367 Background: Anemia in patients with cancer has been associated with lower quality of life, diminished performance status, and potentially even delays in chemotherapy. Multiple professional societies, including the NCCN and ESMO, recommend routine testing for iron deficiency and iron replacement if deficiency is identified. The aim of this quality improvement project was to increase testing for nutritional causes of anemia, especially iron deficiency, among patients admitted to the onco-hospitalist teaching service at MD Anderson Cancer Center. Methods: A process map was constructed to identify pitfalls with the current process for identifying and ordering testing for nutritional (iron, B12, and folate deficiency) causes of anemia. The primary intervention for our Plan-Do-Study-Act (PDSA) Cycle was creating and implementing an electronic medical record smart phrase to be included in each note prompting consideration of reversible causes of anemia and whether testing was ordered in the last 6 months or needs to be ordered. Education was also provided to residents regarding reversible causes of anemia and appropriate studies to order. Fliers describing the intervention and the recommended testing algorithm were placed in the resident workroom. A retrospective chart review of all patients admitted to the onco-hospitalist teaching service from August 2023 to February 2024 was employed to collect pre- and post-intervention data, and a run chart was created to plot rates of screening over time. Results: Of the pre-intervention cohort (n=263) from August to December 2023, 196 (74.5%) were identified as having anemia; of these patients, 109 (55.6%) underwent screening for nutritional causes of anemia during the admission. After our intervention was implemented, of all patients admitted to the service (n=186), a total of 156 (81.7%) were found to have anemia and 116 (74.3%) were screened for reversible causes of anemia. Almost all reversible causes of anemia were found to be secondary to iron deficiency. Conclusions: Our data shows that anemia is prevalent in our patient population yet inconsistently evaluated at baseline. At the same time, a combination of smart phrase utilization and education successfully increased rates of screening from 55.6% to 74.3% of patients admitted to the onco-hospitalist teaching service. One potential future endeavor is addition of a smartphrase to the admitting H&P templates to prompt teams to consider reversible causes of anemia, especially iron deficiency, during the admission.

Subsets of multiple myeloma (MM) and monoclonal gammopathies of undetermined significance (MGUS) present with a monoclonal immunoglobulin specific for hepatitis C virus (HCV), thus are presumably HCV-driven, and antiviral treatment can lead to the disappearance of antigen stimulation and improved control of clonal plasma cells. Here we studied the role of hepatitis B virus (HBV) in the pathogenesis of MGUS and MM in 45 HBV-infected patients with monoclonal gammopathy. We analyzed the specificity of recognition of the monoclonal immunoglobulin of these patients and validated the efficacy of antiviral treatment (AVT). For 18 of 45 (40%) HBV-infected patients, the target of the monoclonal immunoglobulin was identified: the most frequent target was HBV (n=11), followed by other infectious pathogens (n=6) and glucosylsphingosine (n=1). Two patients whose monoclonal immunoglobulin targeted HBV (HBx and HBcAg), implying that their gammopathy was HBV-driven, received AVT and the gammopathy did not progress. AVT efficacy was then investigated in a large cohort of HBV-infected MM patients (n=1367) who received or did not receive anti-HBV treatments and compared to a cohort of HCV-infected MM patients (n=1220). AVT significantly improved patient probability of overall survival (P=0.016 for the HBV-positive cohort, P=0.005 for the HCV-positive cohort). Altogether, MGUS and MM disease can be HBV- or HCV-driven in infected patients, and the study demonstrates the importance of AVT in such patients.

