Post-implementation Period Research Articles

Medication shortage behaviour change with multidisciplinary clinician-designed digital notification intervention.

To evaluate the effect of a clinician-designed digital notification system on the use of intravenous paracetamol during a medication shortage. An in-house digital notification platform was designed through multidisciplinary collaboration. A 4-week pre- and post-implementation methodology was employed to evaluate the effect of the intervention. There was significantly lower use of intravenous paracetamol in the post-implementation period compared to the pre-implementation period (median 80 doses per day, interquartile range 58 to 93, vs 94, interquartile range 83 to 122, P < .001). Multidisciplinary clinician-designed digital notification platforms may assist during times of medication shortage.

Improved use of antibiotics following implementation of antimicrobial stewardship in a neonatal intensive care unit.

Inappropriate antibiotic use in infants can have multiple adverse effects and contribute to the development of bacteria resistant to antimicrobials. Antimicrobial stewardship programs can reduce unnecessary antibiotic use in children. The aim of this study was to evaluate the effect of an antimicrobial stewardship program implemented in 2017 in the Neonatal Intensive Care Unit (NICU) at The Children's Hospital Iceland. The study included all infants who were admitted to the NICU during the study period (January 1st 2012-October 31st 2020). Data was collected from hospital records. Three periods were defined: preimplementation (2012-2014), peri-implementation (2015-2016) and postimplementation (2017-October 2020). Antibiotic use was quantified using days of therapy (DOT) per 1000 bed days (BD). For statistical analysis the pre- and postimplementation periods were compared. Antibiotics were administered in 38.6% (1372) of admissions to the NICU during the study period. Antimicrobial use per year decreased from 584.6 to 317.1 DOT/1000 BD per year (P < 0.001). Use of broad-spectrum antibiotics decreased significantly. The average number of BD per month decreased from 297.8 to 220.9 BD/month (P = 0.0096). There were no significant changes in the length of stay for each infant or the proportion of readmissions or retreatment. Increased awareness of appropriate use of antimicrobials in the NICU led to shorter treatments and less use of broad-spectrum antibiotics. No increase in adverse effects such as readmissions or retreatment was observed.

Using 'Situation-Background-Assessment-Recommendation' Method in Palliative Care to Enhance Handover Quality and Nursing Practice: A Mix Method Study.

To evaluate the impact of using 'Situation-Background-Assessment-Recommendation' method ('SBAR') in a palliative care setting. Effective handover communication is crucial for patient safety. Standardised communication tools, such as the SBAR method, are recommended to reduce errors and improve care coordination, but their use in palliative care is not investigated. Mixed method study design, adhering to the GRAMMS guideline. From January to October 2021, a SBAR guide tailored for palliative care was developed using the Delphi method and implemented in a Hospice setting. Data on 150 nurse handovers were collected before and after implementation to assess changes in nursing outcomes, including medication errors, adverse events and the identification of psychological and spiritual needs. Nurses' perceptions on the handover process were gathered through a qualitative survey. The SBAR guide significantly improved the handovers quality, reducing medication errors and eliminating adverse events postimplementation. The identification of psychological and spiritual needs increased during postimplementation period. Nurses also reported improved clarity, accuracy and completeness of information during handover. This is the first study to evaluate the impact of SBAR for handover in palliative nursing care. Findings show the added value of using communication tools.

The Optimized Use of a Contact-Free Continuous Monitoring System on Clinical Outcomes During COVID-19.

The purpose of this study was to examine the impact of a contact-free continuous monitoring system on clinical outcomes including unplanned intensive care unit (ICU) transfer (primary), length of stay (LOS), code blue, and mortality. A secondary aim was to evaluate the return on investment associated with implementing the contact-free continuous monitoring program during the COVID public health emergency. An interrupted time series evaluation was conducted to examine the association between the use of contact-free continuous monitoring and clinical outcomes. A cost-benefit analysis was planned to evaluate the return on investment. Use of contact-free continuous monitoring was not significantly associated with unplanned ICU transfers, deaths, ICU LOS, and or rapid response team calls. However, there were significant increases in code blue events (P = 0.02) and mean hospital LOS (P = 0.01) in the postimplementation period when compared with the preimplementation period. Due to the lack of improvement, costs were calculated but a cost-benefit analysis was not conducted. Contact-free continuous monitoring bed use during the COVID-19 public health emergency was not associated with improvements in clinical outcomes, although there was substantial confounding. Future studies should include large randomized controlled trials to control for factors not under direct experimental control including unit staffing, staff turnover, and differences in the patient population related to surges in the COVID-19 pandemic.

