Mercy Medical Center Research Articles

Translating Evidence into Practice: How Chaplains Used EBP to Improve the Spiritual and Emotional Well-being of Bedside Nurses.

The Pastoral Care department at Mercy Medical Center in Baltimore embarked on an evidence-based practice (EBP) project to identify best practices for improving nurses' well-being. This article describes the EBP model and its application. The project resulted in increased nurse awareness of the chaplain's role, nurses' confidence in using chaplain services, and nurses' well-being. The project's success indicates the value of chaplains learning an EBP model and incorporating it into their practice.

Orthopaedic Foot and Ankle Surgery Leadership Trends: A Cross-Sectional Study of Fellowship Directors and Division Chiefs

Category: Other Introduction/Purpose: Foot and ankle surgery is a growing subspecialty within orthopaedic surgery due to the increasing demand for lower extremity trained specialists. Fellowship directors for foot and ankle surgery are uniquely tasked with the responsibilities of creating an educational experience while teaching trainees to manage lower extremity pathology. Similarly, foot and ankle division chiefs serve as clinical leaders who oversee their department's delivery of lower extremity care while acting as mentors. The primary aim of this study was to quantitatively describe and compare the demographic and professional characteristics of current foot and ankle surgery fellowship directors and division chiefs. Methods: The American Orthopaedic Foot & Ankle Society (AOFAS) fellowship directory for 2021 to 2022 was reviewed for the 48 AOFAS-recognized fellowship programs in the United States. After screening all institutional websites, fellowship directors and division chiefs were directly contacted via email. Surveys were administered between March 31, 2021 and June 1, 2021 to collect demographic, education, and professional data. Publicly accessible online sources such as institutional biographies, media accounts, uploaded curriculum vitae, and the Scopus Web of Science database were accessed to collect any missing information. The H-index value was determined for each leader by accessing the Scopus Web of Science search engine, a database that analyzes peer-reviewed scientific publications with a built-in citation tracking feature. Univariate and bivariate statistical analyses were performed. Results: A total of 42 of the 48 (87.5%) fellowship directors and 18 of the 23 (78.3%) division chiefs responded to the questionnaire. Of the 48 fellowship directors, 45 (93.8%) were male, 43 (89.6%) identified as Caucasian, their average age at leadership appointment was 42.6+-7.5 (range, 32-70) years, and the average time between fellowship graduation and leadership appointment was 9.9+-7.8 (range, 0-36) years. Most of the fellowship directors graduated from OrthoCarolina (10.4%), Oakland Bone and Joint Specialists (Roger Mann) (10.4%), and Mercy Medical Center (8.3%) (Figure 1). Of the 23 chiefs, 22 (95.7%) were male, 20 (87.0 %) identified as Caucasians, their average age at leadership appointment was 41.7+-7.8 (range, 32-53) years, and the average time between fellowship graduation and leadership appointment was 9.8+-6.8 (range, 2-21) years. The average H-index for the chiefs was greater than that of the fellowship directors (18.4 vs 13.4, P=.0373) when controlling for years of training. Conclusion: This is the first study to record professional and demographic characteristics amongst orthopaedic foot and ankle surgery fellowship directors and division chiefs. The utility of this analysis comes from highlighting common attributes of successful leaders within the field for aspiring trainees, while also drawing attention to the lack of diversity within the foot and ankle surgery community.

