Pre-intervention Group Research Articles

Clinical and Microbiological Impact of Implementing a Decision Support Algorithm through Microbiologic Rapid Diagnosis in Critically Ill Patients: An Epidemiological Retrospective Pre-/Post-Intervention Study.

Data on the benefits of rapid microbiological testing on antimicrobial consumption (AC) and antimicrobial resistance patterns (ARPs) are scarce. We evaluated the impact of a protocol based on rapid techniques on AC and ARP in intensive care (ICU) patients. A retrospective pre- (2018) and post-intervention (2019-2021) study was conducted in ICU patients. A rapid diagnostic algorithm was applied starting in 2019 in patients with a lower respiratory tract infection. The incidence of nosocomial infections, ARPs, and AC as DDDs (defined daily doses) were monitored. A total of 3635 patients were included: 987 in the pre-intervention group and 2648 in the post-intervention group. The median age was 60 years, the sample was 64% male, and the average APACHE II and SOFA scores were 19 points and 3 points. The overall ICU mortality was 17.2% without any differences between the groups. An increase in the number of infections was observed in the post-intervention group (44.5% vs. 17.9%, p < 0.01), especially due to an increase in the incidence of ventilator-associated pneumonia (44.6% vs. 25%, p < 0.001). AC decreased from 128.7 DDD in 2018 to 66.0 DDD in 2021 (rate ratio = 0.51). An increase in Pseudomonas aeruginosa susceptibility of 23% for Piperacillin/tazobactam and 31% for Meropenem was observed. The implementation of an algorithm based on rapid microbiological diagnostic techniques allowed for a significant reduction in AC and ARPs without affecting the prognosis of critically ill patients.

A streamlined Emergency Department approach to moderate risk chest pain in patients with no pre-existing coronary artery disease: A pilot study.

Moderate risk patients with chest pain and no previously diagnosed coronary artery disease (CAD) who present to ED require further risk stratification. We hypothesise that management of these patients by ED physicians can decrease length of stay (LOS), without increasing patient harm. A prospective pilot study with comparison to a pre-intervention control group was performed on patients presenting with chest pain to an ED in Perth, Australia between May and October 2021, following the introduction of a streamlined guideline consisting of ED led decision making and early follow up. Patients had no documented CAD and were at moderate risk of major adverse cardiac events (MACE). Electronic data was used for comparison. Primary outcomes were total LOS and LOS following troponin. One hundred eighty-six patients were included. Median total LOS was reduced by 62 min, but this change was not statistically significant (482 [360-795] vs 420 [360-525] min, P = 0.06). However, a significant 60 min decrease in LOS was found following the final troponin (240 (120-571) vs 180 (135-270) min, P = 0.02). There was no difference in the rate of MACE (0% vs 2%, P = 0.50), with no myocardial infarction or death. Our study suggests that patients with no pre-existing CAD can be safely managed by emergency physicians streamlining their ED management and decreasing LOS. This pathway could be used in other centres following confirmation of the results by a larger study.

Post-tonsillectomy bleeding rate decreases with limitation in maximum post-operative ibuprofen dosage: A quality improvement study

ObjectiveThe objective of this study is to investigate the effect of a reduction in the prescribed post-operative ibuprofen dosage on frequency of post-tonsillectomy bleeding. MethodsA quality improvement study was conducted at a single tertiary care pediatric hospital with patients weighing >40 kg undergoing tonsillectomy. The intervention was limiting the post-operative ibuprofen dosage to a maximum of 400 mg per dose. Data was collected on all patients returning to the hospital with bleeding after tonsillectomy. The primary outcome was the rate of post-tonsillectomy bleeding. Statistical analysis was conducted using nonparametric comparisons and a run chart. ResultsA total of 199 tonsillectomy patients >40 kg were included in the study. There were 119 (59.8 %) females and 80 (40.2 %) males total. The pre-intervention group had a total of 56 patients while the post-intervention group had a total of 143 patients. There was no statistical difference in age, weight, or sex between the pre- and post-intervention groups (p > .05). The post-tonsillectomy hemorrhage rate was 11/56 (19.6 %) before the intervention, and 11/143 (7.7 %) after the intervention (p = .016). Children who experienced a bleeding event were significantly older (mean 15.9 years, 95 % CI 14.5–17.3) than those who did not (13.5 years, 95 % CI 12.9–14.1; p = .011). The run chart revealed that the intervention resulted in a nonrandom decrease in rate of post-tonsillectomy bleeding. ConclusionsPost-tonsillectomy bleeding rate decreased with a ceiling post-operative ibuprofen dose of 400 mg/dose in this quality improvement study. Further research is warranted.

