Prescribing In Emergency Department Research Articles

N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study.

Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful. ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836. DERR1-10.2196/50417.

Association between Acute Pain Scores in Children with Sickle Cell Disease and Emergency Department Disposition and Return Visit Rates

Introduction Reducing pain through prompt administration of pain medication in the emergency department (ED) is a primary driver of national guidelines for sickle cell disease (SCD), yet there are few data on how pain scores and changes in pain scores are associated with both the disposition at the initial visit and the likelihood of a return visit. In this study, we analyzed acute pain scores from ED visits for children with uncomplicated SCD pain crisis to determine the relationships between pain scores and disposition (admission or discharge) or occurrence of a return ED visit. Objectives For children with uncomplicated SCD pain crises, we aimed to determine (1) the association between initial pain score, last pain score, change in pain scores and the disposition of index ED visits, and (2) the association between these pain score values, number of parenteral opioid doses in the ED, whether an opioid prescription was provided at discharge, and an ED return visit within 14 days. Methods This is a multicenter retrospective cohort study of acute pain scores of ED visits by children for uncomplicated SCD pain crises. It was conducted using electronic health care data from the Pediatric Emergency Care Applied Research Network (PECARN) Registry across 7 sites (Lurie Children's, Children's Hospital of Philadelphia, Cincinnati Children's Hospital, Children's National Medical Center, Children's Colorado, Children's Wisconsin, and Nationwide Children's). Index ED visits were defined as uncomplicated pain crises with no preceding ED visits within 14 days between 01/2017 - 11/2021. We collected the following ED pain scores: initial, last, and change in scores (initial minus last) as measured by a numeric rating scale (0-10). For analyses related to disposition, we modeled the relationship between the three pain scores and hospital disposition adjusting for age, sex and uncomplicated pain crisis visit admission rate. For analyses related to return visits, we utilized the same predictor variables and added both the number of parenteral opioid doses administered in the ED and whether or not a prescription for an opioid was given at discharge. For all analyses, adjustment for site was made using generalized estimating equations with an exchangeable correlation structure to account for clustering within site. Modified Poisson regression was used to identify associations. SAS software version 9.4 was used for all statistical analyses. Results A total of 4,985 index visits for uncomplicated SCD pain crisis were included; 52% resulted in hospitalization. Overall, 39% of the children were <12 years old, 54% were female, and 96% were Black. Eligible index ED visits per site varied from 157 to 1855. The overall ED median (IQR) initial pain score was 8.0 (6.0-10).The median last pain score was 5.0 (2.0-8.0); median change in ED pain score was 2.0 (0.0-5.0). In univariate analyses, higher initial and last pain scores and a smaller change in pain scores were all associated with higher hospitalization rates. Adjusted rate ratios (95% CI) from multivariable models showed last pain score was the best predictor of admission 1.16 (1.12, 1.19), with change in pain score no longer significant 0.98 (0.96, 1.00). Examining percent of children hospitalized by last pain score shows over 80% of children with a last pain score of 7 or higher were hospitalized, compared to less than 40% if 4 or lower (Figure 1). 29% of the 2,377 visits that were originally discharged to home had a return visit within 14 days. None of the included pain scores from the initial visit (initial, last, or change) were associated with having a return visit within 14 days. However, both an increased number of ED opioid doses and failure to receive a prescription for an opioid at discharge were associated with increased return visits. Figure 2 shows the ED opioid doses and prescription for opioid combination and their respective return visit rates, with a high of 36% for ≥ 3 doses of ED opioid doses and no prescription and a low of 22% if 1 opioid given and a prescription at discharge. Conclusions: We found that for a child with SCD presenting to the ED with an uncomplicated pain crisis, the last ED pain score was a better predictor of hospitalization than initial or change in pain score. None of those pain scores predicted a return visit after discharge; however, fewer opioid doses in the ED and receipt of an opioid prescription at discharge were associated with fewer return visits.

Trends in Outpatient Influenza Antiviral Use Among Children and Adolescents in the United States.

