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Wilde AM, Song M, Moore SE, Bohn BC, Swingler EA, Schulz PS. The Norton Healthcare electronic antimicrobial stewardship program: An opt-out approach to antimicrobial stewardship. Am J Health Syst Pharm 2023; 80:75-82. [PMID: 36194261 DOI: 10.1093/ajhp/zxac285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE To describe the Norton Healthcare electronic antimicrobial stewardship program (E-ASP), a novel prospective audit and feedback approach that leverages the electronic medical record to overcome efficiency barriers. Additionally, to describe an accompanying opt-out antimicrobial stewardship approach that addresses provider nonresponsiveness. SUMMARY Prospective audit and feedback is recommended by antimicrobial stewardship guidelines; however, execution can be difficult due to labor requirements, delays in communication, and provider nonparticipation. The Norton E-ASP was developed to address these issues by reliably identifying target patients, documenting assessments, streamlining recommendation delivery, promoting handoff, and providing automated tracking of recommendation responses. Opt-out stewardship allows recommendations to be implemented if not rejected after 24 hours. CONCLUSION A 25% reduction in target antimicrobial use has been achieved and sustained with the program. Use of the Norton E-ASP, including opt-out antimicrobial stewardship, broadened the reach and furthered the impact of infectious diseases pharmacists. Successes of this program justified addition of 3 full-time infectious diseases pharmacist positions at a large community health system. This strategy may serve as a model for tele-antimicrobial stewardship or other pharmacy recommendations.
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Affiliation(s)
- Ashley M Wilde
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Matthew Song
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Sarah E Moore
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Brian C Bohn
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Elena A Swingler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Paul S Schulz
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
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Qualitative study of the factors impacting antimicrobial stewardship programme delivery in regional and remote hospitals. J Hosp Infect 2018; 101:440-446. [PMID: 30267740 DOI: 10.1016/j.jhin.2018.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Many regional and remote ('regional') hospitals are without the specialist services that support antimicrobial stewardship (AMS) programmes in hospitals in major cities. This can impact their ability to implement AMS activities. AIM To identify factors that impact on the delivery of AMS programmes in regional hospitals. METHODS Healthcare clinicians who have primary AMS responsibilities or provide AMS support to a health service or across health services with an Australian Statistical Geography Standard Remoteness classification of inner regional, outer regional, remote or very remote were recruited purposively and via snowballing. A series of focus groups and interviews were held, and the discussions were audiotaped and transcribed verbatim. The transcripts were coded by two researchers, and thematic analysis was undertaken using a framework method. FINDINGS Four focus groups and one interview were conducted (22 participants). Six main themes that impacted on AMS programme delivery were identified: culture of independence and self-reliance by local clinicians, personal relationships, geographical location of the hospital influencing antimicrobial choice, local context, inability to meaningfully benchmark performance, and lack of resources. Possible strategies to support the delivery of AMS programmes in regional hospitals proposed by participants were categorized into two main themes: those that may be best developed or managed centrally, and those that should be a local responsibility. CONCLUSION AMS programme delivery in regional hospitals is influenced by factors that are not present in hospitals in major cities. These findings provide a strong basis for the development of strategies to support regional hospitals to implement sustainable AMS programmes.
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Abstract
Antibiotic stewardship programs are needed in all health care facilities, regardless of size and location. Community hospitals that have fewer resources may have different priorities and require different strategies when defining antibiotic stewardship program components and implementing interventions. By following the Centers for Disease Control and Prevention Core Elements and using the strategies suggested in this article, readers should be able to design, develop, participate in, or improve antibiotic stewardship programs within community hospitals.
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Affiliation(s)
- Whitney R Buckel
- Intermountain Healthcare Pharmacy Services, 4292 South Riverboat Road, Suite 100, Taylorsville, UT 84123, USA.
