Order Sets Research Articles

Modern Features of Radioactive Substance Content Dynamics Simulation in Multi-walled Stores

The world’s sustainable development of nuclear power engineering during last decades resulted in large number of radioactive wastes. Currently, each state having nuclear power engineering systems in possession, utilizes the concept of geological disposal as a long-term strategy of radioactive wastes treatment that requires continuous advancements in methods and means due to wastes and standards of radiation monitoring stringency. The article considers the features of radioactive substance content dynamics simulation for single- and multi-walled solid radioactive waste stores, being the product of uranium production, represented by one-dimensional equations and the second and first order sets of equations. The potentials of the existing models, that take into account complex interactions between radionuclides and environment along with possible sources of pollution and mechanisms of radioactive substance transfer, were reviewed. The data availability of temporary radionuclide content evolution inside the store to assess possible effect on environment and people based on the results of mathematical modelling of the considered numerical expressions was emphasized. It was shown, that current models allow analysing and predicting transfer of radionuclide solutions and other substances due to finding solution to contemporary scientific engineering and environmental problems. It was noted, that nowadays there is no model providing forecast of radionuclide content spatial and temporal variations within various store layers to study the accumulated radioactive wastes revealing the mechanisms of their formation, to analyse the features of their distribution, to determine the areas of their active concentration and to define the radionuclide migration activity during storage.

The Use of an Electronic Order Set to Improve Latent Tuberculosis Screening Among Hospitalized Patients Who Are Initiating Immunosuppression: A Cross-Sectional Analysis

The Use of an Electronic Order Set to Improve Latent Tuberculosis Screening Among Hospitalized Patients Who Are Initiating Immunosuppression: A Cross-Sectional Analysis

Implementing an Updated Alcohol Withdrawal Symptom Management Order Set Focused on Patient Safety.

Patients experiencing alcohol withdrawal often receive care on inpatient mental health units. Registered nurses on one such unit had several concerns and questions about the existing alcohol withdrawal symptom management order set. To address these issues, a multidisciplinary team including nurses, psychiatrists, and pharmacists was formed. The aims for this project were to review and revise the existing order set, educate staff, implement the changes, and evaluate outcomes. The Plan-Do-Study-Act quality improvement framework guided the project. Five phases were completed to revise the order set and implement: a survey of nurses on the unit, community practice evaluation, and order set revisions. A simulation escape room facilitated nursing education. Patient records were reviewed to identify adverse events. Diazepam replaced lorazepam as the primary medication choice, and a front-loading protocol was added. Order set clarity was improved, education increased nursing staff confidence to competently complete a patient assessment with the Clinical Institute Withdrawal Assessment Alcohol Scale Revised, and no adverse patient events occurred after implementation. A revised order set for symptom management of patients experiencing alcohol withdrawal reflected up-to-date evidence while maintaining patient safety. All nurses agreed the revised order set was clear and easy to follow; pharmacists and physicians were satisfied with the revisions. Implications for leaders include having a multidisciplinary team, sufficient resources to answer clinical questions, and regular discussions by all involved disciplines to review any adverse events as well as newly published evidence. Close monitoring of patients early in implementation is recommended to detect adverse events.

Capitalizing on Implementation Science to Advance Antimicrobial Stewardship and Health Equity in Treating Pediatric UTI’s

