Pre-intervention Group Research Articles

Manualised Attachment-Based Interventions for Improving Caregiver-Infant Relationships: A Two-Stage Systematic Review

Abstract As attachment-based interventions can improve caregiver-infant relationships and their subsequent psychological outcomes, the identification of relevant and effective interventions can facilitate their implementation into clinical practice. This systematic review aimed to a) provide an overview of manualised attachment-based interventions, without video-feedback as the main component, for caregivers and infants from conception to two years, and b) determine which of these interventions were effective in demonstrating improvements in caregiver-infant relational outcomes. To identify eligible interventions and their empirical evidence base, two search stages were conducted for 1) relevant interventions and 2) studies of interventions identified in the first stage that focussed on caregiver-infant relational outcomes. All studies included in Stage 2 were quality assessed and findings analysed. Twenty-six interventions were eligible for inclusion at Stage 1 but studies reporting on relational outcomes were identified for 16 interventions only. Forty studies reporting on those 16 interventions met inclusion criteria and were synthesised at Stage 2. Most studies were of good quality. Observer-rated measures were used in 90% of studies. There was evidence for these interventions in relation to improving caregiver-infant relational outcomes: 80% of studies reported a statistically significant positive change in a relational outcome for the intervention compared to pre-intervention or control group. The most promising evidence was identified for Attachment and Biobehavioral Catch-Up (ABC), Minding the Baby (MTB) and Circle of Security (COS). This systematic review offers guidance to healthcare professionals, commissioners and policymakers within perinatal sectors in relation to the training, delivery and implementation of evidenced manualised attachment-based interventions.

High-intensity interval training is an effective exercise mode to maintain normal blood pressure during pregnancy: a randomized control trial.

Pregnant women are more susceptible to high blood pressure (BP) than the general adult population; therefore, all means of preventing this condition should be considered. High-intensity interval training (HIIT) is effective in this regard in the general population, but there is a lack of evidence of its effectiveness during pregnancy. This study aimed to compare an 8-week HIIT program to self-performed moderate-to-vigorous physical activity among pregnant women by evaluating changes in BP after a maximal progressive cardiorespiratory exercise test (CPET) performed at pre-intervention and post-intervention time points. A total of 54 Caucasian women in uncomplicated, singleton pregnancies (age 32 ± 4 years, 22 ± 4 weeks of gestation; M ± SD) with normal BP values completed the interventions. The experimental (HIIT) group (n = 34) completed an online supervised HIIT program consisting of three sessions per week and supplemented by an educational class once per week. Participants in the education (EDU) group (n = 20) attended an educational class once per week and were encouraged to perform moderate-to-vigorous physical activity (PA) on their own. Pre- and post-intervention, all women underwent a CPET on a cycle ergometer with a respiratory gas analyzer. On the day of the CPET, maternal systolic and diastolic BP (mmHg) was measured at rest (before the CPET) and approximately 60min after the CPET using an electronic BP monitor. Identical CPET and BP measurement protocols were employed for both the HIIT and EDU groups at the pre- and post-intervention time points. Pre-intervention, the HIIT and EDU groups both showed a decrease in systolic and diastolic BP after the CPET, though only the change in systolic BP was statistically significant (HIIT group: p = 0.01; EDU group: p = 0.001). Post-intervention, there were no significant differences in either group between resting and post-CPET BP. There were significant post-intervention differences in VO2peak (p < 0.001) and HRmax (p = 0.002) between the HIIT and EDU groups. From pre- to post-intervention, the EDU and HIIT groups both showed decreases in resting systolic or diastolic BP; there was a significant difference in systolic BP in the EDU group (p = 0.005) and a significant difference in diastolic BP in the HIIT group (p = 0.03). Both groups maintained normal BP values throughout the experiment. However, HIIT, in addition to maintaining normotension, improved cardiorespiratory fitness in pregnant women. It seems that both supervised HIIT and self-performed moderate-to-vigorous PA can be recommended as strategies to prevent BP disorders during pregnancy. More studies are needed to confirm our findings.Trial registration The full study protocol was registered in ClinicalTrials.gov (NCT05009433).

Improving Outcomes for Patients With Tracheostomy Through Implementation of AARC Clinical Practice Guidelines.

