Pre-protocol Period Research Articles

The Efficacy of a Multidisciplinary Approach and Diagnostic-Therapeutic Algorithm for Vertebral Metastases with Spinal Cord Compression.

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic-therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail.

Impact of a hospital sepsis management protocol on the selection of empirical antibiotics in infectious disease consultations

It is well-established that Infectious Diseases consultation (IDC) enhances the prognosis of bloodstream infections. However, it is unclear if adoption of an institutional sepsis protocol would lead to any further improvement in a setting where IDC and infectious diseases approval (IDA) - available throughout 7 days/24 hours -are mandatory for administering broad spectrum antibiotics. We aimed to evaluate the influence of the institutional sepsis protocol developed by Department of Infectious Diseases and Clinical Microbiology on the selection of appropriate empirical antibiotics by IDC through focusing on patients who had bloodstream infections caused by Extended-spectrum β-lactamase (ESBL) producing Escherichia coli and Klebsiella pneumoniae, which poses a therapeutic challenge. One hundred and fifty-three adult patients (58 patients in the pre-protocol period and 95 patients in the post-protocol period), who received empirical antibiotic treatment for ESBL-producing E. coli and K. pneumoniae, in whom at least one systemic antibiotic was started either on the day blood cultures were drawn or not later than 24 hours were included in the study, retrospectively. The primary outcome was whether the empirical treatment regimen included a carbapenem that was accepted as the appropriate treatment based on the results of the MERINO trial. Secondary outcomes included empirical treatment based on pre-defined risk factors suggesting multidrug resistance (MDR), 30-day inpatient mortality, and appropriate antibacterial treatment according to antimicrobial susceptibility test (AST) results. The median age (Interquartile range) was 61 (48-70.5) years and 76 (49.7%) out of 153 patients were male. The patients in the post-protocol period were older compared to the pre-protocol period (54 years vs 64 years, p = 0.045). The Charlson Comorbidity Index was higher during the post-protocol period compared to the pre-protocol period (4 vs 5, p=0.038). At least one risk factor for MDR bacteria infection was present in 147 (96.1%) of the 153 patients. While the rate of risk factors for MDR bacteria infections did not differ significantly between the pre-protocol and post-protocol periods, the post-protocol period showed a significantly higher level of appropriate antibiotic treatment according to the presence of MDR risk factors compared to the pre-protocol period (44.8% vs 64.2%, p=0.019). There was a significant increase in the use of carbapenems in the post-protocol period compared to the pre-protocol period (34.5% vs. 56.8%, p=0.007). When the subgroup of patients who were likely to have infection caused by ESBL-producing bacteria is taken into consideration, the carbapenem use was more frequent in the post-protocol period (37.8% vs 68.9%, p=0.002). The rate of appropriate empirical treatment according to AST was not statistically different between pre-protocol and post-protocol period. The 30-day mortality rates were similar in both periods (24.1% vs 31.5, p=0.33). However, the rate of susceptibility to piperacillin-tazobactam was statistically higher in the pre-protocol period (82.6% vs 46.2%, p=0.016) when 39.7% of the patients received piperacillin-tazobactam as the empirical treatment. This study highlights the significance of using a structured protocol to attain appropriate empirical treatment for patients suspected of sepsis, even in a setting where IDC is readily available.

Complications and degree of difficulty of orotracheal intubation in the Intensive Care Unit before and after the establishment of an intubation protocol for critically ill patients: a prospective, observational study

ObjectiveThe objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an Intensive Care Unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. MethodsProspective, observational study comparing all intubations performed in our ICU over 2 periods: pre-protocol (January 2015–January 2019) and post-protocol (February 2019–July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. ResultsDuring the study period, 661 patients were intubated - 437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack–Lehane ≥ 2b in 7.6% vs. 29.8%, p < 0.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs. 17.4%, p < 0.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (p = 0.508). We did not find significant differences in complications between the periods studied. ConclusionsIntubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

Complicaciones y grado de dificultad de la intubación orotraqueal en la unidad de cuidados intensivos pre-post instauración de un protocolo de intubación para el paciente crítico. Estudio prospectivo y observacional

