Article Text

Sustained reductions in time to antibiotic delivery in febrile immunocompromised children: results of a quality improvement collaborative
  1. Christopher E Dandoy1,
  2. Selena Hariharan2,
  3. Brian Weiss3,
  4. Kathy Demmel4,
  5. Nathan Timm2,
  6. Janis Chiarenzelli2,
  7. Mary Katherine Dewald2,
  8. Stephanie Kennebeck2,
  9. Shawna Langworthy4,
  10. Jennifer Pomales4,
  11. Sylvia Rineair5,
  12. Erin Sandfoss4,
  13. Pamela Volz-Noe2,
  14. Rajaram Nagarajan4,
  15. Evaline Alessandrini2
  1. 1Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  2. 2Emergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  3. 3Division of Oncology, Children's Hospital Medical Center, Cincinnati, Ohio, USA
  4. 4Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  5. 5Vascular Access Team, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  1. Correspondence to Dr Christopher E Dandoy, Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 11027, Cincinnati, Ohio, 45229, USA; christopher.dandoy{at}cchmc.org

Abstract

Background Timely delivery of antibiotics to febrile immunocompromised (F&I) paediatric patients in the emergency department (ED) and outpatient clinic reduces morbidity and mortality.

Objective The aim of this quality improvement initiative was to increase the percentage of F&I patients who received antibiotics within goal in the clinic and ED from 25% to 90%.

Methods Using the Model of Improvement, we performed Plan-Do-Study-Act cycles to design, test and implement high-reliability interventions to decrease time to antibiotics. Pre-arrival interventions were tested and implemented, followed by post-arrival interventions in the ED. Many processes were spread successfully to the outpatient clinic. The Chronic Care Model was used, in addition to active family engagement, to inform and improve processes.

Results The study period was from January 2010 to January 2015. Pre-arrival planning improved our F&I time to antibiotics in the ED from 137 to 88 min. This was sustained until October 2012, when further interventions including a pre-arrival huddle decreased the median time to <50 min. Implementation of the various processes to the clinic delivery system increased the mean percentage of patients receiving antibiotics within 60 min to >90%. In September 2014, we implemented a rapid response team to improve reliable venous access in the ED, which increased our mean percentage of patients receiving timely antibiotics to its highest rate (95%).

Conclusions This stepwise approach with pre-arrival planning using the Chronic Care Model, followed by standardisation of processes, created a sustainable improvement of timely antibiotic delivery in F&I patients.

  • Ambulatory care
  • Emergency department
  • Quality improvement methodologies
  • Prehospital care
  • Chronic disease management

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Background

Immunocompromised patients receiving radiation and/or chemotherapy for cancer, or undergoing bone marrow transplantation (BMT), are at increased risk for a bacterial infection.1 ,2 Blood stream infections in paediatric oncology and BMT patients lead to prolonged hospitalisation, intensive care admissions, extensive antibiotic treatment and increased mortality.3 ,4 Despite the use of empiric antibiotics, there is a high rate of morbidity and mortality in the febrile neutropenic paediatric oncology/BMT population.5

Among adult patients with septic shock, administration of antibiotics within 1 h of documented hypotension improved outcomes, and progressive delays resulted in increasing mortality.6 ,7 Extrapolating these data to a higher-risk, immune-compromised population, Fletcher et al8 demonstrated that time to antibiotics was an independent risk factor for adverse events in paediatric oncology patients. Despite this evidence, Volpe et al9 showed difficulty in maintaining timely antibiotic administration in paediatric oncology and BMT patients presenting to the emergency department (ED) and recommended a quality improvement initiative to maintain the standard. In the ED setting, where patients with a wide range of symptoms, diagnoses and severity of illness are cared for simultaneously, it is critical to have systems in place to risk stratify patients and treat them effectively in a timely fashion in order to maximise outcomes of care.10

Given the risk of morbidity and mortality in this patient population and the large numbers of immunocompromised children for whom we care through our Cancer and Blood Disease Institute (CBDI), we developed a theory-driven, interdisciplinary, patient and family co-produced series of interventions.11 ,12 Implementation of our interventions was phased-based upon our theories including components of the Chronic Care Model.10 Our goal was to develop a system to reliably administer antibiotics to febrile immunocompromised (F&I) children within 1 h of triage in the clinic and ED and to sustain the improvement over time.

