Pre-intervention Group Research Articles

Effect of implementation of a colorimetric quantitative blood loss system for postpartum hemorrhage.

To evaluate if the implementation of a colorimetric quantitative blood loss (QBL) system during cesarean delivery improves clinical outcomes. We conducted a retrospective cohort analysis after cesarean section before and after implementation of the Triton based colorimetric QBL system. Prevalence of postpartum hemorrhage, amount of blood products transfused, length of hospitalization, and rates of intensive care unit (ICU) admission were compared. A total of 2221 patients were included. There were 1192 patients in the pre-intervention group and 1029 patients in the post-intervention group. There was no significant difference between groups in the prevalence of postpartum hemorrhage (8.6% vs 9.3%, P= 0.57), amount of packed red blood cells (pRBCs) transfused (45 vs 30, P= 0.41) or average length of hospital stay in days (3.0 vs 3.0, P= 0.37). There was a statistically significant decrease in ICU admissions between the pre- and post-intervention groups (2.2% vs 1.0%, P= 0.02). There was no effect of implementation of the colorimetric QBL application system on diagnosis of postpartum hemorrhage, amount of blood products transfused, or length of hospital stay. Although a significant decrease in ICU admissions was observed, we could not determine if these transfers were hemorrhage related.

Implementing a Clinical Decision Tool to Improve Oncologic Venous Thromboembolism Management.

Background:Cancer patients with venous thromboembolic (VTE) disease are complex, and many factors must be considered when initiating anticoagulation management. Clinical decision support systems can aid in decision-making by utilizing guidelines at the point of care.Objectives:The purpose of our project was to develop, implement, and evaluate an electronic clinical decision tool (CDT) utilizing evidence-based guidelines to aid in decision-making for adult oncologic patients who present with new VTE to symptom care clinics.Methods:We compared a pre-intervention group of patients who were prescribed anticoagulation (n = 98) with two post-intervention groups: CDT applied (n = 96) and not applied (n = 46). Outcomes included whether the CDT anticoagulation recommendations were followed and if the tool was perceived to be helpful or improve confidence in initiating management for new VTE by the SCC advanced practitioners and physicians.Results:There was no significant difference between the pre- and post-intervention groups in how many of the CDT anticoagulation recommendations were followed (68.8% pre-intervention, 60.8% post-intervention tool applied, and 63.5% post-intervention tool not applied; χ2 [2, N = 161] = .921, p = .631). However, the tool was found to be helpful and improved confidence of the providers in initiating management for new VTE (pre median = 3, interquartile range [IQR] = 2, 3.5; post median = 3, IQR 3, 4; p = .033).Conclusion:This CDT provided evidence-based anticoagulation recommendations for cancer-associated VTE and enhanced familiarity with the standard of care. Further development of the CDT will be required to account for situations that resulted in deviation from the recommendations.

Cost Reduction for Knee-Spanning External Fixation in the Staged Treatment of Tibial Plateau Fractures: A Practical Intervention.

To determine whether an educational intervention affects surgeon implant decision making measured by total implant costs for temporizing a knee-spanning external fixation construct. A total of 24 cases were prospectively collected after an educational intervention and matched to 24 cases before intervention using Schatzker classification and by surgeon. A single Level 1 trauma center. Forty-eight patients with Schatzker II-VI tibial plateau fractures. Education session to create transparency with component pricing and to provide 3 clinical cases of Orthopaedic Trauma Association/AO 41-C3 (Schatzker VI) with accompanying images and fixator construct costs. Total implant costs displayed in the session ranged from $2354 to $11,696. External fixator construct cost. The mean cost of constructs in the postintervention group was $4550.20 [95% confidence interval (CI) $3945.60-$5154.00], which was significantly different compared with the preintervention group cost of $6046.75 (95% CI = $5309.54-$6783.97, P = 0.003). After 1 year, the total implant costs of external fixation constructs were reduced by an average of almost $1500 per patient. An educational intervention created a reduction in the average total implant construction costs for temporary knee-spanning external fixation in the treatment of tibial plateau fractures. Surgical implant selection and cost variance remain an ideal area to improve value for patients and hospitals. Empowering surgeons with knowledge regarding implant prices is a critical part of working toward the cost reductions of external fixation constructs.

