Delays in the administration of antimicrobials in the emergency department and the impact of an educational intervention to improve this administration

Abstract

The aim of the study was to assess the factors associated with delays in emergency department (ED) antimicrobial administration and to determine whether an educational intervention would reduce the incidence of such delays. We carried out a retrospective observational cohort study of patients aged 18-89 years who received intravenous antimicrobial(s) in a single ED and were subsequently admitted (March 2011). Using multivariable logistic regression, we analyzed whether demographic and operational factors were significantly associated with delayed ED antimicrobial administration (> 30 min from physician order to nurse initiation time). We then conducted an educational intervention with ED/hospital staff to disseminate knowledge of these identified factors. After the intervention, we carried out a prospective observational cohort study of participants with the same inclusion criteria (March 2012), using the large sample z-test to analyze whether the incidence of such delays was significantly reduced. A total of 575 ED antimicrobial orders (302 patients) before the intervention and 493 antimicrobial orders (275 patients) after the intervention fulfilled the inclusion criteria. The median time to antimicrobial administration (interquartile) was 48 min (17-130 min) before the intervention and 49 min (17-156 min) after the intervention. Variables significantly increasing or decreasing the odds of delayed ED antimicrobial administration were older age [OR: 1.01, 95% confidence interval (CI) 1.003-1.03], one-time dosing (OR: 0.53, 95% CI 0.31-0.92), and second (OR: 2.40, 95% CI 1.39-4.14), and third (OR: 3.66, 95% CI 1.69-7.92) antimicrobial administration (multiple agents ordered). The incidence of antimicrobial administration was 35.8% within 30 min before the intervention and 34.7% after the intervention (z-test: 0.39, P = 0.70). Older age, multiple agent orders, and dosing ordering pattern showed a significant association with delays in ED antimicrobial administration. An educational intervention to disseminate knowledge of these factors did not result in a reduction in such delays.