Decreasing antibiotic prescribing in acute respiratory infections through implementation of nurse driven clinical decision support

项目总结 过度使用抗生素治疗急性呼吸道感染(ARIS)继续推动抗生素耐药性的增加。 提供商驱动的临床决策支持(CDS)对减少抗生素处方的影响微乎其微 费率。此应用程序的总体目标是1)实施注册护士(RN)驱动的CDS 包含综合临床预测规则(ICPR)[嵌入电子健康记录中的决策辅助工具 根据患者病史和体检因素确定细菌感染风险] 2)确定RN驱动的CDS对不适当的抗生素处方和资源使用的影响。这个 中心假设是使用ICPR的RN将准确地确定患者患细菌性ARI的风险，建议 根据这种风险进行适当的测试和治疗，并将有较低的不适当抗生素使用率 与提供者相比，开处方。这个项目的基本原理是，CDS工具可以允许RN在 全面审查他们的执照，减少不适当的抗生素处方。这一中心假设将是 使用三个具体目标进行测试：1)采用和实施RN驱动的ICPR工具进行评估和治疗 在初级护理和紧急护理实践中的ARIS患者；2)确定RN驱动的ICPR的影响 关于抗生素处方、诊断测试排序、资源使用模式和成本效益；以及3)使用 理论驱动的实施框架，以确定障碍和促进者，并优化影响因素， 有效实施一项由RN驱动的ICPR。对于第一个目标，先前开发和研究的提供商 ICPR将适用于RN工作流程，并将实施RN培训计划，以培训RN使用其 患者评估和治疗。对于第二个目标，将进行阶梯式楔形整群随机试验 在四个参与机构的初级保健和紧急护理诊所进行。对于第三个目标， 将使用技术接受模型(TAM3)和Proctor框架作为评估的指南 实施结果并使用调查结果来推动实施后工具优化并创建 实施工具包。拟议的项目具有创新性，因为它：1)使用具有风险分层的CDS工具 使RNS能够领导最初的ARI评估和治疗；2)使用循证实施 评估成果并确定障碍和促进者的框架；以及3)评估 干预，这对增加传播潜力至关重要。这项拟议的研究具有重要意义 因为预计它将提供一个可扩展的实施模型，利用CDS和RN培训工具 减少抗生素的过度使用，降低护理成本，最终减少抗生素耐药性。

Project summary Overuse of antibiotics for acute respiratory infections (ARIs) continues to drive increasing antibiotic resistance. Provider-driven clinical decision support (CDS) has had a minimal impact on decreasing antibiotic prescribing rates. The overall objectives of this application are to 1) implement registered nurse (RN)-driven CDS containing integrated clinical prediction rules (iCPRs) [decision aids embedded into the electronic health record which determine risk of bacterial infection based on elements of the patient history and physical examination] and 2) determine the impact of RN-driven CDS on inappropriate antibiotic prescribing and resource use. The central hypothesis is that RNs using iCPR will accurately determine patients’ risk for bacterial ARI, recommend appropriate testing and treatment based on that risk and will have lower rates of inappropriate antibiotic prescribing compared to providers. The rationale for this project is that a CDS tool can allow RNs to work at the full scope of their licenses and decrease inappropriate antibiotic prescribing. This central hypothesis will be tested using three specific aims: 1) adapt and implement an RN driven iCPR tool for evaluation and treatment of patients with ARIs in primary care and urgent care practices; 2) determine the impact of the RN driven iCPR on antibiotic prescribing, diagnostic test-ordering, resource use patterns, and cost-effectiveness; and 3) use a theory-driven implementation framework to identify barriers and facilitators to, and optimize factors influencing, effective implementation of an RN-driven iCPR. For the first aim, the previously developed and studied provider iCPR will be adapted for RN workflow and a RN training program will be implemented to train RNs in its use for patient evaluation and treatment. For the second aim, a stepped wedge cluster randomized trial will be conducted at primary care and urgent care clinics at the four participating institutions. For the third aim, the Technology Acceptance Model (TAM3) and Proctor’s Framework will be used as guides to assess implementation outcomes and use findings to drive post-implementation tool optimization and create an implementation toolkit. The proposed project is innovative because it: 1) uses CDS tools with risk stratification to enable RNs to lead initial ARI assessment and treatment; 2) uses an evidence-based implementation framework to evaluate outcomes and identify barriers and facilitators; and 3) evaluates the cost of the intervention which is critical in increasing dissemination potential. The proposed research is significant because it is expected to provide a scalable implementation model leveraging CDS and RN training tools to decrease antibiotic overuse, lower the cost of care, and ultimately reduce antibiotic resistance.