Best Practice Alert Research Articles

Best practice alert and cost transparency information for high cost oncology medications.

323 Background: Oncology medication cost is often absent from therapy decision process until issues arise with payer denial resulting in potential patient financial toxicity. To incorporate cost, Best Practice Alert (BPA) and Cost Transparency Information (CTI) for high cost oncology medication (HCOM) were implemented into prescribing platform as care coordination tools. Methods: Ten HCOM were identified in gastrointestinal (GI) and breast oncology groups for which BPA and CTI were developed. Over a 6 month period, HCOM prescriptions triggered BPAs to alert providers and to place automated referrals to social work (SW). CTI – with drug costs and comparable treatment plan(s) – were posted in prescribing platform. Descriptive analyses examined differences in total payment to hospital and patients out-of-pocket payments (OPP) between treatment plans. Pre- and post-intervention surveys evaluated oncologists’ perception and behavior toward treatment cost. Results: The analysis included 162 patients and 1406 medication claims. In the GI group, BPAs effectively identified treatments incurring higher mean total payment (diff = 46733, p < 0.001) and higher mean OPP (diff = 115, p < 0.001). For the breast group, the impact was mixed. BPAs identified treatments with higher total payment at the 90% quantile (p < 0.001) and higher mean total payment (diff = 72612, p < 0.001), but there was no statistically significant difference in OPP between treatments. Pre-intervention survey (n = 26, 50% response rate) indicated 46% of oncologists rarely discuss medication cost with patients and 35% rarely refer patients to SW. Only 4% of oncologists strongly agreed that they could easily acquire cost information. Post-intervention survey highlighted that CTI improved oncologists’ awareness of medication costs, but BPA exerted no substantial influence on provider behaviors. Conclusions: BPA intervention effectively highlighted treatment cost and accurately identified patients at risk for financial toxicity. The lack of statistically significant difference in oncologists’ behavior and perception may be due to a small sample size. Comments from providers suggest that BPA combined with OPP would be more useful in reducing financial toxicity.

Effectiveness of a Best Practice Alerts at Improving Hypertension Control.

Inadequately treated hypertension (HTN) leads to considerable morbidity and mortality. Despite many treatment options, blood pressure (BP) control is suboptimal. Missed opportunities due to the growing complexity of primary care office visits contribute. Electronic health records (EHRs) offer best practice alerts (BPA) tools to support clinicians in identifying poor BP control. BPAs have demonstrated effectiveness for other health outcomes. EHR data were collected for patients ≥18 years old seen for primary care office visits prior to, during, and after the BPA active period and used to identify patients for whom the BPA fired or would have fired during control periods. Logistic regression examined the association of BPA activation with follow-up BP check within 14-90 days and with BP control at follow-up, controlling for demographics and health conditions. The BPA active period was associated with reduced patient follow-up; however, a number of covariates were predictive of increased follow-up: Black non-Hispanics, Hispanics, patients on the chronic kidney disease, HTN, or diabetes registries, as well as the morbidly obese, insurance status, and seasonal factors. For those who did follow-up, BPA activation was associated with improved BP control. BPA activation was associated with worse patient follow-up but improved BP control. Some subgroups had significantly different rates of follow-up and BP control. This study did not have an experimental design as the BPA was a quality improvement initiative. These results highlight the critical importance of planning experimentally designed organizational initiatives to fully understand their impact.

Harnessing the electronic health record to optimize oral anticancer therapy monitoring and follow-up.

305 Background: UCHealth pursued and became certified as a Quality Oncology Program from the Quality Oncology Practice Initiative (QOPI) through the American Society of Clinical Oncology (ASCO) in 2015. During our gap analysis to prepare for certification, we identified a deficit in our education, monitoring, and follow up relating to oral anti-cancer therapies. Although we used QOPI as a benchmark, we sought to improve patient care and safety in the realm of oral anti-cancer therapies. Methods: UCHealth has implemented policies surrounding oral chemotherapy to include patient education, consent, use of the EHR for ordering, and patient monitoring of adherence and toxicity through development of a flowsheet. This includes the use of Best Practice Alerts (BPA) to trigger staff to evaluate adherence and compliance, smart texts to pull data into progress notes, silent BPAs to remind staff to call patients within 10 days of starting oral chemotherapy, and weekly reporting of staff compliance with assessing patient adherence. Results: EHR changes were implemented in May, 2015 with reporting of staff compliance beginning in September. At that time, UCHealth was only monitoring adherence and toxicity in 24% of patients on an oral anti-cancer therapy. Through continued quality improvement projects, staff education, and optimization of clinical decision support tools, UCHealth consistently monitors adherence and toxicity in over 85% of patients on an oral anti-cancer therapy. Results have been monitored for over two years with continued improvements seen. Conclusions: Using the reporting data, we are able to identify quality improvement projects to include discrete data such as individual staff member compliance. Continuous refinements of the BPA and report have occurred as a result of discrete data analysis by a multi-disciplinary committee.

