Unplanned Encounters Research Articles

Socioeconomic Deprivation Correlates With Incomplete Radiotherapy Treatment in Head and Neck Cancer

There is a high burden of socioeconomic deprivation across Merseyside and, along with this, poorer cancer outcomes. The incidence of head and neck squamous cell carcinoma (HNSCC) within this region is higher than the national average and there are often additional complexities to individual treatment pathways such as poor health literacy, lack of social support and transport options which can impact on adherence to prescribed treatments. AimsThis work aims to understand the impact of deprivation on patients diagnosed with HNSCC undergoing chemoradiotherapy (CRT) or radiotherapy (RT) treatment by identifying barriers to adherence. Materials and methodsPatients with HNSCC treated between June 2022 and June 2023 were included and data was collected through retrospective case note review. Approval was obtained from relevant NHS institution audit departments. Key examined variables were indices of multiple deprivation (IMD), unplanned admission rate, hospital transport use, social support network and provision of additional ad hoc appointments during treatment courses. All were correlated with missed radiotherapy appointments. ResultsOut of 359 evaluable patients there were high levels of unplanned appointments with health professionals during CRT/RT (71% of those receiving CRT and 55% of those having RT). 11% (n = 39) missed at least one radiotherapy appointment with the commonest reason being unplanned admission to hospital. Despite missed appointments, 25/39 patients completed treatment within prescribed window due to effective RT compensation strategies. On multivariate analysis, unplanned admission, hospital-provided transport and crime deprivation quintiles (p=<0.001, p = 0.007 and p = 0.027, respectively) were found to significantly increase the chance of missed radiotherapy treatment appointments. ConclusionHigh levels of unplanned encounters with health care professionals are encouraging adherence to non-surgical HNSCC treatments. Formalising these ad hoc appointments will provide an equitable, robust service. Undertaking hospital transport increases the potential for missed treatment appointments. Gaining insight into patient experiences and investing in improved transport services are essential for maximising adherence.

Factors associated with unplanned clinical encounters for ureteral stent-related symptoms.

Ureteral stent-related symptoms (USRS) often result in unplanned phone calls and ER visits. We hypothesize that patient factors can be identified to predict these unplanned encounters. Retrospective analysis of indwelling ureteral stent placements from 2014 to 2019 at a single institution by CPT code was performed. Patient demographics, discharge medications, and clinical factors were evaluated using multiple logistic regression with respect to postoperative telephone and emergency room (ER) encounters for USRS. Of 374 patients, 75 (20.1%) had one or more encounters for USRS: 48 (12.8%) called the clinic and 39 (10.4%) returned to the ER. Chronic opioid use was predictive of calls to clinic and ER visits (OR 3.21 [CI 1.42-6.97], p < 0.01 and OR 3.64 [CI 1.45-8.98], p < 0.01). Survival analysis stratified by history of chronic opioid use and discharge opioid prescriptions demonstrated that opioid naïve patients receiving opioids at discharge had unplanned encounters sooner and more often [Calls p = 0.025, ER p = 0.041]), whereas patients with chronic opioid usereturned to the ER sooner and more frequently when prescribed additional opioids (Calls p = 0.4, ER p = 0.002). Patients with a history of chronic opioid use may experience more intense USRS or have a lower threshold to seek medical care than opioid naïve patients and tend to bypass calling the clinic for the ER. Given that none of the studied medications reduced unplanned patient contact for USRS, urologists should consider upfront definitive management of urinary obstruction when appropriate.

2843. Risk Factors for Unplanned Healthcare Encounters in Patients Discharged from the Emergency Department with Extended-spectrum β-lactamase Urinary Tract Infections

