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Tverdek FP, Aitken SL, Mulanovich VE, Adachi J, Wu C, Cantu SS, McDaneld PM, Chemaly RF. Implementation of an Automated Antibiotic Time-out at a Comprehensive Cancer Center. Open Forum Infect Dis 2024; 11:ofae235. [PMID: 38798895 PMCID: PMC11127483 DOI: 10.1093/ofid/ofae235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Background Antimicrobial stewardship programs can optimize antimicrobial use and have been federally mandated in all hospitals. However, best stewardship practices in immunocompromised patients with cancer are not well established. Methods An antimicrobial time out, in the form of an email, was sent to physicians caring for hospitalized patients reaching 5 days of therapy for targeted antimicrobials (daptomycin, linezolid, tigecycline, vancomycin, imipenem/cilastatin, meropenem) in a comprehensive cancer center. Physicians were to discontinue the antimicrobial if unnecessary or document a rationale for continuation. This is a quasi-experimental, interrupted time series analysis assessing antimicrobial use during the following times: period 1 (before time-out: January 2007-June 2010) and period 2 (after time-out: July 2010-March/2015). The primary antimicrobial consumption metric was mean duration of therapy. Days of therapy per 1000 patient-days were also assessed. Results Implementation of the time-out was associated with a significant decrease in mean duration of therapy for the following antimicrobials; daptomycin: -0.89 days (95% confidence interval [CI], -1.38 to -.41); linezolid: -0.89 days (95% CI, -1.27 to -.52); meropenem: -0.97 days (95% CI, -1.39 to -.56); tigecycline: -1.41 days (95% CI, -2.19 to -.63); P < .001 for each comparison. Days of therapy/1000 patient-days decreased significantly for meropenem (-43.49; 95% CI, -58.61 to -28.37; P < .001), tigecycline (-35.47; 95% CI, -44.94 to -26.00; P < .001), and daptomycin (-9.47; 95% CI, -15.25 to -3.68; P = .002). Discussion A passive day 5 time-out was associated with reduction in targeted antibiotic use in a cancer center and could potentially be successfully adopted to several settings and electronic health records.
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Affiliation(s)
- Frank P Tverdek
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics, UTHealth McGovern Medical School, Houston, Texas, USA
| | - Victor E Mulanovich
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Adachi
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cai Wu
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry S Cantu
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick M McDaneld
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Impact of Antibiotic Time-Outs in Multidisciplinary ICU Rounds for Antimicrobial Stewardship Program on Patient Survival: A Controlled Before-and-After Study. Crit Care Explor 2023; 5:e0837. [PMID: 36699244 PMCID: PMC9829256 DOI: 10.1097/cce.0000000000000837] [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] [Indexed: 01/27/2023] Open
Abstract
The antimicrobial stewardship program (ASP) is an important quality improvement initiative that is recommended in the ICU. However, the shortage of infectious disease physicians in Japan has led to the need for simpler methods for implementing ASPs. We investigated whether antibiotic time-outs (ATOs) during multidisciplinary rounds as part of an ASP can improve patient survival and reduce the number of days of therapy (DOT) with antibiotics. DESIGN Single-center controlled before-and-after study. SETTING Medical/surgical ICU in a tertiary university medical center in Tokyo, Japan. PATIENTS All patients 16 years old or older admitted consecutively in the ICU between October 2016 and March 2020. INTERVENTIONS An intensivist-driven ICU multidisciplinary round was introduced in October 2016, and ATOs with ICU rounds were implemented in June 2018. ATOs were conducted 3, 7, and 14 days after initiation of antibiotics. MEASUREMENTS AND MAIN RESULTS The primary outcome was the subdistribution hazard ratio (SHR) of survival to hospital discharge compared between multidisciplinary rounds (phase 1) and ATO during multidisciplinary rounds (phase 2) using the multivariable Fine-Gray model. The secondary outcomes were the SHR of survival to ICU discharge and the trends in the DOT with IV antibiotics per 1,000 patient-days between October 2016 and March 2020 by using interrupted time-series analysis. The number of patients in phases 1 and 2 was 777 and 796, respectively. The group that underwent ATO during multidisciplinary rounds showed a significant increase in the survival to hospital discharge in comparison with the multidisciplinary round-only group (SHR, 1.13; 95% CI, 1.02-1.25); however, the SHR of survival to ICU discharge showed no significant intergroup difference. The DOT with total IV antibiotics decreased after ATO implementation (change in intercept, -178.26; 95% CI, -317.74 to -38.78; change in slope, -7.00; 95% CI, -15.77 to 1.78). CONCLUSIONS ATOs during multidisciplinary rounds are associated with improved patient survival and reduced DOT.
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Implementation of a multidisciplinary 48-hour antibiotic timeout in a pediatric population. Infect Control Hosp Epidemiol 2021; 43:253-254. [PMID: 34526159 DOI: 10.1017/ice.2021.347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Stang CR, Jaggi P, Tansmore J, Parson K, Nuss KE, Sapko M, Thompson RZ, Gallup N, Buckingham D, Abdel-Rasoul M, Watson JR. Implementation of a Pharmacist-Led Antimicrobial Time-Out for Medical-Surgery Services in an Academic Pediatric Hospital. J Pediatr Pharmacol Ther 2021; 26:284-290. [PMID: 33833631 PMCID: PMC8021243 DOI: 10.5863/1551-6776-26.3.284] [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: 05/14/2020] [Accepted: 09/22/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This report describes a quality improvement initiative to implement a pharmacist-led antimicrobial time-out (ATO) in a large, freestanding pediatric hospital. Our goal was to reach 90% ATO completion and documentation for eligible patients hospitalized on general pediatric medicine or surgery services. METHODS A multidisciplinary quality improvement team developed an ATO process and electronic documentation tool. Clinical pharmacists were responsible to initiate and document an ATO for pediatric medicine or surgery patients on or before the fifth calendar day of therapy. The quality improvement team educated pharmacists and physicians and provided ATO audit and feedback to the pharmacists. We used statistical process control methods to track monthly rates of ATO completion retrospectively from October 2017 through March 2018 and prospectively from April 2018 through April 2019. Additionally, we retrospectively evaluated the completion of 6 data elements in the ATO note over the final 12-month period of the study. RESULTS Among 647 eligible antimicrobial courses over the 19-month study period, the mean monthly documentation rate increased from 54.6% to 83.5% (p < 0.001). The mean ATO documentation rate increased from 32.8% to 74.2% (p < 0.001) for the pediatric medicine service and from 65.0% to 88.1% for the pediatric surgery service (p = 0.006). Among 302 notes assessed for completeness, 35.8% had all the required data fields completed. A tentative antimicrobial stop date was the data element completed least often (49.3%). CONCLUSIONS We implemented a pharmacist-led ATO, highlighting the role pharmacists play in antimicrobial stewardship. Additional efforts are needed to further increase ATO completion rates and to define treatment duration.
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Subbe CP, Tellier G, Barach P. Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review. BMJ Open 2021; 11:e047446. [PMID: 33441368 PMCID: PMC7812113 DOI: 10.1136/bmjopen-2020-047446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Review available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research. DESIGN Scoping review to map existing evidence and identify gaps for future research. DATA SOURCES PubMed, the Cochrane Library, EMBASE, Trial registers. STUDY SELECTION Eligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures. RESULTS The search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety. CONCLUSIONS Published evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs.
