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A Quality Improvement Initiative to Decrease Time to Antibiotics for Children with Intestinal Failure, Fever, and a
Selena Hariharan1,2, Ethan A Mezoff3, Christopher E Dandoy2,4
1Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Insights
Improving antibiotic timing for pediatric intestinal failure (IF) patients in the emergency department (ED) significantly reduced sepsis treatment delays. This process adaptation enhanced patient care for a high-risk group.
Area of Science:
- Pediatric critical care
- Healthcare process improvement
- Infectious disease management
Background:
- Pediatric intestinal failure (IF) patients face high morbidity, particularly sepsis from central line-associated bloodstream infections.
- Adult sepsis research links time to antibiotic administration (TTA) with mortality.
- Adapting a successful febrile immunocompromised pediatric oncology protocol for IF patients in the emergency department (ED) was explored.
Purpose of the Study:
- To adapt and implement a process improvement model for timely antibiotic administration in febrile pediatric intestinal failure (IF) patients.
- To increase the percentage of IF patients receiving antibiotics within 60 minutes of ED arrival from 46% to a target of 90%.
Main Methods:
- A multidisciplinary team utilized the Model for Improvement framework.
- Key drivers included pre- and postarrival processes, staff/family engagement, and a focus on failure analysis.
- Plan-Do-Study-Act cycles targeted family engagement, prearrival efficiency, and postarrival consistency.
Main Results:
- Evaluated 276 encounters of febrile IF patients from November 2012 to March 2017.
- Achieved a sustained reduction in median time from arrival to antibiotic administration (TTA), decreasing from 71 to 45 minutes.
- Reduced TTA to under 60 minutes for 77% of evaluated febrile IF patients.
Conclusions:
- Process improvement principles are transferable between high-risk pediatric populations.
- Adaptations are necessary to account for the unique characteristics of different patient groups.
- This study demonstrates successful translation of a sepsis management protocol to pediatric IF patients.
Introduction:
Pediatric intestinal failure (IF) patients experience significant morbidity, including sepsis related to central line-associated bloodstream infections. Adult studies of sepsis demonstrate an association between time to antibiotic administration (TTA) and mortality. To overcome challenges in treating pediatric IF patients in an emergency department (ED), we appropriated an existing, reliable system for febrile immunocompromised oncology/bone marrow transplant children. We describe the translation of this process to febrile IF patients in the ED and steps toward sustained improvement.
Methods:
We formed a multidisciplinary team and used the Model for Improvement to define aims and identify key drivers. The goal was to use an existing improvement process to increase the percentage of patients with IF who receive antibiotics within 60 minutes of arrival to the ED from 46% to 90%. Key drivers included pre- and postarrival processes, staff and family engagement, and a preoccupation with failure. We performed Plan-Do-Study-Act cycles targeting family engagement, prearrival efficiency, and postarrival consistency.
Results:
Two hundred seventy-six encounters involving febrile IF patients between November 2012 and March 2017 were evaluated. There was a sustained reduction in the median time from arrival to antibiotic administration (71-45 minutes). We decreased TTA to less than 60 minutes for 77% of febrile IF patients.
Conclusions:
The basic tenets of process improvement for 1 high-risk population can be translated to another high-risk population but must be adjusted for variability in characteristics.
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