1144. Evaluation of Procalcitnonin Usage in Neonates Presenting with Fever or Suspected Sepsis

Background Clinical evaluation alone is not effective in identifying serious bacterial infections (SBI) in neonates presenting with suspected sepsis and fever. A clinical decision making tool to aide in evaluating neonates presenting to the pediatric emergency department (PED) uses urinalysis, absolute neutrophil count (ANC), and procalcitonin (PCT) and together has high negative predictive value (NPV) for SBI. Use may decrease invasive testing, antibiotic exposure, and rates of admission. The tool was incorporated into hospital guidelines in October 2020. The purpose is to assess implementation and prediction of SBIs. Methods This is a single-center quality improvement study at an academic medical center. Neonates less than 60 days presenting with fever or suspected sepsis were included in the baseline group from October 2019- March 2020 or the post-implementation group from October 2020- March 2021. Exclusion criteria were receiving antibiotics 48 hours before PED visit, pre-existing medical conditions, indwelling devices, soft-tissue infections, and ≤ 36 weeks gestation. Implementation and guideline compliance was assessed in neonates aged 29-60 days as the primary outcome. Secondary endpoints include initiation of empiric antibiotics, rates of admission, rates of re-presentation within 30 days, and rates of lumbar punctures in all included patients. Results The baseline group had 29 patients and the post-implementation group had 35 patients who met inclusion/exclusion criteria. Baseline characteristics were similar with higher SBI rates in the post-implementation group having 8 SBIs while the baseline group had 4. There were 16 patients aged 29-60 days in the baseline (55%) and 17 in the post-implementation groups (49%). Complete labs were available for 9 patients (53%) and guideline compliance was 89%. NPV in neonates aged 0-60 days with negative urinalysis, ANC, and PCT was 100%. Rates of secondary endpoints were slightly higher in the post-implementation group along with higher rates of infections. Conclusion High NPV in this small cohort is an indication for continued use of this tool in neonates presenting to the PED with suspected sepsis or fever. Further education to increase use and expansion to all neonates should be considered based on overall NPV and previous studies. Disclosures All Authors: No reported disclosures

920 Improving the Management of Post-Operative Hypocalcaemia In Thyroid Surgery

Aim Hypocalcaemia is a frequent, and potentially dangerous, complication of total thyroidectomy [1, 2] due to the removal of the parathyroid glands. This quality improvement (QI) project was undertaken in a large Ear, Nose and Throat department in the East of England over a year. The project improved postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, appropriate prescribing and the monitoring and management of hypocalcaemia. Method A baseline audit was conducted to determine initial guideline compliance. The QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover. Results The measurement of PTH at four hours improved from 42.5% to 52.2%. The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%. Conclusions By optimising postoperative care this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.

1445 Using BOAST Guidelines to Boost Standards: An Audit of Adherence to BOAST Open Fracture Guidelines

Aim Open fractures require prompt management and appropriate infrastructure is required to deliver optimal care. The BOAST Open Fracture guidelines (2017) set out best practice in their management and advocate a combined Orthoplastics approach. Method All patients with open tibial fractures who presented to or were referred to our hospital from January 2018 - March 2020 were included in our audit. The standard used was the BOAST Open Fracture Guidelines. Data was collected retrospectively for cycle one (January – December 2018) then prospectively for cycle two (November 2019 – March 2020). Between cycles, results from cycle one was used to facilitate a business case for the creation of a second scheduled weekly Orthoplastics list in our hospital. Results 61 injuries met inclusion criteria in cycle one and 23 in cycle two. In cycle one, 28% of cases missed the 72-hour soft tissue coverage target, 11% missed the 7-day target. Only 10% of cases had both Orthopaedics and Plastics consultants involved at initial debridement. Following the invention of an additional weekly Orthoplastics list, the percentage of patients missing the 7-day target for soft tissue coverage halved to 5% and the percentage of cases with both Orthopaedics and Plastics consultants involved at initial debridement more than doubled to 26%. Conclusions We advocate multiple weekly Orthoplastics lists to ensure prompt consultant-led management and minimise delays for patients with open fractures. We have demonstrated that audit of current practice is a simple and effective tool to facilitate improvement in guideline compliance.

