Association between emergency department sepsis order set design and delay to second dose piperacillin-tazobactam administration.

BACKGROUND: Delay to first antibiotic dose in patients with sepsis has been associated with increased mortality. Second dose antibiotic delay has also been linked to worsened patient outcomes. Optimal methods to decrease second dose delay are currently unclear. The primary objective of this study was to evaluate the association between updating an emergency department (ED) sepsis order set design from one-time doses to scheduled antibiotic frequencies and delay to administration of second piperacillin-tazobactam dose. METHODS: This retrospective cohort study was conducted at eleven hospitals in a large, integrated health system and included adult patients treated in the ED with at least one dose of piperacillin-tazobactam ordered through an ED sepsis order set over a two year period. Patients were excluded if they received less than two doses of piperacillin-tazobactam. Midway through the study period, the enterprise-wide ED sepsis order set was updated to include scheduled antibiotic frequencies. Two patient cohorts receiving piperacillin-tazobactam were compared: those in the year before the order set update and those in the year post-update. The primary outcome was major delay, defined as an administration delay >25% of the recommended dosing interval, which was evaluated with multivariable logistic regression and interrupted time series analysis. RESULTS: 3219 patients were included: 1222 in the pre-update group and 1997 in the post-update group. The proportion of patients who experienced major second dose delay was significantly lower in the post-update group (32.7% vs 25.6%, p < 0.01; adjusted OR 0.64, 95% CI 0.52 to 0.78). No between-group difference was detected in the slope of monthly major delay frequency, but there was a significant level change (post-update change -10%, 95% CI -17.9% to -1.9%). CONCLUSIONS: Including scheduled antibiotic frequencies in ED sepsis order sets is a pragmatic mechanism to decrease delays in second antibiotic doses.

Understanding Factors Associated with Quality of Life in Patients with Venous Thromboembolism.

INTRODUCTION: Quality of life (QoL) deficits have been noted among patients with venous thromboembolism (VTE) but understanding of the drivers of that poorer QoL is limited. The objective of this study was to examine associations between a variety of factors and QoL in patients with VTE. METHODS: Adult patients who had experienced at least one VTE episode within the past 2 years completed an online survey between May and July 2016 with responses to a variety of questions designed to ascertain QoL scores, Optum Short Form-12, and potential factors associated with these scores. RESULTS: Most of the 907 patients were female (56.7%) and Caucasian (88.6%). Physical and mental QoL scores below the general population average were present in 76.0 and 56.7% of patients, respectively. Multiple regression modeling revealed several factors associated with below average physical QoL scores including unemployment (odds ratio [OR] 3.77, 95% confidence interval [CI] 1.76-8.05), gastrointestinal bleeding (OR 2.54, 95% CI 1.28-5.01), high depression scores (OR 4.02, 95% CI 1.88-8.58), or difficulty accessing VTE care (OR 4.24, 95% CI 1.77-10.17). Factors associated with below average mental QoL scores included experiencing VTE within the last month (OR 3.85, 95% CI 1.58-9.41), unemployment (OR 2.83, 95% CI 1.30-6.16), or high depression (OR 3.85, 95% CI 1.60-9.28) and/or anxiety (OR 9.17, 95% CI 4.81-17.47) scores. CONCLUSION: Most patients with recently diagnosed VTE reported below average QoL. Many of the factors associated with below average QoL are modifiable, indicating that patients with VTE could potentially benefit from interventions aimed at improving QoL.

Impact of an Antimicrobial Stewardship Bundle for Uncomplicated Gram-Negative Bacteremia.

BACKGROUND: Recent studies in gram-negative bacteremia (GNB) suggest that intravenous (IV) to oral (PO) switch and short treatment durations yield similar clinical outcomes and fewer adverse events. Antimicrobial stewardship program (ASP) bundled initiatives have been associated with improved clinical outcomes for bloodstream infections. METHODS: This single-center retrospective cohort evaluation included inpatient adults from 11/2014-10/2015 and 10/2017-9/2018 with GNB. The pre-ASP period was before the establishment of an ASP program. In the post period, the ASP promoted IV-to-PO switches, avoidance of repeat blood cultures, and short treatment durations for patients with uncomplicated GNB. The primary outcome was duration of antibiotic therapy. Secondary outcomes included process measures associated with the bundle and clinical outcomes. RESULTS: One hundred thirty-seven patients met criteria for inclusion, with 51 patients in the pre group and 86 patients in the post group. Background characteristics were similar between groups. The median duration of therapy (interquartile range) was 14 (10-16) days in the pre group and 10 days (7-14) in the post group (P < .001). The median day of IV-to-PO switch was day 5 (4-6) in the pre group vs day 4 (3-5) in the post group (P = .046). The average total hospital cost per case decreased by 27% in the post group (P = .19). Mortality rates and bacteremia recurrence were not significantly different between groups. CONCLUSIONS: An ASP bundle for uncomplicated GNB was associated with reduced durations of therapy and earlier PO switch. These findings highlight the synergistic role of ASPs in optimizing antibiotic use and promoting patient safety.