"Point education" and "rotation communication" on antimicrobial policy implementation: an interrupted time series analysis of declining cephalosporin skin test rates.

内容摘要

Following China's 2021 national policy canceling routine cephalosporin skin testing (CST), substantial implementation barriers persist in some hospitals due to traditional clinical practices and fears about liability. For example, prescribers often order CST out of habit, citing concerns about potential allergic reactions and the risk of adverse events being attributed to them without a documented skin test. A similar challenge exists in the nephrology department of our hospital. Three months following the release of the national policy, the rate of routine CST remained persistently high. This highlights an urgent need for clinical pharmacists to implement targeted interventions to facilitate policy adoption and improve practice adherence. This study compares two different strategies: pharmacist-led Collaborative Learning in Practice(CLiP)-aligned "point education" (concentrated, personalized training) vs. "rotation communication" (without pharmacist-led point education, indirect knowledge diffusion through physician rotations and informal information sharing). We analyze their differential effectiveness in reducing skin test rates in a real-world clinical setting. A retrospective observational study collected data on hospitalized nephrology patients planned for cephalosporin use between January 2021 and April 2023. Using the April 2022 pharmacist intervention in one treatment team as the node, interrupted time series analysis compared pre-/post-level and trend changes of skin test rates among wards (first nephrology group, second nephrology group, Nephrology Intensive Care Unit (NICU)) and physicians. The overall skin test rate decreased dramatically from 96.02% pre-intervention to 25.19% post-intervention. The second nephrology ward receiving point education showed a significant immediate drop post-intervention (-71.081%, P&#x2009;<&#x2009;0.001) with a sustained downward trend (slope: -0.121, P&#x2009;<&#x2009;0.001). The first nephrology group and NICU, without direct intervention, demonstrated no significant immediate effects but significant continuous declining trends (slope: -0.282, P&#x2009;=&#x2009;0.009 and -&#x2009;0.326, P&#x2009;=&#x2009;0.026, respectively). Physician-level analysis paralleled ward-level findings, with directly educated physicians showing more rapid declines. Notably, after positive skin tests, 43.1% of patients were switched to quinolone antibiotics, indicating continued clinical caution and antibiotic stewardship considerations. These findings confirm our hypotheses: point education showed an immediate effect, while rotation communication showed a sustained trend. The cephalosporin skin test rate in the Second Nephrology Ward, where the clinical pharmacist was based, showed an immediate decline, which may be associated with the pharmacist-led "point education". On the basis of this initial effect, "rotation communication" achieved slower but sustained policy implementation across a broader range of clinical settings through peer-to-peer exchanges during physician rotations. These two mechanisms may complement each other to support effective policy implementation in complex clinical settings. These findings provide empirical evidence for optimizing clinical pharmacy service models and developing policy dissemination strategies for antimicrobial stewardship.