Reducing overuse of antibiotics at discharge home: A single-center mixed methods pilot study.
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ABSTRACT: Background
Antibiotic overuse at hospital discharge is common and harmful; however, methods to improve prescribing during care transitions have been understudied. We aimed to pilot a pharmacist-facilitated antibiotic timeout prior to discharge.Methods
From May 2019 to October 2019, we conducted a single-center, controlled pilot study of a pharmacist-facilitated antibiotic timeout prior to discharge. The timeout addressed key elements of stewardship (eg, duration) and was designed and implemented using iterative cycles with rapid feedback. We evaluated implementation outcomes related to feasibility, including usability, adherence, and acceptability, using mixed methods. Pre versus postintervention antibiotic use at discharge in intervention versus control groups was assessed using logistic regression models controlling for patient characteristics.Results
Pharmacists conducted 288 antibiotic timeouts. Timeouts were feasible (mean 2.5 minutes per timeout) and acceptable (85% [40/48] of hospitalists believed timeouts improved prescribing). Pharmacists recommended an antibiotic change in 25% (73/288) of timeouts with 70% (51/73) of recommended changes accepted by hospitalists. Barriers to adherence included unanticipated and weekend discharges. Compared to control services, there were no differences in antibiotic use after discharge during the intervention.Conclusions
A pharmacist-facilitated antibiotic timeout at discharge was feasible and holds promise as a method to improve antibiotic use at discharge.
SUBMITTER: Giesler DL
PROVIDER: S-EPMC9142756 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundStrategies to optimize antibiotic prescribing at discharge are not well understood.MethodsIn fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies. The association of reported strategies with discharge antibiotic overuse (unnecessary, excess, suboptimal fluoroquinolones) for community-acquired pneumonia (CAP) and urinary tract infection (UTI) was evaluated in 2 ways: (1) all strategies assumed equal weight and (2) strategies were weighted based on the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework (ie, Tier 1-Critical infrastructure, Tier 2-Broad inpatient interventions, Tier 3-Discharge-specific strategies) with Tier 3 strategies receiving the highest weight.ResultsBetween 1 July 2017 and 30 July 2019, 39 hospitals with 20 444 patients (56.5% CAP; 43.5% UTI) were included. Survey response was 100%. Hospitals reported a median (interquartile range [IQR]) 12 (9-14) of 34 possible stewardship strategies. On analyses of individual stewardship strategies, the Tier 3 intervention, review of antibiotics prior to discharge, was the only strategy consistently associated with lower antibiotic overuse at discharge (adjusted incident rate ratio [aIRR] 0.543, 95% confidence interval [CI]: .335-.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR 0.957, 95% CI: .927-.987, per weighted intervention); discharge-specific stewardship strategies were associated with a 12.4% relative decrease in antibiotic overuse days at discharge.ConclusionsThe more stewardship strategies a hospital reported, the lower its antibiotic overuse at discharge. However, Tier 3, or discharge-specific strategies, appeared to have the largest effect on antibiotic prescribing at discharge.
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Project description:ObjectiveTo assess association of pharmacist gender with acceptance of antibiotic stewardship recommendations.DesignA retrospective evaluation of the Reducing Overuse of Antibiotics at Discharge (ROAD) Home intervention.SettingThe study was conducted from May to October 2019 in a single academic medical center.ParticipantsThe study included patients receiving antibiotics on a hospitalist service who were nearing discharge.MethodsDuring the intervention, clinical pharmacists (none who had specialist postgraduate infectious disease residency training) reviewed patients on antibiotics and led an antibiotic timeout (ie, structured conversation) prior to discharge to improve discharge antibiotic prescribing. We assessed the association of pharmacist gender with acceptance of timeout recommendations by hospitalists using logistic regression controlling for patient characteristics.ResultsOver 6 months, pharmacists conducted 295 timeouts: 158 timeouts (53.6%) were conducted by 12 women, 137 (46.4%) were conducted by 8 men. Pharmacists recommended an antibiotic change in 82 timeouts (27.8%), of which 51 (62.2%) were accepted. Compared to male pharmacists, female pharmacists were less likely to recommend a discharge antibiotic change: 30 (19.0%) of 158 versus 52 (38.0%) of 137 (P < .001). Female pharmacists were also less likely to have a recommendation accepted: 10 (33.3%) of 30 versus 41 (8.8%) of 52 (P < .001). Thus, timeouts conducted by female versus male pharmacists were less likely to result in an antibiotic change: 10 (6.3%) of 158 versus 41 (29.9%) of 137 (P < .001). After adjustments, pharmacist gender remained significantly associated with whether recommended changes were accepted (adjusted odds ratio [aOR], 0.10; 95%confidence interval [CI], 0.03-0.36 for female versus male pharmacists).ConclusionsAntibiotic stewardship recommendations made by female clinical pharmacists were less likely to be accepted by hospitalists. Gender bias may play a role in the acceptance of clinical pharmacist recommendations, which could affect patient care and outcomes.
