46. Antimicrobial Stewardship’s Selective Antibiotic Suppression Does Not Lead to Adverse Outcomes in Neutropenic Patients with Gram-Negative Bacteremia

Abstract Background An antimicrobial stewardship program (ASP) strategy to minimize the use of overly broad antimicrobials is to suppress specific antimicrobial susceptibility results when isolates are sensitive to narrow antibiotics. There is limited data on possible adverse outcomes of this method. Patients with febrile neutropenia (FN) and gram-negative bacteremia (GNB) whose culture is sensitive to non-pseudomonal antibiotics still require broader pseudomonal coverage to treat the syndrome of FN. We evaluated if ASP suppression of anti-pseudomonal antibiotics adversely affects patients with FN and GNB. Methods In February 2018, our institution’s ASP began suppressing cefepime and meropenem susceptibility results from E. coli, Klebsiella spp, and Proteus spp when sensitive to cefepime (MIC ≤ 2), ceftriaxone and ceftazidime. We performed a retrospective analysis of patients with FN and GNB from 2016 – 2020 to evaluate the appropriateness of antibiotic regimens before and after the ASP intervention. Antibiotic regimens were deemed inappropriate if the patient was de-escalated to a narrow-spectrum, non-pseudomonal agent while neutropenic. Of 338 inpatient encounters identified with any bacteremia and FN, 49 were due to non-Pseudomonas, non-ESBL GNB, 20 before and 29 after the intervention. Sixteen of the 29 post-intervention patients were excluded, as their isolates did not meet suppression criteria. This resulted in a total of 13 patients in the post-intervention group. Results After culture susceptibility reports were released, 3 out of 20 patients in the pre-intervention group (15%) and 4 out of 13 patients in the post-intervention group (30.8%) were inappropriately tailored to narrow-spectrum antibiotics (p=0.39). There was no significant difference in 30-day mortality, 10.0% pre- and 0% post-intervention (p=0.50), or amount of meropenem prescribed, 45% pre- and 38.5% post-intervention (p=0.74). Conclusion These data show no significant difference in inappropriate antibiotic regimens prescribed for patients with FN and GNB after ASP antibiotic suppression was implemented. 30-day mortality was also not affected. The ASP intervention did not decrease meropenem prescriptions in this patient group, which may be appropriate. Larger studies are needed to verify these findings. Disclosures Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support) Mary Burgess, MD, Pfizer Inc (Grant/Research Support)

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The Impact of a New Best Practice Advisory on the Management of Diabetic Ketoacidosis

Current Diabetes Reviews ◽

10.2174/1573399816999201103141726 ◽

2020 ◽

Vol 16 ◽

Author(s):

Diala Alawneh ◽

Moustafa Younis ◽

Majdi S. Hamarshi

Keyword(s):

Diabetic Ketoacidosis ◽

Best Practice ◽

Intervention Group ◽

Post Intervention ◽

Management Algorithm ◽

Significant Difference ◽

Before And After ◽

Practice Advisory ◽

The Impact ◽

Post Intervention Group

Background: According to the Center for Disease Control and Prevention, diabetic ketoacidosis (DKA) hospitalization rates have been steadily increasing. Due to the increasing incidence and the economic impact associated with its morbidity and treatment, effective management is key. We aimed to streamline the management of DKA in our intensive care units (ICU) by implementing a Best-Practice Advisory (BPA) that notifies providers when DKA has resolved. Methods: A BPA was implemented on 9/15/2018. We conducted a retrospective review of patients admitted to the ICU with DKA a year before and after 9/15/2018. Adults (≥18 age) meeting DKA criteria on admission and treated with continuous insulin infusion (CII) were included. Pre-intervention group included patients admitted before BPA implementation and post-intervention group included patients admitted after. Summary and univariate analyses were performed. Results: A total of 282 patients were included; 162 (57%) pre-intervention and 120 (43%) post-intervention. Mean (±SD) age was 44 (±17) years. There was no significant difference in baseline characteristics such as age, sex, race, BMI, HbA1c, initial blood glucose, anion gap or bicarbonate concentration between both groups (p>0.05). Mean (±SD) total time on CII in hours was significantly lower in the post-intervention group 14.8 (±7.7) vs 17.5 (±14.3) p=0.041, 95% CI: 0.11-5.3. The incidence of hypoglycemia was lower in the post-intervention group n=4 (3%) vs 17 (10%), p=0.024. There was no significant difference in hypokalemia, mortality, LOS or ICU stay between both groups (p>0.05). Conclusions: The BPA introduced in our DKA management algorithm successfully reduced total time on insulin and the incidence of hypoglycemia.

