User login
Streamlining the Acute Care Pharmacy Consultation Process for Patients With Dysphagia or Enteral Feeding Tubes
Streamlining the Acute Care Pharmacy Consultation Process for Patients With Dysphagia or Enteral Feeding Tubes
Medication regimens may require adjustment in acute care settings due to dysphagia and/or enteral feeding tubes. When a patient has dysphagia and/or a feeding tube, the health care team must review the pharmacotherapy regimen to assess the appropriateness of medication formulations. Patient anatomy, the type of feeding tube in place, pharmacokinetic and pharmacodynamic properties of medications, risk of feeding tube obstruction, and potential for interactions between enteral nutrition and medications should be considered when clinicians administer medications through feeding tubes. The risk of feeding tube obstruction and clogging rises with increasing tube length and decreasing tube lumen. Incidence of obstructed percutaneous endoscopic gastrotomy tubes is reported to be 23% to 35%.1
A coordinated effort by all members of the health care team is essential to provide safe and effective care to patients with dysphagia and/or enteral feeding tubes. To decrease the risk of feeding tube obstruction, medications should be dissolved in water or administered in liquid form, saline fluids should be avoided, and the tube should be flushed with water before and after administering medications.
The pharmacokinetics of medications can be altered when tablets are crushed or capsules are opened. The bioavailability of dabigatran, for example, increases by 75% when the capsules are opened and pellets are taken orally.2 Medications may become intolerable after manipulation due to taste.3 Others may also increase the risk of feeding tube obstruction, such as omeprazole granules that increase the risk of small-bore feeding tube obstruction.4
Prior assessments of drug administration for patients with dysphagia and/or enteral feeding tubes has shown medication errors are prevalent.5-7 The Institute for Safe Medication Practices (ISMP) issued a Medication Safety Alert that provides a framework for preventing medication errors when preparing and administering medications via enteral feeding tubes.8 Other resources, such as monographs, are also available to guide pharmacotherapy decisions when oral medications require manipulation for administration to patients with dysphagia and/or enteral feeding tubes.9-11
In 2021, the Kansas City Veterans Affairs Medical Center (KCVAMC) was recognized as a Veterans Health Administration (VHA) Shark Tank finalist for improving the safety of medication administration for patients with enteral feeding tubes.12 This involved the addition of a Computerized Patient Record System (CPRS), clinical reminder order check (CROC), and a comprehensive medication review by a pharmacist. After implementing the CROC alert and pharmacy e-consultation workflow, the KCVAMC team reported that the number of inappropriate medications (ie, drugs on the ISMP do not crush list) was reduced from 41 to 6 in 1 year, resulting in an 85.4% reduction in potential medication errors.13
In 2014, the Richard L. Roudebush VAMC (RLRVAMC) created a pharmacy consultation process for patients with dysphagia and/or enteral feeding tubes. Any clinician could place a pharmacy consultation in CPRS. A pharmacist then reviewed patient charts, medication information resources, the VA formulary, and RLRVAMC pharmacy inventory. The pharmacist conferred with the patient’s care team to adjust pharmacotherapy, completed a consultation note, and updated medication order comments in Veterans Health Information Systems and Technology Architecture (VistA). These comments interfaced with the barcode medication administration software for the health care professional administering medications.
Despite the 2014 quality improvement (QI) process, medication errors involving the inappropriate ordering, preparation, and administration of medications for patients with dysphagia and/or enteral feeding tubes continued to be reported. Additionally, anonymous feedback revealed that only 3 of 10 responding pharmacists were satisfied with the existing medication use process for patients with dysphagia and/or enteral feeding tubes. Pharmacists expressed concerns that (1) clinicians were inappropriately crushing and/or manipulating new medications that were ordered after pharmacy consultations; (2) there was a lack of comprehensive documentation in CPRS; and (3) there were too many manual steps in the process. In response, RLRVAMC initiated a new QI initiative to improve the medication use process for patients with dysphagia and/or enteral feeding tubes in the acute care setting.
Quality Improvement Project
This multidisciplinary RLRVAMC QI project began November 2024 to improve pharmacotherapy care for patients with dysphagia and/or enteral feeding tubes in acute care. It was approved by the RLRVAMC Pharmacy Service. This intervention addressed the pharmacy consultation template, standardization of equipment, standardization of language, creation of clinical alerts, and sustainment (Table 1).
RLRVAMC has about 8600 annual inpatient admissions and 159 acute care beds.14 The project charter was drafted, and local stakeholders were identified including pharmacy technicians, pharmacists, nurses, speech language pathologists, and acute care clinicians. Pharmacy consultation workload was retrospectively reviewed to describe the scope of the existing state.
A workshop with 12 QI project stakeholders in December 2024 used A3 methodology to define the current process and the target state, barriers and solutions, prioritize interventions on an impact-effort matrix, perform a gap analysis, identify rapid plan-do-study-act (PDSA) experiments, and develop a completion plan (Figure). Five postworkshop PDSA experiments engaged additional stakeholders, clinical application coordinators, and medical supply representatives to ascertain the feasibility of the tools implemented.
Abbreviations: BCMA, barcode medication administration; CDSS, clinical decision support system; CPRS, Computerized Patient Record System;
EHR, electronic health record; SOP, standard operating procedure; VistA, Veterans Health Information Systems and Technology Architecture.
About 3% of RLRVAMC admissions involve a pharmacy consultation to review medications for dysphagia and/or enteral feeding tubes. Clinicians reviewed 30 preimplementation inpatient pharmacy consultations involving 200 oral medications. Pharmacists were more frequently consulted for inpatients with dysphagia (19 [63%]) than for patients with enteral feeding tubes (11 [37%]) (Table 2).
Pharmacy Consultation Template
The pharmacy consultation was updated in CPRS. Prior to this QI project, the ordering clinician was prompted to select 1 option for the indication: dysphagia or enteral feeding tube. The type of enteral feeding tube was not prompted by the consultation text nor required to be specified in the consultation. The ordering clinician could provide free-text comments. Of 11 preimplementation consultations, the type of enteral feeding tube was specified in 5 (45%). The consultation template entry was updated to include an option to check a box for the consultation indication from 3 options: dysphagia, enteral feeding, or other patient- specific condition/request. If enteral feeding tube is selected, then the clinician is prompted to select the type of enteral feeding tube. Since the completion of the project, there have been no patient safety reports concerning an erroneous or incomplete consultation entry (Supplemental Material).
The note template was updated to import the list of active inpatient medications and provide sections for the adjudicating pharmacist to document which medications can be crushed (or opened), which require adjustment, and which are hazardous and require special handling. Additionally, the revised template added a statement clarifying that the documented recommendations apply only to the medication regimen at the time of the consultation (Supplemental Material).
Standardizations
There are multiple pill-crushing devices used at RLRVAMC that vary in crushing mechanism, corresponding medication pouches, and degree of protection when manipulating hazardous medications. Prior to this QI project, RLRVAMC used 3 pill-crushing devices (about 30 total devices in inpatient care areas). Only 1 device with corresponding closed pouches for preparation of hazardous medications was available, which was stored in the RLRVAMC inpatient pharmacy. This workflow resulted in waste and posed potential risks for delays in care. This project incorporated a standard pill-crushing system with the corresponding medication pouches in all inpatient care areas, which provided safeguards for clinicians to prepare and administer hazardous medications (Supplemental Material).
Patients requiring medications to be crushed or opened on discharge should receive education, written instruction, and have care plans documented in CPRS. RLRVAMC patients receive education and a printed medication list. Prior to this QI project, the instructions for crushing or opening medications could only be entered by free text in the electronic medication reconciliation tool, allowing for the potential for inconsistent language or omissions.
This QI project included an update to the electronic medication reconciliation tool. An optional checkbox selection was added for patients requiring medications to be manipulated. When checked, a radial selection for individual medications is displayed, prompting the clinician and pharmacist to indicate either do not crush tablet or OK to crush tablet. These selections appear in clinical care notes and on the printed medication list provided to the patient (Supplemental Material).
Clinical Alerts
As part of the RLRVAMC QI initiative, a CROC alert was implemented, based on the KCVAMC intervention for patients with enteral feeding tubes.13 The RLRVAMC CROC alert also included patients with dysphagia. A nursing text order was made available in CPRS for patients requiring medications and remains active throughout the duration of the patient’s admission or until discontinued. It generates CROC alerts in CPRS and VistA when new medication orders are entered and reviewed by pharmacists.
Clinicians used clinical decision support systems to create daily lists of patients receiving medications by feeding tube and patients receiving crushed/opened medications due to dysphagia. This allows pharmacists to perform a census review of all inpatients to confirm appropriateness of medication orders. Clinical alerts for patients with enteral feeding tubes are advised by the ISMP and have data demonstrating a reduction in medication errors (Supplemental Material).14,15
Sustainment
During the sustainment phase, process owners were identified and a Pharmacy Service standard operating procedure (SOP) was written. The development of an institutional do not crush medication list was discussed; however, it was determined to be difficult to develop and maintain. An institutional tertiary resource list was selected in favor of a locally developed resource. These resources include the Handbook of Drug Administration via Enteral Feeding Tubes, Third Edition, the Pharmacist’s Letter list, “Meds that Should Not be Crushed,” and the Up- ToDate Lexidrug list, “Oral Medications That Should Not Be Crushed or Altered.”9-11 Links to the resources were added to the RLRVAMC pharmacy service SharePoint. In addition to defining the preferred tertiary resources, the SOP defined the process for reviewing inventory and the process for reviewing medication orders for hazard risk.
Discussion
Continued patient safety reports and low satisfaction rates among pharmacists prompted this QI project to improve safety for patients with dysphagia and/or enteral feeding tubes at RLRVAMC. The project engaged stakeholders and also identified and addressed gaps with potential for patient harm.
The tools implemented by this initiative drew from previous work by the KCVAMC and from framework provided by the ISMP.8,13 We expanded the QI intervention to include acute care patients with dysphagia.
RLRVAMC did not take steps to track the impact of the interventions on medication errors. However, no patient safety reports concerning an erroneous or incomplete pharmacy consultation entry have been reported. We also think that it is reasonable to assume that the adoption of the safety tools described here will have a positive impact on patient safety. RLRVAMC pharmacists have noted an increased appreciation for medication safety when processing medication orders for patients with dysphagia and/or enteral feeding tubes. While the workflow took time to adopt and integrate, clinical pharmacists perceived it as an improvement in patient safety. Our future focus is aimed at translating the process improvement into the Oracle/Cerner electronic health record, which is scheduled to be deployed at the RLRVAMC in August 2026.