Background: Pediatric urinary tract infections represent the most common pediatric infection with increasing gram-negative antibiotic resistance. Overutilization of antimicrobials including third generation cephalosporins are known drivers of this resistance. Antimicrobial stewardship (AS) efforts have recently shown that antibiotic selection may be influenced by patient race. Implementation science (IS) can provide frameworks and strategies to improve antimicrobial utilization and equity. Methods: This was a pre/post study of 2 geographically different children’s hospitals general pediatric floors assessing the impact of a set of implementation strategies developed to improve provider knowledge of best practice antimicrobials (based on local susceptibilities for treatment of UTI’s) and influence uptake of best practice prescribing. IS strategies included provider education, local clinical champion and opinion leader involvement, leadership involvement, local policy changes, and stakeholder co-design of decision support tools (a clinical pathway, a specific ITI antibiogram, and a dynamic order set). No education was provided regarding racial differences in prescribing habits. Outcomes were measured utilizing a portion of the RE-AIM Framework of assessing adoption of “Right” antibiotic, order set adoption, and equitable reach (racial differences in prescribing). Results: Hospital A and B had a first-generation cephalosporin prescription rate of 29.7% (n=441) and 20.6% (n-557) pre implementation and 44.6% (n=84) and 47.5% (n=118) post (p < 0 .001). Both hospitals also saw a significant reduction in third-generation cephalosporins. In Hospital A, APRN’s were more likely to prescribe a first generation cephalosporin (52.4%) than a DO (42.1%) or MD (26.4%) pre-implementation (p=0.004). In Hospital B, APRN’s were less likely to prescribe first generation cephalosporins (5.4%) than a DO (28.9%) or MD (19.4%) pre-implementation (p=0.004). No statistical significance was seen post implementation for antimicrobial selection by provider type for either hospital. Based on race, both hospitals had Black and Other patients receiving more first-generation cephalosporins while white patients were more likely to receive third-generation cephalosporins (p=0.033) pre implementation. No statistical significance was seen post implementation for antimicrobial selection based on race. No improvement was seen in order set utilization. Conclusion: With order set utilization not improving with implementation of new dynamic order set, other strategies such as education, clinical champion and opinion leader involvement, and provision of a local UTI antibiogram were likely contributors to the improvement in best antimicrobial for treatment of UTI’s. Further mixed method research is warranted to improve understanding of the relative performance of our strategies, especially the lack of provider adoption of the novel dynamic order set.Disclosure: Jessica Snowden: Advisory board - Pfizer

Improving 1-Deamino-8-D-Arginine Vasopressin (DDAVP) Challenges in Pediatric/Young Adult Patients With Bleeding Disorders: A Quality Improvement Study.

Background: Desmopressin (1-deamino-8-D-arginine vasopressin [DDAVP]) has demonstrated efficacy as a treatment option for patients with inherited bleeding disorders. Because of individuals' variable response to the medication, it is recommended to complete a challenge to document appropriate hemostatic response to the medication before recommending its use prior to surgical procedures or treatment of bleeding symptoms. The project aimed to reduce the errors in hemostatic response assessments for patients with bleeding disorders undergoing a DDAVP challenge (process outcome), particularly timing and number of blood samples drawn, from an error rate baseline of 36% to 0% by December 2021 and sustained for one year. Method: Plan-Do-Study-Act methodology was employed for this qualitative improvement initiative. Interventions designed and implemented included: an order set with medication doses and corresponding laboratory orders as clinically indicated for the bleeding disorder indication, clinical procedure guidelines for infusion nurses to follow, hemostasis nurse coordination of appointments with patients, and family education. Results: Baseline data on 22 patients who completed a DDAVP challenge demonstrated a 36% error rate not involving doses of medication administered. Errors encountered included improper timing of laboratory draw after DDAVP administration, incomplete laboratory evaluation, laboratory results displayed incorrectly due to testing orders released at once instead of in a sequential manner. These interventions resulted in a reduction of DDAVP challenge errors to 0% that were sustained for one year. Conclusion: Improvement in procedural medication administration and appropriate laboratory evaluation of patients undergoing a DDAVP challenge leads to a complete and reliable assessment of hemostatic response following medication administration.

Timing Is Everything: Recognizing the Importance of Infusion Duration in Preoperative Antimicrobial Prophylaxis

