Electronic Medical Record Order Sets Research Articles

Improving Time to Antibiotics for Long-Bone Open Fractures: A Quality Improvement Initiative.

Open fractures, which are exposed to the external environment, are at a high risk of infection. Administering antibiotics within 60 minutes of emergency department (ED) arrival is crucial to prevent infection. However, this is difficult to achieve due to high ED patient volumes. The purpose of our project was to improve time to antibiotics for patients presenting with long-bone open fractures at a Level 1 trauma center ED. We used the Lean Six Sigma Define, Measure, Analyze, Improve, and Control project framework to guide our efforts. Our interventions composed of developing educational initiatives, creating an electronic medical record order set, and restructuring the ED workflow to prioritize long-bone open fractures for immediate evaluation and antibiotic administration in our critical care zone. After our intervention, the time to antibiotics for long-bone open fractures improved significantly, decreasing from 76 to 40 minutes (p < .001), with the percentage of patients receiving antibiotics within 60 minutes of ED arrival increasing from 64% to 92% (p < .001). Age, sex, mechanism of injury, antibiotic choice, and location of the open fracture remained consistent between the two groups. Our results highlight the successful application of process improvement methodologies in improving antibiotic administration time for long-bone open fractures.

S. aureus Surveillance and Decolonization Associated with Decreased MRSA, but not MSSA, Infections in the Neonatal ICU

Background: Invasive Staphylococcus aureus infections cause significant morbidity and mortality in neonatal intensive care unit (NICU) infants.1 Colonization (asymptomatic carriage in the nose, skin, or gut) is a risk factor for subsequent invasive infection (e.g., pneumonia, bone infections, bloodstream infections, etc.). Active surveillance and decolonization measures for S. aureus-colonized infants have been associated with decreased invasive infection rates. 2-4 Methods: A methicillin-resistant S. aureus (MRSA) surveillance and decolonization program, consisting of admission and weekly MRSA nasal cultures followed by intranasal mupirocin plus chlorhexidine baths for colonized infants, was implemented in our level IV NICU with 150 beds in 2006.5 Due to poor compliance with decolonization protocols5, existing practices were reviewed and multiple interventions to increase compliance were implemented in 2018. These renewed efforts included revision of the existing MRSA decolonization protocol, updating the associated electronic medical record order set, re-education of unit staff, and weekly review by the Infection Prevention (IP) and NICU leadership teams to ensure the decolonization protocol was followed for newly colonized infants. Mean MRSA bloodstream infection (BSI) rates were calculated quarterly pre- (January 2014-December 2017) and post- (January 2018-December 2023) implementation of renewed efforts and compared via unpaired t-test. In July 2020 a similar methicillin-susceptible S. aureus (MSSA) surveillance and decolonization program was implemented with an associated revision of existing documents, education campaign, and weekly review of infants with new MSSA colonization. Mean MSSA BSI rates pre- (July 2018-June 2020) and post- (July 2020-December 2023) implementation were compared via unpaired t-test. Results: Renewed implementation of MRSA surveillance and decolonization was associated with a sustained decrease in the mean MRSA BSI rate (Figure 1): 0.10 per 1000 patient-days pre-implementation, 0.03 post-implementation (p=0.02). Following implementation of MSSA surveillance and decolonization, there was no statistically significant change in the mean MSSA BSI rate (Figure 2): 0.20 per 1000 patient-days pre-implementation, 0.15 post-implementation (p=0.32). Conclusions: Implementation of a robust MRSA surveillance and decolonization program in the NICU was associated with a sustained decrease in invasive MRSA infections. No change in invasive MSSA infection rates was observed following implementation of a similar protocol for MSSA. Additional research is needed to better understand the role of MSSA surveillance and decolonization in the NICU.

Improved Cardiac Rehabilitation Referral Rate Utilizing a Multidisciplinary Quality Improvement Team.

