Rural Academic Medical Center Research Articles

Gender and Autism Program: A novel clinical service model for gender-diverse/transgender autistic youth and young adults

Objective: Situated in Children’s National Hospital (CNH)’s Neuropsychology Division, the Gender and Autism Program (GAP) is the first clinical service dedicated to the needs of autistic gender-diverse/transgender youth. This study describes GAP clinical assessment profiles and presents a multi-perspective programmatic review of GAP evaluation services. Method: Seventy-five consecutive gender- and neuropsychologically-informed GAP evaluations were analyzed, including demographics, gender and autism characterization, and primary domains evaluated. Three program-based Delphi studies were conducted and identify: clinician priorities and challenges in providing care, program administrator lessons learned and ongoing barriers, and considerations adapting this model for a rural academic medical center. Results: Nearly two-thirds of referrals were transfeminine. Most youth had existing autism diagnoses; of those undiagnosed, three-quarters were found to be autistic. Five goals of evaluations were identified: Mental health was always assessed, and most evaluations also assessed gender-related needs in the context of autism neurodiversity. Neuropsychological characterization of strengths and challenges informed personalized accommodations to support youth gender-related self-advocacy. Clinicians emphasized frequent youth safety concerns. Administrators emphasized the need for specialized training for working with families. Components for adaptation of the GAP in a rural academic medical center were identified. Conclusions: Since its founding, the GAP has proven a sustainable neuropsychology-based service with consistent referral flow and insurance authorizations. Capturing staff perspectives through rigorous Delphi methods, and addressing the GAP’s feasibility and replicability, this study provides a road map for replicating this service. We also highlight GAP training of specialist clinicians, fundamental to addressing the desperate shortage of providers in this field.

Evaluating the Impact of Telehealth on Carbon Footprint During Three Phases of the Pandemic at a Rural Academic Medical Center.

Background: Climate change is primarily driven by greenhouse gases, such as carbon dioxide (CO2). Telehealth visits have been found to mitigate carbon emissions by reducing patient and physician transport. Dartmouth Hitchcock Medical Center (DHMC) is the most rural academic medical center in the country, serving a population where the majority of patients reach the hospital by car. No large study or systematic review has evaluated the impact of telehealth visits on CO2 emissions (CO2e) across multiple specialties in a purely rural setting. Further, no sizable rurally focused study has compared CO2e avoided during the various stages of the pandemic. Methods: We extracted data for all outpatient telehealth visits at DHMC from three periods: prepandemic, early pandemic, and late pandemic. The extracted data included the pandemic stage of the virtual visit, the type of visit (video or telephone), the specialty, and the distance from the patient's home to DHMC. Results: The total CO2e avoided among all three pandemic stages analyzed in this study was 23,658,898 kg (n = 251,832). During period 1, the mean driving distance = 159.0 miles; CO2e avoided per encounter = 128.3 kg; period 2, mean distance = 84.85 miles; average CO2e avoided per encounter = 68.47 CO2e kg; and period 3, mean distance = 112.9 miles; average CO2e avoided per encounter = 91.08 kg. Conclusions: This data supported long distances to the medical center and large savings in CO2e avoided across multiple specialties that spanned all pandemic periods. Further, this level of averted emissions could translate to over $3M in saved fuel costs and the avoidance of six excess deaths. While discussions of the future of telehealth commonly focus on access, use cases, technology, costs, and satisfaction, the impact on carbon footprint is an additional important metric, particularly in largely rural regions.

1246. Impact of Leveraging Clinical Decision Support Tools to Implement a Tiered Antimicrobial Stewardship Workflow at a Rural Academic Medical Center

