P3.J192: Improving Adherence to Clinical Practice Guidelines For The Treatment Of Acute Otitis Media – An Antibiotic Stewardship Initiative In A Community Hospital Network

Purpose/Objectives: Children are prescribed 7 million antibiotic courses annually in US Emergency Departments (ED), most from community EDs. Acute Otitis Media (AOM) accounts for a large proportion of these prescriptions. AAP 2013 AOM Clinical Practice Guideline (CPG) recommends shorter treatment duration in children over 2 years and 48-72 hour observation without antibiotics in patients with non-severe features. Baseline data from our network of academic-affiliated community EDs showed longer treatment durations in children ≥2 years and infrequent use of observation.


Aim: Within one year, in patients diagnosed with AOM in the ED:
- Increase rate of guideline-concordant antibiotic duration in children ≥ 2 years by 20 percent
- Increase percentage of observation with Safety Net Antibiotic Prescriptions (SNAP) in eligible patients age ≥ 6 months by 20%.

Design/Methods: Six community EDs, staffed by over 100 providers including pediatricians, emergency physicians and physician assistants, and using different EMRs, collaborated with their local multidisciplinary teams in multiple PDSA cycles. Baseline data was collected from August 2022- January 2023 and post-intervention data from February 2023- January 2024. We included all patients aged 6 months to 18 years without underlying chronic disease or concomitant bacterial infection, who received a new diagnosis of AOM and prescribed oral antibiotics. We developed a visual algorithm representing the CPG, updated the network clinical pathway, posted visual reminders at workstations, created smart phrases to assist medical decision making and made EMR order sets. Sites using EPIC also used discharge smart sets with preselected antibiotic duration by age and SNAP discharge instructions. Data was analyzed using run charts.

Results: There were 2464 patients, 891 in baseline and 1573 in the intervention period. 319 charts with incomplete documentation [Baseline = 151 (17%); Intervention =168 (10.9%)] were excluded from analysis.
The median percentage of 5-day antibiotic duration (including SNAP) for patients ≥ 6y increased from 2.8% to 27.4%, met the 20 % goal, and the improvement has been sustained for more than 6 months (Figure 1). The median percentage of 7-day antibiotic duration for patients 2-5 years old increased from 40% to 58%, which was just below the 20 % goal. Median percent use of observation (SNAP %) in eligible patients with sufficient documentation increased from 5.5% to 40.4% and surpassed the improvement goal (Figure 2). There was no significant increase in ED return visits, 33 (3.7%) in baseline and 63 (4.1 %) in intervention period. There was no increase in antibiotic failure [7 in baseline (0.8%); 6 during intervention (0.4%)], and no documented complications.

Conclusion/Discussion: A community hospital collaborative improved emergency care of patients with AOM, both for treatment duration and use of observation. We plan to keep up our improvement efforts as well as expand the project to 2 other EDs in the network.