Primary Attending Research Articles

Opioid Dose Variation in Cardiac Surgery: A Multicenter Study of Practice.

Although high-opioid anesthesia was long the standard for cardiac surgery, some anesthesiologists now favor multimodal analgesia and low-opioid anesthetic techniques. The typical cardiac surgery opioid dose is unclear, and the degree to which patients, anesthesiologists, and institutions influence this opioid dose is unknown. We reviewed data from nonemergency adult cardiac surgeries requiring cardiopulmonary bypass performed at 30 academic and community hospitals within the Multicenter Perioperative Outcomes Group registry from 2014 through 2021. Intraoperative opioid administration was measured in fentanyl equivalents. We used hierarchical linear modeling to attribute opioid dose variation to the institution where each surgery took place, the primary attending anesthesiologist, and the specifics of the surgical patient and case. Across 30 hospitals, 794 anesthesiologists, and 59,463 cardiac cases, patients received a mean of 1139 (95% confidence interval [CI], 1132-1146) fentanyl mcg equivalents of opioid, and doses varied widely (standard deviation [SD], 872 µg). The most frequently used opioids were fentanyl (86% of cases), sufentanil (16% of cases), hydromorphone (12% of cases), and morphine (3% of cases). 0.6% of cases were opioid-free. 60% of dose variation was explainable by institution and anesthesiologist. The median difference in opioid dose between 2 randomly selected anesthesiologists across all institutions was 600 µg of fentanyl (interquartile range [IQR], 283-1023 µg). An anesthesiologist's intraoperative opioid dose was strongly correlated with their frequency of using a sufentanil infusion (r = 0.81), but largely uncorrelated with their use of nonopioid analgesic techniques (|r| < 0.3). High-dose opioids predominate in cardiac surgery, with substantial dose variation from case to case. Much of this variation is attributable to practice variability rather than patient or surgical differences. This suggests an opportunity to optimize opioid use in cardiac surgery.

Baseline Sociodemographic Characteristics and Mental Health Status of Primary Caregivers and Children Attending Schools on the Navajo Nation During COVID-19.

Despite historical and contemporary trauma, American Indian and Alaska Native (AIAN; Indigenous) communities responded with resilience to the COVID-19 pandemic. However, AIANs experienced disproportionate rates of infection, hospitalization, death, and reduced life expectancy. School closures exacerbated disparities, leading to learning loss, economic instability, and mental health challenges among AIAN youth. The Project SafeSchools cohort study employed a comprehensive longitudinal convergent mixed-methods approach, integrating community-based participatory research principles. The study enrolled Navajo Nation caregivers whose children were eligible to attend local reservation-based schools. We conducted an analysis of caregiver self-report baseline data collected between August 2021 and May 2022. A total of 242 caregivers completed at least part of the baseline assessment and were included in data analysis. Caregivers were primarily female (88.7%), non-Hispanic (97%), and Indigenous (97%). Most caregivers were in their late 30s (mean age 38), with varying educational backgrounds and employment statuses. Children were evenly split between males and females and distributed across different age groups. Most children attended school at baseline in various formats, including in-person, hybrid, and online-only settings. Caregivers reported a range of psychosocial and behavioral risks, including general mental distress, depressive symptoms, and anxiety for themselves and their children. Furthermore, caregivers and children exhibited various protective factors, such as strong cultural identity, resilience, and academic self-efficacy. This study highlights the higher rates of mental health distress among participating caregivers and children compared to national averages. Despite these challenges, cultural protective factors remained strong and should guide future crisis response efforts.

A Mobile Post Anesthesia Care Unit Order Reminder System Improves Timely Order Entry

