Effect of Communication Errors During Calls to an Antimicrobial Stewardship Program

Abstract

Objective-To determine the effect of inaccurate communication of patient data-from clinicians caring for inpatients to prior-approval antimicrobial stewardship programs (ASP) staff (practitioners)-on the incidence of inappropriate antimicrobial recommendations by ASP practitioners Design-A retrospective cohort design was utilized. The accuracy of communicated patient data was evaluated against patients' medical records for pre-determined, clinically significant inaccuracies. Inappropriate antimicrobial recommendations were defined when an expert panel unanimously rated the actual recommendations as inappropriate after reviewing vignettes derived from inpatients' medical records. Setting-The setting was an academic medical center with a prior-approval ASP.Patients-All inpatient subjects of ASP prior-approval calls were eligible for inclusion.Results-The panel agreed on whether the antimicrobial recommendation was inappropriate or not in 163 (82%) of 200 ASP calls; the 163 calls were then the basis for further analyses. After controlling for confounders, inaccurate communications were associated with inappropriate antimicrobial recommendations with an odds ratio (OR) of 2.2 (p=0.03). In secondary analyses of specific data types, only inaccuracies of microbiological data were associated with the study outcome (OR 7.5, p=0.002). The most common reason given by panelists for an inappropriate rating was that antimicrobials were not indicated.Conclusions-Inaccurate communication of patient data, particularly microbiological data, during prior-approval calls is associated with an increased risk of inappropriate antimicrobial Corresponding Author: Darren R.

Diagnostic Errors that Lead to Inappropriate Antimicrobial Use

“…14,15 The inter-rater agreement in this study was similar to that reported previously in studies of antimicrobial appropriateness. 14,15 Second, our cases were diverse, and judgments were complex, involving diagnostic accuracy and appropriateness of initial and subsequent antimicrobial choices, dose, route, and duration.…”

“…Criteria for appropriateness, in order of priority, were the following: (1) whether treatment followed CDSS recommendations, (2) alternatives consistent with published guidelines, high-quality evidence, and antimicrobial susceptibility patterns, and (3) reasonable alternatives, given specific circumstances. 14,15 Adjustments to antimicrobial therapy based on clinical response and test results were considered. 16 Reviewers ignored trivial errors (eg, 1-2-day deviations from recommended treatment durations) that were otherwise clinically appropriate.…”

Antimicrobial stewardship for inpatient facilities

“…38 A follow-up by the same group demonstrated that inaccurate communication was significantly associated with inappropriate antimicrobial recommendations (odds ratio [OR] 2.2; P ¼ .03); this was particularly the case for inaccuracies in microbiologic data (OR 7.5; P ¼ .002). 55 Also, if all-hours support is not provided, at least 1 study has shown some physicians may engage in ''stealth dosing,'' that is, avoiding having to obtain preauthorization for restricted antimicrobials by waiting until off-hours to place orders. 56 The latter can be dealt with by following up on such orders with a prospective audit and feedback component of the program.…”

Factors associated with adherence to antimicrobial stewardship after-hours

“…Minimising access to restricted antimicrobials on select wards did not influence the likelihood of adherence after‐hours when compared to wards where restricted antimicrobials were freely available; although the cause cannot be determined within the current study, it might mean that restricted antimicrobials that are freely available in high use wards are not contained within those areas. The increased likelihood of approval following after‐hours drug acquisition on weekdays compared to weekends could simply be due to poor documentation and miscommunication . However, weekend antimicrobial prescribing has been associated with inappropriate, often excessive, prescribing elsewhere .…”

“…The increased likelihood of approval following after-hours drug acquisition on weekdays compared to weekends could simply be due to poor documentation and miscommunication. [21] However, weekend antimicrobial prescribing has been associated with inappropriate, often excessive, prescribing elsewhere. [22] As such, there may be a need to consider alternate strategies on Mondays.…”