Original Slides Research Articles

The Importance of eSlide Macro Images for Primary Diagnosis with Whole Slide Imaging

Introduction: A whole slide image (WSI) is typically comprised of a macro image (low-power snapshot of the entire glass slide) and stacked tiles in a pyramid structure (with the lowest resolution thumbnail at the top). The macro image shows the label and all pieces of tissue on the slide. Many whole slide scanner vendors do not readily show the macro overview to pathologists. We demonstrate that failure to do so may result in a serious misdiagnosis. Materials and Methods: Various examples of errors were accumulated that occurred during the digitization of glass slides where the virtual slide differed from the macro image of the original glass slide. Such examples were retrieved from pathology laboratories using different types of scanners in the USA, Canada, Europe, and Asia. Results: The reasons for image errors were categorized into technical problems (e.g., automatic tissue finder failure, image mismatches, and poor scan coverage) and human operator mistakes (e.g., improper manual region of interest selection). These errors were all detected because they were highlighted in the macro image. Conclusion: Our experience indicates that WSI can be subject to inadvertent errors related to glitches in scanning slides, corrupt images, or mistakes made by humans when scanning slides. Displaying the macro image that accompanies WSIs is critical from a quality control perspective in digital pathology practice as this can help detect these serious image-related problems and avoid compromised diagnoses.

Pulmonary sclerosing pneumocytoma remains a diagnostic challenge using frozen sections: a clinicopathological analysis of 59 cases.

Using intraoperative frozen sections to diagnose pulmonary sclerosing pneumocytoma is always challenging. However, an accurate diagnosis is needed to guide surgical management and prevent unnecessary treatment. The aim of this study was to investigate the most frequently misdiagnosed histological patterns and evaluate the potential diagnostic pitfalls of using frozen sections. We reviewed retrospectively 59 cases of sclerosing pneumocytoma that underwent an intraoperative frozen section examination. All original frozen section slides and permanent section slides were reviewed. The rate of accurate diagnosis using frozen sections was 44.1%, the deferral rate was 15.3% and 10 cases (16.9%) were misdiagnosed as malignancy. A solid-predominant pattern is misdiagnosed more frequently than other growth patterns. We also summarised the five major diagnostic pitfalls, including hypercellularity, glandular spaces, desmoplasia-like sclerosis, cellular atypia and coagulative necrosis. In addition to evaluating the tumour circumscription and identifying the various growth patterns, we propose that the key to avoiding a misdiagnosis is to recognise the dual-cell populations in a tumour, i.e. cuboidal surface cells and stromal round cells.

Incidence of Pulmonary Edema After Initiation of Parenteral Prostacyclin Therapy for Group I Pulmonary Arterial Hypertension

SESSION TITLE: Pulmonary Hypertension - Advances in Management and Therapy SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 02:45 PM - 04:15 PM PURPOSE: To determine the incidence of pulmonary edema after initiation of parenteral prostacyclin therapy in patients with Group I PAH without suspicion of pulmonary veno-occlusive disease (PVOD) METHODS: A retrospective cohort study of Group I PAH patients without suspicion of PVOD treated with intravenous prostacyclin therapy at the Cleveland Clinic. We determined the incidence of pulmonary edema after initiation of prostacyclin therapy. New onset pulmonary edema was defined as the presence of at least one symptom of pulmonary congestion (worsening dyspnea, orthopnea) and at least one sign of pulmonary edema (new or worsening rales on pulmonary examination or signs of new or worsening pulmonary congestion on chest radiograph). Chest radiograph signs of pulmonary congestion were defined as at least one of the following: Kerley B lines, interstitial infiltrates, vascular cephalization, alveolar infiltrates or pleural effusions. We also analyzed the association between pulmonary edema and hospital LOS, as well as mortality. RESULTS: A total of 155 patients were included in the study. Median age was 50 years (IQR 38-57), females 127 (82%), Caucasian 132 (85%), etiology was predominantly idiopathic PAH 98 (63%), followed by CTD-PAH 36 (23%). Median left ventricular ejection fraction was 55% (IQR 55-60). On right heart catheterization median PAP was 54 (IQR 47-64), median PCWP 12 (IQR 8-16), median RAP 10 (IQR 5-16), median CI 1.9 (IQR 1.6-2.5) and median DLCO 58% (IQR 40-73). The predominant prostacyclin analogue used was IV epoprostenol in 134 (86%), followed by IV treprostinil in 18 (11.6%) and SQ treprostinil in 3 (2%). Median prostacyclin initiation dose of epoprostenol was 2ng/kg/min (IQR 2-3) and for treprostinil was 2ng/kg/min (IQR 1.25-3.25). Median hospital LOS was 6 days (IQR 4-8). Pulmonary edema occurred in 33 (21%) of patients after initiation of prostacyclin therapy. Median duration to onset of pulmonary edema was 2 days (IQR 1-4). 16 (48%) patients required intravenous diuretic therapy, 8 (24%) required de-escalation/discontinuation of prostacyclin therapy. Two patients required invasive mechanical ventilation. The development of pulmonary edema was associated with a longer hospital LOS with mean increase in 2.2 days, (95% CI 1.0- 3.4, p< 0.001) and increased 6-month mortality (OR 4.3, 95% CI 1.3 - 14.8, p<0.05). CONCLUSIONS: Pulmonary edema occurred in 21% of patients with group 1 PAH without suspicion of PVOD after the initiation of parenteral prostacyclin therapy. The development of pulmonary edema was associated with prolonged hospital LOS and increased 6-month mortality. CLINICAL IMPLICATIONS: Pulmonary edema occurs in 1 in 5 PAH patients treated with parenteral prostacyclin therapy. This is associated with worse outcomes and is in line with recently emerging evidence pointing at a high prevalence of microscopic vein involvement in PAH. DISCLOSURE: The following authors have nothing to disclose: Nauman Khan, Rizwan Khan, Raed Dweik, Gustavo Heresi No Product/Research Disclosure Information

Work Productivity Among People With Sleep Apnea With Excessive Sleepiness: Findings From the 2016 US National Health and Wellness Survey

