DNP 810 Module 1 From Practice Problem to PICOT Example

The Second Dose Nobody Scheduled: Turning Delayed Antibiotic Redosing in Emergency Department Boarders Into a Focused PICOT Question

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 810: Evidence-based Practice for Quality Improvement

Instructor Name

Month Day, Year

The Second Dose Nobody Scheduled: Turning Delayed Antibiotic Redosing in Emergency Department Boarders Into a Focused PICOT Question

Sepsis care has focused intensely on the first hour: recognizing sepsis, drawing blood cultures and giving the first dose of antibiotics quickly. Much less attention goes to what happens next. While an admitted patient boards in the emergency department waiting for a ward bed, the second antibiotic dose can fall between the emergency team, which considers its work done, and the inpatient team, whose orders may not yet be active. This paper describes that practice problem at a composite community hospital, examines the local and published evidence of its size and consequences, and develops a focused PICOT question to guide an evidence-based quality improvement project.

The Practice Problem

At the composite hospital, a 360-bed community hospital, admitted patients waited a median of 5.5 hours in the emergency department for inpatient beds last year, and some waited more than 12 hours. Emergency nurses noticed that septic patients who had received their first antibiotics promptly were sometimes still waiting when a second dose was due, and that no one had ordered it. The first dose was ordered as a one-time emergency order; the second depended on admission orders written by the hospitalist, often hours later, and then on the pharmacy verifying and dispensing the drug.

A retrospective audit of 150 consecutive adults admitted with sepsis over four months found that 57 (38%) got their second dose after 125% or more of the recommended interval had passed, the threshold for a major delay. Delays were most common for antibiotics dosed every six or eight hours, such as piperacillin-tazobactam and cefepime, and for patients who boarded in the emergency department for more than four hours.

The problem is also a nursing one. Emergency nurses caring for boarders often have new arrivals as well, and without an active order or a prompt, a due dose is easy to miss. Several nurses told the student that they had discovered late doses only when the inpatient nurse called for report and asked when the next antibiotic was given.

Is the Problem Significant?

The local findings mirror published evidence. In a retrospective cohort of 828 patients admitted with sepsis from the emergency department of an academic medical center, one in three patients crossed that same threshold for the second dose. Delay was far more common with shorter dosing intervals, reaching 72% for six-hour intervals, and boarding in the emergency department more than doubled the odds of delay. In exploratory analysis, patients with a major delay died in hospital more often and more often needed a ventilator (Leisman et al., 2017). The study was observational and could not establish that delay caused worse outcomes, but it established that the problem is common, predictable and plausibly harmful.

Current sepsis guidelines reinforce the importance of dosing. They recommend optimizing antimicrobial dosing based on pharmacokinetic and pharmacodynamic principles, which assumes that doses arrive when planned (Evans et al., 2021). A late second dose leaves drug concentrations below effective levels for hours, early in the illness when control of infection matters most.

Building the PICOT Question

A PICOT question breaks a clinical problem into population, intervention, comparison, outcome and time. Each element must be specific enough to guide the evidence search and the project design.

Population: adult patients, 18 years or over, with sepsis or septic shock who are being admitted through the emergency department or septic shock who receive a first antibiotic dose in the emergency department and remain there when the second dose is due. Limiting the population to boarders focuses the project on where delays occur, while excluding patients who reach inpatient units before the second dose is due. Intervention: a nurse and pharmacist redosing protocol in which the pharmacist enters the second dose, timed from the first administration, as soon as the first dose is given, and the emergency nurse is prompted when it is due. Comparison: current practice, in which second doses depend on admission orders. Outcome: the proportion of patients with major second-dose delay, the primary outcome, with time from first to second dose as a secondary outcome. Time: six months after implementation, compared with the preceding six months.

The Question

The resulting PICOT question is: among adults admitted from the emergency department with sepsis who are still boarding when their second antibiotic dose is due (P), does a nurse and pharmacist redosing protocol that schedules the second dose at the time of the first (I), compared with second-dose timing determined by admission orders (C), reduce the proportion of major second-dose delays (O) over six months (T)?

The question is an intervention question and implies a comparison over time, which fits a quality improvement design. The intervention is also plausible to implement: at one academic emergency department, expanding pharmacists' role to reorder subsequent antibiotic doses for high-risk boarders reduced major delays from 48% to 13% compared with the previous year (Payne-Cardona et al., 2021). It deliberately does not claim to test mortality, which a single hospital's six-month project could not detect reliably; instead, mortality and length of stay will be monitored as secondary outcomes.

Considerations and Limits

Two considerations shape the question. First, the protocol involves pharmacists, whose scope of practice and staffing must allow order entry, so the question depends on institutional support that must be confirmed. Second, second-dose delays might also be addressed by reducing boarding itself, a larger system problem beyond the project's scope; the question focuses on what nursing and pharmacy can change now. Finally, the retrospective audit relied on documentation, and some doses may have been given but charted late; the project will validate the audit method before using it as a baseline.

Conclusion

Delayed second antibiotic doses among sepsis patients boarding in the emergency department are common at the composite hospital and in published research, predictable from dosing interval and boarding, and plausibly harmful. Defining each element of a PICOT question carefully, including a population limited to boarders, a specific nurse and pharmacist intervention and a measurable primary outcome, turns an observation by emergency nurses into a question the evidence can answer and a project can test.

References

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., . . . Levy, M. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063-e1143. https://doi.org/10.1097/CCM.0000000000005337

Leisman, D., Huang, V., Zhou, Q., Gribben, J., Bianculli, A., Bernshteyn, M., Ward, M. F., & Schneider, S. M. (2017). Delayed second dose antibiotics for patients admitted from the emergency department with sepsis: Prevalence, risk factors, and outcomes. Critical Care Medicine, 45(6), 956-965. https://doi.org/10.1097/CCM.0000000000002377

Payne-Cardona, M., San Luis, V. A., Aazami, R., Dermendjieva, M., Erin, M., Kirkwood, J., Tong, C., Marks, G., Smith, E. A., Torbati, S. S., & Gilmore, J. F. (2021). Pharmacist driven antibiotic redosing in the emergency department. The American Journal of Emergency Medicine, 50, 160-166. https://doi.org/10.1016/j.ajem.2021.07.039