The Impact of Emergency Department Crowding Measures on Time to Antibiotics for Patients With Community-Acquired Pneumonia

Introduction: We examined our local sepsis patient population, and specifically our most vulnerable patients - those presenting to the emergency department (ED) in septic shock - for variables predictive of survival to hospital discharge. We applied the familiar ED paradigm of, “Door to,” to calculate the impact of time to antibiotics against patient survival to hospital discharge. Methods: Retrospective chart review of patients aged > = 18 years, presenting to tertiary care ED between 01 Nov 2014 and 31 Oct 2015. Patients determined to have sepsis if A) > = 2 SIRS criteria and ED suspicion of infection (ED acquisition of blood/urine cultures or antibiotic administration) and/or B) received ED or Hospital discharge diagnosis of sepsis (ICD-10 diagnostic codes A4xx and R65). Patients sub-classified with septic shock if A) triage SBP < = 90mmHg, B) triage MAP < = 65mmHg or C) serum lactate > = 4mmol/L. “Door Time” was defined as the earliest time recorded for the patient encounter, either the time the patient registered in the Emergency Department, or the triage time. A generalized linear model was performed with a binomial distribution using survival to discharge as the response variable. Age, sex, ED arrival method, time to antibiotics, ED serum lactate and ED serum glucose level were the predictor variables. Results: 13506 patient encounters met inclusion criteria (10980 unique patients). Linear regression of time to antibiotics against survival to hospital discharge failed to achieve statistical significance. Linear regression of the secondary outcome variables achieved statistical significance for age and serum lactate level. Per the model, as age increased by 1 year, the odds of dying prior to hospital discharge increased by 3.8% and as serum lactate increased by 1 mmol/L, odds of dying prior to hospital discharge increased by 11.1%. Conclusion: We found no association between time to antibiotic treatment and mortality. Causal relationships require randomized controlled trials, and this analysis contributes to clinical equipoise.

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Type of facility influences lengths of stay of children presenting to high volume emergency departments

BMC Pediatrics ◽

10.1186/s12887-020-02400-6 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Rhonda J. Rosychuk ◽

Brian H. Rowe

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Emergency Departments ◽

High Volume ◽

Population Based ◽

Initial Assessment ◽

Teaching Hospitals ◽

Emergency Department Crowding ◽

Academic Teaching ◽

The Impact

Abstract Background Emergency department crowding may impact patient and provider outcomes. We describe emergency department crowding metrics based on presentations by children to different categories of high volume emergency departments in Alberta, Canada. Methods This population-based retrospective study extracted all presentations made by children (age < 18 years) during April 2010 to March 2015 to 15 high volume emergency departments: five regional, eight urban, and two academic/teaching. Time to physician initial assessment, and length of stay for discharges and admissions were calculated based on the start of presentation and emergency department facility. Multiple metrics, including the medians for hourly, facility-specific time to physician initial assessment and length of stay were obtained. Results About half (51.2%) of the 1,124,119 presentations were made to the two academic/teaching emergency departments. Males presented more than females (53.6% vs 46.4%) and the median age was 5 years. Pediatric presentations to the three categories of emergency departments had mostly similar characteristics; however, urban and academic/teaching emergency departments had more severe triage scores and academic/teaching emergency departments had higher admissions. Across all emergency departments, the medians of the metrics for time to physician initial assessment, length of stay for discharges and for admission were 1h11min, 2h21min, and 6h29min, respectively. Generally, regional hospitals had shorter times than urban and academic/teaching hospitals. Conclusions Pediatric presentations to high volume emergency departments in this province suggest similar delays to see providers; however, length of stay for discharges and admissions were shorter in regional emergency departments. Crowding is more common in urban and especially academic emergency departments and the impact of crowding on patient outcomes requires further study.

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The impact of emergency department crowding on outcomes, other aspects should not be ignored

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2017.07.010 ◽

2017 ◽

Vol 35 (10) ◽

pp. 1561-1562

Author(s):

Xianshi Zhou ◽

Zhongde Zhang ◽

Jun Li ◽

Ye Ye ◽

Guanghua Tang ◽

...

