DNP 810 Module 8 Complete EBP Quality Improvement Proposal Example

On Time, Every Time: An Evidence-Based Quality Improvement Proposal to Prevent Late Second Antibiotic Doses in Emergency Department Boarders With Sepsis

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 810: Evidence-based Practice for Quality Improvement

Instructor Name

Month Day, Year

On Time, Every Time: An Evidence-Based Quality Improvement Proposal to Prevent Late Second Antibiotic Doses in Emergency Department Boarders With Sepsis

This proposal brings together the work of the course into a single plan for approval by the hospital's sepsis committee and nursing and pharmacy leadership. It addresses a gap in sepsis care that receives little attention: the second antibiotic dose for patients admitted with sepsis who are still in the emergency department when that dose is due. The proposal summarizes the problem and evidence, states the aim, describes the intervention and its implementation, sets out the design and measures, and gives the resources and timeline required.

Problem and Evidence

In a local audit of 150 sepsis admissions, 38% had a major second-dose delay, meaning the dose was given at least a quarter of the dosing interval late, with delays concentrated among patients on six- and eight-hour antibiotics who boarded more than four hours. A published cohort of 828 patients found the same pattern at a similar rate, 33%, and in exploratory analysis associated major delay with higher mortality and need for mechanical ventilation (Leisman et al., 2017). The only published test of an intervention, a pre-post study in which emergency pharmacists reordered subsequent doses for boarded patients, found major delays fell from 48% to 13% (Payne-Cardona et al., 2021). International sepsis guidelines call for antimicrobial dosing guided by pharmacokinetic principles, which late doses undermine (Evans et al., 2021).

The evidence for the problem is strong and consistent; the evidence for the intervention is promising but limited to one quasi-experimental study. That grade supports a carefully evaluated pilot rather than an immediate hospital-wide mandate.

Aim and Question

Aim: cut major second-dose delays among eligible boarders from 38% to 15% within six months of implementation, without increasing duplicate antibiotic doses. Question: among adults admitted with sepsis who are still in the emergency department when the second dose is due, does a pharmacist and nurse redosing process, compared with current practice, reduce major second-dose delays over six months?

Framework and Intervention

The project follows the revised Iowa Model, whose explicit decision on the sufficiency of evidence and central pilot step suit a promising intervention with limited testing (Iowa Model Collaborative, 2017). The intervention has three parts. When the first antibiotic dose is charted in the emergency department, the second dose is created automatically as a pending order timed from the first administration, which the emergency pharmacist verifies. The nurse receives a work-list task 30 minutes before the dose is due. At transfer, the report template shows when the latest dose was given and when the next is due, and the admission order set does not duplicate a dose that is already active.

Implementation

A barrier assessment built on the 2022 revision of the Consolidated Framework for Implementation Research, which sorts determinants into the innovation, outer setting, inner setting, individuals and process (Damschroder et al., 2022), identified unclear ownership of the second dose, thin overnight pharmacy coverage, alert fatigue and weak handoffs. Matched strategies include a consensus rule on ownership, the automatic pending order to reduce overnight pharmacist workload, a work-list task instead of a pop-up alert, a revised transfer template, shift champions, and audit and feedback every two weeks. Implementation proceeds in three PDSA cycles: one day shift, then all day shifts for two weeks, then all shifts for four weeks, each with a stated prediction and a choice at the end to keep, modify or drop the change.

Design and Measures

The design is an interrupted time series with 12 baseline months drawn from existing records and 6 intervention months. The primary outcome, the monthly percentage of eligible boarders with a major delay, will be displayed on a p-chart with month-specific control limits and interpreted with standard rules for special cause variation (Mohammed et al., 2008). Process measures are the proportion of second doses entered within 30 minutes of the first and the proportion of tasks acknowledged. Balancing measures are duplicate doses, pharmacist time per patient and nurse-reported interruptions. Deaths and hospital days will be tracked for information only and not presented as results of the change. Data come from barcode scan times and pharmacy logs, with 20% dual abstraction to confirm accuracy. The project is expected to receive a quality improvement determination; data will be de-identified and reported only in aggregate.

Resources and Timeline

Resource needs are modest. Informatics build time for the pending order, task and report changes is estimated at 60 hours; pharmacist and nurse champion time for training and audits at about 80 hours; and analyst time for monthly reports at 4 hours a month. At blended internal rates, the total is about $18,000, most of it staff time rather than new spending. If late doses fall as expected, the time saved in handling late-dose events and any reduction in intensive care transfers would offset part of this cost, although the project does not rely on savings for its justification.

The timeline runs nine months: approvals and informatics build in months one and two, the three PDSA cycles in month three, full implementation from month four, monthly review through month nine, and a report to the sepsis committee in month nine with a recommendation on adoption.

Risks

The main risks are duplicate doses if order reconciliation fails, loss of momentum if champions leave, and competing priorities in a busy emergency department. The balancing measure on duplicates will be reviewed weekly in the first month, champions will be named for each shift with backups, and the sepsis committee's sponsorship will keep the project visible.

A further risk is that boarding times fall for unrelated reasons, which would reduce late doses without the intervention. The chart annotations and process measures will help separate the two.

Conclusion

Late second antibiotic doses affect more than a third of admitted sepsis patients who wait in the emergency department, a problem that is common, predictable and plausibly harmful. A pharmacist and nurse redosing process, supported by electronic record changes and implemented through tested cycles with a clear family of measures, offers a low-cost, evidence-informed way to close the gap. The committee is asked to approve the pilot and the resources described, with a decision on hospital-wide adoption to follow the six-month evaluation.

References

Damschroder, L. J., Reardon, C. M., Widerquist, M. A. O., & Lowery, J. (2022). The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science, 17, Article 75. https://doi.org/10.1186/s13012-022-01245-0

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

Iowa Model Collaborative. (2017). Iowa Model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

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

Mohammed, M. A., Worthington, P., & Woodall, W. H. (2008). Plotting basic control charts: Tutorial notes for healthcare practitioners. Quality and Safety in Health Care, 17(2), 137-145. https://doi.org/10.1136/qshc.2004.012047

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