Experience and Results of a Nurse-Initiated Antibiotic Timeout (NATO) Project in a Third-Level Hospital in Panama

Background

Pediatric cancer patients have a higher risk of infections and, consequently, frequent and prolonged exposure to antibiotics. We implemented the NATO (Nurse-initiated Antibiotic Time-Out) quality improvement project at Hospital del Niño Doctor José Renán Esquivel to optimize antibiotic use in febrile neutropenia episodes at 72 hours after antibiotic initiation. In NATO, bedside nurses initiate an alert to prescribers to reevaluate antibiotic appropriateness based on updated clinical and microbiology results. The objective of this study is to present the results obtained in 2 years of NATO implementation.

Methods

Using the Model for Improvement, we set a target of NATO performance in 70% of febrile neutropenia episodes. Data was collected through a data collection instrument (CRF) using TrialMaster platform. Data was analyzed with R Data Analytics (version 4.4.2), and descriptive statistics, including NATO performance rate, NATO decision adherence to institutional guidelines, and changes in antibiotic therapy during NATO, were summarized monthly. We engaged in iterative PDSA cycles to test change ideas in response to these data.

Results

From October 2022 to November 2024, 93 NATOs were performed on 132 episodes of fever and neutropenia resulting in a 70% NATO performance rate overall. The mean age of included patients was 8 years (range 0-15), with a nearly equal distribution of female (54%) and male (46%) patients. Acute lymphoblastic leukemia was the most common underlying diagnosis, accounting for 53% of cases.

The median incidence of change in antibiotic therapy was 46%, and 60% of antibiotic decisions adhered to institutional guidelines. Selected broad-spectrum antibiotics, meropenem, and vancomycin, were used infrequently; each was started in 4 episodes, and each antibiotic was discontinued once. Admission to a higher level of care decreased when comparing pre-and post-NATO periods.

Conclusions

The initiative to involve nursing staff in activities that result in a change in patient treatment has shown positive results, however, some areas require improvement. The data obtained so far will be of great value to continue with efforts to improve the quality of care and antimicrobial stewardship in hemato-oncological patients and in other areas of the hospital.