Electronic Alerts Research Articles

Impact of electronic AKI alert/care bundle on AKI inpatient outcomes: a retrospective single-center cohort study

Background Outcomes among acute kidney injury (AKI) patients are poor in United Kingdom (UK) hospitals, and electronic alerts and care bundles may improve them. We implemented such a system at West Suffolk Hospital (WSH) called the ‘AKI order set’. We aimed to assess its impact on all-cause mortality, length of stay (LOS) and renal function among AKI patients, and its utilization. Methods Retrospective, single-center cohort study of patients ≥ 18 years old with AKI at WSH, a 430-bed general hospital serving a rural UK population of approximately 280,000. 7243 unique AKI events representing 5728 patients with full data were identified automatically from our electronic health record (EHR) between 02 September 2018 and 1 July 2021 (median age 78 years, 51% male). All-cause mortality, LOS and improvement in AKI stage, demographic and comorbidity data, medications and AKI order set use were automatically collected from the EHR. Results The AKI order set was used in 9.8% of AKI events and was associated with 28% lower odds of all-cause mortality (multivariable odds ratio [OR] 0.72, 95% confidence interval [CI] 0.57–0.91). Median LOS was longer when the AKI order set was utilized than when not (11.8 versus 8.8 days, p < .001), but was independently associated with improvement in the AKI stage (28.9% versus 8.7%, p < .001; univariable OR 4.25, 95% CI 3.53–5.10, multivariable OR 4.27, 95% CI 3.54–5.14). Conclusions AKI order set use led to improvements in all-cause mortality and renal function, but longer LOS, among AKI patients at WSH.

Blood Culture Ordering After Sepsis Alerts and Subsequent Patient Outcomes: An Electronic Health Record-Based Study.

Sepsis is a global health priority associated with high mortality. Clinical decision support systems have been developed to support clinicians with sepsis management. Ordering blood cultures (BCs) for suspected sepsis patients are strongly recommended by clinical guidelines. However, limited evidence exists investigating BC ordering following sepsis alerts and subsequent patient outcomes. This study aimed to investigate this issue using electronic health record data from an acute care hospital in Australia. Of 4,092 patients, only 16.6% had a BC ordered following a sepsis alert. The median time from the first sepsis alert to a BC order was 15.3 hours. Patients had 5.89 times higher odds of being diagnosed with sepsis if a BC was ordered following a sepsis alert than those without BC ordered (p<0.0001). Further investigation is needed to understand reasons behind the delay or failure to order a BC despite receiving electronic sepsis alerts and how decision support can be optimized to improve patient outcomes.

Electronic Alerts in Acute Kidney Injury—More Questions Than Answers

Electronic Alerts in Acute Kidney Injury—More Questions Than Answers

Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury

Despite the expansion of published electronic alerts for acute kidney injury (AKI), there are still concerns regarding their effect on the clinical outcomes of patients. To evaluate the effect of the AKI alert combined with a care bundle on the care and clinical outcomes of patients with hospital-acquired AKI. This single-center, double-blind, parallel-group randomized clinical trial was conducted in a tertiary teaching hospital in Nanjing, China, from August 1, 2019, to December 31, 2021. The inclusion criteria were inpatient adults aged 18 years or older with AKI, which was defined using the Kidney Disease: Improving Global Outcomes creatinine criteria. Participants were randomized 1:1 to either the alert group or the usual care group, which were stratified by medical vs surgical ward and by intensive care unit (ICU) vs non-ICU setting. Analyses were conducted on the modified intention-to-treat population. A programmatic AKI alert system generated randomization automatically and sent messages to the mobile telephones of clinicians (alert group) or did not send messages (usual care group). A care bundle accompanied the AKI alert and consisted of general, nonindividualized, and nonmandatory AKI management measures. The primary outcome was maximum change in estimated glomerular filtration rate (eGFR) within 7 days after randomization. Secondary patient-centered outcomes included death, dialysis, AKI progression, and AKI recovery. Care-centered outcomes included diagnostic and therapeutic interventions for AKI. A total of 2208 patients (median [IQR] age, 65 [54-72] years; 1560 males [70.7%]) were randomized to the alert group (n = 1123) or the usual care group (n = 1085) and analyzed. Within 7 days of randomization, median (IQR) maximum absolute changes in eGFR were 3.7 (-6.4 to 19.3) mL/min/1.73 m2 in the alert group and 2.9 (-9.2 to 16.9) mL/min/1.73 m2 in the usual care group (P = .24). This result was robust in all subgroups in an exploratory analysis. For care-centered outcomes, patients in the alert group had more intravenous fluids (927 [82.6%] vs 670 [61.8%]; P < .001), less exposure to nonsteroidal anti-inflammatory drugs (56 [5.0%] vs 119 [11.0%]; P < .001), and more AKI documentation at discharge (560 [49.9%] vs 296 [27.3%]; P < .001) than patients in the usual care group. No differences were observed in patient-centered secondary outcomes between the 2 groups. Results of this randomized clinical trial showed that the electronic AKI alert did not improve kidney function or other patient-centered outcomes but changed patient care behaviors. The findings warrant the use of a combination of high-quality interventions and AKI alert in future clinical practice. ClinicalTrials.gov Identifier: NCT03736304.

