P148 Solriamfetol Titration & AdministRaTion (START): Dosing and titration strategies in patients with narcolepsy starting solriamfetol

Introduction Solriamfetol (Sunosi) is a dopamine/norepinephrine reuptake inhibitor approved (EU/US) to treat excessive daytime sleepiness (EDS) in adults with narcolepsy (75–150 mg/day) or obstructive sleep apnoea (OSA) (37.5–150 mg/day). This study characterised real-world dosing and titration with solriamfetol in patients with narcolepsy. Methods A retrospective patient chart review was conducted among US-based physicians prescribing solriamfetol. Initiation strategies were de novo (no prior EDS medication), transition (switched/switching from existing EDS medications to solriamfetol), or add-on (adding solriamfetol to current EDS medication). Results Twenty-three physicians entered data from 70 patients with narcolepsy (type 1, 24/70; type 2, 46/70; mean+/-SD age, 40+/-11 years; 57% female; 6 also had OSA). EDS was mainly moderate (59%) or severe (36%). Nineteen patients (27%) initiated de novo, 31 (44%) transitioned, and 20 (29%) were add-on. Most patients started solriamfetol at 75 mg (86%) and were stable at 150 mg (76%). Most (67%) had 1 dose adjustment; median (range) time to a stable dose was 14 (1–60) days. EDS severity (44% of patients) was frequently considered when titrating. Fourteen of 22 (64%) transitioning from wake-promoting agents (WPAs) stopped them abruptly; 5/9 (56%) using stimulants tapered off. Discussion In a real-world study, most physicians prescribing solriamfetol to patients with narcolepsy started at 75 mg, tapered stimulants, abruptly discontinued WPAs, and made 1 dose adjustment. Support Jazz Pharmaceuticals

Epidemiology of hip fracture in Botswana

Summary A retrospective population-based survey in the Republic of Botswana determined the incidence of fractures at the hip over 3 years. The estimated number of such fractures nationwide for 2020 was 103 and is predicted to increase. Objective This article describes the epidemiology of hip fractures in the Republic of Botswana. Methods A retrospective patient chart review was conducted to identify from hospital registers the number of patients diagnosed with hip fracture in 2009, 2010, and 2011. Age- and sex-specific incidence of hip fracture was determined from which lifetime probabilities and future projections for hip fracture were calculated. Results The incidence of hip fracture was low and comparable to rates reported from Tunisia. The remaining lifetime risk of hip fracture at the age of 50 years in men and women was 1.4 and 1.1%, respectively. The incidence of hip fracture suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2020 was 103 and is predicted to increase by more than threefold to 372 in 2050. Conclusion The hip fracture rates can be used for healthcare planning. Additionally, these data can be used to create a FRAX model to help guide decisions about treatment.

The Impact of EHR based simulation during Intern Boot Camp on EHR utilization (Preprint)

BACKGROUND Accurate data retrieval is an essential part of patient care in ICU. The electronic health record (EHR) is the primary method of data storage and data review. We previously reported that residents participating in EHR based simulations have varied and nonstandard approaches to data finding in the ICU, with subsequent errors in recognition of patient safety issues. We hypothesized that a novel EHR simulation based training exercise would decrease variability in EHR use among intervention interns irrespective of prior EHR experience. OBJECTIVE To understand the impact of a novel, short, high-fidelity, simulation-based electronic health record learning activity on intern data gathering workflow and satisfaction. METHODS Seventy-two internal medicine interns across the 2018-19 academic years underwent a dedicated EHR training session as part of a week-long boot camp early in their training. We collected data on previous EHR and ICU experience for all subjects. Training consisted of an hour of guided review of a high-fidelity, simulated ICU patient chart focusing on best practices for navigation for data retrieval. Specifically, the activity focused on utilizing high and low yield data visualization screens determined by expert-consensus. Intervention group interns then had 20 minutes to review a new simulated patient chart before group review. EHR screen navigation was captured utilizing screen recording software and compared with data from existing ICU residents performing the same task on the same medical charts (N=62). Learners were surveyed immediately and 6-months after the activity to assess satisfaction as well as preferred EHR screen use. RESULTS Participants found the activity useful and enjoyable immediately and after six months. Intervention interns used more individual screens than reference residents (18 vs 20, p=0.008) but the total number of screens used were the same (35 vs 38, p=NS). Significantly more of the intervention interns used the ten most common screens (73% vs 45%, p=0.001). Intervention interns used high-yield screens more often and low-yield screens less often than the reference residents, which persistent on self-report 6 months later. CONCLUSIONS A short, high-fidelity, simulation-based learning activity focused on provider-specific data gathering was found to be enjoyable and to persistently modify navigation patterns. This suggests that workflow specific simulation-based EHR training throughout training is of educational benefit to residents. CLINICALTRIAL n/a

