Preprinted Order Research Articles

Quality Improvement Initiatives for Pleural Infection Managed with Intrapleural Therapy.

Rationale Pleural infection is associated with significant mortality and its management is complex. Little attention has been given to care process metrics such as management delays, pleural drainage practices, and adequacy of intrapleural therapy administration despite their potential impact on outcomes. Audits revealed gaps in those care processes in our institution. Objectives To assess the impact of quality improvement initiatives on pleural effusion management in adults. Methods We performed a retrospective comparison of patients treated with intrapleural therapy for pleural infection at the McGill University Health Centre before (April 2013-April 2016, N=109) and after interventions (June 2020-June 2021, N=44). Interventions included a pleural drainage policy and order set, an intrapleural therapy protocol and pre-printed order, implementation of intrapleural therapy administration by nurses, local pleural infection guideline development, and an online learning module for physicians. Major outcomes (length of stay, mortality, surgical treatment) and care process metrics (management delays, pleural drainage practices, intrapleural therapy administration) were compared between the two periods. Results After implementation of the interventions, in-hospital mortality and length of stay were unchanged, but surgical management went from 14% to 0% (p=0,01). Delays in drain insertion and intrapleural therapy initiation were not significantly different. Insertion of drains smaller than 12Fr decreased from 51% to 7% (p<0,001). Drain blockage decreased from 20% to 2% (p=0,004). Additional drain insertions went from 62% to 48% (p=0,12). After interventions, 70% of intrapleural therapy doses were given by nurses, the intrapleural therapy protocol was more often adequately followed, less doses were missed, and less extended therapy was prescribed. Complications related to drain insertion and intrapleural therapy were similar between the two periods. Conclusions Following the implementation of multifaceted quality improvement interventions for pleural infection including involvement of nurses in pleural drain flushing and intrapleural therapy, improvements were observed in intrapleural therapy administration, chest drainage practices, and need for surgery. However, length of stay, mortality, and management delays were unchanged.

System-Wide Thromboprophylaxis Interventions for Hospitalized Patients at Risk of Venous Thromboembolism: Focus on Cross-Platform Clinical Decision Support.

Thromboprophylaxis of hospitalized patients at risk of venous thromboembolism (VTE) presents challenges owing to patient heterogeneity and lack of adoption of evidence-based methods. Intuitive practices for thromboprophylaxis have resulted in many patients being inappropriately prophylaxed. We conducted a narrative review summarizing system-wide thromboprophylaxis interventions in hospitalized patients. Multiple interventions for thromboprophylaxis have been tested, including multifaceted approaches such as national VTE prevention programs with audits, pre-printed order entry, passive alerts (either human or electronic), and more recently, the use of active clinical decision support (CDS) tools incorporated into electronic health records (EHRs). Multifaceted health-system and order entry interventions have shown mixed results in their ability to increase appropriate thromboprophylaxis and reduce VTE unless mandated through a national VTE prevention program, though the latter approach is potentially costly and effort- and time-dependent. Studies utilizing passive human or electronic alerts have also shown mixed results in increasing appropriate thromboprophylaxis and reducing VTE. Recently, a universal cloud-based and EHR-agnostic CDS VTE tool incorporating a validated VTE risk score revealed high adoption and effectiveness in increasing appropriate thromboprophylaxis and reducing major thromboembolism. Active CDS tools hold promise in improving appropriate thromboprophylaxis, especially with further refinement and widespread implementation within various EHRs and clinical workflows.

Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies

IntroductionVenous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for...

Dose Rounding and Cost Reduction of Anticancer Agents at King Fahad Medical City, Saudi Arabia: A 1-Year Feasibility Study

Introduction: The exponential increase in the price of anticancer drugs has warranted looking for a cost-saving measure to counter their price rise. We aim to study the impact of dose rounding of biological and anticancer agents within a range of 10% of the ordered dose. Method: The study involved patients treated with anticancer agents between January 2018 and December 2018 at King Fahad Medical City’s (KFMC) comprehensive cancer center. An anticancer medication database was created for data collection and processing. All the eligible orders were processed by hematology and oncology physicians. A performance improvement methodology was used. The dose rounding was based on the patient’s preprinted order and the nearest available vial size. The potential impact on cost was measured in Saudi Riyals (SAR). Descriptive statistics were applied for data analysis and interpretation of the results. Results: A total of 26 anticancer medications were used for treating cancer patients, and 208 prescriptions were found to be eligible for dose rounding. Brentuximab was among the drugs, showing the highest cost saving at an estimated 20,600 SAR. In addition to reducing wastage and cost of medications, 7 min were saved per preparation episode in the post-intervention period. Conclusion: Data reflected that dose rounding of chemotherapy and biological agents up to a limit of 10% is a feasible approach and could potentially save extra cost and wastage of medications in the comprehensive cancer center of KFMC.