Abstract Background The Infectious Diseases Society of America and The Joint Commission recommend Antimicrobial Stewardship Programs (ASPs) incorporate preauthorization and/or prospective audit and feedback (PAF) as mechanisms for stewardship interventions. However, each institution must customize their ASP workflow. The ASP at West Virginia University Hospitals (WVUH), a rural, comprehensive academic medical center, was recently revamped by leveraging clinical decision support (CDS) tools via a tiered workflow in efforts to prioritize stewardship interventions for preauthorization and PAF. Methods In March 2021 ASP pharmacists created a tiered workflow incorporating CDS tools from Theradoc® and Epic®. Review of patients identified on CDS alerts (Table 1), preauthorization, and PAF were conducted Monday through Friday 8:00 am to 5:00 pm by ASP pharmacist(s). Tiered workflow effectiveness was measured by internal and external benchmarking: antimicrobial days of therapy (DOT)/1000 days present, antimicrobial spend, and Standardized Antimicrobial Administration Ratio (SAAR). Interventions were documented within the electronic medical record and tracked via a Quality Assurance and Performance Improvement (QAPI) format. Post implementation data from March 2021 to March 2023 was analyzed and compared to baseline 2019 data. CRE: Carbapenem-resistant Enterobacterales; ESBL: Extended Spectrum Beta-Lactamase; HIV: Human Immunodeficiency Virus Results The following outcomes were observed within the post implementation timeframe. Monthly average DOT/1000 days present decreased ≥ 20% for the following antimicrobials: vancomycin (27%), ceftaroline (53%), cefepime (20%), ertapenem (59%), aztreonam (68%), tigecycline (23%), fosfomycin (80%), micafungin (27%), ceftazidime-avibactam (40%). Monthly average total antimicrobial SAAR decreased by 11% from 1.216 to 1.074. Additionally, monthly average antimicrobial spend/patient day decreased by 36% from $26.47 to $16.95. QAPI data demonstrated a 74% intervention acceptance rate including correction of 344 drug-bug matches. Conclusion Implementation of a tiered ASP workflow effectively identified patients for interventions, decreased antimicrobial utilization, and demonstrated antimicrobial cost containment. Acceptance of stewardship interventions was favorable. This tiered approach may serve as a model for other ASPs. Disclosures All Authors: No reported disclosures

752. Development of an Outpatient Infectious Disease Rotation for Internal Medicine Residents at a Rural Academic Medical Center

Abstract Background Infectious disease (ID) training is essential to the education of internal medicine residents and has traditionally occurred on inpatient rotations focused on hospitalized patients. However, these rotations offer limited experience with infectious diseases managed in the outpatient setting. Furthermore, inpatient rotations expose residents to only one aspect of the multifaceted contributions ID specialists provide. Given the nationwide decline in ID providers, demonstrating the diverse career paths that can stem from ID training is a potential opportunity to attract trainees to this field. Developing interest in ID amongst residents is even more crucial in rural areas where the infectious disease provider shortage is severe. Here, we describe an ambulatory ID rotation for internal medicine residents at a rural academic medical center. We provide a model for a structured rotation with diverse learning opportunities for medical residents, and show the rotation has been received positively by those residents who have completed it to date. Methods We established an outpatient ID rotation to offer as an elective for internal medicine residents. The rotation consisted of working one-on-one with ID faculty in a variety of settings in 2 or 4 week rotation blocks. A schedule was provided to each resident. Anonymous evaluations of the rotation were obtained upon completion of each block and aggregated. Results There were a total of 11 internal medicine residents who participated in the ambulatory ID rotation from 7/1/2020 until 1/3/2023. Residents participated in a variety of clinical experiences, conferences, and didactics as summarized in Table 1. Each day of the rotation was divided into morning and afternoon clinics with conferences and didactics scheduled first thing in the morning or at noon. A sample rotation schedule is provided in Figure 1. Resident evaluations of the rotation were positive overall as summarized in Table 2.Figure 1.Example medical resident rotation schedule for outpatient ID elective rotation Conclusion We present a model for an ambulatory outpatient ID rotation consisting of a wide variety of educational and clinical opportunities that also provides a more comprehensive overview of different career paths within the ID specialty. Residents who have completed the rotation today have evaluated it favorably. Disclosures All Authors: No reported disclosures

A - 152 Won't Get Fooled Again: Factors in Persistent Complaints Following Youth Concussion.

