IMPROVEMENT IN TIME TO ANTIBIOTICS FOR MGH PEDIATRIC ED PATIENTS MASSACHUSETTS GENERAL HOSPITAL Publication Year: 2014

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1 IMPROVEMENT IN TIME TO ANTIBIOTICS FOR MGH PEDIATRIC ED PATIENTS MASSACHUSETTS GENERAL HOSPITAL Publication Year: 2014 SUMMARY: This innovation reduces time to pediatric antibiotic administration by using standardized doses, readily available in the ED omnicells. SUBMISSION CATEGORY: Safety and Quality Flow and Efficiency Care Coordination Patient Experience Cost-Consciousness HOSPITAL: Massachusetts General Hospital LOCATION: Boston, MA CONTACT: Nancy Balch, PharmD, Senior Attending Pharmacist, Emergency Department Pharmacist Massachusetts General Hospital, CATEGORY: C: Clinician Initial Evaluation D: Disposition Decision/Throughput KEY WORDS: Communication Continuity of Care Length of Stay Patient Satisfaction Decrease Time to Treatment HOSPITAL METRICS: Annual ED Volume: Over 100,000 Hospital Beds: 999 Ownership: Not-For-Profit, Partners Healthcare Trauma Level: Level I Trauma Center, Level I Pediatric Trauma Center and Level I Burn Center Teaching Status: Yes, the largest teaching hospital affiliated with Harvard Medical School TOOLS PROVIDED: Charts and additional information are included CLINICAL AREAS AFFECTED: ED Fast Track Inpatient Units Laboratory Pediatrics STAFF INVOLVED: Administrators Communications ED Staff IT Staff Nurses Pharmacists Physicians Residents 1

2 Innovation Decreasing time to antibiotics decreases morbidity and mortality associated with delayed time to treatment. Multidisciplinary committee created standardized pediatric antibiotic doses, system requirements for using such doses, education, and review to determine effectiveness of innovation. Background Prolonged time to antibiotics is associated with increased morbidity and mortality. Recent PICU (MGH Pediatric ICU) data showed that, for admissions to the MGH PICU from the ED, the average time to antibiotic was almost 5 hours, national standards for septic patients is 1 hour. When antibiotics are not readily available (e.g. stocked in the ED omnicell), administration can be delayed due to the time required to obtain the medications from the central pharmacy. Team focused on interventions which would be low effort and high yield. Mapping the medications ordering, preparation and delivery process highlighted the delay to administration associated with the need to prepare the medication in central pharmacy. This intervention, as designed, eliminates that Project Leaders Cohen MD; Division Chief, Pediatric Emergency Medicine Denise Lozowski RN, MSN MGHfC Quality and Safety Nurse Coordinator Project Sponsors Pharmacy: Ray Mitrano, Interim Chief, Pharmacy ED: Mary Fran Hughes, RN, Nursing Director ED Executive Sponsors Elizabeth Mort MD; Senior Vice President, Quality & Safety Mary Cramer, Senior Director, Process Improvement Team Members Pharmacists: Bob Young, David Nickerson, Nancy Balch Pharmacy Technician and pharmacy IT specialist: Aaron Sacco Nursing: Cathie Harris, Kara Brevault Physicians: Annie Murray, Nina Gluchowski, (Chief Residents), Chadi El Saleeby MD, (Infectious Disease), Brian Cummings (PICU) CPIP Coach: Brian Cummings, MD; MGH Pediatric Intensive Care Unit (PICU) process. Percent of eligible antibiotics dispensed from ED stock increased from a baseline mean of 75% to mean of 96% following the intervention. Innovation Implementation Task 1: determine current process of antibiotic ordering, delivery, and administration to pediatric patients in the emergency department (ED). 2

3 Task 2: identify potential barriers to process. Task 3: create resolution involving common antibiotic doses and stocking these doses in the ED. 3

4 Task 4: determine common antibiotics used in ED Pediatric patients and create standardized doses for them.eligible Medications: ampicillin, vancomycin, ceftriaxone, levofloxacin, and cefepime for ED patients under 21 years of age. Task 5: pharmacy determines stability of standardized doses and potential par levels. Determination of impact on pharmacy services: time required to make standardized doses, increased omnicell stocking time (ED & pharmacy), potentially increased time destocking if any expire prior to use. Determine pharmacy IS services required to add standardized dosing to order entry system, pharmacy system, pharmacy omnicell menu, ED omnicell menu. 4

5 Task 6: Education, providers, ordering standardized doses for first dose of ampicillin, vancomycin, ceftriaxone, levofloxacin, and cefepime. Education, nursing and pharmacy staff on dosing charts, ordering, and stocking of standardized doses. 5

6 Task 7: correct potential problems and review. Timeline 4 month period, which includes time prior to initiative, which was required for data to determine potential effectiveness of innovation. Results/Evaluation Baseline Data 9/13 10/13 Baseline and Post Intervention Balance Measure % 6

7 Cost/Benefit Analysis Decreased time of pharmacy to mix exact doses which are now being standardized and administered from floor stocks. Decreased interruptions in pharmacy work; prior to standardized doses being stocked, all doses were STAT from pharmacy and potentially increased time for doses to other patients. Costs, calculations are in progress and will also require IRB information. Will also include whatever decrease in length of stay, if any, was achieved by faster time to antibiotics. At this time, it is known that the use of standardized doses, from the omnicell has increased. This has decreased the stat doses from pharmacy. Advice and Lessons Learned 1. To ensure success, from the start include: leadership of all departments potentially affected, ED & In-patient Pediatrics, Nursing, Pharmacy, IT. 2. Initiate education of staff prior to roll-out; ensure educational materials available in all areas and very visible. 3. Potentially create pathway, starting in triage, to initiate standardized antibiotics even more rapidly. Sustainability Continue subsequent PDSA cycles with: Expansions of Posters/ID tags to ED Acute Implementation of EDOE electronic ordering system with decision support Future interventions in IV timing and triage recognition for pediatric sepsis In addition, we are planning to create standardized physician orders in the electronic order entry system and will continue education efforts for new staff, and reminders to staff, regarding standardized dosing. An IRB has been submitted to look at the actual time to antibiotic administration and we will compare ICU vs floor patients as sub groups. We should have this data in a couple months. We know that for these 5 antibiotics the numbers increased as in the slides. We are also moving toward a change in electronic order entry to better incorporate this into the provider ordering work flow. 7