Postimplementation Group Research Articles

Evaluation of an Empiric Vancomycin Dosing Protocol on Goal Troughs and Acute Kidney Injury in a Neonatal Intensive Care Unit.

Review the efficacy and safety of an updated empiric vancomycin dosing protocol in a neonatal intensive care unit (NICU). Retrospective chart review including neonates with postmenstrual age (PMA) less than 40 weeks without renal dysfunction who received vancomycin per protocol at a single institution's NICU before and after implementation of an updated dosing protocol. The primary outcome is the proportion of initial therapeutic troughs. Secondary outcomes include average trough, achievement of a therapeutic trough, number of days before attainment of a therapeutic trough, and proportion of acute kidney injury (AKI) during therapy. The 2 groups were similar in gestational age, race, birth weight, PMA, and weight at time of vancomycin initiation. The post-implementation group had a higher proportion of initial therapeutic troughs (33.0% vs 55.1%) and a lower proportion of a subtherapeutic (58.7% vs 43.8%) and supratherapeutic (8.3% vs 1.1%) initial troughs (p = 0.002). The median trough was not different (9.20 vs 10.50 mg/L; p = 0.092). There was no difference in the proportions of achieving a therapeutic trough throughout therapy (69% vs 76%; p = 0.235); however, the post-implementation group achieved a therapeutic trough 1 day earlier (3 vs 2 days; p < 0.001). There was no difference in proportions of AKI developing between the pre-implementation vs post-implementation groups (10.1% vs 5.6%; p = 0.251). Implementation of an updated vancomycin dosing protocol yielded a higher percentage of initial therapeutic vancomycin troughs and patients reached the therapeutic range 1 day earlier without increasing the proportion of AKI.

Implementation of a Protocol for Management of Febrile Neutropenia in the Emergency Department at Veteran Health Indiana.

Febrile neutropenia (FN) is a life-threatening oncologic emergency requiring timely evaluation and treatment. Unrecognized fever and infection can progress quickly and have been shown to increase morbidity and mortality in patients with malignancy. It is critical to identify patients with neutropenic fever on presentation to the emergency department (ED) and to initiate treatment immediately. This quality improvement initiative sought to optimize ED care of patients presenting with FN. Delays in antibiotic prescribing for patients with FN presenting to the ED were identified. A protocol was implemented to streamline clinical decision making and decrease the time from triage to the first dose of antibiotics in the ED. Key interventions included obtaining ED staff support, developing a standard empiric therapy protocol, increasing prescriber awareness of the neutropenic fever protocol and integrating it into the electronic health record. Before the protocol, the mean time from triage to the first dose of antibiotics was 3.3 hours with only 6% of patients receiving appropriate empiric therapy within 1 hour. Postimplementation, the average time to antibiotics decreased to 2.3 hours. In the postimplementation group, 17% of patients within 1 hour. Early identification and timely empiric antibiotic therapy are critical to improving outcomes for patients presenting to the ED with FN. Additional optimization of the order sets along with increased protocol comfort and staff education will help to further reduce the time to antibiotic administration in alignment with guideline recommendations.

Evaluation of an Automated, Pharmacist-Driven, Antimicrobial Patient Acuity Scoring System for Hospitalized Bacteremic Patients.

Purpose: The implementation of an automated, pharmacist-driven, scoring system within the EMR has been shown to improve patient care in patients with Staphylococcus aureus bacteremia by increasing the adherence to disease specific quality-of-care measures. However, there are a lack of studies evaluating the incorporation of blood culture review into standard, non-antimicrobial stewardship pharmacist workflow. Our institution implemented an automated, pharmacist-driven, antimicrobial scoring system in the electronic medical record (EMR) on August 6, 2019. Methods: This was a retrospective, single-center, quasi-experimental study of hospitalized, non-critically ill adult (18-89 years of age) patients with bacteremia between July 6, 2018 and July 5, 2019 (pre-implementation group) and September 6, 2019 and September 5, 2020 (post-implementation group). The primary outcome was time to directed antibiotic therapy in patients with positive blood cultures. Secondary outcomes included hospital length-of-stay, days of therapy (DOT) while inpatient, time to effective therapy, 30-day all-cause mortality, and rates of Clostridioides difficile infections documented within 3 months of positive culture results. Results: Implementation of the antimicrobial scoring system did not result in a significant change in time to directed antibiotic therapy (32.5 hours vs 37.4 hours; P = .757). There was also no difference found for time to effective antibiotic therapy (-12.6 hours vs -14.2 hours; P =.905) and no difference found for all other secondary outcomes. Conclusion: The implementation of the antimicrobial scoring system did not lead to an improvement in clinical outcomes. Further research is needed to better define a patient population that may benefit from this system.

