- Email: [email protected]
8 Simple Interventions Positively Affect Emergency Physician Blood Culture Orders
Research Forum Abstracts traumatic brain injury (ciTBI) for each criteria strata from the original study. For included patients, decision support responded with recommendations stating head CT indicated, observation or head CT indicated, or head CT not indicated. Results: Pre-intervention data was retrospectively reviewed for a one-year period an showed head CT utilization of 28% in pediatric patients presenting to the ED with mild head injury. Post-intervention, 227 patients were evaluated over the nine-week pilot. Physician utilization of CDST was 78%. Adherence to CDST recommendations was 98% with one head CT obtained on a low risk patient. Head CT utilization decreased to 21% representing a relative risk reduction of 25% and an absolute reduction of 7%. Conclusion: Shared decisionmaking and decision support tools can significantly reduce head CT utilization in pediatric patients presenting to the ED with mild head injury.
8
Simple Interventions Positively Affect Emergency Physician Blood Culture Orders
Powell J, Ahlers E/Christiana Care Health System, Newark, DE
7
Reduced Head Computed Tomography Utilization for Pediatric Mild Head Injury After Implementation of Decision Support Tools and Shared Decisionmaking
Engineer R, Ferguson S, Podolsky S, Jimenez H, Grover P, Fertel BS/The Cleveland Clinic Foundation, Cleveland, OH
Study Objectives: Literature suggests that radiation causes iatrogenic cancer in 1:1500 to 1:3000 pediatric patients undergoing head computed tomography (CT). While many of these head CTs are clinically necessary, research from the PECARN study suggests that clinicians may over-utilize head CT in pediatric patients with mild head injuries. We sought to determine whether a pediatric mild head injury care path, focused on implementing the PECARN decision rule through physician education, shared decisionmaking, and clinical decision support tools, can reduce head CT utilization. Methods: We conducted a quality improvement project to reduce inappropriate head CT utilization through five interventions: (1) Engagement of emergency department (ED) nurse and physician leadership explaining the rationale and proposed interventions; (2) Physician education through on-site presentation, distributed Power Point slides, and face-to-face support; (3) Incorporation of a parent/patient shared decisionmaking model into the ED visit; (4) Clinical decision support tool (CDST) embedded into the electronic medical record (EMR); (5) Importation of all data into the clinical note to reduce keystrokes and drive compliance. The study was conducted at two sites, a pediatric ED based in a large community hospital and a freestanding ED. Participants included all pediatric patients with a chief complaint of minor head injury or associated ICD-9 codes, as determined by the care path committee prior to launch. Data was collected for a predetermined 9-week period after implementation. This was compared to baseline data from the preceding year. Targets for care path utilization (60%) and head CT reduction (15% relative reduction) were established a priori. The shared decisionmaking tool was a pink sheet placed in the patient room for parent review prior to the provider entry. It included all questions from the PECARN decision rule, translated into understandable layman’s terms. This was then reviewed by the provider with the parent(s) during the interview. Decision support involved a separate care path navigator and best practice alert (BPA) within the EMR (EPIC). A BPA was built to fire when a pediatric head CT was ordered. It would remind the provider to utilize the CDST. The CDST prompted providers to enter exclusion criteria, high risk criteria, and moderate risk criteria and displayed the rate of clinically important
S4 Annals of Emergency Medicine
Study Objectives: Primary Objective: To determine if evidence-based blood culture ordering guidelines reduce the total number of blood cultures generated in the emergency department (ED) without negatively affecting patient care. Secondary Objectives: Does the intervention affect hospital length of stay (LOS) and laboratory quality measures, such as contaminated blood cultures? What is the sensitivity of the blood culture ordering guidelines? Methods: This is a prospective observational study performed at a health system that comprises a tertiary care level 1 trauma center with a large residency program, an urban hospital and rural freestanding emergency department. Inclusion criteria consist of all patients age 18 and older for whom blood cultures were obtained in the emergency department and analyzed in the lab. Prior to the introduction of ED blood