Improving the Pre-Admission Testing (PAT) Through Informatics Enhancement

<h3>Introduction</h3> At Mercy Medical Center (MMC) the Pre-Admission Testing (PAT) Department ensures diagnostic documents (DD) required by the Anesthesia are in the Chart by the Day of Surgery (DOS) to facilitate the perioperative process. Missing pre-operative diagnostics can lead to DOS OR Case Cancelations due to an identified medical reason and/or a need for medical clearance. These cancelations are problematic for the patient and the organization. <h3>Identification of the Problem</h3> Following the implementation of an Electronic Medical Record (EMR) in the Fall of 2018, the PAT Staff recognized difficulties locating the DD in the patient's EMR. This decrease was resulting in an elevated DOS Cancelation Rate "due to medical reasons" which reached a high of 1.6% in September 2018. A need for EMR Enhancement was identified along with a focused collaboration with the Surgical Team. <h3>QI question/Purpose of the study</h3> Does collaboration with EMR Analysts and Leadership improve availability of DD within the EMR increase the efficacy of PAT staff to complete pre-surgical charts and result in a decrease of case cancellations on DOS? / To improve the integration process of DD in the EMR thus reducing DOS cancellations by 0.8 % in 1 Year. <h3>Methods</h3> Collaboration with the EMR Analysts and Leadership to fine-tune the EMR to increase the ability for PAT staff to complete the presurgical chart. <h3>Outcomes/Results</h3> The targeted goal was to decrease the DOS Cancelations "due to medical reasons" to be below 1.6%. In September of 2020* the DOS Cancelations "due to medical reasons" reached 0.7%. *The COVID Pandemic impacted the final stages of implementation and delayed outcome data. <h3>Discussion</h3> Collaborations with the PAT Staff, Specialty Offices, and Leadership took place February to July 2019. PAT Staff also met with the EMR Analysts to enhance the EMR. The changes made to the EMR workflow for scanning DD were implemented. <h3>Conclusion</h3> Continued collaboration with PAT Staff, Informatics, the Surgical Team, Anesthesia Providers, and Leadership is key to ensure the required DD are present in the EMR to decrease the chance of a DOS Cancelation due to medical reasons. <h3>Implication for Perianesthesia nurses and future research</h3> Continuous monitoring, evaluation, and collaboration with the entire team are essential to consistently improve patient safety and preparedness for the DOS.

69. Implementation of a Pharmacist-Driven Blood Culture Communication Process in a Non-Profit Community Hospital

Abstract Background Rapid diagnostic testing allows for faster identification of culture results and quicker time to targeted antimicrobial therapy. For this to be effective, however, the clinician needs to understand its capabilities and limitations. Pharmacists are well-positioned to assist providers in interpreting rapid diagnostic test results and in the selection of optimal antimicrobial therapy. This study aims to determine if implementing a process in which pharmacists communicate positive blood culture and rapid diagnostic test results improves time to optimal antimicrobial therapy in a community-based hospital. Methods In November 2020, Mercy Medical Center implemented a new process in which positive blood culture and rapid diagnostic test results are communicated to a pharmacist instead of a nurse on the patient care unit. The pharmacist is responsible for interpreting the results, assessing patient information, and providing the culture results along with drug therapy recommendations to the appropriate licensed independent practitioner. This study was a single-center, pre-post, quasi-experimental study (Pre: November 2019-March 2020; Post: November 2020-March 2021). The electronic medical record was used to identify admitted patients 18 years and older with positive blood cultures in which treatment was provided. Time from culture positivity to optimal antimicrobial therapy was collected and compared pre-post intervention. Secondary outcomes included hospital length of stay and mortality. Results A total of 480 patients were identified during the study period, of which 247 met inclusion criteria (n = 125 in 2019-2020; n = 122 in 2020-2021) with comparable baseline characteristics. There was no statistical difference in time to appropriate therapy between the groups (p = 0.796). Time to optimal therapy was 6.12 hours shorter in the post-intervention cohort (p = 0.0492). No difference was found for both secondary outcomes of hospital length of stay and inpatient mortality (p = 0.2958, p = 0.096, respectively). Conclusion A pharmacist-led blood culture communication process improved the care of hospitalized patients in a non-academic, community-based hospital by shortening time to optimal antimicrobial therapy. Disclosures All Authors: No reported disclosures

Distribution of β-Lactamase Genes in Clinical Isolates from California Central Valley Hospital Deviates from the United States Nationwide Trends.