Introduction Cardiac rehabilitation (CR) is an underutilized resource in patients with ischemic heart disease, despite being a Class IA recommendation. In this study, a multidisciplinary quality improvement (QI) team aimed to improve CR referrals by standardizing the ordering process at our hospital system. Method By using a collaborative approach involving the electronic medical record (EMR), medical provider education, and hospital protocols, our two-hospital healthcare system was able to successfully identify barriers to CR referral rates and implement interventions for these barriers. All physicians and medical providers, including ancillary staff, were educated on the EMR order sets to improve compliance by using automated order sets in the EMR. The CR referral order in the EMR included a statement regarding the application of evidence-based medicine, and a computerized provider order entry was included as a reminder to the ordering provider. The use of EMR was monitored monthly by the QI committee. Chi-square test and odds ratios were obtained for statistical analysis. Results Through provider-EMR education and patient education on discharge, CR referral rates significantly improved from 51.2 to 87.1% (p = 0.0001) in a 12-month period. The study included 1,499 patients in total. The improvement was statistically significant regardless of patient gender, race, or insurance coverage. Additionally, subgroup analysis in this study found that prior to standardization of the ordering process, African American patients were significantly less likely to be referred to CR compared to Caucasian patients. (51.2% vs. 41.0%, p=0.01). There was no statistically significant difference in the likelihood of CR referral between Caucasian and African American patients following the intervention (84.0% vs. 78.0%, p = 0.166). Conclusion This study shows that CR is an underutilized resource and that effective QI initiatives may not only increase CR referral rates but also close the gap between racial inequities in referral rates. Future research with multi-center randomized control trials is needed to further enhance its external generalizability to other institutions.

Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition.

Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation. Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation. Reduced growth failure at discharge was observed in four of five NICUs, 11-32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2-5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable. Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes.

Maternal Group B Streptococcus Prophylaxis Improvement using an Electronic Medical Record Dynamic Order Set.

To develop and implement a Group B Streptococcal (GBS) dynamic order set to improve adherence to the American College of Obstetricians and Gynecologists/Centers for Disease Control and Prevention (ACOG/CDC) guidelines. A team of information technology and clinical experts developed a dynamic order block. The content was patterned after the CDC "Prevent GBS" mobile app. It was then embedded in the labor and delivery/induction order set and piloted at a single high-volume obstetric unit. Following the pilot and incorporation of the 2019 ACOG update of the CDC guidelines, the order set was rolled out in five additional hospitals within a region of a large health system. Information on GBS prophylaxis performance before and after implementation was available for the pilot site and four of the additional hospitals. Information before implementation was obtained electronically from electronic medical record (EMR) laboratory and pharmacy data and supplemented by manual chart review. Postimplementation data were obtained from discrete order set EMR data elements. Adherence to the guidelines before and after were compared using chi-squared test. There were 7,114 deliveries before implementation and 4,502 after implementation. Preterm delivery occurred in 6.8 and 6.9%, respectively. There was an increase in appropriate treatment of preterm patients (positive and unknown GBS) delivering after implementation (88.7-99.1%, p < 0.001). More patients were reported to have a penicillin allergy before implementation than after implementation (14.7 vs. 11.1%, respectively, p = 0.01). Associated changes in therapy noted after implementation included a nonsignificant decrease in the proportion reporting a high-risk allergy (50.3 vs. 41.9%, p = 0.18), an increase in the appropriate use of clindamycin and vancomycin (64.4 vs. 92.3%, p < 0.001) and a decrease in clindamycin use in those without sensitivity testing. Routine universal use of a dynamic admission labor/induction order set was associated with high and improved adherence to GBS prophylaxis guidelines. · Lapses in GBS prophylaxis are associated with early-onset GBS disease.. · Preterm delivery and penicillin allergic patients are commonly associated with lapses in prophylaxis.. · Dynamic EMR order set use can improve adherence to clinical guidelines..

Implementation of an electronic medical record order set with an opt-out rule increases utilization of ultrasound enhancing agents with transthoracic echocardiography