MANAJEMEN LEAN PADA LAYANAN KEMOTERAPI ANAK RAWAT INAP DI RUMAH SAKIT CIPTO MANGUNKUSUMO

Background: Cancer in children has high morbidity and mortality.
 Retinoblastoma is the most common solid tumor in children at the
 Cipta Mangunkusumo Hospital (RSCM). Chemotherapy is one of
 the therapeutic modalities, interdisciplinary and many procedures.
 Lean management continuously reduces waste and improves work flow.
 Objective: This study used lean management to determine the
 efficiency of health care in teaching hospital.
 Methods: Action research was conducted at RSCM. Sampling by purposive sampling that represents the role in the flow of the service process. The observation guide uses cycle time observation
 sheets, value-added analysis sheets, waiting time and lead time.
 The waste found is listed in the DOWNTIME matrix. Observations
 were made on inpatient chemotherapy services for children and
 then a diagnosis was made using Value Stream Mapping. The
 Kaizen team consisted of pharmacists, nurses, doctors doing a plan-do-study-action, prepared an intervention plan, and conducted
 post-intervention observations. The 5S method is used to improve
 service flow.
 Results: In this study, patients with retinoblastoma in class III in
 patient ward included were 7 patients in the pre-intervention group and 16 patients in the postintervention group. Major decreases in lead time happened in the subprocesses of ordering chemotherapy (75%), decision-making of chemotherapy administration (55%) and
 filling of the resume (41%). Lead time process in chemotherapy administration for retinoblastoma changed from 48 hours, 36 minutes
 (more than 2 days) to 38 hours, 38 minutes (1.6 days or less than
 2 days). The efficiency of the process was measured using value
 added ratio which showed changes from 33% to 37%.
 Conclusion: 
 Lean management applied in the process of chemotherapy administration in the inpatient wards increased the
 efficiency of the process.

Impact of an anti-infective screening and monitoring protocol together with infectious disease consultation in preventing infective adverse events in patients treated with anti-CD20/CD52 agents for multiple sclerosis

BackgroundMonoclonal antibodies have been a milestone in the treatment of multiple sclerosis (MS). Infective complications have been observed in patients on agents targeting lymphoid cells’ surface antigens, namely anti-CD52 (alemtuzumab) and anti-CD20 agents (ocrelizumab and rituximab). Despite increasing emerging data, there is no standardized consensus regarding pre-treatment testing, vaccinations, and patient education before and during MS therapy or optimal infection-control strategies. MethodsWe led a retrospective/prospective real-life study to evaluate the effectiveness of a program of screening and prophylaxis for infective adverse events in patients with multiple sclerosis and related disorders treated with drugs directed against CD20/52 antigens. All patients referring to the MS Clinical Care and Research Center, University of Naples “Federico II”, who started on alemtuzumab, ocrelizumab or rituximab (off-label use) from 1 November 2015 to 30 June 2019 were recruited. From the 1st of February 2018 patients underwent a microbiological screening and were evaluated by an infectious disease specialist (IDs) before monoclonal antibodies infusion to rule out active infections. We evaluated incidence of infective complications and predictors before (retrospectively)and after (prospectively) the introduction of the above-mentioned anti-infective program. ResultsWe enrolled 275 patients, 104 retrospectively (pre-intervention group, PRE) and 171 prospectively (post-intervention group, POST). In PRE group, most patients were treated with alemtuzumab (58% vs 32%, p < 0.001), were more frequently DMT naïve (48% vs 36%, p = 0.044) or had received fingolimod in the past (48% vs 28%, p = 0.044) and the follow-up period was longer than in POST group (750 vs 191 days, p < 0.001). In POST group, patients were older (median age 47 vs 42 years, p = 0.030) and mostly received OCR (54% vs 14%, p < 0.001). Lymphopenia at baseline was significantly more commonly observed in PRE arm (47% vs 8%, p < 0.001). A total of 39 patients (38%) in PRE arm and 42 patients (25% in POST) group experienced one or more infections (p = 0.022); severe infections were significantly more common in PRE patients (23% vs 14%, p = 0.022). Our anti-infective program was associated with a lower IAE incidence both at univariate and multivariate analysis (aHR of infective events in PRE group: 3.652 [CI: 9.03-94.19], p < 0.001). Moreover, DMT naïve patients significantly experienced fewer infective complications (aHR: 0.470, [CI: 1.02-2.55], p = 0.040). ConclusionsA risk mitigation program including infectious disease consultation and standardized screening and prophylactic protocols was effective in reducing infective adverse events in patients receiving anti CD20/CD52 agents for MS.

