Information technology for optimizing the management of infectious diseases

Design and development of a mobile-based patient management and information system for infectious disease outbreaks in low resource environments

BACKGROUND

The design of Patient Management and Information Systems during outbreaks of highly infectious diseases in low resource environments poses special challenges. Such systems necessitate special functional and design requirements to support patient care under austere conditions. A primary concern is to minimize spread of the disease to caregivers and non-infected individuals. Patient management in these conditions requires the design and development of systems customized for complex patient and caregiver workflows.

OBJECTIVE

Design and develop a Patient Management and Information System for healthcare facilities on the frontlines of outbreaks of highly infectious diseases in low resource environments.

METHODS

A team composed of clinicians with experience in Ebola care in affected areas of Africa and informaticians developed detailed hardware, software and functionality requirements. These were translated into hardware designs, software architectures, screen and interface designs and implemented using Common Off-The-Shelf hardware. An experimental app development system was used to develop mHealth software modules.

RESULTS

The system was developed and implemented as a proof of concept. Acceptance testing showed that the system met functionality requirements.

CONCLUSION

Useful Patient Management and Information systems can be developed and implemented for frontline use in low-resource environments during outbreaks of highly infectious diseases.

Use of computer decision support in an antimicrobial stewardship program (ASP)

OBJECTIVE

Document information needs, gaps within the current electronic applications and reports, and workflow interruptions requiring manual information searches that decreased the ability of our antimicrobial stewardship program (ASP) at Intermountain Healthcare (IH) to prospectively audit and provide feedback to clinicians to improve antimicrobial use.

METHODS

A framework was used to provide access to patient information contained in the electronic medical record, the enterprise-wide data warehouse, the data-driven alert file and the enterprise-wide encounter file to generate alerts and reports via pagers, emails and through the Centers for Diseases and Control's National Healthcare Surveillance Network.

RESULTS

Four new applications were developed and used by ASPs at Intermountain Medical Center (IMC) and Primary Children's Hospital (PCH) based on the design and input from the pharmacists and infectious diseases physicians and the new Center for Diseases Control and Prevention/National Healthcare Safety Network (NHSN) antibiotic utilization specifications. Data from IMC and PCH now show a general decrease in the use of drugs initially targeted by the ASP at both facilities.

CONCLUSIONS

To be effective, ASPs need an enormous amount of "timely" information. Members of the ASP at IH report these new applications help them improve antibiotic use by allowing efficient, timely review and effective prioritization of patients receiving antimicrobials in order to optimize patient care.

How to assist clinicians in improving antimicrobial prescribing: tools and interventions provided by stewardship programs

In the last decade, there has been an exponential increase in the microorganisms resistant to antimicrobials and a significant increase in the cost of these types of drugs. This phenomenon has increased interest in the development of interventions for counseling on and control of the use of antimicrobials, referred to as stewardship programs. In this article we review, from various points of view, the tools that have been developed with this purpose. First, we highlight the value of locally adapted guidelines and clinical pathways as an essential part of the operational process. Then we emphasize the importance of the relationship between microbiologists and clinicians for the accurate transmission of the information provided by blood cultures to make the most appropriate choice of antimicrobial for the patient's treatment. We also review the computerized tools that have facilitated the correct use of antimicrobials according to the controls established by the departments of pharmacy. Based on the previous tools, some programs based on "bedside recommendations" provided by multidisciplinary teams have been developed for optimizing the rational use of antimicrobials (PROA programs). Finally, we comment on the peculiarities of the programs targeting antifungals that have been developed in recent years.

Antimicrobial stewardship and automated pharmacy technology improve antibiotic appropriateness for community-acquired pneumonia

BACKGROUND

 The Centers for Medicare and Medicaid Services' (CMS's) Hospital Inpatient Quality Reporting program includes the initial selection of antibiotics for adult community-acquired pneumonia (CAP) patients as a performance measure. A multidisciplinary team defined opportunities for improving performance in appropriate antibiotic use among CAP patients. The team consisted of personnel from the emergency department (ED), the antimicrobial stewardship program (infectious disease, pharmacy), and performance improvement.

