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Stewardship in the ER

Watch the video where Dr Nesrine Rizk discusses antimicrobial stewardship in the ER, the associated challenges, and how to tailor ASP for the ER.
This section is about anti-microbial stewardship in the emergency room. As you’re aware, more than 20% to 50% of all antimicrobials prescribed are not necessary. And this contributes largely to the antimicrobial resistance we have been discussing. There are numerous strategies for encouraging appropriate antimicrobial use in the health care systems. And those are all supported by ASP programmes. There are challenges to the implementation of those ASP interventions in the emergency room. There are numerous strategies for encouraging appropriate antimicrobial reviews in the health care settings. However, many of those strategies commonly employed by ASPs around the world may be difficult to implement in the emergency department.
Because of diagnostic uncertainty and limited patient information, it may be difficult to limit the use of broad spectrum antimicrobials. Effective stewardship approaches should be tailored to the emergency department’s setting. Providers in these settings are faced with unique challenges to rational decision making, such as frequent interruptions, high volume care, and need for rapid decisions with limited information in addition to variation in staff over different shifts and concerns with immediate patient satisfaction. The American Academy of Emergency Physicians issued a call in 2013. It was a call to action on this issue. And it highlights that the ED is the interface between inpatient and outpatient settings. And because of this, ASP programmes tailored to the emergency departments are necessary.
Specific interventions for the implementation of ASP in the ED setting, several programmes or interventions that can be implemented to support antimicrobial stewardship in the emergency room start with the addition of an ED pharmacist, who will be uniquely positioned and trained to promote appropriate anti-microbial use in the emergency department.
A second very important point is education about the importance of antimicrobial stewardship and about specific ASP interventions at the institutional level, developing guidelines and clinical pathways based on evidence based guidelines or other sources and shared periodically with the ED staff, clinical decision support to utilise information technology to deliver actionable patient data to clinicians at the point of care, developing antimicrobial order forms that can be used by the ED physicians and other providers. Another important intervention is post-prescription review, as it involves following up on culture reports to ensure there is no bug-drug mismatch and that the narrowest and most appropriate antimicrobial is used for the patient’s infection.
Another very important tool or an example of an intervention at the level of the emergency department is the introduction and the use of rapid diagnostics that will allow in a very short period of time, the identification of organisms and will help the clinician make a decision, whether it’s, for example, the bacteria or a viral infection. Other interventions include shortening the duration of therapy. And this is based on numerous studies and a lot of evidence that shorter is better in the inpatient setting and the outpatient setting. Dose optimisation is crucial, especially in the clinical care of the critically ill patient where we mostly rely on extended infusions of beta-lactams, for example.
And those should be included in the emergency department with the help of a dedicated pharmacist. Streamlining or de-escalation of therapy is also a very important point that needs to be discussed. And education here is primordial to giving feedback and education to the physicians in the emergency department. Developing these specific antibiograms because those are going to be different than the inpatient antibiograms. The emergency department’s population is very different from the inpatient population. And developing antibiograms that are specific to the setting may help the clinicians and providers in the emergency department decide on the most appropriate antimicrobial to use for the patient population they serve. Next, we will be talking about disease specific interventions.
And we have identified over time, two types of infections that constitute or represent a large number of patients presenting to the emergency room and are areas where misuse and abuse of antibiotics occur. The first one are urinary tract infections or treatment with antibiotics for asymptomatic bacteria. Another example are skin and soft tissue infections where it’s been studied and noted that a lot of providers in the emergency department tend to use antibiotics for the treatment of gram positive and gram negative infections in such situations. The role of rapid diagnostic testing in the emergency room. Rapid diagnostic tests offer the ability to speed up the diagnostic process for infections and to assist with guiding antimicrobial selection and the length of therapy.
Two important examples are the PCR diagnostic test and the procalcitonin test. The PCR diagnostic tools will allow the rapid identification of organisms at the bedside or within a few hours. And therefore, replacing the need for cultures and cumbersome cultures that would take two to three days to get a result. How about procalcitonin in the emergency department? As a tool, procalcitonin is a test that has allowed physicians and providers in the emergency department and other outpatient settings to quickly make a differentiation between bacterial and viral infections and therefore have prevented the misuse and abuse of antibiotics for patients presenting with upper respiratory infections or even lower respiratory infections.

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
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