Key contacts
Dr Benjamin Carter, ST3 Paediatrics, Brighton General Hospital
Dr Dannika Buckley-Denton, ST3 Paediatrics, Worthing General Hospital
Dr Rob Bomont, Consultant Neonatalogist, Trevor Mann Baby Unit
Introduction
NICE guidance for the treatment of presumed or proven early neonatal sepsis stipulates that antibiotic therapy should be commenced within 1 hour of decision to treat. Around the time of delivery it is generally well recognised that there are difficulties in initiating antibiotics when necessary and in a timely manner due to the other demands on the professionals involved. It was felt likely that at the Trevor Mann Baby Unit in Brighton (a tertiary care centre), that missing the NICE mandated target was commonplace. This project was aimed at identifying the timeframes of treatment, where the rate limiting steps lie and then formulating solutions to optimise the care and ensure the standards are better met.
SMART objectives
S: To identify
- Average time taken to administer empirical antibiotic therapy for early neonatal sepsis
- Individual times taken for key steps in patient journey to antibiotic administration
- Differences between care categories for babies, specifically when the decision to treat is in the immediate post natal period on the postnatal wards, after this period, or when babies are admitted to the neonatal unit.
- What improvements can be made to the execution of rate limiting steps
M: All times will be logged through auditing and will give clear indication of total timeframes
A: The project has been planned out for each unit and staff made aware of the audit process. No significant barriers to data collection are anticipated
R: NICE guidelines are set with realistic goals in mind, there is no reason that improvements should not be able to be made to optimise care and bring it to the expected standard
T: The data will be collected over at least a 1 month period or at least until a set of at least 30 patients have been identified
Progress made: What have you learned from doing this?
The initial data shows:
Less than 50% of all patient care groups had antibiotics administered within 1 hour of decision to treat
The average time to administration was 121 mins for decisions within 1hr of birth, 76 mins for decisions after 1hr from birth and 77 mins for babies admitted to the neonatal unit
When the decision to treat was within 1 hour of birth the longest delays were noted in the times taken to generate hospital numbers for the babies – without which antibiotics can not be given (according to hospital policy)
For the post 1hr and NNU groups, the time taken from cannulation to administration appeared to be the rate limiting step – indicating that different approaches are required to improved compliance with NICE guidance in different patient groups.
However this also indicates that there is scope to improve the timing for all steps of the administration pathway – as there is significant ‘knock on effect’ – performing tasks in parallel (similar to methods suggested as part of ARNI course training) may help this.
Effective communication between care teams (doctors, nurses, midwifery) is likely to improve delays by way of making sure the team are aware of tasks that need doing in a prompt fashion. This can be achieved both through new policy and guidelines, but also through maintaining positive teamworking skills.
Work is ongoing to implement new practices to aim to improve timings and then reaudit the data to monitor for progress