ED Pharmacists Improve Antibiotic Redosing

Under ideal conditions, patients receiving a first dose of antibiotics in the emergency department because of serious infection would be transferred to an inpatient bed before subsequent doses are due. However, when hospitals experience overcrowding, patients can be kept in the ED for many hours until a bed is available.

Study authors noted that previous research on this practice, known as "boarding," linked the resulting delays in antibiotic redosing with increased mortality, the need for mechanical ventilation and longer hospital stays.

Delays in antibiotic redosing can be especially risky for patients with sepsis, a life-threatening complication triggered by infection.

"One often-quoted metric is that for septic patients, every hour that goes by without a first dose of antibiotics results in a 10% increase in mortality," said Ethan Smith, PharmD, pharmacy program coordinator for antimicrobial stewardship and co-author of the study. "There isn't as much data on subsequent dosing, but it's clear that making sure these patients get antibiotic doses on time is critical."

Beginning in November 2019, Cedars-Sinai authorized pharmacists to directly order subsequent antibiotic doses for up to 24 hours after an initial order was placed for high-risk adult patients in the emergency department, rather than requesting them through the patient's physician. These included patients with a diagnosis of sepsis or pneumonia; an abnormal chest X-ray; or temperature, blood pressure, heart rate, white blood cell count, or respiration rate within a certain range.

To make their findings, researchers compared data on 117 of these patients admitted from November 2019 to March 2020 with data on 64 patients admitted for pneumonia or sepsis from November 2018 to November 2019. They tracked major redosing delays—defined as 90 minutes for medications with six-hour dosing intervals, two hours for those with eight-hour intervals and three hours for medications with 12-hour intervals—and infection-related deaths.

Among patients in the group admitted before the change in practice, 48% experienced delays in antibiotic redosing, compared with just 13% in the group admitted after the practice was changed. Researchers noted that 11% of patients in the pre-intervention group died in the hospital due to their infections, versus 3% in the post-intervention group, possibly because continuity of ED patient care improved. These results were statistically significant.

"Sepsis can cause multiple organ systems to fail, so time is crucial for these patients," said James Gilmore, PharmD, pharmacy manager responsible for critical care and the emergency department and a senior author of the study. "They could be headed toward intensive care unit admission or could end up on a ventilator or requiring dialysis. With timely recognition and if management in the ED is perfect, part of that being we stay on top of antibiotic dosing, we have a chance to avoid that."

The change in practice also improved workflow for the ED staff, with emergency physicians and nurses freed from the task of redosing antibiotics and able to focus on other tasks.

“We are pleased that our ED pharmacists are making a significant difference in reducing mortality in patients with sepsis and pneumonia,” said Rita Shane, PharmD, vice president of Pharmacy Services and chief pharmacy officer.

Study limitations included the fact that inclusion criteria were broader for the intervention group than for the control group and that the data came from just one medical center.

“We’ve known for a very long time that early antibiotics for patients with serious infections have significant impact on outcomes and knew that proper redosing of antibiotics was important to ensure rapid resolution of infections," said Sam Torbati, MD, medical director of the Ruth and Harry Roman Emergency Department of Cedars-Sinai, and a senior author of the study. "But we didn’t anticipate such a vigorous impact on mortality. This study demonstrated the great value of dedicated pharmacy support for oversight of the medication needs of the very complex patients cared for in our emergency department.”