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Background:Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea in hospitalized patients. Probiotics have been studied as a measure to prevent CDI. Timely probiotic administration to at-risk patients receiving systemic antimicrobials presents significant challenges. We sought to determine optimal implementation methods to administer probiotics to all adult inpatients aged 55 years receiving a course of systemic antimicrobials across an entire health region. Methods: Using a randomized stepped-wedge design across 4 acute-care hospitals (n = 2,490 beds), the probiotic Bio-K+ was prescribed daily to patients receiving systemic antimicrobials and was continued for 5 days after antimicrobial discontinuation. Focus groups and interviews were conducted to identify barriers, and the implementation strategy was adapted to address the key identified barriers. The implementation strategy included clinical decision support involving a linked flag on antibiotic ordering and a 1-click order entry within the electronic medical record (EMR), provider and patient education (written/videos/in-person), and local site champions. Protocol adherence was measured by tracking the number of patients on therapeutic antimicrobials that received BioK+ based on the bedside nursing EMR medication administration records. Adherence rates were sorted by hospital and unit in 48- and 72-hour intervals with recording of percentile distribution of time (days) to receipt of the first antimicrobial. Results: In total, 340 education sessions with >1,800 key stakeholders occurred before and during implementation across the 4 involved hospitals. The overall adherence of probiotic ordering for wards with antimicrobial orders was 78% and 80% at 48 and 72 hours, respectively over 72 patient months. Individual hospital adherence rates varied between 77% and 80% at 48 hours and between 79% and 83% at 72 hours. Of 246,144 scheduled probiotic orders, 94% were administered at the bedside within a median of 0.61 days (75th percentile, 0.88), 0.47 days (75th percentile, 0.86), 0.71 days (75th percentile, 0.92) and 0.67 days (75th percentile, 0.93), respectively, at the 4 sites after receipt of first antimicrobial. The key themes from the focus groups emphasized the usefulness of the linked flag alert for probiotics on antibiotic ordering, the ease of the EMR 1-click order entry, and the importance of the education sessions. Conclusions: Electronic clinical decision support, education, and local champion support achieved a high implementation rate consistent across all sites. Use of a 1-click order entry in the EMR was considered a key component of the success of the implementation and should be considered for any implementation strategy for a stewardship initiative. Achieving high prescribing adherence allows more precision in evaluating the effectiveness of the probiotic strategy.Funding: Partnerships for Research and Innovation in the Health System, Alberta Innovates/Health Solutions Funding: AwardDisclosures: None

Background: Hospital-acquired Clostridioides difficile infection (HA-CDI) rates are highly variable over time, posing problems for research assessing interventions that might improve rates. By understanding seasonality in HA-CDI rates and the impacts that other factors such as influenza admissions might have on these rates, we can account for them when establishing the relationship between interventions and infection rates. We assessed whether there were seasonal trends in HA-CDI and whether they could be accounted for by influenza rates. Methods: We assessed HA-CDI rates per 10,000 patient days, and the rate of hospitalized patients with influenza per 1,000 admissions in 4 acute-care facilities (n = 2,490 beds) in Calgary, Alberta, from January 2016 to December 2018. We used 4 statistical approaches in R (version 3.5.1 software): (1) autoregressive integrated moving average (ARIMA) to assess dependencies and trends in each of the monthly HA-CDI and influenza series; (2) cross correlation to assess dependencies between the HA-CDI and influenza series lagged over time; (3) Poisson harmonic regression models (with sine and cosine components) to assess the seasonality of the rates; and (4) Poisson regression to determine whether influenza rates accounted for seasonality in the HA-CDI rates. Results: Conventional ARIMA approaches did not detect seasonality in the HA-CDI rates, but we found strong seasonality in the influenza rates. A cross-correlation analysis revealed evidence of correlation between the series at a lag of zero (R = 0.41; 95% CI, 0.10–0.65) and provided an indication of a seasonal relationship between the series (Fig. 1). Poisson regression suggested that influenza rates predicted CDI rates (P < .01). Using harmonic regression, there was evidence of seasonality in HA-CDI rates (2 [2 df] = 6.62; P < .05) and influenza rates (2 [2 df] = 1,796.6; P < .001). In a Poisson model of HA-CDI rates with both the harmonic components and influenza admission rates, the harmonic components were no longer predictive of HA-CDI rates. Conclusions: Harmonic regression provided a sensitive means of identifying seasonality in HA-CDI rates, but the seasonality effect was accounted for by influenza admission rates. The relationship between HA-CDI and influenza rates is likely mediated by antibiotic prescriptions, which needs to be assessed. To improve precision and reduce bias, research on interventions to reduce HA-CDI rates should assess historic seasonality in HA-CDI rates and should account for influenza admissions.Funding: NoneDisclosures: None

