Improving Antibiotic Use in Urgent Care Facilities Through Implementation and Evaluation of Core Elements of Outpatient Antibiotic Stewardship

This study will characterize baseline antibiotic prescribing practices throughout the Intermountain Healthcare Urgent Care (IH UC) system and implement a bundle of stewardship interventions throughout the IH UC system with the intention of both scalability across a large number of sites and sustainability. The urgent care (UC) antibiotic stewardship intervention was designed to meet the unique challenges of UC providers and patients and will directly incorporate all Core Elements of Outpatient Antibiotic Stewardship.

Leadership Commitment. Improving the use of antibiotics is a priority for IH leaders. IH leaders created two new system-wide leadership roles to direct antibiotic stewardship efforts across IH's continuum of care: Dr. Eddie Stenehjem is the system's Antimicrobial Stewardship Medical Director and Dr. Whitney Buckel is IH's Antimicrobial Stewardship Pharmacy Manager. Drs. Stenehjem and Buckel direct and lead all inpatient and outpatient stewardship efforts across the system. The creation of a system-wide antimicrobial stewardship leadership structure demonstrates the IH commitment to deploy best practices in antibiotic stewardship across the healthcare system. IH has designated a new system-wide outpatient stewardship leadership position that serves as a direct liaison between UC leadership (Medical Directors and Associate Medical Directors), participating UC facilities, and antibiotic stewardship leadership. The outpatient stewardship leader will participate in education efforts around appropriate antibiotic use and will work closely with prescribers that have been identified to have high rates of inappropriate antibiotic prescribing and/or high rates of sinusitis/AOM diagnoses. Additionally, the Medical Director for UC has designated antibiotic prescribing as one of only two quality metrics that will be assessed longitudinally for UC clinicians across the system.

Action for Policy and Practice. Our bundle of stewardship interventions is based on prior evidence of effectiveness and the unique features of UC sites. Additionally, our bundle allows for adaptability based on knowledge gained from the qualitative components of the proposal described previously and the experiences gained throughout implementation. An essential component to our bundle will be the implementation of tools that are designed to improve the quality and efficiency of care provided in UC settings. The action elements of our intervention will include the following components:

1. Commitment Posters: All UC clinics will display commitment posters demonstrating support from corporate, infectious diseases, and urgent care leaders and signed by providers. These posters will be in the clinic waiting room attesting to the providers' commitment to judicious antibiotic prescribing.
2. EHR Tools: With the input of our frontline clinicians and assistance of our internal EHR developers, the study team has created electronic clinical decision support tools within our EHR to improve antibiotic prescribing for acute bacterial sinusitis and acute otitis media (AOM). This tool will improve efficiency of clinical documentation, improve diagnostic accuracy by embedding the required diagnostic elements of upper respiratory infections, provide quick access to patient education material, and facilitate the ordering of a guideline concordant antibiotic prescription. This tool also incorporates delayed antibiotic prescriptions, which is our new default prescribing method for AOM and sinusitis. The delayed antibiotic prescription order was specifically developed for this intervention to assist in tracking delayed prescribing. These tools will be tailored with help from our frontline caregivers and piloted at a small sampling of UC clinics prior to widespread implementation. The tools are expected to be of special interest for UC clinicians because they target the most common diagnoses associated with antibiotic prescribing, have the potential to enhance efficiency with documentation, and facilitate appropriate antibiotic selection.
3. Prescription Justification: Azithromycin is 2nd most common antibiotic prescribed in the IH outpatient network. However, azithromycin prescriptions are rarely appropriate in UC. Besides a few relatively uncommon ID conditions (e.g., mycobacterial infections), azithromycin is only recommended for community acquired pneumonia, gonorrhea and chlamydia, and Streptococcal pharyngitis with a penicillin allergy. However, in the IH outpatient population, it is the most common antibiotic used for acute bronchitis and cough, 5th most common for sinusitis, and 2nd most common antibiotic given for unspecified acute pharyngitis. Given the very high rates of azithromycin misuse, providers will now be required to justify their ordering of azithromycin with documentation. When azithromycin is ordered, the provider will be required to fill out an "azithromycin justification form" prior to having the order signed. The justification form will populate the medical record and display the indication for the antibiotic that was selected by the provider. This method of "accountable justification" is an effective method to reduce antibiotic overuse.

Tracking and Reporting. Using IH data analysts to access the Enterprise Data Warehouse, system level, facility level, and provider level reports have been developed to detail antibiotic prescribing practices. During the first 4 months of the baseline period, feedback from urgent care clinicians and leaders was generated on the design of the reports.