Early Warning Scores and Their Application in the Inpatient Oncology Settings

Early Warning Score (EWS) systems are tools that use alterations in vital signs to rapidly identify clinically deteriorating patients and escalate care accordingly. Since its conception in 1997, EWSs have been used in several settings, including the general inpatient ward, intensive care units, and the emergency department. Several iterations of EWSs have been developed with varying levels of sensitivity and specificity for use in different populations. There are multiple strengths of these tools, including their simplicity and their ability to standardize communication and to reduce inappropriate or delayed referrals to the intensive care unit. Although early identification of deteriorating patients in the oncology population is vital to reduce morbidity and mortality and to improve long-term prognosis, the application in the oncology setting has been limited. Patients with an oncological diagnosis are usually older, medically complex, and can have increased susceptibility to infections, end-organ damage, and death. A search using PubMed and Scopus was conducted for articles published between January 1997 and November 2020 pertaining to EWSs in the oncology setting. Seven relevant studies were identified and analyzed. The most commonly used EWS in this setting was the Modified Early Warning Score. Of the seven studies, only two included prospective validation of the EWS in the oncology population and the other five only included a retrospective assessment of the data. The majority of studies were limited by their small sample size, single-institution analysis, and retrospective nature. Future studies should assess dynamic changes in scores over time and evaluate balance measures to identify use of health care resources.

Experience in the use of olanzapine in an inpatient ward – clinical cases

Treating both schizophrenia and bipolar disorder require chronic drug therapy that must be chosen after careful consideration of the gains and losses associated with it. Hence, the process of the drug selection must take into account both the profile of patient’s symptoms and his coexisting diseases as well as the patient’s tolerance of earlier therapies. Olanzapine reduces positive symptoms of psychosis and enables stabilization in terms of affective episodes via blocking dopaminergic receptors. An important problem related to olanzapine therapy is its negative effect on the metabolism of carbohydrates and lipids. For this reason, appropriate information for the patient and implementation of appropriate prophylaxis, including monitoring of metabolic parameters, are recommended. Despite the risk of metabolic complications in some patients, olanzapine remains at the forefront of antipsychotic drugs, due to the good balance of benefits and losses associated with pharmacotherapy. In this paper, we present two clinical cases of patients who have been treated with olanzapine for schizophrenia and bipolar disorder.

749. A Nurse-Driven Protocol for Early Detection of Clostridiodes difficile Infections

Background Clostridiodes difficile infections (CDI) are a significant cause of hospital acquired infections, resulting in significant morbidity and mortality. Early detection of CDI has been shown to reduce the spread of CDI within the hospital. As nurses are frequently at the patient’s bedside, we proposed to empower the nursing staff to assess, collect stool samples, and order C. difficile testing. Methods Rates of CDI were measured by our Infection Control Department. Hospital-onset CDI (HO-CDI) was defined as a positive C. difficile PCR assay after 3 days of admission, defined as a stay of at least 3 midnights. Community-onset CDI (CO-CDI) was defined as any case that was diagnosed in the Emergency Department or inpatient ward < 3 days of hospitalization based on stool testing as above. Nursing was instructed and empowered to assess, collect stool specimens, and place an order for C. difficile testing, based on the criteria of ≥3 loose or watery stools over 24 hours. Nursing was also educated to not order a test if patients had received stool softeners, enemas, or laxatives within 24 hours. The protocol was initiated in February 2019. Results Rates of HO-CDI increased during the intervention period, rising from 2.6 cases/10000 patient days and peaking at 17.7 cases/10000 patient days (average 6.7 vs. 12.1 monthly cases per 10,000 patient days. Rates of CO-CDI did not significantly change (12.4 vs. 11.5 monthly cases per 10000 patient days). Due to concerns of inappropriate testing, which included testing after laxatives, enemas, or sending specimens despite < 3 stools over 24 hours, the protocol was discontinued in June 2019. Although the HO-CDI rate remained elevated over the next month, the rate subsequently decreased over the next several months (12.1 vs. 8.0 cases per 10000 patient days). Overall testing also increased over the study period (148.3 vs. 169.9 cases/per 10000 patient days).Figure 1 - Clostridiodes difficile rates Figure 2 - CDI testing rates Conclusion A nursing driven protocol resulted in increased HO-CDI and overall CDI rates suggesting that the intervention may have been a factor in increasing the frequency of HO-CDI diagnoses, although the possibility of misdiagnosis of colonization for true CDI cannot be excluded. Further education of nursing staff may be a potential intervention in improving appropriate CDI testing. Disclosures All Authors: No reported disclosures

Association between Smoking Habit and Pulmonary Tuberculosis at Dr. Soetomo General Academic Hospita

Introduction: Smoking has been reported as one of tuberculosis (TB) risk factor. The association between smoking and TB has been proven in multiple studies, but little known about the association between smoking degree and sputum smear positive. Methods: An analytic observational study using cross-sectional design. Data of patients with pulmonary TB conducted at DOTS (Directly Observed Treatment Short course)/MDR (Multi Drug Resistance) outpatient and inpatient ward in Dr Soetomo General Hospital Surabaya from January to October 2018. The degree of smoking was measured using Brinkman Index (BI). The odds ratio (OR) and 95% confidence intervals (CI) were also estimated.Results: There were 94 patients with pulmonary TB, 56 non-smoker and 38 smoker. Light smoking (P = 0,120, OR = 0.200, 95% CI: 0.022-1.823), moderate smoking (P=0.377, OR = 1.667, 95% CI: 0.533-5.209), heavy smoking (P=0.076, OR= 0.333, 95% CI: 0.96-1.160). Moderate smoking compared to heavy smoking as a control (P=0.33, OR = 5.000, 95% CI=1.096-22.820). Conclusion: There’s no significant correlation between smoking habits and sputum smear positive, but the present study evidenced the patients with smoking habits had greater chance to get sputum smear positive than non-smokers. Patient with moderate smoking compared to heavy smoking had greater chance to get sputum smear positive.