Abstract Background The management of extended spectrum β-lactamase (ESBL) urinary tract infections (UTIs) in the emergency department (ED) has not been well documented in literature. The purpose of this study was to describe treatment and outcomes of patients with ESBL UTIs in the ED, which can inform best practices for antimicrobial stewardship. Methods This IRB approved, retrospective cohort analysis included patients who were discharged from the ED with an ESBL UTI between January 2020 and November 2022. The primary outcome of interest was any unplanned healthcare encounter related to the UTI within 30 days of the index ED visit, which included phone/virtual visits, clinic visits, ED visits, and hospitalizations. Patients ≥18 years of age treated for symptomatic UTI with a monomicrobial urine culture were included, while those with altered mental status, history of renal transplant, abnormal urinary tract, or were on active antibiotic therapy prior to the ED visit were excluded. Patient characteristics, initial and definitive antibiotic therapy, culture results including pathogen and susceptibilities were described. Logistic regression analysis was used to identify any exposures that were independently associated with unplanned healthcare encounters related to the UTI. Results 162 patients were included; 103 (64%) had an unplanned healthcare encounter. Patient characteristics are depicted in Table 1. Complicated lower UTI was most frequent occuring in 71 patients (44%). Susceptibility data revealed that nitrofurantoin was effective in 121 (75%) patients, aminoglycosides in 117 (72%) patients, TMP/SMX in 66 (41%) patients, and quinolones in 62 (38%) patients. 76 (74%) patients with unplanned encounters received an inactive empiric prescription: β-lactams being prescribed to 52 (51%) patients with cephalexin used for 49/52 (94%). Of the 81 patients with lower UTI, 20 (25%) initially received a prescription for nitrofurantoin. Factors associated with an unplanned healthcare encounter are described in Table 2.Table 2.Factors Associated with Unplanned Healthcare Encounters. Abbreviations: Un-Adj OR = unadjusted odds ratio; Adj OD = adjusted odds ratio Conclusion Patients discharged from the ED with an ESBL UTI were at higher risk for unplanned healthcare encounters if they had CKD or were initially prescribed an oral β-lactam. Prescribing first line therapy with nitrofurantoin for lower UTI is a potential area for improvement. Disclosures Michael Veve, PharmD, MPH, National Institutes of Health: Grant/Research Support|Paratek Pharmaceuticals: Grant/Research Support

Road trip field course

ABSTRACT Field study and field courses are integral to the discipline of geography. While there are many forms that a field course might take, in this paper we draw on two university-level field courses in the U.S. Southwest to propose a road trip pedagogy for field study. We reflect on the particular resonance of the road trip in the American West and how Western road trip mythology, combined with our own road trip experiences, helped shape the design of two road trip field courses. The educational value of both planned and un-planned encounters is a key strength of a road trip field course. We conclude by briefly reflecting on two future considerations for road trip pedagogy: possibilities for aligning anti-racist pedagogy with road trip pedagogy and the potential transferability of our American West road trip to other locations.

Law and (Dis)order in the South China Sea: Analyzing Maritime Law-Enforcement Activities in 2010–22

executive summary: This article assesses the role of maritime law-enforcement (MLE) vessels in an apparent trend of heightened competition in the South China Sea and identifies patterns in the maritime policing by MLE vessels of the disputing South China Sea claimants during unplanned encounters at sea. main argumentThe South China Sea disputes, involving six political entities—China, Taiwan, Vietnam, Malaysia, Brunei, and the Philippines—have been a political flashpoint in Southeast Asia since the 1970s. The emergence and growing prominence of civilian MLE vessels (conventionally known as marine police or coast guard vessels) suggests that disputants are taking new measures to assert their claims without overtly militarizing them. Maritime policing has increased in frequency and intensity in the past decade. Yet, when considering four factors—the use of forcible measures, physical damage, human injuries/casualties, and diplomatic protests—an analysis of publicly reported naval incidents in the South China Sea between 2010 and 2022 suggests that conflict escalation primarily happens at sea between the crews. Such incidents, which range from single-day events to months-long confrontations, have, in the worst cases, resulted in intense diplomatic standoffs lasting longer than two months. In general, however, disputants have refrained from taking hostile political or legal actions against harassment at sea. policy implications• Given that reducing misunderstanding and mitigating the risks of physical confrontations is of benefit to all the South China Sea disputants, ongoing talks for a code of conduct for the sea should include a proper legal framework for MLE operations. This framework—to be separate from the existing Code for Unplanned Encounters at Sea, which only applies to naval vessels—should stipulate the threat and/or use of force at sea by MLE vessels because coast guard enforcement duties may require different levels of force. • Disputants should re-establish and refocus talks to address joint fisheries and marine resource management in disputed waters. They would also benefit from reinforcing the regional hotline for maritime emergencies and setting up a crisis management hotline at the coast guard level. • Regional MLE agencies should increase communications both onshore and offshore and hold joint exercises and exchanges that would increase mutual understanding and trust, which would subsequently help prevent unexpected consequences.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events. A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed. 1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p=0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p=0.009). There was no difference in unplanned encounters across repair types (p=0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter. The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution. The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