Transition to the postanesthesia care unit (PACU) requires timely order placement by anesthesia providers. Computerized ordering enables automated order reminder systems, but their value is not fully understood. We performed a single-center, retrospective cohort study to estimate the association between automated PACU order reminders and primary outcomes (1) on-time order placement and (2) the degree of delay in placement. As a secondary post-hoc analysis, we studied the association between late order placement and PACU outcomes. We included patients with a qualifying postprocedure order from January 1, 2019, to May 31, 2023. We excluded cases transferred directly to the ICU, whose anesthesia provider was involved in the pilot testing of the reminder system, or those with missing covariate data. Order reminder system usage was defined by the primary attending anesthesiologist’s receipt of a push notification reminder on the day of surgery. We estimated the association between reminder system usage and timely order placement using a logistic regression. For patients with late orders, we performed a survival analysis of order placement. The significance level was 0.05. Patient (e.g., age, race), procedural (e.g., anesthesia duration), and provider-based (e.g., ordering privileges) variables were used as covariates within the analyses. Reminders were associated with 51% increased odds of order placement prior to PACU admission (Odds Ratio: 1.51; 95% Confidence Interval: 1.43, 1.58; p ≤ 0.001), reducing the incidence of late PACU orders from 17.5% to 12.6% (p ≤ 0.001). In patients with late orders, the reminders were associated with 10% quicker placement (Hazard Ratio: 1.10; 95% CI 1.05, 1.15; p < 0.001). On-time order placement was associated with decreased PACU duration (p < 0.001), decreased odds of peak PACU pain score (p < 0.001), and decreased odds of multiple administration of antiemetics (p = 0.02). An order reminder system was associated with an increase in order placement prior to PACU arrival and a reduction in delay in order placement after arrival.

Withdrawal: Baseline Sociodemographic Characteristics and Mental Health Status of Primary Caregivers and Children Attending Schools on the Navajo Nation and White Mountain Apache Tribe During COVID-19.

Withdrawal: 'Baseline Sociodemographic Characteristics and Mental Health Status of Primary Caregivers and Children Attending Schools on the Navajo Nation and White Mountain Apache Tribe During COVID-19' by Shannon Archuleta MPH, Joshuaa D. Allison-Burbank PhD, Allison Ingalls MPH, Renae Begay MPH, Ryan Grass BS, Francene Larzelere PhD, Vanessa Begaye BS, Lacey Howe BS, Alicia Tsosie BS, Angelina Phoebe Keryte BA, Emily E. Haroz PhD, J Sch Health 2024, 10.1111/josh.13419. The above article, published online on 15 January 2024 in Wiley Online Library (https://onlinelibrary.wiley.com/doi/full/10.1111/josh.13419) has been withdrawn by agreement between the authors, the journal's Editor in Chief, Michael W. Long, the American School Health Association and Wiley Periodicals LLC. The withdrawal has been agreed because consent for publication from one of the tribes participating in the study was pending at the time of publication.

Effect of an algorithm for automatic placing of standardised test order sets on low-value appointments and attendance rates at four Spanish teaching hospitals: an interrupted time series analysis

ObjectiveReducing backlogs for elective care is a priority for healthcare systems. We conducted an interrupted time series analysis demonstrating the effect of an algorithm for placing automatic test order sets...

Coronary Heart Disease, Cognitive Impairment and Patient‐Physician‐Communication: Data from the MenDis‐CHD study

AbstractBackgroundCoronary heart disease (CHD) and dementia often co‐occur in the aging population. In addition, CHD seems to increase the risk for subsequent cognitive decline, which may in turn negatively affect the prognosis of CHD. Current CHD guidelines therefore recommend appropriate diagnosis and management of comorbid cognitive impairment. Here, we present the progression and characteristics of cognitive impairment in a group of patients with CHD and their perception of care in the patient‐physician‐relationship.MethodFor the MenDis‐CHD study, n = 364 patients with CHD were recruited from cardiologic hospital departments, rehabilitation clinics and cardiologist practices in Cologne, Germany. Medical records were used to assess severity of CHD and comorbidities. The New York Heart Association (NYHA) Functional Classification was applied for estimation of heart failure‐related symptom severity. Each patient was screened for cognitive impairment (DemTect) and depressive or anxiety symptoms (HADS questionnaire) as well as for subjective cognitive deficits. Patients were asked whether cognitive impairment was discussed with the treating physician. A follow‐up was carried out after M = 3.19 [2.2‐4.2] years in n = 118 patients. We compared patients whose cognition declined based on DemTect score to those who remained stable using t‐tests/Mann‐Whitney‐U‐tests and X²‐tests.ResultAt baseline, 10.2% of patients were screened positive for cognitive impairment, while 18.4% reported subjective cognitive deficits. Patients with a decline in cognition between study visits were significantly older (M = 67.9 vs. M = 63.1, t(115) = ‐2.7, p = .009) and showed more depressive symptoms (M = 5.0 vs. M = 3.8, t(115) = ‐2.1, p = .039). They also had more severe NYHA grades (M = 2.1 vs. M = 1.7, U(102) = 2044.5, p = .011) and a concomitant cerebrovascular diagnosis was more frequent compared to patients who did not decline (20.0% vs. 4.1%, X²(1) = 5.2, p = .048). Out of those who experienced either subjective or objective impairment at baseline (n = 88), 38.6% indicated that cognitive symptoms had previously been addressed during visits with their primary attending physician and 9.1% had been actively approached by their physician in this regard.ConclusionA relevant proportion of CHD patients displayed cognitive symptoms at baseline with progression at follow‐up. Conversations about cognitive symptoms with the physician occurred only in a minority. Our data supports the importance of raising awareness about the link between CHD and cognitive impairment in physicians.

Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis.

Conflicting evidence exists regarding the risks and benefits of inotropic therapies during cardiac surgery, and the extent of variation in clinical practice remains understudied. Therefore, the authors sought to quantify patient-, anesthesiologist-, and hospital-related contributions to variation in inotrope use. In this observational study, nonemergent adult cardiac surgeries using cardiopulmonary bypass were reviewed across a multicenter cohort of academic and community hospitals from 2014 to 2019. Patients who were moribund, receiving mechanical circulatory support, or receiving preoperative or home inotropes were excluded. The primary outcome was an inotrope infusion (epinephrine, dobutamine, milrinone, dopamine) administered for greater than 60 consecutive min intraoperatively or ongoing upon transport from the operating room. Institution-, clinician-, and patient-level variance components were studied. Among 51,085 cases across 611 attending anesthesiologists and 29 hospitals, 27,033 (52.9%) cases received at least one intraoperative inotrope, including 21,796 (42.7%) epinephrine, 6,360 (12.4%) milrinone, 2,000 (3.9%) dobutamine, and 602 (1.2%) dopamine (non-mutually exclusive). Variation in inotrope use was 22.6% attributable to the institution, 6.8% attributable to the primary attending anesthesiologist, and 70.6% attributable to the patient. The adjusted median odds ratio for the same patient receiving inotropes was 1.73 between 2 randomly selected clinicians and 3.55 between 2 randomly selected institutions. Factors most strongly associated with increased likelihood of inotrope use were institutional medical school affiliation (adjusted odds ratio, 6.2; 95% CI, 1.39 to 27.8), heart failure (adjusted odds ratio, 2.60; 95% CI, 2.46 to 2.76), pulmonary circulation disorder (adjusted odds ratio, 1.72; 95% CI, 1.58 to 1.87), loop diuretic home medication (adjusted odds ratio, 1.55; 95% CI, 1.42 to 1.69), Black race (adjusted odds ratio, 1.49; 95% CI, 1.32 to 1.68), and digoxin home medication (adjusted odds ratio, 1.48; 95% CI, 1.18 to 1.86). Variation in inotrope use during cardiac surgery is attributable to the institution and to the clinician, in addition to the patient. Variation across institutions and clinicians suggests a need for future quantitative and qualitative research to understand variation in inotrope use affecting outcomes and develop evidence-based, patient-centered inotrope therapies.

Appropriate Use of Antibiotic and Principles of Antimicrobial Stewardship in Children.

Antibiotics account for over 10% of the overall drug expense of the National Health System in Italy in 2021. Their use in children is of particular interest on one side, because acute infections are very common in children, while they build their immunologic library of competence; on the other side, although many acute infections are expected and turn out to be of viral origin, caregivers will often ask the family doctor or primary care attending to reassure them by prescribing antibiotic treatment, although it may often be unnecessary. The inappropriate prescription of antibiotics in children may likely be a source not only of undue economic burden for the public health system but also of increasing development of antimicrobial resistance (AMR). Based on those issues, the inappropriate use of antibiotics in children should be avoided to reduce the risks of unnecessary toxicity, increase in health costs, lifelong effects, and selection of resistant organisms causing undue deaths. Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure an optimal use of antimicrobials to improve patient outcomes while limiting the risk of adverse events including AMR. The aim of this paper is to spread some concept of good use of antibiotics for pediatricians or every other physician involved in the choice to prescribe, or not, antibiotics in children. Several actions could be of help in this process, including the following: (1) identify patients with high probability of bacterial infection; (2) collect samples for culture study before starting antibiotic treatment if invasive bacterial infection is suspected; (3) select the appropriate antibiotic molecule based on local resistance and narrow spectrum for the suspected pathogen(s); avoid multi-antibiotic association; prescribe correct dosage; (4) choose the best route of administration (oral vs. parenteral) and the best schedule of administration for every prescription (i.e., multiple administration for beta lactam); (5) schedule clinical and laboratory re-evaluation with the aim to consider therapeutic de-escalation; (6) stop antibiotic administration as soon as possible, avoiding the application of "antibiotic course".

