State University Wexner Medical Center Research Articles

0645 The Association of Hypoglossal Nerve Stimulator Adherence and Insomnia

Abstract Introduction The gold standard for treatment of Obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP). However, CPAP adherence is less than 50%. An alternative treatment is the hypoglossal nerve stimulator (HNS) which displaces the tongue anteriorly to treat upper airway obstruction. Difficulties tolerating HNS are related to stimulation discomfort. In this study, we investigated insomnia as a barrier to adherence. Methods Patients implanted and activated with HNS at The Ohio State University Wexner Medical Center between 2015 and 2019 were eligible. Patient usage data from the previous six months was obtained and subjects were asked to complete an Insomnia Severity Index (ISI). Participants were divided into adherent (defined as use ≥28 hours/week) and non-adherent (use <28 hours/week). Results 32 subjects were enrolled, 22 in the adherent group and 10 in the non-adherent group. There was a significant decrease in mean treatment AHI in both groups: 36.25 to 11.14 in the adherent group and 36.30 to 15.69 in the non-adherent group (p<0.0001). The mean ISI score in the adherent group was 6.84 which is consistent with no clinically significant insomnia and 8.67 in the non-adherent group consistent with subthreshold insomnia. However, there was not a statistically significant difference between the two groups (p=0.441). There was a statistically significant higher score for the question “Do you worry about your sleep problems?” in the non-adherent group (1.78, SD1.39 vs 0.74. SD 0.81) (p =0.018). Conclusion This study suggests that patients who have difficulty with sleep may have more difficulty with HNS adherence than those who do not. In particular the question stating “Do you worry about your sleep problems” had a statistically higher score in the non-adherent group. Prospective studies are needed to further explore a possible relationship between insomnia and HNS adherence. Support N/A

Vestibular Oriented Research Meeting; Originally scheduled for May 1-3, 2020 in Toronto, Ontario, Canada; Hosted by York University and The Ohio State University Wexner Medical Center.

Vestibular Oriented Research Meeting; Originally scheduled for May 1-3, 2020 in Toronto, Ontario, Canada; Hosted by York University and The Ohio State University Wexner Medical Center.

Lower Extremity Discomfort in Registered Nurses: Links to Nursing Unit Layout

This study reports objective measurements of lower extremity activity (amount of walking, standing, sitting) in nurses working in medical/surgical (M/S) and intensive care units (ICU), and explores nurses’ perceptions of nursing unit design impact on workload, lower extremity activity, and musculoskeletal discomfort. Nursing units are expanding in size, leading to nurses spending more time on their feet. Though limited in number, studies consistently report elevated prevalence of lower extremity discomfort/injury in nurses. This was a mixed method approach using physical activity measurement and semi-structured interviews of M/S and ICU nurses. Lower extremity discomfort was prevalent in the study participants. Time on feet and step counts differed between nursing units with different layouts. Average hours on feet ranged from 7.3 to 9.5 across units over 12-hour shifts. Nurses’ comments explained ways in which walking and standing activities were influenced by unit layout design and culture. Nurse leaders must advocate for unit designs that maximize patient safety, promote a culture of team spirit, and provide a physically safe working environment for staff. This study reports objective measurements of lower extremity activity (amount of walking, standing, sitting) in nurses working in medical/surgical (M/S) and intensive care units (ICU), and explores nurses’ perceptions of nursing unit design impact on workload, lower extremity activity, and musculoskeletal discomfort. Nursing units are expanding in size, leading to nurses spending more time on their feet. Though limited in number, studies consistently report elevated prevalence of lower extremity discomfort/injury in nurses. This was a mixed method approach using physical activity measurement and semi-structured interviews of M/S and ICU nurses. Lower extremity discomfort was prevalent in the study participants. Time on feet and step counts differed between nursing units with different layouts. Average hours on feet ranged from 7.3 to 9.5 across units over 12-hour shifts. Nurses’ comments explained ways in which walking and standing activities were influenced by unit layout design and culture. Nurse leaders must advocate for unit designs that maximize patient safety, promote a culture of team spirit, and provide a physically safe working environment for staff. Jing Li, PhD is a former graduate research associate at the College of Engineering, The Ohio State University, in Columbus, Ohio. Carolyn Sommerich, PhD, CPE, is associate professor at the College of Engineering and School of Health and Rehabilitation Sciences, The Ohio State University. Esther Chipps PhD, RN, NEA-BC, is clinical nurse scientist, associate professor of clinical nursing, at The Ohio State University Wexner Medical Center and The Ohio State University College of Nursing. She can be reached at [email protected]

Will Complement Inhibition Be the New Target in Treating COVID-19-Related Systemic Thrombosis?

