Improving antibiotic prescribing practices for Acute Otitis Media (AOM) in a pediatric tertiary care center emergency unit

From the 2021 HVPAA National Conference

Amanda Dube (Washington University in St. Louis), Amy Zhao, Chioma Odozor, Katherine Jordan, Angela Kennedy, Hafsa Lodhi, Becca Scherder, Jason Newland, Oloruntosin Adeyanju

Background

Acute otitis media (AOM) is a commonly overtreated pediatric diagnosis. Since 2014, the American Academy of Pediatrics (AAP) has recommended shorter antibiotic courses for healthy children with mild-to-moderate AOM; specifically, 7 days for children ages 2-6 and 5 days for children over age 6. While this strategy has been successfully implemented in some pediatric emergency units (EUs), studies have shown that 30-90% of children with AOM treated in pediatric EUs do not get care consistent with these guidelines.

Objective

We aimed to assess via chart review and then and then intervene via multiple PDSA cycles to improve antibiotic prescribing practices in our tertiary care children’s hospital EU.

Methods

To assess baseline antibiotic prescribing behavior, we performed a chart review of children >/= 2 diagnosed with AOM in the St. Louis Children’s Hospital (SLCH) EU. Inclusion criteria were age >/= 2 years, diagnosis of any form of “otitis,” and discharged between 5/1/2019 and 7/31/2020. Exclusion criteria were diagnosis of otitis externa, medical complexity, concurrent other bacterial illness, ear tubes, or recent antibiotic use. Severity was estimated using presence/height of fever, symptom duration, and presence of otorrhea/ear pain/bulging tympanic membrane. A sampling of patients were called 14-60 days post-discharge to assess for satisfaction with ED care and whether further medical care was required related to their AOM. We analyzed all data using R v.3.5.2 software.

For our first PDSA cycle, we: 1) created a guideline card with a flowchart for assessing and treating AOM; 2) added a clickable button in the amoxicillin prescription order box for a 5-day duration to the existing 7- and 10-day duration buttons; and 3) provided education to EU providers. For our second PDSA cycle, we initiated sending monthly progress/reminder emails to EU providers. For our third PDSA cycle, we are implementing a discharge smartset for AOM that will default to correct duration antibiotics based on age.

Results

For our baseline data, 642 charts were reviewed and 570 were included in the analysis. Only 41% of patients who were prescribed antibiotics were prescribed an appropriate duration based on their age and estimated AOM severity. Throughout our first two PDSA cycles, we were able to increase the percentage of patients who received appropriate duration antibiotics to an average of 61%. 23 families answered our follow-up questions by phone. There was no difference in satisfaction, resolution of symptoms by the time of the phone call, or the need for non-routine medical visits for patients prescribed shorter duration (5-7 day) antibiotics versus longer duration (10+ days) antibiotics. Our next step is to make an EU discharge order smartset which will provide default for appropriate duration antibiotics based on age.

Conclusions

AOM management in our tertiary care children’s hospital EU is often not consistent with AAP guidelines. Our first two PDSA cycles resulted in an improvement in the rate of appropriate duration antibiotic prescribing, based on both patient age and AOM severity, from 41% to 61%. Follow-up phone calls suggest no difference in satisfaction or need for non-routine follow-up care based on prescription length.

Clinical Implications

This project improved the quality of patient care by reducing unnecessary antibiotic days for pediatric patients with AOM seen in a large children’s hospital EU. Decreasing unnecessary antibiotic days is important for decreasing healthcare costs as well as decreasing the development of antibiotic resistance.

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