e13581 Background: COVID-19 has led to several waves of outbreaks over the last 2 years. Cancer patients are among the most vulnerable and have high morbidity and mortality rates. We aimed to determine the association between presenting symptoms and symptom burden and COVID hospitalization outcomes among cancer patients. Methods: We conducted a retrospective cohort study on all adult hospitalized cancer patients during their first admission at our cancer center from March 2020 to May 2021. We reviewed medical charts to identify reported symptoms. We used the Foundry data platform to compile and analyze data, including patient and hospitalization characteristics and outcomes. We used the chi-square test to test differences in categorical variables. Results: Our cohort included 595 patients, 272 with hematologic malignancies (45.7%) and 323 with solid tumor malignancies (54.3%). 52.1% were male, with an age range of 18 to 91 years (median age: 62). 64.2% self-identified as Caucasian, 16.1% as other, 14.3% as African American, and 3.5% as Asian. After univariate analysis, we found that female patients had higher rates of abdominal pain (21.4% vs. 14.5%, p=0.03), GI symptoms (36% vs. 27.4%, p=0.03), and sore throat (14.4% vs. 8.4%, p=0.02) than male patients. Smoking status or Charlson comorbidity score were not associated with any presenting symptoms. Solid tumor patients had higher rates of abdominal pain (26.6% vs. 7.4%, p <0.01) than patients with hematologic malignancies. Patients with hematologic malignancies had higher rates of fever (59.2% vs. 42.7%, p<0.01), cough (66.2% vs. 50.8%, p<0.01), and shortness of breath (53% vs. 41.8%, p<0.01) than solid tumor patients. Solid tumor patients more frequently reported more than 3 symptoms (52% vs. 39.2%, p<0.01) than patients with hematologic malignancies. In terms of COVID outcomes, patients with cough (34.4% vs. 12%, p<0.01), shortness of breath (38.5% vs. 12.9%, p <0.01), and fever (29.1% vs. 20.6%, p=0.02) were more likely to have severe COVID-19. Patients with more than 3 symptoms were more likely to have severe COVID-19 (31.7% vs. 21.3% vs. 7.8%, p< 0.01) than those with 1-3 symptoms or no symptoms. Patients with cough (15.1% vs. 6.4%, p<0.01) and shortness of breath (15.5% vs. 7.9%, p< 0.01) had higher inpatient mortality. Patients with chills (5.8% vs. 12.9%, p< value 0.03) and headache (4.4% vs. 12.7%, p=0.02) had lower inpatient mortality. Conclusions: Our study showed that certain presenting COVID-19 symptoms are associated with patient and clinical characteristics, severity of disease, and inpatient mortality among adult hospitalized cancer patients.

e18700 Background: Advanced care planning (ACP) is the comprehensive process of clarifying, communicating, and implementing patient preferences, personal values, and goals as they pertain to medical care and quality of life, and is especially important for patients with cancer. Early communication regarding ACP can improve patient satisfaction and limit unwanted hospital visits and treatments. One study of 200 cancer patients showed that only 24% reported having conversations with any provider regarding end-of-life care despite 82.5% wanting to do so. The lack of ACP documentation is particularly concerning in patients with malignancies due to their high risk of sudden deterioration, especially during hospitalization. Therefore, there is an unmet need to complete ACP documentation which can be addressed during hospital admissions. Methods: We created a comprehensive process map for the current ACP note documentation process to determine areas for improvement in our inpatient hospital medicine resident team, where we take care of patients with GI, lung, endocrine, breast, and head/neck malignancies. We analyzed hospital admissions 4 weeks before and 4 weeks after our intervention to determine the rates of ACP note documentation, as well as ACP note documenter provider specialty. Our intervention consisted of (1) providing education during team orientation with individualized slides emphasizing on the importance of ACP documentation and how to write such note, (2) displaying instructional flyers in the communal workroom, and (3) implementing a new electronic medical record admission template with a forcing function. We established the percent of ACP note documentation as our primary outcome measure which was modeled via run chart. Results: Of the sixty-four patients admitted to our hospital team during the 1 month prior to our intervention, 24 (38%) had an ACP note documented within the first 72 hours of admission and 5 of the 24 patients had two ACP notes written by different providers. In total there were 13 notes completed by hospitalists, 7 by oncologists, 5 by ER physicians, 2 by supportive care providers and 1 by a medicine resident. One month after our intervention, 38 of the 44 (86%) patients admitted had an ACP note documented within 72 hours of admission and only one patient had 2 notes from different providers. In this cohort, there were 28 notes completed by residents, 3 by hospitalists, 3 by oncologists, 3 by supportive care providers and 2 by ER physicians. At 3 months post-intervention, 22 patients (34%) of the pre-intervention cohort were deceased, 14 (64%) of whom had ACP documentation. Conclusions: Cancer patients are at an increased risk of deterioration during their clinical course. Quality improvement interventions to promote ACP documentation during hospital admissions leads to care better aligned with patients' wishes and fulfills an unmet need in addressing goals of care.

En este trabajo se exponen cinco aportaciones del pensamiento de Franz Hinkelammert en el campo de los derechos humanos que están interrelacionadas y muy vinculadas entre sí: 1) una fe antropológica por el ser humano; 2) la crítica a la razón utópica extendida a los procesos idolátricos y fetichistas de las producciones humanas, junto con los principios de imposibilidad de las ciencias empíricas y a la forma como afecta a la condición humana; 3) la inversión ideológica de los derechos humanos; 4) el imperativo categórico contra los procesos de victimización; y 5) el criterio y el principio de producción, reproducción y desarrollo de la vida humana en su circuito con la Naturaleza.

