Background/problem: Information transfer between emergency medical services (EMS) and emergency medicine (EM) is at high risk for omissions and errors. EM awareness of prehospital medication administration affects patient management and medication error. In April 2020, we surveyed emergency physicians and emergency department nurse practitioners (NPs) and physician assistants (PAs) regarding the EMS handoff process. Emergency physicians and NPs/PAs endorsed knowing what medications were given, or having received direct verbal handoff from EMS "Often" or "Always" only 20% of the time (n = 71), identifying a need to improve the written handoff process. To assess rates of medication error due to lack of awareness of prehospital administered medications, we measured glucocorticoid redosing in the emergency department (ED) following prehospital dexamethasone administration. In 2020, glucocorticoids were redosed 30% of the time, and our aim was to reduce glucocorticoid redosing to 10% by June 2022.Intervention: We developed and implemented a system innovation where prehospital-administered medications documented in a nursing flowsheet during verbal handoff are pulled directly into the triage note where they are more likely to be reviewed by receiving EM clinicians.Results: Shewhart p-charts were used to evaluate for statistical process change in the process measure of triage note documentation of prehospital medication administration and the outcome measure of glucocorticoid redosing. While the frequency of prehospital dexamethasone administration in the triage note increased, no statistical process change outcome measure of glucocorticoid redosing was observed. However, on repeat survey of EM clinicians in July 2022, 50% now indicated they were aware of prehospital medication administration "Often" or "Always" (n = 61, p = 0.003), 87% maintained they use the triage note as the main source of information regarding prehospital medication administration, and 81% "Always" review the triage note.Conclusions: Innovations that improve accessibility of written documentation of prehospital medication administration were associated with improved subjective assessment of EM clinician awareness of prehospital medications, but not the outcome measure of medication error. Effective error reduction likely requires better system integration between prehospital and EM records.

42%identi fi edhypothyroidism.While87% and33% reportedhaving used abdominal Ultrasound and fi broscan, interestingly, only 2 third yearresidents had screened with Fibrosis-4or anotherscoring system. The majorityreported having recommendedlifestyle (83%) or dietary changes (58%), but only 20% had used medications. Surprisingly, only 1 third year resident had referred a patient to hepatology for overt fi ndings of cirrhosis. Conclusion: Our preliminarystudy showed that signi fi cant gaps exist in screening, management and referral patterns across IM resident training levels, including low utilization of noninvasive diagnostic tools like scoring systems and fi broscan, raising the question of awareness. Residents were generally knowledgeable about the prevalence, risk factors and complications of NAFLD. Medication use was signi fi cantly lower compared to other management strategies, however, this is unsurprising as pharmacological treatment is still in development. Finally, despite the majority identifying cirrhosis as potentially irreversible, referral trends were lower than expected. Although limited by response number, this study highlights the need for ongoing education on diagnostic modalities, medical management, and appropriate timing of hepatology referral to optimize care of NAFLD patients.

Introduction: Acute inflammatory demyelinating polyneuropathy (AIDP) is rare disorder that may be associated with GI dysmotility in some patients. The timeline for the improvement in dysautonomia is variable but often occurs in concert among organ systems. We present a case of AIDP in an otherwise healthy man who noted significant improvement in GI symptoms after IVIG and metoclopramide despite persistent dysautonomia in other organ systems. Case Description/Methods: A 60-year-old previously healthy man presented with 2 months of numbness, orthostatic hypotension, syncope, nausea, vomiting, anorexia and weight loss. His labs were notable for hyponatremia which was attributed to SIADH. Serologic studies looking for an etiology from infections, metabolic derangements, autoimmune diseases or micronutrient deficiencies were normal. CSF analysis was notable for an elevated protein of 54. MR imaging of the brain and spine were normal as were CT scans of the chest, abdomen and pelvis. EMG/NCS demonstrated a moderate, distally accentuated and predominantly sensory polyneuropathy. The patient was diagnosed with AIDP and treated with 7 days of IVIG. His hypotension was treated with fludrocortisone and midodrine. The patient’s GI symptoms were treated with metoclopramide 10 mg three times daily. Tube feeds were later started given malnutrition with moderate loss of muscle mass and fat stores. Symptoms persisted while on tube feeds; the patient was unable to tolerate the goal rate of feeds until the seventh day. Two weeks after starting metoclopramide, the tube feeds were gradually tapered and the patient was tolerating frequent small, low-fat, low-fiber meals. Weeks later, the patient was able to increase oral nutrition to allow for adequate caloric intake. Despite improvement in GI symptoms within the first few weeks of being diagnosed with AIDP, other symptoms of dysautonomia remained present for 3 months. Discussion: Gastroparesis, paralytic ileus and diarrhea are among the different forms of GI dysmotility that patients with AIDP experience. Often, these symptoms progress and resolve concurrently with weakness, hypotension and other common signs and symptoms of AIDP. The literature to date does not demonstrate a significant improvement in GI symptoms following medical management without global improvement in dysautonomia. This case highlights that gastroparesis-like symptoms in AIDP can be managed with metoclopramide which may enhance the rate of improvement relative to other symptoms of dysautonomia.