Abstract Background Use of ultrasound-enhancing agents (UEA) decreases the frequency of non-diagnostic transthoracic echocardiography (TTE) studies and improves accuracy for identification of potentially life-threatening conditions. However, several logistical barriers have led to UEA underutilization, including the need for a separate order for UEA in electronic medical records (EMR). We sought to determine the impact of implementing an EMR order set on utilization of UEA at the echocardiography laboratory of a tertiary care center. Methods EMR order for all TTE studies (complete, limited) was modified to include the use of UEA by default with an "opt-out" option for ordering physician when UEA is deemed unnecessary. During study performance, sonographers determined the need for UEA use and utilized existing order to dispense perflutren protein-type A microspheres to complete the examination. Internal policy for UEA use was developed in keeping with Intersocietal Accreditation Commission recommendations. We compared rates of UEA utilization 10 months before and after the implementation date (March 2022) for the new EMR rule. Results A total of 10,666 TTE studies were performed prior to, and 11,406 studies after the implementation of the new EMR rule. Of those, 54.3% were performed in outpatient setting, 12% in ICU, and the rest in non-ICU inpatient setting. Prior to the EMR rule implementation, UEA was used in 10% of total studies, 6.0% of outpatient studies, 11.2% of non-ICU inpatient studies, and 24.2% of ICU studies. Following the implementation of the new rule, UEA utilization increased significantly, including 89% increase in total use, 90% increase in outpatient setting, 129% in non-ICU inpatient setting, and 48% increased use in ICU (Figure). No adverse events were reported with UEA during the study period. Conclusions The implementation of a standing order in EMR, including default use of UEA with an "opt-out" option facilitates sonographer-driven use and administration of UEA across all patient care settings. While this approach was safe and significantly increased UEA utilization, whether it would translate to improvement in clinical outcomes or hospital length of stay requires further studies.Impact of EMR rule on UEA utilization

Improving rates of referrals for fertility preservation among adult patients with cancer.

462 Background: Urgent fertility preservation (FP) represents a critical unmet need for patients of child-bearing potential undergoing cancer-directed therapies. A retrospective review of electronic medical record (EMR) based FP referrals placed prior to initiation of systemic cancer-directed therapies in patients aged 18-50 years, identified only 26 referrals to urology and 2 referrals to reproductive endocrinology during 2020. To address this issue, we conducted a division-wide survey to identify barriers to FP and designed and implemented a new FP referral EMR order set to facilitate timely fertility evaluation in patients about to begin cancer-directed therapy. Methods: We conducted a division-wide survey of faculty and fellows to identify barriers to FP (PDSA cycle 1), which identified that 50% of respondents did not know how to make a referral and 85% did not know the correct pre-requisite labs. Based on these results, we gathered multi-stakeholder input from reproductive endocrinology, urology, and stakeholders from different hematology/oncology disease groups to develop and design a common FP referral EMR order set (PDSA 2). The FP order set was tested and refined based on stakeholder input. Once the order set was implemented, we gave educational presentations at division-wide and disease group-specific conferences, placed informational flyers throughout the Cancer Center, and Cancer Center-wide communications via email to increase provider awareness (PDSA 3). The primary objective of the study was to increase in number of referrals for FP evaluation in patients aged 18-50 years undergoing cancer-directed therapy. We tracked number of FP referrals pre and post-intervention using EMR data. Results: In PDSA Cycle 2 and 3, the number of referrals increased further to 62 for urology and 35 for reproductive endocrinology. Of those referred, 35/97 (36.1%) were female. Regarding race/ethnicity, the largest percentage of patients referred identified as White and Asian with the lowest percentage being of Southwest Asian/North African or Black/African American (see Table 1). Conclusions: The development and implementation of a FP order set greatly increased the number of patients who underwent fertility evaluation prior to starting cancer-directed therapy. We did identify differences in groups with regards to referral rates with fewer women being referred, and fewer number of racial/ethnic minorities being referred. Further analysis is needed to identify potential areas of intervention to increase referrals and access to FP, particularly in under-represented groups.[Table: see text]

Standardizing Opioids Prescribed at Discharge in Trauma Surgery

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

Primary Care Provider HIV PrEP Knowledge, Attitudes, and Prescribing Habits: A Cross-Sectional Survey of Late Adopters in Rural and Suburban Practice.

Pre-exposure prophylaxis (PrEP) is a recommended strategy for HIV prevention, yet PrEP prescribing rates in primary care remain low. The aim of this study was to further describe the current knowledge, attitudes, and prescribing behaviors of HIV PrEP in primary care providers with a focus on the perceived barriers and facilitators to PrEP prescribing. Cross-sectional survey of primary care providers at rural and suburban practices in a large academic institution. Survey response rate was 48.0% (n = 134). Most respondents (96.3%) reported little clinical experience in care of persons living with HIV. Respondents self-reported positive attitudes and high overall knowledge of PrEP with low prescribing rates and less comfort with lab testing. More respondents are asked about PrEP by patients (54%) than start conversations about PrEP with patients (39%). Family Physicians and providers 5 to 10 years from completion of training overall reported higher knowledge, attitudes and prescribing behaviors. Lack of PrEP education was identified as the greatest barrier and an electronic medical record order set as the greatest facilitator to prescribing PrEP. With the goal to end the HIV epidemic, PrEP provision in nonurban primary care settings may be an important strategy for increased access to PrEP and reduced HIV transmission. This study, which includes a variety of providers that possess high knowledge, yet low experience prescribing PrEP, likely demonstrates the limitations of interventions which solely focus on provider education. System-based practice solutions, such as order sets, may be needed to target infrequent prescribers of PrEP.

