さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

Role of postgraduate year 2 pharmacy residents in providing weekend antimicrobial stewardship coverage in an academic medical center.

Role of postgraduate year 2 pharmacy residents in providing weekend antimicrobial stewardshipcoverage in an academic medical center.

 

www.ncbi.nlm.nih.gov

 

 2017年 Am J Health Syst Pharm に報告された、2年目の薬剤師レジデントによるweekend ASPに関するNYU Langone Medical Center (725-bed tertiary care academic hospital) の研究。

 

 

 

KEY POINTS

 

  • Providing antimicrobial stewardship program (ASP) cover- age at all times remains a challenging task, and pharmacy residents are an underutilized resource for expanding hospital ASP services.

  • Postgraduate year 2 pharmacy residents in infectious diseases (ID) or critical care are ideal candidates for expanding ASP services due to their advanced clinical knowledge and independent decision-making skills.

  • ASP weekend coverage as a longitudinal learning experience offers an interactive learning environment for advancing residents’ skills in ID pharmacotherapy and stewardship.

 

Abstract

 

PURPOSE: 

 

The integration of pharmacy residents into an antimicrobial stewardship program (ASP) is described, and data on the residents' ASP interventions and outcomes are reported.

 

SUMMARY: 

 

ASP coverage of nighttime, holiday, and weekend shifts is often provided by infectious diseases (ID) medical fellows and staff pharmacists, potentially leading to inconsistent stewardship practices. As part of an initiative by a large urban hospital to provide around-the-clock, comprehensive ASP services 7 days a week, postgraduate year 2 (PGY2) pharmacy residents in ID or critical care were assigned to provide ASP coverage on weekends. Over a 12-month period, residents providing ASP weekend coverage documented a total of 1,443 interventions, of which 1,000 (69%) were pursuant to 72-hour prospective audit and feedback review and 443 (31%) occurred during ASP phone coverage. A comparison of overall antimicrobial utilization (mean ± S.D. days of therapy [DOT] per 1,000 patient-days [PD]) before and after implementation of resident ASP coverage on weekends showed a decrease in aggregate antimicrobial use from 799.3 ± 46.8 to 740.7 ± 17.3 DOT/1,000 PD (a difference of 58.6 DOT/1,000 PD, p = 0.08), with a corresponding decline in the incidence of hospital-onset Clostridium difficile infection (from 1.18 cases to 0.9 case per 1,000 PD).

 

CONCLUSION: 

 

By expanding the hospital's ASP services by assigning PGY2 pharmacy residents to weekend coverage, the institution was able to provide high-level clinical care 7 days per week, which benefited both patients and PGY2 pharmacy residents while meeting national ASP regulatory requirements.

 

 

 

The ASP at NYULMC was initiated in 2008 and expanded to include interprofessional and collaborative roles involving the ID medical director, ID medical attendings and fellows, ID-trained pharmacists, and rounding clinical pharmacotherapy specialists. On weekdays from 8 a.m. to 4 p.m., ID-trained ASP pharmacists provide approvals for restricted antimicrobials via the ASP phone. Additional responsibilities include prospective audit and feedback for restricted and broad-spectrum antimicrobials at 72 hours after initiation based on ASP reports generated by the CPOE system, medication reconciliation targeting patients receiving ART, and PK dosing and monitoring of aminoglycosides and vancomycin. In 2014, rapid microbiological diagnostic testing (RDT) with polymerase chain reaction (PCR) analysis for blood culture results indicating the presence of gram-positive cocci (GPC) in pairs and clusters was introduced as a new ASP initiative. ID-trained ASP pharmacists receive electronic noti cations 3 times daily to facilitate optimal therapy based on results of PCR analysis, including deescalating or discontinuing unnecessary empirical therapy. ASP interventions are directly communicated to the primary team, as no policy regarding automatic pharmacy interventions is currently established at our hospital. Also, all pharmacists document interventions using the Epic iVent system (Epic Systems Corporation), which is designed to accommodate different levels of care. ASP interventions (quantity and type) are reported quar- terly and annually at the institutional level: to the antimicrobial subcommittee, the medication safety committee, and the pharmacy and therapeutics committee. Prior to 2014, ID fellows were solely responsible for providing approvals for restricted antimicrobials during the weekday hours of 4 p.m.–10 p.m. and on weekends during the hours of 8 a.m.–10 p.m. ID fellows did not provide prospective audit and feedback for antimicrobial orders and did not document approvals of restricted antimicrobials in the CPOE system. Therefore, baseline weekend intervention data were not available for the purposes of the data comparisons described later in this article.