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Affiliation(s)
- Christian Peter Subbe
- School of Medical Sciences, Bangor University, Bangor, UK
- Medicine, Ysbyty Gwynedd, Bangor, UK
| | | | - Paul Barach
- Pediatrics, Wayne State University, Detroit, Michigan, USA
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Paulson CM, Handley JF, Dilworth TJ, Persells D, Prusi RY, Brummitt CF, Torres KM, Skrupky LP. Impact of a Systematic Pharmacist-Initiated Antibiotic Time-Out Intervention for Hospitalized Adults. J Pharm Pract 2020; 35:388-395. [PMID: 33353452 DOI: 10.1177/0897190020980616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Antibiotic time-outs (ATO) are a recommended antimicrobial stewardship action, but data assessing their impact are lacking. This study investigated the impact of a systematic, pharmacist initiated ATO intervention. METHODS This pre-post study included inpatients on hospitalist and intensivist services receiving empiric antibiotics for ≥48 hours. The ATO was initiated by pharmacists after 48 hours of empiric therapy and the outcome was documented including antibiotic indication, plan, and duration. An electronic medical record (EMR) alert facilitated ATO completion and pharmacists and prescribers received education prior to implementation. The primary outcome was EMR documentation of an antibiotic plan by 72 hours. Secondary outcomes included antibiotic utilization and antibiotic therapy modifications by 2 hours. RESULTS 399 patients were included, 199 pre- and 200 post-intervention. The most common indications were pneumonia (32%), intra-abdominal infection (20%) and urinary tract infection (19%), with no between-group differences. EMR documentation of an antibiotic plan significantly improved in the post-intervention group (19% vs. 79%, p<0.0001) as did modifications to antibiotic therapy. The median duration of in-hospital antibiotic therapy was similar between groups (4.0 vs. 4.0 days, p = 0.2499). Approximately 45% of patients in each group received discharge antibiotics and median duration of discharge antibiotic therapy prescribed was reduced (7 vs. 5 days in the pre- and post-intervention groups, respectively; p = 0.0140). DISCUSSION Implementation of pharmacist initiated ATO was associated with improvements in supporting EMR documentation and antibiotic therapy modifications. These findings highlight an important role in which pharmacists can serve as part of a collaborative antibiotic stewardship team.
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Affiliation(s)
- Calley M Paulson
- Department of Pharmacy Services, 577980Advocate Aurora Health, Aurora BayCare Medical Center, Green Bay, WI, USA
| | - Jillian F Handley
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Thomas J Dilworth
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Dan Persells
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Rachael Y Prusi
- Department of Education, University of Chicago Medicine, Chicago, IL, USA
| | | | - Katherine M Torres
- Department of Infectious Disease, Aurora Medical Group, Green Bay, WI, USA
| | - Lee P Skrupky
- Department of Education, 6915Mayo Clinic, Rochester, Minnesota, USA
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Langford BJ, Daneman N, Leung V, Langford DJ. Cognitive bias: how understanding its impact on antibiotic prescribing decisions can help advance antimicrobial stewardship. JAC Antimicrob Resist 2020; 2:dlaa107. [PMID: 34223057 DOI: 10.1093/jacamr/dlaa107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The way clinicians think about decision-making is evolving. Human decision-making shifts between two modes of thinking, either fast/intuitive (Type 1) or slow/deliberate (Type 2). In the healthcare setting where thousands of decisions are made daily, Type 1 thinking can reduce cognitive load and help ensure decision making is efficient and timely, but it can come at the expense of accuracy, leading to systematic errors, also called cognitive biases. This review provides an introduction to cognitive bias and provides explanation through patient vignettes of how cognitive biases contribute to suboptimal antibiotic prescribing. We describe common cognitive biases in antibiotic prescribing both from the clinician and the patient perspective, including hyperbolic discounting (the tendency to favour small immediate benefits over larger more distant benefits) and commission bias (the tendency towards action over inaction). Management of cognitive bias includes encouraging more mindful decision making (e.g., time-outs, checklists), improving awareness of one's own biases (i.e., meta-cognition), and designing an environment that facilitates safe and accurate decision making (e.g., decision support tools, nudges). A basic understanding of cognitive biases can help explain why certain stewardship interventions are more effective than others and may inspire more creative strategies to ensure antibiotics are used more safely and more effectively in our patients.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada.,Toronto East Health Network, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Dale J Langford
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Cluster randomized trial of an antibiotic time-out led by a team-based pharmacist. Infect Control Hosp Epidemiol 2020; 41:1266-1271. [PMID: 32814610 DOI: 10.1017/ice.2020.347] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Antibiotic time-outs (ATOs) have been advocated to improve antibiotic use without dedicated stewardship resources, but their utility is poorly defined. We sought to evaluate the effectiveness of an ATO led by a team-based pharmacist. DESIGN Cluster randomized controlled trial. SETTING Six medicine teams at an academic medical facility. PATIENTS Inpatients who received antibiotics and were cared for by a medicine team. INTERVENTION In phase A (2 months) pharmacist-led ATOs were implemented on 3 medicine teams (ATO-A) while 3 teams maintained usual care (UC-A). In phase B (2 months), ATOs were continued in the ATO group (ATO-B) and ATOs were initiated in the UC group (UC ATO-B). We targeted 2 ATO points: early (<72 hours after antibiotics were initiated) and late (after the early period but ≤5 days after antibiotic initiation). RESULTS In total, 290 ATOs were documented (181 early, 87 late, and 22 subsequent) among 538 admissions. The most common ATO recommendations were narrow therapy (148 of 290), no change (124 of 290), and change to oral (30 of 290). ATO initiation was lower in the UC ATO-B group than in either ATO group (21.8% UC ATO-B vs 69.2% ATO-A and -B). Overall antibiotic use was not different between the groups (P = .51), although intravenous (IV) levofloxacin use decreased in the UC group after ATO implementation (49 DOT/1,000 PD vs 20 DOT/1,000 PD; P = .022). The ratio of oral (PO) to intravenous (IV) DOT was lower in the UC group than in any of the ATO groups (P = .032). We detected no differences in mortality, length of stay, readmission, C. difficile infection, or antibiotic adverse events. CONCLUSIONS Implementation of a pharmacist-led ATO was feasible and well accepted but did not change overall antibiotic use. An ATO may promote increased use of oral antibiotics, but more effective strategies for self-stewardship are needed.
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Thom KA, Tamma PD, Harris AD, Dzintars K, Morgan DJ, Li S, Pineles L, Srinivasan A, Avdic E, Cosgrove SE. Impact of a Prescriber-driven Antibiotic Time-out on Antibiotic Use in Hospitalized Patients. Clin Infect Dis 2020; 68:1581-1584. [PMID: 30517592 DOI: 10.1093/cid/ciy852] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/26/2018] [Indexed: 12/17/2022] Open
Abstract
A multicenter quasi-experimental study of a provider-driven antibiotic "time-out" in 3470 antibiotic courses showed no difference in antibiotic use before and after implementation, but did show a decrease in inappropriate therapy (45% vs 31%, P < .05). Single time-outs without input from antibiotic stewardship teams are insufficient to optimize prescribing.
