(Management Case Study) Impact of Centralized Clinical Pharmacy Services Urine Culture Review Following Emergency Department Discharge

Purpose: Pharmacist integration in urgent care centers for antimicrobial stewardship has demonstrated quicker follow-up on urine culture results and greater adherence to guideline-driven antibiotic prescribing. Due to the delayed time to growth, urine cultures for patients seen in the Emergency Department (ED) have historically been worked by ED providers, sometimes in consult with infectious disease specialists or ED pharmacists, after the patients are already home. We hypothesized review of urine cultures by a telephonic outpatient centralized pharmacy service will yield improved clinical outcomes and antimicrobial stewardship compared to provider-managed urine culture follow-up services following an ED visit.

Methods: Medical records of patients 18 years or older with urine culture specimens collected from any of five Geisinger EDs between 06/01/2021-04/30/2022 were included in this study. Patients were excluded if they were admitted or transferred to another facility, did not require antibiotic therapy changes, or had yeast growth on their urine culture. Pharmacist follow-up services included promotion of antimicrobial stewardship and adherence to guideline and culture-directed antibiotics. The pharmacist intervention was active at two of the five ED locations, and standard of care (provider follow-up services) was active at the other three ED locations. The primary endpoint was difference in time until appropriate antibiotic therapy was addressed (including initiation, change, or discontinuation of antibiotic). Secondary endpoints included the number of patients who received appropriate antibiotic therapy; returned to the ED for urinary complaints within 30 days; or conversely, called their primary care provider instead when/if experiencing future urinary complaints. Additionally, to better understand the details of the time spent on urine culture review, a survey was conducted to subjectively measure the time spent on each step of urine culture follow-up tasks (analysis, patient contact, documentation).

Results: When empiric antibiotic therapy was inappropriate, the pharmacist group had statistically significant improved time to culture-directed antibiotic changes or discontinuations (i.e. intervention), with the average time from finalized urine culture result to time of intervention being 60.5 hours in the provider group and 9.2 hours in the pharmacist group (p < 0.05). Moreover, 100% of cultures managed in the pharmacist group were treated with sensitive, appropriate antibiotics versus just 9% of those managed in the provider group (p < 0.05). There was no statistically significant difference between groups in number of patients returning to the ED for urinary complaints, calling their PCP first when/if experiencing future urinary complaints, nor in the responses to the time study survey. In the survey, most providers (58.3%) reported not having enough time in their daily workflow to provide quality urine culture follow up, while others reported they “sometimes” (33.3.%) or typically do (8.3%). In contrast, most pharmacists (60%) reported typically having enough time to provide quality urine culture follow up, with the other (40%) reported they “sometimes” do, leaving 0% pharmacist response reporting not having enough time.

Conclusion: Compared to the ED provider group, the pharmacist follow-up service addressed urine cultures in less time and made significant improvements in antimicrobial stewardship. Utilizing outpatient pharmacist services for culture review will allow ED providers and ED pharmacists more time to address currently admitted ED patients by removing this responsibility for patients who were already discharged.