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Goedken CC, Butler JM, Judd J, Brown N, Rubin M, Goetz MB. Antimicrobial physician and pharmacist experience and perception of an antimicrobial Self-Stewardship Time-Out Program (SSTOP) intervention at eight Veterans' Affairs medical centers. Infect Control Hosp Epidemiol 2023; 44:1511-1514. [PMID: 36691809 DOI: 10.1017/ice.2022.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We explored experiences and perceptions surrounding the Self-Stewardship Time-Out Program (SSTOP) intervention across implementation sites to improve antimicrobial use. Semistructured qualitative interviews were conducted with Antibiotic Stewardship physicians and pharmacists, from which 5 key themes emerged. SSTOP may serve to achieve sustainable promotion of antibiotic use improvements.
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Affiliation(s)
- Cassie Cunningham Goedken
- Center for Access Delivery & Research and Evaluation, (CADRE) Iowa City Veterans' Affairs (VA) Health Care System, Iowa City, Iowa
| | - Jorie M Butler
- Salt Lake City VA Healthcare System, Salt Lake City, Utah
- University of Utah, Salt Lake City, Utah
| | - Joshua Judd
- Salt Lake City VA Healthcare System, Salt Lake City, Utah
- University of Utah, Salt Lake City, Utah
| | - Nui Brown
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- University of California Los Angeles, Los Angeles, California
| | - Michael Rubin
- Salt Lake City VA Healthcare System, Salt Lake City, Utah
- University of Utah, Salt Lake City, Utah
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- University of California Los Angeles, Los Angeles, California
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2
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Stagg BC, Tullis B, Asare A, Stein JD, Medeiros FA, Weir C, Borbolla D, Hess R, Kawamoto K. Systematic user-centered design of a prototype clinical decision support system for glaucoma. OPHTHALMOLOGY SCIENCE 2023; 3:100279. [PMID: 36970116 PMCID: PMC10033738 DOI: 10.1016/j.xops.2023.100279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/05/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
Purpose To rigorously develop a prototype clinical decision support (CDS) system to help clinicians determine the appropriate timing for follow-up visual field testing for patients with glaucoma and to identify themes regarding the context of use for glaucoma CDS systems, design requirements, and design solutions to meet these requirements. Design Semistructured qualitative interviews and iterative design cycles. Participants Clinicians who care for patients with glaucoma, purposefully sampled to ensure a representation of a range of clinical specialties (glaucoma specialist, general ophthalmologist, optometrist) and years in clinical practice. Methods Using the established User-Centered Design Process framework, we conducted semistructured interviews with 5 clinicians that addressed the context of use and design requirements for a glaucoma CDS system. We analyzed the interviews using inductive thematic analysis and grounded theory to generate themes regarding the context of use and design requirements. We created design solutions to address these requirements and used iterative design cycles with the clinicians to refine the CDS prototype. Main Outcome Measures Themes regarding decision support for determining the timing of visual field testing for patients with glaucoma, CDS design requirements, and CDS design features. Results We identified 9 themes that addressed the context of use for the CDS system, 9 design requirements for the prototype CDS system, and 9 design features intended to address these design requirements. Key design requirements included the preservation of clinician autonomy, incorporation of currently used heuristics, compilation of data, and increasing and communicating the level of certainty regarding the decision. After completing 3 iterative design cycles using this preliminary CDS system design solution, the design was satisfactory to the clinicians and was accepted as our prototype glaucoma CDS system. Conclusions We used a systematic design process based on the established User-Centered Design Process to rigorously develop a prototype glaucoma CDS system, which will be used as a starting point for a future, large-scale iterative refinement and implementation process. Clinicians who care for patients with glaucoma need CDS systems that preserve clinician autonomy, compile and present data, incorporate currently used heuristics, and increase and communicate the level of certainty regarding the decision. Financial Disclosures Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Brian C. Stagg
- Department of Ophthalmology and Visual Sciences, John Moran Eye Center, University of Utah, Salt Lake City, Utah
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
- Correspondence: Brian C. Stagg, MD, MS, 65 Mario Capecchi Drive, Salt Lake City, UT 84132.