Incidence of Acute Pulmonary Edema Before and After the Systematic Use of Ultrasound B-Lines

Introduction: Acute pulmonary edema (APE) due to fluid overload is considered the most feared complication in hemodialysis patients. Various diagnostic tests have been proposed to assess the fluid status in patients with end-stage kidney failure (ESKF); among these, lung ultrasound (measuring the number of B-lines) is emerging as a promising tool to identify pulmonary congestion in this patient population. Methods: We compared the incidence of APE before and after the implementation of lung ultrasound as a routine practice in our unit. The pre (from 1 January 2007 to 31 December 2008)- and post (from 1 January 2017 to 31 December 2018)-B-line implementation periods included 98 and 108 hemodialysis patients, respectively. By accurately reviewing their electronic medical records, all episodes of APE were collected. The 10-year interval between the two periods was specifically chosen to ensure no overlap between patients of the two cohorts whereas the single-center design was adopted to minimize the influence of center effect on the study results. Results: APE episodes occurred more frequently in patients from the pre-B-line implementation group (18/98, i.e., 18.4%) compared with those from the post B-line implementation group (6/108, i.e., 5.5%) (p = 0.004). An analysis based on repeated APE events showed that the incidence rate of APE was significantly higher during the pre-implementation period (2.0 APE episodes per 100 person-months, 95% CI: 1.4–2.7) than during the post-implementation period (0.3 APE episodes per 100 person-months, 95% CI: 0.1–0.7), with an incidence rate ratio (post- versus pre-) of 0.17 (95% CI: 0.07–0.40; p &lt; 0.001). The odds of experiencing APE episodes were 74% lower (odds ratio: 0.26, 95% CI: 0.10–0.69) in patients from the post B-line implementation period compared with those from the pre-implementation period. Notably, adjusting for potential confounders did not affect the strength of this association, which remained statistically significant (p ≤ 0.030). Finally, dominance analysis indicated that the implementation of B-lines was the primary factor explaining the difference in APE episodes between the two periods, followed by dialysis duration and intra-dialysis weight gain. Conclusions: The systematic use of lung ultrasound (a simple, easy-to-learn, rapid and non-invasive method, easily performed at the patient’s bed) in everyday clinical practice was associated with a drastic reduction in episodes of APE in hemodialysis patients. Further observational and interventional studies are needed to confirm these results.

Impacto del uso universal del videolaringoscopio McGrath como primera opción para todas las intubaciones en el quirófano: protocolo del estudio prospectivo, multicéntrico VIDEOLAR-SURGERY con metodología pre-post

IntroductionUsual tracheal intubation performed in the operating room is based on direct laryngoscopy, using a standard Macintosh laryngoscope. Several authors recommend the universal use of a videolaryngoscope as the first option for all intubations, regardless of whether the patient has predictors of a difficult airway or not. We hypothesize that using the McGrath videolaryngoscope as the first intubation option increases the frequency of patients with easy intubation, and decreases complications associated to the intubation. Methods and analysisThe VIDEOLAR-SURGERY trial is a prospective, multicenter, open-label, interventional, before-after study. In the pre-implementation period (non-interventional phase, 6-9months [2600 intubations]), 35 anesthesiologists from 8hospitals perform all tracheal intubations for an elective or urgent surgical procedure using the standard Macintosh direct laryngoscope as the first intubation option. During the implementation period (2months), a McGrath Mac videolaryngoscope is provided to each anesthesiologist to train in its use. During the post-implementation period (interventional-phase, 6-9months [2600 intubations]), the 35 anesthesiologists perform all tracheal intubations using a McGrath Mac videolaryngoscope as the first intubation option. The main objective of present study is to evaluate whether the use of a McGrath Mac videolaryngoscope as the first intubation option, improves the percentage of patients with easy intubation compared with the standard Macintosh laryngoscope. Ethics and disseminationThe study protocol was approved May 2, 2023, by the Ethics Committee of Galicia, Spain (CEI-SL, code No. 2023-177), and was registered into the Clinicaltrials.gov clinical trials registry with No. NCT NCT05850260. Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If videolaryngoscope improves easy intubation compared with Macintosh direct laryngoscope when it is used for all intubations in operating room, its use may will become standard practice, thereby decreasing complications associated with the intubation procedure.

Impact of universal use of the McGrath videolaryngoscope as the first option for all intubations in the operating room: The multicentre prospective before-after VIDEOLAR-SURGERY study protocol

IntroductionStandard tracheal intubation performed in the operating room is based on direct laryngoscopy using a standard Macintosh laryngoscope. Several authors recommend the universal use of a video laryngoscope as the first option for all intubations, regardless of whether the patient has predictors of a difficult airway or not. We hypothesize that using the McGrath video laryngoscope as the first intubation option increases the frequency of patients with easy intubation, and decreases intubation-related complications. Methods and analysisThe VIDEOLAR-SURGERY trial is a prospective, multicentre, open-label, interventional, before-after study. In the pre-implementation period (non-interventional phase, 6-9 months [2600 intubations]), 35 anaesthesiologists from 8 hospitals perform all tracheal intubations for an elective or urgent surgical procedure using the standard Macintosh direct laryngoscope as the first intubation option. During the implementation period (2 months), each anaesthesiologist is given a McGrath Mac video laryngoscope and trained in its use. During the post-implementation period (interventional-phase, 6-9 months [2600 intubations]), the 35 anaesthesiologists perform all tracheal intubations using a McGrath Mac video laryngoscope as the first intubation option. The main objective of this study is to evaluate whether the use of a McGrath Mac video laryngoscope as the first intubation option increases the percentage of patients with easy intubation compared with the standard Macintosh laryngoscope. Ethics and disseminationThe study protocol was approved on 2 May 2023 by the Ethics Committee of Galicia, Spain (CEI-SL, code No. 2023-177), and was registered on the Clinicaltrials.gov clinical trials registry under No. NCT NCT05850260. Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If video laryngoscopy improves easy intubation compared with Macintosh direct laryngoscopy in all operating room intubations, its use may well become standard practice, thereby decreasing the risks of intubation-related complications.

Multifaceted implementation strategy to improve the evaluation of penicillin allergies in perioperative patients: a pre-post feasibility implementation study.

The U.S. Centers for Disease Control and Prevention encourages nurses to evaluate penicillin allergies as part of hospital-based antibiotic stewardship programs. We evaluated the feasibility of an implementation strategy to improve nurses' comprehensive documentation of penicillin allergies. We defined feasibility as the uptake and acceptability of documentation procedures. Six-month pre-post feasibility implementation study. Outpatient surgical areas of an academic medical center located in the U.S. The implementation strategy was guided by the Capability, Opportunity, Motivation Model for Behavior Change and included, building an interdisciplinary coalition to iteratively evaluate the implementation effort, educational meetings with surgical prescribers and perioperative nurses, the development and distribution of educational pocket cards, and structured communication messages in the electronic medical record. A total of 426 patients with 487 penicillin allergy records (216 records pre-implementation period, 271 records post-implementation period) were analyzed. Penicillin allergy documentation contained the following information in the pre- versus post-implementation period: symptoms of the reaction (87% vs 87%), timing/years since reaction (8% vs 26%), onset of reaction in relation to taking penicillin (0% vs 21%), how symptoms resolved (0% vs 21%), and penicillin re-exposure (3% vs 21%). Focus groups revealed nurses perceived documentation procedures as highly acceptable. Major drivers of acceptability included the perceived effectiveness of a detailed allergy history and self-efficacy in conducting a detailed allergy history. Nurses perceived the comprehensive documentation of penicillin allergy history intervention as acceptable, and uptake improved following a theory-informed implementation strategy. We offer implementation strategy components to facilitate nurses' engagement in penicillin allergy evaluation.

Influence of process-focused patient care on clinical outcomes among hospitalized heart failure patients in the cardiology ward

Abstract Background The implementation of a process-oriented organizational structure in patient care allows for a comprehensive and optimized approach. In the context of heart failure (HF), it remains uncertain whether the establishment of a specialized hospitalisation team can contribute to improved major clinical outcomes. Purpose To analyse the rates of all-cause hospitalisation, cardiovascular hospitalization, HF hospitalization and overall mortality at 180 days among patients admitted to the Cardiology ward for HF, both prior to and after the implementation of a specialized HF hospitalisation team. Methods The study included all patients discharged from the Cardiology department with HF as the primary diagnosis and subsequent outpatient follow-up by the Community HF Unit in both 2019 and 2022. Clinical outcomes were compared between two distinct periods: the pre-implementation year of 2019 and the subsequent year of 2022, characterized by process-oriented HF care. Statistical analyses were performed using Kaplan-Meier and adjusted Cox proportional-hazards models. Results A total of 140 patients were enrolled in the study, comprising 55 individuals receiving care from a conventional ward team in 2019 and 85 under the specialized HF team in 2022. The mean age of the cohort was 69.4 years (+/-11.8), with a mean LVEF of 40.6%. The pre-implementation group showed a higher percentage of male patients (73% vs. 47%; p=0.003) and LVEF was lower in the HF team period (38.9% vs. 43.4%; p=0.045), with no statistically significant differences in other baseline variables. As shown in figure 1, over 180 days of follow-up, 15 patients (27.6%) were admitted to hospital in the conventional ward team period and 13 (15.3%) in the HF team period (hazard ratio [HR] 0.44; 95% confidence interval [CI] 0.19 to 0.99; P=0.047). Of these hospitalisations, 13 patients (23.6%) in pre-implementation period and 10 (11.8%) in post-implementation period were attributed to cardiovascular events (HR 0.40; 95% CI 0.16 to 0.99; P=0.049). Additionally, there was a reduction in the rate of heart failure admissions in the post-implementation period compared to the pre-implementation time (HR 0.30; 95% CI 0.09 to 0.94; P=0.039). Furthermore, a significant decline in all-cause of death was observed in patients treated by HF-team in 2022 compared to patients receiving care from the conventional ward team (log-rank test, p=0.015). Conclusions The implementation of a process-oriented organizational model within the Cardiology unit consisting in the provision of patient care by a team specialized in HF management, is associated with a statistically significant reduction in major clinical outcomes such as all-cause hospitalization, cardiovascular hospitalization and HF readmission, alongside a reduction in overall mortality rates at 180 days.

Clinical impact of the implementation of monocyte distribution width (MDW) measurement on time to anti-infective administration in sepsis patients in the emergency department: a before/after cohort study

BackgroundTimely recognition of sepsis in emergency department (ED) is challenging. We evaluated the impact of implementing the biomarker monocyte distribution width (MDW) at bedside, on the time to anti-infective administration.MethodsWe conducted a before-and-after cohort study in the ED of an academic hospital in Paris, to compare sepsis patients care and outcomes, before and after the implementation of point of care (POC) MDW measurement in the ED. During post-implementation period (period-2), MDW was measured with complete blood count by ED nurses with results given in 2 min: if above 21.5 units, ED physicians were asked to consider sepsis and to start an anti-infectious as soon as possible. Primary endpoint was time to anti-infectious administration (TTA) from ED arrival, and secondary endpoints were TTA from sepsis onset (TTAS), length of stay, mortality, and hospitalization rates.ResultsIn total, 255 patients (period-1) and 180 patients (period-2) with sepsis were included. The TTA was 5.4 h (3.5–7.7) period-1 and 4.9 h (IQR 2.5–7.1) in period-2 (p = 0.06). MDW implementation significantly reduced the median TTAS from to 3.7 h (IQR 1.5–5.8) in period-1, to 2.2 h (IQR 0.5–4.5) in period-2 (p < 0.001). Mortality rates remained similar between the two periods (18% vs. 16% respectively, p = 0.4), as did hospitalization rates (93% vs. 91%, p = 0.4) and ED length of stay (7.2 h (5.3–9.8) vs 7.0 (5.4–9.4), p = 0.7).ConclusionImplementing POC MDW measurement in the ED protocols enhances the timeliness of anti-infective administration from sepsis onset, meeting current sepsis management guidelines.

The Impact of Clinical Pharmacist-Driven Weekend Antimicrobial Stewardship Coverage at a Quaternary Hospital.

Extending a consistent pharmacy antimicrobial stewardship weekend service was a newly implemented initiative. We sought to evaluate the impact of incorporating an Infectious Diseases (ID)-trained clinical pharmacist into an antimicrobial stewardship program (AMS) during weekends. The number of documented interventions was 451 on 362 patients compared to 115 interventions on 108 patients during the pre-implementation period (p = 0.04), with interventions primarily targeting Watch antibiotics, as classified by the WHO AWaRe classification. A reduction in the LOS was observed, with a median of 16 days (8-34) during the post-implementation period compared to 27.5 days (10-56) during the pre-implementation period (p = 0.001). The median DOT increased during the post-implementation period to 8 (6-11), versus the increase to 7 (4-11) during the pre-implementation period (p ≤ 0.001). Finally, there was no significant difference observed in healthcare-associated CDI and infection-related readmission. This is a retrospective single-center, pre-post quasi-experimental study. Data including the documented pharmacist interventions were collected from the electronic medical record (EMR), the pre-implementation phase was in 2020, and post-implementation was in 2021. The primary outcome was to identify the number of AMS interventions through prospective audit and feedback review analysis. Secondary outcomes included antibiotic days of therapy (DOT), length of hospital stay (LOS), healthcare-associated Clostridioides difficile infection (CDI), and infection-related readmission. The pharmacist-driven weekend AMS is an opportunity for pharmacists to intervene and optimize patients' care plans. This initiative demonstrated significant increased AMS-related interventions, promoted judicious antimicrobial use, and contributed to a reduced length of hospital stay. Our findings need to be replicated in a larger prospective study.

