Admission Order Set Research Articles

Effects of a Revision to the Standard Admission Order Set on Laxative Prescribing for Opioid-Induced Constipation

Purpose: Opioid-induced constipation (OIC) is highly prevalent in patients with cancer-related pain on opioid analgesics and has negative consequences on physical and psychological well-being and quality of life. Oncology clinical practice guidelines recommend the use of osmotic and stimulant laxatives for the prevention and management of opioid-induced constipation, not stool softeners such as docusate sodium. Prescribing practices continue to fall behind these recommendations. Methods: This quality improvement project revised the laxative options available in the standard admission order set in the electronic medical record. Specifically, docusate sodium was removed and replaced with senna and polyethylene glycol 3350. Results: A total of 2,742 patient admissions preintervention were compared to 2,752 admissions postintervention. The number of orders for docusate (p < .001) and docusate-senna (p = .002) orders decreased significantly after the intervention, in addition to the number of OIC diagnoses (p < .001). However, the number of orders for polyethylene glycol (p = .559), senna (p = .582), other laxatives (p = .245), or functional bowel disorder medications (p = .533) did not change significantly. No significant differences were observed in the frequency of laxative orders placed within 24 hours of an opioid order, number of laxatives prescribed at discharge, admissions related to bowel-related complications, or length of stay. Conclusions: Interventions utilizing the electronic medical record can facilitate evidence-based management of OIC. Development of clinical practice guidelines and tailoring these interventions further is needed to adapt this approach at other institutions and sustain practice change.

Optimizing Comprehensive Care for the Hospitalized Hip Fracture Patients: Time to Surgery and Bone Health at Discharge

Background: Approximately 300,000 older people ( 65 years and older) are hospitalized yearly for hip fractures, according to the CDC. Hip fracture is considered a life-altering event with increased morbidity and up to 30% mortality. The Clinical Practice Guidelines by the American Academy of Orthopedic Surgeons highlight the importance of an interdisciplinary team approach while caring for these patients and recommend surgery within 24 hours for improved outcomes. Most of these fractures are considered fragility fractures occurring from a simple ground-level fall and, thus, a manifestation of osteoporosis. Yet, only a few patients, 26%, receive osteoporosis treatment within 30 days of surgery, as per a recent study. ACP recommends replenishing Vitamin D and Calcium in all fragility fracture patients, followed by the initiation of bisphosphonates. At our institution, hip fracture patients used to be admitted to internal medicine or orthopedic services based on their complexity. There was a perceived feeling that those admitted to primarily internal medicine service received less comprehensive care and were likely delayed in getting to the OR given the competing priorities of a sick internal medicine service load. Vitamin D levels were not being checked or replaced despite having it be part of the admission order set used for hip fracture patients. Our project aimed at improving overall care for hospitalized hip fracture patients. Our goal was to increase the percentage of hospitalized hip fracture patients going to the operating room within 24 hours to 85% by the end of 2023. Additional goals were to improve the percentage of checking vitamin D levels and supplementing them at discharge by 25% by the end of 2023. Methods: Our intervention was to build a fragility fracture orthopedic and internal medicine co-management service where hip fracture patients were admitted. We collected outcome, process, and balancing measures, including time to surgery, unnecessary cardiac testing and consultation before surgery, percentage of ordering vitamin-D levels, and vitamin-D supplementation at discharge. Qualitative satisfaction with the process was also included. Data was collected biweekly from Jan 2023 to Dec 2023. Run chart analysis was utilized for statistical analysis. Results: Our results showed that the percentage of patients going to surgery within 24 hours did not differ (median of approximately 80%). Patients rarely got unnecessary cardiac testing or consultations, so we stopped following this measure. The median of vitamin-D level checking and supplementation at discharge had improved from 45% to 77% and 35% to 50%, respectively, sustaining a shift using run chart analysis rules. Conclusions: Our project shows that establishing a dedicated service for hospitalized fragility hip fractures has improved care for our patients. While time to surgery had not improved, it had been within the reported national average. Time to surgery is being delayed mostly when further medical optimization is required. However, having this service improved bone-focused care with vitamin-D testing and supplementation. The future PDSA cycle will focus on post-discharge osteoporosis management and treatment when appropriate.

