Sustained reductions in time to antibiotic delivery in febrile immunocompromised children: results of a quality improvement collaborative.
BACKGROUND
Timely delivery of antibiotics to febrile immunocompromised (F&I) paediatric patients in the emergency department (ED) and outpatient clinic reduces morbidity and mortality.


OBJECTIVE
The aim of this quality improvement initiative was to increase the percentage of F&I patients who received antibiotics within goal in the clinic and ED from 25% to 90%.


METHODS
Using the Model of Improvement, we performed Plan-Do-Study-Act cycles to design, test and implement high-reliability interventions to decrease time to antibiotics. Pre-arrival interventions were tested and implemented, followed by post-arrival interventions in the ED. Many processes were spread successfully to the outpatient clinic. The Chronic Care Model was used, in addition to active family engagement, to inform and improve processes.


RESULTS
The study period was from January 2010 to January 2015. Pre-arrival planning improved our F&I time to antibiotics in the ED from 137 to 88 min. This was sustained until October 2012, when further interventions including a pre-arrival huddle decreased the median time to <50 min. Implementation of the various processes to the clinic delivery system increased the mean percentage of patients receiving antibiotics within 60 min to >90%. In September 2014, we implemented a rapid response team to improve reliable venous access in the ED, which increased our mean percentage of patients receiving timely antibiotics to its highest rate (95%).


CONCLUSIONS
This stepwise approach with pre-arrival planning using the Chronic Care Model, followed by standardisation of processes, created a sustainable improvement of timely antibiotic delivery in F&I patients.
Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Christopher E
http://orcid.org/0000-0002-4001-9203
CE
Dandoy
Emergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Selena
S
Hariharan
Division of Oncology, Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Brian
B
Weiss
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Kathy
K
Demmel
Emergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Nathan
N
Timm
Emergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Janis
J
Chiarenzelli
Emergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Mary Katherine
MK
Dewald
Emergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Stephanie
S
Kennebeck
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Shawna
S
Langworthy
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Jennifer
J
Pomales
Vascular Access Team, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Sylvia
S
Rineair
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Erin
E
Sandfoss
Emergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Pamela
P
Volz-Noe
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Rajaram
R
Nagarajan
Emergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Evaline
E
Alessandrini
D000293:Adolescent; D000553:Ambulatory Care / Q000592:standards* / Q000639:trends; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000592:standards* / Q000639:trends; D005260:Female; D005334:Fever / Q000188:drug therapy* / Q000209:etiology; D005500:Follow-Up Studies; D006801:Humans; D016867:Immunocompromised Host; D008297:Male; D009369:Neoplasms / Q000150:complications / Q000276:immunology; D058996:Quality Improvement; D012189:Retrospective Studies; D012720:Severity of Illness Index; D061665:Time-to-Treatment; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents
Ambulatory care; Chronic disease management; Emergency department; Prehospital care; Quality improvement methodologies