Regular Ward Research Articles

Improvements in AML Treatment Outcomes By Twinning at the Instituto De Prevision Social Hospital in Paraguay

Background: The Central Hospital of the Instituto de Prevision Social (IPS) is the primary care point for 30% of the Paraguayan population. Patients with AML were treated on a general ward and had to change citizenship to receive allogeneic stem cell transplant (HSCT) abroad. Following the poor overall survival (OS) of the patients, a twinning program was started in 2015 with the help of the Worldwide network for Blood and Marrow Transplantation (WBMT). Physicians were trained at a JACIE/FACT accredited center for 6 months and the Hospital, staff, and nurses with an experience of 115 mostly autologous HSCT were inspected. The program started in 2016 by daily supervisory telemedicine visits including monitoring of vital signs, blood counts, chemistry and radiological analysis. In 2019, the need to improve treatment of AML prompted the Hospital to include newly diagnosed patients in the twining program. Now after 6 years, the outcome of AML patients was evaluated and compared to the results before the cooperation in 2012-2015. Changes: One of the biggest challenges was the availability of essential drugs. Busulfan and several other preparative regimens and immunosuppressive drugs for HSCT were either not available or accessible only as oral formulation. Supportive therapy was a challenge considering lack of modern antifungal and antiviral therapy. To start the program, essential medications according to the WBMT recommendations were either donated from outside the country, included in the Insurance medications or ordered through the Ministry of Health. The allogeneic HSCT program was started using standard operating procedures (SOP) for central venous line care, neutropenia care, febrile neutropenia, transfusion threshold, visitors, patients per room, multidrug resistant bacteria active search and isolation of colonized patients, bacterial, viral, and fungal prophylaxis, and treatment. It was soon realized that only very few patients with AML survived induction therapy and reached CR. Therefore, the HSCT program started to include patients with AML from diagnosis in 2019. Newly diagnosed AML patients were therefore treated either on the conventional ward with 2-6 beds per room and common bathrooms or in the HSCT unit according to the availability of beds. SOP from HSCT patients were used for induction and consolidation treatments wherever possible. As quality control, OS was evaluated in the AML patients diagnosed in 2019-2021 according to treatment location and compared to the historical controls of 2012-2015 and to the HSCT patients. Results: Between 2019 and 2021, 23 patients received intensive chemotherapy induction, 8 patients in the HSCT Unit (Group A1) and 15 in the Regular Ward (Group A2). The controls included 31 historical patients with AML treated between 2012 - 2015 (Group B) and 50 patients after autologous or allogeneic HSCT between 2016-2021 (Group C). Patient`s characteristics are shown in Table 1. In comparison to the historical controls, diagnostics improved, and the treatment was given according to international protocols. Causes of death due to infection were reduced substantially to 12.5% in group A1 in comparison to 40% and 51% in group A2 and B, respectively. No bleeding fatalities were observed in Group A1 possibly because of strict transfusions according to SOP. In the HSCT control Group C only 4% died of infection and none of bleeding. Figure 1 shows overall survival for all four groups. There were significant differences in median OS of the Group A1 (18 months), Group A2 (0,8 months), Group B (3,2 months) and Group C (not reached; p<0.0001). OS at 12 months amounted to 81% for Group A1, 15% for Group A2, 11% for Group B and 79% for Group C. Conclusions: Improved survival following standardized treatment according to SOP can be achieved with strict adherence to protocols. Lower infection rate following isolation and standardized infection prevention and handling. Infection rate similar to the highest intensity of conditioning (autologous HSCT) and immunodeficiency (allogeneic HSCT). Even with the addition of new antifungal drugs and antivirals available at the regular ward between 2019-2021patients had low overall survival mostly due to bacterial infections following missing isolation, active surveillance, and prophylaxis. With this measures mortality following induction can be reduced effectively and is comparable to regular HSCT patients from developed countries. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Combined interprofessional and intraprofessional clinical collaboration reduces length of stay and consultations: a retrospective cohort study on an intensive collaboration ward (ICW)

