the role of information technology as a part of a hospital's abp

The Role of Information Technology as a part of a Hospital’s Antimicrobial Stewardship Program - Cary D. GreenMHA 6450

The Role of Information Technology as a part of a Hospital’s Antimicrobial Stewardship Program

Cary D. GreenMHA 6450Spring 2011


Table of Contents Page

Introduction …………………………………………………………………………… 3

Key components of an Antimicrobial Stewardship Program …………………………. 4

Governance …………………………………………………………………………… 5

Enterprise Strategy ……………………………………………………………………. 6

The role of Information Technology…………….……………………………………. 7

Microbiology Laboratory ……………………………………………………………... 10

Quality Measurement …………………………………………………………………. 11

Summary ……………………………………………………………………………… 12

References …………………………………………………………………………….. 13


Introduction

We now live in an era where there are major concerns about resistant bacteria becoming

more prevalent in our hospitals. The number of resistant bacteria continues to increase and the

number of effective antibiotics continues to decline. In addition, there are few antibacterial

agents in development to address the problem of increasing resistance among gram-negative

bacteria.1 One of the factors contributing to the problem of antimicrobial resistance is poor

stewardship of existing antibiotic agents.2 The Centers for Disease Control and Prevention

(CDC) recommends four strategies to help minimize antimicrobial resistance. The following

strategies are designed to prevent resistance among hospitalized patients. First, there must be

infection prevention, second, effective diagnosis and treatment, third, the wise use of

antimicrobials and fourth, prevent the transmission of resistance from one species to another.3

Hospitals are experiencing resistance to bacteria across the board. Every physician has

their “favorite” antibiotic that they use daily. The antibiotics that have become their favorite

began while they were in their residency. There are currently one hundred and thirty-two FDA

approved antibiotics in the United States of America.4 Antibiotic resistance occurs when

antibiotics are overused, under dosed, used too long or in other words inappropriately.


The article published in 2007 by Timothy H. Dellit, et. al, outlined how hospitals could

approach building and implementing an effective antimicrobial stewardship program.5 These

types of programs are essential for hospitals to preserve the effectiveness of the antibiotics that

are currently available on the market. This paper addresses the role Information Technology

(IT) systems can play to improve efficiencies of the antimicrobial stewardship program within

the hospital setting.

Key components of an Institutional Antimicrobial Stewardship Program

First, it is critical to have a good understanding of what antimicrobial stewardship is and

its importance. An evidence-based antimicrobial stewardship program should have the

following basic components within its foundation:

1. Hospital administrative support and oversight. This must include active participation,

accountability from and communication to all departments. A major part of this should

be the consideration of organizational and IT redesign to support the organizational and

antimicrobial stewardship team goals.

2. A multi-disciplinary antimicrobial stewardship team or committee. Must consist of

representation from administration, infectious diseases, clinical pharmacy, clinical

microbiology, infection control, information technology, nursing and quality.

3. Collaboration between the antimicrobial stewardship team, Infection Control and the

Pharmacy & Therapeutics Committee or their equivalents. This allows for economies of

scale and simplification of various processes.

The above must agree upon one of the following two strategies as the foundation of their

antimicrobial stewardship program to support the organization’s enterprise strategy.5

Prospective audit with intervention and feedback.

Formulary restriction and preauthorization.


Prospective audit with intervention and feedback strategy allows for the use of education, clinical

decision support tools like clinical algorithms to effectively to used to achieve the goals of

antimicrobial stewardship. Formulary restriction and preauthorization requires more man-hours

and reliance upon opinion and clinical experience rather than strong and quality evidence-based

medicine.

Governance

It is the responsibility of the organization’s executive committee to provide oversight of

all projects within the organization. It is critical to use technology only as a tool to accelerate the

momentum of the organization to achieving their overall vision and enterprise strategy.8 This

includes allocating the appropriate resources to the project, identifying project champions from

all organizational areas, allocating the funds from the budget and communications to the

organization.6 The executive board must also be responsible and accountable for the successful

implementation of any IT systems within the organization. It is their leadership that gains the

necessary buy-in from all the project champions from concept to implementation, organizational

acceptance and long-term value to the organization. The executive committee must be dedicated

to providing the necessary support throughout and far beyond the implementation phase. On-

going feedback from all parts of the organization must be allowed to flow freely at all stages of

the project. Communications addressing all the feedback and suggestions must be ongoing.