Impact of a syndrome-specific antibiotic stewardship intervention on antipseudomonal antibiotic use in inpatient diabetic foot infection management.

To demonstrate that a syndromic stewardship intervention can safely reduce antipseudomonal antibiotic use in the treatment of inpatient diabetic foot infections (DFIs). From November 2017 through March 2018, we performed an antimicrobial stewardship intervention that included creation of a DFI best-practice guideline, implementation of an electronic medical record order set, and targeted education of key providers. We conducted a retrospective before-and-after study evaluating guideline adherent antipseudomonal antibiotic use 1 year before and after the intervention using interrupted time-series analysis. University of Nebraska Medical Center, a 718-bed academic medical center in Omaha, Nebraska. The study included 193 adults aged ≥19 years (105 in the preintervention group and 88 in the postintervention group) admitted to non-intensive care units whose primary reason for antibiotic treatment was diabetic foot infection (DFI). Guideline-adherent use of antipseudomonal antibiotics increased from 39% before the intervention to 68% after the intervention (P ≤ .0001). Antipseudomonal antibiotic use decreased from 538 days of therapy (DOT) per 1,000 DFI patient days (PD) before the intervention to 272 DOT per 1,000 DFI PD after the intervention (P < .0001), with a statistically significant decrease in both level of use and slope of change. We did not detect any changes in length of stay, readmission, amputation rate, subsequent positive Clostridioides difficile testing, or mortality. Our 3-component intervention of guideline creation, implementation of an order set, and targeted education was associated with a significant decrease in antipseudomonal antibiotic use in the management of inpatient DFIs. DFIs are common and should be considered as opportunities for syndromic stewardship intervention.

Reducing Unnecessary Type and Screens Prior to Thoracic Surgery: A Quality Improvement Initiative

IntroductionPrevious work identified that routine preoperative type and screen (T&S) testing before elective thoracic surgery is overutilized. We hypothesized that instituting a quality improvement (QI) initiative to change practice would significantly reduce this unnecessary testing, reduce costs, and improve healthcare efficiency. Materials and methodsA QI initiative was developed at a single, academic center to reduce empiric T&S ordering before elective anatomic lung resections. Two interventions were implemented: 1) education based on current institutional data and 2) an electronic medical record order set modification. Utilization of T&S testing, blood transfusion data, and perioperative outcomes were tracked and compared between a preintervention group (2015-2018) and a postintervention group (2020-2021). Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules. ResultsOf the 553 patients included: 420 were in the preintervention group and 133 were in the postintervention group. The rate of routine T&Ss significantly dropped after implementing the QI initiative (97 versus 20%, P ≤ 0.001). Additionally, no difference in blood transfusion rate was observed (4.3 versus 2.3%, P = 0.29), and there were no differences noted in postoperative complications (P = 0.82), 30-day readmission (P = 0.29), or mortality (P = 0.96). Based on current volumes of ∼200 anatomic lung resections/year, estimated cost savings from reducing T&S testing from 97 to 20% would be at least $40,000 a year. ConclusionsOur QI initiative significantly reduced the use of routine T&S testing. This practice change was achieved while maintaining excellent outcomes demonstrating routine preoperative T&S testing can be safely reduced in most elective thoracic surgery.

Increasing Incentive Spirometry Use in Patients with Sickle Cell Disease Admitted to Children's Mercy Hospital

