Practice Advisory Research Articles

Influenza Vaccination in Perioperative Settings: A Teachable Moment.

Influenza Vaccination in Perioperative Settings: A Teachable Moment.

Interacting with Best Practice Advisory Notifications in Epic Significantly Improves Screening Rates for Abdominal Aortic Aneurysms

Interacting with Best Practice Advisory Notifications in Epic Significantly Improves Screening Rates for Abdominal Aortic Aneurysms

Single-center comparison of cancer genetics referral rates for patients with pancreatic cancer following implementation of a best practice advisory: A quality improvement project.

311 Background: Despite guidelines recommending germline genetic testing (GT) and genetic counseling for individuals with pancreatic ductal adenocarcinoma (PDAC), referrals remain suboptimal. This can have negative implications on treatment, particularly for patients with actionable mutations. This project aims to compare the referral rate to genetic services of MD Anderson Cancer Center at Cooper pre- and post-implementation of an electronic health record (EHR) physician best practice advisory (BPA) recommending a cancer genetics referral order for PDAC patients. Methods: Medical records, cancer genetics referrals (CGR), and germline and somatic testing results were retrospectively reviewed for patients with a PDAC diagnosis in 2019-2020, and prospectively for those diagnosed after BPA implementation from October 2021 through May 2022. The primary outcome was the rate of CGR, and the secondary outcomes were genetic counseling encounters and GT completion. Descriptive statistics were used for analysis. Results: Prior to BPA initiation, CGR were offered to 44 (24.3%) of 181 eligible patients with 39 (88.6%) of those accepting CGR. Germline testing represented 90.9% (30 patients) of the GT performed in the pre-BPA group. Post-BPA, CGR were offered to 23 (51.1%) of 45 eligible patients with 20 (86.95%) of those accepting CGR. Germline testing represented 100% (13 patients) of the GT performed in the post-BPA group. Conclusions: Only 24.3% of patients diagnosed with PDAC between 2019-2020 were referred to cancer genetics, showing that even after updated NCCN guidelines in 2018 the CGR rate remained low. Following BPA implementation, CGR increased to 51.1% over 8 months for newly diagnosed patients. Germline testing increased by 10%. These preliminary results show that implementing a physician BPA can increase CGR and germline GT, which could have positive implications on treatment. Limitations include a lack of a standardized referral process for the pre-BPA group and a limited timeframe to obtain GT for the post-BPA group.[Table: see text]

Interacting With Best Practice Advisory (BPA) Notifications In Epic Significantly Improves Screening Rates For Abdominal Aortic Aneurysms

Best practice advisory notifications (BPAs) have become an integral part of many electronic medical records (EMR) systems. These communications alert providers to recommended therapy or screenings for patients depending on factors identified within the EMR. Our goal was to evaluate the impact of BPAs on the rate of abdominal aortic aneurysm (AAA) screening in patients who met guidelines for screening in a single-center EMR.

SIOG2022-0156 - Adoption Failure or Adoption Opportunity: What happened with G8 Assessment Tool utilization with reflexive best practice advisory (BPA) in a Hispanic-rich U.S. population

SIOG2022-0156 - Adoption Failure or Adoption Opportunity: What happened with G8 Assessment Tool utilization with reflexive best practice advisory (BPA) in a Hispanic-rich U.S. population

35 Increasing Naloxone Prescriptions Through Electronic Medical Record Best Practice Advisory Alerts

Study Objectives: Overdoses are now the leading cause of injury-related death in the United States with recent increases influenced by multiple factors including the COVID-19 pandemic. Among the most recent overdose deaths, about 75% involved a prescription or illicit opioid. Naloxone can rapidly reverse fatal overdose and evidence shows reduced mortality when naloxone is available in the community. Although emergency physicians are generally willing to prescribe naloxone to patients at risk of opioid overdoses, prescriptions remain uncommon.

