LO93: Implementation of sepsis order sets to decrease the time to antibiotics in the emergency department: a quality improvement initiative

Background: Sepsis is a life-threatening syndrome, and delays to appropriate antibiotic therapy increases mortality. Order sets have shown decrease in time to antibiotics in pneumonia, and in sepsis, the implementation of order sets resulted in more intravenous fluids, appropriate initial antibiotics and lower mortality. Aim Statement: The goal was to create an order set for an approach to septic patients, to improve sepsis management. We sought to improve time from triage to first antibiotics, by 15 minutes, for Emergency Department (ED) patients with sepsis in three months after implementation compared to three months before. Measures & Design: We used a literature review, as well as comparison to existing order sets at other EDs to design our initial order set. We underwent multiple revisions based on stakeholder feedback. We educated physician and nursing teams about the order sets, although use was ultimately at physician discretion. We implemented the order set on April 9, 2017. After three months, an electronic retrospective chart review identified patients with a final sepsis diagnosis admitted to the critical care unit. For each patient, we captured triage time using the electronic record, and time to antibiotics from when the antibiotic was taken out of the medication cart. Finally, utilization of order sets was checked via manual chart audit. Evaluation/Results: A run chart did not demonstrate any shifts or trends suggesting a change after implementation. Median time to antibiotics in minutes, 3 months prior (n = 45) and post (n = 55) intervention, increased from 245 to 340 minutes, although the range was very large. Chart audits demonstrated clinicians were not using the order sets. There was 10% usage for 2 of the months and 0% usage the other month, post-intervention. Disucssion/Impact: There was insufficient uptake of the Sepsis Order Set by the Sunnybrook ED to result in any impact on time to antibiotics. Order sets require more than just implementation to be effective. Difficulties in implementation were due to the document not being readily available to physicians. To mediate, we have organized nursing staff to attach the order set onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.

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MP25: Implementation of pain order sets to decrease the time to analgesics in the emergency department: a quality improvement initiative in progress

CJEM ◽

10.1017/cem.2019.160 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S51

Author(s):

K. Akilan ◽

V. Teo ◽

D. Hefferon ◽

A. Verma

Keyword(s):

Emergency Department ◽

Median Time ◽

Acute Pain ◽

Renal Colic ◽

Waiting Times ◽

Retrospective Chart Review ◽

Quality Improvement Initiative ◽

Chart Audit ◽

Order Sets ◽

Order Set

Background: Acute pain is a common presentation in the Emergency Department (ED) and inadequacy in its treatment can lengthen stay. Earlier analgesia use and discharge has been associated with positive patient experiences and improved pain management. Validated ‘fast-track pathways’ to aid physician decision making in analgesic administration is associated with decreased waiting times in renal colic diagnoses. Aim Statement: Our aim was to create an order set, for an approach to patients with acute pain, to reduce median time from point of triage to analgesia. We sought to reduce median time by 15 minutes, for ED patients with renal colic in the three months after implementation as compared to three months before. Measures & Design: We used a literature review and comparison to existing order sets at other EDs to design our draft. We focused our evaluation on patients with renal colic. We underwent multiple revisions based on stakeholder feedback and educated both physician and nursing teams about the order set. The utilization, however, was at physician discretion. We implemented the order set on March 30, 2017. After three months, an electronic retrospective chart review identified patients with a final renal colic diagnosis. For each patient, we captured triage time using electronic records and time to analgesia with the medication cart. Utilization of order sets was confirmed via manual chart audit. Evaluation/Results: A run chart showed worsening times after the intervention. Median time to analgesia in minutes, 3 months prior (n = 90) and post (n = 93) intervention, increased from 228 to 310 minutes, although the range was very large. Chart audits demonstrated a considerably low uptake of the order set with a small gradual increase from 0% to 20% over the 3-month period. Discussion/Impact: There was insufficient uptake of the Acute Pain order set preventing impact on time to analgesia. Changes in occupancy likely contributed to the worsening times. There was an increase in utilization over the 3-month period and could be due to increased awareness. This demonstrates that interventions require more than implementation to be effective. Difficulties in implementation were due to the document not being readily available. We have organized the nursing staff to attach order sets onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.

