Abstract
Abstract Background Prolonged ( > 24 hours) post operative antibiotic (abx) use is the most common reason for inappropriate abx use in hospitalized children occurring in 40% of cases. Effective strategies are needed to reduce inappropriate post operative abx use. One strategy, facilitation, helps people develop the skills to change the structure and processes within a system to reduce the gap between evidence and practice. This study evaluated the best strategy, order set change vs order set change + facilitation, to deimplement unnecessary post operative abxs.Figure 1:Operatic Stepped-Wedge Trial Design Stepped-wedge trial design comparing order set change only (control) versus order set change plus a facilitation workshop (intervention) attended by the ASP team at the beginning of step. Nine children’s hospitals were randomized to 1 of 3 clusters to begin the intervention at either steps 1, 2, or 3. All hospitals were in the intervention in steps 3-5. Each cluster included 3 hospitals and each step was 6 months in duration. Methods A stepped-wedge trial was conducted at 9 US children’s hospitals from 11/1/20-10/31/23 (Fig 1). After 6 months of all hospitals starting in control of changing order sets, 3 hospital antimicrobial stewardship teams in steps 1-3 participated in the intervention (int), a virtual facilitation workshop to help change order sets. The primary outcome was the rate of inappropriate post operative abxs ( > 24 hours) in clean and clean contaminated cases. Hospital data were collected through the National Surgical Quality Improvement Project Pediatrics. Secondary outcomes were rate of surgical site infection (SSI) and C. difficile infection (CDI). Generalized estimating equations (GEE) with logit link function were utilized to investigate the outcome changes across steps.Figure 2.All Cases All NSQIP-P clean and clean-contaminated cases inappropriate rate of post-operative antibiotic use (>24 hours) by step and group (control and intervention). The GEE model of inappropriate antibiotic rate is presented as the least square means with 95% Confidence intervals. Results The study included 17202 cases, 5913 control and 11289 int. Demographics included mean age of 8.4 years (sd 5.9); 51% female; 71% White, 14% Unknown, 9% Black race; and 14% Hispanic ethnicity. The common surgical specialties were orthopedics (31%), general (21%), and neurosurgery (17%). The overall post operative inappropriate rate was 10%, 11% control v. 10% int. 4 hospitals targeted spine cases (n 2733); the inappropriate rate was 28%, 33% control v. 26% int. Controlling for time and hospital, the GEE model showed a significant decrease in inappropriate post operative abx use for all cases and spine cases for the int across steps (Fig 2&3 p< 0.001). SSI and CDI rates were not significantly increased or decreased.Figure 3.Spine CasesSpine cases inappropriate rate of post-operative antibiotic use (>24 hours) by step and group (control and intervention). The GEE model of inappropriate antibiotic rate is presented as the least square means with 95% Confidence intervals. Conclusion Order set change plus facilitation resulted in a significant reduction in inappropriate post operative abx use. This study is the first deimplementation trial to show the impact of a facilitation workshop on inappropriate abx use. Disclosures Jason G. Newland, MD, MEd, Moderna: Grant/Research Support|Pfizer: Grant/Research Support
Published Version
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