ABSTRACT Patients with multiple health problems are a growing population at high risk of receiving fragmented care, resulting in a poorer quality of care, preventable hospitalisations, and higher costs. Health agencies such as the World Health Organization (WHO) advocate the implementation of interprofessional care, which should lead to better patient care. This retrospective cohort study investigated the effect of combined interprofessional and intraprofessional collaboration on the management of mainly elderly patients with multiple health problems on an Intensive Collaboration Ward (ICW). Patient health outcomes, patient experience, and the cost and value of care were assessed. In total, 200 patients admitted to the ICW were compared with 51 control patients with an indication for the ICW who were admitted to a regular ward because of a shortage of ICW beds. Patients admitted to the ICW had a shorter length of hospital stay than control patients (median 5 vs 7 days, p = .004) and had fewer in-hospital consultations (p = .003). Patient satisfaction did not differ between the ICW and control patients (mean rating (1–10) 8.22 vs 8.75, p = .060). This study indicates that interprofessional and intraprofessional clinical collaboration reduces the length of hospital stay and the number of in-hospital consultations, without affecting patient satisfaction.

The impact of pharmacist-led medication reconciliation and interprofessional ward rounds on drug-related problems at hospital discharge

BackgroundDuring transitions of care, including hospital discharge, patients are at risk of drug-related problems (DRPs).AimTo investigate the impact of pharmacist-led services, specifically medication reconciliation at admission and/or interprofessional ward rounds on the number of DRPs at discharge.MethodIn this retrospective, single-center cohort study, we analyzed routinely collected data of patients discharged from internal medicine wards of a regional Swiss hospital that filled their discharge prescriptions in the hospital’s community pharmacy between June 2016 and May 2019. Patients receiving one of the two or both pharmacist-led services (Study groups: Best Care = both services; MedRec = medication reconciliation at admission; Ward Round = interprofessional ward round), were compared to patients receiving standard care (Standard Care group). Standard care included medication history taken by a physician and regular ward rounds (physicians and nurses). At discharge, pharmacists reviewed discharge prescriptions filled at the hospital’s community pharmacy and documented all DRPs. Multivariable Poisson regression analyzed the independent effects of medication reconciliation and interprofessional ward rounds as single or combined service on the frequency of DRPs.ResultsOverall, 4545 patients with 6072 hospital stays were included in the analysis (Best Care n = 72 hospital stays, MedRec n = 232, Ward Round n = 1262, and Standard Care n = 4506). In 1352 stays (22.3%) one or more DRPs were detected at hospital discharge. The combination of the two pharmacist-led services was associated with statistically significantly less DRPs compared to standard care (relative risk: 0.33; 95% confidence interval: 0.16, 0.65). Pharmacist-led medication reconciliation alone showed a trend towards fewer DRPs (relative risk: 0.75; 95% confidence interval: 0.54, 1.03).ConclusionOur results support the implementation of pharmacist-led medication reconciliation at admission in combination with interprofessional ward rounds to reduce the number of DRPs at hospital discharge.

Implementation of a hospital antimicrobial stewardship program to improve vancomycin use in Cyprus: Challenges and opportunity

The Republic of Cyprus is among the highest consumers of antibacterials for systemic use in Europe. The antimicrobial resistance of invasive isolates in Cyprus is also high compared to the European Union. Formal antimicrobial stewardship initiatives are scarce in Cyprus, raising an urgent need to address the challenges for implementing hospital antimicrobial stewardship. To implement an antimicrobial stewardship program and improve vancomycin use in a tertiary care hospital in Cyprus, through implementation of a protocol for treatment and therapeutic drug monitoring (TDM) and to discuss the current challenges present in Cyprus. Following a local audit of practices, we established a hospital antimicrobial stewardship program with limited resources, towards a model of stewardship which included a persuasive approach, education, selective reporting of antimicrobial susceptibility, providing comments on the microbiology results and regular microbiology clinical ward rounds. By implementing our vancomycin protocol, we achieved a statistically significant improvement (P<0.01) in achieving vancomycin therapeutic levels over a 2-year period, while improving administration practices. Meaningful steps toward implementing a local antimicrobial stewardship program are possible even in resource-limited and unfavourable settings.

