1324: THE IMPACT OF CRITICAL CARE ORDER SET CHANGES ON PRESCRIBING AND CLINICAL OUTCOMES

2020 ◽  
Vol 48 (1) ◽  
pp. 639-639
Author(s):  
Natalie Washburn ◽  
Ellen Muniga ◽  
Todd Walroth
Keyword(s):  
Critical Care ◽  
Clinical Outcomes ◽  
The Impact ◽  
Order Set

scholarly journals The Impact of Changes to an Electronic Admission Order Set on Prescribing and Clinical Outcomes in the Intensive Care Unit

2020 ◽  
Vol 11 (01) ◽  
pp. 182-189
Author(s):  
Ellen T. Muniga ◽  
Todd A. Walroth ◽  
Natalie C. Washburn
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Intensive Care ◽  
Clinical Outcomes ◽  
Prescribing Patterns ◽  
Number Of Patients ◽  
Order Sets ◽  
Critical Care Admission ◽  
The Impact ◽  
Order Set

Abstract Background Implementation of disease-specific order sets has improved compliance with standards of care for a variety of diseases. Evidence of the impact admission order sets can have on care is limited. Objective The main purpose of this article is to evaluate the impact of changes made to an electronic critical care admission order set on provider prescribing patterns and clinical outcomes. Methods A retrospective, observational before-and-after exploratory study was performed on adult patients admitted to the medical intensive care unit using the Inpatient Critical Care Admission Order Set. The primary outcome measure was the percentage change in the number of orders for scheduled acetaminophen, a histamine-2 receptor antagonist (H2RA), and lactated ringers at admission before implementation of the revised order set compared with after implementation. Secondary outcomes assessed clinical impact of changes made to the order set. Results The addition of a different dosing strategy for a medication already available on the order set (scheduled acetaminophen vs. as needed acetaminophen) had no impact on physician prescribing (0 vs. 0%, p = 1.000). The addition of a new medication class (an H2RA) to the order set significantly increased the number of patients prescribed an H2RA for stress ulcer prophylaxis (0 vs. 20%, p < 0.001). Rearranging the list of maintenance intravenous fluids to make lactated ringers the first fluid option in place of normal saline significantly decreased the number of orders for lactated ringers (17 vs. 4%, p = 0.005). The order set changes had no significant impact on clinical outcomes such as incidence of transaminitis, gastrointestinal bleed, and acute kidney injury. Conclusion Making changes to an admission order set can impact provider prescribing patterns. The type of change made to the order set, in addition to the specific medication changed, may have an effect on how influential the changes are on prescribing patterns.

scholarly journals Evaluation of Clinical Outcomes after Introduction of a Dedicated Infectious Diseases- Critical Care Medicine Service in Critical Care Units

2021 ◽  
Author(s):  
Polina Trachuk ◽  
Vagish Hemmige ◽  
Ruth Eisenberg ◽  
Kelsie Cowman ◽  
Victor Chen ◽  
...  
Keyword(s):  
Critical Care ◽  
Infectious Diseases ◽  
Clinical Outcomes ◽  
Broad Spectrum ◽  
Critical Care Medicine ◽  
Care Hospital ◽  
Intervention Period ◽  
Broad Spectrum Antibiotics ◽  
Antibiotic Utilization ◽  
The Impact

Abstract Objective Infection is a leading cause of admission to intensive care units (ICU), with critically ill patients often receiving empiric broad-spectrum antibiotics. Nevertheless, a dedicated infectious diseases (ID) consultation and stewardship team is not routinely established. An ID-Critical Care Medicine (ID-CCM) pilot program was designed at a 400-bed tertiary care hospital in which an ID attending was assigned to participate in daily rounds with the ICU team, as well as provide ID consultation on select patients. We sought to evaluate the impact of this dedicated ID program on antibiotic utilization and clinical outcomes in patients admitted to the ICU. Method In this single site retrospective study, we analyzed antibiotic utilization and clinical outcomes in patients admitted to an ICU during post-intervention period from January 1, 2017 to December 31, 2017 and compared it to antibiotic utilization in the same ICUs during the pre-intervention period from January 1, 2015 to December 31, 2015. Results Our data showed a statistically significant reduction in usage of most frequently prescribed antibiotics including vancomycin, piperacillin-tazobactam and cefepime during the intervention period. When compared to pre-intervention period there was no difference in-hospital mortality, hospital length of stay and re-admission. Conclusion With this multidisciplinary intervention, we saw a decrease in the use of the most frequently prescribed broad-spectrum antibiotics without a negative impact on clinical outcomes. Our study shows that the implementation of an ID-CCM service is a feasible way to promote antibiotic stewardship in the ICU and can be used as a strategy to reduce unnecessary patient exposure to broad-spectrum agents.