DESIGN

 Quasi-experimental before-after study.

SETTING

 A large, urban, multicampus academic medical center. Interventions. Interventions included an algorithm for ED providers identifying appropriate antibiotic selections, development of a CAP kit consisting of appropriate antibiotics and dosing regimens bundled with the treatment algorithm, and preloading an automated ED medication dispensing and management system. A quality improvement methodology ("plan, do, check, act") was used to pilot stewardship interventions at one ED campus and later at a second ED campus.

RESULTS

 In the pilot ED, appropriate antibiotic selection for CAP improved from 54.9% before the intervention in 2008 to 93.4% after the intervention in 2011 (P = .001). Subsequently, in the second ED appropriate antibiotic regimens for CAP improved from 64.6% before the intervention in 2008 to 91.3% after the intervention in 2011 (P = .004)). The rates of another CMS measure, antibiotic administration within 6 hours, were not statistically different before and after the interventions. In an interrupted time series logistic regression analysis, the intervention was found to be significantly associated with the improved prescribing ([Formula: see text]).

DISCUSSION

 The combination of interdisciplinary teamwork, antibiotic stewardship, education, and information technology is associated with replicable and sustained prescribing improvements.

Antimicrobial stewardship as part of the infection prevention effort

Antimicrobial stewardship programs (ASPs) optimize antimicrobial use to decrease the incidence of infection with multidrug-resistant organisms (MDRO) and the emergence of drug resistance, to improve patient outcomes and safety, and to decrease hospital costs. ASPs achieve these goals through several types of interventions that can occur before or after the antimicrobial has been prescribed; interventions can also be "active" or "passive." We believe that active post-prescription interventions such as post-prescription audit and feedback have the most supportive evidence and most promise. Stewardship activities must be integrated into already established efforts for infection prevention. We believe it is critical that antimicrobial stewardship, infection control, pharmacy, information technology, and clinical microbiology work collaboratively in order to decrease the incidence of infection due to MDRO.

Infections, bacterial resistance, and antimicrobial stewardship: the emerging role of hospitalists

The care of patients with serious infections both within and outside healthcare settings is increasingly complicated by the high prevalence of resistant or multidrug-resistant (MDR) pathogens. Moreover, infections caused by MDR versus susceptible bacteria or other pathogens are associated with significantly higher mortality, length of hospital stay, and healthcare costs. Antimicrobial misuse or overuse is the primary driver for development of antimicrobial resistance, suggesting that better use of antimicrobials will translate into improved patient outcomes, more efficient use of hospital resources, and lowered healthcare costs. Antimicrobial stewardship refers to the various practices and procedures utilized to optimize antimicrobial use. The primary goal of antimicrobial stewardship is to improve patient outcomes and lower antimicrobial resistance and other unintended consequences of antimicrobial therapy. Secondary goals are to reduce length of hospital stays and healthcare-related costs. Hospitalists are increasingly involved in the care of hospitalized patients throughout the United States. Expertise in managing conditions requiring hospitalization, and experience in quality improvement across a wide range of clinical conditions, make hospitalists well positioned to participate in the development and implementation of hospital-based antimicrobial stewardship programs designed to improve patient outcomes, reduce antimicrobial resistance, and provide more efficient and lower-cost hospital care.