High-flow nasal cannula oxygen therapy for admitted COPD-patients. A retrospective cohort study.

BackgroundThe use of High-flow nasal cannula (HFNC) is increasing in admitted COPD-patients and could provide a step in between non-invasive ventilation (NIV) and standard oxygen supply. Recent studies demonstrated that HFNC is capable of facilitating secretion removal and reduce the work of breathing. Therefore, it might be of advantage in the treatment of acute exacerbations of COPD (AECOPD). No randomized trials have assessed this for admitted COPD-patients on a regular ward and only limited data from non-randomized studies is available.ObjectivesThe aim of our study was to identify the reasons to initiate treatment with HFNC in a group of COPD-patients during an exacerbation, further identify those most likely to benefit from HFNC treatment and to find factors associated with treatment success on the pulmonary ward.Material and methodsThis retrospective study included COPD-patients admitted to the pulmonary ward and treated with HFNC from April 2016 until April 2019. Only patients admitted with severe acute exacerbations were included. Patients who had an indication for NIV-treatment where treated with NIV and were included only if they subsequently needed HFNC, e.g. when they did not tolerate NIV. Known asthma patients were excluded.ResultsA total of 173 patients were included. Stasis of sputum was the indication most reported to initiate HFNC-treatment. Treatment was well tolerated in 83% of the patients. Cardiac and vascular co-morbidities were significantly associated with a smaller chance of successful treatment (Respectively OR = 0.435; p = 0.013 and OR = 0.493;p = 0.035). Clinical assessment judged HFNC-treatment to be successful in 61% of the patients. Furthermore, in-hospital treatment with NIV was associated with a higher chance of HFNC failure afterwards (OR = 0.439; p = 0.045).ConclusionThis large retrospective study showed that HFNC-treatment in patients with an AECOPD was initiated most often for sputum stasis as primary reason. Factors associated with improved outcomes of HFNC-treatment was the absence of vascular and/or cardiac co-morbidities and no need for in-hospital NIV-treatment.

Identifying gaps in global evidence for nurse staffing and patient care outcomes research in low/middle-income countries: an umbrella review

ObjectiveTo identify nurse staffing and patient care outcome literature in published systematic reviews and map out the evidence gaps for low/middle-income countries (LMICs).MethodsWe included quantitative systematic reviews on nurse staffing...

Length of Hospital Stay and Survival of Hospitalized COVID-19 Patients During the Second Wave of the Pandemic: A Single Centre Retrospective Study from Slovenia.

As of writing, there are no publications pertaining to the prediction of COVID-19-related outcomes and length of stay in patients from Slovene hospitals. To evaluate the length of regular ward and ICU stays and assess the survival of COVID-19 patients to develop better prediction models to forecast hospital capacity and staffing demands in possible further pandemic peaks. In this retrospective, single-site study we analysed the length of stay and survival of all patients, hospitalized due to the novel coronavirus (COVID-19) at the peak of the second wave, between November 18th 2020 and January 27th 2021 at the University Clinic Golnik, Slovenia. Out of 407 included patients, 59% were male. The median length of stay on regular wards was 7.5 (IQR 5-13) days, and the median ICU length of stay was 6 (IQR 4-11) days. Age, male sex, and ICU stay were significantly associated with a higher risk of death. The probability of dying in 21 days at the regular ward was 14.4% (95% CI [10.9-18%]) and at the ICU it was 43.6% (95% CI [19.3-51.8%]). The survival of COVID-19 is strongly affected by age, sex, and the fact that a patient had to be admitted to ICU, while the length of hospital bed occupancy is very similar across different demographic groups. Knowing the length of stay and admission rate to ICU is important for proper planning of resources during an epidemic.

Palliative Care e-Learning for Physicians Caring for Critically Ill and Dying Patients during the COVID-19 Pandemic: An Outcome Evaluation with Self-Assessed Knowledge and Attitude.

