Novel Multidisciplinary Approach for Outpatient Antimicrobial Stewardship Using an Emergency Department Follow-Up Program

Purpose: Outpatient antimicrobial stewardship programs (ASPs) are becoming increasingly prevalent in healthcare. Many programs have demonstrated the effectiveness of pharmacist-driven outpatient consultations or follow-up programs to ensure appropriate antimicrobial prescribing. However, there is a paucity of literature describing multidisciplinary approaches in large healthcare systems for patients discharged from the emergency department (ED). The objective of this study was to describe the feasibility and impact of a combined effort between ASP pharmacotherapy specialists and nurse practitioners (NPs) in managing an ED follow-up center. Methods: A retrospective analysis was conducted for patients discharged from the ED between January 2018 and June 2019. Patients were identified for inclusion based on documentation by ASP pharmacotherapy specialists in the electronic health record for patient-specific inquiries from ED follow-up center NPs. The primary outcome of this study was to describe the number and types of interventions made by ASP pharmacotherapy specialists. Results: A total of 1088 patients were included in the study, for 1114 documented ASP calls. The urinary tract was the most common source of positive culture (79%), and third-generation cephalosporins were the most frequent antibiotic associated with calls (20%). Out of total calls, 60% lead to ASP interventions. Among total calls, the most frequent interventions were to correct drug-bug mismatches (20%), initiate new therapy (10%), and discontinue therapy (7%). Conclusion: This report describes a novel initiative that combines the efforts of ED NPs and ASP pharmacotherapy specialists in managing an ED follow-up center at a large healthcare system.

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Pharmacist-Managed Antimicrobial Stewardship Program for Patients Discharged From the Emergency Department

Journal of Pharmacy Practice ◽

10.1177/0897190011420160 ◽

2011 ◽

Vol 25 (2) ◽

pp. 190-194 ◽

Cited By ~ 49

Author(s):

Stephanie N. Baker ◽

Nicole M. Acquisto ◽

Elizabeth Dodds Ashley ◽

Rollin J. Fairbanks ◽

Suzanne E. Beamish ◽

...

Keyword(s):

Emergency Department ◽

Median Time ◽

Antimicrobial Stewardship ◽

Positive Culture ◽

Inpatient Setting ◽

Antimicrobial Stewardship Program ◽

Retrospective Case ◽

Stewardship Program ◽

Control Study

Positive outcomes of antimicrobial stewardship programs in the inpatient setting are well documented, but the benefits for patients not admitted to the hospital remain less clear. This report describes a retrospective case–control study of patients discharged from the emergency department (ED) with subsequent positive cultures conducted to determine whether integrating antimicrobial stewardship responsibilities into practice of the emergency medicine clinical pharmacist (EPh) decreased times to positive culture follow-up, patient or primary care provider (PCP) notification, and appropriateness of antimicrobial therapy. Pre- and post-implementation groups of an EPh-managed antimicrobial stewardship program were compared. Positive cultures were identified in 177 patients, 104 and 73 in pre- and post-implementation groups, respectively. Median time to culture review in the pre-implementation group was 3 days (range 1-15) and 2 days (range 0-4) in the post-implementation group ( P = .0001). There were 74 (71.2%) and 36 (49.3%) positive cultures that required notification in the pre- and post-implementation groups, respectively, and the median time to patient or PCP notification was 3 days (range 1-9) and 2 days (range 0-4) in the 2 groups ( P = .01). No difference was seen in the appropriateness of therapy. In conclusion, EPh involvement reduced time to positive culture review and time to patient or PCP notification when indicated.

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Abstract P229: Is a Multidisciplinary Approach to Hypertension Better Than Traditional Care in Female Hypertensive Patients?

Hypertension ◽

10.1161/hyp.66.suppl_1.p229 ◽

2015 ◽

Vol 66 (suppl_1) ◽

Author(s):

Jessica A Weber ◽

Shital C Shah ◽

Sara Turley ◽

Lynne T Braun ◽

Erica R Kent ◽

...

