A mandatory indication-registration tool in hospital electronic medical records enabling systematic evaluation and benchmarking of the quality of antimicrobial use: a feasibility study

Abstract

Objectives Evaluation of the extent and appropriateness of antimicrobial use is a cornerstone of antibiotic stewardship programs, but it is time-consuming. Documentation of the indication at the moment of prescription might be more time-efficient. We investigated the real-life feasibility of mandatory documentation of the indication for all hospital antibiotic prescriptions for quality evaluation purposes. Methods A mandatory prescription-indication format was implemented in the Electronic Medical Record (EMR) of three hospitals using EPIC or ChipSoft HIX software. We evaluated the retrieved data of all antibiotics (J01) prescribed as empiric therapy in adult patients with respiratory tract infections (RTI) or urinary tract infections (UTI), from January through December 2017 in Hospital A, June through October 2019 in Hospital B and May 2019 through June 2020 in Hospital C. Endpoints were the accuracy of the data, defined as agreement between selected indication for the prescription and the documented indication in the EMR, as assessed by manually screening a representative sample of eligible patient records in the EMR of the three hospitals, and appropriateness of the prescriptions, defined as the prescriptions being in accordance with the national guidelines. Results The datasets of hospitals A, B and C contained 9588, 338 and 5816 empiric antibiotic prescriptions indicated for RTI or UTI, respectively. The selected indication was in accordance with the documented indication in 96.7% (error rate: 10/300), 78.2% (error rate: 53/243), and 86.9% (error rate: 39/298), respectively. A considerable variation in guideline adherence was seen between the hospitals for severe community acquired pneumonia (adherence rate ranged from 35.4 to 53.0%), complicated UTI (40.0–67.1%) and cystitis (5.6–45.3%). Conclusions After local validation of the datasets to verify and optimize accuracy of the data, mandatory documentation of the indication for antibiotics enables a reliable and time-efficient method for systematic registration of the extent and appropriateness of empiric antimicrobial use, which might enable benchmarking both in-hospital and between hospitals.

Detecting inappropriate total duration of antimicrobial therapy using semi-automated surveillance

“…With this study we demonstrated that implementing mandatory indication registration in the EMR enables a reliable and e cient method for systemic registration of two core-elements of ASP: the guideline adherence of the total duration of antibiotic therapy and the guideline adherence of empiric antibiotic choice, the latter we showed in our previous study [10]. It has the potential to become a valuable aid for ASP, as it reduces the amount of manual data collection and has the ability to provide clear targets for local ASP.…”

“…Unfortunately, 17% of prescriptions were linked to an inaccurately selected indication, of which half affected the assessment of guidelineadherent LOT. In our previous study we found similar proportions of inaccurately selected indications in the hospitals where the mandatory indication registration was recently introduced [10]. Based on the Capability-Opportunity-Motivation Behaviour model, designed by Michie and colleagues, behaviour can only occur when an individual has the capability, opportunity and motivation (including habitual process) to perform the behaviour [14].…”

“…Both locations use EPIC software as their electronic medical record and prescribing software. In 2019, a standardized prescription-format (supplemental table 1), was implemented in the EMR, as described in our previous study [10]. This prescription-format requires physicians to select the indication for the prescription from a prede ned list whenever they prescribe an antimicrobial agent for hospital inpatients.…”

“…Due to our inclusion criteria we did not evaluate all antibiotic courses prescribed during hospital admission. We focused on patients that were initially empirically treated to enable reliable data extraction, as this method was already used and validated in our previous study [10]. In addition, we disregarded di cult-to-treat infections and nosocomial infections, as the local guidelines usually do not apply to these infections.…”

“…An in-depth audit assessing the appropriateness of choice and duration of antibiotic therapy for each individual antibiotic course until recently required manual data collection from the (electronic) medical record (EMR), which is time-consuming [7,8]. As a result, the number of antibiotic prescriptions that could be evaluated was limited by available personnel and resources [7,8] Recently, the use of EMR to facilitate automated ASP audits has grown in relevance, as it was demonstrated that this can provide data that enable e cient measurement of the appropriateness of antibiotic use [9,10]. Utilizing indication selected at time of order entry also enable stewardship programs perform targeted real-time interventions, as many other methods (like using ICD-10s) can only occur post-discharge.…”