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Sapozhnikov J, Albarillo FS, Pulia MS. Optimizing Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin North Am 2024; 42:443-459. [PMID: 38641398 DOI: 10.1016/j.emc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.
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Affiliation(s)
- Julia Sapozhnikov
- Medical Science Liaison, Karius Inc, 975 Island Drive, Redwood City, CA 94065, USA
| | - Fritzie S Albarillo
- Department of Medicine, Infectious Diseases Division, Loyola University Medical Center, Loyola University Medical Center is 2160 South First Avenue, Maywood, IL 60153, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
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Abtahi H, Shahmoradi L, Amini S, Gholamzadeh M. Design and evaluation of a Mobile-Based decision support system to enhance lung transplant candidate assessment and management: knowledge translation integrated with clinical workflow. BMC Med Inform Decis Mak 2023; 23:145. [PMID: 37528441 PMCID: PMC10394935 DOI: 10.1186/s12911-023-02249-6] [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: 04/15/2022] [Accepted: 07/27/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Accurate and timely decision-making in lung transplantation (LTx) programs is critical. The main objective of this study was to develop a mobile-based evidence-based clinical decision support system (CDSS) to enhance the management of lung transplant candidates. METHOD An iterative participatory software development process was employed to develop the ImamLTx CDSS. This study was accomplished in three phases. First, required data and standard clinical workflow were identified according to the literature review and expert consensus. Second, a rule-based knowledge-based CDSS application was developed. In the third phase, this CDSS was evaluated. The evaluation was done using the standard Post-Study System Usability Questionnaire (PSSUQ 18.3) and ten usability heuristics factors for user interface design. RESULTS According to expert consensus, fifty-five data items were identified as essential data sets using the Content Validity Ratio (CVR) formula. By integrating information flow in clinical practices with clinical protocols, more than 450 rules and 500 knowledge statements were extracted. This CDSS provides clinical decision support on an Android platform regarding inclusion and exclusion referral criteria, optimum transplant time based on the type of lung disease, findings of initial assessment, and the overall evaluation of lung transplant candidates. Evaluation results showed high usability ratings due to the fact provided accuracy and sensitivity of this lung transplant CDSS with the information quality domain receiving the highest score (6.305 from 7). CONCLUSION Through a stepwise approach, the ImamLTx CDSS was developed to provide LTx programs with timely patient data access via a mobile platform. Our results suggest integration with existing workflow to support clinical decision-making and provide patient-specific recommendations.
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Affiliation(s)
- Hamidreza Abtahi
- Pulmonary and Critical Care Medicine Department, Thoracic Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Shahmoradi
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
- Halal Research Center of IRI, FDA, Tehran, Iran
| | - Shahideh Amini
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Marsa Gholamzadeh
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran.
- Ph.D. in Medical Informatics, Health Information Management and Medical informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran.
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Lee AH, McEvoy DS, Stump T, Stevens R, Deng H, Rubins D, Filbin M, Hayes BD, Rhee C, Dutta S. Implementation of an Electronic Alert to Improve Timeliness of Second Dose Antibiotics for Patients With Suspected Serious Infections in the Emergency Department: A Quasi-Randomized Controlled Trial. Ann Emerg Med 2023; 81:485-491. [PMID: 36669909 DOI: 10.1016/j.annemergmed.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE Delays in the second dose of antibiotics in the emergency department (ED) are associated with increased morbidity and mortality in patients with serious infections. We analyzed the influence of clinical decision support to prevent delays in second doses of broad-spectrum antibiotics in the ED. METHODS We allocated adult patients who received cefepime or piperacillin/tazobactam in 9 EDs within an integrated health care system to an electronic alert that reminded ED clinicians to reorder antibiotics at the appropriate interval vs usual care. The primary outcome was a median delay in antibiotic administration. Secondary outcomes were rates of intensive care unit (ICU) admission, hospital mortality, and hospital length of stay. We included a post hoc secondary outcome of frequency of major delay (>25% of expected interval for second antibiotic dose). RESULTS A total of 1,113 ED patients treated with cefepime or piperacillin/tazobactam were enrolled in the study, of whom 420 remained under ED care when their second dose was due and were included in the final analysis. The clinical decision support tool was associated with reduced antibiotic delays (median difference 35 minutes, 95% confidence interval [CI], 5 to 65). There were no differences in ICU transfers, inpatient mortality, or hospital length of stay. The clinical decision support tool was associated with decreased probability of major delay (absolute risk reduction 13%, 95% CI, 6 to 20). CONCLUSIONS The implementation of a clinical decision support alert reminding clinicians to reorder second doses of antibiotics was associated with a reduction in the length and frequency of antibiotic delays in the ED. There was no effect on the rates of ICU transfers, inpatient mortality, or hospital length of stay.