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Implementation of disease-based standard order sets in emergency department of tertiary care hospital, Pakistan- a novel approach for enhancing patient care

Journal of the Pakistan Medical Association ◽

10.47391/jpma.1281 ◽

2020 ◽

pp. 1-13

Author(s):

Feroza Parveen ◽

Asif Khaliq ◽

Nadeem Ullah Khan ◽

Zainab Mazhar ◽

Aisha Akram ◽

...

Keyword(s):

Emergency Department ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Care Hospital ◽

Order Entry ◽

Post Intervention ◽

Order Processing ◽

Standard Order ◽

Order Sets ◽

Order Set

Abstract Objectives: To evaluate the efficacy of disease-based standard order sets in reducing time of order entry, order processing and medication dispensation in emergency department of a tertiary care hospital. Methods: The pilot study was conducted as part of a retrospective clinical audit using pre- and post-intervention design comprising data from July to September 2013 of the emergency department of a tertiary care hospital in Karachi. Data collected related to the reduction in medicine order entry, processing and dispensing time of eight common emergency conditions with standard order set. Subsequently, standard medication orders for the selected medical conditions were developed together with physicians of emergency and other specialties. Post-intervention data was collected and the two data sets were compared using SPSS version 23.0. Results: Mean medication order entry and processing time from the physician end improved from 67.7±22.7 seconds to 20.5±7.1 seconds. Mean order processing and medication processing and dispensing time at pharmacist end reduced from 70.0±22.4 to 20.6±8.8 seconds. The difference between pre- and post-intervention values was significant (p<0.001). Conclusion: Implementation of disease-based standard order set significantly improved efficiency. Key Words: Standard, Order sets, Emergency department, Disease, Time management. Continuous...

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Abstract TP377: Nurse Entered Stroke Order Sets Improve Emergency Department Metrics at a Comprehensive Stroke Center

Stroke ◽

10.1161/str.51.suppl_1.tp377 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Tawnae C Griffith ◽

Atul Gupta ◽

Stacey Aggabao ◽

Raeesa Dhanji ◽

Denise Gaffney ◽

...

Keyword(s):

Emergency Department ◽

Stroke Care ◽

Cardiac Monitoring ◽

Post Intervention ◽

Improvement Project ◽

Order Sets ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Contrast Ct ◽

Order Set

Introduction: The Joint Commission has established time sensitive metrics for stroke care in the Emergency Department (ED) including door to initial physician evaluation, door to lab and CT order placement, door to lab resulted and door to CT interpretation. Purpose: The purpose of this quality improvement project was to assess if nurse entered protocolized order sets for stroke patients would help to improve these metrics. Methods: A code stroke order set was initiated independently by nursing staff upon symptom recognition in the ED. The order set included CBC, electrolyte panel, BUN, creatinine, glucose, troponin, PT/INR, aPTT, non-contrast CT head, EKG, swallow screen and continuous cardiac monitoring. Data was collected for 3 months pre and post intervention. All ED nurses were trained on order set entry and their skills were validated. Data was analyzed using a T-Test. Results: 60 patient pre and 52 post-implementation were evaluated. Door to initial physician evaluation was faster (7 mins pre vs. 5 mins post; p=0.029). Door to lab order placement was faster (8 mins pre vs. 3 mins post; p=0.038). Door to CT ordered was faster (8 mins pre vs. 6 mins post; p<0.01). Door to labs resulted was faster (32 mins pre vs. 27 mins post; p=0.01). Door to CT interpretation was faster (19 mins pre vs. 18 mins post; p=0.04). Conclusion: Implementation of nurse entered order sets can improve ED metrics for door to initial physician evaluation, door to lab and CT order placement. This subsequently led to faster interpretation of the CT scan and lab results.

