Electronic Order Set Research Articles

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

Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis.

Continuous pulse oximetry monitoring (cSpO2) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO2 overuse in order to reduce overuse and its associated harms. This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO2 study, a cross-sectional study to establish rates of cSpO2 in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO2 use rates to identify barriers and facilitators to addressing cSpO2 overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach. Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO2 use incorporated into electronic order sets, regular education about cSpO2 in bronchiolitis, and visual reminders may be needed to reduce cSpO2 utilization. Parental perceptions and individual clinician comfort affect cSpO2 practice. We identified barriers and facilitators to deimplementation of cSpO2 for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO2 use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO2, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO2.

Developing a multidisciplinary HCV direct-acting antivirals utilization management and assessment program

BackgroundThe introduction of direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) infections has revolutionized outcomes for patients with HCV. Cost-effective use of these antivirals in addition to ensuring patient adherence is of paramount importance. ObjectivesThe goal of this article is to describe the processes by which a tertiary care, multisite institution managed the complexities involved in administering DAA treatment and managing the increased cost of therapy. Specifically, the objectives of this article are to describe the development of a multidisciplinary HCV management program and the role of pharmacists in this program, including formulary management strategies and monitoring of DAAs use in our institution, development of guidelines, electronic prescribing protocols and order sets, and specific outcomes based on a concurrent medication use evaluation. Practice descriptionKing Faisal Specialist Hospital and Research Centre is a tertiary care referral hospital. As a tertiary referral hospital, it offers primary and highly specialized inpatient and outpatient medical care. The process of selecting and developing institutional HCV management program is described. Practice innovationThis article provides key details regarding how a multidisciplinary HCV program using DAAs can be implemented successfully at a tertiary care facility. Key facets of our innovation include establishing formulary guidelines, setting up eligibility criteria for patients, and establishing an HCV taskforce and multidisciplinary HCV program clinic. EvaluationMedication use evaluations were regularly conducted to monitor sustained virologic response rates, adherence to guidelines, adverse reactions, and drug interactions. Methods: Formulary guidelines, setting up an eligibility criterion for patients, and an HCV taskforce and multidisciplinary HCV program clinic were established. ResultsThe involvement of pharmacists in a multidisciplinary HCV program in outpatient settings resulted in improved formulary decision making, reduction of costs, and improvement of adherence to institutional guidelines. Practice implicationsThe role of a pharmacist in the management of patients with HCV with DAAs is important. Pharmacists play an integral part in medication management and overall reduction in health care expenditure. Many disease management programs can be complemented with pharmacists to improve patient care and reduce cost. ConclusionHCV treatment is challenging, and a multidisciplinary approach to treat HCV is critical. It is a rapidly evolving field; therefore, it requires dynamic formulary management and collaborative practice approaches to monitor pharmacotherapy carefully and efficiently. Clinical pharmacists play a pivotal role within the multidisciplinary team by providing support to both patients and health care providers with regard to the treatment of HCV.

Optimizing Pain Management for Children with Sickle Cell Disease Vaso-Occlusive Crisis in the Emergency Department

