ObjectivesTo evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput.DesignRandomised, multicentre clinical trial.SettingFive emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit.Participants88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site.InterventionsPhysicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018.Main outcome measuresPhysicians’ productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians’ productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done.ResultsData were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians’ productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes.ConclusionsScribes improved emergency physicians’ productivity, particularly during primary consultations, and decreased patients’ length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia’s.Trial registrationACTRN12615000607572 (pilot site); ACTRN12616000618459.

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<p><strong>ABSTRACT</strong><br /><strong></strong></p><p><strong>Background:</strong> Antibiotic IV-to-oral (IV–PO) conversion is a key initiative of antimicrobial stewardship programs. Guidelines and education are commonly described interventions to promote IV–PO conversion; however, technological interventions may be more effective in changing practice. <br /><strong></strong></p><p><strong>Objective:</strong> To determine the impact of a clinical decision support (CDS) tool on the adoption and sustainability of an antibiotic IV–PO conversion program at a community-academic hospital.<br /><strong></strong></p><p><strong>Methods:</strong> A quasi-experimental study consisting of 3 phases was conducted. During phase 1, the pre-intervention antibiotic IV–PO conversion rate was determined. During phase 2, the IV–PO conversion policy was updated, education was provided to pharmacists and physicians, and a post-intervention evaluation was conducted. During phase 3, a CDS tool was developed to generate real-time electronic alerts prompting pharmacists to assess antibiotic therapy, and post-intervention audits were performed 1 month, 3 months, and 15 months after implementation of the tool. Pantoprazole IV–PO conversion was assessed during each phase as a non-equivalent dependent variable. The primary outcome was the proportion of patients eligible for IV–PO conversion who were switched to oral therapy. <br /><strong></strong></p><p><strong>Results:</strong> Of 332 patients receiving targeted IV antibiotic therapy during the overall study period, 122 (37%) met the criteria for IV–PO conversion. The phase 2 IV–PO conversion rate of 35% (9/26) was comparable to the pre-intervention rate of 29% (10/35) (p = 0.61). Implementation of the CDS tool significantly increased the conversion rate to 78% (14/18), an increase that was sustained at 3 months (71% [17/24]) and 15 months (74% [14/19]) after implementation (p &lt; 0.05 for all comparisons with phases 1 and 2). Pantoprazole conversion rates were similar across all phases.<br /><strong></strong></p><p><strong>Conclusions:</strong> Implementation of the CDS tool was effective in improving and sustaining antibiotic IV–PO conversion rates and enhancing policy compliance beyond the effects of policy revision and education. Refinement of both the policy and the tool is warranted to maximize adoption of the IV–PO conversion program.</p><p><strong>RÉSUMÉ</strong><br /><strong></strong></p><p><strong>Contexte:</strong> Le passage de l’antibiothérapie par voie intraveineuse (IV) à la voie orale (PO) (IV-PO) est une initiative clé des programmes de gestion des antimicrobiens. On a communément recours à des formations et à des lignes directrices pour encourager le passage d’une voie à l’autre; cependant, les interventions technologiques sont parfois plus efficaces pour favoriser le changement de pratique. <br /><strong></strong></p><p><strong>Objectif :</strong> Déterminer l’impact d’un outil d'aide à la décision clinique (ADC) sur l’adoption et la viabilité d’un programme de conversion IV-PO dans un hôpital universitaire.<br /><strong></strong></p><p><strong>Méthodes :</strong> Une étude quasi expérimentale en trois phases a été menée. La première phase a permis la détermination du taux de conversion IV-PO avant l’intervention. La deuxième phase concernait l’actualisation de la politique de conversion IV-PO, la formation des pharmaciens et médecins et la conduite d’une évaluation après l’intervention. La troisième phase a vu le développement d’un outil ADC qui génère des alertes électroniques en temps réel pour inciter les pharmaciens à évaluer l’antibiothérapie. Des évaluations ont en outre été effectuées 1 mois, 3 mois et 15 mois après la mise en place de l’outil. Le passage de l’administration du pantoprazole par voie intraveineuse (IV) à voie orale (PO) a été évalué au cours de chaque phase comme une variable dépendante non équivalente. Le résultat principal fut la proportion de patients admissibles à la conversion IV–PO qui ont été orientés vers un traitement par voie orale.<br /><strong></strong></p><p><strong>Résultats :</strong> Des 332 patients recevant une antibiothérapie ciblée par voie intraveineuse (IV) pendant l’étude, 122 (37 %) répondaient au critère de la conversion IV–PO. Le taux de conversion IV–PO de 35 % (9/26) de la phase 2 était comparable au taux avant l’intervention de 29 % (10/35)(p = 0,61). La mise en place de l’outil ADC a grandement augmenté le taux de conversion, qui est passé à 78 % (14/18) : une augmentation maintenue trois mois (71 % [17/24]) et 15 mois (74 % [14/19]) après la mise en place (p &lt; 0,05 par rapport aux phases 1 et 2). Les taux de conversion du pantoprazole étaient similaires durant toutes les phases.<br /><strong></strong></p><p><strong>Conclusions :</strong> La mise en place de l’outil ADC a permis d’améliorer et de maintenir les taux de conversion IV–PO et de renforcer le respect des politiques au-delà des effets de la révision des politiques et de la formation à celles-ci. Le perfectionnement de la politique et de l’outil se justifie pour maximiser l’adoption du programme de conversion IV–PO.</p>