Delays In Antibiotic Administration Research Articles

The Role of Procalcitonin in Diagnosis of Sepsis and Antibiotic Stewardship: Opportunities and Challenges.

Sepsis was recently redefined as “a life-threatening organ dysfunction caused by dysregulated host-response to systemic infection” based on the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The incidence of sepsis is increasing despite global initiatives, with a mortality ranging from 30% to 50%. A timely diagnosis of sepsis is pivotal for prompt recognition and appropriate intervention. Each hour of delay in administration of antibiotics results in an increase of 7.6% mortality for septic shock, yet overdiagnosis and inappropriate use of broad-spectrum antibiotics contribute to the emergence of antibiotic resistance. Diagnosis of sepsis is a clinical challenge. Early signs of systemic inflammation such as fever, tachycardia, and leukocytosis are not specific to sepsis. Traditionally, anaerobic and aerobic blood cultures were used to detect and identify the presence of bacterial infection; however, approximately 40% of patients with sepsis are culture-negative. Other biomarkers such as C-reactive protein (CRP;11 inflammatory) and lactate (organ dysfunction) are not early indicators and lack specificity. There is increasing evidence that support the use of procalcitonin (PCT) for diagnosis of bacterial sepsis and act as a guide to discontinue antibiotic therapy. Yet, there are concerns about the efficacy, safety, and availability of PCT. We have asked 5 experts with different roles in this field to share their thoughts on the challenges of PCT-guided diagnosis and antibiotic therapy. 1. What are the challenges in sepsis diagnosis? Joshua Hayden: In clinical journals, the question is “What are the challenges in defining sepsis?” Systemic inflammatory response syndrome (SIRS) criteria have been removed from the new Sepsis-3 definition after 25 years. A clinical syndrome that is this hard to define, not surprisingly, is difficult to diagnose. It is worth noting that the only laboratory values that currently count toward the diagnosis of sepsis are lactate and those included in …

A retrospective study evaluating the efficacy of identification and management of sepsis at a district-level hospital internal medicine department in the Western Cape Province, South Africa, in comparison with the guidelines stipulated in the 2012 Survivi.

Currently there is little information on the identification, management and outcomes of patients with sepsis in developing countries. Simple cost-effective measures such as accurate identification of patients with sepsis and early antibiotic administration are achievable targets, within reach without having to make use of unsustainable protocols constructed in developed countries. To assess the ability of clinicians at a district-level hospital to identify and manage sepsis, and to assess patient outcome in terms of in-hospital mortality and length of hospital stay given the above management. A retrospective descriptive study design was used, analysing data from the routine burden of disease audit done on a 3-monthly basis at Karl Bremer Hospital (KBH) in the Western Cape Province, South Africa. The total sample size obtained was 70 patients, of whom 18 (25.7%) had an initial triage blood pressure indicative of sepsis-induced hypotension. However, only 1 (5.5%) of these 18 patients received an initial crystalloid fluid bolus of at least 30 mL/kg. The median time that elapsed before administration of antibiotics in septic shock was 4.25 hours. Furthermore, a positive delay in antibiotic administration (p=0.0039) was demonstrated. The data also showed that 8/12 patients (66.7%) with septic shock received inappropriate amounts of fluids. The in-hospital mortality rate for sepsis was 4/24 (16.7%), for severe sepsis 11/34 (32.3%) and for septic shock a staggering 9/12 (75.0%). The initial classification process and management of sepsis by clinicians at KBH is flawed. This inevitably leads to an increase in in-hospital mortality.

Delays From First Medical Contact to Antibiotic Administration for Sepsis.