Several studies have confirmed increased mortality among patients with both COVID-19 and cancer. It remains important to continue to report observations of morbidity and mortality from COVID-19 in this vulnerable population. The purpose of this study is to describe the hospitalization characteristics and outcomes of patients with both cancer and COVID-19 admitted to our comprehensive cancer center. This was a descriptive study of the first COVID-19-related hospitalization among adult patients with cancer admitted to our institution. Descriptive statistics were used to summarize patient demographics, clinical as well as hospitalization characteristics. Overall survival (OS) was estimated using the Kaplan–Meier method. A total of 212 patients were included in our cohort with a mean age of 59 years. Fifty-four percent of patients had history of solid tumor malignancy and 46% had hematologic malignancies. Eighty-five percent of our cohort had active malignancy. The mean length of stay (LOS) for hospitalization was 11.2 days (median LOS of 6 days). Twenty-five percent had severe disease and 10.8% died during their initial hospitalization. Those who had severe disease had worse survival at the end of the observation period. COVID-19 among cancer patients causes significant morbidity and mortality as well as repeat hospitalizations. Continued study of COVID-19 in this vulnerable population is essential in order to better inform evolving treatment algorithms, public health policies, and infection control protocols, especially for institutions caring for patients with cancer.

A 68-year-old man was admitted for progressively worsening back pain over the past several months, and he developed tingling of both anterior thighs and gait instability over the past week. Magnetic resonance imaging (MRI) of the spine revealed a left-sided paraspinal mass which extended medially with prominent epidural tumor and spinal cord compression at T4 and T5 levels (Figure 1A, arrows). There were no acute pathologic fractions or leptomeningeal disease. A CT-guided paraspinal biopsy confirmed metastatic adenocarcinoma consistent with a lung primary (Figure 1B). Specifically, it (Figure 1B) revealed metastatic adenocarcinoma with mucinous features, positive for cytokeratin 7 and thyroid transcription factor 1, and consistent with lung primary. A decalcified Haemotoxylin and Eosin stained tissue revealed multiple foci of metastatic adenocarcinoma involving the thoracic vertebra (200x).

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spinal cord compression is an oncologic emergency typically associated with advanced cancers. However, spinal cord compression may also be the initial presentation in those with metastatic disease. CASE PRESENTATION: A 68-year-old man presented to the emergency center with gait instability over the past week along with upper back pain for the past 4 months. The patient needed to use a cane over the past week due to unsteadiness. The back pain was initially intermittent, stabbing, and worse at night. Once it became constant, he sought medical evaluation, but radiograph of the spine was unremarkable and pain medications did not help. He later developed paresthesias of the anterior abdominal wall and bilateral anterior thighs. He was prescribed a steroid dose pack which provided temporary relief. He denied any falls or incontinence. Magnetic resonance imaging (MRI) of the spine revealed a left-sided T4-T5 paraspinal mass with severe cord compression (Figure 1 & 2). Past medical history was significant for elevated prostate specific antigen with negative prior prostate biopsies. He had no history of smoking. Physical exam was remarkable for ataxic gait, and brisk patellar and Achilles reflexes. Labs revealed leukocytosis (17.6 K/μL) and mildly elevated PSA (4.8 ng/mL). Neurosurgery was consulted, and high dose corticosteroids were initiated. Computed tomography (CT) chest revealed a 1.3 cm irregular solid nodule in the left upper lobe along with a 1 cm solid nodule near the mediastinal pleura, and scattered lytic osseous metastases in the spine and pelvis (Figure 3). A CT-guided paraspinal biopsy confirmed metastatic adenocarcinoma with mucinous features (cytokeratin 7 and thyroid transcription factor 1 positive) consistent with a lung primary. Urgent surgical spinal decompression with T2-T8 posterior spinal fusion was performed. After inpatient rehabilitation, he was discharged with symptom resolution. Palliative radiotherapy followed by systemic therapy was planned. DISCUSSION: Worsening and persistent back pain with associated weakness and numbness of the lower extremities warrants additional investigation. Metastatic tumors involving the spinal cord typically include prostate, lung and breast; however, any primary tumor can metastasize to the spinal cord. Only 23% of patient will present with spinal cord compression as the initial manifestation. Lung cancer metastases often involves the thoracic level. The mechanism of involvement may be related to hematogenous spread via the paravertebral plexus or direct tumor invasion. Imaging of the entire spine (preferably with MRI) is ideal and can guide further interventions. Surgical decompression and radiotherapy are associated with improved neurological dysfunction. CONCLUSIONS: Spinal cord compression may be the initial manifestation of metastatic cancer. Early diagnosis and rapid management is vital to prevent irreversible neurological damage. Reference #1: Vasser M, Koroscil M. When Back Pain Turns Deadly: An Unusual Presentation of Lung Cancer. Respir Med Case Rep. 2020;29:101009. https://doi.org/10.1016/j.rmcr.2020.101009 Reference #2: National Collaborating Centre for Cancer (UK). Metastatic Spinal Cord Compression: Diagnosis and Management of Patients at Risk of or with Metastatic Spinal Cord Compression. National Collaborating Centre for Cancer (UK); 2008. Accessed May 29, 2020. https://www.ncbi.nlm.nih.gov/books/NBK55011/ Reference #3: Aaron AD. The management of cancer metastatic to bone. JAMA. 1994;272(15):1206-1209. DISCLOSURES: No relevant relationships by Saadia Faiz, source=Web Response No relevant relationships by Sarah Jaroudi, source=Web Response No relevant relationships by David Rubio, source=Web Response