ObjectiveThe objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an intensive care unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. MethodsProspective, observational study comparing all intubations performed in our ICU over two periods: pre-protocol (January 2015-January 2019) and post-protocol (February 2019-July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. ResultsDuring the study period, 661 patients were intubated —437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack-Lehane ≥2b in 7.6% vs 29.8%, P<.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs 17.4%, P<.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (P=.508). We did not find significant differences in complications between the periods studied. ConclusionsIntubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

Effect of sepsis protocol in inpatient departments triggered by Ramathibodi Early Warning Score (REWS) on treatment processes

Background: Sepsis needs to be more focused on the effect of patient management at the ward level. We aimed to evaluate the effect of implementing the sepsis protocol triggered by the Ramathibodi Early Warning Score (REWS) on treatment processes in inpatients with new-onset sepsis. Methods: We conducted a prospective observational study among adult medical patients admitted to the general wards. A 25-month pre-protocol period was assigned as a control, and a 14-month protocol period was allocated to a protocol group. An inpatient sepsis protocol comprised a nurse-initiated sepsis protocol with REWS ≥2 plus suspected infection, prompt antibiotic, lactate measurement, and fluid resuscitation. Primary outcomes were the achievement of sepsis treatment processes, including the resuscitation and management bundle, namely: 1) the percentage of patients who were taken for the initial laboratory workup for sepsis, especially lactate and blood culture taking before antibiotics; 2) the percentage of patients who received appropriate antibiotics; 3) the percentage of patients who received optimal fluid resuscitation and management; 4) the percentage of patients who performed inferior vena cava ultrasound; 5) the percentage of patients who received steroid and vasopressor drugs; 6) "time-to-antibiotic," the duration from diagnosis of sepsis to receiving antibiotic treatment; 7) "time-to-optimal intravenous fluid management;" 8) "time-to-transfer to ICU. Results: 282 patients were evaluated (141 pre-implementation, 141 post-implementation); 94.7% of patients with sepsis had REWS ≥2. More patients in the protocol period had a lactate measurement and fluid management (89 [63.1%] vs. 44 patients [31.2%], p&lt;0.001 and (50 [35.4%] vs. 22 patients [15.6%], p&lt;0.001, respectively). More patients in the protocol period received antibiotics within 1 hour than in the pre-protocol period (80 [56.7%] vs. 53 patients [37.6%], p=0.001). The time to antibiotic treatment (mean, SD) in the protocol period was shorter than that in the pre-protocol period (81.7 [77.86] vs. 138.22 [145.17], p=0.007). The length of the intensive care unit (ICU) stay was shorter in the protocol period (8 d [3, 16.5] vs. 10 d [5, 20.5], p=0.011). The two groups did not differ in in-hospital mortality, length of hospital stay, or time-to-transfer to the ICU. Conclusions: Implementing an in-hospital sepsis protocol was associated with significant improvement in sepsis treatment processes, namely lactate measurement, starting antibiotic treatment within 1 hour, fluid management, and a shorter length of ICU stay.

A Multipronged Intervention to Reduce Readmissions and Readmission Intensity After Radical Cystectomy

To develop a multipronged, evidence-based protocol to reduce readmission risk and readmission intensity, as represented by the duration of the index readmission, after radical cystectomy. A per-protocol study was performed. The protocol included preoperative nutritional supplementation, early stent removal, and a follow-up phone call within 4-5days of discharge. The preprotocol period was from February 1, 2020 to July 31, 2021 and the postprotocol period was from December 1, 2020 to November 31, 2021. Using multivariate regression models, we compared outcomes among patients treated with radical cystectomy before and after protocol initiation. We identified 70 preprotocol patients and 126 postprotocol patients. After adjusting for age, sex, BMI, and frailty score, there was a significant reduction in 90-day readmission intensity (7 vs 5days; P=.048) among postprotocol patients. After implementation of an evidence-based protocol for patients undergoing radical 90-day readmission intensity decreased significantly. This protocol may move the needle forward on reducing readmissions, but a larger randomized trial is needed.

