Tennessee Valley Healthcare System Research Articles

Implementation and evaluation of interprofessional overdose review team recommendations following intentional or accidental overdose events.

Drug overdose death rates in the United States remain high despite efforts to mitigate this risk. Many communities and hospitals across the country have implemented overdose review teams, including local overdose fatality review teams or postoverdose intervention programs, to address the opioid crisis. The goal of most of these teams is to identify missed opportunities or patient-specific interventions to prevent future opioid overdose fatalities. Few overdose review teams review a combination of both fatal and nonfatal overdose events. The Veterans Affairs Tennessee Valley Healthcare System implemented a novel overdose review team (ORT) that collaboratively reviews all overdose incidents regardless of fatality, intent, or substance involved. This practice description characterizes reported facility overdose events and patient-specific risk-mitigation strategies recommended by the ORT, highlights the implementation rate and time to implementation of ORT recommendations, and discusses potential areas for process improvement. This practice highlights the potential impact of a pharmacist-led, interdisciplinary ORT following accidental or intentional overdose events involving any substance or medication. Key patient-specific interventions implemented following ORT recommendations included overdose prevention education and naloxone distribution, prescribing of medications for opioid use disorder and/or alcohol use disorder, reducing medication supply to limit lethal means access, and facilitation of mental health and/or substance use disorder specialty appointments. Further research to evaluate clinical outcomes related to specific ORT interventions should be considered.

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration

BackgroundDespite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration.MethodsWe conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process.ResultsWe conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal.ConclusionsThe diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Resident operative time as an independent predictor of early post-operative cataract surgery outcomes and supervising attending surgeon impact: a retrospective case series

BackgroundThe authors sought to determine if resident operative time in cataract extraction and intraocular lens insertion (CE/IOL) affects early visual outcomes and post-operative recovery. They further sought to investigate if attending surgeons can reduce resident operative time.MethodsThis retrospective, chart-review, case series at single Veterans Affairs Hospital (VA Tennessee Valley Healthcare System) studied resident cataract surgeries between March 1, 2018 and March 31, 2020. Following power analysis, 420 eyes of 400 patients from all resident cataract surgeries were included. Eyes with attending as primary surgeon, laser-assisted cataract surgery, or concurrent secondary procedures were excluded. Linear mixed effect models were used to study the association between operative time and visual outcomes while adjusting for covariates including cumulative dissipated energy, preoperative factors, and intraoperative complications.ResultsLonger operative time was statistically associated with worse post-operative-day 1 (POD1) pinhole visual acuity (PH-VA) adjusting for cumulative dissipated energy and other operative factors (p = 0.049). Although resident physicians were the primary surgeons, the operative times were different between the ten supervising attending surgeons in the study (p < 0.001).ConclusionThe results suggest that increased resident operative time is a significant, independent risk factor for decreased POD1 PH-VA. Increased resident operative time is not associated with worsened long term visual outcomes. Attending surgeons may be able to reduce resident operative time, which is associated with improved early visual outcomes.

Assessment of interobserver concordance in radiomic tools for lung nodule classification, with a focus on BRODERS and SILA

While CT lung cancer screening reduces lung cancer-specific mortality, there are remaining challenges. Radiomic tools promiss to address these challenges, however, they are subject to interobserver variability if semi-automated segmentation techniques are used. Herein we report interobserver variability for two validated radiomic tools, BRODERS (Benign versus aggRessive nODule Evaluation using Radiomic Stratification) and CANARY (Computer-Aided Nodule Assessment and Risk Yield). We retrospectively analyzed the CT images of 95 malignant lung nodules of the adenocarcinoma spectrum using BRODERS and CANARY. Cases were identified at Mayo Clinic (n = 45) and Vanderbilt University Medical Center and Nashville/Veteran Administration Tennessee Valley Health Care System (n = 50). Three observers with different training levels (medical student, internal medicine resident and thoracic radiology fellow) each performed lung nodule segmentation. All methods were carried out in accordance with relevant guidelines and regulations. Interclass correlation coefficients (ICC) of 0.77, 0.98 and 0.97 for the average nodule volume, BRODERS cancer probability and Score Indicative of Lesion Aggression (SILA) which summarizes the distribution of the CANARY exemplars indicated good to excellent reliability, respectively. The dice similarity coefficient was 0.79 and 0.81 for the data sets from the two institutions. BRODERS and CANARY are robust radiomics tools with excellent interobserver variability. These tools are simple and reliable regardless the observer/operator’s level of training.

