When considering antimicrobial stewardship improvements, pay close attention to the culture follow-up process. “Every group has a mechanism to do this,” explains Michael Pulia, MD, MS, director of emergency medicine antimicrobial stewardship at the University of Wisconsin School of Medicine and Public Health. “But the amount of detail that goes into it varies.”
Pulia suggests appointing a dedicated person who sifts through culture reports, reviews old culture data, and follows up with patients. Ideally, this person would be an expert around the antibiotic spectrum who could tailor therapy to culture results. “A pharmacist who has some interest or background in infectious diseases is the best person to be looped into that,” Pulia offers.
One person does not have to handle every task. A nurse could handle clinical call-backs, ask about the patient’s current conditions, and print any relevant medical data for the pharmacist to review. Presented with all this information, the pharmacist can make an informed recommendation. When the physician scheduled to work that day is presented with the recommendation, he or she can be assured all appropriate information has been considered.
“It will fall on the clinician who is there that day who has a stack of cultures to follow up on,” Pulia says. “Clinicians will do the best they can with it, but that [approach] is not the ideal.”
In his own health system, Pulia says investigators concluded the ED was ordering too many urinalysis tests for patients who did not show signs pointing to a urinary tract infection (UTI). “We were generating a tremendous amount of urine culture data on patients when no one in the ED ever thought these patients had a UTI,” he says. “Because a lot of people had bacteria in their urine, but they didn’t have a UTI, we were getting all of this excess culture data.”
To address this problem, leaders refined the standard triage ordering process so they were no longer ordering urine tests with cultures on every patient who came through the door. “We were being a little more sophisticated about how we were going to allow that to happen,” Pulia says.
Thus, the ED has significantly reduced the number of cultures ordered while preventing inappropriate prescribing.
Appoint a dedicated person who sifts through culture reports, reviews old culture data, and follows up with patients. Ideally, this person would be an expert around the antibiotic spectrum who could tailor therapy to culture results.
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