The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.1 According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.2 A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.3 The ED is a critical and high-yield space for antimicrobial stewardship efforts.4
Urinary tract infections (UTIs) are one of the most common reasons for ED visits.4 In 2018, there were about 3 million UTI discharge diagnoses reported in the US.5 Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.6 Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.6
Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.6 The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.7-13
Program Description
In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).
Methods
This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.
The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.