The evolution and dissemination of antibiotic resistance genes throughout the world are clearly affected by the selection and migration of resistant bacteria. However, the relative contributions of selection and migration at a local scale have not been fully explored. We sought to identify which of these factors has the strongest effect through comparisons of antibiotic resistance gene abundance between a distinct location and its surroundings over an extended period of six years. In this work, we used two repositories of extended spectrum β-lactamase (ESBL)-producing isolates collected since 2013 from patients at Dignity Health Mercy Medical Center (DHMMC) in Merced, California, USA, and a nationwide database compiled from clinical isolate genomes reported by the National Center for Biotechnology Information (NCBI) since 2013. We analyzed the stability of average resistance gene frequencies over the years since collection of these clinical isolates began for each repository. We then compared the frequencies of resistance genes in the DHMMC collection with the averages of the nationwide frequencies. We found DHMMC gene frequencies are stable over time and differ significantly from nationwide frequencies throughout the period of time we examined. Our results suggest that local selective pressures are a more important influence on the population structure of resistance genes in bacterial populations than migration. This, in turn, indicates the potential for antibiotic resistance to be controlled at a regional level, making it easier to limit the spread through local stewardship.

94. Appropriate Urine Legionella Antigen Testing: A Step Towards Diagnostic Stewardship

BackgroundPneumonia is a leading cause of sepsis and hospitalization. Infectious Diseases Society of America and American Thoracic Society (IDSA/ATS) published 2019 practice guidelines for community-acquired pneumonia (CAP), recommending urinary antigen testing (UAT) for Legionella pneumophila (LP) only in patients with severe pneumonia or having epidemiological risk factors. In the last 20 years, there has been no Legionella outbreak in Nebraska. Currently, the urine antigen test is considered based on the discretion of the ordering provider. However, this usually results in over-utilization of the test and associated financial burden.MethodsRetrospective chart review of patients admitted to Bergan Mercy Medical Center, Creighton University, Omaha with the admission diagnosis of community-acquired pneumonia in the year 2019, by using electronic medical records. The charts were reviewed for baseline characteristics, admission diagnoses, and clinical outcomes. The project was submitted to and reviewed by the institutional review board.ResultsFrom January to December 2019, 4738 patients were admitted to the general medical floors with the diagnosis of community-acquired pneumonia. Among those patients, 826 patients (17.43%) had urine Legionella antigen tests done, only 11 (0.23%) were tested positive. Moreover, 140 patients (2.95%) had urine Legionella antigen tests in the absence of a documented diagnosis of community-acquired pneumonia. Patients admitted to intensive care units were not included in the study as guidelines do not restrict from ordering urine Legionella tests in patients with severe sepsis secondary to community-acquired pneumonia.ConclusionA diagnostic stewardship approach should be considered for urine Legionella antigen testing. Moreover, such a retrospective review provides an opportunity for quality improvement initiatives at the academic medical facilities with lower Legionella outbreaks.Disclosures All Authors: No reported disclosures

NICU Collaboration During the COVID-19 Worldwide Pandemic: A Memory of Gratitude.

NICU Collaboration During the COVID-19 Worldwide Pandemic: A Memory of Gratitude.

Universal screening for novel coronavirus disease 2019 (COVID-19) for asymptomatic parturients: May not be beneficial at this time.

The current novel coronavirus disease 2019 (COVID-19) pneumonia pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) has spread worldwide and is a significant global health issue. The possible presence of COVID-19 in pregnant patients is a major cause for concern, as historically, other coronaviruses had severe adverse outcomes in this population. Universal Prenatal testing for SARS CoV-2 the causative agent of COVID-19 has been recommended for all pregnant women in the current epicenter, New York City. However, due to the lack of evidence of vertical transmission, teratogenicity, treatment, or change in management of COVID-19 positive asymptomatic patients, this may not be the solution to controlling its spread. False-negative test results may also give inaccurate reassurance in otherwise infectious patients and false-positive tests may result in unnecessary distress and isolation. Universal testing seems more like a Band-Aid and does not seem to have much benefit at this time. Thus, healthcare professionals should continue to wear clean Personal Protective Equipment (PPE) when treating all patients and take other precautions to decrease the spread of COVID-19. This article is protected by copyright. All rights reserved.

