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Submitted URL:
https://doi.org/10.1017/ice.2020.281
Effective URL:
https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/repurposing-antimicrobial-stew...
Submission Tags: falconsandbox
Submission: On July 06 via api (July 6th 2023, 1:10:37 pm UTC) from US — Scanned from DE

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Infection Control & Hospital Epidemiology

--------------------------------------------------------------------------------

ARTICLE CONTENTS

* Abstract
* Intervention
* Discussion
* Financial support
* Conflicts of interest
* Footnotes
* References

REPURPOSING ANTIMICROBIAL STEWARDSHIP TOOLS IN THE ELECTRONIC MEDICAL RECORD FOR
THE MANAGEMENT OF COVID-19 PATIENTS

Part of: SARS-CoV-2/COVID-19

Published online by Cambridge University Press: 08 June 2020

Matthew W. Davis [Opens in a new window] ,
Dayna McManus ,
Alan Koff ,
Gregory R. Jaszczur ,
Maricar Malinis ,
Charles Dela Cruz ,
Clemente J. Britto ,
Christina Price ,
Veronica Azmy and
Kelsey Kaman
...Show all authors
Show author details

--------------------------------------------------------------------------------

Matthew W. Davis* Affiliation:
Department of Pharmacy Services, Yale New Haven Hospital, New Haven, Connecticut
Dayna McManus* Affiliation:
Department of Pharmacy Services, Yale New Haven Hospital, New Haven, Connecticut
Alan Koff Affiliation:
Section of Infectious Diseases, Yale University School of Medicine, New Haven,
Connecticut
Gregory R. Jaszczur Affiliation:
Information Technology Services, Yale New Haven Health System, New Haven,
Connecticut
Maricar Malinis Affiliation:
Section of Infectious Diseases, Yale University School of Medicine, New Haven,
Connecticut
Charles Dela Cruz Affiliation:
Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School
of Medicine, New Haven, Connecticut
Clemente J. Britto Affiliation:
Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School
of Medicine, New Haven, Connecticut
Christina Price Affiliation:
Section of Rheumatology, Allergy and Immunology, Yale University School of
Medicine, New Haven, Connecticut
Veronica Azmy Affiliation:
Section of Rheumatology, Allergy and Immunology, Yale University School of
Medicine, New Haven, Connecticut
Kelsey Kaman Affiliation:
Section of Rheumatology, Allergy and Immunology, Yale University School of
Medicine, New Haven, Connecticut
David Gaston Affiliation:
Section of Infectious Diseases, Yale University School of Medicine, New Haven,
Connecticut
Kevin Early Affiliation:
Information Technology Services, Yale New Haven Health System, New Haven,
Connecticut
Michelle DeWitt Affiliation:
Information Technology Services, Yale New Haven Health System, New Haven,
Connecticut
Ju-Sung Song Affiliation:
Information Technology Services, Yale New Haven Health System, New Haven,
Connecticut
Claudia Ortiz Affiliation:
Information Technology Services, Yale New Haven Health System, New Haven,
Connecticut
Manisha Juthani-Mehta Affiliation:
Section of Infectious Diseases, Yale University School of Medicine, New Haven,
Connecticut
Jeffrey E. Topal Affiliation:
Department of Pharmacy Services, Yale New Haven Hospital, New Haven, Connecticut
Section of Infectious Diseases, Yale University School of Medicine, New Haven,
Connecticut
*
Author for correspondence: Dayna McManus, E-mail: dayna.mcmanus@ynhh.org. or
Matthew W. Davis, E-mail: Matthew.Davis2@YNHH.ORG
Author for correspondence: Dayna McManus, E-mail: dayna.mcmanus@ynhh.org. or
Matthew W. Davis, E-mail: Matthew.Davis2@YNHH.ORG

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ABSTRACT

During the COVID-19 pandemic, the antimicrobial stewardship module in our
electronic medical record was reconfigured for the management of COVID-19
patients. This change allowed our subspecialist providers to review charts
quickly to optimize potential therapy and management during the patient surge.

--------------------------------------------------------------------------------

Type Concise Communication
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 11 , November 2020
, pp. 1335 - 1337
DOI: https://doi.org/10.1017/ice.2020.281 [Opens in a new window]
Creative Commons
This is an Open Access article, distributed under the terms of the Creative
Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which
permits unrestricted re-use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights
reserved.

