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Jones M, Butler J, Graber CJ, Glassman P, Samore MH, Pollack LA, Weir C, Goetz MB. Think twice: A cognitive perspective of an antibiotic timeout intervention to improve antibiotic use. J Biomed Inform 2016; 71S:S22-S31. [PMID: 27327529 DOI: 10.1016/j.jbi.2016.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 06/01/2016] [Accepted: 06/16/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To understand clinicians' impressions of and decision-making processes regarding an informatics-supported antibiotic timeout program to re-evaluate the appropriateness of continuing vancomycin and piperacillin/tazobactam. METHODS We implemented a multi-pronged informatics intervention, based on Dual Process Theory, to prompt discontinuation of unwarranted vancomycin and piperacillin/tazobactam on or after day three in a large Veterans Affairs Medical Center. Two workflow changes were introduced to facilitate cognitive deliberation about continuing antibiotics at day three: (1) teams completed an electronic template note, and (2) a paper summary of clinical and antibiotic-related information was provided to clinical teams. Shortly after starting the intervention, six focus groups were conducted with users or potential users. Interviews were recorded and transcribed. Iterative thematic analysis identified recurrent themes from feedback. RESULTS Themes that emerged are represented by the following quotations: (1) captures and controls attention ("it reminds us to think about it"), (2) enhances informed and deliberative reasoning ("it makes you think twice"), (3) redirects decision direction ("…because [there was no indication] I just [discontinued] it without even trying"), (4) fosters autonomy and improves team empowerment ("the template… forces the team to really discuss it"), and (5) limits use of emotion-based heuristics ("my clinical concern is high enough I think they need more aggressive therapy…"). CONCLUSIONS Requiring template completion to continue antibiotics nudged clinicians to re-assess the appropriateness of specified antibiotics. Antibiotic timeouts can encourage deliberation on overprescribed antibiotics without substantially curtailing autonomy. An effective nudge should take into account clinician's time, workflow, and thought processes.
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Affiliation(s)
- Makoto Jones
- VA Salt Lake City Health Care System, George E Whalen VA Medical Center, Salt Lake City, UT, USA; University of Utah, Salt Lake City, UT, USA.
| | - Jorie Butler
- VA Salt Lake City Health Care System, George E Whalen VA Medical Center, Salt Lake City, UT, USA; University of Utah, Salt Lake City, UT, USA; IDEAS 2.0 Center, George E. Whalen VA Medical Center, Salt Lake City, UT, USA; Geriatric Research Education and Clinical Center, George E. Whalen VA Medical Center, Salt Lake City, UT, USA
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peter Glassman
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Matthew H Samore
- VA Salt Lake City Health Care System, George E Whalen VA Medical Center, Salt Lake City, UT, USA; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lori A Pollack
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charlene Weir
- VA Salt Lake City Health Care System, George E Whalen VA Medical Center, Salt Lake City, UT, USA; University of Utah, Salt Lake City, UT, USA
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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