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87. Utilization of Methicillin-Sensitive/Resistant Staphylococcus aureus Nares Screen to Decrease Vancomycin and Linezolid Use in Hospitalized Patients with Respiratory Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.132 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S60-S60

Author(s):

Noor F Zaidan ◽

Rachel S Britt ◽

David Reynoso ◽

R Scott Ferren

Keyword(s):

Staphylococcus Aureus ◽

Respiratory Infections ◽

Intervention Group ◽

Kidney Injury ◽

Post Intervention ◽

Gram Positive ◽

Stewardship Program ◽

Screening Protocol ◽

The Impact ◽

Post Intervention Group

Abstract Background Pharmacist-driven protocols for utilization of methicillin-resistant Staphylococcus aureus (MRSA) nares screenings have shown to decrease duration of empiric gram-positive therapy and rates of acute kidney injury (AKI) in patients with respiratory infections. This study evaluated the impact of a pharmacist-driven MRSA nares screening protocol on duration of vancomycin or linezolid therapy (DT) in respiratory infections. Methods Patients aged 18 years and older with a medication order of vancomycin or linezolid for respiratory indication(s) were included. The MRSA nares screening protocol went into effect in October 2019. The protocol allowed pharmacists to order an MRSA nares polymerase chain reaction (PCR) for included patients, while the Antimicrobial Stewardship Program (ASP) made therapeutic recommendations for de-escalation of empiric gram-positive coverage based on negative MRSA nares screenings, if clinically appropriate. Data for the pre-intervention group was collected retrospectively for the months of October 2018 to March 2019. The post-intervention group data was collected prospectively for the months of October 2019 to March 2020. Results Ninety-seven patients were evaluated within both the pre-intervention group (n = 50) and post-intervention group (n = 57). Outcomes for DT (38.2 hours vs. 30.9 hours, P = 0.601) and AKI (20% vs. 14%, P = 0.4105) were not different before and after protocol implementation. A subgroup analysis revealed a significant reduction in DT within the pre- and post-MRSA PCR groups (38.2 hours vs. 24.8 hours, P = 0.0065) when pharmacist recommendations for de-escalation were accepted. Conclusion A pharmacist-driven MRSA nares screening protocol did not affect the duration of gram-positive therapy for respiratory indications. However, there was a reduction in DT when pharmacist-driven recommendations were accepted. Disclosures All Authors: No reported disclosures

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A low-cost intervention to promote immediate skin-to-skin contact and improve temperature regulation in Northern Uganda

African Journal of Midwifery and Women s Health ◽

10.12968/ajmw.2018.0037 ◽

2019 ◽

Vol 13 (3) ◽

pp. 1-12 ◽

Cited By ~ 1

Author(s):

Eva Nissen ◽

Kristin Svensson ◽

Scovia Mbalinda ◽

Kajsa Brimdyr ◽

Peter Waiswa ◽

...

Keyword(s):

Low Cost ◽

Intervention Group ◽

Hospital Staff ◽

Post Intervention ◽

Skin Contact ◽

Group Data ◽

Before And After ◽

Quasi Experimental ◽

Skin To Skin ◽

Post Intervention Group

Background Uninterrupted skin-to-skin contact between mothers and newborns during the first hour after birth has been reported to be 2% in Uganda. Aims To investigate if a low-cost intervention targeting the behaviors of hospital staff would increase skin-to-skin contact and to investigate whether skin-to-skin contact stabilised temperature in the newborn. Methods The study had a quasi-experimental, before and after design. The sample included 110 in the pre-intervention group, and 93 in the post-intervention group. Data collection included observations of skin-to-skin contact and temperature measurements. Data were also collected from medical records and interviews. Findings No infants had skin-to-skin contact before the intervention, whereas the proportion was 54.8% after the intervention. Infants who received skin-to-skin contact (n=51) and infants who did not receive skin-to-skin contact (n=146) increased in temperature; however, infants who received skin-to-skin contact were significantly warmer after 5 minutes and remained so at 60 minutes. Conclusions The intervention increased the practice of skin-to-skin contact, which was found to be safe in regard to temperature stabilisation.

