Suburban Community Hospital Research Articles

P2.04B.03 Low Cost Low Dose CT Scan for Lung Cancer Screening - Seven Year Experience at a Sub-urban Community Hospital

P2.04B.03 Low Cost Low Dose CT Scan for Lung Cancer Screening - Seven Year Experience at a Sub-urban Community Hospital

Acute splenic pathology on CT in patients with babesiosis.

To better understand the occurrence of splenic disease as a potential manifestation of babesiosis by retrospectively estimating the frequency of acute splenic injury on abdominal and pelvic CT in a cohort of patients with active babesia infection. In a search of our single institution, suburban teaching community hospital database, 57 patients were found to have positive babesia infection between the years 2021-2023. 29 of these patients underwent abdominal and pelvic CT (22 with and 7 without intravenous contrast), and 3 underwent abdominal ultrasound without any CT. The imaging was reviewed for the presence or absence of splenic abnormalities, and for follow-up imaging. Parasitemia levels at the time of imaging were also reviewed; parasitemia levels < 4% are associated with mild to moderate disease, whereas parasitemia levels > 4% are associated with severe disease. 21/32 (66%) patients who underwent any type of abdominal imaging (ultrasound, MRI, and CT) had splenomegaly. Of the 22 patients who had IV contrast-enhanced CT scans, 6 were found to have splenic infarction (27%). One of these 22 patients had multiple rounded non-peripheral hypoenhancing foci on both CT and MRI which did not meet criteria for infarction, in association with splenomegaly, and which resolved after treatment. 0/6 patients in the splenic infarction group had parasitemia levels greater than 4%, while 4 of the 16 patients (4/16) without infarction had parasitemia levels of greater than 4%. Our study showed that splenic disease in patients with babesiosis mostly took the form of splenomegaly, and in a substantial minority of patients as splenic infarction. There were no cases of splenic rupture and perisplenic hematoma in our case series, likely reflecting a limitation of the relatively small study size. Concordant with prior studies, we found no identifiable association between parasitemia levels and the presence of splenic infarction.

Evaluating Sepsis Bundle Compliance as a Predictor for Patient Outcomes at a Community Hospital: A Retrospective Study.

Clinicians are encouraged to use the Centers for Medicare & Medicaid Services early management bundle for severe sepsis and septic shock (SEP-1); however, it is unclear whether this process measure improves patient outcomes. The purpose of this study was to evaluate whether compliance with the SEP-1 bundle is a predictor of hospital mortality, length of stay (LOS), and intensive care unit LOS at a suburban community hospital. A retrospective observational study was conducted. A total of 577 patients were included in the analysis. Compliance with the SEP-1 bundle was not a significant predictor for patient outcomes. SEP-1 compliance may not equate with quality of health care. Efforts to comply with SEP-1 may help organizations develop systems and structures that improve patient outcomes. Health care leaders should evaluate strategies beyond SEP-1 compliance to ensure continuous improvement of outcomes for patients experiencing sepsis.

Endocarditis in a Community Teaching Hospital

Background Endocarditis is a life-threatening condition with protean manifestations. The clinical syndrome continues to evolve with an aging population, the opioid epidemic, and changing microbiological profiles. Much of the clinical data for endocarditis comes from tertiary care centers with on-site cardiac surgery. Previous community cohorts do not reflect the current patient populations or current microbiology and predate the current opioid epidemic. We retrospectively reviewed the baseline clinical characteristics, microbiologic spectrum, surgical indication, tertiary referral, and outcomes for patients presenting to a community hospital with infective endocarditis (IE). Methods We retrospectively reviewed all adult medical patient admitted over a 5-year period with a clinical diagnosis of IE, from February 2016 to September 2021, to a single suburban safety net community hospital without on-site cardiac surgery. Results We identified 99 patients with a clinical diagnosis of IE. We observed a bimodal age distribution, with more comorbidities and predisposing cardiac conditions in the older patients and more intravenous drug use in the younger patients. Surgical indications were present in 44% of patients. Staphylococcus aureus was the most common pathogen. Overall survival was associated with fewer comorbidities and the absence of methicillin-resistant S. aureus infection. There was no difference in survival between patients with and without surgical indications. Conclusions IE continues to primarily affect older patients with comorbidities and results in a high 1-year mortality of 33%. A simple score including age, Charlson comorbidity index of 6.5, and methicillin-resistant S. aureus infection was predictive for in-patient, 30-day, and 1-year mortality.

