Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections

The 2016 calendar year established our baseline to account for seasonal variability. Data were reported weekly and reviewed to evaluate the impact of PDSA cycles and inform new interventions.

Measures

Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving any enteral medication. We reasoned that if patients were well enough to take medications enterally, they could be given an enteral antibiotic that is highly bioavailable or readily achieves concentrations that attain pharmacodynamic targets. This practice change was a culture shift, decoupling the switch to enteral antibiotics from discharge readiness. Our EHR query reported only the antibiotic doses given to patients who took an enteral medication on the day of antibiotic administration and excluded patients who received only IV medications.

Outcome measures included antimicrobial costs per patient encounter using average wholesale prices, which were reported in our EHR query, and LOS. To ensure that transitions of IV to enteral antibiotics were not negatively impacting patient outcomes, patient readmissions within seven days served as a balancing measure.

Analysis

An annotated statistical process control p-chart tracked the impact of interventions on the proportion of antibiotic doses that were enterally administered during hospitalization. An x-bar and an s-chart tracked the impact of interventions on antimicrobial costs per patient encounter and on LOS. A p-chart and an encounters-between g-chart were used to evaluate the impact of our interventions on readmissions. Control chart rules for identifying special cause were used for center line shifts.¹⁴

Ethical Considerations

This study was part of a larger study of the residency high-value care curriculum,¹² which was deemed exempt by the CCHMC IRB.

The baseline data collected included 372 patients and the postintervention period in 2017 included 326 patients (Table). Approximately two-thirds of patients had a diagnosis of CAP.

The percentage of antibiotic doses given enterally increased from 44% to 80% within eight months (Figure 2). When studying the impact of interventions, residents on the HM QI team found that the standard EHR template added to daily notes did not consistently prompt residents to discuss antibiotic plans and thus was abandoned. Initial improvement coincided with standardizing discussions between residents and attendings regarding transitions. Furthermore, discussion of all patients on IV antibiotics during the prerounds huddle allowed for reliable, daily communication about antibiotic plans and was subsequently spread to and adopted by all HM teams. The percentage of enterally administered antibiotic doses increased to >75% after the evening huddle, which involved all HM teams, and real-time identification of failures on all HM teams with provider feedback. Despite variability when the total number of antibiotic doses prescribed per week was low (<10), we demonstrated sustainability for 11 months (Figure 2), during which the prerounds and evening huddle discussions were continued and an updated control chart was shown monthly to residents during their educational conferences.

Residents on the QI team spoke directly with other HM residents when there were missed opportunities for transition. Based on these discussions and intermittent chart reviews, common reasons for failure to transition in patients with CAP included admission for failed outpatient enteral treatment, recent evaluation by critical care physicians for possible transfer to the intensive care unit, and difficulty weaning oxygen. For patients with SSTI, hand abscesses requiring drainage by surgery and treatment failure with other antibiotics constituted many of the IV antibiotic doses given to patients on enteral medications.

Antimicrobial costs per patient encounter decreased by 70% over one year; the shift in costs coincided with the second shift in our process measure (Appendix Figure 2A). Based on an estimate of 350 patients admitted per year for uncomplicated CAP or SSTI, this translates to an annual cost savings of approximately $29,000. The standard deviation of costs per patient encounter decreased by 84% (Appendix Figure 2B), suggesting a decrease in the variability of prescribing practices.

The average LOS in our patient population prior to intervention was 2.1 days and did not change (Appendix Figure 2C), but the standard deviation decreased by >50% (Appendix Figure 2D). There was no shift in the mean seven-day readmission rate or the number of encounters between readmissions (2.6% and 26, respectively; Appendix Figure 3). In addition, the hospital billing department did not identify an increase in insurance denials related to the route of antibiotic administration.