Order Sets Research Articles

Pharmacist insights into antimicrobial stewardship: A social marketing approach

BackgroundAntimicrobial resistance is a worldwide public health problem. Antimicrobial stewardship programs (ASPs) optimize antimicrobial use within hospitals. The social marketing framework has been used in analyzing systems and devising best practices. Objective(s): To use the social marketing framework to explore pharmacist experiences and perceptions of structural, behavioral and interventional strategies that support ASPs. MethodsA qualitative approach utilizing semi-structured individual interviews was utilized. A purposive sample of hospital pharmacists was invited to participate. An interview guide was constructed to describe participant experience and perceptions regarding ASPs in their institutions based on elements of social marketing: Behavioral goals; Customer Insight; Segmentation and Targeting; Competition; Exchange; and Marketing and Interventional mix. Interviews were recorded digitally and transcribed verbatim. Thematic analysis was conducted using deductive methods. A combination of case-based and code-based approaches allowed individual and holistic analyses respectively. Codes were collated into themes and subthemes. ResultsSaturation of themes occurred with 25 interviews from 17 hospitals. ASP metrics included: consumption of antibiotics using days of therapy and defined daily dose, rates of C. difficile and multidrug resistant organisms, resistance patterns, and provider adherence to the ASP. Active stewardship tools such as preauthorization, and prospective feedback/audit were preferred over passive tools such as order sets and automatic stop orders. A physician champion and a clinical pharmacist with infectious disease training were core elements in the multidisciplinary team. Despite certain areas being considered key for stewardship, participants emphasized a hospital-wide approach including outpatient departments; discharge stewardship emerged as a primary theme. Leadership supported ASPs with finances, rapid and novel diagnostics, Clinical Decision Support Systems, mobile technology, and continuous staff training. ConclusionsThe social marketing framework has been used to explore pharmacist perceptions that inform successful qualities including metrics, restriction methods, personnel, benefits, barriers, training needs/modes, and promotional avenues that support ASPs in hospitals.

Reentrant canonical spin-glass dynamics and tunable field-induced transitions in (GeMn)Co2O4 Kagomé lattice

We report on the reentrant canonical semi spin-glass characteristics and controllable field-induced transitions in distorted Kagomé symmetry of (GeMn)Co2O4. This B-site spinel exhibits complicated, yet interesting magnetic behaviour in which the longitudinal ferrimagnetic (FiM) order sets in below the Néel temperature T FN ∼ 77 K due to uneven moments of divalent Co (↑ 5.33 μ B) and tetravalent Mn (↓ 3.87 μ B) which coexists with transverse spin-glass state below 72.85 K. Such complicated magnetic behaviour is suggested to result from the competing anisotropic superexchange interactions (J AB/k B ∼ 4.3 K, J AA/k B ∼ −6.2 K and J BB/k B ∼ −3.3 K) between the cations, which is extracted following the Néel’s expression for the two-sublattice model of FiM. Dynamical susceptibility (χ ac (f, T)) and relaxation of thermoremanent magnetization, M TRM (t) data have been analysed by means of the empirical scaling-laws such as Vogel–Fulcher law and Power law of critical slowing down. Both of which reveal the reentrant spin-glass like character which evolves through a number of intermediate metastable states. The magnitude of Mydosh parameter (Ω ∼ 0.002), critical exponent zυ = (6.7 ± 0.07), spin relaxation time τ 0 = (2.33 ± 0.1) × 10−18 s, activation energy E a/k B = (69.8 ± 0.95) K and interparticle interaction strength (T 0 = 71.6 K) provide the experimental evidences for canonical spin-glass state below the spin freezing temperature T F = 72.85 K. The field dependence of T F obtained from χ ac (T) follows the irreversibility in terms of de Almeida–Thouless mean-field instability in which the magnitude of crossover scaling exponent Φ turns out to be ∼2.9 for the (Ge0.8Mn0.2)Co2O4. Isothermal magnetization plots reveal two field-induced transitions across 9.52 kOe (H SF1) and 45.6 kOe (H SF2) associated with the FiM domains and spin-flip transition, respectively. Analysis of the inverse paramagnetic susceptibility after subtracting the temperature independent diamagnetic term (=−3 × 10−3 emu mol−1 Oe−1) results in the effective magnetic moment = 7.654 μ B/f.u. This agrees well with the theoretically obtained = 7.58 μ B/f.u. resulting the cation distribution in support of the Hund’s ground state spin configuration and of Mn4+ and Co2+, respectively. The H–T phase diagram has been established by analysing all the parameters (T F(H), T FN(H), H SF1(T) and H SF2(T)) extracted from various magnetization measurements. This diagram enables clear differentiation among the different phases of the (GeMn)Co2O4 and also illustrates the demarcation between short-range and long-range ordered regions.

Concurrent Hospice and Dialysis Care: Considerations for Implementation.