While symptoms following youth concussion typically resolve within one month of injury, some patients report persistent post-concussive symptoms (PPCS). The current project aims to characterize a sample of sports neuropsychology patients, examine clinical outcomes, and determine relevant factors. Sports neuropsychology evaluated 38 consecutively referred patients at a rural academic medical center. The sample was 50% female, mostly White (91.9%), and ranged from 7-22years of age (M = 16.45, SD = 2.92). Most had pre-existing conditions (medical/psychiatric; 78.9%), and 63% had at least one previous concussion. Months-from-injury varied (median = 4; range = 1-29). FSIQ was average (M = 107, SD = 15.45). We analyzed relationships between factors and outcomes using correlations (Spearman's rho or Pearson's r) and stepwise linear regression to determine prediction. Only nine patients' persistent complaints were due to concussion, while medical or psychiatric etiologies explained PPCS in the majority of the sample (76.3%). Outcomes were uncorrelated with gender, age, race, IQ, or months-since-injury. Pre-existing depression (rs(37) = -0.40, p = 0.01) and migraines (rs(37) = -0.35, p = 0.02) both showed significant moderate correlations with outcome. Stepwise regression indicated that only pre-existing depression (β= -0.360, p = 0.01) significantly predicted the non-concussion clinical outcome. In our sample, the etiology of PPCS was something other than concussion in over 76% of youth seen by sports neuropsychology. Pre-existing depression and migraines were significantly correlated with this outcome, and depression was a significant predictor. These results add to the literature on PPCS in children. Neuropsychologist involvement earlier in concussion care may help prevent PPCS by rapidly connecting patients to the proper interventions, thereby reducing families' economic burden and improving patients' quality of life.

Impact of area deprivation index on clinical outcomes of adults with acute myeloid leukemia at a rural academic medical center.

e18615 Background: Living in a disadvantaged neighborhood may lead to survival disparities amongst patients with acute myeloid leukemia (AML). The Area Deprivation Index (ADI) is a measure of socioeconomic disadvantage by decile used to find discrepancies in healthcare outcomes. Increasing ADI negatively impacts ovarian cancer survival, with each decile increase in state or national ADI corresponding with a 9-10% greater risk of death (Hufnagel D et al., Cancer Epidemiology 2021). Higher ADI was correlated with decreased rates of adjuvant therapy for localized pancreatic cancer (Mora et al., American Journal of Surgery 2021). There are no American studies on ADI and AML. This study aims to identify the impact of socioeconomic disadvantage on survival outcomes for patients with AML in a rural population. Methods: A retrospective review of 180 adults with AML treated at Dartmouth Hitchcock Medical Center (DHMC) between 1/1/2010 - 12/31/2020. Patients with APML, primary treatment outside of DHMC, and those who opted for comfort measures only at diagnosis were excluded. Demographic data, including cytogenetics, treatment type, response to treatment, and survival at one year were recorded. Addresses from the medical record were used to determine state-level ADI using the University of Wisconsin Neighborhood Atlas. Results: Eighty-nine patients were included (64% male; 93% White). Median age was 65 years. Fifty-one patients (57%) had high risk disease, 31 intermediate risk (35%), 5 favorable risk (6%), and unknown risk for 2 (2%). Sixty-two patients (70%) received intensive chemotherapy [7+3] while 27 (30%) received less intensive therapy [hypomethylating therapy]. Twenty-six patients (29%) underwent transplantation. ADI decile was not associated with survival (p = 0.62). Furthermore, when ADI was divided into three groups (deciles 1-3, 4-6, 7-10) there was no difference in survival (p = 0.345). There was no effect of travel distance to DHMC [median 81 minutes] on OS (p = 0.619). There was a significant difference in survival outcomes between the two treatment types (p = 0.001), with median 25.7 vs. 7.1 months in the intensive vs. less intensive groups. This survival advantage was seen on multivariate analysis (p = 0.03). Females had better OS compared to males (p = 0.02) and older age was a negative predictor of outcome (p = 0.007). In those who achieved remission with induction, transplant led to improved survival (p = 0.04). Conclusions: There was no significant difference in treatment outcomes based on ADI, potentially due to equitable quality of care delivered regardless of socioeconomic disparities. This may be due to strong nurse navigation, social work support, specialists from the primary site who provide care in the community, and access to transplantation. Future studies to delineate the impact of various interventions for those with high ADI may be beneficial in treatment planning.

