Standardized Order Sets Research Articles

A Multidisciplinary Survey to Assess Facilitators and Barriers to Successful Organ Donation in the Intensive Care Unit.

Rates of successful organ donation vary between otherwise comparable intensive care units (ICUs). The ICU staff have a unique perspective into the facilitators and barriers underlying this variation in successful deceased organ donation. What do ICU staff perceive to be the most meaningful facilitators and barriers to deceased organ donation? We designed and conducted a survey of all disciplines working in the ICU to ascertain the perceived facilitators and barriers to donation in an academic tertiary care hospital. Survey reliability was assessed using Cronbach α. Factor analysis was used to assess construct validity and identify potentially redundant survey items. We had responses from 108 ICU staff, including nurses (n = 75), respiratory therapists (n = 14), physicians (n = 12), chaplains (n = 2), as well as social work, pharmacy, physiotherapy, and occupational therapy (n = 1 each). Perceived facilitators included availability of organ donation organization coordinators, explicit institutional support for donation, ICU staff culture toward donation, standardized order sets for donation, presence of ICU staff with donation experience, and bedside nurse presence at discussions about donation. Perceived barriers included ICU staff ruling out potentially suitable donors before consulting a donor coordinator, physician communication skills, low priority for organ donation among operating room staff, limited family understanding of patient prognosis and organ donation, and limited emotional readiness of families to discuss donation. Several staff-perceived facilitators and barriers to deceased organ donation were identified in the ICU. Future research could identify strategies to promote these facilitators and overcome barriers.

Abstract TP464: System Changes Decrease Emergency Department Length of Stay for Hemorrhagic Stroke Patients

Background/Purpose: American Stroke Association guidelines recommend that a length of stay (LOS) in the Emergency Department (ED) of less than 6 hours improve outcomes in patients with hemorrhagic stroke. In the second quarter of 2017, patients at our academic medical facility averaged an ED LOS of 6.3 hours. Issues identified that extended LOS were: 1) a lack of process to alert required providers and stroke RN, 2) unfamiliarity of ED nurses with complex hemorrhagic stroke protocols, and 3) need for hemorrhagic stroke clinical care pathways with standardized order sets. Methods: Collaboration was formed between the emergency department, neurosurgery, neuro ICU, stroke program manager, and neuro ICU trained stroke nurses. The following improvements were implemented: 1) a subarachnoid hemorrhage and intra-cerebral hemorrhage (SAH/ICH) activation was developed to formalize a process to alert and mobilize specialty services upon patient arrival in the ED, 2) formation of a collaboration between an ED RN and expertly trained stroke nurses to provide care for the complex hemorrhagic stroke patient, and 3) implementation of standardized order sets for the electronic medical record. Results: Eleven months after the implementation of process improvements, there was a statistically significant reduction in ED LOS for hemorrhagic stroke patients. LOS decreased from an average of 6.3 hours to 3.1 hours. Conclusion: An activation system expediting specialty services and expert nursing care with the use of hemorrhagic stroke clinical care pathways and order sets reduces LOS in the ED and may improve patient outcomes. Future Recommendations: Monitor LOS statistics on a quarterly basis. Periodically re-evaluate the timeliness of SAH/ICH activation and compliance with clinical care pathways and standardized order sets to ensure sustainability.

Abstract WP415: Electronic Stroke Care Pathway Significantly Increases Quality Improvement Metric Documentation and Patient Education