During the COVID-19 pandemic, the care of critically ill and dying patients in isolation wards, intensive care units (ICUs), and regular wards was severely impaired. In order to support physicians in communicative and palliative care skills, an e-learning tool was developed as part of the joint project “Palliative Care in Pandemic Times” (PallPan). This study investigates the feasibility of this e-learning tool. Secondly, we aim to analyze changes in knowledge and attitude upon completion of the e-learning tool. A 38-item questionnaire-based evaluation study with assessment of global and specific outcomes including ICU and non-ICU physicians was performed. In total, 24 questionnaires were included in the anonymous analysis. Feasibility was confirmed by a very high rate of overall satisfaction (94% approval), with relevance reaching 99% approval. Overall, we detected high gains in knowledge and noticeably lower gains on the attitude plane, with the highest gain in naming reasons for incorporating palliative care. The lowest learning gain on the attitude plane was observed when the participants were confronted with their own mortality. This study shows that e-learning is a feasible tool for gaining knowledge and even changing the attitudes of physicians caring for critically ill and dying patients in a self-assessment evaluation.

Comparing complaint-based triage scales and early warning scores for emergency department triage

BackgroundEmergency triage systems are used globally to prioritise care based on patients’ needs. These systems are commonly based on patient complaints, while the need for timely interventions on regular hospital...

618 A Registrar - Delivered Urology Experience Improves Medical Student Knowledge of the Subject and Increases Interest in a Surgical Career

Abstract Introduction Exposure to Urology is thought to vary considerably between medical schools, leading to a lack of competence by foundation doctors in basic urological skills and knowledge, and perhaps low interest in a urological / surgical career. In our hospital students had no dedicated Urology placement until 2020. Method A weeklong Urology placement was designed for 3rd year students. This comprised tutorials on topics set out by the university curriculum, a catheter insertion simulation session, and regular theatre and ward rounds. Most students also had the opportunity to insert a catheter on the ward / theatre. Students were encouraged to complete The National Catheter Education Programme, an online course providing a point for CST applications. This placement is registrar delivered, giving a more accurate idea of what a surgical career involves. Student feedback was obtained on the first and last days to ascertain self-rated confidence on a Likert-type scale regarding urological key topics, as well as career intentions. Results Self – rated knowledge on the 5 identified topics at the start of the week was most likely to be “Poor,” and by the end “Good” or “Very good.” By the end of the week most students indicated they were much more likely to pursue a career in surgery, although the same response was not seen as strongly for the subspeciality of Urology. Conclusions The placement continues to run and develop based on feedback. We look forward with interest to the publication of LEARN (uroLogical tEAching in bRitish medical schools Nationally) — a multicentre audit – to further inform this project.

Early reduction of estimated Glomerular Filtration Rate (eGFR) predicts poor outcome in acutely ill hospitalized COVID-19 patients firstly admitted to medical regular wards (eGFR-COV19 study)

BackgroundAnalysis of autopsy tissues obtained from patients who died from COVID-19 showed kidney tropism for SARS-COV-2, with COVID-19-related renal dysfunction representing an overlooked problem even in patients lacking previous history of chronic kidney disease. This study aimed to corroborate in a substantial sample of consecutive acutely ill COVID-19 hospitalized patients the efficacy of estimated GFR (eGFR), assessed at hospital admission, to identify acute renal function derangement and the predictive role of its association with in-hospital death and need for mechanical ventilation and admission to intensive care unit (ICU). MethodsWe retrospectively analyzed charts of 764 patients firstly admitted to regular medical wards (Division of Internal Medicine) for symptomatic COVID-19 between March 6th and May 30th, 2020 and between October 1st, 2020 and March 15th, 2021. eGFR values were calculated with the 2021 CKD-EPI formula and assessed at hospital admission and discharge. Baseline creatinine and GFR values were assessed by chart review of patients’ medical records from hospital admittance data in the previous year. The primary outcome was in-hospital mortality, while ARDS development and need for non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV) were the secondary outcomes. ResultsSARS-COV-2 infection was diagnosed in 764 patients admitted with COVID-19 symptoms. A total of 682 patients (age range 23–100 years) were considered for statistical analysis, 310 needed mechanical ventilation and 137 died. An eGFR value <60 mL/min/1.73 m2 was found in 208 patients, 181 met KDIGO AKI criteria; eGFR values at hospital admission were significantly lower with respect to both hospital discharge and baseline values (p < 0.001). In multivariate analysis, an eGFR value <60 mL/min/1.73 m2 was significantly associated with in-hospital mortality (OR 2.6, 1.7–4.8, p = 0.003); no association was found with both ARDS and need for mechanical ventilation. eGFR was non-inferior to both IL-6 serum levels and CALL Score in predicting in-hospital death (AUC 0.71, 0.68–0.74, p = 0.55). ConclusionseGFR calculated at hospital admission correlated well with COVID-19-related kidney injury and eGFR values < 60 mL/min/1,73 m2 were independently associated with in-hospital mortality, but not with both ARDS or need for mechanical ventilation.