1227. Analysis of Prescriber Interaction with an Electronic Antibiotic Time-out Best Practice Alert

Abstract Background The impact of antibiotic time-outs (ATOs) on antibiotic use relies heavily on prescriber interaction, which may be reduced due to workflow disruption or alert fatigue. In August 2022, Hartford HealthCare implemented a 72-hour ATO best practice alert. Herein, we evaluated prescriber behavior when interacting with the ATO alert to assess the impact on prescriber stewardship workflow. Methods An ATO alert was designed to fire between 0700 and 1630. Upon firing, prescribers were prompted to assess for antibiotic modification – a composite including discontinuation, de-escalation, inclusion of stop-date, and transition to oral therapies. Additional responses were included to defer re-firing for patients deemed not to be a candidate for antibiotic modification. The primary endpoint was defined as the rate of ATO response aligning with antibiotic modification for the 10 most frequently utilized antibiotics and assessed from 10/1/22 – 12/31/22. A predefined subset of patients was evaluated for ATO appropriateness by prescriber specialty and role. Results A total of 15,383 ATO alerts were included for analysis, corresponding to 3,498 unique patients. The primary endpoint occurred in 21.4% of cases. The most commonly selected ATO response was a reminder in 10 minutes (48.2%). The median time viewing the ATO alert was 5 seconds (IQR 4 – 8s). In a subset of 400 patients, ATO selections were found to be appropriate in 56% of cases. When stratified by prescriber role, attending physicians were more likely to appropriately utilize the ATO compared to resident and advanced practice practitioners (62.7% vs 48.5% vs 46.2%, p = 0.007) and were more likely to select an ATO response aligning with antibiotic modification (39.5% vs 7.6% vs 12.3%, p &amp;lt; 0.001). Conclusion ATO selection corresponding to antibiotic modification was low regardless of prescriber role. Further work optimizing the ATO design will be required to improve integration into stewardship workflow. Disclosures Joseph L. Kuti, PharmD, bioMeriuex Inc.: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Merck &amp; Co, Inc: Grant/Research Support|Shionogi Inc: Advisor/Consultant|Shionogi Inc: Grant/Research Support|Shionogi Inc: Honoraria

1174. Impact of an Electronic Antibiotic Time-out Best Practice Alert on Antibiotic Use and Prescribing Behavior in Hospitalized Patients