Background: Sickle cell disease (SCD) is an inherited blood disorder that predisposes affected children to episodic pain events, known as the Vaso-occlusive crisis (VOC). VOC is the most common reason for emergency department (ED) visits in patients with SCD. This QI project-specific aim was to assess the meantime from check-in to first analgesic delivery to patients with VOC presenting at Holtz Children's Hospital Pediatric Emergency Department (PED) and to reduce this time by at least 20% (from 90 minutes to 72 minutes) during six months in accordance to best practice standard of care. Methods: Standard quality improvement tools and PDSA methodology was utilized to identify root causes and countermeasures. Root cause analysis included surveys from PED staff, residents, and faculty which demonstrated a lack of practitioner familiarity with current evidence and lack of a standardized pathway. Using this data, countermeasures were implemented, including staff education of guidelines, creation, and deployment of a readily accessible SCD VOC clinical pathway (Figure 1) for PED providers to utilize an updated electronic order set "power-plan" named PED Sickle Cell Crisis Powerplan. A balancing measure while we attempt to reduce the time to first analgesic administration, can be an increase in workload for the nursing staff in the PED. A PED orientation introductory email prompted residents to use our clinical SCD VOC pathway, which was also uploaded in a medical mobile app (The Hub®). We displayed point-of-care reminders, including laminated pathway cards in the PED nursing stations. Key drivers for effective pain management in the ED were identified, including a continuous reassessment of pain as well as an effective standardized pharmacological and non-pharmacological care. Institutional Board Review (IRB) approval was obtained. We recruited nursing champions to help sustain our results. Will measure the average time from triage to IV opioid dosage, to ensure IN fentanyl as drug of choice will not delay subsequent IV opioid dosage administration. PED nursing staff trained to administer IN Fentanyl to patients with a nasal mucosa atomizer, available in the Omnicell. Exclusion criteria of patients with Sickle cell disease with other ICD-10 diagnosis codes, such as acute chest syndrome, or another type of etiology for pain not associated with VOC. The main indicators were assessment-to-dose time; registration-to-discharge time; first dose-to-discharge time and rate of VOC admissions (ED/admissions). All data were collected by discrete time stamps. The database was provided by Jackson Memorial Hospital Informatics and Technology (IT) team. Data were statistically analyzed using Microsoft Office Excel 365/Prism-8. The analysis compared baseline with the first PDSA cycle from December 2019 to February 2020. Results: From December 2019 to February 2020, a total of 65 VOC encounters were analyzed. Baseline data average check-in to first dose time was 90.3 minutes, following intervention average time lowered to 70.3 minutes, which corresponds to a 24.6% decrease (Figure 2). Patients ages 15-19 represented the majority of the participants (37.9%). Male-to-female ratio was 51.5% and 48.5%, respectively. Afro-American non-Hispanic participants represented 91.2% of the study and Hispanic 8.8%. Discussion: PED staff surveys demonstrated a lack of familiarity with current VOC guidelines and the lack of a standardized pathway. Nursing surveys reported hesitancy to opioid re-administration from subjective pain assessment and opioid pain management misconception before education. PED staff shift changes, monthly new rotating residents, and the unpredictable nature of PED workflow are factors that can affect consistent VOC management. Implementing a clinical pathway available to the staff and integrating it into the workflow reduces the variability in the management of VOC visits. Hence, through teamwork, continuous pathway reinforcement, and education our outcome was associated with improvement in average time from check-in to first-dose. Conclusion: Standardized procedures to treat and reassess pain for sickle cell disease VOC patients in the PED resulted in check-in to first-dose time reduction by 24.6%. Further steps to sustain our results include guideline reinforcement and interventions with effective pharmacological i.e. intranasal fentanyl and non-pharmacological care. Figure 1 Disclosures No relevant conflicts of interest to declare.

Utilization and Laboratory Monitoring of Andexanet Alfa Reversal of Factor Xa Inhibitors in Bleeding Patients

