A 4-part antibiotic stewardship initiative implemented in an urgent care center decreased the number of patients with viral upper respiratory infections (URIs) who improperly received antibiotics, according to research published in the Journal of the American Association of Nurse Practitioners.

Prior to the intervention, 80% of patients with viral infections were prescribed antibiotics; only 39% of patients at the center received proper treatment according to a baseline analysis. The overall antibiotic care score at the end of the intervention was 78%, just shy of the researchers’ 80% goal.

The primary aim of the intervention was to improve care and prevent misuse of resources; researchers set a goal to improve right care for patients aged 65 years and younger with a viral URI or viral infection of the head, ears, nose or throat from 36.2% to 80% within 90 days.

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Eleven nurse practitioners (NPs) and physician assistants (PAs) rotated through a single provider per each 10-hour shift at an urban hospital-based urgent care center. In addition, the center had a nurse manager, licensed practical nurses, and registration staff. Clinicians saw an average of 40 patients daily, 16% of whom lived below the poverty level.

The 90-day intervention period was divided into 4 plan-do-study-act (PSDA) cycles so that clinicians could build on each component of the initiative as time passed. Researchers established 4 new procedures to form the improvement initiative:

  1. Biweekly quality improvement team meetings
  2. A patient engagement shared decision aid (SDA)
  3. An antibiotic prescribing 5 Ds tool
  4. A retrospective case management log (CML).

During team meetings, 2 to 5 people discussed best practices for antibiotic stewardship and strategies for implementing the other tenants of the intervention. These meetings caused team engagement to rise from 47% to 96%.

Patient engagement was measured through the implementation of SDAs; 208 SDAs were utilized throughout the 90-day intervention to patients with chief complaints of acute bronchitis, acute sinusitis, acute pharyngitis, and pediatric acute otitis media. Patients or their caregivers wrote their symptoms and comments into the SDA, then discussed their notes with their provider during the examination.

Through telephone interviews with 20 patients, researchers observed that 75% of patients were pleased with their visit using an SDA, and 25% of patients were disappointed that they were not prescribed antibiotics. SDAs raised patient engagement scores from 33% at baseline to 93% at the end of the 90 days according to surveys collected at discharge.

A resource for providers titled “5 Ds of Antimicrobial Stewardship Checklist,” which was adapted from the Public Health Ontario clinical reference tool, informed clinicians about choosing the right drug, dose, drug route, dosing interval, and duration.

Overall, the 5 Ds tool increased prescribing accuracy from 20% at baseline to 95% post-intervention.  Based on cross-checking with guidelines indicated by the 5 Ds tool, providers prescribed antibiotics with 91% accuracy in PSDA cycle 2, compared with 93% accuracy in cycle 3 and 95% accuracy in cycle 4.

A total of 279 patients were entered into a retrospective CML; compared with 36% at baseline, the total right care score for proper antibiotic use was 63% in PSDA cycle 1, 72% in PSDA cycle 2, 87% in cycle 3 and 91% in cycle 4. The total right care score for all indicators in the CML increased from 39% at baseline to 62% post-intervention.

Researchers noted that the generalizability of this study’s findings may be limited due to the rotating nature of the providers at the urgent care. Further research is warranted to assess how the intervention would affect patient outcomes in a primary care setting with consistent providers.

“Overprescribing antibiotics could lead to multidrug-resistant infections. Implications for further study should include the sustainability of antibiotic stewardship with quarterly electronic record reports displaying provider antibiotic use for ongoing nurse practitioner peer review feedback to promote the use of the NYSDOH [New York State Department of Health] antibiotic prescribing guidelines,” the study authors concluded.


Forrest CL, Verzone A. Antibiotic stewardship: improving patient-centered right care in urgent care using a shared decision aid and 5 Ds tool. Published online October 7, 2020. J Am Assoc Nurse Pract. doi:10.1097/JXX.0000000000000511