FilmArray® Meningoencephalitis Panel In the Diagnosis of Central Nervous System Infections: Stewardship And Cost Analysis in a Paediatric Hospital in Chile

Background: Central nervous system (CNS) infection has been an ongoing concern in paediatrics. The FilmArray® Meningoencephalitis (FAME) panel has greater sensitivity in identifying the aetiology of CNS infections. This study’s objective was to compare the aetiological identification and hospitalization costs among patients with suspected CNS infection before and after the use of FAME.Methods: An analytical observational study was carried out using a retrospective cohort for the pre-intervention (pre-FAME use) period and a prospective cohort for the post-intervention (post-FAME use) period in children with suspected CNS infection.Results: A total of 409 CSF samples were analysed, 297 pre-intervention and 112 post-intervention. In the pre-intervention period, a total of 85.5% of patients required hospitalization, and in the post-intervention period 92.7% required hospitalization (p<0.05). The P50 of ICU days was significantly lower in the post-intervention period than it was in the pre-intervention period. The overall positivity was 9.4% and 26.8%, respectively (p< 0.001). At ages 6 months and below, we found an increase in overall positivity from 2.6% to 28.1%, along with an increased detection of viral agents, S. agalactiae, S. pneumoniae, and N. meningitidis. The use of this diagnostic technology saved between $2,916 and $12,240 USD in the cost of ICU bed-days. FAME use provided the opportunity for more accurate aetiological diagnosis of the infections and thus the provision of adequate appropriate treatment.Conclusions: The cost/benefit ratio between FAME cost and ICU -bed-day cost savings is favourable. Implementation of FAME in Chilean public hospitals saves public resources and improves the accuracy of aetiological diagnosis.

Impact of Order-Set Modifications and Provider Education Following Guideline Updates on Broad-Spectrum Antibiotic Use in Patients Admitted With Community Acquired Pneumonia

Purpose: Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. Methods: This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). Results: A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, P = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period ( P < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; P = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], P = .002). Conclusion: Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.

1130. Impact of a New Pediatric Antibiotic Stewardship Program on Ceftriaxone Use at an Academic Medical Center

Background Hoop’s Family Children’s Hospital is a pediatric hospital with 72 beds, nested within Cabell Huntington Hospital. There is an established adult antibiotic stewardship program (ASP), however, since 2014 there has not been a pediatric infectious disease (ID) specialist and no pediatric ASP. With the recent hire of a pediatric ID specialist in Oct 2019 and the formation of a targeted pediatric ASP, we tracked the use of ceftriaxone (CRO) in our facility. Methods Starting January 2020, education was provided to pediatric providers in regards to appropriate CRO dosing and clinical indications via email communication. The main goals were to limit 100mg/kg/day dosing to severe infections and reduce CRO use in community-acquired pneumonia. This was sustained through intermittent prospective audits and feedback. A retrospective chart review was done from 2019-2021 for the months of January, April and December of each year. Patients ≤18 years of age who received CRO were included. Dosing, interval frequency, indication, and treatment duration were reviewed. Patients who received a single dose of CRO were excluded. Results From Jan 2019 – April 2021, 391 patient charts were reviewed (189 in the pre-intervention period and 202 in the post intervention period). There were no significant differences in age, race/ethnicity and gender in the two study groups. In the pre-intervention period, 86% of patients were prescribed CRO at severe infection dosing vs 33% in the post intervention period (p&lt; 0.0001) (Figure 1). When dosing was paired with indication, only 20% of patients in the pre intervention period had the appropriate dosing per clinical indication compared to 83% in the post intervention period (p&lt; 0.0001) (Figure 2). We also saw that in the pre-intervention period the most common indication for CRO was pneumonia (66%), which decreased to 57% in 2020 and to 35% in 2021 (p&lt; 0.0001) (Figure 3). Figure 1 describes the percentage of patients receiving ceftriaxone at severe infection dosing. This changed from an average of 86% in the pre-intervention period to 33% in the post-intervention period. Figure 2 describes the percentage of patients receiving ceftriaxone at the appropriate dosing dependent on the clinical indication provided. This changed from 20% in the pre-intervention period to closer to 90% in the post-intervention period. Conclusion Pediatric specific ASP efforts and expertise proved to be crucial in appropriate CRO use in our institution. With a feasible education strategy and targeted prospective audit and feedback, there has been a sustained impact in inappropriate CRO use. This underscores the importance of targeted pediatric ASP efforts in pediatric hospitals within larger adult hospitals. Disclosures All Authors: No reported disclosures

