Presence Of Consultation Research Articles

Evaluating Outcomes for Women with Metastatic Breast Cancer: Palliative Care Consultations, Hospital Charges, and Length of Stay.

Introduction: Women with late-stage metastatic breast cancer are at an increased risk of pain and distress from symptoms and often struggle with associated emotional and financial burden of their disease. Palliative care is known to alleviate symptom burden in patients with end-stage, terminal diseases but is often underutilized in both inpatient and outpatient settings. The current study aims to investigate the prevalence of palliative care consultation on inpatients with metastatic breast cancer and examine the association between palliative care consultation and length of hospital stay and total hospital charges. Methods: Patients diagnosed with metastatic breast cancer between 1998-2017 were abstracted from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Database (NIS). The primary outcome was the presence of a palliative care consultation (PCC) during the inpatient stay. Secondary outcomes were hospital length of stay and total hospital charges. Multivariable logistic regression was used to examine factors associated with the presence of a PCC. The relationship between PCC and hospital length of stay and total hospital charges were investigated using linear regression. Results: 513,509 cases of metastatic breast cancer were identified, 5.7% had a documented in-hospital palliative care encounter. Of those who received PCC, total hospital charges were about USD 5452 less than those who did not receive consultation. Women who received PCC had higher odds of a longer hospital stay. Predictors of PCC were older age, non-White race, and residing in a lower-income ZIP code. Conclusions: Palliative care remains to be an underutilized resource among patients with end-stage metastatic breast cancer.

Risk factors for non-isolation of patients admitted for pulmonary tuberculosis in a high-incidence department: a single-centre retrospective study

Pulmonary tuberculosis (PT) is an airborne disease, justifying the identification of suspect patients on admission, and their hospitalization in individual rooms with the implementation of Airborne Supplementary Precautions (ASP). The aim of this study was to identify, in a high-prevalence hospital, the frequency of non-isolated PT and the factors associated with the delay in implementing ASP.This was a retrospective observational study, including patients with at least one Mycobacterium tuberculosis-positive specimen. Patient demographic and clinical data, as well as data related to the mode of admission, were collected. Univariate and multivariate statistical analyses were performed.During the study period, 256 patients were included. Among them 134 (52.3%) had PT. These included 100 (75%) men, median age 39, 70% foreign-born. Among these patients, 46 (34%) were isolated beyond the 24th hour of admission. The average time to implement ASP was 4.3 days, and 7 patients (5.2%) were not isolated throughout their stay. Three classes of factors were associated by multivariate analysis with isolation. Previous consultation with a general practitioner was protective whereas admission through emergency department was not. Presence of so-called cardinal clinical signs and a suggestive chest X-ray were protective factors. Finally, European patients were less frequently isolated.In our study, 34% of patients admitted with PT were not isolated on admission. The risk of non-isolation was 3 times higher in cases of admission via the emergency department, and European patients were less well isolated. The presence of cardinal signs and prior consultation with a general practitioner were associated with a higher frequency of isolation.

The role of integrating palliative care with systemic anticancer treatment at end-of-life: A single center experience.

e24067 Background: This study examines the utilization of systemic anticancer treatments, including chemotherapy, targeted therapy, and immunotherapy, in advanced cancer patients. Specifically, it aims to underscore the impact of integrating palliative care in the administration of anticancer treatment during the last months of life. Methods: A retrospective chart review of patients who received chemotherapy, targeted therapy, and immunotherapy at Ramathibodi Hospital and passed away between January 1, 2019, and December 31, 2022. Demographic data, cancer type, modality, intent, and route of anticancer therapy, as well as health scheme and referral to palliative care services, were collected. Information regarding systemic anticancer treatments administered at 2 weeks, 1 month, 3 months, and 6 months preceding death underwent thorough analysis. Logistic regression was employed to assess odds ratios (OR) and 95% CIs for factors influencing decision-making regarding anticancer treatments. Results: Among the 542 deceased patients, 378 had received anticancer treatments within the last 6 months of life. The distribution of anticancer treatments categorized by timing—6 months, 3 months, 1 month, and 2 weeks before death—was 378 (69.7%), 388 (71.6%), 206 (38.0%), and 129 (23.8%), respectively. Older adults constituted nearly half of the population (45.2%). The utilization of anticancer treatments, particularly in the realms of targeted therapy and immunotherapy, at the terminal stages of life is showing a discernible upward trend. Palliative care consultations were present in 26.9% of cases during cancer care. The presence of palliative care consultation was significantly associated with lower odds ratios of receiving end-of-life anticancer treatments at 2 weeks and 1 month before death (OR: 0.55 [95% CI: 0.33 to 0.89], p = 0.016 and 0.54 [95% CI: 0.36 to 0.85], p = 0.004, respectively). Specifically, integrating palliative care reduced the use of chemotherapy in treatment at 2 weeks and 1 month before death (OR: 0.51 [95% CI: 0.27 to 0.98], p = 0.042 and OR: 0.55 [95% CI: 0.33 to 0.90], p = 0.019, respectively). However, the data showed a decrease in the number of patients; nonetheless, no statistically significant differences were observed in the utilization of targeted therapy and immunotherapy. In our analysis, we examine the factors influencing the utilization of anticancer treatments, reveal that there were no significant differences observed among other factors, including age, cancer type, and health scheme. Conclusions: Integration of palliative care into oncology services significantly correlated with a reduced risk of receiving anticancer treatments, particularly chemotherapy, within the last 30 days of life for advanced cancer patients. Insufficient evidence exists to ascertain the impact of palliative care on the utilization of targeted therapy and immunotherapy.