The practical dilemma and solutions of international ship-aircraft encounter rules on sea: A Chinese perspective

The fragmentation of international ship-aircraft encounter (SAE) rules has led to practical difficulties; as such, it is necessary to establish an integrated set of regulations for international SAEs. Based on the theoretical considerations of international law and the rules of the Code for Unplanned Encounters at Sea (CUES) and other SAEs, dispute resolution mechanisms such as international arbitration, diplomatic channels, the International Court of Justice, and Alternate Dispute Resolution have been carefully selected as implementation pathways. However, the global stakeholders are facing the fragmentation of such rules in different ways. To this end, this study thoroughly analyses the fragmentation of the international SEA rules and unresolved pertinent issues. While highlighting the reasons and potential threats of the fragmentation, the present paper also provides Chinese and global perspectives to resolve the issues with appropriate recommendations collectively. It concludes that such fragmentation of navigation rules and dispute resolution mechanisms—if effectively addressed with harmonising existing rules and unified international rules—can centrally resolve the encounters between ships and aircraft in the process of international voyages and form a basic, unified understanding of some of the most representative issues.

Serendipity in Science

Prior literature has noted that serendipitous discoveries have played an important role in science. Scholars who have explored the phenomenon generally agree that researchers with a prepared mind stand to benefit from unplanned encounters. However, there are two contrasting perspectives on what form of a prepared mind would be most beneficial. Some scholars have suggested that an open mind would be helpful while others argue that deep experience would be most favorable. Yet, due to its spontaneous nature, serendipitous discoveries have been difficult to study in a systematic manner. In this paper, we leverage a policy shock in which the shelving orders of journals in university libraries were exogenously shifted due to a change in the Anglo-American Cataloging Rules between 1981 to 1989, exposing researchers to unsought journals. In this natural experiment, we find that researchers with a broad set of knowledge, compared to ones with narrow expertise, are more likely to gain from serendipitous encounters.

Editors' Notes on Themed Issue on Civil Society Education: East Asia

This is the fourth themed issue in the Journal of Nonprofit Education and Leadership (JNEL) in which researchers around the world examine regional and national training and education programs for individuals with civil society leadership roles. The issue has its origin in a post-conference airport meeting a few years ago between one of the editors of this series of themed issues and a set of prominent scholars from East Asia. As most researchers would confirm, the value of a research conference is seldom found in the various seminars or panels, but rather in the unplanned encounters that take place at breakfast, over a coffee, or—in this case—at the airport. The mere airport happenstance turned out to be the beginning of several valuable research initiatives. Since then, among other things, the authors and the editors have met and organized public disseminations, including the Nonprofit Higher Education Research Summit at he ISTR International Conference in 2021. The overall result is not only a significant contribution to the series of themed issues, but also, and more importantly, the first mapping of programs in nonprofit and nongovernmental management education in East Asia.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis

Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events. All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated. 438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p=0.04). The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries. Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

MP08-04 USE OF PRE-OPERATIVE TESTOSTERONE PRIOR TO DISTAL HYPOSPADIAS REPAIR DOES NOT INCREASE POST-OPERATIVE COMPLICATIONS

