Developing Clinical Decision Support within a Commercial Electronic Health Record System to Improve Antimicrobial Prescribing in the Neonatal ICU

Abstract

SummaryObjective: To develop and implement a clinical decision support (CDS) tool to improve antibiotic prescribing in neonatal intensive care units (NICUs) and to evaluate user acceptance of the CDS tool. Methods: Following sociotechnical analysis of NICU prescribing processes, a CDS tool for empiric and targeted antimicrobial therapy for healthcare-associated infections (HAIs) was developed and incorporated into a commercial electronic health record (EHR) in two NICUs. User logs were reviewed and NICU prescribers were surveyed for their perceptions of the CDS tool. Results: The CDS tool aggregated selected laboratory results, including culture results, to make treatment recommendations for common clinical scenarios. From July 2010 to May 2012, 1,303 CDS activations for 452 patients occurred representing 22% of patients prescribed antibiotics during this period. While NICU clinicians viewed two culture results per tool activation, prescribing recommendations were viewed during only 15% of activations. Most (63%) survey respondents were aware of the CDS tool, but fewer (37%) used it during their most recent NICU rotation. Respondents considered the most useful features to be summarized culture results (43%) and antibiotic recommendations (48%). Discussion: During the study period, the CDS tool functionality was hindered by EHR upgrades, implementation of a new laboratory information system, and changes to antimicrobial testing methodologies. Loss of functionality may have reduced viewing antibiotic recommendations. In contrast, viewing culture results was frequently performed, likely because this feature was perceived as useful and functionality was preserved. Conclusion: To improve CDS tool visibility and usefulness, we recommend early user and information technology team involvement which would facilitate use and mitigate implementation challenges. Developing Clinical Decision Support within a Commercial Electronic BackgroundInfants in the neonatal intensive care unit (NICU) are at high risk of developing healthcare-associated infections (HAIs), including those caused by multidrug-resistant organisms [1]. Late onset sepsis, meningitis, and necrotizing enterocolitis are clinical scenarios common to all NICUs, but can be caused by pathogens with antimicrobial susceptibility patterns unique to local settings [2][3][4]. Thus, initiation of empiric broad-spectrum antimicrobial therapy, prior to availability of culture results, should be based on local epidemiology as well as the clinical history of individual infants. Optimizing empiric use of antibiotics and then adjusting to targeted therapy when informative culture results are available are recommended clinical practices [5][6][7]. However, as signs and symptoms of sepsis in infants are often non-specific, the practice of initiating and continuing broad-spectrum antibiotics despite negative cultures can lead to overuse of antibiotics with subsequent increases in toxicity, resistance, and healthcare expenditures [8,9]. We have previously reported that approximat...

The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review

“…Fifteen studies assessed aspects of the use and implementation of CDS, such as user satisfaction,[ 2 , 33 , 52 , 67 – 69 ] user uptake,[ 37 , 48 , 59 , 68 ] and acceptance of CDS recommendations. [ 38 , 46 , 50 , 51 , 59 , 70 , 71 , 72 ] Six studies showed improvement of user uptake and satisfaction.…”

“…In a study by Hum and co-workers, 37% of those eligible used CDS while working in a Neonatal Intensive Care Unit. [ 68 ] Sintchenko and co-workers [ 73 ] showed a low level of CDS adoption as only one third of CDS recommendations were accepted, while Evans and co-workers showed that 37% of CDS recommendations were accepted.…”

Combining expert knowledge and knowledge automatically acquired from electronic data sources for continued ontology evaluation and improvement

“…acute bronchitis)[18, 19] or single clinical location (i.e. intensive care or primary care)[14, 20–24], and ADSSs that use their own terminology and cannot be transferred to other EHR systems [15, 18, 25, 26]. To improve the interoperability of future portable ADSSs, we developed and published a bacterial clinical infectious diseases ontology (BCIDO)[16].…”