Understanding Opioid Prescribing Practices of Resident Physicians

Background To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources. Methods An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher’s exact test assessed differences in prescribing practices between specialties. Results Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient’s history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills ( P < .001). Discussion The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.

Abstract 14218: Post-Cardiac Arrest Care Delivery Varies Widely Across Institutions Belonging to the PediRES-Q Collaborative

Introduction: Despite national pediatric post-cardiac arrest care (PCAC) guidelines to improve survival and neurological outcomes, there are limited studies describing PCAC delivery in pediatric institutions. The objective of this study was to describe reported PCAC delivery in pediatric institutions. We hypothesized that there would be variability in PCAC processes across institutions. Methods: An IRB-approved REDCap survey was distributed electronically to the lead resuscitation investigator at each institution belonging to the international Pediatric Resuscitation Quality Improvement collaborative (PediRES-Q). Data were summarized using descriptive statistics. A chi-square test was used to compare categorical data. Results: Twenty-four of 47 centers completed the survey (51%). Most respondents (58%) belonged to large centers (≥1000 annual PICU admissions). Two-third (67%) of centers reported using no specific selection criteria to initiate PCAC with the other third employing order sets, paper forms, or institutional guidelines. Smaller centers (<1000 annual PICU admissions) more frequently reported the use of attending-directed care for PCAC initiation/delivery (80%) versus larger centers (57%), p = 0.04. Common PCAC targets included temperature (96%), glucose (75%), and age-based blood pressure (88%). Most PCAC included EEG (75%) but neuroimaging was only included at 46% of centers. Duration of PCAC was either tailored to clinical improvement and neurological exam (54%) or time-based (45%). Only 25% of centers reported having a mechanism for evaluating PCAC adherence. Common barriers to effective PCAC implementation included lack of time and limited training opportunities (Figure 1). Conclusions: There is wide variation in PCAC delivery among surveyed pediatric institutions. Targeting common themes such as standardization of PCAC initiation and bundle components and implementing adherence evaluation could improve PCAC.

141. Effectiveness of a Multipronged Approach to Improve Prophylactic Antibiotic Prescribing in Patients Undergoing Trans-Arterial Chemoembolization

Background In our institution, the significant use of broad-spectrum antibiotics for antibiotic prophylaxis (AP) in trans-arterial chemoembolization (TACE) was operator dependent and not evidence based. Hence, an AP guideline was developed with the Department of Vascular and Interventional Radiology and launched in May 2019, following department roadshows and creation of user-friendly electronic AP order sets. We analyzed the effectiveness and outcomes of our multipronged approach towards improving the standardization of AP prescribing. Methods This was a retrospective study of TACE procedures from November 2018 to March 2020, pre and post guideline implementation (Figure 1). Single IV cefazolin 2g dose (or IV clindamycin 600mg in the setting of β-lactam allergy) before TACE in patients with an uncompromised sphincter of Oddi was recommended. Patients with active infections prior to TACE were excluded. AP was deemed inappropriate if it deviated from guidelines (antibiotic choice and/or duration). Primary outcome was AP appropriateness and 30-day TACE related infections. Figure 1. Timeline of our multipronged approach Results Seventy patients were included. There were no differences in baseline demographics pre and post implementation (Table 1). Following guideline implementation, there was a significant improvement in AP used for TACE. AP appropriateness pre-implementation and post-implementation was 14/31 (45.2%) and 37/39 (94.9%) respectively (p&lt; 0.001). Guideline compliant antibiotics were selected more frequently (14 [45.2%] vs 38 [97.4%], p&lt; 0.001), and more patients received single dose AP (22 [71.0%] vs 38 [97.4%], p=0.004). Of the 18 patients who did not receive guideline recommended AP, 16 (88.9%) received IV ceftriaxone and metronidazole, 1 (5.6%) IV amoxicillin/clavulanic acid, and 1 (5.6%) IV ciprofloxacin. Ten patients received a prolonged course of AP with a median duration of 6 days (IQR 4.3, 6.5). There were no significant differences in 30-day TACE related infections (1 [3.2%] vs 2 [5.1%], p=1.000) and 30-day mortality (1 [3.2%] vs 1 [2.6%], p=1.000). No patient had surgical site skin infection. Conclusion Our multipronged approach improved AP prescribing in patients undergoing TACE. Single dose IV cefazolin prophylaxis for TACE did not compromise safety outcomes in the post implementation review. Disclosures All Authors: No reported disclosures

95. Reduced Antibiotic Duration Defaults in Outpatient Automated Dispensing Cabinets Change Antibiotic Prescribing Habits in a Tertiary VA Healthcare System