Influenza antivirals improve outcomes in children with duration of symptoms <2 days and those at high risk for influenza complications. Real-world prescribing of influenza antivirals in the pediatric population is unknown. We performed a cross-sectional study of outpatient and emergency department prescription claims in individuals <18 years of age included in the IBM Marketscan Commercial Claims and Encounters Database between July 1, 2010 and June 30, 2019. Influenza antiviral use was defined as any dispensing of oseltamivir, baloxavir, or zanamivir. The primary outcome was the rate of antiviral dispensing per 1000 enrolled children. Secondary outcomes included antiviral dispensing per 1000 influenza diagnoses and inflation-adjusted costs of antiviral agents. Outcomes were calculated and stratified by age, acute versus prophylactic treatment, influenza season, and geographic region. The analysis included 1 416 764 unique antiviral dispensings between 2010 and 2019. Oseltamivir was the most frequently prescribed antiviral (99.8%). Dispensing rates ranged from 4.4 to 48.6 per 1000 enrolled children. Treatment rates were highest among older children (12-17 years of age), during the 2017 to 2018 influenza season, and in the East South Central region. Guideline-concordant antiviral use among young children (<2 years of age) at a high risk of influenza complications was low (<40%). The inflation-adjusted cost for prescriptions was $208 458 979, and the median cost ranged from $111 to $151. There is wide variability and underuse associated with influenza antiviral use in children. These findings reveal opportunities for improvement in the prevention and treatment of influenza in children.

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography.

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

Implementation of Electronic Health Record Integration and Clinical Decision Support to Improve Emergency Department Prescription Drug Monitoring Program Use

To evaluate the implementation of 3 electronic health record (EHR)-based interventions to increase prescription drug monitoring program (PDMP) use in the emergency department (ED): EHR-PDMP integration, addition of a PDMP risk score, and addition of EHR-based clinical decision support alert to review the PDMP when prescribing an opioid. Three intervention stages were implemented using a prospective stepped-wedge design at 5 university-affiliated EDs split into 3 practice groups. The PDMP use and prescribing rates during the 3 stages were compared with baseline before EHR integration and a sustainability stage where the clinical decision support alert was removed, but EHR integration and risk score remained. Generalized linear mixed model with logit link function and a random intercept for clinicians was analyzed. The ED provider PDMP review before opioid prescribing was low in all stages. The highest review rate occurred during interruptive clinical decision support alerts, 23.8% (interquartile range 10.6 to 37.5). Overall, opioid prescribing declined, and PDMP review was not associated with a decrease in opioid prescribing. PDMP review was associated with a reduction in the probability of prescribing an opioid as the number of prior opioid prescriptions increased (odds ratio: 0.92 [95% confidence interval: 0.91 to 0.94] for every additional prescription). The EHR-PDMP integration did not increase PDMP use in the ED, but a PDMP risk score and a clinical decision support alert were associated with modest increases in the probability of PDMP review. When the PDMP is reviewed, ED clinicians are less likely to prescribe opioids to patients with a high number of prior opioid prescriptions.

Real-World Observational Evaluation of Common Interventions to Reduce Emergency Department Prescribing of Opioid Medications.

Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real-world opioid stewardship policies are concurrent and overlapping, the authors examined the effect of such policies on emergency department (ED) opioid prescriptions. The researchers performed observational analysis of all ED visits discharged between December 17, 2016, and December 31, 2019, across seven EDs of a hospital system. Four interventions were examined in chronological order, with each successive intervention added on top of all previous interventions: 12-pill prescription default, EPCS, electronic health record (EHR) pop-up alert, and 8-pill prescription default. The primary outcome was opioid prescribing, which was described as number of opioid prescriptions per 100 discharged ED visits and modeled as a binary outcome for each visit. Secondary outcomes included prescription morphine milligram equivalents (MME) and non-opioid analgesia prescriptions. A total of 775,692 ED visits were included in the study. Compared to the preintervention period, cumulative reductions in opioid prescribing were seen with incremental interventions, including after adding a 12-pill default (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.82-0.94), after adding EPCS (OR 0.7, 95% CI 0.63-0.77), after adding pop-up alerts (OR 0.67, 95% CI 0.63-0.71), and after adding an 8-pill default (OR 0.61, 95% CI 0.58-0.65). EHR-implemented solutions such as EPCS, pop-up alerts, and pill defaults had varying but significant effects on reducing ED opioid prescribing. Policy makers and quality improvement leaders might achieve sustainable improvements in opioid stewardship while balancing clinician alert fatigue through policy efforts promoting implementation of EPCS and default dispense quantities.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O’CAFÉ trial)

