177. Implementation of Pharmacist-Driven Penicillin Allergy Evaluation and Testing with a Focus on Bypassing Penicillin Skin Testing at an Academic Medical Center

Abstract Background Penicillin allergies are reported by approximately 10% of the US population; however, studies reveal that >90% of those patients can tolerate penicillins. Penicillin allergies are associated with negative health outcomes, both clinical and financial, due to reduced efficacy and increased adverse effects of alternative antibiotics. Patient interview, penicillin skin testing (PST) and/or an oral graded challenge can be used to evaluate penicillin allergies. Different facilities use various algorithms for testing. The objective of this project was to determine whether a pharmacist-driven penicillin allergy evaluation and testing protocol which largely bypasses PST could safely de-label patients. Methods Adult patients (≥18 years) admitted with a penicillin allergy were evaluated for eligibility between September 2019 and June 2020. Pregnant patients, critically-ill patients, and patients receiving test-invalidating medication were excluded. Patients were evaluated and tested using institutional protocols, which allowed for the majority of patients to be challenged without PST. Allergies were removed with standardized documentation, and patients were given a pamphlet and counseled to discourage relabeling. Data collected included but were not limited to, the number of patients challenged and de-labeled, number of patients who were relabeled, and number of patients whose change in allergy status resulted in change of therapy. Results Forty-eight patients were interviewed and evaluated. One patient was evaluated by PST and oral graded challenge while 27 patients underwent an oral graded challenge only. Twenty patients were de-labeled as a result of patient interview. One patient failed oral challenge with minor itching that did not require any treatment, while 27 patients passed. Forty-seven allergies were removed or modified. Two patients who were de-labeled were relabeled with no record of a new reaction. Of de-labeled patients, 50% received a penicillin following removal of the allergy. Conclusion Penicillin allergies can be evaluated and removed using a pharmacy-driven algorithm that prioritizes direct challenges when appropriate. Risks of a reaction are low, and removal leads to change in treatment in a significant portion of patients. Disclosures All Authors: No reported disclosures

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Curricular Development and Implementation of a Longitudinal Integrative Medicine Education Experience for Trainees and Health-Care Professionals at an Academic Medical Center

Global Advances in Health and Medicine ◽

10.1177/2164956119837489 ◽

2019 ◽

Vol 8 ◽

pp. 216495611983748 ◽

Cited By ~ 1

Author(s):

Susanne M Cutshall ◽

Tejinder K Khalsa ◽

Tony Y Chon ◽

Sairey M Vitek ◽

Stephanie D Clark ◽

...

Keyword(s):

Health Care ◽

Integrative Medicine ◽

Health Care Professionals ◽

Medical Center ◽

Academic Medical Center ◽

Curricular Development ◽

Medical Needs ◽

Academic Medical ◽

Number Of Patients ◽

Prevention And Health Promotion

A growing number of patients and consumers are seeking integrative medicine (IM) approaches as a result of increasing complex medical needs and a greater emphasis on prevention and health promotion. Health-care professionals need to have knowledge of the evidence-based IM resources that are safe and available to patients. Medical institutions have acknowledged the need for education and training in various IM modalities and whole-health approaches in medical curricula. There is a strong need to develop and incorporate well-structured IM curricula across all levels of learning and practice within medicine. This article provides an example of the development, implementation, impact, and assessment of IM education curricula across all learner levels at a large academic medical center.

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Intravenous Immune Globulin Stewardship Program at a Tertiary Academic Medical Center

Annals of Pharmacotherapy ◽

10.1177/1060028016673071 ◽

2016 ◽

Vol 51 (2) ◽

pp. 135-139 ◽

Cited By ~ 4

Author(s):

Megan A. Rocchio ◽

James W. Schurr ◽

Aaron P. Hussey ◽

Paul M. Szumita

Keyword(s):

