Best Practice Alert Research Articles

S395 Open Access Colonoscopy: Assessing the Outcomes of a Novel Electronic Medical Record Best Practice Alert (BPA) in Reducing Inappropriate Colonoscopy Referrals

S395 Open Access Colonoscopy: Assessing the Outcomes of a Novel Electronic Medical Record Best Practice Alert (BPA) in Reducing Inappropriate Colonoscopy Referrals

It Takes a Village: Leveraging a Multidisciplinary Team and Technology for Urine Culturing Stewardship

Background: Patients without urinary tract infection (UTI) symptoms but with a positive urine culture are considered to have asymptomatic bacteriuria (ASB). This often represents colonization and treatment is not recommended or clinically beneficial. Treatment of ASB can promote antimicrobial resistance and increased rates of Clostriodies difficile infections. Many cases of ASB are incorrectly assigned as CAUTIs due to over-culturing practices. We hypothesized that a urine culture algorithm, embedded within a best practice alert (BPA) in the electronic medical record (EMR), would reduce urine culturing practices for ASB. Methods: From Feb 2022 through May 2023, a multidisciplinary team implemented an Inpatient Urine Culturing Stewardship Guideline. A BPA fired when a provider placed a urinalysis with reflex to culture (UACC) or urine culture (UC) order for patients who met criteria (Image 1). The BPA directed providers to remove the order, select the appropriate pathway from the guideline, or provide a rationale for placing the order. The intervention was piloted on three intensive care units and two progressive care units, containing both medical and surgical patients. Monthly ordering practices, CAUTI rates, and gram-negative rod (GNR) bacteremia rates from a 13-month pre-intervention baseline period were compared to a 16-month intervention period. Over the same time periods, we also assessed changes in ordering practices for comparison units which did not implement the intervention. Pre-and-post intervention cohorts were analyzed using median two sample tests and Exact Poison Method, as appropriate. Results: On intervention units there was a 41.0% reduction in the median number of UACC and UC orders per 1000 patient days from 16.31 during the baseline period to 9.62 in the intervention period (p=0.0036). Pan cultures per 1000 patient days in which one of the orders was a UACC or UC fell by 42.2% from a median of 10.20 per 1000 patient days to 5.90 (p=0.0008). The comparison units saw no significant reductions in UACC and UC orders (p=0.21) or pan cultures (p=1.0). On the intervention units, the CAUTI rate for the baseline period was 1.31 per 1000 catheter days versus 0.79 in the intervention period (IRR = 1.65; p=0.44). GNR bacteremias remained stable on the intervention units between the baseline and intervention periods (p=0.82). Conclusion: This multidisciplinary intervention, leveraging EMR clinical decision support, reduced urine and pan culturing practices while demonstrating a trend towards a reduced CAUTI rate. The prevalence of GNR bacteremias remained consistent with baseline levels, suggesting the intervention did not cause harm.

Characterization of Interventions to Reduce the Frequency of Critical Medication Doses Missed or Delayed During Perioperative and Unit-to-unit Patient Transfers.

When medication administration record (MAR) "hold" capability is enabled in the electronic health record (EHR) during patient transfers, medication doses appear as "held" rather than due. We sought to quantify the incidence of delayed and missed doses of critical medications during MAR hold periods and to implement and evaluate interdisciplinary efforts and technical interventions to reduce missed medication doses during these periods. A list of critical medications was identified. MAR data were collected in patients with at least 1 critical medication dose due during the MAR hold period. MAR times were used to determine if delayed doses or missed doses occurred. Our interventions included: (1) implementation of a patient list indicator to retrospectively identify recently "held" medication doses, and (2) a report for operating room pharmacists to prospectively identify upcoming doses and ensure they were administered on time. Pre- and post-intervention period data were compared using a chi-squared test. During the pre-intervention study period, there were 1044 instances of delayed or missed doses during MAR hold. Most MAR times evaluated were on MAR hold during perioperative patient transfers. Delayed, missed, and multiple missed doses were defined in accordance with internal medication administration policies. There was no significant difference in the incidence of delayed and missed doses (69% vs 66%, P = .31), however, there was a significant reduction in the number of critical medication doses missed multiple times (0.8% vs 6.7%, P < .001) and all missed doses (35% vs 42%, P = .05) between the pre- and post-intervention period. As demonstrated across in both the pre- and post-intervention period of our study, MAR hold is commonly associated with dose delays and missed doses, which has potential negative consequences on patient outcomes. Future considerations will include implementation of a best practice alert (BPA) that directs users to a MAR tab highlighting doses held during transfers.

Successes and challenges of best practice alerts to identify and engage individuals living with hepatitis C virus.

