Postprotocol Cohort Research Articles

A Prevention Protocol Reduces Spinal Cord Ischemia in Patients Undergoing Branched/Fenestrated Endovascular Aortic Repair

ObjectivesSpinal cord ischemia (SCI) is a devastating complication that is associated with thoracoabdominal aortic repair, with higher risk associated with increased aortic coverage length, making patients undergoing branched/fenestrated endovascular repair(B/FEVAR) particularly vulnerable. A bundled SCI prevention protocol was previously reported to reduce SCI rates when compared to a historic cohort in a single-center study. Therefore, this analysis aims to further validate and update outcomes associated with the protocol given the routine implementation of this strategy at two institutions (University of Florida [UF] and the University of Alabama at Birmingham [UAB]) since inception. MethodsComponents of the SCI prevention protocol include selective cerebrospinal fluid (CSF) drainage, specified blood pressure parameters, transfusion goals, and selective pharmacologic adjuncts (naloxone, steroids). This protocol was routinely implemented in May 2015. Patients undergoing B/FEVAR from May 2015-December 2022 constituted the post-protocol cohort(n=402) and were compared to the pre-protocol cohort (n=160, January 2010-April 2015). The primary outcome was SCI incidence and subgroup analysis was conducted among patients deemed to be high-risk (Crawford extent I- III thoracoabdominal aneurysms (TAAA) dissection-related disease, prior aortic repair, coverage proximal to zone 5). Survival analysis was performed using Kaplan-Meier methodology. ResultsThe pre- and post-protocol cohorts were demographically similar, though more post-protocol patients were American Society of Anesthesiology(ASA) class IV (86.1% vs. 55.0%; p<0.001). TAAA was the most common indication in both groups. CSF drain placement was more common in the post-protocol group, particularly among high-risk patients. SCI occurred in 15.9% of pre-protocol patients versus 3.0% of post-protocol patients(p<0.001). In high-risk patients, the pre- and post-protocol cohort SCI incidence was 23.2% vs. 5.0%, respectively (p<0.001). 30-day mortality was decreased in the post-protocol cohort (6.3% vs. 2.2%, p=0.02). Although the post-protocol group had a trend toward improved 1-year survival, this was not statistically significant (84.4% vs. 88.3%, log-rank p=0.35). Among SCI patients, one-year mortality was 28% and 33.3% in the pre- and post-protocol groups, respectively(p=0.46). ConclusionImplementation of a bundled SCI prevention protocol significantly reduces SCI rates in B/FEVAR patients, which has now been validated at two institutions, with the most significant reductions occurring among high-risk patients. Although the overall one-year mortality difference was not significantly different between the cohorts, the high mortality rates among SCI patients highlights the importance of preventative measures.

A Standardized Post-gastrostomy Feeding Protocol for Pediatric Patients Reduces Time to Postoperative Goal Feeding Volume.

Gastrostomy creation is a common pediatric surgical procedure, but the time to initiation of feeds and to goal feeding volumes postoperatively varies greatly. Delays in reaching goal feeding volumes promote malnutrition and may prolong hospital length of stay. We hypothesized that implementing an accelerated, standardized post-gastrostomy feeding protocol would allow patients to reach goal feeding volumes sooner, without increasing postoperative complications. We conducted a retrospective cohort study of children who underwent gastrostomy tube placement between 1/1/2022 and 11/30/2023. The feeding protocol was implemented on 11/16/2022, with patients separated into pre- and post-protocol cohorts. Abstracted data included comorbidities, time to initiation of enteral feeds, time to goal feeding volume, and postoperative complications. 322 patients were included: 166 pre-protocol and 156 post-protocol. The post-protocol cohort had a greater proportion of patients with gastrointestinal and/or cardiac comorbidities (P < .001). Through the protocol, postoperative enteral feeds were initiated significantly faster (5.4hrs [IQR 43-7.7] vs 7.0hrs [IQR 5.6-14.3]; P < .001). The post-protocol cohort also achieved goal feeding volumes sooner (12.8hrs [IQR 9.1-25.3] vs 26.3hrs [IQR 21.6-38.9]; P < .001). Postoperative complication rates did not differ between cohorts. Sub-analysis of children with complex cardiac conditions also demonstrated faster time to goal nutrition without an associated increase in postoperative events. These findings demonstrate that our accelerated post-gastrostomy feeding protocol was effective in achieving goal enteral nutrition earlier without increasing postoperative adverse outcomes. This protocol may be used by other centers to safely expedite time to goal enteral feeds in children postoperatively.

