Gynecologic oncology treatment modifications or delays in response to the COVID-19 pandemic in a publicly funded versus privately funded North American tertiary cancer center.

OBJECTIVE: To compare gynecologic oncology surgical treatment modifications and delays during the first wave of the COVID-19 pandemic between a publicly funded Canadian versus a privately funded American cancer center. METHODS: This is a retrospective cohort study of all planned gynecologic oncology surgeries at University Health Network (UHN) in Toronto, Canada and Brigham and Women's Hospital (BWH) in Boston, USA, between March 22,020 and July 302,020. Surgical treatment delays and modifications at both centers were compared to standard recommendations. Multivariable logistic regression was performed to adjust for confounders. RESULTS: A total of 450 surgical gynecologic oncology patients were included; 215 at UHN and 235 at BWH. There was a significant difference in median time from decision-to-treat to treatment (23 vs 15 days, p < 0.01) between UHN and BWH and a significant difference in treatment delays (32.56% vs 18.29%; p < 0.01) and modifications (8.37% vs 0.85%; p < 0.01), respectively. On multivariable analysis adjusting for age, race, treatment site and surgical priority status, treatment at UHN was an independent predictor of treatment modification (OR = 9.43,95% CI 1.81-49.05, p < 0.01). Treatment delays were higher at UHN (OR = 1.96,95% CI 1.14-3.36 p = 0.03) and for uterine disease (OR = 2.43, 95% CI 1.11-5.33, p = 0.03). CONCLUSION: During the first wave of COVID-19 pandemic, gynecologic oncology patients treated at a publicly funded Canadian center were 9.43 times more likely to have a surgical treatment modification and 1.96 times more likely to have a surgical delay compared to an equal volume privately funded center in the United States.

Antifungal stewardship in a tertiary care paediatric hospital: the PROAFUNGI study.

BACKGROUND: The increasing use of antifungal drugs (AF) in children and the concern for related adverse events and costs has led to the development of specific AF stewardship programmes (AFS). Studies in adult patients have shown improvements in AF prescription and usage after implementation, but paediatric data are scant. The aim of this PROAFUNGI study was to describe the use and appropriateness of AF in a high complexity paediatric centre. METHODS: Observational, prospective, single-centre, modified point-prevalence study (11 surveys, July-October 2018), including paediatric (< 18 years) patients receiving at least one systemic AF. Prescriptions were evaluated by the AFS team. RESULTS: The study included 119 prescriptions in 55 patients (53% males, median age 8.7 years [IQR 2.4-13.8]). The main underlying condition was cancer (45.5% of patients; HSCT in 60% of them); and the first indication for AF was prophylaxis (75 prescriptions, 63.2%). Liposomal amphotericin B was used most commonly (46% prescriptions), mainly as prophylaxis (75%). Among the 219 evaluations, 195 (89%) were considered optimal. The reason for non-optimal prescriptions was mostly lack of indication (14/24), especially in critical patients with ventricular assist devices. The use of AF without paediatric approval accounted for 8/24 inappropriate prescriptions. CONCLUSIONS: A high rate of AF appropriateness was found for the children's hospital as a whole, in relation with a well-established AFS. Nonetheless, the identification of specific areas of improvement should guide future actions of the AFS team, which will focus mainly on prophylaxis in critically ill patients receiving circulatory assistance and the use of non-approved drugs in children.

The cost-effectiveness of a program to reduce intrapartum and neonatal mortality in a referral hospital in Ghana.