Evaluation of physicians prescribing of COVID-19 guideline–directed outpatient treatments in a primary care walk-in clinic

BackgroundCoronavirus disease 2019 (COVID-19) is a respiratory virus that has afflicted millions of individuals in the United States. A few medications have been determined to be beneficial for outpatient treatment. The medications in use against mild-to-moderate COVID-19 in the outpatient setting during the study period are nirmatrelvir-ritonavir, remdesivir, molnupiravir, and bebtelovimab. Proper assessment and treatment of patients with mild-to-moderate COVID-19 in the outpatient setting is critical to reducing rates of disease progression and hospitalization. ObjectiveThis study aimed to evaluate the appropriateness of the prescribing by internal medicine physicians for mild-to-moderate Coronavirus disease 2019 (COVID-19) infections based on the National Institutes of Health (NIH) guideline–directed COVID-19 outpatient treatment options. MethodsThis is a retrospective chart review examining the outpatient treatment of mild-to-moderate COVID-19 by internal medicine physicians between February 2022 and August 2022. Patients were eligible if they were 18 years or older, had a positive home or polymerase chain reaction (PCR) test, completed a telehealth visit within 7 days of the positive test, and were prescribed either nirmatrelvir-ritonavir, remdesivir, molnupiravir, or bebtelovimab for COVID-19 treatment. The primary end point was the appropriateness of COVID-19 treatment in the outpatient setting based on NIH guidelines, patient characteristics, and prescribing information for the medications. The secondary end point was hospitalization within 30 days of initiation of outpatient COVID-19 treatment. The presence or absence of a clinical pharmacist consultation at the time of prescribing was recorded as a process measure. ResultsA total of 376 encounters were assessed, of which 226 were included and analyzed. A total of 210 participants (93%) received nirmatrelvir-ritonavir. The remaining participants received molnupiravir or bebtelovimab. Overall, guideline-concordant treatment for mild-to-moderate COVID-19 was prescribed for 200 participants (88%). Among patient characteristics, only glomerular filtration rate (GFR) had a statistically significant difference between groups prescribed medication for the treatment of mild-to-moderate COVID-19. Fifty-six participants (25%) received clinical pharmacist consultation. Three participants were hospitalized for COVID-19 within 30 days of receiving an appropriately prescribed medication for treatment. Nirmatrelvir-ritonavir was the only medication potentially prescribed inappropriately due to lack of being renally dose adjusted and the extensive drug-drug interactions. ConclusionNirmatrelvir-ritonavir was the most prescribed medication for the treatment of mild-to-moderate COVID-19, consistent with its position as first-line therapy and widespread accessibility. The study results will inform future educational opportunities, such as in-service presentations and handouts, that may improve the prescribing of outpatient treatment for mild-to-moderate COVID-19 moving forward.

Incidence of palliative care consultations in end-of-life care among patients with pancreatic cancer in the US.

