Antibiotic Stewardship Dashboard

Eric Wyatt

Hahn School of Nursing and Health Science, University of San Diego

HCIN 552: Clinical Documentation – Electronic Medical Record Systems

Prof. Cindy Reed

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Executive Summary

Overview

Proper antibiotic usage in the hospital setting can reduce healthcare costs and improve

patient outcomes (Curtis, 2017). Proper usage can also promote stewardship that combats the

growing concern for antimicrobial resistance (Akpan, 2016). A dashboard clinical decision

support tool was implemented as a computerized intervention within a hospital system that

ultimately improved patient outcomes and antibiotic stewardship.

Problem

Antibiotic therapy is an important part of effectively treating bacterial infection in any

hospital setting (Bradley, 2021). Inappropriate antimicrobial use has been shown to be an

important component of antimicrobial resistance (Albarillo, 2019). Proper antibiotic usage can

reduce neonatal mortality, especially if using susceptible-specific therapy (Sharma, 2013). It can

also decrease the cost of antibiotics and the length of inpatient stay (Curtis, 2017).

Solution

A clinical decision support tool in the form of a dashboard can assemble and organize

relevant information. A dashboard serves as a multi-patient monitor for which the clinician can

glance and quickly decide where to focus attention. Simple dashboards provide the greatest

value in fast-thinking environments when presenting the minimum information required to

make a decision (Osheroff et al, 2012).

Team

The Vora Healthcare System (VHS) implemented an Antibiotic Stewardship Dashboard

(ASD) for their Neonatal Intensive Care Units (NICUs). The informatics team at VHS
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implemented this tool in hopes of reducing the average duration of antibiotic usage, and

ultimately cost, in the NICUs within their system. The tool was also aimed at reducing the

overall length of stay for these patients. The pharmacist and provider team at this system

utilized this tool to change the culture of antibiotic therapy usage on their units which promoted

helpful surveillance and stewardship.

Outcome

The ASD tool was utilized at an approximate rate of 25 percent. End-user satisfaction

was gauged with an overall satisfaction that was measured to be 76 percent among providers

and 86 percent among pharmacists. The average length of stay for patients receiving at least 1

dose of an antibiotic demonstrated a 6% reduction. The average duration of therapy was reduced

by 10% which correlated to a reduction in the cost of antibiotics for the system. This resulted in

the VHS receiving the Antimicrobial Stewardship Center of Excellence Designation from the

Infectious Diseases Society of America.

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Antibiotic Stewardship Dashboard

Antibiotic therapy is an important part of effectively treating bacterial infection in any

hospital setting (Bradley, 2021). Inappropriate antimicrobial use has been shown to be an

important component of antimicrobial resistance (Albarillo, 2019). Proper antibiotic usage can

reduce neonatal mortality, especially if using susceptible-specific therapy (Sharma, 2013). This

exists in conjunction with the reality that there is an associated decrease in the cost of antibiotics

and a decrease in in-patient length of stay when proper antibiotic therapy is used (Curtis, 2017).

It is for these reasons that a clinical decision support (CDS) tool, specifically in the form of a

dashboard, that promotes antibiotic surveillance and stewardship is one that has the potential to

make positive change in the neonate population and is worthy of pursuit.

Many hospitals have process and procedures in place that are adjacent to the prescription

of antibiotics (Bradley, 2021). As part of the treatment process, it is crucial that the organism

responsible for the infection is identified so that the appropriate antibiotic therapy is prescribed

(Bias, 2017). If the patient is believed to be septic, many hospitals have blood culture collection

processes in place so that early diagnosis and treatment can follow (Schmatz, 2020). Some

patients are prophylactically treated when infection is suspected with blood cultures collected as

part of an admission process (Verboom, 2020). The proper duration of therapy and the presence

of any accompanying adjunct therapy can additionally play roles in important stewardship

standards (Albarillo, 2019). With this clinical picture and framework in place, it is important for

providers to know what antibiotic therapy to prescribe and in what clinical situation.

The most effective way to address this specific clinical state would be to assist the

pharmacist in determining whether the ordered antibiotic therapy is the most appropriate for the

patient, while also keeping in mind the need for restraint. Helping the pharmacist to visualize all

of the antibiotic therapy on the unit will allow them to quickly determine what patients may
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benefit from therapy modification. Valuable support in judging the appropriateness of antibiotic

therapy would serve the patient, the clinician, and the hospital system well since it would

promote the best therapy at the best time. For purposes of this project, the resource utilized will

be the 27th edition of Nelson’s Pediatric Antimicrobial Therapy as a reference to guide treatment

(Bradley, 2021). This reference will serve as the standard by which the CDS offers support. The

dashboard will use this reference, and will provide a link to the resource, to aid the clinician in

understanding if the antibiotic therapy being used is the most appropriate.

