Electronic Medical Record Alerts Research Articles

Perioperative cefazolin prescribing rates following suppression of alerts for non-IgE-mediated penicillin allergies.

Cefazolin is the preferred antimicrobial for the prevention of surgical site infections (SSIs) in many procedures. The presence of penicillin allergies can influence prescribing of alternative agents like vancomycin. In April 2022, Nebraska Medicine implemented a suppression of alerts for non-IgE-mediated and nonsevere penicillin allergies in the electronic medical record (EMR) upon cephalosporin prescribing. The objective of this study was to evaluate changes in perioperative cefazolin for SSI prophylaxis. This was a quasi-experimental study of patients undergoing procedures for which cefazolin was the preferred agent per institutional guidance. Education on the change was distributed via e-mail to surgical staff and pharmacists. Pre- and post-intervention data were collected from April 2021 through March 2022 and April 11, 2022, through October 2022, respectively. Chart review was performed on patients with reported penicillin allergies for the top surgical procedures with <50% cefazolin utilization pre-intervention. The primary outcome was the administration of perioperative cefazolin in patients with penicillin allergies, including unknown reactions. A total of 6,676 patients underwent surgical procedures (pre-intervention n = 4,147, post-intervention n = 2,529). Documented penicillin allergies were similar between the pre- and post-intervention group (12.3% vs. 12.6%). In individuals with documented penicillin allergies, cefazolin prescribing increased from 49.6% to 74.3% (p < 0.01). Chart review for safety outcomes identified no difference in new severe reactions, rescue medication, SSIs, acute kidney injury, postoperative Clostridioides difficile infection, or methicillin-resistant Staphylococcus aureus infections. Following the suppression of EMR alerts for non-IgE-mediated and nonsevere penicillin allergies, cefazolin prescribing rates for SSI prophylaxis significantly improved.

An emergency department-based system intervention to improve osteoporosis screening for older adults at high-risk of fracture

Abstract Falls and osteoporosis are risk factors for fragility fractures. Bone mineral density (BMD) assessment is associated with better preventative osteoporosis care, but it is underutilized by those at high fracture risk. We created a novel electronic medical record (EMR) alert-driven protocol to screen patients in the emergency department (ED) for fracture risk and tested its feasibility and effectiveness in generating and completing referrals for outpatient BMD testing after discharge. The EMR alert was configured in two tertiary-care EDs and triggered by the term “fall” in the chief complaint, age (≥65 years for women, ≥70 years for men), and high fall risk (Morse score ≥ 45). The alert electronically notified ED study staff of potentially eligible patients. Participants received osteoporosis screening education and had BMD testing ordered. From November 15, 2020 to December 4, 2021, there were 2608 EMR alerts among 2509 patients. We identified 558 patients at high-risk of fracture who were screened for BMD testing referral. Participants were excluded for: serious illness (N = 141), no documented health insurance to cover BMD testing (N = 97), prior BMD testing/recent osteoporosis care (N = 58), research assistant unavailable to enroll (N = 53), concomitant fracture (N = 43), bedridden status (N = 38), chief complaint of fall documented in error (N = 38), long-term care residence (N = 34), participation refusal (N = 32), or hospitalization (N = 3). Of the 16 participants who had BMD testing ordered, 7 scheduled and 5 completed BMD testing. EMR alerts can help identify subpopulations who may benefit from osteoporosis screening, but there are significant barriers to identifying eligible and willing patients for screening in the ED. In our study targeting an innovative venue for osteoporosis care delivery, only about 1% of patients at high-risk of fracture scheduled BMD testing after an ED visit. Adequate resources during and after an ED visit are needed to ensure that older adults participate in preventative osteoporosis care.

Retrospective analysis of the impact of electronic medical record alerts on low value care in a pediatric hospital.

