemoglobin A1c; KPDM = ketosis-prone diabetes mellitus; TDD = total daily dose.

Using clinical decision support through the electronic medical record to increase prescribing of high-dose parenteral thiamine in hospitalized patients with alcohol use disorder

BackgroundPatients with alcohol use disorder (AUD) are at an increased risk of developing Wernicke's encephalopathy (WE), a devastating and difficult diagnosis caused by thiamine deficiency. Even as AUD is present in up to 25% of hospitalized patients on medical floors, appropriate thiamine supplementation in the hospital setting remains inadequate. These patients are particularly susceptible to thiamine deficiency and subsequent WE due to both their alcohol use and active medical illnesses. The electronic medical record (EMR) has become ubiquitous in health care systems and can be used as a tool to improve the care of hospitalized patients. MethodsAs a quality improvement initiative, we implemented a medication order panel in the EMR with autopopulated orders for thiamine dosing to increase the appropriate use of high-dose parenteral thiamine (HPT) for hospitalized patients with AUD. We conducted a retrospective cohort study of all inpatients with AUD who received an Addiction Psychiatry Consult Service consult three months before and after the EMR change. We compared the proportion of patients receiving HPT prior to consultation (primary outcome) and the length of stay (secondary outcome) between the historical control group and the EMR intervention group. ResultsPatients in the EMR intervention group were significantly more likely to receive HPT than the historical control group (20.2% vs. 2.7%, p < 0.0001). This difference remained statistically significant when adjusted for potential confounders (OR: 9.89, 95% CI: [2.77, 35.34], p = 0.0004). There was a trend towards statistical significance that the intervention group had a higher likelihood of being prescribed any thiamine (76.6% vs. 64.6%, p = 0.06) and had a shorter length of stay (median (IQR): 3.8 (2.4, 7.0) vs. 4.6 (2.9, 7.8) days, p = 0.06). ConclusionThese results indicate that providing autopopulated thiamine order panels for patients with AUD can be an effective method for specialty services to increase appropriate care practices without additional education or training for providers. Further research should consider the clinical outcomes of increasing HPT for patients with AUD.

Vital signs on hospital discharge and re admission rates.

Assessing the stability of a patient's vital signs in the 24 hours before discharge has been suggested as an objective and inexpensive way to determine safety for discharge. To determine the association between unstable vital signs at the time of discharge with the readmission rate over a one-year period. An observational cohort multi-center study at three urban community hospitals using electronic health record data collected from November 1, 2016, to October 30, 2017. A total of 29322 hospitalizations to medical floors with complete sets of vital signs were included. The final vital signs collected on the day of discharge were used for analysis. The readmission rates were compared using different variables such as age, sex, insurance payer (Medicare or Medicaid), discharge time, discharge disposition, length of stay at the hospital, the number, and type of abnormal vital signs at discharge. Unstable vital signs at discharge were found in 2862 patients (9.8%). The readmission rate was highest in patients with two (11.3%) unstable vital signs compared to those with one (8.5%) and three or more (0%) instabilities. Patients with a combination of heart rate >100 beats/min and respiratory rate >20 breaths/min at discharge had a 14.1% seven-day readmission rate (P = 0.0057, Odds Ratio = 1.87, Confidence Interval = 1.19-2.95). Vital sign instabilities in the 24 hours before discharge are associated with increased seven-day readmission rate.

Are We Doing Too Many HIT Tests III?