Investigating potential drivers of increased central-line–associated bloodstream infections during the SARS-CoV-2 omicron-variant surge

Background: Central-line–associated bloodstream infection (CLABSI) rates increased nationally during COVID-19, the drivers of which are still being characterized in the literature. CLABSI rates doubled during the SARS-CoV-2 omicron-variant surge at our rural academic medical center. We sought to identify potential drivers of CLABSIs by comparing period- and patient-specific characteristics of this COVID-19 surge to a historical control period. Methods: We defined the study period as the time of highest COVID-19 burden at our hospital (July 2021–June 2022) and the control period as the previous 2 years (July 2019–June 2021). We compared NHSN CLABSI standardized infection ratios (SIRs), central-line standardized utilization ratios (SURs), completion of practice evaluation tools (PETs) for monitoring of central-line bundle compliance, and proportions of traveling nurses. We performed chart reviews to determine patient-specific characteristics of NHSN CLABSIs during these periods, including demographics, comorbidities, central-line characteristics and care, and microbiology. Results: The CLABSI SIR was significantly higher during the study period than the control period (0.89 vs 0.52; P = .03); the SUR was significantly higher during the study period (1.08 vs 1.02; P < .01); the PET completion per 100 central-line days was significantly lower during the study period (23.0 vs 31.5; P < .01); and the proportion of traveling nurses was significantly higher during the study period (0.20 vs 0.08; P < .01) (Fig. 1). Patients with NHSN CLABSIs during the study period were more likely to have a history of COVID-19 (27% vs 3%; P = .01) and were more likely to receive a higher level of care (60% vs 27%; P = .02). During the study period, more patients had multilumen catheters (87% vs 61%; P = .04). The type of catheter, catheter care (ie, dressing changes and chlorhexidine bathing), catheter duration before CLABSI, and associated microbiology were similar between the study and control periods (Table 1). Conclusions: During the SARS-CoV-2 omicron-variant surge, the increase in CLABSIs at our hospital was significantly associated with increased central-line utilization, decreased PET completion, and increased proportion of traveling nurses. Critical illness and multilumen catheters were significant patient-specific factors that differed between CLABSIs from the study and control periods. We did not observe differences in catheter type, duration, or catheter care. Our study highlights key modifiable risk factors for CLABSI reduction. These findings may be surrogates for other difficult-to-measure challenges related to the culture of safety during a global pandemic, such as staff education related to infection prevention and daily review of central-line necessity.Disclosures: None

Investigating potential drivers of increased central line...associated bloodstream infections during the coronavirus disease 2019 (COVID-19) Omicron surge

Central line...associated bloodstream infection rates increased during the Omicron surge at our rural academic medical center. To identify potential drivers of this increase, we investigated period- and patient-specific factors associated with the increase in central line...associated bloodstream infection. Increased central line utilization, decreased central line bundle compliance monitoring, increased proportion of traveling nurses, increased short-term venous catheter use in the internal jugular vein, increased multilumen catheter use, decreased port...associated infection, and increased patient acuity were significantly associated with the surge. Our results helped us target our local infection prevention efforts.

Association between in situ steroids and spine surgical site infections among instrumented procedures.

To estimate the association between in situ steroids and spine surgical-site infections (SSIs), assessing spinal instrumentation as an effect modifier and adjusting for confounders. Case-control study. Rural academic medical center. We identified 1,058 adults undergoing posterior fusion and laminectomy procedures as defined by the National Healthcare Safety Network without a pre-existing SSI between January 2020 and December 2021. We identified 26 SSI as cases and randomly selected 104 controls from the remaining patients without SSI. The primary exposure was the intraoperative administration of methylprednisolone in situ (ie, either in the wound bed or as an epidural injection). The primary outcome was a clinical diagnosis of SSI within 6 months of a patient's first spine surgery at our facility. We quantified the association between the exposure and outcome using logistic regression, using a product term to assess for effect modification by spinal instrumentation and the change-in-estimate approach to select significant confounders. Adjusting for Charlson comorbidity index and malignancy, in situ steroids were significantly associated with spine SSI relative to no in situ steroids for instrumented procedures (adjusted odds ratio [aOR], 9.93; 95% confidence interval [CI], 1.54-64.0), but they were not associated with spine SSIs among noninstrumented procedures (aOR, 0.86; 95% CI, 0.15-4.93). In situ steroids were significantly associated with spine SSI among instrumented procedures. The benefits of in situ steroids for pain management following spine surgery should be weighed against the risk of SSI, especially for instrumented procedures.

