Pre-implementation Period Research Articles

Pediatric Antiretroviral Therapy Coverage and AIDS Deaths in the "Treat All" Era.

In 2015, CD4-based clinical staging criteria for antiretroviral therapy (ART) initiation were removed, expanding ART eligibility ("Treat All") for children, who shoulder an outsized burden of HIV-related deaths. To quantify the impact of "Treat All" on pediatric HIV outcomes, we examined shifts in pediatric ART coverage and AIDS mortality before and after "Treat All" implementation. We abstracted country-level ART coverage (proportion of children <15 years on ART) and AIDS mortality (deaths per 100 000 population) estimates over 11 years. For 91 countries, we also abstracted the year "Treat All" was incorporated into national guidelines. We used multivariable 2-way fixed effects negative binomial regression to estimate changes in pediatric ART coverage and AIDS mortality potentially attributable to "Treat All" expansion, reported as adjusted incidence rate ratios (adj.IRR) with 95% confidence intervals (95% CI). From 2010 to 2020, pediatric ART coverage tripled (16% to 54%), and AIDS-related deaths were halved (240 000 to 99 000). Compared with the pre-implementation period, observed ART coverage continued increasing after "Treat All" adoption, but this rate of increase declined by 6% (adj.IRR = 0.94, 95% CI: 0.91-0.98). AIDS mortality continued declining after "Treat All" adoption, but this rate of decline decreased by 8% (adj.IRR = 1.08, 95% CI: 1.05-1.11) in the post-implementation period. Although "Treat All" called for increased HIV treatment equity, ART coverage continues lagging in children and comprehensive approaches that address structural issues, including family-based services and intensified case-finding, are needed to close pediatric HIV treatment gaps.

Outcomes of Evidence-Based Stratification of Placenta Accreta Spectrum (PAS) Disorders for Team-Based Management [ID: 1375468

INTRODUCTION: Placenta accreta spectrum (PAS) is characterized by placental invasion and adherence to underlying uterine myometrium resulting in significant maternal morbidity and mortality. Despite knowledge that greater placental depth results in worse outcomes, many centers approach PAS with a single uniform management protocol. We aimed to undercover the effect of surgical planning stratification by antenatal suspicion of placental depth. METHODS: This study was a preimplementation and postimplementation of analysis of PAS surgical stratification by suspected depth of placental invasion, accreta (less invasion) or increta/percreta (greater invasion), from 2019 to 2022. Depth of placenta invasion was determined by ultrasonography and/or magnetic resonance imaging. As a control, 4-year (2015–2018) preimplementation group was used to assess the effect of the protocol. This protocol included utilization of a hybrid operating room, uniform uterine artery embolization, as well as staffing by advanced pelvic surgeons. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. Exclusion criteria included pregnancy less than 20 weeks of gestation, fetal demise, and multifetal gestation. RESULTS: During the 8-year time period, a total of 93 patients were managed by our PAS team. Forty-six patients were in the preimplementation period, of which 17 (37%) were suspected increta/percreta. During the postimplementation period, 24 of 53 (45%) cases were suspected increta/percreta. In cases of placenta accreta, no significant differences were noted in blood loss, blood transfusion rates, or operative time. When analyzing outcomes of the suspected increta/percreta cohort, our protocol was associated with lower blood loss (2,500 versus 1,500 mL, P=.008), lower blood transfusion rates (88% versus 54%, P=.03), and longer operative time (240 versus 384 minutes, P=.009). Final pathology confirmed increta/percreta suspicion in 23 of the 24 cases (96%). CONCLUSION: A protocol for the management of PAS cases by antenatally suspected degree of placenta invasion is not only feasible but results in optimal outcomes for patients with the most complex obstetric conditions.

The impact of the early onset neonatal sepsis calculator on antibiotic initiation: a single center study in Israel.

To evaluate the effect of implementation of the Kaiser Permanente (KP) early onset sepsis (EOS) calculator in infants born at 34week's gestation or more on antibiotic utilization and length of hospitalization.A single center, retrospective cohort study included all neonates born in Soroka Medical Center at 34weeks gestation or more between January 1st, 2015, and January 1st, 2019, with a predefined maternal risk factor for EOS. Two cohorts of neonates were compared during two time periods, before and after the implementation of the KP calculator. Multivariable logistic and linear regressions were performed to assess the effect of the KP calculator on antibiotic treatment and length of hospitalization. Also, an interrupted time series (ITS) analysis was used to assess the time trends of the two periods.The study included 3858 neonates in the pre-implementation period and 3081 neonates in the post-implementation cohort. The use of the calculator resulted in a significant reduction (46%) in antibiotics treatment for suspected EOS (5.1 vs. 9.4%, P < 0.001). The ITS analysis demonstrated a sharp decline in the slope of antibiotic treatment in the post intervention period: (b = -0.14, p-value = 0.08). The length of hospitalization was significantly reduced in the post-implementation cohort from 62 to 60h (p-value < 0.001) with no clinical significance. The incidence of EOS was similar in both groups. Conclusion: A significant reduction in antibiotic treatment was demonstrated after the implementation of the KP calculator without an increase incidence of EOS. The calculator is a powerful accessory decision-making tool that can be used safely in combination with, but not replacing, thorough clinical assessment. What is Known: • The EOS calculator is a useful tool that leads to a significant reduction in preemptive antibiotic utilization. What is New: • The EOS calculator is sensitive when applied to the whole-nursery. • The calculator is useful in different populations, also when women are not routinely screened for GBS.

