332 Impact of Emergency Department Clinical Pharmacist Response to an Automated Electronic Notification System on Timing and Appropriateness of Antimicrobials in Severe Sepsis or Septic Shock in the Emergency Department

Abstract

Study Objectives: To determine the effect of an emergency department (ED) clinical pharmacist response to an automated electronic notification system on the timing and appropriateness of antimicrobials in patients with severe sepsis or septic shock in the ED. Methods: The study was conducted in an ED at a tertiary care academic medical center with 80,000 visits annually. This was a prospective interventional cohort (01/21/2010 - 006/20/2010) study with a historical control cohort (01/21/2009-06/20/2009). Potentially eligible patients were identified by an electronic notification system. The electronic notification system criteria/algorithm were previously validated in our ED to detect potential patients with severe sepsis and septic shock. The prospective cohort was identified by application of the electronic notification system criteria via radio page in real-time. The historical control cohort was identified by applying the electronic notification system criteria retrospectively to the ED electronic tracking board which retains and stores all patient information for all ED visits on a Microsoft SQL Server 2005 database. Patients were eligible for the study if they met electronic notification system criteria, had severe sepsis or septic shock (per Surviving Sepsis Campaign Guidelines) and presented to the ED while the pharmacist was present (approximately 80 hours/week). A radio page was sent to an ED clinical pharmacist when a patient met electronic notification system criteria. The pharmacist evaluated the patient for the presence of severe sepsis or septic shock, recommended empiric antimicrobials, and facilitated their procurement and administration. Primary outcome measures were: 1) time from ED room assignment to appropriate antimicrobial administration; and 2) proportion of patients with appropriate antimicrobials administered within 3 hours of ED room assignment. Appropriate antimicrobials were defined as having activity against any isolated pathogen or following national or institutional guidelines in culture negative patients. Determination of severe sepsis or septic shock in all electronic notification system patients and assessment of appropriateness of antimicrobials was done by chart review after completion of the study by blinded reviewers. Results: The electronic notification system was triggered 1232 and 1202 times during the intervention and control cohort study periods, respectively. Of these, 160 (13%) and 143 (12%) patients met inclusion criteria in the intervention and control groups respectively. Baseline demographic characteristics and ED length of stay were similar between groups. There was no significant difference in mean time from ED arrival to meeting electronic notification system criteria. Patients in the intervention group had a shorter median time to appropriate antimicrobial administration than in the control group (173 [IQR 182] versus 217IQR 301] minutes, P = 0.03). There were significantly more patients who received appropriate antimicrobials in the ED (73% versus 61% P=0.03). The proportion of patients who received appropriate antimicrobials within 3 hours of ED presentation (room time) was higher in the intervention group compared to controls (47% versus 35%, P=0.048). Conclusion: An ED pharmacist response to an automated electronic notification system resulted in faster time to appropriate antimicrobial administration and a higher rate of appropriate empiric antimicrobial use within 3 hours of presentation. This method is one means of improving the care of patients with severe sepsis and septic shock in the ED.