To evaluate the association between total medical contact, prehospital, and emergency department delays in antibiotic administration and in-hospital mortality among patient encounters with community-acquired sepsis. Retrospective cohort study. Nine hospitals served by 21 emergency medical services agencies in southwestern Pennsylvania from 2010 through 2012. All emergency medical services encounters with community acquired sepsis transported to the hospital. Among 58,934 prehospital encounters, 2,683 had community-acquired sepsis, with an in-hospital mortality of 11%. Median time from first medical contact to antibiotic administration (total medical contact delay) was 4.2 hours (interquartile range, 2.7-8.0 hr), divided into a median prehospital delay of 0.52 hours (interquartile range, 0.40-0.66 hr) and a median emergency department delay of 3.6 hours (interquartile range, 2.1-7.5 hr). In a multivariable analysis controlling for other risk factors, total medical contact delay was associated with increased in-hospital mortality (adjusted odds ratio for death, 1.03 [95% CI, 1.00-1.05] per 1-hr delay; p < 0.01), as was emergency department delay (p = 0.04) but not prehospital delay (p = 0.61). Both total medical contact and emergency department delay in antibiotic administration are associated with in-hospital mortality in community-acquired sepsis.

Effect of measuring vital signs on recognition and treatment of septic children.

A majority of children presenting with sepsis do not receive adequate fluid resuscitation and have a delay in antibiotic administration despite recommendations from the Surviving Sepsis Campaign. The objective of this study was to evaluate the association of measuring a complete set of five vital signs in the emergency department (ED) with recognition and treatment of septic children presenting to the ED. Records of 218 patients aged 1 month to 17 years treated between February 2011 and December 2011 in a single academic centre with clinical criteria of sepsis, severe sepsis or septic shock were retrospectively evaluated. The presence or absence of complete vital signs was analyzed in relation to timing of fluid resuscitation, and if antibiotics were given in the first hour of medical evaluation. Seventy-six per cent of children who had all five vital signs measured in the ED received fluid resuscitation in the first hour after medical evaluation as opposed to 61% of those who had an incomplete set of vital signs (P<0.04). Twenty per cent of children who had all five vital signs measured received antibiotics in the first hour as opposed to 9% in children who had fewer vital signs measured (P<0.02). In our study population, the measurement of all vital signs in the ED, including blood pressure, was associated with faster administration of antibiotics and improved compliance with existing fluid bolus recommendations, which may have been the result of better recognition of sepsis in children through vital signs measurement.

Protocol for Reducing Time to Antibiotics in Pediatric Patients Presenting to an Emergency Department With Fever and Neutropenia: Efficacy and Barriers.

Patients with febrile neutropenia are at high risk of morbidity and mortality from infectious causes. Decreasing time to antibiotic (TTA) administration is associated with improved patient outcomes. We sought to reduce TTA for children presenting to the emergency department with fever and neutropenia. In a prospective cohort study with historical comparison, TTA administration was evaluated in patients with neutropenia presenting to the Children's of Alabama Emergency Department. A protocol was established to reduce delays in antibiotic administration and increase the percentage of patients who receive treatment within 60 minutes of presentation. One hundred pre-protocol patient visits between August 2010 and December 2011 were evaluated and 153 post-protocol visits were evaluated between August 2012 and September 2013. We reviewed individual cases to determine barriers to rapid antibiotic administration. Antibiotics were administered in 96.9 ± 57.8 minutes in the pre-protocol patient group, and only 35% of patients received antibiotics within 60 minutes of presentation and 70% received antibiotics within 120 minutes. After implementation of the protocol, TTA for neutropenic patients was decreased to 64.3 ± 28.4 minutes (P < 0.0001) with 51.4% receiving antibiotics within 60 minutes and 93.2% within 120 minutes. Implementing a standard approach to patients at risk for neutropenia decreased TTA. There are numerous challenges in providing timely antibiotics to children with febrile neutropenia. Identified delays included venous access (time to effect of topical anesthetics, and difficulty obtaining access), physicians waiting on laboratory results, and antibiotic availability.

