Skrupky, Lee P.

Abstract Background According to consensus guidelines, area under the concentration–time curve (AUC) is recommended for vancomycin dosing rather than trough-based monitoring, but transition to AUC-based dosing requires substantial staff education and resource allocation. We sought to evaluate the level of congruency between vancomycin total daily doses (TDD) determined using a trough concentration goal of 10-15 mcg/mL compared with an online Bayesian calculator targeting an AUC of 400-600 mg·h/L.Patient DemographicsInitial Dose Results Methods We performed a retrospective, multicenter cohort study of vancomycin therapeutic drug monitoring (TDM) in non–critically ill adults hospitalized from March 1, 2017-December 31, 2021. Patients were included if they received intravenous vancomycin for ≥72 hours with a documented trough target of 10 to 15 mg/L, had ≥1 serum vancomycin trough concentration assessed at steady state, and received ≥2 doses of vancomycin after serum assessment with or without dose adjustment. Using an online vancomycin calculator with Bayesian modeling, the study team input patients’ trough-based dosing data to retrospectively estimate the initial vancomycin AUC exposure achieved and the initial and post-trough TDD recommended for an AUC target of 400 to 600 mg⸱h/L. The initial and post-trough vancomycin total daily dose (TDD) derived by the online calculator were compared with the actual doses used for each patient when a trough concentration of 10 to 15 mg/L was targeted.Comparison of Trough-Based and AUC-Based Dosing of Vancomycin AUC indicates area under the concentration–time curve; TDD, total daily dose. Dashed line indicates where the 2 methods are equal; shading indicates where the 2 methods are within 20% of each other Results In total, 89 patients were included in the study. The actual vancomycin TDD with trough monitoring (target, 10-15 mg/L) was within 20% of the recommended AUC-based TDD for 62 patients (70%) with initial dosing and for 74 (83%) after the initial trough concentration. Nephrotoxicity was rarely observed (2%) and the median duration of vancomycin was 4 days. Conclusion Given the frequency of dosing similarity between 400-600 mg·h/L AUC and 10-15 mg/L trough-based dosing, vancomycin trough-based monitoring to a goal of 10-15 mg/L is an option warranting further exploration. Disclosures All Authors: No reported disclosures

OBJECTIVES: Evaluate effectiveness and safety outcomes associated with the use of ketamine for primary analgosedation in the surgical/trauma ICU setting. DESIGN: Retrospective cohort study. SETTING: Academic medical center in Minnesota. PATIENTS: Patients admitted to the surgical ICU between 2015 and 2019 requiring mechanical ventilation and meeting one of three definitions for ketamine primary analgosedation were included: 1) no concomitant opioid infusion, 2) ketamine monotherapy for greater than or equal to 6 hours with subsequent opioid infusion, or 3) ketamine initiated concomitantly or within 4 hours of opioid and total opioid duration less than 4 hours. INTERVENTIONS: None. MEASUREMENTS: Use of ketamine, analgesics, and sedatives were evaluated. Pain, sedation, and delirium assessments immediately before and during ketamine infusion were collected and compared with reported goals. Concomitant analgesics, sedatives, and psychotropics were recorded. Reported failures due to ineffectiveness and toxicity were collected. MAIN RESULTS: Of 164 included patients, 88% never received a concomitant opioid infusion (primary analgosedation definition 1), 12% met alternative criteria for primary analgosedation (definitions 2 and 3). A majority, 68%, were surgical admissions and mean Acute Physiology and Chronic Health Evaluation III score was 90 (± 30). Median mechanical ventilation duration was 2.5 days (1.1–4.5) and ICU length of stay of 4.9 days (3–8). The median ketamine infusion dose and duration were 0.18 mg/kg/hr (0.1–0.3) and 30 hours (15.1–51.8). Concomitant infusions of propofol and dexmedetomidine were administered in 49% and 29% of patients, respectively. During ketamine infusion, the median percent of total pain scores at goal was 62% (33–96%), while 64% (37–91%) of Richmond Agitation Sedation Scale scores were at goal, and 47% of patients were Confusion Assessment Method-ICU positive during the ketamine infusion. Hallucinations were documented in 14% of patients and ketamine failure occurred in 11% of patients. CONCLUSIONS: Ketamine may be an effective primary analgosedation option in intubated surgical ICU patients, but prospective randomized studies are needed to evaluate this strategy.