Will Complement Inhibition Be the New Target in Treating COVID-19-Related Systemic Thrombosis?

Recipients of Public Insurance Have Increased Mortality Post-LVAD

LVADs have revolutionized the care of end-stage heart failure patients. Utilizing block-group census data to characterize neighborhood-level socioeconomic status(nSES), we set out to examine the effect of nSES & public versus private insurance status with respect to overall mortality and readmission. We performed a retrospective review of LVAD recipients bet. Jun 2006 & Dec 2016 at the Ohio State University Wexner Medical Center (n=239). Primary outcomes were time to death and time to readmission. Patients' demographics are shown in Table 1. Patients on public insurance displayed a higher hazard of death post-LVAD compared to private insureds (Fig. 1; log-rank p=0.0004). Medicaid, Medicare, and Medicaid-Medicare dual-enrollment were significant independent predictors of death, with an associated ≥3 fold hazard of death. TR of varying severity was also a significant independent predictor of mortality (Table 2). Median household income (MHI) was not associated with any primary outcomes. LVAD recipients on public insurance were at higher mortality risk compared to private insureds. Block-group level MHI failed to predict mortality and 1 year readmission for these patients. More work is needed to properly contextualize the SES impact on LVAD outcomes.

Mentor of the Month Series: How to Review a Manuscript from an Editor’s Perspective?

The Resident and Fellow Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) is committed to the education of surgical trainees and has many initiatives to connect the candidate members with the leadership of the society. This month, the Mentor of the Month series features Dr. Timothy Pawlik MD, MPH, MTS, PhD. Dr. Pawlik received his medical degree from Tufts University School of Medicine and surgical training at the University of Michigan. He also spent 2 years at the Massachusetts General Hospital as a surgical oncology research fellow and went for an advanced training in surgical oncology at The University of Texas MD Anderson Cancer Center in Houston. Dr. Pawlik is currently the Chair of Surgery, Urban Meyer III and Shelley Meyer Chair for Cancer Research, and the Surgeon in Chief at The Ohio State University Wexner Medical Center. He is discussing his path to becoming co-editor in Chief of the Journal of Gastrointestinal Surgery, how to get involved as a reviewer for the journal, and how to critically review a manuscript.

The Effects of Patient Positioning on the Outcome During Posterior Cranial Fossa and Pineal Region Surgery.

Background: Surgery on posterior cranial fossa (PCF) and pineal region (PR) carries the risks of intraoperative trauma to the brainstem structures, blood loss, venous air embolism (VAE), cardiovascular instability, and other complications. Success in surgery, among other factors, depends on selecting the optimal patient position. Our objective was to find associations between patient positioning, incidence of intraoperative complications, neurological recovery, and the extent of surgery.Methods: This observational study was conducted in two medical centers: The Ohio State University Wexner Medical Center (USA) and The Burdenko Neurosurgical Institute (Russian Federation). Patients were distributed in two groups based on the surgical position: sitting position (SP) or horizontal position (HP). The inclusion criteria were adult patients with space-occupying or vascular lesions requiring an open PCF or PR surgery. Perioperative variables were recorded and summarized using descriptive statistics. The post-treatment survival, functional outcome, and patient satisfaction were assessed at 3 months.Results: A total of 109 patients were included in the study: 53 in SP and 56 in HP. A higher proportion of patients in the HP patients had >300 mL intraoperative blood loss compared to the SP group (32 vs. 13%; p = 0.0250). Intraoperative VAE was diagnosed in 40% of SP patients vs. 0% in the HP group (p < 0.0001). However, trans-esophageal echocardiographic (TEE) monitoring was more common in the SP group. Intraoperative hypotension was documented in 28% of SP patients compared to 9% in HP group (p = 0.0126). A higher proportion of SP patients experienced a new neurological symptom compared to the HP group (49 vs. 29%; p = 0.0281). The extent of tumor resection, postoperative 3-months survival, functional outcome, and patient satisfaction were not different in the groups.Conclusions: The SP was associated with, less intraoperative bleeding, increased intraoperative hypotension, VAE, and postoperative neurological deficit. More HP patients experienced macroglossia and increased blood loss. At 3 months, there was no difference of parameters between the two groups.Clinical Trial Registration: ClinicalTrials.gov: registration number NCT03364283.

