From the 2018 HVPAA National Conference
Wenjing Wei (Parkland Health and Hospital System), Norman Mang (Parkland Health and Hospital System), Jessica Ortwine (Parkland Health and Hospital System), Kristin S. Alvarez (Parkland Health and Hospital System), Bonnie Prokesch (University of Texas Southwestern Medical Center, Dallas, TX;)
Oral (PO) antimicrobials are sometimes perceived to be inferior to intravenous (IV) formulations, however many oral agents produce equivalent therapeutic concentrations and outcomes as their IV counterparts. Although most patients are initially started on IV antimicrobials upon hospital admission, opportunities often exist for conversion to an oral medication.
The primary objective involved improving IV to PO conversions by staff pharmacists through an electronic decision support system with a secondary objective of developing metrics to measure the outcomes of IV to PO conversions electronically without manual chart review. Desired metrics included percentage of eligible antimicrobials ordered as PO, the total number of IV to PO conversions, as well as cost avoidance associated with using the oral as opposed to IV route.
A protocol was approved by the institution’s Pharmacy and Therapeutics committee allowing pharmacists to auto-convert medications from IV to PO when meeting pre-specified criteria. First, the criteria to identify potential conversions were updated and implemented electronically in Epic using a traffic light decision support system to prioritize eligible patients. Next, education was provided both in person and as pocket cards with guidance on eligible antimicrobials for IV to PO conversion. These criteria IV to PO conversion metrics were measured based on monthly antimicrobial utilization data and displayed in a dashboard.
Monthly metrics provided the stewardship team feedback on the effectiveness of the IV to PO program and identified areas for improvement. In fiscal year 2017, cost avoidance by ordering oral as opposed to IV agents was $485,957 with 1,998 IV to PO conversions performed by both providers and pharmacists and a total of 65% of the estimated eligible antimicrobials were ordered as the PO route. Based on these findings, a multidisciplinary and multifaceted approach to further expand the IV to PO initiative was undertaken.
The IV to PO decision support system improves the efficiency of IV to PO review process and reduces time spent on reviewing patients who do not meet criteria for conversion. The development of automated metrics measured monthly is an efficient method to assess the effectiveness of the program as well as identify areas for future development
Implications for the Patient
Benefits of oral therapy include increased patient comfort, mobility, and satisfaction as well as decreased adverse events and healthcare-associated infections related to intravenous catheters. Utilization of a decision support system
allows for easy monitoring of PO conversions and identification of ways to improve the efficiency and effectiveness of the program.