scholarly journals LO068: Physician adherence to Antimicrobial Guidelines for Community Acquired Pneumonia in the St. Michael’s Hospital Emergency Department

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S53-S54
Author(s):  
C.R. Atlin ◽  
M. McGowan ◽  
A. Toma
Keyword(s):  
Emergency Department ◽  
Retrospective Chart Review ◽  
Community Acquired Pneumonia ◽  
Low Risk ◽  
Antibiotic Prescribing ◽  
Local Health ◽  
Prescribing Practices ◽  
Amoxicillin Clavulanic Acid ◽  
Ed Visits ◽  
Physician Adherence

Introduction: The Toronto Central Local Health Integration Network released new antimicrobial guidelines for the treatment of community acquired pneumonia (CAP) in August 2013. These deemphasized antimicrobial coverage for atypical organisms and use amoxicillin-clavulanic acid (AMC) as first-line for low risk CAP. The purpose of this study was to assess physician adherence to these guidelines in St. Michael’s Hospital (SMH) Emergency Department (ED). Methods: A retrospective chart review was conducted from April 1 to May 31 in 2013, 2014 and 2015. All adult patients who were discharged home from the ED with a diagnosis of pneumonia were included. Severity of pneumonia was graded based on the CRB-65 score as per the CAP guidelines. Primary outcome was type of antibiotic prescribed by the ED physician. Data was analyzed using simple descriptive statistics. Results: There were a total of 141 patients analyzed during the study period (N=46 in 2013, N=59 in 2014, N=36 in 2015). Demographics and relevant comorbidities were similar across the years: age (2013: median=53 years, range 20-92 years; 2014: 56, 21-83; 2015: 54, 20-81); preexisting lung disease (30%, 27%, 25% respectively); HIV positive status (9%, 7%, 17%). CRB-65 score was: low risk (0 points)=70% in 2013, 66% in 2014, 75% in 2015; intermediate risk (1-2 points)=30%, 34%, 25%; high risk (3-4 points)=0% in all years. Percentage of patients discharged home with a documented prescription was 83%, 85%, and 94% respectively. In 2013, patients received azithromycin (AZM) (n=17, 43% of antibiotic prescriptions that year); levofloxacin (LVX) (n=10, 25%); AMC (n=5, 13%); clarithromycin (CLR) (n=5, 13%); trimethoprim-sulfamethoxazole (SXT) (n=2, 5%); doxycycline (DOX) (n=1, 3%). In 2014: AMC (n=26, 51%); AZM (n=12, 24%); LVX (n=9, 18%); CLR (n=2, 4%); DOX (n=1, 2%); erythromycin (ERY) (n=1, 2%). In 2015: AMC (n=17, 47%); AZM (n=12, 33%); LVX (n=4, 11%); CLR (n=1, 3%); SXT (n=1, 3%); DOX (n=1, 3%). Number of return ED visits within 2 weeks were: n=16 (35%); n=11 (19%); and n=10 (28%) respectively. Conclusion: The results of this study show that there has been a change in antibiotic prescribing practices in the SMH ED since dissemination of the CAP guidelines, with AMC accounting for nearly half of antibiotic prescriptions. Further antimicrobial stewardship efforts will focus on evaluating factors influencing prescribing practices.

Antibiotics Utilization for Community Acquired Pneumonia in a Community Hospital Emergency Department

2020 ◽  
pp. 089719002095303
Author(s):  
Jessica Yu ◽  
Gillian Wang ◽  
Ann Davidson ◽  
Ivy Chow ◽  
Ada Chiu
Keyword(s):  
Emergency Department ◽  
Community Hospital ◽  
Community Acquired Pneumonia ◽  
Antibiotic Usage ◽  
Prescribing Patterns ◽  
Local Health Authority ◽  
Antibiotic Prescribing ◽  
Local Health ◽  
Moderate Severity ◽  
Stewardship Program