Tool to Track Post-Discharge Lab Results Leads to Improved Rates of Follow Up (P7-7.001)

<h3>Objective:</h3> To improve physician acknowledgement and clinical response times to send-out lab results <h3>Background:</h3> Medical errors lead to thousands of deaths each year. Missing laboratory tests results can contribute to these errors. Factors that may lead to missing results, including improper ordering, numerous handoffs, and a lack of formal system to follow up post-discharge results. We evaluated the efficacy of a tool built into the electronic medical record for results follow up. <h3>Design/Methods:</h3> The residents installed the “Results FYI” tool in Cerner to receive results for patients on whom they had assigned themselves in the role of “resident.” With this tool, any study that results after the patient is discharged appears in the resident’s inbox for review. Common send-out lab results were queried to assess the timeliness with which results were followed up upon, and we compared results from 6 months before and after the tool was implemented. <h3>Results:</h3> In the pre-implementation period, we found that out of the 341 total results, 46 out of 60 positive results were followed up on (76.7%). In the post-implementation period, we found that out of 313 total results, 47 out of 56 positive results were followed up on (83.93%). Overall the average number of days between a lab resulting and the result being acted on decreased in the post-implementation period from an average of 17.59 days to 8.04 days. <h3>Conclusions:</h3> The “Results FYI” tool built into the EMR facilitates faster and more comprehensive follow up on send-out lab results after patients are discharged from the hospital than manually tracking results. Not only were more results followed up on, but it was done in a more timely manner. Universal implementation of this tool will likely lead to faster follow up for study results, leading to fewer adverse delays in patient care. <b>Disclosure:</b> Dr. Kingsford has nothing to disclose. Dr. Hansra has nothing to disclose. Dr. Wiggins has nothing to disclose. Dr. Bryant has nothing to disclose. Dr. Franzen has nothing to disclose. Jay Patel, MD has nothing to disclose. Dr. Greenwood has nothing to disclose. The institution of Dr. Robers has received research support from National Multiple Sclerosis Society. The institution of Dr. Robers has received research support from Bristol Myers Squibb Foundation. The institution of Dr. Robers has received research support from Barrow Neurological Foundation.

Integrating Intimate Partner Violence Screening Programs in Primary Care: Results from a Hybrid-II Implementation-Effectiveness RCT

The Veterans Health Administration initiated implementation facilitation to integrate intimate partner screening programs in primary care. This study investigates implementation facilitation's impact on implementation and clinical effectiveness outcomes. A cluster randomized, stepped-wedge, hybrid-II implementation-effectiveness trial (January 2021-April 2022) was conducted amidst the COVID-19 pandemic. Implementation facilitation was applied at 9 Veterans Health Administration facilities, staged across 2 waves. Participants were all women receiving care at participating primary care clinics 3 months before (pre-implementation facilitation n=2,272) and 9 months after initiation of implementation facilitation (implementation facilitation n=5,149). Implementation facilitation included an operations-funded external facilitator working for 6 months with a facility-funded internal facilitator from participating clinics. The pre-implementation facilitation period comprised implementation as usual in the Veterans Health Administration. Primary outcomes were changes in (1) reach of intimate partner violence (IPV) screening programs among eligible women (i.e., those seen within participating clinics during the assessment period; implementation outcome) and (2) disclosure rates among screened women (effectiveness outcome). Secondary outcomes included disclosure rates among all eligible women and post-screening psychosocial service use. Administrative data were analyzed. For primary outcomes, women seen during the implementation facilitation period were nearly 3 times more likely to be screened for IPV than women seen during the pre-implementation facilitation period (OR=2.70, 95% CI=2.46, 2.97). Women screened during the implementation facilitation period were not more likely to disclose IPV than those screened during the pre-implementation facilitation period (OR=1.14, 95% CI=0.86, 1.51). For secondary outcomes, owing to increased reach of screening during implementation facilitation, women seen during the implementation facilitation period were more likely to disclose IPV than those seen during the pre-implementation facilitation period (OR=2.09, 95% CI=1.52, 2.86). Women screened during implementation facilitation were more likely to use post-screening psychosocial services than those screened during pre-implementation facilitation (OR=1.29, 95% CI=1.06, 1.57). Findings indicate that implementation facilitation may be a promising strategy for increasing the reach of IPV screening programs in primary care, thereby increasing IPV detection and strengthening connections to support services among the patient population. This study is registered at www. gov NCT04106193.