Epidemiology, recognition and documentation of sepsis in the pre-hospital setting and associated clinical outcomes: a prospective multicenter study

Introduction: General practitioners (GPs) and the emergency medical services (EMS) personnel have a pivotal role as points of entry into the acute care chain. This study was conducted to investigate the recognition of sepsis by GPs and EMS personnel and to evaluate the associations between recognition of sepsis in the pre-hospital setting and patient outcomes. Methods Design: prospective, observational study during a 12 week period in the emergency department (ED) of two academic hospitals. Study population: Patients &gt;18 years presenting with sepsis at the ED. The information available in the ED discharge letter and the ED charts was used to make a definite diagnosis of sepsis, severe sepsis and septic shock Outcome measures: primary: recognition/documentation of sepsis. Secondary: ED arrival time to antibiotic administration, in-hospital mortality, hospital length of stay (LOS) and intensive care unit (ICU) admission. Results: A total of 301 patients were included in the study. GPs and EMS personnel correctly identified and documented 31.6% (n=114) and 41.4% of all sepsis patients (n=140) respectively. Recognition and documentation of sepsis improved with increasing severity. The mean time to administration of antibiotics (TTA) was nearly halved for the group of patients where sepsis was documented (GP: 66,4 minutes, EMS: 65,6 minutes) compared to the group in which sepsis was not documented (GP: 123,9 minutes, EMS: 101,5 minutes; p= 0.365 and p= 0.024 respectively). Conclusions: There is room for improvement in the recognition of sepsis, severe sepsis and septic shock by practitioners working in the pre-hospital setting. Documentation of sepsis prior to arrival in hospital led to a reduced time delay in administration of antibiotics.

Prognostic Value of Timing of Antibiotic Administration in Patients With Septic Shock Treated With Early Quantitative Resuscitation

BackgroundThe Surviving Sepsis Campaign recommends initiating broad-spectrum antibiotic treatment within 1 hour of septic shock recognition. However, there is controversy regarding this owing to contradictory studies. This study investigated the relationship between the antibiotic administration interval and 28-day mortality in septic shock patients treated with an early quantitative resuscitation protocol in an emergency department (ED). Methods715 consecutive septic shock patients were prospectively collected from January 2010 to December 2012. Of these, 426 patients developed shock at or after initial assessment, and the time of initial antibiotic administration was recorded. The primary outcome was 28-day mortality. ResultsThe median antibiotic administration interval was 91.5 (47.0–158.0) minutes, and the 28-day mortality was 20.0%. Mortality did not change with hourly delays in antibiotic administration up to 5 hours after shock recognition: 1 hour (odds ratio [OR]: 0.81, 95% confidence interval [CI]: 0.45–1.45), 2 hours (OR: 0.72, 95% CI: 0.40–1.29) and 3 hours (OR: 0.61, 95% CI: 0.30–1.25). However, inability to achieve early resuscitation goals (OR: 1.94, 95% CI: 1.07–3.51), sequential organ failure assessment score (OR: 1.30, 95% CI: 1.17–1.44) and lactic acid concentration (OR: 1.66, 95% CI: 1.11–2.49) were significantly associated with an increased risk of 28-day mortality. ConclusionsAmong septic shock patients who underwent early quantitative resuscitation in an ED, mortality did not increase with hourly delays in antibiotic administration. These data call into question the strength of the association between hourly delays in antibiotic administration and mortality in septic shock patients.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis and Septic Shock From the First Hour

