Regional Academic Medical Center Research Articles

A severe acute respiratory coronavirus virus 2 (SARS-CoV-2) nosocomial cluster with inter-facility spread: Lessons learned.

Despite infection control guidance, sporadic nosocomial coronavirus disease 2019 (COVID-19) outbreaks occur. We describe a complex severe acute respiratory coronavirus virus 2 (SARS-CoV-2) cluster with interfacility spread during the SARS-CoV-2 δ (delta) pandemic surge in the Midwest. This study was conducted in (1) a hematology-oncology ward in a regional academic medical center and (2) a geographically distant acute rehabilitation hospital. We conducted contact tracing for each COVID-19 case to identify healthcare exposures within 14 days prior to diagnosis. Liberal testing was performed for asymptomatic carriage for patients and staff. Whole-genome sequencing was conducted for all available clinical isolates from patients and healthcare workers (HCWs) to identify transmission clusters. In the immunosuppressed ward, 19 cases (4 patients, 15 HCWs) shared a genetically related SARS-CoV-2 isolate. Of these 4 patients, 3 died in the hospital or within 1 week of discharge. The suspected index case was a patient with new dyspnea, diagnosed during preprocedure screening. In the rehabilitation hospital, 20 cases (5 patients and 15 HCWs) positive for COVID-19, of whom 2 patients and 3 HCWs had an isolate genetically related to the above cluster. The suspected index case was a patient from the immune suppressed ward whose positive status was not detected at admission to the rehabilitation facility. Our response to this cluster included the following interventions in both settings: restricting visitors, restricting learners, restricting overflow admissions, enforcing strict compliance with escalated PPE, access to on-site free and frequent testing for staff, and testing all patients prior to hospital discharge and transfer to other facilities. Stringent infection control measures can prevent nosocomial COVID-19 transmission in healthcare facilities with high-risk patients during pandemic surges. These interventions were successful in ending these outbreaks.

Blueprint for community emergency department pediatric simulation.

Gaps in quality of pediatric emergency care have been noted in community emergency departments (CEDs), where >85% of children receive care. Insitu simulation provides opportunities for hands-on experiences and can help close these gaps. We aimed to develop, implement, and evaluate an innovative, replicable, and scalable pediatric insitu simulation-based CED curriculum, under the leadership of a local colleague, through collaborative approach with a regional academic medical center (AMC). Kern's model was used as follows: problem identification and general needs assessment-pediatric readiness assessment and discussions with CED physician and nursing leadership; targeted needs assessment-review of recent pediatric transfer cases; goals and objectives-enhance pediatric knowledge and skills of interprofessional teams and detect latent safety threats; educational strategies-codeveloped by CED and AMC, included prelearning using podcasts and videos, simulation and facilitated debriefing, resource sharing after simulations; implementation-3-h simulation sessions facilitated in person by the CED team and remotely by AMC (leadership required participation and paid staff); and evaluation and feedback-retrospective pre-post survey, Simulation Effectiveness Tool-Modified (SET-M), Net Promoter Score (NPS), and review/feedback meetings. Based on needs assessment, the selected cases included newborn resuscitation, seizure, asthma, and tetrahydrocannabinol ingestion causing altered mental sensorium in a child. Twenty-four 3-h simulation sessions were conducted over 1 year. A total of 168 participants completed the sessions, while 75 participants (54.7% nurses, 22.7% physicians, and others) completed feedback surveys. Seventy-six percent of participants reported completing presimulation education material. Participants reported improved skills at appropriately evaluating a critically ill newborn and critically ill infant/toddler and improved teamwork during the care of a pediatric patient. The majority agreed that simulation was effective in teaching pediatric resuscitation. The NPS was 84% (excellent). A locally facilitated CED insitu simulation curriculum was successfully developed and implemented under local leadership, with remote collaboration by AMC. The curriculum was well received and effective.

