Electronic Medical Record Order Sets Research Articles

864. Adolescent Primary Care Provider Knowledge of HIV Pre-Exposure Prophylaxis (PrEP) and Universal Screening at a Midwest Academic Medical Center

BackgroundHIV remains a problem for adolescents with 21% of new infections in the United States in 2018 occurring in youth. In this study we attempted to assess the knowledge of and comfort with pre-exposure prophylaxis and universal HIV testing among adolescent primary care providers affiliated with one academic medical center.MethodsWe conducted a survey of internal medicine/pediatrics, pediatrics, and family medicine residents and attending physicians affiliated with an academic medical center. Data collected included provider prescribing and referring habits for PrEP and information on their universal HIV testing habits. A “test your knowledge” section followed the survey which asked participants to name PrEP medications and to correctly select laboratory monitoring required for PrEP. Correct answers and prescribing resources were provided on completion of the survey. Results138 (76%) respondents were aware that PrEP is approved for adolescents. There was no significant difference across specialties or between residents and attendings. 44.8% of respondents felt uncomfortable prescribing PrEP and two thirds had never prescribed PrEP. Reasons for not prescribing PrEP included: not seeing adolescents who qualify (n=80), not having enough training (66), confidentiality concerns (22), forgetting to address PrEP (19), and concern incidence of HIV is too low to recommend PrEP (15). Pediatricians were the least likely to test for HIV with 11% of pediatrician, 32% of internal medicine/pediatric, and 38% of family medicine respondents reported universal HIV testing for patients 15 years and older (p < 0.05). Residents were more likely to test for HIV than attendings (33.3% versus 16%, p < 0.05). 111 participants completed the “test your knowledge” section. 31.5% correctly named two approved PrEP medications. There were 183 responses to the survey (49% response rate). ConclusionAdolescent primary care providers are aware that PrEP is FDA approved for adolescents but a gap in PrEP prescribing and HIV testing persists. There remain perceptions that HIV incidence is too low to discuss PrEP and that providers are not seeing patients who qualify. Next steps include developing an institutional PrEP guideline and creating an electronic medical record order set to facilitate PrEP prescribing.Disclosures All Authors: No reported disclosures

Opioid Reduction Through Postoperative Pain Management in Pediatric Orthopedic Surgery.

Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures. Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital. The provider compliance with this order set was monitored and analyzed over time by using provider-level and aggregate control charts. A secondary measure of opioid prescriptions (morphine milligram Eq [MME] dosage per patient) was tracked over time. The balancing measure was the analysis of unanticipated opioid prescription refills. Greater than 90% compliance with the guidelines was achieved and sustained for 20 months. This resulted in a 54% reduction in opioids prescribed during the improvement period (baseline = 71 MME per patient; postintervention = 33 MME per patient) and has been sustained for 12 months. The percentage of unanticipated opioid prescription refills did not significantly change from the period before the institution of the guidelines and after institution of the guidelines (2017 = 3%; 2019 = 3%). The creation of these guidelines has led to a significant reduction in the number of opioids prescribed while maintaining effective postoperative pain management.

Implementation of a Physician Incentivized QI Strategy to Address Time to Parenteral Analgesia in Patients with Voe in the Pediatric Emergency Department