Trends in Opioid Use during Hospitalization following Revision Total Hip Arthroplasty from 2016 to 2021

AbstractThough opioids can be very effective for postoperative pain management after revision total hip arthroplasty (rTHA), many physicians have made an effort to decrease usage of these medications by focusing on alternative pain management strategies to reduce opioid dependence and unwanted side effects. This study sought to investigate trends in opioid consumption during hospitalization following rTHA from 2016 to 2021. We retrospectively reviewed all patients who received rTHA from January 2016 to April 2021. Baseline demographic variables including age, gender, race, body mass index, and American Society of Anesthesiologists classification were recorded. Additional information including patient-reported outcome measures (PROMs), postoperative outcomes, dosage, and type of opioid medication prescribed postoperatively were also collected. Opioid dosage and type were converted to milligram morphine equivalents (MMEs) per day of hospitalization and compared across the 6 years studied. Linear regression as well as t-tests were utilized to determine significant trends in MME consumption over time. In total, 1,096 patients met inclusion and exclusion criteria. The greatest daily average opioid consumption per patient was in 2017 (61.6 ± 155.4 MME per day) and the lowest was in 2021 (31.8 ± 105.8 MME per day). Linear regression analysis detected a downward trend of 4.97 MME per day each year, though these results were not statistically significant (R 2: 0.444, p = 0.089). t-Test analysis, however, did reveal a significant decrease in opioid consumption in the postprotocol cohort (38.41 ± 90.5 vs. 52.18 ± 120.2; p = 0.034). There was a significant increase in preoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement scores (p = 0.007) over time as well as a significant decrease in preoperative visual analog scale pain scores (p = 0.012). The results of this study show that opioid consumption in 2021 was lower than in 2016 and 2017. This result emphasizes the effectiveness of protocols limiting opioid usage during hospitalization following rTHA. Moreover, the relatively consistent patient-reported outcome scores over time demonstrate that this decrease in opioid consumption per year does not impact patient-reported outcomes and satisfaction.

Acute kidney injury surveillance in the high-risk neonatal population following implementation of creatinine screening protocol.

Acute kidney injury (AKI) in neonates is associated with longer hospital stays and higher mortality rates. However, there is significant variability in prevalence rates of AKI and the true burden is incompletely understood. In November 2020, the University of Iowa Stead Family Children's Hospital Neonatal Intensive Care Unit implemented a creatinine screening protocol to enhance kidney function monitoring. We sought to evaluate adherence to the protocol to determine if increased surveillance led to increased detection of AKI events. A retrospective chart review was conducted for neonates born at <30 weeks' gestation admitted between 2015 and 2020. We reviewed 100 charts in both the pre (2015-2016) and post (2020-2021) implementation era of the AKI surveillance protocol. AKI was defined according to neonatal modified KDIGO criteria. Following implementation of the protocol, neonates were significantly more likely to have creatinine checked (p < 0.001). Serum creatinine was drawn according to protocol guidelines 68% of the time, and 42% of patients (34/82) had an 80% or higher adherence to the protocol. There was a significant increase in detection of AKI in the post-protocol cohort (13/82, incidence of 16%) compared to the pre-protocol cohort (5/83, incidence of 6%), (p = 0.047). The implementation of a serum creatinine screening protocol increased the frequency of creatinine draws and detection of AKI.

Impact of implementing a vancomycin protocol to reduce kidney toxicity: A comparative study.