Training the healthcare workforce: the global experience with telementorship for hepatitis B and hepatitis C

BackgroundTelementorship has emerged as an innovative strategy to decentralise medical knowledge and increase healthcare capacity across a wide range of disease processes. We report the global experience with telementorship to support healthcare workers delivering hepatitis B virus (HBV) and hepatitis C virus (HCV) care and treatment.MethodsIn early 2020, we conducted a survey of HBV and HCV telementorship programmes, followed by an in-depth interview with programme leads. Programmes were eligible to participate if they were located outside of the United States (U.S.), focused on support to healthcare workers in management of HBV and/or HCV, and were affiliated with or maintained adherence to the Project ECHO model, a telementorship programme pioneered at the University of New Mexico. One programme in the U.S., focused on HCV treatment in the Native American community, was purposively sampled and invited to participate. Surveys were administered online, and all qualitative interviews were performed remotely. Descriptive statistics were calculated for survey responses, and qualitative interviews were assessed for major themes.ResultsEleven of 18 eligible programmes completed the survey and follow up interview. Sixty-four percent of programmes were located at regional academic medical centers. The majority of programmes (64%) were led by hepatologists. Most programmes (82%) addressed both HBV and HCV, and the remainder focused on HCV only. The median number of participating clinical spoke sites per programme was 22, and most spoke site participants were primary care providers. Most ECHO sessions were held monthly (36%) or bimonthly (27%), with sessions ranging from 45 min to 2 h in length. Programme leaders identified collective learning, empowerment and collaboration to be key strengths of their telementorship programme, while insufficient funding and a lack of protected time for telementorship leaders and participants were identified as major barriers to success.ConclusionThe Project ECHO model for telementorship can be successfully implemented across high and low-and-middle-income countries to improve provider knowledge and experience in management of viral hepatitis. There is a tremendous opportunity to further expand upon the existing experience with telementorship to support non-specialist healthcare workers and promote elimination of viral hepatitis.

Hospital-associated disability due to avoidable hospitalizations among older adults.

Hospital-associated disability (HAD) is a common complication during the course of acute care hospitalizations in older adults. Many admissions are for ambulatory care sensitive conditions (ACSCs), considered potentially avoidable hospitalizations-conditions that might be treated in outpatient settings to prevent hospitalization and HAD. We compared the incidence of HAD between older adults hospitalized for ACSCs versus those hospitalized for other diagnoses. We conducted a retrospective cohort study in inpatient (non-ICU) medical and surgical units of a large southeastern regional academic medical center. Participants were 38,960 older adults 65 years of age admitted from January 1, 2015, to December 31, 2019. The primary outcome was HAD, defined as decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. We used generalized linear mixed models to examine differences in HAD between hospitalizations with a primary diagnosis for an ACSC using standard definitions versus primary diagnosis for other conditions, adjusting for covariates and repeated observations for individuals with multiple hospitalizations. We found that 10% of older adults were admitted for an ACSC, with rates of HAD in those admitted for ACSCs lower than those admitted for other conditions (16% vs. 20.7%, p < 0.001). Age, comorbidity, admission functional status, and admission cognitive impairment were significant predictors for development of HAD. ACSC admissions to medical and medical/surgical services had lower odds of HAD compared with admissions for other conditions, with no significant differences between ACSC and non-ACSC admissions to surgical services. Rates of HAD among older adults hospitalized for ACSCs are substantial, though lower than rates of HAD with hospitalization for other conditions, reflecting that acute care hospitalization is not a benign event in this population. Treatment of ACSCs in the outpatient setting could be an important component of efforts to reduce HAD.

Utilizing the Newest Vital Sign (NVS) to Assess Health Literacy at a Regional Academic Medical Center's Family Medicine Clinic

Utilizing the Newest Vital Sign (NVS) to Assess Health Literacy at a Regional Academic Medical Center's Family Medicine Clinic

Using natural language processing to identify opioid use disorder in electronic health record data

