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Born C, Schwarz R, Böttcher TP, Hein A, Krcmar H. The role of information systems in emergency department decision-making-a literature review. J Am Med Inform Assoc 2024; 31:1608-1621. [PMID: 38781289 PMCID: PMC11187435 DOI: 10.1093/jamia/ocae096] [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: 12/21/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED. MATERIALS AND METHODS We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes. RESULTS Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes. DISCUSSION Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation. CONCLUSION We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.
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Affiliation(s)
- Cornelius Born
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Romy Schwarz
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Timo Phillip Böttcher
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Andreas Hein
- Institute of Information Systems and Digital Business, University of St. Gallen, 9000 St. Gallen, Switzerland
| | - Helmut Krcmar
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
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Sapozhnikov J, Albarillo FS, Pulia MS. Optimizing Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin North Am 2024; 42:443-459. [PMID: 38641398 DOI: 10.1016/j.emc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.
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Affiliation(s)
- Julia Sapozhnikov
- Medical Science Liaison, Karius Inc, 975 Island Drive, Redwood City, CA 94065, USA
| | - Fritzie S Albarillo
- Department of Medicine, Infectious Diseases Division, Loyola University Medical Center, Loyola University Medical Center is 2160 South First Avenue, Maywood, IL 60153, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
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Salwei ME, Hoonakker P, Carayon P, Wiegmann D, Pulia M, Patterson BW. Usability of a Human Factors-based Clinical Decision Support in the Emergency Department: Lessons Learned for Design and Implementation. HUMAN FACTORS 2024; 66:647-657. [PMID: 35420923 PMCID: PMC9581441 DOI: 10.1177/00187208221078625] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the usability and use of human factors (HF)-based clinical decision support (CDS) implemented in the emergency department (ED). BACKGROUND Clinical decision support can improve patient safety; however, the acceptance and use of CDS has faced challenges. Following a human-centered design process, we designed a CDS to support pulmonary embolism (PE) diagnosis in the ED. We demonstrated high usability of the CDS during scenario-based usability testing. We implemented the HF-based CDS in one ED in December 2018. METHOD We conducted a survey of ED physicians to evaluate the usability and use of the HF-based CDS. We distributed the survey via Qualtrics, a web-based survey platform. We compared the computer system usability questionnaire scores of the CDS between those collected in the usability testing to use of the CDS in the real environment. We asked physicians about their acceptance and use of the CDS, barriers to using the CDS, and areas for improvement. RESULTS Forty-seven physicians (56%) completed the survey. Physicians agreed that diagnosing PE is a major problem and risk scores can support the PE diagnostic process. Usability of the CDS was reported as high, both in the experimental setting and the real clinical setting. However, use of the CDS was low. We identified several barriers to the CDS use in the clinical environment, in particular a lack of workflow integration. CONCLUSION Design of CDS should be a continuous process and focus on the technology's usability in the context of the broad work system and clinician workflow.
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Affiliation(s)
- Megan E. Salwei
- Center for Research and Innovation in Systems Safety, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter Hoonakker
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Pascale Carayon
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Douglas Wiegmann
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael Pulia
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Brian W. Patterson
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
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4
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Vu MT, Schwartz H, Straube S, Pondicherry N, Emanuels D, Dhanoa J, Bains J, Singh M, Stark N, Peabody C. Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department. Emerg Med J 2023; 40:847-853. [PMID: 37907325 DOI: 10.1136/emermed-2022-213015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 10/04/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline. METHODS Using the 'Fit between Individuals, Task and Technology (FITT)' framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED's clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive's user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment. RESULTS Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)). CONCLUSION Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.
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Affiliation(s)
- Mai Trang Vu
- UCSF School of Medicine, San Francisco, California, USA
| | - Hope Schwartz
- UCSF School of Medicine, San Francisco, California, USA
| | - Steven Straube
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | | | | | - Jaskirat Dhanoa
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Jaskaran Bains
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Malini Singh
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
| | - Nicholas Stark
- Department of Emergency Medicine, UCSF, San Francisco, California, USA
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Piet E, N’Diaye Y, Marzani J, Pires L, Petitprez H, Delory T. Comments by Microbiologists for Interpreting Antimicrobial Susceptibility Testing and Improving the Appropriateness of Antibiotic Therapy in Community-Acquired Urinary Tract Infections: A Randomized Double-Blind Digital Case-Vignette Controlled Superiority Trial. Antibiotics (Basel) 2023; 12:1272. [PMID: 37627692 PMCID: PMC10451981 DOI: 10.3390/antibiotics12081272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/15/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023] Open
Abstract
In primary care, urinary tract infections (UTIs) account for the majority of antibiotic prescriptions. Comments from microbiologists on interpreting the antimicrobial susceptibility testing (AST) profile for urinalysis were made to improve the prescription of antibiotics. We aimed to explore the added value of these comments on the quality of antibiotic prescribing by a superior double-blind digital randomized case-vignette trial among French general practitioners (GPs). One case vignette with (intervention) or without (control) a 'comment' after AST was randomly assigned to GPs. Among 815 participating GPs, 64.7% were women, at an average age of 37 years. Most (90.1%) used a computerized decision support system for prescribing antibiotics. Empirical antibiotic therapy was appropriate in 71.9% (95% CI, 68.8-75.0) of the cases, without differences between arms. The overall appropriateness of targeted antibiotic therapy (primary outcome) was not significantly increased when providing 'comments': 83.4% vs. 79.9% (OR = 1.26, 95% CI, 0.86-1.85). With the multivariate analysis, the appropriateness was improved by 2-folds (OR = 2.38, 95% CI, 1.02-6.16) among physicians working in healthcare facilities. Among digital-affine young general practitioners, the adjunction of a 'comment' by a microbiologist to interpret urinalysis in community-acquired UTIs did not improve the overall level of appropriateness of the targeted antibiotic.
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Affiliation(s)
- Emilie Piet
- Department of Infectious Diseases, Centre Hospitalier Annecy Genevois, 74370 Epagny Metz-Tessy, France
| | - Youssoupha N’Diaye
- Department of Infectious Diseases, Centre Hospitalier Annecy Genevois, 74370 Epagny Metz-Tessy, France
| | - Johann Marzani
- Department of Infectious Diseases, Centre Hospitalier Annecy Genevois, 74370 Epagny Metz-Tessy, France
| | - Lucas Pires
- Clinical Research Department, Centre Hospitalier Annecy Genevois, 74370 Epagny Metz-Tessy, France
| | - Hélène Petitprez
- Microbiological Analysis Department, Centre Hospitalier Annecy Genevois, 74370 Epagny Metz-Tessy, France
| | - Tristan Delory
- Clinical Research Department, Centre Hospitalier Annecy Genevois, 74370 Epagny Metz-Tessy, France
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7
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Yoon CH, Nolan I, Humphrey G, Duffy EJ, Thomas MG, Ritchie SR. Long-Term Impact of a Smartphone App on Prescriber Adherence to Antibiotic Guidelines for Adult Patients With Community-Acquired Pneumonia: Interrupted Time-Series Study. J Med Internet Res 2023; 25:e42978. [PMID: 37129941 PMCID: PMC10189620 DOI: 10.2196/42978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Mobile health platforms like smartphone apps that provide clinical guidelines are ubiquitous, yet their long-term impact on guideline adherence remains unclear. In 2016, an antibiotic guidelines app, called SCRIPT, was introduced in Auckland City Hospital, New Zealand, to provide local antibiotic guidelines to clinicians on their smartphones. OBJECTIVE We aimed to assess whether the provision of antibiotic guidelines in a smartphone app resulted in sustained changes in antibiotic guideline adherence by prescribers. METHODS We analyzed antibiotic guideline adherence rates during the first 24 hours of hospital admission in adults diagnosed with community-acquired pneumonia using an interrupted time-series study with 3 distinct periods post app implementation (ie, 3, 12, and 24 months). RESULTS Adherence increased from 23% (46/200) at baseline to 31% (73/237) at 3 months and 34% (69/200) at 12 months, reducing to 31% (62/200) at 24 months post app implementation (P=.07 vs baseline). However, increased adherence was sustained in patients with pulmonary consolidation on x-ray (9/63, 14% at baseline; 23/77, 30% after 3 months; 32/92, 35% after 12 month; and 32/102, 31% after 24 months; P=.04 vs baseline). CONCLUSIONS An antibiotic guidelines app increased overall adherence, but this was not sustained. In patients with pulmonary consolidation, the increased adherence was sustained.
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Affiliation(s)
- Chang Ho Yoon
- Big Data Institute, Oxford, United Kingdom
- Infectious Diseases Department, Auckland City Hospital, Auckland, New Zealand
| | - Imogen Nolan
- Infectious Diseases Department, Auckland City Hospital, Auckland, New Zealand
| | - Gayl Humphrey
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Eamon J Duffy
- Infectious Diseases Department, Auckland City Hospital, Auckland, New Zealand
| | - Mark G Thomas
- School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Stephen R Ritchie
- School of Medical Sciences, University of Auckland, Auckland, New Zealand
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Karas DR, Upadhyayula S, Love A, Bigham MT. Utilizing Clinical Decision Support in the Treatment of Urinary Tract Infection across a Large Pediatric Primary Care Network. Pediatr Qual Saf 2023; 8:e655. [PMID: 38571730 PMCID: PMC10990320 DOI: 10.1097/pq9.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/27/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction Cystitis and pyelonephritis are common bacterial infections in infants and children, and initial treatment is usually empirical. Antimicrobial stewardship advocates using narrow-spectrum antibiotics with consideration for local resistance patterns. Narrow-spectrum antibiotic use is critical in addressing the global issue of bacterial antimicrobial resistance, associated with approximately 5 million annual deaths. Methods The antimicrobial stewardship committee developed a guideline for diagnosing and managing urinary tract infections and distributed it to all primary care providers. A standardized order set provided clinical decision support regarding appropriate first-line antibiotic therapy. A chief complaint of dysuria prompted the use of the order set. Prescription rates for the most common antimicrobials were tracked on a control chart. Results From March 2018 through March 2020, there were 4,506 antibiotic prescriptions for urinary tract infections. Utilization of the recommended first-line therapy, cephalexin, increased from 27.5% to 74.8%. Over the same period, trimethoprim-sulfamethoxazole, no longer recommended due to high local resistance, decreased from 31.8% to 8.1%. Providers have maintained these prescribing patterns since the conclusion of the project. Conclusion Using clinical decision support as a standardized order set can sustainably improve the use of first-line antimicrobials for treating pediatric urinary tract infections.
