Stewardship in the ER

In this video, Dr Nesrine Rizk discusses the difficulties involved in practising AMS in the ER and highlights how ASP programmes can be tailored for this environment.

She highlights the challenges in implementing ASP strategies in the Emergency Room due to certain factors (e.g. diagnostic uncertainty and limited patient information) which make it hard to limit the use of broad-spectrum antibiotics.

Effective stewardship approaches should be tailored to the Emergency Department Setting, due to unique challenges such as:

• Frequent interruptions

• The high volume of care

• Need for rapid decisions with limited information

• Variation in staff (over different shifts)

• Concerns with immediate patient satisfaction

The following implementations can be used to tailor ASP programmes for the ED setting:

• Addition of ED pharmacist

• Education

• Development of evidence-based guidelines/clinical pathways

• Clinical Decisions Support

• Development of Antimicrobial Order Forms

• Post-prescription review

• Introduction and use of rapid diagnostics (offer the ability to speed up the diagnostic process for infection)

• PCR – rapid identification of the organism

• Procalcitonin – quickly differentiate between bacterial and viral infections

Other interventions that should be considered are shortening the duration of therapy, dose optimisation, streamlining/de-escalation of therapy and developing ED-specific antibiograms.

It is also important to note that it might be appropriate to introduce disease-specific interventions. There are two types of infection that contribute to a large proportion of antimicrobial misuse in patients in the ED:

1. Urinary Tract Infections
2. Skin and soft tissue infections