In December of 2019, several cases of pneumonia of unknown etiology were
recognized by the World Health Organization (WHO) in Wuhan City, Hubei Province,
China. 1 This pneumonia was rapidly identified to be caused by the SARS-CoV-2
virus and named coronavirus disease 2019 (COVID-19). The presence of
human-to-human transmission was quickly recognized, and on March 11, 2020,
COVID-19 was declared a pandemic by the WHO. Reference Chan, Yuan and Kok2–5

In the United States, the first documented case of COVID-19 occurred in a
35-year-old man in Snohomish County, Washington, on January 19, 2020. Reference
Holshue, DeBolt and Lindquist6 Rapid spread subsequently occurred across the
country, and as of April 23, the United States had recorded >800,000 cases and
>44,000 deaths. 7

Given the spread of this novel virus, hospitals have seen a rapid increase of
COVID-19 patients in a short period. This surge has placed a strain on vital
resources, including personal protective equipment (PPE), mechanical
ventilators, and hospital personnel, including infectious disease consultants.

At Yale New Haven Hospital (YNHH), in anticipation of a surge in COVID-19
patients, a multidisciplinary team comprised of members from allergy and
immunology, antimicrobial stewardship team (AST), hematology, infectious
diseases, pharmacy, pulmonology, and critical care collaborated to provide
guidance on potential treatments and management. One of the primary clinical
challenges to be addressed was the increasing number of new COVID-19 patients
each day. At the height of the surge, in our 1,500-bed hospital, we were caring
for >450 patients with COVID-19. With this rapid increase, the number of total
medical ICU beds was expanded from 56 to 131. Prior to the surge, our 4
inpatient infectious diseases consultants covered ~50 patients. However, during
this time, the hospital staff requested subspecialty guidance for the management
of COVID-19 patients. The number of patients with COVID-19 overwhelmed our
ability to provide optimal subspecialty care. Given this increase, there was a
significant need for a rapid assessment tool to review patients and to
prioritize consultations.

Prior to the COVID-19 pandemic, the YNHH AST customized the antimicrobial
stewardship (AMS) module in our electronic medical record (EMR; Epic, Verona,
WI). This customized module facilitated efficient review of relevant clinical
patient information to provide recommendations for optimizing antimicrobial use.
The existing AMS accordion report contained information regarding vital signs,
fever curve, intake and output, relevant hematology and chemistry laboratory
values, microbiology results, radiology studies, medications, and allergies.
Given the rapid increase in number of patients and the need to provide clinical
oversight, a challenge similar to AMS, a revised version of this tool was
proposed by the AST as a potential solution.

Herein, we describe our process of repurposing the AMS module and associated
technology to optimize the management of COVID-19 patients.

INTERVENTION

To identify COVID-19 patients in real time, with the help of the information
technology (IT) team, 2 patient lists were created in the EMR. The first list
comprised inpatients with positive COVID-19 results based on SARS-CoV-2
polymerase chain reaction assay (PCR). The second list identified patients who
were suspected to be COVID-19 positive based on clinical presentation with a
SARS-CoV-2 PCR in process. At YNHH, in-house SARS-CoV-2 PCR testing was
initiated on March 13, 2020, which allowed for an initial turnaround time of
8–12 hours. Prior to this, SAR-CoV-2 tests were done through the Connecticut
Department of Health. The validation of the in-house testing was timely because
our first COVID-19–positive patient was admitted on March 12, 2020.

After the creation of the COVID-19 patient lists, additional modifications were
made to specifically aid in the assessment of these patients. In addition to the
standard columns within the patients list (ie, admission date, bed, unit,
patient name, age, and gender), the following items were added to help rapidly
identify patients with more severe disease: oxygen requirements, oxygen orders,
and the presence of mechanical ventilation orders (Fig. 1, box 1). To further
triage higher-acuity patients, a column delineating high-sensitivity C-reactive
protein (hsCRP) levels was also created. A dynamic scoring column was built
which would display a designated icon if patients had an hsCRP ≥70 mg/L or an
increase ≥30 mg/L in the previous 24 hours (displayed as COVID-19 CRP). HsCRP
can be elevated in the setting of the cytokine release syndrome phase of
COVID-19, and it is a reliable indicator of disease severity (Fig. 1, box 1).
Reference Ruan, Yang, Wang, Jiang and Song8 Furthermore, the AMS accordion
report described earlier was modified to also include COVID-19–specific
information including inflammatory markers and potential treatment options.

Fig. 1. An image displaying the customized AMS module within our EMR, EPIC. Box
1 illustrates the columns added specifically for COVID-19; oxygen requirement,
oxygen orders, vent order and high sensitivity CRP to triage higher acuity
patients. Box 2 demonstrates the “COVID TRACKING Time Since Review” which shows
the last time a patient has been reviewed to prioritize patients. Box 3 is the
“Document System Scoring Report”, where documentation for follow-up items can be
entered. Box 4 is part of the AMS accordion report which contains vital signs,
fever curve, intake/output, relevant hematology and chemistry laboratory values,
microbiology, radiology, medications and allergies. Due to space limitations,
this is a snap shot of the report so not all of the available data is displayed.
© 2020 Epic Systems Corporation. Used with permission.

