Reducing time to antibiotics in patients with neutropenic fever on a bone marrow transplant unit

Background: Timely administration of antibiotics in patients with neutropenic fever (NF) is essential for reducing morbidity and mortality among oncology patients. Due to their immunocompromised state, neutropenic patients are at particularly high risk of developing severe complications from infection. The optimal time to antibiotics (TTA) for patients with NF is unclear, but IDSA/ASCO guidelines recommend a median TTA within one hour of documented fever. This study focused on identifying barriers at a single academic institution to timely antibiotic administration for patients admitted to the inpatient Bone Marrow Transplant (BMT) unit, and implemented new processes to reduce median TTA to less than 60 minutes. Method(s): Patients who developed NF during their hospital admission were included in the study. Individuals who were transferred from another facility or presented to the Emergency Department with NF were excluded. Chart reviews were performed to identify root causes for delays in antibiotics (abx). Data was collected for the following time points: time from fever to notification of provider, time from notification to abx order, time from order to release, and time from release to administration. The research team also met with key stakeholders from nursing, pharmacy, advance practice providers, and physicians to better understand the process. Result(s): Based on the root cause analysis, 4 interventions were implemented: cefepime was stocked in the pyxis (Int 1 - August 2018), NF guidelines were updated (Int 2 - October 2019), Educational videos were created for just in time learning for house staff rotating on the oncology services and an education campaign for the nursing staff (Int 3 - June 2020), a nurse driven protocol to release and administer abx was piloted on the BMT (Int 4 - December 2021). Baseline TTA was 128 minutes. After Int 1, median TTA decreased to 77.2 minutes. Int 2 and Int 3 did not improve median TTA. In October 2020, median TTA had increased to 98 minutes. After Int-4, on the BMT unit, median TTA decreased to 40 minutes. Conclusion(s): Through iterative changes and process improvement methodology, we were able to improve our median TTA from 128 minutes to 40 minutes. The most impactful changes simplified the process to administer abx. Educational initiatives were less impactful, which is consistent with human factor re-engineering science and change management strategies. This improvement initiative spanned over an extended time period largely because of interruptions due to the COVID pandemic. As a result, the project demonstrated that the goal to implementing and sustaining change requires workflow redesign, culture shifts, and engagement by all key stakeholders.

DIFFERENCES IN PROLONGED MECHANICAL VENTILATION ACROSS RACIAL IDENTITY

SESSION TITLE: Sepsis: Beyond 30cc/kg and Antibiotics SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Despite efforts for racial equality, racial disparities are evident in intensive care units. Numerous studies have demonstrated that Non-White patients have higher rates of sepsis, acute kidney injury, and overall mortality throughout different hospital settings. Mechanical ventilation is a common ICU intervention that has multiple associated complications. Prolonged mechanical ventilation (PMV) has been shown to have increased morbidity and resource utilization. In this study, we hypothesized that Non-White patients would experience PMV at higher rates than White patients. METHODS: The analysis cohort was filtered from de-identified administration registry containing inpatients admitted across a diverse five hospital health system between the years 2014 and 2021. Encounters coinciding with surges in COVID-19 were removed. The study group included discharged inpatients that were 18 years or older and experienced mechanical ventilation during their hospital stay. Prolonged mechanical ventilation (PMV) was defined as mechanical ventilation lasting 21 days or longer in accordance with the Centers for Medicare and Medicaid Services (CMS) definition. Univariate analysis was performed to compare characteristics and outcomes across racial identities. Multivariate logistic regression was completed regarding PMV allowing adjustment for confounding variables and assessment of the independent predictive value of racial identity. The analysis was deemed exempt from IRB review, and was performed using R in R-Studio, p-value ≤0.05 was considered significant. RESULTS: The compiled dataset resulted in 8917 mechanical ventilation cases. Of the 8917 cases, 338 patients experienced prolonged mechanical ventilation. The overall rate of PMV was 4%. There were 176/5987 (2.9%) White patients and 162/2930 (5.5%) Non-white patients that had prolonged mechanical ventilation (p<.001). Specifically for Black patients, logistic regression utilized all significant univariate variables confirmed the independent predictive value multivariate OR of 1.62. Additionally, Non-White patients with PMV had on average longer ICU length of stay and were less likely to be discharged to Hospice. CONCLUSIONS: There has been considerable research in identifying marginalized heath care of Non-white patients throughout the hospital. In the ICU, we looked to identify prolonged mechanical ventilation as it’s associated with numerous deleterious outcomes such as sepsis and delirium. A multihospital single system evaluation identified 338 cases of prolonged mechanical ventilation. Following data analysis, Non-White patients were nearly twice the risk of experiencing PMV as compared to White patients. Further investigation into the specific factors is still needed to reduce racial disparities in mechanical ventilation. CLINICAL IMPLICATIONS: Identification of racial disparities, rates of prolonged mechanical ventilation, and length of stay in the ICU. DISCLOSURES: No relevant relationships by David Barbat No relevant relationships by Camden Gardner