THU293 Enhancement Of Best Practices In Diabetic Ketoacidosis Management Using Standardized Order-sets vs Individual Practitioner Orders

Abstract Disclosure: C. Yim: None. Q. Li: None. T.G. Arnason: None. Diabetic ketoacidosis (DKA) is a hyperglycemic emergency occurring in diabetics due to insulin deficiency. This results in urinary losses of water and electrolytes (sodium, potassium, chloride) and ultimately extracellular fluid volume depletion. Hallmark features of DKA include ketoacidosis, arterial pH &amp;lt; 7.3, bicarbonate &amp;lt;15 mmol/L and an anion gap of &amp;gt;12 mmol/L. The 2018 Diabetes Canada (DC) guidelines outline the key steps of DKA management including fluid resuscitation, resolution of ketoacidosis, correction of electrolytes and management of precipitating factors. Its detailed algorithm identifies three pillars to DKA treatment: IV fluids, serum potassium and acidosis. A 2016 DKA outcome audit at the Royal University Hospital (RUH) in Saskatoon identified that practitioners diverged considerably from (2013) Canadian Diabetes Association guidelines. Subsequently, two standardized preprinted DKA order sets were developed incorporating the 2018 DC recommendations for i) INITIAL and ii) MAINTENANCE DKA management. Their rollout overlapped with annual academic half day sessions on DKA management for postgraduate year 1 residents in internal medicine. These order-sets were initially implemented at RUH in November 2018 and subsequently adopted by some practitioners at St. Paul’s Hospital (SPH). To ensure the order-sets were promoting improved outcomes and adhering to best practices, a retrospective chart review was conducted of all adult DKA admissions at RUH and SPH from Nov. 13, 2018 to December 31, 2020. In total, 279 hospital admissions were reviewed: 99 used practitioners’ own orders, 115 used both initial and maintenance order-sets, 26 used only the initial order-set and 38 used only the maintenance order-set. Use of the INITIAL order set significantly improved compliance (p &amp;lt; 0.0001) with DC 2018 guidelines for recommended insulin dose and timing, fluid resuscitation as well as potassium, sodium and dextrose replacement. Use of the MAINTENANCE order set consistently enhanced outcomes for intravenous fluid selection, subcutaneous insulin overlap, and ensuring a closed anion gap at transition (p &amp;lt; 0.0001). Additionally, the chart review revealed that there were hospital differences for uptake of order sets and compliance to DC 2018 guidelines. There was a significant uptake of order sets at RUH versus SPH (p &amp;lt; 0.0001). RUH consistently met outcomes for appropriate insulin dosing, potassium and dextrose replacement (p &amp;lt; 0.0001). RUH also consistently overlapped IV and SC insulin and ensured a closed insulin gap. The anion gap remained consistently closed post-transition at RUH versus SPH (p = 0.035). These results suggest that utilization of a DKA order set does significantly promote adherence to key best practices outlined in the DC 2018 guidelines. Presentation: Thursday, June 15, 2023

37 Improving Bronchiolitis Management at B.C. Children’s Hospital: Standardizing Care Through a Pre-printed Order

Abstract Introduction/Background Bronchiolitis is the most common cause of hospital admissions during the first year of life. There is significant variation in the management of this disease. Despite supportive care being the hallmark of treatment, investigations and other treatments are commonly prescribed. Standardizing care for bronchiolitis leads to decreased resource utilization and improved patient outcomes. Pre-printed orders can standardize care and improve compliance with evidence-based medicine. Objectives To determine whether a pre-printed order (PPO) would influence length of stay and specific medication use (corticosteroids, antibiotics, bronchodilators) for patients admitted to B.C. Children’s Hospital (BCCH) with a diagnosis of bronchiolitis. Design/Methods We implemented a pre-printed order (PPO) for inpatient management of bronchiolitis at B.C. Children’s Hospital (BCCH), then conducted a retrospective chart review of children admitted to BCCH with a discharge diagnosis of bronchiolitis. We compared primary and secondary outcomes between the pre-PPO (November 24, 2017 to December 31, 2019) and post-PPO (September 22, 2021 to April 12, 2022) periods. The primary outcome was length of stay (LOS) in days, and secondary outcomes included the prescription of specific medications. Results A total of 584 patients were included in the retrospective chart review: 436 patients were from the pre-PPO period and 148 patients were from the post-PPO period. There was no difference in the LOS between the pre-PPO and post-PPO periods: median LOS was 3.00 days (2.00 to 5.00 days) and 3.00 days (2.00 to 5.00 days) in the pre- and post-PPO periods, respectively (p = 0.88). There was a decrease in prescribed antibiotics, from 36.7% to 24.7% (OR = 0.56, 95% CI = 0.37 to 0.86, p = 0.01). Additionally, there was a decrease in prescribed salbutamol, from 41.5% to 29.3% (OR = 0.58, 95% CI = 0.39 to 0.87, p = 0.01). There was no significant difference in rates of PICU admission between the pre- and post-PPO periods (23.6% vs. 26.4%, OR = 1.16, 95% CI = 0.75 to 1.76, p = 0.5). Conclusion The implementation of a PPO for inpatient management of bronchiolitis did not affect length of stay or PICU admissions. However, there was significant reduction in prescribed antibiotics and salbutamol (both reduced in the post-PPO period). Our results suggest that a pre-printed order can improve antimicrobial stewardship and reduce unnecessary medication use, when managing a common paediatric disease. Graph Example for antibiotic/salbutamol and PICU