OBJECTIVE: To evaluate the cost-effectiveness of a program intended to reduce intrapartum and neonatal mortality in Accra, Ghana. DESIGN: Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis. METHODS: A program integrating leadership development, clinical skills and quality improvement training was piloted at the Greater Accra Regional Hospital from 2013 to 2016. The number of intrapartum and neonatal deaths prevented were estimated using the hospital's 2012 stillbirth and neonatal mortality rates as a steady-state assumption. The cost-effectiveness of the intervention was calculated as cost per disability-adjusted life year (DALY) averted. In order to test the assumptions included in this analysis, it was subjected to probabilistic and one-way sensitivity analyses. MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER), which measures the cost per disability-adjusted life-year averted by the intervention compared to status quo. RESULTS: From 2012 to 2016, there were 45,495 births at the Greater Accra Regional Hospital, of whom 5,734 were admitted to the newborn intensive care unit. The budget for the systems strengthening program was US $1,716,976. Based on program estimates, 307 (±82) neonatal deaths and 84 (±35) stillbirths were prevented, amounting to 12,342 DALYs averted. The systems strengthening intervention was found to be highly cost effective with an ICER of US $139 (±$44), an amount significantly lower than the established threshold of cost-effectiveness of the per capita gross domestic product, which averaged US $1,649 between 2012-2016. The results were found to be sensitive to the following parameters: DALYs averted, number of neonatal deaths, and number of stillbirths. CONCLUSION: An integrated approach to system strengthening in referral hospitals has the potential to reduce neonatal and intrapartum mortality in low resource settings and is likely to be cost-effective. Sustained change can be achieved by building organizational capacity through leadership and clinical training.

[Assessment model for evaluating the preparedness plan for COVID-19 in a tertiary care hospital]. / Modelo de evaluación del plan de respuesta frente a la pandemia de COVID-19 en un hospital de tercer nivel.

BACKGROUND AND PURPOSE: During the first wave of the epidemic caused by SARS-CoV-2, hospitals have come under significant pressure. This scenario of uncertainty, low scientific evidence, and insufficient resources, has generated significant variability in practice between different health organisations. In this context, it is proposed to develop a standards-based model for the evaluation of the preparedness and response system against COVID-19 in a tertiary hospital. MATERIALS AND METHODS: The study, carried out at the University Hospital of Vall d'Hebron in Barcelona (Spain), was designed in two phases: 1) development of the standards-based model, by means of a narrative review of the literature, analysis of plans and protocols implemented in the hospital, a review process by expert professionals from the centre, and plan of action, and 2) validation of usability and usefulness of the model through self-assessment and hospital audit. RESULTS: The model contains 208 standards distributed into nine criteria: leadership and strategy; prevention and infection control; management of professionals and skills; public areas; healthcare areas; areas of support for diagnosis and treatment; logistics, technology and works; communication and patient care; and information and research systems. The evaluation achieved 85.2% compliance, with 42 areas for improvement and 96 good practices identified. CONCLUSIONS: Implementing a standards-based model is a useful tool to identify areas for improvement and good practices in COVID-19 preparedness and response plans in a hospital. In the current context, it is recommended to repeat this methodology in other non-hospital and public health settings.

Real-world assessment, relevance, and problems in use of personal protective equipment in clinical dermatology practice in a COVID referral tertiary hospital.

BACKGROUND: Doctors and healthcare workers (HCW) are at frontline in control of the pandemic caused by the novel coronavirus infection (COVID-19). The virus is transmitted by contact, droplet, and airborne transmission; hence, hand hygiene, social distancing, environmental disinfection, and use of appropriate personal protective equipment (PPE) form important components to protect HCWs from cross-infection. Appropriate use of PPE is of paramount importance not only to reduce the risk of transmission but also to maintain adequate stock for those who are dealing directly with COVID-19 patients. AIMS: In this article, we aim to provide the rationale for appropriate use of PPE in the dermatology setting in the current scenario. We have also discussed the scientific evidence for use of each component of protection and the practical problems faced in our COVID referral tertiary hospital. METHODS: Our review was based on articles that have studied or analyzed the efficacy of various protective measures being utilized by health workers against spread of COVID-19. This was done by carrying out a PUBMED search with terms "coronavirus, COVID-19, personal protective equipment (PPE), transmission, mask, face shields, goggles, gloves." We also scrutinized the various pragmatic issues being faced by doctors in our setup while using PPE. RESULTS: In order to maximize the appropriate use of PPE, the rationale for use needs to be understood and problems encountered in daily practice need to be addressed. CONCLUSION: Adherence to protective measures and use of PPE is of utmost importance for HCWs to prevent cross-infection in this pandemic. The use of PPE can limit transmission to a great extent, but appropriate use and avoiding misuse is equally important in the dermatology setting in order to avoid depletion of stock. It is also essential to consider various practical issues with use of PPE and device measures to avoid them so that breach in protocols can be prevented and spread of infection minimized.

