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- 1. Better Health for All DEMYSTIFYING CASCADING Dr. Pramanik Sharmila Poorva Desai April 2016 Efficiency in Preference and Cascading Rules for Microbiology
- 2. Better Health for All © 2013 Santa Clara Valley Health & Hospital System | 2 Efficiency in Preference and Cascading Rules for Microbiology Pramanik Sharmila, M.D. Laboratory Pathologist Santa Clara Valley Medical Center sharmila.pramanik@hhs.sccgov.org Elisabeth Mailhot, M.D. Medical Director of Laboratory Santa Clara Valley Medical Center mailhot.elisabeth@hhs.sccgov.org Desai Poorva, CLS. Beaker Application Coordinator Santa Clara Valley Medical Center poorva.desai@hhs.sccgov.org
- 3. Better Health for All © 2013 Santa Clara Valley Health & Hospital System | 3 • Overview of Santa Clara Valley Medical Center • Review rule types affecting susceptibility results • Advantages of consolidated cascading structure • Deep dive into technical build with examples Agenda
- 4. SANTA CLARA VALLEY MEDICAL CENTER
- 5. Santa Clara Valley Medical Center Services: General acute care, Obstetrical service, High Risk obstetrics, Pediatric service, Psychiatric inpatient service Intensive Care Services: Burn, Medical, Level I Trauma Center, Surgical, Cardiac, Pediatric, Maternal, Neonatal Facility Data: 77% acute care & 23% non-acute care 574 Hospital Beds 16 Outlying Clinics © 2013 Santa Clara Valley Health & Hospital System | 9
- 6. Santa Clara Valley Medical Center Laboratory Statistics: • Total billable tests > 2,000,000/year • Microbiology lab tests > 344,962/year • One main laboratory, 95% testing done onsite • 59% tests performed on outpatients EPIC- Healhlink: • Inpatient, Ambulatory and Beaker version 2014 • Live with Inpatient and Ambulatory - May 2013 • Live with Beaker since - July 2015 © 2013 Santa Clara Valley Health & Hospital System | 10
- 8. General Data Flow for Microbiology © 2013 Santa Clara Valley Health & Hospital System | 12 Physicians
- 9. General Data Flow for Microbiology © 2013 Santa Clara Valley Health & Hospital System | 13 Physicians Beaker
- 10. General Data Flow for Microbiology © 2013 Santa Clara Valley Health & Hospital System | 14 Maldi/Vitek, Microscan Physicians Beaker Instrument
- 11. General Data Flow for Microbiology © 2013 Santa Clara Valley Health & Hospital System | 15 Maldi/Vitek, Microscan Physicians Beaker Instrument
- 12. General Data Flow for Microbiology © 2013 Santa Clara Valley Health & Hospital System | 16 Maldi/Vitek, Microscan Physicians Beaker Instrument
- 13. Microbiology Susceptibility Workflow • Some rules evaluate in instrument • Susceptibility result files into LIS • Preference rules are evaluated • Cascading rules are evaluated • Culture order is placed • Culture is setup • Organism is isolated • Technologist orders susceptibilities Orders Results Microscan Results Orders Orders © 2013 Santa Clara Valley Health & Hospital System | 17
- 14. Various Rules Involved In Cascading Cascading rules Override rules Preference rules Intrinsic rules Instrument limitation © 2013 Santa Clara Valley Health & Hospital System | 18
- 15. Distributed Rules Structure Limitation with antibiotics defined in Instrument Intrinsic rules in instrument Preference and Cascading rules defined in LIS Pre-Beaker workflow © 2013 Santa Clara Valley Health & Hospital System | 19
- 16. Pain Points With Build Distributed rule structure hurdles • Inefficient for maintenance and support • Major changes if susceptibility instrument replaced © 2013 Santa Clara Valley Health & Hospital System | 20
- 17. Pain Points With Build Beaker specific hurdles for cascading rules • Limited guidance on defining cascading rules • No model build available for cascading rules • Large amounts of manual build © 2013 Santa Clara Valley Health & Hospital System | 21
- 18. Consolidated Rules Structure Few instrument specific rules be defined at instrument level Beaker houses : Instrument limitation rules Intrinsic rules Preference rules Cascading rules Override rules Post-Beaker workflow © 2013 Santa Clara Valley Health & Hospital System | 22
