Culture Follow-up Program Description
This study was conducted at Mercy Health Saint Mary’s, a 350-bed community teaching hospital with two affiliated UC sites serving urban Grand Rapids, Michigan. The UC centers are staffed 12-h per day, 7-days per week, and treat more than 32,000 patients each year. The UC culture follow-up program is conducted off-site by 2.0 full-time equivalent (FTE) ED and 1.0 FTE Infectious Disease (ID) clinical pharmacists who staff at the main hospital campus.
The pharmacist-led UC culture follow-up program began in April 2015 following CPA protocol approval by the institution’s Pharmacy and Therapeutics Committee, which specifies physician-pharmacist developed, evidence-based, antimicrobial treatment protocols (agent, dose, and duration); it is stratified by disease state and allows for pharmacists to independently conduct patient follow-up for the most common infectious diagnoses utilizing the outlined protocols. The CPA was developed utilizing local susceptibility data as well as national guidelines for common infectious diseases. The UC CPA was modeled off of an existing CPA for the hospital’s pharmacist-led ED culture follow-up program, which had been in place since October 2013. The CPA was signed by the ED and ID clinical pharmacists as well as the UC physician director.
All culture types for adult and pediatric patients, with the exception of blood, synovial fluid, and cerebrospinal fluid, are managed under the collaborative practice agreement by a pharmacist. Routine culture results are reviewed Monday–Friday each week with only institution-defined critical results (sexually transmitted infections, strep throat, stool, and positive blood cultures) reviewed during weekend days. Culture results are reviewed via a daily printed report from the institution’s Clinical Microbiology Laboratory as well as an electronic print-out of all patients tested for Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, human immunodeficiency virus, and herpes simplex virus. Only positive test results are audited by the pharmacist. Positive cultures are reviewed for follow-up interventions based on susceptibility mismatch, positive culture with no antibiotics prescribed at UC visit, need for renal dose adjustment, and drug-drug interactions. Patients with susceptibility mismatch or who did not receive initial antibiotics and have a subsequent positive urine, wound, or throat culture are assessed via phone by the pharmacist for symptoms prior to prescribing new antibiotic therapy. Under the CPA a new antibiotic prescription is only recommended if a patient has ongoing symptoms at the time of follow-up or if a specific disease state requires treatment regardless of the presence of symptoms (e.g., sexually transmitted infections, asymptomatic bacteriuria in pregnancy). Patients positive for sexually transmitted infections (STIs) are contacted by the pharmacist for notification of results and follow-up counseling as well as the need for treatment. Information regarding all health department-reportable infections were collected by the pharmacist completing culture follow-up and submitted to ED clerical staff for transmission to the health department using a standard form that includes patient information, diagnosis, treatment, and date of notification of results.
The auditing pharmacist is responsible for contacting patients needing follow-up and phoning in or e-scribing new prescriptions as necessary following the protocol outlined in the CPA. The auditing pharmacist additionally provides patient counseling regarding new prescriptions, answers any patient questions, and documents all follow-up activities in the electronic medical record including the amount of time necessary to make the intervention. Patients unable to be reached via telephone after three contact attempts are sent a letter of results notification via certified mail with instructions to call the pharmacist or UC center with any questions. For any culture types falling outside of the collaborative practice agreement (e.g., blood cultures, synovial fluid cultures), the pharmacist will call in the results to the staffing UC provider and work with the provider to develop a follow-up plan.
The expansion of the culture follow-up program to include UC cultures was made possible by including the responsibility as part of the post-graduate year-one (PGY1) pharmacy resident program requirements. The hospital’s two PGY1 residents are involved daily in conducting culture audits and initiating follow-up calls to patients under the supervision of the ED or ID pharmacist. The PGY1 pharmacy residents begin training to conduct culture follow-up services in July during their orientation month and rotate through the service as a longitudinal responsibility with approximately 6 months of coverage required for each resident. The training program and advancement to autonomy are tailored to skills of the individual resident. The first week of orientation typically includes the residents shadowing the ED or ID pharmacist during culture follow-up activities; outside of the first week of orientation, the residents conduct all culture audits and independently develop a follow-up plan. These activities are directly supervised by the ED or ID pharmacist preceptor to ensure appropriate interpretation of culture results and CPA compliance. The residents conduct follow-up phone calls to the patient under the direct supervision of a preceptor. No specific scripting is required; however, there are certain elements of each call that are required (e.g., confirming patient identity using approved patient identifiers, symptom assessment, delivery of culture result, patient verbalizes understanding of care plan). A standard template is used for documentation in the electronic medical record; all notes are reviewed for accuracy by the ED or ID pharmacist until the resident demonstrates competency.
Data Collection and Analysis
Data were collected for all patients with culture results reported between 1 January 1 and 31 December 2016 and included the number of cultures reviewed, the proportion and type of cultures requiring intervention, and the number of follow-up interventions able to be made using the CPA. Additionally, pharmacist workload was characterized by the number of call attempts made, new prescriptions written, and median time to complete follow-up per patient. Call attempts included any instance where the pharmacist spent time on the phone, including when patients returned a call after a message was left. Data were presented using descriptive statistics.