Implementation of a Clinical Decision Support Tool to Improve Antibiotic IV-to-Oral Conversion Rates at a Community Academic Hospital

Abstract

<p><strong>ABSTRACT</strong><br /><strong></strong></p><p><strong>Background:</strong> Antibiotic IV-to-oral (IV–PO) conversion is a key initiative of antimicrobial stewardship programs. Guidelines and education are commonly described interventions to promote IV–PO conversion; however, technological interventions may be more effective in changing practice. <br /><strong></strong></p><p><strong>Objective:</strong> To determine the impact of a clinical decision support (CDS) tool on the adoption and sustainability of an antibiotic IV–PO conversion program at a community-academic hospital.<br /><strong></strong></p><p><strong>Methods:</strong> A quasi-experimental study consisting of 3 phases was conducted. During phase 1, the pre-intervention antibiotic IV–PO conversion rate was determined. During phase 2, the IV–PO conversion policy was updated, education was provided to pharmacists and physicians, and a post-intervention evaluation was conducted. During phase 3, a CDS tool was developed to generate real-time electronic alerts prompting pharmacists to assess antibiotic therapy, and post-intervention audits were performed 1 month, 3 months, and 15 months after implementation of the tool. Pantoprazole IV–PO conversion was assessed during each phase as a non-equivalent dependent variable. The primary outcome was the proportion of patients eligible for IV–PO conversion who were switched to oral therapy. <br /><strong></strong></p><p><strong>Results:</strong> Of 332 patients receiving targeted IV antibiotic therapy during the overall study period, 122 (37%) met the criteria for IV–PO conversion. The phase 2 IV–PO conversion rate of 35% (9/26) was comparable to the pre-intervention rate of 29% (10/35) (p = 0.61). Implementation of the CDS tool significantly increased the conversion rate to 78% (14/18), an increase that was sustained at 3 months (71% [17/24]) and 15 months (74% [14/19]) after implementation (p < 0.05 for all comparisons with phases 1 and 2). Pantoprazole conversion rates were similar across all phases.<br /><strong></strong></p><p><strong>Conclusions:</strong> Implementation of the CDS tool was effective in improving and sustaining antibiotic IV–PO conversion rates and enhancing policy compliance beyond the effects of policy revision and education. Refinement of both the policy and the tool is warranted to maximize adoption of the IV–PO conversion program.</p><p><strong>RÉSUMÉ</strong><br /><strong></strong></p><p><strong>Contexte:</strong> Le passage de l’antibiothérapie par voie intraveineuse (IV) à la voie orale (PO) (IV-PO) est une initiative clé des programmes de gestion des antimicrobiens. On a communément recours à des formations et à des lignes directrices pour encourager le passage d’une voie à l’autre; cependant, les interventions technologiques sont parfois plus efficaces pour favoriser le changement de pratique. <br /><strong></strong></p><p><strong>Objectif :</strong> Déterminer l’impact d’un outil d'aide à la décision clinique (ADC) sur l’adoption et la viabilité d’un programme de conversion IV-PO dans un hôpital universitaire.<br /><strong></strong></p><p><strong>Méthodes :</strong> Une étude quasi expérimentale en trois phases a été menée. La première phase a permis la détermination du taux de conversion IV-PO avant l’intervention. La deuxième phase concernait l’actualisation de la politique de conversion IV-PO, la formation des pharmaciens et médecins et la conduite d’une évaluation après l’intervention. La troisième phase a vu le développement d’un outil ADC qui génère des alertes électroniques en temps réel pour inciter les pharmaciens à évaluer l’antibiothérapie. Des évaluations ont en outre été effectuées 1 mois, 3 mois et 15 mois après la mise en place de l’outil. Le passage de l’administration du pantoprazole par voie intraveineuse (IV) à voie orale (PO) a été évalué au cours de chaque phase comme une variable dépendante non équivalente. Le résultat principal fut la proportion de patients admissibles à la conversion IV–PO qui ont été orientés vers un traitement par voie orale.<br /><strong></strong></p><p><strong>Résultats :</strong> Des 332 patients recevant une antibiothérapie ciblée par voie intraveineuse (IV) pendant l’étude, 122 (37 %) répondaient au critère de la conversion IV–PO. Le taux de conversion IV–PO de 35 % (9/26) de la phase 2 était comparable au taux avant l’intervention de 29 % (10/35)(p = 0,61). La mise en place de l’outil ADC a grandement augmenté le taux de conversion, qui est passé à 78 % (14/18) : une augmentation maintenue trois mois (71 % [17/24]) et 15 mois (74 % [14/19]) après la mise en place (p < 0,05 par rapport aux phases 1 et 2). Les taux de conversion du pantoprazole étaient similaires durant toutes les phases.<br /><strong></strong></p><p><strong>Conclusions :</strong> La mise en place de l’outil ADC a permis d’améliorer et de maintenir les taux de conversion IV–PO et de renforcer le respect des politiques au-delà des effets de la révision des politiques et de la formation à celles-ci. Le perfectionnement de la politique et de l’outil se justifie pour maximiser l’adoption du programme de conversion IV–PO.</p>

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“…Eight studies significantly favored the CDS intervention 25,26,28,29,[31][32][33]35 ; 20% of the studies presented results that favored the CDS intervention without statistical significance 21,23,27 ; 13% of the studies favored the control groups 22,24 ; and 13% of the studies showed that the CDS interventions had no difference compared with the control group. 30,34 One study 24 favors pharmacists' check over CDS; however, this was explained by the authors that the CDS was self-developed and lacks a high level of specificity for drug-drug interactions (DDIs).…”

“…Of the 15 included studies, 5 were randomized controlled trials, 27,30,31,33,34 6 were quasi-experimental, 22,25,28,29,32,35 2 were observational, 23,26 and 2 were cohort studies. 21,24 All of the studies had a control group and all 15 studies were deemed as good quality using the Newcastle-Ottawa Scale.…”

“…Study outcomes were analyzed in three main groups, including quality use of medication, drug and pharmacotherapy safety, and quality of care (►Table 3). Four studies examined the quality use of medications, 23,27,31,35 seven studies looked at drug and pharmacotherapy safety, 22,24,25,29,30,33,34 and five studies evaluated the quality of care. 21,25,26,28,32 One study qualified as both drug and pharmacotherapy safety and quality of care.…”

“…For example, two studies examined a CDS system that calculated the dose of antibiotics for the pharmacist. 23,35 Another study evaluated a CDS system that helped identify medication reconciliation errors. 32 Finally, one study used CDS to examine cost-benefit analysis of medication use.…”

“…Eleven of the 14 studies examined CDS application outside medication verification. 21,23,[27][28][29][30][31][32][33][34][35] Among the 11 studies, 82% presented results that favored the CDS intervention with statistical significance, 21,23,[27][28][29][31][32][33]35 18% of the studies showed that the CDS interventions had no difference compared with the control group, 30,34 and no study favored the control group.…”