Introduction: Stroke accounts for 1 in 20 deaths in the US, and increasing stroke healthcare costs are projected to rise to $185 billion yearly by 2030. Care Pathways use standardized electronic medical record (EMR) documentation, order sets, and clinical decision support to streamline institution-wide care delivery and have been shown to improve outcomes. We hypothesize that the Acute Ischemic Stroke (AIS) Care Pathway increases EMR documentation of quality improvement metrics. Methods: The AIS Care Pathway was implemented starting in 11/2015. It streamlines workflow by providing users with EMR documentation tools, order sets, and clinical aids. We compared the documentation of quality improvement metrics in patients on and off the Care Path, including stroke education and documentation of last known well (LKW), NIH stroke scale (NIHSS), and modified Rankin Scale (mRS). Results: In 2017, 2,728 patients were diagnosed with AIS; 77% of patients were placed On Care Path, and 23% were Not On Care Path. Documentation of LKW (81% vs 29%, p<0.01), admission NIHSS (100% vs 62%, p<0.01), admission mRS (99% vs 60%, p<0.01), discharge NIHSS (75% vs 46%, p<0.01), and discharge mRS (78% vs 49%, p<0.01) were significantly higher for patients On Care Path compared to those Not On Care Path (Table 1). Likewise, a higher proportion of patients On Care Path received nursing stroke education (74% vs 48%, p<0.01). Conclusions: AIS Care Pathway significantly increases documentation of quality improvement metrics and education related to stroke care. These are electronically abstracted data that can eliminate the need for manual abstraction.

Abstract TP350: Expansion of Advanced Practice Provider Stroke Service to 24/7 In-House Coverage Improves Stroke Measure Compliance and Ensures Successful Comprehensive Certification

Background: Successful development of a Comprehensive Stroke Center (CSC) requires resources to meet the certifying body requirements including 24/7 on site coverage of neurocritical care as well as provider resources to support the clinical care on off hours. Non-academic centers may be challenged to meet these needs. PURPOSE: We analyzed the impact of designing and implementing a hybrid stroke/neurocritical care Advanced Practice Provider (APP) service. Methods: A 24/7 APP service was recruited, hired and trained from January 2017 through full implementation in January 2018. APP training included a 12 week orientation with a well-developed neuro critical care center, stroke service training with two CSCs, and Emergency Neurological Life Support certification. Their role was to provide consultation for all stroke alerts as well as in-house clinical management of all stroke patients on service and/or requiring neuro critical care services in the ICU. Stroke attending and fellow physicians continued in a partnership and supportive role. Results: Through retrospective analysis outcomes were compared Pre (January 2017-June 2017) and post(January 2018 - June 2018) Implementation. Primary outcomes measured included length of stay (LOS), compliance with quality metrics, order set utilization, door to needle times, and door to puncture times Transferred patients accepted from other facilities on off hours was also tracked. The results are displayed in the table. Conclusions: These results demonstrate that an APP driven stroke and neurocritical care service is feasible and can lead to improved care such as better compliance with stroke CSC measures including the time specific measures indicating quicker face to face assessments, improved documentation of severity scores, increased standard order set usage, enhanced inpatient stroke alert response, and increased presence with families and nursing staff which improved communication on all shifts.

Cascading Workflow of Healthcare Services

Despite rapid advancements in technology, the healthcare industry is known to lag behind when it comes to adopting new changes. Most often, when a new technology such as CPOE or EHR systems presents themselves in the healthcare industry, clinicians are left struggling to keep up with their workloads while learning to adjust a new workflow. Instead of disrupting the clinician's clinical workflow, the authors propose a system for transforming clinical narratives presented in the form of discharge summaries from the i2b2 Natural Language Processing dataset into a standardized order set. The proposed system uses natural language processing techniques based on Scala, which extracts discharge summary information about a patient and is proven to be highly scalable. The goal of this system is to increase interoperability between CPOE systems by performing further transformations on the extracted data. The authors adhere to HL7's FHIR standards and use JSON as the primary medical messaging format, which is used both in the US and international healthcare industry organizations and companies.

Protocol-Driven Management of Convulsive Status Epilepticus at a Tertiary Children's Hospital: A Quality Improvement Initiative.