Disseminating child abuse clinical decision support among commercial electronic health records: Effects on clinical practice.

The use of electronic health record (EHR)-embedded child abuse clinical decision support (CA-CDS) may help decrease morbidity from child maltreatment. We previously reported on the development of CA-CDS in Epic and Allscripts. The objective of this study was to implement CA-CDS into Epic and Allscripts and determine its effects on identification, evaluation, and reporting of suspected child maltreatment. After a preimplementation period, CA-CDS was implemented at University of Wisconsin (Epic) and Northwell Health (Allscripts). Providers were surveyed before the go-live and 4 months later. Outcomes included the proportion of children who triggered the CA-CDS system, had a positive Child Abuse Screen (CAS) and/or were reported to Child Protective Services (CPS). At University of Wisconsin (UW), 3.5% of children in the implementation period triggered the system. The CAS was positive in 1.8% of children. The proportion of children reported to CPS increased from 0.6% to 0.9%. There was rapid uptake of the abuse order set.At Northwell Health (NW), 1.9% of children in the implementation period triggered the system. The CAS was positive in 1% of children. The child abuse order set was rarely used. Preimplementation, providers at both sites were similar in desire to have CA-CDS system and perception of CDS in general. After implementation, UW providers had a positive perception of the CA-CDS system, while NW providers had a negative perception. CA-CDS was able to be implemented in 2 different EHRs with differing effects on clinical care and provider feedback. At UW, the site with higher uptake of the CA-CDS system, the proportion of children who triggered the system and the rate of positive CAS was similar to previous studies and there was an increase in the proportion of cases of suspected abuse identified as measured by reports to CPS. Our data demonstrate how local environment, end-users' opinions, and limitations in the EHR platform can impact the success of implementation. When disseminating CA-CDS into different hospital systems and different EHRs, it is critical to recognize how limitations in the functionality of the EHR can impact the success of implementation. The importance of collecting, interpreting, and responding to provider feedback is of critical importance particularly with CDS related to child maltreatment.

Effects of a Province-wide Triaging System for TIA: The ASPIRE Intervention.

Urgent transient ischemic attack (TIA) management to reduce stroke recurrence is challenging, particularly in rural and remote areas. In Alberta, Canada, despite an organized stroke system, data from 1999 to 2000 suggested that stroke recurrence after TIA was as high as 9.5% at 90 days. Our objective was to determine whether a multifaceted population-based intervention resulted in a reduction in recurrent stroke after TIA. In this quasi-experimental health services research intervention study, we implemented a TIA management algorithm across the entire province, centered around a 24-hour physician's TIA hotline and public and health provider education on TIA. From administrative databases, we linked emergency department discharge abstracts to hospital discharge abstracts to identify incident TIAs and recurrent strokes at 90 days across a single payer system with validation of recurrent stroke events. The primary outcome was recurrent stroke; with a secondary composite outcome of recurrent stroke, acute coronary syndrome, and all-cause death. We used an interrupted time series regression analysis of age-adjusted and sex-adjusted stroke recurrence rates after TIA, incorporating a 2-year preimplementation period (2007-2009), a 15-month implementation period, and a 2-year postimplementation period (2010-2012). Logistic regression was used to examine outcomes that did not fit the time series model. We assessed 6,715 patients preimplementation and 6,956 patients postimplementation. The 90-day stroke recurrence rate in the pre-Alberta Stroke Prevention in TIA and mild Strokes (ASPIRE) period was 4.5% compared with 5.3% during the post-ASPIRE period. There was neither a step change (estimate 0.38; p = 0.65) nor slope change (parameter estimate 0.30; p = 0.12) in recurrent stroke rates associated with the ASPIRE intervention implementation period. Adjusted all-cause mortality (odds ratio 0.71, 95% CI 0.56-0.89) was significantly lower after the ASPIRE intervention. The ASPIRE TIA triaging and management interventions did not further reduce stroke recurrence in the context of an organized stroke system. The apparent lower mortality postintervention may be related to improved surveillance after events identified as TIAs, but secular trends cannot be excluded. This study provides Class III evidence that a standardized population-wide algorithmic triage system for patients with TIA did not reduce recurrent stroke rate.

