Inappropriate Rate Research Articles

COST EFFECTIVE PROTOCOL WITH LETROZOLE AND 3 DOSES OF GONADOTROPIN COMBINATION AS AN ALTERNATIVE TO CONTINUOUS GONADOTROPIN FOR OVULATION INDUCTION FOR IUI IN CLOMIPHENE CITRATE RESISTANT PCOS PATIENTS - A RCT

Clomiphene citrate (CC) is the primary drug of choice for ovulation induction in PCOS but resistance to ovarian stimulation or stunted follicular growth is a frequent observation with CC. Inappropriate pregnancy rate & inadequate pregnancy outcomes are also observed with CC. The next approach of ovulation induction in CC resistance cases is using continuous Gonadotropin but it has many disadvantages such as high treatment cost, multi follicular development leading to multiple pregnancy, OHSS and frequent shifting of cycle to IVF-ET treatment. Letrozole induces folliculogenesis by releasing H-P axis from tonic inhibitory effect of estrogen & by augmenting gonadotropin secretion. It helps in follicular development without any adverse effect on the peripheral estrogen sensitive tissues. Adding few ampoules of gonadotropin at interval along with letrozole increases FSH at follicular receptor level & produces good quality oocyte. The purpose of the study was: -To evaluate the efficacy of combined Letrozole & 3 doses of gonadotropin in CC resistant IUI cases. -To compare the efficacy and cost effectivity of this protocol with continuous gonadotropin therapy. This RCT was conducted in a tertiary infertility care centre from July 2017 to January 2019. Total 108 anovulatory PCO women in the age group 20 to 36 years who had previous ≥3 failed treatment cycles with CC were randomly divided into Group A (Letrozole plus 3 doses gonadotropin group) & Group B (Continuous gonadotropin group) comprising 54 patients in each group. 2 blood samples from all the patients on Day2 of cycle and on the Day of hCG triggering were analyzed for endocrine profile. Patients in gr A were studied for total 96 cycles (n = 96) who received tab Letrozole 5 mg daily from D2 to D6 and injection U-FSH- HP (75 IU) on D2, D5 and D8 of cycle. Patients in gr B were studied for total 84 cycles (n = 84) & received continuous gonadotropin (U-FSH- HP, 75 IU) starting from D2 of cycle. Folliculometry was started from D9 of cycle & ovulation triggering was done by hCG when dominant follicle reached ≥ 18 mm. Single IUI was performed with documented ovulation. Both groups were evaluated in respect of terminal endocrinological profile, number of follicles, ovulation rate, pregnancy rate & outcome, adverse effects & cost effectivity. Demographic & baseline endocrine profile was comparable. In Gr A & B, mean no of follicles and average terminal estradiol level were 1.8 ±0.6 Vs 4.2 ± 0.8 (p< 0.05) and 266 ± 46 Vs 756 ± 84 pg (p< 0.001) respectively. Ovulation rate and pregnancy rate in both groups were 83.3% Vs 90.5% (p = 0.157) and 18.8% Vs 20.2% (p = 0.774) in Gr A & B respectively. In Gr B, 3 patients (3.6%) developed OHSS and 4 patients (4.8%) needed shifting of cycle to IVF-ET whereas no such incidents happened in Gr A. The average cost per cycle was significantly less in Gr A than Gr B. The combined therapy with Letrozole and 3 doses of gonadotropin is a cost effective treatment protocol in CC resistant PCOS patient before proceeding to costly continuous gonadotropin therapy without any significant difference in ovulation and pregnancy rate.

Primary prevention implantable cardioverter-defibrillators in hypertrophic cardiomyopathy—Are there predictors of appropriate therapy?

