ASP TOC Efforts at Henry Ford Health

Antimicrobial stewardship program (ASP) efforts to improve the use of antimicrobial agents is a responsibility of all clinicians. Health care institutions are required to improve the use of antimicrobial agents. Such efforts should include those which improve antimicrobial resistance and clinical outcomes for patients. ASP interventions to improve antimicrobial resistance (AMR) have focused on patients admitted to the hospital and less on TOC or outpatient settings. Recent published TOC practices include efforts to improve discharge prescriptions by having a pharmacist review them prior to discharge.

In November 2018, HFH expanded ASP TOC efforts to improve prescribing of oral antimicrobial therapy for discharge through implementation of a collaborative, multicenter, pharmacist-led antimicrobial stewardship program transition of care (ASP TOC) intervention. This program aimed to decrease unnecessary and inappropriate antimicrobial exposure by optimizing antibiotic therapy for the following infections:

• Uncomplicated skin & soft tissue (cellulitis, cutaneous, abscess & wound)
• Respiratory (community acquired pneumonia, hospital acquired pneumonia, acute exacerbation of chronic obstructive pulmonary disease & influenza)
• Urinary tract (cystitis, complicated urinary tract infection, catheter-associated urinary tract infection and pyelonephritis)
• Intra-abdominal (spontaneous bacterial peritonitis and complicated with achieved source control)

Patients in the ASP TOC postintervention group were more likely to have optimal antimicrobial prescriptions at discharge and decreased total antimicrobial duration. The proportion of patients with optimized discharge antibiotic regimens improved by 46% with the ASP TOC intervention (144 of 400 patients [36.0%] in the preintervention group, compared to 326 of 400 patients [81.5%] in the postintervention group). The ASP TOC efforts also was associated with fewer adverse drug events, including reduction in ASP efforts and improve antibiotics discharge prescribing.

Additional ASP TOC efforts at HFH includes the ability for clinicians to send an antimicrobial discharge medication cost inquiry (DMCI) to identify patient out of pocket costs and assist with overall discharge planning. The DMCI is a consultation order processed by the outpatient pharmacy in a separate workflow from prescriptions. The result of the DMCI is documented in the patient’s electronic medical record. Most DMCI results are available within 24 hours and offer opportunities to facilitate patient access to discharge antimicrobials.

References:

1. Craynon R, Hager DR, Reed M, et al. Prospective daily review of discharge medications by pharmacists: Effects on measures of safety and efficiency Am J Health-Syst Pharm. 2018; 75:e538-44.
2. Cesarz JL, Steffenhagen AL, Svenson J., et al. Emergency Department Discharge Prescription Interventions by Emergency Medicine Pharmacists. Ann Emerg Med. 2013;61:209-214.
3. Mercuro NJ, Medler CJ, Kenney RM, et al. Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge. JAMA Netw Open. 2022;5(5):e2211331. Published 2022 May 2. doi:10.1001/jamanetworkopen.2022.11331
   
4. Patel N, Davis SL, MacDonald NC, Medler CJ, Kenney RM, Zervos MJ, and Mercuro NJ. Transitions of care: An untapped opportunity for antimicrobial stewardship. J Am Coll Clin Pharm 2022; 5(6):632-643.
   
5. Belza-Mai AC, Efta J, Kenney R, et al. Optimizing discharge antimicrobial therapy: Evaluation of a transitions of care process and electronic scoring system for patients with community-acquired pneumonia or chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2024;81(24):1237-1244. doi:10.1093/ajhp/zxae174
   
6. Griebe KM, Hencken LN, Efta J, et al. An electronic tool for health systems to assess and communicate discharge medication access. Am J Health Syst Pharm. 2022; 7;79(6):477-485.
   
7. Mulugeta SG, MacDonald NC, El-Khoury CJ, Davis SL, Kenney RM. Impact of a Standardized, Pharmacist-Initiated "Test-Claim" Workflow for Anticipating Barriers to Accessing Discharge Antimicrobials. J Pharm Technol. 2023;39(5):218-223. doi:10.1177/87551225231196047