Keyword(s):

Nurse Practitioners ◽

Multidisciplinary Approach ◽

Smoking Status ◽

Bivariate Analysis ◽

Standard Practice ◽

Personalized Care ◽

Moderating Variables ◽

Care Plans ◽

Treatment Type

Background: Rush Heart Center for Women (RHCW) opened in October 2003 to provide a multidisciplinary approach (MDA) for female patients (pts). RHCW provided personalized care plans to address women’s heart health, with an emphasis on female-specific risk factors and symptoms. MDA including cardiologists, dietitians and nurse practitioners to treat female pts was compared to a similar cohort using standard practice in terms of HTN treatment. Methods: A retrospective study identified pts with HTN treated at RHCW using a MDA and compared to a cohort of pts treated by cardiologists and received a standard level of care consistent with guidelines and recommendations (standard practice). Pts seen between 2008 and 2014 with at least 2 visits between 9 and 15 months apart were studied. Demographic moderating variables were race, age, and insurance. Moderating clinical variables were baseline systolic BP, body mass index, diabetes, smoking status, history of coronary disease, stroke, and prior treatment of HTN. Bivariate and multivariate analyses were conducted to determine the effect of treatment type, with pts’ follow-up BP. Results: A total of 1486 pts were evaluated. Pts seen treated by MDA was younger by <3 years. Table shows descriptive statistics and bivariate analysis. Multivariate analysis revealed that pts treated with MDA had a significantly lower BP in their follow-up systolic BP, 3.8 mmHg less, compared to pts treated with standard practice. (p<0.002). Conclusion: The multidisciplinary approach had better BP control in female hypertensive pts. Prospective studies comparing MDA to standard practice may help to assess improved quality of life, compliance and outcomes.

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183. Optimization of an Outpatient Antimicrobial Stewardship Process for Patients Discharged from the Emergency Department at an Academic Medical Center

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.227 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S98-S98

Author(s):

Hannah Kafisheh ◽

Matthew Hinton ◽

Amanda Binkley ◽

Christo Cimino ◽

Christopher Edwards

Keyword(s):

Emergency Department ◽

Antimicrobial Stewardship ◽

Antimicrobial Therapy ◽

Medical Center ◽

Academic Medical Center ◽

Positive Culture ◽

Culture Result ◽

Academic Medical ◽

Positive Culture Result ◽

Therapy Modification

Abstract Background Suboptimal antimicrobial therapy has resulted in the emergence of multi-drug resistant organisms. The objective of this study was to optimize the time to antimicrobial therapy modification for patients discharged from the emergency department (ED) of an academic medical center through implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative (ASI). Methods This was a pre-post, quasi-experimental study that evaluated the impact of a pharmacist-driven outpatient antimicrobial stewardship initiative at a single academic medical center. The pre-cohort was evaluated through manual electronic medical record (EMR) review, while the post-cohort involved a real-time notification alert system through an electronic clinical surveillance application. The difference in time from positive culture result to antimicrobial therapy optimization before and after implementation of the pharmacist-driven ASI was collected and analyzed. Results A total of 166 cultures were included in the analysis. Of these, 12/72 (16%) in the pre-cohort and 11/94 (12%) in the post-cohort required antimicrobial therapy modification, with a 21.9-hour reduction in median time from positive culture result to antimicrobial optimization in the post-cohort (43 h vs. 21.1 h; p < 0.01). Similarly, the median time from positive culture result to review was reduced by 20 hours with pharmacist-driven intervention (21.1 h vs. 1.4 h; p < 0.01). Conclusion The implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative resulted in a significant reduction in time to positive culture review and therapy optimization for patients discharged from the ED of an academic medical center set in Philadelphia, PA. Disclosures All Authors: No reported disclosures

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P024: Obtaining consensus on optimal management and follow-up of patients presenting to the emergency department with early pregnancy complications – a modified Delphi study

CJEM ◽

10.1017/cem.2019.215 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S71-S72

Author(s):

A. Cornelis ◽

R. Clouston ◽

P. Atkinson

Keyword(s):