Reduced rates of pneumonia after implementation of an electronic checklist for the management of patients with multiple rib fractures at a Level One Trauma Center

Traumatic rib fractures are associated with increased morbidity and mortality, with complications including pneumothorax, difficult to control pain, and pneumonia. Use of a bundled, multi-disciplinary approach to the care of patients with multiple rib fractures has been shown to reduce morbidity and mortality. In this study, we investigate the implementation of a checklist for the multidisciplinary management of patients with multiple rib fractures who present to an urban, level 1 trauma center and safety-net hospital. This was a single-institution, retrospective cohort study to assess changes in treatment characteristics and patient outcomes before and after implementation of a comprehensive checklist for the management of high-risk patients with three or more traumatic rib fractures at a level-one trauma center. The primary outcome was pneumonia rates with secondary outcomes of rate mechanical ventilation and mechanical ventilation days, ICU length of stay, mortality, and non-opioid and opioid consumption (morphine milligram equivalents). A total of 104 patients met study eligibility, including 51 patients who presented during the pre-protocol period and 53 patients who received care after implementation. We observed that the checklist was utilized and reviewed in 83% of patients during the post-protocol period. Pneumonia rates were significantly lower in the post-protocol group (35.3% vs 15.1%, p=0.017). There was no difference in the number of patients who required mechanical ventilation or the duration of mechanical ventilation. On unadjusted analysis, median overall length of stay (11.5 days vs 13 days, p=0.71), median ICU stay (4 days vs 5 days, p=0.18), and rate of in-hospital mortality (11.8% vs 7.6%, p=0.47) was not different between the two time periods. In patients with chest wall trauma and associated rib fractures, implementation of a standardized, multidisciplinary checklist to ensure utilization of multimodal analgesia and non-pharmacological interventions was associated with decreased pneumonia rates at our institution.

Early mobilization in children with pneumonia in mechanical ventilation: randomized clinical trial

Immobility in the bed of pediatric patients in intensive care units increases the risk of morbidities such as pneumonia, with consequences for autonomic function. Physiotherapy based on physical exercise is part of the rehabilitation process and can modify autonomic function. To compare the effects of two physical therapy protocols, one conventional and the other based on physical exercise, on heart rate variability, length of stay and invasive mechanical ventilation in children with ventilator-associated pneumonia. This is a randomized clinical trial, the volunteers were divided into a control group (submitted to a physiotherapy protocol with only breathing exercises and passive mobilization) and an experimental group (submitted to a physiotherapy protocol based on physical exercise). Patients aged 1 to 8 years, on invasive mechanical ventilation, with pneumonia were included. The rehabilitation protocol took place for 4 consecutive days. The collection of heart rate variability occurred in the pre-protocol period, on the 2nd day, 1 day after the end of the protocol. 25 patients completed the study. There was a reduction in the time of invasive mechanical ventilation in the experimental group (p = 0.01). There was an improvement in the heart rate variability of the experimental group in all indices (p &lt; 0.01). The post-protocol analysis of the groups showed significant values in all variables (p &lt; 0.05). Exercise-based physical therapy protocol improved autonomic heart rate modulation and reduced IMV time in children with ventilator-associated pneumonia.

Effectiveness of the Alarm System Policy on Reducing Ambulance Response Time in Prehospital Emergency Patient Care

Objective: Reduction of ambulance response time leads to an increase in positive patient outcomes. Therefore, the aim of this study was to determine whether an accomplished response time within eight minutes could be increased after the introduction of an alarm system policy and to study if the mortality rate would be decreased after the introduction of alarm system policy. Material and Methods: An interrupted time series was conducted in the collection of code red patients between the following dates: 1st November 2015 and 31st October 2019. The data was collected from the medical records of Maharaj Nakorn, Chiang Mai Hospital. The collected data were separated into: the pre-protocol period (1st November 2015 to 31st October 2017) and the post-protocol period (1st November 2017 to 31st October 2019). Results: A total of 552 patients were included in the overall analysis. The success rates of response time within eight minutes of patients with code red in the pre-protocol period and post-protocol period were 64.62% and 73.11%, respectively. It was discovered that the success rate was significantly higher (adjusted odd ratio=1.627, 95% confidence interval: [1.017, 2.602]; p-value&lt;0.05) in the post-protocol period versus the pre-protocol period. A decrease in the mortality rate in 24 hours and the mortality rate in the emergency room (ER) was observed in post-protocol period, from the interrupted time series model. However, no significant difference was evident through the process of statistical analysis. Conclusion: The implementation of the protocol could significantly reduce response time; thus, achieving the 8-minute goal. Hence, this protocol will be able to promote better emergency services in pre-hospital-based care.