Hospital costs continue to rise unsustainably. Up to 20% of care is wasteful including low value care (LVC). This study aimed to understand whether electronic medical record (EMR) alerts are effective at reducing pediatric LVC and measure the impact on hospital costs. Using EMR data over a 76-month period, we evaluated changes in 4 LVC practices following the implementation of EMR alerts, using time series analysis to control for underlying time-based trends, in a large pediatric hospital in Australia. The main outcome measure was the change in rate of each LVC practice. Balancing measures included the rate of alert adherence as a proxy measure for risk of alert fatigue. Hospital costs were calculated by the volume of LVC avoided multiplied by the unit costs. Costs of the intervention were calculated from clinician and analyst time required. All 4 LVC practices showed a statistically significant reduction following alert implementation. Two LVC practices (blood tests) showed an abrupt change, associated with high rates of alert adherence. The other 2 LVC practices (bronchodilator use in bronchiolitis and electrocardiogram ordering for sleeping bradycardia) showed an accelerated rate of improvement compared to baseline trends with lower rates of alert adherence. Hospital savings were $325 to $180 000 per alert. EMR alerts are effective in reducing pediatric LVC practices and offer a cost-saving opportunity to the hospital. Further efforts to leverage EMR alerts in pediatric settings to reduce LVC are likely to support future sustainable healthcare delivery.

2505. Using an Electronic Medical Record Alert to Screen Inpatient Encounters for People with Hepatitis C

Abstract Background Despite the availability of effective therapy, rates of linkage and uptake of hepatitis C virus (HCV) treatment remain suboptimal. People with HCV are hospitalized at a rate 3.7 times that of the general population, presenting an opportunity for linkage to care during inpatient admissions. We designed two novel electronic medical record (EMR) alerts to identify patients with HCV in two hospitals, and report on the alerts’ test-performance characteristics. Methods We developed two distinct EMR alerts and ran them silently on all adult hospitalizations at two academic medical centers in Baltimore, MD. Based on laboratory data, and diagnosis codes (Figure 1); the first alert identified all people ever infected with HCV (ever-alert); and, the second, only people with active HCV viremia (active-alert). We evaluated each alert’s positive predictive value (PPV) by manually reviewing all charts alerted during the study period. We evaluated alert sensitivity by reviewing a sample of consecutive hospital encounters during the same period to determine if they were alerted. Results From 6/29/2022-8/9/2022, the alerts examined 7,519 adult hospital encounters. The ever-alert was triggered for 569 encounters; 563 of 569 were truly ever-infected (PPV 98.9% [95% CI 98.1%, 99.8%]), and 202 of 569 were actively-infected (PPV 35.5% [31.6%, 39.4%]), corresponding to an active infection prevalence of 202/7,519 (2.7%). The active-alert was triggered for 267 encounters; 188 of 267 were actively-infected (PPV 70.4% [65.0%-75.8%]), corresponding to a 2.5% prevalence of active infection. The consecutive chart review examined 1157 patients, 122 (10.5%) of whom were ever-infected, including 44 (3.8%) actively-infected. The ever-alert identified 106/122 (sensitivity 86.9% [80.9%, 92.9%]) and the active-alert identified 37/44 (sensitivity 84.1% [73.3%, 94.9%]) of these respectively (Table 1). Conclusion An alert designed to identify only active infection has a comparable sensitivity (84.1% vs 86.9%) but significantly higher PPV (70.4% vs. 35.5%) for active infection than an alert designed to capture any infection (active or ever). These results support the use of an EMR alert for an HCV outreach program to link patients to care. Disclosures Oluwaseun Falade-Nwulia, MBBS ,MPH, Abbvie Inc: Grant/Research Support|Gilead Sciences: Advisor/Consultant Kelly Gebo, MD, MPH, Pfizer: Advisor/Consultant|Spark HealthCare: Advisor/Consultant

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.

Abstract 16357: Reducing Repeat Transthoracic Echocardiograms in the Inpatient Setting