You have accessJournal of UrologyCME1 May 2022MP08-04 USE OF PRE-OPERATIVE TESTOSTERONE PRIOR TO DISTAL HYPOSPADIAS REPAIR DOES NOT INCREASE POST-OPERATIVE COMPLICATIONS Sahar Eftekharzadeh, Sameer Mittal, Nathan Hyacinthe, Dana A. Weiss, Jason Van Batavia, Aseem R. Shukla, Arun K. Srinivasan, Thomas F. Kolon, Stephen A. Zderic, Douglas A. Canning, Mark R. Zaontz, and Christopher J. Long Sahar EftekharzadehSahar Eftekharzadeh More articles by this author , Sameer MittalSameer Mittal More articles by this author , Nathan HyacintheNathan Hyacinthe More articles by this author , Dana A. WeissDana A. Weiss More articles by this author , Jason Van BataviaJason Van Batavia More articles by this author , Aseem R. ShuklaAseem R. Shukla More articles by this author , Arun K. SrinivasanArun K. Srinivasan More articles by this author , Thomas F. KolonThomas F. Kolon More articles by this author , Stephen A. ZdericStephen A. Zderic More articles by this author , Douglas A. CanningDouglas A. Canning More articles by this author , Mark R. ZaontzMark R. Zaontz More articles by this author , and Christopher J. LongChristopher J. Long More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002530.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pre-operative Testosterone (T) administration prior to hypospadias repair with the goal of improving surgical outcomes is a common practice among pediatric urologists, however, there is some literature suggesting an increase in complications. We hypothesized that T administration prior to repair of distal hypospadias would not result in higher rates of complications or unplanned encounters. METHODS: A single-institution prospective database of hypospadias patients was queried to identify primary single-stage distal hypospadias repairs from 2016 to 2021. Patients with known T administration status and documented intraoperative measurement of glans width (GW) were included.Our primary goal was to compare complication rates, unfavorable cosmetic outcomes (i.e. redundant skin, skin bridge, etc.), unplanned encounters (i.e. unplanned office visits, ED visits and readmissions), and reoperation rates between patients who received T vs those who did not. Multivariable logistic regression analysis was used to determine role of T administration in incidence of unfavorable outcomes, unplanned encounters, and reoperation. RESULTS: Of 1545 hypospadias repairs, 542 (35%) patients with a median age of 0.7 years (IQR: 0.6, 1.0) at surgery and a median follow-up of 18 months (IQR: 6, 32) were included in this study. 176/542 (33%) patients received T prior to surgery [Table]. There was no significant difference in surgical outcomes, cosmetic outcomes, unplanned encounters, and 30-day complications between the two groups. Multivariate analysis demonstrated that when controlled for race, ethnicity, and age at surgery, incidence of unplanned encounters and unfavorable outcomes were not affected by administration of T (p>0.05). Additionally, Multivariate analysis showed that Black and African-American patients were at higher risk for unplanned encounters compared to others (OR: 3.3, 95%CI: 1.4 - 7.6, p<0.01). CONCLUSIONS: Pre-operative T administration results in a significant increase in penile glans width. For single-stage repair of distal hypospadias, T is safe and does not increase the rate of surgical complication development. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e126 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sahar Eftekharzadeh More articles by this author Sameer Mittal More articles by this author Nathan Hyacinthe More articles by this author Dana A. Weiss More articles by this author Jason Van Batavia More articles by this author Aseem R. Shukla More articles by this author Arun K. Srinivasan More articles by this author Thomas F. Kolon More articles by this author Stephen A. Zderic More articles by this author Douglas A. Canning More articles by this author Mark R. Zaontz More articles by this author Christopher J. Long More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP44-15 EARLY EXPERIENCE WITH VACUUM ASSISTED URETERAL ACCESS SHEATHS