BackgroundAs opioid prescriptions have risen, there has also been an increase in opioid use disorder (OUD) and its adverse outcomes. Accurate and complete epidemiologic surveillance of OUD, to inform prevention strategies, presents challenges. The objective of this study was to ascertain prevalence of OUD using two methods to identify OUD in electronic health records (EHR): applying natural language processing (NLP) for text mining of unstructured clinical notes and using ICD-10-CM diagnostic codes. MethodsData were drawn from EHR records for hospital and emergency department patient visits to a large regional academic medical center from 2017 to 2019. International Classification of Disease, 10th Edition, Clinic Modification (ICD-10-CM) discharge codes were extracted for each visit. To develop the rule-based NLP algorithm, a stepwise process was used. First, a small sample of visits from 2017 was used to develop initial dictionaries. Next, EHR corresponding to 30,124 visits from 2018 were used to develop and evaluate the rule-based algorithm. A random sample of the results were manually reviewed to identify and address shortcomings in the algorithm, and to estimate sensitivity and specificity of the two methods of ascertainment. Last, the final algorithm was then applied to 29,212 visits from 2019 to estimate OUD prevalence. ResultsWhile there was substantial overlap in the identified records (n = 1,381 [59.2 %]), overall n = 2,332 unique visits were identified. Of the total unique visits, 430 (18.4 %) were identified only by ICD-10-CM codes, and 521 (22.3 %) were identified only by NLP. The prevalence of visits with evidence of an OUD diagnosis in this sample, ascertained using only ICD-10-CM codes, was 1,811/29,212 (6.1 %). Including the additional 521 visits identified only by NLP, the estimated prevalence of OUD is 2,332/29,212 (7.9 %), an increase of 29.5 % compared to the use of ICD-10-CM codes alone. The estimated sensitivity and specificity of the NLP-based OUD classification were 81.8 % and 97.5 %, respectively, relative to gold-standard manual review by an expert addiction medicine physician. ConclusionNLP-based algorithms can automate data extraction and identify evidence of opioid use disorder from unstructured electronic healthcare records. The most complete ascertainment of OUD in EHR was combined NLP with ICD-10-CM codes. NLP should be considered for epidemiological studies involving EHR data.

PediHome: Development of a Family-Reported Measure of Pediatric Home Healthcare Quality.

No validated tools exist to measure pediatric home healthcare quality. The objective of this work was to develop a family-reported survey (PediHome) to measure the quality of home healthcare for children with medical complexity (CMC). A national multidisciplinary expert panel (N=19) was convened to develop survey content domains. Panelist were joined by 3 additional experts to rank candidate survey items for importance and evaluate relevance and structure. Cognitive interviews were conducted with English-speaking (n=12) and Spanish-speaking (n=4) family caregivers of CMC to revise problematic items and clarify response options. A cross-sectional survey was then fielded (6/1/20-10/31/20) to parents whose children receive healthcare at 2 regional academic medical centers. The final measure included N=28 total items with 4 items quantifying access, 1 evaluating overall quality rating, and 21 items assessing provider tasks (11 home nursing only, 2 certified nursing assistant/home health aide only, and 1 dual). Out of 312 caregivers of CMC, 142 (46%) responded and one-half (n=68, 48%) reported a child receiving home nursing. They received a weekly median of 58.4% (IQR ±31.2%) of approved nursing hours with 55% reporting a missed nursing shift within the last month. Median overall quality was 75-9 (0-10 scale) and median scores on specific quality items ranged from 31-4 to 43-4 (0-4 scale). PediHome is a new content-valid family-reported measure of home healthcare quality for CMC that is useful for evaluating healthcare quality across several domains. Future work will involve assessing PediHome's construct and predictive validity.

Effect of the COVID-19 Lockdown on Asthma Biological Rhythms.