Massachusetts BH hospital plans layoffs, considers closing beds

Mercy Medical Center plans to lay off 202 employees at its Providence Behavioral Health Hospital in Holyoke, Massachusetts, when it permanently closes all 74 of its inpatient psychiatry beds there at the end of June, MassLive reported May 11. Mercy, itself owned by Trinity Health Of New England, filed a WARN notice under the federal Worker Adjustment and Retraining Notification Act with the state Executive Office of Labor and Workforce Development May 1. Meanwhile, another state agency — the Department of Public Health's Division of Health Care Facility Licensure and Certification — has yet to rule on Mercy's plan to close the beds following a public hearing April 30 when state regulators heard from advocates, families, employees and state lawmakers opposed to the proposed closure. Mercy said that it's closing the facility because of its inability to recruit and retain psychiatrists to run it, because of two reimbursements paid by insurers for mental health care and because of the age of the facility and the expense of maintaining it. Advocates say those beds are needed now more than ever with people feeling stress from COVID‐19, those in crisis unable to stay safely in an emergency room and the lack of any other pediatric beds for children and teens in the region.

Growth rate assays reveal fitness consequences of β-lactamases.

Antibiotic resistance is a powerful model for studying evolutionary biology and population genetics. For the purpose of these evolutionary studies, fitness data have been approximated through susceptibility testing methods designed for clinical use in providing appropriate antibiotic therapies. An alternative approach for measuring fitness of microbes has experienced growing popularity: growth rates are a highly sensitive approach for measuring the fitness effects of antibiotics and resistance genes, but they differ from susceptibility testing in that a single concentration of antibiotic is used for the assay. Here we show that despite this key difference, the results of growth rates correlate well with clinical determination of resistance by minimum inhibitory concentration (MIC), while providing the sensitivity required for direct input as fitness values into mathematical models. This means that growth rates at a single sublethal inhibitory concentration can help us understand the fitness effects that result in clinical antibiotic resistance. By measuring the growth rates of sequenced clinical isolates obtained from Dignity Health Mercy Medical Center, we detected the fitness effects of individual resistance genes on bacteria exposed to different antibiotics. In our study, the CTX-M-15 gene conferred the highest fitness in assays with cephalosporins. These results show the strong fitness benefit conferred by CTX-M-15.Non-technical summaryAntibiotic resistance is a global human health problem. We partnered with Dignity Health Mercy Medical Center to study antibiotic resistance in clinical isolates. We tested whether growth rates, a sensitive assay used to measure the fitness of bacterial samples, correlate with a clinical test to measure antibiotic resistance. We found a strong correlation between these two methods suggesting that growth rates could be reliably applied to evolutionary studies of clinically relevant problems. Moreover, the sensitivity of the growth rates assay enabled us to identify fitness effects of specific antibiotic resistance genes.

Predictors of prolonged pancreatic fistula in patients undergoing pancreatoduodenectomy (whipple procedure)

