De­creas­ing pe­di­atric an­tibi­otic use through col­lab­o­ra­tion

Modern Healthcare - - BEST PRACTICES - By Maria Castel­lucci

About 60% of chil­dren are pre­scribed an­tibi­otics at some point in their child­hood but 1 out of ev­ery 3 an­tibi­otic pre­scrip­tions writ­ten in the U.S. are deemed med­i­cally un­nec­es­sary.

Im­proper ad­min­is­tra­tion of these drugs can harm kids, caus­ing di­ar­rhea, nau­sea and—in ex­treme cases— death. Overuse of an­tibi­otics can also lead to an­timi­cro­bial-re­sis­tant in­fec­tions, such as E. coli and sal­monella poi­son­ing, which un­til re­cently were not as preva­lent among chil­dren but cur­rently are one of the largest public health is­sues among adults.

Dr. Sarah Parker, a pe­di­atric in­fec­tious dis­ease physi­cian at Chil­dren’s Hos­pi­tal Colorado, said that while an­tibi­otics can be life-sav­ing, clin­i­cians need to use the drugs more ap­pro­pri­ately es­pe­cially as fewer op­tions are avail­able.

As a first step, Chil­dren’s Hos­pi­tal Colorado launched an an­timi­cro­bial stew­ard­ship pro­gram that in­volves Parker and a phar­ma­cist re­view­ing all an­tibi­otics ad­min­is­tered to the hos­pi­tal’s young pa­tients. They look for three things: that the ap­pro­pri­ate an­timi­cro­bial was pre­scribed; that the dosage cor­re­sponds with the pa­tient’s weight and age; and that the an­tibi­otic doesn’t dan­ger­ously in­ter­act with an­other drug the pa­tient is tak­ing.

Since the ini­tia­tive launched in 2011, an­tibi­otic use has dropped by 10.9% and the hos­pi­tal has saved about $1 mil­lion per year. That’s the re­sult of fewer an­tibi­otics be­ing or­dered and pa­tients be­ing less likely to fall ill due to ad­verse re­ac­tions to an­tibi­otics, Parker said.

The pro­gram works by in­clud­ing forms on the hos­pi­tal’s elec­tronic health record sys­tem that re­quire clin­i­cians to log in­for­ma­tion about an­tibi­otics used within the last 24 hours and how the pa­tient has re­acted to the an­tibi­otic af­ter 48 to 72 hours.

Ev­ery day, Parker and a phar­ma­cist re­view on aver­age 50 to 100 re­ports re­lated to an­tibi­otics pre­scribed within the last 24 hours and about 30 to 50 re­ports of pa­tients on an­tibi­otics for up to 72 hours. About 10% of those re­ports are flagged for fol­low-up with the pa­tient’s care team. Parker and the phar­ma­cist will dis­cuss with the care team why an an­tibi­otic was ad­min­is­tered in­cor­rectly and what can be done to fix the is­sue.

Parker notes that it’s crit­i­cal to con­duct fol­low-up ses­sions in per­son. Most an­tibi­otic stew­ard­ship pro­grams will dis­cuss con­cerns over email and long af­ter the fact. The group in­ter­ac­tion cre­ates the op­por­tu­nity for greater dis­cus­sion and un­der­stand­ing—for both the clin­i­cians and the pa­tients.

“Hav­ing our team just go­ing around has re­ally changed the col­lab­o­ra­tive en­vi­ron­ment tremen­dously,” Parker added.

The par­tic­i­pat­ing phar­ma­cists have been able to ef­fec­tively ed­u­cate physi­cians about drug in­ter­ac­tions, which aren’t al­ways a doc­tor’s forte. And as an in­fec­tious dis­ease physi­cian, Parker can of­fer ad­vice about ap­pro­pri­ate an­tibi­otics for cer­tain con­di­tions and warn about po­ten­tial side ef­fects from their ad­min­is­tra­tion.

Also, Parker serves as a sec­ond set of eyes while re­view­ing a pa­tient’s EHR and can catch er­rors un­re­lated to an­tibi­otics—for ex­am­ple, if a doc­tor wants to fig­ure out if a pa­tient has a virus but didn’t order the right test.

The stew­ard­ship pro­gram at Chil­dren’s also in­volves daily rounds on units that haven’t been flagged. This al­lows Parker to ask physi­cians if they have any ques­tions or con­cerns re­lated to an­tibi­otic use. She said usu­ally physi­cians take ad­van­tage of the op­por­tu­nity, es­pe­cially those in pe­di­atric in­ten­sive care. That’s likely be­cause those units more of­ten use an­tibi­otics to help pa­tients through com­plex con­di­tions, Parker said. In fact, the pe­di­atric ICU ex­pe­ri­enced the big­gest de­crease—14.5%—in an­tibi­otic use since 2011.

The stew­ard­ship pro­gram has ed­u­cated staff on an­tibi­otics and has en­abled con­ver­sa­tions about in­fec­tious dis­ease. It’s also given the hos­pi­tal an op­por­tu­nity to ad­here to best prac­tices—some­thing only a third of acute-care hos­pi­tals in the U.S. prac­tice, ac­cord­ing to a 2016 re­port. The Cen­ters for Dis­ease Con­trol and Preven­tion es­ti­mates as many as 2 mil­lion an­timi­cro­bial-re­sis­tant in­fec­tions oc­cur in the U.S. each year, re­sult­ing in 23,000 deaths.

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