- 19. Advantages of Consolidated Structure • Easier maintenance, troubleshooting and support in Beaker • CLSI standard updates only need to be applied in Beaker • Minimal impact when lab replaces susceptibility instruments © 2013 Santa Clara Valley Health & Hospital System | 23
- 20. DEEP DIVE INTO TECHNICAL BUILD (WITH EXAMPLES)
- 21. Build Overview Rules (CER) © 2013 Santa Clara Valley Health & Hospital System | 25
- 22. Susceptibility Interface Build Organism (LLO) Interface (MAC) Preference rules (TRE) Cascading rules (TRE) © 2013 Santa Clara Valley Health & Hospital System | 26
- 23. Susceptibility Interface Interface (MAC) item Interface (MAC) Item 605 – Type 1 - Micro Isolation Item 757 – Result Checking 0 - Deselect Result Checking © 2013 Santa Clara Valley Health & Hospital System | 27
- 24. Susceptibility Interface Interface (MAC) item Interface (MAC) value Item 605 – Type 1 - Micro Isolation Item 757 – Result Checking 0 - Deselect Result Checking Interface (MAC) item Interface (MAC) value Item 605 – Type 1 - Micro Isolation Item 757 – Result Checking 0 - Deselect Result Checking © 2013 Santa Clara Valley Health & Hospital System | 28
- 25. Preference Rules Prioritization Organism (LLO) Interface (MAC) Preference rules (TRE) Cascading rules (TRE) © 2013 Santa Clara Valley Health & Hospital System | 29
- 26. Preference Rules – Prioritization Ln #1 Description: 21R-For Organism Do not report AMP and AMP/Sulbactam Organism Specimen Rule Condition ResultsGroup Type Source All All All 198324 Amp/Sulbactam is (S or I or R) Don’t report [0] for Amp/ Sulbactam © 2013 Santa Clara Valley Health & Hospital System | 30
- 27. Preference Rules – Prioritization 1. Rules specific for specimen types, but general to all organisms 2. Intrinsic rules and instrument limitation rules 3. Primary antibiotics appropriate for the organism or group of organisms © 2013 Santa Clara Valley Health & Hospital System | 31
- 28. Example #1: Preference rules specific to a specimen type but generic to all organisms © 2013 Santa Clara Valley Health & Hospital System | 32 Description: 0-Sterile body site not CSF Don’t report Clindamycin Ln# Organism Type Source Rule Condition Results 1 All All All 195978 Clindamycin is (S or I or R) Don’t Report Clindamycin Description: 0-Specimen site is CSF Don’t report Ciprofloxacin 2 All All All 197549 Ciprofloxacin is (S or I or R) Don’t Report Ciprofloxacin
- 29. Example #2: Ln # Description: E coli-Kleb-Proteus Mirabilis Group Urine 67 Group Rule Report Do not report EKPM Group 195978 Ampicillin Ceftriaxone Gentamicin Trim/Sulfa Pip/Tazobactam Nitrofurantoin Cefazoline Piperacillin Amikacin Amp/sulbactam Cefoxitin Cefepime Cefuroxime Cefuroxime Oral Ceftazidime Aztreonam Levofloxacin Tetracycline Ertapenem Imipenem Preference rules for specimen type urine © 2013 Santa Clara Valley Health & Hospital System | 33
- 30. © 2013 Santa Clara Valley Health & Hospital System | 34
- 31. Example #2: Ln # Description: E coli-Kleb-Proteus Mirabilis Group Non-urine 68 Group Rule Report Do not report EKPM Group Ampicillin Ceftriaxone Gentamicin Trim/Sulfa Pip/Tazobactam Piperacillin Amikacin Amp/sulbactam Cefoxitin Cefepime Cefuroxime Cefuroxime Oral Aztreonam Nitrofurantoin Cefazoline Ceftazidime Levofloxacin Tetracycline Ertapenem Imipenem Tobramycin Preference rules for specimen types non- urine © 2013 Santa Clara Valley Health & Hospital System | 35
- 32. Cascading Rules Prioritization Organism (LLO) Interface (MAC) Preference rules (TRE) Cascading rules (TRE) © 2013 Santa Clara Valley Health & Hospital System | 36
- 33. Cascading Rule - Prioritization 1. Rules specific to specimen types, but general to all organisms 2. Intrinsic rules and instrument limitation rules 3. Override rules 4. Cascading rules appropriate for: • An Organism • A Genus • A Group of organism © 2013 Santa Clara Valley Health & Hospital System | 37
