1791. Leveraging EMR Alerts for Vancomycin Time Outs

Background

Vancomycin represented the most used antibiotic at our academic medical center from 2014-2022. To enhance compliance with the “antibiotic time out” part of the CDC Core Elements for Stewardship, we designed an electronic medical record (EMR) best practice alert (BPA) to assist providers in identifying patients eligible for vancomycin discontinuation.

Methods

This is a single center, retrospective pre (06/01/14-2/24/20)/post (02/25/20-03/31/22) comparison of vancomycin utilization after the introduction of a locally validated automated vancomycin time-out. The BPA alerted on patients who had received vancomycin for 72h, had no microbiological evidence of methicillin resistant S. aureus, and had no infectious diseases consult. While other vancomycin reduction strategies had previously been implemented as part of the stewardship program, no other intervention debuted during the same time period. An interrupted time series analysis was performed to assess immediate and ongoing trend changes of institutional vancomycin use. Wilcoxon rank sum and chi2 analyses were also performed.

Results

There were 36,817 inpatient vancomycin orders placed. The BPA triggered during 1,881 (15.7%) orders in the post-BPA period, which was 49.6% of the 3,794 orders still active at 72h. After BPA introduction, there was an immediate decrease in vancomycin days of therapy (DOT)/1000 patient days (PD) ±SE (-8.5 ±3.6; P = 0.021) followed by a significant decrease in the monthly trend relative to the pre-intervention trend (-0.7 DOT/1000 PD ±0.2; P< 0.001). Median vancomycin DOT/1000 PD decreased from 145.9 (IQR 140.2-153.0) to 117.3 (IQR 107.7-122.6) in pre and post periods respectively (P< 0.001). Length of therapy (LOT) decreased, orders were more commonly discontinued by day 5, and orders were more likely to be discontinued prior to discharge. Separate analysis including only orders with >72h showed similar results (Table 1). Table 1Vancomycin length of therapy (LOT) pre and post-BPA Time Out.Figure 1Vancomycin days of therapy per 1000 patient days (DOT/1000PD) trends pre and post-BPA Time Out.

Conclusion

Introduction of an EMR automated vancomycin time out was an effective tool to decrease vancomycin utilization at an academic medical center.

Disclosures

All Authors: No reported disclosures.

1790. Dethroning Vancomycin: A Multifaceted Stewardship Approach to Reduce Vancomycin in an Academic Medical Center

Background

Vancomycin is a broadly used antimicrobial, and from 2014-2022 represented the most used antibiotic at our academic medical center. Since 2015, the stewardship program has introduced several measures to optimize vancomycin use including pharmacy consultation, addition of MRSA nares PCR testing, embedding MRSA nares PCR order into vancomycin order panel, and introducing an electronic medical record (EMR) best practice alert to assist providers in identifying patients eligible for vancomycin discontinuation. The impact of each of these interventions are described.

Methods

This is a retrospective, single academic center, comparison of vancomycin utilization over time, following the introduction of various stewardship measures. Each intervention remained in place during subsequent periods. Wilcoxon rank sum was used for analysis.

Period 1 (P1): 4/2015-12/2016 vancomycin pharmacy consult

Period 2 (P2): 1/2017-6/2019 pharmacists authorized to order Nasal MRSA PCR

Period 3 (P3): 7/2019-2/2020 embed nasal MRSA PCR into consult panel

Period 4 (P4): 2/2020-3/2022 addition of automated EMR time-out

Results

Each period of vancomycin optimization was associated with a statistically significant decrease in vancomycin length of therapy (LOT) in days, when compared to the period before it (P1 vs P2, p< 0.0001; P2 vs P3, p< 0.0001; P3 vs P4, p< 0.0001). Overall institution vancomycin consumption, expressed as monthly days of therapy (DOT)/1000 patient days (PD) also decreased over time, starting with period 3 (P1 vs P2, p=0.4812; P2 vs P3, p=0.0003; P3 vs P4, p=0.0019) (Table 1). Table 1

Clinical outcomes after IL-6 blockade in patients with COVID-19 and HIV: a case series

BACKGROUND

In hospitalized people with HIV (PWH) there is an increased risk of mortality from COVID-19 among hospitalized PWH as compared to HIV-negative individuals. Evidence suggests that tocilizumab-a humanized monoclonal interleukin (IL)-6 receptor inhibitor (IL-6ri) antibody-has a modest mortality benefit when combined with corticosteroids in select hospitalized COVID-19 patients who are severely ill. Data on clinical outcomes after tocilizumab use in PWH with severe COVID-19 are lacking.