Hospice positively impacts care at the end of life for patients and their families. However, compared to the general Medicare population, patients on dialysis are half as likely to receive hospice. Concurrent hospice and dialysis care offers an opportunity to improve care for people living with end-stage kidney disease (ESKD). We sought to (1) develop a conceptual model of the Program and (2) identify key components, resources, and considerations for further implementation. We conducted a template analysis of qualitative interviews and convened a community advisory panel (CAP) to get feedback on current concurrent care design and considerations for dissemination and implementation. Thirty-nine patients with late-stage chronic kidney disease (CKD), family caregivers, bereaved family caregivers, hospice clinicians, nephrology clinicians, administrators, and policy experts participated in interviews. A purposive subset of 19 interviewees composed the CAP. Qualitative feedback on concurrent care design refinements, implementation, and resources. Participants identified four themes that define an effective model of concurrent hospice and dialysis: it requires (1) timely goals-of-care conversations and (2) an interdisciplinary approach; (3) clear guidelines ensure smooth transitions for patients and families; and (4) hospice payment policy must support concurrent care. CAP participants provided feedback on the phases of an effective model of concurrent hospice and dialysis, and resources, including written and interactive educational materials, communication tools, workflow processes, and order sets. We developed a conceptual model for concurrent hospice and dialysis care and a corresponding resource list. In addition to policy changes, clinical implementation and educational resources can facilitate scalable and equitable dissemination of concurrent care. Concurrent hospice and dialysis care must be systematically evaluated via a hybrid implementation-effectiveness trial that includes the resources outlined herein, based on our conceptual model of concurrent care delivery.

Factors associated with the choice of having multiple sexual partners among male college students with casual heterosexual sex in Zhejiang Province, Eastern China

BackgroundYoung students infected with HIV have become a significant public health issue in China, this study aimed to understand the factors influencing the choice of having multiple sexual partners among male college students who had casual heterosexual sex in Zhejiang Province and to scientifically justify developing HIV/AIDS intervention strategies among them.MethodsA stratified cluster sampling method was used for the survey of students from 13 colleges or universities in Zhejiang Province between October and November 2018. The questionnaire collected information on general demographic characteristics, knowledge of HIV/AIDS prevention and treatment, sexual attitudes and risk awareness, sexual behavioural characteristics, and acceptance of interventions. The univariable and multivariable analyses were conducted in this study.ResultsStudy participants included 362 male college students who exhibited casual heterosexual sex and were aware of the number of sexual partners they had. Among them, 222 students engaged in casual heterosexual sex with multiple sexual partners (61.33%). The results of the multivariable analysis revealed several factors associated with male students’ choice to have multiple sexual partners: monthly living expenses greater than or equal to 1501 CNY (adjusted OR = 2.24, 95% CI = 1.21–4.16), sexual behavior after consuming alcohol (adjusted OR = 2.19, 95% CI = 1.32–3.63), whose casual partner types were non-student (adjusted OR = 2.51, 95% CI = 1.45–4.22), and those who discussed using condoms during sexual intercourse (adjusted OR = 0.50, 95% CI = 0.28–0.89).ConclusionThe choice to engage in casual heterosexual sex with multiple partners was found to be associated with several factors among male college students, including economic status, engaging in sexual behavior after consuming alcohol, the type of the casual partner, and using condoms. These findings highlight the significance of implementing targeted interventions and comprehensive sexual health education programs within college settings in order to encourage safer sexual practices among students.

The PLAY bundle for head deformities: A NICU quality improvement project

BackgroundPremature infants in the Neonatal Intensive Care Unit (NICU) have a greater risk of head deformities and related complications. Numerous evidence-based interventions demonstrate successful prevention and treatment for head deformities with maximized success when combined. Local problemThere was no standardized policy to aid in the prevention, evaluation, and management of head deformities at a local children's hospital. Additionally, the Electronic Health Record (EHR) did not optimize head measurement documentation and documented asymmetrical head measurements did not prompt follow-up. MethodsAuthors developed a nurse-driven order set, or bundle, comprised of Positioning and PT/OT involvement, Learning, Assistive Devices, and You (PLAY) as part of a quality improvement project to reduce the progression of head deformities through education, prevention strategies, and earlier identification and treatment. Data collected for the first 13 weeks was under the current standard of care and data collected under the second 13 weeks was under the PLAY bundle. Results33 infants participated with 19 after PLAY Bundle implementation. Under the current standard of care, 34% of patients (n = 27) had plagiocephaly documentation while just 7% (n = 6) received a PT (Physical Therapist) consultation. Of the participants diagnosed with head deformities since PLAY Bundle implementation, biweekly head measurements improved in 58%, worsened in 20%, worsened then improved in 8%, and stayed the same in 20%. ConclusionsThe PLAY Bundle was successful in the earlier identification and intervention of head deformities. In addition, the PLAY Bundle highlighted the importance of repositioning intervention for head deformities.

Institutional Structures and Processes to Support Sepsis Care: A Multihospital Study

