Evaluating the Addition of a Clinical Pharmacist Service to a Midlevel Provider-Driven Culture Follow-up Program in a Community Emergency Department

2021 ◽  
pp. 875512252110003
Author(s):  
Rebecca Ann Rainess ◽  
Vishal V. Patel ◽  
Joseph Brian Cavanaugh ◽  
Jessica Hill
Keyword(s):  
Emergency Department ◽  
Antimicrobial Therapy ◽  
Clinical Pharmacist ◽  
Antimicrobial Stewardship Program ◽  
Implementation Phase ◽  
Stewardship Program ◽  
Secondary Outcomes ◽  
The Impact ◽  
Antibiotic Dose

Background: The impact that an antimicrobial stewardship program can have on an inpatient setting has been well documented, but there are limited data on the use of an antimicrobial stewardship program in the emergency department (ED). Objective: The objective of this study was to assess the impact of adding a pharmacist service to a midlevel provider-driven culture follow-up program in the ED on achieving optimal therapy. Methods: This was a quasi-experimental study with designations of pre- and post-interventions conducted at a large community hospital with the pre-intervention phase occurring from June 1, 2019, to August 31, 2019, and the post-intervention phase occurring from January 1, 2020, to March 31, 2020. The primary outcome was optimal antimicrobial therapy: a composite of optimal antibiotic, dose, and duration, prescribed after the culture resulted. Secondary outcomes included optimal antibiotic, dose, duration, and return to the ED within 30 days due to infection. Results: Optimal antimicrobial therapy received after the culture resulted occurred in 59 patients (26.81%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase ( P = .003). For the secondary outcomes, optimal antibiotic choice occurred in 115 patients (52.27%) in the pre-implementation phase and 66 patients (72.53%) in the implementation phase ( P = .001). Optimal antibiotic dose occurred in 113 patients (51.36%) in the pre-implementation phase and 65 patients (71.43%) in the implementation phase ( P = .001). Optimal antibiotic duration occurred in 65 patients (29.55%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase ( P = .014). Conclusions: The addition of a clinical pharmacist service in a midlevel provider-driven ED culture callback program resulted in an increased rate of achieving optimal antimicrobial therapy.

Evaluation of Early Versus Late Postdischarge Medication Reconciliation on Readmission Rates and Emergency Department Visits

2017 ◽  
Vol 31 (3) ◽  
pp. 279-283 ◽  
Author(s):  
Tina Joseph ◽  
Rebecca A. Barros ◽  
Elise Kim ◽  
Bupendra Shah
Keyword(s):  
Emergency Department ◽  
Clinical Pharmacist ◽  
Medication Reconciliation ◽  
Emergency Department Visits ◽  
Optimal Timing ◽  
Significant Difference ◽  
The Impact ◽  
Late Group ◽  
Hospital Use

Background: The current literature speculates ideal postdischarge follow-up focusing on transitions from hospital to home can range anywhere between 48 hours and 2 weeks. However, there is a lack of evidence regarding the optimal timing of follow-up visit to prevent readmissions. Objective: The purpose of this study is to evaluate the impact of early (<48 hours) versus late (48 hours-14 days) postdischarge medication reconciliation on readmissions and emergency department (ED) use. Methods: In this retrospective study, data for patients who had a clinic visit with a primary care provider (PCP), clinical pharmacist, or both for postdischarge medication reconciliation were reviewed. Primary outcome included hospital use rate at 30 days. Secondary outcomes included hospital use rate at 90 days and hospital use rate with a postdischarge PCP follow-up visit, clinical pharmacist, or both at 30 days. Results: One hundred sixty patients were included in the analysis: 31 early group patients and 129 late group patients. There was no significant difference on hospital use at 30 days in patients who received early or late groups (32.3% vs 21.8%, P = .947). There was also no significant difference on hospital use at 90 days in patients in early versus late group (51.6% vs 50.3%, P = .842). The type of provider (PCP vs pharmacists) conducting postdischarge medication reconciliation did not show significance on hospital use at 30 days (19.9% vs 21.4%, P = .731). Conclusion: Results from this study suggest patients can be seen up to 14 days postdischarge for medication reconciliation with no significant difference on hospital use.

