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Ayorinde A, Ghosh I, Shaikh J, Adetunji V, Brown A, Jordan M, Gilham E, Todkill D, Ashiru-Oredope D. Improving healthcare professionals' interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators. Front Public Health 2024; 12:1359790. [PMID: 38841670 PMCID: PMC11150712 DOI: 10.3389/fpubh.2024.1359790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions. Methods We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels. Results Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation). Conclusion The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.
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Affiliation(s)
- Abimbola Ayorinde
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Iman Ghosh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Junaid Shaikh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Victoria Adetunji
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Ellie Gilham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Daniel Todkill
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Diane Ashiru-Oredope
- UK Health Security Agency, London, United Kingdom
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
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Ackerhans S, Huynh T, Kaiser C, Schultz C. Exploring the role of professional identity in the implementation of clinical decision support systems-a narrative review. Implement Sci 2024; 19:11. [PMID: 38347525 PMCID: PMC10860285 DOI: 10.1186/s13012-024-01339-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity. METHODS We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists). RESULTS One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system's ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user's professional status and expertise and is improved over the course of implementation. CONCLUSION This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.
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Affiliation(s)
- Sophia Ackerhans
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany.
| | - Thomas Huynh
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
| | - Carsten Kaiser
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
| | - Carsten Schultz
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
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Abell B, Naicker S, Rodwell D, Donovan T, Tariq A, Baysari M, Blythe R, Parsons R, McPhail SM. Identifying barriers and facilitators to successful implementation of computerized clinical decision support systems in hospitals: a NASSS framework-informed scoping review. Implement Sci 2023; 18:32. [PMID: 37495997 PMCID: PMC10373265 DOI: 10.1186/s13012-023-01287-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Successful implementation and utilization of Computerized Clinical Decision Support Systems (CDSS) in hospitals is complex and challenging. Implementation science, and in particular the Nonadoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework, may offer a systematic approach for identifying and addressing these challenges. This review aimed to identify, categorize, and describe barriers and facilitators to CDSS implementation in hospital settings and map them to the NASSS framework. Exploring the applicability of the NASSS framework to CDSS implementation was a secondary aim. METHODS Electronic database searches were conducted (21 July 2020; updated 5 April 2022) in Ovid MEDLINE, Embase, Scopus, PyscInfo, and CINAHL. Original research studies reporting on measured or perceived barriers and/or facilitators to implementation and adoption of CDSS in hospital settings, or attitudes of healthcare professionals towards CDSS were included. Articles with a primary focus on CDSS development were excluded. No language or date restrictions were applied. We used qualitative content analysis to identify determinants and organize them into higher-order themes, which were then reflexively mapped to the NASSS framework. RESULTS Forty-four publications were included. These comprised a range of study designs, geographic locations, participants, technology types, CDSS functions, and clinical contexts of implementation. A total of 227 individual barriers and 130 individual facilitators were identified across the included studies. The most commonly reported influences on implementation were fit of CDSS with workflows (19 studies), the usefulness of the CDSS output in practice (17 studies), CDSS technical dependencies and design (16 studies), trust of users in the CDSS input data and evidence base (15 studies), and the contextual fit of the CDSS with the user's role or clinical setting (14 studies). Most determinants could be appropriately categorized into domains of the NASSS framework with barriers and facilitators in the "Technology," "Organization," and "Adopters" domains most frequently reported. No determinants were assigned to the "Embedding and Adaptation Over Time" domain. CONCLUSIONS This review identified the most common determinants which could be targeted for modification to either remove barriers or facilitate the adoption and use of CDSS within hospitals. Greater adoption of implementation theory should be encouraged to support CDSS implementation.
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Affiliation(s)
- Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sundresan Naicker
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.
| | - David Rodwell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Thomasina Donovan
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Amina Tariq
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Melissa Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Robin Blythe
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Rex Parsons
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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Williams DJ, Martin JM, Nian H, Weitkamp AO, Slagle J, Turer RW, Suresh S, Johnson J, Stassun J, Just SL, Reale C, Beebe R, Arnold DH, Antoon JW, Rixe NS, Sartori LF, Freundlich RE, Ampofo K, Pavia AT, Smith JC, Weinger MB, Zhu Y, Grijalva CG. Antibiotic clinical decision support for pneumonia in the ED: A randomized trial. J Hosp Med 2023; 18:491-501. [PMID: 37042682 PMCID: PMC10247532 DOI: 10.1002/jhm.13101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/06/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED). OBJECTIVE To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED. DESIGN Pragmatic randomized clinical trial. SETTING AND PARTICIPANTS Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States. INTERVENTION CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines. MAIN OUTCOME AND MEASURES The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits. RESULTS 1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes. CONCLUSIONS Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.