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143. Modification of Linezolid Restriction Criteria Reduces ICU Gram-positive Antibiotic Consumption

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.453 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S201-S202

Author(s):

John M Boulos ◽

Kathryn DeSear ◽

Bethany Shoulders ◽

Veena Venugopalan ◽

Stacy A Voils ◽

...

Keyword(s):

Hospital Mortality ◽

Intervention Group ◽

Hospital Length Of Stay ◽

Post Intervention ◽

Gram Positive ◽

Stewardship Program ◽

Days Of Therapy ◽

Secondary Outcomes ◽

The Impact ◽

Post Intervention Group

Abstract Background Antibiotic time out (ATO) policies have been proposed by the Centers for Disease Control and Prevention to limit unnecessary use of antibiotics. Critically ill patients are often treated empirically with MRSA-active agents for a prolonged duration. The objective of this study was to assess the impact of an ATO policy by targeting empiric gram-positive coverage. Methods Before this intervention, linezolid required pre-approval by the antimicrobial stewardship program or infectious diseases (ID) consult service before dispensing, and no automatic ATO policy was in place for any agent. In 2018, restriction of linezolid was modified to allow 72 hours of empiric use in the intensive care unit (ICU). This retrospective, single-center, pre- post-intervention study looked at eight ICUs at our institution from two equal periods. Adults (age ≥ 18 years) were included who received an IV gram-positive antibiotic (IVGP-AB), specifically linezolid or vancomycin, used for empiric therapy and were admitted to the ICU. The primary outcome was antimicrobial consumption of IVGP-AB defined as days of therapy (DOT) per patient. Secondary outcomes included in-hospital length of stay (LOS), ICU LOS, in-hospital mortality, 30-day readmission, and incidence of acute kidney injury (AKI). Figure 1. Flowchart of patient inclusion into the study Results 2718 patients met criteria for inclusion in the study. 1091 patients were included in the pre-intervention group and 1627 patients were included in the post-intervention group. Baseline characteristics between the two groups were similar, with ID consults being higher in the pre-intervention group. Total mean DOT of IVGP-AB in pre- and- post-intervention groups was 4.97 days vs. 4.36 days, p< 0.01. Secondary outcomes of in-hospital LOS, ICU LOS, and in-hospital mortality did not vary significantly between groups. Thirty-day readmission was lower in the post-intervention group (12.9% vs. 3.9%, p< 0.01). AKI did not differ significantly between groups, however the need for renal replacement therapy was higher in the pre-intervention group (1.2% vs. 0.2%, p< 0.01). Conclusion This study assessed the impact of an ATO policy allowing 72 hours of empiric linezolid in the ICU. We found a statistically significant reduction in days of therapy of IVGP-AB without increases in LOS, mortality, readmission, and AKI. Disclosures All Authors: No reported disclosures

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The incidence of acute kidney injury among children treated for fever and neutropenia after elimination of empiric gentamycin use.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.34_suppl.120 ◽

2012 ◽

Vol 30 (34_suppl) ◽

pp. 120-120

Author(s):

Andras Heczey ◽

Kathy McCarthy ◽

Meng-Fen Wu ◽

Curtis Kennedy ◽

Marilyn Hockenberry

Keyword(s):

