To continue our FLOW Hacks series, Dr. Shawn Dowling writes about his team’s innovation aimed at reducing the number of Emergency Department (ED) revisits for repeated IV antibiotic administration.
This intervention was carried out in all of the EDs in Calgary, Alberta. Across all four sites, there is an average of 320, 000 patient visits annually.
Description of the innovation
In order to reduce the number of revisits to the ED for repeated IV antibiotic administration, we implemented a multi-faceted QI project to increase the usage of probenecid in addition to cefazolin. Our intervention included
- Education MD and RN’s about the evidence for probenecid and dosing, indications/contraindications, etc.
- Changes to our Computerized Physician Order Entry (CPOE) order sets to link all cefazolin order with an order for probenecid as a prompt to consider its’ usage.
We also provided clinicians with reminders about the initiative and assessed probenecid usage at a site by site level to ensure uptake was similar across the 4 EDs.
Was a quality improvement methodology Used?
We used PDSA cycles for the interventions (education/dissemination, order set changes, reminders) as well as dashboards to monitor the usage of probenecid over time.
What Data was used?
Using administrative data we extracted 90 days pre- and 90 post-intervention data for all adults ED’s in Calgary. Data included usage of probenecid, cefazolin, ED length of stay (triage to discharge), revisits to ED within 72 H (and/or admission at revisit).
Who was on the team?
Emergency Physicians, nursing, pharmacy, infectious disease
What performance measures were used?
The primary measure was comparing probenecid usage pre and post-intervention in patients with skin and soft tissue infections. Secondary measure were to compare ED revisits, 72 hour readmission rates and ED length of stay (LOS).
How was it implemented?
Over a 3 month period we
- Disseminated the education material (email, posted in MD/RN areas, departmental website)
- Implemented the ED order set changes
- Provided reminders about the initiative to clinicians
- Reviewed the site level data to ensure changes were sustained over time.
How did you get buy in from physicians, nurses, administrators and other allied professionals?
- Ensured there was good evidence to support the usage of probenecid in addition to cefazolin
- Co-designed the intervention with nursing, ID and ED physicians right from the beginning
- Support from departmental leadership by highlighting the impact on the ED (safely reducing ED return visits)
- Including balancing measures (readmission, unanticipated return to ED visits)
What impact has it had on your department?
2512 eligible patients (1148 and 1364 patients in the pre/post phases) were included. Probenecid usage in the pre- and post- intervention phase was 30.2% and 43.0% respectively, for an increase of 12.8% (p=<0.0001). Patients who received probenecid had a 3.3% (9.5% vs 12.8%, p=0.014) lower re-visit rate in the following 72H. ED readmission and LOS rates were 2.0% vs 1.5% and 5.9 vs 5.33 hrs when comparing those who received cefazolin vs cefazolin + probenecid.
What were some of the barriers to success?
- Coming to an agreement on dosing of probenecid (1 vs 2 gm)
- Assuring physicians that this usage of probenecid was a safe intervention (some MD’s felt reassured by having a reassessment in 8 hours at time of repeat IV antibiotic administration)
If you could do it all over again, what changes would you make?
- I would have looked at optimizing IV antibiotic usage (there are some patients who get IV antibiotics that could have been treated with PO antibiotics) prior to increase usage of probenecid
- Used SPC charts methodology rather than pre-post design
- Assessed the impact of this intervention on usage of ceftriaxone (historically, this was used when once daily dosing was preferred and probenecid was not used)
This post was copyedited by Sachin Trivedi (@svt882)