scholarly journals 1510. Improving the Management of Pediatric Complicated Pneumonia

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S549-S549
Author(s):  
Andrew M Nuibe ◽  
Van Tran ◽  
Rebecca E Levorson
Keyword(s):  
Process Model ◽  
The United States ◽  
Care Process ◽  
Intervention Period ◽  
Chest Tubes ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Period 2 ◽  
Stewardship Program ◽  
Complicated Pneumonia

Abstract Background Pneumonia is a leading cause of pediatric hospitalization in the United States. Our Antimicrobial Stewardship Program (ASP) recognized significant variation in the management of pediatric complicated pneumonia. We developed and implemented a quality improvement (QI) intervention to align the management of complicated pneumonia with national guidelines and compared the medical care and clinical outcomes between a pre-intervention period and two post-intervention periods. Methods We queried Webi Universe for all ICD-9 and ICD-10-related admissions for pneumonia at our facility from November 15, 2015 to February 28, 2019. Manual chart review was done to extract clinical points of interest and to ensure that all included patients met inclusion criteria. Our first intervention (period 1) consisted of education to providers to increase use of chest tubes instilled with fibrinolytics and to decrease empiric antistaphylococcal therapy. Our second intervention (period 2) consisted of a care process model which codified the standardized management made by the first intervention, followed by several didactic sessions. Results 29 patients were identified in the pre-intervention period, 11 in post-intervention period 1, and 27 in post-intervention period 2. Streptococcal species were the most common pathogens recovered in all periods. Following our interventions the number of video-assisted thorascopic procedures to drain complicated parapneumonic effusions decreased three-fold in favor of chest tubes instilled with fibrinolytics (P < 0.01). Our interventions also reduced empiric antistaphylococcal therapy within the first 48 hours of admission (P = 0.02) and decreased the use of empiric vancomycin three-fold (P = 0.01). Our interventions did not affect the median length of stay, frequency of pulmonary complications, number of 30-day readmissions, or duration of antimicrobial therapy. Conclusion Our ASP’s QI intervention decreased surgical drainage of complicated parapneumonic effusions and decreased the use of empiric antistaphylococcal agents without an increase in complications or readmissions. Opportunities remain to decrease the use of multiple antimicrobial agents within the first 48 hours of admission and to decrease the empiric use of antistaphylococcal therapy. Disclosures All authors: No reported disclosures.

scholarly journals 1130. Impact of a New Pediatric Antibiotic Stewardship Program on Ceftriaxone Use at an Academic Medical Center

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S656-S656
Author(s):  
Derek Evans ◽  
Mariana M Lanata Piazzon ◽  
Kaitlyn Schomburg
Keyword(s):  
Antibiotic Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Severe Infection ◽  
Audit And Feedback ◽  
Clinical Indication ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Stewardship Program

Abstract Background Hoop’s Family Children’s Hospital is a pediatric hospital with 72 beds, nested within Cabell Huntington Hospital. There is an established adult antibiotic stewardship program (ASP), however, since 2014 there has not been a pediatric infectious disease (ID) specialist and no pediatric ASP. With the recent hire of a pediatric ID specialist in Oct 2019 and the formation of a targeted pediatric ASP, we tracked the use of ceftriaxone (CRO) in our facility. Methods Starting January 2020, education was provided to pediatric providers in regards to appropriate CRO dosing and clinical indications via email communication. The main goals were to limit 100mg/kg/day dosing to severe infections and reduce CRO use in community-acquired pneumonia. This was sustained through intermittent prospective audits and feedback. A retrospective chart review was done from 2019-2021 for the months of January, April and December of each year. Patients ≤18 years of age who received CRO were included. Dosing, interval frequency, indication, and treatment duration were reviewed. Patients who received a single dose of CRO were excluded. Results From Jan 2019 – April 2021, 391 patient charts were reviewed (189 in the pre-intervention period and 202 in the post intervention period). There were no significant differences in age, race/ethnicity and gender in the two study groups. In the pre-intervention period, 86% of patients were prescribed CRO at severe infection dosing vs 33% in the post intervention period (p&lt; 0.0001) (Figure 1). When dosing was paired with indication, only 20% of patients in the pre intervention period had the appropriate dosing per clinical indication compared to 83% in the post intervention period (p&lt; 0.0001) (Figure 2). We also saw that in the pre-intervention period the most common indication for CRO was pneumonia (66%), which decreased to 57% in 2020 and to 35% in 2021 (p&lt; 0.0001) (Figure 3). Figure 1 describes the percentage of patients receiving ceftriaxone at severe infection dosing. This changed from an average of 86% in the pre-intervention period to 33% in the post-intervention period. Figure 2 describes the percentage of patients receiving ceftriaxone at the appropriate dosing dependent on the clinical indication provided. This changed from 20% in the pre-intervention period to closer to 90% in the post-intervention period. Conclusion Pediatric specific ASP efforts and expertise proved to be crucial in appropriate CRO use in our institution. With a feasible education strategy and targeted prospective audit and feedback, there has been a sustained impact in inappropriate CRO use. This underscores the importance of targeted pediatric ASP efforts in pediatric hospitals within larger adult hospitals. Disclosures All Authors: No reported disclosures