e16302 Background: Integration of palliative care in the treatment plan for a variety of diseases has been shown to improve quality of life, reduce aggressive interventions, and reduce cost burdens. This study aimed to explore the incidence of palliative care consultations in pancreatic cancer patients and determine its influence on the utilizations of aggressive interventions towards end of life. Methods: We conducted a retrospective study using a de-identified national Electronic Health Record (EHR) database, which captured deceased patients between January 1, 2000 to December 21, 2018, with a diagnosis of pancreatic cancer. Clinical history from 0-6 months prior to death was examined for the presence of a palliative care consultation (PCC) encounter. Aggressive interventions of interest, namely emergency department visits, chemotherapy, and ICU admissions, were identified and recorded in both the last six months and the last month of life. Demographic variables such as age, gender, race, and location were also considered during analysis. The PCC group and non-PCC group were compared using the Whitney U-test and Chi-squared test. Results: 2,883 deceased patients with PanCa were identified. However, 2,025 of these patients did not receive PCC in the last six months of life. The average age of death was greater at 70.5 years within the PCC group as compared to 68.9 years within the non-PCC group. This difference was statistically significant. In the last 6 months prior to death, 14.1% of patients overall had chemotherapy. The proportion of patients having chemotherapy was greater among the PCC patients compared to those not (22.4% vs 10.6%). Compared to those who did not receive PCC, patients who had PCC in the end of life were also more likely to be hospitalized (81.1% vs 38.2%), visit emergency departments (45.1% vs 23.7%) and stay in the ICU (14.1% vs 4.0%). In the last 30 days of life, trends were similar. Within PCC, 3.4% had chemotherapy while 1.3% had chemotherapy in the non-PCC group. As far as hospitalizations go, among patients with PCC, 51.3% were hospitalized compared to 15.5% hospitalizations in non-PCC. In patients who had PCC, 14.8% had at least one emergency department visit while 4.8% of patients in the non-PCC group had at least one emergency department visit. Lastly, ICU stays showed a similar trend to the previous interventions. In PCC patients, 7.9% had at least one ICU stay while only 1.5% of patients had one in the non-PCC group. Conclusions: Our study found that less than 30% of patients with PanCa received PCC at the end of life. Findings show an urgency to increase awareness and utilization of PCC for such patients. Interventions should be developed to address this urgency to help improve quality and efficiency of care. Future studies will also identify barriers and facilitators in implementing PC and consultation for patients with PanCa.

Evaluation of musculoskeletal injuries after the 2023 Kahramanmaras earthquake: A local hospital experience.

The aim of this study was to evaluate musculoskeletal injuries, clinical follow-ups and treatments of trauma patients admitted to our hospital after the 2023 Kahramanmaras earthquake. Between February 6th, 2023 and February 16th, 2023, a total of 957 trauma patients (452 males, 505 females; mean age: 36.2±19.9 years; range, 0 to 97 years) who were affected by the earthquake were retrospectively analyzed. Age, sex, presence of orthopedic consultation, diagnosis of open/closed fracture, diagnosis of dislocation, presence and classification of soft tissue injury, additional system injury, preoperative and postoperative neurovascular examination status, presence of compartment syndrome, conservative/surgical applications, operation side, fasciotomy surgery and level, amputation surgery and level, length of stay in the hospital and intensive care unit (ICU), the Mangled Extremity Severity Score (MESS) score were collected. A total of 811 of the survivors were Turkish and 146 were Syrians. Of 957 earthquake victims, 40% had soft tissue injuries, 19% had closed fractures, 8.9% had other system injuries, 7.7% had crush injuries, 4.1% had nerve injuries, 2.1% had compartment syndrome, 2.1% had vascular injury, 1.8% had dislocation, and 1.7% had open fracture. Surgical or conservative treatments were applied to 574 patients with musculoskeletal injuries. Conservative treatment was applied to 322 of 574 patients and surgical procedure was applied to 252 patients. The highest patient density is experienced within the first 24 h after a devastating earthquake. The most common injuries due to high-energy trauma are isolated soft tissue injuries and fractures. The definition of the demographic characteristics and clinical outcomes of earthquake patients is critical to the development of preparedness, response, and recovery policies for future disasters..

715 Ocular Complications of Facial Burns in the Pediatric Population

Abstract Introduction Pediatric burns commonly involve the face and periocular areas, with a risk of impairing vision. The aim of this study is to characterize ocular injuries in burn patients and identify the patients at most risk of ocular complications. Methods This study is a retrospective review within a single academic, urban pediatric burn center. All burn patients under 18 years of age admitted from January 2010 to December 2020 with periorbital or ocular involvement were included. Variables analyzed included patient demographics, burn characteristics, presence of ophthalmology consultation, ocular exam findings, follow up time period, and early and late ocular complications. Results In the study period, 2,781 patients were admitted to our burn center, 300 of whom had facial burns involving the eyes and/or eyelids. Etiologies of burn injuries were as follows: 112 (37.5%) scald, 80 (26.8%) flame, 35 (11.7%) contact, 31 (10.4%) chemical, 28 (9.4%) grease, and 13 (4.3%) friction. Overall, 70.9% of patients with ocular burns received an ophthalmology consult. Of these patients, 61.5% had periorbital swelling and 39.8% had corneal injuries. Of the 207 patients who were followed as inpatients by ophthalmology, only 61 (29.5%) presented for a follow-up visit, as recommended, 6 of which had serious ocular sequelae including ectropion, entropion, symblepharon, and corneal decompensation, and 4 of whom had a firework-related injury. Conclusions While burns involving the ocular surface and eyelid margins are infrequent overall, they can lead to long-term sequelae. Ophthalmology consultation is critical, particularly in the setting of chemical and firework-related injury. As ocular and periocular burns can cause immediate as well as delayed sequelae, ophthalmologic evaluation is a key component of assessment. Applicability of Research to Practice This paper characterizes ocular injuries in pediatric patients with facial burn injuries and identifies patients most at risk for ocular complications. We believe this will be valuable for many burn researchers and clinicians in order to better identify patients who could benefit from ophthalmologic evaluation and those at risk for both immediate as well as delayed sequelae from periocular burns.

