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.
BaggsJFridkinSKPollackLASrinivasanAJerniganJA.Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012. JAMA Int Med. 2016;176(11):1639-1648.
2.
WeberBRNobleBNBeardenDT, et al. Antibiotic prescribing upon discharge from the hospital to long-term care facilities: implications for antimicrobial stewardship requirements in post-acute settings. Infect Control Hosp Epidemiology. 2019;40(1):18-23.
3.
HeckerMTAronDCPatelNPLehmannMKDonskeyCJ.Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med. 2003;163(8):972-978.
4.
YogoNHaasMKKnepperBCBurmanWJMehlerPSJenkinsTC.Antibiotic prescribing at the transition from hospitalization to discharge: a target for antibiotic stewardship. Infect Control Hosp Epidemiol. 2015;36(4):474-478.
OliveiraGSCastro-AlvesLJKendallMCMcCarthyR. Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials [published online ahead of print June 30, 2017]. J Patient Saf. doi:10.1097/PTS.0000000000000283
8.
BallingLErstadBLWeibelK.Impact of a transition-of-care pharmacist during hospital discharge. J Am Pharm Assoc. 2015;55(4):443-448.
CowenMEStrawdermanRLCzerwinskiJLSmithMJHalasyamaniLK.Mortality predictions on admissions as a context for organizing care activities. J Hosp Med. 2013;8(5):229-235.
11.
JonesJMLeedahlNDLosingACarsonPJLeedahlDD.A pilot study for antimicrobial stewardship post-discharge: avoiding pitfalls at the transitions of care. J Pharm Pract. 2018;31(2):140-144.
12.
TammaPDAvdicELiDXDzintarsKCosgroveSE.Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med. 2017;177(9):1308-1315.
