Screening for antibiotic resistant Gram-negative bacteria.
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Carbapenems↗
Biomedical subjects
Jonathan R Iredell
Publications and source records attributed to Jonathan R Iredell.
Handheld computer-based decision support reduces patient length of stay and antibiotic prescribing in critical care.
OBJECTIVE: This study assessed the effect of a handheld computer-based decision support system (DSS) on antibiotic use and patient outcomes in a critical care unit. DESIGN: A DSS containing four types of evidence (patient microbiology reports, local antibiotic guidelines, unit-specific antibiotic susceptibility data for common bacterial pathogens, and a clinical pulmonary infection score calculator) was developed and implemented on a handheld computer for use in the intensive care unit at a tertiary referral hospital. System impact was assessed in a prospective "before/after" cohort trial lasting 12 months. Outcome measures were defined daily doses (DDDs) of antibiotics per 1,000 patient-days, patient length of stay, and mortality. RESULTS: The number of admissions, APACHE (Acute Physiology, Age, and Chronic Health Evaluation) II and SAPS (Simplified Acute Physiology Score) II for patients in preintervention, and intervention (DSS use) periods were statistically comparable. The mean patient length of stay and the use of antibiotics in the unit during six months of the DSS use decreased from 7.15 to 6.22 bed-days (p = 0.02) and from 1,767 DDD to 1,458 DDD per 1,000 patient-days (p = 0.04), respectively, with no change in mortality. The DSS was accessed 674 times during 168 days of the trial. Microbiology reports and antibiotic guidelines were the two most commonly used (53% and 22.5%, respectively) types of evidence. The greatest reduction was observed in the use of beta-lactamase-resistant penicillins and vancomycin. CONCLUSION: Handheld computer-based decision support contributed to a significant reduction in patient length of stay and antibiotic prescribing in a critical care unit.
APACHE↗
Comparative impact of guidelines, clinical data, and decision support on prescribing decisions: an interactive web experiment with simulated cases.
OBJECTIVE: The aim of this study was to compare the clinical impact of computerized decision support with and without electronic access to clinical guidelines and laboratory data on antibiotic prescribing decisions. DESIGN: A crossover trial was conducted of four levels of computerized decision support-no support, antibiotic guidelines, laboratory reports, and laboratory reports plus a decision support system (DSS), randomly allocated to eight simulated clinical cases accessed by the Web. MEASUREMENTS: Rate of intervention adoption was measured by frequency of accessing information support, cost of use was measured by time taken to complete each case, and effectiveness of decision was measured by correctness of and self-reported confidence in individual prescribing decisions. Clinical impact score was measured by adoption rate and decision effectiveness. RESULTS: Thirty-one intensive care and infectious disease specialist physicians (ICPs and IDPs) participated in the study. Ventilator-associated pneumonia treatment guidelines were used in 24 (39%) of the 62 case scenarios for which they were available, microbiology reports in 36 (58%), and the DSS in 37 (60%). The use of all forms of information support did not affect clinicians' confidence in their decisions. Their use of the DSS plus microbiology report improved the agreement of decisions with those of an expert panel from 65% to 97% (p=0.0002), or to 67% (p=0.002) when antibiotic guidelines only were accessed. Significantly fewer IDPs than ICPs accessed information support in making treatment decisions. On average, it took 245 seconds to make a decision using the DSS compared with 113 seconds for unaided prescribing (p<0.001). The DSS plus microbiology reports had the highest clinical impact score (0.58), greater than that of electronic guidelines (0.26) and electronic laboratory reports (0.45). CONCLUSION: When used, computer-based decision support significantly improved decision quality. In measuring the impact of decision support systems, both their effectiveness in improving decisions and their likely rate of adoption in the clinical environment need to be considered. Clinicians chose to use antibiotic guidelines for one third and microbiology reports or the DSS for about two thirds of cases when they were available to assist their prescribing decisions.
Anti-Bacterial Agents↗