Postimplementation Group Research Articles

Expansion of a Pharmacist-Led Culture Follow-Up Program to Real-Time Notification of Multidrug-Resistant Microbiology Results in the Emergency Department.

Introduction: There are currently limited published data for a pharmacist-led multidrug-resistant (MDR) culture follow-up program through a collaborative drug therapy management (CDTM) agreement in the emergency department (ED). Objective: The objective of this study was to assess the impact of a pharmacist-led culture follow-up program for MDR microbiology results on ED revisit rate. Methods: A single-center quasi-experimental retrospective study was conducted comparing the outcomes before (December 2017 to March 2019) and after (April 2019 to July 2020) implementation of the ED MDR Culture program. Patients 18 years of age or older; with confirmed positive microbiology culture of extended-spectrum beta-lactamases (ESBL), methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) at any site; and discharged from the ED were included. The primary outcome was to evaluate ED revisit within 30 days due to antimicrobial treatment failure, defined as lack of resolution or worsening of infection. A statistical analysis was performed for categorical data using Fisher's exact test, and for continuous data using unpaired t test or Mann-Whitney U Test, when applicable. Results: A total of 130 patients were included in the analysis. Patients in the post-implementation group (n = 70) had a significant reduction in ED revisits compared to the pre-implementation group (n = 60); 9 [12.9%] versus 17 [28.3%], respectively; P = .046. Conclusion: Implementation of an ED MDR culture program was associated with significantly less ED revisits within 30 days due to antimicrobial treatment failure, thus demonstrating the expanded role of ED pharmacists in antimicrobial stewardship in the outpatient setting.

Interpreter use in sustained nurse home visiting: interpreter experience and support

BackgroundThe aim of this study was to explore the experiences of healthcare interpreters working with child and family health nurses (CFHNs) in providing child and family health nursing (CFHN) services and sustained nurse home visiting (SNHV) programs to culturally and linguistically diverse (CALD) families with limited English proficiency.MethodsA mixed methods longitudinal research design was conducted to develop, implement and evaluate a training and practice support model for healthcare interpreters working with nurses and CALD families in providing CFHN services and SNHV programs in three major local health services in Sydney, Australia. One pre-training survey with 24 healthcare interpreters was conducted; field notes were recorded during training and implementation; and a post-implementation focus group with six healthcare interpreters was conducted. Quantitative survey data were analysed descriptively using Alchemer. The focus group was audio-recorded for transcription purposes, and this and the field notes were thematically analysed applying a socioecological framework.ResultsThree themes were identified from the initial, pre-training survey: facilitate communication and delivery accurately; a bridge linking the clients and the healthcare practitioners; and make everybody feel comfortable. Practice support implementation was negatively impact by system and COVID-19 related barriers. Four themes were developed from evaluative phase of the study including: system-related issues; interpreters’ challenges; working with nurses; and client session related issues.ConclusionQuality interpreting was favourably influenced by adequate time for interpreting the session including a pre- and post-briefing session with CFHNs, an appropriate mode of interpretation, allocation of female interpreters and the same interpreters with CALD mothers and clarity about interpreter role and cultural comfort. These strategies support the quality of communication and relationships in delivery of CFHN services and SNHV programs to CALD mothers with limited English proficiency.

The FIND Program: Improving Follow-up of Incidental Imaging Findings

Incidental findings are findings identified on imaging which are unrelated to the original reason for examination and require follow-up. The Radiology Finding Incidental Disease (FIND) Program was designed to track and improve follow-up of incidental imaging findings. The purpose of this study was to determine the frequency of incidental findings on cross-sectional imaging and the adherence to suggested follow-up of incidental findings prior to and after implementation of a structured reporting and tracking system. A retrospective analysis of 2000 patients with computed tomographic cross-sectional imaging was performed: 1000 patients prior to implementation of the FIND Program and 1000 patients 1 year after establishment of the program. Data collected included the frequency of incidental findings, inclusion of follow-up recommendations in the radiology report, and adherence to suggested follow-up. There was a higher rate of completion of recommended follow-up imaging in the post-implementation group (34/67, 50.7%) compared to the pre-implementation (16/52, 30.8%) (p = 0.03). Implementation of an incidental findings tracking program resulted in improved follow-up of incidental imaging findings. This has the potential to reduce the burden of clinically significant incidental findings possibly resulting in later presentation of advanced disease.

Implementation of an asymptomatic bacteriuria assessment protocol for patients discharged from the emergency department.