Introduction: Bleeding is a known complication of EUS-guided cystgastrostomy (CG). We report 2 patients with prior surgical CG who underwent EUS-CG for recurrent pseudocyst (PC) complicated by severe gastrointestinal (GI) bleeding from a pseudoaneurysm requiring additional interventions. Case Description/Methods: Patient 1: 70-yr M with necrotizing pancreatitis s/p surgical CG. Referred to our center with symptomatic recurrent pseudocyst (Figure 1, 1a). EUS-CG was performed using 15mm LAMS + 7 fr double pigtail plastic stent (DPPS) (Figure 1, 1b). No intra-procedural bleeding. Two days later patient had hematochezia and Hb dropped by 3 gms/dL. CT angiogram (CTA) no bleed, PFC smaller, stents in place. Patient remained stable, sent home, but returned 2 days later with recurrent hematochezia. CTA with actively bleeding pseudoaneurysm from SMA branch close to LAMS (Figure 1, 1c). Embolization performed, bleeding controlled (Figure 1, 1d). LAMS was removed, DPPS left in place (Figure 1, 1e). CT 2 months later without residual cyst, patient doing well. Patient 2: 65-yr M with severe necrotizing pancreatitis s/p surgical CG 1 yr ago. Referred to our center with symptomatic recurrent pseudocyst (Figure 1, 2a). EUS-CG using 15mm LAMS +7 Fr DPPS done, patient went home next day. Five days later, readmitted with hematemesis, anemia, hypotension. CT no bleed, stents in place. EGD revealed LAMS+DPPS in place, active bleeding noted from cyst cavity (Figure 1, 2b). Repeat CTA done, actively bleeding pseudoaneurysm (Figure 1, 2c). Successful embolization done (Figure 1, 2d), but patient continued with intermittent bleeding requiring transfusions. Repeat EGD, active oozing from within cyst cavity. 15cc of novel PuraStat gel used to fill pseudocyst cavity with complete hemostasis (Figure 1, 2e). LAMS removed, a 7-Fr x 4cm DPPS placed into cyst cavity. Patient stabilized, discharged home after 2 days. CT scan 6 weeks later, no residual pseudocyst, patient doing well. Discussion: Surgical CG is rarely performed in the era of EUS-CG with LAMS. Our patients needed EUS-CG for recurrent PC post-surgery. Severe bleeding within 1 week post EUS-CG is unusual. Both patients had nearly identical presentation, bleeding etiology, imaging findings and clinical course. Our experience suggests that patients who undergo LAMS based EUS-CG after initial surgical CG may be at higher risk for bleeding. Initial CTAs may be negative. IR embolization is effective. Endoscopists should keep these caveats in mind when managing such patients.Figure 1.: Endoscopic and fluoroscopic images demonstrating interventions performed in both cases. 1,1a: CT revealing 10 cm pancreatic pseudocyst. 1,1b: Endoscopic view of cystgastrostomy with LAMS and DPPS. 1,1c: IR angiogram revealing 7 mm pseudoaneurysm in close proximity to the LAMS. 1,1d: IR coil embolization of the SMA jejunal branch pseudoaneurysm. 1,1e: LAMS removed and DPPS left in place across the cystgastrostomy. 1, 2a: CT scan showing recurrent 8 x 8 x 7cm pancreatic pseudocyst Image 2b: Oozing of fresh blood through and around the LAMS. 1, 2c: IR angiogram revealing actively bleeding GDA pseudoaneurys. 1, 2d: IR coil embolization of the GDA pseudoaneurysm. 1, 2e: PuraStat gel used to achieve hemostasis within the pseudocyst cavity.

Introduction: Pseudoaneurysm (PA) related bleeding after placement of lumen apposing metal stent (LAMS) for management of pancreatic fluid collections (PFC) is a known complication of EUS-guided cystgastrostomy (CG) using LAMS, with potential for high morbidity/mortality. We report the first case of endoscopic application of the novel Purastat gel within the PFC cavity, as part of a multimodal approach to achieve complete hemostasis in a patient who presented with severe, persistent bleeding post-CG. Case Description/Methods: A 66-year-old man with a history of severe biliary pancreatitis complicated by PFC managed at outside hospital with percutaneous drainage by IR. Course complicated by pancreatic duct injury resulting in re-accumulation of PFC managed by laparoscopic converted to open transgastric pancreatic cystgastrostomy (CG). Four months later patient presented with recurrence of abdominal pain, nausea, poor oral intake, weight loss; CT with 8.5 cm recurrent pseudocyst with extrinsic gastric compression. Patient referred to our center for management. Uneventful EUS-CG performed with 15mm LAMS + 7 Fr x 4 cms double pigtail plastic stent (DPPS). Five days later patient presented with hematemesis and drop in Hb from 11.5 to 8. CT angiogram revealed large amount of blood within stomach, but no active bleeding. Endoscopy revealed oozing of fresh blood from the LAMS not amenable to endoscopic therapy. Angiography of gastroduodenal artery (GDA) demonstrated actively bleeding PA, successful embolization performed. Patient continued to have melena with persistent transfusion requirement. Repeat EGD revealed fresh bleeding from the LAMS. This was treated successfully with Purastat Gel application within the PFC and removal of LAMS. DPPS replaced. Patient discharged 48 hours later with stable Hb and tolerating PO diet. CT 6 weeks later revealed complete resolution of PFC, patient doing well. Discussion: Severe bleeding after EUS-CG with LAMS is well known, IR embolization is effective in most cases. Endoscopic intracystic application of the novel Purastat Gel was used for effective control of persistent bleeding post-embolization in our patient. To our knowledge, this is the first report of successful management of persistent bleeding from a pseudocyst using the novel Purastat Gel. Our experience with this approach in our patient has significant clinical practice implications for managing this problem; endoscopists should consider this as part of the treatment algorithm for pseudocyst. Watch the video at https://tinyurl.com/S2647ACG2023.