1223. Utilizing Multiple Antimicrobial Stewardship Metrics to Trend Vancomycin Use in an Implementation Study

Abstract Background Inpatient IV vancomycin use is often inappropriately prolonged. Methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) nares swabs have shown high negative predictive values for many infections and can guide appropriate vancomycin de-escalation. Antibiotic stewardship programs (ASPs) often monitor vancomycin use in days of therapy (DoT) per 1000 patient days present (PDP). This measure can be affected, especially for smaller facilities, by changes in bed capacity and prolonged stays and thus may not accurately reflect vancomycin use. We evaluated whether alternative metrics of vancomycin use would show different impacts during a multi-step ASP intervention to reduce inappropriate vancomycin use at Veterans Affairs Tennessee Valley Healthcare System. Figure 1 Run chart of vancomycin DoT/1000 PDP at the Tennessee Valley Healthcare System (TVHS) in two years prior to intervention. Methods In September 2021, the ASP, with multiple stakeholders, initiated use of MRSA nasal swabs to inform vancomycin de-escalation. From 7/2022 to 3/2023, we performed iterative Plan-Do-Study-Act intervention cycles including educating medicine and surgical divisions on MRSA swab result interpretation, educating nurses on timely swab collection, replacing MRSA culture swabs with PCR swabs, and adding MRSA swab orders to vancomycin order sets. In April 2022, in addition to DoT/1000 PDP, we began measuring mean, median, and mode DoT per vancomycin course initiated by start week. Results Despite multiple interventions beginning July 2022, vancomycin use in DoT/1000 PDP increased to a peak of 106 DoT/1000 PDP in September 2022. In that same period, median and mode DoT per vancomycin initiation remained steady at 2 days and 1 day, respectively. Figure 2 Run chart of vancomycin DoT/1000 PDP at the TVHS from April 2022 to March 2023. Specific ASP interventions are annotated on the dates they occur. Figure 3 Run chart of mean, median, and mode days of vancomycin therapy per vancomycin course initiated at the TVHS from April 2022 to March 2023. Specific ASP interventions are annotated on the dates they occur. Conclusion DoT/1000 PDP may not be the best metric to evaluate efforts to reduce inappropriate vancomycin use. By tracking mean, median, and mode of DoT per individual vancomycin course, we determined that most providers already practice rapid de-escalation, minimizing patient vancomycin exposure. This method also allows us to quickly detect changes in prescribing patterns and determine whether interventions were warranted. More evaluation of antibiotic use metric appropriateness based on desired outcome is needed in ASPs. Disclosures Milner Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson &amp; Johnson: Stocks/Bonds

Efficacy and Safety of a Novel Non-Myeloablative Conditioning Regimen for Hematopoietic Cell Transplantation in Adults with Severe Aplastic Anemia

Introduction The distinct "age effect" that exists in severe aplastic anemia (SAA) following hematopoietic cell transplantation (HCT) favors the use of reduced intensity conditioning regimens in patients >40 years. For older adults, overall survival and disease-free survival (DFS) is reduced with increasing age and unrelated donor transplant are associated with higher rates of graft failure, Epstein-Barr virus (EBV) reactivation, and post-transplant lymphoproliferative disorders (PTLD) (Rice C, et al. BBMT 2019.). To overcome this, a novel, non-myeloablative conditioning regimen called FCR, which consists of fludarabine, cyclophosphamide, and rituximab, was designed at Vanderbilt University Medical Center (VUMC) and the associated VA Tennessee Valley Healthcare System (TVHS) for use in all SAA patients. This regimen was subsequently evaluated in the first 11 SAA patients treated at VUMC/TVHS and found to result in lower toxicity, graft-versus-host disease (GVHD), and viral reactivation with no graft failure or relapse compared to historical controls (Gatwood KS, et al. BMT 2018.). Given these initial favorable results, FCR has now been expanded as the preferred conditioning regimen for all SAA patients undergoing HCT at our center, warranting follow-up evaluation in a larger cohort. Methods Utilizing institutional registries, all SAA patients were identified who underwent first allogeneic HCT using an FCR regimen (Figure 1) between January 2016 and May 2022. VUMC and TVHS Institutional Review Boards approved this retrospective analysis. Outcomes analyzed included time to engraftment, incidence of graft failure, incidence of acute GVHD (aGVHD) and chronic GVHD (cGVHD), rate of viral reactivation, post-HCT disease status, and number of inpatient hospital days through day +100. An analysis of 1-year GVHD-free, relapse-free survival (GRFS) was conducted in evaluable patients, with differences between the curves determined using log-rank tests. Results Twenty-four SAA patients underwent HCT from January 26, 2016 to May 11, 2022, the majority of which were male with a median age of 43.5 years (range: 22-62). All patients received at least one line of therapy prior to HCT with the most common treatment being the combination of cyclosporin A with anti-thymocyte globulin with or without eltrombopag and/or corticosteroid. Median time from diagnosis to transplantation was 434.5 days (range: 84-6408). Patients received transplants from matched related (n=8), haploidentical (n=2), and matched unrelated donors (n=14) using either a peripheral blood (PB) or bone marrow (BM) stem cell source (PB=15, BM=9). Median time to neutrophil and platelet engraftment was 14 days (range: 10-25) and 18 days (range: 10-38), respectively. No patients experienced graft failure. At median follow-up of 806.5 days (range: 72-2180) post-transplant, all patients were alive and in remission. No patients developed grade III-IV aGVHD and no differences in grade I-II aGVHD rates were noted based on stem cell source. By date of last follow-up, mild to moderate cGVHD graded per 2014 NIH criteria developed in 7 and 3 patients, respectively. There were no cases of severe cGVHD. Only 2 patients experienced a viral reactivation (cytomegalovirus [CMV]=1, EBV=1) by date of last follow-up. The case of EBV reactivation did not require treatment and did not progress to PTLD. The median number of inpatient hospital days required post-engraftment through the first 100 days post-transplant was 5 days (range: 0-21). The unadjusted Kaplan-Meier estimate of 1-year GRFS was 86.3% (95% CI: 72.8%-100%) (Figure 2), with moderate cGVHD accounting for all GFRS events in the study cohort. Conclusions The use of our novel non-myeloablative conditioning regimen in SAA is well tolerated with 0% non-relapse mortality and 100% DFS with low GVHD rates at 1-year post-transplant. Despite a high-risk population with median age >40 years, using primarily matched unrelated donors, and majority peripheral blood stem cell source, there were no deaths and rates of complications remained low. This study further supports the findings of our previous study, redemonstrating low rates of toxicity, severe GVHD and viral reactivation with no graft failure, relapse, or mortality. The use of these regimens needs to be validated in a larger cohort as they have the potential to provide a new standard of care for pre-HCT conditioning in SAA patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of a pharmacist-led outpatient telemedicine clinic on chronic obstructive pulmonary disease in a veteran population

