Quality improvement intervention decreases time to antibiotics in children with intestinal failure and fever

1. Increasing provider education and streamlining antibiotic order sets led to significantly decreased time to antibiotic administration in children with intestinal failure (IF) and fever in a quaternary pediatric emergency department (ED).

2. No significant difference was found in rates of mortality, hypoglycemia, or intensive care unit (ICU) and hospital length of service (LOS) time.

Study Rundown: High rates of bacteremia have been reported among pediatric patients with fever and IF, a condition that affects tens of thousands of children with short bowel syndrome (SBS) in the United States. Patients with bacteremia can quickly develop sepsis, which is linked to a significant of morbidity and mortality. Delayed antibiotic administration worsens outcomes for patients with sepsis. In order to reduce mean time to parenteral antibiotic administration among children with IF on parenteral nutrition (PN) who present with fever, investigators at large, freestanding children’s hospital designed a multi-faceted quality improvement (QI) intervention. The initiative focused on provider education and performance feedback, and triage and order entry simplification. Providers also looked at changes in rates of mortality, hypoglycemia, and ED, hospital and ICU LOS. Results showed a significant decrease in mean time to antibiotic administration after implementation of the QI modifications. LOS in the ED also decreased, but there was no significant change in rates of 30 day mortality, hypoglycemia, or hospital or ICU LOS. This study was conducted at a high resource, quaternary care setting, potentially limiting its generalizability. Furthermore, all interventions in this initiative were implemented simultaneously, making it difficult to determine which intervention(s) were responsible for the improvement. This study suggests low cost, low resource process modifications and education can lead to significant reductions in time to antibiotic administration in patients at high risk of critical illness. It will be important to continue to follow antibiotic administration time in this population to determine if these interventions and improvements are sustainable.

Click to read the study, published today in Pediatrics

 Relevant reading: 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

In-depth [quality report]: Investigators in the ED at a quaternary care children’s hospital implemented several QI interventions to determine the effect on time to antibiotic administration in children with IF on PN who present to the ED. Interventions included improving staff awareness of the risks of bloodstream infections in patients with IF, simplifying order entry by creating an order set in the electronic medical system, altering the triage process and giving consistent feedback to providers involved. A total of 149 ED encounters were analyzed (pre-intervention n = 88, post-intervention n = 69). Overall, time to antibiotic administration decreased by 65.2% from a mean of 112 minutes to 39 minutes. Antibiotic variability also decreased after the QI interventions with more patients receiving piperacillin-tazobactam, per the hospital protocol (67% vs. 95.1%, p < 0.01). ED LOS also decreased from 286 to 247 minutes. No significant changes in rates of 30-day mortality, hypoglycemia during ED visit, hospital and ICU LOS, (p = 0.41, p = 0.24, p = 0.6, and p = 0.72 respectively) were noted. There was a significant increase in hypotension during ED stay from 5.7% of patients to 23% of patients (p = 0.002).

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