Reducing overuse of antibiotics at discharge home: A single-center mixed methods pilot study

Abstract

Background: Antibiotic overuse at hospital discharge is common and harmful; however, methods to improve prescribing during care transitions have been understudied. We aimed to pilot a pharmacist-facilitated antibiotic timeout prior to discharge. Methods: From May 2019 to October 2019, we conducted a single-center, controlled pilot study of a pharmacist-facilitated antibiotic timeout prior to discharge. The timeout addressed key elements of stewardship (eg, duration) and was designed and implemented using iterative cycles with rapid feedback. We evaluated implementation outcomes related to feasibility, including usability, adherence, and acceptability, using mixed methods. Pre versus postintervention antibiotic use at discharge in intervention versus control groups was assessed using logistic regression models controlling for patient characteristics. Results: Pharmacists conducted 288 antibiotic timeouts. Timeouts were feasible (mean 2.5 minutes per timeout) and acceptable (85% [40/48] of hospitalists believed timeouts improved prescribing). Pharmacists recommended an antibiotic change in 25% (73/288) of timeouts with 70% (51/73) of recommended changes accepted by hospitalists. Barriers to adherence included unanticipated and weekend discharges. Compared to control services, there were no differences in antibiotic use after discharge during the intervention. Conclusions: A pharmacist-facilitated antibiotic timeout at discharge was feasible and holds promise as a method to improve antibiotic use at discharge.

Transitions of care: An untapped opportunity for antimicrobial stewardship

“…Careful review of all order sets, methods, and practices associated with entry of discharge prescriptions can identify opportunity for intervention from EHR/information technology support 23 . Adaptation of hospital guidelines for antimicrobial selection, dosage, and duration for incorporation into discharge workflows is also a key component in many interventions, as a supplement to audit and feedback 29,31 …”

“…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.…”

“…The authors also assessed the feasibility, acceptability, adherence, and awareness surrounding the intervention. Most pharmacists and hospitalists described the intervention feasible and helpful, and found that it improved patient care (79%) 29 . Each patient intervention was an additional 5 min to the pharmacists' workflow, however, could be up to 20 min if the discharge prescription had already been signed and sent to the pharmacy prior to communication with a team 29 .…”

“…Most pharmacists and hospitalists described the intervention feasible and helpful, and found that it improved patient care (79%) 29 . Each patient intervention was an additional 5 min to the pharmacists' workflow, however, could be up to 20 min if the discharge prescription had already been signed and sent to the pharmacy prior to communication with a team 29 . Parsels et al also found a high frequency of intervention acceptance (76%) using a model involving patient identification from the hospital outpatient pharmacy, to the ASP pharmacist, who made further recommendations to the primary team when needed.…”

“…4). 19,20,24,[26][27][28][29][30][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.…”