Three improvement cycles, 748 patients

Quality improvement poster

A nurse led project cutting time to antibiotics in suspected sepsis, laid out as an A0 portrait board. The spine of the poster is the cycle chain, because a QI poster has to show the sequence of changes rather than a single intervention, and the results block separates what each change contributed instead of reporting one before and after number.

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The whole board

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RG
Cutting door to antibiotic time in suspected sepsis: a nurse led quality improvement project
K. Patel ¹, S. Chen ¹,², M. Williams ²
1 Emergency Department, Riverbend General Hospital · 2 School of Nursing, University of Northwood
Abstract
National guidance asks for antibiotics within one hour of recognising suspected sepsis. Our department median was 94 minutes, and the audit that found it also found that most of the delay sat before any clinical decision was made. Over three improvement cycles across nine months we introduced a nurse initiated screening trigger at triage, so the pathway no longer waited on a medical review, a pre-assembled sepsis pack held in the resuscitation bay and checked each shift, and a single page prompt at the bedside carrying the six steps and the clock start time. Median time to antibiotics fell from 94 to 41 minutes across 748 consecutive patients, and the proportion treated within the hour rose from 38% to 76%. Variation fell with it: the interquartile range narrowed from 61 minutes to 24. No increase in antibiotic use outside the pathway was recorded, and the share of pathway starts later judged not to be sepsis was unchanged.
HOW THE STUDY RAN
1
Baseline
Three months of consecutive cases audited against the register, 212 patients.
2
Cycle 1
Nurse initiated screening at triage, no doctor required to start the pathway.
3
Cycle 2
Sepsis pack pre-assembled and stored in the resuscitation bay, checked each shift.
4
Cycle 3
One page bedside prompt with the six steps and the clock start time printed on it.
5
Sustain
Run chart reviewed at the weekly safety huddle, ownership handed to the shift lead.
Median minutes
Baseline
Cycle 1
Cycle 2
Cycle 3
0255075100
Figure 1. Median minutes from recognition to first antibiotic dose, by improvement cycle.
Results
Across 748 consecutive patients the median fell from 94 minutes at baseline to 41 minutes after the third cycle, and the proportion treated within one hour rose from 38% to 76%. The three changes did not contribute equally. The largest single gain came from the nurse initiated trigger, which removed a median 23 minute wait for a medical review before the pathway could start at all. The sepsis pack removed a further 19 minutes of assembly time, most of it spent finding the blood culture bottles and the fluid giving set. The bedside prompt added less on its own, 11 minutes, but the run chart shows the variation narrowing sharply after it: the interquartile range fell from 61 minutes at baseline to 24 minutes, which matters more to the patient at the tail than the median does. Safety measures moved in the right direction or not at all. No shift in total antibiotic use was detected across the department. The proportion of pathway starts later judged not to be sepsis was unchanged at 14%, so the faster trigger did not come at the cost of treating more people who did not need it. Blood cultures were taken before the first dose in 94% of cases, up from 81%.
REFERENCES
1.Evans L, et al. Crit Care Med 2021;49(11):e1063-e1143.
2.Seymour CW, et al. N Engl J Med 2017;376(23):2235-2244.
3.Damiani E, et al. PLoS One 2015;10(5):e0125827.
Discussion
The biggest delay was not clinical judgement but permission. Letting the triage nurse start the pathway removed a wait that had nothing to do with the patient in front of them, and it is the change we would tell another department to make first because it costs nothing and needs no equipment. The pack and the prompt then removed assembly time and variation, in that order. Neither would have helped much on its own while the pathway was still waiting on a medical review, which is worth saying because the pack is the change most departments reach for first. This was a single department with a stable senior nursing team. The run chart shows a small drift back toward baseline during a month of high agency staffing, which suggests the gain depends on the people who own it rather than on the pathway document. We did not measure mortality. The project was not sized for it, and treating time to antibiotics as a proxy for survival would overstate what a before and after design can claim. What we can say is that the department now meets the standard it is measured against, on the measure it is measured by.
Conclusion
Three small changes, none of them requiring new equipment or new staff, more than halved the median time to antibiotics and doubled the proportion treated inside the hour. The change that mattered most cost nothing at all: giving the triage nurse permission to start the pathway. Departments looking to copy this should start there, and should expect the gain to need active ownership to hold.
Median 94 to 41 minutes across three cycles
Within the hour: 38% to 76% of patients
Nurse initiated trigger removed a 23 minute wait
Interquartile range narrowed from 61 to 24 minutes
Acknowledgements
We thank the emergency nursing and pharmacy teams at Riverbend General, who ran every cycle alongside a full department, and the clinical audit office for extracting the register each month. The improvement faculty at the University of Northwood advised on the run chart method and reviewed the analysis. The pharmacy team assembled and checked the sepsis pack on every shift for the full nine months. No external funding was received, and the authors report no competing interests.