You have accessJournal of UrologyCME1 May 2022MP44-15 EARLY EXPERIENCE WITH VACUUM ASSISTED URETERAL ACCESS SHEATHS Daniel Wong, and Alana Desai Daniel WongDaniel Wong More articles by this author , and Alana DesaiAlana Desai More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002610.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vacuum assisted ureteral access sheaths (V-UAS) have been eagerly adopted with the hopes of improved surgical outcomes. Reports from outside the US have found increased stone free rates, decreased operative times, and decreased infectious complications with V-UAS. However there have been no data published from the US. Herein, we report our findings 1 year after implementation of Clearpetra V-UAS at our institution. METHODS: From May 2020 to September 2021, all unilateral ureteroscopy cases by a single surgeon using a V-UAS (Clearpetra) were retrospectively reviewed. These were compared to matched cases using an institutional database of stone cases from 2016 to May 2020, when Clearpetra became available. Cases were matched based on regular ureteral access sheath use, surgeon, stone burden, preexisting ureteral stent, preoperative UTI, and neurogenic bladder. Outcomes of interest were stone free rate as determined by follow up ultrasound or CT scan within 3 months of procedure and postop infection defined by T >38°C, WBC >12K or <4K, HR >90, or UTI within 30 days of procedure. RESULTS: There were 27 unique V-UAS cases identified. Randomly matched cases were compared for operative time, stone free rate, infectious complications, and 30-day unplanned encounters. There were no differences in any outcomes of interest (Figure 1). CONCLUSIONS: V-UAS performed on par with standard ureteral access sheaths. There was no increase in complication rate or unplanned encounters, indicating V-UAS is a safe treatment option. V-UAS offered no benefit in terms of operative time, stone free rate, or infectious complications in this initial cohort. It remains to be seen whether there is an optimal stone characteristic for V-UAS or whether V-UAS requires an initial learning curve for improvement. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e758 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Wong More articles by this author Alana Desai More articles by this author Expand All Advertisement PDF DownloadLoading ...

The symbolic costs of advice: how social situations explain the occurrence of unplanned knowledge sharing interactions

PurposeInformal knowledge sharing interactions (IKSI) are of particular value for innovation projects. This is especially true for unplanned IKSI, because they are even more likely to provide non-redundant knowledge and new perspectives than planned IKSI. Seminal studies have shown that the formation of unplanned IKSI can be explained on the basis of spatial structures. Strictly speaking, however, these studies only explain unplanned encounters. Whether unplanned IKSI result from these unplanned encounters, though, cannot be satisfactorily explained on the basis of spatial configurations alone. The purpose of this paper is to tackle this explanatory gap by unraveling the fundamental social processes by application of the symbolic interaction theory.Design/methodology/approachFor this purpose, the formation of 132 IKSI on innovation projects from three research and development departments of large companies was recorded in detail using a combination of diaries and interviews. The data were analyzed using qualitative content analysis.FindingsThe analysis reveals that IKSI cause symbolic costs (image damages), and that these costs vary between types of social situations. Because actors anticipate situation-specific costs, their propensity to initiate IKSI can be explained in terms of the situations in which they encounter one another. Furthermore, the analysis reveals six particularly relevant characteristics of situations and further elaborates the basic argument by analyzing their functioning.Originality/valueThe paper complements previous explanations of unplanned IKSI by opening up the social processes underlying their formation.

157. Impact of Pharmacist-Generated Oral Antimicrobial Test Prescription on Discharge Medication Access and Outcome

BackgroundCost barriers to accessing discharge oral antimicrobials (ABX) may delay discharges and result in suboptimal discharge ABX. Use of electronic test prescriptions (eTP) or “price checks” is controversial due to potential for erroneous dispensing. This study evaluated discharge ABX access and outcome after implementation of a standardized, inpatient pharmacist-initiated ABX eTP process in collaboration with discharge pharmacy. MethodsIRB approved, retrospective, cross-sectional cohort pilot-study. Inclusion: home bound adults admitted for ≥ 72 hours from 1/1/18-2/28/19 and discharged on oral ABX. Patients with an ABX eTP prior to discharge were compared to those discharged on ABX but no eTP. Data were reported using descriptive statistics and bivariate analysis. Primary endpoint: discharge delay after medical stability. Secondary endpoints: medication access, unplanned encounters, and % of patients discharged on first-line ABX. Results84 patients included: 43 no-ETP and 41 eTP. 75 ABX eTP evaluated among 41 patients. Patients in the no-eTP group had higher Charlson comorbidity index (P = 0.004) and immunosuppression (24% vs. 12%; P = 0.014). Median length of stay, days: 6 (5 – 9) eTP vs. 8 (5 – 15) no-eTP (P = 0.026). Most common eTP requested by pharmacist: linezolid (17, 23%) and oral vancomycin (12, 16%) (Figure 1). eTP results were documented in the medical record in < 24 hours for 66 (88%) of inquiries. 49 (65%) prescriptions were approved by insurance; 16 (21%) had no out of pocket cost and 8 (11%) required prior authorization (PA) (Table 1). Linezolid (5, 35%) and public insurance (10, 71%) were frequently associated with barriers. 29 (70%) patients were discharged on the same ABX as the eTP. There were no discharge delays or erroneous dispensing. 14 (33%) no-eTP and 15 (37%) eTP patients experienced unplanned healthcare encounters after discharge. 9/84 (11%) patients were discharged on suboptimal ABX. Non-white race 8/9 (89%) P = 0.047 and public insurance 8/9 (89%) P = 0.063 were associated with suboptimal discharge ABX.Figure 1. Oral Antimicrobial Test Prescription Pattern (n=75) Table 1. Oral Antimicrobial Test Prescription Result (n=75) ConclusionA standardized eTP process appears to be a safe way to evaluate out of pocket cost without prolonging length of stay. Future work will focus on inequity in access to first line ABX.Disclosures Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