Limitations
This QI project did not aim to quantify or compare medication errors before and after the intervention. An accurate number of unreported errors in the medication use process for patients with dysphagia and/or enteral feeding tubes would be challenging to quantify without direct observation. Multiple clinicians are engaged in the medication use process and individual steps may not be documented at all, or documented properly. In addition, medication errors are often underreported and may not reflect the total number of errors and/or potential for errors. That said, reported medication errors in the medication use process for patients with dysphagia and/or enteral feeding tubes are reviewed on a monthly basis by the RLRVAMC Multidisciplinary Medication Safety committee to continuously improve patient safety.
Another potential limitation is the extent to which the project can be adapted at other VHA sites. For example, RLRVAMC uses CPRS; the framework and tools to improve medication safety may not translate to sites using the Oracle/Cerner electronic health record. Furthermore, this QI project included a pharmacy consultation workflow that relied on pharmacists who are available at any hour. Other facilities may not have continuous consultation coverage to review medications for patients with dysphagia and/or enteral feeding tubes.
Conclusions
This QI project drew from ISMP recommendations, previous work within the VHA, local practice, and insight from multiple disciplines on the health care team to revise and create tools to improve medication safety for patients with dysphagia and/or enteral feeding tubes in the acute care setting. These tools included a revised pharmacy consultation workflow with improvements to the pharmacy consultation template, standardization of the pill-crushing devices and language used for patient medication lists, implementation of CROC alerts within the EHR, and development of an SOP.
The RLRVAMC Pharmacy Service intends to continue reviewing patient safety reports, assessing staff perspectives, and refining (and potentially adding) tools for medication safety. Future QI initiatives may focus on improving medication safety for outpatients with dysphagia and/or enteral feeding tubes. We also hope that these tools can be adapted at other VAMCs to promote medication safety for patients with dysphagia and/or enteral feeding tubes.
- Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol. 2014;20:8505-8524. doi:10.3748/wjg.v20.i26.8505
- Pradaxa (dabigatran etexilate). Prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc; 2025. https:// pro.boehringer-ingelheim.com/us/products/pradaxa/bipdf /pradaxa-capsules-us-pi
- Lovell AG, Protus BM, Dickman JR, et al. Palatability of crushed over-the-counter medications. J Pain Symptom Manage. 2021;61:755-762. doi:10.1016/j.jpainsymman.2020.09.020
- Messaouik D, Sautou-Miranda V, Bagel-Boithias S, et al. Comparative study and optimisation of the administration mode of three proton pump inhibitors by nasogastric tube. Int J Pharm. 2005;299:65-72. doi:10.1016/j.ijpharm.2005.04.034
- Demirkan K, Bayraktar-Ekincioglu A, Gulhan-Halil M, et al. Assessment of drug administration via feeding tube and the knowledge of health-care professionals in a university hospital. Eur J Clin Nutr. 2017;71:164-168. doi:10.1038/ejcn.2016.147
- Fodil M, Nghiem D, Colas M, et al. Assessment of clinical practices for crushing medication in geriatric units. J Nutr Health Aging. 2017;21:904-908. doi:10.1007/s12603-017-0886-3
- Zhu LL, Xu LC, Wang HQ, et al. Appropriateness of administration of nasogastric medication and preliminary intervention. Ther Clin Risk Manag. 2012;8:393-401. doi:10.2147/TCRM.S37785
- Institute for Safe Medication Practices (ISMP). Preventing errors when preparing and administering medications via enteral feeding tubes. Acute Care ISMP Medication Safety Alert. November 17, 2022. Accessed March 17, 2026. https://nutritioncare.org/wp-content/uploads/2025/02 /ISMP-Safety-Alert_Medications-and-Enteral-Feeding -Tubes.pdf
- White R, Bradnam V. Handbook of Drug Administration via Enteral Feeding Tubes. 3rd ed. Pharmaceutical Press; 2015.
- Clinical resource, meds that should not be crushed. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. Updated April 2025. Accessed March 17, 2026. https://pharmacist.therapeuticresearch.com/en/Content /Segments/PRL/2014/Aug/Meds-That-Should-Not-Be -Crushed-7309
- Oral medications that should not be crushed or altered. In: Lexidrug. UpToDate, Inc. https://online.lexi.com/lco /action/doc/retrieve/docid/patch_f/4227
- Uttaro E, Zhao F, Schweighardt A. Filling the gaps on the Institute for Safe Medication Practices (ISMP) do not crush list for immediate-release products. Int J Pharm Compd. 2021;25:364-371.
- US Dept of Veterans Affairs. VA Diffusion Marketplace. Improved safety of enteral tube medication administration. Updated 2024. Accessed March 17, 2026. https:// marketplace.va.gov/innovations/improved-safety-of -enteral-tube-medication-administration
- US Dept of Veterans Affairs. About us. VA Indiana Healthcare System. Updated October 17, 2024. Accessed March 2, 2026. https://www.va.gov/indiana-health-care/about-us/
- Wasylewicz ATM, van Grinsven RJB, Bikker JMW, et al. Clinical decision support system-assisted pharmacy intervention reduces feeding tube-related medication errors in hospitalized patients: a focus on medication suitable for feeding-tube administration. JPEN J Parenter Enteral Nutr. 2021;45:625-632. doi:10.1002/jpen.1869
Medication regimens may require adjustment in acute care settings due to dysphagia and/or enteral feeding tubes. When a patient has dysphagia and/or a feeding tube, the health care team must review the pharmacotherapy regimen to assess the appropriateness of medication formulations. Patient anatomy, the type of feeding tube in place, pharmacokinetic and pharmacodynamic properties of medications, risk of feeding tube obstruction, and potential for interactions between enteral nutrition and medications should be considered when clinicians administer medications through feeding tubes. The risk of feeding tube obstruction and clogging rises with increasing tube length and decreasing tube lumen. Incidence of obstructed percutaneous endoscopic gastrotomy tubes is reported to be 23% to 35%.1
A coordinated effort by all members of the health care team is essential to provide safe and effective care to patients with dysphagia and/or enteral feeding tubes. To decrease the risk of feeding tube obstruction, medications should be dissolved in water or administered in liquid form, saline fluids should be avoided, and the tube should be flushed with water before and after administering medications.
The pharmacokinetics of medications can be altered when tablets are crushed or capsules are opened. The bioavailability of dabigatran, for example, increases by 75% when the capsules are opened and pellets are taken orally.2 Medications may become intolerable after manipulation due to taste.3 Others may also increase the risk of feeding tube obstruction, such as omeprazole granules that increase the risk of small-bore feeding tube obstruction.4
Prior assessments of drug administration for patients with dysphagia and/or enteral feeding tubes has shown medication errors are prevalent.5-7 The Institute for Safe Medication Practices (ISMP) issued a Medication Safety Alert that provides a framework for preventing medication errors when preparing and administering medications via enteral feeding tubes.8 Other resources, such as monographs, are also available to guide pharmacotherapy decisions when oral medications require manipulation for administration to patients with dysphagia and/or enteral feeding tubes.9-11
In 2021, the Kansas City Veterans Affairs Medical Center (KCVAMC) was recognized as a Veterans Health Administration (VHA) Shark Tank finalist for improving the safety of medication administration for patients with enteral feeding tubes.12 This involved the addition of a Computerized Patient Record System (CPRS), clinical reminder order check (CROC), and a comprehensive medication review by a pharmacist. After implementing the CROC alert and pharmacy e-consultation workflow, the KCVAMC team reported that the number of inappropriate medications (ie, drugs on the ISMP do not crush list) was reduced from 41 to 6 in 1 year, resulting in an 85.4% reduction in potential medication errors.13
In 2014, the Richard L. Roudebush VAMC (RLRVAMC) created a pharmacy consultation process for patients with dysphagia and/or enteral feeding tubes. Any clinician could place a pharmacy consultation in CPRS. A pharmacist then reviewed patient charts, medication information resources, the VA formulary, and RLRVAMC pharmacy inventory. The pharmacist conferred with the patient’s care team to adjust pharmacotherapy, completed a consultation note, and updated medication order comments in Veterans Health Information Systems and Technology Architecture (VistA). These comments interfaced with the barcode medication administration software for the health care professional administering medications.
Despite the 2014 quality improvement (QI) process, medication errors involving the inappropriate ordering, preparation, and administration of medications for patients with dysphagia and/or enteral feeding tubes continued to be reported. Additionally, anonymous feedback revealed that only 3 of 10 responding pharmacists were satisfied with the existing medication use process for patients with dysphagia and/or enteral feeding tubes. Pharmacists expressed concerns that (1) clinicians were inappropriately crushing and/or manipulating new medications that were ordered after pharmacy consultations; (2) there was a lack of comprehensive documentation in CPRS; and (3) there were too many manual steps in the process. In response, RLRVAMC initiated a new QI initiative to improve the medication use process for patients with dysphagia and/or enteral feeding tubes in the acute care setting.
Quality Improvement Project
This multidisciplinary RLRVAMC QI project began November 2024 to improve pharmacotherapy care for patients with dysphagia and/or enteral feeding tubes in acute care. It was approved by the RLRVAMC Pharmacy Service. This intervention addressed the pharmacy consultation template, standardization of equipment, standardization of language, creation of clinical alerts, and sustainment (Table 1).
RLRVAMC has about 8600 annual inpatient admissions and 159 acute care beds.14 The project charter was drafted, and local stakeholders were identified including pharmacy technicians, pharmacists, nurses, speech language pathologists, and acute care clinicians. Pharmacy consultation workload was retrospectively reviewed to describe the scope of the existing state.
A workshop with 12 QI project stakeholders in December 2024 used A3 methodology to define the current process and the target state, barriers and solutions, prioritize interventions on an impact-effort matrix, perform a gap analysis, identify rapid plan-do-study-act (PDSA) experiments, and develop a completion plan (Figure). Five postworkshop PDSA experiments engaged additional stakeholders, clinical application coordinators, and medical supply representatives to ascertain the feasibility of the tools implemented.
Abbreviations: BCMA, barcode medication administration; CDSS, clinical decision support system; CPRS, Computerized Patient Record System;
EHR, electronic health record; SOP, standard operating procedure; VistA, Veterans Health Information Systems and Technology Architecture.
About 3% of RLRVAMC admissions involve a pharmacy consultation to review medications for dysphagia and/or enteral feeding tubes. Clinicians reviewed 30 preimplementation inpatient pharmacy consultations involving 200 oral medications. Pharmacists were more frequently consulted for inpatients with dysphagia (19 [63%]) than for patients with enteral feeding tubes (11 [37%]) (Table 2).