Background: For preoperative antimicrobials to be most effective in preventing surgical site infection, they must be administered early enough to reach a minimum tissue concentration that is specific to each drug. However, antibiotics have widely ranging infusion durations, from intravenous push over a few minutes to slow infusion over two hours. Heterogeneity in recommended infusion administration instructions, importance of infusion completion prior to incision, and complexity of healthcare systems present just some of the barriers to achieving appropriate preoperative antibiotic prophylaxis. We compared the percentage of infusion completion prior to case start before and after a multidisciplinary intervention. Methods: We performed a retrospective analysis of all patients undergoing a colorectal surgical procedure as defined by the National Healthcare Safety Network at a single university hospital from 10/19/22-10/18/23. A recognition that some antimicrobials were not finished infusing prior to surgery start prompted a multidisciplinary group including antibiotic stewardship, colorectal surgery, perioperative nursing, and anesthesiology to create and deploy an order set shortening metronidazole infusion duration from 60 to 30 minutes and initiating infusion in the preoperative area instead of the operating room. No change to the cefazolin intravenous push over 3-5 minutes was made. Goal antimicrobial infusion was defined as completed infusion within 120 minutes prior to incision, and calculations were made based on infusion start time and case start times. Rate of infusion completion was compared from the pre-intervention period to a post-intervention period from 10/19/23 through the end of the year. Results: For all colorectal surgeries in the pre-intervention period, 95% (n=418/440) of cefazolin doses and 0.002% (n=1/427) doses of metronidazole met goal infusion timing. At-goal infusion timing increased to 99% (n=84/85) of cefazolin doses and 68% (n=56/82) of metronidazole doses in the post-intervention period, resulting in a statistically significant improvement for metronidazole (Fischer’s exact test p < 0 .00001). The average time to metronidazole infusion completion changed from 45 minutes after procedure start to 58 minutes before procedure start. Conclusions: Multidisciplinary team engagement and deployment of an order set incorporating changes in duration and workflow for metronidazole infusion improved all antimicrobial preoperative infusions for colorectal procedures. Increased awareness of completing antimicrobial infusion prior to the incision may improve preoperative antimicrobial administration.Disclosure: Lindsay Donohue: Advisor - Abbvie

Optimizing Comprehensive Care for the Hospitalized Hip Fracture Patients: Time to Surgery and Bone Health at Discharge

Background: Approximately 300,000 older people ( 65 years and older) are hospitalized yearly for hip fractures, according to the CDC. Hip fracture is considered a life-altering event with increased morbidity and up to 30% mortality. The Clinical Practice Guidelines by the American Academy of Orthopedic Surgeons highlight the importance of an interdisciplinary team approach while caring for these patients and recommend surgery within 24 hours for improved outcomes. Most of these fractures are considered fragility fractures occurring from a simple ground-level fall and, thus, a manifestation of osteoporosis. Yet, only a few patients, 26%, receive osteoporosis treatment within 30 days of surgery, as per a recent study. ACP recommends replenishing Vitamin D and Calcium in all fragility fracture patients, followed by the initiation of bisphosphonates. At our institution, hip fracture patients used to be admitted to internal medicine or orthopedic services based on their complexity. There was a perceived feeling that those admitted to primarily internal medicine service received less comprehensive care and were likely delayed in getting to the OR given the competing priorities of a sick internal medicine service load. Vitamin D levels were not being checked or replaced despite having it be part of the admission order set used for hip fracture patients. Our project aimed at improving overall care for hospitalized hip fracture patients. Our goal was to increase the percentage of hospitalized hip fracture patients going to the operating room within 24 hours to 85% by the end of 2023. Additional goals were to improve the percentage of checking vitamin D levels and supplementing them at discharge by 25% by the end of 2023. Methods: Our intervention was to build a fragility fracture orthopedic and internal medicine co-management service where hip fracture patients were admitted. We collected outcome, process, and balancing measures, including time to surgery, unnecessary cardiac testing and consultation before surgery, percentage of ordering vitamin-D levels, and vitamin-D supplementation at discharge. Qualitative satisfaction with the process was also included. Data was collected biweekly from Jan 2023 to Dec 2023. Run chart analysis was utilized for statistical analysis. Results: Our results showed that the percentage of patients going to surgery within 24 hours did not differ (median of approximately 80%). Patients rarely got unnecessary cardiac testing or consultations, so we stopped following this measure. The median of vitamin-D level checking and supplementation at discharge had improved from 45% to 77% and 35% to 50%, respectively, sustaining a shift using run chart analysis rules. Conclusions: Our project shows that establishing a dedicated service for hospitalized fragility hip fractures has improved care for our patients. While time to surgery had not improved, it had been within the reported national average. Time to surgery is being delayed mostly when further medical optimization is required. However, having this service improved bone-focused care with vitamin-D testing and supplementation. The future PDSA cycle will focus on post-discharge osteoporosis management and treatment when appropriate.