scholarly journals 1506. Outcomes of Standardized Neonatal Cephalexin Dosing

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S548-S548
Author(s):  
Melena J Robertson ◽  
Van Tran ◽  
Andrew M Nuibe
Keyword(s):  
Clinical Outcomes ◽  
Kidney Injury ◽  
Optimal Dose ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Stewardship Program ◽  
Optimal Dosing ◽  
Before And After ◽  
Tract Infections

Abstract Background The optimal dosing of cephalexin in infants ≤90 days old is not well known. Our Antimicrobial Stewardship Program (ASP) standardized cephalexin dosing for inpatients ≥30 days old using available literature and released an antimicrobial dosing guideline in September 2016. Recommended antimicrobial dosing for inpatients <30 days old followed in November 2017. We reviewed the indications, cephalexin dosing, and clinical outcomes of patients before and after the release of our ASP’s cephalexin dosing guidelines. Methods Webi Universe was queried for cephalexin orders for inpatients ≤ 90 days old at the Inova Children’s Hospital from January 2016 to November 2018. Manual chart review extracted clinical points of interest and ensured that inclusion criteria were met. For patients <30 days old, the pre-intervention period was January 2016 to October 2017 and the post-intervention period was November 2017 to October 2018. For patients ≥30 days old the pre-intervention period was January 2016 to August 2016 and the post-intervention period was September 2016 to October 2018. Aggregate data from the two pre-intervention and two post-intervention periods were pooled, respectively. Results 41 patients were identified: 25 in the pre-intervention period and 16 in the post-intervention period. The median age of patients in the pre-intervention period was 16 days compared with 31 days in the post-intervention period (P = 0.02). No patients had acute kidney injury requiring cephalexin renal dosing. Skin and soft-tissue infections (18) and urinary tract infections (10) were the most common infections in both periods. 24% of patients received the recommended cephalexin dose in the pre-intervention period compared with 63% in the post-intervention period (P = 0.02). Logistic regression controlling for pathogens and area of care showed that patient age predicted the use of recommended cephalexin dosing (OR 1.1, 95% CI: 1.01–1.21). There were no deaths or recrudescent infections. Conclusion Our ASP’s interventions improved adherence to standardized cephalexin dosing in inpatients ≤90 days old without any adverse clinical outcomes. Patients ≥30 days old were more likely to receive recommended cephalexin dosing. Opportunities remain to best define the optimal dose of cephalexin in infants ≤90 days old. Disclosures All authors: No reported disclosures.

scholarly journals Implementation of a comprehensive intervention focused on hospitalized patients with HIV by an existing stewardship program: successes and lessons learned

2021 ◽  
Vol 8 ◽  
pp. 204993612110105
Author(s):  
Danya Roshdy ◽  
Maggie McCarter ◽  
Jacqueline Meredith ◽  
Rupal Jaffa ◽  
Katie Hammer ◽  
...  
Keyword(s):  
Intervention Group ◽  
Linkage To Care ◽  
Lessons Learned ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Stewardship Program ◽  
National Organizations ◽  
Quasi Experimental ◽  
The Impact