BackgroundIn USA in 2007, it was estimated that approximately one third of hospitalized patients, approximately 12 million patients per year receive heparin. Heparin induced thrombocytopenia (HIT) is one of the serious complications of Heparin resulting from immune mediated antibody.4Ts score is the imperative tool to help differentiate HIT from other causes of thrombocytopenia. The 4Ts score decreases not only risk of bleeding by avoiding anticoagulant but also cost of health care by testing only patients with intermediate to high pretest probability.Our study suggests 4Ts scores calculators are to be introduced as a part of order set for HIT tests.ObjectiveThis retrospective study is Part III of our prior studies “ Are We Doing Too Many HIT tests”, to decrease false positive HIT patients by improving use and awareness about high negative predictive value of 4T score among physicians. This study was carried out to determine outcomes of our previous study of this series in order to assess the reduction of unnecessary ELISA test orders to diagnose HIT in a single urban community hospital in Chicago. MethodA retrospective chart review of medical records of the patients (n=181) who underwent H-PF4-ELISA for HIT screening from January 1st, 2016 to December 31st 2017 was conducted.Data was collected from patient's charts which included the requesting department (i.e. ICU, ED, Medical and surgical floors). Also, date of admission, date of onset of platelet drop, degree of thrombocytopenia, incidence of DVT, PE, arterial thrombosis and bleeding and alternative reasons of platelet count drop other than HIT were collected. For each patient a for calculation of Pretest probability by the 4T score was conducted.We stratified these patients based on 4Ts score (0-3) for low probability, (4-5) intermediate probability and (6-8) high probability risk for HIT.We reviewed all charts for which both ELISA and SRA were ordered. Pharmacy department and Hematology labs were contacted to calculate costs of ELISA, SRA and anticoagulation.ResultsOur results showed that 114 (62.98%) of 181 ELISA tests ordered had low pretest probability for HIT. None of these records were found to be true positive by SRA. However, 24(20%) of low probability category were found positive by ELISA and received anticoagulation and thus were exposed to higher risk of bleeding and additional health care costs.There were 57 (31.49%) out of 181 records had intermediate probability. 16 patients with intermediate probability were ELISA test positive. However, 3 (5.26%) of intermediate probability patients were found to be true positive by SRA.While only 6 (3.31%) out of 181 patients records had high probability for HIT and 3 patients (50%) of high probability were found to be true positive by SRA.However, 11 patients from low probability category and 5 patients from intermediate probability category did not have SRA results in their medical record.DiscussionIn our previous study, 74.3% of patients tested for HIT during Jan.2013 to Dec. 2014were found to have low probability compared to 62.98% of our current study.Interestingly, patients with intermediate probability have increased to 31.49% from 18% from our previous study. This is a desired decreased.Cost for ELISA test for HIT ranges $200 to $300 per test and cost of SRA is roughly $50 to $60. Cost of one day of Argatroban treatment is roughly $670 which brings the total cost per patient roughly $1000 per day for all those patients who are tested positive by ELISA.34,200 USD were spent on ELISA test for 114 patients with low probability 4T score who were found true negative.Furthermore, 20 patients with false positive ELISA from low probability 4T category were exposed to 40,200 USD worth of Argatroban during three days while SRA results were awaited.As per our study, educational interventions in our hospital have made remarkable improvement in decreasing the number of ELISA test in patients with low pretest probability from 74.3% to 62.98%Lastly, more than 74,000 USD per 114 patients (with low probability score) could be reduced by introducing “4T score calculation Alert” as a part of order set for HIT in EMR software.We conclude that incorporating prescreening for HIT with 4T score calculation as a part of order set for ELISA could decrease not only the risk of bleeding but also avoidable additional health care cost. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