Convulsive status epilepticus is a medical emergency. Prompt treatment has been shown to decrease progression to refractory convulsive status epilepticus. We aimed to reduce time to second-line anti-seizure medication through implementation of a standardized treatment protocol. Quality improvement project. We constructed a multidisciplinary team and completed Plan-Do-Study-Act cycles to achieve the project aim. A tertiary care children's hospital. Patients presenting to the Children's Hospital at Montefiore emergency department with convulsive status epilepticus or new-onset seizures during admission to Children's Hospital at Montefiore. Implementation of a standardized treatment protocol, uploading the protocol to the hospital's intranet, adding anti-seizure medications to the hospital's Pyxis system, and creating a standardized convulsive status epilepticus order set in the electronic medical record. The primary outcome measure was time from order to administration of second-line anti-seizure medication, and secondary outcome was total seizure time. Seventy-eight patients were analyzed, including 41 from the baseline period (January 2014 through June 2015) and 37 from the postintervention period (July 2015 through December 2016). The median time to administration of second-line anti-seizure medication decreased from 52 to 21 minutes (p = 0.001) and total seizure time from 65 to 31 minutes (p = 0.09). A standardized treatment protocol for convulsive status epilepticus decreased time to administration of second-line therapy by 60%, but there was no statistically significant decrease in total seizure time.

Decreasing Door-to-Door Times for Infliximab Infusions in a Children's Hospital Observation Unit.

Children with inflammatory bowel disease (IBD) often require infliximab infusions to manage their disease. Infusions administered in the hospital setting require the patient and their families to devote many hours away from home. Changing to a rapid infusion protocol has been shown in the literature to be safe and has the potential to decrease time spent in the hospital receiving infusions. We describe stepwise changes made over a 4-month period to improve infliximab infusion efficiency and lessen the time spent in the hospital by IBD patients and their families. These changes included the implementation of a standardized order set, defaulting to rapid infusions for eligible patients, eliminating the post-infusion observation window, and improving the pharmacy's efficiency in preparing infusion medications. We utilized several established quality improvement tools, including a smart aim, key driver diagram, plan-do-study-act cycles, and statistical process control charts to measure these interventions. Within three months of starting, the average door-to-door time patients spent in the hospital decreased by 128 minutes (2 hours 8 minutes). This improvement amounts to 768 minutes (12 hours 48 minutes) per year of time returned for normal childhood activities outside of the hospital. There were no infusion reactions during the period monitored. Implementation of a rapid infliximab infusion protocol made an impressive impact on freed family time without sacrificing patient safety. The changes we implemented could be helpful to other centers interested in decreasing in-hospital time for patients with IBD and their families.

Standardizing the Use of Albumin in Large Volume Paracentesis

Background Albumin after large volume paracentesis (LVP) reduces paracentesis-induced circulatory dysfunction (PICD). The most efficacious dose of albumin for LVP is unclear. Objective To evaluate the impact of implementing a standardized LVP order set on albumin utilization and patient outcomes. Methods This is a retrospective review of patients with ascites due to cirrhosis who received a therapeutic paracentesis at a large, academic institution. Primary outcome was amount of albumin used prior to and after order set implementation. Albumin doses were standardized in the order set to 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (>10 L). Patient outcomes were rates of hyponatremia, renal impairment, and hypotension. Results There were 100 patients included in each arm of the final analysis. Patients prior to order set implementation received a higher amount of albumin per liter removed compared to those post-implementation (8.3 g/L vs 6.5 g/L, respectively; P < .01). There were no significant differences between groups in absolute changes in serum sodium (0 mEq/L vs −1 mEq/L, P = .64), serum creatinine (0.06 mg/dL vs 0.05 mg/dL, P = .94), or systolic blood pressure (−4 mm Hg vs −3 mm Hg, P = .96). There were no differences between groups in rates of hyponatremia (1.6% vs 6.6%, P = .21), renal impairment (11.3% vs 11.5%, P = .97), or hypotension (17.4% vs 17.6%, P = .97). Conclusions Use of an order set to guide albumin dosing based on amount of ascitic fluid removed during LVP resulted in a significant reduction in the amount of albumin given with no difference in adverse effects.