scholarly journals Vascular Access Support Team: A Multi-Disciplinary Response to Optimise Patients’ Care during COVID-19 Pandemic

2020 ◽  
Author(s):  
Manish Sinha ◽  
Prakash Saha ◽  
Melhem Nabil ◽  
Nicos Kessaris ◽  
Lukla Biasi ◽  
...  
Keyword(s):  
Critical Care ◽  
Clinical Outcomes ◽  
Vascular Access ◽  
Online Survey ◽  
High Rate ◽  
Minor Bleeding ◽  
Complication Rates ◽  
Support Team ◽  
The Uk ◽  
The Impact

Abstract Background: Vascular access support teams have been set up to help offload procedural tasks from critical care teams during the coronavirus disease 2019 (COVID-19) global pandemic. However, the impact of VAST on clinical outcomes and on workload has not been shown previously with no reports to date from the UK. Our aim was to evaluate clinical outcomes of a multidisciplinary vascular access support team (VAST) and the value of the service to critical care teams. Methods: Prospectively collected data on all patients requiring vascular access at St Thomas’ Hospital, London over a 5-week period during the first wave of the pandemic in the UK. At the end of study period, online anonymised questionnaire administered to critical care team members, including nursing and medical professionals, to evaluate their experience of the service. We report access-related complication until discharge from centre and description of results of online survey.Results: 122 patients aged 52.1 ± 13 years with high rate of pre-existing co-morbidities, underwent line insertion including 190 catheters (central venous n=182, arterial n=8). Median (range) number of 5 (0-17) lines were placed per day in patients of whom 90% tested positive for Severe Acute Respiratory Syndrome Coronavirus-type 2 pathogen (SARS-CoV-2). A single line (n=146) was inserted in 96 out of 122 patients (78.7%) and n=18 patients (14.7%) ‘double puncture’ technique used. 45 line insertions (24%) had complications with minor [bleeding (n=19), line infection (n=10)] and 2 lines (1%) with major complication. The survey respondents, n=54 professionals, highlighted ease of referral and timely access placement (>90% responses); with agreement that VAST service saved them precious time and allow them to focus on other jobs.Conclusions: We describe the successful deployment of a multidisciplinary vascular access team with low complication rates and high rates of satisfaction. We recommend similar models can be considered by health services to optimise patient care and ICU management.

Abstract TP339: Stroke Severity Scoring: A Bi-variate Analysis of Clinical Outcomes Post Intravenous t-PA as a Guide to Influence Potential Change in Clinical Practice

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Zia u Rehman ◽  
Mark A Mazer ◽  
Susan D Freeman ◽  
Cristine W Small ◽  
Abid Butt
Keyword(s):  
Blood Pressure ◽  
Critical Care ◽  
Clinical Practice ◽  
Clinical Outcomes ◽  
Stroke Unit ◽  
Stroke Severity ◽  
List Type ◽  
Severity Scores ◽  
Variate Analysis ◽  
The Impact