864 Optimizing Prescribing Strategies for Neck of Femur Fracture Patients: The Role of Electronic Order Sets

864 Optimizing Prescribing Strategies for Neck of Femur Fracture Patients: The Role of Electronic Order Sets

Improving Naloxone Co-prescribing Through Clinical Decision Support.

Despite national guidelines recommending naloxone co-prescription with high-risk medications, rates remain low nationally.This was reflected atour institution with remarkably low naloxone prescribing rates.We sought to determine if a clinical decision support (CDS) tool could increase rates of naloxone co-prescribing with high-risk prescriptions. An alert in the electronic health record was triggered upon signing an order for a high-risk opioid medication without a naloxone co-prescription.We examined all opioid prescriptions written by family and general internal medicine practitioners at the University of Iowa Hospitals and Clinics in outpatient encounters between November 30, 2020, and February 28, 2022.Once triggered by a high-risk prescription, the CDS tool had the option to choose an order set with an automatically selected co-prescription for naloxone along with patient instructions automatically added to the patient's after-visit summary (AVS).We examined the monthly percentage of patients receiving Schedule II opioid prescriptions ≥90 morphine milliequivalents (MME)/day who received concurrent naloxone prescriptions in the 12 months before the CDS went live and the three months following go-live. Concurrent naloxone prescriptions increased from 1.1% in the 12 months prior to implementation in November 2021 to 9.4% (p<0.001) during the post-intervention period across eight family medicine and internal medicine clinics. This single-center quality improvement project with retrospective analysis demonstrates the potential efficacy of a single CDS tool in increasing the rate of naloxone prescription.The impact of such prescribing on overall mortality requires further research. The CDS tool was easy to implement and improved rates of appropriate naloxone co-prescribing.

Implementing an Updated Alcohol Withdrawal Symptom Management Order Set Focused on Patient Safety.

Implementing an Updated Alcohol Withdrawal Symptom Management Order Set Focused on Patient Safety.

S. aureus Surveillance and Decolonization Associated with Decreased MRSA, but not MSSA, Infections in the Neonatal ICU

Background: Invasive Staphylococcus aureus infections cause significant morbidity and mortality in neonatal intensive care unit (NICU) infants.1 Colonization (asymptomatic carriage in the nose, skin, or gut) is a risk factor for subsequent invasive infection (e.g., pneumonia, bone infections, bloodstream infections, etc.). Active surveillance and decolonization measures for S. aureus-colonized infants have been associated with decreased invasive infection rates. 2-4 Methods: A methicillin-resistant S. aureus (MRSA) surveillance and decolonization program, consisting of admission and weekly MRSA nasal cultures followed by intranasal mupirocin plus chlorhexidine baths for colonized infants, was implemented in our level IV NICU with 150 beds in 2006.5 Due to poor compliance with decolonization protocols5, existing practices were reviewed and multiple interventions to increase compliance were implemented in 2018. These renewed efforts included revision of the existing MRSA decolonization protocol, updating the associated electronic medical record order set, re-education of unit staff, and weekly review by the Infection Prevention (IP) and NICU leadership teams to ensure the decolonization protocol was followed for newly colonized infants. Mean MRSA bloodstream infection (BSI) rates were calculated quarterly pre- (January 2014-December 2017) and post- (January 2018-December 2023) implementation of renewed efforts and compared via unpaired t-test. In July 2020 a similar methicillin-susceptible S. aureus (MSSA) surveillance and decolonization program was implemented with an associated revision of existing documents, education campaign, and weekly review of infants with new MSSA colonization. Mean MSSA BSI rates pre- (July 2018-June 2020) and post- (July 2020-December 2023) implementation were compared via unpaired t-test. Results: Renewed implementation of MRSA surveillance and decolonization was associated with a sustained decrease in the mean MRSA BSI rate (Figure 1): 0.10 per 1000 patient-days pre-implementation, 0.03 post-implementation (p=0.02). Following implementation of MSSA surveillance and decolonization, there was no statistically significant change in the mean MSSA BSI rate (Figure 2): 0.20 per 1000 patient-days pre-implementation, 0.15 post-implementation (p=0.32). Conclusions: Implementation of a robust MRSA surveillance and decolonization program in the NICU was associated with a sustained decrease in invasive MRSA infections. No change in invasive MSSA infection rates was observed following implementation of a similar protocol for MSSA. Additional research is needed to better understand the role of MSSA surveillance and decolonization in the NICU.