OBJECTIVES: To identify opportunities for improving hospital-based sepsis care and to inform an ongoing statewide quality improvement initiative in Michigan. DESIGN: Surveys on hospital sepsis processes, including a self-assessment of practices using a 3-point Likert scale, were administered to 51 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan, at two time points (2020, 2022). Forty-eight hospitals also submitted sepsis protocols for structured review. SETTING: Multicenter quality improvement consortium. SUBJECTS: Fifty-one hospitals in Michigan. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the included hospitals, 92.2% (n = 47/51) were nonprofit, 88.2% (n = 45/51) urban, 11.8% (n = 6/51) rural, and 80.4% (n = 41/51) teaching hospitals. One hundred percent (n = 51/51) responded to the survey, and 94.1% (n = 48/51) provided a sepsis policy/protocol. All surveyed hospitals used at least one quality improvement approach, including audit/feedback (98.0%, n = 50/51) and/or clinician education (68.6%, n = 35/51). Protocols included the Sepsis-1 (18.8%, n = 9/48) or Sepsis-2 (31.3%, n = 15/48) definitions; none (n = 0/48) used Sepsis-3. All hospitals (n = 51/51) used at least one process to facilitate rapid sepsis treatment, including order sets (96.1%, n = 49/51) and/or stocking of commonly used antibiotics in at least one clinical setting (92.2%, n = 47/51). Treatment protocols included guidance on antimicrobial therapy (68.8%, n = 33/48), fluid resuscitation (70.8%, n = 34/48), and vasopressor administration (62.5%, n = 30/48). On self-assessment, hospitals reported the lowest scores for peridischarge practices, including screening for cognitive impairment (2.0%, n = 1/51 responded “we are good at this”) and providing anticipatory guidance (3.9%, n = 2/51). There were no meaningful associations of the Centers for Medicare and Medicaid Services’ Severe Sepsis and Septic Shock: Management Bundle performance with differences in hospital characteristics or sepsis policy document characteristics. CONCLUSIONS: Most hospitals used audit/feedback, order sets, and clinician education to facilitate sepsis care. Hospitals did not consistently incorporate organ dysfunction criteria into sepsis definitions. Existing processes focused on early recognition and treatment rather than recovery-based practices.

Implementation of an electronic medical record order set with an opt-out rule increases utilization of ultrasound enhancing agents with transthoracic echocardiography

Abstract Background Use of ultrasound-enhancing agents (UEA) decreases the frequency of non-diagnostic transthoracic echocardiography (TTE) studies and improves accuracy for identification of potentially life-threatening conditions. However, several logistical barriers have led to UEA underutilization, including the need for a separate order for UEA in electronic medical records (EMR). We sought to determine the impact of implementing an EMR order set on utilization of UEA at the echocardiography laboratory of a tertiary care center. Methods EMR order for all TTE studies (complete, limited) was modified to include the use of UEA by default with an "opt-out" option for ordering physician when UEA is deemed unnecessary. During study performance, sonographers determined the need for UEA use and utilized existing order to dispense perflutren protein-type A microspheres to complete the examination. Internal policy for UEA use was developed in keeping with Intersocietal Accreditation Commission recommendations. We compared rates of UEA utilization 10 months before and after the implementation date (March 2022) for the new EMR rule. Results A total of 10,666 TTE studies were performed prior to, and 11,406 studies after the implementation of the new EMR rule. Of those, 54.3% were performed in outpatient setting, 12% in ICU, and the rest in non-ICU inpatient setting. Prior to the EMR rule implementation, UEA was used in 10% of total studies, 6.0% of outpatient studies, 11.2% of non-ICU inpatient studies, and 24.2% of ICU studies. Following the implementation of the new rule, UEA utilization increased significantly, including 89% increase in total use, 90% increase in outpatient setting, 129% in non-ICU inpatient setting, and 48% increased use in ICU (Figure). No adverse events were reported with UEA during the study period. Conclusions The implementation of a standing order in EMR, including default use of UEA with an "opt-out" option facilitates sonographer-driven use and administration of UEA across all patient care settings. While this approach was safe and significantly increased UEA utilization, whether it would translate to improvement in clinical outcomes or hospital length of stay requires further studies.Impact of EMR rule on UEA utilization

A national heart failure initiative is associated with improved use of quadruple guideline-directed medical therapy

Abstract Background Heart Failure (HF) is projected to impact over 8 million people in the US by 2030. The 2022 AHA/ACC/HFSA Guideline for the Management of HF recommend four foundational medication classes for treating HFrEF patients: RAAS inhibitors, preferably angiotensin receptor/neprilysin inhibitor (ARNi), evidence-based beta-blockers (EBBB), sodium-glucose cotransporter-2 inhibitor (SGLT2i) and mineralocorticoid receptor antagonist (MRA) referred to as Quadruple Guideline-Directed Medical Therapy (Q-GDMT). Q-GDMT has shown an estimated 73% relative and 26% absolute reduction in all-cause mortality over 2 years. Yet, despite remarkable clinical potential, these therapies are patently underutilized in clinical practice. It is unknown whether an implementation science strategy may enhance adherence to Q-GDMT for HF. Methods IMPLEMENT-HF (IHF) is a national HF quality improvement initiative composed of a multidisciplinary learning collaborative and resource repository across seven U.S regions. IHF promotes adherence to Q-GDMT by focusing on early adoption and rapid adherence to prescribing at hospital discharge and within 30 days post discharge. Multi-disciplinary participation in the learning collaborative includes pharmacy, provider groups, nursing, quality, social services, outpatient clinics and others. Shared interventions to promote Q-GDMT include formulary changes (e.g., adding SGLT2i), optimizing electronic health record tools (disease-specific order sets, dot phrases), clinician education, and user-friendly patient resources to address medication access. IHF sites receive educational materials, including webinars, learning modules, pocket guideline booklets, and reminder cards to reinforce Q-GDMT. IHF participating hospitals collect Q-GDMT data at discharge and at 30 days post discharge in Get With The Guidelines®-Heart Failure (GWTG-HF). These data were analyzed from baseline (Q1 Q2 2021 aggregate) through Q3 2022. Results Data from 71 IHF participating sites of 13,858 HFrEF patient hospitalization episodes (median age 69, 34% females, median LVEF 24%), demonstrated Q-GDMT prescription at discharge increased from 14% at baseline to 47% in Q3 2022 (p value <0.001). 30-day post discharge data from 52 IHF sites demonstrated an increase in Q-GDMT from 9% at baseline to 58% in Q3 2022 (p value <0.001) as seen in Figure 1. Conclusions Among sites participating in IHF, the use of an implementation science strategy suggest a rapid increase in prescribing Q-GDMT for eligible HFrEF patients at discharge and 30-days post discharge. This multi-region quality improvement initiative demonstrates the potential for this learning collaborative model to drive improvement in adherence to Q-GDMT prescribing, using shared implementation strategies to overcome barriers. Ongoing study will assess continued compliance and clinical outcomes with Q-GDMT beyond the timeframe of this analysis.Quadruple Medication Therapy baseline-Q3

Assessing an Exposure Keratopathy Prevention Strategy in Mechanically Ventilated Patients: A Retrospective Study.