ObjectivesThe primary objective was to evaluate chronic obstructive pulmonary disease (COPD) interventions in a pharmacist-led telemedicine clinic. Secondary objectives were to quantify emergency department (ED) visits and hospitalizations for COPD exacerbations. SettingA single-center, outpatient telemedicine clinic within the Veterans Affairs (VA) Tennessee Valley Healthcare System from January 2021 to June 2021. Practice descriptionPatients with an active COPD diagnosis and assigned to a primary care team within the local VA were reviewed for enrollment. Visits were conducted through VA video connect or telephone. During these appointments, pertinent information was collected and pharmacotherapy and nonpharmacotherapy interventions were implemented to optimize COPD management. Practice innovationVisits were conducted by a postgraduate year 2 ambulatory care pharmacy resident under supervision of a clinical pharmacy specialist with a scope of practice. Appointments were virtual to reduce coronavirus disease 2019 exposure and increase access to care. Patients were identified through a COPD patient report and provider referral to target high-risk patients. EvaluationInterventions made were documented at each visit. Chart review and patient interview were used to quantify ED visits or hospitalizations for COPD exacerbations occurring the year before or during clinic enrollment. ResultsOf 82 charts reviewed, 18 patients were eligible for enrollment. Eleven were followed as 7 patients did not show for initial visits. A total of 31 COPD interventions occurred including 13 nonpharmacotherapy (i.e., inhaler education, smoking cessation) and 18 pharmacotherapy (i.e., optimization of COPD regimens). An average of 3 COPD interventions were completed per patient followed. No ED visits and 2 hospitalizations for a COPD exacerbation occurred during the study period. This cohort had 1 ED visit and 10 hospitalizations the year before enrollment. ConclusionThis telemedicine clinic experience, albeit a small study population, suggests an opportunity for pharmacists to provide pharmacotherapy and nonpharmacotherapy interventions, which may improve COPD-related outcomes and access to care.

Objective ambulatory pH monitoring and subjective symptom assessment of gastroesophageal reflux disease show type of carbohydrate and type of fat matter.

Background:Rising prevalence of gastroesophageal reflux disease (GERD) in US Veterans is concurrent with increasing excess body weight.Objective:The objective of this cross-sectional study is to examine relationships between dietary macronutrients, gastrointestinal hormones, and GERD status.Methods:Ninety-eight veterans with overweight/obesity and empiric proton pump inhibitor (PPI) treatment were enrolled from the Tennessee Valley Healthcare System. Subjects had esophageal manometry and 24-h pH monitoring. Subjective symptoms were assessed with Gastroesophageal Reflux Disease Questionnaire (GERDQ) and Symptom Assessment Scale (GSAS). The primary outcomes, total acid exposure time (AET) and number of reflux episodes, enabled categorizing subjects as either pathologic GERD or inconclusive GERD. Data analysis included independent T-tests, Spearman Rho correlations, and multivariable linear regression modeling.Results:Higher intake of sugar-sweetened beverages (sugar-sweetened tea, soda, and fruit juice) associated with higher AET. Higher saturated-to-unsaturated fat intake is associated with higher AET and number of reflux episodes. Overall, sugar-sweetened beverage intake, saturated-to-unsaturated fat ratio, tomato-based food items, glucagon-like polypeptide 1 (GLP-1) level, time of first meal, and education status accounted for a significant amount of the variability in AET. Pathologic GERD subjects reported more heartburn (p = 0.006), regurgitation (p = 0.01), acid taste (0.001), and nausea severity (p = 0.04). GERDQ score associated with AET (r = 0.31, p = 0.005), but GSAS did not (r = 0.12, p = 0.28).Conclusion:Of the many foods and nutrients tested, the type (not amount) of carbohydrate (simple sugars) and the type (not amount) of fat (saturated vs unsaturated fat) consumed associated with objective and/or subjective GERD testing. These novel findings contribute to the evidence base guiding specific dietary recommendations in the clinical management of GERD.

