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Abstract
Background Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline.
Methods Using the ‘Fit between Individuals, Task and Technology (FITT)’ framework, we identified barriers that prevent
clinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED’s clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive’s user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment.
Results Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)).
Conclusion Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.
- guidelines
- communication
- emergency department
Data availability statement
Data are available upon reasonable request.
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Data availability statement
Data are available upon reasonable request.
Footnotes
Handling editor Alex Novak
Twitter @NickStarkMD
Contributors MTV contributed to the design and development of the clinical guidelines and the E*Drive digital tool described in the manuscript. She also performed the chart review and assisted with data analysis. She also wrote the manuscript and prepared it for submission. HS contributed to the design and development of the clinical guidelines and the E*Drive digital tool described in the manuscript. She also wrote and edited the manuscript. SS contributed to the study design, data analysis, chart review and figure design. He also edited the manuscript. He is a member of California ACEP. NP and NS contributed to the design of the clinical guidelines and the design, development and deployment of the E*Drive digital tool described in the manuscript. They also edited the manuscript. NS is a member of California ACEP. DE contributed to the design of the clinical surveys described in the manuscript. He also edited the manuscript. JD and JB contributed to the design of the clinical guidelines and the E*Drive digital tool described in the manuscript. They also edited the manuscript. They are members of California ACEP. MS contributed to the design of the E*Drive digital tool described in the manuscript. She also contributed to the development of the guidelines. She is a member of California ACEP. CP contributed to the design, development and deployment of the E*Drive digital tool as well as the clinical guidelines described in the manuscript. He also edited the manuscript. He is a member of California ACEP. CP is the guarantor and accepts full responsibility for the work and/or conduct of the study, had access to the data, and controlled the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests CP is a consultant for FujiFilm SonoSite and BrainScope.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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