Rate Of Inappropriate Use Research Articles

Emergency care in Brazil: factors leading to clinically inappropriate use of emergency care among young adult users in the Brazilian context

BackgroundThis study aims to investigate the prevalence and associated risk factors of inappropriate use of emergency services among young adults in Vitória, Brazil.MethodsA cross-sectional study was conducted over 30 consecutive days in November and December 2019, involving systematic random sampling of young adults (aged 18–39) visiting the municipal emergency care unit. Data were collected through structured interviews, utilizing the Hospital Urgency Appropriateness Protocol (HUAP) to identify inappropriate use. Demographic characteristics, healthcare utilization patterns, and medical diagnoses were assessed. Poisson regression models were employed to explore associations between variables.ResultsAmong the 631 young adults surveyed, 30.6% exhibited inappropriate use of the emergency care unit. Factors associated with higher rates of inappropriate use included not seeking previous care in other healthcare services; having specific medical diagnoses like diseases of the respiratory system (PR: 2.03), diseases of the skin (PR: 4.13), and diseases of the ear and mastoid (PR: 3.74).ConclusionThe study underscores the significance of addressing inappropriate use of emergency services among young adults. Though the prevalence of inappropriate use was not significantly different from other age groups, the demographic characteristics and healthcare utilization patterns of young adults contribute to their unique challenges. To mitigate inappropriate use, efforts should focus on improving access to primary healthcare services, enhancing continuity of care, and raising awareness about appropriate healthcare-seeking behaviors among young adults. Ultimately, these interventions can foster a more effective and sustainable healthcare system that better serves the needs of the community.

Point prevalence of antibiotic usage in major referral hospital in Turkey.

The most important and undesirable consequence of inappropriate antibiotic use is the spread of antibiotic resistance, increased adverse effects, increased mortality and healthcare costs. We aimed to assess antibiotic usage characteristics in inpatient setting in our center. A one-day, single center point-prevalence study was carried out on June 9th 2021, in Ankara City Hospital in Turkey. Data of antibiotic consumption, appropriateness of usage and predictors of inappropriate use in adult patients were evaluated. Out of 2640 adult patients, 893 (33.8%) were receiving at least one antibiotic. A total of 1212 antibiotic prescriptions with an average of 1.44±0.64 were found. Antibiotics were most commonly used for therapeutic purpose (84.7%), followed by surgical prophylaxis (11.6%). Majority of therapeutically used antibiotics were empirical (67.9%). Infectious diseases consultation was present in 68.3% with a compliance rate of 95.7%. Rate of inappropriate use was 20%. The most frequent cause of inappropriateness was unnecessary use (52.5%). Most commonly and most inappropriately used antibiotics were carbapenems (17.5%) and first generation cephalosporins (38.7%), respectively. Most of the inappropriateness observed in first-generation cephalosporins was due to inappropriate longer surgical prophylaxis. While age is an independent risk factor for inappropriate antibiotic use (p = 0.042), COVID-19 unit admission, use for therapeutic purpose and infectious diseases consultation were protective factors (p<0.001, p<0.001, p<0.001). Rate of inappropriate use was low, but inappropriate surgical prophylaxis remains an important problem in surgical units. There is a considerable need to implement an antimicrobial stewardship program that focuses on surgical prophylaxis practices.

