P2.E081: Implementing A Notification System for Patients With High-Risk Conditions Presenting With Fever In The Pediatric Emergency Department

Purpose/Objectives: Patients with high-risk conditions (HRC) presenting to the pediatric emergency department (ED) with fever are at greatly increased risk for developing systemic infection or sepsis. Consensus guidelines for these patients emphasize timely evaluation and administration of antibiotics, ideally within 1 hour of presentation. Longer time-to-antibiotics (TTA) has been associated with poorer outcomes. From 2016-2023, 42% of patients admitted to Duke Children’s Hospital who met HRC+Fever received antibiotics within 1 hour of presentation to triage. In this study, our primary objective was to implement an informatics-driven system to immediately identify patients with high-risk conditions who presented to the Duke Pediatric ED with a fever and reduce TTA.

Design/Methods: The prospective study cohort included all patients with a high-risk condition who presented with a fever to the Duke Pediatric ED from 1/1/24-4/1/24. High-risk conditions included active chemotherapy (1+ dose of chemotherapy in past 6 months), receipt of services from transplant team (on solid organ transplant “list”) and sickle cell disease (prior encounter containing sickle cell diagnosis). Fever was defined as a temperature of >38oC measured in the ED or by chief complaint of fever. For each patient who met this HRC+Fever phenotype, an automated notification page was sent to the ED charge nurse and ED pharmacy to coordinate prompt evaluation and treatment. Pages not sent if a patient already received antibiotics. Silent validation was performed from 1/1/24-2/25-24 during which notifications were generated but not sent to clinicians. HRC+Fever notifications went live to clinicians in the Duke Pediatric ED on 2/26/24. We tracked the actionability of notifications as well as TTA via statistical process control charts.

Results: From 1/1/24-4/1/24, 57 patients met the HRC+Fever phenotype. 50 of these notifications (88%) were actionable. 19 (33%) occurred prior to the antibiotic order and 31 (54%) occurred between antibiotic order and administration (54%). There were 7 (12%) non-actionable notifications, occurring when antibiotics were not indicated or a page was sent after antibiotics were given due to delay in data acquisition. Statistical process control charts (Figure 1) showed special cause variation (two points exceeding the upper control limit). These were instances in which the transplant team was consulted for antibiotic decision-making, causing delay in TTA. No other special cause variation was noted. After 1 month of implementation, mean time from ED arrival to antibiotics decreased from 109.0 to 90.6 minutes and compliance with antibiotic administration ( < 1hour) increased from 20.6% to 35.3%, an absolute increase of 14.7% (Table 1).

Conclusion/Discussion: We successfully implemented an informatics-based notification system to identify high-risk patients presenting with fever in the Pediatric ED. In the first month of implementation, mean TTA decreased and antibiotic compliance improved. We will continue to track impact metrics and investigate additional workflow improvements as HRC+Fever notifications continue.