Background: A local health authority in Canada implemented its own Antimicrobial Stewardship Program (ASP) which provide guidelines to clinicians to utilize when treating infectious diseases such as community-acquired pneumonia (CAP). Objectives: The primary objective is to describe antibiotic usage patterns at the community hospital’s emergency department (ED) and to analyze the patterns in relation to ASP goals of reducing risk of infections, adverse drug events and antibiotic resistance, and to identify potential areas of improvement. Methods: This retrospective chart review included 156 adult patients with a diagnosis of CAP admitted to a community hospital ED from December 1, 2015 to November 30, 2016. Results: 50.6% patients were prescribed moxifloxacin across all severity of CAP patients. Low and moderate severity CAP patients were most often prescribed antibiotic duration > 7 days. In low, moderate and high severity CAP patients who were treated using ceftriaxone, 100%, 88.9% and 66.6% patients were treated with ceftriaxone 2000 mg daily respectively. Conclusions: Antibiotic prescribing patterns suggest fluoroquinolones were frequently being over-prescribed, ceftriaxone dosages were often too high, and duration of antibiotics for low and moderate severity CAP were too long. More efforts are needed to promote appropriate antibiotic usage and optimize patient care.

scholarly journals Influenza With an Infiltrate: Investigating the New Community-Acquired Pneumonia Guidelines

2020 ◽  
Vol 41 (S1) ◽  
pp. s302-s302
Author(s):  
Amanda Barner ◽  
Lou Ann Bruno-Murtha
Keyword(s):  
Demographic Data ◽  
Retrospective Chart Review ◽  
Vaccination Rate ◽  
Community Acquired Pneumonia ◽  
Teaching Hospitals ◽  
Antibiotic Prescribing ◽  
Supporting Evidence ◽  
Radiographic Findings ◽  
Significant Difference ◽  
The Impact

Background: The Infectious Diseases Society of America released updated community-acquired pneumonia (CAP) guidelines in October 2019. One of the recommendations, with a low quality of supporting evidence, is the standard administration of antibiotics in adult patients with influenza and radiographic evidence of pneumonia. Procalcitonin (PCT) is not endorsed as a strategy to withhold antibiotic therapy, but it could be used to de-escalate appropriate patients after 48–72 hours. Radiographic findings are not indicative of the etiology of pneumonia. Prescribing antibiotics for all influenza-positive patients with an infiltrate has significant implications for stewardship. Therefore, we reviewed hospitalized, influenza-positive patients at our institution during the 2018–2019 season, and we sought to assess the impact of an abnormal chest x-ray (CXR) and PCT on antibiotic prescribing and outcomes. Methods: We conducted a retrospective chart review of all influenza-positive admissions at 2 urban, community-based, teaching hospitals. Demographic data, vaccination status, PCT levels, CXR findings, and treatment regimens were reviewed. The primary outcome was the difference in receipt of antibiotics between patients with a negative (<0.25 ng/mL) and positive PCT. Secondary outcomes included the impact of CXR result on antibiotic prescribing, duration, 30-day readmission, and 90-day mortality. Results: We reviewed the medical records of 117 patients; 43 (36.7%) received antibiotics. The vaccination rate was 36.7%. Also, 11% of patients required intensive care unit (ICU) admission and 84% received antibiotics. Moreover, 109 patients had a CXR: 61 (55.9%) were negative, 29 (26.6%) indeterminate, and 19 (17.4%) positive per radiologist interpretation. Patients with a positive PCT (OR, 12.7; 95% CI, 3.43–60.98; P < .0007) and an abnormal CXR (OR, 7.4; 95% CI, 2.9–20.1; P = .000003) were more likely to receive antibiotics. There was no significant difference in 30-day readmission (11.6% vs 13.5%; OR, 0.89; 95% CI, 0.21–3.08; P = 1) and 90-day mortality (11.6% vs 5.4%; OR, 2.37; 95% CI, 0.48–12.75; P = .28) between those that received antibiotics and those that did not, respectively. Furthermore, 30 patients (62.5%) with an abnormal CXR received antibiotics and 21 (43.7%) had negative PCT. There was no difference in 30-day readmission or 90-day mortality between those that did and did not receive antibiotics. Conclusions: Utilization of PCT allowed selective prescribing of antibiotics without impacting readmission or mortality. Antibiotics should be initiated for critically ill patients and based on clinical judgement, rather than for all influenza-positive patients with CXR abnormalities.Funding: NoneDisclosures: None

