Use of the Epic Antimicrobial Stewardship Module Optimizes Efficiency and Increases Case Finding for Stewardship Interventions

Background:
Antimicrobial stewardship programs (ASP) rely on clinical decision support tools to identify intervention opportunities. At Stanford Health Care, we enhanced Epic, our electronic medical record (EMR) system’s functionality through the Epic ASP Module for targeted case finding. Prior to this, case finding was a manual process of screening daily antimicrobial order reports.

Methods:
In August 2015, we implemented the Epic ASP module in our existing Epic v.2015 EMR system with Epic Beaker as the microbiology lab platform. We partnered with Epic information technology to define and build rules for restricted antimicrobial orders, microbiology data, bug-drug mismatch, duplicate spectrum coverage, and a patient-specific ASP communication dashboard.

Results:
The ASP module enhanced case finding through the use of In-Basket alerts and targeted system patient lists.  The In-basket tool was built to trigger an alert upon ordering of a restricted antimicrobial agent (fig. 1). Live alerts increased the proportion of restricted antimicrobials triggering audit-and-feedback from 64% (399/623) to 92% (641/696) and expedited the time to review from 41 hours to 14 hours.  Real-time alerts for Enterococcus faecium isolated from blood cultures reduced the time to appropriate empiric antibiotic ordering from 18 hours to 9 hours. Targeted system patient lists were created to identify all patients with restricted antibiotic orders, C. Difficile infections, aminoglycoside orders, and duplicate anaerobic spectrum agents (fig. 2).  A patient-specific ASP dashboard was built to efficiently review ongoing interventions, microbiologic and antimicrobial data, and enhance ASP communication. Interventions increased from an average of 58 to 80 per month with an acceptance rate of 89% and 91%, respectively.

Conclusion:

The Epic ASP Module optimized stewardship activities by: increasing effective audit-and-feedback of restricted antimicrobials through real-time alerts, decreasing time to appropriate empiric antibiotics in patients with E. faecium bacteremia, and facilitating targeted case finding. Our work provides support for the merit of use of an ASP Module and a template from which other institutes can easily adapt and customize it.