| | - Benton Tullis
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Afua Asare
- Department of Ophthalmology and Visual Sciences, John Moran Eye Center, University of Utah, Salt Lake City, Utah
| | - Joshua D. Stein
- Department of Ophthalmology and Visual Sciences, Center for Eye Policy & Innovation, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan
| | | | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Damian Borbolla
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
- Clinical Effectiveness, Wolters Kluwer Health, Salt Lake City, Utah
| | - Rachel Hess
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
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3
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Van Dort BA, Carland JE, Penm J, Ritchie A, Baysari MT. Digital interventions for antimicrobial prescribing and monitoring: a qualitative meta-synthesis of factors influencing user acceptance. J Am Med Inform Assoc 2022; 29:1786-1796. [PMID: 35897157 PMCID: PMC9471701 DOI: 10.1093/jamia/ocac125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/16/2022] [Accepted: 07/16/2022] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To understand and synthesize factors influencing user acceptance of digital interventions used for antimicrobial prescribing and monitoring in hospitals. MATERIALS AND METHODS A meta-synthesis was conducted to identify qualitative studies that explored user acceptance of digital interventions for antimicrobial prescribing and/or monitoring in hospitals. Databases were searched and qualitative data were extracted and systematically classified using the unified theory of acceptance and use of technology (UTAUT) model. RESULTS Fifteen qualitative studies met the inclusion criteria. Eleven papers used interviews and four used focus groups. Most digital interventions evaluated in studies were decision support for prescribing (n = 13). Majority of perceptions were classified in the UTAUT performance expectancy domain in perceived usefulness and relative advantage constructs. Key facilitators in this domain included systems being trusted and credible sources of information, improving performance of tasks and increasing efficiency. Reported barriers were that interventions were not considered useful for all settings or patient conditions. Facilitating conditions was the second largest domain, which highlights the importance of users having infrastructure to support system use. Digital interventions were viewed positively if they were compatible with values, needs, and experiences of users. CONCLUSIONS User perceptions that drive users to accept and utilize digital interventions for antimicrobial prescribing and monitoring were predominantly related to performance expectations and facilitating conditions. To ensure digital interventions for antimicrobial prescribing are accepted and used, we recommend organizations ensure systems are evaluated and benefits are conveyed to users, that utility meets expectations, and that appropriate infrastructure is in place to support use.
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Affiliation(s)
- Bethany A Van Dort
- Biomedical Informatics and Digital Health, School of Medical Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Angus Ritchie
- Health Informatics Unit, Sydney Local Health District, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Melissa T Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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4
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Hemenway AN, DuBois DL. A Scoping Review of the Use of Social and Behavioral Change in Acute Care Antimicrobial Stewardship Initiatives. Hosp Pharm 2022; 57:138-145. [PMID: 35521015 PMCID: PMC9065515 DOI: 10.1177/0018578721990887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Purpose: Antimicrobial stewardship (AS) initiatives are implemented with a goal of reducing antimicrobial resistance. It is unknown exactly how many acute care AS initiatives have since been based on social and behavioral theory. The purpose of this scoping review is to provide an updated review of theory-informed acute care AS initiatives in the published literature, including how social and behavioral theories have been used in the described interventions. Methods: PubMed, EMBASE, CINAHL, PsycINFO, and ProQuest Dissertations were searched using a combination of AS, acute care, and social and behavioral theory search terms from April 2011 to November 2019. Using both an initial review of titles and abstracts and a second review of full text, a total of 4 articles were identified after a review of 2014 records. Each article was coded using a guide that abstracted details of study methods, the AS intervention, and use of theory based on a validated theory coding scheme. Results: The interventions included combinations of decision-making tools, provider education, and prospective audit and feedback. Two studies included an evaluation of the described initiative, with findings indicating improvement in antimicrobial use. All interventions utilized theory in developing AS interventions. However, gaps were evident in the use of theory in the evaluations, including inconsistent measurement of theory constructs and lack of testing of the theory. Conclusion: AS interventions are frequently published; however, theory-based acute care AS interventions are not commonly described. More consistent and comprehensive utilization of social and behavioral theories may enhance effectiveness of AS programs.