Many individuals living with hepatitis C virus (HCV) are unaware of their diagnosis and/or have not been linked to programs providing HCV care. The use of electronic medical record (EMR) systems may assist with HCV infection identification and linkage to care. In October 2021, we implemented HCV serology-focused best practice alerts (BPAs) at The Ottawa Hospital (TOH) via our EMR (EPIC). Our BPAs were programmed to identify previously tested HCV seropositive individuals. Physicians were prompted to conduct HCV RNA testing and submit consultation requests to the TOH Viral Hepatitis Program. We evaluated data post-BPA implementation to assess the design and related outcomes. From 1 September 2022 to 15 December 2022, a total of 2,029 BPAs were triggered for 139 individuals. As a consequence of the BPA prompts, nine HCV seropositive and nine HCV RNA-positive individuals were linked to care. The proportion of total consultations coming from TOH physicians increased post-BPA implementation. The BPA alerts were frequently declined, and physician engagement with our BPAs varied across specialty groups. Programming issues led to unnecessary BPA prompts (e.g., no hard stop to the prompts even though the individual was treated and cured and individuals linked to care without first undergoing HCV RNA testing). A fixed 6-month lookback period for test results limited our ability to identify many individuals. An EMR-based BPA can assist with the identification and engagement of HCV-infected individuals in care. However, challenges including issues with programming, time commitment toward BPA configuration, productive communication between healthcare providers and the programming team, and physician responsiveness to the BPAs require attention to optimize the impact of BPAs.

Best Practice Alert to Promote Screening for Primary Aldosteronism Among People With Apparent Treatment-Resistant Hypertension

ObjectiveGuidelines recommend screening all individuals with resistant hypertension for primary aldosteronism (PA) but less than 2% are screened. We aimed to develop a noninterruptive Best Practice Alert (BPA) to assess if its implementation in the electronic health record improved PA screening rates among individuals with apparent treatment-resistant hypertension (aTRH). MethodsWe implemented a noninterruptive BPA on 9/17/2022 at our ambulatory primary care, endocrinology, nephrology, and cardiology clinics. We assessed clinical parameters of people with aTRH before (9/17/2021-9/16/2022) and after (9/17/2022-9/16/2023) the BPA was implemented. The noninterruptive BPA embedded with an order set identified people with aTRH and recommended screening for PA if it was not previously performed. ResultsThere were 10 944 and 11 463 people with aTRH who attended office visits during the 12 months before and after the BPA implementation, respectively. There were no statistically significant differences in median age (P = .096), sex (P = .577), race (P = .753), and ethnicity (P = .472) between the pre- and post-BPA implementation groups. There was a significant increase in PA screening orders placed (227 [2.1%] vs 476 [4.2%], P < .001) and PA screening labs performed (169 [1.5%] vs 382 [3.3, P < .001) after BPA implementation. PA screening tests were positive in 26% (44/169) and 23% (88/382) of people in the pre- and post-BPA groups, respectively (P = .447). ConclusionImplementation of a real-time electronic health record BPA doubled the screening rate for PA among people with aTRH; however, the overall screening rate was low.

Quality improvement project to reduce medicare 1-day write-offs due to inappropriate admission orders

BackgroundWe identified that Stanford Health Care had a significant number of patients who after discharge are found by the utilization review committee not to meet Center for Mediare and Medicaid Services (CMS) 2-midnight benchmark for inpatient status. Some of the charges incurred during the care of these patients are written-off and known as Medicare 1-day write-offs. This study which aims to evaluate the use of a Best Practice Alert (BPA) feature on the electronic medical record, EPIC, to ensure appropriate designation of a patient’s hospitalization status as either inpatient or outpatient in accordance with Center for Medicare and Medicaid services (CMS) 2 midnight length of stay benchmark thereby reducing the number of associated write-offs.MethodWe incorporated a best practice alert (BPA) into the Epic Electronic Medical Record (EMR) that would prompt the discharging provider and the case manager to review the patients’ inpatient designation prior to discharge and change the patient’s designation to observation when deemed appropriate. Patients who met the inclusion criteria (Patients must have Medicare fee-for-service insurance, inpatient length of stay (LOS) less than 2 midnights, inpatient designation as hospitalization status at time of discharge, was hospitalized to an acute level of care and belonged to one of 37 listed hospital services at the time of signing of the discharge order) were randomized to have the BPA either silent or active over a three-month period from July 18, 2019, to October 18, 2019.ResultA total of 88 patients were included in this study: 40 in the control arm and 48 in the intervention arm. In the intervention arm, 8 (8/48, 16.7%) had an inpatient status designation despite potentially meeting Medicare guidelines for an observation stay, comparing to 23 patients (23/40, 57.5%) patients in the control group (p = 0.001). The estimated number of write-offs in the control arm was 17 (73.9%, out of 23 inpatient patients) while in the intervention arm was 1 (12.5%, out of 8 inpatient patient) after accounting for patients who may have met inpatient criteria for other reasons based on case manager note review.ConclusionThis is the first time to our knowledge that a BPA has been used in this manner to reduce the number of Medicare 1-day write-offs.

Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study.

The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy. The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert. 332 patients were included. The BPA triggered 29 times. The following actions were taken among 16 patients for whom the BPA triggered: "override the alert" (n=13); "cancel the alert" (n=2); and 'remove the opioid order set' (n=1). 12/16 patients had discharge prescriptions: one patient received 20 tablets; two received 10 tablets; and nine received 15 tablets. Top reasons for over prescribing included concerns for pain control and lack of alternatives. Implementing a post-discharge opioid prescribing BPA aligned opioid prescribing following benign minimally invasive hysterectomy with guideline recommendations.