Abstract P4-07-06: Implementation of A Bone Modifying Agent Pathway at UChicago Medicine for Metastatic Breast Cancer Patients

Abstract Background: In 2019, a quality improvement (QI) research project was conducted at UChicago Medicine (UCM) to evaluate bone modifying agent (BMA) use for skeletal-related event (SRE) prevention in patients with metastatic breast cancer and metastatic castration-resistant prostate cancer. Denosumab was the preferred BMA agent at UCM in this setting. Compared to zoledronic acid (ZA), denosumab was associated with higher drug cost and lower adherence rate mainly due to the difficulty of maintaining the 4-weekly frequency. Studies have shown that ZA can be de-escalated from 4-weekly to 12-weekly for SRE prevention. There is still no convincing evidence to show that this de-escalated schedule can be applied to denosumab. One study evaluated the noninferiority of 12-weekly compared with 4-weekly denosumab suggested that the health-related quality of life was non-inferior (Clemons et al., 2021). However, the study was not powered to evaluate the statistical difference in SRE rates. Based on the results of the 2019 QI project, a BMA pathway was generated at UCM in September 2020 with the purpose of guiding physician prescribing patterns, improving adherence rate, and reducing drug costs. This pathway recommended using ZA as the preferred agent for SRE prevention instead of denosumab. Methods: This was a retrospective study that included 198 patients who had metastatic breast cancer and received at least one dose of ZA or denosumab from UCM outpatient oncology clinic for SRE prevention. All included patients must have bone metastases. 107 patients from the pre-implementation study period (July 1st, 2018 to June 30th, 2019) and 91 patients from the post-implementation study period (November 10th, 2020 to November 10th, 2021) were included. Patients were divided into four groups based on study time (pre- or post-implementation period) and BMA agent (ZA and denosumab). The primary outcome was BMA therapy adherence rate, which was defined by those who received greater than or equal to 80% of appropriately scheduled doses. Secondary outcomes included the percentage of patients on ZA or denosumab, SREs, BMA-associated adverse effects, and BMA cost. Descriptive statistics were used SREs and BMA-associated adverse effects. Results: The percentage of patients on ZA significantly increased from 12% to 64% after BMA pathway implementation (P&amp;lt; 0.0001). Denosumab use decreased from 88% to 36% (P&amp;lt; 0.0001). The overall BMA adherence rate including both ZA and denosumab patients during the post-implementation period was 68%, which was not significantly different compared to the overall adherence rate of 74% during the pre-implementation period (P=0.5461). The adherence rates in denosumab groups (63% in pre and 30% in post) were lower than in ZA groups (100% in pre and 90% in post). The most common reason for the lower adherence rates in denosumab groups was scheduling convenience. During the study period, there were 2, 0, 3, and 3 patients who had SREs in the above four groups respectively. The predominant adverse events among all groups were hypocalcemia and hypophosphatemia. The cost analysis showed using ZA as the primary BMA agent saved 1.1 million dollars of drug costs during the post-implementation study period at UCM. Conclusion: Implementing a BMA pathway encouraged the providers to choose ZA as the preferred agent for SRE prevention in metastatic breast cancer patients with bone metastasis, which dramatically reduced drug costs. The overall BMA adherence rate was not significantly improved with the implementation. The difficulty of maintaining a 4-weekly denosumab frequency continued to exist. Citation Format: Kun Lin, Jordan Baur, Sandeep Parsad, Heng Yang. Implementation of A Bone Modifying Agent Pathway at UChicago Medicine for Metastatic Breast Cancer Patients [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-06.

A Telestroke Nurse and Neuroradiologist Model for Extended Window Code Stroke Triage.

BACKGROUND: Distinguishing features of our stroke network include routine involvement of a telestroke nurse (TSRN) for code stroke activations at nonthrombectomy centers and immediate availability of neuroradiologists for imaging interpretation. On May 1, 2021, we implemented a new workflow for code stroke activations presenting beyond 4.5 hours from last known well that relied on a TSRN supported by a neuroradiologist for initial triage. Patients without a target large vessel occlusion (LVO) were managed without routine involvement of a teleneurologist, which represented a change from the preimplementation period. METHODS: We collected data 6 months before and after implementation of the new workflow. We compared preimplementation process metrics for patients managed with teleneurologist involvement with the postimplementation patients managed without teleneurologist involvement. RESULTS: With the new workflow, teleneurologist involvement decreased from 95% (n = 953) for patients presenting beyond 4.5 hours from last known well to 37% (n = 373; P < .001). Compared with patients in the preimplementation period, postimplementation patients without teleneurologist involvement experienced less inpatient hospital admission and observation (87% vs 90%; unadjusted P = .038, adjusted P = .06). Among the preimplementation and postimplementation admitted patients, there was no statistically significant difference in follow-up neurology consultation or nonstroke diagnoses. A similar percentage of LVO patients were transferred to the thrombectomy center (54% pre vs 49% post, P = .612), whereas more LVO transfers in the postimplementation cohort received thrombectomy therapy (75% post vs 39% pre, P = .014). Among LVO patients (48 pre and 41 post), no statistical significance was observed in imaging and management times. CONCLUSION: Our work shows the successful teaming of a TSRN and a neuroradiologist to triage acute stroke patients who present beyond an eligibility window for systemic thrombolysis, without negatively impacting care and process metrics. This innovative partnering may help to preserve the availability of teleneurologists by limiting their involvement when diagnostic imaging drives decision making.