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Impact of order set design on urine culturing practices at an academic medical centre emergency department

BMJ Quality & Safety ◽

10.1136/bmjqs-2017-006899 ◽

2018 ◽

Vol 27 (8) ◽

pp. 587-592 ◽

Cited By ~ 14

Author(s):

Satish Munigala ◽

Ronald R Jackups ◽

Robert F Poirier ◽

Stephen Y Liang ◽

Helen Wood ◽

...

Keyword(s):

Emergency Department ◽

Urine Culture ◽

Temporal Trends ◽

Urine Test ◽

Post Intervention ◽

Order Sets ◽

Ed Visits ◽

Urine Testing ◽

Electronic Order ◽

Order Set

BackgroundUrinalysis and urine culture are commonly ordered tests in the emergency department (ED). We evaluated the impact of removal of order sets from the ‘frequently ordered test’ in the computerised physician order entry system (CPOE) on urine testing practices.MethodsWe conducted a before (1 September to 20 October 2015) and after (21 October to 30 November 2015) study of ED patients. The intervention consisted of retaining ‘urinalysis with reflex to microscopy’ as the only urine test in a highly accessible list of frequently ordered tests in the CPOE system. All other urine tests required use of additional order screens via additional mouse clicks. The frequency of urine testing before and after the intervention was compared, adjusting for temporal trends.ResultsDuring the study period, 6499 (28.2%) of 22 948 ED patients had ≥1 urine test ordered. Urine testing rates for all ED patients decreased in the post intervention period for urinalysis (291.5 pre intervention vs 278.4 per 1000 ED visits post intervention, P=0.03), urine microscopy (196.5vs179.5, P=0.001) and urine culture (54.3vs29.7, P<0.001). When adjusted for temporal trends, the daily culture rate per 1000 ED visits decreased by 46.6% (−46.6%, 95% CI −66.2% to –15.6%), but urinalysis (0.4%, 95% CI −30.1 to 44.4%), microscopy (−6.5%, 95% CI −36.0% to 36.6%) and catheterised urine culture rates (17.9%, 95% CI −16.9 to 67.4) were unchanged.ConclusionsA simple intervention of retaining only ‘urinalysis with reflex to microscopy’ and removing all other urine tests from the ‘frequently ordered’ window of the ED electronic order set decreased urine cultures ordered by 46.6% after accounting for temporal trends. Given the injudicious use of antimicrobial therapy for asymptomatic bacteriuria, findings from our study suggest that proper design of electronic order sets plays a vital role in reducing excessive ordering of urine cultures.

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Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative

Military Medicine ◽

10.1093/milmed/usaa484 ◽

2021 ◽

Author(s):

CindyLee P Neighbors ◽

Michael W Noller ◽

Michael P Avillion ◽

John W Neighbors ◽

Mark C Spaw ◽

...

Keyword(s):