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Affiliation(s)
- Derek J Williams
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Judith M Martin
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hui Nian
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Asli O Weitkamp
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jason Slagle
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Srinivasan Suresh
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jakobi Johnson
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Justine Stassun
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Shari L Just
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Carrie Reale
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Russ Beebe
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Donald H Arnold
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - James W Antoon
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nancy S Rixe
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura F Sartori
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert E Freundlich
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Krow Ampofo
- University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Andrew T Pavia
- University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Joshua C Smith
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Matthew B Weinger
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Yuwei Zhu
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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McGonagle EA, Karavite DJ, Grundmeier RW, Schmidt SK, May LS, Cohen DM, Cruz AT, Tu SP, Bajaj L, Dayan PS, Mistry RD. Evaluation of an Antimicrobial Stewardship Decision Support for Pediatric Infections. Appl Clin Inform 2023; 14:108-118. [PMID: 36754066 PMCID: PMC9908419 DOI: 10.1055/s-0042-1760082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/16/2022] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVES Clinical decision support (CDS) has promise for the implementation of antimicrobial stewardship programs (ASPs) in the emergency department (ED). We sought to assess the usability of a newly developed automated CDS to improve guideline-adherent antibiotic prescribing for pediatric community-acquired pneumonia (CAP) and urinary tract infection (UTI). METHODS We conducted comparative usability testing between an automated, prototype CDS-enhanced discharge order set and standard order set, for pediatric CAP and UTI antibiotic prescribing. After an extensive user-centered design process, the prototype CDS was integrated into the electronic health record, used passive activation, and embedded locally adapted prescribing guidelines. Participants were randomized to interact with three simulated ED scenarios of children with CAP or UTI, across both systems. Measures included task completion, decision-making and usability errors, clinical actions (order set use and correct antibiotic selection), as well as objective measures of system usability, utility, and workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). The prototype CDS was iteratively refined to optimize usability and workflow. RESULTS Usability testing in 21 ED clinical providers demonstrated that, compared to the standard order sets, providers preferred the prototype CDS, with improvements in domains such as explanations of suggested antibiotic choices (p < 0.001) and provision of additional resources on antibiotic prescription (p < 0.001). Simulated use of the CDS also led to overall improved guideline-adherent prescribing, with a 31% improvement for CAP. A trend was present toward absolute workload reduction. Using the NASA-TLX, workload scores for the current system were median 26, interquartile ranges (IQR): 11 to 41 versus median 25, and IQR: 10.5 to 39.5 for the CDS system (p = 0.117). CONCLUSION Our CDS-enhanced discharge order set for ED antibiotic prescribing was strongly preferred by users, improved the accuracy of antibiotic prescribing, and trended toward reduced provider workload. The CDS was optimized for impact on guideline-adherent antibiotic prescribing from the ED and end-user acceptability to support future evaluative trials of ED ASPs.
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Affiliation(s)
- Erin A. McGonagle
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Dean J. Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Robert W. Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Sarah K. Schmidt
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Larissa S. May
- Department of Emergency Medicine, University of California at Davis School of Medicine, Davis, California, United States
| | - Daniel M. Cohen
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus, Ohio, United States
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Shin-Ping Tu
- Department of Medicine, University of California at Davis School of Medicine, Davis, California, United States
| | - Lalit Bajaj
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Peter S. Dayan
- Department of Emergency Medicine and Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
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Machine learning and artificial intelligence: applications in healthcare epidemiology. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 1:e28. [PMID: 36168500 PMCID: PMC9495400 DOI: 10.1017/ash.2021.192] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/21/2022]
Abstract
Artificial intelligence (AI) refers to the performance of tasks by machines ordinarily associated with human intelligence. Machine learning (ML) is a subtype of AI; it refers to the ability of computers to draw conclusions (ie, learn) from data without being directly programmed. ML builds from traditional statistical methods and has drawn significant interest in healthcare epidemiology due to its potential for improving disease prediction and patient care. This review provides an overview of ML in healthcare epidemiology and practical examples of ML tools used to support healthcare decision making at 4 stages of hospital-based care: triage, diagnosis, treatment, and discharge. Examples include model-building efforts to assist emergency department triage, predicting time before septic shock onset, detecting community-acquired pneumonia, and classifying COVID-19 disposition risk level. Increasing availability and quality of electronic health record (EHR) data as well as computing power provides opportunities for ML to increase patient safety, improve the efficiency of clinical management, and reduce healthcare costs.