Background: Several national organizations have advocated for inpatient antiretroviral stewardship to prevent the consequences of medication-related errors. This study aimed to evaluate the impact of a stewardship initiative on outcomes in people with HIV (PWH). Methods: A pharmacist-led audit and review of adult patients admitted with an ICD-10 code for HIV was implemented to an existing antimicrobial stewardship program. A quasi-experimental, retrospective cohort study was conducted comparing PWH admitted during pre- and post-intervention periods. Rates of antiretroviral therapy (ART)-related errors and infectious diseases (ID) consultation with linkage to care were evaluated through selection of a random sample of patients receiving ART in each period. Length of stay (LOS) and mortality were assessed by analyzing all admissions in the post-intervention period. Clinical outcomes including LOS, 30-day all-cause hospital readmission, and in-hospital and 30-day mortality in the post-intervention group were stratified by patients not on ART, on ART at admission, and started on ART as a result of the intervention. Results: A total of 100 patients in the pre-intervention period and 103 patients in the post-intervention period were included to assess ART-related errors and linkage to care. A reduction in errors (70.0 versus 25.7%, p < 0.001) and increased linkage to care (19.0 versus 39.6%, p < 0.01) were demonstrated. Of 389 admissions during the post-intervention period, 30-day mortality rates were similar between PWH on ART at admission and those initiated on ART during admission (5% versus 8%, respectively), but less than those not on ART (21%). A longer LOS was observed in the patients started on ART during admission (5 days if ART started during admission versus 3 days if not started during admission, p < 0.01). Conclusions: This interdisciplinary intervention was successful in reducing inpatient ART-related errors and increasing ID consultation with linkage to care among PWH.

scholarly journals 142. Implementing an Antimicrobial Stewardship Program in the Outpatient Setting

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S82-S82
Author(s):  
Travis B Nielsen ◽  
Maressa Santarossa ◽  
Beatrice D Probst ◽  
Laurie Labuszewski ◽  
Jenna Lopez ◽  
...  
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Inappropriate Prescribing ◽  
The United States ◽  
Outpatient Setting ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Antimicrobial Stewardship Program ◽  
Post Intervention ◽  
Stewardship Program

Abstract Background Antimicrobial-resistant infections lead to increased morbidity, mortality, and healthcare costs. Among the most facile modifiable risk factors for developing resistance is inappropriate prescribing. The CDC estimates that 47 million (or ≥30% of) outpatient antibiotic prescriptions in the United States are unnecessary. This has provided impetus for expanding our antimicrobial stewardship program (ASP) into the outpatient setting. Initial goals included the following: continuous evaluation and reporting of antibiotic prescribing compliance; minimize underuse of antibiotics from delayed diagnoses and misdiagnoses; ensure proper drug, dose, and duration; improve the percentage of appropriate prescriptions. Methods To achieve these goals, we first sent a baseline survey to outpatient prescribers, assessing their understanding of stewardship and antimicrobial resistance. Questions were modeled from the Illinois Department of Public Health (IDPH) Precious Drugs & Scary Bugs Campaign. The survey was sent to prescribers at 19 primary care and three immediate/urgent care clinics. Compliance rates for prescribing habits were subsequently tracked via electronic health records and reported to prescribers in accordance with IRB approval. Results Prescribers were highly knowledgeable about what constitutes appropriate prescribing, with verified compliance rates highly concordant with self-reported rates. However, 74% of respondents reported intense pressure from patients to inappropriately prescribe antimicrobials. Compliance rates have been tracked since December 2018 and comparing pre- with post-intervention rates shows improvement in primary care since reporting rates to prescribers in August 2019. Conclusion Reporting compliance rates has been helpful in avoiding inappropriate antimicrobial therapy. However, the survey data reinforce the importance of behavioral interventions to bolster ASP efficacy in the outpatient setting. Going forward, posters modeled off of the IDPH template will be conspicuously exhibited in exam rooms, indicating institutional commitment to the enumerated ASP guidelines. Future studies will allow for comparison of pre- and post-intervention knowledge and prescriber compliance. Disclosures All Authors: No reported disclosures

Impact of Order-Set Modifications and Provider Education Following Guideline Updates on Broad-Spectrum Antibiotic Use in Patients Admitted With Community Acquired Pneumonia

2021 ◽  
pp. 001857872110557
Author(s):  
Jessica L. Colmerauer ◽  
Kristin E. Linder ◽  
Casey J. Dempsey ◽  
Joseph L. Kuti ◽  
David P. Nicolau ◽  
...  
Keyword(s):  
Broad Spectrum ◽  
Antibiotic Use ◽  
Community Acquired Pneumonia ◽  
Intervention Period ◽  
Provider Education ◽  
Broad Spectrum Antibiotic ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Days Of Therapy ◽  
Order Set