culture ordering guidelines in August 2014, a review of patients who had blood cultures obtained in the ED were analyzed for demographics, blood culture results, length of ED stay, ED disposition, and vital signs. The ED blood culture ordering guidelines were then implemented into the ED computerized physician-ordering entry, and staff was educated regarding the guidelines. After introduction of the guidelines, a review of patients who had blood cultures ordered in the ED was again performed. The primary outcome was the change in the number of blood cultures ordered in the emergency department before and after implementation of the blood culture ordering guidelines. Secondary outcomes included the change in number of contaminated blood cultures, the sensitivity of the blood culture ordering guidelines and the difference in hospital length of stay and ED disposition. Results: Prior to blood culture ordering guideline implementation, an average of 1,668 blood cultures were obtained monthly at our institution. Following implementation, as of March 2015, we decreased ED generated blood cultures to an average of 1,190, which is a 43% reduction. Blood culture contamination rates remained unchanged during the intervention. Analysis of secondary outcomes is ongoing. Conclusion: We developed simple and effective ED blood culture ordering guidelines that reduce unnecessary blood culture ordering in the ED without negatively affecting contamination rate of blood cultures. Analysis of secondary outcomes will delineate effects on hospital length of stay and determine if ED providers failed to order blood cultures when indicated.
9
Acute Care Diagnostic Collaboration: Nasogastric Lavage Assessment of Patients at Low Risk by the Glasgow Blatchford Score and AIMS65 Scoring Systems in Patients With Upper Gastrointestinal Bleeding
Perlini E, Cochon L, Deshpande A, Sussman D, Baez AA/Jackson Memorial Hospital, Miami, FL; Universidad de Barcelona, Barcelona, Spain
Study Objectives: Upper gastrointestinal bleeding (UGIB) is an important contributor to emergency department presentations and subsequent hospital admissions. Scoring systems like the Glasgow Blatchford Score (GBS) and the AIMS65 have been developed to predict the need for endoscopic intervention and mortality; these scoring systems can be used to significantly decrease health care expenditure. Prior studies have revealed nasogastric (NG) lavage has low sensitivity and poor negative likelihood ratio (LR) in UGIB; others have demonstrated no association between the presence of bile and the location of bleeding. One study showed that a negative NG aspiration provided little information as to the source of GI bleeding in patients without hematemesis, with a negative LR of 0.6 . Other groups have published on the usefulness of a simple ratio of heart rate to systolic blood pressure as an accurate
Volume 66, no. 4s : October 2015
8
Simple Interventions Positively Affect Emergency Physician Blood Culture Orders
Powell J, Ahlers E/Christiana Care Health System, Newark, DE
7
Reduced Head Computed Tomography Utilization for Pediatric Mild Head Injury After Implementation of Decision Support Tools and Shared Decisionmaking
Engineer R, Ferguson S, Podolsky S, Jimenez H, Grover P, Fertel BS/The Cleveland Clinic Foundation, Cleveland, OH
Study Objectives: Literature suggests that radiation causes iatrogenic cancer in 1:1500 to 1:3000 pediatric patients undergoing head computed tomography (CT). While many of these head CTs are clinically necessary, research from the PECARN study suggests that clinicians may over-utilize head CT in pediatric patients with mild head injuries. We sought to determine whether a pediatric mild head injury care path, focused on implementing the PECARN decision rule through physician education, shared decisionmaking, and clinical decision support tools, can reduce head CT utilization. Methods: We conducted a quality improvement project to reduce inappropriate head CT utilization through five interventions: (1) Engagement of emergency department (ED) nurse and physician leadership explaining the rationale and proposed interventions; (2) Physician education through on-site presentation, distributed Power Point slides, and face-to-face support; (3) Incorporation of a parent/patient shared decisionmaking model into the ED visit; (4) Clinical decision support tool (CDST) embedded into the electronic medical record (EMR); (5) Importation of all data into the clinical note to reduce keystrokes and drive compliance. The study was conducted at two sites, a pediatric ED based in a large community hospital and a freestanding ED. Participants included all pediatric patients with a chief complaint of minor head injury or associated ICD-9 codes, as determined