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Kelsey EA, Njeru JW, Chaudhry R, Fischer KM, Schroeder DR, Croghan IT. Understanding User Acceptance of Clinical Decision Support Systems to Promote Increased Cancer Screening Rates in a Primary Care Practice. J Prim Care Community Health 2021; 11:2150132720958832. [PMID: 33016170 PMCID: PMC7543103 DOI: 10.1177/2150132720958832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Clinical decision support systems (CDDSs) in the electronic medical record (EMR) have been implemented in primary care settings to identify patients due for cancer screening tests, while functioning as a real time reminder system. There is little known about primary care providers (PCPs) perspective or user acceptance of CDSS. The purpose of this study was to investigate primary care provider perceptions of utilizing CDSS alerts in the EMR to promote increased screening rates for breast cancer, cervical cancer, and colorectal cancer. METHODS An electronic survey was administered to PCPs in a Midwest Health Institution community internal medicine practice from September 25, 2019 through November 27, 2019. RESULTS Among 37 participants (9 NP/Pas and 28 MD/DOs), the NP/PA group was more likely to agree that alerts were helpful (50%; P-value = .0335) and the number of alerts (89%; P = .0227) in the EMR was appropriate. The NP/PA group also was more likely to find alerts straightforward to use (78%, P = .0239). Both groups agreed about feeling comfortable using the health maintenance alerts (MD/DO = 79%; NP/PA = 100%). CONCLUSION CDSSs can promote and facilitate ordering of cancer screening tests. The use of technology can promptly identify patients due for a test and act as a reminder to the PCP. PCPs identify these alerts to be a beneficial tool in the EMR when they do not interrupt workflow and provide value to patient care. More work is needed to identify factors that could optimize alerts to be even more helpful, particularly to MD/DO groups.
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Pallotta AM, Wesolowski J. Implementation of a clinical decision support tool at time of intramuscular penicillin G prescribing reduces medication errors. Am J Health Syst Pharm 2021; 78:1937-1938. [PMID: 34153094 DOI: 10.1093/ajhp/zxab256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Jill Wesolowski
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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Barriers and facilitators influencing medication-related CDSS acceptance according to clinicians: A systematic review. Int J Med Inform 2021; 152:104506. [PMID: 34091146 DOI: 10.1016/j.ijmedinf.2021.104506] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/20/2021] [Accepted: 05/18/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND A medication-related Clinical Decision Support System (CDSS) is an application that analyzes patient data to provide assistance in medication-related care processes. Despite its potential to improve the clinical decision-making process, evidence shows that clinicians do not always use CDSSs in such a way that their potential can be fully realized. This systematic literature review provides an overview of frequently-reported barriers and facilitators for acceptance of medication-related CDSS. MATERIALS AND METHODS Search terms and MeSH headings were developed in collaboration with a librarian, and database searches were conducted in Medline, Scopus, Embase and Web of Science Conference Proceedings. After screening 5404 records and 140 full papers, 63 articles were included in this review. Quality assessment was performed for all 63 included articles. The identified barriers and facilitators are categorized within the Human, Organization, Technology fit (HOT-fit) model. RESULTS A total of 327 barriers and 291 facilitators were identified. Results show that factors most often reported were related to (a lack of) usefulness and relevance of information, and ease of use and efficiency of the system. DISCUSSION This review provides a valuable insight into a broad range of barriers and facilitators for using a medication-related CDSS as perceived by clinicians. The results can be used as a stepping stone in future studies developing medication-related CDSSs.
