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1911. Implementation of Diabetes Medication Management by Pharmacists in a Multidisciplinary Limb-Salvage Clinic

Abstract Background Diabetic foot infections (DFIs) require complex medical care. At our hospital, a team of Infectious Disease (ID) specialists assess all inpatients with DFIs and transition these patients (patients) to an outpatient clinic with an ID and Podiatrist team. Clinical pharmacists have now joined the team to provide diabetes (DM) medication management. The goal of this project is to demonstrate the need for DM care in a multidisciplinary limb-salvage clinic. Methods We performed a retrospective chart review of patients seen in the ID clinic September 2014–June 2015. DM medication management was implemented in August 2017. During clinic visits, the DM care plan is assessed for medication therapy problems related to indication, efficacy, safety, and adherence for all new DFI patients. All findings and interventions are documented, discussed with the team and communicated to the patient’s primary care provider. Patients are followed at each visit to assess response to the intervention. Results Five hundred patients were seen in ID clinic in 2014–2015. One hundred twenty-three patients had DFIs. Ninety-four patients (76%) had uncontrolled DM defined as hemoglobin A1c (HbA1c) ≥7%. The mean baseline HbA1c was 10.13%. Fifty patients (41%) had an amputation prior to the initial clinic visit. Sixty-nine patients (56%) were reevaluated in clinic for recurrent DFI after clinic discharge with a mean time to revisit of 210 days. 54% of these patients developed infections in the opposite foot. Post-implementation, 30 patients were seen by clinical pharmacists between October 12, 2017 and April 26, 2018. All patients had uncontrolled DM with a mean baseline HbA1c of 9.85%. 20 patients (67%) had at least one amputation prior to the initial clinic visit. Twenty-eight patients (93%) had ≥1 medication therapy problem requiring pharmacist intervention. All patients required self-management education. There was a trend toward improved control of DM with an average HbA1c of 7.48% in the 13 patients returning for 3-month follow-up visits. Conclusion All of our patients required pharmacist intervention to improve DM care. Incorporating DM management into the clinic visit was feasible and well received. A registered dietician has been added to the team to aid in DM management. We hypothesize that including DM management in a multidisciplinary approach to limb-salvage is an essential and effective way to manage DFI patients and may lead to reduced readmissions and amputations. Disclosures All authors: No reported disclosures.

Background. Early diagnosis and treatment improve outcomes and delays increase mortality in infective endocarditis (IE). Multidisciplinary teams (MDT) have reported improved outcomes but no guideline exists to develop such a team in United States. From mortality reviews we identified gaps in caring for IE. We describe a process of MDT development for IE at our institution.
(2) Storming: Shared evidence with cardiovascular service line and formulated a plan ( Figure 1). (3) Norming: Designed an outline of streamlined workflow for providers (Figures 2 and 3). (4) Performing: Standardize approach throughout institution by integrating a care process model and then measure care variation with specific metrics derived from this model.
Results. Of 82 cases coded as IE in Vizient™, 29 met definite criteria for IE (Modified Duke Criteria). In 8 (27.6%) cases, there were no indications for surgery. Of the 21 (72.4%) cases who met one or more criteria for surgical intervention per guidelines, only 9 (42.9%) underwent surgery. In 12 (57.1%, leverage point) cases with indications but who did not have surgery, 9 (75%) were left sided IE and 6 (66.67%) died. All right sided IE (3, 25%) survived. Among those who died, at least two cases (22.2%) had potential for early intervention. Our aim statement from leverage point: Reduce the number of patients with left sided IE who did not have surgery despite indications by 50% (57.1% to 28.5%) following implementation of a MDT and care process model for IE. Our process diagram in Figure 3.
Conclusion. Standardizing care for infective endocarditis using a care process model incorporating primary teams, infectious diseases, cardiology, and cardiothoracic surgery services holds promise to improve care for infective endocarditis.    Background. Diabetic foot infections (DFIs) require complex medical care. At our hospital, a team of Infectious Disease (ID) specialists assess all inpatients with DFIs and transition these patients (patients) to an outpatient clinic with an ID and Podiatrist team. Clinical pharmacists have now joined the team to provide diabetes (DM) medication management. The goal of this project is to demonstrate the need for DM care in a multidisciplinary limb-salvage clinic.
Methods. We performed a retrospective chart review of patients seen in the ID clinic September 2014-June 2015. DM medication management was implemented in August 2017. During clinic visits, the DM care plan is assessed for medication therapy problems related to indication, efficacy, safety, and adherence for all new DFI patients. All findings and interventions are documented, discussed with the team and communicated to the patient's primary care provider. Patients are followed at each visit to assess response to the intervention.
Results. Five hundred patients were seen in ID clinic in 2014-2015. One hundred twenty-three patients had DFIs. Ninety-four patients (76%) had uncontrolled DM defined as hemoglobin A1c (HbA1c) ≥7%. The mean baseline HbA1c was 10.13%. Fifty patients (41%) had an amputation prior to the initial clinic visit. Sixty-nine patients (56%) were reevaluated in clinic for recurrent DFI after clinic discharge with a mean time to revisit of 210 days. 54% of these patients developed infections in the opposite foot. Post-implementation, 30 patients were seen by clinical pharmacists between October 12, 2017 and April 26, 2018. All patients had uncontrolled DM with a mean baseline HbA1c of 9.85%. 20 patients (67%) had at least one amputation prior to the initial clinic visit. Twenty-eight patients (93%) had ≥1 medication therapy problem requiring pharmacist intervention. All patients required self-management education. There was a trend toward improved control of DM with an average HbA1c of 7.48% in the 13 patients returning for 3-month follow-up visits.
Conclusion. All of our patients required pharmacist intervention to improve DM care. Incorporating DM management into the clinic visit was feasible and well received. A registered dietician has been added to the team to aid in DM management. We hypothesize that including DM management in a multidisciplinary approach to limb-salvage is an essential and effective way to manage DFI patients and may lead to reduced readmissions and amputations.
Disclosures. All authors: No reported disclosures. Background. Sepsis is a major public health concern. Revised definitions of sepsis in 2016 from the systemic inflammatory response syndrome (SIRS) criteria to the Sequential Organ Failure Assessment (SOFA) score made change in the sepsis case detection. One-hour bundle proposed by the Surviving Sepsis Campaign Bundle 2018 made the process more practically challenging because of its time-constraint.