Spotlight in Plastic Surgery: April 2020

Spotlight in Plastic Surgery: April 2020

Reply re: “Loss of Stimulated Tear Secretion After Orbital Reconstruction”

Dr. Cho is a consultant for Horizon Therapeutics. Dr. Madhan has no financial or conflicts of interest to disclose. Correspondence: Raymond I. Cho, M.D., F.A.C.S., Department of Ophthalmology and Visual Sciences, The Ohio State University Wexner Medical Center and The Ohio State University Comprehensive Cancer Center, James Cancer Hospital and Solove Research Institute, Columbus, OH ([email protected])

The use of longitudinal hemoglobin A1c values to predict adverse obstetric and neonatal outcomes in pregnancies complicated by pregestational diabetes

Although an elevated early pregnancy hemoglobin A1c has been associated with both spontaneous abortion and congenital anomalies, it is unclear whether A1c assessment is of value beyond the first trimester in pregnancies complicated by pregestational diabetes. We sought to investigate the prognostic ability of longitudinal A1c assessment to predict obstetric and neonatal adverse outcomes based on degree of glycemic control in early and late pregnancy. This was a retrospective cohort study of all pregnancies complicated by pregestational diabetes from January 2012 to December 2016 at The Ohio State University Wexner Medical Center with both an early A1c (<20 weeks' gestation) and late A1c (>26 weeks' gestation) available for analysis. Patients were categorized by good (early and late A1c <6.5%), improved (early A1c >6.5% and late A1c <6.5%) and poor (late A1c >6.5%) glycemic control. A multivariate regression model was used to calculate adjusted odds ratios (aOR) for each identified obstetric and neonatal outcome, controlling for maternal age, body mass index, race/ethnicity, type of diabetes, and gestational age at delivery compared to good control as the referent group. A total of 341 patients met inclusion criteria during the study period. The median A1c values improved from early to late gestation in the good (5.7% [interquartile range [IQR], 5.4-6.1%] versus 5.4%; [IQR 5.2-5.7%]), improved (7.5% [IQR, 6.7-8.5] versus 5.9% [IQR, 5.6-6.1%]) and poor (8.3% [IQR, 7.1-9.6%] versus 7.3% [IQR, 6.8-7.9%]) glycemic control groups. There were no statistically significant differences in the rate of adverse outcomes between the goodand improved groups except for an increased rate of neonatal intensive care unit admissions in the improved group (aOR, 3.7; confidence interval [CI], 1.9-7.3). In contrast, the poor control group hadanincreased rate of shoulder dystocia (aOR, 6.8; CI, 1.4-34.0), preterm delivery (aOR, 3.9; CI, 2.1-7.3), neonatal intensive care unit admission (aOR, 2.8; CI, 1.4-5.3), respiratory distress syndrome (aOR, 3.0; CI, 1.1-8.0), hypoglycemia (aOR, 3.2; CI, 1.5-6.9), large for gestational age weight at birth (aOR, 2.7; CI, 1.5-4.9), neonatal length of stay >4 days (aOR, 3.1; CI, 1.6-6.0) and preeclampsia (aOR, 2.4; CI, 1.2-4.6). There were no differences in rates of cesarean delivery, umbilical artery pH <7.1, or Apgar score <7 at 5 minutes after regression analysis. Antenatal hemoglobin A1c values are useful for objective risk stratification of patients with pregestational diabetes. Strict glycemic control throughout pregnancy with a late pregnancy A1c target of <6.5% leads to reduced rates of obstetric and neonatal adverse outcomes independent of early pregnancy glucose control.

A Roadmap for Noninvasive Vascular Laboratory Education

Since 2014, the Registered Physician in Vascular Interpretation (RPVI) designation has been required for a vascular surgery board certification candidate to register for the vascular surgery certifying exam. Although the importance of the noninvasive vascular laboratory (NIVL) is recognized, vascular laboratory education within vascular surgery fellowship programs is heterogeneous and much less regulated compared with clinical education. Evidence suggests that many vascular surgery trainees may not have received ideal training to obtain RPVI certification or direct an NIVL. The NIVL curriculum at The Ohio State University Wexner Medical Center has been used since 2005 and combines didactics, supervised reading, videos, hands-on experience with vascular sonographers, and one on one time with the vascular laboratory medical director. This curriculum is outlined in this article and can be used as a guide for creating NIVL curricula for vascular surgery and other training programs.

