: A Quality Improvement Initiative
CPS ePoster Library. Boutin A. 06/01/17; 176657; 96
Dr. Ariane Boutin
Dr. Ariane Boutin
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Background: Febrile neonates are at high risk of morbidity and mortality from infectious causes. This risk further increases if antibiotics are not received in a timely manner. Current guidelines recommend early initiation (less than 1 hour) of antibiotics for patients with severe sepsis. Time-to-antibiotic administration (TAA) should also be targeted as a quality-of-care (QOC) measure for febrile neonates. A previous evaluation showed that most of these patients were not receiving antibiotics in the first hour at our emergency department (ED).

Objectives: We evaluated whether a simple quality improvement protocol would improve the proportion of febrile neonates receiving antibiotics within 60 minutes of arrival to the ED.

Methods: This was a pre-post intervention study conducted in the ED of an academic pediatric tertiary care hospital with an annual volume of approximately 83,000 patients in 2014-2016. Participants were a random sample of all children younger than 28 days old visiting the ED for a febrile illness. The new protocol, which consisted for the nurses, after triage, to place the patients directly in the resuscitation room for immediate assessment by a physician, was implemented in February 2016. Previously, these children were triaged level 2 on the Canadian Triage and Acuity Scale (CTAS), flagged and placed in a regular examination room waiting for the physician assessment. With the new protocol, IV access, blood culture, urine analysis and culture were immediately obtained by the nurse in charge with the concomitant assessment by the attending physician. Forty charts prior to and 50 charts after protocol initiation were reviewed by an archivist using a standardized form between 2014-2015 and 2016, respectively. The primary outcome was TAA. This was defined as the time from initial ED registration to the beginning of antibiotics infusion. As a secondary outcome, all cases were reviewed individually to determine barriers to rapid antibiotic administration (day, evening, or night shifts, other treatments or investigations, number of attempts for intravenous access) and to elicit new quality improvement strategies. 

Results: During the study periods a total of 178 (pre) and 135 (post) patients fulfilled the inclusion criteria. Among the random samples, 6/50 (12%) of patients received their antibiotics within 60 minutes in the post-intervention period compared to 0/40 (0%) in the pre-implementation period (difference 12%; 95 CI: 1-24%). Within 90 minutes, the proportion improved from 1/40 (2.5%) to 29/50 (58%) (difference 56%; 95 CI: 38-68%). Median TAA in febrile neonates decreased from 182 minutes (interquartile range, 147-219 minutes) in the pre-implementation period to 85 minutes (interquartile range, 73-115 minutes) in the post-implementation period. The main obstacle to the goal of 60 minutes for TAA was the difficulty to get IV access as well as antibiotic availability.

Conclusion: In this study, a new protocol mandating the immediate transfer of febrile neonate from triage to the resuscitation room improved proportion of febrile neonates receiving antibiotics in less than 60 minutes in our ED. Our results suggest that simple interventions can reduce TAA in a selected group of patients presenting to the ED.

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