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.