Adaptive Re-use in Hospital Building for Development Efficiency, Case Study: Regular ward use for a new function of the psychiatric ward at RSUP Dr. Kariadi

This paper aims to develop design guidelines in the architectural design process, especially for developing new facilities in the hospital complex, which is optimized by using existing buildings transformed into a new function. A specific approach for the adaptive re-use technique will help find a comprehensive method and efficiency of construction budgeting. This paper will discuss changes and developments for providing space for specific healthcare treatment facilities that are always developing every time as long as the hospital still stands, besides developing services or specific treatment for a specific disease for improving healthcare services. To answer hospital design and development, which can be adapted for every development, we can also develop adaptive re-use technique as one of the alternatives for accommodating fulfilling the need for new functions or adding new treatment facilities in the existing hospital. Existing buildings can be transformed into new functions with minimum editing or retrofitting procedures, so the existing building can extend the duty for accommodating building functions. This technique is also to save the budget for construction of the new building, for at least use the existing structure as a basic start and find out for optimum re-adjustment in other parts of buildings components to fit new function. The case study took at RSUP Dr. Kariadi Hospital, which transformed from an existing regular ward into a psychiatric ward with specific requirements in inpatient facilities. The result of the research can be used as a guide in the design process for developing the new function in hospital buildings that fulfills the efficiency of the construction budget. A specific approach to the design model will help find a comprehensive design method.

Rotational thromboelastometry in patients with type 2 diabetes and mild COVID-19 pneumonia: A pilot prospective study.

Background:It was repeatedly demonstrated that patients with severe COVID-19 pneumonia, as well as patients with type 2 diabetes (T2D) have higher risk of thromboembolic complications. Rotational thromboelastometry (ROTEM®) is a viscoelastic hemostatic assay which allows complex assessment of hemostasis in whole blood. The aim of this study was to compare changes in hemostasis measured by ROTEM® in diabetic and nondiabetic patients with mild COVID-19 pneumonia.Methods:We performed a pilot, prospective, observational study and enrolled 33 consecutive patients (14 with T2D and 19 nondiabetic ones) admitted to regular ward with mild COVID-19 pneumonia. The control group consisted from 11 healthy, nondiabetic blood donors. Blood samples were tested with ROTEM® using INTEM® and EXTEM® reagents.Results:We detected significant differences in EXTEM® clotting time (CT), clot formation time (CFT), and maximum clot firmness (MCF) comparing patients with mild COVID-19 pneumonia and healthy donors. However, there were no significant differences in EXTEM®, INTEM®, and HEPTEM® parameters (CT, CFT, and MCF) according to diabetes status.Conclusions:Our study demonstrated hypercoagulation in patients with mild COVID-19 pneumonia. T2D did not affected ROTEM® parameters in patients with mild COVID-19 pneumonia.

Influence of Advanced Organ Support (ADVOS) on Cytokine Levels in Patients with Acute-on-Chronic Liver Failure (ACLF).