- 34. Cascading Rules – Override Preference Rule Override preference rules - Item TRE 51590 © 2013 Santa Clara Valley Health & Hospital System | 38
- 35. Example #1: Ln # 21 Intrinsic Resistance Proteus vulgaris 193 Species Rule Condition: If “S” or “I” or “R” Do Not Report Proteus vulgaris Ampicillin Cefazolin Cefuroxime Cephalexin Tetracycline Doxycycline Cefadroxil Cefprozil Nitrofurantoin Minocycline Tigecycline Meropenem Ampicillin Cefazolin Cefuroxime Cephalexin Tetracycline Doxycycline Cefadroxil Cefprozil Nitrofurantoin Minocycline Tigecycline Meropenem Intrinsic rules specific to an organism © 2013 Santa Clara Valley Health & Hospital System | 39
- 36. Example #2: Ln # 21A Urine not reported Ampicillin/ Sulbactam for organisms IR 198 Group Rule Condition Report EBAN Group 198324 Ampicillin Ampicillin /Sulbactam is (S or I or R) Don't report Ampicillin and Ampicillin/Sulbactam Intrinsic rules similar for multiple organisms © 2013 Santa Clara Valley Health & Hospital System | 40
- 37. © 2013 Santa Clara Valley Health & Hospital System | 41
- 38. Example #3: Ln # 21E-Override Cascading and report 2nd drugs when 1st drugs are I/R 201 Group Rule Condition Report Enterobacteriaceae group 196133 Cefepime is S and Ciprofloxacin is I or R Report Cefepime And Ciprofloxacin Prioritizing the override rules © 2013 Santa Clara Valley Health & Hospital System | 42
- 39. 1. Cascading for specific specimen types 2. Intrinsic rules specific to subset of organism within a group 3. Cascading rules for rest of the organisms within a group © 2013 Santa Clara Valley Health & Hospital System | 43 Example #4: Prioritization for more complex scenarios
- 40. Ln # 221Q-Group EBACT Urine isolate, Do not report AMP/SULB if AMP is S or I or R 216 Group Rule Condition Report Enterobacteriaceae group 195978 Amp/Sulbactam (S or I or R) Don’t report Ampicillin/Sulbactam Ln # Ln # 21R-For Organisms Do not report AMP and AMP/SULB 217 Group Rule Condition Report Enterobacteriaceae group 198324 Ampicillin (S or I or R) Don’t report Ampicillin and Ampicillin/Sulbactam Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB 218 Group Rule Condition Report Enterobacteriaceae group 198326 Ampicillin (I or R) Don’t report Ampicillin, Report Ampicillin/Sulbactam 21S-IR Organisms Do not report AMP but report AMP/SULB 219 Group Rule Condition Report Enterobacteriaceae group 195962 Ampicillin (I or R) Report Ampicillin and Ampicillin/Sulbactam © 2013 Santa Clara Valley Health & Hospital System | 44
- 41. Example #4: Ln # 221Q-Group EBACT Urine, Do not report AMP/SULB if AMP is S or I Or R 216 Group Rule Condition Report Enterobacteriaceae group 195978 Amp/Sulbactam is S or I or R Don’t report for Ampicillin/Sulbactam Suppression of antibiotics based on specimen types © 2013 Santa Clara Valley Health & Hospital System | 45
- 42. © 2013 Santa Clara Valley Health & Hospital System | 46
- 43. Example #4: Ln # 21R-For Organisms Do not report AMP and AMP/SULB 217 Group Rule Condition Report Enterobacteriaceae group 198324 Ampicillin is (S or I or R) Don’t report Ampicillin and Ampicillin/Sulbactam Intrinsic rules specific to a subset of organisms within a group © 2013 Santa Clara Valley Health & Hospital System | 47
- 44. © 2013 Santa Clara Valley Health & Hospital System | 48
- 45. Example #4: Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB 218 Group Rule Condition Report Enterobacteriaceae group 198326 Ampicillin is ( I or R) Don’t report Ampicillin Report Ampicillin/Sulbactam Intrinsic rules specific to a subset of organisms within a group © 2013 Santa Clara Valley Health & Hospital System | 49
- 46. © 2013 Santa Clara Valley Health & Hospital System | 50
- 47. Example #4: Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB 219 Group Rule Condition Report Enterobacteriaceae group 195962 Ampicillin is ( I or R) Report Ampicillin Report Ampicillin/ Sulbactam Cascading rules for remaining organisms within a group © 2013 Santa Clara Valley Health & Hospital System | 51