Evaluation of endoscopy requests in the resumption of activity during the SARS-CoV-2 pandemic: denial of nonindicated requests and prioritization of accepted requests.

INTRODUCTION: the global SARS-CoV-2 pandemic forced the closure of endoscopy units. Before resuming endoscopic activity, we designed a protocol to evaluate gastroscopies and colonoscopies cancelled during the pandemic, denying inappropriate requests and prioritizing appropriate ones. METHODS: two types of inappropriate request were established: a) COVID-19 context, people aged ≤ 50 years without alarm symptoms and a low probability of relevant endoscopic findings; and b) inappropriate context, requests not in line with clinical guidelines or protocols. Denials were filed in the medical record. Appropriate requests were classified into priority, conventional and follow-up. Requests denied by specialty were compared and the findings of priority requests were evaluated. RESULTS: between March 16th and June 30th 2020, 1,658 requests (44 % gastroscopies and 56 % colonoscopies) were evaluated, of which 1,164 (70 %) were considered as appropriate (priority 8.5 %, conventional 48 %, follow-up 43 % and non-evaluable 0.5 %) and 494 (30 %) as inappropriate (20 % COVID-19 context, 80 % inappropriate context). The reasons for denial of gastroscopy were follow-up of lesions (33 %), insufficiently studied symptoms (20 %) and relapsing symptoms after a previous gastroscopy (18 %). The reasons for denial of colonoscopies were post-polypectomy surveillance (25 %), colorectal cancer after surgery (21 %) and a family history of cancer (13 %). There were significant differences in denied requests according to specialty: General Surgery (52 %), Hematology (37 %) and Primary Care (29 %); 31 % of priority cases showed relevant findings. CONCLUSIONS: according to our study, 24 % of endoscopies were discordant with scientific recommendations. Therefore, their denial and the prioritization of appropriate ones optimize the use of resources.

Recommendations for the Organization of Multidisciplinary Clinical Care Teams in Parkinson's Disease.

BACKGROUND: Optimal management in expert centers for Parkinson's disease (PD) usually involves pharmacological and non-pharmacological interventions, delivered by a multidisciplinary approach. However, there is no guideline specifying how this model should be organized. Consequently, the nature of multidisciplinary care varies widely. OBJECTIVE: To optimize care delivery, we aimed to provide recommendations for the organization of multidisciplinary care in PD. METHODS: Twenty expert centers in the field of multidisciplinary PD care participated. Their leading neurologists completed a survey covering eight themes: elements for optimal multidisciplinary care; team members; role of patients and care partners; team coordination; team meetings; inpatient versus outpatient care; telehealth; and challenges towards multidisciplinary care. During a consensus meeting, outcomes were incorporated into concept recommendations that were reviewed by each center's multidisciplinary team. Three patient organizations rated the recommendations according to patient priorities. Based on this feedback, a final set of recommendations (essential elements for delivery of multidisciplinary care) and considerations (desirable elements) was developed. RESULTS: We developed 30 recommendations and 10 considerations. The patient organizations rated the following recommendations as most important: care is organized in a patient-centered way; every newly diagnosed patient has access to a core multidisciplinary team; and each team has a coordinator. A checklist was created to further facilitate its implementation. CONCLUSION: We provide a practical tool to improve multidisciplinary care for persons with PD at the organizational level. Future studies should focus on implementing these recommendations in clinical practice, evaluating their potential applicability and effectiveness, and comparing alternative models of PD care.

A clinical audit and cost analysis of latent TB management at a tertiary referral centre in Ireland.

INTRODUCTION: It is estimated that 24.8% of the world's population has latent TB. The World Health Organization's (WHO) End TB Strategy states that the systematic identification and management of LTBI in groups of people at high risk of reactivation is an essential part of TB elimination in low-incidence countries. AIM: Our aims were to evaluate the effectiveness of LTBI management at our tertiary referral outpatient department (OPD) and to identify how our service could be improved. METHODS: We included all patients seen in the infectious diseases outpatient service who were referred querying a diagnosis of latent TB. Patients had to have attended the outpatient clinic at least once in the 6 months from 1 July 2018 to 31 December 2018. Patients who were referred for assessment of possible active TB were not included in. A retrospective review of each patient's electronic record was performed by two auditors. RESULTS: Twenty-five patients reviewed in our TB clinic were referred querying a diagnosis of LTBI. Twenty-two of 25 (88%) were diagnosed with LTBI; 21/25 (84%) were offered treatment. All patients offered treatment accepted treatment. Seventeen of 21 (81%) patients completed treatment. The mean cost per patient seen in the clinic was €1378.66. The mean cost per LTBI successfully treated was €2027.45. No patient had a raised ALT detected. There were no other adverse events. CONCLUSION: Our TB clinic is effective in the assessment and safe management of latent TB in accordance with national guidelines. Interventions for improvement are the creation of referral guidelines and a referral proforma and exploring alternative clinic models.