Abstract Background Antibiotic time-outs (ATOs) are an evolving stewardship strategy capable of widespread impact with relatively low perceived personnel effort. ATO-based interventions have been shown to improve the rates of antibiotic de-escalation and increase the likelihood of antibiotic optimization. In August 2022, Hartford HealthCare implemented a 72-hour ATO best practice alert (BPA) within the electronic medical record (EMR). Herein, we evaluated the impact of this intervention on antibiotic use and describe behaviors associated with alert prompting. Methods This is a multi-center, quasi-experimental, retrospective chart review of admitted patients receiving empiric antibiotics for &amp;gt; 72 hours. An ATO alert was designed and embedded within the EMR and set to fire between the hours of 0700 and 1630. On BPA firing, prescribers were prompted to assess for antibiotic modification – a composite including discontinuation, de-escalation, inclusion of stop-date, and transition to oral therapies. Differences in the rate of antibiotic modification and overall antibiotic prescribing patterns for the 10 most frequently utilized antibiotics were compared between a pre-implementation control period (10/1/21 – 10/31/21) and a post-implementation period (10/1/22 – 10/31/22). Results A total of 800 patients were included for analysis. There was no significant difference in the rate of antibiotic modification when comparing the pre- and post-implementation cohort (54.5% vs 57.5%, p = 0.433); however, there was a numerically lower rate of antibiotic escalation in the post-cohort (9.5% vs 5.8%, p = 0.062). The duration of antibiotic therapy was longer in the post-implementation cohort (4.7 vs 5.0 days, p &amp;lt; 0.001). Conclusion Despite ATO implementation, rates of antibiotic modification were similar between the pre- and post-cohort. Further work to understand the optimal approach to implementing an ATO will be required to improve the impact on antimicrobial therapy. Disclosures Joseph L. Kuti, PharmD, bioMeriuex Inc.: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Merck &amp; Co, Inc: Grant/Research Support|Shionogi Inc: Advisor/Consultant|Shionogi Inc: Grant/Research Support|Shionogi Inc: Honoraria

Intravenous immunoglobulin alteration in response to adverse reactions in neurological conditions: A retrospective cohort study.

Intravenous immunoglobulin (IVIg) is an important treatment in a range of neurological conditions. There is currently limited evidence regarding the frequency and management of IVIg-associated adverse reactions (AR) in neurological disorders. A single-centre 18-month retrospective cohort study was conducted for all patients at a single tertiary hospital receiving IVIg as an inpatient or the medical day unit. Electronic medical record AR and alerts were reviewed for entries relating to IVIg, and prescribing records associated with recent IVIg administration were reviewed for the use of premedications. Case note review was undertaken to identify AR associated with alterations in IVIg treatment (such as reduction in rate, use of premedications or cessation of IVIg). Demographic, patient, and treatment factors were analysed for associations with AR necessitating alteration in IVIg treatment. This study included 98 individuals who received IVIg during the study period. Of these, 12 (12.1%) patients required an alteration in their IVIg treatment. In total, 3 (3.1%) of the 98 included patients required a reduced rate of IVIg, and 10 (10.2%) patients received premedication. The most common premedications were normal saline at the time of the infusion, cetirizine, and hydrocortisone. No demographic factors, indications or comorbidities were found to be associated with an increased likelihood of AR. However, an IVIg daily dose of >35 g and >45 g were associated with an increased likelihood of requiring IVIg treatment alteration due to AR. Alterations to IVIg treatment due to AR are commonly required in neurology patients, and may be associated with higher daily doses of IVIg.

Kidney Outcome Comparisons of Clinician Evaluated Electronic AKI Alerts

Kidney Outcome Comparisons of Clinician Evaluated Electronic AKI Alerts

Artificial intelligence in early detection and prediction of pediatric/neonatal acute kidney injury: current status and future directions.

Acute kidney injury (AKI) has a significant impact on the short-term and long-term clinical outcomes of pediatric and neonatal patients, and it is imperative in these populations to mitigate the pathways leading to AKI and be prepared for early diagnosis and treatment intervention of established AKI. Recently, artificial intelligence (AI) has provided more advent predictive models for early detection/prediction of AKI utilizing machine learning (ML). By providing strong detail and evidence from risk scores and electronic alerts, this review outlines a comprehensive and holistic insight into the current state of AI in AKI in pediatric/neonatal patients. In the pediatric population, AI models including XGBoost, logistic regression, support vector machines, decision trees, naïve Bayes, and risk stratification scores (Renal Angina Index (RAI), Nephrotoxic Injury Negated by Just-in-time Action (NINJA)) have shown success in predicting AKI using variables like serum creatinine, urine output, and electronic health record (EHR) alerts. Similarly, in the neonatal population, using the "Baby NINJA" model showed a decrease in nephrotoxic medication exposure by 42%, the rate of AKI by 78%, and the number of days with AKI by 68%. Furthermore, the "STARZ" risk stratification AI model showed a predictive ability of AKI within 7days of NICU admission of AUC 0.93 and AUC of 0.96 in the validation and derivation cohorts, respectively. Many studies have reported the superiority of using biomarkers to predict AKI in pediatric patients and neonates as well. Future directions include the application of AI along with biomarkers (NGAL, CysC, OPN, IL-18, B2M, etc.) in a Labelbox configuration to create a more robust and accurate model for predicting and detecting pediatric/neonatal AKI.

