Administration of Emergency Medicine
Improving Door-to-Antibiotic Time in Severely Septic Emergency Department Patients

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Abstract

Background

The Surviving Sepsis Campaign (SSC) guidelines recommend that broad-spectrum antibiotics be administered to severely septic patients within 3 h of emergency department (ED) admission. Despite the well-established evidence regarding the benefit of timely antibiotics, adoption of the SSC recommendation into daily clinical practice has been slow and sporadic.

Study Objective

To study the impact of storing broad-spectrum antibiotics in an ED automated dispensing cabinet (ADC) on the timeliness of antibiotic administration in severely septic patients presenting to the ED.

Methods

Retrospective observational study of timeliness of antibiotic administration in severely septic patients presenting to a community ED before and after adding broad-spectrum antibiotics to the ED ADC. Data on 56 patients before and 54 patients after the intervention were analyzed. The primary outcome measure was mean order-to-antibiotic time. Secondary outcome measures included mean door-to-antibiotic time and percentage of patients receiving antibiotics within 3 h.

Results

The final analysis was on 110 patients. Order-to-antibiotic administration time was reduced by 29 min post-intervention (55 min vs. 26 min, 95% confidence interval [CI] 12.5–45.19). Mean door-to-antibiotic time was also reduced by 70 min (167 min vs. 97 min, 95% CI 37.53–102.29). The percentage of severely septic patients receiving antibiotics within 3 h of arrival to the ED increased from 65% pre-intervention to 93% post-intervention (95% CI 0.12–0.42).

Conclusion

Storing key antibiotics in an institution’s severe sepsis antibiogram in the ED ADC can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival.

Introduction

Suspected severe sepsis accounts for approximately 500,000 emergency department (ED) visits annually in the United States, and 20% of all admissions to intensive care units. The disease burden is high, with mortality ranging from 25% to 50% 1, 2. Outcomes have, until recently, remained relatively static. The past decade has seen a growth in clinical trials on sepsis that led to the development of evidence-based guidelines through a formal process led by the Surviving Sepsis Campaign in 2002, with updates and revisions in 2004 and 2008 (3). These guidelines include an early resuscitation bundle to be completed within the first 6 h of presentation that focuses on early diagnosis, initial resuscitation, timely antibiotics, source identification, and source control. These guidelines and associated resuscitation bundle recommend that broad-spectrum antibiotics be administered within 3 h of ED admissions and 1 h of non-ED intensive care unit (ICU) admission (4). This recommendation is based on numerous studies demonstrating that delayed antibiotics are clearly associated with increased mortality. One study by Kumar et al. demonstrated that each hour’s delay from the onset of hypotension to administration of appropriate antibiotic was associated with an average increase in in-hospital mortality of 7.6% (5). In addition, a nationwide study in Finland of patients admitted to ICUs from the ED in septic shock found that of all the components of the resuscitation bundle, delayed initiation of antibiotics (defined as antibiotics administered more than 3 h after ED admission) was an independent predictor of mortality at 1 year (72% if > 3 h vs. 33% if < 3 h, p < 0.001) (6).

The economic impacts of implementing these protocols have also been assessed. One study demonstrated a meaningful reduction in median total hospital costs ($21,985 vs. $16,103, p = 0.008) while at the same time drastically reducing mortality (70% vs. 51.7%, p = 0.04) after successfully implementing the sepsis bundles (7). Another study assessing cost-effectiveness demonstrated an increase in mean hospital costs of $8800 per patient (driven by an increased ICU length of stay), and an incremental cost of $11,274 per life-year saved and a cost of $16,309 per quality-adjusted life year gained (8). These costs are highly favorable compared to other commonly delivered medical interventions considered cost-effective.

Despite these now well-established guidelines, evidence of their cost-effectiveness, and their adoption by many hospitals and centers, implementation of the recommended components of the resuscitation bundle at the bedside has been variable. An analysis on data submitted to the Surviving Sepsis Campaign, including 15,022 subjects at 165 sites from January 2005 through March 2008 showed slow uptake, but increased compliance over the 2 years. Compliance with the entire resuscitation bundle increased from 10.9% to 31.3% (p < 0.0001). It is worth noting that after adjustment for baseline characteristics, compliance with the recommendations on timing of antibiotics was associated with lower hospital mortality (odds ratio 0.86, 95% confidence interval [CI] 0.79–0.93, p < 0.0001). Thus, although scientific evidence regarding the benefit of timely antibiotics in this setting is clear and well established, the adoption into the health care system and daily clinical practice has been slow and sporadic.

The objective of this study is to determine whether storage of key antibiotics on an institution’s severe sepsis antibiogram in the ED automated dispensing cabinet (ADC) improves order-to-antibiotic time (primary outcome) in severely septic ED patients, as well as door-to-antibiotic time and percentage of patients receiving antibiotics within the recommended 3 h of presentation to the ED (secondary outcomes).

Section snippets

Study Design

This is a before-and-after intervention study of the impact of storing broad-spectrum antibiotics in an ED ADC on timeliness of order to antibiotic administration in severely septic patients presenting to the ED. Beginning August 1, 2008, the two most commonly recommended antibiotics on our institution’s antibiogram for severe sepsis, namely vancomycin and piperacillin/tazobactam, were stored in the ED ADC. We conducted a retrospective observational study of mean order to antibiotic time,

Results

The final analysis was done on 110 severely septic patients presenting to the ED. The individual order-to-antibiotic times and door-to-antibiotic times with their respective monthly means pre- and post-intervention are displayed in Figure 3, Figure 4. Independent sample t-test showed a drop in mean order-to-antibiotic time of 29 min post-intervention (55 min vs. 26 min, 95% CI 12.5–45.19). Mean DTA time also dropped significantly by 70 min post-intervention (167 min vs. 97 min, 95% CI 37.53–102.29).

Discussion

Although ADCs that offer point-of-care unit dosing are now available in many EDs and have been shown to improve efficiency of drug dispensing, many broad-spectrum antibiotics still have to be obtained from the traditional central pharmacy (10). The ordering, preparation, and delivery of antibiotics through a central pharmacy adds multiple process steps that lead to additional delays. The safety features of ADCs allow for point-of-care dispensing of ready-to-use antibiotics without compromising

Conclusions

This study supports the storage of key antibiotics in an institution’s severe sepsis and septic shock antibiogram in the ED ADC. The elimination of delays in ordering, preparing, and delivering medications from centralized pharmacies can have significant clinical impact on key outcome measures in the treatment of severely septic patients in the ED.

Article Summary

1. Why is this topic important?

  1. Suspected severe sepsis accounts for approximately 500,000 emergency department (ED) visits annually in the United States and has a high disease

Acknowledgments

The authors would like to acknowledge Jeff McCombs, PhD, for his statistical methodology review.

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