Antimicrobial stewardship for inpatient facilities

Antibiotic stewardship aims to improve patient care and reduce unwanted consequences of antimicrobial overuse or misuse, including lowered efficacy, emergence of antimicrobial resistance, development of secondary infections, adverse drug reactions, increased length of hospital stay, and additional healthcare costs. Recent guidelines make specific recommendations for the development of institutional programs to enhance antimicrobial stewardship. Optimally, such programs should be comprehensive, multidisciplinary, supported by hospital and medical staff leadership, and should employ evidence-based strategies that best fit local needs and resources. An infectious diseases physician and clinical pharmacist with infectious diseases training are recommended as core members of the multidisciplinary team, although a hospitalist with interest (and perhaps additional training) in antimicrobial therapy may be able to fill the void. Program directors and core members should be compensated for their time. Principal proactive strategies--with evidence supporting their consideration--include prospective audits, with intervention and feedback, formulary restriction, and preauthorization. Other strategies include persistent one-on-one education, guidelines adapted to local needs, and informatics to support clinical decision making. Intervention goals are to prevent unnecessary antimicrobial starts, to streamline or de-escalate therapy early in its course, and to convert from parenteral to oral therapy, optimize dosing, and ensure the appropriate length of therapy. Most community hospitals, if sufficiently resourced, should be able to implement a successful antimicrobial stewardship program. Evidence suggests that good antimicrobial stewardship can lead to less overall and inappropriate antimicrobial use, lower drug-related costs, reductions in Clostridium difficile-associated disease, and, in some studies, less emergence of antimicrobial resistance.

Implementation of treatment guidelines to support judicious use of antibiotic therapy

BACKGROUND AND OBJECTIVE

Judicious use of antibiotics is essential considering the growth of antimicrobial resistance and escalating costs in health care. This intervention study used treatment guidelines to improve antibiotic therapy by changing prescribing practice.

METHODS

A before-after intervention study was performed in a 550-bed tertiary care teaching hospital in Switzerland, with an additional follow-up analysis 1 year later. The pre-intervention phase included chart analysis of current antibiotic use in 100 consecutive patients from the representative medical and surgical wards included in the study. Treatment guidelines were defined, taking into account published guidelines, the local antibacterial sensitivity of the pathogens, and the hospital antibiotic formulary defined by the drug and therapeutics committee. The guidelines were presented to the medical residents on a pocket card. They were informed and educated by the pharmacist (intervention). In the post-intervention phase immediately after the instruction, and in the follow-up phase 1 year later, a prospective analysis of antibiotic prescription was performed by chart review of 100 antibacterial treatments in consecutive patients to detect changes in antibiotic prescribing (treatment) and to determine whether these changes were sustained.

RESULTS

The pre-intervention review of antibiotic use showed the need for therapy improvements in urinary tract infections (UTI) and hospital-acquired pneumonia (HAP). In the post-intervention phase 100% of UTI were treated as recommended, compared to 30% before the intervention (P < 0.001). The follow-up analysis showed a decrease in guideline adherence to 39% in patients with UTI. Before implementation of the clinical guidelines, HAP was inappropriately treated like community-acquired pneumonia (CAP). Immediately after the intervention, 50% of HAP patients were treated as recommended, and 1 year later (follow-up phase) 56% of HAP patients received the recommended antibiotic medication. This change in prescription practice was significant (P < 0.05).

CONCLUSION

Antibiotic treatment guidelines for the infections most commonly occurring in hospitalized patients resulted in a significant increase in appropriate antibiotic use. The program was successful in changing prescription practice and achieved a sustained optimization of HAP therapy. Implementing, teaching and monitoring treatment guidelines can have a major impact on patient care.

Antimicrobial stewardship

In response to the global antibiotic resistance crisis, antimicrobial stewardship programs have emerged throughout the United States. Effective programs integrate several strategic methods, including evaluation and feedback regarding the necessity and appropriateness of antimicrobial therapy, staff education, and formulary restrictions. Multidisciplinary teams as well as institutional support are needed to form effective subcommittees to monitor national and local surveillance reports and resistance patterns, and to update antibiograms. Computerized decision support programs have been effective and successful methods of antimicrobial stewardship and can be a powerful tool in stewardship programs. Successful programs have reduced not only institutional resistance rates, but also morbidity, mortality, and cost.

Antimicrobial resistance in critical care

Patients presenting with active infections or at increased risk for infections pose a significant challenge in critical care nursing. It is important for critical care nurses to use effective antimicrobial strategies in patient management to reduce the potential development of antimicrobial resistance. They should be involved actively in promoting patient management through development of research-based nursing guidelines and protocols.