CASE PRESENTATION

We present a multinational case series of 18 PWH with COVID-19 who were treated with IL-6ri's during the period from April to June 2020. Four patients received tocilizumab, six sarilumab, and eight received an undocumented IL-6ri. Of the 18 patients in the series, 4 (22%) had CD4 counts < 200 cells/mm³; 14 (82%) had a suppressed HIV viral load. Eight patients (44%), all admitted to ICU, were treated for secondary infection; 5 had a confirmed organism. Of the four patients with CD4 counts < 200 cells/mm³, three were treated for secondary infection, with 2 confirmed organisms. Overall outcomes were poor-12 patients (67%) were admitted to the ICU, 11 (61%) required mechanical ventilation, and 7 (39%) died.

CONCLUSIONS

In this case series of hospitalized PWH with COVID-19 and given IL-6ri prior to the common use of corticosteroids, there are reports of secondary or co-infection in severely ill patients. Comprehensive studies in PWH, particularly with CD4 counts < 200 cells, are warranted to assess infectious and other outcomes after IL-6ri use, particularly in the context of co-administered corticosteroids.

A Biomimetic, SoC-Based Neural Stimulator for Novel Arbitrary-Waveform Stimulation Protocols

Novel neural stimulation protocols mimicking biological signals and patterns have demonstrated significant advantages as compared to traditional protocols based on uniform periodic square pulses. At the same time, the treatments for neural disorders which employ such protocols require the stimulator to be integrated into miniaturized wearable devices or implantable neural prostheses. Unfortunately, most miniaturized stimulator designs show none or very limited ability to deliver biomimetic protocols due to the architecture of their control logic, which generates the waveform. Most such designs are integrated into a single System-on-Chip (SoC) for the size reduction and the option to implement them as neural implants. But their on-chip stimulation controllers are fixed and limited in memory and computing power, preventing them from accommodating the amplitude and timing variances, and the waveform data parameters necessary to output biomimetic stimulation. To that end, a new stimulator architecture is proposed, which distributes the control logic over three component tiers – software, microcontroller firmware and digital circuits of the SoC, which is compatible with existing and future biomimetic protocols and with integration into implantable neural prosthetics. A portable prototype with the proposed architecture is designed and demonstrated in a bench-top test with various known biomimetic output waveforms. The prototype is also tested in vivo to deliver a complex, continuous biomimetic stimulation to a rat model of a spinal-cord injury. By delivering this unique biomimetic stimulation, the device is shown to successfully reestablish the connectivity of the spinal cord post-injury and thus restore motor outputs in the rat model.

Basic symptoms influence real-life functioning and symptoms in individuals at high risk for psychosis

OBJECTIVE

To investigate potential clinical differences in high-risk profiles presenting with and without basic symptoms, and additionally investigate the association between basic symptoms and clinical symptoms, functioning, and cognition.

METHODS

High-risk individuals (n = 133) were stratified into individuals fulfilling ultra-high-risk (UHR) criteria (n = 59) and individuals fulfilling UHR+ basic symptoms criteria (BS) (n = 74). Group differences were assessed on clinical symptoms, real-life functioning, and cognition. Regression analyses were conducted to elucidate on the relationship between BS and clinical symptoms, functioning, neurocognition, and social cognition.

RESULTS

The group fulfilling both UHR+ BS criteria had significantly more symptoms and lower real-life functioning and quality of life but not more cognitive deficits. BS influenced on attenuated psychotic, depressive, and general symptoms, but only modestly on negative symptoms. No relationship between BS and neuro- and social cognition was established except for an association with emotion recognition processing speed. BS influenced real-life functioning, and this finding was sustained when controlling for the effect of negative symptoms.

CONCLUSIONS

Our findings indicate that BS contribute highly to the distress and symptom load of clinical high-risk individuals. Longitudinal findings are needed to establish the predictive validity of BS on high-risk individuals' clinical and functional prognosis.