Abstract Introduction Andexanet alfa, a reversal agent for factor Xa inhibitors rivaroxaban and apixaban, was approved by the Food and Drug Administration in May 2018 for patients with life-threatening bleeding. It acts by competing with endogenous factor Xa to block anticoagulant activity. Intravenous administration rapidly reduces anti-factor Xa activity. Because andexanet became available only recently, there is high potential for inappropriate use. Our objective was to investigate utilization and laboratory monitoring of andexanet in our hospital system in order to improve utilization. Methods This is a retrospective study with review of charts in the electronic medical record from April 2019 to February 2020. Charts were reviewed for the time of andexanet administration, anti-factor Xa testing before and after administration, turnaround time (TAT) for anti-factor Xa testing, and patient’s status after treatment. Results We identified 33 patients who received andexanet in our hospital system. Intracranial hemorrhage was the most common clinical symptom. Of 33 patients, 12 patients (36%) expired, one transferred to hospice, 18 (55%) were discharged alive, and two recent cases are alive awaiting disposition. Only 12 patients (36%) had anti-factor Xa testing performed prior to administration of andexanet, with one additional patient receiving testing only after administration. Factor Xa activity was misordered for anti-factor Xa in one patient. TAT for anti-factor Xa in these patients ranged from 25–112 minutes, with median 35.5 minutes. Of the 12 patients who had anti-factor Xa testing prior to administration, 4 expired and 8 survived. Pre-administration anti-factor Xa activity was significantly lower in patients who expired than in patients who survived (0.3 vs. 1.8 IU/ml, P value = 0.02). Conclusion Currently, anti-factor Xa testing is not ordered for most patients receiving andexanet alfa in our hospital system. Although not necessary for dosing decisions, anti-factor Xa testing may be useful prior to administration to identify patients unlikely to benefit from anticoagulant reversal. Despite a small sample size, there was a statistically significant difference in anti-factor Xa activity by patient outcome, suggesting that andexanet may be unhelpful in patients with low anti-factor Xa activity. Based on these findings, we are building an electronic order set to facilitate proper administration of this medication.

Development and implementation of an evidence-based malignant hematology clinical pathway program.

304 Background: Clinical pathways provide a means to maximize value-based care for cancer patients. They have been associated with decreased costs and outcome improvements. Our institution entered a transformative partnership with an NCI designated comprehensive cancer center for the treatment of hematologic malignancies. As part of the collaboration, a multidisciplinary task force was established to adapt clinical pathways within our system. Given the multiple new drug approvals for the treatment of Acute Myeloid Leukemia (AML), this was the first pathway created. Methods: The taskforce consisted of physicians, pharmacists, nurses, quality manager, and information technology staff. The group met weekly to draft algorithms in accordance with national guidelines, updated evidence and institutional preferences. Electronic Medical Record (EMR) treatment plans were reviewed in a secondary multidisciplinary workgroup and validated to ensure compliance with the AML pathway. When applicable, specific criteria for use were developed to aid in medication use optimization. The finalized pathway and treatment plans were presented and approved at our clinical standards committee meeting. A chart audit was performed one year after pathway implementation to assess adherence, with a goal of 80% or higher. The results were compared to an audit assessing adherence to best available clinical evidence for the year prior to implementation. Results: The group established a consensus on treatment, laboratory testing, and supportive care, including anti-emetic, anti-microbial, and tumor lysis syndrome (TLS) prophylaxis. Electronic order sets were created for bone marrow biopsies, transfusion support, TLS and febrile neutropenia. Thirty-two EMR treatment plans for AML were built and/or revised, while five were inactivated. A total of 88 patient charts were included in the pathway adherence audit (44 before and 44 after implementation). Pre and post pathway adherence was 64% and 89%, respectively (p=0.006). Deviations were categorized by type (table). Conclusions: AML pathway development and implementation resulted in standardization of treatment regimens, supportive care and higher adherence to institutional evidence based practices. [Table: see text]

S0612 Effectiveness in Using Electronic Order Sets in Suspected Variceal Hemorrhage

