Bridging the gap: opportunities for transitions of care pharmacist review of outpatient parenteral antimicrobial therapy prescriptions prior to hospital discharge.

Purpose: Pharmacist-led initiatives providing optimization of medications during transitions of care (TOC) have shown to have a positive impact on prescribing practices and patient outcomes. This study aims to evaluate the role and impact of TOC pharmacist review of outpatient parenteral antimicrobial therapy (OPAT) prescriptions prior to hospital discharge. Methods: In a retrospective chart review, patients with OPAT prescriptions between November 1, 2022 and January 31, 2023 were evaluated using prescription-specific and intervention-specific data points. Prescription-specific data points included intravenous antimicrobials prescribed, indication, prescribing team, and time from OPAT prescription to TOC pharmacist review. Intervention-specific data points included antimicrobial optimization (dose/frequency, duration, and other), prescription clarification, and laboratory monitoring. Results: Of the 137 OPAT prescriptions evaluated, 67 required intervention by TOC pharmacists (48.9%). The General Infectious Disease Consult team placed 71.5% of OPAT prescriptions and required interventions less frequently (42.9%) compared to the other teams. Antimicrobial optimization interventions accounted for 54.2% of interventions, which were primarily related to medication dose and frequency. Conclusion: The TOC pharmacists can play a key role in the evaluation of OPAT prescriptions at hospital discharge. This intervention demonstrated how TOC pharmacists can effectively collaborate with the OPAT team, which builds on prior evidence of the role and value of pharmacists in the transitional care setting.