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Affiliation(s)
- Alice N. Hemenway
- College of Pharmacy, University of Illinois Chicago—Rockford Health Sciences Campus, Rockford, IL, USA,Alice N. Hemenway, Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago—Rockford Health Sciences Campus, 1601 Parkview Avenue S223, Rockford, IL 61107, USA.
| | - David L. DuBois
- School of Public Health, University of Illinois Chicago, Chicago, IL, USA
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5
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Taber P, Weir C, Butler JM, Graber CJ, Jones MM, Madaras-Kelly K, Zhang Y, Chou AF, Samore MH, Goetz MB, Glassman PA. Social dynamics of a population-level dashboard for antimicrobial stewardship: A qualitative analysis. Am J Infect Control 2021; 49:862-867. [PMID: 33515622 DOI: 10.1016/j.ajic.2021.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate antimicrobial stewards' experiences of using a dashboard display integrating local and national antibiotic use data implemented in the U.S. Department of Veterans Affairs (VA). This paper reports early formative evaluation. DESIGN Qualitative interviewing. SETTING Eight VA hospitals participated with established antimicrobial stewardship (AS) programs participated in the pilot. PARTICIPANTS Six infectious disease physicians and eight clinical pharmacists agreed to be interviewed (n = 14). METHODS A 3-part qualitative interview script was used involving a description of local stewardship activities, a Critical Incident description of dashboard use, and general questions regarding attitudes towards the tool. An inductive open coding approach was used for analysis. RESULTS We found 4 themes showing the complexities of using stewardship tools: (1) Data validity is socially negotiated; (2) Performance feedback motivates and persuades social goals when situated in an empirical distribution; (3) Shared problem awareness is aided by authoritative data; and (4) The AS dashboard encourages connections with local quality improvement culture. CONCLUSIONS Social dimensions of AS tool use emerged as distinct from, and equally important as decision support provided by the dashboard. Successful stewardship tools should be designed to support both the social and cognitive needs of users.
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Affiliation(s)
- Peter Taber
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT.
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT; IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, UT.
| | - Jorie M Butler
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT; IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Geriatric Education and Clinical Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Department of Medicine, University of Utah, Salt Lake City, UT
| | - Christopher J Graber
- Center for Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Medicine, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA; Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Makoto M Jones
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Geriatric Education and Clinical Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Karl Madaras-Kelly
- Department of Pharmacy Boise VA Medical Center, Boise, ID; College of Pharmacy, Idaho State University, Meridian, ID
| | - Yue Zhang
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Geriatric Education and Clinical Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Ann F Chou
- Department of Family and Preventive Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Matthew H Samore
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Geriatric Education and Clinical Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Matthew Bidwell Goetz
- Center for Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Medicine, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA; Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Peter A Glassman
- Center for Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; VA Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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6
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Lamprell K, Tran Y, Arnolda G, Braithwaite J. Nudging clinicians: A systematic scoping review of the literature. J Eval Clin Pract 2021; 27:175-192. [PMID: 32342613 DOI: 10.1111/jep.13401] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND While the quality of medical care delivered by physicians can be very good, it can also be inconsistent and feature behaviours that are entrenched despite updated information and evidence. The "nudge" paradigm for behaviour change is being used to bring clinical practice in line with desired standards. The premise is that behaviour can be voluntarily shifted by making particular choices instinctively appealing. We reviewed studies that are explicit about their use of nudge theory in influencing clinician behaviour. METHODS Databases were searched from April 2008 (the publication date of the book that introduced nudge theory to a wider audience) to November 2018, inclusive. The search strategy and narrative review of results addressed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. RESULTS 22 studies were identified. Randomized trials or pre-post comparisons were generally used in community-based settings; single-site pre-post studies were favoured in hospitals. The studies employed eight intervention types: active choice; patient chart redesign; default and default alerts; partitioning of prescription menus; audit and feedback; commitment messages; peer comparisons; and redirection of workflow. Three core cognitive factors underpinned the eight interventions: bias towards prominent choices (salience); predisposition to social norms; and bias towards time or cost savings. CONCLUSIONS Published studies that are explicit about their use of nudge theory are few in number and diverse in their settings, targets, and results. Default and chart re-design interventions reported the most substantial improvements in adherence to evidence and guideline-based practice. Studies that are explicit in their use of nudge theory address the widespread failure of clinical practice studies to identify theoretical frameworks for interventions. However, few studies identified in our review engaged in research to understand the contextual and site-specific barriers to a desired behaviour before designing a nudge intervention.
