A Quality Improvement Initiative to Decrease Time to Antibiotics for Children with Intestinal Failure, Fever, and a Central Line

Abstract

Introduction:Pediatric intestinal failure (IF) patients experience significant morbidity, including sepsis related to central line–associated bloodstream infections. Adult studies of sepsis demonstrate an association between time to antibiotic administration (TTA) and mortality. To overcome challenges in treating pediatric IF patients in an emergency department (ED), we appropriated an existing, reliable system for febrile immunocompromised oncology/bone marrow transplant children. We describe the translation of this process to febrile IF patients in the ED and steps toward sustained improvement.Methods:We formed a multidisciplinary team and used the Model for Improvement to define aims and identify key drivers. The goal was to use an existing improvement process to increase the percentage of patients with IF who receive antibiotics within 60 minutes of arrival to the ED from 46% to 90%. Key drivers included pre- and postarrival processes, staff and family engagement, and a preoccupation with failure. We performed Plan-Do-Study-Act cycles targeting family engagement, prearrival efficiency, and postarrival consistency.Results:Two hundred seventy-six encounters involving febrile IF patients between November 2012 and March 2017 were evaluated. There was a sustained reduction in the median time from arrival to antibiotic administration (71–45 minutes). We decreased TTA to less than 60 minutes for 77% of febrile IF patients.Conclusions:The basic tenets of process improvement for 1 high-risk population can be translated to another high-risk population but must be adjusted for variability in characteristics.

Predictors of 1‐year enteral autonomy in children with intestinal failure: A descriptive retrospective cohort study

“…With the evolution of intestinal rehabilitation programs, 3 novel liver‐sparing parenteral nutrition strategies, 4–6 and central line–associated bloodstream infection mitigation techniques, 7–10 pediatric IF care has markedly changed over the last two decades. A recent multicenter report, reflecting outcomes a decade after the PIFCon cohort, captured that change, reporting 6‐year incidence of mortality of 10.5% and of transplant of 16.7%, both much lower than the PIFCon report 11 .…”

“…A secondary analysis of those data found presence of an ileocecal valve, necrotizing enterocolitis diagnosis, longer bowel length remaining, and care at a non-transplant center were all predictive of enteral autonomy achievement. 2 With the evolution of intestinal rehabilitation programs, 3 novel liver-sparing parenteral nutrition strategies, [4][5][6] and central line-associated bloodstream infection mitigation techniques, [7][8][9][10] pediatric IF care has markedly changed over the last two decades.…”

Management of Central Venous Access in Children With Intestinal Failure

“…In these scenarios, early intensivist involvement may allow for vasoactive medications to support cardiovascular status. Care can be aided by protocols integrated into the health record at referral centers (55,56); however, many children rely on initial stabilization at a local hospital before transfer to their primary IRP center. In these scenarios, standardized emergency letters and timely communication can aid in expediting the care that they receive.…”