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Kuijpers SME, van Haeringen KJ, Groot T, Sigaloff KCE, van Hest RM, Prins JM, Schade RP. Identifying excessive length of antibiotic treatment duration for hospital-acquired infections: a semi-automated approach to support antimicrobial stewardship. Antimicrob Resist Infect Control 2024; 13:52. [PMID: 38764096 PMCID: PMC11103818 DOI: 10.1186/s13756-024-01406-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 05/01/2024] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND Avoiding excessive antibiotic treatment duration is a fundamental goal in antimicrobial stewardship. Manual collection of data is a time-consuming process, but a semi-automated approach for data extraction has been shown feasible for community-acquired infections (CAI). Extraction of data however may be more challenging in hospital-acquired infections (HAI). The aim of this study is to explore whether semi-automated data extraction of treatment duration is also feasible and accurate for HAI. METHODS Data from a university-affiliated hospital over the period 1-6-2020 until 1-6-2022 was used for this study. From the Electronic Health Record, raw data on prescriptions, registered indications and admissions was extracted and processed to define treatment courses. In addition, clinical notes including prescription instructions were obtained for the purpose of validation. The derived treatment course was compared to the registered indication and the actual length of treatment (LOT) in the clinical notes in a random sample of 5.7% of treatment courses, to assess the accuracy of the data for both CAI and HAI. RESULTS Included were 10.564 treatment courses of which 73.1% were CAI and 26.8% HAI. The registered indication matched the diagnosis as recorded in the clinical notes in 79% of treatment courses (79.2% CAI, 78.5% HAI). Higher error rates were seen in urinary tract infections (UTIs) (29.0%) and respiratory tract infections (RTIs) (20.5%) compared to intra-abdominal infections (7.4%), or skin or soft tissue infections (11.1%), mainly due to incorrect specification of the type of UTI or RTI. The LOT was accurately extracted in 98.5% of courses (CAI 98.2%, HAI 99.3%) when compared to prescriptions in the EHR. In 21% of cases however the LOT did not match with the clinical notes, mainly if patients received treatment from other health care providers preceding or following the present course. CONCLUSION Semi-automatic data extraction can yield reliable information about the indication and LOT in treatment courses of hospitalized patients, for both HAI and CAI. This can provide stewardship programs with a surveillance tool for all in-hospital treated infections, which can be used to achieve stewardship goals.
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Affiliation(s)
- Suzanne M E Kuijpers
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Koen J van Haeringen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas Groot
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Kim C E Sigaloff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Department of Clinical Pharmacology, Department of Hospital Pharmacy, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier P Schade
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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Oertli C, Staub M, Zhang M, Katz SE. Impact of mandatory indications for outpatient antibiotic orders on accurate tracking of antibiotic indications. Infect Control Hosp Epidemiol 2024:1-6. [PMID: 38738537 DOI: 10.1017/ice.2024.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
OBJECTIVE We sought to evaluate whether implementing mandatory indications for outpatient electronic antibiotic orders or using encounter International Classification of Diseases, Tenth Revision (ICD10) codes more accurately reflected clinicians' charted diagnosis in encounter notes. Secondarily, we examined the appropriateness of antibiotic prescriptions. DESIGN Cross-sectional study. METHODS Mandatory indications were added to all outpatient electronic antibiotic orders on May 18, 2022. A randomly selected convenience sample of 1300 outpatient encounters with antibiotics from walk-in clinics was reviewed. Adjusted logistic regression was used to compare the congruence between encounter ICD10 code and charted diagnosis for encounters from July 15 to September 15, 2021 (pre-implementation period) to the congruence between encounter ICD10 code, charted diagnosis, and mandatory indication for encounters from July 15 to September 15, 2022 (post-implementation period). Antibiotic appropriateness based on charted diagnosis was also evaluated. RESULTS Among 1300 outpatient encounters, congruence between charted diagnosis and ICD10 code significantly increased in the post-implementation period (87.7% (565/644)) versus pre-implementation (83.3% (540/648), adjusted odds ratio (aOR) 1.52; 95% CI 1.03-2.25). Congruence between charted diagnosis and mandatory indication during post-implementation was 95.2% (613/644) and >5 times more likely to be congruent than charted diagnosis and ICD10 code during pre-implementation (aOR 5.45; 95% CI 3.26-9.11). Antibiotic prescribing based on charted diagnosis was twice as likely to be appropriate in the post-implementation period (aOR1.99; 95% CI 1.32-2.98). CONCLUSIONS Mandatory indications within antibiotic orders show better congruence with charted diagnosis than ICD10 codes and may increase antibiotic appropriateness and congruence between ICD10 code and charted diagnosis.