Emergency Department ◽

Family Medicine ◽

Nurse Practitioners ◽

Early Pregnancy ◽

Pregnancy Complications ◽

Delphi Study ◽

Pregnancy Loss ◽

Early Pregnancy Loss ◽

Modified Delphi

Introduction: Complications in early pregnancy are common and have many physical and emotional consequences. Locally, there is no early pregnancy loss clinic or standardized guide in the emergency department (ED) for referral and follow-up decisions, and both initial management of patients and follow up can be inconsistent. This study aimed to obtain consensus on the best approach to initial work-up, management, and follow up for patients who present to the ED with early pregnancy complications, with the goal of using this consensus to produce a standardized guide for emergency provider use. Methods: A literature review was completed to produce evidence-based recommendations which were used to initiate a modified Delphi consensus process. A survey was distributed, with three rounds completed. Participants included emergency providers, obstetrician-gynecologists, a radiologist, a sample of family medicine physicians including some involved in primary care obstetrics, and nurse practitioners. An obstetric specialist from outside the local region was also involved. Results: Consensus was reached on several key recommendations, however some areas remained without clear accepted best practice. There was consensus that physical components of early pregnancy complications are addressed well, but that we could improve on patient flow and more consistent follow up. Important investigations to be done for patients were identified. The timing of formal ultrasound, necessity and timing of obstetrician consultation, and safety of discharge was addressed for various patient scenarios including stable and unstable patients, with and without adnexal pain, with intrauterine pregnancy of uncertain viability, and with pregnancy of unknown location. Management of confirmed early pregnancy loss in the ED and family medicine clinics was addressed. Barriers to an early pregnancy loss clinic included lack of funding, space, and staffing as well as lack of resources and uncertain patient volumes. A feasible alternative to an early pregnancy loss clinic was for willing providers to keep appointment times available to facilitate confirmation of follow-up prior to discharge. Other suggested alternatives included an early pregnancy loss clinic, a nurse educator, and having a standardized guideline in the ED. Conclusion: Through a consensus approach, several recommendations were agreed upon for improving care for patients presenting to the ED with early pregnancy complications.

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P137: Automation of follow-up microbiology culture results in patients discharged from the emergency department

CJEM ◽

10.1017/cem.2018.335 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S105-S106

Author(s):

D. M. Shelton ◽

D. Hefferon ◽

P. Sinclair ◽

Z. Janicijevic

Keyword(s):

Emergency Department ◽

Human Error ◽

Data Entry ◽

Positive Culture ◽

Health Sciences ◽

Optimal Care ◽

Sunnybrook Health ◽

New Process ◽

Mean Time

Introduction: At Sunnybrook Health Sciences Centres Emergency Department (ED), delays occurred in reporting positive microbiology culture results of patients discharged from the ED. Follow-up of culture results was driven by a manual paper based process that was inefficient and resulted in a one to three day delay in reporting results. The previous system was time consuming, labour intensive and prone to human error. Timely reporting of microbiology culture results is important to ensuring that patients receive optimal care. The aim is that >80% of positive microbiology culture results of patients discharged from Sunnybrook Health Sciences Centre ED will be followed-up within 24 hours of results being available from the lab. Methods: Outcome Measure Percentage of positive culture results followed up within 24 hours Process Measure Time from availability of culture results from lab to completion of patient follow-up Balancing Measure Number of positive culture results not displayed in ED server Change Idea Electronically push positive culture results to an ED server that is periodically checked daily and acted upon. An electronic interface was created to capture positive results from the microbiology lab in real time. Results: There was a 45 hour reduction in the mean time to complete a patients follow-up of culture results (59 hours pre vs. 14 hours post, p=0.03). We surpassed our aim of >80% follow-up within 24 hours. Conclusion: A significant reduction to completing a patients follow-up of microbiology culture results was achieved by automating the availability of results and eliminating the manual process previously used in relaying results from the microbiology lab to ED. This new process has the following benefits: 1) Improves timely reporting of culture results to patients, that may require initiation or change in antibiotics 2) Enhanced patient safety due to elimination of human error 3) Decreased workload due to elimination of batching of results and data entry 4) Entire process is streamlined, since only positive culture results are transmitted for follow-up.

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Antimicrobial Stewardship in the Emergency Department

Journal of Pharmacy Practice ◽

10.1177/0897190011400555 ◽

2011 ◽

Vol 24 (2) ◽

pp. 196-202 ◽

Cited By ~ 20

Author(s):

Nicole M. Acquisto ◽

Stephanie N. Baker

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Antimicrobial Stewardship Program ◽

Implementation Outcomes ◽

Stewardship Program ◽

Assessment Skills ◽

Barriers To Implementation

The practice of antimicrobial stewardship can be defined as optimizing clinical outcomes while minimizing the consequences of antimicrobial therapy such as resistance and superinfection. Antimicrobial stewardship can be difficult to transition to the emergency department (ED) since the traditional activities include the evaluation of broad-spectrum antimicrobial regimens at 72 and 96 hours and intravenous to oral medication conversion. The emergency medicine clinical pharmacist (EPh) has the knowledge and clinical assessment skills to manage an antimicrobial stewardship program focused on culture follow-up for patients discharged from the ED. This paper summarizes the experiences of developing an EPh-managed antimicrobial stewardship and culture follow-up program in the ED from 2 separate institutions. Specifically, the focus is on the steps for establishing an EPh-managed antimicrobial stewardship program, a description of the culture follow-up process, managing the culture data and cultures that require emergent notification and review, medical/legal concerns, and barriers to implementation. Outcomes data available from institutions with similar ED based antimicrobial stewardship programs are also discussed.