Method

The proposed CDS would be the institution of an antibiotic dashboard to aid the

pharmacist and provider in their surveillance of antibiotic usage on the unit. This antibiotic

dashboard can assess the

appropriateness of the

treatment once the user

enters the order for

antibiotics. Figure 1

represents a simplified
Fig. 1 Macro-workflow
workflow that shows how

the dashboard integrates into the process in practice at the Vora Healthcare System (VHS) under

study. This healthcare system has three NICU units that ultimately implemented the CDS tool

with considerable success. By suggesting review, when appropriate, the Antibiotic Stewardship

Dashboard (ASD) promotes a workflow that continually and consistently monitors whether the

antibiotic therapy in use for a specified patient is the most appropriate. A dashboard was chosen

as the ideal method because of its ability to assemble and organize relevant information on a
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particular topic by filtering and presenting information that helps clinicians see what is

important, new or unusual about one or more patients (Osheroff et al., 2012). The dashboard

method was chosen with the understanding that this method is of the greatest value when they

are simple and when they present the minimum information to make decisions (Osheroff et al.,

2012).

Figure 2 provides a workflow that demonstrates the logic behind how the ASD is

provided the therapy information and how it organizes that for the clinician. When a provider

enters an antibiotic order, it is immediately evaluated for its duration and specificity. The ADS

will also

assess

whether

the specific

patient,

which

must be a

patient

determined
Fig. 2 Micro-workflow
to be

occupying a NICU bed, has an antibiotic therapy already prescribed. Because a blood culture can

be found to be positive at any time during a patient’s hospital stay, the ASD will also examine

and potentially offer review when that occurs. For purposes of the ASD’s Boolean logic, a

culture for which there is no growth will be considered to have that status as an organism. This

will allow the ASD to offer support when that same culture proves to have growth at a later time.
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If the ASD finds the duration of the therapy, the specificity of the therapy, and/or the

presence of adjunct therapy to need review then the ASD will file it under the window “Review

Suggested”. Once reviewed by

a user, the ASD will file it

under the window

“Reviewed”. This is only true

if all of the criteria are

addressed if multiple criteria

are applicable. If the ASD

Fig. 3 Dashboard Interface
determines that the therapy

does not need review based on the suggested criteria then the patient will be filed under the

window “Optimal Therapy”. The filing within the windows will be time-sensitive. For example,

the patient determined to be transmitted in the ASD “Review Suggested” window for the longest

period of time will aggregate to the top of the window. The opposite is true for the other two

windows with the oldest therapies aggregating to the bottom.

Because the ASD is a tool for the pharmacist and the provider, the ASD will also

determine if the patient is assigned to that user so as to better organize the information. For the

pharmacist, all of the patients on that unit for which the pharmacist works will be considered to

be assigned to them. For the providers, all of the patients on the unit for which they are

designated as the attending or rounding provider will be considered to be assigned to them. If the

patient is assigned to the user than they will be highlighted. Figure 3 illustrates what the ASD

interface looks like for the provider user “C. Arthur” which shows that the patients assigned to
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the user will be highlighted regardless of the

window in which they are filed.

Once a patient that the ASD suggests

needs review is selected, the user will be shown

a pop-up box that shows the suggested therapy

and an accompanying reference. The user will

Fig. 4 “Baby A” Review Screen Example
have the option of taking the suggestion or

maintaining the current therapy. Figure 4 shows

an example of a patient for which the ASD has

determined that a shorter duration of therapy

may be most appropriate. Figure 5 shows an

example of a patient for which the ASD has

determined that the current therapy needs to be

Fig. 5 “Baby B” Review Screen Example
reevaluated based on duration and

susceptibility. It is important to note that a patient will not be able to migrate to the “Reviewed”

screen until all of the criteria has been addressed either through selection of a new therapy or

maintenance of a current therapy. It is also important to note that a user may decide, for a

multitude of reasons, to maintain several antibiotic therapies concurrently. To prevent the ASD

from entering an infinite loop, the tool will be time-sensitive and will only assess if there are

multiple therapies if a new order or culture enters the equation once a review is completed. In

other words, the logic of the ASD can combine multiple medication prescriptions as one therapy

once reviewed and approved. For that reason, it is possible for a patient to move to different

windows at different times during the hospital stay.

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Implementation

Approval of the ADS took the VHS approximately 4 weeks to complete. The idea for the

CDS tool originated in the Pharmacy and Therapeutics Committee of which there was a Clinical

Informaticist with a pharmacy background. This individual was selected to be the program

manager with the Director of Medical Informatics fulfilling the role of the executive sponsor.

