Standardized Order Sets Research Articles

Effects of a Revision to the Standard Admission Order Set on Laxative Prescribing for Opioid-Induced Constipation

Purpose: Opioid-induced constipation (OIC) is highly prevalent in patients with cancer-related pain on opioid analgesics and has negative consequences on physical and psychological well-being and quality of life. Oncology clinical practice guidelines recommend the use of osmotic and stimulant laxatives for the prevention and management of opioid-induced constipation, not stool softeners such as docusate sodium. Prescribing practices continue to fall behind these recommendations. Methods: This quality improvement project revised the laxative options available in the standard admission order set in the electronic medical record. Specifically, docusate sodium was removed and replaced with senna and polyethylene glycol 3350. Results: A total of 2,742 patient admissions preintervention were compared to 2,752 admissions postintervention. The number of orders for docusate (p < .001) and docusate-senna (p = .002) orders decreased significantly after the intervention, in addition to the number of OIC diagnoses (p < .001). However, the number of orders for polyethylene glycol (p = .559), senna (p = .582), other laxatives (p = .245), or functional bowel disorder medications (p = .533) did not change significantly. No significant differences were observed in the frequency of laxative orders placed within 24 hours of an opioid order, number of laxatives prescribed at discharge, admissions related to bowel-related complications, or length of stay. Conclusions: Interventions utilizing the electronic medical record can facilitate evidence-based management of OIC. Development of clinical practice guidelines and tailoring these interventions further is needed to adapt this approach at other institutions and sustain practice change.

Yield of Echocardiography with Bubble Studies Among Acute Ischemic Stroke Patients.

Background: Transthoracic (TTE) and transesophageal (TEE) echocardiographic studies with agitated saline, also known as "bubble studies" (BSs), are used to diagnose patent foramen ovales (PFOs) in cryptogenic strokes (CSs). Guidelines limit PFO closure recommendations to CS patients ≤ 60 but BSs are often performed as part of standard order sets, leading to inappropriate studies in older patients with already-established stroke etiologies. Methods: This retrospective single-center study included acute ischemic stroke patients between January 2021 and June 2022 and assessed the stroke etiology and number of the echocardiographic studies performed. Results: A total of 663 patients were admitted during this period with 413 (62.3%) classified as non-CS. Overall, 390 (58.8%) TTE and 40 (6.0%) TEE with BSs were conducted. Of that, non-CS patients received 252 TTE and 17 TEE with BSs. PFOs were diagnosed in 36 CS and 18 non-CS patients and 14 of the 15 PFO closures were performed in the CS patients for primary stroke prevention. The one closure in the non-CS patient was performed in conjunction with the open excision of a mitral valve mass. Conclusions: Therefore, the majority of the BSs performed in non-CS patients yielded no change in management. Our study identifies a large volume of diagnostic studies that are not supported by current clinical guidelines and instead, may contribute to healthcare waste. A new institutional protocol should be established to improve operational efficiency and reduce the downstream implications of diagnostic overuse in ischemic stroke care.

Outcomes of Hospitalized Patients With Sepsis Before and After Implementation of a Sepsis Care Improvement Initiative at a Community Hospital.

Purpose: Prompt treatment of sepsis and septic shock is critical as delays increase mortality risk. Various tools, such as electronic alerts, standardized order sets, and rapid response teams, are used to expedite sepsis bundled care, yet their individual effects on outcomes and antimicrobial timing are unclear. This study evaluated the impact of an Inpatient Code Sepsis protocol, featuring an overhead page and order set, on mortality in hospitalized patients with sepsis and septic shock. Methods: A retrospective cohort study was conducted at a 371-bed hospital from July 1, 2020, to July 31, 2023. Hospitalized adults (≥18 years) diagnosed with sepsis and septic shock before and after the Inpatient Code Sepsis protocol implementation were included. The primary outcome was 30-day all-cause mortality; secondary outcomes were hospital length of stay, 30-day readmission, and time to antibiotic administration. Patients were excluded if they were identified for sepsis without infection, had sepsis due to non-bacterial causes, lost to follow-up within 30 days of admission, received empiric antibiotics in an emergency department or outside hospital, or were missing antibiotic administration time. Results: A total of 138 patients were included in the analysis. Mortality within 30 days did not significantly differ preprotocol and postprotocol (p = 0.381). However, a significant reduction in time to antibiotic administration was noted postimplementation (p < 0.05). Hospital length of stay and 30-day readmission showed no significant changes. Conclusion: The Inpatient Code Sepsis protocol did not impact 30-day mortality but did improve the time to antibiotic administration.