Oncology-hospitalist co-management: A model for efficient, high-quality care and education.

1 Background: Our inpatient oncology service at Smilow Cancer Hospital had long lengths of stay, high readmission rates and burnout among outpatient oncologists who rotated as inpatient attendings. With a proposal to improve length of stay by.25 days in the first year, the health system funded the integration of internal medicine hospitalists. Methods: Patients were randomly assigned to one of two oncology teams, allowing for real time outcome comparisons. Hospitalists were added to the Intervention Team and served as the primary attending with oncologists as consultants; Oncologists served as the primary attending on the Traditional Team. The intervention began in July 2021. Outcome metrics included LOS, readmission rate, case volume, early discharge rate, educational rankings, and oncologist satisfaction. A multidisciplinary steering group met to review data, study, and act on outcome metrics. Using Quality Improvement PDSA cycles, outcomes were reported at 3 months (PDSA 1), followed by improvement interventions; then reported again at 6 months (PDSA 2). Results: The Intervention Team achieved a 1.0-day reduction in LOS compared to Traditional team. There was no difference in Severity of Illness score in comparator groups, demonstrating no imbalance in patient population. The Intervention team cared for a 29% higher volume of patients and improved early discharge rate without an increase in readmissions from baseline. Oncologists reported a high level of satisfaction with the program. Housestaff overall educational rankings increased after the introduction of hospitalists (Table). Discussion: Hospitalist comanagement exceeded business plan LOS reduction target without compromise in quality or educational metrics. PDSA 1 identified need for role clarity among physicians, increased oncology teaching, and preservation of resident autonomy; PDSA 2 identified need for increased nursing-physician collaboration. Conclusions: Hospitalist comanagement can effectively reduce oncology LOS without adverse effect on readmission rates, educational outcomes, or oncologist satisfaction with care.[Table: see text]

010 DSD: The gynecologist perspective

The gynecologist has a role in the Difference of Sex Development (DSD) expert team in many DSD conditions. The gynecologists’ involvement can be related to the diagnostic workup, diagnosis of associated anomalies, medical or surgical therapy, patient support, follow-up and scientific research; in 46XX disorders (ovarian development, androgen excess conditions, vaginal and Müllerian agenesis, cloacal exstrophy), 46XY disorders (testicular development, disorders of androgen synthesis and action), Turner syndrome (45X), mixed gonadal dysgenesis (45X/46XY), ovotesticular disorders (46XX/46XY or 45X/46XY), and Klinefelter syndrome (45XXY). For the women with MRKH-syndrome, the gynecologist will often act as primary attending physician, whereas in Klinefelter syndrome, this role may not go any further than the semen preservation during adolescence.