High-Sensitivity Dry Rehydratable Film Method for Enumeration of Coliforms in Dairy Products: Collaborative Study

A dry-film coliform count plate that is inoculated with 5 mL sample was compared with the Violet Red Bile Agar plate method in a collaborative study by 18 laboratories. Products analyzed were 2% milk, chocolate milk, cream, vanilla ice cream, cottage cheese, and cheese. Collaborators tested blind duplicate uninoculated samples and samples inoculated at low, medium, and high level. Significantly (P&lt; 0.05) higher numbers of coliforms were recovered by the dry-film method from 2% milk samples at the 3 inoculum levels, the chocolate milk at the low- and high-inoculum levels, and the cream at the high-inoculum level. Significantly higher counts were obtained by the agar method for cottage cheese samples at the low-inoculum level. The repeatability standard deviation for the dry-film method was significantly higher for the high-inoculum level chocolate milk sample and the medium-inoculum level cottage cheese. The same statistic was significantly higher for the agar method at all 3 inoculum levels in the 2% milk and the medium-inoculum level cream. The high-sensitivity dry rehydratable film method for enumeration of coliforms in dairy products has been adopted first action by AOAC INTERNATIONAL.

Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study

INTRODUCTION

Procedural sedation and analgesia (PSA) are frequently used for fracture reduction in pediatric emergency departments (ED). Combining intranasal (IN) fentanyl with inhalation of nitrous oxide (N₂O) allow for short recovery time and obviates painful and time-consuming IV access insertions.

METHODS

We performed a bicentric, prospective, observational cohort study. Patients aged 4-18years were included if they received combined PSA with IN fentanyl and N₂O for the reduction of mildly/moderately displaced fracture or of dislocation. Facial Pain Scale Revised (FPS-R) and Face, Leg, Activity, Cry, Consolability (FLACC) scores were used to evaluate pain and anxiety before, during and after procedure. University of Michigan Sedation Score (UMSS), adverse events, detailed side effects and satisfaction of patients, parents and medical staff were recorded at discharge. A follow up telephone call was made after 24-72h.

RESULTS

90 patients were included. There was no difference in FPS-R during the procedure (median score 2 versus 2), but the FLACC score was significantly higher as compared to before (median score 4 versus 0, Δ 2, 95% CI 0, 2). Median UMSS was 1 (95% CI 1, 2). We recorded no serious adverse events. Rate of vomiting was 12% (11/84). Satisfaction was high among participants responding to this question 85/88 (97%) of parents, 74/83 (89%) of patients and 82/85 (96%) of physicians would want the same sedation again.

CONCLUSION

PSA with IN fentanyl and N₂O is effective and safe for the reduction of mildly/moderately displaced fracture or dislocation, and has a high satisfaction rate.

The Fan Study: Intranasal Fentanyl and Inhaled Nitrous Oxide for Fracture Reduction

BACKGROUND: Recently, intranasal (IN) fentanyl and inhaled nitrous oxide/oxygen (N2O) mixture have been increasingly used for procedural sedation and analgesia (PSA) alone or in combination. There is a lack of data on the efficacy of these combined agents.

OBJECTIVES: To evaluate the efficacy of IN fentanyl and N2O as PSA for the reduction of mildly-to-moderately displaced fractures and dislocations.

DESIGN/METHODS: We performed a prospective, observational cohort study between September 2014 and October 2015. Patients were recruited at CHU Sainte Justine (Montréal, Canada) and Royal Children Hospital (Melbourne, Australia). Patients between the age of 4 and 18 years were eligible if PSA consisted of IN fentanyl and N2O for the reduction of mildly-to-moderately displaced fractures or dislocations. Patients received at least IN fentanyl 1.5 mcg/kg (100 mcg max) and at least a 50/50% mixture of N2O with oxygen. Primary outcome was the efficacy of PSA measured by the patient assigned Facial Pain Scale-Revised (FPS-R). The Face, Legs, Activity, Cry, Consolability (FLACC) scale was also recorded. Depth of sedation was evalu-ated using the University of Michigan Sedation Scale (UMSS). Adverse events were recorded following the criteria of the Consensus Panel on Sedation Research of PERC/PECARN. Additional data concerning satisfaction or discomfort were evaluated via questionnaires, and follow-up telephone calls were made to elicit information on adverse events after discharge.

