BETHESDA, MD 23 Nov 2016—Hospitals large and small are exploring pharmacy-managed antimicrobial therapy "time-outs" as part of antimicrobial stewardship strategies.
In Illinois, four Northwestern Medicine hospitals—333-bed Central DuPage Hospital in Winfield, 159-bed Delnor in Geneva, 98-bed Kishwaukee in DeKalb, and 24-bed Valley West in Sandwich—recently presented findings from a study of pharmacist-led antimicrobial therapy time-outs, as did 650-bed University of Nebraska Medical Center in Omaha. The results of the two studies were presented at the October 2016 IDWeek conference in New Orleans.
An antimicrobial therapy time-out, according to the Centers for Disease Control and Prevention's (CDC's) core elements for hospital antimicrobial stewardship programs, is a systemic evaluation, at a set time point, of the need to continue antimicrobial treatment.
ASHP's federally recognized antimicrobial stewardship resource center contains information for clinicians about a variety of topics related to the appropriate use of antimicrobials (www.ashp.org/Antimicrobial).
Additional ASHP support for stewardship includes participation in White House stewardship initiatives and engagement with policymakers at federal agencies, such as the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services.
Although CDC recommends that hospitals adopt a policy of routinely requiring a time-out 48 hours after the initiation of antimicrobial therapy, that timing isn't always practical.
"It takes about 72 hours to turn around our cultures," said Radhika Polisetty, clinical and infectious diseases pharmacist at Central DuPage Hospital. Thus, for their study, the pharmacists at the four Northwestern Medicine hospitals performed time-outs 72 hours after initiating therapy so that their recommendations were backed by microbiology test results.
Overall, the six-month study found that the time-outs did not alter the overall use of antimicrobials at the hospitals, as measured in days of therapy per 1000 patient-days.
But the project successfully highlighted the interventions recommended by pharmacists—443 in all, for 1674 patients—and the 96.8% acceptance rate for those recommendations among physicians.
"We have the data to support that the recommendations that are being made are valid," said Elizabeth Jochum, pharmacy clinical coordinator for the Kishwaukee and Valley West hospitals.
During the study, the pharmacists' interventions included 179 recommendations to discontinue antimicrobial therapy, 86 recommendations to change the duration of treatment, 84 to switch patients from i.v. to oral therapy, and 40 to use a narrower-spectrum drug.
Polisetty said she would have liked to see a drop in antimicrobial use, but she wasn't disappointed in the results.
"Our primary goal was not to just reduce overall use [but] to reduce the use of our broad-spectrum or high-risk antibiotics, like carbapenems, fluoroquinolones, and vancomycin," she said.
The time-out study at the University of Nebraska Medical Center likewise found no effect on total antimicrobial use. But the research team did find that time-outs influenced the conversion of i.v. therapies to oral medications.
The two-month study compared antimicrobial use in 137 patients whose care included a time-out and a usual-care group of 153 patients. For patients whose care included a time-out, the ratio of days of oral versus i.v. therapy was 1.14, on average, compared with a ratio of 0.57 for usual-care patients.
Kiri Rolek, pharmacist coordinator for antimicrobial stewardship at the medical center, said ensuring that i.v.-to-oral switches get done is important.
"I think it's oftentimes a very basic stewardship intervention that falls to the wayside or gets overlooked," she added.
Rolek said the time-out project has earned good reviews on staff surveys.
"We got a lot of positive feedback from the medicine team, who really appreciated that pharmacy was taking ownership of this process. And we also got a lot of good feedback from the pharmacists, [who said] they felt empowered by the process," Rolek said.
Both time-out studies were undertaken, in part, in response to antimicrobial stewardship expectations of the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission. Hospitals accredited by the Joint Commission must have a stewardship program in place starting in January 2017, and CMS this year announced its intent to require stewardship as a condition of hospitals' participation in Medicare.
The two IDWeek studies were also intended to demonstrate how time-outs might fit into the hospitals' overall stewardship activities.
"There's not a lot of published data to show the effect of the intervention. And there's also not a lot of information on how to best perform this intervention," Rolek noted.
Her team evaluated two time-out periods—one at 24–72 hours, when culture results became available, and a second at five or more days after the initiation of antimicrobial therapy.
"At that point, you might have a better idea of definitive therapy," she said. "So it's really just to finalize the antibiotic plan."
Jochum said one of the biggest stewardship challenges for the Northwestern hospitals is that the various electronic medical record (EMR) systems at the facilities don't fully support antimicrobial stewardship activities.
She said a planned transition to a common EMR system will generate direct messages to prescribers alerting them to reassess antimicrobial therapy at set times.
For now, Polisetty said, the pharmacists often use text paging to make recommendations to prescribers, who may be onsite at the hospital only once a day.
"Sometimes we're just chasing the team leader physician for a while," she said. "That sometimes causes a delay [if we] page them and they don't get back to us immediately."
Unlike an academic medical center, Northwestern Medical's community hospitals don't have medical residents and fellows onsite who can respond on behalf of the attending physician, she said.
Rolek said that's not a concern at University of Nebraska Medical Center.
"We're fortunate that we have team-based pharmacists who round with all of the medicine teams. And so we thought they would be a great resource to do the time-out because they [provide] continuity for the patient when the medical residents or the attending physicians are always changing," she said.
Rolek said the time-outs for the study initially involved three medical services but have since been rolled out to additional areas in the hospital.
She said support for the initiative was aided by advance planning and consultation with the pharmacy and medical teams before the initial rollout, which included making sure pharmacists were comfortable with their role.
"One thing that we really emphasized with the pharmacists is that you don't have to necessarily know what to do with the antibiotics. It's really just bringing up the discussion to the team [to] evaluate what's going on at this time point," she said.
Polisetty noted that pharmacists at the community hospitals don't interact routinely with the local physicians, which can be a barrier to making recommendations about therapy.
"We have some pharmacists who are very comfortable doing the time-out and making calls and making recommendations. And then there are some who kind of shy away from it," she said.
But she thinks the project has made prescribers more aware of the problems associated with the need to reduce inappropriate antimicrobial use in their own patients.
"I think they were actually very willing to partner with us to do the study. That was a very pleasant surprise for us," Polisetty said.