PICU admission order set: a quality improvement initiative in a developing country

PICU admission order set: a quality improvement initiative in a developing country

Universal Screening for Syphilis at University of California, Davis, Labor and Delivery: A Response to National Trends [ID 2683426

INTRODUCTION: The number of congenital syphilis cases have been rapidly increasing in the United States despite prenatal screening. In Sacramento County, the rates of congenital syphilis are among the highest in the California. In response to the rapid rise in syphilis rates, there is universal syphilis screening on admission to University of California, Davis, labor and delivery. METHODS: Syphilis IgG was added to the admission order set for patients admitted to University of California, Davis, labor and delivery. To assess the effect of this intervention, charts were reviewed from the electronic medical record 6 months prior to and 6 months after the intervention was implemented. RESULTS: In the 6 months prior to implementing routine screening, there were nine individuals who screened positive for syphilis. Of those individuals, eight had scant or no prenatal care. Seven had a history of syphilis with prior treatment. Three required re-treatment based on follow-up titers. There were no false-positive screens. Four patients had concomitant sexually transmitted infection (STI) diagnoses, and seven had a history of or current drug use. Five had unstable housing. In comparison, after 6 months of routine syphilis screening, there were six individuals who screened positive for syphilis. Two had scant prenatal care. Three of the patients had history of syphilis and two required re-treatment based on follow-up titers. There were three false-positive screens. One patient had concomitant STI diagnosis. Two patients had unstable housing. The two groups had similar demographics in regard to age, gravidity, and parity. CONCLUSION: In the first 6 months of routine screening, there was no increase in identification of syphilis cases when compared to risk-based screening (P=0.17). This finding suggests that using a risk-based model (for example, screening individuals with scant to no prenatal care) is sufficient for identifying individuals in need of treatment.

Hospital-associated venous thromboembolism prophylaxis use by risk assessment at a large integrated health care network in Northern California.

Hospital-acquired venous thromboembolism (HA VTE) is a preventable complication in hospitalized patients. We aimed to examine the use of pharmacologic prophylaxis (pPPX) and compare two risk assessment methods for HA VTE: a retrospective electronic Padua Score (ePaduaKP) and admitting clinician's choice of risk within the admission orderset (low, moderate, or high). We retrospectively analyzed prophylaxis orders for adult medical admissions (2013-2019) at Kaiser Permanente Northern California, excluding surgical and ICU patients. ePaduaKP was calculated for all admissions. For a subset of these admissions, clinician-assigned HA VTE risk was extracted. Descriptive pPPX utilization rates between ePaduaKP and clinician-assigned risk as well as concordance between ePaduaKP and clinician-assigned risk. Among 849,059 encounters, 82.2% were classified as low risk by ePaduaKP, with 42.3% receiving pPPX. In the subset with clinician-assigned risk (608,512 encounters), low and high ePaduaKP encounters were classified as moderate risk in 87.5% and 92.0% of encounters, respectively. Overall, 56.7% of encounters with moderate clinician-assigned risk received pPPX, compared to 7.2% of encounters with low clinician-assigned risk. pPPX use occurred in a large portion of low ePaduaKP risk encounters. Clinicians frequently assigned moderate risk to encounters at admission irrespective of their ePaduaKP risk when retrospectively examined. We hypothesize that the current orderset design may have negatively influenced clinician-assigned risk choice as well as pPPX utilization. Future work should explore optimizing pPPX for high-risk patients only.

Impact of Embedding a Venous Thromboembolism Risk Assessment Model in the Electronic Health Record Versus Usual Care: A Cluster-Randomized Trial.

There are multiple risk assessment models (RAMs) for venous thromboembolism prophylaxis, but it is unknown whether they increase appropriate prophylaxis. To determine the impact of a RAM embedded in the electronic health record, we conducted a stepped-wedge hospital-level cluster-randomized trial conducted from October 1, 2017 to February 28, 2019 at 10 Cleveland Clinic hospitals. We included consecutive general medical patients aged 18 years or older. Patients were excluded if they had a contraindication to prophylaxis, including anticoagulation for another condition, acute bleeding, or comfort-only care. A RAM was embedded in the general admission order set and physicians were encouraged to use it. The decisions to use the RAM and act on the results were reserved to the treating physician. The primary outcome was the percentage of patients receiving appropriate prophylaxis (high-risk patients with pharmacological thromboprophylaxis plus low-risk patients without prophylaxis) within 48 hours of hospitalization. Secondary outcomes included total patients receiving prophylaxis, venous thromboembolism among high-risk patients at 14 and 45 days, major bleeding, heparin-induced thrombocytopenia, and length of stay. Mixed-effects models were used to analyze the study outcomes. A total of 26 506 patients (mean age, 61; 52% female; 73% White) were analyzed, including 11 134 before and 15 406 after implementation of the RAM. After implementation, the RAM was used for 24% of patients, and the percentage of patients receiving appropriate prophylaxis increased from 43.1% to 48.8% (adjusted odds ratio, 1.11 [1.00-1.23]), while overall prophylaxis use decreased from 73.5% to 65.2% (adjusted odds ratio, 0.87 [0.78-0.97]). Rates of venous thromboembolism among high-risk patients (adjusted odds ratio, 0.72 [0.38-1.36]), rates of bleeding and heparin-induced thrombocytopenia (adjusted odds ratio, 0.19 [0.02-1.47]), and length of stay were unchanged. Implementation of a RAM for venous thromboembolism increased appropriate prophylaxis use, but the RAM was used for a minority of patients. URL: https://www.clinicaltrials.gov/study/NCT03243708?term=nct03243708&rank=1; Unique identifier: NCT03243708.