Compelling evidence has shown that aggressive resuscitation bundles, adequate source control, appropriate antibiotic therapy, and organ support are cornerstone for the success in the treatment of patients with sepsis. Delay in the initiation of appropriate antibiotic therapy has been recognized as a risk factor for mortality. To perform a retrospective analysis on the Surviving Sepsis Campaign database to evaluate the relationship between timing of antibiotic administration and mortality. Retrospective analysis of a large dataset collected prospectively for the Surviving Sepsis Campaign. One hundred sixty-five ICUs in Europe, the United States, and South America. A total of 28,150 patients with severe sepsis and septic shock, from January 2005 through February 2010, were evaluated. Antibiotic administration and hospital mortality. A total of 17,990 patients received antibiotics after sepsis identification and were included in the analysis. In-hospital mortality was 29.7% for the cohort as a whole. There was a statically significant increase in the probability of death associated with the number of hours of delay for first antibiotic administration. Hospital mortality adjusted for severity (sepsis severity score), ICU admission source (emergency department, ward, vs ICU), and geographic region increased steadily after 1 hour of time to antibiotic administration. Results were similar in patients with severe sepsis and septic shock, regardless of the number of organ failure. The results of the analysis of this large population of patients with severe sepsis and septic shock demonstrate that delay in first antibiotic administration was associated with increased in-hospital mortality. In addition, there was a linear increase in the risk of mortality for each hour delay in antibiotic administration. These results underscore the importance of early identification and treatment of septic patients in the hospital setting.

1080

Introduction: Early recognition and prompt treatment of the septic child have a demonstrated positive impact morbidity and mortality. However, despite clear recommendations from the Surviving Sepsis Campaign, the majority of children presenting with sepsis do not receive the required fluid resuscitation and many have a delay in antibiotic administration. Methods: The objective of this study was to evaluate the effect of measuring a complete set of five vital signs versus an incomplete set of vital signs on recognition and treatment of septic children presenting to the emergency department. Study design was a single-center retrospective cohort study. Records of 218 patients aged from one month to 18 years treated between February 2011 and December 2011 in a single academic center with a diagnosis of sepsis, severe sepsis, toxic shock or septic shock were evaluated. The presence or absence of vital signs at triage was analyzed in relation to management of these patients, defined by the presence or absence of fluid resuscitation and antibiotics in the first hour within medical evaluation. Results: The absence of complete vital signs was associated with a delay in the administration of fluid resuscitation in 82.9% patients versus 70.4% for patients with all vital signs documented (p <0.04) and in the administration of antibiotics in 77.2% patients versus 22.8% (p<0.02). Meanwhile, 76.9% of the population who received neither antibiotics nor fluid resuscitation in the first hour after medical evaluation did not have complete vital signs taken (p <0.02). Conclusions: In our study population, the measurement of all vital signs, including blood pressure, was correlated with better recognition of sepsis in children, faster antibiotic administration and improved compliance with existing fluid bolus recommendations during the first hour after medical evaluation. This study emphasizes the importance of complete and timely vital sign evaluation to as a key component of the care of children with suspected sepsis.

Prospective Study Of An Emergency Department Febrile Neutropenia Pathway In Patients With Hematologic Malignancies

