Evaluation of an Automated, Pharmacist-Driven, Antimicrobial Patient Acuity Scoring System for Hospitalized Bacteremic Patients.

Purpose: The implementation of an automated, pharmacist-driven, scoring system within the EMR has been shown to improve patient care in patients with Staphylococcus aureus bacteremia by increasing the adherence to disease specific quality-of-care measures. However, there are a lack of studies evaluating the incorporation of blood culture review into standard, non-antimicrobial stewardship pharmacist workflow. Our institution implemented an automated, pharmacist-driven, antimicrobial scoring system in the electronic medical record (EMR) on August 6, 2019. Methods: This was a retrospective, single-center, quasi-experimental study of hospitalized, non-critically ill adult (18-89 years of age) patients with bacteremia between July 6, 2018 and July 5, 2019 (pre-implementation group) and September 6, 2019 and September 5, 2020 (post-implementation group). The primary outcome was time to directed antibiotic therapy in patients with positive blood cultures. Secondary outcomes included hospital length-of-stay, days of therapy (DOT) while inpatient, time to effective therapy, 30-day all-cause mortality, and rates of Clostridioides difficile infections documented within 3 months of positive culture results. Results: Implementation of the antimicrobial scoring system did not result in a significant change in time to directed antibiotic therapy (32.5 hours vs 37.4 hours; P = .757). There was also no difference found for time to effective antibiotic therapy (-12.6 hours vs -14.2 hours; P =.905) and no difference found for all other secondary outcomes. Conclusion: The implementation of the antimicrobial scoring system did not lead to an improvement in clinical outcomes. Further research is needed to better define a patient population that may benefit from this system.

Implementation and Evaluation of a Prior Authorization Workflow for New-Start Inpatient Medications in Preparation for Discharge.

Purpose: Medications that require prior authorization can complicate the discharge planning process. This study implemented and evaluated a process for identifying and completing prior authorizations during the inpatient setting prior to patient discharge. Methods: A patient identification tool was developed within the electronic health record to alert the patient care resource manager of inpatient orders for targeted medications that frequently require prior authorization with the potential to delay discharge. A workflow process using the identification tool and flowsheet documentation was developed to prompt the initiation of a prior authorization, if necessary. Following hospital-wide implementation, descriptive data for a 2-month period was collected. Results: The tool detected 1353 medications for 1096 patient encounters over the 2-month period. The most frequent medications identified included apixaban (28.1%), enoxaparin (14.4%), sacubitril/valsartan (6.4%), and darbepoetin (6.4%). For the medications identified, there were 93 medications documented in the flowsheet data for 91 unique patient encounters. Of the 93 medications documented, 30% did not require prior authorization, 29% had prior authorization started, 10% were for patients discharged to a facility, 3% were for home medications, 3% were medications discontinued at discharge, 1% had prior authorization denied, and 24% had missing data. The most frequent medications documented in the flowsheet included apixaban (12%), enoxaparin (10%), and rifaximin (20%). Of the 28 prior authorizations processed, 2 led to a referral to the Medication Assistance Program. Conclusion: The implementation of an identification tool and documentation process can help improve PA workflow and discharge care coordination.

Defining, capturing, and validating pharmacists' patient profile reviews in the electronic medical record.

PURPOSE: To describe the implementation and validation of a novel patient profile review tool in the electronic medical record (EMR) at an academic medical center. SUMMARY: Pharmacy leaders at The Ohio State University Wexner Medical Center aspired to develop a data-driven approach to clinical pharmacy services. The initial phase of this vision highlighted a need to define the clinical activities of a pharmacist and leverage use of the EMR to seamlessly capture data. A comprehensive list of clinical activities was developed and analyzed to determine which activities were currently uncaptured. Patient profile review was prioritized and determined to be variable among staff and undefined. A profile review tool was developed and implemented across the medical center while requiring minimal additional documentation through the EMR. Phase II determined what user audit trail data in the EMR were automatically recorded based on performing various levels of pharmacist-recorded profile review and validated the consistency in utilization of this tool. The information gathered as a result of this study identified interactions within the patient chart that matched profile reviews that were not captured during manual documentation. The department of pharmacy will utilize the data generated from this tool to better make decisions and build a comprehensive clinical productivity model. CONCLUSION: The implementation of a pharmacist patient profile review tool built within the EMR successfully defined, stratified, validated time spent on, and captured a clinical activity.

Implementation of pharmacist targeted discharge prescription review in an emergency department.

BACKGROUND/PURPOSE: Little data has been published regarding emergency medicine pharmacist (EMP) review of discharge prescriptions. An internal retrospective review of a limited sample size of emergency department (ED) discharge prescriptions demonstrated a 13.6% potential intervention rate by EMPs. With this information, it was postulated that EMPs could provide a valuable service via a process of targeted review of ED discharge prescriptions that would yield intervention rates higher than the internal audit. The aim of this project was therefore to develop a real-time notification system within the electronic health record (EHR) for targeted discharge prescription review, to establish an associated EMP workflow, and to evaluate the intervention rate achieved through targeted discharge prescription review. METHODS: This was a single-center, retrospective review of the implementation of a new pharmacist-driven clinical service over a 12 week period from February 19th, 2018 to May 14th, 2018. Criteria for prescription review were determined after an internal audit by the EMPs and included an assessment of established high-alert medications. Discharge prescriptions that met the inclusion criteria were filtered into a real-time work queue in the EHR for EMP review. When necessary, EMPs discussed recommendations with prescribers, or adjusted prescriptions according to institutional pharmacist privileges. Interventions were reviewed and categorized to assess rate of intervention and the types of medication-related problems (MRPs) identified. RESULTS: EMPs reviewed 378 discharge prescriptions and a total of 158 prescriptions were identified as having at least one MRP. Of these, 70 prescriptions were intervened upon thereby resulting in an 18.5% intervention rate. The most common interventions included a change in the dose/frequency, duration/refills of the medication, and patient education. The highest number of interventions were made for anticoagulant and antiinfective agents. CONCLUSION: Utilization of a real-time notification system for prospective ED discharge prescription review is feasible. Using targeted criteria for review, pharmacists intervened on 18.5% of prescriptions reviewed. Prospective discharge prescription review by EMPs using a real-time notification system within the electronic health record identified opportunities for the pharmacist to ensure safe and optimal prescribing.