Impact of an external ventricular shunt (EVD) handling protocol on secondary meningitis rates: a historical cohort study with propensity score matching

BackgroundExternal ventricular drainage (EVD) is frequently used in neurosurgical procedures for cerebrospinal fluid (CSF) drainage. It is, however, associated with high infection rates, namely secondary meningitis and ventriculitis. Based on a previous high prevalence of these infections among patients with EVDs, we have proposed and implemented a protocol in an effort to decrease the infection rate. The aim of this study was to measure the effect of hospital-wide implementation of the EVD handling protocol on secondary EVD infections.Patients and methodsWe included 409 consecutive patients who received a new EVD for other indications than infectious pathologies from January 2000 until June 2012. Patients above 18 years of age were divided into pre- (n = 228) and post-protocol (n = 181) groups. Patient and disease demographics, as well as EVD data together with confounders for secondary meningitis were recorded in a database. Propensity score matching was then performed to create groups matched for sex, age, reason for drainage, type of shunt, time in situ and duration of surgery to place the EVD. Binomial logistic regression for confounder adjustment and regression discontinuity analyses were then performed on the matched cohort.ResultsInfections occurred more frequently in the pre-protocol group (23% vs 9%, p < 0.001). The incidence of infection was 33/1000 drain-days pre-protocol and 9/1000 drain-days post-protocol. Regression analysis in a propensity score-matched cohort (n = 103 in the pre- and n = 178 in the post-protocol groups) showed that the pre-protocol period was independently associated with more infections (OR 2.69; 95%-CI 1.22–5.95, p = 0.01).ConclusionsThe incidence of secondary EVD infections can be reduced significantly by the implementation of a strict hospital-wide EVD handling protocol.

Reduction in Thrombolytic Usage in Hemodialysis Patients Following a Quality Assurance Review: A Research Letter.

Catheter malfunction in hemodialysis (HD) is increasingly managed with recombinant tissue plasminogen activator (rt-PA, alteplase), though evidence of improved catheter function is lacking. To evaluate the effect of a standardized rt-PA administration protocol on rt-PA usage, catheter function, and adverse events. Observational quality improvement study. Single, urban, community HD unit in Calgary, Alberta. Patients treated with maintenance in-center HD through central venous catheter. Incidence of rt-PA usage, catheter interventions, hospitalizations, and measures of dialysis efficacy. The rt-PA protocol was designed following a consultative and iterative design period with dialysis shareholders, which included focusing on standard objective criteria before use and targeting use to the problematic lumen. Protocol implementation occurred over a 6-month period in 2021. Patient and dialysis data were collected through our regional dialysis electronic health record. Implementation of the rt-PA protocol resulted in decreased rt-PA use (standardized per 100 dialysis sessions) compared to the preprotocol period (incidence rate ratio [IRR] of 0.57, 95% confidence interval [CI]: [0.34, 0.94]). Line procedures were also less frequent (IRR = 0.42, 95% CI: [0.18, 0.89]). Hospitalization rates and measures of dialysis efficacy were similar in both periods. Small sample size with single dialysis center and short duration of follow-up. Implementation of a multidisciplinary designed rt-PA administration protocol decreased incident rt-PA usage.

Triage nurse-initiated X-ray radiography in minor trauma.

Overcrowding of paediatric emergency departments (EDs) is a worldwide issue, where improving the quality of care is a priority. The main objective of this study was to determine the effect of triage nurse-initiated X-ray radiography on length of stay in paediatric emergency admissions. This retrospective, monocentric, descriptive study was performed in two successive 3-month periods: a pre-protocol ('before') period from 3 February to 3 May 2020 and a protocol ('after') period from 4 May to 2 August 2020, when patients underwent nurse-initiated X-ray radiography. The study involved all patients who were aged ≥3 years, valid, non-hyperalgic, accompanied by their parents and consulting at the paediatric ED for a simple closed distal trauma, involving a single limb segment or joint. A total of 695 patients were included, 298 in the first period and 397 in the second period. The median length of stay in the paediatric ED was significantly shorter during the second period (119 min [80, 165] vs. 80 min [60, 105], P < 0.001), i.e.a median reduction time of 39 min or 33% (effect size = - 0.68, 95% confidence interval [-0.84 to -0.53]). Triage nurse requests were judged 'adequate and sufficient' in 95.2% of cases, with only 2.0% of instances deemed 'unnecessary' by the medical team. In 2.8% of cases, 'another X-ray' was required to support diagnosis. The application of a triage nurse X-ray protocol significantly reduced the length of stay in a paediatric ED. The quality of patient management remained unchanged, and nurse requests were relevant.

