Antimicrobial stewardship using electronic prescribing systems in hospital settings: a scoping review of interventions and outcome measures.
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ABSTRACT: Objectives
To identify interventions implemented in hospital electronic prescribing systems and the outcome measures used to monitor their impact.Methods
We systematically searched CINAHL, EMBASE, Google Scholar and Medline using keywords in three strands: (i) population: hospital inpatient or emergency department; (ii) intervention: electronic prescribing functionality; and (iii) outcome: antimicrobial stewardship. The interventions were grouped into six themes: alerts, order sets, restriction of access, mandated documentation, embedded guidelines and automatic prescription stop. The outcome measures were organized into those that measure the quality or quantity of prescribing or clinical decision support (CDS) activity. The impact of each intervention reported was grouped into a positive, negative or no change.Results
A total of 28 studies were eligible for inclusion. There were 28 different interventions grouped into the six themes. Alerts visible to the practitioner in the electronic health record (EHR) were most frequently implemented (n = 11/28). Twenty different outcome measures were identified, divided into quality (n = 13/20) and quantity outcomes (n = 4/20) and CDS activity (n = 3/20). One-third of outcomes reported across the 28 studies showed positive change (34.4%, n = 42/122) and 61.4% (n = 75/122) showed no change.Conclusions
The most frequently implemented interventions were alerts, the majority of which were to influence behaviour or decision-making of the practitioner within the EHR. Quality outcomes were most frequently selected by researchers. The review supports previous research that larger well-designed randomized studies are needed to investigate the impact of interventions on AMS and outcome measures to be standardized.
SUBMITTER: Jenkins JA
PROVIDER: S-EPMC9237448 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundCoronavirus Disease 2019 (COVID-19) is a highly infectious disease that can be treated with antivirals in addition to other antimicrobials in cases of secondary or concomitant infections. This creates potential for antimicrobials misuse, which increases antimicrobial resistance (AMR). Pharmacists are known to undertake prominent roles in combatting AMR.AimThe aim of this review was to characterize pharmacist-driven interventions that have been performed in patients with COVID-19 globally and describe their impact on antimicrobial use.MethodWe followed the Joanna Briggs Institutes manual framework for scoping reviews in our study. Studies that reported antimicrobial stewardship (AMS) interventions performed by pharmacists in COVID-19 patients were included. Articles that did not report outcomes or did not mention pharmacists in the intervention were excluded. Restrictions included English-only articles from inception date until June 2022. Articles were searched from four databases.ResultsEleven publications were included in the review. The most common AMS intervention was pharmacist-driven interventions reported in 63.2% of all studies, followed by guideline development and application (26.3%), and medication supply coordination (10.5%), respectively. The outcomes of the interventions were difficult to compare but showed a reduction in antimicrobial use and prevention of adverse drug reactions with a relatively high acceptance rate from physicians.ConclusionPharmacists played an important role in performing AMS-related interventions in COVID-19 patients and helped in the fight against the worsening of AMR during the pandemic. The impact of pharmacist-driven AMS interventions in patients with COVID-19 seemed to be positive and improved outcomes related to antimicrobial use.
| S-EPMC10171144 | biostudies-literature
Project description:BackgroundUnderstanding antimicrobial consumption is essential to mitigate the development of antimicrobial resistance, yet robust data in children are sparse and methodologically limited. Electronic prescribing systems provide an important opportunity to analyse and report antimicrobial consumption in detail.ObjectivesWe investigated the value of electronic prescribing data from a tertiary children's hospital to report temporal trends in antimicrobial consumption in hospitalized children and compare commonly used metrics of antimicrobial consumption.MethodsDaily measures of antimicrobial consumption [days of therapy (DOT) and DDDs] were derived from the electronic prescribing system between 2010 and 2018. Autoregressive moving-average models were used to infer trends and the estimates were compared with simulated point prevalence surveys (PPSs).ResultsMore than 1.3 million antimicrobial administrations were analysed. There was significant daily and seasonal variation in overall consumption, which reduced annually by 1.77% (95% CI 0.50% to 3.02%). Relative consumption of meropenem decreased by 6.6% annually (95% CI -3.5% to 15.8%) following the expansion of the hospital antimicrobial stewardship programme. DOT and DDDs exhibited similar trends for most antimicrobials, though inconsistencies were observed where changes to dosage guidelines altered consumption calculation by DDDs, but not DOT. PPS simulations resulted in estimates of change over time, which converged on the model estimates, but with much less precision.ConclusionsElectronic prescribing systems offer significant opportunities to better understand and report antimicrobial consumption in children. This approach to modelling administration data overcomes the limitations of using interval data and dispensary data. It provides substantially more detailed inferences on prescribing patterns and the potential impact of stewardship interventions.