Description of changes in clinical outcomes following the implementation of an antibiotic stewardship program in a level IV hospital

Describir los cambios observados en los desenlaces clínicos después de la implementación de un programa de gestión de antibióticos en un hospital de IV nivel de atención. Materiales y métodos. Se llevó a cabo un estudio de cohorte única de pacientes hospitalizados por patologías infecciosas y tratados con antibióticos en una institución médica de alta complejidad. Inicialmente, se recolectaron las historias clínicas anteriores a a la implementación del programa de gestión de antibióticos (2013 a 2015) y luego se compararon con los datos obtenidos después de la implementación del programa de gestión de antibióticos de 2018 a 2019. Se evaluaron los cambios en los desenlaces clínicos como mortalidad y estancia hospitalaria, entre otros. Se analizaron las historias clínicas de 1.066 pacientes: 266 con historia previa a la implementación del programa y 800 con historia posterior a la implementación. El promedio de edad fue 59,2 años y 62 % de la población era masculina. Se encontraron diferencias estadísticamente significativas en mortalidad global (29 Vs. 15 %; p<0,001), mortalidad por causa infecciosa (25 % Vs. 9 %; p<0,001) y promedio de estancia hospitalaria (45 Vs.21 días; p<0,001), con tendencia a disminuir nuevas hospitalizaciones en 30 días por patología infecciosa (14 Vs.10 %; p=0,085). El desarrollo del programa de gestión de antibióticos se asoció con a una disminución en la mortalidad global, la mortalidad por causa infecciosa y la estancia hospitalaria. Esto demuestra la importancia de desarrollar intervenciones dirigidas a mitigar el impacto de la prescripción inadecuada de antibióticos.

Evaluation of a pharmacist-provider collaborative clinic for treatment of iron deficiency in patients with heart failure.

Intravenous iron therapy is recommended to improve symptoms and exercise tolerance in patients with heart failure (HF) with -reduced ejection fraction and iron deficiency (ID), but there are limited published data on the implementation of intravenous iron therapy in practice. A pharmacist-provider collaborative ID treatment clinic was established within an advanced HF and pulmonary hypertension service to optimize IV iron therapy. The objective was to evaluate the clinical impacts of the pharmacist-provider collaborative ID treatment clinic. A retrospective cohort study was performed to compare clinical outcomes among patients of the collaborative ID treatment clinic (the postimplementation group) and a cohort of patients who received usual care (the preimplementation group). The study included patients 18 years of age or older with diagnosed HF or pulmonary hypertension who met prespecified criteria for ID. The primary outcome was adherence to institutional intravenous iron therapy guidance. A key secondary outcome was ID treatment goal achievement. A total of 42 patients in the preimplementation group and 81 in the postimplementation group were included in the study. The rate of adherence to the institutional guidance was significantly improved in the postimplementation group (93%) compared to the preimplementation group (40%). There was no significant difference in the ID therapeutic target achievement rate between the pre- and postimplementation groups (38% vs 48%). Implementing a pharmacist-provider collaborative ID treatment clinic significantly increased the number of patients who adhered to intravenous iron therapy guidance compared to usual care.

1019-P: Implementation Analysis of Pharmacist-Managed Insulin Dosing in an Acute Care Hospital