Impact of customized electronic duplicate order alerts on microbiology test ordering: Financial and environmental cost savings.

To estimate cost savings after implementation of customized electronic duplicate order alerts. Alerts were implemented for microbiology tests at the largest public hospital in Victoria, Australia. These alerts were designed to pop up at the point of test ordering to inform the clinician that the test had previously been ordered and to suggest appropriate reordering time frames and indications. In a 6-month audit of urine culture (our most commonly ordered test) after alert implementation, 2,904 duplicate requesters proceeded with the request and 2,549 tests were cancelled, for a 47% reduction in test ordering. For fecal polymerase chain reaction (PCR), our second most common test, there was a 54% reduction in test ordering. For our most commonly ordered expensive test, hepatitis C PCR, there was a 42% reduction in test ordering: 25 tests were cancelled.Cancelled tests resulted in estimated savings of AU$52,382 (US$33,960) for urine culture, AU$34,914 (US$22,442) for fecal PCR, AU$4,506 (US$2,896) for hepatitis C PCR. For cancelled hepatitis B PCR and Epstein-Barr virus (EBV) and cytomegalovirus (CMV) serology, the cost savings was AU$8,472 (US$5445). The estimated financial cost saving in direct hospital costs for these 6 assays was AU$100,274 (US$67,925) over the 6-month period. Environmental waste cost saving by weight was estimated to be 280 kg. Greenhouse gas footprint, measured in carbon dioxide equivalent emissions for cancelled EBV and CMV serology tests, resulted in a saving of at least 17,711 g, equivalent to driving 115 km in a standard car. Customized alerts issued at the time of test ordering can have enormous impacts on reducing cost, waste, and unnecessary testing.

Care Bundle for Acute Kidney Injury in Cardiac Patients: A Cluster-Randomized Trial.

Detection and timely intervention of acute kidney injury (AKI) is a major challenge worldwide. Electronic alerts for AKI may improve process- and patient-related endpoints. The present study evaluated the efficacy of an AKI electronic alert system and care bundle. This is a two-arm, prospective, cluster-randomized, controlled trial enrolling patients with AKI (KDIGO criteria) and cardiac diseases. Patients were randomly assigned to a routine care group or intervention group (DRKS-IDDRKS00017751). Two hundred patients (age 79 years, 46% female) were enrolled, with 100 patients in each group. The primary endpoint did not differ between patients in the routine care group 0.5 (-7.6-10.8) mL/min/1.73 m2 versus patients in the intervention group 1.0 (-13.5-15.1) mL/min/1.73 m2, p = 0.527. Proportions of patients in both study groups with hyperkalemia, pulmonary edema, and renal acidosis were comparable. The stop of antihypertensive medication during hypotensive periods was more frequent in patients in the intervention group compared to patients in the control group, p = 0.029. The AKI diagnosis and text module for AKI in the discharge letter were more frequently documented in patients in the intervention group (40%/48% vs. 25%/34%, p = 0.034; p = 0.044, respectively). Continued intake of RAAS inhibitors and the presence of a cardiac device were independently associated with a less pronounced decrease in eGFR from admission to the lowest value. In this RCT, electronic alerts for AKI and a care bundle improved process- but not patient-related endpoints.

B-328 Analytical Performance of a Screening Test for Lead Using Dried Blood Spots and ICP-MS