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Affiliation(s)
- David R. Karas
- From the Akron Children’s Hospital, Department of Pediatrics, Akron, Ohio
- Northeast Ohio Medical University, Rootstown, Ohio
| | - Shankar Upadhyayula
- From the Akron Children’s Hospital, Department of Pediatrics, Akron, Ohio
- Northeast Ohio Medical University, Rootstown, Ohio
| | - April Love
- From the Akron Children’s Hospital, Department of Pediatrics, Akron, Ohio
| | - Michael T. Bigham
- From the Akron Children’s Hospital, Department of Pediatrics, Akron, Ohio
- Northeast Ohio Medical University, Rootstown, Ohio
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Rixe N, Frisch A, Wang Z, Martin JM, Suresh S, Florin TA, Ramgopal S. The development of a novel natural language processing tool to identify pediatric chest radiograph reports with pneumonia. Front Digit Health 2023; 5:1104604. [PMID: 36910570 PMCID: PMC9992200 DOI: 10.3389/fdgth.2023.1104604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/16/2023] [Indexed: 02/25/2023] Open
Abstract
Objective Chest radiographs are frequently used to diagnose community-acquired pneumonia (CAP) for children in the acute care setting. Natural language processing (NLP)-based tools may be incorporated into the electronic health record and combined with other clinical data to develop meaningful clinical decision support tools for this common pediatric infection. We sought to develop and internally validate NLP algorithms to identify pediatric chest radiograph (CXR) reports with pneumonia. Materials and methods We performed a retrospective study of encounters for patients from six pediatric hospitals over a 3-year period. We utilized six NLP techniques: word embedding, support vector machines, extreme gradient boosting (XGBoost), light gradient boosting machines Naïve Bayes and logistic regression. We evaluated their performance of each model from a validation sample of 1,350 chest radiographs developed as a stratified random sample of 35% admitted and 65% discharged patients when both using expert consensus and diagnosis codes. Results Of 172,662 encounters in the derivation sample, 15.6% had a discharge diagnosis of pneumonia in a primary or secondary position. The median patient age in the derivation sample was 3.7 years (interquartile range, 1.4-9.5 years). In the validation sample, 185/1350 (13.8%) and 205/1350 (15.3%) were classified as pneumonia by content experts and by diagnosis codes, respectively. Compared to content experts, Naïve Bayes had the highest sensitivity (93.5%) and XGBoost had the highest F1 score (72.4). Compared to a diagnosis code of pneumonia, the highest sensitivity was again with the Naïve Bayes (80.1%), and the highest F1 score was with the support vector machine (53.0%). Conclusion NLP algorithms can accurately identify pediatric pneumonia from radiography reports. Following external validation and implementation into the electronic health record, these algorithms can facilitate clinical decision support and inform large database research.
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Affiliation(s)
- Nancy Rixe
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Adam Frisch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Zhendong Wang
- School of Computing and Information, University of Pittsburgh, Pittsburgh, PA, United States
| | - Judith M Martin
- Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Srinivasan Suresh
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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10
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Hojat LS, Saade EA, Hernandez AV, Donskey CJ, Deshpande A. Can Electronic Clinical Decision Support Systems Improve the Diagnosis of Urinary Tract Infections? A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2022; 10:ofac691. [PMID: 36632418 PMCID: PMC9830539 DOI: 10.1093/ofid/ofac691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Background Urinary tract infection (UTI) is a commonly misdiagnosed infectious syndrome. Diagnostic stewardship interventions can reduce rates of asymptomatic bacteriuria treatment but are often labor intensive, and thus an automated means of reducing unnecessary urine testing is preferred. In this systematic review and meta-analysis, we sought to identify studies describing interventions utilizing clinical decision support (CDS) to optimize UTI diagnosis and to characterize the effectiveness of these interventions. Methods We conducted a comprehensive electronic search and manual reference list review for peer-reviewed articles published before July 2, 2021. Publications describing an intervention intending to enhance UTI diagnosis via CDS were included. The primary outcome was urine culture test rate. Results The electronic search identified 5013 studies for screening. After screening and full-text review, 9 studies met criteria for inclusion, and a manual reference list review identified 5 additional studies, yielding a total of 14 studies included in the systematic review. The most common CDS intervention was urinalysis with reflex to urine culture based on prespecified urinalysis parameters. All 9 studies that provided statistical comparisons reported a decreased urine culture rate postintervention, 8 of which were statistically significant. A meta-analysis including 4 studies identified a pooled urine culture incidence rate ratio of 0.56 (95% confidence interval, .52-.60) favoring the postintervention versus preintervention group. Conclusions In this systematic review and meta-analysis, CDS appeared to be effective in decreasing urine culture rates. Prospective trials are needed to confirm these findings and to evaluate their impact on antimicrobial prescribing, patient-relevant outcomes, and potential adverse effects.
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Affiliation(s)
- Leila S Hojat
- Correspondence: Leila S. Hojat, MD, 11100 Euclid Ave., Mailstop FOL5083, Cleveland, OH 44106, USA (). Elie Saade, MPH, MD, 11100 Euclid Ave, Mailstop FOL5083, Cleveland, OH 44106, USA ()
| | - Elie A Saade
- Correspondence: Leila S. Hojat, MD, 11100 Euclid Ave., Mailstop FOL5083, Cleveland, OH 44106, USA (). Elie Saade, MPH, MD, 11100 Euclid Ave, Mailstop FOL5083, Cleveland, OH 44106, USA ()
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA,Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru
| | - Curtis J Donskey
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, Ohio, USA,Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans’ Affairs Medical Center, Cleveland, Ohio, USA
| | - Abhishek Deshpande
- Center for Value Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA,Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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11
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Time to evaluate decision support systems for antimicrobial prescribing outside the hospital. THE LANCET INFECTIOUS DISEASES 2022; 22:1408-1409. [PMID: 35870479 PMCID: PMC9299723 DOI: 10.1016/s1473-3099(22)00356-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 11/20/2022]
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Applying Diagnostic Stewardship to Proactively Optimize the Management of Urinary Tract Infections. Antibiotics (Basel) 2022; 11:antibiotics11030308. [PMID: 35326771 PMCID: PMC8944608 DOI: 10.3390/antibiotics11030308] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/05/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
A urinary tract infection is amongst the most common bacterial infections in the community and hospital setting and accounts for an estimated 1.6 to 2.14 billion in national healthcare expenditure. Despite its financial impact, the diagnosis is challenging with urine cultures and antibiotics often inappropriately ordered for non-specific symptoms or asymptomatic bacteriuria. In an attempt to limit unnecessary laboratory testing and antibiotic overutilization, several diagnostic stewardship initiatives have been described in the literature. We conducted a systematic review with a focus on the application of molecular and microbiological diagnostics, clinical decision support, and implementation of diagnostic stewardship initiatives for urinary tract infections. The most successful strategies utilized a bundled, multidisciplinary, and multimodal approach involving nursing and physician education and feedback, indication requirements for urine culture orders, reflex urine culture programs, cascade reporting, and urinary antibiograms. Implementation of antibiotic stewardship initiatives across the various phases of laboratory testing (i.e., pre-analytic, analytic, post-analytic) can effectively decrease the rate of inappropriate ordering of urine cultures and antibiotic prescribing in patients with clinically ambiguous symptoms that are unlikely to be a urinary tract infection.
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Abstract
Background Antimicrobial stewardship (AMS) programmes in hospitals support optimal antimicrobial use by utilizing strategies such as restriction policies and education. Several systematic reviews on digital interventions supporting AMS have been conducted but they have focused on specific interventions and outcomes. Objectives To provide a systematic overview and synthesis of evidence on the effectiveness of digital interventions to improve antimicrobial prescribing and monitoring in hospitals. Methods Multiple databases were searched from 2010 onwards. Review papers were eligible if they included studies that examined the effectiveness of AMS digital interventions in an inpatient hospital setting. Papers were excluded if they were not systematic reviews, were limited to a paediatric setting, or were not in English. Results Eight systematic reviews were included for data extraction. A large number of digital interventions were evaluated, with a strong focus on clinical decision support. Due to the heterogeneity of the interventions and outcome measures, a meta-analysis could not be performed. The majority of reviews reported that digital interventions reduced antimicrobial use and improved antimicrobial appropriateness. The impact of digital interventions on clinical outcomes was inconsistent. Conclusions Digital interventions reduce antimicrobial use and improve antimicrobial appropriateness in hospitals, but no firm conclusions can be drawn about the degree to which different types of digital interventions achieve these outcomes. Evaluation of sociotechnical aspects of digital intervention implementation is limited, despite the critical role that user acceptance, uptake and feasibility play in ensuring improvements in AMS are achieved with digital health.
