Impact of a restrictive antimicrobial policy on the process and timing of antimicrobial administration

Abstract

In-hospital antimicrobial approval policies are designed to curb the indiscriminant use of antimicrobials. These policies usually require written forms and/or direct requests to an Infectious Disease specialist (or surrogate) prior to release of the antimicrobial. We hypothesized that the approval processes at our institution results in delayed antimicrobial administration. We performed a retrospective cohort study examining the time from order to administration for 25 different antimicrobials ordered "stat." Antimicrobials were classified as restricted (required approval) or unrestricted. We compared these 2 classes to each other both during the daytime (8 AM to 10 PM), when approval is required for restricted antimicrobials, and at night when the first dose of all antimicrobials is exempted. We defined a delay in administration when the medication was given >1 hour from time of order. We separately examined delays of >2 hours. A higher percentage of >1-hour delays occurred when the antimicrobial was restricted (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.23-1.82). Similar results were seen for >2-hour delays (OR = 1.78; 95% CI = 1.39-2.21). During the exempt-from-restriction time period (10 PM to 8 AM), there was no difference between these 2 classes of antimicrobials. Results were unchanged by adjustment for service (medicine vs. surgery vs. other), patient characteristics (age, sex, race), or by weekday vs. weekend. Statistically significant delays in stat antimicrobial administration occur in our institution when antimicrobials require preapproval. These findings illustrate the importance of considering clinical efficiency when restrictions are put in place for time-sensitive therapies such as antimicrobials.