BackgroundManagement of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk.MethodsWe describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California.DiscussionWe hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter.Trial registrationClinicalTrials.gov NCT05009225. Registered on 17 August 2021.

Does electronic prescribing of controlled substances deter controlled substance prescribing in emergency departments?

ObjectiveTo examine the association between electronic prescribing of controlled substances (EPCS) and controlled substance prescription patterns in U.S. emergency departments (ED). Materials and methodsWe conducted cross-sectional analysis at both the ED level and visit level, using the 2016–2017 National Hospital Ambulatory Medical Care Surveys. ResultsThe sample included 24,296 visits to 316 EDs, 45% of which utilized EPCS. Pain-related visits were associated with significantly higher odds of prescriptions for any controlled substances (OR = 1.52; 95% CI: 1.32–1.75; p < 0.001) and Schedule II substances (OR = 2.13; 95% CI: 1.80–2.52; p < 0.001). Conditional on pain-related visits, EPCS was significantly associated with higher odds of any (OR 1.31; 95% CI: 1.08–1.59; p = 0.006) and Schedule III (OR 1.38; 95% CI: 1.03–1.85; p = 0.031) controlled substance prescriptions. For non-pain related visits, EPCS was not associated with changes in controlled substance prescriptions. DiscussionWhile EPCS transmits prescriptions directly to pharmacies in order to reduce drug diversion problems, the results indicated no significant association between EPCS use and prescriptions for Schedule II drugs which include opioids. As many states move towards mandating EPCS use in order to curb the opioid epidemic, future studies should examine the barriers to the effective implementation of EPCS, in the context of other systems such as Prescription Drug Monitoring Programs. ConclusionEPCS does not appear to deter Schedule II controlled substances prescription including opioids in an ED visit. It may facilitate any and Schedule III controlled substance prescriptions when pain was involved in an ED visit.

Implementation of indication-based antibiotic order sentences improves antibiotic use in emergency departments

IntroductionPrior data have suggested that suboptimal antibiotic prescribing in the emergency department (ED) is common for uncomplicated lower respiratory tract infections (LRTI), urinary tract infections (UTI), and acute bacterial skin and skin structure infections (ABSSSI). The objective of this study was to measure the effect of indication-based antibiotic order sentences (AOS) on optimal antibiotic prescribing in the ED. MethodsThis was an IRB-approved quasi-experiment of adults prescribed antibiotics in EDs for uncomplicated LRTI, UTI, or ABSSSI from January to June 2019 (pre-implementation) and September to December 2021 (post-implementation). AOS implementation occurred in July 2021. AOS are lean process, electronic discharge prescriptions retrievable by name or indication within the discharge order field. The primary outcome was optimal prescribing, defined as correct antibiotic selection, dose, and duration per local and national guidelines. Descriptive and bivariate statistics were performed; multivariable logistic regression was used to determine variables associated with optimal prescribing. ResultsA total of 294 patients were included: 147 pre-group and 147 post-group. Overall optimal prescribing improved from 12 (8%) to 34 (23%) (P < 0.001). Individual components of optimal prescribing were optimal selection at 90 (61%) vs 117 (80%) (P < 0.001), optimal dose at 99 (67%) vs 115 (78%) (P = 0.036), and optimal duration at 38 (26%) vs 50 (34%) (P = 0.13) for pre- and post-group, respectively. AOS was independently associated with optimal prescribing after multivariable logistic regression analysis (adjOR, 3.6; 95%CI,1.7–7.2). A post-hoc analysis showed low uptake of AOS by ED prescribers. ConclusionsAOS are an efficient and promising strategy to enhance antimicrobial stewardship in the ED.

Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments.

Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.

Are There Differences in Postoperative Opioid Prescribing Across Racial and Ethnic Groups? Assessment of an Academic Health System.

Previous studies have demonstrated racial disparities in opioid prescribing in emergency departments and after surgical procedures. Orthopaedic surgeons account for a large proportion of dispensed opioid prescriptions, yet there are few data investigating whether racial or ethnic disparities exist in opioid dispensing after orthopaedic procedures. (1) Are Black, Hispanic or Latino, or Asian or Pacific Islander (PI) patients less likely than non-Hispanic White patients to receive an opioid prescription after an orthopaedic procedure in an academic United States health system? (2) Of the patients who do receive a postoperative opioid prescription, do Black, Hispanic or Latino, or Asian or PI patients receive a lower analgesic dose than non-Hispanic White patients when analyzed by type of procedure performed? Between January 2017 and March 2021, 60,782 patients underwent an orthopaedic surgical procedure at one of the six Penn Medicine healthcare system hospitals. Of these patients, we considered patients who had not been prescribed an opioid within 1 year eligible for the study, resulting in 61% (36,854) of patients. A total of 40% (24,106) of patients were excluded because they did not undergo one of the top eight most-common orthopaedic procedures studied or their procedure was not performed by a Penn Medicine faculty member. Missing data consisted of 382 patients who had no race or ethnicity listed in their record or declined to provide a race or ethnicity; these patients were excluded. This left 12,366 patients for analysis. Sixty-five percent (8076) of patients identified as non-Hispanic White, 27% (3289) identified as Black, 3% (372) identified as Hispanic or Latino, 3% (318) identified as Asian or PI, and 3% (311) identified as another race ("other"). Prescription dosages were converted to total morphine milligram equivalents for analysis. Statistical differences in receipt of a postoperative opioid prescription were assessed with multivariate logistic regression models within procedure, adjusted for age, gender, and type of healthcare insurance. Kruskal-Wallis tests were used to assess for differences in the total morphine milligram equivalent dosage of the prescription, stratified by procedure. Almost all patients (95% [11,770 of 12,366]) received an opioid prescription. After risk adjustment, we found no differences in the odds of Black (odds ratio 0.94 [95% confidence interval 0.78 to 1.15]; p = 0.68), Hispanic or Latino (OR 0.75 [95% CI 0.47 to 1.20]; p = 0.18), Asian or PI (OR 1.00 [95% CI 0.58 to 1.74]; p = 0.96), or other-race patients (OR 1.33 [95% CI 0.72 to 2.47]; p = 0.26) receiving a postoperative opioid prescription compared with non-Hispanic White patients. There were no race or ethnicity differences in the median morphine milligram equivalent dose of postoperative opioid analgesics prescribed (p > 0.1 for all eight procedures) based on procedure. In this academic health system, we did not find any differences in opioid prescribing after common orthopaedic procedures by patient race or ethnicity. A potential explanation is the use of surgical pathways in our orthopaedic department. Formal standardized opioid prescribing guidelines may reduce variability in opioid prescribing. Level III, therapeutic study.