Pilot study to develop a pre-operative "Cardiothoracic Clinical Handover Tool" and its effect on handover quality.

Clinical handover is an essential step in the surgical patient's hospital journey, but one that is not without risk. Within cardiothoracic surgery, endeavours to protocolise post-operative handover from cardiac theatre to cardiac intensive care units have resulted in enhanced patient safety, but little to no effort has focused on the pre-operative setting and the dissemination of information throughout the surgical team. We designed a pre-post study examining the quality of pre-operative cardiothoracic patient handovers before and after the introduction of an intra-departmentally designed "Cardiothoracic Clinical Handover Tool" based on the Royal College of Surgeons of England's guidelines for "Safe Handover". Forty clinical handovers were assessed in each arm of the study. Handover quality improved from a score of 63.75% to 88.57% (p = < 0.001). This prolonged handover duration from a mean of 72.1 to 102.4seconds per case (p = 0.003). Interruptions occurred in 27.5% of pre- and 25% of post-intervention handovers. Interruptions resulted in increased handover duration in both pre- and post-intervention groups (114.6 vs 77.7seconds, p = 0.012) and poorer quality handovers in the pre-intervention group (51.28% vs 68.42%, p = 0.03) but failed to impact handover quality in the post-intervention group (88.57% vs 88.57%, p = 1). Clinical handover tools have the potential to enhance the quality of pre-operative handover and protect against poor handover practices such as interruptions, safe-guarding patient welfare. We provide the first cardiothoracic specific pre-operative handover tool based on the RCSE guidelines.

Effectiveness of Carboplatin-Prescreening Intradermal Skin Tests to Reduce Unanticipated Immediate Hypersensitivity Reactions: A Comparative Study

BackgroundCarboplatin administration poses a risk of immediate hypersensitivity reactions (IHRs) that tend to increase with repeated administration and are mostly IgE-mediated. ObjectiveThis study evaluated the usefulness of carboplatin-prescreening intradermal skin tests (IDTs). MethodsCarboplatin-prescreening IDTs were routinely conducted in patients with a history of receiving six or more carboplatin cycles from January 2021. The primary objective was to assess disparities in the incidence of unanticipated IHRs to carboplatin administration. Comparisons were made between patients in the intervention group (period: 2021–2022) and those who did not undergo prescreening IDTs under the same conditions (pre-intervention group; period: 2019–2020). The secondary objectives included evaluating the sensitivity and specificity of the prescreening IDT and the incidence of carboplatin IHR according to the number of infusion cycles. ResultsThe intervention group comprised 67 patients who were administered 347 carboplatin cycles, whereas the pre-intervention group included 96 patients who were administered 464 carboplatin cycles. The risk of unanticipated carboplatin IHRs decreased by 83.2% in the intervention group compared to the pre-intervention group (pre-intervention group: 3.45%, N=16 vs. intervention group: 0.58%, N=2; p=0.005). The prescreening IDT showed a sensitivity and specificity of 77.78% and 99.41%, respectively. The risk of newly developed IHRs based on the number of carboplatin cycles was <1% (cycle 1-5), 2.11% (cycle 6), 3.90% (cycle 7-12), 2.90% (cycle 13-18), and 0.74% (cycle ≥ 19), respectively. ConclusionsInitiating carboplatin-prescreening IDTs from the seventh cycle significantly reduced the risk of unanticipated IHRs.

Potential effectiveness of integrating human milk banking and lactation support on neonatal outcomes at Pumwani Maternity Hospital, Kenya.

We assessed the potential effectiveness of human milk banking and lactation support on provision of human milk to neonates admitted in the newborn unit (NBU) at Pumwani Maternity Hospital, Kenya. This pre-post intervention study collected data from mothers/caregivers and their vulnerable neonates or term babies who lacked sufficient mother's milk for several reasons admitted in the NBU. The intervention included establishing a human milk bank and strengthening lactation support. Preintervention data were collected between 5 October 2018 and 11 November 2018, whereas postintervention data were collected between 4 September 2019 and 6 October 2019. Propensity score-matched analysis was performed to assess the effect of the intervention on exclusive use of human milk, use of human milk as the first feed, feeding intolerance and duration of NBU stay. The surveys included 123 and 116 newborns at preintervention and postintervention, respectively, with 160 newborns (80 in each group) being included in propensity score matched analysis. The proportion of neonates who exclusively used human milk during NBU stay increased from 41.3% preintervention to 63.8% postintervention (adjusted odds ratio [OR]: 2.68; 95% confidence interval [CI]: 1.31, 5.53) and those whose first feed was human milk increased from 55.0% preintervention to 83.3% postintervention (adjusted OR: 5.09; 95% CI: 2.18, 11.88). The mean duration of NBU stay was 27% (95% CI: 5.8%, 44.0%) lower in the postintervention group than in the preintervention group. The intervention did not affect feeding intolerance. Integrating human milk banking and lactation support may improve exclusive use of human milk among vulnerable neonates in a resource limited setting.

