GME Patient Safety Quality and Innovation Symposium

Background: 

Evidence based procalcitonin algorithms recommend discontinuation of antibiotics at values < 0.25 ng/mL for lower respiratory tract infections. A retrospective study conducted at our academic center in 2021 demonstrated that treatment was continued despite a low PCT value in 80.4% of patients on antibiotics. We examined the impact of a nudge intervention on clinicians' decision to de-escalate antibiotics in patients with a low procalcitonin value. 

Methods: 

We conducted a pre-post intervention study on adult inpatients with a procalcitonin result < 0.25 ng/mL receiving antibiotics for LRTIs. We excluded patients on antibiotics for non-LRTIs, COPD exacerbation, or VAP/HAP, as well as immunosuppressed and ICU patients. In the intervention stage, we used a dynamic EPIC procalcitonin report to identify eligible patients and contacted 1st call providers via EPIC Secure Chat with a standardized message suggesting antibiotic de-escalation if clinically appropriate. Our primary endpoint was antibiotic duration and time from procalcitonin result to antibiotic de-escalation. Differences in mean times were compared using paired t-testing. 

Results: 

We conducted a nudge intervention on 48 patients between August-December 2023, and identified 48 patients between June-July 2023 to serve as a baseline comparison group. The mean antibiotic duration was 105.84 hours and 123.24 hours for the pre-intervention and intervention groups respectively (p=0.29). The time from procalcitonin result to antibiotic de-escalation was 105.85 hours and 108.15 hours for the pre-intervention and intervention groups respectively (p=0.87). In the intervention group, 25% of providers de-escalated antibiotics within 24 hours after nudge intervention. 

Conclusions: 

Nudge interventions did not influence clinician decision making regarding procalcitonin-guided antibiotic de-escalation, when evaluating mean antibiotic duration or time from procalcitonin result to antibiotic de-escalation. Despite high utilization of the procalcitonin assay at our institution, results rarely impact clinical decision-making. The utility of procalcitonin as a tool for antibiotic stewardship, absent more effective decision support, is questionable. 

Recommendations/Next Steps: 

Lack of improvement following a nudge implies that knowledge gaps do not explain discordance between testing and antibiotic prescribing. Future interventions could focus on guidance at the point-of-care through indication-based ordering protocols or other forms of restricted usage.