PD28-07 UROLOGY RESIDENT AUTONOMY IN PERFORMING PENILE PROSTHESES IN THE VETERANS AFFAIRS (VA) HOSPITALS

You have accessJournal of UrologyCME1 May 2022PD28-07 UROLOGY RESIDENT AUTONOMY IN PERFORMING PENILE PROSTHESES IN THE VETERANS AFFAIRS (VA) HOSPITALS Anh Nguyen, Jacob Veliky, John Fastenau, Devashish Anjaria, Joseph Oliver, and Hossein Sadeghi-Nejad Anh NguyenAnh Nguyen More articles by this author , Jacob VelikyJacob Veliky More articles by this author , John FastenauJohn Fastenau More articles by this author , Devashish AnjariaDevashish Anjaria More articles by this author , Joseph OliverJoseph Oliver More articles by this author , and Hossein Sadeghi-NejadHossein Sadeghi-Nejad More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002576.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical resident autonomy is critical for transition to confidence and transition to independent practice post training. This study examines the degree of urology resident autonomy at the VA hospitals in performing penile prosthetic surgery. METHODS: The VA Surgical Quality Improvement Program (VASQIP) was queried for penile prosthesis insertion and removal procedures between 2004 to 2019 at teaching VA hospitals. VASQIP does not track all penile prosthetic procedures. This data was then compared with the five most commonly resident performed non-penile prostheses cases within the database (transurethral resection of prostate, transurethral resection (small, medium, or large tumor), GreenLight laser of prostate, hydrocelectomy, and ureteral stent placement). The cases were stratified by attending supervision: attending as primary surgeon (AP), attending and resident (AR), resident as primary surgeon with the attending not scrubbed (RP). Primary outcome was rate of resident involvement. Secondary outcomes were 30-day mortality and morbidity within the prosthetic procedures by supervision categories. Statistics was performing using Pearson’s Chi Squared. RESULTS: 881 penile prosthesis implantation and removal cases were identified from 2004 to 2019. Of these, 13.2% were AP, 78.5% were AR, and 8.3% were RP compared to the most common procedures (n=127,757) which showed that 33.7% were AP, 40.6% were AR, and 25.7% were RP (p < 0.001). Comparison of AP, AR, and RP penile prostheses demonstrated no statistically significant increase in 30-day all-cause mortality or complications (Table 1). CONCLUSIONS: Within VA hospitals, penile prostheses surgeries are performed by residents without an attending scrubbed less frequently than the most commonly performed urological surgeries. The sensitive and costly nature of implanting prostheses and the higher stakes of post-surgical infection may influence this trend. The latter may affect the residents’ comfort level independently performing these operations after graduation. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e501 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anh Nguyen More articles by this author Jacob Veliky More articles by this author John Fastenau More articles by this author Devashish Anjaria More articles by this author Joseph Oliver More articles by this author Hossein Sadeghi-Nejad More articles by this author Expand All Advertisement PDF DownloadLoading ...

Benchmarking of Anesthesia and Surgical Control Times by Current Procedural Terminology (CPT®) Codes.

Over half of hospital revenue results from perioperative patient care, thus emphasizing the importance of efficient resource utilization within a hospital's suite of operating rooms (ORs).Predicting surgical case duration, including Anesthesia-controlled time (ACT) and Surgical-controlled time (SCT) has been significantly detailed throughout the literature as a means to help manage and predict OR scheduling. However, this information has previously been divided by surgical specialty, and only limited benchmarking data regarding ACT and SCT exists. We hypothesized that advancing the granularity of the ACT and SCT from surgical specialty to specific Current Procedural Terminology (CPT®) codes will produce data that is more accurate, less variable, and therefore more useful for OR schedule modeling and management.This single center study was conducted using times from surgeries performed at the University of Colorado Hospital (UCH) between September 2018 - September 2019. Individual cases were categorized by surgical specialty based on the specialty of the primary attending surgeon and CPT codes were compiled from billing data. Times were calculated as defined by the American Association of Clinical Directors. I2 values were calculated to assess heterogeneity of mean ACT and SCT times while Levene's test was utilized to assess heterogeneity of ACT and SCT variances. Statistical analyses for both ACT and SCT were calculated using JMP Statistical Discovery Software from SAS (Cary, NC) and R v3.6.3 (Vienna, Austria).All surgical cases (n = 87,537) performed at UCH from September 2018 to September 2019 were evaluated and 30,091 cases were included in the final analysis. All surgical subspecialties, with the exception of Podiatry, showed significant variability in ACT and SCT values between CPT codes within each surgical specialty. Furthermore, the variances of ACT and SCT values were also highly variable between CPT codes within each surgical specialty. Finally, benchmarking values of mean ACT and SCT with corresponding standard deviations are provided.Because each mean ACT and SCT value varies significantly between different CPT codes within a surgical specialty, using this granularity of data will likely enable improved accuracy in surgical schedule modeling compared to using mean ACT and SCT values for each surgical specialty as a whole. Furthermore, because there was significant variability of ACT and SCT variances between CPT codes, incorporating variance into surgical schedule modeling may also improve accuracy. Future investigations should include real-time simulations, logistical modeling, and labor utilization analyses as well asvalidation of benchmarking times in private practice settings.

Multicentre analysis of practice patterns regarding benzodiazepine use in cardiac surgery