763. Impact of Two-Step Testing Algorithm on Hospital-onset Clostridioides difficile Infections and Oral Vancomycin Prescription Practices at an Academic Medical Center

Background Clostridioides difficile infection (CDI) is one of the leading causes of hospital –onset (HO) infections. Clinically distinguishing true CDI versus colonization with C.difficile is challenging. We implemented a two-step testing algorithm to discriminate true CDI from colonization then evaluated the effect on rate of HO CDI and oral vancomycin. Methods In May 2020, a two-step testing algorithm was implemented utilizing C. difficile PCR and enzyme immunoassay (EIA) glutamate dehydrogenase (Figure 1). Rates of HO CDI and use of oral vancomycin was compared in the three quarters preceding and after this intervention (July 2019-March 2020 and July 2020-March 2021, respectively). HO CDI was defined based on National Healthcare Safety Network (NHSN) Laboratory Identified (LabID) event as last positive C.difficile test result performed on a specimen collected &gt;3 calendar days after admission to the facility. HO CDI rates were assessed based on Standardized Infection Ratio (SIR) data and antimicrobial use was reported in days of therapy (DoT) per 1000 patient days. Figure 1. Two-Step Testing Algorithm for Diagnosing Clostridioides difficile infection Results During the pre-intervention period 30 HO CDI cases were reported compared to 9 cases in the post-intervention period (p=0.02) (Figure 2). There was a non-statistically significant reduction in CDI SIR in post-intervention period (0.133 vs. 0.305, p=0.11). Oral vancomycin use was similar in the pre- and post-intervention periods (3.89 vs. 3.84, p=0.96). Fidaxomicin use was rare (&lt; 0.2 DoT/1000 pt days). Of 26 HO C.difficile colonized patients in post-intervention period, 14 (54%) patients received oral vancomycin treatment. Infectious diseases was consulted on 7/14 and recommended discontinuation of treatment in 3 while treatment was continued for other patients based on clinical status and immunocompromising conditions. Figure 2. Comparison of pre- and post-intervention trend in Hospital-onset CDI rate Conclusion We successfully reduced our HO CDI infections and SIR below national average after implementation of two-step testing algorithm for CDI. There was no impact on the rate of oral vancomycin use. We observed at 54% rate of treatment for patients categorized as likely colonization. Provider education and stewardship interventions are necessary to reduce inappropriate use of oral vancomycin in colonized patients. Disclosures All Authors: No reported disclosures

Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis

BackgroundRapid revascularisation in acute ischaemic stroke is crucial to reduce its total burden including societal costs. A quality improvement (QI) project that included streamlining the stroke care pathway and simulation-based training was followed by a significant reduction in median door-to-needle time (27 to 13 min) and improved patient outcomes after stroke thrombolysis at our centre. Here, we present a retrospective cost-effectiveness analysis of the QI project.MethodsCosts for implementing and sustaining QI were assessed using recognised frameworks for economic evaluations. Effectiveness was calculated from previously published outcome measures. Cost-effectiveness was presented as incremental cost-effectiveness ratios including costs per minute door-to-needle time reduction per patient, and costs per averted death in the 13-month post-intervention period. We also estimated incremental cost-effectiveness ratios for a projected 5-year post-intervention period and for varying numbers of patients treated with thrombolysis. Furthermore, we performed a sensitivity analysis including and excluding costs of unpaid time.ResultsAll costs including fixed costs for implementing the QI project totalled US$44 802, while monthly costs were US$2141. We calculated a mean reduction in door-to-needle time of 13.1 min per patient and 6.36 annual averted deaths. Across different scenarios, the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29, and the estimated costs per averted death ranged from US$4679 to US$10 543.ConclusionsWe have shown that a QI project aiming to improve stroke thrombolysis treatment at our centre can be implemented and sustained at a relatively low cost with increasing cost-effectiveness over time. Our work builds on the emerging theory and practice for economic evaluations in QI projects and simulation-based training. The presented cost-effectiveness data might help guide healthcare leaders planning similar interventions.