Impact of patient safety bundle and team-based training on obstetric hypertensive emergencies.

Hypertensive disorders of pregnancy, defined as chronic (<20 weeks) or gestational (>20 weeks), are a leading cause of pregnancy related mortality in the United States1. Hypertensive disorders of pregnancy had increased prevalence from 13.3% to 15.9% among delivery hospitalizations between 2017 and 20191. The objective of this project was to increase the percentage of obstetric patients with hypertensive emergency who received evidence-based treatment within 60 minutes at a single academic center. Study Design Data was collected before and after the implementation of a hypertension patient safety bundle. Each occurrence of hypertensive emergency was assessed to determine if evidence-based intervention occurred within 60 minutes, and if the intervention steps were successfully followed. Bundle implementation included creation of a standardized order set and interdisciplinary team-based simulations. Baseline data compared 250 pre-implementation to 250 post-implementation interventions. The quality improvement interdisciplinary team reevaluated data monthly and incorporated process improvements through Plan Do Study Act (PDSA) cycles to achieve a goal of 80% of patients receiving evidence-based treatment within 60 minutes. Results A total of 1025 hypertensive emergencies were identified in 543 patients. Prior to the protocol on average 64% of patients received evidence-based, timely treatment. After implementation of this bundle and several PDSA cycles, we sustained >80% of patients receiving target treatment for the final six months of data collection. The leading deviations were "no medication given" and "incorrect medication". Improvements in order set accessibility and repeated team-based trainings led to improvement in these identified protocol deviations. Conclusion Implementation of a patient safety bundle led to a sustained 6 month improvement in the percentage of patients receiving appropriate treatment of obstetric hypertensive emergency within 60 minutes of the first severe hypertension measurement. Processes that may have helped achieve this outcome included standardized order sets, team awareness of institutional data and team-based simulations.

Coronavirus Disease 2019 (COVID-19) Vaccination Status Prior to Delivery and Administration Among Hospitalized Obstetric Patients

Background This chart review aimed to assess the COVID-19 vaccination status of pregnant patients prior to hospitalization for delivery and vaccine administration while hospitalized postpartum. Methods This was a retrospective chart review of pregnant patients admitted for delivery at WakeMed Hospital during a six-month period who were offered COVID-19 vaccination immediately following delivery. We analyzed demographic characteristics by vaccination status prior to admission, during hospitalization, and at discharge. ANOVA, chi-squared, and multinomial logistic regression analyses were performed. Results Data analysis was performed on 1,476 obstetric patients admitted for delivery, of which 260 (17.6%) were vaccinated prior to admission. Of the 1,216 unvaccinated postpartum patients, 257 (21.1%) received a vaccine dose. Among our population, for every year increase in age, the odds of being vaccinated before admission and receiving vaccination while hospitalized postpartum were higher than those of remaining unvaccinated. The odds of being vaccinated before admission versus remaining unvaccinated at discharge were lower for Black patients compared to White patients. The odds of receiving vaccination during hospitalization were higher for Asian and Hispanic/ Latino patients compared to White patients. The odds of being vaccinated prior to admission versus remaining unvaccinated at discharge were higher for those with private insurance compared to those with public insurance. Limitations At the time of our intervention, we did not collect data on COVID-19 infection status of the patient at the time of admission. Additionally, vaccination counseling and administration had not been added to standardized order sets, thus variations in counseling by providers may have impacted patient acceptance. Conclusions Compared to patients who remained unvaccinated following discharge, patients vaccinated prior to admission were more likely to be older with private insurance, and less likely to be Black, while patients vaccinated during hospitalization once postpartum were more likely to be older and either Asian or Hispanic/Latino.

