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									           Are Patients Who Are Diagnosed With “Potentially Serious Infections”
             Getting Their First Dose Of IV Antibiotic At The Correct Time?
                             Miss Nira Dass, The Trust, Edmonton

Introduction
Many aspects need to be considered when prescribing an antibiotic for an infection. ‘Rational
antibiotic prescribing’, not only includes choice of antibiotic but also prompt administration of the
first dose of the antibiotic5. This is a crucial aspect, and it can possibly impact the length of stay at
hospital, the mortality and morbidity of the patient5.
Acute Bacterial meningitis is a life threatening condition. A study showed that a delay of greater
then 6 hours was alone associated with mortality. It was portrayed that the benefit of initiating
antibiotic treatment overwhelmingly outweighed the risk of not treating4.
Community-Acquired Pneumonia (CAP) is another condition were timing has great value. Antibiotic
treatment should be started immediately in suspected patients. Survival rate actually increased
when the first dose of intravenous (IV) antibiotic was given before the patient arrived at hospital6.
Sepsis is another, frequently seen in hospitals. The Surviving Sepsis Campaign Guidelines for
severe sepsis and septic shock recommends the treatment should be initiated as quickly as
possible, and within one hour of diagnosis of the condition1. They identify that the greatest
improvements can perhaps be made in non-ICU settings.
Therefore, one could argue that why can’t the time of first dose antibiotic administration of all
patients presenting with a “potentially severe infection” be standardized across all wards to ensure
equal care.  

Aim, Objective(s) and Standard
The aim was to assess whether patients diagnosed with a “potentially serious infection” are getting
their first dose of Intravenous antibiotic(s) within a set time period.

Objectives:
       1. Assess if patients are appropriately prescribed IV antibiotics, hence for a “potentially
           severe infection”
       2. Check if the patient has been put on the correct IV antibiotic regimen and dose for the
           indication stated.
       3. Ascertain when the a).Infection is diagnosed by the doctor.
                               b). Prescription is written.
                               c). Drug is administered to the patient.
       4. Calculate if patients on IV antibiotics are given their antibiotics in accordance to the
           standard set -measured by calculating the time difference between the:

           -   time the patient was diagnosed with the infection
           -   time the 1st dose of IV antibiotic(s) was administered.

Standard: All Patients diagnosed with a “potentially serious infection” should receive their first dose
of IV antibiotic regimen within 1 hour of diagnosis. (Based on the standard for severe sepsis and
septic shock for ICU at the Trust). N.B “potentially severe infection” as indicated by the Trust
policy.

Method
A half-day pilot was undertaken involving one acute admission ward. The actual audit (with a few
modifications from the pilot) was carried out on three random days on 3 acute admission wards. A
“Data collection sheet” was compiled and the following details were recorded using various
sources:
   • Patients name
   • Name and dosage of IV antibiotic
   • Indication for treatment
   • Any drug allergies
   • Date & Time of 1).Diagnosis 2).When the 1st dose was given
   •   Whether time of prescribing was noted
   •   Whether a stat dose was given.

It could then be determined whether the: dosage regimen was correct? IV antibiotic was prescribed
for a “potentially severe infection”? (Set with reference to the Trust Antibiotic guidelines, 2008) and
whether the standard set was met?


Results & Discussion
In total, 113 patients’ drug charts were analysed. A total of 26 IV antibiotics formed part of the audit
for analysis.
42% met the standard and 58% of IV antibiotics prescribed for a “potentially serious infection” were
not given within one hour of diagnosis (See figure 1).

Figure 1




The mean time between patient diagnosis and administration of the first dose was 2hrs and
22mins. Large variations between the time difference across the antibiotics analysed were found.
The percentage delay of antibiotics where the time between diagnosis and administration was
greater then 5hours were approximately 12% (See Figure 2).

Figure 2




The indication for all antibiotics were analysed and they all were deemed suitable and followed the
Trust antibiotic policy. In some cases were a stat dose was written by the doctor there was still a
delay in administration by the nurses.
The upmost reason for delay was that a stat dose was not written up, hence the patient got their
first dose of antibiotic at the time circled on the drug chart. Additionally, despite many antibiotics
being stock items, a delay in administration was still observed. There were also occasions where
diagnosis was made in A&E but drug administration was delayed to when the patient was
transferred to the acute admission ward.

Recommendations
   Administration of the 1st dose of IV antibiotic by the prescriber at point of prescribing for serious
   infections (as a stat dose).
   Provide training for doctors/nurses on the importance of prompt administration of the first dose.
   Action guidelines for administration of the 1st dose of IV antibiotics specific to the acute
   admission wards.
   Wards technicians to top up on all acute admission wards
   Revise stock list regularly in line with changes in prescribing.
   Conduct the audit over a longer time (one-two months) to obtain a larger representative
   sample.
   Obtain the time of arrival to A&E- so the overall delay in initiation of therapy can be calculated.
   Further audits: Investigating reasons for the delay in administering IV antibiotics.

References
1.Dellinger,R.P.et al.(2008),Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock, Available from:
http://www.survivingsepsis.org/system/files/images/2008_Guidelines_Final_.pdf,[Accessed: 08
March 2009].

2.”Trust” Guidelines:Antibiotic Guidelines for adults 2008

3. “Trust” Guidelines:Sepsis care bundle 2008

4.Proulx, N.,Fréchette, D., Toye, B., Chan, J. and Kravcik, S. (2005), Delays in the
administration of antibiotics are associated with mortality from adult acute bacterial
meningitis, Vol. 98(4), Available from:
http://qjmed.oxfordjournals.org/cgi/content/abstract/98/4/291,[Accessed: 08 March 2009].

5.Vogtlander,N.P.J.et al. (2004), Improving the Process of Antibiotic Therapy in Daily
Practice, Vol. 164, Available from: http://archinte.ama-assn.org/cgi/reprint/164/11/1206.pdf,
[Accessed: 08 March 2009].

6.WeMeReC Bulletin (1999), Welsh medicines resource centre canolfan adnoddau moddion
cymru, Vol. 6(4), Available from: http://www.ukmi.nhs.uk/NewMaterial/html/docs/22119903.pdf,
[Accessed: 08 March 2009].

								
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