Pharmacist-driven initiative for management of Staphylococcus aureus bacteremia using a clinical decision support system.

PURPOSE: The development and implementation of a clinical decision support system (CDSS) for pharmacists to use for identification of and intervention on patients with Staphylococcus aureus bacteremia (SAB) are described. SUMMARY: A project team consisting of 3 informatics pharmacists and 2 infectious diseases (ID) pharmacists was formed to develop the CDSS. The primary CDSS component was a scoring system that generates a score in real time for a patient with a positive blood culture for S. aureus. In addition, 4 tools were configured in the CDSS to facilitate pharmacists' workflow and documentation tasks: a patient list, a patient list report, a handoff note, and a standardized progress note. Pharmacists are required to evaluate the patient list at least once per shift to identify newly listed patients with a blood culture positive for S. aureus and provide recommendations if necessary. The CDSS was implemented over a period of 2.5 months, with a pharmacy informatics resident dedicating approximately 200 hours in total. An audit showed that the standardized progress note was completed for 100% of the patients, with a mean time to completion of 8.5 hours. Importantly, this initiative can be implemented in hospitals without specialty-trained ID pharmacists. This study provides a framework for future antimicrobial stewardship program initiatives to incorporate pharmacists into the process of providing real-time recommendations. CONCLUSION: A pharmacist-driven patient scoring system was successfully used to improve adherence to quality performance measures for management of SAB. A pharmacist-driven CDSS can be utilized to assist in the management of SAB.

Implementation of a prioritized scoring tool to improve time to pharmacist intervention.

PURPOSE: The implementation of a prioritized scoring tool to improve time to pharmacist intervention is described. SUMMARY: At the Ohio State University Wexner Medical Center, pharmacists are accepted providers of therapeutic drug monitoring of vancomycin and aminoglycosides. At the onset of this initiative and despite the implementation of an integrated electronic medical record (EMR), management of pharmacokinetically monitored medications was conducted using a paper monitoring form. The potential for transcription errors during this process provided an opportunity for improvement. For these reasons, the department of pharmacy focused its initial efforts for a patient scoring system on the pharmacokinetics scoring module. Adjustment of associated medications based on pharmacokinetic values was a core function of pharmacists of the institution and was expected to be conducted without fail. Vancomycin was used as the index surrogate pharmacokinetically monitored medication within the module for testing and validation because of the clear expectations and standardized resources available to pharmacists to complete the task. The pharmacokinetics scoring module was designed specifically for the function of dosing management, searching throughout the EMR and concisely displaying the information a pharmacist needs to make a clinical decision. Importantly, integration of the scoring module reduced the time to intervention from hours to minutes. The median time to intervention was reduced to within a clinical working shift (8 hours) with the scoring module versus 24 hours or longer with the paper monitoring system. CONCLUSION: The implementation of an internally developed pharmacokinetics scoring module built into the EMR substantially reduced the time to clinical intervention for pharmacokinetic monitoring of vancomycin drug levels.

An Automated, Pharmacist-Driven Initiative Improves Quality of Care for Staphylococcus aureus Bacteremia.

BACKGROUND: Infectious diseases (ID) consultation and antimicrobial stewardship intervention have been shown to improve the management of Staphylococcus aureus bacteremia (SAB). As the workload of antimicrobial stewardship programs (ASPs) continues to increase, ASPs must find a way to maximize the efficiency of the program while optimizing patient outcomes. The objective of this study was to evaluate the impact of incorporating health informatics into the management of SAB via a pharmacist-driven initiative. METHODS: Retrospective, single-center quasi-experimental study of hospitalized patients with SAB. During the intervention period, pharmacists were alerted to patients with SAB via a patient scoring tool integrated into the electronic medical record. Pharmacists utilized the scoring tool and the institution's evidence-based practice guideline to make standardized recommendations to promote adherence to SAB quality-of-care measures and encourage ID consultation. The primary outcome was overall compliance along with adherence to individual quality-of-care components. Secondary clinical outcomes were also analyzed. RESULTS: In sum, 84 patients were identified for study inclusion, 45 in the pre-intervention and 39 in the intervention group. As a whole, all 4 quality-of-care components for the management of SAB were significantly more frequently adhered to in the intervention group (68.9% vs 92.3%; P = .008). The incidence of ID consult improved significantly by almost 20% in the intervention group (75.6% vs 94.9%, P = .015). No statistically significant differences in duration of bacteremia, length-of-stay, infection-related length-of-stay, or readmission were observed between the groups. The incidence of all-cause mortality was 6-fold higher in the pre- intervention group compared to the intervention group (15.6% vs 2.6%, P = .063). CONCLUSION: An automated, pharmacist-driven intervention for the management of patients with SAB demonstrated a significant improvement in patients receiving an ID consult, targeted antimicrobial therapy, and adherence to all SAB quality-of-care measures. As antimicrobial stewardship becomes a mandatory aspect of healthcare in all hospitals in the United States, ASPs will be forced to find ways to provide more efficient, impactful, disease state-based patient care. Our study provides the framework for and data to support this intervention in one of the most clinically important infectious diseases.