Impact of a pharmacist-run weight loss medication management service

BackgroundWeight loss medications have been shown to be effective for weight loss and reducing disease state risk in patients who are overweight or obese. However, it is unknown what impact pharmacists have on weight loss when providing medication management services. ObjectiveTo evaluate weight loss outcomes and clinic utilization of a pharmacist-run weight loss pharmacotherapy service at the VA Tennessee Valley Healthcare System (TVHS) in Nashville, TN. Practice descriptionPatients enrolled in the MOVE! weight loss program were referred to a clinical pharmacy specialist (CPS) who was able to assess comorbidities, prescribe weight loss medication, and provide ongoing follow-up via telehealth visits. Practice innovationThis is the first description of a pharmacist-run weight loss pharmacotherapy clinic. This model expanded the role of pharmacists at TVHS, where CPS involvement was previously limited to chart reviews when medication recommendations were requested. EvaluationThis prospective quality improvement project evaluated patients seen by the CPS in the first 6 months of clinic implementation. Primary outcomes included change in weight and proportion of patients with at least 5% weight loss at the end of the study period. Results were compared with patients seen by preventative medicine providers (PMPs) in the same time frame. ResultsA total of 79 patients were seen in the CPS clinic, and 40 met inclusion criteria. The clinic utilization rate was 100%. Mean weight change was −3.6 ± 5.7 kg (P < 0.001), and 25% of patients followed up by the CPS lost at least 5% body weight. In the PMP clinic, 29 patients demonstrated a mean weight change of −1.6 ± 6.0 kg (P = 0.15 compared with baseline), and 17.2% lost at least 5% body weight. ConclusionThis pharmacist-led weight loss clinic demonstrated statistically significant reductions in weight and was able to expand access to care for patients seeking weight loss services.

Comprehensive medication management research gap areas: A call to action for clinical pharmacy researchers

JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACYVolume 4, Issue 10 p. 1260-1262 EDITORIAL Comprehensive medication management research gap areas: A call to action for clinical pharmacy researchers Heather L. Ourth Pharm.D., Corresponding Author heather.ourth@va.gov orcid.org/0000-0001-7687-2305 Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, District of Columbia, USA Correspondence Heather L. Ourth, 110 Timber Ln., Ackworth, IA 50001, USA. Email: heather.ourth@va.govSearch for more papers by this authorM. Shawn McFarland Pharm.D., FCCP, orcid.org/0000-0003-0095-0279 Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, District of Columbia, USASearch for more papers by this authorAshley P. Yost Pharm.D., VA Tennessee Valley Healthcare System, Nashville, Tennessee, USASearch for more papers by this author Heather L. Ourth Pharm.D., Corresponding Author heather.ourth@va.gov orcid.org/0000-0001-7687-2305 Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, District of Columbia, USA Correspondence Heather L. Ourth, 110 Timber Ln., Ackworth, IA 50001, USA. Email: heather.ourth@va.govSearch for more papers by this authorM. Shawn McFarland Pharm.D., FCCP, orcid.org/0000-0003-0095-0279 Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, District of Columbia, USASearch for more papers by this authorAshley P. Yost Pharm.D., VA Tennessee Valley Healthcare System, Nashville, Tennessee, USASearch for more papers by this author First published: 07 October 2021 https://doi.org/10.1002/jac5.1476Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume4, Issue10October 2021Pages 1260-1262 RelatedInformation

Veteran Satisfaction for Upper Respiratory-Tract Infection (URI) Visits Is Not Associated with Antibiotic Receipt But Is Associated with Antibiotic Expectation