The effects of environmental interventions for delirium in critically ill surgical patients.

Delirium occurs at high rates among patients in intensive care units and increases the risk of morbidity and mortality. The purpose of this study was to investigate the effects of environmental interventions on delirium. This prospective cohort study enrolled 192 patients admitted to the surgical intensive care unit (SICU) during the pre-intervention (June 2013 to October 2013) and post-intervention (June 2014 to October 2014) periods. Environmental interventions involved a cognitive assessment, an orientation, and a comfortable environment including proper sleep conditions. The primary outcomes were the prevalence, duration, and onset of delirium. There were no statistically significant differences in incidence rate, time of delirium onset, general characteristics, and mortality between the pre-intervention and post-intervention groups. The durations of delirium were 14.4±19.1 and 7.7±7.3 days in the pre-intervention and post-intervention groups, respectively, a significant reduction (P=0.027). The lengths of SICU stay were 20.0±22.9 and 12.6±8.7 days for the pre-intervention and post-intervention groups, respectively, also a significant reduction (P=0.030). The implementation of an environmental intervention program reduced the duration of delirium and length of stay in the SICU for critically ill surgical patients.

172. Impact of a quality improvement re-training program on the blood culture volume, yield and contamination rates; experience from South India

Abstract Background Blood cultures help to detect causative agents in bacteremia and are important for targeted therapy. Adequate blood culture volume is considered as 8-10ml in each bottle and at least 2 aerobic and 2 anaerobic blood culture bottles are recommended. Inadequate blood culture fills are common and may affect yield. Figure 1 Methods The study was done in our healthcare facility-KIMSHEALTH, Trivandrum, India. Pre-intervention period was between May 2021 and June 2021; post-intervention was between May 2022 and June 2022. The intervention was through plan/do/study/act (PDSA) cycles and included multiple training sessions to the phlebotomy team regarding adequate fill volume which is 8-10 ml in each blood culture bottle. Training for maintaining asepsis during collection was reinforced. All blood culture samples received in the hospital microbiology laboratory during the above period were included in this study and compared between the pre-intervention and post-intervention period. Pediatric blood culture samples were excluded. Results Blood culture samples studied during pre and post intervention period were 1428 and 1716 respectively. In the pre-intervention phase adequate fill volume was noted in 30.81% bottles (figure 1), while in the post intervention adequate fill volume was noted in 68.06% bottles (p &amp;lt; 0.01). Blood culture contamination rate was 3.01% in the pre-intervention period which improved to 2% in the post-intervention period and the difference was significant (p&amp;lt; 0.01). Blood culture yield of a pathogenic organism did not show significant difference after the intervention (11.2% in pre-intervention group Vs 11.45% in post intervention group). Conclusion In this study, an improvement was noted in the blood culture fills by 38% and contamination rate reduced by 1%. Though there was no significant increase in blood culture yield with intervention, the reduction in contamination was noted which will reduce unnecessary antibiotic initiation. Disclosures All Authors: No reported disclosures