IntroductionVaso-occlusive episodes (VOE) are the most common cause of pediatric Emergency Department (ED) visits and hospitalizations in Sickle Cell Disease (SCD). The National Heart Lung and Blood Institute published an Expert Panel Report regarding the management of SCD and VOE. Their consensus statement recommends initiating analgesic therapy within 30 minutes of triage or within 60 minutes of registration in the Emergency Department. Previous studies have demonstrated that earlier maximum opioid has been associated with shorter length of hospitalization and improved time to ED disposition decision.Despite the overwhelming evidence for timely administration of parenteral analgesic, significant delays still exist in delivery of pain medication in the pediatric SCD population. Barriers to timely administration include rapid triage of SCD patients, provider ordering of pain medication, and peripheral intravenous access. Therefore, a standardized approach to pain management may improve ED management of SCD crises.In order to address timely administration of opiates to SCD patients with VOE episodes in our pediatric ED a SCD pain order set was developed. This order set implemented the use of intranasal (IN) fentanyl as a first line analgesic for SCD patients who presents to the ED with VOE. The purpose of this study was addressing barriers to decrease time to parenteral opioid administration in the pediatric ED.MethodsThis Quality Improvement (QI) measure was performed at a free-standing, urban pediatric ED. Patients were included if they had a diagnosis of SCD and presented with a pain score >5 and without fever.A PDSA cycle was utilized for designing and evaluating the proposed changes. This cycle consisted of three intervention phases: (1) electronic medical record (EMR) order set development in October 2019, (2) provider incentive for order set use in January 2020, and (3) nursing/patient & family education in April 2020. Baseline data was collected pre-intervention from April-September 2019.The outcomes measures were mean time to 1 st analgesic, mean time from triage to disposition, Hospital Length of Stay, and overall admission rates. Our balancing measure included 48 hour ED re-visits after discharge.ResultsThere were 67 ED visits from April-September 2019 (pre-intervention) and 104 ED visits in the post-intervention data from October-June 2020. There was no significant difference in age or initial pain score in the pre- and post- intervention groups. Improvements were seen in: mean time to first analgesic (58 to 26 minutes), time to disposition (271 to 213 minutes). Hospital length of stay was found to increase with the introduction of IN fentanyl: pre-intervention (120 hours), phase 1 (148 hours), phase 2 (152 hours), phase 3 (218 hours). However, the overall admission rate decreased (55% to 44%). The number of 48-hour ED re-visits remained stable.ConclusionBy using QI methods to address key barriers in the pediatric ED, we demonstrated that timely administration of parenteral analgesic can be achieved for SCD patients with VOE. Utilizing the EMR order set allowed for more stream-lined care, both by physicians and nursing staff, resulting in more rapid ordering of medication therefore decreasing time to ED disposition. Additional interventions such as provider incentivization to meet the goal of parenteral opioids within 30 minutes of patient arrival led to further improvement. One of the greatest barriers to our QI intervention was hesitancy both by patients and their caregivers regarding the efficacy of IN fentanyl in decreasing pain compared to IV opioid. Further education was needed both for families and medical staff regarding the efficacy of IN fentanyl as a first line analgesic.It is unclear why overall hospital length of stay was not shown to be decreased with these interventions but this can be offset by an overall decrease in hospital admissions seen with our interventions. This data may be limited by the SARS-CoV-2 pandemic and how psychosocial stressors can impact patients with chronic medical conditions. Length of stay is also confounded by other factors during the hospitalization and acquisition of other diagnoses such as acute chest. Future research is needed to determine if the demonstrated trend of admission rates and hospital length of stay can be replicated in other pediatric EDs and whether earlier opioid administration affects the outcome of VOEs beyond the ED. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Evaluating Patterns in ADAMTS13 Testing and Time to Plasma Exchange Initiation for Suspected Thrombotic Thrombocytopenic Purpura at a County Hospital

Introduction: Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a life-threatening disease with a mortality 10-20% despite emergent therapeutic plasma exchange (TPE). The distinguishing aspect of iTTP from other thrombotic microangiopathies is a severe deficiency of ADAMTS13 (<10% activity) with laboratory evaluation of ADAMTS13 activity often requiring hours to days; thus, it is not useful for determining whether plasma exchange for TTP should be initiated. Guidelines also recommend TPE initiation within 4-8 hours (Scully 2012). There is limited literature regarding utilization of ADAMTS13 testing in the hospital, and we sought to understand ordering patterns in various clinical contexts, which services ordered ADAMTS13 activity, and if TPE initiation was timely.Methods: Parkland Health and Hospital System records were reviewed ADAMTS13 activity tests (n = 361) from January 2019 to March 2021, excluding patients with known iTTP and/or outpatient tests; resulting in a final cohort of 42 patients with inpatient ADAMTS13 activity tests for suspected iTTP. Suspicion for iTTP-time zero for our time to TPE analysis-was determined by the time that the ADAMTS13 order was placed. Hematology consultation time was based on when the order was placed by the provider. The initiation of TPE, as documented by the apheresis team, was the end-time for the time to TPE calculation. Thus, time to TPE was the time elapsed between the electronic ADAMTS13 order being placed and TPE being initiated.Results: The median patient age was 43 years with 36% Black patients and 50% Hispanic. Hematology service consultation occurred in 95% of cases, although only 79% of hematology consultations occurred before ADAMTS13 activity orders were placed (Table 1). The most common services to order an ADAMTS13 activity prior to hematology consultation were obstetrics and gynecology (2/2, 100%), neurology (1/1, 100%), and medical intensive care (5/14, 36%) with 88% of these tests being placed for patients with a PLASMIC score ≤ 4. None of these patients were diagnosed with iTTP. Using a PLASMIC score ≥6 as a diagnostic test for iTTP, the sensitivity was 50%, specificity 84%, positive predictive value 20%, and negative predictive value was 94%.A subgroup analysis of patients empirically treated for iTTP (n = 7) demonstrated a wide variation in the time from ADAMTS13 activity orders being placed to initiation of TPE, ranging from 4 hours 44 minutes to 3 days 14 hours (Table 2). Only one patient (without a pre-existing central line) received empiric TPE in under 6 hours (5 hours and 20 minutes). One patient had an ADAMTS13 activity that resulted with a critical ADAMTS13 deficiency and was initiated on TPE; this level was re-analyzed, found to be spurious, and the TPE was ceased immediately. No patients received empiric plasma transfusion.Discussion: At our county, public hospital, 95% of cases with suspected iTTP involved hematology consultation during their evaluation, but the most common situations where hematology was not involved at all or was involved late were due to non-internal medicine services, identifying areas for focused educational interventions. The PLASMIC score demonstrated insufficient sensitivity (50%) to confidently exclude iTTP, suggesting that it is an inadequate risk stratification tool for our specific patient population. This may be due to differences between our patient population (with a median age of 43 and 12% white patients) and the derivation cohort for the PLASMIC score (with a median age of 51 and 77% white patients; Bendapudi 2017). The finding that only one patient without a pre-existing central line received TPE in ≤6 hours suggests that there is room for quality improvement interventions to hasten time to treatment. This initial study has led to the development of systemic, hospital-wide electronic medical record order set changes combined with educational interventions which will be evaluated prospectively for its impact on iTTP diagnosis and treatment. Broadly, this study re-demonstrates that the evaluation, diagnosis, coordination, and treatment of iTTP is often logistically challenging. Promoting earlier hematology consultation and optimizing EMR interventions is likely to facilitate appropriate ADAMTS13 testing, expedite results, and help coordinate the initiation of TPE in patients with suspected iTTP. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Improving Antibiotic Stewardship in Acute Appendicitis through Risk-Based Empiric Treatment Selection.

