Doctors who use a novel Web-based tool to prescribe
special categories of antibiotics to their
hospitalized patients are getting the job done faster and
more safely than by traditional means of
phone, fax and pager, research led by the
Johns Hopkins
Children's Center shows.
The online approval system reduced unnecessary
antibiotics, made ordering faster and saved
costs, researchers write in the Sept. 15 issue of
Clinical Infectious Diseases journal. Their report
appears online ahead of print at
www.journals.uchicago.edu/doi/full/10.1086/591133.
Between one-third and one-half of all hospital
patients receive antimicrobial drugs such as
antibiotics, antifungal and antiviral medications, but up
to half of these prescriptions are unnecessary,
researchers estimate, fueling an already serious bacterial
drugÐresistance problem.
To address the problem, Johns Hopkins and other
hospitals have put more than 30 antimicrobial
drugs on a "restricted" list, requiring approval by an
infectious disease specialist before the pharmacy
can dispense them to a patient. The online antibiotic
approval tool, designed by and used at Johns
Hopkins Children's Center since June 2005, involves
requesting restricted antibiotics via a computer
that automatically alerts infectious disease physicians to
review the request; approvals and denials are
then immediately sent from the online tool via pager to
both the prescriber and pharmacy. Under the
old system, the doctor would call or page an infectious
disease specialist who would verbally approve or
deny a request and call the pharmacy to notify it of any
approval.
The new system not only offers a digital trail of
requests denied and approved, but it has sped
up the approval/denial process of restricted antibiotics
and reduced the number of missed and
unnecessary doses while also helping slash the cost of
antimicrobial drugs by more than $370,000 in
the first year of its use alone, researchers found.
"New technology can be a friend or foe, but this is
one great example of how innovation can help
trim and streamline an otherwise bloated and sluggish
medication approval system, while at the same
time reducing unnecessary and potentially dangerous
antimicrobial use," said senior investigator
Christoph Lehmann, a neonatologist and a specialist of
medical informatics at Johns Hopkins Children's
Center.
Lehmann and a group of infectious disease specialists
designed the Web-based tool, suspecting
it would make antibiotic approval faster and easier.
Integrated into the hospital's text-paging system,
the new system blasts out pager and e-mail alerts to
infectious disease doctors whenever a request
for approval is entered. It also sends periodic reminders
about requests awaiting approval, expired
requests and pending or missing requests.
Comparing delivery time, number of doses administered
and cost and user satisfaction before
and after the tool's launch, researchers found:
♦ The new system helped slash the cost of
restricted antimicrobials by 21 percent because
of fewer unnecessary prescriptions.
♦ Even though the number of approval requests
jumped from 220 to 342 per month, the
number of approved doses of restricted antibiotics dropped
by 11 percent, from 125 to 111 doses per
day, resulting in 5,085 fewer doses per year. This decrease
was despite a comparable number of
inpatients and complexity of cases before and after the
system was launched.
♦ In a survey of 70 pediatricians before the
new system and 50 pediatricians after,
doctors reported 21 percent fewer missed antibiotics doses
with the new system due to delay or
miscommunication, and a 32 percent drop in the number of
delays.
♦ Prescriber satisfaction went up from 22
percent to 68 percent with the new system.
♦ Pharmacists reported a 40 percent drop in
the number of phone calls related to
restricted antibiotics and 37 percent fewer delays in
approval.
The system's database includes the patient census and
a list of restricted and unrestricted
drugs, with individual antibiotic profiles including
precautions, drug interactions and possible side
effects. To send a request, the physician selects a patient
name from the database, the requested
antimicrobial and indication for use, along with any test
results that signal the presence of a viral,
bacterial or fungal infection. An infectious disease
specialist reviews the request and either enters
the allowed duration of treatment or rejects the request
with an explanation. The response is sent
instantly to both the prescriber and the pharmacy via
pager. In addition, the system allows automatic
approval for certain restricted antibiotics for specific
types of infections, further speeding up
approval and freeing up time for reviewing requests that
are more complicated.
Johns Hopkins Children's Center implemented its first
antimicrobial approval protocols in 1983
using phones and pagers, an archaic and sluggish
checks-and-balances system, researchers say, and one
plagued by miscommunication and delays. Overnight requests
did not require prior approval. Once
approval was confirmed, the pharmacy would log the request
in its computer database, and the
medication could be dispensed indefinitely without a
specified stop date.
Allison Agwu of Johns Hopkins is lead author on the
study. Other Johns Hopkins investigators in
the study are Carlton Lee, Sanjay Jain, Jason Topolski,
Robert Miller and Timothy Townsend. Kara
Murray, of the Centennial Medical Center, Nashville, Tenn.,
also was part of the study.
Proceeds from the Johns Hopkins Children's Center
annual Radiothon supported the research.
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