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Gupta J, Zipursky AR, Pirie J, Freire G, Karin A, Bohn MK, Adeli K, Ostrow O. Coming in Hot: A quality improvement approach to improving care of febrile infants. Paediatr Child Health 2024; 29:135-143. [PMID: 38827372 PMCID: PMC11141599 DOI: 10.1093/pch/pxad070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 10/09/2023] [Indexed: 06/04/2024] Open
Abstract
Background and Objectives Significant practice variation exists in managing young infants with fever. Quality improvement strategies can aid in risk stratification and standardization of best care practices, along with a reduction of unnecessary interventions. The aim of this initiative was to safely reduce unnecessary admissions, antibiotics, and lumbar punctures (LPs) by 10% in low-risk, febrile infants aged 29 to 90 days presenting to the emergency department (ED) over a 12-month period. Methods Using the Model for Improvement, a multidisciplinary team developed a multipronged intervention: an updated clinical decision tool (CDT), procalcitonin (PCT) adoption, education, a feedback tool, and best practice advisory (BPA) banner. Outcome measures included the proportion of low-risk infants that were admitted, received antibiotics, and had LPs. Process measures were adherence to the CDT and percentage of PCT ordered. Missed bacterial infections and return visits were balancing measures. The analysis was completed using descriptive statistics and statistical process control methods. Results Five hundred and sixteen patients less than 90 days of age were included in the study, with 403 patients in the 29- to 90-day old subset of primary interest. In the low-risk group, a reduction in hospital admissions from a mean of 24.1% to 12.0% and a reduction in antibiotics from a mean of 15.2% to 1.3% was achieved. The mean proportion of LPs performed decreased in the intervention period from 7.5% to 1.8%, but special cause variation was not detected. Adherence to the CDT increased from 70.4% to 90.9% and PCT was ordered in 92.3% of cases. The proportion of missed bacterial infections was 0.3% at baseline and 0.5% in the intervention period while return visits were 6.7% at baseline and 5.0% in the intervention period. Conclusions The implementation of a quality improvement strategy, including an updated evidence-based CDT for young infant fever incorporating PCT, safely reduced unnecessary care in low-risk, febrile infants aged 29 to 90 days in the ED. Purpose To develop and implement a multipronged improvement strategy including an evidence-based CDT utilizing PCT to maximize value of care delivered to well-appearing, febrile infants presenting to EDs.
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Affiliation(s)
- Joel Gupta
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Amy R Zipursky
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Pirie
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Gabrielle Freire
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Amir Karin
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary Kathryn Bohn
- Department of Laboratory Medicine, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Khosrow Adeli
- Department of Laboratory Medicine, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Olivia Ostrow
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Kucherov V, Russell T, Smith J, Zimmermann S, Johnston EK, Rana MS, Hill E, Ho CP, Pohl HG, Varda BK. Antibiotic Overtreatment of Presumed Urinary Tract Infection Among Children with Spina Bifida. J Pediatr 2024; 272:114092. [PMID: 38734134 DOI: 10.1016/j.jpeds.2024.114092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/26/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE To identify factors associated with overtreatment of presumed urinary tract infection (UTI) among children with spina bifida using such criteria. STUDY DESIGN A retrospective review of children with spina bifida (age <21 years) evaluated in the Emergency Department (ED) at a single institution was performed. Patients with a urinalysis (UA) performed who were reliant on assisted bladder emptying were included. The primary outcome was overtreatment, defined as receiving antibiotics for presumed UTI but ultimately not meeting spina bifida UTI criteria (≥2 urologic symptoms plus pyuria and urine culture growing >100k CFU/mL). The primary exposure was whether the components of the criteria available at the time of the ED visit (≥2 urologic symptoms plus pyuria) were met when antibiotics were initiated. RESULTS Among 236 ED encounters, overtreatment occurred in 80% of cases in which antibiotics were initiated (47% of the entire cohort). Pyuria with <2 urologic symptoms was the most important factor associated with overtreatment (OR 9.6). Non-Hispanic White race was associated with decreased odds of overtreatment (OR 0.3). CONCLUSIONS Overtreatment of presumed UTI among patients with spina bifida was common. Pyuria, which is not specific to UTI in this population, was the main driver of overtreatment. Symptoms are a cornerstone of UTI diagnosis among children with spina bifida, should be collected in a standardized manner, and considered in a decision to treat.
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Affiliation(s)
- Victor Kucherov
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Teresa Russell
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jacob Smith
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Sally Zimmermann
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Elena K Johnston
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Md Sohel Rana
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Elaise Hill
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Christina P Ho
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Hans G Pohl
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Briony K Varda
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC.