scholarly journals Demographic and Risk Factor Differences between Children with “One-Time” and “Repeat” Visits to the Emergency Department for Asthma

2021 ◽  
Vol 18 (2) ◽  
pp. 486
Author(s):  
Pavani Rangachari ◽  
Jie Chen ◽  
Nishtha Ahuja ◽  
Anjeli Patel ◽  
Renuka Mehta
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
Risk Factor ◽  
Childhood Asthma ◽  
Medical Center ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Primary Research ◽  
Ed Visits ◽  
The Individual

This retrospective study examines demographic and risk factor differences between children who visited the emergency department (ED) for asthma once (“one-time”) and more than once (“repeat”) over an 18-month period at an academic medical center. The purpose is to contribute to the literature on ED utilization for asthma and provide a foundation for future primary research on self-management effectiveness (SME) of childhood asthma. For the first round of analysis, an 18-month retrospective chart review was conducted on 252 children (0–17 years) who visited the ED for asthma in 2019–2020, to obtain data on demographics, risk factors, and ED visits for each child. Of these, 160 (63%) were “one-time” and 92 (37%) were “repeat” ED patients. Demographic and risk factor differences between “one-time” and “repeat” ED patients were assessed using contingency table and logistic regression analyses. A second round of analysis was conducted on patients in the age-group 8–17 years to match another retrospective asthma study recently completed in the outpatient clinics at the same (study) institution. The first-round analysis indicated that except age, none of the individual demographic or risk factors were statistically significant in predicting of “repeat” ED visits. More unequivocally, the second-round analysis revealed that none of the individual factors examined (including age, race, gender, insurance, and asthma severity, among others) were statistically significant in predicting “repeat” ED visits for childhood asthma. A key implication of the results therefore is that something other than the factors examined is driving “repeat” ED visits in children with asthma. In addition to contributing to the ED utilization literature, the results serve to corroborate findings from the recent outpatient study and bolster the impetus for future primary research on SME of childhood asthma.

Pharmacist-Driven Implementation of Outpatient Antibiotic Prescribing Algorithms Improves Guideline Adherence in the Emergency Department

2020 ◽  
pp. 089719002093097
Author(s):  
Kristin Stoll ◽  
Erik Feltz ◽  
Steven Ebert
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Guideline Adherence ◽  
Inappropriate Prescribing ◽  
Community Acquired Pneumonia ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Duration Of Therapy ◽  
Tract Infections ◽  
Selection Of

Background: Inappropriate prescribing of antibiotics has been identified as the most important modifiable risk factor for antimicrobial resistance. Objective: The purpose of this project was to improve guideline adherence and promote optimal use of outpatient antibiotics in the emergency department (ED). Methods: Prescribing algorithms for community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) were developed to integrate clinical practice guideline recommendations with local ED antibiogram data. Outcomes were evaluated through chart review of patients prescribed outpatient antibiotics by ED providers. The primary outcome was adherence to clinical practice guidelines, defined as the selection of an appropriate antibiotic agent, dose, and duration of therapy for each patient discharged. Results: When compared to patients discharged from the ED prior to algorithm implementation (N = 325), the post-implementation group (N = 353) received more antibiotic prescriptions that were completely guideline adherent (61.5% vs 11.7%, P < .00001). Post-implementation discharge orders demonstrated improvement in the selection of an appropriate agent (87.3% vs 45.5%, P < .00001), dose (91.5% vs 77.2%, P < .00001), and duration of therapy (71.1% vs 39.1%, P < .01). Additionally, fluoroquinolone prescribing rates were reduced (2.3% vs 12.3%, P < .00001). A reduction in all-cause 30-day returns to the ED or urgent care was observed (15.3% vs 21.5%, P = .036). Conclusion: Pharmacist-driven implementation of antibiotic prescribing algorithms improved guideline adherence in the outpatient treatment of CAP, SSTI, and UTI.

scholarly journals P083: Why do older adults in assisted living facilities use the emergency department: are all these visits necessary?