Hyperglycemia is associated with negative health outcomes such as increased infection, increased thrombosis, decreased wound healing and prolonged hospitalization. The 2022 ADA guidelines for hospitalized patients recommend targeting blood glucose (BG) 140-180 mg/dL in both critically and non-critically ill patients and managing persistent hyperglycemia with insulin. Data evaluating the impact of a pharmacist-managed insulin dosing protocol is currently lacking. The objective of this study was to evaluate the safety and efficacy of a pharmacist-managed basal-bolus (BB) insulin dosing protocol for inpatient hyperglycemia management. This single-center, retrospective, observational study included patients &amp;gt; 18yo with three consecutive BG concentrations 180-350mg/dL admitted to the critical care, telemetry, and medical/surgical floors. The insulin per pharmacy dosing protocol was implemented in December 2020. A total of 494 patients were included in the pre-implementation group (January-November 2020) and 668 patients in the post-implementation group (July-December 2021). No significant difference in baseline characteristics were observed between the two groups. For primary outcome, post-implementation group had a statistically significant higher percentage of normoglycemia defined as BG 70-180 mg/dL (63.4% vs. 50.2%, p&amp;lt;0.01) and a statistically significant lower percentage of hyperglycemia defined as BG &amp;gt;180 mg/dL (35.1% vs. 48.2%, p&amp;lt;0.01). No difference in hypoglycemia rate between the two groups were observed (1.6% vs. 1.5%, p&amp;gt;0.1) confirming protocol safety. For secondary outcome, no difference in average length of stay between the two groups, although goal BG&amp;lt;180 mg/dL was achieved on day 2 in post-implementation group vs. day 6 in pre-implementation group. This study suggests that pharmacists can effectively and safely manage inpatient hyperglycemia in both critically ill and non-critically ill patients utilizing a standardized BB insulin dosing protocol. Disclosure A.G.Hadiprodjo: None. E.M.Scott: None. R.Weng: None.

The SOS-SAH questionnaire in clinical practice: a multi-method evaluation study

BackgroundIn patients with mild disabilities after aneurysmal subarachnoid hemorrhage (aSAH), invisible symptoms might be easily overlooked during consultations in the outpatient clinic. We hypothesize that the Questionnaire for the Screening of Symptoms in aneurysmal Subarachnoid Hemorrhage (SOS-SAH), a disease-specific patient-reported outcome measure, might aid in screening for symptoms after aSAH. The objective of this explorative study is to evaluate the perceived impact of using the SOS-SAH in daily clinical practice for patients after aSAH, as well as to explore potential barriers to further implementation.MethodsThis multi-method study consists of a quantitative and a qualitative component. To evaluate differences in quality of care, a patient experience survey was sent to patients receiving usual care and to patients who received the SOS-SAH. A multiple linear regression model was applied, with the intervention group and case mix adjusters as independent variables. We described differences in the number of symptoms discussed between patients receiving usual care and those receiving care post-implementation. Following implementation, 16 patients and 6 healthcare professionals were interviewed about their perceptions concerning the impact of and barriers to using the SOS-SAH. A thematic analysis was performed to identify the main themes.ResultsThe survey did not reveal any differences between the usual-care group and the post-implementation group on the scales of the patient experience survey. After implementation of the SOS-SAH, the number of symptoms discussed during consultation did not increase. The interviews suggest that the SOS-SAH may improve the preparation of patients by providing them with greater insight into their complaints and by raising issues for the consultation. It could also enhance the structure and efficiency of consultation, in addition to improving communication about issues that matter to patients. All patients and healthcare professionals recommended continuing the use of the SOS-SAH in daily practice.ConclusionsAlthough no quantitative improvements were found in patient experience and symptoms discussed during consultation, implementation of the SOS-SAH could aid in screening for symptoms in patients after aSAH, and it might have a positive influence on patient preparation, while helping to structure consultations between patients and healthcare professionals.

PRISM study-Pre-natal iron deficiency screening and management within an Australian regional centre.

Current Australian guidelines differ in their recommendations on optimal iron deficiency anaemia screening and management during pregnancy. A more active approach to screening and treatment of iron deficiency in pregnancy has been beneficial within a tertiary population. However, this approach has not been evaluated within a regional healthcare setting. To evaluate the clinical impact of standardised screening and management for iron deficiency in pregnancy within a regional Australian centre. Single centre, retrospective cohort observational study that audited medical records pre and post implementation of standardised screening and management for antenatal iron deficiency. We compared rates of anaemia at birth, rates of peripartum blood transfusions and rates of peripartum iron infusions. There were 2773 participants with 1372 participants in the pre-implementation group and 1401 in the post-implementation group. Participant demographics were similar. Anaemia at admission for birth decreased from 35% to 30% (RR 0.87, 95% CI (0.75, 1.00), p 0.043) Fewer blood transfusions were required (16 (1.2%) pre-implementation, 6 (0.4%) post-implementation, RR 0.40, 95% CI(0.16, 0.99), p 0.048). Antenatal iron infusions increased from 12% to 18% of participants post implementation (RR 1.47, 95% CI(1.22, 1.76), p 〈0.001).We audited compliance with the guidelines and found improvements post implementation. This is the first study to show clinically useful and statistically significant reduction in rates of anaemia and blood transfusions, post implementation of routine ferritin screening and management within a regional Australian population. The results of this study suggest there is benefit to implementation of standardised ferritin screening and management packages in Australian antenatal care. It also encourages RANZCOG to review current recommendations on screening for iron deficiency anaemia during pregnancy.

