Scaling the EQUIPPED medication safety program: Traditional and hub-and-spoke implementation models.

BACKGROUND: The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. METHODS: We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. RESULTS: The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. CONCLUSIONS: EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.

Machine learning to predict risk for community-onset Staphylococcus aureus infections in children living in southeastern United States.

Staphylococcus aureus (S. aureus) is known to cause human infections and since the late 1990s, community-onset antibiotic resistant infections (methicillin resistant S. aureus (MRSA)) continue to cause significant infections in the United States. Skin and soft tissue infections (SSTIs) still account for the majority of these in the outpatient setting. Machine learning can predict the location-based risks for community-level S. aureus infections. Multi-year (2002-2016) electronic health records of children <19 years old with S. aureus infections were queried for patient level data for demographic, clinical, and laboratory information. Area level data (Block group) was abstracted from U.S. Census data. A machine learning ecological niche model, maximum entropy (MaxEnt), was applied to assess model performance of specific place-based factors (determined a priori) associated with S. aureus infections; analyses were structured to compare methicillin resistant (MRSA) against methicillin sensitive S. aureus (MSSA) infections. Differences in rates of MRSA and MSSA infections were determined by comparing those which occurred in the early phase (2002-2005) and those in the later phase (2006-2016). Multi-level modeling was applied to identify risks factors for S. aureus infections. Among 16,124 unique patients with community-onset MRSA and MSSA, majority occurred in the most densely populated neighborhoods of Atlanta's metropolitan area. MaxEnt model performance showed the training AUC ranged from 0.771 to 0.824, while the testing AUC ranged from 0.769 to 0.839. Population density was the area variable which contributed the most in predicting S. aureus disease (stratified by CO-MRSA and CO-MSSA) across early and late periods. Race contributed more to CO-MRSA prediction models during the early and late periods than for CO-MSSA. Machine learning accurately predicts which densely populated areas are at highest and lowest risk for community-onset S. aureus infections over a 14-year time span.

Spontaneous vesicoureteral reflux resolution curves based on ureteral diameter ratio.

INTRODUCTION: Various factors influence the clinical course of vesicoureteral reflux (VUR) in the pediatric population. Distal ureteral diameter ratio (UDR) is an objective measure reflective of ureterovesical junction anatomy that has been shown to independently predict both spontaneous resolution and breakthrough febrile urinary tract infection (UTI) in children with primary reflux. UDR resolution curves were created, hypothesizing that a UDR value existed at which spontaneous resolution was unlikely to occur. MATERIALS AND METHODS: UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1-L3 vertebral bodies. Recursive partitioning with 10-fold cross validation methodology for time to event data, utilizing martingale residuals was used to create high and low risk groups based on UDR, and stratified by age at diagnosis and laterality. RESULTS: Three hundred and four patients (226 female, 78 male) were analyzed with a mean age at diagnosis of 1.55 ± 1.98 years. Unilateral reflux (p = 0.02), VUR grades 1-3 (p < 0.001), and lower UDR (p < 0.001) were associated with spontaneous resolution on univariate analysis. UDR values were categorized into risk groups based on recursive partitioning. Low risk patients (those with UDR <0.30) achieved VUR resolution faster and with a continuing rate compared to the high-risk group (≥0.30), which had persistent reflux after 3 years [Summary Figure]. When the 0.30 cutoff was applied randomly to patients in test group, the cutoff significantly discriminated between low and high-risk patients (log rank test p = 0.02). DISCUSSION: Primary VUR is often a self-limiting diagnosis, with conservative management favored in low-risk children, UDR may be used to help distinguish those children who may benefit from intervention. Unlike traditional VUR grading where children with any grade of reflux may spontaneously resolve, there appears to be a consistent UDR cutoff whereby patients are very unlikely to spontaneously resolve, regardless of length of follow-up. Therefore, parents of children with a UDR above the 0.3 cutoff, regardless of VUR grade, may be counselled that VUR is very unlikely to resolve over time - thereby reducing the number of VCUGs and length of time these patients are on prophylactic antibiotic prior to surgical intervention. CONCLUSIONS: Children with primary VUR and a UDR of greater than 0.30 are significantly less likely to spontaneously resolve regardless of length of follow-up, and resolution after 3 years was rare. UDR provides objective prognostic information facilitating individualized patient management.

