Impact of a Mortality Prediction Rule for Organizing and Guiding Antimicrobial Stewardship Program Activities.

BACKGROUND: Antimicrobial stewardship program (ASP) surveillance at our hospital is supplemented by an internally developed surveillance database. In 2013, the database incorporated a validated, internally developed, prediction rule for patient mortality within 30 days of hospital admission. This study describes the impact of an expanded ASP review in patients at the highest risk for mortality. METHODS: This retrospective, quasi-experimental study analyzed adults who received antimicrobials with the highest mortality risk score. Study periods were defined as 2011-Q3 2013 (historical group) and Q4 2013-2018 (intervention group). Primary and secondary outcomes were assessed for confounders and analyzed using both unadjusted and propensity score weighted analyses. Interrupted time-series analyses also analyzed key outcomes. RESULTS: A total of 3282 and 5456 patients were included in the historical and intervention groups, respectively. There were significant reductions in median antimicrobial duration (5 vs 4 days; P < .001), antimicrobial days of therapy (8 vs 7; P < .001), antimicrobial cost ($96 vs $85; P = .003), length of stay (LOS) (6 vs 5 days; P < .001), intensive care unit (ICU) LOS (3 vs 2 days; P < .001), total hospital cost ($10 946 vs $9119; P < .001), healthcare facility-onset vancomycin-resistant Enterococcus (HO-VRE) incidence (1.3% vs 0.3%; P ≤ .001), and HO-VRE infections (0.6% vs 0.2%; P = .018) in the intervention cohort. CONCLUSIONS: Reductions in antimicrobial use, hospital and ICU LOS, HO-VRE, HO-VRE infections, and costs were associated with incorporation of a novel mortality prediction rule to guide ASP surveillance and intervention.

Common Risk Stratification of Hospital and Ambulatory Patients.

The care of patients with multiple chronic conditions and those near the end-of-life is often compromised by miscommunications among the healthcare teams. These might be improved by using common risk strata for both hospital and ambulatory settings. We developed, validated, and implemented an all-payer ambulatory risk stratification based on the patients' predicted probability of dying within 30 days, for a large multispecialty practice. Strata had comparable 30-day mortality rates to hospital strata already in use. The high-risk ambulatory strata contained less than 20% of the ambulatory population yet captured 85% of those with 3 or more comorbidities, more than 80% of those who would die 30 or 180 days from the date of scoring, and two-thirds of those with a nonsurgical hospitalization within the next 30 days. We provide examples how the practice and partner hospital have begun to use this common framework for their clinical care model.