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Affiliation(s)
- Kerri A Thom
- Department of Epidemiology, University of Maryland School of Medicine, Baltimore
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore
| | - Anthony D Harris
- Department of Epidemiology, University of Maryland School of Medicine, Baltimore
| | | | - Daniel J Morgan
- Department of Epidemiology, University of Maryland School of Medicine, Baltimore.,Veterans Affairs Maryland Health Care System, Baltimore
| | - Shanshan Li
- MassMutual Data Science, Springfield, Massachusetts
| | - Lisa Pineles
- Department of Epidemiology, University of Maryland School of Medicine, Baltimore
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Edina Avdic
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Effect of antibiotic time-outs on modification of antibiotic prescriptions in nursing homes. Infect Control Hosp Epidemiol 2020; 41:635-640. [PMID: 32252841 PMCID: PMC9875214 DOI: 10.1017/ice.2020.75] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Antibiotic overuse and misuse is a common problem in nursing homes. Antibiotic time-out (ATO) interventions have led to improvements in antibiotic uses in hospitals, but their impact in nursing homes remain understudied. OBJECTIVE To evaluate the impact of a stewardship intervention, promoting use of ATOs on the frequency and types of antibiotic change events (ACEs) in nursing homes. DESIGN Controlled before-and-after intervention study. SETTING Nursing homes in Wisconsin and Pennsylvania. METHOD Data on antibiotic prescriptions in 11 nursing homes were collected for 25 months. We categorized ACEs as (1) early discontinuation, (2) class modification, or (3) administration modification. Class modification ACEs were further classified based on whether the change narrowed, expanded, or had no effect on bacterial spectrum coverage. Analyses were performed using a difference-in-difference (DiD) approach. RESULT Of 2,647 antibiotic events initiated in study nursing homes, 376 (14.2%) were associated with an ACE. The overall proportion of ACEs did not significantly differ between intervention and control nursing homes. Early discontinuation ACEs increased in intervention nursing homes (DiD, 2.5%; P = .01), primarily affecting residents initiated on broad-spectrum antibiotics (DiD, 2.9%; P < .01). Class modification ACEs decreased in intervention nursing homes but remained unchanged in control nursing homes. CONCLUSION The impact of an ATO intervention in study nursing homes was mixed with increases in early discontinuation ACEs offset by reductions in class modification ACEs. More research on the potential value of ATO interventions in nursing homes is warranted.
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Mastrianni A, Kulp L, Mapelli E, Sarcevic A. Understanding Digital Checklist Use Through Team Communication. EXTENDED ABSTRACTS ON HUMAN FACTORS IN COMPUTING SYSTEMS. CHI CONFERENCE 2020; 2020. [PMID: 32747878 DOI: 10.1145/3334480.3382817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introducing technology support in a complex, team-based work setting requires a study of teamwork effects on technology use. In this paper, we present our initial analysis of team communications in a trauma resuscitation setting, where we deployed a digital checklist to support trauma team leaders in guiding patient care. By analyzing speech transcripts, checklist interaction logs, and videos of 15 resuscitations, we identified several tensions that arose from the use of a checklist in a team-based process with multi-step tasks. The tensions included incorrect markings of in-progress tasks as completed, failure to mark completed tasks due to missed communications, failure to record planned tasks, and difficulties in recording dynamic values. From these findings, we discuss design implications for checklist design for dynamic, team-based activities.
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Affiliation(s)
| | - Leah Kulp
- Drexel University, Philadelphia, PA, USA
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Abstract
Education in quality improvement (QI) is endorsed by the Association of American Medical Colleges across the spectrum of undergraduate, graduate, and postgraduate training. QI training is also a required component of graduate medical training per the American College of Graduate Medical Education. Despite widespread recognition of the importance of QI education and high levels of trainee involvement in QI as reported by pulmonary and critical care fellowship program directors, significant barriers to the implementation of effective and meaningful QI education during training exist. This creates an opportunity for the promotion of successfully implemented QI programs. Research demonstrates that successful QI educational programs involve the teaching of key QI concepts, participation in QI projects, protected time for QI project development, and institutional support. Using QI models such as the Plan-Do-Study-Act cycle and the Standards for Quality Improvement Reporting Excellence framework for reporting new knowledge about healthcare improvements also enhances both the educational value of the QI project and prospects for wider scholarly dissemination. In this perspective article, three examples of QI projects are discussed that serve to illustrate effective strategies of QI implementation.
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Raybardhan S, Kan T, Chung B, Ferreira D, Bitton M, Shin P, Das P. Nurse Prompting for Prescriber-Led Review of Antimicrobial Use in the Critical Care Unit. Am J Crit Care 2020; 29:71-76. [PMID: 31968088 DOI: 10.4037/ajcc2020272] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Developing a sustainable strategy for prescriber-led review of antimicrobial use in a critical care unit may improve antimicrobial use without the need for additional resources. METHODS Using a quality improvement framework, the researchers created a prompt for prescriber-led review of antimicrobial use. The outcome measure was antimicrobial use (days of therapy per 1000 patient days). The process measure was the proportion of relevant cases for which an antimicrobial prompt was provided. Balancing measures included mortality rate, length of stay, 48-hour readmission rates, and multiple organ dysfunction score. Interrupted time series with segmented regression analysis was used for the outcome measure. RESULTS Process analysis identified critical care unit nurses for antimicrobial use prompting. A standard script was developed to incorporate a days of therapy prompt into nurse rounds, with primed prescriber responses. Before the intervention, monthly antimicrobial use was 804 days of therapy per 1000 patient days, with a positive trend (7.3 days of therapy per 1000 patient days, P < .05). After the intervention, there was an immediate reduction of 217 days of therapy per 1000 patient days (P < .05), with a nonsignificant negative trend, representing a 20% (95% CI, -15% to -25%) reduction. No significant change was noted in use of the control class of medications. The proportion of relevant cases for which an antimicrobial prompt was provided increased from 21% to 48% during the intervention period. Balancing measures were comparable before and after the intervention. CONCLUSIONS Nurse prompting can lead to significant reductions in antimicrobial use, providing a sustainable mechanism for independent antimicrobial reassessment.
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Affiliation(s)
| | - Tiffany Kan
- Tiffany Kan is an antimicrobial stewardship pharmacist
| | - Bonnie Chung
- Bonnie Chung is a critical care unit (CCU) pharmacist
| | | | | | - Phil Shin
- Phil Shin is chief of medicine/critical care, and
| | - Pavani Das
- Pavani Das is division chief of infectious diseases, North York General Hospital, Toronto, Ontario, Canada
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Kuper KM, Hamilton KW. Collaborative Antimicrobial Stewardship: Working with Information Technology. Infect Dis Clin North Am 2019; 34:31-49. [PMID: 31836327 DOI: 10.1016/j.idc.2019.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Information technology (IT) is vitally important to making antimicrobial stewardship a scalable endeavor in modern health care systems. Without IT, many antimicrobial interventions in patient care would be missed. Clinical decision support systems and smartphone apps, either stand-alone or integrated into electronic health records, can all be effective tools to help augment the work of antimicrobial stewardship programs and support the management of infectious diseases in any health care setting.
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Affiliation(s)
- Kristi M Kuper
- Vizient Center for Pharmacy Practice Excellence; DoseMe/Tabula Rasa HealthCare, 228 Strawbridge Drive, Moorestown, NJ 08057, USA
| | - Keith W Hamilton
- Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor South Pavilion, Philadelphia, PA 19426, USA.