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Objectives To critically evaluate the quality of hospital medical care at the beginning, during and shortly after regionalization of health boards in Newfoundland and Labrador, and aggregation of hospitals in the StJohn's region. Methods Retrospective chart audits for the years 1995/96, 1998/99 and 2000/01 (at the beginning, during and after restructuring) focused on outcomes in cardiology, respiratory medicine, neurology, nephrology, psychiatry, surgery andwomen's health programmes. Where possible, quality of care was judged on measurable outcomes in relation to published statements of likely optimal care. Comparisons were made over time within the StJohn's region, and separately for hospitals in the rest of the province. Results There was improvement in the use of thrombolytics and secondary measures post-myocardial infarction in both regions. Mortality and appropriateness of initial antibiotic choice for community-acquired pneumonia remained stable in both regions, with an improvement in admission appropriateness based on the severity in St John's. Aspects of stroke management (referral and time to see allied health professionals, imaging and discharge home) improved in both regions, while mortality remained stable. There was improvement in fistula rate, quality of dialysis and anaemia management in haemodialysis patients, and improvement in the peritoneal dialysis patient peritonitis rate. Readmission rate for schizophrenia remained unchanged. Stable mortality rates were observed for frequently performed surgical procedures. The post-coronaryartery by pass grafting (CABG) morbid event rate improved, although access to CABG was not optimal. Conclusions Aggregation of acute care hospitals was feasible without attendant deterioration in patient care, and in some areas care improved. However, access to services continued to be a major problem in all regions.

We show that order set design and support must be thoughtful to result in improved quality of care and reduced waste and that order set use should be monitored to confirm expected impact and detect unanticipated consequences.

Following a detailed review of orders entered into a clinical information system, we propose a framework to define computerized physician order entry types and a more useful formula for calculating order entry rate.

We describe the strategies used to engage organizational and physician leadership through design, preparation, and support to achieve an inpatient Computerized Physician Order Entry (CPOE) rate over 70% by 1,700 physicians.

Objectif: L'orientation des patients atteints de troubles du mouvement vers la neurochirurgie pour stimulation cerebrale profonde a ete examinee afin de determiner si la proportion de ces patients par sexe etait representative de cette proportion dans notre population et pourquoi un certain nombre de ces patients ne subissent pas l'intervention. Methodes: Il s'agit d'une analyse retrospective de l'information demographique sur les patients orientes en chirurgie contenue dans notre base de donnees et obtenue egalement d'une revue detaillee de dossiers. Resultats: Bien qu'un nombre presque egal d'hommes et de femmes soient atteints de troubles du mouvement, seulement 31% des 91 patients orientes en chirurgie etaient des femmes. La chirurgie n'a pas ete effectuee chez soixante et un pour cent d'entre eux, la plupart du temps pour des raisons medicales, soit un declin cognitif chez 21%, des problemes de nature psychiatrique chez 5% et de nature neurologique chez 42%. Conclusions: Un peu moins du tiers des patients orientes vers la chirurgie pour un trouble du mouvement n'ont pas subi cette chirurgie pour des raisons medicales. Cette constatation souligne l'importance d'une evaluation globale par une equipe multidisciplinaire de tous les patients candidats a la chirurgie stereotaxique. Il est interessant de noter que les femmes etaient sous-representees parmi les patients orientes vers la chirurgie. Pour que tous les patients eligibles aient la possibilite d'y avoir acces, l'education des medecins et des patients et des strategies differentes pour rejoindre les femmes pourraient permettre a un plus grand nombre de patients d'en beneficier.