Evaluation of a Diabetic Ketoacidosis Order Set in Adults With Type 1 and Type 2 Diabetes at a Tertiary Academic Medical Centre: A Retrospective Chart Audit

To assess safety and efficacy compared to a historical cohort. Clinical practice guidelines recommend that patients with diabetic ketoacidosis (DKA) be treated with a standardized protocol. We created a multifaceted order set to promote best-practice management of DKA. We performed a retrospective cohort study of admissions to internal medicine for DKA in adults during a 4.5-year period; 2.25years before and after order-set initiation. Groups were compared using independent samples t tests and Pearson chi-square or Fisher exact test (categorical data). The Mann-Whitney U test was used for continuous data not normally distributed. The order-set cohort consisted of 47 admissions, 72.3% with type 1 and 27.7% with type 2 diabetes. The historical cohort consisted of 59 admissions, 69.5% with type 1 and 30.5% with type 2 diabetes. There were no significant differences in initial laboratory values between patients with type 1 and type 2 diabetes in both cohorts. The median length of hospital stay approached significance in the order-set cohort: 3.53days (2.5 to 5.1); in the historical cohort, the median length of stay was 4.6days (2.44 to 8.99) (p=0.102). A standardized DKA order set was as effective and safe in type 1 and type 2 diabetes as individual physician management in an academic care setting. Further study is needed to assess its value in community hospital settings with less expertise and fewer diabetes specialty services.

Utilizing a standardized order set to increase speech pathology referrals in head and neck cancer patients.

324 Background: Treatment of head and neck cancers may include radiation, and side effects will result in short and long-term dysphagia. This can lead to feeding tube usage, malnutrition, loss of social interaction, and reduced quality of life. Rehabilitation therapies are available with speech pathologists to improve outcomes. Evidence supports initiating therapy prior to radiation. Computerized order entry systems (CPOE) support standardization of evidence- based order sets. The purpose of this study was to examine the effect of a standardized order set on referral rates to speech pathology in adult patients undergoing radiation treatment for head and neck cancer. Methods: A quality improvement project was implemented an outpatient oncology clinic within an academic hospital using the PDSA format. Approval was obtained through the hospitals quality assurance officer, and it was determined that IRB approval was not necessary. A chart review was completed to assess the rate of speech pathology consults. A brief education program targeting ordering providers was completed including demonstration of the order set. Post intervention chart review was performed to assess the change in referral rates. Results: A chi square analysis was used to compare the difference in referral rates and found to be statistically significant, x² (1, n = 56) = 17.147, p &lt; 0.01. Demographic data was analyzed using descriptive statistics. The sample was mostly Caucasian (82%), male (84%) with an average age of 63. The most common cancer diagnosis was larynx (36%). The percentage of referrals post intervention (82%) was significantly higher than pre-intervention (18%) consistent with the hypothesis that a standardized order set would increase speech referral rates. Conclusions: Use of a CPOE system with standardized order sets increased the rate of speech pathology referrals. The success of this order set has led to an expansion of the project, and creation of additional order sets. Standardized computerized order sets should be considered to increase referrals to underutilized ancillary services. Providers should be encouraged to create relationships with these services to improve patient’s quality of life and long- term outcomes.

Surgical Universal euGlycemic Attainment during Recovery (SUGAR) Initiative.