Reducing Catheter-Associated Urinary Tract Infections Across a Hospital System Through Urine Culture Stewardship

ObjectiveTo evaluate the effectiveness and safety of an evidence-based urine culture stewardship program in reducing hospital catheter-associated urinary tract infections (CAUTIs) and the rate of CAUTIs across a 3-hospital system. Patients and MethodsThis is a prospective, 2-year quality improvement program conducted from October 1, 2018, to September 30, 2020. An evidence-based urine culture stewardship program was designed, which consisted of the following: criteria for allowing or restricting urine cultures from catheterized patients, a best practice advisory integrated into the ordering system of an electronic medical record, and a systematic provider education and feedback program to ensure compliance. The system-wide rates of CAUTIs (total CAUTIs/catheter days×1000), changes in intercepts, trends, mortality, length of stay, rates of device utilization, and rates of hospital-onset sepsis were compared for 3 years before and 2 years after the launch of the program. ResultsCatheter-associated urinary tract infections progressively decreased after the initiation of the program (B=−0.21, P=.001). When the trends before and after the initiation of the program were compared, there were no statistically significant increases in the ratio of actual to predicted hospital length of stay, intensive care unit length of stay, system-wide mortality, and intensive care unit mortality. Although the rates of hospital-acquired sepsis remained consistent after the implementation of the stewardship program through the first quarter of 2020, the rates showed an increase in the second and third quarters of 2020. However, hospital-onset sepsis events associated with the diagnosis of a urinary tract infection did not increase after the intervention. ConclusionUrine culture stewardship is a safe and effective way to reduce CAUTIs among patients in a large multihospital health care system. Patient safety indicators appeared unchanged after the implementation of the program, and ongoing follow-up will improve confidence in the long-term sustainability of this strategy.

Free the T3: Implementation of Best Practice Advisory to Reduce Unnecessary Orders

Thyroid function tests (TFTs) are commonly overused and amount to 1.6 billion dollars annually in health care spending in the United States.1,2 Although national guidelines recommend a thyroid-stimulating hormone (TSH)-centered approach, clinicians often inappropriately order triiodothyronine (T3) and thyroxine (T4).2 This may be due to lack of knowledge or ease of ordering all 3 tests at once in premature anticipation of an abnormal TSH.3 Additionally, clinicians order free T3 rather than total T3, despite the American Thyroid Association's recommendations to avoid free T3 due to its high rate of variability.

Evaluation of a Best Practice Advisory on Ordering Prothrombin Time, International Normalized Ratio, and Partial Thromboplastin Time Tests

Evaluation of a Best Practice Advisory on Ordering Prothrombin Time, International Normalized Ratio, and Partial Thromboplastin Time Tests

Protocolizing perioperative OSA screening and management: moving in the right direction.

Protocolizing perioperative OSA screening and management: moving in the right direction.

Commentary on: Practice Advisory on Gluteal Fat Grafting

See the Original Article here. I commend the authors for creating this practice advisory on gluteal fat grafting.1 As we all know, concerns about the safety of this procedure began in 2017 with the publication of the report by the Aesthetic Surgery Education and Research Foundation (ASERF) Task Force on the mortality associated with gluteal fat grafting.2 The report highlighted the risks of the procedure, classifying it as the riskiest in aesthetic surgery. The report also contained recommendations to make the procedure safer. The most important safety measure was to transfer the fat in the subcutaneous plane. Other factors to be considered were the size of the cannula, avoidance of syringes, etc. In 2019, a follow-up study was performed by ASERF to document whether these recommendations had helped improve the safety of the procedure. The study showed that 94% of those surveyed were aware of the recommendations...

Interacting With Best Practice Advisory Notifications in EPIC Significantly Improves Screening Rates for Abdominal Aortic Aneurysms

Best practice advisory notifications (BPA) have become an integral part of many electronic medical records (EMR) systems. These communications alert providers to recommended therapy or screenings for patients depending on factors identified within the EMR. Our goal was to evaluate the impact of BPA on the rate of abdominal aortic aneurysm (AAA) screening in patients who met guidelines for screening in a single-center EMR.