We evaluated the impact of an asymptomatic bacteriuria (ASB) assessment protocol on the number of antibiotics prescribed for ASB after discharge from the emergency department (ED). Single-center, before-and-after, retrospective cohort study. The study was conducted at a large community health system in North Carolina. Eligible patients were discharged from an ED without an antibiotic prescription and had a positive urine culture result after discharge from May through July 2021 (preimplementation group) and October through December 2021 (postimplementation group). Patient records were reviewed to determine the number of antibiotic prescriptions for ASB on follow-up call before and after implementation of an ASB assessment protocol. Secondary outcomes included 30-day admissions, 30-day ED visits, 30-day UTI-related encounters, and projected antibiotic days of therapy. The study included 263 patients: 147 in the preimplementation group and 116 in the postimplementation group). There were significantly fewer antibiotic prescriptions for ASB in the postimplementation group (50% vs 87%; P < .0001). There were no differences in the incidence of 30-day admissions (7% vs 8%; P = .9761), 30-day ED visits (14% vs 16%; P = .7805), or 30-day UTI-related encounters (0% vs 0%, NA). Implementation of an ASB assessment protocol for patients discharged from the ED significantly reduced the number of antibiotic prescriptions for ASB on follow-up call without an increase in 30-day admissions, ED visits, or UTI-related encounters.

Value Added from Same-day Discharge after Appendectomy for Children with Simple Appendicitis.

We implemented a clinical practice guideline in September 2019. A surgeon-of-the-week service model and the urgent operating room started in November 2019 and January 2020, respectively. Data for children with simple appendicitis from our academic medical center were gathered prospectively using National Surgical Quality Improvement Program-Pediatric. Patient outcomes before intervention implementation (n = 278) were compared with patients following implementation (n = 264). The average monthly percentage of patients discharged on the day of surgery increased in the postimplementation group (32% versus 75%). Median postoperative length of stay decreased [16.5 hours (interquartile range, 15.9) versus 4.4 hours (interquartile range, 11.7), P < 0.001], and the proportion of patients discharged directly from the postoperative anesthesia care unit increased (22.8% versus 43.6%; P < 0.001). There were no differences in balancing measures, including the return to the emergency department and readmission. Fewer children were discharged home on oral antibiotics after implementation (6.8% versus 1.5%, P = 0.002), and opioid prescribing at discharge remained low (2.5% versus 1.1%, P = 0.385). Using quality improvement methodology and care standardization, we significantly improved the rate of same-day discharge after appendectomy for simple appendicitis without impacting emergency department visits or readmissions. As a result, our health care system saved 140 hospital days over the first 21 months.

906. Impact of Accelerate Rapid Diagnostic Technology on Time to Optimal Antimicrobial Therapy in Gram Negative Bloodstream Infection

Abstract Background Previous studies at our institution evaluating rapid diagnostic testing (RDT) for blood culture identification (BCID) did not show significant differences in time to optimal antimicrobial therapy for Gram negative bloodstream infections (GNBSI). Recent studies of Accelerate Pheno® system (Accelerate-PS) for blood culture identification and susceptibility have shown significant reduction in time to optimal antimicrobial therapy. This study evaluated the impact of Accelerate-PS compared to BCID RDT on time to optimal antimicrobial therapy for GNBSI. Methods A single center, retrospective, cohort study included adult patients with GNBSI from February 2017 to January 2018 (pre-implementation) and February 2020 to January 2021 (post-implementation). The primary outcome was time to optimal antimicrobial therapy for GNBSI, defined as time from positive blood cultures to time patient received optimal antimicrobial therapy. Secondary outcomes include duration of therapy, rate of antimicrobial-related adverse effects, hospital length of stay, in-hospital mortality, and infection-related readmission. Results The final cohort included 190 patients in pre-implementation group and 179 patients in post-implementation group. Escherichia coli and Klebsiella species were the most common pathogens and urinary tract was the most common source of bacteremia in both groups. More patients in the pre-implementation group had congestive heart failure while more patients in the post-implementation group had peripheral vascular disease. Patients in the post-implementation group had higher Pitt bacteremia scores (1.05 vs. 1.37, P=0.017). Patients in the post-implementation group had significantly shorter time to optimal therapy (mean 60.62 hours vs. 20.17 hours, P&amp;lt; 0.001) and shorter duration of therapy (mean 366.56 vs 310.24 hours, P &amp;lt; 0.001) than in the pre-implementation group. There were no differences in mortality or readmission at 30-days. Conclusion The results of this study indicate that incorporation of Accelerate-PS into microbiology lab workflow significantly reduces time to optimal antimicrobial therapy for GNBSI. Rapid diagnostic testing is a vital component of a robust antimicrobial stewardship program. Disclosures John Schrank, MD, Gilead: Speaker's Bureau.

