scholarly journals Thrombolysis implementation intervention and clinical outcome: a secondary analysis of a cluster randomized trial

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Md Golam Hasnain ◽  
Christine L. Paul ◽  
John R. Attia ◽  
Annika Ryan ◽  
Erin Kerr ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Post Treatment ◽  
Trial Registration ◽  
Control Group ◽  
Intervention Period ◽  
Post Intervention ◽  
Individual Level ◽  
Post Intervention Period

Abstract Background Multiple studies have attempted to increase the rate of intravenous thrombolysis for ischemic stroke using interventions to promote adherence to guidelines. Still, many of them did not measure individual-level impact. This study aimed to make a posthoc comparison of the clinical outcomes of patients in the “Thrombolysis ImPlementation in Stroke (TIPS)” study, which aimed to improve rates of intravenous thrombolysis in Australia. Methods A posthoc analysis was conducted using individual-level patient data. Excellent (Three-month post treatment modified Rankin Score 0–2) and poor clinical outcome (Three-month post treatment modified Rankin Score 5–6) and post treatment parenchymal haematoma were the three main outcomes, and a mixed logistic regression model was used to assess the difference between the intervention and control groups. Results There was a non-significant higher odds of having an excellent clinical outcome of 57% (odds ratio: 1.57; 95% CI: 0.73–3.39) and 33% (odds ratio: 1.33; 95% CI: 0.73–2.44) during the active-and post-intervention period respectively, for the intervention compared to the control group. A non-significant lower odds of having a poor clinical outcome was also found in the intervention, relative to control group of 4% (odds ratio: 0.96; 95% CI: 0.56–2.07) and higher odds of having poor outcome of 44% (odds ratio: 1.44 95% CI: 0.61–3.41) during both active and post-intervention period respectively. Similarly, a non-significant lower odds of parenchymal haematoma was also found for the intervention group during the both active- (odds ratio: 0.53; 95% CI: 0.21–1.32) and post-intervention period (odds ratio: 0.96; 95% CI: 0.36–2.52). Conclusion The TIPS multi-component implementation approach was not effective in reducing the odds of post-treatment severe disability at 90 days, or post-thrombolysis hemorrhage. Trial registration Clinical Trial Registration-URL: http://www.anzctr.org.au/ Unique Identifier: ACTRN12613000939796.

scholarly journals Thrombolysis implementation intervention and clinical outcome: A Secondary analysis of a cluster randomized trial.

2020 ◽  
Author(s):  
Md Golam Hasnain ◽  
Christine L Paul ◽  
John R Attia ◽  
Annika Ryan ◽  
Erin Kerr ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Post Treatment ◽  
Control Group ◽  
Intervention Period ◽  
Poor Clinical Outcome ◽  
Post Intervention ◽  
Individual Level ◽  
Post Intervention Period

Abstract BackgroundMultiple studies have attempted to increase the rate of intravenous thrombolysis for ischemic stroke using interventions to promote adherence to guidelines. Still, many of them did not measure individual-level impact. This study aimed to make a posthoc comparison of the clinical outcomes of patients in the “Thrombolysis ImPlementation in Stroke (TIPS)” study, which aimed to improve rates of intravenous thrombolysis in Australia.MethodsA posthoc analysis was conducted using individual-level patient data. Excellent (Three-month post treatment modified Rankin Score 0-2) and poor clinical outcome (Three-month post treatment modified Rankin Score 5-6) and post treatment parenchymal haematoma were the three main outcomes, and a mixed logistic regression model was used to assess the difference between the intervention and control groups.ResultsThere was a non-significant higher odds of having an excellent clinical outcome of 57% (odds ratio: 1.57; 95% CI: 0.73-3.39) and 33% (odds ratio: 1.33; 95% CI: 0.73-2.44) during the active-and post-intervention period respectively, for the intervention compared to the control group. A non-significant lower odds of having a poor clinical outcome was also found in the intervention, relative to control group of 4% (odds ratio: 0.96; 95% CI: 0.56-2.07) and higher odds of having poor outcome of 44% (odds ratio: 1.44 95% CI: 0.61-3.41) during both active and post-intervention period respectively. Similarly, a non-significant lower odds of parenchymal haematoma was also found for the intervention group during the both active- (odds ratio: 0.53; 95% CI: 0.21-1.32) and post-intervention period (odds ratio: 0.96; 95% CI: 0.36-2.52).ConclusionThe TIPS multi-component implementation approach was not effective in reducing the odds of post-treatment severe disability at 90 days, or post-thrombolysis hemorrhage.Trial registrationClinical Trial Registration-URL: http://www.anzctr.org.au/ Unique Identifier: ACTRN12613000939796.

scholarly journals Thrombolysis Implementation Intervention and Clinical Outcome: A Secondary Analysis of a Cluster Randomized Trial.