ASO Visual Abstract: The Use of Pectoralis Blocks in Breast Surgery: A Practice Advisory and Narrative Review From the Society for Ambulatory Anesthesia (SAMBA)

ASO Visual Abstract: The Use of Pectoralis Blocks in Breast Surgery: A Practice Advisory and Narrative Review From the Society for Ambulatory Anesthesia (SAMBA)

Abstract 33: Interventional Cardiologist Beliefs And Practices Before And After Implementation Of An Electronic Health Records-based Safe Contrast Limit Tool For Percutaneous Coronary Interventions

Background: Best Practice Advisories (BPAs) within electronic health record (EHR) systems can inform clinician decision-making and improve patient care. Their success depends on BPA content, clinical context, and staff buy-in. We recently implemented a safe contrast limit tool to reduce contrast-associated AKI (CA-AKI) after percutaneous coronary intervention (PCI). We evaluated the impact of this Contrast Limit BPA on interventional cardiologist attitudes and practices, and examined possible factors that influenced the BPA’s success. Methods: Using a published model, we implemented a BPA in our Epic EHR that displayed calculated individualized safe contrast limits prior to PCI. Cardiologists were surveyed prior to and 9 months after BPA implementation. Pre-implementation questions covered beliefs about CA-AKI, practice patterns, knowledge of CA-AKI risk factors, and asked for safe contrast estimates for example patients. Post-implementation questions assessed practice patterns and the BPA’s perceived accuracy, efficacy, and utility. Survey data was compared to clinician PCI contrast use using logistic regression. Results: We surveyed 8 clinicians pre-implementation and 10 post-implementation. Pre-implementation, 25% (2/8) reported using a contrast limit to make decisions about PCI and 12.5% (1/8) believed that they could improve their CA-AKI rates. In both their assessment of CA-AKI risk factors and contrast limit estimations, respondents often overestimated the contribution of age and diabetes while underestimating the influence of anemia and cardiogenic shock. Post-implementation, 30% (3/10) stated they were often surprised by the contrast limit and 80% (8/10) reported using the Contrast Limit when making PCI decisions. Clinicians who found the BPA to be clear and understandable or had catheterization lab staff discuss the limit prior to PCI had significantly lower odds of exceeding the safe contrast limit (OR=4.63, 95% CI [1.17, 18.35]; OR=6.76, 95% CI [1.81, 25.27]). Conclusion: Clinicians often misestimated safe contrast limits and believed that there was little room for improvement in their CA-AKI rates. Despite initial skepticism, an EHR-based safe contrast limit BPA was frequently used and influenced contrast use.

Abstract 261: Best Practice Advisories Effects On Telemetry Ordering Habits

Background: Inpatient Telemetry detects dysrhythmias. However, data from telemetry influences management on < 1% of patients, and telemetry is often used in cases with no benefit. We are conducting a multi-center study to evaluate the impact of an EMR-based best practice advisory (BPA) on telemetry ordering practice Methods: To assess the effectiveness of a BPA encouraging cessation of telemetry, we performed an analysis of time on telemetry and the number of BPA alerts before and after October 2019 [Figure 1]. We redesigned the telemetry BPA to restrict firing to the hours of (8 AM to 6 PM) and to restrict notifications to the first call and Attending provider. We used Epic-generated data from 88, 832 unique patient telemetry orders and 121, 621 BPA responses from 3 hospitals. The data was normalized for variation in patients hospitalized over time using admission contact serial numbers (CSN) and inpatient admission orders for non-ICU medicine floors. Results: We analyzed data from 243,280 BPA alerts. Pre-BPA implementation mean alerts were 150.01 std 43.07 and post BPA implementation mean alerts were 76.33 std 33.461 p-value 0.00. Mean time on telemetry pre BPA 4481.262 mins std 6531.82 post BPA 4311.14 mins std 6011.18 mins p value 0.001 Conclusion: Despite practice standards, telemetry use outside of the ICU varies widely amongst providers. Reduction in the number of telemetry minutes can lead to a decrease in clinician telemetry review time and offer improvement in patient satisfaction and comfort by not being connected to the device.

The Use of Pectoralis Blocks in Breast Surgery: A Practice Advisory and Narrative Review from the Society for Ambulatory Anesthesia (SAMBA).

