Antimicrobial Stewardship by Transitions of Care Pharmacists at Hospital Discharge

Abstract

Objectives: This study assessed the impact transitions of care (TOC) pharmacists have on optimizing antimicrobial use for patients at high risk for mortality at hospital discharge. In addition, this study aimed to summarize and categorize the types of interventions made. Methods: This was a retrospective descriptive study that included adult patients 18 years of age or older who were at high risk for readmission and mortality. Participants were selected if they had a hospital discharge date between January 2017 and June 2018, but were excluded if they were discharged to a facility where medications were managed by healthcare employees or if they were hospice eligible. TOC pharmacists identified eligible participants and reviewed their discharge medication lists to optimize pharmacological therapy, contacting the discharging prescriber if therapy changes were identified. The therapy recommendations made by TOC pharmacists were documented in an internal database for further analysis. Results: A total of 1100 patients were analyzed by TOC pharmacists during the studied timeframe and a total of 2066 interventions were made. With respect to study objectives, 298 (14.4%) of the interventions made by TOC pharmacists involved antimicrobial recommendations, affecting 255 (23.2%) patients. Recommendations involving dosing (89, 29.9%), treatment duration (74, 24.8%), and drug interactions (41, 13.8%) were the most frequent types of interventions made. Sixty-six (25.9%) patients received multiple interventions and 240 (80.5%) recommendations were accepted by the provider. Conclusion: An opportunity exists to optimize antimicrobial therapy surrounding the time of hospital discharge.

Introduction

Approximately 50% of all patients in the United States are prescribed antibiotics during their hospital stay and roughly 20% of all patients receive antibiotics at hospital discharge.^1,2 Reports have suggested opportunities for improved prescribing in 30% to 50% of these cases. Inappropriate and unneeded prescribing puts patients at increased risk for adverse outcomes including adverse drug reactions, colonization of resistant bacteria, and Clostridioides difficile infection (CDI).^3,4 Currently, the bulk of antimicrobial stewardship efforts focus on the care a patient receives while admitted or as an outpatient in the primary care setting.^5,6 While beneficial, this can leave a patient with little oversight regarding their antimicrobial use when transitioning between these 2 types of settings (eg, the days surrounding hospital discharge).

Pharmacist interventions at transitions of care (TOC) have been shown to reduce medication errors and emergency room visits. ⁷ While numerous studies have reported the types and effects of these interventions, minimal data exists in the literature assessing antimicrobial stewardship activities performed during TOC.^7,8

The TOC pharmacy program at our 537-bed community teaching hospital was implemented in August 2016. During the studied time period, a full-time pharmacist was staffed Monday through Friday, 8 am to 5 pm, with an additional pharmacist staffing an average of 4 hours each afternoon, every day of the week. TOC pharmacists received approximately 1 week of TOC training which focused on daily workflow, documentation, available resources, and patient counseling principles. While the pharmacists did not receive additional antimicrobial stewardship training for TOC, our institution maintains a robust antimicrobial stewardship program with institutionally approved guidelines for all common infectious disease states. These guidelines include recommendations for preferred antimicrobial choices, doses, and durations. We are also part of a multi-hospital statewide collaborative which tracks and scores quality measures for pneumonia and urinary tract infections in both the inpatient and during TOC to the outpatient settings. ⁹ TOC pharmacists worked to ensure compliance with institutional and collaborative recommendations.

Patient review by pharmacy team members is prioritized utilizing an internally developed, previously reported, acuity scoring tool identifying patients at the highest risk for mortality within 30 days. ¹⁰ The TOC pharmacists target patients with the highest risk for 30-day mortality as it was hypothesized that these patients are likely to have the most complicated medication regimens. Identification of patients is facilitated by an internally developed database. The database identifies patients when a discharge medication reconciliation has been completed. TOC pharmacists review discharge medication lists and contact the discharging prescriber if therapy changes are identified. Once potential issues are resolved, the pharmacists attempt to meet with these patients to provide medication education prior to discharge. A follow-up call within 72 hours post-discharge may also be performed to check on a patient or to provide further education to patients that may have been discharged when a pharmacist was not available.