Introduction: Vancomycin is a frequently used antibiotic for treating severe infections caused by multidrug-resistant, Gram-positive pathogens. To ensure its effectiveness and minimize the risk of nephrotoxicity, safe administration and dose monitoring are crucial. Understanding the impact of vancomycin serum levels on clinical outcomes is of paramount importance, necessitating improved knowledge on its use, dose monitoring, nephrotoxicity, and safe administration. Objective: This study aimed to evaluate the incidence of acute kidney injury (AKI) in patients receiving vancomycin before and after the implementation of an institutional protocol for vancomycin administration in a public tertiary hospital in southern Brazil. Materials and methods: A cross-sectional study design was employed, analyzing data from the electronic medical records of 422 patients who received vancomycin. The patient population was divided into two independent cohorts: those treated in 2016 (pre-protocol) and those treated in 2018 (post-protocol), following the implementation of the institutional vancomycin administration protocol. Results: The study included 211 patients in each year of assessment. Patients from both cohorts had a Charlson Comorbidity Index (CCI) score of 4. The post-protocol cohort consisted of older individuals, with a mean age of 62.8years. In addition, patients in the post-protocol year had higher baseline creatinine levels, higher rates of intensive care unit (ICU) hospitalization, and increased use of vasopressors. In the pre-protocol year, patients received vancomycin therapy for a longer duration. When comparing the incidence of AKI between the two groups, an intervention study revealed rates of 38.4% in group 1 and 20.9% in group 2, indicating a significant reduction (p < 0.001) in the post-protocol group. A logistic regression model was developed to predict AKI, incorporating variables that demonstrated significance (p ≤ 0.250) in bivariate analysis and those recognized in the literature as important factors for AKI, such as the duration of therapy, vancomycin serum level, and ICU hospitalization. The logistic regression classification performance was assessed using a receiver operating characteristic (ROC) curve, yielding an area under the curve of 0.764, signifying acceptable discrimination of the regression model. Conclusion: Implementation of the institutional protocol for vancomycin administration resulted in a significant and cost-effective impact, ensuring appropriate therapeutic dosing, reducing adverse events (e.g., nephrotoxicity), and improving clinical outcomes for patients in the study population.

Pain-management protocol aimed at reducing opioids following total knee arthroplasty does not negatively impact patient satisfaction

BackgroundPrior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores. MethodThis study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen. ResultsOf the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in “top box” percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775). ConclusionsProtocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOEIII. Clinical RelevanceThis study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

Effect of cue-based feeding on time to nipple feed and time to discharge in very low birth weight infants

The objective of this study is to evaluate the effectiveness of a cue-based feeding protocol in improving time to nipple feed and time to discharge in very low birth weight infants in a Level III Neonatal Intensive Care Unit. Demographic, feeding, and discharge data were recorded and compared between the two cohorts. The pre-protocol cohort included infants born from August 2013 through April 2016 and the post-protocol cohort included infants born from January 2017 through December 2019. 272 infants were included in the pre-protocol cohort and 314 infants in the post-protocol cohort. Both cohorts were statistically comparable in gestational age, gender, race, birthweight, prenatal care, antenatal steroid use, and rates of maternal diabetes. There were statistically significant differences between the pre- versus post-protocol cohorts in median post-menstrual age (PMA) in days at first nipple feed (PO) (240 vs 238, p = 0.025), PMA in days at full PO (250 vs 247, p = 0.015), and length of stay in days (55 vs 48, p = 0.0113). Comparing each year in the post-protocol cohort, for each outcome measure, a similar trend was noted in 2017 and 2018, but not in 2019. In conclusion, the cue-based feeding protocol was associated with a decrease in the time to first PO, time to full nipple feeds, and the length of stay in very-low-birthweight infants.

