title: Oral antibiotics at discharge for children with acute osteomyelitis: a rapid cycle improvement project.
abstract: BACKGROUND
  Substantial evidence demonstrates comparable cure rates for oral versus intravenous therapy for routine osteomyelitis. Evidence adoption is often slow and in our centre virtually all patients with osteomyelitis were discharged on intravenous therapy.
  
  
  OBJECTIVE
  For patients with acute osteomyelitis admitted to the hospital medicine service, we aimed to increase the proportion of cases discharged on oral antibiotics to at least 70%.
  
  
  METHODS
  The setting for our observational time series study was a large academic children's hospital. The model for improvement and plan-do-study-act cycles were used to test, refine and implement interventions identified through our key driver diagram. Our multifaceted intervention included a shared decision-making tool, an order set in our electronic health record, and education to faculty and trainees. We also included an identify and mitigate intervention to target providers caring for children with osteomyelitis in near-real time and reinforce the evidence-based recommendations. Data were analysed on an annotated g-chart of osteomyelitis cases between patients discharged on intravenous antibiotics. Structured chart review was used to identify treatment failures as well as length of stay and hospital charges in preintervention and postintervention groups.
  
  
  RESULTS
  The osteomyelitis cases between patients discharged on intravenous antibiotics increased from a median of 0 preintervention to a maximum of 9 cases following our identify and mitigate intervention. The direction and magnitude of successive improvements observed satisfied criteria for special cause variation. Improvement has been sustained for 1 year. Treatment failure and complications were uncommon in preintervention and postintervention phases. No significant differences in length of stay or charges were detected.
  
  
  CONCLUSIONS
  Even for uncommon conditions, rapid and sustained evidence adoption is possible using quality improvement methods.
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA The James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Brady
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA The James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: William B
authors.initials: WB
authors.lastname: Brinkman
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Simmons
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Connie
authors.initials: C
authors.lastname: Yau
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Christine M
authors.initials: CM
authors.lastname: White
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Eric S
authors.initials: ES
authors.lastname: Kirkendall
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Joshua K
authors.initials: JK
authors.lastname: Schaffzin
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Centers for Medicare and Medicaid Services, Baltimore, Maryland, USA.
authors.forename: Patrick H
authors.initials: PH
authors.lastname: Conway
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Vossmeyer
mesh_terms: D000208:Acute Disease; D000284:Administration, Oral; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008297:Male; D010019:Osteomyelitis / Q000188:drug therapy*; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge; D016730:Program Development; D058996:Quality Improvement / Q000458:organization & administration
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antibiotic Management; Continuous Quality Improvement; Decision Making; Evidence-Based Medicine; Paediatrics