196. Assessing the Clinical Impact of Intravenous Acyclovir Dosing in Obese Patients: Should We Be Using Ideal, Adjusted, or Total Body Weight?

Background Obesity impacts the pharmacokinetics and pharmacodynamics of medications. Pharmacokinetic studies of intravenous (IV) acyclovir have demonstrated that dosing obese patients according to their ideal body weight (IBW) may provide a sub-therapeutic dose, while dosing based on total body weight (TBW) may increase adverse effects. This has led to the use of adjusted body weight (AdjBW) for dosing in this population; however, this has not been evaluated clinically. The purpose of this study is to assess the impact of different dosing strategies of IV acyclovir in obese patients. Methods This retrospective observational chart review evaluated adult patients admitted to Long Island Jewish Medical Center with a body mass index greater than or equal to 30 kg/m2 who received at least 48 hours of high-dose IV acyclovir therapy during the study period of January 2014 to August 2019. Patients were stratified to IBW, AdjBW, and TBW for analysis. The primary statistical tests utilized include descriptive statistics and logistic regression. The primary endpoint was the outcome of infection. The secondary endpoints included duration of therapy, length of stay, and adverse effects. Results 51 patients were included in the efficacy analysis and 84 patients were included in the safety analysis. Treatment failure occurred in 3 out of 51 patients (1 patient in IBW group, 2 patients in AdjBW group, p=0.445). There was no significant difference in median length of stay (p=0.977) or median duration of IV therapy (p=0.78). Nephrotoxicity occurred in 22.2%, 19.2%, and 22.7% of patients in the IBW, AdjBW, and TBW groups respectively (p=1). Conclusion When comparing different dosing modalities, there was no significant difference in the outcome of infection, duration of therapy, or length of stay. The results of this study were limited by small sample size. However, dosing patients according to AdjBW led to smaller doses of acyclovir, and therefore less drug exposure. Disclosures All Authors: No reported disclosures

Using a geographic and interdisciplinary strategy to improve patient care outcomes.

78 Background: Long Island Jewish Medical Center at Northwell Health is an urban/suburban academic tertiary care hospital located across the street from the Northwell Health Cancer Institute. The Division of Hospital Medicine partnered with Hematology/Oncology and Palliative Care to co-manage inpatient oncology patients on a geographic unit. The goal was to improve patient care through co-ownership and co-accountability of cancer patients in conjunction with a unit-based collaboration with Nursing, Pharmacy, Social Work, Case Management and Physical Therapy. Methods: A unit-based, interdisciplinary care team was formed consisting of Medical Oncologists, Hospitalists, Palliative Care specialists, Radiation Oncologists, as well as unit based and specialty trained nurses, social workers and advanced care practitioners. The team meets Monday thru Friday during interdisciplinary rounds to collaboratively discuss the care plans of each patient. We recently added a hospital-based medical oncologist to support greater continuity and communication. Results: Since full implementation including improvements in patient cohorting, the oncology care model has resulted in a 20% reduction in Medicare readmissions, a significant reduction in CAUTIs and CLABSIs, a 50% reduction in C.diff, a decreased CMI-adjusted length of stay and an improvement in pain management HCAHP scores, despite a 10% increase in CMI. An interdisciplinary approach has also improved documentation of goals of care discussion from 6% to 40-58%, furthering the idea of providing a unified medical voice to a vulnerable population. Conclusions: The oncology care model highlights that implementing multidisciplinary rounding, co-management and population-based geography can deliver a higher quality and more efficient level of care even in the face of higher patient acuity.

Application of Clinical Microsystems Improves the Speed of the Initial Pain Relief in Sickle Cell Disease (SCD) Patients Admitted with Acute Vaso-Occlusive Crisis (VOC)

