Decreasing time to antibiotics in febrile patients with central lines in the emergency department

Abstract

Background and objective: Rapid antibiotic administration is essential for the successful management of patients who have central lines and present with fever. We conducted an emergency department (ED) improvement initiative to deliver antibiotics to 90% of patients within 60 minutes and to minimize process variation.

Methods: Our setting was an academic ED. We assembled a multidisciplinary team, identified contributing factors to the care delivery problem, determined key drivers and intervention steps, implemented changes, and used strategies to engage ED staff and promote sustainability. Outcomes were analyzed by using a time series design with baseline data and continuous postintervention monitoring. Outcomes included percentage of patients receiving antibiotics within 60 minutes, time to antibiotic administration, and accuracy for triage acuity and chief complaint.

Results: An 8-month baseline period revealed that 63% of patients received antibiotics within 60 minutes of arrival, with a mean time to antibiotics of 65 minutes. Multiple Plan-Do-Study-Act (PDSA) cycles were used to improve patient identification and initial management processes. The percentage of patients receiving antibiotics within 60 minutes of arrival was increased to 99% (297 of 301), and mean time to administration decreased to 30 minutes (95% confidence interval: 28-32). These gains were sustained for 24 months. Subanalysis identified a racial discrepancy, with African American patients experiencing significantly longer delays than patients of other races (95 vs 61 minutes; P < .05); this discrepancy was eliminated with our initiative.

Conclusions: Our initiative exceeded our goal of 90% antibiotic delivery within 60 minutes for a sustained period of at least 24 months, decreased process variation and mean time to antibiotic administration, and eliminated race-based discrepancies in care.

Keywords: bloodstream infection; central line; febrile neutropenia; pediatric emergency; quality improvement.