INTRODUCTION: Variceal hemorrhage (VH) is associated with high mortality. Patients require urgent referral to GI specialists, acid suppression, somatostatin analogues, and antibiotic prophylaxis. Our institution noted a delay in initiating vasoactive agents like octreotide in residents' patients suspected to have VH. Therefore this project was initiated to create an electronic order set to help address the delay in initiating octreotide in patients suspected to have VH. Hepatology guidelines recommend the use of proton pump inhibitors, vasoactive agents, and antibiotic prophylaxis the moment a physician suspects VH [1]. Delays in initiating therapy not only can worsen patient outcomes but can increase liability. METHODS: An order set was created to include three medications (pantoprazole, octreotide, and ceftriaxone). A total of 200 patients were randomized & divided into two groups. The baseline group had a total of 50 patients in which no order set was used. The order set group had 45 patients. Each patient met the Baveno VI criteria. Three years of retrospective data was used to evaluate the primary outcome of minutes to medication onset. The secondary outcomes included start time variability between medications, mortality, days hospitalized, & number of blood products. RESULTS: Overall the minutes of onset for pantoprazole, octreotide, and ceftriaxone showed no statistical difference between the baseline & order set group (P = 0.935). All three medications did not have a reduced onset time when the order set was used. There was however a statistical difference in start time variability between the three medications (P = 0.022). The order set group had a median variation of 48 minutes. The baseline group had a median variation of 121.5 minutes. Other outcomes such as mortality, days of hospitalization, days in intensive care, and number of units of blood transfused were all statistically insignificant and showed no difference between the groups. CONCLUSION: Overall this project did not achieve its goal of reducing minutes of onset for initiating octreotide. Though the onset of initiating all medications could not be improved, there was a significant reduction in the start time variability. The order set group had decreased variability by 73.5 minutes when compared to the baseline group. This analysis did provide the insight that increased start time variability did not translate to clinically worse outcomes. Further studies will be needed to show the efficacy of order sets in improving VH outcomes.Table 1.: Demographic Characteristics of Patients in the Baseline and Order Set GroupsTable 2.: Minutes To Onset Of MedicationsTable 3.: Other Secondary Outcomes

Successful Diagnostic Stewardship for Clostridioides difficile Testing in Pediatrics

Background: As many as 40% of infants aged ≤12 months and 10%–28% of children aged 13–24 months are colonized by Clostridioides difficile. The IDSA and the SHEA recommend that testing should never be routinely recommended for infants ≤12 months of age and should not be routinely performed for children 1–2 years of age unless other causes are excluded. We report implementation of C. difficile diagnostic stewardship at 2 children’s hospitals. Methods: We implemented age-based restrictions for C. difficile testing at hospital A (∼200-bed, free-standing, children’s hospital) and hospital B (∼100-bed children’s hospital within a larger hospital). Both sites are part of the same multicampus institution, and both used nucleic acid amplification testing to detect C. difficile throughout the study. In May 2018, we implemented an electronic order set for C. difficile that provided alerts to avoid testing young infants and patients with recent use of laxatives, stool softeners, or enemas, but providers could order C. difficile testing at their discretion. In October 2018, we implemented a more restrictive diagnostic stewardship algorithm for C. difficile. No testing was allowed for infants aged ≤12 months. Approval pediatric infectious diseases staff was required to test children aged 13–24 months. Pathology resident approval was required to test children aged ≥24 months who had received laxatives, stool softeners, or enemas within ≤24 hours. Clinical microbiology laboratory supervisors reinforced rejection of nondiarrheal stool specimens for testing. Providers at both campuses were informed about the new testing guidelines by e-mail. We compared the number of tests sent and positive cases of healthcare facility-onset C. difficile (HO-CDI) by age strata before and after the implementation of the restrictive testing algorithm. Results: After the intervention, the number of tests in infants significantly declined; 2 infants aged ≤12 months and 4 infants aged 13–24 months were tested for C. difficile (Table). After the intervention, the number of tests per month declined at hospital A, as did the number of HO-CDI cases at both hospitals. Rejections of nondiarrheal stools significantly increased after the intervention (P < .001). Conclusions:C. difficile diagnostic stewardship for children was successfully implemented using a rule-based alert system in the electronic health record. This intervention was associated with a reduced number of tests sent and cases of HO-CDI. This strategy was cost-saving and prevented misdiagnosis, unnecessary antibiotic therapy, and overestimation of HO-CDI rates.Funding: NoneDisclosures: None

S3205 Development, Testing, and Implementation of an Opioid-Sparing Proactive Pain Control Order Set for Hospitalized Adults With IBD