1272. Teaching the ABCs of ASB in a 60-minute educational intervention. A quality improvement project.

Abstract Background Asymptomatic bacteriuria (ASB) refers to the presence of bacteria in the urine of individuals that do not present with symptoms of urinary tract infection (UTI). Treatment for ASB is not recommended in most cases. [1] Previous studies have shown that provider education on proper antibiotic use has been effective in mitigating the ongoing wave of antimicrobial-resistant organisms across hospitals in the United States.[2] We aimed to decrease the proportion of cases classified as having asymptomatic bacteria by 20% in four months after the intervention using a small group discussion and a presentation. Methods We evaluated the rates of inappropriate antimicrobial prescribing for asymptomatic bacteriuria (ASB) for 4 months before educational intervention and 4 months after. Data was extracted from the electronic medical record (Cerner®), imported into REDCap®, and with standardized manual chart review. Data analysis was completed using STATA® 17 &amp; 18. Results The mean duration of antibiotic therapy was 7.9 days in the pre-intervention group and 6.1 days in the post-intervention group. See Table 1 for more details on demographics. Following the intervention, the rate of inappropriate use of antimicrobial therapy in ASB was reduced by 29.8% (p-value 0.035). The mean duration of antibiotic therapy decreased by almost 2 days in the post-intervention group. Conclusion This quality improvement project suggests that focused interventions of short interactive educational sessions in small groups may reduce the inappropriate use of antibiotics in ASB by almost 30%. The mean duration in days of antibiotic treatment decreased from 7.9 days to 6.1 days in the pre and post-intervention groups (p-value 0.060). Of note the total number of cases with providers selecting UTI as an indication was also lower in the post-intervention group and although we can’t determine causality, it provided evidence of a lower number of cases, providers initially classified as UTI between the pre and post-intervention period from 33 to 19. Further research may include incorporating small groups and interprofessional educational interventions to help implement good antimicrobial stewardship in inpatient care facilities. [4,5,6] Disclosures All Authors: No reported disclosures

2245. Appropriate use of antibiotics in patients with osteomyelitis due to decubitus ulcers

Abstract Background Decubitus ulcers are a costly and challenging problem in the healthcare system, with an estimated 2.5 million pressure ulcers treated annually in the United States at a cost of $11 billion. Patients with decubitus ulcers may present with evidence of infection or sepsis, but the source is rarely the ulcer itself. Recent guidelines recommend evaluating patients for curative management before pursuing further testing or empiric antimicrobial treatment. This study aimed to assess the appropriateness of antibiotic usage in patients admitted to the hospital with decubitus ulcers, and to determine the rate of appropriate antibiotic use. Methods This study involved a retrospective review of 1678 patients records with decubitus ulcers to assess the appropriate use of antibiotics during their inpatient stay. Appropriateness was determined by one of three criteria. The 1st criteria included patients who met systemic inflammatory response syndrome with suspected infection from osteomyelitis; 2nd criteria included patients who received antibiotics due to another infection (pneumonia, urinary tract infection or bacteremia) and 3rd criteria included use of antibiotics as a bridge therapy to surgical intervention (flap closure or Incision and Drainage). The rate of consultation for infectious disease and plastic surgery was also investigated. Results Of the total 1678 patients, the median age was 70 yrs (IQR=21), of that 51 % were males. Based on the criteria for appropriateness, there were a significant difference in gender (p= 0.000) females were more likely to receive inappropriate antibiotics (Table 2). Similarly, the rate of inappropriate use of antibiotics was 15.9% with ID consults as compared with 84.1% who didn’t receive ID consult (p=0.000) as seen in table 1. What is the payment method you want? What is the payment method you want? What is the payment method you want? What is the payment method you want? Conclusion This study contributes to a better understanding of appropriate antibiotic usage in patients with decubitus ulcers. The findings favor the importance of ID consults in the appropriate use of antibiotics. Additionally, there may be some underlying bias with prescribing antibiotics to females compared to males. Thus, the study provides clinicians with tools in order to make evidence-based decisions on the management of these patients, and for healthcare systems to optimize resource allocation Disclosures All Authors: No reported disclosures

Sociodemographic disparities in child restraint selection and variation in child passenger safety information sources