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Affiliation(s)
- Klay Lamprell
- Macquarie University, Australian Institute of Health Innovation, Sydney, New South Wales, Australia
| | - Yvonne Tran
- Macquarie University, Australian Institute of Health Innovation, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Macquarie University, Australian Institute of Health Innovation, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Macquarie University, Australian Institute of Health Innovation, Sydney, New South Wales, Australia
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7
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Langford BJ, Daneman N, Leung V, Langford DJ. Cognitive bias: how understanding its impact on antibiotic prescribing decisions can help advance antimicrobial stewardship. JAC Antimicrob Resist 2020; 2:dlaa107. [PMID: 34223057 DOI: 10.1093/jacamr/dlaa107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The way clinicians think about decision-making is evolving. Human decision-making shifts between two modes of thinking, either fast/intuitive (Type 1) or slow/deliberate (Type 2). In the healthcare setting where thousands of decisions are made daily, Type 1 thinking can reduce cognitive load and help ensure decision making is efficient and timely, but it can come at the expense of accuracy, leading to systematic errors, also called cognitive biases. This review provides an introduction to cognitive bias and provides explanation through patient vignettes of how cognitive biases contribute to suboptimal antibiotic prescribing. We describe common cognitive biases in antibiotic prescribing both from the clinician and the patient perspective, including hyperbolic discounting (the tendency to favour small immediate benefits over larger more distant benefits) and commission bias (the tendency towards action over inaction). Management of cognitive bias includes encouraging more mindful decision making (e.g., time-outs, checklists), improving awareness of one's own biases (i.e., meta-cognition), and designing an environment that facilitates safe and accurate decision making (e.g., decision support tools, nudges). A basic understanding of cognitive biases can help explain why certain stewardship interventions are more effective than others and may inspire more creative strategies to ensure antibiotics are used more safely and more effectively in our patients.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada.,Toronto East Health Network, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Dale J Langford
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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8
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Mani NS, Lan KF, Jain R, Bryson-Cahn C, Lynch JB, Krantz EM, Bryan A, Liu C, Chan JD, Pottinger PS, Kim HN. Post-Prescription Review with Threat of Infectious Disease Consultation and Sustained Reduction in Meropenem Use Over Four Years. Clin Infect Dis 2020; 73:e4515-e4520. [PMID: 32866224 DOI: 10.1093/cid/ciaa1279] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Following a meropenem shortage, we implemented a post-prescription review with feedback (PPRF) in November 2015 with mandatory infectious disease (ID) consultation for all meropenem and imipenem courses > 72 hours. Providers were made aware of the policy via an electronic alert at the time of ordering. METHODS A retrospective study was conducted at the University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC) to evaluate the impact of the policy on antimicrobial consumption and clinical outcomes pre- and post-intervention during a 6-year period. Antimicrobial use was tracked using days of therapy (DOT) per 1,000 patient-days, and data were analyzed by an interrupted time series. RESULTS There were 4,066 and 2,552 patients in the pre- and post-intervention periods, respectively. Meropenem and imipenem use remained steady until the intervention, when a marked reduction in DOT/1,000 patient-days occurred at both hospitals (UWMC: percentage change -72.1%, (95% CI -76.6, -66.9), P & 0.001; HMC: percentage change -43.6%, (95% CI -59.9, -20.7), P = 0.001). Notably, although the intervention did not address antibiotic use until 72 hours after initiation, there was a significant decline in meropenem and imipenem initiation ("first starts") in the post-intervention period, with a 64.9% reduction (95% CI 58.7, 70.2; P &0.001) at UWMC and 44.7% reduction (95% CI 28.1, 57.4; P & 0.001) at HMC. CONCLUSIONS Mandatory ID consultation and PPRF for meropenem and imipenem beyond 72 hours resulted in a significant and sustained reduction in the use of these antibiotics and notably impacted their up-front usage.