1084. Comparison of Pediatric SARS-CoV-2 Infections During Spring 2020 and Spring 2021

Abstract Background Data is lacking regarding the clinical manifestations of children with SARS-CoV-2 infection during Spring 2021 and how that clinical presentation compares to children who presented during the early months of the pandemic. We sought to compare the presentation and severity of illness among children with a positive PCR test result for SARS-CoV-2 who presented during the Spring 2020 to those who presented for testing during Spring 2021. Methods We identified all patients < 18 years old who had a positive nasopharyngeal polymerase chain reaction (PCR) result for SARS-CoV-2 from 4/1/2020-6/30/2020 and from 4/1/2021-6/30/2021 through a laboratory-based database at a rural academic tertiary care medical center. Data collected included demographics; underlying medical comorbidities; symptoms at the time of SARS-CoV-2 testing; results of SARS-CoV-2 testing and other tests performed at the same time; treatments administered; imaging studies performed; need for hospitalization; and, for those requiring hospitalization, hospital length of stay, and respiratory support. We excluded patients who were hospitalized for reasons other than COVID-19 infection in our hospitalization statistics. Results We identified 331 children with a positive SARS-CoV-2 PCR result who met our inclusion criteria. Among children presenting during the Spring 2021 time period, upper respiratory tract infection (URI) symptoms were much less common than those presenting in Spring 2020 (2% vs 19%, p< 0.001). Additionally, fever and cough were more common among children presenting in Spring 2021 (34% vs 22%, p=0.01) (Table 1). Hospitalization for COVID-19 care occurred in 4% of children overall: 3% of children during the Spring 2020 era and 5% of children during Spring 2021, P=0.587 (Table 2). Self-reported symptoms among children with a positive SARS-CoV-2 polymerase chain reaction test, Spring 2020 vs. Spring 2021. Association of year, patient, and clinical characteristics with hospital admission for care of COVID-19. Conclusion Our study offers insights into the differences in the clinical presentation and outcomes of pediatric patients infected with SARS-CoV-2 during Spring 2020 and Spring 2021, respectively. We found that children infected during Spring 2021 had fever and cough more often and rhinorrhea and nasal congestion less often than children infected during the Spring 2020. Hospitalization was uncommon and was similar in both time periods. Most children requiring hospital admission had an underlying medical comorbidity. Disclosures Jessica E. Ericson, MD, MPH, Abbvie: Advisor/Consultant.

The Use of Telemedicine in Older Patients with Gastrointestinal Diseases.

The COVID-19 pandemic helped us understand that telemedicine provides an alternative way to manage patients remotely, with an added benefit of saving time and travel costs. However, barriers may exist in an older population of patients such as inadequate technology availability and knowledge, and lack of internet connectivity. This systematic review and analysis of data at an academic medical center examines the current literature and investigates the efficacy of telemedicine for older adults requiring gastrointestinal care. In the systematic review, we included 22 manuscripts from an initial 120 that were identified based on inclusion and exclusion criteria. In this existing literature, telemedicine visits were equivalent or better than in-person visits based on many metrics, including patient satisfaction, time and money saved, and standard patient outcomes. At a rural academic medical center, there was a steady decrease in the failure rate of telemedicine visits from April 2020 to May 2022 in all age groups, including the 65 + age group, from 17% in April 2020 to 3% in May 2022. Telemedicine offers a comparable alternative to in-person visits that is convenient, low-cost, and does not compromise quality of care for older patients obtaining GI care. The COVID-19 pandemic has accelerated progress and uptake of telemedicine, and the successful use by all ages including older patients opens the broader conversation about the continued use of telemedicine for care in various areas of medicine.

Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience

IntroductionAs the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. Materials and methodsWe performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. ResultsOver the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). ConclusionsAt our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.

Creating a single point of referral and standardized care pathway for patients with melanoma to improve access to care.