The design,

which took 4

weeks, was

done by a

team of 2

informaticists

in conjunction
Fig. 6 ASD Implementation Gantt Chart for the VHS
with 2 Health

IT members and the vendor. VHS’s contract with their EHR vendor allowed such modifications

and the vendor was interested in developing the dashboard for its potential to be offered to future

customers if proven to be successful. The build and testing, done by the same team, took an

additional 6 weeks with 5 iterations of the ADS proving to be adequate to work out all of the

prospective scenarios. The training of individuals took 3 weeks and was formatted into 3

different modes of education. For the pharmacist team, training was 2 in-person sessions of 1

hour each. For the providers, training was an online module that took approximately 1 hour to

complete. Additionally, the nurses were given a leaflet about the new process. The nurse user

group did not have access to the ASD but needed to take note of changing antibiotic therapy. The

Go-Live was a one-day Big Bang execution with 2 informaticists offering support for the 2
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weeks following launch. Evaluation and monitoring took place for an additional 5 weeks once

the ASD was fully implemented. Figure 6 shows the timeline that took place.

The entire project’s budget took 545 hours to complete. The design, testing, and build of

the ASD took the most amount of time at 10 weeks to complete. Because it took 2 informaticists

and 2 EHR builders approximately 2 hours a day respectively during this time, this part of the

implementation cost 400 hours to complete. The entire training portion of the project took 95

hours to complete. A majority of the training was directed towards the pharmacy team which

consisted of 38 pharmacists. This team included pharmacy management. The training itself

consisted of various scenarios and explained the educational component that is often needed

during provider consultation to promote necessary changes in therapy. The 13 providers were

asked to complete a 1-hour module that explained the purpose and the logic of the ASD. The

module also encouraged providers to seek out guidance from the pharmacy team with any

questions or concerns. Three super users were trained and they completed a training that was 2

meetings at 1 hour in duration each. This training incorporated many components from the

pharmacist base training, but also included discussion of Boolean logic so as to be better able to

troubleshoot end-user experience. The training cost a total of 95 hours.

Monitoring and Evaluation

The monitoring took place for 3 months after implementation and the metrics were

compared to 6 months of data that was compiled before implementation. The metrics took the

form of process measures and outcome measures. End-user satisfaction was also collected. As

far as process measurements were concerned, 187 patients within the 3 months after

implementation were deemed to be needing review with 47 patients receiving a change in

therapy. This represented a 25 percent utilization rate. Measurements of use continue to be

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gathered at 3-month intervals with the hopes of gaining a 50 percent utilization rate in the future.

End-user satisfaction was gauged from the providers and the pharmacists. Overall satisfaction

was measured with a questionnaire that asked if they found the ASD to be a valuable tool that

suggested worthy strategies that were easy to access and implement. The provider group

indicated an overall satisfaction of 76 percent and the pharmacist group indicated an overall

satisfaction of 86 percent. Outcome measures that were chosen included the average length of

stay of patients receiving at least 1 dose of an antibiotic and duration of total antibiotic therapy.

The average length of stay for these patients was determined to be 11.1 days on average after

implementation. This represented a 6% improvement, which was determined to be significant,

from the average of 11.8 days before implementation. The average length of therapy was reduced

from 11.3 days to 10.2 days, which represented a significant 10% reduction in the cost of

antibiotics. This initial monitoring and evaluation cost 50 hours to complete. VHS continues to

monitor these measurements on a 3-month interval as well. Measurements related to neonatal

mortality was not chosen as an outcome measure because of its multi-factorial nature.
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References

Akpan, M., Ahmad, R., Shebl, N., & Ashiru-Oredope, D. (2016). A review of Quality Measures

for assessing the impact of antimicrobial stewardship programs in

Hospitals. Antibiotics, 5(1), 5. https://doi.org/10.3390/antibiotics5010005

Albarillo, F. S., Labuszewski, L., Lopez, J., Santarossa, M., & Bhatia, N. K. (2019). Use of a

clinical decision support system (CDSS) to improve antimicrobial stewardship efforts at a

single Academic Medical Center. Germs, 9(2), 106–109.

https://doi.org/10.18683/germs.2019.1165

Bias, T. E., Vincent, W. R., Trustman, N., Berkowitz, L. B., & Venugopalan, V. (2017). Impact

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Sauberan, J., Smart, J. H., & Steinbach, W. J. (2021). Nelsons pediatric antimicrobial

therapy (27th ed.). American Academy of Pediatrics.

Curtis, C. E., Al Bahar, F., & Marriott, J. F. (2017). The effectiveness of computerized decision

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