 

ASP weekend coverage as a longitudinal learning experience.

The PGY1 pharmacy residency program at NYULMC was initiated in 2010 and has been expanded to encompass a total of 4 PGY1 pharmacy residents. In 2014, PGY2 pharmacy residency programs were created in the specialty areas of ID and CC. Prior to the creation of the PGY2 programs, ASP weekend coverage was provided by ID medical fellows and limited to approvals of restricted antimicrobials. Additionally, there was no phar- macist presence during medical response team (MRT) (i.e., code-blue) and stroke alerts on weekends. To bridge the gaps in pharmacy coverage, a PGY2 “clinical weekend program” was implemented in 2014. The program incorporates longitudinal learning experiences in ASP coverage and emergency response. The longitudinal learning experience was designed to support a hospitalwide initiative to deliver high-level clinical services 7 days a week while still providing a supportive learning environment for PGY2 pharmacy residents. The longitudinal learning experience provided a platform for the PGY2 residents to develop advanced skills in ID pharmacotherapy management in patients with acute and chronic ID issues in different service areas, including CC, general surgery, medicine, urology, hematologyoncology, and rehabilitation. Throughout this experience, the residents engaged in independent decisionmaking and developed the skills to manage complex clinical situations while still supported and subject to oversight and performance assessment by ID-trained ASP preceptors.

 

Responsibilities of residents.

During the 2014–15 residency year, PGY2 pharmacy residents in ID and CC provided full onsite ASP coverage from 8 a.m. to 4 p.m. on Saturdays and Sundays, alternating every other weekend to extend pharmacist-driven ASP coverage to 7 days a week. The PGY2 pharmacy resident was responsible for providing approval of orders for restricted antimicrobials via the ASP phone, prospectively auditing the use of restricted and broad-spectrum antimicrobials at 72 hours after initia- tion, reconciling ART medication regimens, and providing PK/PD-guided dosing and monitoring of aminoglycoside and vancomycin therapy. The PGY2 resident was also responsible for reviewing positive blood culture results with GPC in pairs and clusters after results of RDT with PCR analysis were reported. Additionally, the PGY2 pharmacy resident was responsible for participation in emergency patient management, providing pharmacist coverage for MRT and code-blue alerts and stroke emergencies. All ASP interventions and code response participation required documentation through the Epic iVent system using speci c

ASP intervention categories. An ID- trained ASP pharmacist was available as a backup and to provide clinical support. Patient follow-up from the weekend and a detailed summary of approvals of restricted antimicrobials were communicated to the covering ID-trained ASP pharmacist at the be- ginning of each week for continuity of care and performance assessment.

 

Metrics

 

  1. ASP prospective audit and feedback review.
  2. ASP phone coverage. : calls per day
  3. Antimicrobial utilization.  : DOT/1,000 PD
  4. Rates of hospital-onset Clostridium difficile infection. :  cases/1,000 PD

 

f:id:akinohanayuki:20170604163928p:plain

 

f:id:akinohanayuki:20170604163939p:plain

f:id:akinohanayuki:20170604163951p:plain

f:id:akinohanayuki:20170604164003p:plain

 

感想

 

Weekend ASP を薬剤師レジデントにお願いするという過酷な論文。 

評価項目に、電話数があることも面白いです。

ID-phによるWeekdayと比較しても、なかなかの仕事量。

必要性ありそうですが、多くの病院は休日は主治医が不在で、抗菌薬治療に対する相談が難しく、機能する病院は限られそうですね。

 

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