BackgroundFebrile neutropenia (FN) is an oncologic emergency associated with high morbidity and mortality, particularly in patients (pts) with hematologic malignancies. Delays in antibiotic administration, which can occur in busy emergency departments (EDs), lead to worse outcomes. We instituted a FN pathway (FNP) in the Cleveland Clinic (CC) ED to reduce antibiotic delays. MethodsThis prospective study comparing patients from 06/12 - 06/13 to historical pts from 02/10 - 05/12, represented a collaboration among cancer center, ED, infectious disease, pharmacy, and electronic medical record representatives. Fever was defined as temperature >38°C either at home or in the ED, while neutropenia as absolute neutrophil count <0.5 x 109/L. All CC cancer pts received a special “Neutropenic Risk Hospital Medical Alert Card,” which they presented upon CC ED registration with fever. The pathway formally recognized “fever with a history of cancer” to be a distinct chief complaint and FN to be categorized as Emergency Severity Index level 2 (equivalent to stroke or myocardial infarction) for immediate triage and care. ED-specific electronic FN order sets were created to facilitate antibiotic, laboratory, and blood culture ordering, with antibiotics administered prior to return of neutrophil count. The primary goal of the FNP is administration of empiric broad-spectrum antibiotics within 120 minutes of ED presentation, per Infectious Diseases Society of America guidelines; and the primary outcomes measured were time intervals related to it, e.g. time to blood draw, physician assessment, and antibiotic order/administration. Group comparisons were made using the chi-square, Kruskal-Wallis, Wilcoxon rank-sum, and log rank tests, as appropriate. All reported times were from ED registration. ResultsIn total, 137 consecutive FN episodes in 115 pts with hematologic malignancies occurred during the 12 month study period, 63 episodes in 44 pts in the historical cohort. All pts were triaged and treated using the ED FNP, but use of the specific FN order set was variable: episodes were thus classified as treated per the order set (n=53) or not (n=84 – pts still received antibiotics, but not necessarily per the order set). Overall 60% of pts (n=89) were male and the median age at the time of first ED encounter was 59 years (range 20-88). Cancers were: non-Hodgkin lymphoma (38%), acute myeloid leukemia (21%), other leukemias (15%), and myelodysplastic syndromes (8%). Compared to historical pts, FNP study pts had a higher median ANC (2.0 vs. 0.2, p<0.0001), were less likely to be on growth factors (26% vs. 41%, p=0.06) and more likely to have received prophylactic antibiotics (55% vs. 35%, p=0.006). For the outcome of interest, FNP study pts had significantly shorter time to having blood drawn (median 38.5 vs. 70 minutes, p<0.0001), seeing a doctor (median 44 vs. 71 minutes, p=0.0002) and to receiving antibiotics (median 79 vs. 228 minutes, p<0.0001). Time to admission was also shorter for FNP study pts (4.2 vs. 6.0 hours, p<0.0001), though study pts were less likely to be admitted than historical controls (83% vs. 97%, p=0.005). For FNP pts admitted to the hospital, there was a non-significant decrease in length of stay (median 3.8 vs 4.6 days, p=0.28), ICU admission (7% versus 11%, p=0.26), and length of ICU stay (median 1.9 vs 2.3 days, p=0.83) compared to historical controls.Comparing the two FNP groups treated or not treated per the order set, those treated using the order set had shorter times to antibiotics being ordered (median 28.0 vs. 60.5 minutes, p<0.0001) and administered (median 66.0 vs 92.5 minutes, p=0.002). ED order set pts also had a higher rate of antibiotic use (100% vs 90%, p=0.02). Correct antibiotic use, antibiotic over-use, hospital and ICU admission rates, time to hospital admission, and length of hospital stay were all similar between the two groups (all p>0.28). ConclusionThe FNP significantly decreased time from ED registration to all set time-points, including time to antibiotics by almost three-fold, compared to historical controls in pts with hematologic malignancies. Rate of hospitalization was significantly lower, and ICU and length of stay numerically lower. The FNP is an effective clinical tool to provide prompt antibiotic administration to FN pts and likely represents a significant mechanism for improved outcomes and cost-savings to patients with hematologic malignancies presenting with FN. Disclosures:No relevant conflicts of interest to declare.