Becoming futile: the emotional pain of treating COVID-19 patients.

The COVID-19 pandemic has had a profoundly detrimental impact on the emotional wellbeing of health care workers. Numerous studies have shown that their rates of the various forms of work-related distress, which were already high before the pandemic, have worsened as the demands on health care workers intensified. Yet much less is known about the specific social processes that have generated these outcomes. This study adds to our collective knowledge by focusing on how one specific social process, the act of treating critically ill COVID-19 patients, contributed to emotional pain among health care workers. This article draws from 40 interviews conducted with intensive care unit (ICU) staff in units that were overwhelmed with COVID-19 patients. The study participants were recruited from two suburban community hospitals in Massachusetts and the interviews were conducted between January and May 2021. The results show that the uncertainty over how to treat critically ill COVID-19 patients, given the absence of standard protocols combined with ineffective treatments that led to an unprecedented number of deaths caused significant emotional pain, characterized by a visceral, embodied experience that signaled moral distress, emotional exhaustion, depersonalization, and burnout. Furthermore, ICU workers' occupational identities were undermined as they confronted the limits of their own abilities and the limits of medicine more generally. The inability to save incurable COVID-19 patients while giving maximal care to such individuals caused health care workers in the ICU an immense amount of emotional pain, contributing to our understanding of the social processes that generated the well-documented increase in moral distress and related measures of work-related psychological distress. While recent studies of emotional socialization among health care workers have portrayed clinical empathy as a performed interactional strategy, the results here show empathy to be more than dramaturgical and, in this context, entailed considerable risk to workers' emotional wellbeing.

Implementing a Human Trafficking Educational Module and Protocol in the Emergency Department

IntroductionThe purpose of this quality improvement initiative was to educate emergency nurses and social workers about human trafficking and implement a human trafficking screening, management, and referral protocol adapted from the National Human Trafficking Resource Center. MethodsA human trafficking educational module was developed and delivered at a suburban community hospital emergency department to 34 emergency nurses and 3 social workers through the hospital’s e-learning platform, with learning outcomes evaluated via a pretest/posttest and program evaluation. The emergency department electronic health record was revised to include a human trafficking protocol. Patient assessment, management, and referral documentation were evaluated for protocol adherence. ResultsWith established content validity, 85% of nurses and 100% of social workers completed the human trafficking educational program, with posttest scores being significantly higher than pretest scores (mean difference = 7.34, P ≤ .01) along with high (88%-91%) program evaluation scores. Although no human trafficking victims were identified during the 6-month data collection period, nurses and social workers adhered to the documentation parameters in the protocol 100% of the time. DiscussionThe care of human trafficking victims can be improved when emergency nurses and social workers can recognize red flags using a standard screening tool and protocol, thereby identifying and managing potential victims.

1305. PrEParing for success: An intervention to increase HIV prevention awareness among internal medicine residents.

Abstract Background PrEP (Pre-Exposure Prophylaxis) is a strategy that involves a combination of antiretrovirals medications aimed to reduce HIV transmission among at-risk individuals. The purpose of this quality improvement project is to increase internal medicine residents' knowledge and prescribing of PrEP. Methods We administered an anonymous paper survey to internal medicine residents at all stages of training at our suburban community hospital in the Hudson Valley, NY in the summer of 2021 during the academic half-day of their ambulatory block rotation. The survey consisted of questions about the residents’ demographics, PrEP knowledge, and previous prescribing of PrEP. Following the survey participants were given a 1-hour lecture by the authors on sexual history and PrEP including indications, available options, dosing, monitoring, side effects, and access to the therapy. Six months later we reissued the same survey to the residents. Surveys were analyzed using descriptive statistics. Results All 74 eligible residents completed the survey. Out of the 74, 35 (47.3%) identified as male and 40 (52.7%) identified as female. Medical school graduation year range between 2007 to 2021. Only 69 residents completed the post-survey. To Q1 “which medications are FDA approved to be used as PrEP,” 40 (54.05%) answered correctly prior to the intervention, whereas 51 (73.91%) did after. When they were asked Q3 “How effective was PrEP at reducing the risk of contracting HIV through sex,” 21 (28.38%) responded correctly, which improved to 46 (66.67%) after. To the other knowledge-based questions there was no significant improvement (see table). The number of people who reported prescribing PrEP increased from 2 (2.7%) to 7 (10.14%). PrEP survey Pre and Post results Conclusion Although experiencing this educational intervention did not improve long-term retention of knowledge among the participants, there was a substantial increase in the number of residents who prescribed PrEP. One of the limitations that can contribute to these results; is the short time frame between the intervention and post-survey. These findings demonstrate the need for early introduction of this topic into medical school and residency program curricula. Disclosures All Authors: No reported disclosures.