RESULTS: A total of 91 patients aged 9.7±3.0 years were enrolled. There was no difference between the median FPS-R score during the procedure compared to before: Median 2 and 2 (median difference 0 [95% CI 0, 0]), respectively. The FLACC score was higher during the procedure than before: Median 4 and 0 (median difference 2 [95% CI 1, 3]). UMSS was 1 (95% CI 1, 2) during the procedure. 42 (46%) patients had adverse events, all mild: vertigo (20%), nausea (16%)]or vomiting (12%). A total of 85/88 (97%) parents and 82/85 (96%) ED physicians would want the same sedation in another procedure.

CONCLUSION: PSA with IN fentanyl and N2O seems effective in our cohort study, as evaluated by patient assigned FPS-R. Patients were minimally sedated. Adverse events were frequent but mild. Overall, parents and medical staff would want the same agents used in another procedure. Thus, PSA with IN fentanyl and N2O appears to be an attractive option for reduction of mildly displaced fractures or dislocations.

Evaluation of An Oral Morphine Protocol for Treatment of Acute Pain Crisis in Sickle Cell Patients in the Outpatient Setting

BACKGROUND: Sickle cell vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visit and admission in children with this condition.

OBJECTIVES: To evaluate whether the implementation of an oral morphine protocol has led to improved care of sickle cell disease (SCD), translated by a reduced hospitalization rate, an increased oral administration rate and faster opiate administration time, comparing cohorts of patients presenting to the emergency department (ED) and hematology outpatient clinic (HOC) with VOC pre and post implementation.

DESIGN/METHODS: Retrospective chart review of patients with SCD followed at CHU Ste-Justine, who presented to the ED and HOC with VOC, in the year pre and post implementation of the protocol. Patients with a VOC diagnosis during the study periods were selected in each department’s database. The primary outcome was to evaluate the hospital-ization rate. The rate of oral administration, as well as the opiate administration time from inscription in the ED or arrival in the HOC were also calculated. We estimated that 35 patients per arm would be sufficiently powered to detect at least a 30% rate reduction of admissions, with a power of 80% and a significance of 0.05.

RESULTS: Over the two periods, a total of 105 patients (49 pre and 56 post) were included from the ED and 62 patients (36 pre and 26 post) from the HOC. Both departments showed a reduction in hospitalization rate: a difference of 48% (95% CI 32, 61) in ED and 38% (95% CI 13, 57) in HOC. Both showed an increase in the rate of oral administration: a difference of 36% (95% CI 19, 50) in ED and 33% (95% CI 8, 53) in HOC. There was a non-significant difference of 10 min (95% CI -10, 25) in the opiate administration time in ED, as opposed to HOC where a significant difference of -45 min (95% CI -71, -6) was found, with both presenting median times over the recommended 60 minutes post implementation. Both settings showed an increase in the percentage of patients without IVs; a difference of 17% (95% CI 4, 30) in ED and 55% (95% CI 72, 31) in HOC.

CONCLUSION: This study validates the use of our oral morphine protocol for the treatment of VOC, by showing a significant reduction in hospi-talization rates. Although delays remain in our opiate administration time, our protocol decreased the number of painful IV procedures.

Generation and evaluation of typical meteorological year datasets for greenhouse and external conditions on the Mediterranean coast