PurposeMarginalized and otherwise vulnerable groups remain at higher risk than their counterparts for not having all of their children appropriately restrained during vehicle trips. Little is known about potential sources of these disparities, however a commonly theorized factor has been where caregivers find or obtain information (i.e., their information sources). The objective of this study was to: (1) characterize caregivers’ actual and preferred sources of information related to child passenger safety information, overall and within sociodemographic groups; and (2) determine if, and if so how, sources impact appropriate child restraint use (i.e., child/seat fit). MethodsWe conducted an online, cross-sectional survey of US caregivers. Caregivers answered questions about themselves, their child(ren), their child(ren)’s restraint use during trips, and their information sources to learn which seat their child should be using. We used Fisher’s exact and Pearson chi-square tests to compare used and preferred sources of information across caregiver demographics (age, education, race/ethnicity), as well as to determine whether information sources were associated with caregivers’ appropriate child restraint use. ResultsA total of 1,302 caregivers from 36 states with 2,092 children completed the survey. The majority (91%) of children were appropriately restrained. More caregivers from marginalized and otherwise vulnerable groups had children inappropriately restrained when compared with their counterparts. We identified multiple differences in both used and preferred information sources by caregivers’ age, race/ethnicity, and education level. In addition, we found a trend that caregivers from populations with higher rates of inappropriate use seemingly used fewer information sources. Ultimately, information sources were not associated with appropriate restraint use; however, within vulnerable populations, almost all caregivers had all of their children appropriately restrained if they had used a Child Passenger Safety Technician (CPST)/Inspection Station or their Pediatrician. ConclusionOur findings reiterate calls for more tailored interventions and efforts to combat widening disparities in child restraint use and crash outcomes and suggest one promising method may be providing more access to child passenger safety experts. Future studies must untangle the likely complex relationship between information sources and appropriate/accurate child restraint use.

1775. Interns and Residents’ Knowledge and Perspective on Appropriate Use of Antibiotics for Urinary Tract Infections and Skin and Soft Tissue Infections in the Hospital Setting

Abstract Background Antibiotic resistance is recognized as a significant threat to public health worldwide. The rate of inappropriate use of antibiotics in hospitals has been reported as high as 50%. Exposure to suboptimal antibiotic therapy is associated with higher risk of infections with multidrug-resistant organisms and worse clinical outcomes. In academic hospitals, interns and residents are frontline worker who diagnose and treat infectious diseases (ID). The treatment of urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs) is a common clinical scenario managed by these trainees. Methods A structured, anonymous questionnaire was sent via institutional email to internal medicine interns and residents rotating in three academic hospitals in Miami, FL. The 23-item questionnaire included knowledge questions on rational use of antibiotics and duration of therapy for complicated and uncomplicated UTIs, SSTIs, correct renal dosing of frequently used antibiotics and antivirals, and perception of confidence in antibiotic prescription. Data were entered to Microsoft Excel spreadsheet, then analyzed using JMP Pro software. Results A total of 36 preliminary and categorical interns, and 38 second-and third-year residents completed the initial questionnaire. The mean correct knowledge score on the treatment of UTIs was 52.8% (19/36) for interns and 76.3% (29/38) for residents, respectively. For SSTIs, the scores were 38.9% (14/36) and 65.8% (25/38); and for correct renal dosing of antibiotics, the scores were 47.2% (17/36) vs. 73.7% (28/38). Most of the interns (58.3%, 21/36) did not feel confident prescribing antibiotics for these conditions compared with 18.4% (7/38) of the residents. Conclusion In this cross-sectional study, interns had lower correct knowledge scores and confidence when prescribing antibiotics for UTIs and SSTIs compared to residents. There is room for improvement in advanced years of training. Further studies are necessary to assess the impact of implementing educational strategies to promote the appropriate use of antibiotics. We plan to address this through a pre-/post implementation We will compare antibiotic prescribing patterns and patient outcomes for these indications at one of our three clinical training sites. Disclosures All Authors: No reported disclosures.