Background: Empiric antimicrobial treatment selection for management of appendicitis is based on patient risk of infection with drug-resistant pathogens. Per Surgical Infection Society (SIS) guidelines, only high-risk patients should receive extended spectrum antibiotics. After observing substantial use of piperacillin-tazobactam at an academic medical center, a quality improvement initiative was developed targeting standardization of antibiotics for uncomplicated appendicitis. Patients and Methods: A project was performed to improve antibiotic stewardship in acute appendicitis treatment using plan-do-study-act methodology. We designed educational materials to guide risk-based empiric antimicrobial treatment selection for adult patients presenting with appendicitis. Implementation began January 1, 2020. High-risk criteria included presence of sepsis, presence of one or more comorbidities, and health-care-associated appendicitis. Retrospective chart review included adult patients admitted for appendectomy between January 1, 2019 and December 1, 2020. Pre-/post-implementation analysis and run chart analysis were performed. Primary outcome was the proportion of patients receiving the correct antibiotic. Secondary outcomes included antibiotic cost. Patients treated pre-/post-implementation were compared using univariable analysis, with statistical significance set at p < 0.05. Results: Of the 138 patients, 85 patients were in the pre-implementation group and 53 in the implementation group. The implementation group was 19.1% more likely to receive the correct antibiotic (pre = 31.8%; post = 50.9%; p = 0.03). Average cost per patient was reduced $13.25 (pre = $23.68 ± $18.76; post = $10.43 ± $8.45; p ≤ 0.0001). There were no differences in complications (pre = 2.4%; post = 0%; p = 0.26) or re-admissions (pre = 2.34%; post = 1.9%; p = 0.86). Conclusions: After an educational initiative to raise awareness about SIS guidelines for empiric antibiotic treatment for acute appendicitis, we observed an increase in the number of patients receiving the appropriate antibiotic. Prescribing habits were altered with no adverse impact on clinical outcomes. The next phase will address sustainability by incorporating an electronic medical record order set to integrate just-in-time education within the provider workflow.

A trainee-led quality improvement project to improve fertility preservation counseling and access to fertility preservation services for persons with cancer.