Identifying patients with hypertrophic cardiomyopathy (HCM) who warrant a primary prevention implantable cardioverter-defibrillator (ICD) is crucial. ICDs are effective in terminating life-threatening arrhythmias; however, ICDs carry risks of complications. The purpose of this study was to assess the incidence and predictors of appropriate ICD therapies, inappropriate shocks, and device-related complications in patients with HCM and primary prevention ICDs. All patients with HCM who underwent primary prevention ICD implantation at Toronto General Hospital between September 2000 and December 2017 were identified. Therapies (shocks or antitachycardia pacing) for ventricular tachycardia >180 beats/min or ventricular fibrillation were considered appropriate. Three hundred two patients were followed for a mean 6.1 ± 4.3 years (1801 patient-years of follow-up). Thirty-eight patients (12.6%) received at least 1 appropriate ICD therapy (2.3%/y); the 5-year cumulative probability of receiving appropriate ICD therapy was 9.6%. None of the conventional risk factors nor the European Society of Cardiology risk score was associated with appropriate ICD therapy. In multivariable analysis, age < 40 years at implantation and atrial fibrillation were independent predictors of appropriate ICD therapy. In a subgroup of patients who had undergone cardiac magnetic resonance imaging before ICD implantation, severe late gadolinium enhancement was the strongest predictor of appropriate ICD therapies. ICD-related complications or inappropriate shocks occurred in 87 patients (28.8%), with an inappropriate shock rate of 2.1%/y; the 5-year cumulative probability was 10.7%. The incidence of appropriate ICD therapies in patients with HCM and primary prevention ICDs is lower than previously reported; a high proportion of patients suffer from an ICD-related complication. Traditional risk factors have low predictive utility. Severe late gadolinium enhancement, atrial fibrillation, and young age are important predictors of ventricular tachyarrhythmias in HCM.

The Effect of Beers Criteria-Based Training in General Practitioners on Prescribing Potentially Inappropriate Medications in Elderly Patients

Background: Pharmacotherapy in elderly patients has become a major concern due to their physiological changes, pharmacokinetic and pharmacodynamics variations and poly-pharmacy. In considering the global trend in population aging, we aim to evaluate the effect of “Beers Criteria” education on prescribing medications for elderly patients by General Practitioners (GPs).&#x0D; Methods: Thirty GPs with the highest number of prescriptions were included in this pilot study. All prescriptions written over a three-month period were considered, then prescriptions for geriatric patients were selected and evaluated. The GPs were trained using pamphlets and booklets which were prepared based on Beers 2015 explicit criteria. In order to evaluate the effect of education, appropriateness of prescriptions was analyzed before and 1 month following training.&#x0D; Results: Of 15,447 prescriptions selected during the first step, 1,281 prescriptions were related to geriatric patients in which the prevalence of inappropriate drug prescriptions was 37.3%. The most inappropriate medications identified were Bisacodyl, Alprazolam, and Hyoscyamine. While in the second step 1,055 of 15,154 prescriptions concerned the elderly and inappropriate drug prescription rate was noted as 23.6%. The most common inappropriate medications included Alprazolam, Amitriptyline, and Hyoscyamine. Based on our results, the prevalence of prescribing potentially inappropriate medications (PIMs) for elderly patients is high among GPs and educational interventions that raise awareness about “Beers Criteria” significantly reduce the prescribing PIMs.&#x0D; Conclusion: Given the importance of GP training programs in reducing inappropriate prescription rates among geriatric patients, it will be necessary for the National Committee of Rational Use of Drugs (NCRUD) to consider undertaking comprehensive educational strategies for reducing the prevalence of inappropriate medication use in elderly people.

A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study

ObjectiveTo understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. MethodsWe implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. Results Fifty seven percent(117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. ConclusionWhile the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.

Hepatitis C antibody screening and determinants of initial and duplicate screening in the baby boomer patients of six urban primary care clinics.

In 2012, the Centers for Disease Control and Prevention released updated guidelines recommending universal, one-time hepatitis C virus screening for all individuals born between 1945 and 1965. Prior to the implementation of these guidelines, testing rates were inappropriately low, but unnecessary duplicate antibody testing was also problematic. In the era of increased efforts to screen "baby boomers", the prevalence and social determinants of initial and duplicate hepatitis C testing have not been well described. A hepatitis C screening program was implemented at six urban primary care clinics affiliated with Drexel University College of Medicine. Data was collected regarding the screening patterns in these clinics. Annual screening rates for the program were assessed. Multivariate logistic regression analyses were used to examine the association of demographic variables and the outcomes of subjects having ever been tested and subjects having received duplicate testing. Following the implementation of the program, the screening rate increased from 16% in the first year of analysis to 82% in the final year of analysis. Of the 6,717 patients screened, 1,207 had duplicate testing, of which 14% had inappropriate duplicate antibody screening. African Americans and Asian patients had a higher odds of being screened. Patients with public insurance had a higher odds of duplicate screening. In the setting of an aggressive hepatitis C screening program, high testing rates may be attained in a target population. However, inappropriate duplicate antibody testing rates may be high, which may be a burden in resource-limited settings.