Influence of Mask Wearing during COVID-19 Surge and Non-Surge Time Periods in Two K-12 Public School Districts in Georgia, USA.

BACKGROUND: Into the third year of the COVID-19 pandemic and the second year of in-person learning for many K-12 schools in the United States, the benefits of mitigation strategies in this setting are still unclear. We compare COVID-19 cases in school-aged children and adolescents between a school district with a mandatory mask-wearing policy to one with an optional mask-wearing policy, during and after the peak period of the Delta variant wave of infection. METHODS: COVID-19 cases during the Delta variant wave (August 2021) and post the wave (October 2021) were obtained from public health records. Cases of K-12 students, stratified by grade level (elementary, middle, and high school) and school districts across two counties, were included in the statistical and spatial analyses. COVID-19 case rates were determined and spatially mapped. Regression was performed adjusting for specific covariates. RESULTS: Mask-wearing was associated with lower COVID-19 cases during the peak Delta variant period; overall, regardless of the Delta variant period, higher COVID-19 rates were seen in older aged students. CONCLUSION: This study highlights the need for more layered prevention strategies and policies that take into consideration local community transmission levels, age of students, and vaccination coverage to ensure that students remain safe at school while optimizing their learning environment.

Space-time trends of community-onset Staphylococcus aureus infections in children: a group-based trajectory modeling approach.

PURPOSE: Staphylococcus aureus (S. aureus) remains a serious cause of infections in the United States and worldwide. In the United States, methicillin-resistant S. aureus (MRSA) is the leading cause of skin and soft tissue infections. This study identifies 'best' to 'worst' infection trends from 2002 to 2016, using group-based trajectory modeling approach. METHODS: Electronic health records of children living in the southeastern United States with S. aureus infections from 2002 to 2016 were retrospectively studied, by applying a group-based trajectory model to estimate infection trends (low, high, very high), and then assess spatial significance of these trends at the census tract level; we focused on community-onset infections and not those considered healthcare acquired. RESULTS: Three methicillin-susceptible S. aureus (MSSA) infection trends (low, high, very high) and three MRSA trends (low, high, very high) were identified from 2002 to 2016. Among census tracts with community-onset S. aureus cases, 29% of tracts belonged to the best trend (low infection) for both methicillin-resistant S. aureus and methicillin-susceptible S. aureus; higher proportions occurring in the less densely populated areas. Race disparities were seen with the worst methicillin-resistant S. aureus infection trends and were more often in urban areas. CONCLUSIONS: Group-based trajectory modeling identified unique trends of S. aureus infection rates over time and space, giving insight into the associated population characteristics which reflect these trends of community-onset infection.

Evaluation of a Multifaceted Protocol in Reducing Unnecessary Telemetry Monitoring across a Large Healthcare System.

OBJECTIVES: Telemetry is frequently overused in hospitals. The goal of this study was to evaluate a telemetry protocol aimed at decreasing inappropriate telemetry utilization across four different hospitals within a large healthcare system by modifying the electronic telemetry order to incorporate the 2017 American Heart Association practice guidelines on the appropriate use of telemetry and using an electronic nursing screening task form to safely discontinue telemetry. METHODS: We performed a retrospective analysis of telemetry utilization before and after we implemented a protocol across four hospitals within a large healthcare system. We compared the average number of days of telemetry monitoring and hospital length of stay during the preintervention period with the 6-month postintervention period. RESULTS: There were a total of 23,774 encounters evaluated. There was a statistically and clinically significant 24% decrease in telemetry duration between pre- and postintervention time periods (P < 0.0001). The mean (standard error) telemetry duration was 4.11 (0.17) and 2.36 (0.13) days in pre- and postintervention periods, respectively. CONCLUSIONS: The results of our study demonstrate a statistically significant decrease in overall duration of telemetry monitoring by nearly 1.75 days across each of the four hospitals with the implementation of a multifaceted telemetry protocol that included hardwiring the American Heart Association practice guidelines into the electronic order and using a nursing-driven discontinuation protocol.

Management and Outcomes of Salmonella Gastroenteritis in the Era of Rapid Molecular Testing.