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

2011 ◽  
Vol 25 (2) ◽  
pp. 190-194 ◽  
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.

scholarly journals 1055. Addition of Antimicrobial Stewardship Program Weekend Coverage Increases Interventions while Reducing Antimicrobial Duration and Cost

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S372-S373
Author(s):  
Natasha N Pettit ◽  
Jennifer Pisano ◽  
Cynthia T Nguyen
Keyword(s):  
Antimicrobial Stewardship ◽  
Broad Spectrum ◽  
Total Duration ◽  
Time Frame ◽  
Antimicrobial Stewardship Program ◽  
Clinical Pharmacists ◽  
Duration Of Therapy ◽  
Stewardship Program ◽  
Secondary Outcomes ◽  
The Impact

Abstract Background Expansion of Antimicrobial Stewardship Program (ASP) activities to include coverage of weekends has been shown to facilitate further optimization of antimicrobial usage. Beginning July 2018, we implemented full ASP coverage on weekends from 0700–1530 by infectious diseases (ID) clinical pharmacists and pharmacy residents. We sought to evaluate the impact of the addition of weekend ASP coverage on the number of interventions, antimicrobial duration and cost of target broad-spectrum antimicrobials. Methods Antimicrobials reviewed by ASP on a weekend day between July 14, 2018 and December 16, 2018 were included in the analysis. The primary outcome was the number and type of documented interventions associated with the antimicrobials reviewed. Secondary outcomes included the total duration of meropenem, daptomycin, and micafungin initiated on a weekend, estimated expenditures on these target broad-spectrum antimicrobials, and comparison of the average number of interventions performed per day by ID clinical pharmacists vs. pharmacy residents. For comparison, we also evaluated these secondary outcomes prior to ASP weekend coverage, between July 16, 2017 and December 9, 2017. Results A total of 688 antimicrobials were reviewed on weekend days during the included time-frame with 753 interventions (average number of interventions/day: 37). Table 1 summarizes the type of interventions. The acceptance rate for interventions was 99%. The average number of interventions per day for ID clinical pharmacists vs. pharmacy residents was 57.9 and 26.2, respectively. Table 2 shows the total duration of therapy (DOT) and total expenditures on target antimicrobials before and after ASP weekend coverage. The total DOT of target antimicrobials agents decreased from 21 days to 7 days, with an estimated 3,165 dollar decrease in expenditures during the included time-frame. Conclusion Expansion of ASP coverage to include weekends allowed us to provide 753 interventions over 4 months that would not otherwise have been made when no ASP coverage was available. This was associated with a reduction in broad-spectrum antimicrobial duration of therapy and expenditures when compared with weekends where ASP weekend coverage was not available. Disclosures All authors: No reported disclosures.

Antimicrobial Stewardship in the Emergency Department

2011 ◽  
Vol 24 (2) ◽  
pp. 196-202 ◽  
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.

scholarly journals A Novel Antimicrobial Stewardship Program-Guided Procalcitonin Initiative for Emergency Department Diagnosis of Bacterial Pneumonia in New York City

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S27-S28 ◽  
Author(s):  
George D Rodriguez ◽  
Roman Yashayev ◽  
Bella Yushuvayev ◽  
Anna Kula ◽  
Nathan Warren ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Antimicrobial Stewardship ◽  
Bacterial Pneumonia ◽  
Diagnostic Yield ◽  
Antibiotic Use ◽  
Antimicrobial Stewardship Program ◽  
Stewardship Program ◽  
Tract Infections ◽  
The Impact

