A Clinical Trial Comparing Physician Prompting With an Unprompted Automated Electronic Checklist to Reduce Empirical Antibiotic Utilization

Abstract

Objective To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record (EHR). Design Random allocation design. Setting Medical intensive care unit (MICU) with high-intensity intensivist coverage at a tertiary care urban medical center. Patients Two hundred ninety-six critically ill patients treated with at least one day of empirical antibiotics. Interventions For one MICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient’s daily rounds. On a separate MICU team, attendings and fellows were trained once to complete an EHR-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued. Measurements and main results Prompting led to a more than 4-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1% vs. 70.0%, P=0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs. 0.83 [0.27], P=0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio 1.14, 95% CI 1.05–1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups. Conclusions Face-to-face prompting was superior to an unprompted EHR-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same MICU two years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable EHR-based checklist.

Approaches to promoting the appropriate use of antibiotics through hospital electronic prescribing systems: a scoping review

“…Most evidence came from specialty settings (such as intensive care, emergency medicine and paediatrics); and from high‐risk patient groups (e.g. those at risk for or with infections); and from tertiary care …”

“…In relation to practitioner performance, the studies reported improved turnaround time for first dose of antibiotic, improved selection of antibiotics (e.g. in line with local protocols), optimal dosing, improved adherence to guidelines/protocols, and a decrease in the total number of antibiotics prescribed . Some studies also reported a reduction in prescribing errors and increased de‐escalation, as well as improved antibiotic sensitivity and increase in sensitivity of surgical site infection detection .…”

Exploring the nurses' role in antibiotic stewardship: A multisite qualitative study of nurses and infection preventionists

“…In particular, proper culturing procedures foster patients’ receipt of indicated targeted therapy; the prompt switch from IV to PO may result in shorter inpatient stays 11 ; accurate drug allergy histories promote optimal therapy 12 ; and antibiotic timeouts have been shown to decrease empiric antibiotic therapy. 13 We were interested in 1) participants’ attitudes regarding the belief that nurses should play a major role in antibiotic stewardship; 2) challenges to nurses’ ability to perform recommended practices; and 3) ways to address identified challenges. We also spoke with IPs, all of whom were trained nurses and held nursing education responsibilities, since they would likely offer a unique perspective on this topic.…”

Sticking to minimum standards: implementing antibiotic stewardship in intensive care

“…Reminder systems and stickers have previously been successfully implemented and have changed healthcare in a variety of areas, such as: reducing immunisation drop out rates, improving use of thromboprophylaxis to prevent deep venous thrombosis and improving documentation of resuscitation status; however, the sustainability of these systems has not been fully established. A compulsory computerised system incorporated into an electronic prescribing system or medical record could potentially improve uptake of a reminder system; however, it is likely that it is the discussion around the use of antimicrobials and the subsequent learning that encourages a sustained change in behaviour . We believe that future research in this area needs also to address the social complexities in the process of appropriate antimicrobial prescribing to find sustainable strategies that also fit clinical workflow for busy staff …”

“…A compulsory computerised system incorporated into an electronic prescribing system or medical record could potentially improve uptake of a reminder system; however, it is likely that it is the discussion around the use of antimicrobials and the subsequent learning that encourages a sustained change in behaviour. 32,33 We believe that future research in this area needs also to address the social complexities in the process of appropriate antimicrobial prescribing to find sustainable strategies that also fit clinical workflow for busy staff. 34 There are multiple explanations for inappropriate prescribing in a busy hospital ward.…”