Assessment of antimicrobial use and prescribing practices among pediatric inpatients in Zimbabwe.

This study aims to assess antimicrobial consumption in the pediatric department of a tertiary care public hospital in Zimbabwe. Clinical records of pediatric inpatients admitted to Harare Central Hospital over a 3-week period were reviewed prospectively. Antimicrobial consumption was described as days of therapy per 100 inpatient days (DOT/100 PD). Adherence of antimicrobial drug prescriptions to the National Guidelines was also evaluated. A total of 121 (93.1%) children were prescribed at least one antimicrobial out of 130 children admitted. The median age was 14 months (IQR: 3 - 48 months). Overall antimicrobial consumption was 155.4 DOT/100 PD (95% CI 146-165.2). The most frequently prescribed antimicrobials were benzylpenicillin, gentamicin and ceftriaxone. Prescriptions were adherent to national guidelines in 57.7% of children. This study shows that there is high antimicrobial drug usage in hospitalized children in Zimbabwe and a considerable proportion of prescriptions are non-adherent with national guidelines.

Improving Continuity of Care: An Innovative Primary Care Role in an Acute Care Hospital.

This article describes an innovative organization-spanning collaboration between primary care and acute care in Calgary to support continuity of care for patients with complex needs. Mosaic Primary Care Network provides funding for a primary care navigation nurse to work at the Peter Lougheed Centre, an Alberta Health Services hospital. This role supports hospital in-patients with discharge planning, linking to family physicians and connecting to programs that provide support in the community to vulnerable populations. The commitment of leadership from both organizations was critical for getting this unique role implemented.

COVID-19 pandemic preparedness: A practical guide from an operational pharmacy perspective.

PURPOSE: To describe our medical center's pharmacy services preparedness process and offer guidance to assist other institutions in preparing for surges of critically ill patients such as those experienced during the coronavirus disease 2019 (COVID-19) pandemic. SUMMARY: The leadership of a department of pharmacy at an urban medical center in the US epicenter of the COVID-19 pandemic proactively created a pharmacy action plan in anticipation of a surge in admissions of critically ill patients with COVID-19. It was essential to create guidance documents outlining workflow, provide comprehensive staff education, and repurpose non-intensive care unit (ICU)-trained clinical pharmacotherapy specialists to work in ICUs. Teamwork was crucial to ensure staff safety, develop complete scheduling, maintain adequate drug inventory and sterile compounding, optimize the electronic health record and automated dispensing cabinets to help ensure appropriate prescribing and effective management of medication supplies, and streamline the pharmacy workflow to ensure that all patients received pharmacotherapeutic regimens in a timely fashion. CONCLUSION: Each hospital should view the COVID-19 crisis as an opportunity to internally review and enhance workflow processes, initiatives that can continue even after the resolution of the COVID-19 pandemic.

Time to teach basic and regulatory aspects of art of prescription writing for better doctor-patient safety and keeping communication accessible and straight.

