eP304 - Barriers to De-implementation of Antibiotic Treatment of Acute Uncomplicated Diverticulitis in the Emergency Department

Purpose/Background: Patients with acute uncomplicated sigmoid diverticulitis (AUSD) frequently present to the Emergency Department (ED). Despite randomized trials and society guidelines supporting the practice of omitting antibiotics for most patients with AUSD, many patients in North America will still receive antibiotics. We aim to explore the barriers to adoption of a no-antibiotic strategy for treatment of AUSD in our ED.Methods/Interventions: We developed a basic algorithm to guide no-antibiotic treatment of AUSD, including rationale and suggestions for supportive care measures and patient discharge instructions (Figure). This was distributed to all ED providers and a brief ten-minute education session was given during faculty meeting and resident didactics. An electronic survey on attitudes, past behaviors, and intentions, based on select domains from the theoretical domains framework was then sent via email through Qualtrics to all attending physicians, residents and advance practice providers (APPs). The survey included a summary of national guidelines recommending omitting antibiotic therapy for most patients with AUSD.Results/Outcomes: 156 providers were invited to participate; of these, 110 participated (70% response rate) with 96 completing the survey in its entirety. Most respondents reported that they prescribe antibiotics most of the time or always for AUSD (68%). Attending physicians were more likely to report always prescribing antibiotics (50%) as compared to residents/APPs (26%, p=0.01). Although most respondents were aware of national guidelines regarding no-antibiotic treatment for AUSD (54%), few agreed that it was easy to follow the guidelines during their last 3 months of practice (25%). Few respondents agreed that their colleagues were avoiding antibiotics (12%) or that no-antibiotic treatment was expected of them by their colleagues (20%). Similarly, while most respondents felt that they would feel satisfied and comfortable following national guidelines (60% and 61%) and few felt patients would have a poor outcome (11%), they thought patients would be dissatisfied (67%). Almost all providers supported the integration of a pathway within the electronic medical record that would establish this as the institutional norm (79%) and stated that they intended to follow national guidelines in the future (84%). Qualitative comments included concerns about medical-legal ramifications and a desire for room for provider discretion.Conclusion/

Discussion: Most ED providers reported that they were aware of national guidelines recommending against the use of antibiotics to treat AUSD. However, there were strong injunctive and descriptive norms with regards to use of antibiotics in this population; that is, providers observed that colleagues prescribe antibiotics and felt that there was an expectation that they would do the same. Providers agreed that an established institutional pathway would help them move in line with national guidelines. Next steps include implementation of this pathway with collection of pre- and post-implementation data on compliance and outcomes.Pathway for no-antibiotic treatment of AUSD in the ED