237 Background: For patients of reproductive age with cancer, counseling regarding reproductive risks associated with systemic therapy and facilitating access to fertility services are essential to quality care. We conducted a quality improvement study to improve rates of fertility preservation counseling at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center (SKCCC) in Baltimore, MD. Methods: We formed a multidisciplinary team as part of the ASCO Quality Training Program. We aimed to increase the rate of fertility preservation counseling for patients of reproductive age (18-40 years) with newly diagnosed cancer who were initiating systemic therapy from a baseline (June 2019- January 2020) of 36.7% (25/ 68) to 70.0% by February, 2021. Data sources included the electronic medical record and direct verification with patients by phone. We surveyed patients, oncologists, and experts in reproductive endocrinology and urology to identify barriers to optimal care. After considering a prioritization matrix, we implemented Plan-Do-Study-Act (PDSA) cycles. Results: We identified the following improvement opportunities: (1) oncologist under confidence about counseling, (2) oncologist lack of knowledge about local fertility preservation options/ processes, and (3) lack of a standardized referral mechanism to reproductive endocrinology/ urology. The first PDSA cycle was disrupted due to COVID-19; from February 2020-August 2020, we introduced the initiative at oncology disease site meetings (e.g., leukemia). In September 2020, we implemented a second PDSA cycle. Our interventions included (1) presenting the baseline data and fellow-led initiative at Oncology Grand Rounds (attended by 150 staff members), (2) creating and distributing paper and electronic informative pamphlets to oncologists and patients, and (3) implementing an electronic medical record order set. This order set included instructions for providers and patients, necessary laboratory studies, and a referral to reproductive endocrinology or orders for cryopreservation of sperm. It also added the following to a patient’s after visit summary: contact information for a dedicated fertility coordinator, estimated costs of services, and financial assistance programs. Post-implementation (September 2020- February 2021), the percentage of patients who reported receiving fertility preservation counseling increased from 36.7% to 80.9% (38/ 47). A sustained shift in the process was apparent on a control chart. Conclusions: Despite disruptions caused by the COVID-19 pandemic, we demonstrate how a trainee-led, patient-centered initiative improved fertility care services for people with cancer. Ongoing work focuses on ensuring sustainability of change, assessing the quality of counseling, and evaluating the impact on utilization of fertility care services.

Trainee-Led Quality Improvement Project to Improve Fertility Preservation Counseling for Patients With Cancer.

Oncofertility counseling regarding the reproductive risks associated with cancer therapy is essential for quality cancer care. We aimed to increase the rate of oncofertility counseling for patients of reproductive age (18-40 years) with cancer who were initiating systemic therapy at the Johns Hopkins Cancer Center from a baseline rate of 37% (25 of 68, June 2019-January 2020) to 70% by February 2021. We formed an interprofessional, multidisciplinary team as part of the ASCO Quality Training Program. We obtained data from the electronic medical record and verified data with patients by phone. We surveyed patients, oncologists, and fertility specialists to identify barriers. After considering a prioritization matrix, we implemented Plan-Do-Study-Act (PDSA) cycles. We identified the following improvement opportunities: (1) oncologist self-reported lack of knowledge about counseling and local fertility preservation options and (2) lack of a standardized referral mechanism to fertility services. During the first PDSA cycle (February 2020-August 2020, disrupted by COVID-19), we introduced the initiative to increase oncofertility counseling at faculty meetings. From September 2020 to November 2020, we implemented a second PDSA cycle: (1) educating and presenting the initiative at Oncology Grand Rounds, (2) distributing informative pamphlets to oncologists and patients, and (3) implementing an electronic medical record order set. In the third PDSA cycle (December 2020-February 2021), we redesigned the order set to add information (eg, contact information for fertility coordinator) to the patient after-visit summary. Postimplementation (September 2020-February 2021), counseling rates increased from 37% to 81% (38 of 47). We demonstrate how a trainee-led, patient-centered initiative improved oncofertility care. Ongoing work focuses on ensuring sustainability and assessing the quality of counseling.

Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology.

Primary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice. A multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time. We collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months. Standardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.

The impact of provider training on patient education for pediatric early food introduction

Pediatric food allergies (FAs) present significant health and economic problems. Currently, there are no cures for FAs. Recent studies suggest that early introduction (EI), between 4 and 6 months of age, of commonly allergenic foods (CAFs) may reduce the risk of developing FAs. This contradicts the current standard of care, food avoidance. A federally qualified health center saw 894 patients aged 0-24 months during a 12-month period with only 18.9% receiving nutrition education. New dietary recommendations to prevent FA were not in place. A retrospective chart review was used to evaluate use of an order set with patient education on EI to CAFs in the electronic medical record (EMR). Providers attended training on EI to CAFs and use of the EMR order set. Data were collected on the use of the order set over a 3-month period. Provider training significantly improved knowledge of FA as well as EI guidelines. After 3 months of implementation, 25.95% of eligible encounters contained the EI order set; 52% of patients received the order set during the measurement period. In the impact population, patients 4-12 months of age, 74.55% of patients received the order set. Evidence-based clinical content in EMR order sets coupled with provider training ensure clinical decision support in identifying, monitoring, and optimizing quality care standards.

