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Published on: August 30, 2018
Evaluation of an Antimicrobial Stewardship Decision Support for Pediatric Infections
Erin A McGonagle1, Dean J Karavite2, Robert W Grundmeier2
1Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States.
Insights
A new clinical decision support (CDS) tool for emergency departments significantly improved antibiotic prescribing for pediatric pneumonia and urinary tract infections. Providers preferred the CDS system, which also showed a trend toward reduced workload.
Area of Science:
- Health Informatics
- Clinical Pharmacy
- Pediatric Infectious Diseases
Background:
- Clinical decision support (CDS) systems offer potential for enhancing antimicrobial stewardship programs (ASPs) within emergency departments (EDs).
- Optimizing antibiotic prescribing for common pediatric infections like community-acquired pneumonia (CAP) and urinary tract infections (UTI) is crucial for effective ASP implementation.
Purpose of the Study:
- To evaluate the usability and impact of a novel, automated CDS tool designed to improve guideline-adherent antibiotic prescribing for pediatric CAP and UTI in the ED.
- To compare a CDS-enhanced electronic health record order set against a standard order set in simulated ED scenarios.
Main Methods:
- Comparative usability testing was performed using a prototype CDS-enhanced discharge order set and a standard order set.
- Twenty-one ED clinical providers interacted with simulated pediatric CAP and UTI cases, utilizing both order sets.
- Key metrics included task completion, error rates, antibiotic selection accuracy, and provider workload assessed via the NASA-TLX, with iterative refinement of the CDS based on user feedback.
Main Results:
- Providers significantly preferred the CDS-enhanced order set, citing improved explanations for antibiotic choices and access to additional resources (p < 0.001).
- Simulated use of the CDS resulted in a 31% improvement in guideline-adherent prescribing for CAP.
- While not statistically significant (p=0.117), a trend towards reduced provider workload was observed with the CDS system.
Conclusions:
- The developed CDS-enhanced discharge order set is highly preferred by ED providers and enhances the accuracy of antibiotic prescribing.
- The system's optimization for guideline adherence and user acceptability supports its potential for future trials evaluating ED ASPs.
Objectives:
Clinical decision support (CDS) has promise for the implementation of antimicrobial stewardship programs (ASPs) in the emergency department (ED). We sought to assess the usability of a newly developed automated CDS to improve guideline-adherent antibiotic prescribing for pediatric community-acquired pneumonia (CAP) and urinary tract infection (UTI).
Methods:
We conducted comparative usability testing between an automated, prototype CDS-enhanced discharge order set and standard order set, for pediatric CAP and UTI antibiotic prescribing. After an extensive user-centered design process, the prototype CDS was integrated into the electronic health record, used passive activation, and embedded locally adapted prescribing guidelines. Participants were randomized to interact with three simulated ED scenarios of children with CAP or UTI, across both systems. Measures included task completion, decision-making and usability errors, clinical actions (order set use and correct antibiotic selection), as well as objective measures of system usability, utility, and workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). The prototype CDS was iteratively refined to optimize usability and workflow.
Results:
Usability testing in 21 ED clinical providers demonstrated that, compared to the standard order sets, providers preferred the prototype CDS, with improvements in domains such as explanations of suggested antibiotic choices (p < 0.001) and provision of additional resources on antibiotic prescription (p < 0.001). Simulated use of the CDS also led to overall improved guideline-adherent prescribing, with a 31% improvement for CAP. A trend was present toward absolute workload reduction. Using the NASA-TLX, workload scores for the current system were median 26, interquartile ranges (IQR): 11 to 41 versus median 25, and IQR: 10.5 to 39.5 for the CDS system (p = 0.117).
Conclusion:
Our CDS-enhanced discharge order set for ED antibiotic prescribing was strongly preferred by users, improved the accuracy of antibiotic prescribing, and trended toward reduced provider workload. The CDS was optimized for impact on guideline-adherent antibiotic prescribing from the ED and end-user acceptability to support future evaluative trials of ED ASPs.
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