Abstract Background An accurate diagnosis of bacterial pneumonia in the Emergency Department (ED) is challenging, resulting in inappropriate antibiotic use, adversely impacting patient care and safety. Procalcitonin (PCT), a serum biomarker, has good positive predictive value for bacterial lower respiratory tract infections. We sought to evaluate the impact of using PCT in an antimicrobial stewardship program (ASP)-driven algorithm to manage patients with presumed pneumonia in the ED. Methods We performed an IRB-approved quality initiative, 4-month retrospective evaluation of adult patients evaluated for pneumonia using PCT in a 515-bed university-affiliated hospital. Initial PCT use was restricted to ED for hemodynamically stable patients with presumed pneumonia. Subsequent PCT levels were ordered by ASP team members at 8- to 12-hours and days 3, 5, and 7 to guide the duration of antibiotic use and interpreted as per existing guidelines. Prior to start of initiative, aggressive education was provided by ASP to ED staff, followed by algorithm implementation. Outcomes included hospital admission, days of antibiotics, antibiotic use ≤48 hours, total PCT levels, length of stay, and 30-day pneumonia readmission. Results Baseline demographics of initial 182 patients differed between negative and positive PCT groups with age (78 vs. 84, P = 0.037) and sexfemale (88 vs. 15, P = 0.001). Negative PCT was associated with lower temperature (P = 0.0002), and white blood cell count (P = 0.0001) on admission (Figure 1). Patients with negative PCT had reduced antibiotic initiation (71% vs. 95%, P = 0.001) and were less likely to be admitted (89% vs. 98%, P = 0.078). A total of 460 PCT levels were collected [negative group: 303, median 2(2,2), positive group: 157, median 4(3,4)]. Patients with negative PCT had reduced antibiotic duration (P &lt; 0.001) and length of stay (P = 0.004) (Figures 2 and 3). There were no reported adverse events or differences in 30-day pneumonia readmissions. Conclusion Implementation of a PCT algorithm through ASP is a novel and efficacious addition to improving diagnostic yield, targeting appropriate therapy, and reducing length of stay. The impact on antibiotic resistance remains to be determined. Disclosures All authors: No reported disclosures.

scholarly journals Cumulative Effect of an Antimicrobial Stewardship and Rapid Diagnostic Testing Bundle on Early Streamlining of Antimicrobial Therapy in Gram-Negative Bloodstream Infections

2017 ◽  
Vol 61 (9) ◽  
Author(s):  
P. B. Bookstaver ◽  
E. B. Nimmich ◽  
T. J. Smith ◽  
J. A. Justo ◽  
J. Kohn ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Phase 1 ◽  
Bloodstream Infections ◽  
Antimicrobial Stewardship Program ◽  
Phase 2 ◽  
Beta Lactams ◽  
Gram Negative ◽  
Stewardship Program ◽  
Tof Ms

ABSTRACT The use of rapid diagnostic tests (RDTs) enhances antimicrobial stewardship program (ASP) interventions in optimization of antimicrobial therapy. This quasi-experimental cohort study evaluated the combined impact of an ASP/RDT bundle on the appropriateness of empirical antimicrobial therapy (EAT) and time to de-escalation of broad-spectrum antimicrobial agents (BSAA) in Gram-negative bloodstream infections (GNBSI). The ASP/RDT bundle consisted of system-wide GNBSI treatment guidelines, prospective stewardship monitoring, and sequential introduction of two RDTs, matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) and the FilmArray blood culture identification (BCID) panel. The preintervention period was January 2010 through December 2013, and the postintervention period followed from January 2014 through June 2015. The postintervention period was conducted in two phases; phase 1 followed the introduction of MALDI-TOF MS, and phase 2 followed the introduction of the FilmArray BCID panel. The interventions resulted in significantly improved appropriateness of EAT (95% versus 91%; P = 0.02). Significant reductions in median time to de-escalation from combination antimicrobial therapy (2.8 versus 1.5 days), antipseudomonal beta-lactams (4.0 versus 2.5 days), and carbapenems (4.0 versus 2.5 days) were observed in the postintervention compared to the preintervention period (P < 0.001 for all). The reduction in median time to de-escalation from combination therapy (1.0 versus 2.0 days; P = 0.03) and antipseudomonal beta-lactams (2.2 versus 2.7 days; P = 0.04) was further augmented during phase 2 compared to phase 1 of the postintervention period. Implementation of an antimicrobial stewardship program and RDT intervention bundle in a multihospital health care system is associated with improved appropriateness of EAT for GNBSI and decreased utilization of BSAA through early de-escalation.

