A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization.
OBJECTIVE
To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record.


METHODS
Random allocation design.


METHODS
Medical ICU with high-intensity intensivist coverage at a tertiary care urban medical center.


METHODS
Two hundred ninety-six critically ill patients treated with at least 1 day of empirical antibiotics.


METHODS
For one medical ICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient's daily rounds. On a separate medical ICU team, attendings and fellows were trained once to complete an electronic health record-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued.


RESULTS
Prompting led to a more than four-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1% vs 70.0%, p = 0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs 0.83 [0.27], p = 0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio, 1.14; 95% CI, 1.05-1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups.


CONCLUSIONS
Face-to-face prompting was superior to an unprompted electronic health record-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same medical ICU 2 years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable electronic health record-based checklist.
1Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. 2Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
Curtis H
CH
Weiss
David
D
Dibardino
Jason
J
Rho
Nina
N
Sung
Brett
B
Collander
Richard G
RG
Wunderink
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D057189:Checklist; D003422:Critical Care / Q000379:methods*; D004363:Drug Utilization / Q000706:statistics & numerical data*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D062606:Tertiary Care Centers / Q000706:statistics & numerical data
D000900:Anti-Bacterial Agents