Automating antimicrobial stewardship

EHR integration of a patient scoring tool improved care quality.


Where: The Ohio State University Wexner Medical Center, a 1,367 bed tertiary care facility in Columbus, Ohio.

The issue: Rapid identification and treatment of patients with Staphylococcus aureus bacteremia.

Background

In the past, Ohio State's antimicrobial stewardship team received automated alerts through its rapid diagnostic system when patients were found to have S. aureus bacteremia, but they still had to manually contact the treating physician and make recommendations, said Eric Wenzler, PharmD. “We thought there was probably a better way to do that,” he said. “We had highly skilled information technology (IT) pharmacists at Ohio State, so . . . we worked with them to try to automate this process.”

The result was a patient scoring tool integrated into the electronic health record (EHR), which helps to streamline the process for the pharmacists.

How it works

Once a patient tests positive for S. aureus bacteremia, the scoring tool alerts the pharmacists and prompts them to communicate with the treating physician both orally and by using a templated progress note with recommendations based on the medical center's evidence-based guidelines. What happens next depends on what needs to be done for the patient, whether that's obtaining repeat blood cultures, ordering a specific antibiotic, or consulting with an infectious disease (ID) physician, explained Dr. Wenzler. who completed his residency at the medical center and is now an assistant professor at the University of Illinois at Chicago College of Pharmacy.

“One of the nice things from the physicians' perspective is a lot of [those clinical actions are] automated in our [EHR], so they were able to order those things fairly quickly for their patient,” he said.

Results

Dr. Wenzler and colleagues tested the impact of the scoring tool in conjunction with the pharmacists' intervention on patient care in a retrospective study comparing 45 patients with S. aureus bacteremia before the tool was implemented to 39 patients treated afterward. The primary outcome was clinicians' overall adherence to four quality-of-care components of the management of S. aureus bacteremia: ID consult, repeat blood cultures, echocardiogram, and initiation of targeted antimicrobial treatment.

Overall, clinicians adhered to all four components significantly more frequently under the intervention than before (92.3% vs. 68.9%), according to results published in April by Clinical Infectious Diseases. In addition, the incidence of ID consults was nearly 20% higher (94.9% vs. 75.6%).

Challenges

The most difficult part of the intervention was developing the scoring tool and integrating it into the EHR, said Dr. Wenzler. “In this particular study, the biggest challenge was the logistics, the IT side, getting this thing automated, which was really the crux of what we were doing. That was different from what others did before,” he said. “This was not a manual process, which people have demonstrated does work, but we really wanted to automate it to increase the efficiency of our program and of this intervention.”

Beyond the technical challenges, Dr. Wenzler said another sticking point was asking the pharmacists to take on more work. “They're very busy as it is with order verification and making sure that the right drug gets to the right patient at the right time. Asking them to go above and beyond and do a little more clinical intervention is something that could have been met with some opposition, but I think for the most part, it wasn't,” he said. It also took time for the physicians to understand the purpose of the intervention, but having an ID subspecialist advocate for it helped get everyone on board, Dr. Wenzler added.

Next steps

Ohio State continues to use the scoring tool, he said, and the next step is to try to simplify the process. “What we wanted to do was take this to the next step and have an alert that goes directly to the physicians . . . that says, ‘Hey, your patient has S. aureus bacteremia, here are the things that you should do,’ and give them a sort of order set to start ordering those things automatically,” Dr. Wenzler said.

Logistically, this would be challenging because of potential alert fatigue and the fact that the hospital's clinicians are still adjusting to a relatively new EHR system, he acknowledged. “One of the things that is really untapped from a stewardship perspective is putting stewardship in the hands of prescribers. It really has never been done,” Dr. Wenzler said. “I think getting there at the point of care is really important and is going to be the future of stewardship.”

Words of wisdom

“In the traditional sense, people think of stewardship as a physician, an ID pharmacist, hopefully a microbiologist, maybe a data manager person,” he said. “That's only four people; you really need to push out the efficiency of your program by empowering other people to do what's best for patients by educating them [and] giving them specific instructions on what you want them to do.”