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Affiliation(s)
- Andy H Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | | | | | | | - Hao Deng
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - David Rubins
- Department of Medicine, Brigham and Women's Hospital, Boston, MA; Mass General Brigham Digital Health, Boston, MA; Harvard Medical School, Boston, MA
| | - Michael Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Bryan D Hayes
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Chanu Rhee
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA; Harvard Medical School, Boston, MA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Mass General Brigham Digital Health, Boston, MA; Harvard Medical School, Boston, MA
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Albahar F, Abu-Farha RK, Alshogran OY, Alhamad H, Curtis CE, Marriott JF. Healthcare Professionals’ Perceptions, Barriers, and Facilitators towards Adopting Computerised Clinical Decision Support Systems in Antimicrobial Stewardship in Jordanian Hospitals. Healthcare (Basel) 2023; 11:healthcare11060836. [PMID: 36981493 PMCID: PMC10047934 DOI: 10.3390/healthcare11060836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/24/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
Understanding healthcare professionals’ perceptions towards a computerised decision support system (CDSS) may provide a platform for the determinants of the successful adoption and implementation of CDSS. This cross-sectional study examined healthcare professionals’ perceptions, barriers, and facilitators to adopting a CDSS for antibiotic prescribing in Jordanian hospitals. This study was conducted among healthcare professionals in Jordan’s two tertiary and teaching hospitals over four weeks (June–July 2021). Data were collected in a paper-based format from senior and junior prescribers and non-prescribers (n = 254) who agreed to complete a questionnaire. The majority (n = 184, 72.4%) were aware that electronic prescribing and electronic health record systems could be used specifically to facilitate antibiotic use and prescribing. The essential facilitator made CDSS available in a portable format (n = 224, 88.2%). While insufficient training to use CDSS was the most significant barrier (n = 175, 68.9%). The female providers showed significantly lower awareness (p = 0.006), and the nurses showed significantly higher awareness (p = 0.041) about using electronic prescribing and electronic health record systems. This study examined healthcare professionals’ perceptions of adopting CDSS in antimicrobial stewardship (AMS) and shed light on the perceived barriers and facilitators to adopting CDSS in AMS, reducing antibiotic resistance, and improving patient safety. Furthermore, results would provide a framework for other hospital settings concerned with implementing CDSS in AMS and inform policy decision-makers to react by implementing the CDSS system in Jordan and globally. Future studies should concentrate on establishing policies and guidelines and a framework to examine the adoption of the CDSS for AMS.
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Affiliation(s)
- Fares Albahar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan
- Correspondence:
| | - Rana K. Abu-Farha
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, P.O. Box 541350, Amman 11937, Jordan
| | - Osama Y. Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan
| | - Hamza Alhamad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan
| | - Chris E. Curtis
- Department of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - John F. Marriott
- Department of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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Khadem TM, Ergen HJ, Salata HJ, Andrzejewski C, McCreary EK, Abdel Massih RC, Bariola JR. Impact of Clinical Decision Support System Implementation at a Community Hospital with an Existing Tele-Antimicrobial Stewardship Program. Open Forum Infect Dis 2022; 9:ofac235. [PMID: 35836746 PMCID: PMC9274440 DOI: 10.1093/ofid/ofac235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background Lack of on-site antimicrobial stewardship expertise is a barrier to establishing successful programs. Tele-antimicrobial stewardship programs (TASPs) utilizing a clinical decision support system (CDSS) can address these challenges. Methods This interrupted time series study reports the impact of CDSS implementation (February 2020) within an existing TASP on antimicrobial usage in a community hospital. Segmented regression analysis was used to assess differences in antimicrobial usage from January 2018 through December 2021. Pre- and post-CDSS frequencies of intravenous vs oral antimicrobials, time to optimal therapy (TTOT), pharmacist efficiency (number of documented interventions per month), and percentage of hospitalized patients receiving antimicrobials were compared with descriptive statistics. Results Implementation of a CDSS into an existing TASP was associated with an immediate 11% reduction in antimicrobial usage (level change, P < .0001). Antimicrobial usage was already trending down by 0.25% per month (pre-CDSS slope, P < .0001) and continued to trend down at a similar rate after implementation (post-CDSS slope, P = .0129). Frequency of use of select oral agents increased from 38% to 57%. Median TTOT was 1 day faster (2.9 days pre-CDSS vs 1.9 days post-CDSS). On average, pharmacists documented 2.2-fold more interventions per month (198 vs 90) and patients received 1.03 fewer days of antimicrobials per admission post-CDSS. Conclusions Implementation of a CDSS within an established TASP at a community hospital resulted in decreased antimicrobial usage, higher rates of oral usage, faster TTOT, and improved pharmacist efficiency.
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Affiliation(s)
- Tina M. Khadem
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- UPMC Centralized Health-System Antimicrobial Stewardship Efforts, Pittsburgh PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | | | | | | | - Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | - Rima C. Abdel Massih
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- UPMC Centralized Health-System Antimicrobial Stewardship Efforts, Pittsburgh PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
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