Abstract Introduction There is no safe blood lead levels (BLL) in children and exposure can cause irreversible neurological harm. In 2021, the CDC decreased the blood lead reference value (BLRV) to 3.5 ug/dL from 5.0 ug/dL, based on the 97.5th percentile of BLL among US children under 5 years of age. Despite this, lead poisoning disproportionately affects Black children, those below poverty levels, and living in houses built before 1978. The American Academy of Pediatrics recommends targeted screening for BLL in children aged 12–24 months living in high prevalence areas. Children enrolled in Medicaid also require screening by 24 months of age. Only one-third of children who require screening receive it and lead screening declined by &amp;gt;50% during the COVD-19 pandemic. Quality improvement strategies have included electronic health record alerts and point of care testing. To improve screening rates in our pediatric population, we developed a screening method utilizing dried blood spot (DBS) cards. This study aimed to validate the accuracy and precision of this screening method with emphasis on the performance around the BLRV cut-offs, which would be used to determine the need to follow up with a confirmatory venous lead test. Methods The method was calibrated using certified reference material traceable to NIST SRM 3128 (VHG labs, Manchester, NH, USA) in whole blood. The calibrators, controls and patient samples were spotted onto Whatman 903 cards. A 6 mm filter paper disc in extraction buffer was vortexed, allowed to sit at room temperature for 30 min and centrifuged. The samples were analyzed on the Thermo Fisher iCAP RQ and TQ (Whaltman, MA) in kinetic energy discrimination mode. The assay has a linear range of 1–100 µg/dL, and the recovery ranged from 92%–102%. We evaluated this method for reproducibility, and accuracy across the measurement range. In this study, we focused on the reproducibility and accuracy of DBS at lead concentrations around the BLRV cut-offs. We used in 2 samples spiked with NIST CRM 3128 (Inorganic Ventures, Christiansburg, VA, USA) analyzed 10 times over 3 days and 13 leftover patient samples run over at least 5 days. The total allowable error was 2 µg/dL or 10%. Results In two samples spiked to BLL of 3.5 and 3.9 µg/dL, interday precision (n = 10) ranged from 3.4% to 17.4% (SD 0.1–0.7) in samples run for 3 days. Removal of an apparent outlier decreased the %CV ranged observed to &amp;lt;8.5%. The average bias for each day ranged from 0.1 to 0.6 µg/dL. In 13 patient samples with concentrations around the BLRV ranging from 1.4 to 5.8 µg/dL, the coefficient of variation (CV) ranged from 0.2% to 32% with the largest SD at 0.8 µg/dL. The average bias for this sample set was -0.3 (11.7%). Conclusion The assay’s analytical performance is sufficient for screening purposes, but the clinical performance and the impact of introducing this test to enhance screening rates during 1 and 2 years well visits need to be evaluated further.

Qualitative analysis of a remote monitoring intervention for managing heart failure

BackgroundHeart failure (HF) is one of the most common reasons for hospital admission and is a major cause of morbidity, mortality, and increasing health care costs. The EMPOWER study was a randomized trial that used remote monitoring technology to track patients’ weight and diuretic adherence and a state-of-the-art approach derived from behavioral economics to motivate adherence to the reverse monitoring technology.ObjectiveThe goal was to explore patient and clinician perceptions of the program and its impact on perceived health outcomes and better understand why some patients or clinicians did better or worse than others in response to the intervention.ApproachThis was a retrospective qualitative study utilizing semi-structured interviews with 43 patients and 16 clinicians to understand the trial’s processes, reflecting on successes and areas for improvement for future iterations of behavioral economic interventions.Key resultsMany patients felt supported, and they appreciated the intervention. Many also appreciated the lottery intervention, and while it was not an incentive for enrolling for many respondents, it may have increased adherence during the study. Clinicians felt that the intervention integrated well into their workflow, but the number of alerts was burdensome. Additionally, responses to alerts varied considerably by provider, perhaps because there are no professional guidelines for alerts unaccompanied by severe symptoms.ConclusionOur qualitative analysis indicates potential areas for additional exploration and consideration to design better behavioral economic interventions to improve cardiovascular health outcomes for patients with HF. Patients appreciated lottery incentives for adhering to program requirements; however, many were too far along in their disease progression to benefit from the intervention. Clinicians found the amount and frequency of electronic alerts burdensome and felt they did not improve patient outcomes.Trial registrationClinicalTrials.gov Identifier: NCT02708654.

Harnessing EHR for goals of care: A randomized evaluation of electronic health record alerts for patients with gynecologic malignancies at risk for death in 6 months (165)

Harnessing EHR for goals of care: A randomized evaluation of electronic health record alerts for patients with gynecologic malignancies at risk for death in 6 months (165)

Early recognition and prevention of acute kidney injury in hospitalised children.