A retrospective study comparing postoperative opioid prescribing practices in an academic medical centre.

In the midst of the North American opioid crisis, identifying and intervening on drivers of high-risk opioid prescriptions is an important step towards reducing iatrogenic harm. We aimed to identify factors associated with variations in high-risk opioid discharge prescriptions, following select surgical procedures, to guide future quality improvement initiatives. This retrospective cohort study analyzed 1322 patients who underwent select open pelvic and open abdominal surgeries between January 1 and December 31, 2017, in a tertiary health care centre in Montreal. Patients who underwent open abdominal surgeries were prescribed significantly higher daily doses of morphine milligram equivalents (MME) (45 mg; interquartile range, 30-60), than patients who underwent either a caesarean delivery (20 mg, 20-20) or a hysterectomy (30 mg, 22-30). After adjustment for multiple potential confounders, abdominal surgery was associated with 4 times the odds of receiving more than 50 MME at hospital discharge compared with pelvic surgeries (odds ratio, 3.96; 95% confidence interval, 1.31-11.97). The availability of postoperative preprinted order sets with fixed high doses of opioids was also highly associated with the outcome. In our institution, some surgeries were more likely to receive high-risk opioid prescriptions at discharge. Efforts to optimize safer prescribing practices should address the creation and/or updating of preprinted order sets to reflect current best practice guidelines. This initiative could be overseen by hospital pharmacy and therapeutics committees.

Relationship Between the Use of Preprinted Physician Orders for Hospital-Acquired Fever and Time to Blood Culture Collection: A Single-Center Retrospective Cross-Sectional Study.

PurposeFever is relatively common in patients admitted to general wards. There is no standardized approach, and little is known about how physicians respond to fever. Additionally, preprinted physician orders are routinely used clinically in hospital medicine, and it is not clear how preprinted physician orders for fever affect the care of patients with fever. Therefore, we aimed to determine whether preprinted physician orders for inpatients have an effect on the time from fever measurement to blood culture collection.Patients and MethodsThis was a single-center, retrospective, cross-sectional study of patients with bacteremia. Between January 1, 2015 and December 31, 2019, 137 hospitalized febrile patients diagnosed with bacteremia by blood culture prepared from blood collected 72 h after hospitalization were included.ResultsPreprinted physician orders with instructions to call the physician if the patient has a fever were present for 59 patients. For preprinted physician orders with instructions to notify the physician about fever onset, 62.7% of the blood cultures were collected within 1 h of fever observation; when preprinted orders were not used, only 23.1% met the 1-h collection criterion. Multivariate analysis showed that preprinted physician orders were significantly associated with blood culture collection within 1 h from the reporting of fever (odds ratio, 4.94; 95% confidence interval, 2.27–10.70).ConclusionPreprinted physician orders with instructions to notify the physician about fever onset were present for only 40% of our sample, and this was related to the time of blood culture collection.

Nocturnal Hypoglycemia Associated with Bedtime Administration of Premixed Insulin Preparations in Hospitalized Patients.

