Generalizability of COBRA: A Parsimonious Perioperative Venous Thromboembolism Risk Assessment Model.

INTRODUCTION: Standardized use of venous thromboembolism (VTE) risk assessment models (RAMs) in surgical patients has been limited, in part due to the cumbersome workflow addition required to use available models. The COBRA score-capturing cancer diagnosis, (old) age, body mass index, race, and American Society of Anesthesiologists Physical Status score-has been reported as a potentially automatable VTE RAM that circumvents the cumbersome workflow addition that most RAMs represent. We aimed to test the ability of the COBRA model to effectively risk-stratify patients across various populations. METHODS: Patients were included from the 2014-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Participant Use Data File for two hospitals, representing colorectal, endocrine, breast, transplant, plastic, and general surgery services. COBRA score was calculated for each patient using preoperative characteristics. We calculated negative predictive value (NPV) for VTE outcomes and compared the COBRA score to NSQIP's expected VTE rate for all patients, between the two hospitals, and between subspecialty service lines. RESULTS: Of the 10,711 patients included, those with COBRA <4 (31%) had projected median VTE rate of 0.21% (interquartile range, 0.09-0.68%; mean, 0.54%). Patients with higher scores (69%) had median rate of 0.88% (0.26-2.07%; 1.46%); relative rate 2.7. The median projected VTE rates for patients identified as low risk were 0.21% and 0.16% and as high risk were 0.87% and 0.89% at hospitals one and 2, respectively. The median projected VTE rates for patients identified as low risk were 0.17%, 0.61%, and 0.08% and as high risk were 0.52%, 1.43%, and 0.18% among general, colorectal, and endocrine surgery patients, respectively. COBRA had NPV of 0.995 and sensitivity of 0.871 as compared to NPV 0.997 and sensitivity 0.857 of the NSQIP model. CONCLUSIONS: The COBRA score is concordant with the traditional gold standard NSQIP VTE RAM and demonstrates interhospital and service-specific generalizability, although performance was limited in especially low-risk patients. The model adequately risk-stratifies surgical patients preoperatively, potentially providing clinical decision support for perioperative workflows.

Obstetric operating room staffing and operating efficiency using queueing theory.

INTRODUCTION: Strategies to achieve efficiency in non-operating room locations have been described, but emergencies and competing priorities in a birth unit can make setting optimal staffing and operation benchmarks challenging. This study used Queuing Theory Analysis (QTA) to identify optimal birth center operating room (OR) and staffing resources using real-world data. METHODS: Data from a Level 4 Maternity Center (9,626 births/year, cesarean delivery (CD) rate 32%) were abstracted for all labor and delivery operating room activity from July 2019-June 2020. QTA has two variables: Mean Arrival Rate, λ and Mean Service Rate µ. QTA formulas computed probabilities: P0 = 1-(λ/ µ) and Pn = P0 (λ/µ)n where n = number of patients. P0…n is the probability there are zero patients in the queue at a given time. Multiphase multichannel analysis was used to gain insights on optimal staff and space utilization assuming a priori safety parameters (i.e., 30 min decision to incision in unscheduled CD; ≤ 5 min for emergent CD; no greater than 8 h for nil per os time). To achieve these safety targets, a < 0.5% probability that a patient would need to wait was assumed. RESULTS: There were 4,017 total activities in the operating room and 3,092 CD in the study period. Arrival rate λ was 0.45 (patients per hour) at peak hours 07:00-19:00 while λ was 0.34 over all 24 h. The service rate per OR team (µ) was 0.87 (patients per hour) regardless of peak or overall hours. The number of server teams (s) dedicated to OR activity was varied between two and five. Over 24 h, the probability of no patients in the system was P0 = 0.61, while the probability of 1 patient in the system was P1 = 0.23, and the probability of 2 or more patients in the system was P≥2 = 0.05 (P3 = 0.006). However, between peak hours 07:00-19:00, λ was 0.45, µ was 0.87, s was 3, P0 was 0.48; P1 was 0.25; and P≥2 was 0.07 (P3 = 0.01, P4 = 0.002, P5 = 0.0003). CONCLUSION: QTA is a useful tool to inform birth center OR efficiency while upholding assumed safety standards and factoring peaks and troughs of daily activity. Our findings suggest QTA is feasible to guide staffing for maternity centers of all volumes through varying model parameters. QTA can inform individual hospital-level decisions in setting staffing and space requirements to achieve safe and efficient maternity perioperative care.