910. Impact of Indication-based Antibiotic Order Sentences on Optimal Prescribing in the Emergency Department: A Quasi-experiment

Abstract Background A prior study demonstrated suboptimal antibiotic prescribing in the emergency department (ED) at 77.4% for uncomplicated lower respiratory tract infections (LRTI), urinary tract infections (UTI), and acute bacterial skin and skin structure infections (ABSSSI). This study measured the effect of indication-based antibiotic order sentences (AOS) on prescribing. Methods IRB-approved quasi-experiment of adults prescribed antibiotics in ED for uncomplicated LRTI, UTI, or ABSSSI from January - June 2019 (pre-group) or September - December 2021 (post-group). Exclusion: hospital admission, immunocompromised, active cancer, or prophylactic antibiotics. AOS are lean process, electronic discharge prescriptions retrievable by name or indication; AOS implementation occurred July 2021. Optimal prescribing was defined as the correct antibiotic selection, dose, and duration per local and national guidelines. Seven-day endpoints: antibiotic escalation, ED or hospital readmission, any outpatient contact, and reported adverse drug event (ADE). Descriptive and bivariate statistics performed. Variables considered for multivariable logistic regression had p&amp;lt; 0.2 or plausible association with optimal prescribing. Results 294 patients included: 147-pre and 147-post. Patient characteristics are in Table 1. Overall optimal prescribing improved from 12 (8.2%) to 34 (23.1%) (p&amp;lt; 0.001). Breakdown of optimal prescribing in pre- and post-groups: selection 90 (61.2%) vs 117 (79.6%) (p&amp;lt; 0.001), dose 99 (67.3%) vs 115 (78.2%) (p=0.036), duration 38 (25.9%) vs 50 (34%) (p=0.126). After adjustment, AOS were independently associated with optimal prescribing (Table 2). Secondary endpoints: antibiotic escalation 10 (6.8%) vs 7 (4.8%) (p=0.662), hospital or ED readmission 12 (8.2%) vs 10 (6.8%) (p=0.658), outpatient contact 31 (21.1%) vs 28 (19%) (p=0.662), and ADE 2 (1.4%) vs 4 (2.7%) (p=0.684). Post-hoc analysis showed suboptimal uptake of AOS by ED prescribers. Table 1:Baseline and Clinical CharacteristicsTable 2:Bivariable and Multivariable Regression Analysis of Factors Associated with Optimal Prescribing†Covaries with intervention group; Hosmer and Lemeshow p = 0.68; Method: backwards logistic regression; No variables removed Conclusion AOS is an efficient and promising antimicrobial stewardship strategy; provider re-education is needed to increase AOS uptake. Disclosures All Authors: No reported disclosures.

1747. Emergency Department Antimicrobial Stewardship Intervention Bundle to Optimize Antibiotic Prescribing in Urinary Tract Infections and Skin and Soft Tissue Infections

Abstract Background Emerging literature has demonstrated a positive impact of emergency department (ED)-focused antimicrobial stewardship initiatives on antibiotic prescribing. To date, the majority of interventions focus on urinary tract infections (UTI) and few evaluate electronic medical record (EMR) integration. Methods This retrospective, quasi-experimental study was conducted at five EDs within a large-community health system. An antimicrobial stewardship intervention bundle was implemented in February 2022, consisting of ED-specific discharge antibiotic order sets for UTI and skin and soft tissue infections (SSTI) and education to ED prescribers and pharmacists. Adult patients receiving an ED discharge antibiotic prescription associated with a UTI or SSTI ICD10 code were included. The primary outcome was the percentage of prescriptions matching discharge order set antibiotic regimens for UTI and SSTI in the 2-month pre- and post-implementation periods. Secondary outcomes included evaluation of primary outcome indications (UTI or SSTI), use of recommended agents or durations of therapy, use of combination therapy (SSTI only), and rate of 30-day hospital admission. Results The implementation of this multi-intervention stewardship bundle was associated with a significant initial improvement in the percentage of prescriptions matching discharge order set recommendations for UTI and SSTI (30.9% vs. 35%, P = 0.04). There was a significant improvement in UTI prescribing (54.9% vs. 61.7%, P = 0.01), but the same benefit was not demonstrated for SSTI (6.2% vs. 3.6%, P = 0.04). A significant improvement was also observed in the use of recommended durations of therapy (34% vs. 38.5%, P = 0.023). No significant difference was observed in use of indication recommended agents (75.7% vs. 77.1%, P = 0.43), use of inappropriate combination therapy for SSTI (31.7% vs.26.3%, P = 0.07), or 30-day hospital admission (6% vs. 5%, P = 0.33). Conclusion This novel multi-intervention ED antimicrobial stewardship bundle was associated with overall immediate improvements in antibiotic prescribing for discharged patients. Future directions of research will include evaluation of methods to improve SSTI prescribing, implementation of prescriber data feedback, and expansion to additional indications. Disclosures All Authors: No reported disclosures.