1272. Teaching the ABCs of ASB in a 60-minute educational intervention. A quality improvement project.

Abstract Background Asymptomatic bacteriuria (ASB) refers to the presence of bacteria in the urine of individuals that do not present with symptoms of urinary tract infection (UTI). Treatment for ASB is not recommended in most cases. [1] Previous studies have shown that provider education on proper antibiotic use has been effective in mitigating the ongoing wave of antimicrobial-resistant organisms across hospitals in the United States.[2] We aimed to decrease the proportion of cases classified as having asymptomatic bacteria by 20% in four months after the intervention using a small group discussion and a presentation. Methods We evaluated the rates of inappropriate antimicrobial prescribing for asymptomatic bacteriuria (ASB) for 4 months before educational intervention and 4 months after. Data was extracted from the electronic medical record (Cerner®), imported into REDCap®, and with standardized manual chart review. Data analysis was completed using STATA® 17 &amp; 18. Results The mean duration of antibiotic therapy was 7.9 days in the pre-intervention group and 6.1 days in the post-intervention group. See Table 1 for more details on demographics. Following the intervention, the rate of inappropriate use of antimicrobial therapy in ASB was reduced by 29.8% (p-value 0.035). The mean duration of antibiotic therapy decreased by almost 2 days in the post-intervention group. Conclusion This quality improvement project suggests that focused interventions of short interactive educational sessions in small groups may reduce the inappropriate use of antibiotics in ASB by almost 30%. The mean duration in days of antibiotic treatment decreased from 7.9 days to 6.1 days in the pre and post-intervention groups (p-value 0.060). Of note the total number of cases with providers selecting UTI as an indication was also lower in the post-intervention group and although we can’t determine causality, it provided evidence of a lower number of cases, providers initially classified as UTI between the pre and post-intervention period from 33 to 19. Further research may include incorporating small groups and interprofessional educational interventions to help implement good antimicrobial stewardship in inpatient care facilities. [4,5,6] Disclosures All Authors: No reported disclosures

91. Implementation of a blood culture algorithm in emergency department patients as a diagnostic stewardship intervention

Abstract Background Blood cultures (BCx) are commonly ordered for patients at low risk of bacteremia. Liberal ordering can increase false-positive results due to contamination, along with increasing length of stay, excess antibiotics, and unnecessary diagnostic procedures. We implemented an algorithm for appropriate blood culture obtainment (Figure 1) in an academic tertiary care emergency department (ED) and assessed the intervention’s impact on various operational, clinical, and safety metrics.Figure 1:ED Blood culture algorithm Methods We performed a prospective cohort study in the Duke University Hospital ED from 12/2022 to 3/2023 using historical controls from 12/2020-11/2022. The BCx algorithm was disseminated in-person, electronically, and accessible online. Weekly chart review of all eligible patients for algorithm adherence was completed by 7 ED clinicians with monthly feedback provided to all ED providers. We defined a BCx event as 1 or more BCx sets within 24 hours. We excluded patients &amp;lt; 18 years, absolute neutrophil count &amp;lt; 500 109/L, and heart and lung transplant recipients. We measured BCx order volume, indication, algorithm adherence, BCx positivity rate, antibiotic days of therapy (DOT), and 30-day hospital readmission. Results Average monthly BCx volume was 1387 pre-intervention compared to 1226 post-intervention (p= 0.046). An increase in culture positivity was see post-intervention with a rate of 13.9% compared to 11.23% in the pre-intervention group (Figure 2, p&amp;lt; 0.001). The majority of the 2168 BCx adhered to the algorithm. (Figure 3). The most common reasons for non-adherence were isolated fever or leukocytosis (29%), non-severe community-acquired pneumonia or healthcare-associated pneumonia (6.9%) and non-severe cellulitis (4%). No change in DOT (786 vs. 783 days of therapy per 1000 patient days, p-value 0.85) (Figure 4) or monthly 30-day hospital readmission (21.1% vs 19.6%, p-value 0.30) was observed.Figure 2:Blood cultures drawn per month and % appropriate pre/post-intervention (N=2168)Figure 3:Algorithm Adherent vs. Algorithm Non-Adherent blood cultures per month (N=2168)Figure 4:Emergency Department anti-bacterial days of antibiotic therapy per 1000 patient days Conclusion Introduction of a BCx algorithm in an academic tertiary care ED, resulted in a decrease in BCx volume, increase in BCx positivity rate, and no increase in DOT or readmission was observed. (Table 1)Table 1:Blood culture volume, positivity rate, days of antibiotic therapy, and 30-day readmission Disclosures Jessica Seidelman, MD, MPH, Uptodate: content editor for pelvic osteomyelitis page

Impact of Neonatal Intervention on Left Ventricular Performance in Ebstein’s Anomaly and Tricuspid Valve Dysplasia