- 48. © 2013 Santa Clara Valley Health & Hospital System | 52
- 49. Ln # 221Q-Group EBACT Urine isolate, Do not report AMP/SULB if AMP is S or I or R 216 Group Rule Condition Report Enterobacteriaceae group 195978 Amp/Sulbactam (S or I or R) Don’t report Ampicillin/Sulbactam Ln # Ln # 21R-For Organisms Do not report AMP and AMP/SULB 217 Group Rule Condition Report Enterobacteriaceae group 198324 Ampicillin (S or I or R) Don’t report Ampicillin and Ampicillin/Sulbactam Ln # 21S-IR Organisms Do not report AMP but report AMP/SULB 218 Group Rule Condition Report Enterobacteriaceae group 198326 Ampicillin (I or R) Don’t report Ampicillin, Report Ampicillin/Sulbactam 21S-IR Organisms Do not report AMP but report AMP/SULB 219 Group Rule Condition Report Enterobacteriaceae group 195962 Ampicillin (I or R) Report Ampicillin and Ampicillin/Sulbactam © 2013 Santa Clara Valley Health & Hospital System | 53
- 50. Rules (CER) © 2013 Santa Clara Valley Health & Hospital System | 54 Rules (CER)
- 51. Rules Used in Preference & Cascading •CER rules usage dependent on: • Antibiotic interpretations • Specimen types • Specimen sources • Patient age • Specific organism, genus or organism group © 2013 Santa Clara Valley Health & Hospital System | 55
- 52. Example #1: Rule evaluating antibiotic interpretation and specimen types + 23 additional Sources + 24 additional Types © 2013 Santa Clara Valley Health & Hospital System | 56
- 53. Example #2: Rule evaluating patient age & specimen types © 2013 Santa Clara Valley Health & Hospital System | 57
- 54. Example #3: Rule used with susceptibility test © 2013 Santa Clara Valley Health & Hospital System | 58
- 55. Rule grouping organismsExample #4: © 2013 Santa Clara Valley Health & Hospital System | 59
- 56. Applying Comments with Cascading © 2013 Santa Clara Valley Health & Hospital System | 60 Comments
- 57. Comments used in preference & cascading • Comments applied via preference and cascading rules: • Antibiotics • Organisms • Using a rule (CER)and mnemonic (OVD) to reflex comments: • Culture test (OVT) • Susceptibility test (OVT) © 2013 Santa Clara Valley Health & Hospital System | 61
- 58. Appending Comments Organism comment Antibiotic comment © 2013 Santa Clara Valley Health & Hospital System | 62
- 59. Example #1: Applying comments in culture test(s) © 2013 Santa Clara Valley Health & Hospital System | 63
- 60. © 2013 Santa Clara Valley Health & Hospital System | 64
- 61. Example #2: Applying comments in susceptibility test(s) © 2013 Santa Clara Valley Health & Hospital System | 65
- 62. © 2013 Santa Clara Valley Health & Hospital System | 66
- 63. Lessons Learned © 2013 Santa Clara Valley Health & Hospital System | 67 • Decide early if a consolidated rule structure is right for you • Strategize early on prioritization of rules and comments • Allow time for multiple rounds of testing with cascading rules • Monitor cascading rules for some time after go-live
- 64. Summary © 2013 Santa Clara Valley Health & Hospital System | 68 • Easier maintenance, troubleshooting and support in Beaker • CLSI standard updates only need to be applied in Beaker • Minimal impact when lab replaces susceptibility instruments Advantages of a Consolidated Rule Structure
- 65. Questions? Simplicity is the soul of efficiency © 2013 Santa Clara Valley Health & Hospital System | 69 ―Austin Freeman
- 66. Contacts • Contact information: • Sharmila Pramanik, MD sharmila.pramanik@hhs.sccgov.org • Poorva Desai, CLS/Beaker Analyst poorva.desai@hhs.sccgov.org © 2013 Santa Clara Valley Health & Hospital System | 70
Editor's Notes
- We will be presenting on the of topic Efficiency in Preference and Cascading Rules for Microbiology
- During this presentation we will look at the overview of Santa Clara Valley Medical Center , Review various microbiology specific rule types, advantages of consolidated cascading rule structure and deep dive into technical build with examples.