Appropriateness of alert antibiotics measured by repeated prevalence surveys and impact of direct prescriber interaction and feedback

ABSTRACT Objectives Hospital point prevalence surveys (PPS) are shown to help identifying determinants for inappropriate antimicrobial therapy (AMT) and create feedback opportunities to optimize AMT. Methods PPS were performed at the AZNikolaas hospital, on four wards with high consumption rates of three alert antibiotics (AB) to judge their appropriateness. The impact of a multidisciplinary interaction between a medical microbiologist, a clinical pharmacist and the prescriber on inappropriate AMT, hospital costs and intravenous AMT days, was analyzed. Results During this survey, 7,39% of hospitalized patients in the selected wards received one or more of three alert antibiotics. Out of 78 prescriptions, 35.90% were judged appropriate, 39.74% inappropriate and 24.36% had insufficient data for judgment. Only the oncology ward was associated with more frequent appropriate use of alert AB. In case of an unknown infection focus or a catheter-related infection, the relative risk of inappropriate use was the highest. Multidisciplinary interaction improved inappropriate AMT in 59% of cases. It resulted in a 2478€ healthcare AMT cost saving and a reduction of 30 intravenous AMT days. Conclusions This survey shows high consumption rates and a high rate of inappropriate use of three alert AB in the observed wards. It revealed the lack of a local guideline concerning treatment of neutropenic fever of unknown origin and the need for more diagnostic information in electronical medical records. The survey demonstrated that direct feedback on inappropriate AMT to clinicians can be of added value, cost-saving and reducing length of intravenous AMT days. However, more studies are needed to confirm this.

Applying Machine Learning Techniques to the Audit of Antimicrobial Prophylaxis

High rates of inappropriate use of surgical antimicrobial prophylaxis were reported in many countries. Auditing the prophylactic antimicrobial use in enormous medical records by manual review is labor-intensive and time-consuming. The purpose of this study is to develop accurate and efficient machine learning models for auditing appropriate surgical antimicrobial prophylaxis. The supervised machine learning classifiers (Auto-WEKA, multilayer perceptron, decision tree, SimpleLogistic, Bagging, and AdaBoost) were applied to an antimicrobial prophylaxis dataset, which contained 601 instances with 26 attributes. Multilayer perceptron, SimpleLogistic selected by Auto-WEKA, and decision tree algorithms had outstanding discrimination with weighted average AUC &gt; 0.97. The Bagging and SMOTE algorithms could improve the predictive performance of decision tree against imbalanced datasets. Although with better performance measures, multilayer perceptron and Auto-WEKA took more execution time as compared with that of other algorithms. Multilayer perceptron, SimpleLogistic, and decision tree algorithms have outstanding performance measures for identifying the appropriateness of surgical prophylaxis. The efficient models developed by machine learning can be used to assist the antimicrobial stewardship team in the audit of surgical antimicrobial prophylaxis. In future research, we still have the challenges and opportunities of enriching our datasets with more useful clinical information to improve the performance of the algorithms.

Assessment of Caspofungin use at a Tertiary Teaching Hospital and compliance with IDSA guidelines and FDA labelings

ObjectiveThe aim of this study is to evaluate the utilization pattern of Caspofungin in an academic tertiary care hospital in Riyadh, Saudi Arabia. MethodsThis is a retrospective study, conducted at King Saud University Medical City, Riyadh, Saudi Arabia. Adult patients who received Caspofungin from January 2015 to December 2018 were included. The appropriate use of Caspofungin was evaluated according to the international guidelines and approved recommendations. Caspofungin doses were assessed according to the FDA-approved loading and maintenance doses as well as dose-adjustment per hepatic function for cirrhotic patients and drug-drug interactions. Cultures and laboratory tests were used to evaluate the appropriate duration of Caspofungin therapy. Results388 patients were included. Caspofungin was inappropriately used in 253 (64%) patients. This included 78 (20%) due to inappropriate indication, 165 (42%) due to wrong dosage, and 10 (2%) patients who had a wrong duration of therapy. ConclusionThe rate of inappropriate use of Caspofungin was high. Hence, developing antifungal stewardship and drug restriction program is highly recommended.