Preserving the Pipeline of Surgeon Scientists: The Role of a Structured Research Curriculum

IntroductionWith shrinking National Institute of Health support, increased clinical demands, and less time for research training during residency, the future of surgeon scientists is in jeopardy. We evaluate the role of a structured research curriculum and its association with resident academic productivity. MethodsCategorical general surgery residents who matched between 2005 and 2019 at our institution were analyzed (n = 104). An optional structured research curriculum, including a mentor program, grant application support, didactic seminars, and travel funding was implemented in 2016. Academic productivity, including the number of publications and citations, was compared between residents who started in or after 2016 (postimplementation, n = 33) and those before 2016 (preimplementation, n = 71). Descriptive statistics, Mann–Whitney U test, multivariable logistic regression, and inverse probability treatment weighting were performed. ResultsThe postimplementation group had more female (57.6% versus 31.0%, P = 0.010), and nonwhite (36.4% versus 5.6%, P < 0.001) residents and had more publications and citations at the start of residency (P < 0.001). Postimplementation residents were more likely to choose academic development time (ADT) (66.7% versus 23.9%, P < 0.001) and had higher median (IQR) number of publications (2.0 (1.0-12.5) versus 1.0 (0-5.0), P = 0.028) during residency. After adjusting the number of publications at the start of residency, multivariable logistic regression analysis showed that the postimplementation group was five times more likely to choose ADT (95% CI 1.7-14.7, P = 0.04). Further, inverse probability treatment weighting revealed an increase of 0.34 publications per year after implementing the structured research curriculum among residents who chose ADT (95% CI 0.1-0.9, P = 0.023). ConclusionsA structured research curriculum was associated with increased academic productivity and surgical resident participation in dedicated ADT. A structured research curriculum is effective and should be integrated into residency training to support the next generation of academic surgeons.

A Quasi-Experimental Evaluation of Single Trough-Based Area Under the Curve Guided Dosing on the Incidence of Vancomycin Associated Nephrotoxicity in Veteran Patients.

Background: Two common dosing strategies for vancomycin are trough-based and area under the curve (AUC)-based dosing. Objective: To compare the incidence of nephrotoxicity in trough-based dosing group with the single trough-based AUC dosing at the Salem VA Medical Center. Methods: This retrospective study included patients who received trough-based dosing of vancomycin between January 1, 2017, and January 1, 2019 (preimplementation group) and AUC-based dosing (postimplementation) between October 1, 2019, and October 1, 2021, at the Salem VA Medical Center. The primary outcome was nephrotoxicity at 96 hours, 7 days, and entire hospital length of stay (LOS). Secondary outcomes included 30-day readmission and all-cause mortality rates, cumulative doses at 24, 48, and 72 hours, and percentage of patients considered at goal (AUC 400-600 or trough between 10 and 20 mg/L). Propensity score (PS) matching was utilized to adjust for confounding. Results: After PS matching 100 patients were included in preimplementation and 95 patients in the postimplementation group. The average study patient was a 68-year-old white male. There was significant reduction in the risk of nephrotoxicity in postimplementation cohort at 96 hours (adjusted (a)HR: 0.28, 95% CI (0.12-0.66); 7 days (aHR: 0.39, 95% CI (0.18-0.85); and entire hospital LOS (aHR: 0.46, 95% CI (0.22-0.95). Secondary outcomes showed no difference between the groups except significantly higher proportion of patients were considered at therapeutic goal in the postimplementation cohort compared with pre-implementation cohort. Conclusion: This hypothesis generating study shows that AUC-based dosing calculated using single trough concentration may result in reduced rate of nephrotoxicity than trough-based dosing.