PD12-03 IMPACT OF A RENAL TRAUMA IMAGING PROTOCOL ON DELAYED IMAGING RATES AND HIGH-GRADE RENAL TRAUMA MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023PD12-03 IMPACT OF A RENAL TRAUMA IMAGING PROTOCOL ON DELAYED IMAGING RATES AND HIGH-GRADE RENAL TRAUMA MANAGEMENT Leah Chisholm, George Koch, Rohan Bhalla, Abimbola Ayangbesan, Jennifer Haung, William Walton, and Niels Johnsen Leah ChisholmLeah Chisholm More articles by this author , George KochGeorge Koch More articles by this author , Rohan BhallaRohan Bhalla More articles by this author , Abimbola AyangbesanAbimbola Ayangbesan More articles by this author , Jennifer HaungJennifer Haung More articles by this author , William WaltonWilliam Walton More articles by this author , and Niels JohnsenNiels Johnsen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Delayed-phase imaging (DPI) is recommended by the American Urological Association (AUA) for suspected renal injuries. Our institution historically obtained delays in less than 30% of American Association for the Surgery of Trauma (AAST) grade III-V renal injuries. In August 2021, we implemented a renal trauma imaging protocol to improve AUA guideline adherence (Figure 1). We sought to compare patient outcomes to further evaluate the utility of DPI in high-grade renal trauma. METHODS: Trauma patients with an AAST III-V renal injury presenting from January 2005 to September 2022 were identified from our institutional trauma registry. Patients with a contrasted computed tomography scan of the abdomen on admission were included. For patients without DPI, AAST IV grades were assigned based on the depth and location of renal lacerations and character of retroperitoneal fluid. DPI rates and patient outcomes were compared before and after implementation of our renal trauma imaging protocol. RESULTS: Of 742 patients, 650 (87.6%) were in the pre-protocol group and 92 (12.4%) in the post-protocol group. AAST III renal injuries were the most common among both groups, however AAST IV injuries were more frequent in the post-protocol cohort (30.4%) whereas AAST V injuries were more frequent in the pre-protocol group (11.5%). Following protocol implementation, the rate of DPI on admission for high grade renal trauma patients nearly tripled from 22.8% to 58.7% (p<0.001). The rate of follow-up cross-sectional imaging also increased from 11.7% to 58.7% (p<0.001). Despite increased guideline-adherent imaging, there was no significant difference in interventions for urinary extravasation (6.5% vs. 2.2%, p=0.10). However, there was a significant increase in angioembolizations for hemorrhage (3.5% vs 9.8%, p<0.01). Rates of all-cause readmission (9.1% vs. 5.4%, p=0.24) and renal-specific readmission (0.5% vs. 0.0%, p=0.51) were unchanged. CONCLUSIONS: The implementation of a multi-disciplinary renal trauma imaging protocol improves AUA guideline adherence. While guideline-concordant imaging led to more procedures for bleeding, rates of intervention for urinary extravasation, all-cause readmissions, or renal-specific readmissions were unchanged. Further research into the indications for DPI is needed. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e401 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leah Chisholm More articles by this author George Koch More articles by this author Rohan Bhalla More articles by this author Abimbola Ayangbesan More articles by this author Jennifer Haung More articles by this author William Walton More articles by this author Niels Johnsen More articles by this author Expand All Advertisement PDF downloadLoading ...

Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center.

Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy. Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020. The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed. Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.

Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality.

IntroductionThe purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician.Materials and MethodsDemographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate.ResultsBetween September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery.ConclusionA standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia.

Same day discharge after pediatric laparoscopic appendectomy in community hospitals

IntroductionSame-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units. MethodsPatients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units. ResultsThere were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference. ConclusionSame-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.

One-year Outcomes After Implementation Of A Ruptured Abdominal Aortic Aneurysm Protocol

OBJECTIVE Societal guidelines recommend protocol establishment for patients with ruptured abdominal aortic aneurysms (rAAA), but few reports exist. We describe 1-year outcomes after implementing a rAAA protocol and a survey of team member perceptions. METHODS This was a multi-hospital single healthcare network pre-post investigation (2017-2020) where a single quaternary university hospital (QUH) receives rAAA transfers. Protocol activation engages a multidisciplinary team including vascular surgery, anesthesia, operating room (OR) and emergency department (ED) staff, and was implemented in Feb 2020. Patients are routed from the helipad to the OR or ED for expedited management. Primary outcomes were time from QUH arrival to OR and 30-day mortality. Post-protocol outcomes were compared to historical controls (2017-2019). As a qualitative adjunct, we conducted a survey examining perceptions among participants at 1-year post implementation. Results: 88 patients with rAAA presented during our study period (42 pre; 46 post). Protocol activation occurred in 32 (70%) of post-protocol patients. Presenting characteristics were similar between groups (Table 1). QUH arrival time to OR was lower for the post protocol cohort compared to historical controls (pre 88.9±78.5; post 24.6±28.4 minutes; p<0.01). 30-day mortality did not differ significantly between groups (pre N=17(40%); post N=13(41%); P=.8). Most survey participants believed the protocol improved safety (65%) and care efficiency (63%). Almost all (89%) would want the protocol activated for a family member (Table 2). CONCLUSIONS rAAA protocol implementation reduced OR arrival time and improved patient safety and efficiency perspectives among staff. Protocol development should be considered at centers with high volumes of rAAA. Societal guidelines recommend protocol establishment for patients with ruptured abdominal aortic aneurysms (rAAA), but few reports exist. We describe 1-year outcomes after implementing a rAAA protocol and a survey of team member perceptions. This was a multi-hospital single healthcare network pre-post investigation (2017-2020) where a single quaternary university hospital (QUH) receives rAAA transfers. Protocol activation engages a multidisciplinary team including vascular surgery, anesthesia, operating room (OR) and emergency department (ED) staff, and was implemented in Feb 2020. Patients are routed from the helipad to the OR or ED for expedited management. Primary outcomes were time from QUH arrival to OR and 30-day mortality. Post-protocol outcomes were compared to historical controls (2017-2019). As a qualitative adjunct, we conducted a survey examining perceptions among participants at 1-year post implementation. Results: 88 patients with rAAA presented during our study period (42 pre; 46 post). Protocol activation occurred in 32 (70%) of post-protocol patients. Presenting characteristics were similar between groups (Table 1). QUH arrival time to OR was lower for the post protocol cohort compared to historical controls (pre 88.9±78.5; post 24.6±28.4 minutes; p<0.01). 30-day mortality did not differ significantly between groups (pre N=17(40%); post N=13(41%); P=.8). Most survey participants believed the protocol improved safety (65%) and care efficiency (63%). Almost all (89%) would want the protocol activated for a family member (Table 2). rAAA protocol implementation reduced OR arrival time and improved patient safety and efficiency perspectives among staff. Protocol development should be considered at centers with high volumes of rAAA.