Local problem

The improvement project occurred in the ED and CBDI clinic at Cincinnati Children's Hospital Medical Center (CCHMC). F&I patients constitute a small percentage (<1%) of all visits to the ED and clinic. Our baseline data for the ED (January to June 2009) showed the median time to antibiotics was >135 min in F&I patients. Although these children were recognised as high acuity and triaged as such, there was no coordinated effort between the oncology and EDs. There was no standardised referral process, nor was there consistency among antibiotic choices and the ordering of labs. The baseline data (January to February 2011) for the CBDI clinic were similar, with a median time to antibiotics of 105 min. Analysis of the clinic F&I process showed no standardisation and low urgency among providers to administer antibiotics in a timely manner.

Methods

Improvement team

In July 2010, we established a multidisciplinary improvement team between the ED and the CBDI. The team was comprised of key stakeholders including physicians, nurses, ED intake coordinators and pharmacists. The team reviewed the current antibiotic administration practice and process map, gaps in practice and identified areas for improvement. Using the Model for Improvement, the team first defined their global and smart aims and developed a key driver diagram to represent their theory of improvement.13 For each driver, we defined potential interventions and their level of reliability (LOR) and tested each by using Plan-Do-Study-Act (PDSA) cycles to enable improvement strategies to be tested and refined.13 ,14 Effective interventions were adopted and new process maps developed to represent our new system of care.

Setting and context

The CBDI at CCHMC includes both a haematology oncology unit as well as a BMT unit. The BMT programme performs 95–110 transplants annually with the majority being allogeneic. Approximately 350 new/relapse patients enter the cancer programme each year. Over 95% of F&I patients that come into the ED and clinic have a central venous catheter (CVC). As an institution, we treat all febrile BMT and oncology patients equally as they are immunocompromised regardless of their absolute neutrophil count.15 ,16

The ED at CCHMC is an urban level 1 trauma centre with approximately 90 000 visits per year. F&I patients from the CBDI constitute just 250 patient visits each year (0.3%) of ED visits. The ED consists of 38 physicians and 86 registered nurses (RNs). The CBDI clinic has approximately 20 000 visits each year. F&I patients presenting to the CBDI clinic constitute 90 visits (0.4% of all clinic visits) each year. Forty-five physicians, 15 paediatric haematology oncology fellows and 100 RNs staff the clinic.

CCHMC has a mature quality improvement infrastructure within the James M. Anderson Center for Health Systems Excellence. Hospital faculty and staff are trained in improvement science via multiple course offerings. Quality improvement consultants and data analysts provide assistance for many improvement projects.17

Improvement

Failures related to the pre-arrival process for the ED were found to be delay in antibiotic ordering after patients arrived in the ED, lack of standardisation of antibiotic selection between the ED and CBDI staff, unreliable identification of F&I patients at the time of referral to the ED, variable information collected and delivered at time of referral, intermittent communication among ED staff at time of referral and patients not instructed to place topical anaesthetic of eutectic mixture of local anaesthetics lidocaine/prilocaine (EMLA) on their port prior to seeking care. Failures related to the post-arrival process for the ED were found to be delays in central line access, delays in ordering of antibiotics, delays in rooming of patients/room availability, variable awareness of patient arrival to ED, lack of a standard team approach to patient evaluation and antibiotic administration. Failures related to delays in antibiotic administration in clinic patients were similar to those found in the ED: delay in antibiotic ordering after patients’ arrival, lack of standardisation of antibiotic selection, unreliable identification of F&I patients prior to arrival in the clinic, patients not instructed to place EMLA on their port prior to seeking care, delays in central line access, delays in rooming patients secondary to room availability and delayed registration, lack of a standard team approach to care and variable awareness of the amount of time F&I patients had been in the clinic prior to antibiotic administration.

Based on this assessment, the team established several key drivers to address the delay in antibiotic delivery. The initial key drivers of this process included rapid identification of eligible patients, standardised pre-arrival process, standardised post-arrival process, faculty and staff engagement and buy in, family engagement, preoccupation with failure18 and timely vascular access. These key drivers were categorised as pre-arrival interventions, post-arrival interventions and expanded to include spread to the CBDI clinic. Further, key drivers included availability of correct supplies and equipment required for antibiotic delivery, proper communication with the patient and the CBDI team, proper communication between the ED team and CBDI team, pre-arrival preparation of the patient room and antibiotics (figure 1).