Background: Transthoracic echocardiogram (TTE) is a common cardiovascular imaging test for hospitalized patients. Repeat TTE testing, defined as a TTE done within one year of a prior TTE, contribute to high resource utilization without clear impact on changes in management. Hypothesis: An interruptive electronic medical record (EMR) alert deployed for repeat TTEs will decrease TTE overordering and will help elucidate reasons behind TTE ordering practices. Methods: We created an interruptive EMR alert for five hospitals within the Johns Hopkins Health System (JHHS). The alert was triggered when an inpatient TTE was ordered for non-ICU/non-cardiology service patients with a completed TTE within the prior 90 days. The alert displayed most recent TTE results and prompted the clinician to continue with the order or not. If order continuation was selected a free text clinician reason was required. Outcomes were length of stay (LOS) and reduction in repeat TTE orders. Focus groups were held with internal medicine residents to understand practice behaviors, given this was a leading cohort that continued with orders. Results: From July 2021- July 2022 the alert triggered 4,976 times, of these 32% of orders were discontinued while 68% were continued. There was no significant reduction in repeat TTE order attempts per month. More orders were continued at academic hospitals compared to the community setting (71% vs 63%, p=&lt;0.01). Medicine and non-medicine departments continued the order at similar rates (69% and 67%, p=0.12). Patients who had a repeat TTE had a longer average LOS compared to those who did not (14 vs 11 days, p=0.08). Twenty internal medicine residents were interviewed for focus groups. Top reasons for order continuation were a change in clinical status (n=8), worsening of chronic conditions (n=5), and post procedure monitoring (n=3). Majority (70%) requested more education within the alert to guide indications for repeat TTE ordering. Conclusion: EMR alerts can reduce repeat TTEs without increasing LOS, however knowledge gaps persist for ordering providers. Iterative changes to our health system EMR alert with a focus on best practice guideline incorporation and education may better mitigate overordering, and thus acute care utilization, in the future.

Abstract 16120: Efficacy of an Electronic Medical Record Alert System in Identifying Cardiac Implantable Electronic Device Infection

Introduction: Cardiac Implantable Electronic Device infection (CIED-I) is common, morbid, and frequently under recognized. Electronic Medical Record (EMR) based alerts have been proposed as a solution to improve detection of CIED-I. Hypothesis: Development of a real-time EMR algorithm to identify CIED-I can improve recognition of patients with CIED-I. Methods: An EMR (Epic, Verona, WI) alert system to identify inpatients with CIED-I was developed based on the presence of CIED and positive blood cultures. The presence of CIED was determined using patient problem list, structured data elements describing device implantation, and prior device interrogation. Alerts were generated each time a patient with CIED had a positive blood culture. We examined patients admitted between January 2020 - March 2023. Identified patients were adjudicated manually to confirm: (1) the presence of CIED and (2) true bacteremia versus contaminant based on patient and microbiological characteristics. Results: The algorithm generated 255 alerts, corresponding to 100 unique patients over 142 hospitalizations. Of these alerts, 213 appropriately identified 88 unique patients with positive blood cultures and CIEDs, resulting in an alert specificity of 84% and patient specificity of 88%. The remaining 42 (16.6%) alerts occurred in 10 patients who no longer had CIED due to prior CIED extraction (6 at the time of heart transplant and 4 with extraction without reimplantation) as well as 2 patients with erroneous blood culture identification (one positive syphilis antibody test and one lab documentation error). In patients with appropriate alerts, 27 patients had 4/4 positive blood culture bottles, 5 patients had 3/4, 10 patients had 2/4, 41 patients had 1/4, 2 patients had 2/2, and 1 patient had 1/2. The positive predictive value of the algorithm to identify true bacteremia was 0.65 (138/213). Conclusions: The algorithm has high specificity to identify patients with possible CIED infection. Improving the accuracy of device detection, by incorporating radiology imaging or history of extraction, could further improve specificity. Positive predictive value and alert fatigue could be improved by stratifying alerts by blood culture species and total number of positive blood cultures.

Improving Healthcare Providers’ Adherence to Foot Exams for Type-II Diabetic Patients in a Primary Care Clinic

Foot wounds are complications of type II diabetes mellitus (T2DM), which may be prevented with proper foot assessments. Diabetic foot exams are not consistently performed despite evidence-based screening tools available. Objective: To determine if the implementation of an electronic medical record (EMR) alert using Inlow’s 60-Second Diabetic Foot Screen would impact the number of diabetic foot exams performed among T2DM patients at a primary care level. Method: A quantitative quasi-experiment design was used to implement an electronic medical record (EMR) alert using Inlow’s 60-Second Diabetic Foot Screen to impact the frequencies of diabetic foot exams. Sample size was 65, n=35 in the comparative group and n= 30 in the implementation group. Population consisted of male and female patients ages 18 years and older, diagnosed with T2DM within the last two years, no previous diabetic foot exams or received foot care education, did not perform self-reported foot inspections, and were able to read, write, and speak English. A chi square test was run to analyze the frequencies of foot exams between groups. Results: A Pearson’s chi-square showed a statistically significant increase in the foot exams X2 (1, N=65) = 5.286, p= 0.02 using an EMR alert with Inlow’s 60-Second Diabetic Foot screen. Conclusion: EMR alerts increase performance of diabetic foot exams. Recommendations include sustainment of the program, dissemination of results, and further investigation of the impact of EMR alerts. Keywords: Diabetes, Foot screening, EMR alert

