antibiotic appropriatness

Kuhn, Gloria gkuhn at MED.WAYNE.EDU
Mon Nov 11 13:46:18 UTC 2013


Excellent points Prashant and truly underscore the fact that in the ED we are working with incomplete information and the stakes are very high in many cases.  To delay treatment in the example you describe to be sure that treatment is warranted after all information is gathered  is not a viable option. We need to rely on our colleagues in the inpatient setting who have the luxury of time and complete information to determine that our path was correct or decide it was incorrect for the reasons you and I stated and make a change to the correct path.
Gloria

From: Mahajan, Prashant [mailto:PMahajan at dmc.org]
Sent: Monday, November 11, 2013 5:45 AM
To: 'Society to Improve Diagnosis in Medicine'; Kuhn, Gloria
Subject: RE: antibiotic appropriatness

These are excellent comments - however, there are other issues at play that need to be taken into account - for instance, in the ED setting, the illness has not yet evolved or the information is often incomplete (very common in the pediatric ED setting), but most importantly, the reference standard is sub-optimal which precludes timely diagnoses.
For instance, if we were to be examining a very young febrile infant (less than 60 days of age) then we are balancing the risk between missing a very rare outcome (meningitis) vs.. overtreatment - the screening tests have pathetic test characteristics (complete blood counts and even the newer tests such as procalcitonin) but even more worrisome is the fact that the current reference standard i.e. blood culture is suboptimal as well. Thus in this case, over treatment is often the default - perfect storm of illness that has not yet evolved, rare outcome, minimal if any, findings on clinical examination, sub-optimal screening tests and inadequate reference standard - all of them lead to inappropriate antibiotic use

Best

Prashant


Prashant Mahajan MD MPH MBA
Division Chief and Research Director
Pediatric Emergency Medicine
Professor of Pediatrics & Emergency Medicine
Director Center for Quality and Innovation
Carman & Ann Adams Department of Pediatrics
Children's Hospital of Michigan
Detroit, MI - 48201
Phone: 313-745-5260
Fax: 313-993-7166
Email: pmahajan at dmc.org<mailto:pmahajan at dmc.org> and mahajan at comcast.net<mailto:mahajan at comcast.net>
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________________________________
From: Kuhn, Gloria [mailto:gkuhn at MED.WAYNE.EDU]
Sent: Sunday, November 10, 2013 3:37 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] antibiotic appropriatness
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
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
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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