Background The management of patients with cancer and concurrent heart failure (HF) is challenging. The increased complexity of treatment and the occurrence of multiple overlapping symptoms may lead to frequent hospital admissions, which may result in cancer treatment delays, a diminished quality of life, and an increased financial burden for the patient’s family. To provide holistic care to oncology patients with HF, we implemented the Heart Success Program (HSP), a patient-centered, interprofessional collaborative practice, which decreased the 30-day hospital readmission rate for HF diagnosis from 40 to 27%. However, this rate remains higher than that reported for Medicare beneficiaries. Aim To identify the factors contributing to frequent readmissions, the HSP committee participated in the institution’s Clinical Safety and Effectiveness and utilize quality improvement methodologies and tools to decrease hospital readmission for HF. Methods The DMAIC (Define, Measure, Analyze, Improve and Control) method was used to guide this quality improvement. Areas considered as having high impact and requiring low effort to address were patient education barriers, lack of documentation clarity, and care provider knowledge gaps about the HSP. We implemented workflow changes, improved clarity with documentation of HF diagnosis, and increase provider knowledge about the HSP. Findings After 6 months of implementing quality improvement techniques, the 30-day hospital readmission rate for HF patients fell by 23.43% (from 31.7% for the baseline period to 8.27%), exceeding the target project goal of 10%. Our quality improvement method may also be effective in improving the management of patients with cancer and other comorbid conditions.

Communication failures during patient handoff can lead to serious errors. A quality improvement team created a standardized handoff tool/process (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to) for admitting patients from the emergency department (ED) to the hospitalist inpatient service of a tertiary cancer center. DE-PASS mirrors the institution’s ED workflow, stratifies patients as stable/urgent/emergent, and establishes requirements for verbal and email communications between providers. Comparison of preintervention and postintervention results from the 1-month pilot revealed that within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58% (P = .393), the number of rapid-response team calls by 39% (P = .637), and time to inpatient order by 31% (P = .004). ED physicians’ and hospitalists’ satisfaction with DE-PASS increased. Reduction in intensive care unit transfers was sustained after the pilot (P = .029). DE-PASS feasibility was evidenced by 100% uptake. By stratifying patients by risk level, DE-PASS reduced admission-to-evaluation times for unstable patients, potentially improving patient safety.

