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1265. Penicillin Allergy Delabeling: A Quality Improvement Project
(Oxford University Press, 2023-11-27) Shah, Ibrahim; Sheraz, Sana; Ali, Marriam; Graduate Medical Education, School of Medicine
Background: 15% of all hospitalized patients report a penicillin allergy, and greater than 90% of them are not truly allergic. Penicillin allergy labels are associated with worse clinical outcomes, increasing in-hospital mortality, and increasing hospital stays. Historically, penicillin allergies were delabeled by either allergists or infectious disease specialists. Pharmacy-led delabeling programs are emerging but are limited due to pharmacists not having provider status in all states. Also, after successful delabeling, a significant number of patients were relabeled for penicillin allergies on subsequent hospital visits. Methods: We conducted an internal medicine resident-driven quality improvement project in a 350 bed community hospital. Fifty-six patients with a penicillin allergy label in the electronic medical record (EMR) were randomly selected from the inpatient service. If the patient had a non-allergic reaction or had prior exposure to penicillin without a reaction, they were directly delabeled. The remainder underwent risk stratification using the PENFAST scoring tool. Very low-risk and low-risk patients underwent an oral challenge after obtaining written consent. Following this, a hospital-wide pharmacist-triggered physician-driven delabelling protocol was established. Results: We assessed 56 patients between 04/2022 and 09/2022. Thirty-eight patients were delabeled: 18 by direct delabeling and 20 via oral penicillin challenge. One patient who underwent the oral challenge had an adverse reaction (nausea and vomiting). Seven months later, we conducted a secondary survey to assess the durability of our delabeling. Thirteen percent of patients (n=5) had the penicillin allergy label re-added to their chart on subsequent hospital admissions. Conclusion: Delabeling patients on the inpatient service is effective, carries little risk, and requires minimal resources. Additionally, it does not require specialist services. However, the durability of delabeling needs to be reinforced with a robust hospital delabeling protocol, continuous patient education, and EMR alerts to prevent allergy labels from being added back on subsequent visits.
1340. Yield of Repeat Blood Cultures beyond 48 Hours after Negative Initial Cultures in Patients Hospitalized on a Pediatric Hematology/Oncology Unit
(Oxford University Press, 2022-12-15) Prather, Cassandra S.; Alali, Muayad; Graduate Medical Education, School of Medicine
Background: Repeat blood cultures (BCxs) beyond 48 hours are often obtained despite negative initial BCxs in hospitalized pediatric hematology/oncology patients. This study seeks to determine the yield of repeat BCxs after negative initial cultures in these patients and to characterize new positive BCxs beyond 48 hours and the clinical contexts in which they were obtained. Methods: A retrospective review utilizing MedMined Inc. Data Mining Surveillance database was conducted on all BCxs obtained on hospitalized patients on the pediatric hematology/oncology unit at Riley Hospital for Children in Indianapolis, IN from January 2015 to February 2021. Exclusion criteria are shown in Fig. 1. Patient episodes in which a new pathogen (or commensal treated by the primary team as a pathogen) was identified on a repeat BCx more than 48 hours after negative initial BCxs were further investigated via electronic medical record review. Results: A total of 1,362 BCx sets were obtained beyond 48 hours in 792 patient hospitalizations, resulting in 303 positive BCxs (Fig. 2). Of these positive cultures, 193 were the same pathogen cultured on day 0 and 74 were contaminant cultures (in 4.0% (23/573) of patient hospitalizations without a positive BCx before 48 hours). Only 36 (2.6%) of positive BCxs beyond 48 hours were determined to be new pathogens, or commensals treated as pathogens, that were not cultured before 48 hours, corresponding to seven patient hospitalizations (1.2% (7/573) of patient hospitalizations without a positive BCx before 48 hours). The majority (6/7) of these patients were neutropenic and on broad spectrum antibiotics when the new positive BCxs were obtained. Fever pattern was prolonged in one patient and recurrent in six. No deaths occurred in these seven patients. All patients with new, true pathogens on BCxs beyond 48 hours (n=5) were either hemodynamically unstable (n=3) or had clinical changes (n=2, mucositis, diarrhea) the day the new positive BCx was drawn. Conclusion: The yield of repeat BCxs beyond 48 hours in hospitalized pediatric hematology/oncology patients with negative initial BCxs is low, while the associated costs are high. Repeat BCxs beyond 48 hours after negative initial cultures need not be obtained in febrile patients that remain hemodynamically stable and without clinical changes.
