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Oral antibiotics at discharge for children with acute osteomyelitis: a rapid cycle improvement project
  1. Patrick W Brady1,2,
  2. William B Brinkman1,2,3,
  3. Jeffrey M Simmons1,
  4. Connie Yau1,
  5. Christine M White1,
  6. Eric S Kirkendall1,4,
  7. Joshua K Schaffzin1,
  8. Patrick H Conway1,5,
  9. Michael T Vossmeyer1
  1. 1Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  2. 2The James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  3. 3Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  4. 4Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  5. 5Centers for Medicare and Medicaid Services, Baltimore, Maryland, USA
  1. Correspondence to Dr Patrick W Brady, Division of Hospital Medicine, The James M. Anderson Center for Health Systems Excellence, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 9016, Cincinnati, OH 45229, USA; patrick.brady{at}cchmc.org

Abstract

Background Substantial evidence demonstrates comparable cure rates for oral versus intravenous therapy for routine osteomyelitis. Evidence adoption is often slow and in our centre virtually all patients with osteomyelitis were discharged on intravenous therapy.

Objective For patients with acute osteomyelitis admitted to the hospital medicine service, we aimed to increase the proportion of cases discharged on oral antibiotics to at least 70%.

Methods The setting for our observational time series study was a large academic children's hospital. The model for improvement and plan-do-study-act cycles were used to test, refine and implement interventions identified through our key driver diagram. Our multifaceted intervention included a shared decision-making tool, an order set in our electronic health record, and education to faculty and trainees. We also included an identify and mitigate intervention to target providers caring for children with osteomyelitis in near-real time and reinforce the evidence-based recommendations. Data were analysed on an annotated g-chart of osteomyelitis cases between patients discharged on intravenous antibiotics. Structured chart review was used to identify treatment failures as well as length of stay and hospital charges in preintervention and postintervention groups.

Results The osteomyelitis cases between patients discharged on intravenous antibiotics increased from a median of 0 preintervention to a maximum of 9 cases following our identify and mitigate intervention. The direction and magnitude of successive improvements observed satisfied criteria for special cause variation. Improvement has been sustained for 1 year. Treatment failure and complications were uncommon in preintervention and postintervention phases. No significant differences in length of stay or charges were detected.

Conclusions Even for uncommon conditions, rapid and sustained evidence adoption is possible using quality improvement methods.

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