Using a Built-in Clinical Decision Support to Improve Phosphate Repletion Practice: A Quasi-Experimental Study

BackgroundInpatient serum phosphate replacement is common, but there is great variability in replacement practice, which leads to overuse. Electronic medical record (EMR) interventions with clinical decision support (CDS) can be effective tools to guide clinicians towards best clinical practices. Our objective was to utilize CDS tools to reduce overuse of hypophosphatemia corrections at a large safety-net healthcare system. MethodsOur first intervention involved enhancing an existing order set for phosphate repletion by incorporating CDS to guide appropriate repletion orders based on deficit severity and simplifying ordering. The second intervention was a best practice advisory (BPA) that triggered when an intravenous (IV) phosphate repletion was ordered for a patient with mild to moderate phosphate deficiency without an existing nil per os (NPO) order. The primary outcome measure was the number of patients with mild and moderate hypophosphatemia receiving IV replacement without NPO orders per 1000 patient days. ResultsAcross all hospitals, rate of IV replacement in patients with mild to moderate hypophosphatemia (1.0 to 1.9 mg/dL) without NPO orders decreased from 7.22 to 3.40 per 1000 patient days (53.0% reduction, p<0.001), while the oral replacements in this population increased from 6.39 to 8.87 (38.8% increase, p<0.001). For patients with phosphate levels ≥2.0, IV replacements decreased from 10.66 to 5.36 (49.8% reduction, p<0.001) and oral replacements decreased 19.78 to 16.69 (15.6% reduction, p<0.01). ConclusionsOur intervention successfully reduced inpatient IV phosphate replacements by 53% in patients with mild to moderate hypophosphatemia using a two-pronged electronic health record intervention across a large safety net setting.

The edge fault-tolerance about the strong Menger edge-connectivity of order [formula omitted] among hamming graph

Let r≥0 be a fixed integer. If F is an edge set of a connected graph G satisfying the minimum degree of G−F being at least r, then F is a conditional faulty edge set of order r. The graph G is called F-strongly Menger-edge-connected if each pair of vertices u and v are connected by min{degG−F(u),degG−F(v)} edge-disjoint paths in G−F, where degG−F(u) and degG−F(v) are the degrees of u and v in G−F, respectively. A graph G is m-strongly Menger-edge-connected of order r if G is F-strongly Menger-edge-connected of order r for every F⊂E(G) with |F|≤m and F is a conditional edge fault set of order r, and the maximum value of m is written as smλr(G). Hamming graph KLn has been widely concerned by researchers due to its excellent properties such as good connectivity, scalability, symmetry and iterativity. This paper considers various sufficient conditions of KLn to be F-strongly Menger-edge-connected of order r and determine the exact value of smλ(L−1)r(KLn) by studying the edge-disjoint paths in KLn with edge faults, smλ(L−1)r(KLn)=(L−1)Lr(n−r)−(L−1)n, where 0≤r≤n−2 and n≥3.

Quality Initiative to Improve Emergency Department Sepsis Bundle Compliance Through Resident Education and Awareness