247 Background: Failures in communication lead to serious medical errors particularly during transitions of care. A standardized handoff of patients requiring admission to the inpatient setting between the Emergency Center (EC) and the Hospitalist Inpatient Service (HIS) at a comprehensive cancer center was lacking during this vulnerable time. Methods: A quality pilot study using Plan, Do, Study, Act methodology was conducted. First, root cause analysis and process mapping of the current state was performed to identify pitfalls of the handoff process between the EC and the Hospitalist Service. Second, a validated standardized handoff tool, “I-PASS” (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver) was selected and then transformed to DE-PASS, where D stands for Decisive problem requiring admission and E for Evaluation, to suit the EC workflow. The DE-PASS identified patients at higher risk for complications as urgent and emergent in the evaluation section and required a verbal communication in addition to an email using DE-PASS format. Third, we measured pre versus post intervention impact metrics. ICU transfers and Rescue Team calls within 24 hours were obtained from 822 patients. Time interval between EC admission physician order and HIS order was analyzed in a population of 174 randomly selected patients. Provider satisfaction with handoffs was surveyed. Results: The DE-PASS utilization ranged from 75% to 100% by the end of the pilot. The data analysis revealed a 60% reduction in the number of ICU transfers and a 64% reduction of Rescue Team calls post intervention. There was an 18% reduction in the interval time for an inpatient order in the medical record. EC Physicians satisfaction with DE-PASS increased by 10% and the Hospitalists increased by 40%. Conclusions: Implementation of the standardized handoff tool DE-PASS led to improved communication between two clinical services of a major cancer center. Patients’ safety improved by designation of risk stratification and reducing the time to evaluate unstable patients by the receiving HIS. Physician’s satisfaction with the handoff process increased.

INTRODUCTION:Adverse events leading to patient harm are rarely the result of an individual error but are instead due to a series of errors resulting from system breakdowns. Thus, the Accreditation Council for Graduate Medical Education requires all residents to participate in quality improvement and patient safety programs. However, a major reported obstacle to sustainable quality improvement and patient safety curricula, as well as meaningful practice improvement, is the small number of faculty with expertise or training in these topics.METHODS:This workshop provides a simple framework for redesigning traditional morbidity and mortality conferences for faculty who have minimal quality improvement training. The materials associated with this publication include a standardized presentation template, sample teaching points, and a faculty facilitator's guide.RESULTS:Between August 2014 and February 2015, 135 trainees from one of our tertiary training sites attended seven of these redesigned conferences. The largest gains were made in teaching residents how to use a systems-based approach to analyze medical error and how to identify corresponding error-reduction strategies. Residents also perceived themselves as more likely to put their knowledge into action through filing an incident report after attending the conference. The one item that did not change was the residents' perception of safety culture at their institution, suggesting that attendance at a monthly conference is not sufficient to change culture.DISCUSSION:Similarly formatted M&Mconferences may help institutions address several aspectof the ACGME CLER program that provides programswith periodic feedback regarding trainee education onpatient safety and quality improvement as well.

242 Background: Communication failures cause two-thirds of sentinel events in hospitals. These adverse occurrences are often both fatal and preventable. Consequently, improving the quality of handoffs has been identified by multiple accreditation constituents as a top priority patient safety goal. This project was part of an institutional initiative to standardize handoffs among physicians, trainees, and midlevel providers. Methods: Four subgroups were identified as pilot areas: Gynecologic Oncology (Gyn Onc) fellows to nocturnalists, Surgical Oncology fellows, Pediatric Oncology residents and fellows, and Emergency Center attending staff to inpatient hospitalists. This abstract focuses on the Gyn Onc and Pediatric Oncology services. All teams used a PDSA cycle (Plan, Do, Study, Act) to conduct its pilot study. A gap analysis, root cause analysis, and process mapping were performed in each area to identify specific handoff issues. A validated standardized handoff tool, I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver), was selected. Of note, “Illness severity” highlights patients identified at higher risk for complications and denotes their status as “watcher” or “unstable.” Interventions included I-PASS skills training and utilization of the I-PASS mnemonic. Each service developed a standardized definition to identify patients classified as “watchers.” Medical errors, ICU transfers, and provider satisfaction were assessed pre- and post-intervention. Results: Results from 40 handoff surveys showed communication errors dropped by 10% (16.49 vs 14.93). Minor harm as result of a problematic handoff decreased by 45% (2.55 vs 1.39), with a 55% reduction in ICU transfers. There was an overall increase in handoff satisfaction using I-PASS and 100% standardization of handoffs across the Gyn Onc and Pediatric Oncology units. Conclusions: Implementation of I-PASS, a validated standardized handoff was associated with reductions in medical errors and improvement in communication. Our institution is moving toward implementing I-PASS across all units to increase the safety and quality of patient care.

In this article I explore a possible linkage between the worlds of science-fiction and human rights. There is a science-fiction literature and cinema with a critical and transgresive character, side by side with cheap, commercialized production. Approaching Human Rights and “impossibility principles” as a different way to build our presents by means of fictional futures, such a present may be regarded as a sort of sacrifice. The human condition always appears in a positive or negative fashion in this literature, as well as positions going from recognition of pluralities and differences, to the authoritarian imposition of a single way to be human