Hospital Pharmacy - November 2017 - 679

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research-article2017

HPXXXX10.1177/0018578717726869Hospital PharmacyGhamrawi et al.

Article

Evaluation of Antimicrobial
Stewardship-Related Alerts Using a
Clinical Decision Support System

Hospital Pharmacy
2017, Vol. 52(10) 679-684
© The Author(s) 2017
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https://doi.org/10.1177/0018578717726869
DOI: 10.1177/0018578717726869
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Riane J. Ghamrawi1,2, Alexander Kantorovich3,4, Seth R. Bauer5,
Andrea M. Pallotta5, Jennifer K. Sekeres5, Steven M. Gordon5,
and Elizabeth A. Neuner5

Abstract
Background: Information technology, including clinical decision support systems (CDSS), have an increasingly important
and growing role in identifying opportunities for antimicrobial stewardship-related interventions. Objective: The aim of
this study was to describe and compare types and outcomes of CDSS-built antimicrobial stewardship alerts. Methods:
Fifteen alerts were evaluated in the initial antimicrobial stewardship program (ASP) review. Preimplementation, alerts were
reviewed retrospectively. Postimplementation, alerts were reviewed in real-time. Data collection included total number
of actionable alerts, recommendation acceptance rates, and time spent on each alert. Time to de-escalation to narrower
spectrum agents was collected. Results: In total, 749 alerts were evaluated. Overall, 306 (41%) alerts were actionable (173
preimplementation, 133 postimplementation). Rates of actionable alerts were similar for custom-built and prebuilt alert types
(39% [53 of 135] vs 41% [253 of 614], P = .68]. In the postimplementation group, an intervention was attempted in 97%
of actionable alerts and 70% of interventions were accepted. The median time spent per alert was 7 minutes (interquartile
range [IQR], 5-13 minutes; 15 [12-17] minutes for actionable alerts vs 6 [5-7] minutes for nonactionable alerts, P < .001). In
cases where the antimicrobial was eventually de-escalated, the median time to de-escalation was 28.8 hours (95% confidence
interval [CI], 10.0-69.1 hours) preimplementation vs 4.7 hours (95% CI, 2.4-22.1 hours) postimplementation, P < .001.
Conclusions: CDSS have played an important role in ASPs to help identify opportunities to optimize antimicrobial use
through prebuilt and custom-built alerts. As ASP roles continue to expand, focusing time on customizing institution specific
alerts will be of vital importance to help redistribute time needed to manage other ASP tasks and opportunities.
Keywords
antimicrobial stewardship, clinical decision support systems, infectious diseases

Introduction
Antimicrobial resistance threatens the treatment of once
manageable infections with over 2 million illnesses and
23 000 deaths annually attributed to organisms resistant to
currently available antimicrobials in the United States.1-3
National organizations, including Infectious Diseases
Society of America, have advocated and provided guidance
for establishing antimicrobial stewardship programs (ASPs)
to help alleviate the increasing risk of emerging resistant
microorganisms and to optimize the use of currently available antimicrobials. One of the core interventions of ASPs to
assist with reducing inappropriate use of antimicrobials
includes prospectively auditing and intervening on antimicrobial use, and then providing feedback and recommendations to medical team members.1
Health care information technology has had an increasingly growing and important role in the identification of

ASP-related tasks and interventions. Electronic health
records (EHR) and clinical decision support systems (CDSS),
such as TheraDocTM (Salt Lake City, Utah), provide realtime alerts updated when new microbial culture results
become available or antimicrobial changes occur. These
1

University of Cincinnati- West Chester Hospital, OH, USA
University of Cincinnati- Daniel Drake Center for Post-Acute Care,
OH, USA
3
Chicago State University, IL, USA
4
Advocate Christ Medical Center, IL USA
5
Cleveland Clinic, OH, USA
2

Corresponding Author:
Riane J. Ghamrawi, Pharmacy Clinical Specialist - Antimicrobial
Stewardship/Infectious Diseases, University of Cincinnati- West Chester
Hospital, 7700 University Drive, West Chester, Ohio 45069, USA.
University of Cincinnati - Daniel Drake Center for Post-Acute Care,
151 W Gallbraith Road, Cincinnati, OH 45216, USA.
Email: riane.ghamrawi@uchealth.com

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