Electronic health record intervention to increase use of NSAIDs as analgesia for hospitalised patients: a cluster randomised controlled study

BackgroundPrescribing non-opioid pain medications, such as non-steroidal anti-inflammatory (NSAIDs) medications, has been shown to reduce pain and decrease opioid use, but it is unclear how to effectively encourage multimodal pain...

Utilization of Pharmacologic and Non-Pharmacologic Therapies for Pain in Sickle Cell Disease: A Cross-Sectional Study

Background: The sickling deformity of red blood cells in sickle cell disease (SCD) results in multisystem sequelae, including severe, acute pain from vaso-occlusive crises (VOCs) and chronic pain from central sensitization. Pain is the main cause of poor quality of life and hospital admissions among patients with SCD. While opioid therapy is an important component of treatment for acute SCD pain, it can be complicated by side effects and toxicities. In contrast, chronic SCD pain is best managed with non-pharmacologic therapies. A multimodal, multidisciplinary approach to pain management that promotes non-pharmacologic therapies can improve the quality of care for patients with SCD by addressing biopsychosocial components of the pain experience and is recommended by the American Society of Hematology (ASH). This study examines current usage of pharmacologic and non-pharmacologic therapies among Adolescents and Young Adults (AYAs) with SCD receiving care at our institution. Methods: The electronic medical record and Sickle Cell Knowledgebase, a customized data visualization platform unique to our institution, were utilized to conduct a retrospective chart review of AYAs, ages 13-21 years of age, with SCD from 2016-2021. Data collected included demographic information, diagnosis of chronic pain, emergency department (ED) visits and inpatient admissions for VOCs, as well as pharmacologic and non-pharmacologic therapies utilized in the ED, inpatient setting, and, for patients with chronic pain, in the outpatient setting. Results: The cohort included 90 AYAs with SCD (73% were 13-17 years old). The most common SCD genotypes were HbSS (n=47, 52%) and HbSC (n=32, 36%). The majority were female (n=53, 49%), Black (n=85, 94%), and non-Hispanic (n=86, 96%). There were 95 ED visits for VOC, where the patient was subsequently discharged home, and 246 admissions for VOC during the study period. There was a high frequency of opioid interventions for VOCs during the 95 extracted ED visits (81.8% in 2016, 91.7% in 2021). During VOC admissions, there was consistent use of opioids in 100% of admissions from 2016-2021 with increasing utilization of patient-controlled analgesia (7.7% in 2016, 45.1% in 2021) and subanesthetic ketamine (0% in 2016, 18.3% in 2021) each year during the study period. Compared to pharmacologic measures, non-pharmacologic therapies (i.e., healing touch, massage, art therapy, child life, music therapy, occupational therapy, physical therapy, psychology) were less utilized during VOC admissions. While healing touch and child life therapy were ordered during approximately 85% of VOC admissions, they occurred <50% of the time. All other integrative therapies were ordered between 5-55% of admissions each year and occurred <50% of the time. There was no correlation between length of hospital stay and use of integrative therapies. Seven patients with a diagnosis of chronic pain were identified. All 7 received non-pharmacologic therapies in the outpatient setting, including cognitive behavioral therapy, guided imagery, and psychology consultation. Six received either a gabapentinoid, serotonin and norepinephrine reuptake inhibitor (SNRI), or tricyclic antidepressant (TCA). Conclusion: Per the ASH SCD guidelines, non-pharmacologic therapies are recommended for SCD-related pain. In our cohort, we found that non-pharmacologic therapies occurred in <50% of VOC admissions and were underutilized for SCD-related pain in AYAs when compared to pharmacologic therapies at our institution. Though we speculate that healing touch and child life were frequently ordered as a default within our admission order set, utilization rates were still low. To better understand barriers to non-pharmacologic therapies in SCD, we are conducting qualitative interviews of patients, caregivers, and healthcare providers using the Consolidated Framework for Implementation Research (CFIR) as a theoretical model. Understanding barriers to the use of non-pharmacologic therapies will be essential to maximizing their implementation and hence maximizing pain control, improving quality of life, and increasing self-efficacy.