The Effects of Utilization of Individualized Pain Plans in Treatment of Vaso-Occlusive Crises in the Emergency Department

Background Sickle cell disease (SCD) is an inherited blood disorder that affects millions of people worldwide, with approximately 100,000 Americans affected (Center for Disease Control, 2017). In the U.S., SCD results in over 200,000 emergency department (ED) visits annually, with pain as the most common complaint (Lanzkron S, et al 2010). At The Ohio State University (OSU) Wexner Medical Center, there is a comprehensive care center for patients with SCD. At their initial patient visit, the patient and their hematologist determine a customized pain plan to be enacted when they present to the ED in acute vaso-occlusive crisis (VOC). In January 2015, these plans were implemented to allow for more rapid treatment of pain crisis in the ED at OSU. Methods A multidisciplinary group was formed in order to accelerate the treatment of SCD patients who presented with VOC. The group's goal was to reduce the time to first opioid by utilizing individualized pain plans for each patient. This would reduce the amount of time deciding the best course of treatment. With reduction in time to first opioid, outcomes including overall length of ED stay, disposition, and length of inpatient admission were identified. Data regarding these endpoints were collected from 01/01/14 to 12/31/15. Generalized linear models were fit to compare the clinical outcomes pre and post implementation of the new protocol. Comorbidities were associated with outcomes using the same modeling technique, where univariable models were built and multi-test adjustment was performed through false-discovery rate (FDR). Results During the 2-year study period, 214 patients with SCD accumulated 2429 ED visits in total. The model estimated a 48% decrease in time to first opioid after implementation of the individualized pain plan protocol (p&lt;0.0001). There was also a decrease in the length of ED stay by 22% (p&lt;0.0001). No significant difference between the type of disposition (discharged to home, inpatient admission, eloping from ED, or leaving without being seen) was found. No difference was found between the average number of visits to the ED and the length of inpatient admission pre and post protocol. The data did reveal a 13% increase in length of ED stay in patients with comorbid kidney disease (FDR p=0.02) and a 12% increase in length of stay in the ED for patients with history of venous thromboembolism (VTE) (FDR p=0.04). Patients with history of VTE were also found to have a 39% longer hospital admission than those without (FDR p=0.05). The odds of getting discharged from the ED were 55% lower in patients with essential hypertension (FDR p=0.02) and they were 2 times more likely than patients without hypertension to be admitted to the hospital (FDR p=0.05). Conclusion Utilization of individualized pain plans for patients with sickle cell disease presenting with VOC results in a significant reduction in the amount of time to first opioid administration. Implementation of the protocol also led to a reduction in length of stay in the emergency department, however the probability of admission did not change. In examining the effect of comorbidities on clinical outcomes, patients with history of kidney disease or VTE had increased length of ED stay and those with history of VTE also had longer hospital admissions. Patients with comorbid essential hypertension were also twice as likely to be admitted to the hospital though length of inpatient admission did not change. It is possible that patients with kidney disease have worse disease as evidenced by end-organ damage due to repeated vascular insult, ischemia, and inflammation. Similarly, those with history of VTE may have higher viscosity, endothelial adhesion, and dysfunction leading to clots. Patients with comorbid essential hypertension can also be thought to have recurrent vascular damage leading to systemic hypertension. From this information, it can be concluded that utilizing individualized pain plans in SCD patients with VOC will lead to decreased time to analgesia and perhaps decrease use of healthcare resources. Disclosures Desai: Novartis: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; University of Pittsburgh: Research Funding; Ironwood: Other: Adjudication Board; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Potomac: Speakers Bureau.