Effectiveness of a neonatal intensive care unit-specific antimicrobial stewardship program: A ten-year review.

To evaluate the change in consumption of specific antibiotics in a neonatal intensive care unit after the implementation of an antimicrobial stewardship program (ASP). Retrospective cohort study between January 1, 2010, and December 31,2019. The neonatal intensive care unit at British ColumbiaWomen's Hospital (Vancouver Canada), a tertiary-care center. Admitted neonates prescribed antibiotics. We implemented an ASP with an early implementation phase starting in January 2014 (period 2) and a later phase starting in January 2017 (period 3). Patient demographics were collected, including birth weight, gestational age, history of necrotizing enterocolitis (NEC), and surgical operations from existing databases. Interrupted time-series analysis was used, and comparison of antibiotic days of therapy (DOT) averages were conducted across the preimplementation period (period 1), period 2, and period 3 regarding total patients and subgroups. We identified 4,512 infants. There was a significant decrease in DOT from 472 (95% confidence interval [CI], 431-517) in period 1 to 405 (95% CI, 367-446) in period 2 to 313 (95% CI, 280-350) in period 3. We detected a significant decrease in the use of ampicillin, aminoglycosides, cloxacillin, and linezolid but not in vancomycin or cefotaxime. Subgroup analyses of infants <1,500 g and those without NEC or surgery showed decreases in the use of cloxacillin, aminoglycosides, and linezolid. The implementation of an ASP was associated with a significant decrease in the overall DOT and use of certain antibiotics. This study presents important targets for ongoing ASP work.

Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system

ObjectivesComputerised provider order entry (CPOE) systems have been implemented around the world as a solution to reduce ordering and transcription errors. However, previous literature documented many challenges to attain this...

Abstract WP79: Addition Of Multidisciplinary Novel Processes Reduces The Door-to-Needle Time In Acute Ischemic Stroke

Introduction: It is well established that reduced door-to-needle (DTN) time leads to improved outcomes in acute ischemic stroke. Rhode Island Hospital is a Comprehensive Stroke Center focused on improving outcomes by seeking novel methods to improve the DTN to below the institutional goal of a median of &lt; 30 minutes. Methods: We sought to reduce DTN time by the following methods: 1) Addition of an electronic DTN Timer appearing in the Electronic Medical Record (EMR) to improve situational awareness of elapsed time in Code Strokes in real time (Figure). 2) Creation of a multidisciplinary Thrombolysis Focus Group to analyze data and improve processes. 3) Increased awareness of metric exclusion criteria and ease of processes for providers to document exclusions. 4) Concurrent review of each thrombolysis case with direct provider feedback and opportunity to appropriately document and clarify delays. 5) Creation of a thrombolysis Time-Out process. Results: The median DTN for the pre-implementation period of January 2020 to August 2021 was 40.3 minutes compared to 35.8 min for the post-implantation period of September 2021 to June 2022. Additionally, the percent of thrombolysis cases meeting the institutional goal of under 30 minutes improved from 22.6% to 29.8% percent (Figure) and when exclusions were applied, this percentage improved from 29.8% to 49.4% (Figure). Conclusion: Novel measures to reduce the DTN time in acute stroke thrombolysis can positively impact both the door-to-needle time and percent of cases under the institutional DTN time goal. Figure 1.

Implementation of an automated, user-centered point-of-care ultrasound workflow improves documentation and billing.

Point-of-care ultrasound (POCUS) is a central component of emergency medical care. However, clinicians often fail to adequately document their examinations, causing problems for downstream clinicians and quality assurance processes as well as loss of revenue. The objective of this study was to evaluate the impact of a user-centered POCUS documentation workflow system for examination ordering, documentation, selective archival, and billing on POCUS documentation in a large academic emergency department (ED). In this quasi-experimental study, we examined POCUS documentation 22 months before and 12 months after implementation of a user-centered, automated ultrasound workflow (October 2018-July 2021). The workflow allows for electronic health record (EHR) order entry to populate a virtual ultrasound worklist, automatic demographic information retrieval to ultrasound machines, selective image storage to a hospital picture archive and communications system and/or POCUS archive Ultralinq, generation of an EHR report, and integrated billing triggers. Data were retrieved using Current Procedural Terminology codes for billed POCUS examinations during the study period. We also collected monthly hospital registry data to quantify ED visits to control for volume. We compared the number and per-visit rate of POCUS documented using descriptive statistics and segmented linear regression before and after implementation of the workflow. In the 22-month preimplementation period, 209,725 ED visits occurred. During this period, POCUS was completely documented in 13,514 or in 6.4% of ED visits. There were an average of 614 scans documented per month. In the 12-month postimplementation period, 97,418 ED visits occurred. During this period, POCUS was completely documented in 10,001 visits, or 10.3% of ED visits. There were an average of 833 scans documented per month. Linear regression analysis showed a significant increase in average monthly POCUS documentation of 265.34 scans/month (95% CI 150.60-380.09, p < 0.001) at the time of the intervention. In this single-center study, POCUS documentation increased by more than 60% following the implementation of a user-centered POCUS workflow that reduced the burden on the clinician by automating data entry, improving data flow between ultrasound machines and the EHR and integrating billing.