Background: Antibiotics are not recommended but are often prescribed for upper respiratory-tract infections (URIs). Prescribers cite patient expectation as a driver of inappropriate antibiotic prescribing; prior literature has demonstrated higher satisfaction scores in patients who receive antibiotics compared to those who do not. We assessed whether veteran satisfaction at URI visits was associated with antibiotic receipt or with reported expectation for antibiotics. Methods: We surveyed veterans with documented URI encounters in the Veterans’ Affairs Tennessee Valley Healthcare System between January 1, 2018, and December 31, 2019. Patients not evaluated in person, with documented dementia, or who died prior to the study start date were excluded. Veterans were asked to recall their URI visit and to complete the Patient Safety Questionnaire (PSQ)-18 (Rand Corporation) and questions assessing antibiotic expectations. The PSQ-18, an 18-item survey that assesses patient satisfaction, uses a 5-point Likert scale (ie, strongly disagree, disagree, uncertain, agree, strongly agree), yielding a composite score of 18–90. Higher scores represent more satisfaction with care. Demographic and visit-specific information were extracted via chart review. We used multivariable linear regression to assess differences in composite PSQ-18 satisfaction scores between those who did and did not receive an antibiotic, adjusted for patient and visit characteristics, and to assess differences in satisfaction scores for those who did and did not report expecting antibiotics, adjusted for antibiotic receipt. Results: We identified 1,435 patients seen for URI at 17 sites. After exclusions, 1,343 veterans were eligible for chart abstraction. After excluding 42 responders who responded after study close or returned blank surveys, the final analytic cohort included 432 (32.2%) of 1,343 responders; 225 (52.1%) received an antibiotic and 207 (47.9%) did not. Mean total satisfaction for veterans who received an antibiotic was 67.8 (SD, ±9.4) compared to 66.7 (SD, ±9.7) for those who did not (Figure 1). Increased total satisfaction was not significantly associated with antibiotic receipt (0.65; 95% CI, −2.0 to 3.3). Most veterans (72.0%) disagreed that visit satisfaction depended on antibiotic receipt. However, only 30.8% reported that they would not expect an antibiotic for URI visits. A significant reduction in total satisfaction (−4.1; 95% CI, −6.3 to −1.9) was associated with expecting compared to not expecting an antibiotic. Conclusions: Our findings suggest that prescribing an antibiotic is not associated with increased veteran satisfaction for URI visits but is associated with expecting an antibiotic. Future work will evaluate methods to change veteran antibiotic expectations.Funding: NoDisclosures: None

Opioid Management in Older Adults: Lessons Learned From a Geriatric Patient-Centered Medical Home.

The United States continues to confront an opioid crisis that also affects older adults. Best practices for prescription opioid management in older adults are challenging to implement in this population. We present our experience with a 1-year management of 48 high-risk older patients who received guideline-based best practices for chronic prescription opioid therapy at a US Department of Veterans Affairs (VA) patient aligned care team (PACT) patient-centered medical home. The GeriPACT population at the Nashville Campus of the VA Tennessee Valley Healthcare System has an enrollment of 745 patients of whom 48 (6.5%) receive chronic prescription opioid therapy. The practice is supported by the VA Computerized Patients Record System, including the electronic patient portal, My healtheVet, and telemedicine capabilities. Data were collected by chart review and operations data. The mean (range) age of patients was 70.4 (66-93) years. Many patients had comorbid conditions, such as diabetes mellitus (35%), congestive heart failure (18.6%), and dementia (8.3%). More than half had an estimated glomerular filtration rates (eGFR) < 60 mL/min, indicating at least stage 3 chronic kidney disease, 41.7% used mental health services (41.7%), and 20.8% had a history of opioid use disorder. Most indications for chronic pain were for musculoskeletal pain (95.8%). The mean (range) morphine equivalent daily dose was 37 mg (10-109). More than half had been seen in the emergency department, and 20.8% had been hospitalized in the previous year for an opioid-related hospitalization, and 3% had expired. Over the year, dose reductions of benzodiazepines or narcotics was performed for 12.5% of patients, accidental overdoses occurred in 4.2%, and positive urine drug screens (UDSs) for cocaine and cannabinoid/tetrahydrocannabinol occurred in 10.4%. One patient was terminated from the program for multiple positive UDSs. Guideline-based patient-centered medical home management of patients with chronic pain who were treated with opioids can be an effective model contributing to the health and well-being of older patients. Complex older patients on chronic opioid treatment are best managed by an interdisciplinary team.

The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly.

Background: Suboptimal care transitions increases the risk of adverse events resulting from poor care coordination among providers and healthcare facilities. The National Transition of Care Coalition recommends shifting the discharge paradigm from discharge from the hospital, to transfer with continuous management. The patient centered medical home is a promising model, which improves care coordination and may reduce hospital readmissions. Methods: This is a quality improvement report, the geriatric patient-aligned care team (GeriPACT) at Tennessee Valley Healthcare System (TVHS) participated in ongoing quality improvement (Plan, Do, Study, Act (PDSA)) cycles during teamlet meetings. Post home discharge follow-up for GeriPACT patients was provided by proactive telehealth communication by the Registered Nurse (RN) care manager and nurse practitioner. Periodic operations data obtained from the Data and Statistical Services (DSS) coordinator informed the PDSA cycles and teamlet meetings. Results: at baseline (July 2018–June 2019) the 30-day all-cause readmission for GeriPACT was 21%. From July to December 2019, 30-day all-cause readmissions were 13%. From January to June 2020, 30-day all-cause readmissions were 15%. Conclusion: PDSA cycles with sharing of operations data during GeriPACT teamlet meetings and fostering a shared responsibility for managing high-risk patients contributes to improved outcomes in 30-day all-cause readmissions.

