Role of postgraduate year 2 pharmacy residents in providing weekend antimicrobial stewardship coverage in an academic medical center

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1 Role of postgraduate year 2 pharmacy residents in providing weekend antimicrobial stewardship coverage in an academic medical center Justin Siegfried, Pharm.D., Cristian Merchan, Pharm.D., Marco R. Scipione, Pharm.D., John Papadopoulos, Pharm.D., Arash Dabestani, Pharm.D., Yanina Dubrovskaya, Pharm.D., BCPS-AQ ID, Department of Pharmacy, NYU Langone Medical Center, New York, NY. Address correspondence to Dr. Dubrovskaya (yanina.dubrovskaya@ nyumc.org). Copyright 2017, American Society of Health-System Pharmacists, Inc. All rights reserved /17/ DOI /ajhp Purpose. The integration of pharmacy residents into an antimicrobial stewardship program (ASP) is described, and data on the residents ASP interventions and outcomes are reported. Summary. ASP coverage of nighttime, holiday, and weekend shifts is often provided by infectious diseases (ID) medical fellows and staff pharmacists, potentially leading to inconsistent stewardship practices. As part of an initiative by a large urban hospital to provide around-the-clock, comprehensive ASP services 7 days a week, postgraduate year 2 (PGY2) pharmacy residents in ID or critical care were assigned to provide ASP coverage on weekends. Over a 12-month period, residents providing ASP weekend coverage documented a total of 1,443 interventions, of which 1,000 (69%) were pursuant to 72-hour prospective audit and feedback review and 443 (31%) occurred during ASP phone coverage. A comparison of overall antimicrobial utilization (mean ± S.D. days of therapy [DOT] per 1,000 patient-days [PD]) before and after implementation of resident ASP coverage on weekends showed a decrease in aggregate antimicrobial use from ± 46.8 to ± 17.3 DOT/1,000 PD (a difference of 58.6 DOT/1,000 PD, p = 0.08), with a corresponding decline in the incidence of hospital-onset Clostridium difficile infection (from 1.18 cases to 0.9 case per 1,000 PD). Conclusion. By expanding the hospital s ASP services by assigning PGY2 pharmacy residents to weekend coverage, the institution was able to provide high-level clinical care 7 days per week, which benefited both patients and PGY2 pharmacy residents while meeting national ASP regulatory requirements. Keywords: antimicrobial stewardship, longitudinal learning experience, postgraduate year 2 pharmacy residents, weekend coverage The impact of an antimicrobial stewardship program (ASP) in optimizing clinical outcomes, limiting the burden of antimicrobial resistance, reducing adverse events associated with antimicrobial use, and controlling hospital expenditures is well recognized. 1-3 Recently the U.S. Congress highlighted the importance of ASPs, calling for widespread implementation in all acute care hospitals. 1-3 In recognition of the urgent need to improve antimicrobial use in acute Am J Health-Syst Pharm. 2017; 74: care settings, the Centers for Disease Control and Prevention (CDC) published a report listing core elements of hospital ASPs and providing guidance on implementing policies and interventions to improve antibiotic use. 1 A multidisciplinary ASP often incorporates clinical pharmacists with specialty training in infectious diseases (ID) to facilitate judicious antimicrobial use in hospitalized patients. ID-trained pharmacists perform daily tasks such as approving restricted AM J HEALTH-SYST PHARM VOLUME 74 NUMBER 6 MARCH 15,

2 ANTIMICROBIAL STEWARDSHIP antimicrobials, providing prospective audit and feedback, selecting empirical antimicrobial regimens, optimizing dosing regimens through pharmacokinetic/pharmacodynamic (PK/PD) analysis, reviewing culture results and isolate susceptibilities for potential deescalation of therapy, and performing timely i.v.-to-oral antimicrobial conversion. Healthcare is transitioning toward providing standardized and high-level clinical coverage at all times, including weekends, holidays, evenings, and nights ( WHEN hours ), to improve continuity of care. Aligning ASP activities with this trend by expanding coverage to evenings and weekends remains a challenging task. On evenings and weekends, ID medical fellows are often solely responsible for approval of orders for restricted antimicrobials, which leads to fragmented ASP coverage. 