Change in timing of induction protocol in nulliparous women to optimise timing of birth: results from a single centre study

BackgroundInduction of labour (IOL) is a common obstetric intervention. When planning IOL, especially in women at risk for complications at delivery, the aim should be for delivery to occur when senior staff are available to optimise safe care.MethodsA change in timing of IOL protocol at our institution was introduced in November 2018 aiming to increase births occurring “in-hours” defined as 08:00 to 20:00 h. This retrospective cohort study compares the odds of “in-hours” birth before and after the intervention and the association on birth outcomes. The study compared outcomes during the new IOL pathway period to a historical birth cohort from January to December 2017. Inclusion criteria were nulliparous women undergoing planned IOL at term with a cephalic singleton pregnancy. Logistic regression was used to compare odds of in-hours birth for the 2 periods with adjustment for maternal age at delivery, gestation, more than 2 cervical ripening agents required, undergoing IOL for post-dates pregnancy, mode of birth, whether or not IOL proceeded according to planned protocol and missing values using multiple imputation.ResultsThe rate of deliveries occurring in-hours were higher following the intervention; n = 118/285 (45.6%) pre-intervention versus n = 251/470 (53.4%) post-intervention; adjusted OR = 1.47, 95% CI = 1.07–2.01, p = 0.02). The percentage of caesarean sections (CS) occurring in-hours was significantly lower in the pre-intervention group n = 71/153 (28.3%) compared with the post intervention group = 35/132(46.4%) (p < 0.001)). The rate of CS was higher in the pre intervention n = 132/285(46.3%) compared with the post intervention group n = 153/470 (32.4%)).ConclusionsThe change in induction procedures was associated with a significantly higher rate of births occurring in-hours and a lower rate of overall of CS. This policy change led to a better pattern of timing of birth for nulliparous women undergoing IOL.

The Feasibility of Implementing Targeted SEDation in Mechanically Ventilated Emergency Department Patients: The ED-SED Pilot Trial.

Deep sedation in the emergency department (ED) is common, increases deep sedation in the ICU, and is negatively associated with outcome. Limiting ED deep sedation may, therefore, be a high-yield intervention to improve outcome. However, the feasibility of conducting an adequately powered ED-based clinical sedation trial is unknown. Our objectives were to assess trial feasibility in terms of: 1) recruitment, 2) protocol implementation and practice change, and 3) safety. Patient-centered clinical outcomes were assessed to better plan for a future large-scale clinical trial. Pragmatic, multicenter ( n = 3), prospective before-after pilot and feasibility trial. The ED and ICUs at three medical centers. Consecutive, adult mechanically ventilation ED patients. An educational initiative aimed at reliable ED sedation depth documentation and reducing the proportion of deeply sedated patients (primary outcome). Sedation-related data in the ED and the first 48 ICU hours were recorded. Deep sedation was defined as a Richmond Agitation-Sedation Scale of -3 to -5 or a Sedation-Agitation Scale of 1-3. One thousand three hundred fifty-six patients were screened; 415 comprised the final population. Lighter ED sedation was achieved in the intervention group, and the proportion of deeply sedated patients was reduced from 60.2% to 38.8% ( p < 0.01). There were no concerning trends in adverse events (i.e., inadvertent extubation, device removal, and awareness with paralysis). Mortality was 10.0% in the intervention group and 20.4% in the preintervention group ( p < 0.01). Compared with preintervention, the intervention group experienced more ventilator-free days [22.0 (9.0) vs 19.9 (10.6)] and ICU-free days [20.8 (8.7) vs 18.1 (10.4)], p < 0.05 for both. This pilot trial confirmed the feasibility of targeting the ED in order to improve sedation practices and reduce deep sedation. These findings justify an appropriately powered clinical trial regarding ED-based sedation to improve clinical outcomes.