Asthma has a striking temporal character, in which time-of-day, patient age, and season each influence disease activity. The extent to which rhythms in asthma activity reflect exposure to specific disease triggers remains unclear. In this study, we examined how virus mitigation strategies enacted during the COVID-19 pandemic ("lockdown measures") affected rhythms in asthma clinical activity in children. To this end, we retrospectively analyzed asthma clinical presentations in children aged <18 years to our regional academic medical center, comparing 4 years of medical records prior to COVID-19 lockdown measures with the 12 months immediately after the institution of such measures. We correlated these data to positive viral test results, febrile seizures, and allergic clinical surrogates (allergic reaction visits and Emergency Department [ED] antihistamine prescriptions, respectively) over the same time frame. In the 12 months following the institution of the COVID-19 lockdown, positivity rates for common respiratory viruses dropped by 70.2% and ED visits for asthma among children dropped by 62% compared to pre-COVID years. Lockdown suppressed seasonal variation in positive viral tests and asthma ED visits, while diurnal rhythms in asthma visits were unchanged. Asthma seasonality correlated most strongly with rhinovirus positivity both before and after the institution of COVID lockdown measures. Altogether, our data support a causal role for viruses in driving seasonal variability in asthma exacerbations in children.

862. A Survey of HIV PrEP Prescribing Practices at an Academic Medical Center in the Northwest United States

Abstract Background The prescribing of pre-exposure prophylaxis (PrEP) remains a major means of reducing the incidence of HIV infection in the United States. Many individuals are unaware of their HIV status until further symptom progression has ensued or continue to engage in high-risk behavior despite awareness of the risk of HIV transmission. Primary care providers are instrumental in identifying patients who are at high risk of HIV acquisition and prescribing PrEP with appropriate counseling and monitoring. Methods In order to identify existing barriers to prescribing HIV PrEP at a single academic medical center, a voluntary 14-question de-identified survey was administered electronically to ambulatory care providers in the following departments: family medicine, internal medicine and geriatrics, adolescent and young adult health, student health, and women’s health clinics. Results Following survey dissemination, the response rate was 28% (82/286). The results are displayed in Tables 1-3. Notably, though 74% of survey respondents reported being familiar with CDC 2017 and USTPF 2019 clinical practice guidelines for PrEP prescribing, only 36% (22/61) were able to correctly identify the clinical scenarios in the survey whereby an individual is eligible for HIV PrEP. 57% (47/82) reported that they discuss HIV PrEP with less than 25% of eligible patients. Conclusion A significant proportion of healthcare providers at a major regional academic medical center are either not familiar with HIV PrEP prescribing clinical practice guidelines or are unable to appropriately identify situations whereby an individual meets eligibility for PrEP. In addition, a significant proportion do not discuss HIV PrEP with eligible patients. As such, data from the conducted survey will be used to inform the creation of clinical decision support tool to identify risk factors for HIV acquisition in patients, educate providers on guideline-based indications, and provide the option of a telePrEP referral service. Downstream effects anticipated from this intervention include increased HIV/STI testing, case identification, and increased rates of PrEP counseling and prescribing. Disclosures All Authors: No reported disclosures

Evaluating the Impact of Inadequate Meal Consumption on Insulin-Related Hypoglycemia in Hospitalized Patients

ObjectiveMeal intake is sometimes reduced in hospitalized patients. Meal-time insulin administration can cause hypoglycemia when a meal is not consumed. Inpatient providers may avoid ordering meal-time insulin due to hypoglycemia concerns, which can result in hyperglycemia. The frequency of reduced meal intake in hospitalized patients remains inadequately determined. This quality improvement project evaluates the percentage of meals consumed by hospitalized patients with insulin orders and the resulting risk of postmeal hypoglycemia (blood glucose [BG] <70 mg/dL, <3.9 mmol/L). MethodsThis was a retrospective quality improvement project evaluating patients with any subcutaneous insulin orders hospitalized at a regional academic medical center between 2015 and 2017. BG, laboratory values, point of care, insulin administration, diet orders, and percentage of meal consumed documented by registered nurses were abstracted from electronic health records. ResultsMeal consumption ≥50% was observed for 85% of meals with insulin orders, and bedside registered nurses were accurate at estimating this percentage. Age ≥65 years was a risk factor for reduced meal consumption (21% of meals 0%-49% consumed, P < .05 vs age < 65 years [12%]). Receiving meal-time insulin and then consuming only 0% to 49% of a meal (defined here as a mismatch) was not rare (6% of meals) and increased postmeal hypoglycemia risk. However, the attributable risk of postmeal hypoglycemia due to this mismatch was low (4 events per 1000) in patients with premeal BG between 70 and 180 mg/dL. ConclusionThis project demonstrates that hospitalized patients treated with subcutaneous insulin have a low attributable risk of postmeal hypoglycemia related to inadequate meal intake.