Abstract 4740 Background- The management of acute vaso-occlusive crisis continues to be a challenge in patients with sickle cell anemia. Long Island Jewish Medical Center is a 500 adult bed, tertiary care facility, with more than 500 reported admissions for acute vaso-occlusive crisis in 2009. Suboptimal pain management in the Emergency Department (ED) frequently resulted in unrelieved pain, recurrent admissions, prolonged hospitalization, and increased patient dissatisfaction. Methods- An interdisciplinary team which included a patient with SCD was assembled to meet weekly to address the above issues. The team was educated in Clinical Microsystem methods as described by Nelson et.al (1) over 6 months. Preliminary data was collected to assess performance with respect to pain management in adult SCD patients presenting to the ED through pain diaries. The admission process was analyzed and significant delays were noted from time of presentation to the time that sufficient sustained analgesia was achieved. The PDSA (Plan Do Study Act) cycle method to test and study change was utilized. The specific aim was to achieve a sustained 2 point reduction in subjective pain score within 2 hours of inpatient admission. Four interventions were simultaneously tested. First, given the high frequency of admission from our ED for this patient population, we tested proactive bed designation initiated when the patient presented to the ED. Second, we educated the housestaff on providing appropriately dosed narcotic administration upon admission after pharmacy verification of previous patient specific dose requirements. Third, we arranged expedited transfer to the medical floors for these patients. Lastly, we arranged for storage of PCA pumps on the medical unit designated for SCD patients, facilitating immediate initiation of pain medication via this modality. Timing of analgesic response was assessed based on patient interviews and the above mentioned diaries. Results- During the pre-intervention stage it took an average of 55 hours and 20 minutes to achieve a sustained reduction in pain by two points. Post intervention, the team achieved a sustained 2 point reduction in subjective pain score by an average of 9 hours and 58 minutes (see figure). Conclusion- The Clinical Microsystems Methodology is an effective means of engaging an interdisciplinary team in improving the initial analgesic response to treatment in sickle cell patients admitted with acute vaso-occlusive crisis. Disclosures: No relevant conflicts of interest to declare.

Treatment of hairy-cell leukemia with cladribine: response, toxicity, and long-term follow-up.

PURPOSE To analyze initial and long-term outcomes after treatment of patients with active hairy-cell leukemia (HCL) with a single cycle of cladribine (2-CdA). PATIENTS AND METHODS Forty-nine patients with active HCL were treated with 2-CdA by continuous intravenous infusion at 0.1 mg/kg/d for a total of 7 days at the Long Island Jewish Medical Center between September 1990 and August 1992. Here we report on all patients followed-up until April 1996. RESULTS At 3 months after treatment, complete response (CR) occurred in 37 patients (76%) and partial response (PR) occurred in 12 patients (24%), for an overall response rate of 100% (95% confidence interval, 94% to 100%). At a median follow-up of 55 months, the relapse-free survival is 80% and overall survival is 95%. Ten patients (20%) have relapsed. Of the 26 patients in whom lymphocyte phenotyping was performed, four were found to have a CD25-negative phenotype. All four of these patients had PRs only and all relapsed. Eight patients have been re-treated with 2-CdA, and all achieved at least a partial remission; two of these have already relapsed with remission durations of less than 1 year. Five second malignancies have occurred in four patients. CONCLUSION With a median follow-up of more than 4 years, 39 patients (80%) continue in remission. Only two deaths have occurred. A CD25-negative phenotype may predict for a poorer response to 2-CdA. Patients who relapse may be re-treated with 2-CdA, but subsequent remissions may be of shorter duration. There has not been a markedly increased incidence of second malignancies or late opportunistic infections.

MULTIPLE BIRTHS: A WAKE-UP CALL

Miss Helen can recall when the Dionne quints were born in 1934, an event as rare and heralded as the birth of a white buffalo. But today, in the United States alone, there are 42 sets of quintuplets with all members living, including the three little girls and two boys born recently at Long Island Jewish Medical Center to Pnina and Shmuel Klaver of Flatbush. Triplets are more plentiful still. About 2500 sets are born annually. Twins and other multiples often delight their families, but they also present challenges for them and society as a whole. Multiples are much more prone to premature birth, a situation that can produce a whopping first-year health care tab—more than $1 billion for all low birth weight multiples, 35% of it borne by Medicare and Medicaid. Birth defect rates are also elevated in multiples. The rate of cerebral palsy, for example, is six times that for singletons, according to one study. And financial and child care burdens are heavier. One side effect: studies show child abuse is more common in families of multiples. . . . There is no data about how many multiple births are the result of fertility treatment. But it is estimated that 25% of pregnancies resulting from fertility treatment are multiple pregnancies.