Effect of an electronic medical record nudge to improve quality improvement program tracking of neuraxial catheter replacements in obstetric patients

BackgroundMonitoring complications associated with medical procedures requires reliable and accurate record keeping. Nudge reminders executed by way of electronic medical record (EMR) alerts influence clinician behaviour. We hypothesised that the...

Evaluation of a behavioural intervention to reduce perioperative midazolam administration to older adults

BackgroundOlder patients commonly receive benzodiazepines during anaesthesia despite guidelines recommending avoidance. Interventions to reduce perioperative benzodiazepine use are not well studied. We hypothesized an automated electronic medical record alert targeting anaesthesia providers would reduce administration of benzodiazepines to older adults undergoing general anaesthesia. MethodsWe conducted a retrospective study of adults who underwent surgery at 5 hospitals within one US academic health system. One of the hospitals received an intervention consisting of provider education and an automated electronic medical record alert discouraging benzodiazepine administration to patients aged 70 years or older. We used difference-in-differences analysis to compare patterns of midazolam use 12-months before and after intervention at the intervention hospital, using the 4 non-intervention hospitals as contemporaneous comparators. ResultsThe primary analysis sample included 20,347 cases among patients aged 70 and older. At the intervention hospital, midazolam was administered in 454/4,240 (10.7%) cases pre-alert versus 250/3,750 (6.7%) post-alert (p<0.001). At comparator hospitals, respective rates were 3,186/6,366 (50.0%) versus 2,935/5,991 (49.0%) (p=0.24). After adjustment, the intervention was associated with a 3.2 percentage point (p.p.) reduction in the percentage of cases with midazolam administration (95% CI: (-5.2, -1.1); p=0.002). Midazolam dose was unaffected (adjusted mean difference -0.01 mg, 95% CI: (-0.20, 0.18); p=0.90). In 76,735 cases among patients aged 18–69, the percentage of cases with midazolam administration decreased by 6.9 p. p. (95% CI: (-8.0, -5.7); p<0.001). ConclusionProvider-facing alerts in the intraoperative electronic medical record, coupled with education, can reduce midazolam administration to older patients presenting for surgery but may affect care of younger patients.

Real-world experience of an in-house dihydropyrimidine dehydrogenase (DPYD) genotype test to guide fluoropyrimidine (FP) dosing at a multisite cancer hospital.