Pengaruh Suplementasi Vitamin C Terhadap Tingkat Stres Mahasiswa Fakultas Kedokteran Angkatan 2016 Universitas Ciputra

Introduction: Stress is an event that places a strain or demand on a person, disrupting the body's balance and physical and psychological conditions. Students often experience stress due to the numerous orders placed on them regarding learning and extracurricular activities on campus. Because medical students are prone to stress due to academic factors and the pressure they face, additional treatment is required to ensure that it does not have a long-term impact. Objective: This study aims to show that vitamin C supplementation can help medical students at Ciputra University feel less stressed. Method: A pre-and post-experimental study and the total sampling technique were used, and the respondents were divided into two groups: treatment and control. The DASS (Depression Anxiety Stress Scale) questionnaire was used in this study as the instrument. After that, the paired t-test was used to examine the data. The findings revealed that 66.6 percent of students in the pre-intervention experimental group experienced mild stress. In comparison, 29.16 percent of students in the pre-intervention control group had a normal pre-experimental score of 17.96. With an average result of 11.58, 95.8% of the participants in the post-intervention experimental group or after vitamin C supplementation were classified as usual. In a comparative test, the average stress score before and after supplementation differed significantly (p = 0.05). It can be concluded that supplementing with vitamin C can help students cope with stress.

Impact of pharmacist intervention in reducing vancomycin-associated acute kidney injury: A systematic review and meta-analysis.

The aim was to quantify the relationship between pharmacist intervention and vancomycin-associated acute kidney injury (AKI). Electronic databases were searched up to August 2020 for meta-analyses of cohort studies and/or randomized controlled trials. Studies that compared the incidence of AKI in patients between post- and prepharmacist intervention were investigated. The primary outcome was incidence of AKI. We also evaluated the influence of pharmacist intervention in risk factors of vancomycin-associated AKI. The search strategy retrieved 1744 studies and 34 studies with 19 298 participants were included (22 published articles and 12 abstracts from conference proceedings). Compared with the preintervention group, the postintervention group patients had a significantly lower incidence of vancomycin-associated AKI: 7.3% for post- and 9.6% for preintervention (odds ratio [OR] 0.52, 95% confidence interval [CI]; 0.41, 0.67], P< .00001). The rate of attaining target concentration was significantly higher in the post- than preintervention group (OR 2.86, 95% CI [2.23, 3.67], P< .00001). The postintervention group significantly improved the percentage of serum creatinine laboratory tests than preintervention group (OR = 3.24, 95% CI 2.02, 5.19], P< .00001). Patients postintervention had markedly lower risk of mortality than preintervention patients (OR 0.47, 95% CI [0.31, 0.72], P= .0004). Pharmacist intervention in vancomycin treatment significantly decreased the rate of vancomycin-associated AKI, while improving efficacy and reducing mortality. We speculate that this is because the pharmacist interventions optimized the rationality of vancomycin therapy, monitoring of vancomycin trough concentration and the monitoring of patients' renal function.

Interdisciplinary Protocol for Surgery in Older Persons: Development and Implementation.

As the population ages, more older adults will undergo surgical procedures, and common physiologic changes can raise the risk for surgical complications while increasing morbidity and mortality. In conjunction with the National Surgical Quality Improvement Program, we piloted a comprehensive and interdisciplinary assessment and intervention protocol for perioperative care for patients aged ≥75years undergoing elective general, gynecology-oncologic, and orthopedic surgery. The intervention included screening tools for cognitive, functional, and nutritional deficits, a Geriatric Nurse Champion on each inpatient surgical unit, and an interdisciplinary Geriatric Surgery Quality Committee. Our intervention group was compared to surgical patients during the same time period 1year prior to the intervention, and the groups were well matched in demographics and comorbidities. The intervention group had significantly higher rates of advance care plan documentation in analysis of all patients (P < .001) and in subgroup analysis of those 85 and older (P= .006). The preintervention group had less postoperative delirium compared to the postintervention group but it was not significant and there was no difference in length of stay between groups. Various explanations for the minimal impact of the protocol exist: small sample size, presence of other hospital initiatives to reduce pressure ulcer and delirium, and clinician's awareness of project planning that led to incorporating ideas prior to official implementation. Future research implementing this protocol in naïve and/or underperforming institutions may demonstrate a greater effect. Larger sample size as well as implementation in other surgical fields may reveal a significant impact. However, if additional study does not reveal a meaningful impact of a comprehensive geriatric assessment for surgical patients, then consideration must be made regarding unrecognized factors in surgical care for older adults or perhaps that factors cannot be mitigated in older adults because they are intrinsically a higher surgical risk.