815: TIME TO HEMODYNAMIC STABILITY AFTER IMPLEMENTATION OF A NOREPINEPHRINE RAPID TITRATION PROTOCOL

Introduction: Norepinephrine (NE) is the primary vasoactive medication for many different shock states and is titrated to have a hemodynamic effect. A rapid titration protocol was recently implemented at our institution to provide nurses the ability to quickly titrate NE and comply with Joint Commission regulations. The purpose of this study is to evaluate whether implementing a rapid titration protocol for NE impacted time to hemodynamic stability in critically ill patients. Methods: A single-center, retrospective study of adult ICU patients receiving NE as a first line agent at a large academic medical center was performed. The patients were categorized into the pre-implementation group with standard titration instructions from April 2022 and the post implementation group with the rapid titration instructions from July 2022. Our primary outcome was to evaluate the time to hemodynamic stability based on mean arterial pressure (MAP) goals. Secondary outcomes included ICU and hospital length of stay (LOS), all-cause mortality and safety outcomes with NE administration. Results: A total of 64 patients were included in our analysis, of which, 30 patients were included in the pre-implementation group and 34 in the post-implementation group. Baseline characteristics were similar in both the groups, including NE starting rate (0.07 mcg/kg/min vs 0.08 mcg/kg/min, p=0.9), and Modified Early Warning Score (5 vs. 4, p=0.07). The primary outcome of time to hemodynamic stability based on MAP did not differ between the groups (median 12.5 minutes [IQR 0-28] vs. 11.5 minutes [IQR 0-36], p=0.7). However, the rapid titration group received significantly less concomitant IV vasopressors in the first 24 hours (50% vs. 18%, p=0.006) and experienced longer time to second vasopressor initiation (median 2.5 hours [IQR 0.10-3.6] vs. 10 hours [IQR 2.5-20]). Conclusions: At our institution, rapid titration instructions for NE did not shorten time to hemodynamic stability compared to the standard titration protocol. Our study shows that utilizing the NE rapid titration protocol may be safe and may reduce the need for an additional vasopressor. Further prospective studies are warranted to assess compliance with implementing a rapid titration protocol and its potential benefits.

191: IMPACT OF AN ANTI-IMPULSE PHARMACOTHERAPY ORDER SET IN AORTIC SYNDROMES: INTERIM DATA

Introduction: Anti-impulse therapy is used to describe the strategy to rapidly manage heart rate and blood pressure control in patients presenting with acute aortic syndromes (AAS). Patients presenting with AAS that have delayed transition from intravenous (IV) to oral anti-impulse therapy may encounter increased medication costs and length of stay (LOS). The objective of this study is to determine how an anti-impulse pharmacotherapy order set impacts the transition from IV to oral therapy in medically managed AAS patients and the subsequent impact on length of stay (LOS). Methods: A single-center, retrospective chart review of adult patients admitted to the cardiovascular intensive care unit (CVICU) for medical management of AAS was conducted from December 2020 to May 2022. Prior to this study, an anti-impulse order set was implemented through the electronic health record on March 18, 2022. Data on duration of continuous IV anti-impulse medications were collected to compare patients treated pre- and post-order set implementation. Patient demographics, ICU LOS, hospital LOS, cost of anti-impulse therapy, and time to initiate enteral medications for heart rate and blood pressure control were also obtained. Results: There were 27 patients in the pre-implementation group and seven patients assessed to date in the post-implementation group. The cohort of patients included in this study had a median age of 68 (IQR 55-81), were primarily male (66.7%), and the majority were white (84.8%). Type B aortic dissections was the most common type of medically managed AAS (57.6%). Implementation of an order set resulted in a reduction of continuous IV beta-blocker median duration of therapy by 18.2 hours (49.9 hours pre-implementation vs 31.7 hours post-implementation). Median duration of IV vasodilator therapy was also reduced by 23.7 hours (48.3 hours pre-implementation vs. 24.6 hours post implementation). There was no difference in median ICU LOS, however, hospital LOS was decreased by 35 hours after order set implementation. Conclusions: Interim analysis of use of an anti-impulse order set appears to be associated with a decreased duration of continuous infusion IV beta-blockers and vasodilators resulting in quicker oral therapy stabilization and subsequent decreased hospital length of stay.