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Outcomes of an electronic medical record (EMR)-driven intensive care unit (ICU)-antimicrobial stewardship (AMS) ward round: Assessing the "Five Moments of Antimicrobial Prescribing". Infect Control Hosp Epidemiol 2019; 40:1170-1175. [PMID: 31407651 DOI: 10.1017/ice.2019.218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The primary objective of this study was to examine the impact of an electronic medical record (EMR)-driven intensive care unit (ICU) antimicrobial stewardship (AMS) service on clinician compliance with face-to-face AMS recommendations. AMS recommendations were defined by an internally developed "5 Moments of Antimicrobial Prescribing" metric: (1) escalation, (2) de-escalation, (3) discontinuation, (4) switch, and (5) optimization. The secondary objectives included measuring the impact of this service on (1) antibiotic appropriateness, and (2) use of high-priority target antimicrobials. METHODS A prospective review was undertaken of the implementation and compliance with a new ICU-AMS service that utilized EMR data coupled with face-to-face recommendations. Additional patient data were collected when an AMS recommendation was made. The impact of the ICU-AMS round on antimicrobial appropriateness was evaluated using point-prevalence survey data. RESULTS For the 202 patients, 412 recommendations were made in accordance with the "5 Moments" metric. The most common recommendation made by the ICU-AMS team was moment 3 (discontinuation), which comprised 173 of 412 recommendations (42.0%), with an acceptance rate of 83.8% (145 of 173). Data collected for point-prevalence surveys showed an increase in prescribing appropriateness from 21 of 45 (46.7%) preintervention (October 2016) to 30 of 39 (76.9%) during the study period (September 2017). CONCLUSIONS The integration of EMR with an ICU-AMS program allowed us to implement a new AMS service, which was associated with high clinician compliance with recommendations and improved antibiotic appropriateness. Our "5 Moments of Antimicrobial Prescribing" metric provides a framework for measuring AMS recommendation compliance.
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Antibiotic Stewardship in the PICU: Do We Need to Take a Time Out? Pediatr Crit Care Med 2019; 20:577-578. [PMID: 31162354 DOI: 10.1097/pcc.0000000000001953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES Our aim was to perform an antimicrobial time-out 48-72 hours after commencing therapy in order to achieve a decrease in days of therapy per 1,000 patient days for vancomycin, meropenem, and piperacillin/tazobactam in all PICU patients during an 8-month period. DESIGN This is a pre- and postimplementation quality improvement study. SETTINGS A 30-bed PICU at a tertiary children's hospital. PATIENTS Patients less than 21 years old admitted to the PICU from July 1, 2015, until March 31, 2016, or from July 1, 2016, until March 31, 2017, who received antibiotics for greater than 48 hours were eligible for inclusion. INTERVENTION An antimicrobial time-out was performed after 48-72 hours of antimicrobials for all patients in the PICU during postimplementation. MEASUREMENTS AND MAIN RESULTS The primary outcome measure was days of therapy per 1,000 patient-days for three target antibiotics: vancomycin, meropenem, and piperacillin/tazobactam. Ninety-five patients meeting inclusion criteria were admitted to the PICU during the pre-time-out period and 95 patients during the post-time-out period. The cohort that underwent time-outs had lower days of therapy for vancomycin (81.3 vs 138.1; p = 0.037) and meropenem (34.7 vs 67.1; p = 0.045). Total acquisition cost was 31 % lower for piperacillin/tazobactam and vancomycin and 46% for meropenem post implementation. Time-outs led to antimicrobial duration being defined 63% of the time and deescalation or discontinuation of antimicrobials 29% of the time. CONCLUSIONS A 48-72-hour time-out process in rounds is associated with a reduction in days of therapy for antibiotics commonly used in the PICU and may lead to more appropriate usage. The time-outs are associated with discontinuation, deescalation, or duration being defined, which are key elements of Centers for Disease Control and Prevention-recommended antimicrobial stewardship programs.
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Evaluation of an electronic antimicrobial time-out on antimicrobial utilization at a large health system. Infect Control Hosp Epidemiol 2019; 40:807-809. [PMID: 31099326 DOI: 10.1017/ice.2019.105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We evaluated the impact of an electronic health record based 72-hour antimicrobial time-out (ATO) on antimicrobial utilization. We observed that 6 hours after the ATO, 21% of empiric antimicrobials were discontinued or de-escalated. There was a significant reduction in the duration of antimicrobial therapy but no impact on overall antimicrobial usage metrics.
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Pickens CI, Wunderink RG. Principles and Practice of Antibiotic Stewardship in the ICU. Chest 2019; 156:163-171. [PMID: 30689983 DOI: 10.1016/j.chest.2019.01.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/29/2018] [Accepted: 01/11/2019] [Indexed: 12/29/2022] Open
Abstract
In the face of emerging drug-resistant pathogens and a decrease in the development of new antimicrobial agents, antibiotic stewardship should be practiced in all critical care units. Antibiotic stewardship should be a core competency of all critical care practitioners in conjunction with a formal antibiotic stewardship program (ASP). Prospective audit and feedback, and antibiotic time-outs, are effective components of an ASP in the ICU. As rapid diagnostics are introduced in the ICU, assessment of performance and effect on outcomes will clearly be needed. Disease-specific stewardship for community-acquired pneumonia that relies on clinical pathways may be particularly high-yield. Computerized decision support has the potential to individualize stewardship for specific patients. Finally, infection control and prevention is the cornerstone of every ASP.
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Affiliation(s)
- Chiagozie I Pickens
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Tang SJ, Gupta R, Lee JI, Majid AM, Patel P, Efird L, Loo A, Mazur S, Calfee DP, Archambault A, Jannat-Khah D, Dargar SK, Simon MS. Impact of Hospitalist-Led Interdisciplinary Antimicrobial Stewardship Interventions at an Academic Medical Center. Jt Comm J Qual Patient Saf 2018; 45:207-216. [PMID: 30482662 DOI: 10.1016/j.jcjq.2018.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/17/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes. METHODS A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5). RESULTS Total antibiotic use decreased by 16.8% (p < 0.001), 6.8% (p = 0.08), and 33.0% (p < 0.001) on Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Broad-spectrum antibiotic use decreased by 26.2% (p < 0.001), 7.8% (p = 0.09), and 32.4% (p < 0.001) on the Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Duration of inpatient antibiotic therapy decreased from 4 to 3 days on the Ed+IMPharmDx5 team (p = 0.01). Length of stay for patients who received any antibiotic decreased from 9 to 7 days on the Ed-only team (p < 0.001) and from 9 to 6 days on the Ed+IMPharmDx5 team (p < 0.001). There was no significant change in 30-day readmission to the same facility, transfer to ICU, or in-hospital mortality for any team. CONCLUSION Multidisciplinary, frontline provider-driven approaches to antimicrobial stewardship may contribute to reduced antibiotic use and length of hospital stay.
