Antimicrobial Stewardship Navigator in the EMR

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Antimicrobial Stewardship Navigator in the EMR

Abstract and Introduction

Abstract


Objective. Develop a clinical decision support tool comprised of an electronic medical record alert and antimicrobial stewardship navigator to facilitate antimicrobial stewardship.

Design. We analyzed alerts targeting antimicrobial de-escalation to assess the effectiveness of the navigator as a stewardship tool. The alert provides antimicrobial recommendations, then directs providers to the navigator, which includes order management, relevant patient information, evidence-based clinical information, and bidirectional communication capability.

Setting. Academic, tertiary care medical center with an electronic medical record.

Intervention. Alerts containing stewardship recommendations and immediate access to the navigator were created.

Results. Antibiotic use and response data were collected 1 day before stewardship recommendation via the best practice alert (BPA) tool and 1 day after the BPA tool response. A total of 1,285 stewardship BPAs were created. Two hundred and forty-four (18.9%) of the BPAs were created and acted upon within 72 hours for the purpose of de-escalation: 169 (69%) were accepted, 30 (12%) were accepted with modification, and 45 (18%) were rejected. Statistically significant decreases in total antibiotic use as well as in use of broad-spectrum (anti–methicillin-resistant Staphylococcus aureus and anti-pseudomonal) agents occurred when accepted recommendations were compared with rejected recommendations.

Conclusions. We describe the successful development of a clinical decision support tool to perform prospective audit and feedback comprised of an alert and navigator system featuring evidence-based recommendations and clinical and educational information. We demonstrate that this tool improves antibiotic use through our example of de-escalation.

Clinical Trials Identifier. This project was registered at ClinicalTrials.gov (NCT01573195).

Introduction


Antimicrobial stewardship programs (ASPs) use a variety of methods to improve patient care and outcomes through judicious use of antimicrobial agents, including education and direct interaction and feedback to the prescriber. The Infectious Diseases Society of America (IDSA) and the Society of Healthcare Epidemiology of America (SHEA) identified 2 core strategies and 8 supplemental strategies that comprise a comprehensive stewardship program. One of these core strategies is prospective audit and feedback, which is often labor intensive, necessitating up to 0.5 full-time equivalent physicians and 0.5 to 1 full-time equivalent pharmacist for most programs. Considerable time is spent paging, calling, texting, and educating prescribers about ASP recommendations.

Clinical decision support (CDS) tools provide prescribers with selected, relevant data at the time of decision making and prescribing and can significantly improve the care of patients and the efficiency of ASP. Decision support for antimicrobial prescribing is not a new phenomenon and demonstrated improved clinical and financial outcomes 20 years ago. Some CDS services and electronic medical records have also demonstrated ASP efficacy and reduced antibiotic-associated errors since the initial publications. The increasing prevalence of electronic health and medical records (EMRs) will encourage additional development of CDS tools.

We developed an integrated CDS tool to make ASP recommendations in our EMR (Epic; Verona, WI). Our best practice alert (BPA) tool creates a BPA in the EMR and directs providers to a single location to review the ASP's evidence-based recommendation; evaluate laboratory, radiology, and microbiology data; act on anti-infective orders; and respond to the ASP recommendation. Recommendations and subsequent BPAs are based on strategies outlined in the IDSA/SHEA guidelines. In this article, we describe the pilot application of the BPA tool, demonstrate integration of an evidence-based recommendation with BPA in the EMR, and present data supporting this technique as an effective means to encourage antimicrobial de-escalation.

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