526 Results of Implementation of a Nurse Driven Fluid Resuscitation Protocol in a Regional Burn Center

Abstract Introduction Our prior research has demonstrated the effect of nurse driven fluid resuscitation on provider and nurse team dynamics. Our primary purpose with this new research on our nurse driven fluid resuscitation protocol is to determine the effect of the nurse-driven fluid resuscitation protocol on resuscitation associated complications (i.e., acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and abdominal compartment syndrome). The study hypothesis is that the rate of resuscitation associated complications will remain stable or not increase post-protocol implementation. Methods Retrospective review for all patients within a one-year period pre-protocol implementation and post-protocol implementation was completed. 44 patients were included in the total sample, 22 in the pre-implementation group and 22 in post-implementation group. Exclusion criteria for patients included in nurse driven fluid resuscitation included delayed presentation, morbid obesity, electrical injury, cardiac history, DKA, polytrauma, and renal failure. Results Pre and post nurse driven fluid resuscitation implementation samples of 22 patients with total body surface area (TBSA) greater than 20% were analyzed. The incidence of serious complications including ARDS, compartment syndrome, and wound conversion was not statistically significantly different between samples. Rates of acute kidney injuries were similar across groups. In addition, the mean and median TBSA were not statistically significantly different pre and post implementation. The length of stay for the pre-implementation sample was on average longer than for the post-implementation sample. Our results are limited by the significant comorbidities of the pre-implementation group. Please note tables and graphs were not yet available by time of submission. Attached tables are from prior analysis at approximate half-way of study. Updated graphs and tables will be complete by conference time. Conclusions As hypothesized, there were no differences in outcomes between patients receiving nurse driven fluid resuscitation. Our results indicate that nurse driven fluid resuscitation is a safe and clinically effective practice in the burn center. Coupled with our previous results that indicate a significant increase in nurse satisfaction with interdisciplinary communication associated with nurse driven, these results signal the importance of implementing nurse led resuscitations. Applicability of Research to Practice Nurse driven fluid resuscitation is a safe and effective. Further research into barriers to implementation is warranted.

Utilization and Impact of Pharmacist-led, Urinary Culture Follow-Up After Discharge from the Emergency Department.

Urinary tract infections (UTI) are a common reason for an emergency department (ED) visit. The majority of these patients are discharged directly home without a hospital admission. After discharge, emergency physicians have traditionally managed the care of the patient if a change is warranted (as a result of urine culture results). However, in recent years clinical pharmacists in the ED have largely incorporated this task into their standard practice. In our study, we aimed to 1) describe our unique process in having a pharmacist-led, urinary culture follow-up, and 2) compare it to our previous, more traditional process. In our retrospective study, we evaluated the impact of a pharmacist-led, urinary culture follow-up program after discharge from the ED. We included patients prior to and after the implementation of our new protocol to compare the differences. The primary outcome was time to intervention after urine culture result was released. Secondary outcomes included rate of documentation of intervention, appropriate interventions made, and repeat ED visits within 30 days. We included a total of 265 unique urine cultures from 264 patients in the study: 129 cultures were from the period prior to implementation of the protocol, and 136 were from the post-implementation period. There were no significant differences between pre- and post-implementation groups for the primary outcome. Appropriate therapeutic intervention based on positive urine culture results was 16.3% in the pre-implementation group vs 14.7% in the post-implementation group (P=0.72). Secondary outcomes of time to intervention, documentation rates, and readmissions were similar between both groups. Implementation of a pharmacist-led, urinary culture follow-up program after discharge from the ED led to similar outcomes as a physician-run program. An ED pharmacist can successfully run a urinary culture follow-up program in an ED without physician involvement.

Preventing Surgical Site Hematoma Using Topical with or Without Intravenous Tranexamic Acid in Lumbosacral Surgery: A Quality Improvement Project

