Making the APPropriate Choice: Utilization of a Smartphone Application to Optimize Antimicrobial Decisions Among Internal Medicine Trainees

From the 2021 HVPAA National Conference

Thomas Brooke (Walter Reed National Military Medical Center Internal Medicine Residency Program), Walter Gullory, Herman Pfaeffle, Sorana Raiciulescu, Rose Ressner


Antimicrobial stewardship (AS) increases patient safety and quality of care. Efficacy of a phone application (App) as an AS resource to shape prescribing practices is largely unknown. Walter Reed National Military Medical Center (WRNMMC) is a tertiary military academic medical center with an 81-person Internal Medicine (IM) residency. The WRNMMC AS program transitioned the institutional AS guidance and antibiogram to a mobile App platform in mid-2020.


Determine trainee barriers to AS and the impact of an App combined with a time-spaced learning reinforcement strategy on IM trainee prescribing practices for common Infectious Disease (ID) syndromes.


Trainees were assigned unique identifier codes (blinded to the study team) to link anonymous pre and post survey responses. After a pre-intervention survey, participants completed an orientation to the App. Once weekly educational sessions (ES) reinforcing App content was implemented over 12 weeks after which participants completed a post-intervention survey. Each weekly session covered a specific ID syndrome. Survey data was analyzed using SPSS Version 27.


Amongst 81 trainees, 67 (83%) completed the pre-intervention survey and 59 (73%) completed the post-intervention survey including 39% interns, 31% PGY2, and 27% PGY3. Common AS barriers included lack of knowledge, deference to seniority, established habits, and time needed to make an informed decision. The App and ES improved performance of an antimicrobial timeout (78%), antibiogram knowledge (68%) with 90% of trainees reporting increased access, IV to PO switch (61%), and therapy de-escalation (56%). Weekly ES led to 75% reporting at least moderate impact on learning. Across all ID syndromes, residents reported increased confidence in management post-intervention (paired t-test, P<0.001). Usage of the App increased from 42% to 90% after the intervention, and 95% modified their prescribing practice based on the App. The most common barrier to App usage was forgetting to use the App.


Utilization of an App combined with ES significantly improved multiple domains of AS practice among IM trainees leading to a modification in antimicrobial prescribing practice in the vast majority of participants. This model can be used to build a broader sustainable AS trainee curriculum.

Clinical Implications

AS increases positive patient outcomes and decreases cost, adverse reactions, antimicrobial resistance, and C. difficile infections. This project revealed that App usage reinforced by an educational curriculum can directly improve trainee AS knowledge and prescribing practices which in turn will directly improve patient care as antimicrobials are a top medication prescribed in the inpatient and outpatient setting.

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