Standardized order set for the management of infective endocarditis.

Infective endocarditis (IE) is a potentially life-threatening infection that affects the inner lining of the heart, particularly the heart valves. Patients with preexisting heart conditions, damaged heart valves, or a history of intravenous drug use are at a higher risk of acquiring IE. A rural acute care facility reported that 68.75% of patients who had a methicillin-resistant Staphylococcus aureus infection were diagnosed with IE. Review of medical records showed that 65% of patients with IE did not have antibiotic start/stop dates and 51% were discharged before the 6-week completion date. The quality-improvement project used a pretest and posttest design. An order set was created based on evidence-based guidelines to assist with the management of patients with IE. The order set included administering intravenous (IV) antibiotics for a minimum of 6 weeks for patients with IE and included a set of recommended weekly follow-up laboratory tests. An order set with the standard of care and reminders in the electronic health records (EHRs) were implemented for the management of IE, including antibiotic start and stop dates and weekly follow-up labs. After implementation, there was an improvement in the completion of IV antibiotics, documentation of start/stop dates for IV antibiotics, and completion of recommended laboratory tests. An order set with the standard of care and reminders in the EHR reduced variations in care and improved patient outcomes by ensuring that all providers were following the same evidence-based guidelines for the management of IE.

Improving Inpatient Colonoscopy Bowel Preparation: A Successful Quality Improvement Project.

Inadequate inpatient bowel preparation can lead to repeat procedures, prolonged hospital stays, and increased financial burden. In this quality improvement project, the authors developed an electronic medical record (EMR)-based order set with precise instructions and anticipatory guidance for inpatient bowel preparation before colonoscopy. The current study is a nonrandomized intervention study. The authors compared 2 groups: an intervention group using a newly developed, consensus-based, standardized EMR bowel preparation order set and a control group using previously existing EMR bowel preparation orders. Bowel preparation outcomes were followed over the course of 16 months. The aim was to improve inpatient colonoscopy bowel preparation, as evaluated by the Boston Bowel Preparation Scale, procedure delays, and length of hospital stay. We additionally evaluated the groups' demographics and patient-level factors. A total of 459 inpatient colonoscopies were evaluated over a 16-month period. The intervention group consisted of 227 inpatient colonoscopies, while the control group consisted of 232. The intervention group showed superior Boston Bowel Preparation Scale score and decreased length of hospital stay. The number of adequate bowel preparations increased in the intervention group when compared to the control group from 77% to 86%. The creation of an EMR-based order set is a low-cost and sustainable action that can be easily implemented throughout a hospital system.

Reducing severe maternal morbidity for birthing persons with severe hypertension through a statewide quality improvement initiative

BackgroundHypertensive disorders of pregnancy are a leading preventable cause of severe maternal morbidity and maternal mortality worldwide. ObjectiveTo assess the improvement in hospital care processes and patient outcomes associated with hypertensive disorders of pregnancy after introduction of a statewide Severe Maternal Hypertension quality improvement initiative. Study DesignA prospective cohort design comparing outcomes before and after introduction of the Illinois Perinatal Quality Collaborative statewide hypertension quality improvement initiative among 108 hospitals across Illinois. Participating hospitals recorded data for all cases of new-onset severe hypertension (>160 systolic or >110 diastolic) during pregnancy through 6 weeks postpartum from May 2016 to December 2017. Introduction of the statewide quality improvement initiative included implementation of severe maternal hypertension protocols, standardized patient education and discharge planning, rapid access to medications and standardized treatment order sets, and provider and nurse education. The main outcome measure was the reduction of severe maternal morbidity for pregnant/postpartum patients with severe hypertension. Key process measures include time-to-treatment of severe hypertension, frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow up. ResultsData were reported for 8,073 cases of severe maternal hypertension. The frequency of patients with new-onset severe hypertension treated within 60 minutes increased from 41% baseline to 87% (p<0.001) at the end of the initiative. The initiative was associated with increased proportion of patients receiving preeclampsia education at discharge (41% to 89%, p<0.001), scheduling follow-up appointments within 10 days of discharge (68% to 83%, p<0.001), and having a care team debrief after severe hypertension was diagnosed (17% to 59%, p<0.001). Conversely, severe maternal morbidity was reduced from 11.5% baseline to 8.4% (p<0.002) at the end of the study period. Illinois hospitals were able to achieve time-to-treatment goal regardless of hospital characteristics including geography, birth volume, and patient mix. ConclusionsIntroduction of a statewide quality improvement effort was associated with improved time-to-treatment of severe hypertension, as well as increased frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow up scheduled at discharge, and reduced severe maternal morbidity.