A Self-Sustaining Antibiotic Prophylaxis Program to Reduce Surgical Site Infections.

Background: Our multi-institutional healthcare system had a higher-than-expected surgical site infection (SSI) rate. We aimed to improve our peri-operative antibiotic administration process. Gap analysis identified three opportunities for process improvement: standardized antibiotic selection, standardized second-line antibiotic agents for patients with allergies, and feedback regarding antibiotic administration compliance. Hypothesis: Implementation of a multifaceted quality improvement initiative including a near-real-time pre-operative antibiotic compliance feedback tool will improve compliance with antibiotic administration protocols, subsequently lowering SSI rate. Methods: A compliance feedback tool designed to provide monthly reports to all anesthesia and surgical personnel was implemented at two facilities, in September 2017 and December 2018. Internal case data were tracked for antibiotic compliance through June 2021, and these data were merged with American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data at the case level to provide process and outcome measures for SSIs. Implementation success was evaluated by comparing protocol compliance and risk-adjusted rates of superficial and deep SSI before and after the quality improvement implementation. Results: A total of 20,385 patients were included in this study; 11,548 patients in the pre-implementation and 8,837 in the post-implementation groups. Baseline patient and operative characteristics were similar between groups, except the post-implementation group had a higher median expected SSI rate (2.2% vs. 1.6%). Post-implementation, antibiotic protocol compliance increased from 86.3% to 97.6%, and superficial and deep SSIs decreased from 2.8% to 1.9% (p < 0.001). The odds of superficial and deep SSI in patients in the post-implementation group was 0.69 (0.57, 0.83) times the odds of superficial and deep SSI in pre-implementation patients while adjusting for age, gender, diabetes mellitus, American Society of Anesthesiologists Physical Status (ASA) classification, wound class, smoking, and chronic obstructive pulmonary disease (COPD). Observed-to-expected ratios of superficial and deep SSI decreased from 0.82 to 0.48 after the intervention. Conclusions: Surgical antibiotic prophylaxis standardization and providing near-real-time individualized feedback resulted in sustained improvement in peri-operative antibiotic compliance rates and reduced superficial and deep SSIs.

Timing is Everything: Surgical Outcomes for SARS-CoV-2 Positive Patients.

BACKGROUND: A debate remains on how long to postpone surgery after testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We aimed to determine surgical outcomes at different time points after a positive SARS-CoV-2 test. METHODS: This cohort study included non-preoperative critically ill adult surgical patients from 5/2020-5/2021 and a subset of SARS-CoV-2 positive patients 15-30 days before surgery from 5/2020-12/2021. Demographics, comorbidities, surgical variables, and outcomes were compared between SARS-CoV-2 positive patients within 50 days before surgery to SARS-CoV-2 negative surgical patients. Cases were stratified based on the timing of SARS-CoV-2 positivity before surgery in days (< 15, 15-30, > 30). Outcomes were compared between strata and against SARS-CoV-2 negative controls. A multivariable model was built to determine the association that the timing of SARS-CoV-2 positivity has on the odds of a major complication. RESULTS: The SARS-CoV-2 positive cohort had 262 patients compared to 1,840 SARS-CoV-2 negative patients. Timing strata contained 145 (< 15 days), 53 (15-30 days), and 64 (> 30 days). The SARS-CoV-2 positive group had a higher incidence of comorbidities (87.4% vs. 57.2%) and underwent more emergent surgery (45.7% vs. 9.3%). The odds of major complications in patients positive for SARS-CoV-2 before surgery were 1.88 (1.13-3.15) (< 15 days), 0.43 (0.14-1.30) (15-30 days), and 0.98 (0.44-2.21) (31-50 days) times the odds in SARS-CoV-2 negative surgery patients when controlling for other variables. CONCLUSION: Timing of SARS-CoV-2 positivity before surgery has an impact on major complications. In certain cases, it may be appropriate to postpone surgery 14 days after SARS-CoV-2 positivity.

Anatomy of a successful stewardship intervention: Improving perioperative prescribing in penicillin-allergic patients.

