A four month prospective descriptive exploratory study of patients receiving antibiotics in one Emergency Department
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
References (24)
- et al.
An educational framework for triage nursing based on gatekeeping, timekeeping and decision-making processes
Accident and Emergency Nursing
(2005) - et al.
The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: a prospective before-and-after intervention study
International Journal of Nursing Studies
(2010) Joint ACI/CEC improving the recognition and management of severe infection and sepsis
Clinician Connect
(2010)Sepsis Adult First Dose Empirical Intravenous Antibiotic Guideline v1
(2011)- Canadian Health Institute for Health Information, 2010. Canadian Hospitals Aim to Reduce Mortality Rates, But Severe...
- Canadian Institute for Health Information, 2009. Hospital Standardized Mortality Ratio (HSMR) Public Release,...
- et al.
Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study
Critical Care Medicine
(2010) - et al.
Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008
Critical Care Medicine
(2008) - et al.
Clinical and economic outcomes attributable to health care-associated sepsis and pneumonia
Archives of Internal Medicine
(2010) - et al.
Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units
Intensive Care Medicine
(2004)
The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study
Critical Care
Invasive meningococcal disease – improving management through structured review of cases in the Hunter New England area, Australia
Journal of Public Health
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