| S-EPMC8361331 | biostudies-literature
Project description:AimLittle is known about the determinants of antimicrobial prescribing behaviour (APB), how they vary between hospital prescribers or the mechanism by which interventions are effective. Yet, interventions based on a sound theoretical understanding of APB are more likely to be successful in changing outcomes. This study sought to quantify the potential determinants of APB among hospital doctors in south-west England.MethodsThis multicentre, quantitative study employed a closed answer questionnaire to garner hospital doctors' views on factors influencing their APB. Underlying constructs within the data were identified using exploratory factor analysis and subsequent pairwise comparisons assessed for variance between groups of prescribers.ResultsThe questionnaire was completed by 301 doctors across four centres (response rate ≥ 74%) and three key factors were identified: autonomy, guidelines adherence and antibiotic awareness. The internal consistency for the questionnaire scale and for each factor subscale was good (α ≥ 0.7). Subgroup analysis identified significant differences between groups of prescribers: autonomy scores increased with grade until at the specialist trainee level (P ≤ 0.009), foundation doctors scored higher for guidelines adherence than consultants (P = 0.004) and specialist trainees (P = 0.003) and United Kingdom trained doctors scored higher than those trained abroad for antibiotic awareness (P < 0.0005). Scores did not vary significantly between doctors from different centres.ConclusionAutonomy, guidelines adherence and antibiotic awareness were identified as important factors relevant to APB, which vary with experience and training. A theoretical framework is offered to facilitate development of more effective, tailored interventions to change APBs.
| S-EPMC4972159 | biostudies-literature
Project description:BackgroundFluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system.MethodsIn an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics.ResultsTotal fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P?<?.01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P?<?.01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively.ConclusionA multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.
| S-EPMC7284006 | biostudies-literature
Project description:International efforts have mandated guidelines on antibiotic use and prescribing, therefore the focus is now on encouraging positive behavioral changes in antibiotic prescribing practice. Documentation of indication and intended duration of antibiotic use in drug charts is an evidence-based method of reducing inappropriate antibiotic prescribing. It is also a standard detailed in our local antimicrobial guidelines. We collected baseline data on compliance with documentation of indication and duration in drug charts in a respiratory ward which revealed compliance rates of 24% and 39% respectively. We introduced interventions to improve accessibility to the guideline and to increase awareness by distributing antibiotic guardian pocket cards with a three-point checklist and strategically-placed mini-posters. We also aim to increase team motivation by obtaining their feedback in multidisciplinary team meetings and by introducing certificates for their involvement in the quality improvement process. The results of the second cycle post-intervention showed an increase in compliance rates for documentation of indication and duration of 97% and 69% respectively. After a further awareness and discussion session at the multidisciplinary team meeting with the local antimicrobial management team audit nurses, a third cycle showed compliance rates of 94% and 71% for indication and duration respectively. This project has highlighted the importance of improving accessibility and of encouraging interventions that would bring about a change in personal value and subsequently in behavior and individual practice.
| S-EPMC4752714 | biostudies-literature
Project description:Antimicrobial stewardship programs (ASPs) positively impact patient care, but metrics to assess ASP impact are poorly defined. We used a modified Delphi approach to select relevant metrics for assessing patient-level interventions in acute-care settings for the purposes of internal program decision making. An expert panel rated 90 candidate metrics on a 9-point Likert scale for association with 4 criteria: improved antimicrobial prescribing, improved patient care, utility in targeting stewardship efforts, and feasibility in hospitals with electronic health records. Experts further refined, added, or removed metrics during structured teleconferences and re-rated the retained metrics. Six metrics were rated >6 in all criteria: 2 measures of Clostridium difficile incidence, incidence of drug-resistant pathogens, days of therapy over admissions, days of therapy over patient days, and redundant therapy events. Fourteen metrics rated >6 in all criteria except feasibility were identified as targets for future development.
