#81 – Making the Right Choice Easy: Antimicrobial Stewardship in the Emergency Department
Jun 16, 2023
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Experts in antimicrobial stewardship in the emergency department, Zack Nelson, Alison Dittmer, and Michael Pulia discuss communication considerations, role of lipoglycopeptides, and common stewardship interventions. They also highlight the value of having a pharmacist in the ED for antimicrobial stewardship, preferred medications in the ED, and the importance of drug choice and antimicrobial stewardship.
Collaborative practice agreements and involving pharmacists are crucial for supporting decision-making and appropriate antimicrobial use in the emergency department (ED).
Culture follow-up programs and long-acting antimicrobial agents like Davivance and Ariativance can effectively reduce hospital admissions and costs in the ED.
Order sets play a vital role in promoting standardization and efficiency in antimicrobial prescribing for infections in the ED, although regular reviews and updates are necessary to ensure accuracy and alignment with guidelines.
Deep dives
Optimizing antimicrobial stewardship in the emergency department
In this podcast episode, the panelists discuss the importance of antimicrobial stewardship in the emergency department (ED). They highlight that up to 50% of all healthcare in the United States occurs in the ED, making it a crucial space for implementing stewardship initiatives. The panelists note that the ED presents unique challenges, such as diagnostic uncertainty and time pressures, requiring tailored stewardship strategies. They emphasize the importance of collaborative practice agreements with pharmacists and other healthcare professionals to support decision-making and ensure appropriate antimicrobial use. The panelists also discuss the use of culture follow-up programs and long-acting antimicrobial agents, like Davivance and Ariativance, in the ED. They highlight the benefits of these interventions in reducing hospital admissions and costs. However, they note the need for institutional buy-in, patient education, and clear communication to optimize the use of these agents. The discussion concludes with considerations for alerting providers about long-acting agents and the importance of order sets in promoting standardization and efficiency in antimicrobial prescribing.
Developing effective order sets for antimicrobial prescribing
The panelists discuss the role of order sets in antimicrobial prescribing. They highlight the value of order sets in organizing the diagnostic and treatment approach to infection, as well as streamlining prescribing practices. The panelists share their experiences with developing comprehensive order sets tailored to the emergency department (ED) setting. They emphasize the importance of incorporating discharge prescriptions into the order sets to facilitate efficient prescribing and ensure appropriate follow-up care. The panelists acknowledge the challenge of keeping order sets up to date and recommend regular reviews and updates to maintain accuracy and alignment with current guidelines and evidence-based practices.
Optimizing antibiotic redosing and ordering in borders
The panelists discuss strategies for optimizing antibiotic redosing and ordering in borders, particularly in the context of increasing prevalence. They highlight the need for efforts to improve care for patients who frequently cross borders and encounter challenges in accessing appropriate antibiotic treatment. The panelists acknowledge that there is no perfect solution but suggest making efforts to address the issue. They emphasize the importance of collaboration among healthcare professionals, including pharmacists and infectious disease specialists, to develop protocols and guidelines for antibiotic redosing and ordering. The panelists also stress the need for ongoing education and training to promote awareness and adherence to best practices in antimicrobial prescribing for patients in border regions.
Key takeaways for optimizing antimicrobial stewardship in the ED
The panelists provide key takeaways for optimizing antimicrobial stewardship in the emergency department (ED). They highlight the importance of collaborative practice agreements, involving pharmacists and other healthcare professionals, to support decision-making and ensure appropriate antimicrobial use. The panelists underscore the value of culture follow-up programs and long-acting antimicrobial agents in reducing hospital admissions and costs. They emphasize the need for institutional buy-in, patient education, and clear communication to optimize the use of these interventions. The panelists stress the importance of order sets in promoting standardization and efficiency in antimicrobial prescribing, while also acknowledging the challenge of keeping them up to date. Finally, the panelists discuss strategies for optimizing antibiotic redosing and ordering in borders, emphasizing the need for collaboration, protocols, and ongoing education to improve care for patients in border regions.
The Importance of Ongoing Doses in the Emergency Department
Providing ongoing doses of medications, particularly time-sensitive ones, in the emergency department (ED) for patients who are boarding is crucial. This ensures that patients receive continuous care and medication while waiting for admission. Collaborating with nursing partners and hospital medicine teams is essential to guarantee that orders are released promptly. Additionally, there is a discussion around the concept of ordering multiple doses in the ED, with considerations for certain populations where it may be appropriate and others where it may not be.