A SIMPLE INTERVENTION TO REDUCE ANTICHOLINERGIC DRUG USE WHILE ATTENDING A GERIATRIC DAY HOSPITAL

Attendance at a Geriatric Day Hospital has previously been shown to reduce both the overall number of medications and the number of anticholinergic medications of patients. In the present study, patients enrolled in a Geriatric Day Hospital program from January to February 2019 were divided into a control and intervention group. Anticholinergic medications in the intervention group were flagged by highlighting them in the patient chart and alerting the attending clinician, whereas no alerts were provided in the control group. Anticholinergic load was calculated using the Anticholinergic Cognitive Burden (ACB) and Drug Burden Index (DBI) scores. In comparing admit versus discharge medications in the intervention group, both the mean number of overall medications (10 vs. 9.7) and anticholinergic medications (3.5 vs. 3.1) was reduced; this was not the case in the control group, where the mean number of overall medications remained the same (11.92) and the mean number of anticholinergic medications increased (3.83 vs. 3.92). More significantly, in comparing admit versus discharge scores, both the mean ACB and DBI scores were reduced in the intervention group, but in the control group both the ACB and DBI scores either remained the same or increased at the time of discharge. This clearly shows that a simple intervention (highlighting anticholinergic medications in the patient chart) can have a clinically beneficial outcome of reducing these harmful medications in patients. With approximately 50% of the older population taking at least one anticholinergic drug, the importance of reducing anticholinergic burden cannot be overemphasized.

Neurological Dashboards and Consultation Turnaround Time at an Academic Medical Center

Background Neurologists perform a significant amount of consultative work. Aggregative electronic health record (EHR) dashboards may help to reduce consultation turnaround time (TAT) which may reflect time spent interfacing with the EHR. Objectives This study was aimed to measure the difference in TAT before and after the implementation of a neurological dashboard. Methods We retrospectively studied a neurological dashboard in a read-only, web-based, clinical data review platform at an academic medical center that was separate from our institutional EHR. Using our EHR, we identified all distinct initial neurological consultations at our institution that were completed in the 5 months before, 5 months after, and 12 months after the dashboard go-live in December 2017. Using log data, we determined total dashboard users, unique page hits, patient-chart accesses, and user departments at 5 months after go-live. We calculated TAT as the difference in time between the placement of the consultation order and completion of the consultation note in the EHR. Results By April 30th in 2018, we identified 269 unique users, 684 dashboard page hits (median hits/user 1.0, interquartile range [IQR] = 1.0), and 510 unique patient-chart accesses. In 5 months before the go-live, 1,434 neurology consultations were completed with a median TAT of 2.0 hours (IQR = 2.5) which was significantly longer than during 5 months after the go-live, with 1,672 neurology consultations completed with a median TAT of 1.8 hours (IQR = 2.2; p = 0.001). Over the following 7 months, 2,160 consultations were completed and median TAT remained unchanged at 1.8 hours (IQR = 2.5). Conclusion At a large academic institution, we found a significant decrease in inpatient consult TAT 5 and 12 months after the implementation of a neurological dashboard. Further study is necessary to investigate the cognitive and operational effects of aggregative dashboards in neurology and to optimize their use.

Evaluation of thiamine for the prevention of ifosfamide-induced encephalopathy

Study objective To determine whether thiamine prophylaxis decreases the incidence of ifosfamide-induced encephalopathy in patients receiving ifosfamide for the treatment of lymphoma. Design Retrospective, multi-center, cohort study. Patients A total of 73 patients who received 187 total cycles of ifosfamide, carboplatin, and etoposide chemotherapy for the treatment of lymphoma were included in this study. Forty-four of these patients (114 cycles) were included in the no-thiamine group and 29 (65 cycles) in the thiamine group. Measurements and main results The incidence of ifosfamide-induced encephalopathy was measured using the Common Terminology Criteria for Adverse Events and documentation in the patient chart. Regarding the primary endpoint of ifosfamide-induced encephalopathy, eight patients (18.2%) in the no-thiamine group and three patients (10.3%) in the thiamine group experienced an event ( p = 0.5087). No patient experienced more than one neurotoxic event. Conclusion There was no significant difference found in the incidence of ifosfamide-induced encephalopathy with the addition of thiamine prophylaxis in patients receiving ifosfamide, carboplatin, and etoposide–based chemotherapy regimens for lymphoma. Larger, prospective studies assessing the use of thiamine prophylaxis in this patient population are warranted to better assess its impact on the incidence of ifosfamide-induced encephalopathy.