Effect of automated identification of antimicrobial stewardship opportunities for suspected urinary tract infections

Abstract Objective: We aimed to determine whether automated identification of antibiotic targeting suspected urinary tract infection (UTI) shortened the time to antimicrobial stewardship (AS) intervention. Design: Retrospective before-and-after study. Setting: Tertiary and quaternary care academic medical center. Patients: Emergency department (ED) or admitted adult patients meeting best practice alert (BPA) criteria during pre- and post-BPA periods. Methods: We developed a BPA to alert AS pharmacists of potential ASB triggered by the following criteria: ED or admitted status, antibiotic order with genitourinary indication, and a preceding urinalysis with ≤ 10 WBC/hpf. We evaluated the median time from antibiotic order to AS intervention and overall percent of UTI-related interventions among patients in pre-BPA (01/2020–12/2020) and post-BPA (04/15/2021–04/30/2022) periods. Results: 774 antibiotic orders met inclusion criteria: 355 in the pre- and 419 in the post-BPA group. 43 (35 UTI-related) pre-BPA and 117 (94 UTI-related) post-BPA interventions were documented. The median time to intervention was 28 hours (IQR 18–65) in the pre-BPA group compared to 16 hours (IQR 2–34) in the post-BPA group (P &lt; 0.01). Despite absent pyuria, there were six cases with gram-negative bacteremia presumably from a urinary source. Conclusions: Automated identification of antibiotics targeting UTI without pyuria on urinalysis reduced the time to stewardship intervention and increased the rate of UTI-specific interventions. Clinical decision support aided in the efficiency of AS review and syndrome-targeted impact, but cases still required AS clinical review.

Implementation of a Best Practice Alert and Dedicated Hematology Consultation on Hospitalization Outcomes of Patients with Sickle Cell Disease

Introduction The American Society of Hematology (ASH) guidelines recommend rapid (within 1 hour) administration of tailored pain medication and frequent reassessments to optimize pain control in persons with sickle cell disease (SCD) presenting with acute pain related to SCD (Brandow et al., 2020). Implementation of an individualized pain plan (IPP) has been associated with decreased length of stay and lower rate of 7-day readmissions (Welch-Coltrane et al., 2021).Early initiation of sustained analgesia results in more rapid resolution of vaso-occlusive crises (VOC) in 80% patients. While all of our patients have an IPP, provider knowledge of the existence of IPPs and where to find them has been challenging to properly implement this practice. All inpatient SCD patients receive hematology consults but lack of continuity and experience with patients can be challenging for them. The study aimed to investigate the impact of implementing a Best Practice Alert (BPA) and introduction of dedicated SCD nurse practitioner (NP) on consults on various clinical metrics related to patients with sickle cell disease during hospitalization. Methods We created a best practice alert (BPA) that is triggered when a patient with SCD is admitted to the inpatient service. It directs the admitting team and nursing staff to the IPP and an order set for sickle cell pain crisis. The nursing interface of the BPA also includes a link to an educational module. Data was collected pertaining to length of stay, readmission, and percentage of admissions with a hematology consult placed from before and after implementation of the BPA. Around the same time, a dedicated nurse practitioner managed consults for patients hospitalized with sickle cell VOC and provided education to the primary team. We then conducted a retrospective chart review of all sickle cell patients at the University of Wisconsin from January 1, 2021, to December 31, 2023. We included all patients 18 years and greater with a sickle cell disease diagnosis as identified by the ICD-10 code (D57.00) and excluded patients with restricted research participation. We used descriptive statistics to obtain summaries of patient demographics as percentages for categorical variables and mean values for continuous data. Results Preliminary data demonstrated that the number of distinct patients with admissions decreased from 47 pre-BPA to 30 post-BPA (Table 1, Figure 1). The average length of stay in days decreased with 7.87 days pre-BPA to 6.35 days post-BPA. The average number of days between previous discharge and readmission increased from 45.65 to 85.65 after implementation. Readmissions at 7 and 30 days decreased by 17% and 4%, respectively. Conclusion The goal of this QI initiative was to improve IPP implementation by introducing a BPA in the chart directing admitting providers to the plan for efficient use. Dedicated SCD NP provided continuity and ensured IPPs were followed. While we could not directly measure the implementation of IPP with each BPA trigger, relevant patient-related outcomes such as readmissions and length of stay were reduced with meaningful reduction in LOS by 1.52 days during the first 9 months of these changes. In the future, we plan to further refine this process and expand our outcomes data by obtaining patient and provider feedback via surveys to fully understand the impact of this process and continue improvements. The role of SCD NP will be expanded due to encouraging results. In summary, BPA alerts in the chart for rapid implementation of IPPs, along with a knowledgeable SCD consult provider to ensure proper follow up of plans is a feasible strategy to improve patient outcomes when admitted with VOC.