Methods

This retrospective descriptive study was approved by the institution’s Institutional Review Board and included adult patients 18 years of age or older with a Placement Resource Indicator for System Management (PRISM) score indicating the highest risk for patient 30-day mortality admitted and discharged between January 2017 and June 2018. Patients were excluded if they were discharged to a facility where medications were managed by healthcare employees or if they were hospice eligible.

The primary outcome of this study was to report the incidence of antimicrobial recommendations made by TOC pharmacists. Secondary outcomes included categorizing the types of interventions made, reporting the amount of recommendations accepted by providers, and reporting the number of days of antimicrobial therapy (DOTs) avoided due to TOC pharmacists’ recommendations. DOTs avoided were calculated for accepted interventions by comparing the duration of therapy prescribed in the initial prescription to the duration of therapy prescribed after a TOC pharmacist’s recommendation.

Sample demographics, along with all outcomes, were summarized using means and standard deviations for interval-level variables and frequencies and percentages for categorical variables. Microsoft^® Excel 2016 (Redmond, WA) was used to perform the analyses.

Results

A total of 1100 patients were analyzed by TOC pharmacists during the studied timeframe and a total of 2066 interventions were made. With respect to the primary and secondary outcomes, 298 (14.4%) recommendations made by TOC pharmacists involved antimicrobial agents, affecting 255 (23.2%) patients. Of the 298 interventions made, 240 (80.5%) were accepted by the provider. Recommendations involving dosing (89, 29.9%), treatment duration (74, 24.8%), and drug interactions (41, 13.8%) were the most frequent types of interventions made (Table 1). Sixty-six (25.9%) patients received multiple interventions. All interventions were made within 72 hours of hospital discharge, with 282 (95%) interventions occurring prior to discharge. An estimated 109 DOTs were avoided.

Table 1.

Antimicrobial Interventions Made by TOC Pharmacists.

Intervention type	N (%) (n = 298)
Incorrect dose	89 (29.9)
Incorrect duration	74 (24.8)
Drug interactions	41 (13.8)
Incorrect drug	36 (12.1)
High cost/difficulty finding medication	20 (6.7)
Medication rec discrepancy	9 (3.0)
Other	9 (3.0)
Incorrect instructions	6 (2.0)
Medication without indication	5 (1.7)
Missing medication	4 (1.3)
Duplicate medication	2 (0.7)
Needs refill	2 (0.7)
Drug allergy/intolerance	1 (0.3)

The top 3 infectious disease states that had the highest number of patients receiving TOC pharmacist interventions (Table 2) were pneumonia (110, 43%), septicemia (98, 36%), and urinary tract infections (74, 29%). For patients with pneumonia, recommendations involving dosing (36, 32.7%), duration of therapy (34, 30.9%), and drug interactions (13, 11.8%) were the most frequent recommendations made. Patients with urinary tract infections and septicemia had a similar distribution of recommendations as seen with pneumonia.

Table 2.

Disease States Identified in Patients Receiving an Antimicrobial Intervention. ^a

Disease state	N (%) (n = 255)
Chronic kidney disease	175 (69)
Acute and unspecified renal failure	122 (48)
COPD and bronchiectasis	115 (45)
Pneumonia	110 (43)
Hemodialysis	98 (38)
Septicemia	93 (36)
Urinary tract infection	74 (29)
Bacterial infection	50 (19)
Other upper respiratory infections	39 (15)
Other lower respiratory disease	39 (15)
Influenza	31 (12)
Skin and subcutaneous tissue infection	26 (10)

^aPatients may have had more than 1 diagnosis code.

