Documenting antimicrobial use and intent to optimize your antimicrobial stewardship program

Indication is one of the most important pieces of information antimicrobial stewards need to assess the appropriateness of therapies.  While you may sometimes deduce the indication by reviewing relevant imaging, clinical notes, laboratory, and microbiology results, this is time-consuming and not always accurate. Understanding the intent of prescribing an antimicrobial is essential for pharmacists to provide prospective feedback and analyze prescribing patterns at an aggregate level. In this article, we will explain how to gather this information and use it to improve your AMS program.

Key reasons for collecting indications of antimicrobial use

In Measuring antimicrobial use to assess your ASP, we reviewed how to measure antimicrobial use in a hospital and how it helps you identify program strengths and weaknesses. Once you have identified key antimicrobials to target, analyzing the top indications can help you design specific initiatives to reduce their use. You may implement changes to order sets to help improve empiric antimicrobial selections for these top indications.

The updated 2023 Joint Commission AMS standards element of performance 13 requires that hospitals document the evidence-based use of antibiotics. To assess whether the antibiotic use is evidence-based, the intent of antimicrobial ordered is needed to complete the analysis. Specifically, the Joint Commission FAQ document states that:

The goal of this requirement is for the antibiotic stewardship program to document that all departments and services of the hospital are using antibiotics in a manner supported by evidence as determined by the hospital. Hospitals should be prepared to verify that the hospital's antibiotic use is consistent with the documented evidence-based antibiotic stewardship program recommendations.

Hospital AMS programs provide recommendations using methodologies such as order sets containing empiric regimens for specific infections and preferred antimicrobials for specific organisms; therefore, it would be useful to have the indication available in the data set to facilitate compliance with these recommendations.

The third reason to collect this information is to help you set realistic goals on antimicrobial use reduction leveraging the Standardized Antimicrobial Administration Ratios (SAAR) and Antimicrobial Use Cumulative Attributable Difference (AU-CAD) from NHSN. The AU-CAD is a newly available metric made available as part of the CDC’s Targeted Assessment for Antimicrobial Stewardship framework.

In short, AU-CAD is the number of days of therapy (DOT) that would need to be reduced to achieve a specific target SAAR. For example, a hospital may have an AU-CAD of 75 DOTs over a quarter for anti-MRSA agents to reach a SAAR target of 1.0. Antimicrobial stewards can then reverse engineer the metrics to identify the top indications for vancomycin, daptomycin, and linezolid and determine if the reduction of 75 days is achievable.

Collecting antimicrobial use indication

The most logical place to collect the indication is at the time of order entry during the prescribing process. If you are not already gathering this information in your computerized provider order entry system, you may find the following tips helpful:

1. Explain the intent

   When we add a required field as part of the ordering process, understandably, providers view the additional step as burdensome. Therefore, it’s important to communicate why this information is necessary to drive improvement in antimicrobial use. It is helpful to remind providers that antimicrobial resistance is a problem that impacts everyone, and this data will help us all battle against the rise of antimicrobial resistance.

2. Consider the use case and breadth of the indication list

   To make sure that the data analysis is meaningful, you need a sufficient sample size. Therefore, we do not recommend an exhaustive list of infections but rather use a defined list of infection categories. Furthermore, when presented with an excessively long list at the time of order entry, it leads to provider frustration. Furthermore, avoid the use of free text entry because providers may enter different clinical syndrome names for infections that could be classified into the same group. This heterogeneity will lead to difficult data analysis later.

3. Automate data when it makes sense to do so

   If providers are ordering antimicrobials off of an order set for community-acquired pneumonia, for example, the ordering process should not require the provider to re-enter the indication. By pre-populating the information it leads to fewer steps in the prescribing process and reduces redundant data entry when the intent of the antimicrobial order is obvious. 

4. Engage with IT early and test

   To minimize potential problems later on or make multiple adjustments after going live, we recommend that you collaborate with your IT department or technology vendor early to perform some testing. Using test data, if possible, to see how the data is set up and how it populates data analytics dashboards or other reports. Make the adjustments as necessary before roll out so that the indications list or process does not change too frequently after going live.

Antimicrobial stewardship programs can use the intent of prescribed antimicrobials to help identify areas of focus, assess the appropriateness of their use, and determine whether their use is evidence-based. Adding an extra step to the prescribing process will cause workflow disruption, therefore, it is important to explain why this information is crucial to protecting patients to all stakeholders before rollout.