OBJECTIVE: To evaluate whether a series of quality improvement interventions to promote safe perioperative use of cephalosporins in penicillin-allergic patients improved use of first-line antibiotics and decreased costs. DESIGN: Before-and-after trial following several educational interventions. SETTING: Academic medical center. PATIENTS: This study included patients undergoing a surgical procedure involving receipt of a perioperative antibiotic other than a penicillin or carbapenem between January 1, 2017, and August 31, 2019. Patients with and without a penicillin allergy label in their electronic medical record were compared with respect to the percentage who received a cephalosporin and average antibiotic cost per patient. METHODS: A multidisciplinary team from infectious diseases, allergy, anesthesiology, surgery, and pharmacy surveyed anesthesiology providers about their use of perioperative cephalosporins in penicillin-allergic patients. Using findings from that survey, the team designed a decision-support algorithm for safe utilization and provided 2 educational forums to introduce this algorithm, emphasizing the safety of cefazolin or cefuroxime in penicillin-allergic patients without history of a severe delayed hypersensitivity reaction. RESULTS: The percentage of penicillin-allergic patients receiving a perioperative cephalosporin improved from ∼34% to >80% following algorithm implementation and the associated educational interventions. This increase in cephalosporin use was associated with a ∼50% reduction in antibiotic cost per penicillin-allergic patient. No significant adverse reactions were reported. CONCLUSIONS: An educational antibiotic stewardship intervention produced a significant change in clinician behavior. A simple intervention can have a significant impact, although further study is needed regarding whether this response is sustained and whether an educational intervention is similarly effective in other healthcare systems.

Approach to Perioperative Anaphylaxis in 2020: Updates in Diagnosis and Management.

PURPOSE OF REVIEW: The goal of the paper is to review the epidemiology, pathogenesis, diagnosis, and manifestations of perioperative anaphylaxis (POA). We seek to review the most common culprits of POA and different diagnostic modalities for evaluation. RECENT FINDINGS: Specific IgE testing has a limited role in POA evaluation due to lack of widespread availability and low sensitivity. Basophil activation testing is complementary to skin tests and can assist NMBA sensitivity diagnosis in complex cases. In the past years, there has been an exponential increase in suspected teicoplanin allergic reactions in the European Union. Chlorhexidine is also being increasingly implicated as a culprit in POA. Multiple classes of perioperative medications cause POA. Diagnostic modalities available include skin testing with nonirritating concentrations, basophil activation tests, specific IgE, and drug provocation testing. An accurate record and critical analysis of perioperative events is more important than isolated test results. Future studies evaluating the pathophysiology of these reactions and other therapeutic strategies, such as targeting the MRGPRX2 receptor, are needed.

Development of a Novel Preoperative Venous Thromboembolism Risk Assessment Model.

INTRODUCTION: Standardization of preoperative venous thromboembolism (VTE) risk assessment remains challenging due to variation in risk assessment models (RAMs) and the cumbersome workflow addition that most RAMs represent. We aimed to develop a parsimonious RAM that is automatable and actionable within the preoperative workflow. METHODS: We performed a case-controlled review of all 18 VTE cases reported over a 12-month period and 171 matched controls included in an institutional National Surgical Quality Improvement Project (NSQIP) data set. We examined the predictive value of the Caprini, Padua, and NSQIP RAMs. We identified the 5 most impactful risk factors in VTE development by contribution to the known RAMs. We compared the predictive ability of cancer, age, body mass index, black race, and American Society of Anesthesiologists Physical Status (ASA-PS) score, to the Caprini, Padua, and NSQIP RAMs for VTE outcomes. Finally, we evaluated concordance between each of the models. RESULTS: The Caprini Score was found to be 88.9% sensitive and 32.7% specific using a threshold of 5. The Padua score was found to be 61.1% sensitive and 47.4% specific using a threshold of 4. The novel 5-factor RAM was found to be 94.4% sensitive and 38.0% specific using a threshold of 4. The Caprini and Padua models were discordant in 26% of patients. DISCUSSION: Cumbersome manual data entry contributes to the ongoing challenge of standardized VTE risk assessment and prophylaxis. Universally documented information and patient demographics can be utilized to create clinical decision support tools that can improve the efficiency of perioperative workflow and improve the quality of care.

Management of Coronavirus Disease 2019 Intubation Teams.