A “COVID TRACKING time since review” column was incorporated into the patient
list to display the amount of time since the patient was last reviewed (Fig. 1,
box 2). If the patient had not been reviewed, then the phrase “never reviewed”
was displayed in this column. When a patient was selected from the list, the
optimized AMS accordion report would display relevant COVID-19 data so that the
patient could be reviewed without the need to enter data into the electronic
chart (Fig. 1, box 4). Within the accordion report, a document scoring system
could be used as a hand-off tool to provide a brief synopsis of important
factors and items to follow up in subsequent reviews (Fig. 1, box 3). The option
to post to a progress note was available within the documentation screen if a
specific recommendation needed to be placed into the patient’s chart to
facilitate communication with the primary team. When the review was completed,
the “COVID TRACKING time since review” column was automatically updated to help
avoid duplicate reviews of the same patient.

This customized AMS module became available 2 weeks from the admission our first
COVID-19–positive patient, and education on this tool was provided by the AST.
The multidisciplinary team members, including attending physicians and fellows,
review patients with COVID-19 infection on a daily basis to support and optimize
care in conjunction with the primary team.

DISCUSSION

As a result of the COVID-19 pandemic, consultants are faced with an
unprecedented number of patients to evaluate in a short period. This significant
challenge requires consultants to develop new work flows to provide optimal
patient care.

Similarly, the AST is challenged with reviewing large numbers of patients, often
with limited personnel. Therefore, many ASTs rely on optimizing the EMR to
quickly identify and review patients. The use of technology for antimicrobial
stewardship has been shown to improve the efficiency in identifying and
optimizing the management of patients. Reference Kullar, Goff, Schulz, Fox and
Rose9 With these tools, repurposing the AST workflow and AMS module at our
institution allowed us to quickly adapt to the challenges the pandemic posed as
our COVID-19 census rapidly exceeded 25% of our total hospital capacity. This
workflow offers an efficient way for the consultant to make timely clinical
assessments and recommendations including potential therapeutic options,
clinical trial enrollment, anticoagulation, monitoring adverse effects from
treatment, and antimicrobial use. For the complex COVID-19 cases, a formal
infectious disease consultation was recommended if indicated.

In conclusion, during a pandemic such as COVID-19, with a surge in hospitalized
patients, alternative mechanisms for patient review may need to be utilized. To
help meet this unprecedented challenge, repurposing the existing AMS module and
workflow can potentially facilitate appropriate patient review and timely
intervention.

ACKNOWLEDGMENTS

The authors thank Erol Fikrig, MD, Vincent Quagliarello, MD, and the entire
Section of Infectious Diseases at Yale for their support of this new and
innovative process. We also acknowledge additional members of the COVID-19
treatment team: Zachary Harris, MD, Lauren Pischel, MD, George Goshua, MD, Shana
E. Gleeson, MD, Marwan Azar, MD, Insoo Kang, MD, Stuart Seropian, MD, Harvey
Rinder, MD, Robert Bona, MD, and Alfred Lee, MD, PhD.

FINANCIAL SUPPORT

No financial support was provided relevant to this article.

CONFLICTS OF INTEREST

All authors report no conflicts of interest relevant to this article.

--------------------------------------------------------------------------------

FOOTNOTES

Authors of equal contribution.

--------------------------------------------------------------------------------

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Repurposing antimicrobial stewardship tools in the electronic medical record for
the management of COVID-19 patients
* Volume 41, Issue 11
* Matthew W. Davis (a1), Dayna McManus (a1), Alan Koff (a2), Gregory R.
Jaszczur (a3), Maricar Malinis (a2), Charles Dela Cruz (a4), Clemente J.
Britto (a4), Christina Price (a5), Veronica Azmy (a5), Kelsey Kaman (a5),
David Gaston (a2), Kevin Early (a3), Michelle DeWitt (a3), Ju-Sung Song (a3),
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* DOI: https://doi.org/10.1017/ice.2020.281

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CITATION TOOLS

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www.cambridge.org Open in urlscan Pro 104.16.55.52 Public Scan

Form analysis 5 forms found in the DOM

GET /core/search

GET /core/services/aop-cambridge-core/sendto

GET /core/services/aop-cambridge-core/sendto

GET /core/services/aop-cambridge-core/sendto

POST /core/services/aop-cambridge-core/comments/submit

Text Content

www.cambridge.org Open in urlscan Pro
104.16.55.52 Public Scan

Form analysis
5 forms found in the DOM