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Evaluation of Antibiotic Utilization in an Emergency Department After Implementation of an Antimicrobial Stewardship Pharmacist Culture Review Service

Hospital Pharmacy ◽

10.1177/0018578719844171 ◽

2019 ◽

Vol 55 (4) ◽

pp. 261-267

Author(s):

Megan E. Giruzzi ◽

John C. Tawwater ◽

Jennifer L. Grelle

Keyword(s):

Emergency Department ◽

Median Time ◽

Antimicrobial Stewardship ◽

Antimicrobial Therapy ◽

Hospital Readmissions ◽

Positive Culture ◽

Inadequate Antibiotic Therapy ◽

Quasi Experimental ◽

Appropriate Therapy ◽

The Impact

Background: Antimicrobial stewardship programs (ASP) have been widely implemented in hospitals to improve antimicrobial use and prevent resistance. However, the role of ASP in the emergency department (ED) setting is not well defined. Objective: The objective of this study is to evaluate the impact of an ASP pharmacist culture review service in an ED. Methods: This was a retrospective, quasi-experimental study of all patients discharged from the ED with a positive culture. Patients discharged from the ED from February 1, 2015 to October 31, 2015 were managed by ED providers (pre-ASP), and those discharged from February 1, 2016 to October 31, 2016 were managed by a pharmacist-driven ASP (post-ASP implementation). The primary outcome was median time to change of antibiotic(s) in patients with inadequate antimicrobial therapy based on culture results. Secondary outcomes included time to culture evaluation, appropriateness of antimicrobials, and 30-day readmissions. Results: A total of 790 patients were included in the analysis (398 in pre-ASP group vs 392 in post-ASP implementation group). Median time to modification of inadequate antibiotic therapy decreased from 6.79 days in the pre-ASP group to 1.99 days in the post-ASP implementation group ( P < .0001). Median time to culture review decreased in the post-ASP implementation group from 9.83 to 0.32 days ( P < .0001). Appropriateness of culture-guided therapy increased in the post-ASP implementation group from 85.7 to 91.8% ( P = .047). The rate of combined ED revisits and hospital readmissions was similar between groups ( P = .367). Conclusion: ASP pharmacist evaluation of positive cultures in the ED was associated with a significant decrease in the time to appropriate therapy in patients discharged with inadequate therapy and higher rates of appropriate antimicrobial therapy.

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O9 Are parents and patients happy to see an advanced paediatric pharmacist practitioner (APPP)?

Archives of Disease in Childhood ◽

10.1136/archdischild-2019-nppc.9 ◽

2019 ◽

Vol 104 (7) ◽

pp. e2.61-e2

Author(s):

Andrew Lilley

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Nurse Practitioners ◽

Clinical Skills ◽

List Type ◽

Parent Perception ◽

Hospital Environments ◽

Graduate Certificate ◽

Better Than

IntroductionPharmacist independent prescribers have become common in both community and hospital environments. However most prescribing courses contain limited clinical skills and diagnosis training.1 2 NHS England conducted a study to assess the benefit of having pharmacists in the Emergency department (ED). They found that in order to have the biggest impact pharmacists would need additional training above that of an independent prescriber particularly clinical examination and diagnosis skills.3 One pharmacist from the audit hospital completed the post graduate certificate in Advanced Emergency Medicine at Manchester University. The assessments taught included Respiratory, Gastroenterology, Musculoskeletal, Neurological and ENT examinations.Additionally, it required 210 hours of in practice training. On completion of the course the local centre had no resources to appoint an APPP in ED. Instead the APPP took up the role within the respiratory team due to experience within this speciality. An APPP now reviews new and follow up patients in clinic as well as those acutely ill. As this was a new role it was decided to perform an audit of parent perception of the role.MethodsQuestions were integrated into every consultation for a two month period. Pre clinic: Are you happy to see the pharmacist today instead of the consultant? (Yes/No/Will wait to see outcome) Post clinic: Did you think a pharmacist could perform this role? (Yes/No). Do you feel like you need to see the consultant still? (Yes/No) Were you happy with the consultation? (Yes/No) Further commentsResults132 separate consultations were included. 45 of these were new referrals, 67 were follow up appointments and 20 acute examinations. In 124 consultations parents stated they would decide if they needed to see the consultant after. Of these all were happy with the outcome post consultation and did not see the consultant. 9 parents had no reservations to the pharmacist running the consultation from the outset and remained happy post consultation. 126 stated they did not realise a pharmacist could perform this role. Comments received included ‘I had no idea a pharmacist could perform clinical examinations’; ‘At first I had reservations however if the hospital felt comfortable with you running clinic I am happy’; ‘You took the time to make us feel at ease’; ‘You are always approachable when my child is acutely unwell…you know our child better than any ED doctor and would rather see you’.ConclusionAs with Advanced Nurse Practitioners (ANPs) it will take time for parents and patients to adapt to a pharmacist diagnosing and managing them instead of a doctor. This audit has shown the pre-conceptions of what a pharmacist can do could hold some back; however after seeing the pharmacist all were happy with the consultation. This is an exciting new role for pharmacists however it is essential to undertake advanced clinical and diagnosis skills in order to make it a successful.Referenceshttp://www.edgehill.ac.uk/health/cpd-modules/non-medical-prescribing-v300-2 (accessed June 2018)https://www.ljmu.ac.uk/study/cpd/other-cpd-courses/non-medical-prescribing (accessed June 2018)Pharmacists in Emergency Departments - A commissioned study by health education England. available via: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy%20statements/PIED%20National%20Report.pdf?ver=2016-10-13-150131-640