BackgroundThere is controversy regarding optimal use of benzodiazepines during cardiac surgery, and it is unknown whether and to what extent there is variation in practice. We sought to describe benzodiazepine use and sources of variation during cardiac surgeries across patients, clinicians, and institutions. MethodsWe conducted an analysis of adult cardiac surgeries across a multicentre consortium of USA academic and private hospitals from 2014 to 2019. The primary outcome was administration of a benzodiazepine from 2 h before anaesthesia start until anaesthesia end. Institutional-, clinician-, and patient-level variables were analysed via multilevel mixed-effects models. ResultsOf 65 508 patients cared for by 825 anaesthesiology attending clinicians (consultants) at 33 institutions, 58 004 patients (88.5%) received benzodiazepines with a median midazolam-equivalent dose of 4.0 mg (inter-quartile range [IQR], 2.0–6.0 mg). Variation in benzodiazepine dosage administration was 54.7% attributable to institution, 14.7% to primary attending anaesthesiology clinician, and 30.5% to patient factors. The adjusted median odds ratio for two similar patients receiving a benzodiazepine was 2.68 between two randomly selected clinicians and 4.19 between two randomly selected institutions. Factors strongly associated (adjusted odds ratio, <0.75, or >1.25) with significantly decreased likelihoods of benzodiazepine administration included older age (>80 vs ≤50 yr; adjusted odds ratio=0.04; 95% CI, 0.04–0.05), university affiliation (0.08, 0.02–0.35), recent year of surgery (0.42, 0.37–0.49), and low clinician case volume (0.44, 0.25–0.75). Factors strongly associated with significantly increased likelihoods of benzodiazepine administration included cardiopulmonary bypass (2.26, 1.99–2.55), and drug use history (1.29, 1.02–1.65). ConclusionsTwo-thirds of the variation in benzodiazepine administration during cardiac surgery are associated with institutions and attending anaesthesiology clinicians (consultants). These data, showing wide variations in administration, suggest that rigorous research is needed to guide evidence-based and patient-centred benzodiazepine administration.

Carotico-cavernous fistula - From the eye of an ophthalmologist

Carotid-cavernous fistulas (CCFs) are spontaneous or acquired abnormal connections between the cavernous sinus and the carotid arterial system. It can be a direct connection between the cavernous segment of the internal carotid artery and the cavernous sinus, or an indirect one between the cavernous sinus, and one or more meningeal branches of the internal carotid artery, external carotid artery, or both. Ophthalmologists are called to diagnose and manage the condition in cases that present with ocular features such as decreased vision, conjunctival chemosis, external ophthalmoplegia and proptosis. A high index of suspicion in a case without any history of trauma and collagen vascular disease is the key factor. Prompt diagnosis of intravascular malformations at initial presentation can prevent ophthalmological complications and vision loss. Conventional treatments include carotid ligation and embolization, with minimal significant morbidity or mortality. A team approach including neurosurgeons, emergency physicians and ophthalmologists is needed for the proper management of such patients. Ophthalmologists may be the primary attending physician; therefore, this review aims to help understand the diagnostic approach and possible modes of treatment with expected outcomes.

ICU TRANSITION OF CARE

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: The aim of our project is to formulate a standardized process for transfering patients from the intensive care unit to the medical wards which improves documentation, policy and puts emphasis on communication through a multidisciplinary approach by utilization of a novel hand-off template and implementation of transfer medication reconciliation. METHODS: Following the IHI model, a fishbone diagram was used to identify areas of improvement in the hand-off process. The persons involved, process, policy, and communication were identified as contributing factors in formulating a standardized Transition Of Care (TOC) process. PDSA cycles were used to test change. We measure use of proposed standardized TOC method and number of ICU re-admissions as part of adverse events. RESULTS: After observing the need for this process to become ubiquitous, using the Plan Do Study Act (PDSA) cycle, literature was reviewed, and a TOC template was formulated in PDSA1 which resulted in no significant change. In PDSA2, there was creation of a policy to utilize an existing Transfer Medication Reconciliation (Med Rec.) with our EMR prior to transferring a patient out of ICU. Internal medicine residents, faculty, ICU attendings, ICU committee, ICU Pharmacy, and EMR Department were educated on the implementation of the new procedure was initiated. 100 charts were analyzed post-intervention; of those 61 charts met inclusion criteria. Twenty seven of the 61 charts had an appropriate use of the TOC Template and use of Transfer Med Rec. in addition to communication with the primary attending (44%). Of these, there was 1 Rapid Response (RR) that warranted an ICU readmission (3.7%). There were 0 code blues after transfer from ICU. Of the 34 charts that did not abide to procedure, there were 3 RRs (8.8%). CONCLUSIONS: There were fewer RR when comparing the patients with the ICU TOC implemented compared to those without the documented communication (3.7% vs 8.8%). The ICU readmission noted, should take into account the inherit fragility of this patient population and associated morbidly. Despite our small sample size, the trends are promising that align with the impact of our implementation of ICU TOC process.The goal of this QI project was to use a multisystem approach to standardized transfer process to ensure patient safety. In our next PDSA cycle, there will be a pop-up screen when a Transfer Order out of ICU is clicked, that directs user to Transfer Med Rec. page before proceeding. With this new implementation, there will be an increased compliance to abiding to the process with integration of the EMR with Transfer Med Rec. CLINICAL IMPLICATIONS: The transition of patient care from the Intensive Care Unit (ICU) to the medical wards has been identified as a crucial time for communication and accuracy in these patients who are at high risk for potential harm due to medical errors. Proper transition process is critical, as the lack of a universal standardized hand-off could lead to detrimental consequences. Our community hospital has an “open” ICU and inconsistent transition of care process has been observed. The focus of our project is to formulate a standardized transfer process that improves documentation, policy and puts emphasis on communication through a multidisciplinary approach with utilization of a hand-off template and implementation of transfer medication reconciliation. DISCLOSURES: No relevant relationships by Victoria Gonzalez, source=Web Response No relevant relationships by Zain Kulairi, source=Web Response No relevant relationships by Sarwan Kumar, source=Web Response No relevant relationships by Bernadette Schmidt, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response

