Part 1 of this 2-part series discussed the evaluation of some available rapid blood culture diagnostic platforms from the perspective of pharmacy working in concert with microbiology and other laboratory domains. Part 2 will discuss the choices made at Tampa General Hospital for the implementation of a rapid blood culture diagnostic platform. We investigate this process as we look to explore the vital interrelations between clinical disciplines in the hospital. We invite you to review part 1 of this series in the April issue (medlabmag.com/rapidbloodculture1).
The Roles of Antimicrobial Stewardship and Microbiology
It is essential for the ASP team to work closely with microbiology personnel during the integration of rapid diagnostic platforms and help end users interpret information with appropriate clinical context. The ASP team also should develop a good understanding of microbiology workflow, ascertain how results should ideally appear to the end user, and provide constructive feedback to the microbiology department before and after implementation. Additional points of consideration include whether results will be available to the clinician in real time or if specimens will be batched. ASP and microbiology team members should regularly discuss the overall timeline, as well as information technology (IT) requirements when building this process into the EMR.
Our institution’s ASP team met with microbiology to discuss pre- and post-implementation plans for the diagnostic platform (see the SIDEBAR). Pre-implementation, we decided that a microbiology technician would contact nursing via telephone with a positive blood culture result at the time the panel identified a pathogen. We also decided to use the platform on all blood cultures, as opposed to a specific type of organism (eg, only gram-negative pathogens). Microbiology made a commitment to use this technology 24/7 to ensure real-time data could be made available to clinicians around the clock. We made additional group decisions on which antibiotics should and should not be reported, as well as susceptibility reporting. In addition, we disseminated this information to our Antimicrobial Subcommittee members, who forwarded the information to their colleagues. The organisms identified on the panel were discussed, as well as those organisms that did not have susceptibility data available through the technology.
Post-implementation, the ASP team met again with microbiology to discuss result reporting. We developed a standardized statement for positive blood cultures when the platform did not identify an organism from the panel. We also worked to adjust verbiage related to cefoxitin screening and S. aureus results. The ASP now provides ongoing feedback to the microbiology department and periodically meets as a group to discuss other ideas for optimization of this rapid diagnostic platform at our institution.
Communication of Results with Medical Staff
Rapid diagnostic technology integration within a hospital and/or across a health system cannot be successful without clear communication among the health care team. Although the diagnostic results are reported out in the EMR by the microbiology staff, there are important roles that other clinical team members can assume. When blood culture results are available and communicated by microbiology, the nurse receiving this information maintains a vital role in relaying it to the appropriate clinical provider in the event modifications in antimicrobial therapy are warranted. If nursing is not included in this communication pathway at your institution, this responsibility may be assigned to the microbiology technician who ran the testing. Depending on the institution, this communication may be verbal, electronic, or via the EMR; no matter which method is used, swift communication facilitates timely changes to antimicrobial therapy.
In addition to these team members, pharmacy staff also can play an important role in communicating subsequent updates in blood culture results and recommending escalation or de-escalation of drug therapy. As medication experts, pharmacists are uniquely positioned to make drug therapy recommendations to providers as culture results are updated, especially if results are reported from the microbiology lab in real time. Identified opportunities for de-escalation of antimicrobials minimizes selection pressure, and reduces both acquired drug-resistance and the risk for C. difficile infection. Timely interventions for antimicrobial escalation can help ensure a patient is on effective antimicrobials that will improve clinical outcomes.
At TGH, we received support from pharmacy administration to utilize a real-time blood culture report, which was eventually built as an alert into our information system’s patient scoring build and incorporated into pharmacy workflow. If the medical team does not review the blood culture updates in a timely manner, it is critical to promptly contact them, especially if escalation or de-escalation opportunities exist. Our ASP team created a guide on how to interpret blood culture results and what antimicrobial recommendation(s) should be provided based on our institutional formulary. This pharmacy-based activity at TGH is targeted on patients who do not already have an infectious diseases (ID) provider following their case and providing antimicrobial recommendations.
