Decreasing Antibiotic Prescribing in Acute Respiratory Infections Through Nurse Driven Clinical Decision Support

NYU Langone Health

Status: Completed

Conditions: Acute Respiratory Infection

Treatments: Other: Integrated clinical prediction rule (iCPR) system (iCPR)

Study type: Interventional

Funder types: Other; NIH

Identifiers

NCT04255303

19-01222

2R01AI108680-07A1 (U.S. NIH Grant/Contract)

Details and patient eligibility

About

This study evaluates the effects of a novel integrated clinical prediction tool on antibiotic prescription patterns of nurses for acute respiratory infections (ARIs). The intervention is an EHR-integrated risk calculator and order set to help guide appropriate, evidence-based antibiotic prescriptions for patients presenting with ARI symptoms.

Full description

The proposed project will fill a critical gap in the evidence base and answer the important question: can pivoting ARI CDS tools towards nurses overcome established implementation barriers to reducing antibiotic use? The proposal is highly innovative in three ways: It uses CDS tools to embed evidence-based risk stratification to enable nurse-led ARI management. It creates a nurse training program to support this nurse-led ARI treatment pathway. It will be evaluated and optimized using evidence-based implementation frameworks that will guide assessment of the fidelity, acceptability, adoption, cost, and sustainability of the tool. This will provide comprehensive implementation measures, formative and summative, and enable a rigorous understanding of barriers and facilitators to implementing nurse-led CDS tools for reducing antibiotic overprescribing. This study will provide much needed guidance on how to implement CDS-enabled, nurse-led ARI assessment and treatment to reduce antibiotic overprescribing.

Enrollment: 347 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

Clinics:

• must be primary care and/or urgent care clinics
• should have a minimum of one registered nurse (RN) full time equivalents (FTE)

Nurses :

• be licensed to see patients and prescribed and/or recommend prescriptions for patients
• work a minimum of 0.5 FTE to ensure that they are seeing sufficient numbers of patients to maintain competency
• have access to the clinic EHR system, and use regularly as part of patient care

Patients:

• patients must have been seen at a participating clinic with a complaint of cough or sore throat.
• Ages 3-70 will be included for sore throat and ages 18-70 for cough

Exclusion criteria

• are unable or unwilling to provide informed consent
• are unable to participate meaningfully in an intervention that involves self-monitoring using software available in English (e.g., due to uncorrected sight impairment, illiterate, non-English-speaking, dementia)
• clinics will be excluded if phone call triage of patients with sore throat and cough is not performed by RNs
• Nurses will be excluded if they do not work with the clinic EHR as part of their workflow
• Patients with a history of chronic lung disease or immunosuppression will be excluded since the CPRs were not validated in these groups

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Crossover Assignment

Masking: None (Open label)

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347 participants in 2 patient groups

iCPR group

Experimental group

Description:

Clinic personnel (Providers and Nurses) will receive online training that includes: 1) an overview of the project; 2) iCPR workflows including triage; 3) CPR component review and risk categories; 4) history and physical examination components of the CPRs. The online training will be followed by in-person training to reinforce the online training and teach additional skills. In-person training sessions led by study team will last approximately 60 minutes, and consist of four basic components: 1) a review of the iCPR ARI protocol and tools; 2) on-screen walk-throughs of common scenarios employing the new tools; 3) physical examination technique practice with simulated patients; A 60-minute in-person follow-up nurse training will take place 4-6 weeks after implementation of the intervention.

Treatment:

Other: Integrated clinical prediction rule (iCPR) system (iCPR)

Control no intervention group

No Intervention group

Description:

standard care will continue as usual.