Presenter: May Tee MD, MPH | Mercy Medical Center Background: Postoperative pancreatic fistula (POPF) contributes to substantial morbidity associated with pancreatoduodenectomy (PD). Risk stratification for development of POPF, based on factors such as pancreatic duct size, pancreatic texture, and intraoperative blood loss, may mitigate severity of POPF by treatment with antibiotics, additional drains, or feeding tubes. We aimed to examine predictors of prolonged POPF (POPF at 30 days or greater) in patients undergoing PD to provide further stratification of patients at risk. Methods: The American College of Surgeons National Surgical Quality Improvement Program pancreatectomy procedure targeted participant use file was queried from 2015-2017, when persistent POPF at postoperative day 30 was captured. All PD procedures were extracted with emergent cases excluded. Univariable and multivariable analyses were conducted to examine the association between persistent POPF and 30-day surgical outcomes. Results: N = 12,014 patients undergoing open and minimally invasive PD were evaluated. On univariate analyses, persistent POPF was associated with the following outcomes: surgical site infection (SSI) superficial (11.0% vs. 7.4%, P < 0.001), deep SSI (3.1% vs. 1.2%, P < 0.001), organ space SSI (44.1% vs. 13.1%, P < 0.001), wound dehiscence (2.3% vs. 1.0%, P < 0.001), pneumonia (6.7% vs. 3.5%, P < 0.001), reintubation (9.2% vs. 3.2%, P < 0.001), pulmonary embolus (2.9% vs. 1.1%, P < 0.001), failure to wean off mechanical ventilation (9.2% vs. 2.4%, P < 0.001), renal insufficiency (1.6% vs. 0.6%, P < 0.001), renal failure (2.4% vs. 0.8%, P < 0.001), myocardial infarction (2.3% vs. 1.1%, P=0.001), deep vein thrombosis (6.8% vs. 2.6%, P < 0.001), sepsis (19.2% vs. 8.5%, P < 0.001), septic shock (9.9% vs. 2.4%, P < 0.001), length of stay greater than 12 days (58.9% vs. 23.7%, P < 0.001), discharge to destination other than home (28.9 vs. 12.8%, P < 0.001), return to operating room (13.5% vs. 4.9%, P < 0.001), readmission to hospital (23.8% vs. 15.8%, P < 0.001), delayed gastric emptying (35.2% vs. 15.4%, P < 0.001), percutaneous drain placement (33.3% vs. 10.9%, P < 0.001), and postoperative C. difficile colitis (3.3% vs. 1.8%, P=0.003). On multivariable analyses, independent predictors of prolonged POPF include: male sex (OR=1.6, P < 0.001), obesity (OR=1.5, P < 0.001), operative time greater than 420 minutes (OR=1.2, P=0.03), preoperative chemotherapy (OR=0.6, P=0.002), postoperative blood transfusion (OR=1.7, P < 0.001), pancreatic duct < 3mm (OR=1.7, P=0.002), soft pancreatic texture (OR=2.4, P < 0.001), and drain to suction (OR=1.4, P=0.015). Conclusion: Prolonged POPF is a major source of morbidity following PD but not mortality. Further risk stratification for POPF may be considered for male patients with increased body mass index undergoing prolonged PD procedures. Significant perioperative blood loss requiring transfusion, small pancreatic duct, and soft pancreas remain important predictors of prolonged POPF. Interestingly, drain placed to suction was associated with increased odds of prolonged POPF but neoadjuvant chemotherapy appeared to be protective against prolonged POPF.

1336. Impact of Procalcitonin-Guided Antibiotic Management in Chronic Obstructive Pulmonary Disease Exacerbation and Community-Acquired Pneumonia

BackgroundChronic obstructive pulmonary disease (COPD) exacerbation and community-acquired pneumonia (CAP) are major drivers of antibiotic overuse, primarily due to challenges in pathogen identification. Procalcitonin is a serum biomarker that assists in distinguishing bacterial infection from other causes. The purpose of this study was to determine whether the use of a procalcitonin (PCT) guided algorithm in patients diagnosed with COPD exacerbation and/or CAP can reduce antibiotic exposure without negatively impacting clinical outcomes.MethodsThis was a quasi-experimental study conducted at Mercy Medical Center in Canton, Ohio. The patient data for the retrospective cohort (control group) was collected from the months of September 2017 through January 2018. The prospective phase (PCT group) took place during the months of September 2018 through January 2019. Physicians utilized a procalcitonin guided algorithm to determine appropriate initiation and duration of antibiotic use in patients admitted with a primary diagnosis of COPD exacerbation and/or CAP. The primary outcome was the duration of antibiotic therapy, measured in days. Secondary outcomes included all-cause hospital readmission within 30 days of discharge, respiratory-related hospital readmission within 30 days of discharge, 30-day mortality, hospital length of stay, and adverse events to antibiotics.ResultsA total of 76 patients were included in the study, 43 in the control group and 33 in the PCT group. Baseline characteristics were similar between groups. The use of a PCT algorithm significantly decreased duration of antibiotics by 2.7 days in comparison to the control group (2.6 [n = 33] vs. 5.3 [n = 43] days; P < 0.001; 95% CI). Secondary safety outcomes between the PCT and control group were similar, including all-cause hospital readmission within 30 days of discharge (30.3% vs. 25.6%; P = 0.648), respiratory-related hospital readmission within 30 days of discharge (80.0% [n = 10] vs. 81.8% [n = 11]; P = 0.731), and 30-day mortality (no incidence in either group).ConclusionThe use of a PCT algorithm significantly reduced duration of antibiotics by 2.7 days without negatively impacting clinical outcomes in patients being treated for COPD exacerbation and/or CAP. Disclosures All authors: No reported disclosures.

