Spaulding, Aaron

AbstractAcute mesenteric ischemia (AMI) remains a vascular emergency. Our aim was to explore readmission for AMI. We identified all patients admitted for AMI from the state of California through the Healthcare and Utilization Project from 2005 to 2011. Our primary end point was the rate and etiology for readmission. Our secondary end points were the length of hospitalization and in-hospital mortality. Cox proportional hazard regression was utilized to assess risk of 30-day readmission. There were 534 (9.9%) readmissions at 30 days. The mean age was 67 ± 17 years and 209 (39.1%) were male. The five most common etiologies for readmission were AMI (7.6%), cardiac events (5.3%), severe sepsis (1.2%), dehydration (1.1%), and acute kidney failure (1.1%). Once readmitted, these patients were most likely to experience cardiac catheterizations (25.4%), red blood cell transfusions (23.6%), intubation and mechanical ventilation (17.6%), biopsy of the large intestine (13.9%), reoperation for small bowel resection (10.9%), administration of total parenteral nutrition (10.5%), and transfusion of other blood products (6.9%). This hospitalization was 8.8 ± 12.7 days long. In-hospital mortality was 36 patients (6.7%). On multivariable Cox-regression analysis, severe (hazard ratio [HR]: 2.1 [1.4–3.2], p = 0.0005) and moderate (HR: 1.5 [1.03–2.13], p = 0.04) Elixhauser Comorbidity Group, complications (HR: 1.5 [1.2–1.9], p = 0.0007), and longer index hospitalization (HR: 1.02 [1.01–1.02], p < 0.0001) were predictors of readmission. Conclusion AMI remains a vascular emergency. Readmissions have a significant rate of morbid invasive procedures and can lead to an in-hospital mortality of 6.7%. The adoption of guidelines similar to the European Society for Trauma and Emergency Surgery should be considered.

Background Artificial Intelligent Virtual Assistants (AIVA) is a segment of artificial intelligence that is rapidly developing. However, its utilization to address patients' frequently asked questions remains unexplored. Methods We developed an AIVA to answer questions related to 10 frequent topics asked by plastic surgery patients in our institution. Between July 27, 2018, and August 10 of 2018, we recruited subjects with administrative positions at our health care institution to chat with the virtual assistant. They asked, with their own words, 1 question for each topic and filled out a satisfaction questionnaire. Postsurvey analysis of questions and answers allowed assessment of the virtual assistant's accuracy. Results Thirty participants completed the survey. The majority was female (70%), and the mean age was 27.76 years (SD, 8.68 [19–51] years). The overall accuracy of the plastic surgery AIVA was 92.3% (277/294 questions), and participants considered the answer correct in 83.3% of the time (250/294 answers). Most of the participants considered the AIVA easy to use, answered adequately, and could be helpful for patients. However, when asked if this technology could replace a human assistant, they stayed neutral.

Background: Managing the safety climate in health care is a promising tool for improving employee and patient safety in the health care work environment. Gaps in the theoretical and conceptual underpinnings of safety climate, as well as the evidence base for its practical application in health care remain. The purpose of this study was to evaluate the number of work injuries occurring in health care work units and associated safety climate beliefs. Methods: A retrospective analysis was conducted utilizing organizational staff survey data collected by a large medical hospital in the Midwest in 2015. Employees ( n = 32,327) were invited to identify safety climate perceptions via survey. Injuries, days restricted, and days absent were identified through the Hospital’s Occupational Safety and Health Administration (OSHA) log. Zero inflated negative binomial regressions used injuries as dependent variables and safety climate perceptions as independent variables. Findings: In all, 23,599 employees completed the survey (73% response rate) across 1,805 employee work units which were defined as groupings of employees reporting to a single supervisor. We found that there was an association between fewer injuries and health care workers indicating that they share responsibility for compliance with safety rules and procedures (relative risk [RR] = 0.98, 95% confidence interval [CI] = [0.98, 0.99]). Conclusion/Application to Practice: This study supports the use of a safety climate measure to assess working units’ perceptions of employee safety. A continued focus on the health and safety of employees who interact directly with patients is warranted, as well as employees who do not provide direct patient care.

Background Microsurgery is one of the most complex operative skills. Recent restrictions on residents’ working hours challenge residency program directors to ensure skill acquisition with scant time dedicated to microsurgery practice. We aimed to summarize the contribution of plastic surgery journals in microsurgical education. Methods A comprehensive literature search was performed. Results We observed an increasing number of publications on microsurgery education over the years. This could be due to the adoption of new technologies developed in the last 2 decades, the concerns about quality of resident training in the context of reduced work hours, the well-described benefit of medical simulations in other specialties, and the pressure on trainees to be proficient before operating on patients. The variety of aspects addressed in plastic surgery publications is broad: simulators, courses, skills assessment, national surveys, and technology trends. Conclusion There is an upward trend in the number of publications and plastic surgery journals, demonstrating a remarkable contribution to microsurgery training.