INTRODUCTION: In patients with inflammatory bowel disease (IBD), opioid-use is associated with an increased risk of poor quality of life, infection and death, yet opioids remain commonly prescribed. Many patients are first exposed to opioids during a hospitalization and continue them after hospital discharge. Therefore, opioid reduction strategies in hospitalized patients with IBD are desirable. We aimed to develop an opioid-sparing pain control strategy for hospitalized adults with IBD. METHODS: We conducted a systematic literature review and presented it to a panel of pharmacists, IBD specialists, and pain specialists to identify non-opioid medication regimens for pain in IBD. The panel iteratively developed an algorithm for scheduled and as-needed therapies to treat mild, moderate, and severe pain in patients with IBD. This protocol was used in a limited number of patients to assess feasibility and obtain patient feedback. Based on feedback, small changes were made. The final algorithm was presented to the pharmacy & therapeutics committee, and programmed as a 1-click order set within the electronic health record (Epic®). RESULTS: We developed an algorithm that includes scheduled acetaminophen, celecoxib, gabapentin, and as-needed lorazepam and hydromorphone tailored to mild, moderate and severe pain (Table 1). This algorithm was accepted and approved by a multidisciplinary therapeutics committee, and developed into a single-click electronic order set. CONCLUSION: We developed an evidence-based opioid-sparing algorithm for pain control in hospitalized patients with IBD. This proactive approach using scheduled non-opioid pain medications and as-needed opiates has the potential to both improve pain and reduce opioid use in the hospital. Testing of this proactive algorithm against usual care in a randomized, controlled trial is warranted.Table 1.: Proactive Inpatient Narcotic-Sparing Protocol

Insulin Bolus Calculator: Lessons Learned from Institutional Experience.

Insulin bolus calculators have proven effective in improving glycemia and patient safety. Insulin calculators are increasingly being implemented for inpatient hospital care. Multidisciplinary teams are often involved in the design and review of the efficacy and utilization for these calculators. At times, unintended consequences and benefits of utilization are found on review. Integration of our insulin calculator into our electronic health record system was a multidisciplinary effort. During implementation, several obstacles to effective care were identified and are discussed in the following manuscript. We describe the barriers to utilization and potential pitfalls in clinical integration. We further describe benefits in patient education, time of insulin administration versus meal delivery, variations in insulin bolus for ketone correction, variation in care, and maximum bolus administration. Sharing lessons learned from experiences using electronic insulin calculator order sets will further our goals of improved patient care in the hospital setting.

Web Exclusive. Annals for Hospitalists Inpatient Notes - Realizing the Promises of Hospital Electronic Order Sets.

Web Exclusive. Annals for Hospitalists Inpatient Notes - Realizing the Promises of Hospital Electronic Order Sets.

Effect of Pain Management Electronic Order Sets on Opioid Use in Adult Rib Fracture Patients.

Inpatient pain management order sets are an important and necessary tool for standardizing and enhancing pain management for patients with traumatic injury. The purpose of this study was to assess the impact of revised inpatient pain management electronic order sets on opioid usage for patients with significant chest wall trauma. A retrospective pre-post study was conducted for adult patients with 3 or more rib fractures admitted to the hospital at a Level 1 trauma center. Two periods were compared: 1 year prior to the order set changes and the period immediately after the revisions were implemented. Differences between medians were assessed using Kruskal-Wallis test by ranks, and differences between nominal variables were assessed with χ test. Twenty-five patients were analyzed for each period. There was no significant change between periods in the total amount of opioid received per day. There was a significant reduction in intravenous (IV) opioid use on the general inpatient floor (61% vs. 24%, p = .01), as well as in the percentage of patients who received IV opioid within 24 hr of discharge (40% vs. 4%, p = .002). Revised inpatient pain management order sets did not reduce overall opioid usage in a population of patients with 3 or more rib fractures. However, significant improvements were noted in decreased IV opioid usage on the general inpatient floors and within 24 hr of patient discharge from the hospital.