Geriatric Comanagement of Older Vascular Surgery Inpatients Reduces Hospital-Acquired Geriatric Syndromes.

This study evaluates the impact of a novel model of care called Geriatric Comanagement of Older Vascular surgery inpatients on clinical outcomes. A pre-post study of geriatric comanagement, comparing prospectively recruited preintervention (February-October 2019) and prospectively recruited postintervention (January-December 2020) cohorts. Consecutively admitted vascular surgery patients age ≥65years at a tertiary academic hospital in Concord and with an expected length of stay (LOS) greater than 2days were recruited. A comanagement model where a geriatrician was embedded within the vascular surgery team and delivered proactive comprehensive geriatric assessment based interventions. Primary outcomes of incidence of hospital-acquired geriatric syndromes, delirium, and LOS were compared between groups using univariable and multivariable logistic regression analyses. Prespecified subgroup analysis was performed by frailty status. There were 150 patients in the preintervention group and 152 patients in the postintervention group. The postintervention group were more frail [66 (43.4%) vs 45 (30.0%)], urgently admitted [72 (47.4%) vs 56 (37.3%)], and nonoperatively managed [52 (34.2%) vs 33 (22.0%)]. These differences were attributed to the coronavirus disease 2019 pandemic during the postintervention phase. The postintervention group had fewer hospital-acquired geriatric syndromes [74 (48.7%) vs 97 (64.7%); P= .005] and reduced incident delirium [5 (3.3%) vs 15 (10.0%); P= .02], in unadjusted and adjusted analyses. Cardiac [8 (5.3%) vs 30 (20.0%); P < .001] and infective complications [4 (2.6%) vs 12 (8.0%); P= .04] were also fewer. LOS was unchanged. Frail patients in the postintervention group experienced significantly fewer geriatric syndromes including delirium. This is the first prospective study of inpatient geriatric comanagement for older vascular surgery patients. Reductions in hospital-acquired geriatric syndromes including delirium, and cardiac and infective complications were observed after implementing geriatric comanagement. These benefits were also demonstrated in the frail subgroup.

The Effect of Infant Massage on Nutritional Status and IGf-1 of Malnourished Babies Aged 6-12 Months

Malnourished and poor nutrition are still a health center problem in Indonesia. A good nutritional intake can often not be fulfilled by a child, including due to various factors. Baby massage is a touch therapy that is carried out on baby so that it can provide assurance of ongoing body contact, maintain a feeling of security in the baby and strengthen the parent's love cord with the baby. The purpose of this study was to analyze the effectiveness of baby massage by mothers on improving the nutritional status of baby with malnutrition aged 6-12 months. This study used a quasi-randomized pre-test and post-test control group design. Samples were 48 babies aged 6-12 months with malnutrition divided into two groups (intervention and control group). This research was carried out for 3 months. Results showed that stimulation of baby massage is effective in increasing mean IGF-1 levels for malnourished baby aged 6-12 months, namely the average IGF-1 level in the pre-intervention group for baby massage by 1.37 ± 1.00, showed a significant increase (p = 0.003). Whereas in the control group showed a significant increase (p = 0.001) with the average IGF-1 pretreatment level was 3.37 ± 8.15. The results of the case and control group analysis showed significant differences in mean IGF-1 levels (p = 0.002) or (p &lt;0.05). Baby massage is effective in increasing nutritional status and IGF-1 in baby aged 6-12 months. Babies’ Mother and health provider are recommended to apply baby massage to improve nutritional status of malnourished babies.