Evaluation of Venous Thromboembolism Prevention Practices in US Hospitals

Background Hospital-associated venous thromboembolism (HA-VTE) is a significant, deadly, costly, and growing public health problem. While as many as 70% of cases of HA-VTE in patients could be prevented, proven VTE prevention strategies are not applied systematically across U.S. hospitals systems. There is a need to assess and better understand the landscape around VTE prevention practices in U.S. hospitals. Methods The Joint Commission and the Centers for Disease Control and Prevention (CDC) collaborated in the development of a probability-based hospital survey collected in accordance with the American Association for Public Opinion Research guidelines. The population comprised all U.S. and territorial general medical, general surgical, and critical-access hospitals in the 2019 American Hospital Association database. Hospitals were stratified by bed size (small ≤100 beds; medium 100-399 beds; and large ≥400 beds), then randomly sampled an equal number of hospitals in each group. The intended respondent was the chief medical officer, director of quality or safety, or person of a similar title. The questionnaire comprised 44 items, including topics on hospital policies and protocols, barriers to implementation of VTE prevention practice, quality monitoring and improvement efforts, and risk assessment activities. The χ2 test was used to examine differences in response rates by hospital characteristics. This project was deemed non-research in accordance with federal regulation for the protection of human subjects in research. Results There were 4605 eligible hospitals, of which 1290 were randomly selected for the sample, and 1212 had available contact information and were presumed reached. Of these, 311 submitted sufficient data for inclusion, a response rate of 25.7%. Response rates did not differ significantly by location (urban vs rural) or bed size, however major teaching hospitals were more likely to respond than minor or non-teaching hospitals (p<.001). (Table 1) More than half of hospitals reported having a VTE prevention policy (58.0%) (Table 2). Most had a hospital-wide VTE prevention protocol (81.5%) and/or unit-specific protocols (59.9%). Less than half had a VTE prevention team, committee, or workgroup and only 21.8% had a designated VTE prevention team and 19.2% reported VTE prevention activities were addressed by another committee. Large hospitals were more likely to have a designated team (p<.001). When a team or committee exists, there is representation from at least 2 departments (96.7%). Almost 80% reported they have clinical decision support (CDS) tools to help guide the selection of appropriate VTE prophylaxis for medical and surgical patients. The availability of CDS was greater in large and medium hospitals for both medical and surgical units (p<.002). Approximately 60% reported that their admission order sets addressed VTE prophylaxis and completion is mandatory. Reminders or alerts are provided for patients by about 60% of hospitals. Missed anticoagulant doses are routinely documented at 80.1% of hospitals. Around 50% of hospitals reported they conduct audits and provide feedback related to VTE prophylaxis for patients. Over 70% of hospitals educate patients about VTE prevention, including the importance of VTE prophylaxis, during the hospitalization; a little more than a third of hospitals provide annual VTE prevention education to clinicians. About half reported they have an ambulation protocol for patients. There were no variations by hospital bed size for education or ambulation protocols. Data on the number of newly diagnosed HA-VTE is collected in 75.6% of hospitals. This was lower in small hospitals (p=.004). Whereas just 44.7% track the number of patients with bleeding events and/or complications related to anticoagulant prophylaxis. Only 43.7% collect data on the patients receiving appropriate VTE prophylaxis and even fewer collect data on of patients receiving risk assessment (29.3%). Conclusion This survey of hospital VTE prevention practices identified numerous areas for improvement in the establishment and implementation of HA-VTE prevention policies and procedures. Overall, there were limited differences in prevention practices based on hospital bed size. Improving the awareness and application of evidence-based guidelines and interventions may reduce the incidence of HA-VTE.

Underestimation of Venous Thromboembolism Risk: A Common Health Care Quality Deficit