4 Also, ID medical fellows are not an ideal resource for pharmacy staff support during weekend hours due to their limited knowledge of pharmacy workflows. Recent studies support training of non ID-trained staff pharmacists in specific ASP-driven interventions (e.g., adjusting dosing regimens, switching from i.v. to oral antibiotic therapy, managing antibioticrelated drug interactions to improve clinical outcomes) and incorporating them into the stewardship process. 5,6 Yet, relying on these resources fails to mimic high-level ASP activities provided by ID-trained ASP pharmacists during weekday hours. Also, pharmacy staffing constraints and a lack of funding are significant barriers to incorporating hospitalwide ASP initiatives during evenings and weekends in many acute care facilities. 7 One underutilized resource for expanding a hospital s ASP services is pharmacy residents; however, there is a significant gap in the literature describing pharmacy residents participation in ASP services beyond on-call programs. In 2003, Smith et al. 8 described a postgraduate year 1 (PGY1) pharmacy residency on-call program where pharmacy residents KEY POINTS Providing antimicrobial stewardship program (ASP) coverage at all times remains a challenging task, and pharmacy residents are an underutilized resource for expanding hospital ASP services. Postgraduate year 2 pharmacy residents in infectious diseases (ID) or critical care are ideal candidates for expanding ASP services due to their advanced clinical knowledge and independent decision-making skills. ASP weekend coverage as a longitudinal learning experience offers an interactive learning environment for advancing residents skills in ID pharmacotherapy and stewardship. were accountable for optimizing drug therapy, including PK monitoring, providing drug information, reconciling antiretroviral therapy (ART), and participating in emergency patient management. Although on-call programs provide a broad range of clinical pharmacy services, ASP activities are rarely a priority. Postgraduate year 2 (PGY2) pharmacy residents receiving specialty training in ID and critical care (CC) are ideal candidates for expanding ASP services to the weekends due to their advanced clinical knowledge and independent decision-making skills. In 2015, Chahine et al. 9 proposed specific ASP activities to engage pharmacy residents, such as extended hours for pharmacist-led prior authorization for restricted antimicrobials. However, there is a paucity of literature describing the impact of integrating PGY2 pharmacy residents into ASP services during a residency program. We report our experience with PGY2 pharmacy residents ASP weekend coverage and evaluate the potential impact on ASP interventions and outcomes. Setting NYU Langone Medical Center (NYULMC) is a 725-bed tertiary care academic hospital in New York City. NYULMC s pharmacy department has a state-of-the-art pharmacy that provides 24-hour services from a combination of satellite and centralized pharmacies. Pharmaceutical services are supported by automated dispensing technology (Swisslog Healthcare Solutions AG, Buchs, Switzerland), a DoseEdge workflow management system (Baxter International Inc., Deerfield, IL), an Epic computerized presciber-order-entry (CPOE) system (Epic Systems Corporation, Verona, WI), and Kit Check radiofrequency identification technology (Kit Check, Inc., Washington, DC) and provided in conjunction with collaborative patient care rounds by clinical pharmacotherapy specialists in CC, emergency medicine, ID, internal medicine, and hematology oncology on weekdays during normal business hours. The ASP at NYULMC was initiated in 2008 and expanded to include interprofessional and collaborative roles involving the ID medical director, ID medical attendings and fellows, ID-trained pharmacists, and rounding clinical pharmacotherapy specialists. On weekdays from 8 a.m. to 4 p.m., ID-trained ASP pharmacists provide approvals for restricted antimicrobials via the ASP phone. Additional responsibilities include prospective audit and feedback for restricted and broad-spectrum antimicrobials at 72 hours after initiation based on ASP reports generated by the CPOE system, medication reconciliation targeting patients receiving ART, and PK dosing and monitoring of aminoglycosides and vancomycin. In 2014, rapid microbiological diagnostic testing (RDT) with polymerase chain reaction (PCR) analysis for blood culture results indicating the presence of gram-positive cocci (GPC) in pairs and clusters was introduced as a new ASP initiative. ID- 418 AM J HEALTH-SYST PHARM VOLUME 74 NUMBER 6 MARCH 15, 2017