Patients who are intubated and sedated are at risk for developing exposure keratopathy, which can lead to permanent vision loss. This retrospective study assesses the incidence of exposure keratopathy (EK) in intensive care unit (ICU) patients before and after implementation of an EK Prevention Order Set. At one tertiary care hospital (Bronx, NY), an "Exposure Keratopathy Prevention Order Set" was implemented to ameliorate this risk which included the application of white petrolatum-mineral oil lubricating ointment every 6 hours in both eyes. This retrospective chart review study analyzed the incidence of EK diagnosis before and after implementation of this EK Prevention Order Set. Patients who were on mechanical ventilation at the time of ophthalmology consult request between January 1, 2021, and December 31, 2021, were included. Ophthalmology consult notes of patients with EK diagnosis were reviewed for details regarding the consult request, examination findings, diagnosis, and treatment plan. There were 247 and 361 ventilated ICU patients before and after the order set, respectively. The number of ophthalmology consults decreased slightly after the order set from 15 of 247 to 20 of 361 ventilated patients. In addition, the rate of EK among ventilated patients decreased from 4.5% (11 of 247 patients over 151 days) to 2.2% (8 of 361 patients over 212 days; P =0.154) with a risk ratio of 0.50 (95% CI 0.20-1.22). The number of patients diagnosed with EK trended down after implementation of the EK Prevention Order Set.

Abstract 15182: Evaluation of an Electronic Clinical Decision Support Tool for Incident Elevated Blood Pressure in Adolescents

Introduction: The PedsBP Clinical Decision Support (CDS) is an electronic health record-linked tool developed in an urban health system that aims to improve the quality of blood pressure (BP) measurement and recognition of hypertension in children. Aims: To describe the feasibility of implementing the PedsBP tool for use in a rural health system, and to describe repeat BP measurement among patients 6-17 years with an incident hypertensive BP at high-intensity clinics using the PedsBP CDS. Methods: This is a 3-arm, parallel group, cluster randomized controlled pragmatic trial in 40 community-based primary care clinics in a rural Midwestern health system (Essentia Health). Clinics were randomized 1:1:1 to usual care, low-intensity implementation (PedsBP CDS only), or high-intensity implementation (Peds BP CDS plus in-person training, monitoring CDS use, and feedback). The PedsBP CDS includes an alert to re-measure a hypertensive BP at that visit, an alert that a hypertensive BP should be repeated in 1-3 weeks, and patient-specific order sets. Study outcomes include repeat BP measurement at an index visit and diagnosis of hypertension within 6 months of meeting clinical criteria. Safety outcomes include stroke, transient ischemic attack, acute renal failure, uncontrolled hypertension within 6 months of index visit. Results: Among 22,238 (50.9% female, mean age 11.7 years, SD=3.5 years) patients with visits between 8/1/22-1/31/23 at participating clinics, 4008 (18.0%) had an incident hypertensive BP and 239 (1.1%) met clinical criteria for hypertension. Among those who met clinical criteria for hypertension, there were no cases of uncontrolled hypertension or other safety outcomes. Of 7974 patients with encounters at 13 high-intensity clinics and with a BP measured, the initial BP was elevated for 1307 (16.4%) and remeasured in 628 (48.1%). Among 1265 patients at high-intensity clinics with a BP elevated and with body mass index (BMI) information, 482 (38.1%) were obese (BMI percentile ≥95%), 209 (16.5%) were overweight (BMI percentile 85% to <95%), and 574 (45.4%) were not overweight or obese (BMI percentile <85%). Conclusions: The PedsBP CDS is feasible to implement in a new health system and has the potential to improve the quality of pediatric BP care.

Abstract 16845: Heart Failure Hospitalist Service Line Have Decrease All Cause Readmission, Length of Stay and Cost at 3 UPMC Hospitals in Central Pennsylvania in 2022

