title: Making Improvements in the ED: Does ED Busyness Affect Time to Antibiotics in Febrile Pediatric Oncology Patients Presenting to the Emergency Department?
abstract: OBJECTIVE
  Febrile neutropenic pediatric patients are at heightened risk for serious bacterial infections, and rapid antibiotic administration (in <60 minutes) improves survival. Our objectives were to reduce the time-to-antibiotic (TTA) administration and to evaluate the effect of overall emergency department (ED) busyness on TTA.
  
  
  METHODS
  This study was a quality improvement initiative with retrospective chart review to reduce TTA in febrile children with underlying diagnosis of cancer or hematologic immunodeficiency who visited the pediatric ED. A multidisciplinary clinical practice guideline (CPG) was implemented to improve TTA. The CPG's main focus was delivery of antibiotics before availability of laboratory data. We collected data on TTA during baseline and intervention periods. Concurrent patient arrivals to the ED per hour served as a proxy of busyness. Time to antibiotic was compared with the number of concurrent arrivals per hour. Analyses included scatter plot and regression analysis.
  
  
  RESULTS
  There were 253 visits from October 1, 2010 to March 30, 2012. Median TTA administration dropped from 207 to 89 minutes (P < 0.001). Eight months after completing all intervention periods, the median had dropped again to 44 minutes with 70% of patients receiving antibiotics within 60 minutes of ED arrival. There was no correlation between concurrent patient arrivals and TTA administration during the historical or intervention periods.
  
  
  CONCLUSIONS
  Implementation of a CPG and process improvements significantly reduced median TTA administration. Total patient arrivals per hour as a proxy of ED crowding did not affect TTA administration. Our data suggest that positive improvements in clinical care can be successful despite fluctuations in ED patient volume.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Benner
authors.forename: Erika
authors.initials: E
authors.lastname: Mora
authors.forename: Emily
authors.initials: E
authors.lastname: Mueller
authors.forename: F Jacob
authors.initials: FJ
authors.lastname: Seagull
authors.forename: Kelly
authors.initials: K
authors.lastname: Walkovich
authors.forename: Kaleena
authors.initials: K
authors.lastname: Johnson
authors.forename: Schuyler
authors.initials: S
authors.lastname: Halverson
authors.forename: Ed
authors.initials: E
authors.lastname: Rothman
authors.forename: George
authors.initials: G
authors.lastname: Hucks
authors.forename: John G
authors.initials: JG
authors.lastname: Younger
authors.forename: Michele M
authors.initials: MM
authors.lastname: Nypaver
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D003441:Crowding; D004636:Emergency Service, Hospital / Q000592:standards*; D064147:Febrile Neutropenia / Q000175:diagnosis / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008297:Male; D009369:Neoplasms / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D012189:Retrospective Studies; D061665:Time-to-Treatment / Q000592:standards / Q000706:statistics & numerical data*
chemical_list: D000900:Anti-Bacterial Agents