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Affiliation(s)
| | - Jonathan Penm
- The University of Sydney, School of Pharmacy, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Angus Ritchie
- Health Informatics Unit, Sydney Local Health District, Camperdown, Australia
- The University of Sydney, Faculty of Medicine and Health, Concord Clinical School, Sydney, New South Wales, Australia
| | - Melissa T Baysari
- The University of Sydney, Biomedical Informatics and Digital Health, School of Medical Sciences, Charles Perkins Centre, Faculty of Medicine and Health, Sydney, New South Wales, Australia
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14
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Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.
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Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
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15
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Hajesmaeel Gohari S, Bahaadinbeigy K, Tajoddini S, R Niakan Kalhori S. Effect of Computerized Physician Order Entry and Clinical Decision Support System on Adverse Drug Events Prevention in the Emergency Department: A Systematic Review. J Pharm Technol 2021; 37:53-61. [PMID: 34752539 DOI: 10.1177/8755122520958160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: An adverse drug event (ADE) is an injury resulting from a medical intervention related to a drug. The emergency department (ED) is a ward vulnerable to more ADEs because of overcrowding. Information technologies such as computerized physician order entry (CPOE) and clinical decision support system (CDSS) may decrease the occurrence of ADEs. This study aims to review research that reported the evaluation of the effectiveness of CPOE and CDSS on lowering the occurrence of ADEs in the ED. Data Sources: PubMed, EMBASE, and Web of Science databases were used to find studies published from 2003 to 2018. The search was conducted in November 2018. Study Selection and Data Extraction: The search resulted in 1700 retrieved articles. After applying inclusion and exclusion criteria, 11 articles were included. Data on the date, country, type of system, medication process stages, study design, participants, sample size, and outcomes were extracted. Data Synthesis: Results showed that CPOE and CDSS may prevent ADEs in the ED through significantly decreasing the rate of errors, ADEs, excessive dose, and inappropriate prescribing (in 54.5% of articles); furthermore, CPOE and CDSS may significantly increase the rate of appropriate prescribing and dosing in compliance with established guidelines (45.5% of articles). Conclusion: This study revealed that the use of CPOE and CDSS can lower the occurrence of ADEs in the ED; however, further randomized controlled trials are needed to address the effect of a CDSS, with basic or advanced features, on the occurrence of ADEs in the ED.
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16
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Parzen-Johnson S, Kronforst KD, Shah RM, Whitmer GR, Scardina T, Chandarraju M, Patel SJ. Use of the Electronic Health Record to Optimize Antimicrobial Prescribing. Clin Ther 2021; 43:1681-1688. [PMID: 34645574 DOI: 10.1016/j.clinthera.2021.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE This review summarizes how interventions in the electronic health record (EHR) can optimize antimicrobial stewardship across the continuum of antimicrobial decision making, from diagnosis of infection to discontinuation of therapy. In addition, opportunities to optimize provider communication and patient education are identified. METHODS A narrative review was conducted to identify how interventions in the EHR can influence antimicrobial prescribing behavior. Examples from pediatrics were specifically identified. Interventions were then categorized into high-impact/low-effort, high-impact/high-effort, and low-impact/low-effort groupings based on historical experience. FINDINGS EHR-based interventions can be used for stratifying patients at risk for infection and are useful in identifying patients with new-onset infections. Additional tools include automatically updated antibiograms tailored to specific patient populations, timely authorization of restricted antimicrobials, and more accurate allergy labeling. Medical errors can be reduced and communication between providers can be improved by standardized data fields. Clinical decision support tools can guide appropriate selection of therapy, and visual prompts can reduce unnecessarily prolonged therapy. Benchmarking of antimicrobial use, tailored patient education, and improved communication during transitions of care are enhanced through EHR-based interventions. IMPLICATIONS Prescribing behavior can be modified through a range of interventions in the EHR, including tailored education, alerts, prompts, and restrictions on provider behavior. Further studies are needed to compare the effectiveness of various strategies.
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Affiliation(s)
| | - Kenny D Kronforst
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Grant R Whitmer
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tonya Scardina
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Meg Chandarraju
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sameer J Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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17
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Hagedoorn NN, Wagenaar JHL, Nieboer D, Bath D, Von Both U, Carrol ED, Eleftheriou I, Emonts M, Van Der Flier M, De Groot R, Herberg J, Kohlmaier B, Levin M, Lim E, Maconochie I, Martinon-Torres F, Nijman R, Pokorn M, Rivero Calle I, Tsolia M, Yeung S, Zavadska D, Zenz W, Vermont CL, Oostenbrink R, Moll HA. Impact of a clinical decision rule on antibiotic prescription for children with suspected lower respiratory tract infections presenting to European emergency departments: a simulation study based on routine data. J Antimicrob Chemother 2021; 76:1349-1357. [PMID: 33564871 DOI: 10.1093/jac/dkab023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/11/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Discriminating viral from bacterial lower respiratory tract infections (LRTIs) in children is challenging thus commonly resulting in antibiotic overuse. The Feverkidstool, a validated clinical decision rule including clinical symptoms and C-reactive protein, safely reduced antibiotic use in children at low/intermediate risk for bacterial LRTIs in a multicentre trial at emergency departments (EDs) in the Netherlands. OBJECTIVES Using routine data from an observational study, we simulated the impact of the Feverkidstool on antibiotic prescriptions compared with observed antibiotic prescriptions in children with suspected LRTIs at 12 EDs in eight European countries. METHODS We selected febrile children aged 1 month to 5 years with respiratory symptoms and excluded upper respiratory tract infections. Using the Feverkidstool, we calculated individual risks for bacterial LRTI retrospectively. We simulated antibiotic prescription rates under different scenarios: (1) applying effect estimates on antibiotic prescription from the trial; and (2) varying both usage (50%-100%) and compliance (70%-100%) with the Feverkidstool's advice to withhold antibiotics in children at low/intermediate risk for bacterial LRTI (≤10%). RESULTS Of 4938 children, 4209 (85.2%) were at low/intermediate risk for bacterial LRTI. Applying effect estimates from the trial, the Feverkidstool reduced antibiotic prescription from 33.5% to 24.1% [pooled risk difference: 9.4% (95% CI: 5.7%-13.1%)]. Simulating 50%-100% usage with 90% compliance resulted in risk differences ranging from 8.3% to 15.8%. Our simulations suggest that antibiotic prescriptions would be reduced in EDs with high baseline antibiotic prescription rates or predominantly (>85%) low/intermediate-risk children. CONCLUSIONS Implementation of the Feverkidstool could reduce antibiotic prescriptions in children with suspected LRTIs in European EDs.
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Affiliation(s)
- Nienke N Hagedoorn
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Josephine H L Wagenaar
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - David Bath
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Ulrich Von Both
- Division of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University, Munich, Germany.,Partner site Munich, German Center for Infection Research (DZIF), Germany
| | - Enitan D Carrol
- Institute of Infection, Veterinary and Ecological Sciences Global Health Liverpool, University of Liverpool, UK.,Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - Irini Eleftheriou
- Second Department of Paediatrics, National and Kapodistrian University of Athens, P. & A. Kyriakou Children's Hospital, Athens, Greece
| | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Michiel Van Der Flier
- Paediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Section Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.,Paediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ronald De Groot
- Paediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Section Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Jethro Herberg
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Emma Lim
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Federico Martinon-Torres
- Genetics, Vaccines, Infections and Paediatrics Research Group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ruud Nijman
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Marko Pokorn
- Department of Infectious Diseases, University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - Irene Rivero Calle
- Genetics, Vaccines, Infections and Paediatrics Research Group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Maria Tsolia
- Second Department of Paediatrics, National and Kapodistrian University of Athens, P. & A. Kyriakou Children's Hospital, Athens, Greece
| | - Shunmay Yeung
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Dace Zavadska
- Department of Paediatrics, Children's Clinical University Hospital, Rīgas Stradiņa universitāte, Riga, Latvia
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Clementien L Vermont
- Department of Paediatric Infectious diseases and Immunology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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18
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Laka M, Milazzo A, Merlin T. Can evidence-based decision support tools transform antibiotic management? A systematic review and meta-analyses. J Antimicrob Chemother 2021; 75:1099-1111. [PMID: 31960021 DOI: 10.1093/jac/dkz543] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/17/2019] [Accepted: 12/06/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To assess the effectiveness of clinical decision support systems (CDSSs) at reducing unnecessary and suboptimal antibiotic prescribing within different healthcare settings. METHODS A systematic review of published studies was undertaken with seven databases from database inception to November 2018. A protocol was developed using the PRISMA-P checklist and study selection criteria were determined prior to performing the search. Critical appraisal of studies was undertaken using relevant tools. Meta-analyses were performed using a random-effects model to determine whether CDSS use affected optimal antibiotic management. RESULTS Fifty-seven studies were identified that reported on CDSS effectiveness. Most were non-randomized studies with low methodological quality. However, randomized controlled trials of moderate methodological quality were available and assessed separately. The meta-analyses indicated that appropriate antibiotic therapy was twice as likely to occur following the implementation of CDSSs (OR 2.28, 95% CI 1.82-2.86, k = 20). The use of CDSSs was also associated with a relative decrease (18%) in mortality (OR 0.82, 95% CI 0.73-0.91, k = 18). CDSS implementation also decreased the overall volume of antibiotic use, length of hospital stay, duration and cost of therapy. The magnitude of the effect did vary by study design, but the direction of the effect was consistent in favouring CDSSs. CONCLUSIONS Decision support tools can be effective to improve antibiotic prescribing, although there is limited evidence available on use in primary care. Our findings suggest that a focus on system requirements and implementation processes would improve CDSS uptake and provide more definitive benefits for antibiotic stewardship.