Venous thromboembolism (VTE) is a complication of hospitalization but not all patients are at high risk. VTE risk assessment models have been developed to identify patients whose risk is sufficient to warrant pharmacologic thromboprophylaxis. To ensure all patients are risk assessed upon admission, we implemented a mandatory risk assessment tool embedded in admission order sets in our electronic health record (EHR) system. We hypothesized that the accuracy of these risk assessments was variable. We performed a retrospective cohort study of patients discharged from the Johns Hopkins Hospital medicine service between January 1 st-December 31 st 2019. The cohort consisted of consecutive patients classified into normal, intermediate or low mobility groups using the Johns Hopkins Highest Level of Mobility score. Using a standardized chart review algorithm, elements of the Padua and Improve risk scores were determined using the admission note and the JH-HLM scores for mobility assessment. We report the results of the Padua score comparison. Provider risk assessments, VTE prophylaxis orders, symptomatic VTE, major bleeding (ISTH criteria) and deaths were determined by chart review. We measured concordance between provider risk factors identified and those identified on retrospective chart review. Statistical analyses were done using Chi-squared or Fisher's exact test and were performed using Stata v.18. The cohort consist of 2992 patients with a median age of 58 (Interquartile range (IQR) 45-70). Characteristics of the cohort are in Table 1. The median provider Padua score was 1 (IQR 0,3) compared with 2 (IQR 1,5) for chart review. Providers identified 2480 patients (82.9%) as being low risk compared with 1882 (62.9%) upon chart review (P<0.001). Differences in risk factor assessments are presented in Figure 1. Concordance rates between providers and chart review were high (93.6%-99.6%) for all risk factors except obesity (87.5%), heart failure (76.4%), reduced mobility (72.5%) and acute infection (66.1%).(Figure 1) Thirty-six VTE (27 DVT, 9 PE; 1.2%) occurred during the hospital stay and sixty-one (44 DVT;17 PE; 2.2%) within 3 months. Among patients who suffered an in-hospital VTE, providers assessed 29 (80.6%) as low risk compared with 13 (36.1%) by chart review. Fourteen patients (48.3%) were not prescribed prophylaxis. Forty-seven of 61 patients (77.0%) who developed VTE within 3 months were classified as low risk by providers compared with 26 (42.6%) among chart reviewers. Twenty-five (41.0%) were not prescribed prophylaxis. 727 of 2480 (29.3%) patients risk assessed as low risk by providers were assessed as being at high risk upon chart review. 707 of 2480 (28.5%) low risk patients were not prescribed prophylaxis. 157 of these 707 (22.2%) would have been prescribed prophylaxis based upon chart review. Among these 157 patients, 7 VTE occurred during the hospital stay and 11 events occurred within 3 months. Major bleeding occurred during prophylaxis in 4 patients (0.17%). Underestimation of VTE risk is common in hospitalized medically-ill patients. Development of improved EHR VTE risk assessment tools that assist the provider in identifying patient risk factors could improve VTE prevention and reduce hospital-associated VTE.

Perceived Needs Among Healthcare Providers Caring for Seriously Ill Adults Regarding Electronic Health Record Triggers for Palliative Care Referral.

Many healthcare facilities in the United States currently utilize electronic health record triggers to promote and facilitate palliative care referral. The purpose of this study was to explore perceived needs regarding electronic health record trigger criteria for palliative care referral among healthcare providers caring for seriously ill adult hospitalized patients in a teaching hospital in New York State. A qualitative descriptive approach was utilized with use of individual semistructured interviews. Braun and Clarke's Reflexive Thematic Analysis method was used to analyze data. Data analysis generated one overarching theme, I'm in Favor of an Electronic Health Record Automatic Trigger for Palliative Care, and three key themes, Build a Checklist Screening Tool Into Epic With Predefined Conditions and a Palliative Consult in the Admission Order Set, If Providers Call a Palliative Care Consult Sooner, We Give Patients a Better Quality of Life, and Providers Need to Be Aware of the Different Facets of What Palliative Care Actually Does. Findings revealed that all participants supported incorporating electronic health record palliative care triggers. Future research is needed exploring provider palliative care education approaches to promote understanding of palliative care services and to address personal and/or professional bias.

Utilizing admission ordersets and progress note templates to facilitate Identification and treatment of iron deficiency anemia in the hospitalized heart failure patient.

Utilizing admission ordersets and progress note templates to facilitate Identification and treatment of iron deficiency anemia in the hospitalized heart failure patient.

Standardizing Opioids Prescribed at Discharge in Trauma Surgery

IntroductionExcessive opioid use after sustaining trauma has contributed to the opioid epidemic. Standardizing the quantity of opioids prescribed at discharge can improve prescribing behavior. We hypothesized that adopting new electronic medical record order sets would be associated with decreased morphine milligram equivalents (MME) prescribed at discharge for trauma patients. MethodsThis was a quasi-experimental study examining opioid prescribing practices at a Level 1 Trauma Center. All patients ages 18-89 admitted to the Trauma Service from January 2017 through March 2021 and hospitalized for at least 2 d were included. In November 2020, new trauma admission and discharge order sets were implemented with recommended discharge opioid quantity based on inpatient opioid usage the day prior to discharge multiplied by five. Postintervention prescribing practices were compared to historical controls. The primary outcome was MME at discharge. ResultsBaseline characteristics between preintervention and postintervention cohorts were comparable. There was a significant reduction in median MME prescribed at discharge postintervention (112.5 versus 75.0, P < 0.0001). Median inpatient MME usage also significantly reduced postintervention (184.1 versus 160.5; P < 0.0001). There were trends toward increased ideal prescribing per order set recommendation and a reduction in overprescribing. Patients receiving the recommended opioid quantity at discharge had the lowest opioid refill prescription rate (under: 29.6%, ideal: 7.3%, over: 19.7%, P < 0.0001). ConclusionsFor trauma patients requiring inpatient opioid therapy, a pragmatic and individualized intervention was associated with a reduced quantity of discharge opioids without negative outcomes. Reduction in inpatient opioid use was also associated with standardizing prescribing practices of surgeons with electronic medical record order sets.