Implementation of Sepsis-3 Definition in the Emergency
Methods. We retrospectively reviewed medical records of patients aged over 15 who visited the emergency department (ED) and got admitted to the internal medicine department from January to February 2018 in Somdech Phra Pinklao Hospital. Our study excluded pregnant women and patients who died within 48 hours after the admission. Data needed to complete SIRS, SOFA and quick SOFA (qSOFA) score was collected. Patients' diagnosis, treatments and in-hospital mortality were also reviewed. Prevalence of sepsis according to each definition was calculated. Test performances were summarized separately using sensitivity, specificity, ROC and AUC.
Conclusion. Although SOFA score was a better diagnostic tool to detect sepsis than SIRS, applying the method for all patients in the ED is difficult to be practically implemented. We proposed two-step approach by using SIRS ≥2 followed by SOFA score ≥2 for sepsis case detection.
Disclosures. Background. Sepsis is common and catastrophic. The usefulness of the qSOFA score has been questioned. Thus far, data on the validity of the instrument have been derived from developed countries. The generalizability to developing countries is unknown. This study aimed to ascertain how "qSOFA" predicted death and need for intensive care in patients at a tertiary hospital in Jamaica.
Methods. Seven hundred fifty-two patients admitted between January 2015 and December 2016 with a physician determined diagnosis of infection were randomly selected from the electronic medical database. The details of the first 48 hours of their admission were reviewed.
Results. Most patients were middle-aged females who remained in hospital for an average of 9 days and were managed by Internal Medicine. Two of the most common sites of infection (respiratory and gastrointestinal) were also the two sites associated with the highest risk of death or requiring intensive care. 126 (17%) had a qSOFA score ≥2 at presentation, 4 (0.5%) persons died, and 32 (4%) required admission to ICU. Many more patients met the SIRS criteria than qSOFA at presentation (66% vs. 17%). Meeting the SIRS criteria, however, was not significantly associated with death or needing intensive care. On the other hand, those with a positive qSOFA at presentation were three times more likely to die or need intensive care (OR 3.03; 95% CI 1.1,8.9; P = 0.04). The qSOFA score detected these patients, with a high degree of specificity (84%), especially when utilized at presentation (OR 3.03; 95% CI 1.03-8.92; P = 0.04) and 48 hours after (OR 2.24, 95% CI 0.94-5.37, P = 0.07). The sensitivity of the qSOFA score was poor (39%), but this was improved to 100% when combined with the SIRS score at presentation. There was a suggestion that this combined score also offered the best prognostic accuracy with an AUROC of 0.74 (95% CI 0.66-0.81) when compared with the qSOFA score (AUROC -0.68, 95% CI 0.60-0.76) or SIRS criteria alone (AUROC -0.71, 95% CI 0.63-0.79). However, there was significant overlap of the curves and the differences were not significant.