The COVID-19 global pandemic dramatically increased our institution's tracheostomy census. Comparing our existing protocols with American Association for Respiratory Care (AARC) January 2021 clinical practice guideline (CPG) relevant to caring for adult patients with tracheostomy in the acute care setting revealed numerous opportunities for improving our care of those patients. We assembled an interdisciplinary tracheostomy team to implement AARC CPG recommendations and manage all patients with tracheostomy in our hospital. We examined the effect our interdisciplinary team approach and implementation of AARC CPG recommendations had on the following metrics: average patient length of stay (LOS); ICU LOS; percentage of ventilator days; percentage of tracheostomy mask days; tracheostomy tube changes; decannulations; average time to decannulation; mortality; 30-d readmissions; and consultations for speech-language pathology (SLP), one-way speaking valves, physical therapy, and occupational therapy. A total of 203 subjects with tracheostomy were followed in a quality improvement study from June 2019-June 2023 (94 in the pre-intervention group, 109 in the post group). There were significant increases between before and after intervention groups in percentage of decannulations in acutely patients with tracheostomy/not present on admission, non-COVID subjects who survived hospitalization (11.8% vs 33.3%, P = .043), percentage of SLP consults (53.2% vs 89.0%, P < .001), and percentage of one-way speaking valve consults (17.0% vs 32.1%, P = .02). Establishment of an interdisciplinary tracheostomy team and implementation of AARC CPG recommendations for care of adult patients with tracheostomy in the acute care setting resulted in positive, statistically significant outcomes.

Quality improvement project provides unexpected insights into hospitalized pain management

Patient education and multidisciplinary treatment plans are key best practices for pain management in hospitalized patients. In a routine compliance review, stakeholders at Baylor Scott & White Medical Center – Temple identified pain management patient education as an area needing improvement. A dual-sided medication explanation card was developed, including functional expectations and a QR code linking a companion website with additional pain management educational materials. This short communication details the results from a small quality improvement pilot study using QR code technology to deliver pain management education materials to hospitalized patients. Patients were surveyed the morning after admission and survey results are reported using standard descriptive statistics. Of 46 patients who received the education card, 44 reported well-controlled or moderately-controlled pain and 36 asked for as-needed pain medications. Fourteen patients said that the card was straightforward or made the medication options easy to understand. Per analytics, the companion website had at least 37 unique visitors during the survey period, with at least 8 visitors clicking additional links from the homepage. Though 30 % of patients reported that the education card was helpful and/or straightforward regarding medication options (as intended), five patients with moderately controlled pain who asked for as-needed medications reported they were delayed or ineffective, which revealed that timely administration and adjustments to regimens per patient feedback is also essential. Website analytics suggested that patients utilize and engage with available resources at differing rates. Limitations of this pilot study include small patient population, no pre-intervention comparator group, and disruption in analytics data gathering capabilities during the pilot. Despite limited qualitative data, the quality improvement objectively demonstrated regulatory compliance with pain management education standards and it was adopted throughout all the hospitals of the Baylor Scott & White Healthcare system.

Selective Digestive Decontamination: A Comprehensive Approach to Reducing Nosocomial Infections and Antimicrobial Resistance in the ICU.

Background/Objective: Multidrug-resistant (MDR) bacteria pose a significant threat to global health, especially in intensive care units (ICUs), where high antibiotic consumption drives antimicrobial resistance. Selective digestive decontamination (SDD) is a strategy designed to prevent nosocomial infections and colonization by MDR pathogens. This study aimed to evaluate the impact of implementing an SDD protocol on antibiotic consumption and colonization by carbapenemase-producing Enterobacterale (CPE) in a specific ICU setting. Methods: This quasi-experimental study was conducted in the ICU of a university hospital from June 2021 to June 2023. Patients were divided into two groups: pre-intervention (before SDD) and post-intervention (after SDD implementation). Data on antibiotic consumption (expressed as defined daily doses (DDDs) per 100 stays), nosocomial infections, colonization rates, and the incidence of MDR bacteria were collected. A statistical analysis was conducted to compare the pre- and post-intervention groups. Results: A total of 3266 patients were included, with 1532 in the pre-intervention group and 1734 in the post-intervention group. The implementation of the SDD protocol resulted in a significant reduction in total antibiotic consumption (p = 0.028), with notable decreases in carbapenem use (p < 0.01) and colonization by CPE (p = 0.0099). The incidence of nosocomial infections also decreased in the post-SDD group, although this reduction was not statistically significant. Conclusions: The implementation of the SDD protocol in this ICU setting significantly reduced antibiotic consumption and colonization by CPE. These findings suggest that SDD may be a valuable tool in managing antimicrobial resistance in critical care settings, without contributing to the development of MDR bacteria.

