A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization

Curtis H. Weiss*, David Dibardino, Jason Rho, Nina Sung, Brett Collander, Richard G. Wunderink

*Corresponding author for this work

Research output: Contribution to journalArticle

31 Citations (Scopus)

Abstract

OBJECTIVES: To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record. DESIGN: Random allocation design. SETTING: Medical ICU with high-intensity intensivist coverage at a tertiary care urban medical center. PATIENTS: Two hundred ninety-six critically ill patients treated with at least 1 day of empirical antibiotics. INTERVENTIONS: For one medical ICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient's daily rounds. On a separate medical ICU team, attendings and fellows were trained once to complete an electronic health record-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued. MEASUREMENTS AND MAIN RESULTS: Prompting led to a more than four-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1% vs 70.0%, p = 0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs 0.83 [0.27], p = 0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio, 1.14; 95% CI, 1.05-1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups. CONCLUSIONS: Face-to-face prompting was superior to an unprompted electronic health record-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same medical ICU 2 years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable electronic health record-based checklist.

Original languageEnglish (US)
Pages (from-to)2563-2569
Number of pages7
JournalCritical care medicine
Volume41
Issue number11
DOIs
StatePublished - Nov 1 2013

Fingerprint

Checklist
Clinical Trials
Anti-Bacterial Agents
Physicians
Electronic Health Records
Critical Care
Tertiary Healthcare
Random Allocation
Hospital Mortality
Critical Illness
Length of Stay
Odds Ratio
Mortality

Keywords

  • Checklists
  • Empirical antimicrobial agents
  • Physician decision-making
  • Process of care
  • Prompting

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Weiss, Curtis H. ; Dibardino, David ; Rho, Jason ; Sung, Nina ; Collander, Brett ; Wunderink, Richard G. / A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization. In: Critical care medicine. 2013 ; Vol. 41, No. 11. pp. 2563-2569.
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abstract = "OBJECTIVES: To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record. DESIGN: Random allocation design. SETTING: Medical ICU with high-intensity intensivist coverage at a tertiary care urban medical center. PATIENTS: Two hundred ninety-six critically ill patients treated with at least 1 day of empirical antibiotics. INTERVENTIONS: For one medical ICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient's daily rounds. On a separate medical ICU team, attendings and fellows were trained once to complete an electronic health record-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued. MEASUREMENTS AND MAIN RESULTS: Prompting led to a more than four-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1{\%} vs 70.0{\%}, p = 0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs 0.83 [0.27], p = 0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio, 1.14; 95{\%} CI, 1.05-1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups. CONCLUSIONS: Face-to-face prompting was superior to an unprompted electronic health record-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same medical ICU 2 years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable electronic health record-based checklist.",
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A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization. / Weiss, Curtis H.; Dibardino, David; Rho, Jason; Sung, Nina; Collander, Brett; Wunderink, Richard G.

In: Critical care medicine, Vol. 41, No. 11, 01.11.2013, p. 2563-2569.

Research output: Contribution to journalArticle

TY - JOUR

T1 - A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization

AU - Weiss, Curtis H.

AU - Dibardino, David

AU - Rho, Jason

AU - Sung, Nina

AU - Collander, Brett

AU - Wunderink, Richard G.

PY - 2013/11/1

Y1 - 2013/11/1

N2 - OBJECTIVES: To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record. DESIGN: Random allocation design. SETTING: Medical ICU with high-intensity intensivist coverage at a tertiary care urban medical center. PATIENTS: Two hundred ninety-six critically ill patients treated with at least 1 day of empirical antibiotics. INTERVENTIONS: For one medical ICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient's daily rounds. On a separate medical ICU team, attendings and fellows were trained once to complete an electronic health record-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued. MEASUREMENTS AND MAIN RESULTS: Prompting led to a more than four-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1% vs 70.0%, p = 0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs 0.83 [0.27], p = 0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio, 1.14; 95% CI, 1.05-1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups. CONCLUSIONS: Face-to-face prompting was superior to an unprompted electronic health record-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same medical ICU 2 years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable electronic health record-based checklist.

AB - OBJECTIVES: To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record. DESIGN: Random allocation design. SETTING: Medical ICU with high-intensity intensivist coverage at a tertiary care urban medical center. PATIENTS: Two hundred ninety-six critically ill patients treated with at least 1 day of empirical antibiotics. INTERVENTIONS: For one medical ICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient's daily rounds. On a separate medical ICU team, attendings and fellows were trained once to complete an electronic health record-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued. MEASUREMENTS AND MAIN RESULTS: Prompting led to a more than four-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1% vs 70.0%, p = 0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs 0.83 [0.27], p = 0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio, 1.14; 95% CI, 1.05-1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups. CONCLUSIONS: Face-to-face prompting was superior to an unprompted electronic health record-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same medical ICU 2 years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable electronic health record-based checklist.

KW - Checklists

KW - Empirical antimicrobial agents

KW - Physician decision-making

KW - Process of care

KW - Prompting

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