1534 Background: FPs, including 5-fluorouracil and capecitabine, are widely used to treat solid tumor malignancies like gastrointestinal (GI) cancers. One-third of patients (pts) develop severe toxicities which may lead to treatment delays or hospitalization. Toxicities can be partly due to genetic variations in DPYD. Herein, we describe the implementation of an in-house DPYD test and its impact on FP dosing at a multisite cancer hospital. Methods: This is an observational study of pts starting or continuing FP-based chemotherapy who received DPYD testing as part of routine care. Buccal swabs were collected in clinic and sent to an in-house lab for genotyping using a polymerase chain reaction-based Drug Metabolizing Enzyme assay that interrogates all 5 variants with moderate-to-strong evidence according to the Clinical Pharmacogenetics Implementation Consortium (CPIC) (c.1905+1G&gt;A, c.2846A&gt;T, c.1679T&gt;G, c.1236G&gt;A and c.557A&gt;G). Phenotype translations and dosing were based on CPIC guidelines. Test results and dose recommendations were uploaded to the electronic medical record (EMR) and emailed to the care team. In April 2022, pre- and post-test EMR alerts were built to prompt test ordering and dose modifications. The primary objective was to evaluate the proportion of DPYD variant carriers in tested pts receiving FP. Secondarily, we evaluated turnaround time and impact on FP dosing. Results: From March 2020-December 2022, 491 pts across 14 clinics received DPYD genotyping (54% male, 74% White, 20% Black, median age 53 years). GI cancers (~50% colorectal) represented 90% of the diagnoses. The median lab turnaround time was 3 (IQR 2-6) days. Pretreatment testing was ordered in 389 (79%) pts, of which 360 (93%) had results before cycle 1. Overall, 30 pts (6.1%) were heterozygous carriers (4.9% in pretreatment and 10.8% in reactive testing groups). Variants observed were c.1236G&gt;A (n=13), c.2846A&gt;T (n=8), c.1905+1G&gt;A (*2A) (n=4), c.557A&gt;G (n=4), and c.1679T&gt;G (*13) (n=1). FP dose was modified in 27 (90%) pts (reduced in 25, avoided in 1, discontinued in 1). Of 19 carriers with pretreatment testing, 17 (90%) received an upfront dose reduction (mean reduction 42%; 3 had subsequent dose escalations); 1 avoided FP and 1 declined chemotherapy. Of 11 carriers with reactive testing, 9 had dose reductions (mean reduction 39%) and 2 discontinued FP due to toxicity. The mean FP dose intensity at cycle 1 was 56% in pretreatment carriers, 97% in reactive carriers, and 94% in wild type pts. Conclusions: DPYD genotype-guided FP dosing is feasible at a multisite cancer hospital. In-house rapid turnaround DPYD testing identified variant carriers and resulted in treatment/dose modifications for most carriers, potentially avoiding or mitigating severe toxicities and/or hospitalization, particularly with pretreatment testing. Toxicity evaluation is ongoing.

Implementation of Clinical Cytochrome P450 3A Genotyping for Tacrolimus Dosing in a Large Kidney Transplant Program.

Tacrolimus is a calcineurin inhibitor with a narrow therapeutic range and is metabolized by cytochrome P450 (CYP) isoenzymes CYP3A4 and CYP3A5. The Clinical Pharmacogenetic Implementation Consortium published evidence-based guidelines for CYP3A5 normal/intermediate metabolizers prescribed tacrolimus, yet few transplant centers have implemented routine testing. The objective of this study was to implement preemptive CYP3A genotyping into clinical practice in a large kidney transplant program and to evaluate workflow feasibility, potential clinical benefit, and reimbursement to identify barriers and determine sustainability. Preemptive pharmacogenetic testing for CYP3A5 and CYP3A4 was implemented in all patients listed for a kidney transplant as part of standard clinical care. Genotyping was performed at the listing appointment, results were reported as discrete data in the electronic medical record, and education and clinical decision support alerts were developed to provide pharmacogenetic-recommended tacrolimus dosing. During this initial phase, all patients were administered standard tacrolimus dosing, and clinical and reimbursement outcomes were collected. Greater than 99.5% of genotyping claims were reimbursed by third-party payers. CYP3A5 normal/intermediate metabolizers had significantly fewer tacrolimus trough concentrations within the target range and a significantly longer time to their first therapeutic trough compared to poor metabolizers. The challenge of tacrolimus dosing is magnified in the African American population. The US Food and Drug Administration drug label recommends increased starting doses in African ancestry, yet only ≈66% of African Americans in our cohort were normal/intermediate metabolizers who required higher doses. Routine CYP3A5 genotyping may overcome this issue by using genotype over race as a more accurate predictor of drug response.