Association between a Post-Resuscitation Care Bundle and the Odds of Field Rearrest after Successful Resuscitation from Out-of-Hospital Cardiac Arrest: A Pre/Post Study

Objectives Rearrest after successful resuscitation from out-of-hospital cardiac arrest (OHCA) is common and is associated with worse patient outcomes. However, little is known about the effect of interventions designed to prevent rearrest. We assessed the association between a prehospital care protocol for immediate management after return of spontaneous circulation (ROSC) and rates of field rearrest and survival to discharge in patients with prehospital ROSC. Methods This was a retrospective study of adult patients with OHCA and field ROSC within a large EMS system before (April 2017–August 2018) and after (April 2019–February 2020) implementation of a structured prehospital post-ROSC care protocol. The protocol was introduced in September 2018 and provided on-scene stabilization direction including guidance on ventilation and blood pressure support. Field data and hospital outcomes were used to compare the frequency of field rearrest, hospital survival, and survival with good neurologic outcome before and after protocol implementation. Logistic regression was used to assess the association between the post-implementation period and these outcomes, and odds ratios were reported. The association between individual interventions on these outcomes was also explored. Results There were 2,706 patients with ROSC after OHCA in the pre-implementation period and 1,780 patients in the post-implementation period. The rate of prehospital rearrest was 43% pre-implementation vs 45% post-implementation (RD 2%, 95% CI −1, 4%). In the adjusted analysis, introduction of the protocol was not associated with decreased odds of rearrest (OR 0.87, 95% CI 0.73, 1.04), survival to hospital discharge (OR 1.01, 95% CI 0.81, 1.24), or survival with good neurologic outcome (OR 0.81, 95% CI 0.61, 1.06). Post-implementation, post-ROSC administration of saline and push-dose epinephrine increased from 11% to 25% (RD 14%, 95% CI 11, 17%) and from 3% to 12% (RD 9% 95% CI 7, 11%), respectively. In an exploratory analysis, push-dose epinephrine was associated with a decreased odds of rearrest (OR 0.68, 95% CI 0.50, 0.94). Conclusions Introduction of a post-ROSC care protocol for patients with prehospital ROSC after OHCA was not associated with reduced odds of field rearrest. When elements of the care bundle were considered individually, push-dose epinephrine was associated with decreased odds of rearrest.

Can primary care physician recommendation improve influenza vaccine uptake among older adults? A community health centre-based experimental study in China

BackgroundTo promote influenza vaccination coverage, a Chinese megacity, Shenzhen provides free influenza vaccination to its residents aged 60 years and above through community health centres (CHCs) since October 2016. A community health centre-based experiment was conducted by asking primary care physicians (PCPs) working in the intervention health centres to proactively recommend influenza vaccination to their patients aged 60 and above during their patients’ visits.MethodsThis study used an experimental design and a survey design. The experimental design evaluated the effect of PCP recommendation on influenza vaccination. A total of 24 CHCs were randomly selected as the intervention (involving 3814 participants) and control (3072 participants) group evenly. The intervention study period was during the 2017–2018 flu season. The 2016–2017 flu season was considered as the baseline comparison. The survey design examined changes in knowledge, attitude, and practice of influenza vaccination among older participants before and after the free influenza vaccination implementation. We randomly invited 1200 participants aged 60 and above during their visits to CHCs in October 2016 and followed them up until October 2017; among them, 958 participants completed the follow-up survey using the same questionnaire.ResultsIn the 2017–2018 flu season, 1,100 more patients got vaccinated in the intervention group under PCP recommendation compared with the 2016–2017 flu season. Among the 958 older adults in the post-implementation period, 77.5% had heard about the influenza vaccine, which was 24.7% higher than in the pre-implementation period; 84.8% of participants were aware where to take influenza vaccines, with the most improvement of 37.2% among all knowledge related questions; 62.5% of them agreed that patients with chronic diseases should have influenza vaccine, which was 19.1% higher than those being surveyed before the implementation period. About 83.6% of participants agreed older adults should have influenza vaccine, but there were still 58.4% who considered themselves too healthy to get vaccinated.ConclusionPCP recommendation improved influenza vaccine uptake and knowledge, attitude, and practice levels regarding influenza vaccination among older adults. More health policies and health education should be made to raise vaccination willingness and improve vaccination coverage among older adults.