SESSION TITLE: Obstructive Sleep Apnea: Insights & Management SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 01:30 PM - 03:00 PM PURPOSE: Few population-based studies have explored how excessive sleepiness (ES) affects work productivity among patients with sleep apnea (SA). METHODS: Data were obtained from the 2016 US National Health and Wellness Survey, an annual, representative, cross-sectional, general health survey (N=97,503). Respondents self-reporting a SA diagnosis were categorized as having excessive sleepiness (ES) (Epworth Sleepiness Scale [ESS≥11]) or not having ES (ESS<11) and compared with a non-SA control group. Respondents reporting narcolepsy were excluded. Work productivity in the three groups was measured using the Work Productivity and Activity Impairment General Health (WPAI-GH) questionnaire, a 6-item validated instrument consisting of: absenteeism (percentage of work time missed because of one's health in the past seven days), presenteeism (percentage of impairment while at work in the past seven days because of one's health), overall work productivity loss (an overall impairment percentage estimate combining absenteeism and presenteeism), and activity impairment (percentage of impairment in daily activities because of one's health in the past seven days) (Reilly, Zbrozek, & Dukes, 1993). Outcomes were examined by three groups: SA w/ES, SA w/o ES, and non-SA controls using one-way ANOVAs (continuous outcomes). Generalized linear models controlling for covariates examined the effect of SA/ES status on WPAI-GH. RESULTS: Thirty-five percent of the patients with SA also had ES (358/1,018). Overall, SA w/ES had greater impairment in both work productivity and daily activities compared to the other two groups after controlling for covariates. The SA w/ES group (N=358) missed 7.93% of their work hours in the past week compared to 5.74% in the SA w/o ES group (N=660; p=0.193) and 3.91% in the non-SA control group (N=48,188; p<0.001). Presenteeism was 25.98% in the SA w/ES group compared to 19.24% in the SA w/o ES group (p=0.005) and 14.75% in the non-SA controls (p<0.001 vs SA w/ES). Non work-related activity impairment was 31.09% in the SA w/ES group versus 25.46% in SA w/o ES (p<0.001) and 19.93% in non-SA controls (p<0.001 vs SA w/ES). CONCLUSIONS: These data provide support that people with SA had impaired productivity compared to non-SA controls and that those who also had ES showed even greater deficits. The SA w/ES group was associated with substantial increases in work and daily activity impairment compared to SA patients without ES and non-SA controls. CLINICAL IMPLICATIONS: ES can reduce a patient’s ability to effectively complete work and non-work activities and results in significantly more impairment compared to those who have SA without ES. Therefore, ES is an important symptom to assess during clinical evaluations of patients with SA. DISCLOSURE: Kathleen Sarmiento: Consultant fee, speaker bureau, advisory committee, etc.: Jazz Pharmaceuticals Shay Bujanover: Employee: Jazz Pharmaceuticals, Shareholder: Jazz Pharmaceuticals Kathleen Villa: Employee: Jazz Pharmaceuticals employee, Shareholder: Jazz Pharmaceuticals Vicky Li: Employee: Kantar Health, Consultant fee, speaker bureau, advisory committee, etc.: Jazz Pharmaceuticals Natalia Flores: Employee: Kantar Health, Consultant fee, speaker bureau, advisory committee, etc.: Jazz Pharmaceuticals The following authors have nothing to disclose: Carl Stepnowsky No Product/Research Disclosure Information

Recent Inhaler Device Switch is Not Associated With Poor Inhaler Technique: Analysis of Inhaler Technique in the Adult Calgary COPD and Asthma Clinic

SESSION TITLE: Respiratory Care SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 08:45 AM - 10:00 AM PURPOSE: Inhaled medications are essential for the treatment of asthma and COPD. Poor inhaler technique is linked reduced asthma control, increased hospitalizations and exacerbation rates. Unfortunately, inhaler technique errors are common and rates of poor inhaler technique have not changed despite introduction of educational strategies. Previous research has identified risk factors associated with poor technique, such as, increased age, English as a second language (ESL), and multiple medical comorbidities. We hypothesized that with increasing types of devices available for use a recent device switch may be an emerging risk factor for persistently elevated inhaler error rates. METHODS: 95 adult newly referred patients to the COPD and Asthma Respiratory Education Program were assessed by a certified respiratory education. Baseline demographics and information on inhaler usage was obtained. Critical errors were defined a priori. A patient was categorized as having inadequate inhaler technique if a critical error was identified. RESULTS: The total rate of critical errors/inadequate inhaler technique amongst new referrals was 52.6% (95% CI 42.4%-62.9%). Lower MMRC score in patients with COPD (p=0.016) and ESL (p=0.031) were associated with inadequate inhaler technique. 39% of patients referred had a device switch in the last year. Patients with previously identified risk factors for poor inhaler technique such as increased age (p=0.064), vision impairment (0.027), no high school education (0.006), ESL (0.056), poor asthma control (0.041), and increased number of devices (0.005) were associated with a recent device switch. Overall, there was no evidence to suggest that recent device switch is associated with increased odds of inadequate technique (OR=0.92; 95% CI 0.37-2.28). Interestingly, patients with vision problems who had a recent device switch had lower odds of inadequate inhaler technique (OR = 0.06; 95% CI 0.001-0.74, p=0.007). CONCLUSIONS: This pilot study shows that rates of inhaler error remain unacceptably high. A recent device switch was associated with multiple previously identified risk factors for poor technique. However, a recent device switch itself does not seem to be a risk factor despite the fact that the patient is required to learn a new skill. In fact, in patients with specific risks (ex. visual impairment) a device switch may be protective. CLINICAL IMPLICATIONS: It is important to understand that inhaler error remains a critical issue in respiratory health. As there are increasing numbers of devices available patients are more likely to have a new inhaler device to learn. Further research to understand that role device selection to improve patient technique is needed. DISCLOSURE: The following authors have nothing to disclose: Julia Pritchard, Alex Scurfield, Brandie Walker No Product/Research Disclosure Information

Role of Nailfold Capillaroscopy in the Evaluation of Patients With Interstitial Lung Disease

SESSION TITLE: Diffuse Lung Disease II SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 08:45 AM - 10:00 AM PURPOSE: Distinguishing between idiopathic interstitial pneumonias (IIPs) and other types of interstitial lung diseases (ILD) such a connective tissue disease (CTD)-related ILD can be challenging. In some patients, the clinical features of autoimmunity are subtle. Abnormal capillaries on nailfold capillaroscopy (NC) predict a higher risk of CTD development and the use of NC is common in the evaluation of patients with Raynaud’s phenomenon. NC could help clinicians identify signs of CTD or autoimmune features in patients with ILD, although its clear role in the evaluation of ILD has yet to be defined. This study aims to describe the impact of NC in the evaluation of patients with ILD. METHODS: We retrospectively identified patients with ILD seen in a tertiary care center who underwent a NC as part of their work-up. All diagnoses were established by multidisciplinary consensus according to current guidelines. Patients were categorized into 3 groups according to their final diagnosis: CTD-ILD, interstitial pneumonia with autoimmune features (IPAF) and IIP. RESULTS: NC was performed in twenty-seven patients, 14 of whom were female (52%). There were 11 who had Raynaud’s phenomenon (41%), and the majority had positive antinuclear antibodies (89%). Mean forced vital capacity percent predicted and diffusion capacity percent predicted were 76% and 47% respectively. Morphologic capillary changes were observed in 10 patients (37%): a scleroderma pattern was found in 5 of them while the other 5 had minor capillary changes. Patients carrying a final diagnosis of CTD-ILD (40%) or IPAF (63%) were more likely to have NC abnormalities than those with a diagnosis of IIP (16%). Identification of nailfold capillary abnormalities contributed to establishing a multidisciplinary diagnosis of IPAF in all cases. There were no clinical symptoms, serologies or physiologic variables that were predictive of nailfold abnormalities. CONCLUSIONS: In our cohort, NC contributed to the identification of subtle clinical signs of autoimmune features in patient with ILD and influenced multidisciplinary consensus diagnosis. Further, larger studies are needed to validate these findings, and to better understand the prognostic significance of NC abnormalities in patients with ILD. CLINICAL IMPLICATIONS: In the evaluation of patients with ILD, NC could be useful to identify subtle clinical signs of autoimmune features. DISCLOSURE: The following authors have nothing to disclose: Mathilde Bouchard-Boivin, Sandra Chartrand, Martial Koenig, France Joyal, Deborah Assayag, Julie Morisset No Product/Research Disclosure Information