Retrospective Chart Review ◽

Outcome Variable ◽

Quality Improvement Initiative ◽

New Order ◽

Opioid Prescription ◽

Medication Refill ◽

Before And After ◽

Patient Pain ◽

Prescription Rates ◽

Order Set

ABSTRACT Introduction To compare pain medication refill rates for adult septoplasty and rhinoplasty patients before and after initiating a multimodal analgesic protocol for reducing opioid prescriptions (PROP). Materials and Methods Data from 58 adult patients were retrieved by retrospective chart review (19 septoplasties and 10 rhinoplasties before initiating PROP in September 2018 and 21 septoplasties and 8 rhinoplasties after PROP). We selected consecutive septoplasties and rhinoplasties, at which time a new discharge order set was implemented. The new order set consisted of 10 oxycodone tabs (5 mg), 100 acetaminophen tabs (325 mg), and 28 celecoxib tabs (200 mg). The primary outcome variable was the number of initial opioid prescriptions and refills filled by any provider. Results Among the septoplasties, there was a 46% decrease in total morphine milligram equivalent (MME) prescribed, from a mean of 202.0 mg in the non-PROP group (95% CI, 235.4, 174.6) to 108.6 mg in the PROP group (95% CI, 135.8, 81.4), with no difference in refill rates. Among the rhinoplasties, there was a 51% decrease in total MME prescribed, from a mean of 258.8 mg in the non-PROP group (95% CI, 333.4, 184.1) to 126.6 mg in the PROP group (95% CI, 168.1, 85.0) with no difference in refill rates. Conclusions The outcomes after PROP implementation for septoplasty and rhinoplasty at our institution suggest that opioid prescription rates can be significantly decreased to manage postoperative pain, with no difference in opioid refill rates. The results also warrant further investigation into patient pain, satisfaction, provider efficiency, and healthcare costs.

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Impact of targeted bundles to reduce the nebulization time gap from prescription to administration among red triaged patients in emergency department: An quality improvement initiative

10.21203/rs.3.rs-820832/v1 ◽

2021 ◽

Author(s):

Seema Sachdeva seema sachdeva ◽

Akshay Kumar Akshay Kumar ◽

Parveen Aggarwal Parveen Aggarwal

Keyword(s):

Emergency Department ◽

Tertiary Care ◽

Signs And Symptoms ◽

Fish Bone ◽

Quality Improvement Initiative ◽

Care Hospital ◽

Analysis Model ◽

Post Intervention ◽

Targeted Interventions ◽

Administration Time

Abstract BackgroundSevere exacerbation of asthma are potentially life-threatening and therefore require prompt care and frequent management. Important elements of early treatment includes recognition of early signs and symptoms of breathing difficulty and timely prescription and administration of therapeutic agents. A subsequent delay in receiving nebulization during an acute exacerbation of asthma can leads to cardiac arrest and even death. AimTo reduce the gap in administration of nebulization from its prescription time among red triaged patients by 50% from its baseline. Setting and designThis interventional study was conducted among red triaged patients in emergency department of tertiary care hospital, India . Material and MethodsBaseline information was collected during first 4 weeks to find gap in administration of nebulization from its prescription time. Fish bone analysis and process map were laid down to analyse the situation. The intervention using targeted bundles was done via 3 PDSA (PDSA1: indenting the nebulizers, PDSA 2: training of doctors and nurses, PDSA 3; introducing equipment checklist) to reduce the gap . A run chart using time series analysis model was used to compare the pre and post intervention nebulization gap. ResultsTotal 74 patients (30 in pre- intervention, 44 in post intervention) admitted in red triaged area were observed for nebulization gap from prescription to administration. Median time for nebulization gap before intervention was 46.5 minutes which reduced to 15 minutes in post intervention phase. ConclusionThis bundles of targeted interventions was successful to reduce the nebulization gap. Key words: nebulization gap, prescription time, administration time

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Implementation of an Emergency Department Sepsis Bundle and System Redesign: A Process Improvement Initiative

CJEM ◽

10.1017/cem.2016.351 ◽

2016 ◽

Vol 19 (2) ◽

pp. 112-121 ◽

Cited By ~ 10

Author(s):

Tamara McColl ◽

Mathieu Gatien ◽

Lisa Calder ◽

Krishan Yadav ◽

Ryan Tam ◽

...

Keyword(s):

Emergency Department ◽

Tertiary Care ◽

Intervention Group ◽

Critical Conditions ◽

Absolute Difference ◽

Antibiotic Administration ◽

Post Intervention ◽

Sepsis Management ◽

Sepsis Bundle ◽

Post Intervention Group

AbstractBackgroundIn 2008–2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality.MethodsThis before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use.ResultsWe included a total of 167 and 185 patients in the pre- and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8–17.0; p=0.006). There was also a higher rate of sepsis protocol use in the post-intervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1–65.3; p<0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission.InterpretationThe implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.