127 Background: Access to care is often a challenge for healthcare organizations – especially as pressures on time increase and workforce availability decreases – and is often complex to solve. In this quality improvement (QI) initiative, a team from a rural academic medical center deployed the Lean Six Sigma approach to develop a two-pronged method that reduced the median time to first visit for new melanoma patients. Methods: The project team deployed the Define, Measure, Analyze, Improve, and Control (DMAIC) processes to address access for melanoma patients after the healthcare organization set a goal that 55% of new specialty care patients be seen within 10 days. Define: Concern was raised by the melanoma clinical care team that the lack of a well-defined and standardized referral workflow for melanoma patients could delay patient care. Measure: Data from the electronic medical record (EMR) indicated that only 31% of incoming referrals were seen within 10 days, and the median number of days to first visit was 15, or 50% over the organizational standard. Analyze: Analysis found considerable waste in the existing referral system. First, untrained staff made referral and routing decisions, meaning patients could potentially be seen by inappropriate departments based on the assessment of those not specialized in melanoma care and treatment. This led to the second area of waste: rework. Every referral had to be reviewed by multiple staff in several departments to ensure the referral made was appropriate based on the characteristics of disease. This was a very labor-intensive processes that allowed too many patients to “slip through the cracks” of the system. Improve: Two interventions were deployed to address the identified waste. First, a centralized referral point for all melanomas monitored by the Program Coordinator. Second, a referral questionnaire developed by an interdisciplinary team to guide where routine cases should be referred. Early results show that the interventions had marked impact on the time to first appointment for all referrals, whether originating inside of the organization or out. After the intervention 54% of newly referred patients were seen within 10 days. Results: Control: A standard report was built to support the project team in monthly monitoring of the KPI, days from referral to patient seen. The report is monitored by a dedicated Program Coordinator who can escalate any issues during regular interdisciplinary care team meetings. Conclusions: Improvements in access can be achieved by adopting standard work that is targeted to reduce waste in the referral workflow. The model developed by this QI initiative is easily replicable and may be especially useful for interdisciplinary teams who provide care to complex diseases.[Table: see text]

Pharmacist impact on medication reconciliation of behavioral health patients boarding in the emergency department.

IntroductionThe high demand for psychiatric services has exceeded the capacity of available resources for behavioral health patients, forcing these patients to seek mental health care in the emergency department. Average lengths of stay for behavioral health boarders commonly extend over multiple days and prior-to-admission (PTA) medication administration may be delayed, which could lead to further deterioration and longer inpatient lengths of stay. Addition of a pharmacist-led medication reconciliation process and pharmacist integration into daily emergency department psychiatry rounds may decrease time to initiation of PTA medications and improve outcomes in this population.MethodsThis is a retrospective review of adult patients who required a psychiatric emergency evaluation in a large rural academic medical center emergency department. Objectives were to determine the number and type of medication discrepancies found with pharmacist intervention, and to compare time to initiation of PTA medications with a pharmacist versus a nonpharmacist completing medication reconciliation.ResultsA total of 139 patients were identified, 85 patients in August 2019 (no pharmacist [NP]) and 54 in October 2019 (pharmacist involvement [PI]). Among 484 medications reviewed in the PI group, 298 discrepancies were identified. The most common types of discrepancies were no longer taking (n = 99, 33%) and omission (n = 94, 32%). Time to administration of PTA medications was similar between NP and PI groups (median hours, interquartile range: NP: 10.8, 7.8-16.57; PI: 11.49, 6.16-16; P = .179).DiscussionThis study depicted one of the many values of pharmacists in the hospital setting, especially in the behavioral health patient population where continuation of accurate PTA medications may prevent further clinical deterioration.

What is in the palliative care ‘syringe’? A systems perspective

The diffusion of palliative care has been rapid, yet uncertainty remains regarding palliative care's “active ingredients.” The National Consensus Project Guidelines for Quality Palliative Care identified eight domains of palliative care. Despite these identified domains, when pressed to describe the specific maneuvers used in clinical encounters, palliative care providers acknowledge that “it's complex.” The field of systems has been used to explain complexity across many different types of systems. Specifically, engineering systems develop a representation of a system that helps manage complexity to help humans better understand the system. Our goal was to develop a system model of what palliative care providers do such that the elements of the model can be described concretely and sequentially, aggregated to describe the high-level domains currently described by palliative care, and connected to the complexity described by providers and the literature. Our study design combined methodological elements from both qualitative research and systems engineering modeling. The model drew on participant observation and debriefing semi-structured interviews with interdisciplinary palliative care team members by a systems engineer. The setting was an interdisciplinary palliative care service in a US rural academic medical center. In the developed system model, we identified 59 functions provided to patients, families, non-palliative care provider(s), and palliative care provider(s). The high-level functions related to measurement, decision-making, and treatment address up to 8 states of an individual, including an overall holistic state, physical state, psychological state, spiritual state, cultural state, personal environment state, and clinical environment state. In contrast to previously described expert consensus domain-based descriptions of palliative care, this model more directly connects palliative care provider functions to emergent behaviors that may explain system-level mechanisms of action for palliative care. Thus, a systems modeling approach provides insights into the challenges surrounding the recurring question of what is in the palliative care “syringe.”