Think Globally, Start Locally: Value-Based Breast Cancer Care for Newly Diagnosed Patients in A Safety-Net Medical Center

Introduction We assessed the efficacy of a multidisciplinary, patient-focused approach emphasizing appropriate use of medical resources among a population of breast cancer patients at our safety-net hospital. Methods A multidisciplinary program coordinated and provided value-based care. Surgery, oncology, and navigation were physically co-located. Real time decisions were made by medical and surgical oncologists. Focused institution-specific protocols initiated in 2018, advised against four specific cancer resources that our team had determined as lower-value: imaging tests for indications not recommended in NCCN guidelines, inappropriate Oncotype Dx testing, radiation for patients ≥65 years with stage I hormone-positive disease, and administration of pertuzumab and neratinib as adjuvant therapy in HER2+ breast cancer patients. Time to treatment and rates of use of these resources were monitored. Results Newly diagnosed breast cancer patients from 2015-2019 were compared to the pre-protocol era (2015-2017). Time from first breast clinic visit to oncology appointment decreased 39 days (60% decrease, median of 63.0 vs 22.5 days, p&lt;0.001), no patients ≥65 years with stage I hormone-positive breast cancer in 2018-2019 received radiation therapy, and rates of ordering of CT, PET, and bone scans for asymptomatic patients decreased by 80%. Overall survival did not differ by cohort protocol category/treatment choices (p=0.69) Compared to the pre-protocol cohort, the post-protocol cohort did not have a significantly lower risk of death (Hazard Ratio 0.66, 95% Confidence Interval 0.08-5.38, p=0.69). Overall breast cancer care cost decreased by $3,675,374 between 2018 and 2019 versus 2015 to 2017. Conclusions After initiating a breast cancer program focused on reducing rates of use of four commonly excessively ordered breast cancer resources our team identified as lower-value, care at our safety-net hospital achieved high compliance with NCCN maging guidelines and also reduced use of a low-value diagnostic test, and low-value radiation and chemotherapy.

Strict Surgical Repair for Bile Leakage Following the Roux-en-Y Hepaticojejunostomy.

Background: The optimal bile leakage management strategy in the pediatric population following the initial Roux-en-Y hepaticojejunostomy is still a matter of discussion today. Here, we assessed the roles of bile leakage management and surgical implementation on outcomes for patients with bile leakage.Materials and Methods: A revised protocol for bile leakage management with restricted surgical intervention was implemented at Chongqing Children’s Hospital on March 15, 2013 and Sanxia Hospital on April 20, 2013. We performed a retrospective, historical control analysis for the protocol implementation to compare the short- and long-term outcomes using the corresponding statistical methods.Results: There was a total of 84 patients included in the analysis, including 46 patients in the pre-protocol group and 38 patients in the post-protocol group. No statistical differences for the demographic features were found between the two groups. There was a decrease in redo surgeries in the post-protocol cohort compared to those in the pre-protocol cohort (odds ratio [OR] = 4.48 [95% CI, 1.57–12.77]; p = 0.003). Furthermore, patients in the post-protocol group were less likely to be associated with intensive care unit (ICU) admission (OR = 3.72 [95% CI, 1.11–12.49]; p = 0.024) compared to patients in the pre-protocol group, respectively. There was no mortality between the two groups.Conclusions: A restrictive surgical intervention strategy can effectively reduce the rate of redo surgery and exhibited promising outcomes for bile leakage in terms of postoperative recovery and hospitalization costs.