2020 ◽  
Author(s):  
Md Golam Hasnain ◽  
Christine L Paul ◽  
John R Attia ◽  
Annika Ryan ◽  
Erin Kerr ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Control Group ◽  
Intervention Period ◽  
Poor Clinical Outcome ◽  
Post Intervention ◽  
Lower Odds ◽  
Individual Level ◽  
Post Intervention Period

Abstract Background Multiple studies have attempted to increase the rate of intravenous thrombolysis for ischemic stroke using interventions to promote adherence to guidelines. Still, many of them did not measure individual-level impact. This study aimed to make a posthoc comparison of the clinical outcomes of patients in the “Thrombolysis ImPlementation in Stroke (TIPS)” study, which aimed to improve rates of intravenous thrombolysis in Australia.Methods A posthoc analysis was conducted using individual-level patient data. Excellent and poor clinical outcome and parenchymal haematoma were the three main outcomes, and a mixed logistic regression model was used to assess the difference between the intervention and control groups.Results There was a non-significantly higher odds of having an excellent clinical outcome of 57% (odds ratio: 1.57; 95% CI: 0.73–3.39) and 33% (odds ratio: 1.33; 95% CI: 0.73–2.44) during the active-and post-intervention period respectively, for the intervention compared to the control group. A non-significantly lower odds of having a poor clinical outcome was also found in the intervention, relative to control group of 4% (odds ratio: 0.96; 95% CI: 0.56–2.07) and higher odds of having poor outcome of 44% (odds ratio: 1.44 95% CI: 0.61–3.41) during both active and post-intervention period respectively. Similarly, a non-significant lower odds of parenchymal haematoma was also found for the intervention group during the both active- (odds ratio: 0.53; 95% CI: 0.21–1.32) and post-intervention period (odds ratio: 0.96; 95% CI: 0.36–2.52).Conclusion The TIPS multi-component implementation approach was not effective in reducing the odds of post-treatment severe disability at 90 days, or post-thrombolysis hemorrhage.Trial registration Clinical Trial Registration-URL: http://www.anzctr.org.au/ Unique Identifier: ACTRN12613000939796.

scholarly journals Door to needle time for thrombolysis: A secondary analysis of the TIPS cluster randomized controlled trial

2019 ◽  
Author(s):  
Md Hasnain ◽  
Christine L Paul ◽  
John R Attia ◽  
Annika Ryan ◽  
Erin Kerr ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Controlled Trial ◽  
Intravenous Thrombolysis ◽  
Practice Change ◽  
Intervention Period ◽  
Post Intervention ◽  
Intervention Effects ◽  
Post Intervention Period ◽  
Active Intervention ◽  
Randomized Controlled

Abstract Background The Thrombolysis ImPlementation in Stroke (TIPS) study evaluated a hospital-based intervention aimed at improving the rates of intravenous thrombolysis in Australia. The current study assessed the effects of this intervention on the door-to-needle time for intravenous thrombolysis and also determined the intervention effects on door-to-needle time within metropolitan and non-metropolitan hospital locations. Methods TIPS was a clustered randomized controlled trial that involved 20 hospitals in Australia, with 10 hospitals receiving a multi-component practice-change intervention. De-identified patient data collected in the trial included the arrival, assessment, and treatment times for acute ischemic stroke patients. A posthoc exploration using mixed-effects regression modelling was used to assess intervention effects on door-to-needle time, and the effects within hospital location (metropolitan versus non-metropolitan). Results The intervention vs. control difference in the door-to-needle times was non-significant overall or within a hospital location. To provide additional context for the findings, we also evaluated the results within each intervention hospitals. During the active-intervention period, the intervention hospitals showed a significant decrease in the door-to-needle time of 9.25 minutes (95%CI: -16.93, -1.57), but during the post-intervention period, the result was not significant. During the active intervention period, control hospitals showed a significant decrease in the door-to-needle time of 5.26 minutes (95% CI: -8.37; -2.14) and during the post-intervention period, the decrease was 12.13 minutes (95%CI: -17.44, -6.81). Conclusion Across these primary stroke care centres in Australia, a secular trend towards shorter door-to-needle times across both intervention and control hospitals was evident. The intervention resulted in only a modest but significant reduction within experimental groups during the active intervention period, which was not sustained during the post-intervention period.

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.