Patients with diabetes mellitus for whom premixed insulin preparations (PMIPs) are ordered in the hospital setting may be at risk of hypoglycemia if the PMIP is incorrectly administered at bedtime (instead of suppertime). The primary objective was to determine, retrospectively, the incidence of bedtime administration of PMIPs at a tertiary teaching hospital. The secondary objective was to investigate whether bedtime administration of PMIPs led to an increase in nocturnal hypoglycemia. Inpatient PMIP orders for the period April 1, 2013, to March 31, 2017, were extracted from the pharmacy information system of the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia. Two hundred randomly selected inpatient admissions were audited, and instances of PMIP administration after 2000 (8 pm) were recorded. Data from an additional random sample of inpatient admissions, from January 1, 2016, to December 31, 2017, were reviewed to determine whether bedtime administration of PMIPs was associated with increased incidence of nocturnal hypoglycemia, relative to suppertime administration. In the randomly selected sample of 200 inpatient admissions, a PMIP was administered at bedtime at least once during 47 admissions (24%). In the additional sample of 123 inpatient admissions during which a PMIP had been administered, the mean nocturnal hypoglycemia rate was 4.15% for suppertime administration and 14.85% for bedtime administration (p = 0.13). For a substantial proportion of patients, PMIPs were inappropriately ordered and administered at bedtime in this hospital setting and may have been associated with nocturnal hypoglycemic events. Recommendations to reduce this practice include ongoing education and a review of preprinted order sets.

Improving management of hypersensitivity reactions: A BC Cancer-Victoria quality improvement initiative.

230 Background: Hypersensitivity reactions (HSR) are a documented, predictable side effect of multiple chemotherapy agents. Reactions negatively affect the patient experience, increase the amount of chair time, nursing and physician resources, may result in the omission of a potentially effective cancer management tool from a patient’s treatment plan and could potentially result in death. BC Cancer is a Health Care Organization with 6 cancer centres across British Columbia, Canada. Guideline(GL)s have been developed at BC Cancer to support clinicians to manage reactions acutely and reduce the risk of reactions with subsequent cycles. A recent audit identified that the GLs were not always being followed at the Victoria Centre. Our goal was to encourage physician and nursing staff to follow GLs, which we hypothesized would result in decreased rates of HSR. Methods: Our aim was to decrease HSR to &lt; 5% of doses delivered within 1 year at BC Cancer-Victoria. We engaged stakeholders (nursing, physicians, pharmacy, clerical staff and administration). Our change ideas improved adherence to GLs by focusing on: physician attendance and documentation, written orders for rescue medication, and rate of infusion of the chemotherapy drug rechallenge. Our interventions included: two physician-education sessions, one nursing education session, daily huddles, pre-printed order development for management of the reaction (PPOA) and prophylaxis for subsequent cycles (PPOB), and a modified clinic flow. All interventions were introduced and underwent modifications through PDSA cycles. Our family of measures were: Outcome: number of reactions, percent of reactions per dose given. Process: percent of PPO use per reaction, physician attendance and notes dictated per reaction. Balancing: physician and nursing satisfaction. We analyzed the data using quality improvement run charts and control charts. Results: After the start of our initiative, our total number of reactions displayed special cause variation, and a shift in the baseline from a mean of 11.27 HSR per month to 7.526. This change was reflected in the percentage of reactions per doses given which fell from 3.1% to 1.9%. Average percentage of dictated notes per reaction increased from 55% to 64%. Physician attendance per reaction also showed special cause variation with the average increasing from 57% to 90%. PPOA and PPOB use both increased over time. Nursing and Physician satisfaction data will also be presented. Conclusions: Our successful initiative has resulted in HSR management which more closely reflects GLs, including increased physician attendance and notes, and clear consistent written orders detailed on PPO A and B. This has led to decreased HSRs at our site, resulting in decreased resource use and increased patient safety and quality. This has provincial implications as there is the potential to spread this initiative to other BC Cancer sites.

Prevention of postoperative delirium after cardiovascular surgery: A team-based approach

ObjectiveWe investigated the efficacy of the Delirium Team Approach program for delirium prevention after cardiovascular surgery. MethodsWe retrospectively investigated 256 patients who underwent cardiac or thoracic vascular surgery between May 2017 and May 2020. We compared the outcomes before and after implementation of the Delirium Team Approach program in December 2018. The program included the following components: (a) educational sessions for the medical team regarding delirium and its management, (b) review of preprinted physician orders for insomnia and agitation, and (c) routine screening for delirium. We investigated the early outcomes and effects of the Delirium Team Approach program on postoperative delirium. ResultsThe incidence of postoperative delirium significantly decreased from 53.3% to 37.0% after implementation of the Delirium Team Approach program (P = .008). Although no intergroup differences were observed in the rates of stroke and reexploration for bleeding, the length of intensive care unit stay and the overall length of postoperative hospital stay were shorter in the postintervention group. Hospital costs, excluding surgery, and the cost during intensive care unit stay were lower in the postintervention group. Multivariable analysis showed that the Delirium Team Approach program was associated with a reduction in postoperative delirium (odds ratio, 0.38; 95% confidence interval, 0.21-0.67; P = .001). Other predictors of delirium included age, dementia, chronic kidney disease, and intubation time. After risk adjustment using propensity score matching, the rate of postoperative delirium was lower in the postintervention group. ConclusionsImplementation of the Delirium Team Approach program was associated with a lower incidence of postoperative delirium in patients who underwent cardiovascular surgery.