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S106-S106
Author(s):  
E. Losier ◽  
A. McCollum ◽  
P. Jarrett ◽  
R. McCloskey ◽  
P. Nicholson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Assisted Living ◽  
Demographic Data ◽  
Care Home ◽  
Functional Decline ◽  
Retrospective Chart Review ◽  
Community Services ◽  
Level 3 ◽  
Ed Visits ◽  
One Year

Introduction: Special Care Home (SCH) residents require supervision for activities of daily living but not regular nursing care. Emergency Department (ED) use by seniors in SCHs is poorly studied. A recent study in Nova Scotia found seniors represented over 20% of ED visits. We studied SCH resident ED visits in a community with a population of 30,000 aged over 65 years and with 785 SCH beds, to define reasons for ED visits to a tertiary ED, and if these could be avoided. Methods: We performed a retrospective chart review of SCH residents’ visits to an ED (SCH-ED) which has 56,000 total ED (TED) visits over one year. Reasons for visit, admission data, and avoidability were collected. A geriatrician and ED physician independently reviewed visits. Initial disagreement on avoidability (27%) was adjudicated through case discussion. Results: Demographic data revealed 344 ED visits by 111 SCH residents over one year; 37% of visits resulted in admission. 13.9% of residents visited the ED on at least one occasion (average 3.1 visits); mean age 78.4 years; female 66.7%; ambulance arrival 91.0%. The three most common chief complaints were shortness of breath, weakness and abdominal pain. Most SCH-ED visits were Canadian Triage and Acuity Scale (CTAS) Level 3 (63.4%, TED 53.3%). Of CTAS Level 3 visits, 35.3% were admitted (TED 12.9%). SCH-ED visits were avoidable in 40.6% of cases. Gastrointestinal (18%), pain (16.5%), falls, functional decline or injury (14%) and respiratory (12%) were the most common avoidable diagnostic groups, accounting for 57% of total SCH visits. Conclusion: ED visits by SCH residents demonstrated increased acuity and admission rates with a high number of repeat visits. Of all SCH-ED visits, 40% were potentially avoidable. Further study may determine if improved community services reduces ED visits or hospital admission. Gastrointestinal, respiratory, falls and pain diagnoses may be important areas of focus.

scholarly journals P003: Emergency department quality assurance sepsis project: why are more people dying in southwestern Ontario?

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S78
Author(s):  
A. Aguanno ◽  
K. Van Aarsen ◽  
M. Columbus
Keyword(s):  
Emergency Department ◽  
Septic Shock ◽  
Retrospective Chart Review ◽  
Initial Assessment ◽  
Standardized Mortality Ratio ◽  
Local Health ◽  
Sepsis Diagnosis ◽  
Mortality Ratio ◽  
Time To Antibiotics ◽  
Statistics Canada

