Reducing Overuse of Antibiotics with Decision Support: The ROADS Study

项目摘要 下呼吸道感染（LRTI），包括肺炎、细支气管炎和感染相关 哮喘急性发作占所有急诊（艾德）就诊的近三分之一， 占美国每年儿童感染相关住院病例的三分之一。虽然病毒负责 对于绝大多数下呼吸道感染，抗生素是非常常用的处方。事实上，使用抗生素的天数越多， LRTI比儿童医院的任何其他情况都要多。不必要地使用抗生素， 不太有效或过于广谱的抗生素，以及治疗时间长于必要的所有 导致艾德和住院环境中儿科LRTI的抗生素使用不当。使用 不必要的抗生素会产生深远的后果，包括常见和不常见但严重的不良反应。 副作用，增加医疗保健利用率和成本，并促进抗菌药物的发展 耐药性是一个持续的全球公共卫生威胁。为了减少抗生素的不当使用， 管理计划（ASP）在美国医院已经变得司空见惯，并已被证明是 有效不幸的是，ASP的好处在很大程度上未能转化为独特和快节奏的艾德 环境这是一个关键的错失机会，因为更多的儿童在艾德得到照顾， 与住院患者相比，并且因为艾德护理经常严重影响随后的医院护理。我们 先前的研究表明，高质量的电子健康记录为基础的临床决策支持（CDS）是一个 一种可以弥合艾德抗生素管理差距并减少艾德不适当处方的策略 还有医院我们提出的研究建立在这一基础性工作的基础上，并利用了一个成熟的， 多元化的研究团队，具有跨临床护理连续体和生物医学信息学，临床 和卫生服务研究，实施科学和生物统计学，所有这些都位于支持性和良好的- 资源研究环境。在三家儿童医院内，我们将：定义关键的促进者， 在艾德和住院患者的护理点使用和接受抗生素CDS的障碍 (Aim 1）;创建两种CDS干预措施，无缝集成到艾德和住院医生的临床工作流程中 设置，包括a）抗生素顾问（Abx CDS），和B）实时ASP工具（ASP CDS）（目标2）; 测量Abx CDS和ASP CDS单独和联合治疗与常规治疗相比的有效性， 在一个框架内，增加艾德和住院环境中儿科LRTI的适当抗生素使用， 实用的随机对照试验（目标3）;并评估范围，采用和实施领域 在试验中，在接受Abx CDS和ASP CDS的患者中（目的4）。我们假设我们会 创建以管理为重点的CDS工具，有意义地改善LRTI儿童的抗生素使用， 可扩展，以便在各种环境中优化护理提供和结果。

PROJECT SUMMARY Lower respiratory tract infections (LRTI), including pneumonia, bronchiolitis, and infection-related exacerbations of asthma, are responsible for nearly one-third of all emergency department (ED) visits and 40% of all infection-related hospitalizations in children each year in the United States. While viruses are responsible for the vast majority of LRTIs, antibiotics are very frequently prescribed. In fact, more days of antibiotic use are attributable to LRTI than any other condition in children’s hospitals. Starting antibiotics unnecessarily, using less effective or overly broad-spectrum antibiotics, and treating for longer durations than necessary all contribute to inappropriate antibiotic use in pediatric LRTI in both ED and inpatient settings. Use of unnecessary antibiotics has profound consequences, including common and uncommon but severe adverse side effects, increased health care utilization and costs, and fueling the development of antimicrobial resistance, an ongoing global public health threat. To curtail inappropriate antibiotic use, Antimicrobial Stewardship Programs (ASPs) have become commonplace in United States hospitals and have proven to be effective. Unfortunately, the benefits of ASPs have largely failed to translate to the unique and fast-paced ED environment. This represents a key missed opportunity since many more children are cared for in the ED as compared to inpatient settings, and because ED care often critically influences subsequent hospital care. Our prior research suggests that high quality electronic health record-based clinical decision support (CDS) is a strategy that could bridge the ED antibiotic stewardship gap and reduce inappropriate prescribing in the ED and hospital. Our proposed research builds upon this foundational work and leverages an accomplished and diverse study team with expertise across the continuum of clinical care and in biomedical informatics, clinical and health services research, implementation science, and biostatistics, all housed within supportive and well- resourced research environments. Within three children’s hospitals, we will: define critical facilitators and barriers governing use and acceptance of antibiotic CDS at the point of care in the ED and inpatient settings (Aim 1); create two CDS interventions seamlessly integrated into clinician workflows in the ED and inpatient settings, including a) an antibiotic advisor (Abx CDS), and b) a real-time ASP tool (ASP CDS) (Aim 2); measure the effectiveness of Abx CDS and ASP CDS, alone and in combination, against usual care for increasing appropriate antibiotic use in pediatric LRTI in the ED and inpatient settings within the framework of a pragmatic randomized controlled trial (Aim 3); and evaluate Reach, Adoption, and Implementation domains within the trial among encounters receiving Abx CDS and ASP CDS (Aim 4). We hypothesize that we will create stewardship-focused CDS tools that meaningfully improve antibiotic use for children with LRTI and that are scalable in order to optimize care delivery and outcomes across a wide variety of settings.