Introduction: Acute chest syndrome is one of the leading causes of morbidity and mortality in patients with sickle cell disease. The National Heart, Lung, and Blood Institute (NHLBI) recommends providing ten breaths of incentive spirometry (IS) every two hours while awake for patients with sickle cell disease admitted to the hospital to help prevent development of acute chest syndrome. Methods: We reviewed provision of IS at Children's Mercy Hospital (CMH) in Kansas City, Missouri between 08/01/2021 and 11/01/2021. Data were collected and the target population was identified via a report generated from the electronic medical records of those patients admitted with sickle cell disease and vaso-occlusive pain requiring continuous opioid infusion. We reviewed the frequency with which IS was offered each hospital day and found that during that 3-month time period, no patients were offered IS at the frequency recommended by the NHLBI. Meetings with stakeholders identified that IS orders were inconsistent between electronic medical record order sets and were not based on current NHLBI recommendations. To address this potential root cause, order sets were updated to match NHLBI recommendations. We then reviewed provision of IS following implementation of standardized IS orders between 12/21/2021 and 3/14/2022. Our primary aim with our initial plan-do-study-act (PDSA) cycle was to increase the frequency IS was being offered to patients to meet NHLBI guidelines. Results: Between 08/01/2021 and 11/01/2021, there were 285 hospital days with patients admitted to CMH with a sickle cell vaso-occlusive pain. We excluded days of admission and discharge (94 days). Of 191 full hospital days, only 53% (101/191) had IS documented at all. When IS was documented, 0% of patients were offered the recommended frequency of IS and the median time between IS offerings was 6.3 hours. Following implementation of updated orders on 12/21/2021 IS was offered to patients at the recommended frequency 1% of the time, and the median hours between when IS was offered decreased to 5.9 hours. Conclusion: The initial goal of this project was to increase the daily occurrences of IS offered to sickle cell patients admitted to the hospital with vaso-occlusive pain to meet the NHLBI recommended frequency from 0% to 10% over a 3-month period following the implementation of updated IS orders within Cerner powerplans. Further PDSA cycles will continue to refine our approach to increasing frequency IS is offered to the patient and documented in the medical record. Subsequent PDSA cycles will also focus on increasing patient use of IS as well as analyzing supplemental oxygen use before and after each intervention as a patient outcome measure.

S13 Early Feeding Rates in Acute Pancreatitis Is Associated With Decreased Length of Hospitalization

Introduction: Guidelines recommend that patients with acute pancreatitis (AP) receive early oral or enteral feeding within 24 hours of diagnosis rather than keeping patients nil per os. Early feeding reduces rates of multiorgan failure and necrotizing pancreatitis. We sought to understand whether early feeding affected length of hospitalization for AP, identify factors associated with early feeding, and determine whether an order set for acute pancreatitis would improve early feeding rates. Methods: We identified adult patients (age ≥18 years) hospitalized at Yale New Haven Hospital, a tertiary academic medical center with a diagnosis of AP by ICD-10 code and/or serum lipase ≥3 times the upper limit of normal from April 2019-January 2021 and reviewed their charts to confirm the diagnosis of AP and the timing of diet order entry. We created and implemented an electronic medical record order set for AP including guidelines and diet, imaging, and consult orders in October 2020 (Figure 1). E-mails were sent to notify hospitalists and medicine residents of the order set. Primary outcome was the proportion of patients who received a diet order within 24 hours following diagnosis of AP. Logistic regression was performed to evaluate the relationship between early feeds within 24 hours of AP diagnosis and patient factors. Results: A total of 707 patients were hospitalized with AP, and 496 patients (70.2%) had enteral feeds within 24 hours of AP diagnosis. Patients receiving early feeds had shorter hospitalizations compared to patients receiving delayed feeds (mean [SD] 8.4 days [12.8] versus 5.4 days [8.2]) (P < 0.01) and were less likely to be hospitalized in the intensive care unit (ICU) (odds ratio 0.45, 95% confidence interval 0.32–0.63) (Table 1). There was no difference in gender, race, ethnicity between patients who received feeds within 24 hours of AP diagnosis and those who received feeds >24 hours after AP diagnosis. Implementation of an order set containing guidelines and orders for diet, imaging, and consults did not significantly improve early feeding within 24 hours of AP diagnosis (70.5% versus 68.9%) likely due to limited usage by providers. Conclusion: Early enteral nutrition is associated with shorter hospitalizations among patients with AP. Patients receiving oral or enteral feeds within 24 hours of AP diagnosis were less likely to be in the ICU. Durable and effective quality improvement initiatives are needed to improve rates of early enteral feeding in patients with AP. Table 1. - Factors associated with early enteral feeding in acute pancreatitis Variable Odds Ratio 95% Confidence Interval p-value Intensive Care Unit Hospitalization 0.45 0.32-0.63 < 0.01 Age 1.00 0.99-1.01 0.99 Race White/Caucasian Black/African-American Other/Not Listed reference0.920.98 reference0.63-1.360.63-1.52 0.92 Ethnicity Non-Hispanic Hispanic Other/Not Listed Reference1.160.22 Reference0.75-1.790.02-2.40 0.33 Figure 1: Timeline of Interventions