Appropriateness and subsequent management of inpatient echocardiograms: An evaluation of low value care

Study objectiveTransthoracic echocardiograms (TTE) are perceived to be overused and multiple TTEs are often ordered within one inpatient visit with unclear utility. This study identified inpatients who received multiple TTEs to determine the appropriateness, results, and subsequent management of repeat TTEs. DesignRetrospective Cohort Study. SettingSingle academic medical center. ParticipantsSubjects over age 18 who underwent >1 TTE during hospitalization in 2020. InterventionsN/A Main outcome measuresAppropriateness of TTE, TTE results, subsequent changes in management. ResultsOf the 875 subjects, the average age was 60 years old with a male predominance (57.8%). In comparing the first and second TTE results, the frequency of new abnormal findings decreased significantly from 44.7% to 15.1% (p < .0001). Changes in clinical management in relation to the TTEs decreased from 47.1% to 32.5% (p < .0001), of which medication changes were most common. The majority of tests were appropriate, with a slight increase of inappropriate TTEs from 0.6% to 1.8% (p < .0001) between first and second TTEs. ConclusionsWhile the rate of inappropriate TTE use increased after the initial TTE, the overall rate of inappropriate use was very small indicating that stricter adherence to AUC would not appreciably reduce duplication of inpatient TTEs. The non-negligible frequency of new abnormal findings for the repeat TTEs at 15% cannot be ignored. Our data suggests that the assumption that repeat TTEs are in large part unnecessary is more complicated than originally thought.

Evaluation of asymptomatic bacteruria management before and after antimicrobial stewardship program implementation: retrospective study

BackgroundThe Infectious Diseases Society of America (IDSA) recommends against screening for and/or treating asymptomatic bacteriuria (ASB). This study aims to evaluate the inappropriate use of antibiotics in ASB before and after Antimicrobial Stewardship Program (ASP) implementation and advance towards its appropriate use.MethodWe performed a retrospective study of patients diagnosed with ASB from 2016 to 2019 at a tertiary hospital in Saudi Arabia. This study included hospitalized patients ≥ 18 years old who had a positive urine culture with no documented signs or symptoms of urinary tract infection We excluded pregnant women, solid organ transplant patients, patient on active chemotherapy, and patients about to undergo urological surgery.ResultsA total of 716 patients with a positive urine culture were screened. Among these, we identified 109 patients with ASB who were included in our study. The rate of inappropriate antibiotic use was 95% during the study period. The implementation of the ASP Program was associated with a significant reduction in the use of carbapenems (P = 0.04) and an increase in the use of cephalosporins (P = 0.01). However, overprescribing antimicrobial agents was a concern in both eras. Approximately 90% of the microorganisms identified were gram-negative bacteria. Of those, 38.7% were multidrug-resistant strains.ConclusionThe urine culture order in ASB is considered relatively small number; however, it showed a high rate of the inappropriate use of antibiotics when there is an order of urine culture in both era. ASP ought to focus on targeting the ordering physician, promoting awareness and/or organizational interventions that appear to reduce the incidence of overtreatment.

Outpatient Prescription Practices in Patients with Atrial Fibrillation (From the NCDR PINNACLE Registry)

This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present.

Pattern of blood requisition and utilization in a tertiary care hospital: a chart review study

Background: There is a tendency to order more units of blood than what are actually needed. As blood being finite and recognition of a high rate of inappropriate use, there is a need to monitor and regulate it. It can be done by the analysis of blood requisitions. This study was done to analyze the pattern of blood requisition and utilization in a tertiary care hospital considering the lack of such studies conducted.Methods: A chart review was conducted during April to May, 2020 to analyse 5601 blood requisitions made during April 2019 to March 2020 in the Department of Transfusion Medicine, RIMS Imphal. Data abstraction form was used to abstract data and it was analyzed in IBM Statistical package for social sciences (SPSS) version 21.Results: Out of total 5601 blood requisitions, 52.8% were made for female. Nearly one-fifth (18.4%) of the requisitions were for 50-59 years. Of the blood group, A+ (33.4%) was the commonest. Nearly one-third (32.4%) of blood units requested were from the Medicine Department. Anemia (71.6%) was the most common indication. Out of total 5601 requisitions, 4727 (84.4%) were made for packed RBC, 258 (4.6%) for FFP, 232 (4.1%) for platelets and 44 (0.8%) for whole blood. Majority (14.1%) of requisitions were made during the month of July. Replacement was the commonest mode of issue of blood.Conclusions: Predominant blood requisitions were made for A+ blood group. PRBC constitute majority of the blood requisition. Majority of the requisitions were made from medicine department.