Antimicrobial stewardship in the primary care setting: from dream to reality?

BackgroundClinicians who work in primary care are potentially the most influential healthcare professionals to address the problem of antibiotic resistance because this is where most antibiotics are prescribed. Despite a number of evidence based interventions targeting the management of community infections, the inappropriate antibiotic prescribing rates remain high.DiscussionThe question is how can appropriate prescribing of antibiotics through the use of Antimicrobial Stewardship (AMS) programs be successfully implemented in primary care. We discuss that a top-down approach utilising a combination of strategies to ensure the sustainable implementation and uptake of AMS interventions in the community is necessary to support clinicians and ensure a robust implementation of AMS in primary care. Specifically, we recommend a national accreditation standard linked to the framework of Core Elements of Outpatient Antibiotic Stewardship, supported by resources to fund the implementation of AMS interventions that are connected to quality improvement initiatives. This article debates how this can be achieved.SummaryThe paper highlights that in order to support the sustainable uptake of AMS programs in primary care, an approach similar to the hospital and post-acute care settings needs to be adopted, utilising a combination of behavioural and regulatory processes supported by sustainable funding. Without these strategies the problem of inappropriate antibiotic prescribing will not be adequately addressed in the community and the successful implementation and uptake of AMS programs will remain a dream.

Comparison of clinical characteristics and outcomes of infective endocarditis between haemodialysis and non-haemodialysis patients in China

ObjectiveTo clarify differences in clinical characteristics and outcomes between patients with infective endocarditis (IE) receiving long-term haemodialysis (HD group) and those not receiving haemodialysis (non-HD group).MethodsMedical records of patients with IE, admitted to hospital between January 2010 and December 2017, were retrospectively studied. Clinical characteristics and outcomes were compared between HD and non-HD groups. Risk factors for IE were assessed by COX regression.ResultsTwenty-one HD and 143 non-HD patients were included. Predisposing heart conditions were more frequently observed in the non-HD versus HD group (90.9% versus 19.0%). Inappropriate antibiotic therapy rate before admission and proportion of methicillin-resistant Staphylococcus aureus and Enterococcus-associated IE was higher in the HD versus non-HD group. In the HD group, fewer patients underwent heart surgery (9.5% versus 51.7%), all-cause in-hospital mortality was higher (52.4% versus 21%), and survival rate was lower versus the non-HD group. COX regression analysis revealed that haemodialysis, use of central venous catheter (CVC) and inappropriate antibiotic therapy before admission increased IE mortality, while surgery improved long-term prognosis.ConclusionsHaemodialysis patients with IE may have higher mortality and lower survival rates than patients with IE not receiving haemodialysis. Haemodialysis, use of CVC and inappropriate antibiotic therapy before admission may increase IE mortality. Surgery may improve long-term prognosis.

Choosing Daily Labs Wisely in the Hospital: A Novel Tool for Assessing Laboratory Testing Appropriateness.

The Minnesota Lab Appropriateness (MLAB) criteria were developed for assessing appropriateness of complete blood counts (CBCs) and serum electrolyte panels (SEPs) ordered for adult inpatients. Two independent raters used the MLAB criteria to rate appropriateness of labs ordered during 50 hospitalizations through retrospective medical record review. Evaluation of 208 CBCs and 253 SEPs on a 2-category scale (appropriate/inappropriate) resulted in an inappropriate lab rate of 24% and 25% for CBCs and SEPs, respectively. Using a 3-category Likert scale that included an "equivocal" rating to allow for clinical uncertainty, 17% of CBCs and 20% of SEPs were considered inappropriate. Interrater reliability was "substantial" using the dichotomous scale for both CBCs and SEPs. Using the 3-category Likert scale, reliability was "substantial" for CBCs and "moderate" for SEPs. The MLAB criteria identified inappropriate labs at a rate consistent with published figures, with good interrater reliability.