| S-EPMC5241782 | biostudies-literature
Project description:BackgroundAs meropenem is a restricted antimicrobial, lessons learned from its real-life usage will be applicable to antimicrobial stewardship (AMS) more generally.ObjectivesTo retrospectively evaluate meropenem usage at our institution to identify targets for AMS interventions.MethodsPatients receiving meropenem documented with an 'alert antimicrobial' form at two tertiary care UK hospitals were identified retrospectively. Clinical records and microbiology results were reviewed.ResultsA total of 107 adult inpatients receiving meropenem were identified. This was first-line in 47% and escalation therapy in 53%. Source control was required in 28% of cases after escalation, for predictable reasons. Those ultimately requiring source control had received more prior antimicrobial agents than those who did not (P = 0.03). Meropenem was rationalized in 24% of cases (after median 4 days). Positive microbiology enabled rationalization (OR 12.3, 95% CI 2.7-55.5, P = 0.001) but rates of appropriate sampling varied. In cases with positive microbiology where meropenem was not rationalized, continuation was retrospectively considered clinically and microbiologically necessary in 8/40 cases (0/17 empirical first-line usage). Rationalization was more likely when meropenem susceptibility was not released on the microbiology report (OR 5.2, 95% CI 1.3-20.2, P = 0.02). Input from an infection specialist was associated with a reduced duration of meropenem therapy (P < 0.0001). Early review by an infection specialist has the potential to further facilitate rationalization.ConclusionsIn real-life clinical practice, core aspects of infection management remain tractable targets for AMS interventions: microbiological sampling, source control and infection specialist input. Further targets include supporting rationalization to less familiar carbapenem-sparing antimicrobials, restricting first-line meropenem usage and selectively reporting meropenem susceptibility.
| S-EPMC8210134 | biostudies-literature
Project description:ObjectiveThis scoping review aims to characterize the current literature on electronic patient-reported outcome measures (ePROMs) in rheumatology and assess the feasibility and utility of ePROMs and mobile health technology in the management of rheumatic disease.IntroductionPatient-reported outcome measures (PROMs) are commonly used in rheumatology as they are important markers of disease activity and overall function, encourage shared decision-making, and are associated with high rates of patient satisfaction. With the widespread use of mobile devices, there is increasing interest in the use of mobile health technology to collect electronic PROMs (ePROM).Inclusion criteriaAll primary studies that involve the collection of ePROMs using mobile devices by individuals with a rheumatic disease were included. Articles were excluded if ePROMs were measured during clinic appointments.MethodsA scoping review was performed using Medline, Embase, PsycINFO, and CINAHL with index terms and key words related to "patient-reported outcome measures", "rheumatic diseases", and "mobile health technology".ResultsA total of 462 records were identified after duplicates were removed. Of the 70 studies selected for review, 43% were conference proceedings and 57% were journal articles, with the majority published in 2016 or later. Inflammatory arthritis was the most common rheumatic disease studied. Generic ePROMs were used over three times more often than disease-specific ePROMs. A total of 39 (56%) studies directly evaluated the feasibility of ePROMs in clinical practice, 19 (27%) were clinical trials that used ePROMs as study endpoints, 9 (13%) were focus groups or surveys on smartphone application development, and 3 (4%) did not fit into one defined category.ConclusionThe use of ePROMs in rheumatology is a growing area of research and shows significant utility in clinical practice, particularly in inflammatory arthritis. Further research is needed to better characterize the feasibility of ePROMs in rheumatology and their impact on patient outcomes.
| S-EPMC8297791 | biostudies-literature
Project description:ObjectiveTo assess the effectiveness and acceptability of antimicrobial stewardship-focused implementation strategies on inpatient fluoroquinolones.MethodsStewardship champions at 15 hospitals were surveyed regarding the use and acceptability of strategies to improve fluoroquinolone prescribing. Antibiotic days of therapy (DOT) per 1,000 days present (DP) for sites with and without prospective audit and feedback (PAF) and/or prior approval were compared.ResultsAmong all of the sites, 60% had PAF or prior approval implemented for fluoroquinolones. Compared to sites using neither strategy (64.2 ± 34.4 DOT/DP), fluoroquinolone prescribing rates were lower for sites that employed PAF and/or prior approval (35.5 ± 9.8; P = .03) and decreased from 2017 to 2018 (P < .001). This decrease occurred without an increase in advanced-generation cephalosporins. Total antibiotic rates were 13% lower for sites with PAF and/or prior approval, but this difference did not reach statistical significance (P = .20). Sites reporting that PAF and/or prior approval were "completely" accepted had lower fluoroquinolone rates than sites where it was "moderately" accepted (34.2 ± 5.7 vs 48.7 ± 4.5; P < .01). Sites reported that clinical pathways and/or local guidelines (93%), prior approval (93%), and order forms (80%) "would" or "may" be effective in improving fluoroquinolone use. Although most sites (73%) indicated that requiring infectious disease consults would or may be effective in improving fluoroquinolones, 87% perceived implementation to be difficult.ConclusionsPAF and prior approval implementation strategies focused on fluoroquinolones were associated with significantly lower fluoroquinolone prescribing rates and nonsignificant decreases in total antibiotic use, suggesting limited evidence for class substitution. The association of acceptability of strategies with lower rates highlights the importance of culture. These results may indicate increased acceptability of implementation strategies and/or sensitivity to FDA warnings.