Postoperative surgical site hematoma (SSH) following lumbosacral surgery carries significant morbidity and increased length of stay (LOS). Intravenous tranexamic acid (ivTXA) has been shown to reduce SSH rate. Topical TXA (tTXA) could benefit patients with contraindications to ivTXA. However, this has not been widely studied. We sought to demonstrate that a quality improvement (QI) protocol using tTXA with/without ivTXA in patients undergoing elective open and minimally invasive lumbosacral surgery could decrease the SSH rate and LOS with no increase in associated complications. A retrospective chart review for July 2018-June 2019 demonstrated our pre-implementation baseline SSH rate. We conducted interdisciplinary meetings to develop standardized institutional measures and perioperative tTXA administration protocol. The primary outcome was SSH necessitating evacuation. The secondary outcome was LOS and TXA-related complications. The post-implementation data were collected prospectively from July 2020-October 2020. Univariate analysis was used to compare pre-implementation and post-implementation cohorts. We considered a p-value <.05 significant. Comparing consecutive lumbosacral surgical patients in pre- (219 patients) and post-implementation (258 patients), the post-implementation group demonstrated a significantly reduced rate of SSH requiring evacuation (.38% vs. 3.3%, p<.001), significantly increased tTXA utilization (86.0% vs. 9.6%, p<.001), significantly lower incidence of SSH in tTXA patients (.45% vs.4.8%, p=.037), and significantly decreased LOS (3.4 ± 2.5 vs. 3.1 ± 2.7, p=.003). There were no complications attributable to TXA use. Our QI project successfully increased compliance with the use of tTXA. Post-implementation rate of SSH requiring evacuation and LOS was significantly lowered with no associated complications.

Vaginal Preparation Prior to Planned Cesarean Delivery to Reduce Postpartum Endometritis: A Quality Improvement Study [ID: 1378331

INTRODUCTION: Infection prophylaxis is an important part of perioperative care. Studies have demonstrated that incorporation of pre-cesarean vaginal preparation reduces postoperative rates of endometritis in laboring patients or those with ruptured membranes. Our study aimed to identify whether vaginal preparation decreases the risk of postpartum endometritis among scheduled cesarean deliveries. METHODS: We retrospectively reviewed all pregnant people with scheduled cesarean deliveries in one urban, teaching hospital between April 2018 and November 2020. Deliveries were excluded if they were laboring, had ruptured membranes prior to surgery, had known iodine allergy, or had other intraoperative complications. Deliveries were divided into three groups based on vaginal preparation protocol implementation: preimplementation (April 2018 to March 2019), implementation (April 2019 to November 2019), and postimplementation (December 2019 to November 2020). Only deliveries in the preimplementation versus postimplementation group were compared given implementation learning curve. Descriptive and inferential statistics were computed; χ2 or Fisher’s exact test was used to assess differences in rates of endometritis or other postpartum complications. RESULTS: Overall, 320 scheduled cesarean deliveries were included (N=162 preimplementation; N=158 postimplementation). Rates of endometritis was not different between groups (1.2% versus 2.5% postimplementation; P=.44). Similarly, postpartum complication rates for fever (1.2% versus 3.8% postimplementation, P=.17), wound infection (3.7% versus 3.2% postimplementation, P=.79), sepsis (0% versus 0.6% postimplementation, P=.49), and 30-day readmission unrelated to preeclampsia (3.7% versus 3.3% postimplementation, P=.12) were not different between groups. CONCLUSION: While there was no reduction in postpartum endometritis in patients undergoing planned cesarean delivery, universal implementation may still be a reasonable intervention given its low cost and known benefit in laboring patients or those with ruptured membranes.

Patients’ perceptions of the post-pancreatectomy discharge process

BackgroundComplications after pancreatectomies contribute to poor outcomes. Patients are expected to identify signs/symptoms leading to these complications but may be poorly educated on how to identify them. We assessed the impact of an educational tool on patient perceptions of, and satisfaction with the discharge process, and its effect on readmission rates. MethodsA prospective cohort study with retrospective chart review including patients who underwent pancreatic resection was undertaken. An interactive educational module (iBook) that provided information about the procedure, possible complications, and peri-discharge information was implemented. English-speaking patients were equally divided into the pre- and post-iBook cohorts. Primary outcome was patients’ satisfaction with discharge; Secondary outcomes were 30- and 90-day readmission rates. Results100 patients were included. Mean age was 65.5 ± 12.6, 46% were female, and 92.3% were white. Most patients underwent Whipple procedures (72%), and distal pancreatectomies (26%). In the post-implementation group, 92% were satisfied with the discharge process, and 89% reported it was a good tool. There were no statistical differences in 30- and 90-day readmission rates between cohorts. ConclusionThe iBook positively impacted patients’ satisfaction and preparedness for discharge. Readmission rates were not statistically significantly impacted but could be investigated with further studies of greater sample sizes.