Acute Kidney Injury ◽

Creatinine Clearance ◽

Treatment Success ◽

Intervention Group ◽

Kidney Injury ◽

Post Intervention ◽

Randomized Controlled Clinical Trials ◽

Significant Difference ◽

Baseline Creatinine ◽

Post Intervention Group

120 Background: The mortality rate of chemotherapy-related fever and neutropenia (F&N) has decreased significantly in recent years with attention shifting to antibiotic regimens with the least side effects. Multiple randomized controlled clinical trials have demonstrated that antibiotic regimens without aminoglycosides are sufficient for successful treatment of F&N and the addition of aminoglycosides significantly increases the risk of acute kidney injury among adults. The institutional F&N Guideline of Texas Children’s Hospital (TCH) mandated the use of gentamycin in combination vancomycin and piperacillin-tazobactam (P-T) for the treatment of hig- risk (HR) patients with F&N. To decrease the incidence of nephrotoxicity while maintaining excellent survival, empiric gentamycin use was stopped. Methods: Bacterial susceptibility and characteristics of patients with positive blood cultures treated at TCH during 2009 were retrospectively analyzed (pre-intervention group). Negligible P-T resistance was confirmed among bacterial isolates and empiric use of gentamycin for HR patients with F&N was stopped. After a 6 month adjustment period, data for all patients treated according to the new HR algorithm were prospectively collected (post-intervention group) for 12 months. The pre- and post-intervention groups were evaluated for differences in treatment success and incidence of nephrotoxicity. Results: Data from 69 patients from the pre-intervention group and 39 patients from the post-intervention group who had bacteremia were analyzed. No statistical difference was found between pre- and post-intervention groups for age, gender, survival, baseline creatinine level and baseline estimated creatinine clearance. However, significant difference was found for change in creatinine levels (0.12 vs. 0.04 mg/dl p=0.01), change in estimated creatinine clearance (24.8 vs. 12.1ml/min/1.73m2, p=0.01) and incidence of acute kidney injury (30.1 vs. 11.1%, p=0.04). Conclusions: Children with high risk F&N episode may be treated effectively and safely with decreased incidence of acute kidney injury without the empiric use of gentamycin.

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Three easily-implementable changes reduce median door-to-needle time for intravenous thrombolysis by 23 minutes

BMC Neurology ◽

10.1186/s12883-019-1527-8 ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Demi Tran ◽

Zhu Zhu ◽

Mohammad Shafie ◽

Hermelinda Abcede ◽

Dana Stradling ◽

...

Keyword(s):

Quality Improvement ◽

Intervention Group ◽

Intravenous Thrombolysis ◽

The United States ◽

Quality Improvement Initiative ◽

Great Effort ◽

Post Intervention ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference ◽

Post Intervention Group

Abstract Background The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke is time dependent. Despite great effort, the median door-to-needle time (DNT) was 60 min at the United States stroke centers. We investigated the effect of a simple quality improvement initiative on DNT for IVT. Methods This is a single-center study of patients treated with IVT between 2013 and 2017. A simple quality improvement initiative was implemented in January 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IVT before getting blood test results unless patients were taking oral anticoagulants, and to give IVT in the CT suite. Baseline characteristics, DNT and outcomes at hospital discharge were compared between pre- and post-intervention groups. Results Ninety and 136 patients were treated with IVT in pre- and post-intervention groups, respectively. The rate of IVT was significantly higher in the post-intervention group (20% vs. 14.4%, p = 0.007). The median DNT with interquartile range (IQR) was reduced significantly by 23 min (63[53–81] vs. 40[29–53], p < 0.001) with more patients in the post-intervention group receiving IVT within 60 min (81.6% vs. 46.7%) and 45 min (64.0% vs.17.8%). There was no significant difference in symptomatic intracerebral hemorrhage rate (1.5% vs. 1.1%), modified Rankin Scale 0–1 (29.4% vs. 23.3%), and hospital mortality (7.4% vs. 6.7%) between the 2 groups. Conclusions Three easily-implementable quality improvement initiative increases IVT rate and reduces DNT significantly without increasing the rate of IVT-related complications in our comprehensive stroke center.