Community Pharmacists' Views of the Enforced Antibiotics Dispensing Law and Its Impact on Oral Antibiotics Sales in Saudi Arabia.

Objective(s)The aim of this study was to explore community pharmacists’ views toward the antibiotics dispensing law that was enforced in May 2018 and bans the sale of antibiotics without a prescription in community pharmacy settings in Saudi Arabia. Moreover, the potential impact of the law enforcement on the sales of oral antibiotics in Saudi Arabia was also explored.MethodsA questionnaire-based cross-sectional study was conducted between September 2019 and March 2020 in Riyadh, Saudi Arabia. A multistage sampling technique was used to recruit community pharmacists from different districts. Pharmacists who consented to participate and reported practicing prior to the law enforcement were interviewed about their views of the law using a 14-item newly developed questionnaire. The annual sales of oral antibiotics for the years of 2017, 2018, and 2019 were retrieved from the Saudi Food and Drug Authority (SFDA) database.ResultsTwo hundred and eighty six pharmacists consented to participate and met the inclusion criteria. After the law enforcement, approximately 51% of the participants reported that the percentage of patients seeking antibiotics without a prescription is less than 25%. Moreover, the majority (87.41%) reported a drop in the sales of antibiotics. Additionally, about 90% of the participants believed that the rate of inappropriate use of antibiotics will decrease as a result of the law enforcement. About 41% of the participants reported that the law has negatively impacted their pharmacies’ profits. The sales of oral antibiotics have seen a 16.6% drop in the year of 2019 as compared to 2017.ConclusionThe antibiotics dispensing law is favorably perceived among community pharmacists in Saudi Arabia despite some concerns about its impact on their sales. Exploring different business models that delink the profits from the volume of antibiotics sales is necessary for this vital industry to thrive.

Inappropriate practice in tumor marker requests at a university hospital in Western Saudi Arabia: A 3-year retrospective study.

This study assessed the level of appropriateness of tumor marker requests in a teaching hospital and estimated the financial cost associated with inappropriate use. A retrospective review of patients' electronic records was conducted over a 3-year period (2015-2017) for tumor marker requests, including carcinoembryonic antigen, alpha-fetoprotein, cancer antigen (CA)15-3, CA125, CA19-9, and total and free prostate-specific antigen (PSA and fPSA), along with the associated clinical data that motivated the requests. Inappropriate use was defined as tumor marker requests without any relevant clinical picture. Costs due to inappropriate tumor marker requests were estimated based on the unit costs applied in the institution. A total of 7128 patients had at least one tumor marker request between 2015 and 2017. The clinical picture that motivated tumor marker requests was absent in 71.5%, while 12.9% of the requests were associated with a malignancy. The most frequent prescribing pattern was total prostate-specific antigen alone (2128; 29.9%), followed by alpha-fetoprotein alone (1185; 16.6%), and carcinoembryonic antigen alone (506; 7.1%). Year-over-year analysis revealed an increasing tendency in requesting carcinoembryonic antigen and CA15-3. The rate of inappropriate use varied by tumor marker and ranged between 56.4% for fPSA and 86.8% for total prostate-specific antigen. The overall costs due to inappropriate tumor marker requests were estimated at $2,785,493 over the 3 years, representing an average of $0.93 million per year. Inappropriate use of tumor marker requests is a major issue regarding its high prevalence and the considerable associated costs. The role of laboratories in the management of tumor marker requests should be emphasized.

