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The newspaper of The Johns Hopkins University September 15, 2008 | Vol. 38 No. 3
Web Tool Streamlines Approval, Reduces Excessive Antibiotic Use

By Katerina Pesheva
Johns Hopkins Medicine

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

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 drug–resistance 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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