Background: ADVanced Organ Support (ADVOS) is a novel type of extracorporeal albumin dialysis that supports multiorgan function in patients with acute-on-chronic liver failure (ACLF). No data exist on whether ADVOS affects inflammatory cytokine levels, which play a relevant role in ACLF. Aim: Our aim was to quantify cytokine levels both before and after a single ADVOS treatment in patients with ACLF at a regular dialysis ward. Methods and results: In this prospective study, 15 patients (60% men) with ACLF and an indication for renal replacement therapy were included. Patient liver function was severely compromised, reflected by a median CLIF-consortium ACLF score of 38 (IQR 35; 40). Blood samples were directly taken before and after ADVOS dialysis. The concentration of cytokines for IL-1β, IFN-α2, IFN-γ, TNF-α, MCP-1, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IL-18, IL-23, IL-33 were quantified via a cytometric bead array. We found no significant (p > 0.05) change in cytokine levels, even when patients were stratified for dialysis time (<480 min versus ≥480 min). The relevance of the assessed cytokines in contributing to systemic inflammation in ACLF was demonstrated by Ingenuity pathway analysis®. Conclusion: Concentrations of pathomechanistically relevant cytokines remained unchanged both before and after ADVOS treatment in patients with ACLF.

Implementation of an antimicrobial stewardship programme in three regional hospitals in the south-east of Liberia: lessons learned.

BackgroundAntimicrobial stewardship (AMS) programmes can improve the use of antimicrobial agents. However, there is limited experience in the implementation of such programmes in low- and middle-income countries (LMICs).ObjectivesTo assess the effect of AMS measures in south-east Liberia on the quality of antimicrobial use in three regional hospitals.MethodsA bundle of three measures (local treatment guideline, training and regular AMS ward rounds) was implemented and quality indicators of antimicrobial use (i.e. correct compounds, dosage and duration) were assessed in a case series before and after AMS ward rounds. Primary endpoints were (i) adherence to the local treatment guideline; (ii) completeness of the microbiological diagnostics (according to the treatment guideline); and (iii) clinical outcome. The secondary endpoint was reduction in ceftriaxone use.ResultsThe majority of patients had skin and soft tissue infections (n = 108) followed by surgical site infections (n = 72), pneumonia (n = 64), urinary tract infection (n = 48) and meningitis (n = 18). After the AMS ward rounds, adherence to the local guideline improved for the selection of antimicrobial agents (from 34.5% to 61.0%, P < 0.0005), dosage (from 15.2% to 36.5%, P < 0.0005) and duration (from 13.2% to 31.0%, P < 0.0005). In total, 79.7% of patients (247/310) had samples sent for microbiological analysis. Overall, 92.3% of patients improved on Day 3 (286/310). The proportion of patients receiving ceftriaxone was significantly reduced after the AMS ward rounds from 51.3% to 14.2% (P < 0.0005).ConclusionsAMS measures can improve the quality of antimicrobial use in LMICs. However, long-term engagement is necessary to make AMS programmes in LMICs sustainable.

Intra-aortic balloon pump in patients with acute advanced heart failure. Results from a single-center study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with advanced heart failure are frequently referred to cardiac intensive care unit (CICU) for hemodynamic support. Despite optimum pharmacological therapy many of these patients persist in critical condition, demanding short term circulatory support until recovery or heart transplantation. Intra-aortic balloon pump is commonly used in patients with advanced heart failure in order to stabilize hemodynamically compromised patients as bridge to decision for further therapies. Purpose To investigate the outcomes of patients with acute advanced heart failure referred to cardiac intensive care unit and supported with short term mechanical support. To explore the hemodynamic effects of the Intra-aortic balloon pump therapy in these patients. Material &amp; Method We retrospectively analyzed the data from 104 patients with acute advanced heart failure (either as worsening of existing symptoms of chronic HF or as first onset of HF). All patients had severe left ventricular dysfunction, which was frequently associated with right ventricular dysfunction and increased NT pro BNP levels. Demographic data were collected including co-morbidities. Laboratory data included NT-pro BNP, total bilirubin, serum creatinine, urea and baseline e GFR (MDRD Formula). All patients received IABP support and underwent right heart catheterization. Measurements were made before and after the insertion of the IABP. The study has been approved by the Scientific Committee and the Ethics Committee of the Hospital. Results The mean age of the sample was 44 ± 12 years. 76 patients (73, 08%) were male. 20 patients (19, 23%) were of ischemic etiology. The median time on IABP support for the entire cohort was 13 days (3 – 41, 25). There was statistically significant decrease in the NT-pro BNP levels (p&amp;lt;0, 0001). There was improvement in renal function (e GFR (p&amp;lt;0, 0001) and urea levels (p&amp;lt; 0,001)). There was statistically significant improvement in the right heart catheterization measurements (decrease of the right atrium pressure (p &amp;lt;0, 0001), of the PA pressure (p&amp;lt;0,001), and of the pulmonary capillary wedge pressure (p&amp;lt;0,001)). IABP provided clinical stabilization in 88 patients (87, 62%), that is completed pre-transplant evaluation and proceeded in surgery with permanent mechanical support or heart transplantation or transfer to regular ward, while 16 patients (15, 38%) ended up in CICU while being on IABP. Conclusions In this single center study the use of IABP improved the laboratory findings and the hemodynamic status of patients admitted in the cardiac intensive care unit with acute advanced heart failure. It was an effective method of managing patients as bridge to decision for further therapies.

