Infection Control & Hospital Epidemiology The primary outcome was to assess the impact of the EAM on
ASP interventions. We compared total number of interventions during the preimplementation period (February 1, 2014, through January 31, 2015) versus the postimplementation period (May 1, 2016, through April 30, 2017). The secondary outcomes included assessing: impact on target antimicrobial utilization (days of therapy [DOT] per 1,000 patient days), percentage of patients that received any antibiotic during admission, all-cause inpatient mortality among patients that received antimicrobials, LOS among patients that received antimicrobials, and percentage of total drug expenditures spent on antimicrobials (based on wholesale acquisition cost per patient day). Target antimicrobials were selected based on breadth of spectrum, propensity for toxicities and drug–drug interactions, need for therapeutic drug monitoring to ensure efficacious use, and/or high cost.
Statistical analyses
Data were analyzed using descriptive statistics for total number of interventions, utilization, and cost. The χ2 analysis was used to assess differences in types of interventions relative to total interventions, mortality rates, and discharged patients that received antimicrobials during admission. Average LOS and antimicrobial expenditures were compared using the Mann- Whitney U test. Antibiotic utilization was assessed using the t test. All statistical analyses performed using Stata version 15 software (StataCorp, College Station, TX).
Results
Prior to EAM implementation (pre-EAM), the ASP team docu- mented 5,433 antimicrobial reviews and made 1,436 interventions (119.7 interventions/month) (Table 1). After EAM implementa- tion (post-EAM), the ASP team documented 8,288 reviews with 7,444 interventions made (ie, 620.3 interventions per month). Optimization and monitoring of antimicrobial therapy con- stituted most interventions pre-EAM and post-EAM (46.8% and 54.3%), followed by safety/monitoring (37.2% and 28.2%). We observed a marked increase in the rate of all types of interven- tions. Interventions were accepted >96% of the time. Utilization of target antimicrobial agents decreased in the
post-EAM period compared to the pre-EAM period (Figure 1). Overall, combining all target antimicrobials, the DOTs per 1,000 patient days per group was 5,338.5 (pre-EAM) and 4,753.2 (post- EAM) (P=.04). Relative to overall drug expenditures at our medical center pre-EAM and post-EAM, antimicrobial expendi- tures represented 7.14% and 8.32%, respectively (P>.05). The average LOS was similar between groups (9.2 days vs 9.0 days; P>.05), but the overall inpatient all-cause mortality rate was higher in the pre-EAM group (0.39 vs 0.20; P<.01).
Discussion
Following the implementation of the EAM, all intervention types performed by our ASP team increased markedly, including an increase in the number of safety-related interventions and those related to optimization of therapy. Notably, during the pre-EAM period, the percentage of ASP reviews that resulted in an inter- vention was only 26.5%, and this increased to 89.8% during the post-EAM period. We did not observe a change in the percentage of antimicrobial drug expenditures relative to overall drug
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Table 1. Overall Number and Type of Interventions Before and After the Epic Antimicrobial Stewardship Module (EAM) Implementation Periods
Pre-EAM Interventions Total (all interventions)
Intervention types, no. Optimization of therapya Safety/monitoringb De-escalationc Cost savingsd
ID consult recommendede
(2/1/2014–1/31/ 2015)
1,436
673 534 120 79 30
Post-EAM
(5/1/2016–4/30/ 2017)
7,444
4,040 2,100 758 310 236
P Value <.01
<.01 <.01 .032 .227 .027
NOTE. ID, infectious diseases. aDosage adjustment, alternative therapy, additional therapy. bReview of Staphylococcus aureus and yeast in blood culture alerts, review of anti-retroviral therapy, pathogen–drug mismatch, susceptibility-based reports, monitoring for antibiotic
related toxicities, azole therapeutic drug monitoring, monitoring for drug–drug interactions. cChange in antibiotic to more narrow-spectrum therapy. dModification in therapy to more cost-effective therapy, conversion from intravenous to oral
administration. eRecommendation to primary service to consult ID physician.
expenditures; however, the lack of observed impact on this out- come is likely related to changing drug prices, availability of certain products, changes in utilization of nonantibiotic medica- tions, and changes in patient census. The increased number of antimicrobial orders reviewed and interventions are likely attributable to 2 primary factors. First, the EAM allowed for real-time notification for patients meeting cri- teria for ASP review. Real-time alerts allowed ASP pharmacists to assess appropriateness of antimicrobial agents immediately and provided additional opportunities to identify interventions and implement recommendations. Due to improved efficiency and expanded reporting capabilities, we were able to review additional reports and alerts during the post-EAM period. Second, the EAM allowed for documentation of interventions within the EMR. This represents a more efficient, streamlined, and consistent process for documentation, tracking, and reporting compared to the previous manual method. The average LOS was similar between groups. We observed a
reduction in mortality rate for all patients that received an antimicrobial during their admission. Although reduced mor- tality could be explained by many factors, including targeted quality improvement initiatives for specific infections or differ- ences in acuity of illness of patients, it is possible that this change may also correlate with significantly more ASP interventions, espe- cially those relating to optimization of therapy, safety and monitor- ing, and recommending ID consultation for patients with severe or complicated infections. Previous studies have found a correlation between real-time alerting with ASP follow-up and reduced mortality.5–7 Although these studies focus on specific culture- related alerts, it is evident that real-time notification and inter- vention by the ASP team may contribute to reduced mortality in addition to improvements in other clinical outcomes. The improved process for identification of patients requiring
ASP review and/or intervention as well as streamlined doc- umentation resulting from the EAM have broadened our ability to ensure optimal, safe, and judicious use of antimicrobials. Based on our experience, hospitals looking to establish or improve upon
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