Severe neonatal Ebstein's anomaly (EA) and tricuspid valve dysplasia (TVD) are associated with high perinatal morbidity and mortality. The authors recently demonstrated left ventricular (LV) dysfunction and dyssynchrony to be prevalent in affected newborns and to contribute to poor outcomes. The aim of this study was to investigate the impact of patent ductus arteriosus (PDA) closure, spontaneous or surgical ligation, or right ventricular exclusion (Starnes procedure) on LV performance in neonatal EA and TVD. Neonates with EA or TVD encountered from 2004 to 2018 at three institutions were identified. Pre-and postoperative LV function was assessed using two-dimensional, Doppler-derived deformation (six-segment vector velocity imaging) and two measures of mechanical dyssynchrony (the SD of time to peak and global dyssynchrony index), and values were compared using paired t test analysis or the Wilcoxon rank sum test. Before the intervention, LV function was impaired in the PDA (n=18) and Starnes (n=6) groups and was similar between groups. After PDA closure, LV performance did not change. After the Starnes procedure, however, LV function, including synchrony, improved significantly: fractional area change from 45±5% to 58±8% (P=.003), global circumferential strain from -18.2±5.0% to -32.5±5.5% (P=.01), cardiac index from 1.9±0.3 to 3.9±1.5L/min/m2 (P=.05), and circumferential strain dyssynchrony (dyssynchrony index from 0.19±0.09 to 0.04±0.02 [P=.009] and SD of time to peak from 59.8±18.5 to 29.9±8.2 [P=.02]). The Starnes procedure results in early improvements in LV dysfunction and dyssynchrony, not observed after PDA closure in neonatal severe EA and TVD, which may benefit critically unwell neonates.

The Impact of Screening for Perioperative ICU Admission in Geriatric Hip Fracture Patients: A Retrospective Analysis.

Hip fracture patients are a subset of trauma patients with high peri-operative mortality. To mitigate the mortality risk, the use of predictive scoring systems (e.g., RSI or Nomograms) for risk stratification and monitoring of high-risk patients in the intensive care unit (ICU) has been proposed. Screening patients for ICU admission with relatively low-cost tools may achieve high-quality, low-cost care. The aim of this study was to assess the effectiveness and feasibility of screening postoperative hip fracture patients for ICU admission. This is a retrospective single-site study comparing two groups ofpatients, before and after implementation of a hip fracture postoperative screening intervention in a level 1 trauma center in the United States. All hip fracture patients > 55 years of age admitted to the hospital between January 2021 and May 2023 were included. Trauma team members assessed and screened patients postoperatively in the post-anesthesia care unit (PACU), ordering standardized tests, including laboratory tests, a chest x-ray, and electrocardiogram (EKG). Assessment of the effect of the intervention included a comparison of a number of major adverse events (MAEs), mortality, planned and unplanned ICU admissions, ICU length of stay (LOS), and hospital LOS between pre- and post-intervention groups. Propensity score (PS) estimates were used to compare outcomes between the matched participants in the sample. A predictive model for ICU admission for the overall sample was estimated, and discriminative ability was assessed with an area under the curve (AUC) receiver operator characteristics (ROC) analysis. Lastly, feasibility was assessed by compliance with screening intervention and charges per patient related to the intervention. The sample consisted of 290 patients in the pre-intervention and 180 patients in the post-intervention groups, respectively, with a mean age of81.4 ± (9.9) years. There was a significant increase (p<0.01) in planned ICU admissions (OR=2.387, 95% CI (1.430, 3.983)) after screening protocol implementation. There was no significant difference between the pre-intervention group and post-intervention group in the number of MAEs (p=0.392), mortality (p=0.591), ICU LOS (p=0.617), and hospital LOS (p=0.151). When the PS-matched sample (n=424) was analyzed, there was a significant decrease (p=0.45) in unplanned ICU admissions (OR=6.40, 95% CI (0.81, 50.95)) after protocol implementation. Anticoagulants, emergency department (ED) respiratory rate (RR), injury severity score (ISS), number of comorbidities, substance use disorder (SAD), peripheral artery disease (PAD), and chronic obstructive pulmonary disease (COPD) were significant predictors of ICU admission (p=0.002, 0.022, 0.030, 0.034, 0.039, 0.039, and 0.042), respectively, and, demonstrated the discriminative ability between high and low risk for ICU admission (AUC=0.597, 0.587, 0.581, 0.578, 0.513, and 0.587, respectively). The screening intervention was achievable with 99% compliance (Kappa estimate 0.94) among trauma team members with an average charge of $282 per patient. The addition of a postoperative screening intervention for hip fracture patients > 55 years of age is achievable and decreases unplanned ICU admissions in matched samples. Presenting clinical indicators and comorbidities are associated with ICU admission and provide sufficient discriminatory ability as criteria for ICU admission.