A typical meteorological year (TMY) represents the typical meteorological conditions over many years but still contains the short term fluctuations which are absent from long-term averaged data. Meteorological data were measured at the Experimental Station of Cajamar 'Las Palmerillas' (Cajamar Foundation) in Almeria, Spain, over 19 years at the meteorological station and in a reference greenhouse which is typical of those used in the region. The two sets of measurements were subjected to quality control analysis and then used to create TMY datasets using three different methodologies proposed in the literature. Three TMY datasets were generated for the external conditions and two for the greenhouse. They were assessed by using each as input to seven horticultural models and comparing the model results with those obtained by experiment in practical trials. In addition, the models were used with the meteorological data recorded during the trials. A scoring system was used to identify the best performing TMY in each application and then rank them in overall performance. The best methodology was that of Argiriou for both greenhouse and external conditions. The average relative errors between the seasonal values estimated using the 19-year dataset and those using the Argiriou greenhouse TMY were 2.2 % (reference evapotranspiration), -0.45 % (pepper crop transpiration), 3.4 % (pepper crop nitrogen uptake) and 0.8 % (green bean yield). The values obtained using the Argiriou external TMY were 1.8 % (greenhouse reference evapotranspiration), 0.6 % (external reference evapotranspiration), 4.7 % (greenhouse heat requirement) and 0.9 % (loquat harvest date). Using the models with the 19 individual years in the historical dataset showed that the year to year weather variability gave results which differed from the average values by ± 15 %. By comparison with results from other greenhouses it was shown that the greenhouse TMY is applicable to greenhouses which have a solar radiation transmission of approximately 65 % and rely on manual control of ventilation which constitute the majority in the south-east of Spain and in most Mediterranean greenhouse areas.

Unintentional exposure of young children to camphor and eucalyptus oils

BACKGROUND

Essential oils, such as camphorated and eucalyptus oils, are volatile oils that can be absorbed by mouth and through the skin; if ingested orally by children, they can be harmful, even life-threatening.

OBJECTIVE

To determine the frequency of essential oil ingestion among children in Toronto, Ontario.

METHODS

Charts from December 1995 through March 1997 at the Ontario Regional Poison Information Centre, The Hospital for Sick Children, Toronto were reviewed to collect information on calls about essential oil ingestion, and a search of MEDLINE articles from 1966 to 1998 was conducted using the key words: 'camphor', 'eucalyptus', 'paediatric', and 'poisoning'.

RESULTS

Callers to the Poison Information Centre reported that 251 children had ingested an essential oil or product: eucalyptus oil 50 children; camphorated oil 18 children; VapAir (Drug Trading, Canada) vaporizing liquid 93 children; and Vicks VaporRub (Procter & Gamble, Canada) 90 children. The most common symptoms were cough, vomiting and cough associated with vomiting. Two children had seizures but recovered. The MEDLINE search found 18 reports of paediatric ingestion of the oils or oil products. The main symptoms were vomiting, lethargy, coma and seizures. One child died.

CONCLUSION

Although widely used by health care consumers, essential oils and the products that contain them can be harmful when ingested by children. Further education for parents and other caregivers about the risks involved in exposure to these products is required.

Healthcare costs of methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa infections in veterans: role of vitamin D deficiency

Methicillin resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (P. aeruginosa) infections are frequently associated with hospitalization and increased healthcare costs. Vitamin D deficiency may contribute to increased costs for patients with these infections and there is evidence that vitamin D may have an antimicrobial role. To evaluate the role of vitamin D deficiency in the costs incurred with these infections, we studied the relationship of serum 25(OH)D levels to healthcare costs in veterans in the southeastern United States. Patients with both infections were vitamin D deficient to a similar extent and so were combined for further analysis. Vitamin D deficient patients had higher costs and service utilization than those who were not vitamin D deficient. Those with vitamin D deficiency had higher inpatient costs compared to the non-deficient group, and this difference was across most categories except for the number of inpatient hospitalizations or total number of days as an inpatient. Vitamin D deficiency was not significantly related to outpatient cost or service utilization parameters. We conclude that vitamin D deficiency is intimately linked to adverse healthcare costs in veterans with MRSA and P. aeruginosa infections. Vitamin D status should be assayed in patients with these infections.

A pilot study to assess an online training module to quickly identify drugs on resuscitation trays

OBJECTIVE

To measure the median time required for healthcare professionals to identify drugs on resuscitation trays and to assess the usefulness of an online training module used to identify drugs on resuscitation trays.

STUDY DESIGN

This is a descriptive pilot study conducted in a mother-child university hospital center with a convenience sample of physicians, residents, nurses, pharmacists, pharmacy students or pharmacy technicians (10/group).

METHOD

Participants were given a questionnaire before and after using a simulation module to identify drugs on resuscitation drug trays (30 questions on the full trays with 43 drugs and 15 questions on the partial trays with 21 drugs). The identification times were measured for each drug and for each tray.