Introduction: Timely recognition of sepsis is important for physicians as each hour of delay before sepsis is treated is associated with a 4-9% increase in mortality. In order to monitor the care provided in critically ill patients, the Centers for Medicare &amp; Medicaid Services (CzMS) designed Hospital Quality Initiatives which include The Severe Sepsis and Septic Shock Management Bundle (SEP-1). A prior study conducted by Alexander et al at McLaren Oakland Hospital’s Emergency Department (ED) demonstrated improvement in bundle compliance with standardization in documentation and order entry in EMR in the form of Sepsis Macros. Subsequently, the compliance rates with the SEP-1 bundle at McLaren Oakland were found to have fluctuated monthly. This fluctuation affects both patient outcomes and reimbursement for the care provided. Therefore, we hypothesized further education needed to be provided to ensure quality care of septic patients. Objectives: Our project aimed to improve sepsis bundle compliance at McLaren Oakland by providing education to the PGY-1 class and off-service residents on how to accurately utilize the pre-populated sepsis macro and order sets in EMR in order to recognize and treat sepsis in a timely manner. Methods: We developed a Sepsis Education sheet sent in the form of a monthly educational email. This initiative targeted PGY-1s, instructing them on how to appropriately use the new sepsis macro to have timely recognition of sepsis and appropriate orders placed to meet compliance guidelines. Our monthly educational email was sent from August 2022 to February 2023. Results: Sepsis Compliance data was analyzed from August 2022 to February 2023 and compared to August 2021 to February 2022. After implementation of the Sepsis Education sheet, the mean of compliance rates actually decreased from 64% (SD= 0.101 95% CI: 0.575 to 0.719) to 47% (SD= 0.116 95% CI: 0.388 to 0.560) during intervention (p-value = 0.0101). Conclusion: Our intervention was not successful in increasing compliance with SEP-1 bundle requirements. We therefore determined that PGY-1 awareness of sepsis and use of macros is not the limiting factor in sepsis compliance for McLaren Oakland Hospital’s ED. Further investigation regarding limiting factors in sepsis bundle compliance at our institution will need to be conducted.

Improving Early Sepsis &amp; Severe Sepsis Identification and Management on Internal Medicine service at the Detroit John D. Dingell VA Medical Center

Background: Sepsis is a life-threatening organ dysfunction due to infection, with an incidence of nearly 50 million people each year, causing about 11 million in mortality worldwide. Adhering to Sepsis protocols is a quality metric monitored by both the Centers for Medicare &amp; Medicaid Services (CMS) via the SEP 1 measure and the VA Healthcare System through SEP 90, which consists of an all-or-nothing score comprised of individual metrics. These metrics include specific actions such as early management bundle utilization, lactate monitoring, timely fluid resuscitation, and vasopressor administration, all within defined timeframes. Based on FY 2023 Data, the John D. Dingell VAMC performed nationally in the last quintile with &gt; 72% fallouts. Given that the vast majority of our Sepsis patients are treated and managed by the inpatient Internal Medicine resident service, we initiated a Quality Improvement project to educate them and thereby decrease our number of fallouts. We aim to improve Sepsis, severe Sepsis, &amp; Septic shock Identification and Management by 50% over the course of 8 months on the internal medicine service. Methods: Internal medicine residents are central to the identification and management of early Sepsis and Severe Sepsis at the Detroit VA. Given the monthly turnover of resident teams, we focused on our model for improvement on interventions at the start of each month with targeted educational sessions to define Sepsis, severe Sepsis, and septic shock (and their management). We have also implemented targeted EMR training on utilizing a recently developed “Sepsis Bundle order set” for patients who have been identified as Sepsis. Sepsis Menu data usage was collected based on health factor tags on patients with Sepsis as their ICD-10 code on discharge from the internal medicine service. Results: Internal Medicine Resident educational sessions and EMR training commenced on July 1st, 2024. Sepsis Bundle was implemented in the EMR late 2022 due to rising fallouts of Sepsis and severe sepsis cases. However, its usage remained minimal, as depicted in Figure One, when compared to the number of discharged patients. Following the educational sessions and EMR training, both the identification and management of Sepsis have increased. Prior to intervention, from October 2022 to June 2023, a mean sepsis bundle usage rate of 10% was observed for identified sepsis patients, whereas post-intervention, from July 2023 to March 2024, the mean has increased to 30%. Conclusion/Discussion: Based on the early data, we can confidently note that our monthly education sessions, paired with our process measure (Sepsis bundle use), have been effective. Ongoing opportunities for improvement are improved coordination and handoff between ER and IM/MICU. We continue to see the need for ongoing resident education on identification and appropriate documentation of Sepsis severity along with obtaining labs within a certain time frame.

Do Decision Support Tools Decrease the Prevalence of Hospital-Acquired Venous Thromboembolisms When Compared to Clinical Judgement? A Single-Center Pre-Post Study.