2502. Best Practice Alert for Hepatitis C Virus Screening Demonstrates Importance of Reminders during Disruptive Times (COVID-19)

Abstract Background In 2015, a Best Practice Alert (BPA) was implemented into our electronic health record that prompts ordering of Hepatitis C Virus (HCV) antibody (Ab) screens for unscreened patients born between 1945-1965 (baby boomers: BB). The BPA begins the first step of the three-step care cascade, after which follow-up is needed for RNA testing if Ab-positive and HCV clinic visit if RNA-positive (figure 1). Prior studies found a 3.5-fold increase in HCV Ab screening after BPA implementation. We sought to understand the BPA’s role in cascade navigation during the COVID-19 pandemic. Initial BPA is triggered, which leads to subsequent steps including HCV antibody testing, HCV RNA testing, and ending with a clinic visit for treatment initiation. Methods This retrospective study included BB receiving their first BPA between 7/1/18-12/31/19 (pre-pandemic: PP) and 1/1/20-7/1/21, (intra-pandemic: IP), excluding patients with a death date ≤ 180 days after their BPA. Patients were followed for 180 days for each step and were marked unsuccessful if it was not completed. Successful navigation (SN) was defined as completing all steps or testing negative at any step. Hazard ratios for completion of each step were calculated via Cox Proportional Model. Clinical and demographic predictors of SN were examined via multivariable logistic regression in each cohort. Results Overall, 14,236 unscreened BB had a BPA (8,090 PP, 6,146 IP) fire during the study periods. The cohorts were similar, except for an increase in share with county financial assistance and those cared for by advanced practice providers in the IP cohort (table 1). An increase in HCV Ab screening (aHR 1.31 [95% CI: 1.25, 1.38]) and decreases in HCV RNA testing (aHR 0.79 [0.65, 0.96]) and clinic visits (aHR 0.43 [0.28, 0.66]) were seen in the IP cohort (figures 2A, B, and C). Hispanic patients had increased odds (aOR: 1.25 [1.02, 1.54]) of SN in the IP cohort (figures 3A and B). Compared to family medicine, those cared for in geriatric clinics had lower odds (aOR 0.75 [0.62, 0.91]) of SN in the IP cohort. Lower odds were also seen for those with Charlson Index ≥ 2 (aOR 0.85 [0.74, 0.98]) compared to 0.Table 1.Cohort Demographics.Baseline demographic, comorbidity, and provider factors for the pre-pandemic and intra-pandemic cohorts. Figure 2. Survival-Time Analysis of the HCV Care Cascade. Kaplan-Meier curves with 95% confidence intervals depicting time to completion by day after step initiation in each cohort. Data for the HCV antibody screening (A), HCV RNA testing (B), and liver clinic visit (C) steps are each shown separately. Log-rank test p-values are shown. Figure 3. Logistic Regression Forest Plots Forest plots showing the adjusted odds ratios and 95% confidence intervals for successful cascade navigation in the pre-pandemic (A) and intra-pandemic (B) cohorts. Odds ratio less than 1 indicates lower odds of successful navigation during that period. Odds ratio greater than 1 indicates higher odds of successful navigation. Conclusion The BPA increased the durability of HCV Ab screening rates during the pandemic compared to other steps in the cascade. Disparities in completing all steps of the cascade persisted and likely worsened in some groups during the pandemic. Overall, electronic reminders lessen impacts of disruptions in healthcare services. Disclosures Mamta K. Jain, MD, MPH, Gilead Sciences: Grant/Research Support|Laurent: Grant/Research Support

Increasing cancer genetic referrals via best practice alerts (BPA).

565 Background: Germline genetic testing (GT) is recommended for all patients (pts) with pancreatic cancer (PC). However, genetic referral (GR) rates for PC are low even at academic centers; there is a paucity of literature at safety-net hospitals (SNH) which often treat higher percentages of cancers at advanced stages. Providers focused on the challenging treatment of PC and may not prioritize GT referrals. Technology can be adapted to aid in this process. Best practice alerts (BPA) built in Electronic Medical Records (EMR) can prompt providers to place GR order. We initiated BPA at John Peter Smith (JPS) hospital, a SNH in Texas, and evaluated if the BPA improved referral patterns. Methods: A retrospective review was conducted using JPS tumor registry data. We studied pts diagnosed with pancreatic adenocarcinoma (AC) or neuroendocrine tumors (NET) from 1/1/2018 to 4/30/2023 at JPS. BPA go-live date was 10/19/2022. Data Analytics team queried EMR regarding GR, if pts completed their genetics encounter (GE), and GT. Statistical analysis using a two-tailed T test was performed. Results: 162 PC pts were identified: 155 (96%) AC and 7 (4%) NET, and the median age was 59 years. A majority of patients were diagnosed in house (114/162, 70%), while the rest were referred to JPS after diagnosis elsewhere. A total of 57 pts were excluded due to being placed on hospice, death within 3 months of diagnosis, or refusing oncology services at JPS. 105 pts were included for analyses: 96 were diagnosed with PC before the BPA go-live date (pre-BPA) and 9 after the BPA go-live date (post-BPA). 36 (38%) pts were referred pre-BPA. 23 pre-BPA pts completed GE, median of 15 days from referral. 7 out of 9 (78%) pts received GR post-BPA. Post-BPA pts were all referred due to BPA triggers being fired. 2 post-BPA pts completed GE with a median time of 27.5 days from GR. Since launching the BPA, a statistically significant increase in GR has been observed (p=0.0187). 2 pre-BPA pts who completed GT were found to have a pathogenic variant. Conclusions: BPA has shown a significant improvement in GR for PC. Our study population is limited by rarity of PC, and the BPA alert is set to only fire for pts receiving oncology care at JPS. We noted a large number of pre-BPA pts that have yet to be referred and remain at risk. Updates to the BPA build are needed to capture previously diagnosed pts who are receiving JPS oncology services. For future studies, we will analyze pts with other cancer diagnoses to continue to improve upon the GR process.[Table: see text]

Reducing the receipt of contraindicated medications in patients with Parkinson disease.