Figure 1

Key driver diagram of the F&I process. Interventions of the key drivers included standardised identification of Cancer and Blood Disease Institute patients through the phone triage staff (level of reliability (LOR) 2), eutectic mixture of local anaesthetics lidocaine/prilocaine cream provided to all patients with regular home supply assessment (LOR 2), pre-arrival huddle to anticipate/mitigate complications (LOR 2), rapid analysis of failures (LOR 2), rapid response team to mitigate central line access complications (LOR 2). ED, emergency department. 

Interventions

Interventions were tested through PDSA cycles and categorised as LOR 1 or 2. The LOR 2 interventions, along with the number of PDSA cycles to implement the process, are listed in table 1. Figure 2 contains the most recent flow chart of the clinic/ED F&I process.

Table 1

Barriers to timely antibiotic delivery and associated interventions

Figure 2

Current F&I process in the clinic and emergency department. CVC, central venous catheter; ED, emergency department; EMLA, eutectic mixture of local anaesthetics lidocaine/prilocaine; F&I, febrile immunocompromised; MD, medical doctor; RN, registered nurse; VAT, Vascular Access Team.

Pre-arrival interventions

Patients and family members were made aware of the process through letters and regular clinic discussion. The F&I process was discussed early in therapy and was part of the baseline education for families being treated in the CBDI. Additionally, EMLA cream was provided to all families, instruction on EMLA application, and routine assessment of the home supply was made at the time of discharge and during clinic visits.

When febrile, patients were educated per the CBDI care management team to call the CCHMC operator service through a dedicated CBDI telephone number. The calls would be prioritised as F&I patients and were expedited by the operator service to the oncology fellow on call. The fellow on call would instruct the families, via a standardised script, to place EMLA cream on the port site, ask the families if there was a history of difficulty in accessing the CVC and determine any other variables needed for their care in the ED. The fellow also determined the approximate time of arrival of the patient. Prior to calling the referral in to the ED Referral Coordinators, the fellow would determine the appropriate antibiotic required for the patient through review of electronic medical record (EMR). High-risk patients (ill appearance on presentation, patients with acute myeloid leukaemia, patients with acute lymphoblastic leukaemia (ALL) in consolidation/delayed intensification, recently underwent BMT or history of Streptococcus viridians infection) received broad spectrum Gram-negative and positive coverage, moderate-risk patients (those likely to be neutropenic) would receive broad Gram-negative antibiotic coverage and low-risk patients (patients unlikely to be neutropenic such as those with ALL in maintenance therapy) would receive Gram-negative coverage such as ceftriaxone.

Once identification of F&I patients was made, the CBDI fellow on call referred the patient into the ED physician through the ED Referral Coordinators. The ED Referral Coordinators created an account in the EMR and used a standard question set to reliably identify F&I patients. The fellow was then connected to the ED physician who used a standardised F&I referral checklist that included the corresponding fellow referral script as well as an order set in the EMR. In addition, the referral checklist included pre-populated patient-specific information with a smart phrase and link. The ED physician used a standardised order set that was completed at the time of the referral to place orders for labs and antibiotics. A patient room was identified and made available in anticipation of the patient's arrival. Antibiotics and lab slips that were ordered prior to arrival were placed in the room along with the proper supplies to access the patient's line. A team page was made at time of the referral as well as to alert the physician and charge nurse that an F&I patient would arrive soon. Finally, the ED team created a pre-arrival huddle between the lead physician, nurse and emergency medical technician (F&I team).19 This team would review the checklist, verify the placement of orders, and verify the proper supplies were obtained and room was reserved.

Post-arrival interventions

The ED Referral Coordinator confirmed orders were placed within 10 min of referral, completed a reminder card for the greeter desk in the ED with the patient's name. Once the patient arrived in the ED, the EMR automatically sent an arrival page to the referral group noting the patient had arrived. The Charge RN or designee then escorted the patient to the held room. Central line access supplies were available in the room as well as the appropriate antibiotics. If a patient was anticipated to have port CVC issues in the past, the vascular access team (VAT) was called upon arrival to assist in vascular access. The VAT consists of highly trained nurses that specialise in complex vascular access. Additionally, intramuscular ceftriaxone was given to patients with anticipated antibiotic administration delays, with platelets >50×103/μL. Finally, the EMR sent an alert to the patient's primary team alerting them that the patient was seen in the ED.