Hubungan Antara Kecerdasan Spiritual Dengan Solidaritas Mekanik Umat Beragama (Studi Kasus Di Desa Karangsari, Kec. Cluwak, Kab. Pati, Jawa Tengah)

Research on the relationship between spiritual intelligence and the mechanical solidarity of religious people (Case Study inNgawen Village, Cluwak District, Pati Regency, Central Java) is important research for the development of religious life inIndonesia. That is because, the appreciation of religion is something that accompanies religious life, but at the same timereligion also requires a strong bond of brotherhood. This study tries to look at the relationship between the individual andsocial dimensions of religious life. This study discusses the discussion of spiritual intelligence with the mechanicalsolidarity of Buddhists in Karangsari Village, Kec. Cluwak, Kab. Starch. Obtained from ex-post facto research because thefacts or symptoms that were collected already existed before the respondent or symptoms appeared without the presence ofconsultation. The data in this study were obtained based on respondents' answers in the questionnaire research. Datacollected includes ordinal data. This data refers to the resolution or classification of responses to instrument approval. Thisresearch proves that there is no difference between Spiritual Intelligence and Mechanical Solidarity. Based on dataprocessing, the results of the relationship between the two variables are positive, but in the low category. The lowrelationship between Spiritual Intelligence and Mechanical Solidarity can be interpreted as Buddhist social piety, not fullyrelying on the internal values of Buddhism. However, awareness can be determined by values and norms that are giventogether. The facts that occur in the field can show a phenomenon that is getting stronger and closer, the social ties ofsociety, the deeper the religious feelings and the feelings about the sacred things that accompany each manifestation aregathered.

Role of cardiological specialistic evaluation in patients with chest pain presenting in the emergency department.

Aim of this study was to evaluate the impact of cardiological and echocardiographic evaluation in addition to a standard clinical and instrumental approach on diagnostic and prognostic accuracy in patients presenting in the emergency department (ED) with chest pain (CP). Acute coronary syndromes, pulmonary embolism and acute aortic syndromes (AAS) (triple-rule-out/TRO) were considered. From 7040 patients presenting with CP from 1 January 2015 to 31 December 2017, we randomly selected a sample of 1119. We retrospectively evaluated the clinical course and definitive diagnosis according to the ED final report. A 6-month follow-up to assess incident acute cardiovascular events was made by telephone interview in discharged patients; in hospitalized patients, clinical records were analyzed to evaluate the appropriateness of admissions. Diagnostic and prognostic accuracy wasd estimated through sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, according to the presence or absence of cardiological and echocardiographic consultation. Complete information of 1099 patients out of 1119 was retrieved. Seven hundred and eighty-eight patients (71.70%) had been discharged, eight inappropriately (0.73%). Three hundred eleven (28.30%) had been hospitalized, 14 (1.27%) inappropriately. Diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% PPV and 99% NPV, with an overall accuracy of 98.00%. In patients evaluated by the cardiologist in addition to the ED physician (n = 387) we observed an improvement of sensitivity and NPV at the expense of specificity. Among improperly discharged patients, 7/8 had normal troponin, 7/8 normal ECG and only 1 was evaluated by a cardiologist. Only one inappropriately hospitalized patient was not evaluated by a cardiologist. Early consultation with a cardiologist and echocardiography improves clinical judgment in doubtful cases of CP, increasing diagnostic performance mainly by reducing inappropriate patient discharge and guaranteeing a low rate of inappropriate hospitalizations.

Substance Use/Dependence in Psychiatric Emergency Setting Leading to Hospitalization: Predictors of Continuity of Care.

