Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery

Objective To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. Study Design Retrospective cohort study. Setting County hospital otolaryngology practice. Methods A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. Results We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 ( P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased ( P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased ( P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids. Conclusion Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.

DETERMINANT OF HEALTH PROTOCOL IMPLEMENTATION AMONG ELDERLY WITH CHRONIC DISEASE IN JEMBER

Background: Elderly is one of the vulnerable groups against COVID 19 infection. The mortality rate from COVID 19 is the highest in the elderly. The chronic disease is worsening the outcome. Objective: This study aimed to find the determinant of the implementation of health protocols among the elderly with chronic disease. Methods: This study was a correlational study conducted with a cross-sectional approach. A total of 437 elderly were selected through consecutive sampling techniques. The respondents were asked to fill the KAP questionnaire through a google form. The data were analysed using binary logistic regression and multivariate logistic regression techniques using SPSS. Result: The results showed that educational level (p-value 0,088); living arrangement (p-value 0,035); knowledge (p-value 0,026); occupation (p-value 0, 042) and the implementation of self-care management (p-value 0,047) were correlated with the implementation of health protocols among the elderly with chronic disease. Knowledge became the main determinant of the health protocol implementation among the elderly with OR 8,456 95%CI (3,495 – 20,455). Conclusion: It can be concluded that the elderly with adequate knowledge has the potential to be 8,4 times more likely to implement the health protocols properly. Health education about the appropriate implementation of health protocol needs to be carried out using a plain language that is easily accepted by the elderly

Examining Barriers and Facilitators of Pediatric Enhanced Recovery Protocol Implementation

Background: Enhanced Recovery Protocols (ERPs) are an evidence-based intervention to optimize post-surgical recovery. Several studies have demonstrated that use of an ERP for gastrointestinal surgery results in decreased length of stay, shortened time to regular diet, and fewer administered opioids, while also trending toward lower complication and 30-day readmission rates. Yet, implementation of ERPs in pediatric surgery is lagging compared to adult surgery. The purpose of this study was to conduct a theory-guided evaluation of barriers and facilitators to ERP implementation at US hospitals with a pediatric surgery service.Methods: We conducted semi-structured interviews at 18 hospitals with 48 participants, including pediatric surgeons, anesthesiologists, gastroenterologists, nurses, and physician assistants. Interviews were conducted online, audio-recorded, and transcribed verbatim. To identify barriers and facilitators to ERP implementation, we conducted a thematic analysis using combined inductive as well as deductive logics based on the National Implementation Research Network’s Five Active Implementation Frameworks (AIFs). Results: Framed by the 5AIFs, factors serving as barriers and facilitators to ERP implementation included: fidelity to and operationalization of ERP elements and measurement of outcomes (usable innovations); establishing and standardizing ERP protocols (stages); organizational support, institutional and electronic health record capacity to track patients getting ERP, training on protocol implementation, education on benefits of ERP use and how to adhere to ERPs (implementation drivers); and team, patient, and family buy-in and engagement early in the ERP implementation process (teams). Applying the implementation framework facilitated the identification of potential strategies to support effective practices (evidence-based ERPs and implementation tools), effective implementation (local team infrastructure support including team member roles and responsibilities; a learning collaborative for pediatric surgery groups with monthly support, coaching and training by topic experts, tools to engage key stakeholders), and enabling contexts (a toolkit to support implementation, sustainability assessments, quarterly data-driven feedback sessions, and access to a QI expert on the implementation teams), to achieve the desired outcomes.Conclusions: Comprehensive and systematic application of the 5AIFs allowed organization of the identified barriers and facilitators. Future steps are to apply and evaluate these strategies in a stepped-wedge, cluster randomized trial to increase implementation of ERPs at these 18 hospitals.

