An automated dispensing system for improving medication timing in the emergency department

doi:10.5847/wjem.j.issn.1920-8642.2012.02.004

Abstract

Abstract:

BACKGROUND: Numerous medical conditions require timely medication administration in the emergency department (ED). Automated dispensing systems (ADSs) store premixed common doses at the point-of-care to minimize time to administration, but the use of such automation to improved time to medication administration has not been studied. Since vancomycin is a commonly used empiric antimicrobial, we sought to quantify the effect of using an ADS on time to drug delivery in patients presenting to the ED. The study aimed to determine the efficacy of utilizing an ADS to improve time to administration of vancomycin and determine any negative effects on dosing appropriateness.

METHODS: The institional review board approved the retrospective quality improvement study took place in a single, urban academic tertiary care ED with an annual census of 80 000. Study subjects were all patients receiving vancomycin for the management of sepsis between March 1 to September 30, 2008 and the same time period in 2009. The primary outcome was the proportion of patients who received vancomycin within one hour of bed placement and the secondary outcome was dosing appropriateness.

RESULTS: Sixty-three patients had weight and dosing information available (29 before and 34 after intervention) and were included in the study. Before intervention, no patient received vancomycin in less than 60 minutes, while after intervention 14.7% of the patients received it in less than 60 minutes (difference in proportions 14.7%, 95% CI 0.39%-30.0%, P=0.04). A similar proportion of the patients received correct dosing before and after intervention (44.8% vs. 41.2%, difference in proportions 3.7%, 95% CI -20.0%-26.7%, P=0.770).

CONCLUSION: The use of an ADS may improve the timing of medication administration in patients presenting to the ED without affecting dosing appropriateness.

Key words: Automatic dispensing system, Pharmaceutical, Process improvement, Efficiency

Michael J. Ward, Jeremy S. Boyd, Nicole J. Harger, John M. Deledda, Carol L. Smith, Susan M. Walker, Jeffrey D. Hice, Kimberly W. Hart, Christopher J. Lindsell, Stewart W. Wright. An automated dispensing system for improving medication timing in the emergency department[J]. World Journal of Emergency Medicine, 2012, 3(2): 102-107.

Figures/Tables 4

Figure 1.