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22
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Carter EJ, Greendyke WG, Furuya EY, Srinivasan A, Shelley AN, Bothra A, Saiman L, Larson EL. Exploring the nurses' role in antibiotic stewardship: A multisite qualitative study of nurses and infection preventionists. Am J Infect Control 2018; 46:492-497. [PMID: 29395509 PMCID: PMC6495548 DOI: 10.1016/j.ajic.2017.12.016] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is a growing recognition of the need to partner with nurses to promote effective antibiotic stewardship. In this study, we explored the attitudes of nurses and infection preventionists toward 5 nurse-driven antibiotic stewardship practices: 1) questioning the need for urine cultures; 2) ensuring proper culturing technique; 3) recording an accurate penicillin drug allergy history; 4) encouraging the prompt transition from intravenous (IV) to oral (PO) antibiotics; and 5) initiating an antibiotic timeout. METHODS Nine focus groups and 4 interviews with 49 clinical nurses, 5 nurse managers, and 7 infection preventionists were conducted across 2 academic pediatric and adult hospitals. RESULTS Nurse-driven antibiotic stewardship was perceived as an extension of the nurses' role as patient advocate. Three practices were perceived most favorably: questioning the necessity of urinary cultures, ensuring proper culturing techniques, and encouraging the prompt transition from IV to PO antibiotics. Remaining recommendations were perceived to lack relevance or to challenge traditionally held nursing responsibilities. Prescriber and family engagement were noted to assist the implementation of select recommendations. Infection preventionists welcomed the opportunity to assist in providing nurse stewardship education. CONCLUSIONS Nurses appeared to be enthusiastic about participating in antibiotic stewardship. Efforts to engage nurses should address knowledge needs and consider the contexts in which nurse-driven antibiotic stewardship occurs.
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Affiliation(s)
- Eileen J Carter
- Columbia University School of Nursing, New York, NY; Department of Nursing, NewYork-Presbyterian, New York, NY.
| | - William G Greendyke
- Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, NY; Department of Medicine, Columbia University Medical Center, New York, NY
| | - E Yoko Furuya
- Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, NY; Department of Medicine, Columbia University Medical Center, New York, NY
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Alexa N Shelley
- Columbia University School of Nursing, New York, NY; Department of Nursing, NewYork-Presbyterian, New York, NY
| | - Aditi Bothra
- Columbia University Mailman School of Public Health, New York, NY
| | - Lisa Saiman
- Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, NY; Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Elaine L Larson
- Columbia University School of Nursing, New York, NY; Columbia University Mailman School of Public Health, New York, NY
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23
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Abstract
Appropriate antimicrobial therapy is essential to ensuring positive patient outcomes. Inappropriate or suboptimal utilization of antibiotics can lead to increased length of stay, multidrug-resistant infections, and mortality. Critically ill intensive care patients, particularly those with severe sepsis and septic shock, are at risk of antibiotic failure and secondary infections associated with incorrect antibiotic use. Through the initiation of active empiric antibiotic therapy based upon local susceptibilities, daily evaluation of signs and symptoms of infection and narrowing of antibiotic therapy when feasible, providers can streamline the treatment of common intensive care unit (ICU) infections. Optimizing antibiotic dosing through prolonged infusions can be beneficial in intensive care populations with altered pharmacokinetics. Antimicrobial stewardship teams can assist ICU providers in managing and implementing these tactics. This review will discuss the current literature on antibiotic use in the ICU applying antimicrobial stewardship strategies. Based upon the most recent evidence, ICUs would benefit from employing empiric guidelines for antibiotic use, collecting appropriate specimens and implementing molecular diagnostics, optimizing the dosing of antibiotics, and reducing the duration of total therapy. These strategies for antibiotic use have the potential to enhance patient care while preventing adverse outcomes.
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Affiliation(s)
- Maureen Campion
- 1 Division of Infectious Disease, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gail Scully
- 1 Division of Infectious Disease, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
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A Timeout on the Antimicrobial Timeout: Where Does It Stand and What Is Its Future? CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0146-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
OBJECTIVE To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.
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Arditi C, Rège‐Walther M, Durieux P, Burnand B. Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2017; 7:CD001175. [PMID: 28681432 PMCID: PMC6483307 DOI: 10.1002/14651858.cd001175.pub4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review. OBJECTIVES To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component. DATA COLLECTION AND ANALYSIS Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach. MAIN RESULTS We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.
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Affiliation(s)
- Chantal Arditi
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineLausanneSwitzerlandCH‐1005
| | - Myriam Rège‐Walther
- Lausanne University HospitalInstitute of Social and Preventive MedicineBiopôle 2Route de la Corniche 10LausanneSwitzerland1010
| | - Pierre Durieux
- Georges Pompidou European HospitalDepartment of Public Health and Medical Informatics20 rue LeblancParisFrance75015
| | - Bernard Burnand
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineLausanneSwitzerlandCH‐1005
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Doernberg SB, Chambers HF. Antimicrobial Stewardship Approaches in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:513-534. [PMID: 28687210 DOI: 10.1016/j.idc.2017.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antimicrobial stewardship programs aim to monitor, improve, and measure responsible antibiotic use. The intensive care unit (ICU), with its critically ill patients and prevalence of multiple drug-resistant pathogens, presents unique challenges. This article reviews approaches to stewardship with application to the ICU, including the value of diagnostics, principles of empirical and definitive therapy, and measures of effectiveness. There is good evidence that antimicrobial stewardship results in more appropriate antimicrobial use, shorter therapy durations, and lower resistance rates. Data demonstrating hard clinical outcomes, such as adverse events and mortality, are more limited but encouraging; further studies are needed.
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Affiliation(s)
- Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA.
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, Room 3400, Building 30, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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Checking the lists: A systematic review of electronic checklist use in health care. J Biomed Inform 2017; 71S:S6-S12. [DOI: 10.1016/j.jbi.2016.09.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/29/2016] [Accepted: 09/08/2016] [Indexed: 11/23/2022]
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Implementation of an antibiotic checklist increased appropriate antibiotic use in the hospital on Aruba. Int J Infect Dis 2017; 59:14-21. [PMID: 28347851 DOI: 10.1016/j.ijid.2017.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/03/2017] [Accepted: 03/16/2017] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES No interventions have yet been implemented to improve antibiotic use on Aruba. In the Netherlands, the introduction of an antibiotic checklist resulted in more appropriate antibiotic use in nine hospitals. The aim of this study was to introduce the antibiotic checklist on Aruba, test its effectiveness, and evaluate the possibility of implementing this checklist outside the Netherlands. METHODS The antibiotic checklist includes seven quality indicators (QIs) that define appropriate antibiotic use. It applies to adult patients with a suspected bacterial infection, treated with intravenous antibiotics. The primary endpoint was the QI sum score, calculated by the patient's sum of performed checklist-items divided by the total number of QIs that applied to that specific patient. Outcomes before and after the introduction of the checklist were compared. RESULTS The percentage of patients with a QI sum score ≥50% increased significantly during the intervention (n=173) compared to baseline (n=150) (odds ratio 3.67, p<0.001). However, performance did not improve on each individual QI. The checklist was used in 63.3% of the eligible patients. CONCLUSIONS The introduction of the antibiotic checklist increased appropriate antibiotic use on Aruba. Additional initiatives are necessary for further improvement per QI. These results suggest that the antibiotic checklist could be used internationally.
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Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543. [PMID: 28178770 PMCID: PMC6464541 DOI: 10.1002/14651858.cd003543.pub4] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. OBJECTIVES To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. MAIN RESULTS This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. AUTHORS' CONCLUSIONS We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.
