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Intervention to Reduce Broad-Spectrum Antibiotics and Treatment Durations Prescribed at the Time of Hospital Discharge: A Novel Stewardship Approach.

ABSTRACT: OBJECTIVE For most common infections requiring hospitalization, antibiotic treatment is completed after hospital discharge. Postdischarge therapy is often unnecessarily broad spectrum and prolonged. We developed an intervention to improve antibiotic selection and shorten treatment durations. DESIGN Single center, quasi-experimental retrospective cohort study METHODS Patients prescribed oral antibiotics at hospital discharge before (July 2012-June 2013) and after (October 2014-February 2015) an intervention consisting of (1) institutional guidance for oral step-down antibiotic selection and duration of therapy and (2) pharmacy audit of discharge prescriptions with real-time prescribing recommendations to providers. The primary outcomes measured were total prescribed duration of therapy and use of antibiotics with broad gram-negative activity (ie, fluoroquinolones or amoxicillin-clavulanate). RESULTS Overall, 300 cases from the preintervention period and 200 cases from the intervention period were included. Compared with the preintervention period, the use of antibiotics with broad gram-negative activity decreased during the intervention (51% vs 40%; P=.02), particularly fluoroquinolones (38% vs 25%; P=.002). The total duration of therapy decreased from a median of 10 days (interquartile range [IQR], 7-13 days) to 9 days (IQR, 6-13 days) but did not reach statistical significance (P=.13). However, the duration prescribed at discharge declined from 6 days (IQR, 4-10 days) to 5 days (IQR, 3-7 days) (P=.003). During the intervention, there was a nonsignificant increase in the overall appropriateness of discharge prescriptions from 52% to 66% (P=.15). CONCLUSIONS A multifaceted intervention to optimize antibiotic prescribing at hospital discharge was associated with less frequent use of antibiotics with broad gram-negative activity and shorter postdischarge treatment durations. Infect Control Hosp Epidemiol 2017;38:534-541.

SUBMITTER: Yogo N

PROVIDER: S-EPMC5612407 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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Intervention to Reduce Broad-Spectrum Antibiotics and Treatment Durations Prescribed at the Time of Hospital Discharge: A Novel Stewardship Approach.

Yogo Norihiro N Shihadeh Katherine K Young Heather H Calcaterra Susan L SL Knepper Bryan C BC Burman William J WJ Mehler Philip S PS Jenkins Timothy C TC

Infection control and hospital epidemiology 20170306 5

OBJECTIVE For most common infections requiring hospitalization, antibiotic treatment is completed after hospital discharge. Postdischarge therapy is often unnecessarily broad spectrum and prolonged. We developed an intervention to improve antibiotic selection and shorten treatment durations. DESIGN Single center, quasi-experimental retrospective cohort study METHODS Patients prescribed oral antibiotics at hospital discharge before (July 2012-June 2013) and after (October 2014-February 2015) an i ...[more]

PMID: 28260538

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Project description:Intense antibiotic consumption in Low- and Middle-Income Countries (LMICs) is fueled by critical gaps in laboratory infrastructure and entrenched syndromic management of infectious syndromes. Few data inform the achievability and impact of antimicrobial stewardship interventions, particularly in Sub-Saharan Africa. Our goal was to demonstrate the feasibility of a pharmacist-led laboratory-supported intervention at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, and report on antimicrobial use and clinical outcomes associated with the intervention. Methods: This was a single-center prospective quasi-experimental study conducted in two phases: (i) an intervention phase (November 2017 to August 2018), during which we implemented weekly audit and immediate (verbal and written) feedback sessions on antibiotic prescriptions of patients admitted in 2 pediatric and 2 adult medicine wards, and (ii) a post-intervention phase (September 2018 to January 2019) during which we audited antibiotic prescriptions but provided no feedback to the treating teams. The intervention was conducted by an AMS team consisting of 4 clinical pharmacists (one trained in AMS) and one ID specialist. Our primary outcome was antimicrobial utilization (measured as days of therapy (DOT) per 1,000 patient-days and duration of antibiotic treatment courses); secondary outcomes were length of hospital stay and in-hospital all-cause mortality. A multivariable logistic regression model was used to explore factors associated with all-cause in-hospital mortality. Results: We collected data on 1,109 individual patients (707 during the intervention and 402 in the post-intervention periods). Ceftriaxone, vancomycin, cefepime, meropenem, and metronidazole were the most commonly prescribed antibiotics; 96% of the recommendations made by the AMS team were accepted. The AMS team recommended to discontinue antibiotic therapy in 54% of cases during the intervention period. Once the intervention ceased, total antimicrobial use increased by 51.6% and mean duration of treatment by 4.1 days/patient. Mean LOS stay as well as crude mortality also increased significantly in the post-intervention phase (LOS: 24.1 days vs. 19.8 days; in hospital death 14.7 vs. 6.9%). The difference in mortality remained significant after adjusting for potential confounders. Conclusions: A pharmacist-led AMS intervention focused on duration of antibiotic treatment was feasible and had good acceptability in our setting. Cessation of audit-feedback activities was associated with immediate and sustained increases in antibiotic consumption reflecting a rapid return to baseline (pre-intervention) prescribing practices, and worse clinical outcomes (increased length of stay and in-hospital mortality). Pharmacist-led audit-feedback activities can effectively reduce antimicrobial consumption and result in better-quality care, but require organizational leadership's commitment for sustainable benefits.