Introduction: Hospital-acquired venous thromboembolisms (HA-VTEs) carry a significant health burden on patients and a financial burden on hospitals due to reimbursement penalties. VTE prophylaxis at our institute was performed through utilizing an order set based on healthcare professionals' perceived level of risk. However, the use of standardized risk assessment models is recommended by multiple professional societies. Furthermore, integrating decision support tools (DST) based on the standardized risk assessment models has been shown to increase the administration of appropriate deep vein thrombosis (DVT) prophylaxis. Nonetheless, such scoring systems are not inherently flawless and their integration into EMR as a mandatory step can come at the risk of healthcare professional fatigue and burnout. We conducted a study to evaluate the incidence of HA-VTE and length of stay pre- and post implementation of a DST. Methods: We conducted a retrospective, pre-post-implementation observational study at a tertiary medical center after implementing a mandatory DST. The DST used Padua scores for medical patients and Caprini scores for surgical patients. Patients were identified through ICD-10 codes and outcomes were collected from electronic charts. Healthcare professionals were surveyed through an anonymous survey and stored securely. Statistical analysis was conducted by using R (version 3.4.3). Results: A total of 343 patients developed HA-VTE during the study period. Of these, 170 patients developed HA-VTE in the 9 months following the implementation of the DST, while 173 patients were identified in the 9 months preceding the implementation. There was no statistically significant difference in mean HA-VTE/1000 discharge/month pre- and post implementation (4.4 (SD 1.6) compared to 4.6 (SD 1.2), confidence interval [CI] -1.6 to 1.2, p = 0.8). The DST was used in 73% of all HA-VTE cases over the first 6 months of implementation. The hospital length of stay (LOS) was 14.2 (SD 1.9) days prior to implementation and 14.1 (SD 1.6) days afterwards. No statistically significant change in readmission rates was noted (8.8% (SD 2.6) prior to implementation and 15.53% (SD 9.6) afterwards, CI -14.27 to 0.74, p = 0.07). Of the 56 healthcare professionals who answered the survey, 84% (n = 47) reported to be dissatisfied or extremely dissatisfied with the DST, while 91% (n = 51) reported that it slowed them down. Conclusions: There were no apparent changes in the prevalence of HA-VTE, length of stay, or readmission rates when VTE prophylaxis was mandated through DST compared to a prior model which used order sets based on perceived risk. Further studies are needed to further evaluate the current risk assessment models and improve healthcare professionals' satisfaction with DST.

Late Holocene vegetation dynamics: degree and regional patterns of the Dark Ages woodland regeneration (ad 300–700) in the Netherlands

AbstractDuring the Dark Ages, which include the Late Roman period (ad 270–450) and the Early Middle Ages (ad 450–1050), large-scale vegetation development in northwest Europe was characterised by widespread regeneration of woodlands. This regeneration phase represents a break from the extensive reduction in woodland from human activities in late Holocene vegetation history. In the Netherlands, possible causes for this reversal can be found in a decreased human impact on the landscape, a colder and possibly wetter climate, and geomorphological changes. This paper presents a synthesis from 38 pollen records from a range of sites across the Netherlands, from which regional differences in the degree of woodland regeneration and vegetation composition before and during the Dark Ages have been identified. Both original data as well as vegetation abundance modelled by REVEALS were used to assess the regrowth of the woodland cover. The observed trends were considered in terms of the landscape setting and population estimates in order to disentangle the relative importance of these forcing factors. The results indicate that landscape and human impact were the most important factors determining the vegetation structure and changes to it. The pollen data show that in the Netherlands, the clearance of woodland in the Roman period followed by its regrowth afterwards were greatest in the river area. This can be linked to a high population density there during the Roman period followed by a strong decrease of population in the Dark Ages and to increased flooding.

Improving Cardiac Rehabilitation Referral Rates in Patients with Coronary Heart Disease from Diverse Communities Using an Electronic Order System

