P0130 - Improving Antimicrobial Stewardship in the Emergency Department for Patients Diagnosed with Acute Otitis Media

Background
The American Academy of Pediatrics (AAP) recommends the use of narrow-spectrum antibiotics as first-line therapy for the 4 most common childhood respiratory bacterial illnesses (ear, sinus, throat, and lung infections).1 The AAP Acute Otitis Media (AOM) clinical practice guidelines, which were last updated in 2013, recommend narrow spectrum antibiotic duration of 10 days for children < 2 years of age and 7 days for children ≥ 2 years to minimize side effects and reduce development of antibiotic resistance.2 The Children’s Hospital of Philadelphia (CHOP) AOM clinical pathway also reflects these recommendations.3

Methodology
A multidisciplinary team convened to define aims and identify key drivers. Our overall project goal was to reduce unnecessary care by adhering to antibiotic duration recommendations for patients diagnosed with AOM in the Emergency Department (ED) who are discharged with an antibiotic prescription. We defined adherence as an antibiotic prescription for 7 days or less in patients ≥ 2 years, an antibiotic prescription for 10 days or less in patients <2 years, or an azithromycin prescription for 5 days or less in either age group. The project aim was to increase adherence to recommended antibiotic duration for patients ≥ 2 years from a baseline of 14% to 80% within 4 months of project initiation. Key drivers included lack of knowledge of AAP guidelines and CHOP clinical pathway and imperfect clinical decision support (CDS).

Baseline data from June 2011-September 2019 showed a duration adherence rate of 99.8% for patients < 2 years but only 14.3% for patients ≥ 2 years. Our first PDSA cycle focused on improving the AOM discharge smart set, which previously included a default duration of therapy of 10 days for all age groups. Change concepts of affordance and constraints were used to modify the CDS in the existing smart set to provide dynamically presented, age-specific recommendations for antibiotic duration starting in October 2019. We performed provider education about the new process in November 2019. After analyzing data on smart set usage, we aimed to achieve higher reliability when the smart set was not used. We performed a second PDSA cycle which removed the preselected duration of 10 days for the general amoxicillin prescription in January 2020.

Discussion
Our guideline duration adherence increased from a baseline of 14% to 88% (Figure 1). Since October 2019, we have saved over 2200 antibiotic days in patients ≥ 2 years diagnosed with AOM in the ED without an increase in ED 14-day revisit rates (Figure 2).

Conclusion
Antimicrobial stewardship in the ED aimed at implementing native, non-interruptive CDS tools along with education can significantly improve adherence to antibiotic duration recommendations for patients with AOM and safely reduce unnecessary care.