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P003: Emergency department quality assurance sepsis project: why are more people dying in southwestern Ontario?

CJEM ◽

10.1017/cem.2017.205 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S78

Author(s):

A. Aguanno ◽

K. Van Aarsen ◽

M. Columbus

Keyword(s):

Emergency Department ◽

Septic Shock ◽

Retrospective Chart Review ◽

Initial Assessment ◽

Standardized Mortality Ratio ◽

Local Health ◽

Sepsis Diagnosis ◽

Mortality Ratio ◽

Time To Antibiotics ◽

Statistics Canada

Introduction: London Health Sciences Centre (LHSC) includes two academic, urban hospitals in London, Canada. The hospital-standardized mortality ratio (HSMR) is consistently higher than provincial and national averages. Unpublished data reveals that sepsis contributes the largest number of statistically unexpected deaths to LHSC’s HSMR calculation. Factors contributing to in-hospital sepsis mortality are hypothesized to include demography, emergency department (ED) flow or sepsis treatment. Methods: Retrospective chart review of patients aged >=18 years, presenting to an LHSC ED between 01 Nov 2014 and 31 Oct 2015, with >=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis (ICD-10 diagnostic codes A4xx and R65). Data were abstracted from electronic health records. Regional, provincial and national data was retrieved from CIHI and Statistics Canada. Results: Median age and sex in London and across Canada are similar (48.2 years vs 48.9 years; 48% male vs 49% male). Baseline prevalences of diabetes, hypertension, COPD and mood disorders were similar in the Local Health Integration Network and Ontario (6% vs 7%, 19% vs 19%, 3% vs 4%, and 10% vs 8%). Median “Physician Initial Assessment,” (PIA) times for sepsis patients at LHSC were faster than median Canadian PIA times for CTAS I and II patients (CTAS I: 7 min vs 11 min, CTAS II: 34 min vs 54 min), and slower for CTAS III-V patients (CTAS III: 98 min vs 79 min, CTAS IV: 99 min vs 66 min, CTAS V: 132 min vs 53 min). Median ED length of stay for admitted, high acuity (CTAS I-III) patients was 6 h at LHSC versus 10 h across Canada.Median [IQR] time to intravenous fluid resuscitation was 60.5 min [29.8-101.2] for septic shock patients and 77.0 min [36.0-127.0] for expired patients. Median [IQR] time to antibiotics was 130 min [73.0-229.0] for sepsis patients, 106 min [60.0-189.0] for severe sepsis patients, and 82 min [42.2-142] for septic shock patients. Conclusion: Excess sepsis-related mortality at LHSC is not convincingly related to patient demographics or ED flow. Gains may be made by improving time to antibiotics and IV fluids.

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Multidisciplinary Approach to Improve Utilization and Cost Savings of Multiplex Polymerase chain reaction (PCR) Respiratory Pathogen Testing in a Large Community Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.853 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S353-S354

Author(s):

Ali Hassoun ◽

Jonathan Edwards

Keyword(s):