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Affiliation(s)
- Nandita S Mani
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA
| | - Kristine F Lan
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA
| | - Rupali Jain
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA.,Department of Pharmacy, University of Washington Medical Center, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Chloe Bryson-Cahn
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA
| | - John B Lynch
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA
| | - Elizabeth M Krantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Andrew Bryan
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Catherine Liu
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jeannie D Chan
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA.,Department of Pharmacy, Harborview Medical Center, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Paul S Pottinger
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA
| | - H Nina Kim
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA
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9
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Coughlan JJ, Mullins CF, Kiernan TJ. Diagnosing, fast and slow. Postgrad Med J 2020; 97:103-109. [PMID: 32595113 DOI: 10.1136/postgradmedj-2019-137412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/10/2020] [Accepted: 06/01/2020] [Indexed: 11/04/2022]
Abstract
Diagnostic error is increasingly recognised as a source of significant morbidity and mortality in medicine. In this article, we will attempt to address several questions relating to clinical decision making; How do we decide on a diagnosis? Why do we so often get it wrong? Can we improve our critical faculties?We begin by describing a clinical vignette in which a medical error occurred and resulted in an adverse outcome for a patient. This case leads us to the concepts of heuristic thinking and cognitive bias. We then discuss how this is relevant to our current clinical paradigm, examples of heuristic thinking and potential mechanisms to mitigate bias.The aim of this article is to increase awareness of the role that cognitive bias and heuristic thinking play in medical decision making. We hope to motivate clinicians to reflect on their own patterns of thinking with an overall aim of improving patient care.
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Affiliation(s)
- J J Coughlan
- Cardiology, Saint James's Hospital, Dublin, Ireland
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10
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Antimicrobial stewardship: The influence of behavioral nudging on renal-function-based appropriateness of dosing. Infect Control Hosp Epidemiol 2020; 41:1077-1079. [PMID: 32546288 DOI: 10.1017/ice.2020.253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Failure to adjust doses may contribute to adverse events. We evaluated the effectiveness of providing the estimated glomerular filtration rate on appropriateness of dosing for antimicrobials. The approach increased appropriateness of dosing from 33.9% to 41.4% (P < .001). Nudging prescription behavior can boost strategies for adequate antimicrobial prescription.
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11
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Richards JB, Hayes MM, Schwartzstein RM. Teaching Clinical Reasoning and Critical Thinking: From Cognitive Theory to Practical Application. Chest 2020; 158:1617-1628. [PMID: 32450242 DOI: 10.1016/j.chest.2020.05.525] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022] Open
Abstract
Teaching clinical reasoning is challenging, particularly in the time-pressured and complicated environment of the ICU. Clinical reasoning is a complex process in which one identifies and prioritizes pertinent clinical data to develop a hypothesis and a plan to confirm or refute that hypothesis. Clinical reasoning is related to and dependent on critical thinking skills, which are defined as one's capacity to engage in higher cognitive skills such as analysis, synthesis, and self-reflection. This article reviews how an understanding of the cognitive psychological principles that contribute to effective clinical reasoning has led to strategies for teaching clinical reasoning in the ICU. With familiarity with System 1 and System 2 thinking, which represent intuitive vs analytical cognitive processing pathways, respectively, the clinical teacher can use this framework to identify cognitive patterns in clinical reasoning. In addition, the article describes how internal and external factors in the clinical environment can affect students' and trainees' clinical reasoning abilities, as well as their capacity to understand and incorporate strategies for effective critical thinking into their practice. Utilizing applicable cognitive psychological theory, the relevant literature on teaching clinical reasoning is reviewed, and specific strategies to effectively teach clinical reasoning and critical thinking in the ICU and other clinical settings are provided. Definitions, operational descriptions, and justifications for a variety of teaching interventions are discussed, including the "one-minute preceptor" model, the use of concept or mechanism maps, and cognitive de-biasing strategies.