The greatest system can be a failure if there is one person who isn’t heard or their concerns are

ignored. Resources to effectively manage the IT portion of antimicrobial stewardship must be

effectively managed to make the project a success.


Enterprise Strategy

Every hospital desires to improve their clinical outcomes and provide the best possible

care. The overall direction of the hospital should have its foundation in their enterprise strategy.

The hospital’s enterprise strategy must be behind every decision. In fact, the hospital must

clearly establish their core business, or what they can do better than anyone else. Regardless of

what that is, the hospital must embrace the fact that there are basic elements of their operations at

which they must excel. These include providing a safe and secure environment, access to quality

of care, etc. It is critical that every employee embrace this goal as part of their basic beliefs and

daily decisions and actions.

Hospital administration must embrace the responsibility to create, and clearly

communicate the hospital vision and enterprise strategy throughout the hospital. The

administration must also be responsible and be held accountable to insure that all hospital

employees embrace the enterprise strategy. All decisions and actions affecting the core business

of the hospital must be based upon the enterprise strategy.

Antimicrobial stewardship is a concept to enhance the overall patient safety and to

optimize the clinical outcomes.5 For an antimicrobial stewardship program to be effective and

achieve the results for which it is designed, hospital administration must embrace its value to the

hospital and how such a program is a part of the organization’s enterprise strategy. This

enhances the credibility to the program and improves the likelihood of success. Support of

hospital administration is also critical for the medical staff to completely embrace the program.

An effective antimicrobial stewardship program must be integrated into the hospital’s

electronic health record (eHR) system, to enhance the clinical decision support. Using

information technology systems in the way will lead to increased standardization, more efficient

quality reporting, improved efficiencies and the reduction of medical errors. Integration of the


antimicrobial stewardship program into the eHR system provides, through an effective clinical

decision support tool, to develop clear organizational guidance and the development of clinical

algorithms. Any algorithms must be developed by the antimicrobial stewardship committee,

with medical and nursing staff agreement and buy-in being based upon clear medical evidence.

The medical evidence must follow established guidelines for evaluating the level, strength and

quality of the medical evidence.

Table 1. Infectious Disease Society of America – United States Public Health Service grading system for ranking recommendations in clinical guidelines.7

Category, grade DefinitionStrength of recommendationA Good evidence to support a recommendation for useB Moderate evidence to support a recommendation for useC Poor evidence to support a recommendation for useQuality of evidenceI Evidence from ≥ 1 properly randomized, clinical trialII Evidence form ≥ 1 well-designed clinical trial, without randomization: from cohort or case-

controlled analytical studies (preferably from ≥ 1 center); from multiple time-series; or from dramatic results from uncontrolled experiments.

III Evidence from opinions of respected authorities, based upon clinical experience, descriptive studies, or reports of expert committees.

Any and all hospital utilization guidelines must be based upon clear and strong evidence

to provide the greatest potential for the best patient outcomes and to minimize any potential

liability. Too many times, decisions are made within hospitals based upon opinion or individual

experience rather than any strong medical evidence. It should be administration’s responsibility

1 Bouchner HW, Talbot GH, Bradley JS, et al; [Bad Bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America]. CID. 2009; 48(1):1-12.2 Spellberg B, Guidos D, et al ; [For Infectious Diseases Society of America. The epidemic of antibiotic-resistant infections: a Call to action for the medical community from the Infectious Diseases Society of America]. CID 2008; 46(2):155-164.3 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings: 12 steps to prevent antimicrobial resistance among hospitalized adults. Centers for Disease Control and Prevention Web Site. http://www.cdc.gov/drugresistance/healthcare/ha/slideset.htm. Last updated March 29, 2004. Accessed February 10, 2011.4 2010 Physician’s Desk Reference5 Dellit TH, Ownes, RC, McGowan, Jr. JE, et al. [Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship]. CID. 2007:44 ( 15 January): 159-177.6 Brown GD, Stone TT, Patrick TB, [Strategic Management of Information Systems in Healthcare]. The Foundation of the American College of Healthcare Executives. USA 2005.7 Kish, MA. Guide to development of practice guidelines. CID 2001; 32:851-4.


to insure that these decisions have a foundation in the scientific method and clearly demonstrated

evidence. Anything less should only be allowed when there is a clear lack of evidence based

upon the guidelines from Table 1.