Acute kidney injury is common in hospitalised children and is associated with poor patient outcomes. Once acute kidney injury occurs, effective therapies to improve patient outcomes or kidney recovery are scarce. Early identification of children at risk of acute kidney injury or at an early injury stage is essential to prevent progression and mitigate complications. Paediatric acute kidney injury is under-recognised by clinicians, which is a barrier to optimisation of inpatient care and follow-up. Acute kidney injury definitions rely on functional biomarkers (ie, serum creatinine and urine output) that are inadequate, since they do not account for biological variability, analytical issues, or physiological responses to volume depletion. Improved predictive tools and diagnostic biomarkers of kidney injury are needed for earlier detection. Novel strategies, including biomarker-guided care algorithms, machine-learning methods, and electronic alerts tied to clinical decision support tools, could improve paediatric acute kidney injury care. Clinical prediction models should be studied in different paediatric populations and acute kidney injury phenotypes. Research is needed to develop and test prevention strategies for acute kidney injury in hospitalised children, including care bundles and therapeutics.

Electronic health record alerts for management of heart failure with reduced ejection fraction in hospitalized patients: the PROMPT-AHF trial.

Patients hospitalized for acute heart failure (AHF) continue to be discharged on an inadequate number of guideline-directed medical therapies (GDMT) despite evidence that inpatient initiation is beneficial. This study aimed to examine whether a tailored electronic health record (EHR) alert increased rates of GDMT prescription at discharge in eligible patients hospitalized for AHF. Pragmatic trial of messaging to providers about treatment of acute heart failure (PROMPT-AHF) was a pragmatic, multicenter, EHR-based, and randomized clinical trial. Patients were automatically enrolled 48 h after admission if they met pre-specified criteria for an AHF hospitalization. Providers of patients in the intervention arm received an alert during order entry with relevant patient characteristics along with individualized GDMT recommendations with links to an order set. The primary outcome was an increase in the number of GDMT prescriptions at discharge. Thousand and twelve patients were enrolled between May 2021 and November 2022. The median age was 74 years; 26% were female, and 24% were Black. At the time of the alert, 85% of patients were on β-blockers, 55% on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, 20% on mineralocorticoid receptor antagonist (MRA) and 17% on sodium-glucose cotransporter 2 inhibitor. The primary outcome occurred in 34% of both the alert and no alert groups [adjusted risk ratio (RR): 0.95 (0.81, 1.12), P = .99]. Patients randomized to the alert arm were more likely to have an increase in MRA [adjusted RR: 1.54 (1.10, 2.16), P = .01]. At the time of discharge, 11.2% of patients were on all four pillars of GDMT. A real-time, targeted, and tailored EHR-based alert system for AHF did not lead to a higher number of overall GDMT prescriptions at discharge. Further refinement and improvement of such alerts and changes to clinician incentives are needed to overcome barriers to the implementation of GDMT during hospitalizations for AHF. GDMT remains suboptimal in this setting, with only one in nine patients being discharged on a comprehensive evidence-based regimen for heart failure.

Systematic review and meta-analysis comparing educational and reminder digital interventions for promoting HPV vaccination uptake

Global Human papillomavirus (HPV) vaccination rates remain low despite available WHO-approved vaccines. Digital interventions for promoting vaccination uptake offer a scalable and accessible solution to this issue. Here we report a systematic review and meta-analysis examining the efficacy of digital interventions, comparing educational and reminder approaches, for promoting HPV vaccination uptake (HVU). This study also identifies factors influencing the effectiveness of these interventions. We searched PubMed, PsycInfo, Web of Science, and the Cochrane Library from each database’s inception to January 2023. Three raters independently evaluate the studies using a systematic and blinded method for resolving disagreements. From 1929 references, 34 unique studies (281,280 unique participants) have sufficient data. Client reminder (OR, 1.41; 95% CI, 1.23–1.63; P < 0.001), provider reminder (OR, 1.39; 95% CI, 1.11–1.75; P = 0.005), provider education (OR, 1.18; 95% CI, 1.05–1.34; P = 0.007), and client education plus reminder interventions (OR, 1.29; 95% CI, 1.04–1.59; P = 0.007) increase HVU, whereas client education interventions do not (OR, 1.08; 95% CI, 0.92–1.28; P = 0.35). Digital intervention effectiveness varies based on participants’ gender and the digital platform used. Interventions targeting male or mixed-gender participants demonstrate greater benefit, and reminder platforms (SMS, preference reminders, or electronic health record alerts) are more effective in increasing HVU. Digital interventions, particularly client and provider reminders, along with provider education, prove significantly more effective than client education alone. Incorporating digital interventions into healthcare systems can effectively promote HPV vaccination uptake. Reminder interventions should be prioritized for promoting HVU.

Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey.

Medication errors are common in residential aged care facilities (RACFs) due to several factors. Effective medication management is essential to prevent medication errors among older people particularly due to the complexity of co-morbidities they can experience. This study aimed to examine and quantify the contributing factors of medication errors from nurses' perspectives and the prevention strategies to reduce medication errors among older adults living in RACFs. A survey with 140 completed responses from registered nurses (RNs) and endorsed enrolled nurses (EENs) working in RACFs across Australia were included in the study. The survey had 24 items, related to contributing factors of medication errors, and the prevention strategies. Descriptive statistics and exploratory factor analysis were used in the data analysis process. The study identified medication errors are caused by contributing factors such as use of agency staffing (70.4%) and delays in receipt of laboratory results (94.3%). However, it also identified suggestions to reduce medication errors in RACFs, for example use of electronic alerts (88.3%), and efficient laboratory communication (91.8%). Our results revealed three key factors for causes (workload, interprofessional involvement and interruptions) and suggestions (medication safety alerts, medication process improvement and effective reporting). Medication errors in RACFs are a global problem being one of the leading causes of morbidity and mortality. The knowledge and awareness of the factors associated with medication errors and the prevention strategies can guide potential quality improvement plans and contribute to minimisation of risk associated with medication safety in RACFs. The study recommends strategies for best practices in medication management such as interprofessional collaboration, implementing standardised policies and electronic alerts to reduce medication errors in RACFs.

#4727 FLOZINATION: A ROLLING QUALITY IMPROVEMENT PROGRAMME

Abstract Background and Aims Sodium glucose linked transporter-2 inhibitors (SGLT2i) reduce renal and cardiovascular end points in people with chronic kidney disease (CKD), both with and without diabetes. Despite exciting data from the CREDENCE and DAPA-CKD trials, implementation of new evidence to every day clinical practice can be challenging. We present the results of a rolling quality improvement project regarding SGLT2i prescription. The aim of the project was to support clinicians in the evidence based prescribing of SGLT2i for CKD. Method Three renal units who share a single electronic clinical database agreed a joint protocol and staged implementation programme. These tertiary referral renal units cover a population of around 2.3 million people. The important timeline regarding SGLT2i licensing and interventions is shown in Figure 1. Interventions were as follows: 1. Identification of patients meeting the licensing criteria for prescription of canagliflozin for CKD with diabetes. 2. Addition of an alert to the electronic patient record. 3. SGLT2i protocol developed and advertised via poster in outpatient clinic sites. 4. Evaluation of clinician attitude to prescribing. 5. Measurement of number of patients meeting the licensing criteria for prescription of dapagliflozin for CKD with and without diabetes. Measurement of SGLT2i prescription was audited from the electronic record. Results In the first wave of the programme, 326 patients were identified as suitable under the initial licensing criteria for canagliflozin, and electronic alerts were added to the records of these patients. When measuring number of patients who may be suitable under the dapagliflozin licensing, there were 562 patients with diabetes and 5262 without diabetes. In a survey of clinician attitudes, 94% suggested they felt well equipped to prescribe SGLT2i. Prescribing of SGLT2i across time is shown in Figure 2. 1146 patients have been prescribed SGLT2i. Age was 64±13 years, and the majority were male (68%) with type 2 diabetes mellitus (61%). Most (73.6%) were treated with angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB). More than half (54%) of patients live in areas with high levels of socio-economic deprivation (Scottish Index of Multiple Deprivation quintiles 1 or 2). Estimated glomerular filtration rate was 40.9±23.5ml/min/1.73 m2 and Kidney Failure Risk Equation (KFRE) 5 year risk of end stage kidney disease (ESKD) was 23.2±28.2%. In comparison with the general outpatient clinic population, the distribution of socioeconomic deprivation was similar, but a higher proportion were female (46%). Conclusion An iterative quality improvement project was designed around the evolving drug licensing of SGLT2i and capitalised on local strengths, including an effective and well used clinical electronic database shared across renal units. Clinicians have been supported in SGLT2i prescribing with highly visible clinical protocols, and electronic alerts to highlight candidate patients. A high level of SGLT2i prescribing has been achieved in a population at high risk of ESKD. Further interventions should focus on prescribing in groups where gaps have been identified – such as women and those without diabetes. Other units would be recommended to capitalise on existing strengths, exploit the use of clinical databases, and ensure protocols are inclusive and well-advertised in order to optimise evidence based treatment of CKD.