1840. Implementation of a daptomycin dosing nomogram and assessment of clinical outcomes across a large health system

Abstract Background Daptomycin (DAP) is frequently used for a gram-positive infections with conflicting guidance on optimal dosing, especially dosing weight in obese patients. With newer commercially available vial sizes and limited supporting evidence pointing to an optimal dosing strategy and dosing weight (e.g., actual, ideal, adjusted), we seek to explore the impact of a standardized DAP nomogram (Figure 1) on both clinical and safety outcomes across a large health system. Figure 1.Standardized Daptomycin Dosing Nomogram Methods This retrospective cohort study evaluated patients receiving DAP across 7 campuses within AdventHealth between Sep 1, 2020 to Dec 31, 2020 (pre-implementation with standard mg/kg dosing) and Dec 1, 2021 to Jan 31, 2022 (post-implementation with nomogram dosing). Inclusion criteria: age ≥18, invasive infection (e.g., bone/joint, bacteremia, complicated cellulitis, endocarditis), hospital admission, and duration of DAP ≥72hr. Exclusion: DAP in ambulatory setting, duration of DAP &amp;lt; 72hr, and non-invasive infection, defined as uncomplicated cellulitis not requiring surgical intervention. Primary outcome was clinical success, defined as improvement in signs/symptoms at end of therapy or discharge and absence of repeat positive cultures. Secondary outcomes included mean length of therapy (LOT), adherence to nomogram-guided DAP dosing, and occurrence of adverse events. Results 100 patients were included in each group. Average age was 58 years and most were male (54%). Most common indication for DAP was bacteremia (46%) and S. aureus was isolated in 28% of all cultures. Thirty-four percent of patients in each group were on concomitant statin therapy and average BMI was similar between groups (31.4 kg/m2 vs. 31.9 kg.m2). Clinical success (Figure 2) occurred in 74% of patients in the post-implementation group compared to 70% in the pre-implementation group (p=0.529). Average LOT was similar (10.9 days vs. 9.15 days, p=0.191). Pharmacist adherence to the nomogram was high at 91%. Rates of adverse events were similar between groups, with CPK elevations &amp;gt; 200 units/L occurring in 12% of patients in the pre-implementation group compared to 14% of patients in the post-implementation group (p=0.674). Conclusion A standardized DAP nomogram led to a safe and effective process for treating invasive gram-positive infections. Disclosures All Authors: No reported disclosures.

555: IMPACT OF A PROTOCOL FOR CONTINUOUS-INFUSION ANESTHETIC AGENTS IN REFRACTORY STATUS EPILEPTICUS

Introduction: When status epilepticus (SE) persists despite emergent and urgent treatment with antiepileptic drugs (AED), it is referred to as refractory SE (RSE). Guidelines recommend quickly escalating therapy by either repeating initial agents, choosing an alternative AED, or even initiating continuous intravenous (CIV) anesthetic agents. Adherence to a standardized treatment protocol for general treatment of SE has been associated with better seizure control and shorter intensive care unit and hospital length of stay, but no literature exists evaluating protocols aimed at treating patients for RSE with CIV anesthetic agents. Due to the lack of literature in this area, we aimed to determine the benefits of implementing a standard protocol for use of CIV anesthetic agents in the treatment of RSE. Methods: A retrospective analysis of adult patients admitted to the Methodist University Hospital (MUH) with a diagnosis of RSE was conducted from January 1, 2011 – July 31, 2021. In 2018, MUH began using a standard protocol for treatment for RSE. Therefore, patients were grouped based on whether they received treatment prior to or after implementation of the protocol. Discharge disposition, duration of hospitalization, time to seizure termination, and rates of adverse effects were evaluated. Results: A total of 64 patients were included, with 16 (20%) pre-implementation and 48 (80%) post-implementation. Patients included were predominantly female (61%), had a history of seizures (62.5%), and a mean age of 59 years. For the primary outcome, the percent of patients with in-hospital death or discharge to hospice was numerically lower in the post-implementation group (25% vs 16.7%, p=0.48). Patients who received treatment through the protocol also had a numerically shorter time to seizure termination (21 vs 26.7 hours, p=0.19). Duration of hospitalization (13.8 vs 14.4 hours, p=0.93) was similar between groups. Conclusions: Although there was no statistical difference in the primary outcome between groups, there was a nearly 10% improvement in survival, as well as reduced time to seizure termination, through implementation of an RSE protocol. Further research is needed to determine the overall impact of similar protocols amongst a larger cohort of patients.