Improving Dementia-Specific Referrals From the Acute Care Setting: A Quality Improvement Project.

The purpose of this quality improvement project was to design and implement an education and referral protocol for care coordination staff to use when working with hospitalized patients with dementia and their families. The goal was to increase delivery of dementia resource education and dementia-specific referrals during the discharge planning process. The practice setting for this project was an acute care hospital in Northern California. The care coordination department collaborated with the Northern California Chapter of the Alzheimer's Association to improve the delivery of referrals and follow-up with patients and families who were interested in additional information and support related to dementia. Twenty-one members of the care coordination department received education on the dementia disease process as well as community resources available to the patient population. The registered nurse care coordinators (RNCCs) and social workers (SWs) within the department then implemented a referral protocol to connect patients with dementia and their families to the Alzheimer's Association. Referral volume was captured over a 60-day preimplementation period, a 60-day implementation period, and a 60-day postimplementation period. The Northern California Chapter of the Alzheimer's Association tracked referral volume. A paired-sample t test was used to examine pre/postimplementation Dementia Knowledge Assessment Scale (DKAS) scores to evaluate the impact of the education intervention. Care coordination staff completed a pre/postimplementation survey on knowledge of community resources for dementia and confidence in connecting patients to these resources. They also completed a postimplementation survey about the benefit of the project to their care coordination practice. There was a modest, yet positive increase in referral volume over the 60-day implementation period ( n = 6) compared with the preimplementation period ( n = 1). An increase was sustained during the 60-day postimplementation period ( n = 4). Pre/posttimplementation DKAS scores significantly improved for care coordination staff postimplementation ( p < .001) by an average of 7 points. Fifty-three percent of RNCC and SW staff responded to the postimplementation survey, and results indicated they thought the project was beneficial ( n = 8) or somewhat beneficial ( n = 1) to practice. In addition, RNCC and SW staff reported an increase in awareness of available community resources and confidence in connecting patients and families to these resources. Case management professionals have an important role in providing education and support to patients and families across the continuum of care. The complexity and trajectory of illness, shortage of qualified providers, and gaps in provider knowledge about resources place patients with dementia and their families in an increasingly vulnerable position within the health care system. This quality improvement project demonstrates that care coordination staff can improve referrals to resources when in contact with patients and families in the acute care setting. Case managers can ensure patients with dementia and their families have access to the resources in the community that may prevent return to the emergency department or rehospitalization.

Implementation of remote blood glucose monitoring for gestational diabetes in an underserved population

1) Assess for disparities in frequency of blood glucose (BG) monitoring for gestational diabetes (GDM) between clinics with remote versus in-person BG monitoring programs in a pre-implementation period and 2) determine the impact of implementation of a remote BG monitoring program in an underserved population in a pre-post implementation design. We included patients with GDM receiving prenatal care at either private clinics (Clinic A) or resident clinics (Clinic B) within a university-based hospital setting. First, we performed a retrospective cohort study (Aim 1) comparing Clinic A (remote BG review) to Clinic B (in-person BG review) in the pre-implementation (PRE) period. We then performed a prospective cohort study (Aim 2) evaluating implementation of remote BG review in Clinic B in a pre- (1/1/19-12/31/19; PRE) versus post-implementation (1/1/21-12/31/21; POST) design. The primary outcome was frequency of BG review by a clinician per week diagnosed with GDM. Secondary outcomes included whether patients required medication, mode of delivery, and weight gain in pregnancy. 286 patients met inclusion criteria (Clinic A PRE: 182; Clinic B PRE: 54; Clinic B POST: 50). In the PRE period, patients in Clinic B were more likely to be Hispanic (37.0% vs. 8.2%), Black (38.9% vs. 18.7%), and be either uninsured (16.7% vs. 0.5%) or publicly insured (66.7% vs 9.9%) than in Clinic A. Patients in Clinic A received more BG reviews than Clinic B prior to implementation of remote BG review in Clinic B (83% vs. 41%, p< 0.01) (Table 1). For Aim 2, there were no demographic differences between PRE and POST groups in Clinic B. Importantly, implementation of remote BG monitoring at Clinic B significantly increased the frequency of BG log review (41% vs. 58%, p< 0.01) (Table 1). There were no differences in mode of delivery, total weight gain, or medication use. Remote blood glucose monitoring is an effective intervention to improve BG review among underserved patients with GDM. Future work should examine if interventions such as these can be used to decrease disparities in care.