S1440 Inpatient Management of Decompensated Cirrhosis - A Quality Improvement Initiative

Introduction: Cirrhosis management is centered on the treatment of the causes and management of the complications. The AASLD provides clear recommendations for inpatient management of cirrhosis decompensated by ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy (HE), and hepatorenal syndrome (HRS). Methods: We evaluated the current hospital practice for 150 consecutively admitted patients with cirrhosis complications in the period between 2017 and 2021. Decompensated cirrhosis was identified using ICD code K70.30/K70.31 (alcoholic cirrhosis) or K74.69/K74.60 (cirrhosis without alcohol), in addition to R18.8 (ascites), plus/minus any of the following: K65.2 (SBP), K72.91 (HE), and K76.7 (HRS). Results: 21/150 patients had no evidence of clinically decompensated cirrhosis on chart review and thus 129 patients represented the study cohort (decompensated cirrhosis, by at least ascites). The mean age of the cohort was 60±14 years. 83 patients were men, and the majority were White (88 patients, 68%). The most common cause of cirrhosis was alcohol related (72 patients, 56%), most patients had Child Pugh C (64%), and a mean MELD score of 21±7.7 and 20±7.5 on admission and discharge, respectively. Only 49/129 (38%) patients with cirrhotic ascites underwent diagnostic/therapeutic paracentesis. The second most common complication was esophageal varices (52 patients (40%)). SBP was noted in 8 patients, all of whom received appropriate medical treatment. SBP prophylaxis was indicated in 13 patients, and 10 of whom only received prophylaxis on discharge (77%). 41 patients had history of HE, and 21 of whom (51%) were on lactulose treatment. 14 patients developed HRS and were all started on albumin and octreotide therapy. 72 patients (56%) were placed on the appropriate cirrhotic diet, and daily weight was measured in 33/129 patients (26%) undergoing diuresis during the hospital stay. The mean length of stay was 5.9±4.4 days. 54 patients (42%) were re-admitted, and 13 patients (10%) died during the 90-day follow up period. Conclusion: We here demonstrated that further improvement in the medical care provided to hospitalized cirrhotic patients remains necessary. We recommend further education of the medical staff on the current guidelines to improve the care provided as well as adopting an electronic medical record order set (Figure) topromote consistent evidence-based practice, decrease errors of omission, and support provider efficiency.Figure 1.: Cirrhosis complications order set

A Nonrestrictive Approach to Fluoroquinolone Stewardship at Two Community Hospitals.

BackgroundFluoroquinolones are one of the most prescribed antimicrobials in the United States and have been increasingly used in inpatient and outpatient settings to treat various infectious diseases syndromes. Due to the unwanted collateral effects on antibiotic resistance, poor susceptibility rates among Gram-negative pathogens, and adverse effects, fluoroquinolones are often targeted by hospital antimicrobial stewardship programs to prevent overutilization. This study describes the association of nonrestrictive antimicrobial stewardship interventions at 2 nonacademic community hospitals on levofloxacin utilization, prescribing patterns on alternative antibiotics, and Pseudomonas aeruginosa nonsusceptibility rates to levofloxacin.MethodsNonrestrictive antimicrobial stewardship interventions included monitoring and reporting of fluoroquinolone susceptibility trends to physician groups, performing medication use evaluations of levofloxacin accompanied with prescriber detailing, daily prospective audit and feedback, implementation of beta-lactam-based institutional guidelines for empiric therapy in various infectious disease syndromes, review and adjustment of electronic medical record order sets containing fluoroquinolones, and intensive prescriber education. No preauthorization of levofloxacin was used during this study period. Antibiotic utilization data were collected for the time periods of August 2015 through January 2021. Correlation between levofloxacin and other broad-spectrum antibiotc use was investigated as well as the impact on Pseudomonas aeruginosa levofloxacin nonsusceptibility rates.ResultsBoth hospitals showed an overall downward trend in the prescribing of levofloxacin during the time period of August 2015 to January 2021. There was a significant negative correlation between monthly ceftriaxone and levofloxacin days of therapy for both hospitals (P < .0001). There was a positive correlation between levofloxacin days of therapy and P aeruginosa nonsusceptibility (P < .02 at both hospitals).ConclusionsOur results demonstrate that a nonrestrictive approach to fluoroquinolone stewardship interventions had a significant impact on reducing levofloxacin utilization, increasing ceftriaxone utilization, and improving P aeruginosa levofloxacin susceptibility.