Timeliness of Referrals Using a Diagnostic Imaging Notification Process for Patients Suspected of Having Lung Cancer

SESSION TITLE: Lung Cancer Diagnostics SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: The objectives of this study were to investigate if a Diagnostic Imaging (DI) Notification process has an impact on the timeliness to specialty referral and treatment decision in patients suspected of having lung cancer. METHODS: A retrospective, observational non-randomized study of two groups of patients referred to the Alberta Thoracic Oncology Program-North (ATOP-N) was carried out from 2013-2015 (total n=2766). Group One: Patients who were referred to the ATOP-N clinic where an interpreting CT radiologist initiated the DI notification process leading to a referral to a specialist. Group Two: Patients who were referred to a specialist at ATOP-N through the standard referral process by non-radiologist health care providers. Time intervals between date of suspicious CT chest to date of referral (CT-R), first specialist consult date (CT-C), surgery date (CT-S), and oncology referral date(CT-O) were evaluated. RESULTS: CT-R, CT-C, CT-S, and CT-O were calculated for patients for group one (n=891) and group two (n=1779). The median (75th-90th percentile) CT-R was 4 (7-12) days in group one and 14 (37-67) days in group two (P<0.00001). The median (75th-90th percentile) CT-C was 25 (34-43) days in group one and 39 (62-96) days in group two (P<0.00001). The median (75th-90th percentile) CT-S was 83 (113-154) days in group one and 107 (149-204) days in group two (P<0.00001). The median (75th-90th percentile) CT-O was 27 (58-107) days in group one and 49 (101-167) days in group two (P=0.00005). CONCLUSIONS: A Diagnostic Imaging (DI) Notification process significantly reduced the interval between CT chest imaging suspicious for lung cancer to date of referral, first specialty consultation and treatment. CLINICAL IMPLICATIONS: A Diagnostic Imaging Notification referral process is a novel and effective method to use in the management of patients suspected of having lung cancer. It has overall improved the timeliness of these patients to specialty referral and treatment decision. DISCLOSURE: The following authors have nothing to disclose: Ashley Mae Gillson, James Veenstra, Kenneth Stewart, Teresa Ruston, Jonathan Abele No Product/Research Disclosure Information

Predictors of Nontuberculous Mycobacterial Lung Disease in US Veterans

SESSION TITLE: Lung Infections SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 02:45 PM - 04:15 PM PURPOSE: Nontuberculous mycobacteria lung disease (NTMLD) is an increasingly prevalent condition with significant challenges in clinical management. While it is known that patients who are immunocompromised or have underlying lung disorders are at risk of NTMLD, more research is needed to better understand determinants and associated factors. METHODS: We studied predictors of NTMLD diagnosis and all-cause mortality among U.S. Veterans receiving health care from the U.S. Department of Veterans Affairs (VA). National VA patient records from 2001-2012 were used to identify patients with NTMLD based on the presence of ≥1 NTMLD diagnostic code, ≥1 separate confirmatory code for nontuberculous mycobacterial infection, and ≥1 year of VA service before the first code. Ten comparison patients for each case were sampled at random from all VA patients in care in the month of the first NTMLD code, with no history of NTMLD, and with ≥1 year of prior VA service. A rich set of data on patient demographics, health care utilization, laboratory and physical test results, comorbidities, and prescriptions was linked and used in the analysis. Multivariable logistic regression was used to estimate independent associations of factors with NTM risk. Deaths were identified based on records from VA and Social Security files, and multivariable proportional hazards regression was used to estimate mortality risk associated with NTMLD after adjustment for other variables. RESULTS: The samples consisted of 2,747 patients with NTMLD and 27,470 controls. In the NTMLD group, 96.7% were men, 76.5% were white, and mean age was 66.6 years. NTMLD risk increased with age and was higher in men, African-Americans, and people living in the South. Strong direct associations were found with interstitial lung disease (odds ratio [OR]=11.1, 95% confidence interval [CI]=8.78-14.0), pneumonia (OR=7.83, 95% CI=6.33-9.69), and chronic obstructive pulmonary disease (OR=5.38, 95% CI=4.78-6.05), as well as HIV infection (OR=18.6, 95% CI=13.3-26.1), inflammatory bowel disease (OR=2.26, 95% CI=1.39-3.67), rheumatoid arthritis (OR=2.00, 95% CI=1.36-2.94), chronic hepatitis or cirrhosis (OR=1.79, 95% CI=1.20-2.67), and anemia (OR=1.59, 95%CI=1.35-1.87). NTMLD risk was inversely associated with dementia (OR=0.22, 95% CI=0.12-0.40) and obesity (OR=0.31, 95% CI=0.24-0.40). Medications associated with NTMLD risk included bronchodilators (OR=2.28, 95% CI=1.90-2.73), cytostatic medications (OR=1.95, 95% CI=1.29-2.95), smoking cessation drugs (OR=1.56, 95% CI=1.21-2.00), and oral anticoagulants (OR=1.54, 95% CI=1.28-1.86). Mortality was doubled in patients with NTMLD, but was reduced to a 14% increase (OR=1.14, 95% CI=1.07-1.22) after adjustment for comorbidities and other factors. CONCLUSIONS: NTMLD risk is associated with a number of predisposing pulmonary conditions as well as medical conditions and medications that may reduce immune function and host resistance. CLINICAL IMPLICATIONS: These results suggest the importance of both underlying host factors and environmental exposures in the etiology of NTMLD. Further work is needed to better understand determinants of this condition and optimal strategies for management. DISCLOSURE: Quanwu Zhang: Employee: Employee of insmed inc The following authors have nothing to disclose: Donald Miller, William Powell, Eric Garshick No Product/Research Disclosure Information

Associated Pulmonary Hypertension is an Independent Contributor to 6-Minute Walk Distance in Chronic Fibrosing Interstitial Pneumonias