252 Background: Surgical site infections (SSI) are infections of the surgical incision or organ space within 30 days of surgery and are associated with increased morbidity, mortality and healthcare expenditures. Diabetic patients undergoing laparotomy are at high risk. Prior studies have shown SSI reduction by avoiding hyperglycemia. The aim of our Quality Improvement (QI) initiative is to reduce the SSI rate among diabetic patients undergoing laparotomy by 40% within 2 years compared to the baseline (2/2015-8/2017) rate of 16%. Methods: We formed a multi-disciplinary QI team including physicians, nurses and advanced care providers from Gynecologic Oncology, Pharmacy, Nutrition, Endocrinology, Internal Medicine and Anesthesiology. The intervention began 2/2018 in our main center and 5 satellite sites including: screening gynecologic cancer patients undergoing laparotomy with hemoglobin A1C, intra-operative glucose monitoring with goal of &lt; 180mg/dL, creation and use of a standardized basal-bolus insulin order set for post-operative care, and endocrine and nutritional consultation. The following variables were assessed: age, race, ethnicity, BMI, cancer type, comorbidities, smoking status, surgical procedure, receipt of antibiotic prophylaxis, hemoglobin A1C, post-operative glucose values, intervention compliance, intra-operative complications, post-operative complications including SSI, hospital readmissions, reoperation and mortality. Results: Since 2/2018, 39 gynecologic cancer patients have undergone laparotomy. Overall compliance with HgA1c screening is 64% (25/39), which has improved from 42% in 2/2018 to 70% in 3/2018 and 83% in 4/2018. Causes of non-compliance included unplanned conversion to laparotomy and need for additional education. Five of 39 (13%) patients were diabetic, including one newly diagnosed through this initiative. The post-intervention diabetic SSI rate is 0% (0/5) with all post-intervention glucose values &lt; 180mg/dL. There have been no safety adverse events resulting in patient harm. Conclusions: Implementing a QI initiative to standardize management of diabetic patients undergoing surgery is both safe and feasible. Effectiveness data will continue to be collected.

Can We Improve Physical Health Monitoring for Patients Taking Antipsychotics on a Mental Health Inpatient Unit?

Patients with severe mental illness are at risk of medical complications, including cardiovascular disease, metabolic syndrome, and diabetes. Given this vulnerability, combined with metabolic risks of antipsychotics, physical health monitoring is critical. Inpatient admission is an opportunity to screen for medical comorbidities. Our objective was to improve the rates of physical health monitoring on an inpatient psychiatry unit through implementation of an electronic standardized order set. Using a clinical audit tool, we completed a baseline retrospective audit (96 eligible charts) of patients aged 18 to 100 years, discharged between January and March 2012, prescribed an antipsychotic for 3 or more days. We then developed and implemented a standard electronic admission order set and provided training to inpatient clinical staff. We completed a second chart audit of patients discharged between January and March 2016 (190 eligible charts) to measure improvement in physical health monitoring and intervention rates for abnormal results. In the 2012 audit, thyroid-stimulating hormone (TSH), blood pressure, blood glucose, fasting lipids, electrocardiogram (ECG), and height/weight were measured in 71%, 92%, 31%, 36%, 51%, and 75% of patients, respectively. In the 2016 audit, TSH, blood pressure, blood glucose, fasting lipids, ECG, and height/weight were measured in 86%, 96%, 96%, 64%, 87%, and 71% of patients, respectively. There were statistically significant improvements (P < 0.05) in monitoring rates for blood glucose, lipids, ECG, and TSH. Intervention rates for abnormal blood glucose and/or lipids (feedback to family doctor and/or patient, consultation to hospitalist, endocrinology, and/or dietician) did not change between 2012 and 2016. Electronic standardized order set can be used as a tool to improve screening for physical health comorbidity in patients with severe mental illness receiving antipsychotic medications.

The use of standardized order sets to improve adherence to evidence-based postoperative management in major head and neck surgery

BackgroundStandardized order sets (SOSs) are clinical tools derived from clinical care pathways that have shown improved patient-recovery and economic benefits. The primary objective was to examine the effect of SOSs on adherence to evidence-based postoperative guidelines for laryngectomy patients. MethodsA retrospective chart review comparing handwritten and SOS-based postoperative physician orders was conducted for consecutive laryngectomies performed (n=70) within a 3-year time period. Orders were analyzed for errors and deviations from evidence-based guidelines. Secondary outcome included complications such as thromboembolic disease, return to operating room, fistula formation, salivary bypass tube, length of hospital stay and death. ResultsApproximately 81% of cases utilizing handwritten orders had at least one error (n=36) compared to 38% in the group that used an SOS (n=34) (P<0.0001). Subgroup analyses demonstrated that errors in mechanical deep vein thrombosis prophylaxis (P<0.0001) and antibiotic prophylaxis (P=0.0173) orders were significantly reduced in the SOS group compared to the handwritten group. No significant differences were observed between the two groups for measured postoperative complications (P>0.05) and length of hospital stay (18.6 days in both SOS and handwritten orders groups). ConclusionsSOSs are associated with reduced errors in postoperative orders. They are important tools to improve adherence to standardized guidelines for surgeries requiring complex postoperative management. Clinical care pathways and Enhanced Recovery After Surgery protocols can use SOSs to ensure appropriate orders are being made.

