Neutropenic fever is an oncologic emergency that requires prompt assessment and treatment with antibiotics. Although the term "prompt" is not defined in numbers of minutes in the biomedical literature, the literature does indicate that the sooner antibiotics are initiated, the greater the likelihood of a positive clinical outcome. At Dartmouth-Hitchcock Medical Center in Lebanon, NH, the oncology team was concerned about the length of time before adult inpatients with febrile neutropenia received their initial dose of antibiotics (cycle time). The purpose of this quality improvement project was to reduce treatment delays in patients with febrile neutropenia. A multidisciplinary team charted the existing admission process and identified three areas for improvement: (a) inpatient orders, (b) the admission communication process, and (c) multidisciplinary staff accountability. Following implementation, the hematology and oncology clinical nurse specialist completed a chart review of all patients with febrile neutropenia, which revealed a nearly 50% reduction in cycle time on the inpatient unit.

Improving cancer pain management in a rural setting required a recognition of the contrasting characteristics between a sophisticated academic medical center and a rural community. The successful implementation of quality improvement strategies required a combination of leadership support, internal and external funding, and professional and federal recognition of the problem. Using a quality improvement approach rather than a traditional didactic approach, and fostering communication, trust, and collegiality at our outreach sites were pivotal to our success.

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Context: With the release of an outcome-based quality measure from the Centers for Medicare and Medicaid Services that aimed to reduce emergency department (ED) and hospital admissions for patients receiving outpatient chemotherapy, new models of care needed to be implemented. Clinical Setting: This case study describes development and implementation of a cancer acute care clinic (CACC) within an extremely busy infusion center located in a National Cancer Institute-designated Comprehensive Cancer Center. Modifications that were necessary in the context of COVID-19 pandemic are described. Process: The development of the CACC involved a transdisciplinary team who determined CACC’s purpose; established patient admission criteria; created a nursing leadership and staffing plan; developed initial operating procedures; and made necessary adjustments to provide care during the COVID-19 pandemic. Clinical pathways were developed to guide care. Informal patient and staff surveys were done to evaluate satisfaction with CACC’s services. Outcomes: Of the initial 142 visits, 75.4% of patients were discharged home, and 12.6% and 12.0% were admitted to the ED or hospital, respectively. Both patients and staff reported high levels of satisfaction with CACC services. Conclusion: While COVID-19 disrupted plans for an evaluation of reductions in ED visits, because of high levels of staff and patient satisfaction, plans are underway to expand CACC services and conduct more formal outcome evaluations. Implications for Practice: Description of the processes involved in the development and implementation of the CACC may serve as a model for other organization on how to provide acute care to oncology patients.