Overcoming Resource Limitations in Antimicrobial Stewardship
Resource limitations can impact antimicrobial stewardship efforts in the ED. In such situations, it is important to prioritize ease of ordering the right medication through guidelines, order sets, and applications while making it more challenging to order the wrong medication. Automated dispensing cabinets should contain first-line medications, and medications that are not appropriate should not be available. The crucial role of ED pharmacists in antimicrobial stewardship is emphasized, and if possible, coverage during busy hours or periods is recommended to ensure there is some level of coverage. Moreover, empowering nurses in stewardship activities, such as accurate allergy assessments and proper administration of antibiotics, can significantly contribute to successful stewardship initiatives.
Drs. Zack Nelson (@zacroBID), Alison Dittmer, and Michael Pulia (@DrMichaelPulia) join Dr. Jillian Hayes (@thejillianhayes) to discuss the ins and outs of antimicrobial stewardship in one of the busiest parts of the hospital: the emergency department! Tune in for a discussion on communication considerations in the ED, the role of lipoglycopeptides for common gram-positive syndromes, and a rapid-fire round discussing common stewardship interventions. This podcast was supported by an educational grant from Melinta Therapeutics.
References:
Pulia M, et al. Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin N Am 2018;36(4):853-872. doi: 10.1016/j.emc.2018.06.012. PMID: 30297009.
Rech, Megan A et al. “PHarmacist Avoidance or Reductions in Medical Costs in Patients Presenting the EMergency Department: PHARM-EM Study.” Critical Care Explorations 2021;3(4):e0406. doi:10.1097/CCE.0000000000000406. PMID: 33912836.
Sacdal JPA, Cheon E et al. Oritavancin versus oral antibiotics for treatment of skin and skin structure infections in the emergency department. Am J Emerg Med 2022;60:223-224.
Jenkins TC, Jaukoos JS et al. Patterns of use and perceptions of an institution-specific antibiotic stewardship application among emergency department and urgent care clinicians. Infection Control and Hospital Epidemiology 2020;41:212-215.
Dretske D, Schulz L, Werner E, Sharp B, Pulia M. Effectiveness of oritavancin for management of skin and soft tissue infections in the emergency department: A case series. The American Journal of Emergency Medicine 2021;43:77-80. doi: 10.1016/j.ajem.2021.01.050. PMID: 33545550.
Paul M, Pulia M, Pulcini C. Antibiotic stewardship in the emergency department: not to be overlooked. Clin Microbiol Infect 2021;27(2):172-174. doi: 10.1016/j.cmi.2020.11.015. PMID: 33253938.
Baxa J, McCreary E, Schulz L, Pulia M. Finding the niche: An interprofessional approach to defining oritavancin use criteria in the emergency department. Am J Emerg Med. 2020;38(2):321-324. doi:10.1016/j.ajem.2019.158442.
Pulia MS, Hesse S, Schwei RJ, Schulz LT, Sethi A, Hamedani A. Inappropriate Antibiotic Prescribing for Respiratory Conditions Does Not Improve Press Ganey® Patient Satisfaction Scores in the Emergency Department. Open Forum Infect Dis 2020;7(6): ofaa214. doi:10.1093/ofid/ofaa214.
Pulia MS, Lindenauer PK. Annals for Hospitalists Inpatient Notes - A Critical Look at Procalcitonin Testing in Pneumonia. Ann Intern Med. 2021;174(6):HO2-HO3. doi:10.7326/M21-1913.
Redwood R, Knobloch MJ, Pellegrini DC, Ziegler MJ, Pulia M, Safdar N. Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrob Resist Infect Control. 2018;7. doi:10.1186/s13756-017-0278-9.
Pulia MS, Schwei RJ, Hesse SP, Werner NE. Characterizing barriers to antibiotic stewardship for skin and soft-tissue infections in the emergency department using a systems engineering framework. Antimicrob Steward Healthc Epidemiol. 2022;2(1):e180. doi:10.1017/ash.2022.316.
May L, Gudger G, Armstrong P, et al. Multisite exploration of clinical decision making for antibiotic use by emergency medicine providers using quantitative and qualitative methods. Infect Control Hosp Epidemiol. 2014;35(9):1114-1125. doi:10.1086/677637.
May L, Cosgrove S, L’archeveque M, et al. A Call to Action for Antimicrobial Stewardship in the Emergency Department: Approaches and Strategies. Ann Emerg Med 2013;62(1):69-77.e2. doi: 10.1016/j.annemergmed.2012.09.002. PMID: 23122955.
Schoffelen T, Schouten JA, Hoogerwerf JJ, et al. Quality indicators for appropriate antimicrobial therapy in the emergency department: a pragmatic Delphi procedure. Clin Microbiol Infect 2021;27(2):210-214. doi: 10.1016/j.cmi.2020.10.027. PMID: 33144204.
Yadav K, Stahmer A, Mistry RD, May L. An Implementation Science Approach to Antibiotic Stewardship in Emergency Departments and Urgent Care Centers. Academic Emergency Medicine 2020; 27(1):31-42. doi: 10.1111/acem.13873. PMID: 31625653.
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