Removal of Isolated Cannabis Use as an Order Indication for Urine Drug Screening (UDS) Eliminates Racial Inequity in Maternal UDS Testing and Reporting to Child Protective Services

Abstract Black patients on labor and delivery (L&amp;D) units are more likely to undergo urine drug screening (UDS) and subsequent mandated reporting to child protective services (CPS), which can result in increased separation of the parent and infant, contributes to systemic inequities, and erodes the patient/provider relationship. These disparities are driven by a testing indication of isolated cannabis use (ICU), which based on previous data from our institution, disproportionately selects Black patients for testing. In October 2022, the Barnes-Jewish Hospital (St. Louis, MO) L&amp;D unit removed ICU as a UDS indication; concurrently, we implemented an electronic health record (EHR)-based order question requiring providers to select an indication for testing. The objective of this study was to analyze the impact of this intervention on racial equity in UDS testing and CPS reporting. Data on deliveries, UDS testing, and CPS reports were obtained from the EHR, and data for deliveries occurring during the pre- (1/1/2020-9/30/2022; 33 months) vs. post-implementation (10/1/2022-2/1/2024; 16 months) periods was compared. There were a total of 9,187 and 4,757 deliveries during the pre- and post-implementation periods, respectively. At baseline, there were more deliveries by Black patients in the pre-implementation (47.8%) vs. post-implementation (44.0%) period (p&amp;lt;0.001); there was no difference in age, multiparity, or neonatal outcomes between the two periods. In the pre-intervention period, 29.2% of Black and 13.8% of White patients had UDS testing (p&amp;lt;0.001), and 7.6% of Black and 4.1% of White patients underwent reporting to CPS (p&amp;lt;0.001); in the post-intervention period, 4.5% of Black and 3.6% of White patients had UDS testing (p=0.52), and 4.2% of Black and 3.5% of White patients underwent reporting to CPS (p=0.52). 34.6% vs. 67.8% of UDSs in the pre- and post-implementation were positive for any non-cannabis compound, respectively (p&amp;lt;0.001). In conclusion, removing ICU as an order indication dramatically improves racial equity in UDS testing and CPS reporting on a L&amp;D floor, and improves the pre-test probability of UDS testing for non-cannabis compounds.

Implementation of a Standardized Protocol for Postpartum Anemia: A Prospective Cohort Study.

Implementation of standardized protocols for antepartum anemia increases intravenous iron (IVFe) use and improves predelivery hemoglobin (Hb). However, this condition is often overlooked and inadequately treated in postpartum care settings. We aimed to determine if implementation of a standardized protocol for postpartum anemia increases postpartum IVFe use and affects clinical outcomes. We performed a prospective cohort study evaluating implementation of a standardized inpatient protocol for postpartum anemia. This protocol, implemented in December 2021, recommends (1) IVFe for postpartum Hb 7.0 to 8.9 g/dL and (2) oral iron for postpartum Hb 9.0 to 9.9 g/dL. We compared all postpartum inpatients at a single site from April 2021 (preimplementation period [PRE]) to April 2022 (postimplementation period [POST]). The primary outcome was any IVFe use. Secondary outcomes included number of IVFe doses, oral iron supplementation at discharge, postpartum complications, and length of stay. A total of 805 patients were included (PRE = 401; POST = 404). Patients in the PRE and POST groups differed in ethnicity (PRE: 8.2% Hispanic vs. POST: 14.9% Hispanic, p = 0.003). IVFe use significantly increased from PRE to POST (PRE: 6.0% vs. POST: 11.1%, p = 0.009) even when controlling for differences between groups (adjusted odds ratio: 2.48, 95% confidence interval: [1.08-5.67]). Patients receiving IVFe in the POST group were more likely to receive the recommended three doses of IVFe compared with patients receiving IVFe in the PRE group (POST: 29% vs. PRE: 4%, p = 0.04). Patients in the POST group had shorter lengths of stay than in the PRE group (POST: 1.69 days vs. PRE: 1.81 days, p < 0.001). There were no significant differences in blood transfusion, oral iron supplementation, or postpartum complications. Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay. · Postpartum anemia is associated with postpartum depression, fatigue, impaired cognition, and altered maternal-infant bonding.. · IVFe is more effective and better tolerated than oral iron.. · Implementation of standardized protocols for antepartum anemia has been shown to increase IVFe use.. · Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay..