1086. Antimicrobial Stewardship: From Bedside to Man’s Best Friend

BackgroundAntimicrobial stewardship plays an integral role in ensuring appropriate antimicrobial use in the inpatient hospital setting and is now required by The Joint Commission. Although it is well established that antimicrobial misuse and overuse has societal and ecological implications, the same regulations do not yet apply to our veterinary and agricultural counterparts.MethodsAt The Ohio State University Wexner Medical Center (OSUWMC), the Antimicrobial Stewardship Program (ASP) was created in 2007. A partnership was formed with The Ohio State University Veterinary Medical Center (OSUVMC) in 2017 and was leveraged through a pre-existing campus-wide One Health initiative. The goal was to develop a comprehensive Veterinary Hospital ASP. “The Core Elements of Hospital Antibiotic Stewardship Programs” (Centers for Disease Control and Prevention) and “The Core Principles of Antibiotic Stewardship in Veterinary Medicine” (American Veterinary Medical Association) were also referenced for guidance.ResultsSpecific initiatives within the OSUVMC ASP were modeled after similar interventions in the OSUWMC including development of antibiotic use guidelines by animal type for commonly encountered infections, antimicrobial utilization tracking, antibiogram creation, and both active and passive surveillance of targeted resistant pathogens. A mobile-friendly website was created to allow providers easy access to these ASP tools. Overall antimicrobial prescriptions decreased 22.4% following the first year of program implementation. Planning is currently underway for an ASP outreach program to local veterinary practices to increase awareness of ASP and improve antimicrobial prescribing. A parallel outreach program with rural Ohio hospitals is underway at OSUWMC.ConclusionA comprehensive veterinary hospital ASP was successfully implemented in collaboration with OSUWMC counterparts using successful human interventions applied in the animal setting. Optimizing antimicrobial use and resistance at both sites will likely prevent resistance transmission between these geographically proximate hospitals. Sharing the details of our approach may benefit other institutions looking to expand their stewardship reach.Disclosures All authors: No reported disclosures.

177. Clinical Outcomes of Daptomycin vs. Anti-Staphylococcal β-Lactams in Definitive Treatment of Methicillin-Susceptible Staphylococcus aureus (MSSA) Bloodstream Infections

BackgroundThe preferred management of patients with MSSA bacteremia includes definitive therapy with intravenous anti-staphylococcal β-lactam antibiotics. In β-lactam allergic or intolerant patients, daptomycin has been targeted as a viable alternative. The objective of this study was to assess clinical outcomes of daptomycin compared with nafcillin or cefazolin for the treatment of MSSA bacteremia.MethodsThis was a retrospective cohort study of patients hospitalized from November 1, 2011 to October 31, 2018 at The Ohio State University Wexner Medical Center with MSSA bacteremia. Patients treated with nafcillin, cefazolin or daptomycin were included with 1:1:1 random selection. The primary outcome was a composite of clinical failure, defined as a change in therapy due to persistent/worsening signs and symptoms, bacteremia recurrence or persistence, or inpatient infection-related mortality. Secondary endpoints included 30-day infection-related mortality, duration of bacteremia, 30-day all-cause mortality and adverse events (AEs) necessitating a change in therapy.ResultsAmong patients with MSSA bacteremia, 162 received at least one dose of daptomycin. Of those, 29 received at least 14 days of daptomycin and/or received daptomycin as definitive therapy and thus were included in the analysis. There was no difference in the primary outcome of composite clinical failure comparing daptomycin vs. nafcillin/cefazolin (P = 0.71). In addition, no difference was observed in 30-day infection-related mortality (P = 0.51), duration of MSSA bacteremia (P = 0.9), or 30-day all-cause mortality (P = 0.64). A higher number of AEs necessitating change in therapy were seen in the daptomycin group (P = 0.0002), reflecting initial β-lactam intolerance.ConclusionNo difference in clinical failure was identified in patients treated with daptomycin vs. nafcillin/cefazolin suggesting that daptomycin may serve as a non-inferior alternative for treatment of MSSA bacteremia. A higher number of AEs occurred in the daptomycin group indicating β-lactam intolerance as a primary indication for daptomycin therapy. Given the small sample size, subsequent studies are needed to further evaluate the use of daptomycin in the treatment of MSSA bacteremia.Disclosures All authors: No reported disclosures.

2265. Clinical Outcomes with Single vs. Combination Antibiotic Therapy in the Treatment of Burkholderia cepacia complex Bacteremia and Pneumonia