Decreasing IV magnesium infusion time to improve delivery of patient care.

Hypomagnesemia is a common issue in patients with cancer due to magnesium wasting drugs like calcineurin inhibitors, chemotherapy sides effects such as diarrhea, and poor oral intake. Historically, magnesium has been given over prolonged infusions due to concern for rapid elimination of magnesium when large doses are administered. At UW Health, magnesium was given at a rate of 1g/60 min. A prolonged infusion rate often creates logistical issues including limited IV access, incompatibility concerns and increased chair time. The purpose of this project is to increase the infusion rate of IV magnesium without compromising therapeutic repletion, benefit, and safety. The magnesium infusion rate was increased to the following rates: 4g/60 min, 2g/30 min, 1g/15 min. The primary outcome is the grams of IV magnesium replaced per outpatient visit between the pre-intervention (prolonged) and post-intervention (rapid) groups. Secondary outcomes include assessment of differences in chair time between groups and total incidence of critical magnesium lab values. There was no statistically significant difference in magnesium requirements per outpatient visit between a prolonged and rapid magnesium infusion rate (2.18g vs 2.15g; p = 0.49). Additionally, there was no difference in number of outpatient visits (3 vs 3; p = 1). The average chair time was decreased by 110 min per outpatient encounter between the prolonged and rapid magnesium infusion rate, which was determined to be clinically and statistically significant. This study suggests that there is no difference in magnesium requirements between a rapid or prolonged magnesium infusion in both solid and liquid tumor patients.

Ketorolac Dose Ceiling Effect for Pediatric Headache in the Emergency Department

OBJECTIVE This study sought to demonstrate a non-inferiority analgesic ceiling effect previously ­demonstrated within adults for pediatric patients receiving a maximum ketorolac dose of 15 mg. METHODS We conducted a retrospective cohort study of pediatric ED patients weighing at least 60 kg treated with 30 mg (pre-intervention) or 15 mg (post-intervention) intravenous (IV) ketorolac for headache. The primary outcome included patient-reported pain scores. Additional outcomes included demographic variables, adjunct medication use and adverse effects. Categorical data were evaluated using a χ2 test, and numerical data were evaluated using an ANOVA F test and Welch 2-sample t test. RESULTS The pre- and post-intervention groups included 216 and 62 patients, respectively. Overall demographics were similar between the groups (72.3% female, 49.3% White/Caucasian, mean age 15.5 years, mean weight 79.2 kg, and mean baseline 10-point pain score 7.5). Twelve (5.6%) in the pre-intervention group required rescue analgesic compared with 2 patients (3.2%) in the post-intervention group (p = 0.416). In the pre-intervention group, 198 patients (91.7%) received nausea medication compared with 52 patients (83.9%) in the post-intervention group (p = 0.087). Mean 10-point pain scores following ketorolac administration decreased by 3.9 in the pre-intervention group compared with 5.1 in the post-intervention group (p = &amp;lt; 0.001). Common (0.9%) or rare (0.9%) side effects were infrequent and only seen in the pre-intervention group patients. CONCLUSIONS Truncating the maximum intravenous ketorolac dose in pediatric patients at least 60 kg in weight to 15 mg compared with 30 mg results in effective analgesia in pediatric patients with headache. Future research could explore differences in admission rates, treatment of other indications, or treatment with multiple-dose regimens.

Enhancing timeliness of port placement for new treatment patients: A quality improvement initiative.

