Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial.
OBJECTIVE
Quality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay.


METHODS
An antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol.


RESULTS
Between 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6-11.5) versus intervention 10.1 days (95% CI 8.9-11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0-3.0), p<0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance.


CONCLUSIONS
Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist.
Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands. Electronic address: f.v.vandaalen@amc.nl.
F V
FV
van Daalen
Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands.
J M
JM
Prins
Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands.
B C
BC
Opmeer
Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
M A
MA
Boermeester
Department of Microbiology, Academic Medical Centre, Amsterdam, The Netherlands.
C E
CE
Visser
Department of Pharmacy, Academic Medical Centre, Amsterdam, The Netherlands.
R M
RM
van Hest
Department of Internal Medicine, Flevoziekenhuis, Almere, The Netherlands.
J
J
Branger
Department of Medical Microbiology, Reinier de Graaf, Delft, The Netherlands.
E
E
Mattsson
Department of Internal Medicine, Antoniusziekenhuis, Nieuwegein, The Netherlands.
M F M
MFM
van de Broek
Department of Internal Medicine, Spaarnegasthuis, Hoofddorp, The Netherlands.
T C
TC
Roeleveld
Department of Internal Medicine, Westfriesgasthuis, Hoorn, The Netherlands.
A A
AA
Karimbeg
Department of Hospital Pharmacy, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
E A F
EAF
Haak
Department of Internal Medicine, Spaarnegasthuis, Haarlem, The Netherlands.
H C
HC
van den Hout
Department of Internal Medicine, Division of Infectious Diseases, VU Medical Centre, Amsterdam, The Netherlands.
M A
MA
van Agtmael
Department of Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands.
M E J L
MEJL
Hulscher
Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands.
S E
SE
Geerlings
D061605:Administration, Intravenous; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D004363:Drug Utilization; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D055815:Young Adult
D000900:Anti-Bacterial Agents
Antibiotic checklist; Antibiotic stewardship; Appropriate antibiotic use; Cluster randomized trial; Quality improvement; Quality indicators