Appl Clin Inform 2018; 09(02): 248-260
DOI: 10.1055/s-0038-1641594
Research Article
Schattauer GmbH Stuttgart

Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program

Mustafa Ozkaynak
1  College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
Danny T. Y. Wu
2  Department of Biomedical Informatics and Pediatrics, University of Cincinnati, Cincinnati, Ohio, United States
Katia Hannah
3  Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
Peter S. Dayan
4  Division of Pediatric Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, United States
Rakesh D. Mistry
5  Section of Emergency Medicine, Department of Pediatrics and Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
› Author Affiliations
Funding This study was funded by grants from Emergency Medicine Foundation, University of Colorado School of Medicine and Children's Hospital Colorado.
Further Information

Publication History

02 October 2017

21 February 2018

Publication Date:
11 April 2018 (online)


Background Clinical decision support (CDS) embedded into the electronic health record (EHR), is a potentially powerful tool for institution of antimicrobial stewardship programs (ASPs) in emergency departments (EDs). However, design and implementation of CDS systems should be informed by the existing workflow to ensure its congruence with ED practice, which is characterized by erratic workflow, intermittent computer interactions, and variable timing of antibiotic prescription.

Objective This article aims to characterize ED workflow for four provider types, to guide future design and implementation of an ED-based ASP using the EHR.

Methods Workflow was systematically examined in a single, tertiary-care academic children's hospital ED. Clinicians with four roles (attending, nurse practitioner, physician assistant, resident) were observed over a 3-month period using a tablet computer-based data collection tool. Structural observations were recorded by investigators, and classified using a predetermined set of activities. Clinicians were queried regarding timing of diagnosis and disposition decision points.

Results A total of 23 providers were observed for 90 hours. Sixty-four different activities were captured for a total of 6,060 times. Among these activities, nine were conducted at different frequency or time allocation across four roles. Moreover, we identified differences in sequential patterns across roles. Decision points, whereby clinicians then proceeded with treatment, were identified 127 times. The most common decision points identified were: (1) after/during examining or talking to patient or relative; (2) after talking to a specialist; and (3) after diagnostic test/image was resulted and discussed with patient/family.

Conclusion The design and implementation of CDS for ASP should support clinicians in various provider roles, despite having different workflow patterns. The clinicians make their decisions about treatment at different points of overall care delivery practice; likewise, the CDS should also support decisions at different points of care.

Protection of Human and Animal Subjects

This study was approved as a quality improvement activity by the Organizational Research Risk and Quality Improvement Review Panel, under agreement with the local Institutional Review Board.