Background: Poor adherence to treatment is a common clinical problem in individuals affected by mental illness and substance use/dependence. In Italy, mental care is organized in a psychiatric service and addiction unit (SERD), characterized by dual independent assets of treatment. This difference, in the Emergency Room setting, leads to a risk of discontinuity of treatment in case of hospitalization. In this study we clinically characterized individuals who decided to attend hospital post-discharge appointments at SERD, in accordance with medical advice. Methods: This is a retrospective study, based on two years of discharged records of patients entering “Versilia Hospital” (Viareggio, Italy) emergency room, with urinalyses testing positive for substance use, and hospitalization after psychiatric consultation. The sample was divided according to the presence or absence of SERD consultation after discharge. Results: In the 2-year period of the present study, 1005 individuals were hospitalized. Considering the inclusion criterion of the study, the sample consisted of 264 individuals. Of these, 128 patients attended post-discharge appointments at SERD showing urinalyses positive to cocaine, opiates, and poly use; they were more frequently diagnosed as personality disorder and less frequently as bipolar disorder. The prediction was higher for patients that had already been treated at SERD, for patients who received SERD consultation during hospitalization, and for patients with positive urinalyses to cocaine and opiates at treatment entry. Conversely, patients who did not attend SERD consultation after discharge were affected by bipolar disorders. Limitations: Small sample size. Demographical data are limited to gender and age due to paucity of data in hospital information systems. SERD is located far from the hospital and is open only on weekdays; thus, it cannot ensure a consultation with all inpatients. Conclusions: Mental illness diagnosis, the set of substance use positivity at hospitalization, and having received SERD consultation during hospitalization appeared to have a critical role in promoting continuity of care. Moreover, to reduce the gap between the need and the provision of the treatment, a more effective personalized individual program of care should be implemented.

1379. Vaccination Rates among Liver Transplant Recipients at a Tertiary Care Hospital in Newark, NJ

BackgroundTransplant candidates and recipients are at increased risk of infectious complications of vaccine-preventable diseases due to their longstanding immunosuppressive regimens. We assessed the rates of vaccination in our liver transplant patients at University Hospital (UH) in Newark, NJ. MethodsRetrospective chart-review including patients > 18 years old who underwent liver transplantation at UH for a 3-year period from 01/01/2017 to 07/20/2020. Data collected included demographics, clinical outcomes, eligibility and receipt of vaccinations before and after transplantation, protection titers after administration of hepatitis vaccinations and presence of an ID outpatient consultation. We looked at the following receipt of vaccinations: Prevnar-13, Pneumovax-23, Influenza, TDaP, Shingrix, Varivax, Havrix and Engerix/Heplisav. Characteristics of study participants was analyzed using descriptive statistics and Chi-Square/Fisher’s Exact tests were used to test associations. Results119 unique medical charts were reviewed and no patients were excluded. Of those patients who were eligible to receive Hepatitis A vaccination, only 44.8% were documented to receive vaccination and of those eligible to receive Hepatitis B vaccination, only 47.8% received it. Influenza vaccination pre-transplantation was 46% and 66.1% in post-transplant recipients. For the other vaccinations, during the pre-transplant period, 17.6 % of patients received Prevnar-13, 36.1% Pneumovax-23 and 20.2% TDaP and 26.1% received Shingrix. Patients who had ID consultation were significantly more likely to receive appropriate Hepatitis A and Hepatitis B vaccinations (p values 0.026 and 0.005). ConclusionWe are not meeting national vaccination standards set by the American Society of Transplantation (AST) for optimal vaccination in this population. Our study can inform of possible solutions to increase vaccination rates in this population such as the simple addition of a smartphrase within EMR notes to remind providers to order appropriate vaccinations and eventually, a more long term solution of creation of a dedicated vaccination clinic and/or routine ID pre-transplant evaluations for all transplant candidates. Disclosures All Authors: No reported disclosures

Редкий случай благоприятного исхода диагностики и лечения врожденной диафрагмальной грыжи (грыжа Бохдалека)

The article presents a rare case of congenital diaphragmatic hernia (Bohdalek's hernia) in a 1.5 month old child. There are indications of the difficulty of diagnosing this pathology. SKT, as well as the presence of a well-organized telemedicine consultation has made it possible to make the diagnosis in a timely manner and prescribe a propper treatment

309. The Impact of Addiction Medicine Consultation on Discharges Against Medical Advice in Patients with Opioid Use Disorder and Staphylococcus Aureus Bacteremia

