It has been over a year since the launch of Special Interest Groups (SIGs) in the Middle East and Africa by Oracle Cerner with over 10 sessions on various topics related to data analytics and clinical informatics.

One of the sessions was presented by Amani Moharram, a pharmacy informatics leader and a health informatics specialist from King Faisal Specialist Hospital and Research Centre (KFSH) in the Kingdom of Saudi Arabia, on how KFSH operationalized Oracle Cerner’s infection control antimicrobial stewardship program (ASP) functionalities.

ASP is an important tool that enables optimization of the antimicrobials to prevent the development of antibiotic-resistant microbials to improve patient safety and outcomes.

There were multiple challenges that led to the implementation of the ASP module. Based on the data published by the Centers for Disease Control and Prevention (CDC), one out of two hospital patients take an antibiotic for at least one day¹ and, based on recent studies, 30 – 50% of antibiotics given in hospitals are unnecessary or inappropriate² while also noting that $9 billion is being spent annually on antibiotics in the U.S.³  Moreover, over 23,000 deaths are being recorded annually from C.difficile and multi-drug resistant organisms⁴, and antimicrobial stewardship programs can reduce C.difficile by 32%.⁵

The new CDC data states that more than half of antibiotics prescribed for selected events in hospitals were not consistent with the recommended prescribing practices. The CDC policies, that support optimal antibiotic use, suggest specifying the dose, duration and indication for all antibiotics’ courses to ensure they are readily identifiable. Making this information accessible helps ensure that antibiotics are modified as needed and/or discontinued in a timely manner.

At KFSH, there is a designated governing body for antimicrobial stewardship that is responsible for clinical oversight to ensure the most effective use of antibiotics. This ASP committee is responsible for developing the antimicrobial guidelines and policies, reviewing prevalence reports, conducting audits and providing relevant feedback for ASP outcomes along with educating on health monitoring and electronic clinical decision support.

The practice prior to the ASP module implementation

Prior to the go-live with Oracle Cerner’s ASP module, the process was completely paper-based. The ASP form would be filled out by the ASP team, who need to specify the relevant details specified in the image below.

The relevant records (such as medications and their costs, positive cultures, antibiogram) would also be required to be manually run multiple times throughout the day to filter the patients who need to be monitored.

The Oracle Cerner ASP module implementation phase

Oracle Cerner’s ASP module project was conducted over six months beginning in September 2020 and going live in March 2021. This enabled us to improve patient safety with real-time and quick access to patients who are at high risk for antimicrobial misuse, enhance the departmental experience by saving a considerable amount of time and resources spent on manual processes, increase the compliance rate and standardized sources of the information.

In addition, KFSH implemented a clinical indication field, which is mandatory to fill in, as part of any antimicrobial medication order. The activation of the ASP worklist enabled clinicians to continuously evaluate patients who required intervention and enhanced communication among healthcare professionals.

After implementing the ASP module, below are some examples of the rules implemented and some screenshots of the relevant alerts that appear to our clinicians.

The ASP intervention form, which is coded, is easy to use with relevant tabs and fields to fill in. It also includes additional fields to record the prescriber’s response and the pharma-economic impact of applying this intervention.  

As part of the antimicrobial consumption, auditing after the ASP implementation is essential as it would act as a benchmark to evaluate its outcomes and enable the administrative support to continuously monitor the data available and its feedback. In addition to the ASP worklist that was implemented, analytical tools were also provided to clinicians that automatically calculated the consumption of antimicrobial Days of Therapy (DOT) and Length of Therapy (LOT), in addition to several operational reports covering various ASP aspects.

Following the go-live of the ASP module, the three primary KPIs were DOT (the number of individual days of therapy a patient was on an antibiotic), LOT (the number of days a patient was on antibiotics in total), and the assessment of medication restriction appropriateness. Based on the data from 2020 following the go-live, the average DOT per 100 patient days was 120, which is a benchmark, to monitor these KPIs.

The challenges and lessons learned

With any clinical decision support system, it’s important that it reduces complexity for the users and that it is easy to use. For the ASP module, the clinicians reported that its usability is high and is easy to be accessed at the point of care, which further encouraged the adoption of the ASP module.

One of the major challenges with this project was the lack of any baseline data. Consequently, the newly acquired data since the go-live is being used as KSFH’s new benchmark. The limited number of ASP resources was a hindrance to expanding the module utilization across the hospital and, therefore, was limited to the critical care areas. In addition, loading of worklists was an area to work around which was resolved after implementing relevant order jobs with the Oracle Cerner team.

And lastly, while the reports for cost consumption are currently estimated by the ASP team while documenting the form, the aim is to develop its accuracy by factoring in medication orders and products selected.

Ms. Amani presented this topic at the Clinical Informatics Special Interest Group (SIG) meeting hosted for Oracle Cerner clients. The next Clinical Informatics SIG will be held in Q4 2022; if you are an Oracle Cerner client and would like to participate as an attendee or a speaker at one of our future SIGs, then please reach out to priyanka.bandi@cerner.com.

References:

1. Centers for Disease Control and Prevention. Antibiotic Use in the United States, 2017: Progress and Opportunities. Retrieved from https://www.cdc.gov/antibiotic-use/stewardship-report/hospital.html
2. Ventola CL. The Antibiotic Resistance Crisis. P T. 2015 Apr; 40(4): 277-283.
3. Suda KJ, Hicks LA, et al. Antibiotic Expenditures by Medication, Class, and Healthcare Setting in the United States, 2010–2015. Clinical Infection Diseases. 2018 Jan; 66(2): 185-190.
4. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/drugresistance/biggest_threats.html
5. Baur D, Gladstone, BP, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet. 2017 Jun; 17(9): 990-1001.