The administration of antidopaminergic medications to patients with Parkinson's disease (PD) can exacerbate symptoms, and in the hospital setting, can lead to complications and increased length of stay. Despite efforts to improve medication administration through provider education and patient-centered interventions, the problem persists, with an estimated 21-43% of hospitalized PD patients receiving dopamine blocking medications. In this study, a best practice alert (BPA) was developed that was triggered when an antidopaminergic medication was ordered in the Emergency Department or hospital for a patient with a diagnosis of PD in the EMR. The primary outcomes were receipt of a contraindicated medication, length of stay (LOS) and readmission within 30 days. These outcomes were compared between the 12 months prior to the intervention and the 12 months post intervention. Data were also collected on admitting diagnosis, admitting service, neurology involvement and patient demographics. For pre-intervention inpatient encounters, 18.3% involved the use of a contraindicated medication. This was reduced to 9.4% of all inpatient encounters for PD patients in the first 3 months post-intervention and remained lower at 13.3% for the full 12 months post-intervention. The overall rate of contraindicated medication use was low for ED visits at 4.7% pre-intervention and 5.7% post-intervention. Receipt of a contraindicated medication increased the risk of a longer length of stay, both before and after the intervention, but did not significantly affect 30-day readmission rate. An EMR BPA decreased the use of contraindicated medications for PD patients in the hospital setting, especially in the first 3 months. Strategies are still needed to reduce alert fatigue in order to maintain initial improvements.

FRI123 Development And Impact Of A Best Practice Alert For Primary Aldosteronism Screening

Abstract Disclosure: S. Charoensri: None. L. Bashaw: None. C. Dehmlow: None. T. Ellies: None. A.F. Turcu: None. Background: Primary aldosteronism (PA) is a common cause of secondary hypertension, affecting up to 25% of patients with treatment-resistant hypertension. PA amplifies the risk of cardiovascular morbidity and mortality above that of equivalent primary hypertension. Despite this, &amp;lt;3% of candidates for PA screening are ever evaluated, including in academic centers with facile access to all required resources for PA subtyping and treatment. Clinical decision support tools, such as best practice alerts (BPA), can leverage electronic medical records technology to support health care delivery improvement efforts. Intervention and Measurements: In collaboration with institutional Informational Technology services, we developed an algorithm that identifies PA screening candidates as adult patients with hypertension and one of the following criteria: ≥ 4 current antihypertensive medications; age &amp;lt; 35 years; hypokalemia (defined by potassium supplements or low serum potassium in the past year); or adrenal mass on problem list. The algorithm excluded patients who had both plasma aldosterone and renin measurements within the past 5 years. A non-disruptive BPA to suggest PA screening was constructed and set to trigger in patients meeting inclusion and exclusion criteria when evaluated in outpatient setting by clinicians who treat hypertension, including Internists, Family Practitioners, Cardiologists, Nephrologists, and Endocrinologists. An order set for PA screening and a link to results interpretation guidance were also embedded within the BPA. The BPA was first piloted between Aug-Sept 2021, and then launched on October 1st, 2021. We assessed the number of unique patients identified by the BPA between Oct 1st, 2021- Dec 14th, 2022, stratified by PA screening indications; attitude towards the BPA; and number of patients who received PA screening orders. Results: In total, the BPA identified 14,443 unique candidates for PA screening, including: 6944 patients with treatment-resistant hypertension; 6583 patients with hypertension and hypokalemia; 1527 patients with hypertension &amp;lt;35 years; and 444 with hypertension and an adrenal mass. During the same time frame, 3614 (25%) patients received orders for plasma aldosterone and renin. Patients tested were on average 57 +/-17 years old, 2000 (55.3%) were women, 2573 (71.2%) were White, 712 (19.7%) Black, and 105 (2.9%) Asian. Of new orders, 1364 (37.7%) were placed by Internists, 685 (18.9%) by Family Medicine physicians, 559 (15.5%) by Endocrinologists, 235 (6.5%) by Cardiologists, and 50 (1.4%) by Nephrologists. Family Practitioners and Internists placed most orders via the embedded BPA order set (66.6% and 46.3%, respectively), while Endocrinologists placed 98.6% of the orders outside of the BPA order set. Conclusions: Non-disruptive BPAs enhance the rates of PA screening, particularly among Internists and Family Practitioners. Presentation: Friday, June 16, 2023