Effect of Replacing Vendor QTc Alerts with a Custom QTc Risk Alert in Inpatients

2022 ◽  
Vol 13 (01) ◽  
pp. 019-029
Author(s):  
Steven Stettner ◽  
Sarah Adie ◽  
Sarah Hanigan ◽  
Michael Thomas ◽  
Kristen Pogue ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Clinical Decision ◽  
Qtc Interval ◽  
Intervention Period ◽  
Qtc Prolongation ◽  
Post Intervention ◽  
Medication Knowledge ◽  
Quasi Experimental ◽  
Risk Scoring ◽  
Scoring Tool

Abstract Objective The aim of the study is to implement a customized QTc interval clinical decision support (CDS) alert strategy in our electronic health record for hospitalized patients and aimed at providers with the following objectives: minimize QTc prolongation, minimize exposure to QTc prolonging medications, and decrease overall QTc-related alerts. A strategy that was based on the validated QTc risk scoring tool and replacing medication knowledge vendor alerts with custom QTc prolongation alerts was implemented. Methods This is a retrospective quasi-experimental study with a pre-intervention period (August 2019 to October 2019) and post-intervention period (December 2019 to February 2020). The custom alert was implemented in November 2019. Results In the pre-implementation group, 361 (19.3%) patients developed QTc prolongation, and in the post-implementation group, 357 (19.6%) patients developed QTc prolongation (OR: 1.02, 95% CI: 0.87–1.20, p = 0.81). The odds ratio of an action taken post-implementation compared with pre-implementation was 18.90 (95% CI: 14.03–25.47, p <0. 001). There was also a decrease in total orders for QTc prolonging medications from 7,921 (5.5%) to 7,566 (5.3%) with an odds ratio of 0.96 (95% CI: 0.93–0.99, p = 0.01). Conclusion We were able to decrease patient exposure to QTc prolonging medications while not increasing the rate of QTc prolongation as well as improving alert action rate. Additionally, there was a decrease in QTc prolonging medication orders which illustrates the benefit of using a validated risk score with a customized CDS approach compared with a traditional vendor-based strategy. Further research is needed to confirm if an approach implemented at our organization can reduce QTc prolongation rates.

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 Thrombolysis related symptomatic intracranial hemorrhage in estimated versus measured body weight

2019 ◽  
Vol 15 (2) ◽  
pp. 159-166
Author(s):  
T Truc My Nguyen ◽  
Stephanie IW van de Stadt ◽  
Adrien E Groot ◽  
Marieke JH Wermer ◽  
Heleen M den Hertog ◽  
...  
Keyword(s):  
Body Weight ◽  
Clinical Outcome ◽  
Confidence Interval ◽  
Intracranial Hemorrhage ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Weight Group ◽  
Tissue Plasminogen ◽  
Symptomatic Intracranial Hemorrhage

Background and aim In acute ischemic stroke, under- or overestimation of body weight can lead to dosing errors of recombinant tissue plasminogen activator with consequent reduced efficacy or increased risk of hemorrhagic complications. Measurement of body weight is more accurate than estimation of body weight but potentially leads to longer door-to-needle times. Our aim was to assess if weight modality (estimation of body weight versus measurement of body weight) is associated with (i) symptomatic intracranial hemorrhage rate, (ii) clinical outcome, and (iii) door-to-needle times. Methods Consecutive patients treated with intravenous thrombolysis between 2009 and 2016 from 14 hospitals were included. Baseline characteristics and outcome parameters were retrieved from medical records. We defined symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study (ECASS)-III definition and clinical outcome was assessed with the modified Rankin Scale. The association of weight modality and outcome parameters was estimated with regression analyses. Results A total of 4801 patients were included. Five hospitals used measurement of body weight (n = 1753), six hospitals used estimation of body weight (n = 2325), and three hospitals (n = 723) changed from estimation of body weight to measurement of body weight during the study period. In 2048 of the patients (43%), measurement of body weight was used and in 2753 (57%), estimation of body weight. In the measurement of body weight group, an inbuilt weighing bed was used in 1094 patients (53%) and a patient lift scale in 954 patients (47%). In the estimation of body weight group, policy regarding estimation was similar. Estimation of body weight was not associated with increased symptomatic intracranial hemorrhage risk (adjusted odds ratio = 1.16; 95% confidence interval 0.83–1.62) or favorable outcome (adjusted odds ratio = 0.99; 95% confidence interval 0.82–1.21), but it was significantly associated with longer door-to-needle times compared to measurement of body weight using an inbuilt weighing bed (adjusted B = 3.57; 95% confidence interval 1.33–5.80) and shorter door-to-needle times compared to measurement of body weight using a patient lift scale (−3.96; 95% confidence interval −6.38 to −1.53). Conclusion We did not find evidence that weight modality (estimation of body weight versus measurement of body weight) to determine recombinant tissue plasminogen activator dose in intravenous thrombolysis eligible patients is associated with symptomatic intracranial hemorrhage or clinical outcome. We did find that estimation of body weight leads to longer door-to-needle times compared to measurement of body weight using an inbuilt weighing bed and to shorter door-to-needle times compared to measurement of body weight using a patient lift scale.

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.

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