Spread of the F&I process to the CBDI clinic

After implementation of the F&I process in the ED occurred, many of the same processes were implemented in the CBDI clinic. During clinic hours, the CCHMC operator referred the patient to the CBDI stat line, who was then referred the dedicated ‘F&I provider’ in the clinic. The F&I provider was designated at the beginning of the workday and was responsible for taking all calls from febrile patients. The F&I provider communicated arrival time to the F&I team and placed orders for the visit including antibiotics. Antibiotic selection in the clinic was the same as for patients presenting to the ED. Similar to the ED process, the clinic staff completed a pre-arrival huddle to review the pre-arrival checklist, verify the placement of orders, and verify the proper supplies were obtained and the room was reserved. Upon patient arrival, the patient was rapidly identified, roomed and triaged. Registration was done after arrival. CVC access supplies were available in the room as well as the antibiotics. A timer was set upon arrival in the clinic, and the treating staff was aware of the time remaining to administer antibiotics. Similar to the ED, intramuscular ceftriaxone was given to patients with anticipated antibiotic administration delays.

Sustainability: preoccupation with failure and staff engagement

Intense port access education, along with the F&I process module, was given to all ED and CBDI clinic staff with interval refresher courses. Posting process run-charts in the Quality Improvement board in the ED and clinic made awareness of performance. Results were also placed in the ED and CBDI dashboard for monthly analysis by leadership. All failures were evaluated in real time. Nurses, physicians and family members were contacted shortly after the encounter, and learnings were analysed and implemented when indicated.

Enhancing sustainability by learning from failures

In 2014, we noted the majority of our failures were close to goal in the ED; 50% of failures were within 20 min of goal. Close analysis of failures revelled the majority of failures were secondary to delayed port access. In September 2014, we tested and implemented a rapid response team (separate from the hospital Medical Emergency Team) to address F&I patients upon arrival. The rapid response team, consisting of the ED F&I team plus a VAT member, prioritised the initial assessment of the F&I patient upon arrival in the ED. The VAT was alerted of the anticipated time of the patient's arrival when the call was made to the ED. Upon arrival into the ED, a rapid response pager alerted the team that the patient had arrived and they would evaluate their status in a timely manner. This intervention increased our median percentage of patients receiving timely antibiotics to its highest rate (95%) and decreased our median to its lowest (31 min) meeting special cause using standard P-chart, run-chart rules.

Study of the improvement

Time to antibiotics was measured on all F&I patients presenting to the ED or CBDI clinic and represented the time from initial assessment to the initiation of antibiotics. Time to antibiotics was measured in both the clinic and the ED by two mechanisms: as a percentage of patients receiving antibiotics within goal using a standard P-chart, and as a median time to antibiotics of consecutive encounters using a standard run-chart. Of note, the definition of receiving antibiotics within the goal changed from 90 min (January 2010 to October 2011) to 60 min (November 2011 to February 2015) in the ED. The clinic maintained a definition of 60 min for goal antibiotic administration on all F&I patients. The initial testing phase is shown using five consecutive patients in the clinic during the baseline collection period, followed by 10 consecutive encounters starting in July 2011. We measured 10 consecutive patients secondary to the extreme variability in F&I ED/clinic visits each month.

Early in the project data were collected by the ED data team from the EMR on all F&I patients who presented to the ED with fever and periodically validated by CBDI. Real-time validation by the CBDI Quality staff began in July 2013 using daily on-call reports generated by the fellows and the fever call line operators allowing for immediate failure identification and mitigation. The CBDI clinic measured the time to antibiotic delivery for all patients from the EMR with periodic validation.

Analysis

The process was evaluated through a quantitative time-series study design. Statistical process control methods were used to monitor changes in care processes. Annotated run-charts and P-charts were developed and updated monthly for time to antibiotics and length of stay. We established a mean, illustrated as the centreline on all control charts with upper and lower control limits in the P-chart. Standard industry criteria were used to determine whether observed changes in measures were chance random variation (common cause variation) or due to a specific assignable cause, in this case the intervention (special cause variation).20 ,21

Human subjects protection

The present initiative fell within the CCHMC Institutional Review Board's guidance for quality improvement projects that did not constitute human subjects research.