Clinical impact of physician staffing transition in intensive care units: a retrospective observational study

BackgroundIntensivists play an essential role in improving the outcomes of critically ill patients in intensive care units (ICUs). The transition of ICU physician staffing from low-intensity ICUs (elective intensivist or no intensivist consultation) to high-intensity ICUs (mandatory intensivist consultation or a closed ICU) improves clinical outcomes. However, whether a transition from high-intensity to low-intensity ICU staffing affects ICU outcomes and quality of care remains unknown.MethodsA retrospective observational study was conducted to examine the impact of high- versus low-intensity staffing models on all-cause mortality in a suburban secondary community hospital with 400 general beds and 8 ICU beds. The ICU was switched from a high-intensity staffing model (high-former period) to low-intensity staffing in July 2019 (low-mid period) and then back to high-intensity staffing in March 2020 (high-latter period). Patients admitted from the emergency department, general ward, or operating room after emergency surgery were enrolled in these three periods and compared, balancing the predicted mortality and covariates of the patients. The primary outcome was all-cause mortality analyzed using hazard ratios (HRs) from Cox proportional hazards regression. An interrupted time-series analysis (ITSA) was also conducted to evaluate the effects of events (level change) and time.ResultsThere were 962 eligible admissions, of which 251, 213, and 498 occurred in the high-former, low-mid, and high-latter periods, respectively. In the matched group (n = 600), the all-cause mortality rate comparing the high-former period with the low-mid period showed an HR of 0.88 [95% confidence interval (CI), 0.56, 1.39; p = 0.58] and that comparing the high-latter period with the low-mid period showed an HR of 0.84 [95% CI, 0.54, 1.30; p = 0.43]. The result for comparison between the three periods was p = 0.80. ITSA showed level changes of 4.05% [95% CI, -13.1, 21.2; p = 0.63] when ICU staffing changed from the high-former to the low-mid period and 1.35% [95% CI, -13.8, 16.5; p = 0.86] when ICU staffing changed from the low-mid to the high-latter period.ConclusionThere was no statistically significant difference in all-cause mortality among the three ICU staffing periods. This study suggests that low-intensity ICU staffing might not worsen clinical outcomes in the ICU in a medium-sized community hospital. Multiple factors, including the presence of an intensivist, other medical staff, and practical guidelines, influence the prognosis of critically ill patients.

Description of nurse practitioner functioning as most responsible provider in an intravenous therapy clinic.

IV antibiotic patients at the Strathcona Community Hospital were previously seen through the Strathcona emergency department (ED). This led to decreased patient satisfaction and increased wait times for these patients. The purpose of this study was to describe a nurse practitioner (NP) functioning as the most responsible provider (MRP) in an intravenous therapy (IVT) clinic and to describe the benefits and services the clinic provides within a suburban community hospital setting. Data were collected over a 5-year period from August 2015 to March 2019. Indicators included staff satisfaction, timely change in treatment modality, adherence to antimicrobial stewardship principles, appropriate triaging of IV iron referrals, and continuity of care. Results included patients being seen in the IVT clinic rather than reassessment in the ED, which were 23,573; and patient length of stay, with average length of stay being 4.8-4.9 days for skin and soft tissue infections. Patient survey conducted in 2015 showed an 89% satisfaction rate. Nurse practitioners functioning as MRP in an IVT clinic improve patient access to services, satisfaction, and provide appropriate medical care. The success of this clinical model provides evidence to support an increased presence of NPs as MRPs. A better understanding of the financial breakdown of these clinics may provide additional insight into the full benefit of NP-led clinics on our health care system as a whole.

