126 - Implementation of the core elements of an outpatient antimicrobial stewardship program in pediatric emergency departments and urgent care clinics

Background: We used the Center for Disease Control and Prevention’s 4 core elements (commitment, action for policy and practice, tracking and reporting, education and expertise) to establish an outpatient antibiotic stewardship program (ASP) in 2 pediatric emergency departments (EDs) and 3 urgent care clinics (UCCs) of a healthcare system.

Methods: The outpatient ASP team consists of infectious diseases (ID) physicians, a pharmacist, and data analyst collaborating with ED and UCC providers. We placed a commitment letter in every exam room. We coach and support frontline providers to lead and sustain quality improvement (QI) projects. A monthly report evaluates rates of antibiotic use for viral infections and first-line antibiotic use for bacterial infections. We also compare rates of respiratory diagnoses and overall antibiotic use for all respiratory infections among the different sites. We developed an outpatient antibiotic handbook summarizing diagnosis and treatment recommendations for commonly encountered infections. Progress on prescribing trends and positive reinforcement are shared with providers during cookie rounds at bi-annual division meetings. We provide lectures, workshops, and newsletter articles on wise use of antibiotics.

Results: Pre-implementation data showed < 5% antibiotic use for common pediatric viral infections and >85% use of first-line antibiotics for common bacterial infections. Trends in the report help us identify site-specific improvement opportunities we are working with frontline providers on addressing. In 2 years, our QI efforts have resulted in an increase in safety-net antibiotic prescriptions for acute otitis media in the EDs from 0.4% to over 7.5%, and a decrease in the percentage of rapid streptococcal testing performed in children < 3years old from 13% to 5% in one UCC (Figure 1). We have completed 15 cookie rounds attended by all ED/UCC core providers. In a survey completed by 61 providers, 85% found the handbook to be very beneficial, and 97% report it impacts their daily practice (Table 1).Figure 1: Annotated control charts of 2 quality improvement projects. A. Increase in safety-net antibiotic prescriptions offered to children diagnosed with acute otitis media in the emergency department. B. decrease in the percentage of streptococcal rapid antigen detection tests performed on children younger than 3 years of age in one urgent care clinic
Table 1: Outpatient antibiotic handbook survey results


Conclusion: Seeking leadership support and most importantly engaging frontline providers allowed us to be successful in implementing the suggested core elements of an outpatient ASP and maximize existing resources.