Pharmacy Consultation Template
The pharmacy consultation was updated in CPRS. Prior to this QI project, the ordering clinician was prompted to select 1 option for the indication: dysphagia or enteral feeding tube. The type of enteral feeding tube was not prompted by the consultation text nor required to be specified in the consultation. The ordering clinician could provide free-text comments. Of 11 preimplementation consultations, the type of enteral feeding tube was specified in 5 (45%). The consultation template entry was updated to include an option to check a box for the consultation indication from 3 options: dysphagia, enteral feeding, or other patient- specific condition/request. If enteral feeding tube is selected, then the clinician is prompted to select the type of enteral feeding tube. Since the completion of the project, there have been no patient safety reports concerning an erroneous or incomplete consultation entry (Supplemental Material).
The note template was updated to import the list of active inpatient medications and provide sections for the adjudicating pharmacist to document which medications can be crushed (or opened), which require adjustment, and which are hazardous and require special handling. Additionally, the revised template added a statement clarifying that the documented recommendations apply only to the medication regimen at the time of the consultation (Supplemental Material).
Standardizations
There are multiple pill-crushing devices used at RLRVAMC that vary in crushing mechanism, corresponding medication pouches, and degree of protection when manipulating hazardous medications. Prior to this QI project, RLRVAMC used 3 pill-crushing devices (about 30 total devices in inpatient care areas). Only 1 device with corresponding closed pouches for preparation of hazardous medications was available, which was stored in the RLRVAMC inpatient pharmacy. This workflow resulted in waste and posed potential risks for delays in care. This project incorporated a standard pill-crushing system with the corresponding medication pouches in all inpatient care areas, which provided safeguards for clinicians to prepare and administer hazardous medications (Supplemental Material).
Patients requiring medications to be crushed or opened on discharge should receive education, written instruction, and have care plans documented in CPRS. RLRVAMC patients receive education and a printed medication list. Prior to this QI project, the instructions for crushing or opening medications could only be entered by free text in the electronic medication reconciliation tool, allowing for the potential for inconsistent language or omissions.
This QI project included an update to the electronic medication reconciliation tool. An optional checkbox selection was added for patients requiring medications to be manipulated. When checked, a radial selection for individual medications is displayed, prompting the clinician and pharmacist to indicate either do not crush tablet or OK to crush tablet. These selections appear in clinical care notes and on the printed medication list provided to the patient (Supplemental Material).
Clinical Alerts
As part of the RLRVAMC QI initiative, a CROC alert was implemented, based on the KCVAMC intervention for patients with enteral feeding tubes.13 The RLRVAMC CROC alert also included patients with dysphagia. A nursing text order was made available in CPRS for patients requiring medications and remains active throughout the duration of the patient’s admission or until discontinued. It generates CROC alerts in CPRS and VistA when new medication orders are entered and reviewed by pharmacists.
Clinicians used clinical decision support systems to create daily lists of patients receiving medications by feeding tube and patients receiving crushed/opened medications due to dysphagia. This allows pharmacists to perform a census review of all inpatients to confirm appropriateness of medication orders. Clinical alerts for patients with enteral feeding tubes are advised by the ISMP and have data demonstrating a reduction in medication errors (Supplemental Material).14,15
Sustainment
During the sustainment phase, process owners were identified and a Pharmacy Service standard operating procedure (SOP) was written. The development of an institutional do not crush medication list was discussed; however, it was determined to be difficult to develop and maintain. An institutional tertiary resource list was selected in favor of a locally developed resource. These resources include the Handbook of Drug Administration via Enteral Feeding Tubes, Third Edition, the Pharmacist’s Letter list, “Meds that Should Not be Crushed,” and the Up- ToDate Lexidrug list, “Oral Medications That Should Not Be Crushed or Altered.”9-11 Links to the resources were added to the RLRVAMC pharmacy service SharePoint. In addition to defining the preferred tertiary resources, the SOP defined the process for reviewing inventory and the process for reviewing medication orders for hazard risk.
Discussion
Continued patient safety reports and low satisfaction rates among pharmacists prompted this QI project to improve safety for patients with dysphagia and/or enteral feeding tubes at RLRVAMC. The project engaged stakeholders and also identified and addressed gaps with potential for patient harm.
The tools implemented by this initiative drew from previous work by the KCVAMC and from framework provided by the ISMP.8,13 We expanded the QI intervention to include acute care patients with dysphagia.
RLRVAMC did not take steps to track the impact of the interventions on medication errors. However, no patient safety reports concerning an erroneous or incomplete pharmacy consultation entry have been reported. We also think that it is reasonable to assume that the adoption of the safety tools described here will have a positive impact on patient safety. RLRVAMC pharmacists have noted an increased appreciation for medication safety when processing medication orders for patients with dysphagia and/or enteral feeding tubes. While the workflow took time to adopt and integrate, clinical pharmacists perceived it as an improvement in patient safety. Our future focus is aimed at translating the process improvement into the Oracle/Cerner electronic health record, which is scheduled to be deployed at the RLRVAMC in August 2026.
Limitations
This QI project did not aim to quantify or compare medication errors before and after the intervention. An accurate number of unreported errors in the medication use process for patients with dysphagia and/or enteral feeding tubes would be challenging to quantify without direct observation. Multiple clinicians are engaged in the medication use process and individual steps may not be documented at all, or documented properly. In addition, medication errors are often underreported and may not reflect the total number of errors and/or potential for errors. That said, reported medication errors in the medication use process for patients with dysphagia and/or enteral feeding tubes are reviewed on a monthly basis by the RLRVAMC Multidisciplinary Medication Safety committee to continuously improve patient safety.
Another potential limitation is the extent to which the project can be adapted at other VHA sites. For example, RLRVAMC uses CPRS; the framework and tools to improve medication safety may not translate to sites using the Oracle/Cerner electronic health record. Furthermore, this QI project included a pharmacy consultation workflow that relied on pharmacists who are available at any hour. Other facilities may not have continuous consultation coverage to review medications for patients with dysphagia and/or enteral feeding tubes.
Conclusions
This QI project drew from ISMP recommendations, previous work within the VHA, local practice, and insight from multiple disciplines on the health care team to revise and create tools to improve medication safety for patients with dysphagia and/or enteral feeding tubes in the acute care setting. These tools included a revised pharmacy consultation workflow with improvements to the pharmacy consultation template, standardization of the pill-crushing devices and language used for patient medication lists, implementation of CROC alerts within the EHR, and development of an SOP.
The RLRVAMC Pharmacy Service intends to continue reviewing patient safety reports, assessing staff perspectives, and refining (and potentially adding) tools for medication safety. Future QI initiatives may focus on improving medication safety for outpatients with dysphagia and/or enteral feeding tubes. We also hope that these tools can be adapted at other VAMCs to promote medication safety for patients with dysphagia and/or enteral feeding tubes.
Medication regimens may require adjustment in acute care settings due to dysphagia and/or enteral feeding tubes. When a patient has dysphagia and/or a feeding tube, the health care team must review the pharmacotherapy regimen to assess the appropriateness of medication formulations. Patient anatomy, the type of feeding tube in place, pharmacokinetic and pharmacodynamic properties of medications, risk of feeding tube obstruction, and potential for interactions between enteral nutrition and medications should be considered when clinicians administer medications through feeding tubes. The risk of feeding tube obstruction and clogging rises with increasing tube length and decreasing tube lumen. Incidence of obstructed percutaneous endoscopic gastrotomy tubes is reported to be 23% to 35%.1
A coordinated effort by all members of the health care team is essential to provide safe and effective care to patients with dysphagia and/or enteral feeding tubes. To decrease the risk of feeding tube obstruction, medications should be dissolved in water or administered in liquid form, saline fluids should be avoided, and the tube should be flushed with water before and after administering medications.
The pharmacokinetics of medications can be altered when tablets are crushed or capsules are opened. The bioavailability of dabigatran, for example, increases by 75% when the capsules are opened and pellets are taken orally.2 Medications may become intolerable after manipulation due to taste.3 Others may also increase the risk of feeding tube obstruction, such as omeprazole granules that increase the risk of small-bore feeding tube obstruction.4
Prior assessments of drug administration for patients with dysphagia and/or enteral feeding tubes has shown medication errors are prevalent.5-7 The Institute for Safe Medication Practices (ISMP) issued a Medication Safety Alert that provides a framework for preventing medication errors when preparing and administering medications via enteral feeding tubes.8 Other resources, such as monographs, are also available to guide pharmacotherapy decisions when oral medications require manipulation for administration to patients with dysphagia and/or enteral feeding tubes.9-11
In 2021, the Kansas City Veterans Affairs Medical Center (KCVAMC) was recognized as a Veterans Health Administration (VHA) Shark Tank finalist for improving the safety of medication administration for patients with enteral feeding tubes.12 This involved the addition of a Computerized Patient Record System (CPRS), clinical reminder order check (CROC), and a comprehensive medication review by a pharmacist. After implementing the CROC alert and pharmacy e-consultation workflow, the KCVAMC team reported that the number of inappropriate medications (ie, drugs on the ISMP do not crush list) was reduced from 41 to 6 in 1 year, resulting in an 85.4% reduction in potential medication errors.13
In 2014, the Richard L. Roudebush VAMC (RLRVAMC) created a pharmacy consultation process for patients with dysphagia and/or enteral feeding tubes. Any clinician could place a pharmacy consultation in CPRS. A pharmacist then reviewed patient charts, medication information resources, the VA formulary, and RLRVAMC pharmacy inventory. The pharmacist conferred with the patient’s care team to adjust pharmacotherapy, completed a consultation note, and updated medication order comments in Veterans Health Information Systems and Technology Architecture (VistA). These comments interfaced with the barcode medication administration software for the health care professional administering medications.
Despite the 2014 quality improvement (QI) process, medication errors involving the inappropriate ordering, preparation, and administration of medications for patients with dysphagia and/or enteral feeding tubes continued to be reported. Additionally, anonymous feedback revealed that only 3 of 10 responding pharmacists were satisfied with the existing medication use process for patients with dysphagia and/or enteral feeding tubes. Pharmacists expressed concerns that (1) clinicians were inappropriately crushing and/or manipulating new medications that were ordered after pharmacy consultations; (2) there was a lack of comprehensive documentation in CPRS; and (3) there were too many manual steps in the process. In response, RLRVAMC initiated a new QI initiative to improve the medication use process for patients with dysphagia and/or enteral feeding tubes in the acute care setting.