B-019 Reduction in Culture Media Costs, without Impacting Turnaround Time, Through Implementation of an Automated Microbiology Platform and Gram Stain Interpretation

Abstract Background Automated plating instruments have been shown to improve quality in Microbiology laboratories in a number of ways including consistent streaking patterns that provide better isolation of bacterial colonies compared to manual methods. The time per culture set up and automated camera imaging is dependent upon the amount of media set, such that more individual plates slow down turn around time. Conversely, smaller media surface area and the use of non-selective media may result in mixed colonies that require sub-culture for isolation before identification and susceptibilities can be performed. Based upon these findings, we attempted to reduce our media usage per culture with the implementation of automation, with the goal of using as few plates as possible while at the same time not negatively impacting the turn around time of the culture via the need to subculture poorly isolated colonies. We conducted a pre-and post-implementation study evaluating the costs per culture and turn around time delays related to subculturing in a subset. Methods In the pre-implementation period, from April-January 2023, three individual media plates (sheep blood agar, chocolate agar and CNA/MacConkey bi-plate) were routinely set for general aerobic bacterial culture sources including swabs and body fluids. In the post implementation period, from April-January 2024, a single sheep blood/chocolate agar bi-plate was set unless the gram stain showed evidence of mixed organisms (defined as more than one morphology) at which time a secondary selective media (CNA/MacConkey) was manually set. For urine cultures, in the pre-implementation period 2 plates were set (sheep blood and CNA/MacConkey bi-plate) and in the post-implementation period a single chromogenic agar/sheep blood bi-plate was set. Total numbers of cultures in both periods were collected as well as the number of cultures for which additional media were set based on gram stain results. Orders of subculture media in the laboratory information system were compared per positive cultures. Statistical analysis was performed in GraphPad Prism. Results In the pre- versus post-implementation periods, a total of 16,454 vs 17,782 general aerobic cultures and 50,680 vs 53,916 urine cultures were set, respectively. Only 3.6% of general cultures required additional media set based on gram stain. The difference in cost between pre- and post-implementation was approximately a two-thirds reduction in cost for general cultures and a 25% reduction for urine cultures, with a total savings of approximately $34,238 in media avoidance in the post-implementation period. The frequency of positive cultures requiring subculture was not significantly different between the pre- (average 36% of positive growth) and post-implementation (average 22% of positive growth) periods for both culture types and may actually have been reduced due to automation. Conclusions The implementation of reduced media concomitant with streaking via automation resulted in significant cost savings while not negatively impacting isolation, which in turn impacts culture turn around times. The automation may have reduced need for subculture, perhaps due to better isolation, thus subsequent analyses will explore this additional finding.

The High-Sensitivity HEART Pathway Safely Reduces Hospitalizations Regardless of Sex or Race in a Multisite Prospective US Cohort.

The high-sensitivity HEART pathway (hs-HP) risk stratifies emergency department (ED) patients with chest pain. It is unknown if its safety and effectiveness vary by sex or race. We conducted a subgroup analysis of the hs-HP implementation study, a pre-post interrupted time series at five US EDs. The pre-implementation period (January 2019 to April 2020) utilized the traditional HEART pathway with contemporary troponin (Siemens) and the post-implementation period (November 2020 to February 2022) used the hs-HP using hs-cTnI (Beckman Coulter). Patients were risk-stratified using the hs-HP to rule-out, observation, and rule-in groups. Safety and effectiveness outcomes were 30-day all-cause mortality or myocardial infarction (MI) and 30-day hospitalization. Twenty-six thousand and one hundred twenty-six patients were accrued (12 317 pre- and 13 809 post-implementation), of which 35.3% were non-White and 52.7% were female. Among 9703 patients with complete hs-HP assessments, 48.6% of White and 55.4% of non-White patients were ruled-out (p < 0.001). Additionally, 47.3% of males and 54.4% of females were ruled-out (p < 0.001). Among rule-out patients, 0.3% of White versus 0.3% of non-White patients (p = 0.98) and 0.3% of females versus males 0.3% (p = 0.90) experienced 30-day death or MI. Post-implementation, 30-day hospitalization decreased 17.2% among White patients (aOR 0.49, 95% CI: 0.45-0.52), 14.1% among non-White patients (aOR 0.53, 95% CI: 0.48-0.59), 15.6% among females (aOR 0.50, 95% CI: 0.46-0.54), and 16.6% among males (aOR 0.51, 95% CI: 0.47-0.56). The interactions for 30-day hospitalization between hs-HP implementation and race (p = 0.10) and sex (p = 0.69) were not significant. The hs-HP safely decreases 30-day hospitalizations regardless of sex or race. However, it classifies more non-White patients and women to the rule-out group.