- Among other services listed above Santa Clara Valley Medical Center houses a Burn center and a Trauma center. We are a 574 bed facility with 16 outlying clinics
- Laboratory processes over two million test per year and out of that about 345 thousand tests are processed by Microbiology department. Currently we are on version 201 for Epic inpatient and ambulatory as well as Beaker. We implemented Beaker on July 2015.
- My name is Poorva Desai, some background on myself. I am a Clinical laboratory scientist but had never worked in microbiology so when I started with Beaker Microbiology build Intrinsic resistance and cascading rules were very unfamiliar territory for me. With great help from Dr.Deak the microbiologist I worked with, I was able to understand and implement this great task. To start the presentation, first I would like to take you back when we were in the midst of implementing Beaker and what type of questions were coming up before we approached the cascading build for microbiology. Questions like: What is the most efficient way to setup cascading rules? What are the disadvantages of distributed cascading structure, where some rules are in Microscan and some rules may be are in Beaker. What would be the advantages if all microbiology rules were built in Beaker and is this possible? These kinds of questions lead us to find a creative way to define cascading rules at our institution.
- A Physician places the order, specimen is collected and the specimen is sent to the lab.
- In lab, specimen is received in Beaker
- And this triggers the orders to go out to the instrument for processing
- Once the analysis is complete the results are sent from the instrument to Beaker.
- From there the results travel to the patient chart.
- This was a more generic data flow now lets look at the Micro susceptibility specific workflow: Culture order is placed, sample collected and received and the Culture setup is setup Next the Organism is isolated and Susceptibility test is ordered When the Results travel back Some rules may evaluated at the instrument level Next the Susceptibility result files into Beaker Preference rules are evaluated Depending on the preference rules, cascading rules are triggered
- Lets look at different rules we encounter with microbiology build. Instrument limitation rules are instrument specific, where particular antibiotics is not reliable with the micro broth dilution method (MIC) and thus should not be report to the chart. For example Microscan has limitation with Emipenem against Proteus species. Intrinsic rules are where the organism is genetically resistant to certain antibiotics. So whether the instrument reports susceptible, intermediate or resistant this antibiotic should never be used to treat for this organism. Example Ampicillin with - Kleb pneumo. Again these antibiotics should not report to the chart. Preference rules are where we define the reporting of the primary antibiotics appropriate for that organism or group. Override rules are special situation where the primary antibiotic is susceptible but the cascading antibiotics are intermediate or resistant. In this case it is very important to report both primary and secondary antibiotics just in case the provider preventively started the patient on secondary antibiotics which are in this case not appropriate for treatment. Cascading rules are triggered based on the interpretations of the primary antibiotics. Usually these are second or third generation drugs that should only be used when primary antibiotics are intermediate or resistant or in special circumstances. So these are the different type of rule we have to consider when planning for microbiology build. Now lets take a look at traditionally how and where these rules are built.
- Distributed Rules Structure: Traditionally in many organizations the layout of these rules are as above: The antibiotics limitations with a specific instrument is defined on the instrument Intrinsic rules usually defined on the instrument as well Preference rules and cascading rules usually defined in Beaker
- In general we found two major disadvantages of the distributed rule structure: Maintenance of rules in two system would be very inefficient and Second, in future if the susceptibility instrument was replaced there would be major work effort required to redefine and retest all rules again in the new instrument.
