What is the term that describes a situation where a nurse intervenes and stops a potentially harmful medication order for a pregnant patient with a urinary tract infection (UTI) in the Emergency Department (ED)?

CUS Framework: Concern, Uncomfortable, Safety

This situation describes the CUS framework (Concern, Uncomfortable, Safety), which is a structured communication tool used in healthcare to escalate patient safety concerns when a team member identifies a potentially harmful situation.

Understanding the CUS Framework

The nurse's actions in this scenario demonstrate the three components of CUS:

• Concern: The nurse identified a potential safety issue—prescribing an antibiotic to a pregnant patient without verifying its safety for pregnancy 1
• Uncomfortable: The nurse expressed discomfort with proceeding without this verification, despite the provider's urgency 1
• Safety: The nurse explicitly invoked patient safety by stopping the order and revising the medication to ensure appropriate antimicrobial stewardship 1

Why This Matters in the ED Context

The nurse's intervention exemplifies critical antimicrobial stewardship principles in the Emergency Department, where rapid decision-making must be balanced with patient safety considerations, particularly for vulnerable populations like pregnant women 1.

Key Safety Considerations in Pregnancy UTI Management

• Certain antibiotics pose significant teratogenic risks during pregnancy, including sulfonamides and nitrofurantoin in the first trimester, which are associated with birth defects including anencephaly, heart defects, and orofacial clefts 2
• The American College of Obstetricians and Gynecologists recommends that sulfonamides and nitrofurantoin should only be prescribed in the first trimester when other antimicrobial therapies are deemed clinically inappropriate 2
• Untreated UTIs in pregnancy can lead to serious complications including pyelonephritis, preterm labor, low birth weight, and sepsis, making appropriate antibiotic selection critical 3, 4

ED-Specific Stewardship Challenges

The Emergency Department presents unique challenges for antimicrobial stewardship that make the nurse's intervention particularly important:

• High rates of ED overcrowding and rapid patient turnover create pressure for quick decision-making, often without consultation 1
• The initial antibiotic choice made in the ED significantly influences what therapy is continued in the inpatient setting, representing a critical opportunity for stewardship 1
• Medical liability concerns and requirements to satisfy quality measures have been shown to be associated with antibiotic overuse in the ED setting 1

Distinguishing CUS from Other Communication Tools

This is not the other options because:

• Call Out is used to communicate critical information during emergencies (e.g., "Blood pressure dropping!") rather than stopping an order 1
• Closed Loop Communication involves confirming receipt of information by repeating it back, which did not occur here 1
• SBAR (Situation, Background, Assessment, Recommendation) is a structured handoff tool for presenting patient information, not for stopping potentially harmful orders 1

Clinical Implications

The nurse's use of the CUS framework prevented a potentially inappropriate antibiotic prescription that could have resulted in adverse events, including allergic reactions or teratogenic effects, while also supporting broader antimicrobial stewardship goals 1.

• An estimated 142,500 ED visits annually are for adverse events associated with systemic antibiotics, with nearly 80% due to allergic reactions 1
• Reducing unnecessary or inappropriate antimicrobial use is imperative not only for decreasing antimicrobial resistance but also for individual patient safety 1
• The ED sits at the interface of inpatient and outpatient settings, making ED practitioners uniquely positioned to impact antimicrobial stewardship in both locations 1