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Laka M, Milazzo A, Merlin T. Factors That Impact the Adoption of Clinical Decision Support Systems (CDSS) for Antibiotic Management. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041901. [PMID: 33669353 PMCID: PMC7920296 DOI: 10.3390/ijerph18041901] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 01/22/2023]
Abstract
The study evaluated individual and setting-specific factors that moderate clinicians’ perception regarding use of clinical decision support systems (CDSS) for antibiotic management. A cross-sectional online survey examined clinicians’ perceptions about CDSS implementation for antibiotic management in Australia. Multivariable logistic regression determined the association between drivers of CDSS adoption and different moderators. Clinical experience, CDSS use and care setting were important predictors of clinicians’ perception concerning CDSS adoption. Compared to nonusers, CDSS users were less likely to lack confidence in CDSS (OR = 0.63, 95%, CI = 0.32, 0.94) and consider it a threat to professional autonomy (OR = 0.47, 95%, CI = 0.08, 0.83). Conversely, there was higher likelihood in experienced clinicians (>20 years) to distrust CDSS (OR = 1.58, 95%, CI = 1.08, 2.23) due to fear of comprising their clinical judgement (OR = 1.68, 95%, CI = 1.27, 2.85). In primary care, clinicians were more likely to perceive time constraints (OR = 1.96, 95%, CI = 1.04, 3.70) and patient preference (OR = 1.84, 95%, CI = 1.19, 2.78) as barriers to CDSS adoption for antibiotic prescribing. Our findings provide differentiated understanding of the CDSS implementation landscape by identifying different individual, organisational and system-level factors that influence system adoption. The individual and setting characteristics can help understand the variability in CDSS adoption for antibiotic management in different clinicians.
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Affiliation(s)
- Mah Laka
- School of Public Health, University of Adelaide, Adelaide 5005, Australia; (M.L.); (A.M.)
| | - Adriana Milazzo
- School of Public Health, University of Adelaide, Adelaide 5005, Australia; (M.L.); (A.M.)
| | - Tracy Merlin
- Adelaide Health Technology Assessment (AHTA), School of Public Health, University of Adelaide, Adelaide 5005, Australia
- Correspondence: ; Tel.: +61-(8)-8313-3575
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Dhaliwal JS, Goss F, Whittington MD, Bookman K, Ho PM, Zane R, Wiler J. Reduced admission rates and resource utilization for chest pain patients using an electronic health record-embedded clinical pathway in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1602-1613. [PMID: 33392569 PMCID: PMC7771814 DOI: 10.1002/emp2.12308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Assess the impact of an electronic health record (EHR)-embedded clinical pathway (ePATH) as compared to a paper-based clinical decision support tool on outcomes for patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS). METHODS A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications to evaluate the impact of an EHR-embedded clinical pathway between April 2013 and July 2017. The intervention was implemented in February 2016 at a large academic tertiary hospital and compared to a local community hospital without the intervention. Eligible patients included adults (>18 years) presenting to the ED with chest pain who had a troponin ordered within 2 hours of arrival and a chest pain-related diagnosis. Patients with initial evidence of acute myocardial infarction were excluded. Primary outcomes included rates of admission and stress testing, hospital length of stay, and occurrence of major adverse cardiac events. RESULTS On average, there were 170 chest pain visits per month at the intervention site. The frequency of hospital admission (unadjusted 28.2% to 20.9%, P < 0.001) and stress testing (unadjusted 15.8% to 12.7%, P < 0.001) significantly declined after ePATH implementation. After comparison with the comparator site, ePATH was still associated with a significant reduction in hospital admissions (-10.79%, P < 0.001) and stress testing (-6.05%, P < 0.001). Hospital length of stay and rates of major adverse cardiac events did not significantly change. CONCLUSIONS Implementation of ePATH for patients presenting to the ED with chest pain was associated with safe reductions in hospital admission and stress testing. ePATH appears to be an effective tool for implementing evidence-based guidelines for ED patients with chest pain.