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Affiliation(s)
- Mah Laka
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Adriana Milazzo
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Tracy Merlin
- Adelaide Health Technology (AHTA), School of Public Health, University of Adelaide, Adelaide, Australia
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19
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Baker EW, Dodson CH. Prototype Development and Usability Evaluation of a Clinical Decision Support Tool for Pharmacogenomic Pharmacy in Practice. Comput Inform Nurs 2021; 39:362-366. [PMID: 34224416 DOI: 10.1097/cin.0000000000000722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pharmacogenetics, a subset of precision medicine, provides a way to individualize drug dosages and provide tailored drug therapy to patients. This revolution in prescribing techniques has resulted in a knowledge deficit for many healthcare providers on the proper way to use pharmacogenetics in practice. This research study explored the potential adoption of clinical decision support system mobile apps by clinicians through investigating the initial usability of the PGx prototype application in an effort to address the lack of such tools used in practice. The study method included usage of a clinical decision support system programmed within our pharmacogenomics drug dosage application (called PGx) in a simulated environment. Study participants completed the System Usability Scale survey to report on the perceived usefulness and ease of use of the mobile app. The PGx app has a higher perceived usability than 85% of all products tested, considered very good usability for a product. This general usability rating indicates that the nurse practitioner students find the application to be a clinical decision support system that would be helpful to use in practice.
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Affiliation(s)
- Elizabeth White Baker
- Author Affiliations: School of Business, Virginia Commonwealth University (Dr Baker), Richmond; and School of Nursing, University of North Carolina-Wilmington (Dr Dodson)
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20
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Yuan X, Chen K, Zhao W, Hu S, Yu F, Diao X, Chen X, Hu S. Open-label, single-centre, cluster-randomised controlled trial to Evaluate the Potential Impact of Computerisedantimicrobial stewardship (EPIC) on the antimicrobial use after cardiovascular surgeries: EPIC trial study original protocol. BMJ Open 2020; 10:e039717. [PMID: 33243799 PMCID: PMC7692825 DOI: 10.1136/bmjopen-2020-039717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Inappropriate antimicrobial use increases the prevalence of antimicrobial-resistant bacteria. Surgeons are reluctant to implement recommendations of guidelines in clinical practice. Antimicrobial stewardship (AMS) is effective in antimicrobial management, but it remains labour intensive. The computerised decision support system (CDSS) has been identified as an effective way to enable key elements of AMS in clinical settings. However, insufficient evidence is available to evaluate the efficacy of computerised AMS in surgical settings. METHODS AND ANALYSIS The Evaluate of the Potential Impact of Computerised AMS trial is an open-label, single-centre, two-arm, cluster-randomised, controlled trial, which aims to determine whether a multicomponent CDSS intervention reduces overall antimicrobial use after cardiovascular surgeries compared with usual clinical care in a specialty hospital with a big volume of cardiovascular surgeries. Eighteen cardiovascular surgical teams will be randomised 1:1 to either the intervention or the control arm. The intervention will consist of (1) re-evaluation alerts and decision support for the duration of antimicrobial treatment decision, (2) re-evaluation alerts and decision support for the choice of antimicrobial, (3) quality control audit and feedback. The primary outcome will be the overall systemic antimicrobial use measured in days of therapy (DOT) per admission and DOT per 1000 patient-days over the whole intervention period (6 months). Secondary outcomes include a series of indices to evaluate antimicrobial use, microbial resistance, perioperative infection outcomes, patient safety, resource consumption, and user compliance and satisfaction. ETHICS AND DISSEMINATION The Ethics Committee in Fuwai Hospital approved this study (2020-1329). The results of the trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04328090.
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Affiliation(s)
- Xin Yuan
- State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kai Chen
- State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Zhao
- Information Centre, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shuang Hu
- National Clinical Research Centre of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Yu
- Information Centre, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaolin Diao
- Information Centre, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xingwei Chen
- Department of Pharmacy, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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21
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Evidence of Antimicrobial Stewardship in the Treatment of Uncomplicated Urinary Tract Infection. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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22
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Giancola SE, Higginbotham JM, Sutter DE, Spencer SE, Aden JK, Barsoumian AE. Improvement in adherence to antibiotic duration of therapy recommendations for uncomplicated cystitis: a quasi-experimental study. Fam Pract 2020; 37:242-247. [PMID: 31671172 DOI: 10.1093/fampra/cmz068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Acute uncomplicated cystitis is one of the most common diagnoses for which antibiotic treatment is prescribed in the outpatient setting. Despite the availability of national guidelines, there remains a wide pattern in prescriber choices for therapy. Recent data portray a picture of consistently longer durations than recommended prescribed in outpatient settings. OBJECTIVE The objective was to evaluate the effect of a system-based intervention on adherence to guideline-recommended durations of therapy for uncomplicated cystitis in the outpatient setting. METHODS This quasi-experimental study included women aged 18-64 years who were seen at five family medicine clinics at an academic medical centre and were prescribed targeted antibiotics for uncomplicated cystitis (nitrofurantoin monohydrate/macrocrystals 100 mg, trimethoprim-sulfamethoxazole 160/800 mg or ciprofloxacin 250 mg). The intervention involved revising or adding pre-filled, but modifiable, default prescribing instructions in the electronic health record (EHR) for the targeted antibiotics. We evaluated adherence to guideline-recommended duration of therapy as well as days of therapy (DOT) before and after the intervention. RESULTS A total of 787 pre-intervention and 862 post-intervention cases were included. Adherence to recommended duration of therapy increased from 29.4% to 76.3% (P < 0.01). The average DOT decreased by 23% from 6.6 to 5.1 (P < 0.01). CONCLUSION A stewardship intervention consisting of revising/adding default prescribing instructions to targeted antimicrobials in an EHR was associated with increased adherence to recommended durations of therapy for uncomplicated cystitis and reduction of unnecessary antibiotic exposure. More studies are needed to confirm effectiveness across multiple medical record platforms.
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Affiliation(s)
| | | | | | | | - James K Aden
- Department of Graduate Medical Education, Fort Sam Houston, TX, USA
| | - Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
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23
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Neugebauer M, Ebert M, Vogelmann R. A clinical decision support system improves antibiotic therapy for upper urinary tract infection in a randomized single-blinded study. BMC Health Serv Res 2020; 20:185. [PMID: 32143630 PMCID: PMC7059328 DOI: 10.1186/s12913-020-5045-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 02/26/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Due to increasing bacterial resistance rates choosing a correct empiric antibiotic therapy is getting more and more complex. Often medical doctors use information tools to make the right treatment choice. METHODS One hundred sixty six participants (77 medical doctors and 89 medical students) were asked to provide a diagnosis and antibiotic therapy in a simple fictive paper case of upper urinary tract infection (UTI) in a randomized single-blinded study. Participants were randomized to one of four information tools they were allowed to use in the study or control: 1. free internet access, 2. pharmaceutical pocket guide, 3. pocket guide antibiotic therapy, 4. clinical decision support system (CDSS), and control (no information tool). The CDSS was designed for the study. The adherence to the national German UTI guideline was evaluated. RESULTS Only 27.1% (n = 45/166) provided a correct diagnosis of upper UTI and 19.4% (n = 32/166) an antibiotic treatment recommended by national German treatment guidelines indicating their need for information tools. This result was not significantly different between medical doctors and medical students, residents and medical specialists or level of working experience. Using CDSS improved results significantly compared to conventional tools (diagnosis 57.1%; treatment recommendation 40.5%; p < 0,01). Processing time was not different between the use of CDSS and conventional information tools. CDSS users based their decision making on their assigned information tool more than users of conventional tools (73.8% vs. 48.0%; p < 0.01). Using CDSS improved the confidence of participants in their recommendation significantly compared to conventional tools (p < 0.01). CONCLUSIONS Our study suggests that medical professionals require information tools in diagnosing and treating a simple case of upper UTI correctly. CDSS appears to be superior to conventional tools as an information source.
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Affiliation(s)
- M Neugebauer
- Second Department of Internal Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany
| | - M Ebert
- Second Department of Internal Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany
| | - R Vogelmann
- Second Department of Internal Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany.
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Dodson CH, Baker E. Focus group testing of a mobile app for pharmacogenetic-guided dosing. J Am Assoc Nurse Pract 2020; 33:205-210. [PMID: 32039960 DOI: 10.1097/jxx.0000000000000392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/27/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND A common barrier to implementation of precision medicine is the lack of use of published clinical practice guidelines. Consequently, a user-friendly mechanism to easily adopt these guidelines is imperative. PURPOSE The purpose of this study was to evaluate the perceptions of a prototype of a clinical decision support tool through a mobile application for pharmacogenetics. METHODOLOGICAL ORIENTATION A case study on a patient requiring pharmacogenetic testing was provided to the participants. The participants were given up to 30 minutes to identify the correct dosing in the clinical decision support tool based on clinical evidence-based guidelines. Immediately after the utilization of the mobile app, focus group interviews were conducted to identify the perceptions of the tool, obstacles associated with the tool, and suggestions for improvement of the tool. SAMPLE Focus group interviews with 23 nurse practitioners and nurse practitioner students were conducted. Field notes and audio recordings were taken. CONCLUSIONS Specific feedback for improvement in the font and size of text, color contrast, use of drug calculator, automatic input, and desire for further development of education portal were found within the data. The findings revealed useful feedback to adjust the prototype to improve the ease of use among nurse practitioners. IMPLICATIONS FOR PRACTICE The revision of this mobile app will improve user friendliness to increase applicability within health care. The mobile app can be used for future research to identify improvements in patient outcomes after implementing this tool.