1791. Leveraging EMR Alerts for Vancomycin Time Outs

Abstract Background Vancomycin represented the most used antibiotic at our academic medical center from 2014-2022. To enhance compliance with the “antibiotic time out” part of the CDC Core Elements for Stewardship, we designed an electronic medical record (EMR) best practice alert (BPA) to assist providers in identifying patients eligible for vancomycin discontinuation. Methods This is a single center, retrospective pre (06/01/14-2/24/20)/post (02/25/20-03/31/22) comparison of vancomycin utilization after the introduction of a locally validated automated vancomycin time-out. The BPA alerted on patients who had received vancomycin for 72h, had no microbiological evidence of methicillin resistant S. aureus, and had no infectious diseases consult. While other vancomycin reduction strategies had previously been implemented as part of the stewardship program, no other intervention debuted during the same time period. An interrupted time series analysis was performed to assess immediate and ongoing trend changes of institutional vancomycin use. Wilcoxon rank sum and chi2 analyses were also performed. Results There were 36,817 inpatient vancomycin orders placed. The BPA triggered during 1,881 (15.7%) orders in the post-BPA period, which was 49.6% of the 3,794 orders still active at 72h. After BPA introduction, there was an immediate decrease in vancomycin days of therapy (DOT)/1000 patient days (PD) ±SE (-8.5 ±3.6; P = 0.021) followed by a significant decrease in the monthly trend relative to the pre-intervention trend (-0.7 DOT/1000 PD ±0.2; P&amp;lt; 0.001). Median vancomycin DOT/1000 PD decreased from 145.9 (IQR 140.2-153.0) to 117.3 (IQR 107.7-122.6) in pre and post periods respectively (P&amp;lt; 0.001). Length of therapy (LOT) decreased, orders were more commonly discontinued by day 5, and orders were more likely to be discontinued prior to discharge. Separate analysis including only orders with &amp;gt;72h showed similar results (Table 1). Table 1Vancomycin length of therapy (LOT) pre and post-BPA Time Out.Figure 1Vancomycin days of therapy per 1000 patient days (DOT/1000PD) trends pre and post-BPA Time Out. Conclusion Introduction of an EMR automated vancomycin time out was an effective tool to decrease vancomycin utilization at an academic medical center. Disclosures All Authors: No reported disclosures.

S1441 Improving Rate of Compliance With Hepatitis C Virus Screening

Introduction: Screening patients for hepatitis C virus infection is frequently overlooked. This is a leading cause of chronic liver disease in the US. The US Preventive Services Task Force determined screening is beneficial in patients aged 18-79. Previously, only those born between 1945-1965. The American Association for the Study of Liver Diseases recommends a one-time antibody test in adults 18 years and older. Even though treaTable, screening rate of hepatitis C virus antibody in patients aged 18-55 or 77-79 is only 70% in the primary care settings in Syracuse, Rome, and Binghamton. Inadequate detection leads to missed treatment opportunities and contributes to significant liver disease. Our quality improvement initiative aims to increase compliance rate with hepatitis C virus screening for all outpatient primary care visits for patients aged 18-55 or 77-79 by 20% from baseline of 70% to 90% in 6 months. Methods: Data was obtained from internal medicine and family medicine outpatient clinics at three locations (Syracuse, Rome, and Binghamton). Eligible patients were divided into two groups: 18-55 or 77-79 years was the group of interest and 56-76 years (born between years 1945-1965) was the reference group as testing in this group of patients had previously been practiced. Completed testing from July-September 2021 served as baseline. Gap analysis was performed identifying causes of reduced compliance. Interventions were taken at the patient level (distribution of informational flyers and provider education), provider level (education on guidelines), and system level (electronic medical record alerts). Interventions were initiated in October 2021 and testing rates were tracked until the end of February 2022. IRB approval was not pursued. Results: The rate of screening with hepatitis C virus antibody in patients aged 18-55 or 77-79 improved by 2.3% from 70% to 72.3% from October 1, 2021, to March 31, 2022, across three sites. Binghamton's rate improved by 5%. 397 tests have been ordered during this time and 240 were for the age group of interest. (Figure) Conclusion: Compliance with hepatitis C viral screening is suboptimal in outpatient settings. Focused and simple interventions at the patient, provider, and system levels can increase compliance and help reduce the burden of significant liver disease. We hypothesize continued education and monitoring of data will demonstrate improved rates due to long time between primary care visits. Additional interventions may improve rates further.Figure 1.: Hepatitis C Virus Screening Rates Between July 2021-March 2022 in the Syracuse, Rome, and Binghamton Primary Care Clinics

S1409 Improving Provider Adherence to Nutritional and Metabolic Recommendations in Patients With Acute Alcoholic Hepatitis: A Quality Improvement Initiative