Safety and Effectiveness of a Pharmacist-Driven High-Dose Methotrexate Monitoring Protocol at an Academic Medical Center

Introduction: High-dose methotrexate (HD-MTX) requires extensive monitoring and implementation of supportive care strategies to prevent associated toxicities. Although monitoring protocols for MTX vary across institutions, standardized supportive care measures can improve treatment outcomes. The purpose of this study was to evaluate the impact of a pharmacist-driven monitoring protocol on management of patients with delayed MTX elimination. Methods: This was a single-center, retrospective analysis that included hospitalized adult cancer patients receiving HD-MTX therapy (≥ 1 g/m 2). The study consisted of a pre-protocol group (August 2014 to July 2017) and a post-protocol group (August 2017 to August 2020). Patients were included in the analysis more than once if they had a repeat but separate hospital encounter. The primary outcome measure was to compare the rate of appropriate leucovorin dosage adjustments, defined by adherence to institution-specific HD-MTX monitoring guidelines, before and after protocol implementation (Table 1). Secondary outcomes included MTX concentrations at 24, 48, and 72 hours; time to MTX elimination; evidence of delayed MTX clearance; urine pH; length of stay; drug-drug interactions; and incidence of toxicities. Group comparisons for continuous data were made using Mann-Whitney U test and Chi-square or Fisher's exact test was used for categorical data. A p-value of &lt; 0.05 was used to indicate significance. Results: Of 272 hospital encounters initially identified, 82 pre-protocol encounters and 59 post-protocol encounters were included in the analysis. Thirty-five percent of patient encounters in the pre-protocol group were excluded as a result of inappropriately timed methotrexate levels compared to only 9% in the post-protocol group, indicating improved MTX monitoring after protocol implementation. Baseline characteristics are summarized in Table 2. The most common malignancy was primary CNS lymphoma (53.8%) followed by non-Hodgkin lymphoma (28.8%). HD-MTX monotherapy was the most common regimen used in the pre-protocol group (57.1%) whereas combination therapy with rituximab +/- procarbazine was the most common regimen used in the post-protocol group (62.5%). Twenty-one encounters in the pre-protocol group and 22 encounters in the post-protocol group required leucovorin dose escalations at 24, 48, or 72 hours (Table 3). Following the implementation of the pharmacist-driven protocol, the rate of appropriate leucovorin dose adjustments increased significantly from 61.9% to 90.9% (p = 0.034). The median methotrexate concentration at 48 and 72 hours was higher in the post-protocol group when compared to the pre-protocol group. [0.22 µM/L vs.0.18 µM/L (p = 0.019) and 0.1 µM/L vs. 0.07 µM/L (p &lt; 0.001), respectively]. Median time to methotrexate elimination was slightly longer in patients managed according to the MTX protocol [73 hours vs. 72.4 hours, p = 0.022] with higher rates of delayed clearance noted in these patients [18 (30.5%) vs. 16 (19.5%), p &lt; 0.001]. There were no statistically significant differences in length of stay, urine pH, or drug-drug interactions between the two groups during methotrexate therapy (Table 4). However, a lower percentage of concomitant drug interactions with methotrexate were identified after protocol implementation, suggesting improved drug interaction screening [29 (49.2%) vs. 53 (64.9%), p = 0.857]. Rates of toxicities are shown in Table 5. The post-protocol group experienced a higher incidence of any-grade hyperbilirubinemia [20 (33.9%) vs. 18 (22%), p = 0.019], encephalopathy [10 (17%) vs. 5 (6.1%), p = 0.043], and grade ≥ 3 neutropenia [4 (6.8%) vs. 4 (4.9%), p = 0.009]. These differences in toxicity rates may in part be due to more frequent use of multi-agent chemotherapy in the post-protocol group and greater number of MTX cycles administered to these patients. The incidence of nephrotoxicity was similar in both groups (6 (7.3%) vs. 5 (8.5%), p= 0.493) and in line with previous reports. Conclusion:The implementation of a pharmacist-driven HD-MTX monitoring protocol improved optimal timing of MTX serum concentrations, resulted in a statistically significant improvement in the rate of appropriate leucovorin dose escalations, and led to enhanced detection of drug interactions. These findings demonstrate the important role pharmacists can play in dosing and monitoring high-risk regimens. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Does a Starting Positive End-Expiratory Pressure of 8 cmH2O Decrease the Probability of a Ventilator-Associated Event?