Assessing for differences in opioid administration during inpatient end-of-life care for patients with limited English proficiency.

Patients with limited English proficiency (LEP) may have worse health outcomes and differences in processes of care. Language status may particularly affect situations that depend on communication, such as symptom management or end-of-life (EOL) care. The objective of this study was to assess whether opioid prescribing and administration differs by English proficiency (EP) status among hospitalized patients receiving EOL care. This single-center retrospective study identified all adult patients receiving "comfort care" on the general medicine service from January 2013 to September 2021. We assessed for differences in the quantity of opioids administered (measured by oral morphine equivalents [OME]) by patient LEP status using multivariable linear regression, controlling for other patient and medical factors. We identified 2652 patients receiving comfort care at our institution during the time period, of whom 1813 (68%) died during the hospitalization. There were no significant differences by LEP status in terms of mean OME per day (LEP received 30.8 fewer OME compared to EP, p = .91) or in the final 24 h before discharge (LEP received 61.7 more OME compared to EP, p = .80). LEP was not associated with differences in the amount of opioids received for patients whose EOL management involved standardized order sets for symptom management at our hospital.

SANE Knowledge of HIV nPEP: Identifying Deficits.

Discussing the risk of exposure to human immunodeficiency virus (HIV) and assessing the need for HIV nonoccupational postexposure prophylaxis (nPEP) are essential components of providing care to victims of sexual assault. Current literature on the topic of HIV nPEP for victims of sexual assault surrounds risk of exposure, patient adherence, access and barriers, current practices, and standardized order sets. A significant gap in the literature concerning sexual assault nurse examiner (SANE) knowledge of HIV infection and HIV nPEP evidence-based practice guidelines was identified. The purpose of this research was to assess SANE knowledge surrounding HIV infection and evidence-based practice recommendations for HIV nPEP use in victims of sexual assault. A 20-item knowledge survey was created using QuestionPro. The aim of the survey was to measure SANE knowledge of HIV transmission, pathophysiology, nPEP medications, and evidence-based practice guidelines for victims of sexual assault. In addition to the 20 knowledge items, 15 demographic questions were included. The study design was cross-sectional, descriptive, and comparative. A total of 411 participants completed the survey. Data analysis revealed knowledge deficits for topics such as risk of HIV transmission, nPEP indications, laboratory testing, drug regimens, nPEP timing, mechanism of action, medication contraindications, and adherence issues. The overall mean score for the knowledge survey among all participants was 13.36 out of 20 (66.8%). A knowledge deficit among SANEs surrounding HIV infection and HIV nPEP evidence-based practice guidelines for patients who experienced sexual assault was identified. The study highlights the need for additional education for specialized nurses who are providing care to victims of sexual assault.