Abstract Purpose Mayer's theory of multimedia learning proposes that personalisation and embodiment (P/E) can improve outcomes in e‐Learning. The authors hypothesised that an e‐Learning module enhanced by P/E principles would lead to higher knowledge, perceived P/E and motivation among health care professionals, compared with an unenhanced module. Methods The authors conducted a randomised trial comparing two versions of a 30‐minute multimedia e‐Learning module addressing the antibiotic management of pneumonia. The unenhanced format used slides with voiceover (human voice but no visible speaker), formal language and no specific P/E strategies. The enhanced format additionally implemented P/E strategies including conversational style, polite language, visible author, social congruence, human‐like presence and professional presence by subtly changing the script and substituting several short videos of subject matter experts. Participants included pharmacists, physicians and advanced practice providers from three academic and several community hospitals. Outcomes included knowledge, perceived P/E (assessed by the Congruence Personalisation Questionnaire, CPQ), motivation (assessed via the Instructional Materials Motivation Survey [IMMS] and Motivated Strategies for Learning Questionnaire [MSLQ]) and course satisfaction. Results There were 406 participants including 225 pharmacists, 109 physicians and 72 advanced practice providers. Post‐module knowledge was slightly higher for the enhanced versus the unenhanced format, but the difference did not reach statistical significance (adjusted mean difference, 0.04 of 10 possible, [95% CI −0.26, 0.34], p = 0.78; Cohen d 0.02). Participant perceptions of P/E (measured via CPQ) were significantly greater for the enhanced format (difference 0.46 of 5 possible [0.35, 0.56], p < 0.001; Cohen d 0.85), as were motivational features of the e‐Learning course (measured via IMMS) (difference 0.14 of 5 possible [0.02, 0.26], p = 0.02; Cohen d 0.24). Participants' overall motivational orientation (measured via MSLQ) and course satisfaction were not significantly different between the two formats ( p > 0.05). Conclusion Application of P/E principles to an e‐Learning module led to greater perceived P/E and motivational features but did not influence knowledge.

Abstract Purpose Instructional designs promoting personalization (conversational style and visible author), embodiment (human-like mannerisms and presence), and social and cognitive congruence have been shown to enhance learning. However, measurements of these instructional design features are lacking. The authors sought to develop and validate an instrument to measure personalization, embodiment, and congruence in an online course, collecting evidence of content, internal structure, and relationships with other variables. Method Through literature review, expert review, and pilot testing, the authors developed a 15-item, 5-domain instrument. Participants completed this instrument along with assessments of motivation (Instructional Materials Motivation Survey and Motivated Strategies for Learning Questionnaire), knowledge, and course satisfaction immediately after a 30-minute online multimedia learning module comprising slides with voiceover and (for some participants) short video clips, from January to April 2021. Participants included pharmacists, physicians, and advanced practice providers at academic and community hospitals. Confirmatory factor analysis (CFA) was used to examine model fit, followed by structural revisions guided by exploratory factor analysis (EFA) and tested in a new CFA using a split-sample approach. The authors evaluated associations between the revised instrument scores and motivation, knowledge, and satisfaction. Results There were 406 participants. CFA of the original 15-item instrument revealed poor model fit. EFA using 214 randomly selected participants suggested a 2-domain structure. CFA of the revised structure using the other 192 participants revealed good fit for a 9-item, 2-domain instrument: the Congruence–Personalization Questionnaire (CPQ). Linear regression confirmed positive, statistically significant associations for most hypothesized relationships (R2 ≥ 0.12 and P &lt; .001 for 14 of 18 associations with motivation and satisfaction). Associations with knowledge were weak and nonsignificant (R2 ≤ 0.004, P &gt; .23). Conclusions Evidence of content, internal structure, and relationships with other variables support the validity of CPQ scores for measuring personalization and congruence in an online module.

