From the 2021 HVPAA National Conference
David Reynoso (University of Texas Medical Branch), Ryan (Scott) Ferren, Rachel Britt, Diana Nguyen, Ion (Adi) Mitrache, Rick Trevino, Kyle Palmberg, Natalie Williams-Bouyer, Ping Ren, Phyu Thwe, Janak Patel, Seth Bellister, Stephen Williams, Gulshan Sharma, Philip Keiser
Background
Our antimicrobial stewardship program (ASP) serves adults and children, and consists of infectious diseases and surgical clinicians, pharmacists, infection preventionists, microbiologists, nurses, and data scientists. Since January 1, 2017, our ASP has implemented over 15 evidence-based interventions across four campuses (five hospitals), including prospective audit and feedback (“handshake stewardship”), formulary restriction and pre-authorization for select antimicrobials, pharmacy-driven intravenous-oral switching, “nudging” appropriate antibiotic decisions by optimizing the EMR, and development of institutional guidelines for empiric antibiotics, among others.
Beyond actions to improve the quality and safety of patients receiving antimicrobials, the core elements of ASP include longitudinal tracking and reporting of essential ASP metrics, such as antimicrobial utilization, antimicrobial resistance, Clostridioides difficile infections, and cost of care. Real-time tracking and reporting of these metrics, and taking timely and relevant actions in response, is often limited by the functionality of electronic medical record (EMR), the complexity of health systems that span multiple campuses, cross-talk across software platforms, and accessibility to administrative silos of data.
Objectives
Herein, we report the implementation of a successful multidisciplinary ASP, and establishment of a user-friendly internal advanced data and analytical reporting solution for tracking and reporting.
Methods
To track and report on our progress and process prospectively, we adapted a Qliksense® application to function as a real-time dashboard for antimicrobial resistance rates, Clostridioides difficile infections, cost of care, IV-PO conversions, and antimicrobial utilization. Its functionality allows data to be analyzed by anti-infective class and spectrum, time period, campus, unit, specialty, service, provider, billing diagnosis-related group (DRG), and many other filters and categories. Antimicrobial utilization is tracked as days of therapy per 1000 patient days (DOTs), point prevalence, or proportion of all discharges who received an antimicrobial, and real-time resistance rates can be analyzed by culture type and setting.
Results
At our Galveston campus, monthly utilization of systemic antimicrobials decreased significantly from 553 DOTs pre-ASP to 527 post-ASP (p=0.0224), a 5% decrease from baseline. This was driven by improved use of levofloxacin (69 monthly DOTs pre-ASP vs 47 post-ASP; p<0.0001) and de-escalation from empiric vancomycin and piperacillin-tazobactam combination (230 DOTs pre-ASP vs 192 DOTs post-ASP; p=0.0002). Conversely, use of narrow-spectrum agents increased without impacting costs, resistance, treatment failure or mortality. Testing for, and diagnosis of, C. difficile infections declined significantly after implementing electronic medical record questionnaire and guidance. There is significant variability in antimicrobial utilization across service lines and campuses, which corresponds to variability in acceptance of ASP interventions.
Conclusions
We report implementation of a successful multidisciplinary ASP, and establishment of a user-friendly internal advanced data and analytical reporting solution for tracking and reporting. Collaboration between a multidisciplinary clinician group and a clinical data team allows for useful modeling and display of data to support ASP initiatives.
Clinical Implications
A user-friendly, internal Qliksense® application facilitates and guides interventions of ASP to improve patient outcomes through a real-time dashboard for antimicrobial resistance rates, Clostridioides difficile infections, cost of care, IV-PO conversions, and antimicrobial utilization.