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Affiliation(s)
- Jasmeet S. Dhaliwal
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Foster Goss
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Melanie D. Whittington
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
- Data Science to Patient Value ProgramUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Kelly Bookman
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - P. Michael Ho
- Data Science to Patient Value ProgramUniversity of Colorado School of MedicineAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Richard Zane
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- UCHealth CARE Innovation CenterAuroraColoradoUSA
| | - Jennifer Wiler
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- UCHealth CARE Innovation CenterAuroraColoradoUSA
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12
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May L, Martín Quirós A, Ten Oever J, Hoogerwerf J, Schoffelen T, Schouten J. Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions. Clin Microbiol Infect 2020; 27:204-209. [PMID: 33144202 DOI: 10.1016/j.cmi.2020.10.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Emergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions. OBJECTIVES We aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting. SOURCES (a) a PubMed search for 'antimicrobial stewardship' and 'emergency department', and (b) published reviews on effectiveness combined with publications from the first source. CONTENT (a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review. IMPLICATIONS Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA, USA
| | | | - Jaap Ten Oever
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jacobien Hoogerwerf
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Teske Schoffelen
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
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13
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Ozkaynak M, Metcalf N, Cohen DM, May LS, Dayan PS, Mistry RD. Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments. Appl Clin Inform 2020; 11:589-597. [PMID: 32906153 DOI: 10.1055/s-0040-1715893] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions. METHODS Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis. RESULTS Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing. DISCUSSION The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization). CONCLUSION Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Noel Metcalf
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Larissa S May
- Department of Emergency Medicine, UC Davis Health, Davis, California, United States
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D Mistry
- Department of Pediatrics and Emergency Medicine, Section of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
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14
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Low S, Varma R, McIver R, Vickers T, McNulty A. Provider attitudes to the empiric treatment of asymptomatic contacts of gonorrhoea. Sex Health 2020; 17:155-159. [DOI: 10.1071/sh19165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/13/2019] [Indexed: 11/23/2022]
Abstract
Background
In the current era of antimicrobial stewardship, the availability of highly sensitive assays and faster turnaround times, the practice of empiric treatment of asymptomatic contacts of gonorrhoea needs review. The views of clinicians in a range of settings across Australia and clinic costs associated with a change of practice was examined. Methods: An online anonymous survey for nurses and doctors working in public sexual health clinics and general practices in urban, regional and rural Australia was developed. Information on the relative importance of a range of factors influencing delivery of empiric treatment was collected. Participants were asked whether current guidelines should change. Results: Surveys were distributed to 468 healthcare providers and 188 (40.2%) fully completed the survey. Most of the participants worked in public practice (84.9%) and 86 (43.2%) were doctors. Factors influencing provision of empiric treatment were: if the patient was unable to return (95.9%) or may not return (95.3%); risk of transmission to others (93.3%); likelihood of infection (88.6%); and patient request (82.9%). Respondents were evenly split as to whether current guidelines should change, with providers in private practice being less likely to support guideline change (P = 0.03). The model of empiric treatment of all asymptomatic sexual contacts was 34% more expensive than a model of testing and treatment of those with a positive result. Conclusion: Currently, the majority of clinicians provide empiric treatment for asymptomatic contacts in Australia. There was significant support for a change in guidelines with specific scenarios requiring individualised responses.