335 Background: Timely port placement is crucial for patients beginning new treatments, yet delays can impede care and satisfaction. This initiative aimed to address these delays and improve port placement efficiency for new treatment patients. Methods: A single-center prospective cohort study was conducted between July 2022 and December 2023. Data was collected to assess the time from port order to port placement. Interventions included concurrent scheduling of consult and port placement visits in coordination with interventional radiology (IR) and workflow redesign to enhance oncology navigator involvement by directing port orders to an oncology navigation pool for expedited processing and scheduling. The primary endpoint was to compare the mean difference in days between IR consult order and port placement among pre- and post-intervention groups. Results: The study included 144 patients: 102 in the pre-intervention group (July 2022-June 2023) and 42 in the post-intervention group (July 2023-December 2023). The post-intervention group showed a 26.35% improvement in time to port placement from appointment, compared to pre-intervention intervals. The combined quarterly mean indicated a 14.37% reduction in time to port placement from order. The mean interval between IR consult order and port placement was 15.59 days pre-intervention and 13.35 days post-intervention, with a mean difference of 2.24 days (CI -0.92 to 5.4; p = 0.08). Conclusions: This quality improvement initiative demonstrated substantial progress in reducing delays in port placement for new treatment patients. Optimizing workflow processes and increasing navigator involvement significantly improved timeliness and the overall patient experience. Continued monitoring and refinement of these interventions are essential for sustaining these improvements over time. Mean interval between IR consult order and port placement. Timeframe of Pre-intervention Group Mean of Pre-Intervention Group* Mean of Post-Intervention Group* (July 2023-Dec 2023) Mean Difference Between Pre and Post Intervention Group* Standard Error Confidence Interval p-value July 2022-Dec 2022 16.12 13.35 2.76 1.91 -1.04 to 6.57 0.07 Jan 2023-Jun 2023 14.93 13.35 1.58 1.59 -1.59 to 4.74 0.16 July 2022-Jun 2023 (overall) 15.59 13.35 2.24 1.60 -0.92 to 5.40 0.08 *Mean expressed in days.

The 'vulnerable nerve'; surgically acquired neuropathy in distal humeral surgery patients and the role of a tourniquet.

The complication of neuropathy is high in patients undergoing distal humerus surgery. Tourniquets (TQs) are typically used but can lead to nerve injury. We present a comparative study of a pre-intervention group (n = 38) and a post-intervention group (n = 38) undergoing distal humerus surgery between November 2020 and July 2023. The intervention included TQ discontinuation and the introduction of intravenous tranexamic acid at induction. Our analysis encompasses patient, anaesthetic, and surgical variables, as well as the rates and severity of neuropathy. Post-intervention, the rate of surgically acquired or deterioration in nerve injury improved from 15.8% (n = 6) to 2.6% (n = 1). Pre-intervention, the mean TQ duration was significantly longer for patients with post-operative neuropathy versus those without (120 min, SD = 29 vs. 88 min, SD = 38, p = 0.032). Surgery duration was not significantly longer without a TQ but was associated with a greater reduction in haemoglobin (12.7 g/L, SD = 10.9 vs. 25.2 g/L, SD = 15.5, p = 0.03). Trauma patients have a high risk of acquiring a nerve injury following elbow surgery or deterioration of a pre-surgical nerve injury, which emphasises the concept of vulnerable nerves. The cessation of using a TQ was associated with a lower nerve injury rate, with no cases of major nerve injury and no significant increase in surgical time.

Improving Patient Understanding of Emergency Department Discharge Instructions

Introduction: Previous studies have shown that patients in the emergency department (ED) are frequently given incomplete discharge instructions that are written at least four grade levels above the recommended sixth-grade reading level, leading to poor understanding. Our aims in this study were to implement standardized discharge instructions containing six key components written at a more appropriate reading level for common emergency department (ED) diagnoses to improve patient understanding. Methods: We conducted this study in a 20-bed ED at an urban Veteran’s Administration hospital. Data was collected via in-person patient and clinician interviews. Patient interviews were conducted after patients received their discharge instructions. We compared patient responses to clinician responses and marked them as incorrect, partially correct, or correct with a score of 0, 0.5, or 1, respectively. The maximum possible score for each interview was six. Six key components of discharge instructions were asked about: diagnosis; new medications; at-home care; duration of illness; reasons to return; and follow-up. There were 25 patients in the pre-intervention group and 20 in the intervention group with the standardized set of instructions. We performed a Mann-Whitney U test on the total interview scores in the control and intervention groups and conducted a sub-analysis on the individual scores for each of the six key components. Results: The patients in the intervention demonstrated a statistically significant increase in patient-clinician correlation when compared to the patients in the pre-intervention group overall (P &amp;lt; 0.05), and two of the six key components of the discharge instructions individually showed statistically significant increase in patient-clinician correlation when standardized discharge instructions were used. Conclusion: Patients who received the standardized discharge instructions had improved understanding of their discharge instructions. Future opportunities extending off this pilot study include expanding the number of diagnoses for which standardized instructions are used and investigating patient-centered outcomes related to these instructions.