Impact of Surgical Resident Education and EMR Standardization in Enhancing ERAS Adherence and Outcomes in Colorectal Surgery

Our study aimed at investigating the degree of adherence to ERAS pathway at our institution and to evaluate the role of providing resident education and a standardized EMR order set in improving adherence and patient surgical outcomes. The study is prospective in nature and consists of two phases with a preintervention cohort to assess adherence to ERAS protocol and a postintervention cohort to evaluate improvement in adherence and patient outcomes. Adherence with the ERAS protocol was assessed across preoperative, intraoperative, and postoperative phases. The study took place at MedStar Franklin Square Medical Center in Baltimore, Maryland, involving inpatient care at a surgical ward. During the preintervention phase, patients undergoing elective colorectal surgery were identified over 6 months (N = 77), and their adherence to the ERAS protocol was assessed. Following the intervention of surgical resident and faculty education sessions on the ERAS protocol and the implementation of a standardized order set in the Electronic Medical Record, a postintervention cohort (N = 54) was selected for comparison over another 6 months. Among 77 patients who underwent elective colorectal surgery, the adherence rate to ERAS protocol was notably below 80% for most elements of the postoperative phase. When pre- and postintervention cohorts were compared, there were no significant differences in the baseline demographics and perioperative variables. After the implementation of our intervention, adherence rates were significantly improved in 7 out of 8 ERAS protocol elements of the postintervention phase. Among primary outcome measures, readmission rate (24.7% vs.9.4%; p = 0.022) and length of stay (7.3 ± 4.5 vs. 5.5 ± 3.6; p = 0.014) were significantly lower in the postintervention cohort. Although the rate of postoperative complications did not decrease significantly (33.8% vs. 31.5%; p = 0.284), there were fewer patients with postoperative ileus and surgical site infections. Outcomes were evaluated based on an 8-point score of postoperative ERAS elements. A significant decrease in mean length of stay and readmission rates is observed when at least 5 elements are completed, emphasizing the ERAS pathway's importance as a complementary bundle. Our study highlights the impact of resident education and electronic medical record standardization on ERAS adherence in colorectal surgery. This multidisciplinary approach improves adherence, reduces hospital stay, and enhances communication among healthcare providers for better patient outcomes.

Euglycemic Diabetic Ketoacidosis: Experience with 44 Patients and Comparison to Hyperglycemic Diabetic Ketoacidosis.

Euglycemic diabetic ketoacidosis (DKA) (glucose <250milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period. This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t-tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05. We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P < 0.05) and lower initial glucose (195 vs 561mg/dL, P < 0.001) and potassium (4.3 vs 5.3mmol/L, P < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P = 0.003. Mean times to first bicarbonate >18mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P = 0.02); incidence of hypokalemia (<3.3mmol/L) was 27.3 vs 19.1% (P = 0.23). Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia.

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.

Patterns and Perceptions of Standard Order Set Use Among Physicians Working Within a Multihospital System: Mixed Methods Study.

Electronic standard order sets automate the ordering of specific treatment, testing, and investigative protocols by physicians. These tools may help reduce unwarranted clinical variation and improve health care efficiency. Despite their routine implementation within electronic medical records (EMRs), little is understood about how they are used and what factors influence their adoption in practice. This study aims to (1) describe the patterns of use of standard order sets implemented in a widely used EMR (PowerPlans and Cerner Millennium) within a multihospital digital health care system; (2) explore the experiences and perceptions of implementers and users regarding the factors contributing to the use of these standard order sets; and (3) map these findings to the Capability, Opportunity, and Motivation Behavior (COM-B) model of behavior change to assist those planning to develop, improve, implement, and iterate the use of standard order sets in hospital settings. Quantitative data on standard order set usage were captured from 5 hospitals over 5-month intervals for 3 years (2019, 2020, and 2021). Qualitative data, comprising unstructured and semistructured interviews (n=15), were collected and analyzed using a reflexive thematic approach. Interview themes were then mapped to a theory-informed model of behavior change (COM-B) to identify determinants of standard order set usage in routine clinical practice. The COM-B model is an evidence-based, multicomponent framework that posits that human actions result from multiple contextual influences, which can be categorized across 3 dimensions: capability, opportunity, and motivation, all of which intersect. The total count of standard order set usage across the health system during the 2019 observation period was 267,253, increasing to 293,950 in 2020 and 335,066 in 2021. There was a notable shift toward using specialty order sets that received upgrades during the study period. Four emergent themes related to order set use were derived from clinician interviews: (1) Knowledge and Skills; (2) Perceptions; (3) Technical Dependencies; and (4) Unintended Consequences, all of which were mapped to the COM-B model. Findings indicate a user preference for customized order sets that respond to local context and user experience. The study findings suggest that ongoing investment in the development and functionality of specialty order sets has the potential to enhance usage as these sets continue to be customized in response to local context and user experience. Sustained and continuous uptake of appropriate Computerized Provider Order Entry use may require implementation strategies that address the capability, opportunity, and motivational influencers of behavior.

