IMPORTANCE Management of antithrombotic medications presents a challenge for many clinicians and patients before procedures. Anticoagulation clinic involvement may improve preprocedure coordination, satisfaction on the part of patients and clinicians, last-minute procedure cancellations, and patient safety. OBJECTIVE To assess the implementation of an electronic medical record (EMR) best practice alert (BPA) and anticoagulation clinic referral process to assist with management of antithrombotic medication before gastrointestinal endoscopic procedures. DESIGN, SETTING, AND PARTICIPANTS This multimodal evaluation of a quality improvement intervention using EMRs and survey data included patients using oral antithrombotic medications who were scheduled for elective gastrointestinal endoscopic procedures at an academic medical center along with the clinicians who ordered these procedures. Data were collected from November 1, 2017, through December 19, 2018. Data were analyzed in September 2019. EXPOSURES Following a multidisciplinary intervention, a BPA and referral process for periprocedural antithrombotic medication management was implemented in November 2017. MAIN OUTCOMES AND MEASURES The following implementation outcomes were assessed through EMR review and surveys through December 2018: use of BPAs, patient and clinician satisfaction with preprocedure anticoagulation management, procedure cancelation rates, reach, and spread by patient and clinician characteristics. Multilevel logistic regression was used to estimate variance in BPA use at the clinician level. RESULTS A total of 2082 patients (mean [SD] age, 64.1 [11.9] years) and 144 clinicians were included in the analysis. The BPA was used broadly across the health system, resulting in anticoagulation clinic referral for 1389 patients (66.7%). Referral was more common for patients using anticoagulant vs antiplatelet medications (1041 of 1524 [68.3%] vs 346 of 556 [62.2%]; adjusted odds ratio [aOR], 1.51; 95% CI, 1.15-1.98) and for procedures ordered by gastroenterologists vs primary care clinicians (933 of 1241 [75.2%] vs 365 of 618 [59.1%]; aOR, 2.15; 95% CI, 1.46-3.17). Individual clinician behavior patterns explained 26.5% (95% CI, 18.7%-36.1%) of variation in anticoagulation clinic referrals. Implementation of the intervention was associated with high patient satisfaction and improvements in multidimensional measures of clinician satisfaction (clinician response rate, 44.2% [144 of 326]). In multivariable analysis, the odds of altered or canceled procedures because of medication mismanagement declined after implementation (8 of 50 [16.0%] vs 1 of 52 [1.9%]; aOR, 0.11; 95% CI, 0.01-0.96; P = .02).

Background-Peri-procedural antithrombotic medication management is a complex, often confusing process for patients and their providers. Communication difficulties often lead to suboptimal medication management resulting in delayed or cancelled procedures. Methods-We conducted telephone surveys with patients taking chronic antithrombotic medications who had recently undergone an endoscopy procedure. In the survey, we sought to better understand the peri-procedural process for patients taking antithrombotic medications. We conducted a content analysis of patients' unstructured responses from the peri-procedural patient phone calls. We used a multi-step group coding process to analyze responses. Relationships between different themes and categories were analyzed using original quotes and retrieving thematic segments from the transcripts.

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Up to 10% of hospitalized patients report an allergy to penicillin (PCN). However, over 90% of patients with a reported PCN allergy do not have a true allergy. False reporting can lead to overuse of non-preferred broad-spectrum antibiotics and poorer clinical outcomes. We developed a multidisciplinary protocol for PCN skin testing for hospitalized patients with a documented PCN allergy. Feasibility and impact of this protocol were assessed to determine the necessary resources for broader implementation. METHODS: A pilot study was conducted at Michigan Medicine from July 2018 to January 2019. Patients with PCN allergy were identified from hospitalist and infectious disease services. PCN skin test was performed after screening. Patients' outpatient pharmacies and PCPs were notified of the result and rates of penicillin allergy re-labeling were monitored. RESULTS: 5 of 56 patients tested had negative PCN skin test results. Of those, 16 (29%) switched antibiotics, 19 (35%) were not on antibiotics, 17 (31%) were on appropriate antibiotics, and 3 (5.4%) were not switched due to other factors. 4 PICC lines were avoided. 15 additional patients had the PCN allergy label removed without testing based on prior use. Out of 115 pharmacists contacted, 72 (62.6%) pharmacists deleted the PCN allergy in the pharmacy record. All but 2 patients' PCPs were contacted via EMR, letter or fax. Only 3 of 55 patients (5.45%) were re-labeled with a PCN allergy after six months. CONCLUSIONS: An inpatient PCN testing program was designed and successfully executed to optimize current antibiotic stewardship practices and prevent PCN allergy re-labels.