Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge

Authors

Nicholas J. Mercuro, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan, Department of Pharmacy, Maine Medical Center, Portland
Corey J. Medler, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan.
Rachel M. Kenney, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan.
Nancy C. MacDonald, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan.
Melinda M. Neuhauser, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, Atlanta, Georgia.
Lauri A. Hicks, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, Atlanta, Georgia.
Arjun Srinivasan, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, Atlanta, Georgia.
George Divine, Division of Public Health Sciences, Henry Ford Health System, Detroit, Michigan.
Amy Beaulac, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan.
Erin Eriksson, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan.
Ronald Kendall, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan.
Marilen Martinez, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan.
Allison Weinmann, Division of Infectious Diseases, Henry Ford Health System, Detroit, Michigan.
Marcus Zervos, Division of Infectious Diseases, Henry Ford Health System, Detroit, Michigan.
Susan L. Davis, Department of Pharmacy, Henry Ford Health System, Detroit, Michigan.

Document Type

Article

Publication Date

5-2-2022

Institution/Department

Pharmacy

Journal Title

JAMA network open

MeSH Headings

Adult; Aged; Anti-Bacterial Agents (therapeutic use); Anti-Infective Agents (therapeutic use); Antimicrobial Stewardship; Female; Hospitals, Community; Humans; Male; Patient Discharge; Pharmacists

Abstract

Importance: Although prescribers face numerous patient-centered challenges during transitions of care (TOC) at hospital discharge, prolonged duration of antimicrobial therapy for common infections remains problematic, and resources are needed for antimicrobial stewardship throughout this period. Objective: To evaluate a pharmacist-driven intervention designed to improve selection and duration of oral antimicrobial therapy prescribed at hospital discharge for common infections. Design, Setting, and Participants: This quality improvement study used a nonrandomized stepped-wedge design with 3 study phases from September 1, 2018, to August 31, 2019. Seventeen distinct medicine, surgery, and specialty units from a health system in Southeast Michigan participated, including 1 academic tertiary hospital and 4 community hospitals. Hospitalized adults who had urinary, respiratory, skin and/or soft tissue, and intra-abdominal infections and were prescribed antimicrobials at discharge were included in the analysis. Data were analyzed from February 18, 2020, to February 28, 2022. Interventions: Clinical pharmacists engaged in a new standard of care for antimicrobial stewardship practices during TOC by identifying patients to be discharged with a prescription for oral antimicrobials and collaborating with primary teams to prescribe optimal therapy. Academic and community hospitals used both antimicrobial stewardship and clinical pharmacists in a multidisciplinary rounding model to discuss, document, and facilitate order entry of the antimicrobial prescription at discharge. Main Outcomes and Measures: The primary end point was frequency of optimized antimicrobial prescription at discharge. Health system guidelines developed from national guidelines and best practices for short-course therapies were used to evaluate optimal therapy. Results: A total of 800 patients prescribed oral antimicrobials at hospital discharge were included in the analysis (441 women [55.1%]; mean [SD] age, 66.8 [17.3] years): 400 in the preintervention period and 400 in the postintervention period. The most common diagnoses were pneumonia (264 [33.0%]), upper respiratory tract infection and/or acute exacerbation of chronic obstructive pulmonary disease (214 [26.8%]), and urinary tract infection (203 [25.4%]). Patients in the postintervention group were more likely to have an optimal antimicrobial prescription (time-adjusted generalized estimating equation odds ratio, 5.63 [95% CI, 3.69-8.60]). The absolute increase in optimal prescribing in the postintervention group was consistent in both academic (37.4% [95% CI, 27.5%-46.7%]) and community (43.2% [95% CI, 32.4%-52.8%]) TOC models. There were no differences in clinical resolution or mortality. Fewer severe antimicrobial-related adverse effects (time-adjusted generalized estimating equation odds ratio, 0.40 [95% CI, 0.18-0.88]) were identified in the postintervention (13 [3.2%]) compared with the preintervention (36 [9.0%]) groups. Conclusions and Relevance: The findings of this quality improvement study suggest that targeted antimicrobial stewardship interventions during TOC were associated with increased optimal, guideline-concordant antimicrobial prescriptions at discharge.

First Page

e2211331

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