PURPOSE: The basic and regulatory knowledge of prescription writing is essential for every medical student to evolve into a prescribing physician. Prescription becomes the most important clinical pharmacology tool and evidence of the medication access, prescription errors, prescribing errors, negligence and further litigations once released from the hands of the physicians. A questionnaire based cross-sectional survey was done to evaluate knowledge of basic and regulatory aspects of prescription writing in the light of growing violence against physicians in India. METHODS: The basic and regulatory knowledge and awareness of 90 practicing physicians was evaluated for arts of prescription writing by a novel questionnaire based on Indian regulatory guidelines. It was assessed for content validity, face validity, readability and reliability. A statistical significant Cronbach's alpha values of greater than 0.9, Flesh Reading Ease score of 37.4 and Flesch-Kincaid Grade level of 11.2 were obtained. A total of 39 questions comprised of 70 statements categorised into three broad sections containing 13 questions in each were asked in 30 min. RESULTS: The knowledge of the prescription writing is very limited in doctors. They are not sure that Over-The-Counter drugs do not need prescription, pharmacist is the decoder of their written prescription, cross-prescribing (prescribing drugs of other system of medicine) is illegal and they should not dictate prescription on phone. Majority of the physicians are unaware that writing prescription serial number, Rx, refill information and dispensing direction of habit forming drugs is not legal requirement in India. CONCLUSION: Medication access through prescription writing is marred with prescription errors. The physicians have limited regulatory and basic knowledge of prescription writing. Therefore their training of prescription writing through defined global teaching modules is needed. The prescription communications need to be lucid, accessible, comprehensive and straight between doctors and patients following the tenets of country specific regulatory requirements. Graphical abstract Need of standard uniform global basic and regulatory training guidelines for prescription writing.

Center-related Bias in MELD Scores Within a Liver Transplant UNOS Region: A Call for Standardization.

BACKGROUND: Model for End-Stage Liver Disease (MELD) score-based liver transplant allocation was implemented as a fair and objective measure to prioritize patients based upon disease severity. Accuracy and reproducibility of MELD is an essential assumption to ensure fairness in organ access. We hypothesized that variability in laboratory methodology between centers could impact allocation scores for individuals on the transplant waiting list. METHODS: Aliquots of 30 patient serum samples were analyzed for creatinine, bilirubin, and sodium in all transplant centers within United Network for Organ Sharing (UNOS) region 9. Descriptive statistics, intraclass correlation coefficients (ICCs), and linear mixed-effects regression were used to determine the relationship between center, bilirubin, and calculated MELD-sodium (MELD-Na) score. RESULTS: The mean MELD-Na score per sample ranged from 14 to 38. The mean range in MELD-Na per sample was 3 points, but 30% of samples had a range of 4-6 points. Correlation plots and intraclass correlation coefficient analysis confirmed bilirubin interfered with creatinine, with worsening agreement in creatinine at high bilirubin levels. Center and bilirubin were independently associated with creatinine reported in mixed-effects models. Unbiased hierarchical clustering suggested that samples from specific centers have consistently higher creatinine and MELD-Na values. CONCLUSIONS: Despite implementation of creatinine standardization, centers within a single UNOS region report clinically significant differences in MELD-Na on an identical sample, with differences of up to 6 points in high MELD-Na patients. The bias in MELD-Na scores based upon center choice within a region should be addressed in the current efforts to eliminate disparities in liver transplant access.

Disparities in Access to Musculoskeletal Care: Narrowing the Gap: AOA Critical Issues Symposium.

The current health-care system in the United States has numerous barriers to quality, accessible, and affordable musculoskeletal care for multiple subgroups of our population. These hurdles include complex cultural, educational, and socioeconomic factors. Tertiary referral centers provide a disproportionately large amount of the care for the uninsured and underinsured members of our society. These gaps in access to care for certain subgroups lead to inappropriate emergency room usage, lengthy hospitalizations, increased administrative load, lost productivity, and avoidable complications and/or deaths, which all represent a needless burden on our health-care system. Through advocacy, policy changes, workforce diversification, and practice changes, orthopaedic surgeons have a responsibility to seek solutions to improve access to quality and affordable musculoskeletal care for the communities that they serve.

Reporting adverse events related to medical devices: A single center experience from a tertiary academic hospital.

Intensive care units (ICU) rely on multiple technical resources with extensive use of different medical devices, such as ventilators, vital sign monitors, infusion, and injection pumps. This study explored how ICU nurses approach adverse events related to medical devices in a single tertiary center and identify their level of awareness of the national reporting system for adverse events related to medical devices beside their source for risk information updates. Totally, 297 nurses working in the ICU at King Saud University Medical City completed a survey on medical devices and adverse events reporting and 198 reported experiencing an adverse event related to equipment failure. However, 195 nurses were unaware of an official national reporting system for reporting such events. It is important to develop a framework of safe operation of medical devices based on international standards. This reporting system should include the national patients' safety authorities, and should be anonymous, confidential, and non-punitive.