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Madaline T, Wadskier Montagne F, Eisenberg R, Mowrey W, Kaur J, Malik M, Gendlina I, Guo Y, White D, Pirofski LA, Sarwar U. Early Infectious Disease Consultation Is Associated With Lower Mortality in Patients With Severe Sepsis or Septic Shock Who Complete the 3-Hour Sepsis Treatment Bundle. Open Forum Infect Dis 2019; 6:ofz408. [PMID: 31687417 PMCID: PMC6821928 DOI: 10.1093/ofid/ofz408] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/11/2019] [Indexed: 12/15/2022] Open
Abstract
Objective Severe sepsis and septic shock (SS/SS) treatment bundles reduce mortality, and early infectious diseases (ID) consultation also improves patient outcomes. We retrospectively examined whether early ID consultation further improves outcomes in Emergency Department (ED) patients with SS/SS who complete the sepsis bundle. Method We included 248 adult ED patients with SS/SS who completed the 3-hour bundle. Patients with ID consultation within 12 hours of ED triage (n = 111; early ID) were compared with patients who received standard care (n = 137) for in-hospital mortality, 30-day readmission, length of hospital stay (LOS), and antibiotic management. A competing risk survival analysis model compared risks of in-hospital mortality and discharge alive between groups. Results In-hospital mortality was lower in the early ID group unadjusted (24.3% vs 38.0%, P = .02) and adjusted for covariates (odds ratio, 0.47; 95% confidence interval (CI), 0.25–0.89; P = .02). There was no significant difference in 30-day readmission (22.6% vs 23.5%, P = .89) or median LOS (10.2 vs 12.1 days, P = .15) among patients who survived. A trend toward shorter time to antibiotic de-escalation in the early ID group (log-rank test P = .07) was observed. Early ID consultation was protective of in-hospital mortality (adjusted subdistribution hazard ratio (asHR), 0.60; 95% CI 0.36–1.00, P = .0497) and predictive of discharge alive (asHR 1.58, 95% CI, 1.11–2.23; P-value .01) after adjustment. Conclusions Among patients receiving the SS/SS bundle, early ID consultation was associated with a 40% risk reduction for in-hospital mortality. The impact of team-based care and de-escalation on SS/SS outcomes warrants further study.
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Affiliation(s)
- Theresa Madaline
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Francis Wadskier Montagne
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Ruth Eisenberg
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Wenzhu Mowrey
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | | | - Maria Malik
- Princeton University, Princeton, New Jersey, USA
| | - Inessa Gendlina
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Yi Guo
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Deborah White
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Liise-Anne Pirofski
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Uzma Sarwar
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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16
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Mostaghim M, Snelling T, McMullan B, Ewe YH, Bajorek B. Impact of clinical decision support on empirical antibiotic prescribing for children with community-acquired pneumonia. J Paediatr Child Health 2019; 55:305-311. [PMID: 30161269 DOI: 10.1111/jpc.14191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 06/08/2018] [Accepted: 07/08/2018] [Indexed: 12/13/2022]
Abstract
AIM To assess the impact of a computerised clinical decision support system (CDSS) on antibiotic use in hospitalised children with a presumptive diagnosis of uncomplicated community-acquired pneumonia (CAP). METHODS Codes associated with lower respiratory tract infection were used to identify cases of presumed uncomplicated CAP requiring admission to a tertiary paediatric hospital. Random sampling of the periods between 1 October 2010 and 30 September 2012 (pre-CDSS) and 1 October 2012 and 30 September 2014 (post-CDSS) determined the sequence of case assessment by two independent investigators. Initial antibiotic therapy, associated CDSS approvals and documented signs of clinical deterioration prior to antibiotic decision-making were recorded. RESULTS Statistically significant differences between cases pre- and post-CDSS implementation were minimal. High fever was observed in 57.5% (77/134) cases pre-CDSS and 45.8% (49/107) cases post-CDSS (P = 0.07). Supplemental oxygen was used in 30.6% pre-CDSS and 54.2% post-CDSS cases (P < 0.001). Narrow-spectrum penicillins were prescribed most often, with no statistically significant change post-CDSS implementation (81.3% pre-CDSS, 77.6% post-CDSS, P = 0.47). Macrolides were used consistently throughout the study period (53.7% pre-CDSS, 61.7% post-CDSS; P = 0.21). CONCLUSION CDSS implementation did not reduce already low rates of broad-spectrum antibiotic use for uncomplicated CAP.
