table 3.
Results From the Modified Delphi Process to Develop Structure and Process Indicators for Hospital Antimicrobial Stewardship Programs: Rating and Agreementa on Feasibility and Clinical Importance With Final Decision on Inclusion as Core or Supplemental Indicator
| Indicators, by categoryb | Second round |
Third round |
Rated as Core, % | Final decision on status after in-person expert consensus meeting | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Feasibility |
Clinical importance |
Feasibility |
Clinical importance |
|||||||
| Median (range) | Agreement | Median (range) | Agreement | Median (range) | Agreement | Median (range) | Agreement | |||
| Governance and management | ||||||||||
| 1. Does your facility have a formally defined antimicrobial stewardship program for ensuring appropriate antimicrobial use? | 9 (2–9) | 1.0 | 8 (5–9) | 4.9 | 9 (5–9) | 5.9 | 8 (5–9) | 6.2 | 79 | Core |
| 2. Does your facility have a formal reporting structure responsible for antimicrobial stewardship (eg, a multidisciplinary committee focused on appropriate antimicrobial use, pharmacy committee, patient safety committee, or other relevant structure)? | 9 (4–9) | 1.4 | 7 (5–8) | 3.0 | 8 (5–9) | 2.7 | 7 (5–9) | 1.5 | 56 | Core |
| 3. Does your facility have a named senior executive officer with accountability for antimicrobial leadership? | 9 (5–9) | 4.2 | 6 (5–9) | 1.4 | 8 (5–9) | 4.8 | 6 (4–8) | 1.6 | 21 | Suppl. |
| 4. Has an annual report focused on antimicrobial stewardship (summary antimicrobial use and/or practices improvement initiatives) been produced for your facility in the past year? | 9 (4–9) | 3.1 | 7 (5–9) | 1.8 | 8 (5–9) | 4.8 | 7 (5–9) | 1.8 | 42 | Core |
| 5. Does your facility provide any salary support for dedicated time for antimicrobial stewardship activities (e.g., percentage of full-time equivalent (FTE) staff for ensuring appropriate antimicrobial use)? | 8 (1–9) | 0.8 | 7 (5–9) | 1.6 | 7 (3–9) | 2.0 | 7 (5–9) | 2.7 | 42 | Core |
| Human resources | ||||||||||
| 6. Is an antimicrobial stewardship team available at your facility? | 8 (4–9) | 2.8 | 9 (4–9) | 2.8 | 8 (5–9) | 3.1 | 9 (5–9) | 6.6 | 83 | Core |
| 7. Is clinical infectious disease (ID) consultation available at your facility? | 7 (3–9) | 1.0 | 8 (5–9) | 4.5 | 7 (3–9) | 1.0 | 8 (5–9) | 1.3 | 29 | Suppl. |
| 8. Is there a physician identified as a leader for stewardship activities at your facility? | 8 ( 4–9) | 4.2 | 7 (5–9) | 2.7 | 8 (6–9) | 4.8 | 8 (7–9) | 4.8 | 89 | Core |
| 9. If YES, Are stewardship duties included in the job description and/or annual review? | 9 (5–9) | 2.8 | 7 ( 4–9) | 1.6 | 8 (3–9) | 2.6 | 7 (5–9) | 1.3 | 18 | Suppl. |
| 10. If YES, Is this physician trained in infectious diseases, clinical microbiology, and/or antimicrobial stewardship? | 7 (2–9) | 1.4 | 8 (7–9) | 4.9 | 7 (3–9) | 3.3 | 8 (5–9) | 3.1 | 17 | Suppl. |
| 11. Is there a pharmacist responsible for working to improve antimicrobial use at your facility? | 8 (4–9) | 1.4 | 8 (5–9) | 3.1 | 8 (5–9) | 2.6 | 8 (5–9) | 4.8 | 77 | Core |
| 12. If YES, has this pharmacist had specialized training in infectious disease management or stewardship? Are any of the staff below members involved in stewardship activities at your facility? | 7 (2–9) | 1.4 | 8 (5–9) | 4.5 | 6 (4–9) | 1.3 | 7 (5–9) | 2.6 | 12 | Suppl. |
| 13. Microbiologist (laboratory) | 8 (2–9) | 1.0 | 8 (5–9) | 1.4 | 8 (5–9) | 2.6 | 8 (5–9) | 1.3 | 12 | Suppl. |
| 14. Infection preventionist or hospital epidemiologist | 7 (2–9) | 1.4 | 7 (4–9) | 1.6 | 7 (5–9) | 2.7 | 7 (3–9) | 1.6 | 0 | Suppl. |