Cost-Effectiveness of a Quality Improvement Initiative for the Clinical Management of Children with Newly Diagnosed Immune Thrombocytopenia

To assess the cost-effectiveness of an evidence-informed institutional protocol for physicians that encouraged management of children with newly diagnosed immune thrombocytopenia (ITP) with observation over active therapy, where appropriate. We conducted a probabilistic cost-effectiveness analysis from an institutional perspective using a decision tree with a 1year time horizon. Patient-level data were retrospectively ascertained for children diagnosed in pre-protocol (2007-2009) and post-protocol (2013-2018) time periods. ITP resolution was defined as achieving a sustained platelet count of >100×103/μL at 9-12months after diagnosis. Outpatient care and inpatient costs were obtained from the institution and provincial sources. Intervention costs accounted for quality improvement initiative preparation and staff physician training. Incremental costs, incremental effects, and CIs were calculated from 10 000 model iterations. Forty-eight patients were followed for 1year in the pre-protocol period and 84 in the post-protocol period. After protocol implementation, an average cost savings per child managed of $2055 (95% CI: $656, $3890) Canadian Dollars was observed, as was a higher proportion of resolved ITP cases. The implementation strategy remained less costly and more effective in 99.7% of model iterations. Implementation of an evidence-informed institutional protocol to guide physicians toward increased uptake of observation over active therapy when managing children with newly diagnosed ITP resulted in significant cost savings on a per case basis, even after accounting for training-related costs. Though the long-term cost implications regarding the sustainability of the intervention are not yet known, it is anticipated that continued institutional savings could occur.

Delayed Repeat Contrast Enema for Treatment of Pediatric Intussusception.

Ileocolic intussusception is a common cause of pediatric bowel obstruction. Contrast enema is successful in treating the majority of patients, and if initially unsuccessful, approximately one-third may be reduced with repeat enemas. We sought to study protocol implementation for delayed repeat enema in pediatric patients not reduced completely by an initial contrast enema. Our aims were to assess repeat enema success rates and outcome differences in preprotocol and postprotocol patients with respect to (1) intussusception recurrence, (2) surgical intervention and complication rates, and (3) length of stay. We performed a retrospective review of treatment and clinical outcomes prior to and following protocol implementation for repeat enema for intussusception at two tertiary pediatric referral hospitals. The preprotocol period was defined from 2/2013 to 2/2016, and the postprotocol period was from 8/2016 to 11/2019. There were 112 patients in the preprotocol group, with 74 (66%) having successful reduction following the first enema. Of the 38 patients without successful reduction, 16 (42%) patients underwent repeat enema, and five were successful (31%). The postprotocol group included 122 patients, with 84 (69%) having successful first reduction. Of the 38 patients that failed, 25 patients (66%) underwent repeat enema, of which 13 (52%) were successful. Compared to preprotocol patients, postprotocol patients had significantly more enemas repeated and a trend toward fewer surgical interventions. Protocol implementation of repeat delayed enemas was significantly associated with an increased rate of repeat enemas at our institutions and reduced need for operative intervention during the index stay.