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Affiliation(s)
- Mona Mostaghim
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia.,Pharmacy Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Tom Snelling
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Yean H Ewe
- Junior Medical Unit, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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17
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Mistry RD, May LS, Pulia MS. Improving Antimicrobial Stewardship in Pediatric Emergency Care: A Pathway Forward. Pediatrics 2019; 143:peds.2018-2972. [PMID: 30622157 PMCID: PMC6361355 DOI: 10.1542/peds.2018-2972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Rakesh D. Mistry
- Section of Emergency Medicine, Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado
| | - Larissa S. May
- Department of Emergency Medicine, School of Medicine, University of California, Davis, Davis, California; and
| | - Michael S. Pulia
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, Wisconsin
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18
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Huang MZ, Rhee KE, Gist L, Fisher ES. Barriers to Minimizing Respiratory Viral Testing in Bronchiolitis: Physician Perceptions on Testing Practices. Hosp Pediatr 2019; 9:79-86. [PMID: 30647087 DOI: 10.1542/hpeds.2018-0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess pediatric providers' perceptions on viral testing and to determine barriers to minimizing respiratory viral testing (RVT) in bronchiolitis. METHODS A single-center, cross-sectional study was conducted and included 6 focus group discussions with pediatric providers. Questions were focused on identifying factors associated with obtaining RVT. Focus group discussions were transcribed verbatim and coded for emergent themes. RESULTS Clinicians report that they themselves do not typically obtain RVT in otherwise healthy patients with bronchiolitis. The most commonly cited reasons for not obtaining RVT is that it does not aid medical decision-making and that it is used as an educational opportunity for trainees. However, clinicians tend to obtain RVT when they are directed by another clinician, when they desire reassurance, when RVT is perceived as "doing something," and when there are knowledge gaps on institutional cohorting policies. CONCLUSIONS Clinician medical decision-making is influenced by multiple internal and external factors. Intended behaviors do not always correlate with actual actions because of these influences. Developing interventions in which some of these factors are addressed may help reduce unnecessary RVT among healthy patients with bronchiolitis and could be considered for broader application beyond this patient population.
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Affiliation(s)
| | | | - Lauren Gist
- Developmental-Behavioral Pediatrics, Department of Pediatrics, School of Medicine, University of California, San Diego, San Diego, California
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Abstract
Because of the increasing plague of antimicrobial resistance and antibiotic misuse, antimicrobial stewardship programs (ASPs) are now a mandatory entity in all US hospitals. ASPs can use technological advances, such as the electronic medical record and clinical decision support systems, to impact a larger patient population with more efficiency. Additionally, through the use of mobile applications and social media, ASPs can highlight and propagate educational information regarding antimicrobial utilization to patients and providers in a widespread and timely manner. In this article, the authors describe how technology can play an important role in antimicrobial stewardship.
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Affiliation(s)
- Derek N Bremmer
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA 15212, USA.
| | - Tamara L Trienski
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Thomas L Walsh
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, 4th Floor East Wing, Suite 406, Pittsburgh, PA 15212, USA
| | - Matthew A Moffa
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, 4th Floor East Wing, Suite 406, Pittsburgh, PA 15212, USA
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20
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Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program. Appl Clin Inform 2018; 9:248-260. [PMID: 29642247 DOI: 10.1055/s-0038-1641594] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Clinical decision support (CDS) embedded into the electronic health record (EHR), is a potentially powerful tool for institution of antimicrobial stewardship programs (ASPs) in emergency departments (EDs). However, design and implementation of CDS systems should be informed by the existing workflow to ensure its congruence with ED practice, which is characterized by erratic workflow, intermittent computer interactions, and variable timing of antibiotic prescription. OBJECTIVE This article aims to characterize ED workflow for four provider types, to guide future design and implementation of an ED-based ASP using the EHR. METHODS Workflow was systematically examined in a single, tertiary-care academic children's hospital ED. Clinicians with four roles (attending, nurse practitioner, physician assistant, resident) were observed over a 3-month period using a tablet computer-based data collection tool. Structural observations were recorded by investigators, and classified using a predetermined set of activities. Clinicians were queried regarding timing of diagnosis and disposition decision points. RESULTS A total of 23 providers were observed for 90 hours. Sixty-four different activities were captured for a total of 6,060 times. Among these activities, nine were conducted at different frequency or time allocation across four roles. Moreover, we identified differences in sequential patterns across roles. Decision points, whereby clinicians then proceeded with treatment, were identified 127 times. The most common decision points identified were: (1) after/during examining or talking to patient or relative; (2) after talking to a specialist; and (3) after diagnostic test/image was resulted and discussed with patient/family. CONCLUSION The design and implementation of CDS for ASP should support clinicians in various provider roles, despite having different workflow patterns. The clinicians make their decisions about treatment at different points of overall care delivery practice; likewise, the CDS should also support decisions at different points of care.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Danny T Y Wu
- Department of Biomedical Informatics and Pediatrics, University of Cincinnati, Cincinnati, Ohio, United States
| | - Katia Hannah
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics and Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
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