3 trained ASP pharmacists receive electronic notifications 3 times daily to facilitate optimal therapy based on results of PCR analysis, including deescalating or discontinuing unnecessary empirical therapy. ASP interventions are directly communicated to the primary team, as no policy regarding automatic pharmacy interventions is currently established at our hospital. Also, all pharmacists document interventions using the Epic ivent system (Epic Systems Corporation), which is designed to accommodate different levels of care. ASP interventions (quantity and type) are reported quarterly and annually at the institutional level: to the antimicrobial subcommittee, the medication safety committee, and the pharmacy and therapeutics committee. Prior to 2014, ID fellows were solely responsible for providing approvals for restricted antimicrobials during the weekday hours of 4 p.m. 10 p.m. and on weekends during the hours of 8 a.m. 10 p.m. ID fellows did not provide prospective audit and feedback for antimicrobial orders and did not document approvals of restricted antimicrobials in the CPOE system. Therefore, baseline weekend intervention data were not available for the purposes of the data comparisons described later in this article. ASP weekend coverage as a longitudinal learning experience. The PGY1 pharmacy residency program at NYULMC was initiated in 2010 and has been expanded to encompass a total of 4 PGY1 pharmacy residents. In 2014, PGY2 pharmacy residency programs were created in the specialty areas of ID and CC. Prior to the creation of the PGY2 programs, ASP weekend coverage was provided by ID medical fellows and limited to approvals of restricted antimicrobials. Additionally, there was no pharmacist presence during medical response team (MRT) (i.e., code-blue) and stroke alerts on weekends. To bridge the gaps in pharmacy coverage, a PGY2 clinical weekend program was implemented in The program incorporates longitudinal learning experiences in ASP coverage and emergency response. The longitudinal learning experience was designed to support a hospitalwide initiative to deliver high-level clinical services 7 days a week while still providing a supportive learning environment for PGY2 pharmacy residents. The longitudinal learning experience provided a platform for the PGY2 residents to develop advanced skills in ID pharmacotherapy management in patients with acute and chronic ID issues in different service areas, including CC, general surgery, medicine, urology, hematology oncology, and rehabilitation. Throughout this experience, the residents engaged in independent decision-making and developed the skills to manage complex clinical situations while still supported and subject to oversight and performance assessment by ID-trained ASP preceptors. Responsibilities of residents. During the residency year, PGY2 pharmacy residents in ID and CC provided full onsite ASP coverage from 8 a.m. to 4 p.m. on Saturdays and Sundays, alternating every other weekend to extend pharmacist-driven ASP coverage to 7 days a week. The PGY2 pharmacy resident was responsible for providing approval of orders for restricted antimicrobials via the ASP phone, prospectively auditing the use of restricted and broad-spectrum antimicrobials at 72 hours after initiation, reconciling ART medication regimens, and providing PK/PD-guided dosing and monitoring of aminoglycoside and vancomycin therapy. The PGY2 resident was also responsible for reviewing positive blood culture results with GPC in pairs and clusters after results of RDT with PCR analysis were reported. Additionally, the PGY2 pharmacy resident was responsible for participation in emergency patient management, providing pharmacist coverage for MRT and code-blue alerts and stroke emergencies. All ASP interventions and code response