Introduction: Ventilator-associated events (VAEs) are objective measures as defined by the Centers for Disease Control and Prevention (CDC). To reduce VAEs, some hospitals have started patients on higher baseline positive end-expiratory pressure (PEEP) to avoid triggering VAE criteria due to respiratory fluctuations.Methods: At our institution, VAEs were gathered from January 2014 through December 2019. Using the CDC-defined classifications, VAEs were split into two groups to separate patients with hypoxemia only (VAC) and those with hypoxemia and evidence of inflammation or infection (IVAC-plus). We used the geometric distribution to calculate the daily event probability before and after the protocol implementation. A probability threshold was used to determine if the days between events was exceeded during the post-protocol period.Results: A total of 306 VAEs were collected over the study period. Of those, 155 were VACs and 107 were IVAC-plus events during the pre-protocol period. After implementing the protocol, 24 VACs and 20 IVAC-plus events were reported. There was a non-significant decrease in daily event probabilities in both the VAC and IVAC-plus groups (0.083 vs. 0.068 and 0.057 vs. 0.039, respectively).Conclusion: We concluded a starting PEEP of 8 cmH2O is unlikely to be an effective intervention at reducing the probability of a VAE. Until specific guidelines by the CDC are established, hospitals should consider alternative methods to reduce VAEs.

808. Appropriate Use of Cephalotin Before and After Implementation of a Cardiac Surgery Antibiotic Prophylaxis Protocol in Guatemala

Background The appropriate use of Surgical Antibiotic Prophylaxis (SAP) contributes to reducing the prevalence of Surgical Site Infections (SSI). Inappropriate use increases the risk of SSIs, hospitalization costs and potentially contributes to the emergence of antimicrobial resistance. We aimed to compare the appropriate use before and after implementing a SAP protocol in our institution Methods We conducted a retrospective chart review in patients older than 18 undergoing elective cardiac surgery with cardiopulmonary bypass using cephalotin as SSI prophylaxis. We excluded patients who received other antimicrobials for prophylaxis, those undergoing non-elective surgery, and patients with delayed sternal closure. We identified SSIs according to the Centers for Disease Prevention and Control criteria. We evaluated if appropriate dosing (2g-3g) and timing ( &gt;60 min.) occurred before the surgical incision, if redosing was administered, and if prophylaxis was administered &gt; 48 hours. We evaluated before and after implementation of the protocol (August 2016-July 2017; October 2017-2018) Results The study included 262 and 285 patients before and after protocol implementation, respectively. Patient characteristics were similar between comparator groups (Table 1). We found that 1.1% of patients vs. 63% of patients had appropriate dosing before the surgical incision, before and after protocol implementation, respectively (p &lt; 0.05). There was no difference in appropriate redosing when the duration of surgery was greater than 4 hours and no difference in inappropriate prophylaxis administration &gt; 48 hours after protocol implementation. A total of 8 SSIs were identified in each group, with no statistical difference in the incidence, length of stay, or clinical outcome between comparator groups Table 1. Patient Characteristics and Appropriate use of Cephalotin Before and After Implementation of a Cardiac Surgery Antibiotic Prophylaxis Protocol in Guatemala Conclusion Based on our findings, implementing a local guideline-protocol for SAP resulted in significant improvement of pre-surgical antimicrobial dosing. We observed continual unnecessary administration of antibiotic prophylaxis in the postoperative period that needs more proactive interventional pharmacy-guided strategies such as automatic stops or audits width feedback. Disclosures Lourdes A. Sandoval, Master of Science in Pharmacovigilance and Pharmacoepidemiology, Abbott (Employee)