Accept Yourself! A Pilot Randomized Controlled Trial of a Self-Acceptance-Based Treatment for Large-Bodied Women With Depression

A pilot parallel randomized controlled trial compared a self-acceptance, non-weight-loss intervention, Accept Yourself! (AY), to a weight loss program, Weight Watchers (WW), in order to provide preliminary safety, feasibility, and efficacy data in preparation for a definitive RCT of AY as an intervention to enhance the mental and physical health of larger-bodied women with Major Depressive Disorder (MDD). Adult women with MDD and a Body Mass Index ≥30 were eligible. Nineteen women were randomized by random number table into AY (n = 9) or WW (n = 10). Intake, pretreatment, posttreatment, 3-, 6-, 9-, and 12-month follow-up assessments occurred at a rural academic medical center. Primary outcomes included depression severity and cardiovascular fitness. Chi-square and t-tests assessed attrition and participant preferences for treatment; other analyses used intention-to-treat, linear mixed-effects models for repeated measures, including all participants’ available data. Both groups improved in self-reported, F(5, 43.81) = 7.45, p < .001, partial η2 = .38, and blinded-clinician-rated depression, F(6, 62.03) = 10.41, p < .001, partial η2 = .5. AY was superior to WW in self-reported depression, F(5, 43.81) = 2.72, p = .03, partial η2 = .11. Neither group improved in fitness. Eating disorder symptoms and weight gain worsened in WW. AY appeared safe, feasible, and offered initial evidence of efficacy for depression; it should be investigated in a definitive RCT, with modifications to increase potency. WW may not be suitable as a comparator intervention for AY because of risk to participants.

Designing a Health Care Delivery Innovation Lab: Reflections From The First Year.

This article shares initial experiences designing and operating a new health care delivery innovation program at a rural academic medical center. The program was designed with the belief that dedicated team member time, senior leadership engagement, deliberate project/team selection, and robust, tailored project support would enable rapid and transformative health care redesign. Three teams were supported in the initial 1-year funding cycle; all 3 teams successfully designed, implemented, and tested new care models for different serious illness populations. Results demonstrated improved satisfaction, decreased length of stay, and a positive return on investment. Critical evaluation of current structures and processes will help identify refined strategies to support diverse teams that will challenge the norms of health care delivery and explore novel partnerships, approaches, and settings for care delivery. This article helps advance the conversation on how to think strategically and critically about current and future health care innovation efforts.

Prenatal telemedicine during COVID-19: patterns of use and barriers to access.

ObjectiveTo evaluate patient experience with a prenatal telemedicine visit and identify barriers to accessing telemedicine among rural pregnant people in northern New England during the beginning of the COVID-19 pandemic.Materials and MethodsWe conducted a postvisit electronic survey of pregnant people who successfully participated in a prenatal telemedicine visit at a rural academic medical center in Northern New England. Nineteen questions were included in 5 domains: (1) engagement with prenatal care; (2) barriers to telemedicine and in person healthcare; (3) experience of prenatal care; (4) remote pregnancy surveillance tools; and (5) sources of COVID-19 information.ResultsResponses were obtained from 164 pregnant people. Forty percent of participants had participated in an audio-only telemedicine visit, and 60% in a video telemedicine visit. The visit was easy or somewhat easy for 79% of respondents and somewhat difficult or difficult for 6.8%. The most common barrier to accessing telemedicine was poor internet or phone connectivity, followed by childcare responsibilities, lack of equipment, and lack of privacy. Participants also engaged in additional remote prenatal care including phone calls with registered nurses (7.6%), communication with the obstetrics team through a secure health messaging portal (21.1%), and home health monitoring (76.3%).Discussion and ConclusionsIn this survey, evaluating the experience of pregnant people participating in a prenatal telemedicine visit during the COVID-19 pandemic, respondents had a positive experience with telemedicine overall, but also identified significant barriers to participation including issues with connectivity and lack of equipment for the visit. Most participants used telemedicine in combination with other tools for remote self-care.