Pre-hospital antibiotics for open fractures: Is there time? A descriptive study

Infection is a complication of open fractures. Early administration of intravenous (IV) antibiotics providing cover against gram positive and negative organisms has been shown to be the single most important factor in reducing infection rate in patients with open (compound) fractures. A delay of more than three hours from injury (open fractures or war wounds including fractures) to antibiotic administration is associated with a significantly higher infection rate. The purpose of this study is to identify the proportion of patients in a suburban sample that experience delay of more than 3 hours in antibiotic administration after open fracture. The authors hope to clarify if there would be opportunity and value in pre-hospital antibiotic administration in significantly shortening the delay. A retrospective and prospective descriptive study was conducted of all patients with open fractures of the limbs or girdles arriving via ambulance at a single district hospital in a suburban area in KwaZulu-Natal, South Africa from May to December 2012. Data analysed with descriptive statistics using STATA 11. 38 patients were identified from May to December 2012. The median total time from injury to antibiotics was 465 min (7.5 h) (Q1 = 230 min, Q3 = 615). Administration of antibiotics was delayed beyond 3 h in 78.9% (95% confidence interval (CI) 65.3 – 92.52) of patients and beyond 6 h in 60.5% (95% CI 44.2 – 76.8). A median of 164 min (Q1 = 115, Q3 = 222) was spent out of hospital with emergency medical care practitioners (EMCPs) being in attendance for a median of 56 min (Q1 = 37, Q3 = 64). The longest delay occurred after arrival at the hospital with a median of 363 min (Q1 = 171, Q3 = 505) until antibiotic administration. 26.3% of patients were transported directly from scene of injury to the hospital, while the remainder first presented to a clinic. There is much room for improvement within the study hospital and its drainage clinics in preventing delay in antibiotic administration. However, although much of the delay occurred due to clinic and in-hospital delays, there is also a hypothetical window available to pre-hospital healthcare providers where antibiotics may be administered which would dramatically decrease the time interval and bypass many of the difficulties encountered in-hospital. It would be safer to consider introducing IV antibiotics to the advanced scope of EMCP practise only; due to need to manage complications of antibiotics. Before considering introducing antibiotics to EMCP spectrum of care, efficacy, safety and cost-effectiveness studies would need to be undertaken. Randomised controlled trials are also recommended to determine the effect on reducing delay, infection and occurrence of adverse events.

Electronic prescribing: Reducing delay to first dose of antibiotics for patients in intensive care.

Delays in antibiotic therapy in the context of severe sepsis are associated with increased mortality. One way to reduce such delays may be through modifications to electronic prescribing (EP) systems. The research team evaluated the role of one such EP system in reducing delays in antibiotic administration in an Intensive Care Unit (ICU). First, the delays in antibiotic administration in adult ICU patients was quantified. The EP system was then modified to remove deafult time settings for antibiotic doses, which ensured that all antibiotic doses were scheduled for administration within an hour of the prescription being generated. Enhanced training for clinicians and nurses was also implemented, focusing on the EP system and highlighting the importance of prompt antimicrobial prescribing and delivery to the patient. The antibiotic administration was re-audited, and a significant reduction in delays (p=0.002, Mann-Whitney U test) was found. This study demonstrates how prudent use of EP systems can help to reduce delays in antibiotic administration in an ICU setting, thus potentially contributing to reducing mortality in patients with sepsis.

Emergency Department Crowding and Time to Antibiotic Administration in Febrile Infants

Introduction:Early antibiotic administration is recommended in newborns presenting with febrile illness to emergency departments (ED) to avert the sequelae of serious bacterial infection. Although ED crowding has been associated with delays in antibiotic administration in a dedicated pediatric ED, the majority of children that receive emergency medical care in the United States present to EDs that treat both adult and pediatric emergencies. The purpose of this study was to examine the relationship between time to antibiotic administration in febrile newborns and crowding in a general ED serving both an adult and pediatric population.Methods:We conducted a retrospective chart review of 159 newborns presenting to a general ED between 2005 and 2011 and analyzed the association between time to antibiotic administration and ED occupancy rate at the time of, prior to, and following infant presentation to the ED.Results:We observed delayed and variable time to antibiotic administration and found no association between time to antibiotic administration and occupancy rate prior to, at the time of, or following infant presentation (p>0.05). ED time to antibiotic administration was not associated with hospital length of stay, and there was no inpatient mortality.Conclusion:Delayed and highly variable time to antibiotic treatment in febrile newborns was common but unrelated to ED crowding in the general ED study site. Guidelines for time to antibiotic administration in this population may reduce variability in ED practice patterns.

Time to antibiotic.

115 Background: The aim of this quality improvement (QI) project is to identify the interdisciplinary factors that cause delay of antibiotic administration to febrile Hematology/Oncology patients directly admitted to Pediatric department. Pediatric oncology research has shown that there is significant lower mortality associated with antibiotics given within one hour vs. delayed or no treatment (Adderson, Flynn, and Hoffmann, 2011). Methods: This QI project is conducted at a 32 bed pediatric unit at Kaiser Permanente Los Angeles Medical Center. Hematology/oncology patients admitted to the pediatric floor with fever were included in the study. A six month audit (n=22) showed that current workflow was inadequate and did not meet the time to antibiotic (TA) goal. A three-point workflow was designed to improve the TA outcome. The workflow includes initial documentation of actual time patient arrived to pediatric floor to the time admitted patient is entered in the electronic medical record (EMR) system. This is followed by auditing actual time patient is admitted to EMR to the actual time computerized physician order entry (CPOE) for time to antibiotic protocol is entered. Lastly, CPOE to actual time antibiotic was administered was audited. An ongoing six month audit has begun with the implementation of changes to workflow. Results: Audit prior to TA workflow: Patients (n=22) who met the criteria showed that (22.7%) received initial antibiotics within 1 to 2 hours. Eight patients (36.4%) received the antibiotics within 2 to 3 hours of admission. Four patients (18.2%) received initial antibiotics at 3 to 4 hours of admission. Notably, none (0%) of these patients received antibiotic within the goal of one hour. Audit after implementation of TA workflow: A three month audit (n=14) showed that (57.1%) received antibiotic less than 1 hour from time of admission. Two patients (14.2%) received antibiotic less than 2 hours of admission. Two patients (14.2%) received antibiotic less than 3 hours of admission. Two patients (14.2%) of these patients received antibiotics 3 to 4 hours of admission. Conclusions: Based on current data, the TA protocol showed marked improvement in the delivery and administration of antibiotic received by hematology/oncology patients.

Time to effective antibiotic administration in adult patients with septic shock: A descriptive analysis

To determine the median time to antibiotic administration following the onset of septic shock at our institution as well as the appropriateness of empiric therapy, sources of delay in antibiotic administration and the effect of delays on survival. Retrospective health record review of 55 patients with septic shock admitted to the intensive care unit (ICU) between July 1, 2008 and December 31, 2009. Nine-bed adult medical-surgical ICU within a 300-bed community acute care hospital. Median time to antibiotic administration, appropriateness of empiric therapy, sources of delay in antibiotic administration. The median (min,max) time to the initiation of antibiotics was determined to be 1.7 (0,31) hours. Only 34% (19/55) of patients received antibiotics within the recommended one hour. Empiric antibiotic therapy was determined to be appropriate in 91% (50/55) of patients. The median (min,max) time to administration of effective antibiotic therapy tended to be faster in the emergency room [1.1 (0,16) hours] compared to the ICU [2.3 (0,13)]. The median time to antibiotic administration at our institution following the onset of septic shock was longer than the evidence-based guideline recommendations of within one hour.

The Association of Emergency Department Crowding and Time to Antibiotics in Febrile Neonates

The objective was to assess the relationship between emergency department (ED) crowding and timeliness of antibiotic administration to neonates presenting with fever in a pediatric ED. This was a retrospective cohort study of febrile neonates (aged 0-30 days) evaluated for serious bacterial infections (SBIs) in a pediatric ED from January 2006 to January 2008. General linear models were used to evaluate the association of five measures of ED crowding with timeliness of antibiotic administration, controlling for patient characteristics. A secondary analysis was conducted to determine which part of the ED visit for this population was most affected by crowding. A total of 190 patients met inclusion criteria. Mean time to first antibiotic was 181.7 minutes (range = 18-397 minutes). At the time of case presentation, the number of patients waiting in the waiting area, total number of hours spent in the ED by current ED patients, number of ED patients awaiting admission, and hourly boarding time were all positively associated with longer times to antibiotic. The time from patient arrival to room placement exhibited the strongest association with measures of crowding. Emergency department crowding is associated with delays in antibiotic administration to the febrile neonate despite rapid recognition of this patient population as a high-risk group. Each component of ED crowding, in terms of input, throughput, and output factors, was associated with delays. Further work is required to develop processes that foster a more rapid treatment protocol for these high-risk patients, regardless of ED crowding pressures.