Management of cancer‐associated thrombosis with thrombocytopenia: Impact of the ISTH guidance statement

BackgroundOptimal management of cancer‐associated thrombosis (CAT) in patients with thrombocytopenia remains difficult given competing risks of recurrent thrombosis and increased bleeding. We determine the impact of the ISTH Scientific and Standardization Committee (SCC) guidance on CAT management and thrombocytopenia on platelet transfusion, bleeding, and recurrent thrombosis. MethodsA retrospective review was performed of patients with CAT and thrombocytopenia who required anticoagulation for VTE for 11 months before and after implementation of the ISTH SCC guidance. Medical records were reviewed to identify the type of VTE event, number of platelet transfusions, incidence of bleeding, and VTE recurrence within pre‐ and postintervention time periods. ResultsA total of 41 and 80 cases were included in the preintervention and postintervention periods, respectively. The preintervention group showed a trend toward less acute VTE events (39% vs 55%; P= .05). The postintervention period had an increased per‐patient platelet transfusion (median, 2.5 vs 4; P= .05). Nonmajor bleeding was increased in the postintervention group (2% vs 16%; P= 0.03) and included all six (8%) major hemorrhages (P= .09). There was numerically less recurrent thrombosis in the postintervention group (20% vs 8%; P= .07), which was not significantly different when accounting for acuity of VTE. Management adherence was strong, at 91%, in the postintervention group. ConclusionThe ISTH guidance on management of cancer‐associated thrombosis in patients with thrombocytopenia was successfully implemented in an academic medical center. There was no significant difference in bleeding or recurrent thrombosis outcomes after adjusting for acuity of VTE.

Impact of routine bedside infectious diseases service on clinical management and prognosis of patients with Candida fungemia – an example for Antifungal Stewardship at university level in Germany

BackgroundCandidemia is rare and has a high mortality rate. This study analyses the impact of bedside antifungal stewardship (AFS) on clinical management and prognosis of patients with candidemia at a university hospital in Germany. MethodsAll patients with at least one positive blood culture with Candida species between 2014 and 2016 received bedside AFS with standardized recommendations. Medical records were retrospectively analyzed. Results from the intervention period from 2014-2016 (n=109), with focus on 2016 (n=39), were compared with those from the pre-intervention period in 2013 (n=30). ResultsBedside AFS was performed in 24/35 (69%) surviving patients in 2016 within the first 3 days after diagnosis of candidemia. All surviving patients (n=35) in 2016 received antifungal treatment compared with 24/28 (86%) in 2013 (p=0.0344). Follow-up blood cultures were performed in 25/35 (71%) in 2016 compared with 10/25 (40%) in 2013 (p=0.0046). Survival in the intervention compared with the pre-intervention group did not differ significantly (p=0.58) one year after the diagnosis of candidemia was made. However, patients with candidemia often have multiple serious comorbidities. ConclusionsIndividualized bedside AFS significantly improves adherence to recommendations for patients with Candida fungemia, especially guideline-oriented diagnostics and therapy. Improving the prognosis of patients with candidemia remains a huge challenge for AFS.

Insulin for Hospitalized Patients With Well-Controlled Type 2 Diabetes Mellitus: A Quality Improvement Initiative.

Inpatient management of diabetes mellitus (DM) often involves substituting oral medications with insulin which can result in unnecessary insulin use. Attempting to address unnecessary insulin use, a quality improvement initiative implemented a newly developed evidence-based care pathway for inpatient diabetes management focused on patients with recent hemoglobin A1c values < 8% and no prescription of outpatient insulin. This retrospective observational preintervention and postintervention and interrupted time series analysis evaluates this intervention. Over a 21-month time period, there was a significant decrease in mean units of insulin administered per day of hospitalization from 2.7 (2.2-3.3) in the preintervention group to 1.7 (1.2-2.3) in the postintervention group ( p = .017). During the initial 72 hours after admission, a significant downward trend in mean glucose values and mean insulin units per day was seen after the intervention. There was no significant change in hypoglycemic or hyperglycemic events between the two groups. The proportion of patients who received zero units of insulin during their admission increased from 27.7% to 52.5% after the intervention ( p < .001). An evidence-based pathway for inpatient management of DM was associated with decreased insulin use without significant changes in hypoglycemic or hyperglycemic events.