Evaluation of Statin Use and Prescribing in Patients with Chronic Kidney Disease Not Receiving Treatment with Kidney Transplant or Dialysis

Chronic kidney disease (CKD) is a risk factor for cardiovascular disease. The Kidney Disease Improving Global Outcomes 2013 guidelines and the Canadian Cardiovascular Society 2016 guidelines recommend statins for primary prevention of cardiovascular disease in CKD patients aged 50 years or older who are not receiving treatment with kidney transplant or dialysis. To evaluate statin use for patients in the Vancouver General Hospital Kidney Care Clinic (VGH KCC) and to gain insight into the KCC nephrologists' practices and perspectives regarding the prescribing of statins for patients with CKD. The study comprised 2 parts. Part 1 consisted of a cross-sectional study of all statin-eligible patients in the VGH KCC followed by a retrospective chart review. In the chart review, data were collected for 250 statin users and 250 non-users. Logistic regression analyses were performed to determine associations between demographic variables and statin use or non-use. Part 2 was an electronic survey of VGH KCC nephrologists. Of the 813 statin-eligible patients, 512 (63%) were taking a statin. Patients were approximately 5 times more likely to be receiving statin therapy when it was indicated for secondary versus primary prevention (adjusted odds ratio 4.64, 95% confidence interval 2.95-7.47). Eight of the 9 KCC nephrologists completed the survey, and 7 (87.5%) of these respondents indicated that they never or rarely prescribed statins themselves to KCC patients for primary prevention. However, the same number reported that they sometimes or often suggested statin initiation to family physicians. Three of the respondents indicated agreement with guideline recommendations, but many stated that the decision for statin initiation should be individualized to the patient. Strategies to improve statin prescribing rates that were endorsed by respondents included educating family physicians, creating preprinted orders and laboratory requisitions for statin initiation, providing educational materials about statins to patients, and implementing a protocol for KCC pharmacists to counsel patients about statins. Many statin-eligible VGH KCC patients were not receiving statin therapy, and most of the KCC nephrologists considered statin prescribing as a role for family physicians. Within the KCC, future directions will be to develop a standardized approach to identify patients who would benefit from statin therapy, and to implement strategies to improve statin prescribing rates in appropriate patients.

Variations in Red Blood Cell and Frozen Plasma Transfusion Rates Across 60 Ontario Community Hospitals

Background: A restrictive transfusion strategy has been shown to be equivalent to a liberal transfusion strategy in terms of mortality and morbidity outcomes in major clinical trials.Liberal transfusions have been associated with higher mortality and morbidity, as well as longer lengths of stay in hospital based on observational data. Although patient blood management programs have reduced transfusion rates and improved patient outcomes, these programs have not been universally applied. Recent province wide audits of frozen plasma (FP) use in Ontario showed a high rate of inappropriate transfusions. Similarly, a recent red blood cell (RBC) audit in Ontario showed that approximately 25% of RBC units transfused were inappropriate.Objectives: The primary aim of this study was to compare transfusion rates of RBCs and FP across 60 Ontario community hospitals with more than 50 active treatment beds from 2012-2016. The secondary aims were to identify clinical and hospital factors, which may account for these differences.Methods:This study was a retrospective review of transfusion data from Ontario community hospitals between 2012-2016. RBC and FP transfusion data were acquired through the Canadian Blood Services data warehouse. Acute inpatient bed days and the annual average number of active treatment beds were obtained through the Ministry of Health and Long Term Care of Ontario. Annual transfusion rates were reported as FP and RBC units transfused per 100 acute inpatient days (AIPD), using descriptive statistics. Rates of blood component use were correlated with size of hospital using linear regression to determine whether size of hospital impacted on transfusion practices. Rates of RBC transfusion were correlated with rates of FP transfusion using linear regression. Finally, available data on local transfusion guidelines and pre-existing quality improvement mechanisms, such as pre-printed order sets, the presence of transfusion guidelines at each site were surveyed and reviewed to determine the impact of institutional culture on transfusion practices.Results: From 2012 to 2016, there were decreasing rates of RBC and FP use over time, with a wide range of variation amongst hospitals (Table 1). The average number of FP units transfused was 0.67, 0.62, 0.50, and 0.44 units per 100 AIPD for 2012-2013, 2013-2014, 2014-2015, and 2015-2016 respectively.The average number of RBC units transfused was 6.1, 6.0, 5.5, and 5.4 units per 100 AIPD for 2012-2013, 2013-2014, 2014-2015, and 2015-2016 respectively. Larger hospitals were associated with a significantly higher FP transfusion rate (p<0.05 for all years). However, there was no correlation between RBC transfusion rates and size of hospital. Of the 24 hospitals that responded to the survey, sites with transfusion quality improvement indicators (N=19) had statistically fewer units of FP transfused (p=0.04 for 2014-2015, p<0.01 for 2015-2016), and had a decrease in the units of FPs transfused from year to year. There was a statistically significant association between FP transfusion rates and RBC transfusion rates (p<0.01 for all years).Conclusion and significance: There may be cultural differences at different institutions contributing to the variations in transfusion rates across Ontario community hospitals. Characterization of transfusion practices and understanding of institutional culture surrounding blood component use will hopefully lead to quality improvement (QI) initiatives aimed at creating better guidelines, education, and transfusion order entry systems. These data will serve as a baseline to highlight sites and practices where QI initiatives may be most beneficial and potentially replicated in other provinces and states. [Display omitted] DisclosuresLin:Pfizer: Other: advisory board; Pfizer: Honoraria; Novartis: Research Funding; CSL Behring, Grifols: Other: unrestricted education grant.