Purpose: Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. Methods: This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). Results: A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, P = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period ( P < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; P = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], P = .002). Conclusion: Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.

scholarly journals 1154. Impact of Educational Feedback on Reducing Hospital-Onset Catheter-Associated Urinary tract Infections at an Academic Medical Center

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S412-S412
Author(s):  
Bhagyashri D Navalkele ◽  
Nora Truhett ◽  
Miranda Ward ◽  
Sheila Fletcher
Keyword(s):  
Infection Prevention ◽  
Medical Center ◽  
Academic Medical Center ◽  
Prevention Strategies ◽  
Intervention Period ◽  
Post Intervention ◽  
Frontline Staff ◽  
Post Intervention Period ◽  
Tract Infections ◽  
The Impact

Abstract Background High regulatory burden on hospital-onset (HO) infections has increased performance pressure on infection prevention programs. Despite the availability of comprehensive prevention guidelines, a major challenge has been communication with frontline staff to integrate appropriate prevention measures into practice. The objective of our study was to evaluate the impact of educational intervention on HO CAUTI rates and urinary catheter days. Methods At the University of Mississippi Medical Center, Infection prevention (IP) reports unit-based monthly HO infections via email to respective unit managers and ordering physician providers. Starting May 2018, IP assessed compliance to CAUTI prevention strategies per SHEA/IDSA practice recommendations (2014). HO CAUTI cases with noncompliance were labeled as “preventable” infections and educational justification was provided in the email report. No other interventions were introduced during the study period. CAUTI data were collected using ongoing surveillance per NHSN and used to calculate rates per 1,000 catheter days. One-way analysis of variance (ANOVA) was used to compare pre- and post-intervention data. Results Prior to intervention (July 2017–March 2018), HO CAUTI rate was 1.43 per 1,000 catheter days. In the post-intervention period (July 2018–March 2019), HO CAUTI rate decreased to 0.62 per 1,000 catheter days. Comparison of pre- and post-intervention rates showed a statistically significant reduction in HO CAUTIs (P = 0.04). The total number of catheter days reduced, but the difference was not statistically significant (8,604 vs. 7,583; P = 0.06). Of the 14 HO CAUTIs in post-intervention period, 64% (8/14) were reported preventable. The preventable causes included inappropriate urine culturing practice in asymptomatic patients (5) or as part of pan-culture without urinalysis (2), and lack of daily catheter assessment for necessity (1). Conclusion At our institute, regular educational feedback by IP to frontline staff resulted in a reduction of HO CAUTIs. Feedback measure improved accountability, awareness and engagement of frontline staff in practicing appropriate CAUTI prevention strategies. Disclosures All authors: No reported disclosures.

scholarly journals Enhanced infection control interventions reduced catheter-related bloodstream infections in the neonatal department of Hung Vuong Hospital, Vietnam, 2011–2012: a pre- and post-intervention study

2020 ◽  
Vol 9 (1) ◽  
Author(s):  
Hang Thi Phan ◽  
Thuan Huu Vo ◽  
Hang Thi Thuy Tran ◽  
Hanh Thi Ngoc Huynh ◽  
Hong Thi Thu Nguyen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intervention Study ◽  
Bloodstream Infections ◽  
Incidence Rates ◽  
Intervention Period ◽  
Intravenous Catheter ◽  
Aseptic Technique ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Factors Associated

Abstract Background Catheter-related bloodstream infections (CR-BSI) cause high neonatal mortality and are related to inadequate aseptic technique during the care and maintenance of a catheter. The incidence of CR-BSI among neonates in Hung Vuong Hospital was higher than that of other neonatal care centres in Vietnam. Methods An 18-month pre- and post-intervention study was conducted over three 6-month periods to evaluate the effectiveness of the intervention for CR-BSI and to identify risk factors associated with CR-BSI. During the intervention period, we trained all nurses in the Department of Neonatology on BSI preventive practices, provided auditing and feedback about aseptic technique during catheter care and maintenance, and reorganised preparation of total parenteral nutrition. All neonates with intravenous catheter insertion ≥48 h in the pre- and post-intervention period were enrolled. A standardised questionnaire was used to collect data. Blood samples were collected for cultures. We used Poisson regression to calculate rate ratio (RR) and 95% confidence interval (CI) for CR-BSI incidence rates and logistic regression to identify risk factors associated with CR-BSI. Results Of 2225 neonates enrolled, 1027 were enrolled in the pre-intervention period, of which 53 CR-BSI cases occurred in 8399 catheter-days, and 1198 were enrolled in the post-intervention period, of which 32 CR-BSI cases occurred in 8324 catheter-days. Incidence rates of CR-BSI significantly decreased after the intervention (RR = 0.61, 95% CI 0.39–0.94). Days of hospitalisation, episodes of non-catheter–related hospital-acquired infections, and the proportion of deaths significantly decreased after the intervention (p < 0.01). The CR-BSI was associated with days of intravenous catheter (odds ratio [OR] = 1.05, 95% CI 1.03–1.08), use of endotracheal intubation (OR = 2.27, 95% CI 1.27–4.06), and intravenous injection (OR = 8.50, 95% CI 1.14–63.4). Conclusions The interventions significantly decreased the incidence rate of CR-BSI. Regular refresher training and auditing and feedback about aseptic technique during care and maintenance of catheters are critical to reducing CR-BSI.