Implementation of a patient blood management program in hematopoietic stem cell transplantation (Editorial, p. 2763).

BACKGROUND: Recipients of hematopoietic stem cell transplantation (HSCT) are among the highest consumers of allogeneic red blood cell (RBC) and platelet (PLT) components. The impact of patient blood management (PBM) efforts on HSCT recipients is poorly understood. STUDY DESIGN AND METHODS: This observational study assessed changes in blood product use and patient-centered outcomes before and after implementing a multidisciplinary PBM program for patients undergoing HSCT at a large academic medical center. The pre-PBM cohort was treated from January 1 through September 31, 2013; the post-PBM cohort was treated from January 1 through September 31, 2015. RESULTS: We identified 708 patients; 284 of 352 (80.7%) in the pre-PBM group and 225 of 356 (63.2%) in the post-PBM group received allogeneic RBCs (p < 0.001). Median (interquartile range [IQR]) RBC volumes were higher before PBM than after PBM (3 [2-4] units vs. 2 [1-4] units; p = 0.004). A total of 259 of 284 pre-PBM patients (91.2%) and 57 of 225 (25.3%) post-PBM patients received RBC transfusions when hemoglobin levels were more than 7 g/dL (p < 0.001). The median (IQR) PLT transfusion quantities was 3 (2-5) units for pre-PBM patients and 2 (1-4) units for post-PBM patients (p < 0.001). For patients with PLT counts of more than 10 × 109 /L, a total of 1219 PLT units (73.4%) were transfused before PBM and 691 units (48.8%) were transfused after PBM (p < 0.001). Estimated transfusion expenditures were reduced by $617,152 (18.3%). We noted no differences in clinical outcomes or transfusion-related adverse events. CONCLUSION: Patient blood management implementation for HSCT recipients was associated with marked reductions in allogeneic RBC and PLT transfusions and decreased transfusion-related costs with no detrimental impact on clinical outcomes.

A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement: A Single-Center Quality Comparison Study.

OBJECTIVES: To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs. DESIGN: Retrospective preintervention and postintervention quality comparison study. SETTINGS: Single tertiary community hospital with a 12-bed closed-mixed ICU. PATIENTS: All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B). INTERVENTION: Maebashi early mobilization protocol. MEASUREMENTS AND MAIN RESULTS: Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13-0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $-5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum. CONCLUSIONS: In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.

Validation and cost-effectiveness of an in-house dithiothreitol (DTT) treatment protocol for daratumumab patients in a large tertiary care hospital provides gateway for implementation in smaller community hospitals.

BACKGROUND: Treatment of multiple myeloma with daratumumab (DARA) is increasing fast. Unfortunately, this antibody also attaches to red blood cells (RBCs) and mimics an autoantibody's panreactivity during pre-transfusion testing, necessitating specialized techniques, (e.g. dithiothreitol (DTT)) for alloantibody detection. Many hospitals use a reference lab for such testing, increasing both cost and turn-around time (TAT). Herein, we compare the cost and TAT, pre and post-implementation of an in-house DTT protocol. METHODS: We designed a validation of our in-house DTT protocol from Nov to Dec 2017 with full implementation on January 1, 2018. We retrospectively reviewed all pre-transfusion tests on DARA patients from Feb 2016 to April 2018, pre and post-implementation of in-house DTT testing. Descriptive statistics were used for patient demographics and a Student t-test was used to compare cost and TATs (pre and post-implementation). RESULTS: We identified 49 patients on DARA treatment requiring transfusion. Samples from these patients were sent to the reference lab 104 times and were tested in-house 28 times. The average TAT for the reference lab was 19h25 m compared to our in-house TAT of 5h9m (an average time-savings of 14h16 m). We spent approximately $33,800 ($325 per test) for 104 reference lab samples versus $806.12 (˜$28.79 per test) for in-house testing of 28 samples. CONCLUSION: We provide an easily implementable DTT protocol for pre-transfusion testing community hospitals and beyond. As more monoclonal antibodies are developed and approved for clinical use, the lessons learned with DARA will expand to deal with interference from future targeted therapies.