Nonspecific abdominal pain: Do I have to allocate a specific diagnosis for every patient?

Acute abdominal pain is one of the most common chief complaints in the acute setting all over the world. The definitive diagnoses of these patients vary depending on age, gender, geographical and sociodemographic characteristics etc. Apart from these, aging of the population, obesity, advanced diagnostic imaging modalities and changes in nutritional habits also have an impact on the rates of specific diagnoses. On the other hand, nonspecific abdominal pain constitutes almost half of all visits due to acute abdominal pain in the acute care setting. This phenomenon is the main differential diagnostic problem in the management of these patients because missing a life-threatening condition can cause enormous medicolegal problems for the caregivers. Certain diagnostic scoring systems have also been developed to facilitate recognition and management of these conditions. This article aims to review the entity and underline the challenges it can bring to the scene.

Ocular Emergencies in Children

This chapter covers general bedside and chairside examination procedures and instruments used to examine a pediatric patient in an acute care setting. Pediatric patients may present to an emergency room or present emergently in any clinical setting with a wide variety of acute ocular conditions. When working in an emergency room or hospital-based setting, it is unlikely that a clinician will have all of the exam equipment typically used for routine care. The authors review the various ocular imaging techniques used to obtain a view of the internal structures of the eye, orbit, head, and brain when external examination is not sufficient. The procedures described aid the clinician in appropriately and thoroughly evaluating pediatric patients presenting with ocular emergencies.

The Cost of Patient Education on a Post-Partum Unit in an Acute Care Setting

Four years post-implementation, an interactive patient care system is slated for decommissioning in two hospitals. A team of experts was tasked with evaluating whether to replace or remove the functionalities of this system and the cost associated with either. The largest effects noted were the financial burden and the patient education. The cost to substitute video education with nursing time spent in patient education was determined to not be cost-effective.

Identification of nutritional risk in the acute care setting: progress towards a practice and evidence informed systems level approach

Background To improve nutritional assessment and care pathways in the acute care setting, it is important to understand the indicators that may predict nutritional risk. Informed by a review of systematic reviews, this project engaged stakeholders to prioritise and reach consensus on a list of evidence based and clinically contextualised indicators for identifying malnutrition risk in the acute care setting. Methods A modified Delphi approach was employed which consisted of four rounds of consultation with 54 stakeholders and 10 experts to reach consensus and refine a list of 57 risk indicators identified from a review of systematic reviews. Weighted mean and variance scores for each indicator were evaluated. Consistency was tested with intra class correlation coefficient. Cronbach's alpha was used to determine the reliability of the indicators. The final list of indicators was subject to Cronbach’s alpha and exploratory principal component analysis. Results Fifteen indicators were considered to be the most important in identifying nutritional risk. These included difficulty self-feeding, polypharmacy, surgery and impaired gastro-intestinal function. There was 82% agreement for the final 15 indicators that they collectively would predict malnutrition risk in hospital inpatients. Conclusion The 15 indicators identified are supported by evidence and are clinically informed. This represents an opportunity for translation into a novel and automated systems level approach for identifying malnutrition risk in the acute care setting.

Palliative Care Utilization, Transfusion Burden and Symptoms for Patients with Multiple Myeloma at the End of Life

Introduction: Despite dramatic treatment advances , multiple myeloma (MM) remains a significant source of morbidity and mortality with 13,000 deaths expected annually in the United States. We characterized patterns of mortality, palliative care involvement, and disease course at the end of life for patients with MM over the last decade. Methods: We assessed all consecutive deceased patients with a diagnosis of MM who received health care at a single health care institution from January 2010 to December 2020. Institutional Review Board approval was obtained prior to data review. Descriptive statistics were employed, and chi square was used to compare categorical variables. Results: A total of 456 patients were identified. Patient characteristics and outcomes are listed in Table 1. In the year prior to death, the prevalence of depression was 45.8% (209 patients), whereas 75.4% of patients were on opiates as an outpatient (344 patients). The mean number of lines of treatment received from diagnosis to death was 3 (range 0-12). Two-hundred eleven (46.3%) patients required red blood cell transfusions in the year prior to death. Palliative care physicians saw 207 (45.4%) patients, of which 97 (46.9%) were seen as outpatient (including those who saw both outpatient and inpatient), and 110 (53.1%) exclusively as an inpatient. The median time from first palliative care consultation to death was 10 days for inpatient palliative care (range 0-389 days), and 107 days for outpatient palliative care (range 2-2028 days). Only 42 (9.2%) patients saw palliative care ≥6 months prior to death. Compared to those patients who did not see palliative care, those that saw palliative care ≥6 months prior to death were more likely to be female (61.9 versus 42.2%, p=0.05), younger (median age at diagnosis 66 versus 71, p=0.03), and have a longer survival (46 months versus 35 months, p=0.006) (Table 1 and Figure 1). Amongst the patients for whom place of death was clearly reported (351, 77%), 117 patients (33.3%) died in the acute care setting, 110 (31.3%) died in a hospice facility, and 124 (35.3%) died at home. Outpatient palliative care consultation did not correlate with a statistically significant difference in deaths in an acute care setting (22/81, 27.2% seeing outpatient palliative care versus 57/174, 32.8% for those who did not, p=0.36), or in chemotherapy (any active treatment other than just steroids) utilization in last month of life (30.9% versus 29.7%, p=0.83). Conclusion: In our analysis of the entire trajectory of the MM patient experience from diagnosis to death, we found a substantial proportion of patients with MM report depression, need opiates for pain control, require blood transfusions and are repeatedly hospitalized in the year prior to their death. A fifth of all deaths occur within a year of diagnosis. With a median of three lines of therapy from diagnosis to death, patients may not live to experience therapies reserved for later lines of treatment. A minority of these patients see a palliative care physician during their treatment journey with the median time from palliative care consultation to death only a month. Palliative care referral at this health system is physician-initiated and not based on standard criteria, which may impact these findings. While there is no clear correlation that palliative care consultation impacted the rate of acute care deaths or decreased utilization of MM treatment in the last month of life, (two common but complicated proxies for quality of end-of-life care), further prospective research on optimal utilization of specialist palliative care is required. Figure 1 Figure 1. Disclosures Sborov: GlaxoSmithKline: Consultancy; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; SkylineDx: Consultancy; Sanofi: Consultancy.

