Web-based Tool Reduces Excessive Use of Antibiotics in Hospitalized Patients

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.

Between one-third and a 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, 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 Hopkins Children's since June 1, 2005, involves requesting restricted antibiotics via a computer, which then automatically alerts infectious disease physicians to review a pending request. Approvals and denials are then immediately sent from the online tool via pager to both the prescriber and the pharmacy. Under the old system, the doctor would either call or page an infectious disease specialist who would then verbally approve or deny a request and call the pharmacy to notify them of any approval. The new system not only offers a digital trail or requests denied and approved, but it has sped up the approval/denial process of restricted antibiotics, 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 same time reducing unnecessary and potentially dangerous antimicrobial use," said senior investigator Christoph Lehmann, MD, a neonatologist and a specialist of medical informatics at Hopkins Children's.

Lehmann and a group of infectious disease specialists designed the Web-based tool, suspecting it would make antibiotic approval faster and easier. Integrating the tool into the hospital's text-paging system, the tool allows doctors to receive approval requests on their pagers. The new system blasts out pager and e-mail alerts to infectious disease doctors whenever a new request for approval is entered. It also sends periodic reminders about requests still awaiting approval, expired requests, pending or missing requests.

Comparing delivery time, number of doses administered, cost and user satisfaction before and after the launch of the new system, researchers found:

- The new system helped slash cost of restricted antimicrobials by 21 percent because of fewer unnecessary prescriptions.

- Even though the number of approval requests jumped from 220 per month to 342 per month, the number of approved doses of restricted antibiotics dropped down by 11 percent from 125 doses per day to 111 doses per day after, resulting in 5,085 fewer doses per year. This decrease was despite comparable number of inpatients and complexity of cases before and after the new system was launched.

- In a survey of 70 pediatricians before the new system and 50 pediatricians after the new system, doctors reported 21 percent fewer missed antibiotics doses with the new system due to delay or miscommunication, and 32 percent drop in the number of delays.

- Prescriber satisfaction went up from 22 to 68 percent with the new system.

- Pharmacists reported 40 percent drop in the number of phone calls related to restricted antibiotics and 37 percent fewer delays in approval.

In a survey of 70 pediatricians before the new system and 50 pediatricians after the new system, doctors reported 21 percent fewer missed antibiotics doses with the new system due to delay or miscommunication, and 32 percent drop in the number of delays. Prescriber satisfaction went up from 22 to 68 percent with the new system. Pharmacists reported 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 instantly sent to both the prescriber and the pharmacy via pager. In addition, the new system allows automatic approval for certain restricted antibiotics for certain types of infections, which further speeds up approval and frees up time for reviewing requests that are more complicated.

Hopkins Children's 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 their computer database. Once approved, the medication could be dispensed indefinitely to the patient without a specified stop date.

 Allison Agwu, M.D, of Hopkins, is lead author on the study. Other Hopkins investigators in the study: Carlton Lee, MD, Sanjay Jain, MD, Jason Topolski, Pharm. D, Robert Miller, MD, Timothy Townsend, MD, Kara Murray, Pharm. D, of the Centennial Medical Center, Nashville, Tenn., was part of the study.

Proceeds from the Johns Hopkins Children's Center annual Radiothon supported the research.