Improving Management of Suspected Chlamydia and Gonorrhea in Adolescents with a Rapid Diagnostic Test.

Before 2020, we tested for CT/GC using a batched nucleic acid amplification test, with results available the following day. Starting in January 2020, we implemented rapid nucleic acid amplification test. Our primary outcome variables were undertreatment and overtreatment. We defined undertreatment as GC and/or CT-positive patients who did not receive appropriate treatment. We defined overtreatment as GC or CT-negative patients who received antibiotics. The balancing measure was the LOS. There were 758 patients evaluated in the preimplementation period (2019), 612 in the implementation period (2020), and 626 in the postimplementation period (2021). Postimplementation, overtreatment decreased from 18.4% to 8.1%. Undertreatment did not differ by period but was less common among those tested with rapid versus standard testing (12.7% versus 9.9%, P = 0.05). Median LOS increased from 166 minutes (preimplementation) to 187 minutes (implementation) and 202 minutes (postimplementation; P < 0.001). Rapid CT/GC testing reduced unnecessary antibiotic use but increased LOS due to patients waiting for the test results before being discharged. Given the rapid increases in CT/GC rates and antimicrobial resistance, health systems should consider implementing rapid testing to appropriately direct antimicrobials to patients most likely to benefit.

Operational impact of decreased turnaround times for Candida auris screening tests in a tertiary academic medical center.

Assess turnaround time (TAT) and cost-benefit of on-site C. auris screening and its impact on length of stay (LOS) and costs compared to reference laboratories. Before-and-after retrospective cohort study. Large-tertiary medical center. We validated an on-site polymerase chain reaction-based testing platform for C. auris and retrospectively reviewed hospitalized adults who screened negative before and after platform implementation. We constructed multivariable models to assess the association of screening negative with hospital LOS/cost in the pre and postimplementation periods. We adjusted for confounders such as demographics and indwelling device use, and compared TATs for all samples tested. The sensitivity and specificity of the testing platform were 100% and 98.11%, respectively, compared to send-out testing. The clinical cohort included 287 adults in the pre and 1,266 postimplementation period. The TAT was reduced by more than 2 days (3 (interquartile range (IQR): 2.0, 7.0) vs 0.42 (IQR: 0.24, 0.81), p < 0.001). Median LOS was significantly lower in the postimplementation period; however, this was no longer evident after adjustment. In relation to total cost, the time period had an effect of $6,965 (95% CI: -$481, $14,412); p = 0.067) on reducing the cost. The median adjusted total cost per patient was $7,045 (IQR: $3,805, $13,924) less in the post vs the preimplementation period. Our assessment did not find a statistically significant change in LOS, nevertheless, on-site testing was not cost-prohibitive for the institution. The value of on-site testing may be supported if an institutional C. auris reduction strategy emphasizes faster TATs.

Impact of a monthly antimicrobial stewardship quality assurance tool for elevated vancomycin levels.

We sought to determine the value of an audit-and-feedback monitoring method in facilitating meaningful practice changes to improve vancomycin dosing and monitoring. Retrospective, multicenter, before-and-after implementation observational quality assurance initiative. The study was conducted in 7 not-for-profit, acute-care hospitals within a health system in southern Florida. The preimplementation period (September 1, 2019, through August 31, 2020) was compared to the postimplementation period (September 1, 2020, through May 31, 2022). All vancomycin serum-level results were screened for inclusion. The primary end point was the rate of fallout, defined as vancomycin serum level ≥25 µg/mL with acute kidney injury (AKI) and off-protocol dosing and monitoring. Secondary end points included the rate of fallout with respect to AKI severity, rate of vancomycin serum levels ≥25 µg/mL, and average number of serum-level evaluations per unique vancomycin patient. In total, 27,611 vancomycin levels were analyzed from 13,910 unique patients. There were 2,209 vancomycin serum levels ≥25 µg/mL (8%) among 1,652 unique patients (11.9%). AKI was identified in 379 unique patients (23%) with a vancomycin levels ≥25 µg/mL. In total, 60 fallouts (35.2%) occurred in the 12-month preimplementation period (∼5 per month) and 41 fallouts (19.6%) occurred in the 21-month postimplementation period (∼2 per month; P = .0006). Failure was the most common AKI severity in both periods (risk: 35% vs 24.3%, P = .25; injury: 28.3% vs 19.5%, P = .30; failure: 36.7% vs 56%, P = .053). Overall, the number of evaluations of vancomycin serum levels per unique patient remained consistent throughout both periods (2 vs 2; P = .53). Implementation of a monthly quality assurance tool for elevated outlier vancomycin levels can improve dosing and monitoring practices resulting in enhanced patient safety.