Some patients infected with the Coronavirus Disease 2019 (COVID-19) require endotracheal intubation, an aerosol-generating procedure that is believed to result in viral transmission to personnel performing the procedure. Additionally, donning and doffing personal protective equipment can be time consuming. In particular, doffing requires strict protocol adherence to avoid exposure. We describe the Emory Healthcare intubation team approach during the COVID-19 pandemic. This structure resulted in only 1 team member testing positive for COVID-19 despite 253 patient intubations over a 6-week period with 153 anesthesia providers on service.

A Streamlined Approach to Optimize Perioperative Antibiotic Prophylaxis in the Setting of Penicillin Allergy Labels.

BACKGROUND: Patients with penicillin allergy labels often receive alternative antibiotics for perioperative prophylaxis, as opposed to first-line cephalosporins (cefazolin/cefuroxime). Provider misconceptions about the risk of cross-reactivity likely drive this prescribing behavior, which is problematic because of its association with increased risk of surgical-site infections. OBJECTIVE: To develop, implement, and assess the safety of a streamlined approach to perioperative antibiotic selection for surgical patients with a penicillin allergy label, to reduce the use of second-line antibiotics. METHODS: A multidisciplinary task force developed an institutional algorithm for antibiotic selection in penicillin-allergic surgical patients. The percentage of patients receiving a first-line cephalosporin was compared before and after algorithm utilization. The safety of this approach was assessed via chart review of all patients who received epinephrine or diphenhydramine in the operating room, or diphenhydramine within 24 hours postoperatively, assessing for any adverse reactions to cephalosporin administration. RESULTS: Between September 2016 and May 2019, 9.3% of surgical patients had documented penicillin allergy (n = 2296). At baseline, 22% of these patients received a cephalosporin, with an increase to more than 80% after algorithm implementation (P < .0001). Among 551 patients with penicillin allergy label who received a cephalosporin after algorithm implementation, no immediate allergic reactions requiring epinephrine were identified; 1 patient had a delayed rash that did not require cephalosporin discontinuation. Three patients received diphenhydramine for "itching" without rash in the setting of concomitant narcotic administration. CONCLUSIONS: Using a streamlined algorithm, we were able to significantly reduce the use of second-line antibiotics in penicillin-allergic surgical patients without severe adverse reactions.

Chronic Atypical Antipsychotic Use Is Associated With Reduced Need for Postoperative Nausea and Vomiting Rescue in the Postanesthesia Care Unit: A Propensity-Matched Retrospective Observational Study.

BACKGROUND: Atypical antipsychotics are efficacious for chemoprophylaxis against chemotherapy-induced nausea and vomiting, but perioperative investigations have been scant. We sought to examine the association between chronic atypical antipsychotic therapy and the likelihood of postoperative nausea and vomiting. METHODS: In this single-center, propensity-matched, retrospective, observational study, elective noncardiac surgical cases from January 2014 to December 2017 were examined with regard to the primary outcome of rescue antiemetic administration in the postanesthesia care unit as a measure of postoperative nausea and vomiting. Chronic administration of olanzapine, aripiprazole, and risperidone was the exposure of interest. Other independent variables included outpatient antiemetics, modified Apfel score, age, American Society of Anesthesiologists physical status score, case length, and exposures to emetogenic and chemoprophylactic agents. Logistic regression was performed using case-level data. Conditional logistic regression was performed after 1:2 propensity matching, sampling without replacement. Monte Carlo simulation was performed to compute the mean patient-level treatment effect on the treated. RESULTS: Of 13,660 cases, 154 cases with patients receiving atypical antipsychotics were matched against 308 cases without, representing 115 and 273 unique patients, respectively. In a well-balanced cohort, the mean patient-level odds of being administered rescue antiemetic was lower for patients chronically taking the 3 atypical antipsychotics under consideration as compared to those not on atypical antipsychotics, with an odds ratio of 0.29 (95% CI, 0.11-0.75; P = .015). CONCLUSIONS: Chronic atypical antipsychotic therapy is associated with reduced risk of postanesthesia care unit antiemetic administration. These findings support the need for prospective studies to establish the safety and efficacy of postoperative nausea and vomiting chemoprophylaxis with these agents.

Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study.