Block by block

What each block on the board is for, in the order a reader walks it.

Title band and team
The project title, the nursing and academic authors with generated superscripts, and a QR to the full project write up.
Abstract
The standard, the baseline against it, the three changes and the result, with the variation figure alongside the median because the tail is what harms patients.
How the study ran
A five stage chain across the full width: baseline audit, the three cycles in order, and the sustain step that hands ownership to the shift lead.
The run chart
Median minutes to first antibiotic dose by cycle, the figure a QI reviewer looks for before reading a word of text.
Results
Three paragraphs: the headline change, what each of the three changes contributed separately, and the balancing measures that did not move.
Discussion
Why permission rather than judgement was the bottleneck, why the pack alone would not have worked, and the drift back during a month of agency staffing.
Conclusion and takeaways
A short conclusion naming the change to copy first, then four checked points carrying the numbers.
References and acknowledgements
Three journal style references and an acknowledgements block naming the teams, the funding position and the competing interests. The three references are invented for this fictional study, because the reference block is required on this layout; on your board, replace them with your sources.
How to adapt this board
One PDSA cycle per stage of the chain, and no more than five, because a sixth is dropped rather than drawn. If the project ran more cycles, merge the ones that tested the same change and say so in the methods entry. The run chart is the only figure and it should carry the cycle annotations, since that is what turns a line into an argument. The balancing measure belongs in the results next to the process measure, not in the discussion, because a QI reader is looking for evidence that nothing else got worse while the target moved.

What makes this board work

The cycles are the structure

Baseline, three cycles and a sustain step run across the board as a numbered chain. A QI poster that hides the sequence in a paragraph loses the one thing that makes it a QI poster rather than an audit.

Each change gets its own number

The trigger saved 23 minutes, the pack 19, the prompt 11, and they sum to the 53 minute total. That lets another department copy the change that mattered most rather than all three.

The safety measures are reported

Total antibiotic use, the share of pathway starts later judged not to be sepsis, and blood cultures before the first dose are all stated. A speed improvement without balancing measures is not a finished project.

Questions people ask

What should a quality improvement poster show?

The problem with its baseline number, the changes in the order you made them, a run chart or similar over time, the outcome, and the balancing measures. The sequence matters as much as the result.

Is a QI poster different from a research poster?

Yes. There is usually no randomisation and no control group, so the credibility comes from the run chart, the baseline and the balancing measures rather than from a p value.

Should I claim a clinical outcome?

Only if you measured it. This board says plainly that mortality was not measured and that treating time to antibiotics as a proxy would overstate the claim, which is the honest position for a before and after design.

How do I show the cycles?

The chain on this layout holds five stages. You can retype every stage's name and detail, but a sixth stage is dropped rather than drawn, so merge steps until five carry the story.

How many PDSA cycles fit?

Five, because the chain on this layout has five stages and a sixth is dropped rather than drawn. If you ran more cycles, merge the ones that tested the same change. The run chart underneath is where every cycle still shows as an annotation.

What do reviewers look for on a QI board?

The SQUIRE elements, in order: the problem, the local context, the changes tested, the measures and what was learned. This board follows that order, which is why the context sits above the results rather than in a footnote.

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Sources

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