Antibiotic stewardship to reduce inappropriate antibiotic prescribing in integrated academic health-system urgent care clinics.

OBJECTIVE: To develop and implement antibiotic stewardship activities in urgent care targeting non-antibiotic-appropriate acute respiratory tract infections (ARIs) that also reduces overall antibiotic prescribing and maintains patient satisfaction. PATIENTS AND SETTING: Patients and clinicians at the urgent care clinics of an integrated academic health system. INTERVENTION AND METHODS: The stewardship activities started in fiscal 2020 and included measure development, comparative feedback, and clinician and patient education. We measured antibiotic prescribing in fiscal years 2019, 2020, and 2021 for the stewardship targets, potential diagnosis-shifting visits, and overall. We also collected patient satisfaction data for ARI visits. RESULTS: From FY19 to FY21, 576,609 patients made 1,358,816 visits to 17 urgent care clinics, including 105,781 visits for which stewardship measures were applied and 149,691 visits for which diagnosis shifting measures were applied. The antibiotic prescribing rate decreased for stewardship-measure visits from 34% in FY19 to 12% in FY21 (absolute change, -22%; 95% confidence interval [CI], -23% to -22%). The antibiotic prescribing rate decreased for diagnosis-shifting visits from 63% to 35% (-28%; 95% CI, -28% to -27%), and the antibiotic prescribing rate decreased overall from 30% to 10% (-20%; 95% CI, -20% to -20%). The patient satisfaction rate increased from 83% in FY19 to 89% in FY20 and FY21. There was no significant association between antibiotic prescribing rates of individual clinicians and ARI visit patient satisfaction. CONCLUSIONS: Although it was affected by the COVID-19 pandemic, an ambulatory antimicrobial stewardship program that focused on improving non-antibiotic-appropriate ARI prescribing was associated with decreased prescribing for (1) the stewardship target, (2) a diagnosis shifting measure, and (3) overall antibiotic prescribing. Patient satisfaction at ARI visits increased over time and was not associated with clinicians' antibiotic prescribing rates.

Using an online forum to encourage reflection about difficult conversations in medicine.

OBJECTIVE: Medical students encounter many challenging communication situations during the clinical clerkships. We created the Difficult Conversations Online Forum (DC Forum) to give students an opportunity to reflect, debrief, and respond to one another about their experiences. METHODS: The DC Forum is a web-based application with structured templates for student posts and responses, along with a mechanism for faculty feedback. It became a required part of the curriculum for third-year medical students in 2003. We content analyzed data collected during the 2003-2004 and 2004-2005 academic years (N=315). All open-ended responses were coded by two members of the research team; the few disagreements were resolved via discussion. RESULTS: While posts addressed a wide range of topics, more than one-third (35.6%) of students addressed delivering bad news. Nearly half (49.4%) of the students reported they had talked with someone about their difficult conversation, most frequently a resident physician; the suggestions they received varied in terms of helpfulness. Only a small percentage of students (4.7%) reported accessing other resources. CONCLUSION: The DC Forum provides a template that encourages reflection and dialogue about challenging communication situations. The online design is feasible, and enables a virtual discussion that can be joined by students regardless of their clerkship schedule or clinical site. PRACTICE IMPLICATIONS: A structured approach for reflection and a simple, safe mechanism for feedback are essential components of the learning process regarding difficult conversations. While the DC Forum was created for medical students, the online approach may prove useful across the continuum of medical education.