RESULTS

The median time to identify the drugs varied from 4s (range 2-46) for dextrose to 18s (range 4-78) for epinephrine. The median times to locate a drug on full and partial trays were, respectively: pharmacists 7 (2-103) and 6 (1-31), physicians 10 (3-78) and 7 (2-61) and nurses 10 (3-83) and 7 (2-53). All 60 participants strongly agreed that the online simulation module was a good tool for healthcare staff and that it would allow them to locate drugs more quickly in emergency situations.

CONCLUSION

The online simulation module can be used by various groups of professionals and it can allow them to locate drugs on resuscitation tray more rapidly during an emergency.

Total body bone mineral content and density during weight loss and maintenance on a low- or recommended-dairy weight-maintenance diet in obese men and women

BACKGROUND

Diets high in either dairy or calcium during moderate weight reduction both prevent loss of bone mineral density (BMD) and suppress bone turnover. The purpose of this study was to determine whether recommended dairy and calcium intakes during weight maintenance favorably affect total body BMD (TBBMD) and bone mineral content (TBBMC) in obese adults.

METHODS

Obese men (n=49) and women (n=64), aged 40.8+/-0.6 years, underwent 12 weeks of moderate energy restriction (approximately 1200 kcal/day) followed by 24 weeks on either a low or recommended dairy weight maintenance diet. The TBBMC and TBBMD values were measured using dual energy X-ray absorptiometry at baseline, 12, 24 and 36 weeks. Concentrations of calcium, intact parathyroid hormone (iPTH), 25OH and 1,25 (OH)(2) vitamin D in plasma were also measured. Data were analyzed using a two-factor repeated measures analysis of variance.

RESULTS

After weight loss, women exhibited a small, but statistically significant, increase in TBBMC (1.17+/-0.57%), whereas TBBMD increased in the men (1.34+/-0.28%). The iPTH concentration decreased significantly in all subjects. Despite significantly greater intakes of calcium, vitamin D and protein compared with the recommended dairy diet, there were no treatment-related differences in outcome variables after 24 weeks of weight maintenance. The TBBMC remained unchanged in women during weight stabilization; both TBBMC and TBBMD decreased in men (-1.59+/-0.51% and -0.70+/-0.25%, respectively).

CONCLUSIONS

In summary, results of this study do not provide convincing evidence that moderate weight loss through energy restriction and mild exercise reduces TBBMC in obese men and women. Similarly, a weight-maintenance diet providing the recommended daily servings of dairy does not seem to affect changes in BMC after weight loss.

Unintentional household poisoning in children

Despite the major reduction in fatal paediatric poisonings that has been achieved in industrialised countries over the last few decades, unintentional paediatric poisoning remains a major public health issue worldwide. In this article, we aim to provide clinicians dealing with poisoned children an overview of the problem and specific guidance on the identification and management of significant poisoning. Substances most frequently ingested by children in the developed world include household chemicals, medication, and plants. Although the great majority of such poisonings have no or limited clinical effects, it puts substantial burden on health care systems. Importantly, a few poisons can kill after ingestion of very small amounts. Unintentional poisoning in developing countries can be much more serious, following ingestion of kerosene, caustic agents, herbal remedies, insecticides or herbicides. Management of symptomatic patients involves supportive care, if available the administration of antidotes, and the removal of the offending drug from the body. Recent position papers on gastric decontamination indicate that such interventions are only rarely necessary. To further reduce the number of deaths and disabilities in the industrialised world and to begin to have an effect in the developing world, much more work is required to both identify and implement prevention strategies to reduce the number of cases of paediatric poisoning.

Epidemiology of electrical and lightning related deaths and injuries among Canadian children and youth

Among burn injuries, electrical injuries constitute a small but devastating fraction. To describe the epidemiology of electrical injuries in Canadian children, data on deaths and emergency department visits related to electrical injuries, including lightning strikes, were obtained from provincial coroners' offices and the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) respectively, for the years 1991-96. Twenty one deaths and 606 emergency visits highlight that electrical related deaths, more frequent among school age children, are more likely the result of high voltage and lightning strike, while emergency department visits, more frequent among younger children, are more likely the result of low voltage. While the introduction of legislated standards for child safe outlets and educational programs for parents, children, and youth are recommended strategies toward reducing the frequency of these incidents, these strategies require further evaluation before their effectiveness can be estimated.