Immune Globulin ◽

Medical Center ◽

Academic Medical Center ◽

Intravenous Immune Globulin ◽

Solid Organ ◽

Organ Rejection ◽

Guideline Compliance ◽

Stewardship Program ◽

Academic Medical ◽

Number Of Patients

Background: In October 2010, a pharmacist-driven stewardship program was implemented at the Brigham and Women’s Hospital to ensure continued adherence to the prescribing guideline, focusing on indications for intravenous immune globulin (IVIG) use and dosing per ideal body weight. Objective: The primary objective was to describe an IVIG stewardship program at a tertiary academic medical center. Methods: This was a prospective, observational study from January 2013 through December 2014. All patients ordered to receive IVIG during the defined study period were included. The intervention assessed describes a pharmacist-driven IVIG stewardship program for medication approval. The primary end point was guideline compliance based on indication, dose, dosing weight, and frequency. Secondary end points included the number of patients receiving IVIG, indications, orders discontinued as a result of guideline nonadherence, and total amount dispensed. Results: A total of 418 patients were identified during the study time frame. The top indications were: hypogammaglobulinemia in bone marrow transplantation and hematological malignancy (50.7%), acute solid organ rejection (11.8%), and immune thrombocytopenia with bleeding (10.1%). In all, 12 patients (2.9%) received IVIG for an indication nonadherent with the IVIG prescribing guideline; 9 patients (2.2%) and 2 patients (0.5%), respectively, received a different dose or frequency per the prescribed indication; and 12 orders (2.9%) for indications nonadherent to the guideline were discontinued. A total of 26 033 g of IVIG were dispensed during the study period. Conclusions: An IVIG stewardship program, including an institution-specific prescribing guideline and a pharmacist-driven stewardship program, may ensure guideline compliance for appropriateness of indication and dose at an academic medical center.

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Evaluation of inpatient cancer pain management at an academic medical center.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.34_suppl.128 ◽

2012 ◽

Vol 30 (34_suppl) ◽

pp. 128-128

Author(s):

Michael Mearis ◽

Joseph Shega ◽

Randall Knoebel

Keyword(s):

Pain Management ◽

Cancer Pain ◽

Medical Center ◽

Academic Medical Center ◽

Cancer Pain Management ◽

Nccn Guidelines ◽

Academic Medical ◽

Number Of Patients ◽

Increased Risk ◽

Cancer Network

128 Background: The National Comprehensive Cancer Network (NCCN) guidelines on cancer pain management were developed to direct pain assessment and management. The purpose of this study was to assess whether adherence to guidelines was associated with improved outcomes. Methods: One-hundred and nine patients admitted to the inpatient hematology oncology service that received at least one dose of morphine, oxycodone, or hydromorphone were evaluated and allocated into groups based on adherence to the NCCN guidelines. Safety and achievement of analgesia (pain score ≤ 4) at 24-hours after opioid initiation were compared between the two groups. A multivariate analysis was performed to identify predictors of opioid regimens non-adherent to guidelines. Results: Sixty-four percent of patients were initiated on regimens adherent to the NCCN guidelines. 63% of patients initiated on regimens adherent to NCCN guidelines reached the endpoint of analgesia at 24 hours compared to 41% of those who were not (p = 0.028). Adverse events were infrequent (p > 0.5). Opioid tolerance was the variable most predictive of being initiated on regimens non-adherent to guideline recommendations (OR 3.1, 95% confidence interval 1.24-7.82). Conclusions: A significant number of patients presenting with cancer pain are initiated on regimens non-adherent to NCCN guidelines, leading to reduced attainment of adequate analgesia. Opioid tolerant patients are at an increased risk of inadequate analgesia, and should be identified and initiated on proper pain regimens taking home opioid usage into consideration.

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Characteristics of Postgraduate Physician Assistant Residency/fellowship Programs: A National Survey

10.21203/rs.3.rs-136568/v1 ◽

2021 ◽

Author(s):

Vasco Kidd ◽

Sarah Vanderlinden ◽

Roderick Hooker

Keyword(s):