BACKGROUND: The significance of intraoperative anesthesia handoffs on patient outcomes are unclear. One aspect differentiating the disparate results is the treatment of confounding factors, such as patient comorbidities and surgery time of day. We performed this study to quantify the significance of confounding variables on composite adverse events during intraoperative anesthesia handoffs. METHODS: In this retrospective study, we analyzed data from the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP). We examined the effects of intraoperative handoffs between anesthesia personnel. A total of 12,111 cases performed examined at two hospitals operated by a single healthcare system that were that included in the ACS NSQIP database performed. The presence of attending and anesthetist or resident handoffs, patient age, sex, body mass index, American Society of Anesthesiologists Physical Status (ASA-PS) classification, case length, surgical case complexity, and evening/weekend start time were measured. RESULTS: A total of 2586 of all cases in the NSQIP dataset experienced a handoff during the case. When analyzed as a single variable, attending handoffs were associated with higher rates of adverse outcomes. However, once confounding variables were added into the analysis, attending handoffs and complete care transitions were no longer statistically significant. CONCLUSIONS: Inclusion of significant covariates is essential to fully understanding the impact provider handoffs have on patient outcomes. Case timing and lengthy case duration are more likely to result in both a handoff and an adverse event. The impact of handoffs on patient outcomes seen in the literature are likely due, in part, to how covariates were addressed.

Highly visible sepsis publications from 2012 to 2017: Analysis and comparison of altmetrics and bibliometrics.

PURPOSE: We sought to delineate highly visible publications related to sepsis. Within these subsets, elements of altmetrics performance, including mentions on Twitter, and the correlation between altmetrics and conventional citation counts were ascertained. MATERIALS AND METHODS: Three subsets of sepsis publications from 2012 to 2017 were synthesized by the overall Altmetric.com attention score, number of mentions by unique Twitter users, and conventional citation counts. For these subsets, geolocated Twitter activity was plotted on a choropleth, the lag between publication date and altmetrics mentions was characterized, and correlations were examined between altmetrics performance and normalized conventional citation counts. RESULTS: Of 57,152 PubMed query results, Altmetric.com data was available for 28,344 (49.6%). The top 50 publications by Altmetric.com attention score and Twitter attention represented a mix of original research and other types of work, garnering attention from Twitter users in 143 countries that was highly contemporaneous with publication. Altmetrics performance and conventional citation counts were poorly correlated. CONCLUSIONS: While unreliable to gauge impact or future citation potential, altmetrics may be valuable for parties who wish to detect and drive public awareness of research findings and may enable researchers to dynamically explore the reach of their work in novel dimensions.

Determination of ED50 and time to effectiveness for intrathecal hydromorphone in laboring patients using Dixon's up-and-down sequential allocation method.

BACKGROUND: With the increasing occurrence of drug shortages, understanding the pharmacokinetics of alternative intrathecal opioid administration has gained importance. In particular, additional data are needed to comprehensively evaluate the analgesic properties of intrathecal hydromorphone in the laboring patient. In a phase 2 clinical trial, we set out to determine the median effective dose (ED50) and time to effectiveness for this drug in this population. METHODS: Using Dixon's up-and-down sequential allocation method, twenty women presenting for labor analgesia were prospectively enrolled. A combined spinal-epidural technique was used to deliver the determined dose of intrathecal hydromorphone. Visual analog pain scores were obtained assessing peak pain scores during serial uterine contractions. Effective pain relief was defined as achieving a pain score of less than or equal to 3 out of 10. The dose was deemed to be ineffective if the patient failed to achieve this level of relief after 30 min. RESULTS: The ED50 of hydromorphone in our population was 10.9 µg (95% confidence interval 5.6-16.2 µg). Amongst patients for whom the dose was effective, the median time to pain relief was 24 min. One patient experienced both nausea and pruritus. No other complications were noted. CONCLUSION: Due to the prolonged time to onset, hydromorphone cannot be recommended in favor of substantively better alternatives such as sufentanil and fentanyl. TRIAL REGISTRATION: Clinicaltrials.gov registration number: NCT01598506.

Crowdsourcing sugammadex adverse event rates using an in-app survey: feasibility assessment from an observational study.