- Beaker specific hurdles mainly involved scarcity of build information: Found very limited information on how to set up preference and cascading rules, how to append comments and build CER rules for Microbiology specific scenarios Setting up preference and cascading rules Applying comments from preference and cascading rules Usage of mnemonics for comments for microbiology scenarios Developing rules (CER) for microbiology scenarios There are some variations on how the CLSI standards are interpreted but it would be great to have some model build available for customers so not everyone has to start from scratch Also each line of the preference rule and cascading rules is currently built manually and many times you are building the same info multiple times so it would be great to have a function to copy a line within cascading and preference rules.
- Considering the disadvantages our creative brains lead us to develop a consolidated rules structure, where we built majority of the microbiology specific rule in Beaker.
- Now lets look at the advantages of the consolidated rule structure and its advantages: Since majority of rules are housed in Beaker it leads to Easier maintenance, troubleshooting and support in Beaker CLSI standard updates only need to be applied in Beaker Minimal impact when lab replaces susceptibility instruments
- We looked at the advantages of the consolidated rule structure now lets look at it in more detail with Deep dive into the build with examples
- There are many records that are utilized in the cascading and preference rule setup, here is an overview of few of the important records: LLO records are the organism and organism groups that are built in Beaker MAC record the Interface build for microbiology susceptibilities Next we have the preference and cascading rule definitions And with preference and cascading rules we utilize many types of CER rules.
- Let’s take a look at the susceptibility interface items:
- Two key items defined in susceptibilities interface build are interface type and result checking.
- The interface type for the susceptibility instrument (MAC) record should be micro isolation Second deselect the Result checking in the MAC record. This will then ensure all interpretation of the intrinsic rules, preference rules and cascading rules occur in Beaker.
- Next lets discuss the prioritization of preference rules
- As we said before the preference rules focus on the reporting of preliminary antibiotics for specific organism/genus or group The preference rules evaluation is multilayered and involves line dependency. System looks at the Organism, specimen type and source columns and evaluates from most specific to least specific. Next system will look to the CER rule and performs the action if there are matches . The challenge is how to priorities the lines in preference and cascading rules so the outcome you want becomes possible
- Here I include some suggestions of prioritizing the preference rules.
- Example#1: Building multiple lines listing actions for different specimen type and source in preference and cascading rules can be inefficient. A better option is to build CER rules to handle criteria like specimen types, age and antibiotics interpretations and imbed the CER rules into preference and cascading rules. Here you see two lines where the organism, specimen type and source are not defined so the action will apply to all organism, all specimen type and all source. Here the system will evaluate line 1 and then line 2 in this order looking at the CER rule since all the other criteria is same and perform necessary action.
- Very often the CLSI standard separates the reporting of the preliminary antibiotics based on specimen types. Usually the biggest differentiation is specimen type Urine vs Non-Urines. It may be easier to build two line to handle this in the preference rules. Line 67 was setup to handle urine specimen types via the rule 195978. Line 67 specify if specimen type is urine for EKPM group report Nitrofurantoin and Cefazolin.
- The rule we used specifies specimen type of urine
- Next line 68 is built to handle non-urine specimen types. Here for group EKPM where specimen type is non- urine we are suppressing Nitrofurantoin and Cefazolin Line 67 is very specific since only applies to specimen type urine and then line 68 less specific to handle reporting for all other specimen types. This type of build allows flexibilities to suppress or report antibiotics based on specimen type and it also helps to simplifies the cascading rule later.
- Next let’s look at prioritization of Cascading rules.
- Cascading rules focus on additional antibiotics that can be reported depending on the interpretations of the primary antibiotics. Cascading rules evaluation is also multilayered and involves line dependency. System evaluates from most specific to least specific and performs the action if there are matches. Here are some suggestions for prioritizing cascading rules.
- There is a key item 51590 on the Cascading rules definitions, it is important to have this checked if you want to override the preference rules with the cascading rules.
- In this example Proteus Vulgaris has unique requirement within its group so I built a separate line to address this to define intrinsic resistance.
- In other cases a group of organisms may have similar intrinsic rule requirements.
- In this rule we bring together the organisms with similar intrinsic resistance via this CER rule
- Example # 3 displays the Override rules definition. Again override rules focus on a special situation where the primary antibiotic is susceptible but the secondary antibiotic is intermediate or resistant. Line 201 is an example where we use the CER rule to define if patient age is >11yrs and if Cefepime which is the primary drug is S and secondary drug Ciprofloxacin is I or R then report both Cefepime and Ciprofloxacin.
