Antibiotic clinical decision support for pneumonia in the ED: A randomized trial
Graphical Abstract
Abstract
Background
Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED).
Objective
To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED.
Design
Pragmatic randomized clinical trial.
Setting and Participants
Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States.
Intervention
CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines.
Main Outcome and Measures
The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits.
Results
1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes.
Conclusions
Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.
CONFLICT OF INTEREST STATEMENT
Derek Williams reports in-kind research support from Biomerieux for unrelated work; Judith Martin receives funding from Merck, Sharp, and Dome for unrelated work; Carlos Grijalva reports consultancy fees from Pfizer, Merck, and Sanofi-Pasteur; and grants from Campbell Alliance/Syneos Health and Sanofi for unrelated work. Robert Freundlich reports stock in 3M and consulting from Oak Hill Clinical Informatics for unrelated work.
