Advancing antimicrobial stewardship with streamlining pharmacist management of culture results through implementation of a collaborative practice agreement in a community hospital emergency department.

Abstract

Background: Emergency departments (EDs) often discharge patients before final microbiology results are available, which can delay necessary adjustments to antibiotic therapy. Post-discharge culture follow-up has traditionally been performed by physicians and advanced practice providers (APPs), though clinical pharmacists are increasingly recognized as well-suited for this role. Involving clinical pharmacists more directly in this process may improve both workflow efficiency and antimicrobial stewardship (AS) efforts.

Objectives: To describe the development and iterative implementation of a collaborative practice agreement (CPA) enabling ED clinical pharmacists to review post-discharge positive cultures and prescribe antibiotics under a defined protocol, and to present post-implementation utilization and protocol compliance data.

Practice description: Sibley Memorial Hospital (SMH) is a community hospital in the District of Columbia within the Johns Hopkins Health System. Clinical pharmacists in the ED were already reviewing culture results and providing therapy recommendations in collaboration with APPs; however, they were not permitted to prescribe independently prior to this initiative.

Practice innovation: A CPA was developed through a multi-year, iterative process to enable clinical pharmacists to follow defined treatment protocols and prescribe antibiotics under a "per protocol" model, marking a significant expansion of their scope in ED follow-up care.

Evaluation methods: A pre-implementation audit of pharmacist culture review activities was performed from April through June 2021 to establish baseline workload data. Following CPA approval and implementation in May 2025, a post-implementation process evaluation was conducted from May 2025 through March 2026 (11 months) using embedded pharmacy intervention tracking (i-Vent) data from the electronic health record. All cases of independent pharmacist prescribing under the CPA per protocol model were identified and assessed for protocol compliance on five criteria: protocol formulary concordance, appropriate dosing, appropriate duration, documentation of patient education, and intervention documentation.

Results: During the pre-implementation audit, 350 culture reviews were documented with an intervention rate of 6.0% (21/350). During the 11-month post-implementation period, 898 i-Vent entries were recorded by 2 clinical pharmacists authorized for CPA prescribing, with 129 therapy interventions (14.4%). Twenty-four cases of independent pharmacist prescribing under the CPA per protocol model were verified, performed by 2 authorized pharmacists. Protocol compliance was 100% (24/24) across all five criteria. The most common organisms requiring per protocol intervention were ESBL-producing Enterobacteriaceae (6 cases) and non-ESBL E. coli (5 cases).

Conclusion: This CPA for clinical pharmacist-led post-discharge culture follow-up and prescribing was successfully implemented under a per protocol model. Post-implementation data showed sustained pharmacist engagement with 100% protocol compliance among verified independent prescribing cases. This initiative may serve as a reproducible model for other EDs and AS programs seeking to formalize pharmacist-led culture follow-up services.