Introduction: Despite the benefits of Cardiac Rehabilitation (CR), local and national CR referral and participation rates remain low when compared to established cardiovascular therapies, especially amongst racial/ethnic groups. Objectives: This study investigated the effects of the implementation of a CR program and electronic order set (EOS) in a large health system on CR referral and participation rates among a diverse group of patients with Coronary Heart Disease (CHD). Methods: A total of 360 patients from UCSD Health who presented with ACS were prospectively evaluated during initial hospitalization and 6- and 12-weeks post-discharge. The multivariable logistic regression model assessed referral and participation rates by week 1 and -12 post-discharge, adjusting for gender, age, race, ethnicity, geography, and referring physician subspecialty. Results: UCSD CR program implementation led referral rates to increase at week 1 (Pre- 38.6% and Post-54.9%, p = 0.003) and week-12 (Pre- 54.1% and Post- 59.8%, p = 0.386). Post-CR referrals were more likely at week-1 (OR: 1.93, 95% CI 1.27-2.95) and week-12 (OR: 1.26, 95% CI 0.79-2.00). EOS implementation increased referral rates at week-1 (Pre- 40.3% and Post- 58.7%, p &lt; 0.001) and week-12 (Pre- 54.9% and Post- 60.4%, p = 0.394) with referrals more likely at week-1 (OR: 2.1, 95% CI 1.35-3.29) and week-12 (OR: 1.25, 95% CI 0.795-1.98). Participation in CR following EOS was more likely at both week-1 and week-12. Multivariable analysis revealed disparities in referral based on race, geographic location, and referring physician subspecialty. Conclusion: A CR program and EOS implementation were shown to increase referral rates with long-term potential for increasing referral and participation rates. Condensed abstract: This prospective study investigated the implementation of a Cardiac Rehabilitation (CR) program and Electronic Order Set (EOS) within the same health system on CR referral and participation rates. 360 patients with ACS were evaluated over 12 weeks. UCSD CR program and EOS implementation led referral rates to increase at week-1 and -12. CR participation was more likely to increase at week-1 and -12 following EOS. Multivariable analysis revealed disparities in referrals disproportionally affecting racial and ethnic minority groups and rural communities. CR and EOS implementation may increase CR referral rates for diverse patients with CHD.

Impact of an electronic smart order-set for diagnostic stewardship of Clostridiodes difficile infection (CDI) in a community healthcare system in South Florida

Inappropriate testing for Clostridiodes difficile infection (CDI) increases health care onset cases and contributes to overdiagnosis and overtreatment of patients in a community healthcare system. An electronic smart order set for the testing of CDI was created and implemented to improve the appropriateness of testing. A retrospective review of patients who were tested for CDI, pre and post, was conducted to determine if inappropriate stool testing for CDI decreased post-implementation of the order set. 224 patients were tested for CDI during the study period with the post-implementation period having a higher proportion of patients who met appropriate testing criteria defined by presence of diarrhea (80.5% vs 61.3%; P=.002). The rate of inappropriate CDI stool testing decreased from 31.1% to 11.0% after implementation (P<.001). A higher proportion of CDI patients were readmitted within 30 days of discharge (54.2% vs 33.0%; P=0.001) during the post-implementation period. There was a significant reduction in inappropriate CDI testing following the implementation of the order set. There was an observed increase in the proportion of patients who underwent recent gastrointestinal surgery which may have contributed to the increase in 30-day readmission rates during the post-implementation period.

Production Planning Optimization in a Two-Echelon Multi-Product Supply Chain with Discrete Delivery and Storage at Manufacturer’s Warehouse

In today’s competitive world, customers expect their demands to be met at the shortest possible time, while manufacturers aspire to deliver the orders within a convenient time and at a minimum cost. Thus, manufacturers are compelled to seek ways of lowering the costs of their services in order to satisfy customers and survive the competition in their respective industries. This research paper investigates a multi-product problem in a two-echelon supply chain consisting of a single manufacturer and several retailers. The main objective of this research is to develop and present a multi-product optimization model in which retailers receive their orders through discrete delivery and surplus manufactured goods are stored in the manufacturer’s warehouse. The objective function of the mathematical model in the economic dimension includes the minimization of the total supply chain costs and the maximization of profit. The retailers in this model place new orders when their inventory level drops to zero, and the manufacturer responds to the retailers’ orders at the same time as it begins processing each product. After delivering the last set of orders, the manufacturer stores surplus items in its warehouse in case the retailers place new orders. This optimization problem is modeled using mixed integer nonlinear programming, while numerical scenarios are coded using the MATLAB software which helps estimate the total cost within a short time. Finally, a sensitivity analysis is performed to determine the effects of a number of factors on the total cost, including problem parameters, demand and production rates, the production quantity, and the number of times the manufacturing machines are operated at each production cycle.