Frailty and Survival After In-Hospital Cardiopulmonary Resuscitation.

Older adults face high mortality following resuscitation efforts for in-hospital cardiac arrest. Less is known about the role of frailty in survival to discharge after in-hospital cardiopulmonary resuscitation. To investigate whether frailty, measured by the Clinical Frailty Scale, is associated with mortality after cardiopulmonary resuscitation following in-hospital cardiac arrest in older adults in the USA. Retrospective cohort study. Patients ≥ 65years who had undergone cardiopulmonary resuscitation during an inpatient admission at two urban academic hospitals and three suburban community hospitals within a Boston area healthcare system from January 2018-January 2020. Patients with Clinical Frailty Scale scores 1-3 were considered not frail, 4-6 were considered very mildly, mildly, and moderately frail, respectively, and 7-9 were considered severely frail. In-hospital mortality after cardiopulmonary resuscitation. Among 324 patients who underwent cardiopulmonary resuscitation following in-hospital cardiac arrest, 73.1% experienced in-hospital mortality. Patients with a Clinical Frailty Scale score of 1-3 had 54% in-hospital mortality, which increased to 66%, 78%, 84%, and 84% for those with a Clinical Frailty Scale score of 4, 5, 6, and 7-9, respectively (p = 0.001). After adjusting for age, sex, race, and Charlson Comorbidity Index, higher frailty scores were significantly associated with higher odds of in-hospital mortality. Compared to those with a Clinical Frailty Scale score of 1-3, odds ratios (95% CI) for in-hospital mortality for patients with a Clinical Frailty Scale score of 4, 5, 6, and 7-9 were 1.6 (0.8-3.3), 3.0 (1.3-7.1), 4.4 (1.9-9.9), and 4.6 (1.8-11.8), respectively (p = 0.001). Higher levels of frailty are associated with increased mortality after in-hospital cardiopulmonary resuscitation in older adults. Clinicians may consider using the Clinical Frailty Scale to help guide goals of care conversations, including discussion of code status, in this patient population.

The Comparison of Children Who Were Diagnosed with COVID-19 in the First and the Second Waves of the SARS-CoV-2 Pandemic.

Objective:To compare the clinical and laboratory findings and short-term outcomes of those children diagnosed with COVID-19 in the first and second waves of the SARS-CoV-2 pandemic.Methods:A retrospective study was conducted at a suburban community hospital during a 1-year period. All children who were less than 18 years of age and confirmed with COVID-19 were included in the study population. The demographics, clinical features, laboratories, treatments given, hospitalizations, and outcomes were analyzed.Results:A total of 198 patients were enrolled; median age was 9.3 years. One-hundred four patients were diagnosed with COVID-19 disease in the first wave and 94 (47.5%) patients were diagnosed in the second wave of the pandemic. Those patients who were diagnosed with COVID-19 in the first wave of the pandemic were significantly younger than those in the second wave (medians: 2.7 years vs. 15 years respectively, P < .001). Intra-familial contact was detected in 66.4% vs. 33.6% in the first and second waves of the pandemic, respectively (P < .001). Asymptomatic patients were higher in the second wave than in the first wave (P < .001). Additionally, moderate-to-critically ill patients were significantly higher in the first wave than in the second wave (P < .001). The rate of multisystem inflammatory syndrome (MIS-C) cases was 0.32% in this study.Conclusion:In children, COVID-19 disease affected older children, there was less intra-familial contact and the severity of the disease was milder in the second wave of the pandemic in comparison to the first wave. MIS-C was encountered in the second wave of the pandemic.

Utilization of a waste audit at a community hospital emergency department to quantify waste production and estimate environmental impact

