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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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

Baseline

Three months of consecutive cases audited against the register, 212 patients.

Cycle 1

Nurse initiated screening at triage, no doctor required to start the pathway.

Cycle 2

Sepsis pack pre-assembled and stored in the resuscitation bay, checked each shift.

Cycle 3

One page bedside prompt with the six steps and the clock start time printed on it.

Sustain

Run chart reviewed at the weekly safety huddle, ownership handed to the shift lead.

Figure 1. Median minutes from recognition to first antibiotic dose, by improvement cycle.

Source: Department sepsis register, 2026.

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 weekly audit 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 weekly audit showed 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. 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.

Key finding

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%.

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.

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 and the nursing and academic authors with generated superscripts.
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 cycle figure: Median minutes to first antibiotic dose as four bars, baseline and each of the three cycles, the figure a QI reviewer looks for before reading a word of text. It summarises by cycle rather than plotting every week, so the drift during agency staffing that the discussion mentions is described in text, not shown.
Results: One block in three parts: 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 key finding block restating the median and the within the hour share, then four checked points carrying the numbers.
References and acknowledgements: Three journal style references and an acknowledgements block naming the nursing, pharmacy and audit teams and the university faculty that advised on the analysis. Check each reference against its source before reusing the board.
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 chain detail. The figure is the only chart; a bar per cycle is the simplest reading, and a weekly line chart is the closer match to a true run chart if you have the weekly data. 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 chart of the measure over time or by cycle, the outcome, and the balancing measures. The sequence matters as much as the result. This board opens with a 94 minute baseline median, runs the changes as a numbered chain and closes the results with three balancing measures.

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 baseline, the sequence of changes and the balancing measures rather than from a p value. This board reports a before and after on 748 consecutive patients and says plainly that the design cannot support a claim about survival.

Should I claim a clinical outcome?

Only if you measured it. This board says plainly that mortality was not measured, that the project was not sized for it, and that treating time to antibiotics as a proxy for survival would overstate the claim. That is the honest position for a before and after design, and it keeps the headline on the process measure the department is judged by.

How do I show what each change in a QI project contributed?

Give each change its own number in the results, in the order it was made. This board credits the nurse initiated trigger with 23 minutes, the sepsis pack with 19 and the bedside prompt with 11, which sum to the 53 minute fall from 94 to 41. Another department can then copy the change that mattered most rather than all three.

How many PDSA cycles fit?

Five, because the chain on this layout has five stages and a sixth is dropped rather than drawn. This board uses them for baseline, three cycles and a sustain step. If you ran more cycles, merge the ones that tested the same change, and give the figure one bar per cycle so each still shows its own median.

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, from the 94 minute baseline in the abstract to the chain, the figure and the results, which is why the context sits above the results rather than in a footnote, and the limits close the discussion.

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Sources

Written and checked by the OneCraft team. Last checked 29 September 2026.