M. B. Robertson

Electronic antibiotic stewardship—reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting

OBJECTIVES Antibiotic stewardship is important, but the ideal strategy for providing stewardship in a hospital setting is unknown. A practical, sustainable and transferable strategy is needed. This study evaluates the impact of a novel computerized antimicrobial approval system on antibiotic-prescribing behaviour in a hospital. Effects on drug consumption, antibiotic resistance patterns of local bacteria and patient outcomes were monitored. METHODS The study was conducted at a tertiary referral teaching hospital in Melbourne, Australia. The system was deployed in January 2005 and guided the use of 28 restricted antimicrobials. Data were collected over 7 years: 5 years before and 2 years after deployment. Uptake of the system was evaluated using an in-built audit trail. Drug utilization was prospectively monitored using pharmacy data (as defined daily doses per 1000 bed-days) and analysed via time-series analysis with segmental linear regression. Antibiograms of local bacteria were prospectively evaluated. In-hospital mortality and length of stay for patients with Gram-negative bacteraemia were also reported. RESULTS Between 250 and 300 approvals were registered per month during 2006. The gradients in the use of third- and fourth-generation cephalosporins (+0.52, -0.05, -0.39; P < 0.01), glycopeptides (+0.27, -0.53; P = 0.09), carbapenems (+0.12, -0.24; P = 0.21), aminoglycosides (+0.15, -0.27; P < 0.01) and quinolones (+0.76, +0.11; P = 0.08) all fell after deployment, while extended-spectrum penicillin use increased. Trends in increased susceptibility of Staphylococcus aureus to methicillin and improved susceptibility of Pseudomonas spp. to many antibiotics were observed. No increase in adverse outcomes for patients with Gram-negative bacteraemia was observed. CONCLUSIONS The system was successfully adopted and significant changes in antimicrobial usage were demonstrated.

Providing guidelines and education is not enough: an audit of gentamicin use at The Royal Melbourne Hospital

Background: Aminoglycoside antibiotics are commonly prescribed for the treatment of Gram‐negative infections. Appropriate dosing and therapeutic monitoring of aminoglycosides are important because these agents have a narrow therapeutic index.

A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments

OBJECTIVE The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). DESIGN and INTERVENTIONS Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. SETTING AND PARTICIPANTS Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. MAIN OUTCOME MEASURES Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. RESULTS Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4-8) at baseline to 125/503 (25%, 95% CI 21-29; P < 0.0001) and 102/462 (22%, 95% CI 18-26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16-23) to 132/462 (30%, 95% CI 26-34; P < 0.0001) and 132/462 (29%, 95% CI 24-33; P < 0.001), respectively. CONCLUSIONS Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

Management of Acute Coronary Syndromes at Hospital Discharge: Do Targeted Educational Interventions Improve Practice Quality?

&NA; Evidence‐based guidelines exist for the management of patients with acute coronary syndromes (ACS), yet adherence is suboptimal. The Discharge Management of Acute Coronary Syndrome project used a quality improvement approach, with targeted intervention strategies to optimize: prescription of guideline‐recommended medications; education regarding lifestyle modifications, including cardiac rehabilitation (CR); and communication between hospital staff, patients, and general practitioners. Hospitals across Australia participated in a quality improvement cycle of audit, feedback, intervention, and reaudit. Interventions involved educational meetings, academic detailing and point‐of‐care reminders, and feedback of baseline audit results. Outcome measures included prescription of guideline‐recommended medications, referral to CR, and documentation and communication of management plan. At baseline, 49 hospitals recruited 1,545 patients, and postintervention, 45 hospitals remained active in the project and recruited 1,589 patients. Three thousand and thirty‐four hospital staff attended group education or academic detailing sessions. Postintervention, there was a significant increase in the prescription of all four guideline‐recommended medications (69% vs. 57%; p<.0001); short‐acting nitrates (68% vs. 56%; p<.0001); and documented referral to CR (68% vs. 57%; p<.0001). There were significant increases in documented discharge medication counselling, smoking cessation counselling, and communication of management plans. Targeted educational interventions used as part of a quality improvement cycle can enhance adherence to evidence‐based guidelines for the management of patients with ACS.

Guidance DS: A web-based clinical decision support system for antimicrobial stewardship in hospitals

Abstract We describe a web-based drug approval and clinical decision support system called Guidance DS. The system was developed by a multidisciplinary team of clinicians, pharmacists, software developers and epidemiologist at the Royal Melbourne Hospital (RMH). Its design was informed by contextual enquiry and formative evaluation processes. Guidance DS has role based workflows for clinicians, senior prescribers, pharmacists, administrators and auditors. Its primary use has been antimicrobial stewardship, and the system has demonstrated significant improvements in antibiotic use and antimicrobial resistance since its deployment at the RMH in 2005 and at the Peter MacCallum Cancer Centre in 2007. The technology is suited to any clinical algorithm, guideline or other class of drug that requires surveillance or monitoring. In 2008, the government funded mandatory introduction of electronic antimicrobial stewardship systems to all major public hospitals in Victoria. As a result, we are now implementing Guidance DS to twelve other sites. These hospitals have widely variable infectious diseases support, information technology infrastructure and prescribing cultures. We will describe a tool that can be used to assess the readiness of a large institution to receive this type of technology, and therefore guide resource allocation to facilitate implementation. Based on our own experiences of instituting organisational change, we have also developed a detailed implementation checklist that we provide to all sites in conjunction with a consultative process.