Evaluation of a Diabetes Screening Clinical Decision Support Tool

IntroductionWe evaluated if an electronic health record clinical decision support system (EHR CDSS) improves diabetes screening across a health system. MethodsStudy population included adults without diabetes attending a visit at 27 primary care clinics. Outcomes including the monthly screening laboratory order rate and completion rate among eligible patient visits. We performed logistic regression using a Generalized Estimating Equations model and interrupted time series (ITS) analysis to evaluate the change in the outcome from baseline to implementation and post-implementation periods. ResultsFrom the baseline to post-implementation period, screening laboratory order rates increased from 53% to 66% and completion rates increased from 46% to 54%, respectively. Odds of laboratory order and completion increased significantly from the baseline to post-implementation period (test order: OR 3.7, 95%CI 3.4-4.1, p<0.001; test completion: OR 2.1, 95%CI 2.0-2.3, p<0.001). In the ITS analysis, laboratory order and completion rates increased significantly from the baseline period (p<0.001 for both). ConclusionsWe developed and implemented a CDSS alert that automatically identifies eligible patients and facilitates single-click ordering of a diabetes screening test. An easily implementable and scalable CDSS alert can improve diabetes screening.

Effect of streamlining prior authorization processes for systemic cancer treatments on efficiency and financial losses.

412 Background: Prior authorizations (PAs) for systemic cancer treatments are a barrier to timely quality cancer care delivery. The high administrative burden to complete peer to peer’s (P2P) and appeals leads to care delays and revenue losses. At our tertiary academic cancer center, in partnership with our cancer registry and Epic teams, we shifted the clerical work required for PAs from clinicians to certified tumor registrars (CTRs) to increase authorization efficiency and decrease financial losses from denials. Methods: Clinicians place the treatment plan order which goes to the CTR work queue. We leveraged the Epic staging smart form to consolidate and auto-populate common elements needed for PA. The CTRs then complete and validate the form prior to the authorization specialists obtaining the PA. We compared the pre (1/2022-9/2022) and post-implementation (11/2022-4/2024) periods on our primary outcomes: average monthly number of PAs pending review (including P2P, appeals and authorizations requiring clarifying clinical documentation), average monthly denial rate and average time spent on PAs by the authorization specialists. We compared the financial losses from denied PAs from calendar year 2022 to 2023. Analyses were conducted using descriptive statistics. Results: There was a 1.4% reduction in the average monthly number of PA’s pending review (350 vs 345). The average monthly authorized rate was steady from the beginning of the intervention (94%) to present time (95%). The average monthly denial rate was 2.9% at the beginning of the intervention and 0.9% at present time. There was a consistent decrease in the average time a PA was spent in pending review status: 118 hours in 2022, 102 hours in 2023 and 79 hours in quarter 1 of 2024. Despite the overall increase in volume of authorizations submitted, there was an overall cost savings of $27,392,894 from 2022 ($49,964,703) to 2023 ($22,571,809) from the decrease in denials. In 2022, 6.2% of total approved charges were denied and this decreased to 2.7% in 2023. Conclusions: By leveraging the EHR and optimizing existing non-clinical staff workflows, we maintained sustained average authorized and denial rates despite overall volume going up due to improved authorization efficiency and reduced financial losses due to denials. Additionally, there were overall cost savings for the institution due to the decreased percent of denials of total approved charges. Future work will include further refinement of treatment and disease specific optimizations.

Impact on ambulatory palliative appointment lead times by standardizing scheduling protocols based on cognitive computing models.

62 Background: Although palliative care is available across the United States, access continues to remain variable. In Texas, only 52% of hospital systems have palliative services. As a result, optimizing existing systems is critical to providing timely services to this vulnerable population. The Supportive Care Services Clinic at University Health in San Antonio, TX provides ambulatory palliative services to patients including physical and psychosocial symptom management and care coordination. For the period April 1, 2023 to June 30, 2023 average lead times for new palliative patient visits (NPPV) and hospital consult discharge visits (HCDV) was 53 days and 39 days respectively. The aim of this project was to decrease the lead times for NPPV and HCDV through standardization of scheduling criteria. We hypothesized that by applying a scheduling protocol utilizing cognitive computing models (CCM) calculating readmission risk scores to prioritize referrals, we could reduce appointment lead times. Methods: During the implementation phase, we developed referral triage criteria to prioritize patients on a scheduling wait list, including patients who were at higher risk of hospitalization or rapid decline based on CCM readmission risk scores calculated within the electronic medical record. Patients were assigned to next available in template. If a cancelation occurred, patients were pulled forward and vacancy was filled based on priority score. Results: For the initial post-implementation period between September 1, 2023 and November 30, 2023 NPPV average lead time was 47 days which was a reduction of 11% from baseline. The average lead time for HCDV was 33 days which was a reduction of 15% from baseline. In a second follow-up period from February 1, 2024 to April 30, 2024, the average lead time of NPPV was 22 days, a 58% decrease from baseline. The average lead time for HCSV was 24 days which was a significant reduction (p-value = 0.011) of 38% from the pre-implementation baseline. Conclusions: Utilization of CCM risk scores to triage NPPV and HCDV significantly reduced the lead times and resulted in more timely services for critical patients. We also noted increased template utilization. Future projects aim to study the effects of scheduling protocols on template utilization, cancellation rates, no-show rates, readmission rates and other health care utilization. Palliative appointment lead times. April-June 2023 Sept-Nov 2023 Feb-Apr 2024 Total Pt Seen 292 364 534 Avg Lead Time (d) 41 38 29 New Patient New Patient New Patient Completed 66 82 74 Avg Lead Time (d) 53 47 22 Hospital Discharge Hospital Discharge Hospital Discharge Completed 27 28 25 Avg Lead Time (d) 39 33 24

