Using evidence-based guidelines to improve prescribing

Clinical practice guidelines serve as essential tools for guiding the appropriate care of patients with specific clinical indications.

Clinical practice guidelines are developed by panels of experts that systematically evaluate available evidence and provide recommendations to assist practitioners in decision making that delivers optimal patient outcomes. Current clinical practice guideline recommendations can also be found in Wolters Kluwer’s solution, UpToDate. Implementing these clinical practice guidelines across a hospital or health system is an excellent step in ensuring patients receive equitable and evidence-based care. 

To address this, the updated 2023 Joint Commission AMS standards added a new element of performance (EP 18). This element of performance states that hospitals are required to implement at least two evidence-based guidelines for common indications requiring antibiotics. Hospitals may select, at minimum, any two evidence-based guidelines to implement. These guidelines must be based upon national guidelines and account for local susceptibilities, formulary options, and the patient population. The standards also provide examples of evidence-based guidelines hospitals can implement, which can include but are not limited to, community-acquired pneumonia, urinary traction infections, skin and soft tissue infections, Clostridioides difficile colitis, asymptomatic bacteriuria, parenteral to enteral antibiotic conversion plans, or antibiotics used for surgical prophylaxis. Furthermore, the Joint Commission FAQ document states that:

Hospitals should be prepared to discuss how the evidence-based guidelines were selected and implemented. 

Selecting evidence-based guidelines to implement

When selecting which evidence-based guidelines a hospital should implement, it’s important to determine what might provide the most benefit to providers when making decisions for antibiotic prescribing. It is crucial to capture indications for antimicrobial prescriptions, as this information can assist antimicrobial stewardship programs in determining whether antibiotic prescriptions follow evidence-based guidelines for certain indications and when more guidance might be needed.

Important considerations for selecting guidelines to implement:

1. Are there specific indications in which the appropriate laboratory and diagnostic tests are not ordered, not ordered in a timely manner, or ordered incorrectly?
2. Are there specific indications in which laboratory or diagnostic test results are not consistently interpreted correctly to prescribe antibiotics appropriately?
3. Do prescribers routinely select appropriate evidence-based antibiotics for the indication (appropriate antibiotic selection includes drug, dose, route, and frequency)?
4. Are antibiotics prescribed for an appropriate duration of therapy, as supported by the evidence?

Asking these questions may reveal the best opportunities for the antimicrobial stewardship program to partner with prescribers to ease workflows and implement evidence-based guidelines. Using a clinical decision support and surveillance system can help pharmacists identify patients who should be reviewed. Furthermore, pharmacists can document their activities within the system and easily obtain relevant process, outcomes, and performance metrics to measure their stewardship programs. 

Implementing evidence-based guidelines

While guidelines summarize the best practices in the medical literature and provide recommendations to help clinicians manage a patient, they often include multiple options with equivalent grading of evidence, making it challenging to determine what to prescribe. This is where the antimicrobial stewardship program can guide on the key elements of the evidence-based guideline most applicable to the institution or system: 

Method of delivering the guideline

The best method for providing institution or system-specific guidance may vary. Some institutions may have great uptake and utilization of comprehensive order sets, while others may use order panels with embedded questions and clinical guidance to assist ordering the correct diagnostic test or drug therapy. 

Diagnostic tests

Like drug therapies, there are various diagnostic tests available to clinicians that are supported in guidelines. Antimicrobial stewardship programs should collaborate with prescribers and laboratory personnel to ensure that appropriate laboratory tests are utilized, provide meaningful turn-around times, and ensure results can be correctly interpreted by the clinicians. 

Drug formulary

For certain indications, several antimicrobials may have good quality evidence supporting a recommendation in a clinical guideline; however, it’s important for the stewardship program to only include options available on the institution’s formulary in locally developed guidelines to minimize non-formulary or inappropriate prescribing. Lexicomp’s Custom Formulary Management Solution facilitates visibility and adherence to local drug formulary. 

Antimicrobial resistance

In addition to evaluating the drug formulary, antimicrobial stewardship programs should go a step further to only include antimicrobial options with optimal activity based on local susceptibility and resistance trends. It is recognized that for antimicrobials, certain options recommended in guidelines may not provide the same level of activity in different institutions based on resistance trends.

To facilitate acceptance and collaboration surrounding the implementation of new guidelines, determining the best method for delivering education at the individual institution is essential. Providing a forum for users to understand the purpose and goals of the initiative before implementation is key to success.

Evaluating adherence to evidence-based guidelines

Implementing evidence-based guidelines is an excellent first action an antimicrobial stewardship program can take; however, it’s important to go back and assess adherence and effectiveness of the intervention. In EP 19, the 2023 Joint Commission AMS standards require hospitals to further assess adherence to evidence-based guidelines, stating that the hospital must evaluate at least one of the implemented guidelines.

Measuring adherence to evidence-based guidelines can be time-intensive for antimicrobial stewardship programs, depending on the technology and resources available. However, the Joint Commission addresses that it is appropriate to evaluate a sample of patients for the clinical indication or pertinent clinical area. Evaluating and sharing the findings with clinicians can further identify opportunities to improve the guidelines and strengthen collaboration between clinicians and the antimicrobial stewardship program.