Introduction: Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. Despite numerous evidence-based strategies in the literature aiming at reducing HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days. Methods: Patients with both primary diagnosis HF at UPMC Harrisburg/West Shore/Community General totaled to 1574 in 2022. Hospitalist, Cardiologist, teaching service N= 547 (36%); CHF hospitalist Team N=1027 (64%). Heart failure order set usage, length of stay, all-cause 30-day readmission rates, readmission with HF, cost per case were assessed between these two groups for 2022. Results: All-cause 30-day HF readmission rates at UPMC (Harrisburg, West Shore, Community General Hospitals) for all other providers (Hospitalist, Cardiologist, teaching service) is 32%. HF Hospitalist team at 3 UPMC hospitals had lower 30 day all cause readmission rates: 8.46%. All other providers length of stay was 7.7 days while length of stay while on HF hospitalist service was 6.3 days. Potential cost savings to UPMC hospitals greater than $2.3 million dollars since start of HF Hospitalist service line. Conclusions: HF patients rarely have a consistent provider when readmitted. To address this health care priority at a system level, UPMC Central Pennsylvania’s strategy of creating a HF hospitalist service line has shown to be a unique method to not only develop trusting relationships with our patients but also attain impressive results. The HF Hospitalist service line was created to support an environment of patient-centered care by providing continuity of care for HF admissions and HF patients admitted for non-HF medical issues. At this community-based healthcare system, HF Hospitalist outcomes include decreased 30 day all-cause readmission to an impressive 8.2%, and reduced 30 day HF readmissions 4.12%. This was done while reducing healthcare costs during the 5yrs of the HF Hospitalist service line now at 3 hospitals at UPMC.

Abstract 18106: Keeping up With the Newest Guideline Directed Medical Therapy for Heart Failure With Reduced Ejection Fraction, Resident-Driven Quality Improvement Project

Introduction: Chronic Heart Failure (CHF) is an epidemic associated with high morbidity and mortality. As per 2022 AHA/ACC/HFSA guidelines, the management of Heart Failure with reduced Ejection Fraction (HFrEF) includes Angiotensin Receptor-Neprilysin Inhibitors (ARNIs), Angiotensin-Converting Enzyme Inhibitors (ACEIs)/Angiotensin Receptor Blockers (ARBs), Beta-Blockers (BB), Mineralocorticoid Receptor Antagonists (MRA) and Sodium-Glucose co-transporter 2 Inhibitors (SGLT2I) as class 1 recommendations. Considering the new guidelines for HFrEF we decided to perform a quality improvement project to improve the GDMT prescription rate in patients with HFrEF. Methods: Our project included: dot phrase creation for all physicians through electronic medical records (EMR) system, educational sessions, monthly emails and weekly EMR chat messages regarding GDMT and CHF order set to physicians, A4 sized posters distributed on all hospital floors. We then performed retrospective review and analysis of patient charts who were admitted to three UPMC Central PA hospitals with diagnosis of HFrEF exacerbation during December 2019 to January 2021 (pre-intervention) and March 2022 to September 2022 (post-intervention). Results: Total 615 patients were included. There were no significant differences in demographics between pre intervention (357) and post intervention (258) groups including age, sex, race. There were no differences in prescription rate and target dose at discharge between BB groups (92.72% vs 91.86%%, p=0.693 and 7.25% vs 7.17%, p=0.978). The intervention helped in increasing prescription of ARNIs from 6.2% to 30.62%, p< 0.0001 and 13.92% were discharged on target dosages. The prescription of MRA was increased (47.62%vs 51.55%). Furthermore, initiation of SGLT2I was achieved in 41.47% in post-intervention from 0% in the pre-intervention group. Conclusions: Despite higher awareness of GDMT and the trend towards having more patients discharged on therapeutic dosages of GDMT, it is evident that GDMT is still underused among patients with HFrEF. Our results indicate that more emphasis should be placed on rapid up-titration of GDMT.

Optimizing Acute Sickle Cell Care at Community Health Partners Medical Center

CONCLUSION Sickle cell disease (SCD) is an inherited disease affecting more than 100,000 Black and Hispanic patients in the US. An adult with SCD has an average life expectancy of 54 years compared to 76 years in a typical US adult. This poor survival rate can be attributed to disease and race-related biases, a lack of standardized procedures and dedicated care providers, and delayed or insufficient pain management in the acute care setting. Delays and disparities in care, particularly pain management in acute care setting, have been identified as one of the key deficiencies leading to a decreased quality of care and patient reported outcomes. This SCD quality improvement project seeks to improve the quality and timeliness of acute sickle cell vaso-occlusive care by utilizing an ED pain pathway, SCD-specific inpatient order sets, and educating providers on care-related biases for patients seeking acute care at Community Health Partners Medical Center (CHP). The primary objective is to improve efficacy, timeliness and patient-centered care in order to optimize health outcomes for patients with SCD seeking acute care at CHP. This is a collaborative effort between ED, Hospitalist and Pain Management teams. By identifying areas of strength and areas for improvement, we can work towards delivering more efficient, effective, and patient-centered care, ultimately leading to better health outcomes for patients with SCD disease in need of emergency services. Using the Epic EMR, a metric dashboard was created for SCD patients to measure time from arrival to ED order placement, time from arrival to medication administration, number of inpatient admissions, and length of stay. We focused on crucial time metrics and patient outcomes to gauge the department's efficiency and quality of care for SCD Vaso-occlusive pain crisis. Our intervention included delivering an educational presentation to the ED providers regarding appropriate recognition and treatment of SCD pain episodes, and by creating ED and inpatient SCD-specific order sets. The baseline data was evaluated from 3/1/2021-2/28/2022, and metrics were followed for one year after implementation of the intervention from 3/1/22-2/28/23. After implementation, the average time from arrival to ED order placement improved from 94.9 minutes to 69.4 minutes, a difference of 25.5 minutes or 27%. The average time from arrival to medication administration improved from 158.5 minutes to 135.3 minutes, a difference of 23.2 minutes or 14.6%. The average length of stay increased from 5.7 days to 8.4 days, an increase of 2.7 days or 32.2%. By providing education and SCD-specific order sets, we were able to significantly decrease the total amount of time to medication administration for SCD patients experiencing acute pain crises. While our methods were aimed at ED providers to simplify the input of orders, it did not address the time for nursing to obtain and administer the medication; future improvements could be made towards educating nursing staff to help administer medications sooner. One complicating factor is that these metrics were evaluated during the COVID pandemic, which was responsible for an overall increase in patient admissions and length of stay during this time period. These additional burdens have strained the ability of providers and nurses to provide timely care to SCD patients, though this will hopefully continue to improve as the pandemic recedes. Additionally, the proportion of ED patients who were admitted for further management decreased marginally from 25/39(61%) to 36/63(57%) though the overall number of patients seeking care in our acute care setting has increased. This increase in the number of patients utilizing our acute care may be partly due to an expanding Sickle Cell program at our facility. This analysis shows that by providing appropriate education and using a standardized order set and pathway, we observed a significant decrease in time to order placement to facilitate a faster administration of medications. While the results indicate positive changes in the acute setting, there are opportunities for continued improvement, particularly in reducing the time from order placement to medication administration to ensure more efficient, effective, and patient-centered care.

