Outcomes of an electronic medical record (EMR)–driven intensive care unit (ICU)-antimicrobial stewardship (AMS) ward round: Assessing the “Five Moments of Antimicrobial Prescribing”

Abstract

Objective:The primary objective of this study was to examine the impact of an electronic medical record (EMR)–driven intensive care unit (ICU) antimicrobial stewardship (AMS) service on clinician compliance with face-to-face AMS recommendations. AMS recommendations were defined by an internally developed “5 Moments of Antimicrobial Prescribing” metric: (1) escalation, (2) de-escalation, (3) discontinuation, (4) switch, and (5) optimization. The secondary objectives included measuring the impact of this service on (1) antibiotic appropriateness, and (2) use of high-priority target antimicrobials.Methods:A prospective review was undertaken of the implementation and compliance with a new ICU-AMS service that utilized EMR data coupled with face-to-face recommendations. Additional patient data were collected when an AMS recommendation was made. The impact of the ICU-AMS round on antimicrobial appropriateness was evaluated using point-prevalence survey data.Results:For the 202 patients, 412 recommendations were made in accordance with the “5 Moments” metric. The most common recommendation made by the ICU-AMS team was moment 3 (discontinuation), which comprised 173 of 412 recommendations (42.0%), with an acceptance rate of 83.8% (145 of 173). Data collected for point-prevalence surveys showed an increase in prescribing appropriateness from 21 of 45 (46.7%) preintervention (October 2016) to 30 of 39 (76.9%) during the study period (September 2017).Conclusions:The integration of EMR with an ICU-AMS program allowed us to implement a new AMS service, which was associated with high clinician compliance with recommendations and improved antibiotic appropriateness. Our “5 Moments of Antimicrobial Prescribing” metric provides a framework for measuring AMS recommendation compliance.

Visual mapping of team dynamics and communication patterns on surgical ward rounds: an ethnographic study

“…Indeed, ensuring discontinuation of unnecessary antibiotics remains the most common recommendation in AMS interventions. 42 Studies have shown that in the absence of the full team compliment or if decisions are not communicated to the pertinent role player, potential time delays can have an impact on patient outcomes. 43 Lack of standardisation has been noted in other surgical teams 19 44 45 where key aspects of care may be overlooked and is associated with suboptimal patient outcomes.…”

“…46 49 In addition, inconsistent provision of clinical and infection-related information in the update can result in loss of valuable time, limiting the ability for generating relevant and correct information. 50 Despite the increasing threat of antibiotic resistance and HCAIs, it is interesting to note that few of the existing checklists, other than those designed for dedicated AMS rounds, 42 alert a surgical team to the key aspects of AMS and infection prevention and management. An opportunity exists to apply AMS and IPC principles to every single patient on every ward round and should not be reserved to dedicated stewardship rounds only.…”

Building on Antimicrobial Stewardship Programs Through Integration with Electronic Medical Records: The Australian Experience

“…The core activity of many Australian AMS programs are post-prescription ward rounds [1,12,32,33]. These multidisciplinary rounds comprised of an AMS pharmacist and an ID physician are a highly visible service in Australian hospitals with paper-based medication charts, enabling opportunity for impromptu discussions between clinicians and AMS teams about patients of concern.…”

Standard of practice in infectious diseases for pharmacy services

“…Local evidence for hospital AMS programs led by or including ID pharmacists has shown increased antimicrobial prescribing appropriateness, reduced use of target antimicrobials and provision of cost savings without adversely impacting clinical outcomes such as length of stay and mortality 22‐25 . Pharmacists are continuing to show their expertise in specific subspecialty areas within AMS, including antifungal stewardship, 26 and antimicrobial allergy de‐labelling 27,28 .…”