Long-term outcomes of 265,737 patients hospitalised with atrial fibrillation and atrial flutter from 2008 to 2015

Abstract Background Atrial fibrillation/atrial flutter (AF/AFL) hospitalisations are common, however, little is known about the long-term outcomes of these episodes. Objective To examine the incidence of mortality, all-cause and cause-specific re-hospitalisations at up to 8 years after a hospitalisation for AF/AFL. Methods Unique patients hospitalised with a primary diagnosis of AF/AFL from 2008–2015 were identified using nation-wide hospitalisation data from Australia and New Zealand. All-cause mortality was the primary outcome. Secondary endpoints included all-cause and cause-specific re-hospitalisations. Results were reported as incident rate per 100 patient-years. Results We included 265,737 patients (mean age 69.9±13.9y, female 45.2%, elective 28.7%). The median length of stay was 1 day (Interquartile range [IQR] 0–4 days) and the median CHA2DS2-VASc score was 2 (IQR 1–2). During the index hospitalisation, 9,837 (3.7%) patients underwent catheter or surgical ablation and 52,634 (19.8%) underwent cardioversion. During the median follow-up time of 3.4 years (range 0–8.0 years), 53,669 patients died (incident rate of 5.7/100 patient-years) with a survival probability gradually decreasing from 92.8% (95% CI 92.7–92.9%) at 1-year to 65.4% (95% CI 64.9–65.8%) at 8-years post-discharge (Table 1 and Figure 1). All-cause re-hospitalisations occurred in 210,118 patients (incident rate of 22.2/100 patient-years) with a rehospitalisation-free survival probability of 7.1% (95% CI 6.9—7.3%) at the end of follow-up. Unplanned re-hospitalisations occurred more frequently than planned episodes (incident rate of 17.2 vs. 16.6/100 patient-years respectively). AF/AFL accounted for 25.1% of all-cause re-hospitalisations (incident rate of 8.9/100 patient-years) and the probability of freedom from re-hospitalisations for AF/AFL was 55.4% (95% CI 55.0–55.8%) at 8-years. Incident rates of re-hospitalisations for catheter ablation (1.5/100 patient-years), stroke (1.6/100 patient-years), heart failure (2.7/100 patient-years), and acute myocardial infarction (1.0/100 patient-years) were low. In subgroup analyses, worse survival was observed in female patients, older age groups, patients with comorbid heart failure, hypertension, diabetes, and those who did not undergo ablation during the index hospitalisation. Conclusion Nearly two-thirds of patients were surviving by 8-years following an AF/AFL hospitalisation with a low rate of re-hospitalisations for stroke, heart failure, and myocardial infarction. However, re-hospitalisations for recurrent atrial arrhythmia were common. Efforts to reduce re-hospitalisations, especially unplanned encounters, are required to improve patient outcomes. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of Australia