SESSION TITLE: Diffuse Lung Disease II SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 08:45 AM - 10:00 AM PURPOSE: Associated pulmonary hypertension (APH) is frequently observed in fibrosing interstitial pneumonias (FIP), such as idiopathic pulmonary fibrosis (IPF). APH is associated with greater functional impairment and worse prognosis. APH may be out of proportion with the extent of FIP. Six-minute walk distance (6MWD) is widely used to assess functional capacity in pulmonary hypertension. We hypothesized that APH independently affects 6MWD in FIP irrespective of the underlying fibrosis. METHODS: Patients diagnosed with FIP (September 2009-January 2017) were included in the study if they underwent right heart catheterization (RHC), chest high-resolution CT (HRCT) scan and six-minute walk test. Patients with connective tissue disease were excluded. APH was defined as mean pulmonary artery pressure (mPAP) ≥25 mmHg and pulmonary capillary wedge pressure ≤15 mmHg. Demographic, PFT and pulmonary hemodynamic data were collected for analysis. The extent of fibrosis was quantified with a standard HRCT fibrosis score. Stepwise multiple regression model was performed to select independent contributors of 6MWD. RESULTS: Forty-seven patients (forty with IPF, seven with non-IPF FIP) were included. Thirty-six patients had APH. mPAP and pulmonary vascular resistance (PVR) were negatively and significantly correlated with 6MWD % pred (r=-0.32, p=0.031; rho=-0.40, p=0.007, respectively). mPAP and PVR were each independent predictors of 6MWD % pred based on stepwise regression analysis. Quantitative HRCT fibrosis score and pulmonary function tests were not significantly correlated with 6MWD % pred, and were not significant predictors on stepwise regression. CONCLUSIONS: The presence of APH in FIP is associated with reduced 6MWD. This association is independent from the extent of underlying lung fibrosis. Therefore, APH has an independent impact on exercise capacity, which may be out of proportion with the extent of lung fibrosis. CLINICAL IMPLICATIONS: 6MWD is commonly used to monitor functional capacity in primary pulmonary hypertension. We show that APH is independently associated with exercise incapacity quantified by 6MWD. Therefore 6MWD in patients with APH may not necessarily reflect the course of FIP, while it may be used to monitor APH. DISCLOSURE: The following authors have nothing to disclose: David Yoo, Maurizio Zompatori, Marco Mura No Product/Research Disclosure Information

The Age Adjusted 12-Year Incidence and Mortality Rates of Sepsis Using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) on MIMIC-III Data

SESSION TITLE: Sepsis & Septic Shock SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 01:30 PM - 03:00 PM PURPOSE: Prior epidemiologic studies defining sepsis incidence have been based on SIRS criteria and ICD-9 codes. While not considered a part of the definition of sepsis, the recent Sepsis-3 criteria are considered a less sensitive but more specific predictor of life threatening infection than the SIRS criteria. The objective of this study is to examine the differences of age adjusted incidence of sepsis in intensive care unit (ICU) patients when applying Sepsis-3 criteria on administrative claims data based on ICD-9 codes for sepsis. METHODS: Retrospective cohort study evaluating 36503 adult (>=18) ICU patients from 2001 to 2012 in the MIMIC-III dataset. Patients were divided into subgroups based on age at admission. The 12-year age adjusted incidence of sepsis was defined after applying Sepsis-3 criteria. Incidence was compared to two prior methods used in prior sepsis incidence studies (Angus method and ICD-9 explicit method). The independency and differences of incidences were tested using Fisher’s test and McNemar’s test, respectively. RESULTS: Within the MIMIC-III data, 43.9%, 27.0%, and 7.0% of the adult ICU patients were identified as defined sepsis when Sepsis-3 criteria, Angus method, and ICD-9 explicit method were applied, respectively. We observed the largest 12-year incidence rate in each of the 7 age groups when the Sepsis-3 definition was applied. When comparing Sepsis-3 with Angus definition, the smallest incidence difference occurred in the age 30-40 group (33.5% vs. 21.4% p<0.0001), while the largest occurred in the age 60-70 group (45.5% vs. 26.3% p<0.0001). When comparing Sepsis-3 with ICD-9 explicit, the smallest incidence difference also occurred in the age 30-40 group (33.5% vs. 5.6% p<0.0001), but the largest occurred in the age 70-80 group (48.2% vs. 7.3% p<0.0001). Meanwhile, the respective overall sepsis-related mortality rates for Sepsis-3, Angus, and ICD-9 explicit were 15.4%, 22.5%, and 38.6%, and within each of the 7 age groups, the mortality rate under Sepsis-3 was significantly smaller than those under two other definitions of sepsis. CONCLUSIONS: Sepsis-3 criteria yield a larger 12-year incidence of sepsis and a smaller 12-year sepsis-related mortality rate as compared to the two other ICD-9 claims definitions within all 7 age groups. CLINICAL IMPLICATIONS: An accurate understanding of discrepancies in sepsis burden among different definitions and ages has critical public health and policy implications if new criteria are to be considered in future sepsis definitions. DISCLOSURE: The following authors have nothing to disclose: Chen Feng, Shravan Kethireddy, Griffin Paul, Yajun Mei No Product/Research Disclosure Information

Outcomes of Early vs Late Oral Nutrition in Patients With Diabetic Ketoacidosis Admitted to a Single Academic Institution Medical ICU

SESSION TITLE: Improving Outcomes in the ICU SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: Diabetic ketoacidosis (DKA) is a potentially dangerous complication of diabetes often necessitating admission to the intensive care unit (MICU). It is associated with severe insulin deficiency, electrolyte abnormalities, and dehydration requiring insulin infusion and close electrolyte and blood glucose monitoring. Upon resolution of DKA, patients are gradually transitioned to subcutaneous insulin and oral nutrition. However, there is no recommendation on timing of oral nutrition. Potential disadvantages of early oral intake include fueling lipolysis and promoting ketogenesis, difficulty in blood sugar control, and development of ileus, all of which can lead to deterioration and longer ICU stay. Due to these concerns and lack of definitive recommendations, many institutional protocols prefer initial NPO status and often associate initiation of oral nutrition with resolution of DKA. Our study is aimed to investigate safety of oral nutrition prior to resolution of DKA in adult patients admitted to MICU. METHODS: Retrospective observational study was conducted at a single academic medical center. Time to DKA resolution was defined by the presence of both: 1) Glucose < 200 and 2) two of the three: pH ≥ 7.3, serum bicarbonate ≥15, and anion gap ≤12. Descriptive statistics and bivariate analysis was used to analyze patients' age, gender, race, Apache IV length of stay and mortality indices as well as the outcomes which included 28- and 90-day mortality, hospital and ICU length of stays and time to resolution of DKA. RESULTS: Between 12/2015 and 01/2017 there were 330 admissions to Scott and White Medical Center MICU with diagnosis of DKA. After excluding repeated hospitalizations of the same patients for DKA the final sample consisted of 146 unique patient admissions. Of those, 78 patients received oral nutrition prior to and 68 received oral nutrition after the resolution of DKA. No statistically significant difference was found between groups in age, gender, APACHE IV length of stay or APACHE IV mortality scores. There was a significant difference in race distribution, although proportions of caucasian and african-american patients comprising most of the study population were similar (23% vs 26% and 64% vs 69% in early vs late nutrition group respectively). Comparing the mortality of patients receiving early vs late oral nutrition no statistically significant difference was found: 5 patients died in the first 28 days (2 vs 3, p=0.68) and 6 died within 90 days (2 vs 4, p=1.0). Groups did not significantly differ in their mean hospital length of stay (5.6 vs 7.1 days in early vs late group respectively, p=0.3) but there was statistically significant difference in the mean ICU length of stay (2.4 vs 3.6 days, p=0.044) and the mean time to DKA resolution (53.8 vs 133.1 hours, p<0.0001). CONCLUSIONS: Oral nutrition in patients admitted to MICU for DKA initiated prior to the resolution of ketoacidosis appears safe and could potentially decrease the time to resolution of DKA and ICU length of stay. CLINICAL IMPLICATIONS: A larger prospective study can be conducted randomizing patients in early vs late oral nutrition groups seeking to replicate our findings and further analyze the impact of oral nutrition in this complex physiologic condition. DISCLOSURE: The following authors have nothing to disclose: Kirill Lipatov, Susan Seago, Kevin Kurian, Jonathan Walsh, Mason Sanders, Molly Clark, Jason Ettlinger, Megan Newman No Product/Research Disclosure Information