Background Ten percent of adult, outpatient visits result in an antibiotic prescription (Rx). At the start of our intervention, our VA healthcare system consisted of 13 community-based outpatient clinics (CBOCs), 9 of which did not have an onsite pharmacy but utilized automated dispensing cabinets (ADCs) for prepackaged outpatient Rxs. ADC antibiotic orders are generated from electronic medical record (EMR) order sets. The stewardship team shortened the durations of 5 antibiotics in the ADC order sets to make them consistent with current literature and guidelines. We assessed the impact of these changes on antibiotic prescribing habits. Methods We compared outpatient antibiotic Rx data between 10/1/2018-9/30/2019 (pre-intervention) and 10/1/19-9/30/20 (post-intervention) from 8 CBOCs with ADCs (1 closed during the pandemic). Amoxicillin-clavulanate 875/125mg (AMC), cephalexin 500mg (CPH), levofloxacin 500mg and 750mg (LEV 500 and LEV 750), and sulfamethoxazole-trimethoprim 800/160mg (SXT) prescription durations were all reduced by 3 days. Process metrics included days supplied/1000 prescriptions (DS/1000 Rx), median DS, and ADC utilization rates. We used Mann-Whitney U and correlation statistical analyses to assess differences and associations. Results The DS/1000 Rx of antibiotics with a default duration change decreased in the post-intervention phase for CBOCs with ADCs (AMC, -25.4%; CPH, -21.1%; LEV 500, -18.9%; LEV 750, -28.0%; SXT, -27.4%). The median DS for these antibiotics all reduced by 3 days in concordance with new ADC prescriptions defaults (AMC, 10 vs 7 days, P&lt; 0.001; CPH, 10 vs 7 days, P&lt; 0.001; LEV 500, 8 vs 5 days, P&lt; 0.001; LEV 750, 8 vs 5 days, P&lt; 0.001; SXT 10 vs 7 days, P&lt; 0.001). Due to COVID-19, 7/8 ADC CBOCs closed for in-person visits from 3/20/20-5/4/20. ADC utilization was inversely proportional to DS/1000 Rx for most antibiotics (R: -0.51 to -0.77) except SXT. Conclusion EMR-driven reductions in ADC default Rx durations led to a corresponding decrease in overall outpatient antibiotic prescribing. Higher DS/1000 Rx were often associated with lower ADC utilization. Informatics-driven antibiotic interventions may be potential outpatient stewardship tools to increase guideline-concordant prescribing across multisite healthcare systems. Disclosures Sharanie Sims, PharmD, AbbVie (formerly Allergan) (Speaker’s Bureau)

1125. Decreasing Concomitant Vancomycin and Piperacillin-Tazobactam Use in Children to Reduce Incidence of Acute Kidney Injury

Background Concomitant use of vancomycin (V) and piperacillin-tazobactam (PT) is associated with increased incidence of acute kidney injury (AKI). AKI develops 3 times faster on this combination compared to alternative vancomycin combinations. We sought to reduce AKI in our patients by reducing concomitant use of V/PT using a QI framework. Methods We implemented several PDSA cycles to reduce concomitant V/PT use at a 415-bed quaternary children’s hospital in Boston, MA. Interventions included substitution of PT with other agents in surgical prophylaxis guidelines and order sets starting in February 2020 and in the hospital-wide sepsis order set in March 2021. The Antimicrobial Stewardship Program reinforced these changes during daily audit-and-feedback reviews. In November 2020, we implemented an electronic alert that apprises clinicians of the AKI risk when V/PT are ordered and recommends an alternative regimen. We measured the monthly number of patients on combination V/PT, new exposures to nephrotoxic medications, AKI events, and the percentage of days with serum creatinine monitoring for patients on ≥2 nephrotoxic medications. Results From 02/01/20 to 05/31/21, the number of patients exposed to combination V/PT decreased from 23 to 6 per month (Figure 1). New nephrotoxic medication exposures declined from 17.1 to 7.7 per 1,000 patient days, and AKI events dropped from 2.8 to 0.6 per 1,000 patient days (Figures 2 and 3). The percentage of days with serum creatinine monitoring increased from 60% to 66%. Rate of New Exposures to Nephrotoxic Medications per 1000 Patient Days Conclusion Revising guidelines and electronic order sets and implementing an order alert led to marked decreases in exposures to V/PT and nephrotoxic medications overall and was associated with reduced AKI events. Use of electronic health record tools is an effective way to drive safer antimicrobial use. Disclosures Gabriella S. Lamb, MD, MPH, Nothing to disclose

