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Pediatr Qual Saf. 2019 Jan 9;4(1):e128. doi: 10.1097/pq9.0000000000000128. eCollection 2019 Jan-Feb.

Audit-and-Feedback and Workflow Changes Improve Emergency Department Care of Critically Ill Children.

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Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH.
Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH.



Children with severe infection have improved outcomes when they received antibiotics promptly. Positive cultures help guide physicians in antibiotic selection. In 2011, 30% of children intubated in the emergency department received antibiotics and had respiratory culture collected within 60 minutes of intubation. Knowing the risk of delaying appropriate antibiotics, we charted a quality improvement team to improve compliance with 80% of intubated patients receiving both.


The team evaluated all children intubated with concern for infection in the emergency department. Using a multidisciplinary team and employing quality improvement methods, we implemented multiple plan-do-study-act cycles to improve time to antibiotics and respiratory cultures. The team continued to implement successful interventions and restarted interventions directly affecting improvement.


While multiple interventions had small effects on the baseline of 30% compliance, 2 interventions appeared more influential than others. Workflow changes and audit-and-feedback created the largest, persistent positive changes. The importance of audit-and-feedback became very obvious when the project entered sustain mode. An abrupt decrease in compliance occurred when audit-and-feedback stopped. Complete recovery in compliance to greater than 80% occurred with the resumption of the audit-and-feedback intervention.


Workflow changes and audit-and-feedback interventions resulted in large improvements. Loss of compliance with cessation of the audit-and-feedback and resumption demonstrated the importance of this intervention. Recovery to >80% compliance with the renewal of the audit-and-feedback program indicates its strength as a positive intervention.

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