Corticosteroid Prescribing Patterns in the Emergency Department for Acute COPD Exacerbations: A Retrospective Analysis Following an Educational Intervention.

COPD is a progressive lung disease with marked airflow limitation. It has a large global prevalence and is managed with antibiotics, bronchodilators, and corticosteroids. Despite the prevalence, corticosteroid prescribing regimens differ widely amongst providers. This study aims to evaluate baseline corticosteroid prescribing patterns, the ability to change corticosteroid prescribing patterns with the utilization of an educational initiative, and to evaluate the effect of corticosteroid dose on length of stay, 30-day hospital readmission, mortality, and total hospital insulin dosing. This study was conducted via a retrospective observational study. Providers at a single institution answered a baseline questionnaire on COPD corticosteroid prescribing patterns and subsequently received an educational presentation regarding evidence-based corticosteroid recommendations. Data were then retrospectively obtained and analyzed evaluating corticosteroid prescribing patterns both pre- and post-educational intervention. Data were analyzed using IBM SPSS Version 25. The provider survey revealed that most (95.3%) administered 125 mg of methylprednisolone to patients treated for AECOPD. The most common reason a particular dose of corticosteroid was administered was due to previous teaching or practice patterns. The mean initial steroid dose of methylprednisolone decreased following the educational initiative from 114.24 mg to 72.8 mg (p < 0.01). This corresponded to a 69% (n=41) decrease of providers using 125 mg methylprednisolone (p < 0.01), and increased prescribing of 62.5 mg methylprednisolone by 42.6% (n=66). The mean LOS following hospital admission for AECOPD in the pre-intervention group was 5.80 days, while the mean LOS following the targeted educational intervention decreased to 4.82 days (p = 0.01). The implementation of an educational intervention may change provider corticosteroid prescribing patterns. Additionally, lower corticosteroid dose in the Emergency Department may decrease patient length of stay. Keywords: Corticosteroid, COPD, LOS, recommendations, steroid.

WP1.18 - A Surgical Post-Take Ward Round Checklist Proforma: A Prompt for Improved Documentation

Abstract Aims Surgical ward rounds are often swift, therefore documentation of diagnostic and management decisions is frequently incomplete. The Royal College of Surgeons of Edinburgh (RCSEd) devised a ward round checklist toolkit to improve documentation of surgical post-take ward rounds. Methods We conducted a baseline audit of our district general hospital general surgery post-take ward round documentation, based on the RCSEd checklist. Documentation in each domain was recorded for each ward round entry for both pre and post intervention groups. Control patients were identified from the surgical take list across 7 different days in a month. The checklist toolkit was then adapted into a proforma for our institution and used on post-take ward rounds for a trial period of 7 days. Results 40 patients were included in the pre-intervention group, 17 in the post intervention group. Following the introduction of the post take ward round proforma, documentation of most recent observations improved from 40% to 82%, admission blood results from 27.5% to 94%, and imaging results from 42% to 90%. Areas of existing good practice improved; history and examination findings were documented in 100% of patients, an improvement from 80% pre-intervention. Nil by mouth status was documented in 80% of cases, up from 50%, and IV fluid requirement in 58%, up from 10%. Conclusions A proforma for post take ward rounds improved documentation of key diagnostic and management information. As a result, we recommend a standardised approach to documentation to encourage consistency of recording key information in the patient record.

SP8.5 - Enhancing the confidence of FY1 Doctors in managing General Surgical Patients through the introduction of an online handbook– A quality improvement project