- Example #4 is a more complex scenario where multiple line were defined to handle the different reporting requirement within the group Enterobacteriaceae group. (Not E.coli, Klebsiella spp, P. mirabillis, salmonella spp and Shigellas spp)
- At one glance here are the four lines setup to handle this scenario. Let’s look at each line in more detail
- For group Enterobacteriaceae Ampicillin is a primary antibiotics and should always be reported. Also if Ampicillin is “I” or “R” it should cascade and report Ampicillin-sulbactam. One exception is if specimen type is urine. For urines we only want to report Ampicillin as primary and there is no further cascading (to Amp-sulbactam). We address this in line 216 via a CER rule where if specimen type is urine for group Enterobacteriaceae we do not report Amp-sulbactam
- Here is the CER rule we used specifying urine as specimen type.
- In this example within the Enterobacteriaceae group there two subset of organisms where the intrinsic resistance is slightly different. If we review line 217 we see that a subset of organism within the Enterobacteriaceae group is intrinsically resistant to Ampicillin and Amp-Sulbactam.
- In this rule we bring together the organisms with similar intrinsic resistance via this CER rule
- Next, Line 218 address the second subset of organisms that are only intrinsically resistant to Ampicillin. So for this group of organisms we stop Ampicillin from reporting but report the Amp-sulbactam.
- Again we use the CER rule to group these organisms
- And lastly the line 219 we define if specimen type not urine and for all other organism in group Enterobacteriaceae report both Ampicillin and Amp-sulbactam when Ampicillin is I or R.
- The CER rule specified Not equal to urine specimen types”
- So as you can see in this example we went from very specific down to non specific via prioritization of the cascading rules using many types of CER rules . Basically one has to experiment and prioritize the cascading rules to the outcome one desires.
- Now lets look at CER rules we use with micro specific scenarios.
- These are the various situation where CER rules prove to be efficient for many micro scenarios.
- This is an example of Suppressing / reporting of antibiotic based on interpretations and specimen type In this rule we define if Vancomycin is Intermediate or Resistant and the specimen type is sterile body sites then perform a specific action. This rule was used to reflex a comment from a susceptibility test.
- This rule was used in preference and cascading rule to report an antibiotic where the patient age is greater than 11 years and specimen type is urine.
- Following is an example of a rule used with susceptibility OVT to report a comment only when the genus is Enterococcus and Penicillin interpretation is susceptible.
- Example 4 is where we grouped the organisms to trigger similar cascading
- Comments play an integral part in microbiology reporting
- Few options to append comments: Via the preference and cascading rules Use the culture and susceptibility tests linked to a CER rule and a mnemonic (OVD) to append comments
- Preference rules and cascading rules have fields where one can attach the organism related and antibiotics related comments. This proves to be a very inefficient build that make troubleshooting very tedious but may be applicable for some scenarios.
- We mostly used the second method to append micro specific comments via the culture and susceptibility tests (OVTs) In this example the culture test was used to reflex a comments.
- In example 2 we used the susceptibility test to reflex a comment via associated mnemonic if rule 198157 is true
- The rule specifies if organism is Enterococcus faecalis and ESBL facalis and Ampicillin is susceptible then append the comment form the associated mnemonic.
- I would like to mention some lessons learned during our implementation. In course of the cascading build we built about 72 line to handle the preference rules and about 262 line to handle the cascading and override rules. If possible you want to get a head start on making the decision if you want to take advantage of the consolidated rule structure and handle all rule types in Beaker. Review the CLSI standards and work with the microbiologist at your institution and strategies on what types of cascading you will need. Strategize how many comments you want to appended and how you what to append them Although it is literary impossible to test every single situation ,allow plenty of time for multiple rounds of testing the cascading. Another great idea we used is for one month after the go live the micro techs compared the manual copy of Microscan results to Beaker and monitored that cascading happened appropriately
- The message I want to leave you with is no need to be intimidated with Beaker Microbiology build If a non-microbiologist who was a new the topic of cascading can achieve it you can definitely achieve it. Finally I want to leave you with the advantages of Consolidated Cascading Rule Structure and open the floor to questions.
- Include services we’ve rolled out to