Factors Influencing Noninvasive Ventilation Initiation in Amyotrophic Lateral Sclerosis

SESSION TITLE: Respiratory Care SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 08:45 AM - 10:00 AM PURPOSE: Respiratory failure is the most common cause of death in Amyotrophic Lateral Sclerosis (ALS). Noninvasive ventilation (NIV) has been shown to improve survival and quality of life in patients with daytime respiratory symptoms or when forced vital capacity (FVC) falls below 50% of predicted value. However, the optimal timing to initiate NIV is unknown. Preliminary data suggests that early NIV initiation (at FVC>50% predicted), applied during nocturnal sleep, may prevent respiratory function decline and further improve survival. Current practice guidelines recommend NIV initiation when FVC is ≤ 50% predicted. Our objective is to describe NIV practices at a tertiary ALS referral center with respect to guidelines. METHODS: We retrospectively reviewed a cohort of 96 patients between 2015-2017. We analyzed respiratory and bulbar symptoms, FVC at diagnosis and NIV initiation, time gap between diagnosis and NIV initiation. Logistic regression analysis was performed to determine predictors of early NIV initiation (FVC>50). RESULTS: NIV was initiated in 67.7% of patients (mean age 63.7). At time of diagnosis, mean FVC was 63.3%, mean FVC at NIV initiation was 51.6%. Respiratory and bulbar symptoms were present in 75% and 60% of patients, respectively. Mean FVC was 65.6% versus 77.7% for those with and without bulbar involvement, respectively. Mean FVC at NIV initiation was 49% versus 56.6% for those with and without bulbar involvement, respectively. Early NIV (initiated at FVC>50) was implemented in 51% of patients due to respiratory (67%) or bulbar symptoms (52%). Mean FVC at early NIV initiation was 66.6%. Average time from diagnosis to NIV initiation was 232.3 days, with a mean FVC decline of 9%. NIV was implemented in 49% of patients per practice guidelines (FVC≤50). Mean FVC at NIV initiation per guidelines was 36%. Respiratory and bulbar symptoms were present in 84% and 68.7%, respectively. Average time from diagnosis to NIV initiation was 42.7 days, with a mean FVC decline of 14.8%. Logistic regression analysis showed that respiratory symptoms were significantly associated with early NIV initiation (OR 10.4, 95% CI 2.6-41.8, p<0.001). Only 10 patients (15%) with baseline FVC>50% at time of diagnosis were started on NIV late in the disease course (i.e. FVC≤40). CONCLUSIONS: Majority of patients were initiated on nocturnal NIV appropriately or earlier than current practice guidelines due to respiratory or bulbar symptoms. Early NIV initiation may be considered for patients with symptoms related to respiratory or bulbar involvement. CLINICAL IMPLICATIONS: Further research is needed to clarify optimal timing of a critical intervention (NIV) which may further prolong survival, improve quality of life, and potentially delay respiratory function decline. DISCLOSURE: The following authors have nothing to disclose: Pradeep Doddamreddy, Gaurav Singh, Brittany Schultz, Michelle Cao No Product/Research Disclosure Information

Factors Correlate With Early Palliative Care Timing Among Critically Ill Patients With Chronic Lung Disease

SESSION TITLE: Improving Outcomes in the ICU SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: To examine how demographic, clinical and provider factors correlate with the timing of palliative care consult (PCC) among critically ill patients with known chronic lung disease (CLD). METHODS: We conducted a retrospective case-control study of all inpatient admissions with primary discharge diagnoses codes of chronic obstructive lung pulmonary disease (COPD) and interstitial lung disease (ILD) between July 2010 and June 2015 who stayed in the intensive care unit for at least 24-hour and received PCC during or over 6 month prior to index admission. Exclusion criteria included admission to or discharge from the lung transplant service. Timing of PCC was calculated from the day of admission to the first PCC consult note available on the electronic medical records. Patients were grouped into those of received early PCC (occurring prior to or during first week of admission) and those who received delayed PCC (occurring after the first week of hospitalization). Patient demographics and clinical and provider characteristics of both groups were compared. We used logistic regression analyses to determine independent predictors of delayed PCC among critically ill patients with CLD. RESULTS: There were 19851 CLD admissions to non-transplant services, of which 5409 (27.2%) had an ICU stay. Among these, 614(11.3%) received a PCC; 335(54.6%) had early PCC and 279(45.4%) had delayed PCC. There was no statistical difference in demographic variables, reason for hospitalization, or admission to ICU between the two groups. ILD patients were more likely to receive a delayed PCC (OR: 2.5; 95%CI: 1.6, 3.9, p<0.001) while cardiac arrest requiring CPR prior to ICU transfer correlated with higher likelihood of an early PCC (OR: 0.4, 95%CI: 0.1, 0.9, p=0.019). The delayed PCC group had a higher rate of intubation, re-intubation, and in-hospital mortality compared to those who received early PCC (p<0.001). Patients admitted to non-pulmonary medicine services or had different admitting and discharging services throughout their hospitalization were more likely to receive a delayed PCC. In multivariate logistic regression analyses, a history of ILD (OR: 2.7; 95%CI: 1.7, 4.3, p<0.001), longer time between admission and initial intubation (OR: 3.2; 95%CI: 2.3, 4.6, p<0.001), cardiac arrest requiring CPR prior to ICU admission (OR: 0.3; 95%CI: 0.1, 0.7, p=0.003), and admission to a pulmonary medicine service (OR: 0.6; 95%CI: 0.4, 0.8, p=0.001) were all independent correlates of delayed PCC. CONCLUSIONS: Our results indicate that the type of CLD, severity of presentation, type and continuity of inpatient provider are independent predictors of PCC timing among critically ill patients with CLD. Future studies are encouraged to examine how strategies addressing these factors impact the timing of PCC among critically ill patients with CLD. CLINICAL IMPLICATIONS: Various clinical and provider factors correlate with the timing of PCC among critically ill patients with CLD. DISCLOSURE: The following authors have nothing to disclose: Roozbeh Sharif, Aline Zouk, James O'Conner, Joao deAndrade No Product/Research Disclosure Information