BackgroundPeople who inject drugs (PWID) are at risk for infectious complications of their injection practices, including Staphylococcus aureus (SA) bacteremia. Prolonged hospitalization is sometimes required; however, rates of discharges against medical advice (AMA) are elevated in this patient population. Inadequate control of pain and opioid withdrawal are commonly cited. Our aim was to assess the effectiveness of addiction medicine consultation for preventing AMA discharges.MethodsWe performed a retrospective chart review of adult PWID admitted to an urban hospital with SA bacteremia between August 2016 and May 2018. Demographics, HIV and HCV status, and presence or absence of addiction medicine consultation were recorded. We assessed whether discharges were planned or AMA; the number of hospitalizations at 30 days, 90 days, and 1 year from index admission; and death within one year. EpiInfo6 was used for data analysis.ResultsA total of 360 patients with SA bacteremia were reviewed. Of these, 101 reported intravenous opioid use at admission. Average age was 37 years, and 64% were male. HIV and HCV were present in 13% and 82% of patients, respectively. Addiction medicine was consulted on 29 patients. Of these, 4/29 (13.8%) left AMA, compared to 27/72 (37.5%) of patients without an addiction consult (RR = 0.3678 [95% CI = 0.1412 - 0.9583], p = 0.02).Patients receiving addiction medicine consultation averaged 0.17 readmissions within 30 days of their index admission, compared to 0.39 readmissions in the group without addiction medicine consult (p = 0.27). Readmissions at 90 days and 1 year were also lower but not statistically significant. At 1 year, 6 deaths were observed; 2 who had addiction medicine consultation and 4 who did not.ConclusionConsultation with an addiction medicine specialist significantly reduced the number of patients discharged AMA in a high-risk cohort of PWID presenting with SA bacteremia. Numerically fewer readmissions occurred after consultation, though this difference was not statistically significant. Mortality in both groups was low. There were high rates of HIV and HCV in this patient population, suggesting a particularly vulnerable patient population, which warrants further study.Disclosures All Authors: No reported disclosures

291. Impact of Surveillance and Offered Infectious Diseases Consults for Staphylococcus aureus Bacteremia on Quality of Care Indicators

Background Staphylococcus aureus bacteremia (SAB) remains the leading cause of bloodstream infections and is associated with 20–40% mortality. Past studies demonstrated that Infectious Diseases (ID) consultation is associated with better adherence to quality of care indicators (QCIs), including follow-up blood cultures, echocardiography, early source control, and appropriate choice and duration of antibiotics. A 2014 quality improvement project at Medstar Washington Hospital Center (MWHC) by Narsana et al. showed significantly better adherence to SAB QCIs among patients with ID consults and a non-significant trend towards lower mortality. In 2015, MWHC instituted a policy advocating ID consultation for all SAB patients, and active surveillance was performed by the ID Section to offer prompt consults prospectively. Our study aimed to assess the impact of this policy and the proactively offered ID consults on adherence to SAB QCIs and mortality rates amongst patients with SAB with and without ID consults.MethodsWe retrospectively reviewed 557 patients diagnosed with SAB between July 1st, 2015 - June 30th, 2018. Data included follow-up blood cultures, echocardiography, presence of a focal source of infection, use of appropriate antibiotics, measurement of vancomycin levels, duration of therapy, death during hospitalization, and presence of an ID consultation. Chi-Square and Fisher exact tests, and t-test and Wilcoxon rank sum test were used to analyze categorical and continuous variables, respectively.ResultsA total of 513 patients were included in the analysis, 88% (n=453) of whom had ID consultations. Patients with ID consultations were more likely to have a focal source of infection (84% vs. 50%, p < 0.0001), echocardiography (97% vs. 56%, p < 0.0001), use of a beta-lactam antibiotic for methicillin-susceptible S. aureus (90% vs 65%, p < 0.0001), and a longer duration of therapy (33 vs 9 days, p< 0.0001). Mortality was lower among patients with ID consults (16% vs. 23%, p=0.1495), but the difference was not statistically significant.Table 1 ConclusionOur study demonstrates that ID consultation is associated with better adherence to SAB QCIs, with a trend towards lower mortality. Hospital systems should support mandatory ID consultation for patients with Staphylococcus aureus bacteremia.Disclosures All Authors: No reported disclosures

211. A Comprehensive Assessment of Carbapenem Use across 90 Veterans Health Administration Hospitals with Defined Stewardship Strategies for Carbapenems

