Automating the workflow and tracking an antimicrobial stewardship program by customizing electronic medical records may decrease antimicrobial usage, according to study results published in Open Forum Infectious Diseases.
In 2007, a joint publication by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America laid out guidelines for developing an antimicrobial stewardship program at acute care hospitals and highlighted the importance of involving an information systems specialist. All antimicrobial stewardship programs share the goals of improving outcomes, limiting unintended consequences of drug resistance and superinfections, and reducing healthcare expenditures. For quality improvement and continued support by hospital leadership, it is essential to document the actions and effects of an antimicrobial stewardship program regardless that such programs may operate in varied settings and have distinct scopes. Each program must develop ways to identify situations that may require an intervention, review details to decide whether to intervene, communicate and follow up on recommendations, and track these efforts and their outcomes.
Therefore, this study describes how the electronic medical record was customized at the Penn State Health Milton S Hershey Medical Center to facilitate workflow and data analysis and also highlights principles that can be adapted to other antimicrobial stewardship programs.
The electronic medical record and documentation system at the Penn State Health Milton S Hershey Medical Center consisted of the creation of a novel and intuitive antimicrobial stewardship program form in each chart reviewed and 2 mutually exclusive tracking systems. The first tracking system was for active forms to facilitate the daily antimicrobial stewardship program workflow and the second for finalized forms to enable generation of cumulative reports. The antimicrobial stewardship program pharmacist creates the program’s form that is edited by the program’s physician, which is then reopened by the pharmacist to assess whether the recommendation was followed and to quantify any antimicrobial days avoided or added, the program physician then reviews and finalizes the form. Active forms are visible on a real time page, while finalized forms are compiled nightly into 65 informative tables and associated graphs.
Implementation of this system has yielded positive results. Researchers noted a steady increase in the total number of charts reviewed from 3500 in 2014 to 6600 in 2017. Similarly, the number of charts leading to an antimicrobial stewardship program recommendation also increased from 900 to more than 1400. In addition, recommendations in the “de-escalation” category increased from 58% to 66%
Monitoring how often clinicians accept recommendations from an antimicrobial stewardship program is a key indicator of the appropriateness of those recommendations and the effectiveness of their communication. The results showed that although the number of recommendations increased, the rate of acceptance was consistent at approximately >80%, including those for stopping all antibiotic therapy. A direct effect of this antimicrobial stewardship program in the most recent year was a net of 2054 days of inpatient antimicrobial therapy avoided and thus the reduction of total antimicrobial usage by 9.3 days of therapy/1000 patient-days. This has resulted in a 21% decrease in total days of antibiotic therapy per 1000 patient-days since the antimicrobial stewardship program began (P <.0001). The most significant example was demonstrated in fluoroquinolone usage, which decreased 58% (P <.0001).
Further outcomes from the implementation of antibiotic stewardship programs included increased susceptibility to ciprofloxacin (72% to 78% for Escherichia coli, and 78% to 83% for Pseudomonas aeruginosa). Resistance to vancomycin in cases of Enterococcus infection decreased from 23% to 15%.
Overall, the study authors concluded that, “This system and its underlying principles have automated much of the documentation, facilitated follow-up of interventions, improved the completeness and validity of recorded data and analysis, enabled our [antimicrobial stewardship program] to expand its activities, and [has] been associated with decreased antimicrobial usage, drug resistance, and Clostridioides difficile infections.”
Katzman M, Kim J, Lesher MD, et al. Customizing an electronic medical record to automate the workflow and tracking of an antimicrobial stewardship program [published online August 2, 2019]. Open Forum Infect Dis. doi:10.1093/ofid/ofz352