#6321 ELECTRONIC CREATININE ALERT SYSTEM. A FIRST STEP TOWARDS PREVENTING HOSPITAL ACQUIRED ACUTE KIDNEY INJURY

Abstract Background and Aims Acute kidney injury (AKI) is a common complication in the critically ill and non-critically ill patient. There is currently no specific treatment for patients who develop AKI, so early recognition may help prevent progression to more advanced stages and the need for kidney replacement therapies (KRT). Electronic Alert Systems (EAS) emerge as a useful tool in different clinical scenarios to alert the clinician to potentially harmful situations. One of the utilities of the EAS is the AKI scenario, in which the clinician can be alerted early to serum creatinine (SCr) changes in real time and thus establish early intervention protocols to avoid the poor outcomes described above. The aim of the present study is to analyze the incidence of AKI in a tertiary hospital using an EAS based on SCr changes (Electronic Creatinine Alert System -ECAS-). Method Retrospective study conducted in a tertiary referral hospital. All discharges of patients over 18 years of age, which were issued from 1 January 2019 to 31 December 2021, were analyzed. Exclusion criteria were: discharges from critical care units, patients admitted to the emergency room, patients with AKI criteria on admission, patients admitted to the nephrology department and patients with CKD G5 or on KRT. The ECAS was developed with the aim of alerting patients with and increase of ≥ 0.3mg/dL of SCr or an elevation of ≥ 1.5 times the baseline creatinine value, based on AKI SCr from the KDIGO guidelines. The aims of the present study were: 1. Number of hospitals discharges that activated the ECAS, as well as the severity of AKI; 2. Categorize the departments in which ECAS was common; and 3. Assessing length of hospital stay, survival and kidney recovery during admission defined as SCr less than 1.5 times baseline. Results A total of 69,002 discharges were analyzed over 3 years. Finally, 46,149 discharges were included in the analysis, of which 5,593 (13.5%) discharges activated the ECAS. The distribution by year in which the ECAS was activated was 1,788 (11,8%) of all discharges in 2019, 1,860 (12,4%) in 2020 and 1,945 (12,1%) in 2021. The median age was 75 years (65 – 83), 62% were male. The 5 departments with the highest number of ECAS activations were: Geriatric (14.2%), Cardiology (11.9%), General Surgery (9.9%), Infectious Diseases (9.2%) and Cardiac Surgery (7.6%). Baseline SCr was 1.12mg/dL (0.80-1,79), maximum SCr was 1.99mg/dL(1.40 - 3.19) and SCr at discharge was 1.39 (0.96 - 2.23). 69,7% of patients had AKI stage 1, 21,3% had AKI stage 2 and finally 9% had AKI stage 3. Length of hospital stay was significantly elevated in patients who activated the ECAS [6 days (3 - 11) vs. 13 (8 - 22); p: &amp;lt;0.001], the survival distributions for the ECAS activation were statistically different, X2 (2) = 5.522, p: 0.019. Finally, kidney recovery at discharge was significantly lower in AKI 2 (18.5%) and AKI 3 (8.5%) patients compared to AKI 1 patients (73%) (p: &amp;lt;0.001 for all). Conclusion The ECAS is a suitable electronic alert system that allows rapid identification of patients with AKI. The activation of ECAS is associated with poor outcomes. This study led to the adoption of a nephrology rapid response team for early detection of AKI before creatinine elevation using among others Point-of-care ultrasonography and acute kidney stress biomarkers.