Quality Improvement Project
This multidisciplinary RLRVAMC QI project began November 2024 to improve pharmacotherapy care for patients with dysphagia and/or enteral feeding tubes in acute care. It was approved by the RLRVAMC Pharmacy Service. This intervention addressed the pharmacy consultation template, standardization of equipment, standardization of language, creation of clinical alerts, and sustainment (Table 1).
RLRVAMC has about 8600 annual inpatient admissions and 159 acute care beds.14 The project charter was drafted, and local stakeholders were identified including pharmacy technicians, pharmacists, nurses, speech language pathologists, and acute care clinicians. Pharmacy consultation workload was retrospectively reviewed to describe the scope of the existing state.
A workshop with 12 QI project stakeholders in December 2024 used A3 methodology to define the current process and the target state, barriers and solutions, prioritize interventions on an impact-effort matrix, perform a gap analysis, identify rapid plan-do-study-act (PDSA) experiments, and develop a completion plan (Figure). Five postworkshop PDSA experiments engaged additional stakeholders, clinical application coordinators, and medical supply representatives to ascertain the feasibility of the tools implemented.
Abbreviations: BCMA, barcode medication administration; CDSS, clinical decision support system; CPRS, Computerized Patient Record System;
EHR, electronic health record; SOP, standard operating procedure; VistA, Veterans Health Information Systems and Technology Architecture.
About 3% of RLRVAMC admissions involve a pharmacy consultation to review medications for dysphagia and/or enteral feeding tubes. Clinicians reviewed 30 preimplementation inpatient pharmacy consultations involving 200 oral medications. Pharmacists were more frequently consulted for inpatients with dysphagia (19 [63%]) than for patients with enteral feeding tubes (11 [37%]) (Table 2).
Pharmacy Consultation Template
The pharmacy consultation was updated in CPRS. Prior to this QI project, the ordering clinician was prompted to select 1 option for the indication: dysphagia or enteral feeding tube. The type of enteral feeding tube was not prompted by the consultation text nor required to be specified in the consultation. The ordering clinician could provide free-text comments. Of 11 preimplementation consultations, the type of enteral feeding tube was specified in 5 (45%). The consultation template entry was updated to include an option to check a box for the consultation indication from 3 options: dysphagia, enteral feeding, or other patient- specific condition/request. If enteral feeding tube is selected, then the clinician is prompted to select the type of enteral feeding tube. Since the completion of the project, there have been no patient safety reports concerning an erroneous or incomplete consultation entry (Supplemental Material).
The note template was updated to import the list of active inpatient medications and provide sections for the adjudicating pharmacist to document which medications can be crushed (or opened), which require adjustment, and which are hazardous and require special handling. Additionally, the revised template added a statement clarifying that the documented recommendations apply only to the medication regimen at the time of the consultation (Supplemental Material).
Standardizations
There are multiple pill-crushing devices used at RLRVAMC that vary in crushing mechanism, corresponding medication pouches, and degree of protection when manipulating hazardous medications. Prior to this QI project, RLRVAMC used 3 pill-crushing devices (about 30 total devices in inpatient care areas). Only 1 device with corresponding closed pouches for preparation of hazardous medications was available, which was stored in the RLRVAMC inpatient pharmacy. This workflow resulted in waste and posed potential risks for delays in care. This project incorporated a standard pill-crushing system with the corresponding medication pouches in all inpatient care areas, which provided safeguards for clinicians to prepare and administer hazardous medications (Supplemental Material).
Patients requiring medications to be crushed or opened on discharge should receive education, written instruction, and have care plans documented in CPRS. RLRVAMC patients receive education and a printed medication list. Prior to this QI project, the instructions for crushing or opening medications could only be entered by free text in the electronic medication reconciliation tool, allowing for the potential for inconsistent language or omissions.
This QI project included an update to the electronic medication reconciliation tool. An optional checkbox selection was added for patients requiring medications to be manipulated. When checked, a radial selection for individual medications is displayed, prompting the clinician and pharmacist to indicate either do not crush tablet or OK to crush tablet. These selections appear in clinical care notes and on the printed medication list provided to the patient (Supplemental Material).
Clinical Alerts
As part of the RLRVAMC QI initiative, a CROC alert was implemented, based on the KCVAMC intervention for patients with enteral feeding tubes.13 The RLRVAMC CROC alert also included patients with dysphagia. A nursing text order was made available in CPRS for patients requiring medications and remains active throughout the duration of the patient’s admission or until discontinued. It generates CROC alerts in CPRS and VistA when new medication orders are entered and reviewed by pharmacists.
Clinicians used clinical decision support systems to create daily lists of patients receiving medications by feeding tube and patients receiving crushed/opened medications due to dysphagia. This allows pharmacists to perform a census review of all inpatients to confirm appropriateness of medication orders. Clinical alerts for patients with enteral feeding tubes are advised by the ISMP and have data demonstrating a reduction in medication errors (Supplemental Material).14,15
Sustainment
During the sustainment phase, process owners were identified and a Pharmacy Service standard operating procedure (SOP) was written. The development of an institutional do not crush medication list was discussed; however, it was determined to be difficult to develop and maintain. An institutional tertiary resource list was selected in favor of a locally developed resource. These resources include the Handbook of Drug Administration via Enteral Feeding Tubes, Third Edition, the Pharmacist’s Letter list, “Meds that Should Not be Crushed,” and the Up- ToDate Lexidrug list, “Oral Medications That Should Not Be Crushed or Altered.”9-11 Links to the resources were added to the RLRVAMC pharmacy service SharePoint. In addition to defining the preferred tertiary resources, the SOP defined the process for reviewing inventory and the process for reviewing medication orders for hazard risk.
Discussion
Continued patient safety reports and low satisfaction rates among pharmacists prompted this QI project to improve safety for patients with dysphagia and/or enteral feeding tubes at RLRVAMC. The project engaged stakeholders and also identified and addressed gaps with potential for patient harm.
The tools implemented by this initiative drew from previous work by the KCVAMC and from framework provided by the ISMP.8,13 We expanded the QI intervention to include acute care patients with dysphagia.
RLRVAMC did not take steps to track the impact of the interventions on medication errors. However, no patient safety reports concerning an erroneous or incomplete pharmacy consultation entry have been reported. We also think that it is reasonable to assume that the adoption of the safety tools described here will have a positive impact on patient safety. RLRVAMC pharmacists have noted an increased appreciation for medication safety when processing medication orders for patients with dysphagia and/or enteral feeding tubes. While the workflow took time to adopt and integrate, clinical pharmacists perceived it as an improvement in patient safety. Our future focus is aimed at translating the process improvement into the Oracle/Cerner electronic health record, which is scheduled to be deployed at the RLRVAMC in August 2026.
Limitations
This QI project did not aim to quantify or compare medication errors before and after the intervention. An accurate number of unreported errors in the medication use process for patients with dysphagia and/or enteral feeding tubes would be challenging to quantify without direct observation. Multiple clinicians are engaged in the medication use process and individual steps may not be documented at all, or documented properly. In addition, medication errors are often underreported and may not reflect the total number of errors and/or potential for errors. That said, reported medication errors in the medication use process for patients with dysphagia and/or enteral feeding tubes are reviewed on a monthly basis by the RLRVAMC Multidisciplinary Medication Safety committee to continuously improve patient safety.
Another potential limitation is the extent to which the project can be adapted at other VHA sites. For example, RLRVAMC uses CPRS; the framework and tools to improve medication safety may not translate to sites using the Oracle/Cerner electronic health record. Furthermore, this QI project included a pharmacy consultation workflow that relied on pharmacists who are available at any hour. Other facilities may not have continuous consultation coverage to review medications for patients with dysphagia and/or enteral feeding tubes.
Conclusions
This QI project drew from ISMP recommendations, previous work within the VHA, local practice, and insight from multiple disciplines on the health care team to revise and create tools to improve medication safety for patients with dysphagia and/or enteral feeding tubes in the acute care setting. These tools included a revised pharmacy consultation workflow with improvements to the pharmacy consultation template, standardization of the pill-crushing devices and language used for patient medication lists, implementation of CROC alerts within the EHR, and development of an SOP.
The RLRVAMC Pharmacy Service intends to continue reviewing patient safety reports, assessing staff perspectives, and refining (and potentially adding) tools for medication safety. Future QI initiatives may focus on improving medication safety for outpatients with dysphagia and/or enteral feeding tubes. We also hope that these tools can be adapted at other VAMCs to promote medication safety for patients with dysphagia and/or enteral feeding tubes.
- Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol. 2014;20:8505-8524. doi:10.3748/wjg.v20.i26.8505
- Pradaxa (dabigatran etexilate). Prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc; 2025. https:// pro.boehringer-ingelheim.com/us/products/pradaxa/bipdf /pradaxa-capsules-us-pi
- Lovell AG, Protus BM, Dickman JR, et al. Palatability of crushed over-the-counter medications. J Pain Symptom Manage. 2021;61:755-762. doi:10.1016/j.jpainsymman.2020.09.020
- Messaouik D, Sautou-Miranda V, Bagel-Boithias S, et al. Comparative study and optimisation of the administration mode of three proton pump inhibitors by nasogastric tube. Int J Pharm. 2005;299:65-72. doi:10.1016/j.ijpharm.2005.04.034
- Demirkan K, Bayraktar-Ekincioglu A, Gulhan-Halil M, et al. Assessment of drug administration via feeding tube and the knowledge of health-care professionals in a university hospital. Eur J Clin Nutr. 2017;71:164-168. doi:10.1038/ejcn.2016.147
- Fodil M, Nghiem D, Colas M, et al. Assessment of clinical practices for crushing medication in geriatric units. J Nutr Health Aging. 2017;21:904-908. doi:10.1007/s12603-017-0886-3
- Zhu LL, Xu LC, Wang HQ, et al. Appropriateness of administration of nasogastric medication and preliminary intervention. Ther Clin Risk Manag. 2012;8:393-401. doi:10.2147/TCRM.S37785
- Institute for Safe Medication Practices (ISMP). Preventing errors when preparing and administering medications via enteral feeding tubes. Acute Care ISMP Medication Safety Alert. November 17, 2022. Accessed March 17, 2026. https://nutritioncare.org/wp-content/uploads/2025/02 /ISMP-Safety-Alert_Medications-and-Enteral-Feeding -Tubes.pdf
- White R, Bradnam V. Handbook of Drug Administration via Enteral Feeding Tubes. 3rd ed. Pharmaceutical Press; 2015.