Computerized Electronic Order Set: Use and Outcomes for Heart Failure Following Hospitalization

BackgroundQuality improvement initiatives improve health care delivery but may be resource intensive and disrupt clinical care. An embedded heart failure order set (HFOS) within a computerized physician order-entry system may mitigate these concerns. MethodsAn HFOS, based on proven interventions, was implemented within an existing computerized physician order-entry system in all adult acute-care hospitals in a single Canadian metropolitan city and interrogated between January 1, 2013 and December 31, 2015. The composite of repeat hospitalization or death within 30 days of hospital discharge and hospital length of stay were reported. ResultsIn total, 8969 patients were included with mean age 75.6 ± 13.5 years; 4673 (52.1%) were male. The HFOS was used in 731 (8.2%) patients. After analysis of 724 pairs of propensity-score matched cohorts, patients with HFOS use experienced a lower median length of stay (8.6 vs 9.4 days, P = 0.016) and a trend toward lower composite repeat hospitalization or death (14.5% vs 17.7%, P = 0.115, hazard ratio 0.79 (0.60–1.05). Patients with HFOS use were more likely to undergo a test for left ventricular ejection fraction (88.6% vs 76.7%, P < 0.001, and to be referred to a heart failure clinic (48.5% vs 6.3%), with similar rates of discharge prescription of beta-blockers (88.7% vs 86.3) and angiotensin-converting enzyme inhibitors (87.4% vs 89.0%). ConclusionsUse of a designated HFOS within a computerized physician order-entry system is associated with shorter hospital length of stay without increase in deaths or readmissions. These findings should be confirmed in a prospective controlled trial.

The cirrhosis care Alberta (CCAB) protocol: implementing an evidence-based best practice order set for the management of liver cirrhosis - a hybrid type I effectiveness-implementation trial

BackgroundLiver cirrhosis is a leading cause of morbidity, premature mortality and acute care utilization in patients with digestive disease. In the province of Alberta, hospital readmission rates for patients with cirrhosis are estimated at 44% at 90 days. For hospitalized patients, multiple care gaps exist, the most notable stemming from i) the lack of a structured approach to best practice care for cirrhosis complications, ii) the lack of a structured approach to broader health needs and iii) suboptimal preparation for transition of care into the community. Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial which aims to address these gaps. The proposed intervention is initiated at the time of hospitalization through implementation of a clinical information system embedded electronic order set for delivering evidence-based best practices under real-world conditions. The overarching objective of the CCAB trial is to demonstrate effectiveness and implementation feasibility for use of the order set in routine patient care within eight hospital sites in Alberta.MethodsA mixed methods hybrid type I effectiveness-implementation design will be used to evaluate the effectiveness of the order set intervention. The primary outcome is a reduction in 90-day cumulative length of stay. Implementation outcomes such as reach, adoption, fidelity and maintenance will also be evaluated alongside other patient and service outcomes such as readmission rates, quality of care and cost-effectiveness. This theory-based trial will be guided by Normalization Process Theory, Consolidated Framework on Implementation Research (CFIR) and the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Framework.DiscussionThe CCAB project is unique in its breadth, both in the comprehensiveness of the multi-component order set and also for the breadth of its roll-out. Lessons learned will ultimately inform the feasibility and effectiveness of this approach in “real-world” conditions as well as adoption and adaptation of these best practices within the rest of Alberta, other provinces in Canada, and beyond.Trial registrationClinicalTrials.gov: NCT04149223, November 4, 2019.

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.

Physician Experience with Electronic Order Sets.

Electronic medical record (EMR) and electronic health record (EHR) are used interchangeably to describe a computerized medical information system that collects, stores and displays patient information (Boonstra and Broekhuis 2010). Blumenthal and Tavenner (2010) suggested that computerized medical implementation improves decision-making and patient management. As part of its EMR, Humber River Hospital has implemented electronic order sets (EOSs) by building them into the computerized physician order entry (CPOE) system. Electronic prescribing renders paper prescriptions obsolete as it reduces errors; increases accuracy; and enhances efficiency, compliance and record-keeping (Canada Health Infoway 2017). The aim of this research was to explore physicians' perspectives and experiences using EOSs. This qualitative study examined the perceptions of various physicians on the impact of EOSs. Data were collected through semi-structured, in-depth interviews with eligible physicians. Domains explored included usability, efficiency, safety and implications for the physician profession. Major themes that emerged included usability, efficiency and safety. Several implications for physician practice were also revealed. The findings from our study support previous studies that describe the benefits of EOSs, including ease of use and efficiency, real-time information that is evidence-based, increased safety and minimization of memory burden. EOSs were not perceived to be a replacement for clinical reasoning.