PD10-11 INTRAOPERATIVE CONTRAST ENHANCED ULTRASOUND TO REDUCE UNNECESSARY URETERAL STENT PLACEMENT AFTER URETEROSCOPY

You have accessJournal of UrologyImaging/Radiology: Uroradiology I (PD10)1 Sep 2021PD10-11 INTRAOPERATIVE CONTRAST ENHANCED ULTRASOUND TO REDUCE UNNECESSARY URETERAL STENT PLACEMENT AFTER URETEROSCOPY Justin Ahn, David Bayne, Fadl Hamouche, Marshall Stoller, and Thomas Chi Justin AhnJustin Ahn More articles by this author , David BayneDavid Bayne More articles by this author , Fadl HamoucheFadl Hamouche More articles by this author , Marshall StollerMarshall Stoller More articles by this author , and Thomas ChiThomas Chi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001978.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stents are a significant source of morbidity. The decision to place one at the time of retrograde intrarenal surgery (RIRS) is often subjective. A reliable tool is needed to guide urologists and avoid unnecessary stent placement. Contrast enhanced ultrasound (CEUS) is a safe, readily adaptable technology where a microbubble contrast agent is instilled into the upper urinary tract (Figure 1). We propose an intraoperative retrograde CEUS test during RIRS to help predict post-operative ureteral drainage and the need for ureteral stent placement. METHODS: For this pilot feasibility study, we performed CEUS in patients undergoing RIRS for nephrolithiasis. After stone treatment, the renal collecting system was decompressed, then 1 ml of CEUS contrast and a 2 ml flush was instilled per ureteral catheter. For the flush, iodinated contrast was substituted for saline to permit comparison with fluoroscopic drainage. After catheter removal and 2 minutes for ureteral rest, the bladder was cycled with irrigation and then scanned with CEUS and fluoroscopy for passage of either contrast agent (Figure 1). Ureteral stent placement was determined based on preexisting standard of care. Post-operative unplanned encounters (PUE) were tracked. RESULTS: 41 renal units underwent CEUS during RIRS (Figure 2). Stent omission was successful with no PUE in 91% with CEUS drainage. Compared to those who had a stent placed based on no CEUS drainage, those who did not have a stent based on drainage had a significantly lower incidence of complications (9% vs 53%, p=0.006) Fluoroscopic drainage was discordant with CEUS drainage in 12 renal units. In all cases of discordance, drainage was seen on CEUS but not on fluoroscopy. CONCLUSIONS: CEUS is a novel means to objectively assess upper tract drainage at the time of RIRS. Our results suggest that retrograde CEUS could predict successful stent omission and may be more sensitive for predicting drainage than fluoroscopy due to low contrast volumes. Source of Funding: AUA Care Foundation © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e131-e131 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Ahn More articles by this author David Bayne More articles by this author Fadl Hamouche More articles by this author Marshall Stoller More articles by this author Thomas Chi More articles by this author Expand All Advertisement Loading ...

Preferences in Oncology History Documentation Styles Among Clinical Practitioners.

Clinical notes function as the de facto handoff between providers and assume great importance during unplanned medical encounters. An organized and thorough oncology history is essential in care coordination. We sought to understand reader preferences for oncology history organization by comparing between chronologic and narrative formats. A convenience sample of 562 clinicians from 19 National Comprehensive Cancer Network Member Institutions responded to a survey comparing two formats of oncology histories, narrative and chronologic, for the same patient. Both histories were consensus-derived real-world examples. Each history was evaluated using semantic differential attributes (thorough, useful, organized, comprehensible, and succinct). Respondents choose a preference between the two styles for history gathering and as the basis of a new note. Open-ended responses were also solicited. Respondents preferred the chronologic over the narrative history to prepare for a visit with an unknown patient (66% preference) and as a basis for their own note preparation (77% preference) (P < .01). The chronologic summary was preferred in four of the five measured attributes (useful, organized, comprehensible, and succinct); the narrative summary was favored for thoroughness (P < .01). Open-ended responses reflected the attribute scoring and noted the utility of content describing social determinants of health in the narrative history. Respondents of this convenience sample preferred a chronologic oncology history to a concise narrative history. Further studies are needed to determine the optimal structure and content of chronologic documentation for oncology patients and the provider effort to use this format.

