Improving Time to Stat Intravenous Antibiotic Administration: An 8-Year Quality Initiative.

BACKGROUND AND OBJECTIVES: Prompt antibiotics have been shown to improve outcomes in pediatric sepsis, which continues to be a leading cause of death in children. We describe the quality improvement (QI) efforts of a single academic children's hospital to improve antibiotic timeliness. METHODS: Using the electronic health record, we report time from order to the administration of stat intravenous (IV) antibiotics from 2012 to 2020 using statistical process control charts. We describe QI interventions initiated over the study period. These include the formation of a Pediatric Sepsis Committee, routine use of automated dispensing machines for stat IV antibiotics, creation of sepsis order sets, manual and automated sepsis screening implementation, participation in national sepsis QI collaboratives, creation of difficult intravenous access guidelines, and an automated notification system for charge nurses. As a balancing measure, we assessed stat IV antibiotic use normalized to total emergency department visits and inpatient days. RESULTS: Multiple quality improvement interventions were initiated and sustained under the direction of the hospital Pediatric Sepsis Committee. We improved our stat IV antibiotics given within 1 hour of order from 33% in 2012 to 77% in 2019 and maintained this through the end of the study period in July 2020. CONCLUSIONS: By using a multipronged quality improvement approach, we demonstrated consistent and sustained improvement in the timely administration of stat IV antibiotics over an 8-year period at our institution. Further study is needed to assess whether this is associated with reduced length of stay or improved survival in children with sepsis.

Continuous lidocaine infusion for the relief of refractory malignant pain in a terminally ill pediatric cancer patient.

Despite aggressive pain management with opiates, debilitating pain still occurs in a subset of children with terminal cancer. A 5-year-old girl with metastatic retinoblastoma, profound opiate tolerance, and refractory pain was treated. Continuous lidocaine infusion was initiated at a dose of 35 microg/kg per minute and increased over 4 days to 50 microg/kg per minute, at which point the patient was discharged for continued end-of-life comfort care. The patient had excellent pain relief without the associated lethargy of high-dose opiates. No complicating neuroexcitatory symptoms or cardiac conduction abnormalities were experienced. Intravenous lidocaine may be an effective alternative to opioids in the treatment of refractory malignant pain in the pediatric patient with terminal cancer.