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Project description:BackgroundOccupational therapists who work in hospitals need to assess patients' home environment in preparation for hospital discharge in order to provide recommendations (eg, technical aids) to support their independence and safety. Home visits increase performance in everyday activities and decrease the risk of falls; however, in some countries, home visits are rarely made prior to hospital discharge due to the cost and time involved. In most cases, occupational therapists rely on an interview with the patient or a caregiver to assess the home. The use of videoconferencing to assess patients' home environments could be an innovative solution to allow better and more appropriate recommendations.ObjectiveThe aim of this study was (1) to explore the added value of using mobile videoconferencing compared with standard procedure only and (2) to document the clinical feasibility of using mobile videoconferencing to assess patients' home environments.MethodsOccupational therapists assessed home environments using, first, the standard procedure (interview), and then, videoconferencing (with the help of a family caregiver located in patients' homes, using an electronic tablet). We used a concurrent mixed methods design. The occupational therapist's responsiveness to telehealth, time spent on assessment, patient's occupational performance and satisfaction, and major events influencing the variables were collected as quantitative data. The perceptions of occupational therapists and family caregivers regarding the added value of using this method and the nature of changes made to recommendations as a result of the videoconference (if any) were collected as qualitative data, using questionnaires and semistructured interviews.ResultsEight triads (6 occupational therapists, 8 patients, and 8 caregivers) participated. The use of mobile videoconferencing generally led occupational therapists to modify the initial intervention plan (produced after the standard interview). Occupational therapists and caregivers perceived benefits in using mobile videoconferencing (eg, the ability to provide real-time comments or feedback), and they also perceived disadvantages (eg, videoconferencing requires additional time and greater availability of caregivers). Some occupational therapists believed that mobile videoconferencing added value to assessments, while others did not.ConclusionsThe use of mobile videoconferencing in the context of hospital discharge planning has raised questions of clinical feasibility. Although mobile videoconferencing provides multiple benefits to hospital discharge, including more appropriate occupational therapist recommendations, time constraints made it more difficult to perceive the added value. However, with smartphone use, interdisciplinary team involvement, and patient participation in the videoconference visit, mobile videoconferencing can become an asset to hospital discharge planning.International registered report identifier (irrid)RR2-10.2196/11674.
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Project description:Patients with invasive candidiasis (IC) have complex medical and infectious disease problems that often require continued care after discharge. This study aimed to assess echinocandin use at hospital discharge and develop a transition of care (TOC) model to facilitate discharge for patients with IC. This was a mixed method study design that used epidemiologic assessment to better understand echinocandin use at hospital discharge TOC. Using grounded theory methodology focused on patients given echinocandins during their last day of hospitalization, a TOC model for patients with IC, the invasive candidiasis [I Can] discharge model was developed to better understand discharge barriers. A total of 33% (1405/4211) echinocandin courses were continued until the last day of hospitalization. Of 536 patients chosen for in-depth review, 220 (41%) were discharged home, 109 (20%) were transferred, and 207 (39%) died prior to discharge. Almost half (46%, 151/329) of patients discharged alive received outpatient echinocandin therapy. Independent predictors for outpatient echinocandin use were osteomyelitis (OR, 4.1; 95% CI, 1.1-15.7; p = 0.04), other deep-seated infection (OR, 4.4; 95% CI, 1.7-12.0; p = 0.003), and non-home discharge location (OR, 3.9, 95% CI, 2.0-7.7; p < 0.001). The I Can discharge model was developed encompassing four distinct themes which was used to identify potential barriers to discharge. Significant echinocadin use occurs at hospital discharge TOC. The I Can discharge model may help clinical, policy, and research decision-making processes to facilitate smoother and earlier hospital discharges.