Pilot of the Life-Sustaining Treatment Decisions Initiative Among Veterans With Serious Illness.

Prior to national spread, the Department of Veterans Affairs implemented a pilot of the life-sustaining treatment decisions initiative (LSTDI) to promote proactive goals of care conversations (GoCC) with seriously ill patients, including policy and practice standards, an electronic documentation template and order set, and implementation support. To describe a 2-year pilot of the LSTDI at 4 demonstration sites. Prospective observational study. A total of 6664 patients who had at least one GoCC. Descriptive statistics characterized patient demographics, goals of care, LST decisions, and risk of hospitalization or mortality among patients with at least one GoCC. Participants were on average 71.4 years old, 93.2% male, 87.1% white, and 64.7% urban; 27.3% died by the end of the pilot period. Fifteen percent lacked decision-making capacity (DMC). Nonmutually exclusive goals included to be cured (7.6%), to prolong life (34%), to improve/maintain quality of life (61.5%), to be comfortable (53%), to obtain support for family/caregiver (8.4%), to achieve life goals (2.1%), and other (10.5%). Many GoCCs resulted in a do not resuscitate (DNR) order (58.8%). Patients without DMC were more likely to have comfort-oriented goals (77.3% vs 48.8%) and a DNR (84% vs 52.6%). Chart abstraction supported content validity of GoCC documentation. The pilot demonstrated that standardizing practices for eliciting and documenting GoCCs resulted in customized documentation of goals of care and LST decisions of a large number of seriously ill patients and established the feasibility of spreading standardized practices throughout a large integrated health care system.

Implementation of a Perinatal Hospice Program.

In 2017, the Nebraska Unicameral passed legislative bill 506, which required physicians to inform patients carrying fetuses diagnosed with a life-limiting anomaly of the option to enroll in a comprehensive perinatal hospice program. The bill also required the Department of Health & Human Services to provide information about statewide hospice programs. Families enrolled in hospice programs are better prepared for the birth and death of their child. This large academic medical center was listed on the registry but did not have a formal perinatal hospice program. Implementation of a comprehensive perinatal hospice program. The program was designed and implemented, beginning with the formation of an interdisciplinary team. Guidelines were developed for program referral, care conferences, team communication, and family follow-up. The team was educated. Electronic record documentation and order set were implemented. A data collection process was developed to track referrals and critical data points. The perinatal hospice program has been accepting referrals but has not had any qualifying referrals. The development of an evidence-based guideline for referral that can improve referral consistency. While trisomy 13 and 18 diagnosis was historically considered life-limiting, these families now have the option of full intervention and transfer for specialists. Future research will include collecting data from patients who could have benefited from hospice, including infants who were born 20 to 22 weeks, or for maternal reasons. Future research will evaluate the experience after bereavement, the hospice team's experience, and the effectiveness of the referral process.

MP30: Reducing unnecessary oral contrast in patients undergoing enhanced abdomen/pelvis computed tomography in the emergency department: A multicentre project