506 Review of Empiric Voriconazole Dosing in Large TBSA Burn Patients – A Case Series
(Oxford University Press, 2023-05-15) Lautenslager, Lauren; Boyd, Allison; Hartman, Brett; Spera, Leigh; Graduate Medical Education, School of Medicine
Introduction: Burn patients are significantly immunocompromised and susceptible to opportunistic fungal infections. Treatment includes aggressive surgical debridement with topical and systemic anti-fungal agents. Voriconazole (VCZ) is a systemic anti-fungal and an approved first line treatment of invasive Aspergillus and Fusarium species. Standard dosing is a 6 mg/kg loading dose twice followed by 200 mg enterally twice daily. Therapeutic drug monitoring is recommended to confirm a goal trough concentration of >1 mcg/mL, once steady state is reached, approximately 4-7 days after initiation. At our institution, VCZ levels are a send out lab, averaging 4-7 days for results. We reviewed a series of three patients with invasive fungal infections and their VCZ treatment dosing to assess impact of altered pharmacokinetics and time delays with drug monitoring. Methods: Three patients with significant burn injury (TBSA >40%) and invasive fungal wound infections were reviewed. Two were treated with standard dosing of VCZ (200 mg BID). The %TBSA, weight, albumin at time of VCZ initiation, initial VCZ dosing, initial trough concentration, time from initiation to trough result and final VCZ dose was reviewed. Consideration of the subtherapeutic drug level of prior patients led to initiation of VCZ treatment at an increased initial empiric dose (300 mg BID) for a third patient, followed by assessment and review of the same variables. Results: For the two patients treated with standard VCZ dosing, initial trough concentrations were subtherapeutic (0.4 mcg/mL and 0.9mcg/mL) and took 13 and 10 days from initiation to trough result, respectively. The albumin concentrations for these patients were 2.1 and 1.6 g/dL. Initial trough concentration for the third patient started on increased empiric dosing was therapeutic (4.9 mcg/mL), despite an albumin of < 1 g/dL. (Table 1). Conclusions: Fungal infections significantly increase the morbidity and mortality of burn patients. The time lapse from initial dose to steady state plus turnaround time of send out labs may result in 1-2 weeks of subtherapeutic treatment. Results from our case series demonstrate that standard VCZ dosing could be inadequate for large TBSA burn patients ( >40%) and higher empiric doses should be considered. Applicability of Research to Practice: Consider use of increased initial VCZ dosing for large burn patients to reach therapeutic serum levels more expeditiously.
5th Annual IUSM Education Day Program Brochure
(2024-04-26) Kochhar, Komal; Potter, Maddie
Program for the 5th annual Indiana University School of Medicine Education Day held at Hine Hall Conference Center on the IUPUI campus on April 26, 2024. An inherent challenge of operating a large multi-campus educational system is being able to provide professional development opportunities for all our medical educators across the state. To address this need, the Indiana University School of Medicine implemented an annual “Education Day”to promote educational scholarship across our nine-campus system. Held each spring, Education Day showcases the educational scholarship of IUSM faculty, staff, and learners, and provides a forum to share best educational practices and forge new collaborations in educational research.