Background Burkholderia cepacia complex (Burkholderia cenocepacia and Burkholderia multivorans) (BCC) are uncommon, yet serious often drug-resistant pathogens of immunocompromised patients, especially in lung transplants; pre-operative infection/colonization is seen as a contraindication to transplant. Optimal treatment for these difficult infections is not known. We examined impact of single vs. combination therapy on patient outcomes.MethodsAll cases of BCC positive pulmonary or blood cultures at The Ohio State University Wexner Medical Center between January 1, 2012 and June 30, 2018 were analyzed. No cystic fibrosis patients were included. All combinations thereof were evaluated. The primary outcomes were 30 all-cause mortality and 30-day infection-related mortality. Secondary outcomes included sterilization of cultures, isolation of a non-susceptible isolate within 30 days of therapy, hospital and intensive care unit (ICU) length of stay, and adverse drug effects (ADE) of therapy including: hyperkalemia, acute kidney injury (AKI), transaminitis, and QTc prolongation.ResultsThere were 90 unique patients who grew BCC (22 patients with 92 positive blood cultures; 54 patients with 87 positive pulmonary cultures). Four patients had mixed pulmonary and blood cultures. Ten patients died prior to having treatment for their cultures and were not evaluated. Overall, there were 85 evaluable infection events. Overall 30-day all-cause mortality was 20/85 (23.5%); mortality in blood culture monotherapy 3/14 (21.4%); combination therapy 3/18 (16.7%) (P = 1.00). Mortality in pulmonary culture monotherapy was 6/32 (18.75%); combination 10/30 (33.3%) (P = 0.19). Among blood cultures monotherapy was associated with 8 ADE while combination therapy was 11 (P = 0.82). In pulmonary patients, monotherapy had 16 ADE while combination had 23 (P = 0.03).ConclusionOverall mortality trends improved with combination therapy in blood culture patients and with monotherapy patients in pulmonary cultures. These findings are influenced by the limited number of patients available, and the medical co-morbidities of these patients. In lung patients there were significantly fewer ADE associated with monotherapy as opposed to combination therapy.Disclosures All authors: No reported disclosures.

1036. Clinical impact of an antibiotic time out initiative at an academic medical center

BackgroundThe Infectious Diseases Society of America’s guideline for implementing antibiotic (abx) stewardship recommends routine review of abx use. Several studies demonstrate antibiotic time out (ATO) programs result in de-escalation, but there is limited evidence of improved outcomes. The aim of this study was to evaluate the clinical impact of ATO.MethodsThis retrospective study included hospitalized patients at The Ohio State University Wexner Medical Center receiving abx and a documented ATO from 7/1/2017 to 6/30/2018. ATO patients were matched by infection type to abx-treated patients lacking an ATO note. Patients were excluded if they were identified as a protected population, were in the ICU at the time of ATO, had an ATO within 48 hours of discharge, cystic fibrosis, or febrile neutropenia. The primary objective was to evaluate abx optimization in patients with documented ATO vs. those without ATO. Abx optimization was defined as the selection of ideal abx based on guidelines, culture and susceptibility results, or expert opinion when undefined. Secondary outcomes included vancomycin-associated acute kidney injury (VAN-AKI), infection-related length of stay (LOS), all-cause 30-day readmission or mortality, abx days, and nosocomial C. difficile infection (CDI) rates. The Student t-test/Fisher’s exact test and Wilcoxon-rank sum were utilized as appropriate.ResultsOne hundred ATO patients were compared with 100 non-ATO patients. Baseline characteristics and infection types were similar between groups. ATO resulted in improved optimization of abx selection (P = 0.05) and duration (P < 0.01), and reduced piperacillin/tazobactam (P/T) and vancomycin (VAN) utilization. No difference was observed in VAN-AKI (22 vs. 20%, P = 0.73), 30-day readmission (28 vs. 27%, P = 0.87), mortality (5 vs. 5%, P = 1), or CDI rates (6 vs. 5%, p = 0.76) in the ATO vs. non-ATO group. However, inpatient abx days (12 vs. 8, P = 0.004) and infection-related LOS (10 vs. 8, P = 0.0006) were shorter in the non-ATO group.ConclusionATO improved optimization of abx selection and duration, and reduced P/T and VAN use. Despite this, clinical outcomes were not improved.Disclosures All authors: No reported disclosures.

Interventions to Reduce Burnout and Improve Resilience: Impact on a Health System's Outcomes.