1010: IMPACT OF USP-800 ON ADMINISTRATION TIMES OF HAZARDOUS INTRAVENOUS ANTIEPILEPTIC MEDICATIONS

Introduction: USP general chapter < 800> establishes comprehensive guidelines for safe handling of hazardous drugs, including some antiepileptics, by healthcare personnel. This guidance increases the number of steps required to safely compound and deliver medications, potentially resulting in a delay of care for time-sensitive medications. The aim of this study is to assess the impact that implementation of USP < 800> had on the timeliness of administration of antiepileptic medications at an academic medical center. Methods: A single center, retrospective study of time from verification to administration pre- and post-USP < 800> implementation of adult one-time orders of intravenous (IV) fosphenytoin (FOS), phenytoin (PHT), and valproic acid (VPA) was conducted. The study period includes 10 months immediately prior to adoption of USP < 800> and five months post adoption. One-time orders were included if scheduled administration time was within 90 minutes of verification. The primary outcome was time in minutes from order verification to medication administration. Subgroup analyses compared the results based on method of medication delivery (pneumatic tube system (PTS) vs hand delivery) and if orders were designated as “STAT”. Results: A total of 248 orders met inclusion criteria: 33 FOS, 12 PHT, and 203 VPA, (pre: 176, post: 72). Time from verification to administration was 15 minutes longer in the post-implementation group for aggregate antiepileptic orders (54 [35-72] vs 69 [48-90], p=0.0013). This increase in time to administration post-implementation was comparable across each of the medications assessed. Subgroup analysis of orders marked as “STAT” showed a similar increase in median time to administration (43 [28-65] vs 56 [34-86], p=0.0406). There was no difference in time to administration comparing PTS to hand delivery (71 [46-109] vs 68 [51-88], p=0.6603). Conclusions: Implementation of USP < 800> increased the median time from order verification to administration for three hazardous IV antiepileptic medications. In patients with status epilepticus, a 15 minute delay could prolong time to seizure termination resulting in worse clinical outcomes. Institutions will need to develop alternative methods for compounding and delivery to ensure timely administration while maintaining safety.

Assessing the impact of telehealth implementation on postpartum outcomes for Black birthing people

The COVID-19 pandemic led to the rapid uptake of telemedicine services, which have been shown to be potentially cost-saving and of comparable quality to in-person care for certain populations. However, there are some concerns regarding the feasibility of implementation for marginalized populations, and the impact of widespread implementation of these services on health disparities has not been well studied. This study aimed to assess the impact of telehealth implementation on postpartum care during the COVID-19 pandemic on racial disparities in visit attendance and completion of postpartum care goals. In this retrospective cohort study at a single tertiary care center, differences in outcomes between all Black and non-Black patients who had scheduled postpartum visits before and after telehealth implementation for postpartum care were compared. The primary outcome was postpartum visit attendance. The secondary outcomes included postpartum depression screening, contraception selection, breastfeeding status, completion of postpartum 2-hour glucose tolerance test, and cardiology follow-up for hypertensive disorders of pregnancy. In multivariable analysis, interaction terms were used to evaluate the differential impact of telehealth implementation by race. Of 1579 patients meeting the inclusion criteria (780 in the preimplementation group and 799 in the postimplementation group), 995 (63%) self-identified as Black. In the preimplementation period, Black patients were less likely to attend a postpartum visit than non-Black patients (63.9% in Black patients vs 88.7% in non-Black patients; adjusted odds ratio, 0.48; 95% confidence interval, 0.29-0.79). In the postimplementation period, there was no difference in postpartum visit attendance by race (79.1% in Black patients vs 88.6% in non-Black patients; adjusted odds ratio, 0.74; 95% confidence interval, 0.45-1.21). In addition, significant differences across races in postpartum depression screening during the preimplementation period became nonsignificant in the postimplementation period. Telehealth implementation for postpartum care significantly reduced racial disparities in postpartum visit attendance (interaction P=.005). Telehealth implementation for postpartum care during the COVID-19 pandemic was associated with decreased racial disparities in postpartum visit attendance.

FATE: The Effect of Fetal Antenatal Testing Education on Patient Knowledge and Satisfaction.