The Role of Information Technology

Information technology application in health care in the form of electronic health records,

computerized physician order entry (CPOE) and clinical decision support can improve

antimicrobial decisions by effectively integrating data on patient-specific microbiology cultures

and susceptibilities, hepatic and renal function, drug-to-drug interactions, allergies and cost. The

use of technology in this manner is supported by established evidence in the literature and noted

with a B-II recommendation (see table 1).

Technology when used correctly and wisely is a tool which can accelerate the momentum

in achieving the enterprise goal of the organization.8 Technology must fit directly into the

enterprise strategy and help the organization more effectively or efficiently accomplish their

vision and enterprise goal for it to a worthwhile investment. Technology must never be the

driver of any direction taken by an organization.

In the case of antimicrobial stewardship, the technology must improve the process and

efficiencies by eliminating steps, potential errors and the overall improvement of patient

outcomes. Technology provides the opportunity to standardize care around published guidelines

which have clearly demonstrated improvement in the quality of care. These guidelines must be

based upon the best evidence available and constantly re-evaluated and updated. This approach

supports patient safety goal number seven from the Joint Commission9, the “Get Smart for

Health Care program from the CDC10 and the need to preserve currently available antimicrobials

8 Collins, Jim [Good to Great, why some companies make the leap and other don’t]. First Edition. HarperCollins Publishers. 20019 Joint Commission: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/10 CDC: http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html


in the face of trends of increasingly multi-drug resistant organisms. Consensus organizational

guidelines should be an integral part of any clinical decision support system within the

organization’s CPOE system.

Computer surveillance and decision support, integrating eHR with pharmacy,

microbiology and CPOE can be a powerful tool to insure appropriate antimicrobial utilization,

while minimizing the potential for drug-to-drug interactions, medication errors and developing

antimicrobial resistance. When embraced by equally throughout the hospital, these systems can

lead to improving quality of care over time. Another benefit that can potentially be realized with

the integration of the various systems to improve antimicrobial stewardship is improving cost-

effectiveness and overall cost savings.

The integration of clinical algorithms into the IT system clinical decision support and

CPOE has been shown to lead to more appropriate dosing of antimicrobials and the reduction of

adverse drug events.11 Other studies have shown that a decision clinical support system was

associated with a 59% reduction in the rate of pharmacy intervention for erroneous drug doses

and 36% and 28% decreases in the rates of subtherapeutic and excessive antimicrobial dosing

days, respectively. These studies also show a 9% reduction of the cost of antimicrobial agents

used.5

There is an opportunity to change prescribing habits using information technology. To

many times, empiric antimicrobial therapy is not changed once microbiology patient-specific

susceptibility data is known. It is a well-known standard of practice that once patient-specific

microbiology susceptibilities are available and known, empiric antimicrobial therapy should be

adjusted, tailoring the antimicrobial therapy to the most appropriate antimicrobial agent.

Adjustments should be based upon the microbiology susceptibility data, patient-specific 11 Evans RS, Pestotnik SL, Classen DC, Burke JP. [Evaluation of a computer-assisted antibiotic-dose monitor]. Annals of Pharmacotherapy 1999; 33:1026-31.


conditions, medications, allergies, organ function and antimicrobial cost. Cost should always be

the last variable and a balance between cost to the organization, staffing levels and cost to the

patient.

There is also opportunity to encourage the heterogeneity of antimicrobial utilization to

minimize selective pressure on potentially resistance organisms and other unintended

consequences to the organization, community and patient. Studies have demonstrated that there

is an association between antibiotic use and antibiotic resistance.12 Antibiotics should not be

over used so as to select out resistant microorganisms nor should they be held in reserve. It has

been shown in various studies that hospitals which restrict certain classes of antimicrobial agents,

over time have a greater problem with resistance than do hospitals with an open formulary.13

Physicians get into the habit of using a select few antimicrobial agents, which in turn adds to the

selection process leading to increased antimicrobial resistance. Technology can help insure that

antimicrobials are utilized more appropriately based upon patient-specific microbiology cultures

and susceptibilities, hepatic and renal function, drug-to-drug interactions, allergies, cost and

utilization history.