With the continuously changing health care environment and dramatic shift in patient demographics, institutions have the responsibility of identifying and dedicating resources for maintaining and improving wellness and resilience among front line providers to assure the quality of patient care. Our institution, the Ohio State University Wexner Medical Center (OSUWMC), has addressed the goal to decrease burnout for providers in a multistep, multiprofessional, and multiyear program starting firstly with institutional cultural change then focused provider interventions, and lastly, proactive resilience engagement. We describe herein our approach and outcomes as measured by provider wellness and health system outcomes. In addition, we address the overall feasibility and effectiveness of these programs in promoting provider compassion and mindfulness while reducing burnout and improving resilience. Institutional culture change and readiness were initiated in 2010 with the introduction of Crew Resource Management training for all providers across the OSUWMC. This multiyear program was implemented and has been sustained to the current day. Focused interventions to improve mindfulness were undertaken in the form of both Mindfulness in Motion (MIM) training for intensive care unit personnel and a "flipped classroom" mindfulness training for faculty and residents. Lastly, sustainable changes were introduced in the form of the Gabbe Health and Wellness program which consists of interprofessional MIM training and other wellness offerings for staff, faculty, and residents embedded across the entire medical center. The introduction of Crew Resource Management in 2010 continues to be endorsed and supported throughout OSUWMC for all providers, including residents and students. The improvements seen have not only improved patient satisfaction but also reduced patient safety events and improved national reputation for the institution as a whole. Subsequently, MIM training for intensive care unit providers has resulted in improved resilience as well as decreased patient safety events. In addition, the "flipped classroom" mindfulness training for residents and faculty has resulted in improvements in providing calm and compassionate care, improvements in physician wellbeing, and reductions in emotional exhaustion and depersonalization. Lastly, implementing the Gabbe Health and Wellness program inclusive of interprofessional MIM training for staff, faculty, and residents has resulted in significant reductions in burnout while significantly increasing resilience postintervention. The engagement from staff and enthusiasm to continue this program have escalated and been positively accepted across OSUWMC. To reduce the incidence of burnout, improve resilience, and ultimately improve patient outcomes, a health system must identify and prioritize a commitment and dedication of resources to develop and sustain a multimodal and interprofessional approach to change. These initiatives at OSU originated with cultural transformation allowing the acceptance of change in the form of mindfulness training, resilience building, and the engagement of organizational science, so as to demonstrate the outcomes and impact to the health system and academic peers. Herein we describe the work that has been done thus far, both published and in progress, to understand our journey.

P130. Intraoperative neuromonitoring findings are predictive of neurological outcomes after decompression for cervical spondylotic myelopathy

BACKGROUND CONTEXT Intraoperative Neuromonitoring (IONM) is frequently used by spine surgeons to predict emerging neurological insult and to provide functional feedback prior to development of irreversible neural injury. Despite its widespread use, however, it remains unclear whether various IONM changes are predictive of neurological outcomes in patients who undergo decompression surgery for cervical spondylosis with myelopathy (CSM). PURPOSE To evaluate the prognosticative ability of IONM changes for neurological outcomes after surgical decompression in patients with CSM. STUDY DESIGN/SETTING Retrospective evaluation of a prospectively enrolled cohort of patients who underwent surgery for CSM at the Ohio State University Wexner Medical Center. PATIENT SAMPLE A total of 39 patients were prospectively enrolled in a CSM trial at our institution and underwent decompression surgery between 2013-17. All patients with available intraoperative somatosensory evoked potential (iSSEP), motor evoked potential (iMEP), and spontaneous electromyography (iEMG) recordings as well as perioperative mJOA scores were included in the study. OUTCOME MEASURES The modified Japanese Orthopaedic Association (mJOA) scale evaluated at 1-year following surgery. METHODS Either univariate ANOVA with post hoc analysis (Student–Newman–Keuls) or t-tests were used to analyze DmJOA in relation to iSSEP, iMEP, and iEMG changes. RESULTS During surgery, iMEPs either improved, remained stable, or decreased in 5, 29 and 5 patients, respectively. iSSEPs improved, remained stable, or decreased in 1, 37 and 1 patient, respectively. Twenty-five patients showed spontaneous iEMG activity, which ultimately resolved in all cases. In patients in whom iMEP decreased, remained stable, or improved, mJOA improved by 1.3, 2.0, and 2.8 points 12 months after surgery, respectively. In contrast to iSSEP (p=0.58), iMEP changes and the presence/absence of iEMG activity during surgery were predictive of DmJOA at 12 months (p=0.02 and 0.007, respectively). CONCLUSIONS Decompressive surgery for CSM is generally associated with positive neurologic outcomes. Our findings suggest that patients in whom iMEPs improve potentially benefit the most, whilst those with iMEP decreases or spontaneous iEMG activity benefit the least. Whether IONM findings can prognosticate the degree of functional recovery after decompressive surgery for CSM will need to be confirmed in larger scale studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Return to Sport Rates in Physically Active Individuals 6 Months After Arthroscopy for Femoroacetabular Impingement Syndrome.