This study aimed to evaluate the effect of a physician-created educational infographic on the knowledge and attitudes of patients undergoing antenatal fetal surveillance. This single-center prospective cohort study evaluated the impact of implementing an electronic educational infographic about antenatal fetal surveillance. English-speaking women receiving antenatal surveillance between the ages of 18 to 50 years were approached for inclusion. The preimplementation group enrolled women receiving antenatal surveillance between March 8, 2021, and April 2, 2021, who received usual care. Postimplementation, from April 5 to May 6, 2021, patients at our site received the infographic about antenatal fetal surveillance at their first antenatal testing appointment. Both pre- and postimplementation groups received a 5-question multiple-choice knowledge and 12-question attitude survey between 320/7 to 336/7 weeks at baseline (prior to receipt of infographic in postimplementation group) and again between 350/7 to 366/7 weeks. Patients were included in the analysis only if they completed both surveys. Differences from initial to final survey were compared between groups. Of 106 patients who completed the initial survey, 74 (69.8%) participants finished both surveys (preimplementation = 39 and postimplementation = 35). There were no significant differences in demographics between the two groups, including in baseline knowledge (p = 0.58) or attitude tests (p = 0.57). There was no significant difference in knowledge on final surveys between groups (p = 0.79). However, utilization of the infographic was associated with a significant increase in attitude survey score from initial to final survey in the postimplementation group as compared with usual care (median difference: pre = 0, interquartile rang [IQR]: [-1 to +4] vs. post = +3, IQR: [+1 to +6], p = 0.016). A physician-created infographic on antepartum fetal testing was associated with overall improved patient attitude toward fetal testing, showing that small education interventions can increase patient satisfaction with care. · A physician-created, readable, and patient-oriented education resource is feasible.. · Infographic patient-education materials do not change patient knowledge about antenatal testing.. · Infographic patient-education materials can improve patient attitude toward antenatal testing..

Reducing postoperative fasting times by implementing a food service in the Post Anaesthesia Care Unit (PACU).

Early oral postoperative nutrition is a proven beneficial element of postoperative care, resulting in improvement in quality of life and a shorter hospital stay. Guidelines state that postoperative oral nutrition can safely be started within the first hours after surgery. However, oral nutrition is mainly investigated starting from postoperative day one (POD1). This pragmatic study assessed whether a food service in the Post Anaesthesia Care Unit (PACU) may reduce postoperative fasting times on postoperative day zero (POD0) early after surgery on this high care unit. The primary outcome was postoperative fasting time in the PACU. Secondary outcomes were postoperative patient experiences and nutritional tolerance. This pragmatic prospective before-after study, included adult patients with a planned overnight stay in the PACU, and without anticipated postoperative dietary restrictions. A food service was developed, allowing re-uptake of oral nutrition early after surgery, already at POD0. Postoperative fasting time in the PACU was defined as the duration of time between the moment of arrival at the PACU, until first postoperative intake or until 9 a.m. on POD1, when most patients were discharged to the surgical ward. Secondary outcomes such as postoperative patient experiences and nutritional tolerance were scored on POD0 at 8 p.m. and on POD1 at 8 a.m. A total of 235 patients were included, 119 in the pre-implementation (control) and 116 in the post-implementation (intervention) group. Mean postoperative fasting time was reduced by a mean of 6.0h (95% CI 4.8-7.4, p-value ≤ .001), from 17.5h in controls to 11.5h in the intervention group. In the intervention group, 45% of patients had nutritional intake on POD0 (8 p.m.), increasing to 80% of patients on POD1 (8 a.m.), compared to no intake at both time-points in the control group. In the intervention group, average patient satisfaction increased over time. Flatus frequency was higher in the intervention group on POD1 (45% vs. 22%, p-value ≤ .001), while postoperative nausea and/or vomiting, and usage of anti-emetic medication were not different between groups. In a heterogeneous group of adult post-surgical patients with a planned overnight stay in the PACU, implementation of a food service resulted in a significant and clinically relevant reduction of postoperative fasting time, and increased patient satisfaction without compromising nutritional tolerance. Registered at www.isrctn.org with study ID ISRCTN17976930.

The impact of an autonomous nurse-led high-flow nasal cannula oxygen protocol on clinical outcomes of infants with bronchiolitis.

To investigate the relationship of the implementation of a nurse-led high-flow nasal cannula oxygen protocol on the clinical outcomes of infants with bronchiolitis in a regional paediatric unit. Bronchiolitis is a common lower respiratory illness and is the leading cause for hospitalisation of infants globally. Standard care involves the provision of supportive measures. Historically, supplemental oxygen was provided by low-flow nasal cannula. High-flow nasal cannula oxygen has been increasingly adopted despite limited evidence of its efficacy. This study employed non-equivalent, post-implementation only design to explore clinical outcomes of infants with bronchiolitis admitted for high-flow nasal cannula oxygen therapy. The study compared infants in the 24 months before and after the initiation of a high-flow nasal cannula protocol. The primary clinical outcome was length of stay, secondary outcomes included time on high flow, weaning time, escalation of care and time outside of physiological parameters. Implementation strategy evaluation was measured by compliance with applying the protocol, reported as episodes of variance, and duration of variance. The StaRI checklist was selected as the most appropriate reporting guideline. A total of 80 patients were admitted with bronchiolitis and received high-flow nasal cannula oxygen therapy during a 48-month period; 37 patients were prior, and 43 after, the introduction of a nurse-led high-flow nasal cannula protocol. Length of stay was significantly reduced in the post-implementation group compared to the historical control group (83.8 vs. 61.3 h). Time on high flow and weaning time was decreased in the post-implementation group compared to the control group (33.5 vs. 26.7 h and 26 vs.12.25 h, respectively); however, these did not reach statistical significance. There was varied application of the HFNC protocol. The implementation of a nurse-led high-flow nasal cannula protocol was associated with a reduced length of stay. This study demonstrated that infants with bronchiolitis that were treated with a nurse-led high-flow nasal cannula (HFNC) therapy protocol had positive effects on clinical outcomes including a shorter length of stay than compared with those with physician-directed care in a regional paediatric unit. A weight-based (2L/kg) HFNC therapy was safely administered to infants with bronchiolitis in a regional hospital paediatric ward with no paediatric intensive care unit (PICU).