BACKGROUND AND OBJECTIVES: Molecular diagnostics provide a rapid and sensitive diagnosis of gastroenteritis compared with a stool culture. In this study, we seek to describe the changes in medical management and outcomes of children with Salmonella gastroenteritis as our hospital system adopted molecular diagnostics. METHODS: This study is a retrospective chart review of children <18 years of age diagnosed with nontyphoidal Salmonella gastroenteritis between 2008 and 2018 at a large pediatric health care system in the southeastern United States. Those with immunocompromising conditions and hemoglobinopathies were excluded. Patients diagnosed via molecular testing were compared with those diagnosed solely by stool culture for aspects of management including admission rates, blood culture obtainment, and antibiotic administration. RESULTS: Of 965 eligible patients with Salmonella gastroenteritis, 264 (27%) had a stool molecular test and 701 (73%) only had a stool culture performed. Groups were similar in age and presentation. Those diagnosed by molecular methods had higher hospitalization rates (69% vs 50%, P <.001), more blood cultures obtained (54% vs 44%, P <.01), and received more antibiotics (49% vs 34%, P <.001) despite statistically similar rates of bacteremia (11% vs 19%, P = .05). CONCLUSIONS: The rapid diagnosis of Salmonella gastroenteritis by molecular methods was associated with increased hospital admission rates, blood culture obtainment, and antibiotic use. This suggests possible overmedicalization of uncomplicated Salmonella gastroenteritis, and clinicians should remain cognizant of the possibility of providing low-value care for uncomplicated disease.

A molecularly integrated amygdalo-fronto-striatal network coordinates flexible learning and memory.

Behavioral flexibility-that is, the ability to deviate from established behavioral sequences-is critical for navigating dynamic environments and requires the durable encoding and retrieval of new memories to guide future choice. The orbitofrontal cortex (OFC) supports outcome-guided behaviors. However, the coordinated neural circuitry and cellular mechanisms by which OFC connections sustain flexible learning and memory remain elusive. Here we demonstrate in mice that basolateral amygdala (BLA)→OFC projections bidirectionally control memory formation when familiar behaviors are unexpectedly not rewarded, whereas OFC→dorsomedial striatum (DMS) projections facilitate memory retrieval. OFC neuronal ensembles store a memory trace for newly learned information, which appears to be facilitated by circuit-specific dendritic spine plasticity and neurotrophin signaling within defined BLA-OFC-DMS connections and obstructed by cocaine. Thus, we describe the directional transmission of information within an integrated amygdalo-fronto-striatal circuit across time, whereby novel memories are encoded by BLA→OFC inputs, represented within OFC ensembles and retrieved via OFC→DMS outputs during future choice.

Real-world treatment drop-off among recurrent or metastatic cervical cancer patients: A US community oncology-based analysis.

OBJECTIVE: Understanding real-world treatment patterns and proportions of eligible patients in each line of treatment is imperative to inform future clinical trial designs and multi-line treatment algorithm development. METHODS: We conducted a retrospective observational cohort study of adult women who received first-line (1 L) therapy for r/mCC between 01 September 2014 and 31 December 2019, using The US Oncology Network electronic health records and chart review data. Patients were followed to 31 December 2020. Patient demographic and clinical characteristics, treatment patterns, and clinical outcomes were assessed descriptively. RESULTS: A total of 262 patients with r/mCC met study inclusion criteria (mean age = 53 years). The majority of patients in 1 L received platinum-based chemotherapy doublet plus bevacizumab (66%) or chemotherapy doublet alone (24%). Nearly half the patients (48%) completing 1 L received 2 L therapy. Among these patients, there was no consistent 2 L treatment of choice. Overall median time to treatment discontinuation was 3.5 months from 1 L treatment initiation, and median overall treatment-free interval was 2.1 months from 1 L discontinuation. Besides elevated serum creatinine, abnormal BMI indicated a directional trend for lower likelihood of receiving 2 L. Other predictors may include no prior bevacizumab, worse ECOG, and earlier disease prevention. CONCLUSIONS: >50% of the patients who initiated 1 L treatment did not receive 2 L therapy, highlighting the need for novel and effective treatment options. As the treatment landscape continues to evolve, we anticipate that more patients will live longer with more treatment options across multiple lines of therapies in the r/mCC setting.

