Improving Prescribing Practices at Hospital Discharge With Pharmacist-Led Antimicrobial Stewardship at Transitions of Care

Abstract

Background: Antimicrobial stewardship (AMS) is recommended in hospital, postacute, and outpatient settings. Transitions of care (TOC) are important in each of these settings; however, AMS efforts during TOC have been limited. Beginning in October 2018, we sequentially implemented a pharmacist-led multidisciplinary review of oral antimicrobial therapy prescribed at hospital discharge from general and specialty medicine wards across a health system. Pharmacists facilitated data input of discharge prescriptions following early identification and collaborative discussion of patients to be discharged on oral antimicrobials The purpose of this study was to evaluate the impact of AMS during TOC. Methods: This project was an IRB-approved stepped-wedge, quasi-experimental study in a 5-hospital health system that included hospitalized adults with skin, urinary, intra-abdominal, and respiratory tract infections who had been discharged from general and specialty wards with oral antimicrobials. Patients with complicated infections, neutropenia, or who were transferred from an outside hospital were excluded. The primary end point was optimization of antimicrobial therapy at time of hospital discharge, defined by correct selection, dose, and duration according to institutional guidance. Outcomes were compared before and after the intervention. Results: In total, 800 patients were included: 400 in the preintervention period and 400 in the postintervention period. Among this cohort, 252 (63%) received the intervention by a pharmacist per protocol during TOC. Patients had similar comorbid conditions before and after the intervention. Preintervention patients were more likely to be discharged from community hospitals. Before the intervention, 36% of discharge regimens were considered optimized, compared to 81.5% after the intervention (P < .001); this difference was largely driven by a reduction in patients receiving a duration of therapy beyond the clinical indication (44.5 vs 10%; P < .001). We observed similar clinical resolution, 30-day readmission, and adverse drug events (ADEs) between the pre- and postintervention periods. Postdischarge antimicrobial duration of therapy was reduced from 4 days (range, 3–5) to 3 days (range, 2–4) (P < .001) Severe ADEs occurred more frequently in the preintervention group (9 vs 3.3%; P = .001), which was driven by isolation of multidrug-resistant pathogens (7 vs 2.5%; P = .003) and Clostridioides difficile (1.8 vs 0.5%; P = .094). Patients who received optimal therapy at discharge were less likely to develop an ADE (aOR, 0.530; 95% CI, 0.363–0.773). Conclusions: Implementation of an AMS TOC protocol reduced antimicrobial days, optimized therapy selection, and reduced duration. This intervention was associated with improved safety without compromise of clinical effectiveness. To increase patient safety, AMS programs should target antimicrobial optimization during TOC.Funding: This work was completed under CDC contract number 200-2018-02928.Disclosures: None

Transitions of care: An untapped opportunity for antimicrobial stewardship

“…Over this period, we were able to optimize the discharge antibiotics of over 1500 patients (Figure 1). The overall protocol adherence during this time was 63%, sustained over a 9‐month period 31 . Adherence in the first phase (academic center) was 70%, 61% in the second (academic and community centers), and 44% in the third (community centers) (Figure 1).…”

“…Pharmacists practicing in antimicrobial stewardship, emergency department, general medicine, and outpatient settings have played essential roles in ASP during TOC (Table 4). 19,20,24,26‐31 Workflows and checklists for pharmacists were integrated into multiple ASP TOC care models. A common approach for antimicrobial review is providing audit and feedback in real‐time once a prescription has been entered or signed.…”

“…Impactful interventions that are feasible, practical, and nonresource intensive are of highest value to both ASPs and health system administrators. Antimicrobial stewardship interventions during TOC are associated with reduced antibiotic‐related adverse effects and readmissions; however, treatment‐related effects on such outcomes are generally multifactorial and confounded, and these results have only been demonstrated in nonrandomized study settings to date 20,31 . Conducting medication‐use evaluations to identify opportunities specific to the health system can increase the likelihood of success and uptake of a pilot study/intervention.…”

“…Over the study period, duration of antibiotic and frequency of adverse events decreased 36 . The clinical impact on safety and patient‐centered outcomes will prove to be critical in future efforts in advocacy for ASP TOC support, with authors reporting improvements in quality or prescribing, adverse events, and even possibly readmissions 28,31,36 …”

“…By service line, protocol adherence was as follows: Family Medicine, 71%; Internal Medicine, 64%; Pulmonology, 76%; Hospitalist, 73%; Infectious Diseases, 79%; Cardiology, 59%; Nephrology, 68%. Following the implementation of the intervention, the frequency of optimal antibiotic course received at discharge increased from 36% to 81.5%; the discharge antibiotic duration was reduced from 4 (interquartile range [IQR], 3‐5) days to 3 (IQR, 2‐4) days 31 . There was no difference in clinical success, hospital readmissions, or mortality, however, incidence of serious antibiotic‐related adverse events was reduced 31 …”