Introduction:Patients who present to the hospital with acute coronary syndromes (ACS) often have poor control of cardiac risk factors. Multiple studies have demonstrated that lipid lowering therapy is not appropriately initiated or intensified in these patients.Hypothesis:We hypothesized that an interruptive alert delivered via the electronic medical record would increase the initiation and intensification of lipid lowering therapies.MethodsUsing Epic EHR (Epic Systems, Verona, WI), an interruptive alert was designed to trigger upon opening the patient’s chart when the patients were admitted with an ICD code that indicated an ACS (i.e., STEMI, NSTEMI, or Unstable Angina). The alert included an order set to obtain a cholesterol panel or if a cholesterol panel had already been collected it would be displayed and suggest modifications to the patient’s current medication regimen. These alterations included statin intensification or the addition of ezetimibe.ResultsBetween September 1, 2021 and May 30, 2022 172 unique patients were identified. The mean age was 64.8 ±13.8 years, 64.5% were male, 74% were white, and 12% were black. The identified patients had multiple comorbidities including cerebrovascular disease (23%), heart failure (47%), peripheral vascular disease (30%), and being a current or former smoker (53%). The triggered order set had a direct effect on 42 (24%) patients, with 10 initiating ezetimibe and 32 having their statins intensified. The most common indicated reason for overriding the alert (n=99) was not meeting criteria. Of these 99 patients, 4 were ultimately started on ezetimibe, 57 had their statin intensified, and 23 were appropriately excluded (including patients with type II myocardial infarctions who were not the target of this intervention). Of note, 15 patients should have received intensified therapy but had their alert over ridden.ConclusionsThis targeted alert led to direct intensification of lipid lowering therapy in 24% of ACS patients with an additional 35% of patients identified by the alert also having therapeutic intensification. This alert will remain in place to allow for further assessment of its effects and can be easily translated to other clinical systems.
Background
In patients receiving mechanical ventilation, spontaneous awakening trials reduce morbidity and mortality when paired with spontaneous breathing trials. However, spontaneous awakening trials are not performed every day they are indicated and little is known about spontaneous awakening trial protocol use in cardiac intensive care units.
Local Problem
Spontaneous awakening trial completion rate at the study institution was low and no trial protocol was regularly used.
Methods
A preintervention-postintervention retrospective cohort study was performed in adult patients with at least 24 hours of invasive mechanical ventilation in Michigan Medicine’s cardiac intensive care unit. Patients with SARS-CoV-2 infection were excluded. Data included demographics, sedation, mechanical ventilation duration, and in-hospital mortality. A nurse-driven spontaneous awakening trial protocol modified for the cardiac intensive care unit was implemented in October 2020.
Results
Compared with the preintervention cohort (n = 29, May through July 2020), the postintervention cohort (n = 27, October 2020 through February 2021) had a higher ratio of number of trials performed to number of days eligible for trial (0.91 vs 0.52; P < .01). Median continuous sedative infusion duration was shorter after intervention (2.3 vs 3.6 days; P = .02). Median mechanical ventilation duration (3.8 vs 4.7 days; P = .18) and mortality (41% vs 41%; P = .95) were similar between groups.
Conclusions
Spontaneous awakening trial protocol implementation led to a higher trial completion rate and a shorter duration of continuous sedative infusion. Larger studies are needed to assess the impact of protocolized spontaneous awakening trials on cardiac intensive care unit patient outcomes.
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