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Impact of a Pharmacist-Driven Respiratory Viral Panel Stewardship Program on Antibiotic Exposure Within a Multicenter Community Health System

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.851 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S353-S353

Author(s):

Ashley Cubillos ◽

Sandy Estrada ◽

Harrison Bachmeier ◽

Edgar Turner

Keyword(s):

Antimicrobial Stewardship ◽

Respiratory Infections ◽

Intervention Group ◽

Care Hospital ◽

Antibiotic Exposure ◽

Post Intervention ◽

Stewardship Program ◽

Laboratory Test Results ◽

The Impact ◽

Post Intervention Group

Abstract Background Strategies to ensure optimal use of multiplex polymerase chain reaction (mPCR) testing results for antimicrobial stewardship in acute respiratory infections remain to be elucidated. This study sought to assess the impact of pharmacist intervention (by means of prospective feedback to prescribers) on overall antibiotic exposure in patients with viral-positive mPCR Respiratory Viral Panel (RVP) laboratory test results. Methods This retrospective cohort study included patients ≥18 years of age admitted to an acute care hospital with a viral-positive nasopharyngeal FilmArray Respiratory Panel test result receiving antibiotics for a suspected respiratory tract infection. Immunocompromised patients, patients with RVP samples from bronchiolar lavage, patients in the intensive care unit when samples were obtained, and patients receiving antibiotics for non-respiratory infections were excluded. Antibiotic exposure days, antibiotic discontinuation at 72 hours, and culture-positive bacterial superinfection were compared in two cohorts of patients, before and after the rollout of an educational pharmacist RVP stewardship initiative. Results Median antibiotic exposure days did not differ between the pre- and post-intervention groups (6 days vs. 7 days, P = 0.20). Antibiotic discontinuation at 72 hours was significantly lower in the post-intervention group (38% vs. 25%, P = 0.02). More patients in the post-intervention group had positive bacterial respiratory cultures (2.7% vs. 10%, P = 0.007) and chest radiographs suggestive of pneumonia (34.7% vs. 46%, P = 0.05). Patients with peak serum procalcitonin levels <0.25 ng/mL were more likely to have antibiotics discontinued at 72 hours than those with peak levels ≥0.25 ng/mL (36% vs. 0%, P = 0.02). Conclusion An antimicrobial stewardship initiative by pharmacists among patients with viral-positive RVP results did not appear to impact antibiotic exposure days. Serum procalcitonin levels appeared to influence antibiotic discontinuation decisions. Alternative strategies for maximizing the antimicrobial stewardship impact of RVP testing should be explored. Disclosures All authors: No reported disclosures.

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The impact of an innovative pharmacist-led inpatient opioid de-escalation intervention in post-operative orthopedic patients

Journal of Opioid Management ◽

10.5055/jom.2020.0565 ◽

2020 ◽

Vol 16 (3) ◽

pp. 167-176

Author(s):

Thuy Bui, BPharm ◽

Richard Grygiel, MPharm ◽

Alex Konstantatos, MB BS (Hons), FANZCA, Dip Obs, MRCA ◽

Nick Christelis ◽

Susan Liew, MB BS (Hons), FRACS ◽

...

Keyword(s):

Pain Intensity ◽

Intervention Group ◽

Public Health Problem ◽

Prescription Opioid ◽

Opioid Use ◽

Post Intervention ◽

Before And After ◽

Orthopedic Patients ◽

The Impact ◽

Post Intervention Group

Objective: Many patients are discharged from hospital after surgery with excessive doses of opioid, and prescription opioid addiction has become a serious public health problem. Inpatient opioid de-escalation performed by clinical pharmacists may assist in reducing opioids before discharge. We aimed to evaluate whether clinical pharmacist-led opioid de-escalation for inpatients after orthopedic surgery led to significant reductions in opioid use at discharge, without resulting in greater pain intensity and side effects.Design: This retrospective pre-/post-intervention study evaluated patients before and after implementation of a pharmacist-led opioid de-escalation service.Setting: A major tertiary institution.Participants: Ninety eight participants underwent de-escalation, and 98 controls received standard care following orthopedic surgery.Intervention: Pharmacist-led opioid de-escalation was initiated after discharge from the institution's Acute Pain Service.Main outcome measure: Primary outcome was total morphine oral equivalence (MOE) required in the 24-hours before discharge between the two groups. Secondary outcomes included pain intensity scores and opioid-related side effects. Results: The post-intervention group used significantly less opioids in the 24 hours preceding discharge compared with the precohort (total MOE 30 vs 45 mg; p = 0.025).There were no differences in pain intensity at rest (p = 0.19) or with movement (p = 0.19). Cases experienced significantly less constipation (29 vs 49 percent; p = 0.004); no differences were observed for other side effects.Discussion: We observed statistically similar pain intensity ratings, in the setting of significantly lowered opioid doses among the post-intervention group prior to discharge.Conclusion: Pharmacist-led inpatient opioid de-escalation is effective, does not increase pain intensity, and reduces constipation. Hospitals should explore the viability of extending pharmacist-led opioid de-escalation to other surgical patients and following hospital discharge, aiming for opioid cessation.