Improving decision making, communication and documentation regarding advance resuscitation decisions in a tertiary care hospital in Sri Lanka

BACKGROUND Resuscitation decisions made in advance are especially important to prevent negative patient outcomes at end-of-life. We conducted a clinical audit to assess the current practice of these decisions in Sri Lanka and then introduced interventions to improve the same. MATERIALS AND METHODS An auditor-administered questionnaire developed through a focused group discussion among experts was used to analyze the medical records of deaths during a period of sixty days focusing on advance resuscitation decisions and factors affecting them. The junior doctors directly involved in the care of each patient were interviewed regarding their retrospective judgement about the most appropriate resuscitation decision, which was later compared with the decision of an expert panel, who decided on the most appropriate resuscitation decision based on the medical records of the patient. An educational session for doctors was then conducted to improve their knowledge about advance resuscitation decisions including the importance of meticulous documentation of such decisions. The outcome was assessed after sixty days following the introduction of the intervention using the same questionnaire. RESULTS There was a significant improvement in the number of documented advance resuscitation decisions from 4/40 (10%) to 17/38 (44.73%) (Z = 3.5, P = 0.0006), with a significant increase in DNACPR decisions from 4/40 (10%) to 14/38 (36.8%) (Z = 2.8, P = 0.005) following the intervention. Unsuccessful CPR attempts decreased significantly from 31/40 (77.5%) to 14/38 (36.8%) (Z = 3.6, P = 0.0003) in the post-intervention period. The resuscitation decisions suggested by junior doctors that matched with expert decision increased significantly for both interns ((from 11/40 (27.5%) to 22/38 (57.9%) (Z = 2.7, P = 0.0066)) and registrars ((18/40 (45%) to 27/38 (71.05%) (Z = 2.3, P = 0.0202)) in the post-intervention period. CONCLUSION Documentation and practice regarding advance resuscitation decisions is suboptimal in Sri Lanka. This can be improved by interventions targeting improving the knowledge about the concept and its proper documentation among health care professionals.

Combined antibiotic stewardship and infection control measures to contain the spread of linezolid-resistant Staphylococcus epidermidis in an intensive care unit

Background The unrestricted use of linezolid has been linked to the emergence of linezolid-resistant Staphylococcus epidermidis (LRSE). We report the effects of combined antibiotic stewardship and infection control measures on the spread of LRSE in an intensive care unit (ICU). Methods Microbiological data were reviewed to identify all LRSE detected in clinical samples at an ICU in southwest Germany. Quantitative data on the use of antibiotics with Gram-positive coverage were obtained in defined daily doses (DDD) per 100 patient-days (PD). In addition to infection control measures, an antibiotic stewardship intervention was started in May 2019, focusing on linezolid restriction and promoting vancomycin, wherever needed. We compared data from the pre-intervention period (May 2018–April 2019) to the post-intervention period (May 2019–April 2020). Whole-genome sequencing (WGS) was performed to determine the genetic relatedness of LRSE isolates. Results In the pre-intervention period, LRSE were isolated from 31 patients (17 in blood cultures). The average consumption of linezolid and daptomycin decreased from 7.5 DDD/100 PD and 12.3 DDD/100 PD per month in the pre-intervention period to 2.5 DDD/100 PD and 5.7 DDD/100 PD per month in the post-intervention period (p = 0.0022 and 0.0205), respectively. Conversely, vancomycin consumption increased from 0.2 DDD/100 PD per month to 4.7 DDD/100 PD per month (p < 0.0001). In the post-intervention period, LRSE were detected in 6 patients (4 in blood cultures) (p = 0.0065). WGS revealed the predominance of one single clone. Conclusions Complementing infection control measures by targeted antibiotic stewardship interventions was beneficial in containing the spread of LRSE in an ICU.