Optimizing Utilization of SGLT2 Inhibitors in an Outpatient LVAD Population

<h3>Purpose</h3> SGLT2 inhibitors (SGLT2i) decrease morbidity and mortality in patients with HFrEF and have potential but unstudied benefits in LVAD patients. The purpose of this study was to assess the impact of a provider education program and SGLT2i initiation protocol on SGLT2i prescribing and to determine barriers to SGLT2i utilization. <h3>Methods</h3> This was a single center, retrospective, cross-sectional cohort study of an outpatient LVAD patient population. The primary outcome was the proportion of patients on SGLT2i therapy seen in clinic prior to (May/June 2019) and after (May/June 2020) pharmacist-led protocol development and provider education. Candidates for SGLT2i were those with NYHA Class II-IV symptoms, MAP ≥ 80 mmHg, and eGFR ≥ 20 mL/min. Chi-square and t-tests were used to compare categorical and continuous data, respectively. <h3>Results</h3> A total of 272 LVAD outpatient encounters were evaluated; patient characteristics were similar between the pre- and post-protocol cohorts (<b>Table 1</b>). No patients in the pre-protocol cohort received SGLT2i therapy despite 67 being appropriate candidates. In the post-protocol cohort, 25 patients (16.0%) were already receiving an SGLT2i (p<0.001 vs pre-protocol) and 109 patients were candidates. Of those, 9 patients (5.8%) were initiated on an SGLT2i (p=0.01 vs pre-protocol). NYHA Class I (23.4%) and MAP <80 mmHg (21.3%) were the most common reasons patients were not SGLT2i candidates. Rationale for failing to initiate SGLT2i post-protocol was poorly documented, but primarily included other medication changes (n=12) or patient instability (n=7) (<b>Table 2</b>). In addition to improved rates of SGLT2i prescribing, rates of prescribing of other guideline-directed therapies also improved (<b>Table 1</b>). <h3>Conclusion</h3> Pharmacist-led provider education and initiation protocols can increase SGLT2i utilization in outpatients supported by LVADs, leading to a larger patient population in which the potential benefits of these therapies on clinical outcomes can be evaluated.

Preoperative MRI and LDH in women undergoing intra-abdominal surgery for fibroids: Effect on surgical route.

Our institution implemented a preoperative protocol to identify high-risk cases for which power morcellation should be avoided. In this retrospective cohort study, an institutional protocol requiring preoperative Magnetic Resonance Imaging with diffusion-weighted imaging and serum Lactate Dehydrogenase levels was implemented. Chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. A total of 1,085 women were included, 479 before and 606 after implementation of the Magnetic Resonance Imaging / Lactate Dehydrogenase protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p = 0.022) and women using tamoxifen (2% vs. 0%, p = 0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of open surgery for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (open hysterectomy rate was 19% vs. 16% in pre- and post-protocol groups, respectively, P = 0.463, and open myomectomy rate was 10% vs. 9% rates in pre- and post-protocol groups, respectively, P = 0.776). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p<0.001) and an increased use of containment bags (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of women who had abnormal Magnetic Resonance Imaging / and Lactate Dehydrogenase results, abnormal Magnetic Resonance Imaging results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal Magnetic Resonance Imaging and Lactate Dehydrogenase tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal Lactate Dehydrogenase results alone did not influence route. Rates of MIS procedures were decreased for women with abnormal preoperative Magnetic Resonance Imaging results. False positive results appear to be one of the main drivers for the use of an open surgical route.