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Affiliation(s)
- Crystal Heath Dodson
- School of Nursing, University of North Carolina at Wilmington, Wilmington, North Carolina
| | - Elizabeth Baker
- School of Business, Virginia Commonwealth, Richmond, Virginia
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25
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Thematic analysis of nurse practitioners use of clinical decision support tools and clinical mobile apps for prescriptive purposes. J Am Assoc Nurse Pract 2019; 31:522-526. [DOI: 10.1097/jxx.0000000000000170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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26
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Bagheri F, Al Baha ZGM, Panackal A, Abraham M. An observational study of antibiotic prescription in management of urinary tract infection in the Arabian Gulf. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415819837459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: The aim of this study was to describe antibiotic prescription for management of urinary tract infections (UTIs) in daily clinical practice in the Arabian Gulf and to compare prescription patterns with the recommendations of different recent guidelines. Method: This was a multicentre, cross-sectional, observational study evaluating antibiotic prescription in the management of UTIs in five countries from the Arabian Gulf. Randomly selected physicians who routinely treat patients with UTIs enrolled consecutively adult patients prescribed an antibiotic for treatment or prophylaxis of a UTI. Data were collected on UTI symptoms, antibiotic prescription, co-medications and relevant diagnostic laboratory tests. Results: Fifty physicians enrolled 522 eligible patients. The reason for antibiotic prescription was treatment of a UTI in 502 patients, and prophylaxis in 20 patients. The most frequent types of UTI documented were cystitis (301 cases) and urethritis (143 patients). Overall, the most frequently prescribed antibiotics for treatment of active UTIs were levofloxacin (344 patients; 68.7%), ciprofloxacin (69 patients; 13.8%) and ceftriaxone (34 patients; 6.8%). The pattern of antibiotic prescription was essentially similar irrespective of the indication. Only six patients with uncomplicated acute cystitis received the treatment recommended as first choice in the European Association of Urology or Infectious Diseases Society of America and European Society of Clinical Microbiology and Infectious Disease guidelines (nitrofurantoin or trimethoprim/sulfamethoxazole). Conclusions: We observed pronounced divergence from international practice guidelines for the use of antibiotics for the treatment or prophylaxis of UTIs in the Arabian Gulf, even though most participating physicians, and essentially all urologists, claimed to be familiar with them. In this context, the development and diffusion of regional practice guidelines may be particularly useful. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
- Fariborz Bagheri
- Urology Department, Dubai Health Authority, Dubai Hospital, Dubai, UAE
| | - Ziad GM Al Baha
- Department of Urology, Bahrain Specialist Hospital, Manama, Kingdom of Bahrain
| | - Arun Panackal
- Department of Urology, Kims Hospital, Muscat, Sultanate of Oman
| | - Mathew Abraham
- Department of Internal Medicine, Al Safa Polyclinic, Doha, Qatar
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Rittmann B, Stevens MP. Clinical Decision Support Systems and Their Role in Antibiotic Stewardship: a Systematic Review. Curr Infect Dis Rep 2019; 21:29. [PMID: 31342180 DOI: 10.1007/s11908-019-0683-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article is to perform a systematic review over the past 5 years on the role and effectiveness of clinical decision support systems (CDSSs) on antibiotic stewardship. RECENT FINDINGS CDDS interventions found a significant impact on multiple outcomes relevant to antibiotic stewardship. There are various types of CDSS implementations, both active and passive (provider initiated). Passive interventions were associated with more significant outcomes; however, both interventions appeared effective. In the reviewed literature, CDSSs were consistently associated with decreasing antibiotic consumption and narrowing the spectrum of antibiotic usage. Generally, guideline adherence was improved with CDSS, although this was not universal. The effect on other outcomes, such as mortality, Clostridiodes difficile infections, length of stay, and cost, inconsistently showed a significant difference. Overall, CDDS implementation has effectively decreased antibiotic consumption and improved guideline adherence across the various types of CDSS. Other positive outcomes were noted in certain settings, but were not universal. When creating a new intervention, it is important to identify the optimal structure and deployment of a CDSS for a specific setting.
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Affiliation(s)
- Barry Rittmann
- Virginia Commonwealth University Health Systems, Richmond, USA. .,, 825 Fairfax Avenue, 4th Floor, Norfolk, VA, 23507, USA.
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28
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Ha DR, Haste NM, Gluckstein DP. The Role of Antibiotic Stewardship in Promoting Appropriate Antibiotic Use. Am J Lifestyle Med 2019; 13:376-383. [PMID: 31285722 PMCID: PMC6600622 DOI: 10.1177/1559827617700824] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are one of the most significant medical discoveries in human history. The widespread use of antibiotics has resulted in the emergence of antibiotic-resistant pathogens. This fact, coupled with the paucity of new antibiotic developments, has spurred efforts to combat antibiotic resistance. One of the most critical components of these efforts is antibiotic stewardship, a multidisciplinary endeavor, employing a collection of interventions in a variety of health care settings with the aim of promoting appropriate utilization of antibiotics. This article describes antibiotic stewardship programs and key practices used to minimize the development and spread of antibiotic-resistant pathogens including the optimization of antibiotic pharmacokinetics and pharmacodynamics, the application of rapid diagnostic tools, and the use of computerized provider order entry tools.
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Affiliation(s)
- David R. Ha
- David R. Ha, PharmD, Keck Graduate Institute
School of Pharmacy, 535 Watson Drive, Claremont, CA 91711; e-mail:
| | - Nina M. Haste
- Keck Graduate Institute School of Pharmacy, Pomona
Valley Hospital Medical Center, Claremont, California (DRH)
- University of California San Diego Health and
University of California San Diego Skaggs School of Pharmacy and Pharmaceutical
Sciences, La Jolla, California (NMH)
- Infectious Diseases, Pomona Valley Hospital Medical
Center, Pomona, California (DPG)
| | - Daniel P. Gluckstein
- Keck Graduate Institute School of Pharmacy, Pomona
Valley Hospital Medical Center, Claremont, California (DRH)
- University of California San Diego Health and
University of California San Diego Skaggs School of Pharmacy and Pharmaceutical
Sciences, La Jolla, California (NMH)
- Infectious Diseases, Pomona Valley Hospital Medical
Center, Pomona, California (DPG)
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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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Carracedo-Martinez E, Gonzalez-Gonzalez C, Teixeira-Rodrigues A, Prego-Dominguez J, Takkouche B, Herdeiro MT, Figueiras A. Computerized Clinical Decision Support Systems and Antibiotic Prescribing: A Systematic Review and Meta-analysis. Clin Ther 2019; 41:552-581. [PMID: 30826093 DOI: 10.1016/j.clinthera.2019.01.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/16/2019] [Accepted: 01/30/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study was to perform a systematic review and meta-analysis of studies performed in primary care centers and hospital facilities that evaluated the effectiveness of computerized clinical decision support systems (CDSSs) in decision making on the prescription of any given antibiotic. METHODS We conducted a search of the MEDLINE and EMBASE databases. A meta-analysis was then conducted of all variables with results reported in >2 studies. FINDINGS A total of 42 of the 46 studies included in the review identified a statistically significant advantage for CDSSs in ≥1 study variables. The effect of CDSSs on the percentage accuracy of the antibiotic spectrum prescribed empirically with respect to the microbial agent's susceptibility, which is one of the most frequently studied outcome variables, was examined in 7 studies, all undertaken in hospital settings. In all these studies but one, CDSSs resulted in a statistically significant increase in percentage accuracy. The other study variables present in >2 studies had more inconsistent results. Although the results of the meta-analysis of the variables percentage accuracy, antibiotic prescription rate in hospital, percentage adherence to antibiotic prescription guidelines in primary care or hospital, and percentage of inappropriate prescriptions for antibiotics in primary care were statistically significantly favorable to CDSSs; in the case of hospital length of stay and mortality, they were favorable although not statistically significantly. IMPLICATIONS CDSSs appear to be useful for variables such as the percentage of appropriate empirical treatment in the hospital setting or to induce changes in antibiotics prescription rate. Even so, more better quality studies are required to draw clearer conclusions in respect of morbidity and mortality outcome variables and other settings.
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Affiliation(s)
- Eduardo Carracedo-Martinez
- Santiago de Compostela Health Area, Galician Health Service (Servizo Galego de Saúde-SERGAS), Spanish National Health System, Santiago de Compostela, Spain.
| | - Christian Gonzalez-Gonzalez
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Antonio Teixeira-Rodrigues
- Department of Medical Sciences and Institute for Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Jesus Prego-Dominguez
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Bahi Takkouche
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain
| | - Maria Teresa Herdeiro
- Department of Medical Sciences and Institute for Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain; Institute of Health Research of Santiago de Compsotela (IDIS), Spain
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Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med 2019; 74:285-296. [PMID: 30611639 DOI: 10.1016/j.annemergmed.2018.10.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED). METHODS A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias. RESULTS A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials. CONCLUSION Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
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Abstract
Pediatric emergency medicine quality work continues to focus on the National Academies of Sciences, Engineering, and Medicine's 6 domains of quality, with a need for specific emphasis on equity and patient centeredness. Adopting the principles of high-reliability organizations, pediatric emergency departments should become increasing transparent with benchmarking and collaboration across institutions in order to develop an infrastructure for quality and safety to improve the care of pediatric patients in the emergency department.
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Affiliation(s)
- Brandon C Ku
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19146, USA.
| | - James M Chamberlain
- Department of Pediatrics, Division of Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine, 111 Michigan Avenue NW, Washington, DC 20010, USA
| | - Kathy N Shaw
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19146, USA
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Abstract
The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.