Effect of a Computerized Alert on Emergency Department Hepatitis A Vaccination in Homeless Patients During a Large Regional Outbreak

BackgroundWhile the overall incidence of hepatitis A has declined markedly since the introduction of a vaccine, sporadic cases and outbreaks of the disease continue to occur. ObjectiveOur aim was to evaluate the effectiveness of an electronic health record (EHR) provider alert as part of an outbreak-control vaccination program implemented in the emergency department (ED). MethodsWe conducted a retrospective study assessing the impact of a Best Practice Alert (BPA) built into an EHR to prompt providers when a patient was homeless to consider hepatitis A vaccination in the ED. Data were collected over three 6-month time periods: a historical control period, a pre-intervention period, and an intervention period. ResultsThere were no vaccinations given in the ED in the historical period, which increased to 465 after the implementation of the BPA. During the implementation period, there were 1,482 visits identified among 1,131 patients that met the inclusion criteria. Of these, there were 1,147 (77.5%) visits where the patient either received the vaccine in the ED, had already received the vaccine, or it was not indicated due to the current medical issue. There were also 333 (22.5%) visits where the BPA was active for potential vaccination eligibility, but did not receive it in the ED. ConclusionsWe leveraged an informatics tool developed within our EHR to identify high-risk patients and remind providers of the availability of vaccination in the ED. Using these tools enabled providers to increase vaccination efforts within our ED to help control the community-wide outbreak.

Implementation of a Collaborative HIV and Hepatitis C Screening Program in Appalachian Urgent Care Settings.

IntroductionWith the current hepatitis C (HCV) epidemic in the Appalachian region and the risk of human immunodeficiency virus (HIV) co-infection, there is a need for increased secondary prevention efforts. The purpose of this study was to implement routine HIV and HCV screenings in the urgent care setting through the use of an electronic medical record (EMR) to increase a provider’s likelihood of testing eligible patients.MethodsFrom June 2017 through May 2018, EMR-based HIV and HCV screenings were implemented in three emergency department-affiliated urgent care settings: a local urgent care walk-in clinic; a university-based student health services center; and an urgent care setting located within a multi-specialty clinic. EMR best practice alerts (BPA) were developed based on Centers for Disease Control and Prevention (CDC) guidelines and populated on registered patients who qualified to receive HIV and/or HCV testing. Patients were excluded from the study if they chose to opt out from testing or the provider deemed it clinically inappropriate. Upon notification of a positive HIV and/or HCV test result through the EMR, patient navigators (PNs) were responsible for linking patients to their first medical appointment.ResultsFrom June 2017 through May 2018, 48,531 patients presented to the three urgent care clinics. Out of 27,230 eligible patients, 1,972 patients (7.2%) agreed to be screened for HIV; for HCV, out of 6,509 eligible patients, 1,895 (29.1%) agreed to be screened. Thirty-one patients (1.6%) screened antibody-positive for HCV, with three being ribonucleic acid confirmed positives. No patients in either setting were confirmed positive for HIV; however, two initially screened HIV-positive. PNs were able to link 17 HCV antibody-positive patients (55%) to their first appointment, with the remainder having a scheduled future appointment.ConclusionIntroducing an EMR-based screening program is an effective method to identify and screen eligible patients for HIV and HCV in Appalachian urgent care settings where universal screenings are not routinely implemented.

