Use of a Computer Decision Support System and Antimicrobial Therapy Appropriateness

Filice, Gregory; Drekonja, Dimitri; Thurn, Joseph R.; Rector, Thomas S.; Hamann, Galen M.; Masoud, Bobbie T.; Leuck, Anne Marie; Nordgaard, Curtis L.; Eilertson, Meredith K.; Johnson, James R.

doi:10.1086/670627

Cited by 28 publications

(47 citation statements)

References 33 publications

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“…12 The median age of the 500 subjects was 66 years (interquartile range, 58-78), and 97% were male. Index conditions, specialty of the primary providers, hospital location, and provider experience all varied significantly in relation to whether index conditions were community-acquired, healthcare-associated, or nosocomial (Table 1).…”

Section: Resultsmentioning

confidence: 99%

“…Inpatients who received systemic antimicrobial drugs during the study period, October 2007 to September 2008, for therapy rather than prevention were identified from the Veteran's Administration (VA) electronic medical record system. 12 A "course" was defined as 1 or more consecutive doses of systemic antimicrobials administered to an inpatient. Overall, 4,338 separate antimicrobial courses were given to 3,180 patients.…”

Section: Methodsmentioning

confidence: 99%

“…12 Extractors recorded verbatim the provider diagnosis for the index condition at the time antimicrobial therapy was initiated (provider diagnosis). For each antimicrobial given during the period of treatment for an index condition, extractors recorded the drug, dosage, route, and duration.…”

Section: Data Extractionmentioning

confidence: 99%

“…12 A secondary hypothesis was that a portion of inappropriate antimicrobial courses would result from inaccurate initial diagnoses of infectious or potentially infectious conditions when providers initiated antimicrobial therapy. Despite a benefit associated with decision support, 62% of antimicrobial courses were still inappropriate, and the most common reason was that providers did not make an accurate initial diagnosis of infectious or potentially infectious conditions.…”

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confidence: 99%

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Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Filice

Drekonja

Thurn

et al. 2015

Infect. Control Hosp. Epidemiol.

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Background. We have reported that diagnostic errors factor into 89% of inappropriate inpatient antimicrobial (AM) courses. Here we describe in detail the diagnostic errors that led to inappropriate courses.Methods. We studied AM courses given to 500 randomly selected VA hospital inpatients between 2007 and 2008. We recorded information about the syndrome or disease that led to AM use (index condition), the initial provider diagnosis of the index condition ( provider diagnosis), and AM drug(s), dose, route, and duration. Each case summary was assigned randomly to 2 of 4 blinded reviewers. Based on data available to providers in real time, reviewers classified the provider diagnosis as correct, uncertain, not correct, or a sign or symptom of a potential infection rather than a syndrome or disease (sign or symptom) and the index AM course as appropriate or not, considering drug selection, route, dose, and duration.Results. Overall, provider diagnoses were correct in 292/500 (58%) of cases, but accuracy varied by diagnosis. For the 6 most common diagnostic groups (376 [75%] of all cases), accuracy ranged from 90% for bacteremia or sepsis to 27% for cystitis, pyelonephritis, or urosepsis (P < .001). Provider AM courses were considered appropriate in 191/500 (38%) of cases overall, but appropriateness varied in relation to diagnostic accuracy. When provider diagnoses were correct, 181/292 (62%) of courses were appropriate compared with only 10/208 (5%) when diagnoses were incorrect, uncertain, or signs or symptoms (P < .001). Considering the 111 cases in which provider diagnoses were correct and AM courses were inappropriate, reasons included wrong AM drug(s) (81, 73%), wrong duration (43, 39%), wrong dose (5, 5%), another type of drug error (1, 1%), and AM therapy not indicated (11, 4%). In contrast, of the 198 cases in which provider diagnoses were incorrect or uncertain or were signs or symptoms and AM courses were inappropriate, AM therapy was not indicated in 171 (86%) cases. Other reasons included wrong AM drugs (31, 16%), incorrect duration (13, 7%), wrong dose (2, 1%), and another type of drug error (1, 0.5%).Conclusion. Efforts to improve AM courses should include strategies to help providers make accurate diagnoses of syndromes that might be due to infection.

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Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Data Extractionmentioning

confidence: 99%

mentioning

confidence: 99%

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Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Filice

Drekonja

Thurn

et al. 2015

Infect. Control Hosp. Epidemiol.