THU293 Enhancement Of Best Practices In Diabetic Ketoacidosis Management Using Standardized Order-sets vs Individual Practitioner Orders

Abstract Disclosure: C. Yim: None. Q. Li: None. T.G. Arnason: None. Diabetic ketoacidosis (DKA) is a hyperglycemic emergency occurring in diabetics due to insulin deficiency. This results in urinary losses of water and electrolytes (sodium, potassium, chloride) and ultimately extracellular fluid volume depletion. Hallmark features of DKA include ketoacidosis, arterial pH &amp;lt; 7.3, bicarbonate &amp;lt;15 mmol/L and an anion gap of &amp;gt;12 mmol/L. The 2018 Diabetes Canada (DC) guidelines outline the key steps of DKA management including fluid resuscitation, resolution of ketoacidosis, correction of electrolytes and management of precipitating factors. Its detailed algorithm identifies three pillars to DKA treatment: IV fluids, serum potassium and acidosis. A 2016 DKA outcome audit at the Royal University Hospital (RUH) in Saskatoon identified that practitioners diverged considerably from (2013) Canadian Diabetes Association guidelines. Subsequently, two standardized preprinted DKA order sets were developed incorporating the 2018 DC recommendations for i) INITIAL and ii) MAINTENANCE DKA management. Their rollout overlapped with annual academic half day sessions on DKA management for postgraduate year 1 residents in internal medicine. These order-sets were initially implemented at RUH in November 2018 and subsequently adopted by some practitioners at St. Paul’s Hospital (SPH). To ensure the order-sets were promoting improved outcomes and adhering to best practices, a retrospective chart review was conducted of all adult DKA admissions at RUH and SPH from Nov. 13, 2018 to December 31, 2020. In total, 279 hospital admissions were reviewed: 99 used practitioners’ own orders, 115 used both initial and maintenance order-sets, 26 used only the initial order-set and 38 used only the maintenance order-set. Use of the INITIAL order set significantly improved compliance (p &amp;lt; 0.0001) with DC 2018 guidelines for recommended insulin dose and timing, fluid resuscitation as well as potassium, sodium and dextrose replacement. Use of the MAINTENANCE order set consistently enhanced outcomes for intravenous fluid selection, subcutaneous insulin overlap, and ensuring a closed anion gap at transition (p &amp;lt; 0.0001). Additionally, the chart review revealed that there were hospital differences for uptake of order sets and compliance to DC 2018 guidelines. There was a significant uptake of order sets at RUH versus SPH (p &amp;lt; 0.0001). RUH consistently met outcomes for appropriate insulin dosing, potassium and dextrose replacement (p &amp;lt; 0.0001). RUH also consistently overlapped IV and SC insulin and ensured a closed insulin gap. The anion gap remained consistently closed post-transition at RUH versus SPH (p = 0.035). These results suggest that utilization of a DKA order set does significantly promote adherence to key best practices outlined in the DC 2018 guidelines. Presentation: Thursday, June 15, 2023

Standardized Order Sets Do Not Eliminate Racial or Ethnic Inequities in Postpartum Pain Management.