Physician Assistant ◽

Medical Center ◽

Academic Medical Center ◽

Postgraduate Education ◽

Physician Assistants ◽

Teaching Hospitals ◽

Assigned Reading ◽

Academic Medical ◽

Wide Range ◽

The Us

Abstract Introduction: The development of postgraduate programs for physician assistants (PAs) began in 1973 and by 2020 there were approximately 100 programs spread across a broad range of medical and surgical disciplines. An assessment of these programs was undertaken. Method: A non-experimental, descriptive research study was designed to obtain information on the characteristics of PA postgraduate education programs in the US. The source of information was from surveyed members of the Association of Postgraduate Physician Assistant Programs. Questions were drawn from consensus discussions. Programs that were operational in 2020 were eligible to participate. Results: Seventy-two programs were invited to the survey and 34 replied. They are geographically distributed across the US in 13 states. The respondents represent a wide range of medicine: surgery, emergency medicine, critical care, orthopaedics, hospitalist, psychiatry, oncology, primary care, pediatrics, and cardiology. Most programs are associated with an academic medical center. The curriculum includes bedside teaching, lectures, mentorship, assigned reading, procedures, simulation, and conferences. The PA fellow serves as house officer alongside physician residents and fellows. An average program length is 12 months and awards a certificate. Stipends for PA fellows are $50,000-80,000 (2020 dollars) and benefits include paid time off, health and liability insurance. About half of the programs bill for the services rendered by the PA. Over 90% of graduates are employed within two months of fellowship completion. Conclusion: A trend is underway in American medicine to include PAs in postgraduate education. PA fellowships occur across a broad spectrum of medical and surgical areas, as well as diverse institutions and organizations overseeing the programs. Most are in academic medical centers or teaching hospitals. This study expands information on PA fellowships and their operation.

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Abstract 247: Process Improvement Initiatives to Reduce No Show Rates in Rural Communities

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.247 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Tara Haskell ◽

Melissa Cushman

Keyword(s):

Rural Communities ◽

Process Improvement ◽

Private Practice ◽

Medical Center ◽

Academic Medical Center ◽

Recommended Care ◽

Academic Medical ◽

Improved Outcomes ◽

Number Of Patients ◽

Data Tracking

Objective: A large pediatric academic medical center (AMC) acquired an out-of-state private cardiology practice serving rural communities and without an EMR. No show rates at the private practice consistently ranged from 20-40%, compared to 11% at the AMC. No shows contribute to inefficient use of clinician time and access to care challenges for other patients. Upon acquisition, process improvement efforts began with the goal of decreasing the abnormally high no show rates. Methods/Findings: Under private practice, staff scheduled patient appointments without inquiring for their availability and then notified patients of their appointment date and time via letter 10 days prior to the scheduled appointment and then by phone 2 days prior to the appointment. Immediately following the acquisition in December 2018, staff began calling patients to inquire when they would like to be scheduled based on their availability. Patients were scheduled six months out, so the true impact of this process change would be fully realized in May 2019. Once an EMR was implemented, a dashboard was created to monitor no show rate data and identify trends. After six months, no show rates only slightly improved, so in addition to the automated emails, calls, or text reminders from the scheduling center, a dedicated staff member began making reminder calls to patients the day before their appointment. As a result of the process improvement efforts, no show rates decreased from a high of 42% to 16% in eight months. Further, to better understand why patients were not showing for their appointments, staff began calling patients after a no-show appointment to determine if there were barriers for not showing and offering to reschedule the appointment. Data collected shows that out of 470 no show appointments from May 2019 to December 2019, 117 patients had disconnected phone numbers, 230 had appointment reminder messages left on their voicemail, 68 did not answer the call and did not have voicemail to leave a message and 55 patients confirmed their appointment with staff, but did not show for the appointment. Of the 470 no shows, 394 were pediatric patients and 76 were adults. Data shows 185 out of 470, or 39% of reminders never reached the patient, and an additional 49% went to voicemail and may not have been heard. Conclusion: No show appointments negatively impact clinic efficiencies and the ability to provide care to the greatest number of patients. When a patient doesn’t show for their appointment, they are non-compliant with their recommended care and reserve a clinic appointment that another patient may need. Small tests of change were made in phases to ensure appointments were convenient for patients and families and metrics were set and tracked to monitor improvement. By implementing new patient-centric processes and data tracking, more patients in rural communities receive the required follow up CHD care, leading to improved outcomes.

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Are USMLE Scores Valid Measures for Chief Resident Selection?

