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Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis
- Jeffrey Gerber, Robert Grundmeier, Keith Hamilton, Lauri Hicks, Melinda Neuhauser, Nicole Frager, Muida Menon, Ellen Kratz, Anne Jaskowiak, Leigh Cressman, Tony James, Jacqueline Omorogbe, Ebbing Lautenbach
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s188-s189
- Print publication:
- October 2020
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Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.
Funding: None
Disclosures: None
Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Acute Bronchitis
- Ebbing Lautenbach, Keith Hamilton, Robert Grundmeier, Melinda Neuhauser, Lauri Hicks, Anne Jaskowiak, Leigh Cressman, Tony James, Jacqueline Omorogbe, Nicole Frager, Muida Menon, Ellen Kratz, Jeffrey Gerber
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s32
- Print publication:
- October 2020
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Background: Antibiotic resistance has increased at alarming rates, driven predominantly by antibiotic overuse. Although most antibiotic use occurs in outpatients, antimicrobial stewardship programs have primarily focused on inpatient settings. A major challenge for outpatient stewardship is the lack of accurate and accessible electronic data to target interventions. We sought to develop and validate an electronic algorithm to identify inappropriate antibiotic use for outpatients with acute bronchitis. Methods: This study was conducted within the University of Pennsylvania Health System (UPHS). We used ICD-10 diagnostic codes to identify encounters for acute bronchitis at any outpatient UPHS practice between March 15, 2017, and March 14, 2018. Exclusion criteria included underlying immunocompromising condition, other comorbidity influencing the need for antibiotics (eg, emphysema), or ICD-10 code at the same visit for a concurrent infection (eg, sinusitis). We randomly selected 300 (150 from academic practices and 150 from nonacademic practices) eligible subjects for detailed chart abstraction that assessed patient demographics and practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm. Because antibiotic use is not indicated for this study population, appropriateness was assessed based upon whether an antibiotic was prescribed or not. Results: Of 300 subjects, median age was 61 years (interquartile range, 50–68), 62% were women, 74% were seen in internal medicine (vs family medicine) practices, and 75% were seen by a physician (vs an advanced practice provider). On chart review, 167 (56%) subjects received an antibiotic. Of these subjects, 1 had documented concern for pertussis and 4 had excluding conditions for which there were no ICD-10 codes. One received an antibiotic prescription for a planned dental procedure. Thus, based on chart review, 161 (54%) subjects received antibiotics inappropriately. Using the electronic algorithm based on diagnostic codes, underlying and concurrent conditions, and prescribing data, the number of subjects with inappropriate prescribing was 170 (56%) because 3 subjects had antibiotic prescribing not noted based on chart review. The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were the following: sensitivity, 100% (161 of 161); specificity, 94% (130 of 139); positive predictive value, 95% (161 of 170); and negative predictive value, 100% (130 of 130). Conclusions: For outpatients with acute bronchitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future studies.
Funding: None
Disclosures: None
Investigating the Relationship Between Social Support and Durable Return to Work
- Bruce D. Watt, Lucas Ford, Rebekah M. Doley, Sabrina Ong, Richard E. Hicks, Katarina Fritzon, Tony Cacciola
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- Journal:
- The Australasian Journal of Organisational Psychology / Volume 8 / 2015
- Published online by Cambridge University Press:
- 08 April 2015, e3
- Print publication:
- 2015
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The aim of the current study was to investigate the relationship between social support and durable return to work (RTW) post occupational injury. A total of 1,179 questionnaires were posted to clients previously receiving vocational rehabilitation services from the Return to Work Assist program in Queensland, Australia. Participants were asked to indicate their current RTW status, in addition to completing questionnaires measuring their relationship with their superior, relationships with colleagues, and social support external to the workplace. The statistical analysis included 110 participants. An ANOVA indicated that participants in the RTW group reported significantly better relationships with their superiors and colleagues than participants in the non-durable RTW group. No significant differences were observed between the RTW, non-durable RTW and no RTW groups on a measure of social support external to the workplace. Although the findings were limited by the low response rate, an evaluation of demographics indicated the respondents were representative of the original target sample. The findings suggested that providing support in the workplace is an important area for intervention and may be a means of increasing durable RTW outcomes.
Hospital Bed Surge Capacity in the Event of a Mass-Casualty Incident
- Daniel P. Davis, Jennifer C. Poste, Toni Hicks, Deanna Polk, Thérèse E. Rymer, Irving Jacoby
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- Journal:
- Prehospital and Disaster Medicine / Volume 20 / Issue 3 / June 2005
- Published online by Cambridge University Press:
- 28 June 2012, pp. 169-176
- Print publication:
- June 2005
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Introduction:
Traditional strategies to determine hospital bed surge capacity have relied on cross-sectional hospital census data, which underestimate the true surge capacity in the event of a mass-casualtyincident.
Objective:To determine hospital bed surge capacity for the County more accurately using physician and nurse manager assessments for the disposition of all in-patients at multiple facilities.
Methods:Overnight- and day-shift nurse managers from each in-patient unit at four different hospitals were approached to make assessments for each patient as to their predicted disposition at 2, 24, and 72 hours post-event in the case of a mass-casualty incident, including transfer to a hypothetical, onsite nursing facility. Physicians at the two academic institutions also were approached for comparison. Age, gender, and admission diagnosis also were recorded for each patient.
Results:A total of 1,741 assessments of 788 patients by 82 nurse managers aabnd 25 physicians from the four institutions were included. Nurse managers assessed approximately one-third of all patients as dischargeable at 24 hours and approximately one-half at 72 hours; one-quarter of the patients were assessed as being transferable to a hypothetical, on-site nursing facility at both time points. Physicians were more likely than werenurse managers to send patients to such a facility or discharge them, but less likely to transfer patients outof the intensive care unit (ICU). Inter-facility variability was explained by differences in the distribution of patient diagnoses.
Conclusions:A large proportion of in-patients can be discharged within 24 and 72 hours in the event of a mass-casualty incident (MCI). Additional beds can be made available if an on-site nursing facility is made available. Both physicians and nurse managers should be included on the team that makes patient dispositions in the event of a MCI.