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Affiliation(s)
- Charles Oertli
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Milner Staub
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Infectious Diseases Section, Medical Service Line, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Minhua Zhang
- Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sophie E Katz
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Nishiguchi JL, Bio LL, Cornell ST, Schwenk HT. Indication-driven order entry decreases stewardship and pharmacist interventions. Infect Control Hosp Epidemiol 2024; 45:120-122. [PMID: 37529840 DOI: 10.1017/ice.2023.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Indication-driven order entry (IDOE) was implemented at our pediatric institution for cefazolin, piperacillin-tazobactam, and meropenem; the 3 most intervened upon antibiotics during prospective audit and feedback (PAF) by the antimicrobial stewardship program (ASP). IDOE was associated with a significant reduction in both ASP PAF recommendations and clinical pharmacist interventions.
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Affiliation(s)
- Jacey L Nishiguchi
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Sean T Cornell
- Center for Pediatric & Maternal Value, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Hayden T Schwenk
- Department of Pediatrics, Stanford School of Medicine, Stanford, California
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Evaluation of the accuracy of a mandatory indication field for outpatient antibiotic prescriptions. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e35. [PMID: 36865710 PMCID: PMC9972531 DOI: 10.1017/ash.2022.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 03/03/2023]
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Feather C, Appelbaum N, Darzi A, Franklin BD. Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis. BMJ Qual Saf 2023; 32:357-368. [PMID: 36788034 DOI: 10.1136/bmjqs-2022-015452] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/27/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Despite recommendations, documentation of indication on prescriptions and inpatient medication orders is not routinely practised. There has been a recent systematic review of indication documentation for antimicrobials, but not for interventions relating to indication documentation for medication more broadly. Our aims were to 1) identify, describe and synthesise the literature relating to effectiveness of interventions aimed at improving indication documentation and/or indication-based prescribing in both primary and secondary healthcare; 2) synthesise participant perspectives to identify barriers and facilitators to these interventions; and 3) make recommendations for both practice and research. METHODS A systematic literature search was conducted using Medline, Embase and CINAHL using two search concepts: electronic prescribing systems, and indication documentation and/or indication-based prescribing. Qualitative, quantitative and mixed-methods studies were included; outcome measures and results were extracted to produce a narrative synthesis. Quality appraisal by two independent reviewers was undertaken using the Mixed Methods Appraisal Tool. RESULTS We identified 21 studies evaluating interventions to aid indication documentation. Indication documentation was either via free-text, selection from a list, or by use of pre-defined indication-based order sentences for individual medications. For a number of outcomes, there was a mostly positive impact, including appropriateness of the medication order (6 of 8 studies), rates of prescribing error (2/2) and some less commonly reported clinical (2/4) and workflow-related outcomes (2/3). There was a less favourable impact on accuracy of indication documentation and rates of medication use, highlighting some unintended consequences that may occur when implementing new interventions. Participant insights from prescribers and other healthcare professionals complemented quantitative study results, highlighting both facilitators and barriers to indication documentation and the associated interventions. For example, barriers included long drop-down lists and the need to use workarounds to navigate approval systems due to time or knowledge constraints. Facilitating factors included the perceived benefits of indication documentation on communication among the healthcare team and with the patient. CONCLUSION Indication documentation has the potential to improve appropriate prescribing and reduce prescribing errors. However, further benefits to the prescriber, multidisciplinary team and patient may only be realised by developing methods of indication documentation that integrate more efficiently with prescriber workflows. PROSPERO REGISTRATION NUMBER CRD42021278495.