| 15. Information technology (IT) staff member | 6 (2–9) | 1.0 | 6 (4–9) | 1.6 | Removed in second round | |||||
| 16. Quality improvement staff member | 7 (2–9) | 0.9 | 6 (3–7) | 1.3 | Removed in second round | |||||
| Laboratory | ||||||||||
| 17. Does your facility produce a cumulative antimicrobial susceptibility report at least annually? | 9 (6–9) | 4.9 | 8 (5–9) | 3.1 | 9 (5–9) | 4.8 | 8 (5–9) | 4.5 | 74 | Core |
| 18. If YES, has a current susceptibility report been distributed to prescribers at your facility | 9 (5–9) | 4.3 | 8 (4–9) | 1.4 | 8 (2–9) | 1.3 | 7 (5–9) | 2.9 | 23 | Remove |
| Information technology | ||||||||||
| Which of the following information technology (IT) systems are currently available and used in your facility: | ||||||||||
| 19. IT system for prescribing (computerized order entry)? | 7 (2–9) | 0.7 | 7 (2–9) | 1.4 | Removed in second round | |||||
| 20. If YES, Does the computer order entry system support clinical decision making for prescribing antimicrobial agents? | 5 (2–9) | 0.3 | 7 (2–9) | 1.6 | Removed in second round | |||||
| 21. Does your facility have the IT capability to support the needs of the antimicrobial stewardship activities? | 6 (3–9) | 1.4 | 8 (5–9) | 3.3 | 6 (4–9) | 1.4 | 8 (6–9) | 4.8 | 26 | Core |
| Policies for appropriate use | ||||||||||
| 22. Does your facility have a defined formulary of antimicrobial agents? | 9 (7–9) | 6.6 | 7 (2–9) | 2.8 | 9 (5–9) | 6.2 | 7 (5–9) | 2.7 | 44 | Remove |
| 23. Does your facility have a written policy that requires prescribers to document in the medical record or during order entry a dose, duration, and indication for all antimicrobial prescriptions? | 8 (4–9) | 1.35 | 8 (5–9) | 1.35 | 7 (2–9) | 1.3 | 8 (5–9) | 4.8 | 50 | Core |
| Guidelines | ||||||||||
| Does your facility have treatment recommendations, based on national guidelines and local susceptibility, to assist with antimicrobial selection for the following common clinical conditions: | Corec | |||||||||
| 24. Surgical prophylaxis | 9 (6–9) | 4.9 | 9 (5–9) | 4.9 | 9 (7–9) | 6.2 | 9 (5–9) | 4.8 | 67 | Suppl. |
| 25. Community-acquired pneumonia | 9 (6–9) | 4.9 | 8 (5–9) | 4.9 | 8 (7–9) | 4.8 | 8 (5–9) | 4.8 | 50 | Suppl. |
| 26. Urinary tract infection | 9 (6–9) | 4.5 | 8 (5–9) | 4.9 | 8 (6–9) | 4.8 | 8 (5–9) | 4.8 | 44 | Suppl. |
| 27. Are these treatment recommendations easily accessible to prescribers on all wards (printed “pocket guide” or electronic summaries at workstations) | 9 (5–9) | 3.1 | 8 (5–9) | 4.9 | 8 (2–9) | 2.6 | 8 (5–9) | 4.8 | 22 | Suppl. |
| Protocols | ||||||||||
| Are any of the following actions implemented in your facility to improve antibiotic prescribing: | ||||||||||
| 28. Standardized criteria for changing from intravenous to oral antimicrobial therapy in appropriate situations? | 8 (5–9) | 2.8 | 7 (4–9) | 2.8 | 8 (5–9) | 4.1 | 7 (5–9) | 1.5 | 39 | Suppl. |
| 29. Dose optimization (pharmacokinetics/pharmacodynamics) to optimize the treatment of organisms with reduced susceptibility? | 7 (3–9) | 1.6 | 8 (5–9) | 2.75 | 7 (2–9) | 1.5 | 8 (3–9) | 4.3 | 26 | Suppl. |
| 30. Discontinuation of specified antimicrobial prescriptions after a predefined duration? | 7 (5–9) | 1.4 | 8 (1–9) | 1.35 | 7 (5–9) | 1.5 | 8 (1–9) | 1.3 | 39 | Suppl. |
| Activities and interventions | ||||||||||
| 31. Do prescribers in your facility routinely use antimicrobial ordering forms (printed or electronic)? | 7 (4–9) | 3.1 | 6 (3–8) | 0.1 | Removed in second round | |||||