P3.11-08 Lung Cancer Screening at an Academic Medical Center: Early Patterns of Practice

Lung cancer screening with low dose computed tomography (LDCT) is associated with a reduction in lung cancer mortality. The Center for Medicare and Medicaid Services (CMS) offers coverage for LDCT, indicated for lung cancer screening, if patients are between ages 55 and 77, are a current smoker or former smoker who has quit smoking in the past 15 years, have a greater than 30 pack year smoking history, and shows no signs or symptoms of lung cancer (hemoptysis and/or weightless). Rush University Medical Center has a Best Practice Alert (BPA) in Epic to notify physicians of patients who meet criteria to receive LDCT scans for lung cancer screening. The BPA fires based on patient’s age and documented pack year smoking history. Successful utilization of the BPA relies heavily on accurate smoking documentation. As part of an ongoing project characterizing the population who ultimately undergoes screening, it became evident that a significant number of patients whom may be eligible for screening are missed due to incomplete smoking documentation. These initial findings highlight the need to develop an improved, accurate, and more convenient system to document smoking history. A retrospective chart review was performed, utilizing electronic medical records, for data from October 2015-October 2017. Data was collected on age, gender, and smoking status. Based on this timeframe, data for 50,421 patients from Rush University Medical Center (RUMC) and Rush Oak Park Hospital (ROPH) was analyzed. Age was restricted to 55-77 years to match CMS re-imbursement criteria. Of the 50,421 patient charts analyzed, 2,720 (5%) met eligibility criteria for lung cancer screening based on their documented smoking history. The majority of patients, 38,197 (76%), had incomplete smoking history documentation. Out of the patients with incomplete smoking history documentation, many charts were missing documentation of smoking history in pack year, and/or the number of years it has been since the patient quit smoking. Data identifies a key weakness in electronic health record documentation of smoking history at RUMC and ROPH. Since the BPA for lung cancer screening only triggers with a documented smoking history of greater than 30 pack years, patients who may be eligible for lung cancer screening are not being identified. By advocating for more thorough documentation of patient smoking history, we can optimize use of the BPA and provide patients with better health management.

P3.11-06 Improving Lung Cancer Screening Completion Rates in a Primary Care Practice in Large Urban Academic Medical Center

Despite implementation of a physician-facing electronic health record (EHR) best practice alert (BPA) with robust medical decision making and documentation, only 7.3% of eligible patients (85 of 1170) throughout the institution completed a low-dose CT (LDCT) for lung cancer screening in 6 months (May 1st to November 1, 2017). The objective is to improve lung cancer screening by: 1. Describing primary care referral patterns and status among eligible patients 2. Identifying system, patient and provider-level barriers to referral and completion 3. Developing and testing targeted interventions Success will be measured by reducing number of eligible patients overdue for screening by 50% in the next 6 months. An Epic EHR report identified patients with an overdue lung cancer screening BPA within one practice representing approximately 40% of primary care (16,000 visits in 6 months). Through chart review, we quantified number of patients at different points of the referral pathway. New interventions were developed for the most common categories of patients overdue for screening: Those with orders that had not scheduled the exam and those with no order and no documentation of why in the EHR. Lung Cancer Screening Coordinators contacted patients with current orders and began scheduling LDCT exams. (Intervention 1). Division leadership, medical directors, primary care providers (PCP), and the practice nurse manager were engaged to design an intervention to address patients with no LDCT order (Intervention 2) The total number of LDCTs performed in the first 12 weeks after starting the intervention was almost equal to the performed in the 6 month baseline period. (12 vs 14). The percentage of patients overdue with orders increased from 28% to 37.5%. Only 7 of the original 18 with orders not scheduled remained in that category at 12 weeks. The percentage of patients overdue with no order and no documentation decreased from 65.9% of to 51.3%. Fifteen of 41 with no order and no reason documented (36.5%) were newly identified at 12 weeks, i.e. not identified by the baseline query. The most significant limitation to measuring 12-week outcomes is that patients have not yet completed their scheduled PCP appointments and LDCT appointments. Multiple challenges were identified at system, patient and provider levels: *The BPA lacks specificity. *This patient subpopulation has a high prevalence of comorbidities and chronic conditions. *PCPs expressed skepticism regarding evidence for lung cancer screening, perceived lack of benefit for some patients and competing demands.