Journal of Graduate Medical Education ◽

10.4300/jgme-d-19-00782.1 ◽

2020 ◽

Vol 12 (4) ◽

pp. 441-446

Author(s):

Elaine R. Cohen ◽

Joshua L. Goldstein ◽

Clara J. Schroedl ◽

Nancy Parlapiano ◽

William C. McGaghie ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Chief Resident ◽

Academic Medical ◽

The Us ◽

Residency Selection ◽

P 16 ◽

Usmle Step 1 ◽

Usmle Step ◽

Resident Selection

ABSTRACT Background The US Medical Licensing Examination (USMLE) Step 1 and Step 2 scores are often used to inform a variety of secondary medical career decisions, such as residency selection, despite the lack of validity evidence supporting their use in these contexts. Objective We compared USMLE scores between non–chief residents (non-CRs) and chief residents (CRs), selected based on performance during training, at a US academic medical center that sponsors a variety of graduate medical education programs. Methods This was a retrospective cohort study of residents' USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores from 2015 to 2020. The authors used archived data to compare USMLE Step 1 and Step 2 CK scores between non-CR residents in each of the eligible programs and their CRs during the 6-year study period. Results Thirteen programs enrolled a total of 1334 non-CRs and 211 CRs over the study period. There were no significant differences overall between non-CRs and CRs average USMLE Step 1 (239.81 ± 14.35 versus 240.86 ± 14.31; P = .32) or Step 2 scores (251.06 ± 13.80 versus 252.51 ± 14.21; P = .16). Conclusions There was no link between USMLE Step 1 and Step 2 CK scores and CR selection across multiple clinical specialties over a 6-year period. Reliance on USMLE Step 1 and 2 scores to predict success in residency as measured by CR selection is not recommended.

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Use of a Beta-Lactam Graded Challenge Process at an Academic Medical Center

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1183 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s502-s502

Author(s):

Andrew Watkins ◽

Lee Amaya ◽

Macey Wolfe ◽

John Schoen ◽

Erica Stohs ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Guidance Document ◽

Beta Lactam ◽

Full Dose ◽

Stewardship Program ◽

Academic Medical ◽

Ige Mediated ◽

Graded Challenge ◽

Order Set

Background: A penicillin allergy guidance document containing an algorithm for challenging penicillin allergic patients with β-lactams was developed by the antimicrobial stewardship program (ASP). As part of this algorithm, a “graded challenge” order set was created containing antimicrobial orders and safety medications along with monitoring instructions. The process is designed to challenge patients at low risk of reaction with infusions of 1% of the target dose, then 10%, and finally the full dose, each 30 minutes apart. We evaluated outcomes from the order set. Methods: Orders of the graded challenge over 17 months (March 2018 through July 2019) were reviewed retrospectively. Data were collected on ordering and outcomes of the challenges and allergy documentation. Use was evaluated based on ASP-recommended indications: history of IgE-mediated or unknown reaction plus (1) no previous β-lactam tolerance and the reaction occurred >10 years ago, or (2) previous β-lactam tolerance, now requiring a different β-lactam for treatment. Only administered challenges were included and descriptive statistics were utilized. Results: Of 67 orders, 57 graded challenges were administered to 56 patients. The most common allergies were penicillins (87.7%) and cephalosporins (38.6%), with the most common reactions being unknown (41.7%) or hives (22%). The most common antibiotics challenged were ceftriaxone (43.9%), cefepime (21.1%), and cefazolin (5.3%). Antibiotics given prior to challenge included vancomycin (48.2%), fluoroquinolones (35.7%), carbapenems (21.4%), aztreonam (19.6%), and clindamycin (12.5%). The median duration of challenged antibiotic was 6 days. The infectious diseases service was consulted on 59.6% of challenges and 75.4% of challenges were administered in non-ICU settings. There was 1 reaction (1.8%) involving a rash with the second infusion, which was treated with oral diphenhydramine and had no lasting effects. Based on indications, 80.7% of challenges were aligned with ASP guidance criteria. The most common use outside of these criteria was in patients without IgE-mediated reactions (10.5%). Most of these had minor rashes and could have received a full dose of a cephalosporin. Allergy information was updated in the electronic health record after 91.2% of challenges. Conclusions: We demonstrated the utility of a graded challenge process at our academic medical center. It was well tolerated, ordered frequently by noninfectious diseases clinicians, administered primarily in non-ICU settings, and regularly resulted in updated allergy information in the medical record. With many patients initially receiving broad-spectrum antibiotics with high costs or increased rates of adverse effects, graded challenges can potentially prevent the use of suboptimal therapies with minimal time and resource investment.Funding: NoneDisclosures: Scott Bergman reports a research grant from Merck.