MP39-15 IMPLEMENTATION OF AN OPIOID FREE PAIN PATHWAY IN MINIMALLY INVASIVE UROLOGICAL ONCOLOGIC SURGERIES

You have accessJournal of UrologyCME1 Apr 2023MP39-15 IMPLEMENTATION OF AN OPIOID FREE PAIN PATHWAY IN MINIMALLY INVASIVE UROLOGICAL ONCOLOGIC SURGERIES Abdulla Alameeri, Omar Almidani, Ammar Al Homsi, Rashed Rowaiee, Heather Brown, and Waleed Hassen Abdulla AlameeriAbdulla Alameeri More articles by this author , Omar AlmidaniOmar Almidani More articles by this author , Ammar Al HomsiAmmar Al Homsi More articles by this author , Rashed RowaieeRashed Rowaiee More articles by this author , Heather BrownHeather Brown More articles by this author , and Waleed HassenWaleed Hassen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: An optimal pain management is essential to establish an effective fast-track surgery model. In patients undergoing minimally invasive oncological surgeries including radical prostatectomy (RP) and Radical Nephrectomy (RN), multiple studies have assessed the efficacy of various analgesic medications. Therefore, we aim in our study to compare the efficacy of post-operative analgesic regimen after the implementation of an opioid-free regimen at a large tertiary care center. METHODS: Mixed retrospective and prospective, non-randomized, pre and post interventional trial was performed at our institution between November 2015 and October 2022. Sample included patients undergoing RP and RN during that time frame. An opioid-free pain regimen was developed and instituted in April 2019, which included preoperative education and counseling regarding opioids and pain expectation management, round-the-clock intravenous acetaminophen as inpatient and prescriptions of oral acetaminophen as outpatients. Comparison was made between patients in the opioid-regimen group (pre-implementation) vs. the opioid-free regimen group (post-implementation) in terms of pain score and the need for additional analgesics. RESULTS: A total of 226 (44.66%) patients were in the pre-implementation group, with both RP and RN included in the total, and 280(55.33%) patients were in the post-implementation group. The intervention significantly reduced postoperative opioid administration from [Pre: 78.3% vs Post: 14.6%, p <0.001]. The post-implementation group had a significantly lower maximum pain score [Pre: 6.3± 2.1 vs Post: 4.5 ± 2.6, p= 0.04] and lower average pain score [Pre: 3.1 ± 1.4 vs Post: 2.0 ± 1.8, p < 0.001]. However, the post-implementation group had higher rates of return visits for postoperative pain management [Pre:1.2% vs Post: 5.1%, p = 0.274].Pre implementation patients followed up for uncontrolled pain were 1(0.44%) and 7 (2.5%) post implementation presented to the ER for uncontrolled pain. CONCLUSIONS: The results support the efficacy of opioid-free pain management regimen in patients undergoing minimally invasive upper tract and pelvic urologic surgery. To Date, this study is considered one of the largest highlighting the efficacy of opioid free regimen post op. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e541 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abdulla Alameeri More articles by this author Omar Almidani More articles by this author Ammar Al Homsi More articles by this author Rashed Rowaiee More articles by this author Heather Brown More articles by this author Waleed Hassen More articles by this author Expand All Advertisement PDF downloadLoading ...

Effect of a Pharmacist-Led Discharge Counseling Service at a Children's Hospital.

To evaluate the effect of a pharmacist-led discharge counseling service at a pediatric hospital. This was a prospective observational cohort study. Patients in the pre-implementation phase were identified by the pharmacist at the time of admission medication reconciliation, whereas patients in the pos-timplementation phase were identified at the time of pharmacist discharge medication counselling. Caregivers were contacted within 2 weeks of the patients' discharge date to complete a 7-question telephone survey. The primary objective was to measure the effect of the pharmacist-led service on caregiver satisfaction, using a pre- and post- implementation telephone survey. The secondary objectives were to evaluate the effect of the service on 90-day medication-related readmissions and determine the change in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response (Question 25) regarding discharge medications following implementation of the new service. A total of 32 caregivers were included in both the pre- and post-implementation groups. The most common reason for inclusion was high-risk medications (84%) in the pre-implementation group and device teaching (62.5%) in the post-implementation group. The primary outcome, the average composite score on the telephone survey, was 30.94 ± 3.50 (average ± SD) in the pre-implementation group and 32.5 ± 2.26 in the post-implementation group (p = 0.038). There were no medication-related readmissions within 90 days in either group. The score on HCAHPS Question 25 was not different between groups (p = 0.761). Implementation of a pharmacist-led discharge counseling service in pediatric patients improved caregiver satisfaction and understanding as shown by a postdischarge telephone survey.