scholarly journals 90. Impact of Discrepant Rapid Diagnostic Test (RDT) Results on Antimicrobial Stewardship Program (ASP) Interventions in Patients with Bloodstream Infections (BSI) due to Gram-Negative Bacilli (GNB)

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S61-S61
Author(s):  
Evan D Robinson ◽  
Heather L Cox ◽  
April E Attai ◽  
Lindsay Donohue ◽  
Megan Shah ◽  
...  
Keyword(s):  
Susceptibility Testing ◽  
Bloodstream Infections ◽  
Standard Of Care ◽  
First Year ◽  
Beta Lactam ◽  
Gram Negative ◽  
Stewardship Program ◽  
Few Data ◽  
The Impact

Abstract Background Implementation of the Accelerate PhenoTM Gram-negative platform (AXDX) paired with ASP intervention projects to improve time to definitive institutional-preferred antimicrobial therapy (IPT). However, few data describe the impact of discrepant RDT results from standard of care (SOC) methods on antimicrobial prescribing. Here we evaluate the prescribing outcomes for discrepant results following the first year of AXDX + ASP implementation. Methods Consecutive, non-duplicate blood cultures for adult inpatients with GNB BSI following combined RDT + ASP intervention were included (July 2018 – July 2019). AXDX results were emailed to the ASP in real time then released into the EMR upon ASP review and communication with the treating team. SOC identification (ID; Vitek® MS/Vitek® 2) and antimicrobial susceptibility testing (AST; Trek SensititreTM) followed RDT as the reference standard. IPT was defined as the narrowest susceptible beta-lactam, and a discrepancy was characterized when there was categorical disagreement between RDT and SOC methods. When IPT by AXDX was found to be non-susceptible on SOC, this was characterized as “false susceptible“. Conversely, “false resistance” was assessed when a narrower-spectrum agent was susceptible by SOC. Results were also deemed discrepant when the AXDX provided no/incorrect ID for on-panel organisms, no AST, or a polymicrobial specimen was missed. Results Sixty-nine of 250 patients (28%) had a discrepancy in organism ID or AST: false resistance (9%), false susceptible (5%), no AST (5%), no ID (4%), incorrect ID (2%), and missed polymicrobial (2%). A prescribing impact occurred in 55% of cases (Table 1), where unnecessarily broad therapy was continued most often. Erroneous escalation (7%) and de-escalation to inactive therapy (7%) occurred less frequently. In-hospital mortality occurred in 4 cases, none of which followed an inappropriate transition to inactive therapy. Conclusion Though the AXDX platform provides rapid ID and AST results, close coordination with Clinical Microbiology and continued ASP follow up are needed to optimize therapy. Although uncommon, the potential for erroneous ASP recommendations to de-escalate to inactive therapy following AXDX results warrants further investigation. Disclosures Amy J. Mathers, MD, D(ABMM), Accelerate Diagnostics (Consultant)

scholarly journals An evaluation of toxigenic Clostridioides difficile positivity as a patient outcome metric of antimicrobial stewardship in Saudi Arabia

2021 ◽  
Author(s):  
Christopher A. Okeahialam ◽  
Ali A. Rabaan ◽  
Albert Bolhuis
Keyword(s):  
Patient Outcome ◽  
Saudi Arabia ◽  
Antimicrobial Stewardship ◽  
Laboratory Data ◽  
Hospitalized Patients ◽  
Antimicrobial Stewardship Program ◽  
Repeated Testing ◽  
Clostridioides Difficile ◽  
Stewardship Program ◽  
The Impact

