Setting

The University of Texas Southwestern Medical Center (UTSW) is an academic medical center consisting of two university hospitals with 825 beds. The OPAT program was established in August 2020 to provide dedicated management of patients receiving IV antimicrobial therapies in the outpatient setting. The OPAT program consists of an ID-trained pharmacist, a nurse coordinator, and an ID physician. Due to limited resources, the OPAT program currently only manages patients who are internally referred by ID providers, which represents ∼70% of the total OPAT patients discharged from the hospital per an internally conducted data collection study. In 2023, the TOC pharmacists reviewed 105 OPAT prescriptions per month on average.

The UTSW TOC pharmacist team consists of 15 TOC pharmacists to provide various services, including pre-discharge bedside education, discharge medication review, and discharge medication counseling. Thirteen of the 15 TOC pharmacists are located in the hospitals with three dedicated to patients who recently underwent solid organ transplantation and two who are dedicated to patients discharging from the emergency department (ED). This hospital team provides coverage every day (weekdays: 7 a.m.–7:30 p.m.; weekends: 7 a.m.–5:30 p.m.; ED: 2 p.m.–12 a.m.). The TOC pharmacists have been integrated into the OPAT workflow since early 2021. The TOC OPAT prescription queue is constantly reviewed by at least one TOC pharmacist during the TOC hours. The expectation is for the OPAT prescriptions to be reviewed by a TOC pharmacist within 30 minutes of prescription entry. Timing of OPAT prescription verification and documenting of the verification as a chart note are dependent on intervention(s) needed and the timeliness of the provider response.

Table 1.

Characteristics and frequencies of outpatient parenteral antimicrobial therapy (OPAT) prescription and transitions of care (TOC) pharmacist interventions

^a Meropenem (8), ampicillin-sulbactam (5), penicillin G (3), ganciclovir (3), micafungin (2), fluconazole (2), ceftazidime-avibactam (2), cefoxitin (2), amikacin (2), metronidazole (2), levofloxacin (1), ceftazidime (1), ceftaroline (1), ampicillin (1)

^b Solid organ transplant (21), pulmonary (2), internal medicine (2), digestive and liver disease (2), bone marrow transplant (1), colorectal surgery (1), and geriatrics (1)

^c Reasons for other antimicrobial-optimization interventions included discharge antimicrobial(s) mismatching with hospital-administered antimicrobial(s) (7), available alternative antimicrobial(s) with better ease of administration (2), duplicate spectrum of activity in antimicrobials prescribed (1), drug–drug interaction (1), and missing supportive hydration (1)

The inpatient providers prescribe IV medications for discharge by utilizing a Care Coordination order set. Within the order set, providers are expected to include the following details for each prescription: medication name, dose, route, frequency, intended duration of therapy, end date, and laboratory monitoring parameters. After a provider submits a prescription for outpatient IV antimicrobial(s), the order is routed to the TOC OPAT prescription queue. A TOC pharmacist then ensures that the IV antimicrobial(s) is/are prescribed in accordance with institution-specific OPAT recommendations, including guidance for medication dosing and laboratory monitoring. If edits are needed, the TOC pharmacists intervene and work with providers within the treatment team to update the prescription. After the prescription deemed to be appropriate, the TOC pharmacists verifiy the prescription and acknowledge their review in a note documented in the electronic medical record (Epic^®). This note instructs the inpatient care coordinators to start the discharge medication set-up process.

Education specific to OPAT was provided to the TOC pharmacist team by an ID-trained OPAT pharmacist on a quarterly basis for a year following the initial TOC integration. Since then, the education is given on an as-needed basis. Communication about any changes to the institution-specific OPAT guidance is regularly communicated to the TOC pharmacist team, and the OPAT team is available throughout the day (weekdays 8 a.m.–5 p.m.) for questions regarding OPAT prescriptions. Once the OPAT prescription is verified by a TOC pharmacist, the OPAT team continues to monitor the patient on a daily basis (with the exception of weekends) until discharge and assumes full management of IV antimicrobial therapies after the patient is discharged from the hospital.

Design

This retrospective chart review included patients with Care Coordination orders containing IV antimicrobial prescriptions at UTSW that were entered between November 1, 2022, and January 31, 2023. Patient information was collected through the iVent feature on Epic, where pharmacists can categorize and document interventions made regarding patient care. The patient was excluded if the treatment plan did not include an IV antimicrobial, if the antimicrobial therapy was completed during inpatient admission, or if the admission resulted in a self-directed discharge. From the initial list of patients meeting the eligibility criteria, the data collector reviewed every second patient. Prescription-specific and intervention-specific data points were collected using REDCap (Research Electronic Data Capture). ^{Reference Harris, Taylor and Minor5} The prescription-specific data points included admission and discharge dates, date and time of OPAT prescription, date and time of TOC OPAT review, prescribing provider team (General ID, Transplant ID, Cystic Fibrosis, and other teams), indication for OPAT, and type(s) of intervention(s) made by TOC pharmacists. The TOC pharmacists’ interventions were categorized as following: safety monitoring laboratory parameters, prescription clarification, antimicrobial optimization, and other for interventions outside of these categories. Antimicrobial optimization interventions were further classified into dose/frequency-related, duration-related, drug allergy clarification, or other interventions. The UTSW Human Research Protection Program determined that this quality improvement study did not require Institutional Review Board oversight.