1130. Optimizing Use of COVID-19 Personal Protective Equipment among Resident Physicians at a Veterans Affairs Hospital

BackgroundCorrect personal protective equipment (PPE) use is key to prevent infection. Observations on a single unit at the Veterans Affairs (VA) Tennessee Valley Healthcare System (TVHS) prior to COVID-19 (October 2019-February 2020) showed low rates of correct PPE use among healthcare workers (HCWs) (Figure 1). In response to the COVID-19 epidemic, the VA implemented new PPE protocols. Based on our initial observations, we were concerned that incorrect use of PPE may increase the risk of COVID-19 exposure among HCWs. Resident physicians, who work at many sites, may be at high-risk for incorrect PPE use due to rapid turnover and limited site-specific PPE training. We aimed to assess and improve COVID-19 PPE use among internal medicine residents rotating at the VA TVHS.Figure 1: Pre-COVID-19 Observations of Adherence to Contact Precaution Protocols at the Veterans Affairs Tennessee Valley Healthcare System MethodsWe used the plan, do, study, act (PDSA) model. Prior to starting VA rotations, residents were emailed PPE education to review. We implemented a 1-hour video conference PPE protocol review at rotation start followed by in-person PPE use evaluations for residents performed by infectious diseases fellows on day 2 and day 5-6 post-review to provide just-in-time educational intervention. Errors at each PPE don/doff step were tracked. Correct PPE use data from both observations were compared using McNemar’s test. Baseline and post-implementation resident surveys assessed PPE use knowledge and comfort.ResultsPre-implementation survey response rate was 72% (21/29); 19/21(91%) reported knowing which PPE to use and 16/21(76%) reported knowing how to safely don/doff PPE. Twenty of 29 (69%) residents completed both observations. Errors decreased by 55% (p=0.0045) from 17/20 (85%) to 6/20 (30%) between initial and follow up observations. Errors in hand hygiene, inclusion of all donning/doffing steps, and PPE reuse decreased, but PPE don/doff order errors increased (Figure 2). Post-project survey response rate was 16/29 (55%). All 16 reported knowing which PPE to use and how to safely don/doff PPE, and 11/16 (69%) residents felt both online and in-person interventions were helpful.Figure 2: COVID-19 PPE Errors and Correction Types by Observation ConclusionCorrect COVID-19 PPE use is essential to protect HCWs and patients. Just-in-time education intervention for PPE training may yield higher correct use compared to pre-recorded or online training.Disclosures All Authors: No reported disclosures

COVID-19 and Venous Thromboembolism Pharmacologic Thromboprophylaxis.

Coagulopathy has emerged as a hallmark issue of the coronavirus 2019 (COVID-19). Medical facilities are faced with the challenge of developing institutional thromboprophylaxis protocols; however, due to the novelty of the disease, there is a dearth of high-quality, prospective evidence for decision making. The US National Institutes of Health along with 4 leading societies in the fields of thrombosis and hemostasis have published guidance based on expert consensus that helps provide a framework for local policy development. While there is agreement in a few areas, there are notable and sometimes considerable differences in recommendations that facilities should discuss when developing local guidance. This document aims to streamline and simplify the available guidance so health care providers can readily identify consensus and divergence of COVID-19 thromboprophylaxis recommendations. Additionally, the authors provide and briefly highlight the COVID-19 thromboprophylaxis protocol of the US Department of Veterans Affairs Tennessee Valley Healthcare System in Nashville and Murfreesboro to serve as an example of a guideline-directed approach for order-set development.