SEC Scrutiny and the Evolution of Non-GAAP Reporting

2008 ◽  
Vol 83 (1) ◽  
pp. 157-184 ◽  
Author(s):  
Kalin Kolev ◽  
Carol A. Marquardt ◽  
Sarah E. McVay
Keyword(s):  
Securities And Exchange Commission ◽  
Unintended Consequences ◽  
Intervention Period ◽  
Post Intervention ◽  
Special Items ◽  
Post Intervention Period

We empirically examine the effects of intensified scrutiny over non-GAAP reporting on the quality of non-GAAP earnings exclusions. We find that, on average, exclusions are of higher quality (i.e., more transitory) following intervention by the Securities and Exchange Commission (SEC) into non-GAAP reporting. We further find that firms that stopped releasing non-GAAP earnings numbers after the SEC intervention had lower quality exclusions in the pre-intervention period. These results are consistent with the SEC's objectives of improving the quality of non-GAAP earnings figures. However, when we decompose total exclusions into special items and other exclusions, we find evidence that the quality of special items has decreased in the post-intervention period, which suggests that managers adapted to the new disclosure environment by shifting more recurring expenses into special items. This suggests that there may be unintended consequences arising from the heightened scrutiny over non-GAAP reporting.

scholarly journals A Daytime Fast Track Improves Throughput in a Single Physician Coverage Emergency Department

CJEM ◽  
2015 ◽  
Vol 17 (6) ◽  
pp. 648-655 ◽  
Author(s):  
Julie Copeland ◽  
Andrew Gray
Keyword(s):  
Emergency Department ◽  
Fast Track ◽  
Community Hospital ◽  
Wait Time ◽  
Intervention Period ◽  
Post Intervention ◽  
Study Objective ◽  
Post Intervention Period ◽  
Left Without Being Seen ◽  
Physician Coverage

AbstractObjectivesFast tracks are one approach to reduce emergency department (ED) crowding. No studies have assessed the use of fast tracks in smaller hospitals with single physician coverage. Our study objective was to determine if implementation of an ED fast track in a single physician coverage setting would improve wait times for low-acuity patients without negatively impacting those of higher acuity.MethodsA daytime fast track opened in 2010 at Strathroy Middlesex General Hospital, a southwestern Ontario community hospital. Before and after intervention groups comprised of ED visits in 2009 and 2011 were compared. Pooled comparison of all Canadian Triage and Acuity Scale (CTAS) patients in each period, and between subgroups CTAS 2-5 comparisons were performed for: wait time (WT), length of stay (LOS), WTs that met national CTAS time guidelines (MNCTG), and proportion of patients that left without being seen (LWBS).ResultsWT and LOS were six minutes (88 min to 82 min, p=0.002) and 15 minutes (158 min to 143 min, p<0.001) lower, respectively, in the post-intervention period. Subgroup analysis showed CTAS 4 had the most pre- to post-intervention decrease in WT, of 13 minutes (98 min to 85 min, p<0.001). There was statistical improvement in MNCTG in the post-intervention period. No differences were found in outcome measures for higher-acuity patients or LWBS rates.ConclusionsImplementation of a fast track in a medium-volume community hospital with single physician coverage can improve patient throughput by decreasing WT and LOS without negatively impacting high-acuity patients. This may be clinically relevant, particularly for hospital administrators, given the improvement in meeting national WT standards we found post-intervention.

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