Date Published: January 29, 2019
Publisher: Public Library of Science
Author(s): Chang Ho Yoon, Stephen R. Ritchie, Eamon J. Duffy, Mark G. Thomas, Stephen McBride, Kerry Read, Rachel Chen, Gayl Humphrey, Mehreen Arshad.
Mobile phone apps have been shown to enhance guideline adherence by prescribers, but have not been widely evaluated for their impact on guideline adherence by prescribers caring for inpatients with infections.
To determine whether providing the Auckland City Hospital (ACH) antibiotic guidelines in a mobile phone app increased guideline adherence by prescribers caring for inpatients with community acquired pneumonia (CAP) or urinary tract infections (UTIs).
We audited antibiotic prescribing during the first 24 hours after hospital admission in adults admitted during a baseline and an intervention period to determine whether provision of the app increased the level of guideline adherence. To control for changes in prescriber adherence arising from other factors, we performed similar audits of adherence to antibiotic guidelines in two adjacent hospitals.
The app was downloaded by 145 healthcare workers and accessed a total of 3985 times during the three month intervention period. There was an increase in adherence to the ACH antibiotic guidelines by prescribers caring for patients with CAP from 19% (37/199) to 27% (64/237) in the intervention period (p = 0.04); but no change in guideline adherence at an adjacent hospital. There was no change in adherence to the antibiotic guidelines by prescribers caring for patients with UTI at ACH or at the two adjacent hospitals.
Provision of antibiotic guidelines in a mobile phone app can significantly increase guideline adherence by prescribers. However, providing an app which allows easy access to antibiotic guidelines is not sufficient to achieve high levels of prescriber adherence.
In response to the growing threat of antibiotic resistance, antibiotic stewardship programmes in primary and secondary care have introduced myriad prescribing and decision support tools in order to improve rates of appropriate antibiotic prescribing . Whilst high levels of adherence to antibiotic guidelines result in improved patient safety, improved treatment outcomes, and reduced antibiotic resistance [1, 2], adherence to these guidelines often remains low [3–5]. Multiple factors are thought to contribute to this problem: difficulties with accessing the guidelines; prescribers’ lack of confidence in the processes used for guideline development; prescribers’ perceptions that their own expertise results in better treatment decisions than those suggested by the guidelines; and institutional healthcare cultures which support idiosyncratic prescribing behaviour [4, 6].
We designed our study to test the hypothesis that the introduction of the SCRIPT app, which provides the ACH antibiotic guidelines in a user-friendly, decision-making process format, would increase prescriber adherence to these guidelines. We investigated the early impact of SCRIPT on the initial empiric treatment of adult patients admitted to ACH with either community-acquired pneumonia (CAP) or urinary tract infection (UTI). The study was approved by the New Zealand Health and Disabilities Ethics Committee (reference number: 16/STH/6).
Only 53 prescribers downloaded SCRIPT during the first month of the intervention period. This number rose gradually to 145 healthcare workers by the end of the study and the respiratory guidelines were the most frequently accessed during the study(Table 1).
The introduction of the SCRIPT antibiotic guideline app at ACH had a statistically significant, positive impact on prescriber adherence to the ACH antibiotic guidelines in patients with CAP. The rate of antibiotic guideline adherence improved by an absolute value of 8%, a relative increase of 42%, despite relatively slow uptake of the app. Importantly, in CAP, the introduction of SCRIPT was associated with a statistically significant rise in appropriate treatment (reductions in both over-treatment and in under-treatment). Whilst over-treatment with unnecessarily broad-spectrum antibiotics may cause harm by accelerating the development of antibiotic resistance, the potential consequences of under-treatment can be more immediately detrimental to patients. Although the 30-day mortality in the patients with CAP was not significantly reduced during the intervention period, this study was not designed to detect a significant change in patient outcomes, such as 30-day mortality or the rate of hospital readmission; larger studies would be required to answer such questions.