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Multidisciplinary Prerounding Meeting as a Continuous Quality Improvement Tool: Leveraging to Reduce Continuous Benzodiazepine Use at an Academic Medical Center

Journal of Intensive Care Medicine ◽

10.1177/0885066618769015 ◽

2018 ◽

Vol 34 (9) ◽

pp. 707-713 ◽

Cited By ~ 1

Author(s):

Alexander H. Flannery ◽

Melissa L. Thompson Bastin ◽

Ashley Montgomery-Yates ◽

Corrine Hook ◽

Evan Cassity ◽

...

Keyword(s):

Quality Improvement ◽

Continuous Quality Improvement ◽

Medical Center ◽

Academic Medical Center ◽

Successful Implementation ◽

Multidisciplinary Meeting ◽

Continuous Quality ◽

Academic Medical ◽

Number Of Patients ◽

Benzodiazepine Use

Background: Evidence-based medicine often has many barriers to overcome prior to implementation in practice, hence the importance of continuous quality improvement. We report on a brief (≤10 minutes) multidisciplinary meeting prior to rounds to establish a dashboard for continuous quality improvement and studied the success of this meeting on a particular area of focus: continuous infusion benzodiazepine minimization. Methods: This was a prospective observational study of patients admitted to the medical intensive care unit (MICU) of a large academic medical center over a 4-month period. A morning multidisciplinary prerounding meeting was implemented to report on metrics required to establish a dashboard for MICU care for the previous 24 hours. Fellows and nurse practitioners on respective teams reported on key quality metrics and other important data related to patient census. Continuous benzodiazepines were tracked daily as the number of patients per team who had orders for a continuous benzodiazepine infusion. The aim of this report is to describe the development of the morning multidisciplinary prerounding meeting and its impact on continuous benzodiazepine use, along with associated clinical outcomes. Results: The median number of patients prescribed a continuous benzodiazepine daily decreased over this time period and demonstrated a sustained reduction at 1 year. Furthermore, sedation scores improved, corresponding to a reduction in median duration of mechanical ventilation. The effectiveness of this intervention was mapped post hoc to conceptual models used in implementation science. Conclusions: A brief multidisciplinary meeting to review select data points prior to morning rounds establishes mechanisms for continuous quality improvement and may serve as a mediating factor for successful implementation when initiating and monitoring practice change in the ICU.

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Implementation and Evaluation of a Smartphone Application for the Perioperative Care of Neurosurgery Patients at an Academic Medical Center: Implications for Patient Satisfaction, Surgery Cancelations, and Readmissions

Operative Neurosurgery ◽

10.1093/ons/opx112 ◽

2017 ◽

Vol 14 (3) ◽

pp. 303-311 ◽

Cited By ~ 3

Author(s):

Daniel R Felbaum ◽

Jeffrey J Stewart ◽

Amjad N Anaizi ◽

Faheem A Sandhu ◽

Mani N Nair ◽

...

Keyword(s):

Postoperative Complications ◽

Medical Center ◽

Academic Medical Center ◽

Smartphone Application ◽

Control Group ◽

Pain Scores ◽

Phone Calls ◽

Academic Medical ◽

Number Of Patients ◽

Before And After

Abstract BACKGROUND Smartphone applications (apps) in the health care arena are being increasingly developed with the aim of benefiting both patients and their physicians. The delivery of adequate instructions both before and after a procedure or surgery is of paramount importance in ensuring the best possible outcome for patients. OBJECTIVE To demonstrate that app-based instructions with built-in reminders may improve patient understanding and compliance and contribute to reducing the number of surgery cancellations and postoperative complications and readmissions. METHODS We prospectively accrued 56 patients undergoing routine neurosurgery procedures who subsequently downloaded the app. The median age was 54 (range 27-79). Patients were followed for successful registration and use of the app, compliance with reading instructions before and after surgery, and sending pain scores and/or wound images. The number of surgeries cancelled, postoperative complications, 30-d readmissions, and phone calls for surgery-related questions were examined. RESULTS Fifty-four of the 56 patients successfully registered, downloaded, and used the app and read and complied with instructions both before and after surgery. There were no cancelled surgeries. There was 1 postoperative complication. There were no readmissions. Eight of the 54 patients (14.8%) called the office on a single occasion for a surgery related question. CONCLUSION We demonstrate the utility of a smartphone application in the perioperative neurosurgical care setting with regard to patient compliance and satisfaction as well as surgery cancellations and readmissions. Further study of a larger number of patients with a control group is warranted.

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