1802. Evaluation of Clinical Pharmacists Use of a Blood Culture Follow-up Protocol Utilizing Rapid Molecular Diagnostic Testing

BackgroundStudies have shown molecular rapid diagnostic testing (RDT) have been associated with improved clinical outcomes in bloodstream infections when combined with antimicrobial stewardship (AMS) intervention. Mercy Medical Center implemented the RDT Verigene® Blood-Culture Gram-Negative and Gram-Positive panels. After implementation, our prior study that evaluated time to optimal therapy after implementation of Verigene along with AMS intervention showed an improved time to optimal therapy (65 vs. 33 hours, P < 0.001). However, the process implemented was labor intensive for the AMS team to provide coverage 7 days per week. Therefore, we incorporated clinical pharmacists (CP) to provide coverage during evenings and weekends.MethodsWe performed a single-center, retrospective analysis of adult patients who were identified as having a positive blood culture from January 2016 to October 2017. The primary outcome was appropriateness of the CP recommendation based on RDT results compared with AMS recommendations. Secondary outcomes were time to RDT follow-up, and time to optimal antibiotic therapy. A survey of CP assessed workflow and confidence in performing this task. We evaluated each pharmacist’s recommendation based on RDT results, patient specific criteria, and antimicrobial reference tool. Suboptimal recommendations included: no de-escalation, no escalation to effective coverage, or lack of discontinuation.ResultsA total of 160 adult patients, 80 in each group were included. The AMS group provided optimal antibiotic therapy recommendations more often than CP (94% vs. 70%, P < 0.001). Time to follow-up by CP was significantly shorter compared with AMS (3.8 vs. 11; P < 0.001). The majority of the suboptimal recommendations were due to no de-escalation of antibiotic therapy. Time to optimal therapy was similar between groups (24.5 vs. 28; P = 0.920). A third of CP stated they are unlikely to recommend de-escalation to optimal therapy if patients were on effective therapy.ConclusionCP can be utilized to expand coverage of RDT follow-up. The AMS team did provide significantly more optimal antimicrobial recommendations compared with CP. This study shows there is a need for continued education of CP on the importance of de-escalating patients to optimal antimicrobial therapy.Disclosures All authors: No reported disclosures.

Community-Academic Partnership to Investigate Low Birth Weight Deliveries and Improve Maternal and Infant Outcomes at a Baltimore City Hospital.

Purpose Mercy Medical Center (MMC), a community hospital in Baltimore Maryland, has undertaken a community initiative to reduce low birth weight (LBW) deliveries by 10% in 3years. MMC partnered with a School of Public Health to evaluate characteristics associated with LBW deliveries and formulate collaborations with obstetricians and community services to improve birth outcomes. Description As part of the initiative, a case control study of LBW was undertaken of all newborns weighing <2500 grams during June 2010-June 2011 matched 2:1 with newborns ≥2500 grams (n=862). Assessment Logistic regression models including maternal characteristics prior to and during pregnancy showed an increased odds of LBW among women with a previous preterm birth (aOR 2.48; 95% CI: 1.49-4.13), chronic hypertension (aOR: 2.53; 95% CI: 1.25-5.10), hospitalization during pregnancy (aOR: 2.27; 95% CI:1.52-3.40), multiple gestation (aOR:12.33; 95% CI:5.49-27.73) and gestational hypertension (aOR: 2.81; 95% CI: 1.79-4.41). Given that both maternal pre-existing conditions and those occurring during pregnancy were found to be associated with LBW, one strategy to address pregnant women at risk of LBW infants is to improve the intake and referral system to better triage women to appropriate services in the community. Meetings were held with community organizations and feedback was operationalized into collaboration strategies which can be jointly implemented. Conclusion Education sessions with providers about the referral system are one ongoing strategy to improve birth outcomes in Baltimore City, as well as provision of timely home visits by nurses to high-risk women.

