Computer-Assisted Antimicrobial Recommendations for Optimal Therapy: Analysis of Prescribing Errors in an Antimicrobial Stewardship Trial.

Clinician education and prospective audit and feedback interventions, deployed separately and concurrently, did not reduce antimicrobial use errors or rates compared to a control group of general medicine inpatients at our public hospital. Additional research is needed to define the optimal scope and intensity of hospital antimicrobial stewardship interventions. Infect Control Hosp Epidemiol 2017;38:857-859.

Lost in translation? Reliability of assessing inpatient antimicrobial appropriateness with use of computerized case vignettes.

OBJECTIVE: To describe and measure reliability of a computer-assisted method of case vignette assembly and expert review to assess the appropriateness of antimicrobial therapy for hospitalized adults. DESIGN: Feasibility and reliability analysis of computer-assisted tool used to compare the effects of antimicrobial stewardship interventions. SETTING: Public teaching hospital. PATIENTS: Randomly selected adult antimicrobial recipients admitted to inpatient medicine services. METHODS: Clinical data abstracted from 504 paper medical records were merged with computerized laboratory and pharmacy data to assemble case vignettes that underwent expert review for appropriateness. We performed 3 validations, as follows: data for 35 vignettes abstracted independently by 2 research assistants were assessed for interrater agreement, expert review of 24 vignettes was compared with review of the corresponding paper medical records, and interrater reliability of antimicrobial appropriateness assessments by 2 experts was determined for 70 case vignettes. RESULTS: Vignette assembly and expert review each required 10-12 minutes per case. Potentially important discrepancies occurred in 0%-32% of clinical findings abstracted independently by 2 research assistants. Expert review of 24 vignettes and the corresponding full paper medical records yielded fair agreement (kappa, 0.30). The 2 experts identified inappropriate initial antimicrobial therapy in 67% and 61% of case vignettes reviewed independently; interrater agreement was improved after sequential case discussion and stringent application of appropriateness criteria (kappa, 0.72). CONCLUSIONS: Our case vignette assembly and expert review method is efficient, but improvements in both technical and human performance are needed to be able to yield valid estimates of the prevalence of inappropriate antimicrobial use. Assessments of antimicrobial appropriateness require validation.

Antibiotic combinations with redundant antimicrobial spectra: clinical epidemiology and pilot intervention of computer-assisted surveillance.

Redundant antibiotic combinations are a potentially remediable source of antibiotic overuse. At a public teaching hospital, we determined the incidence, cost, and indications for such combinations and measured the effects of a pharmacist-based intervention. Of 1189 inpatients receiving >or=2 antibiotics, computer-assisted screening identified 192 patients (16.1%) receiving potentially redundant combinations. Chart reviews showed that 137 episodes (71%) were inappropriate. Physician overprescribing errors were found in 77 episodes (56%); most involved redundant coverage for gram-positive or anaerobic organisms. In 76 episodes (55%), lapses in the medication ordering and distribution system led to the persistence in the pharmacy records of regimens no longer active according to the patient charts. The incidence of redundant antibiotic combinations was significantly higher in the intensive care unit and surgery services, compared with medical services. Interventions to discontinue redundant agents were successful in 134 (98%) of the 137 episodes. Potential drug cost savings and reduction in redundant antibiotic combination days were 10,800 dollars and 584 days, respectively; pharmacist time for patient review and intervention cost 2880 dollars. Use of redundant antibiotic combinations was common, and a pharmacist-based intervention was feasible, with a potential annualized cost savings of 48,000 dollars.

Development of a clinical data warehouse for hospital infection control.

Existing data stored in a hospital's transactional servers have enormous potential to improve performance measurement and health care quality. Accessing, organizing, and using these data to support research and quality improvement projects are evolving challenges for hospital systems. The authors report development of a clinical data warehouse that they created by importing data from the information systems of three affiliated public hospitals. They describe their methodology; difficulties encountered; responses from administrators, computer specialists, and clinicians; and the steps taken to capture and store patient-level data. The authors provide examples of their use of the clinical data warehouse to monitor antimicrobial resistance, to measure antimicrobial use, to detect hospital-acquired bloodstream infections, to measure the cost of infections, and to detect antimicrobial prescribing errors. In addition, they estimate the amount of time and money saved and the increased precision achieved through the practical application of the data warehouse.