P073 Patient with rheumatoid arthritis on regular rituximab infusions with severe COVID-19 pneumonitis despite both vaccinations

Background/AimsCoronavirus Disease 2019 (COVID-19) is a global pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). International mass vaccination schemes are implemented to control the disease and reduce mortality. The data on serological immune response among rheumatology patients receiving immunosuppressive therapy following SARS-CoV-2 vaccines is very sparse. We present a case of a rheumatoid arthritis patient receiving rituximab (RTX) who developed fatal nosocomial COVID-19 infection despite receiving SARS-CoV-2 vaccine.MethodsA 71-year-old Caucasian male with longstanding seropositive rheumatoid arthritis, interstitial lung disease with bullous emphysema, paraproteinemia, osteoporosis, anxiety, and depression. His treatment included hydroxychloroquine, sulfasalazine, oral prednisolone (2-5 mg), and RTX every 6 months. He received his last cycle of RTX almost 8 weeks before vaccination. This gentleman received two doses of COVID-19 mRNA Vaccine (BioNTech-Pfizer) eleven weeks apart. Nine weeks after the second vaccination he was admitted with supraventricular tachycardia and heart failure. This admission coincided with a COVID-19 outbreak in the ward. Eight patients and one staff member tested (PCR) positive during regular ward screening. All patients were initially asymptomatic, and six of them were fully vaccinated. He was allowed to go home with advice to self-isolate for 10 days. Two days after discharge, he presented to the emergency department with shortness of breath, lethargy, and cough. The diagnosis was COVID-19 pneumonitis and pre-renal acute kidney injury. He received supplemental oxygen, dexamethasone, and intravenous co-amoxiclav. Unfortunately, he died from COVID-19 pneumonitis on his sixth day of admission. Our patient was the only one among the nine SARS-CoV-2 positive individuals who developed symptomatic disease.ResultsIt is known that RTX along with other immune modulatory drugs reduce the response to some vaccines such as the seasonal flu vaccine, and it is expected that the same effect could be seen after COVID-19 vaccination. Octave study is evaluating immune responses in patients with a range of chronic rheumatic conditions on specific immunomodulatory and biologic treatments. This has shown the response to vaccine was dependent on the disease cohort, with 90% of those with RTX-treated antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and 54% of those with inflammatory arthritis responding less well than the baseline for healthy subjects. There is no evidence to suggest how long after RTX a patient should delay vaccination with a COVID-19 vaccine, but published consensus suggests 4-8 weeks.ConclusionMore studies are needed to assess the response to SARS-COV-2 vaccines among immunocompromised patients and the need for a third vaccine dose if antibodies level were low. The first approved monoclonal antibody treatment—Ronapreve™ for treating and preventing acute covid-19 in adults, is a promising drug for poor vaccine responders who develop COVID-19 infection. This case also highlights the importance of infection control within hospital setting.Disclosure N. Abdullah: None. A. Kinder: None. D. Jenkins: None. V. Patel: None.

