Multi-center retrospective evaluation of antimicrobial discharge medication reconciliation
Patrick Acton, Jennifer K. RossAbstract
Objective:
Analyze the impact of two different discharge medication reconciliation (DMR) models on antibiotic prescribing at hospital discharge across a health system.
Design:
Multi-center, retrospective evaluation from September 1, 2024, to August 31, 2025.
Setting:
The M Health Fairview system consists of ten hospitals, eight in the Minneapolis/St. Paul area, one of which is a quaternary level academic medical center (AMC). The other two hospitals are located >60 miles from a metropolitan area.
Patients:
Participants ≥18 years discharged with an oral antibiotic prescription intended to treat pneumonia, urinary tract infection, or Gram-negative bacteremia were included. Participants with a history of hematopoietic stem cell or solid organ transplant, or neutropenia during the index admission were excluded.
Intervention:
At nine of the hospitals, pharmacists complete a full DMR, which includes documentation of pharmacist interventions, the rated significance of the intervention, and time to complete DMR. The AMC completes DMR only on “high risk” medications which includes oral antimicrobials.
Results:
No statistically significant difference in pharmacist intervention rates between DMR models was detected. The overall pharmacist intervention rate was 8.4%, though the targeted DMR site was higher at 13.6%. The most common pharmacist intervention was recommending an alternative duration. The mean duration exceeded reference durations in the indications of CAP, cUTI, and Gram-negative bacteremia from a urinary source.
Conclusions:
This review emphasizes the opportunity for pharmacist interventions given the low rates of appropriate antibiotic durations seen across the health system. Accurate recording of interventions is an opportunity for automated integration within the EHR.