421. Babesiosis: Retrospective Review of 38 Cases from Upper Midwest

BackgroundBabesiosis is a tick-borne illness caused by protozoal infection of the genus Babesia. Clinical presentation varies widely from asymptomatic to rapidly fatal infection and diagnosis requires a high index of clinical suspicion. It is an emerging health risk and clinicians need to be aware of its different clinical manifestations.MethodsWe retrospectively collected and analyzed data from 38 patients with babesiosis from 1990 to 2015.ResultsMean age of patients was 63 years. 68% of patients required hospitalization with 21% requiring intensive care unit (ICU) stay. Mean length of illness before diagnosis was 15.6 days and symptoms comprised of malaise (82%), subjective fever (71%), chills (55%), anorexia (29%), arthralgia (29%), and nausea (16%). Only 47% of the patients recalled tick bites. Mean hemoglobin in the outpatients was 12.4 g/dL compared with 9.8 g/dL in the hospitalized patients (P < 0.01). Among hospitalized patients, mean hemoglobin for ICU admissions was 7.5 g/dL vs. 10.9 g/dL (P < 0.01) for those without ICU stay. Mean parasitemia was 10.1% in those requiring ICU compared with 1.4% in those admitted to the medical floor (P < 0.01). 28.9% had Lyme disease, and 10.5% had anaplasma coinfection. Co-morbidities included diabetes mellitus (n = 3), asplenia (n = 5), and immunosuppression (n = 3). Diagnosis was made with PCR and peripheral smear in 50% of patient whereas 50% were diagnosed with PCR alone. In 27% of patients with positive PCR, peripheral smear was negative. All patients with asplenia required hospitalization with 3/5 requiring ICU with initial parasitemia ranging from 2.5 to 28% and duration of parasitemia ranging from 10 to 142 days. Initial treatment comprised of clindamycin plus quinine in 31% of patients whereas combination of atovaquone and azithromycin was used in 69% of patients. Median duration of treatment was 10 days. Overall three patients underwent exchange transfusion with parasitemias ranging from 12.3 to 28.5%. None of the patients died during hospitalization.ConclusionLess than half of the patients with babesiosis recall tick bites. There is usually a delay in diagnosis of up to 2 weeks due to nonspecific nature of symptoms. In more than one-fourth of patients with babesiosis peripheral smear may be falsely negative. Hemoglobin and percentage parasitemia seemed to correlate with severity of illness.Disclosures All authors: No reported disclosures.

Vibrations Serviceability of a Medical Facility Floor for Sensitive Equipment Replacement: Evaluation with Sparse In Situ Data

Vibrations serviceability of building floors has been a growing concern over the years. For steel-framed systems, vibrations serviceability checks often govern the structural design. When the floor is carrying vibration-sensitive equipment, vibrations serviceability evaluation is more critical because the serviceability on the floor involves the use of expensive equipment generally related to human health (patient rooms, operating rooms, medical laboratories, etc.) This article summarizes a study in which a new (replacement) magnetic resonance imaging (MRI) unit with a weight of 8.6 t (19,000 lb) was to replace a heavier MRI unit weighing 37.2 t (82,000 lb) on an elevated floor of a medical facility. Although the dynamic characteristics of the floor would change with this drastic load difference on the bay, the vibration response of the floor for nearby footfall excitations was also expected to change. This brought up the question of whether the footfall-induced excitations would pass the maximum acceleration limit set by the manufacturer of the replacement MRI unit. The authors were provided with in situ vibration measurements collected when the old MRI unit was in place and were asked to decide if the footfall-induced excitations around the replacement unit would exceed its manufacturer criteria. Sparse in situ vibration measurements of the old MRI configuration were used to calibrate a detailed finite-element model that was later used to predict the footfall response for the replacement MRI unit configuration. The predicted accelerations were then compared with the manufacturer’s limiting accelerations for the replacement MRI unit. It was determined that the accelerations estimated for the replacement unit were not more than the manufacturer’s limiting criteria.

Oral Ppi VS IV Ppi in Hospitalized Patient

Objectives: Of this study have been produced in order to promote effective use of proton pump inhibitors (PPIs) and (H2RAs) histamine II receptor antagonists at AL-Zahraa University Hospital (ZUH) in Lebanon. The aims: Of the study are to ensure PPIs use is limited to situations where there is indicated and there is a clear evidence of benefit, in order to decrease the cost when possible without affecting the patient’s clinical outcome. Setting: Medical and surgical in-patients floors at AL-Zahraa University Hospital (ZUH) were used for this study, which include 57medical and 43 surgical beds. Methods: In this study 100 patients files were reviewed for appropriate IVPPIs uses in two separate time intervals, over six months period started on January 1st, 2016 and ended on June 30th, 2016 and divided into two equal separate time intervals, pre implementation and post implementation of restriction dispensing policy, in order to determine the proper indication and the cost impact of restriction procedure. The main outcomes measure the cost difference between pre and post restriction periods. Results: During the pre-restriction period, the majority of IVPPIs vials were dispensed to patients able to tolerate oral medications with no proper indications to IVPPIs use, the daily consumption of IVPPIs were 48 vials (960 $) in the pre-restriction period as compared to only 2 vials (40$) in the post restriction period, therefore the associated daily cost was reduced from 960$ to 40$. Conclusion: This study highlighted the impact of proper use of PPIs based on implantation of the dispensing authorization restriction form of IVPPIS use which based on the international protocols for peptic ulcer drugs uses, leading to statistically significant in hospital patient’s daily cost reduction by 24 folds.