Results

ED results

The ED study period was from January 2010 through January 2015. During this time, 1120 F&I patients were seen in the ED (figure 3A, B). Baseline data were obtained through July 2010. Only 25% of patients received antibiotics within 90 min, and the median time to antibiotics was 135 min. In July 2010, PDSA testing and process implementation increased the percentage of patients receiving antibiotics within 90 min to a median of 70% (median time 85 min). Post-arrival interventions decreased the median time to antibiotics to 35 min, with 92% of patients receiving antibiotics within 60 min. On 31 October 2011, the definition of successful timely delivery of antibiotics was transitioned from 90 min to 60 min. The median time to antibiotics remained relatively stable at 40 min from January 2012 to September 2014 (sustainability period). In 2014, we noted the majority of our failures were close to goal in the ED; antibiotics administered in 63 min instead of 60. Our median time to antibiotics remained constant; however, the success rate remained steady at 85%. In September 2014, we tested and implemented a rapid response team to address febrile oncology/BMT patients upon arrival. This intervention increased our median percentage of patients receiving timely antibiotics to its highest rate (95%) and decreased our median time to antibiotics meeting special cause using standard P-chart and run-chart rules, respectively.

Figure 3

(A) P-chart demonstrating the percentage of patients receiving antibiotics within goal in the emergency department (ED). Goal was changed from 90 min to 60 min on 31 October 2011. (B) Run-chart demonstrating the median time to antibiotic administration for febrile immunocompromised (F&I) patients in the ED. (a) Baseline data. (b) Pre-arrival Plan-Do-Study-Acts (PDSAs) creating standardised referral process to the ED, electronic medical record checklist, pre-arrival team huddle and standard order set that was completed at the time of referral. (c) Post-arrival PDSAs were tested and implemented creating a standardised arrival process and a standardised room-to-antibiotic process. (d) During the sustaining of interventions phase, PDSA cycles were tested and implemented to sustain improvement. These PDSA tests included: standardised education module for all ED staff including interval refresher courses, posting of updated run-charts for staff and monthly review of F&I results on ED dashboards, rapid analysis of all failures, standardised process to review eutectic mixture of local anaesthetics lidocaine/prilocaine cream availability at home upon hospital discharge and during clinic visits. (e) During the enhancing sustainability phase, we implemented a rapid response team, which included a member of the vascular access team to assist in implantable port access.

Spread and implementation in the cancer and blood disease clinic

The study period in the CBDI clinic was from February 2011 through January 2015. During this time, 280 F&I patients were seen in the clinic (figure 4A, B). Initial PDSA testing in the clinic started in February 2011. At the time, no patient received antibiotics in <60 min, and the median time was 107 min (range 90–210 min). Implementation of the various process including pre-arrival planning and pre-arrival order placement increased the median percentage of patients receiving antibiotics in <60 min to 45%. By August 2011, our interventions increased the percentage of patients receiving antibiotics to 89% with a median time to antibiotics to 37 min meeting special cause using standard P-chart and run-chart rules, respectively. The median time to antibiotics has been maintained through January 2015, and the median percentage of patients receiving antibiotics within 60 min has increased to 95%.

Figure 4

(A) P-chart demonstrating the percentage of patients receiving antibiotics within 60 min in the clinic. (B) Run-chart demonstrating the median time to antibiotic administration in the clinic. (a) Clinic specific interventions during the Plan-Do-Study-Act (PDSA) testing period included standardised process of identification of febrile immunocompromised (F&I) patients prior to arrival in the clinic, standardised prompt registration process for F&I patients and use of a 60 min countdown timer for all F&I patients. These PDSA tests occurred from February 2011 to July 2011. (b) Sustaining of interventions phase. During the sustaining of interventions phase, PDSA cycles were tested and implemented to sustain improvement. These PDSA tests included standardised education module for all clinic staff including interval refresher courses, posting of updated run-charts for staff and monthly review of F&I results on the Cancer and Blood Disease Institute dashboards, rapid analysis of all failures, standardised process to review eutectic mixture of local anaesthetics lidocaine/prilocaine cream availability at home upon hospital discharge and during clinic visits.

Summary

We describe a stepwise approach of implementing and sustaining the time to antibiotic initiative for febrile oncology and BMT patients. Our work initially focused on the chronic care model and pre-arrival planning of care. Once this component of care was standardised, we focused our efforts on the care in the ED by standardising our processes, which included rooming of the patient, CVC access and antibiotic administration. Many of the learnings from the ED were spread to the CBDI clinic. Family member engagement was critical to the success of timely antibiotic administration. Family members actively engaged in the efforts by placing EMLA cream on the ports, remained knowledgeable of the steps and clear communication with the CBDI staff. Additionally, further analysis of our failures showed that the majority of the failures were <5 min from the goal. Implementation of the rapid response team has increased the percentage of patients receiving timely antibiotics to 95% (our highest rate to date) and decreased our median time to 32 min.

