Supporting Advance Practice Providers in the Emergency Department Using Telehealth

This chapter focuses on the role of advanced practice providers (APPs) in the context of emergency telehealth by describing one of the first successful programs, started in 2003, at the University of Mississippi Medical Center (UMMC). Important issues germane to developing a program to provide telehealth supervision to APPs are covered. Specific concerns addressed by UMMC as the program was developed are described and generalized to the current health care environment. Major considerations regarding delivery models, contracts, technology, rationale for using APPs, regulatory concerns, and educational preparation are also discussed.

Impact of Two-Step Testing Algorithm on Reducing Hospital-Onset Clostridioides difficile Infections

Clostridioides difficile infection (CDI) is one of the leading causes of hospital–onset infections. Clinically distinguishing true CDI versus colonization with C. difficile is challenging and often requires reliable and rapid molecular testing methods. At our academic center, we implemented a 2-step testing algorithm to help identify true CDI cases. The University of Mississippi Medical Center is a 700+ bed academic facility located in Jackson, Mississippi. Hospital-onset (HO) CDI was defined based on NHSN Laboratory Identified (LabID) event as the last positive C. difficile test result performed on a specimen using a multistep testing algorithm collected >3 calendar days after admission to the facility. HO-CDI data were collected from all inpatient units except the NICU and newborn nursery. HO-CDI outcomes were assessed based on standardized infection ratio (SIR) data. In May 2020, we implemented a 2-step testing algorithm (Figure 1). All patients with diarrhea underwent C. difficile PCR testing. Those with positive C. difficile PCR test were reflexed to undergo enzyme immunoassay (EIA) glutamate dehydrogenase antigen (Ag) testing and toxin A and B testing. The final results were reported as colonization (C. difficile PCR+/EIA Ag+/Toxin A/B−) or true CDI case (C. difficile PCR+/EIA +/Toxin A/B +) or negative (C. difficile PCR−). All patients with colonization or true infection were placed under contact isolation precautions until diarrhea resolution for 48 hours. During the preintervention period (October 2019–April 2020), 25 HO-CDI cases were reported compared to 8 cases in the postintervention period (June 2020–December 2020). A reduction in CDI SIR occurred in the postintervention period (Q3 2020–Q4 2020, SIR 0.265) compared to preintervention period (Q4 2019–Q1 2020, SIR 0.338) (Figure 2). We successfully reduced our NHSN HO-CDI SIR below the national average after implementing a 2-step testing algorithm for CDI. The 2-step testing algorithm was useful for antimicrobial stewardship to guide appropriate CDI treatment for true cases and for infection prevention to continue isolation of infected and colonized cases to reduce the spread of C. difficile spores.Funding: NoDisclosures: None

642. Trends and cost burden of Legionella urine antigen test

Background Legionella urine antigen (LUAg) testing is used to identify the pathogen Legionella pneumophila serotype 1 which accounts for 50 to 70% of Legionella pneumonia and has 80% sensitivity and 95% specificity. The 2019 ATS/IDSA CAP guidelines recommend against routinely testing urine for LUAg except when indicated by epidemiological factors or severe cases of CAP; however, the recommendation is based on a low quality of evidence. In 2014 & 2015 there were 32 and 39 cases, respectively in the state of Mississippi. The purpose of this study was to evaluate the trends of ordering LUAg, positive results and estimate the cost burden at the University of Mississippi Medical Center (UMMC). Methods We performed a retrospective study of all patients who received the LUAg test at UMMC from January 3, 2013 to December 31, 2019. Patient Cohort Explorer was used to obtain de-identified patient data from EPIC. We obtained the number of encounters and patients on whom the LUAg test was performed during their inpatient hospitalization. Coding and billing offices provided the cost per LUAg test. Results LUAg test was ordered 2,642 times on 2350 patients between 2013 and 2019. 22 LUAg test results were positive in 21 patients. 2,627 tests were done on patients admitted in the hospital. Of the 1,181 tests ordered in female patients, 11 were positive and of the 1461 tests done in male patients, 11 were positive. The minimum age for ordered test was under 1 year while the oldest patient is 89 years old with a median age of 57 years. The youngest patient to be positive is 21 and the oldest patient was 72 years. 1,471 tests were done in African American patients and 1084 tests in Caucasian patients. At the end of study period 1901 were alive and 741 deceased. The median length of stay for the patient receiving the test was 7 days with 1726 patients discharged within 10 days. 174, 255, 301, 433, 467, 395, 613 tests were ordered respectively from 2013 to 2019. At self pay cost of $132.82 in 2019 USD, the total cost of 2642 tests was $350,910.44. About $15,950.47 was spent for each positive LUAg test during the study period. Conclusion Incidence of pneumonia from Legionella in Mississippi is low. Based on our study, we recommend to follow the current ATS/IDSA guidelines and order the test in select patients as recommended, in efforts to reduce diagnostic costs. Disclosures All Authors: No reported disclosures