Abstract INTRODUCTION: Significant burden of pain syndromes are reported in patients with hematological malignancies undergoing HSCT mostly due to underlying disease and associated treatments. Opioid analgesics and benzodiazepines are routinely used for symptomatic management in this patient population. The use of narcotic analgesics and benzodiazepines in non-transplant hospitalized patients has been shown to adversely affect health related outcomes such as length-of-stay (LOS), falls and other complications. However, there is a significant knowledge gap regarding the patterns of opioid and benzodiazepine use and their impact on health outcomes in HSCT patients. METHODS: We identified 275 patients from the year 2015-2018 who underwent HSCT (allogeneic and autologous transplants) at our center for a variety of hematological malignancies. Opioid exposure was defined in three groups of patients 1) Opioid naïve: those did not report prior use of opioid at admission and who were not prescribed opioid during hospitalization, 2) Previous Opioid users: those who reported active use of opioid at admission and continued during hospitalization 3) New Opioid users: Patients who did not report opioid use at admission but were prescribed opioid during hospitalization. Multivariable analysis was performed to identify differences in opioid status, opioid use, benzodiazepine use, disease diagnosis, Karnofsky score, gender, age, race, and marital status with associated complications (Poisson regression), emergency department visits (Logistic Regression) and length of stay (Ordinal Logistic Regression) Figure 1 and Figure 2. RESULTS: The median age of patients was 59 (range: 25-74 ) years with slight male predominance (57%). Patients undergoing autologous transplants for multiple myeloma (MM) comprised 48% of the population. The majority (72 %) were exposed to opioid during hospitalization. Ninety two percent of the opioid naïve population (28% of the total population) underwent autologous transplant. Conversely, 36% of patients undergoing autologous transplants never received opiates during hospitalization as compared to 7% of those who received an allogeneic transplant. Median morphine milligram equivalent daily dose was 3.1 mg. Median diazepam equivalent daily dosage in patients that were opiate exposed was 2.07 milligram. Of the total transplant population, 55% received benzodiazepine concurrently with opiates during hospitalization. 76 % of the population was exposed to both opioid and benzodiazepine. Twenty five percent of those who were exposed to opioid did not receive benzodiazepines. Sixty four percent of the MM patients were exposed to opioid of which majority (59%) were previous opioid users. Of the non-MM patients undergoing HSCT, 80% were exposed to opioid of which 36% were previous opioid users and 64% were new users. A wide range of complications from neutropenic fever to death, were seen in 89% of all patients (opioid users and non-users) but all the falls occurred in patients who were on opioid medications. Autologous transplant recipients had higher odds of having a greater number of complications compared to Allogeneic transplant patients (OR 1.25, 95% CI: 1.01 - 1.55, p=0.04), as well as a reduced odds of having a medium or high length of stay (OR 0.03, 95% CI: 0.02 - 0.07). Of the opioid naïve patients, 6% presented to the ED within 30 days of discharge versus 15% of those that were exposed to opiates during hospitalization. Benzodiazepine use at admission for HSCT was associated with greater odd of presenting to ED within 30 days of discharge (OR 3.94, 95% CI: 1.55-10.04) and this was more significant in patients with MM (OR 4.08, 95% CI: 1.01-16.44). Finally, we also saw a trend towards longer stay in patients who were exposed to opioids as compared to opioid naïve (40% vs. 17%). CONCLUSION: Our study, albeit limited due to its retrospective design, is among the first to report the patterns of use and the impact of opioids and benzodiazepines in patients undergoing HSCT. Our results indicate that the use of these medications is frequent in this population and as in the non-transplant hospitalized patients and is associated with more emergency room visits post discharge, along with other potentially adverse outcomes. Disclosures Kharfan-Dabaja: Incyte Corp: Speakers Bureau; Seattle Genetics: Speakers Bureau; Alexion Pharmaceuticals: Speakers Bureau. Ailawadhi:Amgen: Consultancy; Pharmacyclics: Research Funding; Celgene: Consultancy; Takeda: Consultancy; Janssen: Consultancy.