THU607 Improving Screening For Primary Aldosteronism Among People With Apparent Treatment Resistant Hypertension

Abstract Disclosure: K. Zekarias: None. K. Tessier: None. J. Kohlenberg: None. Introduction: The screening rate for primary aldosteronism (PA) is low among people with resistant hypertension. People with PA experience significantly more cardiovascular complications than those with primary hypertension and an equivalent degree of blood pressure control1. Therefore, identification of people with PA for early-directed therapy is crucial. Objective: We aimed to improve the screening rate for PA among people with apparent treatment resistant hypertension (aTRH), defined as blood pressure &amp;gt;140/90 despite the concurrent use of three antihypertensive drug classes or any person with hypertension on &amp;gt;4 antihypertensive medications. Methods: Using an electronic medical record (EMR) best practice alert (BPA), we implemented a quality improvement (QI) program from 9/17/2022-3/16/2023. We included adults ≥18 years of age with aTRH, who were identified using ICD codes, the last three blood pressure measurements and the antihypertensive medication list. During office visits with nephrologists, cardiologists, endocrinologists, family medicine physicians, and internists, a BPA notified providers if the person with aTRH had not been previously screened for PA with plasma aldosterone and plasma renin activity. The alert defined aTRH, suggested that screening be performed regardless of active medications, and contained an order set for plasma aldosterone, plasma renin activity, and plasma potassium. Furthermore, the BPA suggested referral to an endocrinologist if the patient fulfilled criteria for positive case detection for PA, defined as plasma renin activity &amp;lt; 1 ng/mL/hour and plasma aldosterone concentration (PAC) &amp;gt; 10 ng/dL or the plasma aldosterone to renin ratio (ARR) &amp;gt; 30 with PAC &amp;gt; 10. We compared the PA screening rate after the implementation of the BPA to the PA screening rate over the 1 year prior to the BPA implementation (9/16/2021-9/16/2022). Results: Plasma aldosterone lab orders were placed for 3.4% (179/5,261) of people with aTRH post-BPA implementation compared to 1.9% (211/10,944) pre-BPA implementation (p&amp;lt;0.01). Positive case detection for PA occurred in 25% (38/152) of people screened post -BPA implementation compared to 27% (47/173) pre-BPA implementation (p=0.66). People with aTRH who were younger (p&amp;lt;0.01) were more likely to be screened for PA pre-BPA implementation and this did not change post-implementation. Conclusion: Implementation of a QI program employing a BPA with an embedded order set in the EMR improved the screening rate for PA among adults with aTRH. Reference 1. Monticone S, D'Ascenzo F, Moretti C, Williams TA, Veglio F, Gaita F, Mulatero P. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2018 Jan; 6 (1):41-50. Presentation: Thursday, June 15, 2023

Electronic Health Record-Driven Approaches in Primary Care to Strengthen Hypertension Management Among Racial and Ethnic Minoritized Groups in the United States: Systematic Review.

Managing hypertension in racial and ethnic minoritized groups (eg, African American/Black patients) in primary care is highly relevant. However, evidence on whether or how electronic health record (EHR)-driven approaches in primary care can help improve hypertension management for patients of racial and ethnic minoritized groups in the United States remains scarce. This review aims to examine the role of the EHR in supporting interventions in primary care to strengthen the hypertension management of racial and ethnic minoritized groups in the United States. A search strategy based on the PICO (Population, Intervention, Comparison, and Outcome) guidelines was utilized to query and identify peer-reviewed articles on the Web of Science and PubMed databases. The search strategy was based on terms related to racial and ethnic minoritized groups, hypertension, primary care, and EHR-driven interventions. Articles were excluded if the focus was not hypertension management in racial and ethnic minoritized groups or if there was no mention of health record data utilization. A total of 29 articles were included in this review. Regarding populations, Black/African American patients represented the largest population (26/29, 90%) followed by Hispanic/Latino (18/29, 62%), Asian American (7/29, 24%), and American Indian/Alaskan Native (2/29, 7%) patients. No study included patients who identified as Native Hawaiian/Pacific Islander. The EHR was used to identify patients (25/29, 86%), drive the intervention (21/29, 72%), and monitor results and outcomes (7/29, 59%). Most often, EHR-driven approaches were used for health coaching interventions, disease management programs, clinical decision support (CDS) systems, and best practice alerts (BPAs). Regarding outcomes, out of 8 EHR-driven health coaching interventions, only 3 (38%) reported significant results. In contrast, all the included studies related to CDS and BPA applications reported some significant results with respect to improving hypertension management. This review identified several use cases for the integration of the EHR in supporting primary care interventions to strengthen hypertension management in racial and ethnic minoritized patients in the United States. Some clinical-based interventions implementing CDS and BPA applications showed promising results. However, more research is needed on community-based interventions, particularly those focusing on patients who are Asian American, American Indian/Alaskan Native, and Native Hawaiian/Pacific Islander. The developed taxonomy comprising "identifying patients," "driving intervention," and "monitoring results" to classify EHR-driven approaches can be a helpful tool to facilitate this.