Successful Reduction in the Heart Failure Length of Stay through Standardized Management

Background As the focus to decrease in-hospitalization medical expenses increases, length of stay (LOS) has become a focal point of analysis particularly in the heart failure (HF) population. This is a reasonable goal as HF is the leading cause of hospital admission in patients older than 65 years old and research has shown that shorter LOS is associated with better outcomes. The purpose of this project was to standardize the management of HF patients and to decrease the HF average length of stay (ALOS) by one day. Method In this single center observational study, five areas of potential improvement were identified: Initial Furosemide dosage, early involvement of cardiology team, utilization of a standardized HF order set, multi-disciplinary rounding and close monitoring from the nursing staff. The data showed that the majority of the HF patients were receiving Furosemide 40mg or less as the first dose in the Emergency Department (ED) which was associated with a two day increase in the length of stay, as compared to those receiving 60mg and higher. Furthermore, the data also showed low utilization of the HF order set, and lack of early cardiology consultation. Process benchmarking revealed an opportunity to restructure the multidisciplinary rounds to give focus on the progression of care. Review of literature uncovered the need to restructure the responsibilities of the HF nurse coordinator to support the initiative. Based on the identified opportunities, a HF management algorithm was created to standardize the approach. A HF nurse was appointed to oversee and promote these 5 key areas of focus. Results Improvements in the aforementioned processes, utilization of at least Furosemide 60mg in the ED increased from 22% to 67% in six months. Furthermore, order set utilization increased from 32% to 81% and cardiology consult increased from 75% to 95% both within a few months. These enhancements resulted in a 1.04 day reduction in the ALOS. In HF admissions, ALOS decreased from 7.72 days (2016) to 6.68 days (01/2017 - 07/2017). A true measure of this improvement is the LOS index which is the ratio of actual LOS over expected LOS. HF LOS index steadily trended down from 1.42 (01/2017) to 1.1 in (6/2017) (Vizient data). Conclusion In conclusion, the expansion of these five key milestones were the fundamental drivers in lowering the LOS by more than 1 day.

The use of a standardized order set reduces systemic corticosteroid dose and length of stay for individuals hospitalized with acute exacerbations of COPD: a cohort study.

BackgroundSystemic corticosteroids (SC) are an integral part of managing acute exacerbations of COPD (AECOPD). However, the optimal dose and duration vary widely in clinical practice. We hypothesized that the use of a “PowerPlan” order set in the electronic health system (EHS) that includes a 5-day SC order would be associated with a reduced steroid dose and length of stay (LOS) for individuals hospitalized with AECOPD.Patients and methodsWe conducted a retrospective cohort study of Medicare recipients discharged with an AECOPD diagnosis from our University Hospital from 2014 to 2016. Our EHS-based “COPD PowerPlan” order set included admission, laboratory, pharmacy, and radiology orders for managing AECOPD. The default SC option included intravenous methyl-prednisolone for 24 hours followed by oral prednisone for 4 days. The primary endpoint was the difference in cumulative steroid dose between the PowerPlan and the usual care group. Secondary endpoints included hospital LOS and readmission rates.ResultsThe 250 patients included for analysis were 62±11 years old, 58% male, with an FEV1 55.1%±23.6% predicted. The PowerPlan was used in 72 (29%) patients. Cumulative steroid use was decreased by 31% in the PowerPlan group (420±224 vs 611±462 mg, P<0.001) when compared with usual care. PowerPlan use was independently associated with decreased LOS (3 days; IQR 2–4 days vs 4 days; IQR 3–6 days, P=0.022) without affecting 30- and 90-day readmission rates.ConclusionUse of a standardized EHS-based order set to manage AECOPD was associated with a reduction in steroid dose and hospital LOS.