- Clinical resource, meds that should not be crushed. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. Updated April 2025. Accessed March 17, 2026. https://pharmacist.therapeuticresearch.com/en/Content /Segments/PRL/2014/Aug/Meds-That-Should-Not-Be -Crushed-7309
- Oral medications that should not be crushed or altered. In: Lexidrug. UpToDate, Inc. https://online.lexi.com/lco /action/doc/retrieve/docid/patch_f/4227
- Uttaro E, Zhao F, Schweighardt A. Filling the gaps on the Institute for Safe Medication Practices (ISMP) do not crush list for immediate-release products. Int J Pharm Compd. 2021;25:364-371.
- US Dept of Veterans Affairs. VA Diffusion Marketplace. Improved safety of enteral tube medication administration. Updated 2024. Accessed March 17, 2026. https:// marketplace.va.gov/innovations/improved-safety-of -enteral-tube-medication-administration
- US Dept of Veterans Affairs. About us. VA Indiana Healthcare System. Updated October 17, 2024. Accessed March 2, 2026. https://www.va.gov/indiana-health-care/about-us/
- Wasylewicz ATM, van Grinsven RJB, Bikker JMW, et al. Clinical decision support system-assisted pharmacy intervention reduces feeding tube-related medication errors in hospitalized patients: a focus on medication suitable for feeding-tube administration. JPEN J Parenter Enteral Nutr. 2021;45:625-632. doi:10.1002/jpen.1869
- Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol. 2014;20:8505-8524. doi:10.3748/wjg.v20.i26.8505
- Pradaxa (dabigatran etexilate). Prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc; 2025. https:// pro.boehringer-ingelheim.com/us/products/pradaxa/bipdf /pradaxa-capsules-us-pi
- Lovell AG, Protus BM, Dickman JR, et al. Palatability of crushed over-the-counter medications. J Pain Symptom Manage. 2021;61:755-762. doi:10.1016/j.jpainsymman.2020.09.020
- Messaouik D, Sautou-Miranda V, Bagel-Boithias S, et al. Comparative study and optimisation of the administration mode of three proton pump inhibitors by nasogastric tube. Int J Pharm. 2005;299:65-72. doi:10.1016/j.ijpharm.2005.04.034
- Demirkan K, Bayraktar-Ekincioglu A, Gulhan-Halil M, et al. Assessment of drug administration via feeding tube and the knowledge of health-care professionals in a university hospital. Eur J Clin Nutr. 2017;71:164-168. doi:10.1038/ejcn.2016.147
- Fodil M, Nghiem D, Colas M, et al. Assessment of clinical practices for crushing medication in geriatric units. J Nutr Health Aging. 2017;21:904-908. doi:10.1007/s12603-017-0886-3
- Zhu LL, Xu LC, Wang HQ, et al. Appropriateness of administration of nasogastric medication and preliminary intervention. Ther Clin Risk Manag. 2012;8:393-401. doi:10.2147/TCRM.S37785
- Institute for Safe Medication Practices (ISMP). Preventing errors when preparing and administering medications via enteral feeding tubes. Acute Care ISMP Medication Safety Alert. November 17, 2022. Accessed March 17, 2026. https://nutritioncare.org/wp-content/uploads/2025/02 /ISMP-Safety-Alert_Medications-and-Enteral-Feeding -Tubes.pdf
- White R, Bradnam V. Handbook of Drug Administration via Enteral Feeding Tubes. 3rd ed. Pharmaceutical Press; 2015.
- Clinical resource, meds that should not be crushed. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. Updated April 2025. Accessed March 17, 2026. https://pharmacist.therapeuticresearch.com/en/Content /Segments/PRL/2014/Aug/Meds-That-Should-Not-Be -Crushed-7309
- Oral medications that should not be crushed or altered. In: Lexidrug. UpToDate, Inc. https://online.lexi.com/lco /action/doc/retrieve/docid/patch_f/4227
- Uttaro E, Zhao F, Schweighardt A. Filling the gaps on the Institute for Safe Medication Practices (ISMP) do not crush list for immediate-release products. Int J Pharm Compd. 2021;25:364-371.
- US Dept of Veterans Affairs. VA Diffusion Marketplace. Improved safety of enteral tube medication administration. Updated 2024. Accessed March 17, 2026. https:// marketplace.va.gov/innovations/improved-safety-of -enteral-tube-medication-administration
- US Dept of Veterans Affairs. About us. VA Indiana Healthcare System. Updated October 17, 2024. Accessed March 2, 2026. https://www.va.gov/indiana-health-care/about-us/
- Wasylewicz ATM, van Grinsven RJB, Bikker JMW, et al. Clinical decision support system-assisted pharmacy intervention reduces feeding tube-related medication errors in hospitalized patients: a focus on medication suitable for feeding-tube administration. JPEN J Parenter Enteral Nutr. 2021;45:625-632. doi:10.1002/jpen.1869
Streamlining the Acute Care Pharmacy Consultation Process for Patients With Dysphagia or Enteral Feeding Tubes
Streamlining the Acute Care Pharmacy Consultation Process for Patients With Dysphagia or Enteral Feeding Tubes
Impact of Rapid Blood Culture Identification on Antibiotic De-escalation at a Veterans Affairs Medical Center
Impact of Rapid Blood Culture Identification on Antibiotic De-escalation at a Veterans Affairs Medical Center
About 530,000 to 628,000 episodes of bloodstream infections (BSI) occur annually in the US.1 Early identification and treatment of bacteremia are essential to improve patient outcomes because it allows for more timely targeted antibiotic therapy.2 Organism identification and susceptibility testing can take 2 to 5 days, prolonging the use of broad-spectrum empiric antibiotics and increasing the risk of adverse events.3,4 The Infectious Disease Society of America recommends the use of rapid diagnostic testing and antimicrobial stewardship programs (ASPs) to improve rates of antibiotic susceptibilities to targeted antibiotics and optimize resource utilization.3 Rapid blood culture identification (BCID) technologies reduce the duration of empiric antibiotics in patients with contaminated blood cultures, resulting in shorter hospital stays and saving money per each patient tested.4
In March 2023, Veteran Health Indiana (VHI) implemented the BioFire FilmArray Blood Culture Identification (BCID2), a BSI panel test that identifies select gram-negative bacteria, gram-positive bacteria, yeast, and antimicrobial resistance genes with an aggregate sensitivity of 99% and a specificity of 99.8%. The BCID2 presents clinically relevant information faster than traditional culture methods, allowing clinicians to make more efficient and educated antibiotic regimen decisions than with previous methods.5
It takes 24 to 48 hours from blood collection for culture incubation, positivity, and gram staining to occur at VHI. If the gram stain is positive, the blood culture is placed on the BioFire BCID2 in addition to traditional culture medium. BioFire BCID2 results are ready in 45 to 60 minutes. Results are uploaded into the electronic health record (EHR) ≤ 2 hours after they are obtained and the primary team is notified if the test is positive for certain critical results. Susceptibility testing of an identified organism typically requires an additional 24 to 48 hours for finalization. VHI Infectious Disease created an evidence-based antibiotic recommendation chart for certain medication(s) and alternate therapies based on the reported organism and its interpreted presence of resistance markers (eg, ceftriaxone for Escherichia coli when extended-spectrum beta lactamases are not detected vs meropenem if extended-spectrum beta lactamases marker are present). These charts optimize the antibiotic regimen while awaiting susceptibility finalizations.
Two previous studies describe the impact of rapid diagnostic testing technology at US Department of Veterans Affairs (VA) medical centers.6,7 In Texas, the ASP reviewed BCID panel results via clinical decision support software for about 1 hour per day.6 A Los Angeles study analyzed the impact of Biofire BCID with an interpretation guide centered on unnecessary vancomycin use and determined that shorter duration of the medication may have been the result of more frequent infectious disease consultation.7
This study assessed the time to optimal antibiotic de-escalation before and after the implementation of BioFire BCID2 with results reviewed by the ASP without active notification or assistance of any clinical decision support technology. The primary objective was to evaluate difference in time to optimal antibiotics from blood culture draw pre- vs postintervention. Secondary objectives included differences in time to organism identification, difference in time on broad-spectrum antibiotics, and difference in time to appropriate antibiotics.
Methods
This quasi-experimental retrospective chart review assessed the impact of BioFire BCID2 use on timely antibiotic de-escalation for patients who experienced a BSI at VHI between March 1, 2022, and October 1, 2023. Microbiology laboratory records identified eligible patients with positive blood cultures within the study time frame. Data were collected from the VHI EHR.
Patients were included if they had a positive bacterial blood culture and received ≥ 1 antibiotic indicated for bacteremia while receiving inpatient care. Patients were excluded if they died prior to blood culture results, transferred out of VHI, left against medical advice, or had untreated contaminants in blood culture results (ie, never received antibiotics aimed at the contaminated culture).
Patient lists were generated for before and after implementation of BioFire BCID2 (pre- and postintervention) using the VHI EHR and microbiology laboratory record system. The pre- and postinterventions groups were different sizes. As a result, a random sampling of the preintervention group was selected and included patients from March 1, 2022, through March 26, 2023. The postintervention group was smaller due to time constraints between initiation of BioFire BCID2 for data collection and included all patients from March 27, 2023, through October 1, 2023.
Optimal antibiotics were defined as escalation from inappropriate therapy to broader agent(s), de-escalation from broad-spectrum therapy to targeted agent(s), discontinuation of therapy due to an organism being identified as a contaminant, or optimization of a regimen to the preferred antimicrobial agent based on evidence-based consensus guidelines. Broad-spectrum antibiotics included: piperacillin/tazobactam, cefepime, ceftazidime, ceftazidime-avibactam, cefiderocol, carbapenems, fluroquinolones, vancomycin, daptomycin, ceftaroline, linezolid, or aztreonam. Appropriate antibiotics were defined as those with activity toward the final identified organism(s).
Deidentified participant data were entered into Microsoft Excel and kept on a secure VA server to complete statistical analyses. Parametric continuous data, such as age, were analyzed using the t-test, while nonparametric continuous data, such as time to optimal antibiotics, were analyzed using the Mann-Whitney U test. Categorical data, like sex and race, were analyzed using either Fisher exact test for small sample sizes or X2 test for a larger sample size. Statistical significance levels was defined as P < .05.