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Affiliation(s)
- Jeremy B Richards
- Center for Education, Shapiro Institute for Education and Research, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Margaret M Hayes
- Center for Education, Shapiro Institute for Education and Research, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Richard M Schwartzstein
- Center for Education, Shapiro Institute for Education and Research, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
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12
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Castro-Sánchez E, Sood A, Rawson TM, Firth J, Holmes AH. Forecasting Implementation, Adoption, and Evaluation Challenges for an Electronic Game-Based Antimicrobial Stewardship Intervention: Co-Design Workshop With Multidisciplinary Stakeholders. J Med Internet Res 2019; 21:e13365. [PMID: 31165712 PMCID: PMC6746106 DOI: 10.2196/13365] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Serious games have been proposed to address the lack of engagement and sustainability traditionally affecting interventions aiming to improve optimal antibiotic use among hospital prescribers. OBJECTIVE The goal of the research was to forecast gaps in implementation, adoption and evaluation of game-based interventions, and co-design solutions with antimicrobial clinicians and digital and behavioral researchers. METHODS A co-development workshop with clinicians and academics in serious games, antimicrobials, and behavioral sciences was organized to open the International Summit on Serious Health Games in London, United Kingdom, in March 2018. The workshop was announced on social media and online platforms. Attendees were asked to work in small groups provided with a laptop/tablet and the latest version of the game On call: Antibiotics. A workshop leader guided open group discussions around implementation, adoption, and evaluation threats and potential solutions. Workshop summary notes were collated by an observer. RESULTS There were 29 participants attending the workshop. Anticipated challenges to resolve reflected implementation threats such as an inadequate organizational arrangement to scale and sustain the use of the game, requiring sufficient technical and educational support and a streamlined feedback mechanism that made best use of data arriving from the game. Adoption threats included collective perceptions that a game would be a ludic rather than professional tool and demanding efforts to integrate all available educational solutions so none are seen as inferior. Evaluation threats included the need to combine game metrics with organizational indicators such as antibiotic use, which may be difficult to enable. CONCLUSIONS As with other technology-based interventions, deploying game-based solutions requires careful planning on how to engage and support clinicians in their use and how best to integrate the game and game outputs onto existing workflows. The ludic characteristics of the game may foster perceptions of unprofessionalism among gamers, which would need buffering from the organization.
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Affiliation(s)
- Enrique Castro-Sánchez
- National Institute for Health Research Health Protection Research Unit in Healthcare-Associated Infection and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Anuj Sood
- National Institute for Health Research Health Protection Research Unit in Healthcare-Associated Infection and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Timothy Miles Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare-Associated Infection and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Jamie Firth
- Jamie Firth Consultancy Ltd, London, United Kingdom
| | - Alison Helen Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare-Associated Infection and Antimicrobial Resistance, Imperial College London, London, United Kingdom
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13
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Evaluation of an electronic antimicrobial time-out on antimicrobial utilization at a large health system. Infect Control Hosp Epidemiol 2019; 40:807-809. [PMID: 31099326 DOI: 10.1017/ice.2019.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We evaluated the impact of an electronic health record based 72-hour antimicrobial time-out (ATO) on antimicrobial utilization. We observed that 6 hours after the ATO, 21% of empiric antimicrobials were discontinued or de-escalated. There was a significant reduction in the duration of antimicrobial therapy but no impact on overall antimicrobial usage metrics.
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O’Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial. BMC MEDICAL EDUCATION 2019; 19:12. [PMID: 30621679 PMCID: PMC6325867 DOI: 10.1186/s12909-018-1444-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 12/28/2018] [Indexed: 05/18/2023]
Abstract
BACKGROUND Cognitive bias is an important source of diagnostic error yet is a challenging area to understand and teach. Our aim was to determine whether a cognitive forcing tool can reduce the rates of error in clinical decision making. A secondary objective was to understand the process by which this effect might occur. METHODS We hypothesised that using a cognitive forcing tool would reduce diagnostic error rates. To test this hypothesis, a novel online case-based approach was used to conduct a single blinded randomized clinical trial conducted from January 2017 to September 2018. In addition, a qualitative series of "think aloud" interviews were conducted with 20 doctors from a UK teaching hospital in 2018. The primary outcome was the diagnostic error rate when solving bias inducing clinical vignettes. A volunteer sample of medical professionals from across the UK, Republic of Ireland and North America. They ranged in seniority from medical student to Attending Physician. RESULTS Seventy six participants were included in the study. The data showed doctors of all grades routinely made errors related to cognitive bias. There was no difference in error rates between groups (mean 2.8 cases correct in intervention vs 3.1 in control group, 95% CI -0.94 - 0.45 P = 0.49). The qualitative protocol revealed that the cognitive forcing strategy was well received and a produced a subjectively positive impact on doctors' accuracy and thoughtfulness in clinical cases. CONCLUSIONS The quantitative data failed to show an improvement in accuracy despite a positive qualitative experience. There is insufficient evidence to recommend this tool in clinical practice, however the qualitative data suggests such an approach has some merit and face validity to users.