A composite hydrogel-3D printed thermoplast osteochondral anchor as example for a zonal approach to cartilage repair: in vivo performance in a long-term equine model

Recent research has been focusing on the generation of living personalized osteochondral constructs for joint repair. Native articular cartilage has a zonal structure, which is not reflected in current constructs and which may be a cause of the frequent failure of these repair attempts. Therefore, we investigated the performance of a composite implant that further reflects the zonal distribution of cellular component both in vitro and in vivo in a long-term equine model. Constructs constituted of a 3D-printed poly(ϵ-caprolactone) (PCL) bone anchor from which reinforcing fibers protruded into the chondral part of the construct over which two layers of a thiol-ene cross-linkable hyaluronic acid/poly(glycidol) hybrid hydrogel (HA-SH/P(AGE-co-G)) were fabricated. The top layer contained Articular Cartilage Progenitor Cells (ACPCs) derived from the superficial layer of native cartilage tissue, the bottom layer contained mesenchymal stromal cells (MSCs). The chondral part of control constructs were homogeneously filled with MSCs. After six months in vivo, microtomography revealed significant bone growth into the anchor. Histologically, there was only limited production of cartilage-like tissue (despite persistency of hydrogel) both in zonal and non-zonal constructs. There were no differences in histological scoring; however, the repair tissue was significantly stiffer in defects repaired with zonal constructs. The sub-optimal quality of the repair tissue may be related to several factors, including early loss of implanted cells, or inappropriate degradation rate of the hydrogel. Nonetheless, this approach may be promising and research into further tailoring of biomaterials and of construct characteristics seems warranted.

Clinical Pharmacist-Led Impact on Inappropriate Albumin Utilization and Associated Costs in General Ward Patients.

Inappropriate albumin use in clinical practice remains problematic. Health-systems face continued challenges in promoting cost-appropriate use. To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin use in general ward patients. A retrospective cohort study evaluated all adult (≥18 years) general ward patients administered ≥1 dose of albumin at a university medical center over a 2-year period. The intervention consisted of a clinical pharmacist-led strategy intervening on all albumin orders not in accordance with institutional guidelines. The primary end point was to compare inappropriate albumin utilization before and after implementation. Secondary end points compared the rates of inappropriate albumin use adjusted for hospital admission and patient-days as well as associated costs by appropriateness between study periods. A total of 4420 patients were screened, with 1971 (44.6%) patients meeting inclusion criteria. The clinical pharmacist strategy significantly reduced inappropriate albumin (grams) utilization by 86.0% (P < 0.001). A 7-fold reduction of inappropriate albumin administered adjusted for the number of patient admissions was found from the preimplementation period following clinical pharmacist intervention strategy implementation (415.3 ± 83.2 vs 57.5 ± 34.2 g per 100 general ward hospital admissions, respectively; P < 0.001). Also, the adjusted inappropriate albumin rate was reduced from 62.2 ± 12.3 to 8.6 ± 5.2 g per 100 patient-days in the preimplementation and postimplementation periods, respectively (P < 0.001). Annual cost savings were $421 455 overall, with $341 930 resulting from mitigation of inappropriate use. Clinical pharmacist-led interventions significantly reduced inappropriate albumin use and costs in hospitalized patients.

Improving intravenous fluid prescribing.

Intravenous (IV) fluid therapy is integral to the care of patients in hospitals but involves complex decisions. Errors in fluid prescribing are common, leading to significant harm due to inappropriate fluid type, rate or volume. British national guidelines have been developed to improve prescribing, but adherence has been generally poor. The Scottish Government has set up a National IV Fluid Improvement Programme to implement national guidelines throughout Scotland. This article reviews the need for such guidance and discusses how the Scottish National IV Fluid Improvement Programme hopes to achieve its aims across Scotland. This may provide an improvement framework for fluid prescribing in other regions.