Project description:BackgroundAboriginal language interpreters are under-utilised in healthcare in northern Australia. Self-discharge from hospital is an adverse outcome occurring at high rates among Aboriginal people, with poor communication thought to be a contributor. We previously reported increased Aboriginal interpreter uptake and decreased rates of self-discharge during implementation of a 12-month hospital-based intervention. Interrupted time-series analysis showed sudden increase and up-trending improvement in interpreter use, and a corresponding decrease in self-discharge rates, during a 12-month intervention period (April 2018-March 2019) compared with a 24-month baseline period (April 2016 -March 2018). This paper aims to investigate reasons for these outcomes and explore a potential causal association between study activities and outcomes.MethodsThe study was implemented at the tertiary referral hospital in northern Australia. We used the Template for Intervention Description and Replication (TIDieR) as a framework to describe intervention components according to what, how, where, when, how much, tailoring, modifications and reach. Components of the study intervention were: employment of an Aboriginal Interpreter Coordinator, 'Working with Interpreters' training for healthcare providers, and championing of interpreter use by doctors. We evaluated the relative importance of intervention components according to TIDieR descriptors in relation to outcomes. Activities independent of the study that may have affected study findings were reviewed. The relationship between proportion of hospital separations among Aboriginal people ending in self-discharge and numbers of Aboriginal interpreter bookings made during April 2016-March 2019 was tested using linear regression. 'Working with Interpreters' training sessions were undertaken at a regional hospital as well as the tertiary hospital. Training evaluation comprised an anonymous online survey before the training, immediately after and then at six to eight months. Survey data from the sites were pooled for analysis.ResultsEmployment of the Aboriginal Interpreter Coordinator was deemed the most important component of the intervention, based on reach compared to the other components, and timing of the changes in outcomes in relation to the employment period of the coordinator. There was an inverse association between interpreter bookings and self-discharge rate among Aboriginal inpatients throughout the baseline and intervention period (p = 0.02). This association, the timing of changes and assessment of intercurrent activities at the hospital indicated that the study intervention was likely to be casually related to the measured outcomes.ConclusionsCommunication in healthcare can be improved through targeted strategies, with associated improvements in patient outcomes. Health services with high interpreter needs would benefit from employing an interpreter coordinator.

