Update on antibiotics for ED pneumonia patients
New timeframe makes it easier for EDs to comply
If your ED has been struggling with The Joint Commission's requirement that antibiotics be given within four hours of presentation for patients diagnosed with community-acquired pneumonia (CAP), you now have some more breathing room. The standard has been changed to require antibiotic administration within six hours.
This change will make it easier for EDs to comply with the standard, and it also will be better for patients, says Victoria Leavitt, RN, CEN, BSN, MSN, regional nurse educator for emergency services for Federal Way, WA-based Franciscan Health System. "One of the problems that our three EDs faced was the rush to diagnosis," she says. "It is simply not feasible to accurately diagnose all patients within that timeframe, as well as hang the appropriate antibiotic."
Most EDs struggle to meet the four-hour timeframe, because the only other option was to use the antibiotic "shotgun" approach, says Leavitt. "This approach is in direct conflict with the call to decrease the number of antibiotics that are unnecessarily prescribed," she says.
The initial impression might be that the patient doesn't have pneumonia. However, later in the ED visit, the physician decides it could be, or is, pneumonia, and orders the antibiotics — which might be longer than four hours later, says Nina M. Fielden, MSN, RN, CEN, clinical nurse specialist for emergency and critical care services at Cleveland Clinic. Another problem is the attending physicians may decide that it is pneumonia and the patients need to be admitted, so they write orders for admission and intravenous antibiotics at the same time, she says.
"The chart goes to our secretary, and by the time the admission is arranged, the nurse then finds the antibiotic orders," says Fielden. "We've asked the docs to let the nurse know they are writing for antibiotics so they can get them started before the admission is arranged by the secretary."
The ED is trying a new process of having the radiologist call the physician when he or she finds an infiltrate, says Fielden. Chest X-rays and labs are initiated from triage if no room is available in the ED, so the X-ray results can come back while the patient still is in the lobby, she explains. "If the radiologist notifies us, we can move the patient back to the ED and start antibiotics."
For many years, Fielden posted the results of the ED's quality monitoring every quarter. "But we are doing so well now that we just review the delays with the nurse or physician," she says. "I have gotten to know the data abstracter very well, so I can question him about why a patient was considered a failure."
At CGH Medical Center in Sterling, IL, door-to-antibiotic time was reduced after the following changes were implemented:
- If a patient presents to triage with pneumonia-type symptoms, the nurse initiates the advanced triage protocols for CAP. (See the ED's protocol.)
- A blue card with a picture of lungs is placed on the front of the patient's chart to remind all staff and physicians that the clock is ticking for treatment for this patient.
- Radiology technicians are encouraged to notify the ED physician immediately if they notice markings in the chest film that might indicate the patient has pneumonia.
The physician knows to read that film right away and order an antibiotic if necessary, says Rhonda Miller, RN, MS, CEN, CCRN, TNS, education/quality improvement coordinator for the ED. "When the nurses see the lung card on the patient's chart, they also remind the physician that we may need to order an antibiotic immediately," Miller says.
Sources
For more information on treatment of community-acquired pneumonia in the ED, contact:
- Nina M. Fielden, MSN, RN, CEN, Clinical Nurse Specialist, Emergency & Critical Care Services, Cleveland Clinic, 9500 Euclid Ave., MS E19, Cleveland OH 44195. Phone: (216) 444-0153. Fax: (216) 444-9734. E-mail: [email protected].
- Victoria Leavitt, RN, CEN, BSN, MSN, Regional Nurse Educator, Emergency Services, Franciscan Health System, 11315 Bridgeport Way S.W., Lakewood, WA 98499. Phone: (253) 512-2864. E-mail: [email protected].
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