Medicaid Accountable Care Organizations and Disparities in Pediatric Asthma Care

Nearly 6 million children in the US have asthma, and over one-third of US children are insured by Medicaid. Although 23 state Medicaid programs have experimented with accountable care organizations (ACOs), little is known about ACOs' effects on longstanding insurance-based disparities in pediatric asthma care and outcomes. To determine associations between Massachusetts Medicaid ACO implementation in March 2018 and changes in care quality and use for children with asthma. Using data from the Massachusetts All Payer Claims Database from January 1, 2014, to December 31, 2020, we determined child-years with asthma and used difference-in-differences (DiD) estimates to compare asthma quality of care and emergency department (ED) or hospital use for child-years with Medicaid vs private insurance for 3 year periods before and after ACO implementation for children aged 2 to 17 years. Regression models accounted for demographic and community characteristics and health status. Data analysis was conducted between January 2022 and June 2024. Massachusetts Medicaid ACO implementation. Primary outcomes were binary measures in a calendar year of (1) any routine outpatient asthma visit, (2) asthma medication ratio (AMR) greater than 0.5, and (3) any ED or hospital use with asthma. To determine the statistical significance of differences in descriptive statistics between groups, χ2 and t tests were used. Among 376 509 child-year observations, 268 338 (71.27%) were insured by Medicaid and 73 633 (19.56%) had persistent asthma. There was no significant change in rates of routine asthma visits for Medicaid-insured child-years vs privately insured child-years post-ACO implementation (DiD, -0.4 percentage points [pp]; 95% CI, -1.4 to 0.6 pp). There was an increase in the proportion with AMR greater than 0.5 for Medicaid-insured child-years vs privately insured in the postimplementation period (DiD, 3.7 pp; 95% CI, 2.0-5.4 pp), with absolute declines in both groups postimplementation. There was an increase in any ED or hospital use for Medicaid-insured child-years vs privately insured postimplementation (DiD, 2.1 pp; 95% CI, 1.2-3.0 pp), an 8% increase from the preperiod Medicaid use rate. Introduction of Massachusetts Medicaid ACOs was associated with persistent insurance-based disparities in routine asthma visit rates; a narrowing in disparities in appropriate AMR rates due to reductions in appropriate rates among those with private insurance; and worsening disparities in any ED or hospital use for Medicaid-insured children with asthma compared to children with private insurance. Continued study of changes in pediatric asthma care delivery is warranted in relation to major Medicaid financing and delivery system reforms.

Exploring attitudes and perceptions regarding a self-driving demonstration

Purpose Public opinion regarding autonomous vehicles (AV) heavily influences how quickly the technology will be implemented and adopted in the future. However, there is a dearth of empirical evaluations in the literature about riders' perceptions toward service characteristics of shared autonomous vehicles (SAVs) and their attitudes toward developing AVs. Therefore, the aim of this study is to identify attitudes, views and concerns regarding a self-driving demonstration called RAPID (Rideshare, Automation and Payment Integration Demonstration) incorporated with an already-existing on-demand ridesharing service in Arlington, Texas. Design/methodology/approach This study developed a ridership survey to collect data from those who had experience using the service at least once during the service deployment. As the RAPID service operations were restricted to the areas near the University of Texas at Arlington (UTA) campus, sample population of this study is highly skewed with all participants being affiliated with UTA. Findings Findings indicated that survey respondents positively perceived the service features, including comfort, boarding the vehicles, ride safety, booking and scheduling, vehicle speed, climate control and service cost. To complement the survey results, the authors conducted interviews and a focus group study and used conventional content analysis to gain more in-depth insights about RAPID service operations from the perspectives of users and non-users in the post-implementation period. The results indicated that geographic accessibility, service availability and trip cost were the primary concerns of the focus group participants. Originality/value This study offers critical insights into individual attitudes and perceptions toward shared AVs (SAVs) that will assist local, state and federal transit authorities and planners in formulating policies and transportation strategies to target SAV ridership when the service is more widespread.