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Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

10.21203/rs.2.14476/v3 ◽

2019 ◽

Author(s):

Demi Tran ◽

Zhu Zhu ◽

Mohammad Shafie ◽

Hermelinda Abcede ◽

Dana Stradling ◽

...

Keyword(s):

Quality Improvement ◽

Intervention Group ◽

Intravenous Thrombolysis ◽

The United States ◽

Quality Improvement Initiative ◽

Great Effort ◽

Post Intervention ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference ◽

Post Intervention Group

Abstract Background: The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke is time dependent. Despite great effort, the median door-to-needle time (DNT) was 60 minutes at the United States stroke centers. We investigated the effect of a simple quality improvement initiative on DNT for IVT. Methods: This is a single-center study of patients treated with IVT between 2013 and 2017. A simple quality improvement initiative was implemented in January 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IVT before getting blood test results unless patients were taking oral anticoagulants, and to give IVT in the CT suite. Baseline characteristics, DNT and outcomes at hospital discharge were compared between pre- and post-intervention groups. Results: Ninety and 136 patients were treated with IVT in pre- and post-intervention groups, respectively. The rate of IVT was significantly higher in the post-intervention group (20% vs. 14.4%, p=0.007). The median DNT with interquartile range (IQR) was reduced significantly by 23 minutes (63[53-81] vs. 40[29-53], p<0.001) with more patients in the post-intervention group receiving IVT within 60 minutes (81.6% vs. 46.7%) and 45 minutes (64.0% vs.17.8%). There was no significant difference in symptomatic intracerebral hemorrhage rate (1.5% vs. 1.1%), modified Rankin Scale 0-1 (29.4% vs. 23.3%), and hospital mortality (7.4% vs. 6.7%) between the 2 groups. Conclusions: Three easily-implementable quality improvement initiative increases IVT rate and reduces DNT significantly without increasing the rate of IVT-related complications in our comprehensive stroke center.

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Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

10.21203/rs.2.14476/v1 ◽

2019 ◽

Author(s):

Demi Tran ◽

Zhu Zhu ◽

Mohammad Shafie ◽

Hermelinda Abcede ◽

Dana Stradling ◽

...

Keyword(s):

Quality Improvement ◽

Intervention Group ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Quality Improvement Initiative ◽

Great Effort ◽

Post Intervention ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference ◽

Post Intervention Group

Abstract Background:The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) is time dependent. Despite great effort, the median door-to-needle time (DNT) was 60 minutes at the U.S. stroke centers. We investigated the effect of a simple quality improvement initiative on DNT for IVT. Methods: This is a single-center study of patients treated with IVT between 2013 and 2017. A simple quality improvement initiative was implemented in January 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IVT before getting blood test results unless patients were taking oral anticoagulants, and to give IV tPA in the CT suite. Baseline characteristics, DNT and outcomes at hospital discharge were compared between pre- and post-intervention groups. Results: Ninety and 136 patients were treated with IVT in pre- and post-intervention groups, respectively. The rate of IVT was significantly higher in the post-intervention group (20% vs. 14.4%, p=0.007).The median DNT with interquartile range (IQR) was reduced significantly by 23 minutes (63[53-81] versus 40[29-53],p<0.001) with more patients in the post-intervention group receiving IVT within 60 minutes (81.6% versus 46.7%) and 45 minutes (64.0% versus 17.8%). There was no significant difference in symptomatic intracerebral hemorrhage rate (1.5% vs 1.1%), functional independence at discharge (mRS 0-1, 29.4% vs 23.3), and hospital mortality (7.4% vs 6.7%) between the 2 groups. Conclusions:Three easily-implementable quality improvement initiative increases IVT rate and reduces DNT significantly. It is safe and can be easily adopted at other stroke centers.

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