A Novel Approach to Point-of-Care Ultrasound (POCUS) Education: One-page Documents with Embedded E-Curriculum
(2025-04-25) Markus, Nathan; Brenner, Daniel; Duncan, Francesca; Sanjuan, Adriano; Osborn, Eric; Carlos, Grahm; Jackson; Rishi, Muhammed; Jackson, Edwin
Background: Point-of-care ultrasound (POCUS) has proven to be a valuable adjunct to the modern physical exam. The gold-standard approach of 1-on-1 learning image acquisition from sonographers and interpretation from clinician-experts is resource intensive, highlighting a need for alternative methods of teaching POCUS. Methods: This educational project utilized iterative development with the help of established POCUS educators and learner feedback in the form of surveys. Pre- and post- 30-day rotation surveys were administered and collected in Microsoft Forms. The survey questions comprised several categories including interest in learning POCUS, technical skill/image acquisition, and confidence in image interpretation. Learners were asked to rate their confidence in image acquisition and interpretation on a 5-level scale from “no skill” to “expert skill” as defined in the figures. Results: Preliminary survey data (n = 14) have been collected. Detailed results available in figures 2 and 3. In summary, 60% of learners were likely/very likely to use POCUS in clinical practice and 40% of learners were unlikely/very unlikely. Pre-intervention, 10% of learners rated their proficiency at image acquisition/probe placement at “no skill”, which decreased to 0% post-intervention. Sufficient skill in image acquisition increased from 20% pre-intervention to 50% post-intervention. Regarding image interpretation, 30% of learners rated skill in identifying anatomy as “no skill” or “little skill”. After the intervention, these groups decreased to 0%. Lastly, all participants felt that they were more confident in identifying cardiac anatomy after engaging with this project. All participants also reported that they would continue to use this resource this to learn POCUS. Conclusions: Learners perceive both value and effectiveness of this educational module. More work must be done to improve objectivity of results including engagement data, competency-based assessments, and randomization against the current standard education model.
A Pilot Study of a Mobile Intervention to Support Mental Health and Adherence Among Adolescents Living with HIV in Western Kenya
(Springer, 2022) Chory, Ashley; Callen, Grant; Nyandiko, Winstone; Njoroge, Tabitha; Ashimosi, Celestine; Aluoch, Josephine; Scanlon, Michael; McAteer, Carole; Apondi, Edith; Vreeman, Rachel; Graduate Medical Education, School of Medicine
Mobile technologies represent potentially novel and scalable intervention delivery platforms for adolescents living with HIV (ALWH) in low- and middle-income countries. We conducted a prospective, mixed methods pilot study to evaluate the acceptability and feasibility of the WhatsApp® platform to deliver individual counseling services and facilitate peer support for ALWH in western Kenya. Thirty ALWH (17 female, mean age 15.4) on ART, engaged in HIV care and aware of their status, were enrolled. After 6 months, participants described their experiences with the intervention. Treatment adherence, stigma, and mental and behavioral health were assessed prospectively. Participants reported overall positive experiences and indicated that the platform encouraged peer network development. They endorsed potential benefits for treatment adherence, stigma reduction, and mental and behavioral health. All participants supported intervention expansion. In western Kenya, WhatsApp® was an acceptable and feasible platform for mobile counseling and peer support for ALWH.
A Roadmap to Surgical Education: A Scoping Review of Educational Needs in Surgery
(2024-04-26) Yan, Yichuan; Krusing, Madeline; Awad, MIchael; Stefanidis, Dimitrios
Purpose: Understanding the educational needs can help organizations like the Association for Surgical Education to develop relevant solutions. However, relevant literature is limited to know the needs. Thus, the aim of this study was to identify the educational needs in surgical education literature. Methods: Following the PRISMA Statement guideline, we performed a scoping review with three search terms in two databases in tandem with three inclusion criteria to identify the literature pertinent to educational needs in surgery. Through content analysis of the abstracts of the identified literature, we inquired about the objectives, methods, data sources, and conclusions in each identified article to tease out the trends, specialties, participants, and topics of educational needs in surgical education literature. Descriptive statistics of frequency were used to present the data. Results: The PRISMA article selection procedures resulted in 212 peer-reviewed journal articles in the scoping review. The content analysis identified the trends of the needs in four areas including the trends of educational needs, surgical specialties, participants, and topics of educational needs. To synthesize the results of the data analysis, a heat map was created with the cross-section of the trends and topics of educational needs showing the hot topics and potential gaps in surgical education literature. Conclusions: The scoping review provides surgical educators and trainees an overview of the educational needs in the literature that can serve as a roadmap of educational needs to be taken into consideration by organizations like the ASE to help address the needs and advance the field.