Costing pressure ulcer care in an Irish acute care setting: a feasibility study

Objective: To test the feasibility of using a standardised data collection tool to estimate the cost of stage 2–4 pressure ulcer (PU) care within an acute care setting. Method: Data on resource use and cost were obtained through a retrospective survey of nursing and medical notes collecting cost data for individual patients who received care for stage 2–4 PUs. Results: Data for 20 patients (12 male/8 female) were analysed. The average patient age was 69 years (range: 37–95 years). Of this sample, seven patients had hospital-acquired PUs (HAPUs) and 14 patients had community-acquired PUs (CAPU) (one patient had both—in different anatomical areas). Over half of the total sample (55%; n=11) had a stage 2 PU. The average length of stay was 31.8 days (range: 5–119 days). Most of the patients (70%; n=14) had a CAPU. The average cost per patient with PU care was €878 (range: €39–2393). The mean cost for patients with a HAPU was €866 (SD: €1313) versus €911 (SD: €567) for patients with a CAPU. The majority of the cost related to equipment and staff time for treatment. Conclusion: Overall, the application of the standardised data collection tool to obtain cost data from retrospective inspection of nursing and medical notes is feasible. The cost of PU care in this sample was high, indicating that these wounds may impose a substantial burden on health systems. The costs varied greatly between patients in the sample, reflecting the complexity of PU care. Furthermore, given that costs increased with the higher PU stages, there is a potential to reduce costs by preventing the development of higher stage PUs. Larger-scale studies are required to understand the cost variation and full economic impact of PU care. Declaration of interest: The authors have no conflicts of interest.

60. Penicillin Allergy Delabeling Program in the Post-acute Care Setting

Background A significant proportion of inpatients labeled with penicillin allergies do not have a true IgE-mediated hypersensitivity, which may unnecessarily limit options for treatment of infection and lead to suboptimal antibiotic selection. Post-acute care settings may provide a unique opportunity to capture patients at risk for adverse outcomes related to penicillin allergy labels. The objective of the study was to assess the feasibility and impact of a penicillin delabeling program in an inpatient rehab setting. Methods We conducted a prospective observational study. Inpatients with penicillin allergies were identified weekly by manual review of electronic medical records. A clinical pharmacist reviewed each patient’s chart and identified patients for inclusion. Patients were excluded if they had a history of IgE-mediated hypersensitivity to penicillin within last 5 years, a history of a non-IgE mediated hypersensitivity, were severely immunocompromised, or were prescribed a contraindicated medication. Results A total of 72 charts were reviewed over nine months, and 37 (51.4%) had their penicillin allergy updated to reflect prior beta-lactam tolerance. Of the 72 patient that were evaluated, 28 (38.9%) were eligible for potential penicillin allergy delabeling, and 44 (61.1%) were ineligible. 59 (81.9%) of the patients had a moderate-high risk allergy, 12 (16.6%) had a low risk allergy, and 1 (1.4%) had an intolerance. Of the 28 eligible patients, 11 (39.3%) had their allergy removed, 13 (46.4%) deferred testing, and 4 (14.2%) could not be tested due to staffing. Of the 28 patients that had their allergy delabeled, 7 (21.4%) had their allergy removed by MAR review, 2 (7.2%) had a skin test with a negative result, and 2 (7.2%) had a direct oral challenge with a negative result. Conclusion A penicillin allergy delabeling program using a collaborative physician-pharmacist team model efficiently removed reported allergies in post-acute care patients. The post-acute care setting is an opportune environment to conduct a penicillin allergy delabeling program for patients not currently needing acute medical treatment. Disclosures All Authors: No reported disclosures