participation required documentation through the Epic ivent system using specific ASP intervention categories. An IDtrained ASP pharmacist was available as a backup and to provide clinical support. Patient follow-up from the weekend and a detailed summary of approvals of restricted antimicrobials were communicated to the covering ID-trained ASP pharmacist at the beginning of each week for continuity of care and performance assessment. Results During ASP weekend coverage by PGY2 pharmacy residents from July 1, 2014, to July 1, 2015 (i.e., for the duration of the residency training year), a total of 1,443 interventions were documented, of which 1,000 (69%) were prompted by prospective audit and feedback review and 443 (31%) occurred through ASP phone coverage. In comparison, a total of 1,783 interventions were documented by ID-trained ASP pharmacists during weekday coverage over the same 12-month period (656 interventions [37%] involved prospective audit and feedback, and 1,127 [63%] were ASP phone interventions). The PGY2 residents also participated in 63 emergency patient management responses. ASP prospective audit and feedback review. Among the 1,000 prospective audit and feedback interventions documented by the PGY2 pharmacy residents, the most common were PK/PD dosing and monitoring of aminoglycosides or vancomycin (n = 288, 29% of the total); discontinuation of unnecessary therapy (n = 179, 18%); antibiotic dose adjustment (n = 167, 17%); recommendations of alternative therapy, including remediation of bug drug mismatches (n = 86, 9%); and narrowing of empirical broad-spectrum antimicrobial therapy (n = 41, 4%) (Table 1). The most common interventions documented by PGY2 pharmacy residents during weekend coverage were similar to those documented during weekday coverage except for narrowing of empirical broad-spectrum antimicrobial therapy, which was more frequent during weekday coverage AM J HEALTH-SYST PHARM VOLUME 74 NUMBER 6 MARCH 15,

4 ANTIMICROBIAL STEWARDSHIP Table 1. Comparative Data on Prospective Audit and Feedback Interventions on Weekdays and Weekends a No. (%) Interventions Intervention Type or Recommendation (n = 65, or 10% of interventions) than on weekend coverage (n = 41, or 4% of interventions). Fifty-four conversions from i.v. to oral therapy for antimicrobials with high oral bioavailability and 28 ART medication reconciliation interventions were also documented during weekend coverage. Review of positive blood culture reports after RDT with PCR analysis in 18 cases resulted in discontinuation of unnecessary antibiotics in 6 cases and deescalation to optimal therapy (e.g., vancomycin deescalation to oxacillin for methi cillin-susceptible Staphylococcus aureus [MSSA] bacteremia) in 1 case. During prospective audit and feedback review on weekends, the most common antimicrobial agents whose use required intervention were vancomycin (38% of interventions), piperacillin tazobactam (15%), cefepime (8%), meropenem (5%), and azithromycin (5%) (Table 2). ASP phone coverage. During 12 months of PGY2 resident weekend Weekdays (ID-Trained Clinical Pharmacist) Weekends (PGY2 Residents) Total PK/PD dosing 100 (15) 288 (29) 388 (23) Change dose 165 (25) 167 (17) 332 (20) Discontinue therapy 96 (15) 179 (18) 275 (17) Recommend alternative therapy 53 (8) 86 (9) 139 (8) Narrow drug therapy 65 (10) 41 (4) 106 (6) Change route 31 (5) 54 (5) 85 (5) Recommend duration of therapy 35 (5) 39 (4) 74 (4) ART reconciliation 40 (6) 28 (3) 68 (4) Drug interactions 12 (2) 2 (0.2) 14 (1) Recommend culture 11 (2) 2 (0.2) 13 (1) Recommend ID consult 5 (1) 6 (0.6) 11 (1) Other 43 (7) 108 (11) 151 (10) Total 656 1,000 1,656 a PGY2 = postgraduate 2, PK/PD = pharmacokinetic/pharmacodynamic, ART = antiretroviral therapy, ID = infectious diseases. coverage, there were 443 documented ASP phone encounters, a mean of 4.2 calls per day. The majority of calls during weekend coverage were for antimicrobial recommendations or culture and susceptibility review, which together accounted for 166 calls (50% [166/331] of general calls), and approvals of orders for restricted antimicrobials, which accounted for 112 calls (25% [112/443]). The overall approval rate for restricted antimicrobials during weekend coverage was 68% (76/112), with 36 individual