To quantify the extent to which a standardized pain management order set reduced racial and ethnic inequities in post-cesarean pain evaluation and management. We conducted a retrospective cohort study to quantify racial and ethnic differences in pain evaluation and management before (July 2014-June 2016) and after implementation of a standardized post-cesarean order set (March 2017-February 2018). Electronic medical records were queried for pain scores >7/10, number of pain assessments, and opioid, nonsteroidal anti-inflammatory drug (NSAID), and acetaminophen doses. Outcomes were grouped into 0 to <24 and 24-48 h postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black [NHB], non-Hispanic White [NHW], Asian, and other), as documented in the electronic health record. Analyses included logistic regression for the categorical outcome of pain score >7 (severe pain), and linear regression, with propensity score adjustment. Main effect and interaction terms were used to calculate the difference-in-difference in pain process and outcome measures between the baseline and follow-up periods. After order set implementation (N=888), severe pain remained more common among NHB patients (% pain scores >7 NHW vs. NHB 0 to <24 h: 22% vs. 33%, p=0.003; 24-48 h: 26% vs. 40%, p<0.001). Among all patients, pain management processes changed after implementation of the order set, with overall fewer assessments, less Opioids, and more nonopioid analgesics. However, racial and ethnic inequities in a number of assessments and in treatment were unchanged (all p for interaction >0.05), with the exception of a modest increase in NSAID doses 24-48 h postpartum for Hispanic patients. A standardized pain management order set reduced overall postpartum opioid use, but did not reduce racial and ethnic disparities in pain evaluation and management. Future work should investigate racial equity-focused education and interventions designed to eliminate disparities in pain management.

83 Success of Amoxicillin Oral Challenges in Children at Low Risk of Allergy Requiring Antibiotic in the Emergency Department

Abstract Background Up to 10% of children are labelled as penicillin allergic, requiring the use of suboptimal antibiotics as an alternative. In these children, a low-risk oral challenge with amoxicillin can be done to evaluate the accuracy of this allergy. An oral challenge pre-written order was implemented in our institution’s emergency department (ED). Objectives The aim of this study was to assess the success of the amoxicillin oral challenges in children labelled penicillin allergic in the ED. Design/Methods This is an ongoing prospective observational study conducted at a tertiary care paediatric hospital. Children considered at low risk of penicillin allergy (https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/Medicaments/Outil_aide-decision_allergies-EN_VF.pdf) and requiring amoxicillin according to the ED physician were prescribed an amoxicillin challenge according to a pre-written order set. In the absence of a reaction, patients were discharged with an amoxicillin prescription. Parents were contacted one month after the challenge to assess for late-onset reactions. Results Since June 2021, 70 children (24 female) underwent an amoxicillin challenge in the ED (Figure 1). The patients’ median age was 1 yo (6 months–12 yo). The most frequent discharge diagnoses in the ED were otitis media (65%) and pneumonia (24%). The challenge was successful in the ED for 69/70 (99%) patients. Sixty-two (89%) patients were successfully contacted for a follow-up phone call. Among them, 55/62 (89%) did not present any reaction. In total, 7/62 (11%) of the children had a reported reaction, one (1%) child had an immediate reaction to the challenge in the ED, while 6/62 (10%) had a rash appearing 1 to 61 days after the first dose of antibiotics. No severe reactions were reported by the parents after discharge from the ED. A correlation between the amoxicillin administration and the delayed reaction was considered less likely for 3/6 patients because of the later onset of symptoms (28-61 days). The three other patients were considered not to have a penicillin allergy after formal assessment at the allergy clinic. Conclusion Using a standardized pre-written order set for an amoxicillin challenge in the ED allowed 99% of participating children to be discharged safely with an amoxicillin prescription. Despite 10% presenting a rash after discharge, none were considered to have a late-onset reaction. This removed safely and rapidly the label of “penicillin allergy” from those paediatric ED patients, allowing optimal first-line antibiotics. It also eliminates the need for a consultation with an allergist in the majority of patients.

The Shieh Score as a Risk Assessment Instrument for Reducing Hospital-Acquired Pressure Injuries: A Prospective Cohort Study.