Clinic-based interventions to increase preexposure prophylaxis awareness and uptake among United States patients attending an obstetrics and gynecology clinic in Baltimore, Maryland

Cisgender women account for one of every five new U.S. HIV diagnoses, with the majority (86%) attributed to heterosexual contact. HIV pre-exposure prophylaxis (PrEP) is an effective prevention strategy; however, PrEP awareness and prescriptions among women are low. Our objective was to increase PrEP counseling and uptake among cisgender women attending obstetrics/gynecology (OB/GYN) clinics. The study included three OB/GYN clinics within a single health system in a high HIV prevalence region. There were three phases: baseline (three-month period before the clinical trial that included provider education and training of a registered nurse about PrEP [PrEP-RN]), clinical trial (three-month period during which eligible patients were randomized to an active control or PrEP-RN intervention), and maintenance (three-month period after the trial ended). Electronic medical record (EMR) clinical decision support tools (CSTs) were available to both arms during the clinical trial, which included best practice alerts (BPAs), order sets, progress note templates, and written and video PrEP educational materials for patients. In the intervention arm, a PrEP-nurse contacted and counseled patients, and was equipped to prescribe PrEP. We evaluated the phases through the RE-AIM framework (Reach-Effectiveness-Adoption-Implementation-Maintenance). The primary outcome of the study was effectiveness (e.g., percentage of eligible patients with documented HIV prevention counseling in the EMR or PrEP prescriptions). Secondary outcomes included reach (e.g., percentage of BPAs that providers acted upon or the percentage of eligible patients who spoke with the PrEP-RN), adoption (e.g., percentage of eligible patients with a BPA that triggered or the percentage of eligible patients the PrEP-RN attempted to contact), and maintenance (e.g., percentage of patients with documented HIV prevention counseling or PrEP prescriptions during the maintenance phase). There were 904 unique patients in all phases with a mean age of 28.8+/-7.7 years, and 46% were pregnant; 436 patients were randomized in the clinical trial phase. Reach/Adoption: BPAs were triggered for 100% of eligible encounters; however, providers acted on 52% of them. The PrEP nurse attempted to contact every patient and successfully spoke with 81.2% of them in the PrEP-RN arm. Compared to the active control, there were significantly more patients counseled about PrEP in the PrEP-RN group (66.5% vs. 12.3%, p<0.001), while PrEP prescriptions were equivalent (p=1.0). Among the subgroup of patients who were counseled about PrEP, 18.5% of patients in the active control and 3.4% in the PrEP-RN arm were prescribed PrEP (p=0.02). Maintenance: CSTs alone resulted in PrEP counseling of 1.0% of patients during the maintenance phase versus 0.6% during baseline and 11.2% during the clinical trial (p<0.001). PrEP prescriptions were not statistically different between the three phases (p=0.096). A PrEP nurse effectively increased HIV prevention discussions but did not lead to more PrEP prescriptions than the PrEP-focused CSTs used by providers. The decrease in PrEP counseling following the trial phase suggests that persistent interventions are needed to maintain effects.

Paediatric clinical decision support: Evaluation of a best practice alert for red blood cell transfusion.

Providing red blood cell (RBC) transfusion to paediatric patients with a haemoglobin (Hb) level of <7 g/dL is the current best practice, but it is often difficult to ensure appropriateness of RBC transfusion on a health system level. Electronic health record (EHR) clinical decision support systems have been shown to be effective in encouraging providers to transfuse at appropriate Hb thresholds. We present our experience with an interruptive best practice alert (BPA) at a paediatric healthcare system. An interruptive BPA requiring physician response was implemented in our EHR (Epic Systems Corp., Verona, WI, USA) in 2018 based on Hb thresholds for inpatients. The threshold was initially <8 g/dL and later changed to <7 g/dL in 2019. We assessed total activations, number of RBC transfusions and hospital metrics through 2022 compared to the 2 years prior to implementation. The BPA activated 6956 times over 4 years, slightly less than 5/day, and the success rate, with no RBC transfusions within 24 h of order attempt, was 14.5% (1012/6956). There was a downward trend in the number of total RBC transfusions and RBC transfusions per admission after implementation, non-significant (p = 0.41 and p = >0.99). The annual case mix index was similar over the years evaluated. The estimated cost savings based on acquisition costs for RBC units were 213,822 USD or about $51,891 per year. BPA implementation led to sustained change in RBC transfusion towards best practice, and there were long-term savings in RBC expenditure.

386-P: Inpatient Hypoglycemic Rate Reduction through the Implementation of Prescriber Targeted Decision Support Tools

