Care, Review, Assessment and Feedback Tool In Acute Respiratory infections (CRAFT-IAR) - Unnecessary antibiotic prescribing is a potentially avoidable source of iatrogenic harm, particularly in unscheduled outpatient care settings. Urgent outpatient care visits for acute upper respiratory infections (URIs) account for approximately 40% of all outpatient antibiotic prescribing, contributing to the high rates of antibiotic- associated adverse events and the global threat of antimicrobial resistance. Seen in emergency department (ED), retail clinic, and walk-in clinic settings, an estimated 23%–51% of all outpatient antibiotic prescriptions for URIs are unnecessary. Despite the recognized effectiveness of interventions based on audit and feedback and clinical decision support systems embedded in electronic health records for improving clinician behavior, existing antimicrobial stewardship programs are hampered by frequent underperformance and lack of sustainability of multifaceted, complex interventions because of the time-pressured nature of urgent clinics, lack of patient continuity, failure to consider clinician workflow, lack of usability of electronic tools, and inability to scale successful interventions. Our interdisciplinary team of experts in emergency medicine and infectious diseases, human factors engineering, biomedical informatics, clinical trials, biostatistics, and implementation science employed user- centered design to develop and pilot the Care, Review, Assessment and Feedback Tool (CRAFT) to provide automated feedback on patient outcomes and clinical processes of prescribing in urgent outpatient care settings as part of a Department of Veterans Affairs (VA)-funded grant. In addition to automated feedback, the intervention included clinician education through academic detailing, leadership engagement, clinical champions, and non-financial incentives. In the proposed CRAFT-IAR (CRAFT bundle In Acute Respiratory infections) study, we seek to adapt this intervention to a new healthcare system outside the VA, add electronic clinical decision support, and examine the effectiveness of the CRAFT bundle on antibiotic prescribing in a hybrid type 1 randomized clinical trial in a total of 31 EDs, retail clinics, and walk-in clinics across a single non-VA healthcare system in Middle Tennessee with over 90,000 annual acute URI visits and a potentially inappropriate prescribing rate of 27%, pursuing the following Aims: 1) Engage EDs, retail clinics, and walk-in clinics to understand workflows and implementation climate. 2) Adapt, refine, and implement the CRAFT bundle. 3) Examine the effectiveness and implementation of the CRAFT bundle vs. usual care antimicrobial stewardship on antibiotic prescribing and implementation outcomes for patients with acute URIs in unscheduled outpatient clinic visits. The advanced development and scalability of the previous iteration of the CRAFT bundle, our team’s expertise in clinical decision support development, and the engagement of operational leaders makes this important and minimal risk trial highly feasible and ready for evaluation in a real-world environment.