Background: Traditionally, radiologists have routinely recommended oral contrast agents (such as Telebrix®) for patients undergoing a computed tomography of the abdomen/pelvis (CTAP), but recent evidence has shown limited diagnostic benefits for most emergency department (ED) patients. Additionally, the use of oral contrast has numerous drawbacks, including patient nausea/vomiting, risk of aspiration and delays to CTAP completion and increased ED length of stay (LOS). Aim Statement: The aim was to safely reduce the number of ED patients receiving oral contrast prior to undergoing CTAP and thereby reduce ED length of stay. Measures &amp; Design: An evidence-based ED protocol was developed in collaboration with radiology. PDSA cycle #1 was implementation at a pilot site to identify potential barriers. Challenges identified included the need to change the electronic order sets to reflect the new protocol, improved communication with frontline providers and addition of an online BMI calculator. PDSA cycle #2 was widespread implementation across all 4 ED's in the Calgary zone. The protocol was incorporated into all relevant electronic ED order sets to act as a physician prompt. Using administrative data, we extracted and analyzed data using descriptive and inferential statistics for the outcomes and balancing measures from a period of 12 months pre- and 12 months post-intervention. Evaluation/Results: A total of 14,868 and 17,995 CTAP exams were included in the pre and post periods, respectively. There was a reduction in usage of oral contrast from 71% to 30% (P &lt; 0.0001) in the pre- and post-study period, respectively. This corresponded to a reduction in average time of CT requisition to CT report completed from 3.30 hours to 2.31 hours (-0.99 hrs, P = 0.001) and a reduction in average ED LOS from 11.01 hours to 9.92 hours (-1.08 hrs, P &lt; 0.0001). The protocol resulted in a reduction of 19,434.6 patient hrs in the ED. Run charts demonstrate change was sustained over time. Our protocol did not demonstrate an increase in rates of repeat CTAP (P = 0.563) at 30 days, nor an increase in patient re-admission within 7 days (P = 0.295). Discussion/Impact: Successful implementation of an ED and radiology developed protocol significantly reduced the use of oral contrast in patients requiring enhanced CTAP as part of their diagnostic work up and, thereby, reduced overall ED LOS without increasing the need for repeat examinations within 30 days or re-admission within 7 days.

LO36: Reducing emergency department bloodwork and eliminating waste

Background: Patients presenting to the Emergency Department (ED) may be subjected to unnecessary bloodwork. This leads to excessive work for front-line nurses, physicians and laboratory staff, contributing to increased ED length of stay (LOS), patient discomfort, and health care costs. Aim Statement: By January 1, 2020, we will reduce the number of targeted blood tests (AST, GGT, aPTT and CK) by 40% in the Mount Sinai ED, as measured by the percent per 1000 ED visits of AST to ALT, GGT to ALT, aPTT to INR and CK to troponin. Measures &amp; Design: This was a prospective time series quality improvement study. Using the Model for Improvement, we engaged front-line ED staff, as well as stakeholders from Consultant, Laboratory and Information Services. Data was analyzed using run chart rules. Intervention: a) Removed rarely used tests from electronic nursing order sets b) Uncoupled order panels c) Developed six presentation-based medical directives with appropriate blood testing. d) Staff education Family of measures Outcomes: percent of targeted uncoupled test per 1000 ED visits for each of AST to ALT, GGT to ALT, aPTT to INR, and CK to troponin; Total number of blood tests ordered per 1000 ED visits Process: number of “separate and hold” tubes; number of blood tubes used in the ED; proportion of staff attending education Balancing: volume of blood drawn; LOS Evaluation/Results: Outcome: Estimated relative reduction in proportion of all uncoupled tests per 1000 ED visits by: • 33% AST/ALT • 52% GGT/ALT • 50% CK/troponin •18% aPTT/INR Total number of lab tests per 1000 ED visits decreased by 7.7% (5742 to 5331). Evidence of special cause variation on all outcomes. Process measures: 1. 100% reduction in weekly “Separate and Hold” tubes (56 to 0). 2. Monthly total of blood tubes used in the ED decreased by 2.8% (11620 to 11300) 3. Attendance pending. Balancing measures: Monthly average volume of blood drawn decreased by 1.4L(2%) from 50.4L to 49.0L; LOS pending Discussion/Impact: A multi-pronged intervention resulted in a decrease in blood testing in the ED. We achieved the sub-aim of reducing targeted blood tests and are on track to achieve the overall aim of total lab reduction in the ED by April 2020. Final interventions to be implemented in the coming months include changes to the ED paper record and replacement of the paper add-on order process with an electronic ordering tool. Complete data will be available by April 2020. This intervention is scalable and has the potential to reduce costs and preventable harm to patients.