requests for restricted antimicrobials determined to be unnecessary or inappropriate, and the PGY2 pharmacy resident provided recommendations for alternative therapy during 33% of encounters. Similarly, the majority of ASP phone encounters during weekday coverage were for antimicrobial recommendations or culture and susceptibility review, and the approval rate for orders for restricted antimicrobials during weekday hours was 67% (Table 3). The most common antimicrobial agents targeted during ASP phone interventions were vancomycin (27%), piperacillin tazobactam (11%), ciprofloxacin (8%), cefpodoxime (8%), and cefepime (7%) (Table 4). Antimicrobial utilization. Antimicrobial utilization was evaluated during the 12 months after the introduction of weekend coverage by PGY2 pharmacy residents and compared with utilization during the prior 12 months. Aggregate antimicrobial use was measured in days of therapy per 1,000 patient-days (DOT/1,000 PD) according to CDC standards. 10 Mean ± S.D. values for quarterly antimicrobial use before and after implementation of ASP weekend coverage by PGY2 pharmacy residents were compared; p values were determined by independent-samples t test. Overall, aggregate antimicrobial use during the period of PGY2 resident weekend coverage decreased by 58.6 DOT/1,000 PD from the preceding 12-month period (from ± 46.8 to ± 17.3 DOT/1,000 PD, p = 0.08); fluoroquinolone use remained low and decreased by 1.3 DOT/1,000 PD (from 27.3 ± 4.6 to 26.0 ± 1.6 DOT/1,000 PD, p = 0.64), and carbapenem use decreased by 3.5 DOT/1,000 PD (from 38.4 ± 3.5 to 34.9 ± 5.1 DOT/1,000 PD, p = 0.31). Mean ± S.D. values for use of antibiotics with activity against methicillin-resistant S. aureus also decreased during the period of resident weekend coverage, as compared with the previous 12 months. Of note, vancomycin use decreased by 11.4 DOT/1,000 PD (from ± 8.2 to ± 5.4 DOT/1,000 PD, p = 0.07), linezolid use decreased by 3.0 DOT/1,000 PD (from 18.1 ± 6.1 to 15.1 ± 2.4 DOT/1,000 PD, p = 0.42), and daptomycin use decreased by 2.8 DOT/1,000 PD (from 9.2 ± 2.7 to 6.4 ± 1.2 DOT/1,000 PD, p = 0.12); these results may have been partly due to a new ASP initiative incorporating RDT with PCR analysis because there was a corresponding increase of 1.5 DOT/1,000 PD in use of antistaphylococcal penicillin therapy (oxacillin or nafcillin) for MSSA bacteremia (from 420 AM J HEALTH-SYST PHARM VOLUME 74 NUMBER 6 MARCH 15, 2017

5 3.7 ± 0.9 to 5.2 ± 1.6 DOT/1,000 PD, p = 0.17). During the period of PGY2 resident coverage, use of broad-spectrum antibiotics with antipseudomonal activity (piperacillin tazobactam and cefepime) decreased by 6.5 DOT/1,000 PD from prior 12-month levels (from ± 3.9 to ± 44.7 DOT/1,000 PD, p = 0.35), with a simultaneous increase in ceftriaxone therapy of 7.1 DOT/1,000 PD (from 36.7 ± 4.2 to 43.8 ± 4.3 DOT/1,000 PD, p = 0.08); micafungin use also decreased, by 6.1 DOT/1,000 PD (from 16.4 ± 3.8 to 10.3 ± 1.6 DOT/1,000 PD, p = 0.04). Rates of hospital-onset Clostridium difficile infection. The frequency of hospital-onset CDI decreased from 1.18 to 0.9 cases/1,000 PD after implementation of ASP weekend coverage by PGY2 pharmacy residents. There had been 141 cases of hospital-onset CDI in the 12 months prior to implementation but only 117 cases during the resident coverage period. The observed lower CDI rate was likely due to multifactorial initiatives implemented by the infection control and prevention department, including hospitalwide campaigns to improve hand hygiene and cleaning of frequently touched surfaces. Extending prospective audit and feedback interventions by the PGY2 residents during weekend coverage may have contributed to lower CDI rates as well. Discussion Here we describe our experience integrating PGY2 pharmacy residents into ASP coverage during weekends to mimic the high-level clinical care provided by ID-trained ASP pharmacists during weekdays. Prior to the residency year, ASP weekend coverage was provided by ID medical fellows and limited to approvals of orders for restricted antimicrobials, without prospective audit and feedback review during weekends from 8 a.m. to 10 p.m. An internal analysis was conducted from January 1, 2013, to May 31, 2014, to evaluate the volume of restricted