585. A Cost-Effective Implementation Reducing The Number Of Urine Cultures In An Acute Care Community Hospital

BackgroundAsymptomatic bacteriuria is a common finding in hospitalized patients. This is defined as bacteriuria of ≥105 colony-forming units (cfu) per mL without any genitourinary signs or symptoms. Treatment for such leads to increased antimicrobial resistance and is especially common in the inpatient setting. One study showed a lack of appropriate clinical indication to order a urinalysis in more than half of the patients. In order to expedite a patient’s care, it is common to order a urinalysis and urine culture together and await the results. One study evaluated the impact of changing the order set in inpatients and yielded a 45% reduction in the urine cultures ordered and cost savings as high as $103,845. Reflex testing is used to facilitate effective and efficient patients care while remaining compliant with state and federal regulations in the ordering of lab test.MethodsStarting October 25, 2019, the electronic medical record order set was changed so there were only 2 options from the previous 9 options. The modified options included a “Urine analysis with reflex culture” and “Urine analysis with microscopy.” The reflex was not encouraged to be used for those who were pregnant, neutropenic, or had any evidence of immunocompromise.ResultsFollowing the implementation of this initiative in October 2019, there was a decrease in overall urine culture cost. From Jan 2019 to September 2019, the cost ranged between $13428.96 to $15157.44/month in the Emergency Department. On the inpatient side, it ranged between $5141.12 to $6559.36/month. After revision of the new order set, the ED cost had dropped to as low as $5672.96/month and $3811.52/month for inpatients. This is a cost reduction of approximately $9484.48 and $2747.84 for the ED and inpatient, respectively.The total number of cultures also reduced from an average of 326/month in the ED to 193/month. The inpatient number of cultures dropped from an average of 130/month to 102/month.ConclusionModifying the process of urine culture ordering has significantly cut down cost for both the hospital and patient. With clear education and modification of the electronic medical record, such interventions can dramatically improve the unnecessary testing for UTI’s.Disclosures All Authors: No reported disclosures

Early Extended Neonatal Screening for Congenital Cytomegalovirus Infection: A Quality Improvement Initiative

Identification of congenital cytomegalovirus (cCMV) infection in neonates is important for early diagnosis of sensorineural hearing loss. Therefore, a quality improvement project was designed with an aim to improve newborn CMV screening by 25% from a baseline rate of 22%. This project was conducted across two hospital sites at one medical center with two tertiary care newborn nurseries and neonatal intensive care units. Symptomatic neonates with suggestive findings of cCMV, who had failed the newborn hearing screen, who had not had a hearing screen performed by 10 days of age, or who were infants of HIV-positive mothers were screened for cCMV. Serial interventions (formalized teaching sessions using an algorithm and involving a nurse educator, creation of electronic medical record order sets, huddle board reminders, and regular audits) were conducted, and statistical process control p-charts were used to identify any signals and to determine if there was any special cause variation. Of 5,817 infants born in 2018, 903 were eligible for screening. Small for gestational age (46%) was the most common indication for screening. After multiple interventions, the median screening rate increased from a baseline of 22% in 2016 to 74% during the one-year study period. Four infants had positive CMV screen and received appropriate treatment as a result of these interventions. Multidisciplinary quality improvement initiatives can improve newborn screening for cCMV infection in a tertiary care environment.

Programmatic Specialization and Pathway Development Improves Outcomes in Mechanical Circulatory Support

Cardiac surgery continues to transform into areas of sub-specialization and expertise. With increasing complexity of cases and scrutiny of outcome-based reimbursement, it is imperative that these cases are performed with reduced variability and superior outcomes. This can be achieved by introducing sub-specialization in mechanical circulatory support (MCS) therapies, implementing clinical care pathways and using standardized protocols during various stages of patient care. We analyzed the impact of protocol and clinical pathway-driven sub-specialization on MCS outcomes. A single center retrospective analysis was conducted of patients undergoing long term MCS device placement between 2002-2018. The analysis was conducted comparing management of patients before (Era 1: 2003-2011) vs. after (Era 2: 2012-2018) introduction of MCS sub-specialization. Since 2012, multiple initiatives were introduced in our program, 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. Quality metrics were analyzed every month, and process improvement projects were initiated during this era. During Era 1, five cardiac surgeons implanted LVADs in 181 patients, while in Era 2, three MCS/transplant trained surgeons implanted LVADs in 326 patients. Era 2 included higher number of INTERMACS 1 and 2 profile patients (66% vs. 85%) reflecting higher-acuity patient population. With implementation of the sub-specialization services, 1-year survival improved from 58% to 96%. 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. With improved outcomes in Era 2, the program grew 200%. Introduction of sub-specialization services, with 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.

The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery.

Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population. After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores. The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924). Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations. Therapeutic, III.