Connecting Hispanic Women in Baltimore to the Mercy Medical Center Sexual Assault Forensic Examiners/Forensic Nurse Examiners Program: A Preliminary Assessment of Service Utilization and Community Awareness.

Sexual violence and gender-based violence represent a major public health problem causing significant negative mental, physical, and social outcomes for victims. The rapidly growing population of Hispanic women in Baltimore are both more vulnerable to sexual assault and less able to access postassault services. In an effort to assess service utilization and community awareness of the Mercy Medical Center Sexual Assault Forensic Examiners/Forensic Nurse Examiners Program, we conducted a retrospective chart review of 2,322 women who were seen by the program between 2010 and 2013 and found that only 2.5% of the women were identified as Hispanic, about half of what Baltimore City demographic data would predict. This exploratory pilot project, augmented by key informant interviews, reveals that Hispanic women are underutilizing sexual assault services. Multiple barriers exist for Hispanic women in obtaining victim services, including lack of awareness within the community that the services exist, cultural factors, language barriers, lack of awareness of legal rights, and a fear of deportation.

Abstract C86: Adapting patient navigation to promote cancer screening in Chicago's Chinatown

Abstract Women in Chicago's Chinatown experience high rates of breast and cervical cancer. Despite the availability of health services in close proximity to Chinatown, breast and cervical cancer screening and follow-up rates are unacceptably low for Chinese women in this area. However, within this community exist complex barriers to care many women are uninsured or publicly insured, culturally isolated, and are limited English speakers. The Chinatown Patient Navigation Program is a joint effort by the Chinese American Service League (CASL), Northwestern University, and Mercy Hospital and Medical Center to evaluate a community-based patient navigation program to promote breast and cervical cancer screening and follow-up among Chinatown women. CASL is a trusted community organization in Chinatown for over 35 years; it is where the Chinatown community goes for comprehensive services and cultural events. Mercy Hospital is a community hospital located adjacent to Chinatown with a Cancer Center and Comprehensive Breast and Women's Health Center. Additionally, Mercy Hospital is the largest provider of screening mammograms and Pap tests for the Illinois Breast and Cervical Cancer Program (IBCCP) for uninsured women. Northwestern University brings patient navigation research expertise. Moreover, a Community Advisory Board (CAB) has been established and has been strengthening relationships with the Chinatown community for over five years through CASL's partnership. In this program, bicultural and multilingual (Cantonese, Mandarin, Toishanese, English speaking) patient navigators guide women through the clinics, specialty referrals, diagnostic/testing sites, and social services necessary for addressing complex barriers to care. Each navigator contributes different strengths to the team and provides cross-training to complement other team member skills with adequate linguistic, cultural, medical, and insurance knowledge. The community navigation program has comprehensively assisted over four-hundred women in the two years since we've launch the program. Outreach takes place in various community settings, and we regularly host workshops on various topics on women's health and health insurance. In the process of obtaining screenings and timely follow-up, we are helping to build women's trust in the health system and in physicians and staff; increase health coverage for the whole family; create a habit of regular exams; improve women's knowledge in patients' rights and standard clinical care experiences; and decrease fears of hospitals. Our program seeks to not only impact women's health and screening rates, but to positively change the health knowledge and healthcare access of patient's families and friends as well. A large part of the navigators' role has become that of a one-on-one educator on insurance, due to the Affordable Care Act (ACA). The complications of health insurance are compounded by language barriers and lack of knowledge of America's health system. Moreover, systems-level challenges persist, including lack of Chinese-speaking primary-care physicians, shrinking local and state budgets, along with limited cancer education, insurance information and resource availability in Chinese. The Chinatown Patient Navigation Program has an important research component. This includes focus groups to explore Chinatown women's experiences with the U.S. health care delivery system and individual survey interviews to understand Chinese women's barriers to accessing health care along with their social support and networks. Detailed patient navigation efforts are tracked for a comprehensive process evaluation that can help us better understand service delivery, as well as women's needs and behaviors for obtaining health services independently. In addition, utilization data and medical records will be used to assess changes in community-wide breast and cervical cancer screening rates. Findings from these research activities will help future activities to develop, implement, and disseminate effective and culturally appropriate community-based health programs to eliminate health disparities for Chinese American women. Future directions are to establish a one-stop shop for healthcare services featuring fully integrated Chinese support and to expand navigation services to other chronic diseases and illnesses. This partnership will also serve as a viable model for other community-academic partnerships in underserved communities seeking to improve local health care systems. Citation Format: Ivy S. Leung. Adapting patient navigation to promote cancer screening in Chicago's Chinatown. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C86.