Results
Using patient lists drawn from the EHR and the microbiology laboratory records, 110 electronic charts were randomly selected for review. Fifteen patients were excluded: 8 had untreated contaminants, 4 died, and 3 were transferred out of VHI. Of the 95 patients included, 48 were in the preintervention group and 47 were in the postintervention group (Figure 1).
Baseline characteristics were similar between the 2 groups (Table 1). Most patients were White males aged > 70 years in the EHR. The urinary tract was the most common source of infection, impacting 12 patients in each group (Figure 2). Escherichia coli, Klebsiella, Staphylococcus, and Streptococcus were the most common bloodstream isolates identified.
The median time to optimal antibiotics in the preintervention group was 58.5 hours vs 43.4 hours in the postintervention group (P = .11). The median time to organism identification was 37.8 hours in the preintervention group vs 16.9 hours in the postintervention group (P < .001). The median time on broad-spectrum antibiotics was 45.2 hours in the preintervention group vs 46.6 hours in the postintervention group (P = .99). The median time on appropriate antibiotics in the preintervention group was 2.3 hours vs 1.9 hours in the postintervention group (P = .79). Differences in other measured outcomes between the groups were not statistically significant (Table 2).
Although implementation of rapid diagnostic technology reduced the median time to optimal antibiotics, the results were not statistically significant. Shorter time to organism identification in the postintervention group compared to the preintervention group was the lone statistically significant metric (P < .001).
Discussion
A lack of statistical significance in the primary outcome may have been due to nonadherence to facility de-escalation protocols or a suboptimal BioFire BCID2 result notification system. Additionally, use of rapid BCID at VHI may improve over time as clinicians become more familiar with the technology. Gaps in clinical pharmacy coverage during the night shift may have also contributed to delays in antibiotic optimization, particularly if other clinicians are not equipped with the knowledge or training to appropriately deescalate antibiotics based on microorganisms identified. A 2017 study by Donner et al concluded that physician interpretation of BCID results is suboptimal and should be augmented with clinical decision support tools as new technology becomes available.8 Despite the statistically insignificant results of this study, it did highlight potential areas of improvement which can lead to improved patient care.
Previous research has evaluated the impact of rapid BCID technology on antibiotic treatment and clinical outcomes. Chiasson et al found that median time to optimal therapy was 73.8 hours in the pre-BCID arm compared to 34.7 hours in the post- BCID arm (P ≤ .001), emphasizing the importance of combining rapid BCID with clinical decision support tools and pharmacy input.6 Senok et al found that BCID2 implementation led to a significant decrease in median time to culture result, which informed optimal antibiotic therapy and decreased 30-day mortality in the intensive care setting.9 In contrast, the current study did not stratify patients according to medical ward or illness severity even though clinicians may be less likely to de-escalate antibiotic therapy in critically ill patients.
Bae et al reported findings consistent with the current study and concluded that BCID did not affect the clinical outcomes of overall BSIs; however, it contributed to early administration of effective antibiotics in cases of BSIs caused by multidrug-resistant organisms.10 Results of this study were not stratified according to multidrug-resistant organisms because the sample size was too small. The current study also included patients with polymicrobial infections, which may have impacted the results due to a less streamlined approach to antibiotic optimization.
Limitations
This single-center, retrospective study had a small sample size, short time frame, and lacked patient diversity, and therefore may not be generalizable to other health care systems. The sample size was limited by shorter date range and smaller patient list between BioFire BCID2 implementation and data collection, which was used to determine the number of charts selected in each group. Some patients received antibiotics prior to blood cultures being drawn, which may falsely decrease time to optimal/ appropriate antibiotics and falsely increase time on broad spectrum/any antibiotics due to early antibiotic administration. The total number of patients on broad-spectrum antibiotics differed from the total number of patients for other outcomes because several patients never received the defined broad spectrum antibiotics.
Conclusions
When combined with a pre-existing ASP without active notification, the implementation of BioFire BCID2 did not return statistically significant data showing a decrease in time to optimal antibiotics, time to appropriate antibiotics, or time on broad-spectrum antibiotics at VHI. To make this program more successful, pharmacist intervention and clinical decision support tools may be needed.
Additional research is required to determine the optimal integration of antimicrobial stewardship, rapid diagnostic technology, and pharmacy services for maximum benefit. Even though the primary outcome was not statistically significant, the results may be clinically significant from a stewardship perspective. Realigning microbiology workflows to mimic other research, which emphasizes the importance of funneling rapid BCID results through the ASP, may improve outcomes. Future studies may be warranted following the implementation of clinical decision support tools to assess their impact on stewardship practices and patient outcomes.
- Goto M, Al-Hasan MN. Overall burden of bloodstream infection and nosocomial bloodstream infection in North America and Europe. Clin Microbiol Infect. 2013;19(6):501- 509. doi:10.1111/1469-0691.12195
- Pardo J, Klinker KP, Borgert SJ, Butler BM, Giglio PG, Rand KH. Clinical and economic impact of antimicrobial stewardship interventions with the FilmArray blood culture identification panel. Diagn Microbiol Infect Dis. 2016;84(2):159-164. doi:10.1016/j.diagmicrobio.2015.10.023.
- 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. Clin Infect Dis. 2016;62(10):e51-e77. doi:10.1093/cid/ciw118
- BIOFIRE® Blood Culture Identification 2 (BCID2) Panel. Biomerierux. Updated 2025. Accessed May 10, 2025. https://www.biofiredx.com/products/the-filmarray-panels/filmarraybcid/
- Huang AM, Newton D, Kunapuli A, et al. Impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. Clin Infect Dis. 2013;57(9):1237-1245. doi:10.1093/cid/cit498
- Chiasson JM, Smith WJ, Jodlowski TZ, Kouma MA, Cutrell JB. Impact of a rapid blood culture diagnostic panel on time to optimal antimicrobial therapy at a veterans affairs medical center. J Pharm Pract. 2022;35(5):722-729. doi:10.1177/08971900211000686
- Wu S, Watson RL, Graber CJ. 2007. Impact of combining rapid diagnostics with an interpretation guide on vancomycin usage for contaminant blood cultures growing coagulase- negative staphylococci (CoNS). Open Forum Infect Dis. 2019;6(Suppl 2):S674. doi:10.1093/ofid/ofz360.1687
- Donner LM, Campbell WS, Lyden E, Van Schooneveld TC. Assessment of rapid-blood-culture-identification result interpretation and antibiotic prescribing practices. J Clin Microbiol. 2017;55(5):1496-1507. doi:10.1128/JCM.02395-16
- Senok A, Dabal LA, Alfaresi M, et al. Clinical impact of the BIOFIRE blood culture identification 2 panel in adult patients with bloodstream infection: a multicentre observational study in the United Arab Emirates. Diagnostics (Basel). 2023;13(14):2433. doi:10.3390/diagnostics13142433
- Bae JY, Bae J, So MK, Choi HJ, Lee M. The impact of the rapid blood culture identification panel on antibiotic treatment and clinical outcomes in bloodstream infections, particularly those associated with multidrug-resistant micro-organisms. Diagnostics (Basel). 2023;13(23):3504. doi:10.3390/diagnostics13233504
About 530,000 to 628,000 episodes of bloodstream infections (BSI) occur annually in the US.1 Early identification and treatment of bacteremia are essential to improve patient outcomes because it allows for more timely targeted antibiotic therapy.2 Organism identification and susceptibility testing can take 2 to 5 days, prolonging the use of broad-spectrum empiric antibiotics and increasing the risk of adverse events.3,4 The Infectious Disease Society of America recommends the use of rapid diagnostic testing and antimicrobial stewardship programs (ASPs) to improve rates of antibiotic susceptibilities to targeted antibiotics and optimize resource utilization.3 Rapid blood culture identification (BCID) technologies reduce the duration of empiric antibiotics in patients with contaminated blood cultures, resulting in shorter hospital stays and saving money per each patient tested.4
In March 2023, Veteran Health Indiana (VHI) implemented the BioFire FilmArray Blood Culture Identification (BCID2), a BSI panel test that identifies select gram-negative bacteria, gram-positive bacteria, yeast, and antimicrobial resistance genes with an aggregate sensitivity of 99% and a specificity of 99.8%. The BCID2 presents clinically relevant information faster than traditional culture methods, allowing clinicians to make more efficient and educated antibiotic regimen decisions than with previous methods.5
It takes 24 to 48 hours from blood collection for culture incubation, positivity, and gram staining to occur at VHI. If the gram stain is positive, the blood culture is placed on the BioFire BCID2 in addition to traditional culture medium. BioFire BCID2 results are ready in 45 to 60 minutes. Results are uploaded into the electronic health record (EHR) ≤ 2 hours after they are obtained and the primary team is notified if the test is positive for certain critical results. Susceptibility testing of an identified organism typically requires an additional 24 to 48 hours for finalization. VHI Infectious Disease created an evidence-based antibiotic recommendation chart for certain medication(s) and alternate therapies based on the reported organism and its interpreted presence of resistance markers (eg, ceftriaxone for Escherichia coli when extended-spectrum beta lactamases are not detected vs meropenem if extended-spectrum beta lactamases marker are present). These charts optimize the antibiotic regimen while awaiting susceptibility finalizations.
Two previous studies describe the impact of rapid diagnostic testing technology at US Department of Veterans Affairs (VA) medical centers.6,7 In Texas, the ASP reviewed BCID panel results via clinical decision support software for about 1 hour per day.6 A Los Angeles study analyzed the impact of Biofire BCID with an interpretation guide centered on unnecessary vancomycin use and determined that shorter duration of the medication may have been the result of more frequent infectious disease consultation.7
This study assessed the time to optimal antibiotic de-escalation before and after the implementation of BioFire BCID2 with results reviewed by the ASP without active notification or assistance of any clinical decision support technology. The primary objective was to evaluate difference in time to optimal antibiotics from blood culture draw pre- vs postintervention. Secondary objectives included differences in time to organism identification, difference in time on broad-spectrum antibiotics, and difference in time to appropriate antibiotics.
Methods
This quasi-experimental retrospective chart review assessed the impact of BioFire BCID2 use on timely antibiotic de-escalation for patients who experienced a BSI at VHI between March 1, 2022, and October 1, 2023. Microbiology laboratory records identified eligible patients with positive blood cultures within the study time frame. Data were collected from the VHI EHR.
Patients were included if they had a positive bacterial blood culture and received ≥ 1 antibiotic indicated for bacteremia while receiving inpatient care. Patients were excluded if they died prior to blood culture results, transferred out of VHI, left against medical advice, or had untreated contaminants in blood culture results (ie, never received antibiotics aimed at the contaminated culture).
