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BackgroundAntibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline.MethodsUsing the ‘Fit between Individuals, Task and Technology (FITT)’ framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED’s clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive’s user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment.ResultsData demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)).ConclusionAntibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.

Past literature has suggested maximizing customer satisfaction as a strategic choice to increase customer loyalty and ensuring revenues. However, the relationship between increased customer satisfaction and resultant revenue has remained unexamined. This research focuses on optimizing customer satisfaction rather than maximizing it. This optimization of customer satisfaction is based on maximizing profitability. In aiming for higher customer satisfaction levels with no regard to profitability, a company runs the risk of self-annihilation. Based on conceptual foundations of prior research on Return on Quality (ROQ), we propose the construct of Return on Satisfaction (ROS).We review frameworks of customer satisfaction examined by scholars in marketing and then propose a conceptual ROS model. We use empirical data (n =1597) obtained from an institution of higher education to test the conceptual model we propose. Results indicate that the data demonstrates construct validity and points to promising directions for further research. We conclude by underscoring managerial implications as well as the scholarly contributions of this research.