Brain Tumor Classification and Segmentation Based on Morphological Operations using Image Processing Techniques

Brain Tumour is the solitary cause for the assassination of many individuals. A brain tumour is an accretion or widening of isolated cells in your brain. It can be identified by several tests like MRI (Magnetic Resonance Imaging), CT (Computer Tomography) scan along with several tests like biopsy, spinal tap etc. Classification and Segmentation activity take part a significant role in interpretation of brain tumours. In this paper the images should be taken in the form of jpeg format. The images are processed using data mining and machine learning classification methods. Previous research studies are intended as long as identifying brain tumours using dissimilar classification and segmentation approaches. The initiated system consists of certain process for recognition of the tumour. The first step is about Pre-processing and the next is about segmentation, Feature extraction is the third step in this process and Classification is used to detect the tumour. Morphological Operations are performed in this process based on the tumour size, shape and colour. Neural Network is used for classification along with -Support Vector Machine (SVM) classifiers are worn for structured recognition. Due to this we can reduce the inappropriate or false diagnosis error rate of brain tumour identification for the patients and also, we can get faster and accurate results.

Inappropriate Peak Inspiratory Flow Rate with Dry Powder Inhaler in Chronic Obstructive Pulmonary Disease

Optimal peak inspiratory flow rate (PIFR) is crucial for optimizing dry powder inhaler (DPI) effectiveness for chronic obstructive pulmonary disease (COPD). This study provide an insight that there was a substantial proportion of improper PIFRs (not only insufficient but also excessive) among COPD patients using DPIs. We enrolled 138 COPD patients from a medical center in Taiwan and measured PIFRs against different internal resistances of DPIs. Proportion of excessive, optimal, suboptimal, and insufficient PIFRs were 2%, 54%, 41%, 3%, respectively, against medium-high resistance; 2%, 77%, 20%, 1%, respectively, against medium resistance; 27%, 63%, 9%, 1%, respectively, against medium-low resistance; and 42%, 57%, 1%, 0%, respectively, against low resistance (p < 0.01). Although most PIFRs against medium-high (54%), medium (77%), medium-low (63%) and low (57%) resistance were optimal, a substantial proportion of PIFRs against low resistance were excessive (42%, p < 0.01), irrespective of age, body-mass index, dyspnea severity score, and COPD severity. Insufficient PIFRs were infrequent, but suboptimal/insufficient PIFRs were most prevalent in patients older than 75 years than in younger patients (36% vs. 56%, p = 0.036) against medium-high resistance. Regularly monitoring PIFRs against the specific resistance of the DPIs and instructing patients to employ a proper inspiration effort may help to optimize the effects of DPIs.

Nigeria’s Fiscal Performance: Exploring the Role of Exchange Rate

The paper offers empirical justifications for the instrumentality of external sector in influencing the fiscal position of a country through the exchange rate. In the study, ARDL bounds test approach to cointegration analysis is adopted to examine the long run and short run relationship between exchange rate and fiscal performance in Nigeria. The validity of the findings is based on time series data between 1981 and 2017. The emerging evidence reveals that the exchange rate movement has a substantial influence on the fiscal performance, as there exists a significant adverse relationship between exchange rate and fiscal deficit in the long run as well as in the short run, while the association between exchange rate and public debt is found to be significantly positive in both periods. Empirical elucidations posit that an appreciation of the exchange rate could lead to decreasing fiscal deficits. However, the exchange rate appreciation might not induce a reduction in public debt, as it could stimulate demand for loanable funds by the government, although such effect could be mitigated through strategic investment policy and subsidized funding schemes to aid domestic production. Given that fiscal performance is considerably driven or constrained by the exchange rate movement, the study suggests that developing a strategic framework for ensuring a realistic exchange rate and the mitigation of regular fluctuations or correcting inappropriate exchange rate is crucial.

Relationships between exchange rate regime, real exchange rate volatility and currency structure of government bonds in emerging markets

Abstract Public foreign currency borrowing is a common problem of emerging markets. Scholars named it the original sin of foreign debt. It has a proven negative influence on economic growth and development, undermining financial stability, and increasing the probability of monetary crises. The roots of the original sin often lay in emerging markets’ institutional underdevelopment, with low-quality monetary policy, inappropriate exchange rate regime choice, and exchange rate mismanagement being stated among the most important causes. This paper evaluates the influence of the exchange rate policy on the emission of foreign currency sovereign bonds in emerging markets. The relationship is estimated using panel data and GMM approach, with exchange rate regime type (both de jure and de facto) and real exchange rate volatility serving as explanatory variables. The findings reveal that fixed exchange rate regime and high real exchange rate volatility is promoting the foreign currency borrowing. Thus countries that want to reduce the burden of the original sin should lean towards a more flexible exchange rate policy while maintaining their real exchange rate stable.