149 Patterns of Fluoroquinolone Use in the Emergency Department 2009 - 2019

Fluoroquinolone antibiotics, with high concentration in the prostate and lung tissue, are excellent candidates for urinary and respiratory infections. However, since 2008, their usage might have been declining, potentially secondary to adverse effects, per warning by the US Food and Drug Administration. This study aims to examine the trend in fluoroquinolone prescribing in emergency departments (ED) from 2009-2019.

Predicting at-risk opioid use three months after ed visit for trauma: Results from the AURORA study

ObjectiveWhether short-term, low-potency opioid prescriptions for acute pain lead to future at-risk opioid use remains controversial and inadequately characterized. Our objective was to measure the association between emergency department (ED) opioid analgesic exposure after a physical, trauma-related event and subsequent opioid use. We hypothesized ED opioid analgesic exposure is associated with subsequent at-risk opioid use.MethodsParticipants were enrolled in AURORA, a prospective cohort study of adult patients in 29 U.S., urban EDs receiving care for a traumatic event. Exclusion criteria were hospital admission, persons reporting any non-medical opioid use (e.g., opioids without prescription or taking more than prescribed for euphoria) in the 30 days before enrollment, and missing or incomplete data regarding opioid exposure or pain. We used multivariable logistic regression to assess the relationship between ED opioid exposure and at-risk opioid use, defined as any self-reported non-medical opioid use after initial ED encounter or prescription opioid use at 3-months.ResultsOf 1441 subjects completing 3-month follow-up, 872 participants were included for analysis. At-risk opioid use occurred within 3 months in 33/620 (5.3%, CI: 3.7,7.4) participants without ED opioid analgesic exposure; 4/16 (25.0%, CI: 8.3, 52.6) with ED opioid prescription only; 17/146 (11.6%, CI: 7.1, 18.3) with ED opioid administration only; 12/90 (13.3%, CI: 7.4, 22.5) with both. Controlling for clinical factors, adjusted odds ratios (aORs) for at-risk opioid use after ED opioid exposure were: ED prescription only: 4.9 (95% CI 1.4, 17.4); ED administration for analgesia only: 2.0 (CI 1.0, 3.8); both: 2.8 (CI 1.2, 6.5).ConclusionsED opioids were associated with subsequent at-risk opioid use within three months in a geographically diverse cohort of adult trauma patients. This supports need for prospective studies focused on the long-term consequences of ED opioid analgesic exposure to estimate individual risk and guide therapeutic decision-making.

Impact of the Choosing Wisely Canada recommendations on potentially inappropriate antibiotic prescribing in emergency medicine across Alberta, Canada: An interrupted time-series analysis.