Rapid diagnostic technology platforms continue to offer more advanced capabilities; this is particularly true for blood culture specimens. ASPs and microbiology departments are uniquely positioned to evaluate available options when determining which platform may best fit the needs of their institution. Clear and direct communication with hospital administrators is crucial when making the case in favor of these technologies, as the expense may overshadow the known clinical benefit in some cases.
Once integrated into the institution’s workflow, timely communication of results to the provider is necessary in order to evaluate for escalation or de-escalation of therapy. Teamwork and communication across the health care provider spectrum is essential for benefits to be seen with rapid diagnostic blood culture platforms and improvements in patient clinical outcomes.
Ripal Jariwala, BS, PharmD, BCIDP, AAHIVP, is co-chair of the Tampa General Hospital (TGH) antimicrobial subcommittee. She received her BS in chemistry from the Georgia Institute of Technology in 2003 and her Doctor of Pharmacy degree from the University of Tennessee in 2008.
Nicholas Piccicacco, PharmD, BCIDP, AAHIVP, co-chair of the TGH antimicrobial subcommittee, received his Doctor of Pharmacy degree from the University of Florida in 2014. He then went on to complete a pharmacy practice residency at TGH and an Infectious Diseases specialty residency at Morton Plant Hospital – BayCare Health System in Clearwater, Florida.
Kristen Zeitler, BS, PharmD, BCPS, co-chair of the TGH antimicrobial subcommittee, received a BS in chemistry from Fairfield University in Connecticut in 2007, followed by a Doctor of Pharmacy from the University at Buffalo in 2011. Upon completion of a pharmacy practice residency and an infectious diseases specialty residency at the Hospital of the University of Pennsylvania in Philadelphia, Kristen joined TGH in 2013.
Case Study of TGH’s Implementation Experience
In November 2018, Tampa General Hospital went live with a rapid diagnostic testing platform. Prior to this, our institution did not utilize any rapid diagnostic technology on positive blood cultures. Thus, the decision-making, integration, and rollout process of this technology required an integrated team effort.
Rolling out the program required multiple meetings among hospital administration, microbiology, and ASP. We needed to decide on a technology platform, determine the best workflow process in microbiology when positive blood cultures were identified, and make decisions related to reporting of antimicrobial susceptibilities on pathogens included in the instrument’s panels. The ASP team also collaborated with microbiology in order to tailor the reporting of susceptibilities to match the hospital’s medication formulary.
As highlighted in the article, the unit-based pharmacists are integrated at our institution to receive real-time alerts when blood culture pathogen identification or drug susceptibility results are updated in the EMR. This occurs for patients who do not have an ID physician involved in their care. This alert for pharmacists is built into an Antimicrobial Stewardship section of patient scoring in the information system (see FIGURE 1), notifying them that updates require their review. A score of 10 for pathogen identification, as well as drug susceptibility, is reported in order to highlight the significance of this result (see FIGURE 2).
Since implementation of the platform, our institution has shown an impressive decrease in the time to pathogen identification and susceptibility reporting. Our internal data showed a reduction in the time to pathogen identification of 30.5 hours and a decrease in time to susceptibility results of 37 hours. Once data was available for clinicians, we also saw swift de-escalation was taken for most patients. In an early review of 138 positive blood cultures prior to involvement by the unit-based pharmacists (excluding coagulase negative Staphylococcus spp. isolates, as those were routinely considered contaminants), we identified the median time to targeted antimicrobial therapy as 14.6 hours during the week and 20.8 hours on the weekends. We also saw similar times to targeted therapy between ID providers and non-ID providers, likely demonstrating interventions from the ASP team early on and the confidence providers have with our team.
We continue to expand upon our experience with the rapid diagnostic testing platform, educating our providers and pharmacy staff on its utility and innovative technology so that its rapid results are able to aid in clinical decision-making for our patients.
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