The Effect of Implementation of Guideline Order Bundles Into a General Admission Order Set on Clinical Practice Guideline Adoption: Quasi-Experimental Study

Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs' impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations. We aimed to determine how integrating disease-specific order groups into a common general admission order set influences adoption of CPG-specific order bundles for patients meeting CPG inclusion criteria admitted to the general pediatrics service. We integrated order bundles for asthma, heavy menstrual bleeding, musculoskeletal infection, migraine, and pneumonia into a common general pediatrics order set. We compared pre- and postimplementation order bundle use rates for eligible encounters at both an intervention and nonintervention site for integrated CPGs. We also assessed order bundle adoption for nonintegrated CPGs, including bronchiolitis, acute gastroenteritis, and croup. In a post hoc analysis of encounters without order bundle use, we compared the pre- and postintervention frequency of diagnostic uncertainty at the time of admission. CPG order bundle use rates for incorporated CPGs increased by +9.8% (from 629/856, 73.5% to 405/486, 83.3%) at the intervention site and by +5.1% (896/1351, 66.3% to 509/713, 71.4%) at the nonintervention site. Order bundle adoption for nonintegrated CPGs decreased from 84% (536/638) to 68.5% (148/216), driven primarily by decreases in bronchiolitis order bundle adoption in the setting of the COVID-19 pandemic. Diagnostic uncertainty was more common in admissions without CPG order bundle use after implementation (28/227, 12.3% vs 19/81, 23.4%). The integration of CPG-specific order bundles into a general admission order set improved overall CPG adoption. However, integrating only some CPGs may reduce adoption of order bundles for excluded CPGs. Diagnostic uncertainty at the time of admission is likely an underrecognized barrier to guideline adherence that is not addressed by an integrated admission order set.

A64 THE UPTAKE AND IMPACT OF AN ELECTRONIC CIRRHOSIS ADMISSION ORDER SET: AN EARLY EXPERIENCE AT A SINGLE CENTRE

Abstract Background Cirrhosis is a chronic disease that confers high morbidity and mortality. It is a leading cause for hospital admissions and leads to significant healthcare resource utilization. Several guidelines outline recommendations to provide best practice to hospitalized patients with cirrhosis. Despite studies supporting a reduction in mortality when guideline based care is followed, this is achieved in less than 50% of hospitalized patients with cirrhosis1. Standardized electronic order sets can be a potential tool to improving clinical outcomes and bridging this gap in care. Purpose Since March 2021, an electronic cirrhosis admission order set has been available for at our hospital site. Using administrative data, we aimed to describe our early experience with: a) order set uptake by various services, b) characteristics of the population in which the order set was used versus not used, and explore c) the impact of order set use on in-hospital mortality. Method In this single centre cohort study, patients with cirrhosis were identified based an administrative data algorithm containing codes for cirrhosis and complications. This data was used to retrieve parameters such as patient age, sex, primary admitting service, resource intensity weight (RIW), Charlson comorbidity index (CCI) and in-hospital mortality. The chi-squared test and independent samples t-test were used to compare characteristics of patients in whom the order set was used versus not used. Multivariable logistic regression was used to determine the impact of order set use on in-hospital mortality. P value significance was established at &amp;lt;0.05. Result(s) A total of 825 patients were included in the analysis. The overall mean age (standard deviation) of patients was 58.5 (14.2) years with 57.5% being male. Average length of stay was 11.3 days with a mean CCI of 3.2 (2.3) and RIW of 3.3 (7.2). The primary admitting service was Gastroenterology in 36.1%, Internal Medicine in 35.6% and other services in 28.3% of cases. Of those admitted, the order set was used in 27.2% of cases. The overall in-hospital mortality of patients was 14.2%. Mean age, sex and CCI were not significantly different in patients admitted with the order set versus without. In patients admitted with the order set compared to without, RIW was significantly lower (2.06 (2.62) versus 3.80 (8.2), p&amp;lt;0.001), as was length of stay (9.5 (11.8) days compared to 12.0 (18.6) days, p =0.03) and in-hospital mortality (8.5% versus 16.3%, p =0.003). On multivariable regression analysis (Table 1), after adjustment for age, RIW and CCI, use of the order set was associated with lower in-hospital mortality (odds ratio 0.53 (95% CI 0.3 to 0.9), p=0.02). Image Conclusion(s) Uptake of the electronic cirrhosis admission order set was modest at only 27% of eligible admissions. Although it appears to be associated with lower in-hospital mortality, a chart review is in process to assess if this association still holds after accounting for the impact of additional confounders. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A Simple Admission Order-set Improves Adherence to Canadian Guidelines for Hospitalized Patients With Severe Ulcerative Colitis.