Training Program for Ultrasound-Guided Intravenous Catheter Insertion

ABSTRACT Introduction Ultrasound guidance is now widely available in military treatment facilities and civilian hospitals alike, both in the USA and in forward-deployed military environments. Technical mastery of ultrasound-guided peripheral intravenous (USGPIV) catheter insertion can be easily achieved through a short training course. Mastery can be achieved even when trainees have a limited medical background before course attendance. An evidence-based practice project team sought to improve the knowledge, confidence, and skills in the placement of USGPIV catheters by clinicians at Naval Hospital Jacksonville. Completion of an USGPIV training program can equip healthcare providers with knowledge and confidence for placement of peripheral access necessary in critical situations such as those requiring medications or blood products. Materials and Methods The project team conducted a literature review to evaluate the appropriateness of USGPIV training for the nurses and military medical technicians in this setting. The team developed and delivered a USGPIV training program based on adaptations from the literature. During the training period, knowledge and confidence scores were reported by each trainee to evaluate the perceptions of the quality of training. The number of attempted catheter placements and ultrasound utilization was recorded in the pre- and post-implementation periods to evaluate the project’s effect on the delivery of patient care. Statistical analysis was conducted to evaluate project outcomes. Results In the pre-intervention period, none of the 252 intravenous catheters were placed with the USGPIV technique, compared to 50 of 267 in the post-intervention period. These results demonstrate an 18.7% increase in the USGPIV access approach by nursing staff. Mean knowledge scores significantly increased following the delivery of the training, 60% versus 80% in the pre- and post-training assessments, respectively (P &lt; .001). Mean self-reported skill confidence scores also significantly improved (P &lt; .001). Conclusion Knowledge and self-reported confidence in USGPIV access improved for the trainees. Mean knowledge improved from 60% to 80%, while mean confidence scores increased from 2.74 to 3.79 for corpsman and from 3.0 to 3.88 for nurses. Utilization of the USGPIV technique increased by 18.7% in the post-intervention period. These results demonstrate that implementing this training program can improve knowledge, confidence, and use of ultrasound during the placement of PIV catheters.

Nudging Commuters to Increase Public Transport Use: A Field Experiment in Rotterdam

A large-scale field experiment in Rotterdam, Netherlands, tested whether nudging could increase public transport use. During one work week, 4000 commuters on six bus lines, received a free travel card holder. On the three bus lines in the experimental condition, the card holders displayed a social label that branded bus passengers as sustainable travelers because of their bus use. On the three bus lines in the control condition, there was no such message on the card holders. Analysis of the number of rides per hour showed that the intervention led to a change from pre-intervention (619 days) to post-intervention period (176 days) that was estimated to be 1.18 rides per day greater on experimental lines than on control lines. This experiment shows that public transport operators can increase public transport use by incorporating messages that positively label passengers as sustainable travelers in their communication strategies.

Bridging Policy and Service Performance of Hospital-Based Nutrition Support by Healthcare Information Technology

Although the healthcare policy was implemented to incentivize the multidisciplinary services of hospital-based nutrition support team (NST) in South Korea, timely completion of the services has been challenging in the hospitals. We enhanced NST healthcare information technology (NST−HIT) to bridge the gap between policy implementation and seamless execution of the policy in the hospital system. A 48 month pre-test−post-test study was performed, including a 12 month pre-intervention period, a six month intervention period, and a 30 month post-intervention period. The enhanced NST−HIT provided sufficient patient data and streamlined communication processes among end-users. A Student’s t-test showed that the timely completion rate of NST consultations, the reimbursement rate of NST consultations, average response times of NST physicians and nurses, and length of hospital stay significantly improved during the post-intervention period. A segmented regression analysis of interrupted time series showed that the average response times of NST physicians had sustained after the interventions. We believe that well-structured, multi-pronged initiatives with leadership support from the hospital improved service performance of hospital NST in response to national-level healthcare policy changes.