Intravenous Antibiotic Duration for Nontyphoidal Salmonella Bacteremia in Children.

BACKGROUND AND OBJECTIVE: The optimal duration of intravenous (IV) antibiotic therapy for children with nontyphoidal Salmonella bacteremia (NTSB) is unknown. The objective of the authors of this study is to evaluate differences in outcomes among children with NTSB who received a short (≤3 days; short-duration group [SDG]) versus long (>3 days; long-duration group [LDG]) course of IV antibiotics. METHODS: This is a retrospective study of children 3 months to 18 years old with NTSB admitted to a tertiary pediatric health care system in the southeastern United States between 2008 and 2018. RESULTS: Among 57 patients with NTSB without focal infection, 24 (42%) were in the SDG and received IV antibiotics for a median of 3.0 days and 33 (58%) were in the LDG and received IV antibiotics for a median of 5.0 days. Demographic and clinical characteristics were similar between the SDG and LDG. The median total duration of antibiotics was 11.5 days in the SDG and 13.0 in the LDG (P = .068). The median length of stay was 3.0 days in the SDG and 4.0 in the LDG (P ≤ .001). Two children in the SDG (8%) and 1 child in the LDG (3%) returned to the emergency department for care unrelated to the duration of their IV antibiotic therapy (P = .567). None of the children were readmitted for sequelae related to salmonellosis. CONCLUSIONS: The duration of IV antibiotics varied for NTSB, but the outcomes were excellent regardless of the initial IV antibiotic duration. Earlier transitions to oral antibiotics can be considered for NTSB.

Comparison of Mid-turbinate Nasal Swabs, Saliva, and Nasopharyngeal Swabs for SARS-CoV-2 Reverse Transcription-Polymerase Chain Reaction Testing in Pediatric Outpatients.

CONTEXT.­: Diagnostic testing for SARS-CoV-2 in symptomatic and asymptomatic children remains integral to care, particularly for supporting return to and attendance in schools. The concordance of SARS-CoV-2 detection in children, using various specimen types, has not been widely studied. OBJECTIVE.­: To compare 3 sample types for SARS-CoV-2 polymerase chain reaction (PCR) testing in children, collected and tested at a single facility. DESIGN.­: We prospectively recruited 142 symptomatic and asymptomatic children/young adults into a sample comparison study performed in a single health care system. Each child provided self-collected saliva, and a trained health care provider collected a mid-turbinate nasal swab and nasopharyngeal (NP) swab. Specimens were assayed within 24 hours of collection by using reverse transcription-polymerase chain reaction (RT-PCR) to detect SARS-CoV-2 on a single testing platform. RESULTS.­: Concurrently collected saliva and mid-turbinate swabs had greater than 95% positive agreement with NP swabs when obtained within 10 days of symptom onset. Positive agreement of saliva and mid-turbinate samples collected from children with symptom onset >10 days prior, or without symptoms, was 82% compared to NP swab samples. Cycle threshold (Ct) values for mid-turbinate nasal samples more closely correlated with Ct values from NP samples than from saliva samples. CONCLUSIONS.­: These findings suggest that all 3 sample types from children are useful for SARS-CoV-2 diagnostic testing by RT-PCR, and that concordance is greatest when the child has had symptoms of COVID-19 within the past 10 days. This study provides scientific justification for using sample types other than the NP swab for SARS-CoV-2 testing in pediatric populations.

Voiding cystourethrogram: Who gets a cyclic study and does it matter?