A qualitative examination of the current management of opioid use disorder and barriers to prescribing buprenorphine in a Canadian emergency department

BackgroundEmergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD). The objective of this study was to identify the current knowledge, attitudes, and behaviours of ED physicians on the management of OUD in the ED, including barriers and facilitators to prescribing buprenorphine.MethodsWe purposefully selected emergency physicians from one ED in Toronto which had recently received education on OUD management and had a new addiction medicine follow-up clinic, to participate in semi-structured interviews. We used semi-structured interviews to explore experiences with patients with OUD, conceptions of role of the ED in addressing OUD, and specifically ask about perceptions and experience on using buprenorphine for opioid withdrawal. Our analysis was informed by constructivist grounded theory to help uncover contextualized social processes and focus on what people do and why they do it. Two researchers independently coded transcripts using an iterative constant comparative and interpretative approach.ResultsResults fell broadly into facilitators and barriers. Generally, management of OUD in the ED varied significantly. Physician-level facilitators to treating opioid withdrawal with buprenorphine included: knowledge about OUD an7d buprenorphine, positive experiences with substitution therapy in the past, and the presence of physician champions. Systems-level facilitators included timely access to follow-up care and pre-printed order sets. Barriers included provider inexperience, lack of feedback on treatment effectiveness, limited time to counsel patients, and pressure to discharge patients quickly. Additional barriers included concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes.ConclusionThis study describes barriers and facilitators to addressing OUD and prescribing buprenorphine in a Canadian ED. These findings suggest a role for additional provider education, involvement of allied health professionals in counseling, and mentorship by physician champions in the department.

Practice variation in the immediate postoperative care of pediatric liver transplant patients: Framework for a national consensus.

Advancements in critical care management have led to improvement in pediatric LT outcomes. However, there are no specific guidelines for many aspects of immediate post-LT care. This survey examines practice variations in the immediate postoperative care of pediatric LT patients at a large number of active US centers. This study is a cross-sectional survey of medical directors at PALISI-affiliated PICU in the United States. Centers performing pediatric LT were analyzed. Study measures included PICU practices regarding staffing, composition of the multidisciplinary team, early post-LT graft and patient monitoring, and anticoagulation. Of the thirty-five responding centers, twenty-five had a LT program which accounted for one-half of all US pediatric LTs. For analysis, centers were categorized by volume: high (7), medium (11), and low (7). The majority of PICU teams included an intensivist (80%) and hepatologist (84%). High-volume centers were less likely to have 24-hour in-house attending coverage (29%, compared to 64% (medium) and 100% (low)). High-volume centers were most likely to have pre-printed orders, but least likely to have written PICU management protocols. Most centers utilize routine daily liver ultrasound. Routine prophylactic anticoagulation, and the agent of choice, was variable. There is marked inconsistency in post-LT practice across PALISI centers in regards to team composition and immediate post-LT management. A national US consensus for post-LT PICU practices would facilitate outcomes research and would establish a platform for multicenter studies.