4417 Association between Brain Volumes and Posttraumatic Stress Disorder in Intensive Care Unit Survivors

OBJECTIVES/GOALS: To explore the severity of posttraumatic stress disorder (PTSD) symptoms in association with hippocampal and amygdala volumes in ICU survivors. We hypothesize that the severity of posttraumatic stress symptoms in ICU survivors is associated with lower volumes of both the hippocampus and amygdala. METHODS/STUDY POPULATION: Secondary analysis of the VISIONS study, a prospective sub-study of the BRAIN-ICU cohort, which included survivors of critical illness. Patients were screened for preexisting PTSD before discharge. The PTSD Checklist Specific (PCL-S) was used at 3 and 12 months to evaluate the ICU as a traumatic experience. A score of &gt;30, indicated significant symptoms of PTSD. A Philips Achieva 3T MRI scanner was used to scan patients at both discharge and 3-month follow-up. To compare median brain volumes at discharge and 3 months for those with and without significant PTSD symptomatology (PCL-S ≥30) at 3 and 12 months, we used a Kruskal-Wallis (KW) equality-of-populations rank test. RESULTS/ANTICIPATED RESULTS: The median age for our sample was 58.5 (52.6, 63.7). One-third of the sample was female, and 90% were Caucasian. Fifty-seven percent of individuals (N = 12) had at least one prior mental health diagnosis, with two having a prior history of PTSD. One third of individuals experienced delirium during their critical illness. At 3-month follow up, there were three patients with PTSD symptomatology and one at 12-month follow up. Median brain volumes (hippocampus or amygdala) did not differ between individuals with or without PTSD symptomatology at either 3 or 12 months (p-values for all tests &gt;0.05). DISCUSSION/SIGNIFICANCE OF IMPACT: Although our study did not reveal significant differences in brain volumes between PTSD patients and non-PTSD patients, sample size is a major limitation and larger scale studies should be undertaken to elucidate possible neurobiological markers of PTSD in ICU survivors. CONFLICT OF INTEREST DESCRIPTION: Dr. Wilson would like to acknowledge salary support from the Vanderbilt Faculty Research Scholars Program (1KL2TR002245), HL111111 and GM120484. Drs. Ely and Jackson as well as Mrs. Kiehl all receive funding for their time working on this investigation from AG035117 and HL111111. Dr. Ely would additionally like to acknowledge salary support from the Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC). Dr. Ely will also disclose additional funding for his time from AG027472 and having received honoraria from Orion and Hospira for CME activity; he does not hold stock or consultant relationships with those companies. The authors would like to acknowledge the following: this work was conducted in part using the resources of the Center for Computational Imaging at Vanderbilt University Institute of Imaging Science and the Advanced Computing Center for Research and Education at Vanderbilt University, Nashville, TN, and study data were collected and managed using REDCap electronic data capture tools hosted at Vanderbilt University.

Temporal trends in receipt of adjuvant chemotherapy for veterans with colorectal cancer.

e19171 Background: For patients with National Comprehensive Cancer Network (NCCN) high risk stage II or stage III colorectal cancer (CRC), adjuvant chemotherapy improves disease free (DFS) and overall survival (OS). Rates of use vary significantly across health care settings. Several demographic and healthcare factors are associated with decreased receipt of chemotherapy; however, few studies have assessed utilization patterns over time. We evaluated receipt of chemotherapy from 2000-2015 among patients treated at a Southeast Regional Veterans Health Administration (VHA) facility to determine local targets for quality improvement initiatives. Methods: We reviewed 1,107 electronic medical records of patients undergoing colorectal surgery from January 1, 2000 to December 31, 2015 at VHA Tennessee Valley Healthcare System. We included patients with NCCN eligible pathologic high risk stage II (T4/perf, R1, &lt; 12LN, LVI) or stage III CRC and excluded for age ≥80, age ≥75 hospitalized in the prior year with a major co-morbidity, and death or hospice within 30 days of surgery. The primary predictor was year of surgery, partitioned 2000-2005 (N = 60), 2006-2010 (N = 64), 2011-2015 (N = 56) to reflect changes in NCCN guidelines. The primary outcome was receipt of any chemotherapy. Results: Of 1,107 colorectal surgeries, we excluded 623 for non-cancers, 212 for stage I or low-risk stage II cancer, 47 for metastatic disease, and 45 for age, co-morbidity, death, and hospice, yielding a final cohort of 121 colon and 59 rectal cancers. Most patients were male (96%), white (79%), with median age 64 years [Interquartile Range 60, 70]. Overall, 117 of 180 (65%) received chemotherapy with a median time to treatment of 50.5 days [40,64]. Adjusting for known correlates, receipt of chemotherapy decreased over time; 2000-2005 (72%), 2006-2010 (69%), 2011-2015 (53%) p = 0.02. Regardless of CRC stage, more patients declined chemotherapy in 2011-2015 (27%) compared to 2000-2005 (6%) and 2006-2010 (8%) p &lt; 0.01. Conclusions: We identified decreased utilization of adjuvant chemotherapy in a non-elderly veteran cohort, which appeared to be due to patients declining chemotherapy regardless of cancer stage. Understanding patient and provider decisions around adjuvant chemotherapy and evaluating trends outside the VHA may offer important insights to implementing quality improvement measures.