A Patient-Centered Programmatic Approach for Higher-Risk Myelodysplastic Syndromes (HR-MDS) in the US Community Oncology Setting

Introduction: Prompt diagnosis and treatment are critical for patients with higher-risk myelodysplastic syndromes (HR-MDS) given the high likelihood of progression to leukemia and adverse clinical outcomes. However, pre-diagnosis dynamics can contribute to delays in diagnosis, genetic testing, and treatment initiation, especially among patients receiving care in the community oncology setting. A patient-centered program has been designed and is proposed to be executed in 4 phases: understanding adherence to guideline-concordant care for HR-MDS patients; gaining perspectives to contextualize the patient experience; and implementing a program that can monitor the process for improving patient outcomes (Figure 1). The objectives of this study are to evaluate and address the gaps and disparities of care in the diagnostic and treatment journey of patients with HR-MDS treated in a community oncology setting in order to provide an evidence-based understanding of the patient characteristics and journey to testing, diagnosis, and treatment (Phase 1 of the program). Methods: This is a retrospective chart review including patients treated in the community oncology network and identified in the Integra PrecisionQ deidentified database. Patients were identified as diagnosed with HR-MDS between January 1, 2014 and June 30, 2022, using a combination of ICD codes and receipt of hypomethylating agents in line with National Comprehensive Cancer Network guidelines as their first treatment. Eligible patients had at least 3 months of follow-up and at least 6 months of look-back prior to HR-MDS diagnosis. Signs and symptoms such as fatigue, weight loss, bruise, chills, night sweats, anemia, thrombocytopenia, and neutropenia that initiated the HR-MDS diagnosis journey were collected by manual curation. Results: A total of 350 patients aged 18 years or older diagnosed with HR-MDS over the study period were selected. The majority of patients included in this sample were White (82.6%) and male (59.4%) (Table 1). More than 50% of the 350 patients were ≥75 years old at diagnosis and most of them (91%) were diagnosed by a hematologist/oncologist in an outpatient setting. The median time from first sign/symptom to bone marrow biopsy and treatment initiation were 19.3 months (interquartile range [IQR] 8.9, 44.3) and 22 months (IQR 11.4, 45.8), respectively. Of the 350 patients included in the study, 342 (97.7%) had at least 1 sign or symptom leading to HR-MDS diagnosis, with the majority of patients presenting with anemia (77.2%), followed by thrombocytopenia (66.4%), fatigue (64.3%), and neutropenia (43.3%). International Prognostic Scoring System (IPSS) scores were not documented for nearly half (43.7%) of the patients included in this chart review. Conclusions: This initial analysis highlights several challenges in the HR-MDS patient care journey, including long time intervals elapsed between first sign/symptom and bone marrow biopsy, leading to further treatment, accompanied by a relatively high absence of IPSS score documentation. These findings suggest several potential opportunities to optimize patient care, such as shortening the time from symptoms to diagnosis and time from diagnosis to treatment, utilization and documentation of IPSS score, and prompt treatment initiation. Ultimately, this program aims to utilize this Phase 1 data to identify the gaps in care and to formulate quality measures to optimize care and facilitate timely diagnosis and appropriate treatment initiation among HR-MDS patients.

Underestimation of Venous Thromboembolism Risk: A Common Health Care Quality Deficit

