Incorporation of Clinical Staff Pharmacists in the Emergency Department Sepsis Response at a Single Institution
Background: Sepsis is a medical emergency in which timely, appropriate antibiotic therapy improves patient outcomes. While the addition of emergency department (ED) pharmacists has been found to optimize timely antimicrobial therapy in patients with sepsis, the role of clinical staff pharmacists (CSPs) in the sepsis response has not been studied.
Methods: We implemented a process of incorporating CSPs in sepsis antimicrobial management in the ED. To evaluate the accuracy of antimicrobial selection by CSPs with a sepsis antibiotic algorithm and vancomycin dosing nomogram, a retrospective cohort study was conducted on patients with sepsis presenting to the ED from December 3, 2018 through March 31, 2020.
Results: Of the 157 sepsis alerts included in this study, CSPs correctly used the antibiotic selection algorithm in 154 (98%) instances and the vancomycin dosing nomogram in 147 (94%) instances.
Conclusions: A process incorporating CSPs into the ED sepsis response resulted in high rates of accuracy for antibiotic selection and vancomycin dosing.
Median time to antibiotic administration from the sepsis alert was 39 minutes—well within SSC recommendations (60 minutes).2 Previous internal analyses at Lexington VAHCS demonstrated the mean time to first dose of antibiotics in the ED has been 39 minutes since about 2015. Thus, this initiative did not necessarily make this process quicker; however it did remove 1 responsibility from LIPs so that they could focus their efforts on other components of sepsis management.
Further studies are needed to evaluate the effects of this initiative on other aspects of the sepsis bundle, such as volume of fluid administered and appropriateness of laboratory tests. It was noted that while the time to first-dose antibiotic administration was < 1 hour from order placement, the median time from ED presentation to antibiotic administration was 96 minutes. This suggests that another focus of the sepsis workgroup should be on speeding recognition of sepsis, triggering the sepsis alert even sooner, and evaluating the feasibility of storing first doses of antibiotics in the automatic dispensing cabinets in the ED.
Limitations
This descriptive study evaluating CSPs’ ability to accurately use the newly developed antibiotic selection algorithm and vancomycin dosing nomogram had no control group for outcome comparison. This study was not designed to evaluate clinical outcomes, such as mortality, so the impact of these interventions need to be further studied. In addition, as veterans receive most of their care at our facility, with their allergies and previous cultures readily available in our electronic health record, this process may not be feasible at other facilities where patients' care is divided among multiple facilities/systems.
Moreover, as the veteran population studied was predominately male patients aged > 60 years, implementation at other hospitals may require the dosing nomograms and treatment algorithms to be adapted for a broader population, such as children and pregnant women. In particular, the ISC chose to implement an algorithm that did not differentiate between suspected source of infections and included anti-Pseudomonal coverage in all regimens based on the most encountered diseases among our veteran population and our local antibiogram; implementation at other facilities would require a thoughtful evaluation of the most appropriate site-specific regimen. Finally, many of the CSPs at our facility are board certified and/or residency trained, so more staff development may be required prior to implementation at other facilities, depending on the experience and comfort level of the CSPs.
Strengths
This study describes an example of a protocolized and multidisciplinary approach to improve sepsis recognition and standardize the response, consistent with SSC guideline recommendations. To the best of our knowledge, this is the first study to demonstrate the incorporation of CSPs into the interdisciplinary sepsis response. This allows for CSPs to practice at the top of their license and contributes to their professional development. Although it was not formally assessed, anecdotally CSPs reported that this process presented a negligible addition to their workload (< 5 minutes was the most reported time requirement), and they expressed satisfaction with their involvement in the sepsis response. Overall, this presents a possible solution to improve the sepsis response in hospitals without a dedicated ED pharmacist.
Conclusions
This study describes the successful incorporation of CSPs into the sepsis response in the ED. As CSPs are more likely than ED pharmacists to be present at a facility, they are arguably an underused resource whose clinical skills can be used to optimize the treatment of patients with sepsis.