643. Trends, outcomes and cost analysis of Streptococcus urinary antigen testing

Background Streptococcus pneumoniae urinary antigen (SUAg) testing detects the capsular polysaccharide of S. pneumoniae; which has a sensitivity and specificity of about 75% and 95%, respectively. IDSA/ATS guidelines recommend empirically covering those who present with community acquired pneumonia (CAP) for common pathogens including S. pneumoniae. These guidelines also recommend against routinely performing SUAg testing in adults with CAP unless the presentation is severe. However, the guidelines acknowledge that this a conditional recommendation based on a low quality of evidence. This study aims to investigate the utility of testing patients with pneumonia for S. pneumoniae and the economic burden. Methods We performed a retrospective study of all patients who received the SUAg test at University of Mississippi Medical Center (UMMC) from January 3, 2013 to December 31, 2019. Patient Cohort Explorer was used to obtain de-identified patient data from EPIC. We obtained the number of encounters and patients on whom the SUAg test was performed. Coding and billing offices provided the self pay cost of $101.37 per SUAg test in 2019 USD. Results The SUAg was ordered 2,507 times with 105 (4.18%) total positives results. Age range was 1 to 89 years with a median age of 57 years for ordering the test. 136, 256, 314, 419, 433, 382, 566 SUAg tests were ordered respectively from 2013 to 2019. 59% of the positive results were in female patients while 54% percent of the negative results were in male patients. Current every day smokers were more likely to test positive (29% versus 18% negative). Median length of stay was longer for a negative test (6 days versus 5 days). 16% of the patients with a positive result expired compared to 10.5% with a negative result. Over the study period, 2,507 tests cost an estimated $254,134.59 using the 2019 pricing. Therefore, approximately $2420.32 was spent in testing to identify each positive result. Conclusion With low positive rate and Streptococci pneumonia that is already covered with empirical antibiotics, we recommend following the current ATS/IDSA guidelines and order the test in select patients as recommended, in efforts to reduce diagnostic burden and health care costs. However a positive result showed a decreased length of stay and higher mortality. Disclosures All Authors: No reported disclosures

4146 Establishment of Screening Methods for G6DP Deficiency – Translational and Clinical Applications

OBJECTIVES/GOALS: To develop feasible screening methods for activity of the enzyme Glucose-6-phosphate dehydrogenase (G6PD) with point of care applicability. METHODS/STUDY POPULATION: Current knowledge establishes the relevance of G6PD as a critical therapeutic determinant for effective antimalarial therapy due to the occurrence of mutations that lead to post-treatment severe adverse effects. We present our findings on development of cost effective point-of-care screening methodologies to ascertain G6PD deficiency. RESULTS/ANTICIPATED RESULTS: Using Patient Cohort Explorer and data from the Department of Pathology, we established the prevalence of G6PD deficiency at the University of Mississippi Medical Center, Jackson, MS as high as 11.8% (African-American males in all population, n = 2518). Next, for selection of potential target groups, we set up a protocol for recruitment of volunteers based on ethnic background, parental ethnicity, and medical history. G6PD activity was evaluated using point of care methods [Trinity Biotech test or CareSTART Biosensor], and Gold Standard quantitative spectrophotometric assay (LabCorp). Determinations in >20 subjects have showed comparable concordance. If used with a conservative interpretation of the signal, the Trinity Biotech test showed superior potential for use in the field relative to the CareSTART Biosensor. DISCUSSION/SIGNIFICANCE OF IMPACT: We established the prevalence of G6PD deficiency in our medical center. We have also setup tests for point-of-care assessment of G6PD. Pending evaluation of the relative tests performance, we will be in position to screen individuals and select them for a prospective clinical trial to evaluate the safety of antimalarial agents on scope of G6PD deficiency.