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A protocol for telemedical consultation

Journal of Telemedicine and Telecare ◽

10.1258/1357633971931084 ◽

1997 ◽

Vol 3 (3) ◽

pp. 163-168 ◽

Cited By ~ 10

Author(s):

S Tachakra ◽

A Sivakumar ◽

J Hayes ◽

M Dawood

Keyword(s):

Emergency Department ◽

Nurse Practitioners ◽

Depth Perception ◽

Record Keeping ◽

Face To Face ◽

Main Hospital ◽

Accident And Emergency ◽

Specialist Referral ◽

Accident And Emergency Department

We have developed a protocol for telemedical consultations. This has been used by emergency nurse practitioners to consult doctors in a main hospital accident and emergency department, using videoconferencing at 384kbit s. A telemedical consultation should simulate a face-to-face one. The protocol starts with an explanation for the patient of what will happen, followed by the necessary introductions. After relaying the history, the generalist should show the abnormal part to the specialist. Attention should be paid to colour. Depth perception is often enhanced by rotating the camera through 180 . The diagnosis and management, together with their implications, should be discussed with the patient by the specialist. Referral and follow-up should also be discussed. Proper clinical record-keeping is essential. In the first 15 months of using the protocol, we completed more than 300 teleconsultations. An analysis of the first 50 teleconsultations showed that about half were for discussing a radiograph and about half were for examining a patient.

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Implementation of an emergency department–based clinical pharmacist transitions-of-care program

American Journal of Health-System Pharmacy ◽

10.2146/ajhp150511 ◽

2016 ◽

Vol 73 (15) ◽

pp. 1180-1187 ◽

Cited By ~ 6

Author(s):

Elizabeth Hohner ◽

Melinda Ortmann ◽

Umbreen Murtaza ◽

Sheeva Chopra ◽

Patricia A. Ross ◽

...

Keyword(s):

Emergency Department ◽

Ambulatory Care ◽

Clinical Pharmacist ◽

Intervention Program ◽

Transitions Of Care ◽

Patient Specific ◽

Chronic Obstructive ◽

Ambulatory Care Setting ◽

Home Based

Abstract Purpose The implementation of an emergency department (ED)–based clinical pharmacist transitions-of-care (TOC) program is described. Summary The intervention program consisted of collaboration between ED and ambulatory care pharmacists to provide patient-specific comprehensive medication review and education in the ED setting and to help ensure a coordinated transition to the ambulatory care setting by scheduling an ambulatory pharmacy clinic or home-based visit. Patients who sought care at an adult ED for an exacerbation of asthma, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF) were assessed for issues with medication adherence or administration technique, patient-specific concerns regarding medication use, access to medications at discharge, the need for modification of chronic therapy, contraindicated medications, and vaccination status, if applicable. The pharmacist then referred the patient to follow up in an ambulatory care pharmacy clinic or with the home-based medication management (HBMM) program. Of the 18 program participants who were referred to follow-up care, 5 successfully followed up with a pharmacist after ED discharge. The mean time from the ED visit to follow-up for these 5 patients was 16.6 ± 8.6 days. In addition, 5 patients followed up with their primary care provider within 30 days of the initial ED visit; 2 of these patients also followed up with a pharmacist. Within 30 days of the initial ED encounter, 4 patients had ED revisits. Conclusion A TOC pharmacist-led program targeting patients who arrived at the ED with the chief complaint of asthma exacerbation, COPD, or CHF provided interventions from an ED or ambulatory care pharmacist as well as follow-up opportunities at outpatient clinics or an HBMM program.

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