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Key Points: Question: Can computerized provider order entry (CPOE) prompts that provide patient-specific risk estimates for multidrug-resistant organisms (MDROs) reduce empiric extended-spectrum antibiotic use in patients admitted with pneumonia? Findings: In a cluster-randomized trial of 59 hospitals (n = 44 780 adults in the intervention period), CPOE prompts promoting standard-spectrum antibiotics for patients at low risk of infection with MDROs significantly reduced empiric extended-spectrum antibiotic use in hospitalized patients with pneumonia by 28.4%, without increasing intensive care unit transfers or length of stay. Meaning: Real-time electronic health record–generated recommendations for standard-spectrum antibiotics using patient-specific risk for MDRO-associated infections can substantially and safely reduce empiric extended-spectrum antibiotic use in patients hospitalized for pneumonia. Importance: Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. Objective: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non–critically ill patients admitted with pneumonia. Design, Setting, and Participants: Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non–critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. Intervention: CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. Main Outcomes and Measures: The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Results: Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P <.001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. Conclusions and Relevance: Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. Trial Registration: ClinicalTrials.gov Identifier: NCT03697070 This clinical trial examines the effect of an antibiotic stewardship bundle (education, feedback, and real-time multidrug-resistant organism risk-based CPOE prompts) vs routine stewardship on antibiotic selection during the first 3 hospital days in adults with pneumonia. [ABSTRACT FROM AUTHOR]

Key Points: Question: Can computerized provider order entry prompts that present patient-specific multidrug-resistant organism (MDRO) risk estimates reduce empiric extended-spectrum antibiotics in patients admitted with urinary tract infection (UTI)? Findings: In a cluster-randomized trial of 59 hospitals (n = 55 412 adults in the intervention period), computerized provider order entry prompts promoting standard-spectrum antibiotics for patients at low risk of infection with MDROs significantly reduced empiric extended-spectrum antibiotic use in hospitalized patients with UTI by 17.4% without increasing intensive care unit transfers or length of stay. Meaning: Real-time electronic health record–generated recommendations for standard-spectrum antibiotics using patient-specific risk for MDRO-associated infections can safely reduce empiric extended-spectrum antibiotic use in patients hospitalized for UTI. Importance: Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. Objective: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Design, Setting, and Participants: Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017–September 30, 2018) and 15-month intervention period (April 1, 2019–June 30, 2020). Interventions: CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. Main Outcomes and Measures: The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Results: Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P <.001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Conclusions and Relevance: Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. Trial Registration: ClinicalTrials.gov Identifier: NCT03697096 This clinical trial evaluates whether computerized provider order entry prompts providing patient- and pathogen-specific multidrug-resistant organism risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of urinary tract infections. [ABSTRACT FROM AUTHOR]

Judy Munday,1– 4 Niall Higgins,1,2,5 Saira Mathew,1,2 Lizanne Dalgleish,1,2,5 Anthony S Batterbury,1,2,5 Luke Burgess,1,2,4 Jill Campbell,1,2,5 Lori J Delaney,1,2,6 Bronwyn R Griffin,1,2 James A Hughes,1,2,5 Jessica Ingleman,1,2 Samantha Keogh,1,2,5,7 Fiona Coyer1,2,5 1Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia; 2School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia; 3 Department of Health and Nursing Science, University of Agder, Grimstad, 4879, Norway; 4Mater Research Institute-UQ, South Brisbane, QLD 4101, Australia; 5Royal Brisbane and Women’s Hospital, Herston, QLD 4029, Australia; 6Colleges of Health and Medicine, Australian National University, Acton, ACT 2601, Australia; 7Alliance for Vascular Access Teaching and Research, Griffith University, Brisbane, QLD, 4111, AustraliaCorrespondence: Judy MundaySchool of Nursing, Rm 529, Level 5, N Block, Victoria Park Road, Kelvin Grove, QLD 4059, AustraliaTel +61 3138 8209Email judy.munday@qut.edu.auPurpose: Nurses provide care at each phase of the complex, perioperative pathway and are well placed to identify areas of care requiring investigation in randomized controlled trials. Yet, currently, the scope of nurse-led randomized controlled trials conducted within the perioperative setting are unknown. This scoping review aims to identify areas of perioperative care in which nurse-led randomized controlled trials have been conducted, to identify issues impacting upon the quality of these trials and identify gaps for future investigation.Methods: This scoping review was conducted in reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Searches were conducted in PubMed, Embase, Cumulative Index for Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials, with a date range of 2014– 19. Sources of unpublished literature included Open Grey, and ProQuest Dissertation and Theses, Clinical Trials.gov and the Australian and New Zealand Clinical Trials Registry. After title and abstract checking, full-text retrieval and data extraction, studies were appraised using the Joanna Briggs Institute Critical Appraisal Checklists for randomized controlled trials. Data were synthesized according to the main objectives. Key information was tabulated.Results: From the 86 included studies, key areas where nurses have led randomized controlled trials include patient or caregiver anxiety; postoperative pain relief; surgical site infection prevention: patient and caregiver knowledge; perioperative hypothermia prevention; postoperative nausea and vomiting; in addition to other diverse outcomes. Issues impacting upon quality (including poorly reported randomization), and gaps for future investigation (including a focus on vulnerable populations), are evident.Conclusion: Nurse-led randomized controlled trials in the perioperative setting have focused on key areas of perioperative care. Yet, opportunities exist for nurses to lead experimental research in other perioperative priority areas and within different populations that have been neglected, such as in the population of older adults undergoing surgery.Keywords: perioperative, nursing, randomized controlled trial, scoping review

Objective: Performing accurate medication history and reconciliation is recognized to reduce medication discrepancies and errors resulting in improved patient safety. This quality improvement project retrospectively evaluated the impact of a newly implemented pharmacy-led admission medication reconciliation program for several hospitals. Methods: In 2020, a pharmacy-led admission medication reconciliation program was implemented in 16 hospitals across a large health system. The program targeted high-risk, complex inpatients admitted through the emergency department and directly to the hospital. Medication history technicians captured the best possible medication list and medication reconciliation pharmacists reviewed the list, collaborating with providers to complete reconciliation, and intervening to optimize drug therapy. A retrospective, pre-post analysis was performed comparing the preimplementation time period of June to November 2019 to the postimplementation time period of June to November 2020. Outcomes evaluated included pharmacy staff productivity, adverse drug events (ADEs), complications, and healthcare professional satisfaction. Results: A total of 311,473 patients were admitted to the 16 hospitals during the pre- and postimplementation time periods. During the six-month postimplementation period, nearly 80,000 medication histories and reconciliations were completed, with 39.9% of those histories requiring medication clarification. Both the ADE rate and complication rate decreased significantly after program implementation, 12% decrease (p < 0.017) and 14% decrease (p < 0.001), respectively. Healthcare professional survey results from nurse, physician, and pharmacist respondents indicated a statistically significant improvement in satisfaction. Conclusion: After implementation of pharmacy-led admission medication reconciliation, patient ADEs and complications decreased during hospitalization, and physician, nurse, and pharmacist satisfaction significantly improved. [ABSTRACT FROM AUTHOR]