Effectiveness of a standardized electronic admission order set for acute exacerbation of chronic obstructive pulmonary disease

BackgroundVariation in hospital management of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may prolong length of stay, increasing the risk of hospital-acquired complications and worsening quality of life. We sought to determine whether an evidence-based computerized AECOPD admission order set could improve quality and reduce length of stay.MethodsThe order set was designed by a provincial COPD working group and implemented voluntarily among three physician groups in a Canadian tertiary-care teaching hospital. The primary outcome was length of stay for patients admitted during order set implementation period, compared to the previous 12 months. Secondary outcomes included length of stay of patients admitted with and without order set after implementation, all-cause readmissions, and emergency department visits.ResultsThere were 556 admissions prior to and 857 admissions after order set implementation, for which the order set was used in 47%. There was no difference in overall length of stay after implementation (median 6.37 days (95% confidence interval 5.94, 6.81) pre-implementation vs. 6.02 days (95% confidence interval 5.59, 6.46) post-implementation, p = 0.26). In the post-implementation period, order set use was associated with a 1.15-day reduction in length of stay (95% confidence interval − 0.5, − 1.81, p = 0.001) compared to patients admitted without the order set. There was no difference in readmissions.ConclusionsUse of a computerized guidelines-based admission order set for COPD exacerbations reduced hospital length of stay without increasing readmissions. Interventions to increase order set use could lead to greater improvements in length of stay and quality of care.

P040: Describing antibiotic utilization and uptake of the chronic obstructive pulmonary disease order set in Saskatoon emergency departments

Introduction: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Canada. The Anthonisen criteria utilizes the cardinal symptoms of acute exacerbations of COPD (AECOPD), increased shortness of breath, increased sputum production, and increased sputum purulence, to determine which patients should receive antibiotics. In July 2015, a COPD Order Set Pilot was implemented in Saskatoon emergency departments (ED). The order set utilizes the Anthonisen criteria to optimize AECOPD patient management and ensure appropriate antibiotic usage. By January 2019, we aim to optimize AECOPD patient management in Saskatoon ED. We aim to increase physician uptake of the order set to 50% and to increase appropriate antibiotic prescription to 90%. Methods: Our project was designed following the Plan-Do-Study-Act method. Our primary outcome was to measure the rate of appropriate antibiotic prescription when managing AECOPD patients. Our secondary outcome was to measure physician uptake of the order set. We believed that a standardized order set would optimize patient care. We hypothesized that 80% of AECOPD patients would be managed with antibiotics appropriately and that 25% of emergency physicians would utilize the order set. A chart review was conducted examining AECOPD patient management in Saskatoon ED. The study period included the 6 months following the implementation of the order set. Our inclusion criteria were patients diagnosed with AECOPD and managed in the ED. Our exclusion criteria were patients currently prescribed antibiotics or patients requiring inpatient admission. A convenience sample of 125 charts was selected for review, enabling an accurate representation of order set utilization and antibiotic usage. A secondary reviewer abstracted a random 15% sample of the charts to ensure validity of the data. Results: Our results showed that, during our study period, none of the AECOPD patients were managed with the order set. Of the patients receiving antibiotic therapy, only 32 of the 53 (60.38%) met the Anthonisen criteria and were appropriately prescribed antibiotics. Of the patients not given antibiotics, 15 of the 42 (35.71%) met the Anthonisen criteria and should have been managed with antibiotics. These results refuted both of our hypotheses. Conclusion: As COPD is one of the leading causes of morbidity and mortality in Canada, proper management is crucial. Our results state that uptake of the order set is low and that antibiotic utilization is not optimized. These results demonstrate the need to modify and promote the current order set. We believe that by encouraging the use of the order set and streamlining the management guidelines, we can increase physician uptake. This will subsequently increase appropriate antibiotic prescription and improve AECOPD patient care. A second identical chart review for 2017 has been completed. Data analysis will be finalized prior to the conference.