Compliance with the 24-Hour Movement Behavior Guidelines and Associations with Adiposity in European Preschoolers: Results from the ToyBox-Study

In 2019, the World Health Organization (WHO) published 24 h movement behavior guidelines for preschoolers with recommendations for physical activity (PA), screen time (ST), and sleep. The present study investigated the proportion of preschoolers complying with these guidelines (on a total week, weekdays and weekend days), and the associations with adiposity. This cross-sectional study included 2468 preschoolers (mean age: 4.75 years; 41.9% boys) from six European countries. The associations were investigated in the total sample and in girls and boys separately. PA was objectively assessed by step counts/day. Parent-reported questionnaires provided ST and sleep duration data. Generalized estimating equations were used to analyze the association between guideline compliance and adiposity indicators, i.e., body mass index (BMI) z-score and waist to height ratio (WHR). Only 10.1% of the preschoolers complied with the 24 h movement behavior guidelines, 69.2% with the sleep duration guideline, 39.8% with the ST guideline and 32.7% with the PA guideline. No association was found between guideline compliance with all three movement behaviors and adiposity. However, associations were found for isolated weekday screen time (BMI z-scores and WHR: p = 0.04) and weekend day sleep duration (BMI z-scores and WHR: p = 0.03) guideline compliance with both lower adiposity indicators. The latter association for sleep duration was also found in girls separately (BMI z-scores: p = 0.02; WHR: p = 0.03), but not in boys. Longitudinal studies, including intervention studies, are needed to increase preschoolers’ guideline compliance and to gain more insight into the manifestation of adiposity in children and its association with 24 h movement behaviors from a young age onwards.

Evaluation of Turner Syndrome International Consensus Guideline Compliance in Multiple Subspecialty Clinics Verses a Coordinated Multidisciplinary Clinic Format

Turner syndrome’s (TS) lifelong association with multi-organ system comorbidities necessitates the effective implementation of, and adherence to, screening guidelines. Our team evaluated the effectiveness in implementing the 2016 Cincinnati International Turner Syndrome consensus guidelines [1] in a single, coordinated, multidisciplinary clinic (MDC) day format compared to multiple separate subspecialty clinic visits. A retrospective analysis of patients with TS followed at our pediatric tertiary referral center between December 2016 and April 2020 was conducted. Exclusion criteria included patients that were not seen in our pediatric endocrine clinic for over 24 months, age over 22 years, and those without confirmed genetic diagnosis of TS. The population was separated into two groups; girls who attended at least 1 MDC day each year and girls who had at least 1 endocrinology clinic visit in the last 14 months, but who were not part of the MDC (non-MDC). Age appropriate screenings included TSH, hepatic function test, Vitamin D level, blood glucose and/or HgA1C, celiac screening panel, hearing/auditory screening, eye examination, electrocardiogram, and echocardiogram. A total of 112 girls met study criteria. Sixty-eight were managed in the MDC and 44 managed in non-MDC. Only 36.6% of all the girls met all the above age-appropriate screening recommendations, 75.6% of which were managed in MDC (p-value 0.014). MDC girls had higher screening compliance rates vs non-MDC girls for TSH (95% vs 76%, p-value 0.017), auditory evaluation (85% vs 50%, p-value <0.001), HgA1c and/or serum blood glucose levels (97% vs 76%, p-value 0.017), and tissue transglutaminase levels (95% vs 83%, p-value 0.048). No statistically significant difference was found with overall screening guideline compliance and insurance status, race/ethnicity, or age at time of the patients last recorded clinic visit. In conclusion, the MDC day format showed superior screening guideline compliance, both overall and to multiple specific screening tests, compared to those seen in multiple uncoordinated, single-disciplinary individual provider clinics. Overall guideline adherence remained low (36.6%), highlighting the need for continued optimization and improvement in guideline compliance. Reference: [1] Gravholt, C.H., et al., Eur J Endocrinol, 2017. 177(3): p. G1-G70.

683 A Quality Improvement Project (QIP) To Increase Compliance with Peri-Operative Antibiotic Guidelines in Colorectal Surgery (CS)

Introduction In CS, the correct use of antibiotics is important in order to reduce the risk of surgical site and intra-abdominal infections, whilst balancing risks from overuse of antibiotics. The Commissioning for Quality and Improvement (CQUIN) of 2019/20 identified that antibiotic prophylaxis guideline compliance could be enhanced in CS. This QIP aimed to improve local CS antibiotic prophylaxis and extension guideline compliance. Method In December 2019, an educational session was held to highlight the details of the local guideline and prescribing discrepancies. A3 posters of the guideline were created for accessible reference in operating theatres. Perioperative antibiotic prescription data from all colorectal elective cases in January 2020 were extracted and analysed using descriptive methods. Results Out of 93 cases in the sample, 70 (75.3%) were compliant with the prophylaxis guideline. However, metronidazole was commonly used in perianal surgery, which is not recommended. 13 cases required extension of the antibiotic course, of which seven were compliant (53.8%). The main issues included: use of agents and course durations which were not indicated; and a lack of antibiotic switch after a pause in therapy. Conclusions To further improve compliance with antibiotic guidelines, targeting historic practice, increasing awareness, and making systemic change is required for the next cycle.

Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals

ObjectivesTo assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance.DesignThe Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation.SettingThe study was undertaken at three hospitals (one regional, two metropolitan) in Australia.ParticipantsSAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods.InterventionQSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing.ResultsThe site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance.ConclusionsThe barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.