ObjectiveTo evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention.MethodsThe intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18 – 65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2).ResultsAdherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods.ConclusionsA stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.

OBJECTIVES:Results of pre-post intervention studies of sepsis early warning systems have been mixed, and randomized clinical trials showing efficacy in the emergency department setting are lacking. Additionally, early warning systems can be resource-intensive and may cause unintended consequences such as antibiotic or IV fluid overuse. We assessed the impact of a pharmacist and provider facing sepsis early warning systems on timeliness of antibiotic administration and sepsis-related clinical outcomes in our setting. DESIGN:A randomized, controlled quality improvement initiative. SETTING:The main emergency department of an academic, safety-net healthcare system from August to December 2019. PATIENTS:Adults presenting to the emergency department. INTERVENTION:Patients were randomized to standard sepsis care or standard care augmented by the display of a sepsis early warning system-triggered flag in the electronic health record combined with electronic health record-based emergency department pharmacist notification. MEASUREMENTS AND MAIN RESULTS:The primary process measure was time to antibiotic administration from arrival. A total of 598 patients were included in the study over a 5-month period (285 in the intervention group and 313 in the standard care group). Time to antibiotic administration from emergency department arrival was shorter in the augmented care group than that in the standard care group (median, 2.3 hr [interquartile range, 1.4-4.7 hr] vs 3.0 hr [interquartile range, 1.6-5.5 hr]; p = 0.039). The hierarchical composite clinical outcome measure of days alive and out of hospital at 28 days was greater in the augmented care group than that in the standard care group (median, 24.1 vs 22.5 d; p = 0.011). Rates of fluid resuscitation and antibiotic utilization did not differ. CONCLUSIONS:In this single-center randomized quality improvement initiative, the display of an electronic health record-based sepsis early warning systemtriggered flag combined with electronic health record-based pharmacist notification was associated with shorter time to antibiotic administration without an increase in undesirable or potentially harmful clinical interventions.

Background and Objectives National guidelines recommend prescribing naloxone to patients receiving chronic opioids. However, provider adherence to naloxone co‐prescribing best practices is poor and knowledge gaps for improvement efforts are large. As part of a system‐wide quality improvement intervention to improve opioid safety, we sought to improve access to naloxone for patients with opioid prescriptions. Methods A prompt for naloxone co‐prescribing was implemented in the electronic health record. Baseline data and data after implementation were collected for naloxone co‐prescribing and fill rates on naloxone prescriptions s (n = 9122 pre, 8368 post). Results In the 9 months following the implementation of the electronic prompt, the total number of naloxone prescriptions increased more than 15‐fold. Patients prescribed naloxone filled their naloxone prescriptions similarly (42%) before and after the prompt implementation, resulting in a marked increase in the absolute number of patients with access to naloxone. Patient fill rates varied by clinical area (33% emergency medicine to 47% general medicine). Conclusion and Scientific Significance An electronic prompt, encouraging providers to prescribe naloxone to at‐risk patients led to a marked increase in the percentage of patients with an active naloxone prescription. The availability of naloxone in communities saves lives and this study is the first to demonstrate an intervention, which led to increased naloxone prescribing and reported on actual pharmacy fills of naloxone when co‐prescribed with opioids. (Am J Addict 2020;00:00–00)