The financial toxicity order set: A simple intervention to better connect patients with resources.

6596 Background: Rising cancer care costs have led to significant hardship for patients and caregivers, defined as “financial toxicity.” Prior research has focused on experiences of financial toxicity and identified risk factors, but there are limited interventions, despite a growing need for both patient-level and systems-based solutions. We present a novel electronic medical record (EMR) financial toxicity order that streamlines referrals for financial assistance and/or counseling for patients in need. Methods: A multidisciplinary team developed, tested, and implemented an EMR order set to refer patients directly to patient financial services, due to specific financial concerns. Following a 3-month service-based pilot, the order set was activated enterprise-wide March 2021. All team members could place the order, and referrals were tracked on an institutional dashboard. Order indications and frequency of orders across patient and provider demographics were evaluated. Results: From March-December 2021, 617 orders were placed for 580 unique patients, by 272 individuals across 49 services. Nurses placed 45% of orders, followed by advanced practice providers (20%) and attending physicians (14%). Primary indications for the order included high/outstanding balance or out-of-pocket costs (41%), difficulty meeting basic needs (i.e., transportation, food; 30%), co-payment assistance (28%), or out-of-network insurance (11%); 29% of referrals included multiple reasons. Most orders (69%) were placed for patients on active treatment. Compared to the distribution of institutional averages by age, more patients 30-39 years (8% of all orders vs. 5% of all patients), 50-59 years (22% of all orders vs. 19% of all patients), and 60-69 years (33% of all orders vs. 26% of all patients) received an EMR financial toxicity order. Compared to institutional race and ethnicity averages, Black patients (15% of all orders vs. 9% of all patients) and Hispanic patients (12% of all orders vs. 7% of all patients) were over-represented among orders. Disease sites over-represented among orders included breast (25% of orders vs. 21% of patients) and lung (10% of orders vs. 7% of patients); and Hodgkin’s lymphoma (8% of orders vs. 5% of patients). More female patients received orders than their representation among patients (62% of orders vs. 57% of patients). Conclusions: Our findings represent a first step toward improving the process by which patients experiencing financial toxicity are referred to relevant counseling and tangible financial resources. Multilevel interventions are necessary to address financial toxicity, and hospital-based EMR interventions represent progress in empowering the care team to connect patients to available resources. Categorizing the amount and type of financial help provided as a result of the EMR order is next, and efforts to proactively screen patients for financial toxicity risk are underway.

Lessons Learned From Rapid Deployment of 100% Mortality Review for Patients With COVID-19 Across a Health System.

Mortality review is one approach to systematically examine delivery of care and identify areas for improvement. Health system leaders sought to ensure hospitals were adapting to the rapidly changing medical guidance for COVID-19 and delivering high-quality care. Thus, all patients with a COVID-19 diagnosis within the 6-hospital system who died between March and July 2020 were reviewed within 72 hours. Concerns for preventability advanced review to level 2 (content experts) or 3 (hospital leadership). Reviews included available autopsy and cardiac arrest data. Overall health system mortality for COVID-19 patient admissions was 12.5% and mortality for mechanically ventilated patients was 34.4%. Significant differences in mortality rates were observed among hospitals due to demographic variations in patient populations at hospitals. Mortality reviews resulted in the dissemination of evolving knowledge among sites using an electronic medical record order set, implementation of proning teams, and development of checklists for converting COVID-19 floors and units.

Surgical Specialization and Standardization of Care Improves Outcomes in Mechanical Circulatory Support: A Single Center Experience

