In this episode, I’ll discuss a pharmacy-driven rapid bacteremia response program.
While rapid diagnosis of bacteremia infections is wonderful, nothing matters until the patient actually receives effective antibiotic treatment. However the lag time between laboratory notification, physician order selection, pharmacy verification and dispensing, and nurse administration can be significant as each step in the process introduces a delay.
Pharmacists are uniquely positioned to break through these barriers and eliminate the delay in time to effective antibiotics. To examine the pharmacist’s role in improving this aspect of care, one 1500 bed health system recently published their results in AJHP of a pharmacy-driven rapid bacteremia response program.
The program involved the following workflow for positive blood culture gram stain results:
- Results are called to the pharmacy from the micro lab as soon as they are available 24/7 for all adult patients
- The pharmacist uses a pre-approved algorithm to evaluate current antibiotic therapy and if the patient is not already receiving adequate antibiotic therapy they order a one-time STAT dose of an appropriate antibiotic without needing to first contact a provider
- The pharmacist communicates with nursing staff and pharmacy technicians to expedite the preparation, delivery and administration of the antibiotic
- If blood cultures show gram-positive cocci in clusters, the pharmacists order 2 sets of repeat blood cultures per protocol and communicates the orders to the bedside nurse
- Rapid diagnostic tests are also called to the pharmacy and the pharmacist is empowered to order isolation and contact the provider with recommendations. If the provider does not return the page within 1 hour an on call ID pharmacist in consultation with a medical director discuss the case and provide antibiotic orders
The program has additional documentation requirements and before implementation needed to satisfy concerns from medical staff as well as required significant education for all disciplines involved.
In the first year after implementation over 2000 results were called to the pharmacy and about one-third resulted in the pharmacist ordering an antimicrobial.
In the cohort of patients who were not already on antibiotics, the authors report the median time from gram stain to antibiotic administration was just 51 minutes, down from 10 hours prior to implementation.
While the authors did not measure the clinical impact of this improvement, many studies support the benefit of timely antibiotics and such a dramatic improvement would be likely to have conferred a clinically meaningful benefit to the post-implementation cohort.
Such a program would take a significant amount of cooperation between disciplines to implement at another institution but has the potential to dramatically decrease the time to appropriate first antibiotic for patients with newly diagnosed bacteremia.
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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.