Background: Care of the acute stroke patient in a dedicated stroke unit or ICU has been associated with improved outcomes. Not all post tPA patients require ICU level care, however general practice is admission to the ICU for 24 hours following tPA administration. In a Certified Primary Stroke Center nestled in the buckle of the stroke belt, 800+ patients with a primary diagnosis of stroke are admitted annually. There is a dedicated stroke unit with continuous multichannel telemetry. All post tPA patients are admitted to the medical ICU for the first 24 hours. Purpose: Hospitals administering intravenous tPA should continuously evaluate the impact of patient selection, unit placement and overall outcomes to include clinical efficiency, cost effectiveness, quality, safety, complications and deaths. Partnering with critical care physicians to evaluate stroke severity scores is essential for empirical consideration. Methods: Data analysis of clinical elements that may predict patient outcomes and serve as a guide to influence change in clinical practice was reviewed. Bi-variate analysis of stroke severity scores, whereby the first National Institute of Health Stroke Scale (NIHSS), < 15 and > 15 Review of comorbities Blood pressure control Complications to include symptomatic bleeding Discharge disposition Death Results: Clinical outcomes of 171 patients post tPA administration were reviewed over a two year period. • 80% of patients with NIHSS < 15 were discharged to home or rehab • 42% of patients with NIHSS > 15 were discharged to home or rehab • Four deaths occurred in patients with NIHSS < 15. Three deaths unrelated to tPA administration included one cardiac arrest and two respiratory failure. The fourth death, a regional transfer with advanced age, complex comorbities and uncontrolled blood pressure, resulting in a symptomatic bleed. • 16 deaths occurred in the patients with NIHSS > 15 Conclusions: Analytical review of outcome data, specifically stroke severity scores, should serve to influence ICU admission criteria and processes. Engagement of board certified neurocritical physicians or intensivists supports empirical evidence for improved utilization of resources and critical care beds using NIHSS < 15 as a reference.

scholarly journals A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Sara Malone ◽  
Virginia R. McKay ◽  
Christina Krucylak ◽  
Byron J. Powell ◽  
Jingxia Liu ◽  
...  
Keyword(s):  
Public Health ◽  
Clinical Outcomes ◽  
Antibiotic Stewardship ◽  
Implementation Strategies ◽  
Antibiotic Use ◽  
Low Risk ◽  
Stepped Wedge ◽  
Cluster Randomized ◽  
The Impact ◽  
Order Set

Abstract Background Antibiotic-resistant infections have become a public health crisis that is driven by the inappropriate use of antibiotics. In the USA, antibiotic stewardship programs (ASP) have been established and are required by regulatory agencies to help combat the problem of antibiotic resistance. Post-operative antibiotic use in surgical cases deemed low-risk for infection is an area with significant overuse of antibiotics in children. Consensus among leading public health organizations has led to guidelines eliminating post-operative antibiotics in low-risk surgeries. However, the best strategies to de-implement these inappropriate antibiotics in this setting are unknown. Methods/design A 3-year stepped wedge cluster randomized trial will be conducted at nine US Children’s Hospitals to assess the impact of two de-implementation strategies, order set change and facilitation training, on inappropriate post-operative antibiotic prescribing in low risk (i.e., clean and clean-contaminated) surgical cases. The facilitation training will amplify order set changes and will involve a 2-day workshop with antibiotic stewardship teams. This training will be led by an implementation scientist expert (VRM) and a pediatric infectious diseases physician with antibiotic stewardship expertise (JGN). The primary clinical outcome will be the percentage of surgical cases receiving unnecessary post-operative antibiotics. Secondary clinical outcomes will include the rate of surgical site infections and the rate of Clostridioides difficile infections, a common negative consequence of antibiotic use. Monthly semi-structured interviews at each hospital will assess the implementation process of the two strategies. The primary implementation outcome is penetration, which will be defined as the number of order sets changed or developed by each hospital during the study. Additional implementation outcomes will include the ASP team members’ assessment of the acceptability, appropriateness, and feasibility of each strategy while they are being implemented. Discussion This study will provide important information on the impact of two potential strategies to de-implement unnecessary post-operative antibiotic use in children while assessing important clinical outcomes. As more unnecessary medical practices are identified, de-implementation strategies, including facilitation, need to be rigorously evaluated. Along with this study, other rigorously designed studies evaluating additional strategies are needed to further advance the burgeoning field of de-implementation. Trial registration NCT04366440. Registered April 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04366440.