Impact of a cardiology pharmacist‐led intervention on high‐intensity statin prescribing upon discharge after acute myocardial infarction

AbstractIntroductionStandard of care after an acute myocardial infarction (AMI) includes high‐intensity statin therapy to lower the risk of future cardiovascular events. However, the use of high‐intensity statins post‐AMI remains suboptimal, presenting an opportunity for clinical pharmacist services to improve clinical care.ObjectiveTo evaluate the impact of a cardiology clinical pharmacist intervention upon the rate of high‐intensity statins issued at hospital discharge after AMI.MethodsThis was a single‐center, pre‐post study that included patients 18 to 75 years of age who were discharged from one investigative site with a primary diagnosis of AMI (as determined by ICD‐10 codes) between July 2019 to December 2020. The primary outcome was the proportion of patients prescribed high‐intensity statins, defined as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg daily, at discharge pre and postimplementation of a cardiology clinical pharmacist intervention. Patients were stratified into two groups for comparison: pre‐ (07/01/2019‐3/31/2020) and post‐ (04/01/2020‐12/31/2020) intervention, for which the latter included cardiology pharmacist‐driven communication and documentation via the electronic health record.ResultsA total of 418 patients were included: 223 (53.3%) preintervention and 195 (46.7%) postintervention. The overall cohort was approximately two‐thirds men and 90% Caucasian, with a mean ± SD age of 61.4 ± 9.7 years; the pre and postintervention groups were similar in terms of demographics. The rate of high‐intensity statin prescribing at discharge improved from 83.0% preintervention to 95.4% postintervention (P &lt;.0001). A total of 9.9%, 1.8%, and 5.4% of patients in the preintervention group received moderate‐intensity, low‐intensity, or no statin at discharge, respectively, lowering to 3.1%, 1.0%, and 0.5% postintervention.ConclusionThere was a statistically significant increase in the rate of high‐intensity statin prescribing post‐AMI after the implementation of targeted cardiology clinical pharmacist services.

812 GERIATRIC PERIOPERATIVE CARE IS ASSOCIATED WITH REDUCED LENGTH OF STAY IN UROLOGY PATIENTS

Abstract Introduction Comprehensive Geriatric Assessment (CGA) is associated with reduced length of stay and perioperative complications in older orthopaedic, gastrointestinal and vascular surgical patients [1,2,3]. Limited published data from a single UK centre [4] reports reproducing these outcomes in a urological setting. It is unclear whether these outcomes can be repeated in other urological centres. Method We piloted a Geriatric Perioperative Care service delivering CGA to older emergency urology patients admitted to within a tertiary centre. The aim of the service was to reduce length of hospital stay (LOS). We evaluated it using quality improvement methodology. Patients for review were identified using age ≥ 65 and the Clinical Frailty Scale. Patients that were transferred to another hospital team prior to discharge were excluded. Results 101 patients were included: 35 in the pre-intervention group and 66 in the post-intervention group. Mean LOS in the pre-intervention group was 7 days. In the post-intervention group, mean LOS was reduced to 3.5 days, 6 days and 5.5 days in the first, second and third months respectively. Conclusion We found that perioperative geriatric care was associated with reduced length of stay in older urology patients. These data would support the need for larger and/or multicentre studies to evaluate the relationship between geriatric intervention in urological inpatients and length of hospital stay.

Impact of Nutrition Support Team in Achieving Target Calories in Children Admitted in Pediatric Intensive Care Unit.

To determine the impact of nutrition support team (NST) on achieving an early target caloric goal in mechanically ventilated children admitted in pediatric intensive care unit (PICU). An early enteral nutrition protocol (EENP) was implemented by NST to ensure early and adequate nutrition provision to PICU patients. All children (1 month- 18 years) that were admitted in PICU for >2days and received mechanical ventilation, with no contraindications to enteral feed, were included and data was compared with those of pre-intervention. The adequacy of energy intake was defined as 70% achievement of target energy intake on the third day of admission. Chi-square/t-test was used to determine the difference between different variables pre and post intervention. Total 180 patients (99 and 81 in pre- and post-intervention group, respectively) were included. Overall, 115 (63.9%) received adequate calories (70%) on third day of admission. Of which 69 (85.2%) were from post intervention (P < 0.001; odds ratio [OR] 6.6, 95% confidence interval [CI] 3.195-13.73). Moreover, NST intervention also promoted adequate protein intake in 62 (76.5%) children compared to 37 (37.4%) in pre-intervention group (P < 0.001, OR 5.468, 95% CI 2.838- 10.534). The median (interquartile range) length of PiCU stay in pre-NST group was 6 (4-9) days and in NST supported group was 4 (3-4) days (OR 0.580, CI 0.473-0.712, P < 0.001). Age, severity of illness, multiorgan dysfunction syndrome, sepsis, need of organ support had no effect in achievement of caloric target in both the groups (P > 0.05). Introduction of EENP with NST helped in the achievement of better and quicker target caloric intake.