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Affiliation(s)
- Calandra Feather
- Department of Surgery and Cancer, Imperial College London, London, UK
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
| | | | - Ara Darzi
- Institute of Global Health Innovation at Imperial College London, London, UK
| | - Bryony Dean Franklin
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
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Saini S, Leung V, Si E, Ho C, Cheung A, Dalton D, Daneman N, Grindrod K, Ha R, McIsaac W, Oberai A, Schwartz K, Shiamptanis A, Langford BJ. Documenting the indication for antimicrobial prescribing: a scoping review. BMJ Qual Saf 2022; 31:787-799. [PMID: 35552253 DOI: 10.1136/bmjqs-2021-014582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/05/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice. OBJECTIVES We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations. ELIGIBILITY CRITERIA Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing. SOURCES OF EVIDENCE A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature. CHARTING AND ANALYSIS Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively. RESULTS We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice. CONCLUSION There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.
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Affiliation(s)
- Sharon Saini
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Elizabeth Si
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Certina Ho
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Safe Medication Practices, Toronto, Ontario, Canada
| | - Anne Cheung
- West Park Healthcare Centre, Toronto, Ontario, Canada
| | | | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Rita Ha
- North York Family Health Team, Toronto, Ontario, Canada
| | - Warren McIsaac
- Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anjali Oberai
- Wawa Family Health Team, Wawa, Ontario, Canada
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Kevin Schwartz
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Bradley J Langford
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, Ontario, Canada
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Chan AJ, Nisenbaum R, Downing M, Langford BJ. Evaluating the impact of mandatory indications on antibiotic utilization in a community hospital. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e121. [PMID: 36483345 PMCID: PMC9726569 DOI: 10.1017/ash.2022.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We evaluated the impact of introducing a mandatory indication field into electronic order entry for targeted antibiotics in adult inpatients. DESIGN Retrospective, before-and-after trial. SETTING A 400-bed community hospital. INTERVENTIONS All adult electronic intravenous (IV) and enteral orders for targeted antibiotics (moxifloxacin, ciprofloxacin, clindamycin, vancomycin, and metronidazole) had a mandatory indication field added. Control antibiotics (amoxicillin-clavulanate, ceftriaxone and piperacillin-tazobactam) were chosen to track shifts in antibiotic prescribing due to the introduction of mandatory indication field. METHODS Descriptive statistics were used to summarize the primary outcome, measured in Defined Daily Doses (DDD) per 1000 patient days (PD). Interrupted time-series (ITS) analysis was performed to compare levels and trends in antibiotic usage of targeted and control antibiotics during 24 months before and after the intervention. Additionally, a descriptive analysis of mandatory indication fields for targeted antibiotics in the postintervention period was conducted. RESULTS In total, 4,572 study antibiotic orders were evaluated after the intervention. Preset mandatory indications were selected for 30%-55% of orders. There was decreased usage of targeted antibiotics (mean, 92.02 vs 72.07 DDD/1000-PD) with increased usage of control antibiotics (mean, 102.73 vs 119.91 DDD/1000-PD). ITS analysis showed no statistically significant difference in overall antibiotic usage before and after the intervention for all targeted antibiotics. CONCLUSION This study showed moderate use of preset mandatory indications, suggesting that the preset list of indications can be optimized. There was no impact on overall antibiotic usage with the use of mandatory indications. More prospective research is needed to study the utility of this intervention in different contexts.