Abstract Background Emerging as a Foundation Year 1 (FY1) doctor from undergraduate training can be daunting. Furthermore, working in Colorectal Surgery can pose challenges: managing both elective and acute surgical patients with complex needs. We designed a General Surgery and Colorectal Surgery handbook to help FY1 doctors navigate training. This Quality Improvement Project aimed to assess the impact of and alleviate some of the uncertainty experienced by FY1 doctors during this transitional phase. Methods An electronic handbook was compiled with contributions from across the Multidisciplinary Team which was reviewed and approved for distribution within our Trust. An online questionnaire was distributed to assess pre-placement confidence in key domains on a 10-point Likert scale. This was sent to FY1 doctors who had previously completed a rotation within colorectal surgery without the handbook. The handbook was distributed to new cohort of FY1 doctors a week prior to the start of their rotation in Colorectal Surgery. An identical questionnaire was sent to the new cohort of FY1s within a month of their rotation and results were compared with previous cohort. Results In all surveyed areas, there was an improvement in confidence in the post-intervention group compared to that shown in the pre-intervention group. The average improvement in median score across all areas was 3.8 points. Conclusion This project demonstrated an overwhelmingly positive response to a formalised handbook by FY1 doctors in training. This intervention has helped FY1 doctors manage colorectal and general surgery patients with enhanced confidence thus paving way for safer patient care.

Buprenorphine Use in the Military Health System (MHS).

The CPG's updated recommendation is supported by buprenorphine's lower risk of overdose and misuse.(1) In comparison to full mu-opioid agonists, buprenorphine possesses a superior safety profile with respect to respiratory depression, even in non-dependent individuals, and fatal overdose, when not combined with other sedating medications.(2-5) Purpose/hypothesis: This project identifies prescribing trends of buprenorphine for chronic pain before and after implementing two pharmacy interventions. Procedures/data/observations: Patient charts were reviewed before and after removal of a drug authorization key in the electronic health record and development of an educational presentation for providers. In the pre-intervention group, 19 patients were included and 13 patients in the post-intervention group. Prescriptions for buprenorphine decreased by 31.5% from the pre-intervention to post-intervention period, but three new prescriptions were started after interventions. Adverse reactions were the cause of the decrease in prescriptions, most commonly nausea and vomiting. This data may be valuable to providers as they expand their knowledge about buprenorphine's analgesic use. This is a longitudinal project and identifying barriers that may limit prescribing of buprenorphine may be beneficial for future educational interventions.

Improving effective coverage of medical-oxygen services for neonates and children in health facilities in Uganda: a before–after intervention study

Medical oxygen services are essential for the care of acutely unwell patients. We aimed to assess the effects of a multilevel, multicomponent health-system intervention on hypoxaemia detection, oxygen therapy, and mortality among neonates and children attending level IV health centres and hospitals in Uganda. For this before-after intervention study, we included children who attended paediatric or neonatal wards of 24 level IV health centres and seven general or regional referral hospitals in the Busoga and North Buganda regions of Uganda between June 1, 2020, and June 30, 2022. All neonates younger than 1 month and children aged 1 month to 14 years were eligible for inclusion. We excluded neonates who were not sick but stayed in the maternity ward for routine postnatal care. The intervention involved clinical training, mentorship, and supportive supervision; provision of pulse oximeters and cylinder-based oxygen sources; biomedical-capacity support; and support to develop and disseminate oxygen supply strategies, oxygen therapy guidelines, and lists of essential oxygen supplies. Trained research assistants extracted individual patient data from case notes using a standardised electronic data collection form. Data were collected on health-facility details, age, sex, clinical signs and symptoms, admission diagnoses, pulse oximetry readings, oxygen therapy details, and final patient outcome. The primary outcome was the proportion of admitted neonates and children with a pulse oximetry oxygen saturation reading documented in their patient case notes on day 1 of health-facility admission (ie, pulse oximetry coverage). We used mixed-effects logistic regression to evaluate the effect of the intervention. We obtained data on 71 997 eligible neonates and children admitted to 31 participating health facilities; the primary analysis included 10 001 patients in the pre-intervention period (ie, June 1 to Oct 30, 2020) and 51 329 patients in the post-intervention period (ie, March 1, 2021, to June 30, 2022). Because 1356 patients had missing data for sex, 4365 (46·7%) of 9347 in the pre-intervention group and 22 831 (46·2%) of 49 410 in the post-intervention group were female; 4982 (53·3%) in the pre-intervention group and 26 579 (53·8%) in the post-intervention group were male. The proportion of neonates and children with pulse oximetry at admission increased from 2365 (23·7%) of 10 001 in the pre-intervention period to 45 029 (87·7%) of 51 328 in the post-intervention period. Adjusted analysis indicated greater likelihood of a patient receiving pulse oximetry during the post-intervention period compared with the pre-intervention period (adjusted odds ratio 40·10, 95% CI 37·38-42·93; p<0·0001). Large-scale improvements in hospital oxygen services are achievable and have the potential to improve clinical outcomes. Governments should be encouraged to develop national oxygen plans and focus investment on interventions that have been shown to be effective, including the introduction of pulse oximetry into routine hospital care and clinical and biomedical mentoring and support. Bill & Melinda Gates Foundation and ELMA Philanthropies. For the Luganda and Lusoga translations of the abstract see Supplementary Materials section.