Tu1111 EFFECT OF A QUALITY IMPROVEMENT INITIATIVE ON INAPPROPRIATE FORCEPS POLYPECTOMY FOR NON-DIMINUTIVE POLYPS

Forceps polypectomy of non-diminutive colorectal polyps is associated with higher rates of incomplete polyp resection compared to snare polypectomy, and for this reason the ESGE and others recommend snare polypectomy for non-diminutive polyps. However, there are a paucity of data on the rate of inappropriate use of forceps for polypectomy, and no data on efforts to improve this rate. We sought to quantify the incidence and predictors of inappropriate forceps use and to measure the effect of a quality improvement initiative to encourage snare polypectomy for non-diminutive polyps. We performed a retrospective study of all colonoscopies with polypectomies performed at two U.S. health systems (an academic tertiary care hospital and safety-net health system) between 10/1/2017 and 9/30/2019. The primary outcome was colonoscopies with an inappropriate forceps polypectomy, i.e. use of forceps polypectomy for any polyp ≥5mm. We measured the prevalence of inappropriate forceps polypectomy and used multivariate logistic regression to identify factors associated with inappropriate forceps polypectomy. We examined the effect of a quality improvement initiative, implemented 11/15/2019, in which avoidance of inappropriate forceps polypectomy was included as a quality metric tied to a modest financial incentive for the gastroenterology division. We identified 10118 colonoscopies with polypectomies. Overall, 1940 (18.9%) included inappropriate forceps polypectomy, including 20.8% of colonoscopies at the tertiary care hospital and 18.5% at the safety-net health system. Implementation of the quality improvement initiative was associated with a reduction in inappropriate forceps polypectomy (27.0% vs. 14.7%; OR 0.45, 95%CI 0.40 – 0.51) in adjusted analysis (Figure 1). In multivariate analysis, an adequate bowel preparation (OR 0.78, 95%CI 0.66 – 0.91) and fellow involvement in the procedure (OR 0.62, 95%CI 0.55 – 0.71) were associated with decreased odds of inappropriate forceps polypectomy, while number of polyps (OR 2.27, 95%CI 1.98 – 2.60 for 3-9 polyps; OR 4.65, 95%CI 3.57 – 6.05 for 10 or more polyps) and polyps in the right and left colon (OR 1.44, 95%CI 1.23 – 1.69) were associated with increased inappropriate forceps use. Among colonoscopies that employed forceps polypectomy for non-diminutive polyps, 41% included forceps polypectomy for polyps 6mm or larger. Nearly 1 in 5 colonoscopies had inappropriate forceps polypectomy for non-diminutive polyps, with higher proportions in those with inadequate bowel prep, higher number of polyps, and the presence of polyps in both the right and left colon. A simple quality improvement initiative significantly reduced use of inappropriate forceps polypectomy.

Prevention of Nosocomial Catheter-Associated Urinary Tract Infections Through Computerized Feedback to Physicians and a Nurse-Directed Protocol.

Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection. The authors' baseline rate of CAUTI for general medical service was elevated at 36 per 1000 catheter-days. The medical literature has consistently linked inappropriate catheter use with the development of CAUTI. The baseline data also revealed a high rate of inappropriate use of indwelling urinary catheters. Using the dual modalities of technology through prompts in the computerized order/entry system and handheld bladder scanners, as well as in combination with staff education and nurse empowerment, the authors were successful in reducing the use and duration of urinary catheters as well as the incidence of CAUTI. In subsequent data collection cycles over the following 2 years, 81% reduction in device use and a 73% reduction in the clinical end point of nosocomial CAUTI (36/1000 catheter-days to 11/1000 catheter-days; P < .001) was demonstrated.

