Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program

Mustafa Ozkaynak; Danny T Y Wu; Katia Hannah; Peter S Dayan; Rakesh D Mistry

doi:10.1055/s-0038-1641594

Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program

Appl Clin Inform. 2018 Apr;9(2):248-260. doi: 10.1055/s-0038-1641594. Epub 2018 Apr 11.

Authors

Mustafa Ozkaynak¹, Danny T Y Wu², Katia Hannah³, Peter S Dayan⁴, Rakesh D Mistry⁵

Affiliations

¹ College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States.
² Department of Biomedical Informatics and Pediatrics, University of Cincinnati, Cincinnati, Ohio, United States.
³ Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States.
⁴ Division of Pediatric Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, United States.
⁵ Section of Emergency Medicine, Department of Pediatrics and Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States.

Abstract

Background: Clinical decision support (CDS) embedded into the electronic health record (EHR), is a potentially powerful tool for institution of antimicrobial stewardship programs (ASPs) in emergency departments (EDs). However, design and implementation of CDS systems should be informed by the existing workflow to ensure its congruence with ED practice, which is characterized by erratic workflow, intermittent computer interactions, and variable timing of antibiotic prescription.

Objective: This article aims to characterize ED workflow for four provider types, to guide future design and implementation of an ED-based ASP using the EHR.

Methods: Workflow was systematically examined in a single, tertiary-care academic children's hospital ED. Clinicians with four roles (attending, nurse practitioner, physician assistant, resident) were observed over a 3-month period using a tablet computer-based data collection tool. Structural observations were recorded by investigators, and classified using a predetermined set of activities. Clinicians were queried regarding timing of diagnosis and disposition decision points.

Results: A total of 23 providers were observed for 90 hours. Sixty-four different activities were captured for a total of 6,060 times. Among these activities, nine were conducted at different frequency or time allocation across four roles. Moreover, we identified differences in sequential patterns across roles. Decision points, whereby clinicians then proceeded with treatment, were identified 127 times. The most common decision points identified were: (1) after/during examining or talking to patient or relative; (2) after talking to a specialist; and (3) after diagnostic test/image was resulted and discussed with patient/family.

Conclusion: The design and implementation of CDS for ASP should support clinicians in various provider roles, despite having different workflow patterns. The clinicians make their decisions about treatment at different points of overall care delivery practice; likewise, the CDS should also support decisions at different points of care.

Schattauer GmbH Stuttgart.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Antimicrobial Stewardship*
Child
Decision Support Systems, Clinical*
Emergency Service, Hospital*
Humans
Tertiary Care Centers
Time Factors
Workflow*

Grants and funding

Funding This study was funded by grants from Emergency Medicine Foundation, University of Colorado School of Medicine and Children's Hospital Colorado.