<h3>Purpose</h3> Cardiac surgery continues to transform into areas of sub-specialization and expertise to reduce variability and have superior outcomes. We sought to analyze the impact of surgical sub-specialization and use of protocol and clinical pathways on outcomes with MCS at the time of LVAD implantation. <h3>Methods</h3> A single center retrospective analysis of long term durable MCS patients between 2004-2019 was performed. The analysis was conducted comparing management of patients before (Era 1: 2004-2011) vs. after (Era 2: 2012-2019) based on before and after introduction of MCS sub-specialization. Since 2012, multiple initiatives were introduced namely recruitment of specialized MCS/transplant surgeons, multidisciplinary team rounds, establishment of a shock team, development of clinical care pathways, electronic medical record order sets and clinical practice guidelines. <h3>Results</h3> A total of 542 patients were included. During Era 1, five cardiac surgeons implanted LVADs in 123 patients, while in Era 2, two MCS/transplant trained surgeons implanted LVADs in 419 patients. Era 2 included higher number of INTERMACS 1 and 2 profile patients (41% vs. 63%) reflecting higher-acuity patient population. With implementation of the sub-specialization services, 1-year survival improved from 70% to 90%. Median ICU stay decreased from 13 to 8 days and percent of patients discharged to home increased from 62% to 95%. Standardized protocols for management of high LDH, GI bleeding, and blood pressure management resulted in significant reduction in overall hospital length of stay. With introduction of clinical care pathways, the average time for workup from admission to LVAD implant decreased from 27.6 days to 8.5 days. <h3>Conclusion</h3> Introduction of surgical sub-specialization and standardization of care with the use of clinical pathways and protocols in managing patients with LVADs can help improve survival, reduce variability in medical care, and reduce ICU length of stay.

Adherence to a Pediatric Continuous Infusion Propofol Policy for Sedation in Mechanically Ventilated Patients: Opportunities for Change and Improvement.

To evaluate adherence to an institutional continuous infusion propofol policy for sedation in mechanically ventilated patients, investigate the rate of propofol-related infusion syndrome (PRIS), and explore areas of improvement to enhance policy compliance and safety. This was a single center, retrospective chart review of patients admitted to a pediatric or cardiac intensive care unit within a large free-standing quaternary care pediatric hospital who received continuous propofol for non-procedural continuous sedation for at least 6 hours between 2014 and 2019. Propofol exposure (dose and duration), laboratory data, and hemodynamic outcomes of patients were evaluated. A total of 104 patients (108 admissions and 133 treatment courses) met inclusion criteria. Policy adherence to propofol dosing and duration limitations were 70% (93/133 courses) and 68% (91/133 courses), respectively. Adherence to all elements of laboratory and hemodynamic monitoring was 23%. Hypotension and bradycardia were common among patients during propofol treatment courses. Except for hypertriglyceridemia, no significant difference in specific laboratory values were detected between patients exposed to greater than 66 mcg/kg/min (4 mg/kg/hr), compared with those exposed to less than 66 mcg/kg/min of propofol. Patients receiving therapy for longer than 48 hours had the highest rates of laboratory values associated with PRIS. No patient in the study cohort met full criteria for PRIS. Adherence to elements of an institutional propofol policy was variable. Improvements in policy adherence may be enhanced by updating policy features, leveraging the electronic medical record order-set, and gaining consensus among key stakeholders.

Trends in testing and prevalence of elevated Lp(a) among patients with aortic valve stenosis

Background and aimsLipoprotein(a) [Lp(a)] is causally associated with aortic valve stenosis (AS) but Lp(a) testing among AS patients is not broadly incorporated into clinical practice. We evaluated trends in Lp(a) testing in an academic medical center. MethodsEducational efforts and adding Lp(a) to the lipid panel on the electronic medical record (EMR) and pre-procedure order sets were used to increase awareness of Lp(a) as a risk factor in AS. Medical records at University of California San Diego Health (UCSDH) were analyzed from 2010 to 2020 to define the yearly frequency of first time Lp(a) testing in patients with diagnosis codes for AS or undergoing transcatheter aortic valve replacement (TAVR). ResultsLp(a) testing for any indication increased over 5-fold from 2010 to 2020. A total of 3808 patients had a diagnosis of AS and 417 patients had TAVR. Lp(a) levels >30 mg/dL were present in 37% of AS and 35% of TAVR patients. The rates of Lp(a) testing in AS and TAVR were 14.0% and 65.7%, respectively. In AS, Lp(a) testing increased over time from 8.5% in 2010, peaking at 24.2% in 2017, and declining to 13.9% in 2020 (p < 0.001 for trend). Following implementation of EMR order-sets in 2016, Lp(a) testing in TAVR cases increased to a peak of 88.5% in 2018. ConclusionsElevated Lp(a) is prevalent in AS and TAVR patients. Implementation of educational efforts and practice pathways resulted in increased Lp(a) testing in patients with AS. This study represents a paradigm that may allow increased global awareness of Lp(a) as a risk factor for AS.