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Progress in Universal cPOE Indication Based Antibiotic Ordering
Christopher McCoy, Monica Mahoney, Tiffany Lee, Howard Gold
Introduction/Problem
Beth Israel Deaconess Medical Center
A gap analysis was conducted for the 144 antimicrobial agents on the Inpatient Formulary and cPOE
programmed indication selection with clinical decision support for dosing including adjustment s for renal
impairment or obesity. In May of 2016, we determined that indication based requirements were in place
for 47% of antimicrobials, dosing guidance for 65%, indication based dosing for 10%, and 37.5% require
preprescriptive approval, with less than 5% programmed for calculated weight based dosing, therapeutic
interchange, or automated IV to PO conversion.
New mandates around antimicrobial stewardship including those from the Centers for Medicare &
Medicaid Services include evidence of indications for all antibiotic orders in the medical record.
The combination of indication based entry and clinical decision support has been shown to optimize the
pharmacokinetics and clinical outcomes, decrease potential for adverse events, and improve costs when
incorporated for antimicrobial ordering.
At BIDMC, the Antimicrobial Stewardship program with Pharmacy and Infectious Diseases began
programming cPOE so that order entry requires an indication starting as early as 2002. This requires light
programming but time and resources have been limited.
A new endeavor to revisit programming for all antibiotics was started in May of 2016 and covers all
inpatient areas.
The Interventions
Gap analysis performed by reviewing all cPOE order screens for 160 antibiotics looking for indication
based documentation at the point of entry.
Stewardship, Infectious Diseases and Pharmacy task force reviewed literature for indication based
dosing for all antibiotics to optimize pharmacokinetics and consider weight and renal function.
Using a “soft” programming approach performed by Stewardship and Pharmacy staff, screens and
rules were created systematically for antibiotics lacking support.
To validate and ensure correct entries and programming, testing of indication based dosing was
performed by Pharmacy residents.
Results/Progress to Date
Indications
Guideline
links
26
56
65
3
5
Formulary
total
Total
Dosing
provided
Weight
Based
dose
47%
55%
Non
Formulary
Aim/Goal
We have completed an internal audit of all antibiotics and the order screens in cPOE as well as clinical
decision support including dosing guidance, and weight based dosing.
We endeavored to complete soft programming for indication based ordering screens for 100% of the
antibiotics after second quarter of FY17, that include clinical decision support for renally-based or weightbased dosing.
The Team
Christopher McCoy, PharmD
Monica Mahoney, PharmD
Tiffany Lee, PharmD
Howard Gold, MD
Steve Maynard
Pharmacy/Stewardship
Pharmacy/Stewardship
Pharmacy
Infectious Diseases/Stewardship
Pharmacy
144
118
Indication
Therapeutic IV TO
based
Restricted
Interchange PO
dose
14
10%
3
2
54
38%
In May of 2016, our initial gap analysis and inventory for antibiotic indication based ordering was 47%.
Dosing guidance was at 55%, with preprescriptive approvals required for 38%.
Since then, we have advanced towards 80% of antibiotics with indication based ordering.
For more information, contact:
Christopher McCoy, PharmD, Associate Director Antimicrobial Stewardship cmccoy@bidmc.harvard.edu
�Progress in Universal cPOE Indication Based Antibiotic Ordering
Christopher McCoy, Monica Mahoney, Tiffany Lee, Steve Maynard, Howard Gold
Beth Israel Deaconess Medical Center
More Results/Progress to Date
Cefepime indication validation
Indication based dosing was designed by the group to be user friendly for the prescriber with a prepopulated
drop down list
Ceftazidime pre-support
Post-support
A medication utilization evaluation was performed for cefepime, an agent with indication based support
since 2006 to assess the concordance of prescriber entered indication and medical records. Discordance
was low with dosing off by 1 or 2g a day.
Lessons Learned
Given limited information technology support for “hard” programming, clinician resources were
utilized to design and build soft programming in Pharmacy dictionaries. This is a significant time
commitment and quality assurance testing is a must given the multiple entry permutations.
Based on previously built indication based dosing, e.g. cefepime from 2006, prescriber order entry
was generally well documented and matched the medical record.
Indications for antimicrobial order entry assist in more optimized dosing for the site of infection and
can turn the dial toward better prescribing.
Next Steps
In order to meet Antimicrobial Stewardship mandates, the group will continue to program and test
indication based dosing towards 100%.
Documentation of indications will help with Stewardship goals toward better utilization reviews and
potential for better defined durations.
Ceftazidime indication based entry and dosing support was turned live in November. Post-support, there was
more optimized utilization of correctly selected dosing, including a trend away from 2g q8h toward 2g q12h.
For more information, contact:
Christopher McCoy, PharmD, Associate Director Antimicrobial Stewardship cmccoy@bidmc.harvard.edu
�
Dublin Core
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Christopher McCoy (<a href="mailto:cmccoy@bidmc.harvard.edu">cmccoy@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Pharmacy<br />Infectious Diseases<br />Antimicrobial Stewardship
Location or Affiliate
BIDMC
Project Team
Christopher McCoy<br />Monica Mahoney<br />Tiffany Lee<br />Howard Gold<br />Steve Maynard
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Progress in universal cPOE indication based antibiotic ordering
Date
A point or period of time associated with an event in the lifecycle of the resource
2017
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness