Implementation of a computerised antimicrobial approval system in a hospital environment: lessons learned

The use of antimicrobials in a hospital setting is often inappropriate. This impacts on drug costs, drug toxicity, patient outcome and the resistance patterns of local bacteria. For certain broad-spectrum antibiotics, restriction of access, monitoring of prescribing patterns and consultation with an infectious diseases (ID) specialist is justified. A computerised antimicrobial approval system was developed at The Royal Melbourne Hospital by a multidisciplinary team. Apilot system addressing just one class of drug was deployed in 2001 and the final system, covering 23 antimicrobial agents, was deployed in 2005. All clinical staff had orientation sessions, and the pharmacists and ID registrars provided ongoing education and support. Feedback from users was sought by formal and informal means. This was discussed at monthly team meetings, and responded to with iterative changes in the system. It took 12 months for the system to be fine-tuned and thereafter it became entrenched with high levels of use, maintained for a further 2 years. An average of 250-300 approvals was obtained every month. The use of broad-spectrum antibiotics fell and antibiotic sensitivity profiles of local bacteria seemed to improve. These data have been reported elsewhere. The purpose of this paper is specifically to discuss implementation issues to inform clinicians considering adopting such a system. The lessons learned are based on reports in the published literature, and informed by the researchers' own experience. Acomputerised antimicrobial approval system can be successfully implemented in a hospital environment. Features important to adoption included clinical workflow integration, tailoring functionality to complement the existing ID service, integration with other hospital databases, linking to external (internet) information sources, ease of auditing to provide feedback, and deployment accompanied by a clear description of individual responsibilities and defined governance procedures.