Assessment and Management of Febrile Neutropenia in Emergency Departments within a Regional Health Authority—A Benchmark Analysis

Febrile neutropenia is considered an oncologic emergency, for which prompt initiation of antibiotics is essential. We conducted a retrospective cohort study for the 2006 calendar year involving all adult oncology patients presenting with febrile neutropenia to a regional health authority's emergency departments. The objective was to determine the time from triage to antibiotic administration and its impact on patient outcomes. We identified 68 patients presenting with febrile neutropenia, most of whom (76%) were seen in tertiary care centers. Of those patients, 65% were triaged to be seen within 15 minutes of arrival in the emergency room; however, the median time to reassessment was 57 minutes. The median time from triage to antibiotic administration was 5 hours (range: 1.23-22.8 hours). No increased risk of death or increased length of hospital stay was associated with delayed antibiotic administration. Older patients and patients without caregiver support were more likely to experience delayed antibiotic administration (odds ratio: 3.8 and 12.7 respectively). We were not able to show a deleterious effect of delay in antibiotic administration, but our analysis identified several points at which patient flow through the emergency room could be improved.

Development of Tools and Processes to Improve Treatment Times in Patients With Febrile Neutropenia

Despite medical advances, febrile neutropenia remains a potentially life-threatening emergency for patients with cancer undergoing chemotherapy. A current literature review found only two oncology nursing studies addressing timeliness of antibiotic administration during a febrile neutropenic episode. Anecdotal patient reports and chart audits reflected up to a seven-hour delay in antibiotic administration for patients with febrile neutropenia presenting to the study hospital’s emergency department. This article describes a multidisciplinary best practice model with tools developed for achieving timely recognition of febrile neutropenia and a one-hour benchmark for antibiotic administration at any point of entry to the hospital. Collaboration between the cancer center and emergency department provided a vehicle for critically analyzing current practice and developing effective throughput pathways. The Neutropenic Fever Team process reduced throughput to an average of 53 minutes for patients with febrile neutropenia. Educational tools were developed and used to reinforce what patients and families can do to reduce the risk of life-threatening complications. Nurses are encouraged to implement this best practice model in different settings and to investigate how throughput processes and educational tools improve clinical outcomes for this high-risk population.

Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol*

We sought to determine the association between time to initial antibiotics and mortality of patients with septic shock treated with an emergency department-based early resuscitation protocol. Preplanned analysis of a multicenter randomized controlled trial of early sepsis resuscitation. Three urban U.S. emergency departments. Adult patients with septic shock. A quantitative resuscitation protocol in the emergency department targeting three physiological variables: central venous pressure, mean arterial pressure, and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all end points were achieved or a maximum of 6 hrs. Data on patients who received an initial dose of antibiotics after presentation to the emergency department were categorized based on both time from triage and time from shock recognition to initiation of antibiotics. The primary outcome was inhospital mortality. Of 291 included patients, mortality did not change with hourly delays in antibiotic administration up to 6 hrs after triage: 1 hr (odds ratio [OR], 1.2; 0.6-2.5), 2 hrs (OR, 0.71; 0.4-1.3), 3 hrs (OR, 0.59; 0.3-1.3). Mortality was significantly increased in patients who received initial antibiotics after shock recognition (n = 172 [59%]) compared with before shock recognition (OR, 2.4; 1.1-4.5); however, among patients who received antibiotics after shock recognition, mortality did not change with hourly delays in antibiotic administration. In this large, prospective study of emergency department patients with septic shock, we found no increase in mortality with each hour delay to administration of antibiotics after triage. However, delay in antibiotics until after shock recognition was associated with increased mortality.