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

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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.


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.


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.


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.

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