Relationship of Anxiety and Post-Vaccination Nurse Caring During The Covid P-19 Pandemic in Indonesia Hospital

Introduction: Anxiety is a psychological aspect that everyone will feel when they are in a situation that threatens their comfort. Caring is a behavior that is identical with nurses as health workers who provide services to clients. Nurses providing services to clients during the Covid-19 pandemic will undoubtedly be riskier because many clients without signs and symptoms are in the service area. This condition can certainly affect the nurse's psychology to increase the nurse's anxiety which will later affect the nurse's caring for the clients she cares for. Aim: To describe the relationship between nurses' anxiety and care after the Covid-19 vaccination at the hospital. Method: Non-experimental using a correlational research design to explain the correlative relationship between variables. The population of this study was nurses in the inpatient ward of the Hospital in Indonesia, with 191 nurses. The sampling technique used by researchers in this study is random sampling. The data collection technique used is by using a questionnaire. Result and Analysis: Respondent data shows that anxiety and caring nurses have a relationship with the value of (α = 0.031). The nature of the relationship between the two variables is very low, with a value (r = 0.156). Discussions: Anxiety with caring for nurses after covid-19 vaccination has a weak relationship. The vaccination program is expected to reduce a person's infection rate. The virus is hoping that people who have been vaccinated can carry out daily activities without any worries, including nurses who work to provide services to clients to care for clients without any anxiety. Keywords: Anxiety, Caring, Covid-19 Vaccination, nurses, hospitals.

Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties

Purpose We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward. Methods 200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period. Results 166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%. Conclusion Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

Pharmacists’ interventions on 2 years of drug monitoring in an oncology pediatric inpatient ward

Background In oncology, pharmacists contribute to safety and effectiveness of drug treatment, identifying, preventing and forwarding solutions to drug-related problems (DRPs). However, it is still necessary to elucidate the profile of drug-related problems in pediatric cancer treatment to contribute to guide clinical pharmacy activities. Methods A retrospective cross-sectional study was conducted. Records on Excel® spreadsheets of 2 years of pharmaceutical assistance were analyzed regarding the prescriptions of chemotherapy for hospitalized patients aged 0–19 years. Data on age, sex, cancer diagnosis, protocol and drugs prescribed were collected. Causes and types of DRPs and pharmacists’ interventions as their rate of acceptance were measured according to PCNE V 9.0. Results Drug-related problems were identified for 84 patients, in 5.3% of analyzed prescriptions. Leukemias, patients aged 0–4 years and male sex were associated with higher rates of drug-related problems. The BFM 2009 protocol for acute lymphocytic leukemia treatment had the highest frequency of prescriptions with drug-related problems. Main drug-related problems were related to effectiveness (49.2%) and safety (33.2%), with most of them due to drug selection and dose. Rate of acceptance of interventions was 92.2% and 90.6% of drug-related problems were fully resolved. Mercaptopurine and filgrastim were the drugs most associated with drug-related problems. Oral antineoplastic agents represented 36% of the prescriptions with drug-related problems. Conclusion The high rate of acceptance of pharmacist interventions demonstrates the relevance of the pharmacist participation in the care of hospitalized pediatric patients undergoing chemotherapy. Pharmacists need to take attention to cases of necessity of drug prescription, intervening with other health professionals. Special attention to oral chemotherapy is required.

Vascular Endothelial growth factor A in HCV infected patients before and after treatment with DAAS and its possible relation to HCC development

Background HCC comprises 5.6% of all cancersworldwide representing the fifth most common cancer.It is also the second most common cause of cancer death. Objective To study the impact of DAAs on appearance of H.C.C in HCV infected patients. Patients and Methods After obtaining approval from the Institutional Review Board (IRB) and the Department of Internal Medicine, Ain Shams University and written informed consent obtained from all patients, this cross-sectional study was performed in Suez canal authority hospitals (Outpatient Clinic and the Inpatient Ward), at Ismailia Egypt.Sample size on 50 patients divided into 25 cases and 25 controls. Results Our results w obtained and show that there was no statistically significant difference could be detected between HCV subdivided groups.There was statistically significant difference could be detected between HCC subdivided groups. Conclusion Angiogenesis plays an important role in the progression of HCC. VEGF is aprimary driving force for both phisological and pathological angiogenesis and overexpression of VEGF is observed in HCC. Circulating levels of VEGF increase significantly remain high until end of treatment and decline to pretreatment level within 12 week of end of therapy.It has angiogenic properties. Elevated Circulating levels of VEGF after RF (radiofrequency) or TACE correlate with poor prognosis for patient with HCC (hepatocellular carcinoma).

Rapid reinfection with SARS-CoV-2 variant-of-concern Alpha detected in a nurse during an outbreak at a non-covid inpatient ward: lessons learned

We describe the lessons learned during a SARS-CoV-2 variant-of-concern Alpha outbreak investigation at a normal care unit in a university hospital in Amsterdam in December 2020. The outbreak consisted of nine nurses and two roomed-in patient family members. (attack rate 18%). One nurse tested positive with a phylogenetically distinct variant, after a documented infection 83 days prior. Three key points were taken from this investigation. First, it was controlled by adherence to existing guidelines, despite increased transmissibility of the variant. Second, viral sequencing can inform transmission cluster inference, but the epidemiological context is essential to draw appropriate conclusions. Third, reinfections with Alpha variants can occur rapidly after primary infection.