Introduction: London Health Sciences Centre (LHSC) includes two academic, urban hospitals in London, Canada. The hospital-standardized mortality ratio (HSMR) is consistently higher than provincial and national averages. Unpublished data reveals that sepsis contributes the largest number of statistically unexpected deaths to LHSC’s HSMR calculation. Factors contributing to in-hospital sepsis mortality are hypothesized to include demography, emergency department (ED) flow or sepsis treatment. Methods: Retrospective chart review of patients aged &gt;=18 years, presenting to an LHSC ED between 01 Nov 2014 and 31 Oct 2015, with &gt;=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis (ICD-10 diagnostic codes A4xx and R65). Data were abstracted from electronic health records. Regional, provincial and national data was retrieved from CIHI and Statistics Canada. Results: Median age and sex in London and across Canada are similar (48.2 years vs 48.9 years; 48% male vs 49% male). Baseline prevalences of diabetes, hypertension, COPD and mood disorders were similar in the Local Health Integration Network and Ontario (6% vs 7%, 19% vs 19%, 3% vs 4%, and 10% vs 8%). Median “Physician Initial Assessment,” (PIA) times for sepsis patients at LHSC were faster than median Canadian PIA times for CTAS I and II patients (CTAS I: 7 min vs 11 min, CTAS II: 34 min vs 54 min), and slower for CTAS III-V patients (CTAS III: 98 min vs 79 min, CTAS IV: 99 min vs 66 min, CTAS V: 132 min vs 53 min). Median ED length of stay for admitted, high acuity (CTAS I-III) patients was 6 h at LHSC versus 10 h across Canada.Median [IQR] time to intravenous fluid resuscitation was 60.5 min [29.8-101.2] for septic shock patients and 77.0 min [36.0-127.0] for expired patients. Median [IQR] time to antibiotics was 130 min [73.0-229.0] for sepsis patients, 106 min [60.0-189.0] for severe sepsis patients, and 82 min [42.2-142] for septic shock patients. Conclusion: Excess sepsis-related mortality at LHSC is not convincingly related to patient demographics or ED flow. Gains may be made by improving time to antibiotics and IV fluids.

scholarly journals 2193. Factors Impacting the Duration of Antimicrobial Therapy for Community-Acquired Pneumonia

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S746-S747
Author(s):  
Avnish Sandhu ◽  
Erin Goldman ◽  
Jordan Polistico ◽  
Sarah Polistico ◽  
Ahmed Oudeif ◽  
...  
Keyword(s):  
Risk Factors ◽  
Medical Center ◽  
Clinical Signs ◽  
Retrospective Chart Review ◽  
Signs And Symptoms ◽  
Community Acquired Pneumonia ◽  
Prescribing Patterns ◽  
Antibiotic Prescribing ◽  
Factors Associated ◽  
Specific Risk

Abstract Background Pneumonia is a common cause of infection associated with hospitalization. Treatment durations for community-acquired pneumonia (CAP) often exceed guideline recommended durations of 5–7 days without a clear explanation. The objective of this study was to determine factors that may lead to durations exceeding this recommendation. Methods A retrospective chart review of 89 patients admitted to the Detroit Medical Center (DMC) for the treatment of pneumonia was conducted. Demographics, clinical signs and symptoms, antibiotic data, pneumonia severity score (CURB 65), risk factors for resistance, microbiology results, and outcomes were recorded and analyzed for factors associated with increased durations of antibiotics. Average durations of antibiotics and durations of antibiotics greater that 7 days were assessed for each risk factor. Results Average durations of antibiotics was 9 days (SD 3.8) for the cohort, and 55 (61%) received durations of > 7 days. Average durations of antibiotics for risk factors are shown in Table 1. Factors associated with durations of antibiotics longer than 7 days are shown in Table 2. There was a trend toward longer average durations of antibiotics for persons with risk factors for resistance [Drug Resistance in Pneumonia (DRIP) score ≥ 4 (increased duration of antibiotics by 1.7 days, P = 0.07] and those with a positive legionella antigen [increased durations of antibiotics by 6.6 days, P = 0.07]. Conclusion Specific risk factors could not be associated with increased durations of antibiotics, although there was a trend toward longer durations for persons with markers for resistance and positive legionella testing. Efforts to reduce durations of antibiotics must target global clinician antibiotic prescribing patterns and not specific risk factors. Disclosures All authors: No reported disclosures.

scholarly journals Patient Controlled Analgesia for Adults with Sickle Cell Disease Awaiting Admission from the Emergency Department