How to Foster Academic Promotion and Career Advancement of Women in Gastroenterology

How to Foster Academic Promotion and Career Advancement of Women in Gastroenterology

A Single Institution's Adherence to Heparin-Induced Thrombocytopenia and Thrombosis Testing Guidelines

Introduction:What was once an under-recognized clinical entity, heparin induced thrombocytopenia and thrombosis (HITT) has become a well-recognized and frequently tested disease. HITT is a serious and potentially fatal antibody mediated drug reaction to platelet factor 4 and early identification and treatment is essential. The 4T score is well-validated to guide appropriate testing of HITT where a low-probability score of 0-3 equates to a 99.8% negative predictive value for HITT2,3. In an effort to promote cost-conscious care and efficient use of healthcare resources, the American Society of Hematology (ASH) recommends against testing for HITT if the 4T score is 3 or less4. HITT laboratory testing at our institution is not restricted based on 4T score. We hypothesize that many providers are not following cost-conscious guidelines regarding HITT testing at our institution.Methods:We performed a single-institution retrospective analysis of patients who had a heparin-induced platelet antibody assay with reflexive serotonin release assay ordered between July 1, 2016 to July 1, 2017 at the University of Virginia Medical Center (UVA). We primarily assessed how our institution's ordering of heparin-induced platelet antibody for HITT compared to ASH's Choosing Wisely recommendation of forgoing laboratory testing on patients with a 4T score of 0-3 by retrospectively calculating 4T scores on all patients who had laboratory testing4. Patients were also assessed for episodes of bleeding and clotting and were scored on severity via the CTCAE and ISTH grading systems. Data on anticoagulant used after HITT testing was collected. We also checked to see if the blood specimen for assay was collected 2 hours after last heparin product as recommended by lab. Patients were excluded if they were not inpatient when their heparin-induced platelet antibody assay was drawn or if they were transferred or discharged immediately after assay was collected. Ultimately, of the initial 196 patients who had heparin-induced platelet antibody assay collected during this time frame, 184 patients were included for analysis.Results:Of the 184 patients who had a heparin-induced platelet antibody assay sent and were included in analysis, 55.4% of the patients (n=102) had a low pre-test probability of HITT with a 4T score of less than or equal to 3. Of the patients who had HITT testing sent, only 44% (n=81) received treatment with a non-heparin anticoagulant. Of the 102 patients who had a low pre-test probability of HITT with a 4T score of ≤3, 37.3% (n=38) were placed on an alternative anticoagulant. Of this low pre-test probability of HITT cohort, 7.8% (n=8) experienced bleeding as a complication. Interestingly, 15.5% (n=29) of all patients who had HITT testing continued to receive heparin products while awaiting results. Additionally, 19.3% (n=36) of samples were drawn within 2 hours of receiving heparin products.Conclusion:The guidelines for HITT testing and treatment have been well-validated and widely disseminated. Despite providers' familiarity with this clinical entity, the results depict that ordering practices at our institution do not follow guidelines in cost-conscious ordering nor in standard of treatment. Applying ASH's Choosing Wisely recommendation of not ordering laboratory testing on patients with a 4T low-probability score of 0-3, we see that 55.6% of the HITT assays ordered in this time period were inappropriate and at a cost of $455 to the institution per assay resulted in $46,865 of unnecessary health care costs to our institution in one year's time. This does not include the cost of alternative anticoagulation. Heparin costs just $0.04 per mL while argatroban costs $3.81 per mL and bivalirudin $12 per mL resulting in a 100 to 300 fold cost increase respectively.Standard work regarding HITT assay collection and treatment does not exist at our institution. Of concern, 15.5% of patients continued to receive heparin products after HITT testing was sent. The results of this study prompted implementation of a quality improvement project to decrease inappropriate HITT testing and standardize treatment of suspected HITT via an electronic medical record order set that uses the 4T score to suggest appropriate ordering of assays. We plan to collect data on changes in our ordering practices after this intervention. DisclosuresNo relevant conflicts of interest to declare.

A Learning Collaborative Approach Increases Specificity of Diagnosis of Acute Liver Failure in Pediatric Patients

Many pediatric patients with acute liver failure (PALF) do not receive a specific diagnosis (such as herpes simplex virus or Wilson disease or fatty acid oxidation defects)-they are left with an indeterminate diagnosis and are more likely to undergo liver transplantation, which is contraindicated for some disorders. Strategies to facilitate complete diagnostic testing should increase identification of specific liver diseases and might reduce liver transplantation. We investigated whether performing recommended age-specific diagnostic tests (AS-DTs) at the time of hospital admission reduces the percentage PALFs with an indeterminate diagnosis. We performed a multinational observational cohort study of 658 PALF participants in the United States and Canada, enrolled at 10 medical centers, during 3 study phases from December 1999 through December 2014. A learning collaborative approach was used to implement AS-DT using an electronic medical record admission order set at hospital admission in phase 3 of the study. Data from 10 study sites participating in all 3 phases were compared before (phases 1 and 2) and after (phase 3) diagnostic test recommendations were inserted into electronic medical record order sets. The percentage of subjects with an indeterminate diagnosis decreased significantly between phases 1-2 (48.0%) and phase 3 (to 30.8%) (P= .0003). The 21-day cumulative incidence rates for liver transplantation were significantly different among phase 1 (34.6%), phase 2 (31.9%), and phase 3 (20.2%) (P= .030). The 21-day cumulative incidence rates for death did not differ significantly among phase 1 (17.9%), phase 2 (11.9%), and phase 3 (11.3%) (P= .20). In a multinational study of children with acute liver failure, we found that incorporating diagnostic test recommendations into electronic medical record order sets accessed at time of admission reduced the percentage with an indeterminate diagnosis that may have reduced liver transplants without increasing mortality. Widespread use of this approach could significantly enhance care of acute liver failure in children.