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Affiliation(s)
- Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
| | - Robert Redwood
- Department of Family Medicine and Community Health, University of Wisconsin Madison School of Medicine and Public Health, 1100 Delaplaine Ct, Madison, WI 53715
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, 4150 V Street, Suite 2100, Sacramento, CA 95817, USA
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34
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Mostaghim M, Snelling T, Bajorek B. Factors associated with adherence to antimicrobial stewardship after-hours. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2018; 27:180-190. [PMID: 30281178 DOI: 10.1111/ijpp.12486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 08/08/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Assess restricted antimicrobials acquired after standard working hours for adherence to antimicrobial stewardship (AMS) and identify factors associated with increased likelihood of adherence at the time of acquisition, and the next standard working day. METHODS All documented antimicrobials acquired from a paediatric hospital after-hours drug room from 1 July 2014 to 30 June 2015 were reconciled with records of AMS approval, and documented AMS review in the medical record. KEY FINDINGS Of the 758 antimicrobial acquisitions from the after-hours drug room, 62.3% were restricted. Only 29% were AMS adherent at the time of acquisition, 15% took place despite documented request for approval by a pharmacist. Antimicrobials for respiratory patients (OR 3.10, 95% CI 1.68-5.5) and antifungals (2.48, 95% CI 1.43-4.30) were more likely to be AMS adherent. Half of the acquisitions that required review the next standard working day were adherent to AMS (51.8%, 129/249). Weekday acquisitions (2.10, 95% CI 1.20-3.69) and those for patients in paediatric intensive care (2.26, 95% CI 1.07-4.79) were associated with AMS adherence. Interactions with pharmacists prior to acquisition did not change the likelihood of AMS adherence the next standard working day. Access to restricted antimicrobial held as routine ward stock did not change the likelihood of AMS adherence at the time of acquisition, or the next standard working day. CONCLUSION Restricted antimicrobials acquired after-hours are not routinely AMS adherent at the time of acquisition or the next standard working day, limiting opportunities for AMS involvement.
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Affiliation(s)
- Mona Mostaghim
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.,Department of Pharmacy, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Thomas Snelling
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Perth, WA, Australia.,Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
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Foolad F, Nagel JL, Eschenauer G, Patel TS, Nguyen CT. Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management. J Antimicrob Chemother 2018; 72:3232-3244. [PMID: 29177489 DOI: 10.1093/jac/dkx266] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.
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Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Gregory Eschenauer
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.,College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI 48109, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, University of Chicago Medicine, 5841 S. Maryland Ave. MC0010, Chicago, IL 60637, USA
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Catho G, De Kraker M, Waldispühl Suter B, Valotti R, Harbarth S, Kaiser L, Elzi L, Meyer R, Bernasconi E, Huttner BD. Study protocol for a multicentre, cluster randomised, superiority trial evaluating the impact of computerised decision support, audit and feedback on antibiotic use: the COMPuterized Antibiotic Stewardship Study (COMPASS). BMJ Open 2018; 8:e022666. [PMID: 29950480 PMCID: PMC6042555 DOI: 10.1136/bmjopen-2018-022666] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Inappropriate use of antimicrobials in hospitals contributes to antimicrobial resistance. Antimicrobial stewardship (AMS) interventions aim to improve antimicrobial prescribing, but they are often resource and personnel intensive. Computerised decision supportsystems (CDSSs) seem a promising tool to improve antimicrobial prescribing but have been insufficiently studied in clinical trials. METHODS AND ANALYSIS The COMPuterized Antibiotic Stewardship Study trial, is a publicly funded, open-label, cluster randomised, controlled superiority trial which aims to determine whether a multimodal CDSS intervention integrated in the electronic health record (EHR) reduces overall antibiotic exposure in adult patients hospitalised in wards of two secondary and one tertiary care centre in Switzerland compared with 'standard-of-care' AMS. Twenty-four hospital wards will be randomised 1:1 to either intervention or control, using a 'pair-matching' approach based on baseline antibiotic use, specialty and centre. The intervention will consist of (1) decision support for the choice of antimicrobial treatment and duration of treatment for selected indications (based on indication entry), (2) accountable justification for deviation from the local guidelines (with regard to the choice of molecules and duration), (3) alerts for self-guided re-evaluation of treatment on calendar day 4 of antimicrobial therapy and (4) monthly ward-level feedback of antimicrobial prescribing indicators. The primary outcome will be the difference in overall systemic antibiotic use measured in days of therapy per admission based on administration data recorded in the EHR over the whole intervention period (12 months), taking into account clustering. Secondary outcomes include qualitative and quantitative antimicrobial use indicators, economic outcomes and clinical, microbiological and patient safety indicators. ETHICS AND DISSEMINATION Ethics approval was obtained for all participating sites (Comission Cantonale d'Éthique de la Recherche (CCER)2017-00454). The results of the trial will be submitted for publication in a peer-reviewed journal. Further dissemination activities will be presentations/posters at national and international conferences. TRIAL REGISTRATION NUMBER NCT03120975; Pre-results.
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Affiliation(s)
- Gaud Catho
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marlieke De Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Roberta Valotti
- Division of Infectious Diseases, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Stephan Harbarth
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Laurent Kaiser
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Luigia Elzi
- Division of Infectious Diseases, Ospedale San Giovanni, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Rodolphe Meyer
- Division of Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Enos Bernasconi
- Division of Infectious Diseases, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Benedikt D Huttner
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Jun S, Plint AC, Campbell SM, Curtis S, Sabir K, Newton AS. Point-of-care Cognitive Support Technology in Emergency Departments: A Scoping Review of Technology Acceptance by Clinicians. Acad Emerg Med 2018; 25:494-507. [PMID: 28960689 DOI: 10.1111/acem.13325] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/12/2017] [Accepted: 09/23/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Cognitive support technologies that support clinical decisions and practices in the emergency department (ED) have the potential to optimize patient care. However, limited uptake by clinicians can prevent successful implementation. A better understanding of acceptance of these technologies from the clinician perspective is needed. We conducted a scoping review to synthesize diverse, emerging evidence on clinicians' acceptance of point-of-care (POC) cognitive support technology in the ED. METHOD We systematically searched 10 electronic databases and gray literature published from January 2006 to December 2016. Studies of any design assessing an ED-based POC cognitive support technology were considered eligible for inclusion. Studies were required to report outcome data for technology acceptance. Two reviewers independently screened studies for relevance and quality. Study quality was assessed using the Mixed-Methods Appraisal Tool. A descriptive analysis of the features of POC cognitive support technology for each study is presented, illustrating trends in technology development and evaluation. A thematic analysis of clinician, technical, patient, and organizational factors associated with technology acceptance is also presented. RESULTS Of the 1,563 references screened for eligibility, 24 met the inclusion criteria and were included in the review. Most studies were published from 2011 onward (88%), scored high for methodologic quality (79%), and examined POC technologies that were novel and newly introduced into the study setting (63%). Physician use of POC technology was the most commonly studied (67%). Technology acceptance was frequently conceptualized and measured by factors related to clinician attitudes and beliefs. Experience with the technology, intention to use, and actual use were also more common outcome measures of technology acceptance. Across studies, perceived usefulness was the most noteworthy factor impacting technology acceptance, and clinicians generally had positive perceptions of the use of POC cognitive support technology in the ED. However, the actual use of POC cognitive support technology reported by clinicians was low-use, by proportion of patient cases, ranged from 30% to 59%. Of the 24 studies, only two studies investigated acceptance of POC cognitive support technology currently implemented in the ED, offering "real-world" clinical practice data. All other studies focused on acceptance of novel technologies. Technical aspects such as an unfriendly user interface, presentation of redundant or ambiguous information, and required user effort had a negative impact on acceptance. Patient expectations were also found to have a negative impact, while patient safety implications had a positive impact. Institutional support was also reported to impact technology acceptance. CONCLUSIONS Findings from this scoping review suggest that while ED clinicians acknowledge the utility and value of using POC cognitive support technology, actual use of such technology can be low. Further, few studies have evaluated the acceptance and use of POC technologies in routine care. Prospective studies that evaluate how ED clinicians appraise and consider POC technology use in clinical practice are now needed with diverse clinician samples. While this review identified multiple factors contributing to technology acceptance, determining how clinician, technical, patient, and organizational factors mediate or moderate acceptance should also be a priority.
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Affiliation(s)
- Shelly Jun
- Department of Pediatrics University of Alberta Edmonton AlbertaCanada
| | - Amy C. Plint
- Departments of Pediatrics and Emergency Medicine University of Ottawa (ACP) Ottawa OntarioCanada
| | - Sandy M. Campbell
- The John W. Scott Health Sciences Library University of Alberta Edmonton AlbertaCanada
| | - Sarah Curtis
- Department of Pediatrics University of Alberta Edmonton AlbertaCanada
| | - Kyrellos Sabir
- The School of Medicine National University of Ireland Galway (KS) Galway Ireland
| | - Amanda S. Newton
- Department of Pediatrics University of Alberta Edmonton AlbertaCanada
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Antimicrobial Stewardship Efforts to Improve Management of Uncomplicated Urinary Tract Infections in the Ambulatory Care Setting: a Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0150-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Evaluating antibiotic therapies prescribed to adult patients in the emergency department. Med Mal Infect 2017; 46:207-14. [PMID: 27210280 DOI: 10.1016/j.medmal.2016.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/12/2016] [Accepted: 04/18/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The proper use of antibiotics is a public health priority to preserve their effectiveness. Little data is available on outpatient antibiotic prescriptions, especially in the emergency department. We aimed to assess the quality of outpatient antibiotic prescriptions in our hospital. PATIENTS AND METHODS Retrospective monocentric study of antibiotic prescriptions written to adult patients managed at the emergency department without hospitalization (November 15th, 2012-November 15th, 2013). Prescriptions were evaluated by an infectious disease specialist and an emergency physician on the basis of local recommendations compiled from national and international guidelines. RESULTS A total of 760 prescriptions were reviewed. The most frequent indications were urinary tract infections (n=263; 34.6%), cutaneous infections (n=198; 26.05%), respiratory tract infections (n=101; 13.28%), and ENT infections (n=62; 8.15%). The most frequently prescribed antibiotics were fluoroquinolones (n=314; 40.83%) and amoxicillin-clavulanic acid (n=245; 31.85%). Overall, 455 prescriptions (59.86%) did not comply with guidelines. The main reasons for inadequacy were the absence of an indication for antibiotic therapy (n=197; 40.7%), an inadequate spectrum of activity, i.e. too broad, (n=95; 19.62%), and excessive treatment duration (n=87; 17.97%). Rates of inadequate prescriptions were 82.26% for ENT infections, 71.2% for cutaneous infections, 46.53% for respiratory tract infections, and 38.4% for urinary tract infections. CONCLUSION Antibiotic prescriptions written to outpatients in the emergency department are often inadequate. Enhancing prescribers' training and handing out guidelines is therefore necessary. The quality of these prescriptions should then be re-assessed.
