Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department

Abstract

IntroductionInfants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival. MethodsThe team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts. ResultsThrough use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes. DiscussionThe use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.