365 The Effect of an Electronic Decision Support Tool on Emergency Department Prescribing of Naloxone

The prescription of naloxone or “take-home naloxone” has been advised for patients who are at risk for opioid overdose. The provision of naloxone from the ED for these patients is a relatively new operational implementation. The purpose of this study was to evaluate the effect of an electronic health record (EHR) best practice alert (BPA) on the prescription of naloxone from the ED. This was a cross-sectional study performed at a tertiary care health system’s 2 EDs (1 urban and 1 suburban). Included were patients 18 years of age and older who were considered high-risk for opioid overdose based on: 1) the listing of methadone or fentanyl formulations in the EHR medication list, and 2) a documented diagnosis of “substance abuse” or the ICD10 equivalent diagnosis in the EHR and 3) prescription of an opioid at ED discharge. Methadone and fentanyl derivatives were chosen because they are considered high-risk opioids as identified by the Joint Commission Sentinel Event Alert on opioids. A BPA fired in the EHR for those patients who met these high-risk criteria. The BPA informed the ED provider of the patient’s high-risk status for opioid overdose and asked the ED provider if a discharge prescription for naloxone should be issued. The provider could choose to prescribe naloxone via the BPA or disregard the prompt. Data on naloxone prescribing rates at ED discharge were collected from 5/1/2016 after the BPA was implemented through 10/31/2017. There were no prescriptions given at discharge for naloxone from the ED during the 18 months prior to the implementation of the BPA. During the 18 months after the BPA was implemented, there were 596 ED discharges for which the BPA was triggered. Among these, 22 (3.7%) received a prescription at discharge for naloxone. An additional 73 patients received a prescription without receiving a BPA. The majority of patients were male (55.3%) and were between 35-64 years of age (69.2%). Visits with a naloxone discharge prescription were more likely to have a higher acuity ESI score of 1 or 2 compared to those without a prescription (15.4% versus 5.8%, p<0.001). Visits where a naloxone prescription were more likely to be given compared to visits where it was not given were those with an ESI score of 1 or 2 (15.4% versus 5.8%, p<0.001). Among visits with and without a naloxone prescription, there were no differences among sex, age group or patients with multiple visits (p’s>0.05). Implementation of a BPA in the EHR used to identify patients considered high-risk of opioid overdose resulted in a small increase in the rate of naloxone prescriptions issued for this population and a higher increase in prescribing among those not considered high-risk for overdose. Reasons for higher rates of naloxone prescribing among those patients for whom the BPA did not activate in the EHR may be attributed to general increased provider awareness of the availability of the antidote. Overall, more focus is needed to facilitate prescribing of naloxone from the ED among high-risk patients.

Malnutrition Documentation: Accuracy and Areas for Improvement

Upon completion, participants will be able to demonstrate understanding behind the importance of accurately accepting and documenting best practice alerts (BPA).

Implementation of Best Practice Alert in an Electronic Medical Record to Limit Lower-Value Inpatient Echocardiograms

There are increasing efforts nationally and at our institution to reduce lower-value care, including some use of imaging studies such as transthoracic echocardiography (TTE). In an effort to avoid repeating unnecessary studies on inpatients who recently underwent TTE, we implemented a best practice alert (BPA) in our electronic health record to notify ordering clinicians that a TTE had been performed in the past 6 months. The BPA requires the ordering clinician to acknowledge the alert and provide a reason for proceeding with the order and provides a link to ASE AUC criteria. Data on initial use were reviewed after approximately 6 months (February 16, 2017 to September 12, 2017.) This included review of the number of TTE orders removed, number reordered within the same day, subspecialty of ordering clinician, type of ordering clinician (MD vs NP, and so on), and length of stay in patients with orders that were confirmed versus removed. Independent t tests, Chi-square, and Fisher's exact tests were used for analysis. Over 209 days, the BPA triggered 3,226 times with 20% of these TTEs cancelled by the ordering clinician and remaining cancelled after 24 hours. There were no statistically significant differences in the proportion of removed TTE orders between subspecialties or types of clinician (p = 0.144.) There was no statistically significant difference in the length of stay in patients with orders kept (9.2 days) compared with orders cancelled (10.5 days). An electronic health record alert triggered by an order for an inpatient TTE within 6 months of a previous study effectively reduced study volume by 20%.

Using Clinical Decision Support Within the Electronic Health Record to Reduce Incorrect Prescribing for Acute Sinusitis.

