163 - Improving Strep Throat Swab Collection Prior to Provider Evaluation for Patients Presenting with Sore Throat

Publication Number: 3157.163

Megan Feick, NemoursAlfred I. duPont Hospital for Children, Philadelphia, PA, United States; Laura Santry, NemoursAlfred I. duPont Hospital for Children, Wilmington, DE, United States; Courtney Nelson, Nemours Children's Hospital, Wilmington, DE, United States

Background: Prolonged emergency department (ED) Length-of-Stay (LOS) can worsen outcomes and increase costs. Advanced triage nursing protocols and point-of-care (POC) testing are effective methods to reduce ED LOS. Prior institutional data demonstrated that patients with rapid strep swabs performed prior to provider evaluation had shorter average time from room to discharge or clinical team time (CTT).

Objective: To increase the percentage of rapid strep swabs performed by nursing before provider evaluation from 21% to 40% over 6 months for patients presenting with a chief complaint (CC) of sore throat and Emergency Severity Index (ESI) 4 or 5.

Design/Methods: In February 2024, a group of providers and nurses convened to identify key drivers for ED LOS for patients presenting with sore throat. The target population included patients > 3 years old presenting with a CC of sore throat and ESI of 4 or 5. Outcome measures included: (1) % of patients with rapid strep testing that had testing prior to provider evaluation and (2) CTT for patients undergoing strep testing. Process measure: % of strep swabs ordered per nursing protocol. Balancing measures: (1) % of patients with a CC of sore throat undergoing rapid strep testing and (2) 72-hour ED return rate. We executed Plan-Do-Study-Act (PDSA) cycles to refine interventions such as expansion of nursing education, updating Epic RN and provider ordersets, aligning the sore throat pathway with revised Epic ordersets and sharing data at daily ED huddles.

Results: After initiation in July 2024, the % of patients with rapid strep tests completed by nursing prior to provider evaluation increased from 21% to 36% in August 2024 and 65% in November 2024 (Fig 1A). CTT decreased from 106 minutes to 98 minutes (Fig 1B). The % of rapid strep swabs obtained from the nursing per protocol orderset increased from 30% to 48% in July 2024 and 76% in November 2024 (Fig 2). The ED 72-hour return rate remained unchanged at 2%. The % of patients presenting with a CC of sore throat who underwent rapid strep testing remained unchanged at 72% (Fig 3).

Conclusion(s): A quality improvement initiative successfully increased the % of strep swabs performed by nursing prior to provider evaluation for patients with sore throat by updating nursing protocol orders, modifying Epic ordersets and sharing data at daily ED huddles. Future work is needed to identify strategies to address additional factors impacting CTT.

Figure 3.
PAS Abstract Figure 3.pdfBalancing Measures: p Chart demonstrating percentage of patients with a chief
complaint of sore throat who underwent rapid strep testing remained unchanged at 72%
throughout the quality improvement initiative.

Figure 1.
PAS Abstract Figure 1.pdfPrimary outcome measures (A) p chart demonstrating increase in percentage of rapid strep
swabs obtained prior to provider evaluation from a baseline of 21% to a new mean of 65% over a 6-month
period (B) XbarS chart demonstrating decrease in clinical team time for patients undergoing rapid strep
testing from a baseline of 106 minutes to new mean of 98 minutes over 6 months

Figure 2.
PAS Abstract Figure 2.pdfProcess measure: p chart demonstrating % of rapid strep swabs obtained from nursing per protocol EPIC orderset increased from a baseline of 30% to 76% over 6 months.