Impact of travel distance on timeliness of adjuvant chemotherapy in veterans with colorectal cancer.

e19159 Background: Rural patients have well described disparities in quality cancer care. The VA Budget and Choice Improvement Act (2015) and VA Mission Act (2018) were passed to increase timely access to cancer care for veterans living at greater distances from VA facilities by paying for community oncology care. We sought to evaluate the baseline timeliness of adjuvant colorectal cancer (CRC) chemotherapy among patients living at increased distances from the Veterans Health Administration Tennessee Valley Healthcare System (VHA-TVHS) to determine local metrics for quality improvement initiatives. Methods: We reviewed 1,107 electronic medical records of patients with colorectal surgeries from January 1, 2000 to December 31, 2015 at the VHA-TVHS. We included patients with NCCN eligible pathologic high-risk stage II (T4/perf, R1, &lt; 12LN, LVI) or stage III CRC and excluded those age ≥80, age ≥75 hospitalized in the prior year with a major co-morbidity, and death or hospice within 30 days of surgery. Primary exposure was travel distance from central zip code of patient residence to VHA-TVHS, categorized &lt; 50 miles (N = 64), 55-99 miles (N = 60), and ≥ 100 miles (N = 56) to account for changes in referral patterns. Outcomes were days from surgery to first chemotherapy treatment and achieving a VHA timeliness standard of 56 days. Eligible patients not receiving chemotherapy were capped at 120 days per Commission on Cancer standard. Results: Of 1,107 colorectal resections, we excluded 623 for non-cancer, 212 for stage I or low risk stage II, 47 for metastases, and 45 for age, co-morbidity, death, and hospice, yielding a final cohort of 121 colon and 59 rectal cancer patients. Patients were predominantly male (96%), white (79%), and median age 64 years [Interquartile Range 60, 70]. Median days to chemotherapy were 62.5 days [48.5, 120] for those who lived &lt; 50 miles, 58.5 days[46.5, 120] for distance 50-99 miles, and 84 days [50.5, 120]) for distance ≥ 100 miles. There were only 41%, 48%, and 32% in each distance group meeting the 56-day standard, respectively. Adjusting for known correlates, time to chemotherapy was 10.6 days longer for patients living ≥ 100 miles compared to &lt; 50 miles (p = 0.08). Conclusions: Distance to care may influence timeliness of chemotherapy among southeast regional veterans. Given the observed overall low rate of timely chemotherapy, understanding modifiable health system factors associated with omissions and delays, as well as the impact of recent VA legislation merits further exploration.

Coronavirus Disease 2019: Withdrawing Mechanical Ventilation to Reallocate Life Support Under Crisis Standards of Care-Nonequivalence of the Equivalence Thesis.

Coronavirus Disease 2019: Withdrawing Mechanical Ventilation to Reallocate Life Support Under Crisis Standards of Care-Nonequivalence of the Equivalence Thesis.

Travel distance and time to adjuvant chemotherapy in veterans with colorectal cancer.

84 Background: Patients from rural areas have well described disparities in quality cancer care. We hypothesized that longer travel distance is associated with less chemotherapy acceptance and less timely treatment. Methods: We reviewed 705 electronic medical records of patients with colorectal surgeries from January 1, 2000 to December 31, 2015 at the Veterans Health Administration Tennessee Valley Healthcare System. Two trained abstractors reviewed standard elements (k = 0.79 – 0.92). The study sample included patients with pathological stage high risk II or III CRC and excluded those with metastatic disease or documented National Comprehensive Cancer Network (NCCN) defined medical exclusions from chemotherapy. Primary exposure was distance to care calculated from central zip code of residence to Nashville infusion center. Primary outcomes were receipt of any chemotherapy, and days from surgery to first treatment (truncated at 120 days). We analyzed 2 populations; chemotherapy received and a second sensitivity population who were eligible for, but did not receive, chemotherapy (no documentation of NCCN ineligibility or declined). Results: Of 705 colorectal resections, we excluded 262 for non-cancer, 220 for stage I or low risk stage II, and 46 for NCCN exclusion criteria, yielding 177 cases: 120 colon and 57 rectal. Most patients were male (98%) and white (85%); median age was 64 [Interquartile Range 60, 70]. Distribution by travel distance was 60/177 [33.9%] &lt; 50 miles, 61/177 [34.5%] 50-99 miles, and 56/177 [31.6%] &gt; 100 miles. Of all eligible patients, 123/177 [69.5%] patients received chemotherapy and 54/177 [30.5%] did not receive chemotherapy. Among receivers, median times to treatment were 52 days [40, 61] &lt; 50 miles; 48.5 [40,61] 50-99 miles; and 54 [43,77] &gt; 100 miles, p = 0.3. Patients not receiving chemotherapy varied by distance: 15/60 (25%) &lt; 50 miles; 18/61 (30%) 50-99 miles; 21/56 (38%) &gt; 100 miles, p = 0.3. Including non-receivers, median times to treatment were 58 days [43, 120] &lt; 50 miles; 58.5 [46.5, 120] 50-99 miles; and 80 [48.5, 120] &gt; 100 miles, p = 0.1. Conclusions: Distance to care may influence acceptability of chemotherapy. Understanding patient/provider reasons for omission merits exploration.