ObjectivesIn Alberta, Canada, we quantified the rate of potentially inappropriate oral antibiotic prescribing in emergency departments for viral infections or conditions not likely requiring antibiotics from 2010-2020 and assessed the impact of two Choosing Wisely Canada (CWC) campaigns (2015/2016 and 2018) discouraging inappropriate antibiotic prescribing in emergency medicine.&#x0D; ApproachWe linked emergency department adult and pediatric records from the National Ambulatory Care Reporting System and medication dispensations from community-based pharmacies in the Pharmaceutical Information Network. From January 2010 to February 2020, we identified emergency department visits for 5 conditions that were potentially inappropriately treated using antibiotics per CWC recommendations (bronchitis, asthma, bronchiolitis, pharyngitis, and acute otitis media). We used an interrupted time series design to detect changes in antibiotic prescribing by fitting Autoregressive Integrated Moving Average (ARIMA) models to account for secular trends and seasonality, allowing for change in slopes to measure the effect of each CWC intervention.&#x0D; ResultsAntibiotics were commonly prescribed in emergency departments for bronchitis (proportion of visits with antibiotics: 57%) and asthma (22%) in adults; bronchiolitis in children (43%); pharyngitis (39%) and acute otitis media (54%) in adults and children. Based on visual inspection, the proportion of emergency department visits for each condition where antibiotics were dispensed remained relatively consistent. The ARIMA models demonstrated mixed impacts on potentially inappropriate antibiotic prescribing associated with two interruptions: the 2015/2016 CWC recommendations and subsequent 2018 CWC Using Antibiotics Wisely campaign. Following each interruption, antibiotic prescribing was slightly reduced for bronchitis&#x0D; (-1.0%/year,p=0.03; -4.4%/year,p=0.004, respectively) and bronchiolitis (not significant)&#x0D; (-0.7%/year,p=0.57; -2.5%/year,p=0.34), but unchanged for asthma (-0.6%/year,p=0.30; 0.7%/year,p=0.74) and pharyngitis (0.0%/year,p=0.95; -0.2%/year,p=0.93), and slightly increased for acute otitis media (not significant) (1.4%/year,p=0.07; 5.9%/year,p=0.052).&#x0D; ConclusionRates of potentially inappropriate antibiotic prescribing remained constant over the past 10 years in Alberta. Campaigns to rethink antibiotic use in emergency medicine may have resulted in small decreases in antibiotic use; however, further initiatives building upon existing campaigns are required to substantially reduce rates of inappropriate antibiotic prescribing.

Shifting practice in pediatric prescription opioid use in the emergency department for fractures

ObjectivesJudicious opioid use is important for balancing patient comfort and safety. Although opioid use is well studied in adult populations, pediatric opioid prescription practices are less understood and there are very few guidelines regarding its usage. The purpose of this study was to investigate pediatric opioid prescription trends by emergency medicine physicians over the last ten years, including assessing proxies for the adequacy of pain control and risk of any opioid-related adverse events including overdose. MethodsA retrospective analysis was performed of all patients age 0 to 18 who presented to an urban county hospital emergency department (ED) between 2007 and 2017 for acute fracture care. Data collected included age, opioids given in the ED, opioid prescriptions from the ED, adverse events, and secondary opioid prescriptions. Opioid prescription quantities were assessed in morphine equivalents (Meqs). ResultsOut of 4713 patients diagnosed with acute fracture, opioid prescriptions from the ED were given to 1772 patients (37.6%), with a mean quantity of 107.0 Meqs (SD = 69.1). Over the ten-year period studied, prescription rates declined from 54.8% in 2007 to 13.6% in 2017. Although 201 (4.3%) fracture patients had a second fracture-related ED visit, only 27 visits (0.57%) were for inadequate pain control, with no significant differences in year-to-year analysis. During the ten-year study period, there were zero opioid overdoses reported among pediatric fracture patients. ConclusionsA major shift has occurred in the last ten years, as emergency medicine physicians now favor non-opioid pain management regimens over opioids for the majority of pediatric fracture patients. There was no increase in the rate of inadequate pain control requiring a return to the ED, even as opioid prescription rates declined during the study period.

Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults.

ObjectiveIt is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach.MethodsWe conducted a secondary analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2018. Visits where patients were aged 10 to 24 years were included. Predictors of ED-RX and DC-RX were identified via machine learning methods. Separate weighted logistic regressions were performed to determine the association between each predictor, and ED-RX and DC-RX, respectively.ResultsThere were 12,693 ED visits identified within the study time frame, with the majority being female (58.6%) and White (70.7%). Approximately 12.3% of all visits were administered an opioid during the ED visit, and 11.5% were prescribed one at discharge. For ED-RX, the strongest predictors were fracture injury (odds ratio [OR], 5.24; 95% confidence interval [CI], 3.73–7.35) and Southern geographic region (OR, 3.01; 95% CI, 2.14–4.22). The use of nonopioid analgesics significantly reduced the odds of ED-RX (OR, 0.46; 95% CI, 0.37–0.57). Fracture injury was also a strong predictor of DC-RX (OR, 5.91; 95% CI, 4.24–8.25), in addition to tooth pain (OR, 5.47; 95% CI, 3.84–7.69).ConclusionsMachine learning methodologies were able to identify predictors of ED-RX and DC-RX, which can be used to inform ED prescribing guidelines and risk mitigation efforts among adolescents and young adults.