A waste audit can clarify waste composition and inform improvements in waste disposal, thereby decreasing carbon emissions and reducing costs. The purpose of this study was to conduct a waste audit in the Emergency Department of a suburban community hospital to identify waste content, estimate environmental impact and explore avenues for improvement in waste disposal. A 24-hour waste audit was performed in the ED of a community hospital in January 2020. The audit examined all waste generated in the ED during the study period. Waste was collected, manually sorted by predominant material, and weighed. Direct pollutant emissions were calculated using the M+WasteCare Calculator. A total of 255.30 kilograms (kg) of waste was produced in a 24-h period, of which 98.2% was solid waste and 1.8% was regulated medical waste. A total of 1.63 kg of waste was produced per patient encounter. The largest category of waste was plastic (61.0%), followed by paper (18.2%). More than 170 unused items (5.2% of total waste) were identified during the audit, including unopened boxes of gloves, surgical face masks, suturing material, and medications. The audit also identified 418 Styrofoam cups disposed of in a 24-h period, which extrapolates to an estimated 152,570 disposed cups each year. Direct pollutant emissions from waste disposal in the ED were estimated at 304 kg of carbon dioxide per day. This 24-h waste audit in the ED of a community hospital identified waste content, estimated environmental impact, and proposed potential avenues for improvement in waste disposal.

Hospital length-of-stay among COVID-19 positive patients

This study aims to determine COVID-19 patient demographics and comorbidities associated with their hospital length of stay (LOS). Design: Single-site, retrospective study. Setting: A suburban 700-bed community hospital in Newark, Delaware, USA. Patients: Patients admitted to the hospital from March 11, 2020, to August 11, 2020, with a positive COVID-19 status. We followed a time-to-event analysis approach and used Kaplan-Meir curves and log-rank tests for bivariate analyses, and an accelerated failure time model for a multivariable model of hospital LOS. Six hundred and eighty-seven patients discharged alive (mean [SD] age, 60.94 [18.10] years; 339 men [49.34%]; 307 Black/African-American [44.69%]; and 267 White [38.86%]) were included in the investigation. Bivariate analysis using Kaplan-Meir curves showed that patients' age, sex, ethnicity, insurance type, comorbidity of fluid and electrolyte disorder, hypertension, renal failure, diabetes, coagulopathy, congestive heart failure, peripheral vascular disease, neurological disorder, coronary artery disease, and cardiac arrhythmias to be significantly associated with LOS (P<0.05). In the multivariable analysis, patients' age, sex, ethnicity, number of Elixhauser comorbidities, and number of weeks since onset of the pandemic was significantly associated with LOS (P<0.05). Fluid and electrolyte disorder is the only comorbidity independently associated with LOS after adjusting for patients' age, sex, race, ethnicity, number of Elixhauser comorbidities, and weeks since onset of pandemic. COVID-19 patients LOS vary based on multiple factors. Understanding these factors are crucial to improving the prediction accuracy of COVID-19 patient census in hospitals for resource planning and care delivery. Understanding of the factors associated with LOS of the COVID-19 patients may help the care providers and the patients to better anticipate the LOS, optimize the resources and processes, and prevent protracted stays.

Disparities in Access to Minimally Invasive Hysterectomy in a Suburban Community Hospital: A Patient-Level Analysis

Study Objective Prior studies have identified differences in access to minimally invasive hysterectomy (MIH) based on demographic characteristics. These differences do not always persist when including patient-level information that may affect surgical decision-making. This study aims to identify racial or ethnic differences in access to MIH (laparoscopic or robotic) at our institution, as well as trends in access over time. Design Retrospective cohort study. Setting Suburban community hospital. Patients or Participants All adult women undergoing hysterectomy for benign indications, January 2015– December 2019. Exclusion criteria were a preoperative diagnosis of pelvic malignancy, concurrent sacrocolpopexy, emergent hysterectomy, or vaginal hysterectomy. Interventions N/A Measurements and Main Results A total of 1,632 patients were included in the analysis. 54% were non-Hispanic white, 17% non-Hispanic black, 21% Hispanic of any race, and 8% Asian, Native American, Pacific Islander or self-identified as “other”. Black and Hispanic women were significantly less likely to undergo MIH than white women, OR 0.490 (CI 0.371 – 0.646, p Conclusion This study identified a disparity in likelihood of undergoing MIH for non-white women. This was eliminated for black and “other” women after controlling for patient-level information but persisted in Hispanic women. Further study is warranted to better understand the factors underlying this finding.

Improving Quiet at Night on a Telemetry Unit: Introducing a Holistic Sleep Menu Intervention.