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Fahs I, Shrayteh Z, Abdulkhalek R, Salameh P, Hallit S, Malaeb D. Professional practice evaluation of emergency department prescriptions for community-acquired infections in Lebanon. Int J Infect Dis 2017; 64:74-79. [PMID: 28941632 DOI: 10.1016/j.ijid.2017.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/02/2017] [Accepted: 09/05/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Selecting the appropriate antibiotic regimen is extremely important in improving patient outcomes, minimizing antimicrobial resistance, and reducing costs. This study was conducted to evaluate current prescribing practices for empiric antibiotics at the time of admission to the emergency department (ED) and to assess their appropriateness in Lebanon. METHODS A retrospective observational study was conducted at three different Lebanese hospitals between June and December 2016. Adult patients who received antibiotics in the ED during the study period were included. The assessment of antibiotic therapy based on adherence to international guidelines, including the choice of antibiotic, dosing, or both, was considered for analysis. RESULTS A total of 258 patients who had a single diagnosis of an infectious disease were included. Adherence to international guidelines was noted in only 32.6% of cases; the frequency was highest for skin and soft tissue infections (50.0%), followed by urinary tract infections (40%). Among the different antibiotic classes, the highest percentage of drug incompatibility was for β-lactam prescriptions (70.8%). The percentage of incompatibility with guidelines for administered regimens on the basis of drug selection, dosing, or both was 53.4%, 10.3%, and 36.2%, respectively. CONCLUSIONS Inappropriate antibiotic use in the ED is prevalent, and physician adherence to international guidelines for empiric antibiotic prescriptions in the ED remains low. This emphasizes the importance of monitoring the use of antibiotics in the ED, as there is growing concern for antibiotic resistance and healthcare safety.
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Affiliation(s)
- Iqbal Fahs
- Department of Pharmaceutical Sciences, Lebanese International University, Mouseitbeh, Beirut, Lebanon.
| | - Zeina Shrayteh
- Department of Pharmaceutical Sciences, Lebanese International University, Mouseitbeh, Beirut, Lebanon.
| | - Rima Abdulkhalek
- Department of Pharmaceutical Sciences, Lebanese International University, Mouseitbeh, Beirut, Lebanon.
| | - Pascale Salameh
- Faculty of Pharmacy, Lebanese University, Hadath, Lebanon; Faculty of Medicine, Lebanese University, Hadath, Lebanon.
| | - Souheil Hallit
- Faculty of Pharmacy, Lebanese University, Hadath, Lebanon; Faculty of Pharmacy, Saint-Joseph University, Beirut, Lebanon; Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Kaslik, Lebanon; Research Department, Psychiatric Hospital of the Cross, Jal El Dib, Lebanon.
| | - Diana Malaeb
- Department of Pharmaceutical Sciences, Lebanese International University, Mouseitbeh, Beirut, Lebanon.
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Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review. PLoS One 2017; 12:e0183062. [PMID: 28837665 PMCID: PMC5570266 DOI: 10.1371/journal.pone.0183062] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/28/2017] [Indexed: 12/18/2022] Open
Abstract
Background Inappropriate antimicrobial use has been shown to be an important determinant of the emergence of antimicrobial resistance (AMR). Health information technology (HIT) in the form of Computerised Decision Support (CDS) represents an option for improving antimicrobial prescribing and containing AMR. Objectives To evaluate the evidence for CDS in improving quantitative and qualitative measures of antibiotic prescribing in inpatient hospital settings. Methods A systematic literature search was conducted of articles published from inception to 20th December 2014 using eight electronic databases: MEDLINE, EMBASE, PUBMED, Web of Science, CINAHL, Cochrane Library, HMIC and PsychINFo. An updated systematic literature search was conducted from January 1st 2015 to October 1st 2016 using PUBMED. The search strategy used combinations of the following terms: (electronic prescribing) OR (clinical decision support) AND (antibiotic or antibacterial or antimicrobial) AND (hospital or secondary care or inpatient). Studies were evaluated for quality using a 10-point rating scale. Results Eighty-one studies were identified matching the inclusion criteria. Seven outcome measures were evaluated: adequacy of antibiotic coverage, mortality, volume of antibiotic usage, length of stay, antibiotic cost, compliance with guidelines, antimicrobial resistance, and CDS implementation and uptake. Meta-analysis of pooled outcomes showed CDS significantly improved the adequacy of antibiotic coverage (n = 13; odds ratio [OR], 2.11 [95% CI, 1.67 to 2.66, p ≤ 0.00001]). Also, CDS was associated with marginally lowered mortality (n = 20; OR, 0.85 [CI, 0.75 to 0.96, p = 0.01]). CDS was associated with lower antibiotic utilisation, increased compliance with antibiotic guidelines and reductions in antimicrobial resistance. Conflicting effects of CDS on length of stay, antibiotic costs and system uptake were also noted. Conclusions CDS has the potential to improve the adequacy of antibiotic coverage and marginally decrease mortality in hospital-related settings.
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Affiliation(s)
- Christopher E. Curtis
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
| | - Fares Al Bahar
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - John F. Marriott
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Dinh A, Duran C, Davido B, Bouchand F, Deconinck L, Matt M, Sénard O, Guyot C, Levasseur AS, Attal J, Razazi D, Tritz T, Beauchet A, Salomon J, Beaune S, Grenet J. Impact of an antimicrobial stewardship programme to optimize antimicrobial use for outpatients at an emergency department. J Hosp Infect 2017; 97:288-293. [PMID: 28698021 DOI: 10.1016/j.jhin.2017.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 07/04/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Antimicrobial stewardship programmes (ASPs) have been effective in optimizing antibiotic use for inpatients. However, an emergency department's fast-paced clinical setting can be challenging for a successful ASP. AIM In April 2015, an ASP was implemented in our emergency department and we aimed to determine its impact on antimicrobial use for outpatients. METHODS This was a single-centre study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016). For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24h) were evaluated by an infectious disease specialist and an emergency department physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified. FINDINGS Before and after ASP, 34,671 and 35,925 consultations were registered at our emergency department, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (P < 0.0001). There were 484 (62.9%) and 271 (46.7%) (P < 0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliance included unnecessary antimicrobial prescriptions, 197 (25.6%) vs 101 (17.4%) (P<0.0005); inappropriate spectrum, 108 (14.0%) vs 54 (9.3%) (P=0.008); excessive treatment duration, 87 (11.3%) vs 53 (9.1%) (P>0.05); and inappropriate choices, 11 (1.4%) vs 15 (2.6%) (P>0.05). CONCLUSION The implementation of an ASP markedly decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.
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Affiliation(s)
- A Dinh
- Infectious Diseases Unit, Raymond Poincaré University Hospital, Versailles Saint Quentin University, Garches, France.
| | - C Duran
- Infectious Diseases Unit, Raymond Poincaré University Hospital, Versailles Saint Quentin University, Garches, France
| | - B Davido
- Infectious Diseases Unit, Raymond Poincaré University Hospital, Versailles Saint Quentin University, Garches, France
| | - F Bouchand
- Pharmacy Department, Raymond Poincaré University Hospital, Versailles Saint Quentin University, Garches, France
| | - L Deconinck
- Infectious Diseases Unit, Raymond Poincaré University Hospital, Versailles Saint Quentin University, Garches, France
| | - M Matt
- Infectious Diseases Unit, Raymond Poincaré University Hospital, Versailles Saint Quentin University, Garches, France
| | - O Sénard
- Infectious Diseases Unit, Raymond Poincaré University Hospital, Versailles Saint Quentin University, Garches, France
| | - C Guyot
- Emergency Department, Ambroise Paré University Hospital, Versailles Saint Quentin University, Boulogne-Billancourt, France
| | - A-So Levasseur
- Emergency Department, Ambroise Paré University Hospital, Versailles Saint Quentin University, Boulogne-Billancourt, France
| | - J Attal
- Emergency Department, Ambroise Paré University Hospital, Versailles Saint Quentin University, Boulogne-Billancourt, France
| | - D Razazi
- Emergency Department, Ambroise Paré University Hospital, Versailles Saint Quentin University, Boulogne-Billancourt, France
| | - T Tritz
- Pharmacy Department, Ambroise Paré University Hospital, Versailles Saint Quentin University, Garches, France
| | - A Beauchet
- Medical Informatic Department, Ambroise Paré University Hospital, Versailles Saint Quentin University, Garches, France
| | - J Salomon
- Infectious Diseases Unit, Raymond Poincaré University Hospital, Versailles Saint Quentin University, Garches, France
| | - S Beaune
- Emergency Department, Ambroise Paré University Hospital, Versailles Saint Quentin University, Boulogne-Billancourt, France
| | - J Grenet
- Emergency Department, Ambroise Paré University Hospital, Versailles Saint Quentin University, Boulogne-Billancourt, France
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Losier M, Ramsey TD, Wilby KJ, Black EK. A Systematic Review of Antimicrobial Stewardship Interventions in the Emergency Department. Ann Pharmacother 2017; 51:774-790. [PMID: 28539060 DOI: 10.1177/1060028017709820] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND/OBJECTIVE To improve antimicrobial utilization, development and implementation of antimicrobial stewardship programs in the emergency department (ED) has been recommended. The primary objective of this review was to characterize antimicrobial stewardship (AMS) in the ED and to identify interventions that improve patient outcomes or process of care and/or reduce consequences of antimicrobial use. METHODS This study was completed as a systematic review. The following databases were searched from inception through November, 2016: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Web of Science. Randomized controlled trials, nonrandomized controlled trials, controlled and uncontrolled before-and-after studies, interrupted time series studies, and repeated-measures studies evaluating AMS interventions in the ED were included in the review. Studies published in languages other than English were excluded. RESULTS A total of 43 studies meeting inclusion criteria were identified from our search. Patient or provider education and guideline or clinical pathway implementation were the most commonly reported interventions. Few studies reported on audit and feedback, and no study evaluated preauthorization. Impact of interventions showed variable results. Where identified, benefits of AMS interventions primarily included improvement in delivery of care or a decrease in antimicrobial utilization; however, most studies were rated as having unclear or high risk of bias. CONCLUSION AMS interventions in the ED may improve patient care. However, the optimal combination of interventions is unclear. Additional studies with more rigorous design evaluating core components of AMS programs, including prospective audit and feedback are needed.
