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 journalArticlepeer-review

45 Scopus citations


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
Issue number11
StatePublished - Nov 2013


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

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine


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