Although pectoralis (PECS) blocks are commonly used for breast surgery, recommendations regarding the efficacy of these blocks have thus far not been developed by any professional anesthesia society. Given the potential impact of PECS blocks on analgesia after outpatient breast surgery, The Society for Ambulatory Anesthesia (SAMBA) convened a task force to develop a practice advisory on the use of this analgesic technique. In this practice advisory, we compare the efficacy of PECS blocks with systemic analgesia, local infiltration anesthesia, and paravertebral blockade. Our objectives were to advise on two clinical questions. (1) Does PECS-1 and/or -2 blockade provide more effective analgesia for breast-conserving surgery than either systemic analgesics or surgeon-provided local infiltration anesthesia? (2) Does PECS-1 and/or -2 blockade provide equivalent analgesia for mastectomy compared with a paravertebral block (PVB)? Among patients undergoing breast-conserving surgery, PECS blocks moderately reduce postoperative opioid use, prolong time to analgesic rescue, and decrease postoperative pain scores when compared with systemic analgesics. SAMBA recommends the use of a PECS-1 or -2 blockade in the absence of systemic analgesia (Strength of Recommendation A). No evidence currently exists that strongly favors the use of PECS blocks over surgeon-performed local infiltration in this surgical population. SAMBA cannot recommend PECS blocks over surgical infiltration (Strength of Recommendation C). For patients undergoing a mastectomy, a PECS block may provide an opioid-sparing effect similar to that achieved with PVB; SAMBA recommends the use of a PECS block if a patient is unable to receive a PVB (Strength of Recommendation A).

ASO Author Reflections: SAMBA's Practice Advisory for the Use of Pectoralis Blocks in Breast Surgery: Overview and Lingering Questions.

ASO Author Reflections: SAMBA's Practice Advisory for the Use of Pectoralis Blocks in Breast Surgery: Overview and Lingering Questions.

Practice Advisory on Gluteal Fat Grafting

On January 31, 2018, The Multi-Society Task Force for Safety in Gluteal Fat Grafting released a Practice Advisory regarding gluteal fat grafting. The Task Force was assembled in the wake of several highly publicized patient deaths involving Brazilian Butt Lift ("BBL") and produced a second practice advisory in August 2019. In 2021 the ASAPS President commissioned a Working Group on BBL Patient Safety, charging the Group to address new guidelines affecting safety and welfare of BBL patients. The "Practice Advisory on Gluteal Fat Grafting" is the first advisory developed since the Working Group was formed. In addition to surgical technique as a major cause of fatal complications of BBL, the Working Group focused on micro-economic trends of operative time and regional BBL pricing and considered fatigue and distraction in formulating the current guidelines. In Florida the majority of BBL deaths occur at the end of the week. Such a non-normalized distribution most likely represents the result of fatigue and/or distraction, which has been linked to surgical mortality in multiple published communications. In addition, mortality is likely due to uncertainty or lack of documentation as to the correct plane of fat injection. Therefore, the newest and most compelling recommendations from these guidelines include the use of ultrasound-guided documentation of cannula placement prior to and during fat injection, and the limitation of 3 BBL cases as a maximum amount of total operative cases per day. The authors thank members of the Task Force for the insights they brought to this process.

Early Palliative Care Consultation Reduces Length Of Stay And Cost In Patients Hospitalized With Acute Decompensated Heart Failure

Early Palliative Care Consultation Reduces Length Of Stay And Cost In Patients Hospitalized With Acute Decompensated Heart Failure

Can Automated Alerts in the Electronic Health Record Encourage Referrals for Genetic Counseling and Testing Among Patients at High Risk for Hereditary Cancer Syndromes?

Up to 10% of cancers may be associated with an inherited mutation that increases cancer risk. National guidelines emphasize referral for genetic counseling and testing for patients whose personal and/or family history increases their risk of having a hereditary cancer syndrome. To increase appropriate referrals for cancer genetic counseling and testing, we piloted an automated alert known as a Best Practice Advisory (BPA) in the electronic health record, Epic, to notify oncology providers when a patient had a personal and/or family history that merited referral to cancer genetics. Epic could not gather the complex clinical data needed for the referral decision automatically, necessitating staff completion of a questionnaire. After educating providers, the BPA was implemented with resources to support its use. Initial interaction with the alert was high but rapidly dwindled, resulting in questionnaire completion in 7.2% of more than 32,000 encounters and 14.9% of patients over 9 months. However, cancer genetics referrals increased 95.9% during the pilot (P < .0001), with 18.5% placed through the BPA and the rest from a non-BPA mechanism. Semistructured interviews with key stakeholders revealed not only general acceptance of the BPA concept but also barriers to completion, such as pressure to room patients quickly in the face of competing BPAs and lack of buy-in from some providers. These results suggest that provider engagement and BPA fatigue are significant obstacles to acceptance of a new automated alert. Despite interest in a tool for cancer genetics, the demand on clinical time for this complex BPA was poorly tolerated.