BackgroundCarbapenems are an important target for antimicrobial stewardship (AS) efforts. In this study, we sought to compare different hospital-based strategies for improving carbapenem use.MethodsWe analyzed a cohort of all patients hospitalized at Veterans Health Administration (VHA) acute-care hospitals during 2016 and mandatory survey data that characterized each hospital’s carbapenem-specific AS strategy into one of three types: no strategy (NS), prospective audit-and feedback (PAF), or restrictive policies (RP). Sites that could not be classified were excluded. Inpatient carbapenem use was compared across strategies using risk-adjusted generalized estimating equations that accounted for clustering within hospitals. Two Infectious Disease (ID) physicians independently performed manual chart reviews in 425 randomly-selected carbapenem-treated cases (100 for PAF/NS and 225 for RP). Auditors assessed for the presence of ID consultation and carbapenem appropriateness on day 4 of therapy. Assessments were categorized as follows: appropriate (1), acceptable (2), suboptimal (3), unnecessary (4) and inappropriate (5). Assessment scores across strategies were compared with the Kruskal-Wallis test.ResultsThere were 429,602 admissions in 90 sites (8 PAF, 24 NS, 58 RP). Median carbapenem use across sites was 17.4 (IQR 8.6–28.4) days of therapy/1,000 days-present. Inpatient carbapenem use was lower at PAF than NS sites [RR 0.67 (95% CI, 0.46–0.98); p=0.04] but similar between RP and NS sites [RR 0.86 (95% CI, 0.61–1.22); p=0.41].Carbapenem use was considered appropriate or acceptable in 215 (50.6%) of the reviewed cases. Assessment scores were higher (i.e. worse) at NS than RP sites (mean 2.7 vs 2.3; p< 0.01) but did not differ significantly between NS and PAF sites (mean 2.7 vs 2.5; p=0.14).ID consultations were more common at PAF/RP than NS sites (51% vs 29%; p< 0.01). ID consultations were associated with lower (i.e. better) assessment scores (2.3 vs. 2.6; p< 0.01).ConclusionIn this VHA cohort, AS strategies and ID consultations were associated with either less or more appropriate carbapenem-prescribing. The use of AS and ID consultations may be complementary, and hospitals could leverage both to optimize carbapenem use.DisclosuresDaniel J. Livorsi, MD, MSc, Merck and Company, Inc (Research Grant or Support)

57. Evaluating the Utility of a Penicillin Allergy Reconciliation Program within an Infectious Diseases Consult Population in a Community Health System

BackgroundPenicillin allergy reconciliation is an important aspect of antimicrobial stewardship with ~10% of the population reporting a penicillin allergy. Our facility utilizes a Penicillin Allergy Reconciliation Program (PARP) led by an Infectious Diseases (ID) Pharmacist and pharmacy students to identify patients with penicillin allergies to reconcile and intervene when necessary. Information is collected by interview, electronic medical record (EMR) review, prescription outpatient fill history. This study evaluated reconciliations with and without a PARP in patients in a community health system.MethodsThis was a retrospective study that compared reconciliations performed on adult patients admitted at least once in 2019 with a self-reported penicillin allergy and ID physician consult at a hospital with a PARP (Institution 1) and one without a formal evaluation and intervention program (Institution 2) within the same community health system with same ID physicians. The primary outcome was documented reconciliation of a patient’s penicillin allergy during an inpatient visit in 2019. Reconciliation was defined as an edit or clarification (updating the severity, reaction, or comments section, as well as deleting) to a patient’s penicillin allergy in the EMR. The secondary outcome evaluated the percentage of total and ID consult patients with a penicillin allergy.ResultsThere were 245 patients who met criteria and were included in the study, 113 from Institution 1 and 132 from Institution 2. For the primary outcome, there were 82 (72.6%) reconciliations at Institution 1 and 15 (11.4%) reconciliations at Institution 2 (p < 0.001). Interventions at Institution 1 and 2 resulted in 74 EMR updates and 8 removals and 14 EMR updates and 1 removal, respectively. Reconciliation was performed on the same visit as the ID consult in 59/82 patients (72%) at Institution 1 and 11/15 patients (73.3%) at Institution 2. All reconciliations at Institution 2 were made by pharmacist (10) or nurses (5). For the secondary outcome, 10.9% of patients with an ID consult and 12.6% of all patients admitted in 2019 had a penicillin allergy (p=0.027).ConclusionA PARP led by an ID pharmacist and students was an effective method to perform penicillin allergy reconciliations, even in the presence of active ID consultation.DisclosuresBruce M. Jones, PharmD, BCPS, ALK-Abello (Research Grant or Support)Allergan/Abbvie (Speaker’s Bureau) Christopher M. Bland, PharMD, FCCP, FIDSA, BCPS, ALK Abello, Inc. (Grant/Research Support)Biomerieux (Consultant)Merck (Consultant, Grant/Research Support, Advisor or Review Panel member, Speaker’s Bureau)Tetraphase (Speaker’s Bureau)

Pneumonia: Does Age or Gender Relate to the Presence of an SLP Dysphagia Consultation?