by the care path committee prior to launch. Data was collected for a predetermined 9-week period after implementation. This was compared to baseline data from the preceding year. Targets for care path utilization (60%) and head CT reduction (15% relative reduction) were established a priori. The shared decisionmaking tool was a pink sheet placed in the patient room for parent review prior to the provider entry. It included all questions from the PECARN decision rule, translated into understandable layman’s terms. This was then reviewed by the provider with the parent(s) during the interview. Decision support involved a separate care path navigator and best practice alert (BPA) within the EMR (EPIC). A BPA was built to fire when a pediatric head CT was ordered. It would remind the provider to utilize the CDST. The CDST prompted providers to enter exclusion criteria, high risk criteria, and moderate risk criteria and displayed the rate of clinically important
S4 Annals of Emergency Medicine
Study Objectives: Primary Objective: To determine if evidence-based blood culture ordering guidelines reduce the total number of blood cultures generated in the emergency department (ED) without negatively affecting patient care. Secondary Objectives: Does the intervention affect hospital length of stay (LOS) and laboratory quality measures, such as contaminated blood cultures? What is the sensitivity of the blood culture ordering guidelines? Methods: This is a prospective observational study performed at a health system that comprises a tertiary care level 1 trauma center with a large residency program, an urban hospital and rural freestanding emergency department. Inclusion criteria consist of all patients age 18 and older for whom blood cultures were obtained in the emergency department and analyzed in the lab. Prior to the introduction of ED blood culture ordering guidelines in August 2014, a review of patients who had blood cultures obtained in the ED were analyzed for demographics, blood culture results, length of ED stay, ED disposition, and vital signs. The ED blood culture ordering guidelines were then implemented into the ED computerized physician-ordering entry, and staff was educated regarding the guidelines. After introduction of the guidelines, a review of patients who had blood cultures ordered in the ED was again performed. The primary outcome was the change in the number of blood cultures ordered in the emergency department before and after implementation of the blood culture ordering guidelines. Secondary outcomes included the change in number of contaminated blood cultures, the sensitivity of the blood culture ordering guidelines and the difference in hospital length of stay and ED disposition. Results: Prior to blood culture ordering guideline implementation, an average of 1,668 blood cultures were obtained monthly at our institution. Following implementation, as of March 2015, we decreased ED generated blood cultures to an average of 1,190, which is a 43% reduction. Blood culture contamination rates remained unchanged during the intervention. Analysis of secondary outcomes is ongoing. Conclusion: We developed simple and effective ED blood culture ordering guidelines that reduce unnecessary blood culture ordering in the ED without negatively affecting contamination rate of blood cultures. Analysis of secondary outcomes will delineate effects on hospital length of stay and determine if ED providers failed to order blood cultures when indicated.
9
Acute Care Diagnostic Collaboration: Nasogastric Lavage Assessment of Patients at Low Risk by the Glasgow Blatchford Score and AIMS65 Scoring Systems in Patients With Upper Gastrointestinal Bleeding
Perlini E, Cochon L, Deshpande A, Sussman D, Baez AA/Jackson Memorial Hospital, Miami, FL; Universidad de Barcelona, Barcelona, Spain
Study Objectives: Upper gastrointestinal bleeding (UGIB) is an important contributor to emergency department presentations and subsequent hospital admissions. Scoring systems like the Glasgow Blatchford Score (GBS) and the AIMS65 have been developed to predict the need for endoscopic intervention and mortality; these scoring systems can be used to significantly decrease health care expenditure. Prior studies have revealed nasogastric (NG) lavage has low sensitivity and poor negative likelihood ratio (LR) in UGIB; others have demonstrated no association between the presence of bile and the location of bleeding. One study showed that a negative NG aspiration provided little information as to the source of GI bleeding in patients without hematemesis, with a negative LR of 0.6 . Other groups have published on the usefulness of a simple ratio of heart rate to systolic blood pressure as an accurate
Volume 66, no. 4s : October 2015