Acute sinusitis has viral etiology in more than 90% of cases, but antibiotics are prescribed for more than 80% of adults in the United States. While applications of computer-assisted guidelines have been found effective in reducing inaccurate prescribing for acute respiratory infections, there is a paucity of research focused specifically on the utilization of electronic best practice alerts (BPA) in improving treatment for acute sinusitis. This observational cohort study examined prescribing behavior for sinusitis at a single Federally Qualified Health Center 1 year prior and during the first year of implementation of a BPA in the electronic health record (EHR) reminding providers of the recommended treatment of sinusitis. The advisory included a link to national guidelines and a note template was installed to assist providers in documentation. The BPA appeared on the providers' screen when an ICD-9 code of acute or bacterial sinusitis was entered during the patient visit. After adjusting for select patient and provider factors, the computer-assisted guidelines effectively reduced the overall antibiotic prescribing among these patients by 31% (relative risk: 0.69, 95% confidence interval: 0.51-0.95) and reduced incorrect prescribing from 88.5% to 78.7% (P=0.02). Clinical reminders within the EHR can be an effective tool to reduce inappropriate antibiotic use and improve providers' decisions regarding the correct antibiotic choices for patients with acute sinusitis.

Evaluating the efficacy of best practice alerts to improve Clostridium difficile early detection in hospital settings: A 6-month interim analysis of the 2-year prospective study.

Introduction:Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness with high burden on the health-care system.Design:Observational, retrospective, prospective, pre- and post-intervention study on the incidence and prevalence rates of CDIs. The primary outcome is the healthcare-onset CDIs (HO-CDIs) incidence rate and proportion.Methods:Best practice alerts (BPAs) for CDI were developed in electronic medical records and released on July 13, 2016. When high-risk patients for CDI are identified, BPAs are triggered requiring nurses to order contact isolation and stool studies followed by other subsequent BPAs encouraging providers to de-escalate antibiotics and order probiotics. Data on admission count, patient-days, CDIs categories prevalence, and incidence rates were collected for the 24-month preintervention and will be collected for the 24-month postintervention period.Results:An interim analysis comparing the data from the first 6-month postintervention period with the average 6-month data of the preintervention period showed that short-term BPAs use is associated with significant increase in the overall CDI infection rate (71.47 vs. 38.38, P < 0.0001), incidence rate (53.81 vs. 28.76, P < 0.0001), overall prevalence rate (1.86 vs. 1.32, P = 0.001), and admission prevalence rate (1.10 vs. 0.70, P < 0.0001). Despite the observed overall shift from HO toward CO; no statistically significant difference in the HO-CDI event number and proportion was detected (28 [21.4%] vs. 22 [29.1%], P = 0.094).Conclusion:Short-term BPAs use is associated with significant increase in the overall CDI incidence and prevalence along with a non-statistically significant decline in HO-CDI proportion. Final analysis with full sample size is essential to provide a better picture about the long-term effect.

Hepatitis C Screening in Commercially Insured U.S. Birth-cohort Patients: Factors Associated with Testing and Effect of an EMR-based Screening Alert.

Background and ObjectivesHepatitis C virus (HCV) testing rates among U.S. birth-cohort patients have been studied extensively, limited data exists to differentiate birth-cohort screening from risk- or liver disease-based testing. This study aims to identify factors associated with HCV antibody (HCV-Ab) testing in a group of insured birth cohort patients, to determine true birth cohort testing rates, and to determine whether an electronic medical record (EMR)-driven Best Practice Alert (BPA) would improve birth cohort testing rates.MethodsAll birth-cohort outpatients between 2010 and 2015 were identified. HCV-Ab test results, clinical, and demographic variables were extracted from the EMR, and factors associated with testing were analyzed by logistic regression. True birth-cohort HCV screening rates were determined by detailed chart review for all outpatient visits during one calendar month. An automated Best Practice Alert was used to identify unscreened patients at the point of care, and to prompt HCV testing. Screening rates before and after system-wide implementation of the BPA were compared.ResultsThe historic HCV-Ab testing rate was 11.2% (11,976/106,753). Younger age, female gender, and African American, Asian, or Hispanic ethnicity, and medical comorbidities such as chronic hemodialysis, HIV infection, and rheumatologic and psychiatric comorbidities were associated with higher testing rates. However, during the one-month sampling period, true age cohort-based testing was performed in only 69/10,089 patients (0.68%). Following the system-wide implementation of the HCV BPA, testing rates increased from 0.68% to 10.76% (P<0.0001).ConclusionsWe documented low HCV-Ab testing rates in our baby boomers population. HCV testing was typically performed in the presence of known risk factors or established liver disease. The implementation of an EMR-based HCV BPA resulted in a marked increase in testing rates. Our study highlights current HCV screening gaps, and the utility of the EMR to improve screening rates and population health.