P3.10-003 Assessing and Addressing Knowledge Gaps to Improve Lung Cancer Screening Rates

The National Lung Screening Trial showed that annual screening with low-dose computed tomography (LDCT) in high-risk patients reduced lung cancer mortality by 20%. The United States Preventative Services Task Force (USPSTF) now recommends lung cancer screening (LCS) for high-risk individuals. However, only about 10% of eligible individuals are referred for LDCT possibly in part due to a lack of familiarity among primary care physicians with LCS guidelines. In this analysis, we sought to obtain a baseline acumen of providers’ knowledge and awareness about LCS and develop a series of interventions including embedding USPSTF criteria into electronic medical record (EMR) ordering to educate providers and facilitate more effective use of LCS for high-risk patients. A Lung Cancer Screening Program was started in 2015 led by a nurse practitioner. Internal medicine residents at the University of Illinois – Chicago (UIC) General Medicine Clinic (GMC) were surveyed using paper questionnaires. The survey included 6 questions on USPSTF LCS guidelines. Next, educational efforts were addressed through a lecture, email reminders, and informational clinic flyers. Finally the EMR order set was updated to include USPSTF criteria directed ordering. The number of appropriately ordered screens through GMC was tracked monthly. A post-intervention survey was distributed to evaluate if providers’ knowledge was improved by these interventions. Fifty-three IM residents were surveyed regarding LCS guidelines appropriate for LDCT screening. Of the respondents, 87% knew the correct test for screening was LDCT, 66% knew only smokers with ≥30 pack year history were eligible, 45% knew the minimum age criteria (55 years-old), 28% knew the maximum age (80 years-old), 42% knew interval to re-order screening for a negative test (1 year), and 38% knew the maximum time since quitting (15 years). Following the initial interventions there was an increase in the rate of appropriately ordered LDCT screening tests ordered through GMC clinic (from 6.8 per month [May 2016 to September 2016] to 10.8 per month [Oct. 2016 to Apr. 2017]). Post-intervention knowledge assessment is underway and will be presented. Although LCS is recommended by USPSTF, there are gaps in knowledge about eligibility criteria among internal medicine residents. We present data that suggests using educational interventions and changes in EMR to increase awareness and knowledge is associated with an increase in appropriate usage of LDCTs for LCS. Ultimately, we plan to broaden these interventions to additional primary care clinics (e.g., Family Medicine, Pulmonary) to improve proper use of LCS at our institution.

Achieving Optimal Specialty Cerebrospinal Fluid (CSF) Testing: Are Electronic Medical Record Order Sets Helpful?

BackgroundSpecialty PCR testing has become available for lumbar puncture to determine the cause of infectious meningitis and encephalitis. Testing with low pre-test probability may increase antimicrobial therapy while results are pending and create increased direct costs. We aim to describe the appropriateness of testing before and after the implementation of electronic medical record (EMR) order sets designed to reduce excessive testing of CSF by creating two lists of tests: (1) a routine panel for all patients and (2) a list of optional specialty tests designed to be utilized after the nucleated cells are resulted.MethodsRetrospective study of adult patients undergoing lumbar puncture with suspicion for CNS infection pre-and post-implementation of EMR order sets from January 2016–March 2017. Consecutive patients with complete charts were reviewed from a tertiary care center. Data collected included demographics, co-morbid conditions, clinical presentation, and lumbar puncture results. The primary outcome of interest was the frequency of CSF specialty testing in patients with ≤ 10 nucleated cells/µL in the CSF.ResultsTwo hundred patients had ≤ 10 nucleated cells/µL in the CSF (n = 108 in pre-EMR group; n = 92 in post-EMR group). Of these patients 74% and 48.9% had Herpes Simplex Virus (HSV) PCR testing done pre and post EMR changes (P < 0.05). Enterovirus PCR testing remained similar among both groups (37% pre-EMR order sets vs. 36.9% post-EMR order sets, P = 0.99). Lyme PCR testing decreased between pre- and post-groups (26.8% vs. 9.7%, P < 0.05). CSF Epstein-Barr virus PCR testing also dropped significantly from 26.9% to 7.6% (P < 0.05). All specialty PCR testing that was performed on patients with ≤ 10 nucleated cells/µL in the CSF were negative. Paradoxically, HSV antibody testing increased post-implementation of EMR order sets (21.7% vs. 0%, P <0.05). Total costs of tests on average decreased by $70.71 per patient post EMR changes.ConclusionIn this cohort, CSF specialty testing was common but decreased after EMR changes. Laboratory stewardship can be improved with EMR changes but further education is needed to prevent unnecessary tests. Unwanted tests (HSV antibodies) may be increased as prescribers are unable to locate familiar tests.Disclosures M. D. Nailor, Astellas: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. Merck: Grant Investigator, Research grant.

