Status: Active

Duke University Health System (DUHS) is a national leader in antimicrobial stewardship. The Duke Center for Antimicrobial Stewardship and Infection Prevention (DCASIP) primarily focuses on inpatient antimicrobial stewardship efforts through the efforts of the Antimicrobial Stewardship and Evaluation Team. Strengthening the outpatient pediatric stewardship presence in Duke and Duke-affiliated clinics is an important quality and practice improvement need and a health system priority.

The primary goal of our implementation project is to improve guideline concordant-prescribing for acute upper respiratory tract infection (ARTI) in children seen at outpatient clinical sites within our health system. We will focus on overall rates of antibiotic prescribing, the use of amoxicillin (a narrow spectrum antibiotic) as first-line therapy, and variations in prescribing by practice site and patient sociodemographic characteristics.

WHAT WILL THIS PROJECT DO?

DUHS includes multiple outpatient practice settings for pediatric patients including emergency departments, urgent care sites, and the two networks of primary care clinics. These community-based primary care practices serve as the primary provider for children in Durham, North Carolina and surrounding areas. In total, 55 care delivery sites within DUHS care for children and are eligible for participation in this project. The sites include primary care (17 sites), internal medicine-pediatric (3 sites), and family practice (23 sites) practices, urgent cares (9 sites) and emergency departments (ED) (3 sites) located in urban, sub-urban, and rural areas of Durham, Orange, and Wake County in central North Carolina.

We will expand the eligibility age to include children up to 18 years as an adaptation to the interventions. This adaption aligns with current guideline recommendations from the AAP and the IDSA for the management of acute bacterial sinusitis, group A streptococcal pharyngitis, and community-acquired pneumonia, which encompass older children and adolescents and contribute to a more robust adoption of the interventions at the proposed sites. The frontline care delivery staff who will be involved in delivery of the intervention/program include faculty physicians, resident physicians, and advanced practice providers including nurse practioners and physician assistants. We expect that 607 prescribers (inclusive of both physicians and advanced practice providers) will be trained and expected to participate in the proposed implementation project.

We have identified barriers to appropriate antibiotic prescribing with the input of leadership at clinical sites and community members. Our overall implementation approach focuses on implementing evidence-based interventions to these existing barriers that will lead to meaningful practice change and improve healthcare and health outcomes. Our approach includes a base bundle and a proactive bundle that encompass the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Antibiotic Stewardship. The base bundle includes provider education, patient-facing educational materials, online prescribing dashboard, a clinical decision support tool, communication training, and clinic antibiotic stewardship champions. The proactive bundle will direct audit and feedback with antimicrobial stewardship experts accompanied by individualized reports to prescribers at each clinical site. The proactive bundle will direct audit and feedback with antimicrobial stewardship experts accompanied by individualized reports to prescribers at each clinical site. The base bundle interventions will be implemented at clinical sites at once and the proactive bundle will be implemented in a randomized, stepped wedge manner over 11 months. Based on historical electronic health records (EHR) data, the intended reach of this implementation initiative is approximately 57,000 patient encounters during the 15 month implementation period.

STAKEHOLDERS INVOLVED IN THIS PROJECT

• Medical directors: We have discussed the interventions and proposal with medical directors of the participating sites and have long-standing partnerships with these individuals. The medical directors have shared the project with key personnel within their clinical settings and have shared constructive input on this proposal.
• Professional organizations: our work is of importance to the AAP, IDSA, and the Pediatric Infectious Diseases Society who have a vested interested in antibiotic use. Further, our stewardship leaders are active members of the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient (SHARPS-OP) Collaborative which includes pediatric antimicrobial stewards nationally.
• Community partners: We have received formative feedback on this proposal from patient parents and community members through Duke’s Community Consultation Studio. We will continue to utilize the perspectives of this group through planned Community Consultation Studios in the pre-implementation period. We will tailor the group to include caregivers of patients seen in outpatient settings of our health system to ensure we are capturing the experiences of our targeted population.

IMPLEMENTATION STRATEGIES

• Prescriber education: structured education by antibiotic stewardship expersts to all prescribers
• Patient-facing educational materials: we will provide existing Centers for Disease Control and Prevention patient-facing educational materials to clinical sites
• Online antibiotic prescribing dashboard: we will create an interactive online dashboard accessible to all clinics and prescribers. This dashboard will allow providers to access information on their prescribing practices, compare them to their peers, and analyze how their prescribing varies based on demographic characteristics of the patients
• Clinical decision support embedded in the EHR: when prescribers make antibiotic prescriptions for ARTIs, a pop-up query will prompt them to confirm their decision and suggest a narrow-spectrum antibiotic
• Communication training: we will provide existing Dialogue Around Respiratory Illness Treatment (DART) training to prescribers to share evidence-based, patient-partnered communication strategies regarding antibiotic use
• Clinic antibiotic stewardship champions: we will train clinic antibiotic stewardship champions at each site. These champions will lead prescriber education and advocacy for antibiotic stewardship within their clinical setting.
• Directed audit and feedback with antimicrobial stewardship experts: Prescribers will receive individualized prescribing reports via email and antimicrobial stewardship experts will meet with outlying prescribers, medical directors, and clinic champions for on-site audit and feedback sessions.

This work is supported by the PCORI Health Systems Implementation Initiative (HSII).