Contexte: Les ataxies spinocerebelleuses (ASCs) constituent un groupe heterogene de maladies neurodegeneratives tant au point de vue genetique qu'au point de vue clinique. Leur frequence relative est tres variable selon le groupe ethnique et le lieu geographique. Objectifs: 1) determiner la frequence d'ASCs hereditaires et sporadiques debutant chez l'adulte chez des patients frequentant une clinique de desordres du mouvement ; 2) evaluer si on retrouve chez ces patients des premutations du gene FMR1 causant le syndrome de retard mental du X fragile. Methodes: Nous avons procede a une revue retrospective de dossiers de patients chez qui un diagnostic d'ASC de l'adulte a ete pose. Des tests de biologie moleculaire ont ete faits pour detecter des anomalies des genes responsables de l'ASC de type 1, 2, 3, 6, 7 et 8, de l'atrophie dentato-rubro-pallido-luysienne (ADRPL), de l'ataxie de Friedrich (AF) ainsi que l'expansion de FMR1. Resultats: 69 patients appartenant a 60 familles differentes ont ete identifies. Chez 21 familles (35%), l'heredite etait autosomique dominante (AD) et chez 2 (3.3%) l'heredite etait autosomique recessive (AR). Une histoire familiale positive mal definie etait presente chez 9 familles (15%). La maladie semblait sporadique chez 26 patients (43,3%). Chez les familles ou l'heredite etait AD, la mutation la plus frequents etait une mutation du gene ASC3 (23,8%) suivie d'ASC2 (14,3%) et d'ASC6 (14,3%). Une mutation du gene ASC1 et ASC8 a ete identifiee chez 4,8% des patients. Une mutation du gene de l'AF a ete identifiee dans un pedigree ou la maladie etait pseudo dominante et dans un ou la maladie etait AR. Chez un cas sporadique on a trouve une mutation du gene ASC3. Les tests pour l'ADRPL et le FMR 1 etaient negatif. Conclusion: Une histoire familiale positive etait presente chez 53,3% des patients atteints d'ASC adulte. Un diagnostic genetique specifique a pu etre etabli chez 61,9% des pedigrees ou l'heredite etait dominante et une mutation du gene ASC3 etait l'anomalie la plus frequente, suivie d'ASC2 et d'ASC6. Le rendement etait faible chez les cas sporadiques. La premutation du gene responsable du syndrome du X fragile n'etait pas responsable de l'ASC chez nos cas.

Objective: In this study we evaluated medication reconciliation and ordering of dopamine blocking medications in Parkinson9s disease (PD) patients admitted to hospital. Background Patients with PD are often admitted to acute care hospitals with a variety of medical and surgical issues. Their care providers in such situations are often not the physicians in charge of their PD care, and as a result, there is a potential for lack of familiarity with PD treatment regimens. Design/Methods: Patients of the Movement Disorders Clinic residing in Calgary with PD were cross-referenced with the Calgary hospital admissions database for 2010. Medication reconciliation of PD medications at admission was examined for medication total dosage, scheduling, omission, and formulation (either long acting(CR), or immediate release(IR)). Ordering of dopamine blocking medications, either metoclopramide or neuroleptics was also assessed. Results: 403 patients of the MDC were screened. 55 admissions for 44 PD patients were analyzed. In 44/55(80%), medication reconciliation discrepancies or prescription of dopamine blocking medications were noted. 53/55(96.4%) of admissions were for patients taking levodopa. Of these 53, 26/53(49.0%) had differences between pre-admission and admission levodopa orders: in 3/53(5.7%) no levodopa was ordered; 15/53(28.3%) had dosage differences; 8/53(15.1%) had scheduling differences; and 12/53(22.6%) were ordered the incorrect formulation. 19/55(34.5%) of admissions were for patients who were on PD medications in addition to levodopa:7/19(36.8%) had differences in the ordering of these medications at the time of admission. Dopamine blocking agents were ordered during 24/55(43.6%) admissions. Conclusions: Our study identifies deficiencies in the in-hospital prescribing of medications for patients with PD. This includes a failure to seamlessly continue usual PD medications when patients are admitted, and perhaps of even greater concern, the inappropriate addition of dopamine blocking agents during their hospital stay. Widespread education of providers and safe-prescribing protocols are urgently needed to address these unsafe care issues. Disclosure: Dr. Wiltshire has nothing to disclose. Dr. Furtado has nothing to disclose. Dr. Ghali has nothing to disclose. Dr. Kraft has nothing to disclose.