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Affiliation(s)
- Mia Losier
- 1 Dalhousie University, Halifax, NS, Canada
| | - Tasha D Ramsey
- 1 Dalhousie University, Halifax, NS, Canada.,2 Nova Scotia Health Authority, Halifax, NS, Canada
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Rawson TM, Moore LSP, Hernandez B, Charani E, Castro-Sanchez E, Herrero P, Hayhoe B, Hope W, Georgiou P, Holmes AH. A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately? Clin Microbiol Infect 2017; 23:524-532. [PMID: 28268133 DOI: 10.1016/j.cmi.2017.02.028] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/23/2017] [Accepted: 02/25/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. METHOD PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation. RESULTS Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor. CONCLUSION Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence.
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Affiliation(s)
- T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK.
| | - L S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - B Hernandez
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - E Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - E Castro-Sanchez
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - P Herrero
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - B Hayhoe
- School of Public Health, Imperial College, London, UK
| | - W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
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Current State of Antimicrobial Stewardship in Children's Hospital Emergency Departments. Infect Control Hosp Epidemiol 2017; 38:469-475. [PMID: 28173888 DOI: 10.1017/ice.2017.3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) effectively optimize antibiotic use for inpatients; however, the extent of emergency department (ED) involvement in ASPs has not been described. OBJECTIVE To determine current ED involvement in children's hospital ASPs and to assess beliefs and preferred methods of implementation for ED-based ASPs. METHODS A cross-sectional survey of 37 children's hospitals participating in the Sharing Antimicrobial Resistance Practices collaboration was conducted. Surveys were distributed to ASP leaders and ED medical directors at each institution. Items assessed included beliefs regarding ED antibiotic prescribing, ED prescribing resources, ASP methods used in the ED such as clinical decision support and clinical care guidelines, ED participation in ASP activities, and preferred methods for ED-based ASP implementation. RESULTS A total of 36 ASP leaders (97.3%) and 32 ED directors (86.5%) responded; the overall response rate was 91.9%. Most ASP leaders (97.8%) and ED directors (93.7%) agreed that creation of ED-based ASPs was necessary. ED resources for antibiotic prescribing were obtained via the Internet or electronic health records (EHRs) for 29 hospitals (81.3%). The main ASP activities for the ED included production of antibiograms (77.8%) and creation of clinical care guidelines for pneumonia (83.3%). The ED was represented on 3 hospital ASP committees (8.3%). No hospital ASPs actively monitored outpatient ED prescribing. Most ASP leaders (77.8%) and ED directors (81.3%) preferred implementation of ED-based ASPs using clinical decision support integrated into the EHR. CONCLUSIONS Although ED involvement in ASPs is limited, both ASP and ED leaders believe that ED-based ASPs are necessary. Many children's hospitals have the capability to implement ED-based ASPs via the preferred method: EHR clinical decision support. Infect Control Hosp Epidemiol 2017;38:469-475.
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Kilsdonk E, Peute L, Jaspers M. Factors influencing implementation success of guideline-based clinical decision support systems: A systematic review and gaps analysis. Int J Med Inform 2017; 98:56-64. [DOI: 10.1016/j.ijmedinf.2016.12.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 12/02/2016] [Accepted: 12/04/2016] [Indexed: 01/19/2023]
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Amoxicillin-clavulanic acid prescriptions at the Greater Paris University Hospitals (AP-HP). Med Mal Infect 2016; 47:42-49. [PMID: 27765474 DOI: 10.1016/j.medmal.2016.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 04/01/2016] [Accepted: 09/13/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We aimed to document amoxicillin-clavulanic acid prescription to improve the proper use of antibiotics in hospital settings. We used three criteria: quality of medical charts, adequacy of indications, and adequacy of treatment duration. METHOD This study was designed as a one-day point prevalence survey carried out by antibiotic lead specialists. RESULTS We included 387 prescriptions from 32 hospitals. Immunodeficiency was recorded as a risk factor in 30% of patients. Computerized prescriptions were observed in 79% of cases. The indication was mentioned in 73% of cases and a 48/78-hour re-assessment of the antibiotic therapy was performed in 54% of cases. The antibiotic indication was primarily for pneumonia and was deemed appropriate in 75% of patients. Adult mean treatment duration was 11.1 days. Use of dual combination therapy and/or treatment duration exceeding two weeks accounted for the main reasons for an inappropriate use of antibiotics. Prescriptions recorded as having been made by senior physicians were of the shortest treatment duration (P=0.0163). CONCLUSION Medical charts should be better filled in. Reinforcing the role of senior physicians in supervising antibiotic prescriptions is likely to result in a better control of treatment duration and ultimately in a reduced antibiotic consumption. By reinforcing the collaboration between pharmacists and antibiotic lead specialists, the improvement of computerized prescriptions at hospital level should help better detect the "at risk" prescriptions, namely those exceeding seven days or those combining antibiotics.
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The effectiveness of information technology to improve antimicrobial prescribing in hospitals: A systematic review and meta-analysis. Int J Med Inform 2016; 92:15-34. [DOI: 10.1016/j.ijmedinf.2016.04.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/06/2016] [Accepted: 04/17/2016] [Indexed: 12/19/2022]
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Dickstein Y, Nir-Paz R, Pulcini C, Cookson B, Beović B, Tacconelli E, Nathwani D, Vatcheva-Dobrevska R, Rodríguez-Baño J, Hell M, Saenz H, Leibovici L, Paul M. Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey. Clin Microbiol Infect 2016; 22:812.e9-812.e17. [PMID: 27373529 DOI: 10.1016/j.cmi.2016.06.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 10/24/2022]
Abstract
We aimed to assess the current status of infectious diseases (ID), clinical microbiology (CM) and infection control (IC) staffing in hospitals and to analyse modifiers of staffing levels. We conducted an Internet-based survey of European Society of Clinical Microbiology and Infectious Diseases members and affiliates, collecting data on hospital characteristics, ID management infrastructure, ID/IC-related activities and the ratio of physicians per 100 hospital beds. Regression analyses were conducted to examine factors associated with the physician-bed ratio. Five hundred sixty-seven hospital responses were collected between April and June 2015 from 61 countries, 81.2% (384/473) from Europe. A specialized inpatient ward for ID patients was reported in 58.4% (317/543) of hospitals. Rates of antibiotic stewardship programmes (ASP) and surveillance activities in survey hospitals were high, ranging from 88% to 90% for local antibiotic guidelines and 70% to 82% for programmes monitoring hospital-acquired infections. The median ID/CM/IC physician per 100 hospital beds ratio was 1.12 (interquartile range 0.56-2.13). In hospitals performing basic ASP and IC (including local antibiotic guidelines and monitoring device-related or surgical site infections), the ratio was 1.21 (interquartile range 0.57-2.14). Factors independently associated with higher ratios included compliance with European Union of Medical Specialists standards, smaller hospital size, tertiary-care institution, presence of a travel clinic, beds dedicated to ID and a CM unit. More than half of respondents estimated that additional staffing is needed for appropriate IC or ID management. No standard of physician staffing for ID/CM/IC in hospitals is available. A ratio of 1.21/100 beds will serve as an informed point of reference enabling ASP and infection surveillance.
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Affiliation(s)
- Y Dickstein
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - R Nir-Paz
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - C Pulcini
- Université de Lorraine, Université Paris Descartes, EA 4360 APEMAC and CHU de Nancy, Service de Maladies Infectieuses et Tropicales, Nancy, France
| | - B Cookson
- Division of Infection and Immunity, University College London, Gower Street, London, United Kingdom
| | - B Beović
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia
| | - E Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine I, DZIF Center, Tübingen University Hospital, Tübingen, Germany
| | - D Nathwani
- Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom
| | - R Vatcheva-Dobrevska
- Department of Microbiology and Virology, University Hospital Queen Joanna, Sofia, Bulgaria
| | - J Rodríguez-Baño
- Unidad Clínica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Seville, Spain; Departamento de Medicina, Universidad de Sevilla, Seville, Spain
| | - M Hell
- Department of Hospital Epidemiology and Infection Control, University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - H Saenz
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Basel, Switzerland
| | - L Leibovici
- Medicine E, Rabin Medical Centre, Beilinson Hospital, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - M Paul
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine-Technion, Israel Institute of Technology, Haifa, Israel.
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Cresswell K, Mozaffar H, Shah S, Sheikh A. Approaches to promoting the appropriate use of antibiotics through hospital electronic prescribing systems: a scoping review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 25:5-17. [DOI: 10.1111/ijpp.12274] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kathrin Cresswell
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | - Hajar Mozaffar
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | | | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
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