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Affiliation(s)
- Eoin D. O’Sullivan
- Department of Renal Medicine, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA UK
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15
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Horst S, Kawati R, Rasmusson J, Pikwer A, Castegren M, Lipcsey M. Impact of resuscitation fluid bag size availability on volume of fluid administration in the intensive care unit. Acta Anaesthesiol Scand 2018; 62:1261-1266. [PMID: 29851027 DOI: 10.1111/aas.13161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/15/2018] [Accepted: 04/16/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Iatrogenic fluid overload is associated with increased mortality in the intensive care unit (ICU). Decisions on fluid therapy may, at times, be based on other factors than physiological endpoints. We hypothesized that because of psychological factors volume of available fluid bags would affect the amount of resuscitation fluid administered to ICU patients. METHODS We performed a prospective intervention cross-over study at 3 Swedish ICUs by replacing the standard resuscitation fluid bag of Ringer's Acetate 1000 mL with 500 mL bags (intervention group) for 5 separate months and then compared it with the standard bag size for 5 months (control group). Primary endpoint was the amount of Ringer's Acetate per patient during ICU stay. Secondary endpoints were differences between the groups in cumulative fluid balance and change in body weight, hemoglobin and creatinine levels, urine output, acute kidney failure (measured as the need for renal replacement therapy, RRT) and 90-day mortality. RESULTS Six hundred and thirty-five ICU patients were included (291 in the intervention group, 344 in the control group). There was no difference in the amount of resuscitation fluid per patient during the ICU stay (2200 mL [1000-4500 median IQR] vs 2245 mL [1000-5630 median IQR]), RRT rate (11 vs 9%), 90-day mortality (11 vs 10%) or total fluid balance between the groups. The daily amount of Ringer's acetate administered per day was lower in the intervention group (1040 (280-2000) vs 1520 (460-3000) mL; P = .03). CONCLUSIONS The amount of resuscitation fluid administered to ICU patients was not affected by the size of the available fluid bags. However, altering fluid bag size could have influenced fluid prescription behavior.
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Affiliation(s)
- S. Horst
- Department of Surgical Sciences, Anesthesiology and Intensive Care; Uppsala University Hospital; Uppsala Sweden
| | - R. Kawati
- Department of Surgical Sciences, Anesthesiology and Intensive Care; Uppsala University Hospital; Uppsala Sweden
| | - J. Rasmusson
- Department of Anesthesiology and Intensive Care; Gävle County Hospital; Gävle Sweden
| | - A. Pikwer
- Centre for Clinical Research Sörmland; Uppsala University; Uppsala Sweden
| | - M. Castegren
- Perioperative Medicine and Intensive Care; Karolinska University Hospital and CLINTEC; Karolinska Institute; Stockholm Sweden
| | - M. Lipcsey
- Department of Surgical Sciences, Anesthesiology and Intensive Care; Uppsala University Hospital; Uppsala Sweden
- Hedenstierna Laboratory, CIRRUS; Department of Surgical Sciences, Anesthesiology and Intensive Care; Uppsala University Hospital; Uppsala Sweden
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Abstract
Appropriate antimicrobial therapy is essential to ensuring positive patient outcomes. Inappropriate or suboptimal utilization of antibiotics can lead to increased length of stay, multidrug-resistant infections, and mortality. Critically ill intensive care patients, particularly those with severe sepsis and septic shock, are at risk of antibiotic failure and secondary infections associated with incorrect antibiotic use. Through the initiation of active empiric antibiotic therapy based upon local susceptibilities, daily evaluation of signs and symptoms of infection and narrowing of antibiotic therapy when feasible, providers can streamline the treatment of common intensive care unit (ICU) infections. Optimizing antibiotic dosing through prolonged infusions can be beneficial in intensive care populations with altered pharmacokinetics. Antimicrobial stewardship teams can assist ICU providers in managing and implementing these tactics. This review will discuss the current literature on antibiotic use in the ICU applying antimicrobial stewardship strategies. Based upon the most recent evidence, ICUs would benefit from employing empiric guidelines for antibiotic use, collecting appropriate specimens and implementing molecular diagnostics, optimizing the dosing of antibiotics, and reducing the duration of total therapy. These strategies for antibiotic use have the potential to enhance patient care while preventing adverse outcomes.
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Affiliation(s)
- Maureen Campion
- 1 Division of Infectious Disease, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gail Scully
- 1 Division of Infectious Disease, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
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A Timeout on the Antimicrobial Timeout: Where Does It Stand and What Is Its Future? CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0146-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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