The Impact of Clinical Decision Support Alerts on Clostridioides difficile Testing: A Systematic Review.

Several studies have investigated the utility of electronic decision support alerts in diagnostic stewardship for Clostridioides difficile infection (CDI). However, it is unclear if alerts are effective in reducing inappropriate CDI testing and/or CDI rates. The aim of this systematic review was to determine if alerts related to CDI diagnostic stewardship are effective at reducing inappropriate CDI testing volume and CDI rates among hospitalized adult patients. We searched Ovid Medline and 5 other databases for original studies evaluating the association between alerts for CDI diagnosis and CDI testing volume and/or CDI rate. Two investigators independently extracted data on study characteristics, study design, alert triggers, cointerventions, and study outcomes. Eleven studies met criteria for inclusion. Studies varied significantly in alert triggers and in study outcomes. Six of 11 studies demonstrated a statistically significant decrease in CDI testing volume, 6 of 6 studies evaluating appropriateness of CDI testing found a significant reduction in the proportion of inappropriate testing, and 4 of 7 studies measuring CDI rate demonstrated a significant decrease in the CDI rate in the postintervention vs preintervention period. The magnitude of the increase in appropriate CDI testing varied, with some studies reporting an increase with minimal clinical significance. The use of electronic alerts for diagnostic stewardship for C. difficile was associated with reductions in CDI testing, the proportion of inappropriate CDI testing, and rates of CDI in most studies. However, broader concerns related to alerts remain understudied, including unintended adverse consequences and alert fatigue.

Implementing Mycoplasma genitalium testing across a London-based sexual health service: A quality improvement project.

Recent national guidelines recommended testing for Mycoplasma genitalium (MG) in clinically-indicated conditions (CIC) including non-gonococcal urethritis (NGU), pelvic inflammatory disease (PID) and epididymo-orchitis. Over five months in 2018 a quality improvement project (QIP) was carried out across three London sexual health clinics with the aim of increasing MG testing rates in CICs. Three Plan-Do-Study-Act (PDSA) cycles were completed: improving IT access, an education event and reminder emails for clinicians who did not test in CIC. To measure testing rates ten patients from each CIC were randomly selected each week and MG testing outcomes were collected. As a balancing measure, we identified the rate of inappropriate MG testing. MG testing rates in patients with NGU increased to 90% following QIP initiation (baseline rate 60%) and this increase was sustained. No increase in MG testing was seen in PID and epididymo-orchitis. Inappropriate MG test rates were high (median of 11%) but remained constant throughout the QIP period. As MG testing is expanding across the UK, we outline a QIP integrating MG testing into a busy multi-site, sexual health service improving testing uptake while not increasing inappropriate testing.

22 Design and Implementation of A Nutrition Clinical Pathway for Patients with Fractured Neck of Femur

Abstract Background Patients with a fractured neck of femur (FNOF) are commonly malnourished pre-admission, have reduced oral intake in hospital and a hypermetabolic state up to three months postoperatively (E Paillaud 2000). Malnutrition is associated with functional deterioration, higher morbidity and mortality. Evidence suggests nutritional supplementation post-surgery can reduce postoperative complications. As a result, nutritional assessment is included in the National Hip Fracture Database best practice tariff (Avenell, Cochrane Database of Systematic Reviews 2016). Introduction Our aim was to design and implement a clinical pathway for patients with FNOF to identify malnutrition and provide appropriate nutritional support. Intervention A retrospective audit of 25 patients was completed to understand baseline rates of assessment, prescription of supplements and referral to dietetics. Using these data meetings were arranged to develop a clinical pathway. Key stakeholders included dietetics, orthopaedic surgeons, geriatricians, physiotherapists and nurses. The pathway was evaluated and optimised with two Plan-Do-Study-Act (PDSA) cycles looking at 25 patients each time. Results Baseline: 79% received a nutritional assessment, 32% had nutritional supplements prescribed and 36% (n=9) met criteria for referral to a dietician, of which 55%were referred. However, an additional 5 referrals were made to dietetics for patients who did not meet criteria, a 50% inappropriate referral rate. PDSA cycle 1: increased nutritional assessment (85%), increased nutritional supplements prescribed (92%), decreased inappropriate referrals to dietetics (43%). PDSA cycle 2: increased nutritional assessment &amp; nutritional supplements prescribed (100%), increased inappropriate referrals to dietetics (80%). Conclusions The implementation of a nutrition pathway has led to increased identification and treatment of malnutrition, which has in addition improved accrual of the best practice tariff. However, greater number of inappropriate referrals have been made to dietetics. This is partly attributed to difficulty weighing patients on admission, and where no weight is inputted on the Malnutrition Universal Screening Tool a “High Risk” score is generated triggering a referral. We are now looking at alternative methods to obtaining a weight such a mid-upper arm circumference.