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Affiliation(s)
- Peter Davey
- University of DundeePopulation Health SciencesMackenzie BuildingKirsty Semple WayDundeeScotlandUKDD2 4BF
| | - Charis A Marwick
- University of DundeePopulation Health Sciences Division, Medical Research InstituteDundeeUK
| | - Claire L Scott
- NHS Education for ScotlandScottish Dental Clinical Effectiveness ProgrammeDundee Dental Education CentreSmall's WyndDundeeUKDD1 4HN
| | - Esmita Charani
- Imperial College LondonNIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial ResistanceDu Cane RoadLondonUKW12 OHS
| | - Kirsty McNeil
- University of DundeeSchool of Medicine147 Forth CrescentDundeeScotlandUKDD2 4JA
| | - Erwin Brown
- No affiliation31 Park CrescentFrenchayBristolUKBS16 1NZ
| | - Ian M Gould
- Aberdeen Royal InfirmaryDepartment of Medical MicrobiologyForesterhillAberdeenUKAB25 2ZN
| | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Susan Michie
- University College LondonResearch Department of Primary Care and Population HealthUpper Floor 3, Royal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61-e111. [PMID: 27418577 PMCID: PMC4981759 DOI: 10.1093/cid/ciw353] [Citation(s) in RCA: 1981] [Impact Index Per Article: 247.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.
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Affiliation(s)
- Andre C. Kalil
- Departmentof Internal Medicine, Division of Infectious Diseases,
University of Nebraska Medical Center,
Omaha
| | - Mark L. Metersky
- Division of Pulmonary and Critical Care Medicine,
University of Connecticut School of Medicine,
Farmington
| | - Michael Klompas
- Brigham and Women's Hospital and Harvard Medical School
- Harvard Pilgrim Health Care Institute, Boston,
Massachusetts
| | - John Muscedere
- Department of Medicine, Critical Care Program,Queens University, Kingston, Ontario,
Canada
| | - Daniel A. Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine,
University of California, San
Diego
| | - Lucy B. Palmer
- Department of Medicine, Division of Pulmonary Critical Care and Sleep
Medicine, State University of New York at Stony
Brook
| | - Lena M. Napolitano
- Department of Surgery, Division of Trauma, Critical Care and Emergency
Surgery, University of Michigan, Ann
Arbor
| | - Naomi P. O'Grady
- Department of Critical Care Medicine, National
Institutes of Health, Bethesda
| | - John G. Bartlett
- Johns Hopkins University School of Medicine,
Baltimore, Maryland
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari
de Bellvitge, Bellvitge Biomedical Research Institute, Spanish Network for Research in
Infectious Diseases, University of Barcelona,
Spain
| | - Ali A. El Solh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep
Medicine, University at Buffalo, Veterans Affairs Western New
York Healthcare System, New York
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious
Diseases, EVK Herne and Augusta-Kranken-Anstalt
Bochum, Germany
| | - Paul D. Fey
- Department of Pathology and Microbiology, University of
Nebraska Medical Center, Omaha
| | | | - Marcos I. Restrepo
- Department of Medicine, Division of Pulmonary and Critical Care
Medicine, South Texas Veterans Health Care System and University
of Texas Health Science Center at San Antonio
| | - Jason A. Roberts
- Burns, Trauma and Critical Care Research Centre, The
University of Queensland
- Royal Brisbane and Women's Hospital,
Queensland
| | - Grant W. Waterer
- School of Medicine and Pharmacology, University of
Western Australia, Perth,
Australia
| | - Peggy Cruse
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Shandra L. Knight
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Jan L. Brozek
- Department of Clinical Epidemiology and Biostatistics and Department of
Medicine, McMaster University, Hamilton,
Ontario, Canada
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Baysari MT, Jackson N, Ramasamy S, Santiago P, Xiong J, Westbrook J, Omari A, Day RO. Exploring sub-optimal use of an electronic risk assessment tool for venous thromboembolism. APPLIED ERGONOMICS 2016; 55:63-69. [PMID: 26995037 DOI: 10.1016/j.apergo.2016.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 12/03/2015] [Accepted: 01/11/2016] [Indexed: 06/05/2023]
Abstract
International guidelines and consensus groups recommend using a risk assessment tool (RAT) to assess Venous Thromboembolism (VTE) risk prior to the prescription of prophylaxis. We set out to examine how an electronic RAT was being used (i.e. if by the right clinician, at the right time, for the right purpose) and to identify factors influencing utilization of the RAT. A sample of 112 risk assessments was audited and 12 prescribers were interviewed. The RAT was used as intended in only 40 (35.7%) cases (i.e. completed by a doctor within 24 h of admission, prior to the prescription of prophylaxis). We identified several reasons for sub-optimal use of the RAT, including beliefs about the need for a RAT, poor awareness of the tool, and poor RAT design. If a user-centred approach had been adopted, it is likely that a RAT would not have been implemented or that problematic design issues would have been identified.
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Affiliation(s)
- Melissa T Baysari
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia.
| | - Nicola Jackson
- Vascular Medicine, St Vincent's Hospital, Sydney, Australia
| | - Sheena Ramasamy
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Priscila Santiago
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Juan Xiong
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Johanna Westbrook
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Abdullah Omari
- Vascular Medicine, St Vincent's Hospital, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW Medicine, UNSW, Sydney, Australia
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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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Pollack LA, van Santen KL, Weiner LM, Dudeck MA, Edwards JR, Srinivasan A. Antibiotic Stewardship Programs in U.S. Acute Care Hospitals: Findings From the 2014 National Healthcare Safety Network Annual Hospital Survey. Clin Infect Dis 2016; 63:443-9. [PMID: 27199462 DOI: 10.1093/cid/ciw323] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/14/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The National Action Plan to Combat Antibiotic Resistant Bacteria calls for all US hospitals to improve antibiotic prescribing as a key prevention strategy for resistance and Clostridium difficile Antibiotic stewardship programs (ASPs) will be important in this effort but implementation is not well understood. METHODS We analyzed the 2014 National Healthcare Safety Network Annual Hospital Survey to describe ASPs in US acute care hospitals as defined by the Center for Disease Control and Prevention's (CDC) Core Elements for Hospital ASPs. Univariate analyses were used to assess stewardship infrastructure and practices by facility characteristics and a multivariate model determined factors associated with meeting all ASP core elements. RESULTS Among 4184 US hospitals, 39% reported having an ASP that met all 7 core elements. Although hospitals with greater than 200 beds (59%) were more likely to have ASPs, 1 in 4 (25%) of hospitals with less than 50 beds reported achieving all 7 CDC-defined core elements of a comprehensive ASP. The percent of hospitals in each state that reported all seven elements ranged from 7% to 58%. In the multivariate model, written support (adjusted relative risk [RR] 7.2 [95% confidence interval [CI], 6.2-8.4]; P < .0001) or salary support (adjusted RR 1.5 [95% CI, 1.4-1.6]; P < .0001) were significantly associated with having a comprehensive ASP. CONCLUSIONS Our findings show that ASP implementation varies across the United States and provide a baseline to monitor progress toward national goals. Comprehensive ASPs can be established in facilities of any size and hospital leadership support for antibiotic stewardship appears to drive the establishment of ASPs.
