Antimicrobial Stewardship Rounds Template & Metrics Pack

Welcome — How to use this pack

This pack gives stewardship teams a usable daily rounds agenda, a structured case-review checklist you can use in-person or virtually, discharge-order prompts to reduce unnecessary continuation, and a starter metrics set with clear definitions so your team can measure progress. Use the agenda and checklist as-is or adapt fields to match your EHR and local terminology.

What this pack contains

• Daily rounds agenda (template and roles)
• Case-review checklist (indication, culture review, de-escalation, IV→PO triggers, duration)
• Antibiotic stop/review prompts for discharge orders
• Starter metrics pack and dashboard layout suggestions (DOTs, guideline concordance, C. difficile signals)
• Governance and implementation tips

Daily Stewardship Rounds — template agenda

Purpose: efficiently review priority patients, identify de-escalation and IV→PO opportunities, and capture stewardship recommendations.

• Frequency: daily weekdays (adjust to capacity)
• Duration: 30–60 minutes depending on census
• Participants: Clinical pharmacist (stewardship lead), ID physician (as available), frontline nurse representative (rotating), ward/service prescriber liaison, data analyst or quality rep (weekly)

1. Pre-round prep (5–10 min): review automated flags (broad-spectrum starts >48h, culture-positive, prolonged therapy)
2. Rapid case review (20–40 min): apply checklist below per prioritized case
3. Document recommendations and acceptance status in EHR (5–10 min)
4. Follow-up & education items (5 min): quickly note recurring problems, guideline gaps, or needed decision-support changes

Case-Review Checklist (use for each patient)

Use concise fields to standardize conversations and documentation.

• Patient & context: unit/service, attending, relevant allergies
• Indication: suspected vs proven infection; working diagnosis and source
• Antibiotics on chart: agent(s), dose, route, start date/time
• Culture & microbiology: cultures taken, Gram stain, preliminary/definitive results, susceptibilities
• Source control: any procedures planned/complete (e.g., drainage, device removal)
• Patient factors: renal/hepatic function, pregnancy status, immunosuppression
• Appropriateness: therapy matches suspected/confirmed pathogen and local guideline? (Yes/No/Unclear)
• De-escalation opportunity: narrow spectrum, stop unnecessary agents, convert IV→PO (criteria: clinically improving, tolerating oral, functioning GI tract)
• Duration & stop date: is a planned stop/review date documented? If not, propose one based on diagnosis
• Adverse event risk: C. difficile risk factors, QTc risk, drug interactions
• Recommendation & owner: clear action (e.g., narrow to ceftriaxone, stop metronidazole), who should place the order, and when to re-review
• Acceptance: accepted/modified/rejected (note reason) and follow-up plan

Antibiotic Stop/Review Prompts for Discharge Orders

Embed these prompts as part of discharge reconciliation or order sets.

• Is the infection confirmed by culture? If not, document clinical rationale for continuation.
• Is the planned total duration consistent with guideline-recommended duration for this diagnosis?
• Is there an oral alternative that achieves appropriate coverage with shorter course or fewer side effects?
• Set a clear stop date in the discharge medication list or schedule outpatient follow-up for reassessment.

Starter Metrics Pack — definitions and calculation tips

Define metrics consistently so comparisons are meaningful. Below are common stewardship measures you can begin with.

1. Days of Therapy (DOT) per 1,000 patient-days

Definition: Sum of days each antimicrobial was administered to patients during the period, divided by total inpatient patient-days, then multiplied by 1,000.

Use: trend antibiotic consumption by unit or service. Break out by agent class (e.g., carbapenems, anti-pseudomonal beta-lactams).

2. Guideline concordance (%)

Definition: Percent of sampled antibiotic starts that match local guideline choice and recommended duration for the documented indication.

Use: measures adherence to empiric treatment guidance; sample denominator should be all new starts or a stratified sample.

3. IV→PO conversion rate (%)

Definition: Proportion of eligible cases that were converted from IV to oral therapy within a specified time after eligibility criteria met.

4. Time to de-escalation (median hours)

Definition: Median time from availability of organism/susceptibility data to narrowing or stopping broad-spectrum therapy.

5. C. difficile rate (events per 10,000 patient-days)

Definition: Lab-identified C. difficile infection events normalized per patient-days. Use institutional surveillance definitions.

Dashboard & reporting suggestions

• Top panel: facility-level DOT trend (overall and by key classes)
• Middle panel: unit/service heatmap of guideline concordance and new starts
• Alerts panel: cases flagged for >48h broad-spectrum therapy without documented review, missed IV→PO opportunities, culture-positive but no de-escalation
• Case list: actionable patients for next rounds with quick links to chart and microbiology
• Monthly report: stewardship recommendations vs. acceptance rate, education topics, and one improvement action

Governance & operational tips

• Establish a clear stewardship lead and backing from clinical leadership so recommendations are heard and acted on.
• Keep rounds focused on high-value cases (e.g., broad-spectrum use >48h, culture-positive bloodstream infections, prolonged therapy).
• Document recommendations consistently in the chart and track acceptance rates to build credibility and identify barriers.
• Use a respectful, collaborative communication script: state the clinical observation, propose a concrete action, note the rationale, and ask for the prescriber’s plan.
• Embed decision support where feasible (order-set defaults, stop dates, antibiotic duration prompts) and measure the effect after implementation.

Implementation roadmap (practical milestones)

1. Week 1–4: adopt agenda and checklist; run daily focused rounds with small case volume.
2. Month 1–3: start reporting basic DOT and guideline concordance; track stewardship recommendations and acceptance.
3. Month 3–6: pilot EHR prompts (stop/review dates, IV→PO reminders); refine dashboard and expand rounds coverage as capacity grows.

Suggested templates & starter artifacts

• Printable rounds checklist (adapt columns for EHR capture)
• Spreadsheet template for DOT calculations and trend charts
• Prescriber communication examples and one-page guideline summaries for common syndromes

Next steps & capability ideas

To raise impact, consider adding interactive checklist capture during rounds, automated DOT calculations from medication administration data, and a live dashboard with unit-level drilldowns. These require platform integration and routine data feeds.

Use, adapt, and share this pack as a starting structure — stewardship improves when teams iterate on processes and metrics that fit local workflows.