Beeler Patrick

Summary

The impact of electronic reminders encouraging early switches from intravenous to oral administration of antibiotics was studied in a hospital-wide, prospective, controlled trial. The reminders were displayed within electronic health records 60 h after onset of intravenously administered antibiotic therapy and if some patient-specific conditions were met. This intervention fostered early switching from intravenous to oral antibiotics, and thereby significantly reduced the mean duration of intravenous administration by 17%.

Introduction

Paper-based interventions have been shown to encourage switching from intravenous (IV) to oral (PO) administration of antibiotics. The purpose of this study was to determine whether automated electronic reminders are able to promote early switching.

Methods

In this controlled before-and-after study, an algorithm – starting 60 h after onset of IV antibiotic therapy – automatically checked whether: (i) the therapy was scheduled for an additional 24 h or longer, (ii) the neutrophil count of the patient exceeded 0.5 G/l, (iii) body temperature was below 38 °C, and (iv) the patient had the ability to swallow as indicated by active PO orders. If these conditions were met, a noninterruptive reminder was displayed within the electronic health record (EHR). These reminders – offering guidance on reassessment of the initial therapy – were displayed within the EHR in 12 units during the intervention period (year 2012). In contrast, no reminders were visible during the baseline period (year 2011) and in the control group (17 units). Comparisons of the duration of therapy were performed using the log-rank test. Levels of p ≤0.05 were considered significant.

Results

A total of 22,863 courses of IV antibiotics were analysed, and 6,082 (27%) were switched to PO. In the intervention group, 757 IV therapies were administered for a mean duration (±standard deviation) of 5.42 (±8.14) days before switching to PO in the baseline period and 794 courses for 4.47 (±5.49) days in the intervention period (p = 0.0035), corresponding to a 17% reduction of the IV administration time. No significant decrease of the IV administration time was observed in the control group.

The top five IV antibiotics that had been switched to PO were amoxicillin/enzyme inhibitor (EI), representing 45.5% of the switched IV therapies (most often switched to →PO amoxicillin/EI), piperacillin/EI (13.1%;→PO amoxicillin/EI), ceftriaxone (7.1%; →PO amoxicillin/EI), ciprofloxacin (5.7%; →PO ciprofloxacin), and cefuroxime (5.6%; →PO cefuroxime).

Discussion

The electronic reminders significantly reduced the time until switching from IV antibiotic therapies to the oral route of administration by 17%. They were triggered with a delay of 60 h after onset of the IV treatment and only if some patient-specific conditions were met, in order to limit alert fatigue.

As opposed to previous studies using paper-based interventions, this computer-based approach allows for hospital-wide implementation with an open-ended intervention period since no manpower is required for the continued operation of electronic reminders within the EHR.

Correspondence

Correspondence:

Dr. med. Patrick E. Beeler

Research Center for Medical Informatics

University Hospital Zurich and University of Zurich

Rämistrasse 100

CH-8091 Zurich

patrick.beeler[at]usz.ch

Copyright

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