Oral antibiotics at discharge for children with acute osteomyelitis: a rapid cycle improvement project

Abstract

Background Substantial evidence demonstrates comparable cure rates for oral versus intravenous therapy for routine osteomyelitis. Evidence adoption is often slow and in our centre virtually all patients with osteomyelitis were discharged on intravenous therapy. Objective For patients with acute osteomyelitis admitted to the hospital medicine service, we aimed to increase the proportion of cases discharged on oral antibiotics to at least 70%. Methods The setting for our observational time series study was a large academic children’s hospital. The model for improvement and plan-do-study-act cycles were used to test, refine and implement interventions identified through our key driver diagram. Our multifaceted intervention included a shared decision-making tool, an order set in our electronic health record, and education to faculty and trainees. We also included an identify and mitigate intervention to target providers caring for children with osteomyelitis in near-real time and reinforce the evidence-based recommendations. Data were analysed on an annotated g-chart of osteomyelitis cases between patients discharged on intravenous antibiotics. Structured chart review was used to identify treatment failures as well as length of stay and hospital charges in preintervention and postintervention groups. Results The osteomyelitis cases between patients discharged on intravenous antibiotics increased from a median of 0 preintervention to a maximum of 9 cases following our identify and mitigate intervention. The direction and magnitude of successive improvements observed satisfied criteria for special cause variation. Improvement has been sustained for 1 year. Treatment failure and complications were uncommon in preintervention and postintervention phases. No significant differences in length of stay or charges were detected. Conclusions Even for uncommon conditions, rapid and sustained evidence adoption is possible using quality improvement methods.

The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review

“…Most of the studies were conducted in the UK (n = 8/ 32) [35,36,38,44,46,49,57,58] or in the USA (n = 8/ 32) [34,37,43,53,54,[60][61][62]. Other studies were conducted in Canada (n = 6/32) [39-41, 45, 51, 59], Netherlands (n = 1/32) [31], Norway (n = 1/32) [48], South Africa (n = 2/32) [32,33], and Sweden (n = 6/32) [42,47,50,52,55,56] (Table 1).…”

Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis

“…5, 6, 8 -11 Second, although consensus building and the Model for Improvement have been used successfully in a diverse array of circumstances, context is believed to affect organization and practice change, and our project took place in an institution with a longstanding culture of QI. 14,33,34 Third, the magnitude of expected change in inpatient charges could vary substantially across institutions.…”

Clinical Decision Support in the Pediatric Hospital Setting

“…They can also drive the adoption of evidence-based medicine and guideline use, can drive diagnosis recognition, and can create a perceived improvement in quality of care [44][45][46][47]. As with CPOE, order sets may also have unintended consequences (such as defaulting absolute medication dosing for patients that require weight-based dosing) that should be monitored [48].…”