Facilitation or Hindrance: Physicians’ Perception on Best Practice Alerts (BPA) Usage in an Electronic Health Record System

ABSTRACTA qualitative study was conducted to examine physicians’ perception on best practice alerts (BPAs) usage under the theoretical framework of technology acceptance model (TAM). In particular, 20 face-to-face in-depth interviews were conducted from September 2016 to February 2017 to collect data. Four themes emerged from the current set of data: support, de-escalation, management, and enhancement are physicians’ perceived motivations of using BPAs; interactivity, timing, and interface design are key factors that influence physicians’ perceived experiences of using BPAs; alert fatigue and inaccurate alters are major challenges and issues faced by physicians when using BPAs; and, control and team approach are physicians’ perceptions on the future improvement of BPAs. This study not only offers a detailed description of physicians’ perception of BPAs, revealing the rich meanings associated with this phenomenon, but also enriches our understanding of the TAM in the context of BPAs by uncovering the key dimensions of abstract constructs in the model.

Failure of a Best Practice Alert to Reduce Antibiotic Prescribing Rates for Acute Sinusitis Across an Integrated Health System in the Midwest.

Antimicrobial resistance is a growing concern, and in recent years, there has been increased interest in ambulatory antimicrobial stewardship. Acute rhinosinusitis (ARS) is one of the most common outpatient diagnoses that results in an antibiotic prescription. To determine if a best practice alert (BPA) will affect the percentage of oral antibiotic prescriptions for adults with ARS. A prospective, pre/post study was initiated to evaluate the percentage of oral antibiotic prescriptions for ARS in 117 primary care clinics in the Midwest. Included in the study results were 16,570 adults who had an office visit for ARS: 8,106 patients from December 1, 2015, to February 28, 2016, were in the pre-intervention group without an active BPA, and 8,464 patients from December 1, 2016, to February 28, 2017, were in the post-intervention group when the BPA was active. The primary outcome was the number of oral antibiotic prescriptions for ARS compared with the number of office visits for ARS in the pre- and postintervention groups. The percentage of oral antibiotics prescribed for the pre- and postintervention groups were 94.8% and 94.3%, respectively (P = 0.152). The BPA displayed for 7,780 visits, prompting discontinuation of an antibiotic for 10 (0.1%) visits in the postintervention group. This study suggests that, although an electronic alert may be attractive to facilitate antimicrobial stewardship, it may be ineffective. These results warrant alternative measures to facilitate ambulatory antimicrobial stewardship. No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Hansen, D. Leedahl, and N. Leedahl. Hansen and N. Leedahl took the lead in data collection, with assistance from Carson and D. Leedahl. Data interpretation was performed by all the authors. The manuscript was written by Hansen, along with the other authors, and revised by all the authors.

Improving Rates of Screening for Anemia in Infancy.

In 2010, the American Academy of Pediatrics recommended universal screening for anemia at approximately 1 year of age. This quality improvement study sought to improve anemia screening in an ambulatory setting. In a large university-based setting, a best practice alert (BPA) was placed within the electronic health record. The primary outcome was overall screening rate in ambulatory family medicine (DFM) and pediatrics (PEDS) clinics. From 2545 pre-BPA clinic visits over a 12-month period, the screening rate was 48.2%. Among 2186 post-BPA clinic visits over an 8-month period, the screening rate improved to 72.7%, P < .0001. Follow-up over a second 7-month period demonstrated sustained improvements (70.8%) but was not higher after educational sessions between the periods. Screening rates were higher in PEDS than DFM at each time point; P < .0001. This technology-based intervention increased and maintained higher screening rates for anemia at 1 year, with higher rates in PEDS.

Treatment Bundle Improves Outcomes in the Management of Candidemia at Large Urban Academic Medical Center