Abstract P402: The Impact of Preeclampsia Education in Rural Communities

Preeclampsia (PE) and other hypertensive disorders of pregnancy are the leading cause of maternal and perinatal morbidity and mortality. There are 4,000 PE cases/year in IA. Rural counties are at a significantly higher risk of pregnancy-related mortality. A lack of PE education regarding signs and symptoms may contribute to this risk. PE complications and mortality may be preventable with early implementation of patient education on preeclampsia during pregnancy. Our objective was to determine if implementing a magnet as an intervention increases patients' knowledge of the signs and symptoms of PE. A magnet that includes common signs and symptoms of PE was designed to serve as an educational visual aid for patients. Pregnant patients ≥18 years old from two hospitals in Northwest IA were recruited. A pre-survey was given at a prenatal appointment prior to receiving the magnet. The post-magnet survey was administered during admission for delivery. The control group did not receive the magnet. Pre- and post-surveys asked about preeclampsia and current understanding, if they received a magnet, if it was referenced, number of healthcare visits, questions during visits about PE, and if they were diagnosed with PE. Between 8/23-5/24, 62 pre- and 83 post-magnet surveys were collected. Statistical analyses were performed using a 95% confidence interval with p&lt;0.05 considered significant. Ages ranged from 18-42 years old, with majority Caucasian patients (69% in pre-survey and 58% in post-survey). Levels of highest education obtained ranged from 4 th grade to doctoral degree, with the majority completing high school as the highest level of education (29%).The magnet group rated their level of understanding of PE as good to excellent which was higher than both pre-intervention and control groups. Both control and magnet groups identified more symptoms and complications of PE on the post-survey compared to the pre-survey. Both control and magnet groups were noted to have increased discussions about preeclampsia with their physician. Lastly, both groups had increased knowledge on what to do if they developed symptoms on the post-survey compared to pre-survey responses. Of the magnet group, 71% thought receiving a magnet was helpful to increase awareness of PE. Implementation of a magnet increased patient literacy regarding the signs, symptoms, and complications of PE, discussions with physicians, and knowledge of what to do if patients develop symptoms of PE.

An Economic Cost Analysis of Implementing a Frailty Care Bundle to Reduce Risk of Hospital Associated Decline Among Older Patients.

To conduct an economic cost analysis and budget impact assessment (BIA) of implementing the Frailty Care Bundle (FCB) intervention nationally over five-years for hip fracture patients. The FCB was designed to reduce hospital associated decline in older hospitalised patients. The FCB was delivered in two Irish hospitals on two wards per hospital. A micro level cost analysis, from the Irish health service perspective was undertaken. Direct costs of the FCB were considered (personnel, training, resources), expressed in Euros (2020). For the BIA national population estimates for hip fracture and costs avoided were based on 18% difference in patients returning to their baseline capability in the post compared to pre-intervention group, valued using cost estimates of functional decline. We estimated total intervention costs at €53,619 (89% for personnel) and the average cost per patient was €156.03. The expected costs of implementing the FCB nationally over 12-months was €57,274 per hospital (€72.92 per patient). The BIA for an expected targeted population (16,000 over 5 years), estimated that the cost of implementing the FCB (€1.2m) was less than the expected value of functional decline avoided owing to the intervention (€3.6m), suggesting a positive net effect (€2.4m). Investment in the FCB can be offset with more rapid patient return to baseline functional capability, reducing health care costs. Trial and Protocol Registration (retrospective): BMC ISRCTN 15145850, (https://doi.org/10.1186/ISRCTN15145850).

A pre and post interventional audit of an 'apple juice on arrival' protocol to reduce excessive clear fluid fasting times in paediatric patients.