The Use of Extracorporeal Membrane Oxygenation in Severe Adenovirus Pneumonia Complicated by ARDS: A Single-Center Experience

SESSION TITLE: Infections in the ICU SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 07:30 AM - 08:30 AM PURPOSE: Acute respiratory distress syndrome (ARDS) in adenovirus pneumonia has a high mortality. Data on extracorporeal membrane oxygenation (ECMO) outcomes in severe adenovirus pneumonia is limited. METHODS: We reviewed case records of patients with severe viral pneumonia requiring ECMO at a single intensive care unit (ICU) between January 2011 and January 2017. Diagnosis was based via viral PCR from endotracheal aspirates or nasopharyngeal specimens. RESULTS: 32 patients with severe viral pneumonia required venovenous ECMO; 8 had adenovirus. Most were male (62.5%), and of Chinese race (62.5%). Between the adenovirus and non-adenovirus groups, there was no difference in baseline characteristics such as age (43.0 years vs 48.0 years; p=0.685), BMI (25.7 kg/m2 vs 25.8; p=0.428), Charlson Comorbidity Index (0 vs 1; p=0.220), APACHE II (21 vs 20; p=0.782), SOFA (7.5 vs 9.0; p=0.815), RESP (4 vs 4; p=0.281) and PRESERVE (2 vs 4; p=0.630). The cohort had only 1 immunocompromised patient (non-adenovirus group). More patients in the adenovirus group received corticosteroids (37.5% vs. 4.2%; p=0.039). The pre-ECMO ICU length of stay (LOS) (4 vs 1 days; p= 0.041), and mechanical ventilation (MV) duration (3.5 vs 1 days; p=0.024) were longer in this group. They also had longer i) ECMO runs (15.5 days vs 7.0 days; p=0.004), ii) MV (20 vs 14.5 days; p=0.009), and iii) ICU LOS (21 vs 15.5 days; p=0.008). There was no difference in hospital LOS (32 vs 28.5 days; p=0.234). Bleeding complications on ECMO were higher in the adenovirus group (75% vs 33.3%; p=0.096), largely contributed by intracranial haemorrhage (accounted for 50% of bleeding in this group). There were 2 (20%) and 5 (20.8%) deaths on ECMO in the adenovirus and non-adenovirus groups respectively. Survival to discharge was comparable (57.1% vs 66.7%; p=0.676). CONCLUSIONS: Survival of ECMO patients with severe adenovirus pneumonia appeared comparable to other viral pneumonias in spite of longer ICU and MV days before ECMO, and more prolonged ECMO runs. An increased risk of intracranial haemorrhage was observed in adenovirus patients. CLINICAL IMPLICATIONS: Severe adenovirus pneumonia requiring ECMO will have significant impact on ICU resource planning and utilisation; further research into management is needed to improve outcomes. DISCLOSURE: The following authors have nothing to disclose: Michelle Kam, Hui Zhong Chai, Ken Junyang Goh, Qiao Li Tan, Duu Wen Sewa, Aik Hau Tan, Melvin Tay, Ghee Chee Phua No Product/Research Disclosure Information

Norepinephrine Dosing in Obese Patients: Impact of Weight-Based Dosing on Short- and Long-Term Mortality

SESSION TITLE: Sepsis & Septic Shock SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 01:30 PM - 03:00 PM PURPOSE: Obesity is thought to be protective in septic shock. Norepinephrine (NE) is frequently dosed by a weight-based regimen, and potentially higher doses of NE are used in the obese population. The interaction of body mass index (BMI) with NE dosing and their influence on clinical outcomes has been only limitedly explored. METHODS: Historical cohort study of all adult septic shock patients requiring NE admitted between 2010 through 2015 to all intensive care units (ICU) at Mayo Clinic Rochester. Patients with BMI 25-39.9 kg/m2 were classified into overweight (25-29.9 kg/m2), obesity class I (30-34.9 kg/m2) and obesity class II (35-39.9 kg/m2). Patients with normal BMI (18.5-24.9 kg/m2) formed the control group. Patients with chronic respiratory failure, repeat ICU admissions, ICU stay <1day, lactate <2 mmol/L and BMI <18.5 and ≥ 40 kg/m2 were excluded. The primary outcome was in-hospital mortality and secondary outcomes included new cardiac arrhythmias, acute kidney injury (AKI) and one-year mortality. Odds ratios (OR) [95% confidence intervals (CI)] were used to represent univariate and multivariate outcomes respectively. A two-tailed p<0.05 was considered significant. RESULTS: During this 6-year period, 4774 patients met our study criteria - BMI 18.5-24.9, 25-29.9, 30-34.9 and 35-39.9 kg/m2 had 1406 (29%), 1608 (34%), 1151 (24%) and 609 (13%) patients respectively. The baseline characteristics revealed significant inter-group differences in age, race, gender and baseline creatinine, but no differences in comorbidity burden, severity of illness or use of corticosteroids in the ICU. Median NE dose increased linearly with increase in BMI cohorts - 5 gm (interquartile range [IQR] 1-13) (BMI 18.5-24.9 kg/m2), 5.3 gm (IQR 2-14) (BMI 25-29.9 kg/m2), 6 gm (IQR 2-16) (BMI 30-34.9 kg/m2) and 7 gm (IQR 2-18) (BMI 35-39.9 kg/m2), p<0.001. There was no difference in number, type or total doses of additional vasoactive medications. In-hospital (29%, 24%, 22%, 22%; p<0.001) and one-year mortality (46%, 53%, 53%, 51%; p=0.001) were significantly different between patients with BMI 18.5-24.9, 25-29.9, 30-34.9 and 35-39.9 kg/m2 respectively. Unadjusted log10NE levels were associated with higher in-hospital mortality (OR 2.9 [95%CI 2.6-3.3]; p<0.001), AKI (OR 1.8 [95% CI 1.6-1.9]; p<0.001), cardiac arrhythmias (OR 1.4 [95% CI 1.3-1.5]; p<0.001) and one-year mortality (OR 1.8 [95% CI 1.6-2]; p<0.001). After adjusting for age, gender, BMI, comorbidity burden, severity of illness, cardiac injury, AKI, cardiac arrhythmia and use of mechanical ventilation, log10NE was an independent predictor of in-hospital (OR 2.2 [95% CI 1.9-2.7]; p<0.001) and one-year mortality (OR 1.4 [95% CI 1.2-1.7]; p<0.001). CONCLUSIONS: Total NE use was independently associated with worse short and long-term mortality, AKI and cardiac arrhythmias in patients independent of BMI. CLINICAL IMPLICATIONS: Alternative strategies to weight-based NE dosing are recommended in obese patients. DISCLOSURE: The following authors have nothing to disclose: Aditya Kotecha, Saraschandra Vallabhajosyula, Dinesh Apala, Erin Frazee, Vivek Iyer No Product/Research Disclosure Information