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Affiliation(s)
- Lori A Pollack
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katharina L van Santen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lindsey M Weiner
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Margaret A Dudeck
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jonathan R Edwards
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51-77. [PMID: 27080992 PMCID: PMC5006285 DOI: 10.1093/cid/ciw118] [Citation(s) in RCA: 1826] [Impact Index Per Article: 228.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022] Open
Abstract
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
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Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lilian M Abbo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco
| | - Audrey N Schuetz
- Department of Medicine, Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Houston
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Yngve T Falck-Ytter
- Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Neil O Fishman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia
| | | | | | - Pamela A Lipsett
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Preeti N Malani
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor
| | - Larissa S May
- Department of Emergency Medicine, University of California, Davis
| | - Gregory J Moran
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Sylmar
| | | | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Missouri
| | - Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew H Samore
- Department of Veterans Affairs and University of Utah, Salt Lake City
| | - Susan K Seo
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
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Chevrier R, Child K, Shah S, Best T, Hopkins P. Baseline observation of performance and inter-professional utilisation of institutional hospital electronic technologies to access and communicate key clinical information in a central london teaching hospital critical care unit. Intensive Care Med Exp 2015. [PMCID: PMC4798012 DOI: 10.1186/2197-425x-3-s1-a864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chaves NJ, Ingram RJ, MacIsaac CM, Buising KL. Sticking to minimum standards: implementing antibiotic stewardship in intensive care. Intern Med J 2015; 44:1180-7. [PMID: 25070720 DOI: 10.1111/imj.12539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 07/20/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND In Australia, antimicrobial stewardship programmes are a compulsory component of hospital accreditation. Good documentation around anti-microbial prescribing aids communication and can improve prescribing practice in environments with multiple decision makers. AIM This study aims to develop and implement an intervention to improve antimicrobial prescribing practice in a 24-bed intensive care unit in a tertiary referral adult hospital. METHODS We conducted a four-phase (observation, reflection, implementation, evaluation) prospective collaborative before-after quality improvement study. Baseline audits and surveys of antimicrobial prescribing practices identified barriers to and enablers of good prescribing practice. A customised intervention was then implemented over 6 weeks and included a yellow medication record sticker, quarterly education sessions and intensive care unit-specific empiric antimicrobial prescribing guidelines. Post-implementation, the effects were monitored by serial antimicrobial prescribing audits for 1 year. The primary outcomes were clear documentation of the start date, the planned stop date or review date and the indication for an antibiotic. These were all considered the 'minimum standards' for an antimicrobial prescription on the medication record. RESULTS Documentation of minimum standards specifically addressed by the sticker improved (start date (72% to 90%, P < 0.001), stop date (16% to 63%, P < 0.001), antimicrobial indication documented on medication chart (58% to 83%, P < 0.01)). Overall, adherence to all three minimum standards (start date, stop date and indication) improved from 41/306 (13%) to 306/492 (63%) (P < 0.001). One-year post-implementation, the yellow sticker had become embedded into daily practice. CONCLUSION A systematic approach to quality improvement combined with the implementation of a tailored, multi-faceted intervention can improve antimicrobial prescribing practices.
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Affiliation(s)
- N J Chaves
- Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia
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Abstract
OBJECTIVE To determine the point prevalence of drug-induced hypotension episodes in critically ill patients, to assess the episodes resulting from error, and to describe how episodes are treated. DESIGN Multicenter observational, 24-hour snapshot study. SETTING Forty-seven ICUs in 27 institutions located in the United States, Canada, and Singapore. PATIENTS A total of 688 ICU patients were evaluated. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were included in the study if they had an episode of hypotension in the 24 hours prior to the clinical pharmacists' evaluation. The definition for a hypotensive episode is either a systolic blood pressure less than 90 mm Hg or a decrease in systolic blood pressure of 30 mm Hg over a 2-hour period. Each episode of unintentional hypotension was assessed for suspected drug-related causes. When a drug-related cause was suspected, an objective assessment tool, the modified Kramer, was used to determine causality. A score of at least "possible" was considered drug induced, referred to as a "drug-related hazardous condition." A drug-related hazardous condition is the temporal gap (intermediate stage) between the identification of an adverse drug reaction and the subsequent onset of drug-induced injury, known as an "adverse drug event." Drug-induced episodes were evaluated for medication errors and treatment. One hundred fifty-eight patients experienced 204 hypotensive episodes that were considered unintentional and drug related. Common drugs implicated included propofol, fentanyl, metoprolol, lorazepam, hydralazine, and furosemide. A total of 54 episodes (26.5%) resulted from medication errors. Common error types were improper dose/quantity (46%) and prescribing (25%). A total of 56.9% episodes were treated. CONCLUSIONS Many hypotensive episodes in the ICU are drug related and require treatment. A substantial portion of these episodes result from errors and are therefore preventable. This presents opportunities to improve prescribing including optimizing drug dosing to avoid possible patient harm from drug-induced hypotension.
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Pah AR, Rasmussen-Torvik LJ, Goel S, Greenland P, Kho AN. Big Data: What Is It and What Does It Mean for Cardiovascular Research and Prevention Policy. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0424-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Thongprayoon C, Harrison AM, O'Horo JC, Berrios RAS, Pickering BW, Herasevich V. The Effect of an Electronic Checklist on Critical Care Provider Workload, Errors, and Performance. J Intensive Care Med 2014; 31:205-12. [PMID: 25392010 DOI: 10.1177/0885066614558015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 09/11/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE The strategy used to improve effective checklist use in intensive care unit (ICU) setting is essential for checklist success. This study aimed to test the hypothesis that an electronic checklist could reduce ICU provider workload, errors, and time to checklist completion, as compared to a paper checklist. METHODS This was a simulation-based study conducted at an academic tertiary hospital. All participants completed checklists for 6 ICU patients: 3 using an electronic checklist and 3 using an identical paper checklist. In both scenarios, participants had full access to the existing electronic medical record system. The outcomes measured were workload (defined using the National Aeronautics and Space Association task load index [NASA-TLX]), the number of checklist errors, and time to checklist completion. Two independent clinician reviewers, blinded to participant results, served as the reference standard for checklist error calculation. RESULTS Twenty-one ICU providers participated in this study. This resulted in the generation of 63 simulated electronic checklists and 63 simulated paper checklists. The median NASA-TLX score was 39 for the electronic checklist and 50 for the paper checklist (P = .005). The median number of checklist errors for the electronic checklist was 5, while the median number of checklist errors for the paper checklist was 8 (P = .003). The time to checklist completion was not significantly different between the 2 checklist formats (P = .76). CONCLUSION The electronic checklist significantly reduced provider workload and errors without any measurable difference in the amount of time required for checklist completion. This demonstrates that electronic checklists are feasible and desirable in the ICU setting.
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Affiliation(s)
- Charat Thongprayoon
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
| | - Andrew M Harrison
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA Medical Scientist Training Program, Mayo Clinic, Rochester, MN, USA
| | - John C O'Horo
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ronaldo A Sevilla Berrios
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brian W Pickering
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Vitaly Herasevich
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
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Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:480. [PMID: 25405992 PMCID: PMC4281952 DOI: 10.1186/s13054-014-0480-6] [Citation(s) in RCA: 188] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.
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The authors reply. Crit Care Med 2014; 42:e310. [PMID: 24633119 DOI: 10.1097/ccm.0000000000000167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU? Curr Opin Crit Care 2014; 19:448-52. [PMID: 23995122 DOI: 10.1097/mcc.0b013e328364d538] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Failed opportunities to reduce morbidity and mortality occur when evidence-based therapies are not fully implemented in clinical practice. We reviewed the recent literature on implementation strategies in the intensive care unit, with particular attention to antibiotic therapy. RECENT FINDINGS Emphasis in implementation science has shifted to new models that focus more on direct, point-of-care interaction with providers as opposed to an administrative or top-down approach. Prompting physicians to use a multifaceted checklist was associated with a decrease in severity-adjusted mortality and length of stay. The majority of the benefit appears to correlate with decreased use of empirical antibiotics. A subsequent study demonstrated that face-to-face prompting regarding empirical antibiotics alone was still superior to an electronic checklist, but that long-term changes in use of empirical antibiotics resulted from the previous prompting study. Other studies demonstrate that checklists result in enhanced communication between caregivers, which may be a major explanation for their benefit. SUMMARY Newer implementation strategies focused on real-time, point-of-care interventions have been associated with greater impact. The most common of these new interventions is use of checklists. Greater checklist use has led to the realization that a prompting or forcing function is required for optimal benefit.