Keyword(s):

Emergency Department ◽

Emergency Department Crowding ◽

The Impact

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The impact of ﬁrst Timing of antibiotics for community acquired pneumonia in emergency department

10.22514/sv.2020.16.0107 ◽

2020 ◽

Keyword(s):

Emergency Department ◽

Antibiotic Treatment ◽

Relevant Literature ◽

Severity Of Illness ◽

Clinical Situation ◽

Community Acquired Pneumonia ◽

Antibiotic Administration ◽

Eligibility Criteria ◽

Antibiotic Overuse ◽

The Impact

Background and objective: For patients with community-acquired pneumonia (CAP), reported associations between timing of the first dose of antibiotics and short-term mortality are inconsistent. To reduce the risks of antibiotic overuse in the emergency department, this summary of the relevant literature identified patients with CAP who benefit most from early antibiotic administration. Methods: A PubMed and Google Scholar search was performed for articles concerning the epidemiology, prognosis, diagnosis, and preliminary management of CAP. Results: Duplicate studies were eliminated and 370 citations were screened. Finally, 16 studies met the eligibility criteria. The review found that, in the presence of sepsis, antibiotics should not be delayed but administered as soon as possible. For patients with moderate-to-severe symptoms, antibiotics should be administered if a diagnosis of CAP is highly likely. For stable, non-critically ill patients with CAP, the timing of antibiotics remains unclear, but available evidence does not indicate strict requirements. For best quality of care, antibiotic timing whether rapid or delayed depends on the clinical situation. Conclusions: In suspected cases of pneumonia presenting in the emergency department, starting antibiotics early solely to conform to dogmatic guidelines within a rigid timeframe has led to unnecessary antibiotic treatment of uninfected patients, while the outcomes of patients with pneumonia have not improved. Since severity of illness is the key factor associated with poor outcomes in pneumonia, the timing of initial antibiotic treatment should be guided by the severity of symptoms.

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10 The Impact of Triage-Leveling in an Environment of Emergency Department Crowding

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2014.07.035 ◽

2014 ◽

Vol 64 (4) ◽

pp. S4-S5

Author(s):

M. Hocker ◽

C. Gerardo ◽

J. Broder ◽

H. Sanddesara ◽

R. Donohoe ◽

...

Keyword(s):

Emergency Department ◽

Emergency Department Crowding ◽

The Impact

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Dosing of Appropriate Antibiotics and Time to Administration of First Doses in the Pediatric Emergency Department

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-20.4.309 ◽

2015 ◽

Vol 20 (4) ◽

pp. 309-315

Author(s):

Abby M. Bailey ◽

Maria Stephan ◽

Kyle A. Weant ◽

Stephanie Baker Justice

Keyword(s):

Emergency Department ◽

Complex Disease ◽

Pediatric Emergency ◽

Turnover Time ◽

Community Acquired Pneumonia ◽

Disease States ◽

Complicated Skin ◽

Timely Fashion ◽

The Impact ◽

Selection Of

OBJECTIVES: Emergency department (ED) providers are faced with the challenge of diagnosing and treating patients in a timely fashion given many obstacles including limited patient information, complex disease states, and high patient turnover. Time delays in administration or selection of appropriate drug therapies have been associated with negative outcomes in severe infections. This study was conducted to assess the impact of an emergency medicine pharmacist (EPh) on the selection of appropriate antibiotics and the timeliness of administration in pediatric patients in the ED. METHODS: Patients younger than 18 years were evaluated who were admitted through the ED and received 1 dose of intravenous antibiotic for the following conditions: community-acquired pneumonia, complicated skin and soft tissue infection (SSTI), meningitis, and sepsis. To evaluate the impact of the presence of an EPh, patients with orders placed during the EPh's hours of 1 pm and 11 pm were compared to those with an order placed between 11 pm and 1 pm. RESULTS: A total of 142 patients were included in the study. Patients seen during EPh hours received an appropriate first antibiotic 93.4% of the time (p = 0.157) and second antibiotic 96.8% of the time (p = 0.023). Time from order to verification was significantly shorter for the first 2 antimicrobials in the EPh group (10.5 minutes [p = 0.003] and 11.4 minutes [p = 0.047], respectively). The days from discharge to return to readmission to the ED were also significantly different (17.5 days vs. 62.4 days, p = 0.008). CONCLUSIONS: The available data suggest that patients are more likely to receive appropriate doses of antimicrobials, and in a more timely fashion, whenever the EPh is present. Areas for future investigation include whether the presence of EPhs at the bedside has the potential to impact areas of patient care, including readmission rates, drug costs, and medication errors.

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