Stopping the revolving door: An exploratory analysis of health care super-utilization in gynecologic oncology

The objective of this study was to determine the prevalence of and risk factors for health care super-utilization among gynecologic oncology patients at a single academic hospital. A retrospective cohort study of gynecologic oncology patients with an index unplanned encounter between January and December 2018 was performed. Super-utilizers were defined as patients with 3 or more unplanned hospital encounters during a 12-month period starting at the time of the index unplanned encounter. We identified 553 patients with gynecologic cancer. Of those, 37(7%) met inclusion criteria for super-utilizers accounting for 193/310(62%) of unplanned visits. The median number of unplanned visits was 4 (range 3–24). The most common cancers were uterine (N = 15 (41%)) and ovarian (N = 11 (30%)). Nineteen (51%) super-utilizers had advanced stage disease. Phases of oncologic care at index unplanned encounter included primary diagnosis (N = 24 (65%)), recurrence (N = 10 (27%)), and surveillance (N = 2 (5%)). Twelve super-utilizers (32%) had new diagnoses of cancer without prior therapy, 19(51%) had prior chemotherapy, 17(46%) had prior surgery, and 10(27%) had prior radiation therapy at the time of initial encounter. Fifteen super-utilizers (41%) were in the last year of life. The most common reasons for unplanned encounters were pain (66%) and gastrointestinal symptoms (61%). Multivariable analysis adjusting for key variables demonstrated that Medicaid insurance, ASA classification, and disease status are risk factors for health care super-utilization. The majority of health care utilization occurred during the first year of diagnosis. This exploratory analysis suggests an opportunity to decrease health care utilization, particularly during upfront treatment.

Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative

Opioid prescriptions have been implicated as one of the proximate causes of the national opioid epidemic. Children and adolescents and their families are at risk for increased opioid exposure through prescriptions after surgery. In pediatric urologic surgery, indications for postoperative opioids can vary widely and a focus on opioid stewardship is important to reduce potential harms. To measure the efficacy of a quality improvement initiative aimed to reduce post-operative opioids for pain management in a large pediatric surgical cohort. Patients undergoing ambulatory pediatric urologic surgery at a tertiary children's hospital between July 2016 to June 2019 were analyzed. Structured physician peer-to-peer comparisons, electronic health record redesign and a standardized pain management protocol were implemented. Rate of opioid prescriptions per month, utilization of non-opioid analgesia, unplanned encounters in the emergency department and/or office during implementation were aggregated. Opioid doses and prescribed opioid days before and after protocol implementation were analyzed. A subcohort, from October-December 2018 was administered a patient-reported outcome questionnaire focused on pain management and return to baseline activity. A total of 6684 consecutive outpatient urologic cases were included (median age=3.3 years old (IQR 0.9-9.2) and 92.3% male). Comparing 6 months pre-intervention and the post-intervention latest 6 month intervals, opioid prescription rate decreased from 43.9% to 2.3% (p<0.001). Additionally, non-opioid analgesia with ketorolac increased from 30.7% to 50.6% (p<0.001). Concurrently, no differences in the rate of office visits within 5 days, overall ED visits, ED visits for pain or for bleeding within 30 days after implementation were identified. Between October to December 2018, 373 cases were performed and a Patient-Reported Outcome (PRO) questionnaire was completed for 128 of those patients (34%). Families reported a low patient pain score of 3.7 (SD 2.4) and a rapid postoperative recovery time of a median 2 (IQR 1-4) days to full resumption of pre-operative level of activity. High satisfaction with opioid reduction in post-operative pain management was reported (median score of 10 (IQR 8-10)). Opioid prescriptions and utilization may be minimized without increasing unplanned encounters or adversely affecting quality of life. The QI framework utilized in this process can be implemented to reduce opioid exposure in other surgical patient populations.

Using Digital Storytelling to Reduce Unplanned Health Care Encounters

There is a growing body of literature establishing digital storytelling as an efficacious strategy to improve hypertension outcomes. The purpose of this nurse-led project was to explore the use of digital storytelling to reduce unplanned health care encounters and to determine whether the approach was feasible. Half of adults in the United States have hypertension. However, only 1 in 4 has his or her condition under control. In addition, the annual economic burden is more than $51 billion. Digital storytelling was employed with residents in northeast Louisiana. Videos of individuals with well-managed hypertension shared success stories with less well-managed individuals over a 16-month long program. The study found that 55 (93%) of listeners had no unplanned provider visits, 57 (94.9%) had no emergency department room visits, and 57 (94.9%) were not hospitalized over the study period. Digital storytelling reduced unplanned encounters, and the program was deemed feasible.