In a patient's recovery process, restful sleep is crucial. Although the essential role of sleep in healing has long been recognized, excessive noise in hospital environments remains a persistent and pervasive problem. For hospitalized patients, environmental noise can result in sleep deprivation and adverse health outcomes; not surprisingly, hospital noise ranks as a major patient complaint. At a small suburban community hospital, patients responding to a quiet-at-night question in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey gave the hospital's telemetry unit the lowest possible score: 1 out of 5 points. In response, the unit's quality improvement team, coordinated by a clinical nurse leader, introduced a holistic "sleep menu" intervention. The multicomponent intervention subsequently improved patients' care experience and staff engagement. The percentage of patients who self-reported five or more hours of uninterrupted sleep rose from 31% at baseline to 80% during the intervention. This improvement was sustained over the three-month intervention period and led to a quiet-at-night HCAHPS score of 4. The sleep menu initiative resulted in substantial benefits that optimized both patient and organizational outcomes.

Emergency Department Visits for Serious Diagnoses During the COVID‐19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has significantly affected health care utilization in the United States. Although reductions in routine outpatient visits and elective procedures were intentional in preparation for increases in COVID-19-related volume,1 National Syndromic Surveillance Program data indicate that weekly emergency department (ED) visits decreased 42% during the early stages of the pandemic.2 This reduction may have been driven by a public fear of seeking care,3,4 ultimately delaying interventions for time-sensitive serious conditions.

Proactive C-L Psychiatry Beyond Academic Hospital Settings: A Pilot Study of Effectiveness in a Suburban Community Hospital

Proactive consultation-liaison psychiatry improves identification of psychiatric needs and reduces time to psychiatric consultation and length of stay (LOS) among medical inpatients in academic clinical settings. To evaluate the effect of a proactive model on LOS, consult rate, and consultation latency in a nonacademic community hospital. We implemented a modified proactive consultation-liaison service (PCS) in a 32-bed acute care medical-surgical unit in a community hospital. We compared outcomes during a 90-day PCS intervention period to preintervention and postintervention cohorts receiving consultation-as-usual in the same unit. During the intervention, a psychiatrist reviewed the electronic medical record of patients admitted to the study unit to guide recommendations and collaborated with existing unit staff. Primary outcomes were LOS, consultation rate, and consultation latency. Secondary outcomes included restraint utilization, 1:1 companion utilization, and a survey completed by unit nursing staff. Half of patients on the study unit had psychiatric comorbidity. Median LOS in the PCS cohort was 3.0 days versus 5.0 days in the preintervention and postintervention cohorts. The consultation rate was higher in the PCS cohort (1.4% before intervention; 33% intervention; 6.5% after intervention), and median consultation latency was also reduced during the intervention (57.6 h before intervention; 19.2 h intervention; 48 h after intervention). Implementation of a modified PCS model is feasible in a community hospital setting and can reduce LOS, enhance psychiatric service utilization, and reduce consultation latency. This study demonstrates that proactive consultation-liaison may offer the same benefits to nonacademic community hospitals as it does to large academic centers.

Attitudes, Perceptions, and Knowledge of Breastfeeding Among Professional Caregivers in a Community Hospital

ObjectiveTo explore the knowledge, attitudes, and perceptions of exclusive breastfeeding among professional caregivers in a suburban community hospital who typically provide, or influence, the care of parturient women. DesignCross-sectional quantitative study. SettingAcute care community hospital in suburban New Jersey with 3,500 births per year. ParticipantsObstetricians, midwives, neonatologists, pediatricians, and registered nurses. Interventions/MeasurementsWe designed a survey using two instruments—the Iowa Infant Feeding Attitudes Scale and the Breastfeeding Attitudes Scale—to explore concepts of breastfeeding knowledge, attitudes, and perceptions. Data were analyzed by using descriptive and inferential statistics with SPSS (Version 19). Independent sample t tests, Pearson’s correlation coefficient, and Pearson’s chi-square test (×2) were used to assess differences between the groups. ResultsWhen the physician scores were separated out by specialty, statistically significant differences in mean scores were found (p = .002). Pediatricians had lower scores on attitude toward breastfeeding. In contrast, mean scores for perceptions and knowledge of breastfeeding were positive for physicians and nurses, regardless of area of specialization, with no statistically significant differences found. ConclusionAlthough pediatricians’ attitudes, perceptions, and knowledge of breastfeeding cannot be deemed the sole cause for our organization’s low rates of sustained exclusive breastfeeding in the postpartum period, this study provided an avenue for exploration that we did not immediately consider as we dissected our performance metrics related to exclusive breastfeeding. We encourage teams at other organizations to replicate and build on this work to explore influences surrounding low rates of exclusive breastfeeding.