BACKGROUND: Despite major medical advances in the IBD world, the incidence of Pediatric Inflammatory Bowel Disease (IBD) continues to increase. This patient population is at risk for higher rates of complications from their chronic disease. The transition from pediatric to adult care is crucial as this population is at an increased risk for loss to follow up, delays in receipt of appropriate medical care, poor adherence, and increased emergency department visits and hospital admissions. To address these issues at our academic center, we piloted an EMR template with the goal of improving the process from both the patient and provider perspectives. We present our review of what we learned from this process and how it shaped our final product. METHODS: This study was an IRB-approved prospective cohort assessment performed at our academic tertiary care center from 2018-2021. An EMR template was designed as a comprehensive summary based on components of the medical record that adult gastroenterology (GI) providers identified as critical to successful transition of care. This template was then integrated into pediatric GI office notes provided to the adult GI team at the start of transition. A 7-question survey was distributed to pediatric providers to assess ease of use and provider perceptions of the template. RESULTS: A total of 64 patients transitioned following implementation of the template and 19 (29.7%) of those had a template in their chart upon transition. Audit of charts revealed that of the 13 pediatric GI providers, only one was actively using the template. Twelve (92%) of the 13 pediatric GI providers responded. Barriers to template use included: ease of use, lack of included narrative history, lack of auto-populated data and accessibility. Subsequently, stakeholders from our Pediatric and Adult IBD centers met to create a universal progress note that would provide one cohesive patient summary. The conception of this medical document now occurs in the pediatric setting; it will accompany the patient through their medical journey and be a permanent part of their medical record. CONCLUSION: Adult and Pediatric Gastroenterologists all agree that effective transition of IBD care is critical to the patient’s well-being. However, adult and pediatric providers may have differing views of the importance of certain aspects of the psychosocial and preventative care components of IBD management. In our institution, we are able to provide IBD care to patients for their entire life span. To the benefit of patients, this is becoming more common at academic centers, making the use of a universal IBD template critical for excellent continuity of care. As a result of our inter-departmental meetings, we were able to learn why different aspects mattered at different stages of a patient’s life. This allowed us to create a flexible template to incorporate these changing priorities. We believe that our current IBD progress note is a functional mesh of those factors and is less cumbersome than a separate template required by adult providers. Most importantly, it presents a united front, and demonstrates to patients that their care is a continuum within our institution.

Introduction: In patients with liver disease, the practice of supplementing vitamin K in an attempt to reverse perceived coagulopathy has become routine. No specific guidelines on how or when supplementation should be given are available and there is a lack of evidence supporting its benefits. Additionally, recent literature demonstrates that although cirrhotics have an increased risk of bleeding due to coagulopathy, there is also an increased risk of thrombosis potentially leading to harms from vitamin K supplementation. The aim of this study was to assess the understanding of vitamin K supplementation and the practice variations among providers at our institution. Methods: This survey study was conducted at a large academic tertiary care center. An anonymous 12 question questionnaire was emailed to providers that were likely to have taken care of patients with liver disease in the inpatient setting, including resident, fellow, and attending physicians in internal medicine, gastroenterology, hepatology, pulmonary critical care, anesthesia, cardiac critical care, general surgery, and transplant surgery. Results: A total of 105 responses were collected. 61% said they believed an elevated international normalized ratio (INR) in a patient with cirrhosis is a sensitive marker of coagulopathy and bleeding risk. 76% give vitamin K supplementation to patients with cirrhosis and an elevated INR. There was no clear consensus on what level to consider supplementing vitamin K for an elevated INR (Table). Most respondents (63%) preferred oral vitamin K over intravenous. No respondents give more than 3 doses of vitamin K and the majority (60%) said they give 3 doses on average. 66% said that they do not consider a patient’s comorbidities prior to giving vitamin K. The majority of respondents (54%) expect INR to improve by 10.1-25% after vitamin K supplementation. No single question had a majority of greater than 66%. Conclusion: The lack of consensus higher than 66% and wide range of responses to each question demonstrates that the practice of vitamin K supplementation for patients with liver disease is lacking consistency. This survey highlights that specific guidelines regarding this practice would be beneficial to providers to prevent unnecessary and potentially harmful interventions for this tenuous patient population. Further investigation with prospective interventional trials of vitamin K supplementation in liver disease and its effect on INR should be considered.