BACKGROUND: Mobile applications (apps) have become a ubiquitous source of clinical decision support. We sought to ascertain the feasibility of using an app platform to obtain a crowdsourced measure of adverse drug reaction reporting rates associated with sugammadex administration and compare it with traditionally-derived estimates. METHODS: Using the widely-distributed anesthesia calculator app, 'Anesthesiologist', we surveyed anesthesia providers regarding their experience with adverse drug reactions associated with sugammadex administration. RESULTS: Data were analyzed from 2770 participants in 119 countries responding between March 2016 and May 2017, who were estimated to have administered between 1.6-2.9 million doses (588-1040 administrations per participant). A low and high-end reporting rate of adverse events was estimated based on respondents' reported frequency and duration of sugammadex use. The estimated reporting rate of anaphylaxis due to sugammadex was 0.0055-0.098%, similar in range to previously published estimates. CONCLUSIONS: Use of an in-app survey facilitated a global assessment of anesthesia providers and could have useful applications in monitoring adverse events and estimating their rates. Further work is needed to validate this approach for other medications and clinical domains.

Initial experience with the unrestricted introduction of sugammadex at a large academic medical center: a retrospective observational study examining postoperative mechanical ventilation and efficiency outcomes.

BACKGROUND: Sugammadex rapidly reverses deep neuromuscular blockade, but owing to cost, questions remain about its optimal utilization. After the unrestricted introduction of sugammadex at Emory University Hospital, we hypothesized that reductions would be demonstrated in the primary outcome of post-anesthesia care unit (PACU) mechanical ventilation (MV) and secondary outcomes of PACU length of stay (LOS) and emergence time (surgery end to anesthesia end time in the PACU). METHODS: This retrospective observational study included patients undergoing general anesthesia over a 12-month period. Using multiple variable penalized logistic regression in a one-group before-and-after design, we compared the categorized rates of PACU MV to examine the effect of sugammadex introduction following a post-hoc chart review to ascertain the reason for postoperative MV. Additionally, multiple variable linear regression was used to assess for differences in PACU LOS and emergence time within a propensity-matched set of patients receiving neostigmine or sugammadex. RESULTS: In total, 7,217 surgical cases met the inclusion criteria: 3,798 before and 3,419 after sugammadex introduction. The incidence of PACU MV was 2.3% before and 1.8% after (P = 0.118) sugammadex introduction. PACU MV due to residual neuromuscular blockade (rNMB) decreased from 0.63% to 0.20% (P = 0.005). Ventilation because of other causes was unchanged. PACU LOS and emergence time were unchanged in the propensity-matched set of 1,444 patients. CONCLUSIONS: rNMB was an important contributor to PACU MV utilization and its incidence significantly decreased after sugammadex introduction. The selected efficiency measures may not have been sufficiently granular to identify improvements following introduction.

Variable effectiveness of stepwise implementation of nudge-type interventions to improve provider compliance with intraoperative low tidal volume ventilation.

BACKGROUND: Identifying mechanisms to improve provider compliance with quality metrics is a common goal across medical disciplines. Nudge interventions are minimally invasive strategies that can influence behavioural changes and are increasingly used within healthcare settings. We hypothesised that nudge interventions may improve provider compliance with lung-protective ventilation (LPV) strategies during general anaesthesia. METHODS: We developed an audit and feedback dashboard that included information on both provider-level and department-level compliance with LPV strategies in two academic hospitals, two non-academic hospitals and two academic surgery centres affiliated with a single healthcare system. Dashboards were emailed to providers four times over the course of the 9-month study. Additionally, the default setting on anaesthesia machines for tidal volume was decreased from 700 mL to 400 mL. Data on surgical cases performed between 1 September 2016 and 31 May 2017 were examined for compliance with LPV. The impact of the interventions was assessed via pairwise logistic regression analysis corrected for multiple comparisons. RESULTS: A total of 14 793 anaesthesia records were analysed. Absolute compliance rates increased from 59.3% to 87.8%preintervention to postintervention. Introduction of attending physician dashboards resulted in a 41% increase in the odds of compliance (OR 1.41, 95% CI 1.17 to 1.69, p=0.002). Subsequently, the addition of advanced practice provider and resident dashboards lead to an additional 93% increase in the odds of compliance (OR 1.93, 95% CI 1.52 to 2.46, p<0.001). Lastly, modifying ventilator defaults led to a 376% increase in the odds of compliance (OR 3.76, 95% CI 3.1 to 4.57, p<0.001). CONCLUSION: Audit and feedback tools in conjunction with default changes improve provider compliance.