BACKGROUND: Voiding cystourethrogram (VCUG) images the urethra and bladder during both bladder filling and emptying, as well as the ureters and kidneys when vesicoureteral reflux (VUR) is present. Given the variation in VCUG technique and reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016, which included the recommendation of at least 2 voiding cycles to identify intermittent VUR and/or ureteral ectopia. STUDY DESIGN: VCUG were assessed for adherence to performance of cyclic study. Children who underwent cyclic evaluation were compared to those who underwent a single cycle VCUG. Radiation dosage was also analyzed. Studies performed on patients >18 years of age and those obtained as part of a trauma evaluation were excluded from study. RESULTS: Two hundred and eighty-four VCUGs were analyzed, 97 (34.2%) were positive for VUR on the initial cycle. Of the remaining 187 studies, 116 (62%) had multiple filling-voiding cycles while in 71 (38%) only a single cycle was performed. One hundred and sixty-one (86.1%) were negative for vesicoureteral reflux. Twenty-six (13.9%) children were diagnosed with VUR after the initial filling-voiding cycle: 6 were diagnosed with grade I, 2 grade II, 11 grade III, 2 grade IV and 5 grade V. Of the 123 total children found to have VUR, 26 (21.2%) were diagnosed after an initial negative cycle. Younger children were significantly more likely to have a cyclic study performed; mean age of patients undergoing a cyclic study was 1.09 ± 2.16 years versus 3.86 ± 4.5 years (p ≤ 0.0001). Categorically, 74.1% of children less than 1 year of age underwent a cyclic study compared to 6.9% of children older than 5 years of age (p ≤ 0.0001). There was no difference based on sex with 49.1% of males and 50.9% of females (p = 0.667) undergoing cyclic evaluation. Children undergoing a cyclic study had lower median radiation dose 2.15 microGy m2 (range 0.09-111) compared to 4.41 (range 1.3-104) [p = 0.01]. DISCUSSION: Vesicoureteral reflux may occur intermittently and cyclic VCUG is thought to enhance the ability to detect reflux. In our cohort, 26 children (9.2%) were only diagnosed after an additional cycle - ie 21.1% of reflux would have been missed had a cyclic study not been performed. The majority of these patients (69.2%, 18 of 26) were found to have dilating, and thus perhaps more clinically significant, reflux. Our study highlights the importance of obtaining as much information as possible and adhering to the standardized VCUG protocol. CONCLUSION: Younger children are more likely to undergo cyclic VCUG. While most reflux is detected with the initial filling-voiding cycle, 26 (21.2%) patients were diagnosed after an initial negative cycle with the majority being dilating VUR.

Burden and Correlates of Mental Health Symptoms Among Young Black Gay, Bisexual, and Other Men Who Have Sex with Men Engaged in HIV Care in Atlanta.

Mental health comorbidities are prevalent among young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) living with HIV and can adversely impact HIV-related outcomes. We conducted a cross-sectional survey study with 100 YB-GBMSM recruited from two HIV care centers in Atlanta, and constructed multivariable logistic and linear regression models to examine correlates of depression, anxiety, trauma symptoms, and general well-being. In adjusted models, full-time employment was associated with fewer depressive symptoms, while HIV stigma and substance use were associated with higher levels of depressive symptoms. Younger age and full-time employment were negatively associated with severe anxiety, while HIV stigma was positively associated with severe anxiety and trauma symptoms. Trust in physicians, lower HIV stigma, full-time employment, and lack of substance use were associated with higher average general well-being scores. In conclusion, we found high frequency of depressive, anxiety, and trauma-related symptoms among this sample of YB-GBMSM living with HIV. Unemployment, substance use, and HIV stigma emerged as particularly salient correlates of psychological morbidity, suggesting a need for structural and community-level interventions to address mental health in this population.

Portal vein complications and outcomes following pediatric liver transplantation: Data from the Society of Pediatric Liver Transplantation.

Children who undergo liver transplantation are at risk for portal vein complications (PVCs) including thrombosis (PVT) and stenosis (PVS). Using multicenter data from the Society of Pediatric Liver Transplantation, we analyzed the prevalence, timing, and risk factors for PVC following a first liver transplantation, and assessed the potential impact of PVC on patient outcomes. Our cohort included 4278 patients, of whom 327 (7.6%) developed PVC. Multivariate analysis discovered several factors independently associated with PVC: younger recipient age, lower weight at time of transplantation, diagnosis of biliary atresia (BA), receiving a technical variant graft (TVG), warm ischemia time over 3 h, PVT in the recipient's pretransplantation native liver, and concurrent hepatic artery thrombosis (all p < 0.05). Subgroup analysis of those with BA found higher prevalence in patients transplanted at less than 2 years of age and those with TVGs. There was no difference in PVC prevalence among patients with BA with vs. without prior Kasai portoenterostomy. Most PVT (77.7%) presented within 90 days after transplantation. Patients with PVC had a higher risk of graft failure (23.9% vs. 8.3%; adjusted hazard ratio [HR], 3.08; p < 0.001) and a higher risk of death (16.4% vs. 8.9%; adjusted HR, 1.96; p = 0.01). Recurrence after retransplantation was similar to the overall prevalence in the cohort (8.2%). Our results recognize the common occurrence of PVC following pediatric liver transplantation, describe independently associated risk factors, and determine that patients with PVC have worse outcomes. Further studies are needed to improve PVC prevention, detection, and management strategies.