Evidence-Based Opioid Education That Reduces Prescribing: The 10 Principles of Opioid Prescribing in Foot and Ankle Surgery

Over half of opioid misusers last obtained access to opioids via a friend or relative, a problematic reflection of the opioid reservoir phenomenon, which results from an unused backlog of excess prescription opioids that are typically stored in the American home. We aim to determine if a voluntary educational intervention containing standard opioid and nonopioid analgesic prescribing ranges for common surgeries is effective in altering postoperative prescribing practice. We utilized a mixed methods approach and sent out a questionnaire to American podiatric physicians, including residents (baseline group A), via email in early 2020 for baseline data; then, we interviewed foot and ankle surgeons and the primary themes of these semistructured interviews informed us to target residents for an educational intervention. We repeated the survey 3 years later in summer 2022 (preintervention group B). We created an opioid guide and emailed it to residents in fall 2022. Another repeat survey was done in spring 2023 (postintervention group C). We used the Mann-Whitney U test to examine differences between the groups among their reported postoperative opioid quantities for a first metatarsal osteotomy surgical scenario. Groups A, B, and C had 60, 100, and 99 residents, respectively. There was no significant difference (p = .9873) between baseline group A and preintervention group B. There was a difference (p < .0001; -5 median) between preintervention group B and postintervention group C (same residency year). In postintervention group C, a majority (91/99) reported viewing the guide at least once, and the number of residents that reported supplementing with NSAIDs also doubled compared to preintervention group B. This novel opioid educational intervention resulted in meaningful change in self-reported postoperative prescribing behavior among residents.

Impact of a systematic framework for anticipatory compounding on medication waste reduction in a mid-size community hospital.

In current hospital pharmacy practice, the need to compound medications ahead of patient orders often results in an increase in medication waste. The purpose of this study was to implement a strategic approach for anticipatory sterile compounding and evaluate its effect on the reduction of expired medication waste. This was a pre-/post-intervention quasi-experimental study with 3 weeks of data collection for both arms and a 1-week washout period to implement process changes. A par log was placed on the medication storage refrigerator used for anticipatory compounding, with minimum and maximum levels determined by the demand-forecasting model. The primary outcome was the percentage of observations associated with waste. The secondary outcomes were the overall percentage of sterile compounding spending attributable to waste, median wasted dollars per sterile compounded product, and median dollars spent per sterile product compounded as anticipatory stock. Descriptive statistics were calculated using Minitab version 20, with the α level set to 0.05. A total of 4,619 observations were included in the analysis: 2,433 in the preintervention group and 2,186 in the postintervention group. Despite the median price being higher in the postintervention group than in the preintervention group, both the primary and secondary outcomes indicated that waste was reduced following the intervention. Overall, implementation of the framework reduced sterile products waste at our institution. More research is needed to evaluate the effects of this framework at institutions of different sizes and with different patient populations. Further research on probabilistic models for sterile compounded products is also needed.

Impact of stewardship intervention on antibiotic prescribing prior to dental procedures in a veteran population

BackgroundDentists are an overlooked group of prescribers but are responsible for up to 10% of antibiotic prescriptions written in the United States annually, most of which are for prophylaxis. Dental prophylaxis in orthopedic patients has been an area of confusion, with discordance among societal guidelines. In 2020, an antimicrobial stewardship (AS) group spearheaded a collaborative effort among dental, orthopedic surgery, and infectious diseases specialties to develop a protocol for the use of dental antibiotic prophylaxis for patients with total joint replacements (TJRs) based on the most current American Dental Association-American Academy of Orthopaedic Surgeons statement. ObjectiveThis study aimed to assess antibiotic prescribing for dental prophylaxis before and after an AS intervention. MethodsThis study is an interventional, pre-post review of dental encounters with patients with a history of TJR before (October 2019 to July 2021) and after (August 2021 to April 2023) the intervention. Charts were reviewed to determine the frequency and appropriateness of dental procedure prophylactic antibiotics. ResultsA total of 1587 encounters from October 2019 to April 2023 were identified. Notably, 179 encounters in the pre- and 183 encounters in the postgroup were analyzed, 31 encounters (17%) in the pregroup versus 33 (18%) in the postgroup had a prophylactic antibiotic associated with it (P > 0.05), 26 of 31 antibiotics (84%) in the pregroup were prescribed for prosthetic joint infection prophylaxis compared with 18 of 33 (55%) in the postgroup (P > 0.05), and 151 of 179 encounters (84.3%) were guideline adherent in the preintervention group compared with 160 of 183 encounters (87.4%) in the postintervention group (P > 0.05). ConclusionThis study observed a shift in the distribution of antibiotic indications and a decreased rate of inappropriate prophylactic prescriptions in dental patients with a history of TJR after an AS-led, collaborative intervention. Although the overall rate of prophylactic antibiotic prescribing remained the same and the changes did not reach statistical significance, lessons learned through this process can help inform future interventions in our institution and for others.