Background A candidemia treatment bundle (CTB) may increase adherence to guideline recommended candidemia management and improve patient outcomes. The purpose of this study was to evaluate the impact of a best practice alert (BPA) and order-set on optimizing compliance with all CTB components and patient outcomes.Methods A single center, pre-/post-intervention study was completed at Grady Health System from August 2015 to August 2017. Post-CTB intervention began August 2016. The CTB included a BPA that fires for blood cultures positive for any Candida species to treatment clinicians upon opening the patient’s electronic health record. The BPA included a linked order-set based on treatment recommendations including: infectious diseases (ID) and ophthalmology consultation, repeat blood cultures, empiric echinocandin therapy, early source control, antifungal de-escalation, intravenous to oral (IV to PO) switch, and duration of therapy. The primary outcome of the study was total adherence to the CTB. The secondary outcomes include adherence with the individual components of the CTB, 30-day mortality, and infection-related length of stay (LOS).ResultsForty-five patients in the pre-group and 24 patients in the CTB group with candidemia were identified. Twenty-seven patients in the pre-group and 19 patients in the CTB group met inclusion criteria. Total adherence with the CTB occurred in one patient in the pre-group and threepatients in the CTB group (4% vs. 16%, P = 0.29). ID was consulted in 15 patients in the pre-group and 17 patients in the CTB group (56% vs. 89%, P = 0.02). Source control occurred in three and 11 patients, respectively (11% vs. 58% P < 0.01). The bundle components of empiric echinocandin use (81% vs. 100%, P = 0.07), ophthalmology consultation (81% vs. 95%, P = 0.37), and IV to PO switch (22% vs. 32%, P = 0.5) also improved in the CTB group. Repeat cultures and antifungal de-escalation were similar among groups. Thirty-day mortality decreased in the CTB group by 10% (26% vs. 16%, P = 0.48). Median iLOS decreased from 30 days in the pre-group to 17 days in the CTB group (P = 0.05).Conclusion The CTB, with a BPA and linked order-set, improved guideline recommended management of candidemia specifically increasing the rates of ID consultation and early source control. There were quantitative improvements in mortality and iLOS.Disclosures All authors: No reported disclosures.

Decrease of Hospital-Onset Clostridium difficile through Enhanced Electronic Decision Support

BackgroundLiterature supports appropriate testing as a key factor affecting hospital onset (HO) Clostridium difficile (CDIF). It was recognized that our institution was a significant outlier in HO CDIF with a standardized infection ratio (SIR) of 2.567 in the second quarter of 2016 compared with a national SIR of 0.997. A February 2015 – April 2015 line list of CDIF LabID events were pulled from the National Healthcare Safety Network (NHSN) and medical records were reviewed for test appropriateness based on CDC/IDSA guidelines. Of these, 50% were related to inappropriate testing. Infection Prevention and Quality identified this as an opportunity for improvement and Executives dedicated resources to reduction efforts.MethodsA report was created using our data warehouse to track specimens that were not collected within 24 hours of an order, as well as patients that had testing done in the previous 7 days. Physician and nurse education was completed on appropriate testing for CDIF, including symptoms and timely specimen collection. An enhanced order set was launched which embedded the testing algorithm into a series of cascading questions and best practice alerts (BPAs) which prompt the provider to reconsider ordering if the patient has less than 3 episodes of diarrhea in a 24 hour period, and/or has alternative explanations for diarrhea, including tube feedings and/or laxatives. Any CDIF test results from the past 30 days appear on the order screen to further guide physician ordering.ResultsBased on our NHSN data, HO CDIF cases were identified from October 2015 – September 2016, resulting in a peak (SIR) of 2.567. Since the interventions in November 2016, we have decreased our SIR to 0.356 in the first quarter of 2017. This shows a 50% overall decrease in HO CDIF. The data warehouse report showed 99% compliance of specimens collected within 24 hours of an order and only 5% of patients with an order in the past 7 days.ConclusionBy implementing targeted education and a sophisticated order entry process that includes decision support, as well as recent results and treatments in the electronic medical record, CDIF cases are being appropriately ordered and collected, ensuring appropriate classification within NHSN and a decrease in overall SIRDisclosures All authors: No reported disclosures.

Partners eCare Research Core for Clinical Research: Pilot to Build and Test Silent Best Practice Alert Notifications for Recruiting Inpatient Study Participants

