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JAC Advance Access originally published online on March 26, 2008
Journal of Antimicrobial Chemotherapy 2008 61(6):1384-1388; doi:10.1093/jac/dkn113
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© The Author 2008. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Original research

Design of a ‘day 3 bundle’ to improve the reassessment of inpatient empirical antibiotic prescriptions

Céline Pulcini1,2,*, Sylviane Defres3, Ila Aggarwal3, Dilip Nathwani3 and Peter Davey2,3

1 Service d’Infectiologie, Hôpital l’Archet 1, Centre Hospitalier Universitaire de Nice, Route St Antoine de Ginestière, BP 3079, 06202 Nice Cedex 3, France 2 Informatics Section, Division of Community Health Sciences, MacKenzie Building, Kirsty Semple Way, Dundee DD2 4BF, Scotland, UK 3 Infection Unit, East Block, Level 4, Ninewells Hospital and Medical School, Dundee DD1 9SY, Scotland, UK

Received 8 November 2007; returned 10 January 2008; revised 19 February 2008; accepted 22 February 2008

* Correspondence address. Service d'Infectiologie, Hôpital l'Archet 1, CHU de Nice, Route de Antoine de Ginestière, BP 3079, 06202 Nice Cedex 3, France. Tel: +33-492035515; Fax: +33-493965454; E-mail pulcini.c{at}chu-nice.fr

Objectives: To develop and test a set of process measures of quality of care in the reassessment of inpatient empirical antibiotic prescriptions, to determine the inter-rater reliability of medical notes’ review in assessment of these measures and to test these measures on one ward.

Methods: Measures of process of care were identified from a literature review. Forty sets of medical notes were reviewed by two independent doctors and the inter-rater reliability determined using observed percentage agreement and the kappa statistic. These measures were collected weekly and fed back to doctors in order to stimulate improvement.

Results: Four process measures were identified and were grouped together to create a ‘day 3 bundle’: antibiotic plan, review of the diagnosis, adaptation to microbiology and intravenous–oral switch. The inter-rater agreement was ≥80% for all measures. Data collection was feasible and was easily sustained over several weeks. The reassessment of antibiotic prescriptions around day 3 was better documented using real-time feedback of the measures to the medical team.

Conclusions: Our measures of care are suitable for the reassessment of empirical inpatient antibiotic prescriptions, with good inter-rater reliability. This quality intervention should be part of a more comprehensive and multifaceted plan to improve antibiotic use in hospitals.

Keywords: indicator , quality assurance , switch therapy , antibiotic therapy , medical decision-making , prescribing practice , hospital infections


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