P0512 - Optimizing the Utilization of a Safety Net Antibiotic Prescription for Acute Otitis Media in Pediatric Emergency Departments

Background: Acute otitis media (AOM) is the most common reason for pediatric antibiotic prescriptions. The 2013 American Academy of Pediatrics (AAP) AOM guidelines recommend a watchful waiting/safety-net antibiotic prescription (WW/SNAP) for non-severe AOM. A random chart review revealed that of 589 patients with AOM seen in two emergency departments (EDs) between August 2017 and April 2018, 190 (32%) qualified for WW/SNAP. All but 3 received immediate antibiotic prescriptions.

Aim: Increase WW/SNAP in children greater than 6 months old diagnosed with non-severe AOM in our two EDs from 0.5% to 15% by May 2020. Measures: Outcome-1) Percent offered WW/SNAP and 2) Percent parental acceptance of WW/SNAP. Balancing-1) Rate of return to the ED within 14 days and 2) Tympanic membrane (TM) perforation.

Methodology: We conducted a quality improvement project at a large, urban pediatric hospital which has EDs at 2 sites with differing throughput and staffing models. A pre-intervention survey in June 2018 provided information on knowledge gaps and guideline adherence among providers. During the first plan-do-study-act (PDSA) cycle in August 2018, we developed an algorithm summarizing AAP AOM guideline treatment recommendations to help providers quickly identify WW/SNAP eligible patients. We presented the algorithm at monthly ED staff meetings and displayed it prominently in workrooms for providers to readily see and utilize. During the second PDSA cycle in December 2018, a monthly email was sent by one ED to recognize providers who discussed WW/SNAP. The second ED utilized standardized electronic medical record templates for WW/SNAP education and implementation. In October 2019, for the third PDSA cycle, both EDs began to utilize standardized electronic prescriptions for AOM antibiotics grouped by AOM severity and patient age. We used a control chart to compare rates of WW/SNAP before and after interventions.

Results: Our results are summarized in the individual site control charts in Figures 1 and 2. The mean percentage offered WW/SNAP at Site 1 has improved to 7.9% and at Site 2 the mean has improved to 7.2%. The balancing measures, return visits to the ED within 14 days and TM perforations, are unchanged.

Discussion: Since implementation, the percentage of patients offered WW/SNAP for non-severe AOM has overall improved in both EDs. Parents are also more willing to accept the WW/SNAP approach compared to baseline. The implementation of additional interventions is briefly on hold due to the decrease in census and additional stressors associated with the coronavirus pandemic (COVID-19).

Conclusion: Watchful waiting and a safety-net antibiotic prescription in conjunction with parent education is effective in reducing the use of antibiotics in children with non-severe AOM in the ED setting. We plan to continue increasing WW/SNAP rates by implementing future PDSA cycles.