Etiology and Prognostic Impact of Mcconnell's Sign in Medical ICU

SESSION TITLE: Rapid Session: Bedside Imaging SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 07:30 AM - 08:30 AM PURPOSE: McConnell’s sign (MCS) describes a pattern of right ventricular dysfunction with hypokinesia of the body and relatively preserved contractility of the apex seen on echocardiogram. It was thought to be specific for pulmonary embolism (PE), but subsequent research demonstrated that other etiologies for MCS including myocardial infarction and pulmonary arterial hypertension. We are reporting the etiologies and prognostic impact of MCS in a cohort of patients in a tertiary center medical intensive care unit (MICU). METHODS: We did a retrospective chart review of patients admitted to the MICU at a tertiary academic hospital in the United States between October 2014 and October 2016 who underwent an echocardiogram showing MCS. We determined the etiology of MCS by compiling data from discharge summaries, past medical history, imaging studies, autopsies and treatment plans. We collected and analyzed mortality data to calculate the odds ratio of in hospital mortality based on etiology of McConnell's sign whether it was caused by PE or other etiologies. RESULTS: Out of 48 patients with MCS in the MICU, 26 (54%) had pulmonary embolism. Of the remaining 22 cases, 11 (23%) had hypoxemic respiratory failure with sepsis, 6 (13%) had pulmonary arterial hypertension, 4 (8%) were multifactorial, and one case was due to a cholangiocarcinoma tumor embolism. Of the 48 cases, 12 (25%) patients died during their hospitalization. The mortality rate for patients with MCS due to pulmonary embolism was 15% while the mortality rate for those with other etiologies was 36%. The odds ratio for in hospital mortality in patient with McConnell's sign due to PE compared to other etiologies was 0.32 (95% Confidence Interval 0.085-1.204, P value 0.094). CONCLUSIONS: This study demonstrates different etiologies for MCS in a medical intensive care unit. It shows that PE is less common as an etiology in this patient population (54% compared to 94% reported in literature). We also observed a trend for increased mortality when MCS was not due to pulmonary embolism but was not statistically significant. CLINICAL IMPLICATIONS: This should help clinicians understand the various etiologies and prognostic impact of MCS in MICU. DISCLOSURE: The following authors have nothing to disclose: Paul Stevenson, Almotasembellah Aljaafareh, Hassan Alnuaimat No Product/Research Disclosure Information

Measuring Success: Development of a Standardized Outcomes Scorecard for CHEST Live Learning Courses

SESSION TITLE: Medical Education SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 30, 2017 at 07:30 AM - 08:30 AM PURPOSE: Measurement of educational outcomes is essential to ensure CHEST course participants receive a high quality training experience and the knowledge, skills, and attitudes that they can implement in their clinical practice. Although CHEST Live Learning (simulation) courses have been popular and effective for more than a decade, evaluation and performance improvement processes have been course specific. The purpose of this project was to develop a standardized scorecard to measure all Live Learning program outcomes and provide actionable feedback to course chairs and faculty, the Education Committee, and CHEST leadership. METHODS: The CHEST Educational Outcomes Subcommittee defined 3 outcome domains: Learners (demand, learner feedback), Quality and Performance (Q&P, instructional design and outcomes measures), and Sustainability. Common goals for each domain were defined using historical attendance data, ACCME and SSIH accreditation standards, and best evidence when available. Data were retrospectively collected for each of the 12 Live Learning courses in 2016. Courses received feedback for each domain as a percentage of goal. A Total Score was also calculated with an emphasis on Q&P (70%). Data were expressed as mean+/-SD. RESULTS: Mean Total Score for all Live Learning courses was high at 96 +/-11 % of goal. For the domain of Q&P, the average score was 101+/-13%, with the highest metrics for individual courses being concentrated in skills testing (8 courses) and pre/post-test improvement (7 courses). In contrast, the lowest scores for individual courses were most commonly observed in the metrics for curriculum mapping (9 courses), pre/post-test improvement (4 courses), and question reliability (4 courses). The lowest Q&P scores were in updating curriculum maps (mean % of goal: 71+/-26) and the most variability was in pre/post-test improvement (mean % of goal: 115+/-69), though the result was always positive. Because scores for the separate Learner’s domain included course attendee evaluation completion rates (mean % of goal: 65 +/-17), this domain was the most variable (mean % of goal: 74 +/- 17) of the 3 domains. CONCLUSIONS: Using a systematically developed, standardized Outcomes Scorecard we found that CHEST Live Learning courses conducted in 2016 scored highly in all three domains of Learners, Quality and Performance, and Sustainability, with most variability in the Learners’ domain. For the domain of Q&P, the highest scores for courses tended to be concentrated in skills testing and pre/post-test improvement while the lowest scores tended to occur in the metrics for curriculum map, pre/post-test improvement, and question reliability. These scorecard results provide an objective assessment of both the many strengths of CHEST programs and actionable areas for ongoing quality improvement. CLINICAL IMPLICATIONS: These Outcomes Scorecard results demonstrate the value and effectiveness of CHEST’s Live Learning courses, and help target resources towards important areas for improvement such as psychometrics of test questions. DISCLOSURE: The following authors have nothing to disclose: Greg Lasko, Robert Ramillosa, Alexander Niven, William Kelly, J Madison No Product/Research Disclosure Information

Implementation of a Modified Pulmonary Embolism Response Team (PERT) in a Community Hospital: Targeting Intermediate-Risk Pulmonary Embolism

SESSION TITLE: Diagnosis and Evaluation of Venous Thromboembolism SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 08:45 AM - 10:00 AM PURPOSE: Catheter directed thrombolysis (CDT) has recently been established as the preferred treatment in intermediate-risk pulmonary embolisms (PE). Despite acquiring the technology for CDT in July 2015, the under diagnosis of intermediate risk PE has led to under utilization of this modality in our facility. We implemented a modified pulmonary embolism response team (PERT) based on Massachusetts General Hospital’s existing PERT model with aims to streamline referral process and to increase rates of referral for CDT among eligible patients. METHODS: A retrospective chart review was performed on all patients admitted with a diagnosis of PE from July 2015 to February 2017. Pre-intervention phase was from July 2015 to September 2016 and post-intervention phase was from October 2016 to February 2017. The intervention consisted of educational sessions with hospitalists and internal medicine and family medicine residents. A referral algorithm which both risk-stratified patients and directed them to appropriate therapy was created. Data was collected to risk stratify patients into “high risk”, “intermediate risk” or “low risk” based on hemodynamic stability and evidence of right ventricular strain. The patients that fulfilled the criteria for intermediate risk PE were assessed for CDT eligibility and the treatment modality offered was studied. RESULTS: In the pre-intervention phase, 141 patients were admitted with a diagnosis of PE. Of those, 24 were identified as intermediate-risk PE (17%). Of those 24, 3 (12.5%) received CDT and 21 (87.5%) did not. Of those patients that did not receive CDT but were potentially eligible, 1 had an absolute contraindication and 5 had relative contraindications. Thus, 15 patients (62.5%) were eligible but were not offered CDT. In the post-intervention phase from October 2016 to February 2017, 48 patients were admitted with a diagnosis of PE. Of those, 7 were identified as intermediate-risk PE (14.5%). Of those 7, 3 (42.9%) received CDT and 4 (57.1%) did not. Of those patients that did not receive CDT but were potentially eligible, 1 had an absolute contraindication and 1 had a relative contraindication. Thus, 2 patients (28.6%) were eligible but were not offered CDT. CONCLUSIONS: Despite meeting criteria for intermediate risk PE and not having contraindications to therapy, a large number of patients were not referred for CDT. This could be due to incorrect stratification of patients and inadequate knowledge on the topic. Often hemodynamically stable, these patients are frequently stratified as “low-risk.” Classic risk stratification tools such as PESI and sPESI do not take into account right ventricular dysfunction, myocardial damage, or clot burden, and therefore cannot readily identify this subset of patients. Post-intervention, we saw an increase by 33.9% for the appropriate referral of CDT. Physician education and early risk stratification is the cornerstone of appropriate management of patients with PEs. CLINICAL IMPLICATIONS: Our education based modified PERT model is easily replicable in smaller, community-based hospitals and has been shown to be effective in the identification and appropriate management of patients with intermediate risk PEs. DISCLOSURE: The following authors have nothing to disclose: Amirahwaty Abdullah, Lydia Winnicka, Zabu Aung, Manidhar Lekkala, Crystal Duran, Shilpa Pedapati, Kim Norville, Sudhakar Sattur No Product/Research Disclosure Information