The addition of a pre-arrival checklist, along with allocation of the necessary resources needed to deliver the antibiotics, significantly deceased delays in the process. Key drivers of success for this project were dependent on adequate communication with the staff from the CBDI with the family, and concurrent communication between the ED and the CBDI staff.

Verification of the home EMLA cream supply on each encounter at visits, as well as frequent discussions surrounding the F&I process and role of the family in preparedness, decreased the frequency of delayed access to ports from families not placing EMLA cream on the port. Having the CBDI representative remind the family to place the EMLA cream onto the port prior to coming into the ED decreased the frequency as well.

Current guidelines recommend antibiotic administration within 60 min of fever as delays can be associated with worse outcome. The F&I patient population constitutes a small percentage of the ED patient volume; in our institution, it is only 0.3% of the patients seen in the ED. Identification of this small patient population prior to arrival was imperative. Pre-arrival selection of antibiotics eliminated the waiting time for lab work, and only a small percentage of patients (5%) required broadening of antibiotics after given narrow spectrum coverage such as ceftriaxone.

The Chronic Care Model uses six fundamental areas to form a system that encourages high-quality care. We used various aspects of the Chronic Care Model in constructing our pre-arrival process. Self-management support encourages patients and families members with chronic disease to know basic information about their disease. In the F&I process, family members and patients were given a foundation of knowledge to help them understand the basics of their disease, what treatments they were receiving, what type of CVC they had along with any CVC issues and it required them to place EMLA cream on the port site prior to arrival. The delivery of care to patients with chronic conditions requires a coordinated delivery system design that allows for up-to-date information regarding the patient's status. Our EMR allows easy access for the referring oncology/BMT physician as well as the ED physician to rapidly gain access to the patient's record. Additionally, the EMR alerts the primary CBDI physician each time the patient is seen in the ED to allow for scheduling of a follow-up visit if indicated.10 ,22

Limitations

There are several limitations to this study. First, due to the rare nature of mortality, our work has not yet been associated with a decrease in mortality, and we have not yet systematically captured a reduction in morbidity. However, we will be conducting a retrospective review of the outcomes of F&I patients. Second, our balancing measure is door-to-physician assessment time for non-F&I patients in the ED. Our analysis reveals that door-to-physician time has not been adversely impacted by the F&I work. However, we do not have routine quantitative data to know whether the process resulted in interruptions in delivering interventions to other ill children in the ED. Third, institutions may not have the necessary resources (VAT, rapid response team and quality improvement infrastructure) to implement aspects of the project, limiting successful replication.

Future direction

The processes applied to this population are being generalised to other high-risk populations at CCHMC. One group identified as amenable to intervention is patients with gastrointestinal disorders and indwelling central lines. In October 2013, the F&I pre-arrival process was implemented with these families. Physicians and staff were educated about the expansion of immediate bedding, triage and the order set for this population. Data are currently being collected and analysed about the success of the generalisability of this process.

We describe a stepwise approach to implementation of an F&I process in the ED and clinic using components of the Chronic Care Model. Many of the key drivers and interventions that were used in this project are translatable to other paediatric EDs and clinics. We believe the concept of prehospital planning, which includes family engagement and use of a dedicated team, can decrease the time to antibiotic delivery in F&I patients.

This report employed the Standards for Quality Improvement Reporting Excellence (SQUIRE) publication guidelines for reporting healthcare quality improvement research.23

Acknowledgments

The authors wish to thank the physicians, nurses, patient care attendants, nurse practitioners, hospitalists, fellows, and staff at CCHMC, and especially the patients and their families. They also thank Dr Rich Ruddy, Dr John Perentesis and Dr Stella Davies for their guidance and support of this work.

References

Supplementary materials

  • Supplementary Data

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Footnotes

  • Contributors CED, SH, BW, KD, NT, and EA conceptualised and designed the study, drafted the initial manuscript and approved the final manuscript as submitted. JC, MKD, SK, SL, JP, SR, ES, PV-N and RN carried out and tested various components of the F&I process in both the clinic and ED, assisted in the collection of data, reviewed and revised the manuscript, and approved the final manuscript as submitted.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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