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Project description:BackgroundSurveys play a vital role in cancer research. During the COVID-19 pandemic, the use of electronic surveys is crucial to improve understanding of the patient experience. However, response rates to electronic surveys are often lower compared with those of paper surveys.ObjectiveThe aim of this study was to determine the best approach to improve response rates for an electronic survey administered to patients at a cancer center during the COVID-19 pandemic.MethodsWe contacted 2750 patients seen at Moffitt Cancer Center in the prior 5 years via email to complete a survey regarding their experience during the COVID-19 pandemic, with patients randomly assigned to a series of variations of prenotifications (ie, postcard, letter) or incentives (ie, small gift, modest gift card). In total, eight combinations were evaluated. Qualitative interviews were conducted to understand the level of patient understanding and burden with the survey, and quantitative analysis was used to evaluate the response rates between conditions.ResultsA total of 262 (9.5%) patients completed the survey and 9 participated in a qualitative interview. Interviews revealed minimal barriers in understanding or burden, which resulted in minor survey design changes. Compared to sending an email only, sending a postcard or letter prior to the email improved response rates from 3.7% to 9.8%. Similarly, inclusion of an incentive significantly increased the response rate from 5.4% to 16.7%, especially among racial (3.0% to 12.2%) and ethnic (6.4% to 21.0%) minorities, as well as among patients with low socioeconomic status (3.1% to 14.9%).ConclusionsStrategies to promote effective response rates include prenotification postcards or letters as well as monetary incentives. This work can inform future survey development to increase response rates for electronic surveys, particularly among hard-to-reach populations.
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Project description:Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital.To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice.A mixed methods analysis of 598 patient safety incident reports in England and Wales related to 'Discharge' from the National Reporting and Learning System.Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice.A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with 'safe discharge' checklists, discharge coordinators, and family involvement.Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.
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Project description:BackgroundFrailty is associated with adverse health outcomes in people with chronic kidney disease (CKD). Evidence supporting targeted interventions is needed. This pilot randomised controlled trial (RCT) aimed to inform the design of a definitive RCT evaluating the effectiveness of a home-based exercise intervention for pre-frail and frail older adults with CKD.MethodsParticipants were recruited from nephrology outpatient clinics to this two-arm parallel group mixed-methods pilot RCT. Inclusion criteria were: ≥65 years old; CKD G3b-5; and Clinical Frailty Scale score ≥4. Participants categorised as pre-frail or frail using the Frailty Phenotype were randomised to a 12-week progressive multi-component home-based exercise programme or usual care. Primary outcome measures included eligibility, recruitment, adherence, outcome measure completion and participant attrition rate. Semi-structured interviews were conducted with participants to explore trial and intervention acceptability.ResultsSix hundred and sixty-five patients had an eligibility assessment with 217 (33%; 95% CI 29, 36) eligible. Thirty-five (16%; 95% CI 12, 22) participants were recruited. Six were categorised as robust and withdrawn prior to randomisation. Fifteen participants were randomised to exercise and 14 to usual care. Eleven (73%; 95% CI 45, 91) participants completed ≥2 exercise sessions/week. Retained participants completed all outcome measures (n = 21; 100%; 95% CI 81, 100). Eight (28%; 95% CI 13, 47) participants were withdrawn. Fifteen participated in interviews. Decision to participate/withdraw was influenced by perceived risk of exercise worsening symptoms. Participant perceived benefits included improved fitness, balance, strength, well-being, energy levels and confidence.ConclusionsThis pilot RCT demonstrates that progression to definitive RCT is possible provided recruitment and retention challenges are addressed. It has also provided preliminary evidence that home-based exercise may be beneficial for people living with frailty and CKD.Trial registrationISRCTN87708989; https://clinicaltrials.gov/.