Introduction: Alcoholic hepatitis (AH) is an acute, inflammatory liver disease associated with high morbidity and mortality, both short and long term. Current medical therapy for severe alcoholic hepatitis relies on corticosteroids, which have modest efficacy. Alcohol abstinence is of critical importance but recidivism is high. Efficacious medical treatments for alcoholic hepatitis are lacking. Preliminary and Preclinical studies include use of Antibiotics, IL-1 inhibitors, GCSF and antioxidants. Malnutrition and sarcopenia are common among hospitalized AH patients with negative impact on outcome.[1] Current guidelines generally recommend daily protein intake of 1.2–1.5 g/kg/day and caloric intake of 30- 40 kcal/kg/day in alcoholic hepatitis patients. [2][3] Our objective is to implement methods to facilitate adherence to nutritional recommendations in hospitalized patients with AH. Methods: We conducted a 12-month retrospective study followed by a 3-month prospective interventional study at Presbyterian Medical Center. Chart review was performed to evaluate adherence with nutritional recommendations in patients with AH. A 3-month intervention was performed to improve compliance. This included the creation of a customized best practice advisory alert (BPA) in the Electronic medical record (EMR). The triggers included elevated ALT/AST, bilirubin >3 and documented alcohol use within 8 weeks. Alert encouraged physicians to request a nutrition consult if the diagnosis of AH was appropriate. Results: 105 patients with 82 in the pre- and 23 post-intervention periods were reviewed. No significant difference in patient characteristics and demographics was noted between the 2 groups. The intervention implemented revealed a 79% increase in adherence to nutritional recommendation (P < 0.023). Adherence was quantified as modified diet orders in EMR to include high protein diet ( minimum of 60 grams/daily ) and/or addition of supplemental high protein milk shakes to meals and/or electronic consult to nutritionist. Conclusion: AH has high morbidity and mortality. Current pharmacological options remain limited. Patients with AH are commonly malnourished and sarcopenic. System based auto-generated EMR alerts help increase compliance with the nutritional recommendations as well as enforce evidence-based practices in this select patient population.

Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial.

To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing. We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors. Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]). Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse. Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines. NCT02709772.

Increasing Naloxone Co-Prescribing Among At-Risk Individuals: Evaluation of a Quality Improvement Project in a Large Health System

Background: Naloxone availability and early administration is key in preventing death following opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of at-risk patients had naloxone prescriptions Methods: Included in this study were all patients of MaineHealth, a health system comprising 9 hospitals and 30 primary care practices, serving approximately 1.1 million patients. Between 2017 and 2020, we implemented several system-wide quality improvement interventions to increase rates of naloxone co-prescribing among at-risk individuals. Risk factors included prescribed opioids ≥50 morphine milligram equivalents, concurrent prescriptions for opioids and benzodiazepines or sedative/hypnotics, a diagnosis of substance use disorder, or a history of opioid overdose. Our interventions included (1) a standing order for naloxone in the hospital pharmacy, (2) in-person naloxone trainings for all clinical and non-clinical primary care staff, (3) online training modules, (4) guidelines on naloxone co-prescribing sent via email, and (5) automated alerts in the electronic medical record (EMR). To evaluate these interventions, the EMR for, was queried for patients with one or more risk factors for opioid overdose, and whether they had naloxone on their medication list between 2017 and 2020. Results: Over the course of the study period, overall rate of naloxone co-prescribing system-wide increased from 0.4% to 26% of patients. Automatic EMR alerts were associated with an increase of 4.5%, the largest single-quarter increase. Online education modules and guideline dissemination were associated with smaller increases of 0.9% and 3% in the two quarters following their implementation. In-person trainings and making naloxone available without a prescription were followed by Conclusions: Our most effective intervention was automatic alerts in the EMR, while e online trainings and guidelines produced modest effects. A notable increase was also seen in one hospital system whose entire leadership and staff deliberately prioritized increasing naloxone access. Even with these gains, we have not yet achieved adequate co-prescribing across our system.

Recruitment and Retention of Urban Pregnant Women to a Clinical Study Administering an Oral Isotope Dietary Tracer.