Interview With Cathleen Wheatley, DNP, RN, CENP

There are interviews with colleagues that are intriguing. Then there are interviews that raise the level of nursing’s collective consciousness. Cathleen Wheatley, DNP, RN, CENP, does both. As president of Wake Forest Baptist Medical Center and system chief nurse executive of Wake Forest Baptist Health System, her impact and influence not only benefit those in her care, but those nursing professionals aspiring to effect lasting change. She humbly shares her thoughts and ideas about the changing health care milieu, never realizing how relevant they truly are.

COVID-19 Collaborative Model for an Academic Hospital and Long-Term Care Facilities

The COVID-19 pandemic is devastating post-acute and long-term care (PA/LTC). As geriatricians practicing in PA/LTC and a regional academic medical center, we created this program for collaboration between academic medical centers and regional PA/LTC facilities. The mission of the Geriatric Engagement and Resource Integration in Post-Acute and Long-Term Care Facilities (GERI-PaL) program is to support optimal care of residents in PA/LTC facilities during the COVID-19 pandemic. There are 5 main components of our program: (1) Project ECHO; (2) nursing liaisons; (3) infection advisory consultation; (4) telemedicine consultation; and (5) resident social contact remote connections. Implementation of this program has had positive response from our local PA/LTC facilities. A key component of our program is our interprofessional team, which includes physicians and nursing, emergency response, and public health experts. With diverse professional backgrounds, our team members have created a new model for academic medical centers to collaborate with local PA/LTC facilities.

Impact of discharge medication bedside delivery service on hospital reutilization.

To evaluate the impact of a medication to bedside delivery (meds-to-beds) service on hospital reutilization in an adult population. A retrospective, single-center, observational cohort study was conducted within a regional academic medical center from January 2017 to July 2017. Adult patients discharged from an internal medicine unit with at least one maintenance medication were evaluated. The primary outcome was the incidence of 30-day hospital reutilization between two groups: discharged patients who received meds-to-beds versus those who did not. Additionally, the incidence of 30-day hospital reutilization between the two groups was compared within predefined subgroup patient populations: polypharmacy, high-risk medication use, and patients with a principal discharge diagnosis meeting the criteria set by the Centers for Medicare and Medicaid Services 30-day risk standardized readmission measures. A total of 600 patients were included in the study (300 patients in the meds-to-beds group and 300 patients in the control group). The 30-day hospital reutilization (emergency department visits and/or hospital readmissions) related to the index visit was lower in the meds-to-beds group, but the difference was not statistically significant between the two groups (8.0% in the meds-to-beds group versus 10.0% in the control group; odds ratio, 0.78; 95% confidence interval, 0.45-1.37). There was no significant difference in the 30-day hospital reutilization related to the index visit between the control and meds-to-beds groups within the three subgroups analyzed. There was no difference in 30-day hospital reutilization related to the index visit with the implementation of meds-to-beds service in the absence of other transitions-of-care interventions.

302. The efficacy of ketamine for improvement of postoperative pain control in adolescent patients undergoing spinal fusion surgery for idiopathic scoliosis