Randomized trial of two maintenance doses of vitamin D in children with chronic kidney disease.

BACKGROUND: Correction of nutritional vitamin deficiency is recommended in children with chronic kidney disease (CKD). The optimal daily dose of vitamin D to achieve or maintain vitamin D sufficiency is unknown. METHODS: We conducted a phase III, double-blind, randomized trial of two doses of vitamin D3 in children ≥ 9 years of age with CKD stages 3-5 or kidney transplant recipients. Patients were randomized to 1000 IU or 4000 IU of daily vitamin D3 orally. We measured 25-hydroxvitamin D (25(OH)D) levels at baseline, 3 months and 6 months. The primary efficacy outcome was the percentage of patients who were vitamin D replete (25(OH)D ≥ 30 ng/mL) at 6 months. RESULTS: Ninety-eight patients were enrolled: 49 randomized into each group. Eighty (81.6%) patients completed the study and were analyzed. Baseline plasma 25(OH)D levels were ≥ 30 ng/mL in 12 (35.3%) and 12 (27.3%) patients in the 1000 IU and 4000 IU treatment groups, respectively. At 6 months, plasma 25(OH)D levels were ≥ 30 ng/mL in 33.3% (95% CI: 18.0-51.8%) and 74.4% (95% CI: 58.8-86.5%) in the 1000 IU and 4000 IU treatment groups, respectively (p = 0.0008). None of the patients developed vitamin D toxicity or hypercalcemia. CONCLUSIONS: In children with CKD, 1000 IU of daily vitamin D3 is unlikely to achieve or maintain a plasma 25(OH)D ≥ 30 ng/mL. In children with CKD stages 3-5, a dose of vitamin D3 4000 IU daily was effective in achieving or maintaining vitamin D sufficiency. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01909115.

Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme.

Enhancing quality of prescribing practices for older adults discharged from the Emergency Department (EQUIPPED) aims to reduce the monthly proportion of potentially inappropriate medications (PIMs) prescribed to older adults discharged from the ED to 5% or less. We describe prescribing outcomes at three academic health systems adapting and sequentially implementing the EQUIPPED medication safety programme.EQUIPPED was adapted from a model developed in the Veterans Health Administration (VA) and sequentially implemented in one academic health system per year over a 3-year period. The monthly proportion of PIMs, as defined by the 2015 American Geriatrics Beers Criteria, of all medications prescribed to adults aged 65 years and older at discharge was assessed for 6 months preimplementation until 12 months postimplementation using a generalised linear time series model with a Poisson distribution.The EQUIPPED programme was translated from the VA health system and its electronic medical record into three health systems each using a version of the Epic electronic medical record. Adaptation occurred through local modification of order sets and in the generation and delivery of provider prescribing reports by local champions. Baseline monthly PIM proportions 6 months prior to implementation at the three sites were 5.6% (95% CI 5.0% to 6.3%), 5.8% (95% CI 5.0% to 6.6%) and 7.3% (95% CI 6.4% to 9.2%), respectively. Evaluation of monthly prescribing including the twelve months post-EQUIPPED implementation demonstrated significant reduction in PIMs at one of the three sites. In exploratory analyses, the proportion of benzodiazepine prescriptions decreased across all sites from approximately 17% of PIMs at baseline to 9.5%-12% postimplementation, although not all reached statistical significance.EQUIPPED is feasible to implement outside the VA system. While the impact of the EQUIPPED model may vary across different health systems, results from this initial translation suggest significant reduction in specific high-risk drug classes may be an appropriate target for improvement at sites with relatively low baseline PIM prescribing rates.

Order Set Use and Education Association With Pediatric Acute Pancreatitis Outcomes.