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Project description:BackgroundPoint-of-care ultrasound (POCUS) competence consists of image acquisition, image interpretation, and clinical integration. Limited data exist on POCUS usage patterns and clinical integration by emergency medicine (EM) residents. We sought to determine actual POCUS usage and clinical integration patterns by EM residents and to explore residents' perspectives on POCUS clinical integration.MethodsWe conducted an explanatory sequential mixed-methods study at a 4-year EM residency program. In phase 1, EM ultrasound (US) attendings observed PGY-4 EM residents' clinical integration of POCUS in real time while on shift in the emergency department (ED). EM US attendings evaluated residents on their intent to perform POCUS, actual POCUS usage, and competence per patient encounter. We used logistic regression to analyze these parameters. In phase 2, we conducted semi-structured interviews with the observed PGY-4 residents regarding POCUS usage and clinical integration in the ED. We analyzed qualitative data for themes.ResultsEmergency medicine US attendings observed 10 PGY-4 EM residents during 254 high-acuity patient encounters from December 2018 to March 2019. EM US attendings considered POCUS indicated for 26% (66/254) of patients, possibly indicated for 12% (30/254) and not indicated for 62% (158/254). Of the 66 patients for whom EM US attendings considered POCUS indicated, PGY-4s intended to perform POCUS for patient management 61% (40/66) of the time. PGY-4s subsequently incorporated POCUS into patient management 73% (48/66) of the time. EM US attendings considered PGY-4s entrustable to perform POCUS independently 81% (206/254) of the time. We did not find a statistically significant association between shift volume, shift type, or POCUS application, and resident intent to perform POCUS nor competence. Interviews identified three factors that influence PGY-4's POCUS clinical integration: motivations to use POCUS, barriers to utilization, and POCUS educational methods.ConclusionsThis mixed-methods study identified a significant gap in POCUS utilization and clinical integration by PGY-4 EM residents for clinically indicated cases identified by EM US attendings. As clinical integration is a cornerstone of POCUS competence, it is important to ensure that EM resident POCUS curricula emphasize training on clinical utilization and indications for POCUS while on shift in the ED.
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Project description:BackgroundOccupational therapists working in hospitals are usually involved in discharge planning to assess patients' safety and autonomy upon returning home. However, their assessment is usually done at the hospital due to organizational and financial constraints. The lack of visual data about the patients' home may thus reduce the appropriateness and applicability of the support recommended upon discharge. Although various technological tools such as mobile devices (mobile health) are promising methods for home-based distance assessment, their application in hospital settings may raise several feasibility issues. To our knowledge, their usefulness and added value compared to standard procedure have not been addressed yet in previous studies. Moreover, several feasibility issues need to be explored.ObjectiveThis paper aims to (1) document the clinical feasibility of using an electronic tablet to assess the patient's home environment by mobile videoconferencing and (2) explore the added value of using mobile videoconferencing, compared to the standard procedure.MethodsA feasibility and comparative study using a mixed-methods (convergent) design is currently undergoing. Six occupational therapists will assess the home environment of their patients in the hospital setting: they will first perform a semistructured interview (a) and then use mobile videoconferencing (b) to compare "a versus a+b." Interviews with occupational therapists and patients and their caregivers will further explore the advantages and disadvantages of mobile videoconferencing. Two valid tools are used (the Canadian Measure of Occupational Performance and the telehealth responsivity questionnaire). Direct and indirect time is also collected.ResultsThe project was funded in the spring of 2016 and authorized by the ethics committee in February 2017. Enrollment started in April 2017. Five triads (n=4 occupational therapists, n=5 clients, n=5 caregivers) have been recruited until now. The experiment is expected to be completed by April 2019 and analysis of the results by June 2019.ConclusionsMobile videoconferencing may be a familiar and easy solution for visualizing environmental barriers in the home by caregivers and clinicians, thus providing a promising and inexpensive option to promote a safe return home upon hospital discharge, but clinical feasibility and obstacles to the use of mobile videoconferencing must be understood.International registered report identifier (irrid)DERR1-10.2196/11674.
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