Venous thromboembolism (VTE) is a complication of hospitalization but not all patients are at high risk. VTE risk assessment models have been developed to identify patients whose risk is sufficient to warrant pharmacologic thromboprophylaxis. To ensure all patients are risk assessed upon admission, we implemented a mandatory risk assessment tool embedded in admission order sets in our electronic health record (EHR) system. We hypothesized that the accuracy of these risk assessments was variable. We performed a retrospective cohort study of patients discharged from the Johns Hopkins Hospital medicine service between January 1 st-December 31 st 2019. The cohort consisted of consecutive patients classified into normal, intermediate or low mobility groups using the Johns Hopkins Highest Level of Mobility score. Using a standardized chart review algorithm, elements of the Padua and Improve risk scores were determined using the admission note and the JH-HLM scores for mobility assessment. We report the results of the Padua score comparison. Provider risk assessments, VTE prophylaxis orders, symptomatic VTE, major bleeding (ISTH criteria) and deaths were determined by chart review. We measured concordance between provider risk factors identified and those identified on retrospective chart review. Statistical analyses were done using Chi-squared or Fisher's exact test and were performed using Stata v.18. The cohort consist of 2992 patients with a median age of 58 (Interquartile range (IQR) 45-70). Characteristics of the cohort are in Table 1. The median provider Padua score was 1 (IQR 0,3) compared with 2 (IQR 1,5) for chart review. Providers identified 2480 patients (82.9%) as being low risk compared with 1882 (62.9%) upon chart review (P<0.001). Differences in risk factor assessments are presented in Figure 1. Concordance rates between providers and chart review were high (93.6%-99.6%) for all risk factors except obesity (87.5%), heart failure (76.4%), reduced mobility (72.5%) and acute infection (66.1%).(Figure 1) Thirty-six VTE (27 DVT, 9 PE; 1.2%) occurred during the hospital stay and sixty-one (44 DVT;17 PE; 2.2%) within 3 months. Among patients who suffered an in-hospital VTE, providers assessed 29 (80.6%) as low risk compared with 13 (36.1%) by chart review. Fourteen patients (48.3%) were not prescribed prophylaxis. Forty-seven of 61 patients (77.0%) who developed VTE within 3 months were classified as low risk by providers compared with 26 (42.6%) among chart reviewers. Twenty-five (41.0%) were not prescribed prophylaxis. 727 of 2480 (29.3%) patients risk assessed as low risk by providers were assessed as being at high risk upon chart review. 707 of 2480 (28.5%) low risk patients were not prescribed prophylaxis. 157 of these 707 (22.2%) would have been prescribed prophylaxis based upon chart review. Among these 157 patients, 7 VTE occurred during the hospital stay and 11 events occurred within 3 months. Major bleeding occurred during prophylaxis in 4 patients (0.17%). Underestimation of VTE risk is common in hospitalized medically-ill patients. Development of improved EHR VTE risk assessment tools that assist the provider in identifying patient risk factors could improve VTE prevention and reduce hospital-associated VTE.

Real World Analysis of G6PD Testing Prior to the Use of Rasburicase in Hematologic Malignancies; A Single Center Experience

Introduction: The use of Rasburicase is contraindicated in patients with (Glucose -6-Phosphate Dehydrogenase) G6PD deficiency. The FDA recommends screening for G6PD deficiency prior to the use of Rasburicase, especially in those of African or Mediterranean ancestry. This recommendation, however, is not implemented uniformly. Methods: This was an IRB approved study. A retrospective chart analysis of adult patients with hematological malignancies treated in both the inpatient and outpatient setting between 2019 and 2022 was conducted. Data was reviewed and collected by investigators and compiled in a confidential platform. Results: A total of 437 patients were reviewed. The median age was 67 years. 54.9% were male and 45.1% were female. 65.6% of the patients were White, 23.5% were Black. Other ethnicities included Hispanics 3.8%, Asians 3.7%, Native American or Alaskan Natives 0.4% and unknown ethnicity in 4.3%. 37.3% of the patients had a diagnosis of Diffuse Large B Cell Lymphoma/High Grade B Cell Lymphoma, 34.1% had AML, 29.1% had CLL, 6.2 % had B or T-ALL, 2% had Burkitt lymphoma, and 1.6% had anaplastic T cell lymphoma. Rasburicase was utilized in 85/437 (19.5%) patients for the treatment of hyperuricemia of malignancy 50/85 (59%) and in 35/85 (41%) patients for the treatment of tumor lysis syndrome. G6PD was tested in 197 patients (45%) of which 39.5% were White, 21.8% were Black, 3.5% were Hispanic, 1% were Asian and 2.5% of unknown ethnicity. G6PD status was unknown in 55% patients. 7 cases of G6PD deficiency were identified, and 2 cases were highly suspicious for it due to the development of hemolysis after Rasburicase administration. 8/9 of these patients were African-American. In those patients who received Rasburicase, 70/85 (82.3%) received the medication prior to the G6PD results being available; 6 patients developed hemolysis and 1 patient developed methemoglobinemia. Of these 7 patients, 4 had unknown G6PD status, 2 had G6PD levels which were elevated but sent after signs of hemolysis were present and 1 was G6PD deficient. Of these patients, 3 were Black, 3 were Hispanic and 1 was White. Conclusions: G6PD testing was requested in 45% of patients being evaluated for hematologic malignancies. Of these, only 17.7% had results available before the administration of Rasburicase. 2% of this sample were found to either be G6PD deficient or had clinical suspicion for the same. 89% of them were Black. 8.2% of patients receiving Rasburicase developed complications related to oxidant injury caused by G6PD of which 43% were Black and 43% were Hispanic, though they constituted only 27.3% of the population. This study goes on to highlight the ethnic prevalence of G6PD deficiency, especially in the Black population. Strategies to increase testing for G6PD for all new diagnoses of hematological malignancies known to have a risk of TLS and reducing the time to resulting of G6PD levels can mitigate known adverse events from Rasburicase. The incorporation of G6PD testing as part of chemotherapy order set labs or use of hard stops prior to signing the treatment plan can be potential options to increase testing and screening.

Improving rates of referrals for fertility preservation among adult patients with cancer.