Use of Scheduled Nonopioid Analgesia to Decrease Inpatient Opioid Consumption After Scheduled Cesarean Birth

ObjectiveTo compare opioid use and pain scores in women who had scheduled cesarean birth before and after implementing a scheduled nonopioid analgesia practice guideline. DesignQuality improvement project with a comparison of pre-/postintervention. Setting/Local ProblemA 170-bed community hospital where the administration of postcesarean pain medications was unstandardized. ParticipantsConvenience sample of 175 individuals who were scheduled for cesarean birth (106 in preintervention group and 69 in postimplementation group). Intervention/MeasurementsAll participants had received a dose of 150 mcg of intrathecal morphine intraoperatively. Care of participants in the postimplementation group included a new practice guideline using preoperative oral acetaminophen 1 g and postoperative intravenous ketorolac 30 mg that transitioned to ibuprofen 600 mg orally every 6 hours until discharge. Acetaminophen 1 g every 6 hours also continued until discharge. For breakthrough pain, oxycodone 5 mg to 10 mg was available. ResultsResults were analyzed using the chi-square and t test. There was a statistical difference in the mean milligram morphine equivalent consumed after scheduled cesarean birth (preintervention = 21.15 vs. postintervention = 3.91, p < .001). Postimplementation, 84.1% of participants did not consume any opioids beyond the intrathecal dose compared to 47.2% of participants preintervention. Mean pain scores decreased from 2.49 to 1.62 (p < .001), and there was an observed decrease of the highest reported pain score from 5.39 to 4.03 (p < .001). ConclusionThe results of this project support the current literature indicating that the administration of a scheduled nonopioid multimodal analgesia regimen to individuals with scheduled cesarean birth is an effective postoperative pain management strategy. This approach to managing surgical birth pain can decrease subjective reports of pain and overall opioid consumption during the hospital stay.

Pharmacy program to improve care for veterans with transient ischaemic attack: a pilot implementation evaluation

BackgroundEarly evaluation and effective communication to manage transient ischaemic attacks (TIA) may lead to a reduction of up to 70% in recurrent events for patients with TIA/minor stroke, along with...

Comparing Opioid Usage in Non-Intensive Care Unit Trauma Patients After Implementing Multimodal Analgesia Order Sets

Opioid addiction frequently occurs after exposure to prescribed pain medications. Trauma patients are likely to receive opioids due to injuries and surgeries resulting in high levels of pain. Multimodal analgesia has been shown to decrease opioid consumption postoperatively. A multimodal analgesia order set was implemented with the goal of increasing prescription of multimodal analgesia contributing to decreased overall opioid use. We hypothesized that the multimodal order set would be associated with significantly less opioid utilization without affecting pain scores. This single-center retrospective cohort analysis included non-intensive care unit trauma patients. Patients were propensity-matched by the year of treatment. Oral morphine equivalents and pain scores were compared before and after implementation of the order set. The primary objective was to evaluate differences in oral morphine equivalents 24h prior to discharge before and after implementation of the multimodal analgesia order sets. One hundred and fourteen patients in the preimplementation group and 121 patients in the postimplementation group met inclusion criteria. Oral morphine equivalents did not differ significantly between the cohorts, 21.3 [0-53.5] OME in 2018 versus 18.8 [0-56.3] in 2020 (P=0.85). Pain scores 24h prior to discharge, 6 [4-8] versus 5.7 [3.5-7] (P=0.4), did not differ significantly between groups despite more operations in the 2020 cohort. Implementation of a multimodal order set was not associated with significant reduction in the amount of opioids used in non-intensive care unit trauma patients. However, pain scores were unchanged despite an increased number of procedures performed suggesting that multimodal analgesia sets may be a useful tool to aid in decreasing opioid utilization after traumatic injuries.