BACKGROUND CONTEXT Adolescent idiopathic scoliosis is the most common form of scoliosis and occurs most commonly in girls. When surgical intervention is required, the corrective operation is associated with significant postoperative pain which is primarily treated with morphine or morphine equivalents such as hydromorphone. The ideal regimen for postoperative pain management for pediatric spinal fusion has not been determined. PURPOSE The present study is a prospective randomized double-blinded control trial comparing the use of a preincision ketamine bolus, slow intraoperative infusion, and continued infusion postoperatively for 48 hours, to the placebo group's standard morphine regimen for corrective spinal fusions for idiopathic scoliosis in pediatric patients. The primary outcome for this study is patient satisfaction, and secondary outcomes include morphine equivalent opioid consumption, incidence of side effects, pain scores, and duration of hospital stay. We aimed to show that the addition of ketamine to standard pain control regimen will reduce pain scores and overall morphine equivalent consumption on a mg/kg basis, and thereby improve patient satisfaction. STUDY DESIGN/SETTING Prospective randomized double-blinded control trial performed at a regional academic medical center in New York. PATIENT SAMPLE A total of 50 patients allocated between placebo group and experimental (ketamine) group. ASA I-III. Mean age of 14. All undergoing posterior spinal fusion surgery for correction of adolescent idiopathic scoliosis refractory to non-surgical interventions. OUTCOME MEASURES Patient satisfaction, morphine equivalent consumption (mg/kg), incidence of side effects, pain scores, length of stay. METHODS A racemic ketamine bolus of 0.5 mg/kg (experimental - ketamine) or saline bolus (placebo) was given and then the ketamine or saline infusion of 0.2 mg/kg/hr was initiated prior to incision and continued intraoperatively. Postoperative pain management included continuation of the study drug for 48 hours in combination with standard morphine patient-controlled analgesia (PCA) and acetaminophen 15 mg/kg (up to 1 g) IV. Hourly pain scores were collected by bedside nurses, and the highest pain score for each 4-hour time period until postoperative day 2 (48 hours) was recorded. Patient and parental satisfaction scores were collected at postoperative hours 1, 24, and 48. Satisfaction scores ranged from 0 – 4, with 4 being the most satisfied. RESULTS Of the 49 total patients analyzed: 25 received the placebo, 24 received ketamine. Demographic and surgical variables were the same across groups except for age and gender. The placebo group had a mean intraoperative morphine equivalent consumption of 20.5 mg, 95% CI (17.2 – 23.8), and the experimental group had a mean of 17.4 mg, 95% CI (14.3 – 20.4), yielding no significant difference (p = 0.16). The placebo group had a median PACU morphine equivalent consumption of 6.67 mg, IQR [0.25 – 8.67], and the experimental group had a median of 2.34 mg, IQR [0 – 7.17], yielding no significant difference (p = 0.31). Postoperative morphine equivalent consumption (mg/kg) was significantly lower in the experimental group, median of 0.443 mg/kg, IQR [0.299 – 0.789], compared to the placebo group, median of 0.703 mg/kg, IQR [0.43 – 1.28] (p = 0.042). This yields a 37% reduction in consumption. Initial comparison of pain scores was insignificant with a placebo mean VAS score of 3.9, 95% CI (3.14 – 4.66), and an experimental mean VAS score of 3.17, 95% CI (2.45 – 3.89) (p = 0.155). Multiple linear regression analysis of pain scores yielded a significant reduction in pain within the experimental group when accounting for differences in age and gender (decrease of 1.5/10 on the VAS) (p CONCLUSIONS The use of ketamine alongside the standard morphine equivalent pain control regimen reduces the amount of IV PCA opioids consumed in the 48-hour postoperative time period. The significant reduction in the incidence of nausea and vomiting provides an additional benefit to this alternative analgesic therapy. This effect may be a secondary result of the reduction in total opioid consumption on a mg/kg basis, therefore reducing the known effects of opioids to induce nausea and vomiting. The application of ketamine as an analgesic in conjunction with the current standard of morphine-based therapy may serve as a superior pain control regimen for spinal surgeries in young populations. This regimen enhancement may be generalizable to other surgery subtypes within similar populations. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

Implementation of the HEART Pathway: Using the Consolidated Framework for Implementation Research