Introduction:Pregnant women are a vulnerable population that are difficult to engage in clinical research. We report successful recruitment and retention strategies used in a longitudinal pilot study of urban racially/ethnically diverse pregnant women that involved administration of an orally ingested isotope tracer, multiple venipunctures, biopsy of placenta after delivery, and cord or placental blood collection.Materials and Methods:We used direct strategies to recruit English-speaking obese and nonobese pregnant women aged 17–45 years, who were in the third trimester of pregnancy. The study required data collection at 32–34 and 34–36 gestational weeks and delivery. Strategies included frequent personal engagement with participants and staff to build relationships and trust, tangible appreciation, and the study team being present at delivery. In addition, leveraging hospital information technology (IT) services was critical to ensure retention through labor and delivery (LD).Results:A racially (52% Black, 23% White, and 10% other) and ethnically (15% Hispanic or Latinx) diverse sample of pregnant women was enrolled. Of the 52 women enrolled, 85% of women completed all procedures.Conclusions:This is the first report of successful strategies for recruitment and retention of racially/ethnically diverse pregnant women in a longitudinal study requiring oral administration of an isotope tracer. Personal engagement with multiple touch points, starting with recruitment and continuing regularly throughout the third trimester, was the most successful strategy. Creating and maintaining relationships with the LD providers and staff and utilizing hospital IT, including targeted electronic medical record alerts, ensured successful retention for the duration of the study.Trial Registration:Not applicable.

Abstract WMP32: EMR Alert Improves Compliance With Dysphagia Assessment In Stroke Patients

Introduction: Dysphagia in patients after a stroke is very common. There is a risk factor for aspiration pneumonia and is associated with worse patient outcomes. The American Heart Association guidelines recommend that a swallow screening be performed on all stroke patients prior to any oral intake. Stroke can present with a variety of symptoms and may not be identified at the time of the patient’s presentation. In analyzing patient data in which the dysphagia screening was not completed, it was identified to occur at the first oral intake of a medication. Our hypothesis is that if the nurse was alerted at the time of medication administration that a dysphagia screening needs to be completed, we could improve our compliance with this quality measure. Method: A new Electronic Medical Record (EMR) process was developed, that based on certain criteria, triggered an alert for the nurse when the first oral medication barcode was scanned. Within the alert there is a link to document the dysphagia screening. After documentation of the screening, the nurse is returned to the medication administration record to continue her administration. The criteria for triggering the alert is twofold. The first trigger is based on the presenting chief complaint on arrival to the emergency department. These would include chief complaints such as stroke symptoms, dizziness, weakness, etc. The second trigger occurs when the physician enters an order for dysphagia screening to be completed by nursing. With each of these triggers, the EMR logic looks to see if a dysphagia screen has already been documented and the alert only is generated if it has not. This process was initiated in the EMR in February 2021 for all 12 hospitals in the University Hospitals health system. Results: At University Hospitals Parma Medical Center dysphagia screening compliance improved from 82% in QTR 3 2020 to 90% in QTR 2 2021. Overall, in the University Hospital health system compliance improved from 85% in QTR 3 2020 to 89% in QTR 2 2021. Conclusion: An EMR alert has assisted the nurse to remember to complete this important dysphagia screening and improved compliance with this quality measure. In addition, nurses have reported an increase in satisfaction with the new workflow.

Distribution of Genomic Testing Resources by Oncology Practice and Rurality: A Nationally Representative Study.

Oncologists are increasingly using molecular profiling to inform personalized patient treatment decisions. Despite its promising utility, the integration of genomic testing into diverse clinical health care settings across geographic settings has been understudied. We used data from the National Survey of Precision Medicine in Cancer Treatment, a nationally representative sample of practicing US oncologists, to assess the availability of six genomic testing resources, including on-site pathology, contracts with outside laboratories, on-site genetic counselors, internal policies or protocols for using genomic and biomarker testing, electronic medical record alerts, and genomic or molecular tumor boards. We used multivariate logistic regression models to examine differences in the availability of each genomic testing resource by practice type and rurality while adjusting for payer mix and patient volume. A larger proportion of multispecialty group and academic practices had genomic testing resources available compared with solo and nonacademic practices. Electronic medical record alerts were the least available resource, whereas contracts with outside laboratories were the most available resource. Compared with urban practices, there were significantly fewer practices located in rural areas that had on-site pathology, on-site genetic counselors, protocols for genomic tests, and molecular tumor boards. Genomic testing resources varied by practice type and geography among a nationally representative sample of practicing oncologists. This variation has important implications for the development of interventions and policies to support the more equitable delivery of precision oncology to patients with cancer.