Antimicrobial Stewardship Processes Streamlined with Software
Many antimicrobial agents require prior authorization before use, and indeed, prior authorization is a core antimicrobial stewardship intervention recommendation by the US Centers for Disease Control and Prevention. At HUP, prior authorization has been a cornerstone of their antimicrobial stewardship program since its inception; however, the process was not always smooth.
“There were several steps to our original prior authorization process,” explained investigator, Keith W. Hamilton, MD, assistant professor of Clinical Medicine, University of Pennsylvania School of Medicine, HUP, Philadelphia, Pennsylvania. “Providers were required to call a pager. They would send a numeric page through to the pager and 1 of our pharmacists or 1 of our infectious disease physicians would return the page. If the infectious disease physician or pharmacist approved the drug, they would actually have to call in to the pharmacy to let them know that they granted their approval.”
In addition to being a rather inefficient, multistep process, use of the pager system to request approval sometimes meant that pages were missed, particularly if providers sent pages during the hours that the pager was not operational. “During that time, pages would just go into the ether and no one would be able to get the request,” lamented Dr. Hamilton. Furthermore, the antimicrobial stewardship team found that it was rather difficult to audit the process.
It was for these reasons that Dr. Hamilton and his team set out to study the effect of implementing a new electronic prior authorization approval platform that worked within their existing clinical decision support platform.
The new software was introduced to prescribers at HUP in January 2017. The study was a descriptive analysis of the process over the entire year of 2017. Specifically, Dr. Hamilton and his team wanted to look at the time it took for approvals to be submitted in the system, as well as the indications and antibiotics for which approvals were requested.
In the new system, when a provider enters in an order for a restricted agent, the name of an approver is now a required field. The request for approval is triggered when the provider selects the patient and indication for use. Providers have the option to select any additional risk factors they may want to alert to the attention of the approver, as well as any relevant cultures. The desired antimicrobial is selected, and then the provider enters in their contact information and submits the request. The antimicrobial stewardship team is able to respond to the request through the system, and following the approval and pharmacy safety check, the drug is approved, oftentimes without having to make a phone call.
In addition, to streamlining the approval process, Dr. Hamilton explained that the new software also aided in tracking antibiotic use.
“Previously, before the new system, we had to have a manual spreadsheet entry system for tracking what antibiotics were approved over time,” said Dr. Hamilton. “It was difficult to track, and it required additional entry steps.”
He explained how the new software increased the efficiency of tracking antibiotic use and approvals, as well as additional capabilities it afforded that would have been too laborious to complete previously (see video).
With the new system, Dr. Hamilton and his antimicrobial stewardship team were able to respond to requests for prior authorization quickly, with a median time to response of 18 minutes (range 8-42 minutes) during antimicrobial stewardship program hours, as well as track antibiotic use more efficiently. In addition, the antimicrobial stewardship team has not had to report any safety events for missed pages, and has been able to more efficiently audit antibiotic prescribing and they readily see on their screens more clinical information about the request than they were receiving in the past, thus making them feel more informed on the process.
Study results indicated there were a total of 437 unique users of the new system. A total of 1934 patients had 3329 requests submitted. Indications for prophylaxis, other, and pneumonia, were the most frequent, and the most commonly requested antibiotics were levofloxacin (36.76% of patients), followed by meropenem, caspofungin, and fluconazole. A total of 88.7% of the overall requests by providers were approved.
The new system was quickly adopted by providers at HUP and in fact, the providers using the system have been extremely pleased with it as they aren’t required to wait by the phone for a call back with the approval (see video).
Implementing a new software system was not without its challenges, according to Dr. Hamilton. The introduction of a new workflow requires a lot of buy-in from all individuals who are involved in the process, and as such, he stressed the importance of meeting with all key stakeholders in the process to understand, before implementation, their perspectives and needs on the process. Dr. Hamilton and his team revised the software iteratively, based on these needs and requests.
Educating an entire institution on the changes with new software also proved challenging, and so Dr. Hamilton and his team provided a host of upfront education during the first 2 months of the software rollout aimed at all clinicians who would interact with the software, from house staff, to advanced practice providers, to physicians’ assistants.
Furthermore, it was important that the new software worked within the provider’s current clinical decision support software, according to Dr. Hamilton (see video).
For providers looking to implement a similar program at their institution, Dr. Hamilton offered the following advice (see video).
Limitations of the study include that is was a single-center study, conducted at a large academic hospital with a moderately restricted formulary. According to Dr. Hamilton, about 60% of all of antimicrobials have some sort of a restriction attached to them, making their hospital pretty heavy on prior authorization. Furthermore, the stewardship program at HUP has been in effect for over 25 years, and so the results of the study may not be applicable to other institutions.