The Learning Curve in Arthroscopic ACL Reconstruction. The impact on the Surgical Time and Postoperative Clinical Results

2018 ◽  
Vol 69 (10) ◽  
pp. 2874-2876
Author(s):  
Teodor Negru ◽  
Stefan Mogos ◽  
Ioan Cristian Stoica
Keyword(s):  
Anterior Cruciate Ligament ◽  
Learning Curve ◽  
Clinical Outcomes ◽  
Positive Impact ◽  
Cruciate Ligament ◽  
Clinical Results ◽  
Single Bundle ◽  
Surgical Time ◽  
Anterior Cruciate ◽  
The Impact

Rupture of the anterior cruciate ligament (ACL) is a common injury. The objective of the current study was to evaluate if the learning curve has an impact on surgical time and postoperative clinical outcomes after anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) using an outside-in tunnel drilling hamstrings technique. The learning curve has a positive impact on surgical time but has no influence on postoperative clinical outcomes at short time follow-up.

Projecting the long-term benefits of single pill combination therapy for patients with hypertension in five countries

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
C Borghi ◽  
J.G Wang ◽  
A.V Rodionov ◽  
M Rosas ◽  
I.S Sohn ◽  
...  
Keyword(s):  
Combination Therapy ◽  
South Korea ◽  
Health Outcomes ◽  
Clinical Outcomes ◽  
Funding Source ◽  
Combination Therapies ◽  
Private Company ◽  
Treatment Pathways ◽  
Single Pill ◽  
The Impact

Abstract Background It is well established that single pill combination (SPC) therapies have the potential to improve patient adherence versus multi-pill regimens, thereby improving blood pressure control and clinical outcomes in populations with hypertension. Purpose To develop a microsimulation model, capturing different treatment pathways, to project the impact on clinical outcomes of using single pill combination therapies for the management of hypertension in five countries (Italy, Russia, China, South Korea and Mexico). Methods The model was designed to project health outcomes between 2020 and 2030 for populations with hypertension managed according to four different treatment pathways: current treatment practices [CTP], single drug with dosage titration first then sequential addition of other agents [start low and go slow, SLGS], free choice combination with multiple pills [FCC] and combination therapy in the form of a single pill [SPC]. Model inputs were derived from Global Burden of Disease 2017 dataset, including demographics, health status/risk factors, transition probabilities and treatment attributes/healthcare utilization, and the model incorporated real-world challenges to healthcare delivery such as access to care, SBP measurement error, adherence and therapeutic inertia. Simulated outcomes of mortality, incidence of chronic kidney disease (CKD), stroke and ischemic heart disease (IHD), and disability-adjusted life years (DALYs) due to these conditions were estimated for population of 1,000,000 simulated patients for each treatment pathway and country. Results SPC therapy was projected to improve health outcomes over SLGS, FCC and CTP over 10 years in all five countries. SPC was forecast to reduce mortality by 5.4% (Italy), 4.9% (Russia), 4.5% (China), 2.3% (South Korea) and 3.6% (Mexico) versus CTP and showed greater projected reductions in mortality than SLGS and FCC. DALYs were projected to be reduced with SPC therapy by between 5.7% (Italy) and 2.2% (South Korea) compared with CTP and reductions in the incidence of clinical events were also projected with SPC therapy, with decreases in the range of 11.5% (Italy) to 4.9% (South Korea) versus CTP. Conclusions Ten-year projections of clinical outcomes associated with different anti-hypertensive treatment pathways in five countries indicated that both combination therapies (FCC and SPC) are likely to reduce the disease burden of hypertension compared with conventional management approaches, with SPC showing the greatest overall benefits due to improved adherence. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Sanofi, Gentilly, France

scholarly journals 288. Follow-Up Blood Cultures in Gram-Negative Bacteremia: How Do They Impact Outcomes

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S144-S144
Author(s):  
Azza Elamin ◽  
Faisal Khan ◽  
Ali Abunayla ◽  
Rajasekhar Jagarlamudi ◽  
aditee Dash
Keyword(s):  
Clinical Outcomes ◽  
Antibiotic Treatment ◽  
Readmission Rate ◽  
Blood Cultures ◽  
Categorical Variables ◽  
Gram Negative ◽  
Number Of Patients ◽  
Significant Difference ◽  
The Impact