AbstractBackgroundAntimicrobial stewardship has been associated with a reduction in the incidence of health care associated Clostridium difficile infection (HA-CDI). However, CDI remains under-recognized in many low and middle-income countries where clinical and surveillance resources required to identify HA-CDI are often lacking. The rate of toxigenic C. difficile stool positivity in the stool of hospitalized patients may offer an alternative metric for these settings, but its utlity remains largely untested.Aim/ObjectiveTo examine the impact of an antimicrobial stewardship on the rate of toxigenic C. difficile positivity among hospitalized patients presenting with diarrhoeaMethodsA 12-year retrospective review of laboratory data was conducted to compare the rates of toxigenic C. difficile in diarrhoea stool of patients in a hospital in Saudi Arabia, before and after implementation of an antimicrobial stewardship programResultThere was a significant decline in the rate of toxigenic C difficile positivity from 9.8 to 7.4% following the implementation of the antimicrobial stewardship program, and a reversal of a rising trend.DiscussionThe rate of toxigenic C. difficile positivity may be a useful patient outcome metric for evaluating the long term impact of antimicrobial stewardship on CDI, especially in settings with limited surveillance resources. The accuracy of this metric is however dependent on the avoidance of arbitrary repeated testing of a patient for cure, and testing only unformed or diarrhoea stool specimens. Further studies are required within and beyond Saudi Arabia to examine the utility of this metric.

scholarly journals Community-based aftercare following an emergency department presentation for attempted suicide or high risk for suicide: study protocol for a non-randomised controlled trial

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Vida V. Bliokas ◽  
Alex R. Hains ◽  
Jonathan A. Allan ◽  
Luise Lago ◽  
Rebecca Sng
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Suicide Attempt ◽  
Repeated Measures ◽  
Hospital Emergency Department ◽  
Hospital Emergency ◽  
Community Based ◽  
Treatment As Usual ◽  
The Impact

Abstract Background Suicide is a major public health issue worldwide. Those who have made a recent suicide attempt are at high risk for dying by suicide in the future, particularly during the period immediately following departure from a hospital emergency department. As such the transition from hospital-based care to the community is an important area of focus in the attempt to reduce suicide rates. There is a need for evaluation studies to test the effectiveness of interventions directed to this stage (termed ‘aftercare’ interventions). Methods A controlled non-randomised two group (intervention vs treatment-as-usual control) design, using an intention-to-treat model, will evaluate the effectiveness of a suicide prevention aftercare intervention providing follow-up after presentations to a hospital emergency department as a result of a suicide attempt or high risk for suicide. The intervention is a community-based service, utilising two meetings with a mental health clinician and follow-up contacts by peer workers via a combination of face-to-face and telephone for four weeks, with the option of extension to 12 weeks. Seventy-five participants of the intervention service will be recruited to the study and compared to 1265 treatment-as-usual controls. The primary hypotheses are that over 12 months, those who participate in the aftercare follow-up intervention are less likely than controls to present to a hospital emergency department for a repeat suicide attempt or because of high risk for suicide, will have fewer re-presentations during this period and will have lower all-cause mortality. As a secondary aim, the impact of the intervention on suicide risk factors for those who participate in the service will be evaluated using pre- and post-intervention repeated measures of depression, anxiety, stress, hopelessness, belongingness, burdensomeness, and psychological distress. Enrolments into the study commenced on 1 November 2017 and are anticipated to cease in November 2019. Discussion The study aims to contribute to the understanding of effective interventions for individuals who have presented to a hospital emergency department as a result of a suicide attempt or at high risk for suicide and provide evidence in relation to interventions that incorporate peer-workers. Trial registration ACTRN12618001701213. Registered on 16 October 2018. Retrospectively registered.

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