antimicrobial approvals by ID Table 2. Targets of Prospective Audit and Feedback Interventions by Residents Medication or Class No. (%) Interventions (n = 1,000) Vancomycin 380 (38.0) Piperacillin tazobactam 150 (15.0) Cefepime 84 (8.4) Meropenem 54 (5.4) Azithromycin 50 (5.0) Metronidazole 38 (3.8) Fluconazole 35 (3.5) Antiretrovirals a 28 (2.8) Ceftriaxone 27 (2.7) Ciprofloxacin 25 (2.5) Linezolid 23 (2.3) Vancomycin oral solution 22 (2.2) Micafungin 19 (1.9) Aminoglycosides 19 (1.9) Sulfamethoxazole trimethoprim 18 (1.8) Daptomycin 14 (1.4) Levofloxacin 14 (1.4) a Interventions targeted ritonavir (n = 10), darunavir (n = 10), and atazanavir (n = 8). medical fellows versus ID-trained ASP pharmacists during weekdays. During that period, the volume of ASP calls for restricted antimicrobials was similar to that during the period of weekend resident coverage; the most commonly requested agents were ciprofloxacin and meropenem. Both restricted antibiotics were suggested to be overutilized relative to narrower-spectrum antimicrobial therapy, which led to the concept of implementing ASP weekend coverage by PGY2 pharmacy residents with a goal of improving antimicrobial utilization. Previous reports have demonstrated that IDtrained ASP pharmacists can make more appropriate recommendations than ID medical fellows, with better outcomes. Also, one study indicated that ID medical fellows found participation in an ASP service to be burdensome and distracting from their primary activities and often approved broader-spectrum and more costly antimicrobials than were necessary. 4 Financial justification may be necessary prior to the initiation of a specialty PGY2 pharmacy residency program. From January 1 to July 31, 2012 (a 7-month period), ID-trained ASP pharmacists documented 997 accepted interventions (an average of 7 interventions per weekday) associated with an estimated cost savings of $1, per day and total estimated cost savings for the 7-month period of $177, Although there are limitations to evaluating the cost savings associated with ASP interventions (i.e., savings associated with interventions that improve patient outcomes or avoid adverse events are not as easy to estimate as costs associated with drug acquisition and administration), it can be estimated that interventions by PGY2 pharmacy residents during weekend coverage could produce significant cost savings to provide justification for supporting PGY2 pharmacy residency programs. AM J HEALTH-SYST PHARM VOLUME 74 NUMBER 6 MARCH 15,

6 ANTIMICROBIAL STEWARDSHIP Table 3. Comparative Data on Pager Calls Handled by Antimicrobial Stewardship Program Pharmacists on Weekdays and Weekends a Table 4. Antimicrobial Therapies Targeted by Resident Interventions Medication or Class Variable No. (%) Interventions (n = 443) Vancomycin (i.v.) 120 (27.1) Piperacillin tazobactam 49 (11.1) Ciprofloxacin 35 (7.9) Cefpodoxime 35 (7.9) Cefepime 31 (6.9) Meropenem 31 (6.9) Ceftriaxone 27 (6.1) Aminoglycosides 27 (6.1) Metronidazole 22 (4.9) Vancomycin (oral) 18 (4.1) Azithromycin 13 (2.9) Levofloxacin 13 (2.9) Linezolid 13 (2.9) Aztreonam 9 (2.0) Weekdays (ID-Trained Pharmacists) Weekends (Residents) No. calls 1, ,570 Evaluation period, days Mean no. calls per day Calls for approval of restricted antimicrobials, no. (% of calls) Requests 380 (34) 112 (25) 492 (31) Approvals 255 (67) 76 (68) 331 (67) No change in therapy recommended 151 (59) 50 (66) 201 (61) Change in dose/route recommended 50 (20) 23 (30) 73 (22) Duration of therapy recommendation 39 (15) 3 (4) 42 (13) Culture recommended 15 (6) 0 15 (4) Not approved 125 (33) 36 (32) 161 (10) Alternative therapy recommended 114 (91) 33 (92) 147 (91) No therapy needed 11 (9) 3 (8) 14 (9) General calls, no. (% of calls) 747 (66) 331 (75) 1,078 (69) Antimicrobial recommendation 422 (56) 166 (50) 588 (55) Call from staff pharmacist 217 (29) 80 (24) 297 (27) PK/PD dosing request 65 (9) 66 (20) 131 (12) Other 30 (4) 15 (5) 45 (4) ID consult recommendation 13 (2) 4 (1) 17 (2) a ID = infectious diseases, PGY2 = postgraduate year 2, PK/PD = pharmacokinetic/pharmacodynamic. Total Aside from shifting ASP responsibilities away from ID medical fellows and financial justification, designating PGY2 pharmacy residents to perform weekend ASP activities allowed