Association Between Health System Factors and Utilization of Routine Laboratory Tests in Clinical Teaching Units: a Cohort Analysis.

Few studies have looked at health system factors associated with laboratory test use. To determine the association between health system factors and routine laboratory test use in medical inpatients. We conducted a retrospective cohort study on adult patients admitted to clinical teaching units over a 3-year period (January 2015 to December 2017) at three tertiary care hospitals in Calgary, Alberta. Patients were assigned to a Case Mix Group+ (CMG+) category based on their clinical characteristics, and patients in the top 10 CMG+ groups were included in the cohort. The examined health system factors were (1) number of primary attending physicians seen by a patient, (2) number of attending medical teams seen by a patient, (3) structure of the medical team, and (4) day of the week. The primary outcome was the total number of routine laboratory tests ordered on a patient during their admission. Statistical models were adjusted for age, sex, length of stay, Charlson comorbidity index, and CMG+ group. The final cohort consisting of 36,667 patient-days in hospital (mean (SD) age 62.5 (18.4) years) represented 5071 unique hospitalizations and 4324 unique patients. Routine laboratory test use was increased when patients saw multiple attending physicians; with an adjusted incidence rate ratio (IRR) of 1.46 (95% CI, 1.37-1.55) for two attending physicians, and 2.50 (95% CI, 2.23-2.79) for three or more attending physicians compared to a single attending physician. The number of routine laboratory tests was slightly lower on weekends (IRR 0.98, 95% CI, 0.96-0.99) and on teams without a senior resident as part of their team structure (IRR 0.89, 95% CI 0.830.96). The associations observed in this study suggest that breaks in continuity of care, including increased frequency in patient transfer of care, may impact the utilization of routine laboratory tests.

Barriers and Benefits of the Scheduled Telephone Referral Model (DETELPROG): A Qualitative Approach.

The recently developed scheduled mobile-telephone referral model (DETELPROG) has achieved especially important results in reducing waiting days for patients, but it has been decided to explore what barriers and positive aspects were detected by both primary care physicians (PCPs) and hospital attending physicians (HAPs) regarding its use. For this, a qualitative descriptive study was carried out through six semi-structured interviews and two focus groups in a sample of eleven PCPs and five HAPs. Interviews were carried out from September 2019 to February 2020. Data were analysed by creating the initial categories, recording the sessions, transcribing the information, by doing a comprehensive reading of the texts obtained, and analysing the contents. The results show that DETELPROG gives the PCP greater prominence as a patient’s health coordinator by improving their relationship and patient safety; it also improves the relationship between PCP and HAP, avoiding unnecessary face-to-face referrals and providing safety to the PCP when making decisions. The barriers for DETELPROG to be used by PCP were defensive medicine, patients’ skepticism in DETELPROG, healthcare burden, and inability to focus on the patient or interpret a sign, symptom, or diagnostic test. For HAP, the barriers were lack of confidence in the PCP and complexity of the patient. As a conclusion, DETELPROG referral model provides a lot of advantages and does not pose any new barrier to face-to-face referral or other non-face-to-face referral models, so it should be implemented in primary care.