Abstract WP302: Simulating the Impact of Reducing Door-in-Door-out Times for Acute Stroke Transfers

Introduction: Some acute stroke (AS)patients require transfer to comprehensive stroke centers (CSCs) for time-sensitive, advanced treatments that lead to better outcomes. However, door-in-door-out (DIDO). PSC DIDO processes at primary stroke centers (PSCs) can be prolonged and result in delay or failure to deliver the advanced treatments at the CSC. We simulated the impact of reducing PSC DIDO times on the rate of inappropriate transfers to CSCs, a potential consequence of such efforts. Methods: Clinicians from3Chicago-area CSCs and 3 affiliated PSCs and the two main ambulance providers created a PSC DIDO process map Patient-level data from the 3 PSCs (N-108) and estimates from the literature were used to determine the distribution, range, or proportion of each step in the process. Datainputs were varied using Python™ in simulations with 100 replications. Outputswere DIDO time, % patients transferred to CSC, and % inappropriate CSC transfers. Sensitivity analyses assessed most impactful factors on DIDO time. Results: Three key decision points for transfer of an AS patient to a CSC were identified: (1) After stroke code activation; (2) After telestroke consultation; and (3) Post-tPA administration(most common current process). The figureshows that increasing PSC transfer ratesimmediately after stroke code activation by 5% decreased DIDO time by 10 minutes (11%), while increasing the inappropriate CSC transfer rate by 4%. Sensitivity analyses show that total DIDO time is most sensitive to the proportion of PSC hemorrhagic strokes, accuracy of AS detection at triage, and proportion of AS patients arriving by EMS. Conclusions: A strategy of earlier detection of acute stroke at triage, followed rapidly by stroke code activation and streamlined transfer of AS patients is likely to benefit from CSC care is predicted to a large impact on DIDO times, with a very small trade-off in increasing inappropriate transfers.

Effect of Audiovisual Cardiopulmonary Resuscitation Feedback Device on Improving Chest Compression Quality

The one month survival rate after out-of-hospital cardiac arrest (OHCA) in the paediatric population remains low. Improving survival in paediatric OHCA by enhancing the quality of cardiopulmonary resuscitation (CPR) is important. In this study, we aimed to analyse the factors associated with CPR quality by using a real-time feedback device. Participants were prospectively divided into 4 groups: paediatric research fellows, paediatric residents, medical students (clerks), and paediatric critical care nurses. Then, the participants were asked to perform 5 cycles of CPR on a paediatric simulation manikin without prompts from feedback devices, and to repeat another 5 cycles of CPR after education with the 2015 paediatric advanced life support guidelines. A total of 75 participants were evaluated. In the overall analysis, an improvement in the percentage of participants meeting the target compression rate was observed (from 49.82% to 71.23%, P < 0.001). The percentage of participants achieving the target compression depth improved from 73.77% to 85.63% (P = 0.005). Among the 4 groups, the residents showed the most significant improvement in both compression rate (from 48.41% to 86.57%, P < 0.001) and compression depth (from 63.50% to 95.57%, P < 0.001). Inappropriate rate was a more important factor resulting in inadequate CPR performance than inappropriate depth. An excessive compression rate was also a common problem. In conclusions, the real-time CPR feedback device may help clinical physicians and nurses in improving the quality of chest compression. Excessive CPR compression rate may be a major cause of inadequate CPR performance.