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

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.