Patient lists were generated for before and after implementation of BioFire BCID2 (pre- and postintervention) using the VHI EHR and microbiology laboratory record system. The pre- and postinterventions groups were different sizes. As a result, a random sampling of the preintervention group was selected and included patients from March 1, 2022, through March 26, 2023. The postintervention group was smaller due to time constraints between initiation of BioFire BCID2 for data collection and included all patients from March 27, 2023, through October 1, 2023.
Optimal antibiotics were defined as escalation from inappropriate therapy to broader agent(s), de-escalation from broad-spectrum therapy to targeted agent(s), discontinuation of therapy due to an organism being identified as a contaminant, or optimization of a regimen to the preferred antimicrobial agent based on evidence-based consensus guidelines. Broad-spectrum antibiotics included: piperacillin/tazobactam, cefepime, ceftazidime, ceftazidime-avibactam, cefiderocol, carbapenems, fluroquinolones, vancomycin, daptomycin, ceftaroline, linezolid, or aztreonam. Appropriate antibiotics were defined as those with activity toward the final identified organism(s).
Deidentified participant data were entered into Microsoft Excel and kept on a secure VA server to complete statistical analyses. Parametric continuous data, such as age, were analyzed using the t-test, while nonparametric continuous data, such as time to optimal antibiotics, were analyzed using the Mann-Whitney U test. Categorical data, like sex and race, were analyzed using either Fisher exact test for small sample sizes or X2 test for a larger sample size. Statistical significance levels was defined as P < .05.
Results
Using patient lists drawn from the EHR and the microbiology laboratory records, 110 electronic charts were randomly selected for review. Fifteen patients were excluded: 8 had untreated contaminants, 4 died, and 3 were transferred out of VHI. Of the 95 patients included, 48 were in the preintervention group and 47 were in the postintervention group (Figure 1).
Baseline characteristics were similar between the 2 groups (Table 1). Most patients were White males aged > 70 years in the EHR. The urinary tract was the most common source of infection, impacting 12 patients in each group (Figure 2). Escherichia coli, Klebsiella, Staphylococcus, and Streptococcus were the most common bloodstream isolates identified.
The median time to optimal antibiotics in the preintervention group was 58.5 hours vs 43.4 hours in the postintervention group (P = .11). The median time to organism identification was 37.8 hours in the preintervention group vs 16.9 hours in the postintervention group (P < .001). The median time on broad-spectrum antibiotics was 45.2 hours in the preintervention group vs 46.6 hours in the postintervention group (P = .99). The median time on appropriate antibiotics in the preintervention group was 2.3 hours vs 1.9 hours in the postintervention group (P = .79). Differences in other measured outcomes between the groups were not statistically significant (Table 2).
Although implementation of rapid diagnostic technology reduced the median time to optimal antibiotics, the results were not statistically significant. Shorter time to organism identification in the postintervention group compared to the preintervention group was the lone statistically significant metric (P < .001).
Discussion
A lack of statistical significance in the primary outcome may have been due to nonadherence to facility de-escalation protocols or a suboptimal BioFire BCID2 result notification system. Additionally, use of rapid BCID at VHI may improve over time as clinicians become more familiar with the technology. Gaps in clinical pharmacy coverage during the night shift may have also contributed to delays in antibiotic optimization, particularly if other clinicians are not equipped with the knowledge or training to appropriately deescalate antibiotics based on microorganisms identified. A 2017 study by Donner et al concluded that physician interpretation of BCID results is suboptimal and should be augmented with clinical decision support tools as new technology becomes available.8 Despite the statistically insignificant results of this study, it did highlight potential areas of improvement which can lead to improved patient care.
Previous research has evaluated the impact of rapid BCID technology on antibiotic treatment and clinical outcomes. Chiasson et al found that median time to optimal therapy was 73.8 hours in the pre-BCID arm compared to 34.7 hours in the post- BCID arm (P ≤ .001), emphasizing the importance of combining rapid BCID with clinical decision support tools and pharmacy input.6 Senok et al found that BCID2 implementation led to a significant decrease in median time to culture result, which informed optimal antibiotic therapy and decreased 30-day mortality in the intensive care setting.9 In contrast, the current study did not stratify patients according to medical ward or illness severity even though clinicians may be less likely to de-escalate antibiotic therapy in critically ill patients.
Bae et al reported findings consistent with the current study and concluded that BCID did not affect the clinical outcomes of overall BSIs; however, it contributed to early administration of effective antibiotics in cases of BSIs caused by multidrug-resistant organisms.10 Results of this study were not stratified according to multidrug-resistant organisms because the sample size was too small. The current study also included patients with polymicrobial infections, which may have impacted the results due to a less streamlined approach to antibiotic optimization.
Limitations
This single-center, retrospective study had a small sample size, short time frame, and lacked patient diversity, and therefore may not be generalizable to other health care systems. The sample size was limited by shorter date range and smaller patient list between BioFire BCID2 implementation and data collection, which was used to determine the number of charts selected in each group. Some patients received antibiotics prior to blood cultures being drawn, which may falsely decrease time to optimal/ appropriate antibiotics and falsely increase time on broad spectrum/any antibiotics due to early antibiotic administration. The total number of patients on broad-spectrum antibiotics differed from the total number of patients for other outcomes because several patients never received the defined broad spectrum antibiotics.
Conclusions
When combined with a pre-existing ASP without active notification, the implementation of BioFire BCID2 did not return statistically significant data showing a decrease in time to optimal antibiotics, time to appropriate antibiotics, or time on broad-spectrum antibiotics at VHI. To make this program more successful, pharmacist intervention and clinical decision support tools may be needed.
Additional research is required to determine the optimal integration of antimicrobial stewardship, rapid diagnostic technology, and pharmacy services for maximum benefit. Even though the primary outcome was not statistically significant, the results may be clinically significant from a stewardship perspective. Realigning microbiology workflows to mimic other research, which emphasizes the importance of funneling rapid BCID results through the ASP, may improve outcomes. Future studies may be warranted following the implementation of clinical decision support tools to assess their impact on stewardship practices and patient outcomes.
About 530,000 to 628,000 episodes of bloodstream infections (BSI) occur annually in the US.1 Early identification and treatment of bacteremia are essential to improve patient outcomes because it allows for more timely targeted antibiotic therapy.2 Organism identification and susceptibility testing can take 2 to 5 days, prolonging the use of broad-spectrum empiric antibiotics and increasing the risk of adverse events.3,4 The Infectious Disease Society of America recommends the use of rapid diagnostic testing and antimicrobial stewardship programs (ASPs) to improve rates of antibiotic susceptibilities to targeted antibiotics and optimize resource utilization.3 Rapid blood culture identification (BCID) technologies reduce the duration of empiric antibiotics in patients with contaminated blood cultures, resulting in shorter hospital stays and saving money per each patient tested.4
In March 2023, Veteran Health Indiana (VHI) implemented the BioFire FilmArray Blood Culture Identification (BCID2), a BSI panel test that identifies select gram-negative bacteria, gram-positive bacteria, yeast, and antimicrobial resistance genes with an aggregate sensitivity of 99% and a specificity of 99.8%. The BCID2 presents clinically relevant information faster than traditional culture methods, allowing clinicians to make more efficient and educated antibiotic regimen decisions than with previous methods.5
It takes 24 to 48 hours from blood collection for culture incubation, positivity, and gram staining to occur at VHI. If the gram stain is positive, the blood culture is placed on the BioFire BCID2 in addition to traditional culture medium. BioFire BCID2 results are ready in 45 to 60 minutes. Results are uploaded into the electronic health record (EHR) ≤ 2 hours after they are obtained and the primary team is notified if the test is positive for certain critical results. Susceptibility testing of an identified organism typically requires an additional 24 to 48 hours for finalization. VHI Infectious Disease created an evidence-based antibiotic recommendation chart for certain medication(s) and alternate therapies based on the reported organism and its interpreted presence of resistance markers (eg, ceftriaxone for Escherichia coli when extended-spectrum beta lactamases are not detected vs meropenem if extended-spectrum beta lactamases marker are present). These charts optimize the antibiotic regimen while awaiting susceptibility finalizations.
Two previous studies describe the impact of rapid diagnostic testing technology at US Department of Veterans Affairs (VA) medical centers.6,7 In Texas, the ASP reviewed BCID panel results via clinical decision support software for about 1 hour per day.6 A Los Angeles study analyzed the impact of Biofire BCID with an interpretation guide centered on unnecessary vancomycin use and determined that shorter duration of the medication may have been the result of more frequent infectious disease consultation.7
This study assessed the time to optimal antibiotic de-escalation before and after the implementation of BioFire BCID2 with results reviewed by the ASP without active notification or assistance of any clinical decision support technology. The primary objective was to evaluate difference in time to optimal antibiotics from blood culture draw pre- vs postintervention. Secondary objectives included differences in time to organism identification, difference in time on broad-spectrum antibiotics, and difference in time to appropriate antibiotics.
Methods
This quasi-experimental retrospective chart review assessed the impact of BioFire BCID2 use on timely antibiotic de-escalation for patients who experienced a BSI at VHI between March 1, 2022, and October 1, 2023. Microbiology laboratory records identified eligible patients with positive blood cultures within the study time frame. Data were collected from the VHI EHR.
Patients were included if they had a positive bacterial blood culture and received ≥ 1 antibiotic indicated for bacteremia while receiving inpatient care. Patients were excluded if they died prior to blood culture results, transferred out of VHI, left against medical advice, or had untreated contaminants in blood culture results (ie, never received antibiotics aimed at the contaminated culture).
Patient lists were generated for before and after implementation of BioFire BCID2 (pre- and postintervention) using the VHI EHR and microbiology laboratory record system. The pre- and postinterventions groups were different sizes. As a result, a random sampling of the preintervention group was selected and included patients from March 1, 2022, through March 26, 2023. The postintervention group was smaller due to time constraints between initiation of BioFire BCID2 for data collection and included all patients from March 27, 2023, through October 1, 2023.
Optimal antibiotics were defined as escalation from inappropriate therapy to broader agent(s), de-escalation from broad-spectrum therapy to targeted agent(s), discontinuation of therapy due to an organism being identified as a contaminant, or optimization of a regimen to the preferred antimicrobial agent based on evidence-based consensus guidelines. Broad-spectrum antibiotics included: piperacillin/tazobactam, cefepime, ceftazidime, ceftazidime-avibactam, cefiderocol, carbapenems, fluroquinolones, vancomycin, daptomycin, ceftaroline, linezolid, or aztreonam. Appropriate antibiotics were defined as those with activity toward the final identified organism(s).