Effect of a ketogenic diet vs mediterranean diet on hba1c: The keto-med randomized crossover trial

Background: Growing interest in very low carbohydrate diets, and in particular the ketogenic diet, has been met with some resistance. Important gaps exist regarding what diet to compare to the ketogenic diet. The objective of this study was to compare a Well Formulated Ketogenic Diet (WFKD) with a Mediterranean-Plus diet (Med-Plus;Mediterranean with emphasis on eliminating added sugars and refined grains), in a crossover study, stratified by diabetes status (T2D vs Prediabetes). Methods: The intervention involved having participants follow the WFKD and Med-Plus, for 12 weeks each, in random order. All meals were provided for the first 4 weeks of each diet phase (food delivery);then participants were responsible for purchasing and preparing their own foods (self-provided). The primary outcome was glycosylated hemoglobin (HbA1c). Secondary outcomes included weight, glucose as measured by continuous glucose monitor (CGM), and cardiometabolic risk factors, such as fasting insulin, glucose, and lipids. Results: Among participants randomized (n = 42), 33 had complete data at both diet phases (some missing data attributable to COVID disruptions). Participants were 60 ± 9 (mean ± sd) years of age, 61% men, with BMI 31 ± 5 kg/m2. Adherence for both diets was higher during the food delivery than the self-provided phase, but similar between diets for both phases. HbA1c concentrations were not significantly different between diets, but average CGM glucose levels were significantly lower during the WFKD compared to Med-Plus (p = 0.03). Additionally, WFKD induced a significantly greater decrease in triglycerides (-16% vs -5%, p = 0.02) and greater increase in LDL-C levels (10% vs -5%, p = 0.01), compared to Med-Plus. Weight change on WFKD vs Med-Plus was -8% vs -7% (p = 0.05). Sensitivity analyses largely confirmed the main findings. Conclusions: Participants improved in glucose control and weight management on both diets relative to baseline;however, glucose control was superior on the WFKD. Some caution is warranted when interpreting these results due to pandemic disruptions and a small sample size. A fair comparison of the two diets should also take into consideration non-glycemic effects.

The association of soluble ACE2 change with metabolic health, body composition and proteome dynamics during a weight loss diet intervention: Implications for the COVID-19 pandemic

Background: Angiotensin-converting enzyme 2 (ACE2) serves protective functions in metabolic, cardiovascular, renal and pulmonary diseases and is linked to COVID-19 pathology. We explored the association between soluble AC2 (sACE2) and metabolic health and proteome dynamics during a weight loss diet intervention. Methods: We analyzed 457 healthy individuals (mean age 39.8±6.6) with BMI 28-40 kg/m2 who participated in the Diet Intervention Examining the Factors Interacting with Treatment Success (DIETFITS). Biochemical markers of metabolic health and 236 proteins measured by Olink CVD II, CVD III and Inflammation arrays were available at baseline and 6 months following dietary intervention. We determined clinical and routine biochemical correlates of the diet-induced change in sACE2 (ΔsACE2) using stepwise linear regression. We then combined feature selection models and multivariable-adjusted linear regression to identify protein dynamics associated with ΔsACE2. Results: sACE2 decreased significantly on average at 6-months in the diet intervention. A stronger decline in sACE2 during the diet intervention was independently associated with female sex, lower HOMA-IR and LDL cholesterol at baseline, and a stronger decline in HOMA-IR, triglycerides, HDL-cholesterol and fat mass. In line, participants with decreasing HOMA-IR and triglycerides had significantly higher odds for a decrease in sACE2 during the diet intervention than those who did not (P≤0.0073 for both). Feature selection models linked ΔsACE2 to changes in AMBP, E-selectin, HAOX1, KIM-1, MERTK, PGF, thrombomodulin and TRAIL-R2. ΔsACE2 remained independently associated with these protein changes in multivariable-adjusted linear regression. Conclusion: Decrease in sACE2 during a weight loss diet intervention was associated with improvements in metabolic health, fat mass and markers of angiotensin peptide metabolism, vascular injury, renal function, chronic inflammation and oxidative stress. Our findings may improve the risk stratification, prevention, and management of cardiometabolic and COVID-19- related complications. (Figure Presented).