A Taste of Agile to Create Change in Medical Education
(2024 AAMC Group on Regional Medical Campus Conference, 0024-06-03) Birnbaum, Deborah R.; Sipes-Fears, Debra; Rohr-Kirchgraber, Theresa; Breffle, Kelly
A Taste of Agile provides an introduction to developing an agile mindset and will model and dive into two agile tools. Participants will get an overview of agile science and participate in an Innovation Forum, an agile tool used for idea generation and problem solving, to help solve a problem specific to regional campuses. Participants will also use a reflection tool to generate timely, actionable, nonjudgmental feedback. In addition to learning how to use these tools, participants will get tips on how to apply these tools back at their jobs, and other resources to learn agile change that can be applied in medical education and health care.
A Taste of Agile to Create Change in Medical Education
(2024 AAMC Staff Track Conference, 0024-09) Birnbaum, Deborah R.; Sipes-Fears, Debra; Rohr-Kirchgraber, Theresa; Breffle, Kelly
Change is difficult. It is frequently stated that it takes an average of 17 years for research evidence to reach clinical practice. Over the past decade, an interdisciplinary team of scientists at Indiana University developed agile methods to design, implement, and diffuse evidence-based behavioral and social science interventions. Such methods incorporate rapid, iterative, and adaptive problem-solving techniques that are based on insights from agile science. Agile science integrates findings from behavioral economics, complexity science, and network science to understand, predict, and nudge the behavior of both an individual human and that of a social organization of humans such as a healthcare delivery system or medical school. While earning a graduate certificate in Innovation and Implementation Science, I became curious about the use of agile science in education, in general, and medical education and interprofessional education, in particular. A literature search indicated that little of agile science has found its way into traditional education, medical education or interprofessional education. In working with classmates also engaged in educating the next generation of health care providers, we believe this approach holds great promise, is completely feasible for medical education and is transferable to any institution. A Taste of Agile provides an introduction to developing an agile mindset and will model and dive into two agile tools. Participants will get an overview of agile science and participate in an Innovation Forum, an agile tool used for idea generation and problem solving, to help solve a problem specific to staff. Participants will also use a reflection tool to generate timely, actionable, nonjudgmental feedback. In addition to learning how to use these tools, participants will get tips on how to apply these tools back at their jobs, and other resources to learn agile change that can applied in medical education and health care.
An Abscessed Tooth that Wasn't: An Unusual Case of Mumps in an Elderly Patient
(2020-03) Lin, Jenny; Willhite, Sydney; Moore, Hannah; Smith, Maddie; Duncan, Francesca
Case: A 62-year-old African American female with history of self-resolving parotitis initially presented with progressive neck and bilateral facial swelling. She attributed this to an abscessed tooth. CT revealed parotitis with inflammatory changes and mass effect on the hypopharynx and larynx, although the patient denied breathing difficulty. Antibiotics were administered for two days, discontinuing due to lack of abscess. Six days later, the patient presented with worsening facial swelling, sore throat, and dysphagia. She remained afebrile but with a WBC count of 12.8. Antibiotics and steroids were given. MRI displayed retropharyngeal space involvement of 2.6 cm in thickness. ENT performed surgical debridement and culture collection. Upon return from the OR, respiratory distress and inability to manage secretions resulted in intubation via an upright awake fiberoptic approach given concern for impending airway compromise. Finally, a positive IgM antibody to mumps virus was detected from the debridement culture. Discussion: The differential for nonsuppurative parotitis includes viruses, autoimmune disorders, and granulomatous inflammation. Paramyxovirus, specifically mumps, is the most common viral cause, with EBV, HSV, CMV, and HIV as other concerns. Autoimmune causes are Sjogren syndrome and SLE. Mycobacterium species are the likely granulomatous culprit. Though mumps is the most common viral cause of parotitis, it typically occurs in children and young adults, not fitting of the patient described. However, mumps cases have increased recently. MMR vaccination began in 1967 and cases decreased more than 99%; yet, since 2006 there have been outbreaks. Vaccine-induced protection may wane over time. Mumps is highly contagious and complications include meningitis, encephalitis, pancreatitis, and deafness, occurring more commonly in elderly patients. Patients with nonsuppurative parotitis should thus be surveyed for vaccination history and examined for MMR titers.

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