BACKGROUND AND OBJECTIVES: National guidelines recommend a 5- to 7-day course of antibiotics for most skin and soft-tissue infections (SSTIs). Our aim was to increase the percentage of pediatric patients receiving 5 to 7 days of oral antibiotics for SSTIs in our pediatric urgent care clinics (UCCs) from 60% to 75% by December 31, 2021. METHODS: We performed cause-and-effect analysis and surveyed UCC providers to uncover reasons for hesitation with short antibiotic courses for SSTIs. Plan- Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers and addressed providers’ concerns. PDSA cycle 2 modified the electronic health record to display antimicrobial prescription sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older in UCCs with a final diagnosis of SSTIs. We used a Shewhart control chart to identify special cause variations. RESULTS: After completing our PDSA cycles, we found that the percentage of children receiving 5 to 7 days of oral antibiotics for SSTIs exceeded 85%. The improvement was sustained over multiple months. There was no increase in the proportion of patients returning to the UCCs with an SSTI diagnosis within 14 days. CONCLUSIONS: By addressing primary drivers uncovered through quality improvement methodology, we shortened the antibiotic course for children seen in our UCCs with SSTIs. Outpatient antimicrobial stewardship programs may apply similar methods to other diagnoses to further improve duration of antibiotic prescriptions.
ObjectivesAcute otitis media (AOM) is the most common reason for pediatric antibiotic prescriptions. The 2013 American Academy of Pediatrics' AOM guidelines recommend observation for nonsevere AOM. Our aim was to increase the percentage safety-net antibiotic prescription (SNAP) offered to patients 6 months of age or older diagnosed with AOM in 2 pediatric emergency departments (EDs) from a baseline of 0.5% to 15% in 20 months.MethodsThis is a quality improvement study at a quaternary pediatric medical center with 2 locations, both with EDs. A random chart review revealed that 27.5% of patients diagnosed with AOM in the ED would qualify for a SNAP, but only 0.5% were offered it. Quality improvement interventions were designed to improve safety-net antibiotic prescribing. Both EDs conducted multiple interventions, including algorithm development, provider education, and electronic medical record aids. The primary outcome measure was the percentage of patients offered a SNAP for AOM.ResultsA total of 8226 children 6 months of age or older were diagnosed with AOM in our 2 EDs during the 20-month intervention period. The percentage offered a SNAP increased at both EDs. One ED had a single shift in the mean to 7.9%, whereas the other had 2 shifts in the mean, an initial shift to 5.1% and a second to 7.3%. Providers consistently used the algorithm and electronic medical record aids.ConclusionsSafety-net antibiotic prescriptions in conjunction with parent education was effective in reducing the use of immediate antibiotic prescriptions in children with AOM in 2 pediatric EDs. Offering a SNAP can reduce unnecessary use of antibiotics, which in turn may decrease antibiotic-related adverse events and antibiotic resistance.
Background Acute otitis media (AOM) is the most common diagnosis for which antibiotics are prescribed in pediatrics. National guidelines recommend offering a safety net antibiotic prescription (SNAP) to select patients, to be filled if symptoms worsen or do not improve within 48-72 hours. However, clinicians continue to prescribe immediate antibiotics for most cases of AOM. Our goal was to increase the percentage of eligible patients diagnosed with AOM in our pediatric urgent care (PUC) clinics who are offered a SNAP from our baseline of 7.7% to 40% within nine months. Methods A multidisciplinary team of PUC clinicians, an Infectious Diseases physician, and a data analyst, used quality improvement (QI) methodology to identify barriers to offering SNAP (Figure 1). Patients without chronic ear conditions were considered eligible for SNAP if they had no or mild otalgia for < 48 hours, fever < 39oC, no otorrhea, and for patients ≤ 24 months old, if they had only unilateral AOM. We analyzed all encounters of patients ≥ 6 months old with a discharge diagnosis of AOM from three PUC clinics during baseline (October 2020 – September 2021) and study (October 2021 – March 2022) periods. Interventions included clinician education, standardized discharge instructions, electronic health record updates to improve documentation, and educational flyers for clinicians and families. Our outcome measure was the percentage of eligible encounters during which SNAP was offered. Our process measure was the percentage of AOM encounters in which SNAP eligibility was documented. Our balancing measure was the percentage of patients returning with AOM symptoms within 14 days. Results We reviewed 12,502 encounters from October 2020 through March 2022. At baseline, clinicians documented SNAP eligibility in 5.5% of AOM encounters and offered SNAP to 7.7% of eligible patients. By March 2022, clinicians documented SNAP eligibility in 58.9% of AOM encounters and offered SNAP to 40.7% of eligible patients (Figure 2). There was no change in our balancing measure. UCL: Upper control limit. LCL: Lower control limit. Conclusion Using QI methodology, we increased the percentage of eligible patients with AOM who were offered SNAP, reducing antibiotic exposure in PUC clinics. Efforts are ongoing to further improve this process. Disclosures Brian R. Lee, PhD, MPH, CDC: Grant/Research Support|Merck: Grant/Research Support.
Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. Children with SSTIs often receive > 7 days of antibiotics, although current guidelines recommend 5-7 days for most diagnoses. At Children’s Mercy Hospital (CMH) urgent care clinics (UCC), only 58% patients received the recommended 5-7 days of antibiotics. We aimed to increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021. Methods We formed a multidisciplinary team in April 2020. A provider survey assessed factors influencing prescribing habits. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Interventions were chosen based on the potential for highest impact and lowest effort. Our first Plan-Do-Study-Act (PDSA) cycle provided an update on current guidelines for UCC providers. The second PDSA cycle updated prescription sentences in the electronic health record (EHR) and organized them from shortest to longest duration. The third PDSA cycle provided a project update via email to UCC providers. Our outcome measure is the percentage of patients receiving 5-7 days of antibiotics for SSTIs. Process measure is the number of updated prescriptions used. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using a run chart. Results After initiation of the project in April 2020, the percentage of patients receiving 5-7 days of antibiotics increased to 68% (Figure 2). This percentage increased to our goal of 75% after the 1st PDSA cycle (October-December 2020), 80% following the second PDSA cycle in February 2021, and 90% following the third PDSA cycle in April 2021. There was no change in balancing measure numbers. Run Chart Conclusion Prior to our project, only 58% of children seen in CMH UCCs for SSTIs received the recommended antibiotic duration. By addressing the primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)
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