Clinical Faceoff: Are Distal-third Diaphyseal Humerus Fractures Best Treated Nonoperatively?

D istal-third diaphyseal fractures of the humerus are so variably treated that they seem to be a paradigm for bias and misconceptions in surgery. Conceptually, a functional brace seems ‘‘too low,’’ but the fractures almost always heal, although some fractures heal with varus deformity. The surgery is not easy because there is often a butterfly fragment—meaning that the plate must extend proximal, placing the radial nerve at risk. In order to get good fixation, one needs to extend the plate down the posterior, nonarticular part of the lateral column, which makes it difficult to use a straight plate. Consequently, the most distal screws might be unicortical, and subject to pull out in osteoportic bone. I invited two experts in the field of orthopaedic surgery to discuss the many treatment options associated with distal-third diaphyseal fractures of the humerus. Andrew Jawa MD is an orthopaedic surgeon at New England Baptist Hospital in Boston, MA, USA, whose primary clinical interests include shoulder reconstruction for instability, arthritis, and trauma. Lisa K. Cannada MD is an orthopaedic traumatologist from Saint Louis University Hospital and St. John’s Mercy Medical Center in Saint Louis, MO, USA. Her major interests include long bone malunion, pilon fractures, and general trauma orthopaedics.

Silent kidney disease and hypertension in Cambodia--a pilot study in Mercy Medical Center Cambodia.

The incidence and prevalence of end-stage renal disease (ESRD) has been increasing in most developed countries. In developing countries, however, there has been a lack of reliable data. To assess the frequency of unsuspected urine abnormality and hypertension in Cambodia. From April to December 2012, 1,013 new patient records of the Mercy Medical Center (MMC) in Cambodia were reviewed. 915 patients aged ≥ 18 years were included for analysis. Patients with history of hypertension (HT) were excluded for blood pressure (BP) analysis. Patients with history of diabetes mellitus (DM), hypertension (HT), chronic kidney disease (CKD), or with symptoms of renal disease were excluded for urinalysis study. 820 patients had no history of HT. Among this group, 73 (8.9%) had abnormal BP with 60 (7.3%) having BP ≥ 140/90 mmHg and 13 (1.6%) having isolated systolic HT (BP ≥ 140/ 5/high power field (HPF)), 156 (30.6%) having either significant proteinuria or hematuria; and 199 (39.0%) had urine white blood cell count (WBC) ≥ 1+. Overall, 275 patients (53.9%) had 1 or more urinary abnormalities on urinalysis. Abnormal urinalysis (53.9%) and abnormal BP measurement (8.9%) were common findings among asymptomatic patients referred to the MMC. Unlike findings in other countries, no association of family history of DM, HT, or CKD and the risk of kidney disease or abnormal BP was found. A comprehensive community screening program for HT and kidney disease is urgently needed to prevent ESRD in Cambodia.

A clinical evaluation of alternative fixation techniques for medial malleolus fractures

BackgroundMedial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site. SettingSaint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO. MethodsAfter IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation. ResultsSeven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12–208 weeks). There were no screw removals for painful hardware and no cases of non-union. ConclusionsHeadless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation.

Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections

BackgroundApproximately 41 000 central line-associated bloodstream infections (CLABSI) occur annually in US hospitals. We previously developed a simulation-based mastery learning (SBML) curriculum in central venous catheter (CVC) insertion that significantly...