Introduction of a ROTEM-assisted strategy improves patient blood management in children undergoing open craniosynostosis repair

Purpose The surgical correction of craniosynostosis by open cranial vault reconstruction (OCVR) is often associated with significant blood loss and perioperative blood transfusion demand. Because of transfusion risks, several attempts have been made to eliminate the need for perioperative homologous blood transfusion with the implementation of goal-directed transfusion protocols. The aim of this study was to determine whether the introduction of a rotational thromboelastometry (ROTEM)–assisted patient blood management strategy would decrease the intraoperative blood transfusion and blood loss levels. Methods Patients younger than 2 years of age who were diagnosed with nonsyndromic single suture synostosis and underwent primary OCVR were investigated in this retrospectively designed cohort study. The children were equally divided into 2 study groups according to the availability of the ROTEM-assisted protocol. The control group had surgery before introduction of the new protocol, whereas the study group was operated on subsequently. Demographic, blood loss, and transfusion data of the preprotocol cohort were compared with those of the postprotocol cohort. Results In total, 100 children, separated in 2 groups (50 patients each), were analyzed. The mean age at the time of surgery was 8.5 months in the pre-ROTEM-assisted protocol group, and 8.7 months in the postimplementation group. The estimated blood volume loss dropped from 60.8 mL/kg to 49.6 mL/kg after initiation of the current strategy. The intraoperative packed red blood cell (PRBC) transfusion volume decreased from 32.6 mL/kg to 17.1 mL/kg. Administration of PRBCs in the postoperative period also was reduced, compared with the period before implementation of the ROTEM-assisted regimen, from 21.8 mL/kg to 15.9 mL/kg. The average length of hospital stay was reduced from 5.4 days to 4.7 days after use of the ROTEM-assisted protocol. Conclusions As indicated by our results, the use of a ROTEM-assisted protocol is associated with considerable reduction in blood volume loss and perioperative allogeneic transfusion requirements in the surgical management of craniosynostosis with OCVR.

Protocol-driven Antibiotic Treatment of Pediatric Empyema After Fibrinolysis.

The duration of antibiotic treatment after resolution of empyema in children is variable. We evaluated the efficacy and safety of a protocol-driven antibiotic regimen aimed to decrease antibiotic duration following treatment with fibrinolysis. Our institutional protocol consisted of 7 further days of antibiotics upon removal of the thoracostomy tube, with the patient being afebrile, off supplemental oxygen, and having negative cultures. A prospective observational study was then performed between September 2014 and March 2019. Empyema recurrence and antibiotic-related complications were recorded. Results were compared with previously published data from the preprotocol era. A total of 37 patients were included. Mean total duration of antibiotics decreased from 26 ± 6.5 days in the preprotocol group to 22 ± 9.7 days in the postprotocol group (P = 0.004). This resulted in a significant decrease in hospital stay from the preprotocol cohort to the postprotocol cohort, respectively (9.3 ± 4.8 d versus 6.8 ± 3.1 d, P = 0.003). Sixty-two percentage of the patients were intended to treat according to the protocol, with a 50% adherence rate. Patients in which the protocol was followed had an average of 2.8 fewer days of antibiotics after discharge (P = 0.004), although overall duration was not statistically different. Significantly fewer antibiotic-related complications were noted after protocol initiation. There was no difference in empyema recurrence or readmissions. Institution of a protocol-driven approach to antibiotic duration following resolution of pleural space disease may reduce antibiotic duration and complications without reducing efficacy.

An Evidence-Based Care Protocol Improves Outcomes and Decreases Cost in Pediatric Appendicitis

BackgroundAppendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care. MethodsIn 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics. ResultsAmong the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01). ConclusionsThis study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs.

Implementation of an interdisciplinary tracheostomy care protocol to decrease rates of tracheostomy-related pressure ulcers and injuries.

Tracheostomy-related pressure injuries (TRPI) have been demonstrated to occur in approximately 10% of tracheostomy patients. In this study, we present TRPI outcomes after implementation of a standardized tracheostomy care protocol. A tracheostomy care protocol was developed by an interdisciplinary quality improvement program and implemented on July 1, 2016. The protocol was designed to minimize factors that contribute to the development of TRPI. Rates of TRPI over the subsequent 20months were compared to the year before implementation. 9 out of 85 patients (10.6%) developed TRPI in the pre-protocol cohort compared to 0 of 137 (0%) in the post-protocol cohort, which was a statistically significant decrease by Fisher's exact test with a p-value of 0.0001. Pearson's correlation coefficient demonstrated a negative correlation between age and post-operative day of diagnosis (r=-0.641, p=0.063), indicating that older patients develop TRPI more quickly. Interdisciplinary peri-operative tracheostomy care protocols can be effective in decreasing rates of TRPI.