Abstract Background Diffuse large B cell lymphoma (DLBCL) with high-risk features carries a poor prognosis despite treatment with immunochemotherapy regimen incorporating rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP). Hence, dose adjusted rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA.R-EPOCH), a higher intensity regimen, is suggested as an upfront treatment of high-risk DLBCL. In our study, we analyzed the outcomes in a prospectively followed cohort of patients with de novo high-risk DLBCL who received DA.R-EPOCH, and compared them to the patients who received R-CHOP. Furthermore, we conducted a cost analysis to determine which of the two treatments produces a larger financial burden. Method Patients diagnosed with DLBCL who received chemo-immunotherapy at our center between January 2011 to December 2016 were included in the analysis. High-risk DLBCL was defined by the presence of any of the following features at diagnosis: NCCN- IPI score ≥4, tumor measuring ≥5 cm, MYC ± BCL2 or BCL6 rearrangement by FISH or MYC overexpression (>40% by immunohistochemistry [IHC]), Ki-67 index ≥80% and non-GCB immunophenotype by Hans algorithm. Responses were evaluated at middle and end of chemotherapy. Overall (OS) and progression free survival (PFS) were calculated. For the cost analysis, standardized costs were obtained from Mayo Clinic Florida cost data warehouse based upon patient encounters and treatments. Report cost-to-charge ratios were multiplied by the charges for all hospital billed services, and all resulting costs were adjusted to 2016 dollars with the Gross Domestic Product (GDP) Implicit Price Deflator. Patients who did not receive their complete planned treatment at our facility were excluded from the cost analysis. Results Of 80 patients with high-risk DLBCL, 52 (65%) patients were treated with R-CHOP and 28 (35%) with DA.R-EPOCH. The median follow-up was 11.2 months (range: 0.7- 151.3 months). The planned treatment completion rate and complete remission rate at the end of treatment were similar in both groups. There was no significant difference in OS and PFS among the patients treated with DA.R-EPOCH compared to R-CHOP. The hazard ratio (HR) for PFS was 0.79 (95% CI- 0.28-2.29, P=0.67) and OS was 0.86 (95% CI- 0.26-2.78, P=0.80) (Figure 1). In Cox-regression analysis, low baseline albumin, ECOG performance status ≥2, above-normal LDH, high NCCN- IPI and low cumulative chemotherapy doses were associated with poor OS and PFS. Overall incidence of grade ≥ 3 neutropenia, neuropathy, and unplanned hospitalizations were similar between the two treatment groups. Patients treated with DA.R-EPOCH required more red cell transfusions during the treatment (P=0.004). The total mean cost associated with DA.R-EPOCH and R-CHOP regimens was $106,940 ± $39,351 and $58,509 ± 24,588, respectively (P<0.001). The cost associated with hospital services, laboratory testing and evaluation and management were higher in DA.R-EPCOH group compared to R-CHOP group (P<0.001) (Table 2). Conclusion Our study showed that there was no significant difference in PFS and OS of patients with DLBCL with high-risk features when treated with R-CHOP compared to DA.R-EPOCH. DA.R-EPOCH was associated with higher red cell transfusion requirement and treatment related expenses. A prospective randomized comparison is warranted between these two regimens specifically for patients with high-risk DLBCL. Disclosures No relevant conflicts of interest to declare.