Abstract 18106: Keeping up With the Newest Guideline Directed Medical Therapy for Heart Failure With Reduced Ejection Fraction, Resident-Driven Quality Improvement Project

Introduction: Chronic Heart Failure (CHF) is an epidemic associated with high morbidity and mortality. As per 2022 AHA/ACC/HFSA guidelines, the management of Heart Failure with reduced Ejection Fraction (HFrEF) includes Angiotensin Receptor-Neprilysin Inhibitors (ARNIs), Angiotensin-Converting Enzyme Inhibitors (ACEIs)/Angiotensin Receptor Blockers (ARBs), Beta-Blockers (BB), Mineralocorticoid Receptor Antagonists (MRA) and Sodium-Glucose co-transporter 2 Inhibitors (SGLT2I) as class 1 recommendations. Considering the new guidelines for HFrEF we decided to perform a quality improvement project to improve the GDMT prescription rate in patients with HFrEF. Methods: Our project included: dot phrase creation for all physicians through electronic medical records (EMR) system, educational sessions, monthly emails and weekly EMR chat messages regarding GDMT and CHF order set to physicians, A4 sized posters distributed on all hospital floors. We then performed retrospective review and analysis of patient charts who were admitted to three UPMC Central PA hospitals with diagnosis of HFrEF exacerbation during December 2019 to January 2021 (pre-intervention) and March 2022 to September 2022 (post-intervention). Results: Total 615 patients were included. There were no significant differences in demographics between pre intervention (357) and post intervention (258) groups including age, sex, race. There were no differences in prescription rate and target dose at discharge between BB groups (92.72% vs 91.86%%, p=0.693 and 7.25% vs 7.17%, p=0.978). The intervention helped in increasing prescription of ARNIs from 6.2% to 30.62%, p&lt; 0.0001 and 13.92% were discharged on target dosages. The prescription of MRA was increased (47.62%vs 51.55%). Furthermore, initiation of SGLT2I was achieved in 41.47% in post-intervention from 0% in the pre-intervention group. Conclusions: Despite higher awareness of GDMT and the trend towards having more patients discharged on therapeutic dosages of GDMT, it is evident that GDMT is still underused among patients with HFrEF. Our results indicate that more emphasis should be placed on rapid up-titration of GDMT.

Abstract 326: The Impact of a Critical Care Outreach Team on the Collection of In-Hospital Cardiac Arrest Resuscitation Quality Data

Introduction: Critical Care Outreach Teams (CCOTs) serve to recognize clinical deterioration and respond to rapid response activations prior to in-hospital cardiac arrest (IHCA) in non-intensive care unit (ICU) patient care areas. In some hospitals, the CCOT operates separately from the IHCA resuscitation team. However, limited data exist regarding the outcomes of CCOT and IHCA resuscitation team collaboration during IHCA. Research Question: The purpose of this pilot study was to determine if the addition of a CCOT member to an IHCA resuscitation team would improve the collection of quality metrics during adult IHCA resuscitations. Goals: The primary goal of this study was to increase the documentation of two quality metrics identified by the American Heart Association’s Get with the Guidelines®-Resuscitation (AHA GWT-R) program during adult IHCAs in non-ICU patient care areas: 1) documentation of initial pulseless rhythm and 2) documentation of time to first intervention (epinephrine or defibrillation). The secondary goal was to increase the percentage of completed IHCA records/code sheets integrated into the electronic medical record (EMR). Methods: All non-ICU IHCAs that occurred prior to the intervention during a year-long period (June 1 st , 2021, to May 31 st , 2022) were used to establish baseline resuscitation quality metrics. During the intervention period (June 1 st , 2022, to May 31, 2023), a member of the CCOT responded to inpatient IHCA activations to serve as the designated event recorder and assist with the resuscitation. At the end of the study period, all IHCA activations were reviewed. Results: There were 74 IHCAs in the pre-intervention group and 76 IHCAs in the post-intervention group. In the post-intervention group, integration of IHCA records/code sheets into the EMR increased in the post-intervention group from 56.8% (42/74) to 96% (73/76). In the post-intervention group, there was also an increase in the documentation of initial pulseless rhythm from 75.7% (56/74) to 96% (73/76) and documentation of the first intervention from 71.4% (n=40) to 98.6% (n=72). Conclusions: This pilot demonstrated that adding a CCOT member to non-ICU IHCA resuscitations improves the accuracy of IHCA documentation and AHA GWT-R quality metrics.