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Affiliation(s)
| | - Rosane Nisenbaum
- University of Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Ontario, Canada
- Applied Health Research Centre and MAP Centre for Urban Solutions, Ontario, Canada
| | - Mark Downing
- Unity Health Toronto, Ontario, Canada
- University of Toronto, Ontario, Canada
| | - Bradley J. Langford
- Public Health Ontario, Ontario, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, Ontario, Canada
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Muro FJ, Lyamuya FS, Kwobah C, Bollinger J, Bodinayake CK, Nagahawatte A, Piyasiri B, Kurukulasooriya R, Ali S, Mallya R, Rolfe R, Ruwanpathirana A, Sheng T, Østbye T, Drew R, Kussin P, Woods CW, Anderson DJ, Mmbaga BT, Tillekeratne LG. Opportunities for Improving Antimicrobial Stewardship: Findings From a Prospective, Multi-Center Study in Three Low- or Middle-Income Countries. Front Public Health 2022; 10:848802. [PMID: 35548085 PMCID: PMC9081325 DOI: 10.3389/fpubh.2022.848802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/24/2022] [Indexed: 11/26/2022] Open
Abstract
Background To develop effective antimicrobial stewardship programs (ASPs) for low- and middle-income countries (LMICs), it is important to identify key targets for improving antimicrobial use. We sought to systematically describe the prevalence and patterns of antimicrobial use in three LMIC hospitals. Methods Consecutive patients admitted to the adult medical wards in three tertiary care hospitals in Tanzania, Kenya, and Sri Lanka were enrolled in 2018-2019. The medical record was reviewed for clinical information including type and duration of antimicrobials prescribed, indications for antimicrobial use, and microbiologic testing ordered. Results A total of 3,149 patients were enrolled during the study period: 1,103 from Tanzania, 750 from Kenya, and 1,296 from Sri Lanka. The majority of patients were male (1,783, 56.6% overall) with a median age of 55 years (IQR 38-68). Of enrolled patients, 1,573 (50.0%) received antimicrobials during their hospital stay: 35.4% in Tanzania, 56.5% in Kenya, and 58.6% in Sri Lanka. At each site, the most common indication for antimicrobial use was lower respiratory tract infection (LRTI; 40.2%). However, 61.0% received antimicrobials for LRTI in the absence of LRTI signs on chest radiography. Among patients receiving antimicrobials, tools to guide antimicrobial use were under-utilized: microbiologic cultures in 12.0% and microbiology consultation in 6.5%. Conclusion Antimicrobials were used in a substantial proportion of patients at tertiary care hospitals across three LMIC sites. Future ASP efforts should include improving LRTI diagnosis and treatment, developing antibiograms to direct empiric antimicrobial use, and increasing use of microbiologic tests.
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Affiliation(s)
- Florida J. Muro
- Community Health Department, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
| | - Furaha S. Lyamuya
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Internal Medicine Department, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
| | - Charles Kwobah
- Moi University/Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - John Bollinger
- Duke-Margolis Center for Health Policy, Washington, DC, United States
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | - Champica K. Bodinayake
- Duke Global Health Institute, Durham, NC, United States
- University of Ruhuna, Galle, Sri Lanka
| | - Ajith Nagahawatte
- Duke Global Health Institute, Durham, NC, United States
- University of Ruhuna, Galle, Sri Lanka
| | | | | | - Shamim Ali
- Moi University/Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Rose Mallya
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Reproductive and Child Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Robert Rolfe
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | | | - Tianchen Sheng
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | - Truls Østbye
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | - Richard Drew
- Duke University, Durham, NC, United States
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, United States
| | | | - Christopher W. Woods
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | - Deverick J. Anderson
- Duke University, Durham, NC, United States
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, United States
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Duke Global Health Institute, Durham, NC, United States
- Paediatric and Child Health Department, Kilimanjaro Christian Medical Centre, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - L. Gayani Tillekeratne
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
- University of Ruhuna, Galle, Sri Lanka
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"Antibiotic hardstop" on electronic prescribing: impact on antimicrobial stewardship initiatives in patients with community acquired pneumonia (CAP) and infective exacerbations of chronic obstructive pulmonary disease (IECOPD). BMC Infect Dis 2022; 22:135. [PMID: 35135486 PMCID: PMC8822740 DOI: 10.1186/s12879-022-07117-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) remains a major public health threat and the exploration of interventions which may reduce inappropriate antimicrobial use are of particular interest. An Antibiotic Hardstop (AH) was included within the eMeds system introduced to the Central Coast Local Health District (CCLHD) in 2018. The function allows prescribers to set a predetermined time at which antibiotic orders would cease. By default, the function set prescribed length to 5 days with a view to encourage prescribers to review existing antimicrobial orders and reduce inappropriate use. METHODS Records of adult inpatients prescribed broad spectrum antimicrobials with a registered indication of community acquired pneumonia (CAP) or an infective exacerbation of chronic obstructive pulmonary disease (IECOPD) between the 1st of March 2017 and 31st May 2017 for the pre eMeds cohort and 1st March 2019 and 31st May 2019 for the post eMeds cohort were randomly selected from our local health network's Guidance MS® system. Baseline demographics, antimicrobial prescribing records and documented adverse events related to the AH function were collated/analysed. The days of therapy (DOT) and length of therapy (LOT) for each encounter were calculated manually and results analysed using a two-tailed t-test or Mann-Whitney U test. RESULTS Of patients eligible to have the AH function activated during their admission, 34% (n = 34) had the function deployed at least once. Following the introduction of eMeds mean DOT for the pooled indications cohort was reduced by 3.02 days (CI 95% 0.41-5.63, p < 0.05) and mean LOT by 1.97 days (CI 95% 0.39-3.55, p < 0.05). The hardstop function resulted in 2 cases of delayed or unintentionally ceased therapies. CONCLUSIONS Following the introduction of electronic prescribing and AH, a significant reduction was observed in the DOT and LOT for antimicrobial use for inpatients with CAP and IECOPD without a significant increase in adverse events. Further research is required to determine the extent to which the AH functionality directly contributed to this effect and if the effect is present across a broader range of indications.
