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Buckingham, D., Dunaway, A., Reynolds, M., Shoemaker, D., Spencer, S. P., & Stevens, C. (2020). Triage standing orders decrease time to antibiotics in neonates in pediatric emergency department. Journal of Emergency Nursing. 46(6), 768-779. https://doi.org/10.1016/j.jen.2020.06.008

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Why was this project needed- This project was needed because studies show that early administration of antibiotics improve outcomes in other patient populations such as children with sepsis. Infants often don't show other indications of serious infections until the illness has progressed further along meaning timely administration is needed.

Gap in Practice- While clinical tools exist for infants older than 28 days, this hospital did not have standing orders for febrile infants less than 28 days. They did see improvements when they initiated quality improvement projects for other groups population groups such as high-risk patients.

The rationale was if they initiated standing orders for antibiotic administration to neonates, the could decrease the average administration time from 192 minutes to 120 minutes consistently.

Supporting Background- Only 19% of neonates aged 0-28 days being evaluated for an SBI was receiving antibiotics within 120 minutes. The QI team set a goal to reach 80% and sustain it for at least 6 months.

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To analyze the data the QI team used SPC Shewhart charts to review process variation and performance. The aim was to identify improvements over the course of the project.

Outcome Measure- How many neonates age 0-28 days old being seen for an SBI received antibiotics within 120 minutes.

Process Measure- The percentage of TSO use on TSO-eligible patients. TSO eligible patients= 0-28 days old, documented fever of 38C.

Balancing Measure- ED length of stay for all patients classified as an emergency level 2.

To validate the quantitative data collected the team conducted a t test comparing baseline averages from July of 2014 to December of 2015. They determined the percentage of infants receiving antibiotics within the 120 minute window to be significant as it increased from 19% to 77%.

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The quantitative research data involving 367 patients from July 2014- December 2015 showed that increased TSO use significantly improved antibiotic administration time. It improved early recognition and SBI evaluation by nurses before the physician assessment. This study suggests that TSO may result in improvement in outcomes. Although outcomes were not included in the data, other studies suggest early administration of antibiotics improve outcomes such as patient mortality. The recommendation for change as that TSO use be continued.

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Plan-Do-Study-Act

Plan- A QI team made of ER nurses, doctors, pharmacists and analysts met  and brainstormed. They identified where antibiotic administration had delays and determined increasing TSO use may be prevent such delays thus decreasing administration time in neonates.

Do- The team implemented regular education on a rolling basis including presentations at shift sigh-outs, meetings, new staff orientation, newsletters and flyers. They requested feedback and streamlined the process. They improved communication barriers as well.

Study- Data was collected and analyzed using SPC Shewhart charts to determine improvements over the course of the project. The team determined they achieved their goal of 80% of newborn receiving antibiotics within 120 minutes of ED arrival for at least 6 months.

Act- The QI team is continuing this project including working on additional interventions to improve patient antibiotic administration such as 1-click TSO orders and reminders and parent handouts.

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Buckingham, D., Dunaway, A., Reynolds, M., Shoemaker, D., Spencer, S. P., & Stevens, C. (2020). Triage standing orders decrease time to antibiotics in neonates in pediatric emergency department. Journal of Emergency Nursing. 46(6), 768-779. https://doi.org/10.1016/j.jen.2020.06.008

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Gap In Practice- No standing orders for the administration of antibiotics to neonates in the pediatric emergency department.

Supporting Background- There were delays in neonates, infants aged 0-28 days, receiving timely antibiotics while they are being evaluated for serious bacterial infections (SBI) in the Nationwide Children's Hospital Emergency Department. Research revealed that other hospital systems could administer antibiotics for this population group in 60-90 minutes while this hospital' s average administration time was 192 minutes. It was discovered that this hospital's emergency department did not have a formal policy or standing orders for early administration of antibiotics to neonates.

Supporting Data- Serious bacterial infections occur in up to 8-13% of neonates and have complications including mortality.

Only 19% of the neonates received antibiotics within 120 minutes upon admission with the average time being 192 minutes.

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The QI team identified delays in both nurse and physician assessment, orders and testing and cultures. They initiated regular education sessions to increase triage standing order ( TSO) usage including regular surveys meant to target knowledge gaps and target new staff members as well as posted flyers. They used feedback to streamline the orders and after identfing communication issues, they added a communication flag to the TSO.

Participants-  All nurses and physicians within the ED department

Tools, models and equipment- The team used the Institutes for Healthcare Improvement's Model with the Plan-Do-Study-Act Cycle

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Future recommendations for implementation 

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Future recommendations for implementation 

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The future recommendation is that the QI team add additional interventions such as an alert pop-up for triage nurses to  allow for TSO ordering via one- click but to remind the nurses of the availability.