Evaluation of First-Dose, Intravenous Push Penicillins and Carbapenems in the Emergency Department.

BACKGROUND: Early appropriate antibiotic administration is associated with improved outcomes in infectious illnesses. During drug shortages in 2017, the American Society of Health-System Pharmacists recommended intravenous push (IVP) administration of medications when possible to conserve small-volume parenteral solutions. Data supporting IVP penicillins and carbapenems was limited. OBJECTIVE: The primary objective of this study compared time from patient emergency department (ED) arrival to antibiotic administration between IVP and intravenous piggy-back (IVPB) administration. METHODS: This single-center pre-post protocol study assessed changes in administration timing and safety of ampicillin/sulbactam, piperacillin/tazobactam, and ertapenem from 2015-2018. Medication administration by IVPB (pre) or IVP (post), ED arrival, antibiotic order and administration times, potential effectors of administration time, and safety events were assessed. Acquisition costs were estimated. RESULTS: A total of 696 administrations were included, with 351 and 345 subjects in the IVPB and IVP cohorts, respectively. The median time from ED arrival to initiation of antibiotic administration was 140 (IQR 87-221) minutes and 110 (IQR 68-181) minutes in the IVPB and IVP cohorts, respectively, (P < 0.01). IVP administration increased the proportion of indexed antibiotics administered within 60 minutes of ED arrival compared to IVPB (20% vs. 12%, respectively, P < 0.01). There was no difference in adverse events between both cohorts. Supply acquisition cost savings totaled an more than $5,000 with the IVP protocol. CONCLUSION: IVP administration of ampicillin/sulbactam, piperacillin/tazobactam, and ertapenem improved times to initiation of empiric, first-dose antibiotics in the ED without an increase in adverse events, saving over $5,000 annually.

Intravenous Push Cephalosporin Antibiotics in the Emergency Department: A Practice Improvement Project.

Delays in administration of appropriate antibiotics to patients with septic shock are associated with increased mortality. To improve the care of patients with sepsis within our 73-bed emergency department (ED), a "first-dose" intravenous push (IVP) cephalosporin antibiotic protocol was initiated. This project was aimed at improving the time from provider order of antibiotic to administration, which follows the Sepsis Core Measure of timely antibiotic administration.This was a single-center, retrospective analysis of a practice improvement study. Time from provider order of an IV cephalosporin antibiotic to administration was compared between postprotocol dates of March to May 2016 (n = 1110) and preprotocol dates of November 2015 to January 2016 (n = 1146). The cost of supplies for IVP was compared with traditional infusion. Prior to implementation of the IVP protocol, ED nursing staff completed a survey of administration preferences and then received one-on-one instruction about the protocol from the clinical nurse specialist and clinical nurse educator. In addition, a tip sheet was developed and IVP kits complete with all needed supplies were made available in the automated medication dispensing system.Median time from IV cephalosporin antibiotic order to administration significantly decreased by 8, 12, 14, and 13 min for ceftriaxone, ceftazidime, cefepime, and cefazolin, respectively (p < 0.007 for all). This was true for all indications of antibiotic use. Nursing staff favored IVP administration over traditional IV infusion (87%). Supply cost to administer IVP antibiotics was $0.83 compared with $9.53 for traditional IV infusion.A "first-dose IVP" protocol decreased time to administration by eliminating the need for procurement of an infusion pump, setup, and documentation of a secondary infusion. It was also preferred by ED nursing staff and associated with cost savings.

Improved Administration of Antibiotics in the Emergency Department: A Practice Improvement Project.

PROBLEM: Although consensus exists among experts that early intravenous antibiotic therapy has an impact on patient mortality, the medical literature includes little information about ensuring that the patient receives the complete dose. At our emergency department, it had become standard clinical practice to administer antibiotics with primary pump tubing and an infusion pump. Clinical pharmacy staff identified this practice as a cause for concern, because at least 20 mL (up to 40%) of the dose volume remains in the tubing. This practice improvement project was aimed at improving the administration of antibiotics by programming a secondary infusion to ensure the complete dose would be administered. METHODS: A multidisciplinary educational intervention was initiated consisting of one-on-one instruction with each emergency nurse (n = 103) at the department's annual Skills Sessions, distribution of educational tip sheets, and reinforcement of the proper procedure at the patient's bedside. Emergency nurses were educated via simulation regarding correct secondary pump programming, using smart pump technology. RESULTS: Surveys indicated that 8% of emergency nurses used secondary tubing along with a smart pump to administer antibiotics before the intervention, compared with 96% after the intervention (P < .0001). IMPLICATIONS FOR PRACTICE: This project demonstrates that our educational intervention improved awareness of the need to administer the entire antibiotic dose and adherence to the use of secondary tubing along with smart pump technology to administer antibiotics.