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Parzen-Johnson S, Kronforst KD, Shah RM, Whitmer GR, Scardina T, Chandarraju M, Patel SJ. Use of the Electronic Health Record to Optimize Antimicrobial Prescribing. Clin Ther 2021; 43:1681-1688. [PMID: 34645574 DOI: 10.1016/j.clinthera.2021.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE This review summarizes how interventions in the electronic health record (EHR) can optimize antimicrobial stewardship across the continuum of antimicrobial decision making, from diagnosis of infection to discontinuation of therapy. In addition, opportunities to optimize provider communication and patient education are identified. METHODS A narrative review was conducted to identify how interventions in the EHR can influence antimicrobial prescribing behavior. Examples from pediatrics were specifically identified. Interventions were then categorized into high-impact/low-effort, high-impact/high-effort, and low-impact/low-effort groupings based on historical experience. FINDINGS EHR-based interventions can be used for stratifying patients at risk for infection and are useful in identifying patients with new-onset infections. Additional tools include automatically updated antibiograms tailored to specific patient populations, timely authorization of restricted antimicrobials, and more accurate allergy labeling. Medical errors can be reduced and communication between providers can be improved by standardized data fields. Clinical decision support tools can guide appropriate selection of therapy, and visual prompts can reduce unnecessarily prolonged therapy. Benchmarking of antimicrobial use, tailored patient education, and improved communication during transitions of care are enhanced through EHR-based interventions. IMPLICATIONS Prescribing behavior can be modified through a range of interventions in the EHR, including tailored education, alerts, prompts, and restrictions on provider behavior. Further studies are needed to compare the effectiveness of various strategies.
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Affiliation(s)
| | - Kenny D Kronforst
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Grant R Whitmer
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tonya Scardina
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Meg Chandarraju
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sameer J Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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11
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van den Broek AK, Beishuizen BHH, Haak EAF, Duyvendak M, Ten Oever J, Sytsma C, van Triest M, Wielders CCH, Prins JM. A mandatory indication-registration tool in hospital electronic medical records enabling systematic evaluation and benchmarking of the quality of antimicrobial use: a feasibility study. Antimicrob Resist Infect Control 2021; 10:103. [PMID: 34217361 PMCID: PMC8254448 DOI: 10.1186/s13756-021-00973-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/18/2021] [Indexed: 12/20/2022] Open
Abstract
Objectives Evaluation of the extent and appropriateness of antimicrobial use is a cornerstone of antibiotic stewardship programs, but it is time-consuming. Documentation of the indication at the moment of prescription might be more time-efficient. We investigated the real-life feasibility of mandatory documentation of the indication for all hospital antibiotic prescriptions for quality evaluation purposes. Methods A mandatory prescription-indication format was implemented in the Electronic Medical Record (EMR) of three hospitals using EPIC or ChipSoft HIX software. We evaluated the retrieved data of all antibiotics (J01) prescribed as empiric therapy in adult patients with respiratory tract infections (RTI) or urinary tract infections (UTI), from January through December 2017 in Hospital A, June through October 2019 in Hospital B and May 2019 through June 2020 in Hospital C. Endpoints were the accuracy of the data, defined as agreement between selected indication for the prescription and the documented indication in the EMR, as assessed by manually screening a representative sample of eligible patient records in the EMR of the three hospitals, and appropriateness of the prescriptions, defined as the prescriptions being in accordance with the national guidelines. Results The datasets of hospitals A, B and C contained 9588, 338 and 5816 empiric antibiotic prescriptions indicated for RTI or UTI, respectively. The selected indication was in accordance with the documented indication in 96.7% (error rate: 10/300), 78.2% (error rate: 53/243), and 86.9% (error rate: 39/298), respectively. A considerable variation in guideline adherence was seen between the hospitals for severe community acquired pneumonia (adherence rate ranged from 35.4 to 53.0%), complicated UTI (40.0–67.1%) and cystitis (5.6–45.3%). Conclusions After local validation of the datasets to verify and optimize accuracy of the data, mandatory documentation of the indication for antibiotics enables a reliable and time-efficient method for systematic registration of the extent and appropriateness of empiric antimicrobial use, which might enable benchmarking both in-hospital and between hospitals. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-00973-0.