A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis.

The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg-1 . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing. The primary aim was to deliver cefazolin 30 mg·kg-1 to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order. Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups. Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg-1 from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg-1 was significantly higher when given after an electronic order than when given verbally, 94% vs 76%. This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.

A Systems-Based Approach to Improve Fibrinogen Testing and Treatment of Low Fibrinogen in Patients Receiving Massive Transfusions: A Quality Improvement Initiative

Background: Uncontrolled hemorrhage is the most common treatable cause of death and four of every ten trauma patients die as a results of exsanguination, or its late effects (Curry et al. Scand J Trauma 2014). There is an increasing understanding of the state of acute coagulopathy and the role that fibrinogen plays in major hemorrhage (Wikkelso A et al. Cochrane Syst Rev 2013). Fibrinogen is a critical protein for hemostasis and clot formation. Low fibrinogen is a risk factor for hemorrhage in patients with major hemorrhage including surgical, obstetrics and trauma patients. Observational studies have reported improved survival with higher fibrinogen:RBC transfusion ratios in trauma.At Regions Hospital, St. Paul, MN, the Transfusion Committee observed that many patients receiving massive transfusions did not have fibrinogen activity tested.Aim: To improve fibrinogen testing and treatment of low fibrinogen in patients receiving massive transfusions by using a hospital-wide, electronic medical record (EMR)-based Massive Transfusion Protocol (MTP) order set. Outcomes, including survival and transfusion requirements will also be evaluated.Methods: Retrospective analysis of data from existing databases identified 127 patients who had massive hemorrhage as defined by activation of the massive transfusion protocol (MTP) at Regions Hospital between 2014-2016. We performed chart reviews to assess fibrinogen replacement practice 6 months before (n=68) and 6 months (n=59) after implementation of an EMR-based MTP order set in a quality improvement model. The order set automatically orders fibrinogen activity, in addition to hemoglobin, platelet count, INR, and PTT. Once the order set is activated, it will alert the provider to a low fibrinogen activity result using a best practice alert. The alert then directs therapy by opening the order for administration of cryoprecipitate. To evaluate the impact of this order set on fibrinogen testing and clinical outcomes, we constructed multivariable logistic regression models.Results: During the study period, 127 patients had the MTP activated. The median age was 51 years and 67% were male. The majority of MTPs were activated for trauma (57%) located primarily in ED (64%). The common admitting diagnoses were motor vehicle accident (29%), heart surgery/procedure (18%), or GI bleed (16%). The admitting hemoglobin, platelet count, INR, and PTT were similar pre and post-intervention. Prior to the use of the MTP order set, only 32% of patients receiving the MTP had fibrinogen tested. Of the patients with a fibrinogen activity tested, over one-third had a low fibrinogen and of those 56% did not receive cryoprecipitate. Fibrinogen testing increased after the intervention (61% vs 32%, p=0.001), and among patients with low fibrinogen, transfusion of cryoprecipitate occurred more often (70% vs 44%, p=0.370). Blood transfusion requirements for red blood cells (7.0 vs 9.9, p=0.133), fresh-frozen plasma (4.9 vs 6.7, p=0.063), and platelets (1.2 vs 1.6, p=0.068) decreased post-intervention. In multivariate analysis, patients were approximately 3 times more likely to have fibrinogen activity tested after the intervention (OR 3.06, p=0.003). Deaths within 24 hours of MTP were more likely to occur among patients in the pre-intervention period (OR=1.45; 95% CI 0.42-5.00) and those with low fibrinogen (OR=1.34; 95% CI 0.26-7.08), however, due to the limited number of events, these estimates did not reach statistical significance.Conclusions: A systems-based approach with a hospital-wide EMR order set for the MTP improved the testing for and treatment of low fibrinogen in patients with massive hemorrhage. This resulted in a trend towards improved outcomes. We did not achieve 100% fibrinogen testing after the intervention because the MTP can still be activated without using the order set, and this will be corrected in a future update. The treatment of patients with traumatic hemorrhage remains challenging and varies widely between trauma centers. Standardized treatment, automation of lab ordering, and the use of alerts can help providers improve the quality of care and clinical outcomes for patients. DisclosuresNo relevant conflicts of interest to declare.