The HEART Pathway is an evidence-based decision tool for identifying emergency department (ED) patients with acute chest pain who are candidates for early discharge, to reduce unhelpful and potentially harmful hospitalizations. Guided by the Consolidated Framework for Implementation Research, we sought to identify important barriers and facilitators to implementation of the HEART Pathway. Data were collected at 4 academic medical centers. We conducted semi-structured interviews with 25 key stakeholders (e.g., health system leaders, ED physicians). We conducted interviews before implementation of the HEART Pathway tool to identify potential barriers and facilitators to successful adoption at other regional academic medical centers. We also conducted postimplementation interviews at 1 medical center, to understand factors that contributed to successful adoption. Interviews were recorded and transcribed verbatim. We used a Consolidated Framework for Implementation Research framework-driven deductive approach for coding and analysis. Potential barriers to implementation include time and resource burden, challenges specific to the electronic health record, sustained communication with and engagement of stakeholders, and patient concerns. Facilitators to implementation include strength of evidence for reduced length of stay and unnecessary testing and iatrogenic complications, ease of use, and supportive provider climate for evidence-based decision tools. Successful dissemination of the HEART Pathway will require addressing institution-specific barriers, which includes engaging clinical and financial stakeholders. New SMART-FHIR technologies, compatible with many electronic health record systems, can overcome barriers to health systems with limited information technology resources.

What Can We Learn From Point-of-Care Blood Glucose Values Deleted and Repeated by Nurses?

Hospitals rely on point-of-care (POC) blood glucose (BG) values to guide important decisions related to insulin administration and glycemic control. Evaluation of POC BG in hospitalized patients is associated with measurement and operator errors. Based on a previous quality improvement (QI) project we introduced an option for operators to delete and repeat POC BG values suspected as erroneous. The current project evaluated our experience with deleted POC BG values over a 2-year period. A retrospective QI project included all patients hospitalized at two regional academic medical centers in the Pacific Northwest during 2014 and 2015. Laboratory Medicine POC BG data were reviewed to evaluate all inpatient episodes of deleted and repeated POC BG. Inpatient operators choose to delete and repeat only 0.8% of all POC BG tests. Hypoglycemic and extreme hyperglycemic BG values are more likely to be deleted and repeated. Of initial values <40 mg/dL, 58% of deleted values (18% of all values) are errors. Of values >400 mg/dL, 40% of deleted values (5% of all values) are errors. Not all repeated POC BG values are first deleted. Optimal use of the option to delete and repeat POC BG values <40 mg/dL could decrease reported rates of severe hypoglycemia by as much as 40%. This project demonstrates that operators are frequently able to identify POC BG values that are measurement/operator errors. Eliminating these errors significantly reduces documented rates of severe hypoglycemia and hyperglycemia, and has the potential to improve patient safety.

A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center.

Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.

Prehospital blood transfusions in pediatric trauma and nontrauma patients: a single-center review of safety and outcomes.

Prehospital transfusions are a novel yet increasingly accepted intervention in the adult population as part of remote damage control resuscitation, but prehospital transfusions remain controversial in children. Our purpose was to review our pediatric prehospital transfusion experience over 12years to describe the safety of prehospital transfusion in appropriately triaged trauma and nontrauma patients. Children (<18years) transfused with packed red blood cells (pRBC) or plasma during transport to a single regional academic medical center between 2002 and 2014 were identified. Admission details, in-hospital clinical course, and outcomes were analyzed. 28 children were transfused during transport; median age was 8.9±7years and 15 patients were male (54%). Most patients required at least one additional unit of blood products during their hospitalization (79%), and/or required operative intervention (53%), endoscopy (7%), or died during their hospitalization (14%). Comparison of trauma patients (n=16) and nontrauma patients (n=12) revealed that nontrauma patients were younger, more anemic, more coagulopathy on admission, and required more ongoing transfusion in the hospital. Trauma patients were more likely to need operative intervention. No patient had a transfusion reaction. Remote damage control prehospital transfusions of blood products were safe in this small group of appropriately triaged pediatric patients. Further studies are needed to determine if outcomes are improved and to devise a rigorous protocol for this prehospital intervention for critically ill pediatric patients.