| S-EPMC9999290 | biostudies-literature
Project description:ImportanceThe feasibility of core Infectious Diseases Society of America-recommended antimicrobial stewardship interventions in community hospitals is unknown.ObjectiveTo determine the feasibility and results of implementing 2 core stewardship intervention strategies in community hospitals.Design, setting, and participantsThree-stage, multicenter, prospective nonrandomized clinical trial with crossover design. The setting was 4 community hospitals in North Carolina (median bed size, 305; range, 102-425). Participants were all patients receiving targeted study antibacterial agents or alternative, nonstudy antibacterial agents. The study dates were October 2014 through October 2015. All statistical analyses were completed as of October 2016.InterventionsTwo antimicrobial stewardship strategies targeted vancomycin hydrochloride, piperacillin-tazobactam, and the antipseudomonal carbapenems on formulary at the study hospitals: (1) modified preauthorization (PA), in which the prescriber had to receive pharmacist approval for continued use of the antibiotic after the first dose, and (2) postprescription audit and review (PPR), in which the pharmacist would engage the prescriber about antibiotic appropriateness after 72 hours of therapy. Two hospitals performed modified PA for 6 months, then PPR for 6 months after a 1-month washout. The other 2 hospitals performed the reverse.Main outcomes and measuresThe primary outcome was the feasibility of implementing the interventions, determined by (1) approval by hospital administration and committees at each study hospital; (2) completion of pharmacist training; (3) initiation and implementation as determined by number, type, and outcomes of interventions performed; and (4) time required for interventions. Secondary outcomes included antimicrobial use (days of therapy) compared with matched historical periods and length of hospitalization.ResultsA total of 2692 patients (median age, 65 years; interquartile range, 53-76 years) underwent a study intervention; 1413 (52.5%) were female, 1323 (49.1%) were white, and 1047 (38.9%) were African American. Intervention approvals took a median of 95 days (range, 56-119 days); during these discussions, strict PA was deemed not feasible. Instead, the modified PA intervention was used throughout the study. Pharmacists performed 1456 modified PA interventions (median per hospital, 350 [range, 129-628]) and 1236 PPR interventions (median per hospital, 298 [range, 273-366]). Study antimicrobials were determined to be inappropriate 2 times as often during the PPR period (41.0% [435 of 1060] vs 20.4% [253 of 1243]; P < .001). Pharmacists recommended dose change more often during the modified PA intervention (15.9% [232 of 1456] vs 9.6% [119 of 1236]; P < .001) and de-escalation during PPR (29.1% [360 of 1236] vs 13.0% [190 of 1456]; P < .001). The median time dedicated to the stewardship interventions varied by hospital (range of median hours per week, 5-19). Overall antibiotic use decreased during PPR compared with historical controls (mean [SD] days of therapy per 1000 patient-days, 925.2 [109.8] vs 965.3 [109.4]; mean difference, -40.1; 95% CI, -71.7 to -8.6), but not during modified PA (mean [SD] days of therapy per 1000 patient-days, 931.0 [102.0] vs 926.6 [89.7]; mean difference, 4.4; 95% CI, -55.8 to 64.7).Conclusions and relevanceStrict PA was not feasible in the study hospitals. In contrast, PPR was a feasible and effective strategy for antimicrobial stewardship in settings with limited resources and expertise.Trial registrationClinicalTrials.gov identifier: NCT02212808.
| S-EPMC6704742 | biostudies-literature