AbstractIntroductionAlthough letters of reference (LORs) are required for postgraduate year one (PGY1) residency applications and used to distinguish between candidates, an evaluation of residency program director (RPD) perceptions and values surrounding LORs has not been described.ObjectiveThe aim of the study was to describe PGY1 RPDs' processes, values, and perceptions surrounding LORs.MethodsThis was a cross‐sectional descriptive survey. After assessing content validity, the Education and Training Practice and Research Network (PRN) taskforce sent a 25‐item electronic survey to 1266 PGY1 RPDs. Survey questions captured program demographics, LOR requirements, processes for LOR review, and perceptions about the value of LORs. Two open‐ended questions solicited suggestions for LORs and the existing standardized form; responses were evaluated via thematic analysis.ResultsA total of 291 (24%) programs completed the survey. LORs were rated as extremely or quite valuable by 82% of respondents and moderately valuable by 16% of respondents. Scoring rubrics for LOR evaluation were used by 79% of programs, and performance ratings were reported to impact interview consideration by a majority of programs. Accuracy, detailed comments, and inclusion of specific candidate strengths and areas for improvement were rated as extremely or quite important characteristics by 90% or more of respondents. Specific strengths were reported to be present in LORs more than half of the time by 81% of programs; however, accuracy, detailed comments, and inclusion of specific areas for improvement were only reported to be present about half the time or less by 41%, 63%, and 63% of respondents. Among 207 suggestions submitted to improve LOR utility, common themes included a desire for LOR authors to have candid discussions with candidates prior to letter writing, to contextualize their relationship with the candidate, and provide honest and specific assessments.ConclusionLORs remain highly valued by PGY1 RPDs during application review. Several notable findings were observed, resulting in recommendations for LOR authors, residency applicants, and the standardized LOR form.

Abstract Background More than 90% of reported penicillin allergies are found inaccurate when formally assessed. These allergy labels lead to decreased utilization of first-line beta-lactam antibiotics, and adverse clinical outcomes. The objective of this study was to develop a multi-disciplinary approach to decrease inaccurate labeling among hospitalized patients with documented penicillin allergy. Methods A team of clinicians, pharmacists, and nurses utilized the DMAIC quality strategy to improve accuracy of penicillin allergy labeling. Allergic reactions were stratified to develop a penicillin allergy de-labeling algorithm (Figure 1). Admission to the intensive care unit (ICU) for anaphylaxis was defined as a balancing measure. We reviewed baseline data from patients with a documented penicillin allergy admitted to a single inpatient floor at Mayo Clinic, Rochester between June and October 2019. A cause and effect diagram was used to conduct a root cause analysis. The intervention was then applied to patients who reported penicillin allergy admitted to the same floor from November 2019 to January 2020. Study data were collected and basic descriptive statistics generated. Figure 1: Penicillin allergy delabeling algorithm Results 96 patients were included in the control group with mean age of 71 years (range 65–84 years) and 55% females. Breakdown of documented allergic reactions are represented in Figure 2. 58 (60%) received an antibiotic for a median duration of 1.5 days (IQR: 0 – 6). Of these, 7(12%) received penicillin-class antibiotics, and 41 (70.6%) received non-beta-lactam antibiotics. 2 (2%) of these patients were de-labeled without any penicillin skin tests. Detailed metrics of each PDSA cycle are shown in Table 1. During PDSA cycle 2, inaccurate penicillin documentation was removed in 9/19 (47.4%) of hospitalized patients. There were no ICU admissions for anaphylaxis. Figure 2: Graphic representation of proportion of type of documented allergic reactions to penicillin Table 1: Metrics and outcomes at baseline and during successive PDSA cycles Conclusion Various factors contribute to penicillin allergy mislabeling. Our comprehensive algorithm addresses nuances of penicillin allergic reactions and increased accurate penicillin allergy labeling in 47.4% of the cases. Beta-lactam use also increased to 37% through our pilot project while maintaining patient safety. A multi-disciplinary and patient-centered approach aligned with institutional workflows is necessary to improve patient outcomes. Disclosures All Authors: No reported disclosures