462 Background: Urgent fertility preservation (FP) represents a critical unmet need for patients of child-bearing potential undergoing cancer-directed therapies. A retrospective review of electronic medical record (EMR) based FP referrals placed prior to initiation of systemic cancer-directed therapies in patients aged 18-50 years, identified only 26 referrals to urology and 2 referrals to reproductive endocrinology during 2020. To address this issue, we conducted a division-wide survey to identify barriers to FP and designed and implemented a new FP referral EMR order set to facilitate timely fertility evaluation in patients about to begin cancer-directed therapy. Methods: We conducted a division-wide survey of faculty and fellows to identify barriers to FP (PDSA cycle 1), which identified that 50% of respondents did not know how to make a referral and 85% did not know the correct pre-requisite labs. Based on these results, we gathered multi-stakeholder input from reproductive endocrinology, urology, and stakeholders from different hematology/oncology disease groups to develop and design a common FP referral EMR order set (PDSA 2). The FP order set was tested and refined based on stakeholder input. Once the order set was implemented, we gave educational presentations at division-wide and disease group-specific conferences, placed informational flyers throughout the Cancer Center, and Cancer Center-wide communications via email to increase provider awareness (PDSA 3). The primary objective of the study was to increase in number of referrals for FP evaluation in patients aged 18-50 years undergoing cancer-directed therapy. We tracked number of FP referrals pre and post-intervention using EMR data. Results: In PDSA Cycle 2 and 3, the number of referrals increased further to 62 for urology and 35 for reproductive endocrinology. Of those referred, 35/97 (36.1%) were female. Regarding race/ethnicity, the largest percentage of patients referred identified as White and Asian with the lowest percentage being of Southwest Asian/North African or Black/African American (see Table 1). Conclusions: The development and implementation of a FP order set greatly increased the number of patients who underwent fertility evaluation prior to starting cancer-directed therapy. We did identify differences in groups with regards to referral rates with fewer women being referred, and fewer number of racial/ethnic minorities being referred. Further analysis is needed to identify potential areas of intervention to increase referrals and access to FP, particularly in under-represented groups.[Table: see text]

Perceived Needs Among Healthcare Providers Caring for Seriously Ill Adults Regarding Electronic Health Record Triggers for Palliative Care Referral.

Many healthcare facilities in the United States currently utilize electronic health record triggers to promote and facilitate palliative care referral. The purpose of this study was to explore perceived needs regarding electronic health record trigger criteria for palliative care referral among healthcare providers caring for seriously ill adult hospitalized patients in a teaching hospital in New York State. A qualitative descriptive approach was utilized with use of individual semistructured interviews. Braun and Clarke's Reflexive Thematic Analysis method was used to analyze data. Data analysis generated one overarching theme, I'm in Favor of an Electronic Health Record Automatic Trigger for Palliative Care, and three key themes, Build a Checklist Screening Tool Into Epic With Predefined Conditions and a Palliative Consult in the Admission Order Set, If Providers Call a Palliative Care Consult Sooner, We Give Patients a Better Quality of Life, and Providers Need to Be Aware of the Different Facets of What Palliative Care Actually Does. Findings revealed that all participants supported incorporating electronic health record palliative care triggers. Future research is needed exploring provider palliative care education approaches to promote understanding of palliative care services and to address personal and/or professional bias.

Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus.

Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.

Outcomes of patients placed on comfort care at a large, urban, quaternary care medical center.

229 Background: End-of-life care in the typical hospital setting has several drawbacks including lack of interdisciplinary hospice teams, less comfortable environments, and lack of provider experience. In addition, patients at the end of their life are often severely symptomatic and imminently dying and thus have barriers to appropriate disposition. Few studies have explored the outcomes of patients placed on comfort care with respect to hospice disposition. The objective of this study was to perform a retrospective analysis of patients who transitioned to comfort care at Thomas Jefferson University Hospital (TJUH) to better understand the ultimate disposition of patients placed on comfort care. Methods: We conducted a retrospective study of patients placed on the comfort care order set between July 1st, 2021, until June 30th, 2022. A report of all patients placed on our institutions “comfort care order set” was run using Qlik analytics and data platform. Each individual patient chart was then analyzed to collect multiple clinical variables, including diagnoses, palliative care involvement, time on comfort care, hospital length of stay (in total and after comfort care order set placed), healthcare utilization prior to hospitalization, and IV medications used for symptom management. Participants were limited to those 18 years or older. IRB approval was obtained as per institutional guidelines. Results: 541 patients were included in the analysis. 424 (78.37%) patients died while still admitted to the hospital. This amounts to 1.5 patients a day requiring comfort care support. 60% of patients on comfort care were in the intensive care unit (ICU). The ICU population spent on average 11.04 (+/- 24) hours on comfort care. 19% of these patients were on comfort care for longer than 12 hours. Subspecialty and hospital medicine patients were on comfort care for 3.3 (+/- 3.3) days and 5 (+/- 9.5) days respectively. Within oncology patients, the average time was 3 (+/- 2.4) days. 94% of the patients placed on comfort care in the ICU died in the hospital as compared to 53% of subspecialty and 59% of hospital medicine patients. 40% of non-ICU patients were discharged with hospice services. The average length of stay for the study population was 12.5 (+/- 13.0) days. Conclusions: The majority of patients placed on comfort care died during their hospitalization demonstrating a real need for comprehensive end of life care and immediate hospice services for our patient population. For those discharged with hospice services, they spent an excessive amount of time in the hospital waiting for services to be arranged. Establishing a hospital based inpatient hospice unit has the potential to improve the patient and family experience, provide better end of life care, and reduce length of stay. Previous studies have also demonstrated decreased costs. Ongoing work is underway at our institution to provide optimal end of life care for this patient population.