200. Preventing surgical site hematoma with intravenous and topical tranexamic acid in lumbosacral surgery in a community teaching hospital: a resident-driven quality improvement project

<h3>BACKGROUND CONTEXT</h3> Postoperative hematoma following lumbosacral surgery carries significant morbidity. Tranexamic acid (TXA) has been shown to mitigate perioperative blood loss in lumbosacral fusion. <h3>PURPOSE</h3> We sought to report a quality improvement (QI) protocol using intravenous (iv) and/or tTXA to reduce postoperative surgical site hematoma (SSH) in patients undergoing elective lumbosacral surgery. <h3>STUDY DESIGN/SETTING</h3> Longitudinal comparative cohort. <h3>PATIENT SAMPLE</h3> Consecutive adults who underwent elective lumbosacral laminectomy and/or fusion in a single institution. <h3>OUTCOME MEASURES</h3> SSH hematoma necessitating evacuation of hematoma or readmission to the hospital due to hematoma. <h3>METHODS</h3> The FADE model was used. A feasibility study was performed in 2019 using IV or tTXA. Retrospective chart review demonstrated preimplementation baseline (7/1/18-6/30/19) SSH rate. Multiple interdisciplinary meetings were conducted to ensure standardized coagulopathy screening, TXA administration, drug supply, and compliance monitoring. Topical TXA was given in 2 g/250 NS via 60mL bulb syringe while ivTXA was given as 1 g bolus over 10 minutes. The QI project was integrated with the residents' patient safety activity. The QI start date was February 2020 with the interim analysis set for June 2020. The primary outcome was postoperative hematoma necessitating evacuation or hospital readmission. The secondary outcome was hospital length of stay. The post-implementation data were collected prospectively. A final analysis was performed for July 2020 - October 2020. Univariate analysis was used to compare outcome measures between pre- and postimplementation populations. A p-value < .05 was considered significant. A sample size calculation determined that there should be 198 patients in each group for a total of 396 patients. <h3>RESULTS</h3> During interim analyses, we found inadequate compliance with tTXA usage (68.5%). Stakeholders were reeducated regarding usage of tTXA and the implementation date was redefined as 7/1/2020. Comparing consecutive lumbosacral surgical patients in pre- (219 patients) and postimplementation (258 patients), the postimplementation group demonstrated significantly reduced incidence of SSH requiring evacuation (.38% vs 3.3%, p<.001) TXA compliance significantly improved after QI implementation (86.8% vs 9.6%, p=.001). The postimplementation tTXA group demonstrated that our standardized protocol resulted in a significantly lower incidence of SSH (.45% vs 4.8%, p=.004). <h3>CONCLUSIONS</h3> Our QI project demonstrated that the use of IV and tTXA was associated with a significantly lower rate of SSH requiring evacuation. We also demonstrated that the use of standardized administration of tTXA was associated with similar benefits when compared with nonstandardized tTXA administration. <h3>FDA DEVICE/DRUG STATUS</h3> tranexamic acid (Investigational/Not Approved)

Reducing the incidence of stroke-associated pneumonia: an evidence-based practice

BackgroundPulmonary infection is a frequent complication among stroke patients and adversely affects clinical outcomes, increases the length of hospitalization stay and costs, and aggravates the financial burden of the national medical health system. Early identification and management of high-risk patients are necessary and imperative to reduce the incidence of stroke-associated pneumonia (SAP).AimThe evidence-based practice project evaluated the effectiveness of a standard care bundle intervention in preventing the occurrence of SAP.MethodsThe project was conducted in a neurology department of a teaching hospital. Given the variation in assessment and management standards, evidence-based practice (EBP) methodology was used to establish a process for quality improvement. A thorough literature search was conducted to identify evidence-based interventions to manage and prevent SAP. Thorough critiques of the literature and synthesis of the evidence were completed. A systematic management flow and care bundle interventions were established. The care bundle included interventions, such as the utilization of tools for SAP risk screening; dysphagia screening and rehabilitation; feeding modification, oral care, airway management, position management, and the nursing techniques of traditional Chinese medicine.ResultsA significant improvement was observed in preventing SAP in patients in the postimplementation group compared with those in the preimplementation group (14.0% vs. 37.2%, p = 0.025). In addition, significantly lower duration of hospitalization, lower rate of aspiration, and improvements in albumin and oral hygiene were found after the implementation of the care bundle.ConclusionsEvidence-based care bundles successfully empower nurses to reduce the incidence of SAP. The management flow of SAP prevention could be promoted to other units of the neurology department in the future. The results of the project reflect positively on the capacity to implement EBP in an acute care setting for stroke. The EBP methodology can be utilized to solve other clinical problems.