| 32. Is it routine practice for specified antimicrobial agents to be approved by a physician or pharmacist prior to dispensing (preauthorization) in your facility? | 7 (5–9) | 3.5 | 8 (5–9) | 3.1 | 7 (5–9) | 3.1 | 8 (5–9) | 4.5 | 39 | Core |
| 33. Is there dedicated time during which the clinical team reviews antimicrobial orders for their assigned patients (antimicrobial ward rounds)? | 6 (1–9) | 0.5 8 (3–9) | 4.2 | Removed in second round | ||||||
| 34. Is there a formal procedure for a physician, pharmacist, or other staff member to review the appropriateness of an antimicrobial after 48 hours from the initial order (postprescription review)? | 7 (3–9) | 1.0 | 8 (5–9) | 4.2 | 7 (3–9) | 3.0 | 8 (5–9) | 4.8 | 73 | Core |
| 35. Are results of antimicrobial audits or reviews provided directly to prescribers through in-person, telephone, or electronic communication? | 7 (3–9) | 1.3 | 8 (6–9) | 4.9 | 7 (3–9) | 1.8 | 8 (7–9) | 4.8 | 58 | Core |
| 36. Do prescribers ever receive education about how they can improve their antimicrobial prescribing? | 6 (3–9) | 0.6 | 8 (5–9) | 4.2 | 7 (3–9) | 1.3 | 8 (4–9) | 3.8 | 65 | Remove |
| Monitoring appropriate use | ||||||||||
| 37. Does your facility monitor antimicrobial use by counts of antimicrobial(s) administered to patients per day (Days of Therapy; DOT)? | 6 (1–9) | 0.9 | 7 (2–9) | 1.6 | 8 (6–9) | 4.8 | 8 (5–9) | 3.1 | 90 | Core |
| 38. Does your facility monitor antimicrobial use by number of grams of antimicrobials used (Defined Daily Dose; DDD)? | 8 (4–9) | 4.5 | 7 (5–9) | 3.4 | ||||||
| 39. Does your facility monitor whether the indication for treatment is recorded in the medical record? | 6 (3–9) | 1 | 7 (5–9) | 1.4 | 6 (4–9) | 1.5 | 7 (5–9) | 1.3 | 28 | Core |
| 40. If YES, is the indication for treatment is recorded in clinical case notes in >80% of sampled cases in your facility? | 6 (3–9) | 1.4 | 8 (5–9) | 2.4 | 6 (1–8) | 1.1 | 8 (5–9) | 2.6 | 6 | Remove |
| 41. Does your facility measure the number of antimicrobial prescriptions that are consistent with the local treatment recommendations for either urinary tract infection (UTI) or community-acquired pneumonia (CAP)? | 6 (3–9) | 0.1 | 8 (5–9) | 4.5 | 6 (4–9) | 1.5 | 8 (5–9) | 2.7 | 39 | Suppl. |
| 42. If YES, are antimicrobial prescriptions for UTI compliant with facility-specific guideline in >80% of sampled cases in your facility? | 6 (1–9) | 3.3 | 8 (1–9) | 4.9 | 7 ( 3–8) | 1.1 | 8 (5–9) | 2.6 | 0 | Remove |
| If YES, are antimicrobial prescriptions for CAP compliant with facility-specific guideline in >80% of sampled cases in your facility? | Added to third round | 6 (3–9) | 0.2 | 8 (5–9) | 2.6 | 6 | Remove | |||
| 43. Does your facility review surgical antimicrobial prophylaxis? | 7 (3–9) | 1.0 | 8 (5–9) | 2.8 | 7 (3–9) | 2.7 | 8 (5–9) | 4.1 | 50 | Core |
| 44. If YES, are antimicrobial prescriptions for surgical antimicrobial prophylaxis compliant with facility-specific guideline in >95% >80% of sampled cases in your facility? | 7 (3–9) | 1.4 | 8 (5–9) | 2.8 | 7 (3–9) | 0.8 | 8 (5–9) | 2.6 | 29 | Suppl. |
a
A higher number indicates higher agreement in the ratings among the experts.
b
The numbers correspond to the number of the indicator at the start of the second round. Bolded numbers indicate revisions between the second and third rounds (strikethrough for deleted text; added text is italicized).
c
The wording of many core indicators was revised in accordance with feedback from the in-person meeting. For this indicator, 3 separate indicators on condition-specific treatment guidelines were merged into a more general phrase, “…for common clinical conditions.”