Abstract INTRODUCTION: Patients undergoing HSCT are reported to have a high prevalence of depression and anxiety. These comorbid mood disorders have been known to be associated with alteration in pain perception in patients without hematological malignancies. Pharmacological compounds such as opioid and benzodiazepines are frequently used to manage patient symptomology including pain and anxiety. Patients undergoing HSCT are a unique population where the impact of depression and anxiety on opioid and benzodiazepine use has not been well studied. METHODS: The study population consisted of patients who underwent HSCT at a single center for a variety of hematological malignancies from 2015-2018. Opioid and benzodiazepine exposure and dosage was defined in a) Patients who were exposed to opioid including those who were previously exposed and those who were exposed during hospitalization for HSCT b) Patients who were neither exposed to opioid previously, nor during the hospitalization for HSCT. Depression and Anxiety was defined as per PHQ-9 and GAD-7 scales prior to hospital admission. Multivariable analysis was performed to identify differences in opioid status, previous benzodiazepine use, transplant type, Karnofsky score, gender, age, race, and marital status with associated Diazepam Equivalent Daily Dosage (DEDD) (Negative Binomial Regression), and Morphine Milligram Equivalent Daily Dosages (MMEDD) (Logistic and Zero Truncated Negative Binomial Regression). RESULTS: A total of 275 patients underwent HSCT including autologous and allogeneic from 2015-2018. Anxious or depressed HSCT recipients had an increased incidence of higher DEDD with an IRR of 1.69 (95% CI: 1.15, 2.49) compared to those who were neither depressed nor anxious (Figure 1). However, patients who reported anxiety and depression did not have a different DEDD than those not anxious nor depressed. In addition, patients who were not naïve to benzodiazepine use prior to admission had an increased incidence of a higher DEDD [IRR of 2.23 (95% CI: 1.61, 3.05)]. Patients undergoing autologous stem cell transplant had a decreased incidence of receiving a higher DEDD [IRR of 0.65 (95% CI: 0.47-0.90)]. African American and other populations had a decreased incidence of receiving a higher DEDD [IRR of 0.40 (95% CI: 0.27, 0.59)]. Patients receiving higher MMEDD had a higher DEDD incidence [IRR of 1.01 (95% CI: 1.01, 1.02)]. Patients who were both anxious and depressed had increased odds of receiving an opioid [OR of 3.35 (95% CI: 1.62, 6.94)] compared to patients who were neither depressed nor anxious. However, patients who were either depressed or anxious did not have different odds of receiving an opioid compared to those who were neither depressed nor anxious. Patients undergoing autologous stem cell transplant had reduced odds of receiving an opioid [OR of 0.17 (95% CI: 0.07, 0.40)]. Patients with less than normal Karnofsky performance status (<90 on scale of 1-100) had an increased incidence of receiving a higher MMEDD [IRR of 2.34 (95% CI: 1.07, 5.12)] when modeled by Zero Truncated Negative Binomial Regression. Finally, HSCT recipients who were both anxious and depressed had reduced odds of being naïve to opioids [OR0.31 (95% CI: 0.15, 0.67)] compared to recipients who were neither depressed nor anxious. New opioid users had reduced odds of receiving a greater MMEDD [OR of 0.98 (95% CI: 0.96, 0.99)] when compared to previous users. In addition, autologous stem cell transplant recipients had reduced odds of receiving greater MMEDD compared to allogeneic transplant recipients (OR 0.33, 95% CI: 0.16, 0.66). CONCLUSION: Comorbid depression and /or anxiety impact opioid and benzodiazepine use in patients undergoing HSCT. The presence of these comorbid conditions and their association with increased use of opioids and benzodiazepines can also affect various health related outcomes. Larger studies are needed to fully understand the potential impact of this association on health related outcomes. Figure 1. Figure 1. Disclosures Kharfan-Dabaja: Incyte Corp: Speakers Bureau; Alexion Pharmaceuticals: Speakers Bureau; Seattle Genetics: Speakers Bureau. Ailawadhi:Amgen: Consultancy; Pharmacyclics: Research Funding; Celgene: Consultancy; Janssen: Consultancy; Takeda: Consultancy.

Introduction/objective Improving graduate medical trainee involvement with patient safety and incident reporting is an important task in teaching hospitals that has been recognised across the country and led to numerous efforts to address barriers to incident reporting. A variety of studies have started to define the reasons why trainees are not optimally involved and interventions that may be helpful. The present study aims to add to this literature by primarily addressing barriers that can be considered ‘non-technical’ such as fears surrounding potential professional repercussions after submitting a report, perceptions that reporting incidents is not useful, and concerns about anonymity. Methods Barriers to incident reporting were previously analysed at our institution. A video was produced to directly target the barriers discovered. A 2-hour educational session was delivered which included the video intervention. The educational session was part of the standard patient safety curriculum at our institution. Paper surveys were used to capture changes in perceived barriers to incident reporting. Baseline and postintervention surveys were analysed for changes using t-tests and a p value of <0.05 to determine significance. Survey development included literature review, patient safety expert discussion and cognitive interviews. Results Perceived knowledge about the reporting process significantly improved after the intervention (t=−4.49; p<0.05). Attitudes about reporting also significantly improved with reduction in fear of negative consequences and anonymity. Perceptions of reporting being a futile activity were also diminished after the intervention. Conclusions This study demonstrates that targeting non-technical barriers to incident reporting with a video intervention is an effective way to improve perceived knowledge and attitude about incident reporting.

Hospitals are expected to fulfill a role in the communities they serve by improving the health of the population in the community as mandated in the Affordable Care Act. One way hospitals achieve this is to create partnerships with diverse organizations, such as local public health departments, state/federal agencies, and other health care organizations. The aim of this study is to examine characteristics of hospitals that developed partnerships based on improving population health. This study utilized the 2015 Population Health Survey, American Hospital Association Database, and Dartmouth Atlas of Health Care. Hospital characteristics included size, ownership status, part of a system, teaching status location, Medicare percentage, Medicaid percentage, average stay length, and inpatient days per 1000 persons. Level of partnership was measured by the hospital's current working relationship with other hospitals/health care systems or local/state/other agencies. Univariate, bivariate, and multivariate regression analyses were used to analyze the relationship between hospital partnerships and organizational characteristics. Hospitals with strong relationships tend to be larger and not-for-profit hospitals, hospitals with system members and located in urban areas, and teaching-affiliated hospitals. This study also found hospital characteristics were related to hospitals' partnerships. Hospitals within health care systems and with high inpatient volume were more likely to report relationships that were stronger. This study provides a systematic and updated look at hospitals' partnership when looking at commitment to population health improvement and contributes to the literature by informing about the greater need to support rural and smaller hospitals with population health outreach activities.