Effect of microbiology comment nudging on antibiotic use in asymptomatic bacteriuria: A before-and-after quasi-experimental study.

To describe the effect of a microbiology comment nudge on antibiotic use for asymptomatic bacteriuria (ASB). Single-center, before-and-after, quasi-experimental study. Community-based, public, not-for-profit teaching hospital in the southeastern United States. Adult inpatients with a positive urine culture and the absence of urinary tract infection signs and symptoms. Implementation of a microbiology comment nudge on urine cultures. In total, 204 patients were included in the study. Antibiotics were less likely to be continued beyond 72 hours in the postimplementation group: 57 (55%) of 104 versus 38 (38%) of 100 (P = .016). They were less likely to have antibiotics continued beyond 48 hours: 60 (58%) of 104 versus 43 (43%) of 100 (P = .036). They were also less likely to have antibiotics prescribed at discharge 35 (34%) of 104 versus 20 (20%) of 100 (P = .028). In addition, they had fewer total antibiotic days of therapy: 4 (IQR, 1-6) versus 1 (IQR, 0-6) (P = .022). Microbiology comment nudging may contribute to less antibiotic utilization in patients with ASB.

Implementation of a pharmacist toxicology service on treatment of paracetamol (acetaminophen) overdose

Introduction Paracetamol is a leading cause of fatality following a toxic ingestion. Individualized treatment is imperative in improving outcomes. Acetylcysteine is the standard of care for paracetamol overdose. Laboratory values and other clinical criteria can be used to guide treatment duration. Our hospital’s protocol allows paracetamol overdose to be managed by the emergency department pharmacists. The purpose of this study was to evaluate the effect of a pharmacist toxicology service on the management of paracetamol overdose. Methods This was a single center, retrospective, cohort evaluation. All patients receiving acetylcysteine were divided into pre- and post-implementation groups with data obtained from August 1, 2013 to January 14, 2018 and January 15, 2018 to September 30, 2021, respectively. The primary outcome was the frequency of individualized acetylcysteine therapy. Results A total of 238 patients were screened for inclusion in the study with 120 patients included in the final analysis. There were 60 patients included in each cohort. The frequency of individualized acetylcysteine therapy was significantly higher in the post-implementation group versus the pre-implementation group (85% vs. 60% [95% CI 9.1–39.4; P = 0.002]). Conclusions The implementation of a pharmacist toxicology service correlated with increased poison center consultation as well as increased frequency of individualized acetylcysteine therapy and decreased number of missed acetylcysteine doses.

Validation of Brain Injury Guidelines in the Elderly Trauma Patient Presenting at a Level Two Trauma Center.

Retrospective analysis, validating the brain injury guideline (BIG) in the management of traumatic head injury in our level II trauma center after implementation of the protocol, and compare the outcomes to those seen before the protocol, of 542 patients seen in the Emergency Department (ED), with head injury between 2017 and 2021 was completed. Those patients were divided into two groups: Group 1 (pre BIG protocol implementation) and Group 2 (post BIG protocol implementation). Data included age, race, length of stay (hospital and ICU), comorbid conditions, anticoagulant therapy, surgical intervention, GCS, ISS, findings of head CT and any subsequent progression, mortality, and readmission within one month. Student's t-test and Chi-square test were used for statistical analysis. There were 314 patients in group 1 and 228 patients in group 2. Mean age of group 2 was significantly higher than group 1 (67 vs 59years, p=0.0001), however their gender was similar. Data available on 526 patients were classified as BIG 1=122, BIG 2=73, and BIG 3=331 patients. Post-implementation group were older (70 vs 44years, P=0.0001) with more females (67% vs 45%, P=0.05) and had significantly more than 4 comorbid conditions (29% vs 8%, P=0.004), with the majority presented with a size of 4mm or less of acute subdural or subarachnoid hematoma. No patient in either group had progression of their neurological examination, neurosurgical intervention, or readmission.. Elderly trauma patients may benefit from implementation of BIG criteria protocol, thus reducing cost of patient care, however a larger sample size is needed.