Unplanned Extubations and Falls During Implementation of an ABCDEF Bundle in a Medical ICU

SESSION TITLE: Airway/Mechanical Ventilation SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 08:45 AM - 10:00 AM PURPOSE: To evaluate the patient safety counterbalance measures of unplanned extubations and patient falls while implementing an ABCDEF bundle (Assess for and management of pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of sedation and analgesia, Delirium monitoring and management, Early mobility, and Family engagement) in a medical ICU. METHODS: We conducted a case-control and before-after quality improvement study of patients who were admitted to a medical ICU from June 1st to November 30th, 2016. We measured the baseline incidence of unplanned extubations and number of patient falls in the pre- and post- intervention phase (June 1st to July 12th and July 12th to November 30th, respectively). The intervention was carried out in patients on one of the two ICU services (cases) from July 12th to November 30th and involved protocolized huddles that included a multi-professional team (advanced practice providers, physicians, occupational and physical therapists, nurses, respiratory therapists, and pharmacists). RESULTS: The intervention patients had 180 ventilator-days before and 453 ventilator days after the intervention. The control patients had 157 ventilator-days before and 477 ventilator days after the intervention. The unplanned extubation rate before the intervention was 1.7 per 100 ventilator-days (1.7%) for the intervention team (cases) vs. 1.9% for the controls. During the intervention phase, the intervention group’s unplanned extubation rate was 1.1% vs. 2.1% for the control (P=0.23, two-sample test of proportions). There was no significant increase in the unplanned extubation rate for the intervention group (1.7% before vs 1.1% after P=0.54). There were 0 patient falls before the intervention in either group. There were 4 falls among 1048 patient-days in the control group (0.4 per 100 patient-days) during the intervention period and 2 falls among 1441 patient-days in the intervention group (0.1 per 100 patient-days, P<0.11, two-sample test of proportions). None of the falls occured while implementing the mobility protocol. CONCLUSIONS: Following the implementation of the ABCDEF bundle, there was no significant increase in the unplanned extubation or fall rates before and after the intervention, or between cases and controls during the intervention. We observed statistically non-significant trends for fewer unplanned extubations and falls during ABCDEF bundle implementation as a possible signal of additional value of the intervention. CLINICAL IMPLICATIONS: When implementing a quality improvement program, it is important to look at potential adverse effects, or counterbalancing measures, to ensure patient safety is maintained. Although the ABCDEF bundle is part of current Pain Agitation Delirium guidelines, it is not being practiced in many hospitals. Safety concerns, particularly unplanned extubations and falls, have been cited as barriers to implementing the bundle. Our findings suggest that in the setting of multi-professional protocolized huddles, ABCDEF bundle implementation in an academic tertiary care center does not lead to an increased incidence of unplanned extubations or falls, and in fact might be protective. Larger studies are needed to confirm and extend the external validity of these findings. DISCLOSURE: The following authors have nothing to disclose: Erica Schneider, Amy Dean, George Kallingal, Markos Kashiouris, Ashley Daniels, Kim Varney, Martha Booth, Ken-Nisha Norris, Sarah Knizewski, Curtis Sessler, Lois Rowland, Kristin Miller No Product/Research Disclosure Information

Brain Natriuretic Peptide/Troponin I Ratio in Pulmonary Embolism

SESSION TITLE: Diagnosis and Evaluation of Venous Thromboembolism SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 08:45 AM - 10:00 AM PURPOSE: Elevated Brain Natriuretic Peptide (BNP) and Troponin I (TnI) have been shown to have good predictive value for poor outcomes in pulmonary embolism. An increased BNP/TnI ratio (BTR) has been shown to be predictive of Takotsubo’s Cardiomyopathy and a decreased ratio is predictive of cardiac ischemia as an etiology for chest pain in patients admitted to an ER. The role of BTR in acute pulmonary embolism (PE) remains undefined. The aim of this study was to determine if an increased BTR was associated with a worse prognosis in acute PE. METHODS: All patients who were diagnosed with pulmonary embolism in an urban, teaching hospital were enrolled in a prospective registry. We retrospectively evaluated the clinical characteristics, echocardiographic abnormalities, BNP, TnI, BTR and survival rates in consecutive patients. RESULTS: In 263 patients, mean age 58 years, we found that BTR was higher in patients with RV dilation (7,373 vs 5,034, p=0.996) and with RV hypokinesis (7,070 vs 5,153, p=0.896) on echocardiogram. A lower BTR was found in patients who survived to discharge (5,286 vs 11,535, p=0.450), 30 days (5,587 vs 8,949, p=0.263, n=222) and 90 days (5,590 vs 9,620, p=0.049, n=116). The BTR was higher in patients who were admitted to ICU (8,069 vs 5,078, p=0.546) than those admitted to a hospital floor. The BTR was lower (3,378 vs 5,686, p=0.029) in patients with a central PE, defined as saddle or main pulmonary artery. CONCLUSIONS: We conclude that an elevated BTR can be a useful diagnostic tool and that it may predict an increased 90 day mortality following an acute PE. The statistically significant decrease in BTR in patients with a central PE could be secondary to less RV dilation, and/or more myocardial necrosis. CLINICAL IMPLICATIONS: While BNP and TnI have both been used independently to risk stratify patients with an acute pulmonary embolism, their relative role has not been clearly defined. BTR adds to our knowledge in this field and suggests elevation in BNP out of proportion to elevation in TnI may portend a worse outcome. DISCLOSURE: The following authors have nothing to disclose: Eric Bondarsky, Matthew Schaikewitz, Jason Filopei, David Steiger No Product/Research Disclosure Information