antibiotic appropriatness

Kuhn, Gloria gkuhn at MED.WAYNE.EDU
Sun Nov 10 20:36:47 UTC 2013

Dear Alan,
I sense and share your frustration.  Please remember that in the ED we are often operating with incomplete information coupled with demands of making decisions under time constraints imposed by CMS.  I know that many of us are frustrated that the concept that decisions made in the ED "clearly misdirects the whole team from what is really the correct diagnosis" implies that the team is incapable of looking at new evidence and making decisions that will put the team and the patient on the correct course. Clearly all of us within medicine need to be aware of the biases of premature closure and anchoring.
I have followed our discussions regarding 90 biases and still finding more with a sense of wonder.  After reading your impressive e-mail I am convinced if we would tackle and decrease the biases of premature closure and anchoring we would be doing countless patients a true service.
Add to this concept the requirement to actually look at the tests we order and mandatory stoppage of orders after a pre agreed number of days unless renewed by a physician or midlevel provider and we could really make an impact on error rates.
I wonder if as a group we could put together a program to do just that and see if it makes an impact.
Certainly not as grand as other research but I do believe we could do this and really help patients.
Gloria Kuhn
From: Sanders, Alan [Alan.Sanders at SPHP.COM]
Sent: Friday, November 08, 2013 2:54 PM
Subject: [IMPROVEDX] antibiotic appropriatness

I have been involved intimately with two antibiotic stewardship programs for the past seven years, and it is remarkable how many inappropriate course of antimicrobials are prescribed, for days, when no infection is ever documented.  Most commonly, these  antimicrobials are initiated in the ED and continued on the hospital ward, often on a hospitalist service, for  a “urosepsis”  which never exists.  This makes up a major part of our daily stewardship rounds which we do on the wards, with the charts, and EMR.  Going down the wrong road with this and other diagnoses (often CAP) leads to enormous antimicrobial costs, and clearly misdirects the whole team from what is really the correct diagnosis.
Alan Sanders, MD
Chief of Medicine
St.Peter’s  Hospital , Albany NY

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