| | - John J Veillette
- Division of Infectious Diseases and Epidemiology, Intermountain Infectious Diseases TeleHealth Service, 5121 South Cottonwood Drive, Murray, UT 84107, USA
| | - Todd J Vento
- Intermountain Infectious Diseases TeleHealth Service, 5121 South Cottonwood Drive, Murray, UT 84107, USA
| | - Edward Stenehjem
- Intermountain Healthcare and TeleHealth Service, 5121 South Cottonwood Drive, Murray, UT 84107, USA
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Smith T, Philmon CL, Johnson GD, Ward WS, Rivers LL, Williamson SA, Goodman EL. Antimicrobial stewardship in a community hospital: attacking the more difficult problems. Hosp Pharm 2014; 49:839-46. [PMID: 25477615 DOI: 10.1310/hpj4909-839] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Antibiotic stewardship has been proposed as an important way to reduce or prevent antibiotic resistance. In 2001, a community hospital implemented an antimicrobial management program. It was successful in reducing antimicrobial utilization and expenditure. In 2011, with the implementation of a data-mining tool, the program was expanded and its focus transitioned from control of antimicrobial use to guiding judicious antimicrobial prescribing. OBJECTIVE To test the hypothesis that adding a data-mining tool to an existing antimicrobial stewardship program will further increase appropriate use of antimicrobials. DESIGN Interventional study with historical comparison. METHODS Rules and alerts were built into the data-mining tool to aid in identifying inappropriate antibiotic utilization. Decentralized pharmacists acted on alerts for intravenous (IV) to oral conversion, perioperative antibiotic duration, and restricted antimicrobials. An Infectious Diseases (ID) Pharmacist and ID Physician/Hospital Epidemiologist focused on all other identified alert types such as antibiotic de-escalation, bug-drug mismatch, and double coverage. Electronic chart notes and phone calls to physicians were utilized to make recommendations. RESULTS During 2012, 2,003 antimicrobial interventions were made with a 90% acceptance rate. Targeted broad-spectrum antimicrobial use decreased by 15% in 2012 compared to 2010, which represented cost savings of $1,621,730. There were no statistically significant changes in antimicrobial resistance, and no adverse patient outcomes were noted. CONCLUSIONS The addition of a data-mining tool to an antimicrobial stewardship program can further decrease inappropriate use of antimicrobials, provide a greater reduction in overall antimicrobial use, and provide increased cost savings without negatively affecting patient outcomes.
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Affiliation(s)
- Terri Smith
- Clinical Pharmacy Specialist, Department of Pharmacy, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas
| | - Carla L Philmon
- Clinical Pharmacy Manager, Department of Pharmacy, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas
| | - Gregory D Johnson
- Pharmacy Director, Department of Pharmacy, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas
| | - William S Ward
- Decision Support Analyst, Department of Finance, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas
| | - LaToya L Rivers
- Data Warehouse Administrator, Department of Quality Improvement, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas
| | - Sharon A Williamson
- Infection Prevention Manager, Department of Infection Prevention, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas
| | - Edward L Goodman
- Hospital Epidemiologist, Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas
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van Limburg M, Sinha B, Lo-Ten-Foe JR, van Gemert-Pijnen JE. Evaluation of early implementations of antibiotic stewardship program initiatives in nine Dutch hospitals. Antimicrob Resist Infect Control 2014; 3:33. [PMID: 25392736 PMCID: PMC4228167 DOI: 10.1186/2047-2994-3-33] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 09/10/2014] [Indexed: 11/27/2022] Open
Abstract
Background Antibiotic resistance is a global threat to patient safety and care. In response, hospitals start antibiotic stewardship programs to optimise antibiotic use. Expert-based guidelines recommend strategies to implement such programs, but local implementations may differ per hospital. Earlier published assessments determine maturity of antibiotic stewardship programs based on expert-based structure indicators, but they disregard that there may be valid deviations from these expert-based programs. Aim To analyse the progress and barriers of local implementations of antibiotic stewardship programs with stakeholders in nine Dutch hospitals and to develop a toolkit that guides implementing local antibiotic stewardship programs. Methods An online questionnaire based on published guidelines and recommendations, conducted with seven clinical microbiologists, seven infectious disease physicians and five clinical pharmacists at nine Dutch hospitals. Results Results show local differences in antibiotic stewardship programs and the uptake of interventions in hospitals. Antibiotic guidelines and antibiotic teams are the most extensively implemented interventions. Education, decision support and audit-feedback are deemed important interventions and they are either piloted in implementations at academic hospitals or in preparation for application in non-academic hospitals. Other interventions that are recommended in guidelines - benchmarking, restriction and antibiotic formulary - appear to have a lower priority. Automatic stop-order, pre-authorization, automatic substitution, antibiotic cycling are not deemed to be worthwhile according to respondents. Conclusion There are extensive local differences in the implementation of antibiotic stewardship interventions. These differences suggest a need to further explore the rationale behind the choice of interventions in antibiotic stewardship programs. Rather than reporting this rationale, this study reports where rationale can play a key role in the implementation of antibiotic stewardship programs. A one-size-fits-all solution is unfeasible as there may be barriers or valid reasons for local experts to deviate from expert-based guidelines. Local experts can be supported with a toolkit containing advice based on possible barriers and considerations. These parameters can be used to customise an implementation of antibiotic stewardship programs to local needs (while retaining its expert-based foundation). Electronic supplementary material The online version of this article (doi:10.1186/2047-2994-3-33) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maarten van Limburg