In terms of interventions made by pharmacologic class, fluoroquinolone (91, 30.5%) and beta-lactam (89, 29.9%) antibiotics contained the higher number of interventions. The agents in the fluoroquinolone class that received interventions were ciprofloxacin and levofloxacin, both encompassing a similar distribution of interventions. For the beta-lactam antibiotics, cephalexin (30, 33.7%), cefpodoxime (23, 25.8%), and amoxicillin-clavulanate (14, 15.7%) were the antibiotics that had the highest incidence of interventions.

Discussion

The results of this study show that TOC pharmacists have the opportunity to extend antimicrobial stewardship efforts beyond a patient’s hospital admission. The pharmacists involved in this study intervened on over 2000 medication orders in 1100 patients, with 298 (14.4%) orders being related to antimicrobial therapy.

The antimicrobial interventions made by the TOC pharmacists played a crucial role in ensuring adherence to institutional and national guidelines, as well as state quality collaborative initiatives. ⁹ Specifically, choosing the appropriate antimicrobial agent at an appropriate dose, along with confirming a proper duration of therapy were the types of interventions most relatable to antimicrobial stewardship. In fact, an estimated 109 days of unnecessary antimicrobial therapy were saved, which may decrease the risk of associated adverse events. Outside of the interventions made that relate directly to guideline adherence, TOC pharmacists mitigated drug interactions (eg, chelating agents, warfarin, and serotonin syndrome) and facilitated medication acquisition issues for discharging patients (eg, vancomycin oral formulations, oral cephalosporin availability). Pneumonia, septicemia, and urinary tract infections were the most common infectious disease states that received these antimicrobial interventions, making these conditions a potential target for TOC pharmacists to offer their services.

The opportunity for medication optimization during TOC is not a new discovery; however, there are few reports of coordinated antimicrobial stewardship program efforts during this sensitive time in a patient’s care.^8,11 The results of this study highlight opportunities for coordinated antimicrobial stewardship program efforts during TOC. The optimal model for coordinated TOC efforts is likely institution-specific and further research is needed to highlight novel processes and to assess clinical outcomes, including infection-related readmission rates, CDI incidence, and antimicrobial adverse event avoidance following care transitions. Our use of a scoring tool for patients at the highest risk for 30-day mortality is a unique strategy chosen to target patients felt to have the most opportunity for improvements in prescribing. While our scoring tool was institution-specific, additional acuity scoring tools are readily available and may help guide the distribution of TOC activities in resource-limited settings.

There were several limitations to our study other than the retrospective descriptive nature of the analysis. First, assessing patient outcomes was beyond the scope of our analysis; however, the optimization of antimicrobial use likely avoided unintended consequences as demonstrated by Tamma and colleagues who found that every 10 days of unneeded antibiotic use led to a 3% increase in adverse events. ¹² Second, information surrounding the interventions made to the patients relied entirely on the TOC pharmacists providing accurate and valid documentation. For example, TOC pharmacists may not have documented all interventions made during their shift, leading to a lower number of total interventions made. In addition, TOC pharmacists may not have accurately documented the exact intervention made, leading to an inaccurate distribution of interventions. Retrospective data validation was completed on a random sampling of interventions, each demonstrating accurate documentation; however, since data validation was not done on all 298 interventions, the potential still exists for inaccurate or incomplete documentation. Additionally, many antimicrobial discharge prescriptions are not assessed by TOC pharmacists as the model targets patients based on mortality risk rather than prescription type or disease state. Lastly, not all patients with the highest risk for mortality were able to be seen by a TOC pharmacist due to time constraints. This introduces selection bias as the TOC pharmacist usually prioritizes their day with addressing more problematic patients first, potentially artificially inflating the percentage of patients requiring interventions.

Conclusion

Our study showed that an opportunity exists to optimize antimicrobial therapy surrounding the time of hospital discharge. Improper dosing, duration of therapy, and drug interactions were the most frequent types of interventions made by our TOC pharmacists. Additional studies are needed to adequately assess clinical outcomes for these types of interventions to ultimately determine the necessity and degree of antimicrobial stewardship required during TOC.