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Affiliation(s)
- Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Berend H H Beishuizen
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
| | - Eric A F Haak
- Department of Hospital Pharmacy, OLVG, Location Oost, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Michiel Duyvendak
- Department of Hospital Pharmacy, Antonius Hospital, Location Sneek, Bolswarderbaan 1, 8601 ZK, Sneek, The Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Chris Sytsma
- Department of Information Technology, Antonius Hospital, Location Sneek, Bolswarderbaan 1, 8601 ZK, Sneek, The Netherlands
| | - Mieke van Triest
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
| | - Cornelia C H Wielders
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Affiliation(s)
- Jaap Ten Oever
- Department of Internal Medicine & Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, The Netherlands
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13
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Beardsley J, Vestal M, Rosario N, Meosky K, Johnson J, Luther V, Ohl C, Williamson J. Accuracy of and prescriber perceptions related to documenting antibiotic indications during order entry at an academic medical center. Am J Health Syst Pharm 2020; 77:282-287. [PMID: 31909417 DOI: 10.1093/ajhp/zxz318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To assess the accuracy of antibiotic indication documentation provided during order entry and prescriber perceptions of the requirement to specify indications. METHODS Patients who received 1 of 6 selected antibiotics from May 1 through June 30, 2017, were identified. Records of 30 randomly selected patients who received each study antibiotic were retrospectively reviewed. The primary endpoint was indication accuracy, defined as agreement of the indication entered during order entry with that documented in progress notes at the time of order entry. Secondary endpoints included correlation of entered indication and final diagnosis for empiric antibiotics. A brief survey was emailed to prescribers to assess the burden and perceptions of requiring an indication during order entry. RESULTS Four thousand five hundred twenty-four patients received 1 or more doses of a study antibiotic. For the 180 patients selected for evaluation, 89.4% of indications were accurate. Indications for antibiotics ordered for prophylaxis were more likely to be inaccurate than those for empiric or definitive antibiotics (accuracy rates of 46%, 94%, and 92%, respectively, p < 0.05). For empiric antibiotics, 78.5% of indications documented at order entry matched the final diagnosis. Two hundred fifty-four of 863 prescribers (29%) responded to the survey request. Most respondents felt that documenting the indication took no more than 20 seconds, was a "minor nuisance" or "occasionally burdensome," and had no impact on their consideration of antibiotic appropriateness. CONCLUSION With the exception of prophylaxis, the indications documented during order entry were sufficiently accurate to assist antimicrobial stewardship efforts. Although indication documentation was perceived as a minor burden, surveyed prescribers indicated it had only a minimal beneficial effect on antibiotic prescribing.