Success of a Colorectal Surgical Site Infection Prevention Bundle in a Multihospital System.

Surgical site infections, readmissions, and extended hospital stays are risks for patients undergoing colon surgeries. These procedures are often urgent, and patients may have multiple comorbidities. Preoperative and postoperative steps to reduce the number of complications provide substantial benefits clinically, economically, and psychologically. We used a multidisciplinary, collaborative approach to identify best practices when developing and implementing a standardized approach to the management of patients undergoing elective colon surgery. Interventions included nutrition supplements and preoperative and postoperative protocols. Our management project showed a 74.6% reduction in readmissions, a 22.73% reduction in length of stay, an 85% reduction in colon surgical site infections measured by incidence (84.5% reduction) and standard infection ratio (54.55% reduction), and 95% compliance with the use of both order sets during an 18-month period. Applying standardized order sets for assessing and addressing patient comorbidities before colorectal surgery can result in a substantial and sustainable reduction in complications.

Impact of a Nurse-Driven Opioid Titration Protocol on Appropriateness of Orders at End of Life (S710)

•Determine appropriate symptom management for inpatients at end of life.•Describe the impact of a standardized symptom management protocol on the appropriateness of orders at end of life. A nursing-driven opioid titration protocol and symptom management order set were developed at a community teaching hospital to be used to manage pain and dyspnea in patients at the end of life. The aim of this study is to evaluate the impact of the opioid titration protocol and order set on symptom management at the end of life. This is a retrospective study in which medical records of adult patients that received morphine infusions for end of life were analyzed. An order set and nursing-driven opioid titration protocol were implemented in August 2016 following extensive nursing education. Medical records were reviewed during 3-month periods pre and post implementation (PRE-group and POST-group) for the presence of supportive care management and appropriate opioid infusion orders. Morphine orders were considered appropriate if they included an as-needed bolus dose with an objective indication, and specific infusion titration instructions. There were 32 patients included in the PRE-group and 37 patients in the POST-group. In the PRE-group, 6 of 32 orders (18.8%) were considered appropriate compared to 35 of 37 orders in the POST-group (94.6%, p<0.0001 for comparison). Of the orders considered inappropriate in the PRE-group, 12 included a sedation score as a target, 7 listed “comfort” as a target, and 7 did not state any goal or target. Morphine infusion orders in the POST-group were significantly more likely to include a maximum dose (p=0.041) and an initial bolus dose (p<0.0001) compared to the PRE-group. In addition, patients in the POST-group were significantly more likely to receive additional medications to manage other end of life symptoms (p<0.05 for all). In this study, implementation of a standardized opioid titration protocol and symptom management order set led to an improvement in the management of symptoms such as pain and dyspnea at end of life.

Improving the Quality of Inpatient Bowel Preparation for Colonoscopies.

Hospitalized patients completing bowel preparation for colonoscopy typically have preparations of poorer quality when compared to outpatient populations. Our study aimed to evaluate the effectiveness of a performance improvement program in improving colonoscopy preparation for an inpatient population. We identified a cohort of adult patients (n=641) undergoing an inpatient colonoscopy during a 12-month period at an academic medical center and compared a multifactor intervention group to a historical baseline group. During this 12-month period, a performance improvement program including use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations in the inpatient setting was made available to the cohort group. The primary outcome was quality of bowel preparation for colonoscopy as rated by endoscopists using the modified Aronchick scale. When comparing the baseline group to the intervention group, the rate of acceptable preparations, characterized as excellent, good, or adequate, increased from 69.9 to 78.9%, which was statistically significant (p<0.001). A comprehensive performance improvement program improved the quality of colonoscopy preparation among inpatients. The use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations are recommended in the inpatient setting for an effective bowel preparation.