Impact of an emergency endovascular aneurysm repair protocol on 30-day ruptured abdominal aortic aneurysm mortality

ObjectiveTo characterize the longstanding impact of an emergency endovascular aneurysm repair (EVAR) protocol for ruptured abdominal aortic aneurysm (rAAA) on 30-day mortality. MethodsAll adult patients with an rAAA who underwent a surgical or endovascular intervention at a tertiary care center between March 2001 and December 2018 were evaluated. An emergency EVAR protocol was introduced in January 2004. The primary outcome was 30-day mortality, which was calculated using risk-adjusted logistic regression for the preprotocol and postprotocol periods. A risk-adjusted cumulative sum analysis examined changes in 30-day mortality after protocol implementation. ResultsWe identified 376 patients with rAAA between 2001 and 2018 (75 preprotocol and 301 postprotocol), with a decreasing incidence of rAAA during the study period. The introduction of the protocol in 2004 was associated with increased EVAR use (63.6% vs 6.7%; P < .001). Patients managed according to the protocol were more frequently unstable (systolic blood pressure [SBP] of ≤80 mm Hg, 46.5% postprotocol vs 22.7% preprotocol; P < 0.001), with a lower average SBP (87.4 mm Hg postprotocol vs 106 mm Hg preprotocol; P < .001) and worse renal function (estimated glomerular filtration rate 61.5 mL/min postprotocol vs 83.2 mL/min preprotocol; P < .001). The risk-adjusted 30-day mortality was 23.2% with the emergency EVAR protocol, versus 35.8% preprotocol (P = .0727). A subgroup analysis demonstrated improved the 30-day mortality for unstable patients (SBP of ≤80 mm Hg) at 38.0% (vs 62.4% preprotocol introduction; P = .0190). A cumulative sum analysis demonstrated worse than expected mortality outcomes in the preprotocol period, and stability of surgical performance over 15 years after protocol introduction. ConclusionsOn reflection of a 17-year experience with EVAR for rAAA, the implementation of an emergency EVAR protocol demonstrated stable surgical performance for all patients with an rAAA and evidence of improved 30-day mortality for unstable patients with an rAAA. Since the protocol introduction, EVAR has become a mainstay intervention and, despite an increase in comorbid patients, the overall incidence of rAAA is declining. EVAR should be considered the first-line intervention for the appropriate patient unstable with an rAAA.

Effect of a Boarding Restriction Protocol on Emergency Department Crowding.

PurposeAccess block due to the lack of hospital beds causes crowding of emergency departments (ED). We initiated the “boarding restriction protocol” that limits the time of stay in the ED for patients awaiting hospitalization to 24 hours from arrival. The purpose of this study was to determine the effect of the boarding restriction protocol on ED crowding.Materials and MethodsThe primary outcome was ED occupancy rate, which was calculated as the ratio of the number of occupying patients to the total number of ED beds. Time factors, such as length of stay (LOS), treatment time, and boarding time, were investigated.ResultsThe mean of the ED occupancy rate decreased from 1.532±0.432 prior to implementation of the protocol to 1.273±0.353 after (p<0.001). According to time series analysis, the absolute effect caused by the protocol was -0.189 (-0.277 to -0.110) (p=0.001). The proportion of patients with LOS exceeding 24 hours decreased from 7.6% to 4.0% (p<0.001). Among admitted patients, ED LOS decreased from 770.7 (421.4–1587.1) minutes to 630.2 (398.0–1156.8) minutes (p<0.001); treatment time increased from 319.6 (198.5–482.8) minutes to 344.7 (213.4–519.5) minutes (p<0.001); and boarding time decreased from 298.9 (109.5–1149.0) minutes to 204.1 (98.7–545.7) minutes (p<0.001). In pre-protocol period, boarding patients accumulated in the ED during the weekdays and resolved on Friday, but this pattern was alleviated in post-period.ConclusionThe boarding restriction protocol was effective in alleviating ED crowding by reducing the accumulation of boarding patients in the ED during the weekdays.

A physiotherapy-led early mobilisation protocol for neurosurgical patients with external ventricular drains in intensive care: A service evaluation

