Do you delay antibiotics? Patients may be put at risk

The diagnosis of meningitis was clear: The one-month-old infant showed classic signs and symptoms. A lumbar puncture was ordered, but antibiotics weren’t given until several hours later, and the child suffered severe brain damage. The result of the ensuing malpractice lawsuit: A $1 million settlement.

The sooner antibiotics can be given to patients with conditions such as meningitis, fever in neutropenia, and fever in neonates, the better, stresses Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS, clinical educator for the ED at Children’s Memorial Hospital in Chicago. "I would not want to defend delayed antibiotic administration in a courtroom case involving a patient who is neurologically devastated or dead," she says.

Rapid treatment of bacterial meningitis can prevent potential complications including seizures, neurologic damage, hearing loss, vision loss, learning disabilities, or paralysis, says Marianne Hatfield, RN, system director of emergency services at Children’s Healthcare of Atlanta. "A bacterial infection of the central nervous system can lead to septic shock and death," she says.

Overcrowded EDs and long wait times increase risks for patients and emergency nurses, adds Steve Rasmussen, RN, CEN, clinical coordinator for the ED at Virginia Commonwealth University in Richmond. "With increased holding times in the EDs across the country, rapid recognition and administration of antibiotic therapy, along with sequential antibiotic dosing and serial labs and blood levels, is of greater nursing concern," he says.

To decrease delays in antibiotic administration, take these steps:

• Use standing orders at triage.

At Children’s Healthcare of Atlanta, a nurse-initiated neonatal fever protocol is used for infants with suspected meningitis ages 28 days or fewer, with a rectal temperature of 38° C or higher, a history of fever at home of 38° C or higher, stable vital signs, and no respiratory distress. If the patient meets the above criteria:

• The nurse obtains a full set of vital signs.

• He or she places the patient on a cardiac monitor.

• The nurse applies topical anesthetic to prepare for a lumbar puncture.

• He or she performs a urinary catheterization and sends the specimen for urinalysis and culture.

• The nurse inserts a peripheral intravenous line and draws blood for a complete blood count with differential and blood cultures.

• He or she sets up a lumbar puncture tray.

• Cerebral spinal fluid is carried by hand to the lab for stat results, and the ED physician writes orders for antibiotics, which are given immediately.

• The infant is closely monitored for signs of septic shock including fever, tachypnea, tachycardia, decreased blood pressure, rashes, lethargy, irritability, decreased level of consciousness, and signs of dehydration.

The protocol speeds the diagnosis and administration of antibiotics, because the nurse doesn’t need to wait for a physician to write all of the orders for procedures and tests, Hatfield explains.

"We estimate that this protocol can save as much as 30-45 minutes in expediting treatment for these infants," she says. "We also have a protocol for antibiotic treatment for sickle cell patients presenting with fever."

• Have nurses administer antibiotics.

At Children’s Memorial, nurses have ready access to multiple parenteral antibiotics via an automated medication dispenser, and they mix and administer the drugs themselves, says Steinmann. Most ED situations are considered to be exempt from the "first-dose rule" of the Joint Commission on Accreditation of Healthcare Organizations. That rule requires the initial dose of any medication to be verified by pharmacy but the ED is exempt because there is 24-hour oversight of all patients by attending physicians, she explains.

The advantage is that antibiotics are not delayed waiting for pharmacy to verify dosages, Steinmann explains. "I have worked in EDs where all intravenous antibiotics have to be ordered from the pharmacy, and I have seen antibiotic administration delayed for over an hour despite numerous phone calls attempting to procure the needed drug," she says.

But immediate availability comes at a cost to ED nurses, says Steinmann. "This places a tremendous responsibility on the nursing staff to confirm patient allergies, confirm that the appropriate medication and dosage has been ordered for the child, confirm that the appropriate antibiotic is dispensed, and correctly calculate and administer the appropriate dose," she says.

Double-checking with a second nurse is advised to decrease the potential for errors, says Steinmann. "We use pre-printed flow sheets for many diagnoses that list the most commonly prescribed antibiotics and the appropriate dosages, usual doses in kilograms, how to reconstitute them, and the timeframe for how rapidly the medication should be infused," she says. Lists are constantly revised as new antibiotics are added to the formulary to reflect current best practices for ordering practices.

Ideally, ED nurses should have access to a limited number of pre-packaged standard doses of intravenous antibiotics to treat emergent infectious diseases, says Steinmann. "Unfortunately, this only works for adults who generally receive a standard dose, not for children, since their dose is based on kilograms of body weight," she notes.

Sources

For more information on decreasing delays of antibiotic administration in the ED, contact:

  • Marianne Hatfield, RN, System Director of Emergency Services, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Road NE, Atlanta, GA 30342. Telephone: (404) 785-4968. E-mail: marianne.hatfield@choa.org.
  • Steve Rasmussen, RN, CEN, Clinical Coordinator, Emergency Department, Virginia Commonwealth University Medical Center, 401 N. 12th St., Richmond, VA 23298. Telephone: (804) 828-7330. E-mail: srasmussen@mcvh-vcu.edu.
  • Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS, Clinical Educator, Emergency Department, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614. Telephone: (773) 975-8764. E-mail: rsteinmann@childrensmemorial.org.