急诊脓毒症医嘱集设计与第二剂哌拉西林他唑巴坦给药延迟的关系。
Association between emergency department sepsis order set design and delay to second dose piperacillin-tazobactam administration.
机构信息
Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.
Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.
出版信息
Am J Emerg Med. 2023 May;67:41-47. doi: 10.1016/j.ajem.2023.01.057. Epub 2023 Feb 7.
BACKGROUND
Delay to first antibiotic dose in patients with sepsis has been associated with increased mortality. Second dose antibiotic delay has also been linked to worsened patient outcomes. Optimal methods to decrease second dose delay are currently unclear. The primary objective of this study was to evaluate the association between updating an emergency department (ED) sepsis order set design from one-time doses to scheduled antibiotic frequencies and delay to administration of second piperacillin-tazobactam dose.
METHODS
This retrospective cohort study was conducted at eleven hospitals in a large, integrated health system and included adult patients treated in the ED with at least one dose of piperacillin-tazobactam ordered through an ED sepsis order set over a two year period. Patients were excluded if they received less than two doses of piperacillin-tazobactam. Midway through the study period, the enterprise-wide ED sepsis order set was updated to include scheduled antibiotic frequencies. Two patient cohorts receiving piperacillin-tazobactam were compared: those in the year before the order set update and those in the year post-update. The primary outcome was major delay, defined as an administration delay >25% of the recommended dosing interval, which was evaluated with multivariable logistic regression and interrupted time series analysis.
RESULTS
3219 patients were included: 1222 in the pre-update group and 1997 in the post-update group. The proportion of patients who experienced major second dose delay was significantly lower in the post-update group (32.7% vs 25.6%, p < 0.01; adjusted OR 0.64, 95% CI 0.52 to 0.78). No between-group difference was detected in the slope of monthly major delay frequency, but there was a significant level change (post-update change -10%, 95% CI -17.9% to -1.9%).
CONCLUSIONS
Including scheduled antibiotic frequencies in ED sepsis order sets is a pragmatic mechanism to decrease delays in second antibiotic doses.
背景
脓毒症患者首次给予抗生素的时间延迟与死亡率增加有关。第二剂抗生素的延迟也与患者预后恶化有关。目前，减少第二剂延迟的最佳方法尚不清楚。本研究的主要目的是评估将急诊科（ED）脓毒症医嘱集设计从单次剂量更新为预定抗生素频率与哌拉西林他唑巴坦第二剂给药延迟之间的关系。
方法
这是一项在一个大型综合医疗系统的 11 家医院进行的回顾性队列研究，纳入了在 ED 接受至少一剂哌拉西林他唑巴坦治疗的成年患者，这些患者在两年期间通过 ED 脓毒症医嘱集进行了治疗。如果患者接受的哌拉西林他唑巴坦少于两剂，则将其排除在外。在研究期间的中途，整个企业范围的 ED 脓毒症医嘱集进行了更新，纳入了预定的抗生素频率。比较了接受哌拉西林他唑巴坦的两组患者：医嘱集更新前一年的患者和更新后一年的患者。主要结局是主要延迟，定义为给药延迟超过推荐给药间隔的 25%，采用多变量逻辑回归和中断时间序列分析进行评估。
结果
共纳入 3219 例患者：更新前组 1222 例，更新后组 1997 例。更新后组发生主要第二剂延迟的患者比例明显低于更新前组（32.7%比 25.6%，p < 0.01；调整后的 OR 0.64，95%CI 0.52 至 0.78）。两组间每月主要延迟频率的斜率无差异，但存在显著的水平变化（更新后变化-10%，95%CI-17.9%至-1.9%）。
结论
在 ED 脓毒症医嘱集中纳入预定抗生素频率是减少第二剂抗生素延迟的一种实用机制。
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