Individuals hospitalized with severe ulcerative colitis represent a complex group of patients. Variation exists in the quality of care of admitted patients with inflammatory bowel disease. We hypothesized that implementation of a standardized admission order set could result in improved adherence to current best practice guidelines (Toronto Consensus Statements) for the management of this patient population. A retrospective cohort study of patients admitted with severe ulcerative colitis to a Montreal tertiary center was conducted. Two cohorts were defined based on pre- and post-implementation of a standardized order set. Adherence to 11 quality indicators was assessed before and after implementation of the intervention. These included: Clostridioides difficile and stool cultures testing, ordering an abdominal X-ray and CRP, organizing a flexible sigmoidoscopy, documenting latent tuberculosis, initiating thromboprophylaxis, use of intravenous steroids, prescribing infliximab if refractory to steroids, limiting narcotics, and surgical consultation if refractory to medical therapy. Adherence to 6 of the 11 quality indicators was improved in the post-intervention cohort. Significant increases were noted in adherence to C difficile testing (75.5% versus 91.9%, P < 0.05), CRP testing (71.4% versus 94.6%, P < 0.01), testing for latent tuberculosis (38.1% versus 84.6%, P < 0.01), thromboprophylaxis (28.6% versus 94.6%, P < 0.01), adequate corticosteroids prescription (72.9% versus 94.6%, P < 0.01), and limitation of narcotics prescribed (68.8% versus 38.9%, P < 0.01). Implementation of a standardized order set, focused on pre-defined quality indicators for hospitalized patients with severe UC, was associated with meaningful improvements to most quality indicators defined by the Toronto Consensus Statements.

217: IDENTIFICATION OF MODIFIABLE CAUSES OF HYPOGLYCEMIA IN THE ICU

Introduction: Hypoglycemia is associated with increased mortality in the ICU. Studies have shown that modifiable causes of hypoglycemia may include anti-hyperglycemic medication, reduced caloric intake & change in nutrition without insulin adjustment. The primary objective of the study was to identify modifiable risk factors for hypoglycemia in our ICUs in order to decrease its incidence. Methods: This was a retrospective review from July to September 2020 of adult ICU patients at a tertiary medical center with a hypoglycemic event (glucose < 80mg/dL) given intravenous rescue dextrose. Medical, surgical, cardiac & neuro ICU patients were included. Exclusion criteria were COVID-19, comfort measures & hyperkalemia. Descriptive statistics were used for statistical analysis. Results: A total of 56 out of 784 patients (median age 64; 60.7% male) had 180 discrete hypoglycemic events. Common risk factors were nothing by mouth orders (NPO) at the time of the event (69.2%), a timeframe of 1900 to 0700 (64.2%), active insulin orders (48.3%), being within 24 hours of a procedure (42.8%) or 24 hours of admission (33.9%), or having AKI (42.8%), diabetes (39.3%) or sepsis (41.1%). Of the 48.3% of patients on insulin, 40% were on an insulin infusion, 39% sliding scale & 21% long-acting. As compared to weekdays, hypoglycemia occurred 37.5%, 87.5%, and 137.5% more often on weekend days, weeknights, and weekend nights, respectively. Conclusions: The most common iatrogenic risk factors for hypoglycemia in the ICU identified in this review were the initial 24 hours of ICU admission, active insulin orders and both periprocedural and NPO status. Hypoglycemia was more common overnight but this is also when daily BMPs are collected. Interventions such as dextrose-containing maintenance fluids while NPO, removal of periprocedural NPO at midnight orders, the addition of fingerstick checks to ICU admission order sets and when a patient is NPO, and cautious insulin use are warranted to help mitigate these events. This pharmacy resident project led to a multidisciplinary policy change to hold tube feeds for patients with an ET tube or trach immediately before they travel to a procedural area instead of at midnight, or 6 hours prior to procedures with planned airway interruption or NPO status needed for bowel cases.

