Pharmacist Review of ER Visits Reduces Prevalence of Inappropriately Prescribed Antimicrobials

Up to one-fifth of adult patients discharged from emergency departments may require antimicrobial prescription revisions.

Adding pharmacists to the post-emergency department visit review process reduces the prevalence of inappropriate antimicrobial prescriptions, according to a paper published online in The American Journal of Emergency Medicine.

Researchers from the Allegheny Health Network in Pittsburgh, Pennsylvania, evaluated antimicrobial prescriptions and culture results from emergency department visits between May 1, 2012, and October 31, 2012, and compared them to a similar cohort between February 1, 2013, and July 31, 2013.

In the study, a nurse reviewed each emergency department chart from the previous day for discrepancies in final laboratory and imaging results. Using electronic medical records, an emergency medicine resident and a pharmacy resident who were not involved in the nurse-driven process reviewed information about the discharged patients’ age, sex, history of renal and/or liver disease, home medications, reported medication allergies, cultures sent to the emergency department and their results, and discharged antimicrobial prescriptions and patient instructions, or lack thereof.

“We, like many emergency departments, have a quality assurance process to follow up on patient results and make adjustments based on culture results,” Arvind Venkat, MD, Vice Chair for Research and Faculty Academic Affairs at the Allegheny Health Network, told Pharmacy Times in an exclusive interview. “However, we were not sure if even that process was providing evidence-based and safe therapies to patients who commonly have complex medical histories. For that reason, we chose to evaluate whether our existing quality assurance processes were adequate in the case of discharged emergency department patients, and whether we could improve that review process with the addition of pharmacists.”

The researchers found 411 of 3208 cultures in the pre-pharmacist cohort and 459 of 3790 in the post-pharmacist group met the inclusion criteria. From the included cohorts, 73 of 411 pre-pharmacist cultures and 75 of 459 post-pharmacist cultures required revised or new antimicrobial prescriptions for the respective discharged patients.

“The study confirmed our expectations that the specialized knowledge of pharmacists would improve the evidence-based nature and safety of our quality assurance process in discharged emergency department patients who received antibiotics based on an empirical infectious disease diagnosis,” Dr. Venkat continued. “The one moderate surprise was that the major issues that were improved focused upon the duration of prescription and the susceptibility of the causative organism, rather than safety issues surrounding medication interactions and adjustments for renal or liver dysfunction.”

Data from the study suggested that 13% to 21% of positive cultures among discharged adult patients might require antimicrobial revision, which reinforces the importance of treatment review and re-evaluation.

“Health care today is a team sport. Every health care professional—physician, nurse, pharmacist, among others—has an important area of expertise that can and should be brought to bear to safely and effectively treat often complex patients,” Dr. Venkat said. “Merely having a quality assurance process does not ensure improved care.”