Case Report Chest Non-contrast ct-scan findings and follow up a patient suspected covid-19 infection

Background Covid-19 is an infection caused by SARS-CoV-2. Chest X-Ray (CXR) examination doesn’t show the radiographiccharacteristic of Covid-19 infection. Thorax CT-Scan is the gold standard imaging for pneumonia Covid-19 infection.Aim The purpose of this report is to describe a case of bronchopneumonia in a male patient aged 48 years old at Bethesda Hospital Yogyakarta during the Covid-19 pandemic.Case Description A 48 years old male patient came to the Bethesda Hospital in Yogyakarta with a complaint of fever 1 week before being hospitalized. The patient also complained of cough, sore throat, rhinorrhea, shortness of breath, malaise, and decreased appetite. The rapid test result shows SARS-CoV2 IgM and IgG (+), PCR swab Covid-19 results (+). Bronchopneumonia was concluded by CXR examination and chest non-contrast CT-Scan showed Covid-19 infection imaging characteristics. Later on, the patient showed clinical and radiological improvement.Conclusion Covid-19 is an infection caused by the SARS-CoV-2. Common symptoms are fever, cough, sore throat, shortness of breath, and malaise. CXR examinations on patients with Covid-19 infection show images of pneumonia, in this case, bronchopneumonia was concluded. CT-scan shows characteristic imaging of Covid-19 infection can support the decision on regular ward admission versus ICU and for follow-up in regular ward admission.

Bioethics in an oncological surgery unit during the COVID-19 pandemic: the Verona experience

The spread of COVID-19 has overwhelmed medical facilities across the globe, with patients filling beds in both regular wards and in intensive care units. The repurposing of hospital facilities has resulted in a dramatic decrease in the capacity of hospitals—in terms of available beds, surgical facilities, and medical and nursing staff— to care for oncology patients. The Italian National Board of Bioethics provided precise and homogeneous guidelines for the allocation of the scarce resources available. In our experience, strictly following these general guidelines and not considering the clinical vocation of each single health care center did not allow us to resume usual activities but generated further confusion in resource allocation. To face the scarcity of available resources and guarantee our patients fair access to the health care system we created a surgical triage with four fundamental steps. We took into consideration “ well defined and widely accepted clinical prognostic factors ” as stated by the Italian Society of Anesthesia and Resuscitation. We were able to draw up a list of patients giving priority to those who theoretically should have a greater chance of overcoming their critical situation. The age criterion has also been used in the overall evaluation of different cure options in each case, but it has never been considered on its own or outside the other clinical parameters. Although not considered acceptable by many we had to forcefully adopt the criterion of comparison between patients to give priority to those most in need of immediate care.

Short and Concise Peer-to-Peer Teaching-Example of a Successful Antibiotic Stewardship Intervention to Increase Iv to Po Conversion.

Antibiotic stewardship (ABS) programs aim to combine effective treatment with minimized antibiotic-related harms. Common ABS interventions are simple and effective, but their implementation in daily practice is often difficult. The aim of our study was to investigate if a single, short, peer-to-peer teaching intervention (junior doctor to junior doctor) during clinical routine can successfully improve antibiotic prescriptions. We performed a quasi-experimental before–after study on a regular care cardiology ward at a large academic medical center in Germany. We evaluated antibiotic use metrics retrospectively and calculated defined daily doses (DDD) with the anatomical therapeutic chemical/DDD classification system of the World Health Organization. We hypothesize that the over-representative use of intravenous administration is a potentially modifiable target, which can be proven by antibiotic use metrics analysis. After a single peer-to-peer teaching session with a focus on indications for iv to po conversion, the normalized percentage of intravenous compared to oral administration significantly decreased (from 86.5 ± 50.3% to 41.4 ± 70.3%). Moreover, after the intervention, antibiotics with high oral bioavailability were no longer administered intravenously at all during the following quarter. Our results indicate that even a single peer-to-peer training session is highly effective in improving the iv to po conversion rate in the short term.