PC1034: Improving Time to Antibiotics for Patients with High Risk Fever in a Pediatric Emergency Department

Purpose/Objectives: In high risk populations, fever can be the first sign of serious bacterial infections. Delayed antibiotic administration has been associated with increased mortality rates in children with sepsis. Therefore, prompt administration of broad-spectrum antibiotics is important when vulnerable patients present to the emergency department (ED) with fever to prevent progression of serious bacterial infections to sepsis. The primary aim was to decrease the average door to antibiotic time for patients with sickle cell disease (SCD), an underlying oncologic diagnosis, or a central venous catheter (CVC) presenting with fever to a pediatric ED (PED) from 101 minutes to 60 minutes over 9 months.

Design/Methods: A time series quality improvement initiative was undertaken by convening a multidisciplinary team including representatives from emergency medicine, hematology/oncology, infectious diseases, antimicrobial stewardship program, and a process engineer. High risk fever (HRF) patients were considered those with SCD, an underlying oncologic diagnosis, or a CVC without an oncologic diagnosis who presented to the PED with fever. Analysis of key drivers and learnings from several plan-do-study-act (PDSA) cycles led to interventions including documentation of discrete chief complaints for improved visibility, streamlined clinical pathways, revision of provider and nursing order sets, improvements in central line access, education, monthly chart review with feedback, and staff recognition. The main outcome measure was the average door to antibiotic time. The balancing measures included ED and hospital length of stays (LOS), and rates of appropriate antibiotic usage. Measures were analyzed using statistical process control charts and standard rules were applied to determine special cause variation.

Results: A total of 270 patients met inclusion criteria with 102 patients in the pre-implementation period (January 2020 to December 2020) and 168 patients in the post-implementation period (January 2021 to February 2022). The average door to antibiotic time decreased from 101 to 76 minutes, with special cause evident in January 2021. There were no significant differences in ED and hospital LOS or rates of appropriate antibiotic usage between the pre- and post-implementation groups.

Conclusion/Discussion: Implementation of a multimodal intervention bundle successfully improved the average door to antibiotic time for HRF patients presenting to the PED with fever without increasing ED or hospital LOS. Although the primary aim of average time to antibiotics of 60 minutes was not achieved, there was a decrease of 25 minutes from baseline. This improvement can be attributed to the collaborative effort amongst a multidisciplinary team to recognize and raise awareness of the importance of prompt antibiotic administration for HRF patients presenting with fever.