Enhancing Antimicrobial Stewardship for Pneumonia in the Emergency Department Utilizing a Clinical Decision Support Tool

Background. Pneumonia (PNA) ideal antibiotic regimen (IAbxR) selection from the Emergency Department (ED) has been directly correlated to improved outcomes, reduced hospital length of stay, costs and secondary infections. The Christiana Care Health System Antimicrobial Stewardship Program (CCHS-ASP) provides recommendations on initial ideal antibiotic regimen (IAbxR). Historically, CCHS ED provider compliance with IAbxR was 55%, with the major gap being overutilization of fluoroquinolones in the absence of a severe β- lactam allergy. A key barrier to optimal performance of IAbxR selection is the vast potential for selection of multiple antibiotics through our Computerized Provider Order Entry (CPOE) system and provider knowledge gaps.

Methods. Using change management principles and tools including stakeholder engagement, data gathering, Plan Do Check Act (PDCA), and rapid cycle testing, we attempted to change practicing culture at CCHS across 3 ED locations. Our project team successfully addressed organizational behaviors, project barriers and organizational goals, culminating in the development and integration of an electronic ED PNA clinical decision support rule (ED-PNA-CDS) for IAbxR selection. Post implementation of the ED-PNA-CDS tool, a fifty patient retrospective chart review was conducted to assess the rate of IAbxR compliance with CCHS-ASP guidelines for adult patients admitted to the hospital through the ED with PNA.

Results. The ED-PNA-CDS launched for all ED providers on February 17, 2015. To date a total of 699 CDS activations have occurred with 183 activations specific for PNA. The ED-PNA-CDS opt out rate was 8.2% (15 of 183). The post project rate of IAbxR compliance was 90% (p = 0.0002). Fluoroquinolones were only used in patients with a severe β-lactam allergy.

Conclusion. The development and integration of an electronic ED-PNA-CDS resulted in significant culture change by increasing IAbxR compliance from 55% to 90% for adult ED patients admitted with PNA. Other potential benefits that warrant further investigation include improved clinical patient outcomes, broader institutional antimicrobial stewardship, and improved financial performance for CCHS (ie: reimbursement, length of stay, drug cost).

Disclosures. All authors: No reported disclosures.

Author notes