Prescribing errors and associated factors in discharge prescriptions in the emergency department: A prospective cross-sectional study.

Evidence regarding the prevalence of medication prescribing errors (PEs) and potential factors that increase PEs among patients treated in the emergency department (ED) are limited. This study aimed to explore the prevalence and nature of PEs in discharge prescriptions in the ED and identify potential risk factors associated with PEs. This was a prospective observational cross-sectional study in an ambulatory ED in a tertiary teaching hospital. Data were collected for six months using a customized reporting tool. All patients discharged from ED with a discharged prescription within the study period were enrolled in this study. About 13.5% (n = 68) of the 504 prescriptions reviewed (for 504 patients) had at least one error. Main PEs encountered were wrong dose (23.2%), wrong frequency (20.7%), and wrong strength errors (14.6%). About 36.8% of identified PEs were related to pediatric prescriptions, followed by the acute care emergency unit (26.5%) and the triage emergency unit (20.6%). The main leading human-related causes associated with PEs were lack of knowledge (40.9%) followed by an improper selection from a computer operator list (31.8%). The leading contributing systems related factors were pre-printed medication orders (50%), lack of training (31.5%), noise level (13.0%), and frequent interruption of prescriber and distraction (11.1%). Prescribers' involved with the identified errors were resident physicians (39.4%), specialists (30.3%), and (24.4%) were made by general practitioners. Physicians rejected around 12% of the pharmacist-raised recommendations related to the identified PEs as per their clinical judgment. PEs in ED setting are common, and multiple human and systems-related factors may contribute to the development of PEs. Further training to residents and proper communication between the healthcare professionals may reduce the risk of PEs in ED.

Toward a Common Goal: Improving Safety of Oral Chemotherapy Prescribing Practices at a Jurisdictional Level.

Extending the safety agenda from parenteral to oral chemotherapy was identified as a provincial improvement priority in the 2014-2019 Cancer Care Ontario (CCO) Systemic Treatment Provincial Plan. Elimination of handwritten prescriptions for oral chemotherapy was one of the specific goals and led to a provincial quality improvement (QI) initiative involving systemic treatment facilities across 14 regional cancer programs. The initiative was centrally organized by CCO but locally implemented by the regional partners. CCO provided templates and tools, such as preprinted orders (PPOs), project charters, and an evaluation plan, and facilitated cross-jurisdictional knowledge sharing and exchange. Regions had flexibility in determining their local implementation strategies and were responsible for conducting chart audits to evaluate implementation success. Each participating hospital completed 3 audits-at baseline, immediately after implementation (audit 1), and 1 year later (audit 2)-using either a clinic-based or an outpatient pharmacy-based assessment. Thirty-five facilities providing systemic treatment participated. At baseline, the provincial average for the use of computerized physician order entry (CPOE) or PPOs for prescribing oral chemotherapy was 71%. After implementation of the QI initiative, the provincial average for the use of CPOE or PPO increased to 91% at audit 1 and 95% at audit 2. Although not all facilities met the goal of 100% CPOE or PPO compliance, the QI initiative led to improvement in safe prescribing practices for oral chemotherapy. A coordinated QI approach between a central decision maker and local partners can be an effective strategy to encourage high-quality cancer care and promote a culture of safety across a jurisdiction.

LO68: Kelowna emergency department buprenorphine/naloxone for opioid use disorder: a program evaluation study

Introduction: Emergency department (ED) buprenorphine/naloxone inductions for opioid use disorder are an effective and safe way to initiate addictions care in the ED. Kelowna General Hospital's ED buprenorphine/naloxone (KEDSS) program was implemented in September 2018 in order to respond to a community need for accessible and evidence-based addictions care. The objective of our program evaluation study was to examine the implementation of the first five months of the KEDSS program through evaluating patient characteristics and service outcomes. Methods: The KEDSS treatment pathway consists of a standardized protocol (pre-printed order set) to facilitate buprenorphine/naloxone induction and stabilization in the acute care setting (ED and inpatient wards) at Kelowna General Hospital, a community academic hospital. All patients referred to the outpatient addictions clinic via the order set during September 2018-January 2019 (the first 5 months) were included in the study population. A retrospective descriptive chart review was completed. Outcome measures included population characteristics (sociodemographic information, clinical characteristics) and service outcomes (number of patients initiated, patient follow-up). Descriptive statistics and bivariate analyses using t-tests or Pearson's χ2 statistic, as appropriate, were conducted to compare the ED-initiated group with the inpatient-initiated group. Results: During the first five months of the KEDSS program, a total of 35 patients (26% female, mean age 36.6 years, 54% homeless) were started on the treatment pathway, 16 (46%) in the ED. Compared to the inpatient-initiated group, the ED-initiated group were less likely to have psychiatric comorbidities (ED 1.0 vs. inpatient 1.5, p = 0.002), require methadone or sustained-release oral morphine (ED 13% vs. inpatient 37%, p = 0.048), and have attended follow-up (ED 56% vs. inpatient 84%, p = 0.004). Conclusion: This study provides a preliminary look at a new opioid agonist therapy (OAT) treatment pathway (KEDSS) at Kelowna General Hospital, and provides insight into the population that is accessing the program. We found that the majority of patients who are started on buprenorphine/naloxone in the ED are seen in follow-up at the addictions clinic. Future work will examine ongoing follow-up and OAT adherence rates in the study population to quantify the program's impact on improving access to addictions treatment within this community hospital setting.