3:54 PM Abstract No. 171 Socioeconomic factors may affect patient referrals patterns for uterine fibroid embolization

To evaluate socioeconomic disparities in referral patterns for uterine fibroid embolization IRB approval was obtained from both hospitals. A retrospective review of all patients who underwent UFE between 2010-2019. Data collected was demographic in nature including insurance status. Underinsured was defined as medicaid, charity care, or no insurance. A total of 108 patients (mean age, 43.5 ± 7.2 years) were referred for UAE at two institutions: urban inner city hospital (n = 74, mean = 42.6, ± 7.6) and suburban community hospital (n = 34, mean age 45.5 ± 5.7 years). For comparison purposes, demographic data pertaining to the socioeconomic status of the population in the surrounding county and state were obtained from an epidemiologic source (https://www.datausa.io). Comparisons between groups were made using a chi square analysis. A goodness to fit analysis was performed to compare observed groups to county and state level data. The proportion of UAE referrals from both hospitals that were underinsured was 63% compared to 25% of the general population of the state. On the other hand, the proportion of UAE referrals that had commercial insurance was 32% compared to 62% of the state population. (χ2 GTF = 82.1; P = <0.001). Black/Hispanic patients accounted for 80% of the referrals, of which 72% were underinsured. White/Other patients accounted for 20% of referrals, of which 23% were underinsured. (χ2 = 18.1; P < 0.0001). The patients referred to the urban hospital were more likely to be underinsured when compared to the suburban hospital (χ2 = 64.3; P < 0.001). The proportion of UAE referrals from the urban inner city hospital that were underinsured was 88.5% compared to 31.5% of population in the county. On the other hand, the proportion of UAE referrals that had commercial insurance was 3.85% compared to 58.64% of county population. (χ2 GTF = 81.2; P < 0.001). The proportion of UAE referrals from the urban community hospital were 11.8% underinsured and 85.3% insured compared to 8.9% underinsured and 70.3% insured population in the county. (χ2 GTF = 6.67; P = > 0.05). Socioeconomic factors i.e., race and insurance may affect UFE referral patterns.

Abstract TP363: A Successful Nurse-Driven Acute Stroke Code Algorithm to Reduce Door-to-Needle Time at a Telestroke Site

Background and Issues: In Hawaii, where stroke remains the 3 rd leading cause of death, a large comprehensive stroke center serves as the telestroke hub site for multiple telestroke spoke sites. Among these spoke sites, an 80-bed suburban community hospital within the same healthcare system has the highest number of IV alteplase administrations in Hawaii. Although both hospitals share similar resources and clinical expertise, the median “door-to-needle” (DTN) time at the spoke site was significantly longer compared to the hub site (by ~13-15 minutes). The main difference between the two sites was the traditional acute stroke (in person) vs. telestroke (telemedicine) workflow. Purpose: To transform the process and experience of a telemedicine stroke code into those similar to that of an in-person stroke code, with the aim to reduce the median IV alteplase DTN time to 20 minutes at the telestroke spoke site. Methods: Upon case review, the telestroke neurologist was seen as ineffective in running the stroke code remotely, an on-site stroke code leader was necessary to efficiently guide the team through the stroke code. The stroke code leader did not need to be an expert in stroke neurology, thus it was decided to have the primary nurse or charge nurse be the code leader. The code leader followed a simple Acute Stroke Code Checklist similar to that of the ACLS algorithm. The checklist included time targets to focus on the 20 minute DTN goal. In addition, the neurological exam was standardized into a primary and secondary assessment; imaging studies were also separated into primary and secondary neuro-imaging. The DTN times between pre- and post- period were compared by non-parametric Wilcoxon test. Results: The ED Acute Stroke Code Checklist was implemented on October 16, 2017. Following implementation DTN times decreased; the first 5 cases after the intervention were under the pre-intervention median time. DTN time decreased from a median DTN: Pre vs. Post 42.5 to 33.0 min (p = 0.0012) with data through March 2019 analyzed. Conclusions: The nurse-driven acute stroke code algorithm significantly improved the DTN times and reduced variation in outcomes in a community hospital telestroke site.