Evaluation of a Second-Sign Process for Antimicrobial Prior Authorization.

Abstract

A second-sign prospective restriction of select broad-spectrum antimicrobials was fully implemented in January 2015 as a pediatric antimicrobial stewardship program (ASP) initiative to help ensure the most appropriate empiric use of ceftaroline, cefepime, fidaxomicin, linezolid, and vancomycin (intravenous). The objective of this evaluation is to assess the effectiveness of a forced second-sign process in the electronic medical record as a pediatric ASP strategy. We anticipated that the second-sign process for antibiotics would increase the appropriateness of empiric antibiotic use, as defined by preapproved criteria, clinical pathways, national guidelines, and pediatric-specific infectious diseases reference texts, while not causing significant delay in the initial administration of antibiotic therapy. This was a retrospective before and after intervention chart review conducted from July 2014 to June 2015. The study was conducted at a 187-bed, freestanding teaching children's hospital that included the following: level-1 pediatric trauma center, 18-bed pediatric intensive care unit, and 32-bed neonatal intensive care unit. A total of 1178 orders were identified, and 389 met inclusion criteria. The vast majority of second-sign orders were for vancomycin (92%), 61% were written for males, and the median age was 6 years old. Appropriateness of second-sign restricted antibiotic use significantly increased after second-sign implementation (84.5% to 92.9%, P = .01). The secondary outcome of time from initial order entry to medication administration was not different between the before and after groups (median time, 184.5 [interquartile range, 110.25-280.75] vs 174 [interquartile range, 104-228] minutes; P = .342). The use of a second-sign approval process for antimicrobial restriction can lead to increased appropriateness of antibiotic use at a pediatric hospital, without causing a delay in administration.