P008 A Novel Smartphone Application to Reduce Infusion Suite Wait Times.

Patients with inflammatory bowel disease (IBD) are often treated with biologic medications that require visits to an infusion suite. Due to the high cost of biologics, they are not mixed and released from the pharmacy until patient arrival. This typically leads to long wait times after patient check in. An investigator-developed novel smartphone application (app) titled Almost There was created to reduce wait times through the use of geofences to notify the infusion suite when patients are nearing their destination (the hospital). Our aim was to perform a pilot study to assess the feasibility of Almost There for patients with IBD coming for infusions at a rural academic medical center. Adult patients with Crohn's disease (CD) or ulcerative colitis (UC) currently receiving intravenous biologic therapy were recruited for this pilot study. Patients received instructions on how to download the app onto their smartphone. Patients activated the application prior to leaving their homes and answered standard screening questions to assess for active infections. Using geofences, the app automatically notified the infusion suite when the patient was within 10 miles of the hospital. The infusion suite alerted the pharmacy who immediately proceeded with medication preparation. Patients completed surveys upon arrival to the infusion suite collecting basic demographics and disease information, perceived wait times for that visit and previous visits prior to using the app. The infusion suite staff recorded actual wait times from check in to medication administration. The app was trialed successfully for 12 total visits among 9 patients (5 CD, 4 UC). 78% of app users were 25-44 years old and 22% were 45 years and older. 56% of patients were receiving infliximab and 44% were receiving vedolizumab. 11 patients were recruited and 9 patients out of 11 were able to successfully use the app. Reasons for app failure included one user who forgot their phone at home, one with loss of cell service, and one app malfunction. The median actual wait time from when patients arrived at the infusion suite to the start of the infusion was 38-40 minutes. In 67% of visits, there was decreased perceived wait time for patients using the app compared to their prior visits. When using the app, perceived wait times were shorter than actual wait times in 75% percent of patients. In this pilot feasibility study, the Almost There app led to decreased perceived wait times for IBD patients coming for biologic infusions. The application was not effective for 18% of patients for a variety of reasons. If this or a similar app was improved to allow for more consistent usability it should be studied compared to a control group to evaluate if it leads to decreased wait times for any medical infusion.

Impacts on Clinical and Surgical Volume after Development of a Gynecology Gender Health Program at a Rural Tertiary Care Center

<h3>Study Objective</h3> To evaluate changes in clinical and surgical volume pre- and post- establishment of a dedicated Gynecology Gender Health Program at a rural academic medical center. <h3>Design</h3> We conducted a retrospective chart review of transgender and gender diverse individuals who sought care and/or underwent gender affirming gynecologic surgery at our institution. <h3>Setting</h3> Rural academic medical center. <h3>Patients or Participants</h3> We included patients who identify as transgender or gender diverse presenting for gender care (including surgery) at the generalist outpatient gynecology clinic from 2017-2018 compared to the dedicated Gynecology Gender Health Program from 2019-2020. <h3>Interventions</h3> A dedicated Gynecology Gender Health Program was started in 2019 providing evidence-based multidisciplinary gender care including minimally invasive gender affirming hysterectomies and other surgeries. <h3>Measurements and Main Results</h3> In this retrospective chart review, we used descriptive statistics to assess total number of patients served (new patients and total encounters) and surgical volume for gender affirming hysterectomies in the two years before and after the creation of a dedicated program. Total patient numbers increased by 3.86 times (from 15 to 58 patients) and new patients per year increased five-fold (from 9 to 46 patients). Hysterectomies performed increased four-fold. Of the 20 surgeries performed over the last two years, 18 were laparoscopic total hysterectomies, while two were vaginal approach. Eighty percent of patients underwent concomitant salpingo-oophorectomy, while two patients underwent concomitant laparoscopic upper vaginectomy. <h3>Conclusion</h3> The development of a Gynecology Gender Health Program has led to an increase in clinical and surgical volume over the last two years, improving access to care for this often medically underserved, rural population. Our data demonstrates demand for specialized care even in rural communities once these programs are established. We anticipate continued growth at our institution, with our primary means of new patient recruitment through word of mouth as well as internet searches.