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Affiliation(s)
- James Beardsley
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC, and Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Mark Vestal
- Department of Pharmacy, Duke University Hospital, Durham, NC
| | - Norbert Rosario
- Department of Pharmacy, Valley Baptist Health System, Brownsville, TX
| | - Kalyn Meosky
- Department of Pharmacy, New Hanover Regional Medical Center, Wilmington, NC
| | - James Johnson
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC, and Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Vera Luther
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christopher Ohl
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - John Williamson
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC, and Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
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Scardina T, Stach L, Sun S, Kociolek LK, Reuter C, Vogt M, Patel S. Documentation of Indications: Agreement Between Order Entry and Clinical Notes and Effect on Time to Antibiotic Administration. J Pharm Pract 2020; 35:13-19. [PMID: 32643519 DOI: 10.1177/0897190020938225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND/OBJECTIVES Antibiotic indication documentation at the time of order entry is mandated by the Joint Commission. Inclusion of indication at order entry may have an impact on the time to administration. Our primary objective was to evaluate agreement between indication selected during order entry and clinical notes. Our secondary objective was to observe if there was a change in time to administration after indications were required during order entry. METHODS Patients ≤18 years old who received ≥1 dose of vancomycin or ceftriaxone during a preintervention period and 3 postintervention periods were included. Indication for use, agreement between order and clinical note, and timing of antibiotic administration were collected. RESULTS Most common indication for vancomycin (total: 789) was sepsis (26%, n = 204). Common indications for ceftriaxone (total: 1071) were sepsis (12%, n = 127), perforated appendicitis (12%, n = 125), and urinary tract infection (10%, n = 107). Postintervention, agreement between the indication selected during order entry and indication documented in clinical note for ceftriaxone and vancomycin orders were 41% and 46%, respectively. Median time to administration decreased among patients who received ceftriaxone (P < .01) but had no significant impact on time to administration of vancomycin (P = .49). CONCLUSIONS Indication for ceftriaxone and vancomycin selected during order entry and reported in clinical notes inconsistently matched. Inclusion of antibiotic indication may impact time to administration.
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Affiliation(s)
- Tonya Scardina
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | | | - Shan Sun
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Larry K Kociolek
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Caroline Reuter
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Michael Vogt
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Sameer Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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15
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Fischer MA, Mahesri M, Lii J, Linder JA. Non-Infection-Related And Non-Visit-Based Antibiotic Prescribing Is Common Among Medicaid Patients. Health Aff (Millwood) 2020; 39:280-288. [DOI: 10.1377/hlthaff.2019.00545] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michael A. Fischer
- Michael A. Fischer is an associate professor of medicine at Harvard Medical School and an associate physician in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, both in Boston, Massachusetts
| | - Mufaddal Mahesri
- Mufaddal Mahesri is a research specialist in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital
| | - Joyce Lii
- Joyce Lii is a programmer in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital
| | - Jeffrey A. Linder
- Jeffrey A. Linder is the Michael A. Gertz Professor of Medicine in the Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, in Chicago, Illinois
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Restriction-free antimicrobial stewardship initiative targeting fluoroquinolone reduction across a regional health-system. Infect Prev Pract 2019; 1:100019. [PMID: 34368680 PMCID: PMC8335920 DOI: 10.1016/j.infpip.2019.100019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/08/2019] [Indexed: 12/19/2022] Open
Abstract
Background Fluoroquinolone (FQ) antibiotics have become a target of many antimicrobial stewardship programmes. Multiple post-marketing warnings from the Food and Drug Administration caution against use of this drug class for certain infections due to risk of harmful adverse effects outweighing benefit. Commonly employed strategies to affect antibiotic prescribing can be restrictive and without improvement in overall antibiotic appropriateness or decrease in collateral damage. Aim To develop a strategy for sustainable optimization of FQ antibiotics. Setting Multi-state health-system of 14 hospitals and medical centers. Methods The health-system antimicrobial stewardship program identified the opportunity to improve FQ utilization. In collaboration with our data and analytics team, specific targets of FQ use in pneumonia and chronic obstructive pulmonary disease were established. Face-to-face provider education and prospective audit and feedback were the mainstays of the campaign. Enhancements to the electronic medical record to support the initiative were also implemented. Findings There was an overall decrease in FQ utilization by 56.9%. For pneumonia use of FQs decreased from 16.4% to 8.1% and in COPD changed from 29.6% to 9.7% over the same time period. Conclusions A non-restrictive FQ optimization initiative based on education and feedback decreased both FQ consumption and total antibiotic use across a large multi-hospital health-system.
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