Background: Participant recruitment remains one of the greatest challenges for many research groups. For an observational prospective study of objective and subjective measures in outpatients with chronic obstructive pulmonary disease (COPD) to assess clinical deterioration (Emerald-COPD) at Partners Connected Health, recruiting COPD patients from the inpatient setting was inefficient and low-yielding. To screen for eligible participants, Research Coordinators spent over two hours per day manually searching through the EPIC Reporting Workbench from three hospitals and reviewing admission notes to determine whether patients met eligibility criteria. Objective: This pilot project, conducted in collaboration with Partners eCare Research Core (PeRC), examines a new EPIC functionality built to support inpatient recruitment for clinical trials. The silent Best Practice Alert (BPA) system identifies potentially eligible participants in real time to help research teams maximize recruitment accuracy and efficiency of resources. Methods: This out-of-the-box solution alerts study staff of the inpatient admission of potential participants through EPIC In-Basket messages. The silent BPA notifications detect an event of interest, in this case hospital admissions, using criteria pre-selected by Emerald-COPD research staff. Criteria included: patient class, admit diagnosis, prescribed medications, and presence of COPD on the EPIC problem list; these were used to flag potential participants at multiple Partners hospitals. We hypothesized that this tool would reduce the daily screening time, the number of missed potential participants as well as the time needed to recruit the targeted number of patients. Results: To date, there have been 171 potentially eligible patients identified through BPA notifications. Of those, we have enrolled 26 participants into the Emerald- COPD study. Since implementation, there have been an average of 3 additional patients each week that were missed during our previous method of screening. In addition to expanding the pool potential participants, this tool has decreased screening time for Research Coordinators. The silent BPA screening method has proven to be 4 times faster than our previous screening method, projected to save 442.5 hours over the duration of the study. Conclusions: Automation of the recruitment process has allowed us to identify potential participants in real time and avoid missing patients. This has made a substantial impact in raising our enrollment numbers. Silent BPA screening is a considerably faster method which allows for Research Coordinators to devote more time to other important aspects of research such as retention of enrolled participants. When time is allocated effectively, the study can run smoothly and be more cost effective. The outcomes have all been favorable, notably our experience working with the PeRC team. From the build process to implementation, the team was responsive and engaged. This was essential to the speed of production and our encouraging progress. This innovative and instrumental functionality can be specified to the needs of other clinical research groups hoping to utilize EPIC for participant recruitment.

Before and after standardizing the controversial sepsis resuscitation bundle in a large hybrid academic center

Background: Sepsis is a life-threatening disease associated with a high mortality and cost. Studies have shown that implementation of standardized measures in the processes of care can improve patient outcomes in sepsis. However, compliance with bundle recommendations varies across hospital systems. The purpose of this study was to analyze the clinical outcomes of patients before and after implementation of a standardized multidisciplinary sepsis protocol linked to a best practice alert (BPA). Methods: The study was conducted in a 560-bed hybrid medical staff hospital consisting of both community and academic providers. All sepsis, severe sepsis, and septic shock patients based on ICD-9 coding admitted through the emergency department (ED) over a year were retrospectively reviewed prior to protocol implementation. We developed a multidisciplinary, standardized sepsis protocol based on the 2012 Surviving Sepsis Campaign (SSC) guidelines which included an electronic medical record (EMR) BPA, standardized ED and intensive care unit order sets, and a sepsis alert team. Sepsis alerts were called to streamline ICU admission. Intensive house wide education on the new process was performed and the protocol was implemented. We compared mortality, length of stay (LOS), time to fluids, antibiotics, and blood culture before and after protocol implementation for severe sepsis and shock patients. Results: Prior to protocol implementation, 1,194 total patients were diagnosed with sepsis, severe sepsis, or septic shock; 134 (11%) initially presented with either severe sepsis or septic shock to the ED. Post implementation, 450 BPAs were triggered over a 1 year period. In total, 116 of these resulted in a “sepsis alert”, indicating severe sepsis or septic shock. Pre-protocol mortality was 56/134 (41.8%) versus 32/116 {27.6%; χ 2 [1]=5.50, P=0.024} post-protocol. There was a significant decrease in the time to obtaining blood cultures (pre: 219±42 min; post: 40±14 min, P<0.001), time to delivering antibiotics (pre: 273±59 min, post: 98±16 min, P=0.005), and time to fluids (pre: 190±52 min; post: 61±14 min, P=0.017) from initial ED vitals. Cultures, fluids, and antibiotics timing goals (within 3 hours) were achieved in 50.0% post implementation vs. 24.6% prior. LOS did not differ between groups {pre: 11.2±1.3; post: 9.7±0.8, t[247]=1.00, P=0.32}. Conclusions: Timely sepsis identification, antibiotic delivery, fluid administration, and blood culture drawing significantly improved in our hospital after protocol implementation. There was a significant improvement in mortality with no statistically significant change in LOS. Standardized processes of care with education and practice alerts could improve sepsis outcomes.