Impact of 1-hour and 3-hour sepsis time bundles on antibiotic use in emergency departments in Queensland, Australia: a before-and-after cohort study

Abstract

Objective: To determine if the introduction of an emergency department (ED) sepsis screening tool and management bundle affects antibiotic prescribing and use.

Design: Multicentre, cohort, before-and-after study design.

Setting: Three tertiary hospitals in Queensland, Australia (median bed size 543, range 520-742).

Participants: Adult patients, presenting to the ED with symptoms and signs suggestive of sepsis who had blood cultures collected. These participants were further assessed and stratified as having septic shock, sepsis or infection alone, using Sepsis-3 definitions. The study dates were 1 July 2017-31 March 2020.

Intervention: The breakthrough series collaborative 'Could this be Sepsis?' Programme, aimed at embedding a sepsis screening tool and treatment bundle with weighted-incidence syndromic combined antibiogram-derived antibiotic guidelines in EDs.

Main outcome measures: The primary outcome was the rate of empirical prescriptions adherent to antibiotic guidelines during the ED encounter. Secondary outcomes included the empirical prescriptions considered appropriate, effective antibiotics administered within 3 hours and assessment of harm measures.

Results: Of 2591 eligible patients, 721 were randomly selected: 241 in the baseline phase and 480 in the post-intervention phase. The rates of guideline adherence were 54.0% and 59.5%, respectively (adjusted OR (aOR) 1.41 (95% CI 1.00, 1.98)). As compared with baseline, there was an increase in the rates of appropriate antibiotic prescription after bundle implementation (69.9% vs 57.1%, aOR 1.92 (95% CI 1.37, 2.68)). There were no differences between the baseline and post-intervention groups with respect to time to effective antibiotics, adverse effects or ED rates of broad-spectrum antibiotic use.

Conclusion and relevance: The use of an ED sepsis screening tool and management bundle was associated with an improvement in the rates of appropriate antibiotic prescription without evidence of adverse effects.

Keywords: accident & emergency medicine; adverse events; infectious diseases; microbiology; protocols & guidelines; quality in health care.

Figure 1

Control chart: number of ED patients prescribed broad-spectrum^a antibiotics per 1000 ED presentations. ^aCeftriaxone, amoxicillin–clavulanate, piperacillin–tazobactam, cefepime and meropenem. Site 1 and Site 2: study sites using electronic medication dispensing services (Pyxis) linked to a hospital-based corporate information system to allow determination of number of patients prescribed broad-spectrum antibiotics in the ED. Vertical line corresponds to date of pathway implementation at each study site. The upper control limit and lower control limit are CL±3√CL. CL, control limit; ED, emergency department.