Six months is the expected time frame to return to sport (RTS) after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). The primary aims of this study were to (1)report the RTS rate of physically active individuals 6 months after arthroscopic surgery for FAIS and (2)compare the self-reported hip function between those who were able to RTS against those who had not. Cohort study. The Ohio State University Wexner Medical Center. A total of 42 physically active individuals scheduled for hip arthroscopy for FAIS. Self-reported function, including preinjury and current activity levels and ability to participate in sport, were collected on 42 individuals with FAIS prior to surgery and at 6-month follow-up. Participants were allocated into 2 groups based on self-reported RTS status at 6-month follow-up. Separate 2-way analyses of variance were used to test the interaction of groups (those who did/did not RTS). Main effects were reported in the absence of statistically significant interactions (P ≤ .05). Altogether, 28 of 42 participants (66%) returned for 6-month follow-up; 5 of the 14 participants (35.7%) lost to follow-up underwent contralateral hip surgery within the study time frame. At the 6-month follow-up, 16 of the remaining 28 participants (57.1%) reported that they had returned to sport, 5 of whom returned at their prior level of participation. There was no statistically significant interaction of group and time for either hip outcome score subscale (P ≥ .20). Self-reported hip function improved over time, regardless of group (P ≤ .001). Participants in the yRTS group demonstrated higher hip outcome score-sport scores than did the nRTS group, regardless of time (P = .04). Though just over half of participants returned to sport 6 months after hip arthroscopy for FAIS, only 18% returned to their previous level of sports participation. Participants who returned to sport reported better function than those who did not, but self-reported hip function improved over time regardless of group. The most commonly reported reasons for not returning to sport were weakness (69.6%), fear (65.2%), and pain (56.5%).

Development and Evaluation of Predictive Models Designed to Drive an Intelligent Clinical Decision Support System for Optimizing Inpatient Glycemic Control

Background: Achieving glycemic control in critically ill patients is of paramount importance, and has been linked to reductions in mortality, ICU length of stay (LOS), and morbidities such as infection, regardless whether or not the patient has diabetes. The myriad of illnesses and patient conditions render maintenance of glycemic control very challenging in this setting. Methods: This study involved collection of continuous glucose monitoring (CGM) data, and other associated measures, from the electronic medical records of 127 patients for the first 72 hours of ICU admission at The Ohio State University Wexner Medical Center (OSWMC). Data collected was used to develop a neural network-based predictive models. Findings: The model was shown to be accurate in predicting glucose using patient data not leveraged for model training. Model error, expressed as mean absolute difference percent, was 10.6% and 15.9% with respect to interstitial and serum blood glucose values, respectively. Clarke Error Grid Analysis (CEGA) of model predictions with respect to the reference CGM and blood glucose measurements revealed that >99% of model predictions could be regarded as clinically acceptable. Interpretation: The noted clinical acceptability of these models illustrates their potential utility within a clinical decision support system to assist healthcare providers in the optimization of glycemic management in critical care patients. Funding Statement: This study was supported by a $98,366 grant provided by the State of Ohio's Third Frontier Program (Grant #TECG20140125) and $20,000 provided by the Department of Anesthesiology at OSUWMC. Declaration of Interests: Dr. Jaume has nothing to disclose. Mr. Owais has nothing to disclose. Dr. Papadimos has nothing to disclose. Dr. Tripathi has nothing to disclose. Dr. Mavarez Martinez has nothing to disclose. Dr. Cameron has received one initial payment from the University of Toledo that was due to an initial licensing fee paid by Analytic Diabetic Systems, Inc. as part of licensing the patents referenced above as part of potential future commercial product development of a clinical decision support system. Dr. Pappada reports grants and personal fees from Analytic Diabetic Systems, Inc., personal fees from University of Toledo, during the conduct of the study; In addition, Drs. Pappada and Cameron hold patents (U.S. Patent No. 8,762,306 B2 and U.S. Patent No. 9,076,107 B2) related to the GlyCU CDSS with royalties paid to the University of Toledo and Co-Inventors (Drs. Pappada and Cameron) from Analytic Diabetic Systems, Inc. Dr. Pappada is on the Board of Directors for Analytic Diabetic Systems, Inc. and is a Co-Founder of the company, and holds an equity position in the corporation. Ethics Approval Statement: The study protocol was approved by The Ohio State University Institutional Review Board. All patients or their next of kin (if the patient had lost decision-making capacity) provided written informed consent.