Utilization history would allow the system to monitor the antimicrobial agent utilization

and when a pre-determined utilization was reached, that antimicrobial would be eliminated from

the list of choices from which to select. That would only be relevant until there were few

choices left. This could be one way in which the technology could help to insure heterogeneity

was practiced.

Microbiology Laboratory

12 Tacconelli E. [Antimicrobial use: risk driver of multidrug resistant microorganisms in healthcare settings]. Curr Opin Infect Dis 2009; 22:352-358.13 Lutters, M., Herrmann, F., Dayer, P., & Vogt, N. (1998). [Antibiotic utilization in a university geriatric hospital and drug formularies]. Schweizerische Medizinische Wochenschrift, 128(7), 268-271. Retrieved from EBSCOhost.


The clinical microbiology laboratory plays a critical role in the timely identification of

microbial pathogens, and susceptibility patterns within each hospital. It is critical that

physicians have access to the timely patient-specific microbial susceptibility data, no more than

seventy-two hours. Timely access means that the physicians have immediate access to the

patient-specific microbial susceptibility data in order to make effective decisions to direct

antimicrobial therapies. This carries an A-III recommendation (see table 1).

Information technology provides avenues to facilitate the integration of microbiology

patient-specific susceptibility results to be reported through the hospital’s eHR system. The

microbiology data once available would be posted to the patients e-HR file, the appropriate

physician would be notified that the data is available for review. With the rapid development of

technology, physicians could be notified at the workstation within the hospital, their smart

phone, or other electronic device. Microbiology IT systems must be integrated into the patient

eHR. Patient-specific susceptibility data used in collaboration with clinical decision support

algorithms can provide recommendations for de-escalation or directed antimicrobial therapy.

This must be accomplished with the review and application of the best medical evidence,

susceptibility data, patient-specific data (potential drug-to-drug interaction data, renal function

data, etc.), utilization history and cost data from the hospital pharmacy to recommend the top

three to five choices. At which point, the physician would have access to recommendations

based upon a pre-established algorithm. Once the physician chooses the antimicrobial agent

using the hospital’s CPOE system, other data checks to insure correct dosing based upon patient-

specific renal and hepatic function tests would be made to insure the most appropriate dosing of

the antimicrobial agent.

Quality Measurement


Quality is the opportunity to improve upon current processes and outcomes. The primary

goal of an effective antimicrobial stewardship program should be an improvement on the quality

of patient outcomes and the reduction of unintended consequences of antimicrobial use,

including toxicity or selection of resistant microorganisms. Information Technology systems can

track changes to patient outcomes, antimicrobial resistance patterns, medical errors, etc. to

document where the hospital was before implementing antimicrobial stewardship to the present

(see example in Figure 2). It is always a good idea to see where the organization is, where the

organization was, and where the organization needs to go in the future.

Summary

There is a significant need for hospital organizations to understand and embrace the need

for an antimicrobial stewardship program. An effectively run antimicrobial stewardship program

can optimize clinical outcomes and minimize unintended consequences of antimicrobial use.

The unintended consequences can include toxicity, drug-drug interactions, allergies, the selection

of resistance microorganisms, etc. There is a significant need to be more judicious with the use

of antimicrobial agents if we are to maintain their usefulness for the time until more become

available. Hospitals can implement an antimicrobial stewardship program without using


technology. However, technology provides the platform to improve efficiencies, standardizing

clinical algorithms and insuring more heterogeneity in the utilization of antimicrobial agents.

When developing an antimicrobial stewardship program, the hospital should establish the clear

lines of governance. Information Technology has a clear role and must become an integral part

of the hospital’s antimicrobial stewardship program to improve efficiencies, standardize clinical

algorithms and act as a tool to improve the quality of care and patient outcomes. The hospital

can effectively use technology to accelerate their momentum to achieving their vision and

enterprise goal of improving clinical outcomes while minimizing unintended consequences.

References

the role of information technology as a part of a hospital's abp

Documents