Hospital Pharmacy - November 2017 - 681
681
Ghamrawi et al.
Table 2. Characteristics of Patients in Study Population.
Variable
Age, y, median (IQR)
Male, n (%)
Hospital LOS, d, median (IQR)
Primary service, medical, n (%)
Primary service, surgical, n (%)
Infectious diseases consultation, n (%)
Preimplementation
62 (53-72)
194 (52.0)
12 (6.5-26.5)
195 (52.3)
178 (47.7)
177 (47.5)
Postimplementation
61 (47-70.8)
197 (52.4)
12 (6-24.8)
214 (56.9)
162 (43.1)
178 (47.3)
P
.018
.942
.879
.213
1
Note. IQR = interquartile range; LOS = length of stay.
Friday), and interventions were acted upon by contacting
clinicians after reviewing the available data in CDSS and
EHR. Along with ASP alert evaluations, pharmacists were
involved in patient care rounds, pharmacokinetics dosing
services, and teaching. In the preimplementation phase,
patients were identified retrospectively for inclusion using
the electronic medical record and the same criteria used to
trigger alerts in the postimplementation phase. Included
patients and related intervention opportunities were retrospectively reviewed by an infectious diseases (ID) clinical
pharmacy specialist.
For each included patient, the total number of actionable
alerts, number of attempted interventions (post-CDSS
implementation), and percentage of accepted interventions
were recorded. In addition, the reason for nonactionable
items and time spent on each type of alert was documented.
Actionable alerts were defined as an intervention that was
or could have been attempted based on clinical features as
deemed appropriate by the pharmacist. Intervention time was
the time a pharmacist spent evaluating alerts in the CDSS,
reviewing the EHR, and intervening on alerts, if deemed necessary. Time to de-escalation of therapy was the opportunity
time once the alert signaled in the CDSS to time the broadspectrum antimicrobial was stopped. Time to appropriate
therapy was the time from culture draw to time at which targeted antimicrobial therapy was initiated or escalated based
upon in vitro susceptibility data.
Categorical variables are reported as n (%) and were analyzed using the Pearson chi-square or Fisher exact test, as
appropriate. Continuous variables are reported as median
(interquartile range [IQR]) and were analyzed using the
Mann-Whitney U test as the data were not normally distributed. Survival analysis was utilized to evaluate the times to
escalation and de-escalation. Median and 95% confidence
intervals (CI) were calculated and survival distributions were
analyzed with the log-rank test. All tests were 2-tailed, and a
P value of ≤.05 was considered statistically significant.
Analyses were performed using SPSS, version 15.0 for
Windows (SPSS Inc, Chicago, Illinois).
Results
A total of 572 patient cases were included (304 preimplementation and 268 postimplementation), and 774 alerts were
reviewed in the study. Of these, 25 alerts in pediatric patients
were excluded for a total of 749 included alerts in the final
evaluation-373 and 376 alerts in the preimplementation
and postimplementation groups, respectively. A summary of
baseline characteristics of the study patient population is outlined in Table 2. The primary service was most frequently
medical (52% vs 57%), and there was an infectious diseases
consult for 48% and 47% of alerts in the preimplementation
and postimplementation groups, respectively.
Summary of alert outcomes is presented in Table 3. The
most common alert types were prebuilt de-escalation and
escalation (ie, bug-drug mismatch) Therapeutic Antibiotic
Monitoring (TAM) alerts (614 of 749, 82%), custom-built
de-escalation alerts (63 of 749, 8%), and custom-built drug
interaction alerts (54 of 749, 7%). Custom-built therapy
escalation and adverse drug reaction monitoring resulted in
the least number of alerts. Overall, 306 (41%) of alerts were
deemed actionable (173 [46.4%] preimplementation and 133
[35.4%] postimplementation, P = .002). There was no difference in the percentage of actionable interventions between
custom-built (53 of 135, 39%) and prebuilt alerts (253 of
614, 41%, P = .68). In the postimplementation group, an
intervention was attempted in 97% of alerts that were deemed
actionable, with a 70% acceptance rate. The majority of
these interventions were discussed with physician residents
and infectious diseases-attending physicians and fellows-intraining. Reasons for alert nonacceptance included provider
discretion to maintain course of therapy based on additional
patient information, patient status change to comfort care, a
pending ID consult, and no return call from provider.
Reasons for nonactionable alerts are presented in Table 4.
The most common reason for nonactionable alerts in both
the preimplementation and postimplementation groups
included no need for intervention or therapy deemed appropriate at the time of review (ie, antimicrobial therapy appropriate based on additional available cultures; 87% vs 72.4%
in the preimplementation and postimplementation groups,
respectively).
In the postimplementation phase, pharmacists tracked
time spent reviewing and intervening on alerts. The median
(IQR) time spent on each alert was 7 (5-13) minutes. More
time was spent on each actionable alert compared with each
individual nonactionable alert (median [IQR]: 15 [12-17] vs
6 [5-7] minutes, respectively, P < .001).
Table of Contents for the Digital Edition of Hospital Pharmacy - November 2017
AKD—The Time Between AKI and CKD: What Is the Role of the Pharmacist?
Letter to the Editor
Antithrombotic Therapy Post Endovascular Stenting for Superior Vena Cava Syndrome
Pharmaceutical Pipeline Update
Janus Kinase Inhibitors for the Treatment of Rheumatoid Arthritis
Formulary Drug Reviews
Etelcalcetide
Treatment of Hypertriglyceridemia-Induced Acute Pancreatitis With Insulin, Heparin, and Gemfibrozil: A Case Series
Evaluation of Antimicrobial Stewardship–Related Alerts Using a Clinical Decision Support System
Compatibility, Stability, and Efficacy of Vancomycin Combined With Gentamicin or Ethanol in Sodium Citrate as a Catheter Lock Solution
Development of Institutional Guidelines for Management of Gram-Negative Bloodstream Infections: Incorporating Local Evidence
Underutilization of Aldosterone Antagonists in Heart Failure
Stability of Procainamide Injection in Clear Glass Vials and Polyvinyl Chloride Bags
Development of a Local Health-System Pharmacy Resident Society
Challenges and Solutions to New Manager Onboarding
Hospital Pharmacy - November 2017 - 649
Hospital Pharmacy - November 2017 - 650
Hospital Pharmacy - November 2017 - 651
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Hospital Pharmacy - November 2017 - AKD—The Time Between AKI and CKD: What Is the Role of the Pharmacist?
Hospital Pharmacy - November 2017 - 662
Hospital Pharmacy - November 2017 - Letter to the Editor
Hospital Pharmacy - November 2017 - Pharmaceutical Pipeline Update
Hospital Pharmacy - November 2017 - Janus Kinase Inhibitors for the Treatment of Rheumatoid Arthritis
Hospital Pharmacy - November 2017 - Formulary Drug Reviews
Hospital Pharmacy - November 2017 - Etelcalcetide
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