Are Approval Codes ANTI-Antimicrobial Stewardship?

Introduction

When I first started as an enthusiastic AMS pharmacist, I was determined to reduce the consumption of restricted antimicrobials. I believed that strictly enforcing approval codes would be the most effective strategy.

I started in the pharmacy. I began with an audit of antimicrobials supplied without a code and hassled my peers when they supplied without proper authorization. The pharmacists were generally happy to stick to the restricted antimicrobials policy, and we reduced the supply dispensed from the pharmacy.

Discovering Hidden Stashes

It seemed we were on track, but to my horror, I noticed on ward rounds that the patients with no approval codes were still getting their doses as normal. I investigated further and found that the ward nurses were keeping stashes of restricted antibiotics in case they couldn't get any supply from the pharmacy. They felt it was their duty of care to supply a dose if it was charted, approval code or not.

The nurses were double-ordering from charts with an active approval and then stashing the extra antibiotics in a drawer in the drug room. One ward just left them out in the open on a shelf, another even kept some in the ward clerk's desk drawer. I am sure there were other places which were too smart for me to find. If one ward was missing something in their secret stash they would walk over to the other ward and trade on the antibiotic black market.

Well, this certainly wouldn't fly. I had a new stewardship mission. During my ward rounds, I would find their stashes and confiscate any antibiotics which were either unlabelled, or for a discharged patient. I had to cart a giant bag with me to fit them all. The problem was solved. The restriction system could now do what it was meant to do.

New Issues Arise

I started to notice some missed doses, and I thought this was a good thing. Less consumption must mean less resistance surely.

But there was a new issue. The nighttime doses were still being given, even if the daytime doses were omitted.

Our hospital had a 'satellite pharmacy' which is a big room full of drugs that staff can access after hours when the pharmacy is closed. As soon as the pharmacy doors closed, they would make a run on the satellite pharmacy, and the restricted antimicrobial stock would be cleared out. I would catch staff lined up outside the satellite pharmacy right on main pharmacy closing time.

Battling the Satellite Pharmacy

I had to work hard to convince the after-hours drug room managers to check if a patient had an active approval code before supplying the antibiotic. Support for the idea was variable; some managers were keen to enforce approval codes, others simply ignored them. Even if the after-hours staff had restricted supply, the staff would find another patient charted that antimicrobial, or go to the ICU or the ED which had the drugs available in their drug rooms.

There was no way to plug the holes fast enough. My campaign for an effective restriction system was defeated. Worse still, during the campaign, countless patients had missed doses and received suboptimal antimicrobial concentrations.

This actually encouraged the growth of resistant organisms... I had been doing anti-AMS...

So, this raises the question, if approval codes don't stop antimicrobial consumption, and worse still promote missed doses, why are they recommended as a staple component for an AMS program?

Finding a Balanced Approach

I think approval codes have a time and a place. In sites using an electronic medications platform, the actual need for approval codes is essentially eliminated. AMS teams can see exactly which antibiotics each patient is on and generate a list of patients to review straight from the eMeds platform. They can even add a layer of decision support to better identify drug-bug mismatches, incorrect dosing, or indication vs. treatment mismatches (as in Clinical Branches and the RAPA tool).

In hospitals still using paper charts, you have no idea who is charted what. In this case, approval codes are certainly needed; they ensure patients prescribed a restricted antibiotic can be tracked by the AMS team, and patients without codes can be flagged for review when they come to the pharmacy for supply.

In both EMR and paper based hospitals they still do serve a purpose. They are a tool that allows junior medical staff to access decision support without retribution from their team leader who said 'give that patient ceftriaxone'.

But, the restriction of supply by the pharmacy is never going to prevent the patient from actually receiving at least some of their doses, and attempting to truly restrict through supply is going to cause more problems than it solves.

It will increase the length of stay, increase the risk of resistance, and place unnecessary strain on the relationship between the pharmacy and hospital wards.

For that reason, I think approval codes are only good 'on paper'. They are good to have as an imaginary requirement to cut through ego's and help drive conversations or promote use of digital decision support for prescribing.

Ultimately, the real behaviour change comes from the enablement that they provide, the approval code itself is just smoke and mirrors.

Written by John Shanks - Antimicrobial Stewardship Pharmacist and Software Developer at Kraken Coding