Background: After publication of the Clostridioides difficile infection (CDI) guidelines by the Infectious Disease Society of America (IDSA) in early 2018, we identified that many prescribers at our institution continued to practice using the older guidelines. Objective: This study aimed to determine whether the implementation of an electronic order set for CDI would increase prescriber compliance to current IDSA recommendations for CDI management. Methods: This was a single-center, prospective cohort study of adult inpatients with a confirmed CDI. The study was conducted between March 1, 2018, and April 1, 2019. Patients were stratified into a preintervention and postintervention group before and after order set implementation. The primary outcome was a composite of appropriate CDI therapy selection and discontinuation of nonessential antimicrobials and acid-suppressive agents. The secondary outcome evaluated appropriate CDI therapy medications prescribed at hospital discharge. Results: Of the 149 patients included in this study, 96 were included in a preintervention group and 53 included in a postintervention group. The primary outcome was met in 45% of patients in the preintervention group and 66% of patients in the postintervention group ( P = .01). The secondary outcome occurred in 86% of patients in the preintervention group and 100% of patients in the postintervention group ( P = .02). Conclusion: Implementation of a CDI electronic order set and alert bundle was associated with enhanced prescriber adherence to guideline-directed therapy. Our results suggest that order sets not only improve inpatient compliance to guidelines but may also improve medication-related adherence to guideline recommendations upon discharge.
Existing risk tools that identify patients at high risk of medication-related iatrogenesis are not sufficient to holistically evaluate a patient’s entire medication regimen. This study used a novel medication risk score (MRS) which holistically evaluates medication regimens and provides actionable solutions. The main purpose of this study was to quantify adults ≥ 65 years with a high medication risk burden using the MRS and secondarily, appraise MRS association with hospital readmission. This retrospective cohort study included all consecutive patients in a 6-month period aged 65 years and older, admitted for at least 48 h, and prescribed at least five medications upon discharge. Out of 3017 patients screened, 1386 met all criteria. The primary outcome was the proportion of patients with a score of ≥ 20 and the secondary outcome was the 30-day readmission rate. In the overall population, 17% of patients had an MRS ≥ 20. For patients discharged home, there was a 19% readmission rate for a score ≥ 20 and 11% for <20 (p = 0.009). A score of ≥ 20 was associated with a 1.8-fold increased risk of readmission in patients discharged home. Only 7% of patients met these criteria, which can help direct future use of the MRS at patients with the highest risk of medication-related iatrogenesis.
Background:
Current American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend brain imaging with computed tomography (CT) within 20 minutes of emergency department (ED) arrival and treatment with tissue plasminogen activator (tPA) in eligible patients with acute ischemic stroke within 60 minutes of arrival. In January 2017, we implemented a direct-to-CT protocol which consisted of direct patient transportation by emergency medical services (EMS) personnel from ambulance to CT scanner. Patients were then transported to the ED for evaluation and treatment as appropriate via telemedicine and ED staff.
Objective:
To determine if a direct-to-CT protocol would improve the percentage of patients with door-to-needle (DTN) time ≤ 60 minutes.
Methods:
This was a single center retrospective cohort study of patients who received tPA for acute ischemic stroke in the ED between October 2016 and May 2018. Patients were grouped based on the use of a direct-to-CT protocol.
Results:
Of 64 included patients, 23 patients (36%) were transported via the direct-to-CT protocol and 41 patients (64%) arrived via private vehicle or EMS without use of the protocol. Goal DTN time ≤ 60 minutes was achieved in 78% of patients when the protocol was used compared to 44% when it was not (p=0.0078). The mean DTN time was significantly shorter when the protocol was used (52.83±13.8 vs 70.98±32.6, p=0.003). Following adjustments for time of day and the need for blood pressure management with intravenous anti-hypertensives, a greater percentage of patients in the direct-to-CT protocol group achieved DTN ≤ 60 minutes (OR=8.09;95%CI=1.99-32.91, p=0.003).
Conclusions:
An EMS activated direct-to-CT protocol improved the percentage of patients achieving DTN ≤ 60 minutes and significantly reduced mean DTN time.
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