Many studies have reported prolonged fasting times in children, associated with negative metabolic and behavioural outcomes. We felt that although our paediatric preoperative clear fluid fasting guideline was only for 2 hours, prolonged fasting still occurred for some patients. We conducted an audit of paediatric fasting times, before and after introducing a new protocol of 'apple juice on arrival', in which, on arrival to the children's ward, all children received 3 ml/kg of apple juice. Data were collected prospectively from patients and their parents for two 4-week periods (before and after introduction of the protocol). Data included fasting time (solids and clear fluids), capillary blood glucose levels, knowledge of fasting requirements and sources of fasting information before surgery. Thirty-nine and 40 children, respectively, were included in each group before and after protocol introduction. Clear fluid fasting times reduced from an average of 9.9 hours pre-intervention to 3.5 hours post intervention (P < 0.01). In addition, mean preoperative blood sugar levels increased from 4.9 mmol/L (pre-intervention group) to 5.6 mmol/L in the post-intervention group (P < 0.001). The implementation of an apple juice on arrival protocol appeared to be an effective method to reduce clear fluid fasting times in children in our institution.

Combination of a Rapid Diagnostic Assay and Antimicrobial Stewardship Intervention for Gram-Negative Bacteremia.

Traditional blood cultures for gram-negative bacteremia can take up to 72 hours or more to return results, prolonging the duration of empiric broad-spectrum intravenous antibiotics. The Accelerate Pheno system provides rapid identification and susceptibilities for blood cultures in gram-negative bacteremia. Current data on its clinical utility are mixed overall, so the system requires further research. A multicenter, retrospective quasi-experimental study was conducted comparing the Accelerate Pheno rapid diagnostic system with antimicrobial stewardship intervention and traditional blood cultures alone. A total of 264 patients with blood cultures with gram-negative bacteria growth were included in the final analysis (102 pre-intervention, 162 post-intervention). The antimicrobial stewardship team made 364 recommendations in 152/162 (93.8%) patients in the post group. Duration of intravenous therapy was shorter (P < .001) for the post-intervention group (median, 4.0 days) compared with the pre-intervention group (median, 7.5 days). Hospital length of stay was also shorter (P < .001) for the post-intervention group (median, 5.1 days) compared with the pre-intervention group (median, 7.0 days). Readmission rates within 30 days were reduced (P = .042) post-intervention (13.0%) compared with pre-intervention (22.6%). In the post-intervention group, a larger proportion of patients were transitioned to oral therapy at any point (126/162, 77.8%) compared with pre-intervention (62/102, 60.8%; P < .001). These results suggest that the Accelerate Pheno system, with active review and intervention by a multidisciplinary antimicrobial stewardship team, is a useful tool in improving both patient-centric and antimicrobial stewardship outcomes.

Risk evaluation and mitigation strategy compliance for pulmonary hypertension medications after policy implementation with computerized provider order entry support.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Treatment for pulmonary hypertension includes medications with risk evaluation and mitigation strategy (REMS) programs. Health-system inpatient pharmacies dispensing these agents must comply with inpatient REMS dispensing criteria. Implementing a health-system policy with computerized provider order entry (CPOE) decision support may improve REMS compliance. This was a retrospective, quasi-experimental study comparing REMS compliance before and after development of a policy with CPOE decision support that was implemented in August 2019. Patients 18 years of age or older with a diagnosis of pulmonary hypertension were included if they received at least one dose of an endothelin receptor antagonist or riociguat while hospitalized. Patients were included in the preintervention group if they were hospitalized between August 1, 2017, and August 31, 2019, and in the postintervention group if they were hospitalized between September 1, 2019, and August 31, 2021. The primary outcome was the REMS compliance rate. Secondary endpoints included the time to REMS compliance and independent factors associated with failed or delayed REMS compliance. A total of 150 patients were included, with 75 patients in both the pre- and postintervention groups. Compliance increased significantly from the preintervention (50%) to postintervention (92%) group (P < 0.001). Time to compliance was also significantly reduced from 770 minutes in the preintervention group to 140 minutes in the postintervention group (P = 0.031). Factors independently associated with REMS compliance were being in the postintervention group (odds ratio, 16.9; 95% confidence interval, 5.8-49.2) and being admitted to a pulmonary hypertension center for comprehensive care. (odds ratio, 7.8; 95% confidence interval, 2.9-21.2). A health-system policy with CPOE decision support improved both the rate of and time to compliance with inpatient REMS dispensing procedures.