Pharmacists Expanded Their Antimicrobial Stewardship Role During Pandemic

By Marilynn Larkin

July 07, 2020

NEW YORK (Reuters Health) - To help limit hospital staff contact with SARS-CoV-2 patients, pharmacists at a university hospital consolidated the number of times medications needed to be administered throughout the day, optimized pharmacotherapy and led therapeutic drug monitoring efforts.

"We leveraged the pharmacist's role as well as our clinical decision-support system to help protect our colleagues on the front lines and conserve personal protective equipment (PPE), while still maintaining optimal care for patients with SARS-CoV-2," Ashley Jones of Emory Healthcare in Atlanta told Reuters Health by email.

"Pharmacists were able to readily identify patients infected with SARS-CoV-2 or under investigation and make recommendations to providers via phone after reviewing electronic medical records, with no face-to-face contact with patients or providers," she said. "This initiative was executed along with our pharmacy department's transition to telecommuting."

As reported in Infection Control and Hospital Epidemiology, decentralized pharmacists performed daily patient chart reviews to optimize pharmacotherapy, including antimicrobials. They also used clinical surveillance software with both real-time alerts and structured workflows for anticoagulation monitoring, renal dose adjustments, therapeutic drug monitoring, and microbiology review.

Because positive SARS-CoV-2 PCR results were incorporated into pharmacists' daily workflow via the surveillance software, pharmacists could identify infected patients and assess their medication administration record for optimization. Individuals under investigation were identified during routine chart review.

The initiative provided pharmacists with guidance on strategic methods of consolidating the medication administration record based on three domains:

1) Consolidation of medication administration times. Guidance was provided after considering safety of early or late doses during the transition, and potential drug-drug interactions (e.g., doxycycline with calcium supplementation).

2) Optimizing pharmacotherapy. Pharmacists were encouraged to recommend therapy modifications that maintained both safety and efficacy, while decreasing exposure to healthcare staff. For example, a patient on twice-daily NPH insulin as an outpatient might be switched to once-daily long-acting insulin while an inpatient. This approach later led to a streamlined protocol for managing mild-to-moderate diabetic ketoacidosis with subcutaneous insulin.

3) Therapeutic drug monitoring. With regard to vancomycin dosing and monitoring, for example, the team encouraged pharmacists to reduce obtaining unnecessary levels (e.g., for uncomplicated skin and soft tissue infections or an anticipated short course of therapy) to help further decrease healthcare worker exposure. If the pharmacist determined a level was needed, he or she placed a timed order for phlebotomy or nursing.

Jones said, "Phlebotomy staff recognized that these efforts improved their team's efficiency and reduced PPE requirements. One of the lessons learned is that we should explore using this approach for infections that are highly transmissible in the hospital, such as Clostridioides difficile."

Deborah Sadowski, Director of Pharmacy Services at Deborah Heart and Lung Center in Browns Mills, New Jersey, commented in an email to Reuters Health, "The approach seems quite feasible, although some modifications of the process may be necessary based on bed size and the pharmacy staffing model at individual hospitals."

"While many of these interventions are routinely done as part of good clinical practice, taking this more aggressive approach to a wider view of any and all medications/therapies is a real positive," she said.

"My concern would be twofold," she said. "First, the ability of hospitals of varying sizes to adapt a similar process, whether they are currently using a clinical surveillance software program or not, and second, assuring the process includes both known and suspected positive patients and applying consistency of process in all areas of the hospital involved in their care."

"I would also emphasize the significant clinical value these aggressive reviews of therapy can provide to the patients, in addition to the operational and safety value provided to healthcare workers," she concluded.

Erin Marriott, clinical and regulatory support manager for Guardian Pharmacy Services in Atlanta, also commented by email. "Before these best practices were brought to the forefront, consultant pharmacists at skilled nursing and assisted living facilities were already employing many of the strategies described in the study," she told Reuters Health. "Our teams streamline med pass times and optimize medication therapy regularly, and we only carry out drug monitoring when appropriate and necessary."

"We have found these strategies particularly valuable now, in this pandemic, when minimizing patient touch points reduces the risk of exposure for patients and staff members," she said.

"My primary concern is ensuring the necessary follow through when optimizing the medication therapy," she added. "Streamlining the medication administration times is fairly straightforward, but when it is time to change medications and dosing frequency, it's important that the monitoring and follow-up not be lost in transition."

SOURCE: Infection Control and Hospital Epidemiology, online June 19, 2020.