BACKGROUND: The management of acute pancreatitis (AP) in children was historically derived from adult practice recommendations. Pediatric-specific recommendations for treatment of AP were recently developed by North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, but their impact on clinical outcomes has yet to be evaluated. We developed an AP order set on the basis of these recommendations to assess impact on clinical outcomes. METHODS: Patients admitted to a single center with 3 children's hospitals in 2017 and 2018 for isolated AP were included in a retrospective review. Patient demographic data, order set use, treatment variables (eg, fluid type, rate, type and timing of diet initiation, and narcotic use), and outcome variables (eg, length of stay [LOS], PICU admission, and 30-day readmission) were collected. Mixed-effects modeling was used to estimate the impact of order set use on clinical outcomes. RESULTS: There were 159 pancreatitis encounters and 137 unique patients who met inclusion criteria. In 2018, when using the log transform of LOS in a linear mixed-effects model for clustering by hospital, there was a 10% decrease in mean LOS, but this failed to reach statistical significance (P = .30). Among the 107 encounters who received at least 1 dose of narcotic, there were significantly fewer doses prescribed after implementation of the order set: mean (SD) of5.22 (2.86) vs 3.59 (2.47) (P < .001). Thirty-day readmission (P = .25) and PICU admission rates (P = .31) were not different between years. CONCLUSIONS: The implementation of a pancreatitis order set is associated with a significant decrease in narcotic use in pediatric patients with AP without increasing readmission rates or PICU admissions.

The RADx Tech Test Verification Core and the ACME POCT in the Evaluation of COVID-19 Testing Devices: A Model for Progress and Change.

Faced with the COVID-19 pandemic, the US system for developing and testing technologies was challenged in unparalleled ways. This article describes the multi-institutional, transdisciplinary team of the "RADxSM Tech Test Verification Core" and its role in expediting evaluations of COVID-19 testing devices. Expertise related to aspects of diagnostic testing was coordinated to evaluate testing devices with the goal of significantly expanding the ability to mass screen Americans to preserve lives and facilitate the safe return to work and school. Focal points included: laboratory and clinical device evaluation of the limit of viral detection, sensitivity, and specificity of devices in controlled and community settings; regulatory expertise to provide focused attention to barriers to device approval and distribution; usability testing from the perspective of patients and those using the tests to identify and overcome device limitations, and engineering assessment to evaluate robustness of design including human factors, manufacturability, and scalability.

Fast track dialysis: Improving emergency department and hospital throughput for patients requiring hemodialysis.

OBJECTIVE: To describe the impact of a novel communication and triage pathway called fast track dialysis (FTD) on the length of stay (LOS), resource utilization, and charges for unscheduled hemodialysis for end stage renal disease (ESRD) patients presenting to the emergency department (ED). METHODS: Prospective and retrospective cohorts of ESRD patients meeting requirements of routine or urgent hemodialysis at a tertiary academic hospital from September 25th, 2016 to September 25th, 2018 in 1 year cohorts. Two sample t-tests were used to compare most outcomes of the cohorts with a Mann-Whitney U test used for skewed data. Nephrology group outcomes were analyzed by two-way ANOVA and Kruskal-Wallis and chi-square tests. RESULTS: There were 98 encounters in the historical cohort and 143 encounters in the fast track dialysis cohort. FTD had significantly lowered median ED LOS (4.05 h, vs 5.3 h, p < 0.001), median hospital LOS (12.8 h vs 27 h, p < 0.001), time to hemodialysis (4.78 h vs 7.29 h, p < 0.001), and median hospital charges ($26,040 vs $30,747, p < 0.016). The FTD cohort had increased 30 day ED return for each encounter compared to the historical cohort (1.85 visits vs 0.73 visits, p < 0.001), however no significant increase in 1 year ED visits (6.52 visits vs 5.80, p = 0.4589) or 1 year readmissions (5.89 readmissions vs 4.81 readmissions, p = 0.3584). Most nephrology groups had significantly lower time to hemodialysis order placement and time to start hemodialysis. CONCLUSION: A multidisciplinary approach with key stakeholders using a standard pathway can lead to improved efficiency in throughput, reduced charges, and hospital resource utilization for patients needing urgent or routine hemodialysis. A study with a dedicated geographic observation unit for protocolized short stay patients including conditions ranging from low risk chest pain to transient ischemic events that incorporates FTD patients under this protocol should be considered.