Impact of a Multimodal Analgesia Protocol in an Intensive Care Unit: A Pre-post Cohort Study.

Introduction Opioids are the mainstay of pain management in critically ill patients. However, recent attention to their adverse effects in the intensive care unit (ICU) has led to the use of strategies that aim to reduce these side effects. Among these strategies, there are multimodal analgesia protocols, which prioritize pain management and employ a combination of different analgesics to spare excessive doses of opioids and sedatives in continuous infusion.ObjectiveThe objective of this study is to evaluate the impact of a multimodal analgesia protocol on clinical outcomes and consumption of sedatives and analgesics in two intensive care units.Methods We conducted a single-center, quasi-experimental, retrospective, and prospective cohort study comparing clinical outcomes and consumption of sedatives and analgesics before and after the implementation of a multimodal pain management protocol in critically ill adult patients. We included 465 patients in 2017 (pre-intervention group) and 1508 between 2018 and 2020 (post-intervention group).ResultsIn the analysis of the primary outcome, there was a significant reduction in mortality between 2017 and 2020 (27.7% - 21.7%, p=0.0134). There was no statistical difference in mechanical ventilation time or concerning the infection rate. Patients who received the multimodal analgesia protocol had a decrease of 24% regarding mean fentanyl intake and a progressive reduction in morphine milligram equivalents (MME) (8.4% - 19%). There was an increasing trend in the use of adjuvant analgesics and morphine in preemptive and therapeutic analgesia.ConclusionThe implementation of a multimodal pain control protocol significantly reduced morbidity and mortality and the use of opioids in the ICU.

The Effect of an Automated Order on Postpartum Opioid Use After Uncomplicated Vaginal Deliveries.

Background: To address the opioid epidemic, physicians are encouraged to identify means of reducing patient opioid exposure. Electronic medical records (EMRs) often include default order sets with automated orders for opioid medications, which may influence how much opioids physicians prescribe. We sought to evaluate the impact of de-selecting an automated order for oxycodone-acetaminophen from an EMR order set for postpartum vaginal deliveries on inpatient opioid exposure by comparing the proportion of patients who received an opioid after an uncomplicated vaginal delivery before and after the EMR change. As secondary outcomes, the impact on average total morphine milligram equivalents (MMEs) and discharge opioid prescriptions was investigated. Materials and Methods: A quality improvement study was conducted through retrospective chart review of uncomplicated vaginal deliveries for the four quarters before and after the EMR order set change occurred. The total proportion of patients who received an opioid in the postpartum period was then determined for the preexposure and postexposure groups. The total average MME consumed for patients who received an opioid in each group was determined and the total proportion of patients who received an opioid prescription at discharge was compared. Results: A total of 5826 records of uncomplicated vaginal deliveries met the criteria for analysis. In the preintervention group, 32.9% of patients received an opioid postpartum, compared to 12.5% of patients in the postintervention group, representing a decrease of 62.0% (p < 0.001). Of those who received opioids, the preintervention mean total opioid consumption was 28.4 MME (±27.6) compared to 33.6 MME (±46.4) postintervention, and there was no significant difference in median total opioid consumption: 22.5 MME (interquartile range [IQR]: 7.5-47.5) preintervention compared with 20.8 MME (IQR: 7.5-45.0) postintervention (p = 0.902). No significant difference was found with discharge opioid prescriptions between the two groups. Conclusion: Order sets within EMR systems appear to have a significant influence on physician prescribing behaviors and removing these automated orders for opioids should be considered.