Educating the next frontier of transfusionists: a transfusion camp pilot program for nurse practitioners.

Blood transfusion is common and potentially lifesaving but is associated with risk and overuse. Nurse practitioners (NPs) in multidisciplinary care teams are increasingly expanding their scope of practice to transfusion medicine (TM). Resources aimed at NPs are lacking, and little is known about NP TM knowledge. Thus, we developed a pilot TM curriculum for NP credentialing and assessed its impact. NP leads and TM directors adapted the successful Canadian Transfusion Camp for medical postgraduate trainees into a 3-day curriculum for NPs. Two modalities were used to assess the pilot: 1) a participant demographics survey and needs assessment; and 2) the validated BEST-TEST knowledge assessment exam administered before and after the course. Of the 23 volunteer participants, the majority reported prescribing blood products within the last year, primarily red blood cells. Minimal opportunities to undertake continuing medical education in TM were identified. NPs often used preprinted order forms, consultation with physicians sharing care, or local fact sheets to guide transfusion; rather than TM physician consultation or guidelines. Exam scores significantly improved after the course (before, 35.2% vs. after, 50.3%; p = 0.005), suggesting average initial knowledge being below medical postgraduate trainee-level improving to postgraduate trainee level. Questions on appropriate transfusion triggers and correct recipient identification were most correctly answered; and responses to transfusion reaction questions required improvement. Our needs assessment suggests that TM resources for NPs are relevant but lacking. Our initiative supports the generalizability, scalability, and effectiveness of the Transfusion Camp program. Further implementation, refinement, and future impact assessments are required.

1094. Safety of Administering Cefazolin vs. Other Antibiotics in Penicillin Allergic Patients with Anaphylaxis for Surgical Prophylaxis

BackgroundApproximately 10% of patients report a history of penicillin allergy. Recent literature suggests cross-reactivity between cephalosporins and penicillins are due to side-chain similarities. Since cefazolin has a unique side-chain from other β lactams, it can be safely administered in penicillin-allergic patients for surgical prophylaxis. Since October 2018, our hospital updated all surgical prophylaxis preprinted orders to use cefazolin in penicillin-allergic patients, except in those with histories of cefazolin-specific allergy or delayed skin reactions (e.g., Stevens–Johnson syndrome). This study aims to retrospectively determine outcomes and safety of cefazolin as compared with other antibiotics for surgical prophylaxis in penicillin-allergic patients with histories of anaphylaxis prior to implementation of cefazolin preprinted orders.MethodsAll patients with reported anaphylactic reactions to penicillins prescribed surgical prophylaxis from October 9, 2017 to October 9, 2018 were included. Patients were stratified based on antibiotic received (i.e., cefazolin, clindamycin, vancomycin, other antibiotic) and a retrospective chart review was performed to assess for outcomes and safety.ResultsOne-thousand-seventy-three prescriptions for prophylactic antibiotics were identified. Of these, 223 cases met inclusion with histories of anaphylaxis to pencillins: 72 (32%) cefazolin, 70 (31%) clindamycin, 34 (15%) vancomycin, and 47 (21%) other antibiotics. General and orthotrauma surgeries used the most cefazolin in penicillin-allergic patients, while gynecology clindamycin and thoracics vancomycin. Amongst those receiving cefazolin, no critical incidents of allergic reactions were reported and the rates of adverse events, such as pruritus, hives and rash, did not differ between any antibiotic group.ConclusionCefazolin appears to be a safe option for surgical prophylaxis in patients with history of penicillin anaphylaxis. No differences in incidences of allergic reactions, complications or surgical delays were reported, as compared with alternate antibiotics. Further larger studies are needed to confirm our findings and determine rates of adverse events associated with the various antibiotic regimens.Disclosures All authors: No reported disclosures.