Abstract Background As opposed to Staphylococcus. aureus bacteremia, there are no guidelines to recommend repeating blood cultures in Gram-negative bacilli bacteremia (GNB). Several studies have questioned the utility of follow-up blood cultures (FUBCs) in GNB, but the impact of this practice on clinical outcomes is not fully understood. Our aim was to study the practice of obtaining FUBCs in GNB at our institution and to assess it’s impact on clinical outcomes. Methods We conducted a retrospective, single-center study of adult patients, ≥ 18 years of age admitted with GNB between January 2017 and December 2018. We aimed to compare clinical outcomes in those with and without FUBCs. Data collected included demographics, comorbidities, presumed source of bacteremia and need for intensive care unit (ICU) admission. Presence of fever, hypotension /shock and white blood cell (WBC) count on the day of FUBC was recorded. The primary objective was to compare 30-day mortality between the two groups. Secondary objectives were to compare differences in 30-day readmission rate, hospital length of stay (LOS) and duration of antibiotic treatment. Mean and standard deviation were used for continuous variables, frequency and proportion were used for categorical variables. P-value &lt; 0.05 was defined as statistically significant. Results 482 patients were included, and of these, 321 (67%) had FUBCs. 96% of FUBCs were negative and 2.8% had persistent bacteremia. There was no significant difference in 30-day mortality between those with and without FUBCs (2.9% and 2.7% respectively), or in 30-day readmission rate (21.4% and 23.4% respectively). In patients with FUBCs compared to those without FUBCs, hospital LOS was longer (7 days vs 5 days, P &lt; 0.001), and mean duration of antibiotic treatment was longer (14 days vs 11 days, P &lt; 0.001). A higher number of patients with FUBCs needed ICU care compared to those without FUBCs (41.4% and 25.5% respectively, P &lt; 0.001) Microbiology of index blood culture in those with and without FUBCs Outcomes in those with and without FUBCs FUBCs characteristics Conclusion Obtaining FUBCs in GNB had no impact on 30-day mortality or 30-day readmission rate. It was associated with longer LOS and antibiotic duration. Our findings suggest that FUBCs in GNB are low yield and may not be recommended in all patients. Prospective studies are needed to further examine the utility of this practice in GNB. Disclosures All Authors: No reported disclosures

scholarly journals Effect of Obesity on Clinical Failure of Patients Treated with Beta-Lactams

2021 ◽  
Author(s):  
Nathan A Pinner ◽  
Natalie G Tapley ◽  
Katie E Barber ◽  
Kayla R Stover ◽  
Jamie L Wagner
Keyword(s):  
Treatment Failure ◽  
Clinical Outcomes ◽  
Hospital Length Of Stay ◽  
Source Control ◽  
Definitive Treatment ◽  
Therapeutic Drug ◽  
Obese Patients ◽  
Definitive Therapy ◽  
All Cause Mortality ◽  
The Impact

Abstract Background Altered pharmacokinetics in obese patients raise concerns over worse clinical outcomes. This study assessed whether obese patients receiving a beta-lactam (BL) have worse clinical outcomes compared to non-obese patients and to identify if therapeutic drug monitoring (TDM) may be beneficial. Methods This multi-center, retrospective cohort included hospitalized adults admitted from July 2015-July 2017 treated with a BL as definitive monotherapy against a Gram-negative bacilli for ≥72 hours. Patients were excluded if there was lack of source control or if polymicrobial infections required &gt;1 antibiotic for definitive therapy. Patients were classified based on body mass index (BMI): non-obese (BMI ≤29.9 kg/m 2) and obese (BMI ≥30.0 kg/m 2). The primary outcome was clinical treatment failure, and secondary were hospital length of stay (LOS), inpatient all-cause mortality, and 30-day all-cause readmission. Results There were 257 (43.6%) obese patients and 332 (56.4%) non-obese patients included. The most common infections were urinary (50.9%) and respiratory (31.4%). Definitive treatment was driven by 3 rd generation cephalosporins (46.9%) and cefepime (44.7%). Treatment failure occurred in 131 (51%) obese patients and 109 (32.8%) non-obese patients (p&lt;0.001). Obesity and respiratory source were independently associated with increased likelihood of treatment failure. Obese patients were hospitalized longer than non-obese patients (p=0.002), but no differences were found for all-cause mortality (p=0.117) or infection-related readmission (0=0.112). Conclusions Obese patients treated with BLs have higher rates of treatment failure and longer hospitalization periods than non-obese patients. Future studies are needed to assess the impact of TDM and specific dosing recommendations for targeted infection types.

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