A four month prospective descriptive exploratory study of patients receiving antibiotics in one Emergency Department

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Abstract

Background

Any infection can potentially develop into sepsis. Many patients present to the Emergency Department (ED) with infection and go on to require antibiotics. However, the timeliness of antibiotics can make a difference to patient survival and reduce the risk of infection developing into sepsis and or septic shock.

Methods

Our study was a 4 month prospective descriptive exploratory pilot study.

Results

Of all adult (n = 18,807) presentations 3339 (18%) patients had a primary diagnosis related to infection. The study collected data on 104 (3%) patients who were administered antibiotics. One hundred (95%) patients who received antibiotics were admitted to hospital. Triage code did not influence time to antibiotic (p = .352). Eighty-five (81%) patients waited longer than 1 h for their first antibiotic with the shortest administration time 19 min (mean 233 min, SD 247) and the maximum wait for antibiotics was 1481 min. For sepsis or septic shock patients (n = 8) the average time to antibiotics was 411 min (SD = 455 min).

Conclusion

The study provides a detailed analysis of ED patients receiving antibiotics. Further research is needed to identify strategies to improve the timely delivery of antibiotics for patients with infections.

Introduction

Globally, severe infection cost the healthcare systems billions of dollars (Eber et al., 2010, Sepsis Alliance, 2011b). If severe infection is left unrecognised and/or untreated the development of sepsis and/or septic shock can ensue. While care practices have improved trauma, myocardial infarction and stroke outcomes, sepsis outcomes remain a serious health issue (ACI, 2010, Rivers et al., 2012). In the United States of America (USA) there are nearly one million new cases of sepsis diagnosed each year and 40% of severe septic patients die (Sepsis Alliance, 2011b, Sepsis Alliance, 2012). In Canada, 2008–2009, there were 30,500 sepsis hospital admissions and of intensive care patients with severe sepsis over 38% died (Canadian Health Institute for Health Information, 2010). In the UK, an 8 year study identified that 27% (92,672) of hospital ICU admissions were diagnosed with having severe sepsis (Harrison et al., 2006). Similarly in Australasia the sepsis rate identified by Finfer et al. (2004), while less than that of other international countries, was substantial with an ICU sepsis rate of 0.77 per 1000 population and a mortality rate of 26.5%.

A delay in antibiotic administration in the ED, can result in patient deterioration and the development of sepsis and/or septic shock. Sepsis mortality rate has been shown to be increased through poor recognition and antibiotic delay (Dellinger et al., 2008, Gao et al., 2005, Guimont et al., 2009, Kumar et al., 2006, Reade et al., 2010, Shapiro et al., 2005). Given the variety of infective presentations, clinical urgency and signs and symptoms, early recognition of severe infection and/or sepsis can often be difficult for ED clinicians. Yet ED clinicians are responsible for the early recognition and prompt treatment of patients with infection both minor and severe.

Often patients with infection require antibiotics to prevent deterioration and/or sepsis developing. With any infection there is a risk that sepsis or septic shock can develop. However, timely antibiotics have been shown to optimise patient outcomes and stop deterioration (Sepsis Alliance, 2011a). Indeed, the time of antibiotic delivery for patients with severe infection has been identified as a critical predictor of patient death (Kumar et al., 2006). Similarly, it has been identified that sepsis mortality rate increases by 7.6% with every hour’s delay before antibiotic therapy begins within the first 6 h of arrival (ACI, 2010, Kumar et al., 2006). Many studies have demonstrated that prompt delivery of antibiotics will improve patient outcome and more specifically survival (Castellanos-Ortega et al., 2010, Dellinger et al., 2008, Puskarich et al., 2009).

Patient admissions due to infection are a serious health burden. In the USA, during 1998–2006, there were 1.7 million hospital admissions due to infection annually (Eber et al., 2010). Many patients present with infection to Emergency Departments (EDs) and a proportion of these patients will go on to require hospital admission, intensive care beds and intravenous antibiotic administration. However, there is little understanding of the patients presenting with infection and subsequently requiring antibiotics in Australian EDs.

The aim of our research was to explore the (i) prevalence of patients presenting to one ED with infection; (ii) triage characteristics and time to antibiotic for patients receiving antibiotics, and (iii) patients physiological characteristics and time to antibiotic, clinical interventions and disposition.

Section snippets

Methods

This was a 4 month prospective descriptive exploratory study.

Study design

The four month study (1st April–31st July 2011) was conducted to explore the prevalence of adult (>16 years) ED patients presenting with infection. All adult patients who presented to the ED and received antibiotics were eligible for enrollment. All children (<16 years) were excluded from the study as there were specific clinical guidelines for this patient groups.

A survey tool was developed to document patient clinical information including: triage-antibiotic time and types, administration

Results

During the four month study there were 18,807 adult patient presentations of which 3339 (18%) patients had a primary diagnosis related to infection. Respiratory infection (n = 885; 27%) was the most frequent diagnostic group (Table 1). One hundred and four (3.1%) patients received antibiotics. More females (n = 55; 53%) received antibiotics. The majority of antibiotics were administered for abdominal (n = 33; 32%) or respiratory (n = 29; 29%) infections (Table 1). There was no significant difference

Discussion

The study demonstrated that the prevalence of patients presenting to one ED with infection was substantial. We suggest that the study underestimates the presentation rate for infection given that selected diagnoses such as pancreatitis were excluded given its multiple etiologies. However, for some of these cases there would have been infection associated with the presentation.

The study demonstrated that triage codes did not significantly influence the delivery time of antibiotics. Nor did a

Limitations

There are several limitations to our study. The patient infection rate was determined retrospectively using the ED computer database. However, there is capacity for clinicians to over-ride the diagnosis menu. The consistency and reliability of the database may compromise interpretation and generalisability. A different interpretation may result if data were collected prospectively. While the database may not reflect the patient infection rate accurately this is the standard method for reviewing

Conclusions

The study provides an analysis of patients receiving antibiotics in one ED. To improve the time to antibiotic, system processes need to be reviewed to determine where delays occur and can ultimately be resolved. ED processes need to ensure the early recognition, management and safe discharge of patients with infection to prevent deterioration and/or development of sepsis.

While the study adds to the sepsis literature factors that influence triage to antibiotic time require further investigation

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