Introduction: Hypoglycemia has been shown to increase mortality and length of hospital stay in patients with and without diabetes. The purpose of this study is to determine if the implementation of prescriber targeted decision support tools reduces the incidence of inpatient hypoglycemic events. Methods: This pre-post intervention study included adult patients who experienced an inpatient hypoglycemic event within 24 hours of insulin administration from October 2018 to December 2019. Pregnant women and patients receiving insulin infusions were excluded. Best Practice Alerts (BPAs) and banners were implemented in January 2019 to alert providers of patients at risk for hypoglycemia. Triggers for the BPAs and banners include use of sulfonylureas with reduced renal function, high weight-based basal doses, a previous episode of hypoglycemia during the admission, or concomitant use of fluoroquinolones and scheduled insulin. The primary outcome was to measure the incidence of hypoglycemia per 1000 patient days in pre- vs. post-intervention groups. Results: In total, 1186 hypoglycemic events in the pre-intervention group were compared to 5260 events in the post-intervention group. The implementation of EMR alerts significantly decreased hypoglycemia (glucose ≤ 70 mg/dL) from 22.91 events/1000 patient days to 18.27 events/1000 patient days (p&amp;lt;0.001). Severe hypoglycemia (glucose &amp;lt; 54 mg/dL) was not significantly reduced (1.65 events/1000 patient days vs. 1.79 events/1000 patient days (p=0.453)). The use of high weight-based basal insulin doses was reduced in the post-intervention patients with normal renal function, 23.0% vs. 16.7% (p&amp;lt;0.001), and patients with impaired renal function, 7.1% vs. 4.9% (p=0.017). Conclusion: The implementation of prescriber targeted decision support tools was successful in reducing the overall incidence of inpatient hypoglycemia. Disclosure R.Goldstein: None. J.M.Odom: None.

Effect of a Best-Practice Alert on the Rate of Smoking Cessation among Pregnant Women.

This study aimed to determine if a best-practice alert (BPA) implementation increases the rate of smoking cessation during pregnancy and affects pregnancy outcomes associated with smoking. This was a pretest-posttest study design where a BPA was added to electronic medical records (EMR) of pregnant persons who reported active smoking. The BPA provided the 5A's method to conduct counseling on smoking cessation. The rates of smoking cessation during pregnancy were compared 1.5 years before and after implementation of the BPA. Secondary outcomes examined whether counseling on smoking cessation was done, the number of the counseling sessions during pregnancy, and obstetric outcomes associated with maternal smoking. After implementation of the BPA, the rate of smoking cessation in pregnancy increased from 17.5% prior to BPA implementation to 54.9% after BPA implementation (p < 0.001). The rate of counseling on smoking cessation increased from 66.6% prior to BPA implementation to 95.6% after BPA implementation, with an increase noted also in the number of smoking cessation counseling sessions. In multivariate analyses, after controlling for maternal demographic and clinical factors, BPA implementation was significantly associated with higher rates of smoking cessation (adjusted odds ratio [aOR]: 3.44, 95% confidence interval [CI]: 2.17-5.51), higher rates of documented smoking cessation counseling in the EMR (aOR: 12.44, 95% CI: 6.06-25.64), and higher odds of conducting the counseling more than once (aOR: 6.90 95% CI: 4.45-10.88). The rate of smoking cessation and number of times pregnant persons were counseled increased after implementation of a BPA. The BPA could be a useful EMR tool to increase smoking cessation rates during pregnancy. · Smoking during pregnancy is a maternal and fetal concern.. · Prenatal care offers the chance to address smoking.. · BPA increases rates of smoking counseling and cessation..

Examining the effects of organizational influencers on the implementation of clinical innovations: A qualitative analysis

Background: The FIRST Trial is a 5-year study funded by the Agency for Healthcare Research and Quality. Our investigation is situated within a more extensive study to restrict fluoroquinolone antibiotics by requiring providers to obtain authorization from an infectious disease physician before prescribing fluoroquinolones. Our research team is performing a systematic evaluation to identify organizational characteristics and influencers of the fluoroquinolone preprescription authorization implementation process to understand variables that may facilitate or hinder implementation success. Methods: To address this critical gap, we present a qualitative analysis from our ongoing, multisite research project aimed at systematically assessing the adoption of an antimicrobial stewardship intervention in the form of an EHR-integrated best-practice alert (BPA) at each site to identify work system factors that impact uptake and variability in the implementation of the BPA at each location. The evaluation provides a detailed explanation of activities through the implementation process (eg, before implementation, during implementation, and after implementation) to assess how an organization effectively negotiates the phases and transitions, ultimately influencing the impact of the intervention. We have used a contextual determinant framework (CFIR) that has enabled us to perform a systematic and comprehensive exploration and identification of potential explanatory themes or variables to shed light on the complex social phenomenon of implementation. Results: Participants who will be a part of our poster presentation will learn about implementing a BPA, the potential barriers to implementation, and strategies for overcoming these barriers. Stakeholders within our study include site coordinators, medical doctors, nurses, pharmacists, and clinical informaticists. Our analysis synthesizes their experiences implementing and sustaining this evidence-based antimicrobial stewardship intervention. It includes (1) a detailed description of the process of change, (2) work-system factors (eg, inner setting and outer setting) that they believe influenced the success of the intervention, (3) barriers and facilitators (eg, CFIR constructs) within the implementation process; and (4) description of how these could have influenced the outcomes of interest (eg, implementation and intervention effectiveness). Conclusions: Our research is expected to advance patient safety research and initiatives by providing a more robust approach to performing systematic intervention evaluations. By outlining stakeholders’ experiences within our study, implementation leaders within healthcare systems will utilize our findings to aid them in their design and implementation process when designing and implementing similar types of healthcare interventions.Disclosures: None