In the JournalsPerspective

Automated EMR tool improves antimicrobial stewardship

Researchers customized a Pennsylvania hospital’s electronic medical record to automate antimicrobial stewardship documentation and found that the tweak increased the number of charts that could be reviewed and was associated with a decrease in antimicrobial use, drug resistance and Clostridioides difficile infections.

Michael Katzman, MD, FACP, FIDSA, professor of infectious diseases at Penn State College of Medicine and director of the antimicrobial stewardship program at Milton S. Hershey Medical Center, and colleagues noted that quality improvement and leadership support of antimicrobial stewardship programs hinge on documenting their actions and impact.

“An EMR can be adapted to track what an antimicrobial stewardship program (ASP) does by providing a standardized format for tallying the number of charts reviewed, types of ASP recommendations, to whom and by what means those recommendations were communicated, documenting whether the recommendations were followed and recording any effects on antimicrobial days of therapy,” Katzman told Infectious Disease News.

“This report describes how we harnessed the power of the EMR to improve the completeness and accuracy of our data entry and subsequent analysis, which has made our ASP more efficient and allowed us to expand our activities.”

They designed the hospital’s automated EMR documentation program to include a “novel and intuitive” ASP form that is created in any EMR open for review, and two exclusive tracking systems, “one for active forms to facilitate the daily ASP workflow and one for finalized forms to generate cumulative reports,” Katzman explained.

According to Katzman and colleagues, the system automated much of the documentation that ASP members had to complete manually, facilitated follow-up of interventions, improved data completeness and validity and allowed the expansion of ASP activities.

“By using this system, our daily ASP rounds and follow-up of recommendations have become more efficient, permitting us to cast a wider net to review more charts and thus intervene in more situations,” Katzman said.

Specifically, the system led to an increase in the number of charts reviewed from approximately 3,500 in 2014 to 6,600 in 2017, and in the number of charts that led to an ASP recommendation, from about 900 to more than 1,400 over the same time, the researchers reported.

“From a patient-centered perspective across our institution, our efforts have been associated with a continuing decrease in antimicrobial usage and concomitant decreases in antibiotic resistance and C. difficile infections,” Katzman said.

The researchers observed a net of 2,054 inpatient antimicrobial days of therapy avoided in the most recent year. Moreover, the rate of vancomycin resistance for Enterococcus isolates decreased from 23% in 2011 to 15% in 2018, they reported.

“The underlying goals of recording and tracking valid data for quality improvement purposes and to maintain support by hospital leadership are universal for any ASP,” Katzman said. “Further efforts will continue to optimize ways to identify, review and intervene in clinical situations where antimicrobial usage can be improved, such as the widespread overtreatment of asymptomatic bacteriuria. Adapting the principles and methods of stewardship (including the system described in our paper) to the outpatient setting and to partnering health care institutions are also important.” - by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

Researchers customized a Pennsylvania hospital’s electronic medical record to automate antimicrobial stewardship documentation and found that the tweak increased the number of charts that could be reviewed and was associated with a decrease in antimicrobial use, drug resistance and Clostridioides difficile infections.

Michael Katzman, MD, FACP, FIDSA, professor of infectious diseases at Penn State College of Medicine and director of the antimicrobial stewardship program at Milton S. Hershey Medical Center, and colleagues noted that quality improvement and leadership support of antimicrobial stewardship programs hinge on documenting their actions and impact.

“An EMR can be adapted to track what an antimicrobial stewardship program (ASP) does by providing a standardized format for tallying the number of charts reviewed, types of ASP recommendations, to whom and by what means those recommendations were communicated, documenting whether the recommendations were followed and recording any effects on antimicrobial days of therapy,” Katzman told Infectious Disease News.

“This report describes how we harnessed the power of the EMR to improve the completeness and accuracy of our data entry and subsequent analysis, which has made our ASP more efficient and allowed us to expand our activities.”

They designed the hospital’s automated EMR documentation program to include a “novel and intuitive” ASP form that is created in any EMR open for review, and two exclusive tracking systems, “one for active forms to facilitate the daily ASP workflow and one for finalized forms to generate cumulative reports,” Katzman explained.

According to Katzman and colleagues, the system automated much of the documentation that ASP members had to complete manually, facilitated follow-up of interventions, improved data completeness and validity and allowed the expansion of ASP activities.

“By using this system, our daily ASP rounds and follow-up of recommendations have become more efficient, permitting us to cast a wider net to review more charts and thus intervene in more situations,” Katzman said.

Specifically, the system led to an increase in the number of charts reviewed from approximately 3,500 in 2014 to 6,600 in 2017, and in the number of charts that led to an ASP recommendation, from about 900 to more than 1,400 over the same time, the researchers reported.

“From a patient-centered perspective across our institution, our efforts have been associated with a continuing decrease in antimicrobial usage and concomitant decreases in antibiotic resistance and C. difficile infections,” Katzman said.

The researchers observed a net of 2,054 inpatient antimicrobial days of therapy avoided in the most recent year. Moreover, the rate of vancomycin resistance for Enterococcus isolates decreased from 23% in 2011 to 15% in 2018, they reported.

“The underlying goals of recording and tracking valid data for quality improvement purposes and to maintain support by hospital leadership are universal for any ASP,” Katzman said. “Further efforts will continue to optimize ways to identify, review and intervene in clinical situations where antimicrobial usage can be improved, such as the widespread overtreatment of asymptomatic bacteriuria. Adapting the principles and methods of stewardship (including the system described in our paper) to the outpatient setting and to partnering health care institutions are also important.” - by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Nicolas W. Cortes-Penfield

    Nicolas W. Cortes-Penfield

    The successful ASP needs to document its outcomes. Hospital administrators want proof that their ASP is adding value to patient care by optimizing antimicrobial use, reducing antibiotic-associated adverse events, shortening length of stay and reigning in excess pharmacy costs attributable to unnecessary antimicrobial prescription. This month in Open Forum Infectious Diseases, Katzman and colleagues describe their experience implementing an integrated EMR tool to streamline and automate the ASP workflow by tracking ASP activities and interventions.

    The authors designed an autopopulating EMR template for review of antibiotic prescriptions, an instance of which was created whenever an ASP member opened a patient chart. The form allowed ASP members to document the details and recommendations of the case, whether the primary team accepted the recommendations, and if there were any changes in the days of antimicrobial therapy prescribed. The EMR actively tracked these forms, which could be continually updated until closed by an ASP member, at which point, the data were compiled into a cumulative report on the ASP’s activities. 

    Before the implementation of this EMR tool, ASP members had been manually entering antimicrobial stewardship review and intervention data into a shared spreadsheet. With the simplification of this process via the EMR tool, their ASP was able to nearly double the number of charts reviewed (from 3,500 to 6,600 charts per year) over a 3-year period; similarly, the number of antibiotic recommendations made increased by more than 50%, from 900 to 1,400 per year. Moreover, the primary teams’ adherence to the recommendations remained high (>80%) despite the increase in the number of recommendations, suggesting that the additional recommendations translated into improved patient care.

    Studies like this demonstrate the value that collaborating with information systems specialists can bring to clinical care. Section chiefs, senior partners and others serving in leadership and administrative roles should take note: thoughtful customization of the EMR systems your antimicrobial stewards and ID clinicians interact with can significantly improve their productivity and reach.

    • Nicolas W. Cortes-Penfield, MD
    • Assistant professor of infectious diseases
      University of Nebraska Medical Center

    Disclosures: Cortes-Penfield reports no relevant financial disclosures.