Leveraging the electronic medical record (EMR) to improve sepsis care in cancer outpatients.

319 Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated response to infection and a major healthcare problem in cancer patients. Patients with cancer are at increased risk of morbidity and mortality from sepsis. Approaches like the modified Early Warning Score (mEWS) could offer an opportunity to identify patients at risk for sepsis earlier and to prompt a timely evaluation. However, available evidence for cancer outpatient settings remains scarce. The aim of this presentation is to describe first results of the mEWS implementation at Huntsman Cancer Hospital (HCC) outpatient clinics. The question, whether patients with sepsis can be detected using this approach will be answered. Methods: In 2015, the University of Utah Healthcare implemented mEWS as prediction tool for sepsis. The automated calculation of mEWS is based on real-time data from the EMR. For this analysis, we extracted a cancer outpatient population from a 15-month time frame (from December 2016 to February 2018) within the EHR. We selected patients with a mEWS &gt; 4, grouped these patients according to the process of care after mEWS scoring (e.g., admitted to ICU) and analyzed subgroup based upon mEWS score, discharge disposition and sepsis diagnosis. Results: Within the analyzed time frame 502 cancer outpatients had a mEWS score of 4 or higher. 88 of these patients (17.5%) were diagnosed with sepsis after mEWS screening. Out of the patients with sepsis, 22 were admitted to ICU, 63 were admitted to a medical floor and 3 were treated at the Huntsman Acute Care Clinic. Out of the 414 without a diagnosis of sepsis, 13 patients were admitted to ICU, 72 patients were admitted to a medical floor (in each case for other reasons then sepsis) and 329 patients were sent to home. Conclusions: Sepsis is a serious problem in cancer outpatient care. In our analysis, one in six patients with a mEWS score of 4 and higher were diagnosed with sepsis. This analysis has shown that the implementation of a real-time, EMR based scoring system like mEWS can support the early detection and treatment of sepsis in this population.

Hospital Chain Switches to Telepsychiatry for E.R., Inpatient Psych Consults

A new telepsychiatry service in the emergency department and on the medical floors at Sutter Health hospitals allows psychiatrists to reach rural locations not before served.