Background An external ventricular drain (EVD) is used to relieve elevated intracranial pressure in neurosurgical patients, and remains in place for an average of 8 days post-surgery. The presence of an EVD poses a major barrier to early mobilisation due to safety concerns. Eligibility criteria published in EVD mobilisation protocols only consisted of parameters related to the neurological system (Moyer et al., 2017; Young et al., 2019). Parameters pertaining to cardiovascular, respiratory and musculoskeletal systems deemed safe for mobilisation were not stated. Aims To determine the safety, feasibility and effectiveness of implementing an early mobilisation protocol, which included physiological parameters, in patients with EVDs. Methods A retrospective service evaluation was conducted in a neurological intensive care unit. Medical records were reviewed for 2 periods from October 2017 to March 2018 (pre-protocol period) and October 2019 to March 2020 (protocol period). Eligible patients for out-of-bed mobilisation were screened and identified by physiotherapists. Results After protocol implementation, there was a 64.8% increase in the proportion of patients with EVDs mobilised (95% CI, 35.9–82.1%, p &lt;0.0001). Median time from EVD placement to 1st mobilisation decreased from 14 to 3.5 days (p &lt;0.0001). Moreover, the median intensive care and hospital length of stays were significantly reduced from 8 to 3.5 days (p = 0.037) and 38 to 22.5 days (p = 0.030) respectively. No adverse events were recorded in the protocol period. Conclusion The early mobilisation protocol for patients with EVDs enabled safe, feasible and effective mobilisation. Future prospective, controlled research studies are warranted.

510. Reduced Mortality Rate in Critically Ill Patients with COVID-19 with the Implementation of a Treatment Protocol—Experience of a Tertiary Care Center in the Midwest During the Initial Surge of COVID-19

Abstract Background COVID-19 has been an unprecedented pandemic resulting in high mortality. We report our experience of using a treatment protocol in the intensive care unit (ICU) during the first peak of the pandemic. Methods All patients diagnosed with SARS-CoV-2 infection admitted to the ICU between April 14-June 14, 2020 were included. Remdesivir was made available for use in our institution on May 14th 2020, and thereafter, a treatment protocol combining remdesivir, corticosteroids and tocilizumab was implemented in the ICU, with doses as follows: Remdesivir 200mg intravenously (I.V.) on day 1, then 100 mg for 4 days; tocilizumab 400 mg I.V. once a day for 2 days; dexamethasone 6 mg I.V. daily for 10 days followed by taper. During pre-protocol period, patients were receiving hydroxychloroquine (400 mg once on day 1 followed by 200 mg twice daily orally for 4 days). We compared the pre-protocol period (labeled as P1: April 14, 2020- May 13, 2020) with protocol period (P2: May 14, 2020 -June 14, 2020) for clinical outcomes. Results A total of 32 and 48 patients were included during P1 and P2 respectively. Both groups were similar in terms of demographic characteristics, mean (±SD) age [55(±10) and 54 (±12) years] and mean Charlson-Deyo risk score at admission [2.4(±0.8) and 2.5 (±0.9) respectively]. During both periods, a comparable number of patients needed mechanical ventilation (65% and 66% respectively), anticoagulation (74% and 76% respectively) and inotropes (41% and 40%). The mean duration of ICU stay during P1 was significantly longer than P2 [15.4 (±2.8) days versus 9.3 ± (3.8) days, p&amp;lt; 0.0001)]. During P1, mean duration of mechanical ventilation [10 (±1.6) days] was also significantly longer than P2 [7.1 (±2.7) days] (p= 0.0004). There was a significant reduction in mortality rate from 68% (22/32) during P1 to 10.4% (5/48) in P2 (p&amp;lt; 0.0001). Patients were 4.3 times more likely to die during P1 than P2 (95% CI= 2.47-7.86). Conclusion Our results showed a decrease in ICU mortality rate by 57.6% with the implementation of a treatment protocol combining remdesivir, tocilizumab and corticosteroids during the first months of the initial surge of the pandemic, with a significant decline in length of ICU stay and duration of mechanical ventilation; and support the therapeutic data endorsed by IDSA/NIH guidelines. Disclosures All Authors: No reported disclosures

Does a Starting Positive End-Expiratory Pressure of 8 cmH2O Decrease the Probability of a Ventilator-Associated Event?