Deidentified participant data were entered into Microsoft Excel and kept on a secure VA server to complete statistical analyses. Parametric continuous data, such as age, were analyzed using the t-test, while nonparametric continuous data, such as time to optimal antibiotics, were analyzed using the Mann-Whitney U test. Categorical data, like sex and race, were analyzed using either Fisher exact test for small sample sizes or X2 test for a larger sample size. Statistical significance levels was defined as P < .05.
Results
Using patient lists drawn from the EHR and the microbiology laboratory records, 110 electronic charts were randomly selected for review. Fifteen patients were excluded: 8 had untreated contaminants, 4 died, and 3 were transferred out of VHI. Of the 95 patients included, 48 were in the preintervention group and 47 were in the postintervention group (Figure 1).
Baseline characteristics were similar between the 2 groups (Table 1). Most patients were White males aged > 70 years in the EHR. The urinary tract was the most common source of infection, impacting 12 patients in each group (Figure 2). Escherichia coli, Klebsiella, Staphylococcus, and Streptococcus were the most common bloodstream isolates identified.
The median time to optimal antibiotics in the preintervention group was 58.5 hours vs 43.4 hours in the postintervention group (P = .11). The median time to organism identification was 37.8 hours in the preintervention group vs 16.9 hours in the postintervention group (P < .001). The median time on broad-spectrum antibiotics was 45.2 hours in the preintervention group vs 46.6 hours in the postintervention group (P = .99). The median time on appropriate antibiotics in the preintervention group was 2.3 hours vs 1.9 hours in the postintervention group (P = .79). Differences in other measured outcomes between the groups were not statistically significant (Table 2).
Although implementation of rapid diagnostic technology reduced the median time to optimal antibiotics, the results were not statistically significant. Shorter time to organism identification in the postintervention group compared to the preintervention group was the lone statistically significant metric (P < .001).
Discussion
A lack of statistical significance in the primary outcome may have been due to nonadherence to facility de-escalation protocols or a suboptimal BioFire BCID2 result notification system. Additionally, use of rapid BCID at VHI may improve over time as clinicians become more familiar with the technology. Gaps in clinical pharmacy coverage during the night shift may have also contributed to delays in antibiotic optimization, particularly if other clinicians are not equipped with the knowledge or training to appropriately deescalate antibiotics based on microorganisms identified. A 2017 study by Donner et al concluded that physician interpretation of BCID results is suboptimal and should be augmented with clinical decision support tools as new technology becomes available.8 Despite the statistically insignificant results of this study, it did highlight potential areas of improvement which can lead to improved patient care.
Previous research has evaluated the impact of rapid BCID technology on antibiotic treatment and clinical outcomes. Chiasson et al found that median time to optimal therapy was 73.8 hours in the pre-BCID arm compared to 34.7 hours in the post- BCID arm (P ≤ .001), emphasizing the importance of combining rapid BCID with clinical decision support tools and pharmacy input.6 Senok et al found that BCID2 implementation led to a significant decrease in median time to culture result, which informed optimal antibiotic therapy and decreased 30-day mortality in the intensive care setting.9 In contrast, the current study did not stratify patients according to medical ward or illness severity even though clinicians may be less likely to de-escalate antibiotic therapy in critically ill patients.
Bae et al reported findings consistent with the current study and concluded that BCID did not affect the clinical outcomes of overall BSIs; however, it contributed to early administration of effective antibiotics in cases of BSIs caused by multidrug-resistant organisms.10 Results of this study were not stratified according to multidrug-resistant organisms because the sample size was too small. The current study also included patients with polymicrobial infections, which may have impacted the results due to a less streamlined approach to antibiotic optimization.
Limitations
This single-center, retrospective study had a small sample size, short time frame, and lacked patient diversity, and therefore may not be generalizable to other health care systems. The sample size was limited by shorter date range and smaller patient list between BioFire BCID2 implementation and data collection, which was used to determine the number of charts selected in each group. Some patients received antibiotics prior to blood cultures being drawn, which may falsely decrease time to optimal/ appropriate antibiotics and falsely increase time on broad spectrum/any antibiotics due to early antibiotic administration. The total number of patients on broad-spectrum antibiotics differed from the total number of patients for other outcomes because several patients never received the defined broad spectrum antibiotics.
Conclusions
When combined with a pre-existing ASP without active notification, the implementation of BioFire BCID2 did not return statistically significant data showing a decrease in time to optimal antibiotics, time to appropriate antibiotics, or time on broad-spectrum antibiotics at VHI. To make this program more successful, pharmacist intervention and clinical decision support tools may be needed.
Additional research is required to determine the optimal integration of antimicrobial stewardship, rapid diagnostic technology, and pharmacy services for maximum benefit. Even though the primary outcome was not statistically significant, the results may be clinically significant from a stewardship perspective. Realigning microbiology workflows to mimic other research, which emphasizes the importance of funneling rapid BCID results through the ASP, may improve outcomes. Future studies may be warranted following the implementation of clinical decision support tools to assess their impact on stewardship practices and patient outcomes.
- Goto M, Al-Hasan MN. Overall burden of bloodstream infection and nosocomial bloodstream infection in North America and Europe. Clin Microbiol Infect. 2013;19(6):501- 509. doi:10.1111/1469-0691.12195
- Pardo J, Klinker KP, Borgert SJ, Butler BM, Giglio PG, Rand KH. Clinical and economic impact of antimicrobial stewardship interventions with the FilmArray blood culture identification panel. Diagn Microbiol Infect Dis. 2016;84(2):159-164. doi:10.1016/j.diagmicrobio.2015.10.023.
- 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. Clin Infect Dis. 2016;62(10):e51-e77. doi:10.1093/cid/ciw118
- BIOFIRE® Blood Culture Identification 2 (BCID2) Panel. Biomerierux. Updated 2025. Accessed May 10, 2025. https://www.biofiredx.com/products/the-filmarray-panels/filmarraybcid/
- Huang AM, Newton D, Kunapuli A, et al. Impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. Clin Infect Dis. 2013;57(9):1237-1245. doi:10.1093/cid/cit498
- Chiasson JM, Smith WJ, Jodlowski TZ, Kouma MA, Cutrell JB. Impact of a rapid blood culture diagnostic panel on time to optimal antimicrobial therapy at a veterans affairs medical center. J Pharm Pract. 2022;35(5):722-729. doi:10.1177/08971900211000686
- Wu S, Watson RL, Graber CJ. 2007. Impact of combining rapid diagnostics with an interpretation guide on vancomycin usage for contaminant blood cultures growing coagulase- negative staphylococci (CoNS). Open Forum Infect Dis. 2019;6(Suppl 2):S674. doi:10.1093/ofid/ofz360.1687
- Donner LM, Campbell WS, Lyden E, Van Schooneveld TC. Assessment of rapid-blood-culture-identification result interpretation and antibiotic prescribing practices. J Clin Microbiol. 2017;55(5):1496-1507. doi:10.1128/JCM.02395-16
- Senok A, Dabal LA, Alfaresi M, et al. Clinical impact of the BIOFIRE blood culture identification 2 panel in adult patients with bloodstream infection: a multicentre observational study in the United Arab Emirates. Diagnostics (Basel). 2023;13(14):2433. doi:10.3390/diagnostics13142433
- Bae JY, Bae J, So MK, Choi HJ, Lee M. The impact of the rapid blood culture identification panel on antibiotic treatment and clinical outcomes in bloodstream infections, particularly those associated with multidrug-resistant micro-organisms. Diagnostics (Basel). 2023;13(23):3504. doi:10.3390/diagnostics13233504
- Goto M, Al-Hasan MN. Overall burden of bloodstream infection and nosocomial bloodstream infection in North America and Europe. Clin Microbiol Infect. 2013;19(6):501- 509. doi:10.1111/1469-0691.12195
- Pardo J, Klinker KP, Borgert SJ, Butler BM, Giglio PG, Rand KH. Clinical and economic impact of antimicrobial stewardship interventions with the FilmArray blood culture identification panel. Diagn Microbiol Infect Dis. 2016;84(2):159-164. doi:10.1016/j.diagmicrobio.2015.10.023.
- 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. Clin Infect Dis. 2016;62(10):e51-e77. doi:10.1093/cid/ciw118
- BIOFIRE® Blood Culture Identification 2 (BCID2) Panel. Biomerierux. Updated 2025. Accessed May 10, 2025. https://www.biofiredx.com/products/the-filmarray-panels/filmarraybcid/
- Huang AM, Newton D, Kunapuli A, et al. Impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. Clin Infect Dis. 2013;57(9):1237-1245. doi:10.1093/cid/cit498
- Chiasson JM, Smith WJ, Jodlowski TZ, Kouma MA, Cutrell JB. Impact of a rapid blood culture diagnostic panel on time to optimal antimicrobial therapy at a veterans affairs medical center. J Pharm Pract. 2022;35(5):722-729. doi:10.1177/08971900211000686
- Wu S, Watson RL, Graber CJ. 2007. Impact of combining rapid diagnostics with an interpretation guide on vancomycin usage for contaminant blood cultures growing coagulase- negative staphylococci (CoNS). Open Forum Infect Dis. 2019;6(Suppl 2):S674. doi:10.1093/ofid/ofz360.1687
- Donner LM, Campbell WS, Lyden E, Van Schooneveld TC. Assessment of rapid-blood-culture-identification result interpretation and antibiotic prescribing practices. J Clin Microbiol. 2017;55(5):1496-1507. doi:10.1128/JCM.02395-16
- Senok A, Dabal LA, Alfaresi M, et al. Clinical impact of the BIOFIRE blood culture identification 2 panel in adult patients with bloodstream infection: a multicentre observational study in the United Arab Emirates. Diagnostics (Basel). 2023;13(14):2433. doi:10.3390/diagnostics13142433
- Bae JY, Bae J, So MK, Choi HJ, Lee M. The impact of the rapid blood culture identification panel on antibiotic treatment and clinical outcomes in bloodstream infections, particularly those associated with multidrug-resistant micro-organisms. Diagnostics (Basel). 2023;13(23):3504. doi:10.3390/diagnostics13233504
Impact of Rapid Blood Culture Identification on Antibiotic De-escalation at a Veterans Affairs Medical Center
Impact of Rapid Blood Culture Identification on Antibiotic De-escalation at a Veterans Affairs Medical Center