A RARE CAUSE OF BRONCHOBILIARY FISTULA

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Bronchobiliary fistula (BBF) is a rare medical condition that presents a diagnostic dilemma. It may be congenital or acquired, with the former having a prevalence of less than 1 million. Once diagnosed its etiology is often evident, however with its incidence due to echinococcal origin being < 2 percent, patients often have multiple hospitalizations prior to diagnosis. We present a rare case of a BBF, treated successfully with a minimally invasive approach. CASE PRESENTATION: 74 year old Syrian female with prior of history of a liver cyst drained of 200 millimeters 3 years prior at another institution comes with right upper quadrant abdominal pain, nausea and vomiting. She has an abdominal magnetic resonance imaging, subsequent CT-guided fine-needle aspiration and is diagnosed with hydatid cyst, treated conservatively with albendazole. She is discharged and presents 3 days later, with productive cough of yellow/green mucus, malaise and fever. She is treated as a healthcare associated pneumonia. Sputum culture shows gram positive cocci and antibiotics are tailored from cefepime and vancomycin to cephalexin in view of MSSA. The patient improves clinically and is discharged on albendazole plus cephalexin and scheduled for elective hepatic cyst resection. She returns 8 days later for fever and productive cough. She is found to have persistent pneumonia with elevated right hemidiaphragm on chest x-ray, treated with piperacillin-tazobactam and vancomycin empirically along with albendazole for hydatid cyst. She has a laparoscopic echinococcal cyst resection with some hepatic resection to facilitate cyst removal. While on the medical floor, she develops bilioptysis and leukocytosis. A BBF is suspected and confirmed with DISIDA scan. An endoscopic retrograde cholangiopancreatography (ERCP) is done with sphincterotomy and stent placement. She continues to clinically improve and is subsequently discharged with no cough for outpatient follow-up. DISCUSSION: Acquired BBF is a rare complication of echinococcal origin. While bilioptysis is the hallmark sign of BBF it may not always be present. This poses a diagnostic dilemma for physicians and potential life threatening complications for patients. The diagnosis is made with a DISIDA. Historically treatment has been surgical, but conservative options such as embolization and stent placement have been proposed. In this case, an ERCP sphincterotomy and stent placement is successfully used. This intervention results in a decrease in the transpapillary pressure gradient, thereby facilitating biliary flow to the intestine and healing of the BBF. CONCLUSIONS: BBF of echinococcal origin has an incidence of < 2%. Bilioptysis, a clinical hallmark, maybe absent posing a clinical dilemma resulting in multiple hospitalizations. This case highlights a rare diagnosis of BBF secondary to hydatid cyst and a successful conservative option, to a once surgical problem. Reference #1: Mohammadreza Seyyedmajidi MD, Mojtaba Kiani MD, Hamid Javadi MD, Alireza Raeisi MD, Majid Assadi MD. Hepatobiliary scintigraphy with SPET in the diagnosis of bronchobiliary fistula due to a hydatid cyst. Hellenic Journal of Nuclear Medicine. 2015 May - August; 18(2):160-162. Reference #2: Guan-Qun Liao, Hao Wang, Guang-Yong Zhu, Kai-Bin Zhu, Fu-Xin Lv, Sheng Tai. Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years. World Journal of Gastroenterology. 2011 September; 17(33): 3842-3849. Reference #3: Anton Crnjac, Vid Pivec, Arpad Ivanecz. Thoracobiliary fistulas: literature review and a case report of fistula closure with omentum majus. 2013 Radiol Oncol; 47(1): 77-85. DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Killol Patel, source=Web Response No relevant relationships by Shanta Shrestha, source=Web Response

Intensive Care Need and Its Predictors Among Patients Admitted With Acute on Chronic Liver Failure: A Retrospective Study From a Single Tertiary Care Center

Introduction: Acute-on-chronic liver failure (ACLF) among patients with chronic liver disease has high mortality secondary to organ failure (OF). Data on need for ICU care in ACLF patients are scanty. Methods: Medical charts were reviewed on patients admitted to a tertiary care center with discharge diagnosis of cirrhosis to analyze ACLF patients (based on organ failures Gastroenterology 2013; 144: 1426-37) for ICU care and its predictors. ICU transfer was initiated based on criteria as for any other patient on medical floor or emergency room. Results: Of 567 patients discharged with cirrhosis diagnosis between 7/1/16 and 6/30/17, 123 (22%) met criteria for ACLF diagnosis (mean age 55yrs., 50% males, 79% white, 54% alcoholic cirrhosis, 80% with prior decompensation, mean MELD score 27, mean white cell count 10.6/cmm), precipitated by alcoholic hepatitis (33%), infection (31%), GI bleed (15%), and unknown in 20%. Coagulation failure (INR>2.5) was most common in 91 (74%) followed by renal (creatinine >2 mg/dL or dialysis) in 80 (65%), brain (grade III-IV encephalopathy) in 64 (52%), liver (bilirubin> 12 mg/dL) in 60 (49%), lung (mechanical ventilation) in 42 (34%), and heart (use of pressor) in 40 (33%). Of 123 ACLF patients, 66 (54%) needed ICU care. Of these, 50 were ACLF grade 3, 12 grade 2, and 4 grade 1 (p= Conclusion: ICU care is frequently needed among ACLF patients, with higher inpatient mortality and use of hospital resources. Studies are needed to develop criteria for early ICU transfer among ACLF patients, as basis for improving outcomes of patients with ACLF.