our residents to gain extensive learning experiences in ID pharmacotherapy management. In addition to managing approvals for restricted antimicrobials during weekend coverage, residents documented 1,000 interventions, including discontinuation or deescalation of broad-spectrum antimicrobial therapy and optimization of dosing regimens through interventions such as PK/PD monitoring. Also, expansion of ASP pharmacist coverage to weekends resulted in more uniformity and provided for smoother patient handoffs to clinicians assigned to weekday coverage, promoting continuity of care. After initiation of full weekend ASP coverage by PGY2 pharmacy resi- 422 AM J HEALTH-SYST PHARM VOLUME 74 NUMBER 6 MARCH 15, 2017

7 dents, trends of decreased aggregate antimicrobial use and CDI rates from levels documented during the previous 12 months were observed; this finding was most likely a result of multifactorial interventions made during the residency year, including expansion of rounding pharmacists to all internal medicine teams and implementation of hospitalwide antimicrobial usage guidelines. However, prospective audit and feedback interventions by the PGY2 pharmacy residents during weekend coverage may have influenced antimicrobial utilization, as these interventions would have been omitted or delayed in prior years. PGY2 pharmacy residents providing weekend coverage produced a volume of interventions similar to that produced by ID-trained ASP pharmacists during the weekdays. However, a higher percentage of prospective audit and feedback interventions, as opposed to ASP phone interventions, was reported during weekend coverage than during weekday coverage by ID-trained ASP pharmacists. A possible explanation for this difference is that specialty teams in CC, emergency medicine, internal medicine, and hematology oncology at our hospital do not include rounding clinical pharmacotherapy specialists during weekend hours. In their absence, there is more opportunity for PGY2 pharmacy residents to make significant ASP interventions, specifically PK/PD dosing and monitoring, dosing regimen adjustments, and discontinuation or narrowing of therapy if culture and susceptibility data become available over the weekend. Also, there were fewer interventions involving narrowing antimicrobial therapy on weekends, which may be due to weekend medicine surgery coverage teams deferring antimicrobial therapy changes until the primary coverage team returns to service on weekdays. Although there were relatively fewer ASP phone encounters during weekend coverage, the average number of calls per day was similar to that during weekday coverage, in which a majority were for antimicrobial therapy recommendations. The next most common ASP calls were from staff pharmacists with antimicrobial questions upon verification, such as appropriate antimicrobial dosing including PK/PD monitoring or verifying the concordant approval source for restricted antimicrobial utilization. Lastly, there was a lower percentage of i.v.-to-oral switches during weekend versus weekday coverage, which may have been due to interventions by rounding clinical pharmacotherapy specialists during weekdays and a hospitalwide initiative promoting i.v.-to-oral switches prior to patient discharge. In addition to enhancing patient care, PGY2 pharmacy residents participation in ASP services provides an invaluable learning experience. Residents are able to improve their critical thinking, gain exposure to management of a variety of ID clinical cases, and acquire the skills to transition to a more autonomous, higher-level, clinical practice experience. Conclusion By expanding the hospital s ASP services by assigning PGY2 pharmacy residents to weekend coverage, the institution was able to provide highlevel clinical care 7 days per week, which benefited both patients and PGY2 pharmacy residents while meeting national ASP regulatory requirements. Disclosures The authors have declared no potential conflicts of interest. References 1. Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs (2014). healthcare/pdfs/core-elements.pdf (accessed 2016 Dec 8). 2. Barlam TF, Cosgrove SE, Abbo LM et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. 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