Retrospective evaluation of an intervention bundle on OPAT implementation in a large non-university hospital

ABSTRACT Objectives Optimization of outpatient parenteral antimicrobial therapy (OPAT) requires interdisciplinarity and an operational algorithm. This report retrospectively assesses the impact of a multimodal quality-enhancement intervention bundle on the implementation rate, efficacy, and safety of a home OPAT program in a Belgian large community-based hospital. Methods OPAT recipients between 1 March 2019 and 30 June 2022 were included. The OPAT trajectories were divided into pre-intervention (from 1 March 2019 to 31 October 2020) and post-intervention (from 1 November 2020 to 30 June 2022) groups. The quality-enhancement intervention bundle consisted of the involvement of an infectious disease specialist, revision and implementation of a state-of-the-art prosthetic joint infection diagnosis and treatment protocol, weekly multidisciplinary discussion of all prosthetic joint infections, revision of the OPAT algorithm, and the introduction of teicoplanin as an OPAT-convenient antimicrobial. Results Eighty-five patients were included in a total of 96 OPAT trajectories (n = 33 pre-intervention; n = 63 post-intervention). After the intervention, the number of OPAT trajectories nearly doubled. The number of patients with a recurrent infection within 6 months after OPAT completion decreased 15%. The overall 6-month mortality and readmission rates during OPAT treatment decreased 8% and 10%, respectively. Mortality during OPAT treatment did not change. These differences between pre- and post-intervention did not achieve statistical significance, despite the higher risk for complications in the post-intervention group because of increased infection complexity and required treatment duration. Conclusion Within a Belgian, single, large community-based hospital, a multimodal intervention bundle resulted in increases in OPAT implementation, infection complexity, and required treatment durations without statistically significant differences in outcomes.

Novel Dosing and Monitoring of Aspirin in Infants With Systemic-to-Pulmonary Artery Shunt Physiology: the SOPRANO Study.

Provision of pulmonary blood flow with a systemic-to-pulmonary artery shunt is essential in some patients with cyanotic congenital heart disease. Traditionally, aspirin (ASA) has been used to prevent thrombosis. We evaluated ASA dosing with 2 separate antiplatelet monitoring tests for accuracy and reliability. This is a retrospective, pre-post intervention single center study. Two cohorts were evaluated; the pre-intervention group used thromboelastography platelet mapping (TPM) and post-intervention used VerifyNow aspirin reactivity unit (ARU) monitoring. The primary endpoint was to compare therapeutic effect of TPM and ARU with regard to platelet inhibition. Inadequate platelet inhibition was defined as TPM <50% inhibition and ARU >550. Data from 49 patients were analyzed: 25 in the TPM group and 24 in the ARU group. Baseline characteristics were similar amongst the cohorts. The TPM group had significantly more patients with inadequate platelet inhibition (14 [56%] vs 2 [8%]; p = 0.0006) and required escalation with additional thromboprophylaxis (15 [60%] vs 5 [21%]). There was no difference in shunt thrombosis (1 [2%] vs 0 [0%]; p = 0.32), cyanosis requiring early re-intervention (9 [36%] vs 14 [58%]; p = 0.11), or bleeding (15 [60%] vs 14 [58%]; p = 0.66). With similar cohorts and the same ASA-dosing nomogram, ARU monitoring resulted in a reduced need for escalation of care and concomitant thromboprophylaxis with no difference in adverse outcomes. Our study suggests ARU monitoring compared with TPM may be a more reliable therapeutic platelet inhibition test for determining ASA sensitivity in children with congenital heart disease requiring systemic-to-pulmonary artery shunt.

To assess the impact of training about hospital infection control measures related to hemodialysis services on the knowledge of healthcare providers (HCPs) at the teaching institution of Haryana.

Adequate knowledge among nursing professionals toward hospital infection control measures related to hemodialysis (HD) services is essential to decrease infection among patients. This study assessed nursing professionals' knowledge about hospital infection control measures related to HD services and the effect of training interventions. It was a single group, a pre-post-interventional study conducted on nursing professionals of a single apex medical college of Haryana. A pretested questionnaire consisting of two parts was used as a study tool. Various statistical tests such as paired t-test and Pearson's correlation were used. The pre-intervention group had a lower mean knowledge score (mean knowledge = 90.2786, strongly disagree [SD] = 15.52682, standard error [SE] = 1.09518) and then the post-intervention mean knowledge score (mean knowledge = 137.5622, SD = 9.72252, SE = 0.68577). The training program or educational intervention proved very useful for enhancing nursing professional's knowledge about hospital infection control measures related to HD services.