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Fésüs A, Matuz M, Papfalvi E, Hambalek H, Ruzsa R, Tánczos B, Bácskay I, Lekli I, Illés Á, Benkő R. Evaluation of the Diagnosis and Antibiotic Prescription Pattern in Patients Hospitalized with Urinary Tract Infections: Single-Center Study from a University-Affiliated Hospital. Antibiotics (Basel) 2023; 12:1689. [PMID: 38136723 PMCID: PMC10741002 DOI: 10.3390/antibiotics12121689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/21/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
UTIs (urinary tract infections) are common bacterial infections with a non-negligible hospitalization rate. The diagnosis of UTIs remains a challenge for prescribers and a common source of misdiagnosis. This retrospective observational study aimed to evaluate whether recorded diagnosis by clinicians and empirical antibiotic therapy met the EAU (European Association of Urology) guideline in patients hospitalized with UTI. The study was conducted at an internal medicine unit of a tertiary care medical center in Hungary. The diagnosis was assessed based on clinical presentation, physical examination, and laboratory (including microbiological) results, considering all the potential risk factors. Diagnosis was considered misdiagnosis when not confirmed by clinical presentation or clinical signs and symptoms. Evaluation of empirical antibiotic therapy was performed only for confirmed UTIs. Empirical treatment was considered guideline-adherent when complying with the relevant recommendations. Out of 185 patients, 41.6% failed to meet EAU-based UTI diagnosis criteria, of which 27.6% were misdiagnosed and 14.1% were ABU (asymptomatic bacteriuria). The diagnosis of urosepsis recorded at admission (9.7%, 18/185) was not confirmed either by clinical or microbiological tests in five (5/18) cases. The initial empirical therapies for UTI showed a relatively low rate (45.4%) of guideline adherence regarding agent selection. The most common guideline-non-adherent therapies were combinations with metronidazole (16.7%). Dosage appropriateness assessments showed a guideline adherence rate of 36.1%, and underdosing due to high body weight was common (9.3%). Overall (agent, route of administration, dose, duration) guideline adherence was found to be substantially low (10.2%). We found a relatively high rate of misdiagnosed UTIs. Written protocols on the ward may be crucial in reducing misdiagnosis and in optimizing antibiotic use.
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Affiliation(s)
- Adina Fésüs
- Department of Pharmacology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary; (A.F.); (B.T.); (I.L.)
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary;
- Institute of Healthcare Industry, University of Debrecen, H-4032 Debrecen, Hungary
| | - Mária Matuz
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
- Central Pharmacy, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
| | - Erika Papfalvi
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
- Department of Emergency Medicine, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
| | - Helga Hambalek
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
| | - Roxána Ruzsa
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
| | - Bence Tánczos
- Department of Pharmacology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary; (A.F.); (B.T.); (I.L.)
| | - Ildikó Bácskay
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary;
- Institute of Healthcare Industry, University of Debrecen, H-4032 Debrecen, Hungary
| | - István Lekli
- Department of Pharmacology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary; (A.F.); (B.T.); (I.L.)
| | - Árpád Illés
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary;
| | - Ria Benkő
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
- Central Pharmacy, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
- Department of Emergency Medicine, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
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Hernandez S, Gilson AM, Gassman M, Ford JH. Piloting an opioid callback program in community pharmacies. J Am Pharm Assoc (2003) 2023; 63:1796-1802. [PMID: 37574197 PMCID: PMC11165930 DOI: 10.1016/j.japh.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Although opioid prescribing has recently trended downward, opioid-related overdoses and deaths have drastically increased. Community pharmacists are accessible health care providers who are well positioned to disseminate information on opioid safety and to educate and counsel on medication use, managing adverse events, and proper medication disposal. Patient callbacks facilitate appropriate medication usage. We developed an opioid callback program that provides a framework for pharmacists to follow up with patients with an opioid prescription. OBJECTIVES This study aimed to (1) describe the development of the opioid callback initiative and (2) report results from a pilot test in 2 community pharmacies. METHODS The opioid callback process and data collection forms were collaboratively developed with community pharmacists at each site. Data recorded on the opioid callback forms were descriptively analyzed and chi-square test of independence explored differences by pain durations related to opioid disposal, security, and safety. Participating pharmacy staff were interviewed to identify facilitators and barriers to implementation, as well as opportunities for improvement. RESULTS Forty-one opioid callbacks were attempted and 36 were completed (87.8%). Pharmacists were statistically significantly more likely to discuss naloxone with patients with chronic pain (89.5%) than those with acute pain (46.2%). Pharmacists reported that the program successfully raised awareness of opioid disposal opportunities and safe opioid practices, including storage and naloxone ownership. They expressed patients' willingness to answer questions and appreciation for the extra attention and care. CONCLUSION Community pharmacists are well positioned to address the opioid crisis as access points for medication questions, opioid safety education, opioid disposal, naloxone, and medications for people with an opioid use disorder. This study presents a proof of concept for a pharmacist-led opioid callback program. Expansion could help inform patients about how to use opioids safely, how to treat an opioid overdose, and where to dispose of unused medications.
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Affiliation(s)
- Sara Hernandez
- University of Wisconsin – Madison, School of Pharmacy – Social and Administrative Sciences Division, Madison, WI 53705
| | - Aaron M. Gilson
- University of Wisconsin – Madison, School of Pharmacy – Social and Administrative Sciences Division, Madison, WI 53705
| | - Michele Gassman
- University of Wisconsin – Madison, School of Pharmacy – Social and Administrative Sciences Division, Madison, WI 53705
| | - James H. Ford
- University of Wisconsin – Madison, School of Pharmacy – Social and Administrative Sciences Division, Madison, WI 53705
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