Several years ago, Sharp Chula Vista Medical Center
(Sharp CV) in Chula Vista, Calif., added a dedicated pharmacist, Kim Schwab, to its emergency department (ED) team. Schwab quickly noticed there did not seem to be established guidelines for ordering cultures. As a result, wound cultures were ordered indiscriminately. This cost the hospital money and took staff time away from patient care.
Beginning in 2013, Schwab teamed up with pharmacy resident Hazel Tran and biostatistician Ron Floyd to see if collaboration between pharmacists and front-line providers could make a difference. The following is adapted from a poster presented at CEP America's 2014 Partnership meeting.
The team set out to determine whether education by the emergency department (ED) pharmacist on an institution-developed, evidence-based wound culture algorithm could reduce the number of indiscriminate wound cultures ordered.
Identification of infection is important in deciding when to culture a wound, since wounds can be contaminated or colonized with non-replicating organisms. However, indiscriminate collection of wound cultures can cause unnecessary burden on labor and financial resources. Both current wound care practices and Infectious Diseases Society of America (IDSA) guidelines recommend that a wound be cultured only if:
- There are signs and symptoms of infection, or
- The patient's immune system is impaired
These recommendations are endorsed by the American College of Emergency Physicians, which lists wound cultures among its "10 Things Physicians Should Question"
as part of the Choosing Wisely campaign.
The team conducted a retrospective review of ED wound cultures before and after the delivery of a pharmacist led education program.
To guide ED staff in their ordering decisions, the team developed an institutional wound care algorithm based on IDSA guidelines and current practice recommendations. "Hazel [Tran] did a lot of research and also sought input from our infectious disease physicians," Schwab says. "She did a great job synthesizing all of the information to create a practical tool for our providers."
Next, the pharmacists introduced the algorithm to physicians, PAs and NPs through:
- One-on-one dialogue
- Distribution of educational materials
- Discussions at staff meetings.
The fact that the pharmacists were already integrated into the department — attending staff meetings and engaging with the providers — helped create opportunities for education. “Going into it, we wondered if some of them might be concerned about liability,” Schwab says. "But they were very open to our suggestions."
The team conducted a retrospective analysis comparing cultures ordered during the pre-education period (January through May 2013) and post-education period (October 2013 through February 2014). After predetermined exclusions criteria were applied, providers ordered 102 cultures before the education program and 85 after.
The team's primary research question was whether pharmacist education would lead to more appropriate culture decisions (as defined by the wound culture algorithm). They found that it definitely did. Significantly fewer deviations from the algorithm were observed in the post-education period (2 percent versus 12 percent).
What's more, the team estimated this more discriminate culturing saved the hospital about $8,070 over the five-month study period. When savings were extrapolated to one year, they totaled almost $20,000.
Finally, the team found no statistical significance between pre- and post-education groups for the following secondary outcomes:
• Positive culture
• Change in empiric antibiotic therapy due to culture results
• Revisit to the ED related to skin infections in 14 days
• Type of practitioner (MD, PA/NP) ordering the wound culture
Overall, the education program was quite successful in encouraging compliance with current practice recommendations. The team observed fewer deviations from the algorithm as well as a reduction in the number of wound cultures ordered by both physicians and advanced practitioners. (They did identify one "outlier" who had not received one-to-one education with a pharmacist.)
Discriminate culturing didn't change the course of treatment, and patients weren't any more likely to revisit the ED with an infection in the post-study period. While the team didn't directly measure changes in throughput or provider productivity, patients likely benefited from greater operational efficiency and shorter wait times.
This study did have some limitations. For one, it was retrospective in nature. Data on provider decision-making was gathered from patient charts and dictation notes, which may not have been comprehensive.
It should also be noted that the wound care algorithm has not itself been validated. "While it's based on current recommendations and practices, these sometimes change," Tran says.
Finally, the team was not able to conduct one-on-one education with all ED staff. Some night and weekend staff didn't have a chance to "walk through" the algorithm with a pharmacist and ask questions. One of these was later identified as an outlier when it came to wound culture orders.
Education provided by the ED pharmacist appears to be effective in reducing the number of indiscriminate wound cultures ordered in the ED, and this intervention has led to cost savings.
The ED pharmacists were pleasantly surprised by the impact of the algorithm and education program. While they haven't conducted a formal follow-up analysis, Schwab says she continues to see fewer orders overall.
The team credits much of its success to the collaborative culture in the Sharp CV ED. "Kim has great working relationships with the physicians and PAs, which made them very receptive," Tran says. "I think it really contributed to the success of the project."
The pharmacists hope to create similar education programs for other types of cultures (urine, vaginal). Schwab hopes that perhaps a future pharmacy resident will be interested in taking this on.
Hazel Tran, who spearheaded this project, completed her residency and is now a pharmacist with Sharp CV.
1. Bowler P, Duerden B, Armstrong D. Wound microbiology and associated approaches to wound management.ClinMicrobiol. Rev 2001;14:244-69.
2. Bonham PA. Swab cultures for diagnosing wound infections: a literature review and clinical guideline. J Wound Ostomy. Continence Nurs. 2009;36(4):389-395.
3. Fleck C. identifying infection in chronic wounds. Adv Skin Wound Care. 2006;19(1):20-21.
4. Branom RN. Is this wound infected? CritNurs Q. 2002;25(1):55-62.
5. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clinical Infectious Diseases 2005;41:1373-406.
6. Bryant RA, Nix DP. Acute & chronic wounds: current management concepts. 3rd edition. 2007.
7. Healy B, Freedman A. ABC of wound healing: infections. BMJ. 2006;332(7540):838-841.
8. Calianno C. Wound bed preparation: the key to success for chronic wounds, part II. Nursing.2006;36(3):76-77.
9. Zervos MJ, Freeman K, Vo L, et. al. Epidemiology and outcomes of complicated skin and soft tissue infections in hospitalized patients. J. of Clin.Microbiol. 2012, 50(2):238.
10. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of America for the treatment of Methicillin-Resistant Staphylococcus Aureus infections in adults and children. Clinical Infectious Diseases 2011;52:1-38.