Antimicrobial Stewardship Rounds: Practical Agenda, Decision Aid & Documentation Templates

Purpose

Use this playbook to run focused antimicrobial stewardship (AMS) rounds that produce clear, documented decisions and measurable follow‑up actions. The agenda, decision aid, and templates are intentionally compact so teams can adopt and adapt them quickly.

When & Who

Duration: 30–45 minutes (target). Frequency: daily where feasible, or 3–5x/week depending on service volume.

Typical roles:

• ID pharmacist – case preparation, medication review, dosing recommendations.
• ID physician or stewardship lead – clinical review, stop/de‑escalation decisions, complex cases.
• Ward clinician (attending/resident/advanced practice) – clarifies clinical status and accepts/declines recommendations.
• Microbiology/Laboratory liaison – when cultures or rapid diagnostics influence decisions (may participate remotely or asynchronously).
• Recorder – documents decisions, timelines, and assigned follow‑up in the EHR or rounds log.

Pre‑round Preparation (15–30 min)

• Pull a short list of candidate patients (see selection criteria below).
• Prepare a one‑line summary per patient: indication, antibiotic(s), start date, key labs/cultures, renal function, allergies.
• Attach or link relevant microbiology results and prior stewardship notes in the EHR for quick access.
• Assign a recorder and confirm the EHR order‑set or documentation template location.

Case Selection Criteria (prioritize patients who meet one or more)

• Receiving high‑risk or broad‑spectrum antibiotics (e.g., carbapenems, piperacillin‑tazobactam, vancomycin).
• Culture results that could allow narrowing therapy (e.g., susceptible organism identified).
• Therapy exceeding expected duration (prolonged empiric therapy >48–72 hours without source control).
• Patients with complicated infections, immunocompromised hosts, or therapeutic drug monitoring needs.
• IV‑to‑PO conversion candidates and stewardship opportunities for dose optimization.

Rounds Agenda (30–45 min)

1. Quick check (2–3 min): confirm team, recorder, and urgent items.
2. Case reviews (20–35 min): 3–10 concise reviews depending on complexity—use the one‑line summary as the opener.
3. Decision & documentation (2 min per case): state recommendation aloud, record it, assign follow‑up and timeline.
4. Metrics & process notes (3–5 min): capture any process issues, needed order‑set changes, or education points.

Decision Aid: Simple Clinical Questions

For each case, run the following checklist in order. If any answer resolves the question, document the decision and next steps.

1. Is active infection likely? (Yes/No/Uncertain)
   • No → Recommend stop and document rationale; set safety net (e.g., re‑evaluate in 24–48h if symptoms persist).
   • Uncertain → Recommend short reassessment window (e.g., review after pending culture or imaging results).
2. Is empiric coverage broader than indicated?
   • Yes → Recommend narrowing based on likely pathogen and local susceptibilities; propose specific agent(s).
3. Do culture/rapid diagnostic results allow de‑escalation?
   • Yes → Recommend targeted therapy and discontinue unnecessary agents.
4. Is duration appropriate for the syndrome?
   • No → Recommend stop or define remaining duration with date/time.
5. Are there dosing, route, monitoring, or interaction issues?
   • Yes → Recommend dose adjustment, IV→PO conversion, therapeutic drug monitoring, or reconciliation with renal function.

Documentation Template (use EHR note or rounds log)

Document each recommendation concisely. Suggested fields:

• Patient: Name/MRN/Location
• Indication: Short clinical reason (e.g., pneumonia, UTI, sepsis)
• Current therapy: Drug(s), dose, start date
• Decision: Stop / Narrow to [agent] / Continue X days until [date/time] / Change dose
• Rationale: Key reason (culture result, clinical improvement, etc.)
• Action owner: Ward clinician / ID pharmacist / Nursing
• Follow‑up: Who will confirm change and when (e.g., pharmacist to place order by 6pm; clinician to document acceptance)
• Escalation: When to re‑notify stewardship or ID consult (e.g., cultures positive for resistant organism)

Follow‑up & Accountability

• Assign a single owner per action and a due date/time. Avoid ambiguous handoffs.
• Use short time windows for pending items (e.g., verify narrowed therapy within 24–48 hours of recommendation).
• Record acceptance/refusal in the EHR. If ward clinicians decline a recommendation, document the reason and plan for re‑review if needed.

Core Metrics (recommended and how to measure)

• Days of therapy (DOT) per 1,000 patient‑days: counts of antimicrobial days standardized to occupancy. Useful for trend analysis.
• Time to de‑escalation: median hours from culture result availability to narrowing or stopping therapy.
• Acceptance rate of stewardship recommendations: percent of documented recommendations accepted and implemented within defined timeframe.
• IV→PO conversion rate: percent of eligible patients converted within 48 hours of eligibility.

Implementation Notes & Practical Tips

• Embed the documentation template into an EHR note or a dedicated stewardship flowsheet for quick capture.
• Link to relevant EHR order‑sets for recommended alternatives; include dose calculators and renal‑adjustment guidance.
• Keep rounds lists short and focused—quality over quantity increases uptake.
• Rotate roles so pharmacists develop assessment experience and clinicians see stewardship as collaborative, not policing.

Audit & Continuous Improvement

Periodically audit a sample of rounds entries to check documentation completeness, recommendation acceptance, and timing. Use audits to refine selection criteria and workflow.

Common Pitfalls (Mal Hungers Reminder)

• Making recommendations without documented rationale or an owner—leads to low uptake.
• Relying on checklists without local adaptation to formulary, staffing, and technology.
• Ignoring follow‑up—recommendations must be verified and closed in the EHR.
• Blaming individuals for system issues—focus on process fixes (order‑sets, alerts, staffing) rather than punishment.

How to Tailor This Playbook

• Adjust frequency and duration of rounds to local census and staffing.
• Create syndrome‑specific decision branches (e.g., pneumonia, UTIs, bloodstream infections) for teams that want deeper guidance.
• Map responsibilities to local roles (pharmacist credentialing, prescriber privileges, nursing workflows).

Quick Start Checklist

1. Decide rounds cadence and core team.
2. Implement the documentation template in the EHR or a shared rounds log.
3. Run a 2‑week pilot with 3–5 patients per round; measure acceptance rate and time to de‑escalation.
4. Refine selection criteria and documentation based on pilot findings.

Suggested Resources & Links

Include local order-set links, hospital antibiogram, dosing/renal adjustment references, and the microbiology lab rapid diagnostics hotline.

Adapt and reuse this playbook—stewardship rounds are most effective when short, consistent, well documented, and clearly owned.