Introduction: Ventilator-associated events (VAEs) are objective measures as defined by the Centers for Disease Control and Prevention (CDC). To reduce VAEs, some hospitals have started patients on higher baseline positive end-expiratory pressure (PEEP) to avoid triggering VAE criteria due to respiratory fluctuations.Methods: At our institution, VAEs were gathered from January 2014 through December 2019. Using the CDC-defined classifications, VAEs were split into two groups to separate patients with hypoxemia only (VAC) and those with hypoxemia and evidence of inflammation or infection (IVAC-plus). We used the geometric distribution to calculate the daily event probability before and after the protocol implementation. A probability threshold was used to determine if the days between events was exceeded during the post-protocol period.Results: A total of 306 VAEs were collected over the study period. Of those, 155 were VACs and 107 were IVAC-plus events during the pre-protocol period. After implementing the protocol, 24 VACs and 20 IVAC-plus events were reported. There was a non-significant decrease in daily event probabilities in both the VAC and IVAC-plus groups (0.083 vs. 0.068 and 0.057 vs. 0.039, respectively).Conclusion: We concluded a starting PEEP of 8 cmH2O is unlikely to be an effective intervention at reducing the probability of a VAE. Until specific guidelines by the CDC are established, hospitals should consider alternative methods to reduce VAEs.

SIGNIFICANT REDUCTION IN MORTALITY RATE IN CRITICALLY ILL PATIENTS WITH COVID-19 WITH THE IMPLEMENTATION OF A TREATMENT PROTOCOL-EXPERIENCE OF A TERTIARY CARE CENTER IN MIDWESTERN UNITED STATES DURING THE FIRST PEAK OF THE COVID-19 PANDEMIC

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: COVID-19 has been an unprecedented pandemic resulting in serious morbidity and mortality. Knowledge of optimal treatment regimens for COVID-19 is evolving. The purpose of the study was to evaluate the impact of a treatment protocol on clinical outcomes of patients with COVID-19 in the intensive care unit (ICU) at a tertiary-care center during the first peak of the pandemic in Midwestern United States. METHODS: Methods: All ICU patients diagnosed with SARS-CoV-2 infection hospitalized between April 14-June 14, 2020 were included. Remdesivir was made available for use in our institution on May 14th 2020, and a treatment protocol combining remdesivir, corticosteroids and tocilizumab was implemented in the ICU, with doses as follows: Remdesivir 200mg intravenously (I.V.) on day 1, then 100 mg for 4 days;tocilizumab 400 mg I.V. once a day for 2 days;dexamethasone 6 mg I.V. daily for 10 days followed by taper. During pre-protocol period, patients were receiving hydroxychloroquine (400 mg once on day 1 followed by 200 mg twice daily orally for 4 days). We compared the pre-protocol period (labeled as P1: April 14, 2020- May 13, 2020) with protocol period (P2: May 14, 2020 -June 14, 2020) for clinical outcomes. Famotidine and multivitamins were administered to all patients during P1 and P2. RESULTS: A total of 32 and 48 patients were admitted to the ICU during P1 and P2 respectively. Both groups were similar in terms of demographic characteristics, mean (±SD) age [55(±10) and 54 (±12) years] and mean Charlson-Deyo risk score at admission [2.4(±0.8) and 2.5 (±0.9) respectively]. During both periods, a comparable number of patients needed mechanical ventilation (65% and 66% respectively), anticoagulation (74% and 76% respectively) and inotropes (41% and 40%). The mean duration of ICU stay during P1 was significantly longer than P2 [15.4 (±2.8) days versus 9.3 ± (3.8) days, p<0.0001)]. During P1, mean duration of mechanical ventilation [10 (±1.6) days] was also significantly longer than P2 [7.1 (±2.7) days] (p=0.0004). There was a significant reduction in mortality rate from 68% (22/32) during P1 to 10.4% (5/48) in P2 (p<0.0001). Patients were 4.3 times more likely to die during P1 than P2 (95% CI= 2.47-7.86). CONCLUSIONS: We observed a decrease in ICU mortality rate by 57.6% with the implementation of a treatment protocol combining remdesivir, tocilizumab and corticosteroids;we also noted a significant decline in length of ICU stay and duration of mechanical ventilation. CLINICAL IMPLICATIONS: A treatment-protocol combining remdesivir, tocilizumab and corticosteroids was effective in deceasing mortality rate by more than 50% in our ICU during the first peak of the pandemic. Our results support data recently endorsed by the NIH showing beneficial effects of these pharmacologic therapeutic interventions. DISCLOSURES: No relevant relationships by Sandeep Gupta, source=Web Response No relevant relationships by Jitendrakumar Gupta, source=Web Response No relevant relationships by Ashlesha Kaushik, source=Web Response