Abstract
BackgroundAntimicrobial prophylaxis is an evidence-proven strategy for reducing procedure-related infections; however, measuring this key quality metric typically requires manual review, due to the way antimicrobial prophylaxis is documented in the electronic medical record (EMR). Our objective was to electronically measure compliance with antimicrobial prophylaxis using both structured and unstructured data from the Veterans Health Administration (VA) EMR. We developed this methodology for cardiac device implantation procedures.MethodsWith clinician input and review of clinical guidelines, we developed a list of antimicrobial names recommended for the prevention of cardiac device infection. We trained the algorithm using existing fiscal year (FY) 2008–15 data from the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP), which contains manually determined information about antimicrobial prophylaxis. We merged CART-EP data with EMR data and programmed statistical software to flag an antimicrobial orders or drug fills from structured data fields in the EMR and hits on text string searches of antimicrobial names documented in clinician’s notes. We iteratively tested combinations of these data elements to optimize an algorithm to accurately classify antimicrobial use. The final algorithm was validated in a national cohort of VA cardiac device procedures from FY2016–2017. Discordant cases underwent expert manual review to identify reasons for algorithm misclassification.ResultsThe CART-EP dataset included 2102 procedures at 38 VA facilities with manually identified antimicrobial prophylaxis in 2056 cases (97.8%). The final algorithm combining structured EMR fields and text note search results correctly classified 2048 of the CART-EP cases (97.4%). In the validation sample, the algorithm measured compliance with antimicrobial prophylaxis in 16,606 of 18,903 cardiac device procedures (87.8%). Misclassification was due to EMR documentation issues, such as antimicrobial prophylaxis documented only in hand-written clinician notes in a format that cannot be electronically searched.ConclusionsWe developed a methodology with high accuracy to measure guideline concordant use of antimicrobial prophylaxis before cardiac device procedures using data fields present in modern EMRs. This method can replace manual review in quality measurement in the VA and other healthcare systems with EMRs; further, this method could be adapted to measure compliance in other procedural areas where antimicrobial prophylaxis is recommended.
Highlights
Antimicrobial prophylaxis is an evidence-proven strategy for reducing procedure-related infections; measuring this key quality metric typically requires manual review, due to the way antimicrobial prophylaxis is documented in the electronic medical record (EMR)
We developed a methodology with high accuracy to measure guideline concordant use of antimicrobial prophylaxis before cardiac device procedures using data fields present in modern EMRs
We established a method to accurately classify cardiovascular implantable electronic device (CIED) procedures with pre-incisional antimicrobial prophylaxis by 1) developing an algorithm in SAS and SQL software that combined structured and text data from the Veterans Health Administration (VA) EMR, and 2) testing and validating the algorithm using manual chart review of fiscal year (FY) 2008–2015 cardiac device procedures from the VA Clinical Assessment Reporting and TrackingElectrophysiology (CART-EP) program and from a national dataset reviewed by members of the study team
Summary
Antimicrobial prophylaxis is an evidence-proven strategy for reducing procedure-related infections; measuring this key quality metric typically requires manual review, due to the way antimicrobial prophylaxis is documented in the electronic medical record (EMR). Our objective was to electronically measure compliance with antimicrobial prophylaxis using both structured and unstructured data from the Veterans Health Administration (VA) EMR We developed this methodology for cardiac device implantation procedures. Post-surgical and post-procedural infections, including cardiac device infections following electrophysiology procedures, are highly morbid [1, 2] These severe complications can be prevented with appropriate preincisional antimicrobial prophylaxis, which can reduce rates of infection by approximately 80% and are strongly recommended in multi-society guidelines [3,4,5,6]. Given the high morbidity of these infections and their preventability, pre-incisional antimicrobial compliance is an important quality metric used in most U.S hospitals, including the Veterans Health Administration (VA) Measurement of this key quality metric represents a significant challenge as, unlike most medications, antimicrobials administered in the operating room generally do not require that an order be placed. A time-consuming and expensive manual review process was undertaken to determine compliance with pre-incisional antimicrobial prophylaxis in select surgical procedures [7, 8]; there is currently no infrastructure for tracking compliance in non-surgical procedural areas (i.e., outside the operating room and by an interventionist as opposed to a surgeon) where prophylaxis is recommended
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