#60Minutes: Antibiotic Timeliness in the Emergency Center

1. #60Minutes: Antibiotic Timeliness in the Emergency Center Natashia Bush, MSN, RN, CPEN Charlyn Davis, MSN, RN, CPEN, CPN

2. Special thank you to Co-Authors and Contributors: Bryan Greenfield, MD Binita Patel, MD Julie McManemy, MD Abhay Kulkarni, MD Tarra Kerr, DNP, RN, NEA-BC Mona Shah, MD Sara Liechti, PharmD Elizabeth Wuestner, MSN,RN,CPEN

6. Johnny Jones • 8 y.o. male arrived in the Emergency Center with a history of lung transplant S/T pulmonary hypertension • Presented with fever, decreased PO, cough, vomiting • Triage vital signs: • Temp: 103.2, Pulse: 148 bpm • RR 36, BP: 111/64 • SpO2: 91-93% on RA

7. Johnny Jones, cont’d • A “Medical evaluation” was called upon arrival to room • Patient evaluated by EC Provider • Physical Exam: Tachycardia, LLL crackles, perioral cyanosis, “ill appearing”

8. Johnny Jones: Hospital Course

9. Johnny Jones: Hospital Course

10. Johnny Jones: Hospital Course Lack of awareness of badness Death: 18 hours after presentation

11. 7 y.o. presents with fever and respiratory symptoms Jenny Jones

12. Jenny Jones Lack of timely interventions Jenny DIED within 24 HOURS

14. Pediatric Epidemiology Worldwide sepsis accounts for 60-80% deaths per year in childhood 6 million neonatal and childhood deaths per year Leading cause of illness and death among U.S. children, with severe sepsis affecting >42,000 children annually Highest risk are children with indwelling vascular catheters, short gut, hematogenous malignancies, and solid organ malignancies

15. Impact of Sepsis on Patient Outcomes

16. Quality Improvement Surviving Sepsis Campaign Agency for Healthcare Research and Quality Early identification and treatment is estimated to have significant results 92,000 fewer deaths annually 1.25 million fewer hospital days annually Decrease in costs of over $1.5 billion

17. Previous State of the EC Sepsis Best Practice Alert (BPA)

18. Previous State of the EC • Shock Protocol guideline

19. BASELINE DATA

20. Desired Outcomes Tri-Campus Approach The Woodlands West Campus - Katy The Medical Center

21. Desired Outcomes

22. Desired Outcomes Our goal was to decrease the time to delivery for first-dose antibiotics in febrile neutropenic patients within one hour of presenting to the emergency center(EC) at all three campuses in the Texas Children's Hospital system.

23. Interventions

24. Timeline EHR Optimization Epic Banner Targeted Education Sepsis Response Team Pre-Arrival Antibiotic Order Pilot Situational Awareness Adapted from: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd Ed. Gerald J. Langley, Ronald D. Moen, Kevin M. Nolan, Thomas W. Nolan, Clifford L. Norman, and Lloyd P. Provost; Jossey-Bass 2009

25. Education Platforms

26. State of the Unit

29. Sepsis Education for Nursing & Physicians Sepsis is a Spectrum… Non-Severe Sepsis Severe Sepsis Septic Shock Infection

31. Early detection and identification of Sepsis • Identify and react to entire spectrum • Focus is not solely on the presentation of the patient • Identify specific cohort • Target treatment to patients with fever and cancer and all patients who flag shock protocol

32. Changing the Culture “I know septic shock when I see it” “The child doesn’t appear septic” “He looked so good that I didn’t think he was septic” “I thought his abnormal vitals signs were from his fever” “His blood culture was negative, so he wasn’t septic” “I know what a child with septic shock looks like”

33. New Focus Non-Severe Sepsis Severe Sepsis Septic Shock Infection

34. Transition from being reactive to these types of patients………….

35. ……And become proactive for patients that present like this!

36. Timeline EHR Optimization Epic Banner Targeted Education Sepsis Response Team Pre-Arrival Antibiotic Order Pilot Situational Awareness

37. Sepsis Response Team

38. Sepsis Response Team: Background

39. Sepsis Response Team: Team Members

40. Sepsis Response Team: Process

41. Sepsis Response Team: Process

42. Results of Sepsis Response Team

43. Timeline EHR Optimization Epic Banner Targeted Education Sepsis Response Team Pre-Arrival Antibiotic Order Pilot Situational Awareness

44. Pre-Arrival Antibiotics Workgroup

45. Algorithm Increase communication and pre-arrival orders Defined roles Patient/Family Oncology provider EC provider Nursing – Flow Lead Pharmacy Nursing Staff Tri-Campus Approach

46. Pre Arrival Antibiotics Workflow

47. Pre Arrival Antibiotics Workflow

48. “Are the meds made prior to arrival?” “What if there is no pre-arrival phone call?” “Do all of the patients get 1st dose antibiotics”? “What if the patient arrives at another campus?” “How does everyone know that the patient has pre-arrival antibiotic orders placed?” . . . “What happens to the patient if the trauma room is full?”

49. Timeline EHR Optimization Epic Banner Targeted Education Sepsis Response Team Pre-Arrival Antibiotic Order Pilot Situational Awareness

50. EPIC Banner – Visual Alerts EPIC BANNER