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“…Implementation of e-prescribing systems in hospitals presents a unique opportunity to improve the quality of antimicrobial prescribing and to facilitate AMS. [5][6][7][8][9][10] Evidence for the benefits of AMS functionality within e-prescribing systems comes from published research studies demonstrating positive impact on outcomes including increased guideline adherence 11,12 and effective initial therapy 13 or reductions in antimicrobial prescribing, 14,15 resistance, 16,17 dosing errors, 8 length of hospital or ICU stay 14,18 and mortality. 12,13,19 However, many of these information systems were created on a small scale in individual hospitals or groups of institutions and few reports cover the full potential range of software features that enable AMS.…”

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confidence: 99%

Electronic prescribing system design priorities for antimicrobial stewardship: a cross-sectional survey of 142 UK infection specialists

Hand

Cumming

Hopkins

et al. 2016

J. Antimicrob. Chemother.

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SynopsisThe implementation of electronic prescribing and medication administration systems (EPMAs) is a priority for hospitals and a potential component of antimicrobial stewardship (AMS). ObjectivesThis study aimed to identify software features within EPMAs that could potentially facilitate AMS and to survey practising UK infection specialist healthcare professionals in order to assign priority to these software features. MethodsA questionnaire was developed using nominal group technique and transmitted via email links through professional networks. The questionnaire collected demographic data, information on priority areas and anticipated impact of EPMA. Responses from different respondent groups were compared using the Mann Whitney U test. ResultsResponses were received from 164 individuals (142 analysable). Respondents were predominantly specialist infection pharmacists (48%) or medical microbiologists (37%). 59% of pharmacists had experience of EPMA in their hospitals compared to 35% of microbiologists. Pharmacists assigned higher priority to: indication prompt (p<0.001), allergy checker (p=0.003) treatment protocols (p=0.003), drug-indication mismatch alerts (p=0.031) and prolonged course alerts (p=0.041); and lower priority to a dose checker for adults (p=0.02) and an interaction checker (p<0.05), than microbiologists. A "soft stop" functionality was rated essential or a high priority by 89% of respondents. Potential EPMA software features were expected to have the greatest impact on stewardship, treatment efficacy and patient safety outcomes with lowest impact on Clostridium difficile infection (CDI), antimicrobial resistance and drug expenditure. ConclusionsThe survey demonstrates key differences in health professionals' opinions of different healthcare benefits of EPMA but a consensus of anticipated positive impact on patient safety and antimicrobial stewardship.

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Implementation and outcomes of an advanced antimicrobial stewardship program at a quaternary care hospital in the United Arab Emirates

El-Lababidi

Mooty

Bonilla

et al. 2019

J Am Coll Clin Pharm

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Purpose The implementation of an advanced antimicrobial stewardship program (ASP) at a quaternary care hospital in the United Arab Emirates is described, including a report on the implementation and outcomes of the program. Methods This was a single‐center quasi‐experimental study to assess the impact of the ASP on antimicrobial use measures, ASP interventions performed, and clinical outcomes by comparing the data collected at baseline, from the third quarter (Q3) 1 July 2015 to the fourth quarter (Q4) of 31 December 2017, approximately 2 years following program implementation. Results From 1 July 2015 until 31 December 2017, the program reported a total direct cost savings estimated at $1 339 499, despite a significant increase in patient discharges and total patient‐days. The antimicrobial cost per inpatient‐day decreased by 32% from $47.2 to $32.3. Usage of monitored antimicrobials decreased despite an increase in patient census since hospital opening. Hospital‐onset Clostridioides difficile infection (CDI) rates decreased from 0.46 cases per 1000 patient days in 2015 to 0.12 cases per 1000 patient days in 2017 (P = 0.035, 95% CI 0.08 to 0.91). Hospital‐onset infections due to multidrug‐resistant organisms (MDROs) decreased from 2.39 cases per 1000 patient days in 2015 to 0.38 cases per 1000 patient days in 2017 (P = 0.05, 95% CI 0.09 to 0.28). Overall, the number of ASP interventions amounted to a total of 4123 interventions, with an acceptance rate of 91%. Conclusion The implementation of an advanced ASP at a quaternary care hospital in the United Arab Emirates was associated with a decrease in antimicrobial utilization, antimicrobial expenditure, and a reduction in hospital‐onset CDI and MDRO rates. To our knowledge, this is the first report describing the outcomes of an advanced ASP program at a quaternary care hospital utilizing real‐time surveillance software and CDSS in the Middle East.

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Use of a Computer Decision Support System and Antimicrobial Therapy Appropriateness

Abstract: Use of the CDSS was associated with more appropriate AM use. To achieve greater improvements, strategies are needed to improve provider diagnoses of syndromes that are infectious or possibly infectious.

Cited by 28 publications

References 33 publications

Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

Electronic prescribing system design priorities for antimicrobial stewardship: a cross-sectional survey of 142 UK infection specialists

Implementation and outcomes of an advanced antimicrobial stewardship program at a quaternary care hospital in the United Arab Emirates

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