- Department Psychology Health and Technology, Faculty Behavioral, Management and Social Sciences, University of Twente, Enschede, the Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jerome R Lo-Ten-Foe
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Julia Ewc van Gemert-Pijnen
- Department Psychology Health and Technology, Faculty Behavioral, Management and Social Sciences, University of Twente, Enschede, the Netherlands
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Spivey JR, Townsend ML, Drew RH. Workforce Supply and Training in Antimicrobial Stewardship. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2014. [DOI: 10.1007/s40506-014-0012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Amer MR, Akhras NS, Mahmood WA, Al-Jazairi AS. Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi Arabia. Ann Saudi Med 2013; 33:547-54. [PMID: 24413857 PMCID: PMC6074906 DOI: 10.5144/0256-4947.2013.547] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Antimicrobial stewardship programs (ASPs) have shown to prevent the emergence of antimicrobial resistance associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the prescribing appropriateness rate of the empirical antibiotic therapy before and after the ASP implementation in a tertiary care hospital. Secondary objectives include the rate of Clostridium difficile-associated diarrhea (CDAD), physicians' acceptance rate, patient's intensive care unit (ICU) course, total utilization using defined daily dose, and total direct cost of antibiotics. DESIGN AND SETTINGS This is a comparative, historically controlled study. Adult medical ICU patients were enrolled in a prospective fashion under the active ASP arm and compared with historical patients who were admitted to the same unit before the ASP implementation. This study was approved by the institutional review board, and the need for informed consent was waived because the interventions and recommendations were evidence based and considered the standard of care. The study was conducted at KFSHRC, Riyadh. METHODS Adult medical ICU patients were enrolled under the active ASP arm if they were on any of the 5 targeted antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, vancomycin, tigecycline), and had no official infectious disease consultation. The interventions were conducted via prospective audit and feedback. RESULTS A total of 73 subjects were recruited, 49 in historical control and 24 in the active arm. The appropriateness of empirical antibiotics was improved from 30.6% (15/49) in the historical control arm to 100% (24/24) in the proactive ASP arm (P value < .05). For the ASP group, initially 79.1% (19/24) of the antibiotic uses were inappropriate and diminished by ASPs to 0% on the recommendations implementation. A total of 27 interventions were made with an acceptance rate of 96.3%. The rate of CDAD did not differ between the groups. A reduction in antibiotics utilization and direct cost were also noticed in the ASP arm. CONCLUSION A proactive ASP is a vital approach in optimizing the appropriate empirical antibiotics utilization in an ICU setting in tertiary care hospitals. This study highlights the importance of such a program and may serve as a foundation for further ASP initiatives particularly in our region.
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Affiliation(s)
| | | | | | - Abdulrazaq S Al-Jazairi
- Dr. Abdulrazaq S. Al-Jazairi, Head, Medical/Critical Pharmacy Department,, Division of Pharmacy Services,, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, MBC-11, Riyadh 11211,, Saudi Arabia, T: +966-11-4427603, F: +966-11-4427608,
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Orsi GB, Falcone M, Venditti M. Surveillance and management of multidrug-resistant microorganisms. Expert Rev Anti Infect Ther 2013; 9:653-79. [PMID: 21819331 DOI: 10.1586/eri.11.77] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Multidrug-resistant organisms are an established and growing worldwide public health problem and few therapeutic options remain available. The traditional antimicrobials (glycopeptides) for multidrug-resistant Gram-positive infections are declining in efficacy. New drugs that are presently available are linezolid, daptomicin and tigecycline, which have well-defined indications for severe infections, and talavancin, which is under Phase III trial for hospital-acquired pneumonia. Unfortunately the therapies available for multidrug-resistant Gram-negatives, including carbapenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae, are limited to only colistin and tigecycline. Both of these drugs are still not registered for severe infections, such as hospital acquired pneumonia. Consequently, as confirmed by scientific evidence, a multidisciplinary approach is needed. Surveillance, infection control procedures, isolation and antimicrobial stewardship should be implemented to reduce multidrug-resistant organism diffusion.
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Affiliation(s)
- Giovanni Battista Orsi
- Dipartimento di Sanità Pubblica e Malattie Infettive, Sapienza Università di Roma, P.le Aldo Moro 5, 00185 Roma, Italy
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