Diagnosis and treatment of medication-related osteonecrosis of the jaws from an oncologist's perspectives

Along with the improvement of cancer treatment and the increasing use of bone-modifying agents, medication-related osteonecrosis of the jaw (MRONJ) has become more and more common, which may lead to reduce quality of life for patients and interrupt their regular tumor treatments. Being an oral condition in the maxillofacial region of patients associated with adverse side effect of certain bone-modifying agent related cancer therapies, MRONJ falls in a gray area between oncology and stomatology and can be challenging to treat and manage if standard clinical practice and care management guideline is not well established. Missed diagnosis and misdiagnosis of MRONJ become common when there is lack of elucidated diagnostic criteria and coordination in treatment planning between patient's oncologist and dentist. Patient's primary attending oncologist who initiates therapy with bone-modifying agent should be aware of MRONJ and well knowledgeable in best practices for preventing and managing MRONJ. With the focus on coordination of care in mind, an oral health assessment of the patient should be undertaken before initiating therapy and a dental treatment plan should be developed and implemented in coordination with the patient's dentist. Based on the systematic review of the 2019 "Medication-Related Osteonecrosis of the Jaw MASCC/ISOO/ASCO (Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology/American Society of Clinical Oncology) Clinical Practice Guideline", combined with clinical experience and academic research progress of related subject in recent years, from the perspective of an oncologist, the author summarizes how oncologists play a pivotal role in every step of the way from the initial cancer diagnosis, pre-cancer treatment assessment, care management during bone-modifying agent therapy, to the diagnosis, treatment, and management of MRONJ. The primary focus of the present article is to formulate optimized recommendations and provide guidance for multidisciplinary teams regarding best practices in the prevention and management of MRONJ in patients with cancer, in terms of early awareness, prevention, detection as well as implementation of effective treatment plan to improve clinical outcome and increase quality of life for the patients.

170 Primary Breast Lymphoma-Mimicking Inflammatory Breast Disease: A Case Report

Abstract Primary breast lymphoma (PBL) is an unusual clinical entity accounting for 0.4–0.5% of all breast neoplasms. The usual presentation includes a painless palpable mass similar to that of breast carcinoma. Diffuse large B-cell lymphoma (DLBCL) is the most common identifiable type of PBL based on the histopathological examination. We report an unusual case of 22 years old Bangladeshi woman presented with a 6-month history of a lump on left breast. Although the lump was initially small, it began a rapid growth after 4 months. The swelling was localized and did not show any skin involvement or discharge and as she didn’t have any positive familial history of breast carcinoma her primary attending physician diagnosed it as a case of breast abscess. When local incision and drainage proved ineffective, she was referred to us. After doing an immunohistochemistry from incisional biopsy the diagnosis was confirmed as Diffuse Large B-cell Lymphoma. The patient was treated initially by chemotherapy with CHOP therapy followed by wide local excision. Early and accurate diagnosis of PBL is crucial for selecting the appropriate MDT treatment strategies to avert potentially harmful surgical interventions.

Interactive Case-Based Childhood Adversity and Trauma-Informed Care Electronic Modules for Pediatric Primary Care.

IntroductionTraining health professionals for the skills and capacity to respond adequately to children and adults who have been exposed to adverse childhood experiences is recognized as an essential need in health care. Accessible opportunities to educate physicians and physician-trainees are limited.MethodsFour computer-based e-modules were created focusing on addressing childhood adversity and implementing trauma-informed care in the pediatric primary care setting. These childhood adversity and trauma-informed care (CA-TIC) e-modules were designed as an individualized, self-directed experience to allow for distance learning with flexibility to be embedded into existing coursework. To foster an engaging learning environment, we narrated the modules, prioritized images, and included the opportunity for participant interaction via multiple-choice and short-answer questions. Twenty-eight pediatric residents, two medical students, four attending physicians, and one fellow at Children's National Hospital completed the e-modules.ResultsOverall, participants rated the CA-TIC e-modules 4.6 (SD = 0.5) out of 5 for design and quality. Using paired t tests and Wilcoxon signed rank tests, we found statistically significant score increases from presession to postsession for participants' knowledge, attitudes, practice, and confidence related to CA-TIC. The most commonly cited learning points and practice changes included asking about trauma in practice and the seven C's of resilience.DiscussionA trauma-informed, strengths-based approach to care can assist health care providers in mitigating the link between adversity and related poor health outcomes. The CA-TIC e-modules provide an opportunity to train health professionals using an innovative, self-directed, and low-resource mechanism.