Nasal Swab ◽

Community Hospital ◽

Clinical Information System ◽

Retrospective Chart Review ◽

Respiratory Pathogen ◽

Intervention Period ◽

Post Intervention ◽

Large Community ◽

Intervention Cost ◽

Order Sets

Abstract Background PCR technology can be used for precise detection of infectious agents and improves antibiotic stewardship through: Accelerated de-escalation of therapy Rapid identification of pathogens Detection of resistance genes. In our center, basic respiratory Panel detect 11 targets and cost $100 while Complete panel detect 31 targets and cost $230.The purpose of the study is to improve utilization of these panel testing in a large community hospital. Methods Retrospective chart review of all patients with an order for a complete or basic panel and excluding Patients discharged or deceased prior to result reporting or insufficient specimen quantity to perform. Each patient was evaluated for appropriate respiratory panel collection site and antibiotic regimen changes within 48 hours of results. The preintervention period conducted from 10/2015- 12/2015, evaluated how respiratory panels were being utilized in antibiotic decision-making. Three primary interventions were enacted: Eliminated nasal swabs as a source option for respiratory panels in the clinical information system, restricted complete panel ordering to ID physicians and Eliminated PCR ordering options from all order sets. The postintervention period conducted from 5/2016 – 8/2016, re-evaluated the utilization and costs of respiratory panels. Results 270 tests ordered preintervention (13% basic and 87% complete) and 196 postintervention (84% basic and 16% complete), nasal swab was done in 78% in preintervention vs. 8% in postintervention, action was taken in 51 vs. 44 in pre-vs. post intervention. cost in preintervention period was 57,420 in preintervention vs. 23,660 in post intervension. No difference between ID vs. non-ID specialist in utilization of PCR. Conclusion Nasal swab collections for PCR decreased post-intervention from 78% to 8%. Appropriate sources for PCR specimen, such as sputum, were utilized during the post-intervention period. Post-intervention utilization of the panel results was comparable to pre-intervention period. Elimination of PCR respiratory panels from order sets and restrictions of complete respiratory panel ordering to ID physicians resulted in $33,760 saved. Disclosures All authors: No reported disclosures.

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State-wide quality improvement addressing overutilization of neurokinin-1 receptor antagonists.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.29_suppl.8 ◽

2020 ◽

Vol 38 (29_suppl) ◽

pp. 8-8

Author(s):

Emily R. Mackler ◽

Kelly Marie Procailo ◽

Louise Bedard ◽

Jennifer J. Griggs

Keyword(s):

Quality Improvement ◽

Response Rate ◽

Quality Improvement Intervention ◽

Receptor Antagonists ◽

Post Intervention ◽

Improvement Program ◽

Neurokinin 1 Receptor ◽

Order Sets ◽

Neurokinin 1 ◽

Order Set

8 Background: The overuse of neurokinin-1 receptor antagonists (NK1-RAs) is a focus of quality measurement within the American Society of Clinical Oncology Quality Oncology Practice Initiative (ASCO-QOPI) and the American Board of Internal Medicine (ABIM) as a Choosing Wisely measure. The Michigan Oncology Quality Collaborative (MOQC) is a statewide collaborative with participation of nearly 100% of oncologists. The purpose of this project was to provide quality improvement practice support for deimplementation of NK1-RAs in the upfront prevention of chemotherapy- induced nausea and vomiting (CINV) for low and moderate emetic chemotherapy regimens (QOPI measure SMT28a) to less than 30% in practices across the State, with lower scores indicating better performance. Methods: In 2018, MOQC added the QOPI SMT28a measure as part of its standard quality measure module for collection by all MOQC practices. A quality improvement intervention was initiated that consisted of 1) baseline assessments of measure performance, prescriber knowledge and beliefs, and pre-populated antiemetic order sets, 2) reporting practice and state-level performance to MOQC practices, 3) state-wide CINV education, and 4) a value-based reimbursement (VBR) related to measure performance. Post-intervention performance was assessed with the Fall 2019 and Spring 2020 QOPI-measurement. Results: Responses from a survey assessing pre-populated antiemetic order sets (32/43, 74% response rate), 23% of practices had a pre-populated order set for NK1-RA and/or olanzapine in moderate emetic regimens. The post-education order set survey found that 48% of respondents (25/43, 54% response rate) either modified or were in the process of modifying their order sets. Conclusions: Deimplementation of unnecessary and low value antiemetics in patients receiving low- or moderate emetic chemotherapy was possible via a state-wide quality improvement program that involved performance reporting to practices, collaborative-wide education, modification of standing order sets, and VBR based on performance. [Table: see text]

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