A retrospective study of 1489 hospital records examined the relationship of speech-language pathologist (SLP) consults for dysphagia to age and gender in pneumonia patients from an acute care setting. Age and gender disparities exist in healthcare. The research sought to determine if disparities existed in the presence/absence of SLP dysphagia consults related to age and gender. Results suggested SLPs were consulted on a greater percentage of geriatric patients overall; however, there were differences in the number of consults for each pneumonia type. More males and geriatric patients were seen than females and non-geriatric adults, respectively. Results may be used to address local hospital policies and protocols and thus increase quality of care by improving morbidity and mortality outcomes of geriatric patients with pneumonia.

Optimizing telehealth pain care after COVID-19.

Optimizing telehealth pain care after COVID-19.

How Long Will This Take, Doc? Timing from End-of-Life Orders Until Death (QI628)

•Justify use of an order set for withdrawal of life-sustaining treatment in the intensive care unit.•Propose means to reduce unwarranted variation in practice. Withdrawal of life-sustaining treatment (WLST) is a critically important time in the life of a patient and family and presents unique emotional pressure to all involved. The decision to redirect goals of inpatient care to focus on comfort is best supported by clear, evidence-based treatment. Use of an order set in the electronic health record (EHR) can facilitate best care for the dying patient. Assess time from use of a WLST order set to inpatient death with the goal of reducing variation in practice. One-year, single-center, retrospective cohort study across a large, nonprofit health system in central Ohio. All inpatient decedents for whom care measures were entered using an available WLST order set. Primary outcome was timing from orders being entered until death. Secondary analyses included stratification by presence of palliative consultation and by specialty of ordering provider. 690 patients met inclusion criteria. The median time from WLST orders to death was 3.8 hours. Of 690 patients, 312 (45%) received palliative consultation and median time was 3.9 hours; 378 (55%) without palliative consultation had median time of 3.6 hours (not statistically significantly different). There was no statistically significant difference in time from WLST orders to death between the three mutually exclusive groups: orders by palliative provider and palliative consult, orders by nonpalliative provider and palliative consult, and orders by nonpalliative provider and no palliative consult. Timing from use of a WLST order set to inpatient death was consistent with published studies. There were no statistically significant differences in our secondary analyses. We conclude appropriate timing from WLST to death and reduced variation in practice associated with use of an order set. Next steps include order set optimization as well as detailed analysis of medications received.

1343. Infectious Diseases Consultation Avoided Delayed Therapy and Unnecessary Exposures in the Majority of GeneXpert® MTB/RIF and AFB Smear Negative Pulmonary Tuberculosis Cases in the US County Hospital in Houston, Texas

BackgroundIn 2017, Harris County had a total of 281 cases of newly diagnosed tuberculosis (Mtb), which was the highest incidence in Texas, United States. Lyndon B. Johnson (LBJ) hospital is one of the two HarrisHealth county hospitals which serve a wide population including immigrants and an indigent population. GeneXpert® MTB/RIF (GeneXpert) was implemented in our hospital since 4/2016. However, pulmonary Mtb cases with negative GeneXpert/AFB smears carry significant challenges in the initiation of therapy and hospital infection control. Our aim was to describe how Infectious diseases (ID) consultations helped to identify the cases of both GeneXpert and AFB smear-negative pulmonary Mtb cases without delaying therapy and unnecessary exposures.MethodsThe patients with newly diagnosed pulmonary Mtb in LBJ hospital were identified between January 2017 and December 2018. The patient’s characteristics, GeneXpert results, AFB smear results, and the presence of ID consultation were retrospectively collected. Delayed therapy is defined as the initiation of active four-drug Mtb therapy until the positive culture results.ResultsA total of 52 cases with newly diagnosed pulmonary Mtb confirmed by positive culture were identified, of which 44 cases who had GeneXpert on at least one sputum specimen were included in the final analysis. 7 out of 44 (20%) had negative GeneXpert on the first specimen and all three or more AFB smears were negative. The patients were the median age of 51 years and predominantly female (57%). 5 cases were Hispanic and 2 had HIV/AIDS. In 6 out of the 7 cases, ID consultation was made and anti-tuberculous therapy was empirically initiated without delay and all remained in the isolation. Only one case had delayed therapy despite ID consultation, three consecutive AFB sputum samples, and one GeneXpert was properly performed. The patient had newly diagnosed AIDS (CD4 of 2 cells/µL) and 3 weeks of chronic cough with normal lung parenchyma and minimal right pleural effusion on CT chest at his presentation.ConclusionWe had 7 cases (20%) of GeneXpert and AFB smear-negative pulmonary Mtb. ID consultation properly identified 6 cases without delayed therapy. Early involvement of ID should be considered when pulmonary Mtb is suspected.Disclosures All authors: No reported disclosures.