Table 1

Table 2

Table 3

References 19

1	Fonarow GC, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Grau-Sepulveda MV. et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation 2011; 123:750-758. doi: 10.1161/CIRCULATIONAHA.110.974675 pmid: 21311083
2	Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S. et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1589-1596. pmid: 16625125
3	Lambert L, Brown K, Segal E, Brophy J, Rodes-Cabau J, Bogaty P. Association between timeliness of reperfusion therapy and clinical outcomes in ST-elevation myocardial infarction. JAMA 2010; 303:2148-55. doi: 10.1001/jama.2010.712 pmid: 20516415
4	Services CfMaM. Overview of specifications of measures displayed on hospital compare https://www.cms.gov/HospitalQualityInits/downloads/HospitalOverviewOfSpecs200512.pdfhttps://www.cms.gov/HospitalQualityInits/downloads/HospitalOverviewOfSpecs200512.pdf.
5	Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF. et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010; 38:1045-1053. doi: 10.1097/CCM.0b013e3181cc4824 pmid: 20048677
6	Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R. et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296-327. doi: 10.1097/01.CCM.0000298158.12101.41 pmid: 18158437
7	Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B. et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-1377. doi: 10.1056/NEJMoa010307 pmid: 11794169
8	Morrell M, Fraser VJ, Kollef MH. Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality. Antimicrob Agents Chemother 2005; 49:3640-3645. doi: 10.1128/AAC.49.9.3640-3645.2005 pmid: 16127033
9	Puskarich MA, Trzeciak S, Shapiro NI, Arnold RC, Horton JM, Studnek JR. et al. Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Crit Care Med 2011 May 12 .
10	10 Campaign SS. Timing to Antibiotics. 2010 [cited 2010 9/23]Available from: http://www.survivingsepsis.org/Bundles/Individual_Changes/Pages/improve_antibiotic_time.aspx. doi: 10.1093/aje/kwq112 pmid: 20562190
11	De Miguel-Yanes JM, Munoz-Gonzalez J, Andueza-Lillo JA, Moyano-Villaseca B, Gonzalez-Ramallo VJ, Bustamante-Fermosel A. Implementation of a bundle of actions to improve adherence to the Surviving Sepsis Campaign guidelines at the ED. Am J Emerg Med 2009; 27:668-674. doi: 10.1016/j.ajem.2008.05.010 pmid: 19751623
12	Ferrer R, Artigas A, Levy MM, Blanco J, Gonzalez-Diaz G, Garnacho-Montero J. et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 2008; 299:2294-303. doi: 10.1001/jama.299.19.2294 pmid: 18492971
13	Gao F, Melody T, Daniels DF, Giles S, Fox S. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care 2005; 9:R764-770. doi: 10.1186/cc3909 pmid: 16356225
14	Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J. et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010; 38:367-374. doi: 10.1097/CCM.0b013e3181cb0cdc pmid: 20035219
15	Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR. et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 2007; 35:1105-1112. doi: 10.1097/01.CCM.0000259463.33848.3D pmid: 17334251
16	Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration--2008. Am J Health Syst Pharm 2009; 66:926-946. doi: 10.2146/ajhp080715 pmid: 19420311
17	Wright SW, Trott A, Lindsell CJ, Smith C, Gibler WB. Evidence-based emergency medicine. Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report. Ann Emerg Med 2008; 51:80-86, 6 e1-8. doi: 10.1016/j.annemergmed.2007.04.009 pmid: 17719134
18	18 Mikkelsen ME, Gaieski DF, Goyal M, Miltiades AN, Munson JC, Pines JM. et al. Factors associated with nonadherence to early goal-directed therapy in the ED. Chest. [Research Support, N.I.H., Extramural]. 2010; 138:551-558.
19	Ward MJ DJ, Smith CL, Hart KW, Lindsell CJ, Gibler WB, Wright SW. Implementation of Early Goal-Directed Therapy: Which Components Are Not Performed? Ann Emerg Med 2010; 56:S58-59.

Variables	Before (n=29)		After (n=34)
Age	65	37.0-90.0	59	38.0-86.0
Weight (kg)	79.2	47.3-182.3	74.4	50.0-168.2
Race
White	15	51.7%	16	47.1%
Non-white	14	48.3%	17	50.0%
Not documented	0	0.0%	1	29.0%
Sex
Male	14	48.3%	17	50.0%
Female	15	51.7%	17	50.0%
Admitted	29	100.0%	34	100.0%
Medicare, Medicaid, or others	23	85.2%	18	58.1%
Acuity level
1	2	6.9%	2	0.1%
2	17	58.6%	20	58.8%
3	6	20.7%	6	17.6%
Not documented	4	13.8%	6	17.6%
Central line in ED	21	72.4%	23	67.6%
Peripheral line prior to ED	5	17.2%	7	20.6%
Early goal directed therapy (EGDT) met	9	31.0%	3	8.8%
Death during admission	8	27.6%	12	35.3%

Variables	Before			After		Difference (%)	95% CI (%)	P value
Variables	n		%	n	%	Difference (%)	95% CI (%)	P value
Bed to vancomycin administration
60 mins or less	0	0.0		5	14.7	14.7	0.39-30.0	0.040
Over 60 mins	29	100.0		29	85.3
Correct vancomycin dose
Correct	13	44.8		14	41.2	3.7	-20.0-26.7	0.770
Incorrect	16	55.2		20	58.8
Reason incorrect
Under	15	93.8		16	80.0	13.8	-11.4-35.9	0.477
Over	1	6.3		4	20.0
Vancomycin received in ED
ED	25	86.2		30	88.2	2.0	-15.0-22.4	0.810
Other	4	13.8		4	11.8

Bed to vancomycin administration	Time period
Bed to vancomycin administration	Before (n/%)	After (n/%)
60 minutes or less	0/0.0	5/16.7
61 minutes thru 120 minutes	6/24.0	4/13.3
121 minutes thru 180 minutes	9/36.0	12/40.0
Over 180 minutes	10/40.0	9/30.0