The purpose of this study was to evaluate the Shieh Score's effectiveness in decreasing the rate of hospital-acquired pressure injuries when combined with an early warning notification system and standard order set of preventative measures. This was a prospective cohort study. This target population was nonpregnant, adult, hospitalized patients on inpatient and observation status at a tertiary hospital (Kaiser Permanente, Baldwin Park, California) during the 2020 year of the COVID-19 pandemic. A new, risk assessment instrument, the Shieh Score, was developed in 2019 to predict hospitalized patients at high risk for pressure injuries. Data collection occurred between January 21, 2020, and December 31, 2020. When a hospital patient met the high-risk criteria for the Shieh Score, a provider-ordered pink-colored sheet of paper titled "Skin at Risk" was hung at the head of the bed and a standard order set of pressure injury preventative measures was implemented by nursing staff. Implementation of the program (Shieh Score, early warning system, and standard order set for preventive interventions) resulted in a 38% reduction in the annual hospital-acquired pressure injury rate from a mean incidence rate of 1.03 to 0.64 hospital-acquired pressure injuries per 1000 patient-days measured for the year 2020. The Shieh Score is a pressure injury risk assessment instrument, which effectively identifies patients at high risk for hospital-acquired pressure injuries and decreases the hospital-acquired pressure injury rate when combined with an early warning notification system and standard order set.

Safely Reducing Unnecessary Radiographs in Suspected Pediatric Musculoskeletal Injuries: A Multidisciplinary Developed Algorithm.

While radiographs are a critical component of diagnosing musculoskeletal (MSK) injuries, they are associated with radiation exposure, patient discomfort, and financial costs. Our study initiative was to develop a system to diagnose pediatric MSK injuries efficiently while minimizing unnecessary radiographs. This was a quality improvement trial performed prospectively at a single level one trauma center. A multidisciplinary team with leaders from pediatric orthopedics, trauma surgery, emergency medicine, and radiology created an algorithm delineating which x-rays should be obtained for pediatric patients presenting with MSK injuries. The intervention was performed in the following 3 stages: stage 1: retrospective validation of the algorithm, stage 2: implementation of the algorithm, and stage 3: sustainability evaluation. Outcomes measured included number of extra radiographs per pediatric patient and any missed injuries. In stage 1, 295 patients presented to the pediatric emergency department with MSK injuries. A total of 2148 radiographs were obtained, with 801 not indicated per the protocol, for an average of 2.75 unnecessary radiographs per patient. No injuries would have been missed using the protocol. In stage 2, 472 patients had 2393 radiographs with 339 not indicated per protocol, averaging 0.72 unnecessary radiographs per patient, a significant reduction from stage 1 (P < 0.001). There were no missed injuries identified on follow-up. In stage 3, improvement was sustained for the subsequent 8 months with an average of 0.34 unnecessary radiographs per patient (P < 0.05). Sustained reduction of unnecessary radiation to pediatric patients with suspected MSK injuries was accomplished through the development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach, widespread education of pediatric providers, and standardized order sets improved buy-in and is generalizable to other institutions.Level of Evidence: III.

Therapy plans for therapeutic apheresis in Epic HealthLink.

A common required duty of pathology resident physicians while rotating on transfusion medicine is the medical oversight of the therapeutic apheresis service. A task often performed on this clinical medicine service is formulating and writing orders for therapeutic apheresis procedures. The EpicCare tool called the therapy plan provides unique advantages over a standard electronic order set for therapeutic apheresis. Transfusion medicine physicians, apheresis nurses, pharmacists, and information technology professionals collaborated to create therapy plans for three therapeutic apheresis procedures: plasmapheresis, red cell exchange, and photopheresis. Therapy plans were implemented and have been well-received for several years. Over a six-year time period, a total of 613 therapy plans were created and signed. We speculate that this implementation may have increased both physician efficiency and patient safety. This article reports our experience using therapy plans in EpicCare in order to raise awareness of this tool and to serve as an encouragement for wider adoption.