Do changes in primary care service use over time differ by neighbourhood income? Population-based longitudinal study in British Columbia, Canada

BackgroundStrong primary care systems have been associated with improved health equity. Primary care system reforms in Canada may have had equity implications, but these have not been evaluated. We sought to determine if changes in primary care service use between 1999/2000 and 2017/2018 differ by neighbourhood income in British Columbia.MethodsWe used linked administrative databases to track annual primary care visits, continuity of care, emergency department (ED) visits, specialist referrals, and prescriptions dispensed over time. We use generalized estimating equations to examine differences in the magnitude of change by neighbourhood income quintile, adjusting for age, sex/gender, and comorbidity, and stratified by urban/rural location of residence. We also compared the characteristics of physicians providing care to people living in low- and high-income neighbourhoods at two points in time.ResultsBetween 1999/2000 and 2017/8 the average number of primary care visits per person, specialist referrals, and continuity of care fell in both urban and rural settings, while ED visits and prescriptions dispensed increased. Over this period in urban settings, primary care visits, continuity, and specialist referrals fell more rapidly in low vs. high income neighbourhoods (relative change in primary care visits: Incidence Rate Ratio (IRR) 0.881, 95% CI: 0.872, 0.890; continuity: partial regression coefficient -0.92, 95% CI: -1.18, -0.66; specialist referrals: IRR 0.711, 95%CI: 0.696, 0.726), while ED visits increased more rapidly (IRR 1.06, 95% CI: 1.03, 1.09). The percentage of physicians who provide the majority of visits to patients in neighbourhoods in the lower two income quintiles declined from 30.6% to 26.3%.ConclusionResults raise concerns that equity in access to primary care has deteriorated in BC. Reforms to primary care that fail to attend to the multidimensional needs of low-income communities may entrench existing inequities. Policies that tailor patterns of funding and allocation of resources in accordance with population needs, and that align accountability measures with equity objectives are needed as part of further reform efforts.

Reducing Pediatric Emergency Department Prescription Errors.

Prescription errors are a significant cause of iatrogenic harm in the health care system. Pediatric emergency department (ED) patients are particularly vulnerable to error. We sought to decrease prescription errors in an academic pediatric ED by 20% over a 24-month period by implementing identified national best practice guidelines. From 2017 to 2019, a multidisciplinary, fellow-driven quality improvement (QI) project was conducted using the Model for Improvement. Four key drivers were identified including simplifying the electronic order entry into prescription folders, improving knowledge of dosing by indication, increasing error feedback to prescribers, and creating awareness of common prescription pitfalls. Four interventions were subsequently implemented. Outcome measures included prescription errors per 1000 prescriptions written for all medications and top 10 error-prone antibiotics. Process measures included provider awareness and use of prescription folders; the balancing measure was provider satisfaction. Differences in outcome measures were assessed by statistical process control methodology. Process and balancing measures were analyzed using 1-way analysis of variance and χ2 testing. Before our interventions, 8.6 errors per 1000 prescriptions written were identified, with 62% of errors from the top 10 most error-prone antibiotics. After interventions, error rate per 1000 prescriptions decreased from 8.6 to 4.5 overall and from 20.1 to 8.8 for top 10 error-prone antibiotics. Provider awareness of prescription folders was significantly increased. QI efforts to implement previously defined best practices, including simplifying and standardizing computerized provider order entry (CPOE), significantly reduced prescription errors. Synergistic effect of educational and technological efforts likely contributed to the measured improvement.