Antimicrobial Stewardship by Leveraging Electronic Medical Records

Abstract

This paper describes how an antimicrobial stewardship program was successfully developed and integrated into a university medical center’s electronic healthcare records and improved antibiotic selection.

Introduction

Antibiotics have transformed modern medicine. Swift initiation of antibiotics to treat infection reduces morbidity and mortality in cases like sepsis.¹ Antibiotic resistance and/or abuse are important clinical problems. Centers for Disease Control and Prevention (CDC) estimates that more than 2.8 million antibiotic resistant infections occur in the United States each year, and more than 35,000 people die as a result.² In addition, nearly 223,900 people in the US required hospital care for C. difficile and at least 12,800 people died in 2017.³ Varying estimates have been published, but many reports estimate antibiotic misuse as around 30% of all antibiotic prescribed in the U.S.^{2, 4} Rittman et al. reported that antibiotic resistance may cost the US up to $20 billion in healthcare costs and $35 billion in lost productivity annually.⁵

Antimicrobial Stewardship Programs Are Mandatory

Antimicrobial stewardship programs (ASP) are no longer optional hospital programs, but a mandated program as a direct result of the growing antimicrobial resistant threat. Missouri Department of Health and Senior Services RSMO 192.667.19 states “…each hospital shall establish an antimicrobial stewardship program for evaluating the judicious use of antimicrobials, especially antibiotics that are the last line of defense against resistant infections. The hospital’s stewardship program and the results of the program shall be monitored and evaluated by hospital quality improvement departments and shall be available upon inspection to the department. At a minimum, the antimicrobial stewardship program shall be designed to evaluate that hospitalized patients receive, in accordance with accepted medical standards of practice, the appropriate antimicrobial, at the appropriate dose, at the appropriate time, and for the appropriate duration.” CDC updated its guideline in 2019 highlighting the seven core elements of ASP including hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting and education.²

At Truman Medical Centers (TMC), we implemented an antimicrobial stewardship program in 2009. In our 10 years of experience, we have started our effort with interventions such as prospective review and feedback, antibiotic restriction policy, education, clinical pathways and site-specific guideline for optimal antibiotic use. Since then, we have had opportunity to elevate our antimicrobial stewardship effort with the advances in information technology.

Given the advancement in electronic medical records, TMC partnered and implemented such programs as live Antimicrobial Stewardship (AMS) worklist through our electronic health records (EHR) vendor (Cerner). These EHR activities are collectively called clinical decision support system (CDSS). CDSS is defined as utilizing individual patient data coupled with population statistics and computerized clinical guidance to provide patient-specific management recommendations either on clinician request or at the point of care.⁶ Live alerts in the EHRs changed how the antimicrobial stewardship activities were conducted from daily reports and collecting patient information by hand on those who are on targeted broad spectrum antibiotic for prospective audit to instantly identifying those patients who needs antimicrobial stewardship review. AMS worklist also identifies patients who has de-escalation opportunity, positive culture but no antibiotic, rapid diagnostics results availability, drug-bug mismatch and more. These are all identified by the AMS worklist alert system through rules built to identify patients with potential AMS opportunity. This has enabled our AMS to review more patients any time, any day. We have also published our site-specific antimicrobial guide in an app form, providing easy access for all providers with up to date information on their website or their handheld device. This online/app platform has increased use of the antimicrobial stewardship guidance, as well as enabled us to send push-notification for any updated site-specific guideline. This has been useful to keep our providers up to date on their knowledge and resources.

ASP Prospective Audit and Feedback

Prospective audit and feedback are accomplished through review of lists of patients on antibiotics and alerts for combinations of specific antimicrobials and clinical or microbiology results. These prospective audits are generally done after the antibiotic has already been ordered and often after the first dose has been administered. In ambulatory care areas, prospective audit and feedback are difficult to perform as prescriptions are generated and sent into the outpatient pharmacy before any of the ASP can be performed. In order to solve this problem, we investigated functions of CDSS to help with the dilemma.

We theorized that the CDSS warning alert for the prescribers based on indication and medication could steer prescribers away from ordering inappropriate antibiotics. At TMC, we did a retrospective chart review to evaluate the impact of a computer-based decision warning pop-up sign using CDSS to see if prescribers are appropriately avoiding ordering levofloxacin for indications such as chronic obstructive pulmonary disease, uncomplicated urinary tract infection or sinusitis based on the 2016 FDA warning for fluoroquinolone use in uncomplicated indications. Any time a provider ordered levofloxacin for the above inappropriate indications, a warning (Figure 1) would pop up alerting the provider to avoid levofloxacin. There was substantial effort made so that the pop-up alert would only fire in violation of well-defined indications/contraindications. This in order to reduce warning fatigue.

Figure 1.

Pop-Up Alert Fluoroquinolones

Source: Cerner

Timelines of October 2015 through March 2016 before CDSS and October 2016 through March 2017 after CDSS were compared. There were 1,404 orders of levofloxacin for any indications before CDSS and there were 113 (8.5%) orders of levofloxacin for inappropriate indications. After CDSS, there were 1,142 orders for levofloxacin for any indications and 45 (3.9%) orders for Levaquin for inappropriate indications. This is a statistically significant difference of p<0.0001. There was a reduction in levofloxacin use/1,000 patient days from 41.6 to 33.4 as well as decreased average duration of levofloxacin use from 3.3 days to 1.3 days.

Our results showed less levofloxacin orders for inappropriate indications after the implementation of CDSS. With these results, we extrapolated that this targeted CDSS intervention was beneficial at our particular institution. CDSS may be able to impact inappropriate antibiotic use to help promote improved prescribing habits. At TMC, we are currently working on utilizing indication and medication based targeted CDSS expansion to outpatient antimicrobial stewardship. This should assist providers to prescribe appropriate antibiotics selections real-time, at the point of prescribing based on best-practices medication and indication. This allows prospective rather than retrospective evaluation of prescribing appropriateness.

Conclusion

CDSS is a robust tool that can improve the AMS programs. CDSS can be active or passive as described above at TMC. In other clinical and institutional settings, CDSS can be appropriately designed and personalized. An important learning point we emphasize: CDSS is dependent on provider acceptance of the CDSS interventions. It is critical to educate provider-subscribers the function of CDSS, its use and how it can improve patient care and outcomes.