1310. Provider and Facility Variation in Empiric Broad-Spectrum Antibiotic Use for Hospitalization Pneumonia: A Mixed Methods Study of Veterans Affairs Facilities

Background We previously found widespread variation in the empiric use of antibiotics against methicillin-resistant Staph aureus (anti-MRSA) and Pseudomonas aeruginosa (anti-PAER) for patients hospitalized for pneumonia. To explore this variation further, we conducted (1) quantitative analyses of facility-level versus provider-level variation, and (2) qualitative interviews with emergency department providers. Methods For each hospitalization, we predicted the probability of anti-MRSA and anti-PAER use by fitting machine learning models from 75 patient variables. We estimated the predicted risk of anti-MRSA/anti-PAER and facility features among patients hospitalized at upper versus lower 10% facilities after controlling for patient characteristics. We plotted density curves with the variance attributed to facility and provider alone and together. We then interviewed 16 emergency department (ED) providers at 8 VA facilities using a cognitive task analysis. Results Among 215,803 hospitalizations at 128 VA facilities 1/1/2006-12/31/2016, 31% received empiric anti-MRSA and 29% received empiric anti-PAER antibiotics. Hospitalizations at upper-decile facilities had a 50% and 45% adjusted probability of receiving anti-MRSA and anti-PAER antibiotics, compared to 15% and 20% in the lower-decile facilities. Facility features most predictive of anti-MRSA or anti-PAER use after adjusting for patient characteristics were complexity level (33% and 30% in high versus 15% and 20% in low complexity facilities). Variation in empiric anti-MRSA and anti-PAER use was almost completely at the facility level (Figure 1). Providers reported social influences from the opinions of other providers during decision-making and a high trust in guidelines and order sets. Consideration of pathogens was not mentioned by any providers at high-prescribing facilities. Conclusion Variation in empiric use of anti-MRSA and anti-PAER antibiotics in pneumonia clustered nearly completely at the facility level. ED providers report social influences during decision-making and a high trust in guidelines and order sets. Guidelines, order sets, and facility-level clinical champions that promote consideration of pathogens could be important strategies for de-adoption. Disclosures All Authors: No reported disclosures

The influence of integrating clinical practice guideline order bundles into a general admission order set on guideline adoption

Objectives of this study were to (1) describe barriers to using clinical practice guideline (CPG) admission order sets in a pediatric hospital and (2) determine if integrating CPG order bundles into a general admission order set increases adoption of CPG-recommended orders compared to standalone CPG order sets. We identified CPG-eligible encounters and surveyed admitting physicians to understand reasons for not using the associated CPG order set. We then integrated CPG order bundles into a general admission order set and evaluated effectiveness through summative usability testing in a simulated environment. The most common reasons for the nonuse of CPG order sets were lack of awareness or forgetting about the CPG order set. In usability testing, CPG order bundle use increased from 27.8% to 66.6% while antibiotic ordering errors decreased from 62.9% to 18.5% with the new design. Integrating CPG-related order bundles into a general admission order set improves CPG order set use in simulation by addressing the most common barriers to CPG adoption.

Predicting clinical outcomes among hospitalized COVID-19 patients using both local and published models

Background Many models are published which predict outcomes in hospitalized COVID-19 patients. The generalizability of many is unknown. We evaluated the performance of selected models from the literature and our own models to predict outcomes in patients at our institution. Methods We searched the literature for models predicting outcomes in inpatients with COVID-19. We produced models of mortality or criticality (mortality or ICU admission) in a development cohort. We tested external models which provided sufficient information and our models using a test cohort of our most recent patients. The performance of models was compared using the area under the receiver operator curve (AUC). Results Our literature review yielded 41 papers. Of those, 8 were found to have sufficient documentation and concordance with features available in our cohort to implement in our test cohort. All models were from Chinese patients. One model predicted criticality and seven mortality. Tested against the test cohort, internal models had an AUC of 0.84 (0.74–0.94) for mortality and 0.83 (0.76–0.90) for criticality. The best external model had an AUC of 0.89 (0.82–0.96) using three variables, another an AUC of 0.84 (0.78–0.91) using ten variables. AUC’s ranged from 0.68 to 0.89. On average, models tested were unable to produce predictions in 27% of patients due to missing lab data. Conclusion Despite differences in pandemic timeline, race, and socio-cultural healthcare context some models derived in China performed well. For healthcare organizations considering implementation of an external model, concordance between the features used in the model and features available in their own patients may be important. Analysis of both local and external models should be done to help decide on what prediction method is used to provide clinical decision support to clinicians treating COVID-19 patients as well as what lab tests should be included in order sets.