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Influence of an infectious diseases specialist on ICU multidisciplinary rounds. Crit Care Res Pract 2014; 2014:307817. [PMID: 24860663 PMCID: PMC4016826 DOI: 10.1155/2014/307817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/02/2014] [Accepted: 04/03/2014] [Indexed: 12/12/2022] Open
Abstract
Objective. To ascertain the influence of a physician infectious diseases specialist (IDS) on antibiotic use in a medical/surgical intensive care unit. Method. Over a 5-month period, the antibiotic regimens ordered by the ICU multidisciplinary team were studied. The days of antibiotic therapy (DOT) when management decisions included an IDS were compared to DOT in the absence of an IDS. The associated treatment expense was calculated. Results. Prior to multidisciplinary rounds (MDRs), 79-80% of the patients were receiving one or more antibiotic. IDS participation occurred in 61 multidisciplinary rounding sessions. There were 384 patients who before MDRs had orders for 669 days of antimicrobial therapy (DOT). After MDRs, the antimicrobial DOT were reduced to 511 with a concomitant cost saving of $3772. There were 51 MDR sessions that occurred in the absence of the IDS. There were 352 patients who before MDRs had orders for 593 DOT. After MDRs, the DOT were reduced to 572 with a cost savings of $727. The results were normalized by number of patients evaluated with statistically greater reductions when MDRs included the IDS. In addition, the number of rounding sessions with a reduction in DOT was greater with the participation of the IDS. Conclusion. The addition of an IDS to multidisciplinary ICU patient rounds resulted in a reduction in antibiotic DOT and attendant drug expense.
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Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543. [PMID: 23633313 DOI: 10.1002/14651858.cd003543.pub3] [Citation(s) in RCA: 351] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The first publication of this review in Issue 3, 2005 included studies up to November 2003. This update adds studies to December 2006 and focuses on application of a new method for meta-analysis of interrupted time series studies and application of new Cochrane Effective Practice and Organisation of Care (EPOC) Risk of Bias criteria to all studies in the review, including those studies in the previously published version. The aim of the review is to evaluate the impact of interventions from the perspective of antibiotic stewardship. The two objectives of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second support professionals and patients to reduce unnecessary use and minimize collateral damage. OBJECTIVES To estimate the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial-resistant pathogens or Clostridium difficile infection and their impact on clinical outcome. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE from 1980 to December 2006 and the EPOC specialized register in July 2007 and February 2009 and bibliographies of retrieved articles. The main comparison is between interventions that had a restrictive element and those that were purely persuasive. Restrictive interventions were implemented through restriction of the freedom of prescribers to select some antibiotics. Persuasive interventions used one or more of the following methods for changing professional behaviour: dissemination of educational resources, reminders, audit and feedback, or educational outreach. Restrictive interventions could contain persuasive elements. SELECTION CRITERIA We included randomized clinical trials (RCTs), controlled clinical trials (CCT), controlled before-after (CBA) and interrupted time series studies (ITS). Interventions included any professional or structural interventions as defined by EPOC. The intervention had to include a component that aimed to improve antibiotic prescribing to hospital inpatients, either by increasing effective treatment or by reducing unnecessary treatment. The results had to include interpretable data about the effect of the intervention on antibiotic prescribing or microbial outcomes or relevant clinical outcomes. DATA COLLECTION AND ANALYSIS Two authors extracted data and assessed quality. We performed meta-regression of ITS studies to compare the results of persuasive and restrictive interventions. Persuasive interventions advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive interventions put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. We standardized the results of some ITS studies so that they are on the same scale (percent change in outcome), thereby facilitating comparisons of different interventions. To do this, we used the change in level and change in slope to estimate the effect size with increasing time after the intervention (one month, six months, one year, etc) as the percent change in level at each time point. We did not extrapolate beyond the end of data collection after the intervention. The meta-regression was performed using standard weighted linear regression with the standard errors of the coefficients adjusted where necessary. MAIN RESULTS For this update we included 89 studies that reported 95 interventions. Of the 89 studies, 56 were ITSs (of which 4 were controlled ITSs), 25 were RCT (of which 5 were cluster-RCTs), 5 were CBAs and 3 were CCTs (of which 1 was a cluster-CCT).Most (80/95, 84%) of the interventions targeted the antibiotic prescribed (choice of antibiotic, timing of first dose and route of administration). The remaining 15 interventions aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. Reliable data about impact on antibiotic prescribing data were available for 76 interventions (44 persuasive, 24 restrictive and 8 structural). For the persuasive interventions, the median change in antibiotic prescribing was 42.3% for the ITSs, 31.6% for the controlled ITSs, 17.7% for the CBAs, 3.5% for the cluster-RCTs and 24.7% for the RCTs. The restrictive interventions had a median effect size of 34.7% for the ITSs, 17.1% for the CBAs and 40.5% for the RCTs. The structural interventions had a median effect of 13.3% for the RCTs and 23.6% for the cluster-RCTs. Data about impact on microbial outcomes were available for 21 interventions but only 6 of these also had reliable data about impact on antibiotic prescribing.Meta-analysis of 52 ITS studies was used to compare restrictive versus purely persuasive interventions. Restrictive interventions had significantly greater impact on prescribing outcomes at one month (32%, 95% confidence interval (CI) 2% to 61%, P = 0.03) and on microbial outcomes at 6 months (53%, 95% CI 31% to 75%, P = 0.001) but there were no significant differences at 12 or 24 months. Interventions intended to decrease excessive prescribing were associated with reduction in Clostridium difficile infections and colonization or infection with aminoglycoside- or cephalosporin-resistant gram-negative bacteria, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis. Meta-analysis of clinical outcomes showed that four interventions intended to increase effective prescribing for pneumonia were associated with significant reduction in mortality (risk ratio 0.89, 95% CI 0.82 to 0.97), whereas nine interventions intended to decrease excessive prescribing were not associated with significant increase in mortality (risk ratio 0.92, 95% CI 0.81 to 1.06). AUTHORS' CONCLUSIONS The results show that interventions to reduce excessive antibiotic prescribing to hospital inpatients can reduce antimicrobial resistance or hospital-acquired infections, and interventions to increase effective prescribing can improve clinical outcome. This update provides more evidence about unintended clinical consequences of interventions and about the effect of interventions to reduce exposure of patients to antibiotics. The meta-analysis supports the use of restrictive interventions when the need is urgent, but suggests that persuasive and restrictive interventions are equally effective after six months.
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Affiliation(s)
- Peter Davey
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK.
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Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev 2009; 2009:CD001096. [PMID: 19588323 PMCID: PMC4171964 DOI: 10.1002/14651858.cd001096.pub2] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'. OBJECTIVES To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. SEARCH STRATEGY We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. SELECTION CRITERIA Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. MAIN RESULTS Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). AUTHORS' CONCLUSIONS Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.
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Affiliation(s)
- Kaveh G Shojania
- Director, University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Room D474, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5
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