Project description:Importance:The United States is experiencing an opioid abuse epidemic. Opioid overprescription by physicians may contribute to this epidemic. Objectives:To determine if there was a correlation between a postoperative patient's 24-hour predischarge opioid use and the amount of opioids prescribed at hospital discharge and to determine the number of patients who used no opioids prior to discharge but were still prescribed opioids after hospital discharge. Design, Setting, and Participants:This cross-sectional study performed a retrospective record review of 18 343 postoperative patients at Boston Medical Center and Lahey Hospital and Medical Center-Burlington Campus who were discharged home after a postoperative inpatient admission of at least 24 hours. Data collection spanned from May 22, 2014, to June 30, 2016, in the Boston Medical Center data set and from March 23, 2015, to September 7, 2016, in the Lahey Hospital and Medical Center-Burlington Campus data set. Exposures:Surgery requiring a postoperative inpatient hospital stay longer than 24 hours. Main Outcomes and Measures:The main outcome measures were the patient's 24-hour predischarge opioid use and the total quantity of opioids prescribed at hospital discharge. Potential overprescription was defined as the number of patients who used no opioids in the 24 hours prior to hospital discharge but were still prescribed opioids after hospital discharge. Results:Among the 18 343 patients (10 069 women and 8274 men; mean age, 52.2 years) who underwent 21 452 surgical procedures, there was wide variation in the amount of opioids prescribed at hospital discharge given a postoperative patient's 24-hour predischarge opioid use. A total of 6548 patients (35.7%) used no opioids in the 24 hours prior to hospital discharge; however, 2988 of these patients (45.6%) were prescribed opioids at hospital discharge, suggesting potential overprescription. Services that had the highest rates of potential overprescription (obstetrics [adjusted odds ratio (AOR), 3.146; 95% CI, 2.094-4.765] and gynecology [AOR, 2.355; 95% CI, 1.663-3.390], orthopedics [AOR, 0.943; 95% CI, 0.719-1.242], and plastic surgery [AOR, 0.733; 95% CI, 0.334-1.682]) generally had the highest rates of patients still using opioids at hospital discharge. Pediatric surgery was the only service that did not have any cases of potential overprescription (AOR, 2.09 × 10-7; 95% CI, 0.000-0.016). Conclusions and Relevance:Opioids are not regularly prescribed in a patient-specific manner to postoperative patients. Potential opioid overprescription occurs regularly after surgery among almost all surgical specialties.

Project description:BackgroundEarly morning patient discharge from the hospital is increasingly being recognized as a key dimension of quality of care. At our institution, there is a significantly lower early discharge rate on the teaching hospitalist teams in comparison with the non-teaching teams.ObjectiveTo implement a resident-driven intervention in the teaching medical services to increase overall discharge order rate before 11 am (DOB-11) and assess the effect of this intervention on hospital length of stay (LOS), 30-day readmission rates (RR), and resident perception.DesignInterrupted time series as well as controlled before-after designs.ParticipantsAll inpatients discharged from general medicine units.InterventionsWe implemented an educational didactic in conjunction with resident-attending daily walk rounds followed by resident-led multidisciplinary discharge huddles to identify next-day discharges.Main measuresThe primary outcome was DOB-11 rates 18 months pre- and 12 months post-intervention.Secondary outcomesLOS and RR. Additionally, we assessed residents' perception of the early discharge protocol.Key resultsThe DOB-11 rate increased from 12 to 29% (p?<?0.001), LOS increased by 1.47 days (P?<?0.001), and RR increased by 0.32% (P?=?0.84), respectively, on the teaching teams. Compared with the non-teaching (control) teams, the teaching teams registered a greater increase in DOB-11 rate (by 17%, p?<?0.001; ratio of adjusted ORs 2.16; 95% CI, 1.65, 2.85; p value <?0.001), small increase in LOS (by 0.74 day, p?=?0.39; ratio of adjusted post-/pre-intervention ratio [teaching] and post-/pre- intervention ratio [non-teaching] =?1.05, 95% CI, 0.97, 1.14, p?=?0.23), and relative increase in RR (by 3.98%, p?=?0.07, and ratio of ORs?=?1.35, 95% CI, 1.03, 1.8), p?=?0.03). Approximately 55% (16/29) of the residents agreed that the early discharge initiative helped in understanding the importance of prioritizing patients for early discharge. Additionally, 55% (20/36) of the residents "agreed" that the early discharge initiative compromised their learning during teaching rounds.ConclusionOur study demonstrates that DOB-11 is an achievable goal, not only for non-teaching teams but also for resident-run teaching teams.

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Intervention to Reduce Broad-Spectrum Antibiotics and Treatment Durations Prescribed at the Time of Hospital Discharge: A Novel Stewardship Approach.

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Intervention to Reduce Broad-Spectrum Antibiotics and Treatment Durations Prescribed at the Time of Hospital Discharge: A Novel Stewardship Approach.

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