Rates of inappropriate use of proton pump inhibitors, antipsychotics and benzodiazepines prior to admission to geriatric inpatient units

Rates of inappropriate use of proton pump inhibitors, antipsychotics and benzodiazepines prior to admission to geriatric inpatient units

Efficacy of a strict surveillance policy towards inappropriateness of plasma transfusion

BackgroundPlasma transfusion is not without risks. Despite a limited spectrum of indications, plasma is frequently used as prophylaxis in non-bleeding patients, to correct altered coagulation tests. A high rate of inappropriate use of plasma transfusion is frequently reported, as well as underdosage. Study design and methodsSince 2010 we started an education program that occurred in several phases to disseminate the knowledge of plasma transfusion guidelines. Since 2014 a ‘zero tolerance’ policy was applied: except for massive bleedings, plasma requests were prospectively evaluated, rejecting those without an appropriate indication. When indicated, at least 10 mL/Kg b.w.were issued. The previous five year period (2005–2009) served as control. ResultsThe number of patients transfused/year decreased by 67.6% vs the control period (149 vs 460), and the liters of plasma issued/year decreased by 70.4% (233 vs 795).The deepest fall was observed in acute care wards (-70.8%). The mean volume transfused per episode raised from 731 mL ± 70 to 879 mL ± 154. The Prothrombin Time ratio at the moment of transfusion request increased from a mean of 1.35 (Interquartile range 1.20–2.64) in the control period to 1.62 (Interquartile range 1.43–1.98) in the last period (p < 0.001). ConclusionWith a proactive educational approach a remarkable reduction of plasma order and administration has been obtained, without any consequence on morbidity and mortality and with an estimated saving since 2014 of 750,000 €. A ‘zero tolerance’ policy can be effectively implemented only with a thorough workup with the local physicians, including repeated rounds of information and refreshing of the updated transfusion practice and knowledge of the established guidelines over the time.

MON-004 The Effect of a Pharmacist Led Training Intervention on Reducing Inappropriate Use of Intravenous Levothyroxine in Hospitalized Patients

Background Approximately 88% of endocrinologists agreed that intravenous levothyroxine (IV T4) is not medically necessary in euthyroid patients if they are nothing by mouth (NPO) for less than 3 days. A prior 2013 retrospective database analysis at our institution revealed that a majority of IV T4 was prescribed inappropriately for NPO status. Therefore, we sought to develop an intervention to reduce inappropriate IV T4 use among hospitalized adults. Methods A training session was provided to clinical pharmacists and medical providers in areas with high IV T4 utilization rates (SICU, MICU, CICU, medical and surgical floors). Compelling reasons to use IV T4 were highlighted, including myxedema coma, cardiogenic shock, suspected malabsorption, or NPO status for >3 days. A retrospective 1-year database analysis was conducted after the intervention to assess IV T4 utilization rates and new onset of arrhythmias and troponin elevations among hospitalized patients. Rates of inappropriate use and adverse effects associated with T4 therapy were compared prior to and after the intervention with the chi-square test. Results Prior to the intervention, 76 patients (mean age 65 years) received IV T4 during the 6-month study period. Of these, 80% of IV T4 was prescribed inappropriately for NPO status at the cost of $38,423. Approximately 11% and 8% of these patients developed new onset arrhythmias and troponin elevations, respectively. After the intervention, 183 patients (mean age 61 years) received IV T4 at our institution during the 1-year study period. Of these, 56% of IV T4 was prescribed inappropriately for NPO status with no other compelling indication at the cost of $75,936. Approximately 20% and 12% of these patients developed new onset arrhythmias and troponin elevations, respectively. Approximately 31% of patients who had unwarranted IV T4 after the intervention had a history of atrial fibrillation, congestive heart failure, or coronary artery disease. The pharmacist led training intervention significantly reduced inappropriate use of IV T4 (p<0.05), however total cost and rates of new onset arrhythmia and troponin elevations did not significantly change (p>0.05). Conclusion A pharmacist led training intervention designed to educate providers and pharmacists about appropriate indications to use IV T4 among hospitalized adults led to a significant reduction in the use of inappropriate IV T4. Cost did not significantly change despite the reduction of inappropriate IV T4 use, likely due to rising drug prices. Despite a modest decrease in inappropriate IV T4 use, our institution aims to further reduce adverse effects, inappropriate use, and cost through a variety of quality control measures, such as implementing EMR order sets and/or restricting use of IV T4 subject to endocrinology approval.