Four Moments of Antibiotic Decision Making
The Four Moments of Antibiotic Decision Making are the critical time periods of antibiotic decision making. Frontline staff and prescribing clinicians are encouraged to use the Four Moments framework for all residents whenever the need for antibiotics is being considered and for those who receive antibiotics.
Four Moments Questions
Moment 1 occurs when a resident is assessed for a change in status and there is a concern for infection. Sometimes long-term care staff recognize that something is not quite right with the resident but aren’t clear on what is wrong. The person doing the assessment should pause and consider if the changes they are noticing really suggest an infection rather than another cause.
Moment 2 occurs immediately after the decision is made to prescribe antibiotics.
First, what type of infection does the resident have? The resident should have appropriate cultures ordered and obtained before starting antibiotics.
Second, what empiric antibiotics should be started? The prescriber should choose an antibiotic that covers the most likely pathogens
Moment 3 occurs at the time the prescriber writes the order for antibiotics. Make sure the type of infection being treated, such as urinary tract infection or bacterial pneumonia, and an antibiotic stop date written as a calendar date, like October 15, 2020, are included in every order.
Moment 4 occurs every day the resident receives antibiotics. Nurses and prescribers should ask if the resident still needs antibiotics. If so, can an antibiotic with a narrower spectrum or with fewer side effects be used instead? If the resident is getting an intravenous antibiotic, can they get an oral antibiotic instead?
Implementation of the Four Moments
Integrating the Four Moments into daily practice for frontline staff and prescribing clinicians should lead to improved antibiotic use and enhanced patient safety. Several actions can be taken to integrate the Four Moments into the culture of your institution.
Posters can be reproduced for posting in common areas and work stations. These can also be shared with prescribing clinicians as well as residents and their family members.
The Antibiotic Stewardship Team is encouraged to use Four Moments of Antibiotic Decision Making Form to review 5–10 residents each month. The residents reviewed should be individuals who are being evaluated for or treated for an infection.