1076: QUALITY IMPROVEMENT INITIATIVE TO PREVENT FLUID OVERLOAD IN PEDIATRIC INTENSIVE CARE UNIT PATIENTS

Introduction: Fluid administration for critically ill children frequently exceeds hydration requirements and is associated with increased morbidity and mortality. The global aim of this ongoing single-center quality improvement (QI) initiative is to standardize and implement process improvement tools to detect and prevent fluid overload (FO) in patients admitted to the Pediatric Intensive Care Unit (PICU). Our SMART aim is to reduce the incidence of percent fluid overload (%FO) >/= 10% at 72 hours of PICU admission by 20% in the first 6 months. Methods: In collaboration with key stakeholders, we used Plan-Do-Study Act (PDSA) QI methodology to develop electronic health record (EHR)-based tools and education sessions to help providers detect and prevent FO in PICU patients. We conducted a retrospective chart review with a convenience sample to obtain baseline metrics. We assessed current FO understanding and perceptions of proposed interventions with anonymous surveys distributed to PICU attendings, fellows, residents, advanced practice providers and nurses. In April 2022, we implemented a single screen “Fluid Management accordion” within our EHR that displays all clinical markers used to evaluate a patient’s fluid status, and an EHR-based %FO calculator. In July 2022, we added PICU admission order set modifications to include a total fluid goal. Outcome metrics are collected monthly. Quarterly follow up surveys began in July 2022 and will trend intervention impact and perceptions. Results: Chart review (n=562) revealed a 40% baseline incidence of %FO >/= 10% at 72 hours of PICU admission. Pre-implementation, most respondents (n=115) agreed that we could improve our awareness to patients’ fluid status (92%) and that using standardized EHR orders and tools would be helpful (76%). Few (27%) reported knowing how to calculate %FO. Three months after initial EHR tool launch, many survey respondents (n=49) reported using the fluid management accordion at least once (40%) and 43% reported knowing how to calculate %FO. Six-month implementation data will be available in October 2022. Conclusions: To date we have standardized EHR-based tools for FO detection. We suspect that with continued education and feedback we will likely see a reduction in %FO incidence in our PICU population.

Mandatory Caprini Score Documentation and Incidence of Hospital VTE

ASH Abstract Submission: Background: Hospital acquired VTE continues to be a source of morbidity and mortality for patients. The Caprini risk score is a risk assessment tool for the occurrence of venous thromboembolism. Though initially developed for use among surgical patients, it is now being applied to many hospitalized patients. It involves 20 variables and it is derived from a prospective study of general surgery patients published in 1991. After adding Caprini score documentation to internal medicine admission order sets and general surgery pre-procedural order sets, the 90 day incidence of hospital acquired VTE went from 67 to 0. Prior to the change, documentation of Caprini score was poor and ordered VTE prophylaxis did not align with the documented Caprini score, ultimately effecting compliance to prophylaxis and affecting patient safety. Methods: In order to decrease the rate of VTE throughout the Orlando Health hospital system, changes were made to the electronic medical record (EMR) to better improve selection of proper VTE prophylaxis. Because VTE prophylaxis was frequently not ordered appropriately, the ability to personalize order sets for VTE was removed 5/3/2022. We implemented a mandatory order set requiring documentation of Caprini score in two admission order sets. Subsequent VTE prophylaxis was ordered depending on the calculated score. The EMR changes were implemented 6/8/2022 as a pilot program within both internal medicine admission order sets and general surgery pre-procedure admission order sets. Incidence of hospital acquired VTE as well as re-admission rates were monitored over the subsequent period. Results: In the period immediately prior to implementation of this program, there were 67 hospital acquired DVT/PE events. After the pilot program went live 6/8/22, there were 0 preventable hospital acquired VTE for the subsequent period. VTE prophylaxis was ordered within 24hrs of admission 81% of the time. During the whole study phase there were 95 total readmissions due to DVT/PE, 35 from DVT, 29 from PE, and 25 from DVT/PE. Of these, only 3 occurred after implementation of pilot program. Conclusions: Addition of Caprini score documentation to internal medicine admission order set and pre-procedural general surgery order set prevented hospital acquired VTE across the hospital system over a 30 day period, and dramatically decreased readmission rate due to VTE/PE. These results have a direct effect on patient safety and quality of patient care.

Use of a Cirrhosis Admission Order Set Improves Adherence to Quality Metrics and May Decrease Hospital Length of Stay.

Quality metrics for inpatient cirrhosis management have been created to improve processes of care. We aimed to improve adherence to quality metrics by creating a novel clinical decision support (CDS) tool in the electronic health record (EHR). We developed and piloted an alert system in the EHR that directs providers to a cirrhosis order set for patients who have a known diagnosis of cirrhosis or are likely to have cirrhosis. Adherence to process measures and outcomes when the CDS was used were compared with baseline performance before the implementation of the CDS. The use of the order set resulted in a significant increase in adherence to process measures such as diagnostic paracentesis (29.6%-51.1%), low-sodium diet (34.3%-77.8%), and social work involvement (36.6%-88.9%) ( P < 0.001 for all). There were also significant decreases in both intensive care and hospital lengths of stay ( P < 0.001) as well as in-hospital development of infection ( P = 0.002). There was no difference in hospital readmissions at 30 or 90 days between the groups ( P = 0.897, P = 0.640). The use of CDS in EHR-based interventions improves adherence to quality metrics for patients with cirrhosis and could easily be shared by institutions through EHR platforms. Further studies and larger sample sizes are needed to better understand its impact on additional outcome measures.