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
Josue Santos ◽  
Sasia Jones ◽  
Daniel Wakefield ◽  
James Grady ◽  
Biree Andemariam
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Treatment Algorithm ◽  
Retrospective Chart Review ◽  
Cell Disease ◽  
Patient Controlled Analgesia ◽  
Analgesic Treatment ◽  
Pain Scores ◽  
Ed Visits

Background.A treatment algorithm for sickle cell disease (SCD) pain in adults presenting to a single emergency department (ED) was developed prioritizing initiation of patient controlled analgesia (PCA) for patients awaiting hospitalization.Objectives.Evaluate the proportion of ED visits in which PCA was started in the ED.Methods.A two-year retrospective chart review of consecutive SCD pain ED visits was undertaken. Data abstracted included PCA initiation, low versus high utilizer status, pain scores, bolus opioid number, treatment times, and length of hospitalization.Results.258 visits resulted in hospitalization. PCA was initiated in 230 (89%) visits of which 157 (68%) were initiated in the ED. Time to PCA initiation was longer when PCA was begun after hospitalization versus in the ED (8.6 versus 4.5 hours,p<0.001). ED PCA initiation was associated with fewer opioid boluses following decision to admit and less time without analgesic treatment (allp<0.05). Mean pain intensity (MPI) reduction did not differ between groups. Among visits where PCA was begun in the ED, low utilizers demonstrated greater MPI reduction than high utilizers (2.8 versus 2.0,p=0.04).Conclusions.ED PCA initiation for SCD-related pain is possible and associated with more timely analgesic delivery.

scholarly journals Community acquired pneumonia (CAP): Epidemiology, clinical presentation, management and outcomes in infants and children presenting to Al Wakra Pediatric Emergency Department (PED)

2021 ◽  
Vol 2021 (2) ◽  
Author(s):  
Ibtihal S Abdelgadir ◽  
Haider Almawashi ◽  
Fawzia M Elgharbawy ◽  
Abdo M Alghazali ◽  
Kryzl D Ponce ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pediatric Intensive Care ◽  
Signs And Symptoms ◽  
Pediatric Emergency ◽  
Community Acquired Pneumonia ◽  
Infants And Children ◽  
Pediatric Emergency Department ◽  
Reactive Protein ◽  
Amoxicillin Clavulanic Acid ◽  
In Infants And Children

Background: Community acquired pneumonia (CAP) is defined clinically as the presence of signs and symptoms of pneumonia in a previously healthy child due to an infection that has been acquired outside the hospital. There is no previous data available from children in Qatar on CAP.Objectives: To evaluate the incidence, clinical features, management, outcomes and, complications in infants and children presenting to Al Wakra Hospital, Qatar with CAP. Methods: This is a prospective, observational, non-interventional study that assessed all children aged 3 months to 14 years, during a period of 12 months, from November 2017 to November 2018. Results: The incidence of CAP was found to be 2.8 per 1000 of all patients presenting to Al Wakra Pediatric Emergency Department Qatar (328 of 116,761patients). The majority of cases were children 1-5 years (58.2%). Fifty-one percent and 61.3% of children admitted to inpatient wards had dyspnoea and tachypnea respectively. This is to be compared to 88.5% and 96.2% of patients respectively admitted to the Pediatric Intensive Care Unit (PICU) with dyspnoea and with tachypnea. C-reactive protein (CRP) more than 50 mg/L was noted in 48.2% of patients admitted to inpatient wards and 26.7% of patients admitted to PICU. Oral amoxicillin was prescribed for 1.5% of patients, amoxicillin/clavulanic acid for 18% of patients, a further 18% had cefuroxime, and 29% had clarithromycin. Intravenous (IV) cefuroxime was the most used IV medication (29.6% of all patients). Nearly 50% of patients were admitted to inpatient wards, with 7.9% transferred to PICU, and only 39.3% discharged home without admission. Conclusion: Community acquired pneumonia represents 0.28% of all studied patients. More than 60% of the patients with CAP were admitted either to inpatient wards or to PICU.

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