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

Abstract

Positive outcomes of antimicrobial stewardship programs in the inpatient setting have been 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 ED with subsequent positive cultures conducted to determine if integrating antimicrobial stewardship responsibilities into practice of the dedicated emergency medicine clinical pharmacist (EPh) decreased times to positive culture follow-up, patient or primary care provider (PCP) notification, and appropriateness of empiric or final antimicrobial therapy for patients discharged from the emergency department (ED). Pre-and post-implementation groups of an EPh-managed antimicrobial stewardship program were compared. Data were collected from medical records and the ED culture database. Continuous data were analyzed using Wilcoxon Rank Sum test and categorical data using Chi-squared analysis. 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=0.0001). There were positive cultures that required notification in 74 (71.2%) and 36 (49.3%) on pre- and post-implementation groups, respectively. Median time to patient or PCP notification was 3 days (range 1–9) in the pre-implementation group and 2 days(range 0–4) in the Eph managed program (p = 0.01). No difference in appropriate antimicrobial therapy was seen.

Evaluation of Pharmacist Impact on Culture Review Process for Patients Discharged from the Emergency Department

“…Another core principle is the pharmacist as a crucial member of antimicrobial stewardship programs, because they are knowledgeable on the interpretation of culture and sensitivity results, the appropriate use of antimicrobials, medication dosing, recognition of allergies, route of administration, duration of therapy, and drug interactions. [2][3][4][5] Review of microbiological test results and subsequent modification of empiric antimicrobial therapy may be a daunting task for ED health care personnel due to high patient volume and frequent interruptions. The emergency medicine pharmacist (EMP) is perfectly positioned and equipped with the proper knowledge and tools to review these results and facilitate appropriate modifications to therapy when necessary.…”

“…[2][3][4][5] While proven effective in the inpatient setting, many antimicrobial stewardship programs do not include emergency department (ED) patients in their initiatives. 2,4 The Infectious Diseases Society of America (IDSA) and the Society for Healthcare and Epidemiology of America (SHEA) have identified the clinical A ntimicrobial stewardship is a collection of strategies aimed at optimizing the use of antimicrobials while minimizing unintended consequences of therapy, such as the emergence of resistance due to overuse.…”

“…The emergency medicine pharmacist (EMP) is perfectly positioned and equipped with the proper knowledge and tools to review these results and facilitate appropriate modifications to therapy when necessary. [3][4][5] Antimicrobials are the second most prescribed drug class in the ED and are reportedly used in 12.4% of ED patients. 4,6 Due to the rapid throughput and large volume of patients seen in the ED, many traditional aspects of antimicrobial stewardship are not applied; however, because of the quantity of antimicrobials initiated in the ED, it is an area where the aforementioned principles should be utilized.…”

“…4,6 Due to the rapid throughput and large volume of patients seen in the ED, many traditional aspects of antimicrobial stewardship are not applied; however, because of the quantity of antimicrobials initiated in the ED, it is an area where the aforementioned principles should be utilized. 4,5 The American Society of Health-System Pharmacists (ASHP) has issued a statement declaring that pharmacists in the ED should develop systems to promote safe and effective medication use and optimize patient care. Expansion of clinical pharmacy services in the ED may include the review of positive microbiological test results for patients discharged from the ED.…”

Acute Trauma and Resuscitation Preceptorship

“…An improvement has been demonstrated in the time-to-positive-culturereview and notification of appropriate antimicrobial therapy. 4 Culture review by pharmacists has now become standard practice for many EM pharmacists across the USA.…”