Abstract WMP85: Target Stroke Implementation: Best Practice Strategies Cut Thrombolysis Time to &lt;30 minutes in a 1,550 Bed Academic Urban County Hospital

Introduction: Thrombolytic window for acute ischemic stroke is brief and crucial. The AHA/ASA Target: Stroke Best Practice Strategies (TSBPS) aim to help hospitals improve thrombolysis door-to-needle (DTN) time. We assessed long-term efficacy of TSBPS to reduce DTN in a tertiary care hospital. Methods: We initiated a quality improvement program across one regional academic medical center (1,550 beds, 900 annual stroke admissions) that serves a multi-ethnic population by establishing a multidisciplinary DTN committee to assess causes of delayed DTN and implement focused TSBPS. Strategies included stroke team pre-admission notification, direct transfer to CT scanner, storing and administering IV rt-PA at CT scanner, and immediate stakeholder feedback. Door-to-CT, DTN, CT to IV rt-PA and door-to-groin (DTG) times were analyzed prospectively in consecutive IV rt-PA treated patients over 27 months pre-implementation and 13 months post-implementation. Results: A total of 148 patients were included in the pre-implementation and 126 patients in the post-implementation group. The two groups had similar demographics, comorbidities, anticoagulation status, pre-thrombolysis hypertension treatment, stroke severity (median NIHSS 11 (6-18) vs. 11 (5-17), p= 0.483), arrival by EMS (96% vs. 97%, p=0.708), and arrival after hours. Post implementation, reductions in treatment times were observed for median DTN (IQR) 59 (52-80) to 28.5 (20-41) min (p&lt;0.001), door-to-CT time 17 (14-21) to 16 (12-19) min (p=0.016), CT-to-IV rt-PA time 43 (31-59) to 13 (6-23) min (p&lt;0.001), and DTG time 164 (136-188) min (n=37) to 86 (63-103) min (n=51) (p&lt;0.001). Overall monthly IV r-tPA administration increased post-implementation (5.5 vs. 9.8, p&lt;0.001). Rate of symptomatic intracranial hemorrhage (2.7% vs. 3.2%, p=0.817) and treatment of stroke mimics (9% vs. 13%, p=0.311) were similar pre- and post-implementation. Conclusions: In this study, delay in IV rt-PA administration was predominantly related to prolonged CT to IVrt-PA time. DTN committee implementation is a simple, low-cost intervention, that significantly reduced DTN and DTG with persistent effect and no increase in symptomatic intracranial hemorrhage or stroke mimic treatment rate.

Alteration in Bacterial Culture After Treatment With Topical Mupirocin for Recalcitrant Chronic Rhinosinusitis.

Topical mupirocin therapy is used to treat symptomatic chronic sinusitis (CRS). However, the potential adverse impact of this therapy on the sinus microbiota has not been well quantified. To determine changes in microbiologic culture results before and after topical mupirocin therapy in patients with CRS with medically and surgically refractory disease. We performed a retrospective medical chart review for 22 consecutive adults evaluated and treated between January 1, 2012, and January 1, 2014, at an otolaryngology-rhinology clinic at a regional academic medical center. The patients were 14 men and 8 women, who had undergone functional endoscopic sinus surgery for CRS, and in whom sinus aspirate cultures were performed before and after topical mupirocin therapy for symptomatic disease. Analyses were performed in April 2014. Patients underwent treatment with saline sinus rinse, with the addition of mupirocin, for at least 1 week. Bacterial isolates from sinus aspirate culture. The patients included 14 men and 8 women, 18 to 75 years old, who underwent a mean of 1.9 functional endoscopic sinus surgical procedures. The mean (range) duration of mupirocin therapy was 6 (2-12) weeks. Before mupirocin therapy, cultures from symptomatic patients (14 men and 8 women, ages 18-75 years) revealed common bacteria implicated in CRS, which are characteristically gram-positive. After mupirocin therapy, cultures from symptomatic patients shifted significantly: 19 were gram-positive vs 3 gram-negative before treatment; 9 were gram-positive vs 13 gram-negative after treatment (P = .004), with increased growth of pathogenic gram-negative bacteria and Corynebacterium. These data present evidence supporting the distinct abrogation of culturable sinus bacteria after mupirocin rinses, identifying a shift toward increased pathogenic bacteria. Consideration of healthy host microbiome and immune dysfunction should guide future treatment considerations.